Psychiatry

Question 1

Common side effects of Tricyclic antidepressants?

Answer 1

TCAs are used less commonly now for depression due to their side-effects and toxicity in overdose. They are however used widely in the treatment of neuropathic pain, where smaller doses are typically required.

Common side-effects:
- Drowsiness
- Dry mouth
- Blurred vision
- Constipation
- Urinary retention
- Lengthening of QT interval

“Can’t see, can’t spit, can’t wee, can’t shit, long QT”

Question 2

Most common ophthalmological condition associated with CBS?

Answer 2

Age-related macular degeneration, followed by glaucoma and cataract.

Charles-Bonnet syndrome (CBS) is characterised by persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness. This is generally against a background of visual impairment (although visual impairment is not mandatory for a diagnosis). Insight is usually preserved. This must occur in the absence of any other significant neuropsychiatric disturbance.

Question 3

Examples of atypical antipsychotics?

Answer 3

• Clozapine
• Olanzapine
• Risperidone
• Quetiapine
• Amisulpride
• Aripiprazole

Question 4

Which SSRI has highest incidence of discontinuation symptoms?

Answer 4

Paroxetine.

Question 5

Examples of Serotonin and noradrenaline reuptake inhibitor (SNRI’s)?

Answer 5

• Venlafaxine
• Duloxetine

Question 6

Interaction between SSRIs and Triptans?

Answer 6

Increased risk of serotonin syndrome.

Question 7

Syndrome where patient believes they are dead?

Answer 7

Cotard syndrome.

Cotard syndrome is a rare mental disorder where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent. This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary.

Question 8

Treatment for delirium tremens/alcohol withdrawal?

Answer 8

Chlordiazepoxide (Librium)

First-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol.

Question 9

Management for oculogyric crisis?

Answer 9

Procyclidine.

An oculogyric crisis is a dystonic reaction, typically associated with the use of antipsychotic medications. It presents as sustained, often painful, upward deviation of the eyes. Procyclidine, an anticholinergic drug, is used in the management of extrapyramidal symptoms caused by antipsychotics. It works by blocking the action of acetylcholine in the central nervous system, which helps to reduce muscle stiffness and spasms.

Question 10

Side effects of typical antipsychotics?
(Haloperidol, Chlorpromazine)

Answer 10

Extrapyramidal side-effects and hyperprolactinaemia common.

Extrapyramidal side-effects (EPSEs):
DAPT

• Acute dystonia: sustained muscle contraction (e.g. torticollis, oculogyric crisis)
• Akathisia (severe restlessness)
• Parkinsonism
• Tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)

Question 11

Side effect of atypical antipsychotic?

Answer 11

Adverse effects of atypical antipsychotics:
- Weight gain
- Hyperprolactinaemia

Clozapine: agranulocytosis

In the elderly:
Increased risk of stroke and VTE

Question 12

What is Capgras syndrome?

Answer 12

This is a delusional misidentification syndrome whereby the patient believes that someone significant in their life, such as a spouse or a friend, has been replaced by an identical imposter.

Question 13

Side effects of lithium?

Answer 13

• Nausea/vomiting, diarrhoea
• Fine tremor
• Nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
• Thyroid enlargement, may lead to hypothyroidism
• ECG: T wave flattening/inversion
• Weight gain
• Idiopathic intracranial hypertension
• Leucocytosis
• Hyperparathyroidism and resultant hypercalcaemia

Question 14

Features of Wernicke’s Encephalopathy?

Answer 14

The classic triad is ophthalmoplegia (often a lateral rectus palsy and/or horizontal nystagmus), confusion and ataxia (though any cerebellar signs can be present).

Korsakoff’s syndrome is a complication of Wernicke’s encephalopathy. It’s features include: anterograde amnesia, retrograde amnesia, and confabulation.

Question 15

Triad of symptoms for normal pressure hydrocephalus?

Answer 15

• Cognitive impairment
• Gait disorders (wide gait)
• Urinary incontinence

Question 16

When discontinuing SSRIs, dose should be reduced over how long of a period?

Answer 16

When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine due to its longer half life)

Question 17

First line treatment for PTSD?

Answer 17

• Watchful waiting may be used for mild symptoms lasting less than 4 weeks.
• Trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases.
• Drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used then venlafaxine (SNRI) or a SSRI such as sertraline should be tried.

Question 18

How long should antidepressants be continued to reduce the risk of relapse?

Answer 18

6 months.

Question 19

Difference between somatisation disorder and conversion disorder?

Answer 19

Somatisation disorder
multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results.

Conversion disorder
typically involves loss of motor or sensory function. The patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering).

Question 20

First line pharmacological management for GAD?

Answer 20

Sertraline.

Sertraline should be considered the first-line SSRI.
if sertraline is ineffective, offer an alternative SSRI or a SNRI (duloxetine and venlafaxine).
If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin.

Question 21

What is De Clerambault’s syndrome?

Answer 21

Erotomania (De Clerambault’s syndrome) is the presence of a delusion that a famous is in love with them, with the absence of other psychotic symptoms.

Question 22

What is the peak incidence in time for seizures in alcohol withdrawal?

Answer 22

36 hours.

• Symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
• Peak incidence of seizures at 36 hours
• Peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

Question 23

Which TCA is most dangerous in overdose?

Answer 23

Dosulepin.

Dosulepin is considered the most toxic TCA in overdose. It has a narrow therapeutic index and can lead to serious complications such as cardiac arrhythmias, seizures, and even death due to its significant anticholinergic and sodium channel blocking effects. BNF advises against its use wherever possible due to the high risk of fatal toxicity.

Question 24

Example of typical antipsychotics?

Answer 24

• Haloperidol
• Chlorpromazine

Question 25

SSRI of choice following a myocardial infarction?

Answer 25

Sertraline is useful post myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants.

Question 26

Which SSRI can be discontinued immediately without tapering?

Answer 26

Fluoxetine.

Question 27

Which physiological parameters are raised in anorexia?

Answer 27

• Raised cortisol and growth hormone.
• Hypercholesterolaemia

Other parameters low:
- Hypokalaemia
- Low FSH, LH, oestrogens and testosterone
- Impaired glucose tolerance