Psychiatry

Question 1

What are the 5 criteria needed for detention?

Answer 1

MS THC

Mental health disorder likely

Significantly impaired decision making ability

Treatment is available

Harm to themselves or others

Care on informal/voluntary basis not possible

Question 2

Compare emergency detention, short-term and compulsory treatment orders based on…

Treatment

Personnel needed

Time limit

Right of appeal

Answer 2

EDO // STDO // CTO

No // Yes // Yes

>=FY2 +/- MHO // AMP + MHO // AMP + MHO

72hrs // 28 days // 6 months

No // Yes // Yes

Question 3

Can you extend/renew detention orders?

Answer 3

STDO: EXTEND 3 days before OR 5 days after CTO submission

CTO: RENEW at 6 months then yearly

Question 4

What treatments are not covered by detention orders?

Answer 4

Neurostimulation/surgery

Sex drive blunting

Artificial nutrition

Question 5

SSRI vs SNRI

Venlafaxine

citalopram

sertraline

duloxetine

fluoxetine

Answer 5

SSRI: blocks reuptake of serotonin from synatpic cleft

Citalopram

Fluoxetine

Sertraline

SNRIs: Blocks reuptake of serotonin + noradrenaline

Venlafaxine

Duloxetine

Question 6

Categorise the following TCAs into more or less sedative…

Clomipramine

Dosulepin

Lofepramine

trazadone

Amitriptyline

Notriptyline

Imipramine

Answer 6

NIL DCAT

Less: Nortripyline, imipramine, lofepramine

More: Dosulepin, Clomipramine, Amitriptyline, Trazadone

Question 7

Hyponatraemia, GI upset and QT prolongation can occur with which group of drugs?

Answer 7

SSRIs (-pram prolongs QT)

Question 8

What psych drug class causes dryness, blurred vision, drowsiness and prolonged QT?

Answer 8

TCAs

‘Dryly, drowsily, blurry + QT’

Question 9

If someone on a warfarin/heparin asks for an SSRI, what can you give?

Answer 9

Mirtazepine

Question 10

What is the problem with SSRIs and…

NSAIDs

MAOI, Triptans

Answer 10

NSAIDS: Increased bleeding risk

MAOI, Triptans: serotonin syndrome

Question 11

What antidepressant drugs should be avoided in the following groups?

IHD

HTN

Enlarged prostate

Answer 11

IHD: SNRIs + TCAs

HTN: SNRI

Enlarged prostate: TCAs

Question 12

What antenatal side effects can occur with SSRIs?

Answer 12

1er: congenital heart defects
3er: Persistent pulmonary HTN

Question 13

Compare serotonin syndrome and neuroleptic malignant syndrome in terms of…

Causative drugs

Clinical features

Timescale

Treatment

Answer 13

Serotonin // NMS

Antidepressants, stimulants // antipsychotics

Both: Raised HP, BP, temp, rigidity + sweaty

Hyper-reflexia // hyporeflexia

Hours // days

IV fluids + benzos

Cyproheptadine and chlopromazine // dantrolene

Question 14

What are the counselling points for SSRIs regarding

Starting

Reducing

Answer 14

Starting: Review in 1 week < 30yrs, 2 weeks otherwise

Step down after 6 months stability,

Reduce dose over 4 weeks

GI upset, irritability common side effects

Question 15

The following drugs are members of which antipsychotic group? list the members of the other group

Haloperidol

Chlorpromazine

Answer 15

Typical

Atypicals (ORC cos they look atypical):

Olazapine

Risperidone

Clozapine

Question 16

How do typical and atypical antipsychotics differ in terms of

Receptors

EPSES, hyperprolactinaemia

Answer 16

Typical // Atypical

D2 antagonism // D2-4, 5HT antagonism

More common // Less common

Question 17

What side effects are more associated with atypical antipsychotics?

Answer 17

Agranulocytosis

Seizure threshold reduction

Question 18

What is the name of the following extrapyramidal side effects?

Tremor, bradykinesia, rigidity

Sustained muscle contraction

Severe restlessness

Late jerking, writhing movements

Answer 18

Parkinsonism

Acute dystonia (give procyclidine)

Akathisia:(literally ‘can’t sit’)

Tardive dysKINESIA

Question 19

Regarding lithium, what is the…

Therapeutic range

level checking time after titrating

Level checking time routinely

time to check renal and TFTs

Answer 19

~6.0-1.00 mmol

7 days, 12 hours post dose

3 months, 12 hours post dose

Every 6 months

Question 20

How do you manage a lithium patient experiencing the following…

Increased tremor, reflexes, urination

+ confusion/seizure/coma

Answer 20

Reverse precipitants: Fluids, diuretics, ACE/ARBs, NSAIDs

+ haemodialysis if severe

Question 21

How does lithium affect

Kidneys

Thyroid

White cells

ECG

Answer 21

toxicity

hyper or hypothyroidism

raised WCC

T wave flattening/inversion

Question 22

What advice should be given regarding pregnancy and breastfeeding for lithium?

Answer 22

Pregnancy adjustments needs psych input

breastfeeding is contraindicated

Question 23

What raises suspicion of a depression diagnosis

What further symptoms do you then ask about?

Answer 23

In past month for at least 2 weeks

Feeling down.depressed hopeless AND/OR little pleasure in doing things

+ RISK: want to hurt yourself or others

+ Biological: fatigue, sleep, appetite

+ Psychological: Guilt, worthless

2-4: mild

Functional impairment: Moderate, severe

Question 24

What scoring systems aid depression diagnosis?

Answer 24

HAD >11

PHQ-9: 5-9 mild, 10-19 mod, >=20 severe

Question 25

How is depression managed?

Answer 25

Initial Mild: CBT +/- group support mod/severe: SSRI + regular psychotherapy over 3-4 months Try another SSRI or new gen before TCAs or MAOIs ECT if acute-severe or resistant

Question 26

What should you do before administering ECT

Answer 26

Reduce antidepressant dose Rule out potential ICP

Question 27

How do manic (I) and hypomanic (II) bipolar disorder compare in terms of Duration Psychosis Function/risk

Answer 27

Mania // Hypomania \>=7 days // \< 7 days Yes // no Significant impairment and risk // lesser risk or impairment

Question 28

How do you manage bipolar disorder?

Answer 28

Lithium for mood stability Antidepressant for low mood (fluoxetine) If acute: Stop antidepressant, start antipsychotic

Question 29

How does referral differ between hypomanic and manic bipolar?

Answer 29

hypo: routine Manic: urgent

Question 30

How do GAD panic disorder compare in terms of treatment

Answer 30

Both start with therapy and SSRI (sertraline for GAD) Further GAD: Another SSRI/SNRI --\> pregabalin PD: imipramine/clomipramine (TCAs) --\> specialist

Question 31

What is obsessive compulsive disorder and how is it managed?

Answer 31

Obsessions: unwanted, obstrusive thoughts Compulsions: Repetitive behaviours that are either internal or external Management Mild: CBT + exposure based prevention Mod: SSRI 12 months + intensive CBT

Question 32

How do the following conditions differ in terms of symptom course Alzheimer's Vascular Lewy body Frontotemporal Normal pressure hydrocephalus

Answer 32

Alzheimer's: Short term then executive memory Vascular: Step wise +/- focal neuro symptoms Lewy body: fluctuating cognition, visual hallucinations, parkinsonism Frontotemporal: Disinhibition, memory + perception relatively preserved Normal pressure hydrocephalus: dementia + parkinsons gait + incontinence

Question 33

Which dementias are treated with AChEis

Answer 33

Alzheimer's: donepezil/galmantine/rivastigmine Lewy body: donepezil/rivastigmine --\> galantamine

Question 34

How do you treat vascular dementia

Answer 34

Alter cardiovascular risk factors

Question 35

How do you treat acute stress disorder, how does it compare to PTSD?

Answer 35

Trauma focused CBT +/- benzos for acute symptoms PTSD only 4 weeks after event

Question 36

What are the following unexplained symptom disorders ## Footnote Presence of multiple SYMPTOMS (patient reported) for last 2 years, refusal to accept reassuring negative test results Loss of FUNCTION without feigning or malingering, Can sometimes appear indifferent to the loss Persistent belief of underlying serious DISEASE Fraudulent simulation or exaggeration of symptoms to attain financial or other gain Symptoms that have been intentionally produced (eg taking medication induce symptoms of illness)

Answer 36

Somatisation (SYMPTOMS) Conversion Hypochondriasis/illness anxiety (CANCER) Malingering Munchausen's