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1

List the 7 criteria for alcohol dependence in the ICD10

Compulsion
Lack of control
Physical withdrawal
Tolerance
Neglect of other interests or pleasures, with increased time invested in obtaining, taking, or recovering from alcohol
Persistent abuse despite understanding the harmful consequences manifesting

2

What are the 3 core symptoms of depression?

Anhedonia
Anergia
Low mood (diurnal variation - classically feels worse in morning)

3

A 17 year old girl presents to her GP surgery with low mood. The GP takes a thorough history and finds that this has been ongoing for 18 days, and the girl also describes a lack of energy. She says things have been going well at school recently and her friends are supportive, though this leaves her a little frustrated as she cannot identify what it is she has to be depressed about. She describes a recent lack of confidence, and says she feels her appetite is a little diminished. The GP thoroughly assess her risk, and finds her not to be a danger to herself.

What is the most appropriate next step?

A. Reassure the girl for the time being, and ask her to return for assessment in 2 weeks
B. Explain the concept of CBT to the patient, and explore whether she thinks it may be useful
C. Explain the concept of CBT to the patient, explore whether she thinks it may be useful, and ascertain whether she would be open to taking anti-depressants
D. Prescribe Sertraline on a 4 week trial, and have a conversation about therapies to try in the meantime
E. Prescribe Sertraline and advise her to take it until she is no longer depressed, and then for at least 6 months after

A. Reassure the girl for the time being, and ask her to return for assessment in 2 weeks

This is a history of mild depression: it features 2 core symptoms with 2 non-core which are not particularly severe but have persisted for >2 weeks. The initial approach in these patients is frequently 'watchful waiting', where they are asked to return in 2 weeks for reevaluation. Though this seems like an inadequate and frustrating response, many of these episodes will self-resolve, and so to over-medicalise a self-resolving issue would not be helpful for the patient.

'B' and 'C' would be valid options if the girl returned 2 weeks later with persistent symptoms. 'D' is the most wrong option, because anti-depressants take 4-6 weeks to begin having an effect, therefore a consultation to assess their affect at 4 weeks is pointless. 'E' correctly describes how an SSRI would be used if warranted, but that would be jumping the gun in this case.

4

Define the following terms:

Hallucination
Illusion
Delusion
Blunted affect

Hallucination: A perception in the absence of a stimulus
Illusion: A distorted perception of a stimulus
Delusion: A fixed, false, unshakeable belief that is outside of cultural norms
Blunted affect: Reduced reactivity of mood

5

Which of the following is not a risk factor for schizophrenia?

A. Obstetric complications
B. Urban living
C. Birth in the winter months
D. Depression
E. Immigration

D. Depression

Depression may be a co-morbidity or complication of schizophrenia, and depression may become psychotic in the most severe cases, but it is not a risk factor for developing schizophrenia.

6

A 22 year old man is brought to a GP appointment by his parents who are concerned for his wellbeing. He is studying Politics at university but recently had been withdrawing from his previously active social life, and has stopped attending lectures and tutorials. His girlfriend of 8 months has recently broken up with him, citing his lack of effort in the relationship. When asked why he has isolated himself, he just shrugs. The GP speaks to him and performs a mental state exam, their findings are as follows:

The young man appears dishevelled and has not showered in a few days, his clothes are stained
He seems distant and is difficult to engage in conversation
He says his mood has been normal, and he does not seem to be of low mood, though his affect does not change much during the consultation
He denies any unusual thoughts or hallucinations and does not express any odd beliefs, nor does he act as if he sees or hears anything that isn't there
He is orientated in time and space, but apathetic about his situation and not interested in its resolution

What is the most likely cause of these symptoms?

A. Emerging personality disorder
B. Substance misuse
C. At-risk mental state
D. Depression
E. BPAD

C. At-risk mental state

An at-risk mental state (ARM) is the more modern term for a prodrome to psychosis/ schizophrenia; the term 'prodome' is being phased out because it implies inevitable progression to disease which is inaccurate in this case. The classic picture of ARM is of someone in their late teens or early twenties who begins to withdraw from work and social activity. They stop doing things they previously enjoyed and will allow relationships to deteriorate. This stage does not feature obvious psychotic symptoms, though there may be some mild ones that the patient denies out of fear for their significance.

All of the conditions listed are possible differentials in this case.

7

A 68 year-old man is referred to memory services after his daughter took him to see the GP with concerns about his memory over the previous 4 weeks. You note that prior to this decline, he was admitted to ITU for a week with a severe pneumonia which progressed to sepsis. Your assessment of him reveals some cognitive impairment and disorientation in time but not place.

What is the most appropriate next step?

A. Refer him for an urgent MRI head
B. Ask the GP to reassess him in a few weeks
C. Take blood cultures and a urine dipstick
D. Refer to a dementia specialist and contact OT to assess the home
E. Perform a chest x-ray

B. Ask the GP to reassess him in a few weeks

The cognitive impairment described here is a result of delirium. Delirium refers to a fluctuating state of confusion which comes on quickly and can be the result of drugs, trauma, infection, electrolyte imbalance, or a number of other causes. Though the onset is rapid, delirium can take a long time to fully resolve, with some patients still displaying symptoms at 6 months post-discharge.

Accordingly, memory services will not assess a patient if they have had an episode of delirium within the last 6 weeks as the residual effects will obfuscate the results of the assessment.

8

A 35 year old, known schizophrenic man presents to A&E with fever. His obs show he is tachycardic and hypertensive, and he seems confused. A brief neuro exam shows increased tone in all limbs. He was taking Olanzapine for a time but was recently switched to Clozapine.

What is the most likely diagnosis?

A. Neutropaenic sepsis
B. Serotonin storm
C. Neuroleptic malignant syndrome
D. Thyroid storm
E. Stroke

C. Neuroleptic malignant syndrome

Neuroleptic malignant syndrome is a rare but lethal side-effect of anti-psychotics. It is usually triggered by a change in drugs or dosages and causes muscle stiffness, altered consciousness, fever, tachycardia, and labile BP. Creatine kinase and white cell count will both be elevated in this condition.

9

For which of the following anti-psychotic drug side effects would procyclidine be a useful treatment?

A. Palpitations
B. Painful involuntary twisting of the neck to one side
C. Reduced libido and amenorrhea
D. An unpleasant feeling of restlessness
E. Rhythmic involuntary sucking and chewing movements

B. Painful involuntary twisting of the neck to one side

Procyclidine is used to treat acute dystonias - involuntary, painful, and sustained muscle contractions that start soon after starting medication.

Procyclidine may also be helpful for Parkinsonian features, though those aren't described here.

10

How should you respond to a delusional patient asking if you believe them?

There are a few great examples from Psych PRN of how to respond to this question. I've included them more for the PACES exam and real life practice - they seem like a very useful thing to know:

• I haven’t been through what you’ve been through, but
I can see it’s really frightening you.
• I know you’re not lying. What do your family think
about it?
• I come from a medical background—I think stress has
a lot to do with what you’re experiencing. What do you
think about that?

11

Which of the following statements is true?

A. A section 136 can be used to enter a person's home against their wishes
B. Once a patient is taken to a place of safety, they can't be moved from that place of safety
C. A section 5(2) cannot be used in A&E
D. A nurse has the power to hold a patient for 24 hours under section 5(4)
E. A section 2's primary function is to allow treatment of a detained patient

C. A section 5(2) cannot be used in A&E

12

Who must be present for a Section 135 to be enacted?

An AMP
A registered medical practitioner
A police constable

13

Match each of the following sections of the Mental Health Act (1983) to the correct description:

1. Gives a doctor the power to detain an inpatient in hospital for 72 hours
2. Allows a person to be taken from a public place to a place of safety
3. Allows admission and detention for 6 months for treatment
4. Allows admission and detention for 28 days for assessment
5. Gives a nurse the power to detain an inpatient in hospital for 6 hours
6. Allows a person to be taken from their home to a place of safety but requires a warrant

A. Section 2
B. Section 3
C. Section 5(2)
D. Section 5(4)
E. Section 135
F. Section 136

1. Gives a doctor the power to detain an inpatient in hospital for 72 hours - C. Section 5(2)
2. Allows a person to be taken from a public place to a place of safety - F. Section 136
3. Allows admission and detention for 6 months for treatment - B. Section 3
4. Allows admission and detention for 28 days for assessment - A. Section 2
5. Gives a nurse the power to detain an inpatient in hospital for 6 hours - D. Section 5(4)
6. Allows a person to be taken from their home to a place of safety but requires a warrant - E. Section 135

14

List the ICD10 non-core symptoms of depression

Reduced concentration and attention
Reduced self-esteem and self-confidence
Ideas of guilt and unworthiness (even in a mild type of episode)
Bleak and pessimistic views of the future
Ideas or acts of self-harm or suicide
Disturbed sleep
Diminished appetite

Mild: At least 2 core plus at least 2 other symptoms, should not be intense
Moderate: At least 2 core plus at least 3 other symptoms, preferably 4 for moderate
Severe: All 3 core plus at least 4 other symptoms, somatic syndrome (physical manifestations) almost definitely present
Severe with psychosis: as for severe depression with the added presence of delusions, hallucinations, or depressive stupor

15

You visit the home of a 45 year-old man being treated in the community for his schizophrenia. He was diagnosed 25 years ago and has been mostly well managed, but is now beginning to disengage from psychiatric services. When talking to him you notice his pattern of thought seems disordered, and he occasionally seems to react to sounds or sights that you do not perceive. He also grimaces, and makes rhythmic sucking movements with his mouth in a way that seems unrelated to the conversation.

What is the most likely explanation for the grimacing and sucking movements?

A. Tetany
B. Parkinsonism
C. A reaction to hallucinations
D. Acute dystonia
E. Tardive dyskinesia

E. Tardive dyskinesia

Tardive dyskinesias develop after years of anti-psychotic use, and are characterised by rhythmic involuntary movements of the face, limbs, mouth, and trunk. These movements may includes grimaces or chewing movements, and can be very distressing and alienating for the patient. They can be treated with Tetrabenazine, but not an anti-cholinergic like Procyclidine, as this will probably make then worse.

16

You are called to see a 72 year-old patient who was noted to be distressed and disorientated on the ward yesterday. She seemed mentally well when she was admitted, but over the next several hours became confused and agitated with fluctuating consciousness, and spoke fearfully of the creatures she saw scurrying about on the floor, which the nursing staff could not see. The nurses reported her speech and thought patterns seemed disordered. When you see her she seems calm and reasonable, without much memory of her episode last night. Her drug chart reveals she was prescribed laxatives and steroids after admission.

What is the most likely cause of her symptoms?

A. Vascular dementia
B. Alzheimer's disease
C. Delirium
D. Lewy body dementia
E. Parkinson's disease

C. Delirium

The key features indicating delirium here are: the acute onset, the fluctuating consciousness, and the rapid return to normal. The steroids have most likely caused delirium in this case.

17

A 56 year old woman has been hospitalised for myocardial infarction. 2 nights after admission, she screams that there is a man sitting by her bed. When the light is turned on, she is relieved that ’the man’ is actually a chair with clothes draped over it.

What misperception best describes this?

A. Delusion
B. Hallucination
C. Illusion
D. Projection
E. Formication

C. Illusion

An illusion is the misperception of a stimulus (as has happened here) and though it may appear as part of a pathology, is is not inherently pathological.

A hallucination is a perception in the absence of a stimulus.

18

You are asked to assess a 63 year-old man with Parkinson’s. He seems to be low in mood. When you speak with him, he seems to understand all your questions and answers appropriately, but he appears to have difficulty getting his words out.

Which of the following speech disorders does this describe?

A. Dysphasia
B. Bradykinesia
C. Poverty of speech
D. Dysarthria
E. Loosening of association

D. Dysarthria

19

A 78 year old man attends GP with his daughter who is concerned about his memory. She says his memory and concentration have been significantly reduced from his normal baseline, and that she is especially worried as her mother died a few months ago, and she thinks he cannot cope on his own. On questioning, the man admits to poor memory, sleep, and concentration. He speaks slowly throughout the concentration, and seems rapidly fatigued. His notes show no significant PMHx.

What is the most likely cause of his cognitive impairment?

A. Delirium
B. Vascular dementia
C. Parkinson's disease
D. Alzheimer's disease
E. Depression

E. Depression

This history could potentially describe either Parkinson's disease or depression, and is intended to illustrate how closely the two may resemble each other. It is helpful to break the history down into concise symptoms, which may then be compared with disease-specific criteria, in cases where the overall picture for different diseases is similar.

This history features: cognitive impairment, sleep disturbance, slow speech, and easy fatigue/ anergia. The core features of depression are anergia, low mood, and anhedonia, with at least two of these necessary for a diagnosis of depression. Whilst only anergia is explicitly present in this question, the recent loss of his wife does suggest low mood and a potential trigger for depression.

Conversely, Parkinson's disease is defined by a triad of rigidity, a resting tremor, and bradykinesia. None of these features are present in this history. Though Parkinson's does also feature cognitive impairment (the poor memory and concentration) and slow speech, it is unlikely these symptoms would manifest with none of the classic motor symptoms.

20

Which of the following is true of anti-psychotic drugs?

A. Involuntary painful muscle spasms may occur within hours of starting anti-psychotics
B. Haloperidol is a safe alternative for use in patients at risk of arrhythmia
C. There are no atypical anti-psychotics available as depot injections
D. Neuroleptic malignant syndrome is usually triggered by suddenly decreasing anti-psychotic dose/ sudden non-compliance
E. Typical anti-psychotics usually cause less severe extra-pyramidal side effects

A. Involuntary painful muscle spasms may occur within hours of starting anti-psychotics

Acute dystonia is an extra-pyramidal side-effect (i.e. affecting dopaminergic pathways) of anti-psychotic drugs. It describes an involuntary, sustained, painful muscle contraction (e.g. torticollis - twisting of the neck, oculogyric crisis - eye twists up and can't look down). Acute dystonias can be attenuated using anticholinergic drugs e.g. procyclidine.

21

In bipolar disorder, which of the following is correct?

A. It typically presents with delusions of control
B. Hypermania is a severe form of mania
C. Depressive episodes are usually accompanied by psychotic symptoms
D. Manic episodes are often associated with irritability rather than elevated mood
E. At least 3 episodes of mania are required for the diagnosis

D. Manic episodes are often associated with irritability rather than elevated mood

NB: This question is reproduced from Dr Hugh Hall's Psychiatry Revision lecture

22

A 78 year old man with severe depressive illness is referred to your clinic and started on an antidepressant. A few weeks later he is admitted to hospital with symptomatic hyponatraemia.

Which medication is most likely to have caused this?

A. Amitriptyline
B. Citalopram
C. Mirtazapine
D. Duloxetine
E. Trazadone

B. Citalopram

Citalopram is an SSRI, and although many anti-depressants can cause hyponatraemia, SSRIs are particularly associated with it.

NB: This question is reproduced from Dr Hugh Hall's Psychiatry Revision lecture

23

Which of the following is most important to monitor in patients taking clozapine?

A. BMI & waist circumference
B. ECG
C. FBC
D. Lipid profile and fasting blood glucose
E. Mental state

C. FBC

Anyone taking anti-psychotics will need a wide range of routine blood tests, especially if they are taking clozapine. Though effective at treating resistant schizophrenia, clozapine is a very 'dirty' drug with a huge range of side effects. Surveillance is greatest at initiation of treatment, and is slightly relaxed after several months.

The most important complication of clozapine is agranulocytosis which occurs in ~0.7% of patients. Accordingly, patients taking clozapine have their WCC and neutrophils very closely monitored, and are told to come to A&E if they develop any signs of illness.

Other side effects of clozapine include: prolonged QT interval, dyslipidaemia, hypotension, anaemia, myocarditis, and impaired glucose tolerance. As a result, fasting blood glucose, lipid profile, BMI, waist circumference, basic observations, and an ECG all form part of the monitoring for patients taking clozapine.

NB: All schizophrenic patients should receive regular assessment of cardiovascular health and risk factors regardless of their treatment due to their increased susceptibility.

24

Which of the following is least likely to be a direct physical cause of depression?

A. Hypoactive delirium
B. Hypercalcaemia
C. Beta blocker use
D. Cocaine use
E. Stroke

A. Hypoactive delirium

Hypoactive delirium is an important yet easily missed diagnosis, as patients who make the most noise and cause the most problems will also attract the most attention. Though it mimics depression, hypoactive delirium is a separate disorder. All the rest of the options can be direct physical causes of depression.

25

Which of the following statements about mood disorders is incorrect?

A. The presence of the 'amine' suffix means the drug is a TCA
B. Dexamethasone cortisol suppression tests are often abnormal in patients with depression
C. TCAs are effective, but cardiotoxic in overdose
D. Many anti-depressants can cause hyponatraemia and sexual dysfunction
E. St. John's Wort has some efficacy as an anti-depressant, but is an enzyme inducer

A. The presence of the 'amine' suffix means the drug is a TCA

This is an important point to remember when learning drug names: they are named for their chemical structure, not their function so the 'amine' suffix does not line up with one particular class of drugs, though many TCAs have it.

26

Which of the following interventions would be classified as CBT?

A. Exploring the patient's current and future life for a deeper meaning in order to shift their focus from themselves
B. Allowing transference to guide therapy, thereby illuminating a patient's hidden problematic feelings to them
C. Discussing a patient's own distorted beliefs with them, and challenging their rationale
D. Discussing the underlying issues that patient and doctor believe caused or precipitated mental illness
E. Exploration of previous social, family, and romantic relationships to find trends and explanations for current symptoms

C. Discussing a patient's own distorted beliefs with them, and challenging their rationale

In many conditions, states of mental illness are perpetuated by negative thoughts resulting from the illness, which themselves either worsen the illness or impair the individual's ability to cope. CBT challenges these thoughts and allows the person to control them to avoid this harmful spiral.

27

What is most important to tell a patient taking carbamazepine?

Attend hospital urgently if they develop a sore throat or fever, or if they feel ill because of the risk of agraulocytosis and subsequent sepsis.

28

A woman with known BPAD visits her psychiatrist for counselling regarding getting pregnant. She wants to know how pregnancy will affect her mental health, and whether her medication would need to be changed. She is currently taking lithium and this has been working very well for her.

What should you tell her?

A. Lithium use in pregnancy is associated with fetal neural tube defects
B. Lamotrigine is a safe drug to take during pregnancy and does not require extra monitoring
C. If she becomes pregnant, she should immediately stop taking lithium and book an appointment to discuss medication options
D. Though carbamazepine, lithium, and valproate are risky during pregnancy, they are safe to take whilst breast-feeding
E. She will be at most risk of relapse of her condition in the 6 weeks post-partum

E. She will be at most risk of relapse of her condition in the 6 weeks post-partum

The puerperium (6 weeks post-partum) is a very important time and, amongst other things, it carries the greatest risk of VTE and psychosis of any time in pregnancy.

'A' is incorrect because Lithium use is associated with Ebstein's anomaly (malformation of the tricuspid valve, essentially leading to a single right-sided heart compartment - atrialisation) but not neural tube defects.

'B' is incorrect because although Lamotrigine is a relatively safe drug for the fetus, pregnancy alters metabolism and so Lamotrigine levels have to be frequently monitored.

'C' is incorrect because it is almost never good practice to advise a patient to immediately stop taking medication for a mental health condition. Not only is this dangerous for the mother, it is not guaranteed to protect the fetus because the woman may have been taking lithium for some time before she discovers she is pregnant.

'D' is incorrect because these drugs may all be excreted in breast milk and cause toxicity in the baby.

29

A 16 year old boy is brought to his GP by his guardian. She is becoming increasingly worried at the lability of his moods: he has periods of elation closely followed by low mood. These periods occur multiple times per day, and have been steadily developing over the past months. The boy lives in foster care and has done since he was 9.

What is the most likely cause of his symptoms?

A. Type I BPAD
B. Personality disorder
C. Rapid-cycling BPAD
D. Cyclothymia
E. Type II BPAD

B. Personality disorder

None of the variants of BPAD will cause fluctuation of mood so rapid that they change within a day. Though 'rapid-cycling BPAD' sounds like it matches this clinical picture, rapid-cycling is defined as 4 or more affective episodes per year and certainly does not feature swapping from mania to depression in the same day.

Cyclothymia refers to a rapid-cycling BPAD-like disorder where the depression and mania are not severe enough to be diagnosed as BPAD. These patients do have a risk of developing BPAD, but even cyclothymia will not switch so quickly as to cause different moods within a day.

This history is particularly suggestive of EUPD with the labile mood and disrupted childhood.

30

A 25 year old man visits his GP on the orders of the Prime Minister in order to share his recently discovered cure for death. He exhibits rapid, pressured speech, and speaks at length about the instructions and praise he receives from the Prime Minister directly every day, though he states he has not seen the Prime Minister, only heard him. His GP notes reveal that he was previously seen several months ago for a prolonged period of low mood, diagnosed with depression, and started on an SSRI.

What is the most likely diagnosis?

A. Schizoaffective disorder
B. Acute phase of schizophrenia
C. Substance misuse
D. Cyclothymia
E. BPAD

E. BPAD

This question is intended to illustrate similarities in presentations of different psychiatric conditions

The SSRI has probably helped precipitate the episode.