Mental health service provision, Law, Pharma, Intellectual disability, Childhood, Personality disorders, Alcohol, Alcohol and substance abuse, Eating disorders, Anxiety and somatoform disorders, Anxiety, fear and avoidance, Schizophrenia, Psychosis,...

Algorithm for diagnosis

p130

Algorithm for diagnosing anxiety disorders

p80

Male to female ratio of hyperkinetic disorder

3:1

Male to female ratio

3:2

Those who inherit 1 ApoE allele ɛ4 are roughly how much more likely to inherit late-onset Alzheimer's?

3x.

What is the increased risk of developing late-onset Alzheimer's in a first-degree relative of sufferers?

3x.

Is modification of personality traits easy

No, takes many years

Main problems with MAOIs

"Accumulation of amine neurotransmitters. Impaired metabolism of amines found in some drugs and food. The above can both lead to very high noradrenaline levels resulting in a hypertensive crisis

Indications for lithium

"Acute mania Prophylaxis of BAD Treatment resistent depression Adjuncts for schizoaffective disorder, schizophrenia, aggression/impulsivity"

Main categories of psychotropic medication

"Antidepressents Mood stabilisers Antipsychotics Anxiolytics and hypnotics Other But lots have more than one effect"

What is "automatism" and how can it reduce criminal culpability?

"Automatism": action performed unconsciously or involuntarily e.g. during sleepwalking or epileptic seizure.

Perinatal causes of intellectual disability

"Birth trauma e.g. intracranial haemorrhage, hypoxia Prematurity e.g. intraventricular haemorrhage, hyperbilirubinaemia (kernicterus), infections"

Genetic causes of intellectual disability

"Chromosomal: Down's, fragile X, Prader Willi Other: phenylketonuria, neurofibromatosis, tuberous sclerosis, Lesch-Nyhan syndrome, Tay-Sachs disease."

Prenatal causes of intellectual disability

"Congenital infections: 'TORCH' acronym: toxoplasmosis, rubella, cytomegalovirus, herpes simplex and zoster. Also syphilis and AIDS. Substance use during pregnancy: foetal alcohol syndrome, prescribed drugs with teratogenic effects. Complications of pregnancy: pre-eclampsia, intrauterine growth retardation Antepartum haemorrhage"

Features that often co-present with intellectual disability

"Signs of the specific cause of the intellectual disability e.g. epicanthic folds with oblique palpebral fissures, broad hands with single transverse palmar crease, flattened occiput and cardiac septal defects in Down's syndrome. Aggression, self-injurious behaviours, repetitive stereotypical motor movements and poor impulse control. A third have a comorbid psychiatric illness (most commonly schizophrenia)."

How is intellectual disability assessed

"Defined as an IQ of <70 (2 standard deviations below the mean). This can be assessed using standardised intelligence tests e.g. Wechsler Intelligence Scales for Children."

Adaptive functioning of mild intellectual impairment

"Difficulties may be hard to spot and only become apparent at a later age during academic work. Greatly helped by educational programmes. Usually capable of unskilled or semi-skilled manual labour May be able to live independently or with minimal support"

Treatment of neuroleptic malignant syndrome and serotonin syndrome

"Discontinue offending drugs. Cool the patient. Maintin hydration. Consider ITU for monitoring/ventilation.resus. Use benzos for sedation if severely agitated. For neuroleptic malignant syndrome only: bromocryptine, dantrolene, ECT. For serotonin syndrome only: cyproheptadine"

Indications for valproate

"Epilepsy Acute mania Prophylaxis of BAD"

Indications for lamotrigine

"Epilepsy Prophylaxis of BAD if the majority of episodes are depressive"

Indications for carbamezapine

"Epilepsy Prophylaxis of BAD"

What is the effect of D2 antagonism on the nigrostriatal pathway

"Extra-pyramidal side effects: Parkinsonian symptoms Acute dystonia Akathisia Tardive dyskinesia Neuroleptic malignant syndrome"

Why is medical care often suboptimal in people with intellectual disabilities

"False attribution of symptoms to the intellectual disability. Difficulty communicating."

Other areas of management for intellectual disabilities

"Family support Education: mainstream if possible due to benefits of societal integration, otherwise specialist schools. Supported employment Housing and social support."

Primary prevention and detection of intellectual disabilities

"Genetic screening and councelling for high risk groups. Prenatal testing e.g. amniocentesis, rhesus imcompatability Improved perinatal and neonatal care Early detection of metabolic abnormalities e.g. phenylketonuria, neonatal hypothyroidism. More mild disorders may only be noticed by teachers/doctors later in life."

What does "actus reus" mean?

"Guilty act" or "crime" - means the person is guilty of committing the crime, whatever their intent.

What does "mens rea" mean?

"Guilty intent" or "guilty mind" - which means that the individual realised the nature of, and intended to commit the unlawful act. Varying levels of "mens rea" are recognised, known as "modes of culpability".

Side effects of mirtazapine

"Increased appetite weight gain and sedation (via histamine antagonism) however these can often be used to advantage. Also, headache, dry mouth, dizziness, postural hypotension, tremor and peripheral oedema." Contraindication to mirtazapine

Medical conditions in childhood that can cause intellectual disability

"Infections e.g. meningitis, encephalitis Head injury Toxins e.g. lead, other heavy metals"

Adaptive functioning of moderate intellectual impairment

"Language and comprehension limited Self care and motor skills impaired, may need supervision May be able to do simple practical work without supervision Rarely able to live completely independently"

Adaptive functioning of profound intellectual impairment

"Severely limited in ability to communicate their needs May be able to perform simple tasks under close supervision" Often severe motor impairment with restricted mobility and incontinence Little or no self care Often require residential care"

Is it common for an individual to be considered unfit to plead through mental illness?

No.

Main mood stabilisers

"Lithium Anticonvulsants (valproate, carbamezapine and lamotrigine)"

Downside to using standardised intelligence tests

"Many are aimed at people with average intelligence so may be unsuitable for those with severe impairment. Can be confounded by language, communication or sensory problems. Therefore, patients scoring <70 should not be diagnosed unless there is evidence of significant impairment in adaptive functioning."

Adaptive functioning of severe intellectual impairment

"Marked degree of motor impairment Little or no speech during early childhood, may learn to talk in school-age period Capable of only elementary self care skills

IQ range for mild, moderate, severe and profound

"Mild: 50-69 Moderate: 35-49 Severe: 20-34 Profound: <20"

Occurrence of mild, moderate, severe and profound intellectual disability

"Mild: 85% Moderate: 10% Severe: 3-4% Profound: 1-2%"

Signs of lithium toxicity at 1.5-2 mmol/l

"Nausea and vomiting Apathy Coarse tremor Ataxia Muscle weakness"

Side effects of lamotrigine

"Nausea and vomiting Skin rashes Headache Aggression, irritability Sedation and dizziness Tremor Occassionaly Stevens-Johnson syndrome - withdraw immediately if they get a rash"

Personality traits that increase vulnerability to depression

"Neuroticism" (anxious, moody, shy, easily stressed). Borderline/obsessive-compulsive personality disorders.

Treatment of tardive dyskinesia

"No effective treatment Anticholinergics can make it worse Withdraw antipsychotic if possible or switch to clozapine"

Drugs and foods which may precipitate a hypertensive crisis in combination with MAOIs

"Tyramine rich foods Cheese (especially mature) Degraded protein (pickled herring, smoked fish, chicken liver, hung game) Yeast and protein extract e.g. bovril, oxo, marmite Chianti wine Beer Broad bean pods Soya bean extract Overripe or unfresh food Adrenaline, noradrenaline Amfetamines Cocaine Ephedrine, psuedoephedrine, phenylpropanolamine (found in cough mixtures and decongestants) L-dopa, dopamine Local anaesthetics containing adrenaline"

Prognosis for autistic children achieving independence

1-2% achieve full independence 20-30% achieve partial independence

Lifetime prevalence of hypochondriacal disorder

1-5%

What proportion of mild intellectual impairment has no clear aetiology identified

A third - these may represent the tail of a normal distribution

What proportion of those with cyclothymia have a family member with bipolar?

A third.

Is there a cure for neurodegenerative forms of dementia?

No.

Is there a link between active psychotic symptoms and sexual offending?

No.

Is there an association between fragile X syndrome and schizophrenia?

No.

Do older adults with depression have a higher mortality rate than older adults without depression?

Yes.

Link between depression and anxiety

65% of patients with anxiety will also have depression. Important to determine which symptom arose first and which was secondary.

What is the heritability of bipolar affective disorder?

65-80%.

How to choose an antipsychotic

Based on tolerability. Clozapine is the most effective but is not first line as it has more SEs.

Is ageing a risk factor for mental illness?

Yes.

Determinents of personality in childhood

Constitutional factors: intelligence, temperrament. Environmental factors Physical handicap/illness

Problem often encountered when starting SSRIs/TCA

Initial increase in anxiety. Can be prevented by using benzos as well for the first few days

Prevalence of autism

0.10%

Lifetime prevalence of somatisation disorder

0.2-2%

Prevalence of drug dependence in 65-74 year olds

0.3%

Prevalence of anorexia

0.3% of young women

What % of adults have regular sleepwalking episodes?

0.5%.

Prevalence of bulimia

0.5-1% of young women (although many suffers do not come to the attention of services) Crash course also says that it is 5x more common than anorexia

Lifetime risk of cyclothymia

0.5-1%.

How long should treatment be given for following an episode of schizophrenia

1-2 years

Mortality rate from ECT

1 in 100,000 (same as any minor surgical procedure)

Incidence of puerperal psychosis

1 in 500 childbirths.

Definition of residual schizophrenia

1 year of predominantly negative symptoms which must have been preceded by at least on clear cut psychotic episode in the past.

Prevalence of non-organic encopresis at 5yo

1%

Prevalence/lifetime risk of schizophrenia

1%

Prevalence of hyperkinetic disorder in UK vs. ADHD in USA

1% in UK vs. 3-7% in USA due to stricter criteria from ICD-10.

Lifetime risk of bipolar affective disorder

1%.

Overall UK prevalence of dementia

1%.

Prevalence of schizophrenia in those >65yo?

1%.

What % of children have obstructive sleep apnoea?

1%.

Prevalence of mania in those >65yo?

1%. Unlike depression, the incidence of bipolar affective disorder does not increase with age, although late onset cases seem to be less influenced by genetic factors (fewer of these patients have +ve family history for mood disorders). In 20% of cases, acute mania is precipitated by an acute medical condition e.g. stroke or MI.

Time to perform 1) AMT 2) MMSE 3) CLOX1 4) ACE-R

1) 3 mins. 2) 8 mins. 3) 2 mins. 4) 20 mins.

Prevalence of the following in prison populations: 1) personality disorders 2) dependence on illicit drugs 3) dependence on alcohol 4) neurotic disorder (depression or anxiety) 5) psychotic disorder 6) intellectual disability that adversely affects their ability to cope with incarceration

1) 66%. 2) 45%. 3) 30%. 4) 4.5%. 5) 10%. 6) 20-30%.

First degree relatives of patients with bipolar affective disorder are how many times more likely to also develop the 1) bipolar 2) depression 3) schizophrenia/schizoaffective disorder?

1) 7x 2) 2-3x 3) book does not specify - simply "higher"

Prevalence of intellectual disability

1-2%

What to do, IN ORDER, if a patient with depression has not responded to their antidepressant at the correct dose for the correct length of time?

1) reassess diagnosis - make sure they are not misusing alcohol/substances and look for any ongoing psychosocial stressor 2) consider psychological therapy if not already in place 3) increase dose of current antidepressant 4) change to other SSRI 5) change to another antidepressant from a different class 6) consider augmenting the current antidepressant with lithium, antipsychotics or another antidepressant e.g. mirtazapine 7) consider ECT if criteria met

How long do sleep terrors usually last?

1-10 mins.

Prevalence of conduct disorder

1-10%

Health benefits of alcohol

1-2 units a day for men over 40 and postmenopausal women protects against CV disease

Features of problem solving counselling

More directive and focused as patients are actively assisted in finding solutions to their problems.

ICD-10 diagnostic criteria for PTSD

1. patient must have been exposed to a stressful event or situation (either short or long lasting) of exceptionally threatening or catastrophic nature which would likely cause pervasive distress in almost anyone. 2. must be persistent remembering or reliving of the stressor in intrusive flashbacks, vivid memories or recurring dreams, or in experiencing distress when exposed to circumstances resembling or associated with the stressor (external or internal cues) - may sometimes dissociate and experience the original event as though it were happening at that moment - hallucinations and illusions 3. patient must exhibit an actual or preferred avoidance of circumstances resembling or associated with the stressor (can lead to social withdrawal and emotional numbing). 4. Either of the following must be present: - inability to recall either partially or completely some important aspect of the period of exposure to the stressor OR - persistent symptoms of increased psychological sensitivity and arousal shown by any 2 of the following: -- difficulty falling or staying asleep -- irritability or outbursts of anger -- difficulty concentrating -- hypervigilance -- exaggerated startle response Criteria 2, 3 and 4 must all arise within 6 months of the period of stress. The diagnostic guidelines show that the disorder should only be diagnosed after 6 months if the symptoms are typical and do not constitute one of the other psychiatric diagnoses such as phobic conditions, other anxiety disorders, depression etc.

Are those with a mental illness more or less likely to be the victim of a crime than members of the general population?

4x more likely.

Does reduction of psychotropic medication in those with dementia compared to young adult?

1/10th.

Proportion of those with dementia that live in residential care?

1/3.

What % of those with antisocial personality disorder meet the criteria for psychopathy?

1/3.

What proportion of drinkers have significant anxiety problems?

1/3.

What proportion of those with delirium die?

1/3.

When to PMS symptoms tend to occur?

10 days prior to menstruation and remit in the 2 weeks following.

Lifetime risk if sibling or dizygotic twin has schizophrenia

10%

What percentage die from suicide

10%

Prevalence of PND in developed world

10% (most common complication of childbirth).

What % of people with a first degree relative with bipolar affective disorder develop bipolar?

10%.

Prevalence of depression in those >65yo?

10-15% (often under-diagnosed).

Prognosis of mild cognitive impairment

10-15% of cases convert to dementia per year. Some remain stable or improve.

% of those >65yo that are delirious on admission to hospital?

10-15%.

Prevalence of anxiety disorders in those >65yo?

10-15%.

What % of bipolar patients complete suicide?

10-15%.

How long does each episode of sleep in narcolepsy usually last?

10-20 mins.

What % of dementia patients experience seizures?

10-20%.

Lifetime risk of recurrent depressive disorder in women

10-25%.

Prevalence of personality disorder in those who frequently present to GPs

10-30%

What percentage of people experiencing an event capable of causing PTSD will get it

10-30%

% of medically ill patients in hospital that experience delirium?

10-30%.

What % of children ages 3-5 experience REPEATED nightmares?

10-30%.

% of those >65yo that become delirious during an admission to hospital?

10-40%.

Prevalence of drug dependence in 16-24 year olds

10.2%

How many ml of pure alcohol make up 1 unit

10ml

Those who inherit 2 ApoE allele ɛ4 are roughly how much more likely to inherit late-onset Alzheimer's?

10x.

Normal course of grief after bereavement

5 phases in the following order (although these should not be regarded as a rigid sequence that is passed through only once, and not all patients go through all 5 stages): 1) alarm 2) numbness 3) pining 4) depression and despair 5) recovery and reorganisation

When to test lithium levels

12 hrs after last dose

How many people are killed in the UK each year from drink driving related accidents

12,000

How long does "interpersonal therapy" tend to last?

12-16 sessions.

1 year prevalence of anxiety disorders

12-17% (highest of all psychiatric disorders)

Peak prevalence of sleepwalking

12yo (with an onset between 4 and 8 years old).

Lifetime risk if one parent has schizophrenia

13%

What % of women have eating habits that give cause for concern

5%

% of sleep spent in stage 1

5%.

Prevalence of borderline personality disorder in the prison population

14% of men and 20% of women (significantly higher than the general population). Reasons may include impulsiveness, the presence of comorbid antisocial personality disorder and the high prevalence of substance misuse disorders in theses patients.

Incidence of puerperal psychosis in those with close family member who has bipolar

15 in 500 childbirths.

Decreased life expectancy for a schizophrenic patient

15 years

Lifetime mortality from anorexia

15% (half from starvation, a third from suicide) Highest mortality rate for any psychiatric condition

Theoretical orientation accounts for what % of therapeutic effect?

15%.

Duration of working/short term memory

15-30 seconds.

What is the age of consent in Scotland (age at which it is assumed that the person has capacity)

16

Which antipsychotics are worst for causing extrapyramidal symptoms

1st generation (quetiapine is the best for avoiding them)

Treatment of Tourette's

1st line: CBT etc. + treatment of any comorbidities e.g. anxiety 2nd line: Dopamine antagonists (haloperidol is licensed) (thought it may be caused by excess dopamine)

Treatment of mild depression or persistent sub-threshold symptoms

1st line: lifestyle advice + low intensity psychological intervention (self-help CBT, structured group physical activity). 2nd line: + antidepressant.

How long does buspirone take to work

2 weeks (whereas benzos work quickly)

Presentation of childhood disintegrative disorder

2 years of normal development followed by a loss of previously acquired skills (language, social, play, bowel and bladder control and motor skills) before the age of 10. Also associated with an autism like impairment of social interaction as well as repetitive, stereotyped interests and mannerisms. Thus, after the deterioration, these children may resemble autistic children.

What % of adult women have obstructive sleep apnoea?

2%.

Administration of ECT

2-3 times per week Most patients need 4-12 treatments Anaesthetist gives short-acting induction agent and muscle relaxant to ensure about 5 mins of general anaesthesia. Psychiatrist applies electrodes (unilateral/bilateral) to scalp to induce a seizure for about 15 seconds

What % of children have regular sleepwalking episodes?

2-3%.

F:M ratio of dysthmia

2-3:1.

How many episodes of sleep do most people with narcoelpsy experience?

2-6.

% of women that have PMS symptoms that are bad enough to disrupt their work or lifestyle

5%.

Normal MMSE score

25-30 out of 30.

Prevalence of all mental ilness in those >65yo?

25-30%.

Proportion of cases of delirium that occur in those with dementia?

2/3.

What % of patients with experience obsessions and compulsions during or just after a depressive episode?

20%

What percentage of patients only have a single lifetime episode

20%

Mortality of neuroleptic malignant syndrome

20% if untreated

Overall UK prevalence of dementia in the >80yo

20%.

Normal BMI

20-25

What % of people with a first degree relative with bipolar affective disorder develop depression?

20-30%.

Average age of onset of bipolar affective disorder

20.

Are men most or less likely to experience sexual dysfunction as they age?

More likely (especially erectile problems and lack of interest in sex).

What percentage of people in England drink hazardously

24% of adults (33% of men and 16% of women)

% of sleep spent in stage 3 and 4

25%.

% of sleep spent in stage 5

25%.

How long does a short-term detention order last

28 days

F:M ratio of recurrent depressive disorder

2:1.

What stage of sleep do nightmares usually occur in?

2nd half of night (arise almost exclusively in REM sleep).

At what age is autism usually noticed by

3

Classification of psychosexual problems

3 groups: - sexual dysfunction - disorders of sexual preference (paraphilias) - gender identity disorders

When is gender identity thought to be fully formed by?

3 years old.

Lifetime suicide risk from alcohol

3-4% (60-120 times normal population) Could be due to increased risk of psychiatric disorders or through impaired judgement and disinhibition secondary to alcohol

Lifetime suicide risk for alcohol dependence

3-4% (60-120 x general population)

Lifetime risk of dysthmia

3-6%.

Prevalence of drug dependence

3.4%

People who are depressed and who have pre-existing cardiovascular disease are how much more at risk of death than patients who are not depressed and have cardiovascular disease?

3.5x.

Overall UK prevalence of dementia in the >90yo

30%.

Prevalence of personality disorder in psychiatric OP clinics

30-40%

Autosomal dominant Alzheimer's tends to present at what age?

30-60yo, and sometimes as early as 28 when there is a presenilin-1 mutation.

What % of men have sexual dysfunction?

31%.

What % of those with Gilles de la Tourette's meet the diagnostic criteria with obsessive-compulsive disorder?

35-50%.

In primiparous women, what is the increased risk of developing a psychotic illness and needing hospital admission in the first month following childbirth, compared to the general population?

35x.

Lifetime prevalence of illicit drug use

36.3%

What percentage of adults exceed the safe alcohol limits

37% of men (statistic based on when safe daily alcohol limit for men was 3-4 units/day) and 29% of women

Average duration of survival from time of diagnosis of a late onset dementia?

4 years.

What % of middle-aged men have obstructive sleep apnoea?

4%.

General population prevalence of personality disorder

4-13%

Average number of manic episodes per 10 yrs for those with bipolar?

4.

What percentage of borderline personality patients dissengage with treatment

40%

Examples of psychotic symptoms common in dementia

40% have delusions (mainly persecutory). 30% have hallucinations of any modality (mainly visual).

% of women who report having symptoms of PMS

40%.

Prevalence of personality disorder in psychiatric inpatients

40-50%

What is the heritability of depression?

40-50%.

Prevalence of personality disorder in self-harm

40-80%

What % of women have sexual dysfunction?

43%.

% of sleep spent in stage 2

45%.

Male to female ratio of autism

4:1

Male to female ratio of conduct disorder

4:1

Schizophrenia increases the risk of violent crime by how much?

4x (but 8x more likely to be arrested for it).

Lifetime risk of recurrent depressive disorder in men

5-12%.

Mortality rate for delirium tremens

5-15% (35% if untreated)

What % of bipolar patients have >=4 mood episodes per yr AKA have rapid cycling bipolar?

5-15%.

What % of those with obsessive-compulsive disorder have Tourette's?

5-7%.

What additional receptors do most second generation antipsychotics antagonise

5-HT2 (serotonin)

How many stages of sleep are there?

5.

Lifetime risk if both parents have schizophrenia

50%

Lifetime risk if monozygotic twin has schizophrenia

50%

What % of adults experience OCCASSIONAL nightmares?

50%.

What % of women get postnatal blues?

50%.

What is the risk of developing PND or a similar illness after childbirth in the future, in a women who has already had PND?

50%.

Prognosis for bulimia

50-70% recover after 5 years

Prevalence of personality disorder in prisons

50-80%

How long does a CTO last

6 months

At what age is separation anxiety normal

6 months to 2 years

When is the onset of akathisia

6-60 days

What percentage of patients with treatment resistant schizophrenia are benefited by clozapine

60%

Chance of recurrence of puerperal psychosis after future childbirths?

60%.

After an MI, what % of patients report experiencing symptoms of depression?

65% (major depression in 15-22% of these patients).

After a life-threatening event, what is the increased risk of developing depression compared to the general population?

6x in the following 6 months.

Capacity of working/short term memory

7 +/- 2 items.

Average duration of delirium

7 days.

Overall UK prevalence of dementia in the >65yo

7% (formative exam said 5%).

Prevalence of non-organic enuresis at ages 5, 10 and 15

7, 4 and 1%

How long does an emergency detention certificate last for

72 hours

How common is intellectual disability in autism

75%

What % of patients stop taking their antipsychotics within 2 years

75%

What is the genetic contribution to variance in liability of hyperkinetic disorder

76%, one of the highest of all psychiatric disorders

Prognosis for borderline personality disorder

78-99% show sustained symptomatic remission at 16 year follow up

% of women that describe "cyclical symptoms"

80%.

Relapse rate for schizophrenia

80-98%

Prevalence of conduct disorder amongst young offender population

85%

Chance of recurrence of puerperal psychosis after future childbirths if also have an established mood disorder?

85%.

Common factors (occurring in any model of therapy) account for what % of therapeutic effect?

85%.

What percentage of people in England are alcohol dependent

9% of men and 4% of women aged 16-75

Heritability of autism

90%

Prognosis of non-organic encopresis

90% improve within a year

What % of those who have a manic episode go on to have further ones?

90%.

What % of mental illness is only managed by GPs

95%

How age can reduce criminal culpability in England and Wales

<10 year olds are deemed incapable of criminal intent ("dolci incapax"). Children aged 10-14 years are not considered criminally responsible for their actions unless the prosecution can prove "mens rea". Children are only deemed legally responsible for their actions >14yo.

BMI for high risk of medical complications

<13.5

Anorexia nervosa BMI

<17.5

Age of onset of elective mutism

<5

EEG findings in stage 3 of sleep

<50% delta waves (high amplitude, low frequency (<4Hz).

In what % of cases of narcolepsy are all 4 of the tetrad present?

<50%.

Usually age of onset of hyperkinetic disorder

<7

Alcohol limits for 'hazardous drinking'

>14 units per week

What ages does the Adults with Incapacity (Scotland) Act 2000 cover

>16

What proportion of those with OCD will experience a depressive episode at some point in their life?

>2/3 - distinguished from obsessions and compulsions due to depression as they are present before and persist after the treatment of depression. As OCD is a disabling condition, patients often have chronic mild "reactive" depressive symptoms that do not fully meet the criteria for a depressive episode - these symptoms usually resolve when the OCD is treated and the patient's quality of life improves.

BMI for obesity

>30

Risk factors for PMS

>30yo. Multiparous (increases with the more children you have). Not using oral contraception. Experiencing significant degrees of psychosocial stress.

BMI for gross obesity

>40

EEG findings in stage 4 of sleep

>50% delta waves.

In the UK, it is recommended that all hospital in-patients of what age should have their cognition screened, whether or not they appear impaired?

>65.

Age group of old age psychiatry

>65yo.

Definition of catatonic schizophrenia

>=1 catatonic symptoms

Schneider's first rank symptoms

>=1 of the following in the absence of organic disease: Delusional perception. Delusions of thought control. Delusions of control: passivity experiences of affect, impulse, volition and somatic passivity. Audible hallucinations

ICD-10 criteria for dependence syndrome

>=3 been present together at some time during the previous year: A strong desire or compulsion to take the substance. Difficulties in controlling substance-taking behaviour (onset, termination, levels of use). Physiological withdrawal state when substance has been reduced or ceased; or continued use of the substance to relieve or avoid withdrawal symptoms. Signs of tolerance: increased quantities of substance are required to produce the same effect originally produced by lower doses. Neglect of other interests and activities due to time spent acquiring or taking substance, or recovering from its effects. Persistence with substance use despite clear awareness of harmful consequences (physical or mental).

Management of dysthymia and cyclothymia

Can be treated pharmacologically with the sem drugs used in depression and bipolar but antidepressants should be used with caution in cyclothymia due to occasional tendency to turn mild depressive symptoms into hypomania. Psychological therapy may be useful for both.

Prognosis for antisocial personality disorder

Can improve with time if treated, especially if they form a good relationship with their therapist

What further problem do the physical signs cause

Can make the patient think they are dying/having a heart attack/going mad which can further increase anxiety.

When does psychomotor dysfunction occur in psychosis

Can occasionally be a primary feature, but more commonly a SE of neuroleptic medication

Use of ECT in bipolar

Can precipitate manic episode. BUT, can be an effective antimanic, superior even to lithium, especially in those with severe mania and mixed states that are refractory to drug treatment.

Features of Cushing's disease

Can present with depression or psychosis. Forgetfulness. Central obesity. Hypertension. Easy bruising. Amenorrhoea. Plethoric face. Glucose likely to be elevated.

DSM-IV clusters

A - odd or eccentric B - dramatic, emotional or erratic C - anxious or fearful

What is buspirone

A 5HT1a receptor agonist used for generalised anxiety disorder.

Link between schizotypal personality disorder and schizophrenia

Can progress to it. More common in families of schizophrenics.

1st generation antipsychotics

Chlorpromazine Haloperidol Flupentixol Zuclopenthixol

First generation antipsychotics

Chlorpromazine, haloperidol, surpiride, flupentixol, zuclopenthixol

Definition of stereotypies

A complex movement that does not appear to be goal-directed e.g. rocking to and fro, gyrating

How to distinguish between personality disorders (axis 2) and axis 1 psychiatric disorders

A personality disorder can only be diagnosed when the clinical features begin in adolescence or early adulthood, are relatively stable over time and do not only occur during an episode of a major mental illness e.g. depressive, manic or psychotic episode.

Definition of care plan

A document that sets out the care, treatment and services that it is proposed for the patient to receive. Includes compulsory and non-compulsory measures.

Alternative definition of pseudohallucination that is less widely used

A hallucination that the patient recognises as being a false perception.

Medical management of vascular dementia to maintain cognitive function

Cholinesterase inhibitors are probably also of benefit, but evidence is less strong than for Alzheimer's.

What is adaptive function

A measure of how patients cope with activities of living e.g. communication, self care, social skills, academic and vocational skills.

High penetrance schizophrenia genes

A particular deletion on chromosome 22 is associated with a 33% risk

Definition of hebephrenic schizophrenia

AKA disorganised schizophrenia. Prominant: thought disorganisation, disturbed behaviour, inappropriate/flat affect. Less prominant: delusions, hallucinations

Definition of catatonic stupor

A presentation of akinesis (lack of voluntary movement), mutism and extreme unresponsiveness in an otherwise alert patient (there may be slight clouding of consciousness).

Definition of mental health officer

A social worker, with the necessary registration, experience, education, training and competence in dealing with individuals with mental disorder.

Medical management of Alzheimer's to maintain cognitive function

Cholinesterase inhibitors if MMSE score >10 (donepezil 1st line). Memantine in those with moderate-severe disease or for those who cannot tolerate cholinesterase inhibitors.

Definition of negativism

A seemingly motiveless resistance to all instructions or attempts to be moved; patients may do the opposite to what is asked.

What are primary care liaison teams

A single point GPs can refer to which then allocates patients to psychiatrists, psychologists, CPNs, occupational therapists etc.

Clinical features of Huntington's disease

Chorea = jerky movements of face and body.

Definition of substance withdrawal

A substance-specific syndrome that occurs on reduction or cessation of a psychoactive substance that has usually been used repeatedly, in high doses, for a prolonged period. It is one of the criteria of the dependence syndrome.

Definition of logoclonia

A type of perseveration in which the last syllable of a sentence is repeated

Definition of palilalia

A type of perseveration in which the last word of a sentence is repeated

What is the main use for trazadone

A weak antidepressent but good sedative so can be used as an adjunct to non-sedative antidepressents

Does having 2 ApoE ɛ4 alleles guarantee the development of late-onset Alzheimer's?

No, therefore environmental factors must also be involved.

Aetiology of late-onset schizophrenia

Less likely to have family history of schizophrenia than early-onset. Sensory deprivation (particularly hearing loss) and social isolation are implicated in its aetiology.

In recurrent depression, are later episodes less or more likely to be triggered by life events?

Less likely.

Definition of circumstantial/overinclusive thinking

Less relevant associations made but goal is eventually reached by a circuitous route

Psychosocial treatment of borderline personality disorder

Can provide patients with an authority figure during times of crisis. Regular contact can provide a sense of containment. Psychoeducation Development of coping strategies Relaxation Distraction techniques Improving disturbed relationships and development of skills and hobbies. Addressing of housing, financial and employment issues.

Penalty for possession of each class

A: 7 years in prison OR unlimited fine OR both B: 5 years in prison OR unlimited fine OR both C: 2 years in prison OR unlimited fine OR both

Penalty for dealing each class

A: life in prison OR unlimited fine OR both B: 14 years in prison OR unlimited fine OR both C: 14 years in prison OR unlimited fine OR both

Investigations to considered in person with lowered consciousness level

ABCDE. GCS.

Extra investigations that may be indicated in delirium, depending on what is indicated by history and examination

ABG. TFTs. Blood/urine cultures. CT head. Lumbar puncture. EEG.

How do calculate number of alcohol units

ABV (in %) x volume (in litres)

List of acquired disorders with onset usually in childhood or adolescence

ADHD Conduct disorder Emotional disorders Elective mutism Tic disorders Non-organic enuresis/encopresis

Definition of infestation

AKA Ekbom's syndrome False belief that you are infested with small but visible organisms. May also occur secondary to tactile hallucincations e.g. formication.

Treatment setting for schizophrenia

Initial treatment: home is preferable but may require hospitalisation if risky. Long term treatment: primary care if well controlled; community mental health team; assertive outreach teams.

Effect of chronic alcohol consumption and alcohol withdrawal on the brain

Chronic alcohol consumption: enhances GABA mediated inhibition in the CNS (similar to benzos) and inhibits NMDA-type glutamate receptors. Opposite occurs during alcohol withdrawal.

Typical prognosis of depression

Chronic and relapsing, with 80% having a further depressive episode and the risk of future episodes increasing with each relapse.

Prongosis of somatisation/hypochondriacal disorder

Chronic episodic course, exacerbated by stress.

Prognosis of OCD

Chronic fluctuating course with worsening during times of stress. 15% show progressive deterioration

Definition of tangential thinking

Less relevant associations made leading to the goal not being reached

Dimensional approach

Hypothesises that the personality traits of patients with personality disorders differ from the normal population only in terms of degree i.e. they are on a continuum with normality. Used for research into personality disorders.

Examples of metabolic and endocrine disturbances that commonly cause delirium

Electrolyte disturbances. Uraemia. Hepatic encephalopathy. Porphyria. Hypoglycaemia. Hyper/hypothyroidism. Hyper/hypoparathyroidism. Hyper/hypoadrenocorticism (Cushing's, Addison's). Hypopituitarism.

Counselling and supportive psychotherapy - are they less or more complex than psychodynamic psychotherapy and sophisticated cognitive therapy?

Less.

Management of delirium tremens and Wernicke's encehalopathy

Emergency hospitalisation Vigorous search for medical complication: infection, head injury, liver failure, GI bleed, Wernicke's encephalopathy Medication (see next flashcards)

Presentation of schizoid personality disorder

Emotional coldness Neither enjoys nor desires close or sexual relationships Prefers solitary activities Takes pleasure in few activities Indifferent to praise or criticism Preoccupation with fantasy

Features of numbness phase of grief

Emotionally disconnected - a form of self-protection against acute pain of loss.

General principles of management of a somatoform disorder

Empathetic acknowledgement and explanation can be therapeutic. Dismissing a patient by telling a patient that their symptoms are "all in your mind" is unhelpful and potentially harmful.

Genetic risk factors for alcohol dependence

Familial link shown from twin studies (could either be personality features or metabolic) 50% of East-Asians have a deficiency in mitochondrial aldehyde dehydrogenase, leading to flushing and palpitations after small amounts of alcohol. This reduces consumption and dependence.

General risk factors for developmental disorders

Family discord Psychiatric disorders/criminal convictions in parents. Social disadvantage. Poor schooling. Chronic physical illness e.g. asthma, epilepsy.

Advantages of AMT

Fast.

Role of forensic psychiatrist in court proceedings

Act as expert witness to the court. They can make recommendations, but the ultimate decision comes from the court.

Do you need more or less specialist training to provide counselling and supportive psychotherapy than psychodynamic psychotherapy and sophisticated cognitive therapy?

Less.

Features of delirium

Fluctuating symptoms. Impaired consciousness. Impaired cognitive function. Perceptual and thought disturbance. Sleep-wake cycle disturbance. Mood disturbance.

Reversal of benzo/Z drug overdose

Flumazenil (an antagonist at the benzodiazepine receptor)

What was the first SSRI to be invented (in 1980s)

Fluoxetine (Prozac)

Which antidepressent does not need to be tapered down

Fluoxetine, due to its long half life

Examples of SSRIs

Fluoxetine, sertraline, paroxetine, citalopram, fluvoxamine.

What types of disorders can those who have experienced stressful or traumatic life events develop?

Adjustment disorder. Acute stress reaction. Post-traumatic stress disorder. Normal bereavement reaction. Dissociative disorder. Depression, anxiety or psychotic disorder. Precipitation of other psychiatric illness (even if the onset of symptoms is clearly linked with a stressor, diagnosis of a specific major should be given if diagnostic criteria are met as major mental illnesses are often triggered by major stressors). Malingering.

Description of cognitive analytic therapy (CAT)

Aims to help patient understand the problematic roles that they repeatedly find themselves and others in, and the (dysfunctional) ways they cope with this. Aim to increase the patient's flexibility in ways of relating, and to find "exits" from dysfunctional patterns. Focus on helping with present circumstances, while understanding from the past how things have arisen.

Secondary prevention of intellectual disabilities

Aims to prevent progression of the disability by providing compensatory education and early attempts to reduce behavioural problems.

Types of standardized tests of cognition

Abbreviated Mental Test (AMT). Mini-Mental State Exam (MMSE). Clock Drawing Test (CLOX1). Addenbrooke's Cognitive Examination - Revised (ACE-R).

Investigation results related to starvation

Abnormal LFTs Raised urea (dehydration) Raised cortisol Raised growth hormone Reduced T3 Reduced FSH, LH, oestrogens and testosterone Hypercholesterolaemia Hypoglycaemia Hypercarotenaemia (yellowing of skin) Normocytic anaemia Leucopenia

General characteristics of parasomnias

Abnormal episodes that occur during sleep or sleep-wake transition.

General characteristics of dyssomnias

Abnormalities in the amount, quality or timing of sleep.

Groups of paraphilias

Abnormalities of the objest of sexual interest (e.g. paedophilia, fetishism, transvestic fetishism, zoophilia, necrophilia). Abnormalities of the sexual act (e.g. exhibitionism, voyeurism, sexual sadism, sexual masochism).

Problems with sensory integration associated with schizophrenia

Abnormalities with stereognosis or proprioception

Cause of narcolepsy

Abnormality of the REM-inhibiting mechanism involving hypocretin deficiency.

% of those with moderate-severe depression that respond to antidepressants

About 50% (compared with 30% on placebo) when prescribed at an adequate dose for a sufficiently long period (usually 4-6 weeks or longer in older adults).

What is paroxysmal anxiety

Abrupt onset. Discrete episodes (usually less than 1 hour). Severe. Can present as a panic attack. Strong autonomic component.

Features of recovery and reorganisation phase of grief

Acceptance of loss. Return of food, social and sexual appetite. Weight regained. Grief diminishes but may return for a time at anniversaries of the deceased.

Two main groups of personality disorders

Acquired Specific

General principles of common law to consider when deciding what to do

Act in accordance with the patient's wishes where possible. Presume capacity in adults >16 unless there is evidence to the contrary. What would a 'reasonable doctor' do Act in the patients assumed 'best interests'. Doctrine of necessity: may give emergency treatment to preserve life without consent. Act in accordance with a recognised body of opinion. (Bolam test) Act in a logically defensible manner (Bolitho case). Consider use of applicable statute law if it is suitable. Consider requests for court judgments in difficult cases.

Onset of serotonin syndrome

Acute after 1 or 2 doses of SSRI or MAOI

Musculoskeletal problems from alcohol use

Acute and chronic myopathy Osteoporosis

Other terms for delirium

Acute confusional state. Acute organic brain syndrome. Organic psychosis. Toxic/metabolic encephalopathy.

Good prognostic features in hypochondriacal disorder

Acute onset, brief duration, mild symptoms, presence of genuine physical comorbidity, absence of comorbid psychiatric disorder

When do elementary hallucinations commonly occur

Acute organic states

What did the Bolitho case do

Added that doctors must act on a logical basis to the Bolam test of 'acting in accordance with a recognised body of opinion'

Following miscarriage and abortion, what psychiatric problems is there an increased risk of?

Adjustment and bereavement reactions. Puerperal psychosis risk remains.

Age of onset of specific personality disorders

Adolescence or early adulthood

Average age of onset of cyclothymia

Adolescence, early adulthood.

Definition of catatonic posturing

Adopting an unusual or bizarre position that is maintained for some time

Key difference between schizoaffective disorder and mood disorder with psychotic features

For schizoaffective disorder, the psychotic features must meet the ICD-10 criteria for schizophrenia.

Management of hazardous drinking

Advice about reducing intake by GPs

Common examples of illicitly used inhalants

Aerosols Glue Lighter fluid Petrol

What is it important to distinguish hyperkinetic disorder from

Age-appropriate behaviours in young active children. Children placed in academic settings inappropriate to their intellectual abilities (e.g. children with intellectual disabilities or highly intelligent children in an under-stimulating environment). Other mental illnesses e.g. pervasive developmental disorders, depression/anxiety (which can cause restlessness, overactivity, impaired concentration, inattention).

Additional behavioural features that can occur in autism

Aggressiveness, impulsivity and self-injurious behaviour.

Definition of catatonic excitement

Agitated, excited, seemingly purposeless motor activity, not influenced by external stimuli

If in doubt between agorophobia and severe social phobia, which one should you go for

Agorophobia

Differentials for anxiety with a clear external trigger

Agorophobia Social phobia Specific phobia

What often co-occurs with panic disorder

Agorophobia ( so ICD10 codes it as agorophobia with or without panic disorder)

Specific side effects for clozapine

Agranulocytosis Hypersalivation

Which additional severe side effects are associated with clozapine

Agranulocytosis in 1% of patients. Neutropenia in 3% of patients.

Difference between sort-term/emergency detention and compulsory treatment order for the MHA criteria

For short-term or emergency detention, it only has to be likely that the criteria apply and the second criterion (regarding treatment) does not need to be considered.

Which recreational drug increases the affects of anxiolytics

Alcohol

Substances that can cause anxiety

Alcohol Amfetamines Caffeine Cannabis Cocaine Hallucinogens Inhalants Phencyclidine

Substance withdrawals that can cause anxiety

Alcohol Benzodiazepines Caffeine Cocaine Nicotine Sedatives/hypnotics Opiates

AUDIT questionnaire

Alcohol Use Disorders Identification Test 10 items screening for problem drinking Takes 3 mins

Link with alcohol and other psychiatric disorders

Alcohol abuse and dependence is associated with anxiety, bipolar, depression, schizophrenia and antisocial and borderline personality disorders. Direction of causation is unclear.

Alcohol-related mood disorder

Alcohol can be a cause and an effect of both low mood and mania (some manic patients take it to either try to self-medicate or due to disinhibition). Compounded by the social problems alcoholism can cause. Can only really distinguish which is secondary following abstinence.

In which causes of delirium is the use of benzodiazepines indicated as they are highly effective?

Alcohol- or substance-related delirium.

Recreational drugs associated with sexual dysfunction

Alcohol. Amphetamines. Cannabis. Cocaine. Opiates.

Substances that can causehypersomnia

Alcohol. Antipsychotics. Benzos. Tricyclic antidepressants. Substance withdrawal syndrome.

Drugs and toxins that can cause dementia

Alcohol. Benzodiazepines. Barbiturates. Solvents.

Recreational drugs that can cause delirium

Alcohol. Opiates. Cannabis. Amphetamines.

GI system problems from alcohol use

Alcoholic liver disease (fatty liver, alcoholic hepatitis or cirrhosis) Acute and chronic pancreatitis Peptic ulceration Gastritis Cancer (oropharynx, larynx, oesophagus, liver)

Biggest cause of W-K syndrome

Alcoholism due to poor diet and direct inhibition of GI absorption and storage of thiamine.

Psychological effects of stimulants

Alertness Hyperactivity Euphoria Irritability Aggression Paranoid ideas Hallucinations (especially cocaine formication) Haptic hallucinations - sensation of touch in the absence of stimuli (with cocaine) Psychosis

Definition of implicit memory AKA procedural memory

All material stored of which the individual is NOT consciously aware e.g. ability to speak a language or ride a bicycle.

ICD-10 diagnostic criteria for somatization disorder (Briquet's syndrome)

All of the following: - >=2 years of symptoms with no physical explanation found - numerous symptoms from almost all symptom groups (not just 1 or 2 isolated symptoms) - persistent refusal by the patient to accept reassurance from several doctors that there is no physical cause for the symptoms - some degree of functional impairment due to the symptoms and resulting behaviour

ICD-10 criteria for anorexia nervosa

All of: BMI 15% below expected i.e. (<17.5 in adults) - either lost of never achieved) Self-induced weight loss e.g. poor caloric intake, vomiting, exercise. Overvalued idea: dread of fatness, self perception of being too fat, low target-weight. Endocrine disturbance: hypothalamic-pituitary-gonadal axis resulting in amenorrhoea/loss of sexual interest/impotence, raised cortisol and growth hormone, low T3. Prepubertal: failure to make expected weight gains, delayed pubertal events.

ICD-10 criteria for bulimia nervosa

All of: Binge eating Strong cravings for food Methods to counteract weight gain e.g. vomiting, laxatives, fasting, exercise etc. Overvalued idea: dread of fatness, self perception of being too fat, low target-weight.

Definition of explicit memory AKA declarative memory

All stored material of which the individual is consciously aware and can thus "declare" to others.

Definition of "cognition"

All the mental activities that allow us to perceive, integrate and conceptualise the world around us.

Pathophysiology of mild cognitive impairment

All the processes that cause dementia can also cause mild cognitive impairment so it is normally investigated in the same way.

Examples of cognitive distortions

All-or-nothing thinking. Mind reading. Personalisation. Over-generalisation. Fortune telling. Emotional reasoning. Labelling. Magnification. Shooting down the positive.

What % of those with somatization disorder (Briquet's syndrome) have another coexisting mental illness?

Almost 50%.

Definition of harmful use

An amount of use which CAUSES adverse consequences, without dependence e.g. 4 Ls: LOVE - difficulties with interpersonal relationships e.g. domestic violence, impotence. LIVELIHOOD - problems meeting work or educational obligations e.g. absenteeism. LIVER - behaviours that have impact on physical health or safety e.g. drinking in spite of liver disease, drink-driving. LAW - legal difficulties e.g. arrest for disorderly conduct, stealing to fund habit.

Definition of hazardous use

An amount of use which places the user AT RISK of adverse consequences, without dependence.

Sex ratio in Rett's syndrome

Almost only ever seen in girls

Common causes of generalised cognitive impairments

Altered level of consciousness = generalised cognitive impairment in all aspects of cognition, as it is difficult to concentrate on any tasks when feeling agitated or drowsy. Dementia.

Is consent from an MHO necessary for a STDO

Always

Most common psychiatric comorbidity in Down's

Alzheimer's

Most common type of dementia in women

Alzheimer's.

Types of "cortical" dementias

Alzheimer's. Frontotemporal dementia (including Pick's disease).

Most common types of dementia in descending order

Alzheimer's. Vascular. Mixed (Alzheimer's and vascular). Dementia with Lewy bodies. Frontotemporal dementia (including Pick's disease) - more common if early-onset. Parkinson's disease with dementia.

Common examples of illicitly used stimulants

Amfetamine Cocaine Crack cocaine MDMA (ecstacy) Mephedrone Most 'legal highs'

Examples of tricyclics

Amitryptiline Iofepramine Clomipramine Imipramine

Class B drugs

Amphetamines (not methamphetamine) Mephedrone (MCAT) Barbiturates Cannabis Methylphenidate (Ritalin) Codeine

Which drug has the slang name "poppers"

Amyl nitrite

The genes that have been isolated that cause autosomally dominant familial early-onset Alzheimer's

Amyloid precursor protein (chromosome 21). Presenilin-1 (chromosome 14). Presenilin-2 (chromosome 1). ...they are all involved in the metabolism of amyloid.

Which cluster has the highest rates of suicide and accidental death

B

What is phobic anxiety disorder

An age-inappropriate object of phobia (e.g. monsters under the bed aged 9) or when anxiety levels are clinically abnormal.

Process for applying for a compulsory treatment order

An application must be made by an MHO to the Mental Health Tribunal for Scotland. It consists of: A report be an approved medical practitioner. A report by the patient's GP or another approved medical practitioner. A report by the MHO. A proposed care plan.

How often must liver and haematological function be monitored in a patient on valproate?

For the first 6 months.

Definition of catatonia

An excessive or decreased motor activity that is apparently purposeless and includes abnormalities of movement, tone or position.

Definition of overvalued ideas

An unreasonable preoccupation with a plausible belief leading to distress for the patient or those around them.

How often does anybody on an antipsychotic need screening for metabolic syndrome?

Annually.

Differentials for patients presenting with low weight

Anorexia nervosa Bulimia nervosa Medical causes of low weight e.g. malignancy, GI disease, DM, hyperthyroidism, chronic infection, chronic inflammation. Important to always consider exclude physical causes! Depression Obsessive-compulsive disorder Psychotic disorder Alcohol or substance abuse Dementia

Disorders that can commonly cause overvalued ideas

Anorexia nervosa Hypochondriacal disorder (can also take the form of a somatic hallucination). Dysmorphophobia Paranoid personality disorder Morbid jealousy (can also take the form of a delusion of infidelity)

Key difference between anorexia nervosa and bulimia nervosa

Anorexics have a decreased weight whereas bulimics have normal or increased weight.

Risk factors for PND

Lack of close confiding relationship. Young maternal age. Previous history of depression (and in these women, obstetric complications during delivery). NOT socioeconomic class or parity.

Tests of long term (recent) memory

Anterograde: delayed recall of an address or objects. Retrograde: questions about recent events e.g. what they had for breakfast. ????????????????????????????????????????????

What is forensic psychiatry?

Area of psychiatry concerned with the assessment and treatment of mentally disordered offenders, as well as the management of individuals who may not yet have committed an offence i.e. those that pose a high risk to the safety of others.

Which antipsychotic is best for avoiding weight gain

Aripiprazole

Management of behavioural and psychological symptoms in dementia

Aromatherapy, massage, animal-assisted therapy, multi-sensory stimulation, therapeutic use of music or dancing (for agitation). Agitation or aggression not responding to non-pharmacological strategies and causing significant distress/risk = consider trazodone (anxiolytic).

How many alcohol related hospital admissions were there in England in 2009/2010 and how does this compare to 2002/2003

Around 1 million (double numbers in 2002/2003)

Definition of treatment resistant schizophrenia

Lack of satisfactory clinical improvement despite sequential use of two antipsychotics for 6-8 weeks (one of which should be a second generation antipsychotics).

Most common types of sexual dysfunction in women in decreasing order

Lack of sexual interest. Unable to achieve orgasm. Trouble lubricating. Dyspareunia.

How to relieve symptoms of opiate withdrawal

Lofexidine (alpha-adrenoceptor agonist that reduces sympathetic outflow) Also antiemetics, antidiarrheals, simple analgesics

1st line antidepressants for acute depression in context of bipolar?

SSRIs. Consider quetiapine if not already on antipsychotic as it also has antidepressant properties.

Another name for tactile agnosia

Astereognosia.

What is the effect of D2 antagonism on the chemoreceptor trigger zone

Anti-emetic effect. Prochlorperazine is particularly effective

Other side effects of antipsychotics

Anticholinergic: dry mouth, constipation, urinary retention, blurred vision. Anti-adrenergic: postural hypotension (dizziness, syncope). Antihistamine: sedation, weight gain. Cardiac effects (uncommon): prolonged QT, arrhythmias, myocarditis, sudden death. Metabolic syndrome. Dermatological: photosensitivity, skin rashes.

Treatment of parkinsonian symptoms and acute dystonia

Anticholinergics e.g. procyclidine (because the effects are due to a relative deficiency of dopamine and excess of acetycholine)

Prescribed drugs that can cause delirium

Anticholinergics. Benzodiazepines. Opiates. Antiparkinsonian drugs. Steroids.

Medical drugs associated with sexual dysfunction

Anticonvulsants. Antihistamines. Antihypertensives. BBs. Digoxin. Diuretics.

Treatment of acute depression in context of bipolar

Antidepressants + antimanic agent (only if moderate-severe depressive episode) Start antidepressants on a low dose and then increase gradually. Then gradually discontinue antidepressant once depression has been in remission for 8 weeks. Avoid long-term antidepressants.

Prescribed drugs that can cause anxiety

Antidepressants e.g. SSRIs/tricyclics in the first 2 weeks of use Corticosteroids Sympathomimetics Thyroid hormones Compound analgaesics containing caffeine Anticholinergics Antipsychotics (akithisia - movement disorder of inner restlessness leading to rocking etc.)

Psychiatric drugs associated with sexual dysfunction

Antidepressants. Antipsychotics (especially 1st gen). Benzos. Lithium.

Drugs to be aware of which can impair driving ability

Antidepressents - sedation. Antipsychotics - sedation and EPSEs. Benzos - the most likley psychotropic compound to impair driving. Also consider epileptogenic potential.

Prescribed drugs that can cause psychosis

Antiparkinsonian drugs Corticosteroids Anticholinergics

Role of GPs in managing somatoform disorders

Arrange to see patients at regular fixed intervals, rather than reacting to the patient's frequent requests to be seen. Increase support during times of stress for the patient. Take symptoms seriously but also encourage patients to talk about emotional problems, rather than just focusing on physical complaints. Limit the use of unnecessary medication, especially those that may be abused e.g. benzos opiates. Treat coexisting mental disorders. Limit investigations to those absolutely necessary. Have a high threshold for referral to specialists. If possible, arrange that patients are only seen by one or two doctors in the practice to help with containment and to limit iatrogenic harm. Help patients to think in terms of coping with their problem, rather than curing it. Involve other family members and carers in the management plan. Consider referral to psychiatrist or psychotherapist.

What to describe alongside antidepressant in depressed patient with psychotic features?

Antipsychotic.

Main pharmacological treatment for schizophrenia

Antipsychotics

Drug to avoid in patients with DLB

Antipsychotics - cause a catastrophic precipitation of potentially irreversible parkinsonism, impaired consciousness, severe autonomic symptoms and a 2-3 increase in mortality in 50% of patients.

Treatment of late-onset schizophrenia

Antipsychotics. Patients are often difficult to engage and poor concordance is associated with poor treatment response.

Personality disorders and crime

Antisocial and borderline personality disorders are frequently diagnosed in forensic settings, often in association with comorbid substance abuse.

Which personality disorder is most commonly associated with violent crime?

Antisocial personality disorder.

What is amygdala hyperactivation associated with

Anxiety disorders (however they probably are more caused by abnormalities in networks of brain regions rather than a single area)

Difference between fear and anxiety

Anxiety is in response to an unknown, vague threat whereas fear is in response to a specific known threat

How does the use of SSRIs compare for anxiety and depression

Anxiety requires higher doses for a longer time to work e.g. 12 weeks at max dose

What is separation anxiety disorder

Anxiety upon separation from parents that is markedly different from other children of their age or persists beyond the usual age period.

Clinical uses of relaxation therapy

Anxiety.

Possible additional symptoms of PND

Anxious preoccupation with the baby's health, often associated with feelings of guilt and inadequacy. Reduced affection for the baby with possible impaired bonding. Obsessional phenomena, typically involving recurrent and intrusive thoughts of harming the baby (important to distinguish whether these are ego-dystonic or ego-syntonic, as the latter can pose a potential risk). Infanticidal thoughts (thoughts of killing the baby) - not experienced as distressing (ego-syntonic), may be seriously considered, and may involve planning.

Definition of intellectual disability

Any affliction which manifests as significant intellectual impairment associated with an impaired ability to adapt to the normal demands of daily living.

Who may grant a short term detention order

Any approved medical practitioner

Who can grant an emergency detention certificate

Any fully registered medical practitioner i.e. FY2 and above.

What is a "psychological stressor"?

Any life event, condition or circumstance that places a strain on the person's current coping skills. What constitutes a "stressor" is subjective and depends on that specific person's ability to adapt or respond to a specific life challenge e.g. exams.

Definition of mental disorder in MHA

Any mental illness, personality disorder or learning disability however caused or manifest.

Medical conditions that can cause anxiety

Any that cause dyspnoea Any that cause increased sympathetic activity e.g. hypoglycaemia, phaeochromocytoma Any that cause pain Organic brain disorders

Description of mind reading (type of cognitive distortion)

Assuming a negative response without relevant evidence (e.g. "Because she didn't reply to my text message, she hates me").

Description of fortune telling (type of cognitive distortion)

Assuming knowledge of the future (e.g. "Not I've been told off by my boss, he is going to be on my back forever).

Examples of negative symptoms that can occur in psychosis

Apathy, avolition (poor motivation), anhedonia Poverty of thought and speech (the latter is known as alogia) Blunting of affect Social isolation Poor self-care Cognitive deficits

Examples of other cognitive symptoms of dementia

Aphasia. Apraxia. Agnosia. Impaired executive functioning.

Multiple personality disorder (dissociative identity disorder)

Apparent existence of >=2 personalities within the same person. Rare. Highly controversial diagnosis.

Definition of mannerisms

Apparently goal directed movements e.g. waving, saluting that are performed repeatedly or at socially inappropriate times

Key features of hallucinations

Appears real to the patient; seems exactly the same as normal perception. Experienced as sensations from any of the sensory modalities. NOT ideas, thoughts, images or fantasies which originate in the patients own mind. Occur without any external stimuli. NOT distortions of external stimuli.

Aetiology of postnatal blues

Appears to be no links with life events, demographic factors or obstetric events, which is suggestive of an underlying biological cause (e.g. a sudden fall in progesterone post-delivery).

Social input for schizophrenia

Assess for a care programme approach to coordinate benefits, occupation, accommadation etc.

What do early intervention teams do

Assess, monitor and manage patients with mild symptoms that do not yet meet the criteria for a formal psychiatric disorder e..g. psychosis prodrome as there is evidence that the longer they go untreated, the worse the outcome.

What should be done ASAP for patients detained under an emergency detention certificate

Assessment by an approved medical practitioner to determine if a short-term detention order should be applied or if the patient should be dealt with informally.

When can it be useful to refer functional symptoms to psychiatry?

Associated with a great deal of anxiety, stress or comorbid psychiatric illness.

Genetics of narcolepsy

Associated with a particular HLA type.

Effect on children if PND not treated

Associated with disturbances in mother-infant relationships, which can lead to problems with the child's cognitive and emotional development.

S/Es of benzos and other hypnotics in pregnancy

Associated with floppy infant syndrome (hypotonia, breathing and feeding difficulties) and neonatal withdrawal syndrome.

S/Es of mood stabilisers in pregnancy

Associated with teratogenicity (foetal malformations).

Intellectual diability and crime

Association between intellectual disabilities and sexual offences (especially indecent exposure) and fire-setting (as opposed to arson, which is deliberate fire-raising for secondary gain).

Categorical approach

Assumes distinct categories of personality disorder. Used in the ISD-10 and DSM-IV for clinical use but seldom conforms to reality as there is often considerable overlap between them and few patients fit clearly into a particular one.

How long to give maintenance treatment in bipolar

At least 2 yrs.

How long is the prophylactic effect of antidepressants in reducing relapse of depression?

At least 5 yrs (with imipramine).

When an antidepressant has brought remission of symptoms, how long should it be continued at full dose (i.e. dose that induced remission) to reduce relapse?

At least 6 months.

Description of eye movement desensitisation and reprocessing (EMDR)

At the same time as giving attention to difficult (usually traumatic) memories, the therapist encourages eye movement. This is thought to utilise both sides of the brain, and aid reprocessing of memories.

2nd line pharmacological treatment of hyperkinetic disorder

Atomoxetine (NRI) - best if poor sleep. Dexamfetamine (CNS stimulant).

Macroscopic findings in Parkinson's

Atrophy of substantia nigra and locus coeruleus.

Blowby's attachment theory

Attachment = establishment of dyadic relationships. Bonding = persistence of these relationships

What does ADHD stand for

Attention deficit/hyperactivity disorder

Description of a "defence mechanism": PROJECTION

Attribution of unconscious feelings to others (e.g. a man who strongly dislikes his neighbour states that his neighbour hates him).

How is clozapine different to other antipsychotics

Atypical' - different receptor binding profile so is effective in many patients in whom other antipsychotics have failed. Fewer EPSEs

Most common modality of hallucination

Auditory

List of pervasive developmental disorders

Autism Asperger's Rett's syndrome Childhood disintegrative disorder

What features are often present in the FHx of Asperger's

Autism, mild motor clumsiness

Age of onset of autism/Asperger's

Autism: <3 Asperger's >5

Type of interaction of autism/Asperger's

Autism: aloof/passive Asperger's: active but odd

Focused interests in autism/Asperger's

Autism: intense Asperger's: intense, usually more sophisticated

Intellectual profile of autism/Asperger's

Autism: low verbal IQ Asperger's: high verbal IQ

Clumsiness in autism/Asperger's

Autism: present Asperger's: present but less severe

Social deficits of autism/Asperger's

Autism: severe Asperger's: mild

Speech in autism/Asperger's

Autism: usually not pedantic Asperger's: overly formal, pedantic, unusual rate of speech, odd prosody.

Other name for primary delusions

Autochthonous delusions

Gerstmann-Straussler syndrome

Autosomal dominant disease caused by mutation in PrP gene on chromosome 20.

Genetics of Huntington's disease

Autosomal dominant with complete penetrance of gene on short arm of chromosome 4 that contains an excessive number of trinucleotide (CAG) repeat sequences (usually >40), resulting in the production of the abnormal protein "huntingtin" leading to neuronal death. The length of the abnormal trinucleotide repeat sequence is inversely correlated with the age of onset of the disease.

How to avoid serotonin syndrome

Avoid concurrent use of MAOIs and other antidepressents. Leave 2 week gap between them (3 weeks for clomipramine and 5 weeks for fluoxetine)

S/Es of mood stabilisers during breast-feeding

Avoid lithium if possible as risk of neonatal lithium toxicity as breast milk contains 40% of maternal lithium concentration. Consider use of valproate or carbamazepine, but bear in mind risk of infant hepatotoxicity.

Correct sleep hygiene

Avoid sleeping during the day. Exercise during the day and maintain a healthy diet. Eliminate the use of stimulants (e.g. caffeine, nicotine, alcohol), especially around bedtime. Condition the brain by only using the bed for sleeping and sex - not for reading, watching TV etc. Go to bed and awaken at the same time every day. Avoid stimulating activities before bedtime (e.g. TV, games) - engage in relaxation techniques or reading instead. Try having a hot bath or drinking a cup of warm milk near bedtime. Avoid large meals near bedtime. Ensure that the bed is comfortable and the bedroom is quiet. Do not lie awake in bed for longer than 15 mins - get up and do another relaxing activity and try sleeping later.

Medication to treat delirium

Avoid unless the patient is causing a risk to themselves or others. Consider haloperidol 0.5mg regularly + PRN (with review at least daily). Check kardex for drugs which may perpetuate delirium.

Features of hyperaroused consciousness level

Awake and agitated/hypervigilant/unable to sleep.

Poor prognosic factors for anorexia

Long duration of illness Late age of onset Very low weight Associated binge-purge symptoms Personality difficulties Difficult family relationships Poor social adjustment

Possible neurological symptoms that can occur in dementia

Seizures. Primitive reflexes (e.g. grasp, snout, suck). Myoclonic jerks.

Features of temporal lobe epilepsy

Seizures. Derealisation. Visual hallucinations. Memory loss. Extreme tiredness.

Investigations to perform for anorexia and bulimia

ECG. FBC. U&Es. LFTs. Serum glucose, lipids and amylase. Thyroid function tests.

What is the most effective treatment known for severe depression

ECT - especially in the elderly

Can patients subject to compulsion in hospital be given medication without their consent

EDC: no - unless permitted by common law. STDO/CTO: yes for <2 months. >2 months requires authorisation by a DMP.

Which occupations is anorexia most common in

Ballet dancers, gymnasts, athletes

Additional tests for patients who have injected drugs

BBV (hepatitis, HIV)

Circumstances in which hospitalisation may be necessary for anorexia

BMI <13.5 Rapid weight loss Electrolyte disturbance Syncope Risk of suicide Social crisis

Basis of "interpersonal therapy"

Based on the assumption that problems with interpersonal relationships and social functioning are significant contributors to the development of mental illness (particularly depression). Tends to focus on current problems.

Principles of cognitive behavioural therapy (CBT)

Based on the assumption that the way in which individuals think about things (i.e. their cognitions) subsequently determines how they feel and behave. Likewise, physical and psychological feelings can influence the way in which individuals think and behave.

How can buprenorphine sometimes cause withdrawal

Because it is only a partial agonist, it can cause withdrawal in patients who are already dependent on a high dose of opiates (equivalent to >30mg methadone daily)

Who is regarded as the "father of cognitive therapy"?

Beck.

Age of onset of somatisation disorder

Before 25, often adolescence

Criminal responsibility

Before a defendant can be convicted, criminal responsibility needs to be determined i.e. it should be determined whether, at the time of the offense, the person was able to control their own behaviour and choose whether to commit the unlawful act or not. Integral to this process is the concept of "mens rea".

Monitoring on valproate

Before treatment: LFTs, FBC. Whilst being treated: periodic LFTs during the first 6 months.

What is "acting out"?

Behaving in a certain way in order to express thoughts or feelings that a person is otherwise incapable of expressing.

Management of paraphilias

Behaviour therapy (covert sensitisation; attempt to pair paraphilic thoughts with humiliating consequences). Aversion therapy (paring paraphilic thoughts with a noxious stimulus e.g. unpleasant odour/taste). Individual psychodynamic and group therapies. CBT and anti-androgens (e.g. cyproterone acetate) have shown some efficacy in the treatment of paedophiles and exhibitionists, but there is little evidence that any treatment is consistently effective in either of these conditions.

Treatment of conduct disorder

Behaviour, cognitive, family and group therapy

General treatment of emotional disorders

Behavioural and family therapy

What is a "somatic delusional disorder"?

Belief that something is physically wrong with them is held with delusional intensity.

Under the AWIA what fundamental principles should those acting on behalf of adults with incapacity use

Benefit: any intervention must benefit the patient and this benefit should not be reasonably achievable without the intervention. Least restrictive option: Any intervention must restrict the freedom of the adult as little as possible. Consider their current and previously expressed wishes. Consult with and take into account the opinions of relevant others. Encourage residual capacity (encourage patients to exercise whatever capacity is still present).

Drugs given in detox to relieve severe symptoms and reduce the risk of seizures or delirium tremens, and also treats seizures

Benzodiazepine e.g. chlordiazepoxide, diazepam or lorazepam (IV rarely needed) Have similar neurochemical effects to alcohol Initially high dose, gradually reduce over 5-7 days

Which drug should be avoided in delirium?

Benzodiazepines, unless the patient is a risk and has not responded to haloperidol as they tend to prolong delirium.

Drugs to try and avoid in dementia

Benzodiazepines.

Main classes of anxiolytics

Benzos, Z drugs

Which drugs increase the seizure threshold, making it more difficult to perform ECT

Benzos.

MRI changes in new-variant CJD

Bilateral high signal in the pulvinar (post-thalamic) region.

Which psychiatric condition is most at risk of worsening during pregnancy?

Bipolar affective disorder.

Types of alcohol related cognitive disorders

Blackouts Wernicke-Korsakoff syndrome Dementia

Description of personalisation (type of cognitive distortion)

Blaming self for an event (e.g. "It's all my fault that the relationship ended").

Description of a "defence mechanism": REPRESSION

Blocking painful memories from consciousness (e.g. an adult child has no memory of being beaten by a beloved parent).

Monitoring of clozapine

Blood tests initially every week, then every month.

Description of magnification (type of cognitive distortion)

Blowing things out of proportion (e.g. "I forgot to buy milk: my husband is going to be so angry with me".

Types of cluster B disorders

Borderline (emotionally unstable) Antisocial (dissocial) Histrionic Narcissistic

Most common personality disorder to be encountered in clinical practice

Borderline (therefore the following treatments shall focus on it)

Which has an association with childhood physical, emotional and sexual abuse

Borderline personality disorder

Difference between Wernicke's encephalopathy and Korsakoff's psychosis

Both caused by thiamine (B1) deficiency. Part of a continuum. Wernicke's occurs during acute brain damage and Korsakoff's is the chronic state that emerges after it.

Safe alcohol limits

Both men and women: <14 units per week. Spread over at least 3 days but also try to have some alcohol-free days each week.

Is non-organic encopresis more common in boys or girls

Boys

Age of onset of conduct disorder

Boys: 10-12 Girls: 14-16

Most common ECG abnormality associated with anorexia

Bradycardia.

S/Es of cholinesterase inhibitors

Bradycardia. Bronchoconstriction. Increased gastric secretions.

Additional tests for patients for withdrawal delirium

Brain imaging to exclude additional complications (infection, head injury, brain abscess)

How does CBT work for panic disorders

Breaks the cycle of assuming that the original stimulus is indicative of something harmful

Tests for alcohol use

Breath alcohol level only detects recent use however if it is high in the absence of signs of intoxication then this suggests tolerance from chronic heavy use. Indicators of long term use: Raised MCV Raised GGT, ALT, AST Prolonged prothrombin time (from liver failure) ECG and U&Es changes

Mood disorders with psychotic features

Manic episode with psychotic features Depressive episode, severe with psychotic features

Which generally has a better prognosis - anorexia or bulimia?

Bulimia

Are anorexic or bulimic patients usually more willing to address their illness

Bulimic

How are serotonin and noradrenaline removed from the synaptic cleft

By reuptake pumps

Age of onset of intellectual disability

Manifest at birth or during very early childhood

Management of delirium general principles

EMERGENCY: admit to hospital. Vigorously investigate and treat any underlying medical condition. Relieve symptoms: environment and medication. Review legal status: delirious patients lack capacity - is they are not accepting treatment or attempting to leave, use of legislation may be required

Onset and prognosis of hebephrenic schizophrenia

Earlier onset and worse prognosis

Age of onset of hypochondriacal disorder

Early adulthood

Treatment if this is not the case

CBT to help patients cope with their symptoms and develop alternative strategies for expressing their emotions.

Main psychological treatments used for eating disorders

CBT. Cognitive analytic therapy. Focused psychodynamic therapy. Interpersonal therapy. Family therapy.

Main psychological treatments used for PTSD

CBT. Eye movement desensitisation and reprocessing.

Main psychological treatments used for schizophrenia

CBT. Family therapy.

Main psychological treatments used for alcohol dependence

CBT. Group therapy. Motivational interviewing.

Main psychological treatments used for anxiety disorders

CBT. Mindfulness-based cognitive therapy. Exposure and response prevention (for OCD). Systematic desensitisation (phobias).

Main psychological treatments used for depression

CBT. Mindfulness-based cognitive therapy. Interpersonal therapy. Psychodynamic therapy. Group therapy.

How is CBT different from psychodynamic psychotherapy?

CBT: - time-limited (12-24 sessions) - goal-orientated - predominantly focuses on present problems (less concerned with details of how problems developed or unconscious factors) - therapeutic relationship is strongly collaborative (deciding together on session's agenda and case formulation) - involves patient doing "homework assignments" - due to structured format, is more amenable to efficacy studies

Use of psychological interventions for schizophrenia

CBT: Effective at reducing symptoms. Improves insight and therefore concordance with medication. Helps patients to identify early warning signs of a relapse. Recommended for all patients. Family psychological intervention: Alliance building, reduction of expressions of hostility and criticism (expressed emotion), setting of appropriate expectations and limits and effecting change in relatives behaviour and belief systems. Reduces the rate of relapse and admission. Recommended for all patients with schizophrenia who live with or are in close contact with their family.

Which compulsory orders can patients appeal to the MHTS about

CTO and STDO but not EDC.

Substances that can cause insomnia

Caffeine and other stimulants. Alcohol. SSRIs. Some antipsychotics. Substance withdrawal syndrome.

How effective is CBT in the treatment of depression?

Can be as effective as antidepressants in treating moderate depressive episodes and when used after medication it can reduce the rate of relapse up to 4 years later.

S/Es of SSRIs in pregnancy

Can be associated with withdrawal symptoms in neonates (generally mild and self-limiting). Associated with persistent pulmonary hypertension and low foetal birth weight

What happens if a patient on a community-based CTO refuses medication

Can be detained in hospital for up to 6hrs to receive the treatment.

What happens if a patient is non-compliant with other aspects of a CTO

Can be detained in hospital for up to 72hrs as authorised by the responsible medical officer. Can be extended by a further 28 days with the approval of the RMO and MHO to allow assessment as to whether an application should be made for the CTO to be varied.

Use of structured group cognitive stimulation programmes in the management of dementia

Can be of benefit in mild-moderate cases.

Process for renewing CTOs

Can be renewed for 6 months and then annually thereafter without further application to the MHTS unless a variation to the order is proposed.

Timecourse of positive and negative symptoms

Can be simultaneous or can be positive followed by negative

Common examples of illicitly used cannabinoids

Cannabis Hashish Hash oil

Most commonly consumed drug

Cannabis (6.8% of population)

Definition of delusion of misidentification

Capgras syndrome: false belief that a familiar person has been replaced by an exact double. Fregoli syndrome: false belief that a complete stranger is actually a familiar person already known to one.

What drug to consider if a combination of the 3 first line maintenance drugs for bipolar is not working?

Carbamazepine.

Clinical features of "cortical" dementias

Early aphasia. Speech normal until late. Apraxia. Agnosia. Early calculation impairment. Usually normal posture/tone. No extra movements (may have myoclonus in Alzheimer's).

Assessment of those with dementia who develop behavioural and psychological symptoms

Check for changes in physical health, including development of pain (those with dementia may find it difficult to communicate discomfort). Consider medication S/Es. Assess for depression. Consider changes to person's environment e.g. are they troubled by noise, extremes of temperature or other patients?

Which area of brain damage is OCD associated with

Caudate nucleus

What are the CAMHS tiers

Child And Adolescent Mental Health Services: tier 1-4 in order of increasing intensive and specialist input.

How do specific personality disorders vary over time

Changes are only very gradual

Sleep-wake cycle disturbance in delirium

Characteristic and can range from daytime drowsiness and night-time hyperactivity to a complete reversal of the normal cycle. Nightmares experienced may continue as hallucinations after waking.

EEG findings in Creutzfeldt-Jakob disease

Characteristic sharp wave complexes.

Slang names for cocaine

Charlie

What is the most important environmental risk factor for bipolar?

Childbirth - 50% risk of mania post-partum in those with untreated bipolar affective disorder.

Association between stressful life events and schizophrenia

More likely to occur in the month before episodes but alternatively, the early stages of the disease could be causing stressful life events.

Average age of onset of dysthymia

Childhood, adolescence, early adulthood.

Age group most affected by sleep terrors

Children (6% of 4-12 year olds).

What is Gillick competence

Children <16 may consent to stuff if they show sufficient understanding and intelligence to understand fully what is proposed.

When to consider day-hospital attendance for someone with depression?

Chronic or recurrent illness, especially if poor motivation or low self-esteem has led to reluctance to go outside the home and make contact with others.

Metabolic and endocrine causes of dementia

Chronic uraemia (also dialysis dementia). Liver failure. Wilson's disease. Hyper/hypothyroidism. Hyper/hypoparathyroidism. Cushing's. Addison's.

Prognosis of developmental disorders

Chronic, steady course

Common features of thought disorders

Circumstantial thinking Tangential thinking Flight of ideas Loosening of association/derailment/knight's move thinking Neologisms Idiosyncratic word use Perseveration Echolalia

Definition of somatoform disorder

Class of disorders whose symptoms are suggestive of, or take the form of, physical illness but there are no detectable structural or neurophysiological abnormalities to explain theses symptoms, leading to the presumption that they are caused by psychological factors.

What about not developmental phobias e.g. agorophobia

Classed as an adult phobia rather than a phobic anxiety disorder

Description of a "defence mechanism": SUPPRESSION

Consciously avoiding thinking about disturbing problems (e.g. a student cleans the kitchen while waiting for exam results).

Acutely psychotic patients can resemble delirium - how to tell them apart?

Consciousness level not affected in schizophrenia.

3rd line pharmacological treatment of hyperkinetic disorder

Consider unlicensed use of bupropion, clonidine, modafinil and imipramine by tertiary care only

Things that make psychological therapy more effective for those with borderline personality disorder

Consistent therapy Maintenance of boundaries Empathic and non-judgemental stance of therapist

Mechanism of action of RIMA

Selective and reversible inhibition of monoamine oxidase A. Blocks degredation of serotonin.

Types of common therapeutic factors

Client factors (personal strengths, social supports). Therapist-client relationship factors (empathy, acceptance, warmth). Client's expectancy of change.

Features of pining phase of grief

Constantly reminded of, and preoccupied with, the deceased. Marked by "pangs of guilt" and intense anxiety. May experience hypnagogic, hypnopompic pseudohallucinations and illusions of the deceased, which are transient and always involve the dead person.

Mechanism of action of NARI

Selective presynaptic blockade of noradrenaline reuptake pumps

Mechanism of action of SSRIs (selective serotonin reuptake inhibitor)

Selective presynaptic blockade of serotonin reuptake pumps

Are the symptoms of a somatoform disorder under voluntary control?

No, they occur unintentionally, and are not being feigned. Therefore, they can be subjectively very real and genuinely distressing.

What is the nigrostriatal pathway involved in

Controls motor movement

What is the chemoreceptor trigger zone involved in

Controls nausea and vomiting

What is the tuberoinfundibular pathway involved in

Controls prolactin secretion - dopamine release inhibits prolactin release

How to do benzodiazepine withdrawal

Convert drugs to long acting versions e.g. change lorazepam to diazepam Then gradually reduce dose by a small amount each week

Examples of instrumental ADLs

Cooking, shopping, housework.

What are Community mental health teams

Coordinate secondary care in the community. MDT consisting of psychiatrists, CPNs, social workers, psychologists etc.

Depressive "pseudodementia"

Clinical features resembling dementia that result from underlying depression. As it is often difficult to distinguish from true dementia, depression treatment is trialled if uncertain of the diagnosis, and cognition rechecked after mood has improved.

People that can practice psychological therapy if trained

Clinical psychologists. Psychiatrists. Occupational therapists. Mental health nurses. Art and drama therapists. Counsellors.

Does a serious mental illness preclude a patient from having the capacity to consent to treatment

No, unless their illness interferes with their understanding of relevant information or their decision making process.

Presentation of HIV-related dementia

Clinically presents as sub-cortical dementia.

Which tricyclic has more more potency for serotonin reuptake than noradrenaline

Clomipramine

Which tricyclic is most effective at preventing serotonin reuptake and is therefore the most effective for anxiety

Clomipramine (others tend to more prevent noradrenaline reuptake)

Which antipsychotic can cause hypersalivation

Clozapine (the others usually cause a dry mouth)

Second generation antipsychotics AKA "atypicals"

Clozapine, olanzapine, quetiapine, risperidone, amisulpride

What are early adverse social circumstances (e.g. parental alcoholism, physical or emotional neglect, violence, sexual abuse) associated with

Cluster B

Other relative contraindication to SSRIs

Co-administration of NSAIDs/anticoagulants (risk of bleeding)

Distinguishing clinical features of frontotemporal dementia

Early decline in social and personal conduct (disinhibition, tactlessness). Early emotional blunting. Attenuated speech output, echolalia. perseveration, mutism. Early loss of insight. Relative sparing of other cognitive functions.

What plant is cocaine made from?

Coca plant

Types of psychological therapy used to manage depression

Cognitive-behavioural therapy (CBT) - most effective. Interpersonal therapy (IPT). Psychodynamic therapy. Family and marital interventions. Mindfulness-based cognitive therapy.

What are the parkinsonian motor symptoms

Cogwheel rigidity Bradykinesia/akinesia (expressionless face, slow movements, difficulty initiating movements) Resting tremor (often less prominent than in idiopathic parkinsonism) Postural instability

Features of an acute stress reaction

Combat fatigue and psychic shock immediately after or within a few minutes of a traumatic stressor. Typically sufferers will experience an initial "dazed" state followed by possible disorientation and a narrowing of attention with inability to process external stimuli. This may then be followed either by a period of diminished responsiveness (to the extreme of a dissociative stupor) or psychomotor agitation and overactivity. May have amnesia for the episode.

Memory impairment in dementia

Common feature. Recent memory affected first. As disease progresses, all aspects of memory affected, although highly personal information (name, previous occupation etc.) usually retained until late stages. As memory is also essential to orientation to person, place and time so orientation will become affected in late stages.

Is delirium tremens common

Common for inpatients

What is common law compared to statute law

Common law can be derived from: Long established custom and practice. Clarification of the meaning and extent of statute by the courts. Statements of law by judges ruling on cases where no applicable law exists or fits precisely.

Poor prognostic factors for depression in older adults

Comorbid physical illness. Late detection of illness. Poor concordance with antidepressants.

Epidemiological features of dependent personality disorder

Comorbid with borderline personality disorder

Ganser's syndrome

Complex disorder characterised by "approximate answers" (AKA "near-miss answers" e.g. when asked what colour the grass is, an approximate answer would be blue. Often associated with florid hallucinations and conversion symptoms.

Features of sleepwalking

Complex motor behaviour during sleep. Blank staring face. Relatively unresponsive to communication from others. Difficult to awaken. When they do wake up, either during the episode of the following morning, they have no recollection of the event. Not associated with impairment of cognition or behaviour, but there may be a initial brief period of disorientation subsequent to waking up from a sleepwalking episode.

Definition of Charles Bonnet syndrome

Complex visual hallucinations associated with no other psychiatric symptoms or impairment in consciousness.

Developmental risk factors for schizophrenia

Complications during pregnancy (e.g. starvation) and birth. Perhaps, late-winter/spring births as the mother was more likely to have flu in the second trimester.

What is pyromania?

Compulsion to set fires, followed by a "release of tension".

Description of a "defence mechanism": INTELLECTUALISATION

Concentrating on intellectual aspects to avoid emotional aspects in difficult situations (e.g. a woman diagnosed with terminal cancer develops an intense interest in the classification process of tumour staging).

Principles of behaviour therapy

Concerned with changing maladaptive behaviour patterns that have arisen through learning (classical or operant conditioning). Thought that if a patient changes their behaviour to make it more adaptive, this will have positive effects on how they think about things.

What to do if a patient is admitted to hospital and is currently on a methadone/benzodiazepine substitution programme

Confirm the dose with the original prescriber to make sure they are telling the truth

Terms to avoid when referring to consciousness

Confused, obtunded, clouding of consciousness, stupor - not well defined terms and mean different things to different specialities.

Description of emotional reasoning (type of cognitive distortion)

Confusing feelings with facts (e.g. "I feel anxious: air travel must be dangerous").

Classification of Alzheimer's

Early-onset: onset <65yo, usually familial with relatives also affected <65yo. Late onset/sporadic: onset >65yo, either no family history or relatives affected >65yo.

Epidemiological features of borderline personality disorder

More prevalent in younger age groups and females Aetiological link with childhood sexual abuse Most contact with services in mid-20s 9% suicide rate Associated with poor work history and single marital status Often comorbid with depression, substance abuse, bulimia and anxiety

What time of day should SSRIs be taken at

Morning as they are alerting.

Schizophrenia and crime

Most offences are minor and are manifestations of impaired social skills. Command hallucinations are associated with an increase in violence. More people with schizophrenia are victims of crime than perpetrators.

Prognosis of puerperal psychosis

Most recover by 3 months (75% within 6 weeks).

PND prognosis

Most women respond to standard treatment, but some have a protracted illness requiring long-term treatment and follow-up.

Prognosis of non-organic enuresis

Mostly resolves by adolescence

Creutzfeldt-Jakob disease causes

Mostly sporadic, in those over 50yo. Can be transmitted iatrogenically (e.g. via infected corneal transplants and surgical instruments).

What can be helpful for engaging patients and overcoming treatment resistance in anorexia nervosa

Motivational interviewing Application of transtheoretical model of change

Psychosocial interventions to maintain abstinence

Motivational interviewing CBT Group therapy Alcoholic anonymous (based around a 12 step programme of spiritual and character development) Social support

Psychological therapies for opiate withdrawal

Motivational interviewing CBT (including relapse prevention) Group therapy

Nature of compulsions in Gilles de la Tourette's syndrome

Motor and vocal tics. Echolalia. Coprolalia.

What condition does the pathophysiology of frontotemporal dementia overlap with?

Motor neurone disease.

Age of onset of Tourette's

Motor tics usually present <7yo but can start as young as 2yo

How do the side effects of SSRIs compare to TCAs

Much better

Is there also a risk of hypertensive crisis with RIMAs

Much less because they only reversible inhibit monoamine oxidase A

Are SSRIs cardiotoxic

Much less than other antidepressents. Therefore more suitable for patients with cardiac disease or who are at risk of overdosing.

Sex ratio for Asperger's

Much more common in boys

Epidemiological features of antisocial personality disorder

Much more common in men Highest prevalence in 25-44 year olds Associated with school drop-out, conduct disorder and urban settings Very high prevalence in prisons and forensic settings Highly comorbid with substance abuse

Characteristic pathological changes in Alzheimer's

Cortical beta-amyloid plaques between neurones (extracellular). Intracellular neurofibrillary tangles of hyperphosphorylated tau and ubiquitin inside neurones. Degeneration of cholinergic neurones in the nucleus basalis of Meynert leading to a deficiency of acetylcholine (which can be partially reversed by some anti-dementia medication - cholinesterase inhibitors).

Clinical classification of dementias that can help with diagnosis

Cortical, subcortical or mixed (features of both cortical and subcortical).

What would happen if you didn't treat somebody non-consensually under common law when you should have done

Could be classed as negligence.

Main psychological treatments used for stressful life events, illnesses and bereavements

Counselling.

How to assess whether the accused has "fitness to plead"

Court uses psychiatric and/or psychological evidence to assess whether the accused can (Pritchard criteria): - understand the difference between a plea of guilty and not guilty - understand the nature of the charge - instruct counsel (legal representation) - follow the evidence brought before the court - challenge a juror

What is the meaning of 'autistic spectrum disorder'

Covers all pervasive developmental disorders, including those that do not meet diagnostic criteria

Advantages of MMSE

Covers most cognitive domains.

Infections that can cause dementia

Creutzfeldt-Jakob disease. HIV. Neurosyphilis. Viral encephalitis. Chronic bacterial and fungal meningitides.

Management of puerperal psychosis

Crucial to assess suicide and infanticide risk. Hospitalisation invariably necessary, with joint admission to a mother-and-baby unit preferable, perhaps as detention under mental health legislation. Depending on presentation, may need to use antipsychotics, antidepressants and mood-stabilisers. May need to use benzodiazepines if severe behavioural disturbance. ECT can be particularly effective in severe or treatment-resistant cases. Psychosocial interventions similar to those for other psychotic episodes, but also include providing support for the father.

Social risk factors for alcohol dependence

Cultures and countries that drink a lot of alcohol (although also affected by their style of drinking) Low alcohol prices Significant life events Jobs at increased risk of death from alcoholic liver disease: leisure, catering, doctors, journalists and those involved in shipping and travel Higher risk of alcohol dependence: unskilled workers, unemployed (may in part be due to the "social drift" caused by alcohol dependence)

Dissociative anaesthesia and sensory loss

Cutaneous or visual sensory loss that does not correspond to anatomic dermatomes or known neurological patterns.

Teratogenicity of sodium valproate and its use in pregnancy

Much more teratogenic than lithium, and strongly associated with neural tube defects. Do not use in pregnancy. Preferable not to prescribe to women of childbearing age but if considered necessary, risk counselling and reliable contraception are necessary.

What other receptors can all antipsychotics antagonise

Muscarinic, histamine and alpha-adrenergic (same as TCAs)

Clinical manifestations of refeeding syndrome

Muscle weakness Seizures Peripheral oedema Cardiac dysrhythmias Hypotension Delirium

Features of obstructive sleep apnoea syndrome

Noisy breathing during sleep with loud snoring interspersed with apnoeic episodes lasting 20-90 seconds (sometimes associated with cyanosis).

Physical effects of stimulants

Mydriasis Tremor Hypertension Tachycardia Arrhythmias Hyperthermia and perspiration Fever (especially ecstasy) Convulsions Perforated nasal septum (cocaine)

What can a power of attorney do

Either financial matters, welfare matters (e.g. care, accommodation) or both

Medical conditions that can cause sexual dysfunction

DM. Vascular disease. Vaginitis. Endometriosis. Spinal cord injuries. Pelvic fractures. Prostatectomy. MS. Thyroid disease. Hyperprolactinemia.

Prognosis of schizotypal personality disorder

Either stable over time or can progress to schizophrenia

Name of somatoform autonomic dysfunction disorder of the cardiovascular system?

Da Costa's syndrome.

30% of Parkinson's patients have what other neurological changes?

Damage to other brain regions leading to dementia with predominantly subcortical features: - motor symptoms before cognitive symptoms - dementia very similar to DLB

Distinguishing clinical features in DLB

Day-to-day (or shorter) fluctuations in cognitive performance. Recurrent visual hallucinations. Motor signs of parkinsonism (rigidity, bradykinesia AKA slowness of movement, tremor) that are not drug-induced. Recurrent falls and syncope. Transient disturbances of consciousness.

Consequences of insomnia

Daytime tiredness. If persistent, can significantly effect mood, behaviour and performance. Can lead to an impairment of health-related QoL similar to heart failure or depression.

Cognitive abnormalities that are associated with schizophrenia

Decreased social cognition and memory

Overall description of stages 3 and 4 of sleep

Deep sleep.

What do adoption studies show about schizophrenia

Demonstrate genetic component. Adopted children of schizophrenics still have an increased risk. Children adopted by schizophrenics do not.

Which types of delirium and dementia can cause visual hallucinations and delusions

Delerium Lewy body dementia

Cause of acute, acute-on-chronic or fluctuating cognitive impairment

Delirium.

Differential diagnoses of cognitive impairment

Delirium. Dementia. Mild cognitive impairment. Subjective cognitive impairment. Stable cognitive impairment post-insult. Depression ("pseudodementia"). Psychotic disorders. Mood disorders. Intellectual disability. Dissociative disorders. Factitious disorder and malingering. Amnesic syndrome.

What is it important to distinguish pseudocyesis and couvade syndrome from?

Delusion of pregnancy, as they are both psychosomatic conditions. However, pseudocyesis and delusion of pregnancy can occur together.

Possible psychiatric cause of secondary anxiety concerning fear of being poisoned or killed

Delusional beliefs in paranoid schizophrenia

Main types of abnormal belief

Delusions Overvalued idea

Link between weight loss and schizophrenia

Delusions may command them not to eat Negative symptoms can prevent eating

Most common delusion associated with stalking

Delusions of love (abnormal belief that the subject of the stalking is in love with the perpetrator).

Which type of delusions would point towards schizophrenia rather than a delusional disorder

Delusions of thought control or passivity.

What is the mesolimbic pathway involved in

Delusions/hallucinations/thought disorder, euphoria and drug dependence.

Other psychiatric conditions that can cause weight loss

Dementia Alcohol or substance abuse

In which patients with delirium should haloperidol not be used?

Dementia with Lewy bodies. Parkinson's.

Most common psychiatric conditions in older adults

Dementia, delirium.

Most common causes of chronic cognitive impairment in multiple cognitive domains

Dementia, mild cognitive impairment or depression.

Types of cluster C disorders

Dependent Avoidant (anxious) Obsessive-compulsive (anankastic)

What is non-organic encopresis

Deposition of normal faeces (i.e. not diarrhoea) in inappropriate places in children who should have established bowel control i.e. >4yo

Methods of increasing concordance with antipsychotics

Depot intramuscular medication administered every few weeks. Increased social support. Patient education.

Features of depression and despair phase of grief

Depressed and irritable mood. Thoughts of being "better off dead" or that they should have died with the deceased. Anhedonia. Loss of appetite and weight. Insomnia. Impaired concentration and short-term memory. Although most people will meet the criteria for a depressive episode at some stage during the grieving process, bereavement reactions are not pathological and so no psychiatric diagnosis should be made in these cases.

Link between weight loss and depression

Depressed patients can lose weight but, unlike in anorexia nervosa who are often interested in low-calorie cooking and maintain their appetite until late in the disease, it is associated with loss of appetite and interest in food. Patients with anorexia nervosa can get depressed as a biological consequence of starvation and this resolves with weight gain, or can simply have comorbid depression.

Subclassification of schizoaffective disorder

Depressed type Manic type

Possible psychiatric cause of secondary anxiety concerning ruminatory thoughts of guilt or worthlessness

Depression

What does borderline personality disorder have a familial relationship with

Depression

What can mirtazapine be used for

Depression (particularly when sedation or increased oral intake is desirable)

What can MAOIs be used for

Depression (typically atypical if hypersomnia, overeating and anxiety), anxiety, eating disorders, chronic pain + others

Examples of mood symptoms common in dementia

Depression and anxiety in about half of patients.

OCD is often comorbid with what other psychiatric conditions?

Depression and schizophrenia (but less so).

What is seasonal affective disorder (SAD)?

Depression which occurs predominantly around the winter months.

What can SSRIs be used for

Depression, anxiety, OCD, bulimia nervosa

What can tricyclics be used for

Depression, anxiety, OCD, chronic pain, nocturnal enuresis, narcolepsy

Clinical uses of activity scheduling and target setting therapy

Depression.

Psychiatric conditions that can cause sexual dysfunction

Depression. Anxiety. Alcohol dependence.

Depersonalisation and derealisation may be caused by what physical psychiatric conditions?

Depression. Anxiety. Schizophrenia. Psychosocial stress. Substance abuse. Epilepsy.

What to assess for if a bereavement reaction is abnormal?

Depression. But if the criteria for a depressive episode are not met, diagnose an adjustment disorder.

Common mood disturbances in delirium

Depression. Euphoria. Anxiety/suspicion. Anger. Fear. Apathy.

Differential diagnoses of mainly obsessions

Depressive disorder. Other anxiety disorder (phobias, generalised anxiety disorder). Hypochondriacal disorder. Schizophrenia.

What conditions can dysthymia coexist with?

Depressive episodes ("double depression"). Anxiety disorders. BPD.

Specific exercise that may help vaginismus

Desensitisation, first by finger insertion followed by dilators of increasing size.

Common name for treatment of alcohol withdrawal

Detoxification (only refers to the treatment of withdrawal symptoms though, does not address the biological, psychological and social factors that may have precipitated its development and does not address alcohol dependence)

Expressive dysphasia

Difficulty using words with correct meaning.

Crisis management for borderline personality disorder

Develop a plan with the patient detailing self-management strategies, sources of support (family, friends, telephone based services) and details of how to access emergency care. Share these details with the patient and relevant professionals (GPs, assessment an crisis teams). Consider planning short term drug treatments in advance if there are not more appropriate interventions. Should have acceptable SEs and low dependence profile. Only dispense in small quantities if risk of overdose. Crisis resolution or home treatment teams should be considered before in-patient admission. If admission is required (due to risk to self or others) then try to involve the patient in the decision. Agree the length and purpose of the admission in advance if possible. If the patient is detained under mental health legislation, ensure that it is regularly reviewed and that management on a voluntary basis is resumed at the earliest opportunity. After a crisis has resolved, ensure that the care plan is updated. If drug treatment was started, review this and discontinue if possible.

Description of mentalisation-based therapy (MBT)

Developed from psychodynamic therapy. Focuses on allowing patient to better understand what is going on in both their own minds and in the minds of others. Can utilise both individual and group components. Thought to improve emotional regulation and interpersonal relationships.

What is delirium a risk factor for?

Developing or worsening of dementia.

Late-onset schizophrenia (late paraphrenia)

Development of psychotic symptoms late in life, usually over the age of 60.

Causes of non-organic encopresis

Developmental delay Coercive or punitive potty training Emotional, physical or sexual abuse Disturbed relationships Parental marital conflict Symptom of other psychiatric disorders e.g. autism

Common causes of specific cognitive impairments

Developmental problem. Cerebrovascular accident.

Additional symptoms of alcohol withdrawal syndrome with delirium tremens

Develops 1-7 days after stopping (mean = 2) Altered consciousness and marked cognitive impairment Vivid hallucinations and illusions in any sensory modality - patients often interact or are horrified by them e.g. Lilliputian visual hallucinations (miniature humans/animals), formication (sensation of insects crawling on skin) Marked tremor Autonomic arousal (heavy sweating, raised pulse and BP, fever) Paranoid delusions (often associated with intense fear) Mortality = 5-15% from cardiovascular collapse, hypo/hyperthermia, infection Predisposing factors: physical illness (hepatitis, pancreatitis, pneumonia)

Additional symptoms of alcohol withdrawal syndrome with seizures

Develops 6-48 hours after stopping Occurs in 5-15% of all alcohol-dependent drinkers Generalised and tonic-clonic Predisposing factors: previous history, concurrent epilepsy, low potassium or magnesium

Features of acquired personality disorder

Develops following a recognisable insult. Either organic personality disorder (when it is a form of brain disease or stroke); following a catastrophic event (e.g. hostage situation) or following the development of another psychiatric disorder.

Test to confirm Cushing's disease

Dexamethasone suppression test.

Macroscopic findings in HIV-related dementia

Diffuse multifocal destruction of white matter and subcortical structures.

Two main methods of classifying personality disorders

Dimensional and categorical approach

Therapies derived from CBT and psychodynamic therapy

Dialectical behaviour therapy (DBT). Eye movement desensitisation and reprocessing (EMDR). Mentalisation-based therapy (MBT). Cognitive analytic therapy (CAT). Mindfulness-based cognitive therapy (MCBT).

Types of psychological therapy that can be used for borderline personality disorder

Dialectical behaviour therapy (most effective) Mentalisation-based therapy Cognitive behavioural therapy Cognitive analytical therapy Psychodynamic psychotherapy Therapeutic communities

Main psychological treatments used for borderline personality disorder

Dialectical behaviour therapy. Mentalisation-based therapy. Psychodynamic therapy. CBT. Cognitive analytic therapy. Therapeutic communities.

What can cause people to become lithium toxic on a dose they have previously been fine on?

Diarrhoea, as it causes an increase in serum lithium concentration

Potential negative consequences of specific developmental disorders

Difficulties (e.g. school problems, teasing) might lead to secondary emotional or behavioural problems

What can disordered attachment between infants and their caregivers lead to

Difficulties in relationships throughout life which can manifest as personality disorders

Definition of functional impairment

Difficulties with basic (self-care tasks) or instrumental (tasks not crucial to life but which allow someone to live independently) activities of daily living (ADL).

Receptive dysphasia

Difficulty understanding commands and other words.

Options for when a STDO ends

Discharge, remain as an informal patient, CTO

What happens if you rapidly withdraw and antidepressent

Discontinuation syndrome: GI disturbance, agitation, dizziness, headache, tremor and insomnia.

Treatment of acute mania or hypomania

Discontinue antidepressants (may need to be done gradually if halflife short to avoid discontinuation symptoms). Benzodiazepines short-term: helpful for reducing severe behavioural disturbance. Antipsychotic (olanzapine, quetiapine or risperidone): help reduce behavioural disturbance, stabilise mood and reduce any psychotic features. Lithium or valproate: - is have been of benefit previously, they can be restarted, although can take longer to have effect - not advisable to start lithium in a manic patient who is unlikely to be concordant with long-term treatment because lithium can be harmful if taken for <2 years (discontinuation of lithium can precipitate mania) - if patient already taking antimanic agent, the dose can be increased or augmentation with a further antimanic agent considered

Management of patient with mental disorder who is at risk of committing a violent crime

Discuss with colleagues, especially social workers and forensic mental health specialists. Compulsory hospitalisation may be required. Clinicians have a duty to breach confidentiality (in consultation with the police) to warn potential victims of serious threats that have been made, as per the Tarasoff ruling.

Psychological effects of inhalants

Disinhibition Stimulation Euphoria Clouded consciousness Hallucinations Psychosis

Terms used to describe types of loss of executive function (an umbrella term for many cognitive functions)

Disinhibition. Perseveration. Apathy. Dysexecutive function.

Features of schizophrenia that are almost never found in late-onset schizophrenia

Disorganised thinking. Inappropriate affect. Catatonic features.

Unusual arousal characteristics of stage 3 and 4 sleep

Disorientation. Sleep terrors. Sleepwalking.

The easiest first thing to do for an elderly struggling to remember to take their medication every day

Dispense weekly in a labelled dosette box.

What is "dissociation"?

Disruption in the usually integrated functions of consciousness and cognition. Memories of the past, awareness of identity, thoughts, emotions, movement, sensation and/or control of behaviours become separated from the rest of an individual's personality such that they function independently and are not open to voluntary control.

Types of dissociative disorders

Dissociative amnesia. Dissociative fugue. Dissociative stupor. Dissociative anaesthesia and sensory loss. Dissociative motor disorders. Dissociative convulsions (psychogenic non-epileptic seizures). Ganser's syndrome. Multiple personality disorder (dissociative identity disorder).

What is the link between dissociative convulsions and epilepsy?

Dissociative convulsions are more common in those with a personal or family history of epilepsy

Description of specific developmental disorder

Disturbed acquisition of a SPECIFIC cognitive or motor function but with normal functioning other areas and normal general intelligence

Pharmacological treatment post detox to maintain abstinence

Disulfiram (Antabuse): blocks aldehyde dehydrogenase causing an accumulation of aldehydes if alcohol is consumed. Causes anxiety, flushing, palpitations, headache and nausea very soon after alcohol consumption, therefore acting as a deterrent to drinking. Only available as tablet. Metabolised in liver. Acamprosate (Campral): enhances GABA and reduces the likelihood of relapse by reducing craving. Naltrexone (Nalorex): oral opioid antagonist to reduce both cravings for alcohol, and the pleasant effects of alcohol therefore decreasing the desire to drink ("Sinclair" method).

Risk factors for delirium

Elderly. Infants and children. Abnormal brain (e.g. dementia, previous head injury). Age. Polypharmacy. Sensory impairment.

Features of functional symptoms

Do not correspond to, or are clearly not typical of, any known physical condition. Associated with an absence of any physical signs, structural abnormalities, abnormalities in lab results/imaging/invasive investigations.

Management of psychotic symptoms in dementia

Do not require treatment if they are not distressing to the patient or causing risk to others. Consider a trial of an antipsychotic if significant distress - discontinue if no benefit within 12 weeks.

Problems with actuarial methods of assessing risk of violent crime

Do not take into account the specific factors of the case and therefore, when used in isolation, can be misleading.

Definition of approved medical practitioner

Doctors with the necessary qualifications and experience and training and approval to have special experience in diagnosis and treatment of mental disorders.

Transsexualism (AKA gender dysphoria)

Does not want to live as gender assigned at birth.

Key difference between overvalued ideas and obsessions

Don't recurrently intrude into thought

Names of cholinesterase inhibitors

Donepezil. Rivastigmine. Galantamine.

Apart from clozapine, what is the mechanism of action of all antipsychotics

Dopamine D2 antagonism

Patients with what condition tend to develop neuropathological changes similar to Alzheimer's by middle age and may develop dementia?

Down's syndrome - this has been attributed to triplication and over-expression of the gene for amyloid precursor protein (APP).

Biochemical change with chronic alcohol use that increase the chance of seizures when it is withdrawn

Down-regulate GABA Up-regulate glutamate (NMDA)

Presentation of histrionic personality disorder

Dramatic Exaggerated expressions of emotion Attention seeking e.g. over-concern with physical attractiveness Seductive behaviour Labile shallow emotions

Description of over-generalisation (type of cognitive distortion)

Drawing negative conclusions on the basis of 1 event (e.g. "Because I spelt a word wrong in my essay, I'll get a lower grade").

Process of CBT

Draws on the principle that automatic thoughts and dysfunctional assumptions may be challenged and changed by "behavioural experiments" i.e. testing dysfunctional thoughts against reality.

Psychological effects of sedatives

Drowsiness Disinhibition Confusion Poor concentration Reduced anxiety Feeling of well-being

Adverse effects of TCAs

Drowsiness. Anticholinergic: dry mouth, constipation, urinary retention, blurred vision. Alpha adrenergic antagonism: postural hypotension. Histaminergic antagonism: weight gain, sedation. Cardiotoxic effects: QT prolongation, ST elevation, heart block, arrhythmias.

How to limit the growth suppression caused by methylphenidate

Drug holidays' to allow them to make up growth gains.

Effect of reduced GFR on drug metabolism in elderly patients

Drugs excreted by filtration (e.g. lithium) need LOWER doses. Drug concentration may rise rapidly with dehydration, heart failure etc.

What is onychorrhexis?

Dry nails, often associated with anorexia

Which antidepressent is best for patients who also have stress incontinence

Duloxetine - licensed for both! (joint serotonin and NA reuptake inhibitor)

Ways to categorise memory

Duration of storage (working or long term). Type of information stored (explicit or implicit).

Categories of primary sleep disorders

Dyssomnias. Parasomnias.

Urinary features of somatization disorder (Briquet's syndrome)

Dysuria. Frequency. Urinary retention. Incontinence.

Possible psychiatric cause of secondary anxiety concerning gaining weight

Eating disorder

Examples of basic ADLs

Eating, dressing, washing, toileting, continence, and mobility (being able to make crucial movements like being able to move from bed to chair to toilet).

Presentation of schizotypal personality disorder

Eccentric behaviour Odd beliefs or magical thinking Unusual perceptual experiences (e.g. sensing another's presence) Ideas of reference Suspicious or paranoid ideas Vague or circumstantial thinking Social withdrawal But absence of true delusions or hallucinations

Features of schizotypal personality disorder

Eccentric behaviour and peculiarities of thinking and appearance. But often lack clear psychotic symptoms.

Class A drugs

Ecstasy LSD Heroin Methadone Cocaine Psilocybin (magic mushrooms) Crystal meth Any Class B drug prepared for injection

Demographic most at risk from suicide

Educated young men with some level of insight into their illness. Those recently discharged from hospital.

Types of psychotherapy for anorexia

Education about nutrition and weight Nutritional management and weight restoration: negotiate target weight and make eating plan CBT: 20-24 sessions; can explore control, self-esteem, perfectionism Interpersonal therapy: focus on improving social functioning and interpersonal skills Family therapy: good for adolescents still living with their parents Psychodynamic approach: reserved for specialists

Treatment for patients who simply diet excessively

Education about nutrition and weight monitoring by GP or nurse Self-help groups/volunteer organisations

Evidence for involvement of the above neurotransmitors

Effective treatment with benzos, SSRIs and tricyclics. Genetic link

Categories of auditory hallucination

Elementary. Complex: first, second or third person.

What causes hypnagogic/hypopompuic hallucinations and paralysis in narcolepsy?

Elements of REM sleep intruding into transition between sleep and wakefullness.

Typical blood results for neuroleptic malignant syndrome and serotonin syndrome

Elevated CK, WCC and hepatic transaminases, metabolic acidosis

Medical complications related to starvation

Emaciation Amenorrhoea, infertility, reproductive system atrophy Cardiomyopathy Constipation, abdominal pain Cold intolerance, lethargy Bradycardia, hypotension, cardiac arrhythmia, heart failure Lanugo hair (soft downy hair on trunk) Acrocyanosis (bluish or purplish colouring of hands and feet due to slow circulation) Loss of head hair Peripheral oedema Proximal myopathy, muscle wasting Osteoporosis, fractures Seizures, impaired concentration, depression

Who used the term 'dementia precox' to describe a schizophrenia like state in 1893

Emeli Kraepelin

Different types of compulsory measures available under the MHA

Emergency detention (part 5). Nurses' holding powers. Short-term detention (part 6). Compulsory treatment order (part 7).

Aims of "interpersonal therapy"

Enable patients to evaluate their social interactions and improve their interpersonal skills in all social roles, from close family and friendships to community and work-related roles.

Medical conditions that can cause hypersomnia

Encephalitis and meningitis. Stroke, head injury, space-occupying lesion. Degenerative neurological conditions. Toxic, metabolite or endocrine abnormalities. Kleine-Levin syndrome.

Assessment of insomnia

Exclude medical, psychiatric or substance-related cause. Ask what the normal amount of sleep is for the patient for them to feel refreshed in the morning and what time they normally wake up. As many cases of primary insomnia are related to poor sleep hygiene, you must enquire about sleeping times and patterns, and caffeine consumption. Useful to obtain collateral history from patient's sleeping partner regarding sleep patterns, snoring and movements during the night. In treatment-resistant cases, they may need referral to a sleep specialist (who might perform polysomnography).

Role of pscyhiatrist in diagnosing gender dysphoria

Exclude presence of mental disorder as the cause. Assess and treat any comorbid mental disorders.

Main aim of carrying out investigations of cognitive impairment

Exclude reversible causes.

Nature of obsessions and compulsions in obsessive-compulsive (anakastic) personality disorder

Enduring behaviour pattern of rigidity, doubt, perfectionism and pedantry. Ego-syntonic. No true obsessions or compulsions.

Definition of personality traits

Enduring patterns of perceiving, thinking about, and relating to both self and the environment, exhibited in a wide range of social and personal contexts

Potential S/Es of CNS stimulants

Enhanced alertness, awareness, wakefulness, endurance, productivity, and motivation. Increased arousal, locomotion, heart rate, and BP. Perception of a diminished requirement for food and sleep. Abdominal pain, nausea, dyspepsia.

Management of non-organic enuresis

Exclusion of primary cause Parental education about toilet training Behavioural training e.g. star chart, bladder retraining Last resort = imipramine/nasal desmopressin

Specific exercises that may help female orgasmic disorder

Exercises in sexual fantasy and masturbation, sometimes with a vibrator or dildo.

Common cause of olfactory and gustatory hallucinations

Epilepsy (especially temporal lobe) and other organic diseases.

Common comorbidity with autism

Epilepsy in 25-30% of cases

Features of "postnatal (AKA baby/maternity) blues"?

Episodes of tearfullness, mild depression or emotional liability, anxiety and irritability.

What are "sleep terrors" AKA "night terrors"?

Episodes that feature an individual abruptly waking from sleep, usually with a scream, appearing to be in a state of extreme fear. Often also autonomically aroused: tachycardia, dilated pupils, sweating, rapid breathing. Relative unresponsiveness to efforts of others to comfort them. May appear confused or disorientated. Upon full awakening, there is amnesia for the episode and no recall of any dream or nightmare.

What can be used to measure the level of daytime sleepiness

Epworth sleepiness scale

Sex distribution of personality disorders overall

Equal

Sex ratio of hypochondriacal disorder

Equal

Sex ratio for non-organic enuresis

Equal for young patients but cases that persist tend to be in males

Epidemiological features of avoidant personality disorder

Equal gender ratio Comorbid with social phobia

F:M ratio of bipolar affective disorder

Equal.

F:M ratio of cyclothymia

Equal.

What is "parapraxis"?

Error of memory, speech, writing, reading or action that may be due to interference of repressed thoughts and unconscious features of the individual's personality. Often referred to as "slip of the tongue" or a "Freudian slip".

Features of Freud's "superego" AKA "the ideal"

Ethical and moral part of personality that sets rigid standards for behaviour. Usually internalised from the parents moral code and gives rise to feelings of guilt. Often referred to by the layman as "the conscience".

Definition of tactile (haptic) hallucination

Experience of skin being touched, pricked or pinched.

Who coined the term schizophrenia in 1911

Eugen Bleuler

Psychological effects of opiates

Euphoria Drowsiness Apathy Personality change

Psychological effects of cannabinoids

Euphoria Relaxation Altered time perception Psychosis (especially persecutory delusions with cannabis)

Description of all-or-nothing thinking (type of cognitive distortion)

Evaluating experiences using extremes such as "amazing" or "awful" (e.g. If I don't get this job, I'll never work again).

How often must blood plasma level of lithium be monitored?

Every 3 months.

How often do blood levels of lithium have to be monitored

Every week until the therapeutic levels have been stable for 4 weeks. Then every 3 months.

Who has a right to independent advocacy

Everyone with a mental disorder. Health board must ensure availability of this.

What does ICD-10 specify there must be to diagnose a dissociative symptoms?

Evidence of a psychological causation (stressful event or disturbed relationship) in association with the onset of the dissociative symptoms + no evidence of a physical or psychiatric disorder that might explain the symptoms.

Things to look for in examination

Evidence of acute intoxication or signs of withdrawal Short and long term medical complications

Aetiology of PND

Evidence suggests that biological factors are not as important as they are in postnatal blues and puerperal psychosis. However, psychosocial factors are strongly linked to its development.

Pathophysiology of Cushing's disease

Excess cortisol.

Nature of obsessions in generalised anxiety disorder

Excessive concerns about real-life circumstances. Absence of genuine obsessions or compulsions.

Presentation of dependent personality disorder

Excessive need to be cared for Submissive Clinging behaviour Needs others to assume responsibility for major life areas Fear of separation

What is sibling rivalry disorder

Excessive or persistent sibling rivalry

What is "hypersomnia"?

Excessive sleepiness that manifests as either a prolonged period of sleep or sleep episodes that occur during normal waking hours.

Purpose of blood investigations for psychosis

Exclude medical or substance-related causes. Establish baseline values before commencing drugs which can affect blood composition Assess renal and liver function that could affect drug delivery

Essential aim of psychoanalysis or psychodynamic psychotherapy

Facilitate conscious recognition of symptom-causing unconscious processes.

Which is the most common type of memory to be disrupted?

Explicit. Implicit memory is probably preserved due to its independent neural location associated with the basal ganglia circuitry.

Behaviour therapy techniques

Exposure. Exposure with response prevention. Relaxation. Modelling. Activity scheduling and target setting.

Symptoms of Korsakoff's psychosis

Extensive anterograde and retrograde amnesia - therefore have an inability to learn new material Frontal lobe dysfunction Psychotic symptoms in the absence of delirium

Microscopic findings in all prion diseases

Extracellular prion protein (PrP) plaques in the form of beta pleated sheets, particularly in the cerebellum.

Sex ratio for eating disorders

F:M = 10:1

Sex ratio of somatisation disorder

F:M = 10:1

Investigations for psychosis

FBC ESR U & Es Thyroid function Liver function tests Glucose LFTs Calcium Syphilis serology Urine drug screen ECG: especially if pre-existing heart problems as many antipsychotics can prolong the QT interval. Also consider: EEG/CT scan to exclude organic psychosis.

Monitoring of clozapine

FBC before starting, then weekly after starting for a bit, then monthly.

Routine investigations in delirium

FBC, U&Es, LFTs, Ca, glucose, CRP. CXR. ECG. Urinalysis.

Investigations recommended as a minimum to exclude reversible causes of dementia

FBC, U&Es, LFTs, thyroid function tests, calcium, glucose, vitamin B12/folate (rule out hypothyroidism, hypercalcaemia, Cushing's, Addison's). CT/MRI head (rule out tumour, subdural haematoma, normal pressure hydrocephalus).

Routine investigations in newly diagnosed or hospitalised older adult with mental illness

FBC, U&Es, LFTs, thyroid function tests, calcium, glucose. Urinalysis. CXR. ECG. Consider serum magnesium, phosphate, vitamin B2, folate, CT/MRI head.

What tests need to be done prior to initiating lithium

FBC, renal function and electrolytes, thyroid function, pregnancy test, ECG (if cardiac risk factors)

Description of a "defence mechanism": DENIAL

Failure to acknowledge the existence of an aspect of reality that is obvious to others (e.g. a man that was badly assaulted reports that it did not happen).

Definition of somatic delusions

False belie about your body e.g. that your bowels are rotting. AKA hypochondriacal delusion

Definition of religious delusions

False belief on a religious theme, often grandiose

Definition of delusion of control/passivity/'made' experiences AKA "passivity phenomena"

False belief that an external agency is controlling your thoughts, feelings, actions or impulses e.g: Thought insertion: the external agency is implanting thoughts into your head. Thought withdrawal: the external agency is removing thoughts from your head. Thought broadcasting: your thoughts are being broadcast so that other know what you are thinking.

Definition of delusions of reference

False belief that certain objects people or events have intense personal significance and refer specifically to oneself e.g. believing that a TV newsreader is talking directly to you

Definition of delusion of infidelity (morbid jealousy, Othello syndrome)

False belief that one's lover has been unfaithful (can also be occur in the form of an overvalued idea rather than a delusion).

Definition of delusion of love (erotomania)

False belief that someone is in love with you. Often 'de Clerambault syndrome' in which a women believes that an older man is in love with her

Definition of persecutory delusions

False belief that you are being harmed, threatened etc.

Definition of grandiose delusions

False belief that you are exceptionally powerful, talented or important

Definition of nihilistic delusion

False belief that you, others or the world is non existent or about to end.

Definition of partial delusions

False beliefs that were previously held with delusional intensity but are now held with less conviction. Often occurs following treatment of delusions.

Definition of hygric hallucination

False perception of fluid e.g. feeling water sloshing around the brain.

Definition of thermal hallucination

False perception of heat or cold

Definition of visceral hallucination

False perception of internal organs e.g. throbbing, stretching, distending, vibrating.

Definition of kinaesthetic hallucination

False perception of joint or muscle sense e.g. limbs being vibrated or twisted

Definition of olfactory hallucination

False perception of smell

Definition of gustatory hallucination

False perception of taste

Definitino of extracampine hallucinations

False perceptions that occur outside the limits of a person's normal sensory field e.g. voices coming from hundreds of miles away.

Features of hypothyroidism

Fatigue. Low mood. Dry skin. Dry, thin hair. Bradycardia.

In CBT terms, what are "dysfunctional assumptions"?

Faulty "rules" that individuals live by that underlie what autonomic thoughts occur. When broken (as they inevitably are), the result is normally psychological distress (e.g. "If I don't come first, then I am completely useless"). The "rules" themselves are often inherently problematic (e.g. "If I tell a person how I feel then I'm weak").

Most commonly occurring obsessions and their associated compulsions in descending order

Fear of contamination --> excessive washing and cleaning, avoidance of contaminated object. Pathological doubt e.g. "have I turned the stove off?" --> exhaustive checking of the possible omission. Reprehensible violent, blasphemous or sexual thoughts, images or impulses e.g. impulse to stab husband, having thoughts that one might be a peadophile --> acts of redemption or seeking reassurance. Need for symmetry or precision --> repeatedly arranging objects to obtain perfect symmetry.

Definition of social phobia

Fear of social situations where they might be exposed to scrutiny by others that might lead to humiliation and embarrassment. Can be to specific social situations or to all.

Definition of agorophobia

Fear or entering crowded spaces e.g. shops, trains, buses, elevators, where escape could be difficult. Can lead to patients becoming housebound.

What is "derealisation"?

Feeling that external reality is strange or unreal.

What is "depersonalisation"?

Feeling yourself to be strange or unreal.

What is "counter-transference" in psychodynamic psychotherapy?

Feelings that are evoked in the therapist during the course of therapy. E.g. the therapist may unconsciously act interact with the patient as if they were a significant figure from the patient's past. The therapist pays attention to noticing these feelings, as these may be representative of what the patient is feeling, and so help the therapist empathise with the patient (often therapists have undergone therapy themselves as part of training - this helps them separate out what feelings belong to them, and what feelings to the patient).

Why are SSRIs the 1st line antidepressant in depression?

Fewest S/Es.

Contraindications to ECT

Relative only: - heart disease (recent MI, heart failure, angina) - raised ICP - risk of cerebral bleeding (hypertension, recent stroke) - poor anaesthetic risk

Pathophysiology of delirium

Final common pathway of disrupted homeostasis. The pathophysiological mechanism remains unclear and may vary with cause, but the following have been suggested: - aberrant stress response (neurotoxic effects of excess glucocorticoids) - disrupted blood-brain barrier (allowing entry of toxins and cytokines into brain) - impaired cholinergic neurotransmission

When in a night's sleep do stages 3 and 4 of sleep occur?

First 1/3 to half of the sleep.

When are pervasive developmental disorders usually detected

First few years of life

What sort of course do acquired disorders tend to follow

Fluctuating

Delirium prognosis

Usually resolves when the trigger is treated, but sometimes can be prolonged for weeks or months even after the initial insult is treated.

Distinguishing clinical features of vascular dementia

Focal neurological signs and symptoms. Evidence of cerebrovascular disease or stroke. May be uneven of stepwise deterioration in cognitive function. Insight tends to remain until later in the disease.

Nonorganic dyspareunia.

Genital pain during sex in men or women. Not due to other sexual dysfunction (e.g. poor lubrication-swelling response, vaginismus) or medical condition (e.g. atrophic vaginitis).

Transient global amnesia

For a period of 2-6 hrs there is almost total failure to acquire new information. Patients appear confused and characteristically ask the same questions repeatedly, ignoring any answers. Otherwise, they can do quite complicated things e.g. drive. Quite common. Affects >40 year olds. Associated with migraines.

Scenarios in which detention is suspended

For leave from hospital. The taking into custody and return of patients who abscond. For patients to be transferred to other hospitals.

What is supported accommodation

For patients with severe, enduring mental illness who are unable to live independently.

Management of narcolepsy

Forced naps at regular times. Stimulants may be needed in some cases to reduce daytime sleepiness. Tricyclic antidepressants increase muscle tone and may help control cataplexy and sleep paralysis.

Munchausen syndrome by proxy (AKA fabricated or induced illness)

Form of abuse where a carer (classically a parent) will seek help for fabricated or induced symptoms in a dependent (classically a child). The psychological aim of the carer is for the dependent to be cared for like a patient. Induction of the factitious disorder can be dangerous e.g. poisoning.

What is "group-based peer support"?

Form of self-help delivered to groups of patients with shared symptoms, during which experiences can be shared and progress reviewed by a facilitator.

Most common inherited cause of intellectual disability

Fragile X syndrome causing autism.

What is generalised anxiety

Free-floating anxiety that does not occur in discrete episodes and tends to last for hours, days or even longer and tends to be of mild to moderate severity. Tends to not be about a specific thing but rather excessive worry about a range of normal life events e.g. job, relationships.

How is serotonin (5-HT) synthesised in neurons

From tryptophan

Key brain regions in long term (remote) memory

Frontal and temporal cortex.

Key brain regions in working/short term memory

Frontal cortex.

What are of brain damage is echopraxia associated with

Frontal lobe damage

Area of brain usually damaged in retrograde amnesia

Frontal or temporal cortex - hypothalamic-diencephalic system (I think).

Neurotransmitors implicated in anxiety

GABA Serotonin Noradrenaline

Psychological therapy for moderate-severe: GAD Panic disorder (+/- agorophobia) Social phobia OCD PTSD Specific phobia

GAD: CBT, applied relaxation Panic disorder (+/- agorophobia): CBT Social phobia: CBT OCD: Individual CBT with ERP PTSD: Trauma-focused CBT or EMDR (even if <4 weeks since trauma) Specific phobia: CBT (desensitisation, flooding or modelling)

1st line pharmacological therapy for severe: GAD Panic disorder (+/- agorophobia) Social phobia OCD PTSD Specific phobia

GAD: SSRI (e.g. sertraline) Panic disorder (+/- agorophobia): SSRI Social phobia: SSRI OCD: SSRI PTSD: Paroxetine (SSRI), mirtazapine (atypical) Specific phobia: PRN benzos

Treatment for mild-moderate anxiety with minimal functional impairment: GAD Panic disorder (+/- agorophobia) Social phobia OCD PTSD Specific phobia

GAD: Self-help. Panic disorder (+/- agorophobia): Self-help. Social phobia: Self help. OCD: Self-help, individual/group CBT with ERP. PTSD: Watchful waiting (if within 4 weeks of trauma)/trauma-focused CBT or EMDR (if >4 weeks since trauma). Specific phobia: Self-help

2nd line pharmacological therapy for severe: GAD Panic disorder (+/- agorophobia) Social phobia OCD PTSD Specific phobia

GAD: alternative SSRI, venlafaxine, pregabalin Panic disorder (+/- agorophobia): imipramine, clomipramine (tricyclics) Social phobia: PRN propanolol, MAOI, short term benzos OCD: alternative SSRI, clomipramine PTSD: amitryptaline, phelezine; sleep disturbance: Z drug/benzos. Specific phobia: just 1st line

Which of the SSRI side effects tend to present early and then resolve with time

GI disturbance (nausea, vomiting, diarrhoea, pain) Anxiety and agitation

Common side effects of SSRIs

GI disturbance (nausea, vomiting, diarrhoea, pain) Anxiety and agitation Loss of appetite and weight loss (sometimes weight gain) Insomnia Sweating Sexual dysfunction (anorgasmia, delayed ejaculation) Can cause increased risk of bleeding when used in combination with NSAIDs or anticoagulants.

Definition of irrelevant answers

Giving answers completely unrelated to a question

Most important gene associated with late-onset Alzheimer's

Gene that codes a protein involved in cholesterol metabolism - apolipoprotein (ApoE) - which occurs in 3 different alleles (ɛ2, ɛ3, ɛ4).

Classification of impairments in cognition

Generalised (multiple domains). Specific (one domain only).

Sex ratio (F:M) for: Generalised anxiety disorder Panic disorder Social phobia Specific phobia PTSD OCD

Generalised anxiety disorder: 2-3:1 Panic disorder: 2-3:1 Social phobia: equal Specific phobia: 2:1 PTSD: 2:1 OCD: equal

Macroscopic findings in Alzheimer's on CT

Generalised cortical atrophy (widened sulci), starting in the medial temporal lobes, and compensatory ventricular enlargement.

Differentials for anxiety with no clear external trigger

Generalised: generalised anxiety disorder Paroxysmal: panic disorder

When is the onset of parkinsonian motor symptoms

Generally occurs within a month of starting antipsychotics

Risk factors for non-organic enuresis

Genetic (75% have first degree relative with condition) Developmental delay Psychosocial stressors (e.g. moving house, birth of sibling, start/change of school, divorce, bereavement) Inadequate toilet training

Risk factors for somatisation disorder

Genetic factors: serotonin metabolism and HPA axis. Childhood sexual abuse. Growing up in an environment where physical distress is more readily acknowledged than psychological distress. Stressful events.

How genetics affect the chance of getting bipolar

Genetic risk is likely to be contributed to by multiple genes of individual small effect, although some rare high penetrance alleles probably also exist. Many of the mutations identified so far that slightly increase the risk of bipolar also increase the risk of schizophrenia, including genes related to neuronal development, neurotransmitter metabolism (dopamine and serotonin) and ion channels.

How genetics affect the chance of getting depression

Genetic risk is likely to be contributed to by multiple genes of individual small effect. Some genetic influence may only manifest in particular circumstances e.g. a particular allele of the serotonin transporter gene is associated with an increased risk of depression only in those who experience adverse life events, whereas people who have this allele but do not suffer adverse life events do not experience depression.

Aetiology of PMS

Genetic, hormonal/biological and psychosocial factors have been implicated.

What are personality traits often due to?

Genetics and early upbringing.

Aetiology of depression

Genetics, early upbringing and personality can increase the vulnerability to depression, with episodes arising depending on the level of acute and chronic stress experienced.

Risk factors for conduct disorder

Genetics, parental psychopathology (mental illness, substance abuse, antisocial personality traits, conduct disorder), child abuse, neglect, poor socioeconomic status, educational impairment. Antisocial personality disorder in close family relative (doesn't even have to be biological relative).

Aspects of cognition

Global functions of consciousness, attention and orientation. Specific domains of memory, executive function, language, praxis and perception.

Is depression an independent risk factor in the development of and mortality associated with cardiovascular disease in otherwise healthy persons?

Yes.

Use of benzodiazapines for schizophrenia

Good for short term relief of behavioural disturbance, insomnia, aggression and agitation but don't have any specific antipsychotic effects.

What is protective of PMS?

Good relationships.

Features of Freud's "id" AKA "the pleasurable"

Governed by the pleasure principle. Demands immediate satisfaction. Primitive, instinctive, animalistic, hedonistic.

Description of exposure therapy (type of behaviour therapy)

Graded exposure AKA systematic desensitisation: - a hierarchy of increasingly threatening situations is created (e.g. spider in another room --> spider in same room --> spider near patient --> spider on patient's hand) - patient exposed to (or imagines) the least threatening situation and remains there until their anxiety reduces towards normal levels - when anxiety relief has been achieved, patients are then exposed to increasingly threatening situations Flooding: - patient instantly exposed to highest level of their anxiety hierarchy until their anxiety diminishes (e.g. throwing patient with a fear of water into the deep end of a swimming pool) - flooding by imagination: "implosion therapy"

Distinguishing clinical features of Alzheimer's

Gradual onset with progressive cognitive decline. Early memory loss. Early loss of insight.

Method for reducing relapse rate for schizophrenia

Gradual withdrawal of antipsychotic over a few weeks

Onset of dementia - gradual or acute?

Gradual.

How to avoid discontinuation syndrome

Gradually taper down all antidepressents

Presentation of narcissistic personality disorder

Grandiose sense of self-importance Need for admiration

If the tribunal finds issues that require clarification in the criteria for a CTO what may they do

Grant an interim compulsory treatment order instead

Macroscopic findings in frontotemporal dementia on CT

Greater relative bilateral atrophy of frontal and anterior temporal lobes (atrophied paper-thin gyri known as "knife-blade atrophy"). Degeneration of the striatum.

What is "catharsis"?

Greek word meaning "cleansing" or "purging". Often used to describe a feeling of relief after an outpouring of emotive material.

Main side effect of methylphenidate

Growth suppression with prolonged use (so only prescribed in specialist settings with regular weight and height monitoring every 6 months).

What features does DSM-IV regard are not characteristic of a normal bereavement reaction and suggestive of the developmental of a major depressive episode?

Guilt (other than events surrounding the death of the loved one). Suicidal ideation (other than feeling better off dead or wanting to be with the deceased). Preoccupation with worthlessness. Marked psychomotor retardation. Prolonged and marked functional impairment. Hallucinatory experiences (other than transiently seeing or hearing the deceased).

Treatment of refeeding syndrome

IV replacement of fluids and electrolytes

Mechanism of HIV-related dementia

HIV virus thought to cause direct damage to the brain + opportunistic infections + cerebral lymphoma.

Differential diagnoses of mainly compulsions

Habit and impulse-control disorders: pathological gambling, kleptomania (stealing), trichotillomania. Gilles de la Tourette's syndrome.

Prognosis of PTSD

Half fully recover within 3 months. A third are left with symptoms long term.

Diagnosis of dementia reduces someones remaining life expectancy by roughly how much?

Half.

Types of perception disturbance

Hallucination Illusion Pseudohallucination

Dissociative anaesthetics psychological effects

Hallucinations Paranoid ideas Thought disorganisation Aggression

Alcohol-related psychotic disorder

Hallucinations and delusions can occur, however remember that alcohol abuse is a common comorbidity in bipolar, schizophrenia and overvalued idea/delusions of infidelity (Othello syndrome). However, in some cases perceptual disturbance with retained insight, persecutory/grandiose delusions or visual/auditory hallucinations can occur which resolve with abstinence and which are distinct from acute intoxication (by the lack of cognitive symptoms) and alcohol withdrawal.

Which antipsychotics can be given by depot

Haloperidol, flupentixol, zuclopenthixol, risperidone

Which antipsychotic is the worst for prolonging QT interval?

Haloperidol.

Is it common for people to respond to some classes of antidepressants but not others?

Yes.

Typical background for patients with overvalued ideas

Have had them for several years on a background of a personality disorder

BMI for children

Have to consult a BMI growth chart

Important differential diagnoses of suspected PTSD

Head injuries. Epilepsy.

Most common causes of chronic cognitive impairment in an isolated domain

Head injury or cerebrovascular event.

Physical effects of inhalants

Headache Nausea Slurred speech Loss of motor coordination Muscle weakness Damage to brain/bone marrow/liver/kidneys/myocardium Sudden death

Aetiology of delirium

Healthy individuals: usually a severe insult required e.g. head injury. Vulnerable brain: often a minor insult is sufficient to cause delirium e.g. constipation or UTI.

Risk of what sort of foetal malformations is important with lithium?

Heart defects, especially Ebstein's anomaly (displacement of the opening of the tricuspid valve).

Poisons that can cause delirium

Heavy metals (lead, mercury, manganese). Carbon monoxide.

Other name for childhood disintegrative disorder

Heller's syndrome

Most commonly encountered 'problem drug'

Heroin

Which drug is most treatment for

Heroin

Common examples of illicitly used opiates

Heroin Dihydrocodeine (DF118) Buprenorphine (Subutex)

Role of therapist in psychodynamic psychotherapy

Identify and interpret the unconscious processes (of which the patients are unaware) and to facilitate their understanding of unconscious processes in the context of a safe, caring relationship.

Is substance misuse common in those with psychopathy?

Yes.

2 important variables to explore when assessing someone who may have a pathological response to a stressful event

Nature and severity of the life event. Nature and severity of the person's reaction to the life event.

What is frontotemporal dementia?

Heterogenous group of neurodegenerative disorders associated with degeneration of the anterior part of the brain.

Why should benzos be used with caution in borderline personality disorder

High potential for abuse and dependence.

When to admit someone with depression for in-patient care

Highly distressing hallucinations, delusions or other psychotic phenomena. Acute suicidal ideation or planning, especially if suicide has previously been attempted or many risk factors for suicide present. Lack of motivation leading to extreme self-neglect (e.g. dehydration, starvation).

Features of alarm phase of grief

Highly stressed emotional state + physiological arousal e.g. increased HR and BP.

Brain structures associated with explicit memory

Hippocampal and diencephalic structures.

Key brain regions in long term (recent) memory

Hippocampus. Mamillary bodies.

Organic cause to rule out for encopresis

Hirschprung's disease - nerve cells missing in bowel

Risk factors for violent crime

Historical (past): - previous violence (biggest risk factor) - young age of first violent act - relationship instability - employment problems - alcohol/substance use problems - major mental illness - psychopathy - early maladjustment - personality disorder - prior supervision failure Clinical (present): - lack of insight - negative attitudes - active symptoms of major mental illness - impulsivity - unresponsive to treatment Risk management (future): - plans lack feasibility - exposure to destabilisers - lack of personal support - non-compliance with remediation attempts - stress

Other terms for dissociative disorders

Historically, dissociative disorders have been termed "hysteria". Sometimes also called "conversion" disorders.

Methods used by therapists in psychodynamic psychotherapy

Historically, they used methods such as free association, hypnosis, interpretation of dreams and fantasy material, analysis of defence mechanisms. Modern psychodynamic psychotherapy mainly relies on the analysis of "transference" and "counter-transference".

Investigations for any underlying medical condition in delirium

History (patient, notes, ward staff, relatives, GP) - as many as you can access. Examination (including obs, neurological and AMT/MMSE) as far as the patient can tolerate. Check Kardex to see if patient has been started on new drug or old drug has been stopped. Review recent investigations and carry out new investigations (some routinely always done and some extra depending on what is indicated by history and examination).

Which patients may benefit from taking antidepressants for a longer than 6 months (perhaps for life) after remission induction?

History of recurrent depressive disorder.

Predictors of poor prognosis for antisocial personality disorder

History of violence/crime/arrest/repeated lying, confidence tricks or the use of aliases. Unresolved legal situations on admission. Hospitalisation as an alternative to imprisonment. Presence of organic brain disorder.

History and examination in old age psychiatry

Home assessments: very important to assess a patient in their normal environment and ascertain whether they can be managed at home (i.e. risk of harm to self and others, ability to carry out activities of daily living, drive, manage financial affairs etc.) or whether additional community support or hospitalisation is required. Collateral information from GP, family, friends etc. Assess cognition e.g. with MMSE. Physical examination, especically hearing and vision.

Drugs that can help with PMS

Hormonal contraception. SSRIs. Danazol (testosterone analogue). Gonadotrophin-releasing hormone analogues.

When is further treatment required for bulimia e.g. hospitalisation or high-dose SSRIs

Hospitalisation: - electrolyte disturbance from purging - risk of suicide or self harm High-dose SSRIs: - comorbid substance abuse or depression - can help reduce bingeing and purging behaviour (especially high-dose fluoxetine)

Side effects of carbamezapine

Nausea and vomiting Skin rashes Diplopia/blurred vision Ataxia, drowsiness, fatigue Hyponatraemia and fluid retention Haematological abnormalities (leucopaenia, thrombocytopaenia, eosinophilia) Raised liver enzymes (occasionally causing jaundice)

ADHD is described in the DSM-IV. What is the equivalent in the ICD-10

Hyperkinetic disorder

What did the Ms B case determine

If a doctor treating someone feels unable to treat them in accordance with their wishes, then they have a duty to transfer the care to other doctors.

What is the effect of D2 antagonism on the tuberoinfundibular pathway

Hyperprolactinaemia e.g. galactorrhoea, amenorrhoea, infertility, sexual dysfunction, impaired glucose tolerance

Presentation of avoidant (anxious) personality disorder

Hypersensitivity to critical remarks or rejection Inhibited in social situations Fears of inadequacy

Primary hypersomnia

Hypersomnia for >=1 month, not attributable to medical/mental illness, alcohol/substance misuse or other dyssomnias or parasomnias.

CV system problems from alcohol use

Hypertension Arrhythmias Ischaemic heart disease Alcoholic cardiomyopathy

Features of phaeochromocytoma

Hypertension. Hyperglycaemia. Intermittent episodes of catecholamine release (causing anxiety, tachycardia, sweating, pallor).

Things to monitor for in delirium tremens

Hyperthermia Dehydration Hypoglycaemia Hypokalaemia Hypomagnesaemia

Sexual dysfunction disorders affecting "desire" phase of sexual response cycle

Hypoactive sexual desire disorder. Sexual aversion disorder.

Possible psychiatric cause of secondary anxiety concerning having a serious illness

Hypochondriacal disorder

Metabolic and endocrine system problems from alcohol use

Hypoglycaemia Hyperlipidaemia/hypertriglyceridaemia Hyperuricaemia Hypomagnaesaemia Hypophosphataemia Hyponatraemia Alcohol-induced pseudo-Cushing's syndrome

Investigation results related to vomiting

Hypokalaemic, hypochloraemic metabolic alkalosis Hyponatraemia Hypomagnesaemia Raised serum amylase

Electrolyte abnormalities in refeeding syndrome

Hypophosphataemia Hypokalaemia Hypomagnesaemia Hyponatraemia Metabolic acidosis Thiamine deficiency

Name of somatoform autonomic dysfunction disorder of the GI system?

IBS.

Ways of diagnosing schizophrenia

ICD-10 Schneider's first rank symptoms were previously used

Indicators of good prognosis for autism

IQ>70 Good language development by 5-7 years old Supportive home environment, with good family education and social support

Is there a higher incidence of true obsessive-compulsive disorder in patients with anorexia nervosa than the general population?

Yes.

Treatment of acute behavioural disturbance of confirmed schizophrenia with rapid tranquillisation

If accepting oral medication: Oral lorazepam (2mg) Consider antipsychotic but aim to avoid combining them. If not accepting oral medication and significant risk to self or others: IM lorazepam (2mg) Consider additional IM antipsychotic e.g. olanzapine (not within 1 hour of lorazepam) or haloperidol (5mg) (baseline ECG advised) (Sometimes referred to simply as 2mg and 5mg of lorazepam and haloperidol) Repeat as required every 45-60 mins Consider IV tranquillisation in exceptional circumstances only.

Features of normal consciousness level

If awake, not agitated/hypervigilant/unable to sleep. If not awake, are rousable and remain alert throughout assessment.

Precautions for rapid tranquillisation

If parenteral benzodiazepines are given, flumazenil (benzodiazepine receptor antagonist) must be available. If haloperidol is given, procyclidine must be available (to treat dystonias). Frequently observe vital signs every 10-15 mins for 1 hour, then every half hour until patient is ambulatory.

When does a bereavement reaction tend to last longer or become atypical?

If the death was sudden and unexpected. Problematic relationship before death. In women. Not much social support.

How can serotonin syndrome occur with MAOIs

If they are co-administered with an antidepressent with strong serotonergic effects e.g. SSRI, clomipramine.

Can ECT be given to patients subject to compulsion without their consent

If they can't consent then it requires authorisation by a DMP.

Additional symptoms of alcohol withdrawal syndrome with perceptual disturbance

Illusions or hallucinations (typically visual, auditory or tactile)

First antidepressents to be invented (in 1950s)

Imipramine (tricyclic) and phenelzine (MAOI)

What is a developmental disorder?

Impaired acquisition of expected cognitive, motor, social or adaptive skills, due to abnormalities in the brain development

Key features of hyperkinetic disorder

Impaired attention: difficulty sustaining attention in work or play tasks; not listening when being spoken to; being highly distractible; reluctance to engage in activities that require a sustained mental effort e.g. schoolwork; being forgetful or regularly losing things. Hyperactivity: restlessness; incessant fidgeting; running and jumping around in inappropriate situations; excessive talkativeness or noisiness; difficulty engaging in quiet activities. Impulsivity: difficulty awaiting turn; interrupting others' conversations or games; prematurely blurting out answers to questions. Should be present in more than one situation e.g. home and school and be present for at least 6 months.

Physical effects of cannabinoids

Impaired coordination and reaction time Conjunctival injection Nystagmus Dry mouth

Impaired cognitive function in delirium

Impaired short-term and long-term recent memory with relative preservation of long-term remote memory. Almost always disoriented to time and often to place. Orientation to self seldom lost. Language abnormalities.

Key difference between presentation of Asperger's and autism

Impaired social interaction, restricted stereotyped interests and behaviours but NO significant impairment of language, cognitive development or intelligence (IQ and language can be superior in some cases) in Asperger's

What is a learning difficulty

Impairment in learning. Often specific to one field e.g. dyslexia rather than being a global reduction in IQ. Often associated with intellectual disability though.

Key features of autism

Impairment of social interaction: poor use of non-verbal communication (e.g. eye contact, facial expression, gestures); failure to share in the enjoyment of peer relationships. Impairment in communication: poor development of spoken language; extreme difficulty in initiating or sustaining conversation; repetitive use of idiosyncratic language; lack of imitative or make-believe play. Restricted, stereotyped interests and behaviours: intense preoccupations with interests such as dates, phone numbers and timetables; inflexible adherence to routines and rituals; repetitive stereotyped motor movements such as clapping, rocking or twisting and an unusual interest in parts of hard or moving objects. All 3 must be present for diagnosis to be made.

Difference between implied and express consent

Implied e.g. patient does not object to and cooperates with the procedure. Express: Oral or written permission is explicitly asked for and recorded, often on a detailed consent form (this is needed for more serious interventions e.g. surgery)

Physical examination in those with cognitive impairment

Important, especially neurological examination.

How "diminished responsibility" can reduce criminal culpability

In English law, diminished responsibility depends upon the presence of "an abnormality of mind (whether arising from a condition of arrested or retarded development of mind or any inherent causes or induced by disease or injury)". In English law, a defence of diminished responsibility is only available in relation to charges of murder. If successful, this will lead to the accused being found guilty of manslaughter (known as culpable homicide in Scotland) rather than murder, which allows for flexible sentencing (whilst murder carries mandatory life sentence). "Abnormality of mind" is not a psychiatric term and is open to wide interpretation, leading to successful defences such as "emotional immaturity" and "premenstrual tension".

How "insanity" can reduce criminal culpability

In English law, legal insanity is "at the time of committing the act, the party accused was labouring under such a defect of reason, from disease of the mind, as to not know the nature and quality of the act he was doing, or, if he did know, that he did not know that what he was doing was wrong". This defence is rarely successful due to the high threshold of the legal definition of insanity.

Features of Freud's "ego" AKA "the actual"

In touch with reality. Mediates between the demands of the id, the superego and external reality.

How is amnesia different from dementia?

In amnesia there is a severe disruption of memory with minimal or no deterioration in other cognitive functions (attention, consciousness and global intellectual functioning remain intact).

Can you drive with mania/hypomania

No. Can resume once stable for 3 months (3 years for group 2), compliant with harmful adverse effect free treatment, insight has been regained and subject to a specialist report.

When does treatment need to be authorised by a court

In non-urgent situations where statute law has no clear role and there does not appear to be any relevant legal precedent.

Why does treatment of depression with antidepressants often fail?

Inadequate dose/duration of treatment. Poor concordance.

Definition of incapacity in AWIA

Incapable of at least one of the following: Acting on decisions. Making decisions. Communicating decisions. Understanding decisions. Retaining memory of decisions.

Features of normal pressure hydrocephalus

Incontinence, ataxia, cognitive impairment = "wet, wobbly, wacky".

In general, what do all antidepressentes do to synapses

Increase the levels of one or more monoamines

What are the neuromuscular abnormalities in serotonin syndrome

Increased activity: myoclonus or clonus, hyperreflexia, tremor, muscular rigidity.

Side effects of valproate

Increased appetite and weight gain Sedation and dizziness Ankle swelling Hair loss Nausea and vomiting Tremor Haematological abnormalitites e.g. thrombocytopaenia, leucopenia Raised liver enzymes

Chemical mechanism of dependence

Increased dopamine release from mesolimbic system (stimulation of brain's "reward" system)

S/Es of olanzapine in pregnancy.

Increased risk of gestational diabetes. Prescribe with caution in pregnancy and should use alternatives in women who are already at risk of gestational DM (e.g. obesity, gestational DM in previous pregnancy, strong FMH of DM). Regularly monitor blood and/or urinary glucose during pregnancy.

Immune system problems from alcohol use

Increased risk of infections (especially meningitis and pneumonia)

Possible risks of using benzos in dementia patients.

Increased risk of: - worsening cognition - delirium - falls - disinhibition - aggression

Societal measures for primary prevention of alcohol dependence

Increased tax (most effective at reducing consumption) Limiting availability Curtailing advertising Health education

Are older adults at an increased or decreased risk of completing suicide?

Increased.

Is there an increased or decreased risk of adverse life events in the weeks prior to a spontaneous abortion (miscarriage)?

Increased.

Effect of antipsychotics on lithium

Increases its toxicity

Effect of personality disorders on other psychiatric disorders

Increases the prevalence of them (depression, anxiety, bipolar, schizophrenia) and tends to make them more severe

What does the term "cognition" refer to in cognitive psychology and cognitive therapy?

Individual thoughts or ideas - these are referred to as "cognitions".

What is "gender identity"?

Individual's inner sense of being male or female.

Causes of circadian rhythm sleep disorder (sleep-wake schedule disorder)

Lack of synchrony between an individual's endogenous circadian rhythm for sleep and that demanded by their environment, resulting in their being tired when they should be awake (hypersomnia) and awake when they should be asleep (insomnia). Results from either a malfunction of the internal ""biological clock"" that regulates sleep or from unnatural environmental change (e.g. jet lag, night-shift work).

Age of onset of developmental disorders

Infancy or early childhood

Hypoactive sexual desire disorder

Lack or loss of sexual desire (desire to have or fantasise about sex), not due to other sexual dysfunction e.g. erectile dysfunction.

Microscopic findings in vascular dementia

Infarcted grey and/or white matter.

Common causes of delirium

Infections and sepsis. Dehydration. Anoxia (e.g. respiratory distress, heart failure, MI). Metabolic and endocrine disturbance. Nutritional deficiency. Drugs. Intracranial space-occupying lesions (e.g. tumours, cysts, abscesses, haematomas). Head injury (especially concussion). Intracranial infection (e.g. meningitis, encephalitis). Epilepsy. Cerebrovascular disorders. SOMETIMES NO CAUSE IS FOUND - this does not preclude the diagnosis.

What is a prion?

Infectious protein which can cause fatal degeneration.

Personality traits associated with anorexia

Inhibition Perfectionism Obsessionality Harm avoidance

Features of acute alcohol intoxication

Initially, may produce an enhanced sense of well-being, greater confidence and relief of anxiety, which may lead to disinhibition, talkativeness and flirtatiousness. As blood levels increase, some drinkers may exhibit inappropriate sexual or aggressive behaviour, whereas others might become sullen and withdrawn, with labile mood and possibly self-injurious behaviour. As levels rise further, drinkers can suffer incoordination, slurred speech, ataxia, amnesia and impaired reaction times. At very high concentrations, drinkers can suffer a lowered consciousness level, respiratory depression, coma and death.

Causes of parkinsonism (as opposed to the specific disorder of idiopathic Parkinson's)

Injury to the basal ganglia: - cerebrovascular disease - head injury - carbon monoxide poisoning - dopamine antagonists (including antipsychotics) - other neurodegenerative disorders (e.g. Parkinson's "plus" syndromes such as progressive supranuclear palsy)

Features of Addison's disease

Insidious fatigue, loss of stamina, apathy. Memory problems. Weight loss. Postural hypotension. Hyperpigmentation of palmar creases and buccal mucosa. Hyponatraemia. Hyperkalaemia. Hypoglycaemia.

Onset of neuroleptic malignant syndrome

Insidious within 4-11 days of dopamine antagonist

Indications for Z drugs

Insomnia

Indications for benzos

Insomnia (especially short acting ones) Anxiety disorders Alcohol withdrawal (especially chlordiazepoxide) Akathisia Acute mania or psychosis (sedation)

What is "primary insomnia"?

Insomnia for >=1 month and not attributable to medical/mental illness, alcohol/substance misuse or other dyssomnias or parasomnias.

Basis of "family therapy"

Instead of focussing on the individual, this therapy treats the family as a whole. May include just parents and siblings or extended family. Hoped that improved family communication and conflict resolution will result in improvement in the patient's symptoms. Like group therapy, there are many different orientations, most notably the psychodynamic, structural and systemic approaches.

What is the preferred term to describe someone who is of lower than average intelligence

Intellectual disability

Four broad categories of psychiatric disorders in children and adolescents in ICD-10

Intellectual disability (formerly referred to as mental retardation/learning disability) Developmental disorders (specific and pervasive) Acquired disorders with onset usually in childhood or adolescence Acquired 'adult' disorders with onset in childhood or adolescence

Definition of phobia

Intense, irrational fear of an activity or situation that would not be expected to cause such a level of fear in normal people. Although they may recognise that it is irrational, they try to avoid it.

What is "psychological therapy"?

Interaction between a therapist and a client that aims to impart beneficial changes in the client's thoughts, feelings and behaviours.

What drug can be offered for maintenance treatment of bipolar if most of the episodes are depressive?

Lamotrigine (do not give in during acute mania).

List of specific developmental disorders

Language Reading (i.e. dyslexia) Spelling Arithmetical skills Motor skills

Average age of onset of recurrent depressive disorder

Late 20s.

When do paraphilias tend to develop?

Late adolesence/early adulthood.

When children present with their parents/carers, what is it best to do

Interview the parents/carers first (with or without the children present)

Nervous system problems from alcohol use

Intoxication/withdrawal delirium Withdrawal seizures Cerebellar degeneration Haemorrhagic stroke Peripheral and optic neuropathy Wernicke-Korsakoff syndrome Alcohol-related cognitive impairment

Microscopic findings in Huntington's disease

Intracellular aggregates of huntingtin and ubiquitin.

Microscopic findings in frontotemporal dementia

Intracellular cytoplasmic aggregates of ubiquitin and tau (Pick bodies) - found in a subtype of frontotemporal dementia known as Pick's disease - Pick's bodies must be present on post-mortem to diagnose this form of frontotemporal dementia. OR more commonly intracellular aggregates of ubiquitin and other abnormal proteins.

Reproductive system problems from alcohol use

Intrauterine growth retardation Foetal alcohol syndrome Impotence, erectile dysfunction

Treatment of depression in older adults

Introduce medication cautiously due to increased risk of S/Es. Generally need lower doses. Avoid tricyclic antidepressants as much as possible as the S/Es of postural hypotension and cognitive impairment are very common in older patients. Response to antidepressants often slower, with benefits taking 6-8 weeks to emerge. ECT very effective for severe depression in this age group. Lithium augmentation may be used in treatment-resistant cases, although the dose is generally lower than for younger adults. Often need lifelong antidepressant treatment to reduce the chance of relapse. Important to involve psychosocial intervention in the form of social support and possibly CBT (just as effective as in younger patients).

Definition of flashbacks

Intrusive, unwanted memories/vivid mental images/dreams of the original experience.

Age of onset of bulimia

Late-adolescence and early adulthood

Are most cases of Alzheimer's early- or late-onset?

Late-onset (only about 5% of cases of Alzheimer's are inherited as an autosomal dominant trait).

Onset and prognosis for paranoid schizophrenia

Later onset and better prognosis

How effective are the pharmacological treatments of hyperkinetic disorder in improving ability to sustain attention and academic efficacy

Lead to improvement in 75%

Acute dystonia symptoms

Involuntary sustained muscular contractions or spasms e.g. neck (spasmodic torticollis), clenched jaw (trismus), protruding tongue, eyes rolled upwards (oculogyric crisis)

Definition of "obsession"

Involuntary thoughts, images or impulses that are: - recurrent and intrusive - unpleasant or distressing - enter the mind despite conscious resistance - recognised by patient as being a product of their own mind (opposite to thought insertion) even though they are involuntary and often repugnant - generally recognised by patient as irrational - seen by patient as foreign to or against their "essence" (ego-dystonic or ego-alien) e.g. religious man has recurrent thoughts that he has betrayed God

What is non-organic enuresis

Involuntary voiding of urine (day or night) in children who should have established consistent bladder control i.e. >5yo. Not caused by any medical condition or medication.

Tetrad of narcoplepsy

Irresistible attacks of refreshing sleep that may occur at inappropriate times (e.g. whilst driving). Cataplexy (sudden, bilateral loss of muscle tone, usually precipitated by intense emotion leading to collapse - lasts seconds to minutes). Hypnagogic or hypnopompic hallucinations. Sleep paralysis at the beginning or end of sleep episodes.

Other things to consider before diagnosing a developmental or acquired disorder

Is it just age appropriate behaviour e.g. temper tantrums in 2 year old, or normal separation anxiety in 1 year old? Is there a psychosocial cause e.g. bullying, child abuse? Consider intellectual disability

Disadvantages of ACE-R

Lengthy. Influenced by premorbid IQ, language and culture.

Why are SSRIs usually first line

Less SEs Lower risk from overdose

Why is it difficult to assess thought disorder

It is impossible to tell what a patient is actually thinking; it can only be inferred from their speech and behaviour. There are conflicting classification systems.

Basic assumptions of psychoanalytic therapy that have stayed consistent for decades

It is mainly unconscious thought, feelings and fantasies that give rise to distressing symptoms, and these processes are kept unconscious by "defence mechanisms" (which are employed when anxiety-producing aspects of the self threaten to break through to the conscious mind, potentially giving rise to intolerable feelings).

Where does the name borderline personality disorder come from

It is on the border between neurosis and psychosis

Why can't naltrexone also be used for opiate overdoses

It needs to be given orally which isn't appropriate for someone with reduced consciousness

Genetics of sleepwalking

It runs in families - 80% of sleepwalkers have a +ve family history for sleepwalking or sleep terrors.

What would happen if you gave naltrexone to a patient who is still opiate dependent

It would induce withdrawal

Which drug has the slang name "special K"

Ketamine

Common examples of illicitly used dissociative anaesthetics

Ketamine (short-acting NMDA antagonist) - legitimately used in veterinary surgeries as an anaesthetic

Substances that can cause depersonalisation and derealisation

Ketamine. Tranquilizers. Mescalin. Peyote.

Who was the leading inventor in theorizing object relations theory?

Klein.

Neurological syndromes associated with gross overeating (rare)

Kleine-Levin Kluver-Bucy Prader-Willi

Who developed interpersonal therapy?

Klerman and Weismann.

Who defined the first rank symptoms of schizophrenia in 1959

Kurt Schneider

Types of prion disease

Kuru. Gerstmann-Straussler syndrome. Scrapie (in sheep). Bovine spongiform encephalopathy (BSE) (in cattle). Creutzfeldt-Jakob disease (CJD).

Common examples of illicitly used hallucinogens

LSD (lysergic acid diethylamine) Magic mushrooms

Are women most or less likely to experience sexual dysfunction as they age?

Less likely (except for those who report trouble lubricating).

When is ECT used for depression

Life-threatening poor fluid intake Strong suicidal intent Psychotic features or stupor Antidepressants ineffective or not tolerated

How long does an intellectual disability last for

Lifelong

Treatment of moderate or severe depression

Lifestyle advice + high intensity psychological intervention (individual CBT, individual IPT) + antidepressant.

Duration of long term (remote) memory

Lifetime.

What are home treatment teams (AKA crisis teams)

Like CMHT but available out of hours and visit more regularly. Used to reduce the number of patients who would otherwise have to be admitted.

What are assertive outreach teams

Like CMHTs but more intensive, flexible and frequent. For severe illness or patients who have not engaged properly with services in the past.

Definition of reflex hallucination

Like a functional hallucination but a stimulus in one modality triggers a hallucination in another.

Definition of flight of ideas

Like tangential thinking but with accellerated speed

Prognosis of GAD

Likely to be chronic but fluctuates depending on level of stress

Legal issues in dementia

Likely to lose capacity to make decisions about their welfare and financial affairs - therefore advisable to arrange Power of Attorney ASAP before the person loses capacity to authorise this. They may also wish to consider an Advance Statement. May not be safe to drive and would need to inform the DVLA and insurer of their diagnosis.

What was the first mood stabiliser to be discovered

Lithium

Which drug can cause nephrogenic diabetes insipidus

Lithium

Typical history of contact with medical services of a patient with somatization disorder (Briquet's syndrome)

Long history of contact with medical services, during which numerous investigations may have been conducted. Patients are often seeking relief from their symptoms. This often results in iatrogenic disease with physically explainable symptoms (e.g. abdominal adhesions from frequent exploratory surgery). Due to frequent courses of medication, these patients are often dependent on analgesics and sedatives.

Dementia in alcoholism

Long term alcohol misuse can lead to impaired memory, learning, visuospatial skills and impulse control as well as cortical atrophy and ventricular enlargement. However, it is difficult to separate from the the effects of malnutrition, trauma and comorbid physical illness. Subsequent abstinence leads to some improvement.

Common cause of formication

Long term cocaine use (cocaine bugs) Alcohol withdrawal

Teratogenicity of lithium and its use in pregnancy

Lithium is thought to be teratogenic - the relative risk of foetal malformations is high but the absolute risk is low. This needs to be balanced with the risk of the mother's relapse on stopping lithium. Discussion of risks and benefits of stopping vs not stopping lithium can help women make informed choices. If lithium is continued during pregnancy, it needs to be carefully monitored, as changes in body water during pregnancy can affect levels).

Drugs used as maintenance treatment for bipolar

Lithium. Valproate. Olanzapine. Choice depends on sex, physical comorbidity and patient preference.

Does menopause increase or decrease incidence of mental illness?

Little evidence for either. Psychological symptoms may understandably accompany changes that occur with the menopause, but it is important to remember that this is a time associated with other psychological stressors (e.g. children leaving home, growing awareness of age) which may increase the risk of developing depression independently of the hormonal changes during menopause.

Are people with dysthymia and cyclothymia functionally impaired?

No.

Definition of generalised anxiety disorder

Long-standing, free-floating anxiety. Excessive worry about minor matters. Apprehensive on most days for about 6 months. 3 key elements: Apprehension Motor tension (restlessness, fidgeting, tension headaches, inability to relax. Autonomic overactivity.

Which is the only benzo which has predictable absorption when given IM

Lorazepam

Which benzo is best for someone with liver failure

Lorazepam (short half-life so won't accumulate) (Benzos are hepatically metabolised)

Which benzos can be given IV in addition to oral

Lorazepam and diazepam (all the rest can only be given orally)

Description of loss of executive function

Loss of ability to plan and sequence complex activities or to manipulate abstract information e.g. not able to plan the preparation of a meal.

Sexual/reproductive features of somatization disorder (Briquet's syndrome)

Loss of libido. Ejaculatory/erectile dysfunction. Irregular menses. Menorrhagia. Dysmenorrhoea.

Side effects of ECT

Loss of memory is a common complaint (particularly for events surrounding (particularly before) the ECT but sometimes also for autobiographical memory). 80% experience confusion, headache, nausea, muscle pains. Anaesthetic complications e.g. arrhythmias, aspiration. Prolonged seizures - particularly if on antipsychotics or antidepressants which lower the seizure threshold. ... studies that examine the long-term effects of ECT are difficult to perform.

Adverse life events that often precipitate depressive episodes

Loss or humiliation events e.g. bereavement, relationship break-up or redundancy. ... however, it is important to bear in mind that the life event may not necessarily be causal, as being depressed - or at risk of depression - may also increase the risk of experiencing adverse life events.

Mortality of serotonin syndrome

Low

EEG findings in REM (stage 5) sleep

Low amplitude, high frequency saw-tooth waves.

Factors associated with a better prognosis

Low income country (better family support?) No family history Female Married High IQ Older age of onset Abrupt onset Onset precipitated by life stress Short duration of illness prior to treatment Good response to medication Paranoid subtype is better than hebephrenic Absence of negative symptoms Illness characterised by prominent mood symptoms or family history of mood disorders Good premorbid functioning

Psychological symptoms of PMS

Low mood (71%). Irritability (56%). Tiredness (35%). Insomnia.

Symptoms of PND

Low mood, loss of interest or pleasure, fatigability and suicidal ideation (although suicide is rare). Sleeping difficulties, weight loss and decreased libido can be NORMAL for the first few months.

Tricyclic antidepressants rules during breast-feeding

Low-dose amitriptyline appears safe. Clomipramine may be useful for obsessional phenomena. Avoid doxepin.

What treatment can be used to manage aggressive and violent behaviour in a child with a pervasive developmental disorder?

Low-dose antipsychotics e.g. risperidone.

Effect of decreased total body mass on drug metabolism in elderly patients

Lower doses of drugs needed.

Is the prevalence of self-harm higher or lower in older adults?

Lower.

Effect of most antidepressents on epilepsy

Lowers the seizure threshold

Which antidepressents may be better for atypical depression (hypersomnia, overeating and anxiety)

MAOIs

Cause of Rett's syndrome

MECP2 gene mutation on X chromosome (either sporadically or from germline mutations)

How is are personality disorders measured for the dimensional approach

MMPI Minnesota Multiphasic Personality Inventory

Are pregnant women more likely to develop a new psychiatric illness that the general population?

No.

Inflammatory disorders that can cause dementia

MS. SLE.

Which drug has the slang name "mushies"

Magic mushrooms

Alzheimer's environmental risk factors

Mainly vascular - it is unclear whether vascular insufficiency in part causes the plaques and tangles, or whether the vascular damage reduces the brain's reserves making a given amount of neurodegeneration more likely to manifest clinically. Head injury. Low educational attainment.

Definition of catatonic rigidity

Maintaining a fixed position and rigidly resisting all attempts to be moved

What can CTOs in the community do

Make requirements as to the residence, attendance for treatment and other services, access of staff to the patient's residence, and acceptance of medication for mental disorder.

First step when someone presents with an acute behavioural disturbance

Make sure it is not another diagnosis e.g. mania, delerium, alcohol and substance withdrawal or dementia.

Sexual dysfunction disorders affecting "excitment" phase of sexual response cycle

Male erectile disorder. Female sexual arousal disorder. Inability to attain or maintain sexual intercourse due to an inadequate erection in men, or poor lubrication-swelling response in women.

Sexual dysfunction disorders affecting "orgasm" phase of sexual response cycle

Male/female orgasmic disorder. Premature ejaculation.

Are males or females more at risk of drug dependence

Males

Are more males or females undergoing treatment for drug use

Males

What is the mesocortical pathway involved in

Mediates cognitive and negative symptoms of schizophrenia

Definition of designated medical practitioner

Medical practitioners appointed by the mental wellfare commission to give second opinions regarding the medical treatment of patients subject to compulsion.

Is there a higher prevalence of mental disorders in the prison population compared to the general popultion?

Yes.

What is the main contraindication to SSRIs

Mania

Indications for maintenance treatment for bipolar

Manic episode associated with serious adverse risk or consequences. Manic episode and another disordered mood episode. Repeated hypomanic or depressive episodes with significant functional impairment or risk.

Prognosis of conduct disorder

Many improve by adulthood but some go on to develop antisocial personality disorder and substance-related problems, especially those with an early age of onset.

Management of sexual dysfunction

Many only need reassurance, advice and sexual education. Those with significant relationship difficulties may be advised to have relationship counselling first. Some couples benefit from sex therapy. Physiological male problems: urology. Not responding to non-specific measures: sexual dysfunction clinics. Specific exercises.

Macroscopic findings in Huntington's disease on CT

Marked atrophy of the basal ganglia, caudate nucleus (loss of shouldering) and often frontal lobes. Compensatory dilated ventricles.

Psychological effects of hallucinogens

Marked perceptual disturbances including chronic flashbacks Paranoid ideas Suicidal and homicidal ideas Psychosis

Factors that decrease risk of sexual dysfunction

Married. High educational attainment.

Basis of "group therapy"

May be practised according to different theoretical orientations. Allows patients and therapists to observe and analyse their psychological and behavioural responses to other members of the group in a "safe" social setting. It is thought that group therapy owes its effectiveness to a number of "curative factors" (e.g. universality - the process of patients realising that they are not alone in having particular problems).

S/Es of benzos and other hypnotics during breast-feeding

May cause lethargy in infant.

Endings and transitions with people with borderline personality disorder

May evoke strong emotions and reactions in patients and therefore, should be carefully planned and structured to minimie distress

Use of ECT in BAD

May precipitate a manic episode however it is also an effective treatment for established mania

Dissociative convulsions (psychogenic non-epileptic seizures)

May present like epileptic seizures but tongue-biting, serious injury, urinary incontinence and postictal confusion are uncommon + absence of epileptic activity on EEG.

Management of dependent drinkers

May require more intensive intervention delivered by a specialist alcohol advisory service

Area of brain usually damaged in anterograde amnesia

Medial temporal lobes, especially the hippocampal formation.

What is a "functional symptom"?

Medically unexplained physical symptom (however, this does not necessarily mean that a structural disease does not exist as it may just not have been identified).

Duration of long term (recent) memory

Minutes-months.

Physical effects of opiates

Miosis Conjunctival injection Nausea Pruritus Constipation Bradycardia Respiratory depression Coma

Physical effects of sedatives

Miosis Hypotension Withdrawal seizures Impaired coordination Respiratory depression

Example of NaSSA (naradrenergic and specific serotonergic antidepressant)

Mirtazapine

Alternative to SSRIs for people who are on NSAID/anticoagulant

Mirtazepine

Better antidepressent for people who are concerned about sexual dysfunction

Mirtazepine

Possible perceptual disturbance in delirium

Misinterpretations (e.g. a door slamming is mistaken for an explosion). Illusions (e.g. a crack in the wall is perceived as a snake). Hallucinations (especially visual and, to a lesser extent, auditory).

Definition of illusions

Misperceptions of real external stimuli e.g. shadows in a dark room looking like people.

Are men or women more likely to have transvestic fetishism?

Men (rare in women).

Features of fragile X

Men are much more severely affected. Trinucleotide repeat expansion. Also elongated face, large or protruding ears, macroorchidism, stereotypical movements, social anxiety, epilepsy.

What is "couvade syndrome"?

Men develop typical pregnancy-related symptoms during their partner's pregnancy (e.g. morning sickness, vague abdominal pains, labour pains).

Incidence/prevalence in men compared to women

Men have a greater incidence. But equal prevalence, possibly due to a higher mortality rate in men.

Are paraphilias more common in men or women?

Men.

Is psychopathy more common in men or women?

Men. Some argue that psychopathy doesn't even occur in women.

Key physical features to ask about

Menstrual history Episodes of syncope/presyncope Palpitations Tiredness Muscle weakness Sensitivity to cold

Which drug has the slang name "miaow"

Mephedrone

Which areas of the brain are affected by D2 antagonism

Mesolimbic pathway, mesocortical pathway, nigrostriatal pathway (basal ganglia, striatum), tuberoinfundibular, chemoreceptor trigger zone.

Substitution therapy for opiate dependence

Methadone (an oral long acting opiate) or buprenorphine (Subutex) (a partial opiate agonist) Help to stabilise user's life and prevent the complications of injecting Can be used indefinitely but normally aim for gradual reduction

What does neurodegeneration seem to be associated with in general?

Misplaced proteins e.g. Alzheimer's, dementia with Lewy bodies and frontotemporal dementia all involve accumulation of degradation-resistant protein aggregates.

Aetiology of most cases of sexual dysfunction

Mixture of physiological and psychological factors.

Example of RIMA (reversible inhibitor of monoamine oxidase A)

Moclobemide

Can self-induced ("voluntary") intoxication with alcohol or other drugs be used as a defence on the grounds of insanity or diminished responsibility?

No.

Age of onset of anorexia

Mid-adolescence

Side effects of trazadone

Mild

MMSE score in mild, moderate and severe dementia

Mild = 21-24. Moderate = 10-20. Severe = <10.

Macroscopic findings in DLB

Mild atrophy in frontal, parietal and occipital lobes.

Subjective memory impairment is a risk factor for what?

Mild cognitive impairment. Dementia.

Cognitive effects of hypercalcaemia

Mild memory problems often occur progressing to delirium if calcium levels are very high (>3.8 mmol/L). Confusion.

What is the Yerkes-Dodson law

Mild to moderate levels of anxiety improve performance but high levels impair it

Reasons for referral to secondary care

Moderate to severe mental illness. Serious risk to self, others or property. Uncertainty regarding diagnosis. Poor response to standard treatment. Specialist treatment required e.g. psychological therapies.

When are antidepressants most effective at treating depression/

Moderate-severe depression.

There is a link between increased levels of what neurotransmitters and mania?

Monoamines.

Typical symptoms of an adjustment disorder

Mood and/or anxiety symptoms, which can occasionally be of severity severe enough to cause disturbances of conduct e.g. reckless driving, aggressive behaviour. Many also experience suicidal ideation and increased alcohol consumption.

Usual causes of secondary delusions

Mood disorders

List of adult diorders with onset in childhood

Mood disorders Psychotic disorders Anxiety disorders Substance related problems

Common causes of mood-congruent disorders

Mood disorders e.g. depression/mania with psychotic features

Common causes of second person complex auditory hallucination

Mood disorders with psychotic features. Usually mood congruent i.e. depressed patients will experience critical or persecutory content whereas manic patients will experience complimentary content.

What must you exclude in order to diagnose an adjustment disorder?

Mood, psychotic or anxiety disorder (including PTSD), or a normal bereavement reaction.

Nature of obsessions and compulsions in anorexia nervosa

Morbid fear of fatness (overvalued idea). Thoughts and actions are NOT recognised by the patient as excessive or unreasonable and are not resisted (ego-sytonic). Thoughts do not necessarily provoke, or actions reduce, distress.

Sex ratio for childhood disintegrative disorder

More common in boys

Epidemiological features of paranoid personality disorder

More common in males and lower socioeconomic classes.

Epidemiological features of schizoid personality disorder

More common in males and offender populations

Epidemiological features of narcissistic personality disorder

More common in men and forensic settings

Epidemiological feature common to all cluster 1 personality disorders

More common in relatives of patients with schizophrenia

Epidemiological features of obsessive compulsive personality disorder

More common in white, male, highly educated, married and employed individuals Approximately twice as common in men than women

Sex ratio for anxiety disorders

More common in women apart from social phobia and OCD where they are equal

Link between anxiolytic and hypnotic drugs

Most anxiolytics are hypnotics at higher doses

Abnormal protein in frontotemporal dementia

Most cases: tau. Some cases: progranulin.

Common causes of behavioural problems in patients with intellectual disabilities

Most commonly triggered by a change in life e.g. accommodation, carers etc. rather than a comorbid psychiatric disorder

Set up of "group therapy"

Most groups meet once weekly for an hour and consist of 1 or 2 therapists and about 5-10 patients. Can last for months (CBT orientation) to years (psychodynamic orientation).

S/Es of antipsychotics in pregnancy

Most have no established teratogenic effects, but may cause self-limiting extrapyramidal S/Es in neonates.

Management of primary insomnia

Most important is education about correct sleep hygiene. Limited role for medication: - hypnotics may help in the short term but the development of tolerance to their effects (within 2 weeks), possible dependence and the risk of rebound insomnia limit their use - hypnotics should only be prescribed on a time-limited basis, ideally for use on alternate or occasional nights rather than every night - avoid drugs with a long half-life, to prevent leaving patients feeling drowsy the next day (""chemical hangover"") and to avoid accumulation with repeated doses- may be useful to consider sedative medications (e.g. sedative antihistamines), as they have less potential for dependence or misuse

Neurochemistry of depression

Multiple interacting neurotransmitter pathways are likely to be important. The 2 main abnormalities identified are: - hypothalamic-pituitary-adrenal axis overactivity - deficiency of monoamines (noradrenaline, serotonin, dopamine)

Macroscopic findings in vascular dementia on CT

Multiple small or single large infarct. Cerebral atrophy and compensatory dilated ventricles.

Central over-arching features of somatization disorder (Briquet's syndrome)

Multiple, recurrent, frequently changing physical symptoms, in the absence of identifiable physiological explanation. Numerous symptoms from multiple systems. May have autonomic symptoms, but these are not attributable to only 1 organ or system (as in somatoform autonomic dysfunction disorder). May have pain, but this is not the overwhelmingly dominant symptom.

Requirements for making an advance directive

Must be >18 and must have capacity. Must be signed by a witness.

Age of onset of intellectual disability

Must be before 18 but usually in very early years

Functional impairment in dementia

Must be present to make diagnosis of dementia.

Genetics of personality disorders

Must be some link since monozygotic twins have a higher concordance than dizygotic twins

Causes of familial Parkinson's

Mutations in genes coding for alpha-synuclein and proteins involved in the ubiquitin-proteasome system (e.g. parkin).

Causes of familial forms of frontotemporal dementia

Mutations in genes coding for tau and progranulin.

Physical effects of hallucinogens

Mydriasis Conjunctival injection Hypertension Tachycardia Perspiration Fever Loss of appetite Weakness Tremors

Physical effects of dissociative anaesthetics

Mydriasis Tachycardia Hypertension

GI features of somatization disorder (Briquet's syndrome)

N+V. Diarrhoea/constipation. Food intolerance. Abdo pain.

How memantine works

N-methyl-D-aspartate (NMDA) receptor antagonist - reduces excitotoxic damage by blocking NMDA receptors thus preventing influx of calcium.

Abnormal protein(s) found in vascular dementia

NONE in most cases.

In rare cases, what gene can be linked with vascular dementia?

NOTCH3 on chromosome 19 - involved in vascular smooth muscle cells response to injury.

Diseases that may cause dementia

Neurodegenerative: - Alzheimer's - Frontotemporal dementia - Dementia with Lewy bodies - Parkinson's disease - Huntington's disease - Progressive supranuclear palsy Cerebrovascular disease. Space-occupying lesions. Trauma e.g. head injury, punch-drunk syndrome (dementia pugilistica). Infection. Metabolic and endocrine disorders. Nutritional deficiencies. Drugs and toxins. Chronic hypoxia. Inflammatory disorders. Normal pressure hydrocephalus.

Is there evidence to suggest that response to lithium runs in families?

Yes.

Management of opiate overdose

Naloxone

Drugs to help abstinence post detox of opiates

Naltrexone (opiate antagonist) - blocks the euphoric effects of future opiate use (not naloxone because it would only act short term)

Therepeutic levels of lithium in blood

Narrow: 0.5-1 (>1.5 can be toxic)

Edwards and Gross 1976 alcohol dependence syndrome (on which the ICD-10 criteria are based)

Narrowing of repertoire (drinking becomes increasingly stereotyped with the person drinking the same type of alcohol at the same time of day in the same place). Increased salience of drinking (maintaining the stereotyped pattern of drinking takes priority over other aspects of the patient's life e.g. home and family life, career, previously enjoyed recreational activities) Increased tolerance to alcohol (although remember that tolerance can sometimes decrease considerably in patients who have been drinking heavily for many years) Withdrawal symptoms Relief or avoidance of withdrawal symptoms by further drinking Subjective awareness of the compulsion to drink Rapid reinstatement of dependence features after ending a period of abstinence (e.g. dependence can develop within a few days after abstinence for years)

Is opiate withdrawal dangerous

No, but can be unpleasant and distressing

When can someone with depression be detained under Mental health legislation?

Needs admission but unwilling to accept in-patient treatment due to reduced insight, or lack of capacity to make decisions regarding their treatment.

Environmental causes of intellectual disability

Neglect, malnutrition e.g. iodine, poor linguistic and social stimulation

S/Es of tricyclic antidepressants in pregnancy

Neonatal: hypoglycaemia, low APGAR score, jaundice. Mildly increased risk of foetal malformations.

If an individual has amnesia for committing an offence, does this mean they cannot stand trial?

No.

Which other syndrome can present the same way

Neuroleptic malignant syndrome (caused by neuroleptic drugs e.g. antipsychotics)

Triad that is present in both neuroleptic malignant syndrome and serotonin syndrome

Neuromuscular abnormalities Altered consciousness level Autonomic dysfunction (hyperthermia, sweating, tachycardia, unstable blood pressure)

Causes of idiopathic AKA sporadic Parkinson's

Neuronal death associated with Lewy bodies in the substantia nigra (the site of dopaminergic neurones in the basal ganglia). However, there are often also diffuse Lewy bodies in many brain regions other than the basal ganglia. Abnormal protein degradation may also contribute.

Abnormal proteins in dementia with Lewy bodies (DLB)

Neuronal inclusions of abnormally phosphorylated neurofilament proteins aggregated with ubiquitin and alpha-synuclein in the cortex.

Why does pregnancy a high risk state for relapse/worsening for those already diagnosed with a psychatric illness?

New psychosocial stressors. Change/stop to maintenance medications. Domestic abuse is more common during pregnancy.

Definition of neologisms

New words created by the patient, often combining syllables from other words

Important to distinguish sleep terrors from what other conditions?

Nightmares. Panic attacks. Epileptic seizures.

Examples of parasomnias

Nightmares. Sleep terrors Sleepwalking.

Is an individual with a mental disorder exempt from taking responsibility for their actions?

No, but they should be competent to stand trial and mount a defence against their charges (this capacity is known as "fitness to plead").

Is cannabis use increasing amongst young people

No, it is decreasing

Is there a clear distinction between developmental and acquired disorders

No, many 'acquired' disorders have a very strong genetic component

Can patients subject to a CTO be given medication by physical force in the community

No, must be detained in hospital to do this.

Is unplanned short notice detox good

No, only done if has to be e.g. inpatient for another reason Better to plan in advance to allow the perpetuating factors for dependence to also be addressed

Are all forensic psychiatry patients kept in secure wards?

No, some can be managed in the community.

Can ECT be given in an emergency to patients with capacity who refuse

No

Can antidepressents cause dependence

No

Can confidentiality be maintained if a child tells you they are being abused

No

Does the MMR vaccine cause autism

No

In general, is treatment of medical disorders unrelated to a psychiatric disorder covered by the Mental Health Act

No

Is buspirone associated with dependence or abuse

No

Is capacity task-specific

No

Is psychological debriefing immediately after trauma advised to prevent PTSD

No

Is there a cure for schizophrenia

No

Is mental illness common in those with psychopathy?

No (there is no link with schizophrenia and it is inversely associated with depression).

Can emergency treatment be given under an emergency detention order

No - but emergency treatment may be possible under common law.

Are emotional disorders discrete illnesses

No - exaggerations of normal developmental trends

Is the word addiction good to use

No - use dependence instead as there is confusion over the meaning of addiction

EEG changes in new-variant CJD

No characteristic ones.

Use of HRT for mental illness after the menopause

No clear psychiatric indication for HRT. It should never substitute treatment with recognised antidepressants for depression.

Can you drive with acute psychosis/schizophrenia

No during acute episodes. Can resume once stable for 3 months (3 years for group 2), compliant with harmful adverse effect free treatment and subject to a specialist report.

Social class risk factors for eating disorders

No effect for bulimia May be more common in high classes for anorexia but disputed

Pharmacological treatment of borderline personality disorder

No medications are currently licensed specifically for it however they can be used to treat comorbid mental illness or to manage cases of behavioural disturbance and suicidal behaviour during more severe phases. Antipsychotics (particularly second generation e.g. olanzapine, aripiprazole) can be used to treat the pseudo-psychotic symptoms that are sometimes experienced. Antidepressants can be used to relieve depressive symptoms. SSRIs can also help with obsessive-compulsive symptoms, impulsivity and self-harm. Flupentixol decanoate (another antidepressent) can reduce suicidal behaviour. Mood stabilizers e.g. lithium, sodium valproate and lamotrigine can be used to treat aggression, impulsivity and mood instability. No current evidence for a drug that reduces the overall severity of BPD.

Alcohol limits for 'harmful drinking'

No unit definition. Defined as the actual amount for an individual which causes harmful consequences (not dependence).

Are benzos and Z drugs dangerous in overdose

No usually, unless taken in combination with other sedatives e.g. alcohol, opiates, barbiturates, TCAs, antihistamines (then there is a risk of respiratory depression)

Can you drive with dementia/organic disorders

No, apart from group 1 (cars and motor bikes) who may drive if it is very mild and who undertake an annual review.

If a woman was on an antidepressent during pregnancy, should she be changed onto a antidepressant post-delivery that is "better for breast-feeding"?

No, as this would mean exposing the child to 2 different drugs instead of 1 and, the foetus was exposed to much greater levels of antidepressant in utero than levels transmitted in breast milk so if they are healthy at delivery they are unlikely to be harmed by further lower exposure.

Principles of the MHA

Non-discrimination - mentally ill patients have the same rights as physically ill. Equality - no discrimination. Respect for diversity - treatment should be sensitive to individual background and needs. Reciprocity - where an obligation is placed on a patient, there is also an obligation on the health service to provide appropriate care. Informal care (without compulsory powers) should be used where possible. Patients should be involved in planning wherever possible. Support and listen to the advice of carers. Least restrictive alternative. Benefit - interventions under the act should give benefit not achievable without the act. Child welfare.

What are day hospitals

Non-residential units that patients attend during the day to give a high level of support.

Mechanism of action of MAOIs

Non-selective and irreversible inhibition of monoamine oxidase A and B. Blocks the degradation of serotonin.

Sexual dysfunction disorders - types of sexual pain

Nonorganic dyspareunia. Vaginismus.

Presentation of Rett's syndrome

Normal development antenatally and in the first 5 months after birth - normal head circumference at birth and apparently normal psychomotor development. From 6-24 months, a progressive and destructive encephalopathy results in a deceleration of head growth, loss or lack of development of language and loss of purposeful hand movements and fine motor skills, with subsequent of stereotyped hand movements e.g. midline hand-wringing. After a decade, most girls are bound to a wheelchair with incontinence, muscle wasting and rigidity and almost no language ability.

Clinical features of "subcortical" dementias

Normal language. Dysarthric speech. Normal praxis. Usually no agnosia. Calculation normal until late. Stooped or extended posture, increased tone. Extra movements: tics, chorea, tremor.

Nature of obsessions in depressive disorder

Obsessive-compulsive symptoms occur simultaneously with, or after the onset of, depression and resolve with treatment. Obsessions are mood-congruent e.g. ruminatory thoughts of worthlessness.

Consciousness level in dementia

Normal.

In most cases of dementia, how is a definitive cause established with absolute certainty?

Normally can only be made on post-mortem because, even though the different types have distinguishing clinical features, it can be difficult to tell them apart only on clinical examination.

Short term and working memory in amnesia

Not affected.

Features of lowered consciousness level

Not awake and either not rousable or rousable but then do not stay awake throughout assessment.

Conditions associated with the development of autism

Not exact cause found but genetic, prenatal, perinatal and immunological factors implicated Phenylketonuria Tuberous sclerosis Congenital rubella Fragile X syndrome Rett's syndrome

Definition of primary delusion and different features that can meet the criteria

Not in response to any previous psychopathological state. Still counts as primary even if preceded by a general delusional atmosphere in which the patient has a sense that the world around them has subtly altered. Can also be a 'delusional perception' - when a delusional meaning is attached to a normal perception e.g. believing you are a terrorist target because you heard a plane in the distance.

Mechanisms of action of mood stabilisers

Not known

Mortality risk from bulimia

Not raised, but it increasing risk of depression and substance misuse which can cause mortality

Can antidepressents and benzos be used to maintain abstinence post detox

Not recommended unless there is a comorbid psychiatric illness

Pharmacological treatment of anorexia

Not recommended, particularly in patients who are underweight SSRIs can sometimes be used for comorbid depression and OCD

Disadvantages of MMSE

Not sensitive to mild impairment. Does not test executive function. Influenced by premorbid IQ, language and culture.

Disadvantages of CLOX1

Not sensitive to mild impairment. Very influenced by poor motor control or visual impairment.

Disadvantages of AMT

Not sensitive to mild-moderate cognitive impairment.

How effective are antidepressants for alcoholic patients

Not very effective if they continue drinking due to the powerful psychoactive effects of alcohol

Pathophysiology of obstructive sleep apnoea syndrome

Obstruction of the upper airways during sleep, despite an adequate respiratory effort.

Prognosis for alcohol dependence

Numerous relapses often occur however 65% have abstinence 1 year post treatment

Environmental changes to help relieve symptoms of delirium

Nurse with same staff to limit confusion and foster trust. Calm, consistent, reassuring nursing staff. Encourage presence of friend/family member - comfort and orientation help. Quiet, peaceful room e.g. move to single room. Optimise sensory acuity (e.g. glasses, well lit room, hearing aid) to avoid misinterpretation of stimuli. Orientation aids e.g. clock, calendars, familiar objects.

ICD-10 diagnostic guidelines for obsessive-compulsive disorder

Obsessions or compulsions for >=2 weeks and are a source of distress or interfere with the patient's functioning, and are acknowledged as coming from the patient's own mind. Obsessions are unpleasantly repetitive. At least 1 thought or act is resisted unsuccessfully (in some chronic cases, some symptoms may no longer be resisted). A compulsive act is not in itself pleasurable (excluding the relief of anxiety).

Signs of lithium toxicity at >2 mmol/l

Nystagmus Dysarthria Impaired consciousness Hyperactive tendon reflexes Oliguria Hypotension Convulsions Coma

Possible psychiatric cause of secondary anxiety concerning obsessional thoughts or resisting compulsion

OCD

Which conditions are associated with Tourette's

OCD ADHD

Clinical uses of exposure with response prevention therapy

OCD.

Risk factors for obstructive sleep apnoea

Obesity. Old age. Hypertension. Intellectual disability.

Mild cognitive impairment

Objective cognitive impairment (confirmed with a standardised test) that DOES NOT interfere notably with activities of daily living (no functional impairment).

How is consciousness assessed?

Observing arousal level (hyperaroused or lowered).

Nature of obsessions in hypochondriacal disorder

Obsessions only related to the fear of having serious disease or bodily disfigurement.

What is the most common personality disorder

Obsessive-compulsive (1.2-7.9%)

Differential diagnoses of obsessions and compulsions

Obsessive-compulsive disorder. Eating disorders. Obsessive-compulsive (anakastic) personality disorder.

Most common breathing-related sleep disorder

Obstructive sleep apnoea syndrome.

When do orientation problems occur in dementia compared to delirium?

Occur in late stages in dementia in contrast to being common in delirium from the start.

Symptoms of benzodiazepine withdrawal

Occur within hours to days of stopping benzos, depending on the exact half-life of the benzo Hallucinations Convulsions Delirium

Hypnagogic hallucination

Occurring just as you are falling asleep. Often visual or auditory but healthy patients can get kinaesthetic (e.g. sensation of falling)

Features of REM (stage 5) sleep

Occurs cyclically through the night, every 90 minutes alternating with non-REM sleep. Each episode increases in duration. Most episodes occur in the last third of the night. Get penile erections, skeletal muscle paralysis, surreal dreaming (including nightmares).

When does perceptual disturbance occur in dementia compared to delirium?

Occurs in late stages of dementia in contrast to it being very common in dementia.

Normal stranger anxiety

Occurs in well-adjusted children from 8 months to 1 year old.

Relationship between agorophobia and panic disorder

Patients often fear being in a crowded place in which they couldn't escape if they started having a panic attack. 95% of patients with agorophobia have a history of panic disorder.

What is a "traumatic stressor"?

Occurs outside the range of normal human experience. It's magnitude means that it would be experienced as traumatic by most people. Occurs in situations where a person feels that their own (or loved one's) physical or psychological integrity is under serious threat. E.g. natural disasters, physical or sexual assaults, serious road traffic accidents, terrorist attacks, torture, military combat. Bereavement is also a special case of traumatic stress.

Timescale of acute stress reaction

Occurs within a few minutes of a traumatic stressor. Symptoms normally begin to diminish within 24-48 hrs and are usually minimal after 3 days.

Medical management of frontotemporal dementia to maintain cognitive function

Of little benefit - no medical management currently recommended.

Mania and crime

Offences usually reflect financial irresponsibility or acts of aggression, which are usually not serious.

Risk of violent crime due to delusional jealousy (Othello's syndrome)

Often associated with alcohol abuse and linked to violent crime such as assault and homicide.

Progression of schizophrenia-like psychotic disorder

Often develop into schizophrenia

Aetiology of normal pressure hydrocephalus

Often idiopathic.

Features of specific personality disorder

Often just referred to as 'personality disorders' as they are so much more prevalent. No link to a specific insult.

Insight in dementia

Often poor.

Stigma surrounding those with functional symptoms

Often stigmatised by healthcare providers and given labels such as: "fat folder syndrome", "all in the mind", "the worried well".

2nd generation antipsychotics

Olanzapine Quetiapine Risperidone Aripiprazole Clozapine

Which antipsychotic is widely used for puerperal psychosis?

Olanzapine.

Common cause of Charles Bonnet syndrome

Older adults with loss of vision

Which two types of hallucination often occur together

Olfactory and gustatory

The relationship between psychopathy and antisocial personality disorder

On a spectrum, with psychopathy being an extreme version of it (characterised by antisocial behaviour and emotional impairment, such as diminished capacity for guilt and remorse). ICD-10 and DSM-IV do not recognised psychopathy as a diagnosis but it is narrowly defined by the Hare Psychopathy Checklist - Revised (PCL-R). However, assessments of psychopathy characteristics are widely used in criminal justice settings in some nations.

How often can compulsory treatment orders be appealed

Once during each renewal period.

Management of Munchausen syndrome by proxy

Once the diagnosis is made, remove the dependent from direct influence of the carer and alert the relevant authorities (e.g. child/adult protection agencies). Offer affected carer psychiatric help but as the condition is rare, little is known about effective treatment.

How does "interpersonal therapy" work?

One of the following areas is chosen as the main focus: - role disputes - role transitions - interpersonal deficits - loss or grief

Genetics of ADHD

One of the highest heritabilities of all psychiatric illnesses.

Which antidepressents are best for treating severe depression that requires hospitalisation

Ones that affect both noradrenaline and serotonin e.g. TCAs, high dose venlafaxine.

Who should make the diagnosis of hyperkinetic disorder

Only a specialist psychiatrist, paediatrician or other professional with expertise in the diagnosis of ADHD.

Can you drive with a learning disability

Only if it is mild and doesn't impair functionality

Can you drive with a persistent behavioural disorder

Only if sufficiently controlled with treatment.

When is pharmacotherapy effective for somatoform disorders

Only if there is a genuine comorbid drug-responsive condition e.g. anxiety/depression

Route for lithium

Only oral

S/Es of antipsychotics during breast-feeding

Only small amounts excreted but possible effects on developing nervous system. Avoid high doses due to risk of infant lethargy.

Use of antipsychotic (e.g. haloperidol) in the management of delirium tremens

Only use for severe psychotic symptoms as you risk lowering the patient's seizure threshold

Definition of early-onset dementia

Onset <65yo.

Which other drug class can cause serotonin syndrome with MAOIS

Opiates (particularly pethedine) as they have some serotonin reuptake inhibitory effects.

Which illicit drugs have the greatest potential for dependence

Opiates and cocaine

Freudian stages of emotional development (really wierd...) - read wikipedia page if you want to know what it's all about

Oral Anal Genital Latency Adolescence

Drug given to prevent Wernicke-Korsakoff syndrome

Parenteral (IV) thiamine (Pabrinex) twice daily for 5 days

Risk factors for child abuse

Parents who were abused Parental substance abuse Parental mental illness Step-parent Young, immature parents Parental criminality Poor socioeconomic status and overcrowding Low birth weight or prematurity Early maternal separation Unwanted child Intellectual or physical disability Challenging behaviour Hyperactivity Excessive crying

What route are Z drugs given by

Oral only

What disease is perseveration suggestive of

Organic brain disease

Most common causes of visual hallucinations

Organic disorders e.g. delerium, occipital lobe tumours, epilepsy and dementia. Psychoactive substance abuse e.g. LSD, mescaline, petrol/glue sniffing, alcoholic hallucinosis.

Where does most detoxification take place

Out-patient or community based

Neurotransmitter risk factors for schizophrenia

Overactivity of the mesolimbic dopamine system. Antipsychotics block dopamine receptors and antiparkinsonian drugs potentiate it. BUT could be an effect rather than a cause of schizophrenia. Also, serotonin and glutamate.

Malingering

Patients focus on secondary (external) gain of the secondary consequence of being diagnosed with an illness (e.g. avoidance of military service, evading criminal prosecution, obtaining illicit drugs, obtaining benefits or compensation).

Body dysmorphic disorder (AKA dysmorphophobia)

Patients preoccupied with an imagined or minor defect in their physical appearance. ICD-10 considers it a variant of hypochondriacal disorder.

Are the thoughts held in hypochondriacal disorder and body dysmorphic disorder delusions or overvalued ideas?

Overvalued ideas (as patients are open to some explanation and their fears can be alleviated, at least for a short while).

Early life experiences that increase vulnerability to depression

PARENTAL SEPARATION DURING CHILDHOOD increases risk of depression in adult life, either due to loss of parent or disruption of care. CHILDHOOD NEGLECT, PHYSICAL/SEXUAL ABUSE. POSTNATAL DEPRESSION IN MOTHERS can be associated with indifferent early upbringing, leading to poor self-esteem and increased risk of depression in the child.

Examples of MAOIs (monoamine oxidase inhibitors)

Phenelzine, traylcypromine, isocarboxazid

First antipsychotic to be invented

Phenothiazine chlorpromazine

Examples of behavioural symptoms common in dementia

Pacing. Shouting. Sexual disinhibition. Aggression. Apathy.

Which paraphilias are seen more in the forensic settings and account for the majority of sexual offenders referred to pscyhiatry?

Paedophilia. Exhibitionism.

What is "sexual dysfunction"?

Pain associated with intercourse OR abnormalities of the sexual response cycle that lead to difficulties in participating in sexual activities. Sexual dysfunction disorder can only be diagnosed according the ICD-10 if there is a psychogenic component to the problem.

Medical conditions that can cause insomnia

Painful conditions e.g malignancy, arthritis, GORD. Cardiorespiratory discomfort e.g. SOB, coughing, palpitations. Nocturia. Thyroid disease. Renal or liver failure. CNS lesion.

Hypochondriacal disorder

Patients misinterpret NORMAL BODILY SENSATIONS, which lead them to believe that they may have a serious and progressive physical disease. Not consciously fabricated and under voluntary control. Ask for investigations to definitively diagnose or confirm their underlying disease but despite repeated normal examination and investigations, REFUSE to accept the reassurance of numerous doctors that they do not suffer from a serious physical illness.

Description of modelling therapy (type of behaviour therapy)

Patients observe the therapist being exposed to the phobic stimulus then attempt the same.

Haematological problems from alcohol use

Pancytopaenia Macrocytosis

How is a panic attack different from a sleep terror?

Panic attacks tend not to be associated with confusion and amnesia is incommon following them.

Definition of panic disorder

Panic attacks that occur unpredictably and are not restricted to any particular situation or objective danger. Anticipatory anxiety: patients develop a fear for having further attacks.

Most heritable anxiety disorders

Panic disorder OCD

Where are Lewy bodies in DLB found in the brain?

Paralimbic and neocortical structures.

Neurological features of somatization disorder (Briquet's syndrome)

Paralysis. Paraesthesia. Sensory loss. Seizures. Difficulty swallowing. Impaired coordination/balance.

Types of cluster A disorders

Paranoid Schizoid Schizotypal

In what other conditions are Lewy bodies found?

Parkinson's. Alzheimer's. Down's syndrome. Sometimes in those without dementia.

Types of "subcortical" dementias

Parkinson's. Dementia with Lewy bodies. Huntington's. Progressive supranuclear palsy. Wilson's disease. Normal pressure hydrocephalus. MS. HIV-related dementia.

Which SSRI is contraindicated in pregnancy?

Paroxetine (associated with foetal heart defects such as atrial and ventricular septal defects, especially in the 1st trimester, and neonatal pulmonary hypertension if used later in pregnancy).

S/Es of SSRIs during breast-feeding

Paroxetine and sertraline: very small amounts excreted in breast milk, short half-life. Fluoxetine and citalopram: excreted in larger (but still safe) amounts, however fluoxetine has a longer half-life and may accumulate.

Dissociative amnesia

Partial or complete memory loss for events of a traumatic or stressful nature NOT due to normal forgetfulness, organic brain disorders or intoxication.

Dissociative motor disorders

Partial or complete paralysis of one or more muscle groups not due to any physical cause.

Use of ECT in schizophrenia

Particularly effective for catatonic states, positive psychotic symptoms and schizoaffective disorder

Basis of sex therapy

Partners are treated together. Taught to communicate openly. Educated about sexual anatomy and the physiology of the sexual response cycle. Take part in graded assignments, beginning with caressing of their partner's body, without genital contact, for their own and their partner's pleasure. These tasks progress through a number of stages with increasing sexual intimacy, with the focus remaining on pleasurable physical contact as opposed to monitoring of sexual arousal or preoccupation with achieving orgasm.

Environmental risk factors for bulimia

Past exposure to dieting behaviour e.g. childhood obesity, parental obesity, early menarche Family conflict (more so than for anorexia) Alcohol/substance abuse, personality disorders, depression

Types of psychoanalytic "defence mechanisms"

Pathological: - denial - projection - splitting Immature: - fantasy - somatisation Neurotic: - repression - reaction-formation - intellectualisation Mature: - humour - sublimation - suppression

Cognitive model of panic attack

Patient become aware of a normal body stimulus e.g. the beating of their heart. They miss interpret it as a sign that something is wrong. This triggers sympathetic activation which leads to a vicious circle

Subjective cognitive impairment

Patient complains of cognitive problems but performs normally on standardised tests. Can reflect anxiety or depression, but can also represent early deterioration in a highly educated individual that is unidentifiable using standard tests.

Definition of thought blocking

Patient experiences a sudden cessation to their low of thought, often in mid-sentence. They have no recall of what they were saying or thinking so continue talking about a different topic.

Factitious disorder (Munchausen's syndrome)

Patient focussed on the primary (internal) gain of assuming the sick role (aim to be cared for like a patient, usually in hospital). Symptoms feigned, however this care-seeking behaviour is usually a manifestation of psychological distress.

Definition of third person complex auditory hallucination

Patient hears a voice or voices speaking about them e.g. a running commentary on their thoughts/actions or two voices having a discussion about them.

Definition of second person complex auditory hallucination

Patient hears a voice talking directly to them e.g. being persecutory, critical, complimentary or issuing commands.

Definition of first person complex auditory hallucination

Patient hears their own thoughts as they speak them

Definition of catatonic waxy flexibility (flexibilitas cerea)

Patients can be 'moulded' like wax into a position which is then maintained

Description of exposure with response prevention therapy (type of behaviour therapy)

Patients encouraged to resist carrying out compulsions until their urge/obsessional thought diminishes. They are then exposed to more severe compulsion-evoking situations. Relaxation techniques are used instead to overcome the anxiety associated with not carrying out the compulsion.

Description of activity scheduling and target setting therapy (type of behaviour therapy)

Patients encouraged to structure their day with certain activities, as reduced activity can lead to further lowering of mood due to reduced stimulation and opportunity for positive experiences.

Which is harder to treat: anorexia or bulimia?

Patients with anorexia tend to be ambivalent towards treatment and the psychological consequences of starvation (poor concentration, depression, lethargy) make it more difficult to treat. Patients with bulimia tend to be more motivated to address their eating difficulties.

What is "somatoform autonomic dysfunction disorder"?

Patients with this disorder have 2 types of symptoms, both concerning the autonomic nervous system: - objective evidence of autonomic arousal (e.g. sweating, palpitations, tremor) - subjective symptoms (e.g. pains, burning, heaviness, tightness, feeling bloated) Patients attribute these symptoms to a particular organ or system that is largely under autonomic control e.g. cardiovascular, respiratory or GI systems.

Observational learning theory (modelling) of alcohol dependence

Patterns of drinking are modelled on on those of family and friends ... family studies support the idea that drinking habits follow those of older relatives

Who described "classical conditioning"?

Pavlov.

Definition of hallucination

Perception occurring in the absence of external stimuli

5 key symptom groups of psychosis

Perceptual disturbance Abnormal beliefs Thought disorder Negative symptoms Psychomotor dysfunction

Definition of pseudohallucination

Perceptual experience which arises in the subjective inner space of the mind. Experienced with the mind's eye or the mind's ear but not under conscious control. e.g. distressing flashbacks in PTSD or hearing a voice inside your head.

Personality traits associated with bulimia

Perfectionism (less so than for anorexia)

Operant conditioning explanation of alcohol dependence

Positive reinforcement: pleasant effects of alcohol consumption reinforce drinking (despite adverse social and medical consequences) Negative reinforcement: desire to avoid withdrawal symptoms reinforces drinking

Medical complications related to vomiting

Permanent erosion of dental enamel (perimylolysis), dental cavities Enlargement of salivary glands, especially parotids Calluses on the back of hands from repeated teeth trauma (Russell's sign) Oesophageal tears, gastric rupture

What else needs to be addressed in treating opiate dependence and maintaining abstinence

Perpetuating sociocultural factors

What is social anxiety disorder

Persistent and recurrent fear and/or avoidance of strangers with anxiety that is markedly different to what you would expect at that age or persists beyond usual age period.

What is oppositional defiant disorder

Persistent pattern of negativistic, defiant, hostile and disruptive behaviour but WITHOUT behaviour that violates the law or the basic rights of others e.g. theft, cruelty, bullying, assault. They often deliberately defy requests or rules, are angry and resentful and annoy others on purpose.

Possible consequences of narcolepsy

Persistent tiredness. Problems with memory and concentration.

Criteria for compulsory intervention under MHA

Person has a mental disorder. Medical treatment is available which would likely prevent that disorder worsening or be likely to alleviate the effects of the disorder. There would be a significant risk to the patient's health, safety or welfare, or to the safety of another person if such treatment were not provided. The patient's ability to make decisions about the provision of medical treatment is significantly impaired because of their mental disorder. The making of the order is necessary.

Possible psychiatric cause of secondary anxiety concerning being rejected or inadequate

Personality disorder (avoidant)

Possible psychiatric cause of secondary anxiety concerning separation or abandonment

Personality disorder (emotionally unstable or dependent)

Uses of therapeutic communities

Personality disorders (especially borderline personality disorder). Behavioural problems.

Neuropsychiatric conditions that cause intellectual disability

Pervasive developmental disorders e.g. autism, Rett's syndrome

Diagnostic flow chart for medically unexplained physical symptoms

Pg 101 in crash course.

Assessment of consciousness level flow chart?

Pg 104 of crash course.

Contraindications to MAOIs

Phaeochromocytoma, cerebrovascular disease, hepatic impairment, mania

Sequence of normal psychological and physiological responses to sexual stimulation

Phase 1: desire - sexual fantasies and the desire to have sexual activity Phase 2: excitement - subjective sense of sexual pleasure and the accompanying physiological changes (e.g. erection in the man, vaginal lubrication in the woman) Phase 3: orgasm - peaking of sexual pleasure, release of sexual tension and rhythmic contraction of the perineal muscles and pelvic reproductive organs (men: sensation of ejaculatory inevitably followed by ejaculation; women: contractions of outer third of vagina Phase 4: resolution - sense of muscular relaxation and general well-being - men are refractory to further erection and orgasm for a period of time whilst women may be able to have multiple orgasms

Clinical uses of modelling therapy

Phobias and avoidance.

Clinical uses of exposure therapy

Phobias and avoidance. PTSD.

Specific side effect for chlorpromazine

Photosensitivity

Definition of complex auditory hallucination

Phrases, sentences or dialogue

What should always be ruled out in a patient with prominent visual hallucinations?

Physical illness.

Presentation of child abuse

Physical manifestations Failure to thrive Symptoms of depression, anxiety, aggression Age-inappropriate sexual behaviour Self harm

Shared features of factitious disorder and malingering

Physical or psychological symptoms produced intentionally or feigned. Patients may give convincing histories and often manufacture signs (e.g. warfarin ingestion to simulate bleeding disorders, insulin injection to produce hypoglycaemia, urine contaminated with blood or faeces) or psychological symptoms (e.g. hallucinations, delusions, depression, dissociation).

Slang names for ecstasy

Pills

What does "dangerous severe personality disorder (DSPD)" mean?

Political, rather than clinical, term to describe "individuals from whom the public at present are not properly protected, and who are restrained effectively neither by the criminal law, nor by the provisions of the Mental Health Act". Controversial concept which concerns a lot of psychiatrists.

Risk factors for sexual dysfunction

Poor physical and emotional health. Negative experiences in sexual relationships (history of rape or childhood sexual abuse). Ambivalent attitude about sex or intimacy (e.g. anxiety, fear, guilt, shame). Fears of consequences of sex (e.g. impregnation, STIs). Poor or deteriorating relationship (e.g. feeling oneself or partner to be undesirable, lack of trust, feelings of resentment or hostility, lack of respect, fear or rejection). Anxiety about sexual performance or physical attractiveness. Fatigue, stress, difficult psychosocial circumstances.

Indications for ECT in depression

Poor response to adequate trials of antidepressants. Intolerance of antidepressants due to S/Es. Depression with severe suicidal ideation/psychotic features/severe psychomotor retardation/stupor/severe self-neglect (poor fluid and food intake). Previous good response to ECT. Remember, cannot treat treatment-resistant depression in a patient who has capacity and refuses it.

Sexual dysfunction disorders with the worst prognoses

Poor sexual desire, especially in men.

Common chronic stress circumstances that increase vulnerability to depression

Poor social support (e.g. lack of someone to confide in). Unemployment. Raising young children. Chronic pain/illness, particularly heart disease and stroke.

Does rapid cycling bipolar generally have a good or poor prognosis?

Poor.

Definition of loosening of association/derailment/knight's move thinking

Poorly or unrelated concepts with no clear goal

What sort of symptoms are antipsychotics effective for

Positive but not negative ones

Whenever someone presents with anxiety or depression, what should always be checked for?

Possible psychosocial stressors and how they (if at all) relate to the onset of symptoms - make sure to verify how they were perceived to the patient even if they seem insignificant.

Mechanism of action of benzos

Potentiate the action of GABA (an inhibitory neurotransmitter that reduces the excitability of synapses). Act at the specific benzodiazepine receptor

Difference between a power of attorney and a guardian

Power of attorney can only be granted by somebody >18 and who currenty still has capacity. They are usually used as a 'safety net' for in case they lose capacity in the future. Guardianship is granted by a court once the person has lost capacity and therefore cannot appoint a power of attorney.

Potential environmental triggers for ADHD

Pre- and peri-natal factors Prolonged emotional deprivation

Stages of change according to Prochaska and DiClemente

Pre-contemplation (not thinking about change) Contemplation (thinking about change) Preparation (decision to make change) Action (making change) Maintenance (trying to prevent relapse) Relapse (return to previous behaviour)

What is the risk of discontinuing lithium?

Precipitation of relapse - hence net benefit only likely to be gained after treatment for 2 yrs.

Phases of Prochaska and DiClemente Transtheoretical Model of Change

Precontemplation Contemplation Preparation Action Maintenance (Relapse) Termination

What is a "self-fulfilling prophecy"?

Prediction that directly or indirectly causes itself to become true, by the very terms of the prophecy itself, due to (unconscious) positive feedback between belief and behavior. It is a term used in CBT, and is not a psychodynamic concept.

Features of late-onset schizophrenia

Predominantly delusional thinking (usually persecutory or grandiose, but tend to not be as bizarre as they sometimes are in early-onset schizophrenia). May have hallucinations.

Contraindications to lithium

Pregnancy, breastfeeding, impaired renal function, thyroid disease, cardiac conditions, neurological conditions e.g. Parkinson's or Huntington's.

Who to refer to perinatal psychiatry?

Pregnant with a major mental health condition (bipolar affective disorder, schizophrenia, severe depression). Those with a history of puerperal psychosis who are pregnant or planning pregnancy, even if they have been stable for years. For preconceptual counselling (e.g. women with bipolar). Women who are psychiatrically unwell and are the main carers of babies under 6 months old.

Most common types of sexual dysfunction in men in decreasing order

Premature ejaculation. Lack of sexual interest. Erectile dysfunction. Unable to achieve orgasm.

Presentation of obsessive-compulsive (anankastic) personality disorder

Preoccupation with orderliness, perfectionism and control Devoted to work at expense of leisure Pedantic Rigid and stubborn - often places great strain on interpersonal relationships Overly cautious Unlike OCD however, the obsessive thoughts are ego syntonic and are not distressing Freud previously described it as "anal retentive character"

Predictors of good prognosis for antisocial personality disorder

Presence of anxiety, depression or psychosis.

Criteria for Gilles de la Tourette's syndrome

Presence of both multiple motor tics and >=1 vocal tics for more than 1 year.

Cotard's syndrome

Presence of nihilistic and hypochondriacal delusions as part of a depressive psychosis, typically seen in older adults.

Cause of vascular dementia

Presumed to be multiple cortical infarcts or many small subcortical infarcts in white matter (Binswanger's disease) resulting from widespread cerebrovascular disease. On occasions, can arise from a single infarct.

Mechanism of action of NaSSA

Presynaptic alpha 2 receptor blockade (results in increased release of noradrenaline and serotonin from presynaptic neurons

Mechanism of action of SNRIs

Presynaptic blockade of both noradrenaline and serotonin reuptake pumps (also dopamine at high doses) but with negligible effects on muscarinic, histaminergic or alpha-adrenoreceptors (unlike TCAs)

Mechanism of action of tricyclics

Presynaptic blockade of both noradrenaline and serotonin reuptake pumps (as well as dopamine to a lesser extent). Also blocks muscarinic, histaminergic and alpha adrenergic receptors.

Does possession of 1 of the 3 genes associated with early-onset Alzheimer's guarantee that they will inherit the condition?

Pretty much.

Risk factors for puerperal psychosis

Previous puerperal psychosis. History of mood disorder (particularly bipolar). FMH of puerperal psychosis or bipolar. Primiparous mother. Delivery associated with C-section or perinatal death. Occasionally precipitated by an obstetric complication (e.g. pre-eclampsia, puerperal infection) or medication. Psychosocial factors seem less important e.g. troubled relationships.

Can personality disorders be treated

Previously thought that they couldn't but now known that treatment can be used to improve engagement with sevices, reduce distress, manage comorbid mental illness and substance misuse, improve relationships and optimise quality of life.

Epidemiological features of histrionic personality disorder

Previously thought to be more common in women but probably actually equal

Primary vs. secondary enuresis

Primary = continence has never been established. Secondary: continence has previously been established for at least 6 months.

In what setting can most patients with depression be treated?

Primary care/out-patient psychiatric clinic.

Who acts as the named person if the patient has not nominated one

Primary carer or nearest relative. If <16 then a parent.

Examples of dyssomnias

Primary insomnia. Primary hypersomnia. Narcolepsy. Circadian rhythm sleep disorders. Breathing-related sleep disorders.

Causes of insomnia

Primary sleep disorders: - primary insomnia - circadian rhythm sleep disorders (e.g. jet-lag, shirt work) - breathing-related sleep disorders (e.g. sleep apnoea) - parasomnias Psychiatric: - anxiety - depression - mania - schizophrenia Medical. Substances.

Common causes of hypersomnia

Primary sleep disorders: - primary insomnia - narcolepsy - circadian rhythm sleep disorders (e.g. jet-lag, shirt work) - breathing-related sleep disorders (e.g. sleep apnoea) - parasomnias (all) Psychiatric: depression with atypical features. Medical. Substances. Sleep deprivation.

Ways of classifying delusions

Primary/secondary Mood congruent/incongruent Bizzare/non-bizzare By content

Kuru

Prion disease transmitted by cannibalism of neural tissue. Tribes in New Guinea.

Pathology of specific developmental disorders

Probably a specific biological abnormality in cognitive processing rather than a lack of opportunity to learn, sensory impairment or neurological disease

Developmental problems which were previously thought to be risk factors for schizophrenia but have been discredited

Problems with the relationship between the patient and their family e.g. schizophrenogenic mothers.

Definition of perception

Process of making sense of the the physical information we receive through our sensory modalities

Brain CT appearance in normal ageing

Progressive cortical atrophy. Increasing ventricular size.

Course of dementia - fluctuating or progressive deterioration?

Progressive deterioration.

Description of relaxation therapy (type of behaviour therapy)

Progressive relaxation of muscle groups, breathing exercises, visualising relaxing images and situations ("guided imagery").

Old name for dissociative convulsions

Pseudoseizures.

Definition of paranoid schizophrenia

Prominant: positive symptoms (delusions and hallucinations). Less prominant: negative/catatonic symptoms.

General treatment of Wernicke's encephalopathy

Prompt treatment with Pabrinex (IV thiamine) to prevent progression to Korsakoff's

Treatment of akathisia

Propranolol or short-term benzos.

Definition of schizophrenia-like psychotic disorder

Psychotic episode with schizophrenia-like symptoms BUT: abrupt onset without prodromal phase; precipitated by an acute life stress or of short duration. AKA acute/transient psychotic disorder.

Nature of obsessions in phobias

Provoking stimulus comes from external object or situation rather than patient's own. Absence of genuine obsessions or compulsions.

How does psychodynamic psychotherapy differ from psychoanalysis?

Psychoanalysis: - clients see analysts several times a week for a non-specified period of time, with the client lying on a couch with the analyst sitting behind them out of view - analyst may be quieter than in psychodynamic psychotherapy - there is space for the client to explore what comes into their own mind, and for the analyst to help the client understand how they relate to the therapist (transference) and others - due to it being time- and resource-intensive, it is seldom offered by the NHS but is still available in the private sector Psychodynamic psychotherapy: - based on psychoanalytic theory but it tends to be more interactive - once weekly for 50 mins - patient and therapist sit face to face - number of sessions depends on patient's needs, ranging from 4 months to several yrs - individual or group-based - offered by the NHS

What is "conversion"?

Psychoanalytical term that describes the hypothetical process whereby psychic conflict or pain undergoes "conversion" into somatic or physical form to produce physical symptoms. Considered by ICD-10 as dissociative disorders. Typically involves loss of motor or sensory function. Patient does not conscious feign the symptoms.

Name of somatoform autonomic dysfunction disorder of the respiratory system?

Psychogenic hyperventilation.

What is "repetition compulsion"?

Psychological phenomenon in which a person repeats a traumatic event or its circumstances over and over again. This includes (unconsciously) reenacting the event or putting oneself in situations where the event is likely to happen again.

What is elective mutism associated with

Psychological stress Social anxiety Oppositional behaviour

Self-help resources

Psychological techniques (especially CBT). Educational resources e.g. books, DVDs, interactive websites, discussion groups including internet forums.

General treatment categories for moderate-severe anxiety with functional impairment

Psychological therapy and/or Pharmacological therapy

Main type of treatment for bulimia

Psychological, usually out-patient or community - psychoeducation, self-help manuals groups in mild cases - CBT or interpersonal psychotherapy in more severe cases

Management of PND

Psychological/social support: mother-and-baby groups, relationship counselling, midwives, health visitors, maternal teaching skills by health visitor. Severe: antidepressant (risks and benefits need to be carefully considered with mother, bearing in mind that there is no evidence of harm to babies due to antidepressant transmission in breast-milk and that there are significant risks for the baby's cognitive and emotional development if the mother has untreated depression). Suicidal/infanticidal ideation: may require hospital admission, with admission of the baby to a mother-and-baby unit. ECT sometimes used and results in rapid improvement.

What can contribute to loss of insight in anorexia

Psychopathology of illness Neuropsychological effects of starvation

2 "classes" of nature and severity of the life event

Psychosocial stress. Traumatic stress.

Main aim of long term management of borderline personality disorder

Psychotherapy to address and modify the maladaptive traits of personality (pharmacotherapy is not effective for this)

Main treatment for anorexia

Psychotherapy, preferably with family involvement Weight monitoring Treatment of medical complications Need input from GP, psychiatrist, psychotherapist +/- community mental health team

Other names for psychological therapy

Psychotherapy. Talking therapy.

Presentation of Creutzfeldt-Jakob disease

Rapidly progressing dementia with cerebellar ataxia and myoclonic jerks over 6-8 months.

Specific side effect for haloperidol

QT prolongation

Tests of long term (remote) memory

Questions about past important events. Ask about personal events (episodic) e.g. what school they attended. Ask about general knowledge (semantic).

Other differentials for anxiety

REACTION TO STRESS Acute stress reaction Post-traumatic stress disorder Adjustment disorder OBSESSIVE-COMPULSIVE DISORDER Secondary to other psychiatric disorders (especially depression and psychosis) Secondary to a general medical condition Secondary to psychoactive substance use (especially alcohol)

Another name for stage 5 of sleep

REM (rapid eye movement) sleep.

Biological similarities between depression and dysthymia?

REM latency decreased in both.

Common language abnormalities in delirium

Rambling. Incoherent, rapid or slow speech. Impaired ability to understand.

Typical timeframe of puerperal psychosis

Rapid onset, between 4 days-3 weeks post-delivery (almost always within 8 weeks).

What is "pseudocyesis"?

Rare condition when a non-pregnant woman has the signs and symptoms of pregnancy (e.g. abdominal distension, breast enlargement, cessation of menses, enlargment of the uterus).

Features of neurosyphilis

Rare in the UK. Tertiary syphilis that emerges years after initial syphilis infection. Can include personality change, grandiose behaviour, dementia, upper motor neuron abnormalities such as brisk reflexes and extensor plantars

Is Addison's rare or common?

Rare.

Can you drive with anxiety/depression

Usually. Not if significant memory/concentration problems, behavioural disturbance or suicidal thoughts. Stricter rules for group 2 drivers (lorries and buses)

Dissociative fugue

Rare. Amnesia for personal identity, including memories and personality. Self-care and social interaction maintained. Very often involves seemingly purposeful travel beyond the individual's usual range. In some cases a new identity may be assumed.

Epidemiology of phaeochromocytoma

Rare. Sometimes family history.

Management of treatment resistant schizophrenia

Reassess diagnosis. Check concordance. Check psychological therapies have been offered. Assess for comorbid substance abuse. Once confirmed, offer clozapine at the earliest opportunity, assuming there are no contraindications and the patient is in agreement with taking oral medication and attending for regular blood tests.

Management of postnatal blues

Reassurance and check-up in 1 week to make sure they are not developing postnatal depression.

Non-pharmacological management of PMS

Reassurance. Advice on healthy-eating, stress-reduction and exercise. Abstinence from caffeine or alcohol in the week before menstruation can help. Psychotherapeutic intervention may be beneficial e.g. psychosocial counselling, stress management, CBT.

Example of NARI (selective noradrenaline reuptake inhibitor)

Reboxetine

Contraindications to TCAs

Recent MI, arrhythmias, severe liver disease, mania, high risk of overdose (as this can be very dangerous).

When someone having a manic episode may need hospitalisation

Reckless behaviour endangering the patient or others around them. Significant psychotic symptoms. Impaired judgment e.g. sexual indiscretion, overspending (may commit financial crimes). Excessive psychomotor agitation with risk of self-injury, dehydration or exhaustion. Thoughts of harming self or others. Severe depressive episode (see criteria for admission in with depression). Detention under mental health legislation is often necessary in patients with reduced insight or do not have capacity to make decisions regarding treatment.

Definition of premenstrual syndrome (PMS)

Recurrence of symptoms during the premenstruum, with their absence in the postmenstruum.

Male/female orgasmic disorder

Recurrent absence or delay of orgasm or ejaculation, depsite adequate sexual stimulation.

Premature ejaculation

Recurrent ejaculation with minimal sexual stimulation before the man wishes.

Essential features of a paraphilia (disorder of sexual preference)

Recurrent sexual arousing fantasies, sexual urges or behaviours involving either of: - non-human objects - the suffering or humiliation of oneself or one's partner - children or other non-consenting individuals

Vaginismus

Recurrent, involuntary spasm of the muscles that surround the outer third of the vagina, causing occlusion of the vaginal opening.

Blackouts due to alcohol

Refers to amnesia, NOT collapsing/'blacking out'. Episodes of anterograde amnesia can occur during acute intoxication. Memory loss may be patchy or complete for discrete block of time. Experienced by 2/3 of dependent drinkers and 1/3 of the general male population.

What are rehabilitation units

Reintegrate patients whose social and living skills have been severely handicapped by the effects of severe mental illness and institutionalisation.

Description of a "defence mechanism": SUBLIMATION

Redirecting energy from unacceptable impulses into socially acceptable activities (e.g. an angry man vigorously works out at the gym).

What are the neuromuscular abnormalities in neuroleptic malignant syndrome

Reduced activity (severe rigidity, stiff pharyngeal and thoracic muscles may lead to dysphagia and dyspnoea), bradyreflexia

Contraindications to disulfaram

Reduced cardiorespiratory function

Effect of decreased plasma albumin on drug metabolism in elderly patients

Reduced drug binding, resulting in increased physiologically active unbound fraction.

Physiological changes in elderly patients

Reduced renal clearance (GFR). Decreased lean body mass and total body water. Increased body fat percentage. Decreased plasma albumin. Reduced hepatic metabolism and first-pass metabolism. Increased sensitivity to CNS drugs. Decreased total body mass.

Neurobiological changes associated with recurrent early-onset depression

Reduced volume of the hippocampus, amygdala and some regions of the frontal cortex.

Impaired consciousness in delirium

Reduced, ranging from drowsiness to coma (hypoactive delirium) OR hypervigilant and agitated (hyperactive delirium). Reduced ability to sustain attention and easily distractible.

Features of subdural haematoma

Relatively quick cognitive decline compared to dementia. May have fluctuating consciousness level. Neuro signs. History of head injury. Not uncommon for there to be a latent period of days to weeks between injury and symptoms.

Other things that have to be regularly monitored for lithium

Renal function every 6 months. Thyroid function every 12 months

Excretion of lithium

Renal, therefore clearence is decreased in renal impairment (and with thiazide diuretics) (be aware of other drugs that can cause renal impairment e.g. NSAIDs)

Prognosis for most schizophrenic patients

Repeated episodes with hospitalisations, depression and suicide attempts.

Presentation of antisocial (dissocial) personality disorder

Repeated unlawful or aggressive behaviour Deceitfulness Lying Reckless irresponsibility Lack or remorse or incapacity to experience guilt Often have conduct disorder in childhood

Definition of "rumination"

Repeatedly thinking about the causes and experience of previous distress and difficulties. Voluntary. Not resisted.

Definition of echolalia

Repeating a word of phrase spoken by others around them

Nature of compulsions in habit and impulse-control disorders: pathological gambling, kleptomania (stealing), trichotillomania

Repetitious impulses and behaviour with no other unrelated obsessions/compulsions. Concordant with patient's own wishes (ego-syntonic).

Features of conduct disorder

Repetitive and persistent pattern of: aggression to people and animals; destruction of property; deceitfulness or theft; major violations of age-appropriate societal expectations or rules e.g. truancy, running away from home.

Definition of "compulsions"

Repetitive mental operations (counting, praying, repeating mantra silently) or physical act (checking, seeking reassurance, handwashing, strict rituals) that: - patients feel compelled to perform in response to their own obsessions or irrationally defined "rules" (e.g. I must count to 1000 four times before falling asleep) - performed to reduce anxiety through the belief that they will prevent a "dreaded event" from occurring, even though they are not realistically connected to the event (e.g. compulsive counting each night to prevent a family catastrophe) - experienced as unpleasant - serve no realistically useful purpose despite their tension-relieving properties - patients attempt to resist, which causes increased anxiety

Which of the above obsessions are often isolated without associated compulsions?

Reprehensible violent, blasphemous or sexual thoughts.

Diagnosis of phaeochromocytoma

Require urinary or serum catecholamine assays and imaging of adrenals.

The effective of psychotherapy

Research has shown efficacy for many different types of psychotherapies for many conditions. This has led to the idea that the success of psychotherapy might be due to certain common therapeutic factors as opposed to specific theories or techniques. Therefore, the use of modality with which the person can identify and work may be more important than the theoretical basis of the therapy itself.

General prognosis of emotional disorders

Resolve by adulthood

Why can alcohol intoxication be life-threatening

Respiratory depression Aspiration of vomit Hypoglycaemia Hypothermia Trauma

Side effects of benzos and Z drugs

Respiratory depression. Drowsiness. Ataxia. Reduced motor coordination. Dependence (especially with prolonged use and shorter acting drugs). Withdrawal (despite taking a constant therapeutic dose, long-term use of benzodiazepines may lead to the emergence of withdrawal-like symptoms, particularly between doses).

What do the Caldicott Guardians do

Responsible for protocols and policies regarding patient data

Definition of specific phobia

Restricted to specific object or situation other than agorophobia or social phobia.

Two main types of anorexia nervosa

Restricting Binge/purge

Problems with unaided clinical risk assessment in assessing risk of violent crime

Results in less effective and less accurate risk assessment than evidence-based methods.

What is taken into account when choosing which class of antidepressant to use?

S/E profile (taking into account patient preference and comorbidity) and which symptoms of depression are most troublesome. This is because all antidepressants are similarly effective if prescribed at the correct dose and taken for an adequate length of time.

What is tardive dyskinesia

Rhythmic, asymmetric involuntary movements of head, limbs and trunk, especially chewing, grimacing of mouth, pouting of jaw and protruding, darting movements of tongue. Long term chronic condition associated with long term use of antipsychotics.

Description of a "defence mechanism": SPLITTING

Rigid separation of 2 extremes (e.g. a woman is convinced that her boss is an evil man after she was disciplined at work).

Education for opiate dependent patients

Risks of using contaminated injecting equipment (HIV, hepatitis, infective endocarditis) and unsafe sexual behaviours Needle exchanges, injecting equipment and condoms can be offered (harm reduction service)

Medical management of DLB to maintain cognitive function

Rivastigmine.

Medical management of Parkinson's disease with dementia to maintain cognitive function

Rivastigmine.

Slang names for rohypnol

Roofies

Physical symptoms of PMS

Roughly 1/3 get headaches, abdominal bloating and/or breast tenderness.

Treatment of non-organic encopresis

Rule out organic cause Treat disturbed family dynamics - rule out child abuse! Parental guidance regarding toilet training and behavioural therapy

How can antidepressents cause hyponatraemia

SIADH (particularly SSRIs)

Insidious multi-system diseases that somatization disorder (Briquet's syndrome) can resemble

SLE. MS. AIDs. Hyperparathyroidism. Occult malignancy. Chronic infections.

1st line antidepressent for someone with insomnia

SSRI Mirtazapine is 2nd line because of its sedating properties but insomnia will usually improve with resolution of depression from SSRI.

Which antidepressents are safest in overdose

SSRIs

Which antidepressants may be best for depression with associated psychiatric symptoms such as obsessions or compulsions

SSRIs Clomipramine

Which antidepressents generally have a more favourable side-effect profile

SSRIs (although some patients may value particular side effects as worse than others)

Drug that may help short-term with premature ejaculation

SSRIs (rarely long-term solution).

1st line antidepressants in depression

SSRIs e.g. sertraline, paroxetine, citalopram, fluoxetine.

Which antidepressents are worst for discontinuation syndrome

SSRIs with short half lives (paroxetine and sertraline)

Definition of mental welfare commission

Safeguards the interests of people detained.

What can a guardian do

Same as a power of attorney

Mechanism of action of Z drugs

Same as benzos but act at a different site on the receptor

Risk factors for drug dependence

Same as for alcohol

Risk factors for drug misuse

Same as for alcohol Social deprivation Family environment of substance abuse Conduct disorder in childhood Antisocial personality disorder Severe mental illness

Treatment of mania in those >65yo?

Same as for younger adults.

Presentation of mania in those >65yo?

Same as in younger adults.

Common cause of bizarre delusions

Schizophrenia

In which conditions can catatonia occur

Schizophrenia Brain diseases Metabolic abnormalities Psychoactive substance use

What do cluster A personality disorders have a familial relationship with

Schizophrenia (especially those with schizotypal PD)

Link between schizophrenia and CV disease

Schizophrenia and antipsychotics both increase the risk of CV disease. Annual screen of CV risk factors. ECG if: starting antipsychotic in hospital, history of CV disease, family history of sudden cardiac death, haloperidol or evidence of CV disease on examination e.g. hypertension. Cardiovascular disease and cerebrovascular disease are the leading causes of premature death among schizophrenia patients, who die from heart and blood vessel disorders at a rate double that of persons without the mental disorder. This was initially considered to be due to both an unhealthy lifestyle and the long-term metabolic effects of psychotropic medication. However, recent data has emerged suggesting a genetic component.

Common causes of primary delusions

Schizophrenia and other primary psychotic disorders

Indications for antipsychotics

Schizophrenia, schizoaffective disorder and delusional disorder Depression or mania with psychotic symptoms Psychotic episodes secondary to a medical condition or psychoactive substance use Delirium Behavioural disturbance in dementia Severe agitation, anxiety and violent or impulsive behaviour Motor tics Nausea and vomiting (prochlorperazine) Intractable hiccups and pruritus (chlorpromazine, haloperidol)

Definition of schizoaffective disorder

Schizophrenic and mood (depressed/manic) symptoms either simultaneously or within a few days of each other. Mood symptoms should meet the criteria for either a depressed or manic episode. Should have at least 1 of the major ICD-10 criteria for schizophrenia.

Which of the DSM-IV personality disorders are not included in the ICD-10

Schizotypal (although includes schizotypal disorder seperately) Narcissistic

Type of personality disorder which can cause psychotic-like symptoms

Schizotypal personality disorder. To a lesser extent: borderline, paranoid and schizoid personality disorders.

Difference between school refusal and truancy

School refusal: refusal to go to school because of anxiety in spite of parental pressure - may be due to separation anxiety in younger children, mental illness (depression, anxiety) or bullying/teasing. Truancy: absence from school by choice.

CAGE questionnaire

Screens for alcohol dependence If they answer yes to >=2 then formally assess for alcohol dependence criteria. Have you ever felt you ought to Cut down on your drinking? Have people ever Annoyed you by criticising your drinking? Have you ever felt Guilty about your drinking? Have your ever needed an Eye-opener (drink first thing in the morning to steady your nerves and get rid of a hangover)?

Which antipsychotics are worst for causing metabolic syndrome and lowering seizure threshold?

Second generation

Effect of increased sensitivity to CNS drugs in elderly patients

Sedating drugs may result in drowsiness, confusion, falls and delirium. Tricyclic antidepressants most likely to be associated with anticholingeric and postural hypotension S/Es. Antipsychotics more likely to be associated with parkinsonism and increased risk of cerebrovascular accident.

Diagnosis of female orgasmic disorder

Should only be diagnosed if the ability to achieve orgasm is less than would be reasonably expected for a woman's age, sexual experience and quality of sexual activity, and only if the orgasmic dysfunction results in marked distress or relationship difficulties.

Medical conditions and illicit drugs that can cause psychosis

See book

Risk factors for vascular dementia

See flashcard listing vascular risk factors for Alzheimer's and vascular dementia. Previous stroke. AF. Ageing.

Diagnostic algorithm for cognitive impairment

See pg 110 in crash course.

Causes of hippocampal damage that can cause amnesia

See pg 112 in crash course if think it is worth knowing (probably not).

Causes of hypothalamic-diencephalic system damage that can cause amnesia

See pg 112 in crash course if think it is worth knowing (probably not).

Simplified model of aetiology of mood disorder

See pg 134 in crash course.

Freud's "iceberg metaphor"

See pg 26 (too complex to describe in flashcards).

Diagnostic algorithm for mood disorders

See pg 62 of crash course.

Algorithm for the diagnosis of obsessions and compulsions

See pg 88 in crash course.

Definition of autoscopic hallucination

Seeing an image of oneself in external space

Additional signs that can occur in anorexia nervosa

Self-induced purging, excessive exercise and use of appetite suppressants or diuretics. Whilst these are commonly features of bulimia nervosa, they do not preclude a diagnosis of anorexia nervosa. Can be described as 'anorexia nervosa (binge/purge type)'

Prognosis of postnatal blues

Self-limiting, resolves spontaneously and usually only requires reassurance. However, an apparent bad case may mark the onset of postnatal depression.

Further subdivisions of explicit memory

Semantic: knowledge of facts e.g. Edinburgh is the capital of Scotland. Episodic: knowledge of autobiographical events e.g. remembering you went to Edinburgh as a 10 year old on a school trip.

Example of kinaesthetic hallucination in healthy people

Sensation of falling just as you are falling asleep

Definition of echopraxia

Senselessly repeating or imitating the actions of those around you.

Piagetian stages of cognitive development

Sensori-motor stage: differentiates self from objects. Pre-operational stage: learns to use language and represent objects by images and words. Thinking is egocentric with difficulty seeing other's point of view. Concrete operations: thinks logically about objects and events. Achieves conservation of number, volume and mass. Can classify objects along several dimensions. Formal operations: thinks logically about abstract propositions. Concerned with hypothetical, the future and ideological problems.

What is neuroleptic malignant syndrome similar to

Serotonin syndrome

What is "persistent somatoform pain disorder"?

Severe and persistent pain that cannot be fully explained by physical illness. Pain usually occurs in association with emotional difficulties or psychosocial stressors.

Poor prognostic factors in bulimia

Severe bingeing and purging behaviour Low weight Comorbid depression

Contraindications to detoxification in the community

Severe dependence History of withdrawal seizures or delirium tremens Unsupportive home environment Previous failed community detox

General features of pervasive developmental disorders

Severe impairments in social interactions and communication skills. Restricted, stereotyped interests and behaviours, the pervade all areas of functioning.

Common presentation of acute behavioural disturbance

Severe psychomotor agitation Aggressive behaviour

Features of depresson more prevalent in those >65yo

Severe psychomotor agitation or retardation, cognitive impairment ("depressive pseudodementia"), poor concentration, generliased anxiety, hypochondriasis, hypochondriacal delusions, delusions of poverty, nihilistic delusions.

Dissociative stupor

Severe psychomotor retardation (extreme unresponsiveness, lack of voluntary movement and mutism) not due to a physical or psychiatric disorder e.g. depression, mania, catatonic stupor.

Contraindications to antipsychotics

Severely reduced consciousness level Phaeochromocytoma Parkinson's disease Epilepsy (seizure threshold lowered) Cardiac disease

Sexual aversion disorder

Sexual aversion (avoidance of sex due to negative feelings e.g. fear, anxiety, repulsion) OR lack of sexual enjoyment.

Epidemiological features of schizotypal personality disorder

Slightly more common in men

Zoophilia (bestiality)

Sexual fantasies, urges or behaviours involving animals.

Paedophilia

Sexual fantasies, urges or behaviours involving children.

Necrophilia

Sexual fantasies, urges or behaviours involving corpses.

Transvestic fetishism

Sexual fantasies, urges or behaviours involving cross-dressing.

Fetishism

Sexual fantasies, urges or behaviours involving inanimate objects or parts of the body that are not directly erogenous.

Voyeurism

Sexual fantasies, urges or behaviours involving the act of observing unsuspecting people engaging in sexual activity or undressing.

Exhibitionism

Sexual fantasies, urges or behaviours involving the exposure of genitals to unsuspecting strangers.

Sexual masochism

Sexual fantasies, urges or behaviours involving the infliction of acts of physical or pscyhological suffering or humiliation on ONESELF.

Sexual sadism

Sexual fantasies, urges or behaviours involving the infliction of acts of physical or pscyhological suffering or humiliation on OTHERS.

Which paraphilia is more common in women?

Sexual masochism.

What things do not solely count as mental disorders

Sexual orientation Sexual deviancy Transsexualism Transvestitism Dependence on or use of alcohol or drugs. Exhibiting behaviour that causes or is likely to cause, harassment, alarm or distress to another person. Acting as no prudent person would act.

What are psychosexual problems?

Sexual problems not predominantly due to biological problems.

What was the main shift from the MHA 1984 and the MHA 2003 (Scotland)

Shifts emphasis from detention in hospital to treatment in the community

Crimes associated with depression

Shoplifting. In rare cases, homicide (these are usually due to mood-congruent delusions (e.g. everyone would be better off dead) and are often followed by suicide. Postnatal depression is sometimes a cause of maternal filicide (child murdered by mother).

Features suggestive of diagnosis of depression over dementia

Short history, rapid onset. Biological symptoms e.g. weight loss, sleep disturbance. Patient worried about poor memory. Reluctant to take tests, disappointed with results. Variable MMSE score. Global memory loss (dementia characteristically causes recent memory loss).

Test to diagnose Addion's

Short synacthen test.

Which of the benzos are short acting/long acting

Short: oxazepam, temazepam, lorazepam Long: chlordiazepoxide, diazepam

Important contributors to the development of psychodynamic psychotherapy

Sigmund Freud. Melanie Klein. Carl Jung. Alfred Adler. John Bowlby. Donald Winnicott.

Couples most suitable for sex therapy

Significant psychological component to problem. Reasonable motivation. Reasonably harmonious relationship.

Side effects of venlafaxine

Similar to SSRIs but more severe

What other side effects can MAOIs have

Similar to TCAs

Management of autism

Similar to adults with intellectual disability

Management of depression in dementia

Similar to elderly patients with depression, but be careful with anticholinergics drugs as they can worsen cognition.

Different types of tic

Simple motor tics: eye-blinking, neck-jerking, facial grimacing. Simple vocal tics: grunting, coughing, barking, sniffing. Complex motor tics: jumping, touching self, copropraxia (use of obscene gestures). Complex vocal tics: senseless repetition of words, coprolalia (use of obscene words or phrases).

Definition of elementary auditory hallucination

Simply unstructured sounds e.g. whirring, buzzing, single words.

What is "polysomnography"?

Simultaneous process of monitoring various physical parameters during sleep, including - EEG - ECG - electromyogram - electrooculogram (eye movement) - blood O2 saturation - chest and abdominal excursion - mouth and nose air entry rates - loudness of snoring

What are tics

Sudden repetitive involuntary non-rhythmic motor movements or vocalisations.

Most common type of specific phobia

Situational e.g. public transport, flying, diving, tunnels, bridges or elevators.

Slang names for heroin

Skag

Key things to look for on examination

Skin: lanugo hair, loss of head hair, calluses on knuckles from sticking fingers down throat (Russell's sign). Dentition: abrasions and tooth decay from vomiting CV: postural hypotension from dehydration (make sure to measure lying and standing BP) Abdomen: constipation Musculoskeletal: muscle wasting, inability to rise from a squat without hands, pathological fractures Core temperature Dehydration of mucous membranes Swollen parotids (vomiting)

Who is most associated with "operant conditioning"?

Skinner - he invented the operant conditioning chamber, also known as the "Skinner Box". The box had a lever and a food tray, and a hungry rat could get food delivered to the tray pressing the lever. Skinner observed that when a rat was put in the box, it would wander around, sniffing and exploring, and would usually press the bar by accident, at which point a food pellet would drop into the tray. After that happened, the rate of bar pressing would increase dramatically and remain high until the rat was no longer hungry.

What are the most common features of narcolepsy?

Sleep attacks. Cataplexy.

What is a "primary sleep disorder"?

Sleep disorder presumed to arise from some defect in the individual's endogenous sleeping mechanism (reticular activating system) coupled with unhelpful learned behaviours (e.g. worrying about not sleeping). Not caused by another medical condition, mental illness or secondary to the use of alcohol/substances.

Features of benzo withdrawal

Sleep disturbance, irritability, increased tension and anxiety, panic attacks, hand tremor, sweating, difficulty concentrating, confusion, cognitive difficulty, memory problems, dry retching and nausea, weight loss, palpitations, headache, muscular pain and stiffness, a host of perceptual changes, hallucinations, seizures, and psychosis. Symptoms wax and wane and vary in severity from day to day or week by week instead of steadily decreasing in a straightforward linear manner. Can be so intolerable that may result in suicide.

Lifestyle advice in depression

Sleep hygiene (avoid caffeine and smoking in the evenings, do not sleep during the day, set regular sleep and wake times, do not use the bedroom for studying/watching TV). Regular physical activity (consider referral to exercise group). Avoid alcohol and substance use. Healthy diet.

What is "insomnia"?

Sleep of insufficient quantity or poor quality due to: - difficulty falling asleep - frequent awakening during the course of sleep - early morning awakening with subsequent difficulty getting back to sleep - sleep not refreshing despite adequate in length

EEG findings in stage 2 of sleep

Sleep spindles: short rhythmic waveform clusters of 12-14Hz. K-complexes: sharp negative wave followed by a slower positive component.

What other parasomnia are sleep terrors assocaited with?

Sleepwalking.

Sex ratio for elective mutism

Slightly more common in girls

Vascular risk factors for Alzheimer's and vascular dementia

Smoking. Hypertension. DM. Hypercholesterolaemia. History of MI. Obesity.

Features of frontal lobe lesion

Social disinhibition (e.g. stealing, sexual inappropriateness) Abnormalities of emotional expression (e.g. shallow cheerfulness, aggression, apathy)

What is the main area of difficulty encountered by Asperger's patients in adolescence

Social interaction

Link between autism and schizophrenia

Social withdrawal, communication impairment and poor eye contact can be hard to distinguish from schizoid personality disorder, schizotypal disorder or the negative symptoms of schizophrenia. There are also a number of genetic similarities.

First people to contact if you suspect child abuse

Social worker On-call local paediatrician

Mood stabilisers in decreasing order of their risk of teratogenicity

Sodium valproate. Carbamazepine. Lithium. Lamotrigine.

Possible psychiatric cause of secondary anxiety concerning having many physical complaints

Somatisation disorder

Types of somatoform disorders

Somatization disorder (Briquet's syndrome). Hypochondrial disorder. Body dysmorphic disorder. Somatoform autonomic dysfunction disorder. Persistent somatoform pain disorder.

Differential diagnoses for patient presenting with medically unexplained symptoms

Somatoform disorder. Factitious disorder (Munchausen's syndrome). Malingering. Other psychiatric disease e.g. anxiety/mood/psychotic/dissociative disorder. Insidious multi-systemic disease.

Stable cognitive impairment

Some "one-off" insults to the brain can impair one or more aspects of cognition but not cause progressive deterioration. E.g. stroke, hypoxic brain injury, traumatic brain injury, viral encephalitis. Improvement post-insult can occur over several months so it is important not to make the diagnosis of stable cognitive impairment too soon. Often someone who has had one cerebrovascular accident continues to suffer further episodes, so an initially stable post-stroke cognitive impairment can evolve into vascular dementia.

Cause of familial cases of DLB

Some caused by mutations in the gene coding for alpha-synuclein.

Alcohol-related anxiety disorder

Some patients take alcohol to self-treat agorophobia/social-phobia but alcohol withdrawal can also cause anxiety

Definition of named person

Someone nominated by a person to support them and protect their interests. Entitled to be informed about certain situations and act on the persons behalf in certain circumstances.

Use of antidepressants/lithium for schizophrenia

Sometimes used in addition to antipsychotics in treatment-resistant cases especially when there are significant affective symptoms e.g. in schizoaffective disorder or post-schizophrenia depression.

Another term for sleepwalking

Somnambulism.

Side effects common to all antipsychotics

Somnolence Extrapyramidal (parkinsonian) Weight gain

Things to include in history for personality disorder

Sources of distress e.g. thoughts, behaviours and relationships to self and others. Any comorbid mental illness Specific impairments of functioning at work, home or in social circumstances. Take collateral history to establish pervasiveness and stability of presentation (important to recognise that strong emotional reactions may be elicited by patients with personality disorder (transference and counter-transference), and that they are often perceived as "difficult patients" because of this)

1st line treatment for hyperkinetic disorder

Specialist assessment required in all cases. School-age + severe: CNS stimulants e.g. methylphenidate (Ritalin, Concerta, Equasym) + psychosocial interventions. Mild-moderate or preschool-age: psychosocial interventions e.g. parental education, CBT, social skills training.

Which type of personality disorder are more common

Specific

Most common anxiety disorder

Specific phobia (4.4% 1 year prevalence)

Features that are absent from delusional disorders

Speech, behaviour and social skill disorders.

Slang names for amphetamines

Speed Base

Macroscopic findings in all prion diseases

Spongiform degeneration throughout cortex and subcortical nuclei of the brain, in the absence of an inflammatory immune response.

Specific exercises that may help with premature ejaculation

Squeeze technique: woman squeezes the glans of her partner's penis for a few seconds when he feels he is about to ejaculate. Start-stop method: stimulation halted and arousal allowed to subside when the man feels he is about to ejaculate (repeated). Quiet vagina: man keeps penis motionless in vagina for increasing periods before ejaculation.

Factors for good prognosis of alcohol dependence

Stable relationship Employment Stable living conditions Good social support Good insight and motivation

What stage of sleep do sleep terrors usually occur in?

Stage 3 and 4 - therefore predominantly in the first third of the night.

What stage of sleep does sleepwalking usually occur in?

Stage 3 and 4 - therefore predominantly in the first third of the night.

Definition of tics

Sudden, involuntary, rapid, recurrent, non-rhythmic motor movements or vocalisations

Which is more common in PND: infanticidal or suicidal ideation?

Suicidal ideation, so if infantacidal thoughts are present the risk of suicide should be thoroughly explored.

What should self-harm in an older adult always be considered to be?

Suicidal ideation, until proven otherwise.

Tips for interviewing anorexic patients

Start by asking general questions about life history, premorbid personality, social circumstances, family, friendships, relationships and functionality so as not to alienate the patient early on.

Cognitive-behaviour model for phobia

Step 1: A neutral stimulus is paired with an aversive stimulus (classical conditioning e.g. driving and an accident) OR anxiety is felt about an intrinsically aversive stimulus (e.g. a snake). Step 2: The neutral stimulus is then associated with anxiety and avoiding it reduces anxiety. The association then becomes self reinforcing (operant conditioning) and it becomes increasingly difficult to get exposed to the neutral stimulus.

Reasons for decreased life expectancy

Suicide Increased smoking Socioeconomic deprivation CV disease Respiratory disease

ICD-10 criteria for schizophrenia

Symptoms present for most of at least 1 month in absence of organic brain disease, drug intoxication or withdrawal. >=1 of: Schneider's first rank symptoms Bizarre delusions Auditory hallucinations coming from a body part. OR >=2 of: Other hallucinations that occur every day for weeks or that are associated with fleeting delusions or sustained overvalued ideas. Thought disorganisation. Catatonic symptoms. Negative symptoms. Change in personal behaviour (loss of interest, aimlessness, social withdrawal).

Management of primary hypersomnia

Stimulants: dexamphetamine, methylphenidate, modafenil.

What is the single factor most commonly associated with a good therapeutic outcome?

Strength of the client-therapist relationship (therapeutic alliance), regardless of the modality of therapy.

Increased risk of what when treating elderly patients with antipsychotics?

Stroke and VTE (especially olanzapine and risperidone).

Neurobiological changes associated with bipolar

Structural and functional abnormalities in brain regions linked to emotion - particularly hippocampus, amygdala, anterior cingulate, corpus callosum.

What is akathisia

Subjective feeling of inner restlessness and muscular discomfort, that manifests as inability to sit still or remain motionless. May range in intensity from a sense of disquiet or anxiety, to severe discomfort, particularly in the knees. Patients typically pace for hours because the pressure on the knees reduces the discomfort somewhat; once their knees and legs become fatigued and they are unable to continue pacing, they sit or lie down, although this does not relieve the akathisia

Alcohol/substance misuse and crime

Substance misuse significantly increases the risk of violence, especially in those with comorbid mental illnesses (e.g. schizophrenia). Alcohol intoxication can lead to driving offences and public drunkenness. Offences may be committed to fund drug habits.

Those with PTSD have high rates of comorbid what?

Substance misuse.

Nominal dysphasia

Subtype of expressive dysphasia. Not being able to name items correctly despite knowing what they are.

Types of somatic hallucination

Superficial (on or just under skin): tactile, thermal or hygric Visceral Kinaesthetic

What does the Office of the Public Guardian do

Supervises and maintains a register of those with powers of attorney, guardianship and intervention orders and access to funds. It can investigate complaints relating to these.

Treatment of lithium toxicity

Supportive treatment, ensuring adequate hydration, renal function and electrolyte balance. Anticonvulsants for convulsions. Dialysis for renal failure.

Presentation of paranoid personality disorder

Suspects others are exploiting, harming or deceiving them (but not delusional and beliefs are often not fixed) Doubts of spouses fidelity Bears grudges Tenacious sense of personal rights Litigious

What to do if maintenance treatment of bipolar is not effective?

Switch to alternative drug or augmentation with one of the 3.

Description of a "defence mechanism": REACTION-FORMATION

Switching of unacceptable impulses into opposites (e.g. a man who hates his job works extra hard, and performs incredibly well).

Features of uncomplicated alcohol withdrawal syndrome

Symptoms develop 4-12 hours after stopping Tremulousness (the 'shakes') Sweating Nausea and vomiting Mood disturbance (anxiety, depression, feeling 'edgy') Sensitivity to sound (hyperacusis) Autonomic hyperactivity (tachycardia, hypertension, mydriasis, pyrexia) Sleep disturbance Psychomotor agitation

When can you diagnose an "undifferentiated somatization disorder"?

Symptoms of somatization disorder but for <2 years.

Features of body dysmorphic disorder (AKA dysmorphophobia)

Symptoms should not be better accounted for by another disorder (e.g. concerns regarding weight and body shape are usually more accurately attributed to an eating disorder). Imagined defect or disorder can concern any part of the body (e.g. "crooked nose" or "ugly hands"). The preoccupation causes significant distress or impairment in functioning (e.g. social/occupational etc.)

Definition of dementia

Syndrome of acquired progressive generalised cognitive impairment associated with functional decline for >6 MONTHS.

What is the 'care programme approach' to secondary psychiatric services

Systematic assessment of patients' health and social care needs. Formation of an agreed care plan to address the above. Allocation of a care coordinator to keep in touch with the patient to monitor and coordinate the above care. Usually a CPN, social worker or psychiatrist. Regular review meetings involving all relevant professionals, patients and their carers.

Cerebrovascular disorders that can cause delirium

TIA. Cerebral thrombosis/embolism. Intracerebral/subarachnoid haemorrhage. Hypertensive encephalopathy. Vasculitis e.g. from SLE.

Physical signs of anxiety

Tachycardia Palpitations Hypertension Dyspnoea Chest pain Choking sensation Tremors Muscle tension Dry mouth Sweating Cold skin Nausea/vomiting Diarrhoea Abdominal discomfort (butterflies) Dizziness, light-headedness, syncope Mydriasis Paraesthesia

How else needs to consent for an emergency detention certificate

Technically nobody else but a MHO should agree to it where practicable.

Common examples of illicitly used sedatives

Temazepam Diazepam (Valium) Flunitrazepam (Rohypnol) Gamma-hydroxybutate (GHB) Gamma-butylrolactone (GBL)

Effectiveness of cholinesterase inhibitors in the management of Alzheimer's

Temporarily slow the loss of cognitive function but do not reverse or ultimately prevent it. Up to 1/2 of patients will show a slower rate of cognitive decline and possible improvement in behavioural and psychological symptoms.

Do people's coping skills change throughout life or stay pretty constant?

Tend to be variable throughout developmental life e.g. the distant relative may be far more stressful for a middle-aged man contemplating mortality than for an "invincible" adolescent.

How are behavioural, mood and psychological symptoms in dementia different from in delirium?

Tend to have a more gradual onset in dementia and consciousness level is normal, in contrast to delirium where they are more acute in onset and consciousness level is altered.

Prognosis for induced delusional disorder

Tend to improve once the two patients are separated.

Prognosis for obsessive-compulsive personality disorder

Tends to be stable over time

What is the main S/E of all mood stabilisers (lithium, valproate, olanzapine)?

Teratogenic - women of childbearing age need to use reliable contraception. (avoid valproate in women of childbearing age if possible due to high risk of neural tube defects).

Diogene's syndrome ("senile squalor")

Term used to describe an elderly recluse who lives in a state of perpetual filth and gross self-neglect, often with the hoarding of rubbish. Purely a descriptive term and may be used to describe those with alcohol abuse, frontal lobe dysfunction, personality disorder and chronic psychotic illness.

What may help those with low sexual drive?

Testosterone, if they have low levels.

Advantages of ACE-R

Tests all cognitive domains. Sensitive to mild impairment.

Advantages of CLOX1

Tests praxis and executive function. Resistant to influence from premorbid IQ, language and culture.

What is thought to be the active substance in cannabis?

Tetrahydrocannabinol

Alternative explanation for schizoid and schizotypal personality disorders

That they are neurodevelopmental disorders, possibly within the autistic spectrum

Use of deep brain stimulation

Very occasionally used for treatment resistant depression but a bit more common for severe movement disorders e.g. Parkinson's

Use of vagus nerve stimulation

Very occasionally used for treatment resistant depression. Poor evidence.

Most commonly used violent crime risk assessment tool in the UK

The Historical/Clinical/Risk Management 20-item (HCR-20) scale - form of structured clinical judgement.

Who has the power to discharge patients subject to compulsion

The MWC, if it feels the powers have not been applied properly. It also has a duty to inspect services and conduct enquiries.

Where do appeals against medical treatment decisions go

The Sheriff court

Description of dialectical behaviour therapy (DBT)

Uses a combination of cognitive and behavioural therapies, with some relaxation techniques from Zen Buddhism. Involves both individual and group therapy. Can be quite helpful in reducing self-harming and improving functioning.

What danger can occur just after starting or increasing the dose of an SSRI

The alerting effect can cause agitation and anxiety however it takes a few weeks longer before the mood effects start. Suicide risk therefore increases short term (particularly in adolescents).

Use of ECT in schizophrenia

Very occasionally used with severe catatonic symptoms

Use of psychosurgery

Very rarely used for treatment resistant depression or OCD.

Behavioural, mood and psychological symptoms - are they common in dementia?

Very.

Description of mindfulness-based cognitive therapy (MCBT)

Uses traditional CBT methods + mindfulness and meditation. Mindfulness focuses on becoming aware of thoughts and feelings and accepting them, rather than reacting to them.

What is "working through"?

The concept of working over one's emotional difficulties from the past. In psychotherapy, it usually follows an "impasse" (therapeutic stalemate).

Why are obsessions and compulsions so closely linked?

The desire to resist or neutralise an obsession often produces a compulsive act.

Definition of delusional disorder

The development of a single or set of delusions for at least 3 months is the prominent feature.

How can you treat somebody non-consensually under common law

The doctrine of necessity allows for treatment of mental and physical disorders in adults who are unable to consent in emergency situations. Treatment must be in the best interests of the individual, and must be necessary to sustain life, to prevent serious deterioration or to alleviate severe pain or suffering. Note that the doctrine of necessity is only applicable in emergency situations and treatment should be continued under statute law (e.g. MHA) ASAP. Ideally, common law should only be used for initially restraining them. Your actions should be consistent with what most individuals with your level of training would do in the same situation.

Description of a "defence mechanism": HUMOUR

Using comedy to avoid provoking discomfort in self or others (e.g. a woman laughs and mocks herself after arriving at a formal dinner dressed in casual clothes).

Neurobiology of depression

The final common pathway of the multiple aetiological routes to mood disorder is abnormal brain structure and function. It is likely that mood disorders are due to malfunctioning communication between multiple brain regions involved in emotional regulation, rather than just 1 key abnormal area.

Things to ensure before performing a cognitive assessment on a patient

Using glasses/hearing aids if needed. Not hungry/needing the toilet/exhausted.

Definition of Mental Health Tribunal for Scotland

The legal forum for making decisions regarding applications for certain compulsory orders (and changes and appeals relating to them). Consists of 3 members, one medical, one legal and one lay.

What information must be on an incapacity certificate

The nature and likely duration of the incapacity. The proposed treatment.

How do patients with personality disorders usually present

With consequences of their disorder e.g. self-harm, depression/anxiety, violence or disorderly conduct, PTSD, eating disorders, dissociative or somatoform disorders rather than the personality disorder itself as they do not normally regard it as abnormal

Can patients appeal a STDO

Yes, it will be heard by a tribunal.

In CBT terms, what are "automatic thoughts"?

Thoughts that involuntarily enter an individual's mind in response to specific situations (e.g. "I'm such an idiot", I'm so boring"). A patient is often encouraged to keep a diary of automatic thoughts and from this, the patient's thinking style (technically called "cognitive distortions") can be identified.

Key difference between overvalued ideas and delusions

The patient can give a sound logical reasoning for their idea

Why is lorazepam the preferred benzodiazepine to use.

The only one which is reliably absorbed from IM. Short half-life (10-20 hours). No active metabolites during elimination (accumulation).

Key difference between pychotic symptoms caused by schizotypal personality disorder/neurodevelopmental disorder and schizophrenia

The patient has always been abnormal. Whereas, in schizophrenia there is a clear change in behaviour and functioning

Who's responsibility is it to inform the DVLA if there is a risk of from a disease or medication

The patient. However, doctors should advise the patient to do this. However, if the patient doesn't tell them then doctors may need to break confidentiality to tell the DVLA (however you should inform the patient that you are going to do this).

Chronic stress and its relationship to depression

The psychological and physiological effects of chronic stress may make someone vulnerable to depression and may reduce their ability to cope with more acute stressful life events.

Features of person-centred counselling

Therapist assumes an empathetic and reflective role, allowing patients to discover their own insights using the basic principle that the client ultimately knows best.

Definition of responsible medical officer

The registered medical practitioner in charge of the patient's treatment, usually the consultant.

When would an emergency detention certificate be used instead of a short-term detention order

The situation is urgent and a short term detention order would cause undesirable delay.

Definition of bizarre delusions

Those that are completely impossible e.g. aliens have planted a bomb in your brain.

Definition of paranoid delusions

Those that are unduly self-referential e.g. persecutory, grandiose or reference. NOT the same as persecutory.

Prognosis of specific phobias

Those that start in adulthood are more likely to remit

Management of gender dysphoria

Those who are committed to a gender change can be helped with hormones and surgery, usually after they have completed a "real life test" (living as opposite sex for >=1 year).

Which patients can counselling be helpful for

Those who are experiencing stressful life events, illness or bereavement

In what group of patients with bipolar is lithium less effective?

Those with "rapid cycle" bipolar (>=4 episodes in 1 yr) - alternative mood stabiliser may be more appropriate.

What is "transference" in psychodynamic psychotherapy?

Theoretical process by which the patient (inappropriately and unconsciously) transfers feelings or attitudes experienced in an earlier significant relationship onto the therapist (e.g. a male patient becomes angry with his therapist whom he sees as cold and uncaring, unconsciously reminding him of his mother).

Basis of "milieu therapy" AKA therapeutic community

Therapeutic communities are cohesive residential communities that consist of a group of about 30 patients who are resident for 9-18 months. During this time, residents are encouraged to take responsibility for themselves and others (e.g. by allowing them to be involved in running the unit).

EEG findings in stage 1 of sleep

Theta waves (low amplitude, spike-like waves at 4-7 Hz).

Why do antipsychotics cause extra-pyramidal side effects

They antagonise D2 receptors throughout the whole brain

Are depersonalisation and derealisation considered forms of dissociation?

They can be.

Disadvantage of using sedating antihistamines for insomnia

They have a long duration of action and so can lead to drowsiness the following day

What would happen if you could remove an acquired disorder from a child

They would be relatively normal underneath... "i.e. they are superimposed on a relatively normal developing child

Examples of nutritional deficiencies that can cause delirium

Thiamine (Wernicke's encephalopathy). Vitamin B12. Folic acid. Niacin.

Most common cause of amnesia

Thiamine deficiency resulting in Wernicke's encephalopathy followed by Korsakoff's syndrome.

Nutritional deficiencies that can cause dementia

Thiamine. Vitamin B12. Folic acid. Niacin (causes pellagra).

Patients that counselling is recommended for

Those with minor mental health (e.g. mild anxiety or depression) or interpersonal difficulties. Those experiencing stressful life circumstances (e.g. grief counselling for bereavement).

Side effects of lithium

Thirst, polydipsia, polyuria, weight gain, oedema, fine tremor, precipitates or worsens skin problems e.g. acne, concentration and memory problems, hypothyroidism, impaired renal function, T-wave flattening or inversion, leucocytosis, teratogenicity

Nature of obsessions in schizophrenia

Thought insertion. Lack of insight. Other schizophrenic symptoms.

Prevalence of Asperger's

Thought to be 0.30% but is currently under-recognised

Cause of new-variant CJD (nvCJD)

Thought to be secondary to ingestion of BSE-infected beef products.

Two components to the experience of anxiety

Thoughts of being apprehensive, nervous or frightened The physical reaction to anxiety

Concerning symptoms in puerperal psychosis

Thoughts of self-harm or harming the baby. Severe depressive delusions (e.g. belief that the baby is, or should be, dead). Command hallucinations instructing the mother to harm herself or her baby.

Assessment of sexual dysfunction

Thorough history and examination (especially of genitalia). Blood tests (thyroid function, fasting glucose, liver and renal function, prolactin, testosterone). Further investigations may be needed to exclude medical causes.

Link between OCD and weight loss

Time-consuming compulsions can prevent an adequate diet. Can have obsessions about contamination of food which curtail their caloric intake. Patients with anorexia nervosa also have an increased risk of OCD unrelated to food or body shape.

What makes tics become more prominent

Times of stress

Definition of "consciousness"

To be conscious is to be aware of the environment and of oneself as a subjective being. It is a global cognitive function.

Reasons for admission

To provide a safe environment for the patient or those around them. To allow in-patient assessment e.g. response to a treatment. To institute therapies such as ECT/clozapine.

Criteria that must be present for PHYSIOLOGICAL dependence

Tolerance and/or withdrawal (remember, you can have dependence syndrome without having developed tolerance or withdrawal)

Which other disorder is OCD genetically linked with

Tourette's

Class C drugs

Tranquilizers (benzos) GHB Ketamine Anabolic steroids

Things which the AWIA allows people do do to adults with incapacity

Transfer of powers to a previously appointed power of attorney.f Intromission of funds: individuals can apply to the Public Guardian to access the patients funds to fund their living expenses. Management of resident's finances. Guardianship and intervention orders: the Sherriff Court can grant either a temporary or ongoing authority to make financial or welfare decisions on behalf of the patient to someone. Medical treatment: a practitioner can issue a certificate of incapacity to perform treatment.

Description of a "defence mechanism": SOMATISATION

Transformation of negative feelings towards others into physical symptoms (e.g. a man stuck in an unhappy marriage develops medically unexplained back pain).

Possible thought disturbance in delirium

Transient persecutory delusions. Delusions of misidentification.

Definition of substance intoxication

Transient, substance specific condition that occurs following the use of a psychoactive substance. Symptoms can include disturbed balances of consciousness, perception, mood, behaviour and physiological functions. Severity of intoxication is normally proportionate to dose or levels.

Overall description of stage 1 of sleep

Transition from wakefulness to sleep.

Example of drug with both serotonin 2a antagonist and serotonin reuptake inhibitor (SARI) action

Trazodone

Management of SAD

Treat like mild depression by starting with psychological therapies and follow up with the patient in 2 weeks to ensure that there has been no deterioration. 2nd line = SSRI. Do not give sleeping tablets as this can make symptoms worse. Evidence for light therapy is limited and is not routinely recommended.

Definition of treatment failure with antidepressant

Treatment dose prescribed for 6-8 weeks without a response.

What is the effect of D2 antagonism on the mesolimbic pathway

Treatment of psychotic symptoms

4 areas where treatment may take place without consent

Treatment undertaken under common law. Treatment under provisions of an incapacity act. Treatment under the provisions of a mental health act. Treatment authorised by a court.

Features of hyperthyroidism

Tremor. Tachycardia. Heat intolerance. Increased appetite. Irritability. Anxiety.

Symptoms of serotonin syndrome

Triad of altered consciousness, neuromuscular abnormalities and autonomic instability

Symptoms of Wernicke's encephalopathy

Triad of: Delirium Ophthalmoplegia (mainly nystagmus, 6th nerve palsy or conjugate gaze palsy) Ataxia (can be impossible to distinguish from intoxication)

Slang names for LSD

Trips

What is depressive "pseudodementia" a risk factor for?

True dementia.

Genetic risk factors for bulimia

Twin studies suggest it has a significant effect but specific genes have not been identified Serotonin, noradrenaline and plasma endorphins have all been implicated, although many neurotransmitter abnormalities occur secondary to weight loss and purging Also associated with a family history of depression/substance abuse

Genetic risk factors for anorexia

Twin studies suggest that it has an effect Abnormalities of serotonin metabolism have been implicated

Definition of idiosyncratic word use

Using recognised words for unrecognised meanings

Description of labelling (type of cognitive distortion)

Using unhelpful labels to describe self (e.g. "I'm so horrible").

Definition of dyspraxia AKA apraxia

Type of cognitive impairment. Loss of ability to carry out skilled motor movements despite intact motor function e.g. inability to put a letter in an envelope, button a shirt.

Definition of dysgnosia AKA agnosia

Type of cognitive impairment. Loss of ability to interpret sensory information despite intact sensory organ function e.g. not able to recognise faces as familiar.

Definition of amnesia

Type of cognitive impairment. Loss of ability to store new memories or retrieve memories that have previously been stored e.g. not able to recall time or recent events, not able to learn new skills.

Definition of dysphasia AKA aphasia

Type of cognitive impairment. Loss of language abilities despite intact sensory and motor function.

Definition of echo

Type of first person complex auditory hallucination in which there is a delay between thinking the thought and hearing it.

Definition of formication

Type of tactile hallucination with perception of insects crawling on or under the skin.

Presentation of new-variant CJD

Typically a young adult with mild psychiatric symptoms (e.g depression, anxiety) which then develops into ataxia, dementia and finally death over 18 months.

Age of onset of schizophrenia

Typically after puberty Men: 18-35 Women: 25-35

Clinical features of puerperal psychosis

Typically begins with insomnia, restlessness and perplexity, later progressing to suspiciousness and marked psychotic symptoms. Symptoms can be polymorphic and frequently fluctuate dramatically in nature and intensity over a short space of time. Often retain a degree of insight but may not disclose certain bizarre delusions or suicidal/homicidal thoughts. In the majority of cases, the clinical presentation resembles a mood disorder (depression or mania) with delusions and hallucinations. Even when schizophrenia-like symptoms are present, patients often have associated mood symptoms, although mood and psychotic symptoms may occur at separate times during the same illness.

How is noradrenaline synthesised in neurons

Tyrosine -> DOPA -> dopamine -> noradrenaline

Different ways of assessing the risk of violent crime in a patient with a mental disorder and their pros and cons

UNAIDED CLINICAL RISK ASSESSMENT: drawing on experience of the clinician involved. ACTUARIAL METHODS: using predetermined static actuarial or statistical variables (e.g. demographic factors). STRUCTURED CLINICAL JUDGEMENT: using both empirical actuarial knowledge and clinical expertise.

Features of delusional disorder

Usually begins in middle age and can continue throughout life. Often features persecutory, grandiose and hypochondriacal delusions. Sometimes have a bit of insight into it. Can also have FLEETING hallucinations or depressive episodes.

Features of couselling

Usually brief. Helps people utilise their own strengths, with the therapist being reflective and empathetic. May also provide relevant information and advice. Can be undertaken by healthcare professionals of all specialties.

Prognosis of social phobia

Usually chronic although adults can have long periods of remission. Life stressors can exacerbate symptoms

Timescale of PTSD

Usually develop after 1 month but within 6 months of a traumatic stressor.

Timescale of postnatal depression (PND)

Usually develops within 3 months of delivery. Typically lasts 2-6 months.

Extra possible features in amnesia

Usually disorientated in time due to inability to learn new material in anterograde amnesia. Confabulation (filling of gaps in memory with details which are fictitious but often plausible). Lack of insight. Apathy.

Age of onset of somatization disorder (Briquet's syndrome)

Usually early adult life (the onset of multiple physical symptoms late in life is more likely to be due to a physical illness).

Prognosis of hyperkinetic disorder

Usually improves with age with remission by 12-20 years old. 15% have symptoms persisting into adulthood.

Creutzfeldt-Jakob disease on CT

Usually normal.

Sleep-wake cycle in dementia

Usually normal.

What is "self-help"?

Umbrella term used to describe the process of self-guided improvement.

Retrograde amnesia

Unable to retrieve memories stored before the event (worse for most recent memories) but mostly still able to store new memories from the event onwards.

Anterograde amnesia

Unable to store new memories from the amnesia-causing event onwards but are able to retrieve memories stored before the event occurred.

Categories of symptoms in alcohol withdrawal

Uncomplicated alcohol withdrawal syndrome +/- perceptual disturbance +/- withdrawal seizures +/- delirium tremens

Environmental risk factors for anorexia

Unhealthy cultural views of body shape Relationship difficulties between parents and children e.g. over-protectiveness, conflict avoidance, lack of conflict resolution and rigidity (resistance to change), enmeshment (over-involvement with lack of differentiation between parent and child)

What can reduce the memory loss associated with ECT

Unilateral electrode placement (as opposed to bilateral placement).

Urban/rural risk factor for schizophrenia

Urban

Timescale of dissociative fugue

Usually only lasts hours-days but can be longer.

Are plaques and tangles the cause of neuronal death and damage Alzheimer's?

Unknown whether they are a cause or consequence.

Aetiology of paraphilias

Unknown, but there is often an impaired capacity for affectionate sexual activity and patients with paraphilia often have personality disorders.

Causes of sporadic cases of DLB

Unknown.

Cause of Alzheimer's

Unknown. Appears to be combination of multifactorial genetic risk factors, vascular risk factors and other uncertain environmental factors.

Treatment of hypokalaemia

Unless severe enough for hospital admission, better to correct gradually e.g. by eating high potassium foods or using potassium supplements

How to tell someone with an intellectual disability apart from someone with dementia?

Unlike dementia, intellectual disability manifests in the developmental period (before 18yo) and the level of cognitive functioning tends to be stable over time (does not progressively deteriorate).

Capacity of long term (recent) memory

Unlimited.

Capacity of long term (remote) memory

Unlimited.

Consequences of obstructive sleep apnoea

Unrefreshing sleep. Excessive sleepiness during the day. Cardiovascular and neuropsychiatric morbidity.

Features of delusions

Unshakable false belief that is not accepted by other members of the patient's culture e.g. it does not count as a delusion if the patient is part of a religious group who all share the same belief. Patient is, by definition, unaware that it is not real. It is designated as a false belief because of the faulty reasoning behind it, rather than whether or not it is actually true e.g. if a man believes his wife is cheating on him because of some weird conspiracy plot then it is classed as a delusion even if it turns out that she actually was cheating on him.

Poor prognostic factors in ADHD

Unstable family dynamics Coexisting conduct disorder

Presentation of borderline personality disorder

Unstable intense relationships (fluctuating between extremes of idealisation and devaluation) Unstable self-image Impulsivity (sex, bing-eating, substance abuse, spending money) Chronic feelings of emptiness Repetitive suicidal or self-harm behaviours Fluctuations in mood Frantic efforts to avoid (real or imagined) abandonment Transient paranoid ideation Pseudohallucinations Dissociation

How long may nurses holding powers be used for

Up to 2hrs and may continue for 1hr after the doctor has arrived.

Prognosis of panic disorder

Up to half of patients will be symptoms free after 3 years. A third of those who still have symptoms have significant effect on their quality of life. Agorophobia often develops within a year of onset

Description of a "defence mechanism": FANTASY

Use of imagination to avoid acknowledging a difficult or distressing reality (e.g. a schoolboy thinks about killing a bully rather than taking action to stop the bullying).

What is "eclectic therapy"?

Use of mixture of modalities uniquely tailored to understanding and treating the patient.

Use of transcranial magnetic stimulation

Used as an investigative technique to assess the integrity of neuronal pathways e.g. motor neurone disease, MS. Very occasionally used in treatment resistant depression Poor evidence

Use of psychological treatment for bipolar

Used much less than for unipolar depression. Can improve concordance and awareness of early warning signs of relapse.

What to do if a woman is having infantacidal thoughts?

Urgent psychiatric assessment.

What must you do before starting methadone

Urine drug screen to confirm opiate use as if patients are not already tolerant, it can cause respiratory depression Methadone dose should also be titrated in a controlled clinical environment with facilities to measure physiological response to opiates and with emergency treatment for opiate toxicity (naloxone) close to hand

Best way to test for illicit drugs

Urine/saliva screen (but doesn't test for all, particularly 'legal highs') Collect ASAP as some have very short half-lives

In cases where psychiatric defences are successfully used, what might the Court decide to do?

Use mental health legislation to transfer the individual to a secure hospital for more further assessment and treatment. OR place conditions upon the individual e.g. to adhere to drug treatment programme. OR impose custodial sentence.

Sexual dysfunction disorders with the best prognoses

Vaginismus. Premature ejaculation. Erectile dysfunction.

Most common type of dementia in men

Vascular.

Types of "mixed" dementia

Vascular. Infection-induced (CJD, neurosyphilis, chronic meningitis).

How are the physical signs of blood-injection-injury phobias different from those of other specific phobias

Vasovagal response - bradycardia and possibly syncope

Example of SNRI (serotonin-noradrenaline reuptake inhibitor)

Venlafaxine

Brain abnormality risk factors for schizophrenia

Ventricular enlargement - associated with negative symptoms. Reduced brain size. Reduced connectivity, particularly between the frontal and temporal lobes.

Use of benzos for anxiety

Very effective but rapid development of tolerance and dependence. Can be used short term in PTSD, social phobias or specific phobias e.g. if the patient knows they are going to encounter a trigger

Definition of lilliputian hallucinations

Visual hallucinations of miniature people or animals

Effect of decreased lean body mass, decreased total body water and increased body fat percentage on drug metabolism in elderly patients

Volume of distribution increases for lipid-soluble drugs (most psychotropic drugs) and reduces for water-soluble drugs (e.g. lithium). Half-life of lipid-soluble drugs prolonged.

Tests of working/short term memory

WORLD backwards. Serial 7s.

Features of nightmares

Wakes from sleep due to an intensely frightening dream involving threats to survival, security or self-esteem. Alert and orientated immediately after awakening. Able to recall the bad dream in vivid detail.

Mechanism of action of clozapine

Weak D2 antagonist by strong serotonin and D4 antagonist

What method of drug dispensing can reduce the risk of overdose

Weekly dispensing to avoid patients having access to large quantities

Prognosis of anorexia

Weight and menstrual function usually improve Eating habits and attitudes to food often remain abnormal A fifth recover, a fifth remain unwell, a quarter develop bulimia and the rest follow a relapsing-remitting course

How to calculate BMI

Weight(kg) / height(m)^2

Definition of induced delusional disorder (folie a deux)

When a non-psychotic patient with close emotional ties to a patient with delusions begins to also believe in the delusions.

Definition of functional hallucination

When a normal sensory stimulus is required to precipitate a hallucination in the same modality e.g. a doorbell triggers hearing voices.

Features of an adjustment disorder

When symptoms in response to a psychosocial stress are considered significant enough to be out of proportion to the original stressor, or cause disturbance of social or occupational functioning. The emotion and/or behavioural symptoms need to occur within 1 month (ICD-10) or 3 months (DSM-IV) of the original stressor. Although it is assumed that the disorder would not have arisen without the original stressor, an individual's personality and vulnerability to stress play an important contributing role.

Are alcohol treatment programmes suitable for those who are not dependent

Yes, they may still have harmful use

Definition of perseveration

When an initial response is inappropriately repeated

When can refeeding syndrome occur

When breaking a fast of >5 days

What is elective mutism

When children refuse to speak in certain settings despite having developed normal language abilities (e.g. will speak at home but not at school). Minority may have slight speech delay or articulation problems.

Association between expressed emotion and schizophrenia

When family or carers show 'high expressed emotion' i.e. becoming over-involved, critical or hostile or having contact for >35 hours/week, the risk of relapse is increased.

Definition of personality disorder

When personality traits, that are persistently inflexible and maladaptive and stable over time (not only present when stressed), cause significant personal distress or functional impairment

Description of shooting down the positive (type of cognitive distortion)

When positive experiences are rejected as short-lived and possibly not recurring (e.g. my fibromyalgia symptoms were better this weekend when I rested, but it will never happen again").

What is "guided" or "facilitated" self help?

When self-help materials are provided from , and progress followed and reviewed by, healthcare professionals.

When does an advance directive come into effect

When the patient loses capacity

Situations in which you can break confidentiality

When there is serious risk to the patient or others - you can tell the police and any people who are imminently at risk. Notifiable diseases. When ordered to do so by a judge or presiding officer of a court (unless the information appears irrelevant). If it is relevant to assist the procurator fiscal An official request from a statutory regulatory body where it is necessary in the interests of justice or safety. Children and others who lack capacity to consent. Situations of dual contractual responsibility e.g. working for an insurance company. But always make sure the patient realises this at the start.

Psychiatric defense in court proceedings

Where there are grounds to believe that the accused may have been suffering (or is currently suffering) from a mental disorder, a psychiatric defence may be needed (a psychiatric defence means that the presence of mental disorder may have been a mitigating factor in the offence or may interfere with court proceedings, mainly based on case rather than legislative law).

If coexisting depression and anxiety, which do you treat first

Whichever is the primary disorder i.e. which emerged first

Neurobiological changes associated with depression with onset in later life

White matter hyperintensities on neuroimaging, thought to represent small silent infarctions.

Things you may think when assessing a patient with delirium

Why aren't they listening to me? Why won't they wake up properly? They need to calm down.

Things you may think when assessing a patient with dementia

Why do they keep telling me about the past and asking me the same questions?

How quickly should symptoms of adjustment disorder fully resolve?

Within 6 months of onset (if not, consider different diagnosis).

Without treatment, how quickly will a first depressive episode remit?

Within 6-12 months.

When is the onset of acute dystonic symptoms

Within 72 hours

When do postnatal blues occur?

Within the first 10 days post-delivery and peak at 3-5 days.

Are most offences committed by those with or without a mental illness?

Without.

Is late-onset schizophrenia more common in men or women?

Women.

Speech problems in dementia

Word finding difficulties.

Types of explicit memory

Working/short term. Long-term (recent). Long-term (remote).

What is the effect of D2 antagonism on the mesocortical pathway

Worsening of negative and cognitive symptoms of schizophrenia

Are there higher arrest rates amongst psychiatrically ill patients than offenders without mental illness?

Yes.

Are those who have been bereaved at higher risk of developing depression requiring treatment?

Yes.

Do a lot of people with cyclothymia go on to develop bipolar?

Yes.

Do lots of patients with late-onset Alzheimer's have no ApoE alleles?

Yes.

Are all alcohol withdrawal states potentially life-threatening?

Yes

Are anxiety disorders often underdiagnosed

Yes

Are psychosocial and environmental interventions effective for intellectual disabilities

Yes

Are sedating antihistamines available for insomnia without prescription

Yes

Can acamprosate be used safely while drinking

Yes

Can epileptic seizures happen at night

Yes

Can paroxysmal and generalised anxiety co-occur

Yes

Can treatment for the mental disorder be given under a STDO

Yes

Can withdrawal from benzodiazepines be dangerous

Yes

Can you get tolerance, dependence and withdrawal with anxiolytics

Yes

Do acquired disorders tend to respond well to treatment

Yes

Do indications that a patient has changed their mind override advance directives

Yes

Do other psychiatric conditions commonly cause anxiety

Yes

Is alcohol withdrawal dangerous?

Yes

Is minor emotional disturbance or jealousy normal after the birth of a sibling

Yes

Is there an advantage in early detection and starting medication

Yes

Migrants risk factor for schizophrenia

Yes

Should you also consider whether the decision is consistent with the patient's background, beliefs and previously expressed wishes when capacity existed

Yes

Should you have a low threshold for referral to a specialist eating disorder service for those with anorexia?

Yes

Can alcohol cause delirium

Yes - both acute intoxication (lowered concentration, inability to sustain attention, global cognitive impairment) and withdrawal (delirium tremens)

Is force feeding an acceptible treatment under mental health legislation

Yes - food counts as a treatment for psychiatric impairment caused by starvation In extreme cases, NG or IV feeding may be necessary

Are advance directives legally enforcable

Yes in England and Wales but not in Scotland or Northern Ireland. However, wishes expressed by an individual should always be taken into consideration.

Can tics be voluntarily suppressed

Yes, although it is difficult.

Are genetic factors important

Yes, and consideral overlap with genetics of depression

Is there usually an intelectual disability in pervasive developmental disorders

Yes, but not always. Diagnosis is based on behaviour, social interaction and communication skills rather than intellectual functioning.

Are illusions common in healthy people

Yes, especially in association with inattention or strong emotion.

Is concordance an issue in elderly patient?

Yes, especially with those who are visually impaired, cognitively impaired, take numerous drugs and live alone.

Is psychopathy recognised as a personality disorder under the Mental Health Act 2003?

Yes, however because of the pervasive and persistent nature of psychopathy and the absence of any convincing treatment, individuals with psychopathy tend not to be treated in hospitals (in Scotland), and instead individuals tend to be managed via the criminal justice system.

Risk factors for poor prognosis of paraphilias

Young age of onset. High frequency of acts. No remorse about acts. Lack of motivation for change.

Drugs commonly used to help manage primary insomnia

Z-drugs: zopiclone, zolpidem, zaleplon. Short half-life benzos e.g. temazepam.

What are the Z drugs

Zaleplon, zolpidem, zopiclone

Elimination pharmacokinetics of alcohol

Zero-order kinetics

Difference between cocaine and crack cocaine

http://cocaine.org/the-difference-between-powder-cocaine-and-crack-cocaine/

Increased mortality compared to age matched controls for alcohol dependence

x3.6

Annual cost to the NHS from alcohol

£2.7 billion