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mrcp combined > Psych > Flashcards

Psych Flashcards

1
Q

what is somatisation disorder?

A

Somatisation disorder
• Multiple physical SYMPTOMS present for at least 2 years
• Patient refuses to accept reassurance or negative test results

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2
Q

what is hypochondrial disorder?

A

Hypochondrial disorder
• Persistent belief in the presence of an underlying serious DISEASE, e.g. Cancer
• Patient again refuses to accept reassurance or negative test results

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3
Q

what is conversion disorder?

A

Conversion disorder
• Typically involve loss of motor or sensory function
• Some patients may experience secondary gain from loss of function
• Patients may be indifferent to their apparent disorder
• Psychogenic aphonia is a form of conversion disorder: not speaking after a shocking event.

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4
Q

what is dissociative disorder?

A

Dissociative disorder
• Dissociation is a process of ‘separating off’ certain memories from normal consciousness
• In contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
• Dissociative identity disorder (DID) is the new term for multiple personality disorder as is the
most severe form of dissociative disorder

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5
Q

what is muchausens syndrome?

A

Munchausen’s syndrome
• Also known as factitious disorder
• The intentional production of physical or psychological symptoms

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6
Q

what is malingering?

A

Malingering
• Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain

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7
Q

what is the criteria for body dysmorphic disorder?

A

• Preoccupation with an imagine defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive
• The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
• The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa)

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8
Q

what is SAD?

A

Seasonal affective disorder (SAD) describes depression which occurs predominately
around the winter months. Bright light therapy has been shown to be more effective than placebo for
patients with SAD

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9
Q

what are features of PTSD?

A

• Re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
• Avoidance: avoiding people, situations or circumstances resembling or associated with the
event
• Hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems,
irritability and difficulty concentrating
• Emotional numbing - lack of ability to experience feelings, feeling detached from other people
• Depression
• Drug or alcohol misuse
• Anger
• Unexplained physical symptoms

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10
Q

what is the treatment of PTSD?

A

• Following a traumatic event single-session interventions (often referred to as debriefing) are not recommended
• Watchful waiting may be used for mild symptoms lasting less than 4 weeks
• Trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and
reprocessing (EMDR) therapy may be used in more severe cases
• Drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug
treatment is used then paroxetine or mirtazapine are recommended

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11
Q

what divides mania and hypomania?

A

psychotic symptom

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12
Q

what are the features of sleep paralysis?

A

Features
• Paralysis - this occurs after waking up or shortly before falling asleep
• Hallucinations - images or speaking that appear during the paralysis

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13
Q

what is the management of sleep paralysis?

A

Management
• if troublesome clonazepam may be used

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14
Q

Baby blues:
-is this common?
-when does this occur?

A

Seen in around 60-70% of women
Typically 3-7 days following birth and more common in primips
Mothers: characteristically anxious, tearful and irritable

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15
Q

what is the management of baby blues?

A

Reassurance and support, the health visitor has a key role

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16
Q

Postnatal depression:
-how common is this?
-when does this occur?
-what are the features?

A

Affects around 10% of women
Most cases start within a month and typically peaks at 3 months
Features are similar to depression seen in other circumstances

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17
Q

what is the management of postnatal depression?

A

As with the baby blues reassurance and support are important
Cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline may be used if symptoms are severe - whilst they are secreted in breast milk it is not thought to be harmful to the infant
(fluoxetine is best avoided due to a long half-life)

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18
Q

what is puerperal psychosis?
-how common is this?
-what is the onset?
-what are the features?

A

Affects approximately 0.2% of women
Onset usually within the first 2-3 weeks following birth
Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)

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19
Q

what is the management of puerperal psychosis?

A

Admission to hospital is usually required
There is around a 20% risk of recurrence following future pregnancies

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20
Q

what infections has a role in OCD?

A

• some research suggest childhood group A β-hemolytic streptococcal infection may have a role

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21
Q

• Depression (30%)
• Schizophrenia (3%)
• Sydenham’s chorea
• Tourette’s syndrome
• Anorexia nervosa
are all assoc with…

A

OCD

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22
Q

what can we divide schneider’s first rank symptoms into?

A

Schneider’s first rank symptoms may be divided into auditory hallucinations, thought disorders, passivity phenomena and delusional perceptions

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23
Q

describe auditory hallucinations in schizophrenia?

A

Auditory hallucinations of a specific type:
• Two or more voices discussing the patient in the third person
• Thought echo
• Voices commenting on the patient’s behaviour

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24
Q

describe the thought disorder seen in schizophrenia?

A

Thought disorder (occasionally referred to as thought alienation):
• Thought insertion
• Thought withdrawal
• Thought broadcasting

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25
Q

describe passivity phenomena seen in schizophrenia?

A

Passivity phenomena:
• Bodily sensations being controlled by external influence
• Actions/impulses/feelings - experiences which are imposed on the individual or influenced by
others

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26
Q

describe other features apart from passivity phenomena, thought disorder and auditory hallucinations of schizophrenia?

A

• Impaired insight
• Incongruity/blunting of affect (inappropriate emotion for circumstances)
• ↓ speech
• Neologisms: made-up words
• Catatonia
• Negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive pleasure),
alogia (poverty of speech), avolition (poor motivation)

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27
Q

what are poor prognostic factors in schizophrenia?

A

• Strong family history
• Gradual onset
• LowIQ
• Premorbid history of social withdrawal
• Lack of obvious precipitant

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28
Q

Risk of developing schizophrenia
• Monozygotic twin has schizophrenia =
• Parent has schizophrenia =
• Sibling has schizophrenia =
• No relatives with schizophrenia =

A

Risk of developing schizophrenia
• Monozygotic twin has schizophrenia = 50%
• Parent has schizophrenia = 10-15%
• Sibling has schizophrenia = 10%
• No relatives with schizophrenia = 1%

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29
Q

what is concrete thinking

A

When a patient cannot use abstraction to understand the meaning of a sentence. It is more common in schizophrenia. Literal thinking is of course a feature of autism.

30
Q

in alcohol withdrawal when do symptoms/seizures/delirium tremens occur?

A

Alcohol withdrawal
• Symptoms: 6-12 hours
• Seizures: 36 hours
• Delirium tremens: 72 hours

31
Q

what is the pathophysiology of alcohol withdrawal?

A

• Chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
• Alcohol withdrawal is thought to lead to the opposite (↓ inhibitory GABA and ↑ NMDA glutamate transmission)

32
Q

what is the management of alcohol withdrawal?

A

Management
• Benzodiazepines
• Carbamazepine also effective in treatment of alcohol withdrawal
• Phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures

33
Q

what is the management of bulimia nervosa?

A

Management
• Referral for specialist care is appropriate in all cases
• Cognitive behaviour therapy (CBT) is currently consider first-line treatment
• Interpersonal psychotherapy is also used but takes much longer than CBT
• Pharmacological treatments have a limited role - a trial of high-dose fluoxetine is currently
licensed for bulimia but long-term data is lacking

34
Q

describe the physiological abnormalities of anorexia i.e. biochemistry

A

Anorexia features
• Most things low
• G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinemia

• Hypokalemia
• Low FSH, LH, estrogens and testosterone
• Raised cortisol and growth hormone
• Impaired glucose tolerance
• Hypercholesterolemia
• Hypercarotinemia
• LowT3

35
Q

what are hospitalised bulimia and anorexia patients at risk of?

A

Hospitalized patients with AN and NGT feeding are at risk of refeeding syndrome, which can
lead to profound hypophosphatemia

36
Q

what is the criteria for anorexia?

A

• Person chooses not to eat - BMI < 17.5 kg/m2, or < 85% of that expected
• Intense fear of being obese
• Disturbance of weight perception
• Amenorrhoea = 3 consecutive cycles

37
Q

what is the prognosis of anorexia?

A

The prognosis of anorexia nervosa remains poor. 10% of patients will eventually die.

38
Q

when is chronic fatigue syndrome diagnosed?

A

Chronic Fatigue Syndrome: diagnosed after at least 4 months of disabling fatigue affecting mental and physical function more than 50% of the time in the absence of other disease which may explain symptoms

39
Q

what are the baseline investigations for chronic fatigue syndrome patients?

A

NICE guidelines suggest carrying out a large number of screening blood tests to exclude other pathology e.g. FBC, U&E, LFT, glucose, TFT, ESR, CRP, calcium, CK, ferritin, coeliac screening and also urinalysis

40
Q

what is the management for chronic fatigue syndrome?

A

• CBT - very effective, number needed to treat = 2
• Graded exercise therapy - a formal supervised program, do not advise to go to the gym
• ‘Pacing’ - organising activities to avoid tiring
• Low-dose amitriptyline may be useful for poor sleep
• Referral to a pain management clinic if pain is a predominant feature

41
Q

what are the features of serotonin syndrome?

A

• Agitation
• Hyperthermia
• Tachycardia
• Labile BP
• Hyperreflexia and ↑ tone

42
Q

what are the causes of serotonin syndrome?

A

• SSRI
• MAOI (e.g. Moclobemide)

43
Q

what is the management of serotonin syndrome?

A

• Remove the causative factor
• Supportive measures

44
Q

what are the clinical features of restless legs syndrome?

A

• Uncontrollable urge to move legs (akathisia). Symptoms initially occur at night but as condition progresses may occur during the day. Symptoms are worse at rest
• Paraesthesias e.g. ‘Crawling’ or ‘throbbing’ sensations
• Movements during sleep may be noted by the partner - periodic limb movements of sleeps
(PLMS)

45
Q

what are some causes and association of restless legs syndrome?

A

• There is a positive family history in 50% of patients with idiopathic RLS
• Iron deficiency anaemia
• Uraemia
• Diabetes mellitus
• Pregnancy
The diagnosis is clinical although bloods to exclude iron deficiency anaemia may be appropriate

46
Q

what is the management of restless legs syndrome?

A

• Simple measures: walking, stretching, massaging affected limbs
• Treat any iron deficiency
• Dopamine agonists are first-line treatment (e.g. Pramipexole, ropinirole)
• Benzodiazepines
• Gabapentin

47
Q

for CBT:
how many sessions per week
when should this be completed
how many hours in total

A

• Useful in the management of depression and anxiety disorders
• Usually consists of one to two hour sessions once per week
• Should be completed within 6 months
• Patients usually get around 16-20 hours in total

48
Q

how do antipsychotics work?

A

Antipsychotics: act as dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways. Conventional antipsychotics are associated with problematic extrapyramidal side-effects which has led to the development of atypical antipsychotics such as clozapine

49
Q

what extrapyramidal side effects are seen in antipsychotics?

A

• Parkinsonism
• Acute dystonia (e.g. Torticollis, oculogyric crisis)
• Akathisia (severe restlessness)
• Tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur
in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)

50
Q

apart from extrapyramidal side effects - what other side effects are seen in antipsychotics?

A

• Antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
• Sedation, weight gain
• Raised prolactin: galactorrhoea
• Neuroleptic malignant syndrome: pyrexia, muscle stiffness
• ↓ seizure threshold (greater with atypicals)
• Antipsychotics are not addictive

51
Q

when should atypical antipsychotics be used first line?

A

Atypical antipsychotics should now be used first-line in patients with schizophrenia, according to 2005 NICE guidelines. The main advantage of the atypical agents is a significant reduction in extra-pyramidal side-effects.

52
Q

how does olanzapine work?

A

Olanzapine, like other atypical antipsychotics, is known to block serotonin receptors
(especially 5-HT2 subtype) as well as D2 dopamine receptors

53
Q

what are the side effects of atypical antipsychotics?

A

• W eight gain
• ↑ risk of venous thromboembolism
• Olanzapine and risperidone are associated with an ↑ risk of stroke in elderly patients
• Clozapine is associated with agranulocytosis

54
Q

when should clozapine be used?
-what needs to be monitored during treatment?

A

Clozapine, one of the first atypical agents to be developed, carries a significant risk of agranulocytosis and full blood count monitoring is therefore essential during treatment. For this reason clozapine should only be used in patients resistant to other antipsychotic medication
Adverse effects of clozapine
• Agranulocytosis (1%), neutropaenia (3%)
• ↓ seizure threshold - can induce seizures in up to 3% of patients

55
Q

which two SSRIs are currently most preferred?

A

Citalopram and fluoxetine are currently the preferred ssris

56
Q

which SSRI is used in elderly patients?

A

• Citalopram is useful for elderly patients as it is associated with lower risks of drug interactions

57
Q

which SSRI is used post MI?

A

• Sertraline is useful post myocardial infarction as there is more evidence for its safe use in this
situation than other antidepressants

58
Q

which SSRI is used in children/adolescents?

A

• SSRIs should be used with caution in children and adolescents. Fluoxetine is the drug of choice
when an antidepressant is indicated

59
Q

what side effects exist with SSRIs?

A

• Gastrointestinal symptoms are the most common side-effect
• There is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump
inhibitor should be prescribed if a patient is also taking a NSAID
• Patients should be counselled to be vigilant for increased anxiety and agitation after starting a
SSRI
• Fluoxetine and paroxetine have a higher propensity for drug interactions
• Citalopram and sertraline and more suitable for patients with chronic physical health problems
as they have a lower propensity for drug interactions.

60
Q

what 4 drugs interact with SSRIs

A

• NSAIDs: NICE advised ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
• Warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
• Aspirin: see above
• Triptans: avoid SSRIs

61
Q

how should SSRIs be initiated?

A

Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks. For patients under the age of 30 years or at increased risk of suicide they should be reviewed after 1 week. If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse.

62
Q

how should SSRIs be stopped?

A

When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.

63
Q

what are discontinuation symptoms in SSRIs?

A

Discontinuation symptoms
• Increased mood change
• Restlessness
• Difficulty sleeping
• Unsteadiness
• Sweating
• Gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
• Paraesthesia

64
Q

what are common side effect of tricyclics?

A

• Drowsiness • Constipation • Blurred vision
• Dry mouth • Urinary retention

65
Q

when is amitriptyline used?
-which tricyclic has a lower incidence of toxicity in overdose?
-which tricyclics are considered the most dangerous in overdose?

A

• Low-dose amitriptyline is commonly used in the management of neuropathic pain and the prophylaxis of headache (both tension and migraine)
• Lofepramine has a lower incidence of toxicity in overdose
• Amitriptyline and dosulepin (dothiepin) and considered the most dangerous in overdose

66
Q

more or less sedative:
Amitriptyline Clomipramine Dosulepin Trazodone

A

more

67
Q

more or less sedative:
Imipramine Lofepramine Nortriptyline

A

less

68
Q

what are the features of neuroleptic malignant syndrome?

A

• More common in young ♂ patients
• Onset usually in first 10 days of treatment or after increasing dose
• Pyrexia
• Rigidity
• Tachycardia
A raised creatine kinase is present in most cases. A leukocytosis may also be seen

69
Q

what is the management of neuroleptic malignant syndrome?

A

Management
• Stop antipsychotic
• IV fluids to prevent renal failure
• Dantrolene may be useful in selected cases
• Bromocriptine, dopamine agonist, may also be used

70
Q

what are short term side effects of ECT?

A

• Headache
• Short term memory impairment
• Memory loss of events prior to ECT
• Cardiac arrhythmia
• Physical complications: fractures,
dislocations etc

71
Q

what is an absolute contraindication to ECT?

A

The only absolute contraindication is raised intracranial pressure.

72
Q

what is the long term side effect of ECT?

A

Long-term side-effects: Some patients report impaired memory

mrcp combined (58 decks)

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