Psychiatry Passmed 1

Question 1

What is acute stress disorder? How does it present?

Answer 1

an acute stress reaction that occurs in the first 4 weeks after a person has been exposed to a traumatic event (threatened death, serious injury e.g. road traffic accident, sexual assault etc)

(PTSD occurs after 4 weeks)

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 2

How can acute stress disorder be managed?

Answer 2

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 3

What is the mechanism behind alcohol withdrawal?

Answer 3

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

alcohol withdrawal leads to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)

Question 4

How may alcohol withdrawal present?

Answer 4

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 5

How can alcohol withdrawal be managed?

Answer 5

patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until stabilised

first-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam

Lorazepam may be preferable in patients with hepatic failure

carbamazepine also effective in treatment of alcohol withdrawal

Question 6

Diagnosis of anorexia nervosa is now based on the DSM 5 criteria. What does this include?

Answer 6

1. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
2. Intense fear of gaining weight or becoming fat, even though underweight.
3. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

Question 7

What is the recommended management for children with anorexia nervosa?

Answer 7

NICE recommend ‘anorexia focused family therapy’ as the first-line treatment. The second-line treatment is cognitive behavioural therapy.

Question 8

What signs may be seen in a patient with anorexia nervosa?

Answer 8

reduced body mass index
bradycardia, hypotension
enlarged salivary glands
lanugo hair
failure to develop secondary sexual characteristics
yellow tinge to the skin (hypercarotinaemia)

Question 9

What physiological abnormalities may be seen in a patient with anorexia nervosa?

Answer 9

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

Question 10

Easy way to remember changes seen in anorexia?

Answer 10

most things low
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia

Question 11

Give two examples of typical antipsychotics

Answer 11

Haloperidol
Chlorpromazine

Question 12

What is the mechanism of action of typical anti psychotics?

Answer 12

Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways

Question 13

Give three examples of atypical antipsychotics

Answer 13

Clozapine
Risperidone
Olanzapine

Question 14

What is the mechanism of action of atypical antipsychotics?

Answer 14

Act on a variety of receptors (D2, D3, D4, 5-HT)

Question 15

What Extrapyramidal side-effects (EPSEs) may result from antipsychotic use?

Answer 15

Parkinsonism

acute dystonia
- sustained muscle contraction (e.g. torticollis, oculogyric crisis)
- may be managed with procyclidine

akathisia (severe restlessness)

tardive dyskinesia (involuntary movements of face and jaw, see image)

Question 16

What is tardive dyskinesia?

Answer 16

late onset of choreoathetoid movements (chorea = irregular contractions and athetosis = twisting and writhing)

abnormal, involuntary, may be irreversible

most common is chewing and pouting of jaw

Question 17

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

Answer 17

Increased risk of stroke and VTE

Question 18

Atypical antipsychotics should now be used first-line in patients with schizophrenia. The main advantage of the atypical agents is a significant reduction in extrapyramidal side-effects.

What adverse effects may they present with?

Answer 18

weight gain
hyperlipidaemia
diabetes mellitus
hyperprolactinaemia
Qtc prolongation
clozapine is associated with agranulocytosis - monitor FBC if infection!!

Question 19

What should be introduced if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each for at least 6–8 weeks?

Answer 19

Clozapine

Question 20

What are the adverse effects of clozapine?

Answer 20

agranulocytosis, neutropaenia
reduced seizure threshold
myocarditis: a baseline ECG should be taken before starting treatment
hypersalivation
constipation

Dose adjustment of clozapine might be necessary if smoking is started or stopped during treatment

Question 21

When should the following be monitored in patients taking antipsychotics:

FBC, U&Es, LFTs ?

Answer 21

at the start of therapy
annually
clozapine requires much more frequent monitoring of FBC (initially weekly)

Question 22

The monitoring requires for patients taking antipsychotic medication are extensive. What does the BNF recommend?

Answer 22

FBC, U&Es, LFTs

Fasting blood glucose, prolactin, lipids

Weight

Blood pressure
(baseline, frequently during dose titration)

ECG (baseline)

Cardiovascular risk assessment (annually)

Question 23

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

They therefore are used for a variety of purposes including:

Answer 23

sedation
hypnotic
anxiolytic
anticonvulsant
muscle relaxant

Question 24

Why should benzos be monitored closely?

Answer 24

Risk of developing tolerance or dependence

Only recommended to be prescribed 2-4 weeks at a time

Question 25

If patients withdraw too quickly from benzodiazepines they may experience benzodiazepine withdrawal syndrome, which is very similar to alcohol withdrawal syndrome. This may occur up to 3 weeks after stopping a long-acting drug. Features include:

Answer 25

AAIITTSS anxiety, loss of appetite insomnia, irritability tremor, tinnitus sweating, seizures perceptual disturbances

Question 26

What is the difference in mechanism of action of benzodiazepines and barbiturates?

Answer 26

GABAA drugs benzodiazipines increase the frequency of chloride channels barbiturates increase the duration of chloride channel opening (BarbiDurates increase Duration & Frendodiazepines increase Frequency)

Question 27

Bipolar disorder is a chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression. What are the two types?

Answer 27

type I disorder: mania and depression (most common) type II disorder: hypomania and depression

Question 28

What is mania/hypomania?

Answer 28

both terms = abnormally elevated mood or irritability with mania, there is severe functional impairment or psychotic symptoms for 7 days or more hypomania describes decreased or increased function for 4 days or more the key differentiation in MCQs is psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) which suggest mania

Question 29

What is the mood stabiliser of choice in bipolar disorder?

Answer 29

Lithium Valproate is an alternative

Question 30

How can mania/ hypo mania be managed?

Answer 30

consider stopping antidepressant if the patient takes one; antipsychotic therapy e.g. olanzapine or haloperidol

Question 31

How can depressive episodes in bipolar disorder be managed?

Answer 31

Talking therapies and fluoxetine

Question 32

When should patients with bipolar disorder be referred from primary care?

Answer 32

if symptoms suggest hypomania then NICE recommend routine referral to the community mental health team (CMHT) if there are features of mania or severe depression then an urgent referral to the CMHT should be made

Question 33

What is Bulimia nervosa ?

Answer 33

a type of eating disorder characterised by episodes of binge eating followed by intentional vomiting or other purgative behaviours such as the use of laxatives or diuretics or exercising

Question 34

What examinations findings might you see in bulimia nervosa?

Answer 34

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 35

How can bulimia nervosa be managed?

Answer 35

bulimia-nervosa-focused guided self-help for adults If contraindicated or ineffective after 4 weeks of treatment, NICE recommend individual eating-disorder-focused cognitive behavioural therapy (CBT-ED) children should be offered bulimia-nervosa-focused family therapy high-dose fluoxetine

Question 36

What is Charles-Bonnet syndrome (CBS)?

Answer 36

persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness. This is generally against a background of visual impairment (age related macular degeneration)

Question 37

What are the risk factors for Charles Bonnet syndrome?

Answer 37

Advanced age Peripheral visual impairment Social isolation Sensory deprivation Early cognitive impairment

Question 38

What is Cotard syndrome?

Answer 38

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

Question 39

What is De Clerambault's syndrome?

Answer 39

Also known as erotomania 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 40

Factors suggesting diagnosis of depression over dementia?

Answer 40

short history, rapid onset global memory loss (dementia characteristically causes recent memory loss) 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

Question 41

What is classified as 'less severe' depression?

Answer 41

a PHQ-9 score of < 16

Question 42

What is classified as ‘more severe’ depression?

Answer 42

a PHQ-9 score of ≥ 16

Question 43

How should less severe depression be managed?

Answer 43

guided self-help group / individual CBT group / individual behavioural activation (BA) group exercise, mindfulness and meditation interpersonal psychotherapy (IPT) SSRIs counselling short-term psychodynamic psychotherapy (STPP)

Question 44

How should more severe depression be managed?

Answer 44

a combination of individual cognitive behavioural therapy (CBT) and an antidepressant first line citalopram and sertraline are the SSRIs of choice

Question 45

For how long should antidepressants be continued after remission of symptoms?

Answer 45

6 months to reduce risk of relapse

Question 46

Which two questions can be used to screen for depression?

Answer 46

'During the last month, have you often been bothered by feeling down, depressed or hopeless?' 'During the last month, have you often been bothered by having little interest or pleasure in doing things?'

Question 47

What tools can be used to assess the degree of depression?

Answer 47

Hospital Anxiety and Depression (HAD) scale and the Patient Health Questionnaire (PHQ-9)

Question 48

What symptoms may depression present with?

Answer 48

SIGECAPS Sleep (difficult) Interest ( lack of) , Guilt, Energy ( low) Concentration (poor) and Appetite, Psychomotor retardation , and Suicidal ideation Anhedonia - lack of pleasure in activities

Question 49

What is the guidance for switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI?

Answer 49

the first SSRI should be withdrawn before the alternative SSRI is started

Question 50

What is the guidance on switching from fluoxetine to another SSRI?

Answer 50

withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low-dose of the alternative SSRI

Question 51

What is the guidance for switching from a SSRI to a tricyclic antidepressant (TCA)?

Answer 51

cross-tapering is recommend (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly) - an exception is fluoxetine which should be withdrawn prior to TCAs being started

Question 52

Electroconvulsive therapy is a useful treatment option for patients with severe depression refractory to medication (e.g. catatonia). What are the potential side effects?

Answer 52

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 53

Indications for ECT?

Answer 53

indicated to achieve rapid improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening, in individuals with: catatonia a prolonged or severe manic episode severe depression that is life-threatening

Question 54

What is the absolute contraindication to ECT?

Answer 54

Raised ICP

Question 55

What differentials are important to consider for GAD?

Answer 55

hyperthyroidism, cardiac disease and medication-induced anxiety Medications that may trigger anxiety include : salbutamol, theophylline, corticosteroids, antidepressants and caffeine

Question 56

Give some key risk factors and protective factors for GAD

Answer 56

Risk factors for the development of GAD include; Aged 35- 54 Being divorced or separated Living alone Being a lone parent Protective factors include; Aged 16 - 24 Being married or cohabiting

Question 57

What is the stepwise approach to tx of GAD?

Answer 57

step 1: education about GAD + active monitoring step 2: low-intensity psychological interventions (individual self-help, psychoeducational groups) step 3: high-intensity psychological interventions (CBT) or drug treatment step 4: highly specialist input e.g. Multi agency teams

Question 58

What drug tx is available for GAD?

Answer 58

Sertraline first line SSRI if sertraline is ineffective, offer an alternative SSRI or SNRI examples of SNRIs include duloxetine and venlafaxine If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin

Question 59

What is the mx of panic disorder?

Answer 59

CBT or drug treatment SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered

Question 60

What are the 5 stages of grief?

Answer 60

Denial: feeling of numbness and also pseudohallucinations of the deceased, both auditory and visual. Occasionally people may focus on physical objects that remind them of their loved one or even prepare meals for them Anger Bargaining Depression Acceptance

Question 61

What are the risk factors for atypical grief reactions?

Answer 61

more likely to occur in women Sudden unexpected death Problematic relationship before death Little social support

Question 62

Features of atypical grief reactions include:

Answer 62

delayed grief: sometimes said to occur when more than 2 weeks passes before grieving begins prolonged grief: difficult to define. Normal grief reactions may take up to and beyond 12 months

Question 63

How may speech and thought present in mania ?

Answer 63

pressured flight of ideas: characterised by rapid speech with frequent changes in topic based on associations, distractions or word play poor attention

Question 64

How may behaviour change in mania?

Answer 64

insomnia loss of inhibitions: sexual promiscuity, overspending, risk-taking increased appetite

Question 65

What is chronic insomnia ?

Answer 65

diagnosed if a person has trouble falling asleep or staying asleep at least three nights per week for 3 months or longer

Question 66

How may patients with insomnia present?

Answer 66

decreased daytime functioning decreased periods of sleep (delayed sleep onset or awakening in the night) increased accidents due to poor concentration

Question 67

Give some risk factors for insomnia

Answer 67

Female gender Increased age Lower educational attainment Unemployment Economic inactivity Widowed, divorced, or separated status Alcohol and substance abuse Stimulant usage Poor sleep hygiene Anxiety and depression

Question 68

How is insomnia investigated?

Answer 68

Diagnosis is primarily made through patient interview Sleep diaries and actigraphy may aid diagnosis (Actigraphy is a non-invasive method for monitoring motor activity) Polysomnography is not routinely indicated

Question 69

How should insomnia be managed?

Answer 69

Identify any potential causes e.g. mental/ physical health issues or poor sleep hygiene Advise the person not to drive while sleepy Advise good sleep hygiene: no screens before bed, limited caffeine intake, fixed bed times etc ONLY consider use of hypnotics if daytime impairment is severe.

Question 70

What is Korsakoff’s syndrome?

Answer 70

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

Question 71

What features does Korsakoff’s present with?

Answer 71

anterograde amnesia: inability to acquire new memories retrograde amnesia confabulation

Question 72

Lithium is a mood stabilising drug used prophylactically in bipolar disorder but also as an adjunct in refractory depression. It has a very narrow therapeutic range (0.4-1.0 mmol/L) and a long plasma half-life. What are its adverse effects?

Answer 72

nausea/vomiting, diarrhoea fine tremor nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus thyroid enlargement, may lead to hypothyroidism weight gain idiopathic intracranial hypertension leucocytosis hyperparathyroidism and resultant hypercalcaemia

Question 73

Give some signs of lithium toxicity

Answer 73

ataxic gait vision changes confusion

Question 74

What is the most common endocrine disorder developing as a result of chronic lithium toxicity?

Answer 74

hypothyroidism

Question 75

What ECG changes can lithium cause?

Answer 75

ECG: T wave flattening/inversion

Question 76

When should lithium levels be checked?

Answer 76

the sample should be taken 12 hours post-dose 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.

Question 77

What is the mechanism of action of mirtazipine? Which patients is it particularly useful in?

Answer 77

antidepressant that works by blocking alpha2-adrenergic receptors, which increases the release of neurotransmitters fewer side effects and interactions than many other antidepressants and so is useful in older people Two side effects of mirtazapine, sedation and an increased appetite, can be beneficial in older people that are suffering from insomnia and poor appetite

Question 78

When should mirtazipine be taken?

Answer 78

In the evening as it is sedative

Question 79

Give some risk factors for OCD

Answer 79

family history age: peak onset is between 10-20 years pregnancy/postnatal period history of abuse, bullying, neglect

Question 80

How can OCD be classified?

Answer 80

NICE recommend classifying impairment into mild, moderate or severe Y-BOCS scale an example of 'severe' OCD would be someone who spends > 3 hours a day on their obsessions/compulsions, has severe interference/distress and has very little control

Question 81

How should OCD be managed If functional impairment is mild?

Answer 81

low-intensity psychological treatments: CBT / ERP If this is insufficient or can’t engage in psychological therapy, then offer a either an SSRI or more intensive CBT

Question 82

How should OCD be managed if moderate functional impairment?

Answer 82

SSRI (fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP) consider clomipramine (as an alternative first-line drug treatment to an SSRI if contraindicated)

Question 83

How should OCD with severe functional impairment be managed?

Answer 83

refer to the secondary care mental health team for assessment whilst awaiting assessment - offer combined treatment with an SSRI and CBT

Question 84

What is ERP?

Answer 84

Exposure response prevention psychological method which involves exposing a patient to an anxiety provoking situation and then stopping them engaging in their usual safety behaviour This helps them confront their anxiety and the habituation leads to the eventual extinction of the response

Question 85

How does SSRI tx for OCD compare to that of depression?

Answer 85

compared to depression, the SSRI usually requires a higher dose and a longer duration of treatment (at least 12 weeks) for an initial response In OCD, if treatment with SSRI is effective then continue for at least 12 months to prevent relapse and allow time for improvement

Question 86

What is Othello’s syndrome?

Answer 86

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 87

What are personality disorders?

Answer 87

series of maladaptive personality traits that interfere with normal function in life

Question 88

What are the ‘Cluster A’ personality disorders?

Answer 88

'Weird' Paranoid Schizoid Schizotypal

Question 89

What are the ‘Cluster B’ personality disorders?

Answer 89

'Wild' Antisocial Borderline (Emotionally Unstable) Histrionic Narcissistic

Question 90

What are the ‘Cluster C’ personality disorders?

Answer 90

‘Worriers’ Obsessive-Compulsive Avoidant Dependent

Question 91

How does paranoid personality disorder present?

Answer 91

Hypersensitivity and an unforgiving attitude when insulted Unwarranted tendency to question the loyalty of friends and to perceive attacks on their character Reluctance to confide in others Preoccupation with conspirational beliefs and hidden meaning

Question 92

How does schizoid personality disorder present?

Answer 92

Indifference to praise and criticism Preference for solitary activities Lack of interest in sexual interactions Lack of desire for companionship Emotional coldness Few interests Few friends or confidants other than family

Question 93

How does schizotypal personality disorder present?

Answer 93

Ideas of reference (differ from delusions in that some insight is retained) Odd beliefs and magical thinking Unusual perceptual disturbances Paranoid ideation and suspiciousness Odd, eccentric behaviour Lack of close friends other than family members Inappropriate affect Odd speech without being incoherent

Question 94

How does antisocial personality disorder present?

Answer 94

More common in men Failure to conform to social norms with respect to lawful behaviours Deception (repeatedly lying, use of aliases) Impulsiveness or failure to plan ahead Irritability and aggressiveness (physical fights or assaults) Reckless disregard for the safety of self or others Consistent irresponsibility Lack of remorse

Question 95

How does Borderline - also known as Emotionally Unstable - Personality disorder present?

Answer 95

Efforts to avoid real or imagined abandonment Unstable interpersonal relationships which alternate between idealization and devaluation Unstable self image Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse) Recurrent suicidal behaviour Affective instability Chronic feelings of emptiness Difficulty controlling temper Quasi psychotic thoughts

Question 96

How does histrionic personality disorder present?

Answer 96

Inappropriate sexual seductiveness Need to be the centre of attention Rapidly shifting and shallow expression of emotions Suggestibility Physical appearance used for attention seeking purposes Impressionistic speech lacking detail Self dramatization Relationships considered to be more intimate than they are

Question 97

How does obsessive compulsive personality disorder present?

Answer 97

Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone Demonstrates perfectionism that interferes with completing tasks Is extremely dedicated to work and efficiency to the elimination of spare time activities Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning Is unwilling to delegate Takes on a stingy spending style , stiffness and stubbornness

Question 98

How does avoidant personality disorder present?

Answer 98

Avoidance of significant interpersonal contact due to fears of criticism or rejection Unwillingness to be involved unless certain of being liked Preoccupied with ideas that they are being criticised or rejected in social situations Restraint in intimate relationships due to the fear of being ridiculed Reluctance to take personal risks due to fears of embarrassment Views self as inept and inferior to others Social isolation accompanied by a craving for social contact

Question 99

How does dependent personality disorder present?

Answer 99

Difficulty making everyday decisions without excessive reassurance from others Need for others to assume responsibility for major areas of their life Difficulty in expressing disagreement with others due to fears of losing support Lack of initiative Unrealistic fears of being left to care for themselves Urgent search for another relationship as a source of care and support when a close relationship ends Extensive efforts to obtain support from others Unrealistic feelings that they cannot care for themselves

Question 100

Spot diagnosis : A young woman comes for relationship advice. She is constantly questioning the loyalty of her partner and regularly accuses him of having affairs for no reason. She also regularly falls out with her female friends as she thinks they are belittling her .

Answer 100

paranoid personality disorder

Question 101

Spot diagnosis : A man asks for help with social anxiety. He prefers to be alone and doesn't like to share his beliefs, which other people think are odd. He has a strong interest in the paranormal and talks in an high-pitched voice when talking about his 'spirit-guide'

Answer 101

schizotypal personality disorder

Question 102

Spot diagnosis : A young man is arrested after crashing his car into a pedestrian. He shows little remorse and repeatedly lies to try and avoid prosecution. He is known to police after being involved in repeated fights

Answer 102

antisocial personality disorder

Question 103

Spot diagnosis : A young woman takes a paracetamol overdose after splitting with her boyfriend. Two days later she is in a new relationship which is troubled by her repeated outbursts of anger

Answer 103

borderline personality disorder

Question 104

Spot diagnosis : A woman presents to her male family doctor wearing a low-cut top and a short skirt. She tries to flirt with the doctor. The consultation is filled with drama and she becomes annoyed with the centre of attention shifts from her

Answer 104

- histrionic personality disorder

Question 105

Spot diagnosis : A middle-aged male manager comes in for review after having trouble at work. His colleagues find him arrogant, 'cut-throat' and lacking empathy. He seems to exaggerate his own importance to the company and seems preoccupied with success

Answer 105

- narcissistic personality disorder

Question 106

Spot diagnosis : A female librarian comes for advice. Her colleagues find her inflexible in her approach to her work. She easily becomes annoyed if her 'systems' are interfered with and generally likes to work by herself, using lists and rules to structure her day

Answer 106

obsessive-compulsive personality disorder

Question 107

Spot diagnosis : A young woman complains of feeling lonely. She has stopped seeing her old friends as she is worried about not being liked or criticised

Answer 107

- avoidant personality disorder

Question 108

Spot diagnosis : A middle-aged woman asks for help after splitting up with her partner, who apparently felt she was too 'needy'. She describes him as 'my world' and thinks she won't be able to cope by herself and wants your advice on how to find a new partner quickly

Answer 108

- dependent personality disorder

Question 109

How can personality disorders be managed?

Answer 109

psychological therapies: dialectical behaviour therapy treatment of any coexisting psychiatric conditions