Psychiatry

Question 1

Acute stress disorder vs PTSD

Answer 1

ACUTE stress discorder is defined as an acute stress reaction that occurs in the 4 weeks after a traumatic event, as opposed to PTSD which is diagnosed after 4 weeks

Question 2

acute stress disorder features

Answer 2

Features include:
intrusive thoughts e.g. flashbacks, nightmares
dissociation e.g. ‘being in a daze’, time slowing
negative mood
avoidance
arousal e.g. hypervigilance, sleep disturbance

Question 3

management of acute stress discordr

Answer 3

trauma-focused cognitive-behavioural therapy (CBT) is usually used first-line
benzodiazepines
sometimes used for acute symptoms e.g. agitation, sleep disturbance
should only be used with caution due to addictive potential and concerns that they may be detrimental to adaptation

Question 4

mechanism of alchool withdrawl

Answer 4

chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors

Question 5

what happens first in Alchohol withdrawl

1. 6-12 hours
2. peak incidence of ____ at _____

what happens at 48-72 hours

Answer 5

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 6

Treatment for alchohol withdrawl

1st line

what about people with hepatic failure

Answer 6

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
lorazepam is often preferred in patients with liver cirrhosis

Question 7

Physiological abnormalities
in Anorexia Nervosa

Answer 7

hypokalaemia
low FSH, LH, oestrogens and testosterone
raised cortisol and growth hormone
impaired glucose tolerance
hypercholesterolaemia
hypercarotinaemia
low T3

Question 8

Typical antipsychotics

Answer 8

Haloperidol
Chlorpromazine

Question 9

Atypical antipsychotics

Answer 9

clozapine
olanzapine: higher risk of dyslipidemia and obesity
risperidone
quetiapine
amisulpride
aripiprazole: generally good side-effect profile, particularly for prolactin elevation

Question 10

typical antipsychotics, ESPE

Answer 10

Parkinsonism
acute dystonia
sustained muscle contraction (e.g. torticollis, oculogyric crisis)
may be managed with procyclidine
akathisia (severe restlessness)
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

acute dystonia

may be managed with

Answer 11

sustained muscle contraction (e.g. torticollis, oculogyric crisis)

mx
procyclidine

Question 12

akathisia

Answer 12

akathisia (severe restlessness)

Question 13

tardive dyskinesia

Answer 13

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 14

neuroleptic malignant syndrome:

Answer 14

neuroleptic malignant syndrome: pyrexia, muscle stiffness

Question 15

The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:

Answer 15

increased risk of stroke
increased risk of venous thromboembolism

Question 16

Aphonia describes the inability to speak. Causes include:

Answer 16

recurrent laryngeal nerve palsy (e.g. Post-thyroidectomy)
psychogenic

Question 17

Adverse effects of atypical antipsychotics

Answer 17

weight gain
clozapine is associated with agranulocytosis (see below)
hyperprolactinaemia

Question 20

Benzodiazepines

Answer 20

Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) by increasing the frequency of chloride channels.

Question 21

The BNF gives advice on how to withdraw a benzodiazepine.

Answer 21

The BNF gives advice on how to withdraw a benzodiazepine. The dose should be withdrawn in steps of about 1/8 (range 1/10 to 1/4) of the daily dose every fortnight. A suggested protocol for patients experiencing difficulty is given

Question 22

Russell’s SIGN

Answer 22

recurrent vomiting may lead to erosion of teeth and Russell’s sign - calluses on the knuckles or back of the hand due to repeated self-induced vomiting

Question 23

Charles-Bonnet syndrome

Answer 23

Insight is usually preserved. This must occur in the absence of any other significant neuropsychiatric disturbance.

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).

Question 24

CBS

The most common ophthalmological conditions associated with this syndrome are

Answer 24

The most common ophthalmological conditions associated with this syndrome are age-related macular degeneration, followed by glaucoma and cataract.

Question 25

De Clerambault's syndrome

Answer 25

De Clerambault's syndrome, also known as erotomania, is a form of paranoid delusion with an amorous quality. The patient, often a single woman, believes that a famous person is in love with her.

Question 26

Depression in older people

Answer 26

Older patients are less likely to complain of depressed mood Features physical complaints (e.g. hypochondriasis) agitation insomnia

Question 27

mX OF depresion in older people

Answer 27

SSRIs are first line (adverse side-effect profile of TCAs more of an issue in the elderly)

Question 28

Depression vs. dementia

Answer 28

Factors suggesting diagnosis of depression over dementia short history, rapid onset biological symptoms e.g. weight loss, sleep disturbance patient worried about poor memory reluctant to take tests, disappointed with results mini-mental test score: variable global memory loss (dementia characteristically causes recent memory loss)

Question 29

Short-term side-effects for ECT

Answer 29

Short-term side-effects headache nausea short term memory impairment memory loss of events prior to ECT cardiac arrhythmia Long-term side-effects some patients report impaired memory

Question 30

Management of generalised anxiety disorder (GAD)

Answer 30

step 1: education about GAD + active monitoring step 2: low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups) step 3: high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information step 4: highly specialist input e.g. Multi agency teams

Question 31

Management of generalised anxiety disorder (GAD) DRUG treatment

Answer 31

NICE suggest sertraline should be considered the first-line SSRI if sertraline is ineffective, offer an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI) If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin

Question 32

Management of panic disorder

Answer 32

NICE recommend either cognitive behavioural therapy or drug treatment SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered

Question 33

Hypomania vs. mania DURATION hospitialzation ?psychotic sym

Answer 33

mania Lasts for at least 7 days - Causes severe functional impairment in social and work setting May require hospitalization due to risk of harm to self or others May present with psychotic symptoms Hypomania A lesser version of mania Lasts for < 7 days, typically 3-4 days. Can be high functioning and does not impair functional capacity in social or work setting Unlikely to require hospitalization Does not exhibit any psychotic symptoms

Question 34

Korsakoff's syndrome Overview marked memory disorder often seen in alcoholics thiamine deficiency causes damage and haemorrhage to the mammillary bodies of the hypothalamus and the medial thalamus in often follows on from untreated Wernicke's encephalopathy Features:

Answer 34

anterograde amnesia: inability to acquire new memories retrograde amnesia confabulation

Question 35

Adverse effects of lithium

Answer 35

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 36

ECG chnages in lithium Adverse effects

Answer 36

ECG: T wave flattening/inversion

Question 37

when checking lithium levels, the sample should be taken ______ hours post-dose

Answer 37

when checking lithium levels, the sample should be taken 12 hours post-dose

Question 38

Guide on taking lithium

Answer 38

after starting lithium levels should be performed weekly and after each dose change until concentrations are stable once established, lithium blood level should 'normally' be checked every 3 months after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable. thyroid and renal function should be checked every 6 months

Question 39

Othello's syndrome

Answer 39

Othello's syndrome is pathological jealousy where a person is convinced their partner is cheating on them without any real proof. This is accompanied by socially unacceptable behaviour linked to these claims.

Question 40

PTSD Mx

Answer 40

following a traumatic event single-session interventions (often referred to as debriefing) are not recommended 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

Question 41

drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used

Answer 41

then venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline should be tried. In severe cases, NICE recommends that risperidone may be used

Question 42

Schizophrenia: management

Answer 42

oral atypical antipsychotics are first-line cognitive behavioural therapy should be offered to all patients

Question 43

'Baby-blues' timeframe features

Answer 43

Typically seen 3-7 days following birth and is more common in primips Mothers are characteristically anxious, tearful and irritable

Question 44

Postnatal depression timeframe features tx

Answer 44

Most cases start within a month and typically peaks at 3 months Features are similar to depression seen in other circumstances cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine* may be used if symptoms are severe**

Question 45

Puerperal psychosis

Answer 45

Onset usually within the first 2-3 weeks following birth Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations) Admission to hospital is usually required, ideally in a Mother & Baby Unit

Question 46

Adverse effects of SSRI

Answer 46

gastrointestinal symptoms are the most common side-effect there is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI fluoxetine and paroxetine have a higher propensity for drug interactions

Question 47

Schizophrenia: prognostic indicators

Answer 47

Factors associated with poor prognosis strong family history gradual onset low IQ prodromal phase of social withdrawal lack of obvious precipitant

Question 48

Citalopram and the QT interval

Answer 48

associated with dose-dependent QT interval prolongation and should not be used in those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval

Question 49

ssri interacttions

Answer 49

Interactions NSAIDs: NICE guidelines advise 'do not normally offer SSRIs', but if given co-prescribe a proton pump inhibitor warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine aspirin triptans - increased risk of serotonin syndrome monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome

Question 50

Serotonin and noradrenaline reuptake inhibitors

Answer 50

Examples include venlafaxine and duloxetine. They are used to treat major depressive disorders, generalised anxiety disorder, social anxiety disorder and panic disorder and menopausal symptoms.

Question 51

Sleep paralysis is a common condition characterized by transient paralysis of skeletal muscles which occurs when awakening from sleep or less often while falling asleep. It is thought to be related to the paralysis that occurs as a natural part of REM (rapid eye movement) sleep. Sleep paralysis is recognised in a wide variety of cultures management

Answer 51

if troublesome clonazepam may be used

Question 52

Whilst the evidence base is relatively weak, there are a number of factors shown to be associated with an increased risk of suicide

Answer 52

male sex (hazard ratio (HR) approximately 2.0) history of deliberate self-harm (HR 1.7) alcohol or drug misuse (HR 1.6) history of mental illness depression schizophrenia: NICE estimates that 10% of people with schizophrenia will complete suicide history of chronic disease advancing age unemployment or social isolation/living alone being unmarried, divorced or widowed

Question 53

There are, of course, factors which reduce the risk of a patient committing suicide. These include

Answer 53

family support having children at home religious belief

Question 54

Somatisation disorder

Answer 54

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

Question 55

Illness anxiety disorder (hypochondriasis)

Answer 55

persistent belief in the presence of an underlying serious DISEASE, e.g. cancer patient again refuses to accept reassurance or negative test results

Question 56

Functional neurological disorder (conversion disorder)

Answer 56

typically involves loss of motor or sensory function the patient doesn't consciously feign the symptoms (factitious disorder) or seek material gain (malingering) patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies

Question 57

Dissociative disorder

Answer 57

dissociation is a process of 'separating off' certain memories from normal consciousness

Question 58

Factitious disorder also known as Munchausen's syndrome

Answer 58

the intentional production of physical or psychological symptoms

Question 59

Malingering

Answer 59

fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain