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Flashcards in ICSM Year 5 Psychiatry Deck (483)
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1

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

Hypnagogic

2

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

Hyponopompic

3

What is an extracampine hallucination?

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

4

What is an elemental hallucination?

Simple hallucinations eg. flashes of light/ noise

5

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

Charles de Bonnet syndrome

6

What are the 4 types of auditory hallucination?

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

7

What is formication?

The tactile hallucinatory feeling of bugs crawling under your skin

8

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

Pareidolic illusion

9

What is a delusion?

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

10

What is a reference delusion?

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

11

What is Ekbom's syndrome?

The belief that one is infected with parasites

12

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

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

13

What is Othello syndrome?

False belief partner is being unfaithful

14

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

Erotomania/ De Clerembault's syndrome

15

What is capgras syndrome?

Belief that a close acquaintance has been replaced by an imposter

16

What is fregoli syndrome?

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

Fregoli was Italian actor - think one person acting as many

17

Recall the 3 types of thought disorder

Insertion, withdrawal and broadcasting

18

What is Cotard's syndrome?

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

19

What is Knight's move thinking?

Absence of clear links between successive thoughts

20

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

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

21

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

Circumstantiality

22

What is a neologsim?

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

23

When was the MHA made?

2007

24

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

Section 2: admission for assessment
Section 3: admission for treatment
Section 5(2) Holding for a patient already on the ward
Sectrion 136: Police order to remove someone who is mentally ill from a public place to a place of safety

25

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

Section 2: 28 days
Section 3: 6 months
Section 5(2): 72 hours
Section 136: 24-36 hours

26

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

Sections 2 and 3 = 2 doctors, with at least one being Section 12 approved
Section 5(2) = 1 doctor
Section 136 = a police officer

27

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

Section 4 - it only needs ONE doctor because it's an emergency and the doctor MUST be S12 approved (a psychiatrist)

28

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

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

29

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

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

30

Recall the process for forcibly medicating someone under the MHA

Under Section 3 can be forcibly medicated for 3 months, if then not consenting, need a SOAD assesment (second opinion appointed doctor)

31

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

Must be a psychiatrist

32

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

Detention of an inpatient by a nurse

33

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

6 hours (detention by nurse)

34

What does section 17 of the MHA allow?

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

35

What does section 35 of the MHA permit?

Assesment of a patient accused of committing a crime

36

How long does assesment last under section 35?

28 days

37

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

You can't appeal

38

What does section 37 of the MHA permit?

Treatment of a convicted criminal - otherwise like section 3

39

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

Within 21 days to court, after 6 months to the MHRT (mental health review tribunal)

40

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

Section 41 - a restriction order

41

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

Section 47 - when restriction is added = section 49

42

What is a community treatment order?

Discharge from a previous section providing certain conditions are met - requires renewal every 6 months

43

Describe the role of the Approved Mental Health Professional

95% are social workers, and are responsible for coordinating the assessment and admission of a patient to hospital if needed

44

Describe the role of the Independent Mental Health Advocate

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

45

What does DoLS stand for?

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

46

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

Dopamine receptor antagonists - most block D2 but Clozapine blocks D1 and D4

47

Recall some common side effects of anti-psychotics

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

Hyperprolactinaemia (galacorrhoea, amenorrhoea, gynaecomastia)

Weight gain

48

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

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

49

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

Atypical antipsychotic

50

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

Typical antipsychotic

51

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

Increased risk of stroke and VTE

52

Describe how the dosage of clozapine is controlled

Start low and titrate up slowly, if >48 hours missed medication, need to start again

53

Recall one caution of using clozapine

If patient stops smoking suddenly, the clozapine levels will suddenly go up

54

Recall 2 examples of typical antipsychotics

Haloperidol, chlorpromazine

55

Recall 4 examples of atypical antipsychotics

Clozapine, risperidone, apiprazole, olanzapine, quetiapine

56

Recall one significant side effect to remember of clozapine

Agranulocytosis (1%)

57

Recall one drug interaction of clozapine

Lithium

58

What is neuroleptic malignant syndrome?

A major side effect of antipsychotics characterised by fever, altered mental status, muscle rigidity, and autonomic dysfunction

59

What is akathisia?

An unpleasant subjective feeling of restlessness

60

What is tardive dyskinesia?

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

61

Describe the monitoring process for patients who take antipsychotic medications

Basic obs + bloods (more frequent for clozapine) + assessment of movement disorders, nutritional status and physical activity + ECG if CVD risk factors present

62

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

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

63

Recall the symptoms of suddenly stopping antidepressant medication

FIRM STOP
Flu-like symptoms
Insomnia
Restlesness
Mood swings

Sweating
Tummy problems
Off-balance (ataxia)
Paraesthesia

64

Recall 4 examples of SSRIs

For Sadness, Panic, Compulsion:
Fluoxetine, sertraline, paroxetine, Citalopram

65

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

1-2 weeks

66

Recall one important risk of SSRIs

May increase suicidal thoughts/ self-harm risk

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

67

Recall one important interaction of SSRIs

Triptans - interaction can cause serotonin syndrome - so ask about migraines

68

Recall one important side effect of citalopram

QT prolongation

69

Recall one important side effect of sertraline

Can cause arrhythmias and QT prolongation - but still the antidepressant of choice following an MI (this was asked in a PPQ so nb)

70

Recall the main side effects of all SSRIs

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

71

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

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

72

How long should SSRI medications be continued for?

6 months after remission of first episode, 2 years after remission if it's a recurrence - gradually stop over 4 weeks

73

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

Avoid: TCAs, MAOIs, Venlafaxine - lethal in OD

Use: SSRIs (despite INITIAL suicide risk) or mirtazapine

74

How should different SSRI medications be switched?

Reduce dose over 2 weeks before starting another SSRI

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

75

What does SNRI stand for?

Serotonin-noradrenaline reuptake inhibitor

76

What is the main side effect of SNRIs?

Headache

77

Recall 2 examples of SNRIs

Venlaxafine, duloxetine

78

Describe the side effects of SNRIs

Same '5S' as SSRIs but also constipation, HTN + raised cholesterol

79

What is the mechanism of action of TCAs?

Block serotonin and NA reuptake

80

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

Low dose: blocks H1 and 5HT and aids sleep

Higher doses: blocks all receptors and is used in depression

81

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

Can be fatal in OD

82

What is one key contraindication for TCAs?

If patient is also taking a monoamine oxidase inhibitor

83

Recall the side effects of TCAs

TCA:
Thrombocytopaenia

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

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

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

84

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

"Can't see, can't pee, can't spit, can't shit"

85

Give 2 examples of TCAs

Amitriptyline, clomipramine

86

What type of antidepressant is mirtazapine?

noradrenergic and specific serotonin antidepressant (NaSsA)

87

What is the most common side effect of mirtazapine?

Weight gain

88

When is mirtazapine indicated?

Triad of depression + insomnia + loss of appetite

89

Give 2 examples of MAOI antidepressants

Phenelzine, selegiline

90

What does MAOI stand for?

MonoAmine Oxidase Inhibitor

91

What is the main risk of MAOI use?

Hypertensive cheese reaction

92

What type of antidepressant is moclobemide?

Reversible Inhibitor of Monoamine oxidase A (RIMA)

93

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

2-4 weeks

94

What is the mechanism of action of BDZs and BARBs?

Enhance GABA transmission at GABA-A receptor

95

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

BDZ increases duration of receptor opening, BARB increases frequency of opening

96

Why are barbiturates more dangerous than BDZs?

Less selective so more excitatory transmission

97

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

Diazepam, lorazepam, chlordiazepoxide

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

98

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

Sedative reduces physical + mental activity without producing a loss of consciousness, whereas hypnotic will induce sleep

99

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

Teazepam, oxazepam - used as sedatives

100

What is a Z drug used to treat?

Treats insomnia (similar to a BDZ)

101

Give an example of a Z drug

Zopiclone

102

When should Z drugs be used?

Only when insomnia is severe and disabling

103

What is a key side effect of zopiclone?

Increased risk of falls

104

Describe the withdrawal process from zopiclone

1/8th the daily dose every 2 weeks: reduce by 5mg every 2 weeks until 20mg/day, then reduce by 2mg every 2 weeks until 10mg/day, then reduce by 1mg every 2 weeks until 5mg/day, then reduce by 0.5mg every 2 weeks until completely stopped

105

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

Flumenazil (BDZ antagonist)

106

Why should zopiclone not be used in pregnancy?

Can cause a cleft lip

107

What are stimulants used to treat?

ADHD and narcolepsy

108

Give 2 examples of stimulant drugs used to treat ADHD

Methylphenidate (Ritalin)
Dexaphetamine

109

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

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

110

Recall some side effects of stimulant drug use

Cardiac pathology, drug-induced psychosis, appetite suppression, "risky" behaviour, insomnia, impulsivity

111

What are mood stabilising drugs used to treat?

BPAD, schizoaffective disorder

112

What are the 4 main mood stabilising drugs?

Lithium (1st line), valporate (2nd line), carbamazapine, lamotrigine

113

Recall 4 key side effects of lithium

Mild tremor, hypothyroidism, eyebrow hair loss, nephrogenic DI

114

How does a lithium OD present?

Tremor
Ataxia
GI disturbance/ urinary symptoms
Seizures
AKI

115

What regular monitoring should be done in lithium prescription?

Every 3 months: lithium levels, every 6 months: UandEs and TFTs

116

Why should lithium not be used in pregnancy?

Causes Ebstein's abnormality (heart defect)

117

Recall 2 key side effects of valporate

Hair loss + weight gain

118

What is the main risk of using valporate in pregnancy?

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

119

What is the main risk of using carbamazipine in pregnancy?

Spina bifida

120

What is the key side effect of lamotrigene use?

Severe skin rash - SJS

121

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

Haloperidol

122

Recall the symptoms of the NMS

Gradual onset triad of mental status change (catatonia), muscular rigidity + autonomic instability (hyperthermia + labile BP)
"MMA" fighters are muscular, mental and (autonomically) unstable

123

In what time frame does the NMS develop?

4-11 days after starting any antipsychotic medication

124

What investigations should be done to identify NMS?

FBC (to show leucocytosis), UandEs (show high CK and AKI)

125

How should the NMS be managed?

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

126

Recall the symptoms of the serotonin syndrome

Abrupt onset triad of mental state change, neuromuscular changes and autonomic instability (so very similar to NMS but abrupt onset rather than gradual)

127

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

Diarrhoea and Vomiting

128

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

All the same except the drug used is a BDZ (clonazepam) rather than dantrolene and bromocriptine

129

How does ECT work?

Induces a generalised tonic-clonic seizure under general anaesthetic

130

What are the indications for ECT?

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

131

What is an absolute contraindication for ECT?

Raised intracranial pressure

132

What are the short term side effects of ECT?

Headaches and nausea, muscle aches, cardiac arrhythmia, retrograde amnesia (loss of memories before the ECT)

133

What is the main target of CBT?

So-called 'Negative Automatic Thoughts'

134

What is Beck's negative cognitive triad

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

135

Describe the negative cycle that CBT aims to tackle

Thoughts (eg "She didn't smile at me when she walked past") --> emotions ("I'm such a nobody, no one acknowledges me" --> behaviours ("I'm going to avoid everyone and not waste their time")

136

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

Longitudinal format/ hot-cross bun methods

137

Describe the longitudinal format of CBT

1. Get a detailed history from early life to present - identify early experiences, critical incidents etc
2. How do these early experiences affect core beliefs? (Beck's triad)
3. Identify NATs - eg mental filters/ predictions/ mountains and molehills

138

What is the theoretical basis of psychodynamic psychotherapy?

Problems are shaped by childhood experiences --> causes conflict between conscious and unconscious mind, therapy reveals unconscious mind

139

What is the difference between psychoanalytics and psychodynamics?

Psychoanalytics = internal conflicts
Psychodynamics = interpersonal conflicts

140

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

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

141

Recall 4 protective factors against suicide

Married, lithium medication, faith, no substance abuse

142

What is the reversing agent for overdose on a BDZ?

Flumenazil

143

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

Flumenazil

144

What is the reversing agent for overdose on an opiate?

Naloxone

145

What is the reversing agent for overdose on paracetamol?

N-acetylcysteine

146

What is delirium?

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

147

What are the most important differentials to consider in delirium?

Infection, medication and constipation but there are SO MANY causes, look for many and don't be satisfied with one

148

How is delirium diagnosed?

Confusion Assesment Method

149

How is delirium managed?

Modify risk factors, exclude diagnosed dementia, treat the causes

150

What is the medical management of delirium?

PO antipsychotics, AVOID anticholinergics

151

What is the prognosis for delirium?

37% die within 6 months, only 25% have a clinically important recovery in ADLs

152

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

IM lorazepam

153

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

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

154

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

PO medication (not IM)

Unknown/naïve pt: lorazepam

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

155

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

1 hour at least

156

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

1. IM Lorazepam - wait 30 mins for a response

If response only partial - repeat IM lorazepam dose

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

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

157

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

Presence/ absence of cardiac disease

158

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

Start with haloperidol with promethazine (think - makes sense that last thing on rapid tranq ladder (L-->O --> P+H) is for patients who are known and definitely do not have cardiac disease) -

Wait 30 mins for response and repeat if response only partial

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

159

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

1. Lorazepam - wait 30 mins for response OR olanzapine (repeat if partial response)
2. If no response: wait 1 hour, then give lorazepam/ olanzapine

160

Recall the dosing for oral rapid tranquilisation medications

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

161

Recall the dosing for IM rapid tranquilisation medications

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

162

Describe how rapid tranquilisation should be monitored

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

163

What are the 2 core symptoms of depression?

Low mood + anhedonia

164

What are the adjunct symtpoms of depression?

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

165

Recall 3 medications that may cause depression

Steroids, COCP, propranalol

166

What is dysthymia?

Subthreshold depression (2-5 symptoms) of depression for at least 2 years

167

What is atypical depression?

Just somatic symtpoms (weight gain, hypersomnia)

168

What can improve the symptoms of anxiety-induced insomnia?

Mood is increased by increased sleep and eating

169

What is a depressive stupor?

Such extreme psychomotor retardation that the individual grinds to a halt

170

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

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

171

How would you go about investigating for depression?

Full history and collateral history, physical exam and MSE, bloods to check for anaemia, hypothyroidism and diabetes, and a rating scale (Eg PHQ9, CDI (children), EPDS (pregnancy)

172

Describe the MSE

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

173

How is depression treated in children and young people?

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

Intensive psychological therapy thorugh CAMHS if completely unresponsive to treatment

174

How is depression treated in adults?

Check suicide risk

Step one: if initial suspected depression / subthreshold symptoms --> watchful waiting, with follow up in 2 weeks, education about sleep/ mind.co.uk etc

Step two: if persistent subthreshold/ mild symptoms: group/ computerised CBT/ guided self-help - only give medication if subthreshold symptoms last longer than 2 years

Step three: moderate symtoms/ persistent subthreshold refractory to step 2: individual CBT/IAPT + medications with regular review every 2 weeks for 3 months (or every week if suicidal )

Step four: severe depression/ risk to life/ neglect: high-intensity psychsocial interventions, section if necessary, medications, ECT if necessary

175

What is the first line antidepressant medication?

SSRIs (sertraline, citalopram, fluoxetine, paroxetine)

176

When should a second line antidepressant be tried?

After trying 2 different SSRIs

177

What is the second line antidepressant medication?

SNRIs (venlaxafine, duloxetine)

178

Recall the stepped increase of dose of venlaxafine

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

179

What is the indication for 3rd line antidepressant treatment?

If they are resistant to treatment, you can't augment treatment with further medication

180

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

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

181

What is the ideal blood level of lithium?

0.6-1.0 (toxicity at >2.0)

182

In which scenario is mirtazapine most useful?

When symptoms of insomnia and appetite reduction are evident and debilitating

183

Describe the side effect profile of sertraline

Smallest side-effect profile, so a good one to give to people with comorbid IHD

184

What is the best antidepressant to give to children?

Fluoxetine

185

What is the most common use of paroxetine?

For major depressive episodes

186

When should paroxetine not be used and why?

Pregnancy: in 1st trimester may cause congenital heart defects, in 3rd trimester may cause persistent pulmonary HTN

187

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

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

188

How is BPAD defined in the ICD-10?

>/= 2 episodes, 1 must be manic, mania lasts around 4 months, depression lasts around 6 months, there is complete recovery between 2 episodes

189

How can a manic episode be identified?

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

190

How is mania diagnosed?

Need at least 3 characteristcs of mania on the MSE, lasting at least 7 days and causing an impaired occupational/ social functioning +/- psychosis

191

What is hypomania?

>3 characteristics of mania lasting at least 4 days, no impairment of functioning, no delusions/ psychosis

192

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

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

193

What is rapid cycling BPAD?

More than 4 episodes per year

194

What is the best treatment for rapid cycling BPAD?

Sodium valporate - they respond well

195

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

7 fold

196

What is the rating scale used to investigate BPAD?

Young mania rating scale

197

Why can BPAD be hard to pick up on?

Most BPAD patients present in their depressive episodes, so you always need to ask about mania symptoms

198

Recall some differentials for BPAD?

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

199

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

If there's hypomania just do a routine referral to CMHT, if it's full-on mania do an urgent referral to CMHT or admit

200

How should acute mania be treated?

Gradually taper off and stop medications (eg SSRIs), monitor fluid and food intake, may need to sedate
If not on treatment: aim to stabilise them before starting lithium
If already on treatment, check lithium levels - it might be atypical
If on treatment, also optomise current medications and stop antidepressants

201

How should mania be managed in the longterm?

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

202

How do you manage BPAD if they have comorbid depression?

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

203

What is the use of psychological therapies in BPAD?

May improve compliance with medication long term

204

What is the prognosis for BPAD?

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

205

How does the ICD-10 define schizophrenia?

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

206

Describe the progression of schizophrenia

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

207

What is wavy flexibility?

They will retain any shape you put them into!

208

What is the most common subtype of schizophrenia?

Paranoid schizophrenia

209

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

Paranoid - prominent delusions and hallucinations

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

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

Simple - negative symptoms only eg apathy and social withdrawal

210

How does cannabis use increase risk of schizophrenia?

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

211

What rating scale is used to investigate schizophrenia?

Brief psychiatric rating scale

212

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

Steroids

213

What is schizoaffective disorder?

Schizophrenic and affective symptoms develop together and are balanced

214

What is schizotypal disorder?

Eccentricity with abnormal thoughts

215

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

Crisis Resolution Team and Home Treatment Team

216

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

Early Intervention in Psychosis (EIP) team

217

Recall the stepwise biological treatment of schizophrenia

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

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

2nd line (6 weeks): typical antipsychotic

3rd line (if treatment resistant): clozapine

218

Recall the psychological treatment of schizophrenia

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

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

219

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

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

220

What kind of things influence schizophrenia prognosis?

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

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

221

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

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

222

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

>= 2 weeks

223

What are the diagnostic requirements for schizoaffective disorder?

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

224

How should schizoaffective disorder be treated?

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

225

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

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

226

How should acute psychosis be managed?

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

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

227

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

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

228

How does onset affect prognosis in psychosis?

Rapid onset is associated with a better prognosis

229

How should delusional disorder be managed?

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

230

Recall the important elements of the history in anxiety disorders

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

231

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

Phobia, OCD, PTSD

232

What type of psychological therapy is best for phobias?

Exposure therapy

233

What type fo psychological therapy is best for OCD?

CBT

234

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

All of them - with SSRIs - most often sertraline

235

What is the prognosis for anxiety generally?

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

236

How is GAD defined in the DSM-V?

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

237

Recall the possible symptoms of GAD

Restlessness
Irritability
Fatiguability
Muscle tension
Sleep disturbance
Poor concentration

238

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

3

239

What questionnaire is useful in diagnosis of GAD?

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

240

Recall the stepwise management for GAD

1. Written information + exercise

2. Low intensity psychological intervention - self-help or a psychoeducational group

3. High intensity psychological interventions or medications (step-wise)
- CBT/ applied relaxation
- Step 1 = SSRI/ paroxetine (8 weeks)
- Step 2 = different SSRI (like depression)
- Step 3 = SNRI (venlaxafine) + weekly follow up
- Step 4 = pregabalin (antiepileptic)
- Step 5 = quetiapine (atypical antipsychotic)
Use propranolol as an adjunct for the physical symptoms

241

Which treatments should not be used in phobias?

1. BDZs (high risk of dependence)
2. Antidepressants - specific phobias don't respond well

242

What is agarophobia?

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

243

Into which 2 classifications is agarophobia classified?

As either with or without a panic disorder

244

How is agarophobia managed?

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

245

What is social phobia?

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

246

How can social phobia and agarophobia be differentiated?

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

247

How can specific phobias managed?

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

248

What is panic disorder?

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

249

What is the maximum duration of a panic attack?

30 mins

250

How is panic disorder managed?

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

251

What is OCD?

Disorder that may have recurrent obsessional thoughts or compulsive acts

252

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

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

253

Describe how obsessions are defined

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

254

Describe how compulsions are defined

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

255

Describe the gender balance of OCD prevalence?

Only anxiety disorder to affect men more than women

256

Which part of the brain can be implicated in OCD?

Basal ganglia

257

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

Yale-Brown OCD scale

258

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

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

259

How should OCD with mild functional impairment be managed?

CBT with Exposure Response Prevention

260

How should OCD with moderate functional impairment be managed?

Intensive CBT with ERP or SSRI

261

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

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

262

Recall the 4 phases of cognitive therapy for OCD

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

263

Define Acute Stress Disorder

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

264

What are the key features of adjustment disorder?

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

265

How should adjustment disorder be managed?

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

266

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

Formal, immediate, psychological 'debriefing'

267

How long can adjustment disorder last?

No longer than 6 months

268

Describe the presentation of adjustment disorder

Symptoms of anxiety and depression, without biological symptoms of depression

269

What would make a grief reaction abnormal/ prolonged?

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

270

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

1 month

271

What are the key signs and symptoms of PTSD?

1. Re-experiencing
2. Avoidance of triggers
3. Hyperarousal

272

Which questionnaire should be used in suspected PTSD?

Trauma screening questionnaire

273

How should PTSD be managed?

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

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

Or eye Movement Desensitisation and Reprocessing (EMDR)

274

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

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

275

Recall the features of dependency

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

276

What is the recommended maximum alcohol intake per week?

<14 U (both men and women)

277

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

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

278

What type of hallucinations may occur in delirium tremens?

Liliputian (seeing little people)

279

What type of seizure might present in alcohol withdrawl syndrome?

Grand-mal

280

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

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

281

What are some useful rating scales of alcohol-dependence?

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

282

What alcohol screening tool is used in AandE?

FAST (fast alcohol screening test)

283

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

Ataxia, opthalmoplegia, confusion

284

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

>30 U per day

285

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

Acamprosate/ naltrexone

286

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

IV lorazepam

287

What drugs should be administered in delirium tremens?

Oral lorazepam and IV thiamine/ pabrinex

288

What is the mechanism of action of acamprosate?

Enhances GABA transmission to remove craving for alcohol

289

What psychological therapy is appropriate in alcohol detox?

Motivational interviewing

290

What structure is damaged by B12 deficiency?

Mammillary damage

291

What are the symptoms of Wernicke's encephalopathy?

Ataxia, opthalmoplegia, acute confusion (TRIAD)

292

What are the symptoms of Korsakoff's psychosis?

Anterograde amnesia, confabulation, peripheral neuropathy, cerebellar degenration

293

From what plant are opiates derived?

Papaver somniferum

294

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

Hepatitis C

295

Recall 4 local complications of heroin injection

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

296

Recall 4 systemic complications of heroin injection?

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

297

Recall the symptoms of heroin intoxication

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

298

How should opiate OD be treated?

Naxolone

299

What are the symptoms of opiate withdrawal?

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

300

How long after injection of heroin do withdrawal symptoms begin?

6 hours after injection

301

How long do opiate withdrawal symptoms last?

5-7 days

302

How long do opiates stay in the urine?

2 days

303

How should opiate use be managed?

1. Appoint a key worker and develop a care plan

2. Harm reduction - complete abstinence is unlikely so be pragmatic - needle exchange and vaccinations

3. Health education - 'SMART' recovery

304

What are the two stages of Opiate Substitution Therapy?

Stabilisation and detoxification

305

How long does Opiate Substitution Therapy last as an outpatient?

12 weeks minimum

306

What are the first line treatments for Opiate Substitution Therapy?

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

307

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

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

308

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

6 months

309

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

4 weeks

310

Recall some chronic complications of cannabis use

Dysthymia, anxiety/ depressive illness, amotivational syndrome

311

Recall 4 types of hallucinogenic drug

LSD, phencyclidine, ketamine, magic mushrooms

312

How long can an LSD trip last?

12 hours

313

What is a street name for phencyclidine?

Angel dust

314

What are the symptoms of phencyclidine use?

Violent outbursts and ongoing psychosis

315

Recall the symptoms of ketamine use in smaller and larger doses

Smaller = dissociation
Larger = hallucinations and synaesthesia

316

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

Small = euphoria
Large = hallucinations

317

What can be used to treat hallucinogen withdrawal short term?

BDZs

318

What stimulant is most often used in East African communities?

Khat/ quat/ chat

319

Which recreational stimulant drug class may cause dependence?

Amphetamines

320

Recall some acute side effects of cocaine use

Arrhythmia, intense anxiety, HTN

321

Recall some chronic side effects of cocaine use

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

322

How can ecstasy cause death?

Via dehydration and hyperthermia

323

Recall the 2 phases of cocaine withdrawal

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

324

How long does cocaine remain in urine?

5-7 days

325

What is the most significant risk of BDZ use?

Dependence

326

What is the result of BDZ overdose?

Respiratory depression

327

How should BDZ overdose be treated?

IV flumenazil

328

What are the 2 options for BDZ withdrawal management?

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

329

What is the most common side effect of BDZ withdrawal?

Anxiety

330

At what rate should BDZ dose be reduced?

1/8th dose every 2 weeks

331

What are the 3 medical options for smoking cessation?

Nicotine replacement therapy, varenicline, bupropion

332

What is the mechanism of action of Varenicline and Bupropion?

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

333

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

7-14 days

334

Recall some contraindications for varenicline

<18 y/o, renal disease

335

Recall some contraindications for bupropion

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

336

Recall the 3 Ps necessary to diagnose personality disorder?

Persistent, pervasive and pathological

337

Recall the 3 broad clusters of personality disorders

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

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

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

338

What criteria must be met to diagnose a personality disorder?

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

339

What is the supposed prevalence of personality disorder?

10%

340

What are the differences between schizotypal and schizoid personality disorders?

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

341

Recall the features of paranoid personality disorder

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

342

Recall the features of schizoid personality disorder

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

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

343

Recall the features of histrionic personality disorder

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

344

Recall the features of emotionally unstable personality disorder

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

345

Recall the features of dissocial personality disorder

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

346

Recall the features of anankastic personality disorder

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

347

Recall the features of anxious/ avoidant personality disorder

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

348

Recall the features of dependent personality disorder

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

349

What is 'splitting' in personality disorders?

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

350

In which conditions may splitting be seen?

EUPD/ BPD

351

What does 'dissociation' describe in personality disoder?

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

352

What is sublimation?

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

353

What is a 'reaction formation' in personality disorder?

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

354

What is 'identification' in personality disorder?

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

355

What is 'displacement' in personality disorder?

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

356

What is 'projection' in personality disorder?

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

357

Which medications might be used in cluster A personality disorders?

None

358

Which medications might be used in cluster B personality disorders?

antipsychotics, antidepressants and lithium

359

Which medications might be used in cluster C personality disorders?

Lithium

360

In which personality disorders is dialetical behaviour therapy particularly useful?

EUPD/BPD

361

What are the 2 concepts introduced by DBT?

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

362

Which eating disorder is most genetically heritable?

Anorexia nervosa

363

How can you test for proximal myopathy?

Squat test

364

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

Low

365

What ECG abnormality may be present in bulimia nervosa?

Long QT

366

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

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

367

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

1. BMI < 17.5
2. Deliberate weight loss
3. "Fear of the fat"

368

How are anorexia nervosa and bulimia nervosa distinguished clinically?

AN = underweight, BN = normal/ increased weight

369

What is Russel's sign?

Callous/ cut knuckles from self-induced vomiting

370

How is anorexia nervosa managed?

NO WATCHFUL WAITING - refer immediately

371

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

MARISPAN (Management of Really Sick Patients with AN)

372

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

<15

373

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

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

374

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

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

375

What is the duration of CBT-ED?

40 weekly sessions

376

What is the focus of MANTRA therapy for anorexia nervosa?

Focusing on the cause of the anorexia nervosa

377

Describe SSCM treatment for anorexia nervosa

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

378

What is the target weight gain range for AN patients?

0.5-1.0kg/ week

379

When should pharmacological managemrnt be used in AN?

If physical symptoms, rapid weight loss or BMI <13.5

380

What is the appropriate drug for pharmacological treatment of AN?

Fluoxetine

381

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

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

382

What is the main defining feature of the Refeeding Syndrome?

Low phosphate

383

What is the aetiology of the refeeding syndrome?

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

384

Which electrolytes are low in the refeeding syndrome?

Low K+, low phosphate, low magnesium

385

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

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

386

What are the criteria for diagnosing BN?

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

387

What is BED?

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

388

How should bulimia nervosa be managed?

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

389

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

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

390

Differentiate between dissociative disorder and somatisisation disorder

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

SD = disorders involving pain or autonomically-controlled sensations

391

What is dissociative fugue?

Dissociative amnesia + purposeful travel beyond everyday range

392

What is a dissociative stupor?

Lack of voluntary movement/ normal responses to external stimuli

393

What are trance and posession disorders?

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

394

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

Limbs

395

How can dissociative convulsions be distinguished from an epileptic seizure?

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

396

How can dissociative anaesthesia be distinguished from organic anaesthesia?

Areas of anaesthesia do not follow normal dermatomal distribution

397

How is somatisation defined?

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

398

Recall the 4 subtypes of somatisation disorder

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

399

What are the hallmark features of hypochondrial disorder?

Often cancer
Pre-occupation with a single problem

400

What is somatoform autonomic dysfunction?

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

401

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

65 years old

402

What are the 2 most useful screening questionnaires for dementia?

AMTS, GPCOG

403

What AMTS score suggests cognitive impairment?

<7

404

What is the most detailed assesment of possible dementia?

Addenbrooke's (ACE-R) - 100 questions

405

How many questions are in the MMSE?

30

406

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

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

407

What biomarker can be used to identify Lewy Body dementia?

123|-FP-CIP SPECT

408

What are the 3 theories of Alzheimer's aetiology?

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

409

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

hippocampus

410

Recall 4 genetic risk factors for Alzheimer's

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

411

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

Atrophy from neuronal loss
Plaque formation
Neurofibrilliary tangles
Cholinergic loss

412

How does Alzheimer's characteristically present?

The 4 'A's:
- Amnesia
- Aphasia
- Agnosia
- Apraxia

413

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

Risperidone

414

Recall the options for medical management of Alzheimer's

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

415

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

Structural group cognitive stimulation

416

What checks should be done before anti-cholineesterase prescription?

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

417

What is the common presentation of vascular dementia?

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

418

How should vascular dementia be managed?

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

419

What are Lewy bodies composed of?

Alpha synuclein with ubiquitin

420

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

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

421

Describe the classical presentation of Lewy body dementia

Fluctuating confusion with marked variations in alertness levels

422

What confusing symptoms may be seen in Lewy body dementia?

Lilliputian hallucinations (like delirium)
Parkinsonianism
Frequent falls

423

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

Antipsychotics - they increase risk of cerebrovasvular disease

424

What medical management can be used in Lewy body dementia?

Same as Alzheimers disease - anti-cholineesterases

425

What is another name for frontotemporal dementia?

Pick's disease

426

What is especially unusual about frontotemporal dementia?

Early onset (usually 40 to 60 years)

427

Recall the signs and symptoms of frontotemporal dementia

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

428

What two investigations are most useful in frontotemporal dementia?

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

429

What is the prognosis for frontotemporal dementia?

Death in 5-10 years

430

What is the inheritance pattern of Huntingdon's?

Autosomal dominant so 50% chance of children inheriting

431

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

30-50 years old

432

What is the general clinical picture of Huntingdon's?

Clumsy, speech difficulties

433

Recall some signs and symptoms of Huntingdon's

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

434

What are chorea?

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

435

What is the model for formulation in CAMHS?

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

436

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

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

437

What rating scale can be used to asses ADHD?

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

438

How should ADHD be managed?

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

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

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

439

What are some side effects of methylphenidate?

Abdo pain, nausea, dyspepsia

440

Recall some important things to monitor whilst giving ADHD medication

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

441

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

15%

442

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

Sodium valporate

443

Recall 4 important associations of ASD

Fragile X syndrome
Tuberous sclerosis
Neurofibromatosis
Di-George

444

What is the difference between Asperger's and Autism?

Asperger's has no delay in language/ cognitive development

445

What is Rett syndrome?

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

446

What is the most common form of ASD?

Pervasive Developmental Disorder Not Otherwise Specified (PPD-NOS)

447

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

Social interaction
Communication
Patterns of behaviour/ interests/ activities

448

What are the typical motor mannerisms of children with ASD?

Finger flapping and repetitive whole-body movements

449

Recall a simpler easy diagnostic triad for ASD

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

450

What is one hallmark symptom of Autism spectrum disorder?

Echolalia

451

Recall the 2 gold standard diagnostic tools for ASD

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

452

Describe the management of Autistic spectrum disorder

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

453

Define conduct disorder

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

454

In which age group can oppositional defiant disorder exist?

<10 years old

455

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

6 months

456

How should conduct disorder be managed?

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

457

By what 3 criteria is learning difficulty defined?

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

458

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

IQ <50

459

What is the most prevalent physical symptom of learning difficulties?

Poor sleep/ wake cycle

460

What scale is used to assess intellectual impairment?

WAIS II

461

What medications might be useful in learning difficulties?

Melatonin for sleep

462

Which law protects reasonable adjustment?

Disability act 1995

463

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

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

464

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

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

465

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

7 days later and 12 hours following last dose

466

What electrolyte abnormality is associated with SSRIs?

Hyponatraemia

467

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

Sertralline

468

What is acute dystonia?

Sustained muscle contraction (eg oculogyric crisis, torticollis)

469

How can acute dystonia be managed?

Procyclidine

470

What is acute dystonia a side effect of?

Antipsychotics (typical and atypical alike)

471

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

Hypothyroidism

472

What is the main risk of using paroxetine in pregnancy?

Congenital malformations

473

Which antipsychotic reduces the seizure threshold?

Clozapine

474

What drug can be used to treat tardive dyskinesia?

Tetrabenazine

475

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

Persistent pulmonary hypertension of the newborn

476

What are the metabolic side effects of antipsychotics?

Hyperlipidaemia
Diabetes mellitus

477

How should antidepressant medication be managed prior to ECT treatment?

The dose should be reduced but not stopped

478

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

Diarrhoea

479

What type of incontinence can be caused by TCAs?

Overflow incontinence

480

Which psychiatric drug can cause hyperparathyroidism?

Lithium

481

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

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

482

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

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

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

483

How do bromocriptine and dantrolene work to treat the NMS?

Bromocriptine reverses dopamine blockade
Dantrolene reduces muscle spasm
ECT