Pyschiatry

Question 1

What is the definition of a delusion, and what are the classifications?

Answer 1

A fixed false belief that is out of context with someone’s cultural, religious and/or ethnic background

Onset classification:

• primary delusions appear suddenly without any mental event leading to them
• secondary delusions appear in response to a morbid experience e.g. Mood change or hallucination etc

Theme classification:

• persecutory/paranoid
• grandiose
• delusions of reference
• delusions of misidentification
• delusions of control
• religious delusions
• delusions of guilt
• nihilistic delusions
• somatic delusions

Question 2

Describe post traumatic stress disorder (PTSD), its features, and management.

Answer 2

PTSD can develop in people of any age following a traumatic event, for example a major disaster or childhood sexual abused. It encompasses what became known as ‘shell-shock’ following the First World War. One of the DSM-IV diagnostic criteria is that symptoms have been present for more than one month

Features:

• Re-experiencing e.g. flashbacks, nightmares, repetitive and distressing intrusive images.
• Avoidance e.g. avoiding people, situations or circumstances resembling or associated with the event
• Hyperarousal e.g. hypervigilance for threat, exaggerated startle response, sleep problems, irritability, difficulty concentrating
• Emotional numbing e.g. lack of ability to experience feelings, feeling detached.

Management:

• Following a traumatic event single-session interventions (referred to as debriefing) are not recommended
• watchful waiting may be used for mild symptoms lasting less than 4 weeks
• Military personnel have access to treatment provided by the armed forces
• trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
• Drug treatments should not be used as a routine first-line, if drug treatment is used the paroxetine or mirtazipine are recommended.

Question 3

Give examples of disorders of thought content and briefly describe them

Answer 3

• overvalued ideas: content usually understandable, themes tend to be culturally acceptable, tenacity of conviction less than delusions
• delusions: fixed false beliefs that do not fit with persons normal cultural or religious beliefs, may be classified by onset into primary or secondary of classified by theme

Question 4

Give examples of disturbances of stream of thought

Answer 4

• pressure of thoughts e.g. Ideas arise in an unusual variety and abundance
• poverty of thoughts e.g. Lack of number and variation of thoughts
• thought block e.g. Mind blank

Question 5

Give examples of disturbances of form of thought

Answer 5

• flight of ideas
• loosening of association e.g. Knights move sudden jump, word salad
• neologism i.e. new word made up by patient that only has meaning to them
• perseveration I.e. Persistent repetition of the same thought
• tangentially e.g. Conversation rapidly drifts from original question and does not come back
• circumstantiality e.g. Conversation drifts but eventually circles back
• blocking e.g. patient answer question appropriately but then do not complete answer, they need the original question to be answered before being able to continue

Question 6

Describe schizophrenia, it’s symptoms, it’s subtypes, prognostic factors, and management

Answer 6

A psychiatric condition onset usually in 15-45 year olds. Symptoms may be split into positive (hallucinations, delusions, ideas of reference) and negative symptoms:

• under-activity
• few leisure interests
• lack of convention
• social withdrawal
• decreased speech, motivation, emotional responsiveness

First-rank symptoms include:

• auditory hallucinations
• thought withdrawal, insertion, broadcast
• somatic hallucinations
• delusional perceptions
• passivity phenomenon

Subtypes:
- paranoid schizophrenia, usually presenting with prominent delusions usually with hallucinations
-hebephrenic schizophrenia I.e. Prominent disorganised mood, behaviour, speech
-residual schizophrenia I.e. After a period of positive symptoms only
Negative remain
-simple schizophrenia I.e. Only negative symptoms
-catatonic schizophrenia

Poor Prognostic Factors: FHx of schizophrenia, insidious onset, poor pre-morbid personality especially schizoid, low intelligence, absence of precipitating stressor, lack of affective components in the episode, underlying organic disorder.

Management:

• antipsychotics e.g. Typicals (chlorpromazine/ haloperidol) atypicals (risperidone, onlanzapine, clozapine) SEs include weight gain, diabetes, Extrapyramidal, cardiovascular (QT prolonging), hormonal such as prolactinaemia or decreased sexual function.
• psychological e.g. CBT for psychosis, family therapy
• social intervention I.e. Social skills training, housing support etc

Question 7

Describe first-ranks symptoms of schizophrenia

Answer 7

Symptoms suggestive of schizophrenia if present:

• auditory hallucinations e.g. Hearing thoughts spoken aloud, hearing someone talking about him/her, running commentary
• thought withdrawal, insertion, broadcast
• somatic hallucinations
• delusional perceptions
• passivity phenomena

Question 8

Describe postnatal depression, it’s symptoms and treatment

Answer 8

Risk of major depression is 3x higher in those with recent pregnancy. Have a low threshold for referring to multidisciplinary teams in mother-and-baby units.

Symptoms: low mood in the post-natal period, loss of appeitite, sleep disturbance.
Treatment:
-risk assess
-CBT
-fluoxetine is as good as CBT in short term, may be started after CBT has failed or there is a history of severe depression:

Question 9

Describe abbreviated Mental test

Answer 9

10 questions

1. Age?
2. Time?
3. Address to recall at end of the test
4. Year?
5. Name of this place?
6. Identification of two persons?
7. DOB
8. Yeah of First World War
9. Name of monarch
10. Count backwards from 20 to 1

Question 10

Describe the mini mental state exam

Answer 10

Used to indicate presence of cognitive impatient scored out of 30 with 27 as the cut off and 21-26 mild, 10-20 moderate and less than 10 severe.

Tests various categories:

• Orientation in time (5 points)
• Orientation in place (5 points)
• registration I.e. Repeating 3 name prompts (3 points)
• attention and calculation I.e. Serial sevens or world backwards (5 points)
• recall (3 points)
• language I.e name two objects (2 points)
• repetition I.e. Speak back a phrase (1 point)
• complex command I.e 3 point task and intersecting pentagons (6 points)

Question 11

Describe Beck’s cognitive triad in depression

Answer 11

Consists of negative view of self I.e worthless, dead inside

Negative view of world I.e. Unfair hostile

Negative view of the future I.e. Hopeless, not worth living

Question 12

Describe Borderline Personality Disorder

Answer 12

There is unstable affect regulation, poor impulse control, and poor interpersonal relationships/self-image. When stressed may hear voices, often self-harm

Associated with ADHD and Learning difficulties. Genetics and adverse child events e.g. Abuse are predispositions.

Question 13

Describe refeeding syndrome and its signs

Answer 13

A syndrome due to rapid intake of calories typically after a low calorie diet. Monitor Phosphate

Signs: rhabdomyolysis, respiratory or cardiac failure, hypotension, arrhythmias, seizures, coma, sudden death.

Acute gastric dilation can occur if a poorly nourished patient binges. Monitor serum PO4 and stop refeeding if falling, also watch for hyperglycaemia, hypokalemia, and hypermagnesia.

Question 14

Describe anorexia nervosa, diagnostic criteria, red flags, and treatment

Answer 14

The most fatal of all mental illnesses (~20% if severe). Compulsive need to control eating, low self worth is common and weight loss is an overvalued idea.

Diagnostic Criteria:

• weight less than 85% of predicted (BMI less than 17.5)
• fear of weight gain even when underweight leading to dieting, induced vomiting or excessive exercise
• feeling fat when thin
• amenorrhea (6 consecutive cycles) or decreased libido in men

Red flags:

• BMI less than 13
• weight loss more than 1kg/wk
• body temperature less than 34.5C
• BP less than 80/50 or Pulse less than 40
• SaO2 less than 92%
• weak muscles unable to stand without arms assisting
• ECG showing long QT or flat T waves

Treatment:

• Aim to restore nutritional balance (weight gain of 1.5kg/wk final BMI 20-25).
• Moderate (15-17.5)and mild( 17.5+) self help books and routine referral to community mental health team are sufficient
• Severe anorexia (BMI less than 15 and rapid weight loss and evidence of system failure) requires urgent referral to eating disorder unit if patients lack insight ‘re-feeding’ is considered a treatment under the mental health act. Monitor Phosphate being wary of re-feeding syndrome.

Question 15

Describe malignant neuroleptic syndrome it’s signs and treatment

Answer 15

It is a life-threatening neurological disorder most often caused by an adverse reaction to neuroleptics or antipsychotic drugs.

Signs:

• hyperthermia
• rigidity
• extrapyramidal signs
• labile BP, tachycardia, sweating, urinary continence
• mutism
• confusion
• coma
• increased WCC
• raised CK

Treatment:

• cooling
• stop antipsychotic
• IV fluids to prevent renal failure
• Dantrolene 1-2.5mg/kg IV (10mg/kg/day) may help with bromocriptine 2.5mg QDS

Question 16

What is a Community Treatment Order?

Answer 16

For patients under section 3 (Or 3) of the Mental Health Act 2007 that allows enforcement of treatment in the community. Power given to bring patient back to hospital if they do not comply with treatment order.

Question 17

Describe Section 2 of the Mental Health Act 1983

Answer 17

Describes a compulsory hospitalisation for assessment.

The period of assessment lapses after 28 days.

Patient may appeal, appeal must be sent within 14 days to the Mental Health Tribunal which is composed of a doctor, lay person, and lawyer.

An approved social worker (or the nearest relative) make the application on the recommendation of 2 doctors (not from the same hospital), one of whom ideally both are section 12 approved. The other doctor should ideally know the patient in a professional capacity. If this is not possible, the Code of Practice recommends that the second doctor should be an Approved Doctor

Question 18

Describe Section 3 of the Mental Health Act 1983

Answer 18

Describes compulsory hospitalisation for treatment lasting upto 6 months.

The exact mental disorder must be stated.

Detention is renewable for a further 6 months (annually thereafter).

2 doctors must sign the appropriate forms and know why treatment in the community is contraindicated. They must have seen the patient within 24h. They must state that treatment is likely to benefit the patient, or prevent deterioration; or that it is necessary for the health or safety of the patient or the protection of others.

Question 19

Describe Section 5(2) of the Mental Health Act 1983

Answer 19

Describes the compulsory hospitalisation of a patient already in hospital that lasts up to 72hrs, also known as ‘doctor’s holding power’.

The doctor in charge applies, and it is only available to patients on a ward, patients in a+e must be treated under common law.

Question 20

Describe Section 136 of the Mental Health Act 1983

Answer 20

Valid for upto 72 hours, allows police to arrest a person ‘in a place to which the public have access’ who is believed to be suffering from a mental disorder.

The patient must be conveyed to a ‘place of safety’ (usually a designated a+e or failing that a police station). In hospital there can be full assessment by a doctor and an approved social worker. The patient must be discharged after assessment or detained under section 2 or 3

Question 21

Describe the Mental Capacity Act 2005

Answer 21

Allows for treatment of patients who are unable to understand, retain, weigh up, or communicate a decision, or are cognitively impaired (MMSE less than 27)

Question 22

Define Psychosis

Answer 22

A mental health disorder that causes people to perceive or interpret things differently from those around them. This might involve hallucinations and/or delusions.

Question 23

Describe Bipolar Affective Disorder, its types, signs, treatment

Answer 23

Describes a mood disorder in which there alternating patterns of depression and mania/hypomania (depending on the severity and whether there is psychosis). Increase risk of relapse/episode in pregnancy.

Types:

• Bipolar I, Severe mood episodes from Mania to depression
• Bipolar II, mild mood elevation with hypomania alternating with periods of severe depression.
• Cyclothymia, brief periods of alternating hypomania and mild depression, not as extensive or long lasting as Bipolar.

Signs of Mania:

• Mood: Irritability(80%), Euphoria(71%), Lability(69%)
• Cognition: Grandiosity(78%), Flight of Ideas(71%), Poor concentration(71%), Confusion(25%)
• Behaviour: Rapid Speech(98%), Hyperactivity(87%), Decreased Sleep(81%), Hypersexuality(57%)
• Psychotic symptoms e.g. Delusions, Hallucinations.

Signs of Depression:

• Anhedonia i.e. loss of pleasure/interest
• Poor Appetite
• Early Morning Waking
• Psychomotor Retardation e.g. sluggish thoughts paucity of movements/expressions
• Decreased Sex Drive
• Reduced Concentration
• Ideas of worthlessness and/or guilt
• Thoughts of death, suicide, self harm

Treatment:

• Treat acute moderate/severe mania with olanzapine 10mg PO (SE: Weight Gain, Raised Glucose) or Valproate Semisodium e.g. 250mg/8h PO +/- Anti-psychotic if psychosis
• after successful treatment of the mania or depressive episode should have mood stabiliser for long-term control. If compliance is good and U+E, ECG and T4 normal give Lithium Carbonate 125mg-1/12h PO, Adjust dose to give 0.6-1mmol/L Li on Day 4-7 12 hours post dose. Check lithium levels weekly, until dose constant for 4 weeks then check monthly for 6 months, and then 3 monthly if stable. U+E, TFTs every 6 months as Lithium SE = Hypothyroidism, nephrogenic diabetes insipidus. Stop lithium if blood levels greater than 1.4 mmol/L
• If lithium no tolerated Valproate is used second line as mood stabiliser.

Signs of lithium toxicity: Decreased vision, D+V, Hypokalaemia, ataxia, tremor, dysarthria, coma

Question 24

Describe Depression, signs required for diagnosis, and its management

Answer 24

Around 40% of people per year have quite severe feelings of depression, unhappiness and disappointment. Of these around 20% experience a clinical depression.

Diagnosis of Major Depression begins with anhedonia (loss of interest or pleasure in daily life) plus 4 or more of the following signs (the first 5 of which are biological):

• Poor appetite +/- weight loss
• Early Waking - with diurnal mood variation (worse in mornings)
• Psychomotor Retardation (paucity of spontaneous movement or sluggish though processes)
• Decreased sexual drive
• Reduced ability to concentrate
• Ideas of worthlessness, inappropriate guilt or self-reproach
• Recurrent thoughts of death and suicide, or suicide attempts.

Management:

• Psychological treatment e.g. CBT plays a roll in all severities of depression may be only treatment in milder depression.
• Anti-depressants are particularly useful in patients with biological features of depression especially if symptoms are severe.
• delusions or hallucinations (Psychotic depression) prompt a physical treatment e.g. antidepressants +/- anti-psychotics or ECT.
• Reasons to admit: poor social circumstances, high suicide drive/risk, isolationist

Question 25

Describe ElectroConvulsive Therapy (ECT), its indications, contraindications, and side-effects.

Answer 25

There is MRI evidence for the idea that ECT interrupts the hyperconnectivity between various areas of the brain that maintain depression. Typical course lasts 6 sessions (2/wk). Current is passed through electrodes on anaesthetised patient.

Indications: NICE recommends ECT is used only gain rapid improvement of severe symptoms after an adequate trial of other treatments has proven ineffective and/or when the condition is considered to be potentially life-threatening, in individuals with severe depression, catatonia (e.g. associated with schizophrenia), a prolonged or severe manic episode.

Contraindications: Recent subdural/subarachnoid bleed; No consent (section 58). Caution in those with recent stroke, MI, arrhythmia.

Side-Effects: Anaesthetic problems, amnesia, delirium/agitation.

Question 26

Describe Obsessive-Compulsive Disorder (OCD) and its treatment.

Answer 26

Compulsions are senseless, repeated rituals. Obsessions are stereotyped, purposeless words, ideas or phrases that come into the mind. They are perceived by the patient as nonsensical (unlike delusions) and although out of character, ideas originating from themselves (as opposed to hallucinations, thought insertion).

Treatment: CBT or Exposure response therapy (exposing target patient to source or anxiety) are first line, clomipramine or SSRIs can help.

Question 27

What are the types of Anxiety Disorder?

Answer 27

• Generalised Anxiety Disorder (GAD)
• Panic Disorder
• Phobia
• Post-Traumatic Stress Disorder (PTSD)
• Social Anxiety Disorder
• Obsessive-Compulsive Disorder (OCD)

Question 28

Describe Generalised Anxiety Disorder (GAD), its symptoms, and treatment.

Answer 28

Symptoms: Tension, Agitation, feelings of impending doom, trembling, a sense of collapse, insomnia, poor concentration, hyperventilation, headaches, sweating, palpitations, poor appetite, nausea, difficulty getting to sleep, repetitive thoughts.

Treatment: Regular exercise, meditation, CBT. Drugs may be used alongside psychotherapy, such as benzodiazepines, SSRIs are 1st line.(paroxetine in social anxiety), Venlafaxine is second line, Azapirones (buspirone a partial serotonin agonist), beta-blockers for autonomic symptoms.

Question 29

Describe Section 135 of the Mental Health Act 1983

Answer 29

This empowers an approved social worker who believes that someone is being ill-treated or neglecting themselves to apply to a magistrate for warrant to search for and admit such patients. The approved social worker or a registered medical practitioner must accompany the police.

Question 30

Describe the Deprivation of Liberty Safeguards (DoLS)

Answer 30

• A part of the Mental Capacity Act 2005
• Aim to ensure people in care homes, hospitals and supported living are cared for in the least restrictive way
• Apply to vulnerable people aged 18 or over who have a mental health condition and lack mental capacity but are not under the Mental Health Act 1983
• The safeguards are in place so that when it is deemed necessary to deprive a patient of their liberty in order to care for them safely it is authorised in a lawful way.
• A deprivation of liberty occurs when the person is under continuous supervision and control and is not free to leave, and the person lacks capacity to consent to these arrangements
• Application made to local authority to arrange assessment, completed within 21 days by a best interests assessor and a mental health assessor

Question 31

Describe the Biopsychosocial Model

Answer 31

It is a general approach looking at the biological, psychological and social factors in context of disease.

Biological factors e.g. Illness, Disability, Immunity, Diet,

Psychological factors e.g. Behaviour, Personality, Self-esteem, Self-control, impulsivity, Guilt, Anxiety

Social factors e.g. Economic status, religion, peer group, relationships, culture, social skills

Question 32

Describe Histrionic Personality Disorder

Answer 32

• 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 33

What are the 5 stage of bereavement

Answer 33

1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance

Question 34

What is the difference between hypomania and mania?

Answer 34

The presence of psychotic symptoms differentiates hypomania from mania e.g. Delusions of grandeur or auditory hallucinations.

Question 35

Describe Autism Spectrum Disorder’s (ASDs), its symptoms, and treatment

Answer 35

A developmental disorder consisting of a triad of impaired reciprocal social interaction, impaired imagination (+/- abnormal verbal and nonverbal communication), and restricted repertoires of activities and interests. If one child is affect the risk of the next pregnancy being affected is 5-10%. There is associated epilepsy in 30%.

Symptoms: diagnosis depends on having more than 6 symptoms, with at least 2 A symptoms, and one each from B and C.

• A symptoms, unawareness of the existence and feelings of others, abnormal response to being hurt, impaired imitation, repetitive play, bad at making friends.
• B symptoms, little babbling and few facial expression or no gestures in infancy, avoids mutual gaze, odd speech (echolalia (repetition) and odd use of words, difficulty in initiating or sustaining reciprocal roles in conversations.
• C symptoms, stereotyped movements (hand-flicking, spinning, head-banging), preoccupation with parts of objects, marked distress over changes in trivia, insists on following routines in precise detail, narrow fixations.

Treatment:

• Early intensive behavioural intervention +/- speech therapy +/- special schooling. Starts at 3yrs old
• Parent training helps communication, enriches parent knowledge, enhances parent-child interaction, and decreased parental maternal depression.
• Social skills training, Benefits available.
• Drugs have small role, fish oils may help with tantrums and self harm, atomextine may help with hyperactivity, risperidone may help with irritability, repetition, social withdrawal.

Question 36

Describe Reactive Attachment Disorder and its symptoms.

Answer 36

Uncommon disorder that can affect children. It arises from a. Failure to form normal attachments to primary caregivers in early childhood. This may be due to early experiences of neglect, abuse, separation during early years.

Symptoms: Persistent failure to initiate or respond to most social interactions in a developmentally appropriate away. Also reluctance to accept comfort and affection even when distressed.

Question 37

Describe Gender Dysphoria and its management

Answer 37

Distress experienced by an individual about their assigned gender which is in conflict with their internal gender identity diagnosis relies on having these feelings for at least six months. The Gender Recognition Act 2004 in the UK allows transsexual people to change their legal gender. In order to do this they must have had a diagnosis of gender Dysphoria and have lived in the changed gender for at least 2 years.

Management:

• Referral to Gender Dysphoria specialist/clinic or mental health services.
• MDT approach with psychotherapeutic support
• endocrine treatment
• gender reassignment surgery including chest surgery (breast augmentation or mastectomy), genital surgery (vaginectomy/penectomy + Phalloplasty/Vaginoplasty, facial surgery, vocal surgery.

Question 38

Describe Adjustment Disorder, its symptoms,

Answer 38

Occurs when an individual is unable to cope or adjust to a particular stress or major life event. Sometimes referred to as situational depression. Different to anxiety disorder which lacks the presence of a stressor and PTSD which is associated with a more intense stressor / autonomic response.

Symptoms: loss of interest, feelings of hopelessness, crying spells, anxiety, difficulty sleeping, reckless behaviour, ignoring important tasks, skipping school.

Management:

• CBT or Psychotherapy/counselling through difficult period allowing re-adjustment.
• small doses of antidepressants and anxiolytics may have a role.

Question 39

Describe Conversion Disorder, its symptoms and management.

Answer 39

Descibes patients that present with neurological symptoms such as numbness, blindness, pain, paralysis, or fits which are no consistent witha. Well-established organic cause but cause significant distress. Thought to be in response to stressful stations affecting patients mental health.

Symptoms: Commonly, blindness, paralysis, inability to speak, deafness, numbness, difficulty swallowing, incontinence, balance problems, seizures, tremors, difficulty asking. Usually occurring suddenly.

Management:

• reassurance of non-organic cause
• occupational therapy +/- physiotherapy
• treatment of any comorbid mental health.
• talking therapy may help

Question 40

Describe Serotonin Syndrome, its symptoms, and management.

Answer 40

Syndrome caused as a result of excess presynpatic serotonin. Causes include antidepressants, some analgesics (tramadol, pethidine, fentanyl), antiemetics (Ondansetron, metaclopromide), recreationals (cocaine, MDMA).

Symptoms: Triad of:

• Altered mental status e.g. Confusion, agitation, delirium.
• Neuromuscular hyperactivity e.g. Shivering, tremor, myoclonus, ocular clonus, hyper-reflexia
• Autonomic Instability e.g. Dilated pupils, diarrhoea, profuse sweating, flushing, tachycardia, hyper/hypotension

Management:

• ABCDE + Reversal of hyperthermia
• active cooling techniques including cool IV fluids and fans, ice baths and internal cooling devices.
• Agitation, seizures, and muscle hyperactivity with benzodiazepines.
• Serotonin antagonist e.g. Chlorpromazine if extreme and resistant to above methods but little evidence

Question 41

What are the different types of personality disorder?

Answer 41

Cluster A ‘Odd and Ecentric’ e.g. Paranoid, schizoid, schizotypal

Cluster B ‘Dramatic, Emotional and Erratic’ e.g. Antisocial, borderline, histrionic, narcissistic

Cluster C ‘Anxious and Fearful’ e.g. OCD, Avoidant, Dependant

Question 42

Describe paranoid personality disorder

Answer 42

Suspicious
Feel like other people are being nasty to you
Feel easily rejected
Tend to hold grudges

Question 43

Describe schizoid personality disorders

Answer 43

Emotionally cold
Don’t like contact with other people
Have a rich fantasy world

Question 44

Describe schizotypal personality disorder

Answer 44

Eccentric behaviour
Odd ideas
Difficulties with thinking
lack of emotion or inappropriate emotional reactions
See or hear strange things
Sometimes related to schizophrenia

Question 45

Describe antisocial personality disorder

Answer 45

Don’t care much about the feelings of others
Easily frustrated
Tend to be aggressive
Commit crime
Find it difficult to make close relationships
Impulsive
Little remorse
Do not learn from unpleasant experience s

Question 46

What is De Clerambault’s Syndrome?

Answer 46

Aka erotmania, is a form of paranoid delusion with an amorous quality. The patient, often a single woman, believes that a famous person is in lover with her

Question 47

What is Capgras’ Delusion?

Answer 47

A psychiatric disorder in which a person holds a delusion that a friend, spouse, parent, or other close family member or pet has been replaced by an identical imposter.

Question 48

What is Othello’s Syndrome?

Answer 48

Pathological jealously 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 49

Describe Hypnagogic Hallucinations, its features, and management

Answer 49

Visual, tactile, auditory or other sensory events, usually brief but occasionally prolonged, that occur in the transition from wakefulness to sleep (Hypnagogic) or from sleep to wakefulness (Hypnopompic).

Usually a part of the tetrad of narcolepsy that includes: Cataplexy, Excessive daytime sleepiness, hypnagogic hallucinations, sleep paralysis. However they can occur without narcolepsy.

Features: Vivid usually visual hallucinations occurring at the onset of sleep. Visual hallucination usually consists of simple forms such as coloured circles or parts of objects that may be constant or changing in size. Auditory hallucinations may also occur.

Management:

• REM-supressing antidepressants e.g. venlafaxine, Fluoxetine
• Musical hallucinations may respond to onlanzipine, quetiapine, fluvoxamine, clompiramine, carbamazepine, valproate, donepezil.

Question 50

Describe the psychological defence mechanism regression

Answer 50

Characterised by a return to less mature levels of functioning. This defence mechanism only appears when the levels of anxiety are high, and are not alleviated by more mature defences such as intellectualisation and humour. CBT can help avoid these episodes.

Question 51

Describe the psychological defence mechanism reaction formation.

Answer 51

A defence mechanism in which emotions and impulses which are anxiety-producing or perceived to be unacceptable are mastered by exaggeration of the directly opposing tendency. For example being overly pleasant to a antagonising opponent.

Question 52

Describe the psychological defence mechanism blocking

Answer 52

Blocking is essentially denial and refusal to accept an individuals point of view.

Question 53

Describe the psychological defence mechanism dissociation

Answer 53

Dissociation is associated with removing oneself from the situation, having a view that is disconnected from the current state of affairs. For instance becoming vague and uninterested from a losing argument.

Question 54

Describe the psychological defence mechanism undoing

Answer 54

Characterised by acting out in reverse a previously unacceptable episode of behaviour.

Question 55

What are the poor prognostic factors in schizophrenia?

Answer 55

• Low intelligence,
• Insidious onset,
• lack of precipitating stressor
• underlying organic cause
• FHx of schizophrenia
• Poor pre-morbid personality especially schizoid
• Lack of affective symptoms,

Question 56

What medications are used in the treatment of Tourette’s?

Answer 56

Mild to Moderate Tics: Clonidine or Guanfacine

Moderate to severe tics: Risperidone or haloperidol

Non-tic symptons: SSRIs for anti-obsessional
Methylphenidate for ADHD.

Question 57

What are some risk factors for successful suicide?

Answer 57

• Alcohol (Alcohol dependence increases risk 10fold) + Drug abuse
• Concurrent mental disorder or previous psychiatric treatment
• Unemployment or homelessness
• Physically disabling or painful illness including chronic pain
• Low socio-economic status
• loss of job
• male sex
• Middle age
• previous attempts (30-35fold increased risk)

Question 58

In patients who experience an episode of psychosis what is the probability of a second episode in life?

Answer 58

Over 90%