Week 2 - B - Direct self Harm, Huntingtons disease, Depression and bipolar questions and ECT

Question 1

When talking to a patient, should you use the term deliberate self harm or attempted suicide?

Answer 1

Deliberate self harm is the term that should be used

Question 2

Where is suicides more common? What gender is it more common? When is this not the case?

Answer 2

Sucidies are more common in countries further from the equator ie northern europe

They are more common in males in all countries bar finland

Question 3

What is the risk of suicide in the 12 months after deliberate self harm?

Answer 3

1% risk of suicide

Question 4

By what mechanism is Huntington’s disease inherited? A - Autosomal dominant B – Autosomal recessive C -X-linked recessive D – X-linked dominant E – Multifactorial Inheritance

Answer 4

A - autosomal dominant

Question 5

If your patient has an autosomal dominant condition, what are the chances that their child will get it?A – 100% B – 25% C – 75% D – 12.5% E – 50%

Answer 5

E - 50%

Question 6

The phenomoen in which each generation develops a genetic disease at an earlier age is called: A- Acceleration B – Penetrance C – Anticipation D – Heritability E – Transformation

Answer 6

C - Anticipation

Question 7

Huntingtons disease first described thoroughly in 1872 by George Huntington, although there were some mentions in the literature before this What is its inheritance? What cause huntingtons disease?

Answer 7

It is an autosomal dominant condition

It is caused by a trinucleotide expansion of the CAG nucleotide chain on chromosome 4 due to a mutation in huntingitn gene which codes for the huntingtin protein

CAG normally codes for glutamine so more CAG means more glutamine which causes the huntingtin gene to be misshapen

Question 8

How many CAG repeats are normal in the huntingin gene on chromsome 4? How many will most defintely cause diseasee? How many repeats usually can cause juvenile huntingtins disease?

Answer 8

Normally, the CAG segment is repeated 10 to 35 times within the gene.

In people with Huntingtons, the CAG segment is repeated 36 to more than 120 times.

People with more than 40 almost definitely develop Huntingtons with people with more than 60 CAG repeats developing juvenile huntingtons

Question 9

What percentage of the UK have bipolar 1? A – 0.5% B – 1% C – 2%

Answer 9

1% of the Uk have bipolar I 2% of the UK have bipolar II

Question 10

Which of these symptoms would be inconsitnet with mania with psychotic symptoms? * A – normal sleep pattern * B – irritability instead of elation * C – delusional idea that they are being monitored by the police * D - physical aggression * E – flight of ideas

Answer 10

A - normal sleeping pattern

Question 11

Which of these can be a feature of hypomania? A – hearing a voice saying ‘you are special’ B – hearing a voice saying ‘ everone is watching you’ C – paranoid delusions D – impulsive overspending E – self-neglect causing dehydration

Answer 11

The first three psychotic symptoms, the last one is either severely manic, or severely depressed

D – impulsive overspending is hypomania

Hypomania still have some level of function without the psychotic symptoms , mania you kindve lose the ability to take personal care of yourself

Question 12

How is bipolar disorder inherited? A – autosomal dominant B – recessive C – xlinked D – multifactorial E – no

Answer 12

D - multifactorial

Question 13

Is genetic testing for bipolar disorder useful? A – yes B- No

Answer 13

B - no

Question 14

CASE EXAMPLE 1: A 25 year old woman presents with a 2 month history of low mood, loss of interest, lethargy. She is finding it increasingly difficult to cope with work, takes more than 2 hours to get to sleep and even then wakens repeatedly through the night. She denies any previous similar episodes. 4 months ago her husband left her and she has since been living alone; her parents and family are 200 miles away. a) What is the likely diagnosis?

Answer 14

Her likely diagnosis is depression

Question 15

b) What are the three main groups of antidepressants? Name a specific example from each group. How do they differ in their mechanisms of action?

Answer 15

Monoamine reuptake inhibitors * SSRIs - sectively block the reuptake of serotonin in the synaptic celft (citalopram, fluoxetine, paroxeine) * SNRIs - block the reuptake of noradrenaline and serotonin in the synapctic cleft (duloxetine,) * TCAs - block the reuptake of monoamine in the synaptic cleft - mainly serotonin and noradrenaline MAOI - block the degradation of monoamines via the monoamine oxidase enzyme (phenelzine - irreversible) Atypicals - mirtazapine (Noradrenergic & specific serotonergic antidepressant) & bupropion (dopamine uptake inhibitor)

Question 16

c) How would you decide which group of antidepressants to prescribe from in this situation?

Answer 16

First line is SSRI’s. Also think about patients past medical history, drug history and age/gender. Tell her the possible side effects, how long it takes to work and whether they are addictive.

Question 17

When is a treatment considered non-responsive?

Answer 17

Non-responsive treatment to an anti-depressant occurs after inadequate or no response after six weeks of use at the maximum or best tolerated dose of the drug

Question 18

She is prescribed fluoxetine, but re-attends one month later – she is no better. e) What factors may have contributed to her non-response?

Answer 18

Should take 4-6 weeks for antidepressants to work She may have been non-compliant Dose also may be too low

Question 19

After a further month’s prescription of fluoxetine she has still not improved. She is then prescribed paroxetine 50mg per day, but again does not improve after 2 months. f) What non-pharmacological treatment options are there?

Answer 19

Cognitive behavioural therapy Interpersonal therapy

Question 20

What treatment can be considered for severe, life-threatening depression and when a rapid response is required, or when other treatments have failed?

Answer 20

This would be electroconvulsive therapy

Question 21

g) How would you decide what antidepressant to prescribe next?

Answer 21

Would probably be chossing betweena typicals, TCAs and SNRIs Inform the patient of the pros and cons of each

Question 22

She is prescribed imipramine and responds very well to this. She is able to return to work and feels she is functioning at her normal level. She asks how long she should continue to take imipramine. h) How would you answer her question?

Answer 22

After recovery from depression, continue treatment for at least 6 months before stopping

Question 23

Seven years later she re-presents with a further depressive episode following the death of her mother. i) How would you decide which anti-depressant to prescribe

Answer 23

Would probably use imipramine as she responded well to this last time

Question 24

How long should she take the imipramine for in this case?

Answer 24

Take it for at least 12-24 months

Question 25

CASE EXAMPLE 2: A 25 year old woman has had two previous episodes of depression which have responded well to anti-depressants. She now presents with a 2-week history of increased energy, racing thoughts, overactivity and reduced sleep. She appears grandiose at interview, has flight of ideas and speaks of having invented a machine that will make her millions. a) What is the likely diagnosis?

Answer 25

Her most likely diagnosis is bipolar disorder

Question 26

What factors in her history and presentation would influence the decision to commence him on a mood stabilizer?

Answer 26

She has had periods of depression and mania meaning she needs to be on a mood stabiliser

Question 27

What would be the first line mood stabilizer to use? What is its mechanism of action?

Answer 27

Lithium carbonate It acts as a glycogen synthase kinase 3 B inhibitor or by blocking the phosphatidylinositol pathway

Question 28

d) What would you tell her about common side effects and signs of toxicity?

Answer 28

Side effects - GI upset, fine tremor, sedation, diabetes insipidus causing polyuria, hypothyrodism, hypoparathyroidism, ankle swelling Toxicity - vomiting , diarrhoea, ataxia, coarse tremor drowsiness, convulsions, coma VERY IMPORTANT TO KEEP HYDRATED WHEN ON LITHIUM OR CAN BECOME TOXIC

Question 29

e) What investigations are routinely monitored during the course of therapy?

Answer 29

Monitor U&Es and lithium levels 3 monthly Check TFTs 6 monthly

Question 30

f) If this drug is not tolerated or is ineffective, what alternatives are there?

Answer 30

Anti-convulants - carbamezapine, sodium valproate, lamortigine or Anti-psychotics

Question 31

The initial choice of drug is effective and provides a period of relative stability. 2 years later, she presents to say that she and her husband want to have a child. g) What advice would you give her about whether to discontinue the drug or continue it through pregnancy?

Answer 31

Congenital abnormalities can occur when the mother is taking lithium. Can also cause heart arrhythmias in the child. However if the mother was going to come off the drug then there is a 50% chance of relapse. Need to monitor the drug levels very closely very frequency if taking lithium throughout pregnancy

Question 32

What heart anomalies is the use of lithium during pregnancy associated with?

Answer 32

Ebstein’s anomaly is a congenital heart defect in which the septal and posterior leaflets of the tricuspid valve are displaced towards the apex of the right ventricle of the heart.