psych

Question 1

What are the DSM V criteria for major depression?

Answer 1

Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) criteria for major depression are five or more of the following symptoms persisting over a 2 week period, that are a change from previous functioning, causing clinically important distress or impairing work, social or personal functioning (with depressed mood or decreased interest or pleasure as one of the five):

Depressed mood most of the day, occurring most days(subjective or observed)

Markedly diminished interest or pleasure most of the day, nearly every day

Significant weight or appetite change

Insomnia or hypersomnia nearly every day

Psychomotor agitation or retardation nearly every day (observable by others)

Fatigue or loss of energy nearly every day

Feelings of worthlessness or inappropriate guilt nearly every day

Diminished ability to concentrate or make decisions nearly every day

Thought of death (not just fear of dying), recurrent suicidal ideation without specific plan, or suicide attempt, or a specific plan for suicide

Recurring thoughts of death or suicide plans

Question 2

How should a GP handle a patient whom they suspect is being subject to intimate partner abuse?

Answer 2

GPs should encourage patients to report assault to the police but it is important not to pressure them into making any decisions. GPs should express concern about safety and risk but it is a woman’s right to decide upon her own pathway to safety. It has been found that the gender of the healthcare professional does not impact upon disclosure of intimate partner violence. Intimate partner abuse is common and is a major cause of death and disability of women of child-bearing age. It also has negative health effects on children.

Question 3

Perform a clinical examination to rule out the DDx of depression

Answer 3

obs (? infective delirium)

mental state; delerium, psychosis, mania, withdrawal states

gen med; anaemia, hypothyroid, B12; angular cheilitis

neuro; intracerebral mass, Parkinson, dementia

Question 4

What are the co contributing causes of depression

Answer 4

Genetic; F>M, FHx

Biological; neurohormonal, peripartum, drugs (COCP, CS, B blocker), medical (psych, Parkinson, Dementia, thyroid, post infective states)

Environmental; stressors, seasonal

Question 5

What are the different classes of antidepressants

Answer 5

1) enzyme inhibitors
- MOAI; moclobemide
2) reuptake inhibitors
- NADI; bupropion
- NRI; raboxetine
- SNRI; venlafaxine, duloxetine, amitriptyline
- SSRI; fluoxetine, citalopram, sertraline
3) receptor modulators
- NaSSA; mirtazapine

Question 6

Outline the considerations with antidepressant use in

1. adolescents
2. 18-25yo

Answer 6

generally not utilised unless depression is severe

risk vs benefit ratio is equivocal as may experience a worsening of symptoms — in particular, suicidal ideation

Question 7

What are the precautions for TCAs

Answer 7

epilepsy; lowers seizure threshold

psychiatric; overdose carries high risk of fatality acute

cardiovascular;

proarrythmic (QT prolongation)

chornotropic (may precipitate angina)

orthostatic hypotension is likely to be exacerbated

prostatic hypertrophy; risk of precipitating urinary retention

Question 8

What is the link between antidepressants and bleeding

Answer 8

platelets require serotonin to function. SSRIs thus inhibit this uptake and increase risk (absolute risk is low) of bleeding (especially GIT). Need to contextualise with other bleeding risk factors

Question 9

What are the three primary sites of action and associated functions of serotonin

Answer 9

90% GIT; regulates intestinal movements
10% CNS; mood, appetite, sleep
platelets; some GIT secreted serotonin taken up by platelets and then released when platelets bind to a clot to promote vasoconstriction and clot homeostasis

Question 10

Name five agents that could contribute to serotonin syndrome

Answer 10

TCA, SSRI, MAOi, triptans, St Johns Wart

Question 11

What are the eight clinical features to assess when diagnosing serotonin syndrome

Answer 11

1) agitation 2) temperature 3) diaphoesis 4) ocular clonus 5) tremor 6) peripheral clonus (spontaneous or inducible) 7) hypertonism 8) hyperreflexia

Question 12

Management of Serotonin syndrome?

Answer 12

withdrawal of the offending drugs, aggressive supportive care and occasionally serotonin antagonists such as cyproheptadine

Question 13

Outline the duration of antidepressant therapy for different scenarios

Answer 13

1) first time; 2 weeks for onset, up to 6 weeks for full effect
2) first time with benefit; continue for 6-12 months
3) relapse of depression; likely required for 3 - 5 years

Question 14

Outline the features of antidepressant discontinuation syndrome and steps to prevent it

Answer 14

symptoms may include insomnia, postural imbalance, sensory disturbances, hyperarousal, nausea and flu-like symptoms
are mild, last 1 to 2 weeks, and are rapidly extinguished with reinstitution of the antidepressant
Prevent via tapering by halving dose weekly

Question 15

In a presentation of a depressed patient what are the seven different mood disorders that need be considered

Answer 15

Major Depressive Episode
Post partum blues / depression / psychosis
Bipolar disorder
Dysthymic disorder; low or irritable mood in a young person for most days over 1 year
Cyclothymia
Adjustement disorder with depressed mood
Secondary causes for depression

Question 16

What are the indications for a child or adolescent to be referred to a mental health service

Answer 16

• moderate to severe depression
• complicated depression; suicidality, substance abuse
• diagnostic uncertainty
• before starting antidepressants

Question 17

What are the two distinct age of onsets for Bipolar disorder and the aetiological factors associated with each

Answer 17

Early adulthood = genetic (“primary”)

>40yo for first episode = more likely to be secondary to

drugs (CS, antiparkinsonian)

medical (stroke, tumour, hyperthyroidism)

Question 18

differentiate mania and hypomania

Answer 18

mania = elevated mood that affects function lasting \>7 days
hypomania = mania but lasting between 4 and 7 days

Question 19

differentiate between Bipolar I and II

Answer 19

I = has experienced at least one episode of mania
II = has only experienced hypomania

Question 20

Describe four domains of mania behaviour

Answer 20

Sleep; perceived lack of need for sleep

Goal directed activity; promiscuity, gambling, excessive spending

Risk taking activity

Enhanced perceptual experience; colours are more vivid, music more meaningful

GREPS

Question 21

Describe prominent thought patterns in mania

Answer 21

Racing thoughts / flight of ideas
Reduced ability to focus and complete tasks (despite having many grandiose plans)

Question 22

Name three clinical features that can help to differentiate Bipolar depression from unipolar

Answer 22

Psychomotor retardation
Hyperphagia
Hypersomnia

Question 23

Discuss the three pharmacological treatment domains of bipolar disorder

Answer 23

Usual regime is antipsychotic and mood stabiliser.
Antipsychotics; good efficacy for mania
Mood stabilisers; lithium most commonly used
Antidepressants; can induce ‘switching’ to a manic episode and should not be used without a mood stabiliser concomittantly

Question 24

How is lithium excreted and what can decrease this

Answer 24

renally

fluid status; illness, fluid loss, diuresis
drugs; NSAIDs, diuretics

Question 25

At what time of the day should lithium levels be measured

Answer 25

8-12 hours after last dose

Question 26

With a patient stable on lithium therapy what bloods need testing regularly and how frequently

Answer 26

Lithium levels; 3-6 monthly Thyroid function; 6 monthly Calcium; annually with hyperparathyroid screen if it is raised

Question 27

What is lithiums effect on the thyroid and how should it be treated

Answer 27

Hypothyroidism, responds to thyroxine whilst lithium is still required

Question 28

What is the link between lithium and calcium

Answer 28

Long term lithium therapy can cause hyperparathyroidism and thus calcium levels should be measured annually and if elevated PTH levels added on

Question 29

Describe the lithium toxidrome including toxic dose

Answer 29

Acute overdose rarely results in toxicity (even up to 25g) as it is readily excreted renally. Overdose is more commonly due to chronic use in the setting of decreased excretion (fluid status decreased or concomittant NSAID use) Toxidrome = neuro (ataxia, tremor, dysarthria), GIT (vomiting), muscle twitches and AKI

Question 30

what are the clinically relevant lithium serum levels

Answer 30

therapeutic usually = 0.6-0.8 mmol/L some may need 0.8-1.0 or 0.4-0.6 mmol/L toxicity usually only occurs over 1.5 mmol/L (in the setting of normal renal function)

Question 31

what is the definition of post natal depression

Answer 31

Major depressive episode criteria at any time within 12 months post partum

Question 32

outline the timeframe for post baby blues

Answer 32

depressive sxs peaking at day 5 post partum and resolving by day 10

Question 33

What is the screening tool used for post natal depression

Answer 33

Edinburgh Post Natal Depression Scale

Question 34

What is the most important question to ask a post natally depressed patinet

Answer 34

thoughts of self or infant harm needs immediate action (suicide is the leading cause of maternal death in the perinatal period in developed countries)

Question 35

What are three important conditions that need to be ruled out when suspecting post natal depression

Answer 35

Post partum psychosis Anaemia Hypothyroidism

Question 36

What is the pharmacological mx of post natal depression

Answer 36

same as for normal depression all antidepressants are taking up into breast milk and only case reports are available for its saftey profile thus risk vs benefits need consideration

Question 37

What is the prevalence of post natal depression

Answer 37

one in 7

Question 38

what is the mechanism of action for St Johns Wart and what is a life threatening risk it is associated with

Answer 38

functions similar to SSRIs risk of serotonin syndrome

Question 39

what three areas define anxious behaviour as becoming pathological

Answer 39

disproportionate; fear is greatly out of proportion to risk or threat continuing; response continues beyond existing threat dysfunction; social or occupational function is impaired

Question 40

define panic attack disorder

Answer 40

recurrent, unexpected panic attacks with at least one month of persistent concern about next attack or suffered significant behavioral change panic attack = a discrete episode of intense fear in which anxiety symptoms develop abruptly and peak within 10 mins

Question 41

what are the diagnostic features of Generalised Anxiety Disorder

Answer 41

excessive uncontrollable anxiety and worrying for at least six months about a number of events and activities (eg money, job security, health) three or more of the following (BE SKIM) Blank mind, difficulty concentrating Easy fatigability Sleep disturbance Keyed up, on edge or restless Irritability Muscle tension

Question 42

What are the three diagnostic criteria for obsessive compulsive disorder

Answer 42

1) obsession and / or compulsion 2) recognition that they are excessive / unreasonable 3) result in dysfunction

Question 43

What are the diagnostic criteria for PTSD

Answer 43

1) exposure to a traumatic event 2) persistent re-experiencing of the event 3) three of; emotional numbing, anhedonia, amnesia, avoidance (of reminding thoughts / activities) 4) two or more persistent feelings of arousal; insomnia, irritability, difficulty concentrating, hypervigilance, exaggerated startle response 5) present for \> 1 month

Question 44

Hightlight two features that differentiate grief and depression

Answer 44

Fluctuance; in grief negative feelings come in waves, in depression they are comparatively constant Self esteem; generally not affected in grief

Question 45

What defines complicated grief

Answer 45

\> 6 months OR intense grief associated with impaired function

Question 46

What are the five stages of grief

Answer 46

Denial, anger, bargaining, depression, acceptance

Question 47

Differentiate affect and mood

Answer 47

``` Affect = immediate expression of current emotion Mood = emotional experience over a more prolonged period of time ```

Question 48

Outline the features of a mental state exam

Answer 48

ABS always takes Jennys income Appearance; dressed ^, groomed ^ Behaviour; ^ppropriate, relaxed / agitated, cooperative Speech; ^ rate, ^ volume, prosody is present (emotional inflection exists) Affect; low/ euthymic/ elevated, congruent Thought; ^ obsessions / delusions / hallucinations Judgement; “if you went home and couldn’t find keys to get into house what would you do?” Insight; ^ perception of disease process and need for treatment

Question 49

What is the average age of onset for schizophrenia

Answer 49

young adulthood - mid 20's for women - younger for men (40% have first episode before 20yo)

Question 50

Describe the four temporal stages of schizophrenia

Answer 50

Premorbid; no sxs -\> social, cognitive, perceptual disturbances Prodromal; sudden or insidious onset of delusions / hallucinations Middle; 5 years -\> constant or fluctuant hallucinations / delusions with worsening functional components Late; established illness pattern with functional compromise either stabilising or resolving

Question 51

What are the four domains of schizophrenia symptoms

Answer 51

Positive; hallucinations / delusions Negative; decreased emotional range, anhedonia Cognitive; memory, concentration, executive function Mood; often seem happy or sad in a way that is difficult to comprehend

Question 52

What is the main cause of premature death in people with schizophrenia

Answer 52

Suicide (5% with a 20% attempt rate and higher ideation rate)

Question 53

What is the link between schizophrenia and cardiovascular disease

Answer 53

up to 5 times higher risk of metabolic syndrome with higher risk of smoking, obesity, hyperglycaemia and hyperlipidaemia

Question 54

What is the recurrence rate with antipsychotics vs without and what is the general overall sucess rate of their use

Answer 54

80% recurrence vs 20% when using 30% full resolution of sxs, 30% partial with some ongoing dysfucntion, 30% permanent sxs with significant dysfuction

Question 55

Differentiate between first generation and second generation antipsychotics

Answer 55

First generation - have higher rate of extrapyramidal side effects - eg Haloperidol Second generation - have higher rate of cariac side effects ie QTc prolongation - eg olanzapine, respiradone, quetiapine Importance of distinction is diminishing as efficacy is generally the same between classes and it now primarily reflects the length of time the drugs have been available

Question 56

List common adverse effects that need regular monitoring for patients on long term antipsychotic therapy

Answer 56

the sleepy fat rhythmic arrhythmic can raise neither head, brain nor droopy breast) sedation increased appetite and rapid weight gain movement disorders (eg extrapyramidal effects, akathisia) prolonged QTc sexual dysfunction (this does not appear immediately) orthostatic hypotension hyperprolactinaemia causing breast enlargement and/or galactorrhoea

Question 57

Differentiate the pyramidal and extra pyramidal tracts by anatomy and function

Answer 57

``` Pyramidal = a group of prefrontal cortex motor neurons that run though a specific anatomical aspect of the thalamus to form a triangular bundle. Function to transmit all voluntary skeletal muscle contractions Extrapyramidal = all other motor fibres that do not run through this tract with motor contributions for cerebellum, other cortical (ie non prefrontal cortex) locations and brainstem. Functions to convey automatic motor functions of the skeletal muscle such as gait, posture, coordination and inhibitory / regulatory signals (eg tone) ```

Question 58

What are the three mechanisms by which the extrapyramidal tract pathologically becomes deficient in dopamine

Answer 58

1) Dopamine antagonists (most commonly first generation antipsychotics but also antiemetics such as metoclopramide and droperidol) 2) Rapid reduction / cessation of dopamine agonists (eg parkinsons drugs, cocaine, psychotropics, opioids) 3) Degeneration of the dopamine producing cells of the substantia nigra

Question 59

Differentiate the first and second generation antipsychotics

Answer 59

``` 1st = eg Haloperidol and chlorpromazine. AKA typical antipsychotics. Dopamine antagonists that are more likely to cause extrapyramidal side effects 2nd = eg respiridone, olanzapine, clozapine. AKA atypical antipsychotics. Also function as dopamine antagonists but less likely to cause extrapyramidal side effects and more likely to cause QTc prolongation or weight gain ```

Question 60

Describe a patient presenting with Neuroleptic Malignant Syndrome

Answer 60

5 to 10 days after a dopamine antagonist a decreased GCS diaphoretic patient will present hyperthermic, tachycardic and hypertensive with lead pipe rigidity, sialorrhoea and possible organ dysfunction.

Question 61

Tachycardia, hyperthermia, hypertension, lead pipe rigidity and siallorhea

Answer 61

Neuroleptic Malignant Syndrome

Question 62

Hyperthermia, clonus, tremor

Answer 62

Serotonin Syndrome

Question 63

Describe a patient presenting with an Acute Dystonic Reaction

Answer 63

Hours to day after a dopamine antagonist a patient will present with a sustained involuntary muscle contraction eg torticollis, oculogyric crisis or tongue protrusion

Question 64

What is an oculogyric crisis

Answer 64

A type of acute dystonic reaction after use of a dopamine antagonist

Question 65

What is akathesia

Answer 65

An extrapyramidal symptom of inner restlessness and compelling need to be in constant motion

Question 66

Restless patient, refusing to stay still, in constant motion

Answer 66

Akathesia

Question 67

Describe a patient with Tardive Dyskinesia

Answer 67

Months to years after intiation of an antipsychotic rapid or gradual onset of repetitive involuntary muscle movements

Question 68

Describe five extrapyramidal motor signs

Answer 68

bradykinesia cogwheel rigidity festinating gait postural instability akathesia

Question 69

What are the diagnostic features of ADHD

Answer 69

at least 6 months, in more than one situation and before the age of 12 of one or more of - inattention; easy distraction with frequent change of activity - hyperactivity; excessive movement and restlessness that impairs social functioning - impulsiveness; acting without reflection

Question 70

Describe the three medications available for assistance in chronic alcoholism treatment

Answer 70

Disulfiram; causes unpleasant and potentially harmful side effects when combined with ETOH Acamprosate; GABA analogue that decreases the neuronal hyperexcitability of alcohol withdrawal Naltrexone; blocks endogenous opioids release on ETOH ingestion thus decreases pleasurable effects of ETOH (but not functional impairment)