General Adult Psychiatry

Question 1

DIS

Answer 1

Diagnostic Interview Schedule
1981 Robins
Structured diagnostic interview designed for use by lay interviewers

Question 2

ECA programme

Answer 2

NIMH

Epidemiological Catchment Area Programme

Question 3

CIDI

Answer 3

WHO Composite International Diagnostic Interview

Version of DIS that used ICD criteria

Question 4

NCS

Answer 4

National Comorbidity Survey
First to use the CIDI. 1990-2.
8000 respondents
Reinterviewed between 2000-1 - called NCS-R
Found substantially higher prevalence results than the ECA
Most prevalent anxiety disorder was specific phobia.

Question 5

Findings of ECA and NCS

Answer 5

Number of people with MH problems far outweighed resources available
Did not comment on severity therefore likely overstated demand

Question 6

WMH-CIDI

Answer 6

Revised version of CIDI

Assesses severity and other aspects such as risk factors, socio-demographics and treatments

Question 7

ECA study

Answer 7

Selected neighbourhoods in 5 US communities
1980-5
Each site - 3000 community residents and 500 residents in institutions were sampled (20,000 total)
2 interviews over a year using the DIS
DIS diagnosis of schizophrenia not congruent with psych classifications

Question 8

ECA study - lifetime prevalences

Answer 8

Any disorder 32.3%
Substance misuse disorder 16.4
Anxiety disorder 14.6
Affective disorder 8.3
Schizophrenia and schizophreniform 1.5
Somatization disorder 0.1

Question 9

ECA study - anxiety disorder prevalence (1 month)

Answer 9

Phobia 12.5%
Generalised anxiety and depression 8.5
OCD 2.5
Panic 1.6
Anxiety disorder were twice as common in women as they were in men

Question 10

National Psychiatric morbidity survey 2000

Answer 10

1993-4
Conducted by OPCS (Office for Population Census and Surveys) using CIS (clinical Interview Schedule)
16-64 living in UK
10,000 interviews
Repeated in 2000 and upper age limit increased to 74

Question 11

National Psychiatric Morbidity Survey - Findings

Answer 11

1 in 6 people in Britain have a neurotic disorder
• The most common neurotic/anxiety disorder was mixed anxiety and depression (88 cases per 1000), generalised anxiety was the next most common (44 cases per 1000)
• 5 per 1000 have a psychotic disorder
• Older people report less neurotic symptoms
• Prevalence rates were higher in women than men for all neurotics disorders except
panic (equal)

Question 12

National Psychiatric Morbidity Survey - Findings (2)

Answer 12

44 per 1000 were classed as having a personality disorder, the prevalence being
slightly higher in men
• The most common personality disorder was anankastic (obsessive compulsive
personality disorder) (twice as common as all the others)
• The prevalence of alcohol dependence in the overall population was 74 per 1000
• 10% of people reported using illicit drugs in the year prior to interview, cannabis was
the most commonly used

Question 13

World Mental Health Survey Initiative

Answer 13

Surveys in 28 countries
5000 interviews per country
Sample size >154,000
Interviews face to face by lay interviewers (trained)

Use the WMH-CIDI
The US has the highest prevalence of any disorder
Anxiety d most common followed by mood disorder

Question 14

Male:Female ratios

Answer 14

Reading disorder 3-4:1
ASD 4-5:1
Asperger's 5:1
Tourette's 2-5:1
ADHD children 2:1
ADHD adults 1.6:1
Major depression 1:2
BPAD1 1:1
Panic with agoraphobia 1:3
Panic without agoraphobia 1:2
GAD 1:2
OCS 1:1
Specific phobia 1:2
Conversion disorder 1:2-10
Anorexia 1:9
Bulimia 1:9
BOD 1:3

Question 15

Bipolar disorder - epidemiology

Answer 15

lifetime prevalence 0.3-1.5%
6/12 month prevalence - same
mean age of onset - 17 (community), 21 (hospital studies)
Gender M=F
Comorbidity - substance misuse and anxiety disorder

Question 16

Major depression - epidemiology

Answer 16

lifetime prevalence 4-30%
6/12 month prevalence - same
mean age of onset - 27
Gender M:F 1:2
Comorbidity - substance misuse and anxiety disorder
Most prevalent in 18-44 group
People born since 1945 in industrialised countries have higher lifetime risk and earlier age of onset
Higher rates in women become apparent at puberty
Higher rates in unemployed, divorced, lower socio-economic class, urban areas

Question 17

Major Depression - genetics

Answer 17

Twin studies - risk in 1st degree relatives is about 3 fold
MZ concordance rate = 45%
DZ concordance rate = 20% Heritability = 37%
Polygenic inheritance
GWAS have yet to report any convincingly replicated loci in depression

Question 18

Monamine theory of depression

Answer 18

suggests that allelic variation in genes coding for monoamine synthesis or metabolism or specific receptors may contribute to the risk of mood disorders

Question 19

Serotonin transporter gene

Answer 19

a particular allele has been shown to increase the risk of a subsequent episode of major depression when exposed to childhood adversity (Caspi et al, 2003)

Question 20

Sociotropy

Answer 20

A strong need for approval

a/w increased risk of depression after adverse life events

Question 21

Neuroticism

Answer 21

Measured by EPQ

Predisposes to major depression

Question 22

Parental deprivation and depression

Answer 22

Death of parent in childhood - does not increase risk

Parental separation - increases risk, particularly divorce - due to discord and diminished care

Question 23

Relationship with parents and depression

Answer 23

Physical and seual abuse clear risk factors

Non-caring and overprotective parenting styles are a risk (non-melancholic depression)

Question 24

Depression - precipitating factors

Answer 24

Recent life events - 6 fold excess of adverse life events in months before onset
Poor social support
Physical illness - source of stress but can also have organic mood disorder e.g. HIV, endocrine, brain disease

Question 25

Psychoanalytic theories - Freud

Answer 25

Mourning and melancholia | Loss of an 'object'

Question 26

Psychoanalytic theories - Melanie Klein

Answer 26

Weaning represents a major symbolic loss for the infant Leads to attempt at reparation and concern for others Failure in this can result in depressive reactions in the face of future losses

Question 27

Psychoanalytic theories - John Bowlby

Answer 27

Insecure attachment can increase the risk of depression

Question 28

Cognitive theories - Beck

Answer 28

Cognitive distortions such as arbitrary inference, selective abstraction, overgeneralization and personalisation lead to persistence of negative automatic thoughts. Believes that dysfunctional beliefs (schemas) precede and predispose to depression.

Question 29

The monoamine hypothesis

Answer 29

depressive disorder is due to abnormality in a monoamine neurotransmitter at one or more brain sites noradrenaline and dopamine are catecholamines

Question 30

5-HT function

Answer 30

Plasma tryptophan levels are decreased in untreated depressed patients Shown in CSF studies (impulsive suicide attempts), neuroendocrine tests (blunted 5-HT neuroendocrine responses), imaging studies (decreased brain 5-HT1a receptor binding (PET) and decreased brain 5-HT re-uptake sites (SPECT and PET))

Question 31

Noradrenaline function

Answer 31

Increased brain noradrenaline elevates growth hormone. GH response is blunted in depressed patients Catecholamine synthesis can be reduced with AMPT. AMPT leads to depressive relapse in those with a personal h/o depression

Question 32

Dopamine function

Answer 32

CSF levels of HVA are consistently low in depressed patients | AMPT leads to clinical relapse

Question 33

Amino acid neurotransmitters

Answer 33

Decreased levels of glutamate in the anterior brain regions in depressed patients

Question 34

Endocrine abnormalities

Answer 34

50% of patients with Cushing's syndrome suffer from major depression Addison's disease, hypothyroidism and hyperparathyroidism also associated

Question 35

HPA axis

Answer 35

Plasma cortisol secretion is increased throughout the 24h cycle in 50% of those with mod-sev depression A/w enlargement of the adrenal gland Increased cortisol response to ACTH challenge

Question 36

Thyroid function

Answer 36

levels of free T3 may be decreased | 1/4 of depressed patients have a blunted TSH response to TRH (also in alcoholism and panic disorder)

Question 37

Organic causes of depression | Medications

Answer 37

``` Riserpine Interferon alpha Beta blockers Levodopa Digoxin Anabolic steroids H2 blockers Oral Contraceptives ```

Question 38

Organic causes of depression | Drug abuse

Answer 38

Alcohol Amphetamine Cocaine Hypnotics

Question 39

Organic causes of depression | Metabolic

Answer 39

``` Hyperthyroidism Hypothyroidism Cushings Addisons Hypercalaemia (can be caused by Li or thiazide diuretics) Hyponatraemia DM ```

Question 40

Organic causes of depression | Nutritional

Answer 40

Pellagra | Vit B12 def

Question 41

Organic causes of depression | Neurological

Answer 41

``` Stroke MS Brain tumour PD Huntington's Epilepsy Syphilis Subdural haematoma ```

Question 42

Organic causes of depression | Haematological

Answer 42

Anaemia | Leukaemia

Question 43

Organic causes of depression | Other

Answer 43

Infection | Carcinoma

Question 44

Revealed depression

Answer 44

Depressive symptoms present during acute psychotic episode but only become apparent as the positive symptoms resolve.

Question 45

Post-schizophrenic depression

Answer 45

Has met criteria for schizophrenia in last 12m Some schizophrenic sx still present but not dominating Depressive sx fulfill the criteria for a depressive episode and present for at least 2 weeks

Question 46

Depression - clinical features Core features

Answer 46

Low mood anhedonia anergia lack of interest

Question 47

Depression - clinical features Negative cognitions

Answer 47

Worthlessness Hopelessness Helplessness Guilt

Question 48

Depression - clinical features Biological symptoms

Answer 48

``` Diminished sleep/insomnia Reduced appetite/weight loss Diurnal mood variation Psychomotor agitation/retardation Fatigue Reduced libido Constipation Anhedonia ```

Question 49

Depression - clinical features Other features

Answer 49

``` Suicidal ideation Poor concentration Self-neglect Isolative behaviour Anxiety/obsessional sx Somatic complaints Irritability Depressive stupor ```

Question 50

Atypical depression

Answer 50

Klein and Davis' description 1969 Low mood with mood reactivity and reversal of features normally seen in depression Hypersomnia, hyperphagia, weight gain and libidinal increases Tend to respond best to MAOIs Response to TCAs is poor, SSRIs in the middle Not in ICD-10

Question 51

Psychotic depression

Answer 51

Psychotic symptoms indicate severe depression and usually mood congruent around themes of worthlessness, guilt Persecutory delusions also seen

Question 52

Cotard delusion

Answer 52

Delusional belief that they are already dead, do not exist, are putrefying or have lost their blood or internal organs

Question 53

Dysthymia

Answer 53

Low-grade depressive symptoms for at least 2 years (1 year in adolescence) Often early onset Lifetime prevelance 3.6% (3-6%) (US)

Question 54

Dysthymia (DSM criteria)

Answer 54

``` depressed mood for most of the day, for more days than not, as well as at least two of the following diagnostic symptoms: • poor appetite or overeating • insomnia or hypersomnia • low energy or fatigue • low self esteem • poor concentration or difficulty making decisions - hopelessness - normal mood for no more than 2 months - no episodes of major depression ```

Question 55

Postnatal depression

Answer 55

Risk is 10% Increased to 25% if there is a hx of depression Increased to 50% if there is a hx of postpartum depression Mod-sev depression = 3-5% Risk is not influenced by obstetric factors (e.g. length of labour) or social class

Question 56

Depression - treatment

Answer 56

First line - SSRI Antidepressants are not 1st line for mild depression Continue for at least 6 months after remission If antidepressants are stopped immediately then 50% of patients experience a relapse within 3-6 months. Continue for at least 2 years in pts with 2 prior episodes of depression 4 step approach

Question 57

Depression - antidepressants

Answer 57

``` First SSRI Then another SSRI or newer gen hen venlafaxine, TCA or MAOI Augment with: Lithium, antipsychotics or another antidepressant (mirtazapine) ```

Question 58

Refractory depression Definition and treatment

Answer 58

2 successive failed attempts at treatment despite good compliance and adequate doses ``` Add lithium ECT Add T3 Combined fluoxetine and olanzapine Add quetiapine to SSRI or SNRI Add risperidone Add aripiprazole Bupropion and SSRI SSRI and venlafaxine, mirtazapine, or mianserin ```

Question 59

Combining antidepressants

Answer 59

Irreversible MAOIs such as phenelzine and tranylcypromine are dangerous in combination with SSRIs - risk of serotonin syndrome

Question 60

St John's Wort

Answer 60

Effective in mild-mod depression but not recommended due to uncertainty about appropriate doses, variation in nature of preparations and potential serious reactions with other drugs Can cause serotonin syndrome Inducer of P450 system - decreases warfarin and ciclosporin, may also effect OCP

Question 61

STAR*D Study

Answer 61

4 levels of treatment Level 1 - citalopram for 14 weeks Level 2 - swap to sertraline, bupropion or venlafaxine or augment with bupropion or buspirone. +/- cognitive psychotherapy Level 3 - swap to mirtazapine or nortriptyline or adding on lithium or T3 Level 4 - swap to MAOI or ven + mirt Outcome = remission

Question 62

STAR*D Study - outcomes

Answer 62

Level 1 - 1/3 achieved remission, +10-15% responded If levels 1 fails - 1 in 4 responded to switch, 1 in 3 responded to combination 50-85% who have a single episode will go on to have a second and 80-90% will have a third

Question 63

Factors known to increase the risk of recurrence of depression

Answer 63

``` Family hx of depression • Recurrent dysthymia • Concurrent non-affective psychiatric illness • Female gender • Long episode duration • Chronic medical illness • Lack of a confiding relationship ```

Question 64

Bipolar disorder - prevalence

Answer 64

Bipolar 1 - 1% Bipolar 2 - 0.4% Lifetime risk 0.3-1.5% Peak age of onset 15-19 yrs Usually begins as depression, 1st manic episode 5yr later Average length of manic episode is 6 months

Question 65

Drugs that precipitate mania

Answer 65

Levodopa Corticosteroids Anabolic-androgenic steroids Antidepressants (TCA and MAOi) Weaker evidence for: Dopaminergic anti-parkinsonian drugs, thyroxine, iproniazid and isoniazid, chloroquine

Question 66

Gerald Klerman subtypes of bipolar disorder

Answer 66

1981 Bipolar III - cyclothymic disorder Bipolar IV: Hypomania or mania precipitated by antidepressant drugs Bipolar V: Depressed patient with a family history of bipolar illness Bipolar VI: Mania without depression (unipolar mania)

Question 67

Bipolar depression is different from unipolar...

Answer 67

Episodes are more rapid in onset Episodes are more frequent Episodes are shorter Likely to involve reverse neurovegetative sx such as hyperphagia and hypersomnia

Question 68

Features suggestive of mania rather than hypomania

Answer 68

``` Duration Flight of ideas Psychotic sx Loss of social inhibitions DSM - hypomania occurs without any marked social or occupational interference ```

Question 69

Rapid cycling BPAD

Answer 69

10-20% of all patients with bipolar disorder Tends to develop late in the course of the disorder and lasts less than 2 years in 50% of pts Increased suicide risk More common in women, earlier age at onset, greater illness burden, higher treatment resistance More related to external factors such as life events, alcohol abuse, antidepressants and medical disorders rather than genetics

Question 70

Medical disorders associated with rapid cycling

Answer 70

``` hypothyroidism Grave's disease SAH Stroke MS Head injury Drugs (propranolol, levodopa, cyproheptadine) ```

Question 71

BPAD depression - treatment - NICE

Answer 71

No drug treatment - fluox + olanz or quet. If no response consider lamotrigine on own On lithium - check level etc. Add fluoxetine with olanz or quet, or lamotrigine if no resp On valproate: Increase dose to max then add fluox + olanz or quet. If no resp consider lamotrigine.

Question 72

BPAD depression - treatment - Maudsley

Answer 72

1st choice - quetiapine 2nd choice - lithium or valproate 3rd choice - lamotrigine 3th choice - antidepressant plus mood stabiliser or antipsychotic

Question 73

BPAD Mania/hypomania - treatment

Answer 73

Stop antidepressant Antipsychotic - haloperidol, olanzapine, quetiapine or risperidone Check Li levels if taking If antipsychotic ineffective try another, if still ineffective add lithium, if this is ineffective or unsuitable consider valproate. Do not offer lamotrigine Children and young people 13+ - aripiprazole Short term benzos

Question 74

Acceptability of antimanic medication Cipriani 2011

Answer 74

Best overall were olanzapine, risperidone, quetiapine and quetiapine

Question 75

Rapid cycling - treatment

Answer 75

Combine lithium and valproate as first line Second line: lithium monotherapy Stop antidepressants Evaluate precipitants Consider combining mood stabilisers. Quetiapine best choice based on limited evidence

Question 76

BPAD - long-term management

Answer 76

Lithium as first line, long term If lithium is ineffective, consider adding valproate If lithium is poorly tolerated or not suitable, consider valproate or olanzapine instead, or if prev effective during episode, quetiapine NICE recommend li, olanz, quet, valp

Question 77

Sodium valproate - s/e

Answer 77

hepatic failure pancreatitis suicidal behaviour and ideation thrombocytopenia

Question 78

Carbamazepine s/e

Answer 78

marrow suppression hyponatraemia and SIADH skin reactions, inc TEN and SJS suicidal behaviour and ideation

Question 79

Lamotrigine s/e

Answer 79

skin reactions, TEN, SJS suicidal behaviour and ideation blood dyscrasias

Question 80

Gabapentin s/e

Answer 80

DRESS/multiorgan hypersensitivity anaphylaxis/angioedema suicidal behaviour and ideation

Question 81

Topiramate s/e

Answer 81

acute myopia and secondary angle closure glaucoma oligohydrosis and hyperthermia suicidal behaviour and ideation kidney stones

Question 82

Other uses of lithium

Answer 82

Aggressive and self mutilating behaviour Steroid induced psychosis To raise WCC in people using clozapine Reduced completed suicide in patients with BPAD

Question 83

Valproate - side effects

Answer 83

``` Tiredness Significant weight gain (affects 30-50%) Tremor (25%) Hair loss (5-10%) Teratogenic effects ```

Question 84

BPAD Mortality

Answer 84

8% of men and 5% of women hospitalised for BPAD died by suicide Life expectancy is reduced by 13 years in men and 9 years in women

Question 85

Schizophrenia - prevalence

Answer 85

1.4-4.6%

Question 86

Schizophrenia - incidence

Answer 86

0.16 per 1000

Question 87

Schizophrenia - gender

Answer 87

1:1

Question 88

Schizophrenia | Increased risk/prevalence with...

Answer 88

``` winter births (5-15% higher) urbanicity migration and ethnic minorities (AESOP) lower socio-economic class LD (3% vs 1%) Family history Obstetric complications (prenatal nutritional deprivation, prenatal brain injury, prenatal influenza) no difference with race ```

Question 89

Selection drift hypothesis

Answer 89

This suggests that people with schizophrenia tend to drift towards the lower class due to their inability to compete for good jobs etc

Question 90

Schizophrenia and family history Gottesman (1982) Lifetime risk of developing schizophrenia

Answer 90

``` Gen pop 1% First cousin 2 Uncle/aunt 2 Nephew/niece 4 Grandchildren 5 Parents 6 Half sibling 6 Full sibling 9 Children 13 Fraternal twins 17 Off of dual matings 46 Identical twins 48 ```

Question 91

Schizophrenia and cannabis use

Answer 91

Overall, cannabis use appears to confer a two-fold risk of later schizophrenia or schizophreniform disorder People are 4.5 times more likely to be schizophrenic at 26 if they were regular cannabis smokers at 15, compared to 1.65 times for those who did not report regular use until age 18 Lifetime risk of developing psychosis increased by 40% (odds ratio = 1.41) if a person had ever used cannabis (Moore, 2007) Age at onset of psychosis for cannabis users was 2.70 years younger than for nonusers (Large, 2011).

Question 92

Schizophrenia - macroscopic pathological features

Answer 92

Ventricular enlargement Reduced brain vol (up to 5%) Reduced left planum temporale gray matter, and reversed planum temporale surface area asymmetry (L larger than R in R-handed person)

Question 93

Schizophrenia - microscopic findings

Answer 93

Reduction of the size of the dorsolateral prefrontal cortex | Reduction of the size of the hippocampus

Question 94

AESOP study

Answer 94

Incidence of all psychoses was found to be higher in African-Caribbean (x9) and Black African (x6) populations compared to white british group.

Question 95

Schizophrenia - Positive sx

Answer 95

Hallucinations Delusions Thought disorder

Question 96

Schizophrenia - negative sx

Answer 96

``` social withdrawal apathy lack of energy poverty of speech (alogia) flattening of affect anhedonia Amisulpride has the most evidence for treating negative sx ```

Question 97

Psychogenic polydipsia

Answer 97

Fluid drinking that greatly surpasses physiological requirements Results in hyponatraemia - vomiting, agitation, ataxia, seizures, coma Manage by fluid restriction

Question 98

PANSS

Answer 98

7 positive symptom items, 7 negative and 16 general psychopathology Each item scored on 7 point severity scale

Question 99

Schizophrenia subtypes (ICD-10)

Answer 99

``` Paranoid Hebephrenic (disorganised) Catatonic Undifferentiated (doesn't conform to any subtype) Post-schizophrenic depression Residual Simple (predominate;y neg sx w/o being preceded by overtly psychotic sx Other Unspecified ```

Question 100

Bouffee delirante

Answer 100

Brief short lived psychosis that last less than 3 months

Question 101

Schizophrenia subtypes (Crow)

Answer 101

Type 1 - positive symptoms - excess of dopamine D2 receptors - respond better to antipsychotics Type 2 - negative sx - underlying/anatomical abnormality such as ventricular enlargement or cortical atrophy - respond poorly to tx, chronic course, poor outcome

Question 102

Schizophrenia: DSM-5 vs ICD-10

Answer 102

ICD-10 - sx present for at least 1 month, DSM-V - 6 months with 1 mnth active sx Less than 1m in ICD - acute and transient psychotic disorder and DSM - brief psychotic disorder. In DSM if between 1-6m then its schizophreniform disorder DSM requires some impairment of social and occupational dysfunction - not in ICD

Question 103

Early onset schizophrenia

Answer 103

``` Affects 1 in 1000 children EOS - 13-18yrs VEOS - before 13yrs Insidious onset More severe premorbid neurodevelopmental abnormalities More frequent terrifying visual hallucinations Constant inappropriate of blunted affect Higher rate of familial psychopathology Minor response to tx Poorer outcome ```

Question 104

Antipsychotics in schizophrenia - minimum effective doses

Answer 104

``` Chlorpromazine 200mg Haloperidol 2mg Sulpride 400mg Amisulpride 400mg Aripiprazole 10mg Olanzapine 5mg Quetiapine 150mg Risperidone 2mg ```

Question 105

Antipsychotics in schizophrenia - maximum doses

Answer 105

``` Clozapine 900mg Haloperidol 20mg Olanzapine 20mg Quetiapine 750mg Risperidone 16mg Aripiprazole 30mg Flupentixol depot 400mg/week Zuclopenthixol 600mg/week Haloperidol depot 300mg 4 weekly ```

Question 106

Antipsychotic Adverse Effects

Answer 106

Hypertension (mostly clozapine) Reduction of the seizure threshold (esp clozapine)(haloperidol, sulpride and trifluperazine are good choices) Sexual dysfunction (in order: risperidone, haloperidol, olanzapine, quetiapine, aripiprazole) Weight gain

Question 107

Antipsychotic weight gain - mechanisms

Answer 107

5-HT2c antagonism H1 antagonism Hyperprolactinaemia Increased serum leptin (leading to desensitisation)

Question 108

Antipsychotic weight gain - high risk

Answer 108

Clozapine | Olanzapine

Question 109

Antipsychotic weight gain - medium risk

Answer 109

``` Chlorpromazine Quetiapine Risperidone Paliperidone Zotepine ```

Question 110

Antipsychotic weight gain - low risk

Answer 110

``` Amisulpride Asenapine Aripiprazole Haloperidol Sulpride Trifluoperazine Ziprasidone ```

Question 111

Tardive dyskinesia

Answer 111

Typically affects the face (75%), also limbs (50%) and trunk (25%) Increasing dose of antipsychotic tends to lessen problem temporarily Anticholinergics tend to worsen the movements. Believed to be due to postsynaptic D2 receptor hypersensitivity in the nigrostriatal pathway. Develops over months to years

Question 112

Risk factors for TD

Answer 112

``` Advancing age Females- not consistent finding Ethnicity - higher in african americans ?higher in affective disorders First gen antipsychotics Mental retardation Substance abuse ```

Question 113

TD - treatment

Answer 113

Withdraw antipsych and switch to atypical e.g. clozapine or quetiapine Discontinue anticholinergic Tetrabenzine ( only licensed tx in UK - has depressogenic effects) Benzos Vit E (slows deterioration) Ginkgo biloba Propranolol

Question 114

Schizophrenia - physical health monitoring

Answer 114

``` FBC, U&E, LFT - baseline and yearly lipids - baseline, 3m then yearly weight - baseline, freq for 3m then yearly glucose - baseline, 4-6m then yearly ECG - baseline and after dose change BP - baseline and freq during titration prolactin - baseline, 6m then yearly CPK - baseline, then if NMS suspected TFT - yearly if on quetiapine ```

Question 115

Depots Suggested role in...

Answer 115

Zuclopenthixol decanoate (has slight advantage in terms of efficacy) - aggressive patients Flupentixol - depressed patients Haloperidol - prophylaxis of mania Pipotiazine palmitate - when EPSEs are a problem

Question 116

Chlorpromazine

Answer 116

1st drug used for psychosis | Photosensitivity reactions

Question 117

Clozapine

Answer 117

``` Reduced suicidality 30% would respond by 6wks A further 20% by 3m Additional 10-20% by 6m 30% do not respond (Meltzer 1992) Need level of 350-450ng/ml before a pt is considered resistant ```

Question 118

Clozapine resistance - augmentation

Answer 118

``` Sulpride or amisulpride Lamotrigine Aripiprazole Haloperidol Risperidone Avoid: Pimozide, olanzapine ```

Question 119

Clozapine resistance - other options

Answer 119

* Allopurinol + antipsychotic * Max dose amisulpride * Max dose aripiprazole * D-Alanine and D-Serine * ECT * High dose olanzapine (usually tried first, if failed then... * Olanzapine with various combinations

Question 120

Lithium increases WCC - mechanism

Answer 120

?Stimulation of GM-CSF ?Demargination No left shift

Question 121

Clozapine levels (reference range)

Answer 121

350-500ug/L

Question 122

Catatonia complications

Answer 122

Dehydration DVT PE Pneumonia

Question 123

Catatonia - treatment

Answer 123

Benzos (1st line) ECT Antipsychotics best avoided during acute phase

Question 124

CATIE

Answer 124

Compared older vx newer antipsychotic meds Phase 1 compared old and new antipsych 1400 participants 1 of 4 atypicals (OLZ, QTP, RIS, ZIP) or typical (perphenazine) OLZ slightly better than others but weight gain significant EPSEs not seen more with older drug

Question 125

CATIE - Phase 2

Answer 125

Guidance on what to try next If ineffective - tried clozapine If intolerable - tried ziprasidone Clozapine was much more effective than other atypicals

Question 126

NCEP criteria for metabolic syndrome

Answer 126

• Central obesity: waist circumference 102 cm or 40 inches (male), 88 cm or 36 inches(female) • Dyslipidaemia: TG 1.7 mmol/L (150 mg/dl) • Dyslipidaemia: HDL-C < 40 mg/dL (male), < 50 mg/dL (female) • Blood pressure 130/85 mmHg • Fasting plasma glucose 6.1 mmol/L (110 mg/dl)

Question 127

CATIE study - metabolic syndrome

Answer 127

The prevalence of MS at baseline in the CATIE group was 40.9%. By gender this was 51.6% in females and 36% in males. Male patients were twice as likely to have MS than matched controls, and female patients were three times as likely compared to matched controls.

Question 128

Antipsychotic non-compliance in psychotic patients

Answer 128

``` 25-75% - of these, 90% are intentional Following d/c from hospital non-compliance is: 25% at ten days 50% at one year 75% at 2 years ```

Question 129

DAI

Answer 129

Drug Attitude Inventory Assess' patient attitude to medication - to predict compliance Other scales: ROMI, Beliefs about medication questionnaire, MARS

Question 130

Schizophrenia - course and prognosis

Answer 130

Ram (1992) concluded that over a 2 year period, one-third of patients with schizophrenia showed a benign course, and two-thirds either relapsed or failed to recover. 2-3 fold increased risk of premature death The risk of dying over the next year for people with schizophrenia is 2.6 times higher than for people without it. (SMR 2.6) - mainly due to CVD SMR falls with age due to early peak of suicides and gradual rise of population mortality

Question 131

Agoraphobia

Answer 131

Age at onset: 20s Gender distribution: F>M 12m prevalence: 1.8%

Question 132

Specific phobia

Answer 132

Age at onset: childhood Gender distribution: F>M 12m prevalence: -

Question 133

Social phobia

Answer 133

Age at onset: late teenage/early 20s Gender distribution: F=M (more F in comm) 12m prevalence: 2.3%

Question 134

OCD

Answer 134

Age at onset: 25-35 years Gender distribution: F>M 12m prevalence: 0.7%

Question 135

PTSD

Answer 135

Age at onset: Gender distribution: F>M 12m prevalence: 1.1-2.9%

Question 136

GAD - Epidemiology

Answer 136

Prevalence (12m) - 4.4% Rates in women are twice as high as in men A/w lower household income, unemployment, divorce and separation

Question 137

GAD - Cognitive Theories

Answer 137

Looming cognitive style - increased attention to potentially threatening stimuli, overstimulation of environmental threat, enhances memory of threatening material Lack of a sense of control of events and of personal effectiveness

Question 138

GAD - Personality

Answer 138

Personality traits - neuroticism | Personality disorder - anxious-avoidant

Question 139

GAD - Neurobiology

Answer 139

- Amygdala and hippocampus implicated - Noradrenergic neurons that originate in the locus coeruleus have been shown to increase arousal and anxiety - GABA receptors are inhibitory and reduce anxiety, as fo the associated benzo-binding sites - Probably a role for corticotropin-releasing hormone

Question 140

GAD - Diagnosis

Answer 140

6 months with prominent tension, worry and feelings of apprehension about every day events and problems At least 4 of following (and at least 1 of 1st 4) (1) Palpitations or pounding heart, or accelerated heart rate (2) Sweating (3) Trembling or shaking (4) Dry mouth (not due to medication or dehydration) (5) Difficulty breathing (6) Feeling of choking (7) Chest pain or discomfort (8) Nausea or abdominal distress (9) Feeling dizzy, unsteady, faint or light-headed (10) Feelings that objects are unreal (derealization), or that one's self is distant or 'not really here' (depersonalization) (11) Fear of losing control, going crazy, or passing out (12) Fear of dying

Question 141

GAD - Diagnosis (2)

Answer 141

(13) Hot flushes or cold chills (14) Numbness or tingling sensations (15) Muscle tension or aches and pains (16) Restlessness and inability to relax (17) Feeling keyed up, or on edge, or of mental tension (18) A sensation of a lump in the throat, or difficulty with swallowing (19) Exaggerated response to minor surprises or being startled (20) Difficulty in concentrating, or mind going blank, because of worrying or anxiety (21) Persistent irritability (22) Difficulty getting to sleep because of worrying

Question 142

GAD Management - NICE

Answer 142

``` Step 1 - mild - education and active monitoring Step 2 - (no response to step 1) - low intensity psychological intervention Step 3 - (no response to step 2 or marked impairment) - high intensity psychological intervention or drug treatment Step 4 (no response to step 3 or marked impairment, comorbidity, risks) - complex drug/psychological treatment, input from MDT, crisis services, day hospital, inpatient care ```

Question 143

GAD - Medication - NICE

Answer 143

Benzodiazepines should not be used beyond 2-4wks 1st line - SSRIs (sertraline) - warn of increased risk of suicidal thinking and self-harm if under 30 - weekly follow-up for 1m If pt cannot tolerate SSRI or SNRI - offer pregabalin Continue treatment for at least 1 year

Question 144

Kava

Answer 144

Piper methysticum | Effective in reducing anxiety but a/w hepatotoxicity - not recommended

Question 145

Specific phobia - epidemiology

Answer 145

Lifetime prevalence: men 7%, women 17% Age of onset usually childhood 7 years for animals, 8 years for blood Early twenties for most situational phobias

Question 146

Specific phobia - Blood-infection-injury type

Answer 146

Bradycardia and hypotension often follow the initial tachycardia that is common to all phobias Genetic link - may have particularly strong vasovagal reflex

Question 147

Specific phobia - treatment

Answer 147

Behaviour therapy | Graded exposure

Question 148

Social phobia - Epidemiology

Answer 148

Lifetime prevalence - 12% Equally frequent in men and women who seek treatment, but more common in women in the community surveys Associated with depression and alcoholism

Question 149

Social phobia - genetics

Answer 149

First-degree relatives of persons with social phobia are about three times more likely to be affected with social phobia

Question 150

Social phobia - clinical picture

Answer 150

Whereas breathlessness, dizziness, a sense of suffocation, and a fear of dying are common in panic disorder and agoraphobia, the symptoms associated with social phobia usually involve blushing, muscle twitching, and anxiety about scrutiny.

Question 151

Social phobia - treatment

Answer 151

Meds - antidepressants, anxiolytics, BB | Behaviour therapies - relaxation training and CBT

Question 152

Agoraphobia - Epidemiology

Answer 152

Prevalence considerably more in women (75%) Age of onset early or middle 20s, with further peak in mid thirties Typically starts with a panic attack

Question 153

Agoraphobia - Classical Conditioning Approach

Answer 153

a noxious stimulus (e.g., a panic attack) that occurs with a neutral stimulus (e.g., a bus ride) can result in the avoidance of the neutral stimulus.

Question 154

Agoraphobia - situations that provoke anxiety have 3 common themes

Answer 154

Distance from home Crowding Confinement

Question 155

Agoraphobia - treament

Answer 155

Medication - anxiolytics and antidepressants | Behaviour therapy, CBT

Question 156

Panic disorder - Epidemiology

Answer 156

20 years of age, highest in the 25-44 year age group. Rarely after 65yo High comorbidity Association with benign joint laxity (15 fold increase)

Question 157

Panic disorder - Panicogens

Answer 157

IV infusion of sodium lactate can induce panic | Others: carbon dioxide, bicarbonate, yohimbine, mCPP, flumazenil, cholecystokinin, caffeine

Question 158

Panic disorder - Cognitive theory

Answer 158

• Thoughts of imminent catastrophe have been identified as triggers of panic attacks • Patients with panic disorder relative to healthy and patient controls have been shown to be: ⁃ 1. Characterized by strategic and automatic information processing (i.e., memory, attention) biases for physical threat cues; ⁃ 2. More accurate, in some instances, at detecting body sensations; ⁃ 3. More likely to report fear of somatic sensations and beliefs in their harmful consequences

Question 159

Suffocation alarm theory of anxiety

Answer 159

States that some people have a hypersensitive central chemoreceptor leading to carbon dioxide sensitivity.

Question 160

Panic attacks in different disorders

Answer 160

SOB more common in panic attacks is agoraphobia Blushing more common in social phobia More dizziness, paraesthesia, shaking, chest pain in panic disorder

Question 161

Panic disorder - Management

Answer 161

1st line - SSRIs 2nd line - no response after 12 wk - imipramine or clomipramine Sedating antihistamine, antipsychotics and benzos should not be used Encourage CBT based self-help Continue antidepressant for at least 6m after optimal dose reached

Question 162

OCD - Epidemiology

Answer 162

1-3% of population Begins in early adulthood, mean age 20yrs (slightly earlier in men) Very slightly higher prevalence in women Lifetime prevalence for major depressive disorder is 67%, social phobia 25%

Question 163

OCD - Personality

Answer 163

Only about 15-35% of patients with OCD have had premorbid obsessional traits

Question 164

OCD - Psychodynamic theory

Answer 164

Disturbances in normal growth and development related to the anal-sadistic phase of development Magical thinking - persons believe that merely by thinking about an event in the external world they can cause the event to occur without intermediate physical actions

Question 165

OCD - Biological causes

Answer 165

Historically associated with Encephalitis Lethargica Increased glucose metabolism in the caudate nucleus and orbitofrontal cortex

Question 166

OCD - Neuroimaging

Answer 166

FDG-PET - increased glucose metabolism in the OFC, caudate, thalamus, prefrontal cortex and anterior cingulate HMPAO-SPECT - increased and decreased blood flow to various brain regions including the OFC, caudate, various areas of the cortex and thalamus

Question 167

Obsessions

Answer 167

Recurrent intrusive thoughts, images, ruminations or impulses that a person recognises as his own, occurring against his will but he finds it difficult to resist it. - Most common is contamination, followed by washing - Obsessional sx occur in 20% of cases of severe depression

Question 168

Compulsions

Answer 168

Obsessional motor acts.

Question 169

OCD - Treatment

Answer 169

High dose SSRIs and clomipramine 8-16wks needed for maximal therapeutic benefit Behaviour therapy (ERP) and CBT ERP - habituation leads to eventual extinction of the response

Question 170

Hypochondriasis - Epidemiology

Answer 170

6m prevalence of 4-6%, but may be as high as 15% M=F 20-30yo most commonly 80% have coexisting anxiety or depressive disorders

Question 171

Hypochondriasis - Psychodynamic theory

Answer 171

Aggressive and hostile wishes toward others are transferred (through repression and displacement) into physical complaints

Question 172

Hypochondriasis - common features

Answer 172

Avoidance Bodily checking Reassurance seeking

Question 173

Hypochondriasis - name in DSM V

Answer 173

Illness Anxiety Disorder

Question 174

Body dysmorphic disorder

Answer 174

Most common area perceived to be affected is the skin, followed by hair, nose, toes and then weight Classified under hypochondriasis in ICD-10 Psychological therapy (CBT)

Question 175

Somatoform and Dissociative Disorders - differences in classification

Answer 175

• In DSM-5, somatoform disorders as a category has been replaced by somatic symptom and related disorders. Somatisation disorder has been eliminated. • A further confusion relates to the relationship between conversion disorder and somatoform/dissociative disorders. In ICD-10, conversion is used synonymously with dissociation I.e. ‘Dissociative (conversion) disorders’. In DSM-4 and DSM-5, conversion is a subtype of somatoform/somatic symptom disorder. DSM-5 gives the alternative name of functional neurological symptom disorder.

Question 176

Briquet's syndrome (Somatisation disorder) - Epidemiology and Aetiology

Answer 176

``` Lifetime prevalence 0.2% More common in females (5:1) Onset: childhood to early 30s A/w childhood sexual abuse Increased freq in 1st degree relatives ```

Question 177

Briquet's syndrome (Somatisation disorder) - Presentation

Answer 177

Multiple, recurrent and frequently changing physical sx of at least 2 years duration If short-lived or less striking sx - undifferentiated somatoform disorder

Question 178

Somatic symptom disorder

Answer 178

Excessive preoccupation and worry about somatic symptoms Inversely related to social class (more common in low ed and low income) More common in women Sx may or may not be a/w med condition Sx DO NOT need to be medically unexplained to qualify for diagnosis

Question 179

Somatoform autonomic dysfunction

Answer 179

* Da Costa's syndrome * Cardiac neurosis * Neurocirculatory asthenia * Dyspepsia * Pylorospasm * Irritable bowel syndrome * Psychogenic flatulence * Psychogenic cough * Hyperventilation * Psychogenic frequency * Dysuria

Question 180

Somatisation disorder - treatment

Answer 180

Communicate the diagnosis Acknowledge symptom severity and experience of distress as real but emphasise negative investigations and lack of structural abnormality Reassure patient of continuing care Attempt to reframe symptoms as emotional Assess for and treat psychiatric comorbidity Reduce and stop unnecessary drugs

Question 181

Dissociative disorders

Answer 181

Complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements. ``` Only disorders of physical functions normally under voluntary control and loss of sensations are included here. Disorders involving pain and other complex physical sensations mediated by the autonomic nervous system are classified under somatization disorder (F45.0). ```

Question 182

Dissociative amnesia

Answer 182

Inability to recall important personal memories, usually of a stressful nature, too extensive for N forgetfulness

Question 183

Dissociative fugue

Answer 183

Rare. Loss of memory coupled with wandering away from the person's usual surroundings. Some deny knowledge of personal identity.

Question 184

DID

Answer 184

Multiple personality disorder in ICD-10 | Sudden alternations between 2 patterns of behaviour, each of which is forgotten by the pt when the other is present

Question 185

PD - Prevalence

Answer 185

``` Any PD 4.4% Paranoid 0.7 Schizoid 0.8 Schizotypal 0.06 Antisocial 0.6 Borderline 0.7 Avoidant 0.8 Dependent 0.1 Obsessive-compulsive (anankastic) 1.9 ```

Question 186

PD - Prevalence by population

Answer 186

* Community prevalence –2-3% (according to some studies, up to 10%) * GP attenders –20% * Psychiatric outpatients –40% * Psychiatric inpatients –50% * Male prisoners – 60%

Question 187

PD Screening - SAPAS

Answer 187

``` Interview. 8 areas 2minutes to complete Score between 0 and 8 Yes/no answers to 8 q Score of 3 or more warrants further assessment ```

Question 188

PD Screening - FFMRF

Answer 188

Self reported 30 items rated 1-5 for each item Based on symptoms rather than diagnosis

Question 189

PD Screening - IPDE

Answer 189

Interview method, self reported Semistructured clinical interview Compatible with ICD-10 and DSM-IV Includes patient questionnaire and an interview

Question 190

PD Screening - PDQ-R

Answer 190

Self reported 100 true/false questions 30 mins to complete Based on DSM-IV criteria

Question 191

PD Screening - IPDS

Answer 191

Interview method 11 criteria Takes less than 5 mins

Question 192

PD Screening - IIP-PD

Answer 192

Self reported Contains 127 items Items rated 0-4

Question 193

PD Classification - ICD-10

Answer 193

1. Paranoid, Schizoid 2. Dissocial, Emotionally Unstable (Impulsie, borderline), Histrionic 3. Anankastic, Anxious (avoidant), Dependent

Question 194

PD Classification - DSM-V

Answer 194

Cluster A - Paranoid, Schizoid, Schizotypal Cluster B - Antisocial, Borderline Cluster C - Obsessive-compulsive, Avoidant, Dependent

Question 195

PD - Antisocial - male prisoners

Answer 195

47% of male prisoners

Question 196

Antisocial (dissocial) PD ICD-10

Answer 196

At least 3 of following: • Callous unconcern for the feelings of others; • Gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations; • Incapacity to maintain enduring relationships, though having no difficulty in establishing them; • Very low tolerance to frustration and a low threshold for discharge of aggression, including violence; • Incapacity to experience guilt or to profit from experience, particularly punishment; • Markedly prone to blame others or to offer plausible rationalizations for the behaviour that has brought the person into conflict with society.

Question 197

Antisocial (dissocial) PD DSM-V

Answer 197

Disregard for and violation of the rights of others, occurring since age 15, as indicated by three (or more) of: ⁃ Failure to conform to social norms with respect to lawful behaviours ⁃ Deceitfulness, as indicated by repeated lying or conning of others for personal profit or pleasure ⁃ Impulsivity or failure to plan ahead ⁃ Irritability and aggressiveness, as indicated by repeated fights or assaults ⁃ Reckless disregard for safety of self or others ⁃ Consistent irresponsibility, as indicated by repeated failure to sustain work or honour financial obligations ⁃ Lack of remorse, as indicated by being indifferent or rationalising having hurt, mistreated, or stolen from another Must be evidence of conduct disorder before age 15.

Question 198

Avoidant PD - clinical features

Answer 198

• Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection. • Unwillingness to be involved unless certain of being liked • Preoccupied with ideas that they are being criticised or rejected in social situations • Restraint in intimate relationships due to the fear of being ridiculed • Reluctance to take personal risks doe to fears of embarrassment • Views self as inept and inferior to others • Social isolation accompanied by a craving for social contact

Question 199

Borderline PD - clinical features

Answer 199

• Efforts to avoid real or imagined abandonment • Unstable interpersonal relationships which alternate between idealization and devaluation • Unstable self image • Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse) • Recurrent suicidal behaviour • Affective instability • Chronic feelings of emptiness • Difficulty controlling temper • Quasi psychotic thoughts

Question 200

BPD and abuse

Answer 200

• Up to 87% have suffered childhood trauma of some sort, ⁃ 40-71% have been sexually abused ⁃ 25-71% have been physically abused (Winston, 2000).

Question 201

Dependent PD - DSM-IV

Answer 201

At least 5 of: • Difficulty making everyday decisions without excessive reassurance from others • Need for others to assume responsibility for major areas of their life • Difficulty in expressing disagreement with others due to fears of losing support • Lack of initiative • Unrealistic fears of being left to care for themselves • Urgent search for another relationship as a source of care and support when a close relationship ends • Extensive efforts to obtain support from others • Unrealistic feelings that they cannot care for themselves

Question 202

Dependent PD - ICD-10

Answer 202

At least 3 of following • Encouraging or allowing others to make most of one's important life decisions; • Subordination of one's own needs to those of others on whom one is dependent, and undue compliance with their wishes; • Unwillingness to make even reasonable demands on the people one depends on; • Feeling uncomfortable or helpless when alone, because of exaggerated fears of inability to care for oneself; • Preoccupation with fears of being abandoned by a person with whom one has a close relationship, and of being left to care for oneself; • Limited capacity to make everyday decisions without an excessive amount of advice and reassurance from others.

Question 203

Histrionic PD

Answer 203

* Inappropriate sexual seductiveness * Need to be the centre of attention * Rapidly shifting and shallow expression of emotions * Suggestibility * Physical appearance used for attention seeking purposes * Impressionistic speech lacking detail * Self dramatization * Relationships considered to be more intimate than they are

Question 204

Narcissistic PD

Answer 204

* Grandiose sense of self importance * Preoccupation with fantasies of unlimited success, power, or beauty * Sense of entitlement * Taking advantage of others to achieve own needs * Lack of empathy * Excessive need for admiration * Chronic envy * Arrogant and haughty attitude

Question 205

Obsessive-Compulsive PD DSM-IV Criteria

Answer 205

4 of more of: • Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone • Demonstrates perfectionism that hampers with completing tasks • Is extremely dedicated to work and efficiency to the elimination of spare time activities • Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values • Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning • Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things • Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness

Question 206

Anankastic (Obsessive-Compulsive) PD ICD-10 Criteria

Answer 206

At least 3 of: • Feelings of excessive doubt and caution • Preoccupation with details, rules, lists, order, organization or schedule • Perfectionism that interferes with task completion • Excessive conscientiousness, scrupulousness, and undue preoccupation with productivity to the exclusion of pleasure and interpersonal relationships • Excessive pedantry and adherence to social conventions • Rigidity and stubbornness • Unreasonable insistence by the patient that others submit to exactly his or her way of doing things, or unreasonable reluctance to allow others to do things • Intrusion of insistent and unwelcome thoughts or impulses

Question 207

Paranoid PD

Answer 207

* Hypersensitivity and an unforgiving attitude when insulted * Unwarranted tendency to questions the loyalty of friends * Reluctance to confide in others * Preoccupation with conspirational beliefs and hidden meaning * Unwarranted tendency to perceive attacks on their character

Question 208

Schizoid PD

Answer 208

* Indifference to praise and criticism * Preference for solitary activities * Lack of interest in sexual interactions * Lack of desire for companionship * Emotional coldness * Few interests * Few friends or confidants other than family

Question 209

Schizotypal PD

Answer 209

* Ideas of reference (differ from delusions in that some insight is retained) * Odd beliefs and magical thinking * Unusual perceptual disturbances * Paranoid ideation and suspiciousness * Odd, eccentric behaviour * Lack of close friends other than family members * Inappropriate affect * Odd speech without being incoherent

Question 210

Treatment for PD - Meds

Answer 210

- Low dose neuroleptics in cluster B and schizotypal disorders - Carbamazepine for behavioural dyscontrol in borderline PD - Lithium for aggressive behaviour - SSRIs in impulsive behaviour - MAOIs or imipramine in comorbid atypical depression in histrionic and borderline PD - Comorbid PD and depression may benefit from ECT (good initial response)

Question 211

Psychotherapy for BPD

Answer 211

``` DBT MBT SFT TFP STEPPS CAT (Ryle) Some evidence for IPT Therapeutic communities - milieu therapy ```

Question 212

Acute Stress Reaction

Answer 212

• There is an initial stage of a daze, followed by symptoms of disorientation, inattention, and inability to comprehend external stimuli. • This is then usually followed by a rapidly changing picture of symptoms which might include flight reactions, panic, autonomic hyperarousal, anger, or despair. • Symptoms usually diminish within 24-48 hours and should be minimal after 3 days.

Question 213

PTSD - epidemiology

Answer 213

Female preponderance Lifetime incidence - 9-15% Lifetime prevalence - 8% of general population

Question 214

PTSD - aetiology

Answer 214

- Ambient cortisol levels lower than normal due to chronic adrenal exhaustion from inhibition of the HPA axis by persistent severe anxiety. - Decreased hippocampal volume - Amygdala - mediates unconscious memories - Hippocampus - mediates conscious memories - Neuroimaging studies - decreased activity in medial prefrontal and anterior cingulate, increased activity in amygdale.

Question 215

Moderate impact traumas

Answer 215

Precede PTSD in 5-20% e.g. diagnosis of life threatening illness in self or loved one, sudden death of a loved one, witnessing death or serious injury of another person, direct involvement in a serious accident and involvement in fires, floods or small scale natural disaster

Question 216

High impact traumas

Answer 216

Precede PTSD in >20% e.g. muggings, threats with a weapon, serious domestic violence, rape, childhood sexual abuse, war/combat, kidnap, torture, large-scale or man-made disasters.

Question 217

PTSD - ICD-10 criteria

Answer 217

• Exposure to a traumatic event which would be likely to cause pervasive distress in almost anyone. • The event must be persistently remembered or relived, as evidenced by flashbacks, vivid memories, or nightmares. • The patient must actively avoid situations which remind them of the event. Plus 1 of: • Partial amnesia for part of the event • Persistent symptoms of psychological arousal such as, poor sleep, poor concentration, hypervigilance, exaggerated startle response, irritability. Above must occur within 6m of event

Question 218

PTSD - Treatment - Children and Young people

Answer 218

Do not offer psychological debriefing - Sx for >1m - individual trauma-focused CBT intervention - Consider EMDR for children 7-17 with sx >3m with no response to CBT - Do not offer drug tx

Question 219

PTSD - Treatment - Adults

Answer 219

- Do not offer psychological debriefing - 1st line - Individual trauma-focused CBT or EMDR (non-combat related only and if pt prefers) or supported trauma-focussed computerised CBT - Do not offer drug treatments to prevent PTSD - Venlafaxine or SSRI (not 1st line) - Antipsychotics if severe hyperarousal or psychotic sx

Question 220

EMDR

Answer 220

Francine Shapiro in 1980s

Question 221

Grief - John Bowlby

Answer 221

1. Shock and protest including disbelief (few days) 2. Preoccupation - involves yearning and anger (few weeks) 3. Disorganisation - includes despair and acceptance of loss (several months) 4. Resolution (1-2 years)

Question 222

Grief - Kubler-Ross 1969

Answer 222

``` Stage 1 - Denial Stage 2 - Anger Stage 3 - Bargaining Stage 4 - Depression Stage 5 - Acceptance ```

Question 223

Abnormal grief - Inhibited

Answer 223

Absence of expected grief sx at any stage

Question 224

Abnormal grief - Delayed

Answer 224

Avoidance of painful sx within 2 weeks of loss

Question 225

Abnormal grief - chronic/prolonged

Answer 225

Continued significant grief related sx 6m after loss

Question 226

Features that distinguish normal grief from depression

Answer 226

Generalised guilt Thoughts of death (except in relation to the deceased) Feeling worthless Psychomotor retardation Prolonged functional impairment Hallucinations (except in relation to the deceased)

Question 227

Dyssomnias

Answer 227

Intrinsic sleep disorder Extrinsic sleep disorders Circadian rhythm disorders

Question 228

Parasomnias

Answer 228

- Arousal disorders - sleepwalking, sleep terrors - Sleep wake transition disorders - RMD, sleep talking, nocturnal leg cramps - Parasomnias a/w REM sleep - nightmare, sleep paralysis

Question 229

Intrinsic sleep disorder

Answer 229

``` Narcolepsy Psychopsycholical insomnia Idiopathic hypersomnia RLS Periodic Limb Movement disorder OSA ```

Question 230

Extrinsic Sleep disorders

Answer 230

Inadequate sleep hygiene | Alcohol dependent Sleep disorder

Question 231

Circadian Rhythm Disorders

Answer 231

``` Jet lag syndrome Shift work sleep disorder Irregular sleep wake pattern Delayed sleep phase syndrome Advanced sleep phase disorder ```

Question 232

Cataplexy

Answer 232

Sudden loss of bilateral muscle tone provoked by strong emotion Seen in Narcolepsy Few sec to few mins Treat with TCA such as protriptyline or imipramine

Question 233

Narcolepsy

Answer 233

Commonly begins in 2nd decade Peak incidence around 14yo Repeated episodes of sleep of short duration

Question 234

Modafinil

Answer 234

Enhances wakefulness, attention and vigilance Not addictive, lacks euphoric effect, does not tend to precipitate psychosis Used in narcolepsy, OSA, chronic shift work, depression

Question 235

Periodic Limb Movement Disorder

Answer 235

Repetitive and highly stereotyped limb movements during sleep A/w partial arousal or awakening

Question 236

Restless Leg Syndrome

Answer 236

Disagreeable leg sensations that usually occur prior to sleep onset causing irresistible urge to move the legs - partial or complete relief when legs moved

Question 237

RLS - risk factors

Answer 237

* Older age * Female sex * Pregnancy * Iron deficiency and anemia * Renal failure * Hypothyroidism * Diabetes * B12 deficiency

Question 238

Jet leg syndrome

Answer 238

Sx typically last longer following eastward flights

Question 239

Shift work sleep disorder

Answer 239

Sleep length reduced by 1-4 hours and mainly affects REM and stage 2 sleep

Question 240

Non 24hr sleep wake syndrome

Answer 240

Chronic steady pattern comprising one to two hour daily delays in sleep onset and wake times

Question 241

Sleepwalking

Answer 241

During slow-wave sleep - therefore 1st 1/3 of the night or following sleep deprivation Peak between 4-8yo Lithium can exacerbate or induce it

Question 242

Sleep terrors

Answer 242

sudden arousal from slow wave sleep with a piercing scream or cry, accompanied by autonomic and behavioural manifestations of intense fear. May have micturition Amnesia for episode

Question 243

Rhythmic Movement Disorder

Answer 243

Stereotyped, repetitive movements | involving large muscles, usually of the head and neck

Question 244

Sleep starts

Answer 244

sudden, brief contractions of the legs, sometimes also involving the arms and head, that occur at sleep onset

Question 245

Nocturnal leg cramps

Answer 245

Painful sensations of muscular tightness or tension, usually in calf Few seconds up to 30min One or two episodes nightly several times a week

Question 246

Nightmares

Answer 246

Usually awaken the sleeper from REM sleep | Long dreamlike feature differentiates it from sleep terrors

Question 247

Sleep paralysis

Answer 247

Transient paralysis of skeletal muscles which occurs when awakening from sleep or when falling asleep Hallucinations Clonazepam may be used

Question 248

Insomnia - short term

Answer 248

Hypnotic drug e.g. temazepam or z drug only if daytime impairment is severe Max 2 weeks

Question 249

Insomnia - long-term

Answer 249

CBT Meds for up to 4 weeks If over 55 - melatonin - 3w, if response then cont for 10w

Question 250

Neurasthenia (F48)

Answer 250

Excessive fatigue following mental or physical effort

Question 251

Neurasthenia - ICD-10

Answer 251

* Either persistent and distressing complaints of increased fatigue after mental effort, or bodily weakness and exhaustion after minimal effort * At least two of the following: muscular aches, dizziness, tension headaches, sleep disturbance, inability to relax, irritability, dyspepsia * Inability to recover through rest, relaxation or enjoyment * Duration exceeds 6 months * Does not occur in the presence of organic mental disorders, affective disorders or panic or GAD

Question 252

Somatisation disorder

Answer 252

* multiple physical SYMPTOMS present for at least 2 years | * patient refuses to accept reassurance or negative test results

Question 253

Hypochondrial disorder

Answer 253

* persistent belief in the presence of an underlying serious DISEASE, e.g. cancer * patient again refuses to accept reassurance or negative test results

Question 254

Conversion disorder

Answer 254

• typically involves loss of motor or sensory function • the patient doesn't consciously feign the symptoms (factitious disorder) or seek material gain (malingering) • patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies

Question 255

Dissociative disorder

Answer 255

* 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

Question 256

Munchausen's syndrome

Answer 256

* also known as factitious disorder | * the intentional production of physical or psychological symptoms

Question 257

Malingering

Answer 257

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

Question 258

BDD - Epidemiology

Answer 258

• Equal sex incidence • Less than 1% prevalence but markedly over-represented in some groups (e.g. plastic surgery - 10% - and dermatology) • 10% incidence in first-degree family members

Question 259

BDD - Treatment

Answer 259

* SSRI - fluoxetine 20mg increasing to 60mg * If ineffective try Clomipramine up to 250mg * Antipsychotic if delusional features * Psychological - CBT, with ERP

Question 260

Premenstrual tension syndrome (ICD-10)

Answer 260

Known as Premenstrual dysphoric disorder in DSM-V - mood lability, irritability, dysphoria, and anxiety symptoms that occur repeatedly during the premenstrual phase of the cycle and remit around the onset of the menses.

Question 261

Premenstrual tension syndrome - treatment

Answer 261

SSRIs Gonadotrophin releasing hormone analogues ?Vit B6 ?Bright light therapy For mastalgia - Danazol, evening primrose oil Progesterone has no effect

Question 262

Drugs affecting contraception

Answer 262

Carbamazepine Phenytoin Topiramate

Question 263

Valproate and carbamazepine in pregnancy

Answer 263

Increase risk of neural tube defect (1-2% and 0.5-1% resp)

Question 264

Lithium in pregnancy

Answer 264

Ebstein's anomaly (relative risk 10-20 times that of control, absolute risk 1:1000)

Question 265

Benzos in pregnancy

Answer 265

Oral clefts in newborns and floppy baby syndrome

Question 266

Antipsychotics in pregnancy

Answer 266

Olanzapine is recommended choice

Question 267

Paroxetine in pregnancy

Answer 267

More commonly a/w neonatal withdrawal, increased risk of cong malformations (particularly heart defects)

Question 268

Pregnancy

Answer 268

spontaneous abortion 10-20% Major malformations 2-3% (1 in 40) Drugs account for 5% of all abnormalities

Question 269

Antidepressants recommended in pregnancy

Answer 269

Fluoxetine, sertraline, amitriptyline, imipramine

Question 270

Antidepressants recommended in breastfeeding

Answer 270

Sertraline

Question 271

Antipsychotics rec in pregnancy

Answer 271

Olanzapine, quetiapine, haloperidol, clozapine, chlorpromazine

Question 272

Antipsychotics rec in breastfeeding

Answer 272

Olanzapine

Question 273

Mood stabilisers in pregnancy

Answer 273

Avoid if possible

Question 274

Mood stabilisers in breastfeeding

Answer 274

Avoid if possible | Valproate if essential

Question 275

Sedatives in preg

Answer 275

Promethazine (little data) | Benzos (avoid in late preg)

Question 276

Sedatives in breastfeeding

Answer 276

For anxiety - lorazepam | For insomnia - zolpidem

Question 277

Baby blues

Answer 277

30-75% transient mood disturbance characterised by emotional lability, sadness, and tearfulness. This usually clears up by 2 weeks Onset 3-5 days following birth

Question 278

Postpartum depression

Answer 278

10-15% Similar to major depression Risk increased to 25% with h/o depression and 50% with h/o postpartum depression 3-5% will be mod-sev

Question 279

Postpartum psychosis

Answer 279

1-2 per 1000 Approx 50% have FH of mood disorder Usually begins within 1st 2wk following birth (2-14d)

Question 280

HIV and CD4 count

Answer 280

Most individuals are asymptomatic when their CD4 counts are >500 x 10^6/l. They are at greatest risk when this count falls below 200 x 10^6/l.

Question 281

Non-nucleoside reverse-transcriptase inhibitors

Answer 281

Efavirenz - can cause psychosis, suicide, mania | Nevirapine

Question 282

Nucleoside reverse-transcriptase inhibitors

Answer 282

Abacavir | Didanosine

Question 283

Protease inhibitors

Answer 283

Retinovir | Indinavir

Question 284

Others (HIV drugs)

Answer 284

Enfuvirtide

Question 285

Psychosis in HIV

Answer 285

Atypicals | Risperidone widely used

Question 286

Delirium in HIV

Answer 286

Atypicals and low-dose short acting benzos

Question 287

Depression in HIV

Answer 287

SSRIs, esp citalopram. Also SNRIs, mirtazapine and bupropion

Question 288

Bipolar in HIV

Answer 288

Valproate, lamotrigine Lithium ok but poorly tolerated Avoid carbamazepine Atypicals

Question 289

MS - primary progressive

Answer 289

5-10% | Steady progression no remissions

Question 290

MS - relapsing-remitting

Answer 290

20-30% | Relapsing-remitting course

Question 291

MS - secondary progressive

Answer 291

60% | Initially relapsing-remitting but followed by phase of progressive deterioration

Question 292

Depression in MS

Answer 292

Lifetime prevalence of 25-50% Somatic sx not good discriminators in MS SSRIs 1st line Interferon-beta - start on antidepressant prophylaxis if there is h/o depression

Question 293

Risk factors for suicide in MS

Answer 293

* Male gender * Young age at onset of illness * Current or previous history of depression * Social isolation * Substance misuse

Question 294

Mania in MS

Answer 294

More common | Mood stabilisers recommended in preference to lithium due to tolerance issues

Question 295

Pathological laughing/crying

Answer 295

uncontrollable laughing and/or crying but without the associated affect and is a common feature of Multiple sclerosis Use amitriptyline or fluoxetine 10% in MS

Question 296

Emotional lability in MS

Answer 296

Amitriptyline and SSRIs recommended

Question 297

Porphyria - drugs that precipitate

Answer 297

* Barbiturates * Benzodiazepines * Sulpiride * Certain mood stabilizers

Question 298

Porphyria - symptoms

Answer 298

* Abdominal pain * Mental state changes * Constipation * Vomiting * Muscle weakness

Question 299

Post-concussion syndrome - symptoms

Answer 299

* headache * fatigue * anxiety/depression * dizziness

Question 300

Wilson's disease - inheritance

Answer 300

Autosomal recessive inheritance

Question 301

Wilson's disease - cause

Answer 301

Mutation in Wilson disease protein (ATP7B) gene | Low levels of ceruloplasmin and total serum copper, high levels of copper in liver and brain

Question 302

Wilson's disease - presentation

Answer 302

movement disorders such as dystonia, parkinsonian tremor, and rigidity combined with behavioural problems and a degree of dementia is often seen. Kayser-Fleischer ring is the term given to the brown ring seen around the iris in people with Wilson's disease.

Question 303

Suicide - Epidemiology

Answer 303

M:F = 4:1 in western countries, 2:1 in asian countries, higher in women in China. GENERAL 3:1 Average suicide rate = 1 per 10,000 in gen pop Most common in 40-44 age group

Question 304

Suicide - most popular methods in desc order

Answer 304

* Hanging/strangulation * Self-poisoning * Jumping and multiple injuries (mainly jumping from a height or being struck by a train) * CO poisoning and drowning (these occur at approximately the same rate) * Cutting and stabbing

Question 305

Patient suicides

Answer 305

28% of gen population suicides 10% of patient suicides occurred as inpatients Suicide is rate is 1 in 1000 (x10 higher than gen pop) 1st 3m after discharge is high risk

Question 306

Risk factors for completed suicide

Answer 306

``` ⁃ Male ⁃ Elderly age. ⁃ Single, divorced, or widowed ⁃ Living alone ⁃ Poor social support ⁃ Unemployed ⁃ Low socio-economic class ⁃ Previous self harm ⁃ Any mental disorder ⁃ Dependence on substances ⁃ Recent inpatient treatment ⁃ Concurrent physical disorder ⁃ Bereavement in recent past ```

Question 307

Suicide - protective factors

Answer 307

* Children in the home * Sense of responsibility to family * Pregnancy * Religiosity * Life satisfaction * Reality testing ability * Positive coping skills * Positive problem-solving skills * Positive social support * Positive therapeutic relationship

Question 308

Self-harm

Answer 308

Annual prevalence 0.5% 16% of pt repeat within 1yr 3-12 session of psychological intervention for self-harm Do not offer drug treatment specifically for self-harm

Question 309

SCOFF questionnaire

Answer 309

• Do you ever make yourself Sick because you feel uncomfortably full? • Do you ever worry that you have lost Control over how much you eat? • Have you recently lost more than One stone in a three month period? • Do you believe yourself to be Fat when others say you are too thin? • Would you say Food dominates you life? Score 2 or more indicated AN or bulimia 84.6% sensitivity and 98.6% specificity, NPV 99.3%

Question 310

AN - DSM-V

Answer 310

• Restriction of energy intake relative to requirements, leading to a significantly low body weight (generally speaking a BMI < 18.5) • Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight • Disturbance in the way in which one’s body weight or shape is experienced,

Question 311

AN - DSM-V (severity)

Answer 311

* Mild = BMI > 17 * Moderate = BMI 16 – 16.99 * Severe = BMI 15 – 15.99 * Extreme = BMI < 15

Question 312

AN - cardiac complications

Answer 312

bradycardia, hypotension, arrhythmia, prolonged QT, ventricular tachy, peripheral oedema, sudden death

Question 313

AN - skeletal complications

Answer 313

osteoporosis

Question 314

AN - haematologic complication

Answer 314

anaemia, leukopenia, thrombocytopenia

Question 315

AN - reproductive complications

Answer 315

amenorrhea, low levels of LH and FSH, premature births

Question 316

AN - metabolic complications

Answer 316

Hypothyroidism, hypothermia, dehydration, hypoglycaemia, hypokalaemia, hypomagnesia, metabolic alkalosis

Question 317

AN - Gastrointestinal complications

Answer 317

Delayed gastric emptying, constipation, pancreatitis

Question 318

AN - CNS complications

Answer 318

Cerebral atrophy, depression, cognitive impairment

Question 319

AN - Dermatological complications

Answer 319

Lanugo, hypercarotanaemia, acrocyanosis, hypertrichiosis

Question 320

AN - Treatment

Answer 320

CAT, CBT, IPT, focal psychodynamic therapy and family interventions Aim 0.5-1kg/wk weight gain inpatient, or 0.5kg outpatient No medication for sole or primary tx for AN but olanzapine can effect weight restoration

Question 321

MARSIPAN - high risk items for AN

Answer 321

``` BMI <13 Pulse <40bpm SUSS test <2 Sodium <130mmol/L Potassium <3 mmol/L Serum glucose <3mmol/L QTc >450ms ```

Question 322

AN f/u over 29yr period

Answer 322

50% recovered completely 1/3 had partial recovery 20% had chronic eating disorder 5% died

Question 323

Factors for poor prognosis with anorexia

Answer 323

``` Patients with a long duration of hospital care Psychiatric co-morbidity Being adopted Growing up in a 1 parent household Having a young mother Lower minimum weight Poor family relationships Failed treatment Late age of onset Social problems ```

Question 324

Bulimia Nervosa - Prevalence

Answer 324

``` Prevalence 2-3% F:M = 10:1 Depression more prominent than in AN Alcohol abuse occurs in 15% 13% have co-morbid BPD ```

Question 325

BN - aetiology | Risk factors

Answer 325

?decreased CCK levels ``` Childhood sexual abuse Male homosexuality Having an occupation that focuses on weight Low self-esteem Female gender ```

Question 326

BN - DSM-IV

Answer 326

- Recurrent episodes of binge eating (large amount of food with lack of control) - Recurrent inappropriate compensatory behaviour in order to prevent weight gain - Above occur at least twice a week for 3 months - Self-evaluation is unduly influenced by body shape and weight - Disturbance does not occur exclusively during episodes of AN - Can be over or underweight

Question 327

Ipecac

Answer 327

Produces vomiting within 15-30min A/w serious cardiac toxicity, including cardiomyopathy and left ventricular dysfunction Causes elevated serum amylase levels

Question 328

BN - Physical Complications

Answer 328

* Hypokalemia * Hypochloremia * Hyperphosphatemia (note in anorexia a low phosphate level is usually seen) * Metabolic alkalosis (if induced vomiting is main method) * Metabolic acidosis (if purging is main method) * Parotid gland enlargement (sialadenosis) * Dental erosion * Gastric and oesophageal rupture * Seizure

Question 329

BN - treatment

Answer 329

- 1st line - evidence-based self-help program or/plus antidepressant - SSRI (fluoxetine 60mg OD) - CBT-BN 16-20 sessions - IPT but takes 8-12m

Question 330

BN - Outcome

Answer 330

Standardised Mortality Rate 1.3 | BN is preceded by AN in about 25% of cases or AN-like state

Question 331

Metabolic complications in eating disorders - Electrolytes

Answer 331

* Hypokalemia * Hypomagnesemia * Hypocalcemia * Hypophosphatemia (note in bulimia a high phosphate level is generally seen)

Question 332

Metabolic complications in eating disorders - Endocrine

Answer 332

* Low estradiol * Low luteinizing hormone (LH) * Low follicular stimulating hormone (FSH) * Low T3 (low T3 syndrome/ sick euthyroid syndrome), TSH and T4 are usually normal * Hypercortisolism * Hypoglycemia * Elevated growth hormone

Question 333

Metabolic complications in eating disorders - other

Answer 333

* Hypercarotenemia * Hypercholesterolemia * Urea and creatinine low

Question 334

Complications of purging - vomiting

Answer 334

Na high, low or N K low Chloride low pH high

Question 335

Complications of purging | - laxatives

Answer 335

Na high or N K low Chloride high or low pH high or low

Question 336

Complications of purging - diuretics

Answer 336

Na low or N K low Chloride low pH high

Question 337

Transsexualism

Answer 337

Desire to live and be accepted as a member of the opposite sex Feelings persistent for 2yrs

Question 338

Dual-role transvestism

Answer 338

Wearing of clothes of the opposite sex in order to enjoy the temporary membership of opposite sex w/o desire for permanent change. No sexual excitement

Question 339

Gender identity disorder of childhood

Answer 339

Persistent intense distress about assigned sex, together with desire to be other sex, manifests before puberty. M>F

Question 340

Risk factors for QTc prolongation

Answer 340

``` Long QT prolongation Bradycardia IHD Myocarditis MI LVH Hypokalaemia Hypomagnesia Hypocalcaemia Extreme Extreme physical exertion Stress or shock AN Extremes of age Female gender ```

Question 341

Drugs causing prolonged QTc (non-psych)

Answer 341

Ampicillin, Erythromycin Amiodarone, sotalol Chloroquine, quinine Methadone, tamoxifen, amantadine

Question 342

Priapism

Answer 342

Persistent and painful erection Caused by alpha blockade, ?also by serotonin Drugs that cause: trazodone, chlorpromazine Treatment: Alpha-adrenergic agonists

Question 343

Drugs that raise ALT

Answer 343

``` clozapine haloperidol olanzapine quetiapine chlorpromazine mirtazapine moclobemide SSRIs Carbamazepine lamotrigine valproate ```

Question 344

Drugs that lower ALT

Answer 344

vigabatrin

Question 345

Drugs that raise ALP

Answer 345

``` haloperidol clozapine olanzapine duloxetine sertraline carbamazepine ```

Question 346

Drugs that raise AST

Answer 346

clozapine olanzapine valproate methadone

Question 347

Drugs that lower AST

Answer 347

trifluperazine

Question 348

Drugs that raise TSH

Answer 348

aripiprazole carbamazepine lithium

Question 349

drugs that lower TSH

Answer 349

moclobemide

Question 350

Drugs that raise thyroxine

Answer 350

dexamfetamine | moclobemide

Question 351

Drugs that raise thyroxine

Answer 351

lithium aripiprazole (rare) quetiapine (rare)

Question 352

Sedatives in liver impairment

Answer 352

lorazepam oxazepam temazepam zopiclone

Question 353

Serotonin syndrome

Answer 353

⁃ neuromuscular abnormalities (myoclonus, and clonus, hyperreflexia, muscular rigidity), ⁃ altered mental state ⁃ autonomic dysfunction. Onset usually after 1 or 2 doses of the medication Most frequently due to co-administration of MAOI and SSRI Mild cases: benzos and fluids Severe: ITU

Question 354

NMS

Answer 354

- result of dopamine blockade at the hypothalamus which messes up the thermo-regulatory system and hence results in hyperthermia - also suggested that the use of antipsychotics (neuroleptics) causes calcium uptake into muscles resulting in muscle rigidity, then rhabdomyolysis and elevated CPK - Caused by antipsychotics, also antidepressants and lithium - Onset - within 2w of initial treatment usually - Management: removal of drug, control of fever, benzos, sometimes ECT, bromocriptine, dantrolene - Mortality up to 20%

Question 355

Risk factors for NMS

Answer 355

``` Younger age Make Physical exhaustion Dehydration or electrolyte imbalance Previous and FH of NMS Organic mental disorders Low serum iron levels Raised CK levels Comorbid substance misuse Higher loading dose Faster rate of loading High potency Sudden withdrawal ```

Question 356

NMS vs serotonin syndrome

Answer 356

SS has acute onset, NMS more insidious

Question 357

SADHART study

Answer 357

Found sertraline to be a safe treatment for depression post-myocardial infarction.

Question 358

Hyponatraemia a/w antidepressant use

Answer 358

Recurs upon rechallenge, even if a different antidepressant is rx Sx: n&v, confusion, lethargy, irritability, muscular spasm and cramp, seizures

Question 359

SIADH

Answer 359

Drug induced hyponatraemia (due to excessive secretion of ADH) Fluid overload Antidepressants and antipsychotics Risk factors: elderly, female, smokers, med co-morbidity, polypharmacy, low body weight, reduced renal function, warm weather Normally develops within a few weeks of starting the new drug

Question 360

Antidepressants a/w SIADH

Answer 360

``` SSRIs TCAs Trazodone Phenelzine Tranylcypromine Venlafaxine ```

Question 361

Antipsychotics a/w SIADH

Answer 361

``` Chlorpromazine Fluphenazine Trifluoperazine Thioridazine Thiothizene Haloperidol Clozapine ```

Question 362

Treatment of SIADH

Answer 362

Fluid restriction Sometimes demeclocycline Consider switching to noradrenergic drug such as nortriptyline and lofepramine or an MAOI such as moclobemide

Question 363

Tamoxifen (SERM)

Answer 363

Metabolised by CYP2D6 - some antidepressants inhibit this therefore decrease the anticancer effect. Paroxetine, fluoxetine, bupropion, duloxetine interact (strong). Sertraline, escitalopram, doxepin are moderate inhibitors. Venlafaxine is a weak inhibitor.

Question 364

Teratogens - valproic acid

Answer 364

Spina bifida (1-2% vs 0.2-0.5% background risk), hypospadias

Question 365

Teratogens - Lithium

Answer 365

Ebstein's anomaly

Question 366

Teratogens - alcohol

Answer 366

Fetal alcohol syndrome

Question 367

Teratogens - phenytoin

Answer 367

Craniofacial defects, limb defects, cerebrovascular defect, mental retardation

Question 368

Teratogens - carbamazepine

Answer 368

Fingernail hypoplasia, craniofacial defects

Question 369

Teratogens - diazepam

Answer 369

Cleft lip/palate