Passmed wrong answers

Question 1

ICD-10 criteria for depressive illness

Answer 1

In typical depressive episodes, individuals usually suffer from depressed mood, loss of interest in things you would normally find pleasure in (anhedonia), and reduced energy levels (anergia). Other common symptoms include:

• Reduced concentration and attention
• Decreased self-esteem and confidence
• Feelings of guilt and unworthiness
• Bleak and pessimistic views of the future
• Ideas or acts of self-harm or suicide
• Disturbed sleep
• Diminished appetite and weight loss
• Psychomotor agitation or retardation
• Marked loss of libido

1. Mild Depressive Episode:
   At least 2 of the main 3 symptoms of depression, and at least two of the other symptoms, should be present for a definite diagnosis. None of the symptoms should be present to an intense degree
   Minimum duration of the whole episode is about 2 weeks
   Individuals may be distressed by symptoms, but should be able to continue work and social functioning
2. Moderate Depressive Episode:
   At least 2 of the main 3 symptoms of depression, and at least three (and preferably four) of the other symptoms, should be present for a definite diagnosis
   Minimum duration of the whole episode is about 2 weeks
   Individuals will usually have considerable difficulty continuing with normal work and social functioning
3. Severe Depressive Episode:
   All three of the typical symptoms should be present, plus at least four other symptoms, some of which should be of severe intensity
   The minimum duration of the whole episode should last at least 2 weeks, but if the symptoms are particularly severe then it may be appropriate to make an early diagnosis
   Can also experience psychotic symptoms with severe depressive episodes
   Individuals show severe distress and/or agitation

Question 2

What is the PHQ-9 and what scores indicate the types of depression?

Answer 2

Patient Health Questionnaire (PHQ-9)
- asks patients ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’
- 9 items which can then be scored 0-3
- includes items asking about thoughts of self-harm

Less severe depression encompasses subthreshold and mild depression, and more severe depression encompasses moderate and severe depression. Thresholds on validated scales were used in this guideline as an indicator of severity
1. a score < 16 on the PHQ-9: less severe depression
2. a score of ≥ 16 on the PHQ-9: severe depression

Question 3

What are the DSM-5 criteria for major depressive disorder?

Answer 3

Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Question 4

Why is lithium not used in acute mania? What should be used instead?

Answer 4

Lithium is used as a mood stabiliser but can take up to 2 weeks to become effective, so a second-generation antipsychotic would be used first. Lithium would be used if the response to the antipsychotic is inadequate.

Olanzapine

Question 5

What are the types of bipolar disorder?

Answer 5

Bipolar disorder is a chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression.

Two types of bipolar disorder are recognised:
type I disorder: mania and depression (most common)
type II disorder: hypomania and depression

Question 6

What is the difference between mania and hypomania?

Answer 6

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 but < 7 days
from an exam point of view the key differentiation is psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) which suggest mania

Question 7

How is bipolar disorder managed?

Answer 7

• psychological interventions specifically designed for bipolar disorder may be helpful
• lithium remains the mood stabilizer of choice. An alternative is valproate

management of mania/hypomania
- consider stopping antidepressant if the patient takes one; antipsychotic therapy e.g. olanzapine or haloperidol
management of depression
talking therapies; fluoxetine is the antidepressant of choice
address co-morbidities
there is a 2-3 times increased risk of diabetes, cardiovascular disease and COPD

Question 8

What is the mechanism of action of benzodiazepines?

Answer 8

Its mechanism of action involves enhancing the effect of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter in the brain. This enhancement is achieved by increasing the frequency of chloride channel opening within the GABA-A receptor complex, leading to hyperpolarisation of neurons and ultimately decreased neuronal excitability.

Question 9

Why do symptoms of alcohol withdrawal occur?

Answer 9

chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)

Symptoms of alcohol withdrawal occur as GABA is the main inhibitory neurotransmitter in the central nervous system. This has certain binding sites for ethanol, so increases inhibition in the CNS when present. Long-term alcohol exposure to GABA results in continuous inhibition effects on the brain. Further, ethanol binds to glutamate, which is an excitatory amino acid in the CNS. When this binds to glutamate, this inhibits excitation of the CNS, worsening the inhibitory effect.

Question 10

What is the timeline of symptoms following the last drink in alcohol withdrawal?

Answer 10

Generally:
symptoms: 6-12 hours
seizures: 36 hours
delirium tremens: 72 hours

Mild symptoms can occur within six hours of alcohol cessation and the times in this question are rough guidelines. This will vary depending on individual patient factors such as their duration of alcohol dependence, and typical use. Early symptoms can include tremors, hyperreflexia, anxiety, gastrointestinal upset, headache, and palpitations.

Moderate symptoms include hallucinations and alcohol withdrawal seizures that can occur 12 to 24 hours after cessation of alcohol and are typically generalised in nature. Approximately half of those that have a withdrawal seizure will go on to have delirium tremens. Delirium tremens is the most severe form of alcohol withdrawal and occur due to autonomic dysfunction from excitation of the CNS. Vital sign abnormalities also occur. This can present with visual hallucinations, tachycardia, hypertension, hyperthermia, agitation, and diaphoresis. These symptoms can last up to seven days after alcohol withdrawal and sometimes can progress even longer than this.

Question 11

How is alcohol withdrawal treated?

Answer 11

patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised
- first-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol
- carbamazepine also effective in treatment of alcohol withdrawal
- phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures

Question 12

Which factors suggest depression over dementia?

Answer 12

Factors suggesting diagnosis of depression over 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)

Question 13

What is an acute stress disorder and how is it managed?

Answer 13

An acute stress disorder occurs within the first 4 weeks after a person is exposed to a traumatic event (PTSD is diagnosed after 4 weeks). The first-line management is trauma-focused cognitive behavioural therapy. Benzos may be used for acute symptoms eg agitation and sleep disturbance, should only be used with caution due to addictive potential and concerns they may be detrimental to adaption

Question 14

What are the features of acute stress disorder?

Answer 14

• intrusive thoughts e.g. flashbacks, nightmares
• dissociation e.g. ‘being in a daze’, time slowing
• negative mood
• avoidance
• arousal e.g. hypervigilance, sleep disturbance

Question 15

What is the biggest risk factor for schizophrenia?

Answer 15

Family history
Having a parent with schizophrenia leads to a relative risk (RR) of 7.5.

Risk of developing schizophrenia
monozygotic twin has schizophrenia = 50%
parent has schizophrenia = 10-15%
sibling has schizophrenia = 10%
no relatives with schizophrenia = 1%

Question 16

What are some risk factors for psychotic disorders?

Answer 16

Family history
Black Caribbean ethnicity
Migration
Urban environment
Cannabis use

Question 17

How are SSRIs stopped?

Answer 17

When stopping a SSRI the dose should be gradually reduced over a 4 week period. Can cause withdrawal if stopped abruptly eg dizziness, sleep disturbance, anxiety and mood changes

Question 18

What are the indications/CI for the SSRI options?

Answer 18

• citalopram (although may lengthen QT interval - don’t use in long QT or in combination with other meds that lengthen QT) and fluoxetine are currently the preferred SSRIs
• sertraline is useful post myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants
• SSRIs should be used with caution in children and adolescents. Fluoxetine is the drug of choice when an antidepressant is indicated

Question 19

What are the SSRI interactions?

Answer 19

• NSAIDs: NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
• warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
• aspirin
• triptans - increased risk of serotonin syndrome
• monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome

Question 20

Effects of SSRIs in pregnancy

Answer 20

• BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
• Use during the first trimester gives a small increased risk of congenital heart defects
• Use during the third trimester can result in persistent pulmonary hypertension of the newborn
• Paroxetine has an increased risk of congenital malformations, particularly in the first trimester

Question 21

SSRI discontinuation symptoms

Answer 21

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

• increased mood change
• restlessness
• difficulty sleeping
• unsteadiness/dizziness
• sweating
• gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
• paraesthesia and electric shock sensations

Question 22

What are the physiological abnormalities in anorexia nervosa?

Answer 22

hypokalaemia
low FSH, LH, oestrogens and testosterone
raised cortisol and growth hormone
impaired glucose tolerance
hypercholesterolaemia
hypercarotinaemia
low T3

Question 23

What is schizotypal personality disorder?

Answer 23

Patients diagnosed with schizotypal personality disorder may lack close friends other than family and can have odd or eccentric behaviour, speech, and beliefs. They may display magical thinking (the false belief that unrelated events are connected despite no evidence of a causal link), ideas of reference (the false belief that innocuous events relate to oneself,) unusual perceptual disturbances, paranoid ideation, inappropriate affect, and odd but coherent speech.

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

Question 24

What is schizoid personality disorder?

Answer 24

A person with a schizoid personality disorder may display indifference to praise and criticism, prefer time alone, lack interest in companionship or sexual interactions, and have few interests and few friends other than family

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

Question 25

What is antisocial personality disorder?

Answer 25

A person with an antisocial personality disorder may display impulsiveness, irresponsible behaviour, repeated deception (lying, use of aliases, conning others for personal gain), lack of respect for the law or social norms, irritability and aggressiveness, lack of remorse and reckless disregard for the safety of themselves or others. Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest; More common in men; Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure; Impulsiveness or failure to plan ahead; Irritability and aggressiveness, as indicated by repeated physical fights or assaults; Reckless disregard for the safety of self or others; Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations; Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

Question 26

What is avoidant personality disorder?

Answer 26

A person with an avoidant personality disorder may avoid work and relationships due to fear of criticism or rejection, avoid taking risks due to fear of embarrassment, be preoccupied with fears of criticism or rejection in social situations, and feel socially isolated whilst craving social contact. Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection. Unwillingness to be involved unless certain of being liked Preoccupied with ideas that they are being criticised or rejected in social situations Restraint in intimate relationships due to the fear of being ridiculed Reluctance to take personal risks due to fears of embarrassment Views self as inept and inferior to others Social isolation accompanied by a craving for social contact

Question 27

What are the 3 clusters of personality disorders?

Answer 27

Cluster A: 'Odd or Eccentric' Paranoid Schizoid Schizotypal Cluster B: 'Dramatic, Emotional, or Erratic' Antisocial Borderline (Emotionally Unstable) Histrionic Narcissistic Cluster C: 'Anxious and Fearful' Obsessive-Compulsive Avoidant Dependent

Question 28

What is paranoid personality disorder?

Answer 28

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

Question 29

What is EUPD?

Answer 29

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

Question 30

What is histrionic personality disorder?

Answer 30

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

Question 31

What is narcisstic personality disorder?

Answer 31

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

Question 32

What is obsessive compulsive personality disorder

Answer 32

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

Question 33

What is dependent personality disorder?

Answer 33

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

Question 34

What are the atypical antipsychotics?

Answer 34

The main advantage of the atypical agents is a significant reduction in extrapyramidal side-effects. - clozapine - olanzapine: higher risk of dyslipidemia and obesity - risperidone - quetiapine - amisulpride - aripiprazole: generally good side-effect profile, particularly for prolactin elevation

Question 35

Adverse effects of atypical antipsychotics?

Answer 35

- weight gain - clozapine is associated with agranulocytosis - hyperprolactinaemia The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients: - increased risk of stroke - increased risk of venous thromboembolism

Question 36

Major side effect of clozapine? other effects?

Answer 36

Clozapine, one of the first atypical agents to be developed, carries a significant risk of agranulocytosis and full blood count monitoring is therefore essential during treatment. For this reason, clozapine should only be used in patients resistant to other antipsychotic medication. The BNF states: Clozapine should be introduced if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each for at least 6–8 weeks. Adverse effects of clozapine - agranulocytosis (1%), neutropaenia (3%) reduced seizure threshold - can induce seizures in up to 3% of patients constipation myocarditis: a baseline ECG should be taken before starting treatment hypersalivation Dose adjustment of clozapine might be necessary if smoking is started or stopped during treatment.

Question 37

How are benzos used in alcohol withdrawal?

Answer 37

The key parts of management involve utilising long-acting benzodiazepines and ensuring the dose gradually reduces to decrease the need for medication as the acute withdrawal period passes

Question 38

Factors associated with poor prognosis for schizophrenia

Answer 38

- strong family history - gradual onset - low IQ - prodromal phase of social withdrawal - lack of obvious precipitant

Question 39

What is a pseudohallucination?

Answer 39

generally accepted definition that a pseudohallucination is a false sensory perception in the absence of external stimuli when the affected is aware that they are hallucinating. An example of a pseudohallucination is a hypnagogic hallucination 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. These are pseudohallucinations as the affected person is able to determine that the hallucination was not real. Pseudohallucinations commonly occur in people who are grieving.

Question 40

How is general anxiety disorder managed?

Answer 40

NICE suggest a step-wise approach: step 1: education about GAD + active monitoring step 2: low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups) step 3: high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information step 4: highly specialist input e.g. Multi agency teams Drug treatment NICE suggest sertraline should be considered the first-line SSRI if sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI) examples of SNRIs include duloxetine and venlafaxine If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month

Question 41

How is panic disorder managed?

Answer 41

Again a stepwise approach: step 1: recognition and diagnosis step 2: treatment in primary care - see below step 3: review and consideration of alternative treatments step 4: review and referral to specialist mental health services step 5: care in specialist mental health services Treatment in primary care NICE recommend either cognitive behavioural therapy or drug treatment SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered

Question 42

What is sleep paralysis and how is it managed?

Answer 42

Sleep paralysis is a common condition characterized by transient paralysis of skeletal muscles which occurs when awakening from sleep or less often while falling asleep. It is thought to be related to the paralysis that occurs as a natural part of REM (rapid eye movement) sleep. Sleep paralysis is recognised in a wide variety of cultures Features paralysis - this occurs after waking up or shortly before falling asleep hallucinations - images or speaking that appear during the paralysis Management if troublesome clonazepam may be used

Question 43

What is neuroleptic malignant syndrome?

Answer 43

Neuroleptic malignant syndrome is a medical emergency which occurs in patients taking antipsychotics. It is characterised by altered mental state, generalised rigidity, fever, fluctuating blood pressure and high temperature.

Question 44

What is Lithium and what is its mechanism of action?

Answer 44

Lithium is mood stabilising drug used most commonly prophylactically in bipolar disorder but also as an adjunct in refractory depression. It has a very narrow therapeutic range (0.4-1.0 mmol/L) and a long plasma half-life being excreted primarily by the kidneys. Mechanism of action - not fully understood, two theories: - interferes with inositol triphosphate formation - interferes with cAMP formation

Question 45

What are the adverse effects of lithium?

Answer 45

- nausea/vomiting, diarrhoea - fine tremor - nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus - thyroid enlargement, may lead to hypothyroidism - ECG: T wave flattening/inversion - weight gain - idiopathic intracranial hypertension - leucocytosis - hyperparathyroidism and resultant hypercalcaemia

Question 46

How should patients taking lithium be monitored?

Answer 46

- when checking lithium levels, the sample should be taken 12 hours post-dose - after starting lithium levels should be performed weekly and after each dose change until concentrations are stable - once established, lithium blood level should 'normally' be checked every 3 months - after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable. - thyroid and renal function should be checked every 6 months - patients should be issued with an information booklet, alert card and record book

Question 47

What is exposure and response prevention (ERP)?

Answer 47

ERP is a central technique within cognitive-behavioural therapy (CBT) designed to treat obsessive-compulsive disorder (OCD). This modality is rooted in the concept of habituation: by exposing an individual to the trigger of their obsessive thoughts or behaviours without permitting the ensuing compulsion, the anxiety or urge usually diminishes over time. In practice, the exposure is methodically staged (systemic exposure), initiating with less anxiety-producing situations or thoughts and progressively challenging the patient with more potent triggers. Over consistent sessions, the patient learns that their anticipated negative outcomes or internal discomfort don't materialise or persist, even if they don't act on their compulsions. Furthermore, ERP aids patients in learning to tolerate and manage the discomfort, unease, or internal drive they feel.

Question 48

What is aversive conditioning?

Answer 48

This is a form of behavioural therapy where unwanted behaviours are paired with an unpleasant stimulus to reduce or eliminate the behaviour. It might be used in cases of addiction, like pairing the taste of alcohol with nausea.

Question 49

What is cognitive reframing?

Answer 49

This technique involves identifying and then disputing irrational or maladaptive thoughts. It's about changing negative thinking patterns and is often used as a key component of cognitive-behavioural therapy (CBT) to address various disorders, from depression to phobias.

Question 50

What is systematic desensitisation?

Answer 50

It's an exposure therapy that treats anxiety disorders. It combines relaxation exercises with graded exposure to the feared stimulus to extinguish the anxiety response. This method is particularly effective for specific phobias, like fear of flying or heights.

Question 51

What is obsessive compulsive disorder?

Answer 51

Obsessive-compulsive disorder (OCD) is characterised by the presence of either obsessions or compulsions, but commonly both. The symptoms can cause significant functional impairment and/ or distress. An obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person's mind. Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one's mind.

Question 52

What are the risk factors for OCD?

Answer 52

- family history - age: peak onset is between 10-20 years - pregnancy/postnatal period - history of abuse, bullying, neglect

Question 53

How is OCD severity classified?

Answer 53

NICE recommend classifying impairment into mild, moderate or severe - they recommend the use of the Y-BOCS scale - an example of 'severe' OCD would be someone who spends > 3 hours a day on their obsessions/compulsions, has severe interference/distress and has very little control/resistance

Question 54

How is OCD treated differently when functional impairment is mild, moderate or severe?

Answer 54

1. If functional impairment is mild - low-intensity psychological treatments: cognitive behavioural therapy (CBT) including exposure and response prevention (ERP) - If this is insufficient or can’t engage in psychological therapy, then offer a choice of either a course of an SSRI or more intensive CBT (including ERP) 2. If moderate functional impairment - offer a choice of either a course of an SSRI (any SSRI for OCD but fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP) - consider clomipramine (as an alternative first-line drug treatment to an SSRI) if the person prefers clomipramine or has had a previous good response to it, or if an SSRI is contraindicated 3. If severe functional impairment - refer to the secondary care mental health team for assessment - whilst awaiting assessment - offer combined treatment with an SSRI and CBT (including ERP) or consider clomipramine as an alternative as above NOTE: if treatment with SSRI is effective then continue for at least 12 months to prevent relapse and allow time for improvement compared to depression, the SSRI usually requires a higher dose and a longer duration of treatment (at least 12 weeks) for an initial response

Question 55

Which drug can help maintain alcohol abstinence?

Answer 55

Acamprosate - helps maintain alcohol abstinence in those who have stopped drinking. It works by modulating the balance between excitatory and inhibitory neurotransmission, therefore reducing the craving for alcohol. It is taken three times a day. However, it is not effective in treating acute alcohol withdrawal symptoms.

Question 56

Which drug is used in alcohol aversion therapy?

Answer 56

Disulfiram - used in alcohol aversion therapy. It acts by inhibiting the enzyme acetaldehyde dehydrogenase, leading to the accumulation of acetaldehyde when alcohol is consumed. The build-up of acetaldehyde within twenty to thirty minutes of alcohol consumption results in unpleasant symptoms, including facial flushing and nausea and vomiting. The reaction can be life-threatening, so disulfiram is not recommended for patients with underlying frailty, neurological, cardiac or hepatic conditions. Disulfiram is taken once daily and its effects last seven days, working as a deterrent to prevent alcohol relapse. (Often causes violent vomiting)

Question 57

Which antipsychotic medications are more likely to cause acute dystonic reactions and what might these be?

Answer 57

First generation/Typical Torticollis, opisthotonus, dysarthria and oculogyric crises.

Question 58

What are the mechanisms of action of typical vs atypical antipsychotics? What are their associated adverse effects?

Answer 58

Typical: - Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways - Extrapyramidal side-effects and hyperprolactinaemia common Atypical: - Act on a variety of receptors (D2, D3, D4, 5-HT) - Extrapyramidal side-effects and hyperprolactinaemia less common - Metabolic effects

Question 59

What are the side effects of SSRIs and how should their use be monitored?

Answer 59

- gastrointestinal symptoms are the most common side-effect - there is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID - Hyponatraemia - patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI - fluoxetine and paroxetine have a higher propensity for drug interactions - it advised that citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval Monitoring: Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks. For patients under the age of 25 years or at increased risk of suicide should be reviewed after 1 week. If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse.

Question 60

What are the features of PTSD?

Answer 60

- re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images - avoidance: avoiding people, situations or circumstances resembling or associated with the event - hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating - emotional numbing - lack of ability to experience feelings, feeling detached from other people: - depression - drug or alcohol misuse - anger - unexplained physical symptoms

Question 61

How is PTSD managed?

Answer 61

- 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) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases - drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used then venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline should be tried. In severe cases, NICE recommends that risperidone may be used

Question 62

What is the electrolyte effect of lithium use?

Answer 62

Hypercalcaemia Long-term lithium use can result in hyperparathyroidism and resultant hypercalcaemia. This is postulated to occur by altering the homeostatic regulation of calcium, leading to parathyroid hyperplasia. A urea and electrolyte panel (U&Es), alongside parathyroid hormone levels (PTH), are useful investigations to establish the diagnosis. May present as bone pains, digestive symptoms such as nausea/vomiting, poor appetite or constipation, feeling fatigued or confused, muscle weakness or twitchiness, increased thirst/poluria

Question 63

Which antidepressant can help to stimulate appetite? How does it work and what are its side effects?

Answer 63

Mirtazapine is an antidepressant that works by blocking alpha2-adrenergic receptors, which increases the release of neurotransmitters. (Tricyclic) Mirtazapine has fewer side effects and interactions than many other antidepressants and so is useful in older people who may be affected more or be taking other medications. Two side effects of mirtazapine, sedation and an increased appetite, can be beneficial in older people that are suffering from insomnia and poor appetite. It is generally taken in the evening as it can be sedative.

Question 64

Which antipsychotics cause hyperprolactinaemia? Which is known to affect prolactin levels the LEAST?

Answer 64

Nearly all typical and some atypical antipsychotics like risperidone & amisulpride cause hyperprolactinaemia Aripiprazole has the most tolerable side effect profile of the atypical antispsychotics, particularly for prolactin elevation

Question 65

What is the phenomenon where there is repetition of someone else's speech including the questions being asked, and what might it suggest?

Answer 65

Echolalia is the repetition of someone else's speech including the questions being asked. It is a feature of schizophrenia, typically catatonic schizophrenia which is characterised by negative symptoms including blunting of affect, alogia (poverty of speech) and avolition (poor motivation).

Question 66

What is the phenomenon of involuntary performing of obscene or forbidden gestures or inappropriate touching?

Answer 66

Copropraxia

Question 67

What is the phenomenon of meaningless repetition or imitation of the movement of others?

Answer 67

Echopraxia

Question 68

What is the phenomenon of automatic repetition of one's own words, phrases or sentences?

Answer 68

Palilalia

Question 69

What are neologisms?

Answer 69

New word formations, which might include the combining of two words

Question 70

What are clang associations?

Answer 70

When ideas are related to each other only by the fact they sound similar or rhyme (alliteration also)

Question 71

What is word salad?

Answer 71

Completely incoherent speech where real words are strung together into nonsense sentences

Question 72

What is Night's move thinking?

Answer 72

A severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another. It is a feature of schizophrenia.

Question 73

What is flight of ideas?

Answer 73

Flight of ideas, a feature of mania, is a thought disorder where there are leaps from one topic to another but with discernible links between them.

Question 74

What is capgras syndrome?

Answer 74

This is a delusional misidentification syndrome whereby the patient believes that someone significant in their life, such as a spouse or a friend, has been replaced by an identical imposter.

Question 75

What is Fregoli syndrome?

Answer 75

This is another delusional misidentification syndrome where the patient believes that multiple people are in fact all the same person, who is constantly changing their appearance.

Question 76

What are Schneider's first rank symptoms for schizophrenia?

Answer 76

1. Auditory hallucinations of a specific type: - Two or more voices discussing the patient in the third person - Thought echo - Voices commenting on the patient's behaviour 2. Thought disorders - Thought insertion - Thought withdrawal - Thought broadcasting 3. Passivity phenomena: - Bodily sensations being controlled by external influence - Actions/impulses/feelings - experiences which are imposed on the individual or influenced by others 4. Delusional perceptions - A two stage process where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. 'The traffic light is green therefore I am the King'.

Question 77

Other than the first rank symptoms, what are some other features of schizophrenia?

Answer 77

Other features of schizophrenia include: - Impaired insight - negative symptoms: *incongruity/blunting of affect *anhedonia (inability to derive pleasure) *alogia (poverty of speech) *avolition (poor motivation) *social withdrawal - neologisms: made-up words - catatonia

Question 78

What are the adverse effects of clozapine?

Answer 78

- agranulocytosis (1%), neutropaenia (3%) - reduced seizure threshold - can induce seizures in up to 3% of patients - constipation - myocarditis: a baseline ECG should be taken before starting treatment - hypersalivation

Question 79

What can affect clozapine blood levels?

Answer 79

Smoking cessation can cause a significant rise in clozapine levels, and so it should be discussed with a psychiatrist before stopping smoking. Starting smoking, or smoking more, can reduce clozapine levels. Stopping drinking can also reduce levels, as alcohol binges can increase the level..

Question 80

What are the metabolic side effects of atypical antipsychotics?

Answer 80

Hyperlipidaemia Hypercholesterolaemia Hyperglycaemia Weight gain

Question 81

What is circumstantiality?

Answer 81

Circumstantiality is the inability to answer a question without giving excessive, unnecessary detail. However, this differs from tangentiality in that the person does eventually return to the original point.

Question 82

Which physical cause can lead to similar symptoms to anxiety?

Answer 82

Hyperthyroidism

Question 83

How should patients that develop acute mania on a background of depression (or mania likely secondary to antidepressant) be managed?

Answer 83

The risk seems higher with SSRIs and tricyclic antidepressants (TCAs) and particularly high with venlafaxine. 'If a person develops mania or hypomania and is taking an antidepressant (as defined by the BNF) as monotherapy: - Consider stopping the antidepressant and - Offer an antipsychotic regardless of whether the antidepressant is stopped.' NICE guidance then recommends that the choice of antipsychotic should be one of: - Haloperidol - Olanzapine - Quetiapine - Risperidone If one of these antipsychotics fails at the maximum tolerated dose or is not tolerated, then an alternative from the same list should be tried next. If these fail, the addition of lithium is the third line, and sodium valproate is the fourth line.

Question 84

How long do symptoms last in brief psychotic disorder?

Answer 84

Less than a month

Question 85

What is de clerambault's syndrome (erotomania)?

Answer 85

A delusional disorder where the patient has delusions that a famous person is in love with them, with the absence of other psychotic symptoms.

Question 86

Which drugs are associated with lower seizure thresholds?

Answer 86

- Antibiotics: Imipenem, penicillins, cephalosporins, metronidazole, isoniazid - Antipsychotics (mostly clozapine) - Antidepressents: Bupropion, Tricyclics, Venlafaxine - Tramadol - Fentanyl - Ketamine - Lidocaine - Lithium - Antihistamines

Question 87

What is an alternative to methadone for opiate replacement therapy?

Answer 87

Buprenorphine A mixed opioid agonist/antagonist. It is typically given as a sublingual tablet and provides an alternative opiate replacement therapy to methadone. Patient's often describe buprenorphine as less sedating, which can be a benefit or drawback depending on the context and patient. Prescribers must also be aware that because of the opioid antagonist properties of methadone it can render regularly prescribed analgesia, such as co-codamol, ineffective.

Question 88

What drugs can precipitate a benign leucocytosis?

Answer 88

Corticosteroids, Lithium and Beta blockers

Question 89

When is ECT indicated?

Answer 89

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 ECT: Euphoria (mania), Catatonia, Tearful (depression)

Question 90

What are the side effects of ECT?

Answer 90

1. Short-term side-effects - headache - nausea - short term memory impairment - memory loss of events prior to ECT - cardiac arrhythmia 2. Long-term side-effects some patients report impaired memory

Question 91

What is an absolute contraindication to ECT?

Answer 91

Raised ICP

Question 92

What physical signs might suggest bulimia?

Answer 92

recurrent vomiting may lead to erosion of teeth and Russell's sign - calluses on the knuckles or back of the hand due to repeated self-induced vomiting

Question 93

How is bulimia treated?

Answer 93

- 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

Question 94

What are z-drugs and what are their risks?

Answer 94

Z drugs have similar effects to benzodiazepines but are different structurally. They act on the α2-subunit of the GABA receptor. They can be divided into 3 groups: Imidazopyridines: e.g. zolpidem Cyclopyrrolones: e.g. zopiclone Pyrazolopyrimidines: e.g. zaleplon Adverse effects - similar to benzodiazepines - increase the risk of falls in the elderly

Question 95

What are the 5 stages of grief and what features might indicate an atypical grief reaction?

Answer 95

One of the most popular models of grief divides it into 5 stages. 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 It should be noted that many patients will not go through all 5 stages. Abnormal, or atypical, grief reactions are more likely to occur in women and if the death is sudden and unexpected. Other risk factors include a problematic relationship before death or if the patient has not much social support. Features of atypical grief reactions include: - 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

Question 96

How do tricyclics act ad what are the resulting side effects?

Answer 96

The primary mechanism by which TCAs exert their antidepressant effects is through the inhibition of the reuptake of neurotransmitters - Serotonin (5-HT): This neurotransmitter has a pivotal role in mood regulation. Inhibition of its reuptake leads to increased concentrations in the synaptic cleft, enhancing serotonergic neurotransmission. - Noradrenaline (NA): Similar to 5-HT, blocking the reuptake of NA increases its synaptic cleft concentration, intensifying noradrenergic neurotransmission. As well as 5-HT and NA, tricyclics interact with number of other receptors that contribute to their side-effect profile: - antagonism of histamine receptors *drowsiness - antagonism of muscarinic receptors *dry mouth *blurred vision *constipation *urinary retention - antagonism of adrenergic receptors *postural hypotension -lengthening of QT interval

Question 97

What are the features of Korsakoff's syndrome?

Answer 97

Overview - marked memory disorder often seen in alcoholics - thiamine deficiency causes damage and haemorrhage to the mammillary bodies of the hypothalamus and the medial thalamus - in often follows on from untreated Wernicke's encephalopathy Features - anterograde amnesia: inability to acquire new memories - retrograde amnesia - confabulation

Question 98

What are the risk factors for the development of GAD?

Answer 98

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

Question 99

How is acute dystonia secondary to antipsychotics managed?

Answer 99

Procyclidine will help to reverse the event. It belongs to a class of medication called anticholinergics that work by blocking acetylcholine. This helps decrease muscle stiffness, sweating, and the production of saliva, and helps improve walking ability in people with Parkinson's disease.

Question 100

How should missed doses of Clozapine be managed?

Answer 100

If doses are missed for more than 2 consecutive days (48 hours), you will need to restart their clozapine slowly (like when they first started on it). This restart of treatment needs to be under the direction of a Psychiatrist. This is because when you start Clozapine after a break of >48 hours, it can make side effects worse, such as blood pressure changes, drowsiness and dizziness. If there is a gap in treatment of 3 days (72 hours) then you may also require more frequent blood tests for a short period.

Question 101

What are the DSM-5 and ICD-10 criteria for schizoid personality disorder?

Answer 101

DSM-5: - Neither desires nor enjoys close relationships, including being part of a family. - Almost always chooses solitary activities. - Has little, if any, interest in having sexual experiences with another person. - Takes pleasure in few, if any, activities. - Lacks close friends or confidants other than first-degree relatives. - Appears indifferent to the praise or criticism of others. - Shows emotional coldness, detachment, or flattened affectivity. ICD-10: - Few, if any, activities provide pleasure. - Displays emotional coldness, detachment, or flattened affectivity. - Limited capacity to express warm, tender feelings for others as well as anger. - Appears indifferent to either praise or criticism from others. - Little interest in having sexual experiences with another person (taking into account age). - Almost always chooses solitary activities. - Excessive preoccupation with fantasy and introspection. - Neither desires, nor has, any close friends or confiding relationships (or only one). - Marked insensitivity to prevailing social norms and conventions; if these are not followed this is unintentional.

Question 102

which antipsychotic is most effective for negative symptoms?

Answer 102

Clozapine

Question 103

How can severe tardive dyskinesia be treated?

Answer 103

With Tetrabenazine

Question 104

Which type of incontinence is seen with anticholinergics?

Answer 104

Overflow - they lead to urinary retention which can cause frequent leaking

Question 105

What is the difference between acute and chronic insomnia?

Answer 105

Acute insomnia is more typically related to a life event and resolves without treatment. Chronic insomnia may be diagnosed if a person has trouble falling asleep or staying asleep at least three nights per week for 3 months or longer.

Question 106

How is insomnia managed?

Answer 106

1, Short-term management of insomnia: - Identify any potential causes e.g. mental/ physical health issues or poor sleep hygiene. - Advise the person not to drive while sleepy. - Advise good sleep hygiene: no screens before bed, limited caffeine intake, fixed bed times etc. - ONLY consider use of hypnotics if daytime impairment is severe. There is good evidence for the efficacy of hypnotic drugs in short-term insomnia. However, there are many adverse effects e.g. daytime sedation, poor motor coordination, cognitive impairment and related concerns about accidents and injuries. In addition, tolerance to the hypnotic effects of benzodiazepines may be rapid (within a few days or weeks of regular use). Guidance on using hypnotics: - The hypnotics recommended for treating insomnia are short-acting benzodiazepines or non-benzodiazepines (zopiclone, zolpidem and zaleplon). - Diazepam is not recommended but can be useful if the insomnia is linked to daytime anxiety. - Use the lowest effective dose for the shortest period possible. - If there has been no response to the first hypnotic, do not prescribe another. You should make the patient aware that repeat prescriptions are not usually given. - It is important to review after 2 weeks and consider referral for cognitive behavioural therapy (CBT). Other sedative drugs (such as antidepressants, antihistamines, choral hydrate, clomethiazole and barbiturates) are not recommended for managing insomnia.

Question 107

What is catatonia?

Answer 107

Stopping of voluntary movement or staying still in an unusual position = catatonia Catatonia is a group of symptoms that are believed to occur due to abnormalities in the balance of dopamine and other neurotransmitter systems. It is most commonly described to be associated with certain types of schizophrenia. Catatonia can be managed using benzodiazepines and some centres may use electroconvulsive therapy.

Question 108

What do MMSE scores tell you?

Answer 108

24-30- no cognitive impairment 18-23- mild cognitive impairment 0-17- Severe cognitive impairment

Question 109

What is selegiline?

Answer 109

A MAOI

Question 110

What should be monitored at initiation of venlafaxine and at each dose titration?

Answer 110

BP Venlafaxine and other serotonin noradrenaline reuptake inhibitors (SNRIs) are associated with the development of hypertension. NICE recommend that all patients have their blood pressure monitored at initiation and each dose titration of venlafaxine. If the patient is hypertensive a dose reduction should be considered.