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YR5 Specialties > ICSM Year 5 Psychiatry > Flashcards

ICSM Year 5 Psychiatry Flashcards

1
Q

What is the medical term for the state before falling asleep?

A

Hypnagogic

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2
Q

What is the medical term for the state before waking up?

A

Hypnopompic

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3
Q

What is an extracampine hallucination?

A

A sense of presence/ movement in the absence of a stimulus

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4
Q

What is an elemental hallucination?

A

Simple hallucinations eg. flashes of light/ noise

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5
Q

What is the term given to visual hallucinations in individuals who have lost their sight?

A

Charles de Bonnet syndrome

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6
Q

What are the 4 types of auditory hallucination?

A
  1. Thought echo (pt’s thoughts are projected out loud)
  2. 3rd person voices
  3. Running commentary
  4. Command
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7
Q

What is formication?

A

Tactile hallucinatory feeling of bugs crawling under your skin

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8
Q

What is the name given to the perception of meaningful images from a vague stimulus?

A

Pareidolic illusion

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9
Q

What is a delusion?

A

A fixed, false belief, held despite evidence to the contrary that is not explained by the patient’s background

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10
Q

What is a reference delusion?

A

Patient believes unsuspicious thing has reference to them, eg. TV programme dialogue refers to them

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11
Q

What is Ekbom’s syndrome?

A

The belief that one is infected with parasites

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12
Q

What is the difference between hypochondriasis and Munchausen/ factitious disorder?

A

Hypochondriasis is unconscious pretending to have a medical disorder
Munchausen is conscious

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13
Q

What is Othello syndrome?

A

False belief partner is being unfaithful

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14
Q

What are the names given to a delusionary disorder of excessive sexual desire (eg VIP is in love with them)?

A

Erotomania/ De Clerembault’s syndrome

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15
Q

What is capgras syndrome?

A

Belief that a close acquaintance has been replaced by an imposter

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16
Q

What is fregoli syndrome?

A

False belief that different people are in fact same person in multiple disguises

Fregoli was Italian actor - think one person acting as many

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17
Q

Recall the 3 types of thought disorder

A

Insertion, withdrawal + broadcasting

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18
Q

What is Cotard’s syndrome?

A

Nihilistic delusion in which pt believes they are rotting/ dead - can occur in severe depression

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19
Q

What is Knight’s move thinking?

A

Absence of clear links between successive thoughts

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20
Q

What is flight of ideas, and what psychiatric disorder is it a feature of?

A

Jumping of thoughts but, unlike Knight’s move, with a CLEAR LINK between ideas. A feature of mania but not of psychosis

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21
Q

What is the name given to when a person cannot answer a question without going into massive extra detail?

A

Circumstantiality

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22
Q

What is a neologsim?

A

The formation of new words, which may involve the combining of two words

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23
Q

When was the MHA made?

A

2007

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24
Q

Recall and differentiate between the 4 different non-emergency sections of the MHA under which a patient may be detained

A

S2: admission for assessment
S3: admission for tx
S5(2) Holding for a patient already on the ward
S136: Police order to remove someone who is mentally ill from a public place to a place of safety

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25
Q

What is the maximum duration of each of the non-emergency sections of the MHA?

A

S2: 28d
S3: 6m
S5(2): 72h
S136: 24-36h

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26
Q

What is the requirement for recommendation for detainment under each of the non-emergency sections on the MHA?

A

S2 + 3 = 2 DRs, with at least 1 being Section 12 approved
S5(2) = 1 DR
S136 = a police officer

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27
Q

Under what section of the MHA is emergency treatment undertaken, and who may apply for it?

A

S4: it only needs 1 DR because it’s an emergency + the DR MUST be S12 approved (a psychiatrist)

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28
Q

Who may apply for section 2/3 detainment under the MHA?

A

AMHP (approved mental health professional) or NR (nearest relative)

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29
Q

Who may apply for discharge from a section 2 MHA detention?

A

NR or Mental Health Review Tribunal (MHRT) within first 14d of detention
OR
At any time: by the responsible clinician

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30
Q

Recall the process for forcibly medicating someone under the MHA

A

Under S3 can be forcibly medicated for 3m, if then not consenting, need a SOAD assessment (second opinion appointed DR)

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31
Q

What qualification is required for someone to detain a patient under Section 4 of the MHA?

A

Must be a psychiatrist

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32
Q

What does section 5(4) of the MHA allow?

A

Detention of an inpatient by a nurse

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33
Q

What is the maximum duration of detention under section 5(4) of the MHA?

A

6h (detention by nurse)

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34
Q

What does section 17 of the MHA allow?

A

Allows leave from a current section, but is not permanent discharge

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35
Q

What does section 35 of the MHA permit?

A

Assesment of a patient accused of committing a crime

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36
Q

How long does assesment last under section 35?

A

28d

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37
Q

What are the appeal requirements to section 35 of the MHA?

A

You can’t appeal

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38
Q

What does section 37 of the MHA permit?

A

Tx of a convicted criminal - otherwise like section 3

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39
Q

What are the appeal requirements to section 37 of the MHA?

A

Within 21d to court
After 6m to the MHRT (mental health review tribunal)

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40
Q

What section of the MHA is applied for by the Crown Court?

A

S41: a restriction order

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41
Q

Under which section of the MHA can a serving prisoner be transferred to hospital?

A

S47
When restrictions are added: S49

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42
Q

What is a community treatment order?

A

Discharge from a previous section providing certain conditions are met
Requires renewal every 6m

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43
Q

Describe the role of the Approved Mental Health Professional

A

95% are social workers
Responsible for coordinating assessment + admission of a patient to hospital if needed

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44
Q

Describe the role of the Independent Mental Health Advocate

A

Advocate trained to help the patient find out their rights under the MHA + provide support - you can’t have one under sections 4, 5, 135 or 136

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45
Q

What does DoLS stand for?

A

Deprivation of Liberty Safeguards (within MCA 2005) - which can be within a carehome or hospital

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46
Q

What is the mechanism of action of most antipsychotic drugs vs clozapine?

A

Dopamine receptor antagonists: most block D2
Clozapine blocks D1 + D4

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47
Q

Recall some common side effects of anti-psychotics

A

Extrapyramidal - dystonia/ akathisia/ parkinsonisms/ tardive dyskinesias (more common in typicals)

Hyperprolactinaemia (galacorrhoea, amenorrhoea, gynaecomastia)

Weight gain

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48
Q

Why do atypical antipsychotic drugs have fewer side effects than typicals?

A

More selective (just antagonise D2 + 5-HT2 receptors)

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49
Q

What class of drug is the first line treatment in schizophrenia?

A

Atypical antipsychotic

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50
Q

What class of drug is the first line treatment in relapsed schizophrenia?

A

Typical antipsychotic

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51
Q

In the elderly, what extra risk do antipsychotic drugs carry?

A

Increased risk of stroke + VTE

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52
Q

Describe how the dosage of clozapine is controlled

A

Start low + titrate up slowly
If >48h missed medication, need to start again

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53
Q

Recall one caution of using clozapine

A

If patient stops smoking suddenly, clozapine levels will suddenly rise

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54
Q

Recall 2 examples of typical antipsychotics

A

Haloperidol
Chlorpromazine

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55
Q

Recall 4 examples of atypical antipsychotics

A

Clozapine
Risperidone
Aripiprazole
Olanzapine
Quetiapine

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56
Q

Recall one significant side effect to remember of clozapine

A

Agranulocytosis (1%)

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57
Q

Recall one drug interaction of clozapine

A

Lithium

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58
Q

What is neuroleptic malignant syndrome?

A

A major SE of antipsychotics characterised by:
Fever
Altered mental status
Muscle rigidity
Autonomic dysfunction

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59
Q

What is akathisia?

A

An unpleasant subjective feeling of restlessness

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60
Q

What is tardive dyskinesia?

A

Rhythmic involuntary movements of the mouth, face, limbs + trunk

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61
Q

Describe the monitoring process for patients who take antipsychotic medications

A

Basic obs + bloods (more frequent for clozapine)
Assessment of movement disorders, nutritional status + physical activity
ECG if CVD RFs present

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62
Q

When should an FBC be done in a patient taking clozapine?

A

At frequent intervals for monitoring + every time there’s an infection as need to check there’s no agranulocytosis

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63
Q

Recall the symptoms of suddenly stopping antidepressant medication

A

FIRM STOP
Flu-like Sx
Insomnia
Restlesness
Mood swings

Sweating
Tummy problems
Off-balance (ataxia)
Paraesthesia

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64
Q

Recall 4 examples of SSRIs

A

For Sadness, Panic, Compulsion:
Fluoxetine
Sertraline
Paroxetine
Citalopram

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65
Q

For approx how long do SSRIs make someone feel worse before they feel better?

A

1-2 weeks

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66
Q

Recall one important risk of SSRIs

A

May increase suicidal thoughts/ self-harm risk

Depression can stop people performing ADLs due to extreme lethargy/ apathy: when antidepressant begins to work + enable people to do things again, they are also more able to act on thoughts of self-harm

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67
Q

Recall one important interaction of SSRIs

A

Triptans
Interaction can cause serotonin syndrome, so ask about migraines

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68
Q

Recall one important side effect of citalopram

A

QT prolongation

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69
Q

Recall one important side effect of sertraline

A

Can cause arrhythmias + QT prolongation
But still the antidepressant of choice following an MI

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70
Q

Recall the main side effects of all SSRIs

A

The 5 ‘S’s:
Suicidal idealisation
Stomach (weight gain, DNV)
Sexual dysfunction
Sleep (insomnia)
Serotonin syndrome

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71
Q

When prescribing an SSRI for anxiety, how long should you advise the patient it may take to work?

A

Anxiety may initially worsen, will need 4-6w to work

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72
Q

How long should SSRI medications be continued for?

A

6m after remission of 1st episode
2y after remission if it’s a recurrence
Gradually stop over 4w

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73
Q

Recall 3 drugs that should be avoided in suicide risk, and 2 that are particualrly useful when there is a suicide risk

A

Avoid: TCAs, MAOIs, Venlafaxine - lethal in OD

Use: SSRIs (despite INITIAL suicide risk) or mirtazapine

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74
Q

How should different SSRI medications be switched?

A

Reduce dose over 2w before starting another SSRI

If fluoxetine, wait 4-7d after before starting new SSRI, due to long half life

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75
Q

What does SNRI stand for?

A

Serotonin-noradrenaline reuptake inhibitor

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76
Q

What is the main side effect of SNRIs?

A

Headache

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77
Q

Recall 2 examples of SNRIs

A

Venlaxafine
Duloxetine

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78
Q

Describe the side effects of SNRIs

A

Same ‘5S’ as SSRIs +
Constipation
HTN
Raised cholesterol

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79
Q

What is the mechanism of action of TCAs?

A

Block serotonin + NA re-uptake

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80
Q

What can TCAs be used for at low vs high doses?

A

Low dose: blocks H1 + 5HT + aids sleep

Higher doses: blocks all receptors- used in depression

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81
Q

Why are TCAs not given if there is risk of suicide?

A

Can be fatal in OD

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82
Q

What is one key contraindication for TCAs?

A

If patient also taking a monoamine oxidase inhibitor

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83
Q

Recall the side effects of TCAs

A

TCA:
Thrombocytopaenia

Cardiac (QT prolongation, ST elevation, heart block, arrhythmias)

Anticholinergic (urinary retention, dry mouth, blurry vision, constipation)

Also:
Weight gain + sedation from histaminergic receptor blockade
Postural hypotension from alpha-adrenergic receptor blockade

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84
Q

What are the anticholinergic side effects that are possible with all types of antidepressant?

A

“Can’t see, can’t pee, can’t spit, can’t shit”

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85
Q

Give 2 examples of TCAs

A

Amitriptyline
Clomipramine

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86
Q

What type of antidepressant is mirtazapine?

A

noradrenergic + specific serotonin antidepressant (NaSsA)

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87
Q

What is the most common side effect of mirtazapine?

A

Weight gain

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88
Q

When is mirtazapine indicated?

A

Triad of depression + insomnia + loss of appetite

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89
Q

Give 2 examples of MAOI antidepressants

A

Phenelzine
Selegiline

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90
Q

What does MAOI stand for?

A

MonoAmine Oxidase Inhibitor

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91
Q

What is the main risk of MAOI use?

A

Hypertensive cheese reaction

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92
Q

What type of antidepressant is moclobemide?

A

Reversible Inhibitor of Monoamine oxidase A (RIMA)

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93
Q

What is the max length of prescription for a BDZ drug?

A

2-4w

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94
Q

What is the mechanism of action of BDZs and BARBs?

A

Enhance GABA transmission at GABA-A receptor

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95
Q

How does the mechanism of action of BDZs and BARBs differ?

A

BDZ increases duration of receptor opening
BARB increases frequency of opening

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96
Q

Why are barbiturates more dangerous than BDZs?

A

Less selective so more excitatory transmission

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97
Q

Give 3 examples of long-acting benzodiazepene medications, and what these are useful for

A

Diazepam, lorazepam, chlordiazepoxide

Useful as an anxiolytic, in delirium tremens/ acute alcohol withdrawal

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98
Q

What is the difference between a sedative and a hypnotic drug?

A

Sedative reduces physical + mental activity without producing a loss of consciousness
Hypnotic: induces sleep

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99
Q

Give 2 examples of short-acting BDZs and recall their main clinical use

A

Temazepam
Oxazepam
Used as sedatives

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100
Q

What is a Z drug used to treat?

A

Treats insomnia (similar to a BDZ)

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101
Q

Give an example of a Z drug

A

Zopiclone

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102
Q

When should Z drugs be used?

A

Only when insomnia is severe + disabling

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103
Q

What is a key side effect of zopiclone?

A

Increased risk of falls

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104
Q

Describe the withdrawal process from zopiclone

A

1/8th the daily dose every 2w: reduce by 5mg every 2w until 20mg/d
Then reduce by 2mg every 2w until 10mg/d
Then reduce by 1mg every 2w until 5mg/d
Then reduce by 0.5mg every 2w until completely stopped

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105
Q

What is the antidote to zopiclone, and its mechanism of action?

A

Flumenazil (BDZ antagonist)

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106
Q

Why should zopiclone not be used in pregnancy?

A

Can cause a cleft lip

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107
Q

What are stimulants used to treat?

A

ADHD
Narcolepsy

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108
Q

Give 2 examples of stimulant drugs used to treat ADHD

A

Methylphenidate (Ritalin)
Dexaphetamine

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109
Q

What is the mechanism of action of stimulant drugs used in ADHD?

A

Potentiate the effect of monoamine neurotransmitters (DA, NA, 5HT)

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110
Q

Recall 6 side effects of stimulant drug use

A

Cardiac pathology
Drug-induced psychosis
Appetite suppression
“Risky” behaviour
Insomnia
Impulsivity

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111
Q

What are mood stabilising drugs used to treat?

A

BPAD
Schizoaffective disorder

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112
Q

What are the 4 main mood stabilising drugs?

A

Lithium (1st line)
Valporate (2nd line)
Carbamazapine
Lamotrigine

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113
Q

Recall 4 key side effects of lithium

A

Mild tremor
Hypothyroidism
Eyebrow hair loss
Nephrogenic DI

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114
Q

How does a lithium OD present?

A

Tremor
Ataxia
GI / urinary Sx
Seizures
AKI

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115
Q

What regular monitoring should be done in lithium prescription?

A

Every 3m: lithium levels
Every 6m: U+Es + TFTs

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116
Q

Why should lithium not be used in pregnancy?

A

Causes Ebstein’s abnormality (heart defect)

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117
Q

Recall 2 key side effects of valporate

A

Hair loss + weight gain

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118
Q

What is the main risk of using valporate in pregnancy?

A

Spina bifida
Do NOT prescribe to a woman of child-bearing age unless a pregnancy prevention programme is in place

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119
Q

What is the main risk of using carbamazipine in pregnancy?

A

Spina bifida

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120
Q

What is the key side effect of lamotrigene use?

A

Severe skin rash - SJS

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121
Q

What is the most likely drug to cause the neuroleptic malignant syndrome?

A

Haloperidol

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122
Q

Recall the symptoms of the NMS

A

Gradual onset triad of:
Mental status change (catatonia)
Muscular rigidity
Autonomic instability (hyperthermia + labile BP)
“MMA” fighters are muscular, mental + (autonomically) unstable

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123
Q

In what time frame does the NMS develop?

A

4-11d after starting any antipsychotic medication

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124
Q

What investigations should be done to identify NMS?

A

FBC (to show leucocytosis)
U+Es (show high CK + AKI)

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125
Q

How should the NMS be managed?

A
  1. ABC
  2. A+E/ ITU admission
  3. Stop antipsychotics
  4. Supportive (fluids, dialysis etc to deal with AKI)
  5. Dantrolene, bromocriptine
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126
Q

Recall the symptoms of the serotonin syndrome

A

ABRUPT onset triad of:
Mental state change
Neuromuscular changes
Autonomic instability (very similar to NMS but ABRUPT rather than gradual)

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127
Q

What symptom is likely to present in the serotonin syndrome but not the NMS?

A

D+V

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128
Q

How does management differ in the serotonin syndrome compared to the NMS?

A

The same except the drug used is a BDZ (clonazepam) rather than dantrolene + bromocriptine

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129
Q

How does ECT work?

A

Induces a generalised tonic-clonic seizure under general anaesthetic

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130
Q

What are the indications for ECT?

A

ECT:
Euphoric (manic episodes)
Catatonia (not moving in an unusual position)
Tearful (severe depression that is life-threatening)

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131
Q

What is an absolute contraindication for ECT?

A

Raised intracranial pressure

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132
Q

What are 5 short term side effects of ECT?

A

Headaches
Nausea
Muscle aches
Cardiac arrhythmia
Retrograde amnesia (loss of memories before the ECT)

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133
Q

What is the main target of CBT?

A

So-called ‘Negative Automatic Thoughts’

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134
Q

What is Beck’s negative cognitive triad

A

Self-perpetuating triad of:
- Negative self-view
- Negative future view
- Negative world view

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135
Q

Describe the negative cycle that CBT aims to tackle

A

Thoughts (eg “She didn’t smile at me when she walked past”)
–> emotions (“I’m such a nobody, no one acknowledges me”
–> behaviours (“I’m going to avoid everyone + not waste their time”)

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136
Q

Recall the name of 2 CBT methods used to tackle negative thought patterns

A

Longitudinal format/ hot-cross bun methods

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137
Q

Describe the longitudinal format of CBT

A
  1. Get a detailed hx from early life to present: identify early experiences, critical incidents etc
  2. How do these early experiences affect core beliefs? (Beck’s triad)
  3. Identify NATs: eg mental filters/ predictions/ mountains + molehills
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138
Q

What is the theoretical basis of psychodynamic psychotherapy?

A

Problems are shaped by childhood experiences
–> causes conflict between conscious + unconscious mind
Therapy reveals unconscious mind

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139
Q

What is the difference between psychoanalytics and psychodynamics?

A

Psychoanalytics = internal conflicts
Psychodynamics = interpersonal conflicts

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140
Q

How does the aim of psychodynamic psychotherapy differ from CBT primarily?

A

Aims to change personality + emotional development, rather than aiming to understand thoughts + see how that impacts the individual

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141
Q

Recall 4 protective factors against suicide

A

Married
Lithium medication
Faith
No substance abuse

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142
Q

What is the reversing agent for overdose on a BDZ?

A

Flumenazil

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143
Q

What is the reversing agent for overdose on a Z drug?

A

Flumenazil

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144
Q

What is the reversing agent for overdose on an opiate?

A

Naloxone

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145
Q

What is the reversing agent for overdose on paracetamol?

A

N-acetylcysteine

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146
Q

What is delirium?

A

Disturbance of attention/ awareness that develops over a short period of time that is a change from baseline - that can’t be better explained by another condition

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147
Q

What are the most important differentials to consider in delirium?

A

Infection
Medication
Constipation
SO MANY causes, look for many + don’t be satisfied with 1

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148
Q

What assessment tools are used for delirium diagnosis?

A

Confusion Assesment Method
4AT

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149
Q

Describe the conservative management of delirium

A

Re-orientation techniques
Treat precipitants
De-escalation techniques for distress + agitation

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150
Q

What is the medical management of delirium?

A

Haloperidol
Lorazepam (if parkinsons)
Chlordiazepoxide (if alcohol withdrawal)

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151
Q

What is the prognosis for delirium?

A

37% die within 6m
Only 25% have a clinically important recovery in ADLs

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152
Q

What drug can be used IM to rapidly tranquilise if the individual refuses PO medications?

A

IM lorazepam

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153
Q

Recall 3 things that are important to consider before the administration of rapid tranquilisation

A
  1. Is there an advance decision in place?
  2. What is the therapeutic goal (ie. desired level of sedation)?
  3. What medicines have they had in the past 24h + how did they respond?
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154
Q

How should the INITIAL method of rapid tranquilisation differ between an unknown/ neuroleptic naïve patient, and a patient with a confirmed history of antipsychotic use?

A

PO medication (not IM)

Unknown/naïve pt: lorazepam

Known/ confirmed antipsychotic use: lorazepam/ olanzapine/ haloperidol + promethazine (acronym = Lots Of Hallucinations + Panic)

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155
Q

How long should be left to assess a patient’s response to oral tranquilisation?

A

1 hour at least

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156
Q

What is the convention for IM tranquilisation in an unknown/ neuroleptic naïve patient?

A

IM Lorazepam: wait 30m for a response

If response only partial: repeat IM lorazepam dose

If no response: WAIT until >1h since lorazepam, then give IM olanzapine OR IM haloperidol + promethazine
(check there is no cardiac disease with ECG)

Acronym for orders of anti-psychotics = Lots Of Hallucinations AND Panic (Lorzaepam, Olanzapine, Haloperidol AND promethazine)

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157
Q

What is the most important factor to guide use of IM medication for rapid tranq in a known patient/ patient with a confirmed history of antipsychotic use?

A

Presence/ absence of cardiac disease

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158
Q

What is the convention for administering IM tranquilisation in a known patient with NO cardiac disease?

A

Start with haloperidol with promethazine (Last thing on rapid tranq ladder (L–>O –> P+H) is for patients who are known + definitely do not have cardiac disease)

Wait 30m for response + repeat if response only partial

If no response: lorazepam (if not already used) or olanzapine

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159
Q

What is the convention for administering IM tranquilisation in a known patient WITH cardiac disease?

A
  1. Lorazepam: wait 30m for response OR olanzapine (repeat if partial response)
  2. If no response: wait 1h, then give lorazepam/ olanzapine
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160
Q

Recall the dosing for oral rapid tranquilisation medications

A

Lorazepam: 1-2mg (max in 24h = 4mg)
Olanzapine: 5-10mg (max in 24h = 20mg)
Haloperidol: 5-10mg (max in 24h = 20mg)
Promethazine: 25-50mg (max in 24h = 100mg)

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161
Q

Recall the dosing for IM rapid tranquilisation medications

A

Lorazepam: 1-2mg (max in 24h = 4mg)
Olanzapine: 5-10mg (max in 24h = 20mg)
Haloperidol: 2.5-5mg (max in 24h = 12mg)
Promethazine: 25-50mg (max in 24h = 100mg)

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162
Q

Describe how rapid tranquilisation should be monitored

A

Ensure baseline is taken
For oral PRN: monitor hourly for minimum 1h on NEWS form
For IM monitor every 15m for minimum 1h on rapid tranquilisation monitoring form

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163
Q

What are the 2 core symptoms of depression?

A

Low mood + anhedonia

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164
Q

What are the adjunct symtpoms of depression?

A

Fatigue
Insomnia
Concentration problems
Appetite change
Suicidal thoughts/ acts
Agitation/ slowing of movements
Guilt

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165
Q

Recall 3 medications that may cause depression

A

Steroids
COCP
Propranalol

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166
Q

What is dysthymia?

A

Sub-threshold depression (2-5 Sx) of depression for at least 2y

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167
Q

What is atypical depression?

A

Just somatic Sx (weight gain, hypersomnia)

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168
Q

What can improve the symptoms of anxiety-induced insomnia?

A

Mood is increased by increased sleep + eating

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169
Q

What is a depressive stupor?

A

Such extreme psychomotor retardation that the individual grinds to a halt

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170
Q

Recall the roles of the different monoamines, which are reduced in depression

A

Noradrenaline (mood, energy)
5-HT/serotonin (sleep, appetite, memory, mood)
Dopamine (psychomotor activity, reward)

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171
Q

How would you go about investigating for depression?

A

Full hx + collateral hx
Physical exam + MSE
Bloods to check for anaemia, hypothyroidism + diabetes
Rating scale (Eg PHQ9, CDI (children), EPDS (pregnancy)

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172
Q

Describe the MSE

A

Appearance
Behaviour
Speech (rate, tone, volume)
Emotion (mood subjective + objective, affect)
Thought (formal thought disorder? Content? (delusions)
Perception (illusion + hallucination)
Cognition (orientation to time/ place/ person), AMTS/ MOCA score
Insight (into both dx + tx)

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173
Q

How is depression treated in children and young people?

A

If mild, watchful waiting, self-help + lifestyle advice
If moderate-severe:
5-11y = family therapy, IPT/ individual CBT, referral made through CAMHS
12-18y = psychological intervention, probably individual CBT, if really bad + fluoxetine
Must try to avoid medication if at all possible

Intensive psychological therapy thorugh CAMHS if completely unresponsive to tx

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174
Q

How is depression treated in adults?

A

Check suicide risk

  1. Initial suspected depression / sub-threshold Sx: watchful waiting, with follow up in 2w, education about sleep/ mind.co.uk etc
  2. Persistent sub-threshold/ mild Sx: group/ computerised CBT/ guided self-help - only give medication if sub-threshold Sx last > 2y
  3. Moderate Sx/ persistent sub-threshold refractory to 2: individual CBT/IAPT + medications with regular review every 2w for 3m (or every week if suicidal )
  4. Severe depression/ risk to life/ neglect: high-intensity psychsocial interventions, section if necessary, medications, ECT if necessary
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175
Q

What is the first line antidepressant medication?

A

SSRIs (sertraline, citalopram, fluoxetine, paroxetine)

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176
Q

When should a second line antidepressant be tried?

A

After trying 2 different SSRIs

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177
Q

What is the second line antidepressant medication?

A

SNRIs (venlaxafine, duloxetine)

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178
Q

Recall the stepped increase of dose of venlaxafine

A

37.5mg BD –> 75mg BD –> 75mg morning, 150mg evening

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179
Q

What is the indication for 3rd line antidepressant treatment?

A

If they are resistant to tx, you can’t augment tx with further medication

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180
Q

What are the 3rd line treatment options for depression medication?

A

Antipsychotic (eg quetiapine), lithium, or other antidepressant eg mirtazapine

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181
Q

What is the ideal blood level of lithium?

A

0.6-1.0 (toxicity at >2.0)

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182
Q

In which scenario is mirtazapine most useful?

A

When Sx of insomnia + appetite reduction are evident + debilitating

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183
Q

Describe the side effect profile of sertraline

A

Smallest SE profile, so good to give to people with co-morbid IHD

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184
Q

What is the best antidepressant to give to children?

A

Fluoxetine

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185
Q

What is the most common use of paroxetine?

A

For major depressive episodes

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186
Q

When should paroxetine not be used and why?

A

Pregnancy:
In 1st trim may cause congenital heart defects
In 3rd trim may cause persistent pulmonary HTN

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187
Q

How can you differentiate between psychotic depression and schizophrenia in the history?

A

“He wants to kill me”, “Why is that?”, “the world is better off without me” = depression
“I have no idea, but I got the message “ = schizophrenia

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188
Q

How is BPAD defined in the ICD-10?

A

> /= 2 episodes
1 must be manic
Mania lasts ~4m
Depression lasts ~6m
Complete recovery between 2 episodes

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189
Q

How can a manic episode be identified?

A

It’s more associated with irritability than elevated mood
May have grandiose delusions, flight of ideas, over-optism OR suicidal ideas

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190
Q

How is mania diagnosed?

A

Need >,3 characteristics of mania on the MSE, lasting at least 7d + causing an impaired occupational/ social functioning +/- psychosis

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191
Q

What is hypomania?

A

> 3 characteristics of mania lasting >,4d
No impairment of functioning
No delusions/ psychosis

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192
Q

What is the difference between type 1 and type 2 BPAD?

A

Type 1 has proper manic episodes
Type 2 has recurrent depressive episodes with less prominent hypomanic episodes

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193
Q

What is rapid cycling BPAD?

A

> 4 episodes per year

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194
Q

What is the best treatment for rapid cycling BPAD?

A

Sodium valporate

195
Q

How much is BPAD risk increased by a 1st degree relative having BPAD?

A

7 fold

196
Q

What is the rating scale used to investigate BPAD?

A

Young mania rating scale

197
Q

Why can BPAD be hard to pick up on?

A

Most BPAD patients present in depressive episodes
So always need to ask about mania Sx

198
Q

Recall some differentials for BPAD?

A

Organic: drugs, dementia, frontal lobe disease, delirium, cerebral HIV
Schizophrenia
Cyclothymia (persistent mild mood instability: never severe enough to cause BPAD/ depression)
Puerperal disorders

199
Q

How should the urgency of referral be judged in suspected BPAD?

A

If hypomania: routine referral to CMHT
If full-on mania: urgent referral to CMHT or admit

200
Q

How should acute mania be treated?

A

Gradually taper off + stop medications (eg SSRIs)
Monitor fluid + food intake
May need to sedate
If not on tx: aim to stabilise them before starting lithium
If already on tx, check lithium levels: it might be atypical
+ optimise current medications + stop antidepressants

201
Q

How should mania be managed in the longterm?

A

First line is lithium alone - which needs regular monitoring and may take up to 5 weeks to titre correctly
Second line is adding valporate (which doesn’t need monitoring but has naff side effects like hair loss, weight gain and nausea)
If lithium isn’t tolerated try olanzapine/ valporate alone

202
Q

How do you manage BPAD if they have comorbid depression?

A

You can’t use antidepressants alone as they may cause mania!
Try first: fluoxetine and olanzapine
Seond try quetiapine alone

203
Q

What is the use of psychological therapies in BPAD?

A

May improve compliance with medication long term

204
Q

What is the prognosis for BPAD?

A

15% willl commit suicide, but lithium reduces this to same level as general population

205
Q

How does the ICD-10 define schizophrenia?

A

A. More than 1 of Shneider’s 1st rank symptoms for >=1 month duration -
These are:
- Formal thought disorder (echo, insertion, withdrawal, broadcasting)
- Delusions of passivity/ control
- Other bizzare delusion
- Running commentary hallucination

206
Q

Describe the progression of schizophrenia

A
  1. Prodrome/ at-risk mental state: the negative symptoms are dominant, there is social withdrawal and loss of interest in work/ relationships
  2. Acute phase (positive symptoms dominant) - eg delusions, halllucinations and thought interference
  3. Chronic
207
Q

What is wavy flexibility?

A

They will retain any shape you put them into!

208
Q

What is the most common subtype of schizophrenia?

A

Paranoid schizophrenia

209
Q

What are the different subtypes of schizophrenia, and how are they characterised?

A

Paranoid - prominent delusions and hallucinations

Hebephrenic/ disorganised - mainly focused on speech/ thought, disorganised mood and speech, neologisms and knight’s move thinking, inappropriate affect (eg laugh at something sad)

Catatonia - psychomotor disturbance - stupor, wavy flexibility, automatic obedience, forced grasping

Simple - negative symptoms only eg apathy and social withdrawal

210
Q

How does cannabis use increase risk of schizophrenia?

A

Val allele encoding COMT insead of Met allele in non-smokers

211
Q

What rating scale is used to investigate schizophrenia?

A

Brief psychiatric rating scale

212
Q

What type of prescription drug use may cause symptoms of schizophrenia?

A

Steroids

213
Q

What is schizoaffective disorder?

A

Schizophrenic and affective symptoms develop together and are balanced

214
Q

What is schizotypal disorder?

A

Eccentricity with abnormal thoughts

215
Q

By what teams should schizophrenia be managed in an urgent emergency?

A

Crisis Resolution Team and Home Treatment Team

216
Q

By which team should schizophrenia be managed when it is not urgent?

A

Early Intervention in Psychosis (EIP) team

217
Q

Recall the stepwise biological treatment of schizophrenia

A

1st line (6 wks): atypical antipsychotic - apiprazole/ quetiapine are more gentle, olanzapine/ risperidone are stronger and have more side effects

  • Can augment these treatments with BDZ/ mood-stabiliser (lithium/ valporate)

2nd line (6 weeks): typical antipsychotic

3rd line (if treatment resistant): clozapine

218
Q

Recall the psychological treatment of schizophrenia

A

1st line is CBT, which should be offered to all patients regardless of severity of schizophrenia - emphasis is on testing reality. Note: NOT proven to be effective for schizophrenia without concomitant pharmacological intervention.

2nd line is family therapy, especially if the patient is young - it helps to control the highly expressed emotions of schizophrenia and helps the family to cope

219
Q

Recall the community monitoring that is important when treating someone for schizophrenia

A
  1. Baseline measurements - their basic obs, bloods, a screen for movement disorders, assesment of nutritional status and an ECG (as CV risk is bad in quite a few of the meds)
  2. There is a high CVD risk in patients on schizophrenia medications so monitor
220
Q

What kind of things influence schizophrenia prognosis?

A

Good prognostic indicators: sudden onset, late in ilfe, due to a stressful event, with no FHx and a higher IQ

Bad prognostic indicators: gradual onset, early in life, with a lack of precipitating factor, a pos FHx and a lower IQ

221
Q

What are the different subtypes of schizoaffective disorder, and how do they differ?

A

Manic and depressive type - the manic type combines schizophrenia and mania, the depressive type combines schizophrenia and depression - in both the non-schizophrenic symptoms are more prevalent

222
Q

How long do psychotic episodes need to last for a diagnosis of schizoaffective disorder?

A

> = 2 weeks

223
Q

What are the diagnostic requirements for schizoaffective disorder?

A

2 episodes of psychosis are required:
1 must last >2 weeks without any symptoms of mood disorder
1 must demonstrate an obvious overlap of mood and psychotic symptoms

224
Q

How should schizoaffective disorder be treated?

A

As per schizophrenia, and if the affective component is not being controlled add a mood stabiliser

225
Q

How quickly must psychosis resolve in order for it to be classified as an acute episode?

A

Within 3 months - and aim is to keep symptoms to <3m duration as psychosis is toxic to the brain

226
Q

How should acute psychosis be managed?

A

Biological: Antipsychotics short-term/ BDZ (eg high dose olanzapine) + antidepressants/ mood stabilisers

Psychosocial: try to deal with specific social issues too, and add reality-oriented psychotherapy

227
Q

What is delusional disorder, according to the ICD-10?

A

Persistent/ life-long delusions with no/few hallucinations: cannot inclue schizophrenic symptoms/ evidence of organic or brain disease/ clear auditory hallucinations

228
Q

How does onset affect prognosis in psychosis?

A

Rapid onset is associated with a better prognosis

229
Q

How should delusional disorder be managed?

A

There’s poor evidence for biologicals in this disorder - may use a BDZ for anxiety
Psychosocial - lots of psychoeducation, and social skills training

230
Q

Recall the important elements of the history in anxiety disorders

A

Anxious people want to be SEDATED
S - symptoms of anxiety
E - episodic/ continuous?
D - drink/ drugs?
A - avoidance and escape
T - timing and triggers
E - effect on life
D - depression

231
Q

If the history reveals episodic anxiety, which 3 differentials should be considered?

A

Phobia, OCD, PTSD

232
Q

What type of psychological therapy is best for phobias?

A

Exposure therapy

233
Q

What type fo psychological therapy is best for OCD?

A

CBT

234
Q

Which anxiety disorders can be treated with medication, and which medication is best?

A

All of them - with SSRIs - most often sertraline

235
Q

What is the prognosis for anxiety generally?

A

Rule of 1/3s - 1/3 recover fully, 1/3 improve partially, 1/3 fare poorly

236
Q

How is GAD defined in the DSM-V?

A

At least 6 months of excessive, difficult to control worry and everyday issues that causes distress/ impairment

237
Q

Recall the possible symptoms of GAD

A

Restlessness
Irritability
Fatiguability
Muscle tension
Sleep disturbance
Poor concentration

238
Q

How many symptoms need to be present most of the time for a GAD diagnosis?

A

3

239
Q

What questionnaire is useful in diagnosis of GAD?

A

GAD-7
(Beck’s anxiety inventory/ HADS can also be used)

240
Q

Recall the stepwise management for GAD

A
  1. Written information + exercise
  2. Low intensity psychological intervention - self-help or a psychoeducational group
  3. High intensity psychological interventions or medications (step-wise)
    - CBT/ applied relaxation
    - Step 1 = SSRI/ paroxetine (8 weeks)
    - Step 2 = different SSRI (like depression)
    - Step 3 = SNRI (venlaxafine) + weekly follow up
    - Step 4 = pregabalin (antiepileptic)
    - Step 5 = quetiapine (atypical antipsychotic)
    Use propranolol as an adjunct for the physical symptoms
241
Q

Which treatments should not be used in phobias?

A
  1. BDZs (high risk of dependence)
  2. Antidepressants - specific phobias don’t respond well
242
Q

What is agarophobia?

A

Fear of leaving home/ entering shops/ crowds/ public places etc

243
Q

Into which 2 classifications is agarophobia classified?

A

As either with or without a panic disorder

244
Q

How is agarophobia managed?

A
  1. Education, reassurance and self-help
  2. Exposure Response Prevention
  3. CBT
245
Q

What is social phobia?

A

The fear of scrutiny of other people leading to avoidance of social situations

246
Q

How can social phobia and agarophobia be differentiated?

A

In social phobia they will tolerate anonymous crowds but smaller groups will spike anxiety

247
Q

How can specific phobias managed?

A

Education/ self-help/ Exposure Response Prevention
BDZs can be given short term

248
Q

What is panic disorder?

A

Recurrent attacks of severe anxiety that are not restricted to any particular circumstances and are therefore unpredictable

249
Q

What is the maximum duration of a panic attack?

A

30 mins

250
Q

How is panic disorder managed?

A

Pretty much same as anxiety with education, self-help, and low-intensity psychological interventions
High intensity treatment:
1st line = CBT + SSRI (citalopram)
If not working after 12 weeks –> change to TCA (imipramine) or add BDZ plus psychodynamic

251
Q

What is OCD?

A

Disorder that may have recurrent obsessional thoughts or compulsive acts

252
Q

How long do OCD behaviours need to persist for OCD to be diagnosed?

A

> /= 2 consecutive weeks - must be a source of stress that interferes with ADLs

253
Q

Describe how obsessions are defined

A

SUTURE
Must be:
- Self-recognised as a product of own mind
- Unpleasantly repetitive
- Themed
- Unpleasurable to think about
- Resisted unsuccessfully at least once
- Egodystonic

254
Q

Describe how compulsions are defined

A

Repetitive mental operations or physical acts, in response to own obsessions/ irrationally-defined rules, performed to reduce anxiety through an irrational belief that it will prevent a dreaded event

255
Q

Describe the gender balance of OCD prevalence?

A

Only anxiety disorder to affect men more than women

256
Q

Which part of the brain can be implicated in OCD?

A

Basal ganglia

257
Q

What is the rating scale that should be used for OCD?

A

Yale-Brown OCD scale

258
Q

Recall some examples of good questions to ask in an OCD history

A

Do you wash or clean a lot?
Do you check the time a lot?
Is there any thought that keeps bothering you that you would like to get rid of
Do your daily activities take a long time to finish
Are you concerned about putting things in a special order or are you very upset by mess?
Do these problems trouble you?

259
Q

How should OCD with mild functional impairment be managed?

A

CBT with Exposure Response Prevention

260
Q

How should OCD with moderate functional impairment be managed?

A

Intensive CBT with ERP or SSRI

261
Q

Recall the start doses of fluoxetine for:
1. Depression
2. Anxiety
3. OCD
4. Bulimia nervosa

A

Depression, OCD: 20mg
Anxiety: 40mg
Bulimia nervosa: 60mg/ 80mg

262
Q

Recall the 4 phases of cognitive therapy for OCD

A
  1. Relabel (tell self hands are not dirty)
  2. Reattribute (Tell self it is OCD making them feel that way)
  3. Refocus (divert attention)
  4. Revalue (do not give importance to OCD thoughts)
263
Q

Define Acute Stress Disorder

A

A transient disorder that develops in an indivisual without any other apparent mental disorder, in response to exceptional physical and mental stress that usually subsides within hours or days

264
Q

What are the key features of adjustment disorder?

A

Initial daze, constriction of conscious field, narrowing of attention, inability to comprehend stimuli, disorientation

265
Q

How should adjustment disorder be managed?

A

Support and reasurance, may give BDZs for short-term distress

266
Q

What may increase the risk of progression to PTSD from adjustment disorder?

A

Formal, immediate, psychological ‘debriefing’

267
Q

How long can adjustment disorder last?

A

No longer than 6 months

268
Q

Describe the presentation of adjustment disorder

A

Symptoms of anxiety and depression, without biological symptoms of depression

269
Q

What would make a grief reaction abnormal/ prolonged?

A

Delayed onset, increasing intensity of symptoms, suicidal idealisation, hallucinatory experiences

270
Q

For how long do symptoms need to persist in order to make a diagnosis of PTSD?

A

1 month

271
Q

What are the key signs and symptoms of PTSD?

A
  1. Re-experiencing
  2. Avoidance of triggers
  3. Hyperarousal
272
Q

Which questionnaire should be used in suspected PTSD?

A

Trauma screening questionnaire

273
Q

How should PTSD be managed?

A

If symptoms <4 weeks –> watchful waiting + treatment of comorbidities (eg depression)

CBT with ‘trauma focus’ has best evidence:
- combo of exposure therapy and trauma-focused theray

Or eye Movement Desensitisation and Reprocessing (EMDR)

274
Q

What mnemonic can be used for investigating substance misuse in the history?

A

TRAP:
T = type
R = route
A = amount
P = pattern

275
Q

Recall the features of dependency

A

Tolerance
Craving
Withdrawal
Difficulty controlling
Continuing despite negative consequences
Primacy (neglecting other interests)
(reinstatemnt)
(narrowing of repetoire)

276
Q

What is the recommended maximum alcohol intake per week?

A

<14 U (both men and women)

277
Q

How many units EtOH per week are associated with hazardous and harmful drinking?

A

Hazardous = 15-35 units per week
Harmful = > 35 units/ week

278
Q

What type of hallucinations may occur in delirium tremens?

A

Liliputian (seeing little people)

279
Q

What type of seizure might present in alcohol withdrawl syndrome?

A

Grand-mal

280
Q

What is a useful initial questionnaire for alcohol dependence investigation, and what are the questions?

A

CAGE
Have you ever tried to Cut down?
Have you ever been Annoyed by people suggesting that you have a problem with your drinking?
Have you ever felt Guilty about drinking?
Have you ever needed a drink to get you going in the morning (Eye-opener)?

281
Q

What are some useful rating scales of alcohol-dependence?

A

1st line = AUDIT (alcohol use disorders identification test) - 0-7 = low risk
2nd line = SADQ (severity and dependence questionnaire)

282
Q

What alcohol screening tool is used in AandE?

A

FAST (fast alcohol screening test)

283
Q

What is the triad of symptoms in Wernicke’s encephalopathy?

A

Ataxia, opthalmoplegia, confusion

284
Q

How many units a day does someone need to drink in order to be admitted as an inpatient for withdrawal?

A

> 30 U per day

285
Q

What are the 1st line chronic treatments for alcohol withdrawal?

A

Acamprosate/ naltrexone

286
Q

What drug should be administered in the case of an alcohol withdrawl seizure?

A

IV lorazepam

287
Q

What drugs should be administered in delirium tremens?

A

Oral lorazepam and IV thiamine/ pabrinex

288
Q

What is the mechanism of action of acamprosate?

A

Enhances GABA transmission to remove craving for alcohol

289
Q

What psychological therapy is appropriate in alcohol detox?

A

Motivational interviewing

290
Q

What structure is damaged by B12 deficiency?

A

Mammillary damage

291
Q

What are the symptoms of Wernicke’s encephalopathy?

A

Ataxia, opthalmoplegia, acute confusion (TRIAD)

292
Q

What are the symptoms of Korsakoff’s psychosis?

A

Anterograde amnesia, confabulation, peripheral neuropathy, cerebellar degenration

293
Q

From what plant are opiates derived?

A

Papaver somniferum

294
Q

What is the most serious infection that you can get from injecting heroin?

A

Hepatitis C

295
Q

Recall 4 local complications of heroin injection

A

Abscess, cellulitis, DVT, emboli (AbCDE) + pseudoaneurysm

296
Q

Recall 4 systemic complications of heroin injection?

A

Septicaemia, infective endocarditis, blood-borne infections, risk of OD

297
Q

Recall the symptoms of heroin intoxication

A

Euphoria and ‘warmth’
OD: pinpoint pupils and low RR
Low-dose side effects: constipation, anorexia, decreased libido

298
Q

How should opiate OD be treated?

A

Naxolone

299
Q

What are the symptoms of opiate withdrawal?

A

Craving, insomnia, agitation, flu-like symptoms, the ‘runs’ (D+V, lacrimation, rhinorrhoea), goose flesh, mydriasis

300
Q

How long after injection of heroin do withdrawal symptoms begin?

A

6 hours after injection

301
Q

How long do opiate withdrawal symptoms last?

A

5-7 days

302
Q

How long do opiates stay in the urine?

A

2 days

303
Q

How should opiate use be managed?

A
  1. Appoint a key worker and develop a care plan
  2. Harm reduction - complete abstinence is unlikely so be pragmatic - needle exchange and vaccinations
  3. Health education - ‘SMART’ recovery
304
Q

What are the two stages of Opiate Substitution Therapy?

A

Stabilisation and detoxification

305
Q

How long does Opiate Substitution Therapy last as an outpatient?

A

12 weeks minimum

306
Q

What are the first line treatments for Opiate Substitution Therapy?

A

Methadone or buprenorphine - and offer naxolone to take home with them and training on when/ how to use it

307
Q

What is the second line drug for Opiate Substitution Therapy, and when would it be indicated?

A

Lofexidine (alpha-2-agonist)
Indications = rapid detox, mild dependence, preference

308
Q

What is the minimum duration of follow-up care following opiate detoxification?

A

6 months

309
Q

For how long following last use is cannabis present in urine?

A

4 weeks

310
Q

Recall some chronic complications of cannabis use

A

Dysthymia, anxiety/ depressive illness, amotivational syndrome

311
Q

Recall 4 types of hallucinogenic drug

A

LSD, phencyclidine, ketamine, magic mushrooms

312
Q

How long can an LSD trip last?

A

12 hours

313
Q

What is a street name for phencyclidine?

A

Angel dust

314
Q

What are the symptoms of phencyclidine use?

A

Violent outbursts and ongoing psychosis

315
Q

Recall the symptoms of ketamine use in smaller and larger doses

A

Smaller = dissociation
Larger = hallucinations and synaesthesia

316
Q

Recall the symptoms of magic mushroom use in smaller and larger doses

A

Small = euphoria
Large = hallucinations

317
Q

What can be used to treat hallucinogen withdrawal short term?

A

BDZs

318
Q

What stimulant is most often used in East African communities?

A

Khat/ quat/ chat

319
Q

Which recreational stimulant drug class may cause dependence?

A

Amphetamines

320
Q

Recall some acute side effects of cocaine use

A

Arrhythmia, intense anxiety, HTN

321
Q

Recall some chronic side effects of cocaine use

A

Nasal septum necrosis, foetal damage, panic and anxiety, delusions, psychosis

322
Q

How can ecstasy cause death?

A

Via dehydration and hyperthermia

323
Q

Recall the 2 phases of cocaine withdrawal

A
  1. Crash phase - depression, agitation, irritability
  2. Withdrawal - poor concentration, insomnia, slowed movements
324
Q

How long does cocaine remain in urine?

A

5-7 days

325
Q

What is the most significant risk of BDZ use?

A

Dependence

326
Q

What is the result of BDZ overdose?

A

Respiratory depression

327
Q

How should BDZ overdose be treated?

A

IV flumenazil

328
Q

What are the 2 options for BDZ withdrawal management?

A
  1. Slow-dose reduction
  2. Switch to diazepam equivalent dose and then slow-dose reduction
329
Q

What is the most common side effect of BDZ withdrawal?

A

Anxiety

330
Q

At what rate should BDZ dose be reduced?

A

1/8th dose every 2 weeks

331
Q

What are the 3 medical options for smoking cessation?

A

Nicotine replacement therapy, varenicline, bupropion

332
Q

What is the mechanism of action of Varenicline and Bupropion?

A

Varenicline = partial nicotine receptor agonist
Bupropion = selective DA and NA reuptake inhibitor (weak)

333
Q

How long before the quit date should Bupropion and Varencline be started?

A

7-14 days

334
Q

Recall some contraindications for varenicline

A

<18 y/o, renal disease

335
Q

Recall some contraindications for bupropion

A

<18 y/o, seizures, CNS disorder, eating disorder, BPAD, cirrhosis

336
Q

Recall the 3 Ps necessary to diagnose personality disorder?

A

Persistent, pervasive and pathological

337
Q

Recall the 3 broad clusters of personality disorders

A

Cluster A = odd/ eccentric (weird) - paranoid, schizoid, schizotypal

Cluster B = dramatic/ erratic/ emotional (wild) - dissocial, borderline, histrionic, narcissistic

Cluster C = anxious/ fearful (worried) - anankastic, anxious-avoidant, dependent

338
Q

What criteria must be met to diagnose a personality disorder?

A

REPORT:
R - relationships affected (pathological)
E - enduring (persistent)
P - pervasive
O - onset in childhood (persistent)
R - results in distress (Pathological)
T - Trouble in occupational/ social performance (pathological)

339
Q

What is the supposed prevalence of personality disorder?

A

10%

340
Q

What are the differences between schizotypal and schizoid personality disorders?

A

Schizotypal: some positive schizophrenia symptoms = eccentricity, paranoia, social withdrawal and inappropriate affect
Schizoid: just negative schizophrenia symptoms

341
Q

Recall the features of paranoid personality disorder

A

SUSPECT
S - sensitive
U - unforgiving
S - suspicious
P - possessive/ jealous
E - excessive self-importance
C - conspiracy theories
T - tenacious sense of rights

342
Q

Recall the features of schizoid personality disorder

A

ALL ALONE
A - anhedonic
L - limited emotional range
L - little sexual interest

A - apparent indifference to praise/ criticism
L - lacks close relationships
O - one-player activities
N - normal social conventions ignored
E - excessive fantasy world

343
Q

Recall the features of histrionic personality disorder

A

ACTORS
A - attention-seeking
C - concerned with appearance
T - theatrical
O - open to suggestive
R - racy/ suggestive
S - shallow affect

344
Q

Recall the features of emotionally unstable personality disorder

A

AEIOU
A - affective instability
E - explosive behaviour
I - impulsive
O - outbursts of anger
U - Unable to plan/ consider consequences

345
Q

Recall the features of dissocial personality disorder

A

FIGHTS
F - Forms, but cannot maintain relationships
I - irresponsible
G - guiltless
H - heartless
T - temper easily lost
S - someone else’s fault

346
Q

Recall the features of anankastic personality disorder

A

DETAILED
D - doubtful
E - excessive detail
T - tasks not complicated
A - adheres to rules
I - inflexible
L - likes own way
E - excludes pleasure and relationships
D - dominated by intrusive thoughts

347
Q

Recall the features of anxious/ avoidant personality disorder

A

AFRAID
A - avoids social contact
F - fears rejection/ criticism
R - restricted lifestyle
A - apprehensive
I - inferiority
D - doesn’t get involved unless sure of acceptance

348
Q

Recall the features of dependent personality disorder

A

SUFFER
S - subordinate
U - undemanding
F - fears abandonement
F - feels helpless when alone
E - encourages others to make decisions
R - reassurance needed

349
Q

What is ‘splitting’ in personality disorders?

A

An immature response where a person cannot reconcile the good and bad in someone and only views them as ‘good’ or ‘bad’

350
Q

In which conditions may splitting be seen?

A

EUPD/ BPD

351
Q

What does ‘dissociation’ describe in personality disoder?

A

An immature ego defence where one assumes a differerent identity to deal with a situation

352
Q

What is sublimation?

A

A mature ego defence where one takes an unacceptable personality trait and uses it to drive a respectable work that does not conflict with their ego/values (i.e. a youth with anger issues signs up to a boxing academy)

353
Q

What is a ‘reaction formation’ in personality disorder?

A

An immature ego defence where one supresses unacceptable emotions and replaces them with their exact opposite (eg a gay man becomes a champion of anti-homosexual policy)

354
Q

What is ‘identification’ in personality disorder?

A

Modelling the behaviour of someone else (eg child who was abused becomes abuser, or child who has lost younger brother playing with younger brother’s toys)

355
Q

What is ‘displacement’ in personality disorder?

A

Defence mechanism whereby someone takes out their emotions on a neutral person

356
Q

What is ‘projection’ in personality disorder?

A

Where a person assumes an innocent or neutral character is guilty for the patient’s actions

357
Q

Which medications might be used in cluster A personality disorders?

A

None

358
Q

Which medications might be used in cluster B personality disorders?

A

antipsychotics, antidepressants and lithium

359
Q

Which medications might be used in cluster C personality disorders?

A

Lithium

360
Q

In which personality disorders is dialetical behaviour therapy particularly useful?

A

EUPD/BPD

361
Q

What are the 2 concepts introduced by DBT?

A

Validation (your emotions are acceptable)
Dialectics (things in life are rarely black and white)

362
Q

Which eating disorder is most genetically heritable?

A

Anorexia nervosa

363
Q

How can you test for proximal myopathy?

A

Squat test

364
Q

What is the expetced T4 thyroid measurement in patients with an eating disorder?

A

Low

365
Q

What ECG abnormality may be present in bulimia nervosa?

A

Long QT

366
Q

What are some indications for immediate admission in high risk patients with eating disorders?

A

Low BMI (not defined by NICE, but approx <13)
Weight loss of >1kg in a week
Septic-looking signs
HR,40/ long QT
Suicide risk

367
Q

What is required for anorexia nervosa diagnosis in the ICD-10?

A
  1. BMI < 17.5
  2. Deliberate weight loss
  3. “Fear of the fat”
368
Q

How are anorexia nervosa and bulimia nervosa distinguished clinically?

A

AN = underweight, BN = normal/ increased weight

369
Q

What is Russel’s sign?

A

Callous/ cut knuckles from self-induced vomiting

370
Q

How is anorexia nervosa managed?

A

NO WATCHFUL WAITING - refer immediately

371
Q

What are the AandE guidelines used for patients with anorexia nervosa?

A

MARISPAN (Management of Really Sick Patients with AN)

372
Q

At what BMI should someone be referred to Community Eating Disorder Services urgently?

A

<15

373
Q

Alongside a referral, in what 3 ways should anorexia nervosa be managed by the GP?

A
  1. Engage and educate (eg stop laxative abuse because it doesn’t affect calorie intake)
  2. Signpost support (eg BEAT, MIND)
  3. Treat co-morbid psychiatric illness
374
Q

What are the first line options for treatment of anorexia nervosa in secondary care?

A

CBT-ED
MANTRA (Maudsley AN Treatment in Adults)
SSCM (Specialist Supportive Clinical Management)

375
Q

What is the duration of CBT-ED?

A

40 weekly sessions

376
Q

What is the focus of MANTRA therapy for anorexia nervosa?

A

Focusing on the cause of the anorexia nervosa

377
Q

Describe SSCM treatment for anorexia nervosa

A

Explore problems of anorexia, educate on nutrition and eating habits, explore a future beyond anorexia

378
Q

What is the target weight gain range for AN patients?

A

0.5-1.0kg/ week

379
Q

When should pharmacological managemrnt be used in AN?

A

If physical symptoms, rapid weight loss or BMI <13.5

380
Q

What is the appropriate drug for pharmacological treatment of AN?

A

Fluoxetine

381
Q

What are the first and second line treatments for children with AN?

A

1st line = family therapy
2nd line = ED-CBT

382
Q

What is the main defining feature of the Refeeding Syndrome?

A

Low phosphate

383
Q

What is the aetiology of the refeeding syndrome?

A

Intracellular shift in (already low) ions due to insulin release upon refeeding

384
Q

Which electrolytes are low in the refeeding syndrome?

A

Low K+, low phosphate, low magnesium

385
Q

What screening questionnaire can be used to screen for anorexia as well as bulimia?

A

SCOFF:
Do you ever make your self SICK because you feel uncomfortably full?
Do you worry you have lost CONTROL over how much you eat?
Have you recently lost more than ONE stone in a 3-month period?
Do you believe yourelf to be FAT when others say you’re too thin?
Would you say that FOOD dominates your life?

386
Q

What are the criteria for diagnosing BN?

A

Must have all 3 of:
1. Binging/ irresistable craving for food
2. Purging behaviours
3. Psychopathology (feeling loss of control. Morbid dread of fatness)

387
Q

What is BED?

A

Binge eating disorder - most common ED, does not include purging pathology

388
Q

How should bulimia nervosa be managed?

A

Like anorexia, refer immediately and screen for immediate admission (most are managed in the community)

389
Q

How should bulimia nervosa be managed by the GP alongside referral?

A
  1. Treat medical complications (eg do a regular dental review)
  2. Treat co-morbid psychiatric illness
  3. For moderate to severe BN, use SSRIs high dose (fluoxetine)
390
Q

Differentiate between dissociative disorder and somatisisation disorder

A

DD = disorders of physical functions under voluntary control and loss of sensation

SD = disorders involving pain or autonomically-controlled sensations

391
Q

What is dissociative fugue?

A

Dissociative amnesia + purposeful travel beyond everyday range

392
Q

What is a dissociative stupor?

A

Lack of voluntary movement/ normal responses to external stimuli

393
Q

What are trance and posession disorders?

A

Temporary loss of personal identity and full sense of awareness of surroundings

394
Q

What part of the body is affected by dissociatve motor disorders?

A

Limbs

395
Q

How can dissociative convulsions be distinguished from an epileptic seizure?

A

Tongue-biting, bruising from falls and incontinence are rare
A real seizure will raise prolactin, but a dissociative seizure will have a normal post-ictal prolactin

396
Q

How can dissociative anaesthesia be distinguished from organic anaesthesia?

A

Areas of anaesthesia do not follow normal dermatomal distribution

397
Q

How is somatisation defined?

A

Multiple, recurrent and frequently changing physical symptoms of 2 years duration without evidence of underlying organic cause

398
Q

Recall the 4 subtypes of somatisation disorder

A
  1. Undifferentiated somatoform disorder
  2. Hypochondrial disorder
  3. Somatoform autonomic dysfunction
  4. Persistent somatoform pain disorder
399
Q

What are the hallmark features of hypochondrial disorder?

A

Often cancer
Pre-occupation with a single problem

400
Q

What is somatoform autonomic dysfunction?

A

Symptoms presented as if due to an ANS-controlled system (eg CVS, GIT, Resp) with ANS arousal (eg palpitations, sweating, flushing, tremor) + subjective non-specific symptoms (pain/ burning)

401
Q

What is the age-limit for early-onset dementia?

A

65 years old

402
Q

What are the 2 most useful screening questionnaires for dementia?

A

AMTS, GPCOG

403
Q

What AMTS score suggests cognitive impairment?

A

<7

404
Q

What is the most detailed assesment of possible dementia?

A

Addenbrooke’s (ACE-R) - 100 questions

405
Q

How many questions are in the MMSE?

A

30

406
Q

What would be the appearance on MRI of a brain affected by Alzheimer’s?

A

Grey matter atrophy, wide ventricles and sulci, temporal lobe atrophy

407
Q

What biomarker can be used to identify Lewy Body dementia?

A

123|-FP-CIP SPECT

408
Q

What are the 3 theories of Alzheimer’s aetiology?

A

Amyloid (beta secretase replaces alpha secretase –> toxic aggregates that form A-Beta protein)
Tau (hyperphosphorylated tau is insoluble)
Inflammation (to do with CNS macrophages)

409
Q

Which region of the brain is the first to be affected by Alzheimer’s disease?

A

hippocampus

410
Q

Recall 4 genetic risk factors for Alzheimer’s

A

Presenelin 1
Presenelin 2
Beta-amloid precursor protein gene
Co-existent Downs syndrome

411
Q

What are the 4 key elements of pathophysiology in Alzheimer’s?

A

Atrophy from neuronal loss
Plaque formation
Neurofibrilliary tangles
Cholinergic loss

412
Q

How does Alzheimer’s characteristically present?

A

The 4 ‘A’s:
- Amnesia
- Aphasia
- Agnosia
- Apraxia

413
Q

If a short-term antipsychotic is required in Alzheimer’s disease, which is most appropriate?

A

Risperidone

414
Q

Recall the options for medical management of Alzheimer’s

A

1st line (mild-moderate) = anticholineesterases: donezepil/ galantamine/ rivastigmine
2nd line (moderate - severe) = memantine - a NMDA (glu) partial receptor agonist

415
Q

What is the first line option for psychological management of Alzheimer’s?

A

Structural group cognitive stimulation

416
Q

What checks should be done before anti-cholineesterase prescription?

A

1st = ECG
Check medications: absolute contraindications are anticholinergics, beta-blockers, NSAIDs and muscle-relaxants
Relative contra-indications = asthma, COPD, GI disease, braadycardia, AV block

417
Q

What is the common presentation of vascular dementia?

A

Step-wise decline that starts with emotional/ personality changes (including labile emotion) and deteriorates to produce cognitive deficit

418
Q

How should vascular dementia be managed?

A

Manage RFs (daily aspirin, dietary advice, stop smoking etc)
Same psychological treatment as alzheimer’s dementia

419
Q

What are Lewy bodies composed of?

A

Alpha synuclein with ubiquitin

420
Q

Describe the distribution of Lewy bodies in Lewy Body Dementia vs Parkinsons disease

A

LBD = brainstem, cingulate gyrus and neocortex
In PD = just brainstem

421
Q

Describe the classical presentation of Lewy body dementia

A

Fluctuating confusion with marked variations in alertness levels

422
Q

What confusing symptoms may be seen in Lewy body dementia?

A

Lilliputian hallucinations (like delirium)
Parkinsonianism
Frequent falls

423
Q

What is an important medication NOT to offer in Lewy body dementia?

A

Antipsychotics - they increase risk of cerebrovasvular disease

424
Q

What medical management can be used in Lewy body dementia?

A

Same as Alzheimers disease - anti-cholineesterases

425
Q

What is another name for frontotemporal dementia?

A

Pick’s disease

426
Q

What is especially unusual about frontotemporal dementia?

A

Early onset (usually 40 to 60 years)

427
Q

Recall the signs and symptoms of frontotemporal dementia

A
  1. Frontotemporal symptoms (disinhibition, personality changes)
  2. Semantic dementia (progressive loss of understanding of verbal and visual meaning)
  3. Progressive non-fluent aphasia (1st they get naming difficulties, this progresses to mutism)
428
Q

What two investigations are most useful in frontotemporal dementia?

A

FDG-PET (fluorodeoxyglucose), MRI (to see frontal lobe shrinkage)

429
Q

What is the prognosis for frontotemporal dementia?

A

Death in 5-10 years

430
Q

What is the inheritance pattern of Huntingdon’s?

A

Autosomal dominant so 50% chance of children inheriting

431
Q

When in the life-course is the onset of Huntingdon’s?

A

30-50 years old

432
Q

What is the general clinical picture of Huntingdon’s?

A

Clumsy, speech difficulties

433
Q

Recall some signs and symptoms of Huntingdon’s

A

Movement: chorea, slurred speech, stumbing/ clumsiness
Cognitive: difficulty organising, learning, being flexible
Psychiatric - depression, irritability, suicide in 9%

434
Q

What are chorea?

A

Involuntary jerking movement that tend to flow from one area to another

435
Q

What is the model for formulation in CAMHS?

A

Biological, psychological and social for the 4 ‘P’s: predisposing, precipitating, perpetuating and protecting

436
Q

What are the ICD-10 criteria for diagnosis of ADHD?

A

Impaired attention and overactivity, present prior to 6 years of age, of long duration, and present in
two or more settings

437
Q

What rating scale can be used to asses ADHD?

A

Conner’s Comprehensive Behaviour Rating Scale (age 6-18)

438
Q

How should ADHD be managed?

A

MDT focused
1st line: consider watchful waiting for up to 10 weeks - refer to specialist if severe symptoms > 10 weeks

If child is under 5:
- 1st line = ADHD-focused group parent-training programme
- 2nd line is referral to a specialist service

If child is over 5:
- 1st line = same (ADHD-focused group parent-training programme)
- 2nd line = referral and medications if ADHD persists
Medications:
- 1st line: methylphenidate
- 2nd line: lisdexaphetamine
- 3rd line: dexaphetamine
- 4th line: atomoxetine

439
Q

What are some side effects of methylphenidate?

A

Abdo pain, nausea, dyspepsia

440
Q

Recall some important things to monitor whilst giving ADHD medication

A
  1. Weight every 3 months (if <10 yo) or every 6 months (>10 yo)
  2. Measure height, HR and BP (as meds may cause interruptions to growth)
441
Q

What % of children with ADHD have it as an adult?

A

15%

442
Q

What medication during pregnancy can increase risk of Autism spectrum disorder?

A

Sodium valporate

443
Q

Recall 4 important associations of ASD

A

Fragile X syndrome
Tuberous sclerosis
Neurofibromatosis
Di-George

444
Q

What is the difference between Asperger’s and Autism?

A

Asperger’s has no delay in language/ cognitive development

445
Q

What is Rett syndrome?

A

Medical disorder that affects girls > boys: X-linked, MECP2 gene - develop normally until about 2 y/o then sudden deterioration and less social interaction - constantly moving hands

446
Q

What is the most common form of ASD?

A

Pervasive Developmental Disorder Not Otherwise Specified (PPD-NOS)

447
Q

In what 3 spheres of life are there abnormalities in Autistic spectrum disorder?

A

Social interaction
Communication
Patterns of behaviour/ interests/ activities

448
Q

What are the typical motor mannerisms of children with ASD?

A

Finger flapping and repetitive whole-body movements

449
Q

Recall a simpler easy diagnostic triad for ASD

A

Deficits in:
1. Verbal and non-verbal communication
2. Reciprocal social interaction
3. Restrictive or repetitive behaviours/ interests

450
Q

What is one hallmark symptom of Autism spectrum disorder?

A

Echolalia

451
Q

Recall the 2 gold standard diagnostic tools for ASD

A
  1. ADI-R (autism diagnostic inventory - revised)
  2. ADOS (Autism Diagnostic Observatory Schedule)
452
Q

Describe the management of Autistic spectrum disorder

A

MDT-based
1st line = play-based interventions (play specialists) and SALT doing reciprocal communication exercices
If challenging behaviour:
- psychosocial assesment: reduce impairment in communication (eg visual aids), treat co-existing physical disorders

453
Q

Define conduct disorder

A

Repetitive and persistent pattern of antisocial behaviour which violates basic rights of others that are not in line with age-appropriate social norms

454
Q

In which age group can oppositional defiant disorder exist?

A

<10 years old

455
Q

For how long must symptoms persist for a diagnosis of conduct disorder?

A

6 months

456
Q

How should conduct disorder be managed?

A

1st line = parent management training programme (eg Webber-Stratton, Triple-P)
If parental engagement is weak, try:
2nd line = child individual or group interventions focussed on problem-solving and anger management

457
Q

By what 3 criteria is learning difficulty defined?

A

IQ < 70, impaired social/ adaptive functionning, onset in childhood

458
Q

At what IQ level is the cause of LD considered to be always organic?

A

IQ <50

459
Q

What is the most prevalent physical symptom of learning difficulties?

A

Poor sleep/ wake cycle

460
Q

What scale is used to assess intellectual impairment?

A

WAIS II

461
Q

What medications might be useful in learning difficulties?

A

Melatonin for sleep

462
Q

Which law protects reasonable adjustment?

A

Disability act 1995

463
Q

Which MMSE scores indicate no impairment/ mild impairment/ severe impairment?

A

24-30 - No cognitive impairment
18-23 - Mild cognitive impairment
0-17- Severe cognitive impairment

464
Q

In anorexia nervosa, which things will be high on a blood test?

A

G’s and C’s raised: growth hormone, glucose, salivary Glands, cortisol, cholesterol, carotinaemia

465
Q

How long after a change in lithium dose should the levels be taken?

A

7 days later and 12 hours following last dose

466
Q

What electrolyte abnormality is associated with SSRIs?

A

Hyponatraemia

467
Q

What is the anti-depressant of choice following a myocardial infarction?

A

Sertralline

468
Q

What is acute dystonia?

A

Sustained muscle contraction (eg oculogyric crisis, torticollis)

469
Q

How can acute dystonia be managed?

A

Procyclidine

470
Q

What is acute dystonia a side effect of?

A

Antipsychotics (typical and atypical alike)

471
Q

What is the most common endocrine disorder developing as a result of chronic lithium toxicity?

A

Hypothyroidism

472
Q

What is the main risk of using paroxetine in pregnancy?

A

Congenital malformations

473
Q

Which antipsychotic reduces the seizure threshold?

A

Clozapine

474
Q

What drug can be used to treat tardive dyskinesia?

A

Tetrabenazine

475
Q

What is the main risk of SSRI use in the third trimester of pregnancy?

A

Persistent pulmonary hypertension of the newborn

476
Q

What are the metabolic side effects of antipsychotics?

A

Hyperlipidaemia
Diabetes mellitus

477
Q

How should antidepressant medication be managed prior to ECT treatment?

A

The dose should be reduced but not stopped

478
Q

What is the most prominent symptom of SSRI-discontinuation syndrome?

A

Diarrhoea

479
Q

What type of incontinence can be caused by TCAs?

A

Overflow incontinence

480
Q

Which psychiatric drug can cause hyperparathyroidism?

A

Lithium

481
Q

Which antipsychotics can be given as a long-acting depot injection, and which of these are typical vs atypical antipsychotics?

A

Typicals: Zuclopenthixol is the main one (Clopixol), also flupentixol
Atypicals: Risperidone

482
Q

How can you differentiate the NMS with serotonin syndrome based on the neuromuscular abnormalities they produce?

A

NMS: reduced activity (‘lead pipe’ rigidity, dysphagia/ dyspnoea due to pharyngeal stiffness)

SS: Increased activity (myoclonus/ clonus, hyperreflexia, tremor, less severe muscular rigidity than the NMS)

483
Q

How do bromocriptine and dantrolene work to treat the NMS?

A

Bromocriptine reverses dopamine blockade
Dantrolene reduces muscle spasm
ECT

YR5 Specialties (27 decks)

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