Questions Flashcards
[] personality disorder: prefer to be alone, don’t like relationships, low libido
Schizoid personality disorder:
- prefer to be alone, don’t like relationships, low libido
Could be avoidant personality disorder at first, the key difference is that in this example (schizoid), he doesn’t care about praise/criticism from his colleagues
schizoid sounds like android. So they are robotic in character: little interest in sex, solitary, indifferent.
NB:
- Whilst being asexual is recognised as being part of the LGBTQ+ spectrum both the DSM-5 and ICD-10 list lack of interest in sex as being part of the diagnostic criteria:
In patients suspected of having bulimia nervosa, investigation for electrolyte imbalances, specifically [], is crucial due to frequent self-induced vomiting and laxative use.
In patients suspected of having bulimia nervosa, investigation for electrolyte imbalances, specifically hypokalaemia, is crucial due to frequent self-induced vomiting and laxative use.
You suspect a patient is suffering from bulimia nervosa.
Which electrolyte changes should you investigate? [3]
. Calcium, phosphate and magnesium should be part of the investigations.
You suspect someone has LBD.
What is the underlying pathological change in their brain? [1]
Alpha-synuclein cytoplasmic inclusions in the substantia nigra and paralimbic areas.
The antipsychotics most commonly used in the treatment of manic episodes or mixed episodes in bipolar affective disorder are [4]
The antipsychotics most commonly used in the treatment of manic episodes or mixed episodes in bipolar affective disorder are quetiapine, olanzapine, risperidone and haloperidol.
Which conditions should you cholinesterase inhibitors with caution? [2]
sick sinus syndrome and peptic ulcer disease
Describe the treatment plan for post-partum depression [4]
First-line treatments typically involve self-help strategies and psychological therapies such as Cognitive Behavioural Therapy (CBT) or Interpersonal Therapy (IPT).
High severity: SSRIs
- Paroxetine and Sertraline (safe in breastfeeding)
- Assess if admission needed
When does grief reaction expire? [1]
starts within 3 months of the stressor and does not persist for longer than 6 months.
- if longer then probably depression
FTD is strongly associated with [],
Amyotrophic lateral sclerosis
- around 40% of people with FTD carry the same genetic mutations that are also implicated in ALS, such as mutations in the C9ORF72 gene. This overlap makes ALS a recognised comorbidity in patients with FTD.
Which drugs are used first line for acute mania and why?
antipsychotics are used first line for acute mx, as lithium takes a couple of weeks to work
A patient has an infection, they take clozapine.
What would indicate someone has clozapine toxicity (as opposed to neutrophilia?)
symptoms of clozapine toxicity – confusion, drowsiness, ataxia and tachycardia
NB - clozapine is metabolised by CYP450 enzymes, it is postulated that downregulation of these enzymes by cytokines in an infection/inflammation decreases the metabolism of clozapine, leading to a raised clozapine level.
During which time period is postpartum psychosis most likely to be seen? [1]
Postpartum psychosis can include paranoia, delusions, hallucinations, mania, depression or confusion, and generally develops within the first two weeks of giving birth.
Describe an occular side effect of TCA use [1]
Blurred vision
Which of the following might be side effects of his sodium valproate?
Hair loss, weight gain and tremor
Confusion, ataxia and bone marrow suppression
Hirsutism, gingival hyperplasia and lymphadenopathy
Weight gain, hyperglycaemia and hypertriglyceridaemia
Tremor, hypothyroidism, nephrogenic diabetes insipidus
Hair loss, weight gain and tremor
The main side effects of valproate can be remembered with the mnemonic “VALPROATE”
What are the side effects? [+]
Vomiting
Alopecia
Liver toxicity
Pancreatitis/Pancytopenia
Retention of fats (ie. weight gain)
Oedema
Anorexia
Tremor
Enzyme inhibition
A 57 year old man is referred to the neurology clinic with memory problems. He was, until recently, a lawyer. He has stopped working after being disciplined at work for inappropriate behaviour and he was recently given a caution by the police for stealing chocolate from a shop.
Which of the following signs would he be most likely to exhibit?
Constructional apraxia
1
Orofacial apraxia
2
Shuffling gait
3
Vivid visual hallucinations
4
Slurred speech
Constructional apraxia
- This patient most likely has frontotemporal dementia, a relatively rapidly progressive dementia affecting younger people. Patients have marked personality change and MRI shows significant atrophy of the frontal and temporal lobes. Constructional apraxia i.e. failure to draw interlocking pentagons may be a key feature in the early stages
What sleep pattern. is pathognomonic of depression? [1]
Early morning waking
A patient’s symptoms suggest frontotemporal dementia (FTD).
What drug can you use to manage behavioural symptoms such as disinhibition? [1]
SSRIs can help manage behavioural symptoms such as disinhibition, which are common in FTD.
A patient is started on Memantine.
Which of the following is most likely to be a side effect of this therapy?
Diarrhoea
1
Constipation
2
Drooling
3
Bradycardia
4
Urinary incontinence
Constipation
- think anticholinergic side effects = cant see pee sht or spit = blur vision, urine retention, constipation, dry mouth
Which medication already being prescribed would mean that wouldn’t use an SSRI first line for depression? [1]
An SSRI is associated with an increased risk of bleeding when prescribed with anticoagulants, especially among the elderly
A 65-year-old patient with frontotemporal dementia presents with behavioural changes, disinhibition, and apathy.
Which of the following is a recommended first-line intervention for managing these symptoms?
Atypical antipsychotics
1
Antidepressants
2
Antiepileptic drugs
3
Behavioural interventions and environmental modifications
4
Cholinesterase inhibitors
Behavioural interventions and environmental modifications
Which drugs are indicated for postpartum psychosis? [2]
olanzapine and quetiapine.
What would indicate that someone has undergone a TCA overdose? [+]
Describe the ECG changes? [2]
What would blood gas show? [1]
confusion, seizure, tachycardia, hypotension and dilated pupils (mydriasis)
prolonged QRS duration and QTc interval
Leads to metabolic acidosis
How long do you continue SSRI tx to ensure successful management of a patients:
- OCD? [1]
- GAD/depression? [1]
OCD - continue for 12 months
GAD/Depression - 6 months
If CBT or EMDR therapy are ineffective in PTSD, the first line drug treatments are [2]
If CBT or EMDR therapy are ineffective in PTSD, the first line drug treatments are venlafaxine or a SSRI
According to ICD-10 criteria, how long must symptoms last to be classified as a depressive episode? [1]
2 weeks
A patient you are looking after is started on imipramine for depression. Which combination of side-effects is most likely to be seen in a patient taking this class of antidepressants?
Dry mouth + urinary frequency
Hypertension + sweating
Gastrointestinal bleeding + dyspepsia
Headache + myoclonus
Blurred vision + dry mouth
Blurred vision + dry mouth
- Impramine = TCA
The risk of developing schizophrenia if one monozygotic twin is affected is approximately:
10%
20%
50%
75%
>95%
50%
What do the following terms mean?
- Loss of ideation
- Thought expulsion
- Ideas of reference
- Tactile hallucination
- Thought withdrawal
Loss of ideation - Unable to form ideas or concepts
Thought expulsion - Made up rubbish
Ideas of reference - belief or perception that irrelevant, unrelated or innocuous things in the world are referring to them directly or have special personal significance.
Tactile Hallucination - a false perception of tactile sensory input that creates a hallucinatory sensation of physical contact with an imaginary object.
Thought withdrawal - The belief that an external force is extracting thoughts from your mind.
Which one of the risks is associated with zopiclone use in the elderly?
Convulsions
Tremor
Hyperventilation
Diarrhoea
Increased risk of falls
Zopiclone increases the risk of falls in elderly patients
Describe what characterises a BPD? [1]
How do people with BPD often view other people? [2]
Borderline personality disorder (BPD) is characterised by challenging behaviours to try and cope with strong emotions when relationships are strained.
- Devaluation is a defence mechanism whereby the individual suggests things or people are worthless: patients often quickly switch their emotions, there is no middle ground
[] can be an effective treatment for BPD.
Dialectical behaviour therapy can be an effective treatment for BPD.
A patient is taking lithium for their bipolar disease.
What finding might you see on a FBC? [1]
Lithium can precipitate a benign leucocytosis
A psychiatrist wants to change a patient’s lithium dose.
When would it be most appropriate to re-check her levels?
In 1 month
In 1 week
In 3 days
In 3 months
In 6 months
After a change in dose, lithium levels should be taken a week later and weekly until the levels are stable
Lithium levels are normally measured one week after starting treatment, one week after every dose change, and weekly until the levels are stable. Once levels are stable, levels are usually measured every 3 months.
NB: specifically: the sample should be taken 12 hours post-dose
Describe a change in behaviour that is associated with a poor prognosis with schizophrenia? [1]
What are other risk factors for a poor prognosis
A prodromal phase of social withdrawal is associated with a poor prognosis in schizophrenia
Also:
* strong family history
* gradual onset
* low IQ
* lack of obvious precipitant
[Drug class] should be avoided in patients taking a SSRI
- Describe why? [2]
Triptans should be avoided in patients taking a SSRI
- Triptans x SSRIs precipitate serotonin syndrome (agitation, restlessness, confusion, muscle rigidity, hyperreflexia, dilated pupils and flushed skin.)
Whats a mneumonic for remembering the side effects of SSRIs? [4]
SSSSRIs
Stomach Upset
Sexual Dysfunction
Sodium Low
Serotonin Syndrome
. The GP also notices that the patient repeats the last word of any question that he is asked.
What is this phenomena called?
Copropraxia
Echolalia
Echopraxia
Neologism
Palilalia
Echolalia
What do the following mean [3]
Copropraxia
Echopraxia
Palilalia
Copropraxia:
a motor tick, involuntarily repeating inappropriate or rude gestures.
Echopraxia:
Repeating someone else’s movements involuntarily.
Palilalia:
Repeating words or sounds over and over, like a broken record.
Which class of drug have the Medicines and Healthcare products Regulatory Agency warned may be associated with an increased risk of venous thromboembolism in elderly patients?
Tricyclic antidepressants
5HT3 antagonists
Third generation cephalosporins
Benzodiazepines
Atypical antipsychotics
Antipsychotics in the elderly - increased risk of stroke and VTE
What are two examples of features of an atypical grief reaction? [2]
delayed grief: sometimes said to occur when more than 2 weeks passes before grieving begins
prolonged grief: difficult to define. Normal grief reactions may take up to and beyond 12 months
Which of the following is most likely to cause a rise in clozapine blood levels?
Alcohol abstinence
Omitting doses
Smoking cessation
Stress
Weight gain
Smoking cessation
- it is the TAR in cigarettes that induce the CYP450 (1A2) activity, causing an increased metabolism of Clozapine = Lower blood levels in smokers.
Mnemonic for side effects of lithium? [+]
LITHIUM:
Lethargy
Insipidus (diabetes)
Tremor
Hypothyroidism
Insides (gastrointestinal)
Urine (increased)
Metallic taste
What is a useful way of remembering the beneficial side effects of mitrazapine? [2]
MirtaZapine.
M is for ‘Mmmm’ (increases appetite)
Z if for ‘Zzzzz’ (makes you sleepy)
Clomipramine is used to treat which pathology? [1]
What is the MoA? [1]
What is are side effects? [3]
Clomipramine, a tricyclic antidepressant (TCA) used in OCD treatment, can cause anticholinergic side effects like dry mouth, blurred vision, and weight gain due to its cholinergic receptor antagonism and antihistaminic effects.
Describe what a conversion disorder is [1]
Which clinical test can be used to assess for it? [1]
- Describe how to perform it [3]
This condition commonly presents with a loss of motor and sensory function, which typically arises during periods of stress
Hoover’s sign is a clinical test used to evaluate functional neurological disorders: assessing for discrepancies between voluntary and involuntary hip extension.
- In cases of genuine limb paresis, both voluntary and involuntary hip extension would be rated as 0/5 in strength.
- To perform the test, voluntary hip extension is initially assessed in the ‘weak’ limb. Should this reveal weakness, the examiner subsequently tests hip flexion in the contralateral limb while placing their hand beneath the heel of the patient’s ‘weak’ limb.
- Ordinarily, hip flexion on one side results in automatic contralateral hip extension. Absence of this response may indicate true weakness; however, if involuntary hip extension is observed, it suggests an inconsistency between voluntary and involuntary movements’raising suspicion for a functional neurological disorder
A patient want to abruptly stop their SSRIs. What should you advise may happen if they do so? [1]
Gastrointestinal side-effects such as diarrhoea are seen in SSRI discontinuation syndrome
- diarrhoea is most likely
What is the a general difference in the description of signs of dyskinesia vs dystonia? [1]
lip puckering is a classic sign of tardive dyskinesia
A dystonia is more likely to present with oculogyric crisis/torticollis/trismus
Oculogyric Crisis:
- This is a type of acute dystonia characterized by involuntary, sustained spasms of the extraocular muscles, leading to a deviation of the eyes, often upward.
Torticollis:
* This refers to a condition where the neck muscles contract, causing the head to be twisted or tilted to one side.
Trismus:
* This is a condition characterized by spasms of the jaw muscles, leading to difficulty opening the mouth.
This man has been diagnosed with mild Alzheimer’s disease and started on first-line pharmacological therapy, which will be an acetylcholinesterase inhibitor such as Donepezil, Galantamine or Rivastigmine.
Which of the following is most likely to be a side effect of this therapy?
Constipation
Tachycardia
Urinary retention
Dry mouth
Diarrhoea
These drugs cause cholinergic side effects such as diarrhoea, nausea and vomiting, bradycardia, increased salivary production and urinary incontinence
How do you differentiate between a delusional perception and grandiose delusion? [1]
Delusional perception is a delusion that is formed in response to an external stimulus without any logical sense.
Grandiose delusion may be present without any external stimuli.
An acute presentation of a patient with chronic alcohol use should prompt a possible complication of [], as it is a medical emergency that should not be missed. Hence, [] is the next best investigation for a patient presenting with ?alcohol intoxication
An acute presentation of a patient with chronic alcohol use should prompt a possible complication of hypoglycaemia, as it is a medical emergency that should not be missed. Hence, blood glucose is the next best investigation for this man.
What area of the brain is responsible for the activation of the ‘flight or fight’ response?
Hippocampus
1
The amygdala
2
The substantia nigra
3
The frontal cortex
4
The hypothalamus
The amygdala
Which anti-pyschotic is best for treating negative symptoms of schizphrenia? [1]
Clozapine
A 45-year-old man with schizophrenia taking chlorpromazine develops an oculogyric crisis. What side-effect of antipsychotic medication is this an example of?
Neuroleptic malignant syndrome
Parkinsonism
Acute dystonia
Tardive dyskinesia
Akathisia
Acute dystonia
- prolonged involuntary upward deviation of the eyes, is a type of acute dystonia
Tardive dyskinesia is another potential side effect of long-term use of antipsychotic medications, but it typically presents with repetitive, involuntary movements such as grimacing, tongue protrusion or rapid blinking rather than oculogyric crisis.
A 16-year-old girl attends the eating disorders clinic with her parents, who report a significant reduction in her food intake over two months. The patient has a fear of gaining weight and perceives herself as overweight, despite evidence to the contrary, which has led to a decrease in her caloric intake. She denies low mood or any other anxieties.
On examination, she has a BMI of 17 kg/m², a heart rate of 60 beats per minute, and a blood pressure of 100/80 mmHg. Blood tests are normal.
Alongside a structured eating plan, what is the first-line therapy for this patient’s condition?
Adolescent-focused psychotherapy
Anorexia-focused family therapy
Dialectical behavioural therapy
Eating disorder focused cognitive behavioural therapy
Fluoxetine
Anorexia focused family therapy is the first-line treatment for children and young people with anorexia nervosa
What advise do you give for switching between SSRIs? [1]
Switching from fluoxetine to another SSRI - withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low dose of the alternative SSRI
[] has the most tolerable side effect profile of the atypical antispsychotics, particularly for prolactin elevation
Aripiprazole has the most tolerable side effect profile of the atypical antispsychotics, particularly for prolactin elevation
A person comes in with an aucte history of pyschotic symptoms.
[] could easily cause a psychotic picture and is important to rule out. How?
Drug intoxication could easily cause a psychotic picture and is important to rule out
- Urine toxicology
Which of the following is a cardinal feature of lithium toxicity?
Hyperthermia
Cog-wheel rigidity
Bradycardia
Coarse tremor
Fine tremo
Coarse tremor
- A fine tremor may be seen in patients taking lithium at a therapeutic dosage, this does not indicate toxicity.
A patient is exhibiting features of severe lithium toxicity, which is generally seen if serum levels are above [] mmol/l
patient is exhibiting features of severe lithium toxicity, which is generally seen if serum levels are above 3.5 mmol/l
NB: Generally speaking, raised lithium levels above 4 regardless of whether any symptoms are present or not, would prompt dialysis.
What is the first-line management of panic disorder?
Fluoxetine
1
Cognitive behavioural therapy (CBT)
2
Eye movement desensitisation and reprocessing (EMDR) therapy
3
Diazepam
4
Sertraline
Cognitive behavioural therapy (CBT)
A patient is on put on sertraline
Which of the following is most commonly associated with this drug?
Galactorrhoea
1
Blurred vision
2
Hypersalivation
3
Diarrhoea
4
Hypernatraemia
Diarrhoea
- Sertraline increases serotonin activity in the gut, leading to increased motility. Patients should be informed that these side effects often improve with time.
- Sertraline commonly causes gastrointestinal side effects, particularly diarrhoea, especially during the initial weeks of treatment.
64-year-old man is admitted from his care home after suffering from recurrent falls. His most recent fall was unwitnessed and may have hit his head. His carers report that he hasn’t quite been himself in the past twelve months. He has been more difficult to manage as he often wets himself and now has difficulty mobilising. He has not had any headaches, nausea nor vomiting.
What is the dx? [1]
This man is is presenting with the triad of “Wet, Wobbly & Weird”. This is typical of Normal Pressure Hydrocephalus
A 64-year-old man is admitted from his care home after suffering from recurrent falls. His most recent fall was unwitnessed and may have hit his head. His carers report that he hasn’t quite been himself in the past twelve months. He has been more difficult to manage as he often wets himself and now has difficulty mobilising. He has not had any headaches, nausea nor vomiting.
Which imaging would you use to investigate further? [1]
What would imaging show? [2]
Enlarged ventricles and absent sulci seen on CT brain scan
- The sulci are absent because they are compressed by the ventricles which allows for the pressure to be normal despite the CSF increase
Which of the following phenomena are most characteristic of emotionally unstable personality disorder?
Law breaking
1
Splitting
2
Sexual inappropriateness
3
Grandiosity
4
Magical thinking
Splitting
- Splitting is a phenomenon sometimes seen in EUPD, whereby relationships alternate between idealisation and devaluation. As a result, patients may regard others as either wholly good, or wholly bad, often without reasonable grounds to hold such opinions.
A patient has lithium toxicity, with levels above 3.5 mmol/.
How would you tx? [1]
This patient is exhibiting features of severe lithium toxicity, which is generally seen if serum levels are above 3.5 mmol/l. Haemodialysis is appropriate for patients experiencing severe lithium toxicity because left untreated they will develop sustained seizure activity
If left untreated, lithium toxicity can progress to more severe neurological symptoms such as [3]
If left untreated, lithium toxicity can progress to more severe neurological symptoms such as visual disturbances, including blurred vision or nystagmus, seizures, and coma.
If CBT or EMDR therapy are ineffective in PTSD, the first line drug treatments are [] or a []
If CBT or EMDR therapy are ineffective in PTSD, the first line drug treatments are venlafaxine or a SSRI
A 33-year-old woman is brought to the psychiatry clinic by her friend. The friend reports that the patient has been exhibiting unusual behaviour. This behaviour includes staying up all night, talking rapidly, excessive gambling, and saying she will conquer the stock market and become a billionaire.
The patient has a background of depression for which she takes sertraline.
On examination of her mental state, there is evidence of overly familiar behaviour, pressured speech, and flight of ideas.
What is the most appropriate pharmacological treatment
Management of mania/hypomania in patients taking antidepressants: consider stopping the antidepressant and start antipsychotic therapy e.g. olanzapine
Pseudohallucinations are more common after [] and do not imply psychosis
- Which key distinguishing feature seperates pseudo- with a true hallucination? [1]
Pseudohallucinations are more common after bereavement and do not imply psychosis
- Insight seperates pseudo and true hallucinations.
What is the difference between a conversion disorder and somatisation disorder? [2]
Functional neurological disorder (conversion disorder) - typically involves LOSS of motor or sensory function
Somatisation disorder is the repeated presentation with medically unexplained symptoms, and the WITH distress and anxiety associated with these.
NB:
Conversion disorders - a person CONVERTS an emotionally charged event into a physical symptom
What are the three corse features of PTSD? [3]
What is a pneumonic for the features? [5]
Common features of PTSD
re-experiencing e.g. flashbacks, nightmares
avoidance e.g. avoiding people or situations
- including emotional detachment
hyperarousal e.g.hypervigilance, sleep problems
HEART:
Hyperarousal
Emotional numbing
Avoidance of triggers
Re-experiencing
Time
[2] symptoms and global memory loss point to a diagnosis of depression rather than dementia
Rapid onset, biological symptoms and global memory loss point to a diagnosis of depression rather than dementia
[] is the inability to answer a question without giving excessive, unnecessary detail
Circumstantiality is the inability to answer a question without giving excessive, unnecessary detail
Describe the treatment plan for OCD If it is causing severe functional impairment [3]
refer to the secondary care mental health team for assessment
whilst awaiting assessment - offer:
- combined treatment with an SSRI and CBT (including ERP) or consider clomipramine as an alternative
[] presents after taking antipsychotics for a long period of time
- Describe this [3]
Tardive dyskinesia presents after taking antipsychotics for a long period of time
- lip smacking, difficulty swallowing and excessive blinking
NB: Tardive = late -> symptoms will come on later on
Antidepressants should be continued for at least [] months after remission of symptoms to decrease risk of relapse
Antidepressants should be continued for at least 6 months after remission of symptoms to decrease risk of relapse
When starting an SSRI how long after should you check on a patient if they are under 30? [1]
Why? [1]
Therefore, it is essential to conduct a follow-up within one week of commencing treatment in this age group.
- risk of suicide
Catatonia can be managed using [drug class] and some centres may use [] therapy.
Catatonia can be managed using benzodiazepines and some centres may use electroconvulsive therapy.
What’s a way of remembering when a seizure vs DT will occur after stopping alcohol? [2]
Day one and a bit (36hrs) -> have a fit
DTs-> Deux-Trois, days 2-3 (48-72 hrs)
[] is the most likely SSRI to lead to QT prolongation and Torsades de pointes
Citalopram is the most likely SSRI to lead to QT prolongation and Torsades de pointes
[] is the SSRI of choice post myocardial infarction
Sertraline is the SSRI of choice post myocardial infarction
[] should be used first-line for acute stress disorders
Trauma-focused cognitive-behavioural therapy (CBT) should be used first-line for acute stress disorders
A patient presents with depression. Based off their symptoms you determine them to have severe depression.
What PHQ score would this mean they have above? [1]
What would this mean with regards to their initial treatment plan? [1]
PHQ score of over 15 / 16 indicating ‘more severe’ depression
- NICE most strongly recommend a combination of individual cognitive behavioural therapy and an antidepressant as this has been found to be the most clinical and cost-effective treatment for ‘more severe’ depression
- Sertraline is first line unless under 18, in which it is flouxetine
[] is the strongest risk factor for psychotic disorders
Family history is the strongest risk factor for psychotic disorders
OCD: all patients with [] should be referred to the secondary care mental health team - treatment can be started whilst waiting for assessment
OCD: all patients with severe functional impairment should be referred to the secondary care mental health team - treatment can be started whilst waiting for assessment
What is meant by circumstantiality? [1]
Circumstantiality is the inability to answer a question without giving excessive, unnecessary detail
Tricyclic antidepressants may cause [], particularly in patients with BPH
Tricyclic antidepressants may cause urinary retention, particularly in patients with BPH
What is a key cognitive side effect of lorazepam that need to know? [1]
One of the side effects of this drug is that this can cause anterograde amnesia.
- memory recall and the creation of new memories is significantly impaired
How do you differentiate OCD from pyschosis? [1]
Obsessive-compulsive disorder can be differentiated from psychosis by the level of insight into their actions (OCD has insight)
Venlafaxine and other serotonin noradrenaline reuptake inhibitors (SNRIs) are associated with the development of [cardiac issue].
Venlafaxine and other serotonin noradrenaline reuptake inhibitors (SNRIs) are associated with the development of hypertension.
Some anti-psychotic medications and antidepressants are associated with weight gain, for example, []
Although some anti-psychotic medications and antidepressants are associated with weight gain, for example, mirtazapine
What is a potential risk of fluoxetine when used in the third trimester of pregnancy?
Persistent pulmonary hypertension
Congenital heart defects
Intrauterine growth restriction
Spina bifida
Patent ductus arteriosus
Persistent pulmonary hypertension
What class of drugs does mirtazapine belong to?
Selective serotonin reuptake inhibitors
Serotonin-noradrenaline reuptake inhibitors
Monoamine oxidase inhibitors
Noradrenergic and specific serotonergic antidepressants
Tricyclic antidepressants
Mirtazapine is a noradrenergic and specific serotonergic antidepressant which increases release of neurotramsitters by blocking alpha2 adrenoreceptors
For moderate/severe OCD, [] may be used as an alternative first-line drug treatment to an SSRI if the person prefers [] or has had a previous good response to it, or if an SSRI is contraindicated
For moderate/severe OCD, clomipramine may be used as an alternative first-line drug treatment to an SSRI if the person prefers clomipramine or has had a previous good response to it, or if an SSRI is contraindicated
Describe what is meant by catatonia [1]
Stopping of voluntary movement or staying still in an unusual position = catatonia
You decide together to try venlafaxine as a second-line option.
What should be monitored at initiation and dose titration of this medication?
Blood pressure
- Venlafaxine and other serotonin noradrenaline reuptake inhibitors (SNRIs) are associated with the development of hypertension.
You review a 47-year-old man with a history of moderate to severe depression. He has a past medical history of type 2 diabetes and also pericarditis following a viral illness. He has a family history of hypertension. He has previously tried fluoxetine without a significant improvement in his mood. His wife finds her citalopram prescription very helpful for her generalised anxiety disorder. He now wishes to try citalopram himself.
What should be monitored prior to starting citalopram in this patient?
The BNF states that ‘QT prolongation, and/or ventricular arrhythmias including torsade de pointes have been reported in people taking citalopram or escitalopram.’ The BNF advises taking an ECG and measuring the QT interval in patients with a history of cardiac disease prior to starting citalopram. Given this man’s history of pericarditis, ECG is the correct answer.
Which specific cardiac issues are associated with citalopram? [3]
The BNF states that ‘QT prolongation, and/or ventricular arrhythmias including torsade de pointes have been reported in people taking citalopram or escitalopram.’ The BNF advises taking an ECG and measuring the QT interval in patients with a history of cardiac disease prior to starting citalopram. Given this man’s history of pericarditis, ECG is the correct answer.
A 75-year-old woman presents to the emergency department with new onset confusion. She has a past medical history of depression, for which she takes sertraline, and oesophagitis for which she takes omeprazole. She also has a diagnosis of type 2 diabetes. Her dose of sertraline was last increased two weeks ago. Her physical observations are within normal parameters.
What would you perform first to identify the cause of this patient’s confusion?
Urea and electrolytes
- The BNF advises when starting a serotonin specific reuptake inhibitor (SSRI) to ‘observe all people taking antidepressants for signs of hyponatraemia.
How often should you monitor for hyponatraemia in U&Es? [3]
For people at high risk, measure the serum sodium level before starting treatment, 2-4 weeks after starting treatment and every 3 months thereafter.’
I’‘m walking to the shop hop slop flip-flop’.
What type of thought disorder is this? [1]
Clang associations - ideas related only by rhyme or being similar sounding
Antidepressants should be continued for at least [] after remission of symptoms to decrease risk of relapse
Antidepressants should be continued for at least 6 months after remission of symptoms to decrease risk of relapse
A 45-year-old man presents to the emergency department with agitation, confusion, and tremors. Despite none being present, he is complaining of severe itching due to a termite infestation affecting his skin and is insistent on their presence. The patient admits to chronic excessive alcohol consumption.
How long has it most likely been since the patient’s last drink?
4 hours ago
6 hours ago
12 hours ago
36 hours ago
72 hours ago
delusions 48-72 hours after admission → ?delirium tremens
NB: DT = Day Three and Delirium Tremens OR
DTs-> Deux-Trois, days 2-3 (48-72 hrs)
Day one and a bit (36hrs) -> have a fit
How do you differentiate between schizotypal, schizoid and paranoid personailty disorders? [3]
Schizoid
* social isolation in SzPD tends to be more extreme; patients often lack relationships even with family and may entirely detach from society.
* SzPD is characterised by ‘negative’ symptoms only and is not associated with ‘positive’ symptoms such as overvalued ideas and odd beliefs.
* Patients tend to have obscure interests, particularly in fantasy.
* Indifference to praise and criticism
* Preference for solitary activities
* Lack of interest in sexual interactions
* Lack of desire for companionship
* Emotional coldness
* Few interests
* Few friends or confidants other than family
Schizotypal
* Ideas of reference (differ from delusions in that some insight is retained)
* Odd beliefs and magical thinking
* Unusual perceptual disturbances
* Paranoid ideation and suspiciousness
* Odd, eccentric behaviour
* Lack of close friends other than family members
* Inappropriate affect
* Odd speech without being incoherent
Paranoid
* Hypersensitivity and an unforgiving attitude when insulted
* Unwarranted tendency to questions the loyalty of friends
* Reluctance to confide in others
* Preoccupation with conspirational beliefs and hidden meaning
* Unwarranted tendency to perceive attacks on their character
NB:
schizoid pd = social isolation - odd beliefs
schizoptypical pd = social isolation + odd beliefs
A 23-year-old man undergoes electroconvulsive therapy (ECT) for treatment-resistant depression.
Which of the following side effects is he most likely to experience?
Constipation
Retrograde amnesia
Anterograde amnesia
Galactorrhea
Hypothermia
Retrograde amnesia
- Retrograde amnesia (remembering events prior to the insult) is far more common that anterograde amnesia (loss of ability to form new memories after the insult)
elecTROconvulsive therapy
reTROgrade amnesia
OR
RECTum
Retrograde amnesia due to ECT
What is torticollis? [1]
What may cause it? [1]
or ‘wry’ neck can be diagnosed where there is unilateral pain and deviation of the neck with pain on palpation and restricted range of motion.
- commencing a typical antipsychotic - haloperidol.
Duloxetine mechanism of action = ?
Duloxetine mechanism of action = serotonin and noradrenaline reuptake inhibitor
Dulo = duel = serotonin and noradrenaline reuptake inhibitor
How would you differentiate between pseudodementia (from depression) and dementia? [1]
Describe a classic presentation [1]
Pseudodementia:
* key feature present is a global memory loss affecting both short and longer-term memory
- its short-term however it affects both short and long-term memory
E.g
increasing forgetfulness. Her daughter is worried that over the last four weeks her mother has been forgetting her grandchildren’s names and stories from her upbringing
What is the mechanism of action of temazepam?
Inhibits the effect of acetylcholine
Enhances the effect of gamma-aminobutyric acid
Inhibits the effect gamma-aminobutyric acid
Inhibits the effect of glutamate
Inhibits the effect of noradrenaline
Enhances the effect of gamma-aminobutyric acid
When is electroconvulsive therapy (ECT) indicated? [3]
catatonia
a prolonged or severe manic episode
severe depression that is life-threatening
What would indicate someone is suffering from SSRI discontinuation syndrome? [3]
- How would you differentiate this from NMS? [2]
may present with dizziness / imbalance, electric shock sensations / paraesthesia, and anxiety
- NMS: is a rare reaction that can occur with antipsychotic use. It may present with fever, confusion and muscle rigidity.
Mneumonic for SSRI discontin. syndrome? [6]
Sx of SSRI discontinuation syndrome - FINISH:
Flu-like sx (headache, myalgia, lethargy)
Imbalance (vertigo, lightheadedness)
Nausea (vomiting, diarrhoea)
Insomnia
Sensory disturbances (electric shocks, paraesthesia, numbness)
Hyperarousal (agitation, tremor).
Describe how people with OC personality disorders present with regards to views of others [2]
Patients with obsessive-compulsive personality can be rigid with respect to morals, ethics and values and often are reluctant to surrender work to others
How do you differentiate between someone with illness anxiety disorder and somatisation disorder [1]
Unexplained symptoms
Somatisation = Symptoms
hypoChondria = Cancer
People w somatisation focus on the symptoms, whereas hypochondria focus on the diagnosis.
Give classic presentation of schizoid vs schizoidal personality disorder? [2]
Schizoid personality disorder is the most likely diagnosis in this case based on his general lack of interest in social relationships. Individuals usually live a solitary lifestyle and show a lack of emotion towards others or apathy. In this case, the patient seems unbothered by his solitary lifestyle, making schizoid personality disorder the most likely option
- Schizoid = android = like a robot.
Schizotypal personality disorder presents more typically with positive psychotic symptoms such as thought disorder, hallucinations and unconventional ‘magical’ beliefs. Individuals may have transient psychosis and show paranoia towards others. also odd beliefs and magical thinking
What type of urinary incontinence is the most associated with amitriptyline? [1]
Amitriptyline belongs to the drug class of tricyclic antidepressants (TCAs). TCAs have anticholinergic effects which may lead to urinary retention, leading to frequent leaking.
An effective treatment for borderline personality disorder is []
- Describe this treatment [1]
An effective treatment for borderline personality disorder is dialectical behaviour therapy (DBT)
- a targeted therapy that is based CBT, but has been adapted to help people who experience emotions very intensely.
Which of the following features is needed to make a diagnosis of a personality disorder?
The presence of psychotic symptoms
The presence of a concurrent physical health condition
A history of substance abuse
Over 18 years of age
A family history of mental health disorders
Over 18 years of age
When stopping a SSRI the dose should be gradually reduced over a [] week period
When stopping a SSRI the dose should be gradually reduced over a 4 week period
NSAID x which antidepressant = increased risk of GI bleed? [1]
SSRI + NSAID = GI bleeding risk - give a PPI
An elderly patient in a nursing home is started on quetiapine due to persistent aggressive behaviour that has not responded to non-pharmacological approaches. Which of the following adverse effects do antipsychotics increase the risk of in elderly patients?
Atrial fibrillation
Myocardial infarction
Aspiration pneumonia
Stroke
Breast cancer
Stroke
DT x seizures = how many hours ago stopped drinkin? [1]
seizures: 36 hours
delirium tremens: 72 hours
A 35-year-old man with no known psychiatric history is admitted to the psychiatry ward, after presenting to the emergency department with delusions and homicidal ideations.
Following a negative drugs screen, antipsychotic treatment is initiated with haloperidol.
The patient is reviewed 3-hours after the initiation of treatment and is noted to have a sustained upward deviation of both eyes. When asked, he reports that his eyes are extremely painful.
Based on the likely diagnosis, what initial management option is most appropriate? [1]
Acute dystonia secondary to antipsychotics is usually managed with procyclidine
NB: The scenario described refers to an oculogyric crisis, an acute dystonic reaction that can occur as part of the spectrum of extrapyramidal side-effects (EPSEs) of antipsychotics.
[] has the most tolerable side effect profile of the atypical antispsychotics, particularly for prolactin elevation
Aripiprazole has the most tolerable side effect profile of the atypical antispsychotics, particularly for prolactin elevation
Aripriprazole is Aripropriate (appropriate) - appropriate drug to give due to low side effect profile :)
What’s a way of remembering the physiological changes seen in anorexia nervosa? [2]
Anorexia features
most things low
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
Patients with poor oral compliance to antipsychotics should be considered for [1]
Patients with poor oral compliance to antipsychotics should be considered for once monthly IM antipsychotic depot injections
How would you differentiate betwen hypomania and mania with regards to lenght of symptoms and presenting symptoms ? [2] in SBAs
mania = psychosis
hypomania = no psychosis
hypomania < 7 days
mania >/= 7 days
What is the most appropriate action to take with regards to this medication prior to ECT treatment for this patient?
Increase the sertraline daily dose
Reduce the sertraline daily dose
Stop the sertraline completely
Switch sertraline to citalopram
Switch sertraline to lithium
Antidepressant medication should be reduced but not stopped when a patient is about to commence ECT treatment
What is Cotard syndrome ? [1]
Which pathology is it associated with? [1]
Cotard syndrome is associated with severe depression
- This patient is presenting with Cotard’s syndrome, a rare subtype of nihilistic delusions, in which they believe they or part of them is dead or does not exist
A 36-year-old with a long standing history of schizophrenia presents to the emergency department in status epilepticus. Once he is treated, he tells the doctor he has been having a lot of seizures recently.
Which of the following medications is most likely to be causing the seizures?
Clozapine
Diazepam
Fluoxetine
Haloperidol
Olanzapine
Clozapine reduces seizure threshold, making seizures more likely
A young male with schizophrenia says during the ward round that MI5 is recording his thoughts and watching him around the clock. He says that he often has ideas about internet security but forgets them quickly after they have formed, as MI5 is taking them away from him.
What type of thought disorder is exhibited?
Thought withdrawal is characterised by the belief that one’s thoughts are being taken away, leading to disruptions in the thought process.
A patient has ?NMS.
What investigations would support this dx? [4]
Clinical signs and symptoms include fever, muscle rigidity, confusion, rhabdomyolysis (hence the raised creatine kinase and subsequent electrolyte derangements such as hyperkalaemia and hypocalcaemia), metabolic acidosis, autonomic lability, and a raised white cell count.
Describe how you would manage someone who takes clozapine but has missed their last two doses? [1]
- Why? [1]
If doses are missed for more than 2 consecutive days (48 hours), you will need to restart their clozapine slowly (like when they first started on it)
- This is because when you start Clozapine after a break of >48 hours, it can** make side effects worse, such as blood pressure changes, drowsiness and dizziness.**
- If there is a gap in treatment of 3 days (72 hours) then you may also require more frequent blood tests for a short period.
Tardive dyskinesia and acute dystonia are both complications of anti-pyschotic use.
- When do they occur (with regards to length of tx for pyschosis)? [2]
- What can you give to treat each? [2]
TArdive dyskinesia - have been TAking antipsychotics for several years -> give Tetrabenezine
acute dySTonia – common when STarting antipsychotics -> give procyclidine
What is there an increased risk of in the first trimester with sertraline?
Congenital heart defects
Ebstein’s anomaly
Spina bifida
Cleft lip and palate
Diaphragmatic hernia
What is the risk if used in the third trimester? [1]
What is there an increased risk of in the first trimester with sertraline?
Congenital heart defects
Use during the third trimester can result in persistent pulmonary hypertension of the newborn
