Pass medicine 2 Flashcards
(100 cards)
1
Q
What are the classes of personality disorders and which ones fit into which group?
A
Cluster A (weird/mad) Schizoid, paranoid, schizotypal
Cluster B (wild/bad) Histrionic, emotionally unstable (borderline), dissocial/antisocial, narcissistic
Cluster C (worried/sad) Dependent, avoidant, anankastic/obsessional
2
Q
What are the most prevalent PDs?
A
Dissocial 3%
Histrionic 2-3%
Paranoid 0.5-2.5%
3
Q
What are the risk factors for personality disorders?
A
- low socioeconomic status
- social reinforcement of abnormal behaviour
- family history
- dysfunctional family/parental deprivation
- childhood abuse
4
Q
What are the features of a paranoid PD?
A
SUSPECTS
Suspicious of others Unforgiving (bears grudges) Spouse fidelity questioned Perceives attack Envious (jealous) Criticism not liked/cold affect Trust in others reduced Self-reference
5
Q
What are the features of a schizoid PD?
A
DISTANT
Detached (flattened) affect Indifferent to praise or criticism Sexual drive reduced Tasks done alone Absence of close friends No emotion (cold) Takes pleasure in few activities
6
Q
What are the features of a emotionally unstable/borderline PD?
A
AM SUICIDE
Abandonment feared Mood instability Suicidal behaviour Unstable relationships Intense relationships Control of anger poor Impulsivity Disturbed sense of self (identity) Emptiness (chronic)
7
Q
What are the features of a dissocial/antisocial PD?
A
CORRUPT
Callous Others blamed Reckless disregard for safety Remorseless (lack of guilt) Underhanded (deceitful) Poor planning Temper/tendency to violence
8
Q
What are the features of a histrionic PD?
A
PRAISE
Provocative behaviour Real concern for physical attractiveness Attention seeking Influence easily Shallow/seductive inappropriately Egocentric (vain)/ exaggerated emotions
9
Q
What are the features of a dependent PD?
A
RELIANCE
Reassurance required Expressing disagreement is difficult Lack of self-confidence Initiating projects is difficult Abandonment feared Needs others to assume responsibility Companionship sought Exaggerated emotions
10
Q
What are the features of an anxious/avoidant PD?
A
CRIES
Certainty of being liked needed before becoming involved with people
Restriction to lifestyle in order to maintain security
Inadequacy felt
Embarrassment potential prevents involvement in new activities
Social inhibition
11
Q
What are the features of an anankastic/obsessional PD?
A
LAW FIRMS
Loses point of activity (due to preoccupation with detail)
Ability to complete tasks compromised (due to perfectionism)
Workaholic at the expense of leisure
Fussy (excessively concerned with minor detail)
Inflexible
Rigidity
Meticulous attention to detail
Stubborn
12
Q
What are the features of a narcissistic PD?
A
GP CASTLE
Grandiose sense of self importance Preoccupation with fantasies of unlimited success, power, or beauty Chronic envy Arrogant and haughty attitude Sense of entitlement Taking advantage of others to achieve own needs Lack of empathy Excessive need for admiration
13
Q
What is the SSRI of choice in children and adolescents
A
Fluoxetine
14
Q
Which SSRI can be used post MI?
A
Sertraline
15
Q
A 34-year-old female has been suffering from depression for the past 3-years and is managed with sertraline and psychological interventions. During her most recent admission to the psychiatric intensive care unit, one of the nurses has noticed that she has been in a fairly fixed position for the past few hours and has not moved much. The patient does not appear agitated.
Which of the following would be an appropriate first-line treatment for the patient?
Quetiapine Olanzapine Risperidone ECT Haloperidol
A
ECT is indicated for catatonic patients
16
Q
What is an absolute contraindication for ECT?
A
Raised intracranial pressure
MI < 3 months ago, major unstable fracture
Aneurysm (cerebral)
Raised ICP
Stroke <1 month ago, a history of Status epilepticus, Severe anaesthetic risk
17
Q
What are the side effects of ECT?
A
Short-term side-effects
PC DAMS has headache and nausea
- peripheral nerve palsies
- cardiac arrhythmias, confusion
- dental and oral trauma
- anaesthetic risks (laryngospasm, sore throat, N+V)
- muscular aches and headaches, memory loss of events prior to ECT
- short term memory impairment, status epilepticus
- headache
- nausea
Long-term side-effects
- some patients report impaired memory (anterograde and retrograde). Worse in those who receive bilateral ECT versus unilateral.
18
Q
A 68-year-old man is started on amitriptyline for his neuropathic pain. Ten days later, he complains of frequent urinary leakage.
What type of urinary incontinence is the most associated with amitriptyline?
A
overflow incontinence
Anticholinergic effects may lead to urinary retention, leading to frequent leaking.
19
Q
What are the side effects of zopiclone?
A
metallic taste and headache
20
Q
If someone has a diagnosis of bipolar and develops symptoms of mania or depression what should you do?
A
refer them urgently to secondary care
A routine referral to CMHT would be indicated for hypomania or non-severe depression.
21
Q
When does bipolar typically present?
A
19 years
22
Q
What’s the lifetime risk of bipolar?
A
2%
23
Q
What is mania/hypomania?
A
- both terms relate to abnormally elevated mood or irritability
- with mania there is severe functional impairment or psychotic symptoms for 7 days or more
- hypomania describes decreased or increased function for 4 days or more
- from an exam point of view the key differentiation is psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) which suggest mania
24
Q
A 21-year-old female presents to surgery as she is 10 weeks pregnant and upset that her midwife has advised she discontinue her sertraline. She says she continued it throughout her previous two pregnancies and now has two healthy children. She demands to know what the risks of are.
What is there an increased risk of in the first trimester with sertraline?
A
Congenital heart defects
25
What's the risk to the foetus of using SSRIs in the last trimester?
persistent pulmonary hypertension of the newborn
26
Which SSRI has an increased risk of congenital malformations, particularly in the first trimester?
Paroxetine
27
Give examples of SNRIs. When are they used?
venlafaxine and duloxetine
They are used to treat:
- major depressive disorders
- generalised anxiety disorder
- social anxiety disorder and panic disorder
- menopausal symptoms
28
A 45-year-old man taking chlorpromazine for schizophrenia develops involuntary pouting of the mouth. What side-effect of antipsychotic medication is this an example of?
Tardive dyskinesia (stiff, jerky movements of your face and body that you can't control)
29
Joseph, a 55-year-old man, goes to his GP describing a lack of energy, low mood and lack of pleasure doing activities he normally enjoys for the past 10 days. According to ICD-10 criteria, how long must Joseph's symptoms last to be classified as a depressive episode?
2 weeks
30
What tools can be used to assess the severity of depression?
Hospital Anxiety and Depression (HAD) scale and the Patient Health Questionnaire (PHQ-9)
31
What is a common side effect of clozapine?
constipation
32
How does mirtazapine work?
Mirtazapine is a NASSA (noradrenaline-serotonin specific antidepressant) that has histaminergic properties and is an alpha1 and alpha2-adrenergic receptor blocker. It therefore increases appetite and is a sedative.
33
What are potentially useful side effects of mirtazapine?
Sedation and weight gain
34
What are the stages of grief reaction?
1. Denial: this may include a feeling of numbness and also pseudohallucinations of the deceased, both auditory and visual. Occasionally people may focus on physical objects that remind them of their loved one or even prepare meals for them
2. Anger: this is commonly directed against other family members and medical professionals
3. Bargaining
4. Depression
5. Acceptance
35
What are the risk factors for an abnormal grief reaction?
- women
- death is sudden and unexpected
- a problematic relationship before death
- if the patient has not much social support
36
What are the features of an atypical grief reaction?
- delayed grief: sometimes said to occur when more than 2 weeks passes before grieving begins
- prolonged grief: difficult to define. Normal grief reactions may take up to and beyond 12 months
37
A 22-year-old man has been admitted to the psychiatric ward following concerns from his GP that he was experiencing symptoms of psychosis. The psychiatric team is considering a diagnosis of schizophrenia.
Which of these features in the history would be most consistent with this diagnosis?
```
Low appetite
Recent foreign travel
Insomnia
History of psoriasis
Family history of Alzheimer's dementia
```
Insomnia. Circadian rhythm disturbance is a feature of schizophrenia
38
What is the mechanism of action of duloxetine?
SNRI
39
Which factors are associated with a poor prognosis for schizophrenia?
- strong family history
- gradual onset
- low IQ
- premorbid history of social withdrawal
- lack of obvious precipitant
40
You are considering prescribing a selective serotonin reuptake inhibitor for a patient with depression. Which class of drug is most likely to interact with a selective serotonin reuptake inhibitor?
```
Beta-blocker
Thiazolidinediones
Tetracycline
Statin
Triptan
```
Triptans
41
A 14-year-old girl is diagnosed with anorexia nervosa. Her parents initially presented as they had noticed she was severely limiting her dietary intake and losing weight. What treatment is she most likely to be offered?
Anorexia focused family therapy is the first-line treatment for children and young people with anorexia nervosa. The second-line treatment is cognitive behavioural therapy.
42
What's the epidemiology of AN?
- 90% of patients are female
- predominately affects teenage and young-adult females
- prevalence of between 1:100 and 1:200
43
What's the prognosis of AN?
| What is associated with a poor outcome?
The prognosis of patients with anorexia nervosa remains poor.
- 20% good outcome; short lived and recover fully
- 10-20% develop a chronic and intractable disorder
- rest progress to another eating disorder and have relapsing illness
- Up to 10% of patients will eventually die because of the disorder. 60% as a direct effect of the illness, 27% due to suicide.
Poor outcome:
- long duration prior to presentation
- onset in adulthood
- severe weight loss
- vomiting
44
How do you treat adults with AN?
For adults with anorexia nervosa, NICE recommend we consider one of:
- individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
- Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
- specialist supportive clinical management (SSCM).
45
A 14-year-old patient presents to her GP complaining of unexpected weight gain and tiredness. She has been in contact with mental health services recently for treatment of anorexia nervosa.
Which of the following is the most likely cause of these symptoms?
```
Adequate treatment for anorexia nervosa
Binge-eating disorder
Hyperthyroidism
Hypothyroidism
Cushing's syndrome
```
Anorexia can cause hypothyroidism in some individuals
46
What do the MMSE scores mean?
24-30- no cognitive impairment
18-23- mild cognitive impairment
0-17- Severe cognitive impairment
<20 is highly suggestive of dementia
47
What factors would indicate a diagnosis of depression rather than dementia?
- short history, rapid onset
- biological symptoms e.g. weight loss, sleep disturbance
- patient worried about poor memory
- reluctant to take tests, disappointed with results
- mini-mental test score: variable
- global memory loss (dementia characteristically causes recent memory loss)
48
How do you treat persistent subthreshold depressive symptoms or mild to moderate depression?
General measures
- sleep hygiene
- active monitoring for people who do want an intervention
Drug treatment
do not use antidepressants routinely but consider them for people with:
- a past history of moderate or severe depression or
- initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least 2 years) or
- subthreshold depressive symptoms or mild depression that persist(s) after other interventions
- if a patient has a chronic physical health problem and mild depression complicates the care of the physical health problem
'low-intensity psychosocial interventions' may be useful
(Includes behavioural activation and problem-solving techniques)
49
A 53-year-old gentleman with a long-term diagnosis of paranoid schizophrenia has a relapse in symptoms after not taking his medications regularly, resulting in an admission under section 2 of the Mental Health Act following a formal assessment of his mental state. His long-term medication was Risperidone orally once daily which had stabilised his mental state for numerous years in the community. Given his non-compliance, what would be the best suitable treatment option for this patient?
Switching to a once monthly IM anti-psychotic depot injection
50
Which antipsychotic reduced the seizure threshold?
Clozapine
51
A 60-year-old male is admitted to the in-patient psychiatric unit last night. On reviewing him this morning, he is a poor historian, answering most questions minimally and stating he does not need to be here as he is deceased, and hospitals should be for living patients.
What is the name of this delusional disorder and which condition is it most commonly associated with?
Cotard syndrome is associated with severe depression
52
A 23-year-old man presents do his GP complaining of worsening headaches for the past few months. They are generalized and present most of the day. He also complains that he is more forgetful, forgetting appointments and telephone numbers. He attends with his partner who complains he has been more irritable in the past few months. He currently takes no medications and has no past medical history of note. He plays rugby for his local team but denies any major bumps to the head. He concedes that he has had a few rough matches this season.
What is the most likely diagnosis?
Post concussion syndrome. Initial trauma resulting in post-concussion syndrome may be trivial.
53
What are the features of post concussion syndrome?
headache
fatigue
anxiety/depression
dizziness
54
What is catatonia?
Stopping of voluntary movement or staying still in an unusual position
55
What are the features and physical abnormalities that you would expect in AN?
Features
- reduced body mass index
- bradycardia
- hypotension
- enlarged salivary glands
Physiological abnormalities
- hypokalaemia
- low FSH, LH, oestrogens and testosterone
- raised cortisol and growth hormone
- impaired glucose tolerance
- hypercholesterolaemia
- hypercarotinaemia
- low T3
- most things low
- G's and C's raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
56
How old do you need to be to be diagnosed with a personality disorder?
It is generally accepted that a personality disorder can only be diagnosed after the age of 18 but in practice it occurs many years later. The only exception is borderline personality disorder which may be diagnosed before then provided there is sufficient evidence the patient has fully undergone the process of puberty.
57
What are obsessions and compulsions?
Obsessions are unwanted intrusive thoughts that cannot be removed from your head, and compulsions are acts that patients do to try and reduce the number of obsessions that they get.
58
A 36-year-old man with a history of asthma and schizophrenia presents to his local GP surgery. He complains of 'tonsillitis' and requests an antibiotic. On examination he has bilateral inflammed tonsils, temperature is 37.8ºC and the pulse is 90/min. His current medications include salbutamol inhaler prn, Clenil inhaler 2 puffs bd, co-codamol 30/500 2 tabs qds and clozapine 100mg bd. You decide to prescribe penicillin. What is the most appropriate further action?
- Asking him to stop taking the clozapine for the duration of the antibiotic therapy
- Check his PEFR
- Arrange a full blood count
- Prescribe a course of prednisolone as well
- Prescribe a stat dose of oral fluconazole
Arrange a full blood count. It is extremely important in patients who take clozapine to exclude neutropaenia if they develop infections.
59
What's the term for pathological jealousy?
Othello's syndrome
60
What's the term for a form of paranoid delusion with an amorous quality?
De Clerambault's syndrome, also known as erotomania
61
What's the management for PTSD?
If symptoms are present within 3 months of a trauma:
- following a traumatic event single-session interventions (often referred to as debriefing) are not recommended
- watchful waiting may be used for mild symptoms lasting less than 4 weeks
- military personnel have access to treatment provided by the armed forces
- trauma-focused cognitive behavioural therapy (CBT) should be given at least once a week for 8-12 sessions.
- short-term drug treatment may be considered in the acute phase for sleep disturbance (e.g zopiclone)
- risk assess for suicide
Symptoms >3 months after trauma
- trauma focused psychological intervention (CBT or eye movement desensitisation and reprocessing (EMDR) therapy)
- drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used then paroxetine or mirtazapine are recommended. Amitriptyline and phenelzine are also licensed for PTSD.
62
What may be used to treat moderate/severe tardive dyskinesia?
Tetrabenazine
63
Which drugs are useful for acute dystonia?
Procyclidine and benztropine
64
What is useful for akathisia (restlessness)?
Propanolol
65
You are counselling a 38-year-old female with major depressive disorder who is considering undergoing electroconvulsive therapy (ECT).
Which of the following is a short term side effect of this treatment?
```
Epilepsy
Mania
Cardiac arrhythmias
Parkinson's disease
Glaucoma
```
Cardiac arrhythmias
66
What is the tyramine cheese reaction?
The tyramine cheese reaction is a classic side effect of MAOI (monoamine oxidase inhibitor) antidepressants, such as phenelzine. Consumption of foods high in tyramine (such as cheese) can result in a hypertensive crisis.
67
Give examples of acute dystonia
torticollis, oculogyric crisis
68
What are the risk/protective factors for GAD?
Risk factors for the development of GAD include;
- Aged 35- 54
- Being divorced or separated
- Living alone
- Being a lone parent
Protective factors include;
- Aged 16 - 24
- Being married or cohabiting
69
What's the management for GAD?
- SSRI anti-depressants
- buspirone (5-HT1A partial agonist)
- beta-blockers
- benzodiazepines: use longer acting preparations e.g. diazepam, clonazepam
- cognitive behaviour therapy
70
A 23-year-old man presents as he is concerned about a number of recent episodes related to sleep. He finds when he wakes up and less often when he is falling asleep he is 'paralysed' and unable to move. This sometimes associated with what the patient describes as 'hallucinations' such as seeing another person in the room. He is becoming increasingly anxious about these recent episodes. What is the most likely diagnosis?
Sleep paralysis
71
What are the features of sleep paralysis?
- paralysis - this occurs after waking up or shortly before falling asleep
- hallucinations - images or speaking that appear during the paralysis
72
How do you manage sleep paralysis?
if troublesome clonazepam may be used
73
How do MAOs work?
Inhibits monoamine oxidase in the presynaptic cell that breaks down serotonin and noradrenaline
74
Give an example of a non-selective monoamine oxidase inhibitor. When are they used?
- e.g. tranylcypromine, phenelzine
- used in the treatment of atypical depression (e.g. hyperphagia) and other psychiatric disorder
- not used frequently due to side-effects
75
What are the adverse effects of MAOIs?
- hypertensive reactions with tyramine containing foods e.g. cheese, pickled herring, Bovril, Oxo, Marmite, broad beans
- anticholinergic effects
76
When can ECT be used?
It is recommended that electroconvulsive therapy (ECT) is used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening, in individuals with:
- catatonia
- a prolonged or severe manic episode
- severe depression that is life-threatening
77
What can cause a rise in clozapine blood levels?
Smoking cessation
n.b stopping drinking can reduce levels
78
How do you manage people with mild depression or subthreshold depressive symptoms who request an intervention?
Consider a period of active monitoring, and:
- Provide information about the nature and course of depression.
- Arrange follow up, normally within 2 weeks (consider contacting the person if they do not attend follow-up appointments).
79
How should you manage people with persistent subthreshold depressive symptoms or mild-to-moderate depression?
- Consider a psychological intervention. This is accessed by referral or self-referral to IAPT (Improving Access to Psychological Therapies).
- Avoid the routine use of antidepressants, but consider this for people with a history of moderate or severe depression, subthreshold depressive symptoms that have persisted for a long period (typically at least 2 years) or mild depression that is complicating the care of a chronic physical health problem.
80
How should you manage people with moderate or severe depression?
- Offer an antidepressant and a high-intensity psychological intervention
If this is the first episode of depression, consider:
Prescribing a generic selective serotonin reuptake inhibitor (SSRI), such as citalopram, fluoxetine, paroxetine, or sertraline.
If this is a recurrent episode of depression, consider:
- Prescribing an antidepressant that the person has had a good response to previously.
- Avoiding antidepressants that the person has previously failed to respond to or could not tolerate
81
You review a patient who has been taking citalopram for the past two years to treat depression. He has felt well now for the past year and you agree a plan to stop the antidepressant. How should the citalopram be stopped?
Withdraw gradually over the next 4 weeks
| This not necessary with fluoxetine due to its longer half-life.
82
A 36-year-old homeless man is admitted to hospital as he sees what he describes as an 'ocean of bees' all around him. He says that the bees appeared suddenly. He struggles to give a comprehensive history as he is extremely anxious and confused, repeatedly shouting that the 'buzzing is deafening.' His heart rate is 140 beats per minute and his respiratory rate is 23 breaths per minute. On looking through his notes, you see that he has had repeated admissions into the emergency department following alcohol intoxication.
What is the first line treatment for his condition?
```
Haloperidol
Aripiprazole
Fluoxetine
Chlordiazepoxide
Acetylcysteine
```
Chlordiazepoxide is used in the treatment of delirium tremens.
Although haloperidol would be helpful in calming him down, the first line treatment for delirium tremens is 10-30 mg of chlordiazepoxide 4 times a day.
83
What's the antidote to paracetamol?
N-acetylcysteine
84
What's the antidote to opiates?
Naloxone
85
What's the antidote to benzos?
Flumazenil
86
What's the antidote to warfarin?
Vitamin K
87
What's the antidote to beta blockers?
Glucagon
88
What's the antidote to TCAs (amitriptyline)?
Sodium bicarbonate
89
What's the antidote to organophosphates?
Atropine
90
A 64-year-old woman presents as she is feeling down and sleeping poorly. After speaking to the patient and using a validated symptom measure you decide she has moderate depression. She has a past history of ischaemic heart disease and currently takes aspirin, ramipril and simvastatin. What is the most appropriate course of action?
```
Stop aspirin, start sertraline
Start venlafaxine
Start sertraline + lansoprazole
Stop aspirin, start clopidrogrel + sertraline
Start sertraline
```
Start sertraline + lansoprazole
| SSRI + NSAID = GI bleeding risk - give a PPI
91
A 21-year-old female comes to the emergency department with palpitations. Her ECG shows first-degree heart block, tall P-waves and flattened T-waves. An arterial blood gas shows:
```
pH 7.55
HCO3- 30mmol/L
pCO2 5.8kPa
p02 11kPa
Chloride 85mmol/L
```
What is the underlying cause of this presentation?
Bulimia nervosa
This patient's ECG shows features of hypokalaemia. This is likely the cause of the palpitations.
The ABG shows a metabolic alkalosis. The low chloride suggests the cause of this metabolic alkalosis is loss of hydrochloric acid from the stomach (through vomiting). Severe vomiting would also account for the hypokalaemia shown on ECG.
92
How do you manage BN?
- referral for specialist care is appropriate in all cases
- NICE recommend bulimia-nervosa-focused guided self-help for adults
- If bulimia-nervosa-focused guided self-help is unacceptable, contraindicated, or ineffective after 4 weeks of treatment, NICE recommend that we consider individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
- children should be offered bulimia-nervosa-focused family therapy (FT-BN)
- pharmacological treatments have a limited role - a trial of high-dose fluoxetine is currently licensed for bulimia but long-term data is lacking
93
A 44-year-old man attends his GP surgery. He explains that his long term partner died last month. When he woke up this morning he thought he was lying next to her. He claims he heard her voice saying his name. Although he realizes this is not possible it has caused him significant distress. He is worried that he may be 'going mad.' He has no other psychiatric history of note.
What is the most likely diagnosis?
Pseudohallucination
Pseudohallucinations are commoner after bereavement and do not imply psychosis
The patient has insight due to the fact he realizes that the voice and feeling came from his own mind. This separates the incident from a true hallucination, a symptom which would be seen in more serious psychiatric conditions.
94
What is a hallucination?
false sensory perception in the absence of an external stimulus. Maybe organic, drug-induced or associated with mental disorder.
95
What is a hypnagogic hallucination?
A type of pseudohallucination which occurs when transitioning from wakefulness to sleep. These are experienced vivid auditory or visual hallucinations which are fleeting in duration and may occur in anyone.
96
What's the term for a hallucination present when transitioning from sleep to wakefulness?
Hypnopompic
97
A 76-year-old, frail elderly woman on the geriatric ward complains of sleepless nights and requests to be prescribed something to help with her insomnia. The consultant prescribes a short-course of zopiclone.
Which one of the risks is associated with zopiclone use in the elderly?
```
Convulsions
Tremor
Hyperventilation
Diarrhoea
Increased risk of falls
```
Zopiclone increases the risk of falls in elderly patients
98
What are the side effects of zopiclone?
- agitation
- bitter taste in mouth
- constipation
- decreased muscle tone
- dizziness
- dry mouth
- increased risk of falls (especially in the elderly)
99
What are the classes of z drugs? Give an example for each
Imidazopyridines: e.g. zolpidem
Cyclopyrrolones: e.g. zopiclone
Pyrazolopyrimidines: e.g. zaleplon
100
Which symptoms differentiates mania from hypomania?
Psychotic symptoms:
- delusions of grandeur
- auditory hallucinations
