Psych

Question 1

Define the term ‘psychosis’

Answer 1

A mental state in which reality is greatly distorted

Question 2

Name and define symptoms associated with psychosis

Answer 2

Delusions - a fixed, false belief firmly held despite evidence to the contrary, against normal social and cultural beliefs
Hallucinations - perception in the absence of external stimulus
Thought disorder - impaired ability to form thoughts from logically connected ideas

Question 3

List some differentials for psychosis

Answer 3

Organic - drug induced, iatrogenic (levodopa, steroids), SLE, delirium, temporal lobe epilepsy, SOL, Lewy body dementia, cushing’s syndrome, vitamin B12 deficiency, syphillis
Functional - schizophrenia, schizotypal disorder, schizoaffective disorder, acute psychotic episode, mood disorder (+ psychosis), puerperal (post partum), delusional disorder

Question 4

List different types of delusions

Answer 4

Grandiose
Persecutory
Reference
Guilt
Nihilistic
Hypochondriacal
Infestation
De clérambault's syndrome (erotomania)
Othello syndrome (jealousy, unfaithful)
Capgras' syndrome (misidentification)

Question 5

List different types of hallucinations

Answer 5

Visual (*organic brain disease/substance misuse)
Auditory (second/third/running commentary)
Olfactory
Gustatory
Somatic (bodily sensations)

Question 6

List different types of thought disorder

Answer 6

Loosening of association (derailment, tangential, word salad

Neologisms

Question 7

Describe how to undertake a psychiatric interview (history taking)

Answer 7

Sociodemographic details - name, age, gender, marital status, children, occupation, religious and ethnic background
HPC - onset, severity, duration, progression, precipitating events/aggravating/relieving factors, associated symptoms
PPH - diagnoses (date, duration), previous admissions (informal, MHA), treatments (medication, psychological, ECT) and response/side effects
PMH - head injury, cranial surgery, neurological conditions (epilepsy), endocrine abnormality (thyroid, cushing’s)
DH - medication (+ psychotropic), allergies
FH - +quality of family relationships
PH - early childhood (birth complications, milestones, childhood illness, family dynamics, home atmosphere, abuse), education (attendance, enjoyment, bullying, qualifications, higher education), employment (chronological list, duration, redundancy/choice, work environment), relationships (sexual orientation, major relationships, current relationships, children), forensics (offences, sentences, arrested)
SH - accommodation, social support, finances, hobbies, alcohol (units, type), illicit drugs (cannabis), smoking (pack years)
Premorbid personality (collateral)

Question 8

Describe how to undertake a mental state examination (examination)

Answer 8

ASEPTIC:
Appearance and behaviour - physical state (unkempt, weight, EPSE, posture), clothing and accessories, personal hygiene, eye contact, facial expression, motor activity/abnormal movements, arousal, ability to build rapport, disinhibition
Speech - rate, rhythm, volume, content, quantity, tone, dysarthria
Emotion (mood and affect) - objective, subjective, labile
Perception (hallucination) - visual/auditory/olfactory/gustatory/somatic, pseudohallucination, depersonalisation, derealisation
Thought - content (delusion, overvalued idea, obsession, compulsion), form, stream, suicide and self harm/harming others
Insight - intact, partial, non existent
Cognition - mentation to time, place and person, tools (MMSE/AMT/ACE)

Question 9

List Schneider’s first rank symptoms of schizophrenia

Answer 9

Delusional perception
Third person auditory hallucination
Thought interference
Passivity phenomenon

Question 10

Define the terms ‘mood’, ‘affect’, ‘insight’

Answer 10

Mood - sustained, subjective, experienced emotion over a period of time
Affect - observe a patient’s posture, facial expression, emotional reactivity and speech
Insight - extent to which the patient understands the nature of the problem and if they are in agreement with treatment

Question 11

Give an example of a MSE for a patient with paranoid schizophrenia

Answer 11

A&B - appropriate, normal, able to build rapport
S - normal rate, rhythm, tone, no formal thought disorder
E - subjectively good, objectively euthymic, appropriate affect
P - delusion, auditory third person hallucination (reacting to stimulus)
T - persecutory delusion
I - none - no presence of illness, no desire for treatment
C - orientated to TPP, cognition normal

Question 12

List risk factors for depression

Answer 12

FAPS:
Female
Family history
Alcohol
Adverse events
Past depression
Physical comorbidities
Low social support/socioeconomic background

Question 13

List the core symptoms of depression

Answer 13

Low mood
Anergia
Anhedonia
>2 weeks

Question 14

List cognitive symptoms of depression

Answer 14

Lack of concentration, negative thoughts, excessive guilt, suicidal ideation

Question 15

List biological symptoms of depression

Answer 15

DVM, EMW, loss of libido, psychomotor retardation, weight loss, loss of appetite

Question 16

Describe how you would classify severity of depression

Answer 16

Mild - 2 core, 2 other
Moderate - 2 core, 3-4 other
Severe - 3 core, >4 other

Question 17

What is Beck’s triad of depression?

Answer 17

Sad thoughts about self, World and the future

Question 18

List investigations you would perform in a patient with suspected depression

Answer 18

Questionnaire - PHQ-9

Bloods - FBC, TFTs, calcium, glucose

Question 19

Describe management of depression

Answer 19

Biological - antidepressants (SSRI, SNRI, TCA etc.), adjuvants, ECT
Psychological - psychotherapy, self help programmes, physical activity
Social - social support groups

Question 20

List indications for ECT in depression

Answer 20

Life threatening severe depression
Rapid response required
Depression with psychotic features
Severe psychomotor retardation/stupor
Failure of other treatments

Question 21

Give an example of a MSE for a patient with depression

Answer 21

A&B - unkempt, poor personal hygiene, difficulty establishing rapport, psychomotor retardation, poor eye contact, hunched position
S - slow rate, monotonous, no formal thought disorder
E - objectively and subjectively low, blunted affect
P - delusions of guilt, hallucinations
T - poverty of thought, suicidal ideation, self harm
I - good insight - accepts diagnosis and treatment
C - poor concentration

Question 22

List symptoms of mania

Answer 22

I DIG FASTER:
Irritability
Distractibility, disinhibition (sexual, social, spending)
Insight impaired, increased llbido
Grandiose delusions
Flight of ideas
Activity/appetite increased
Sleep decreased
Talkative (pressured speech)
Elevated mood, energy increased
Reduced concentration, reckless, restless

Question 23

List investigations you would perform in a patient with suspected bipolar disorder

Answer 23

Mood disorder questionnaire
Bloods - FBC, TFTs, U&E, LFT, glucose, calcium
Urine drug screen
CT head

Question 24

Describe management of mania

Answer 24

Biological - mood stabiliser, benzodiazepine, antipsychotics, ECT
Psychological - psychoeducation, CBT
Social - social support groups, self help groups, calming activities

Question 25

List ADRs of lithium

Answer 25

Polydipsia, polyuria (diabetes insipidus), metallic taste in mouth, fine tremor, weight gain, hypothyroidism, decreased renal function, oedema, teratogenic *ECG - T wave flattening, widened QRS

Question 26

List symptoms of lithium toxicity

Answer 26

``` Toxicity (1.5-2.0) - nausea, vomiting, coarse tremor, ataxia, muscles weakness Severe toxicity (>2.0) - nystagmus, dysarthria, hyperreflexia, oliguria, reduced consciousness, convulsions, coma, death ```

Question 27

What investigations are required before commencing a patient on lithium therapy?

Answer 27

U&Es TFTs Pregnancy status ECG

Question 28

Give an example of a MSE for a patient with mania

Answer 28

A&B - flamboyantly dressed, psychomotor agitation S - pressured speech, increased intonation, excessive punning, clang association, disinhibition E - objectively and subjectively elated in mood, labile P - no hallucinations, delusions of grandeur T - delusion, loosening of association, thought acceleration I - non existent insight C - orientated to TPP, poor attention

Question 29

List positive and negative symptoms of schizophrenia

Answer 29

Positive (Delusions Held Firmly Think Psychosis) - delusions, hallucinations, formal thought disorder, thought interference, passivity phenomena Negative (As) - avolition, asocial behaviour, anhedonia, alogia (poverty of speech), affect blunted, attention deficits

Question 30

Describe management of psychosis

Answer 30

Biological - antipsychotics, adjuvant, ECT Psychological - CBT, family intervention, art therapy Social - social skills training, support groups, peer support, supported employment programmes

Question 31

What is anxiety?

Answer 31

Unpleasant emotional state involving subjective fear and somatic symptoms

Question 32

List different anxiety disorders

Answer 32

Phobic - agoraphobia, social phobia, specific phobia Other anxiety - panic, generalised, mixed anxiety and depressive Obsessive compulsive Reactional - acute stress reaction, PTDS, adjustment disorder

Question 33

List common symptoms of anxiety disorders

Answer 33

Psychological - anticipatory fear of impending doom, worrying thoughts, exaggerated startle response, restlessness, poor concentration/attention, irritability, depersonalisation/derealisation Cardiovascular - palpitations, chest pain Respiratory - hyperventilation, chest tightness GI - abdo pain (butterflies), loose stools, nausea, vomiting, dysphagia, dry mouth Genitourinary - increased micturition, failure of erection, menstrual discomfort Neuromuscular - tremor, myalgia, headache, paraesthesia, tinnitus

Question 34

Describe how you would assess a patient's cognitive function

Answer 34

GOAL CRAM(P): General - consciousness, alertness Orientation - awareness of surroundings (time, place, personal identity) Attention & Concentration - focus, distractible Language - fluency, naming, comprehension, repetition Calculation - simple arithmetics Right hemisphere function - hand-eye coordination (clock drawing) Abstraction - proverb interpretation Memory - short term (10 mins), long term (1 week) --> MMSE, AMTS, CAMCog

Question 35

What is the purpose of the mental health act (MHA)?

Answer 35

Allows detention and treatment of patients in the least restrictive way to minimise the undesirable effects of mental illness Can only be used to treat mental illness

Question 36

Define sections 2, 3, 5(2), 5(4), 17, 117, 135, 136

Answer 36

2 - detain for up to 28 days for a period of assessment and/or treatment, seen by two doctors (at least one S12 approved) and 1 AMHP, can be carried out in community/hospital *NOT prison, right to appeal within first 14 days, tribunal in 7 days 3 - detain for up to 6 months for treatment of a known mental illness, right to appeal to tribunal and hospital managers 5(2) - doctor can hold an inpatient for up to 72hrs, patient cannot appeal, can only sedate, no treatment 5(4) - MH nurse can detain inpatient for up to 6hrs for medical assessment 17 - whilst detained in hospital a patient may have leave 117 - entitled to care from the state 135 - police power to remove someone from their home to a place of safety 136 - police power to remove someone from a public place for up to 72h for an assessment by an AMHP and 1 doctor

Question 37

What is capacity?

Answer 37

Ability to make a decision

Question 38

What is the purpose of the mental capacity act (MCA)?

Answer 38

A right to make unwise decisions Treatment should be least restrictive of a person's freedom of action and their rights and must be done in their best interests Assessment is time and decision specific If in doubt, second opinion, ultimate referral is to the high courts

Question 39

How is capacity assessed?

Answer 39

1. The person has a disorder of brain function 2. Does the person understand the information needed to make a decision 3. Can they retain the information given to them 4. Can they weigh up pros and cons of the information given to them 5. Can they communicate their decisions by any means - -> if a person cannot do any of 2-5, they do not have capacity

Question 40

What are DOLS?

Answer 40

Deprivation of liberty safeguards - for patients in hospital or care homes who lack capacity and are unlikely to recover capacity e.g. dementia

Question 41

List examples and ADRs of SSRIs

Answer 41

Fluoxetine (long half life, safe in children), sertraline (most cardioprotective), paroxetine (short half life), citalopram (long QTc/toursades) ADRs - suicidal ideation, nausea, loss of appetite, dyspepsia, bloating, diarrhoea, constipation, hyponatraemia, headache, insomnia, fatigue, sweating, sexual dysfunction, increased risk of bleeding (aspirin, NSAIDs)

Question 42

List examples and ADRs of SNRIs

Answer 42

Venlafaxine, duloxetine | ADRs - sleep disturbance, nausea, dry mouth, headache, dizziness, sexual dysfunction, hypotension, tachycardia

Question 43

List examples and ADRs of TCAs

Answer 43

Amitriptiline, imipramine, clomipramine (OCD) ADRs - dry mouth, blurred vision, urinary retention, constipation, worsening glaucoma, drowsiness, weight gain, prolonged QTc, fine tremor, *dangerous in overdoes (sudden cardiac death)

Question 44

Describe serotonin syndrome

Answer 44

Too much serotonin from antidepressants, tramadol, amitriptyline - restlessness, excess sweating, tremor, shivering, myoclonus, confusion, convulsions, death

Question 45

List examples and ADRs of typical antipsychotics

Answer 45

Haloperidol - sedative, EPSE Chlorpromazine - sedative, anticholinergic side effects, EPSE Sulpiride - less EPSE ADRs - parkinsonism, akathisia, dystonia (*give procyclidine), tardive dyskinesia

Question 46

List examples and ADRs of atypical antipsychotics

Answer 46

Olanzapine, quetiapine, amisulpiride, risperidone, clozapine ADRs - hyperprolactinaemia, amenorrhoea, galactorrhea, gynaecomastia, sexual dysfunction, osteoporosis, sedation, postural hypotension, prolonged QTc interval (sudden cardiac death)

Question 47

List monitoring required for antipsychotic therapy

Answer 47

Metabolic - weight, BMI, waist circumference, BP, glucose, lipids ECG *clozapine - FBC, clozapine levels

Question 48

Describe neuroleptic malignant syndrome (NMS)

Answer 48

Rare idiosyncratic response to antipsychotics Medical emergency EPSE - rigidity, akinetic mutism, stupor Autonomic dysfunction - hyperpyrexia, tachycardia, unstable blood pressure, excessive sweating, salivation, urinary incontinence CK increased Complications - renal failure, pneumonia, thromboembolism

Question 49

List examples and ADRs of drugs used in dementia

Answer 49

Mild/moderate - acetylcholinesterase inhibitors - donepezil, rivastigmine, galantamine ADRs - nausea, vomiting, anorexia, diarrhoea, fatigue, insomnia, headaches, muscle cramps, bradycardia, syncope *regular HR monitoring Moderate/severe - NMDA antagonist - memantine ADRs - contipation, dyspnoea, headache, dizziness, drowsiness

Question 50

List different types of dementia

Answer 50

Alzheimer's disease Vascular Lewy body CJD, AIDS

Question 51

Define the term 'delirium'

Answer 51

Acute confusional state, decreased consciousness/cognitive function Can be hypoactive/hyperactive/mixed agitation

Question 52

List risk factors for delirium

Answer 52

``` Age (>65) Pre existing dementia/cognitive impairment Comorbidities AKI/CKD Male Current hip fracture Sensory impairment ```

Question 53

List causes of delirium

Answer 53

``` Hypoxia Infection Drugs (steroids, benzodiazepines) Dehydration Pain Constipation/urinary retention ```

Question 54

List indications for ECT

Answer 54

Severe depressive illness Uncontrolled mania Catatonia

Question 55

List side effects of ECT

Answer 55

From anaesthesia - MI, arrhythmias, aspiration pneumonia, prolonged apnoea, nausea, adrenocortical suppression (with etomidate), malignant hyperthermia, muscle aches, death From ECT - confusion, headache, status epileptics, stroke, arrhythmias, bleeding from ulcers, PE, raised intraocular pressures, broken teeth

Question 56

List contraindications of ECT

Answer 56

Raised ICP, cerebral aneurysm, recent cerebrovascular event MI within 3 months, unstable angina, DVT, potassium imbalance, uncontrolled HR/BP Acute respiratory infection, other respiratory conditions Recent food/fluids/chewing gum/cigarettes/sweets Cochlear implants, phaeochromocytoma, unstable fractures, bariatric patients *consider with pregnancy, controlled epilepsy, pacemakers

Question 57

What is an intellectual disability?

Answer 57

A significant developmental intellectual impairment Concurrent deficits in social functioning or adaptive behaviours The condition is manifest before the age of 18 IQ = 0-70

Question 58

Define the term 'phobia' and list different types

Answer 58

An intense, irrational fear of an object, situation, place or person that is recognised as excessive or unreasonable e.g. agoraphobia, social phobia, specific phobia

Question 59

Describe panic disorder

Answer 59

Recurrent panic attacks not consistently associated with a specific situation or object

Question 60

Describe clinical features and management of PTSD

Answer 60

An intense, prolonged, delayed reaction following an exceptionally traumatic event (<6 months) 1. Reliving - flashbacks, vivid memories, nightmares 2. Avoidance - avoiding reminders, ruminating, inability to recall aspects of trauma 3. Hyperarousal - irritability, loss of concentration, exaggerated startle response 4. Emotional numbing - negative thoughts, detachment Mx - trauma focused psychological intervention (CBT/EMDR), zopiclone, paroxetine/mirtazapine/amitriptyline/phenelzine

Question 61

Describe clinical features and management of OCD

Answer 61

Obsessional thoughts +/- compulsive acts for most days for >2 weeks. Obessions - unwanted intrusive thoughts, images or urges, egodystonic Compulsions - repetitive, stereotyped behaviours/mental acts, overt/covert Obsession --> anxiety --> compulsion --> relief FORD CAr - failure to resist, originate from patient, repetitive, distressing, carrying out thought is not pleasurable Mx - CBT (exposure and response prevention), SSRIs, clomipramine, antipsychotic

Question 62

Describe clinical features of anorexia nervosa

Answer 62

FEED >3 months Fear of weight gain, Endocrine disturbance (amenorrhoea, impotence), Emaciated (BMI <17.5), Deliberate weight loss, Distorted body image Amenorrhoea, No friends (social isolation), Obvious weight loss, Restriction of food intake, Emaciated, Xerostomia, Irrational fear of fatness, Abnormal hair growth (lanugo)

Question 63

Describe clinical features of bulimia nervosa

Answer 63

Bulimia Patients Fear Obesity Behaviours to prevent weight gain (vomit, starvation, drugs, excess exercise), Preoccupation with eating (compulsion --> binging +/- regret/shame), Fear of fatness, Overeating (>2 episodes per week for 3 months) Binge eating, Use of drugs, Low potassium, Irregular periods, Mood disturbance, Irrational fear of fatness, Alternating periods of starvation

Question 64

List symptoms and management of alcohol dependence

Answer 64

Subjective awareness of compulsion, relief drinking, withdrawal symptoms, drink seeking behaviour, reinstatement, increased tolerance, narrowing of drinking repertoire Mx - high dose benzodiazepines (chlordiazepoxide), thiamine

Question 65

List symptoms and management of alcohol withdrawal

Answer 65

6-12h - malaise, tremor, insomnia 36h - seizures 72h - delirium tremens Mx - disulfiram, acamprosate, naltrexone, motivational interviewing, CBT

Question 66

Describe features of delirium tremens

Answer 66

``` Cognitive impairment Vivid perceptual abnormalities Paranoid delusions Marked tremor Autonomic arousal ```

Question 67

Describe the three different types of personality disorders

Answer 67

``` Cluster A (weird) - paranoid, schizoid Cluster B (wild) - emotionally unstable, dissocial, histrionic Cluster C (worriers) - dependent, anxious, anankastic ```

Question 68

What are the antidotes for overdose of paracetamol, opiates, benzodiazepines, warfarin, beta blockers, TCAs and organophosphates

Answer 68

``` *activated charcoal within 1hr Paracetamol - NAC Opiates - naloxone Benzodiazepines - flumazenil Warfarin - vitamin K B-blockers - glucagon TCAs - sodium bicarbonate Organophosphates - atropine ```

Question 69

List clinical features of delirium

Answer 69

DELIRIUM Disordered thinking - slowed, irrational, incoherent thoughts Euphoric, fearful, depressed, angry Language impaired - rambling speech, repetitive Illusions, delusions, hallucinations Reversal of sleep/wake pattern Inattention - inability to focus, clouding of consciousness Unaware/disoriented - disorientated to time, place or person Memory deficits

Question 70

Define autism and describe the clinical features

Answer 70

Pervasive developmental disorder characterised by a triad of impairment in social interaction, impairment in communication and restricted, stereotyped interests and behaviours, onset before the age of 3 Asocial, Behaviour restricted, Communication impaired

Question 71

List clinical features and management of hyperkinetic disorder (ADHD)

Answer 71

Inattention Hyperactivity Impulsivity Age of onset 3-7, duration of at least 6 months Mx - psychoeducation, CBT, methylphenidate (Ritalin) for school age, atomoxetine, dexamfetamine

Question 72

List the triad of symptoms for intellectual disability

Answer 72

Low intellectual performance (IQ <70) Onset at birth/during early childhood Wide range of functional impairment (social handicap, lack of ADLs)

Question 73

Define criteria for severity of LD

Answer 73

``` Mild = 50-70 (mental age 9-12) Moderate = 35-49 (mental age 6-9) Severe = 20-34 (mental age 3-6) Profound = <20 (mental age <3 years) ```

Question 74

Describe specific congenital conditions associated with LD

Answer 74

Down's syndrome - genetic disorder (trisomy 21), LD, dysmorphic facial features, multiple structural abnormalities Fragile X syndrome - sex linked Prader-Willi - deletion on chromosome 15, obesity, hypogonadism, behavioural problems (compulsive eating, disruptive behaviour) Cri du chat - partial deletion of chromosome 5, high pitched cry (like a cat), low birth weight, feeding difficulties DiGeorges - CATCH22, psychosis