Session 11 - Group Work

Question 1

5) Sally, a 32 year old lady has attended A&E (reluctantly) at the request of her husband. Sally works as a lawyer but concerns have been raised by her colleagues that she is becoming increasingly preoccupied with wanting to seek legal action for her own personal matters. She informs the staff in A&E that she has been mounting a case against Adele (the singer) and JK Rowling, as she believes that they have both taken credit for her work (writing music and Harry Potter), she has already written to their agents informing them of her plan to take them to court. She also shows staff various new songs she has written, which she is convinced is going to make her millions. Her husband reports that for the last 10 days she has been sleeping less (around 3 hours a night) and is more irritable than normal.
a) What disorder do you think Sally may be suffering from?

Answer 1

• Mania (first time presentation) with psychotic symptoms

(Differentials

• Schizophrenia
• Bipolar disorder)

Question 2

5) Sally, a 32 year old lady has attended A&E (reluctantly) at the request of her husband. Sally works as a lawyer but concerns have been raised by her colleagues that she is becoming increasingly preoccupied with wanting to seek legal action for her own personal matters. She informs the staff in A&E that she has been mounting a case against Adele (the singer) and JK Rowling, as she believes that they have both taken credit for her work (writing music and Harry Potter), she has already written to their agents informing them of her plan to take them to court. She also shows staff various new songs she has written, which she is convinced is going to make her millions. Her husband reports that for the last 10 days she has been sleeping less (around 3 hours a night) and is more irritable than normal.
b) Which symptoms have you identified from the description that are in keeping with this?

Answer 2

• Grandiose delusions
• Full of energy/restlessness (also doesn’t feel the need to sleep)
• Attention cannot be sustained

Question 3

5) Sally, a 32 year old lady has attended A&E (reluctantly) at the request of her husband. Sally works as a lawyer but concerns have been raised by her colleagues that she is becoming increasingly preoccupied with wanting to seek legal action for her own personal matters. She informs the staff in A&E that she has been mounting a case against Adele (the singer) and JK Rowling, as she believes that they have both taken credit for her work (writing music and Harry Potter), she has already written to their agents informing them of her plan to take them to court. She also shows staff various new songs she has written, which she is convinced is going to make her millions. Her husband reports that for the last 10 days she has been sleeping less (around 3 hours a night) and is more irritable than normal.
c) About what other symptoms would you want to enquire about to confirm the diagnosis?

Answer 3

• Elevated mood
• Increased energy
• Auditory hallucinations
• Have you had any low/depressed periods?
• Any previous episodes?
• How long have you been feeling like this?
• Family history
• Any children/recent childbirth?

(Depression - low mood, low energy, low interest (anhedonia)

Mania - elevated mood, elevated energy, increased activity. Includes disinhibition such as flirting, driving recklessly)

Question 4

5) Sally, a 32 year old lady has attended A&E (reluctantly) at the request of her husband. Sally works as a lawyer but concerns have been raised by her colleagues that she is becoming increasingly preoccupied with wanting to seek legal action for her own personal matters. She informs the staff in A&E that she has been mounting a case against Adele (the singer) and JK Rowling, as she believes that they have both taken credit for her work (writing music and Harry Potter), she has already written to their agents informing them of her plan to take them to court. She also shows staff various new songs she has written, which she is convinced is going to make her millions. Her husband reports that for the last 10 days she has been sleeping less (around 3 hours a night) and is more irritable than normal.
d) Which pharmacological treatments does NICE recommend for this illness?

Answer 4

First line: Haloperidol - central D2 receptor antagonist
- stop any antidepressants

Lithium - but this is nephrotoxic (monitor eGFR) and can damage the thyroid. Also affects your heart so monitor ECG.

Question 5

5) Sally, a 32 year old lady has attended A&E (reluctantly) at the request of her husband. Sally works as a lawyer but concerns have been raised by her colleagues that she is becoming increasingly preoccupied with wanting to seek legal action for her own personal matters. She informs the staff in A&E that she has been mounting a case against Adele (the singer) and JK Rowling, as she believes that they have both taken credit for her work (writing music and Harry Potter), she has already written to their agents informing them of her plan to take them to court. She also shows staff various new songs she has written, which she is convinced is going to make her millions. Her husband reports that for the last 10 days she has been sleeping less (around 3 hours a night) and is more irritable than normal.
e) Sally has previously been treated for 2 episodes of moderate depression (both treated with SSRIs). Does this change your working diagnosis?

Answer 5

Bipolar 1

Question 6

5) Sally, a 32 year old lady has attended A&E (reluctantly) at the request of her husband. Sally works as a lawyer but concerns have been raised by her colleagues that she is becoming increasingly preoccupied with wanting to seek legal action for her own personal matters. She informs the staff in A&E that she has been mounting a case against Adele (the singer) and JK Rowling, as she believes that they have both taken credit for her work (writing music and Harry Potter), she has already written to their agents informing them of her plan to take them to court. She also shows staff various new songs she has written, which she is convinced is going to make her millions. Her husband reports that for the last 10 days she has been sleeping less (around 3 hours a night) and is more irritable than normal.
f) In view of the diagnosis, a mood stabiliser is necessary for her longer term management. Which pharmacological treatments does NICE recommend for this?

Answer 6

Lithium

If not working Sodium Valproate on top of the lithium

But these are teratogenic

Question 7

5) Sally, a 32 year old lady has attended A&E (reluctantly) at the request of her husband. Sally works as a lawyer but concerns have been raised by her colleagues that she is becoming increasingly preoccupied with wanting to seek legal action for her own personal matters. She informs the staff in A&E that she has been mounting a case against Adele (the singer) and JK Rowling, as she believes that they have both taken credit for her work (writing music and Harry Potter), she has already written to their agents informing them of her plan to take them to court. She also shows staff various new songs she has written, which she is convinced is going to make her millions. Her husband reports that for the last 10 days she has been sleeping less (around 3 hours a night) and is more irritable than normal.
g) Are there any mood stabiliser that would be advised against for Sally? If so, why?

Answer 7

You shouldn’t give Sodium Valporate to any women of child-bearing age unless as a last resort, but complications MUST be explained.

Increases risk by 20 of getting a neural tube defect.

Question 8

5) Sally, a 32 year old lady has attended A&E (reluctantly) at the request of her husband. Sally works as a lawyer but concerns have been raised by her colleagues that she is becoming increasingly preoccupied with wanting to seek legal action for her own personal matters. She informs the staff in A&E that she has been mounting a case against Adele (the singer) and JK Rowling, as she believes that they have both taken credit for her work (writing music and Harry Potter), she has already written to their agents informing them of her plan to take them to court. She also shows staff various new songs she has written, which she is convinced is going to make her millions. Her husband reports that for the last 10 days she has been sleeping less (around 3 hours a night) and is more irritable than normal.
h) What measure has the MHRA put in place in regard to this mood stabiliser – please describe it

Answer 8

SV shouldn’t be given to any woman of child-bearing age.

Pregnancy Prevention Programme

• assessment for potential pregnancies
• pregnancy test before and during treatment
• counselling
• reviewed at least annually

Question 9

5) Sally, a 32 year old lady has attended A&E (reluctantly) at the request of her husband. Sally works as a lawyer but concerns have been raised by her colleagues that she is becoming increasingly preoccupied with wanting to seek legal action for her own personal matters. She informs the staff in A&E that she has been mounting a case against Adele (the singer) and JK Rowling, as she believes that they have both taken credit for her work (writing music and Harry Potter), she has already written to their agents informing them of her plan to take them to court. She also shows staff various new songs she has written, which she is convinced is going to make her millions. Her husband reports that for the last 10 days she has been sleeping less (around 3 hours a night) and is more irritable than normal.
i) Please now watch the video shown by your facilitator. This is of a different patient, but please identify signs (as part of a mental state examination) that may be in keeping with thought disorder

Answer 9

[Psychiatric Interviews for Teaching: Mania UoN - YouTube video]

Question 10

5) Sally, a 32 year old lady has attended A&E (reluctantly) at the request of her husband. Sally works as a lawyer but concerns have been raised by her colleagues that she is becoming increasingly preoccupied with wanting to seek legal action for her own personal matters. She informs the staff in A&E that she has been mounting a case against Adele (the singer) and JK Rowling, as she believes that they have both taken credit for her work (writing music and Harry Potter), she has already written to their agents informing them of her plan to take them to court. She also shows staff various new songs she has written, which she is convinced is going to make her millions. Her husband reports that for the last 10 days she has been sleeping less (around 3 hours a night) and is more irritable than normal.
j) Refer to the abstracts for the articles by Clark and Sahakian (2008) and Phillips and Swartz (2014). Which areas of the brain have been implicated in imaging (structural and functional) studies of bipolar disorder/mania?

Answer 10

Prefrontal cortex (interaction with subcortical regions including striatum and thalamus) and temporal lobe structures (amygdala, hippocampus)

Question 11

5) Sally, a 32 year old lady has attended A&E (reluctantly) at the request of her husband. Sally works as a lawyer but concerns have been raised by her colleagues that she is becoming increasingly preoccupied with wanting to seek legal action for her own personal matters. She informs the staff in A&E that she has been mounting a case against Adele (the singer) and JK Rowling, as she believes that they have both taken credit for her work (writing music and Harry Potter), she has already written to their agents informing them of her plan to take them to court. She also shows staff various new songs she has written, which she is convinced is going to make her millions. Her husband reports that for the last 10 days she has been sleeping less (around 3 hours a night) and is more irritable than normal.
k) List 5 functions of the prefrontal cortex

Answer 11

• Moderating social behaviour
• Complex cognitive behaviour
• Personality expression
• Decision making
• Moral judgement

Also
- taste, smell, Broca’s area (language) and short-term memory

Question 12

5) Sally, a 32 year old lady has attended A&E (reluctantly) at the request of her husband. Sally works as a lawyer but concerns have been raised by her colleagues that she is becoming increasingly preoccupied with wanting to seek legal action for her own personal matters. She informs the staff in A&E that she has been mounting a case against Adele (the singer) and JK Rowling, as she believes that they have both taken credit for her work (writing music and Harry Potter), she has already written to their agents informing them of her plan to take them to court. She also shows staff various new songs she has written, which she is convinced is going to make her millions. Her husband reports that for the last 10 days she has been sleeping less (around 3 hours a night) and is more irritable than normal.
l) What neurochemical changes are thought to occur in mania?

Answer 12

Too much dopamine in the brain - overdrive of the substantia nigra pars compacta leading to manic behaviours

In mania, there are also abnormalities of thyroid function which include subclinical hypothyroidism and reduced pituitary responsiveness to thyrotropin-releasing hormone. Thyroid dysfunction has frequently been implicated in rapid cycling bipolar disorder, and is one of the most consistent findings within this subpopulation of those with bipolar illness. Thyroid supplementation may also be of some benefit in the treatment of rapid cycling.

Question 13

1) Josie is a twenty five year old lady who suffers from generalised anxiety disorder and is seeing you as the FY2 in the Psychiatry Outpatients clinic.
a) Name two physical symptoms of anxiety that Josie might experience

Answer 13

• Palpitations
• Sweating
• Trembling
• Shaking
• Chest pain
• Breathlessness
• Nausea
• Feeling dizzy
• Faint
• Light-headedness

Question 14

1) Josie is a twenty five year old lady who suffers from generalised anxiety disorder and is seeing you as the FY2 in the Psychiatry Outpatients clinic.
b) Explain the (patho)physiology behind these symptoms, considering the structure and function of the autonomic nervous system

Answer 14

Stress will activate her sympathetic nervous symptoms, releasing noradrenaline/adrenaline, therefore this will explain her physical symptoms

e. g. - adrenal medullary secretions will increase
- frequency of urination due to relaxation of detrusor muscle
- palpitations explained by heart muscle increasing contractions

Question 15

1) Josie is a twenty five year old lady who suffers from generalised anxiety disorder and is seeing you as the FY2 in the Psychiatry Outpatients clinic.
c) What other nervous system structures are involved in the stress response and what is their role?

Answer 15

Limbic system - amygdala excites the stress response but

• hippocampus inhibits the stress responses.
• Hypothalamus releasing CRH onto the anterior pituitary to release ATCH which then goes to the adrenal gland, causing the release of cortisol.

Question 16

1) Josie is a twenty five year old lady who suffers from generalised anxiety disorder and is seeing you as the FY2 in the Psychiatry Outpatients clinic.
d) Josie is given a benzodiazepine by her GP to help with her anxiety. By what mechanism of action will this drug reduce her anxiety symptoms?

Answer 16

GABA is the main inhibitory NT, GABA levels increased in cortex of pts with anxiety.

BZD, increase GABA, therefore reduces inhibition.

GABA binds to the receptor GABA-A receptor, which opens chloride channels, hyperpolarising the cell, which will reduce the neuronal excitability. So binding GABA is enhanced by BZD bc it changes the conformation of the receptor, so the GABA-R has a higher affinity for GABA, so BZD helps hyperpolarisation. GABA is involved in calming things down.

Question 17

1) Josie is a twenty five year old lady who suffers from generalised anxiety disorder and is seeing you as the FY2 in the Psychiatry Outpatients clinic.
e) Why are benzodiazepines generally not recommended for use in patients with anxiety disorders?

Answer 17

• Can increase chance of dependency
• Can cause respiratory depression if OD
• Can be a street drug (sold on the streets) e.g. diazepam

Question 18

2) Ian is a thirty year old man who has upsetting thoughts that he may have run someone over whilst out driving in his car. Because of this, he spends several hours a day retracing his route to work, checking that no one has been hurt. This often makes him late for work, and he is becoming frustrated that he is ‘wasting so much time’. He has presented to you, his GP, for help.
a) Identify the obsessions and compulsions in Ian’s case

Answer 18

Obsessions (unpleasant, unwanted, persistent thoughts when trying to resist, and they are your own) - he thinks he has run someone over.

Compulsions (action done in belief it will alleviate the obsession) - retrace his route to work every day

Question 19

2) Ian is a thirty year old man who has upsetting thoughts that he may have run someone over whilst out driving in his car. Because of this, he spends several hours a day retracing his route to work, checking that no one has been hurt. This often makes him late for work, and he is becoming frustrated that he is ‘wasting so much time’. He has presented to you, his GP, for help.
b) What are the ICD-10 diagnostic criteria for obsessive compulsive disorder? Does he meet these criteria?

Answer 19

• Must be present in the mind of the patient
• Must be unpleasant and repetitive
• Must be unreasonable and excessive, and acknowledged
• Must have tried resisting it, but failed

To qualify for a disorder, it must affect their lives in some way. He meets this criteria because it is making him late for work.

OCD can contain just obsessions, just compulsions, or both.

Question 20

2) Ian is a thirty year old man who has upsetting thoughts that he may have run someone over whilst out driving in his car. Because of this, he spends several hours a day retracing his route to work, checking that no one has been hurt. This often makes him late for work, and he is becoming frustrated that he is ‘wasting so much time’. He has presented to you, his GP, for help.
c) Considering the ‘OCD re-entry circuit theory’ involving the basal ganglia, can you explain Ian’s behavioural response to his upsetting thoughts?

Answer 20

Re-entry circuit - excites the direct pathway so there is overactivity - so even when you’ve done an action and you don’t need to do it anymore (normal), there’s re-entry circuit which tells you you haven’t done something enough so you have to do it again.

Question 21

2) Ian is a thirty year old man who has upsetting thoughts that he may have run someone over whilst out driving in his car. Because of this, he spends several hours a day retracing his route to work, checking that no one has been hurt. This often makes him late for work, and he is becoming frustrated that he is ‘wasting so much time’. He has presented to you, his GP, for help.
d) What results have been found by studies looking at brain imaging in patients with OCD? Take a look at Pubmed

Answer 21

Adults with OCD have

• smaller hippocampus
• larger globus pallidus volumes

Paeds - change in hypothalamus size??

• Reduced serotonin
• Reduced activity in dorsolateral prefrontal cortex
• Reduced activity in orbitofrontal cortex
• Increased activity in cingulate cortex

Question 22

2) Ian is a thirty year old man who has upsetting thoughts that he may have run someone over whilst out driving in his car. Because of this, he spends several hours a day retracing his route to work, checking that no one has been hurt. This often makes him late for work, and he is becoming frustrated that he is ‘wasting so much time’. He has presented to you, his GP, for help.
e) How might Ian’s OCD be managed using the bio-psychosocial approach?

Answer 22

• Higher dose of SSRI
• Antipsychotics
• Brain stimulation
• Augmentation (augment effect of antidepressant/antipsychotic)
• CBT: feelings, behaviour and thoughts and they all affect you e.g. if you’re feeling ashamed or sad you tend to think more negatively about yourself/other people which might make you behave in a different way e.g. people don’t like me so I’m gonna stay indoors, so it’s a circle of behaviour, thoughts and feelings which affect each other - CBT aims to break through this cycle, making you think in a different way and then behave in a different way
• Support groups
• Charities
• Help from families

Question 23

2) Ian is a thirty year old man who has upsetting thoughts that he may have run someone over whilst out driving in his car. Because of this, he spends several hours a day retracing his route to work, checking that no one has been hurt. This often makes him late for work, and he is becoming frustrated that he is ‘wasting so much time’. He has presented to you, his GP, for help.
f) Are there any infections associated with the emergence of OCD-like symptoms? What is the pathophysiology behind this association?

Answer 23

PANDAS

Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections.

You have autoimmune antibodies which cross-react with neurones inside basal ganglia and that causes illness.

• Extremely rare, seen in children, might have a throat infection caused by Strep, can get PANDAS. So rare that some articles say it’s a theory rather than evidence.

Question 24

3) Jim is a twenty three year old man who you are seeing as an FY1 in Accident and Emergency. Jim tells you that he believes his neighbours are monitoring him. He has come to this conclusion as he feels that they are able to access his thoughts from inside his head and play them to others using a radio device. He also hears them commenting on what he is doing, for example ‘Jim is brushing his teeth’. Jim is seen by the Mental Health team and a diagnosis of paranoid schizophrenia is made.
a) What symptoms support this diagnosis?

Answer 24

His ideas thought-broadcasting and auditory hallucinations of ‘running commentary’ - one of the classical symptoms of schizophrenia.

Delusion of control - believing someone is making you do things.

These are +ve symptoms of schizophrenia, there are also -ve symptoms such as withdrawal, apathy (they manifest clinically a bit like depression)

Question 25

3) Jim is a twenty three year old man who you are seeing as an FY1 in Accident and Emergency. Jim tells you that he believes his neighbours are monitoring him. He has come to this conclusion as he feels that they are able to access his thoughts from inside his head and play them to others using a radio device. He also hears them commenting on what he is doing, for example ‘Jim is brushing his teeth’. Jim is seen by the Mental Health team and a diagnosis of paranoid schizophrenia is made.
b) Which two pathways are affected in this condition?

Answer 25

Mesolimbic and mesocortical pathways

Mesolimbic becomes overactive - memory, emotion, arousal, excitation, motivation, pleasure, reward

Mesocortical becomes underactive - modulation of behaviour, emotional response

Question 26

3) Jim is a twenty three year old man who you are seeing as an FY1 in Accident and Emergency. Jim tells you that he believes his neighbours are monitoring him. He has come to this conclusion as he feels that they are able to access his thoughts from inside his head and play them to others using a radio device. He also hears them commenting on what he is doing, for example ‘Jim is brushing his teeth’. Jim is seen by the Mental Health team and a diagnosis of paranoid schizophrenia is made.
c) Which receptors are important in this condition and what is their role in the production of symptoms?

Answer 26

Dopamine receptors (D2 receptors)

No one really knows the role

• All you need to know is dopamine is involved in schizophrenia but no one really knows the role.

Question 27

3) Jim is a twenty three year old man who you are seeing as an FY1 in Accident and Emergency. Jim tells you that he believes his neighbours are monitoring him. He has come to this conclusion as he feels that they are able to access his thoughts from inside his head and play them to others using a radio device. He also hears them commenting on what he is doing, for example ‘Jim is brushing his teeth’. Jim is seen by the Mental Health team and a diagnosis of paranoid schizophrenia is made.

Jim is admitted to the ward, and as he is not compliant with oral medication, he is given an injection of a typical antipsychotic. He starts to experience some unpleasant involuntary movements.

d) Why may Jim have developed these movements?

Answer 27

Most antipsychotics lower dopamine levels so there is less inhibition.

Acute dystonia

Typical anti-psychotics are the older drugs and they do not have specificity and they can cause these movements which is quite common. Recently, newer drugs were made called atypical antipsychotics which don’t give the side effects as much but then have other issues?

Question 28

3) Jim is a twenty three year old man who you are seeing as an FY1 in Accident and Emergency. Jim tells you that he believes his neighbours are monitoring him. He has come to this conclusion as he feels that they are able to access his thoughts from inside his head and play them to others using a radio device. He also hears them commenting on what he is doing, for example ‘Jim is brushing his teeth’. Jim is seen by the Mental Health team and a diagnosis of paranoid schizophrenia is made.

Jim is admitted to the ward, and as he is not compliant with oral medication, he is given an injection of a typical antipsychotic. He starts to experience some unpleasant involuntary movements.

Jim’s medication is changed to an atypical antipsychotic called risperidone. A few months later he is seen in outpatients and complains of sexual problems.

e) Why might Jim be suffering from these problems?

Answer 28

This is a common side effect of the drug, due to interaction with one of the dopamine pathways.

Prolactin and dopamine are linked, dopamine inhibition causing release of prolactin - high prolactin leads to ED in some pts. Galactorrhoea is a side effect of hyperprolactinoaemia.

Question 29

3) Jim is a twenty three year old man who you are seeing as an FY1 in Accident and Emergency. Jim tells you that he believes his neighbours are monitoring him. He has come to this conclusion as he feels that they are able to access his thoughts from inside his head and play them to others using a radio device. He also hears them commenting on what he is doing, for example ‘Jim is brushing his teeth’. Jim is seen by the Mental Health team and a diagnosis of paranoid schizophrenia is made.

Jim is admitted to the ward, and as he is not compliant with oral medication, he is given an injection of a typical antipsychotic. He starts to experience some unpleasant involuntary movements.

Jim’s medication is changed to an atypical antipsychotic called risperidone. A few months later he is seen in outpatients and complains of sexual problems.

Jim asks you whether he might pass his illness onto his children.

f) How would you answer this question?

Answer 29

48% if both parents have it

13% if one parent has it

1% in your family if neither parent has it

Question 30

4) Tara, a forty year old lady, comes to see you, her GP. She complains of low mood and tiredness. She has no significant past medical history.
a) Are there any physical investigations you might wish to carry out in Tara’s case?

Answer 30

x

Question 31

4) Tara, a forty year old lady, comes to see you, her GP. She complains of low mood and tiredness. She has no significant past medical history.
b) What other symptoms would you need to inquire about to make a diagnosis of depressive disorder?

Answer 31

x

Question 32

4) Tara, a forty year old lady, comes to see you, her GP. She complains of low mood and tiredness. She has no significant past medical history.

You feel that Tara would benefit from a selective serotonin reuptake inhibitor (SSRI).

c) What evidence is there for the serotonin hypothesis of
depression?

Answer 32

x

Question 33

4) Tara, a forty year old lady, comes to see you, her GP. She complains of low mood and tiredness. She has no significant past medical history.

You feel that Tara would benefit from a selective serotonin reuptake inhibitor (SSRI).

d) What side effects might Tara experience as a result of taking an SSRI? Can you explain these side effects considering the mechanism of action of SSRIs?

Answer 33

x

Question 34

4) Tara, a forty year old lady, comes to see you, her GP. She complains of low mood and tiredness. She has no significant past medical history.

You feel that Tara would benefit from a selective serotonin reuptake inhibitor (SSRI).

After discussion with Tara she decides she does not want to take any medication for her depression.

e) How might you proceed with her care from here?

Answer 34

x