PSYCH

Question 1

PSYCH HX + AX

What are the components of a psychiatric history?

Answer 1

PC, HPC, Past psych Hx, PMH, Medications (regular, OTC, allergies), FHx (mental + physical), personal Hx (timeline from birth–adulthood, education, employment, relationships, psychosexual), SH, Forensic Hx (law involvement either perpetrator/victim)

Question 2

PSYCH HX + AX

What are the components of a mental state examination?

Answer 2

ASEPTIC –

• Appearance + behaviour
• Speech
• Emotions (mood + affect – objectively + subjectively).
• Perceptions (hallucinations, etc).
• Thoughts (alientation, disordered)
• Insight
• Cognition

Question 3

PSYCH HX + AX

What should you do after a psychiatric assesssment?

Answer 3

Risk assessment at the end, consider how likely the event is, when it might occur + how bad the consequences will be (e.g. self-harm, harm to others, self-neglect)

Question 4

PSYCH HX + AX

What are the 5Ps in formulation and what do they mean?

Answer 4

• Presenting problem (what the pt presents with)
• Predisposing factors (what increases a pts risk of developing a mental illness)
• Precipitating factors (potential trigger to the onset of current problem)
• Perpetuating factors (what maintains the problem once it’s been established)
• Protective factors (strengths that reduce the severity of problems)

Question 5

PSYCH HX + AX

Give examples of what might come under the 5Ps (excluding presenting).

Answer 5

• Predisposing = genetics, life events, temperament
• Precipitating = abuse, drug misuse, loss of family
• Perpetuating = drug abuse, lack of social support, financial difficulties
• Protective = family support, children, marriage

Question 6

PHENOMENOLOGY

What is a mental disorder?

Answer 6

Any disorder or disability of the mind, excluding substance abuse

Question 7

PHENOMENOLOGY

Define psychosis

Answer 7

Severe mental disturbance characterised by a loss of contact with external reality (schizophrenia)

Question 8

PHENOMENOLOGY

Define neurosis

Answer 8

Relatively mild mental illness in which there is no loss of connection with reality (depression, anxiety)

Question 9

PHENOMENOLOGY

Define phenomenology

Answer 9

The study of signs + symptoms describing abnormal states of mind

Question 10

PHENOMENOLOGY

Define illusion

Answer 10

The false perception of a real external stimulus

Question 11

PHENOMENOLOGY

Define hallucination

Answer 11

An internal perception occurring without a corresponding external stimulus. The person experiences it as they would a real perception.

Question 12

PHENOMENOLOGY
In terms of hallucinations, what are...
i) the main senses?
ii) somatic?
iii) hypnogogic/hypnopompic
iv) autoscopic?
v) reflex?
vi) extracampine?

Answer 12

i) Auditory, visual, olfactory, gustatory, tactile
ii) within the person
iii) when going to sleep/when waking up
iv) seeing oneself
v) production of a hallucination in one sensory modality by a stimulus in a different modality
vi) hallucinations which are experienced outside the normal sensory field (seeing something behind them)

Question 13

PHENOMENOLOGY
What is Charles-Bonnet Syndrome?
What conditions may it be seen in?

Answer 13

• Complex visual hallucinations in a patient with partial/severe blindness (macular degeneration, diabetic retinopathy).
• Pts understand that the hallucinations are not real + so often have insight

Question 14

PHENOMENOLOGY

Define pseudo-hallucination

Answer 14

A perception in the absence of an external stimulus, experienced in one’s subjective inner space of the mind rather than external sensory objects – often have insight

Question 15

PHENOMENOLOGY

Define over-valued idea

Answer 15

A false or exaggerated belief held with conviction but not with delusional intensity. This idea although perhaps reasonable, dominates their life + causes distress

Question 16

PHENOMENOLOGY

Define delusion

Answer 16

A fixed, false, unshakable belief which is out of keeping with the patient’s educational, cultural + social norms. It’s held with extraordinary conviction + certainty (even despite contradictory evidence)

Question 17

PHENOMENOLOGY
In terms of delusions, what are...
i) persecutory?
ii) grandiose?
iii) nihilistic?
iv) guilt?

Answer 17

i) the idea that someone/something is trying to inflict harm on them (being followed, poisoned, drugged, spied)
ii) idea that the person themselves are powerful/crucially important beyond truth
iii) theme involves intense feelings of emptiness, sense of everything being unreal
iv) ungrounded feeling of remorse or guilt for situations, can be due to a minor error or unrelated to them (may feel responsible for world disasters)

Question 18

PHENOMENOLOGY
In terms of delusions, what are...
i) poverty?
ii) reference?
iii) inadequacy?
iv) religious?

Answer 18

i) pt strongly believes they are financially incapacitated
ii) false belief that insignificant remarks/objects in one’s environment have personal meaning/significance (newspaper has hidden text related to them)
iii) false belief of inability to accomplish tasks + meet expectations
iv) false belief related to religious themes/subject matter.

Question 19

PHENOMENOLOGY

What are the 3 delusional misidentification syndromes?

Answer 19

• Capgras = idea someone has been replaced by an imposter.
• Fregoli = idea various people are the same person
• Intermetamorphosis = one significant relative is replaced by another (father is son).

Question 20

PHENOMENOLOGY

Define delusional perception and give an example

Answer 20

A primary delusion of two components – where a normal perception is subject to delusional interpretation
E.g. – traffic light changed red so that means I am the son of God

Question 21

PHENOMENOLOGY

Define thought alienation. What are the 3 components of this?

Answer 21

Sx of psychosis in which patients feel that their own thoughts are in some way no longer in their control
Insertion = delusional belief thoughts placed into pts head from external
Withdrawal = delusional belief thoughts removed from head from external
Broadcast = delusional belief thoughts are accessible directly to others without expressing them

Question 22

PHENOMENOLOGY

Define concrete thinking

Answer 22

Loss of ability to understand abstract concepts + metaphorical ideas leading to a strictly literal form of speech

Question 23

PHENOMENOLOGY

Define thought disorder and formal thought disorder

Answer 23

TD = disorganised thinking as evidenced by disorganised speech/beliefs
FTD = pts expressive language (form) indicates that the links between consecutive thoughts aren't meaningful (disorganised speech evident from disorganised thinking)

Question 24

PHENOMENOLOGY
In terms of thought disorders, what is...
i) flight of ideas?
ii) pressure of speech?
iii) poverty of speech/alogia?

Answer 24

i) Abrupt leaps between topics as a result of thoughts presenting more rapidly than can be articulated. Each thought = more associations. ?Discernible links between successive ideas. Presents as pressure of speech.
ii) Rapid speech w/out pauses which is difficult to interrupt as a consequence of pressure of thought. Connection between sequential ideas may become increasingly hard to follow
iii) speech lacking in amount or content

Question 25

``` PHENOMENOLOGY In terms of thought disorders, what is... i) tangentiality? ii) thought block? iii) clang association (± alliteration) iv) circumstantiality? ```

Answer 25

i) wandering from the topic + never returning to it or providing info asked ii) sudden + unintentional break in chain of thought, may be explained as due to thought withdrawal iii) severe form of flight of ideas whereby ideas are related only by similar/rhyming sounds rather than meaning iv) irrelevant wandering in conversation (going around the point).

Question 26

``` PHENOMENOLOGY In terms of thought disorders, what is... i) loosening of association? ii) perseveration? iii) echolalia? ```

Answer 26

i) aka derailment/Knight's move thinking = a lack of logical association between sequential thoughts, often leading to incoherent speech, impossible to follow train of thought. ii) persistent repetition of words/ideas that were initially appropriate but continue past this point + when the topic changes iii) repeating other's words/phrases

Question 27

``` PHENOMENOLOGY In terms of thought disorders, what is... i) neologisms? ii) incoherence/word salad? iii) poverty of thought? ```

Answer 27

i) making up new words ii) confused or unintelligible mixture of seemingly random words and phrases iii) subjective experience of being devoid of thoughts + having a feeling of emptiness, often leads to poverty of speech

Question 28

PHENOMENOLOGY | Define confabulation + state what conditions you would find this in

Answer 28

Giving a false account to fill in a gap in memory. | Korsakoff's psychosis + dementia

Question 29

PHENOMENOLOGY | Define passivity phenomena + somatic passivity

Answer 29

- Delusion that one is a passive recipient of actions from an external agency against their will - The same but sensations are controlled by an external agency

Question 30

PHENOMENOLOGY | Define psychomotor retardation + state what conditions you would find this in

Answer 30

- Slowing of thoughts + movements with decreased spontaneous movement, often due to subjective sense of actions being laborious - Parkinson's, depression

Question 31

PHENOMENOLOGY | Define incongruity of affect

Answer 31

Emotional responses that differs markedly from the expected emotion for the situation/subject like laughing whilst discussing trauma

Question 32

PHENOMENOLOGY | Define blunting of affect

Answer 32

A limited range of normal emotional responsiveness

Question 33

PHENOMENOLOGY | Define flattening of affect

Answer 33

Diminution of the normal range of emotions

Question 34

PHENOMENOLOGY | Define depersonalisation + derealisation

Answer 34

- Where a person doesn't believe themselves to be real | - Where a person doesn't believe the world/people around them to be real

Question 35

PHENOMENOLOGY | Define obsession

Answer 35

Recurrent thoughts/feelings/images/impulses which are intrusive + persistent despite efforts to resist. They are recognised as the person's own thoughts (insight preserved)

Question 36

PHENOMENOLOGY | Define compulsion

Answer 36

Repetitive, purposeful behaviour performed in response to an obsession despite the recognition of its senselessness + anxiety if not performed

Question 37

PHENOMENOLOGY | Define thought echo

Answer 37

Experience of an auditory hallucination in which the content is the individual's current thoughts spoken aloud as if next to them

Question 38

PHENOMENOLOGY | Define catatonia/stupor

Answer 38

Abnormality of movement + behaviour arising from a disturbed mental state, typically severe depression or schizophrenia

Question 39

PHENOMENOLOGY | Define anhedonia

Answer 39

Inability to feel pleasure in normally pleasurable activities

Question 40

PHENOMENOLOGY | Define belle indifference

Answer 40

A surprising lack of concern for, or denial of, apparently severe functional disability (not specific to psych)

Question 41

PHENOMENOLOGY | Define dissociation

Answer 41

When a person feels disconnected from themselves or their surroundings (including emotions)

Question 42

PHENOMENOLOGY | Define conversion

Answer 42

Development of features suggestive of physical illness but which are attributed to psych illness or emotional disturbance rather than organic pathology

Question 43

PHENOMENOLOGY | Define sterotypy

Answer 43

Repetitive + bizarre act which is not goal-directed. Action may have delusional significance to the pt

Question 44

PHENOMENOLOGY | Define mannerism

Answer 44

Abnormal + occasionally bizarre performance of voluntary, goal-directed activity

Question 45

PHENOMENOLOGY | Define projection + give an example

Answer 45

What is emotionally unacceptable in the self is unconsciously rejected + projected to others (e.g. mother projects anxiety on children claiming they're anxious)

Question 46

MENTAL HEALTH ACT 1983 | What does the main part of the MHA allow for?

Answer 46

- 'Sectioning' = compulsory admission to hospital for those that are mentally ill. - Drs should persuade pts to come in voluntarily if they have capacity, but not always possible (esp if they lack insight)

Question 47

MENTAL HEALTH ACT 1983 | What are the main principles of the MHA?

Answer 47

- Respect for pts wishes + feelings (past + present) - Minimise restrictions on liberty - Public safety - Pts well-being + safety - Effectiveness of treatment

Question 48

MENTAL HEALTH ACT 1983 | What is does an individual have to show to be sectioned?

Answer 48

- Evidence of MH disorder - Evidence they're serious risk to self, safety or others - Evidence there is good reason to warrant attention in hospital - Appropriate treatment must be available for a S3

Question 49

MENTAL HEALTH ACT 1983 What is a... i) section 12 approved dr? ii) approved mental health professional?

Answer 49

i) ≥ST4 Dr who has done extra training in MH to get S12 approved to section pts ii) AMHPs are often social workers who have done extra training in MH

Question 50

MENTAL HEALTH ACT 1983 | Who can remove sections?

Answer 50

- Consultant psychiatrist - MH review tribunal (MHT) if pt disagrees w/ section - Nearest relative can make an order to discharge pt from hospital with 72h written notice

Question 51

MENTAL HEALTH ACT 1983 | If a relative requests a section removal how can the clinician respond if they disagree?

Answer 51

- Issue a barring report within 72h which stops discharge up to 6m from then - Can still apply to MHT if disagrees

Question 52

MENTAL HEALTH ACT 1983 | What is the purpose, duration, location + professionals involved for a Section 2?

Answer 52

P – admission for assessment, treatment can be given w/out consent D – 28d, cannot be renewed, can be converted to S3 L – anywhere in community (airports, jail, A+E, etc) Prof – 2 Drs (1x S12), 1 AMHP, or nearest relative

Question 53

MENTAL HEALTH ACT 1983 What is the purpose, duration, location + professionals involved for a Section 3? Who is involved if a pt is medicated without consent?

Answer 53

P – admission for treatment D – 6m, can be renewed L – anywhere in community Prof – 2 Drs (1x S12), 1 AMHP, nearest relative Second opinion appointed doctor (SOAD) – after 3m SOAD reviews if medication w/out consent is necessary

Question 54

MENTAL HEALTH ACT 1983 | What is the purpose, duration, location + professionals involved, evidence needed for a Section 4?

Answer 54

``` P – emergency order D – 72h L – anywhere in community P – 1 S12 Dr, 1 AMHP, nearest relative E – same as S2 but only in an urgent necessity when waiting for a second dr (for a S2) would lead to undesirable delay/outcome ```

Question 55

MENTAL HEALTH ACT 1983 Where can you apply a S5? What can the team not do?

Answer 55

- Voluntary pt in hospital that wants to leave (NOT A+E as not admitted) - Coercively treat the pt

Question 56

MENTAL HEALTH ACT 1983 | What is the purpose, duration + professionals involved for a Section 5(2)?

Answer 56

P – Drs holding power, allows for S2/3 assessment D – 72h Prof – 1 Dr (usually in charge of their care or nominated deputy

Question 57

MENTAL HEALTH ACT 1983 | What is the purpose, duration + professionals involved for a Section 5(4)?

Answer 57

P – nurses holding power until Dr attends to assess D – 6h Prof – 1 registered nurse

Question 58

MENTAL HEALTH ACT 1983 | What are the 2 police sections and their differences? What is the duration and purpose of these?

Answer 58

- S135 – needs magistrates court order to access pts home + remove them - S136 –person suspected of having mental disorder in a public place D – 24h (extend to 36h if intoxicated but should be seen sooner) P – taken to place of safety (local psych unit, police cell) for further assessment

Question 59

ANTI-PSYCHOTICS What are the two types of anti-psychotics? Give examples.

Answer 59

- Typical/1st gen = haloperidol, zuclopenthixol (decanoate = depot), chlorpromazine - Atypical/2nd gen = olanzapine, risperidone (depot), clozapine, aripiprazole (depot), quetiapine

Question 60

ANTI-PSYCHOTICS What is the mechanism of action of typical anti-psychotics? What is the issues?

Answer 60

- Antagonism of Dopamine D2 receptors - Reduced release of dopamine from dopaminergic neurones + so reduced electrical activity in dopaminergic pathways - Not selective so can bind to other dopaminergic pathways causing generalised dopamine receptor blockade

Question 61

ANTI-PSYCHOTICS What pathway do typical anti-psychotics work on to... i) have anti-psychotic effect? ii) cause side effects?

Answer 61

i) Mesolimbic pathway (reduces +ve Sx) | ii) Nigrostriatal (Parkinsonism), tuberoinfundibular (prolactin)

Question 62

ANTI-PSYCHOTICS What is the mechanism of action of atypical anti-psychotics? What is the benefit of atypical anti-psychotics? What anti-psychotic has a reduced SE profile and why?

Answer 62

- Antagonists at dopamine D2 receptors but more selective in dopamine blockade + so block serotonin 5-HT2a - More useful in treating -ve Sx of schizophrenia + less likely to cause EPSEs - Aripiprazole as partial dopamine agonist

Question 63

ANTI-PSYCHOTICS What is the most crucial adverse effect of clozapine? What is the most common adverse effect? What other adverse effects may it have?

Answer 63

- Severe life-threatening agranulocytosis - Constipation (big issue in elderly) - Reduced seizure threshold, hypersalivation (Rx hyoscine hydrobromide)

Question 64

ANTI-PSYCHOTICS | What are the 5 broad categories of SEs caused by anti-psychotics?

Answer 64

- Extra-pyramidal side effects (EPSEs) - Hyperprolactinaemia - Metabolic - Anticholinergic - Neurological

Question 65

ANTI-PSYCHOTICS | What are the EPSEs?

Answer 65

- Acute dystonic reaction - Parkinsonism - Akathisia - Tardive dyskinesia

Question 66

ANTI-PSYCHOTICS How does Parkinsonism present? How is it managed?

Answer 66

- Bradykinesia, rigid, resting pill-rolling tremor + postural instability - Reduce dose or switch to atypical anti-psychotic

Question 67

ANTI-PSYCHOTICS How does akathisia present? What is a risk of this? How is it managed?

Answer 67

- Motor restlessness, typically lower legs (can't sit still) - Massive RF for suicide in young men with schizophrenia - Reduce dose, introduce beta-blocker (propranolol)

Question 68

ANTI-PSYCHOTICS How does tardive dyskinesia present? When does it present? How is it managed?

Answer 68

- Purposeless involuntary movements (chewing, lip smacking, blinking, tongue protrusion) - After months-years of Tx - Prevention crucial, switch to atypical anti-psychotic, tetrabenazine used if mod–severe but unlikely to completely resolve

Question 69

ANTI-PSYCHOTICS | What are the SEs from hyperprolactinaemia?

Answer 69

- Sexual dysfunction (+ anti-adrenergic) - Osteoporosis risk - Amenorrhoea - Galactorrhoea, gynaecomastia + hypogonadism in men

Question 70

ANTI-PSYCHOTICS | What are the metabolic SEs?

Answer 70

- Weight gain (esp. olanzapine) - Hyperlipidaemia, risk of stroke + VTE in elderly - T2DM risk + metabolic syndrome

Question 71

ANTI-PSYCHOTICS | What are the anticholinergic SEs?

Answer 71

``` Can't see, pee, spit, shit – - Blurred vision - Urinary retention - Dry mouth - Constipation + tachycardia ```

Question 72

ANTI-PSYCHOTICS | What are the neurological SEs?

Answer 72

- Seizures - Postural hypotension (anti-adrenergic) - Sedation - Headaches

Question 73

ANTI-PSYCHOTICS | What baseline investigations are done for people starting on anti-psychotics?

Answer 73

- FBC, U+Es, LFTs, lipids, BMI, fasting glucose, prolactin, BP, ECG (QTc prolongation) + smoking status (can reduce effects by enhancing metabolism so issues if suddenly stop)

Question 74

ANTI-PSYCHOTICS | What regular investigations are done for people on anti-psychotics?

Answer 74

- Lipids + BMI at 3m - Fasting glucose + prolactin at 6m - Frequent BP during dose titration - FBC, U+Es, LFTs, lipids, BMI, fasting glucose, prolactin + CV risk yearly

Question 75

ANTI-PSYCHOTICS What specific monitoring is required for clozapine? What happens if they miss a dose?

Answer 75

- FBC at baseline + weekly for 18w, fortnightly until 1y + monthly after - If not taken for 48h needs retitrating

Question 76

ANTI-DEPRESSANTS What monitoring is needed when starting someone on an anti-depressant? When can an anti-depressant be stopped?

Answer 76

- 2 weekly to ensure dose working + patient stable, may take up to 6w to start working, weekly if <30y as increased suicide risk - Carried on 6m after Sx resolved even if patient feels better

Question 77

ANTI-DEPRESSANTS How should anti-depressants be stopped? Why?

Answer 77

- Gradual dose reduction over 4w - Sudden cessation can cause severe withdrawal effects (mostly GI) – pain, diarrhoea, vomiting, restlessness, sweating + mood change

Question 78

ANTI-DEPRESSANTS What is the mechanism of action of SSRIs? Give some examples

Answer 78

- Prevents reuptake + subsequent degradation of serotonin from synaptic cleft by inhibiting its reuptake transporter on the post-synaptic membrane - Prolonged serotonin in synaptic cleft = prolonged neuronal activity - Citalopram, sertraline, fluoxetine

Question 79

ANTI-DEPRESSANTS | What are the side effects of SSRIs?

Answer 79

- GI Sx most common (N+V, hyponatraemia, abdo pain, bowel issues, increased bleed risk) - Sedation + sexual impotence - Citalopram + QTc prolongation (dose-dependent)

Question 80

ANTI-DEPRESSANTS | What are some cautions for SSRIs?

Answer 80

- Suicidal thoughts may increase initially, esp. younger patients - May precipitate manic phase in bipolar - 1st trimester risk of CHD, 3rd trimester risk of persistent pulmonary HTN

Question 81

ANTI-DEPRESSANTS | What are some interactions for SSRIs?

Answer 81

- NSAIDs + aspirin = increased risk of bleeding, co-prescribe PPI - Can lower seizure threshold - Do not start until 2w after stopping MAOI + vice-versa as increased risk of serotonin syndrome

Question 82

ANTI-DEPRESSANTS What is the mechanism of action of SNRIs? Give some examples

Answer 82

- Prevents reuptake + subsequent degradation of serotonin AND noradrenaline from synaptic cleft by inhibiting reuptake transporters on post-synaptic membrane - Venlafaxine, duloxetine

Question 83

ANTI-DEPRESSANTS What are some side effects of SNRIs? What are some interactions of SNRIs?

Answer 83

- GI (N+V, constipation), central/peripheral effects (SIADH, rhabdomyolysis) - NSAIDs + warfarin (increased risk of bleeding), lower seizure threshold

Question 84

ANTI-DEPRESSANTS What is the mechanism of action of monoamine oxidase inhibitors (MAOI)? Give some examples.

Answer 84

- Inhibits monoamine oxidase enzyme which reduces breakdown of adrenaline, noradrenaline + serotonin so increases level - Selegiline is selective MAO-B inhibitor which also increases dopamine - Isocarboxazid, phenelzine

Question 85

ANTI-DEPRESSANTS | What are some side effects from MAOIs?

Answer 85

- Sexual dysfunction, weight gain + postural hypotension

Question 86

ANTI-DEPRESSANTS | What are some cautions with MAOIs?

Answer 86

- Increased risk of serotonin syndrome if used with other serotonergic drugs - Hypertensive crisis with ingestion of foods containing tyramine (aged cheeses, smoked/cured meats, pickled herring, Bovril, Marmite)

Question 87

ANTI-DEPRESSANTS What is the mechanism of action of tricyclic antidepressants (TCAs)? Give some examples

Answer 87

- Prevents reuptake + subsequent degradation of serotonin + noradrenaline from synaptic cleft by inhibiting reuptake transporters on post-synaptic neuronal membrane - Amitriptyline, dosulepin, imipramine

Question 88

ANTI-DEPRESSANTS | What are the side effects of TCAs?

Answer 88

- Anticholinergic (can't see, pee, spit, shit)

Question 89

ANTI-DEPRESSANTS | What cautions are there for TCAs?

Answer 89

- Caution in CVD, avoid following MI | - Cardiotoxic in overdose so caution in suicidal patients (QTc prolongation)

Question 90

ANTI-DEPRESSANTS In terms of TCA overdose... i) mild-moderate Sx? ii) severe Sx? iii) ECG signs? iv) management?

Answer 90

i) Dilated pupils, dry mouth, urinary retention, increased tendon reflexes + extensor plantars ii) Fits, coma, cardiac arrhythmias > arrest iii) Sinus tachy, wide QRS, prolonged QT interval iv) Sodium bicarbonate

Question 91

ANTI-DEPRESSANTS What is the mechanism of action of mirtazapine? What are some side effects?

Answer 91

- Blocks alpha-2 adrenergic receptors > increased release of neurotransmitters - Increased appetite + weight gain + sedation are big ones, also increased triglyceride levels

Question 92

MOOD STABILISERS What are some examples of mood stabilisers? What is the mechanism of action? Important drug information?

Answer 92

- Lithium (first line), AEDs such as valproate, carbamazepine, lamotrigine - Lithium inhibits cAMP production which inhibits monoamines - Narrow therapeutic range 0.4–1.0mmol/L

Question 93

MOOD STABILISERS | What are the side effects of lithium?

Answer 93

LITHIUM – - Leukocytosis - Insipidus (diabetes, nephrogenic) - Tremors (fine if SE, coarse if toxicity) - Hydration (easily dehydrates, renally cleared) - Increased GI motility (N+V, diarrhoea) - Underactive thyroid - Mums beware (Ebstein's anomaly) Can cause weight gain + derm (acne, psoriasis) long-term too

Question 94

MOOD STABILISERS | What drugs does lithium interact with?

Answer 94

- NSAIDs, ACEi, ARBs + diuretics may increase lithium levels | - Diuretics = dehydration, NSAIDs = renal damage

Question 95

MOOD STABILISERS | What baseline measurements are taken for lithium?

Answer 95

- FBC, U+Es, eGFR, TFTs, BMI + ECG

Question 96

MOOD STABILISERS | What regular monitoring is done for lithium?

Answer 96

- Weekly serum lithium after initiation + dose changes until stable then every 3m for a year, then every 6m (sample taken 12h after dose) - 6m = TFTs, U+Es, eGFR - Annual = BMI

Question 97

MOOD STABILISERS | What might carbamazepine and lamotrigine interfere with?

Answer 97

- Contraceptive pill

Question 98

BDZs | What is the mechanism of action of anxiolytics/benzodiazepines (BDZs)?

Answer 98

- Enhance effect of inhibitory GABA by increasing frequency of Cl- channels + flow of Cl- ions causing hyperpolarisation of membrane + so prevention of further excitation

Question 99

BDZs Give some examples of BDZs? What are they suitable for?

Answer 99

- Diazepam (longer duration), lorazepam + temazepam (shorter duration), clonazepam, chlordiazepoxide - Short-term Tx (<4w), sedation + anxiolytic

Question 100

BDZs | What are some adverse effects of BDZs?

Answer 100

- Amnesia, ataxia (esp elderly = falls risk), confusion, drowsiness, dizziness next day (hangover effect), tolerance - Monitor for resp depression (caution in resp disease)

Question 101

BDZs What drugs can BDZs interact with? How would you manage an overdose? Risk of this?

Answer 101

- Anti-hypertensives as enhanced hypotensive effect | - IV flumazenil (danger of inducing status epilepticus or death though)

Question 102

HYPNOTICS What is the mechanism of action of hypnotics? Give some examples What are the adverse effects?

Answer 102

- GABA agonists on alpha2-subunit of GABA(A)-BDZ receptor/Cl- channel complex - Zopiclone, zolpidem, BDZs used for hypnotic effect (lorazepam, temazepam) - Same as BDZs

Question 103

ECT What are the reasons why ECT can be done? When is electroconvulsive therapy (ECT) recommended?

Answer 103

- Rapid improvement of severe Sx after adequate trial of other Tx proven ineffective and/or condition potentially life threatening - Severe mania or depression, suicide risk, catatonia, Rx resistant psychosis

Question 104

ECT | What are some contraindications to ECT?

Answer 104

- NO absolute, all relative - General anaesthesia (reactions) - Cerebral aneurysm - Recent MI, arrhythmias - Intracerebral haemorrhage

Question 105

ECT | What are some adverse effects of ECT?

Answer 105

- Short-term retrograde amnesia - Headache - Confusion + clumsiness

Question 106

DEPRESSION What is depression? How common is it?

Answer 106

- Persistent low mood ± loss of pleasure in activities – unipolar depression. - 2–6% prevalence globally, F>M but men more likely to be substance misusers + commit suicide

Question 107

DEPRESSION | What are 2 theories speculating the causes of depression?

Answer 107

- Stress vulnerability = someone with high vulnerability will withstand less stress before becoming mentally unwell - Monoamine hypothesis = depression caused by deficiency in monoamines (serotonin, noradrenaline) hence why Tx works

Question 108

DEPRESSION | What are the biological causes of depression?

Answer 108

- Personal/FHx + genetics - Personality traits (dependent, anxious, avoidant) - Physical illness (hypothyroid, anaemia, childbirth) - Iatrogenic (beta-blockers, steroids, substance misuse)

Question 109

DEPRESSION What are the... i) psychological ii) social causes of depression?

Answer 109

i) Disrupted relationships, child abuse, poor coping mechanisms ii) Low socioeconomic status, poor social support, discrimination, divorce, refugee

Question 110

DEPRESSION | What are some risk factors for depression?

Answer 110

- Physical co-morbidities, esp. chronic + painful (MS, stroke, DM) - Genetics + FHx, female, older age, substance abuse - Traumatic events (+ve/-ve) like divorce/marriage, (un)employment, poverty, loss - Adverse childhood experiences like abuse, poor parent relationships

Question 111

DEPRESSION | What are the 3 diagnostic criteria for depression?

Answer 111

- Sx present most days ≥2 weeks + change from baselines - Sx not attributable to other organic or substance causes - Sx impair daily function + cause significant distress

Question 112

DEPRESSION | What are the three core symptoms of depression?

Answer 112

- Low mood - Anhedonia - Anergia

Question 113

DEPRESSION | What are some psychological symptoms of depression?

Answer 113

- Guilt, worthlessness, hopelessness - Self-harm/suicidality - Low self-esteem

Question 114

DEPRESSION | What are some cognitive symptoms of depression?

Answer 114

- Beck's triad = negative views about oneself, the world + the future - Poor concentration + impaired memory - Avoiding social contact + performing poorly at work (social Sx too)

Question 115

DEPRESSION | What are some somatic, or biological, symptoms of depression?

Answer 115

- Disturbed sleep (EMW, initial insomnia, frequent waking) - Disturbed appetite + weight - Loss of libido - Diurnal mood variation (worse in morning) - Psychomotor retardation

Question 116

DEPRESSION | What are the 4 classifications of depression?

Answer 116

- Mild = ≥2 core + ≥2 other (minimal interference) - Mod = ≥2 core + ≥3 other (variable interference) - Severe = all core + ≥4 other (marked interference) - Psychotic = Sx of depression + psychosis

Question 117

DEPRESSION | What are some features of psychotic depression?

Answer 117

- Mood congruent hallucinations (auditory = derogatory or accusatory voices, olfactory = bad smells) - Nihilistic delusions - Delusions of poverty, guilt, hypochondriacal - Catatonia or marked psychomotor retardation (depressive stupor)

Question 118

DEPRESSION | What is Cotard's syndrome?

Answer 118

- Delusional belief that they are dead, do not exist, are rotting or have lost their blood + internal organs

Question 119

DEPRESSION What are some... i) psychiatric ii) organic differentials for depression?

Answer 119

i) Dysthymia, stress-related disorders, bipolar, schizophrenia, anxiety, substance misuse/withdrawal ii) Dementia, Parkinson's, anaemia, hypoglycaemia, Addison's, Cushing's

Question 120

DEPRESSION | What are some complications of depression?

Answer 120

- Reduce QOL - Increased morbidity + mortality (IHD, DM) - Suicide (20x more likely than gen pop)

Question 121

DEPRESSION | What are some investigations for depression?

Answer 121

- FBC, ESR, B12/folate, U+Es, LFTs, TFTs, glucose, Ca2+ - ECG, MSE + risk assessment - Urine drug screen - PHQ-9 + HADS to screen for depression

Question 122

DEPRESSION | When would you consider hospital admission ± MHA in depression?

Answer 122

- Serious risk of suicide or harm to others - Severe depressive or psychotic symptoms - Initiation of ECT

Question 123

DEPRESSION | What is the management of mild depression?

Answer 123

- Watchful waiting - Low-intensity psychosocial interventions first line (computerised CBT, individual-guided CBT, structured group physical activity programme) + psychoeducation

Question 124

DEPRESSION | Should biological therapy be used in mild depression?

Answer 124

No unless... - Consider if PMH mod-severe depression - Mild depression for 2y or persists after interventions

Question 125

DEPRESSION | What is the management of moderate–severe depression?

Answer 125

- Combination of SSRI + high-intensity psychosocial interventions first line - CBT with professional, interpersonal therapy, behavioural activation therapy - Psychoeducation

Question 126

DEPRESSION | What is the CAMHS management of depression?

Answer 126

- Watch + wait, lifestyle - First-line = CBT ± family ± interpersonal therapy (may need intensive if no response) - 1st line antidepressant = fluoxetine - Mood + feelings questionnaire (MFQ) to follow-up monitoring in secondary care to assess progress

Question 127

DEPRESSION | What is the management for resistant depression?

Answer 127

- Different antidepressants (SNRI, MAOI, mirtazapine) or sometimes two - Augmentation with lithium, atypical antipsychotic or tryptophan

Question 128

DEPRESSION | What is the management of psychotic depression?

Answer 128

- ECT first line + v effective in severe cases followed by antidepressant - Antipsychotic initiated before antidepressant if ?primary psychotic disorder then add SSRI

Question 129

DEPRESSION What is atypical depression? What is the management?

Answer 129

- Mood depressed but reactive - Hypersomnia (>10h/day) - Hyperphagia (excessive eating + weight gain) - Leaden paralysis (heaviness in limbs ≥1h/day) - Oversensitivity to perceived rejection - Phenelzine or another MAOI, if not SSRI

Question 130

DEPRESSION What is dysthymia? What is the management?

Answer 130

- Chronic, low-grade or sub-threshold depressive Sx which don't meet diagnostic criteria over a long period of time - Typically >2y of mildly depressed mood + diminished enjoyment, less severe but more chronic - SSRIs + CBT first line

Question 131

DEPRESSION What is seasonal affective disorder? What is the management?

Answer 131

- Episodes of depression which recur annually at same time each year (Jan-Feb) with remission in between - Light therapy + SSRI

Question 132

SELF-HARM + SUICIDE What is self-harm? What are some causes? Why do people self harm?

Answer 132

- Act of intentionally injuring yourself - Bullying, bereavement, homophobia, low self-esteem - Feel in control, reduces feelings of tension or distress, if they feel guilty can be a punishment

Question 133

SELF-HARM + SUICIDE What are some methods of self-harm? What are some risk factors? What does previous self-harm indicate?

Answer 133

- Self-poisoning (paracetamol), cutting, head banging - F, social deprivation, single or divorced, LGBTQ+, mental illness - Greatest predictor of future self-harm + increased suicide risk

Question 134

SELF-HARM + SUICIDE What is suicide? What are some methods? Why is depression higher in females but suicide higher in males?

Answer 134

- Act of intentionally ending your life - Overdose, violent means (jumping from height, into traffic, hanging, cutting) - Men tend to use violent means which are irreversible

Question 135

SELF-HARM + SUICIDE What is parasuicide? Why might this occur?

Answer 135

- Act that mimics suicide but does not result in death | - Someone interrupts them, not enough pills, vomited some of the substances out

Question 136

SELF-HARM + SUICIDE | What are some risk factors for suicide?

Answer 136

``` SAD PERSONS – - Sex (M>F) - Age (peaks in young + old) - Depression - Previous attempt - Ethanol - Rational thinking loss (psychotic illness) - Social support lacking (unemployed, homeless) - Organised plan (avoid discovery, plan, notes, final acts) - No spouse - Sickness (physical illness) 0–4 low, 5–6 mod (?hospital), ≥7 high ```

Question 137

SELF-HARM + SUICIDE | What are some protective factors for suicide?

Answer 137

- Married men - Active religious beliefs - Social support - Good employment

Question 138

SELF-HARM + SUICIDE | What are some indicators someone may commit suicide?

Answer 138

- Obsessive thoughts of death, feelings of hopeless/helplessness - Active planning (buy equipment, manage affairs, leave notes

Question 139

SELF-HARM + SUICIDE | How should a suicide assessment be conducted?

Answer 139

- Before (?trigger) – amount of planning, notes, final acts? - During – method, attempt to avoid discovery, lethality? - After – regret? Intend to re-attempt? Evidence of hopelessness?

Question 140

SELF-HARM + SUICIDE | How should paracetamol overdose be managed?

Answer 140

- Acetylcysteine if staggered (>1h) or above treatment line | - Rarely if present <1h then activated charcoal can be used

Question 141

SELF-HARM + SUICIDE | What is the general management for suicide?

Answer 141

- Plan for further suicidal thoughts + coping strategies - Reduce social isolation, regular contact with services - Manage depression (if present) - ?Inpatient stay or ECT

Question 142

BIPOLAR DISORDER What is bipolar affective disorder? When is the peak age of onset?

Answer 142

- Recurrent episodes of altered mood + activity involving both upswings or (hypo)mania + downswings or depression - Early 20s

Question 143

BIPOLAR DISORDER | What are the 4 types of bipolar?

Answer 143

- Bipolar 1 = mania + depression in equal proportions, M>F - Bipolar 2 = more episodes of depression, mild hypomania (easy to miss), F>M - Cyclothymia = chronic mood fluctuations over ≥2y (episodes of depression + hypomania, can be subclinical) - Rapid cycling = ≥4 episodes of (hypo)mania or depression in 1 year

Question 144

BIPOLAR DISORDER What are some potential causes of bipolar? What are some risk factors?

Answer 144

- Structural brain abnormalities, neurotransmitter imbalances - FHx of depression or bipolar, genetics, traumatic life event (abuse), drugs + other meds (antidepressants, BDZs, steroids) + sleep deprivation

Question 145

BIPOLAR DISORDER | What is the diagnostic criteria for bipolar?

Answer 145

- ≥2 episodes of mood disturbance (1 or which MUST be [hypo]manic)

Question 146

BIPOLAR DISORDER | What is the clinical presentation of hypomania?

Answer 146

>4d with ≥3 Sx – - Elevated mood (euphoria) - Increased energy - Increased talkativeness - Poor concentration - Mild reckless behaviour (overspending) - Over-familiar, increased self-esteem - Increased libido - Decreased need for sleep - Appetite change - Partial insight

Question 147

BIPOLAR DISORDER | What is the clinical presentation of mania?

Answer 147

>1w with ≥3 Sx – - Extreme elation or irritability - Overactivity + distractibility - Pressure of speech + flight of ideas - Impaired judgement - Extreme risks (jump off buildings, spending spree) - Social disinhibition + grandiosity - Sexual disinhibition - Decreased need for sleep, restless - MOOD CONGRUENT PSYCHOTIC Sx - TOTAL loss of insight

Question 148

BIPOLAR DISORDER In order to differentiate a manic and hypomanic episode, psychotic symptoms must be present. What are some of these?

Answer 148

- Grandiose idea may be delusional - Persecutory delusions sometimes - Pressure speech may become so great that it's incomprehensible - Irritability > violence - Preoccupation with thoughts > self-neglect - Catatonia 'manic stupor'

Question 149

BIPOLAR DISORDER What are some... i) psychiatric ii) organic differentials for bipolar?

Answer 149

i) substance abuse (cocaine, amphetamines), schizophrenia, schizoaffective disorder, ADHD ii) Hyperthyroidism, steroid-induced psychosis, Cushing's

Question 150

BIPOLAR DISORDER | What investigations would you perform in suspected bipolar?

Answer 150

- Full Hx, MSE + physical exam to exclude organic | - FBC, U+Es, LFTs, glucose, TFTs, calcium, syphilis serology, urine drug test, ?neuroimaging if SOL

Question 151

BIPOLAR DISORDER | What is the acute biological management of bipolar disorder?

Answer 151

- Antipsychotic (olanzapine, risperidone) - Lithium (both acutely + long-term) is first-line - ?Stop any antidepressants as can precipitate mania - ?ECT if severely psychotic, catatonic or suicide risk

Question 152

BIPOLAR DISORDER | What is the long-term biological management of bipolar disorder?

Answer 152

- Lithium first-line (antipsychotics in pregnancy) | - Fluoxetine SSRI of choice if depressive episode

Question 153

BIPOLAR DISORDER What type of referral would you do in bipolar? What is the psychological management of bipolar disorder?

Answer 153

- Hypomania = routine CMHT referral, mania or severe depression = urgent - CBT for depression, bipolar support groups + psychoeducation

Question 154

SCHIZOPHRENIA What is schizophrenia? What area of the brain is most affected?

Answer 154

- Splitting or dissociation of thoughts, loss of contact with reality - Temporal lobe

Question 155

SCHIZOPHRENIA | What is the neurodevelopmental hypothesis in schizophrenia?

Answer 155

- Hypoxic brain injury, viral infections in-utero, TLE + cannabis smoking = risk of schizophrenia indicating brain development link - Imaging has showed enlarged ventricles (poor prognostic feature), small amounts of grey matter loss + smaller, lighter brains

Question 156

SCHIZOPHRENIA | What is the neurotransmitter hypothesis in schizophrenia?

Answer 156

- Excess dopamine + overactivity in mesolimbic tract = +ve Sx - Lack of dopamine + underactivity in mesocortical tracts = -ve Sx - Overactivity of dopamine, serotonin, noradrenaline + underactivity of glutamate + GABA

Question 157

SCHIZOPHRENIA What is the epidemiology of schizophrenia? What are some risk factors?

Answer 157

- 1% lifetime risk, M=F, mortality 25y before gen pop. - Affects 1/100, 2 incidence peaks – men earlier (18–25), women (25–35) - Strongest RF = FHx, others = Black Caribbean, migrants, urban areas, cannabis use + traumatic pregnancy (emergency c-section)

Question 158

SCHIZOPHRENIA | What are the 6 different types of schizophrenia?

Answer 158

- Paranoid (most common) - Hebephrenic - Simple - Catatonic - Undifferentiated - Residual ('burnt out')

Question 159

SCHIZOPHRENIA What are the features of... i) paranoid ii) hebephrenic iii) simple schizophrenia?

Answer 159

i) Persecutory delusions + auditory hallucinations ii) Dx in adolescents with mood changes, unpredictable behaviour, shallow affect + fragmentary hallucinations, poor outlook as -ve Sx may develop rapidly iii) Pts never really experienced +ve Sx, mostly -ve

Question 160

SCHIZOPHRENIA What are the features of... i) catatonic ii) undifferentiated iii) residual schizophrenia?

Answer 160

i) Psychomotor disturbance such as posturing, rigidity + stupor ii) Sx do not fit neatly into other subtypes iii) Previous +ve symptoms less marked, prominent -ve Sx

Question 161

SCHIZOPHRENIA | What can cause schizophrenia?

Answer 161

- Thought to be combination of biopsychosocial factors | - Schizophrenia susceptibility + emotional life experiences may = trigger

Question 162

SCHIZOPHRENIA What are the first rank symptoms of schizophrenia? What is the relevance?

Answer 162

- Delusional perceptions - Auditory hallucinations (3 types) - Thought alienation (insertion, withdrawal + broadcasting) - Passivity phenomenon, incl. somatic - ≥1 for at least 1m is strongly suggestive Dx

Question 163

SCHIZOPHRENIA | What are the three types of auditory hallucinations that count as a first rank symptom?

Answer 163

- 3rd person = talking about the patient (he/she) - Running commentary = often on person's actions or thoughts - Thought echo = thoughts spoken aloud

Question 164

SCHIZOPHRENIA What are some secondary symptoms of schizophrenia? What is the relevance?

Answer 164

- 2nd person auditory or hallucinations in other modalities - Other delusions (persecutory, reference) - Formal thought disorder - Lack of insight - Negative Sx (incl. catatonia) - ≥2 for at least 1m is strongly suggestive Dx

Question 165

SCHIZOPHRENIA | What is the difference between positive and negative symptoms of schizophrenia?

Answer 165

- +ve = presence of change in behaviour or thought, something added (all of the first rank + secondary Sx) - -ve = decline in normal functioning, something removed

Question 166

SCHIZOPHRENIA | What are the negative symptoms of schizophrenia?

Answer 166

Often early prodromal, 5As – - Affect blunting, flattening or incongruity - Anhedonia + amotivation - Asociality - Alogia (poverty of speech) - Apathy (Delusional mood = ominous feeling of something impending)

Question 167

SCHIZOPHRENIA What are some... i) psychiatric ii) organic iii) substance differentials for schizophrenia?

Answer 167

i) Delusional disorder, transient psychosis, mania, psychotic depression ii) TLE, encephalitis, delirium, syphilis/HIV, SOL iii) Drug-induced psychosis, alcoholic hallucinosis, steroid-induced

Question 168

SCHIZOPHRENIA | What are the investigations for first-episode psychosis?

Answer 168

- Full Hx, MSE + risk assessment - FBC, CRP/ESR, U+Es, LFTs, TFTs, fasting glucose, Ca2+, phosphate, B12 + folate - Urine + serum drugs screen - ?Serological syphilis + HIV - CT/MRI head if ?SOL

Question 169

SCHIZOPHRENIA | What teams would be involved in the management of schizophrenia?

Answer 169

- Early intervention team = initial referral after first episode psychosis - CMHT = provide daily support + treatment - Crisis resolution team = pts with acute psychotic episode, often pre-existing diagnosis

Question 170

SCHIZOPHRENIA | What would warrant hospital admission ± MHA in schizophrenia?

Answer 170

- High risk of suicide or homicide - Severe psychotic, depressive or catatonic Sx - Failure of OP treatment or non-compliance

Question 171

SCHIZOPHRENIA | What is the biological management of schizophrenia?

Answer 171

- Anti-psychotic (tailor SE profile to patient) | - Aim for minimal effective dose, use depot if non-compliant to prevent relapse

Question 172

SCHIZOPHRENIA What is treatment resistant schizophrenia? What is the management?

Answer 172

- ≥2 antipsychotics (1 atypical) trialled for ≥6w but ineffective - Clozapine - ECT is last line if resistant to therapy or catatonic

Question 173

SCHIZOPHRENIA | What is the psychological management for schizophrenia?

Answer 173

- All patients offered CBT | - Family therapy + psychoeducation to reduce or notice relapses

Question 174

SCHIZOPHRENIA | What is the social management of schizophrenia?

Answer 174

- Social work + housing involvement may be needed - Drop-in community centres + support groups - Substance misuse service if needed - Depot non-attendance at GP/CPN appt may act as early warning system

Question 175

SCHIZOPHRENIA After a Mental Health Act detention, what approach should be taken to their care? What does it involve?

Answer 175

- Care programme approach | - Assess health + social needs, create care plan, appoint key worker as point of contact + review treatment

Question 176

PARAPHRENIA What is paraphrenia? How does it compare to schizophrenia?

Answer 176

- Late-onset schizophrenia >45y | - Less emotional blunting + personality decline, F>M

Question 177

PARAPHRENIA Why is it often undiagnosed? What are some risk factors?

Answer 177

- Older patients tend to be socially isolated | - Social isolation, poor eyesight + hearing, reclusive + suspicious pre-morbid personality

Question 178

PARAPHRENIA What is the clinical presentation of paraphrenia? How is it managed?

Answer 178

- Delusions, hallucinations + paranoia usually about neighbours - Partition delusions where they believe people + objects can go through walls - Less -ve Sx + formal thought disorder - Low dose antipsychotics

Question 179

TRANSIENT PSYCHOSIS What is transient psychosis? What may cause it? What is it associated with?

Answer 179

- Brief psychotic episodes that last less than time required to diagnose schizophrenia (<1m) - Usually resolves within that time - Acute stressor (loss, marriage, unemployment) - Paranoid, borderline + histrionic personality disorders

Question 180

DELUSIONAL DISORDER | What is a delusional disorder?

Answer 180

- Pt experiences strong delusional beliefs (often non-bizarre) + perceptions but with the absence of prominent hallucinations, thought or mood disorder or significant flattened affect - ICD 10 ≥3m (if less it's persistent delusional disorder)

Question 181

DELUSIONAL DISORDER | What is erotomania or De Clerambault's syndrome?

Answer 181

- Delusion in which patient (usually single woman) believes another person (typically higher social status) is in love with them

Question 182

DELUSIONAL DISORDER | What is Othello syndrome?

Answer 182

- Delusional jealousy | - Patients (typically men) possess fixed belief that their partner has been unfaithful + often try to collect evidence

Question 183

DELUSIONAL DISORDER | How else might delusional disorder present?

Answer 183

- Delusions about illness, cancer or skin infestation - Grandiose delusions - Persecutory delusions

Question 184

DELUSIONAL DISORDER | What is the management of delusional disorder?

Answer 184

- Antipsychotics, ?SSRIs | - Individual therapy = establish therapeutic alliance, maybe CBT

Question 185

SCHIZOAFFECTIVE What is schizoaffective disorder? What are the two types? How does it differ to schizophrenia?

Answer 185

- Features of both affective disorder + schizophrenia present in equal proportion - Manic type or depressive type - Psychotic Sx tend to wax + wane, unlike in schizophrenia

Question 186

SCHIZOAFFECTIVE What is the prognosis of schizoaffective disorder? What is the management of it?

Answer 186

- Better than schizophrenia but worse than primary mood disorders - Antipsychotics, mood stabilisers of antidepressants (depends on affective disorder)

Question 187

GAD What is Generalised Anxiety Disorder (GAD)? What can it be comorbid with?

Answer 187

- Syndrome of excessive, persistent worry + apprehensive feelings about everyday events that the patient recognises as excessive + inappropriate - Other anxiety disorders, depression, substance abuse, IBS

Question 188

GAD | What are 3 cardinal features of GAD?

Answer 188

- Symptoms of muscle + psychic tension - Causes significant distress + functional impairment - No particular stimulus

Question 189

GAD | What is the epidemiology of GAD?

Answer 189

- Highest prevalence 45–69y, F>M - Early onset = childhood fears + marital or sexual disturbance - Late onset = stressful event, single, unemployment

Question 190

GAD | What model can be used to explain the causes of GAD?

Answer 190

Triple vulnerability – - Generalised biological - Generalised psychological (diminished sense of control) - Specific psychological (stressful events)

Question 191

GAD | What are some organic differentials for GAD?

Answer 191

- Endo = hyperthyroidism, pheochromocytoma, hypoglycaemia - CVS = arrhythmias, cardiac failure, anti-hypertensives, MI - Resp = asthma (excessive salbutamol), COPD, PE

Question 192

GAD | What are some risk factors for GAD?

Answer 192

- Alcohol, BDZs or stimulants (particularly withdrawal) - Co-existing depression, FHx, female - Child abuse/neglect or excessively pushy parents - Life stresses (finance, divorce) - Physical health problems

Question 193

GAD What is the ICD criteria of GAD? What are the groups of symptoms present in GAD?

Answer 193

- Difficulty controlling worry, present for more days than not for ≥6m - ≥4 symptoms with ≥1 from autonomic arousal section - Autonomic arousal, physical, mental, general, tension, other

Question 194

GAD What symptoms in GAD come under the following categories... i) autonomic arousal? ii) physical? iii) mental? iv) general? v) tension? vi) other?

Answer 194

i) Palpitations, tachycardia, sweating, tremor ii) Breathing issues, choking, CP, nausea, abdo distress iii) Dizzy, derealisation + depersonalisation, fear of losing control, impending death iv) Numbness + tingling, hot flushes + chills, sleep issues (initial insomnia, fatigue on waking) v) Muscle aches + pains, restless, lump in throat vi) Exaggerated responses to minor surprises/startled

Question 195

GAD | What are the investigations for GAD?

Answer 195

- History, MSE + risk assessment - GAD-7 + Hospital Anxiety + Depression Scale (HADS) questionnaire - Exclude organic (FBC, U+Es, LFTs, TFTs, fasting glucose, PTH)

Question 196

GAD | What is the stepwise management for GAD?

Answer 196

- Education + active monitoring, exercise - Low-intensity psychological interventions like individual self-help or groups - High-intensity psychological interventions (CBT, applied relaxation, arts + music therapy) or biological management

Question 197

GAD | What is the role of CBT in GAD?

Answer 197

- Cognitive = educate about bodily response to anxiety | - Behavioural = use of relaxation to overcome

Question 198

GAD | What is the biological management used in GAD?

Answer 198

- Sertraline first line, if ineffective offer alternative SSRI or SNRI - If SSRI/SNRI not tolerated then pregabalin - Beta-blockers like propranolol for physical Sx sometimes

Question 199

GAD | What is the CAMHS management of GAD?

Answer 199

- Watch + wait - Self-help (meditation, mindfulness), diet + exercise - CBT, counselling + SSRI like sertraline may be considered if more severe (specialists)

Question 200

PANIC DISORDER | What is panic disorder?

Answer 200

- Recurrent panic attacks that are unpredictable + unrestricted in terms of situation, ≥4/week for ≥4w - Usually persistent worry about having another attack - Chronic relapsing condition > distress + social dysfunction

Question 201

PANIC DISORDER | What is a panic attack?

Answer 201

- Period of intense fear characterised by range of physical Sx that develop rapidly, peak intensity at 10m, generally no longer than 20–30m

Question 202

PANIC DISORDER | What is the epidemiology of panic disorder?

Answer 202

- Females 2–3x more likely | - Bimodal distribution

Question 203

PANIC DISORDER What is panic disorder associated with? What are some risk factors?

Answer 203

- Meds like SSRIs, BDZs, zopiclone withdrawal | - Widowed, divorced or separated, living in city, limited education, physical or sexual abuse, FHx

Question 204

PANIC DISORDER | What are the 3 key elements of panic disorder?

Answer 204

- Sudden onset panic attack with ≥4 characterised Sx - Not necessarily associated with a specific stimulus - Pt preoccupied with suffering death or severe life-threatening illness

Question 205

PANIC DISORDER | What are the features of panic attacks?

Answer 205

Same as GAD but in discrete attacks – - Palpitations, tachycardia, sweating, tremor - Breathing issues, choking, CP, nausea, abdo distress - Dizzy, derealisation + depersonalisation, fear of losing control, impending death - Numbness + tingling, hot flushes + chills, muscle aches + pains

Question 206

PANIC DISORDER | What is the stepwise management of panic disorder?

Answer 206

- Recognition + diagnosis with treatment in primary care - CBT or drug therapy (SSRIs 1st line, if C/I or no response after 12w then imipramine or clomipramine) - Psychodynamic psychotherapy + specialist MH services if severe

Question 207

PANIC DISORDER | What is the social management of panic disorder?

Answer 207

- Healthy eating, exercise, avoid caffeine. | - Meditation, mindfulness, self-help groups

Question 208

SIMPLE PHOBIAS | What is a simple or specific phobia?

Answer 208

- Recurring excessive + unreasonable anxiety attacks, in the (anticipated) presence of a specific feared object or situation, leading to avoidance if possible

Question 209

SIMPLE PHOBIAS What might people be phobic of? Give some examples.

Answer 209

- Animals, blood, injection or injury, situational, natural environment - Emetophobia, claustrophobia, arachnophobia, iatrophobia

Question 210

SIMPLE PHOBIAS | What is the epidemiology of simple phobias?

Answer 210

- F>M | - Mean age is 15 (animal phobias can be as young as 7)

Question 211

SIMPLE PHOBIAS | What are some potential causes of phobias?

Answer 211

- Psychoanalytical = phobia is symbolic representation of repressed unconscious conflict - Learning theory = conditioned fear response to traumatic situation with learned avoidance

Question 212

SIMPLE PHOBIAS | What is the clinical presentation of simple phobias?

Answer 212

Same features as GAD but to a specific stimulus – - Palpitations, tachycardia, sweating, tremor - Breathing issues, choking, CP, nausea, abdo distress - Dizzy, derealisation + depersonalisation, fear of losing control, impending death - Numbness + tingling, hot flushes + chills, muscle aches + pains

Question 213

SIMPLE PHOBIAS | What is the management of simple phobias?

Answer 213

- Exposure + response prevention (ERP) - CBT (education + anxiety management, coping strategies) - BDZs in severe cases to reduce avoidance

Question 214

SIMPLE PHOBIAS What are the two methods of ERP? Which is preferred?

Answer 214

- Desensitisation with relaxation + graded exposure - Flooding where exposed to most frightening situation instantly - Desensitisation as flooding can be highly traumatic

Question 215

AGORAPHOBIA | What is agoraphobia?

Answer 215

- Anxiety + panic symptoms associated with places or situations where escape may be difficult or embarrassing leading to avoidance. - ≥2 from: crowds, public places, travelling alone or away from home.

Question 216

AGORAPHOBIA What may be seen in patients with agoraphobia? What is the epidemiology?

Answer 216

- Predisposition towards overly interpreting situations as dangerous - F>M, 15–35y, may have co-morbid panic disorder

Question 217

AGORAPHOBIA | What is the clinical presentation of agoraphobia?

Answer 217

Same as GAD but to the specific situations – - Palpitations, tachycardia, sweating, tremor - Breathing issues, choking, CP, nausea, abdo distress - Dizzy, derealisation + depersonalisation, fear of losing control, impending death - Numbness + tingling, hot flushes + chills, sleep issues (initial insomnia, fatigue on waking)

Question 218

AGORAPHOBIA | What is the biological management of agoraphobia?

Answer 218

- SSRIs as for panic disorder | - BDZs for short-term use only (clonazepam)

Question 219

AGORAPHOBIA | What is the psychological management of agoraphobia?

Answer 219

- CBT (teach about bodily responses related to anxiety and exposure + desensitisation techniques, relaxation training)

Question 220

SOCIAL PHOBIA | What is social phobia?

Answer 220

- Sx of incapacitating anxiety that are restricted to particular social situations, leading to a desire for escape or avoidance (may reinforce belief of social inadequacy)

Question 221

SOCIAL PHOBIA | What is the epidemiology of social phobia?

Answer 221

- Bimodal distribution with peaks at 5y + 11–15y, may present in 30s

Question 222

SOCIAL PHOBIA | What is the clinical presentation of social phobia?

Answer 222

≥2 Somatic Sx in response to the situation – - Blushing, trembling, dry mouth, sweating - Excessive fear of humiliation, embarrassment, micturition or others noticing how anxious they are. - Characteristically self-critical + perfectionist

Question 223

SOCIAL PHOBIA | What is the impact of social phobia?

Answer 223

- Avoiding situations may lead to relationship issues, education + vocational problems (difficulty interacting with others, presentations)

Question 224

SOCIAL PHOBIA | What is the biological management of social phobia?

Answer 224

- SSRIs (sertraline) > SNRIs > MAOIs - Beta-blockers like propranolol - Clonazepam may be useful short-term

Question 225

SOCIAL PHOBIA | What is the psychological management of social phobia?

Answer 225

- Either individual or group CBT first-line with SSRI (relaxation training, social skills, graded exposure) - Psychodynamic psychotherapy

Question 226

OCD | What is obsessive compulsive disorder (OCD)?

Answer 226

- Condition characterised by obsessions + compulsions which must cause distress or interfere with their social or individual functioning (usually by wasting time)

Question 227

OCD | What are some examples of obsessions and compulsions?

Answer 227

- Obsessions = being followed, everything being dirty or contaminated - Compulsions = checking, washing, doubting, bodily fears, counting, symmetry, aggressive thoughts

Question 228

OCD What are the two types of compulsions? What is the natural cycle in OCD?

Answer 228

- Overt = can be observed (checking the door) - Covert = can't be observed (repeating a phrase in their mind) - Obsession > anxiety > compulsion > relief

Question 229

OCD What is the epidemiology of OCD? What is a potential cause of OCD?

Answer 229

- Adolescents or early adulthood (20y mean age), M=F | - Neurochemical dysregulation of 5-HT system

Question 230

OCD | What are some risk factors for OCD?

Answer 230

- Genetics = FHx of OCD or tic disorder - Abuse, neglect, teasing + bullying - Parental overprotection - Paediatric neuropsychiatric disorders associated with streptococci (PANDAS)

Question 231

OCD | What are the key features of OCD?

Answer 231

- Obsessions ± compulsions present most days >2w - Acknowledged as excessive + unreasonable + originate from inside patient's mind (not influenced by outside) - Repetitive or unpleasant + pt tries to resist them unsuccessfully - Time consuming, interferes with ADLs, distress to pt - Avoidance of stimuli that trigger Sx

Question 232

OCD | What is the biological management of OCD?

Answer 232

- 1st line SSRIs = sertraline - 2nd line = clomipramine (TCA) with specific anti-obsessional action - ?Psychosurgery (stereotactic cingulotomy if intractable > 2 antidepressants, 3 combination Tx, ECT + behavioural therapy

Question 233

OCD | What is the psychological management of OCD?

Answer 233

- CBT but behavioural approach - ERP (stop carrying out compulsion in response to stimulus) - Psychotherapy (incl. family, groups)

Question 234

OCD | What is the OCD management for CAMHS?

Answer 234

- Mild can be managed with psychoeducation or self-help | - Referral to CAMHS, CBT + initiation of SSRI with CAMHS specialist guidance

Question 235

ACUTE STRESS REACTION | What is acute stress reaction?

Answer 235

- Transient disorder that can occur as an immediate response to exceptional stressor with threat to security or physical integrity (rape, natural catastrophe) but typically resolves once stressor removed/after few days

Question 236

ACUTE STRESS REACTION | How does acute stress reaction present?

Answer 236

- Anger, depression/anxiety, excessive grief, social withdrawal, narrow attention - Basically presents as PTSD but <1m so not called PTSD (only if no resolution >1m)

Question 237

ADJUSTMENT DISORDER | What is adjustment disorder?

Answer 237

- Abnormal or excessive reaction to an identifiable life stressor

Question 238

ADJUSTMENT DISORDER | What is the clinical presentation of adjustment disorder?

Answer 238

- More severe reaction than expected with functioning impairment, may be subthreshold manifestation of mood/anxiety disorders - E.g. self-harming to kill self + depressive Sx for 1w after long-term relationship breakdown

Question 239

ADJUSTMENT DISORDER | How is adjustment disorder managed?

Answer 239

- Supportive psychotherapy to enhance capacity to cope with stressor

Question 240

GRIEF REACTION What is the normal grief reaction? How does it present?

Answer 240

- Normal reaction after a sad event e.g. sad after death of loved one - Usually occurs <6m from event (delayed grief = >2w until grieving, prolonged grief = hard to define but >12m)

Question 241

GRIEF REACTION | What are the stages of a normal grief reaction?

Answer 241

- Denial incl. numbness, pseudohallucinations of deceased (auditory, visual), may focus on physical objects that remind them - Anger usually to family or HCPs - Bargaining, depression + acceptance (may not go through all 5 stages)

Question 242

PTSD What is post-traumatic stress disorder (PTSD)? What counts as a traumatic event?

Answer 242

- Severe psychological disturbance following a traumatic event (within 6m usually). - Catastrophic event where there is threat to security or physical integrity (life-threatening) such as war, surviving tsunami, sexual assault, not everyday trauma (divorce)

Question 243

PTSD | What are some risk factors for PTSD?

Answer 243

- Low education or social class - F>M - Previous PTSD/psych issues - First responders (ambulance, police, fire) - Military (dependent on duration of combat exposure, lower rank, low morale)

Question 244

PTSD What are the 4 core symptoms of PTSD? How long do they need to be present for to diagnose?

Answer 244

HEAR (≥1m) – - Hyperarousal - Emotional numbing - Avoidance + rumination - Re-experiencing (involuntary)

Question 245

PTSD In terms of PTSD, what are signs of... i) hyperarousal? ii) emotional numbing?

Answer 245

i) Hypervigilance for threat, exaggerated startle response, irritability, difficulty concentrating or sleeping (falling + staying asleep) ii) Difficulty experiencing emotions, restricted range of affect, detachment from others

Question 246

PTSD In terms of PTSD, what are signs of... i) avoidance + rumination? ii) re-experiencing?

Answer 246

i) Avoiding people, situations, thoughts or circumstances resembling or associated to event ii) Flashbacks, nightmares, vivid memories, distressing images or other sensory impressions from event which intrude during waking day, reminders of event = distress

Question 247

PTSD | What is the mainstay of management in PTSD?

Answer 247

Psychological therapy – - Trauma-focused CBT - Eye movement desensitisation and reprocessing (EMDR)

Question 248

PTSD | What is trauma-focused CBT?

Answer 248

- Education about nature of PTSD, self-monitoring of Sx, anxiety management, breathing techniques + exposure in supportive setting

Question 249

PTSD | What is EMDR?

Answer 249

- Voluntary multi-saccadic eye movements to reduce anxiety associated with disturbing thoughts + help process emotions

Question 250

PTSD | What is the medical management of PTSD?

Answer 250

- Venlafaxine or SSRI like sertraline | - Risperidone for severe cases where resistant to treatment or psychotic

Question 251

SUBSTANCE ABUSE What is an addiction? What is an addictive behaviour? Why is it addictive?

Answer 251

- Compulsive substance taking behaviour with physiological withdrawal state - Behaviour which is both rewarding + reinforcing - Related to dopamine + mesolimbic reward system a motivational circuit

Question 252

SUBSTANCE ABUSE | What are the physical effects of dependent drug use?

Answer 252

- Acute = injecting complications, SEs, OD, poor pregnancy outcomes - Chronic = BBV transmission, chronic illnesses

Question 253

SUBSTANCE ABUSE What are the... i) psychological ii) social effects of dependent drug use?

Answer 253

i) MH issues, fearing withdrawal, craving, guilt, pre-occupation with finding next fix ii) Effects on relationships, criminality + imprisonment, social exclusion, poverty (no money for food)

Question 254

SUBSTANCE ABUSE | What is dependence?

Answer 254

- The inability to control the intake of a substance to which one is addicted to

Question 255

SUBSTANCE ABUSE | List 8 features of dependence

Answer 255

- Withdrawal - Cravings - Continued use despite harm - Tolerance - Primacy/salience - Loss of control - Narrowed repertoire - Rapid reinstatement

Question 256

SUBSTANCE ABUSE What is withdrawal? Give an example

Answer 256

- Physiological withdrawal state when substance stopped with Sx + substance use to prevent - Early morning drinking

Question 257

SUBSTANCE ABUSE | What are cravings?

Answer 257

- Very strong desire for the substance

Question 258

SUBSTANCE ABUSE What is continued use despite harm? Give an example

Answer 258

- Despite clear problems caused by substance, person cannot stop - Injecting heroin despite abscess formation

Question 259

SUBSTANCE ABUSE What is tolerance? Give an example

Answer 259

- Larger doses required to gain the same effect as previously (NB: individuals often show no signs of being on a drug at dose ordinary people would) - Opiate-dependent people may inject enough heroin to kill a non-tolerant person

Question 260

SUBSTANCE ABUSE What is primacy/salience? Give an example

Answer 260

- Obtaining + using substance becomes so important other interests are neglected - Not eating to save money for drugs

Question 261

SUBSTANCE ABUSE What is loss of control? Give an example

Answer 261

- Difficulties controlling starting, stopping or amounts used - Becomes hard to say no

Question 262

SUBSTANCE ABUSE What is narrowed repertoire? Give an example

Answer 262

- Less variation in types of substances used | - Dependent drinker will drink same amount of same drink in same way (usually cheapest)

Question 263

SUBSTANCE ABUSE What is rapid reinstatement? Give an example

Answer 263

- When a user relapses after period of abstinence, risk of returning to previous dependent pattern quicker - Someone who used to smoke 10/d may quickly return to this after 1 fag

Question 264

SUBSTANCE ABUSE | What are some primary care interventions for drug users?

Answer 264

- Health checks + BBV screening - Contraception, smear + sexual health advice - General immunisation status + hep A/B - Information on local drug services (needle exchange)

Question 265

SUBSTANCE ABUSE | How can harm be reduced in drug users?

Answer 265

- Not injecting or safe injecting (don't share, new one each time) - Not mixing resp depressants or using drugs alone - Reduce amount taken after intervals tolerance is lost

Question 266

ALCOHOL DEPENDENCE | What is alcohol abuse?

Answer 266

- Regular or binge consumption of alcohol which is sufficient to cause physical, neurological, psychiatric or social damage

Question 267

ALCOHOL DEPENDENCE How do you calculate number of units in a drink? What is 1 unit of alcohol? What is the recommended weekly units for men and women?

Answer 267

- % ABV x volume (L) - 10ml or 8g - 14 units/week

Question 268

ALCOHOL DEPENDENCE | What are the components to alcohol abuse?

Answer 268

- Psychological dependence = feelings of loss of control, cravings, pre-occupation - Physiological dependence = physical withdrawal Sx - +ve reinforcement = drinking to feel euphoric - -ve reinforcement = drinking to avoid withdrawal Sx

Question 269

ALCOHOL DEPENDENCE | What areas of the brain can alcohol affect?

Answer 269

- Amygdala + nucleus accumbens - Cerebral cortex - Pre-frontal cortex - Cerebellum - Hypothalamus + pituitary - Medulla

Question 270

ALCOHOL DEPENDENCE How does alcohol affect... i) amygdala + nucleus accumbens? ii) cerebral cortex? iii) pre-frontal cortex? iv) cerebellum? v) hypothalamus + pituitary? vi) medulla?

Answer 270

i) Euphoria, pleasure + reward centre ii) Slows thinking + speech iii) Slow behavioural inhibition centres (confident + relaxed) iv) Slows movement + impairs coordination v) Alters mood + hormones (libido increases) vi) Decreases breathing, consciousness + body temp

Question 271

ALCOHOL DEPENDENCE | How does alcohol affect the activity of neurotransmitters in the brain?

Answer 271

- Ethanol > ADH > acetaldehyde > ALDH > acetate > CO2 + H2O - Ethanol binds to GABA + makes inhibitor/depressant effect stronger - Glutamate antagonism which decreases excitatory neurotransmission - Activates opioid receptors to release endorphins - Release dopamine + serotonin

Question 272

ALCOHOL DEPENDENCE | What are some causes/risk factors for alcohol dependence?

Answer 272

- Genetics – more likely if FHx, M>F, less likely if acetaldehyde dehydrogenase deficiency - Occupation – army, Drs - Culture/beliefs/background – high in Scottish, Irish, lower in Muslims + Jews - Cost of alcohol - Early use of substances - Social reinforcement - Chronic illnesses - Traumatic life events

Question 273

ALCOHOL DEPENDENCE What are the acute effects of alcohol intoxication? When is it classed as alcohol dependence?

Answer 273

- Euphoria, impaired judgement, reduced anxiety, ataxia, vomiting - ≥3 features of dependence

Question 274

ALCOHOL DEPENDENCE | What are the 3 stages of alcohol withdrawal?

Answer 274

- 6–12h = tremors, diaphoresis, tachycardia, anxiety, irritability + aggression - 36h = seizures - 48–72h = delirium tremens

Question 275

ALCOHOL DEPENDENCE | What are some chronic complications of alcohol dependence?

Answer 275

- Cardiac = dilated cardiomyopathy, arrhythmias - Liver etc – fibrosis, cirrhosis, oesophageal varices, pancreatitis - Wernicke's + Korsakoff's

Question 276

ALCOHOL DEPENDENCE | What are some common causes of death in alcohol dependence?

Answer 276

- Accidents + violence - Malignancies (head + neck, pancreatic, stomach, colon, hepatic, breast + gynae) - CVA, IHD

Question 277

ALCOHOL DEPENDENCE | What are some blood markers for alcohol consumption?

Answer 277

- Red blood cell mean corpuscular volume (MCV) raised - Gamma glutamyl transpeptidase (GGT) raised - Carbohydrate deficient transferrin (CDT) raised

Question 278

ALCOHOL DEPENDENCE | What are some clinical tools for assessing alcohol dependence or withdrawal?

Answer 278

- CAGE - AUDIT - Clinical Institute Withdrawal Assessment

Question 279

ALCOHOL DEPENDENCE | What are the CAGE questions?

Answer 279

- Have you ever felt you need to CUT down on your drinking? - Have people ANNOYED you by criticising your drink? - Have you ever felt GUILTY about your drinking? - EYE-opener – ever felt you need drink first thing in morning to steady your nerves?

Question 280

ALCOHOL DEPENDENCE | What are the AUDIT questions?

Answer 280

- How often do you have a drink containing alcohol? - How many units of alcohol do you drink on a typical day? - How often did you have >6 units on a single occasion in the past year?

Question 281

ALCOHOL DEPENDENCE What is blood alcohol content? How is it affected? What is the drink drive limit?

Answer 281

- mg ethanol/100ml blood - Affected by amount of ethanol consumed, person's blood volume (males have increased), if eaten, any meds - Illegal to drive with BAC ≥0.08%

Question 282

ALCOHOL DEPENDENCE | What are public health measurements to help prevent alcohol abuse?

Answer 282

- Increasing tax on alcohol + restricting advertisement on alcohol - Drinkaware + know your limits campaign - Keeping alcohol out of site (behind counter + having to ask for it) - School alcohol education to reduce long-term alcohol use + binge drinking

Question 283

ALCOHOL DEPENDENCE | What are the indications for an inpatient detoxification?

Answer 283

- Withdrawal seizures or delirium tremens in past - Significant mental/physical illness, including suicidality - Lack of stable home environment

Question 284

ALCOHOL DEPENDENCE | What is the regime for acute detoxification?

Answer 284

- Chlordiazepoxide 1st line (2nd = diazepam) for withdrawal Sx + preventing seizures - Thiamine (PO or IV) - Rehydrate with fluids (often IV), correct electrolyte disturbance - Reducing regime (slowly reduce doses over days)

Question 285

ALCOHOL DEPENDENCE | What factors make detoxification more likely to work?

Answer 285

- Younger users with less time addicted + lower level of drug use

Question 286

ALCOHOL DEPENDENCE | What are the 3 biological treatments used in alcohol dependence?

Answer 286

- Naltrexone - Acamprosate - Disulfiram

Question 287

ALCOHOL DEPENDENCE | What is the mechanism of action of naltrexone?

Answer 287

- Opioid receptor antagonist - Blocks euphoric effects of alcohol - Helps people stick to detox programme + avoid relapse

Question 288

ALCOHOL DEPENDENCE | What is the mechanism of action of acamprosate?

Answer 288

- NMDA antagonist acts on GABA to reduce cravings + risk of relapse

Question 289

ALCOHOL DEPENDENCE What is the mechanism of action of disulfiram? What affects does it have?

Answer 289

- Inhibits acetaldehyde dehydrogenase > build-up of acetaldehyde - Produces hangover-like Sx when alcohol is drunk = deterrent (flushing, headaches, anxiety, nausea, reduced BP)

Question 290

ALCOHOL DEPENDENCE | What are some psychological treatments for alcohol dependence?

Answer 290

- Motivational intervention - Aversion therapy - CBT, prevention measures (relapse prevention strategies)

Question 291

ALCOHOL DEPENDENCE | What is motivational intervention?

Answer 291

- Discuss potential harm caused, reasons for changing behaviour, cover obstacles to change, strategies to combat obstacles > motivation

Question 292

ALCOHOL DEPENDENCE | What is aversion therapy?

Answer 292

- Designed to put the patient off the undesirable habit by causing them to associate it with an unpleasant effect

Question 293

ALCOHOL DEPENDENCE | What is the social management of alcohol dependence?

Answer 293

- Housing, economical + employment issues - Alcoholics anonymous - Developing social routines that are not reliant on alcohol

Question 294

OPIATES/OPIOIDS | What are opiates?

Answer 294

- Derived from opium poppy, synthetic compounds with similar properties are called opioids with heroin most commonly abused

Question 295

OPIATES/OPIOIDS | How do opioids work?

Answer 295

- Bind to m-receptor > endogenous endorphins causing cortical inhibitor effects (analgesia) almost immediately - Addictive as high reward for minimal effort

Question 296

OPIATES/OPIOIDS What routes can opioids be taken via? How long does it take for withdrawal symptoms to develop? What are some examples?

Answer 296

- Smoking, PO, snorted, parenterally (IM/IV) - 6h post-dose - Morphine, diamorphine (heroin), codeine, methadone

Question 297

OPIATES/OPIOIDS With opioids, what is the... i) psych effect? ii) physical effect? iii) withdrawal?

Answer 297

i) Euphoria, relaxation, drowsiness, analgesia ii) Resp depression (esp. OD), pinpoint pupils, bradycardia, constipation iii) "Goose flesh" (piloerection), raised HR/BP, fever, pupil dilatation, abdo cramps, insomnia, agitation (everything runs > D+V, lacrimation, rhinorrhoea, diaphoresis)

Question 298

OPIATES/OPIOIDS What are some complications from opioids? What are some complications with injecting heroin?

Answer 298

- Resp depression, constipation, N+V, coma, OD + death | - Abscesses, cellulitis, infective endocarditis, BBV (hep B/C, HIV), VTE

Question 299

OPIATES/OPIOIDS | What is the management of opioid overdose?

Answer 299

- 400mg IV naloxone | - M-receptor inverse agonist > blockade (almost immediate)

Question 300

OPIATES/OPIOIDS | What are some maintenance therapies for opioids?

Answer 300

- Methadone (full opioid agonist) or buprenorphine (partial agonist/antagonist) - Start low + titrate up

Question 301

OPIATES/OPIOIDS | What are the pros of methadone?

Answer 301

- Reduces mortality, drug-related morbidity, crime, spread of BBV

Question 302

OPIATES/OPIOIDS | How does maintenance therapies help?

Answer 302

- Don't get high but reduces cravings | - Less dangerous than heroin + safe in pregnancy (risk of miscarriage if stop in pregnancy)

Question 303

OPIATES/OPIOIDS | What drug can be used to prevent relapses?

Answer 303

- Naltrexone | - Opiate antagonist which prevents lapse > relapse

Question 304

OPIATES/OPIOIDS What is the first line detox management in opioids? How long does detox last?

Answer 304

- Motivational intervention - Alternative therapies = exercise, art therapy, counselling - 4w = inpatient, 12w = community

Question 305

SEDATIVES What are some types of sedatives? What is a 'date-rape' drug? What routes can it be taken?

Answer 305

- BDZs, barbiturates (increased duration of Cl- channels) often taken for their anxiolytic effects - Rohypnol > intoxicant, aphrodisiac + anterograde amnesia - PO + IV

Question 306

SEDATIVES What are the... i) psych ii) physical iii) withdrawal effects of sedatives?

Answer 306

i) Euphoria + disinhibition, hallucinations, paranoid, agitation, time passes slowly ii) Unsteady gait, dysarthria, hypotension, nystagmus iii) Sweating, myalgia, tremors, risk of seizures

Question 307

STIMULANTS What is the action of stimulants? What are some examples?

Answer 307

- Potentiate mood enhancing neurotransmission (dopamine, serotonin, noradrenaline) by blocking their uptake + increase cortical excitability - Cocaine, ecstasy (MDMA), amphetamines (speed)

Question 308

STIMULANTS | What different routes of taking these drugs?

Answer 308

- Cocaine inhaled or IV - MDMA + amphetamines PO - Crack cocaine releases all dopamine straight away when smoked

Question 309

STIMULANTS What are the... i) psych ii) physical iii) withdrawal effects of stimulants?

Answer 309

i) Euphoria, increased alertness + endurance, grandiosity, hallucinations, aggression, impulsivity ii) Tachycardia, HTN, N+V, pupil dilation, CP + convulsions iii) Psychomotor agitation, dysphoric mood, insomnia + bizarre/unpleasant dreams

Question 310

STIMULANTS | What are some other adverse effects of cocaine?

Answer 310

- Arrhythmias, MI + damage to nasal septum if used chronically

Question 311

CANNABINOIDS Why is cannabis addictive? What can heavy use lead to?

Answer 311

- Addictive as causes release of dopamine, anxiolytic | - Anxiety + depression, use in youth > schizophrenia

Question 312

CANNABINOIDS What are the... i) psych ii) physical iii) withdrawal effects of cannabinoids?

Answer 312

i) Euphoria + disinhibition, hallucinations, paranoid, agitation, time passes slowly ii) Increased appetite, dry mouth, tachycardia iii) Anxiety, irritable, tremor, conjunctival injection

Question 313

HALLUCINOGENS Give some examples of hallucinogens. What are some psych + physical effects of hallucinogens?

Answer 313

- LSD, magic mushrooms (PO) - Hallucinations, illusions, depersonalisation + derealisation, paranoia, impulsivity, anxiety, magic mushrooms > euphoria as serotonin release - Tachycardia, palpitations, sweating, blurred vision

Question 314

VOLATILE SOLVENTS Give some examples of solvents. What are some psych + physical effects of solvents? Are they dangerous?

Answer 314

- Aerosols, paint, glue, petrol (inhaled) - Apathy, lethargy, impaired judgement, psychomotor retardation - Decreased consciousness, unsteady gait, diplopia - Very – laryngospasm due to cold temp, brain damage, hypoxia

Question 315

ANOREXIA NERVOSA | What are the 2 types of anorexia nervosa?

Answer 315

- Restrictive = limit food intake | - Binge/purge = binge eat + purge straight away (different from bulimia due to BMI)

Question 316

ANOREXIA NERVOSA How is anorexia classified based on BMI? What is the outcome of anorexia nervosa?

Answer 316

- Anorexia = <17.5kg/m^2 - Medium risk = 13–15 - High risk = <13 - 1/3 recover, 1/3 relapse + remit, 1/3 chronic lifelong

Question 317

ANOREXIA NERVOSA | What is the epidemiology of anorexia?

Answer 317

- F>M | - Onset is early to mid adolescence

Question 318

ANOREXIA NERVOSA | What premorbid experiences may lead to anorexia development?

Answer 318

- Dieting behaviour in family/personal experience, over-protective family - Criticism about weight, personal Hx of obesity, adverse events (abuse) - Perfectionism, low self-esteem, disturbed body image, obsessional traits

Question 319

ANOREXIA NERVOSA | What is the diagnostic criteria for anorexia?

Answer 319

FEED ≥3m with absence of binge eating – - Fear of fatness - Endocrine disturbance - Extreme weight loss - Deliberate weight loss

Question 320

ANOREXIA NERVOSA | How may fear of fatness present?

Answer 320

- Over-valued idea - Self-esteem unduly influenced by weight/shape - Intense fear of gaining weight > body image distortion

Question 321

ANOREXIA NERVOSA | How may endocrine disturbance present?

Answer 321

- Amenorrhoea - Reduced libido/fertility - Abnormal insulin secretion - Delayed/arrested puberty if onset pre-pubertal

Question 322

ANOREXIA NERVOSA | How may extreme weight loss present?

Answer 322

- >15% below expected for height (BMI ≤17.5kg/m^2)

Question 323

ANOREXIA NERVOSA | How may deliberate weight loss present?

Answer 323

- Restrictive eating (skipping meals) - Over-exercising - Vomiting - Appetite suppressants - Laxatives

Question 324

ANOREXIA NERVOSA | What are some physical symptoms of anorexia?

Answer 324

- GI Sx = constipation, dysphagia (vomiting), abdo pains - Dizziness/fainting, headaches, cold intolerance - Polyuria (diuresis), polydipsia

Question 325

ANOREXIA NERVOSA | What are some clinical signs of anorexia?

Answer 325

- Lanugo hair = fine, soft body hair - Gaunt face, dry skin, loss of muscle mass - Acrocyanosis = blue colouration of peripheries due to slow circulation

Question 326

ANOREXIA NERVOSA | What are some complications of anorexia?

Answer 326

- Osteoporosis, thyroid issues, cardiac atrophy - Electrolyte disturbances (hypokalaemia > arrhythmias) - Decrease in WBC > increased infections - Death due to health complications or suicide

Question 327

ANOREXIA NERVOSA | What screening tool can be used in anorexia?

Answer 327

SCOFF – - Do you ever make yourself SICK as too full? - Do you ever feel you've lost CONTROL over eating? - Have you recently lost more than ONE stone in 3m? - Do you believe you're FAT when others say you're thin? - Does FOOD dominate your life?

Question 328

ANOREXIA NERVOSA | What are some investigations for anorexia?

Answer 328

- Sit up squat stand (SUSS) test /3 - BP (low), temp (low) - ECG (brady, T-wave changes, QTc prolongation) - FBC (anaemia, dehydrated), LFTs, urinalysis, serum proteins - U+Es, Ca2+, Mg2+, phosphate > vomiting, laxatives, diuretics, water loading - DEXA scan after 1y of underweight (osteopenia)

Question 329

ANOREXIA NERVOSA | In anorexia, most things are low apart from what?

Answer 329

Gs + Cs – - GH, Glucose, salivary Glands - Cortisol, Cholesterol, Carotinaemia

Question 330

ANOREXIA NERVOSA | What risk assessment tool can be used for assessing if a patient with anorexia needs inpatient psychiatric admission?

Answer 330

- Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN)

Question 331

ANOREXIA NERVOSA | What are the MARSIPAN indicators of admission?

Answer 331

- BMI <13, severe malnutrition or dehydration - HR <40, ECG changes - BP <90 systolic, <70 diastolic esp with postural drop - Temp <35 - Severe electrolyte disturbances (K+, Na+, Mg2+, phosphate = low) - SUSS test of 0 or 1 - Significant suicide or serious self-harm risk

Question 332

ANOREXIA NERVOSA | How should the physical complications of anorexia be managed?

Answer 332

- Monitor U+Es + ECGs - Oral supplements for electrolytes, thiamine - Multivitamins + mineral supplements, calcium + vitamin D - Safely + slowly re-feed pt + avoid refeeding syndrome

Question 333

ANOREXIA NERVOSA | What are the biological treatments for anorexia nervosa?

Answer 333

- Fluoxetine, chlorpromazine + TCAs may be used for weight gain

Question 334

ANOREXIA NERVOSA | What are the psychological therapies for anorexia?

Answer 334

- Individual therapy (eating disorder focussed CBT, CBT-ED) - Maudsley anorexia nervosa treatment for adults (MANTRA) - Specialist supportive clinical management (SSCM)

Question 335

ANOREXIA NERVOSA | What is the social management for anorexia?

Answer 335

- Avoid over exercise - Food diary/dietary advice - Self-help groups

Question 336

ANOREXIA NERVOSA | What is the CAMHS treatment for anorexia?

Answer 336

- Family therapy 1st line, pt + carer education, self-help resources - Adolescent-focussed psychotherapy, individual CBT-ED - May require SSRIs

Question 337

ANOREXIA NERVOSA What is refeeding syndrome? What are some risk factors?

Answer 337

- Metabolic disturbances due to reintroduction of nutrition to a starving patient who is fed too much, too quickly - Low BMI, poor nutritional intake (>5d), Hx of high alcohol intake, chemo, unintentional weight loss

Question 338

ANOREXIA NERVOSA | What is the pathophysiology of refeeding syndrome?

Answer 338

- Reduced carb consumption leads to reduced insulin secretion so the body switches from carb > fat + protein metabolism - Electrolyte stores depleted as needed to convert glucose>energy - Reintroducing food causes abrupt shift from fat>carb metabolism + insulin secretion surges, driving electrolytes from serum>cells to help convert glucose>energy causing further serum concentration decrease

Question 339

ANOREXIA NERVOSA What is the clinical presentation of refeeding syndrome? What are the consequences of refeeding syndrome?

Answer 339

- Fatigue, weakness, confusion, dyspnoea (risk of fluid overload) - Abdo pain, vomiting, constipation, infections - Can lead to cardiac arrhythmias, convulsions, cardiac failure, coma + death

Question 340

ANOREXIA NERVOSA | What are the biochemical features of refeeding syndrome?

Answer 340

- Hypophosphataemia main disturbance due to role of converting glucose>energy - Hypokalaemia, hypomagnesaemia + thiamine deficiency too - Abnormal fluid balance

Question 341

ANOREXIA NERVOSA | What should be monitored before + during refeeding?

Answer 341

- U+Es (Na+, K+), phosphate, magnesium, glucose, ECG, fluid balance

Question 342

ANOREXIA NERVOSA | What is the management of refeeding syndrome?

Answer 342

- Start up to 10cal/kg/day + increase to full needs SLOWLY over 4–7d - Start PO thiamine, B vitamins + supplements before + during feeding - K+, phosphate + magnesium replacement

Question 343

BULIMIA NERVOSA | What is bulimia nervosa?

Answer 343

- Characterised by recurrent episodes of binge eating + compensatory behaviours (purges)

Question 344

BULIMIA NERVOSA | What is a binge?

Answer 344

- Episodes of overeating a large amount of food in a discrete period of time where an individual feels that they cannot control their eating

Question 345

BULIMIA NERVOSA | What are purges?

Answer 345

- Compensatory behaviours to prevent weight gain like induced vomiting, laxative misuse, diuretics, appetite suppressants, enemas, fasting or excessive exercise

Question 346

BULIMIA NERVOSA | What is the epidemiology + aetiology of bulimia?

Answer 346

- F>M, common in adolescent, very common premorbid experiences to anorexia (dieting behaviour, weight criticisms, perfectionism)

Question 347

BULIMIA NERVOSA | What is the diagnostic criteria for bulimia?

Answer 347

BPFO ≥2 a week for ≥3m – - Behaviours to prevent weight gain - Preoccupation with eating (compulsion to eat but regret after) - Fear of fatness - Overeating ≥2/week

Question 348

BULIMIA NERVOSA | What are some physical symptoms of bulimia?

Answer 348

- Similar to anorexia but less severe - GI (constipation, bloating, sore throat, GORD + dyspepsia from vomiting, abdo pains) - Dizziness/fainting, headaches, cold intolerance - Polyuria (diuresis), polydipsia, lethargy

Question 349

BULIMIA NERVOSA | What are some clinical signs of bulimia?

Answer 349

- Russel's sign (calluses on dorsum of dominant hand due to vomiting) - Dental enamel erosion - Mouth ulcers - Salivary gland, especially parotid, enlargement

Question 350

BULIMIA NERVOSA | What are some complications of bulimia?

Answer 350

- Cardiomegaly (ipecac toxicity = plant taken PO + can cause vomiting) - Arrhythmias, cardiac failure - Mallory-Weiss tears from vomiting

Question 351

BULIMIA NERVOSA | What are some investigations for bulimia?

Answer 351

- SCOFF - BP (low), temp, SUSS test - ECG (arrhythmias from hypokalaemia) - FBC (anaemia), LFTs, urinalysis, serum proteins - Monitor U+Es, calcium, magnesium, phosphate in vomiting, laxative abuse, diuretics or waterloading (for deceitful weighing)

Question 352

BULIMIA NERVOSA | What metabolic abnormalities may be present?

Answer 352

- Hypochloraemic hypokalaemic metabolic alkalosis due to vomiting - Hypokalaemia > muscle weakness + arrhythmias

Question 353

BULIMIA NERVOSA | When should bulimia be managed as inpatient?

Answer 353

- Suicidality, physical problems, extreme refractory cases | - Pregnancy (risk of spontaneous abortion)

Question 354

BULIMIA NERVOSA | What is the management of bulimia?

Answer 354

- Guided self-help first line with psychoeducation + support group - CBT-ED - Bulimia focussed family therapy in CAMHS - Limited evidence for high-dose fluoxetine

Question 355

BINGE EATING DISORDER | What is binge eating disorder?

Answer 355

- Episodes where person excessively overeats, often as expression of underlying psychological distress - Not restrictive so tends to be overweight

Question 356

BINGE EATING DISORDER | How does binge eating disorder present?

Answer 356

- Planned bine with binge foods - Eating very quickly + becoming uncomfortably full - Eating in "dazed" state - Unrelated to if hungry

Question 357

BINGE EATING DISORDER | What is the management of binge eating disorder?

Answer 357

- Self-help, CBT-ED, may benefit from SSRIs

Question 358

PERSONALITY DISORDERS | What are personality disorders?

Answer 358

- Deeply engrained + enduring patterns of behaviour that are abnormal in a particular culture

Question 359

PERSONALITY DISORDERS | What is the epidemiology of personality disorders?

Answer 359

- Younger adults - Antisocial PD most prevalent amongst prisoners - Dx not made in <18 as personality still developing

Question 360

PERSONALITY DISORDERS | What are some risk factors for personality disorders?

Answer 360

- FHx of PD or other mental illness - Abusive, unstable or chaotic life - Adverse events - Dx of childhood conduct disorder (antisocial PD)

Question 361

PERSONALITY DISORDERS | What are cluster A personality disorders?

Answer 361

- Characterised by odd, eccentric thinking or behaviour | - MAD

Question 362

PERSONALITY DISORDERS | What is paranoid personality disorder?

Answer 362

- Pervasive + unwarranted tendency to interpret the actions of others as demeaning or threatening

Question 363

PERSONALITY DISORDERS In terms of paranoid personality disorder... i) think the world is? ii) think people are? iii) acts as if? iv) common behaviour? v) least likely to be? vi) emotional hotspot?

Answer 363

i) Conspiracy ii) Devious, trying to cause harm iii) Always on guard + suspicious of others, emotionally cold/distant iv) Watchfulness v) Trusting (fear others will use information against you) vi) Being discriminated against

Question 364

PERSONALITY DISORDERS | What is schizoid personality disorder?

Answer 364

- Pervasive pattern of indifference to social relationships + restricted range of emotional experience + expression

Question 365

PERSONALITY DISORDERS In terms of schizoid personality disorder... i) think the world is? ii) think people are? iii) thinks they are? iv) common behaviour? v) least likely to be? vi) emotional hotspot? vii) other?

Answer 365

i) Uncaring ii) Pointless, replaceable iii) Only person they can depend on iv) Withdrawal, prefer to be alone v) Emotionally available + close vi) Being over-cared for or smothered by others vii) Inability to take pleasure from activities, little interest in sex

Question 366

PERSONALITY DISORDERS | What is schizotypal personality disorder?

Answer 366

- Pervasive pattern of deficits in interpersonal relatedness + peculiarities of ideation, experience, appearance + behaviour

Question 367

PERSONALITY DISORDERS | What are some features of schizotypal personality disorder?

Answer 367

- Ideas of reference (not delusions as insight) - Excessive social anxiety with lack of close friends + social withdrawal - "Magical thinking" believing you can influence people/events with thoughts - Unusual perceptions (illusions, overvalued ideas) - Odd/eccentric behaviour, beliefs, speech or appearance - Inappropriate affect with paranoid or suspicious ideas

Question 368

PERSONALITY DISORDERS | What are some differentials of schizotypal personality disorder?

Answer 368

- Autism - Asperger's - Schizophrenia (50% may develop it)

Question 369

PERSONALITY DISORDERS | What are cluster B personality disorders?

Answer 369

- Characterised by dramatic, overly emotional or unpredictable thinking or behaviour (BAD)

Question 370

PERSONALITY DISORDERS | What is dissocial/antisocial personality disorder?

Answer 370

- Childhood conduct disorder before 15 + pattern of irresponsible + antisocial behaviour after age 15

Question 371

PERSONALITY DISORDERS What is a psychopath? What is a sociopath?

Answer 371

- When they get in trouble with the law | - Same traits but without law involvement

Question 372

PERSONALITY DISORDERS In terms of antisocial personality disorder... i) think the world is? ii) think people are? iii) thinks they are? iv) common behaviour? v) least likely to be? vi) emotional hotspot? vii) other?

Answer 372

i) Predatory ii) Weak iii) Autonomous + alone iv) Aggressive/violent v) Gentle + sensitive, conform to social norms vi) Perceiving exploitation vii) Disregard for others' needs, feelings, safety, impulsive + lacks remorse

Question 373

PERSONALITY DISORDERS What is borderline/emotionally unstable personality disorder? What is a big risk factor?

Answer 373

- Pervasive pattern of instability of mood, interpersonal relationships + self image - Often Hx of childhood sexual abuse

Question 374

PERSONALITY DISORDERS In terms of EUPD... i) think the world is? ii) think people are? iii) common behaviour? iv) least likely to be? v) emotional hotspot? vi) other?

Answer 374

i) Contradictory ii) Untrustworthy iii) Self-harm/suicide (impulsive + unpredictable) iv) Able to show self-compassion v) Abandonment (extreme reactions) vi) Paranoid when stressed, labile mood, unstable + intense relationships

Question 375

PERSONALITY DISORDERS In terms of EUPD, what is the difference between... i) impulsive type? ii) borderline type?

Answer 375

i) Difficulties with impulsive + risky behaviours (unsafe sex, gambling) + anger ii) Difficulties with relationships, self-harm + feelings of emptiness

Question 376

PERSONALITY DISORDERS | What is histrionic personality disorder?

Answer 376

- Pervasive pattern of excessive emotionality + attention seeking

Question 377

PERSONALITY DISORDERS In terms of histrionic personality disorder... i) think the world is? ii) think people are? iii) common behaviour? iv) least likely to be? v) emotional hotspot? vi) think they are? vii) think relationships with others are?

Answer 377

i) Their audience (crave attention) ii) In competition for attention iii) Exhibitionism (provocative for attention) iv) Able to listen to others v) Actively or passively side-lined vi) Vivacious, easily influenced by others, excessive concern with physical appearance vii) Closer than what they really are

Question 378

PERSONALITY DISORDERS | What is narcissistic personality disorder?

Answer 378

- Pervasive pattern of grandiosity, lack of empathy + hypersensitivity to the evaluation of others

Question 379

PERSONALITY DISORDERS In terms of narcisssitic personality disorder... i) think the world is? ii) think people are? iii) thinks they are? iv) common behaviour? v) least likely to be? vi) emotional hotspot? vii) other?

Answer 379

THINK LUKE i) Competition ii) Inferior iii) Special + more important than others iv) Competitiveness v) Humble vi) Loss of social rank/status or being embarrassed vii) Failure to recognise other's needs or feelings, arrogance, envy (both ways)

Question 380

PERSONALITY DISORDERS | What are cluster C personality disorders?

Answer 380

- Characterised by anxious, fearful thinking or behaviour (SAD)

Question 381

PERSONALITY DISORDERS | What is anxious/avoidant personality disorder?

Answer 381

- Pervasive pattern of social discomfort, fear of negative evaluation + timidity

Question 382

PERSONALITY DISORDERS In terms of anxious/avoidant personality disorder... i) think the world is? ii) think people are? iii) thinks they are? iv) common behaviour? v) least likely to be? vi) emotional hotspot? vii) other?

Answer 382

i) Evaluative ii) Judgemental iii) Inept iv) Inhibition (social, avoids this) v) Assertive vi) Exposed, ridicule, criticism or rejection vii) Feeling inadequate or inferior, extreme shyness, fear of disapproval

Question 383

PERSONALITY DISORDERS | What is dependent personality disorder?

Answer 383

- Pervasive pattern of dependent + submissive behaviour

Question 384

PERSONALITY DISORDERS In terms of dependent personality disorder... i) think the world is? ii) think people are? iii) they are? iv) common behaviour? v) least likely to be? vi) emotional hotspot? vii) other?

Answer 384

i) Overwhelming ii) Stronger + more competent than themselves iii) Needy iv) Clinging v) Self-sufficient vi) Making a decision, abandonment vii) Requires excessive advice/reassurance, tolerant of abusive treatment, relationship hops, difficult disagreeing with others

Question 385

PERSONALITY DISORDERS What is anankastic/obsessive-compulsive personality disorder? What may it be seen in?

Answer 385

- Pervasive pattern of perfectionism + inflexibility lacking insight - Hx of family pressure + wanting approval

Question 386

PERSONALITY DISORDERS In terms of anankastic/OC personality disorder... i) think the world is? ii) think people are? iii) think they are? iv) common behaviour? v) least likely to be? vi) emotional hotspot? vii) other?

Answer 386

i) Sloppy ii) Irresponsible iii) Responsible iv) Controlling v) Flexible vi) Making a mistake vii) Preoccupied with order, extreme perfectionism, neglect friends due to excessive project commitment, rigid + stubborn

Question 387

PERSONALITY DISORDERS | What are some investigations for personality disorders?

Answer 387

- Assessed (Hx + MSE) more than once - Minnesota Multiphasic Personality Inventory (MMPI) - Eysenck Personality Inventory + Personality Diagnostic Questionnaire

Question 388

PERSONALITY DISORDERS | What is the biological management of personality disorders?

Answer 388

- Only use to treat comorbid conditions or if Sx distressing (e.g. antipsychotics in group A to reduce suspiciousness)

Question 389

PERSONALITY DISORDERS | What are the psychological therapies for personality disorders?

Answer 389

- Dialectical behavioural therapy for EUPD - CBT (change unhelpful ways of thinking) - Cognitive analytical therapy (recognise + change unhelpful patterns in relationships + behaviours) - Psychodynamic therapy (looks at how past experiences affect present behaviour)

Question 390

DELIRIUM TREMENS | What is delirium tremens?

Answer 390

- Acute, toxic confusional state secondary to alcohol withdrawal (48–72h after)

Question 391

DELIRIUM TREMENS | How does delirium tremens present?

Answer 391

- Clouding of consciousness, disorientation + amnesia of recent events - Autonomic = diaphoresis, fever, tachycardia (risk of CV collapse) - Psychomotor agitation, delusions + coarse tremor - Visual, auditory + tactile hallucinations

Question 392

DELIRIUM TREMENS | Describe the hallucinations in delirium tremens

Answer 392

- Characteristically of small people or animals (Lilliputian hallucinations) - May feel 'ants crawling'

Question 393

DELIRIUM TREMENS | What is the management of delirium tremens?

Answer 393

- ABCDE approach as emergency - IV thiamine (pabrinex), supportive fluids - PO lorazepam first line to prevent fitting (IV or haloperidol if refused)

Question 394

WERNICKE'S | What is Wernicke's encephalopathy?

Answer 394

- Atrophy of mammillary bodies due to thiamine deficiency, often alcohol abuse

Question 395

WERNICKE'S | How does Wernicke's present?

Answer 395

Triad – - Ataxia - Confusion - Ophthalmoplegia + nystagmus

Question 396

WERNICKE'S | What is the management of Wernicke's?

Answer 396

- ABCDE approach as emergency - IV pabrinex immediately - Treat high risk patients (alcoholics) with prophylactic vitamins

Question 397

KORSAKOFF'S | What is Korsakoff's psychosis?

Answer 397

- Thiamine deficiency causes damage + haemorrhage to the mammillary bodies of the hypothalamus + medial thalamus - Complication of untreated Wernicke's

Question 398

KORSAKOFF'S | What are some causes of Korsakoff's?

Answer 398

- Heavy alcohol drinkers - Head injury, post-anaesthesia - Basal or temporal lobe encephalitis - CO poisoning - Other causes of thiamine deficiency (anorexia, starvation, hyperemesis)

Question 399

KORSAKOFF'S | What is the clinical presentation of Korsakoff's?

Answer 399

- Profound short-term memory loss with inability to lay down new memories (antero + retrograde amnesia) - Confabulation

Question 400

KORSAKOFF'S | What is the management of Korsakoff's?

Answer 400

- ABCDE approach as emergency - PO thiamine replacement + multivitamin supplements (for up to 2y) - OT assessment + cognitive rehab

Question 401

LITHIUM TOXICITY What is lithium toxicity? What can precipitate it?

Answer 401

- Serum lithium >1.5mmol/L - >2mmol/L = life-threatening - Dehydration, renal failure, diuretics, anti-HTNs + NSAIDs

Question 402

LITHIUM TOXICITY What is... i) acute ii) chronic iii) acute-on-chronic lithium toxicity?

Answer 402

i) Acute ingestion in patient not chronically on lithium ii) Patients on long-term lithium without acute OD iii) Ingestion of excess lithium in patients on chronic lithium

Question 403

LITHIUM TOXICITY | What is the clinical presentation of lithium toxicity?

Answer 403

- Ataxia, dysarthria, confusion (drunk) - COARSE tremor, blurred vision, hyperreflexia - N+V, diarrhoea - Myoclonus, seizures + coma if severe

Question 404

LITHIUM TOXICITY | What are some complications of lithium toxicity?

Answer 404

- Arrhythmias (VT) - Acute renal failure - Syndrome of irreversible lithium-effectuated neurotoxicity (SILENT) after cessation of lithium >2m = truncal ataxia, ataxic gait, scanning speech, incoordination

Question 405

LITHIUM TOXICITY | What is the management of lithium toxicity?

Answer 405

- ABCDE approach as emergency - Stop + check lithium levels, serum creatinine, U+Es - IV fluids (bolus + 1.5–2x maintenance - ?Whole bowel irrigation with polyethene glycol for severe, acute ingestion - Haemodialysis

Question 406

LITHIUM TOXICITY | When would you do haemodialysis in lithium toxicity?

Answer 406

- Serum [Li] >5mmol/L OR >4 + renal dysfunction OR severe toxicity (seizures, coma, life-threatening arrhythmias)

Question 407

ACUTE DYSTONIA What is an acute dystonic reaction? What may it be caused by?

Answer 407

- Sustained painful muscle contraction in ≥1 muscle groups - ?Imbalance of dopamine + cholinergic transmission where D2 receptors become so blocked that excess output of cholinergics

Question 408

ACUTE DYSTONIA What is the clinical presentation of acute dystonic reaction? What is the life-threatening complication?

Answer 408

- Rapid onset after dose given or changed - Spasm of muscles of tongue, face, neck + back - Oculogyric crisis (prolonged involuntary upward deviation of eyes) - Torticollis (twisted neck) - Tongue protrusion - Laryngeal dystonia > airway compromised

Question 409

ACUTE DYSTONIA | What is the management of acute dystonia?

Answer 409

- ABCDE approach as emergency - Anticholinergic – IM procyclidine - Stop antipsychotic (switch to atypical as less EPSEs)

Question 410

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

Answer 410

- Dopamine antagonism often due to typical antipsychotic OD or acute withdrawal of Parkinson's meds

Question 411

NMS | How quickly does NMS present?

Answer 411

- Onset within 2w of drug or dose change (onset + progression slow) - May last 7–10d after PO or 21d after depot

Question 412

NMS | What is the clinical presentation?

Answer 412

Bodybuilder– - Pyrexia >38 + diaphoresis - Muscle rigidity (diffuse "lead-pipe" rigidity) - Confusion, agitation, altered consciousness - Tachycardia, high/low BP - Hyporeflexia

Question 413

NMS | What are the complications of NMS?

Answer 413

- Resp failure, CV collapse - Rhabdomyolysis - DIC

Question 414

NMS | What are some investigations for NMS?

Answer 414

- FBC (leukocytosis) - Low serum iron - U+Es, Ca2+, phosphate - Urinary myoglobin (raised) - Serum creatinine phosphokinase (CPK) may be raised - CK raised

Question 415

NMS | What is the management of NMS?

Answer 415

- ABCDE approach - Stop antipsychotic (wait >2w before restarting, consider atypical) - Give L-dopa if dopamine withdrawal in Parkinson's - IV dantrolene or lorazepam to reduce rigidity 1st line (amantadine second) - Bromocriptine prophylaxis

Question 416

NMS | What is the supportive management for NMS?

Answer 416

- Oxygen, cooling blankets, antipyretics, ice-water enema for pyrexia - IV access to correct volume depletion + reduce risk of rhabdomyolysis with fluids (cooled)

Question 417

NMS | How is risk of rhabdomyolysis reduced?

Answer 417

- Vigorous hydration | - Alkalinisation with IV sodium bicarbonate (target urine pH of 6)

Question 418

SEROTONIN SYNDROME | What is serotonin syndrome?

Answer 418

- Disorder caused by excess serotonin in brain

Question 419

SEROTONIN SYNDROME | What are some causes of serotonin syndrome?

Answer 419

- Antidepressants = SSRIs (inhibit reuptake), SNRIs, St. John's wart, MAOI (decreased metabolism) - Drugs = ecstasy, amphetamines, LSD, anti-emetics

Question 420

SEROTONIN SYNDROME | What is the clinical presentation of serotonin syndrome?

Answer 420

Sx onset + recovery fast – - Neuro = confusion, agitation - Neuromuscular = myoclonus, tremors (incl. shivering), hyperreflexia, ataxia - Autonomic = hyperthermia, diarrhoea, tachycardia, mydriasis

Question 421

SEROTONIN SYNDROME | What are some investigations for serotonin syndrome?

Answer 421

- FBC, U+Es, biochemistry (Ca2+, Mg2+, phosphate), CK, drug toxicology scren - ECG monitoring for prolonged QRS or QTc interval

Question 422

SEROTONIN SYNDROME | What is the management of serotonin syndrome?

Answer 422

- ABCDE - Stop offending agent - IV access to correct volume + reduce risk of rhabdomyolysis as in NMS - BDZs like slow IV lorazepam for agitation, seizures + myoclonus - Serotonin receptor antagonists like PO cyproheptadine or chlorpromazine if severe

Question 423

SEROTONIN SYNDROME | What is the management of serotonergic drug OD?

Answer 423

- ?Gastric lavage ± activated charcoal

Question 424

CATATONIA | What is catatonia?

Answer 424

- Group of Sx that usually involve lack of movement + communication.

Question 425

CATATONIA | What are the 3 types of catatonia?

Answer 425

- Akinetic = won't move or communicate - Excited = may move around but movement pointless or impulsive, may be agitated, combative, delirious - Malignant = Sx > other health problems (changes in temp, BP, breathing, HR)

Question 426

CATATONIA | What are some causes of catatonia?

Answer 426

- Mania (#1), depression (manic or depressive stupor) | - Can be caused by heat stroke, BDZ withdrawal + Parkinsonism

Question 427

CATATONIA | What is the clinical presentation of catatonia?

Answer 427

- Mutism + staring - Posturing (stays in fixed position), rigidity - Negativism (resistance to attempts to move) - Echopraxia + echolalia

Question 428

CATATONIA | What are some complications of catatonia?

Answer 428

- Long-term issues with dehydration, VTE or renal failure

Question 429

CATATONIA | What are some investigations for catatonia?

Answer 429

- Temp, BP, pulse, FBC, U+Es, LFTs, glucose, TFTs, cortisol, prolactin

Question 430

CATATONIA | What is the management of catatonia?

Answer 430

- BDZs (PO/IM lorazepam) - Barbiturates (amobarbital) - ECT - Address underlying issue

Question 431

LEARNING DISABILITIES | What is a learning disability?

Answer 431

- Condition of arrested or incomplete development of mind, characterised by impairment of skills that contribute to overall intelligence (language, cognition, social) which has manifested during developmental period

Question 432

LEARNING DISABILITIES | How is a learning disability different to learning difficulties?

Answer 432

- Learning difficulties (dyslexia) are difficulties in acquiring knowledge + skills to the normal level expected of those of the same age, especially due to a mental disability or cognitive disorder

Question 433

LEARNING DISABILITIES | What is the triad in learning disabilities?

Answer 433

- Low intellectual performance (IQ < 70) - Onset during birth or early childhood - Wide range of functional impairment

Question 434

LEARNING DISABILITIES | What is the epidemiology of learning disabilities?

Answer 434

- M>F, biggest risk factor is FHx

Question 435

LEARNING DISABILITIES | What are some causes of learning disabilities?

Answer 435

- Genetic = Down's, Fragile X, Prader-Willi, neurofibromatosis - Antenatal = TORCH - Perinatal = asphyxia, intraventricular haemorrhage - Postnatal = meningitis, kernicterus - Environmental = malnutrition, smoking or alcohol in pregnancy

Question 436

LEARNING DISABILITIES | What physical disorders may be present in those with learning disabilities?

Answer 436

- Motor disabilities (ataxia, spasticity) - Epilepsy - Impaired hearing/vision - Incontinence

Question 437

LEARNING DISABILITIES How is mild learning disability characterised by... i) IQ? ii) mental age? iii) mobility? iv) speech? v) academia? vi) self-care?

Answer 437

i) 50–69 ii) 9–12 iii) Mobile iv) Mostly adequate v) Difficulties reading + writing vi) Most independent

Question 438

LEARNING DISABILITIES How is moderate learning disability characterised by... i) IQ? ii) mental age? iii) mobility? iv) speech? v) academia? vi) self-care?

Answer 438

i) 35–49 ii) 6–9 iii) Mobile iv) Simple-no speech, may sign, reasonable comprehension v) Limited, some learn to read, write + count vi) Lifelong supervision, may need prompting + support

Question 439

LEARNING DISABILITIES How is severe learning disability characterised by... i) IQ? ii) mental age? iii) mobility? iv) speech? v) academia? vi) self-care?

Answer 439

i) 20–34 ii) 3–6 iii) Marked impairment iv) Simple-no speech, may sign, reasonable comprehension v) Limited, some learn to read, write + count vi) Lifelong supervision, may need prompting + support

Question 440

LEARNING DISABILITIES How is profound learning disability characterised by... i) IQ? ii) mental age? iii) mobility? iv) speech? v) academia? vi) self-care?

Answer 440

i) <20 ii) <3 iii) Severe impairment iv) Basic non-verbal comms, understands basic commands v) None vi) Complete dependency

Question 441

SEPARATION ANXIETY What is separation anxiety? What may cause it?

Answer 441

- Children become distressed if separated from attachment figure (usually mum) - Parental overprotection, may develop following stressful event

Question 442

SEPARATION ANXIETY | Is separation anxiety normal?

Answer 442

- Yes for toddlers | - Pathological in older children when interferes with social functioning (off school, inability to sleep without parent)

Question 443

SEPARATION ANXIETY | What are the stages of attachment?

Answer 443

- Indiscriminate attachment (0–3m) - Preference for main caregivers (3–6m) - Only main caregiver (6–12m) - Increasingly able to separate from main caregiver (>12m)

Question 444

SEPARATION ANXIETY | What is the importance of attachment?

Answer 444

- Infants need to develop relationship with ≥1 primary caregiver for successful social + emotional development, especially learning how to effectively regulate emotions

Question 445

SCHOOL PHOBIA/REFUSAL What is school phobia/refusal? When may it occur? How is it managed?

Answer 445

- Child refuses to attend school due to specific fear (bullying, unsympathetic teacher, fear of failure) - May occur in families with 'precious' child (issues conceiving, sibling death) - Address anxieties of child + parent + reintroduce to school ASAP

Question 446

AUTISM SPECTRUM What is autism? What is associated with autism? What is Asperger's syndrome?

Answer 446

- Pervasive development disorder which manifests before age 3 - Learning difficulties - ASD without cognitive impairment + fewer problems with language

Question 447

AUTISM SPECTRUM | What are some risk factors for autism?

Answer 447

- M>F - Obstetric complications - Perinatal infection (rubella) - Genetic disorders (Fragile X, Down's)

Question 448

AUTISM SPECTRUM | What are the 3 areas of impaired functioning that need to be present in autism?

Answer 448

- Social interaction - Communication (speech + language) - Behaviour (imposition of routine with ritualistic or repetitive behaviour)

Question 449

AUTISM SPECTRUM | Give some examples of impaired social interaction

Answer 449

- Failure to notice + respond to social cues + others' emotional states - Difficulty establishing friendships - Lack of eye contact - Delay in smiling

Question 450

AUTISM SPECTRUM | Give some examples of impaired communication

Answer 450

- Expressive speech + comprehension usually delayed or minimal - Concrete thinking (lack imagination) - Absence of gestures - Later speech consists of monologues, endless questions, echolalia

Question 451

AUTISM SPECTRUM | Give some examples of impaired behaviours

Answer 451

- Inability to adapt to new environments (distress) - Tendency to have rigid routine with resistance to change - Greater interest in objects, numbers + patterns than people - Stereotypical repetitive movements which may be self-stimulating movements to comfort themselves (rocking, hand-flapping)

Question 452

AUTISM SPECTRUM | What is the management of autism?

Answer 452

- No cure so MDT for best environment to support child + parent - CAMHS, paediatrician, SALT, dieticians, social workers, specially trained educators, special school environments - Picture based timetables - Charities for support (national autistic society)

Question 453

TIC DISORDERS What are tics? What might cause them?

Answer 453

- Repetitive, involuntary, purposeless movements + sounds | - Stress, gestational + perinatal insults, PANDAS

Question 454

TIC DISORDERS | What is the epidemiology of tics?

Answer 454

- Transient simple tics affect 10% of children - May be associated with OCD, ADHD + ASD - M>F, usually present around or after 5y

Question 455

TIC DISORDERS What are the two types of tics? How may they manifest?

Answer 455

- Simple - Complex - May be invisible to observer (abdo tensing, toe crunching)

Question 456

TIC DISORDERS | Give some examples of simple tics

Answer 456

- Throat-clearing - Blinking - Sniffing - Head jerking - Eye rolling

Question 457

TIC DISORDERS | Give some examples of complex tics

Answer 457

- Physical movements (twirling on spot, touching objects) - Copropraxia (obscene gestures) - Coprolalia (obscene words) - Echolalia

Question 458

TIC DISORDERS What improves or worsens tics? What sensations are felt before tics?

Answer 458

- Stress + stimulant meds worsen, distraction improves - Premonitory = pts feel urge to perform tic, often several times to get relief from that urge (can be suppressed but internal tension builds)

Question 459

TIC DISORDERS What is Tourette's syndrome? How does Tourette's syndrome present?

Answer 459

- Development of tics that are persistent for >1y - More severe expression of the spectrum of tic disorder - Multiple motor tics + at least 1 phonic tic (coprolalia)

Question 460

TIC DISORDERS | What is the management of mild tics?

Answer 460

- Watch + wait (usually improve over time - Education + reassurance - Avoid caffeine + stress

Question 461

TIC DISORDERS | What is the management of severe tics?

Answer 461

- Habit reversal training - ERP - Antipsychotics considered in VERY severe cases

Question 462

ENURESIS | What is enuresis?

Answer 462

- Involuntary discharge of urine by day, night or both in child aged ≥5y, in the absence of an organic cause - Common, M>F

Question 463

ENURESIS What are the 2 types of enuresis? Why may it occur?

Answer 463

- Primary = bladder control never mastered - Secondary = follows at least 1y of continence - Often emotional upset, polyuria from diabetes

Question 464

ENURESIS | What can cause enuresis?

Answer 464

- Detrusor instability - Bladder neck weakness - Lack of attention to bladder sensation - Neuropathic bladder - UTI

Question 465

ENURESIS | What is the management of enuresis?

Answer 465

- Reassurance, advice on diet + toileting behaviour, restrict fluids before bed - Positive reinforcement (star charts for dry night) - 1st line Mx = enuresis alarm if <7, desmopressin if >7y

Question 466

ADHD | What is attention deficit hyperactivity disorder (ADHD)?

Answer 466

- Extreme end of hyperactivity + inability to concentrate, affecting person's ability to carry out everyday tasks, develop normal skills + perform well in school

Question 467

ADHD | What are some risk factors for ADHD?

Answer 467

- Epilepsy, low socioeconomic status, learning difficulties - Premature or LBW - Brain damage (in vitro or after severe head injury later)

Question 468

ADHD | What is the epidemiology of ADHD?

Answer 468

- M>F | - Dx between 6–12y (must be ≥6y but show Sx before 12y)

Question 469

ADHD | What is the triad of symptoms in ADHD?

Answer 469

- Inattention - Impulsivity - Hyperactivity

Question 470

ADHD | How does inattention present?

Answer 470

- Short attention span - Quickly changes task as loses interest - Easily distracted - Loses important items - Careless mistakes

Question 471

ADHD | How does impulsivity present?

Answer 471

- Blurts answer before questions completed - Difficulty awaiting turn - Interrupts others - Teenagers have impulsive behaviours (car accidents, pregnancy)

Question 472

ADHD | How does hyperactivity present?

Answer 472

- Constantly fidgeting - Constant "on the go" or "driven by a motor" - Excessive talking

Question 473

ADHD | How is a diagnosis of ADHD reached?

Answer 473

- Features consistent across ≥2 settings (home, school) - Diagnosed ≥6y when Sx present continuously for ≥6m - Information from teachers, school reports, family etc used

Question 474

ADHD | What is the management of ADHD?

Answer 474

Conservative initially (watch + wait) – - Family education on ADHD + parenting advice - Establish normal balanced diet, exercise can improve Sx - Food diary to identify any triggers + eliminate with dietician

Question 475

ADHD | What is the management for severe ADHD?

Answer 475

- CNS stimulants like methylphenidate (increase monoamine pathway activity, not addictive) - S/E = appetite suppression, insomnia, psychosis, important to monitor growth, baseline ECG (cardiotoxic) - Atomoxetine (SE = liver dysfunction, suicidality) - (Lis)dexamfetamine

Question 476

CONDUCT DISORDER What is conduct disorder? What are the 2 types?

Answer 476

- Persistently, marked antisocial behaviours - Socialised = child has peer group, often share antisocial behaviour - Unsocialised = rejected by others so more isolated + hostile

Question 477

CONDUCT DISORDER What is the epidemiology of conduct disorder? What are some risk factors?

Answer 477

- M>F, more common in adolescents - Urban upbringing, deprivation, parental criminality, harsh or inconsistent parenting (behaviours often learned from parents)

Question 478

CONDUCT DISORDER | What is the clinical presentation of conduct disorder?

Answer 478

- Aggression/violence towards people or animals - Destruction of property - Deceitfulness or theft - Serious violations of rules

Question 479

CONDUCT DISORDER | How is conduct disorder managed?

Answer 479

- 3–11y = group parent training programme (focus on parenting skills to improve child's behaviour) - 9–14y = child-focused programmes (focus on child's behaviours) - Older = multimodal interventions with many services

Question 480

CONDUCT DISORDER | What can be used as a last resort in conduct disorder?

Answer 480

- Antipsychotic like risperidone to reduce aggressive tendencies

Question 481

ODD What is oppositional defiant disorder (ODD)? What may be linked to ODD?

Answer 481

- Negative, hostile + defiant behaviour particularly directed towards authority figures like parents + teachers - Common in children with ADHD, may be linked to parenting styles

Question 482

ODD | How can ODD and conduct disorder be differentiated?

Answer 482

- Less severe + more common | - Children are NOT aggressive and do NOT destroy property or steal etc.

Question 483

ODD | What is the clinical presentation of ODD?

Answer 483

- Loses temper + argumentative - Actively defies or refuses to comply with adult's requests or rules - Blames others for their mistakes or misbehaviour

Question 484

ODD | What is the management of ODD?

Answer 484

- Child-focussed programmes + group parent training programmes

Question 485

CONVERSION DISORDERS | What is a conversion disorder?

Answer 485

- Actual loss or disturbance of normal motor/sensory function which initially appears to have neuro or physical cause but is later credited to psychological

Question 486

CONVERSION DISORDERS | What is the most severe form of dissociative/conversion disorders?

Answer 486

- Dissociative identity disorder (multiple personality disorder) = inability to recall personal information, may have loss of identity.

Question 487

CONVERSION DISORDERS | What are the features of conversion disorders?

Answer 487

- Paralysis (any pattern) - Aphonia (complete loss or whispered speech) - Sensory loss (area may cover patient's beliefs about anatomy) - Seizure (NEAD) - Amnesia (short-term memory loss usually too severe for forgetfulness)

Question 488

CONVERSION DISORDERS | When would you suspect conversion disorder?

Answer 488

- Clinically inconsistent nature (or absence) of signs - Excluded underlying organic disease - Convincing psychological explanation for deficit (can be induced by stressful event)

Question 489

CONVERSION DISORDERS | What is the management of conversion disorder?

Answer 489

- Present Dx of positive (emphasise likelihood of recovery) - May need physio - CBT, interpersonal therapy, supportive psychotherapy or family therapy may help

Question 490

SOMATISATION DISORDER | What is somatisation disorder?

Answer 490

- Multiple, atypical + inconsistent presentations with MUS, affecting multiple organ systems. - Symptoms present ≥2y, F>>M

Question 491

SOMATISATION DISORDER | What is the clinical presentation of somatisation disorder?

Answer 491

- Non-specific + atypical Sx (usually derm, GI) - Discrepancy between subjective + objective findings (S = Sx) - Sx often in one system, may move to another once Dx possibilities exhausted - Often results in multiple needless investigations + operations (pt refuses to accept -ve results)

Question 492

SOMATISATION DISORDER | What is the management of somatisation disorder?

Answer 492

- Rule out all organic illnesses - Communicate Dx but acknowledge Sx severity - Reassure patient of continuing care - May benefit from CBT, group therapy or psychotherapy

Question 493

HYPOCHONDRIASIS | What is hypochondriacal disorder?

Answer 493

- Preoccupation with fear of having a serious disease (C = condition) which persists despite -ve Ix + appropriate reassurance

Question 494

HYPOCHONDRIASIS | What is the clinical presentation of hypochondriasis?

Answer 494

- Over-valued idea of having serious medical condition, often fatal - Ruminates on possibility, misinterprets insignificant bodily abnormalities as signs of serious disease needing investigation - Unable to be reassured by negative investigations

Question 495

HYPOCHONDRIASIS | What is the management of hypochondriasis?

Answer 495

- Clarify Sx real but emphasise absence of organic cause - SSRIs may help - ERP to illness cues, CBT to identify + challenge misinterpretations + substitute realistic interpretations

Question 496

SOMATOFORM PAIN | What is somatoform pain disorder?

Answer 496

- Complaint of persistent + distressing pain which is not adequately explained by organic pathology

Question 497

SOMATOFORM PAIN | What is the management of somatoform pain disorder?

Answer 497

- Atheoretical "see what works" approach - Pain clinics (anaesthetics led, antidepressants, transcutaneous electrical nerve stimulation/TENS, local + regional nerve blocks) - Relaxation training, CBT, hypnotherapy

Question 498

MUNCHAUSEN'S | What is Munchausen's (factitious disorder)?

Answer 498

- Pt intentionally falsifies their Sx, past Hx + fabricate signs of physical or mental disorder with primary aim of obtaining medical attention + Tx - May flee when story questioned

Question 499

MUNCHAUSEN'S | What are the 3 subtypes of Munchausen's?

Answer 499

- Wandering - Non-wandering - By proxy

Question 500

MUNCHAUSEN'S | What is wandering Munchausen's?

Answer 500

- M>F | - Move hospital-hospital, job-job, place-place, makes elaborate stories, changes name

Question 501

MUNCHAUSEN'S | What is non-wandering Munchausen's?

Answer 501

- F>M - More stable lifestyles, less dramatic presentations - Often paramedical professionals - Associated with EUPD

Question 502

MUNCHAUSEN'S | What is Munchausen's by proxy?

Answer 502

- F>M - Mothers, carers, paramedic staff who simulate or prolong illness in their dependents - Clinical focus to prevent further harm on the dependent

Question 503

MUNCHAUSEN'S | What is the management of Munchausen's?

Answer 503

- Reduce iatrogenic harm from inappropriate tests + treatment - Challenge pt in non-punitive manner - Healthcare systems change to prevent harm (blacklisting)

Question 504

MALINGERING What is malingering? Give some examples

Answer 504

- Fraudulent simulation or exaggeration of Sx for personal gain - Drug-seeking behaviours, avoid army service, compensation

Question 505

COUNSELLING | What is counselling?

Answer 505

- Relieving distress via dialogue between 2 people | - Therapist listens + helps patient find own solutions

Question 506

PSYCHOEDUCATION | What is psychoeducation?

Answer 506

- Briefing patients about their illness so they understand it better - Problem solving training so they know how to deal with it better - Communication training so they can express their emotions better - Self-assertiveness training, relatives included

Question 507

CBT | What is the role of cognitive behavioural therapy (CBT)?

Answer 507

- Identify + challenge negative thoughts + modify abnormal core beliefs - Based on idea disorder not caused by life events but way patient views these events > better emotional regulation

Question 508

DBT | What is dialectical behavioural therapy (DBT)?

Answer 508

- Helps to change unhelpful ways of thinking (anger) + behaving (self-harm) like CBT but also focuses on accepting who you are at same time (accept + change

Question 509

DBT | What are the two components to DBT?

Answer 509

- Individual therapy = therapist validates pt's responses, reinforces adaptive behaviours + facilitates analysis of maladaptive behaviours + their triggers - Group therapy = teaching on mindfulness, interpersonal effectiveness skills (problem solving, communication), emotional modulation skills

Question 510

PSYCHOANALYTICAL PSYCHOTHERAPY | What is psychoanalytical psychotherapy?

Answer 510

- Childhood experiences, past conflicts + relationships influence individual's current situation - Once inner struggles brought to light, behaviour + feelings improve

Question 511

GROUP PSYCHOTHERAPY What is group psychotherapy? Give some examples

Answer 511

- Individuals brought together under therapist's guidance with goals of reducing distress + Sx, increasing coping or improving relationships - Support groups, activity groups (art, music), self-help groups (AA)

Question 512

FAMILY THERAPY | What is family therapy?

Answer 512

- Enables those in close relationships to better understand, support each other better, explore each other's thoughts + build on family strengths together

Question 513

INTERPERSONAL THERAPY What is interpersonal therapy? What is it used in?

Answer 513

- Identify + address problems in their relationships with idea that poor relationships can leave you depressed + depression in turn can make relationships worse - Depression (severe or not responded to other therapies)

Question 514

BEHAVIOURAL ACTIVATION What is behavioural activation therapy? What is it used for?

Answer 514

- Aim to give patients motivation to make simple, practical steps towards enjoying life again - Also teaches problem-solving skills - Depression

Question 515

GENDER DYSPHORIA | What is gender dysphoria?

Answer 515

- Mismatch between biological sex + gender identity of an individual causing distress

Question 516

GENDER DYSPHORIA Define... i) transsexual ii) trans woman iii) trans man

Answer 516

i) Person who emotionally + psychologically feels that they belong to opposite sex ii) Assigned male sex 46XY at birth who later identifies as a woman iii) Assigned female sex 46XX who later identifies as a man

Question 517

GENDER DYSPHORIA | What act is relevant to gender dysphoria?

Answer 517

- Gender recognition act 2004 - Allows transsexual people to legally change their gender - Have to demonstrate Dx of gender dysphoria + have lived as gender role for ≥2y

Question 518

GENDER DYSPHORIA | What is the clinical presentation of gender dysphoria?

Answer 518

- Low self-esteem, self-neglect, social isolation - Depression, anxiety + suicidality - Only comfortable when in preferred gender role - Strong desire to hide physical signs + dislike of genitals of biological sex

Question 519

GENDER DYSPHORIA What is the management of gender dysphoria in... i) <18? ii) >18?

Answer 519

i) Referral to gender identity development service (GIDS) with MDT (CAMHS, clinical psychologist, social worker, family therapist) ii) Referral to gender dysphoria clinic (GP or self-referral)

Question 520

GENDER DYSPHORIA | What surgical procedures may be offered?

Answer 520

- TM = mastectomy, hysterectomy, nipple repositioning, phalloplasty or penile implant, scrotoplasty + testicular implants - TW = orchidectomy, penectomy, vaginoplasty, vulvoplasty or clitoroplasty

Question 521

GENDER DYSPHORIA | What biological treatment can be used in <16y?

Answer 521

- Very few young people who meet strict criteria may have gonadotropin-releasing hormone analogues (hormone blockers) as reach puberty

Question 522

GENDER DYSPHORIA | What biological treatment can be used >16?

Answer 522

- Cross-sex/gender-affirming hormones if on hormone blockers for ≥12m – Oestrogen for breasts + feminine features – Testosterone for deep voice + masculine features (body hair)

Question 523

GENDER DYSPHORIA What psychological treatment can be given to... i) <18y? ii) >18y?

Answer 523

i) Family therapy, individual child psychotherapy, parental support/counselling ii) Counselling, SALT to help sound like gender identity

Question 524

GENDER DYSPHORIA | What social management is there for gender dysphoria?

Answer 524

- Quit smoking (may increase risks of side effects from treatments) - Lose weight if overweight to reduce risks from cross-sex hormones) - Social transitioning incl. changing name by deed poll

Question 525

GENDER DYSPHORIA | What are some risks of the hormone therapy?

Answer 525

- Oestrogen = clots, gallstones, high triglycerides - Testosterone = polycythaemia, acne, dyslipidaemia - Both = elevated LFTs, infertility, weight gain

Question 526

SLEEP DISORDERS | What is insomnia?

Answer 526

- Issues with – falling to, maintaining or poor quality of sleep (≥3d/week for 1m)

Question 527

SLEEP DISORDERS | What are the 2 types of insomnia?

Answer 527

- Primary = intrinsic + Extrinsic factors (fear of falling asleep, poor sleep hygiene, change of environment) - Secondary = to illness or substance misuse (sleep apneoa, circadian rhythm disorder, shift work)

Question 528

SLEEP DISORDERS | What is the management of insomnia?

Answer 528

- Rx with zopiclone if good sleep hygiene unsuccessful | - Mirtazapine

Question 529

SLEEP DISORDERS What is narcolepsy? What is cataplexy?

Answer 529

- Hypersomnolence, sleep paralysis, hypnogogic + hypnopompic hallucinations - Cataplexy = sudden loss of muscle tone often triggered by emotion

Question 530

SLEEP DISORDERS | What is the management of narcolepsy?

Answer 530

- Multiple sleep latency EEG, early onset REM sleep | - Rx with daytime stimulants (modafinil) + night-time sodium oxybate

Question 531

SLEEP DISORDERS | What is circadian rhythm disorder?

Answer 531

- Mismatch between sleep-wake cycle + circadian rhythms (jet lag, shift work)

Question 532

SLEEP DISORDERS | What is parasomnia?

Answer 532

- Restless leg syndrome - Nightmares + night tremors - Sleep walking + talking

Question 533

SLEEP DISORDERS | What are some sleep hygiene advice?

Answer 533

- Limit caffeine, alcohol + cigarettes - Reduce noise, lights + phone use, wind down before bed - Reduce sleep during day + try establish regular pattern