Psych

Question 1

What are the types of memory disturbances?

Answer 1

Memory disturbances:
* Topographical - inability to orientate oneself
* Autobiographical/episodic (extrinsic memory) - specific events and issues related to onself
* Procedural (instrinsic memory) - memory/knowledge of “how to do things” aka unconscious motor skills like driving
* Semantic memory - “knowledge base” and is unrelated to specific experiences or events

Question 2

What do the following mean?
1. Perseveration
2. Confabulation
3. Déjà vu
4. Ganser’s syndrome
5. Jamais vu

Answer 2

1. Perseveration - an appropriate response to a stimulus the first time but then giving the same reponse incorrectly to a different second stimulus (almost exclusively in organic brain disease). This can be verbal or motor
2. Confabulation - phenomenon whereby false memories occur and results in incorrect answers being given
3. Déjà vu - phenomenon whereby the person feels the sense of familiarity of having encountered an event before, even though this is a new experience for them. Can be seen as a feature of frontal lobe epilepsy but can also be present in non-pathological states
4. Ganser’s syndrome - unusual phenomenon whereby people give ‘approximate’ answers, among other symptoms, such as, ‘How many legs does a cow have?’ ‘Five’. It has caused considerable debate as to whether it represents an organic psychotic disorder or a dissociative disorder.
5. Jamais vu - sensation that a familar event or place has never been encountered before

Question 3

What is an illusion and what do these specific illusions mean?

1. Affect illusion
2. Completion illusion
3. Pareidolic illusion

Answer 3

An illusion is a misinterpretation of a perception (unlike a halluciation where a new perception is experienced in the absence of a stimulus). These are usually not pathological.

Affect illusion - perception is altered depending on the mood state (i.e. frightened woman waking up from sleep and misinterprets a hanging gown as an attacker)

Completion illusion - lack of attention and a perception is incorrectly interpreted (i.e. skipping over a misprint in a book because you are tired)

Pareidolic illusion - shapes being seen in other objects (i.e. seeing animals in cloud formations). These become more vivid with concentration.

Question 4

What is a hallucination and what do these specific hallucinations mean?

1. Visual hallucination
2. Tactile hallucination
3. Extracampine hallucination
4. Functional hallucination
5. Hypnagogic hallucination
6. Hypnopompic hallucination
7. Reflex hallucination

Answer 4

A halluciation where a new perception is experienced in the absence of a stimulus

Visual hallucination - seeing something in the absence of a stimulus

Tactile hallucination - tactile (touch) sensation in the absence of a stimulus

Extracampine hallucination - false perceptions that occur outside the limits of a person’s normal sensory field (i.e. saying you are hearing other people speaking in another country)

Functional hallucination - where a hallucination is only experienced when an external stimulus is present in the same modality (i.e. hearing voices when listening to classical music)

Hypnagogic hallucination - hallucinations that occur on falling asleep

Hypnopompic hallucination - hallucinations that occur on waking up

Reflex hallucination - similar to functional but the stimulus is a different modality to the hallucination (e.g. woman with schizophrenia hearing voices every time her child looks at her)

Question 5

How do you differentiate the following?
1. Delusional perception
2. Authochthonous delusion
3. Autoscopy
4. Delusional atmosphere
5. Delusional memory

Answer 5

Delusional perception - occurs when a normal perception is invested with a delusional meaning - gives it a whole new false and bizzare meaning (i.e. seeing a magazine cover and now believing a cult is trying to kill them)

Authochthonous delusion - one that arises out of the blue (and unlike delusional perception is not attached to a real stimulus). It should be distinguished from secondary delusions in which the beliefs are understandable in the context of the sufferer’s mood or history (e.g. a mood-congruent depressive delusion). A primary delusion is by definition un-understandable in any context

Autoscopy - sensation of seeing oneself, although aetiology and psychopathology is controversial

Delusional atmosphere - aka delusional mood. It refers to the state of perplexity or bewilderment in which sufferers feel that something is ‘going on’ but without being able to state exactly what. It often occurs prior to a delusion forming and the sufferer will often describe feeling odd and that everything around them has new ‘meanings’ and significance to them in particular

Delusional memory - when patients recall a memory from the past and interpret it with a delusional meaning

Question 6

Schneider’s first rank symptoms

Answer 6

Delusional perceptions
Running commentary
Somatic passivity
Thought alienation - withdrawal and insertion
Thought broadcasting
Auditory hallucinations

Question 7

What do the following speech abnormalities mean?

Logoclonia
Alogia
Dysarthria
Echolalia
Neologism

Answer 7

Logoclonia - the repetition of the last syllable of a word repeatedly (often seen in Parkinson’s). This is different aetiology to stammering or tics seen in Tourette’s

Alogia - extreme poverty of speech with “not having any words”. Commonly seen in severe negative schizophrenia or dementia

Dysarthria - difficulty in the manufacture of speech, commonly due to structural lesions to the vocal cords or brainstem

Echolalia - phenomenon where words/sentences that the patient hears are repeated back, sometimes continuously and incessantly. Often seen in organic causes like dementia or brain injury but also functional disorders like schizophrenia

Neologisms - creation of new words with specific meaning to them, usually linked to delusional beliefs

Question 8

What are night terrors?

Answer 8

They are not the same as nightmares and they do not occur in REM sleep.

The sufferer (usually children) does not remember any bad dreams but will awake from sleep in a state of abject terror and confusion, often shouting and sometimes lashing out.

Question 9

What is catatonia and what are its associations?

Answer 9

Catatonia is a state of either stupor in which the patient is entirely unresponsive or excited - it is associated with schizophrenia and many other conditions.

Catalepsy - limbs become rigid and some limbs move into unusual positions even if they are extremely uncomfortable (NOT TO BE CONFUSED WITH CATAPLEXY which is when there is a sudden and transient loss of muscle tone resulting in collapse)

Echolalia

Negativism - patients do the automatic opposite of what they are asked to do - patients are not ususally resisting instructions/movements but are actually attempting to perform the opposite instruction/movement

Question 10

Do delirium tremens patients experience formication?

Answer 10

No, they may complain of visual hallucinations of small insects but formincations (the sensation of insects crawling over one’s skin) is usually seen in cocaine intoxication

Question 11

What is chronic alcohol dependence associated with?

Answer 11

Vitamin B12 deficiency as a result of poor nutritional intake and a direct toxic effect of alcohol on bone marrow.

It is also associated with thrombocytopenia (as a result of vitamin B12 and folate deficiency), hypoglycaemia and hypokalaemia

Question 12

How do you mange delirium?

Answer 12

There is usually an acute confusional state with a recognised cauitive factor (i.e. infection), the patient is usually older age and has fluctuating confusion

The first step is conservative management (i.e. side room, keeping light levels appropriate to the time of day, repeated reassuring - anything that would improve orientation of the patient)

If medication is needed, then you would consider low-dose antipsychotics like haloperidol (typical antispychotics with fewer anticholinergic effects)

Bezodiazepines are 2nd line agents but patients are prone to respiratory depression and “paradoxical excitation”

Question 13

What are the psychiatric side effects of corticosteroid use?

Answer 13

Mania is the main side effect (steroid psychosis) but there can also be depression (less common), and the two can co-exist.

Depression can result from acute or chronic use, or discontinuation of corticosteroids - mediation by the HPA axis (for example depression is a common symptom in Cushing’s disease, as a result of chronic hypercotisolism)

*It can also cause delirium

Question 14

What are signs of frontal lobe injury?

Answer 14

The frontal lobe is extremely vulnerable in traumatic brain injury - it often involves personality changes:
1. Inappropriate or “fatuous” affect
2. Lability and irritability of mood
3. Hypersexuality
4. Hyperphagia or overeating
5. “Childishness” or prankish josking (akak Witzelsucht)
*There is usually no insight into this change in behaviour

Other changes include poor concentration and “forced utilisation” - a strange phenomenon when patients will use objects they see in front of them irrespective of whether they need to use them or not, e.g. patients may get undressed and go to bed on entering a bedroom in the middle of the day despite not being tired. There may also be the emergence of primitive reflexes, such as the grasp reflex.

Question 15

What is the role of the basal ganglia?

Answer 15

It is the deep grey matter (subcortical) structure with strong connections to the cortex and thalamus. It is mostly involved in complex roles in motor behaviour, but can present with neuropsychiatric symptoms due to their strong connections to the frontal cortex.
However, these are usually associated with ‘negative’ symptoms such as slowing of movement and lack of spontaneity. There is also an increase in obsessional symptoms (basal ganglia are thought to be heavily involved in the pathogenesis of OCD)

Contusions are unlikey given the anatomical location but it is very susceptible to cerebral hypoxia

Question 16

What is the limbic system and what is its function?

Answer 16

The limbic system involves deep structures such as the hippocampus, parahippocampal gyrus, the amygdala, the fornix, cingulate gyrus and the thalamus.

They have varied functions, but are principally involved in pleasure responses and memory. Injury to the limbic system would usually result in amnesia.

Question 17

What are lesions of the parietal lobe associated with?

Answer 17

They are associated with visuo-spatial deficients:

Agnosia - inability to recognise objects
Dyspraxia - inability to coordinate motor activites
*There may also be dysphasias (motor or sensory)

Grestmann’s syndrome is a parietal lobe injury with 4 components:
‘Left-right’ disorientation
Dyscalculia (inability to perform arithmetical tasks)
Finger agnosia (inability to distinguish the fingers on the hand)
Agraphia (inability to write)

Non-dominant parietal lobe injuries may lead to body image disturbances, such as ‘anosognosia’ (inability to recognise injury to a particular limb) or ‘hemisomatognosia’ (the feeling that one side of the body is missing)

Question 18

How do occipital lobe injurys present?

Answer 18

There are complex visual disturbances with vivid visual hallucinations

Anton’s syndrome = bilateral occipital lobe injury that renders the patient cortically blind but they have no insight and continue to affirm adamantly that they can see

Question 19

What are signs of Wilson’s disease?

Answer 19

Neuropsychiatric signs:
* Aggression
* Reckless behaviour
* Disinhibition
* Self-harm
* Tremor
* Writhing arm movements

General signs:
* Jaundice
* Kayser-Fleischer rings (also seen in PBC)

Question 20

How does young onset Parkinson’s present?

Answer 20

It is extremely rare (~5/100,000 under 40y)

Patient swill present with classic PD but will have more dystonic symptoms

Depression may occur but dementia is extremely rare (unlike in classical PD)

Question 21

What is the most common psychiatric manifestation following a stroke?

Answer 21

Depression

*Make sure not to miss in aphasic patients

Question 22

What are the typical symptoms of third ventricle wall/floor tumours?

Answer 22

Amnesia
Confabulation

You also ger symptoms of hypersomnia, hyperphagia, pyrexia and polydipsia (due to close proximity of the thalamus and hypothalamus)

Question 23

How does niacin - B3 (pellagra) deficiency present?

Answer 23

Triad of:
* Gastrointestinal disturbnace - anorexia, diarrhoea and gastritis
* Dermatological symptoms - symmetrical, bilateral bullous lesions in sun-exposed areas
* Heterogenous constellation of psychiatric symptoms - apathy, depression, irritability (in later stages it can resemble delirium, psychosis or Korsakoff-like presentation)

Question 24

How does Pick’s disease present?

Answer 24

It is a frontotemporal dementia that presents in the sixth decade of life (much earlier than other neurodegenerative disorders).

It presents with behaviour and personality changes before amnesic symptoms. These can include disinhibition, aggression, antisociality or the reverse of apathy

Question 25

How does acute intermittent porphyria present?

Answer 25

Abdominal pain Arm weakness Diminished reflexes Agitation Auditory hallucinations *It is a haem metabolism disorder resulting in the build-up of porphyria and their precuroses. Attacks can be precipitated by menstruation, alcohol, poor nutrition and certain drugs like OCP

Question 26

What are the different common types of schizophrenia?

Answer 26

Hebephrenic (aka disorganised) - predominance of thought disorder and affective symptoms (usually fatuous and childlike). Social withdrawal is common. Delusions and hallucinations are present but these are usually fragmented and not the most striking feature. Negative symptoms tend to develop early and quickly, and for this reason this subtype is considered to have a poor prognosis. Catatonic - characterised as psychomotor disturbances or catatonic behaviour. This is often stupor or florid over-activity. There are often unusual symptoms such as automatic obedience, in which people will follow a command without questioning, or the opposite (negativism). In severe cases, people may take on odd postures for long periods, or the limbs may be moved into positions and will remain there (waxy flexibility). Paranoid ("classical" type) - dominated by delusions and hallucinations. Thought disorder is less common. Residual - late-stage schizophrenia in which the syndrome of ‘positive’ symptoms (delusions, hallucinations, thought disorder) are replaced by predominately ‘negative’ symptoms (apathy, social withdrawal, avolition, blunting of affect, poverty of speech, self- neglect). Simple - efined by ICD-10 as ‘the insidious development of oddities of conduct, inability to meet the demands of society, and decline in total performance’. There are usually no overt psychotic symptoms.

Question 27

What is the pathophysiology of neuroleptic malignant syndrome (NMS)?

Answer 27

It is as a result of antipsychotic medication use and is thought to be the result of dopamine blockade in the hypothalamus (pyrexia) and nigrostriatal pathway (extrapyramidal symptoms such as tremor and rigidity). Peripheral blockade can cause changes in skeletal muscle contractility, which may exacerbate stiffness and cause muscle breakdown (with the consequent risk of rhabdomyolysis and renal failure). It is an emergency where the antipsychotic should be stopped and supportive treatment (especially to ensure cardiovascular stability) needs to be considered

Question 28

Which one confers with a positive prognostic feature of schizophrenia? * Absence of mood symptoms * Being male * Being young * Poor initial response to treatment * Rapid onset of symptoms * Lack of social networks * Being single * Poor pre-morbid educational attainment * Predominately negative symptoms * Long duration of illness before treatment

Answer 28

Rapid onset of symptoms *All the others are poor prognostic features of schizophrenia!!

Question 29

Which of the following is a not side effect of antipsychotic treatment? * Akathisia * Convulsions * Hypotension * Renal failure * Tachycardia

Answer 29

Renal failure (most antipsychotics are hepatically metabolised - kidneys only affected in rhabdomyolysis caused by NMS) Pathophysiology of side effects: Akathisia - EPSEs Convulsions - seizure threshold lowered Hypotension - adrenergic blockade Tachycardia - alongisde cardiac arrythmias and prolonged QT intervals

Question 30

What is depressive stupor?

Answer 30

It is a rare presentation of depressive disorder where there is mutism and akinesis (lack of movements). Depression with severe psychomotor retardation can lead to dehydration and pressure sores and should be treated urgently.

Question 31

What are the signs and symptoms of brucellosis?

Answer 31

Fevers Headaches Fatigue Pain Depression It is a contagious zoonosis transmitted via unpasteurised goat's milk or through contact with infected animals

Question 32

Which of the following is most likely to cause depression? * Methyldopa * Atenolol * Ibuprofen * Prednisolone * Amlodipine

Answer 32

Methyldopa - The side effects of methyldopa include depression, suicidal ideation and nightmares Corticosteroids such as prednisolone, hydrocortisone and dexamethasone are associated with mania but may also cause depression. Some beta-blockers which cross the blood–brain barrier, such as propranolol, may cause depression but atenolol does not. Ibuprofen is a non-steroidal anti-inflammatory drug and is rarely associated with depression. Amlodipine is a calcium-channel blocker, indicated for the treatment of hypertension. Depression is an occasional side effect of calcium channel blockers.

Question 33

What are the psychiatric associations of neurosyphilis?

Answer 33

Psychosis Mania Depression

Question 34

What are risk factors for depression?

Answer 34

Family history Female gender Childhood abuse Poverty Social isolation *No relation with old age. Higher education is a protective factor

Question 35

What is nihilism?

Answer 35

It is a psychological feature of depression characterised by an overwhelming feeling of hopelessness and negativity, which may amount to delusional intensity Other psychological features of depression that can occur concurrently are low mood, anhedonia, hopelessness, guilt, poor concentration, irritability, low self-esteem and suicidal thoughts

Question 36

What are the symptoms of anxiety?

Answer 36

Somatic (physical) - due to autonomic arousal: * gastrointestinal - dry mouth, epigastric discomfort, diarrhoea * respiratory - SOB, hyperventilation * CVS - palpitations, tachycardia * genitourinary - urgency, impotence, menstrual disturbances * neuro - tremor, sleep disturbance, headache Psychological: * intense worries or fear * irritability * hypersensitivity to noise * poor concentration

Question 37

What is the role of beta blockers in social phobia?

Answer 37

Despite not having any role in tackling the source of the phobia, they are used for symptomatic relief in unavoidable stressful social situations

Question 38

What is PANDAS?

Answer 38

Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections - an autoimmune reaction following from beta-haemolytic streptococcal infections in children. The neuropsychiatric consequences include obsessive-compulsive symptoms and tic disorders

Question 39

What pathological finding on brain MRI is most inkeeping with Alzheimer's disease?

Answer 39

Hippocampus atrophy is the main finding * You can also get generalised cerebral atrophy and enlarged ventricles

Question 40

Which compound has an effect on the symptoms of dementia? * Serotonin * Dopamine * Acetylcholine * Histamine * GABA

Answer 40

Acetylcholine - has an effect on cognition in dementia

Question 41

What is the common presenting triad in Lewy body dementia?

Answer 41

Visual hallucinations Fluctuating cognitive impairment Parkisonism

Question 41

Which of the following would suggest a diagnosis of depression rather than dementia in a patient presenting with memory loss? * Delusions * Fluctuating conscious level * Low mood * Poor verbal fluency * Excessive worry over memory loss

Answer 41

Excessive worry over memory loss

Question 42

What is somatisation?

Answer 42

It is the dispacement of psychological distress such as depression into physical symptoms. This is commonly seen in the depressed elderly as a way of alleviating their distress.

Question 43

What are relative contraindicatiosn for ECT?

Answer 43

There are very few but some contraindications include: * heart disease * raised ICP * Poor anaesthetic risk

Question 44

How does late-onset bipolar affectve disorder present?

Answer 44

It is commonly in patients above the age of 50, presenting latently following many years of severeal depressive episodes

Question 45

What is very late-onset schizophrenia-like psychosis (VLOSLP)?

Answer 45

It typically affects women more than men, and sufferers often have no personality or congnitive problems. Delusions can take any form, but it is very common for sufferers to describe ‘partition delusions’, in which solid structures become permeable to people or substances. Antipsychotic response is relatively poor, with formal psychological interventiosn offering more relief.

Question 46

How does chronic alcohol use and dependence present?

Answer 46

Alcohol dementia with many different pathologies: * Irreversible cognitive problems * Predisposition to cerebrovascular disease, head injury (and subsequent Alzheimer's disease) * Korskoff's syndrome

Question 47

What should you be weary of in new presentation of hypercalcaemia?

Answer 47

Malignancy where there is producted or PTHrp

Question 48

Which of the following statements is true about medicines in older age? * Antipsychotics are the drugs of choice for behavioural disturbance in dementia * Fat-soluble drugs (such as diazepam) will have a longer duration of action because of increased body fat in older people * Lithium doses in older people should generally be lower because the liver cannot excrete it as efficiently * Older people are less sensitive to the effects of benzodiazepines * Tricyclic antidepressants will not cause constipation in older people because of a general increase in gut motility

Answer 48

**Fat-soluble drugs (such as diazepam) will have a longer duration of action because of increased body fat in older people** - older people have a higher body fat content and less body water so there is an increased volume of distribution

Question 49

In personality disorders, what does ICD-10 state is required?

Answer 49

ICD-10 specifies that the individual’s inner experiences or behaviour must be manifest in more than one of the following areas (but not necessarily all): * Cognition * Affectivity * Control over impulses * Manner of relating to others

Question 50

How many factors are there to describe personality?

Answer 50

5 (OCEAN) Openess to experience Conscientiousness Extraverson/intraversion Agreeableness Neuroticism

Question 51

Which of the following is least likely to predict dangerous behaviour? * Co-morbid mental disorder * Co-morbid substance abuse disorder * Juvenile delinquency * Pathological lying * Superficial charm

Answer 51

Co-morbid mental disorder Even though co-morbid mental disorder can increase dangerouness (i.e. the presence of violent command hallucinations, high levels of perceived threat in paranoid states), overall there is very little violence directly attributable to mental illness

Question 52

How is Freud's model to understand our instincts and drives divided?

Answer 52

Id - unconscious part of the mind that contains innate instincts such as sexuality and aggression Ego - conscious part of the mind that composes rational thinking and balances the needs of the individual against the demands of the outside world Superego - analagous to what we might call ‘conscience’ and contains our moral rules. Freud believed it developed from our identification with authority figures and is part conscious, part unconscious

Question 52

What different types of defence mechanisms are there?

Answer 52

Denial - refusal to accept reality despite all logical evidence. Repression - unconscious exclusion of painful desires, thoghts or fears. Idealisation - perceiving another individual as having more positive traits or qualities than they may actually possess (part of splitting) Splitting - an individual perceives things as either all good (idealisation), or all bad (devaluation). Often seen in EUPD Regression - the individual revers to an earlier stage of development in order to avoid stressful events. This is thought to occur in those stuck at a particular stage of psychosexual development Sublimation (mature defence mechanism) - transformation of negative emotions or situations into positive feelings or behaviours Dissociation - modification of one's personality or identity in order to avoid distress (in severe forms, known as dissociative identity disorder) Projection - ascribing one’s own thoughts, fears, attributes or emotions to the external world, usually another person, while denying them as one’s own (used to decrease anxiety) Projective identification - ‘self-fulfilling prophecy’ whereby in projected emotions or feelings, the recipient begins to alter their behaviour in order to make the behaviour ‘real’

Question 53

What is CBT?

Answer 53

Cognitive behavioural therapy A type of talking therapy usually short-term and practical that aims to change the way individuals think or behave with regrds to themselves and others, by exploring erroneous patterns of thoughts, feelings and behaviours Focuses on 'here and now' to a greater extent than psychodynamic psychotherapy, with the therapist uncovering 'core beliefs' the individual may hold about themselves or the world This differs from psychotherapy which focusses on looking at deep-rooted problems as a result of past trauma or stresses, including in the individual’s childhood development

Question 54

Which of the following statements regarding CBT is false? * CBT may be carried out without a full qualification in CBT * CBT may make reference to early childhood experiences * CBT is more effective than medication for generalised anxiety disorder * CBT is not useful in dementia * CBT may involve family members

Answer 54

CBT is not useful in dementia

Question 55

What is the difference between erectile dysfunction, sexual aversion disorder and hypoactive sexual desire disorder?

Answer 55

Erectile dysfunction - inabibility to develop or maintain an erection during intercourse. Causative factors include previous negative experiences (leading to performance anxiety), drugs, alcohol, stress and fatigue Sexual aversion disorder - depressed sexual desire Hypoactive sexual desire disorder - milder version of aversion disorder, associated with a lack of interest in sex

Question 56

What is Wittmaack-Ekbom syndrome?

Answer 56

Also known as Restless Leg Syndrome There are uncomfortable, often painful sensations in the legs, which are relieved by movement. The condition is either idiopathic or familial in most cases. It is associated with a number of medical conditions including rheumatoid arthritis, uraemia and iron deficiency anaemia.

Question 57

What is Kleine-Levin symdrome?

Answer 57

It is characterized by distinct periods of extreme somnolence and excessive hunger. Males are far more affected than females. Other symptoms which may manifest include sexual disinhibition, confusion, irritability, euphoria, hallucinations and delusions.

Question 58

Define hypnic jerks

Answer 58

They occur at the onset of sleep and are associated with contractions of the limbs, neck or body. When wakened by the jerks there is a characteristic feeling of falling into space

Question 59

Which of the following is not a recognised complication of sustained anorexia nervosa? * Bradycardia * Heart failure * Hypercholesterolaemia * Parotid gland enlargement * Thrombocytosis

Answer 59

Thrombocytosis - you would expect thrombophilia.

Question 60

What are characteristics of harmful use (of substances)?

Answer 60

Continued over a long period (at least 1 month) despite damage to the user's physical or mental health Occupation and family are often severely affected, with the patient downplaying the severity

Question 61

How does complicated withdrawal differ from (normal) withdrawal symptoms?

Answer 61

Complicated withdrawal is when the withdrawal state is associated with delirium, seizures or psychotic features. Normal withdrawal includes features specific to individual drugs and can include both physical symptoms (e.g. appetite change and fatigue) and/or psychological symptoms (e.g. anxiety and depression) - these are relieved by reinstatement of the substance.

Question 62

Why is procyclidine contraindicated in myasthenia gravis?

Answer 62

Procyclidine is an antimuscarinic (anticholinergic) agent used in Parkinson's disease and to treat EPSEs of antipsychotic medication Thsis is contraindicated in MG as it is an autoimmune neurological disorder caused by anti-acetylcholine receptor antibodies at the postsynaptic neuromuscular junction - this would worsen the condition

Question 63

What is Asperger's syndrome?

Answer 63

Now thought to be on the same spectrum of disorders as autism (autism spectrum disorder), it is a condition that shares several similarities - abnormalities in social interactions, intense interest in a restricted range of behaviours or activites and motor clumsiness However, there is usually no marked languaged delay or cognitive difficulties (unlike in autism)

Question 64

How does conduct disorder differ from oppositional defient disorder (ODD)?

Answer 64

ODD may progress to a more frank conduct disorder, it usually manifests in younger children and is characterised by disobedient and disruptive behaviour, but without the frank aggression and violence (seen in conduct disorder) Conduct disorder is also thought to be strongly associated with adult dissocial personality disorder (psychopathy)

Question 65

What are appropriate treatments for the management of conduct disorder?

Answer 65

Cognitive behavioural therapy Family therapy Methylphenidate Parent management training

Question 66

Which of the following statements regarding learning disability is correct? 1. Epilepsy is over-represented in patients with learning disability 2. Mild learning disability is usually defined by an IQ between 35 and 49 3. The point prevalence of schizophrenia in people with learning disability is equal to that of the general population 4. Suicide is more common in people with learning disability than the general population 5. A person with learning disability cannot consent to treatment for medical conditions

Answer 66

Epilepsy is over-represented in patients with learning disability (1 is correct). The same can be said for schizophrenia (hence 3 is wrong). Mild learning disability is between 70 and 50. Moderate is between 49 and 35. Severe is under 34 (so 2 is wrong). Suicide is less common in people with moderate and severe learning disabilities (4 is wrong) . However self-injurous behaviours are common in learning disability and can increase with severity of disability. While capacity must be carefully assessed when consenting someone with learning disability for medical treatment, by no means does this mean that a learning disability automatically assumes incapacity. Capacity is decision-specific and must be assessed each time a decision is required (5 is wrong)

Question 67

Which of the following regarding trisomy 21 is correct? 1. Alzheimer's disease is more common in people with Down's syndrome than the general population 2. Mosaicism is responsible for approximately 20% of cases of Down's syndrome 3. Not all cases of trisomy 21 will result in learning disability 4. People with Down's syndrome cannot live independently 5. People with Down's syndrome have a lower incidence of anxiety than the general population

Answer 67

Alzheimer's disease is more common in people with Down's syndrome than the general population - for those that survive to their 60s, at least 50% will show clinical evidence of dementia (as the amyloid precursor protein is encoded on Chromosome 21) Mosaicism as opposed to non-dysjunction only accounts for 1-2% of Down's cases (2 is wrong) All trisomy 21 people will have some degree of learning disability (3 is wrong) 4 is wrong - they may require more support but are still able to live independently People with Down’s syndrome are at a higher risk of most psychiatric disorders, including anxiety problems (5 is wrong)

Question 68

What is Section 2?

Answer 68

* admission for assessment for up to 28 days, not renewable * an Approved Mental Health Professional (AMHP) or rarely the nearest relative (NR) makes the application on the recommendation of 2 doctors * one of the doctors should be 'approved' under Section 12(2) of the Mental Health Act (usually a consultant psychiatrist) * treatment can be given against a patient's wishes

Question 69

What is Section 3?

Answer 69

* admission for treatment for up to 6 months, can be renewed * AMHP along with 2 doctors, both of which must have seen the patient within the past 24 hours * treatment can be given against a patient's wishes

Question 70

What is Section 4?

Answer 70

* 72 hour assessment order * used as an emergency, when a section 2 would involve an unacceptable delay * a GP and an AMHP or NR * often changed to a section 2 upon arrival at hospital

Question 71

What is Section 5(2)?

Answer 71

a patient who is a voluntary patient in hospital can be legally detained by a doctor for 72 hours

Question 72

What is Section 5(4)?

Answer 72

similar to section 5(2), allows a nurse to detain a patient who is voluntarily in hospital for 6 hours

Question 73

What is Section 17a?

Answer 73

* Supervised Community Treatment (Community Treatment Order) * can be used to recall a patient to hospital for treatment if they do not comply with conditions of the order in the community, such as complying with medication

Question 74

What is Section 135?

Answer 74

a court order can be obtained to allow the police to break into a property to remove a person to a Place of Safety

Question 75

What are side effects of ECT?

Answer 75

Short-term: * Headache * Nausea * Muscle aches * Cardiac arrhythmia Long-term: * Impaired memory (retrograde > anterograde)

Question 76

How do you treat akathisia?

Answer 76

Low-dose propanolol or lorazepam

Question 77

Presentation of opioid withdrawal

Answer 77

Generalised muscle and joint pains Abdominal cramps Fever "Everything runs" - diarrhoea, vomiting, lacrimation, rhinorrhoea Agitation with dilated pupils and goosebumps

Question 78

Presentation of benzodiazepine withdrawal

Answer 78

Sweating Insomnia Headache Tremor Tinnitus Nausea Psychological features - anxiety, depression, panic attacks

Question 79

Presentation of cocaine intoxication

Answer 79

Euphoric feeling Tachycardia Nausea Hypertension Dilated pupils Hallucinations

Question 80

Presentation of cocaine withdrawal

Answer 80

Two phases First phase: "crash" - depression, exhaustion, agitation and irritability Second phase: Increased cravings, irritability, lack of energy, poor concentration, insomnia, slowed activity

Question 81

What class of drug is mirtazipine?

Answer 81

Noradrenergic and specific serotoninergic antidepressant (NaSSA) It improves sleep and stimulates appetite

Question 82

What is an extracampine hallucination?

Answer 82

Hallucination that exceeds the limits of a normal senosry field i.e. hearing a voice projected form Mars

Question 83

What is a pareidolic illusion?

Answer 83

When meaningful images are perceived from a vague stimulus (e.g. seeing a face in a fire)

Question 84

What psychotherapies can be offered in anorexia nervosa in adults?

Answer 84

* Eating disorder-focused CBT * Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) * Specialist Supportive Clinical Management (SSCM) - more practical than MANTRA *If the above don't work, then consider focal psychodynamic therapy (FPT)

Question 85

What pharmacological treatment can be given in Alzheimer's?

Answer 85

First line: acetylcholinesterase inhibitors (donepezil, rivastigmine, glantamine) Second line: NMDA antagonist (memantine)

Question 86

What is used to assess the severity of alcohol withdrawal?

Answer 86

Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar)

Question 87

What is the triad of Wernicke's encepahlopathy?

Answer 87

Opthalmoplegia Ataxia Confusion

Question 88

What is the triad in Korsakoff's syndrome?

Answer 88

Amnesia (especially anterograde) Confabulation Psychosis *This is irreversible

Question 89

What are the following sexual preferences (paraphilias)? Fetishism Sadism Masochism Bondage

Answer 89

Fetishism - arousal on an inanimate object Sadism - gratification by inflicting pain on a partner Masochism - gratification by being humiliated or being in pain Bondage - practice that involves tying/restraining a partner

Question 90

What is the triad of clinical features in PTSD?

Answer 90

Re-experiencing Avoidance Autonomic hyperarousal

Question 91

What is an overvalued idea?

Answer 91

A reasonable idea that is pursued beyond the bounds of reason - i.e. thinking about redoing a garden is reasonable, but quitting a job to do this is unreasonable

Question 92

What is flumazenil?

Answer 92

GABA antagonist that is used to reverse the efects of benzodiazepine overdose.

Question 93

What are pseudo-hallucinations in grief reactions?

Answer 93

These difer from true hallucinations as the patient has insight that the hallucinations are not real

Question 94

What is an acute and transient psychotic disorder?

Answer 94

Abrupt onset of delusions, hallucinations and incoherent speech that is precipitated by an acute stressful event (approximately 1-2 weeks prior) The time interval between the first appearance of any psychotic symptoms and the presentation of the fully developed disorder should be <2weeks, with no evidence of drug use or organic disease Full recovery is often within days or weeks, but cna take up to 3 months

Question 95

Match the psychotherapy to the correct explanation: 1. Psychodynamic psychotherapy 2. Eye movement desensitisation and reprocessing (EMDR) 3. Congnitive Behavioural Therapy (CBT) 4. Dialectal Behaviour Therapy (DBT) 5. Mentalisation-based Therapy A - It will teach you how your thoughts, feelings, and behaviours influence each other and that negative thoughts and feelings can trap you in a vicious cycle B - It involves making side-to-side eye movements by following the movement of the therapist’s finger while recalling traumatic events C - It involves exploring the relationship between the therapist and client and allows you to understand how the past influences current behaviour D - It teaches you how to accept who you are and how to deal with difficult emotions by recognising them and challenging them E - It teaches you how to think about thinking and examine your own thoughts and beliefs and assess whether they are useful or realistic

Answer 95

1C 2B 3A 4D 5E

Question 96

Side effects of SSRIs

Answer 96

Common: * Drowsiness * Nausea * Dry mouth * Insomnia * Constipation/Diarrhoea * Headache * Blurred vision * Sexual dysfunction - reduced libido, anorgasmia, erectile dysfunction Rare: * Alopecia * Movement disorders * Hyponatraemia * Serotonin syndrome

Question 97

Presentation of benzodiazepine overdose

Answer 97

Drowsiness Ataxia Dysarthria Nystagmus Respiratory depression *Treat with flumazenil

Question 98

What should you consider when withdrawing benzodiazepines?

Answer 98

Switch patients from short-acting benzodiazepines (i.e. tenazepam) to a long-acting one (e.g. diazepam) with the dose gradually reduced over a number of weeks

Question 99

What do you do when fluoxetine does not work after 12 weeks in OCD?

Answer 99

Trial an alternative SSRI or clomipramine (TCA)

Question 100

What IQ tests are there in children?

Answer 100

Aged 2-7: Wechsler Preschool and Primary Scale of Intelligence (WPPSI) Aged 6-16: Wechsler Intelligence Scale for Children (WISC)

Question 101

What are the categories of the Wechsler Intelligence Scale for Children (WISC)?

Answer 101

Mild: 50-70 Moderate: 35-49 Severe: 20-34 Profound: <20

Question 102

Which blood test would you see in anorexia nervosa? 1. High cortisol, high growth hormone, low cholesterol, low amylase 2. High cortisol, high growth hormone, high cholesterol, low amylase 3. High cortisol, low growth hormone, low cholesterol, high amylase 4. Low cortisol, low growth hormone, high cholesterol, high amylase 5. High cortisol, high growth hormone, high cholesterol, high amylase

Answer 102

**5** High cortisol - stress hormone to stimulate gluconeogenesis High growth hormone - stimulates gluconeogenesis, lipolysis, and protein synthesis High cholesterol - not understood but thought to be due to increased cholesterol ester transfer protein activity High amylase - elevated after repeated bouts of purging

Question 103

How do you classify insomnia?

Answer 103

Primary - no identifiable comorbidity vs. Secondary - resulting from another condition OR Short-term (<4 weeks) vs. Long-term (>4weeks)

Question 104

How do you manage short-term insomnia?

Answer 104

Sleep hygiene advice - relaxing before bed, maintaining a comfortable sleeping environment, avoiding daytime napping, avoiding caffeine, nicotine and alcohol Hypnotics (if severe and only for 2 weeks with a review) - consider short-acting benzodiazepines (e.g. tenazepam) or non-benzodiazepine ‘Z-drugs’ (e.g. zopiclone) *Diazepam can be used if there is insomnia associated with daytime anxiety

Question 105

What is the treatment for long-term insomnia?

Answer 105

Sleep hygiene review Hypnotic drug (not recommended) can be used up to 4 weeks Cognitive or behavioural interventions (e.g. CBT, relaxation training, sleep restriction therapy and stimulus control therapy) If >55yo can consider modified-release melatonin for up to 13 weeks If all fails, refer to sleep clinic

Question 106

What are screening tools for social phobia?

Answer 106

Social phobia inventory (SPIN) Liebowitz social anxiety scale

Question 107

What is the most appropriate SSRI to prescribe in a patient with a history of ischaemic heart disease?

Answer 107

Sertraline

Question 108

Management of paracetamol overdose

Answer 108

If presents within 1 hour of ingestion, consider activated charcoal (to reduce paracetamol absorption) Measure plasma paracetamol levels at 4 hours after ingestion (if possible) to decide whether IV N-acetylcysteine infusion is necessary or not *Can consider gastric lavage but this is rarely done

Question 109

Treatment of neuroleptic malignant syndrome

Answer 109

Stop the causative agent immediately Supportive treatment - fluids, cooling blankets, DVT prophylaxis Medications for: *Agitation - lorazepam *Malignant hyperthermia - dantrolene *Dopamine blockade - bromocriptine

Question 110

What are the 4 subgroups of conduct disorder behaviours?

Answer 110

Aggression to people and animals: bullying, fighting, cruelty to animals, sexual assault Destruction of property: fire-setting, vandalism Deceitfulness or theft: shoplifting, breaking and entering Serious violation of rules: truancy, staying out late *For a diagnosis of conduct disorder, at least 3/4 subgroups need to be present for at least 12 months

Question 111

What are risk factors for conduct disorder?

Answer 111

Urban upbringing Mental health conditions Low socioeconomic status Harsh and inconsistent parenting Parental substance abuse

Question 112

What medications are used in alcohol withdrawal to prevent relapse?

Answer 112

1st line (anti-craving): acamprosate or naltrexone 2nd line: disulfiram (acetyl dehydrogenase inhibitor which causes patients to feel sick immediately after drinking)

Question 113

What can you give in assisted withdrawal of opioids?

Answer 113

Methadone (oral liquid): μ-opioid receptor agonist with a long half-life Buprenorphine (sublingual): μ-opioid partial agonist ————————— Lofexidine and clonidine are alpha2 agonists and can be considered if the above are unacceptable or if the dependency is mild

Question 114

What are the side effects of lithium?

Answer 114

LITHIUM **L**eucocytosis **I**nsipidus (nephrogenic) **T**remor **H**ypothyroidism **I**ncrease **U**rine **M**others (teratogenic) Others: GI upset, weight gain, T-wave inversion, eyebrow hair loss

Question 115

How do you assess for learning disabilities?

Answer 115

Intellectual impairment using WAIS III (Wechsler Adult Intelligence Scale) Adaptive/social functioning using ABAS II (Adaptive Behaviour Assessment System) Screen for presence of symptoms in childhood history

Question 116

What are antenatal causes of learning disability?

Answer 116

* Intrauterine infections - CMV, rubella, syphilis * Intoxication (maternal) - alcohol, cocaine, lead, smoking * Physical damage - injury, radiation, hypoxia * Endocrine - Hypothyroidism, Hypoparathyroidism, diabetes

Question 117

What are perinatal causes of learning disability?

Answer 117

* Late pregnancy maternal conditions - placental insufficiency, pre-eclampsia, bleeding * Birth and newborn complications - birth trauma, hypoxia, hypoglycaemia, intraventricular haemorrhage, kernicterus, neonatal infections

Question 118

What are postnatal causes of learning disability?

Answer 118

* Injury - accidental or non-accidental * Infections - meningoencephalitis * Intoxication - lead, drugs * Early physical disorders - brain tumours, vascular events * Malnutrition - protein-energy insufficiency, iodine deficiency

Question 119

What are genetic causes of learning disability?

Answer 119

* Dominant genes - neurofibromatosis, tuberous sclerosis, myotonic dystrophy * Recessive genes - phenylketonuria, homocystinuria, urea cycle disorders * Chromosomal abnormalities - Down's, Klinefelter's, Turner's * X-linked disorders - Lesch-Nyhan syndrome, Fragile X syndrome * Genomic imprinting - Prader-Willi, Angelman's

Question 120

How can you describe thought disorders in a MSE?

Answer 120

Thought form: * Speed of thoughts (racing, slow) * Coherence of thoughts (tangential, flight of ideas, thought block) Thought content: * Delusions * OCD thoughts * Suicidal thoughts * Violent thoughts * Overvalued ideas Thought possession: * Thought insertion * Thought withdrawal * Thought broadcasting

Question 121

What medication should be avoided in cocaine-induced myocardial infarction?

Answer 121

Beta blockers as they may cause further coronary vasospasm due to unopposed alpha blockade

Question 122

What is Couvade syndrome?

Answer 122

Sympathetic pregnancy, is a condition in which a pregnant woman’s partner begins to experience symptoms that mimic pregnancy. The symptoms can include nausea, weight gain, disturbed sleep patterns and even, in some cases, labour pains and postpartum depression.

Question 123

What is the pupillary sign in tertiary syphilis?

Answer 123

Argyll Robertson pupils - acommodations but do not react

Question 124

What is the difference between a somatic delusion and a referential delusion?

Answer 124

Somatic delusion = fixed belief that is related to the ptient's health or bodily function Referential delusion = beliefs that ordinary events have hidden meanings relating to the person (e.g. secret mesages through the TV)

Question 125

What is progessive supranuclear palsy?

Answer 125

Parkinson’s plus syndrome that presents similarly to Parkinson’s disease but is also classically associated with an upgaze palsy

Question 126

What are Parkinson plus disorders?

Answer 126

Progressive supranuclear palsy Corticobasal degeneration Multiple system atrophy Dementia with lewy bodies

Question 127

What is the name of the questionnaire used to assess the severity of OCD?

Answer 127

Yale-Brown

Question 128

What should you trial if lithium is not tolerated in long-term management of bipolar disorder?

Answer 128

Sodium valproate. Then consider olanzapine or quetiapine

Question 129

What is the Edinburgh Postnatal Depression Scale (EDPS)?

Answer 129

Ten-item questionnaire that is self-administered. Women are asked to describe their feelings **over the last 7 days**, typically a score of 12 or above indicates that the patient is likely to be suffering from PND. *Patient must be at least 2 weeks postpartum

Question 130

What is the difference between Persistent Grief Disorder (PGD) and Persistent Complex Bereavement Disorder (PCBD)?

Answer 130

PGD = when symptoms persist over 6 months which dinstinguishes it from normal grief reaction. Patients also often exhibit preoccupation with the deceased and feelings of guilt or self-blame. PCBD = when symptoms present for over 12 months and patients often express a desire to die "to be with their loved ones"

Question 131

What are complications of epilepsy?

Answer 131

Bio: * Status epilepticus may result in long term damage * May injure self durin seizure * Side effects of anti-epileptic medication Psycho: * Impact on learning and education * Impact on mental wellbeing Social: * DVLA * Triggers e.g. flashing lights may prevent certain activities * No swimming alone

Question 132

Different types of epilepsy

Answer 132

Generalised: * Absence * Myoclinic * Tonic * Tonic-clonic Focal: * Frontal * Temporal * Occipital * Parietal

Question 133

What are the 5 As of Alzheimer's?

Answer 133

Aphasia Agnosia Amnesia Ataxia Anomia

Question 134

What should you do when switching from fluoxetine to another SSRI?

Answer 134

Withdraw completely, leave a wash-out period of 4-7 days, start low-dose alternative SSRI

Question 135

21 y/o woman admitted to psych ward for an acute episode. She has been prescribed Amisulpride for the past 3 weeks and is now worries she is pregnant because she has missed her period, however her pregnancy test is negative. Which blood test should be requested in addition to routine bloods? a. Luteinising hormone b. Progesterone c. Prolactin d. Thyroid stimulating hormone e. Triglycerides

Answer 135

Prolactin Amisulpride is an antipsychotic medication that can increase levels of prolactin, a hormone responsible for milk production in breastfeeding women. Elevated levels of prolactin can lead to changes in menstrual cycles and cause amenorrhea (absence of menstruation).

Question 136

What is the temporal lobe involved in and what condition is related to temporal lobe dementia?

Answer 136

The temporal lobe, specifically the medial temporal lobe structures, including the hippocampus, is crucial for memory formation and retrieval. It plays a significant role in the consolidation of new memories and the retrieval of past memories. Alzheimers presents with hippocampus atrophy which is related to episodic memory

Question 137

28 y/o man is given regular medication for BPAD and has also been taking Naproxen for a sports injury. He presents to A&E with ataxia, confusion, and tremor. Which medication has most likely caused his symptoms? a. Carbamazepine b. Lithium c. Olanzapine d. Sertraline e. Sodium valproate

Answer 137

Lithium - this is a case of lithium toxicity Coarse tremor Hyperreflexia Nystagmus CNS (seizures, ataxia) GI (N&V)

Question 138

20 y/o man with schizophrenia tells his support worker that the TV news presenter talks about him. What psychotic phenomenon is he describing?

Answer 138

Delusion of reference

Question 139

35 y/o man presents to A&E agitated and requesting medication. He has mild tremor, cool and clammy skin, and goosebumps (piloerection). Ambulance staff found him in the street with an empty bottle of cider. Temperature 36.8, BP 140/100, HR 100. What is the most likely diagnosis? a. Alcohol intoxication b. Alcohol withdrawal syndrome c. Opiate intoxication d. Opiate withdrawal syndrome e. Tricyclic antidepressant intoxication

Answer 139

Opiate withdrawal syndrome He is requesting medication which is in-keeping with opiate seeking behaviour. The alcohol is a red herring

Question 140

58 y/o man attends addiction services for initial alcohol dependence assessment. He regularly attends A&E following overdose attempts. He requests detoxification. He lives alone with few social contacts and has poorly controlled asthma. What is the most appropriate next step in management? a. CBT b. Community detoxification c. Disulfiram d. Inpatient detoxification e. Motivational interviewing

Answer 140

Motivational interviewing

Question 141

John is a 78 year old male who was admitted 2 days ago with a productive cough and consolidation on his chest x-ray. On admission he was confused, and his next of kin report he is off his baseline. Over the next few days his confusion appears to fluctuate and he has at times become anxious reportedly seeing snakes on the ward. Nurses call you as John has become increasingly agitated and has removed his IV required for his antibiotics. He is shouting and wandering trying to get off the ward. The nurse informs you they have tried verbal de-escalation techniques. You review John’s notes and find he is allergic to nitrofurantoin. His regular medication includes aspirin, ramipril, levo-dopa and metformin. He is being treated with IV co-amoxiclav and clarithromycin. What is the most appropriate management? 500 mcg Haloperidol PO 0.5 mg Lorazepam PO Ask nurses to re-insert cannula with use of mittens 500mcg Haloperidol IM 0.5 mg Lorazepam IM

Answer 141

0.5 mg Lorazepam PO *He cannot have haloperidol due to his previous diagnosis of PD (he is on levodepa). You should also always try oral medication before IM.

Question 142

What is the chance of puerperal psychocis recurrence?

Answer 142

1 in 2 (according to NHS website)

Question 143

What is the presentation of atypical anorexia nervosa?

Answer 143

Same presentation as normal anorexia nervosa but with normal weight and BMI and no amenorrhoea

Question 144

How long after starting a SSRI should a patient be reviewed?

Answer 144

If <25 yrs: 1 week (due to increased risk of suicidal ideation in younger patients) If >25yrs: 2 weeks

Question 145

What does the mental capacity act involve?

Answer 145

Understanding Retaining Weighing Communicating

Question 146

What is the treatment of Lewy Body Dementia? And what is contraindicated?

Answer 146

Acetylcholinesterase inhibitors (Donepezil or Rivastigmine) Do not offer antipsychotics as this can worsen symptoms and increase the risk of cerebrovascular disease!!

Question 147

What is used to treat hypersalivation in clozapine patients?

Answer 147

Hyoscine