Psychiatry

Question 1

Body dysmorphic disorder

Answer 1

• Excessive preoccupation with perceived defects or flaws in physical appearance.
• CBT with ERP. SSRI

Question 2

Schizophrenia

Answer 2

> > Auditory hallucinations of a specific type:
two or more voices discussing the patient in the third person
thought echo
voices commenting on the patient’s behaviour

> > Thought disorders
thought insertion
thought withdrawal
thought broadcasting

> > Passivity phenomena:
Bodily sensations being controlled by external influence
actions/impulses/feelings - experiences which are imposed on the individual or influenced by others

> > Delusional perceptions
a two-stage process) where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. ‘The traffic light is green therefore I am the King’.

Other features of schizophrenia include
impaired insight
negative symptoms
Incongruity/blunting of affect
anhedonia (inability to derive pleasure)
alogia (poverty of speech)
avolition (poor motivation)
social withdrawal
Neologisms: made-up words
catatonia

Question 3

De Clerambault’s

Answer 3

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 4

Cotard Syndrome

Answer 4

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.

Cotard syndrome is associated with severe depression and psychotic disorders

Question 5

SSRI ( Escitalopram)

Answer 5

Gastrointestinal side-effects such as diarrhoea are seen in SSRI discontinuation syndrome.

Question 6

Paroxetine has a higher incidence of Discontinuation symptoms.

Answer 6

Discontinuation symptoms
increased mood change
restlessness
difficulty sleeping
unsteadiness
sweating
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia

Question 7

Schizophrenia Management

Answer 7

• Oral atypical antipsychotics are first-line.
• Cognitive behavioural therapy should be offered to all patients.

Question 8

Choice of Tricyclic Antidepressants

Answer 8

Choice of tricyclic
- low-dose amitriptyline is commonly used in the management of neuropathic pain and the prophylaxis of headache (both tension and migraine)
- lofepramine has a lower incidence of toxicity in overdose
- amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose

Question 9

Suicide

Answer 9

An increased risk of suicide
- 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

If a patient has actually attempted suicide, there are a number of factors associated with an increased risk of completed suicide at a future date:
- efforts to avoid discovery
- planning
- Leaving a written note
- final acts such as sorting out finances
- violent method

Protective factors

There are, of course, factors which reduce the risk of a patient committing suicide. These include
- family support
- having children at home
- religious belief