Targeted cards Flashcards
(779 cards)
1
Q
Aim of Primary Prevention?
A
Reduce incidence of disease by preventing development of new cases
2
Q
Aim of secondary prevention
A
Reduce total number of existing cases by more rapid effective interventions that shortens duration of illness
3
Q
Aim of tertiary intervention
A
For individuals to reach their highest level of functioning
4
Q
Types of prevention under IOM
A
Universal Preventive Intervention
Selective Preventive Intervention
Indicated Preventive Intervention
5
Q
Who does a selective preventive intervention target?
A
Members of population with higher than average risk factors.
6
Q
Who does indicated preventive intervention target?
A
Members of population with subsyndromal symptoms of a disorder, or diagnosed with another associated disorder.
7
Q
Who described the prevention paradox?
A
Geoffrey Rose, 1981
8
Q
Who conducted the first ECT and when?
A
Lucio Cereletti
Ugo Bini
1938
9
Q
Indications for ECT
A
Depressive illness Mania Schizophrenia Catatonia Parkinsons Neuroleptic Malignant Syndrome Intractable seizure disorders (raises seizure threshold)
10
Q
When is ECT first line treatment for depressive illness?
A
Emergency treatment where rapid response is needed
Treatment resistant depression where a person has responded to ECT previously
11
Q
Absolute CI of ECT?
A
None
12
Q
Relative CI of ECT?
A
Acute respiratory infection MI in past 3 months Uncontrolled cardiac failure Cardiac arrhythmias CVE in past month Raised ICP Untreated cerebral aneurysm Untreated Pheochromocytoma Unstable major fracture DVT - until anticoagulation (to reduce risk of PE) Acute/impending retinal detachment High anaesthetic risk
13
Q
Relapse rate of ECT
A
51% in 12 months
37% in 6 months
14
Q
Which drugs raise seizure threshold?
A
Benzodiazepines
Barbituates
Anticonvulsants
15
Q
Which drugs lower seizure thresholds?
A
Antipsychotics
Antidepressants
Lithium
16
Q
Which drugs need to be stopped 24 hours pre-ECT?
A
Clozapine
Moclobemide
17
Q
Difficulties with Lithium and ECT?
A
Best avoided as may increase cognitive side effects and increase likelihood of neurotoxic effects of Lithium.
18
Q
Who developed TMS for brain stimulation?
A
Anthony Barker, 1985
19
Q
Results for rTMS in depression
A
40% response rate that is sustained for 6 months
20
Q
Who carried out the first pre-frontal leucotomy and when?
A
Moniz and Lima
1995
21
Q
What key functions did Moss identify for multidisciplinary teams?
A
Continuing proactive care of those with long-term serious MH problems
Uninterrupted access to information and support, intervention and treatment before and during crises
An organised response to requests for help from primary care
22
Q
What is Assertive Community Treatment (ACT) based on?
A
Stein & Test (1980) evaluated training in community living. Main issue was transfer of learning in social skills training in real life when patients move from inpatient units to community.
23
Q
What did the UK 700 study report?
A
Caseload is the most important predictor of outcome of an ACT service.
24
Q
What led to the introduction of the CPA?
A
Case of Sharon Campbell who killed her SW (DSHH, 1991)
25
What types of CPA are there?
Enhanced
| Standard
26
Who are enhanced CPA for?
Those whose care needs are best served by regular MDT meetings
27
Who developed the filter model?
Goldberg
| Huxley
28
What are the five levels of mental illness occurrence?
```
Community
Primary Care Attendees
Diagnosed primary care attendees
Level of Psychiatrist
Level of psychiatric inpatient care
```
29
What is used for the criteria of early intervention?
PACE-UHR (Personal assistance and Crisis Evaluation service)
30
What are the PACE-UHR criteria?
Uses 'close in' strategy
Specificity>sensitivity
Ages 14-30
Considers experiencing attenuated positive symptoms or episodes of frank psychosis (BLIPS - brief limited intermittent psychotic sx)
Having schizotypal personality or FHx of schizophrenia
31
What is used to assess prediction of sx from basic to schizophrenia?
Bonn Scale for Assessment of Basic Symptoms
32
How good is Bonn Scale for Assessment of Basic Symptoms?
Predicts conversion from basic symptom to schizophrenia in 78% of individuals
33
Which studies show that the initial gain from early intervention may not be sustained if it is discontinued after 2 years?
PEPP (London, Ontario)
| TIPS (Norway)
34
What did the SOCRATES study show?
Compared CBT with supportive counselling for first or second-episode schizophrenia.
At 18 month follow-up, addition of both CBT + counselling showed significant improvement.
35
What did the PRIME study show?
Olanzapine at low dose prevents progression of psychosis.
36
What did EPPIC study from Melbourne (McGorry et al) show?
Combination of CBT and Risperidone reduced conversion rate at 6 months.
37
What did the Lambeth Early Onset (LEO) study show?
Compared specialised care (low dose antipsychotic, CBT, family counselling) based on assertive outreach with standard care and found relapse rates were lower with the former.
38
Who recognised 'Duration of Untreated psychosis' (DUP) as a prognostic marker?
Wyatt
39
What was the first study that challenged the pessimism about schizophrenia recovery?
Vermont Longitudinal study
40
Recovery rate of schizophrenia
38% at 15 and 25 years
41
Who identified internal and external conditions for recovery?
Jacobson and Greenley
42
Who reported on the treatment gap in MH?
Kohn 2004 in the WHO Bulletin
43
What is the treatment gap for psychosis?
32% worldwide untreated
18% in Europe
40% in Europe with Bipolar untreated
>50% with depression and anxiety untreated
44
Who reported that improving adherence can have a greater impact on population health than anything else?
Haynes in 2001 Cochrane Review
45
Who did a study on Psychiatry and Human Rights?
Drew et al. 2011
46
What did Drew et al. 2011 find re Human rights in MH?
The right to marry and hvae children is often denied on the grounds of mental illness.
47
What is Article 2?
Right to Life
48
What is Article 3?
Prohibition of torture
49
What is Article 5?
Right to liberty
50
What is Article 6?
Right to a fair hearing
51
What is Article 8?
Right to a private/family life
52
What is Article 9?
Freedom of thought & religion
53
What is Article 10?
Freedom of expression
54
What is Article 14?
Right not to be discriminated against
55
Rules for drivers with acute psychosis, mania/hypomania and schizophrenia re Group 1 for the DVLA?
Driving must cease during acute illness.
56
When can relicensing be considered for a Group 1 driver who had psychosis?
All must be fulfilled:
Patient has remained well and stable for at least 3 months
Compliant with treatment
Free from adverse effects of medication which could impair driving
Subject to specialist favourable report
Regained insight in case of bipolar mania or hypomania
57
Psychosis and Group 2 drivers?
Driving should cease pending outcome of medical enquiry.
58
When can Group 2 drivers with psychosis drive again?
Person must be well and stable for minimum of 3 years with insight into condition before driving can be resumed.
59
What study looked into the decision-making capacities of people in hospital with MI?
MacArthur Treatment Competence Study 1988
60
What tool did the MacArthur Treatment Competence Study create?
MacCAT:
Choosing: ability to state a choice
Understanding: understand relevant information
Appreciating: appreciate nature of ones own stiuation
Reasoning: reason with information
61
Who created the Traumagenic Dynamics Model?
Finkelhor (1988)
62
What is the Traumagenic Dynamics model?
```
Adverse effects of child sexual abuse depend on four factors:
Powerlessness
Betrayal
Traumatic sexualisation
Stigma
```
63
What is used to measure obstetric complications during childbirth?
Lewis-Murray scale
64
What plasma level of clozapine should be reached before patient can be considered non-respondent to clozapine?
350-450ng/ml
65
Non-pharmacological adjuvant to clozapine?
Fish omega oil - ethyl-eicoaspentanoate
66
What does CATIE stand for?
Clinical Antipsychotic Trials of Intervention Effectiveness
67
What type of study was CATIE?
Double-blind pragmatic RCT
68
Patients in CATIE?
1493 patients with chronic schizophrenia across 57 sites from 2001-2004
69
Medications used in CATIE?
```
Olanzapine
Quetiapine
Risperidone
Ziprasidone (added later)
Perphanazine
```
70
How many patients discontinued treatment in 18 months in CATIE?
74%
71
Which medication had lowest discontinuation rate in CATIE?
Clozapine - 10 months
| Olanzapine - 64%
72
Which medication had highest SE burden in CATIE?
Olanzapine
73
Which medication caused most anticholinergic sx in CATIE?
Quetiapine
74
What is CUtLASS?
Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study
75
Primary outcome of CUtLASS?
QoL at 1 year
76
Participants in CUtLASS?
1,227 patients with schizophrenia assessed by their clinical team for medication review because of poor response or adverse effects were randomised
77
Results of CUtLASS?
No advantage of 2nd generation drugs
Those on 1st generation drugs did relatively better
Patients had no clear preference
78
Who did a meta analysis of 10 RCTs into psychotic depression?
Wijkstra et al.
79
What did Wijkstra et al. find re medication treatment for psychotic depression?
Combination of antidepressant and antipsychotic is no better than antidepressant monotherapy.
80
Which combination is superior for psychotic depression compared to monotherapy?
Antidepressant + antipsychotic compared to antipsychotic alone
81
Point prevalence estimate of depression?
7%
82
In how many patients does the initial diagnosis of depression change?
56%
83
What does the initial diagnosis of depression change to in patients?
Schizophrenic spectrum - 16%
PD - 9%
Neurotic, stress-related and somatoform disorders - 8%
Bipolar - 8%
84
In the community, how many patients with a depressive episode go on to develop mania?
One in ten patients within ten years
85
Risk of suicide in patients with mood disorders compared to the general population
14 times greater
86
How many patients with depression will experience a recurrence in 5 years?
50%
87
What is the risk of a patient with 2 major depressive episodes having a third?
70%
88
How long should antidepressants be continued in those with moderate or severe depression?
For at least 6 months after remission
89
Which patients must continue antidepressants for 2 years?
Patients with >2 episodes in recent past or residual impairment
90
How long should treatment be continued for a single episode of depression?
At least 6-9 months after resolution of sx
91
What is NNT for antidepressant response?
4-5
92
What is NNT for antidepressants for remission?
6-7
93
What did Kirsch's meta-analysis include
47 trials including 4-8 weeks RCTs of Nefazadone, Venlafaxine, Fluoxetine and Paroxetine.
94
Weighted mean improvement in Kirsch's meta-analysis between treatment and placebo?
9. 6 points on Hamilton in drug group
| 7. 8 in placebo
95
Did Kirsch's meta-analysis show significance in findings for antidepressant treatment?
Statistical significance but not the three-point Hamilton criterion for NICE for clinical significance.
Magnitude of difference was a function of baseline of severity of depression.
96
What was Geddes research?
Pooled analysis of data from 31 randomised trials of 4,410 patients taking antidepressants
97
Average rate of relapse on antidepressant in Geddes research?
18%
98
Treatment effect duration of antidepressants in Geddes research?
36 months
99
What is STAR*D?
Sequenced treatment alternative for depression was a pragmatic RCT - 2/3 had comorbid physical disorder, 2/3 had co-morbird psychiatric diagnosis and 40% had onset of depression at <18 years of age - similar to the real world.
100
How many patients in the STAR*D study?
4041 patients at 25 sites in the USA
101
How did STAR*D study work?
4 steps of treatment.
| Any patient who failed to meet remission criteria at each step was moved up to the next level.
102
What was Level 1 in the STAR*D study?
Citalopram for up to 12 weeks
103
What was Level 2 in the STAR*D study?
If after 12 weeks patient failed remission, they were randomized as per their preference to switch to either Bupropion, Sertraline or Venlafaxine, to cognitive therapy or to augment citalopram with Bupropion or Buspirone or to combine citalopram with cognitive therapy.
104
What was level 3 in the STAR*D study?
Participants who did not achieve remission after 12 weeks in level 2 were randomised to switch to mirtazapine, nortriptyline or augment level 2 treatment with lithium or thyroid medication.
105
What was level 4 in the STAR*D study?
Patients who did not achieve remission after 12 weeks in level 3 were switched to an MAOI, tranylcypromine or switch to a combination of venlafaxine XR and mirtazapine.
106
Cumulative remission rate after all 4 steps in STAR*D study?
67%
107
Cumulative non-response rate in STAR*D study?
33%
108
How many patients became symptom free after 2 levels in the STAR*D study?
Half of participants
109
What were the findings at level 3 of the STAR*D study?
No statistical difference between the different antidepressants or augmentation with Lithium or T3.
110
What were the results at level 4 in the STAR*D study?
No difference between MAOI and Mirtazapine/Venlafaxine XR combination although degree of symptom relief was better with the latter.
111
Who is at risk of suicidal behaviours when started on antidepressants?
<25 years of age
112
What did Hawton et al study in 2010?
Toxicity of antidepressants in OD
113
Which TCAs are more toxic in an OD?
Dosulepin
| Doxepin
114
What are the 5As which can result in apparent resistance to antidepressant treatment?
```
Alcoholism
Lack of adequate dosage
Lack of adherence
Axis 2 disorders (PD)
Alternative diagnosis
```
115
Prevalence of Bipolar?
1.5%
116
What is NCS-replication?
Part of the World Mental Health survey initiative
117
Lifetime prevalence of bipolar in NCS-replication?
Bipolar 1 - 1%
| Bipolar 2 - 1.1%
118
Suicide rate of Bipolar?
15-18x higher than the general population.
119
How many people with bipolar experience another MH disorder?
2/3
120
Who described an extension to bipolar 1 & 2 classification?
Akiskal and Pinto in 1999
121
How many patients with bipolar get misdiagnosed with depression?
40%
122
Median time to recover from mania with treatment?
4-5 weeks
123
Suicide rate in bipolar?
10-19%
| 15x greater than the general population
124
Risk of recurrence in people with bipolar?
50% in one year
>70% at 4 years
compared with other psychiatric disorders
125
What type of depression is suggestive of bipolar?
Psychotic depression in early adulthood
126
What is rapid cycling?
4 or more episodes in a year - both mania and depression
127
What % of rapid cyclers are women?
80%
128
Which medications are associated with mania?
L-Dopa
| Steroids
129
When is ECT considered in mania?
Severely ill manic patients
Treatment-resistant mania
Those who prefer ECT
Severe mania during pregnancy
130
How long should maintenance treatment be continued for in bipolar?
2 years after episode
| 5 years if high-risk factors for relapse
131
Which study did research in adjunctive antidepressant use in bipolar?
STEP_BD
132
Male:female ratio of schizophrenia?
1.4:1
133
Median prevalence of schizophrenia?
4.6/1000 - point prevalence
134
Period prevalence of schizophrenia
3.3/1000
135
Lifetime prevalence for schizophrenia
4/1000
136
Lifetime morbid risk of schizophrenia
7.2/1000
137
Which study looked at schizophrenia in BME communites?
AESOP study
138
What did the AESOP study find?
All psychoses are more common in BME groups compared to white population in Bristol, SE london and Nottingham
139
What did ONS 2000 Psychiatric comorbidity survey of households find?
5. 5% endorsed at least one psychosis item
4. 2% endorsed hallucination item: of this, 4.2% said they heard/saw something others could'nt, 0.7% reported hearing voices
140
Who did a study into genetic risk of schizophrenia?
Johnstone et al. 2005
141
What did Johnstone et al. 2005's study find re schizophrenia?
10% risk present in those with high risk FHx increases to nearly 50% in subgroup of those who have a high score on schizotypal cognition and social withdrawal.
142
What did the Australian PACE clinic sample show?
20 of 49 high-risk subjects (40.8%) developed a psychotic disorder within 12 months.
143
Incidence of delusional disorders
0.7-1.3 per 100,000
144
Prevalence of delusional disorders
24-30 per 100,000
145
Proportion of people with delusional disorder admitted to hospital
1-3%
146
Mean age of onset of delusional disorder
39 y/o
147
Sex ratio of delusional disorder
1.18:1 - M:F
148
What was the structure of the Iowa study show re outcomes for schizophrenia?
186 people with schizophrenia were followed-up for 35 years.
149
What did the Iowa study show re outcomes for schizophrenia?
46% of people improved or recovered.
150
What was the structure of the Bonn Hospital Study in Germany?
502 people with schizophrenia were followed up for 22.4 years.
151
Results of Bonn Hospital Study in Germany?
22% had complete remission of sx
43% had non-characteristic types of remission (non-psychotic)
35% experienced characteristic schizophrenia residual sx.
152
Structure of Chestnut Lodge study
446 patients with schizophrenia were followed-up for 15 years
153
What did the Chestnut Lodge study show re schizophrenia?
36% recovered or functioned adequately.
154
What did the Vermont longitudinal study show re outcomes of schizophrenia?
68% of patients who underwent a rehab programme had good functioning as per the GAF scale.
155
What was the International study of Schizophrenia (ISoS 1997)
Follow-up analysis of two major WHO incidence cohorts from 9 countries.
156
Results from ISoS 1997 study
52% of patients in developing countries were assessed to be in the 'best' outcome category (single episode followed by partial or full recovery) compared with 39% in developed countries
157
What did ISoS 1997 study show re follow-up of patients with schizophrenia?
At 5 years, 73% of those from developing countries were in the best outcome group compared with 52% in developed countries.
158
Risk of schizophrenia if both parents have schizophrenia
40-50%
159
Single nucleotide polymorphisms (SNPs) linked to schizophrenia
12p13.33
12q24.11
1q42.2
11q23.2
2q33-34
5q33.2
16p13
7q21
1p21
8p12
17p13
18q21
2q32
160
Copy Number Variations (CNVs) linked to schizophrenia
2p16.3 deletion
7q36.3 duplication
Hemi deletion of 22q11
161
Gene of 12p13.33
CACNA1C (L-type calcium channel)
162
What is CACNA1C important for?
Neuronal function
163
What do mutations of CACNA1C cause?
Timothy Syndrome
| Brugada Syndrom
164
Gene of 12q24.11?
D-amino acid oxidase
165
What is D-amino acid oxidase important for?
Degrades d-serine (NMDA co-agonist)
166
Gene of 1q42.2?
DISC-1
167
What is DISC-1 seen in?
Scottish family with 1:11 translocation
| Disrupted in schizophrenia
168
Gene of 11q23.2?
Dopamine D2 receptor
169
Importance of 11q23.2?
Target for antipsychotic action
170
Gene for 2q33-34?
Receptor tyrosine kinase erbB4
171
Importance of 2q33-34?
Neuregulin 1 receptor
172
Gene for 5q22.3?
AMPA receptor subunit 1
173
Importance of 5q33.2?
Affects synaptic plasticity
174
Gene for 16p13?
NMDA receptor subunit 2A
175
Importance of 16p13?
Influences channel conductance and synaptic localisation
176
Gene of 7q21?
Metabotropic glutamate receptor 3
177
Importance of 7q21?
Inhibitory autoreceptor
178
Gene of 1p21?
Micro RNA 137
179
Importance of 1p21?
Regulates transcription
180
Gene of 8p12?
Neuregulin 1
181
Importance of 8p12
Growth factor
182
Gene of 17p13?
Serine racemase
183
Importance of serine racemase?
Synthesizes d-serine from l-serine
184
Gene of 18q21?
Transcription factor 4
185
Importance of transcription factor 4?
Deletion causes Pitt-Hopkins syndrome
186
Gene of 2q32?
Zinc finger 804A
187
Importance of zinc finger 804A?
Affects gene regulation especially in cortical pyramidal neurons
188
Gene of 2p16.3 deletion?
Neurexin 1
189
Importance of Neurexin 1?
Involved in synaptic structure
190
Gene at 7q36.3 duplication?
Vasoactive intestinal peptide receptor 2
191
Importance of VIP receptor 2?
Regulates synaptic transmission in hippocampus and development of neural progenitor cells in dentate gyrus
192
Gene at 22q11
COMT coding genes
193
What does hemi deletion of 22q11 cause?
Velocardiofacial syndrome
194
Which anxiety disorder is most common in boys?
OCD
195
Which anxiety disorder has equal distribution between men and women?
OCD
196
Point prevalence of OCD in adults
1-3%
197
Point prevalence of OCD in children
1-2%
198
Lifetime prevalence of OCD
2-3%
199
Most commonly prevalent psychiatric disorders?
```
Phobias
Alcohol misuse
Depression
OCD
(in that order)
```
200
Gender ratio of OCD in community
1.5:1 female:male
201
What can OCD spectrum disorders be classified into?
Somatic preoccupation e.g. anorexia
Neurological disorders e.g. Tourettes
Impulse control disorders e.g. paraphilias
Anankastic PD
202
What does PANDAS stand for?
Paediatric autoimmune neuropsychiatric disorders associated with strep infection
203
What sx does PANDAS produce?
Tics
Fluctuating OCD sx
Anxiety
204
NIMH diagnostic criteria for PANDAS
Presence of OCD or a tic disorder
Onset between 3 years of age and beginning of puberty
Abrupt onset of sx or a course characterised by dramatic exacerbations of sx
Onset of exacerbation of sx temporally related to infection with GABHS
Abnormal neuro exam during exacerbation
205
What is found to be elevated in those with PANDAS?
AntiDNAseB or Antistreptolysin O titres
| Some may have autoantibodies to neurons in basal ganglia; called basal ganglia antibodies
206
Treatment for mild-moderate OCD (first line)
Self-help
207
2nd line treatment for mild-moderate OCD
CBT with ERP (Exposure and response prevention)
208
3rd line treatment for mild-moderate OCD
SSRIs +/- CBT
209
1st line treatment for severe OCD
SSRIs+/-CBT
210
How long do people with severe OCD need to continue SSRIs if they respond well?
1-2 years +/- booster CBT
211
2nd line treatment for severe OCD
Switch to different SSRI or clomipramine
212
How many patients with OCD show some sort of improvement to SSRI?
60-70%
213
NNT for SSRI for OCD?
6-12
214
When is antipsychotic augmentation with SSRI considered for OCD?
If no response after 3 month trial of maximal dose of SSRI.
| Particularly useful if tics.
215
Point prevalence of PTSD
1%
216
Lifetime prevalence of PTSD in America for adults?
6.8%
217
Lifetime prevalence of PTSD in men vs women
Men: 3.6%
Women: 9.7%
218
How many people exposed to trauma will develop PTSD?
30%
219
Who did research into factors associated with PTSD?
Bisson 2007
220
NICE guidelines for initial management of PTSD in primary care
Watchful waiting if sx are mild and present for <4 weeks after trauma
221
When does NICE recommend px of non-benzo sleeping tablet for PTSD in primary care?
After 4 consecutive nights sleep disturbance
222
NICE Guidelines for PTSD in secondary care
Psychological treatment regularly and continuously (once a week) by the same person
223
What does NICE specifically not recommend for PTSD management in secondary care?
Non-trauma focused interventions such as relaxation/non-directive therapy
224
NICE guidelines for PTSD management in secondary care if sx present within 3 months of trauma
Trauma-focused CBT
225
When should trauma-focused CBT be offered?
Those with severe PTSD
Those with severe PTSD in first month after traumatic event
Those with PTSD within 3 months of event
226
How is trauma-focused CBT delivered?
OP; 8-12 sessions (5 if treatment starts within 1 month of event)
227
NICE guidelines for PTSD if sx present for more than 3 months after trauma
Trauma-focused CBT or EMDR
228
How many sessions of trauma-focused CBT or EMDR are offered for PTSD sx >3 months after trauma?
12 sessions
229
Pharmacological treatment for general use for PTSD
Paroxetine
| Mirtazapine
230
Pharmacological treatment for specialist use for PTSD
Amitriptyline
| Phenelzine
231
Which medication is licensed for females only with PTSD?
Sertraline
232
Who discovered EMDR and how?
Shapiro; used it on herself
233
Which sx is not needed for GAD which is usually needed for other anxiety disorders?
Avoidance
234
Lifetime prevalence of GAD
5%
235
Point prevalence of GAD
2-3%
236
MZ vs DZ concordance of GAD?
41% vs 4% (MZ vs DZ)
237
Risk factors for GAD?
```
Exposure to civilian trauma
Bullying
Higher number of life events
Being first-degree relative of GAD patient
Female
```
238
What is Hamilton anxiety scale?
14-item scale
| Emphasises somatic sx
239
Definition of clinical recovery of GAD
<7 on Hamilton anxiety scale
240
Which SSRIs can be used for GAD?
Escitalopram
Paroxetine
Sertraline
241
Which TCAs can be used for GAD?
Imipramine
242
Which medications can the herb Valerian interact with?
Loperamide and fluoxetine, causing delirium
243
Which medications can evening primrose oil interact with?
Phenothiazides, causing epileptic seizures
244
Point prevalence of social phobia?
2.8%
245
Duration of medication for social phobia (first line)
12 weeks
246
How long should drug treatment continue if good response for social phone?
6-12 months
247
2nd line treatment for social phobia?
Phenelzine
248
Point prevalence of panic disorder
0.9%
249
Lifetime prevalence of panic attacks
28%
250
Lifetime prevalence of panic disorder
4.7%
251
Mean age of onset of any panic attack
22 years
252
How does ICD 10 classify panic disorder?
Recurrent, unpredictable panic attacks with sudden onset of palpitations, CP, choking sensation, dizziness and feelings of unreality, often associated with fear of dying/losing control but w/o requirement for sx to have persisted >1 month.
253
First line treatment for panic disorder
7-14 weeks of CBT (weekly 1-2 hours) completed within 4 months
SSRI
Bibliotherapy
254
How long do SSRIs need to be continued for panic disorder to assess efficacy?
12 weeks
255
2nd line drug treatment for long term treatment of panic disorder
Imipramine
256
Recommendations if initial therapy fails for panic disorder
Add Paroxetine or Buspirone to psychological treatment if partial response
Add Paroxetine while continuing CBT if no response
257
Prevalence of Hypochondriasis
0.8-4.5%
258
Treatment for Hypochondriasis
CBT
Group CBT
SSRIs
259
What can BDD be divided into?
Psychotic
| Non-psychotic
260
Treatment for treatment-resistant BDD?
Fluoxetine with CBT
261
Prevalence rate of somatisation disorder
1-2%
262
Gender ratio of somatisation disorder
2:1 female:male
263
What did Rohricht and Elanjithara (2009) find re MUS?
42% of patients with MUS have primary diagnosis of somatoform disorder
36% had depression medicated by effect of somatic sx
264
What does ICD 10 classify conversion dsorder as?
Dissociative disorder
265
Prevalence of dissociative disorder in adults
10%
266
Recommendation for treatment of dissociative disorder?
Individual psychotherapy; especially structured therapy such as Acceptance and Commitment therapy & DBT
267
What types of ED are recognised in ICD 10?
Anorexia
Bulimia
EDNOS
268
How many patients with bulimia have a hx of anorexia?
1/4 - 1/3
269
Which criteria for anorexia has been eliminated in DSM V?
Amenorrhoea
270
Prevalence of anorexia in teenage girls
0.5-1%
271
Prevalence of bulimia in 16-35?
1-2%
272
Prevalence of anorexia in females per year
19/100,000
273
Prevalence of bulimia in females per year
29/100,000
274
Comorbid psychiatric disorders in patients with anorexia?
65% have depression
34% have social phobia
26% have OCD
275
MZ vs DZ rates of anorexia
55% MZ
| 5% DZ
276
MZ vs DZ rates of bulimia
33% MZ
| 30% DZ
277
Heritablility of ED?
Significant heritability for anorexia
| Not for bulimia
278
Physical sx of ED
```
Increased sensitivity to cold
GI sx - constipation, bloating
Dizziness and syncope
Amenorrhoea, low sexual appetite, infertility
Poor sleep with early morning wakening
```
279
Physical signs of ED
Emaciation, stunted growth and failure of breast development if pre-pubertal
Lanugo on back, forearms and side of face
Russels sign
Swelling of parotid and submandibular glands in bulimia
Perimylolysis
Hypothermia
Bradycardia, orthostatic hypotension, cardiac arrhythmias
Dependent oedema
Week proximal muscles
280
Endocrinel abnormalities in ED
```
Low LH, FSH and oestradiol
Low T3, T4, Normal TSH
Increase in plasma cortisol
Raised GH
Hypoglycaemia
Low leptim
```
281
Haematological abnormalities in ED
Moderate normocytic normochomric anaemia
Mild leucopenia with relative lymphocytosis
Thrombocytopenia
282
Metabolic abnormalities in ED
Hypercholesterolaemia
Raised seum carotene
Low phosphate (refreeding)
Dehydration
283
Most effective treatment for bulimia?
CBT
284
Recovery rate for bulimia with CBT
33-50% make full recovery
285
Therapeutic goals for anorexia?
Engagement
Weight restoration
Psychological therapy - cognitive restructuring
If needed, use of compulsion
286
What therapies should be considered for anorexia?
CBT/CAT
Interpersonal psychotherapy
Focal dynamic therapy
Family interventions focused on ED
287
First line SSRI for bulimia
Fluoxetine 60mg OD
288
Prevalence of PD?
5-13%
289
Most prevalent PD in psychiatric settings
BPD
290
Prevalence of any PD in prison?
78% for male on remand
64% for male sentenced
50% for females
291
Prevalence of PD in prisons
53% of male remand
49% of sentenced
31% of female prisoners
292
Prevalence of antisocial PD in UK
0.6%
293
Median prevalence rate per 1000 of paranoid PD
6
294
Median prevalence rate per 1000 of schizoid PD
4
295
Median prevalence rate per 1000 of schizotypal
6
296
Median prevalence rate per 1000 of antisocial
19
297
Median prevalence rate per 1000 of BPD
16
298
Median prevalence rate per 1000 of histrionic
20
299
Median prevalence rate per 1000 of narcissistic
2
300
Median prevalence rate per 1000 of anankastic
17
301
Median prevalence rate per 1000 of avoidant
7
302
Median prevalence rate per 1000 of dependent
7
303
Median prevalence rate per 1000 of passive aggressive
17
304
Female:male ratio of BPD?
3:1
305
What did McLean Study of Adult Development show re BPD?
Prevalence of five core BPD sx declines with rapidity; quasi-psychotic thought, self-mutilation, help-seeking suicide efforts, treatment regressions and countertransference problems
306
What was Seivewright & Tyrer's study into PD?
12 year follow-up where 178 out of 202 patients were reassessed for their personality status.
307
What did Seivewright & Tyrer's study show?
Personality traits of patients with Cluster B PD became significantly less pronounced after 12 years.
Those with Cluster A and C became more pronounced.
308
Cluster A PDs?
Paranoid
Schizoid
Schizotypal (in DSM)
309
Cluster B PDs
Antisocial
BPD
Histrionic
Narcissistic
310
Cluster C PDs
Avoidant
Dependent
OCD
311
Risk of psychiatric episode postpartum?
Significant increase in first three months; 80% are mood disorder
312
Risk of depression during pregnancy
7-15%
313
Risk of depression in women outside perinatal period?
7%
314
Relapse rate of depression in patients with a history who are pregnant?
50%
315
Risk of postpartum psychosis
0.1-0.25%
316
Risk of postpartum psychosis in bipolar
50%
317
Risk of postpartum psychosis in patients with a hx of postpartum psychosis
50-90%
318
Incidence of puerperal psychosis
One per 1000 births
319
Most used antipsychotic in pregnancy?
Olanzapine
320
Which antipsychotics are commonly used in pregnancy?
```
Chlorpromazine
Trifluoperazine
Haloperidol
Olanzapine
Clozapine
```
321
Treatment of depression in pregnancy
Explore possibility of delaying treatment until 2nd-3rd trimester e.g. CBT
322
Which antidepressant must be avoided in pregnancy
Paroxetine
323
Recommended antidepressants in pregnancy?
Nortriptyline
Amitriptyline
Impramine
Fluoxetine
324
Which patients with bipolar should continue medication?
Severe illness and high risk of relapse
325
When should discontinuation of mood stabilisers be considered in the pregnant woman with bipolar?
Only if absolutely necessary and followed by frequent monitoring
326
Which mood stabilisers should be avoided in pregnancy?
Valproate
| Combination of mood stabilisers
327
What should be done if a pregnant women is on Valproate or Carbamazepine?
Folic Acid 5mg OD from at least a month before conception should be px
Vitamin K should be given to mum and neonate after delivery
328
Risk of SSRIs in pregnancy
13.3% increase in spontaneous abortion
| Risk of decreased gestational age and low birth weight
329
Which drugs increase risk of spontaneous abortion
SSRIs
Mirtazapine
Bupropion
330
Which antidepressant has least placental exposure?
Sertraline
331
Risk of malformation if Lithium used in first trimester?
1 in 10
332
What is Lithium associated with if used in first trimester?
All types of malformation risk increased three-fold
| Cardiac malformations risk increased 8-fold
333
Relative risk of Ebsteins anomaly if on Lithium
10-20 times higher
334
Risk of relapse if a women stops lithium when pregnancy
70% within 6 months
| Faster discontinuation = higher risk of relapse
335
Risk of any birth defect while on Sodium Valproate?
7.2%
336
Findings of IQ of children in mothers who took valproate during pregnancy
42% had verbal IQ <80
| 30% needed special educational support compared to 3-6% of those exposed to other antiepileptic drugs
337
Which malformation is Lamotrigine associated with?
Cleft palate
338
Risk of benzo use during first trimester
0.6% risk of cleft palate & CNS & urinary tract malformations
339
How much lithium is exreted into breast milk?
40-50% of maternal serum level
340
How much can infant serum level of lithium rise up to?
200% of maternal serum conc (5-200%)
341
Which benzos are safe during breastfeeding
Low doses of Temazepam and Oxazepam (short acting)
342
Which benzos should be avoided during breastfeeding?
Diazepam
| Alprazolam
343
Which sedative is safe during breast feeding?
Zolpidem
344
What did SADHART show re impact of Sertraline on depression?
Little difference in depression status after 24 weeks treatment
Effect of Sertraline greater in patients with severe and recurrent depression
345
Prevalence of depression in CCF patients
21.5% (2-3 times higher than general population)
346
Relative risk of mortality in patients with CCF who are depressed
2:1 compared to risk in non-depressed CCF patients
347
M:F ratio of hypothyroidism
1:6
348
Rates of depression in patients with Diabetes
2-3 times more common compared to general population
349
How many patients with erythema migrans develop neuroborreliases?
15%
350
What is neuoborreliases?
Lyme disease where CNS is affected
351
Sx of Lyme disease
Back pain worse at night
Facial numbness
Facial palsy
352
Psychiatric sx of SLE
Depression
Anxiety
Psychosis (Rare)
353
Physical sx of SLE
Chronic, remitting-relapsing course of febrile illness, butterfly rash, inflammation of joints, kidney and serosa
354
Lifetime prevalence of depressive sx in MS
40-50% - 3x higher than general population
355
Suicide rates of people with MS
3% over 6 year period
| 15% over 16 years
356
How many patients with MS on steroids develop mild to moderate mania?
33%
357
Prevalence of post-stroke depression?
35%
358
What type of stroke has high incidence of anxiety?
Cortical
359
Prevalence of post-stroke anxiety?
25%
360
Treatment for mild-moderate post-stroke depression
Increase social interaction
Exercise
Psychosocial intervention
361
Which antidepressants have good evidence for post-stroke depression?
Fluoxetine
| Citalopram
362
Frequency of depression in epilepsy
30-50%
363
Frequency of panic disorder in epilepsy
20%
364
Which type of epilepsy is depression most common in?
TLE
365
Risk of suicide in patients with epilepsy
10-15%
366
Mortality rate if epilepsy and depressed
25x higher than general population
367
Which psychotropic can cause psychosis?
Vigabatrin
368
Which antipsychotics are less epileptogenic?
Sulpride
| Haloperidol
369
Prevalence of depression in Parkinsons
40-50%
370
Prevalence of hypomania/euphoria in Parkinsons
2%/10%
371
Prevalence of anxiety in Parkinsons
50-65%
372
Prevalence of Psychosis in Parkinsons
40% - drug-related
373
Prevalence of cognitive impairment in Parkinsons
19% if no dementia
| 25-40% if dementia
374
Prevalence of psychiatric sx in Huntingtons at first presentation?
30%
375
Suicide rates in patients with Huntingtons
4x higher than general population
376
How many patients with Huntingtons first present with schizophreniform psychosis?
3-6%
377
When can OCD-like sx occur in Huntingtons?
If basal ganglia involvement
378
Where is gene for Huntington Disease?
Short arm of chromosome 4, associated with expanded trinucleotide repeat.
379
When is Huntingtons fully penetrant?
CAG repeats reach 41 or more
380
When does Huntingtons show incomplete penetrance?
36-40 repeats
381
How many patients present with Wilsons disease via psychiatric presentations?
20%
382
Most common psychiatric sx of Wilsons?
Personality disturbance
Mood abnormalities
Cognitive dysfunction
383
How many patients with Wilsons have cognitive impairment?
25%
384
What type of dementia occurs in Wilsons?
Frontosubcortial pattern of dementia
385
How many patients with Wilsons have depression?
30%
386
What does MRI show in patients with Wilsons?
Intense hyperintensity of midbrain with relative sparing of red nucleus, superior colliculus and part of pars reticulata of substantia nigra
Hypointensity of aqueduct - called Giant Panda sign
387
Diagnostic criteria of transient global amnesia
Witnessed attacks with information available from observer
Clear-cut anterograde amnesia during attack
Absence of clouding of consciousness & loss of personal identity
Cognitive impairment limited to amnesia only
No accompanying focal neurological symptoms during attack and no signs afterwards
Absence of epileptic features
Attack resolves within 24 hours
Exclusino of patients with HI or active epilepsy
388
Rate of transient global amnesia
5-10/100,000 per year
389
Rate of transient global amnesia in those >50 years of age
30/1000,000 per year
390
Characteristics of transient global amnesia
Abrupt onset of anterograde amnesia characterised by significant new learning deficit.
Mild confusion and lack of insight into problem but intact sensorium.
391
Episode length of transient global amnesia
6-24 hours
392
What happens in Fahrs disease?
Idiopathic progressive calcium deposition in basal ganglia
393
Onset of Fahrs disease
20-40 years
| 40-60 years
394
Sx of Kluver-Bucy syndrome?
Emotional blunting
Hyperphagia
Visual agnosia
Inappropriate sexual behaviour
395
What causes sx of Kluver-Bucy Syndrome?
Bilateral temporal lobe damage
396
What can be used to control sx in Kluver-Bucy Syndrome?
Carbamazepine
397
Who described Meige Syndrome?
Henri Meidge in 1904
398
What characterisis Meige syndrome?
Repetitive blinking, chin thrusting, lip pursing or tongue movements.
399
What causes secondary Meige's syndrome?
Antipsychotics
Levodopa
Lewy Body Dementia
400
Classification of mild HI
PTA <60 minutes
401
Classification of moderate HI
PTA between 1-24 hours
402
Classification of severe HI
PTA 1-7 days
403
What predicts depression in patients with HI?
Proximity of lesion to left frontal lobe
404
In which type of HI might there by schizophrenia-like psychosis with prominent paranoia?
Left temporal injury
405
In which type of HI might there by affective psychoses?
Right temporal or orbitofrontal injury
406
What are dyssomnias divided into?
```
Primar insomnia
Primary hypersomnia
Circadian sleep disorders
Narcolepsy
Breathing related sleep disorders
Sleep state misperception
```
407
What are parasomnias divided into?
```
Arousal disorders (NREM sleep)
Sleep-wake transition
REM sleep parasomnias
Sleep bruxism
Sleep enuresis
```
408
Prevalence of narcolepsy
0.025%
409
How many patients with narcolepsy have cataplexy?
75%
410
How many patients with narcolepsy have sleep paralysis?
30%
411
How many patients with narcolepsy have all 4 sx: narcolepsy, cataplexy, sleep paralysis and hypnagogic hallucinations?
10%
412
How many patients with narcolepsy have automatic behaviours?
33%
413
What is strongly associated with narcolepsy?
HLA-DQB1*0602
| Low concentration of hypocretin-1 in CSF
414
Treatment for Cataplexy
Imipramine
415
Prevalence of OSA
Men 4%
| Women 2.5%
416
What is sleepwalking?
Partial arousal during slow-wave stages 3 and 4.
417
When do night terrors occur?
During first third of night
| During stages 3-4 of NREM sleep
418
When do REM sleep behavioural episodes occur?
Middle to latter third of night during REM sleep
419
Diagnostic criteria for REM behavioural sleep disorder?
Movements of body or limbs associated with dreams and at least one of:
potentially harmful sleep behaviour
Dreams that appear to be acted out
Sleep behaviour that disrupts sleep continuity
420
Diagnostic criteria for restless leg syndrome in patients >12 y/o
Akathisia usually accompanied by paresthesia (core feature)
Motor restlessness
Sx worse at rest
Sx worse at night
421
Prevalence of restless leg syndrome
3-15%
422
M:F ratio of restless leg syndrome
1:2
423
First licensed drug for restless leg syndrome
Ropinirole
424
Which dopaminergic agents can be used for restless legs?
Nonergot D2 agonists: ropinrole, pramipexole
| Bromocriptine and dopaminergic precursors: levodopa/carbidopa
425
Which anticonvulsants can be used for restless legs?
Gabapentin
| CBZ
426
What is Periodic Limb Movement Disorder?
Periodic episodes of repetitive and stereotyped limb movements during sleep.
Can cause clinical sleep disturbance.
427
How many patients with PLMS also have Narcolepsy?
45-65%
428
How many patients with PLMS also have REM sleep behavioural disorder?
70%
429
What pathology has been linked to PLMS?
Dopaminergic impairment
| Fe deficiency
430
Prevalence of CFS
0.5%
431
M:F ratio of CFS
1:3
432
Mean age of onset of CFS
29-35 years
433
Mean illness duration of CFS
3-9 years
434
CFS criteria
Persistent or relapsing unexplained chronic fatigue of new onset, lasting at least 6 months and not the result of organic disease or continuing exertion, not alleviated by rest.
435
Which sx are required for CFS?
```
Four or more of the following, present for >6 months:
Impaired memory/concentration
Sore throat
Tender cervical/axillary lymph nodes
Muscle pain
Pain in several joints
New headaches
Unrefreshing sleep
Malaise after exterion
```
436
How many patients with CFS have low cortisol?
33%
437
What do family studies of CFS suggest?
Mutation of cortisol transporting globulin
438
Effective treatment of CFS?
CBT
| Graded exercise therapy
439
What sx does CFS not have which depression does?
Absence of lack of motivation, guilt, anhedonia
440
HPA axis in CFS
Downregulation
441
HPA axis in depression
Upregulation
442
Lifetime prevalence of panic disorder in those with CFS
17-25%
443
Lifetime prevalence of GAD in those with CFS
2-30%
444
What has replaced the diagnostic criteria for pain disorder in DSM IV in DSM V?
Somatic Symptom and Related Disorders (SSD)
445
What is SSD diagnosis made on?
The basis of positive sx and signs rather than absence of a medical explanation for somatic complaints.
446
What are the positive sx and signs of SSD?
Distressing somatic sx plus abnormal thoughts, feelings and behaviours in response to these sx
447
Which DSM IV disorders have been removed?
Somatization disorder
Hypochondriasis
Pain disorder
Undifferentiated somatoform disorder
448
Who first introduced the term atypical facial pain?
Frazier and Russell in 1924
449
What is atypical facial pain?
Atypical in distribution, unilateral, poorly localised, lasts most of the day and described as severe ache, crushing or burning.
450
What is the definition of persistent idiopathic facial pain?
Facial pain that is present daily and persists most of the day.
Pain is confined at onset to limited area on one side of the face, deep ache, poorly localised.
451
Predictive markers for HIV Dementia
B2-microglobulin and neopterin levels in CSF
| CD41 cell counts
452
Side effects of Zidovudine
```
Confusion
Agitation
Insomnia
Mania
Depression
```
453
Side effects of Stavudine and Zalcitabine
Peripheral neuropathy
454
Side effects of Efavirenz
Neuropsychiatric side effects:
| 33% depression, 2% psychosis
455
How many patients on Efavirenz develop neuropsychiatric side effects?
46%
456
What makes one suspect psychotropic induced catatonia such as NMS?
Rapid onset
Marked rigidity
Autonomic instability without posturing
457
Total global mortality from suicide
1-2%
458
How many deaths in England and Wales are from suicide?
1%
459
Rate of suicide in England and Wales
8 per 100,000 per year
460
Most common suicide method in men
Hanging
461
How many deaths by men are from hanging?
40%
462
Second most common cause of death by men
OD
463
How many deaths from OD are caused by men?
20%
464
Third most common cause of death by men
Poisoning by car exhaust fumes
465
How many men die by poisoning from car exhaust fumes?
10%
466
Most common method of suicide by women
OD
467
Second most common method of suicide by women
Hanging
468
Third most common method of suicide by women
Drowning
469
How many women die by OD
46%
470
How many women die by hanging?
27%
471
How many women die by drowning?
7%
472
In most countries which age group has the highest rate of suicide?
>75
473
Predictors of suicide in the elderly
Depression
Social isolation
Impaired physical health
Personality traits - anxious, obsessive
474
Suicide due to depression
36-90%
475
Suicide due to alcohol abuse
43-54%
476
Suicide due to drug abuse
4-45%
477
Suicide due to schizophrenia
3-10%
478
Suicide due to organic mental disorder
2-7%
479
Suicide due to PD
5-44$
480
How many patients with a mood disorder will die by suicide?
6-10%
481
Which patients with depression are at highest risk?
Inpatients
Hx of impulsive and aggressive behaviour
Alcohol and drug misuse
Cluster B PD
482
How much does the risk of suicide increase if there is a history of a suicide attempt?
40x increase
483
Lifetime risk of suicide in alcohol dependence
7%
484
Suicide rate in heavy drinks
3.5x higher than general population
485
Suicide rate in alcohol use disorders
15x higher than general population
486
Suicide rate in drug dependence
15x higher than general population
487
Suicide rate in Anorexia
20-fold higher than general population
488
When do majority of schizophrenia patients commit suicide?
Active phase of disorder after suffering depressive sx
489
Global annual suicide rate
1 in 6000/year
490
Male:female ratio of suicide
2-4:1
491
Most common age of suicide
15-24 females
| 25-34 males
492
Mental disorders without much increase in suicide rate
Mental retardation
Dementia
OCD - if no depression
493
Risk of suicide within one year of DSH
0.7%
Males: 1.1%
Females: 0.5%
66x more than general population
494
Diagnosis of those who complete suicide
Major psychiatric disorders
| Substance use
495
Diagnosis of those who attempt suicide
Mental distress
| Reactive depression
496
Cognitive precipitants of those who complete suicide
Guilt
| Hopelessness
497
Cognitive precipitants of those who attempt suicide
Identity difficulties
| Emotional distress
498
How many people who DSH will repeat the act in the next year
20%
499
How many people who DSH will eventually complete suicide?
10%
500
Psychosocial factors suggestive of high suicidal intent
```
Hopelessness
Impulsiveness
Low self-esteem
Recent stressful life event
Relationship instability
Lack of social support
```
501
What scales can be used to assess suicide risk?
SAD PERSONS
Beck Hopelessness
Beck Scale for Suicidal Ideation
502
Outline the SAD PERSONS score
Sex - 1 if male, 0 if female
Age - 1 if <20 or >44
Depression - 1 if depression present
Previous attempt - 1
Ethanol abuse - 1
Rational thinking loss - 1
Social support lacking - 1
Organized plan - 1 if plan is made and lethal
No spouse - 1 if divorced, widowed, separated of single
Sickness - 1 if chronic, debilitating and severe
503
What is Beck Hopelessness Scale?
20 T/F statements focused on pessimism about the future.
504
Scores of Beck Hopelessness Scale
0-3 - minimal risk
4-8 - mild risk
9-14 - moderate risk
15-20 - severe risk
505
Factors associated with dangerousness
```
Younger age
Males
Past hx of criminality and violence
Childhood physical or sexual abuse
Childhood conduct disturbances
Psychiatric diagnosis
Conducive environment
Specific sx
Unemployment
```
506
Which specific sx are linked to dangerousness?
Command hallucinations
Agitation
Hostile suspiciousness
507
Triad of sx of normal prssure hydrocephalus?
Dementia
Gait ataxia
Urinary incontinence
508
Population prevalence of NPH in the elderly
0.4%
509
Common features of SDH
Headache
Drowsiness
Altered consciousness
Confusion - fluctuating severity
510
When might CT not show a SDH?
First 3 weeks as clot is isodense during early phase
511
Complications of surgical treatment of SDH
Seizures
| Re-bleeding
512
Where is Prion protein coded?
PRNP gene on Chromosome 20
513
What are the four forms of prion dementia?
Kuru
CJD
Fatal familial insomnia
Gerstmann Straussler Syndrome
514
Which sign becomes prominent as CJD progresses?
Myoclonus
515
How many CJD cases are sporadic?
85%
516
What does MRI show in CJD?
Non-specific basal ganglia hyperintensities
517
CSF findings in CJD
14-3-3 protein elevated.
518
Characteristics of vCJD?
Anxiety and depressive sx
Personality changes
Progressive dementia
Ataxia and myoclonus
519
What is diagnostic of vCJD?
Pulvinar sign; symmetric high-signal-intensity changes affecting pulvinar and medial areas of thalamus and tectal plate on FLAR sequence in MRI
520
Predicted risk of developing Alzheimers in first-degree relatives
15-19%
| 5% in controls
521
Relative risk of Alzheimers if you have a first-degree relative with the disease?
3-4 times relative to the risk in controls
522
Which genes are associated with early onset Alzheimers?
Presenilin 2 gene
Presenilin 1 gene
Beta amyloid precursor protein gene
523
Which chromosome is Presenilin 2 gene on?
1
524
Which chromosome is Presenilin 1 gene on?
14
525
Which chromosome is beta amyloid precursor protein gene on?
21
526
Where on chromosome 21 is beta amyloid precurser protein gene found?
Long arm
527
Describe structure of the beta amyloid protein
42 amino acid peptide that is a breakdown product of amyloid precursor protein
528
What increases risk of late onset Alzheimers?
Apolipoprotein allele 4
529
Where can Apolipoprotein allele 4 be found?
Chromosome 19
530
Risk of Alzheimers if you have one copy of the Apolipoprotein allele 4 gene?
3x
531
Risk of Alzheimers if you have two copies of the Apolipoprotein allele 4 gene?
8x
532
Cut-off for MMSE?
24/30
533
What scale is commonly used to assess severity and stage of Alzheimers?
DRS
534
What does NPI do?
Rates frequency and severity of a range of neuropsychiatric sx.
535
What does NPI-NH measure?
Rates of occupational disruptiveness, a measure of caregiver distress.
536
How long does CAMCOG take to complete?
40 minutes
537
What does CAMCOG give a score out of?
104
538
Cognitive areas of assessment tested by CAMCOG?
```
Orientation
Comprehension
Perception
Memory
Abstract Thinking
```
539
What does Clock drawing test .. test?
Praxis
| Higher executive function
540
Starting dose of Rivastigmine for Alzheimers?
1.5mg BD
541
Treatment dose of Rivastigmine for Alzheimers?
6mg BD
542
Starting dose of Galantamine for Alzheimers?
4mg BD
543
Treatment dose of Galantamine for alzheimers?
12mg BD
544
Starting dose of Memantine for Alzheimers?
5mg OD
545
Treatment dose of Memantine for Alzheimers?
10mg OD
546
Recommendations from Committee on Safety of Medicines re use of Olanzapine and Risperidone for Dementia?
Each associated with 2x increase in risk of stroke and therefore should not be used
547
What is the NINCDS-AIREN criteria for vascular dementia?
Evidence of CVD both on examination and brain imaging
| Relationship between onset of dementia and CVD
548
What type of dementia is Binswangers disease?
Subcortical
549
Characteristics of Binswangers disease?
```
Slow intellectual decline
Slowness of thought
Decreased STM
Disorientation
Motor problems; gait, dysarthria
```
550
What does CADASIL stand for?
Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy
551
Where is CADASIL gene?
Long arm of chromosome 19
552
How do patients with CADASIL gene present?
Recurrent stroke at age of 40-50
| Hx of migraine
553
How many cases of dementia are lewy body dementia (LBD)?
15-20%
554
Associated features of LBD pathologically
```
Lewy-related neuritis
Plaques
Neurofibrillary tangles
Regional neuronal-loss in brainstem
Synapse loss
Microvacuolation
```
555
Where is regional neuronal loss common in LBS?
Brainstem - locus cereleus and substantia nigra
| Nucleus basalis of Meynert
556
How many patients with Parkinsons go on to develop dementia?
10%
557
What type of deficits are more severe in LBD and Parkinsons vs Alzheimers?
Executive dysfunction:
| planning, reasoning, sequencing
558
FTD accounts for how many cases of presenile dementia?
20%
559
Which chromosome is linked to FTD?
17
560
What does SPECT show in FTD?
Disproportionate decrease in blood flow, radio tracer uptake and glucose metabolism in frontal lobe
561
What causes Picks?
AD
| Mutation in Tau gene with complete penetration
562
Where is the tau gene?
Chromosome 17q 21-22
563
Which conditions are rarely seen in senile patients?
Progressive supranuclear Palsy
Corticobasal degeneration
Frontotemporal degeneration
564
Which genes have been identified in familial Alzheimers with early onset?
Amyoid precursor gene - APP
| Genes encoding PSEN1 and 2
565
Characteristic sx of PSP
Supranuclear opthalmoplegia
Pseudobulbar palsy
Axial dystonia
Vertical gaze palsy
566
Prevalence of delirium on admission to hospital
10-15% of elderly
567
Point prevalence of delirium in the general population
0.4%
568
Major pathway implicated in delirium?
Dosral tegmental pathway which projects from mesenchephalic reticular formation to tectum and thalamus
569
Name the rating scales for delirium
Delirium rating scale - DRS
MMSE
CTD - cognitive test for delirium
CAM - confusion assessment method
570
Most widely used scale for delirium?
DRS
571
Advantage of DRS?
Distinguishes delirium from dementia
572
What is required for DRS use?
Interpretation by skilled clinician
| Information from multiple clinical sources
573
Which delirium rating scale has high sensitivity and specificity?
CAM
574
What does CAM allow?
Diagnosis of delirium
| Incorporated into routine clinical settings
575
Prevalence of depression in >65 age group
10-15%
576
How much more common is depression in nursing homes?
2-3 times more common
577
How many people with dementia have depression?
25%
578
SPECT findings in late onset depression
Reduced cerebral blood flow, sparing the posterior parietal cortex
579
NNT for antidepressant use in elderly
4 - similar to other age groups
580
Depression scales for the elderly
```
Geriatric depression scale
BASDEC
Hamilton
MADRS
Depressive sign scale
CSDD
PHQ 9
```
581
How many items in Geriatric depression scale?
15
582
Scoring in geriatric depression scale?
>5 suggests depressive illness
583
Advantage of geriatric depression scale?
Avoids somatic sx
584
What does BASDEC stand for?
Brief assessment schedule depression cards
585
What is BASDEC?
Series of statements in large print on cards which are shown to patients; answer T/F
586
Why is Hamilton not as appropriate for the elderly?
Somatic items
587
Advantages of MADRS
Sensitive to change in depression
588
Disadvantages of MADRS
Not reliably answered by patients with dementia
589
What does Depressive sign scale consist of?
9 items
590
Advantage of depressive sign scale?
Helps detect depression in people with dementia
591
What does CSDD stand for?
Cornell scale for depression in dementia
592
What is the best validated scale for detecting depression in dementia patients?
CSDD
593
How does CSDD work?
Interviewer-administered
| Using info from both patient and an informant
594
Factors involved in CSDD
General depression
Biologic rhythm disturbances
Agitation/psychosis
Negative sx
595
How many items in PHQ 9?
9
| Self-report
596
Advantages of PHQ 9
Easy to use
| Sensitive to change
597
Cognitive impairment in late onset depression
Specific deficits in attention and executive function, consistent with frontal lobe dysfunction
598
Cognitive deficits in early onset depression
Deficits in episodic memory - consistent with temporal lobe dysfunction
599
How many patients with pseudodementia develop true dementia within 3 years?
40%
600
What did Simpson et al's study show?
Poor response to antidepressants in patients with vascular depression
Drugs used for prevention of CVD might reduce risk of vascular depression
601
Which antidepressants promote ischaemic recovery?
Dopamine or norepinephrine enhancing agents
602
What % of mood disorders in the elderly are due to mania?
5-10%
603
One year prevalence of bipolar among adults >65?
0.4%
604
Who coined the term paraphrenia?
Kraepelin in 1913
605
What is late onset psychosis divided into?
Late onset >40 years
| Very late onset >60 years
606
Prevalence of late onset psychosis in the community
0.1-4%
607
Incidence of late onset psychosis
10-26 per 100,000 per year
608
Point prevalence of paranoid ideation in the elderly population?
4-6%
609
How many patients with late onset psychosis present with delusions only?
10-20%
610
ICD diagnosis of paraphrenia?
No such diagnosis
| Patients must be diagnosed either with schizophrenia or delusional disorder
611
Prevalence of schizophrenia in siblings
7%
612
Prevalence of schizophrenia in parents
3%
613
Most prevalent anxiety disorder in the elderly?
Phobic disorders
614
Least common anxiety disorder in the elderly?
Panic disorder
615
Lifetime prevalence of drug misuse in the elderly
1.6%
616
Most common drugs used in OD in the elderly
Benzos
Analgesics
Antidepressants
617
Psychiatric disorders in elderly who DSH
Depression - half
| Alcohol abuse - one third
618
What did the Monroe County sample find re the elderly and suicide (>50 years)?
Suicide was associated with higher levels or Neuroticism and lower scores on openness to experience
619
What did Harwood and colleagues found in patients >60 who committed suicide?
Anankastic and anxious traits were associated with both depression and suicidality in the elderly
620
Prevalence of PDs in the elderly
5-10%
621
Which PD has the highest prevalence in the elderly?
OCD
622
Prevalence of OCD PD in the elderly?
3.3%
623
What medications reduce REM sleep?
TCAs
624
Impact of SSRIs on sleep
Increase SWS
| Reduce REM
625
What can REM sleep behaviour disorder be an early clinical marker for?
Synucleopathies
626
Name the syncucleopathies
LBD
MSA
Parkinsons
627
Prevalence of REM behaviour disorder in Parkinsons?
15-34%
628
Prevalence of REM behaviour disorder in MSA?
90%
629
How many men >70 have impotence?
10-20%
630
What is phase 1 of grief?
Shock and Protest
631
What does phase 1 of grief involve?
Numbness
Disbelief
Acute dysphoria
632
What is phase 2 of grief?
Preoccupation
633
What does phase 2 of grief involve?
Yearning
Searching
Anger
634
What is phase 3 of grief?
Disorganization
635
What does phase 3 of grief involve?
Despair
| Acceptance of loss
636
What is phase 4 of grief?
Resolution
637
When is improvement expected in normal grief?
2-6 months
638
Percentage of general population who drank alcohol in last week in UK
67% men
| 53% women
639
Percentage of adults who drank above recommended limits
55% men
| 53% women
640
Percentage of children 11-15 who had drunk alcohol at least once
43%
641
Percentage of patients who present to primary care that consume alcohol at a harmful level
20%
642
Annual prevalence of hazardous drinking in UK households
```
38% men
15% women
27% white adults
18% black adults
8% south asian asults
```
643
Peak age of hazardous drinking?
16-19 (women)
| 20-24 (men)
644
Number of all hospital admissions that all alcohol related
1 in 16 hospital admissions
| 1 in 6 ED attencees
645
Age of death of people who are alcohol dependent
60
646
Alcohol use during pregnancy
1 in 10
647
% of adults in the UK 16-59 who took an illicit drug in the last year
8.3%
648
Popular recreational drugs in the UK
Cannabis 6.4%
Cocaine 1.9%
Ecstacy 1.3%
649
Percentage of adults 16-24 taking any drug in last year in the UK
16.3%
650
Percentage of adults 16-59 who had taken a Class A drug in last year
2.6%
651
Percentage of school pupils who took an illicit drug in last year in UK
12%
652
Percentage of drug users in last year who use multiple substances
61% if EtOH included
| 7% if not included
653
Most commonly reported age of first taking drugs
Cannabis - 16
| Cocaine and Ecstacy - 18
654
Average duration of drug use
Cannabis - 6 years
Cocaine - 4.4 years
Ecstacy - 3.9 years
655
Which law classifies recreational drugs?
1971 Misuse of Drugs Act UK
656
Name the Class A drugs
```
Ecstasy
LSD
Heroin
Cocaine
Crack
Magic mushrooms
Methamphetamine
Other amphetamines if prepared for injection
```
657
Name the Class B drugs
Amphetamines
Methylphenidate
Pholcodine
658
Name the Class C drugs
```
Cannabis
Tranquilisers
Some painkillers
GHB
Ketamine
```
659
ICD-10 alcohol dependence criteria
At least 3 of the following in last 12 months:
Intense desire to drink alcohol
Difficulty in controlling onset, termination and level of drinking
Withdrawal sx if alcohol not taken
Use of alcohol to relieve withdrawal sx
Tolerance as evidenced by need to escalate dose over time to achieve same effect
Salience
Narrowing personal repertoire of alcohol use
660
What is salience?
Neglecting alternate forms of leisure or pleasure in life
661
Criteria for DSM IV alcohol dependence
At least 3 of the following lasting for a month
Consuming alcohol for longer period and in larger amounts than intended
Unsuccessful attempts to cut down
Experiencing withdrawal sx if alcohol not taken
Use of alcohol to relieve withdrawal sx
Tolerance - 50% increase from start
Salience
Failure in role obligations and physical health
Giving up alternate pleasures
Continued use despite knowing harm caused
662
Changes in alcohol & substance dependence criteria in DSM V
Combines DSM IV categories of substance abuse and dependence into Substance Use Disorder that is measured from mild (abuse) to severe (dependence).
663
Who created the criteria for alcohol dependence
Edwards & Gross in 1976
664
What are the criteria for alcohol dependence?
```
Narrowed repertoire
Salience of alcohol-seeking behaviour
Increased tolerance
Repeated withdrawals
Drinking to prevent or relieve withdrawals
Subjective awareness of compulsion
Reinstatement after abstinence
```
665
When do features of alcohol withdrawal start?
Within 12 hours of last drink
666
Onset of shakes in alcohol withdrawal?
4-12 hours
667
Onset of perceptual disturbances in alcohol withdrawal?
8-12 hours
668
Seizure onset in alcohol withdrawal
12-24 hours
669
Peak of seizure onset in alcohol withdrawal
48 hours
670
Delirium onset in alcohol withdrawal
72 hours
671
Prominent sx of alcohol withdrawal
```
Tremor
Diaphoresis
Sleeplessness
Anxiety
GI distress
Increased urge and craving for alcohol
```
672
How many patients with alcohol withdrawal will get delirium tremens?
5%
673
Incidence of seizures in untreated alcohol-dependent patients
8%
674
Risk of seizures in alcohol withdrawal if treated
3%
675
How many patients with withdrawal seizures go on to develop delirium tremens?
30%
676
Prevalence of heroin use in the UK
1%
677
M:F ratio of heroin use
2:1
678
Age of most treatment seekers of heroin misuse?
20s
679
Oral bioavailability or morphine
30%
680
How many patients on benzos for 1-5 months will develop dependence?
15%
681
How many patients on benzos for a year will develop dependence?
40%
682
How many 16-29 year olds in the UK have used amphetamines at least once?
22%
683
Features of withdrawal from cocaine
```
Intense craving with lack of physical withdrawal sx
Dysphoria
Anhedonia
Irritability
Hypersomnolence
```
684
When do withdrawal of cocaine sx peak in heavy use?
3 days
685
How many schedules in the Misuse of Drug Regulations 2001?
Five
686
Examples of drugs in Schedule 1
Coca leaf
Cannabis
LSD
Mescaline
687
Regulations of Schedule 1 drugs
No medicinal use.
Supply limited to research or special purposes judged to be in public interest.
Requires Home Office license to possess.
688
Examples of drugs in Schedule 2
```
Diamorphine
Dipipanone
Morphine
Remifentanil
Pethidine
Secobarbital
Glutethimide
Amphetamine
Cocaine
```
689
Regulations of Schedule 2 drugs
Special px requirements and safe custody requirements - except for secobarbital.
Stock drugs must be recorded in a register that meets regulations of the 2001 Regulations
Drug stock must only be destroyed in presence of an appropriately authorized person
690
Schedule 3 drugs?
```
Barbituates except secobarbital
Buprenorphine
Diethylpropion
Mazindol
Meprobamate
Pentazocine
Phentermine
Temazepam
```
691
Regulations of Schedule 3 drugs
Subject to special px requirements except for temazepam.
Not subject to safe custody requirements except for buprenorphine, diethylpropion, flunitrazepam and temazepam.
No need to keep register.
Requirement for retention of invoices for 2 years.
692
Schedule 4 Part 1 drugs
Benzos except temazepam
| Zolpidem
693
Schedule 4 Part 2 drugs
```
Androgenic and anabolic steroids
Clenbuterol
HCG
Non-human chorionic gonadotrophin
Somatotropin
Somatrem
Somatropin
```
694
Regulations of Schedule 4 drugs
Not subject to special px or safe custody requirements.
No need for register.
Requirement for retention of invoices for 2 years.
695
Schedule 5 drugs
Weak preparations of drugs in other schedules e.g. codeine
696
Regulations of Schedule 5 drugs
Exempt from all CD regulations except need to keep invoices for at least 2 years
697
What should all CD px have?
Patients full name, address and age
Name and form of drug written
Dose written
Total quantity of preparation or number of dose units to be supplied in both words and figures
Patient identifier number (NHS)
Signed by prescriber along with GMC number - must be handwritten
698
How long are px of Schedule 1-4 drugs valid?
28 days
699
Which drugs cannot be px on repeat prescriptions?
Schedule 2 & 3 drugs
700
What is Varenicline?
Partial agonist at alpha4beta2 subunit of nicotinic acetylcholine receptor
701
Who first described central pontine myelinolysis?
Adams et al in 1959
702
What happens in central pontine myelinolysis?
Demyelination of central portion of base of pons
703
Sx of central pontine myelinolysis?
```
Pain sensation in limbs
Bulbar palsy
Quadriplegia
Disordered eye movements
VOmiting
Confusion
COma/locked-in syndrome
```
704
Which non-alcoholic diseases can result in central pontine myelinolysis?
```
Wilsons
Malnutrition
Anorexia
Burns
Cancer
Addisons
Severe hyponatraemia
```
705
Heritability of alcohol use disorders
0.51-0.66
706
Risk of alcohol dependence in individuals with both first and 2nd degree relative
4x increase
707
Risk of alcohol dependence in those with affected first degree relative
2x increase
708
Genetic loci linked to alcohol misuse
```
Chromosomes 4p13-12 (GABRB1)
Chromosome 5q33-34
Chromosome 11q23.1
Chromosome 12q24.2
Chromosome 4q22 cluster
```
709
Role of chromosome 12q24.2
Aldehyde dehydrogenase variants
710
Role of chromosome 4q22
Alcohol dehydrogenase polymorphism
711
Screening tools used for alcohol disorders
AUDIT
CAGE
MAST
712
What setting is AUDIT made for?
GP
713
Sensitivity of AUDIT
83% males
| 65% females
714
How can AUDIT be carried out?
Brief structured interview or
| self-report questionnaire
715
What subtype of AUDIT can be used in ED?
FAST - fast alcohol screening test
716
What is the most widely used alcohol screening tool?
CAGE
717
Disadvantages of CAGE
Does not include frequency of alcohol use, levels of consumption or episodes of heavy drinking - all of which identify patients in early stages of alcohol misuse.
718
Who conducted a study into use of CAGE in GP?
Aertgeerts et al. 2001
719
Sensitivity of CAGE in primary care
62% males
| 54% females
720
What does MAST stand for
Michigan Alcohol Screening test?
721
Who was MAST developed for?
Detecting dependent drinkers
722
Structure of MAST
25 questions related to respondents self-appraisal of problems associated with excessive drinking
723
Sensitivity of MAST
86-98%
724
Specificity of MAST
81-95%
725
Drawbacks of MAST
Focus is on lifetime rather than current occurrence of alcohol problems.
Can therefore miss early stages of alcohol misuse
726
How long is amphetamine present in urine?
Up to 48 hours
727
How long are benzos present in urine?
Up to 3 days
728
How long is cannabis present in urine if occasional use?
Up to 3 days
729
How long is cannabis present in urine if heavy use?
Up to 4 weeks
730
How long is cocaine present in urine?
6-8 hours
731
How long is cocaine metabolite present in urine?
2-4 days
732
How long is codeine present in urine?
48 hours
733
How long is methadone present in urine?
3 days or more
734
How long is heroin present in urine?
1-3 days
735
How long is morphine present in urine?
2-3 days
736
How long is PCP present in urine?
3-8 days
737
How long is LSD present in urine?
<24 hours
738
False positive test producer of PCP
Dextromethorphan
739
False positive test producer of marijuana metabolites
Ibuprofen
740
False positive test producer of opiates?
Tonic water
741
False positive test producer of amphetamines
Phenylephrine decongestants
742
What are successive episodes of alcohol withdrawal associated with?
Increasing severity and complications
743
What drugs other than benzos can be used in alcohol detox?
Chlormethiazole
Carbamazepine
Anticonvulsants
Haloperidol
744
Why should Chlormethiazole be avoided?
Risk of respiratory depression, especially when alcohol is consumed during detox
745
First-line alternative to benzos in alcohol detox?
Carbamazepine
746
What is Acamprosate?
Taurine derivative
Inhibits glutamatergic NMDA receptor function
Balances GABA-glutamate imbalance seen in alcohol dependence
747
Odds ratio for abstinence with acamprosate vs placebo
1.73
748
NNT for acamprosate
11
749
What is naltrexone licensed for in the UK?
Ralapse prevention in alcohol dependence
750
What has naltrexone been shown to be superior that placebo in?
```
Maintaining abstinence
Relapse rates
Time to first drink
Reduction in number of drinking days
Reduction in craving
Improvement in GGT
```
751
NNT of naltrexone
9-11
752
How does Nalmefene work?
Opioid receptor modulator
Anatagonist at mu and delta receptors
Partial agonist at kappa receptors
753
When is Nalmefene recommended?
To reduce alcohol consumption in dependent individuals with high drinking level risk after 2 weeks of initial assessment and without physical withdrawal sx and who do not require immediate detox
754
What is the definition of high drinking risk level as per WHO?
>60grams/day in men
| >40grams/day in women
755
How long should Disulfiram be continued if initial beneficial effects?
3-6 months
756
In whom can SSRIs be helpful for alcohol misuse?
Improve drinking outcomes in Type 1 alcoholism
757
In whom can SSRIs be harmful for alcohol misuse?
Worsen outcomes in Type 2 Alcoholism
758
What was project MATCH?
Multisite (9) USA based RCT of 1726 patients testing the hypothesis that matching patient characteristics to specific treatments would improve alcohol dependence.
759
What did project MATCH find?
Patients with low support for drinking derived more benefit from motivational enhancement therapy.
Readiness to change and self-efficacy were the strongest predictors of long-term drinking outcomes.
760
What was the UKATT?
Multicentre (7) pragmatic effectiveness RCT of 742 patients comparing MET and Social Behaviour and Network therapy.
761
Who did a meta-analysis into therapies for alcohol dependence
Slattery et al 2003
762
What is the FRAMES approach to alcohol?
```
Feedback of risks
Responsibility highlighted
Advised to abstain or cut down
Menu of alternative options
Empathic interviewing
Self-efficacy enhanced
```
763
Which drugs should be used in opioid withdrawal if short duration is desirable
Alpha 2 adrenergic agonists
| Buprenorphine
764
Relapse rates of smoking after 6 months?
8%
765
How many smokers quit without assistance?
5-10%
766
How long is nicotine replacement therapy (NRT) given for?
2 weeks
767
How many patients are compliant with patch NRT?
82%
768
Who is Bupropion not licensed for in smoking cessation?
Adolescents
| Pregnant women
769
Contraindications for Bupropion?
Hx of seizures or ED
770
What was pathological gambling classified as in DSM IV?
Impulse Control disorder
771
Prevalence of compulsive buying
2-8%
772
Gender ratio of compulsive buying
>80% are females
773
How many fitness users use anabolic steroids?
13%
774
How many young people in Europe have taken legal highs in the past year?
5-10%
775
When should detox for opioid use be used in pregnant women?
Middle trimester
If done in first trimester - abortion risk
Laster trimester - possible premature birth
776
What needs to be done if a woman starts pregnancy while on methadone
Reduce 1mg every 3 days
| Fetal monitoring
777
What dose of methadone is advocated during maintenance while pregnant
15mg
778
Calculation for odds
Probability / 1 - probability
779
Calculation for probability
Odds / 1 + odds
