Psychiatry

Question 1

Paranoid Personality Disorder - characteristics?

Answer 1

Suspicious, mistrustful
Holds grudges
Entitled to more rights

Question 2

Schizoid personality disorder

Answer 2

Detached, aloof, no interest in friends or sex

Question 3

Schizotypal

Answer 3

Eccentric, odd beliefs

Question 4

BPD/EUPD

Answer 4

Impulsive, feelings of ‘emptiness’, unstable, fear of abandonment

Question 5

Narcissistic

Answer 5

Grandiose…

Question 6

Antisocial

Answer 6

Antisocial, disregard for feelings of others, lack sense of responsibility

Question 7

Histrionic

Answer 7

Theatrical, dramatic, seductive, self-harm

Question 8

Anankastic

Answer 8

Obsessive compulsive, rigid, stubborn, perfectionist

Question 9

Dependent

Answer 9

Dependent on others to make decision, need constant reassurance

Question 10

Anxious avoidant

Answer 10

Persistent anxiety, sensitive to rejection, avoid relationships unless acceptance is guaranteed

Question 11

SSRIs

Answer 11

SSRIs - sertraline (safest in cardiac disease), citalopram (prolongs QT), fluoxetine (adolescents)
First line for depression

Side-effects: Nausea and Vomiting, GI Bleeding, Initial worsening of anxiety/suicidal ideation - because they work on your motivation before they work on your mood, hence more likely to act out suicide

Contra-indications - Warfarin/heparin; NSAIDs (give with PPi)

Coming off SSRI - discontinuation syndrome (NV, Diarh, Insomnia - Paroxetine because short half life). Hence take off slowly over 4 weeks.

Question 12

Serotonin Syndrome

Answer 12

Serotonin syndrome is a potentially life-threatening syndrome that is precipitated by the use of serotonergic drugs and overactivation of both the peripheral and central postsynaptic 5HT-1A and, most notably, 5HT-2A receptors. This syndrome consists of a combination of mental status changes, neuromuscular hyperactivity, and autonomic hyperactivity.

More likely with Fluoxetine because long half life

Question 13

SNRIs

Answer 13

Serotonin-Adrenaline reuptake inhibitor

Venlafaxine
Duloxetine

SEs - Loss of appetite/weight
Fatigue
NV
Reduced libido

Question 14

TCA antidepressants

Answer 14

Amitriptyline (Neuropathic pain)
Clomipramine (OCD)
Donepezil (palliative for Alzheimers)

SEs

Can’t see, can’t pee, can’t spit, can’t shit and drowsiness

Question 15

NaSSAs - Noradrenergic and Specific Serotonergic antidepressants

Block a2 adrenoceptors and specific serotonergic receptor

Answer 15

Mirtazapine

Weight gain
Sleepiness
Constipation
Dry mouth

Question 16

MAOIs

Answer 16

Monamine oxidase inhibitor
prevents breakdown of monoamine neurotransmitters (last line - consultant choice)

Serotonin, melatonin, adrenaline, noad

Hydrazine
Isocarboxazid
Nialamide

Tyramine cheese reaction - pt needs to avoid things with Tyramine such as animal livers, cheese, fortified wine

Increased tyramine. Increased Norad. a1 receptor, vasoconstriction = hypertensive crisis

Question 17

Treatment for hypertensive crisis

Answer 17

hydralazine/sodium nitroprusside

Question 18

Depression core symptoms

Answer 18

Symptoms:

1) Low mood
2) Anhedonia
3) Low energy

• Cognitive (Reduced concentration, negativity, guilt, suicidal ideation)

Beck’s Triad: -ive thoughts about self, world, future

• Biological (mood variation - diurnal, worse in the morning; EMW; loss of libido)

+/- Psychotic symptoms:

• 2nd person auditory hallucinations
• Hypochondriacal, guilt, nihilistic, persecutory delusions

Question 19

Differentials for depression

Answer 19

Anaemia
Thyroid
Hypercalcaemia ("Painful stones, abdominal groans and psychic moans")
LFTs
U&Es

Precipitating factors

Steroids and Long term conditions

Question 20

Diagnosis of depression vs diagnosis of mania duration

Answer 20

> 2 wks depression

>1 wks mania

Question 21

Treatment of Mania

Answer 21

Acute mania: Olanzapine, Risperidone, Quietiapine

Mood stabilisers:
Sodium Valproate
Lithium
Lamotrigine

Carmazapine (linked to benzos)

Note: Quetiapine is first line because of risks with Lithium

Question 22

Lithium SEs

Lithium Toxicity

Answer 22

Lethargy/leucocytosis
Intentional tremor
Teratogenicity
Hypothyroidism
Insipidus
Urine excess/renal failure
Metalic taste

Toxicity – can be fatal
• Confusion, coarse tremor, nausea and vomiting, ataxia and seizures

• Treated with supportive measures – dialysis if necessary
• Potential for toxicity increases with dehydration – advise to drink lots of water in hot climates

Question 23

About to start pt on Lithium, what tests

Answer 23

Baseline U&Es, LFTs, TFTs, Pregnancy, ECG

Not metabolised, just excreted by kidneys - hence need to make sure kidneys are accurately excreting to maintain therapeutic dose

Monitor 12 hour after first dose
Weekly for 4 weeks until therapeutic dose achieved
3 monthly

Every 6 months monitor U&Es
Every year TFTs

Question 24

Causes of psychosis

Answer 24

Non organic: Schizophrenia, Schizotypal disorder, Schizoaffective disorder, Acute psychotic episode, Delusional disorder

Organic: Dementia, Delirium, Huntington’s disease, Endocrine or hypocalcaemia, Syphilis, Drug-induced (Cannibis)

Question 25

Classification of depression

Answer 25

Mild 2 core + 2 others Moderate 2 core + 3-4 others Severe 3 core + others RISK takes you straight to severe

Question 26

Antipsychotics

Answer 26

Typical: Haloperidol, Chlorpromazine Atypical: Olanzapine, Risperidone, Quetiapine, Aripiprazole, CLOZAPINE Block D2 receptor Also have other effects: Serotonergic - help affective symptoms Antihistaminergic - sedative Antiadrenergic - postural hypotension, tachycardia Anticholinergic - Can't see,pee,spit,shit

Question 27

Antipsychotics

Answer 27

Typical: Haloperidol, Chlorpromazine Atypical: Olanzapine, Risperidone, Quetiapine, Aripiprazole, CLOZAPINE Block D2 receptor

Question 28

Extra-pyramidal side effects

Answer 28

Parkinsonism - tremor, rigidity, bradykinesia Akathisia Dystonia (+ Oculogyric crisis) Tardive dyskinesia

Question 29

Dopaminergic pathways and side effect profile of antipsychotic

Answer 29

Mesolimbic pathway - positive symptoms of schizo Mesocortical - negative "" Nigrostriatal pathway (EPS and TD) Tuberoinfundibular - hyperprolactinaemia

Question 30

What can be given to reduce extra-pyramidal side effects of antipsychotics?

Answer 30

Procyclidine Anti-cholinergic

Question 31

Metoclopramide Odansatron Cyclizine

Answer 31

Dopamine antagonist Serotonin antagonist ?

Question 32

SEs of antipsychotics except clozapine

Answer 32

Weight gain - metabolic syndrome - increased bp, incr lipids and glucose, increased abdominal circumference Hyperprolactinaemia - Dec. libido, amenorrhoea, gynaecomastia, dec. bone density

Question 33

Clozapine SEs

Answer 33

Should be used in schizophrenia after two other antipsychotics have not worked • Significant potential for agranulocytosis (severe leukopenia): therefore close monitoring of FBC: weekly for first 18 weeks then fortnightly then monthly. • Significant potential for gastrointestinal hypomobility: constipation, potentially fatal bowel obstruction. • Other side-effects include hypersalivation and urinary incontinence. • Dose titrated slowly upward over two weeks and vital signs monitored due to potential for autonomic dysregulation

Question 34

Neuroleptic Malignant Syndrome

Answer 34

• Rare, life-threatening reaction to antipsychotics • Fever, confusion, muscle rigidity, sweating, autonomic instability • Death usually due to: • Rhabdomyolysis, renal failure, seizures • Risk factors include: • High potency dopamine antagonists (typical antipsychotics) in antipsychotic naive, high doses, young men • Treatment: • Emergency referral to A&E; stop antipsychotics; fluid resuscitation; reduce temperature

Question 35

Benzos

Answer 35

Most typically used are diazepam (long half-life) and lorazepam (shorter half-life) • Bind to GABA receptors to potentiate the effect of GABA and therefore reduce the excitability of neurones. • Therefore they are positive allosteric modulators of GABA receptor • Significant potential for tolerance and dependence • Significant potential for misuse • Use very cautiously and for no more than six weeks • Occasionally cause paradoxical disinhibition

Question 36

Pregabalin

Answer 36

Binds to voltage gated calcium channels in neurones • Increases extra-cellular amounts of the enzyme responsible for synthesis of GABA and therefore increases GABA concentrations in the brain • Reduces neuronal activity (i.e. is a CNS depressant) • Used in anxiety, neuropathic pain and epilepsy • Less potential for misuse and dependence (and tolerance) than benzodiazepines – but still misused – nickname “Budweisers” • BNF says short term use – often used indefinitely • Causes sedation and can cause weight gain

Question 37

Benzo alternative OD treatment

Answer 37

Positive allosteric modulator of GABA Zopiclone, Zolpidem OD of benzo: Flumazenil

Question 38

Lamotrigine

Answer 38

Has a potential to cause Steven Johnson's Syndrome

Question 39

Aspirin give to children - bad...

Answer 39

Reye's (Reye) syndrome is a rare but serious condition that causes swelling in the liver and brain. Reye's syndrome most often affects children and teenagers recovering from a viral infection, most commonly the flu or chickenpox.