UKMLA: Psychiatry

Anorexia: What is the restrictive subtype?

Minimal food intake and excessive exercise

Anorexia: What is the bulimic subtype?

Episodic binge eating followed by inducing vomiting or using laxatives

Anorexia: What is the ICD-11 criteria for diagnosis?

• Significantly low body weight

• Fear of gaining weight

• Distorted body image

• Restrictive eating

Anorexia: What is the DSM-5 criteria for diagnosis?

• Restriction of energy intake

• Intense fear of gaining weight

• Body image disturbance

Anorexia: What are the clinical features?

• BMI less than 17

• Hypotension

• Bradycardia

• Enlarged salivary glands

• Lanugo hair→ fine hair covering skin

• Russell’s sign→ scarring of back of hand

Anorexia: What is the management?

CBT

BPD: What is it?

BPD type 1→ 1+ manic episodes and 1+ depressive episodes

BPD type 2→ recurrent major depressive episodes and hypomanic episodes

BPD: What is the difference between mania and hypomania?

• Mania→ severe increased or decreased function for at least 7 days with psychotic symptoms

• Hypomania→ increased or decreased function for at least 4 days without psychotic symptoms

BPD: What are the signs of mania?

• Elevated or irritable mood

• Extreme self-esteem

• Low need for sleep/sleep disturbance

• High energy levels

• Very chatty

• Impulsive behaviour e.g. gambling, sex, addiction

BPD: What is the management of hypomania?

Routine referral to community mental health team

BPD: What is the management of mania?

Urgent referral to community mental health team

BPD: What is the management of acute mania?

• Mania with agitation→ IM neuroleptic (e.g. olanzopine) or benzodiazepine

• Mania without agitation→ oral quetiapine (or haloperidol, olanzapine, risperidone)

BPD: What is the maintenance therapy of chronic mania?

4 weeks after an acute episode start:

• 1. Lithium (first line)

• 2. Valproate (second line)

BPD: What is the complication of lithium therapy?

Nephrogenic diabetes insipidus→ now referred to as arginine vasopressin resistance (AVP-R).→ presents as extreme thirst and weight loss

BPD: What are the side effects of sodium valproate?

The main side effects of valproate can be remembered with the mnemonic "VALPROATE".

• Vomiting

• Alopecia

• Liver toxicity

• Pancreatitis/Pancytopenia

• Retention of fats (ie. weight gain)

• Oedema

• Anorexia

• Tremor

• Enzyme inhibition

Depression: What is the ICD-11 criteria for diagnosis?

Depressed mood, loss of interest (anhedonia), and reduced energy (fatigue) persisting for at least two weeks.

Depression: What is the ICD-11 criteria for diagnosis?

• Major Depressive Disorder (MDD)→ Presence of a major depressive episode lasting at least two weeks

• Persistent Depressive Disorder (Dysthymia)→A chronic form of depression lasting for at least two years
  

Depression: Which questionnaires are used for diagnosis?

• HAD scale

• PHQ-9

Depression: What is the management?

1. CBT

2. SSRI

3. If severe depression→ ECT

4. If recurrent depression → SSRI + lithium

Patients under 30 on SSRI’s are at high risk for suicidal ideation so have a follow-up appointment within 1 week of starting SSRI’s

OCD: What is the ICD-11 criteria for diagnosis?

• Presence of obsessions, compulsions, or both.

• Time-consuming (more than one hour a day) or causes significant impairment.

• Not attributed to another medical or mental disorder.

OCD: What is the DSM-V criteria for diagnosis?

• Presence of obsessions, compulsions, or both.

• Time-consuming or cause significant distress/impairment.

• Not attributable to another medical or mental disorder.

OCD: What are the clinical features?

• Obsessions: Intrusive, unwanted thoughts or images causing distress.

• Compulsions: Repetitive behaviours or mental acts aimed at reducing anxiety.

• Significant time investment and interference with daily life.

OCD: What is the management?

• Mild functional impairment→ CBT

• Moderate functional impairment→ SSRI

• Severe functional impairment→ CBT + SSRI

OCD: Which drugs are used for management?

SSRI’s for 12 months→ Escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline are all licensed for the treatment of OCD in adults

Paracetamol Overdose: What is the pathophysiology?

Build up of toxic NAPQI metabolite due to depletion of glutathione stores

Paracetamol Overdose: What is the classification?

• Acute→ less than 1 hour

• Staggered→ more than 1 hour

• Therapeutic→ by accident, more than 75mg/kg/24 hours

Paracetamol Overdose: What are the signs and symptoms?

• Nausea and vomiting

• 72 hrs→ RUQ pain + hypotension

• 72-96 hrs→ Metabolic acidosis

• Confusion, drowsiness, jaundice etc.

Paracetamol Overdose: Why is salicylate levels tested?

To look for a mixed overdose with aspirin

Paracetamol Overdose: What is the management?

• Ingestion less than 1 hour ago + dose >150mg/kg: Administer activated charcoal

• Ingestion 1-4 hours ago: Wait until 4 hours to take a level and treat with N-acetylcysteine (NAC) based on level

• Ingestion within 4-8 hours + dose >150mg/kg: Start NAC immediately if there is going to be a delay of >8 hours in obtaining the paracetamol level, otherwise wait for level and treat if level high (above the treatment line on the nomogram)

• Ingestion within 8-24 hours + dose >150mg/kg: Start NAC immediately

Summary → if less than 1 hour ago = charcoal, more than 1 hour ago = NAC

Paracetamol Overdose: What is the drug MOA of NAC (N-acetylcysteine)?

NAC is given as an IV medication - it acts by increasing glutathione levels thereby preventing toxicity:

• Standard regimen of 3 consecutive infusions totalling 21 hours in duration

• The newer SNAP protocol (now recommended by Royal College of Emergency Medicine as standard) where the same dose of NAC is given over 12 hours in two infusions

Personality Disorders: What is a paranoid personality?

• Characterised by a pervasive and enduring pattern of irrational suspicion and mistrust of others

• Demonstrates hypersensitivity to criticism and potential slights

• Exhibits reluctance to confide in others due to fear of information being used maliciously against them

• Often preoccupied with unfounded beliefs about perceived conspiracies against themselves

Personality Disorders: What is a schizoid personality?

• Characterised by an enduring pattern of detachment from social relationships and a restricted range of emotional expression

• Displays a pervasive lack of interest in or desire for interpersonal relationships, often preferring solitary activities

• Shows an emotional coldness, detachment, or flattened affectivity

• Often has few, if any, close relationships outside of immediate family

Personality Disorders: What is an antisocial personality?

• Defined by a pervasive pattern of disregard for and violation of the rights of others.

• Individuals with this disorder exhibit a lack of empathy and frequently engage in manipulative, impulsive actions.

• Manifestations include aggressive, unremorseful behaviour, and consistent irresponsibility, which often results in a failure to obey laws and social norms.

Personality Disorders: What is a borderline personality?

• Characterised by a recurring pattern of abrupt mood swings, unstable personal relationships, and self-image instability.

• The propensity towards self-harm is commonly observed in these patients.

• Relationships often fluctuate between extremes of idealisation and devaluation, a process known as "splitting".

Personality Disorders: What is a histrionic personality?

• Predominantly characterised by attention-seeking behaviours and excessive displays of emotion.

• Individuals may display inappropriate sexual behaviours.

• Their emotional expressions tend to be shallow, dramatic, and often perceived as exaggerated.

• They often perceive relationships as being more intimate than they truly are, reflecting a distorted perception of interpersonal boundaries

Personality Disorders: What is a narcissistic personality?

• Characterised by a persistent pattern of grandiosity, a strong need for the admiration of others, and a marked lack of empathy.

• Individuals with this disorder often display a sense of entitlement and will exploit others to fulfil their own desires.

• Tendency to be arrogant and preoccupied with personal fantasies and desires, often at the cost of disregarding others' feelings and needs

Personality Disorders: What is an avoidant personality?

• Characterised by intense feelings of social inadequacy, fear of rejection, and hypersensitivity to criticism

• Patients often self-impose isolation to avoid potential criticism, despite a strong desire for social acceptance and interaction