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1
Q

Aim of Primary Prevention?

A

Reduce incidence of disease by preventing development of new cases

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2
Q

Aim of secondary prevention

A

Reduce total number of existing cases by more rapid effective interventions that shortens duration of illness

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3
Q

Aim of tertiary intervention

A

For individuals to reach their highest level of functioning

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4
Q

Types of prevention under IOM

A

Universal Preventive Intervention
Selective Preventive Intervention
Indicated Preventive Intervention

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5
Q

Who does a selective preventive intervention target?

A

Members of population with higher than average risk factors.

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6
Q

Who does indicated preventive intervention target?

A

Members of population with subsyndromal symptoms of a disorder, or diagnosed with another associated disorder.

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7
Q

Who described the prevention paradox?

A

Geoffrey Rose, 1981

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8
Q

Who conducted the first ECT and when?

A

Lucio Cereletti
Ugo Bini
1938

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9
Q

Indications for ECT

A 
Depressive illness
Mania
Schizophrenia
Catatonia
Parkinsons
Neuroleptic Malignant Syndrome
Intractable seizure disorders (raises seizure threshold)
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10
Q

When is ECT first line treatment for depressive illness?

A

Emergency treatment where rapid response is needed

Treatment resistant depression where a person has responded to ECT previously

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11
Q

Absolute CI of ECT?

A

None

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12
Q

Relative CI of ECT?

A 
Acute respiratory infection
MI in past 3 months
Uncontrolled cardiac failure
Cardiac arrhythmias
CVE in past month
Raised ICP
Untreated cerebral aneurysm
Untreated Pheochromocytoma
Unstable major fracture
DVT - until anticoagulation (to reduce risk of PE)
Acute/impending retinal detachment
High anaesthetic risk
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13
Q

Relapse rate of ECT

A

51% in 12 months

37% in 6 months

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14
Q

Which drugs raise seizure threshold?

A

Benzodiazepines
Barbituates
Anticonvulsants

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15
Q

Which drugs lower seizure thresholds?

A

Antipsychotics
Antidepressants
Lithium

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16
Q

Which drugs need to be stopped 24 hours pre-ECT?

A

Clozapine

Moclobemide

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17
Q

Difficulties with Lithium and ECT?

A

Best avoided as may increase cognitive side effects and increase likelihood of neurotoxic effects of Lithium.

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18
Q

Who developed TMS for brain stimulation?

A

Anthony Barker, 1985

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19
Q

Results for rTMS in depression

A

40% response rate that is sustained for 6 months

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20
Q

Who carried out the first pre-frontal leucotomy and when?

A

Moniz and Lima

1995

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21
Q

What key functions did Moss identify for multidisciplinary teams?

A

Continuing proactive care of those with long-term serious MH problems
Uninterrupted access to information and support, intervention and treatment before and during crises
An organised response to requests for help from primary care

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22
Q

What is Assertive Community Treatment (ACT) based on?

A

Stein & Test (1980) evaluated training in community living. Main issue was transfer of learning in social skills training in real life when patients move from inpatient units to community.

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23
Q

What did the UK 700 study report?

A

Caseload is the most important predictor of outcome of an ACT service.

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24
Q

What led to the introduction of the CPA?

A

Case of Sharon Campbell who killed her SW (DSHH, 1991)

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25
Q

What types of CPA are there?

A

Enhanced

Standard

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26
Q

Who are enhanced CPA for?

A

Those whose care needs are best served by regular MDT meetings

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27
Q

Who developed the filter model?

A

Goldberg

Huxley

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28
Q

What are the five levels of mental illness occurrence?

A 
Community
Primary Care Attendees
Diagnosed primary care attendees
Level of Psychiatrist
Level of psychiatric inpatient care
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29
Q

What is used for the criteria of early intervention?

A

PACE-UHR (Personal assistance and Crisis Evaluation service)

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30
Q

What are the PACE-UHR criteria?

A

Uses ‘close in’ strategy
Specificity>sensitivity
Ages 14-30
Considers experiencing attenuated positive symptoms or episodes of frank psychosis (BLIPS - brief limited intermittent psychotic sx)
Having schizotypal personality or FHx of schizophrenia

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31
Q

What is used to assess prediction of sx from basic to schizophrenia?

A

Bonn Scale for Assessment of Basic Symptoms

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32
Q

How good is Bonn Scale for Assessment of Basic Symptoms?

A

Predicts conversion from basic symptom to schizophrenia in 78% of individuals

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33
Q

Which studies show that the initial gain from early intervention may not be sustained if it is discontinued after 2 years?

A

PEPP (London, Ontario)

TIPS (Norway)

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34
Q

What did the SOCRATES study show?

A

Compared CBT with supportive counselling for first or second-episode schizophrenia.
At 18 month follow-up, addition of both CBT + counselling showed significant improvement.

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35
Q

What did the PRIME study show?

A

Olanzapine at low dose prevents progression of psychosis.

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36
Q

What did EPPIC study from Melbourne (McGorry et al) show?

A

Combination of CBT and Risperidone reduced conversion rate at 6 months.

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37
Q

What did the Lambeth Early Onset (LEO) study show?

A

Compared specialised care (low dose antipsychotic, CBT, family counselling) based on assertive outreach with standard care and found relapse rates were lower with the former.

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38
Q

Who recognised ‘Duration of Untreated psychosis’ (DUP) as a prognostic marker?

A

Wyatt

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39
Q

What was the first study that challenged the pessimism about schizophrenia recovery?

A

Vermont Longitudinal study

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40
Q

Recovery rate of schizophrenia

A

38% at 15 and 25 years

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41
Q

Who identified internal and external conditions for recovery?

A

Jacobson and Greenley

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42
Q

Who reported on the treatment gap in MH?

A

Kohn 2004 in the WHO Bulletin

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43
Q

What is the treatment gap for psychosis?

A

32% worldwide untreated
18% in Europe
40% in Europe with Bipolar untreated
>50% with depression and anxiety untreated

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44
Q

Who reported that improving adherence can have a greater impact on population health than anything else?

A

Haynes in 2001 Cochrane Review

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45
Q

Who did a study on Psychiatry and Human Rights?

A

Drew et al. 2011

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46
Q

What did Drew et al. 2011 find re Human rights in MH?

A

The right to marry and hvae children is often denied on the grounds of mental illness.

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47
Q

What is Article 2?

A

Right to Life

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48
Q

What is Article 3?

A

Prohibition of torture

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49
Q

What is Article 5?

A

Right to liberty

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50
Q

What is Article 6?

A

Right to a fair hearing

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51
Q

What is Article 8?

A

Right to a private/family life

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52
Q

What is Article 9?

A

Freedom of thought & religion

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53
Q

What is Article 10?

A

Freedom of expression

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54
Q

What is Article 14?

A

Right not to be discriminated against

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55
Q

Rules for drivers with acute psychosis, mania/hypomania and schizophrenia re Group 1 for the DVLA?

A

Driving must cease during acute illness.

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56
Q

When can relicensing be considered for a Group 1 driver who had psychosis?

A

All must be fulfilled:
Patient has remained well and stable for at least 3 months
Compliant with treatment
Free from adverse effects of medication which could impair driving
Subject to specialist favourable report
Regained insight in case of bipolar mania or hypomania

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57
Q

Psychosis and Group 2 drivers?

A

Driving should cease pending outcome of medical enquiry.

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58
Q

When can Group 2 drivers with psychosis drive again?

A

Person must be well and stable for minimum of 3 years with insight into condition before driving can be resumed.

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59
Q

What study looked into the decision-making capacities of people in hospital with MI?

A

MacArthur Treatment Competence Study 1988

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60
Q

What tool did the MacArthur Treatment Competence Study create?

A

MacCAT:
Choosing: ability to state a choice
Understanding: understand relevant information
Appreciating: appreciate nature of ones own stiuation
Reasoning: reason with information

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61
Q

Who created the Traumagenic Dynamics Model?

A

Finkelhor (1988)

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62
Q

What is the Traumagenic Dynamics model?

A 
Adverse effects of child sexual abuse depend on four factors:
Powerlessness
Betrayal
Traumatic sexualisation
Stigma
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63
Q

What is used to measure obstetric complications during childbirth?

A

Lewis-Murray scale

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64
Q

What plasma level of clozapine should be reached before patient can be considered non-respondent to clozapine?

A

350-450ng/ml

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65
Q

Non-pharmacological adjuvant to clozapine?

A

Fish omega oil - ethyl-eicoaspentanoate

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66
Q

What does CATIE stand for?

A

Clinical Antipsychotic Trials of Intervention Effectiveness

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67
Q

What type of study was CATIE?

A

Double-blind pragmatic RCT

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68
Q

Patients in CATIE?

A

1493 patients with chronic schizophrenia across 57 sites from 2001-2004

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69
Q

Medications used in CATIE?

A 
Olanzapine
Quetiapine
Risperidone
Ziprasidone (added later)
Perphanazine
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70
Q

How many patients discontinued treatment in 18 months in CATIE?

A

74%

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71
Q

Which medication had lowest discontinuation rate in CATIE?

A

Clozapine - 10 months

Olanzapine - 64%

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72
Q

Which medication had highest SE burden in CATIE?

A

Olanzapine

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73
Q

Which medication caused most anticholinergic sx in CATIE?

A

Quetiapine

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74
Q

What is CUtLASS?

A

Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study

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75
Q

Primary outcome of CUtLASS?

A

QoL at 1 year

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76
Q

Participants in CUtLASS?

A

1,227 patients with schizophrenia assessed by their clinical team for medication review because of poor response or adverse effects were randomised

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77
Q

Results of CUtLASS?

A

No advantage of 2nd generation drugs
Those on 1st generation drugs did relatively better
Patients had no clear preference

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78
Q

Who did a meta analysis of 10 RCTs into psychotic depression?

A

Wijkstra et al.

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79
Q

What did Wijkstra et al. find re medication treatment for psychotic depression?

A

Combination of antidepressant and antipsychotic is no better than antidepressant monotherapy.

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80
Q

Which combination is superior for psychotic depression compared to monotherapy?

A

Antidepressant + antipsychotic compared to antipsychotic alone

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81
Q

Point prevalence estimate of depression?

A

7%

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82
Q

In how many patients does the initial diagnosis of depression change?

A

56%

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83
Q

What does the initial diagnosis of depression change to in patients?

A

Schizophrenic spectrum - 16%
PD - 9%
Neurotic, stress-related and somatoform disorders - 8%
Bipolar - 8%

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84
Q

In the community, how many patients with a depressive episode go on to develop mania?

A

One in ten patients within ten years

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85
Q

Risk of suicide in patients with mood disorders compared to the general population

A

14 times greater

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86
Q

How many patients with depression will experience a recurrence in 5 years?

A

50%

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87
Q

What is the risk of a patient with 2 major depressive episodes having a third?

A

70%

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88
Q

How long should antidepressants be continued in those with moderate or severe depression?

A

For at least 6 months after remission

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89
Q

Which patients must continue antidepressants for 2 years?

A

Patients with >2 episodes in recent past or residual impairment

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90
Q

How long should treatment be continued for a single episode of depression?

A

At least 6-9 months after resolution of sx

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91
Q

What is NNT for antidepressant response?

A

4-5

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92
Q

What is NNT for antidepressants for remission?

A

6-7

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93
Q

What did Kirsch’s meta-analysis include

A

47 trials including 4-8 weeks RCTs of Nefazadone, Venlafaxine, Fluoxetine and Paroxetine.

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94
Q

Weighted mean improvement in Kirsch’s meta-analysis between treatment and placebo?

A
  1. 6 points on Hamilton in drug group

7. 8 in placebo

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95
Q

Did Kirsch’s meta-analysis show significance in findings for antidepressant treatment?

A

Statistical significance but not the three-point Hamilton criterion for NICE for clinical significance.
Magnitude of difference was a function of baseline of severity of depression.

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96
Q

What was Geddes research?

A

Pooled analysis of data from 31 randomised trials of 4,410 patients taking antidepressants

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97
Q

Average rate of relapse on antidepressant in Geddes research?

A

18%

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98
Q

Treatment effect duration of antidepressants in Geddes research?

A

36 months

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99
Q

What is STAR*D?

A

Sequenced treatment alternative for depression was a pragmatic RCT - 2/3 had comorbid physical disorder, 2/3 had co-morbird psychiatric diagnosis and 40% had onset of depression at <18 years of age - similar to the real world.

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100
Q

How many patients in the STAR*D study?

A

4041 patients at 25 sites in the USA

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101
Q

How did STAR*D study work?

A

4 steps of treatment.

Any patient who failed to meet remission criteria at each step was moved up to the next level.

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102
Q

What was Level 1 in the STAR*D study?

A

Citalopram for up to 12 weeks

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103
Q

What was Level 2 in the STAR*D study?

A

If after 12 weeks patient failed remission, they were randomized as per their preference to switch to either Bupropion, Sertraline or Venlafaxine, to cognitive therapy or to augment citalopram with Bupropion or Buspirone or to combine citalopram with cognitive therapy.

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104
Q

What was level 3 in the STAR*D study?

A

Participants who did not achieve remission after 12 weeks in level 2 were randomised to switch to mirtazapine, nortriptyline or augment level 2 treatment with lithium or thyroid medication.

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105
Q

What was level 4 in the STAR*D study?

A

Patients who did not achieve remission after 12 weeks in level 3 were switched to an MAOI, tranylcypromine or switch to a combination of venlafaxine XR and mirtazapine.

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106
Q

Cumulative remission rate after all 4 steps in STAR*D study?

A

67%

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107
Q

Cumulative non-response rate in STAR*D study?

A

33%

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108
Q

How many patients became symptom free after 2 levels in the STAR*D study?

A

Half of participants

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109
Q

What were the findings at level 3 of the STAR*D study?

A

No statistical difference between the different antidepressants or augmentation with Lithium or T3.

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110
Q

What were the results at level 4 in the STAR*D study?

A

No difference between MAOI and Mirtazapine/Venlafaxine XR combination although degree of symptom relief was better with the latter.

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111
Q

Who is at risk of suicidal behaviours when started on antidepressants?

A

<25 years of age

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112
Q

What did Hawton et al study in 2010?

A

Toxicity of antidepressants in OD

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113
Q

Which TCAs are more toxic in an OD?

A

Dosulepin

Doxepin

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114
Q

What are the 5As which can result in apparent resistance to antidepressant treatment?

A 
Alcoholism
Lack of adequate dosage
Lack of adherence
Axis 2 disorders (PD)
Alternative diagnosis
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115
Q

Prevalence of Bipolar?

A

1.5%

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116
Q

What is NCS-replication?

A

Part of the World Mental Health survey initiative

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117
Q

Lifetime prevalence of bipolar in NCS-replication?

A

Bipolar 1 - 1%

Bipolar 2 - 1.1%

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118
Q

Suicide rate of Bipolar?

A

15-18x higher than the general population.

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119
Q

How many people with bipolar experience another MH disorder?

A

2/3

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120
Q

Who described an extension to bipolar 1 & 2 classification?

A

Akiskal and Pinto in 1999

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121
Q

How many patients with bipolar get misdiagnosed with depression?

A

40%

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122
Q

Median time to recover from mania with treatment?

A

4-5 weeks

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123
Q

Suicide rate in bipolar?

A

10-19%

15x greater than the general population

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124
Q

Risk of recurrence in people with bipolar?

A

50% in one year
>70% at 4 years
compared with other psychiatric disorders

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125
Q

What type of depression is suggestive of bipolar?

A

Psychotic depression in early adulthood

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126
Q

What is rapid cycling?

A

4 or more episodes in a year - both mania and depression

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127
Q

What % of rapid cyclers are women?

A

80%

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128
Q

Which medications are associated with mania?

A

L-Dopa

Steroids

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129
Q

When is ECT considered in mania?

A

Severely ill manic patients
Treatment-resistant mania
Those who prefer ECT
Severe mania during pregnancy

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130
Q

How long should maintenance treatment be continued for in bipolar?

A

2 years after episode

5 years if high-risk factors for relapse

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131
Q

Which study did research in adjunctive antidepressant use in bipolar?

A

STEP_BD

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132
Q

Male:female ratio of schizophrenia?

A

1.4:1

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133
Q

Median prevalence of schizophrenia?

A

4.6/1000 - point prevalence

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134
Q

Period prevalence of schizophrenia

A

3.3/1000

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135
Q

Lifetime prevalence for schizophrenia

A

4/1000

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136
Q

Lifetime morbid risk of schizophrenia

A

7.2/1000

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137
Q

Which study looked at schizophrenia in BME communites?

A

AESOP study

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138
Q

What did the AESOP study find?

A

All psychoses are more common in BME groups compared to white population in Bristol, SE london and Nottingham

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139
Q

What did ONS 2000 Psychiatric comorbidity survey of households find?

A
  1. 5% endorsed at least one psychosis item
  2. 2% endorsed hallucination item: of this, 4.2% said they heard/saw something others could’nt, 0.7% reported hearing voices
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140
Q

Who did a study into genetic risk of schizophrenia?

A

Johnstone et al. 2005

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141
Q

What did Johnstone et al. 2005’s study find re schizophrenia?

A

10% risk present in those with high risk FHx increases to nearly 50% in subgroup of those who have a high score on schizotypal cognition and social withdrawal.

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142
Q

What did the Australian PACE clinic sample show?

A

20 of 49 high-risk subjects (40.8%) developed a psychotic disorder within 12 months.

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143
Q

Incidence of delusional disorders

A

0.7-1.3 per 100,000

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144
Q

Prevalence of delusional disorders

A

24-30 per 100,000

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145
Q

Proportion of people with delusional disorder admitted to hospital

A

1-3%

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146
Q

Mean age of onset of delusional disorder

A

39 y/o

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147
Q

Sex ratio of delusional disorder

A

1.18:1 - M:F

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148
Q

What was the structure of the Iowa study show re outcomes for schizophrenia?

A

186 people with schizophrenia were followed-up for 35 years.

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149
Q

What did the Iowa study show re outcomes for schizophrenia?

A

46% of people improved or recovered.

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150
Q

What was the structure of the Bonn Hospital Study in Germany?

A

502 people with schizophrenia were followed up for 22.4 years.

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151
Q

Results of Bonn Hospital Study in Germany?

A

22% had complete remission of sx
43% had non-characteristic types of remission (non-psychotic)
35% experienced characteristic schizophrenia residual sx.

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152
Q

Structure of Chestnut Lodge study

A

446 patients with schizophrenia were followed-up for 15 years

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153
Q

What did the Chestnut Lodge study show re schizophrenia?

A

36% recovered or functioned adequately.

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154
Q

What did the Vermont longitudinal study show re outcomes of schizophrenia?

A

68% of patients who underwent a rehab programme had good functioning as per the GAF scale.

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155
Q

What was the International study of Schizophrenia (ISoS 1997)

A

Follow-up analysis of two major WHO incidence cohorts from 9 countries.

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156
Q

Results from ISoS 1997 study

A

52% of patients in developing countries were assessed to be in the ‘best’ outcome category (single episode followed by partial or full recovery) compared with 39% in developed countries

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157
Q

What did ISoS 1997 study show re follow-up of patients with schizophrenia?

A

At 5 years, 73% of those from developing countries were in the best outcome group compared with 52% in developed countries.

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158
Q

Risk of schizophrenia if both parents have schizophrenia

A

40-50%

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159
Q

Single nucleotide polymorphisms (SNPs) linked to schizophrenia

A

12p13.33
12q24.11
1q42.2
11q23.2
2q33-34
5q33.2
16p13
7q21
1p21
8p12
17p13
18q21
2q32

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160
Q

Copy Number Variations (CNVs) linked to schizophrenia

A

2p16.3 deletion
7q36.3 duplication
Hemi deletion of 22q11

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161
Q

Gene of 12p13.33

A

CACNA1C (L-type calcium channel)

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162
Q

What is CACNA1C important for?

A

Neuronal function

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163
Q

What do mutations of CACNA1C cause?

A

Timothy Syndrome

Brugada Syndrom

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164
Q

Gene of 12q24.11?

A

D-amino acid oxidase

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165
Q

What is D-amino acid oxidase important for?

A

Degrades d-serine (NMDA co-agonist)

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166
Q

Gene of 1q42.2?

A

DISC-1

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167
Q

What is DISC-1 seen in?

A

Scottish family with 1:11 translocation

Disrupted in schizophrenia

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168
Q

Gene of 11q23.2?

A

Dopamine D2 receptor

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169
Q

Importance of 11q23.2?

A

Target for antipsychotic action

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170
Q

Gene for 2q33-34?

A

Receptor tyrosine kinase erbB4

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171
Q

Importance of 2q33-34?

A

Neuregulin 1 receptor

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172
Q

Gene for 5q22.3?

A

AMPA receptor subunit 1

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173
Q

Importance of 5q33.2?

A

Affects synaptic plasticity

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174
Q

Gene for 16p13?

A

NMDA receptor subunit 2A

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175
Q

Importance of 16p13?

A

Influences channel conductance and synaptic localisation

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176
Q

Gene of 7q21?

A

Metabotropic glutamate receptor 3

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177
Q

Importance of 7q21?

A

Inhibitory autoreceptor

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178
Q

Gene of 1p21?

A

Micro RNA 137

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179
Q

Importance of 1p21?

A

Regulates transcription

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180
Q

Gene of 8p12?

A

Neuregulin 1

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181
Q

Importance of 8p12

A

Growth factor

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182
Q

Gene of 17p13?

A

Serine racemase

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183
Q

Importance of serine racemase?

A

Synthesizes d-serine from l-serine

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184
Q

Gene of 18q21?

A

Transcription factor 4

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185
Q

Importance of transcription factor 4?

A

Deletion causes Pitt-Hopkins syndrome

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186
Q

Gene of 2q32?

A

Zinc finger 804A

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187
Q

Importance of zinc finger 804A?

A

Affects gene regulation especially in cortical pyramidal neurons

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188
Q

Gene of 2p16.3 deletion?

A

Neurexin 1

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189
Q

Importance of Neurexin 1?

A

Involved in synaptic structure

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190
Q

Gene at 7q36.3 duplication?

A

Vasoactive intestinal peptide receptor 2

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191
Q

Importance of VIP receptor 2?

A

Regulates synaptic transmission in hippocampus and development of neural progenitor cells in dentate gyrus

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192
Q

Gene at 22q11

A

COMT coding genes

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193
Q

What does hemi deletion of 22q11 cause?

A

Velocardiofacial syndrome

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194
Q

Which anxiety disorder is most common in boys?

A

OCD

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195
Q

Which anxiety disorder has equal distribution between men and women?

A

OCD

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196
Q

Point prevalence of OCD in adults

A

1-3%

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197
Q

Point prevalence of OCD in children

A

1-2%

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198
Q

Lifetime prevalence of OCD

A

2-3%

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199
Q

Most commonly prevalent psychiatric disorders?

A 
Phobias
Alcohol misuse
Depression
OCD
(in that order)
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200
Q

Gender ratio of OCD in community

A

1.5:1 female:male

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201
Q

What can OCD spectrum disorders be classified into?

A

Somatic preoccupation e.g. anorexia
Neurological disorders e.g. Tourettes
Impulse control disorders e.g. paraphilias
Anankastic PD

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202
Q

What does PANDAS stand for?

A

Paediatric autoimmune neuropsychiatric disorders associated with strep infection

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203
Q

What sx does PANDAS produce?

A

Tics
Fluctuating OCD sx
Anxiety

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204
Q

NIMH diagnostic criteria for PANDAS

A

Presence of OCD or a tic disorder
Onset between 3 years of age and beginning of puberty
Abrupt onset of sx or a course characterised by dramatic exacerbations of sx
Onset of exacerbation of sx temporally related to infection with GABHS
Abnormal neuro exam during exacerbation

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205
Q

What is found to be elevated in those with PANDAS?

A

AntiDNAseB or Antistreptolysin O titres

Some may have autoantibodies to neurons in basal ganglia; called basal ganglia antibodies

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206
Q

Treatment for mild-moderate OCD (first line)

A

Self-help

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207
Q

2nd line treatment for mild-moderate OCD

A

CBT with ERP (Exposure and response prevention)

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208
Q

3rd line treatment for mild-moderate OCD

A

SSRIs +/- CBT

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209
Q

1st line treatment for severe OCD

A

SSRIs+/-CBT

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210
Q

How long do people with severe OCD need to continue SSRIs if they respond well?

A

1-2 years +/- booster CBT

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211
Q

2nd line treatment for severe OCD

A

Switch to different SSRI or clomipramine

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212
Q

How many patients with OCD show some sort of improvement to SSRI?

A

60-70%

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213
Q

NNT for SSRI for OCD?

A

6-12

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214
Q

When is antipsychotic augmentation with SSRI considered for OCD?

A

If no response after 3 month trial of maximal dose of SSRI.

Particularly useful if tics.

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215
Q

Point prevalence of PTSD

A

1%

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216
Q

Lifetime prevalence of PTSD in America for adults?

A

6.8%

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217
Q

Lifetime prevalence of PTSD in men vs women

A

Men: 3.6%
Women: 9.7%

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218
Q

How many people exposed to trauma will develop PTSD?

A

30%

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219
Q

Who did research into factors associated with PTSD?

A

Bisson 2007

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220
Q

NICE guidelines for initial management of PTSD in primary care

A

Watchful waiting if sx are mild and present for <4 weeks after trauma

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221
Q

When does NICE recommend px of non-benzo sleeping tablet for PTSD in primary care?

A

After 4 consecutive nights sleep disturbance

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222
Q

NICE Guidelines for PTSD in secondary care

A

Psychological treatment regularly and continuously (once a week) by the same person

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223
Q

What does NICE specifically not recommend for PTSD management in secondary care?

A

Non-trauma focused interventions such as relaxation/non-directive therapy

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224
Q

NICE guidelines for PTSD management in secondary care if sx present within 3 months of trauma

A

Trauma-focused CBT

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225
Q

When should trauma-focused CBT be offered?

A

Those with severe PTSD
Those with severe PTSD in first month after traumatic event
Those with PTSD within 3 months of event

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226
Q

How is trauma-focused CBT delivered?

A

OP; 8-12 sessions (5 if treatment starts within 1 month of event)

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227
Q

NICE guidelines for PTSD if sx present for more than 3 months after trauma

A

Trauma-focused CBT or EMDR

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228
Q

How many sessions of trauma-focused CBT or EMDR are offered for PTSD sx >3 months after trauma?

A

12 sessions

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229
Q

Pharmacological treatment for general use for PTSD

A

Paroxetine

Mirtazapine

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230
Q

Pharmacological treatment for specialist use for PTSD

A

Amitriptyline

Phenelzine

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231
Q

Which medication is licensed for females only with PTSD?

A

Sertraline

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232
Q

Who discovered EMDR and how?

A

Shapiro; used it on herself

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233
Q

Which sx is not needed for GAD which is usually needed for other anxiety disorders?

A

Avoidance

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234
Q

Lifetime prevalence of GAD

A

5%

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235
Q

Point prevalence of GAD

A

2-3%

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236
Q

MZ vs DZ concordance of GAD?

A

41% vs 4% (MZ vs DZ)

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237
Q

Risk factors for GAD?

A 
Exposure to civilian trauma
Bullying
Higher number of life events
Being first-degree relative of GAD patient
Female
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238
Q

What is Hamilton anxiety scale?

A

14-item scale

Emphasises somatic sx

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239
Q

Definition of clinical recovery of GAD

A

<7 on Hamilton anxiety scale

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240
Q

Which SSRIs can be used for GAD?

A

Escitalopram
Paroxetine
Sertraline

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241
Q

Which TCAs can be used for GAD?

A

Imipramine

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242
Q

Which medications can the herb Valerian interact with?

A

Loperamide and fluoxetine, causing delirium

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243
Q

Which medications can evening primrose oil interact with?

A

Phenothiazides, causing epileptic seizures

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244
Q

Point prevalence of social phobia?

A

2.8%

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245
Q

Duration of medication for social phobia (first line)

A

12 weeks

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246
Q

How long should drug treatment continue if good response for social phone?

A

6-12 months

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247
Q

2nd line treatment for social phobia?

A

Phenelzine

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248
Q

Point prevalence of panic disorder

A

0.9%

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249
Q

Lifetime prevalence of panic attacks

A

28%

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250
Q

Lifetime prevalence of panic disorder

A

4.7%

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251
Q

Mean age of onset of any panic attack

A

22 years

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252
Q

How does ICD 10 classify panic disorder?

A

Recurrent, unpredictable panic attacks with sudden onset of palpitations, CP, choking sensation, dizziness and feelings of unreality, often associated with fear of dying/losing control but w/o requirement for sx to have persisted >1 month.

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253
Q

First line treatment for panic disorder

A

7-14 weeks of CBT (weekly 1-2 hours) completed within 4 months
SSRI
Bibliotherapy

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254
Q

How long do SSRIs need to be continued for panic disorder to assess efficacy?

A

12 weeks

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255
Q

2nd line drug treatment for long term treatment of panic disorder

A

Imipramine

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256
Q

Recommendations if initial therapy fails for panic disorder

A

Add Paroxetine or Buspirone to psychological treatment if partial response
Add Paroxetine while continuing CBT if no response

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257
Q

Prevalence of Hypochondriasis

A

0.8-4.5%

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258
Q

Treatment for Hypochondriasis

A

CBT
Group CBT
SSRIs

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259
Q

What can BDD be divided into?

A

Psychotic

Non-psychotic

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260
Q

Treatment for treatment-resistant BDD?

A

Fluoxetine with CBT

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261
Q

Prevalence rate of somatisation disorder

A

1-2%

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262
Q

Gender ratio of somatisation disorder

A

2:1 female:male

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263
Q

What did Rohricht and Elanjithara (2009) find re MUS?

A

42% of patients with MUS have primary diagnosis of somatoform disorder
36% had depression medicated by effect of somatic sx

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264
Q

What does ICD 10 classify conversion dsorder as?

A

Dissociative disorder

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265
Q

Prevalence of dissociative disorder in adults

A

10%

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266
Q

Recommendation for treatment of dissociative disorder?

A

Individual psychotherapy; especially structured therapy such as Acceptance and Commitment therapy & DBT

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267
Q

What types of ED are recognised in ICD 10?

A

Anorexia
Bulimia
EDNOS

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268
Q

How many patients with bulimia have a hx of anorexia?

A

1/4 - 1/3

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269
Q

Which criteria for anorexia has been eliminated in DSM V?

A

Amenorrhoea

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270
Q

Prevalence of anorexia in teenage girls

A

0.5-1%

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271
Q

Prevalence of bulimia in 16-35?

A

1-2%

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272
Q

Prevalence of anorexia in females per year

A

19/100,000

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273
Q

Prevalence of bulimia in females per year

A

29/100,000

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274
Q

Comorbid psychiatric disorders in patients with anorexia?

A

65% have depression
34% have social phobia
26% have OCD

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275
Q

MZ vs DZ rates of anorexia

A

55% MZ

5% DZ

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276
Q

MZ vs DZ rates of bulimia

A

33% MZ

30% DZ

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277
Q

Heritablility of ED?

A

Significant heritability for anorexia

Not for bulimia

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278
Q

Physical sx of ED

A 
Increased sensitivity to cold
GI sx - constipation, bloating
Dizziness and syncope
Amenorrhoea, low sexual appetite, infertility
Poor sleep with early morning wakening
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279
Q

Physical signs of ED

A

Emaciation, stunted growth and failure of breast development if pre-pubertal
Lanugo on back, forearms and side of face
Russels sign
Swelling of parotid and submandibular glands in bulimia
Perimylolysis
Hypothermia
Bradycardia, orthostatic hypotension, cardiac arrhythmias
Dependent oedema
Week proximal muscles

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280
Q

Endocrinel abnormalities in ED

A 
Low LH, FSH and oestradiol
Low T3, T4, Normal TSH
Increase in plasma cortisol
Raised GH
Hypoglycaemia
Low leptim
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281
Q

Haematological abnormalities in ED

A

Moderate normocytic normochomric anaemia
Mild leucopenia with relative lymphocytosis
Thrombocytopenia

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282
Q

Metabolic abnormalities in ED

A

Hypercholesterolaemia
Raised seum carotene
Low phosphate (refreeding)
Dehydration

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283
Q

Most effective treatment for bulimia?

A

CBT

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284
Q

Recovery rate for bulimia with CBT

A

33-50% make full recovery

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285
Q

Therapeutic goals for anorexia?

A

Engagement
Weight restoration
Psychological therapy - cognitive restructuring
If needed, use of compulsion

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286
Q

What therapies should be considered for anorexia?

A

CBT/CAT
Interpersonal psychotherapy
Focal dynamic therapy
Family interventions focused on ED

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287
Q

First line SSRI for bulimia

A

Fluoxetine 60mg OD

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288
Q

Prevalence of PD?

A

5-13%

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289
Q

Most prevalent PD in psychiatric settings

A

BPD

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290
Q

Prevalence of any PD in prison?

A

78% for male on remand
64% for male sentenced
50% for females

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291
Q

Prevalence of PD in prisons

A

53% of male remand
49% of sentenced
31% of female prisoners

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292
Q

Prevalence of antisocial PD in UK

A

0.6%

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293
Q

Median prevalence rate per 1000 of paranoid PD

A

6

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294
Q

Median prevalence rate per 1000 of schizoid PD

A

4

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295
Q

Median prevalence rate per 1000 of schizotypal

A

6

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296
Q

Median prevalence rate per 1000 of antisocial

A

19

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297
Q

Median prevalence rate per 1000 of BPD

A

16

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298
Q

Median prevalence rate per 1000 of histrionic

A

20

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299
Q

Median prevalence rate per 1000 of narcissistic

A

2

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300
Q

Median prevalence rate per 1000 of anankastic

A

17

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301
Q

Median prevalence rate per 1000 of avoidant

A

7

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302
Q

Median prevalence rate per 1000 of dependent

A

7

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303
Q

Median prevalence rate per 1000 of passive aggressive

A

17

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304
Q

Female:male ratio of BPD?

A

3:1

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305
Q

What did McLean Study of Adult Development show re BPD?

A

Prevalence of five core BPD sx declines with rapidity; quasi-psychotic thought, self-mutilation, help-seeking suicide efforts, treatment regressions and countertransference problems

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306
Q

What was Seivewright & Tyrer’s study into PD?

A

12 year follow-up where 178 out of 202 patients were reassessed for their personality status.

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307
Q

What did Seivewright & Tyrer’s study show?

A

Personality traits of patients with Cluster B PD became significantly less pronounced after 12 years.
Those with Cluster A and C became more pronounced.

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308
Q

Cluster A PDs?

A

Paranoid
Schizoid
Schizotypal (in DSM)

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309
Q

Cluster B PDs

A

Antisocial
BPD
Histrionic
Narcissistic

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310
Q

Cluster C PDs

A

Avoidant
Dependent
OCD

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311
Q

Risk of psychiatric episode postpartum?

A

Significant increase in first three months; 80% are mood disorder

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312
Q

Risk of depression during pregnancy

A

7-15%

313
Q

Risk of depression in women outside perinatal period?

A

7%

314
Q

Relapse rate of depression in patients with a history who are pregnant?

A

50%

315
Q

Risk of postpartum psychosis

A

0.1-0.25%

316
Q

Risk of postpartum psychosis in bipolar

A

50%

317
Q

Risk of postpartum psychosis in patients with a hx of postpartum psychosis

A

50-90%

318
Q

Incidence of puerperal psychosis

A

One per 1000 births

319
Q

Most used antipsychotic in pregnancy?

A

Olanzapine

320
Q

Which antipsychotics are commonly used in pregnancy?

A 
Chlorpromazine
Trifluoperazine
Haloperidol
Olanzapine
Clozapine
321
Q

Treatment of depression in pregnancy

A

Explore possibility of delaying treatment until 2nd-3rd trimester e.g. CBT

322
Q

Which antidepressant must be avoided in pregnancy

A

Paroxetine

323
Q

Recommended antidepressants in pregnancy?

A

Nortriptyline
Amitriptyline
Impramine
Fluoxetine

324
Q

Which patients with bipolar should continue medication?

A

Severe illness and high risk of relapse

325
Q

When should discontinuation of mood stabilisers be considered in the pregnant woman with bipolar?

A

Only if absolutely necessary and followed by frequent monitoring

326
Q

Which mood stabilisers should be avoided in pregnancy?

A

Valproate

Combination of mood stabilisers

327
Q

What should be done if a pregnant women is on Valproate or Carbamazepine?

A

Folic Acid 5mg OD from at least a month before conception should be px
Vitamin K should be given to mum and neonate after delivery

328
Q

Risk of SSRIs in pregnancy

A

13.3% increase in spontaneous abortion

Risk of decreased gestational age and low birth weight

329
Q

Which drugs increase risk of spontaneous abortion

A

SSRIs
Mirtazapine
Bupropion

330
Q

Which antidepressant has least placental exposure?

A

Sertraline

331
Q

Risk of malformation if Lithium used in first trimester?

A

1 in 10

332
Q

What is Lithium associated with if used in first trimester?

A

All types of malformation risk increased three-fold

Cardiac malformations risk increased 8-fold

333
Q

Relative risk of Ebsteins anomaly if on Lithium

A

10-20 times higher

334
Q

Risk of relapse if a women stops lithium when pregnancy

A

70% within 6 months

Faster discontinuation = higher risk of relapse

335
Q

Risk of any birth defect while on Sodium Valproate?

A

7.2%

336
Q

Findings of IQ of children in mothers who took valproate during pregnancy

A

42% had verbal IQ <80

30% needed special educational support compared to 3-6% of those exposed to other antiepileptic drugs

337
Q

Which malformation is Lamotrigine associated with?

A

Cleft palate

338
Q

Risk of benzo use during first trimester

A

0.6% risk of cleft palate & CNS & urinary tract malformations

339
Q

How much lithium is exreted into breast milk?

A

40-50% of maternal serum level

340
Q

How much can infant serum level of lithium rise up to?

A

200% of maternal serum conc (5-200%)

341
Q

Which benzos are safe during breastfeeding

A

Low doses of Temazepam and Oxazepam (short acting)

342
Q

Which benzos should be avoided during breastfeeding?

A

Diazepam

Alprazolam

343
Q

Which sedative is safe during breast feeding?

A

Zolpidem

344
Q

What did SADHART show re impact of Sertraline on depression?

A

Little difference in depression status after 24 weeks treatment
Effect of Sertraline greater in patients with severe and recurrent depression

345
Q

Prevalence of depression in CCF patients

A

21.5% (2-3 times higher than general population)

346
Q

Relative risk of mortality in patients with CCF who are depressed

A

2:1 compared to risk in non-depressed CCF patients

347
Q

M:F ratio of hypothyroidism

A

1:6

348
Q

Rates of depression in patients with Diabetes

A

2-3 times more common compared to general population

349
Q

How many patients with erythema migrans develop neuroborreliases?

A

15%

350
Q

What is neuoborreliases?

A

Lyme disease where CNS is affected

351
Q

Sx of Lyme disease

A

Back pain worse at night
Facial numbness
Facial palsy

352
Q

Psychiatric sx of SLE

A

Depression
Anxiety
Psychosis (Rare)

353
Q

Physical sx of SLE

A

Chronic, remitting-relapsing course of febrile illness, butterfly rash, inflammation of joints, kidney and serosa

354
Q

Lifetime prevalence of depressive sx in MS

A

40-50% - 3x higher than general population

355
Q

Suicide rates of people with MS

A

3% over 6 year period

15% over 16 years

356
Q

How many patients with MS on steroids develop mild to moderate mania?

A

33%

357
Q

Prevalence of post-stroke depression?

A

35%

358
Q

What type of stroke has high incidence of anxiety?

A

Cortical

359
Q

Prevalence of post-stroke anxiety?

A

25%

360
Q

Treatment for mild-moderate post-stroke depression

A

Increase social interaction
Exercise
Psychosocial intervention

361
Q

Which antidepressants have good evidence for post-stroke depression?

A

Fluoxetine

Citalopram

362
Q

Frequency of depression in epilepsy

A

30-50%

363
Q

Frequency of panic disorder in epilepsy

A

20%

364
Q

Which type of epilepsy is depression most common in?

A

TLE

365
Q

Risk of suicide in patients with epilepsy

A

10-15%

366
Q

Mortality rate if epilepsy and depressed

A

25x higher than general population

367
Q

Which psychotropic can cause psychosis?

A

Vigabatrin

368
Q

Which antipsychotics are less epileptogenic?

A

Sulpride

Haloperidol

369
Q

Prevalence of depression in Parkinsons

A

40-50%

370
Q

Prevalence of hypomania/euphoria in Parkinsons

A

2%/10%

371
Q

Prevalence of anxiety in Parkinsons

A

50-65%

372
Q

Prevalence of Psychosis in Parkinsons

A

40% - drug-related

373
Q

Prevalence of cognitive impairment in Parkinsons

A

19% if no dementia

25-40% if dementia

374
Q

Prevalence of psychiatric sx in Huntingtons at first presentation?

A

30%

375
Q

Suicide rates in patients with Huntingtons

A

4x higher than general population

376
Q

How many patients with Huntingtons first present with schizophreniform psychosis?

A

3-6%

377
Q

When can OCD-like sx occur in Huntingtons?

A

If basal ganglia involvement

378
Q

Where is gene for Huntington Disease?

A

Short arm of chromosome 4, associated with expanded trinucleotide repeat.

379
Q

When is Huntingtons fully penetrant?

A

CAG repeats reach 41 or more

380
Q

When does Huntingtons show incomplete penetrance?

A

36-40 repeats

381
Q

How many patients present with Wilsons disease via psychiatric presentations?

A

20%

382
Q

Most common psychiatric sx of Wilsons?

A

Personality disturbance
Mood abnormalities
Cognitive dysfunction

383
Q

How many patients with Wilsons have cognitive impairment?

A

25%

384
Q

What type of dementia occurs in Wilsons?

A

Frontosubcortial pattern of dementia

385
Q

How many patients with Wilsons have depression?

A

30%

386
Q

What does MRI show in patients with Wilsons?

A

Intense hyperintensity of midbrain with relative sparing of red nucleus, superior colliculus and part of pars reticulata of substantia nigra
Hypointensity of aqueduct - called Giant Panda sign

387
Q

Diagnostic criteria of transient global amnesia

A

Witnessed attacks with information available from observer
Clear-cut anterograde amnesia during attack
Absence of clouding of consciousness & loss of personal identity
Cognitive impairment limited to amnesia only
No accompanying focal neurological symptoms during attack and no signs afterwards
Absence of epileptic features
Attack resolves within 24 hours
Exclusino of patients with HI or active epilepsy

388
Q

Rate of transient global amnesia

A

5-10/100,000 per year

389
Q

Rate of transient global amnesia in those >50 years of age

A

30/1000,000 per year

390
Q

Characteristics of transient global amnesia

A

Abrupt onset of anterograde amnesia characterised by significant new learning deficit.
Mild confusion and lack of insight into problem but intact sensorium.

391
Q

Episode length of transient global amnesia

A

6-24 hours

392
Q

What happens in Fahrs disease?

A

Idiopathic progressive calcium deposition in basal ganglia

393
Q

Onset of Fahrs disease

A

20-40 years

40-60 years

394
Q

Sx of Kluver-Bucy syndrome?

A

Emotional blunting
Hyperphagia
Visual agnosia
Inappropriate sexual behaviour

395
Q

What causes sx of Kluver-Bucy Syndrome?

A

Bilateral temporal lobe damage

396
Q

What can be used to control sx in Kluver-Bucy Syndrome?

A

Carbamazepine

397
Q

Who described Meige Syndrome?

A

Henri Meidge in 1904

398
Q

What characterisis Meige syndrome?

A

Repetitive blinking, chin thrusting, lip pursing or tongue movements.

399
Q

What causes secondary Meige’s syndrome?

A

Antipsychotics
Levodopa
Lewy Body Dementia

400
Q

Classification of mild HI

A

PTA <60 minutes

401
Q

Classification of moderate HI

A

PTA between 1-24 hours

402
Q

Classification of severe HI

A

PTA 1-7 days

403
Q

What predicts depression in patients with HI?

A

Proximity of lesion to left frontal lobe

404
Q

In which type of HI might there by schizophrenia-like psychosis with prominent paranoia?

A

Left temporal injury

405
Q

In which type of HI might there by affective psychoses?

A

Right temporal or orbitofrontal injury

406
Q

What are dyssomnias divided into?

A 
Primar insomnia
Primary hypersomnia
Circadian sleep disorders
Narcolepsy
Breathing related sleep disorders
Sleep state misperception
407
Q

What are parasomnias divided into?

A 
Arousal disorders (NREM sleep)
Sleep-wake transition
REM sleep parasomnias
Sleep bruxism
Sleep enuresis
408
Q

Prevalence of narcolepsy

A

0.025%

409
Q

How many patients with narcolepsy have cataplexy?

A

75%

410
Q

How many patients with narcolepsy have sleep paralysis?

A

30%

411
Q

How many patients with narcolepsy have all 4 sx: narcolepsy, cataplexy, sleep paralysis and hypnagogic hallucinations?

A

10%

412
Q

How many patients with narcolepsy have automatic behaviours?

A

33%

413
Q

What is strongly associated with narcolepsy?

A

HLA-DQB1*0602

Low concentration of hypocretin-1 in CSF

414
Q

Treatment for Cataplexy

A

Imipramine

415
Q

Prevalence of OSA

A

Men 4%

Women 2.5%

416
Q

What is sleepwalking?

A

Partial arousal during slow-wave stages 3 and 4.

417
Q

When do night terrors occur?

A

During first third of night

During stages 3-4 of NREM sleep

418
Q

When do REM sleep behavioural episodes occur?

A

Middle to latter third of night during REM sleep

419
Q

Diagnostic criteria for REM behavioural sleep disorder?

A

Movements of body or limbs associated with dreams and at least one of:
potentially harmful sleep behaviour
Dreams that appear to be acted out
Sleep behaviour that disrupts sleep continuity

420
Q

Diagnostic criteria for restless leg syndrome in patients >12 y/o

A

Akathisia usually accompanied by paresthesia (core feature)
Motor restlessness
Sx worse at rest
Sx worse at night

421
Q

Prevalence of restless leg syndrome

A

3-15%

422
Q

M:F ratio of restless leg syndrome

A

1:2

423
Q

First licensed drug for restless leg syndrome

A

Ropinirole

424
Q

Which dopaminergic agents can be used for restless legs?

A

Nonergot D2 agonists: ropinrole, pramipexole

Bromocriptine and dopaminergic precursors: levodopa/carbidopa

425
Q

Which anticonvulsants can be used for restless legs?

A

Gabapentin

CBZ

426
Q

What is Periodic Limb Movement Disorder?

A

Periodic episodes of repetitive and stereotyped limb movements during sleep.
Can cause clinical sleep disturbance.

427
Q

How many patients with PLMS also have Narcolepsy?

A

45-65%

428
Q

How many patients with PLMS also have REM sleep behavioural disorder?

A

70%

429
Q

What pathology has been linked to PLMS?

A

Dopaminergic impairment

Fe deficiency

430
Q

Prevalence of CFS

A

0.5%

431
Q

M:F ratio of CFS

A

1:3

432
Q

Mean age of onset of CFS

A

29-35 years

433
Q

Mean illness duration of CFS

A

3-9 years

434
Q

CFS criteria

A

Persistent or relapsing unexplained chronic fatigue of new onset, lasting at least 6 months and not the result of organic disease or continuing exertion, not alleviated by rest.

435
Q

Which sx are required for CFS?

A 
Four or more of the following, present for >6 months:
Impaired memory/concentration
Sore throat
Tender cervical/axillary lymph nodes
Muscle pain
Pain in several joints
New headaches
Unrefreshing sleep
Malaise after exterion
436
Q

How many patients with CFS have low cortisol?

A

33%

437
Q

What do family studies of CFS suggest?

A

Mutation of cortisol transporting globulin

438
Q

Effective treatment of CFS?

A

CBT

Graded exercise therapy

439
Q

What sx does CFS not have which depression does?

A

Absence of lack of motivation, guilt, anhedonia

440
Q

HPA axis in CFS

A

Downregulation

441
Q

HPA axis in depression

A

Upregulation

442
Q

Lifetime prevalence of panic disorder in those with CFS

A

17-25%

443
Q

Lifetime prevalence of GAD in those with CFS

A

2-30%

444
Q

What has replaced the diagnostic criteria for pain disorder in DSM IV in DSM V?

A

Somatic Symptom and Related Disorders (SSD)

445
Q

What is SSD diagnosis made on?

A

The basis of positive sx and signs rather than absence of a medical explanation for somatic complaints.

446
Q

What are the positive sx and signs of SSD?

A

Distressing somatic sx plus abnormal thoughts, feelings and behaviours in response to these sx

447
Q

Which DSM IV disorders have been removed?

A

Somatization disorder
Hypochondriasis
Pain disorder
Undifferentiated somatoform disorder

448
Q

Who first introduced the term atypical facial pain?

A

Frazier and Russell in 1924

449
Q

What is atypical facial pain?

A

Atypical in distribution, unilateral, poorly localised, lasts most of the day and described as severe ache, crushing or burning.

450
Q

What is the definition of persistent idiopathic facial pain?

A

Facial pain that is present daily and persists most of the day.
Pain is confined at onset to limited area on one side of the face, deep ache, poorly localised.

451
Q

Predictive markers for HIV Dementia

A

B2-microglobulin and neopterin levels in CSF

CD41 cell counts

452
Q

Side effects of Zidovudine

A 
Confusion
Agitation
Insomnia
Mania
Depression
453
Q

Side effects of Stavudine and Zalcitabine

A

Peripheral neuropathy

454
Q

Side effects of Efavirenz

A

Neuropsychiatric side effects:

33% depression, 2% psychosis

455
Q

How many patients on Efavirenz develop neuropsychiatric side effects?

A

46%

456
Q

What makes one suspect psychotropic induced catatonia such as NMS?

A

Rapid onset
Marked rigidity
Autonomic instability without posturing

457
Q

Total global mortality from suicide

A

1-2%

458
Q

How many deaths in England and Wales are from suicide?

A

1%

459
Q

Rate of suicide in England and Wales

A

8 per 100,000 per year

460
Q

Most common suicide method in men

A

Hanging

461
Q

How many deaths by men are from hanging?

A

40%

462
Q

Second most common cause of death by men

A

OD

463
Q

How many deaths from OD are caused by men?

A

20%

464
Q

Third most common cause of death by men

A

Poisoning by car exhaust fumes

465
Q

How many men die by poisoning from car exhaust fumes?

A

10%

466
Q

Most common method of suicide by women

A

OD

467
Q

Second most common method of suicide by women

A

Hanging

468
Q

Third most common method of suicide by women

A

Drowning

469
Q

How many women die by OD

A

46%

470
Q

How many women die by hanging?

A

27%

471
Q

How many women die by drowning?

A

7%

472
Q

In most countries which age group has the highest rate of suicide?

A

> 75

473
Q

Predictors of suicide in the elderly

A

Depression
Social isolation
Impaired physical health
Personality traits - anxious, obsessive

474
Q

Suicide due to depression

A

36-90%

475
Q

Suicide due to alcohol abuse

A

43-54%

476
Q

Suicide due to drug abuse

A

4-45%

477
Q

Suicide due to schizophrenia

A

3-10%

478
Q

Suicide due to organic mental disorder

A

2-7%

479
Q

Suicide due to PD

A

5-44$

480
Q

How many patients with a mood disorder will die by suicide?

A

6-10%

481
Q

Which patients with depression are at highest risk?

A

Inpatients
Hx of impulsive and aggressive behaviour
Alcohol and drug misuse
Cluster B PD

482
Q

How much does the risk of suicide increase if there is a history of a suicide attempt?

A

40x increase

483
Q

Lifetime risk of suicide in alcohol dependence

A

7%

484
Q

Suicide rate in heavy drinks

A

3.5x higher than general population

485
Q

Suicide rate in alcohol use disorders

A

15x higher than general population

486
Q

Suicide rate in drug dependence

A

15x higher than general population

487
Q

Suicide rate in Anorexia

A

20-fold higher than general population

488
Q

When do majority of schizophrenia patients commit suicide?

A

Active phase of disorder after suffering depressive sx

489
Q

Global annual suicide rate

A

1 in 6000/year

490
Q

Male:female ratio of suicide

A

2-4:1

491
Q

Most common age of suicide

A

15-24 females

25-34 males

492
Q

Mental disorders without much increase in suicide rate

A

Mental retardation
Dementia
OCD - if no depression

493
Q

Risk of suicide within one year of DSH

A

0.7%
Males: 1.1%
Females: 0.5%
66x more than general population

494
Q

Diagnosis of those who complete suicide

A

Major psychiatric disorders

Substance use

495
Q

Diagnosis of those who attempt suicide

A

Mental distress

Reactive depression

496
Q

Cognitive precipitants of those who complete suicide

A

Guilt

Hopelessness

497
Q

Cognitive precipitants of those who attempt suicide

A

Identity difficulties

Emotional distress

498
Q

How many people who DSH will repeat the act in the next year

A

20%

499
Q

How many people who DSH will eventually complete suicide?

A

10%

500
Q

Psychosocial factors suggestive of high suicidal intent

A 
Hopelessness
Impulsiveness
Low self-esteem
Recent stressful life event
Relationship instability
Lack of social support
501
Q

What scales can be used to assess suicide risk?

A

SAD PERSONS
Beck Hopelessness
Beck Scale for Suicidal Ideation

502
Q

Outline the SAD PERSONS score

A

Sex - 1 if male, 0 if female
Age - 1 if <20 or >44
Depression - 1 if depression present
Previous attempt - 1
Ethanol abuse - 1
Rational thinking loss - 1
Social support lacking - 1
Organized plan - 1 if plan is made and lethal
No spouse - 1 if divorced, widowed, separated of single
Sickness - 1 if chronic, debilitating and severe

503
Q

What is Beck Hopelessness Scale?

A

20 T/F statements focused on pessimism about the future.

504
Q

Scores of Beck Hopelessness Scale

A

0-3 - minimal risk
4-8 - mild risk
9-14 - moderate risk
15-20 - severe risk

505
Q

Factors associated with dangerousness

A 
Younger age
Males
Past hx of criminality and violence
Childhood physical or sexual abuse
Childhood conduct disturbances
Psychiatric diagnosis
Conducive environment
Specific sx
Unemployment
506
Q

Which specific sx are linked to dangerousness?

A

Command hallucinations
Agitation
Hostile suspiciousness

507
Q

Triad of sx of normal prssure hydrocephalus?

A

Dementia
Gait ataxia
Urinary incontinence

508
Q

Population prevalence of NPH in the elderly

A

0.4%

509
Q

Common features of SDH

A

Headache
Drowsiness
Altered consciousness
Confusion - fluctuating severity

510
Q

When might CT not show a SDH?

A

First 3 weeks as clot is isodense during early phase

511
Q

Complications of surgical treatment of SDH

A

Seizures

Re-bleeding

512
Q

Where is Prion protein coded?

A

PRNP gene on Chromosome 20

513
Q

What are the four forms of prion dementia?

A

Kuru
CJD
Fatal familial insomnia
Gerstmann Straussler Syndrome

514
Q

Which sign becomes prominent as CJD progresses?

A

Myoclonus

515
Q

How many CJD cases are sporadic?

A

85%

516
Q

What does MRI show in CJD?

A

Non-specific basal ganglia hyperintensities

517
Q

CSF findings in CJD

A

14-3-3 protein elevated.

518
Q

Characteristics of vCJD?

A

Anxiety and depressive sx
Personality changes
Progressive dementia
Ataxia and myoclonus

519
Q

What is diagnostic of vCJD?

A

Pulvinar sign; symmetric high-signal-intensity changes affecting pulvinar and medial areas of thalamus and tectal plate on FLAR sequence in MRI

520
Q

Predicted risk of developing Alzheimers in first-degree relatives

A

15-19%

5% in controls

521
Q

Relative risk of Alzheimers if you have a first-degree relative with the disease?

A

3-4 times relative to the risk in controls

522
Q

Which genes are associated with early onset Alzheimers?

A

Presenilin 2 gene
Presenilin 1 gene
Beta amyloid precursor protein gene

523
Q

Which chromosome is Presenilin 2 gene on?

A

1

524
Q

Which chromosome is Presenilin 1 gene on?

A

14

525
Q

Which chromosome is beta amyloid precursor protein gene on?

A

21

526
Q

Where on chromosome 21 is beta amyloid precurser protein gene found?

A

Long arm

527
Q

Describe structure of the beta amyloid protein

A

42 amino acid peptide that is a breakdown product of amyloid precursor protein

528
Q

What increases risk of late onset Alzheimers?

A

Apolipoprotein allele 4

529
Q

Where can Apolipoprotein allele 4 be found?

A

Chromosome 19

530
Q

Risk of Alzheimers if you have one copy of the Apolipoprotein allele 4 gene?

A

3x

531
Q

Risk of Alzheimers if you have two copies of the Apolipoprotein allele 4 gene?

A

8x

532
Q

Cut-off for MMSE?

A

24/30

533
Q

What scale is commonly used to assess severity and stage of Alzheimers?

A

DRS

534
Q

What does NPI do?

A

Rates frequency and severity of a range of neuropsychiatric sx.

535
Q

What does NPI-NH measure?

A

Rates of occupational disruptiveness, a measure of caregiver distress.

536
Q

How long does CAMCOG take to complete?

A

40 minutes

537
Q

What does CAMCOG give a score out of?

A

104

538
Q

Cognitive areas of assessment tested by CAMCOG?

A 
Orientation
Comprehension
Perception
Memory
Abstract Thinking
539
Q

What does Clock drawing test .. test?

A

Praxis

Higher executive function

540
Q

Starting dose of Rivastigmine for Alzheimers?

A

1.5mg BD

541
Q

Treatment dose of Rivastigmine for Alzheimers?

A

6mg BD

542
Q

Starting dose of Galantamine for Alzheimers?

A

4mg BD

543
Q

Treatment dose of Galantamine for alzheimers?

A

12mg BD

544
Q

Starting dose of Memantine for Alzheimers?

A

5mg OD

545
Q

Treatment dose of Memantine for Alzheimers?

A

10mg OD

546
Q

Recommendations from Committee on Safety of Medicines re use of Olanzapine and Risperidone for Dementia?

A

Each associated with 2x increase in risk of stroke and therefore should not be used

547
Q

What is the NINCDS-AIREN criteria for vascular dementia?

A

Evidence of CVD both on examination and brain imaging

Relationship between onset of dementia and CVD

548
Q

What type of dementia is Binswangers disease?

A

Subcortical

549
Q

Characteristics of Binswangers disease?

A 
Slow intellectual decline
Slowness of thought
Decreased STM
Disorientation
Motor problems; gait, dysarthria
550
Q

What does CADASIL stand for?

A

Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy

551
Q

Where is CADASIL gene?

A

Long arm of chromosome 19

552
Q

How do patients with CADASIL gene present?

A

Recurrent stroke at age of 40-50

Hx of migraine

553
Q

How many cases of dementia are lewy body dementia (LBD)?

A

15-20%

554
Q

Associated features of LBD pathologically

A 
Lewy-related neuritis
Plaques
Neurofibrillary tangles
Regional neuronal-loss in brainstem
Synapse loss
Microvacuolation
555
Q

Where is regional neuronal loss common in LBS?

A

Brainstem - locus cereleus and substantia nigra

Nucleus basalis of Meynert

556
Q

How many patients with Parkinsons go on to develop dementia?

A

10%

557
Q

What type of deficits are more severe in LBD and Parkinsons vs Alzheimers?

A

Executive dysfunction:

planning, reasoning, sequencing

558
Q

FTD accounts for how many cases of presenile dementia?

A

20%

559
Q

Which chromosome is linked to FTD?

A

17

560
Q

What does SPECT show in FTD?

A

Disproportionate decrease in blood flow, radio tracer uptake and glucose metabolism in frontal lobe

561
Q

What causes Picks?

A

AD

Mutation in Tau gene with complete penetration

562
Q

Where is the tau gene?

A

Chromosome 17q 21-22

563
Q

Which conditions are rarely seen in senile patients?

A

Progressive supranuclear Palsy
Corticobasal degeneration
Frontotemporal degeneration

564
Q

Which genes have been identified in familial Alzheimers with early onset?

A

Amyoid precursor gene - APP

Genes encoding PSEN1 and 2

565
Q

Characteristic sx of PSP

A

Supranuclear opthalmoplegia
Pseudobulbar palsy
Axial dystonia
Vertical gaze palsy

566
Q

Prevalence of delirium on admission to hospital

A

10-15% of elderly

567
Q

Point prevalence of delirium in the general population

A

0.4%

568
Q

Major pathway implicated in delirium?

A

Dosral tegmental pathway which projects from mesenchephalic reticular formation to tectum and thalamus

569
Q

Name the rating scales for delirium

A

Delirium rating scale - DRS
MMSE
CTD - cognitive test for delirium
CAM - confusion assessment method

570
Q

Most widely used scale for delirium?

A

DRS

571
Q

Advantage of DRS?

A

Distinguishes delirium from dementia

572
Q

What is required for DRS use?

A

Interpretation by skilled clinician

Information from multiple clinical sources

573
Q

Which delirium rating scale has high sensitivity and specificity?

A

CAM

574
Q

What does CAM allow?

A

Diagnosis of delirium

Incorporated into routine clinical settings

575
Q

Prevalence of depression in >65 age group

A

10-15%

576
Q

How much more common is depression in nursing homes?

A

2-3 times more common

577
Q

How many people with dementia have depression?

A

25%

578
Q

SPECT findings in late onset depression

A

Reduced cerebral blood flow, sparing the posterior parietal cortex

579
Q

NNT for antidepressant use in elderly

A

4 - similar to other age groups

580
Q

Depression scales for the elderly

A 
Geriatric depression scale
BASDEC
Hamilton
MADRS
Depressive sign scale
CSDD
PHQ 9
581
Q

How many items in Geriatric depression scale?

A

15

582
Q

Scoring in geriatric depression scale?

A

> 5 suggests depressive illness

583
Q

Advantage of geriatric depression scale?

A

Avoids somatic sx

584
Q

What does BASDEC stand for?

A

Brief assessment schedule depression cards

585
Q

What is BASDEC?

A

Series of statements in large print on cards which are shown to patients; answer T/F

586
Q

Why is Hamilton not as appropriate for the elderly?

A

Somatic items

587
Q

Advantages of MADRS

A

Sensitive to change in depression

588
Q

Disadvantages of MADRS

A

Not reliably answered by patients with dementia

589
Q

What does Depressive sign scale consist of?

A

9 items

590
Q

Advantage of depressive sign scale?

A

Helps detect depression in people with dementia

591
Q

What does CSDD stand for?

A

Cornell scale for depression in dementia

592
Q

What is the best validated scale for detecting depression in dementia patients?

A

CSDD

593
Q

How does CSDD work?

A

Interviewer-administered

Using info from both patient and an informant

594
Q

Factors involved in CSDD

A

General depression
Biologic rhythm disturbances
Agitation/psychosis
Negative sx

595
Q

How many items in PHQ 9?

A

9

Self-report

596
Q

Advantages of PHQ 9

A

Easy to use

Sensitive to change

597
Q

Cognitive impairment in late onset depression

A

Specific deficits in attention and executive function, consistent with frontal lobe dysfunction

598
Q

Cognitive deficits in early onset depression

A

Deficits in episodic memory - consistent with temporal lobe dysfunction

599
Q

How many patients with pseudodementia develop true dementia within 3 years?

A

40%

600
Q

What did Simpson et al’s study show?

A

Poor response to antidepressants in patients with vascular depression
Drugs used for prevention of CVD might reduce risk of vascular depression

601
Q

Which antidepressants promote ischaemic recovery?

A

Dopamine or norepinephrine enhancing agents

602
Q

What % of mood disorders in the elderly are due to mania?

A

5-10%

603
Q

One year prevalence of bipolar among adults >65?

A

0.4%

604
Q

Who coined the term paraphrenia?

A

Kraepelin in 1913

605
Q

What is late onset psychosis divided into?

A

Late onset >40 years

Very late onset >60 years

606
Q

Prevalence of late onset psychosis in the community

A

0.1-4%

607
Q

Incidence of late onset psychosis

A

10-26 per 100,000 per year

608
Q

Point prevalence of paranoid ideation in the elderly population?

A

4-6%

609
Q

How many patients with late onset psychosis present with delusions only?

A

10-20%

610
Q

ICD diagnosis of paraphrenia?

A

No such diagnosis

Patients must be diagnosed either with schizophrenia or delusional disorder

611
Q

Prevalence of schizophrenia in siblings

A

7%

612
Q

Prevalence of schizophrenia in parents

A

3%

613
Q

Most prevalent anxiety disorder in the elderly?

A

Phobic disorders

614
Q

Least common anxiety disorder in the elderly?

A

Panic disorder

615
Q

Lifetime prevalence of drug misuse in the elderly

A

1.6%

616
Q

Most common drugs used in OD in the elderly

A

Benzos
Analgesics
Antidepressants

617
Q

Psychiatric disorders in elderly who DSH

A

Depression - half

Alcohol abuse - one third

618
Q

What did the Monroe County sample find re the elderly and suicide (>50 years)?

A

Suicide was associated with higher levels or Neuroticism and lower scores on openness to experience

619
Q

What did Harwood and colleagues found in patients >60 who committed suicide?

A

Anankastic and anxious traits were associated with both depression and suicidality in the elderly

620
Q

Prevalence of PDs in the elderly

A

5-10%

621
Q

Which PD has the highest prevalence in the elderly?

A

OCD

622
Q

Prevalence of OCD PD in the elderly?

A

3.3%

623
Q

What medications reduce REM sleep?

A

TCAs

624
Q

Impact of SSRIs on sleep

A

Increase SWS

Reduce REM

625
Q

What can REM sleep behaviour disorder be an early clinical marker for?

A

Synucleopathies

626
Q

Name the syncucleopathies

A

LBD
MSA
Parkinsons

627
Q

Prevalence of REM behaviour disorder in Parkinsons?

A

15-34%

628
Q

Prevalence of REM behaviour disorder in MSA?

A

90%

629
Q

How many men >70 have impotence?

A

10-20%

630
Q

What is phase 1 of grief?

A

Shock and Protest

631
Q

What does phase 1 of grief involve?

A

Numbness
Disbelief
Acute dysphoria

632
Q

What is phase 2 of grief?

A

Preoccupation

633
Q

What does phase 2 of grief involve?

A

Yearning
Searching
Anger

634
Q

What is phase 3 of grief?

A

Disorganization

635
Q

What does phase 3 of grief involve?

A

Despair

Acceptance of loss

636
Q

What is phase 4 of grief?

A

Resolution

637
Q

When is improvement expected in normal grief?

A

2-6 months

638
Q

Percentage of general population who drank alcohol in last week in UK

A

67% men

53% women

639
Q

Percentage of adults who drank above recommended limits

A

55% men

53% women

640
Q

Percentage of children 11-15 who had drunk alcohol at least once

A

43%

641
Q

Percentage of patients who present to primary care that consume alcohol at a harmful level

A

20%

642
Q

Annual prevalence of hazardous drinking in UK households

A 
38% men
15% women
27% white adults
18% black adults
8% south asian asults
643
Q

Peak age of hazardous drinking?

A

16-19 (women)

20-24 (men)

644
Q

Number of all hospital admissions that all alcohol related

A

1 in 16 hospital admissions

1 in 6 ED attencees

645
Q

Age of death of people who are alcohol dependent

A

60

646
Q

Alcohol use during pregnancy

A

1 in 10

647
Q

% of adults in the UK 16-59 who took an illicit drug in the last year

A

8.3%

648
Q

Popular recreational drugs in the UK

A

Cannabis 6.4%
Cocaine 1.9%
Ecstacy 1.3%

649
Q

Percentage of adults 16-24 taking any drug in last year in the UK

A

16.3%

650
Q

Percentage of adults 16-59 who had taken a Class A drug in last year

A

2.6%

651
Q

Percentage of school pupils who took an illicit drug in last year in UK

A

12%

652
Q

Percentage of drug users in last year who use multiple substances

A

61% if EtOH included

7% if not included

653
Q

Most commonly reported age of first taking drugs

A

Cannabis - 16

Cocaine and Ecstacy - 18

654
Q

Average duration of drug use

A

Cannabis - 6 years
Cocaine - 4.4 years
Ecstacy - 3.9 years

655
Q

Which law classifies recreational drugs?

A

1971 Misuse of Drugs Act UK

656
Q

Name the Class A drugs

A 
Ecstasy
LSD
Heroin
Cocaine
Crack
Magic mushrooms
Methamphetamine
Other amphetamines if prepared for injection
657
Q

Name the Class B drugs

A

Amphetamines
Methylphenidate
Pholcodine

658
Q

Name the Class C drugs

A 
Cannabis
Tranquilisers
Some painkillers
GHB
Ketamine
659
Q

ICD-10 alcohol dependence criteria

A

At least 3 of the following in last 12 months:
Intense desire to drink alcohol
Difficulty in controlling onset, termination and level of drinking
Withdrawal sx if alcohol not taken
Use of alcohol to relieve withdrawal sx
Tolerance as evidenced by need to escalate dose over time to achieve same effect
Salience
Narrowing personal repertoire of alcohol use

660
Q

What is salience?

A

Neglecting alternate forms of leisure or pleasure in life

661
Q

Criteria for DSM IV alcohol dependence

A

At least 3 of the following lasting for a month
Consuming alcohol for longer period and in larger amounts than intended
Unsuccessful attempts to cut down
Experiencing withdrawal sx if alcohol not taken
Use of alcohol to relieve withdrawal sx
Tolerance - 50% increase from start
Salience
Failure in role obligations and physical health
Giving up alternate pleasures
Continued use despite knowing harm caused

662
Q

Changes in alcohol & substance dependence criteria in DSM V

A

Combines DSM IV categories of substance abuse and dependence into Substance Use Disorder that is measured from mild (abuse) to severe (dependence).

663
Q

Who created the criteria for alcohol dependence

A

Edwards & Gross in 1976

664
Q

What are the criteria for alcohol dependence?

A 
Narrowed repertoire
Salience of alcohol-seeking behaviour
Increased tolerance
Repeated withdrawals
Drinking to prevent or relieve withdrawals
Subjective awareness of compulsion
Reinstatement after abstinence
665
Q

When do features of alcohol withdrawal start?

A

Within 12 hours of last drink

666
Q

Onset of shakes in alcohol withdrawal?

A

4-12 hours

667
Q

Onset of perceptual disturbances in alcohol withdrawal?

A

8-12 hours

668
Q

Seizure onset in alcohol withdrawal

A

12-24 hours

669
Q

Peak of seizure onset in alcohol withdrawal

A

48 hours

670
Q

Delirium onset in alcohol withdrawal

A

72 hours

671
Q

Prominent sx of alcohol withdrawal

A 
Tremor
Diaphoresis
Sleeplessness
Anxiety
GI distress
Increased urge and craving for alcohol
672
Q

How many patients with alcohol withdrawal will get delirium tremens?

A

5%

673
Q

Incidence of seizures in untreated alcohol-dependent patients

A

8%

674
Q

Risk of seizures in alcohol withdrawal if treated

A

3%

675
Q

How many patients with withdrawal seizures go on to develop delirium tremens?

A

30%

676
Q

Prevalence of heroin use in the UK

A

1%

677
Q

M:F ratio of heroin use

A

2:1

678
Q

Age of most treatment seekers of heroin misuse?

A

20s

679
Q

Oral bioavailability or morphine

A

30%

680
Q

How many patients on benzos for 1-5 months will develop dependence?

A

15%

681
Q

How many patients on benzos for a year will develop dependence?

A

40%

682
Q

How many 16-29 year olds in the UK have used amphetamines at least once?

A

22%

683
Q

Features of withdrawal from cocaine

A 
Intense craving with lack of physical withdrawal sx
Dysphoria
Anhedonia
Irritability
Hypersomnolence
684
Q

When do withdrawal of cocaine sx peak in heavy use?

A

3 days

685
Q

How many schedules in the Misuse of Drug Regulations 2001?

A

Five

686
Q

Examples of drugs in Schedule 1

A

Coca leaf
Cannabis
LSD
Mescaline

687
Q

Regulations of Schedule 1 drugs

A

No medicinal use.
Supply limited to research or special purposes judged to be in public interest.
Requires Home Office license to possess.

688
Q

Examples of drugs in Schedule 2

A 
Diamorphine
Dipipanone
Morphine
Remifentanil
Pethidine
Secobarbital
Glutethimide
Amphetamine
Cocaine
689
Q

Regulations of Schedule 2 drugs

A

Special px requirements and safe custody requirements - except for secobarbital.
Stock drugs must be recorded in a register that meets regulations of the 2001 Regulations
Drug stock must only be destroyed in presence of an appropriately authorized person

690
Q

Schedule 3 drugs?

A 
Barbituates except secobarbital
Buprenorphine
Diethylpropion
Mazindol
Meprobamate
Pentazocine
Phentermine
Temazepam
691
Q

Regulations of Schedule 3 drugs

A

Subject to special px requirements except for temazepam.
Not subject to safe custody requirements except for buprenorphine, diethylpropion, flunitrazepam and temazepam.
No need to keep register.
Requirement for retention of invoices for 2 years.

692
Q

Schedule 4 Part 1 drugs

A

Benzos except temazepam

Zolpidem

693
Q

Schedule 4 Part 2 drugs

A 
Androgenic and anabolic steroids
Clenbuterol
HCG
Non-human chorionic gonadotrophin
Somatotropin
Somatrem
Somatropin
694
Q

Regulations of Schedule 4 drugs

A

Not subject to special px or safe custody requirements.
No need for register.
Requirement for retention of invoices for 2 years.

695
Q

Schedule 5 drugs

A

Weak preparations of drugs in other schedules e.g. codeine

696
Q

Regulations of Schedule 5 drugs

A

Exempt from all CD regulations except need to keep invoices for at least 2 years

697
Q

What should all CD px have?

A

Patients full name, address and age
Name and form of drug written
Dose written
Total quantity of preparation or number of dose units to be supplied in both words and figures
Patient identifier number (NHS)
Signed by prescriber along with GMC number - must be handwritten

698
Q

How long are px of Schedule 1-4 drugs valid?

A

28 days

699
Q

Which drugs cannot be px on repeat prescriptions?

A

Schedule 2 & 3 drugs

700
Q

What is Varenicline?

A

Partial agonist at alpha4beta2 subunit of nicotinic acetylcholine receptor

701
Q

Who first described central pontine myelinolysis?

A

Adams et al in 1959

702
Q

What happens in central pontine myelinolysis?

A

Demyelination of central portion of base of pons

703
Q

Sx of central pontine myelinolysis?

A 
Pain sensation in limbs
Bulbar palsy
Quadriplegia
Disordered eye movements
VOmiting
Confusion
COma/locked-in syndrome
704
Q

Which non-alcoholic diseases can result in central pontine myelinolysis?

A 
Wilsons
Malnutrition
Anorexia
Burns
Cancer
Addisons
Severe hyponatraemia
705
Q

Heritability of alcohol use disorders

A

0.51-0.66

706
Q

Risk of alcohol dependence in individuals with both first and 2nd degree relative

A

4x increase

707
Q

Risk of alcohol dependence in those with affected first degree relative

A

2x increase

708
Q

Genetic loci linked to alcohol misuse

A 
Chromosomes 4p13-12 (GABRB1)
Chromosome 5q33-34 
Chromosome 11q23.1
Chromosome 12q24.2
Chromosome 4q22 cluster
709
Q

Role of chromosome 12q24.2

A

Aldehyde dehydrogenase variants

710
Q

Role of chromosome 4q22

A

Alcohol dehydrogenase polymorphism

711
Q

Screening tools used for alcohol disorders

A

AUDIT
CAGE
MAST

712
Q

What setting is AUDIT made for?

A

GP

713
Q

Sensitivity of AUDIT

A

83% males

65% females

714
Q

How can AUDIT be carried out?

A

Brief structured interview or

self-report questionnaire

715
Q

What subtype of AUDIT can be used in ED?

A

FAST - fast alcohol screening test

716
Q

What is the most widely used alcohol screening tool?

A

CAGE

717
Q

Disadvantages of CAGE

A

Does not include frequency of alcohol use, levels of consumption or episodes of heavy drinking - all of which identify patients in early stages of alcohol misuse.

718
Q

Who conducted a study into use of CAGE in GP?

A

Aertgeerts et al. 2001

719
Q

Sensitivity of CAGE in primary care

A

62% males

54% females

720
Q

What does MAST stand for

A

Michigan Alcohol Screening test?

721
Q

Who was MAST developed for?

A

Detecting dependent drinkers

722
Q

Structure of MAST

A

25 questions related to respondents self-appraisal of problems associated with excessive drinking

723
Q

Sensitivity of MAST

A

86-98%

724
Q

Specificity of MAST

A

81-95%

725
Q

Drawbacks of MAST

A

Focus is on lifetime rather than current occurrence of alcohol problems.
Can therefore miss early stages of alcohol misuse

726
Q

How long is amphetamine present in urine?

A

Up to 48 hours

727
Q

How long are benzos present in urine?

A

Up to 3 days

728
Q

How long is cannabis present in urine if occasional use?

A

Up to 3 days

729
Q

How long is cannabis present in urine if heavy use?

A

Up to 4 weeks

730
Q

How long is cocaine present in urine?

A

6-8 hours

731
Q

How long is cocaine metabolite present in urine?

A

2-4 days

732
Q

How long is codeine present in urine?

A

48 hours

733
Q

How long is methadone present in urine?

A

3 days or more

734
Q

How long is heroin present in urine?

A

1-3 days

735
Q

How long is morphine present in urine?

A

2-3 days

736
Q

How long is PCP present in urine?

A

3-8 days

737
Q

How long is LSD present in urine?

A

<24 hours

738
Q

False positive test producer of PCP

A

Dextromethorphan

739
Q

False positive test producer of marijuana metabolites

A

Ibuprofen

740
Q

False positive test producer of opiates?

A

Tonic water

741
Q

False positive test producer of amphetamines

A

Phenylephrine decongestants

742
Q

What are successive episodes of alcohol withdrawal associated with?

A

Increasing severity and complications

743
Q

What drugs other than benzos can be used in alcohol detox?

A

Chlormethiazole
Carbamazepine
Anticonvulsants
Haloperidol

744
Q

Why should Chlormethiazole be avoided?

A

Risk of respiratory depression, especially when alcohol is consumed during detox

745
Q

First-line alternative to benzos in alcohol detox?

A

Carbamazepine

746
Q

What is Acamprosate?

A

Taurine derivative

Inhibits glutamatergic NMDA receptor function
Balances GABA-glutamate imbalance seen in alcohol dependence

747
Q

Odds ratio for abstinence with acamprosate vs placebo

A

1.73

748
Q

NNT for acamprosate

A

11

749
Q

What is naltrexone licensed for in the UK?

A

Ralapse prevention in alcohol dependence

750
Q

What has naltrexone been shown to be superior that placebo in?

A 
Maintaining abstinence
Relapse rates
Time to first drink
Reduction in number of drinking days
Reduction in craving
Improvement in GGT
751
Q

NNT of naltrexone

A

9-11

752
Q

How does Nalmefene work?

A

Opioid receptor modulator
Anatagonist at mu and delta receptors
Partial agonist at kappa receptors

753
Q

When is Nalmefene recommended?

A

To reduce alcohol consumption in dependent individuals with high drinking level risk after 2 weeks of initial assessment and without physical withdrawal sx and who do not require immediate detox

754
Q

What is the definition of high drinking risk level as per WHO?

A

> 60grams/day in men

>40grams/day in women

755
Q

How long should Disulfiram be continued if initial beneficial effects?

A

3-6 months

756
Q

In whom can SSRIs be helpful for alcohol misuse?

A

Improve drinking outcomes in Type 1 alcoholism

757
Q

In whom can SSRIs be harmful for alcohol misuse?

A

Worsen outcomes in Type 2 Alcoholism

758
Q

What was project MATCH?

A

Multisite (9) USA based RCT of 1726 patients testing the hypothesis that matching patient characteristics to specific treatments would improve alcohol dependence.

759
Q

What did project MATCH find?

A

Patients with low support for drinking derived more benefit from motivational enhancement therapy.
Readiness to change and self-efficacy were the strongest predictors of long-term drinking outcomes.

760
Q

What was the UKATT?

A

Multicentre (7) pragmatic effectiveness RCT of 742 patients comparing MET and Social Behaviour and Network therapy.

761
Q

Who did a meta-analysis into therapies for alcohol dependence

A

Slattery et al 2003

762
Q

What is the FRAMES approach to alcohol?

A 
Feedback of risks
Responsibility highlighted
Advised to abstain or cut down
Menu of alternative options
Empathic interviewing
Self-efficacy enhanced
763
Q

Which drugs should be used in opioid withdrawal if short duration is desirable

A

Alpha 2 adrenergic agonists

Buprenorphine

764
Q

Relapse rates of smoking after 6 months?

A

8%

765
Q

How many smokers quit without assistance?

A

5-10%

766
Q

How long is nicotine replacement therapy (NRT) given for?

A

2 weeks

767
Q

How many patients are compliant with patch NRT?

A

82%

768
Q

Who is Bupropion not licensed for in smoking cessation?

A

Adolescents

Pregnant women

769
Q

Contraindications for Bupropion?

A

Hx of seizures or ED

770
Q

What was pathological gambling classified as in DSM IV?

A

Impulse Control disorder

771
Q

Prevalence of compulsive buying

A

2-8%

772
Q

Gender ratio of compulsive buying

A

> 80% are females

773
Q

How many fitness users use anabolic steroids?

A

13%

774
Q

How many young people in Europe have taken legal highs in the past year?

A

5-10%

775
Q

When should detox for opioid use be used in pregnant women?

A

Middle trimester
If done in first trimester - abortion risk
Laster trimester - possible premature birth

776
Q

What needs to be done if a woman starts pregnancy while on methadone

A

Reduce 1mg every 3 days

Fetal monitoring

777
Q

What dose of methadone is advocated during maintenance while pregnant

A

15mg

778
Q

Calculation for odds

A

Probability / 1 - probability

779
Q

Calculation for probability

A

Odds / 1 + odds

Paper B targeted revision (23 decks)

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