Psych

Question 1

5 stages of grief?

Answer 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

Anger: this is commonly directed against other family members and medical professionals

Bargaining

Depression

Acceptance

Question 2

When are abnormal grief reactions more common?

Answer 2

Women

If the death is sudden / unexpected

Question 3

Anorexia nervosa features?

Physiological abnormalities

Answer 3

most things low
reduced body mass index
bradycardia
hypotension
enlarged salivary glands

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

[Most things are low but
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia]

Question 4

Usual use of tricyclics? Why are they less commonly used for depression?

Answer 4

neuropathic pain

Side effects and toxicity in overdose

Question 5

Common tricyclic side effects?

Answer 5

drowsiness
Dry mouth 
Blurred vision 
Constipation 
Urinary retention

Question 6

Which tricyclic is usually used for management of neuropathic pain and prophylaxis of headaches?

Answer 6

low dose amitriptyline

Question 7

Which tricyclics are most dangerous in overdose?

Least?

Answer 7

Dosulepin / amitriptyline

Lofepramine

Question 8

Sedative tricyclic? Less sedative?

Answer 8

Sedative - amitriptyline

les - Imipramine / Lofepramine

Question 9

How do benzodiazepines work?

Answer 9

Enhance effects of GABA by increasing the frequency of chloride channels

Question 10

Uses of Benzos

Answer 10

Sedation
hypnotic
Anxiolytic 
Anticonvulsant 
Muscle relaxant

Question 11

How long is recommended for length of time with benzo prescription?

Answer 11

2-4 weeks

Question 12

How long does withdrawal from Benzos take? Side effects if withdraw too fast?

Answer 12

4 weeks - over 1yr

Insomnia, irritability, anxiety, trmor, loss of appetite, perspiration, seizures, tinitus

Question 13

Way of remembering how Barbiturates work?

Answer 13

Frequently Bend - During Barbeque

benzodiazipines increase the frequency of chloride channels

barbiturates increase the duration of chloride channel opening

Question 14

When would you use clozapine?

Answer 14

tried 2 antipsychotics (at least 1 atypical) for 6-8 weeks

Question 15

Side effects of clozapine

Answer 15

weight gain
excessive salivation
agranulocytosis
neutropenia
myocarditis
arrhythmias

Question 16

Key Mx aspects of Schitz with first diagnosis

Answer 16

Offer atypical antipsychotic first line

CBT should be offered to ALL

Pay attention to CVD risk factor modification due to high rates of CVD
-Due to antipsychotics and smoking

Question 17

Which are the most preferred SSRIs

Answer 17

Fluoxetine and Citalopram (Remember QT interval)

Question 18

Most useful SSRI post MI?

Answer 18

Sertraline

Question 19

Which SSRI in children / adolescents?

Answer 19

fluoxetine

Question 20

Most common side effects with SSRIs ?

Answer 20

GI sx

Question 21

there is an increased risk of gastrointestinal bleeding in patients taking SSRIs.
When would you prescribe a PPI?

Answer 21

If also taking a NSAID Eg aspirin

Question 22

Which SSRI affects QT interval? When should it not be used?

Answer 22

citalopram

congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval

Question 23

Key interactions with SSRIs ?

Answer 23

Warfarin / heparin -
Avoid SSRIs and consider mirtazapine

Triptans - avoid SSRIs

Question 24

How often should you review after initiation of SSRIs ? If increased risk of suicide? Under 30?

Answer 24

2 weeks

1 week

1 week

Question 25

How long should you stay on SSRIs after Sx improvement.? How do you reduce? Discontinuation Sx?

Answer 25

6 months gradually over 4 weeks ``` Discontinuation symptoms increased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia ```

Question 26

Divide up the first rank sx of schitz

Answer 26

auditory hallucinations, thought disorders, passivity phenomena and delusional perceptions: 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 behavior Thought disorder*: thought insertion thought withdrawal thought broadcasting Passivity phenomena: bodily sensations being controlled by external influence actions/impulses/feelings - experiences which are imposed on the individual or influenced by others 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 27

You are called by the husband of a 45-year-old patient who is registered at your practice. Her only history of note is type 2 diabetes mellitus treated with metformin. For the past three days he states that she has been 'talking nonsense' and starting to hallucinate. An Approved Mental Health Professional is contacted and makes her way to the patient's house. On arrival you find a thin, unkempt lady who is sat on the pavement outside her house, threatening to 'kick your head in'. What is the most appropriate action?

Answer 27

Call the police

Question 28

Alice, an 80-year-old recently widowed woman, attends your GP practice with her daughter, who is worried about her mother's memory. For the past few months, she's been forgetting appointments and conversations that they had only a few days ago, needing prompting often to remember recent events. After talking to Alice she tells you she doesn't have much of an appetite nowadays is waking up earlier than she used to. She denies any hallucinations or movement problems. On mini mental state exam Alice scores 23, you notice she's not properly concentrating on your questions, answering many of the questions with 'i don't know'. What is the most likely diagnosis?

Answer 28

Depression

Question 29

Only absolute CI to ECT?

Answer 29

Raised ICP

Question 30

ECT short term side effects ? Long term?

Answer 30

``` headache nausea short term memory impairment memory loss of events prior to ECT cardiac arrhythmia ``` Some report impaired memory

Question 31

Features of an atypical grief reaction?

Answer 31

Delayed - >2 weeks pass before grieving Prolonged - Usually over 12 months

Question 32

Diagnostic criteria for Mild, moderate and severe depression?

Answer 32

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 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 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 33

2 questions used to screen for depression ?

Answer 33

'During the last month, have you often been bothered by feeling down, depressed or hopeless?' 'During the last month, have you often been bothered by having little interest or pleasure in doing things?'

Question 34

2 tools for assessing depression?

Answer 34

Hospital anxiety and depression (HAD) scale PHQ-9

Question 35

A 16-year-old girl is brought for review by her father. She is talented violinist and is due to start music college in a few weeks time. Her parents are concerned she has had a stroke as she is reporting weakness on her right side. Neurological examination is inconsistent and you suspect a non-organic cause for her symptoms. Despite reassurance about the normal examination findings the girl remains unable to move her right arm. What is the most appropriate term for this behaviour? Features of this?

Answer 35

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

Question 36

What is dissociative disorder?

Answer 36

dissociation is a process of 'separating off' certain memories from normal consciousness in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder

Question 37

A 64-year-old woman presents as she is feeling down and sleeping poorly. After speaking to the patient and using a validated symptom measure you decide she has moderate depression. She has a past history of ischaemic heart disease and currently takes aspirin, ramipril and simvastatin. What is the most appropriate course of action?

Answer 37

Start sertraline + lansoprazol

Question 38

2 features of sleep paralysis? | Mx?

Answer 38

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 39

Timing for Parts of alcohol withdrawal? Mx of alcohol withdrawal?

Answer 39

symptoms: 6-12 hours seizures: 36 hours delirium tremens: 72 hour Management first-line: benzodiazepines e.g. chlordiazepoxide. Typically given as part of a reducing dose protocol carbamazepine also effective in treatment of alcohol withdrawal

Question 40

Hypokalaemia on ECG?

Answer 40

first-degree heart block, tall P-waves and flattened T-waves

Question 41

Mx of bulimia?

Answer 41

Refer for specialist care | 1st line - CBT

Question 42

Mechanism for alcohol withdrawal?

Answer 42

Chronic alcohol consumption - Enhances GABA and inhibits NMDA-type glutamate receptors Withdrawal -> opposite

Question 43

Criteria for diagnosis of body dysmorphic disorder

Answer 43

Preoccupation with an imagined defect in appearance / excessive concern over slight anomaly Leads to significant distress / impairment in social, occupational or functioning Cannot be accounted for another disorder Eg body shape and anorexia

Question 44

Step wise Mx of GAD

Answer 44

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 sertraline should be considered the first-line SSRI [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 45

Steps Mx of panic disorder

Answer 45

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 Primary care treatment CBT or drugs -SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered

Question 46

Which psychotic Sx differentiate mania and hypomania? Sx in both (categories)

Answer 46

delusions of grandeur auditory hallucinations Mood predominately elevated irritable Speech and thought pressured flight of ideas poor attention Behaviour insomnia loss of inhibitions: sexual promiscuity, overspending, risk-taking increased appetite

Question 47

``` Mx of PTSD Should you use single session debriefing? When would you watchfully wait? Which therapy? Drugs? ```

Answer 47

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 paroxetine or mirtazapine are recommended

Question 48

Why can fluoxetine be stopped quicker than other SSRIs

Answer 48

Longer half life