Sush Corrected-Unity PSYCH 1700 PDF

Psychiatry-System
Wise 1700-by Sush and Team. 2016

February 17, 2016

Dear Plabber,

• This first ever System Wise 1700 document was created thanks to 3 months of daily hard
work by the PLAB Skype group ‘Unity’ which was brought together by Dr Susmita
Chowdhury.

The team members were:

& Susmita (Lead/most ignorant as she is working full time in public health for 13 years)
& Asad (Invaluable in IT and all types of support/the heart of the group)
& Manu (Volunteered to solve more questions/pathologist/amazing genuine person)
& Saima (Most concise clear notes/ photographic memory)
& Zohaib (Great research/a surgeon)
& Savia (Great research/multi-tasker with two little ones)
& Shanu (Very helpful after her March exam for those appearing in June)
& Mona (Great contributor in discussions)
& Manisha (Gyne/great discussion contributor)
& Sitara (Good discussion contributor)
& Samreena (Stayed a shorter time but great)
& Sami (Contributed the most early on but too brilliant for the group/still great friends)
& Komal (Knowledgeable sweet supportive girl)

• The main purpose was to break down the 1700 Q Bank System wise.

• We did our own reliable research for the options (OHCM/Patient info etc.) and concluded
these keys below on skype. This can save you 100s of hours of research. But I suggest you
also do your own.

• 90% of the document consists of Unity research. We also added information from other
circulating documents and they are referenced as Dr Khalid/Dr Rabia (and her Team).

• However, several keys may be ‘incorrect’ and so please use your own judgment as we take
no responsibility. I suggest cross checking with Dr Khalid’s latest keys (a few of which are still
debatable). Finally decide on your own key.

• Sorry if some members failed to make their answers thorough. The highlights are mostly as
per what the team members wanted to highlight. Blank tables to be ignored.

• Note that some 1700 Questions are missing from here (when members did not do their
share). Questions may not be in order due to merging of documents and there is excess
information than required. Read as much as needed.

• This has been circulated by our team as a generous contribution to the Plabbers’ success and
must not be ‘sold’.

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Psychiatry-System Wise 1700-by Sush and Team. 2016
February 17, 2016

Q: 404 A man is very depressed and miserable after his wife’s death. He sees no point in
living now that his wife is not around and apologises for his existence. He refuses any
help offered. His son has brought him to the ED. The son can’t deal with the father
any more. What is the most appropriate next step?

a. Voluntary admission to psychiatry ward
b. Compulsory admission under MHA
c. Refer to social services
d. Alternate housing
e. ECT

Clincher(s) Refuses any help, Son cant deal with the father anymore
A Refusing help
B Under Mental Health Act can be admitted for treatment forcefully
C
D
E Electro Convulsive Therapy (in depression, last resort is ECT)
KEY B Compulsory admission in hospital under MHA
Additional Information Important that he is ‘refusing’ and ‘suicidal intention’
Reference http://patient.info/doctor/compulsory-hospitalisation
Dr Khalid/Rabia The key is B. Compulsory admission under MHA. [This patient is refusing any help
offered! And his son cannot deal with him anymore! In this situation voluntary
admission to psychiatry ward is not possible and the option of choice is “compulsory
admission under MHA”].

Q:421 A 54yo man with alcohol dependence has tremor and sweating 3days into a hospital
admission for a fx femur. He is apprehensive and fearful. What is the single most
appropriate tx?

a. Acamprossate
b. Chlordiazepoxide
c. Lorazepam
d. Lofexidine
e. Procyclidine

Clincher(s)
A Anti-Alcohol agent but common side effect include ‘Fear’ ‘Confusion”
B Most appropriate (side effect does not include ‘fear’)
C Treatment of anxiety / seconda line – alch withd=rawl
D Antihypertensive, more commonly used for opioid withdrawal or Heroin symptoms
E Anti-cholineergic, used treatment of drug induced parkinsonism/dystonia
KEY B Should be used in low dosages to avoid developing tolerance
Additional Information
Rx of alcohol dependence is Chlordiazepoxide.

Dystonia is a medical term for a range of movement disorders that cause muscle
spasms and contractions.
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Types of dystonia
Dystonia can affect only one muscle or a group of muscles. There are five main types
of dystonia:
• Focal dystonia – where a single region, such as the hand or eyes, is affected.
Cervical dystonia, blepharospasm (abnormal twitch of the eyelid), laryngeal
dystonia and writer's cramp are all examples of focal dystonia. If it only affects
someone during specific activities, such as writing, it's described as task-
specific dystonia.
• Segmental dystonia – where two or more connected regions of the body are
affected. Cranial dystonia (blepharospasm affecting the lower face and jaw or
tongue) is an example.
• Multifocal dystonia – where two or more regions of the body that aren't connected
to each other, such as the left arm and left leg, are affected.
• Generalised dystonia – where the trunk and at least two other parts of the body
are affected. The legs may or may not be affected.
Hemidystonia – where one entire side of the body is affected.

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February 17, 2016

Reference http://www.evidence.nhs.uk/formulary/bnf/current/4-central-nervous-system/41-
hypnotics-and-anxiolytics/412-anxiolytics/benzodiazepines/diazepam#PHP2162

OHCM 282

BNF Page 333

http://www.nhs.uk/Conditions/Dystonia/Pages/Introduction.aspx
Dr Khalid/Rabia The key is B. Chlordiazepoxide. [This is a case of alcohol withdrawal syndrome.
Chlordiazepoxide when used in alcohol withdrawal it is important not to drink alcohol
while taking Chlordiazepoxide.
Chlordiazepoxide should only be used at the lowest possible dose and for a maximum
of up to four weeks. This will reduce the risks of developing tolerance, dependence
and withdrawal].

Q: 423 A man with a family hx of panic disorder is brought to the hospital with palpitations,
tremors, sweating and muscles tightness on 3 occasions in the last 6 wks. He doesn’t
complain of headache and his BP is WNL. What is the single most appropriate long-
term tx for him?

a. Diazepam
b. Olanzapine
c. Haloperidol
d. Fluoxetine
e. Alprazolam

Clincher(s) Panic disorder
A Anxiety.], and alch syndrome, depression with MI
B Bipolar, schizo
C
D SSRI most preferred drug = FLUOXETINE (SSRI ferroxitine will be first choice if given)
E Alprazolam (trade name Xanax ), available under other generic names, is a short-
acting anxiolytic of the benzodiazepine class of psychoactive drugs. Alprazolam, like
other benzodiazepines, binds to specific sites on the GABAAreceptor. Alprazolam is
commonly used and FDA approved for the medical treatment of panic disorder,
and anxiety disorders, such as generalized anxiety disorder (GAD) or social anxiety
disorder (SAD).
KEY D NICE : 1) CBT (cog behavioural therapy) 2) Medication (SSRI’s or TCA)
Additional Information Selective serotonin reuptake inhibitors (SSRIs) are a widely used type of
antidepressant medication.
They're mainly prescribed to treat depression, particularly persistent or severe cases,
and are often used in combination with a talking therapy such as cognitive behavioral
therapy (CBT).
SSRIs are usually the first choice medication for depression because they generally
have fewer side effects than most other types of antidepressant.
As well as depression, SSRIs can be used to treat a number of other mental health
conditions, including:
• generalised anxiety disorder (GAD)
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February 17, 2016

• obsessive compulsive disorder (OCD)
• panic disorder
• severe phobias, such as agoraphobia and social phobia
• bulimia
• post-traumatic stress disorder (PTSD)
SSRIs can sometimes be used to treat other conditions, such as premature
ejaculation, premenstrual syndrome (PMS), fibromyalgia and irritable bowel
syndrome (IBS). Occasionally, they may also be prescribed to treat pain.
How SSRIs work
It's thought that SSRIs work by increasing serotonin levels in the brain.
Serotonin is a neurotransmitter (a messenger chemical that carries signals
between nerve cells in the brain). It's thought to have a good influence on mood,
emotion and sleep.
After carrying a message, serotonin is usually reabsorbed by the nerve cells (known as
"reuptake"). SSRIs work by blocking ("inhibiting") reuptake, meaning more
serotonin is available to pass further messages between nearby nerve cells.
It would be too simplistic to say that depression and related mental health conditions
are caused by low serotonin levels, but a rise in serotonin levels can improve
symptoms and make people more responsive to other types of treatment, such as
CBT.
Types of SSRIs
There are currently seven SSRIs prescribed in the UK:
• citalopram (Cipramil)
• dapoxetine (Priligy)
• escitalopram (Cipralex)
• fluoxetine (Prozac or Oxactin)
• fluvoxamine (Faverin)
• paroxetine (Seroxat)
• sertraline (Lustral)
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February 17, 2016

Reference https://www.nice.org.uk/guidance/cg113

http://www.nhs.uk/conditions/SSRIs-(selective-serotonin-reuptake-
inhibitors)/Pages/Introduction.aspx

http://patient.info/doctor/panic-disorder-pro

Dr Khalid/Rabia The key is D. Fluoxetine. [Recommended treatment for panic disorder is i) CBT ii)
Medication (SSRIs or TCA). NICE recommends a total of seven to 14 hours of CBT to be
completed within a four-month period. Treatment will usually involve having a weekly
one to two-hour session. When drug is prescribed usually a SSRI is preferred.
Antidepressants can take two to four weeks before becoming effective].

Q: 425 A 56yo woman who is depressed after her husband died of cancer 3m ago was given
amitriptyline. Her sleep has improved and she now wants to stop medication but she
still speaks about her husband. How would you manage her?

a. CBT
b. Continue amitriptyline
c. Psychoanalysis
d. Bereavement counselling
e. Antipsychotic

Clincher(s) Depressed , sleep improved
A
B Bereavement = depression & sleepless nights, drug ! sleep improved
C
D
E
KEY B Continue amitriptyline for 6-9 months as improvement visible
Additional Information Amitriptyline belongs to a group of drugs called tricyclic antidepressants. Although
they’re still used to treat anxiety and depression, they’re also now widely used at
lower doses to help block the chronic (long-term) pain of some rheumatic conditions.
The main aim of lower-dose amitriptyline is to relieve pain, relax muscles and improve
sleep, but it may also help reduce any anxiety or depression resulting from the pain.
Low-dose amitriptyline alone won’t be enough to treat severe depression. - See more
at: http://www.arthritisresearchuk.org/arthritis-
information/drugs/amitriptyline/what-it-is.aspx#sthash.m1Hjsj0L.dpuf
Reference http://patient.info/medicine/amitriptyline

http://www.arthritisresearchuk.org/arthritis-information/drugs/amitriptyline.aspx
Dr Khalid/Rabia The key is B. Continue amitriptyline. [depression is important feature of bereavement.
Patient may pass sleepless nights. As this patient sleep has improved it indicate he has
good response to antidepressant and as he still speaks about her husband there is
chance to deterioration of her depression if antidepressant is stopped. For depressive
episodes’ antidepressants should be continued for at least 6-9 months
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February 17, 2016

Q: 549 A 21yo woman has had several sudden onset episodes of palpitations, sweating,
nausea and overwhelming fear. On one occasion she was woken from sleep and
feared she was going insane. There is no previous psychiatric disorder. What is the
most probable dx?

a. Pheochromocytoma
b. Panic disorder
c. GAD
d. Phobia
e. Acute stress disorder

Clincher(s) Several sudden onset episodes
A Overwhelming fear makes panic disorder more likely
B Sudden onset several episodes
C Onset not sudden and would be continuous state of anxiety
D
E
KEY B Panis Disorder for sudden onset of episodes including overwhelming fear
Reference
Dr Khalid/Rabia b. Panic disorder
panic attack is MORE likely... it can be pheochromocytoma but "overwhelming fear"
makes panic attack look more fitting... It cant be phobia, because the attacks are
just random without any known trigger

Pheochromocytoma pressure symptoms

Treatment in primary care
• NICE recommend either cognitive behavioural therapy or drug treatment
• SSRIs are first-line. If contraindicated or no response after 12 weeks then
imipramine or clomipramine should be offered

Q: 565 A 34yo man from Zimbabwe is admitted with abdominal pain to the ED. An AXR
reveals bladder calcification. What is the most likely cause?

a. Schistosoma mansoni
b. Sarcoidosis
c. Leishmaniasis
d. TB
e. Schistosoma haematobium

Clincher(s) Abdominal pain, Bladder calcification
A
B
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February 17, 2016

C
D
E causes urinary schistosomiasis most prevalent & widespread in Africa and ME
KEY E SCHISTOSOMA HAEMATOBIUM

Reference https://web.stanford.edu/class/humbio103/ParaSites2004/Schisto/website.html

OHCM 445
Dr Khalid/Rabia Schistosoma haematobium
Schistosoma Hematobium (Bilhaarziasis). CA urinary bladder and vesicolithiasis are
the two main concern here

S. haematobium causes urinary schistosomiasis, and is the most prevalent and
widespread species in Africa and the Middle East.
Schistosomiasis is associated with anaemia, chronic pain, diarrhoea, exercise
intolerance, and malnutrition.
The first sign may be swimmer's itch
• Fever.
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February 17, 2016

• Hepatosplenomegaly.
• Right upper quadrant pain or tenderness.
• Urticaria may be seen occasionally.
• Lymphadenopathy.
Praziquantel is the drug of choice

Oxamniquine is the only alternative

Complications:
• renal stones
• increased risk of squamous cell carcinoma of bladder that has been noticed
especially in Egypt. It is possible that the infestation and the carcinogens in
tobacco smoke have a synergistic effect.
• Hydronephrosis
• renal failure may occur
• iron-deficiency anaemia
• Portal hypertension

Q: 605 A 32yo lady complains that she hears everyone saying that she is an evil person. What
type of hallucinations is she suffering from?

a. 2nd person auditory hallucinations
b. 3rd person auditory hallucinations
c. Echo de la pense
d. Gedankenlautwerden

Clincher(s) Hears everyone
A
B Everyone talking about her
C
D
E
KEY B
Additional Information Second order hallucinations are auditory hallucinations in which a voice appears to
address the patient in the second person. For example the voice may be talking
directly to the patient - "You are going to die" - or the voice may be telling the patient
to do some action - "kill him". These types of auditory hallucinations are not
diagnostic in the same way as third person auditory hallucinations, but the content of
the hallucination, and the patient's reaction to it, may help in diagnosis.
In a depressive psychosis the comments from the auditory hallucination may be

derisory ("you are useless"), and the patient may accept them as being justified. A
schizophrenic may experience second person hallucinations but may resent the
comments that the voice makes. These interpretations of the content of the
hallucination and the patient's reaction are only indicators to the possible psychiatric
diagnosis.

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February 17, 2016

Third person hallucinations are auditory hallucinations in which patients hear voices
talking about themselves, referring to them in the third person, for example "he is an
evil person".
This type of auditory hallucination is particularly associated with schizophrenia, but

can occur in affective disorders. Such voices may be experienced as commenting on
the patient's intended actions - "he wants to kill her", or describing his current actions
- "he is trying to sleep now". A running commentary by voices is most suggestive of
schizophrenia.

Gedankenlautwerden is a hallucination where a patient hears voices which anticipate

what he or she is about to think, or which state what the patient is thinking as he
thinks it. Sadly, there is no convenient word in English to describe this phenomenon.
It is a symptom suggestive of schizophrenia.
Gedankenlautwerden literally means thoughts becoming loud.

Reference
Dr Khalid/Rabia b. 3rd person auditory hallucinations
She hears everyone
talking ABOUT her. So it's third person hallucination. If she had been hearing
everyone talking TO her, it would've been second person hallucination.

Q: 278 278. A 36yo man walks into a bank and demands money claiming he owns the bank. On being
denied, he goes to the police station to report this. What kind of delusions is he suffering from?
a. Delusion of reference
b. Delusion of control
c. Delusion of guilt
d. Delusion of persecution
e. Delusion of grandeur

Clincher(s) Clinical assessment

A Other people, event, media are referring to the person or communicating a message. e.g.
someone is giving them special messages through Newspaper, TV and radio
B Action, feeling or impulses can be controlled or interfered with by outside influence. Feeling
another person is controlling what you are doing. E.g. Schizophrenia

C Guilty for non realistic reasons, they feel guilt for whatever is happening: eg he feels he is the
reason of war and feel guilty
D Someone or something is interfering with the person. Worried that people are against him/her
and trying to harm him/her.

E Being famous, having supernatural power or enormous wealth. Believe that they have
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February 17, 2016

exceptional abilities or talent and keep praising themselves. E.g. usually seen in high society
figures- actors, mania

KEY e
Additional information
Points in favour = Delusion of grandeur is defined as delusion of exaggerated self worth.

Paranoid Delusion:
Feeling that people are trying to kill them

Q:281 281. An old man comes to the doctor complaining that a part of this body is rotten and he wants
it removed. What is the most likely dx?
a. Guilt
b. Hypochondriasis
. Munchauses
d. Nihilism
e. Capgras syndrome

Clincher(s)
A
B Preoccupation with assumed serious diseases. Commonly patient believes they are suffering
from cancer or HIV even after repeated reassurance with normal investigations for symptoms
and they repeatedly request investigation:

C It is deliberately creating medical symptoms. Usually these people have medical back ground.
Abdominal pain, sexual abuse, hallucination.
Multiple abdominal scars which suggests multiple managements.

D The belief that nothing in the world has real existence. The rejection of all the religious and
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moral principles. Often in the belief that world is meaningless. Psych: patient feels he or part of
himself does not exist or is going away. This can be found Cotard syndrome/Nihilistic delusions
(they feel Nihilistic/believe parts of their body is decaying, need to remove a part of the body).
E A delusion of doubles that oneself or a friend has been replaced by an exact clone.
KEY E, but I think its b


Q: 302 302. A woman presents with complains of abdominal pain, unsteadiness, numbness of lower
limb and palpitations. All inv are normal. What is the dx?
a. Manchausen
b. Somatization
c. Hypochondriac
d. Bipolar

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February 17, 2016

A
B This is multiple, recurrent, medically unexplained symptoms, usually starting early in life. Usually
patient presents with one symptom at a time.
Nausea, Vomiting, Abdomen pain
Neck pain, Back pain, Headache
Etiology is unknown
Investigations are normal

C
D Depression alternating with mania
E
KEY b

Q:316
. A 28 yo female who delivered 6 weeks ago feels sad and has no interest to feeding the baby.
She has been eating poorly and having difficulty sleeping. She feels weak throught the day and
has stopped taking the baby out of the house. She also says that the baby has evil eyes. What is
the most likely diagnosis?
a. Postpartum blues
b. Postpartum depression
c. Postpartum psychosis
d. Schizophrenia
e. Psychotic depression.

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Clincher(s)
A Occurs in 50% women after giving birth• Normal phenomena and resolves within a few days
usually 3-4 days• Poor sleep, anxiety, irritability, tearful, crying for no reason
Management
Family support & Reassuran

B Occurs after delivery. Poor sleep, low confidence, anhedonia•Loss of appetite & weight• Feeling
that she is not capable of looking after her child. Guilt feeling that she is not a good
mother.Tearful, Anxiety.Occurs in the first 3 months after delivery .Mother feels as if
someone/partner wants to harm her baby.

C
Usually occurs within 2 weeks after delivery. Usually starts with post-natal depression
•Delusional ideas that the baby is deformed, evil or otherwise affected in some way and she has
intent to kill the baby, evils or self harm.
Page

D Psychosis (hallucination/sees or listens to some things not there and delusion/false beliefs)
and thought disorder
E
KEY c
Additional information Points in favour: i) features of depression: feels sad, poor eating, difficulty sleep, feeling weak
ii) delusional ideas: no interest to feed baby, thinks baby has evil eyes and not taking the baby
out of the house. These points to postpartum psychosis. [Postpartum psychosis starts within 2
wks (occasionally more later) of delivery and It can take 6 -12 months or more to recover from
postpartum psychosis].

Q: 337 337. A pt with alternating swings or episodes from elation and depression had underwent tx and
gotten better. What medication needed to be continued so he can stay well?
a. Anxiolytics
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February 17, 2016

b. Mood stabilizers
c. Antidepressants
d. Antipsychotics


A
B
C
D
E
KEY b
The key is B. Mood stabilizers [bipolar disorder treated with mood stabilizers].

Q:206 23 yo girl presented with perioral paresthesia and carpopedal spasm 20 mins
after a huge argument with her boyfriend. What is the next step for this pt?
a. SSRI
b. Diazepam
c. Rebreath into a paper bag
d. Propranolol
e. Alprazolam

Clincher(s)
A For long term treatment - SSRi
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February 17, 2016

B
C
D
E
KEY C (acute mx)
Additional What is hyperventilation syndrome?
Information
Hyperventilation syndrome (HVS) is a name given to a collection of physical
and emotional symptoms, largely brought about by hyperventilation. This
happens when we over-breathe.
The main signs of this are when we breathe much more quickly and more
shallowly than our bodies needs. Over time, all sorts of physical changes can
take place in our body. These include a decrease in carbon dioxide pressure
in the alveoli (in our lungs) and arteries, an increase in arterial pH
(respiratory alkalosis), constriction of cerebral arteries and increased
production of lactic and pyruvial acid.
HVS can show itself in different ways. Most people with HVS will have
experienced some, if not many, of the following symptoms.
Respiratory symptoms:
Tetanic symptoms:
Cerebral symptoms:
Cardiac symptoms: Temperature symptoms:
Gastrointestinal symptoms: General symptoms:
breathlessness
tightness around the chest fast breathing
frequent sighing
tingling (e.g. in fingers, arms, mouth) muscle stiffness
trembling in hands
dizziness blurred vision faintness headaches
palpitations
tachycardia (rapid heart beat)
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February 17, 2016

cold hands or feet shivering
warm feeling in the head
sickness abdominal pain
tension anxiety
One of the main causes of HVS is anxiety which is brought on by stress.
Below are some breathing exercises which will help you learn to breathe
deeply. It is important that you breathe in and out at a steady rate and that
you do not have to try too hard.
Exercise 1:
Practice your breathing when sitting or lying in a comfortable position.

Imagine your lungs are divided into three parts. Breathe in gently through
your nose. Imagine the lowest part of your lungs filling with air. If you are
using your diaphragm your stomach will come out a little. Imagine the
middle part of your lungs filling with air and your lungs becoming completely
full. Your shoulders may rise slightly and move backwards.
Gently and slowly exhale fully and completely. Repeat the exercise three or
four times.
Exercise 2:
Take a deep, full breath. Exhale slowly, fully and completely. Inhale again
and count from 1 to 4 (or for as long as feels comfortable). Pause for a few
seconds. Exhale slowly while counting from 1 to 4 (or for as long as feels
comfortable). Repeat the exercise three or four times.
Reference Q. 1. What is the key?
Q. 2. What is the likely diagnosis?
Ans. 1. The key is C. Rebreathin in paper bag. [hyperventilation causes CO2
washout and respiratory
alkalosis. If you continue breathing and rebreathing in paper bag it will allow
CO2 concentration to rise in
paper bag and as you rebreath this again and again you will regain some
washed out CO2 and thus relief
to this alkalosis].
Ans. 2. The girl may have anxiety disorder when it precipitates leads to
hyperventilation syndrome. X
Dr Khalid/Rabia Dr khalid ,nhs.co

Q:207 A 25 yo woman has been feeling anxious and nervous for the last few months.
She also complains of palpitations and tremors. Her symptoms last for a few
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February 17, 2016

minutes and are very hard to control. She tells you that taking alcohol initially
helped her relieve her symptoms but now this effect is wearing off and she has
her symptoms even after drinking alcohol. What is the dx?
a. Panic disorder
b. Depression
c. OCD
d. Alcohol addiction
e. GAD (more than 6 months)

Clincher(s)
A Management of panic disorder

Again a stepwise approach:
step 1: recognition and diagnosis
step 2: treatment in primary care
step 3: review and consideration of alternative treatments
step 4: review and referral to specialist mental health services
step 5: care in specialist mental health services

Treatment in primary care
NICE recommend either cognitive behavioural therapy or drug treatment

SSRIs are first-line. If contraindicated or no response after 12 weeks then
imipramine or clomipranine should be offered

B Diagnostic criteria for Depressive Episodes

Mild Depressive Episode:

At least 2 of the main 3 symptoms of depression, and at least two of the other
symptoms,
should be present for a definite diagnosis. None of the symptoms should be
present to an
intense degree

Minimum duration of the whole episode is about 2 weeks

Individuals may be distressed by symptoms, but should be able to continue
work and
social functioning

Moderate Depressive Episode:

At least 2 of the main 3 symptoms of depression, and at least three (and
preferably four)
of the other symptoms, should be present for a definite diagnosis
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February 17, 2016

Minimum duration of the whole episode is about 2 weeks

Individuals will usually have considerable difficulty continuing with normal
work and
social functioning

Severe Depressive Episode:

All three of the typical symptoms should be present, plus at least four other
symptoms,
some of which should be of severe intensity

The minimum duration of the whole episode should last at least 2 weeks, but
if the
symptoms are particularly severe then it may be appropriate to make an early
diagnosis

Can also experience psychotic symptoms with severe depressive episodes

Individuals show severe distress and/or agitation
SUMMARY
MILD DEPRESSION : i)Low mood ii) Anhedonia iii) Guilt iv) Hopelessness v)
Worthlessness vi) Inability to concentrate. Rx CBT
MODERATE DEPRESSION : Features of mild + vii) Poor sleep viii) Poor Appetite
ix)
Poor libido x) Easy fatiguability . Rx: Antidepressants (SSRi)
*lack of self care
SEVERE DEPRESSION: Features of moderate + xi) Suicidal intensions. Rx ECT
PSYCHOTIC DEPRESSION: Features of severe + xii) Hallucinations xiii) Delusions
xiv) Guilt xv) Nihilism. Rx: ECT
ATYPICAL DEPRESSION: Subtype of major depression or dysthymic disorder
that involves
several specific symptoms, including increased appetite or weight gain,
sleepiness or excessive
sleep, marked fatigue or weakness, moods that are strongly reactive to
environmental
circumstances, and feeling extremely sensitive to rejection

C Obsessive compulsive disorder (OCD) is a mental health
condition where a person has obsessive thoughts and
compulsive activity
D Alcohol & organ damage Liver: (normal in 50% of alcoholics). Fatty liver:
Acute, reversible; hepatitis; ). Gut: D&V; peptic ulcer; erosions; varices;
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pancreatitis. Marrow: 80% progress to cirrhosis (liver failure in 10%)
Cirrhosis: 5yr survival 48% if alcohol intake continues (if it stops, 77%). CNS:
Poor memory/cognition; cortical/cerebellar atrophy; retrobulbar
neuropathy; fi ts; falls; accidents; neuropathy; Korsakoff ’s/Wernicke’s
encephalopathy (OHCM p728; urgent parenteral vitamins are needed
Hb ; MCV . Heart: Arrhythmias; BP ; cardiomyopathy; fewer MIs
(?benefi t only if 55yrs). Skeleton: Heavy drinking disrupts calcium
metabolism (osteoporosis risk ).321 Sperm: Fertility ; sperm motility
(in 34 precisely analysed medical students).322 Malignancy: GI & breast.
Social: Alcohol is related to violent crime and suicide. In medical students,
alcohol correlates with events such as missing study, sexually escapades, fi
sticuff s, etc323 n=194 and students are equally prone to use
alcohol at high doses to relieve stress (this carries on into later years).324
Alcohol and drug levels Regular heavy drinking induces hepatic enzymes;
binging inhibits enzymes; it’s probably not a good idea to indulge in both
and hope for the best. Be alert with phenytoin, warfarin, tolbutamide, etc.
NB: paracetamol may cause N-acetyl-p-benzoquinoneimine (it is
hepatotoxic). Withdrawal signs (Delirium tremens) Pulse ; BP ; tremor;
fi ts; visual or tactile hallucinations, eg of insects crawling under the skin
(formication). : • Admit; monitor vital signs (beware BP ). • For the
1st 3 days give diazepam generously, eg 10mg/6h PO or PR if vomiting—
or IVI during fi ts; chlordiazepoxide is an alternative. After a few days,
diazepam (eg 10mg/8h PO from day 4–6, then 5mg/12h PO for 2
more days). -blockers, clonidine, carbamazepine, and neuroleptics (if no
liver damage) are adjuncts (not advised as monotherapy).325 Psychiatry
Treatment Does the patient want to change? If so, be optimistic, and
augment his will to do so. Should abstinence or controlled intake be the
aim? If the former, remarkable recovery of organs (eg hippocampus) is
possible.326 Treat coexisting depression (p336). Refer to specialists. Self-
help/group therapy (Alcoholics Anonymous) help, ± drugs which produce a
nasty reaction if alcohol is taken (disulfi ram 200mg/24h PO). Reducing the
pleasure that alcohol brings (and craving on withdrawal) with naltrexone
25–50mg/24h PO (an opioid receptor antagonist) can halve relapse
rates.327 N=111 SE: vomiting, drowsiness, dizziness, joint pain. CI:
hepatitis; liver failure; monitor LFT. Get expert help. Acamprosate (OHCM
p445) can treble abstinence rates. CI: pregnancy, severe liver failure,
creatinine >120μmol/L; SE: D&V, libido or ; dose example:
666mg/8h PO if >60kg and <65yrs old. Economic analysis supports its use,
at least in some communities.328 N=448 Non-drug, physician-based brief
interventions for problem drinkers: (Education, counselling, goal-setting +
monitoring of GT in those who have social or physical problems from
alcohol, but who do not exhibit full dependency.) 50% of trials show that
GT falls in the intervention group, but none show clear improvement in
alcohol-related morbidity.OHCM page 363
E Generalised anxiety disorder and panic disorder(GAD)
22
February 17, 2016

Anxiety is a common disorder that can present in multiple ways. NICE define
the central feature
as an 'excessive worry about a number of different events associated with
heightened tension.'

Management of generalised anxiety disorder (GAD)

NICE suggest a step-wise approach:
step 1: education about GAD + active monitoring
step 2: low intensity psychological interventions (individual non-facilitated
self-help or
individual guided self-help or psychoeducational groups)
step 3: high intensity psychological interventions (cognitive behavioural
therapy or
applied relaxation) or drug treatment.
step 4: highly specialist input e.g. Multi agency teams

Drug treatment
NICE suggest sertraline should be considered the first-line SSRI

interestingly for patients under the age of 30 years NICE recommend you
warn patients
of the increased risk of suicidal thinking and self-harm. Weekly follow-up is
recommended for the first month

KEY A
Additional
Information Panic disorder is where you have recurring and regular panic
attacks, often for no apparent reason
Anxiety
Anxiety is a feeling of unease. It can range from mild to severe and can include
feelings of worry and fear.
There are several conditions that can cause severe anxiety including
• phobias – an extreme or irrational fear of an object, place, situation,

feeling or animal
• generalised anxiety disorder (GAD) – a long-term condition that causes
excessive anxiety and worry relating to a variety of situations
• post-traumatic stress disorder – a condition with psychological and
physical symptoms caused by distressing or frightening events
23
February 17, 2016

Panic attacks
A panic attack occurs when your body experiences a rush of
intense psychological (mental) and physical symptoms.
You may experience an overwhelming sense of fear, apprehension

and anxiety. As well as these feelings, you may also have physical
symptoms such as:
• nausea
• sweating
• trembling
• a sensation that your heart is beating irregularly (palpitations
Traumatic life experiences

A trauma, such as bereavement, can sometimes trigger feelings of
panic and anxiety. These feelings may be obvious soon after the
event or they may be triggered unexpectedly years later.
Genetics
Having a close family member with panic disorder is thought to
increase a person's risk of developing it. However, the precise
nature of the risk isn't known.
Neurotransmitters
Neurotransmitters are chemicals that occur naturally in the brain.
It's thought that an imbalance of these chemicals may increase
your risk of developing conditions such as panic disorder.
Increased sensitivity to carbon dioxide

Some experts believe that panic disorder is linked to an increased
sensitivity to carbon dioxide. Breathing in air with high carbon
dioxide levels can bring on panic attacks, and breathing techniques
can help to relieve or stop panic attacks.
Catastrophic thinking
Another theory is that people who experience panic attacks tend to
focus on minor physical symptoms and interpret them in a
24
February 17, 2016

catastrophic
• treatment is by
• cognitive behavioural therapy
• antidepressants like SSRI
•
• Anxiety is a universal experience it is, according to some
reckonings, the chief factor limiting human potential; it
causes much suff ering, costing the UK £5 billion/yr.
Neurosis refers to maladaptive psychological symptoms not
due to organic causes or psychosis, and usually precipitated
by stress. Apart from free-fl oating anxiety
• Classifying anxietyDSM-IV •
• Generalized anxiety disorder (GAD):
• anxiety +3 somatic symptoms and present for ≥6 months
•Panic disorder
• •Phobia, eg agoraphobia
• •Post-traumatic stress disorder and
• depression, such symptoms are: fatigue (27%), insomnia
(25%), irritability (22%), worry (20%), obsessions,
compulsions, and somatization (p640)— all more intense
than the stress precipitating them would warrant.
Symptoms are not just part of a patient’s normal personality,
but they may be an exaggeration of personality: a generally
anxious person may become even more so, ie develop an
anxiety neurosis, as a result of job loss. The type of
neurosis is defi ned by the chief symptom (eg anxiety,
obsessional, depressive). Before diagnosing neurosis,
consider carefully if there is underlying depression needing
antidepressants.156 •Social anxiety disorder •Obsessive–
compulsive disorder Symptoms of anxiety: Tension,
agitation; feelings of impending doom, trembling; a sense of
collapse; insomnia; poor concentration; ‘goose fl esh’;
‘butterfl ies in the stomach’; hyperventilation (so tinnitus,
tetany, tingling, chest pains); headaches; sweating;
palpitations; poor appetite; nausea; ‘lump in the throat’
unrelated to swallowing (globus hystericus); diffi culty in
getting to sleep; excessive concern about self and bodily
functions; repetitive thoughts and activities (p346).
Children’s symptoms: Thumb-sucking; nail-biting; bed-
wetting; foodfads. Causes Genetic predisposition; stress
(work, noise, hostile home), events (losing or gaining a
spouse or job; moving house). Others: Faulty learning or
secondary gain (a husband ‘forced’ to stay at home with
agoraphobic wife). Treatment Symptom control: Listening is
25
February 17, 2016

a good way to anxiety. Explain that headaches are not
from a tumour, and that palpitations are harmless. Anything
done to enrich patients’ relationship with others may well
help. Regular (non-obsessive!) exercise: Benefi cial eff
ects appear to equal meditation or relaxation. Acute anxiety
responds better than chronic anxiety.157 Meditation:
Intensive but time-limited group stress reduction intervention
based on ‘mindfulness meditation’ can have long-term
benefi cial eff ects.158 Cognitive–behavioural therapy
(p373) and relaxation appear to be the best specifi c
measures159 with 50–60% recovering over 6 months.160
N=404 Behavioural therapy employs graded exposure to
anxiety-provoking stimuli. Drugs augment psychotherapy: 1
Benzodiazepines (eg diazepam 5mg/8h PO for <4wks.
SEs/withdrawal, p368, limit utility). 2 SSRI (p340, eg
paroxetine in social anxiety). 161 3 Azapirones
(buspirone, 5HT1A partial agonist; 5mg/8–12h; ?less
addictive/sedating than diazepam, and few withdrawal
issues). 162 4 Old-style antihistamines (eg
hydroxyzine).163 5 -blockers.164 6 Others: pregabalin
and venlafaxine. 165 Progressive relaxation training: Teach
deep breathing using the diaphragm, and tensing and
relaxation of muscle groups, eg starting with toes and
working up the body. Practice is essential. CDs aid
learning; in some contexts, eg stress, relaxation is not as
good as cognitive restructuring.166 N=87 Hypnosis Initially
the therapist induces progressively deeper trances eg using
guided fantasy and concentration on bodily sensations, such
as breathing. Later, some patients will be able to induce
their own trances. It powerfully reduces anxiety, and is
useful, eg medical contexts (eg post-op). 167 N=32
Prognosis GAD often gets better by ~50yrs (often replaced
by somatization).

Reference OHCS page 344
Dr Khalid/Rabia

Q:221 47 yo ex-soldier suffers from low mood and anxiety. He can͛ t forget the images
he faces before and has always had flashbacks. He is not able to watch the
news because there are usually some reports about war. What is he suffering
from?
a. Depression
b. PTSD
26
February 17, 2016

c. Panic attack
d. Agoraphobia
e. GAD

Clincher(s) Flash backs
A No traumatic event
B Post-traumatic stress disorder (PTSD) can develop in people of any age
following a traumatic
event, for example a major disaster or childhood sexual abuse. It encompasses
what became
known as 'shell shock' following the first world war.
Features
Re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive
images
Avoidance: avoiding people, situations or circumstances resembling or
associated with
the event

Hyperarousal: hypervigilance for threat, exaggerated startle response, sleep
problems,
irritability and difficulty concentrating
Emotional numbing - lack of ability to experience feelings, feeling detached
from
other people
Depression
Drug or alcohol misuse
Anger
Unexplained physical symptoms

C Anxiety disorder n no event of trauma in past
D Agoraphobia is a fear of being in situations where escape
might be difficult, or help wouldn't be available if things go
wrong.
Many people assume that agoraphobia is simply a fear of open

spaces but it's more complex than this. A person with agoraphobia
may be scared of:
• travelling on public transport

• visiting a shopping centre
• leaving home
If someone with agoraphobia finds themselves in a stressful
27
February 17, 2016

situation they'll usually experience symptoms of a panic attack
such as:
• rapid heartbeat
• rapid breathing (hyperventilating)
• feeling hot and sweaty
• feeling sick

E It's just the anxiety disorder
KEY B
Additional Post-traumatic stress disorder (PTSD) is an anxiety
Information disorder caused by very stressful, frightening or distressing
events.
Causes of PTSD
The type of events that can cause PTSD include:
• serious road accidents

• violent personal assaults, such as sexual assault, mugging
or robbery
• prolonged sexual abuse, violence or severe neglect
• witnessing violent deaths
• military combat
• being held hostage
• terrorist attacks
• natural disasters, such as severe floods, earthquakes or
tsunamis
• TREATED BY
• Psychotherapy and antidepressants
• Management
•
• following a traumatic event single-session interventions
(often referred to as debriefing)
• are not recommended
•
• watchful waiting may be used for mild symptoms lasting
less than 4 weeks
•
• military personnel have access to treatment provided by the
armed forces
•
• trauma-focused cognitive behavioural therapy (CBT) or eye
movement desensitisation
• and reprocessing (EMDR) therapy may be used in more
28
February 17, 2016

severe cases
•
• drug treatments for PTSD should not be used as a routine
first-line treatment for adults. If
• drug treatment is used then paroxetine or mirtazapine are
recommended
• Acute stress reactions •
• Fearful; horrifi ed; dazed •Helpless; numb, detached
•Emotional responsiveness •Intrusive thoughts
•Derealization (p346) •Depersonalization •Dissociative
amnesia •Reliving of events •Avoidance of stimuli184
•Hypervigilance •Concentration •Restlessness •Autonomic
arousal: pulse ; BP ; sweating •Headaches; abdominal
pain

Reference Nhs,OHCM 343
Dr Khalid/Rabia

Q:222 A 36 yo woman has recently spent a lot of money on buying clothes. She goes
out almost every night with her friends. She believes that she knows better
than her friends, so she should choose the restaurant for eating out. She gave
hx of having low mood at 12 yo. Whats͛ the dx?
a. Mania
b. Depression
c. Bipolar affective disorder
d. Borderline personality disorder
e. Dysthymia

Clincher(s) Both manic and depressive episodes
A Mania is the mood of an abnormally elevated arousal energy level, or "a state
of heightened overall activation with enhanced affective expression together
with lability of affect.
B There is an episode of mania too so ruled out
C Bipolar disorder, formerly known as manic depression, is a
condition that affects your moods, which can swing from one
extreme to another.
If you have bipolar disorder, you will have periods or episodes of:
• depression – where you feel very low and lethargic

• mania – where you feel very high and overactive (less
severe mania is known as hypomania
29
February 17, 2016

What causes bipolar disorder?
The exact causes of bipolar disorder are unknown, although it's
believed that several things can trigger an episode. Extreme
stress, overwhelming problems and life-changing events are
thought to contribute, as well as genetic and chemical factors
Bipolar disorder can occur at any age, although it often develops

between the ages of 18 and 24
Depression
The depression phase of bipolar disorder is often diagnosed
first. You may initially be diagnosed with clinical depression before
having a future manic episode (sometimes years later), after
which you may be diagnosed with bipolar disorder.
Medication
Several medications are available to help stabilise mood swings.
These are commonly referred to as mood stabilisers and include:
• lithium carbonate
• anticonvulsant medicines
• antipsychotic medicines
\\\

D It's a developmental problem so ruled out
Borderline Personality Disorder:
Borderline personality disorder is characterised by pervasive instability of
interpersonal
relationships, self-image and mood and impulsive behavior

Borderline Personality Disorder
Borderline personality disorder is a longstanding pattern of swings -- in
moods, relationships, self-image, and behavior. People with borderline
personality disorder have very strong emotions and often try to hurt
themselves, and may have problems with relationships with people.

People with borderline personality disorder are more likely to have other
mental health problems, too. They are also more likely to have had some
type of trauma as a child than people with bipolar disorder.

Symptoms: A person with borderline personality disorder has trouble
30
February 17, 2016

controlling his thoughts and feelings, and often has impulsive and reckless
behavior. Here are the condition's main symptoms:

Frantic efforts to avoid feeling abandoned
History of unstable, intense relationships
Poor self-image
Impulsiveness (spending, sex, substance abuse, etc.)
Self-harm (e.g., cutting) or suicidal behavior
Mood swings usually because of stressful events or relationships
Feelings of emptiness
Problems with anger
Paranoia
Treatment: Lifelong treatment is necessary for people with borderline
personality disorder. Treatment usually includes medication to control
impulses, aggression, and mood swings. Psychotherapy can help people
manage impulses and reactions to stress. Sometimes, short hospital stays are
also needed to manage times of crisis.

E Dysthymia, or chronic depression, is a form of low mood, but with less severe
symptoms than major depression
What are the signs and symptoms of dysthymia?
The symptoms of dysthymia are the same as those of major depression but not as
intense and include the following:
• Persistent sad or empty feeling

• Difficulty sleeping (sleeping too much or too little)
• Insomnia (early morning awakening)
• Feelings of helplessness, hopelessness and
worthlessness
• Feelings of guilt
• Loss of interest or the ability to enjoy oneself
• Loss of energy or fatigue
• Difficulty concentrating, thinking or making decisions
• Changes in appetite ( overeating or loss of appetite)
• Observable mental and physical sluggishness
• Persistent aches or pains, headaches, cramps, or
digestive problems that do not ease even with
treatment
• Thoughts of death or suicide

KEY C
Additional
Information Difference between bipolar effective disorder and
31
February 17, 2016

personality disorder
Development/Nature of the Illness
Borderline personality disorder is a type of “personality disorder” which essentially means

that it is a developmental condition – something that has evolved through the entire
development of a person’s emotional/behavioral infrastructure.
Bipolar disorder is an illness that presents acutely or subacutely (less than acute) sometime in
a person’s life and is not, at least as we define it now, a condition that is part of a person’s core
personality structure.
Course/Presentation of Symptoms
Borderline symptoms are present as a person’s baseline– their difficulties with mood
regulation and impulsivity, their ups and downs, are part of their life all the time. They are
always up and down.
Bipolar symptoms present in episodes that must be a change from the person’s baseline – that
is part of the diagnostic definition. Their episodes of depression or mania are a change from
who they are when they are feeling well.
Onset and Duration of Mood Episodes

Borderline mood episodes are shorter and more frequent and most often triggered by an event.
These mood episodes are described as reactivity – a loss, a perceived rejection, a frustration,
like an overflow of emotional response well out of proportion to the triggering event. During
these episodes, an individual may appear angry or depressed or feel some degree of anxious
irritability, and episodes last only a few hours to, at most (and rarely), a few days.

Reference Ans. The key is C. Bipolar affective disorder. [Initial depressive episode (may be
befor a long) followed by
mania is bipolar affective disorder]
Signs of mania Mood: Irritability (80%), euphoria (71%), lability (69%). •
Cognition: Grandiosity (78%); fl ight of ideas/racing thoughts (71%);
distractibility/poor concentration (71%); confusion (25%), many confl icting
lines of thought urgently racing in contrary directions; lack of insight.
Behaviour: Rapid speech (98%), hyperactivity (87%), sleep (81%),
hypersexuality (57%), extravagance (55%). Psychotic symptoms: Delusions
(48%), hallucinations (15%). Less severe states are termed hypomania. If
depression alternates with mania, the term bipolar affective disorder is used
(esp. if there is a history of this). During mood swings, risk of suicide is high.
Cyclical mood swings without the more fl orid features (as above) are termed
cyclothymia. Causes Physical: Infections, hyperthyroidism; SLE; thrombotic
thromocytopenic purpura; stroke; water dysregulation/Na+ ; ECT. Drugs:
Amphetamines, cocaine, antidepressants (esp. venlafaxine242), captopril,
steroids, procyclidine, L-dopa, baclofen. Bipolar disorder: (Age at onset: <25.)
In a 1st attack Ask about: Infections, drug use, and past or family history of
psychiatric disorders. Do: CT of the head, EEG, and screen for
32
February 17, 2016

drugs/toxins.243 Treating acute mania Assess: Psychotic symptoms (p316);
cycling speed; suicide risk. for acute moderate/severe mania: olanzapine
10mg PO, adjust to 5–20mg/day (SE: weight ; glucose ), or valproate
semisodium, eg 250mg/8h PO (Depakote®; may be rapidly to 1–2g/24h).
NB: some people are most fulfi lled and creative when manic and don’t want
to change; others recognize, in retrospect, that use of mental health law (a
last resort) was a turning point. Prophylaxis Those who have bipolar aff ective
disorder after successful treatment of the manic or depressive episode should
have a mood stabilizer for longer-term control. If compliance is good, and
U&E, ECG, and T4 normal, give lithium carbonate 125mg–1g/12h PO. Adjust
dose to give a plasma level of ~0.6–1mmol/L Li+, on day 4–7, ~12h post-dose.
A range of 04–1 may be equally valid; consider a tighter range if elderly (
sensitivity to Li+ neurotoxicity).244 • Check Li+ levels weekly (~12h post-
dose) until the dose has been constant for 4wks; then monthly for 6 months;
then 3-monthly, if stable; more often if on diuretic, NSAIDs, ACE-i (all Li+)
or on a low-salt diet or if pregnant (?avoid Li+). • If Li+ levels are progressively
rising, suspect progressive nephrotoxicity. • U&E + TSH 6-monthly; Li+ SE:
hypothyroidism; nephrogenic diabetes insipidus). Avoid changing brands
[Li+ ]. Ensure you can contact urgently if Li+ >14mmol/L. Toxic signs:
vision ; D&V; K+ ; ataxia; tremor; dysarthria; coma.
Dr Khalid/Rabia Dr khalid OHCS 354

Q:228 A 25 yo woman was brought to the ED by her boyfriend. She has many
superficial lacerations on her forearm. She is so distressed and constantly says
her boyfriend is going to end the relationship. She denies trying to end her life.
What is the most likely dx?
a. Acute psychosis
b. Severe depression
c. Psychotic depression
d. Borderline personality disorder
e. Schizophrenia

Clincher(s) Problems with interpersonal relations
A Psychosis is a mental health problem that causes people to
perceive or interpret things differently from those around
them. This might involve hallucinations or delusions.
The two main symptoms of psychosis are:
• hallucinations – where a person hears, sees and, in some

cases, feels, smells or tastes things that aren't there; a
common hallucination is hearing voices
• delusions – where a person believes things that, when
33
February 17, 2016

examined rationally, are obviously untrue
What causes psychosis?

Psychosis isn't a condition in itself – it's triggered by other
conditions.
It's sometimes possible to identify the cause of psychosis as a

specific mental health condition, such as:
• schizophrenia – a condition that causes a range of

psychological symptoms, including hallucinations and
delusions
• bipolar disorder – a mental health condition that affects
mood; a person with bipolar disorder can have episodes
of depression (lows) and mania (highs)
Causes of psychosis
The causes of psychosis have three main classifications.
They are psychosis caused by:
• psychological (mental) conditions

• general medical conditions
• substances, such as alcohol or drugs

B The ICD-10 criteria for depressive illness are as follows:

In typical depressive episodes, individuals usually suffer from depressed mood,
loss of interest
in things you would normally find pleasure in (anhedonia), and reduced energy
levels
(anergia). Other common symptoms include:
· Reduced concentration and attention
· Decreased self-esteem and confidence
· Feelings of guilt and unworthiness
· Bleak and pessimistic views of the future
· Ideas or acts of self-harm or suicide
· Disturbed sleep
· Diminished appetite and weight loss
· Psychomotor agitation or retardation
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February 17, 2016

Marked loss of libido
NICE use the DSM-IV criteria to grade depression:
1. Depressed mood most of the day, nearly every day
2. Markedly diminished interest or pleasure in all, or almost all, activities most
of the day,
nearly every day
3. Significant weight loss or weight gain when not dieting or decrease or
increase in
appetite nearly every day
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt nearly every
day
8. Diminished ability to think or concentrate, or indecisiveness nearly every
day
9. Recurrent thoughts of death, recurrent suicidal ideation without a specific
plan
Minimum duration to categorise severe depression is 2 weeks
With three typical symptoms of depression
C PSYCHOTIC DEPRESSION: Features of severe + xii) Hallucinations xiii) Delusions
xiv)
Guilt xv) Nihilism. Rx: ECT

D As there is interpersonal relationships problems /labile / close to border of
blowing up, attention seekers
E Schizophrenia is a serious mental health condition that causes disordered
ideas, beliefs and
experiences. In a sense, people with schizophrenia lose touch with reality
and do not know which
thoughts and experiences are true and real and which are not.
S/s: Positive: Dellusion , Hallucination and Disordered thought
Negative: Lack of motivation ,Few spontaneous movements ,Facial
expressions do not change much,
Changed feelings
Schneider's first rank symptoms may be divided into auditory hallucinations,
thought disorders,
passivity phenomena and delusional perceptions:
Nice treatment guideline:
oral atypical antipsychotics are first-line
cognitive behavioural therapy should be offered to all patients
close attention should be paid to cardiovascular risk-factor modification due
to the high
rates of cardiovascular disease in schizophrenic patients (linked to
antipsychotic
medication and high smoking rates)
35
February 17, 2016

KEY D
Additional
Information
Reference Borderline personality disorder. [ Borderline personality disorder: Act
impulsively and
develop intense but short-lived emotional attachment to others. They are
usually attention seekers but not suicidal

Dr Khalid/Rabia OHCS n nice guide lines

Q:233 28yo business exec presents at the GP asking for some help because she has
been arguing with her boyfriend frequently. She is worried about her weight,
and she thinks she may be fat. She has been on a diet and lost 7 kgs in the last
2 months on purpose. She is eating less. She used to do a lot of exercise. Now
she says she͛s feeling down, has some insomnia and feels tired and without
energy. She has not showed up at work. She is worried because recently she
got a loan to buy a luxury car. She can͛ t be fired. She complains about her low
mood. She thinks this is weird because she used to be extremely productive.
She used to work showing an excellent performance at the office. She even
received compliments from her boss. How, she says her boyfriend is angry
because her apartment is a chaos. Usually she spends a lot of time cleaning it,
even upto 3 AM. She liked it to be perfect, but not its͛ a mess. On exam:
BMI=23, no other signs. What is the most probably dx?
a. Anorexia nervosa
b. Bipolar disease
c. Binge eating disorder
d. Hyperthyroidism
e. Schizophrenia

Clincher(s)
A Anorexia nervosa: features
Anorexia nervosa is the most common cause of admissions to child and
adolescent psychiatric
wards.
Anorexia nervosa is associated with a number of characteristic clinical signs
and physiological
abnormalities which are summarised below

Epidemiology
90% of patients are female
predominately affects teenage and young-adult females
prevalence of between 1:100 and 1:200

Features
reduced body mass index
36
February 17, 2016

bradycardia
hypotension
enlarged salivary glands

Physiological abnormalities
hypokalaemia
low FSH, LH, oestrogens and testosterone
raised cortisol and growth hormone
impaired glucose tolerance
hypercholesterolaemia
hypercarotinaemia
low T3
Diagnosis (based on the DSM-IV criteria)
person chooses not to eat - BMI < 17.5 kg/m^2, or < 85% of that expected
intense fear of being obese
disturbance of weight perception
amenorrhoea = 3 consecutive cycles
B Mania and depression
C Bulimia nervosa is a type of eating disorder characterised by episodes of binge
eating followed
by intentional vomiting

Management
referral for specialist care is appropriate in all cases
cognitive behaviour therapy (CBT) is currently consider first-line treatment
interpersonal psychotherapy is also used but takes much longer than CBT
pharmacological treatments have a limited role - a trial of high-dose fluoxetine
iscurrently licensed for bulimia but long-term data is lackin
** thickened calluses on the dorsum of the hand due to repeated induced
vomitting

D Psychiatric manifestations more
E Schizophrenia is a long-term mental health condition that
causes a range of different psychological symptoms,
including:
• hallucinations – hearing or seeing things that do not exist

• delusions – unusual beliefs not based on reality that often
contradict the evidence
• muddled thoughts based on hallucinations or delusions
• changes in behaviour

KEY B (productive/ had manic and depressive : bi- both)
Additional Depressive disorders
Information
37
February 17, 2016

A. Unipolar: Depression occurring on it’s own.
B. Bipolar: Depression alternating with mania.
Bipolar affective disorder
A. DEPRESSION
1. Low mood
2. Low energy level
3. Feels sad
4. Anhedonia – loss of interest in daily activities
5. Early morning waking
6. Loss of appetite
7. Feeling guilty
8. Reduced self esteem
9. Thoughts of self-harm
10. Fatigability – feeling tired
11. Loss of libido
B. DYSTHYMIA
It is characterized by the mild depressive illness that lasts intermittently

more than 2 years.
C. SEASONAL AFFECTIVE DISORDER
It is characterized by the recurrent episodes of depressive illness occurring

during the winter months. It occurs annually usually
in winters.
• Atypical symptoms
• Low mood, anhedonia
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February 17, 2016

• Excessive sleep
• Increased appetite and weight gain
Management: Light therapy, Pscho-therapy and antidepressants.
D.POST NATAL DEPRESSION
• Occurs after delivery
• Poor sleep, low confidence, anhedonia
• Loss of appetite & weight
• Feeling that she is not capable of looking after her child
• Guilt feeling that she is not a good mother
• Tearful, Anxiety
• Occurs in the first 3 months after delivery
• Mother feels as if someone/partner wants to harm her baby
E.BABY BLUES
• Occurs in 50% women after giving birth
• Normal phenomena and resolves within a few days usually 3-4 days
• Poor sleep, anxiety, irritability, tearful, crying for no reason
Management: Family support & Reassurance
F.POST NATAL PSYCHOSIS
• Usually occurs within 2 weeks after delivery
• Usually starts with post-natal depression
• Delusional ideas that the baby is deformed, evil or otherwise affected in

some way and she has intent to kill the baby,
Treatment of depressive illness
1. SSRI: Selective Serotonin Re-uptake Inhibitors: First choice of treatment
39
February 17, 2016

• Citalopram- Preferred in IHD
• Escitalopram
• Fluoxetine
• Paroxetine
2. Tricyclic Antidepressant (TCA)
• Amitryptilline
• Dosulepin
• Lofepramine, Trazodone
Contraindication: in Ischaemic Heart Disease (IHD) and Glaucoma
Side Effect’s:
• Arrythmia’s
• Dry Mouth
• Constipation
• Raised Intra-ocular pressure- leads to Glaucoma
3. Other Anti depressants
• Mirtazapine
• Venlafaxine
• Reboxetine
4. Monoamine oxidase inhibitors (MAOI)
• Phenelzine
NB: 1. Depression with obesity=fluoxetine (It helps without weight loss)
2. Depression with sexual dysfunction=mirtazapine
3. Post stroke depression use nortriptyline (TCA)
4. Depression with obsessive compulsive disorder=clomipramine (TCA)
40
February 17, 2016

5. Depression with ischemic heart disease=SSRI e. g citalopram
NON-MEDICAL TREATMENT
a. Electroconvulsive therapy (ECT)
Indications:
1. Refusing to eat and drink and their weight is dangerously going low
2. Dangerously suicidal (Patient’s looking for every opportunity to kill

themselves)
3. Psychotic symptoms
4. Depression not responding to anti-depressants
5. Depression with Psychosis
b. Cognitive Behavior therapy
Good for mild to moderate depression. It is as effective as medical

treatment.
Good for anxiety disorder
It involves identification of abnormal thinking that keeps triggering

depressive, anxiety or any other symptoms and tries to fix
or change it. E.g. Depression, OCD, PTSD
c. Behavior therapy
Based on learning theory
Works as desensitization e.g. in OCD, phobia (arachnophobia- fear of spiders,

agoraphobia- fear of open spaces,
claustrophobia- fear of closed spaces)
d. Interpersonal psychotherapy
Used for depression and eating disorder especially depression triggered by

personal relationship
41
February 17, 2016

Reference Nhs.co.uk
Dr Khalid/Rabia Dr.khalid

3 common in men: alcoholism, mania and schizo; rest in females (ref sami)

Q:234 A woman brought her husband saying she wants the ͚thing͛ on his forehead
removed. The husband is refusing tx saying it improves his thinking. What is
the next most appropriate next step?
a. Assess his mental capacity to refuse tx
b. Remove lesion
c. Refer to ED
d. Mini-mental state exam (
e. Refuse surgery and send pt back

Clincher(s)
A
B
C
D For cognitive assessment eg Alzheimer’s
E
KEY A
Additional
Information
Reference
Dr Khalid/Rabia

Q:235 37 yo man who has many convictions and has been imprisoned many times
has a hx of many unsuccessful relationships. He has 2 boys but doesn͛ t contact
them. What is the most probable dx?
a. Borderline personality disorder
b. Schizophrenia
c. Avoidant personality disorder
d. Histrionic personality disorder
e. Antisocial behavior disorder

Clincher(s) There is lack of concern in consequences of his actions
A Borderline personality disorder
A person with borderline personality disorder is emotionally unstable, has
impulses to self-harm, and has very intense and unstable relationships with
others.
B Schizophrenia is a mental disorder with abnormal social behavior and failure to
recognize what is real
Common symptoms include false beliefs
42
February 17, 2016

Confused thinking
Halucinations
C Avoidant personality disorder
A person with avoidant personality disorder appears painfully shy, is socially
inhibited, feels inadequate and is extremely sensitive to rejection.
Unlike people with schizoid personality disorders, they desire close
relationships with others, but lack the confidence and ability to form them.
D Histrionic personality disorder
A person with histrionic personality disorder is anxious about being ignored.
As a result, they feel a compulsion (overwhelming urge) to be noticed and
the centre of everyone’s attention. Features include:
displaying excessive emotion, yet appearing to lack real emotional sincerity
dressing provocatively and engaging in inappropriate flirting or sexually
seductive behaviour
moving quickly from one emotional state to another
being self-centred and caring little about other people
constantly seeking reassurance and approval from other people
Symptoms and signs may co-exist with borderline and narcissistic personality
disorders.
E Antisocial personality disorder
A person with an antisocial personality disorder sees other people as
vulnerable and may intimidate or bully others without remorse. They lack
concern about the consequences of their actions.
Symptoms include:
lack of concern, regret or remorse about other people's distress
irresponsibility and disregard for normal social behaviour
difficulty in sustaining long-term relationships
little ability to tolerate frustration and to control their anger
lack of guilt, or not learning from their mistakes
blaming others for problems in their lives
KEY E
Additional 6. Antisocial personality disorder
Information
• Involved in criminal offences
• Aggressive and rude behavior
• Involved in dangerous acts
• Lack of capacity to maintain enduring relationship
• Low tolerance of frustration
• Inability to experience guilt
Narcissistic personality disorder
43
February 17, 2016

A person with narcissistic personality disorder swings between seeing
themselves as special and fearing they are worthless. They may act as if they
have an inflated sense of their own importance and show an intense need for
other people to look up to them.
Other symptoms include:
exaggerating their own achievements and abilities
thinking they are entitled to be treated better than other people
exploiting other people for their own personal gain
lacking empathy for other people's weaknesses
looking down on people they feel are "beneath" them, while feeling deeply
envious of people they see as being "above" them
Reference Nhs.co.uk
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
44
February 17, 2016

Information
Reference
Dr Khalid/Rabia

Q:91 A 35yo man who has served in the army presents with lack of interest in
enjoyable activities and feeling low. He doesn’t feel like reading the news or
watching movies as he believes there is violence everywhere. What is the
most appropriate first line therapy?
a. Citalopram
b. Lofepramine
c. CBT
d. Chlordiazepoxide
e. Desensitization

Clincher(s) Served in army, believes there is violence everywhere
A.citalopram It is a selective serotonine reuptake inhibitor(indicated for depressive illness
and panic disorder)
B. Tricyclic atidepressant
C
D Benzodiazepine.its a sedative and hypnotic
E Desensitization: desensitization is defined as the diminished emotional
responsiveness to a negative or aversive stimulus after repeated exposure to
it.
KEY C (Main line is CBT and second line as SSRI)
Additional Post-traumatic stress disorder: Suspect this
Information if symptoms (BOX) become chronic, with these
signs (may be delayed years): difficulty modulating
arousal; isolated-avoidant modes of living;
alcohol abuse; numb to emotions and relationships;
survivor guilt; depression; altered world
view in which fate is seen as untamable, capricious
or absurd, and life can yield no meaning
or pleasure. 185 NB: some people have this with
no known stressor: DSM-IV wrongly calls this adjustment disorder,
whereas
it is a form of existentialism that only the healing power of story-
telling can
transform ‘by serving as an axe for the frozen sea inside us.’ Franz
45
February 17, 2016

https://www.nice.org.uk/guidance/cg26/chapter/guidance#the-treatment-of-ptsd

Reference Ohcs 372(details about different types of behavioural therapies)

Q:124 Pt with hx of alcoholism, ataxic gait, hallucinations and loss of memory. He is given
acamprosate. What other drug can you give with this?
a. Chlordiazepoxide (used in Delerium tremens)
b. Thiamine
c. Diazepam
d. Disulfiram
e. Haloperidol

Clincher(s) Alcoholic,ataxia,loss of memory (triad for Wernicks)
A Sedative and hypnotic
B Vitamin B1
C Diazepam(benzodiazepine)used to treat anxiety,alcohol withdrawal syndrome
46
February 17, 2016

D Disulfiram is used as an adjunct in the treatment of
alcohol dependence (under specialist supervision). It
gives rise to an extremely unpleasant systemic reaction
after the ingestion of even a small amount of alcohol
because it causes accumulation of acetaldehyde in the
body; it is only effective if taken daily. Symptoms can
occur within 10 minutes of ingesting alcohol and include
flushing of the face, throbbing headache, palpitation,
tachycardia, nausea, vomiting,
E Haloperidol is a typical antipsychotic
KEY B
Additional Korsakoff ’s syndrome Hypothalamic damage & cerebral atrophy due to
Information thiamine(vitamin B1) defi ciency (eg in alcoholics). May accompany Wernicke’s
encephalopathy.There is ability to acquire new memories, confabulation
(invented memory,owing to retrograde amnesia), lack of insight & apathy
Acamprosate and naltrexoneare effective treatments for relapse prevention in
patients with alcohol dependence; disulfiram is analternative (see below).

Disulfiram should only be used in patients in whom acamprosate and naltrexone
are not suitable, or if the patient prefers Disufiram.
Acamprosate, in combination with counselling, may be helpful for maintaining

abstinence in alcohol-dependentpatients.
47
February 17, 2016

Reference OHCM,BNF

Q:129 A 32yo woman in tears describing constant irritability with her 2 small children
and inability to relax. She describes herself as easily startled with poor sleep
and disturbed nightmares following a house fire a year ago, while the family
slept. What is the single best tx?
a. Rassurance
b. Relaxation therapy
c. Quetiapine
d. Lofepramine
e. Fluoxetine

Clincher(s) Nightmares following a house fire(PTSD- post traumatic stress disorder)
A Won’t be enough
B
C Atypical antipsychotic
D Tricyclic antidepressant
E Antidepressant(SSRI)
KEY B? CBT/ fluoxetine
Additional
Information
Reference
Dr Khalid/Rabia

Q:132 A pt with thought disorder washes hands 6x each time he uses the toilet. What
is the best management?
a. Psychodynamic therapy
b. CBT
c. Antipsychotics
d. Refer to dermatology
e. Reassure

Clincher(s) washes hands 6 times after he uses toilet
A Given to patients with depression
B
C Antipsychotics are not the drug of choice in OCD
D No relevance
E Not enough
KEY B
48
February 17, 2016

Additional
Information

Reference Ohcs 346
Dr Khalid/Rabia

Q.134 A 32yo had a normal vaginal delivery 10 days ago. Her uterus has involuted
normally. Choose the single most likely predisposing factor for PPH?
a. Retained product
b. DIC
c. Uterine infection
d. Von Willebrand disease
e. Primary PPH

Clincher(s) Uterus involuted normally,
A Patient would present with primary pph which is 1st 24 hrs
B DIC is a pathological process characterized by the widespread activation of the
clotting cascade that results in the formation of blood clots in the small blood
vessels throughout the body. This leads to compromise of tissue blood flow
and can ultimately lead to multiple organ damage
C
D Von Willebrand's disease (vWD) results from the deficiency or abnormal
function of von Willebrand factor (vWF). vWF is a multimeric glycoprotein
encoded for by gene map locus 12p13.[1] It is made in the endothelium and
stored in Weibel-Palade bodies. It has two main functions:
• It assists in platelet plug formation by attracting circulating platelets
to the site of damage.
• It binds to coagulation factor VIII preventing its clearance from the
plasma.
• Women with this disease usually have heavy menstruation and
excessive bleeding during delivery.

E Primary PPH is the loss of greater than 500mL (defi nitions vary) in the fi rst
49
February 17, 2016

24h after delivery.

KEY C
Additional
Information

Reference Ohcs page 84,patient.info
Dr Khalid/Rabia

Q.201 A 29yo teacher is involved in a tragic RTA. After that incident, he has been
suffering from nightmares and avoided driving on the motorway. He has been
dx with PTSD. What is the most appropriate management?
a. CBT
b. Diazepam
c. Citalopram
d. Dosalepin
e. Olanzepin

Clincher(s)
A SSRI(antidepressant)
B Benzodiazepine(anxiolytic,sedative)
C
D TCA
E Atypical antipsychotic (schizophrenia and bipolar disorder)
KEY A
Additional
Information
Reference
Dr Khalid/Rabia

Q.138 138. A 78yo man is depressed after his wife’s death. He has been neglecting
himself. His son found him in a miserable state when he went to visit. The son
can’t deal with his father. What is the appropriate management?
a. Voluntary admission to psychiatry ward
b. Hand over to social worker
c. Request son to move in with father
50
February 17, 2016

d. Send pt to care home

Clincher(s) Neglecting himself after wive’s death
A Can get admitted on his own and get discharge
B
C
D
E
KEY A
Additional
Information
Reference
Dr Khalid/Rabia

Q:1311 A 28yo woman with hx of drug addiction wants to start a family and have a
baby. She would like to stop taking heroin and asked for something to help her
stay away from it. What drug tx would you give her?
a. Naloxone
b. Acamprosate
c. Methadone
d. Chlordiazepoxide
e. Naltrexone

Clincher(s) Wants to stop taking heroine
A
B
C Indications: severe pain,cough in
terminal disease adjunct in treatment
of opioid dependence
D
E
KEY c. methadone
Additional Others for alcohol etc
Information
Reference BNF
Dr Khalid/Rabia Treatment is different if a pt comes with opioid intoxication (NALOXONE
should be given ), and if someone comes and wants to leave opioids i.e,
detoxification (Methadone or buprenorphene would be the choice then )
Chlordiazepoxide and Acamprosate are used for alcoholism. Vit B Complex and
Chlordiazepoxide for alcohol withdrawal and acamprosate for dependence.
Oxazepam is the drug of choice for alcohol detoxification in pts with liver
disease as its not metabolized by liver.
Treatment of opioid intoxication
· If a patient has collapsed and is thought to be acutely intoxicated, call
999/112/911 and refer urgently to hospital.
51
February 17, 2016

· Naloxone (a pure opioid antagonist used for reversing opioid intoxication) has
a rapid onset of action and can be given IM, IV or subcutaneously.
· Therapy is otherwise mostly supportive, eg maintain airway, ventilation if
necessary and IV fluids.
· Tx of detoxification
· Methadone, and buprenorphine are equally effective in detoxification
regimens. The place of lofexidine in detoxification programmes requires
further research.[4]
· Opioid detoxification should be offered as part of a package including
preparation and post-detoxification support to prevent relapse.
· Psychosocial interventions (eg talking therapies, cognitive behavioural
therapy, family therapy) and keyworking should be delivered alongside
pharmacological interventions.[2]
· If detoxification is unsuccessful, patients should have access back into
maintenance and other treatment.

Q:1313 Sush A 52yo man presents with visual hallucinations and features of cognitive
impairment. What is
the most likely dx?
a. Frontotemporal dementia
b. Lewy body dementia
c. Delirium tremens
d. Alzheimer’s disease
e. Huntington’s

Clincher(s)
A There should be symptom of personality change.
B The 3rd commonest cause (15–25%) after Alzheimer’s and vascular causes,
typically with fl uctuating cognitive impairment, det ailed visual
hallucinations (eg small animals or children) and later, parkinsonism (p498).
Histology is characterized by Lewy bodies in brainstem and neocortex.

C
D
E Huntington's disease is associated with increasing depression, bradykinesia,
cognitive impairment and aggression as the disease progresses.[6]Behavioural
difficulties include apathy or lack of initiative, dysphoria, irritability, agitation
or anxiety, poor self-care, poor judgment and inflexibility.[1]Late features
include spasticity, clonus, supranuclear gaze palsy and extensor plantar
responses. The rate of cognitive decline is very variable.
KEY b
Additional Fronto-temporal dementia:
Information
Pathophysiology
52
February 17, 2016

There is atrophy of the frontal and temporal lobes. Distribution is lobar, rather than the
diffuse atrophy of Alzheimer's disease. There may be loss of neurons or gliosis but no
increase in plaque formation. There is a spongy vacuolisation of the frontal and temporal
cortex. There are protein inclusions in neurons and glial cells
Presentation
Onset tends to be insidious and progression gradual. There are three main clinical
syndromes of FTD. These are defined by the predominant symptom at presentation. They
are[1][5] :
• Behavioural variant frontotemporal dementia.
• Progressive non-fluent aphasia.
• Semantic dementia.
Alzheimer’s disease: Suspect Alzheimer’s in
adults with enduring,1 progressive and global cognitive
impairment (unlike other dementias which may affect certain
domains but not others): visuo-spatial skill (getslost), memory,
verbal abilities and executive function (planning) are all aff
ected(use neuropsychometric testing to identify aff ected
domains; see p490), and there
is anosognosia—a lack of insight into the problems engendered
by the disease, egmissed appointments, misunderstood
conversations or plots of fi lms, and mishandling of money and
clerical work. 185 Later there may be irritability; mood
disturbance(depression or euphoria); behavioural change (eg
aggression, wandering, disinhibition);
psychosis (hallucinations or delusions); agnosia (may not
recognize self in themirror). There is no standard natural
history. Cognitive impairment is progressive,but non-cognitive
symptoms may come and go over months. Towards the end,
often but not invariably, patients become sedentary, taking little
interest in anything.

Reference Ohcs,patient.info
Dr Khalid/Rabia Dementia is a syndrome caused by a number of brain disorders which cause
memory loss, decline in some other aspect of cognition, and difficulties with
activities of daily living.
The symptoms fall into three groups:
· Cognitive impairment: causing difficulties with memory, language, attention,
thinking, orientation, calculation, and problem-solving.

· Psychiatric or behavioural disturbances: changes in personality, emotional
control, and social behaviour; depression, agitation, hallucinations, and
delusions.
· Difficulties with activities of daily living, such as driving, shopping, eating, and
dressing.

53
February 17, 2016

There are subtle differences in the presentation of different types of dementia.
Alzheimer's disease tends to have an insidious onset, whereas vascular
dementia typically has a series of stepwise increases in symptom severity. DLB
may present with fluctuating levels of consciousness, hallucinations, sleep
disorders, falls and Parkinsonian features. In Parkinson's disease dementia,
the Parkinsonian features predate the dementia by a significant amount of
time. In frontotemporal dementia, behavioural changes (such as disinhibition
or apathy) and language disturbances are often presenting features. It may be
important to determine the type of dementia - in DLB, for example, making
this diagnosis will have important implications for treatment (use of
neuroleptics is avoided, as motor and mental impairment is worsened and
mortality may be increased). Ans should be Lewy Body dementia bcoz of
presence of hallucinations . Rest of the types are explained above and DT is a
psychotic condition typical of withdrawal in chronic alcoholics, involving
tremors, hallucinations, anxiety, and disorientation

Q:1339 A 9yo child doesn’t play with his peers and has collected 200 cars. He doesn’t
respond to any criticism. What is the dx?
a. Autism
b. Personality disorder
c. Schizophrenia
d. Rett syndrome
e. Social anxiety

Clincher(s)
A Antisocial behavior, have their own world, unresponsive,
B
C
D Rett syndrome is an X-linked neurodevelopmental condition characterised by
loss of spoken language and hand use with the development of distinctive
hand stereotypies. It is a pervasive developmental disorder
(PDD).developmental abnormalities are observed in various stages of disease.
E
KEY A
Additional
Information
Reference
Dr Khalid/Rabia Autism:
Epidemiology

· 75% of children are male
· usually develops before 3 years of age

All 3 of the following features must be present for a diagnosis to be made
· global impairment of language and communication
· impairment of social relationships
54
February 17, 2016

· ritualistic and compulsive phenomena

Other features
· most children have a decreased IQ - the 'idiot savant' is rare

Associated
· Fragile X
· Rett's syndrome

Q:1367 A pt has had 1 ep of depression and 2 eps of mania over the last year and now
presents with depression. He is on anti-depressants. What additional
pharmacological tx would now act as a prophylaxis for his condition?
a. Antidepressants
b. Antipsychotics
c. Mood stabilizers
d. No additions req

Clincher(s) 1 episode of depression and 2 episodes of mania(bipolar)
A
B
C Lithium but if contra: valporate
D
E
KEY C
Additional
Information
Reference
Dr Khalid/Rabia Provide clear written information about bipolar disorder, including NICE's
information for the public and ensure there is enough time to discuss options
and concerns.:[1]
Options available include:
· Pharmacological.
· Lithium should be considered first-line, with the addition of valproate if
ineffective.
· Valproate or olanzapine should be considered for patients intolerant of
lithium or who are not prepared to undergo regular monitoring.
· If symptoms still continue then the patient should be referred to a mental
health specialist. Medications that might be used in this situation are
lamotrigine (especially in bipolar II disorder) or carbamazepine. Lithium will
require monitoring of levels and monitoring of renal function and thyroid
function. Patients need to be advised of adequate rehydration and the dangers
of suddenly stopping treatment.

55
February 17, 2016

Q:1391 A schizophrenic man complains that he can hear voices talking about him and
telling him to end his life by cutting his throat. He only hears them when he
wakes up from sleep and not at other
times. What type of hallucinations is he having?
a. Somatic
b. Kinesthetic
c. Hypnogogic
d. Hypnopompic
e. Lilliputian

Clincher(s) Hears voices when he wakes up from sleep
A Somatic hallucination is an hallucination involving the perception of a physical
experience occurring with the body.

B Kinesthetic hallucination is an hallucination involving the sense of bodily
movement.

C Auditory hallucinations while going to sleep
D Hypnopompic hallucinations are unusual sensory phenomena experienced
just before or during awakening
E hallucination in which things, people, or animals seem smaller than they
would be in real life. Lilliputian refers to the "little people" who lived
(fictionally) on the island of Lilliput i
KEY D
Additional Hallucination: A profound distortion in a person's perception of reality, typically accompanied
by a powerful sense of reality. An hallucination may be a sensory experience in which a person
Information can see, hear, smell, taste, or feel something that is not there.
The types of hallucinations include:
• An auditory hallucination is an hallucination involving the sense of

hearing. Called also paracusia and paracusis.
• A gustatory hallucination is an hallucination involving the sense of
taste.
• A hypnagogic hallucination is a vivid dreamlike hallucination at the
onset of sleep.
• Hypnopompic hallucination is a vivid dreamlike hallucination on
awakening.
• Kinesthetic hallucination is an hallucination involving the sense of
bodily movement.
• Lilliputian hallucination is an hallucination in which things, people, or
animals seem smaller than they would be in reality.
• Olfactory hallucination is an hallucination involving the sense of smell.
• Somatic hallucination is an hallucination involving the perception of a
physical experience occurring with the body.
• Tactile hallucination is an hallucination involving the sense of touch.
56
February 17, 2016

• Visual hallucination is an hallucination involving the sense of sight.

Reference Internet
Dr Khalid/Rabia Hypnagogic - occur on falling asleep and are harmless.
· Hypnopompic - occur on waking up and are harmless.
· Auditory - of one or more talking voices; seen commonly in schizophrenia.
· Charles Bonnet's syndrome - visual hallucinations that blind persons
experience

Q:1392 A 28yo woman complains of hearing strange voices in her bedroom as she is
falling asleep in the night. She says there is no one in the room except her. On
evaluation she has no other problems. What is she suffering from?
a. Delusion of persecution
b. Cotard syndrome
c. Hypnogogic hallucinations
d. Lilliputian hallucinations
e. Schizophrenia

Clincher(s) Hearing voices when falling asleep
A delusion of persecution a delusion that one is being attacked, harassed,
cheated, persecuted, or conspired against
B A rare mental illness can make the sufferer believe they are dead, partly dead
or do not exist.
C Auditory hallucinations while going to sleep
D
E
KEY C
Additional delusion
Information
a false belief that is firmly maintained in spite of incontrovertible and obvious proof to the
contrary and in spite of the fact that other members of the culture do not share the belief.
adj., adj delu´sional.
bizarre delusion one that is patently absurd, with no possible basis in fact.
delusion of control the delusion that one's thoughts, feelings, and actions are not one's own
but are being imposed by someone else or some other external force.
depressive delusion a delusion that is congruent with a predominant depressed mood, such
as a delusion of serious illness, poverty, or spousal infidelity.
erotomanic delusion a delusional conviction that some other person, usually of higher
status and often famous, is in love with the individual; it is one of the subtypes of
delusional disorder.
fragmentary d's unconnected delusions not organized around a coherent theme.
delusion of grandeur (grandiose delusion) delusional conviction of one's own importance,

power, or knowledge, or that one is, or has a special relationship with, a deity or a famous
57
February 17, 2016

person. It is one of the subtypes of delusional disorder.
delusion of jealousy a delusional belief that one's spouse or lover is unfaithful, based on
erroneous inferences drawn from innocent events imagined to be evidence and often
resulting in confrontation with the accused. It is one of the subtypes of delusional disorder.
mixed delusion one in which no central theme predominates. It is one of the subtypes of
delusional disorder.
delusion of negation (nihilistic delusion) a depressive delusion that the self, part of the self,
part of the body, other persons, or the whole world has ceased to exist.
delusion of persecution a delusion that one is being attacked, harassed, cheated,

persecuted, or conspired against.
delusion of reference a delusional conviction that ordinary events, objects, or behaviors of

others have particular and unusual meanings specifically for oneself.
somatic delusion a delusion that there is some alteration in a bodily organ or its function. .
systematized d's a group of delusions organized around a common theme; typical of

delusional disorders or paranoid schizophrenia.

Reference From various websites
Dr Khalid/Rabia

Q:1413 A 43yo man with a hx of hospital admissions talk about various topics, moving
from one loosely connected topic to another. What is the most likely dx?
a. Psychosis
b. Mania
c. Schizophrenia
d. Pressured speech
e. Verbal diarrhea

Clincher(s) Moves from one loosely connected topic to another
A Severe depression, unsual speech
B nearly continuous flow of rapid speech that jumps from topic to topic, usually
based on discernible associations, distractions, or plays on words, but in severe
cases so rapid as to be disorganized and incoherent. It is most commonly seen in
manic episodes but may also occur in other mental disorders such as in manic
phases of schizophrenia

flight of ideas
C
D Pressure of speech is an unusual increase in the rate or speed of conversation.
The person with pressure of speech talks much faster than what is considered
normal or ordinary.
Pressure of speech may be severe enough that the person may not be
58
February 17, 2016

understood

E (found it as an idiom)if someone has verbal diarrhoea, they talk too much.for
example It was awful - a whole evening with this guy who had verbal diarrhoea.
KEY B
Additional Mania: flight of ideas and mania (everything else schiz)
Information
Reference internet
Dr Khalid/Rabia

Q: 643 A 50yo man presents with low mood, poor concentration, anhedonia and
insomnia. He has had
2 episodes of increased activity, promiscuity and aggressive behavior in the
past. He was arrest
8m ago for trying to rob a bank claiming it as his own. Which drug is most likely
to benefit him?
a. Haloperidol
b. Citalopram
c. Desipramine
d. Carbamazepine
e. Ethosuximide

Clincher(s)
A
B
C
D
E
KEY d. Carbamazepine
bipolar (affective) disorder (low mood swings, combination between mania,
hypprmania and depression )

Additional • Lithium should be considered first-line, with the addition of valproate if
Information ineffective.
• Valproate or olanzapine should be considered for patients intolerant of
lithium or who are not prepared to undergo regular monitoring.
• If symptoms still continue then the patient should be referred to a
mental health specialist. Medications that might be used in this situation
are lamotrigine (especially in bipolar II disorder) or carbamazepine.
• If medication is stopped, patients should be made aware of early
warning symptoms of recurrence. Medication should be tailed off
gradually

Reference

Q: 649 A 55yo woman who attends the clinic has recently been dx with a depressive
episode. She
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February 17, 2016

complains of unintentionally waking early in the morning, a recent disinterest in
sex and a loss
of appetite, losing 5kg weight in the last month. She feels that her mood is
worse at the
beginning of the day. What is the most likely dx for this pt?
a. Mild depression
b. Moderate depression
c. Severe depression
d. Low mood
e. Pseudo depression

Clincher(s) Major depression symptoms, insomnia, loosing weight etc

A
B
C
D
E
KEY b. Moderate depression
Physical symptoms like weight loss and early morning insomnia makes it moderate as opposed
to mild

Additional Pseudodepression
"A condition of personality following frontal lobe lesion in which apathy, indifference and a loss of
Information initiative are apparent symptoms but are not accompanied by a sense of depression in the
patient."
(labeled as severe depression- anhodania, low mood and one of the 5)

(moderate depression- criteria)-

Reference Read: Sami’s note table in psychiatry, Afsana’s, saima’s note

Q: 655 A 31yo woman presents with 7-10days following childbirth, with loss of feeling
for the child, loss of appetite, sleep disturbance and intrusive and unpleasant
thoughts of harming the baby. What is the best tx for this pt?
a. Fluoxetine
b. Haloperidol
c. CBT
d. Reassurance
e. ECT

Clincher(s) Thoughts of harming baby- so psychosis- so ECT- immediate assessment and
admission needed
If thought of harming baby is not there; pp depression
60
February 17, 2016

A
B
C
D
E
KEY e. ECT
diagnosis = post partum psychosis

Additional Antipsychotics are given taking into account the breastfeeding factor. Usually lithium is given but
ECT is better way to go. Why we need ECT? As this is psychosis and there is danger to both
Information mother and child we need to control the situation rapidly with high intensity psychological
intervention

Postpartum psychosis is a psychiatric emergency. It requires urgent assessment,
referral, and usually admission, ideally to a specialist mother and baby unit.[8]
Management is primarily pharmacological, using the same guidance as for other

causes of psychosis. Medication would normally involve an antidepressant,
antipsychotic and/or mood stabilising drug. However, choice of medication must
take breastfeeding into account. Mothers requiring lithium treatment should be
encouraged not to breast-feed, due to potential toxicity in the infant. Most
antipsychotics are excreted in the breast milk, although there is little evidence of it
causing problems. Where they are prescribed to breast-feeding women, the baby
should be monitored for side-effects. Clozapine is associated with agranulocytosis
and should not be given to breast-feeding women. Electroconvulsive therapy
(ECT) may also be considered in some cases

Reference

Q: 658 A 24yo woman presents with episodes of peri-oral tingling and carpo pedal
spasms every time
she has to give a public talk. This also happens to her before interviews,
exams and after
arguments. What is the best management strategy for this pt?
a. Diazepam
b. Rebreathe in a paper bag
c. Desensitization
d. Buspirone
e. Propranolol

Clincher(s)
A Anti anxiety
B
C Desensitization is for phobias...like arachnophobia

D Anti anxiety
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February 17, 2016

E Beta blocker…short term in GAD
KEY
b. Rebreathe in a paper bag??? Hyperventilation
SKYPE: propanol for social anxiety,
SSRI suggested in NICE

Additional Hypocalcemia / respirary depression/hypocapnia > due to panic attack
Information Panic attack Rx is deep breathing in bag, CBT, then pharma treatment
She has co2 washout which results in hypocalcemia hence the Peri oral tingling and carpo pedal
spasms
Desensitization is for phobias...like arachnophobia
buspirone is for smoking cessation
For acute attack.. Rebreathe into paper bag
For prophylaxis just like when a pt has to give a public talk or appear in an interview..beta
blocker. .propanolol.
Best Mx is CBT. Desensitization
If CBT doesn't help we go for medical Mx.. SSRI

questions mentions all the events she is worried about and get symptoms from.
What I think is that this is panic disorder which starts at the time public speaking and ends after
its over. As opposed to GAD which is persistent and long lasting.
And if we go according to management of panic attack. Step 1 is education
Step 2 is cbt or ssri.
So i think in this case cbt is the best answer.
If it would be that the patient needs something to calm down while an exam then propranolol
would be best. I mean for one time event.
And if it would be acute and first time episode then rebreathing would be way to go.

Reference

Q: 721 A pt suffering from schizophrenia laughs while talking about his
father’s death. Which term best describes his condition?
a. Depression
b. Flat affect
c. Emotional liability
d. incongruent effect
e. Clang association

Clincher(s)
A
B Flat affect, which is also called blunted affect, is one of the negative
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February 17, 2016

symptoms of schizophrenia. A person with negative symptoms lacks a
normal range of feelings and behaviors
"The difference between flat and blunted affect is in degree. A person with flat
affect has no or nearly no emotional expression. He or she may not react at all to
circumstances that usually evoke strong emotions in others. A person with blunted
affect, on the other hand, has a significantly reduced intensity in emotional
expression".[8]
C Emotional liability also known as pseudobulbar affect is
characterized by involuntary crying or uncontrollable episodes of crying
and/or laughing, or other emotional displays.
occurs secondary to a neurologic disease or brain injury.

D Incongruent affect is a negative symptom of schizophrenia, which can
manifest as laughing at a bad news.
E clanging refers to a mode of speech characterized by association of
words based upon sound rather than concepts (rhyming words)
Example: “He went in entry in trying tieing sighing dying ding-dong dangles
dashing dancing ding-a-ling!”

KEY d. Incongruent affect
Additional
Information Symptoms are said to be mood-congruent if they are consistent with a patient's
mood or mental disorder. Conversely, they are said to be mood-incongruent if
they are inconsistent with their primary mood.

Reference Ohcs 358 7th edition

Q: 723 A 24yo woman is afraid to leave her house as whenever she goes
out, she tends to have SOB and sweating. She has stopped going out
except with her husband. What is the most likely dx?
a. Social phobia
b. Claustrophobia
c. Depression
d. Panic disorder
e. Agoraphobia

Clincher(s)
A Social phobia is when the person is afraid to go to places where
he/she may be judged, commented on, minutely observed or
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February 17, 2016

criticized by others like parties.

B Claustrophobia is fear of a tight space, small room etc.
C
D
E Agoraphobia is fear of large open spaces, crowds, travel, or
situations away from home. (Agar means market)
KEY e. Agarophobia
Additional Rx: Desentisitse patients (repeated exposure to different places, relaxation
Information therapy)
Reference
Dr Khalid/Rabia

Q: 733
A woman is sad, fatigued and she is eating more and also has
sleeping disturbance and hears the voice of her husband who died
3yrs ago. What is the dx?
a. OCD
b. Psychogenic depression
c. Grieving
d. Severe depression

Clincher(s)
A Not grieving as it’s been three years. (psychosis will always mean delusion and
hallucination)
B Psychotic depression is a subtype of major depression that occurs when
a severe depressive illness includes some form of psychosis. The
psychosis could be hallucinations (such as hearing a voice telling you
that you are no good or worthless), delusions (such as, intense feelings
of worthlessness, failure, or having committed a sin) or some other
break with reality.
C
D
E
KEY The key is Psychotic depression.

Additional Depression refers to both negative affect (low mood) and/or absence
Information of positive affect (loss of interest and pleasure in most activities) and
is usually accompanied by an assortment of emotional, cognitive,
physical and behavioural symptoms.It is currently ranked the third
most prevalent moderate and severe disabling condition globally by
the World Health Organization (WHO).
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February 17, 2016

Classification:
(NICE) guidance uses the Diagnostic and Statistical Manual Fourth
Edition (DSM-IV) classification.

To diagnose major depression, this requires at least one of the core
symptoms:
• Persistent sadness or low mood nearly every day.
• Loss of interests or pleasure in most activities.
Plus some of the following symptoms:

• Fatigue or loss of energy.
• Worthlessness, excessive or inappropriate guilt.
• Recurrent thoughts of death, suicidal thoughts, or actual
suicide attempts.
• Diminished ability to think/concentrate or increased
indecision.
• Psychomotor agitation or retardation.
• Insomnia/hypersomnia.
• Changes in appetite and/or weight loss.
Symptoms should have been present persistently for at least two
weeks and must have caused clinically significant distress and
impairment.
Rule out other organic/physical factor like substance abuse, or
chronic illness.

DSM-5 was published in 2013. It proposes the following changes
to the classification of depressive disorders:
• Persistent depressive disorder - this term is proposed to
encompass both chronic major depressive disorder and
dysthymia.
• Removal of the major depression bereavement exclusion -
the diagnosis of major depression was excluded in people
who had recently been bereaved. This has been removed,
leaving more leeway for clinical judgement.
• A new category of mixed anxiety/depressive disorder.
The NICE guidelines encourage a case-finding approach with at-risk

groups (individuals with a past history of depression or a chronic
health problem with associated functional impairment) using a two
question approach:
• During the past month, have you:
o Felt low, depressed or hopeless?
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February 17, 2016

Had little interest or pleasure in doing things?
o
ASSESSMENT:
• The Patient Health Questionnaire (PHQ-9)
• The Hospital Anxiety and Depression (HAD) Scale
• Beck's Depression Inventory
• Full history and examination +mental state examination
• enquire about delusions/hallucinations and suicidal ideas.
• Rule out organic causes of depression like
hypothyroidism/drug side effects
Medications that may cause depressed mood include:
• Centrally acting antihypertensives (eg, methyldopa).
• Lipid-soluble beta-blockers (eg, propranolol).
• Benzodiazepines or other central nervous system depressants.
• Progesterone contraceptives, especially medroxyprogesterone
injection.
Differential diagnosis
• Bipolar disorder.
• Schizophrenia (depression may co-exist).
• Dementia may occasionally present as depression and vice
versa.
• Seasonal affective disorder.
• Dysthymia (recently classified by DSM-5 as a subtype of
persistent depressive disorder) is a chronic depressive state of
more than two years in duration.
• Other psychiatric conditions may co-exist with depression
(eg, generalised anxiety disorder, panic disorder, obsessive-
compulsive disorder, personality disorders).
• Bereavement: depressive symptoms begin within 2-3 weeks
of a death (uncomplicated bereavement and major depression
share many symptoms but active suicidal thoughts, psychotic
symptoms and profound guilt are rare with uncomplicated
bereavement).
INVESTIGATIONS:
Rule out organic causes
Blood tests may include blood glucose, U&Es, LFTs, TFTs, calcium
levels, FBC and inflammatory markers, HIV OR SYPHILIS
SEROLOGY, drug screening.

MANAGEMENT:
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February 17, 2016

• Consider watchful waiting, assessing again normally within
two weeks.
• Guided self-help based on cognitive behavioural therapy
(CBT) principles
• Antidepressants are not recommended for the initial treatment
of mild depression, because the risk:benefit ratio is poor.
However they are recommended in moderate to severe
depression.
• Selective serotonin reuptake inhibitors (SSRIs) are used as
first-line antidepressants in routine care because they are as
effective as tricyclic antidepressants and less likely to be
discontinued because of side-effects; also because they are
less toxic in overdose.
• Citalopram, fluoxetine, paroxetine, or sertraline have equal
efficacy however a recent meta-analysis suggested that
escitalopram had the highest probability of remission and is
the most effective and cost-effective pharmacological
treatment in a primary care setting
• Fluoxetine is the antidepressant of choice for children and
young people.
• Where a patient has concurrent physical health problems,
citalopram or sertraline may be preferred, as they have less
risk of significant drug interactions
Treatments such as dosulepin, phenelzine, combined antidepressants
• Treatments such as dosulepin, phenelzine, combined
antidepressants and lithium augmentation of antidepressants
should be initiated only by specialist mental healthcare
professionals.
• Electroconvulsive therapy (ECT) may be used to gain fast and
short-term improvement of severe symptoms after all other
treatment options have failed, or when the situation is thought
to be life-threatening.
What is Psychosis;
Psychosis is a severe mental disorder in which there is extreme
impairment of ability to think clearly, respond with appropriate
emotion, communicate effectively, understand reality and behave
appropriately.
Psychosis occurs in a number of serious mental illnesses and not just
schizophrenia, eg depression, bipolar disorder (manic-depressive
illness), puerperal psychosis and sometimes with drug and alcohol
abuse
Disabling symptoms include delusions and hallucinations:
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February 17, 2016

• A delusion is a false, fixed, strange, or irrational belief that is
firmly held. The belief is not normally accepted by other
members of the same culture or group. There are delusions of
paranoia (plots against them), delusions of grandeur
(exaggerated ideas of importance or identity) and somatic
delusions (false belief in having a terminal illness).
• An hallucination is sensory perception (seeing, hearing,
feeling, smelling) without an appropriate stimulus, like
hearing voices when no one is talking. Not all hallucination
suggests psychosis.
So to conclude we can see that the patient is the question was
suffering from complicated bereavement associated with psychotic
symptoms.

Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
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February 17, 2016

KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Additional
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February 17, 2016

Information
Reference
Dr Khalid/Rabia

Q:750 A 20yo girl with amenorrhea and BMI of 14 still thinks she has to lose weight.
a. Anorexia nervosa
b. Bulimia nervosa
c. OCD
d. Depression

Clincher(s) Amenorrhea, BMI 14, thinking of loosing more weight
A There is a compulsive need to control eating.
Diagnostic criteria:
• Weight<85% of predicted or BMI <17.5
• Fear of weight gain even when underweight
• Feeling fat when thin
• Amen or Decreased libido
Source OHCS page 348
B Bulimia nervosa is an eating disorder and mental health condition.
People who have bulimia try to control their weight by severely restricting the
amount of food they eat, then binge eating and purging the food from their
body by making themselves vomit or using laxatives.BMI >17.5
Source OHCS pg 349
C OCD is a risk factor as perfectionism for anorexia nervosa people
D Depression again plays as a risk factor for anorexic ppl.
E XX
KEY A
Additional Anorexia nervosa is a serious mental health condition. It is an eating disorder
Information in which people keep their body weight as low as possible.
Severe anorexia:
BMI<15, rapid weight loss plus evidence of systemic failure requires urgent
referral to eating disorder unit EDU, medical unit MU,or paediatric medical
ward P.
Moderate anorexia:
BMI 15-17.5 and no evidence of systemic failure requires routine referral to
community mental health team CMHT or EDU if available.
Mild anorexia:
BMI >17.5 focus on building a trusting relationship and use of self help books
and food diary.
Reference OHCS page 348-349
Dr Khalid/Rabia They didn't write anything.

Q:751 A guy who has several convictions and has been imprisoned several times,
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February 17, 2016

breaks up with his family and doesn’t Contact his children. What type of
personality disorder is this?
a. Borderline
b. Antisocial
c. Schizotypal
d. Schizoid
e. Criminal

Clincher(s) Several conviction and history of repeated imprisonment plus break up with
family and no contact.
A There is a pattern of sometimes rapid fluctuation from periods of confidence
to despair, with fear of abandonment and rejection. There is a particularly
strong tendency towards suicidal thinking and self-harm.

Transient psychotic symptoms, including brief delusions and hallucinations,
may also be present. It is also associated with substantial impairment of social,
psychological and occupational functioning and quality of life.

People with borderline personality disorder are particularly at risk of suicide.

Source :patient info
B A person with antisocial personality disorder may:
• exploit, manipulate or violate the rights of others
• lack concern, regret or remorse about other people's distress
• behave irresponsibly and show disregard for normal social behaviour
• have difficulty sustaining long-term relationships
• be unable to control their anger
• lack guilt, or not learn from their mistakes
• blame others for problems in their lives
• repeatedly break the law
• Source : NHS.uk
C The socially anxious, friendless loner with magical thinking, odd fantasies.
OHCS 323
There are many similarities in the symptoms of schiziod and schizotypical but
one slight difference is that it seems to be that those labeled as Schizotypal
avoid social interaction because of a deep-seated fear of people. The Schizoid
individual simply feels no desire to form relationships, because they quite
literally see no point in sharing their time with others.
D People with schizoid personality disorder are loners (people . If you have this
condition, you're likely to:

• Prefer being alone and usually choose solitary activities
• Prize independence and have few close friendships
• Feel confused about how to respond to normal social cues and
generally have little to say
• Feel little if any desire for sexual relationships
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• Feel unable to experience pleasure
• Come off as dull, indifferent or emotionally cold
• Feel unmotivated and tend to underperform at school or work
E Criminal mind and engaging in wrong doings
KEY B
Additional DSM IV gives nine categories of personality disorder. In DSM-IV there are ten
Information personality disorders that are divided into three clusters, designated A, B, C.

Cluster A: odd or eccentric behaviour ( paranoid, schizoid (loner and avoid
others) ,schizotypical (weirdos who wants to make friends but no one wants
to)

Cluster B: dramatic or emotional behaviour ( antisocial, borderline, histrionic,
narcissistic.

Cluster C: anxious or avoidant behaviour ( obsessive compulsive, avoidant)

Reference Ohcs page 366/ patient info/ nhs.uk/ dr Rabia
Dr Khalid/Rabia

Q:761 A lady with depression has a bag full of meds. She now presents with coarse
tremors. Which drug caused her symptoms?
a. Lithium
b. Thyroxine
c. Amitriptyline (no tremors)
d. Sodium valproate (rarely involuntary muscle movements)
e. Tetrabenazine

Clincher(s) Tremors and history of depression with bag full of medicines.
A S.E: hypothyroidism, nephrogenic DI.
Toxic signs: vision decreased , K dec, ataxia, tremor, dysarthria and coma
Ohcs page 364
B Thyroxine not the drug used in depression but cause tremors.
C It is antidepressant but doesn't cause tremors.
S.E: sedation, dry mouth,urine retention,blurred vision,postural hypotension
tachycardia and constipation. Arrhythmia and convulsions are dose related.
Source Ohcs page 340
D Used for acute/ moderate or severe mania and rarely cause involuntary
muscle movements.
Patient info
E Used to control movement disorders such as tardive dyskinesia which is a
side effect of anti psychotics.
KEY A
Additional Tremors : lithium (fine for side effects but in overdose- coarse tremours)and
Information thyroxine,
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February 17, 2016

Reference Ohcs/ patient info
Dr Khalid/Rabia

Q:844 A 32yo man has been repeatedly admitted to hospital for what was described
as anxiety or panic attacks and palpitations. On occasions he is found to be
tremulous and hypertensive. A persistent weight loss is noted. What is the
most probable dx?
a. Hyperthyroidism
b. Panic attacks
c. Pheochromocytoma
d. Cushing’s disease
e. GAD

Clincher(s) “on occasions”Anxiety, panic attacks, tremulous, hypertensive, weight loss,
palpitation
A All the symptoms described above can be hyperthyroidism but panic attack
and anxiety is very occasionally presented with pts suffering from
hyperthyroidism and mostly present as a common presenting symptom in
pheochromocytoma.
B During an attack you experience a whole range of frightening symptoms, and
worrying thoughts may go through your mind.
A panic attack is an experience of sudden and intense anxiety. Panic attacks
can have physical symptoms, including shaking, feeling confused or
disorientated, rapid heartbeats, dry mouth, sweating, dizziness and chest pain
C There are a number of symptoms that may present but the first four are in
bold as they are almost invariably present:

Headache
Profuse sweating
Palpitations
Tremor
Nausea
Weakness
Anxiety
Sense of doom
Epigastric pain
Flank pain
Constipation
Weight loss
D Symptoms of Cushing disease are :
behavioral changes, depression and mood swings,moon face + central
obesity = lemon on sticks.
muscle wasting and proximal myopathy (patients have difficulty standing
from a seated position without use of arms)
tendency to bruise easily, appearance of red 'stretch marks' on the abdomen,
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February 17, 2016

similar to those which occur during pregnancy
(Oligomenorrhoea) or (Amenorrhoea) impotence , reduced fertility,
decrease in sex drive, hirsutism ,High BP, development of mild diabetes
mellitus
E Patient is worried about different number of events every day. Almost
everything triggers the anxiety
KEY C
Additional phaeochromocytoma is a rare tumour that secretes catecholamines. It is
Information derived from chromaffin cells, usually in the adrenal medulla but
occasionally extra-adrenal phaeochromocytomas or paragangliomas occur.
Many but not all authors define phaeochromocytoma as coming from the
adrenal medulla and if the tumour is similar but located elsewhere, it is
called a paraganglioma.
Surgical resection of the tumour is the treatment of choice and usually

results in cure of the hypertension. Pre-operative treatment with alpha-
blockers and beta-blockers is required to control blood pressure and prevent
intraoperative hypertensive crises.

Reference Patient info, OHCM phaechromocytoma has OCCASIONAL/EPISODIC
presentation
Dr Khalid/Rabia

Q:955 A 24yo woman known to be suffering from panic disorder presents to the
hospital with tingling and numbness in her fingers. ABG: pH=7.52,
PCO2=2.2kPa, PO2=11kPa, Bicarb=20. What is the most likely condition?
a. Acute metabolic alkalosis
b. Acute resp alkalosis
c. Compensated resp alkalosis
d. Compensated metabolic acidosis
e. Acute metabolic acidosis

Clincher(s) PH inc, PCO2 Dec, PO2 normal, HCO3 slightly Dec
A Can't be right because metabolic change means Change in PH inline with HCO3
which is not the case here.
B This figures fits perfectly in this scenario as respiratory alkalosis means if PH
will inc then CO2 will Dec
C If CO2 would have been normal or increased then it would hv been
compensatory change which is not the case here.
D PH and HCO3 are in opposite direction hence its not a metabolic change.

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February 17, 2016

However just FYI
Compensatory metabolic acidosis means when PH and HCO3 both dec and
CO2 is low too to revert the acidosis is a compensatory change.
Ohcm page 684
E Again figures doesn't support metabolic acidosis.
KEY B
Additional Please read page 684 on ohcm.
Information
Remember CO2 is an acidic gas so inc or dec will result in acidosis or
alkalosis respectively.
On the other hand HCO3 is alkaline so inc or dec will cause alkalosis or
acidosis respectively.
Thanks to Asad for this neumonic
Reverse= Respiratory

To illustrate , PH inc CO2 dec respiratory alkalosis
PH dec , CO2 inc respiratory acidosis

In compensatory mechanism CO2 either going to be normal or opposite then
expected then it's compensatory change.

Same= metabolic acidosis (in relation to PH and HCO3)

For examplePH inc HCO3 inc metabolic alkalosis
PH dec HCO3 dec Metabolic acidosis
Again CO2 will try to compensate and in metabolic acidosis CO2 if lower
then it's compensatory

For example
PH dec HCO3 dec CO2 dec then it's metabolic compensatory acidosis
PH inc HCO3 inc CO2 inc then it's compensatory metabolic alkalosis

Reference Ohcm684
Dr Khalid/Rabia Hyperventilation in panic attacks: release more carbon dioxide

Q:959 A 48yo woman always socially withdrawn has stopped going out of the house.
She is afraid to socialize because she fears that people will criticize her. What is
the most probable dx?
a. Agoraphobia
b. PTSD
c. Social anxiety
d. OCD
e. GAD

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February 17, 2016

Clincher(s) Fear about her being criticise, afraid to socialise
A Agoraphobia is a fear of being in situations where escape might be difficult, or
help wouldn't be available if things go wrong.
B Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by very
stressful, frightening or distressing events.

C Social anxiety disorder (social phobia) is a persistent and overwhelming fear of
social situations. It's one of the most common anxiety disorders.
D Obsessive compulsive disorder (OCD) is a mental health condition where a
person has obsessive thoughts and compulsive activity.
E an anxiety disorder characterized by excessive, uncontrollable and often
irrational worry, that is, apprehensive expectation about events or activities.
Patient is worried about different number of events every day. Almost
everything triggers the anxiety
KEY C (Rx: we do CBT – most approp is SSRI/ feroxitine)
Additional
Information
Reference Nhs.uk
Dr Khalid/Rabia

Q:969 A 43yo woman presents with low mood, loss of libido, sleep disturbance,
tiredness, palpitation, chest discomfort, irritability and recurrent worries.
a. Seasonal Affective Disorder
b. Mod depression
c. Dysthymia
d. GAD
e. Bipolar disorder

Clincher(s) Low mood, loss of libido, sleep disturbance, tiredness, palpitation, chest
discomfort, irritability, recurrent worries.
A Seasonal affective disorder (SAD) is a type of depression that comes and goes
in a seasonal pattern.
SAD is sometimes known as "winter depression" because the symptoms are
more apparent and tend to be more severe during the winter. Winter causes
depression: seasonality
B you would normally have more than the five symptoms that are needed to
make the diagnosis of depression. Also, symptoms will usually include both
core symptoms. Also, the severity of symptoms or impairment of your
functioning is between mild and severe.
C Dysthymia is a mild but long-term (chronic) form of depression. Symptoms
usually last for at least two years, and often for much longer than that.
Dysthymia interferes with your ability to function and enjoy life.

D Explained above.
E Bipolar disorder, formerly known as manic depression, is a condition that
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February 17, 2016

affects your moods, which can swing from one extreme to another.
KEY B
Additional Symptoms of depression:
Information
• Loss of interest or pleasure( anhedonia) with dysphoric moods plus >
4 of the foll
• Poor appetite with wt loss
• Early waking, with diurnal mood variation.
• Psychomotor retardation( paucity of spontaneous movement or
sluggish thought process)
• Decreased in sexual drive and other appetites
• Reduced ability to concentrate
• Ideas of worthlessness guilt, or self reproach recurrent thoughts of
death and suicide and suicidal attempts.
Severe depression - you would normally have most or all of the nine
symptoms . Also, symptoms markedly interfere with your normal
functioning.
Moderate depression - you would normally have more than the five
symptoms that are needed to make the diagnosis of depression. Also,
symptoms will usually include both core symptoms. Also, the severity of
symptoms or impairment of your functioning is between mild and severe.
Mild depression - you would normally have five of the symptoms that are
required to make the diagnosis of depression. However, you are not likely to
have more than five or six of the symptoms. Also, your normal functioning is
only mildly impaired.
Subthreshold depression - you have fewer than the five symptoms needed to
make a diagnosis of depression. So, it is not classed as depression. But, the
symptoms you do have are troublesome and cause distress. If this situation
persists for more than two years it is sometimes called dysthymia.
Reference Patient info/ Ohcs pg 336
Dr Khalid/Rabia

Q: 973 973. A young man has been found in the park, drunk and brought to the ED by
ambulance. He recently lost his job and got divorced. He thinks nurses are plotting
against him. What is the most likely dx?
a. Schizoid personality
b. Borderline personality
c. Schizophrenia
d. Psychotic depression
e. Paranoid personality

Clincher(s) Job problem, divorce, plotting (paranoidal delusion)
A Schizoid is a “lonely wolf” he is isolated and he is happy with it
77
February 17, 2016

As opposite to “schizotypal” who is a kind-wierdo and want to socialize but he is weird
and repelling people from him
B Emotionally unstable, attention seeking (Paris Hilton)
C Psychosis (=“auditory” hallucination and/or delusion) + thought disorder
D A depression + psychosis that is consistent with the theme of depression such as
failure and self-worthlessness
E Paranoidal
KEY C (sami will check) SKYPE answer: psychotic depression
Sami: the man is not having depression
he lost his job and got divorced but no mentioning of sadness or anything of
that
so we don't jump and conclude depression that's why it is schizophrenia

Additional Information Personality means for a long time for from childhood
Delusion is a type of psychi
Reference OHCS, Afsana
Dr Khalid/Rabia

Q:977 977. A 26yo political refugee has sought asylum in the UK and complains of poor conc.
He keeps getting thoughts of his family whom he saw killed in a political coup. He is
unable to sleep and feels hopeless about his survival. Because of this he is afraid to go
out. What is the most likely dx?
a. Acute stress disorder
b. PTSD
c. Social phobia
d. OCD
e. GAD

Clincher(s) Refugee
A stress
B The answer
C Fear from socializing
D Perfectionist, ie doctors
E Anxiety > 6 m
KEY B
Additional Information Refugees, soldiers, veterans, rape, torture → PTSD
Reference
Dr Khalid/Rabia

Q: 998 A 32yo man with schizophrenia and a hx of violence and distressing auditory
hallucinations was admitted to the ward with aggressive behavior and has already
smashed his room. He is refusing any oral meds. What is the single most appropriate
injection?
a. Flupenthixol
b. Fluphenazine
c. Haloperidol (only inj)
d. Paraldehyde
e. Risperidone (atypical antipsychotic)
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February 17, 2016

In acute emergency with phase of psychocis- can be only managed with iv ir im inj of
haloperidol
Clincher(s)
A Flupenthixol typical antipsychotic, for schizophrenia and other psychoses, particularly
with apathy and withdrawal but not mania or psychomotor hyperactivity ; depression,
SE: estrapyramidal SE, hyperglycaemia
B Fluphenazine typical antipsychotic, for maintenance EPSE, SLE SIADH
C Haloperidol Injection indicated for acute psychosis
D Paraldehyde It is a central nervous system depressant and was soon found to
be an effective anticonvulsant, hypnotic and sedative.
E Risperidone atypical antipsychotic, indicated for acute psychosis but not injectable
KEY C, typical antipsychotic
Reference
Dr Khalid/Rabia BNF, wikipedia

Q: 1016. A 24yo woman has severe depression 3m after the birth of her first child. She is
breastfeeding but is otherwise unable to look after the baby and is convinced that her
family is likely to kill her (prosecution delusion). She has no interest in anything and
keeps crying. What is the most appropriate tx?
a. Fluoxetine (SSRI- in milk)
b. Citalopram (SSRi- in milk)
c. CBT (this is psychosis)
d. ECT (severe psychotic depression- in case of harming thought –
baby/herself/others)
e. Haloperidol (for schizo)
Psychosis after delivery, breast feeding
Clincher(s) Post natal depression
A Breast-feeding present in milk—avoid
B Breast-feeding present in milk—use with caution
C Not indicated
D The key
E As above
KEY ECT SKYPE: FLUoxetine
Additional Information Antipsychotic Rx:
Breast-feeding There is limited information available on the short- and long-term
effects of antipsychotic
drugs on the breast-fed infant. Animal studies indicate
possible adverse effects of antipsychotic medicines on
the developing nervous system. Chronic treatment with
antipsychotic drugs whilst breast-feeding should be
avoided unless absolutely necessary. Phenothiazine
derivatives are sometimes used in breast-feeding
women for short-term treatment of nausea and vomiting. See also under individual
drugs.
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February 17, 2016

Reference BNF, Passmedicine
Dr Khalid/Rabia

Q: 1023 A 75yo man has been attending the clinic for lower urinary tract symptoms. His mood
is very low and he says he feels unhappy, anxious and unable to sleep. He has been dx
with moderate depression. What tx would be most effective for this pt?
a. Amitriptyline
b. Citalopram
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February 17, 2016

c. CBT
d. Dosulepin
e. Diazepam
TCA (Tricyclic antidepression )cause urinary retention
Clincher(s)
A
B
C
D
E
KEY C, always first line Rx for mild-moderate depression
Reference
Dr Khalid/Rabia amitriptyline and Dosulepin (TCA)both cause urinary retention, Citalopram (SSRI)
causes
insomnia in more than 15% patients, patient is already suffering from both
problems.
MILD DEPRESSION:initial recommended treatment for mild depression is
CBT.
MODERATE-SEVERE: Offer antidepressant medication combined with
high-intensity psychological treatment (CBT or interpersonal therapy (IPT)).
For an individual with a chronic health problem and moderate depression,
this should be high-intensity psychological treatment alone in the first
instance

Q: 1030 1030. A 45yo heroin addict was involved in a car crash and is now paraplegic. During
the 1st week of hospital stay he cried everyday because he couldn’t remember the
accident. What is the most likely dx?
a. PTSD
c. Organic brain damage

Paraplegia
Clincher(s)
A War/rape/torture/refugees/soldiers/veterans
B Suicide/self neglect
C
D
E
KEY Incomplete question
Additional Information symptoms are pointing towards brain damage.
It is a brain injury resulting from a medical cause and not a psychiatric cause. For eg
trauma, hemorrhage, concussion, hypoxia, hypercapnia, stroke, heart infections,
Alzhiemers, degenerative disorders, metabolic causes, kidney liver disease, drug and
alcohol.
Inv and Rx depend on underlying disorder.
Symptoms: agitation, confusion, dementia, delirium
Reference
Dr Khalid/Rabia
81
February 17, 2016

Q: 1044 . An 18yo girl has been dx with anorexia nervosa and has mild depressive symptoms.
She has cut
down her food intake for the last 18m and exercises 2h everyday. Her BMI=15.5,
BP=90/60mmHg. What would be the single most appropriate management?
a. Refer to eating disorder clinic
b. Refer to psychodynamic therapy
c. Refer to acute medical team
d. Prescribe antidepressant

Clincher(s) BMI 15.5, mild depression, BP 90/60
A
B
C
D
E
KEY A

Reference OHCS 349
Dr Khalid/Rabia

Q:

Clincher(s)
A
B
C
D
E
KEY
Reference
Dr Khalid/Rabia

Q: 734 A 40yo teetotaler woman is recovering from a hysterectomy 2days ago. At
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February 17, 2016

night she becomes agitated and complains of seeing animals and children
walking around the ward. What is the most likely dx?
a. Delirium tremens
b. Toxic confusional state
c. Hysteria
d. Mania
e. Drug induced personality disorder

Clincher(s) Surgery 2 days ago, hallucinations
A Results due to alcohol withdrawal
B Toxic confusional state or delirium . key features are impaired consciousness
with onset over hours/days.
.
C Hysteria or dissociation: types include amnesia, dissociative identity disorder,
fugue.
D Mania
E No h/o of substance abuse
KEY B
Additional DELIRIUM: Symptoms can be disorientation, delusion, hallucinations.Causes
Information include infection, drugs (benzodiazepine, opiates, anticonvulsants, digoxin, L-
dopa), surgery, U&E imbalance, epilepsy, trauma, alcohol withdrawal
Investigations: U&E, FBC, blood glucose, blood gases, CXR, ECG, LFT. Consider
CT/MRI and LP.
Management: find the cause and start relevant treatment . If agitated sedation
may be needed before doing tests and examination. Try haloperidol 1-10mg
IV/IM/PO. In alcohol withdrawal use diazepam
Reference Ohcm p350
Dr Khalid/Rabia

Q:735 A woman with a hx of drug abuse and increased alcohol intake, now comes for
help and she is concerned about her problem. What is the most appropriate
management option?
a. Voluntary admission
b. Psychiatry team
c. Mental health team
d.Psychiatry voluntary admission

Clincher(s) Patient’s awareness and stable mental status
A No indication for admission
B For counseling ,history to find reason for relapse
C No need Patient appears to be mentally stable
D No indication for admission
E
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February 17, 2016

KEY B
Additional Psychotherapy, family therapy ,counseling and alcohol and drug anonymous
Information
Reference ohcm
Dr Khalid/Rabia

Q:741 1. A 25yo woman with a hx of several episodes of depression is brought to
the ED after she was found with several empty bottles of her meds. She
complains of coarse tremor, nausea and vomiting. Which of the
following drugs is likely to have caused her symptoms?
a. Fluoxetine
b. Amitryptilline
c. Lithium
d. Phenelzine
e. Olanzapine

Clincher(s) Several relapses
A
B
C
D
E
KEY C
Additional
Information
Reference
Dr Khalid/Rabia

Q:742 A 23yo man feels anxious and agitated when faced with stress. He has an
interview in 3days and would like some help in relieving his symptoms. What is
the most appropriate management?
a. SSRI
b. CBT
c. Propranolol
d. Diazepam

Clincher(s)
A
B
C
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February 17, 2016

D
E
KEY C
Additional
Information Beta-Blockers
Beta blockers can be helpful in the treatment of the physical symptoms of
anxiety, especially social anxiety. Physicians prescribe them to control rapid
heartbeat, shaking, trembling, and blushing in anxious situations for several
hours.
Possible Benefits. Very safe for most patients. Few side effects. Not habit-
forming.
Possible Disadvantages. Often social anxiety symptoms are so strong that beta
blockers, while helpful, cannot reduce enough of the symptoms to provide
relief. Because they can lower blood pressure and slow heart rate, people
diagnosed with low blood pressure or heart conditions may not be able to take
them. Not recommended for patients with asthma or any other respiratory
illness that causes wheezing, or for patients with diabetes.

Reference
Dr Khalid/Rabia

Q:744 A woman presents with a hx of poisoning 10x with different substances. There
are no obvious signs of depression or suicidal behavior. What is the best
preventive step?
a. Open access to ED (in SVT)
b. 24h help line
c. CBT
d. Anti-depressants
e. Insight into problem

Clincher(s)
A
B
C
D
E
KEY E
Additional
Information
Reference
85
February 17, 2016

Dr Khalid/Rabia

Q:746 A 24yo male on remand in prison for murder is referred by the prison doctor.
He is noted to be behaving oddly whilst in prison and complains of seeing
things. He has a prv hx of IV drug abuse. On questioning he provides
inappropriate but approximate answers to all questions stating that Bill Clinton
is the prime minister of England. What is the prisoner suffering from?
a. Capgras syndrome
b. Cotard syndrome
c. Ganser syndrome
d. Ekbom syndrome
e. Tourette’s syndrome

Clincher(s)
A
B
C
D
E
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q:747 A 32yo lady has recently become more active, sleeps less and bought a house
and 2 new cars. What is the most likely dx?
a. Bipolar disorder
b. Mania
c. Hypomania
d. Schizophrenia

Clincher(s) Hyperactive , shopping spree
A
B
C
D
E
KEY C
Additional
Information
Reference
86
February 17, 2016

Dr Khalid/Rabia

Q: 1055 A 30yo woman has experienced restlessness, muscle tension and sleep
disturbance on most days over the last 6m. She worries excessively about a
number of everyday events and activities and is unable to control these
feelings which are impairing her ability to hold down her job. What is the most
likely dx?
a. Panic disorder
b. GAD (generalized anxiety disorder)
c. Pheochromocytoma
d. Acute stress disorder
e. Social phobia

Clincher(s) restlessness, muscle tension and sleep disturbance on most days over the last
6m (CRITERIA for schizophrenia- at least 6 months), worries excessively about
a number of everyday events and activities
A Panic disorder is the experience of intense anxiety along with 4 symptoms of
autonomic hyperactivity lasting less than 30 mins.
B
C Phaeochromocytomas are functional tumours that arise from chromaffin cells
in the adrenal medulla. Diagnosis usually takes place in patients aged 40-50
years. Phaeochromocytomas usually secrete a combination of noradrenaline
and adrenaline, but some tumours may also secrete dopamine and rarely
ACTH causing Cushing's syndrome. Main presenting feature is HTN
D Acute stress disorder is the experience of symptoms by a person under a
maximum period of 1 month following exposure to a traumatic event. (mild
form of PTSD)
E Social phobia is the fear of a situation where something potentially
embarrassing might happen.
KEY: B Dx is GAD (ALSO over 6 months).
Patient is worried about different number of events per day. Almost
everything triggers the anxiety.
GAD is anxiety and +3 somatic symptoms present over a course of 6 months.
Causes of GAD are genetic predisposition, stress and events involving stress.
Treatment of GAD is through symptom control, exercise, meditation,
behavioural therapy, hypnosis and various drugs such as benzodiazepines,
ssris, azapirones, beta blockers and antihistamines.
Prognosis gets better by age 50 years.
87
February 17, 2016

Additional
Information

Reference GPnotebook, OHCS pg: 344

Q: 1065 A 24yo schizophrenic (antipsychotic given) has been under antipsychotic tx for
the last 1 yr and now complains of Erectile Dysfunction (ED). Which drug is
most likely to have caused this?
a. Fluoxetine (SSRI)
b. Citalopram (SSRI)
c. Clozapine- (last schiz drug- due to side effects – cardiac/pericarditis and
agranulocytosis)
d. Haloperidol (typical antiphyscho)
e. Risperidone (first choice for schiz)-

Clincher(s) Which med cause ED
A, B Fluoxetine anti-depression
& Citalopram – antidepression for MI SSRIs (selective serotonin reuptake
inhibitors)
C Clozapine last resort for schizo
D typical antipsychotic doesn’t cause erectile dysfunction
E
KEY: E Risperidone.
C, D and E are the antipsychotics from the options. OHCS states that atypical
antipsychotics cause erectile dysfunction, so haloperidol goes out of the race.
Since there are great chances of agranulocytosis by using clozapine and the
first choice is risperidone for schizo so the patient would have been advised
Risperidone which has caused ED.
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February 17, 2016

Additional typic
Information
Reference More SE of atypical antipsychotics on OHCS pg: 360

Q: 1185 A 36yo woman has recently spent a lot of money on buying clothes. She goes
out almost every night with her friends. She believes that she knows better
than her friends, so she should choose the restaurant for eating out with her
friends. She gave hx of having low mood at 12y. What is the dx?
a. Mania
b. Depression
c. Bipolar affective disorder (both mania and depression- periods)
d. Borderline personality disorder (impulsive/instabile)
e. Dysthymia (chronic mild depression for 2 years)
Clyclothemia- milder bipolar
Clincher(s)
A Mania - is a mood disorder in which the predominant feelings are of elation
and euphoria. Manic episodes may be part of a lifetime pattern of mood
disorder. Lifetime diagnoses which include manic episodes include:
• bipolar affective disorder (mania +depression)
• cyclothymia (hypomania rather than mania; a mild form of bipolar
affective disorder.)
B Depression - mood disorder in which the predominant feelings are of sadness.
Depression describes an individual episode of mood disorder. A depressive
episode may be part of a lifetime pattern of mood disorder. The common
lifetime diagnoses which include depressive episodes are:
• recurrent depressive disorder
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February 17, 2016

• bipolar affective disorder
• persistent affective disorders
C
D Borderline personality disorder - characterized by significant instability of
interpersonal relationships, self-image and mood, and impulsive behavior.
borderline personality disorder is present in just under 1% of the population;
most common in early adulthood
E Dysthymia - lifetime diagnosis in which the individual experiences persistent
(more than 2 years) of chronic low grade depression. Dx - this is a chronic
depressive state (two years or more duration) which is not the consequence of
a partly resolved major depression and does not meet the diagnostic criteria
for major depression
KEY: C Bipolar affective disorder
Bipolar affective disorder is a condition where there are periodic swings of
mood periods of months or years between manic episodes and depressed
episodes (GPnotebook)

Additional Dr. Rabia >> c. Bipolar affective disorder
Information a mental condition marked by alternating periods of elation and depression.
Reference OHCS pg: 354, GPnotebook

Q: 1189 A 45yo woman presents with complaints of abdominal pain and blood in stool.
She brings the stool sample from home but has never been able to produce a
sample at the hospital. Her urine and blood tests are normal. Exam: multiple
scars on the abdomen consistent with laparoscopies and appendectomy. She
insists on getting further inv although no abnormalities are found.
a. Malingering
b. Somatization
c. Hypochondriasis
d. Conversion disorder
e. Munchausen syndrome

Clincher(s) multiple scars on the abdomen consistent with laparoscopies and
appendectomy, no abnormalities are found
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February 17, 2016

A Malingering - This is the conscious and fraudulent simulation or exaggeration
of symptoms for the purposes of external gain. It may often occur in
prisoners, in military personnel and in those pursuing insurance claims.
B Somatization disorder
• multiple physical SYMPTOMS present for at least 2 years
• patient presents with one symptom at a time
• patient refuses to accept reassurance or negative test results
• Onset of a somatization disorder is usually before the age of 30.
Thereafter it runs a chronic course with repeated recurrences of
symptoms.
C Hypochondriac disorder
• persistent belief in the presence of an underlying serious DISEASE, e.g.
cancer, HIV
• patient again refuses to accept reassurance or negative test results
D

E
KEY: E Munchausen syndrome
(GPNotebook) Habitual seeking of hospital or other medical treatment for
apparent acute illness giving a plausible and dramatic history, all of which are
false.

Patients may complain both of physical and psychiatric symptoms and there
may be self-inflicted wounds or infections. Numerous surgical scars from
previous operations may also be present. Munchausen patients often
discharge themselves before investigation, operation or psychiatric
assessment is achieved.
Additional Munchausen syndrome by proxy is when a parent or caregiver gives a false
Information account of a child's symptoms or fakes signs.
Reference GPNotebook, Samsons notes, Dr. Rabia

Q: 1193 A 64yo man believes a female newscaster is communicating directly with him
when she turns a page. What kind of delusions is he suffering from?
a. Persecutory
b. Control
c. Grandeur
d. Nihilistic
e. Reference

Clincher(s) newscaster is communicating directly with him when she turns a page
A Persecutory delusions are a set of delusional conditions in which the affected
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February 17, 2016

person believes they are being persecuted. Specifically, they have been
defined as containing two central elements: The individual thinks that harm is
occurring, or is going to occur.
B Control - This is the belief that thoughts, actions and impulses are controlled
by an external agency. This symptom is highly indicative of schizophrenia, and
care should therfore be taken to make sure that it is correctly identified.
C Grandeur: fixed, false belief that one possesses superior qualities such as
genius, fame, omnipotence, or wealth.
D Nihilistic delusions include beliefs that:
• there is no future for the patient
• the patient is dead that he or she lives in a shadow or limbo world or
that he or she died several years ago and that only the spirit, in a
vaporous form, really exists.
• parts of the body do not exist or are dead
• organs are malfunctioning or rotting e.g. the gut
E
KEY: E Reference
A neutral event is believed to have a special and personal meaning. For
example, a person with schizophrenia might believe a billboard or a celebrity is
sending a message meant specifically for them.
Additional
Information
Reference

Q: 1196 A couple attends their GP because of marital problems. The wife states that
her husband is having affairs although she has no proof of this. The husband
states that she even had him followed by a private detective and this is putting
considerable strain on their marriage. What is the most likely dx?
a. Fregoli syndrome
b. Cotard syndrome
c. Mood disorder
d. Ekbom syndrome
e. Othello syndrome

Clincher(s) wife states that her husband is having affairs, no proof of this, had him
followed by a private detective
A The Fregoli delusion, or the delusion of doubles, is a rare disorder in which a
person holds a delusional belief that different people are in fact a single
person who changes appearance or is in disguise.
B The Cotard delusion (also Cotard's syndrome and walking corpse syndrome) is
a rare mental illness, in which the afflicted person holds the delusion that he
or she is dead, either figuratively or literally
C Mood disorder - a psychological disorder characterized by the elevation or
lowering of a person's mood, such as depression or bipolar disorder.
D Ekbom syndrome, also called delusional parasitosis, is a psychiatric disorder
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February 17, 2016

characterized by the patient's conviction that he or she is infested with
parasites.
E
KEY: E Othello syndrome
Delusional jealousy (Othello's syndrome) - eg believing a partner is being
unfaithful.

Additional
Information
Reference Dr. Rabia, OHCS

Q: 1219 A 26yo man strongly believes that every elderly man he meets is his father.
Although they look different, he is sure it is father wearing different disguises.
What kind of delusions is this man suffering from?
b. Erotomania
c. Delusion of grandeur
d. Delusion of doubles
e. Delusion of reference

Clincher(s) Even though they look different, he is sure it is father wearing different
disguises
A Persecutory delusions are a set of delusional conditions in which the affected
person believes they are being persecuted. Specifically, they have been
defined as containing two central elements: The individual thinks that harm is
occurring, or is going to occur.
B Erotomania - a delusion in which a person (typically a woman) believes that
another person (typically of higher social status) is in love with them
C Grandeur: fixed, false belief that one possesses superior qualities such as
genius, fame, omnipotence, or wealth.
D
E Reference - A neutral event is believed to have a special and personal
meaning. For example, a person with schizophrenia might believe a billboard
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February 17, 2016

or a celebrity is sending a message meant specifically for them.
KEY: D Delusion of doubles

Alson known as Fregoli Delusion these are extremely rare delusions in which
a person believes different people are all just a single person that is capable
of morphing his or her appearance as a disguise. It has been speculated that
these delusions are usually associated with brain lesions or damage.
Additional
Information
Reference

Q:5 A 64yo man has recently suffered from a MI and is on aspirin, atorvastatin and
ramipril. He has been having trouble sleeping and has been losing weight for
the past 4 months. He doesn’t feel like doing anything he used to enjoy and
has stopped socializing. He says he gets tired easily and can’t concentrate on
anything. What is the most appropriate tx?
a. Lofepramine
b. Dosulepin
c. Citalopram
d. Fluoxetine
e. Phenelzine

Clinchers 64yr , post MI STATUS, 4MONTHS HX OF SYMP
Depression—loss of interest + 4other biological sympt for atleast 2weeks
nearly everyday
ie low mood, anhedonia (unable to feel pleasure), self-denigration (“I am
worthless”;
“Oh that I had not been born!”), guilt (“It’s all my fault”), lack of interest in
hobbies and friends plus biological markers of depression (early morning
waking,decrease
appetite, sexual activity, weight); pg 339ohcs

A lofepramine - tricyclic antidepressant , given to patients with Past history of
good response to tricyclics,and now suicidal: less likely to be fatal in overdose;
less risk of fatal arrhythmias).

B Dosulepin is a tricyclic antidepressant .given Uncomplicated depression in
middle age— Avoid if arrhythmia risk (eg post MI). SSRI alternative:
citalopram.

C Selective serotonin reuptake inhibitor (SSRI) (Similar drugs: paroxetine,
citalopram, escitalopram, sertraline, fluvoxamine) fluoxetine

Escitalopram is the active enantiomer of citalopram. Sertraline and
escitalopram are the SSRIs whichare most selective for 5-HT uptake

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February 17, 2016

D Fluoxetine- ssri --Inhibits the reuptake 5-HT into serotonergic neurons, so
potentiating transmitter action. Given in Depression with intellectual disability
and depression with obesity

Increased risk of suicide in young patients. Not prescribed with MAOIs (risk of
serotonin syndrome).
Hyponatraemia in elderly.
.
E Monoamine oxidase inhibitor (MAOI) Depression; may have particular value
for atypical depression. Social phobia. Adverse effects are more frequent than
with the TCAs or SSRIs so MAOIs are second-line treatment for
Depression
KEY The key is C. Citalopram. [Citalopram is the antidepressant of choice in IHD]
. Citalopram is associated with dose-dependent QT interval prolongation and
is contra-indicated in patients with known QT interval prolongation or
congenital long QT syndrome

Additional Diagnosis of major depression:
Information 1 Loss of interest or pleasure—anhedonia in daily life with dysphoric mood
(ie ‘down in the dumps’) plus ≥4 of the following (the fi rst 5 are ‘biological’
symptoms)—present nearly every day for at least 2 weeks:
2 Poor appetite with weight loss (or, rarely, increased appetite).
3 Early waking—with diurnal mood variation (worse in mornings).
4 Psychomotor retardation (ie a paucity of spontaneous movement, or sluggish
thought processes), or psychomotor agitation.
5 Decrease in sexual drive and other appetites.
6 Evidence of (or complaints of) reduced ability to concentrate.
7 Ideas of worthlessness, inappropriate guilt or self-reproach.
8 Recurrent thoughts of death and suicide, or suicide attempts
Reference Rang & Dale pharm flash cards pg 393
Ochs pg 357
Dr Khalid/Rabia SEE sami’s Samson notes for summary for drugs

Q:31 . A 45yo man keeps having intrusive thoughts about having dirt under the bed.
He can’t keep himself from thinking about these thoughts. If he tries to resist,
he starts having palpitations.
a. OC personality (someone who is perfectionists)
b. OCD (CBT is first line)
c. Schizophrenia
d. Panic disorder
e. Phobia

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February 17, 2016

Clincher(s)
A Obsessive-Compulsive Personality Disorder is characterized by a preoccupation
with orderliness, perfectionism, and mental and interpersonal control, at the
expense of flexibility, openness, and efficiency.
B Compulsions are senseless, repeated rituals. Obsessions are stereotyped,
purposeless words, ideas, or phrases that come into the mind. They are
perceived by the patient as nonsensical (unlike delusional beliefs), and,
although out of character, as originating from themselves
(unlike hallucinations or thought insertion). They are often resisted by
the patient, but if longstanding, the patient may have given up resisting them
C Schizophrenia Schizophrenia is a common chronic/relapsing condition often
presenting in
late teens/early 20s with psychotic symptoms (hallucinations, delusi ons);
disorganization
symptoms (incongruous mood, abnormal speech and thought);
negative symptoms (apathy, self-neglect, blunted mood, motivation,
withdrawal);
and, sometimes, cognitive impairment.It has major implications
for patients, work and families.
D Panic disorder- anxiety

E Phobia involve anxiety in specific situations only, and leading to
their avoidance. These are labelled according to specifi c circumstance:
agoraphobia
(agora, Greek for market place) is fear of crowds, travel, or situations
away from home; social phobias (where we might be minutely observed, eg
small dinner parties) and others pg 363 ohcs
KEY 1. b.
Management – CBT(cognitive behavioral therapy ) . Clomipramine or SSRIs
intrusive thoughts and anxiety when trying to fight them mean OCD
Additional
Information
Reference Ohcs
Dr Khalid/Rabia

Q:36 A 37yo lady strongly believes that a famous politician has been sending her
flowers every day and is in love with her. However, this is not the case. What is
the most likely dx?
a. Erotomania
b. Pyromania
c. Kleptomania
d. Trichotillomania
e. Grandiosity

Clincher(s)
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February 17, 2016

A 1. A. [Erotomania is a type of delusion in which the affected person believes
that another person, usually a stranger, high-status or famous person, is in
love with them].
B Pyromania deliberately start fires, in order to relieve tension or for instant
gratification
C Kleptomania is the inability to refrain from the urge to steal items. / likes to
steal items

D Trichotillomania compulsive urge to pull out one's hair, leading to noticeable
hair loss and balding
E Grandiosity refers to an unrealistic sense of superiority.
KEY
Additional
Information
Reference
Dr Khalid/Rabia

Q:56 A 35yo man with a hx of schizophrenia is brought to the ER by his friends due
to drowsiness. On examination he is generally rigid. A dx of neuroleptic
malignant syndrome except:
a. Renal failure
b. Pyrexia
c. Elevated creatinine kinase
d. Usually occurs after prolonged tx
e. Tachycardia

Clincher(s)
A “renal failure” - neuroleptic syndrome can lead to renal failure so we have to
give IV fluids to prevent it.

B Pyrexia present- above 38’c accord to patient info
C ery high activity is also encountered in malignant hyperthermia.
http://www.mayomedicallaboratories.com/test-
catalog/Clinical+and+Interpretive/8336
http://www.ncbi.nlm.nih.gov/pubmed/1170791
D After 10days usually –dr rabia ,

E autonomic instability may manifest as pallor, tachycardia, fluctuating blood
pressure, excessive sweating/salivation, tremor and incontinence.

KEY Key is D. Usually after prolonged tx. It usually occurs within 10 days of starting
treatment. Cause: antipsychotics or dopamenergic drugs (levodopa)
Management: STOP the drug causing it. IV fluids, Dantrolene, Bromocriptine
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Additional Neuroleptic malignant syndrome a rare but potentially life-threatening
Information idiosyncratic reaction to neuroleptic drugs.

It causes fever, muscular rigidity, altered mental status and autonomic
dysfunction. -- associated with potent neuroleptics such as haloperidol and
fluphenazine.
The underlying pathological abnormality is thought to be central D2 receptor
blockade or dopamine depletion in the hypothalamus and nigrostriatal/spinal
pathways. This leads to an elevated temperature set-point, impairment of
normal thermal homeostasis and extrapyramidally induced muscle rigidity
Reference http://www.ncbi.nlm.nih.gov/pubmed/1170791
Dr Khalid/Rabia Neuro malignant syndrome: anesthetic agents – succmethoniaum causes
neuro.. syndrome- rx: dantroline (excuse the typos ☺)

Q:80 A 35yo male is bitterly annoyed with people around him. He thinks that people
are putting ideas into his head. What is the single most likely dx?
a. Thought block
b. Thought insertion
c. Thought broadcasting
d. Thought withdrawal
e. Reference
.

Clincher(s)
A This is when there is a sudden interruption of the train of thought before it is
completed, leaving a blank. The person suddenly stops talking and cannot
recall what he or she has been saying.
B This is when someone believes that the thoughts in their mind are not their
own and that they are being put there by someone else
C This is when someone believes that their thoughts are being read or heard by
others.

D It is when someone believes that thoughts are being removed from their mind
by an outside agency
E Ideas of reference and delusions of reference describe the phenomenon of an
individual's experiencing innocuous events or mere coincidences] and believing
they have strong personal significance.It is "the notion that everything one
perceives in the world relates to one's own destiny.- present in delusional
disorders and schizophrenia
KEY . The key is B. Thought insertion.

Additional Information In which disease you will find this feature?
. It is seen in schizophrenia.
Symptoms called disorders of thought possession may also occur in
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February 17, 2016

schizophrenia. These include:
Thought insertion.
.Thought withdrawal.
Thought broadcasting.
Thought blocking
Reference
Dr Khalid/Rabia

Q:84 A 54yo man has recently been dx with moderate depression. He has hx of MI
and is suffering from insomnia. What is the drug of choice for him?
a. Citalopram (with MI- safest drug)
b. Lofepramine
c. ECT
d. Haloperidol
e. Diazepam

Clincher(s)
A Ssri
B
C NICE recommends ECT is used only to gain rapid (if short-term)
improvement of severe symptoms after an adequate trial of other treatments
has proven ineff ective and/or when the condition is considered to be
potentially
life-threatening, in individuals with: • Severe depression • Catatonia
(eg associated with schizophrenia. • A prolonged or severe manic episode.
Emergency ECT is possible, eg in some elderly patients, but rarely used (but the
success rate is good, eg 80%). Carry on antidepressants when ECT ends: this
may prevent recurrences Typical course length: 6 sessions (2 per week

D Haloperidol - Antipsychotic.
Competitive antagonism of dopamine D2 receptors in the
mesolimbic/mesocortical pathways..
Used in Schizophrenia (less effective against negative symptoms) and other
psychotic states, Mania.,Aggressive behaviour. Tourette’s syndrome.
Adv effect ; . Neuroleptic malignant synd, anti-muscarinic symp

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E Diazepam – benzo diazepene used as Anticonvulsant.

KEY Key is A. Citalopram. [Citalopram is the antidepressant of choice post MI].

Reference
Dr Khalid/Rabia

Q:90 . An 11yo boy is being checked by the diabetic specialist nurse. His HbA1c was
high and he has been skipping meals recently. He has been unhappy at school.
Which single member of the clinical team would you refer him to next?
a. GP
b. Pediatrician
c. Dietician
d. Clinical psychologist

Clincher(s) Unhappy at school, skipping meals
A
B
C
D
E
KEY . The key is D. Clinical psychologist. [Unhappy at school, skipping meals these
are psychological issue. He needs psychological counseling].
There was a discussion on plab forum that the answer should be pediatrician ,
but here the problem is psychological. Had he missed any medication, he
would have had to see pediatrician.

Additional
Information
Reference
Dr Khalid/Rabia
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February 17, 2016

Q: 1567
This condition affects middle aged women more than men and is characterised
by low mood, early morning waking, loss of libido, tiredness and suicidal
intention last for at least 2wks. What
is the most probable dx?
a. Bipolar affective disorder
b. Dysthymia
c. Major depressive disorder
d. Schizoaffective disorder.
e.Recurrent brief depression

Clincher(s) duration of depressive symptoms and suicidal intention last for 2 weeks.
A Bipolar disorder is a chronic episodic illness associated with behavioural

disturbances. It used to be called manic depression. It is characterised by
episodes of mania (or hypomania) and depression. Either one can occur first and
one may be more dominant than the other but all cases of mania eventually
develop depression. Men and women are affected equally.
B Dysthymia (recently classified by DSM-5 as a subtype of persistent depressive

disorder) is a chronic depressive state of more than two years in duration, which
does not meet full criteria for major depression and is not the consequence of a
partially resolved major depression. People with dysthymia are likely to
experience episodes of major depression. Dysthymia increases with age. (milder
symptoms than major depressive)
C major depressive episode is characterized by the presence of a severely

depressed mood that persists for at least two weeks. Severe depression - most
symptoms present and the symptoms markedly interfere with normal function. It
can occur with or without psychotic symptoms.
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D Schizoaffective disorder has features of both schizophrenia and mood disorders
- eg, depression. In order to make the diagnosis, delusions or hallucinations need
to be present for at least two weeks when the mood symptoms are not present.
more in females. Its not a schizophrenia. (not related to schizophrenia)
E Recurrent brief depression (RBD) defines a mental disorder characterized by

intermittent depressive episodes. Phases of normalization.
Key C Major depressive disorder.

Additional
Information
Reference OHCS PG 336, Patient.info

Q: 1611 A 24yo man believes his bowels are blocked and his life is in ruin.
What kind of delusion is he suffering from?
a. Persecutory
b. Factitious
c. Guilt
d. Nihilistic
e. Hypochondriacal

Clincher(s) Bowel obstruction and his life is in ruin.
A Persecutory Delusions- Belief that others, often a vague “they,” are
out to get him or her. These persecutory delusions often involve
bizarre ideas and plots (e.g. "My Wife is trying to poison me with
radioactive particles delivered through my tap water”).
B Factitious disorder
C This is an ungrounded feeling of remorse or guilt of delusional
intensity.
D In PLAB, two types of scenarios will be presented as Nihilistic.

1. Patient thinks he's dead
2. Patient thinks part of his body is dead(upper or lower limbs) or his
bowels are blocked and life is ruined
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E Hypochondriacal dellusions- These are fixed beliefs about a poor state
of health despite convincing medical evidence to the contrary.
KEY D: skype: E?
Additional
Information
Reference
Patient.info, OHCS 316 and PLAB forum.

Q: 1613 A man under psychiatric tx develops GI distress and tremors. Which drug is
most likely to cause these symptoms?
a. Lithium
b. Diazepam
c. Citalopram
d. Clozapine
e. Imipramine

Clincher(s) straightforward question
A Lithium toxicity. GI distress and tremors (coarse or fine)
B
C
D
E
KEY
Additional
Information
Reference

103
February 17, 2016

Q: 1616 A 30yo schizophrenic female attacks her mother believing that aliens have
replaced her with an exact double. What condition is she suffering from?
a. Capgras syndrome
b. Ganser syndrome
c. Todd syndrome
d. Fregoli syndrome
e. Cotard syndrome

Clincher(s) delusion of double, replacement with aliens.
A Capgras syndrome is an irrational belief that a familiar person or place has
been replaced by a duplicate.
B Ganser syndrome is a fictitious disorder in which a patient deliberately acts as

if he has a physical or mental illness when he doesn’t have it. (similar to
malingering where they want some gain)
C Todd syndrome/Alice In Wonderland syndrome/Lilliputian syndrome is a

disorienting neurological condition affecting human perception of size, shape
and time. About other people
D Fregoli syndrome is a delusion of doubles, a delusional belief that different ppl

are infact a single person in disguise or change appearance. (e.g. see other
people and think playing two roles at same time e.g. two sister)
E Cotard’s syndrome/Nihilistic delusions is ‘walking corpse syndrome’, the

person think they are dead or that one of their organs has stopped functioning.
KEY A CAPGRAS SYNDROME

Additional
Information
Reference
Dr Khalid/Rabia DR RABIA NOTES

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February 17, 2016

Q: 1621 A pt comes with weight loss and sleep disturbance has mild
depression. He has a hx of MI. What is the single most appropriate tx?
a. Diazepam
b. ECT
c. Imipramine
d. Lithium
e. Antipsychotics

Clincher(s) Mild depression and MI
A Diazepam is the safest option
B no role in mild depression.
C TCA contracindicated in patients with MI.
D Lithium causes MI.
E No role.
KEY A Diazepam.
Additional (mild depression should not treated with drugs if option there)
Information
Reference
Dr Khalid/Rabia
Q: 1623 A 45yo woman has been extensively investigation for a lump she
believes to be cancer. She doesn’t think doctors take her seriously and
demands another referral. What term best describes her condition?
a. Munchausen syndrome
b. Munchausen’s by proxy
c. Hypochondriasis
d. Malingering
e. Phobia
Clincher(s) h/o extensive investigations.

A Muchausen’s syndrome describes a patient who lies vividly, is
addicted to institutions and goes from hospital to hospital feigning
illnesses hoping for laparotomy or mastectomies.
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B Munchausen’s by proxy defines injury to a dependent person by carer
to gain medical attention. E.g. mother taking child to hospital
attention seeking
C This patient, with her history of extensive investigations or her “fat

folder syndrome” warrant nothing other than the label of being a
Hypochondriac who wants treatment for imaginary illnesses she has
even after being counselled about the severity of her illness.
D Malingering is the creation of a fictitious illness without even the lump

which is present in this case.
E Phobia is a fear of something irrational.
Key C- Hyoochondriasis
Reference Dr Rabia Notes.

Q: 1626 A 40yo divorced man with bipolar affective disorder attends hospital
following an OD of 30 TCA tablets. His new partner has left him and
he has stopped taking his medicine and begun drinking heavily. He
appears depressed, feels hopeless and is ambivalent about being alive.
He is now fit for discharge from the medical ward and acknowledges
the benefits of previous tx. What is the SINGLE most appropriate next
management?
a. Admission to the psychiatry ward

b. Arrange psychiatric outpatient follow-up
c. Discharge to the care of the general practitioner d. Referral to local
alcohol treatment team
e. Referral to clinical psychologist
Clincher(s) Suicidal attempt.

A The patient is high risk on the suicide risk assessment scale and she
needs admission to the psychiatry ward for monitoring and further
evaluation.
B
C
D
E
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February 17, 2016

key A
Reference Dr Rabia Notes.

Q:235 A 37 yo man who has many convictions and has been imprisoned many times
has a hx of many unsuccessful relation ships. He has two sons but he
does not me contact them . What is the m ost p o ssible dx?
a. Borderline personality disorder
b. Schizophrenia
c. Avoidant personality disorder
d. Histrionic personality disorder
e. Antisocial behavior disorder

Clincher(s) H/o crime and unsuccessful relationships.
A Borderline personality disorder: poor impulse control, poor interpersonal
relationships/self-image and unstable affect regulation. e.g, self injury,
sucidality and a difficult life course.(Cluster B- Dramatic and emotional)
B Schizophrenia- Paranoid, schizoid (cold, aloof, introspective), schizotypal. (

Cluster A personality- odd and eccentric)
C Avoidant personality disorders associated with anxiety disorders, especially
social phobia. (Cluster C personality- fearful and anxious)
D Histrionic personality disorder is often associated with somatoform disorders.
They are usually self centred, sexually provocative who enjoys angry
scenes.(Cluster B)
E Antisocial personality disorder increases the risk for anxiety disorders,

substance abuse, somatisation disorder and pathological gambling. They violate
the rights of others and rules of society.(Cluster B)
Correct answer is E
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February 17, 2016

Additional • Antisocial personality disorder is one of nine personality disorders defined in
Information the Diagnostic and Statistical Manual of the American Psychiatric
Association, 4th Edition (DSM-IV).
• Many people with antisocial personality disorder have a criminal conviction
and are imprisoned or die prematurely as a result of reckless behaviour.
• Psychotherapy is at the core of care for personality disorders generally.
Reference oxford handbook of clinical specialities PG 366, Patient.info.

Q:240 A young female who has many superficial lacerations was brought into the ED
by her boyfriend for superficially lashing her upper arm. She is adamant and
screaming that she is not suicidal but scared her boyfriend who wants to leave
her. What is the dx?
a. Acute psychosis
c. Obsessive
d. Bipolar
e. Borderline personality
f. Schizophrenia

Clincher(s) h/o superficial lacerations and relationship issue.
A Acute psychosis include disabling symptoms of delusion and hallucinations. It
occurs in many psychiatric disorders including schizophrenia, bipolar disorder,
depression.
B Depression refers to both negative affect (low mood) and/or absence of positive
affect (loss of interest and pleasure in most activities) and is usually
accompanied by an assortment of emotional, cognitive, physical and behavioural
symptoms.
C Obsessive-compulsive disorder (OCD) may be characterised by the presence of

obsessions or compulsions but commonly both.
D Bipolar disorder is a chronic episodic illness associated with behavioural

disturbances. It used to be called manic depression. It is characterised by
episodes of mania (or hypomania) and depression.
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E Patients with the borderline personality disorder can present with:
• Relationship difficulties
• Recurrent self-harm
• Threats of suicide
• Depression
• Bouts of anger
• Impulsivity
• Social difficulties
• Transient psychotic symptoms.
F Schizophrenia patient presents with the following symptoms

• Delusions
• Hallucinations
• Thought disorder
• Lack of insight
KEY Borderline personality disorder. (Patient has insight as she is threatening

suicide but doesn’t want to: otherwise would be severe depression if actually
suicidal: see Samson notes)
Additional
Information
Reference Oxford handbook of clinical specialities PG 366, patient.info

Q:241 A 22yo woman was brought by her boyfriend with multiple superficial
lacerations. There are scars of old cuts on her forearms. She is distressed
because he wants to end the relationship.
She denies suicide. What is the most likely dx?
a. Acute psychosis
b. Borderline personality disorder
d. Schizoid personality
e. Psychotic depression.

Clincher(s) h/o multiple superficial lacerations.
A Acute psychosis include disabling symptoms of delusion and hallucinations. It
occurs in many psychiatric disorders including schizophrenia, bipolar disorder,
depression.
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February 17, 2016

B Patients with the borderline personality disorder can present with:
• Relationship difficulties
• Recurrent self-harm
• Threats of suicide
• Depression
• Bouts of anger
• Impulsivity
• Social difficulties
• Transient psychotic symptoms.
C Depression refers to both negative affect (low mood) and/or absence of positive
affect (loss of interest and pleasure in most activities) and is usually
accompanied by an assortment of emotional, cognitive, physical and behavioural
symptoms
D Schizophrenia- Paranoid, schizoid(cold, aloof, introspective), schizotypal.(

Cluster A- odd and eccentric)
E Along with depressive symptoms, these patients also presents with
halluccination and delusions.
KEY B-Borderline personality disorder.
Additional
Information
Reference OHCSpeciality PG 366

Q:242 A 31yo single man lives with his mother. He usually drives to work. He always
thinks when the traffic lights change to green, his mother is calling him, so he
drives back home. What is the dx?
a. OCD
b. GAD
c. Schizophrenia
d. Bipolar
e. Cyclothymia

Clincher(s) H/o dellusion that his mother calling him.
A Obsessive-compulsive disorder (OCD) may be characterised by the presence of
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February 17, 2016

B
C Delusion of reference.
D
E Cyclical mood swings without the more florid features (as above) are termed
cyclothymia.
KEY C- Schizophrenia
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February 17, 2016

Additional Schizophrenia is a common chronic/relapsing condition often presenting in late
Information teens/early 20s with psychotic symptoms (hallucinations, delusions); dis-
organization symptoms (incongruous mood, abnormal speech and thought);
negative symptoms (apathy, self-neglect, blunted mood, motivation, with-
drawal); and, sometimes, cognitive impairment.Schizophrenia is the most
common form of psychosis. It is a lifelong, condition, which can take on either a
chronic form or a form with relapsing and remitting episodes of acute illness.
Multiple factors are involved in schizophrenia - eg, genetic, environmental and
social. Risk factors include family history, intrauterine and perinatal
complications,Intrauterine infection, particularly viral, Abnormal early
cognitive/neuromuscular development etc.
Features: The hallmark symptoms of a psychotic illness are:

Delusions,Hallucinations (auditory hallucination like two or more voices
discussing the patient in the third person,thought echo,voices commenting on the
patient's behaviour), Thought disorder (thought insertion,thought withdrawal,
thought broadcasting), Lack of insight.
These “first Rank” or positive symptoms of schizophrenia are absent in other

psychotic disorders.
NICE published guidelines on the management of schizophrenia in 2009.

Key points:
oral atypical antipsychotics are first-line Examples of atypical antipsychotics

clozapine, olanzapine,risperidone,quetiapine,amisulpride.
adverse effects:
weight gain ,clozapine is associated with agranulocytosis. close attention should

be paid to cardiovascular risk-factor modification due to the high rates of
cardiovascular disease in schizophrenic patients (linked to antipsychotic
medication and high smoking rates).
Reference OHCSpeciality PG 356, Dr Rabia Notes.

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Q:249 A nurse comes to you saying that she has recently developed the habit of
washing her hands after every 15-20 mins. She is unable to conc on her work
and takes longer than before to finish tasks as she must constantly washing her
hands. What is the most appropriate management?
a. CBT
b. SSRI
c. ECT
d. Antipsychotics
e. Desensitization

Clincher(s) Repititive actions-hand washing.
A CBT is first line.
B Clomipramine (start with 25mg/day PO) or SSRIs (eg fluoxetine) are second
line.
C ECT is offered in severe psychosis.

D Antipsychotics for schizophrenia
E Desensitization is done in Post-traumatic stress disorder.
KEY A-CBT
Additional
Information

Reference OHCS PG 346
Dr Khalid/Rabia

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February 17, 2016

Q: 255 A 28yo business man came to the sexual clinic. He was worried that he has HIV
infection. 3 HIV tests were done and all the results are negative. After a few
months, he comes back again and claims that he has HIV. What is the dx?
a. Somatization
b. Hypochondriac
c. Mancheusens
d. OCD
e. Schizophrenia

Clincher(s)
A Somatization disorder: characterised by occurrence of chronic multiple somatic
symptoms for which there is no physical cause. They do have multiple
cluster of symptoms
B Hypochondriasis: Patients have a strong fear or belief that they have a serious
often fatal disease that persists despite appropriate medical reassurance.
C Mancheusens syndrome: Severe chronic form of factitious disorder usually

older males who travel widely sometimes in several hospitals in one day.
They are convincing enough to persuade doctors to undertake
investigations but no underlying condition is found. Previous similar
hospital visits can be traced.
D not significant
E not signiticant
Key B Hypochondriasis
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Additional . Somatoform disorders consists of a group psychiatric illnesses in which
Information patients either feel or make up signs and symptoms without existence of
an organic disease. It includes the following disorders :
Somatization disorder : Characterised by occurrence of chronic
multiple somatic symptoms for which there is no physical cause.
Hypochondriasis : Patients have a strong fear or belief that they have a
serious often fatal disease that persists despite appropriate medical
reassurance. (like in this case). Body dysmorphic disorder : A
preoccupation with bodily shape or appearance with belief that one is
disfigured in some way.
Dissociative (conversion) disorder : Characterised by loss or distortion
of neurological function not fully explained by organic disease.
Previously known as Hysteria. Somatoform Pain disorder: Severe,
persistent pain which cannot be explained by medical condition.
Munchausen’s syndrome : Severe chronic form of factitious disorder
usually older males who travel widely sometimes in several hospitals in
one day. They are convincing enough to persuade doctors to undertake
investigations but no underlying condition is found. Previous similar
hospital visits can be traced.
This cannot be Schizophrenia because of absence of specific symptom
featuring in schizophrenia.
Reference Dr Rabia Notes

Q:264 A 34yo woman presents 3 weeks after childbirth. She has had very low mood
and has been suffering from lack of sleep. She also has thought of harming her
little baby. What is the most appropriate management for this pt?
a. ECT
b. CBT
c. IV haloperidol
d. Paroxethine
e. Amitryptiline
Clinchers Postpartum time and depression, intention of harming baby.

A Best treatment for postpartum psychosis.
B CBT is not helpful when there is an ideation of harming baby.
C Psychosis in Schizophrenia
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February 17, 2016

D SSRI
E Tricyclic antidepressant.
KEY A-ECT
Additional
Information

Reference Patient.info

Q:433 A 30yo man complains of episodes of hearing music and sometimes
threatening voices within a
couple of hours of heavy drinking. What is the most likely dx?
a. Delirium tremens
b Wernicke’s encephalopathy
c. Korsakoff’s psychosis
d. Alcohol hallucinosis
e. Temporal lobe dysfunction

Clincher(s)
A Delerium Tremens - Symptoms of visual, auditory, and tactile hallucinations
are indicative of late-stage withdrawal (36-72 h), the stage associated with
delirium tremens and a mortality rate of 5-15%.
B Wernick’s Encephalopathy- Thiamine deficiency – Confusion Ataxia ,
Opthalmoplegia.
C Korsakoff’s psychosis- Complication of WE ( Glucose administered after
Thiamine if needed)
D Alcoholic Hallucinosis- In withdrawal, auditory hallucinations can be indicative
of early-stage withdrawal (6-24 h), the stage associated with withdrawal
seizures
E Temporal Lobe Dysfunction- 1) disturbance of auditory sensation and
perception, 2) disturbance of selective attention of auditory and visual input,
3) disorders of visual perception, 4) impaired organization and categorization
of verbal material, 5) disturbance of language comprehension, 6) impaired
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February 17, 2016

long-term memory, 7) altered personality and affective behavior, 8) altered
sexual behavior.
Causes- Traumatic brain injury
• Infections, such as encephalitis or meningitis, or history of such infections

• A process that causes scarring (gliosis) in a part of the temporal lobe called
the hippocampus
• Blood vessel malformations in the brain
• Stroke
• Brain tumors
• Genetic syndromes

Mayo Clinic
KEY D
Dr. Khalid: Ans. The key is D. Alcoholic hallucinosis. [Alcohol hallucinosis can occur during acute
intoxication or withdrawal. It involves auditory and visual hallucinations, most commonly
accusatory or threatening voices. Source: Wikipedia].
Additional OHCM- 728Wernick’s Encephalopathy-
Information
Reference
Dr Khalid/Rabia *Alcohol withdrawal presents in the following stages:
-Minor withdrawal symptoms- [Appear 6-12 hours after alcohol has stopped.]
Insomnia, tremors, mild anxiety, mild agitation or restlessness, nausea,
vomiting, headache, excessive sweating, palpitations, anorexia, depression and
craving.

-Alcohol hallucinosis- Visual, auditory or tactile hallucinations that can occur
either during acute intoxication or withdrawal. During withdrawal, they [occur
12-24 hours after alcohol has stopped.]

-Withdrawal seizures are generalized tonic-clonic seizures that [appear 24-48
hours after alcohol has stopped.]

-Delirium tremens appears [48-72 hours after alcohol has stopped]. Altered
mental status in the form of confusion, delusions, severe agitation and
hallucinations. Seizures can occur. Examination might reveal stigmata of
chronic alcoholic liver disease.

• Investigation: FBC, LFTs, clotting, ABG to look for metabolic acidosis,
Glucose, blood alcohol levels, U&E, creatinine, amylase, CPK and blood
culture. CXR to check for aspiration pneumonia. CT scan if seizures or
evidence of head trauma. ECG-arrhythmia.

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• Management of alcohol withdrawal-
1. ABC
2. Treat hypoglycemia
3. Sedation: Benzodiazepine (chlordiazepoxide). Alternative- diazepam.
4. Carbamezapine or Mg if history of withdrawal seizures.
5. IV Thiamine to prevent or treat Wernicke’s encephalopathy that might
lead to korsakoff syndrome. Give THIAMINE FIRST.

*Wernicke’s encephalopathy- Triad of ataxia, ophthalmoplegia and mental
confusion). If left untreated, leads to Korsakoff’s syndrome (Wernicke’s plus
confabulation, antero or retrograde amnesia and telescoping of events)
>Investigations: FBC (^MCV), LFTs, Glucose, U&E (^Na, ^Ca, ^Uricaemia), ABG
(^Carbia and Hypoxia), Serum thiamine (low).

Q:436 A schizophrenic pt hears people only when he is about to fall asleep. What is
the most likely dx?
a. Hypnopompic hallucinations
b. Hyponogogic hallucinations
c. Hippocampal hallucinations
d. Delirious hallucinations
e. Auditory hallucinations

Clincher(s)
A Hypnopompic hallucinations- While waking up
B Hyponogogic hallucinations- While falling asleep
C Hippocampal hallucination- Photographic, animated or film-like clarity of
people, animals, faces, flowers, insects etc
D
E Auditory hallucinations- hearing voices that aren’t present

KEY B
Additional
Information
Reference
Dr Khalid/Rabia IN KEYS

Q: 450 A 32yo man has OCD. What is the best tx?
a. CBT
b. SSRI
c. TCA
d. MAO inhibitors
e. Reassure
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February 17, 2016

Clincher(s)
A CBT
B SSRI
C TCA
D MAO inhibitors
E Reassure
KEY B ( WRONG KEY) CORRECT SEEMS A
Additional OCD is treated initially with individual CBT (Cognitive Behavioural therapy) plus
Information exposure and response prevention. If symptoms become severe or do not
improve, SSRIs like fluoxetine or Citalopram etc are introduced. Recent studies
have shown that there is no superiority of one over the other (CBT over SSRIs),
but CBT remains the initial management plan, This question is quite deficient,
and the original key is B. SSRI, but I’m sure in the exam, it will be more
detailed; but this is how OCD is managed. Reference: Patient.co.uk. Link-
http://patient.info/doctor/obsessive-compulsive-disorder-pro
Obsessive-compulsive disorder (OCD) may be characterised by the presence of

• Obsessions are unwanted intrusive thoughts, images or urges that

repeatedly enter the person's mind.
• Compulsions are repetitive behaviours or mental acts that the person
feels driven to perform. They can be overt (observable by others) - eg,
checking a door is locked; or they can be covert - eg, a mental act that
cannot be observed, such as repeating a certain phrase in one's mind.
Epidemiology[1]
Studies vary but the figure for prevalence ranges from 0.8-3% in adults and
0.25-2% in children and adolescents. Onset is most commonly in late
adolescence and early twenties but can occur at any age.
Aetiology[2]
Aetiology seems to be multifactorial, involving several possible components:
• Genetic. Twin studies suggest a genetic predisposition.[3]

• Developmental factors. Abuse or neglect, social isolation, teasing or
bullying may predispose.
• Psychological factors. Personality characteristics maintain OCD.
• Stressors/triggers. A common stressor is pregnancy or the postnatal
period.
• Neurological conditions. Occasionally OCD is a presenting sign of a
neurological condition such as a tumour or frontotemporal dementia,
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or the result of trauma to the brain.
Presentation
Diagnostic criteria
The International Classification of Diseases 10th Edition (ICD-10) definition of

OCD applies the following criteria:[4]
• Either obsessions or compulsions (or both) must be present on most

days for a period of at least two weeks.
• They are acknowledged as originating in the mind of the patient and
are not imposed by outside persons or influences.
• They are repetitive and unpleasant and at least one obsession or
compulsion must
be present that is acknowledged as excessive or unreasonable.
• The subject tries to resist them (but if very long-standing, resistance to
some obsessions or compulsions may be minimal). At least one
obsession or compulsion must be present which is unsuccessfully
resisted.
• Carrying out the obsessive thought or compulsive act is not in itself
pleasurable.
• The obsessions or compulsions cause distress or interfere with the
subject's social or individual functioning, usually by wasting time.
Associated diseases[2]
There are frequently comorbid conditions, namely one of the following:
• Depression.
• Social and other phobias.
• Alcohol misuse.
• General anxiety disorder.
• Body dysmorphic disorder (BDD).
• Eating disorders.
• Schizophrenia.
• Tourette's syndrome.
• Autistic spectrum disorder.
Assessment[5]
People with OCD often do not volunteer their symptoms spontaneously and it
is likely that there is under-diagnosis of this condition. Assessment should
include the following elements:
• Identify cases - for patients at risk of OCD (depression, anxiety, BDD,
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substance misuse or eating disorder), ask the following questions:
o Do you wash or clean a lot?
o Do you check things a lot?
o Is there any thought that keeps bothering you that you would
like to get rid of but cannot?
o Do your daily activities take a long time to finish?
o Are you concerned about putting things in a special order or are
you very upset by mess?
o Do these problems trouble you?
• Assess severity, ie how much it is affecting the patient's ability to
function in everyday life. National Institute for Health and Care
Excellence (NICE) guidance bases management guidelines on degree of
severity but does not specify how this should be assessed. Essentially
assess the effect the condition has on quality of life, school or work,
relationships and social life. Rating scales such as the Yale-Brown
Obsessive Compulsive Scale may be used.[1]
• Assess the risk of self-harm or suicide and the presence of comorbidity
such as depression.
• Arrange referral to appropriate secondary care provision.
• Ensure continuity of care to avoid multiple assessments, gaps in service
and a smooth transition from child to adult services (many patients
have lifelong symptoms).
• Promote understanding - make patients/families aware of the
involuntary nature of symptoms. Consider patient information leaflets,
contact numbers of self-help groups, etc.
• Consider the bigger picture - cultural, social, emotional and mental
health needs.
• If the patient is a parent, consider child protection issues.
Management in adults[1][5]
NICE recommends referral to a specialist multidisciplinary team offering age-

appropriate care.
Mild functional impairment
People with mild functional impairment can be successfully managed with low-
intensity psychological treatment. A psychological intervention should be
recommended as first-line therapy. This is accessed by referral or self-referral
to the Improving Access to Psychological Therapies (IAPT) scheme. Options for
therapy include:
• Individual cognitive behavioural therapy (CBT) plus exposure and

response prevention (ERP).
• Individual CBT and ERP by telephone or internet.
• Group CBT.
• A couples-based course, which has been developed for patients in long-
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term relationships.[6]
If the person has been unable to engage in low-intensity CBT (including ERP) or
the response is inadequate then offer the choice of a selective serotonin
reuptake inhibitor (SSRI) or higher-intensity psychological therapy. (Higher
intensity essentially refers to the level of hours of input of therapy.)
Moderate functional impairment
Those with moderate functional impairment should be offered a choice

between high-intensity CBT and ERP (more than 10 hours per patient) or an
SSRI. Clomipramine may also be used as an alternative to an SSRI.
Severe functional impairment
Those with severe functional impairment should be offered high-intensity

psychological therapy plus an SSRI.
Evidence comparing treatment options
• Cochrane reviews have determined psychological therapies to be

effective in OCD, although have not been able to recommend one
specific technique.[7] Likewise, SSRIs have been shown to have efficacy
over placebo but no evidence supports one over another or shows
superiority between SSRIs and psychological therapies.[8]
• Studies show psychological therapies such as CBT delivered by phone
or internet to be effective.[9][10]
• One randomised comparative trial concluded that group CBT was an
effective treatment but did not exclude the possibility that individual
therapy was superior.[11]
• One study found that two prominent features of OCD - overestimations
of danger and inflated beliefs of personal responsibility - benefited
equally from CBT.[12]
• Inference-based treatment (IBT) is a method of psychological treatment
sometimes used as an adjunct to CBT in OCD patients with obsessional
doubt.[13]
• ERP is a technique in which patients are repeatedly exposed to the
situation causing them anxiety (eg, exposure to dirt) and are prevented
from performing repetitive actions, which lessens that anxiety (eg,
washing their hands). Efficacy has been demonstrated in
studies.[14][15] This method is only used after extensive counselling and
discussion with the patient who knows fully what to expect. After an
initial increase in anxiety, the level gradually decreases. The patient
feels that they have confronted their worst fears without anything
terrible happening. One study found that, providing there was
adherence to a standardised treatment manual, the experience (or
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inexperience) of the therapist did not affect the outcome.
Management in children[1][5]
• Mild dysfunction : offer guided self-help along with support and

information for the family or carers. If this fails, or if it is unavailable
locally, refer to Children and Adolescents Mental Health Services
(CAMHS).
• Moderate-to-severe: refer to CAMHS. Psychological therapy will be
with CBT/ERP as for adults but should involve family/carers. It may be
individual or group therapy, depending on the preference of the
patient. CBT has been shown to be effective in children for OCD and
other associated disorders.[16][17] Furthermore, CBT may be more
effective than SSRI treatment.[18]
• If psychological treatment fails, factors which might require other
interventions may be involved - eg, co-existence of comorbid
conditions, learning disorders, persisting psychosocial risk factors such
as family discord, presence of parental mental health problems.
• Pharmacotherapy: in children over the age of 8, adding an SSRI might
be appropriate, following a multidisciplinary review. In children under
the age of 18, an SSRI should only be prescribed after assessment by a
specialist psychiatrist for this age group (but see below concerning
safety issues).
Using selective serotonin reuptake inhibitors[5]
See also the separate Selective Serotonin Reuptake Inhibitors article.
SSRIs in adults
• There is a range of potential side-effects (see individual drugs),

including worsening anxiety, suicidal thoughts and self-harm, which
need to be carefully monitored, especially in the first few weeks of
treatment. Caution is advised in view of increased risk of suicidal
thoughts and self-harm in people with depression.
• In high-risk patients, prescribe limited quantities, keep in contact
especially during the first few weeks and actively monitor for akathisia
(restlessness and the urge to move), suicidal ideation, agitation and
increased anxiety.
• NICE recommends fluoxetine, fluvoxamine, paroxetine, sertraline or
citalopram. There are no significant differences in efficacy.
• There is commonly a delay in onset of up to 12 weeks, although
depressive symptoms improve more quickly.
• When prescribing, provide written supporting material.
• If there is no response to a standard dose, check compliance, check
interaction with drugs and alcohol, then consider titrating to a
maximum dose according to the Product Characteristics.
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• Monitor all patients around the time of dosage changes.
• Continue for at least twelve months from remission and withdraw
gradually.
• There is a risk of discontinuation/withdrawal symptoms on stopping
the drug, missing doses, or reducing the dose.
• Clomipramine may be used as an alternative if the person is intolerant
of SSRIs, if at least one SSRI has been ineffective, or if they have
previously responded successfully to clomipramine.
SSRIs in children and young people (8-18 years)
• Caution is advised, as there is a risk of self-harm or suicide in patients

with depression. Only prescribed by specialists, in conjunction with
psychological therapy following assessment by a child and adolescent
psychiatrist who should also be involved in dosage changes and
discontinuation.
• Sertraline and fluvoxamine are the only SSRIs licensed for this use,
unless significant co-existing depression is evident, in which case
fluoxetine should be used.
• Discuss adverse effects, dosage, monitoring, etc with the
patient/family/carers, as per adults (see above).
• SSRIs should only be prescribed in conjunction with CBT.
Treatment failures[14]
The following are in conjunction with specialist assessment and

multidisciplinary review:
• Try another SSRI.

• Consider change to clomipramine; however, there is a greater tendency
to produce adverse effects. Do baseline ECG and check BP. Start with a
small dose, titrate according to response and monitor regularly.
• Antipsychotics are sometimes used to augment the effect of an SSRI.
There is evidence for haloperidol, risperidone and aripiprazole.
• Intensive inpatient therapy or residential/supportive care may
occasionally be needed for people with chronic severe dysfunction.
• Neurosurgery may be considered for severely ill patients who do not
respond to CBT and medication. Risks, benefits, long-term
postoperative management and patient selection should all be carefully
considered before embarking on treatment. Patient selection can be
improved by the use of neuroimaging.[19] Anterior capsulotomy is the
traditional procedure.
• Deep brain stimulation is currently being explored and has shown
promise.[20]
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Reference
Dr Khalid/Rabia REF ABOVE

Q:451 A 65yo woman says she died 3m ago and is very distressed that nobody has
buried her. When she is outdoors, she hears people say that she is evil and
needs to be punished. What is the most likely explanation for her symptoms?
a. Schizophrenia
b. Mania
c. Psychotic depression (nihilistic delusion more common)
d. Hysteria
e. Toxic confusional state

Clincher(s)
A Schizophrenia- People with other mental illnesses, such as schizophrenia, also
experience psychosis. But those with psychotic depression usually have
delusions or hallucinations that are consistent with themes about depression
(such as worthlessness or failure), whereas psychotic symptoms in
schizophrenia are more often bizarre or implausible and have no obvious
connection to a mood state (for example, thinking strangers are following
them for no reason other than to harass them). People with psychotic
depression also may be humiliated or ashamed of the thoughts and try to hide
them. Doing so makes this type of depression very difficult to diagnose.
B Mania- IRRITABILITY , EUPHORIA, LABILITY, COGNITION, BEHAVIOUR,
PSYCHOTIC SYMPTOMS, HYPOMANIA,BPD, CYCLOTHYMIA, Bipolar mania,
hypomania, and depression are symptoms of bipolar disorder. The dramatic
mood episodes of bipolar disorder do not follow a set pattern -- depression
does not always follow mania. A person may experience the same mood state
several times -- for weeks, months, even years at a time -- before suddenly
having the opposite mood. Also, the severity of mood phases can differ from
person to person.
Hypomania is a less severe form of mania. Hypomania is a mood that many

don't perceive as a problem. It actually may feel pretty good. You have a
greater sense of well-being and productivity. However, for someone with
bipolar disorder, hypomania can evolve into mania -- or can switch into serious
depression

C Psychotic depression- Psychotic depression is a subtype of major depression
that occurs when a severe depressive illness includes some form of psychosis.
The psychosis could be hallucinations (such as hearing a voice telling you that
you are no good or worthless), delusions (such as, intense feelings of
worthlessness, failure, or having committed a sin) or some other break with
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reality. Psychotic depression affects roughly one out of every four people
admitted to the hospital for depression
D Hysteria- Types of dissociation Amnesia is the commonest type: see BOX.
Depersonalization:Feeling of being detached from one’s body or ideas, as if
one were an outsider, observing the self; “I’m in a dream” or “I’m an
automaton” (unrelated to drugs/alcohol) eg from stress.
Dissociative identity disorder: The patient has multiple personalities which
interact in complex ways. It is present in 3% of acute psychiatric inpatients.
Fugue: Inability to recall one’s past .loss of identity or formation of a new
identity, associated with unexpected purposeful travel (lasts hours to
months, and for which there is no me)
E Toxic confusional state-
KEY C
Additional
Information Psychotic depression consists of a major depressive episode plus psychotic
symptoms like hallucinations or delusions (in this case nihilistic delusions).
Toxic confusional state can be eliminated since there is no history of infection.

Reference
Dr Khalid/Rabia REF

Q: 462 An 18yo previously well student is in his 1st year at uni. He has been brought
to the ED in an agitated, deluded and disoriented state. What is the most
probable reason for his condition?
a. Drug toxicity
b. Delirium tremens
c. Infection toxicity
d. Electrolyte imbalance
e. Head injury

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Clincher(s)
A Drug toxicity- TEENAGE, FIRST YEAR AT UNI
B Delirium tremens- ALCOHOL RELATED
C Infection toxicity- NO HISTORY, The symptoms of toxic shock syndrome (TSS)
normally begin with a sudden high fever (body temperature rises above
38.9C/102F).
Other symptoms then rapidly develop, normally in the course of a few hours.
They may include:
• flu-like symptoms including headache, muscle aches, sore throat and

cough
• nausea and vomiting
• diarrhoea
• fainting or feeling faint
• dizziness or confusion
A widespread sunburn-like skin rash may also occur, with the whites of the
eyes, lips and tongue becoming more red than usual.
One or two weeks after the rash appears, it is common that the skin begins to
shed in large sheets, especially from the palms of the hands and soles of the
feet.
People with streptococcal TSS may also have the symptoms of a serious
streptococcal infection. For example, pain in the muscles, abdominal pain
(such as after childbirth) or cough

D Electrolyte imbalance- NO ILLNESS
E Head injury NOT IN HISTORY
KEY A
Additional
Information Clinchers are teenage, and 1st year of university, where students tend to
experiment with drugs.
Infection toxicity can be ruled out due to lack of any signs of infection like
fever. Lack of history of trauma rules out head injury, and delirium tremens is
due to alcohol withdrawal.

Reference
Dr Khalid/Rabia

Q:470 . A 40yo woman has had intermittent tension, dizziness and anxiety for
4months. Each episode usually resolves after a few hours. She said she takes
alcohol to make her calm. She is in a loving relationship and has no probs at
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work or home. What is the next step in her management?

Clincher(s)
A Collateral info

B CT brain

C CBC

D LFT

E TFT

KEY KEY- A Collateral info. Likely diagnosis is panic disorder. Collateral info from
family, friends & other peers should be asked to find out the cause for her
anxiety
Additional Classifying anxietyDSM-IV
Information • Generalized anxiety disorder (GAD): anxiety +3 somatic symptoms and
present for ≥6 months
• Panic disorder
• Phobia, eg agoraphobia
• Post-traumatic stress disorder
• Social anxiety disorder
• Obsessive–compulsive disorder
Reference
Dr Khalid/Rabia Ref OHCS-361

Q:472 A 71yo woman looks disheveled, unkempt and sad with poor eye contact. She
has recently lost her husband. Which of the following describes her condition?
a. Anxiety
b. Hallucination
c. Mania
d. High mood
e. Low mood

Clincher(s)
A Anxiety
B Hallucination
C Mania
D High mood
E Low mood
KEY E
Additional Dx- Depression. Disheveled and unkempt because she doesn’t take care of
Information herself, plus the loss of her husband, points towards depression
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Reference
Dr Khalid/Rabia REF

Q:480 A 23yo man comes to the ED with a hx of drug misuse. He recognizes that he
has a prb and is willing to see a psychiatrist. Which of the following terms best
describes this situation?

Clincher(s)
A Judgement
B Thought insertion
C Thought block
D Mood
E Insight
KEY E
Additional Insight is the patient's awareness and understanding of the origins and
Information meaning of his attitudes, feelings, and behavior and of his disturbing
symptoms, basically, he is aware that he has a problem
Reference
Dr Khalid/Rabia REF

Q: 492. A 40yo woman presents to the GP with low mood. Of note, she has an
increased appetite and has gone up a dress sizes. She also complains that she
can not get out of bed until the afternoon.

Clincher(s)
A Pseudo depression
B Moderate depression
C Severe depression
D Dysthymia
E Atypical depression
KEY
Additional Atypical depression is a subtype of major depression or dysthymic disorder
Information that involves several specific symptoms, including increased appetite or weight
gain, hypersomnia, marked fatigue or weakness, moods that are strongly
reactive to environmental circumstances, and feeling extremely sensitive to
rejection, or feeling of being weighed down, paralyzed, or "leaden”.

Reference
Dr Khalid/Rabia

129
February 17, 2016

Q:501 A 20yo boy is brought by his parents suspecting that he has taken some drug.
He is agitated, irritated and can’t sleep. Exam: perforated nasal septum. Which
of the following is the most likely to be responsible for his symptoms?

Clincher(s)
A Heroine-pinpoint pupils, decreased consciousness, bradycardia, respiratory
depression, hypoxia. antidote: naloxone
B Cocaine- Nasal Septal Perforation
C Ecstasy/MDMA/amphetamine- agitation, anxiety, confusion, ataxia,
tachycardia, hypertension, hyponatraemia, hyperthermia, rhabdomyolysis
D Alcohol
E Opioids
KEY
Additional Causes of septal perforation After septal surgery trauma; nose picking; body
Information piercings; nasal prongs (O2 delivery); sniffi ng chrome salts or cocaine;
malignancies (eg rodent ulcer); nasal steroid/decongestant sprays, any chronic
mucosal infl ammation/granuloma—eg TB; syphilis; HIV, extra-GI Crohn’s;
sarcoidosis; SLE; granulomatosis with polyangiitis; relapsing polychondritis
(chondritis in auricles, nose and trachea } non-erosive polyarthritis, eye infl
ammation, and vestibular or cochlear damage; it may be fatal).Perforations
irritate, whistle, crust, and bleed.
Reference Ohcs 577
Dr Khalid/Rabia

Q:511 A 26yo woman had bipolar disorder for 10yrs and is on Lithium for it. She is
symptom free for the past 4 years. She is now planning her pregnancy and wants to
know whether she should continue taking lithium. What is the single most
appropriate advice?
a. Continue lithium at the same dose and stop when pregnancy is confirmed
b. Continue lithium during pregnancy and stop when breast feeding
c. Reduce lithium dosage but continue throughout pregnancy
d. Reduce lithium gradually and stop when pregnancy is confirmed
e. Switch to sodium valproate

Clincher(s)
A Continue lithium at the same dose and stop when pregnancy is confirmed
B Continue lithium during pregnancy and stop when breast feeding
C Reduce lithium dosage but continue throughout pregnancy
D Reduce lithium gradually and stop when pregnancy is confirmed
E Switch to sodium valproate
KEY D
Additional symptom free for last 4 years. Lithium is teratogenic.
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Information Adverse effects
• nausea/vomiting, diarrhoea
• fine tremor
• polyuria (secondary to nephrogenic diabetes insipidus)
• thyroid enlargement, may lead to hypothyroidism
• ECG: T wave flattening/inversion
• weight gain

Monitoring of patients on lithium therapy
• inadequate monitoring of patients taking lithium is common - NICE and the
National Patient Safety Agency (NPSA) have issued guidance to try and
address this. As a result it is often an exam hot topic
• lithium blood level should 'normally' be checked every 3 months. Levels
should be taken 12 hours post-dose
• thyroid and renal function should be checked every 6 months
• Pregnancy: avoid in first the trimester (teratogenic). Only use in the second
and third trimester if considered essential, ie a severe risk to the patient,
and monitor levels closely, as dose requirements may alter.
• Breast-feeding: avoid, as present in milk, and there is risk of toxicity in an
infant. Bottle-feeding is advisable.
Withdrawal
Abrupt withdrawal (both because of poor compliance or rapid change in dose) can
precipitate relapse. Withdraw lithium slowly over several weeks, watching for
relapse.

Reference
Dr Khalid/Rabia REF
Q:526 A 34yo man with MS has taken an OD of 100 tablets of paracetamol with intent to
end his life.
He has been brought to the ED for tx but is refusing all intervention.

Clincher(s)
A Assessment
B Evaluate pt’s capacity to refuse tt
C Establish if pt has a prv mental illness
D
E
KEY B
Additional Consent not needed when urgent treatment is required:
Information · To save the patient's life.
· To prevent a serious deterioration in the patient's condition, so long as the
treatment is not irreversible.
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· To alleviate serious suffering so long as the treatment is neither irreversible nor
hazardous.
· To prevent the patient from behaving violently or being a danger to self or others
so long as the treatment is neither irreversible nor hazardous, and represents the
minimum interference necessary.

Reference
Dr Khalid/Rabia
Q: 521 A 22yo man has rushed into the ED asking for help. He describes recurrent
episodes of fearfulness, palpitations, faintness, hyperventilation, dryness of the
mouth with peri-oral tingling and cramping of the hands. His symptoms last 5-10
mins and have worsened since their onset 3months ago. He is worried he may be
having a heart attack. An ECG shows sinus
tachycardia. What is the single most appropriate immediate intervention?
a. High flow oxygen
b. IV sedation
c. Rebreathe into a paper bag
d. Refer for anxiety management course
e. Refer for urgent cardiology opinion

Clincher(s) HYPERVENTILATION
A High flow oxygen
B IV sedation
C Rebreathe into a paper bag
D Refer for anxiety management course
E Refer for urgent cardiology opinion
KEY c
Additional Symptoms of anxiety: Tension, agitation; feelings of impending doom, trembling; a
Information sense of collapse; insomnia; poor concentration; ‘goose fl esh’; ‘butterfl ies in the
stomach’; hyperventilation (so tinnitus, tetany, tingling,
chest pains); headaches; sweating; palpitations; poor appetite; nausea; ‘lump in
the throat’ unrelated to swallowing (globus hystericus); diffi culty in getting to
sleep; excessive concern about self and bodily functions; repetitive
thoughts and activities (p346). Children’s symptoms: Thumb-sucking; nail-biting;
bed-wetting; foodfads.

Symptoms HYPERVENTILATION
• The complaint is usually of a paroxysmal rather than a continuous nature,

although chronic hyperventilation can occur.
• The patient may complain of shortness of breath when an attack occurs.
• Pain or discomfort in the chest is common.
• Paraesthesiae usually affects both arms. The complaint is often of
numbness or tingling in the fingers and sometimes toes.
• Other symptoms include:
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February 17, 2016

o Dizziness.
o Perioral tingling.
o Weakness.
o Tinnitus.
o Palpitations.
o Feeling of choking or suffocation.
o Wheezing.
o Sweating.
o Loss of consciousness (uncommon
Management
Anxiety can cause hyperventilation, producing symptoms that are interpreted as

indicating serious physical illness. This causes more hyperventilation, worse
symptoms and a vicious circle. Careful explanation of the nature of the condition is
needed. Patients may find it difficult to accept the aetiology. Reproducing
symptoms with voluntary hyperventilation may be useful.
• Rebreathing into a paper bag can be used to help build up the pCO2 but this
should only be used where the diagnosis is certain, as it may be dangerous
if there is physical disease.
• Relaxation techniques may be helpful.
• Breathing exercises are frequently used to treat dysfunctional breathing
and hyperventilation syndrome. However, there is currently no strong
evidence of benefit either in children or adults.[9][10]
• Treating asthmatics with dysfunctional breathing, using a brief
physiotherapy intervention (teaching breathing retraining exercises),
improves quality of life but this is only maintained in a quarter of patients
six months on.[11]

Reference http://patient.info/doctor/hyperventilation
Dr Khalid/Rabia
Q:1083 A 24yo lady has been low after the death of her husband and had stopped
contacting her family. She was started on SSRI tx and starts feeling better after a
few months. On discontinuing the meds she starts feeling that she has developed
cancer just like her husband. What is the most appropriate next step?
a. Continue SSRI
b. Add TCA
c. Neuropsychiatric analysis
d. CBT
e. Antipsychotics

Clincher(s)
A Continue SSRI.
B Add TCA.
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February 17, 2016

C Neuropsychiatric analysis
D CBT
E Antipsychotics
KEY C
Additional Delusion of hypochondriasis is the diagnosis. Lady requires a neuropsychiatric
Information analysis. All the other options are wrong. Hypochondriasis
This is a disorder where people fear that minor symptoms may be due to a serious
disease. For example, that a minor headache may be caused by a brain tumour, or
a mild rash is the start of skin cancer. Even normal bodily sensations such as
'tummy rumbling' may be thought of as a symptom of serious illness. People with
this disorder have many such fears and spend a lot of time thinking about their
symptoms.
This disorder is similar to somatisation disorder. The difference is that people with
hypochondriasis may accept the symptoms are minor but believe or fear they are
caused by some serious disease. Reassurance by a doctor does not usually help, as
people with hypochondriasis fear that the doctor has just not found the serious
disease
Reference
Dr Khalid/Rabia REF
Q: 1085 A person doesn’t go outside the home because he thinks that people will look at
him and talk about him. He finds it difficult to associate with his peers in a
restaurant or under social settings.
a. Agoraphobia
b. GAD
c. Panic disorder
d. Adjustment disorder
e. Social phobia

Clincher(s)
A Agoraphobia- agora, Greek for market place) is fear of crowds, travel, or situations
away from home
B GAD
C Panic disorder
D Adjustment disorder
E Social phobia- social phobias (where we might be minutely observed, eg small
dinner parties);
KEY E
Additional Phobic disorders involve anxiety in specifi c situations only, and leading to their
Information avoidance. These are labelled according to specifi c circumstance: agoraphobia
away from home; social phobias (where we might be minutely observed, eg small
dinner parties); simple phobias, eg to dentists, intercourse, Friday the 13th
(triskaidecophobia), spiders (arachnophobia, p372), beetles (paint them red
with black spots on and they are charming ladybirds). There may also be
freefloating ‘fear of fear’, or fear of disgracing oneself by uncontrollable
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screaming.Elicit the exact phobic stimulus. It may be specifi c, eg travelling by car,
not bicycle. Why are some situations avoided? If deluded (“I’m being
followed/persecuted”), paranoia rather than phobia is likely. For panic attacks, try
cognitive-behaviour therapy175 (p373, } eg paroxetine 20–50mg/day PO).
Reference
Dr Khalid/Rabia
Q:1138 A 33yo lady who is a drug addict wants to quit. She says she is ready to stop the
drug abuse. She is supported by her friends and family. What drug tx would you
give her?
a. Benzodiazepines
b. Diazipoxide
c. Lithium
d. Methadone
e. Disulfiram

Clincher(s)
A Benzodiazepines
B Diazipoxide
C Lithium
D Methadone
E Disulfiram
KEY D
Additional The choice of medication for detoxification
Information
Methadone or buprenorphine should be offered as the first-line treatment in
opioid detoxification. When deciding between these medications, healthcare
professionals should take into account:
• whether the service user is receiving maintenance treatment with

methadone or buprenorphine; if so, opioid detoxification should normally
be started with the same medication
• the preference of the service user.
Ultra-rapid detoxification
• Ultra-rapid detoxification under general anaesthesia or heavy sedation

(where the airway needs to be supported) must not be offered. This is
because of the risk of serious adverse events, including death.
The choice of setting for detoxification
Staff should routinely offer a community-based programme to all service users
135
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considering opioid detoxification. Exceptions to this may include service users who:
• have not benefited from previous formal community-based detoxification
• need medical and/or nursing care because of significant comorbid physical

or mental health problems
• require complex polydrug detoxification, for example concurrent

detoxification from alcohol or benzodiazepines
•are experiencing significant social problems that will limit the benefit of
community-based detoxification
http://www.nice.org.uk/guidance/cg52/chapter/Key-priorities-for-
implementation
Reference
Dr Khalid/Rabia reason :methadone is used to treat opioid withdrawal symptoms
Methadone or buprenorphine can be used in opioid dependance treatment
NICE recommends that, if both drugs are equally suitable, methadone should be
prescribed as first choice
- Methadone is used as a pain reliever and as part of drug addiction detoxification

and maintenance programs.
- For detoxification during withdrawals Methadone is the first choice.
- Methadone is also used for maintenance.
- Benzodiazepines, Diazepoxide and Disulfiram are specifically used in alcohol

withdrawal.
- Lithium is used in Mania and Bipolar Affective Disorder.

Q:1170 A 68yo woman has been admitted with poor appetite, weight loss, poor
concentration and self neglect for 3wks. She has not been eating or drinking
adequately and has rarely left her bed. She is expressive suicidal ideas and is
convinced that people are out to kill her. She has been on
antidepressant therapy for the past 3m with no improvement. What is the most
appropriate tx?
a. Anti depressants
b. CBT
c. Interpersonal therapy
d. ECT
e. Antipsychotics
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Clincher(s)
A Anti depressants
B CBT
C Interpersonal therapy
D ECT
E Antipsychotics
KEY D
Additional REASON : suicidal thought is an indication of ECT specially after treatment failure
Information
Indications of ECT
• Severe depressive illness or refractory depression.
• Catatonia.
• A prolonged or severe episode of mania.
• It should only be used if other treatment options have failed or the

condition is potentially life-threatening (eg, personal distress, social
impairment or high suicide risk).
ECT is not useful in schizophrenia

Reference
Dr Khalid/Rabia AS ABOVE
Q: 1171. A 78yo retired teacher was admitted for a hernioplasty procedure. After the
operation he became agitated, aggressive and confused. What is the most
appropriate management?
a. Diazepam
b. Chlordiazepoxide
c. Vit B
d. Clozapine
e. Thiamine

Clincher(s)
A Diazepam
B Chlordiazepoxide
C Vit B
D Clozapine
E Thiamine
KEY B
Additional Treatment of POD has remained constant—identification of underlying medical
Information issues, optimization of environment and pain control, and pharmacological
treatment for refractory cases. It is important to stress that pharmacological
treatment is not first line. However, it may be necessary when agitation puts the
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patient and caregivers at risk of harm or prevents normal postoperative care. The
drug of choice remains haloperidol. It is an antipsychotic D2 dopamine receptor
antagonist and is administered at a dose of 0.5–1 mg i.v. every 10–15 min until the
behaviour is controlled. I.M. dosing is possible as well, but much less desirable. The
dosage is 2–10 mg and interval for titration is 60–90 min. Careful titration is
important to avoid oversedation and prolonged effects secondary to its long (up to
72 h) half-life. Newer antipsychotics have been shown to be effective in acute
agitation when administered as i.m. injections, but have not been tested in medical
and surgical patients.3 Physical restraints are undesirable except in the most severe
cases and then only as a temporary measure while pharmacological and other
interventions have failed. Treatment of POD is summarized in Table 3
http://bja.oxfordjournals.org/content/103/suppl_1/i41.full

Pharmacologic treatment of delirium is required in many elderly patients following
major operations. Neuroleptic agents, particularly haloperidol, are the medication
of choice to treat delirium (Kalisvaart et al 2005; Inouye 2006) (see Figure 1G).
Prospective placebo controlled data has established the superiority of haloperidol
over benzodiazepines (Breitbart et al 1996). Atypical antipsychotics, most notably
respiridone, have been compared with haloperidol for the treatment of delirium,
but have not shown superiority (Han and Kim 2004). Dosing recommendations vary
depending on the severity of the delirium as well as clinical setting of the ICU or
surgical ward.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2546478/
Reference
Dr Khalid/Rabia reason :delirium tremens >>> first line >>> chlordiazepoxide
second line >>> diazepam
Delirium tremens:
Delirium tremens usually begins 24-72 hours after alcohol consumption has been
reduced or stopped,,there are signs of altered mental status eg, Hallucinations
,Confusion, Delusions ,Severe agitation , Seizures can also occur.
Q: 1178. A 57yo man who had MI a few months ago has been having a low mood. A dx
of moderate depression has been established. Which medication is the best tx for
him?
a. SSRI
b. TCA
c. MAOi
d. Benzodiazepam
e. Mood stabilizer

Clincher(s)
A SSRI
B TCA
C MAOi
D Benzodiazepam
E Mood stabilizer
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KEY A
Additional
Information
Reference
Dr Khalid/Rabia . SSRI
Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment
for the majority of patients with moderate depression.
• citalopram (re: QT interval) and fluoxetine are currently the preferred SSRIs
• sertraline is useful post myocardial infarction as there is more evidence for
its safe use in this situation than other antidepressants
• SSRIs should be used with caution in children and adolescents. Fluoxetine is
the drug of choice when an antidepressant is indicated

Q:1515 A 71yo man with no prv immediate hx is brought to the ED by his wife who says he
has become progressively more forgetful, tends to lose his temper and is
emotionally liable. There is no hx of infectious disease of trauma. What’s the single
most likely dx?
a. Pitt’s dementia
b. Fronto-temporal dementia
c. Huntington’s disease
e. Vascular dementia

Clincher(s)
A Pitt’s dementia- Pick’s dementia Prevalence: 15:100,000 aged 45–64yrs. Signs:
Before cognitive
loss, look for: 111 character change, frontal lobe signs, eg tactless disinhibition
} stealing, practical jokes, callousness, sexual (mis)adventures, fatuous
euphoria/depression, odd eating habits/impaired satiety, 112 jargon dysphasia.
Delusions (rare).113 Tests: MRI. : Drugs, eg memantine et al, often fail. 114
B Fronto-temporal dementia- Frontotemporal dementia is one of the less common
forms of dementia. The term covers a range of specific conditions. It is sometimes
called Pick's disease or frontal lobe dementia.
The word frontotemporal refers to the two lobes of the brain that are damaged in
this form of dementia. The frontal lobes of the brain - situated behind the forehead
- control behaviour and emotions, particularly on the right side of the brain. They
also control language, usually on the left. The temporal lobes - on either side of the
brain - have many roles. On the left side, these lobes control the understanding of
words.
This damage to the brain causes the typical symptoms of frontotemporal dementia,
which include changes in personality and behaviour, and difficulties with language.
As frontotemporal dementia is a less common form of dementia, many people
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(including some health professionals) may not have heard of it.
Frontotemporal dementia and younger people
Frontotemporal dementia occurs much less often than other forms of dementia
(such as Alzheimer's disease or vascular dementia). However, it is a significant
cause of dementia in younger people (under the age of 65). Frontotemporal
dementia is probably the third most common cause for people in this age group. It
affects men and women about equally.
Frontotemporal dementia is most often diagnosed between the ages of 45 and 65,
but it can also affect younger or older people. This is considerably younger than the
age at which people are most often diagnosed with the more common types of
dementia such as Alzheimer's disease.
Symptoms
In frontotemporal dementia, a variety of symptoms are caused by damage to

different areas of the frontal and temporal lobes. Based on these symptoms and
the lobes that are affected, a person may have one of three types of
frontotemporal dementia:
• behavioural variant frontotemporal dementia

• progressive non-fluent aphasia
• semantic dementia.
As with most forms of dementia, the initial symptoms can be very subtle, but they
slowly get worse as the disease progresses over several years.
Behavioral variant frontotemporal dementia
This form is diagnosed in about two thirds of people with frontotemporal

dementia. During the early stages, changes are seen in the person's personality and
behavior.
A person with behavioral variant frontotemporal dementia may:
• lose their inhibitions - behave in socially inappropriate ways and act in an

impulsive or rash manner; this could include making tactless or
inappropriate comments about someone's appearance
• lose interest in people and things - lose motivation but (unlike someone
with depression) they are not sad
• lose sympathy or empathy - become less responsive to the needs of others
and show less social interest or personal warmth; this can make the person
appear selfish and unfeeling
• show repetitive, compulsive or ritualised behaviours - this can include
repeated use of phrases or gestures, hoarding and obsessions with
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timekeeping
• crave sweet or fatty foods, lose table etiquette, or binge on 'junk' foods,
alcohol or cigarettes.
It is common for a person with behavioural variant frontotemporal dementia to

struggle with planning and organising or making decisions. These difficulties may
first appear at work or with managing finances.
In contrast to Alzheimer's disease, people with early-stage behavioural variant

frontotemporal dementia tend not to have problems with day-to-day memory or
with visuospatial skills (judging relationships and distances between objects).
It is unusual for a person with behavioural variant frontotemporal dementia to be

aware of the extent of their problems. Even early on, people generally lack control
over their behaviour or insight into what is happening to them. The symptoms are
more often noticed by the people close to them.
Language variants of frontotemporal dementia
In the other two types of frontotemporal dementia, the early symptoms are
progressive difficulties with language. These difficulties become apparent slowly,
often over two or more years.
In progressive non-fluent aphasia, initial problems are with speech. (Aphasia means
loss of language.) Common early symptoms may include:
• slow, hesitant speech - speech may seem difficult to produce and a person
may stutter before they can get the right word out, or may mispronounce it
when they do
• errors in grammar - a person may have 'telegraphic speech', leaving out
small link words such as 'to', 'from' or 'the'
• impaired understanding of complex sentences, but not single words.
In semantic dementia, speech is fluent but people begin to lose their vocabulary
and understanding of what objects are. Common early symptoms may include:
• asking the meaning of familiar words (eg, 'What is knife?')

• trouble finding the right word, leading to less precise descriptions instead
(eg 'the thing for opening tins'), or use of generalised words such as 'animal'
instead of 'cat'
• difficulty recognising familiar people or common objects.
In both of the language forms of frontotemporal dementia, other aspects of mental

function (memory, visuospatial skills, planning and organising) tend to be well
preserved in the early stages.
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Later stages
The rate of progression of frontotemporal dementia varies greatly, from less than
two years to 10 years or more. Research shows that on average, people live for
about eight years after the start of symptoms.
As frontotemporal dementia progresses, differences between the three types

become much less obvious. People with the behavioural variant tend to develop
language problems and may eventually lose all speech, like a person with one of
the language variants.
Similarly, over several years a person with semantic dementia or progressive non-
fluent aphasia will generally develop the behavioural problems typical of
behavioural variant frontotemporal dementia.
In the later stages of all forms of frontotemporal dementia, damage to the brain
becomes more widespread. Symptoms are often then similar to those of the later
stages of Alzheimer's disease. The person may become increasingly less
interested in people and things and have limited communication. They may show
restlessness or agitation, or behave aggressively. At this late stage someone may
no longer recognise friends and family, and is likely to need full-time care to meet
their needs.
Overlapping motor disorders
About 10-20 per cent of people with frontotemporal dementia also develop a
motor disorder, before or after the start of dementia. A motor disorder is one that
causes difficulties with movement. These motor disorders - which are generally
uncommon but more likely in this form of dementia - are:
• motor neurone disease

• progressive supranuclear palsy
• corticobasal degeneration.
Their symptoms are similar but can include twitching, stiffness, slow movements
and loss of balance or coordination. In the later stages there are often difficulties
with swallowing. The three motor disorders share some symptoms with
Parkinson's disease.
These motor disorders are all degenerative diseases of the nervous system,
meaning that they will get worse over time. The condition of a person with
frontotemporal dementia and motor neurone disease can deteriorate quite
quickly. On average, a person with both conditions will live for two or three years
after diagnosis.
Causes
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The cause of frontotemporal dementia is not known. Experts assume that the
disease reflects a mixture of genetic, medical and lifestyle factors. Unlike
Alzheimer's disease or vascular dementia, it doesn't seem that frontotemporal
dementia becomes much more common in older age.
Autopsy studies show that the death of nerve cells in the frontal and temporal
lobes is linked to clumps of abnormal proteins inside the cells, including one called
tau. The tau protein may take the form of Pick bodies, which gave frontotemporal
dementia its original name of Pick's disease.
Frontotemporal dementia runs in families much more often than in the more
common forms of dementia. About one third of people with it have some family
history of dementia.
About 10-15 per cent of people with frontotemporal dementia have a strong family
history of it, with several close relatives in different generations affected. In
contrast, strongly inherited early-onset Alzheimer's disease affects less than 1 in
1,000 people with Alzheimer's. Typically in these cases, frontotemporal dementia is
inherited from a parent as a defect (mutation) in one of three genes: MAPT, GRN or
C9ORF72.
The children or siblings of someone with one of the mutations known to cause
frontotemporal dementia are at 50 per cent risk of carrying the same defective
gene. Families with a known mutation should be offered a referral to a specialist
genetics service for counselling. Diagnosis
Frontotemporal dementia can be hard to diagnose, because it is uncommon and

does not initially cause memory problems. Doctors may also not suspect dementia
in a middle-aged person.
Frontotemporal dementia may be misdiagnosed as atypical Alzheimer's disease (a

form of Alzheimer's disease without early memory loss). Behavioural symptoms
may be mistaken for depression, schizophrenia or obsessive-compulsive disorder.
Problems with language or movement may be misdiagnosed as stroke.
Blood tests and a thorough physical examination are important to rule out other
possible causes of symptoms. A specialist may suspect a diagnosis of
frontotemporal dementia after questioning the affected person and someone who
knows them well. The specialist will take a detailed history of their symptoms and
gather information to gain a wider picture of the person's behaviour and
functioning in their daily life.
Standard cognitive tests, which tend to focus on memory loss, can be less helpful in
the diagnosis of frontotemporal dementia. More specialised tests of social
awareness or behaviour may be needed.
CT (computerised tomography) and MRI (magnetic resonance imaging) brain scans
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should be used to assess the pattern of damage to the brain. They can also rule out
other possible causes of symptoms such as stroke or tumour. If further tests are
needed, more specialised brain scans will be carried out such as PET (positron
emission tomography) and SPECT (single photon emission computerised
tomography) to measure brain activity. These scans are useful as they may detect
reduced activity in the frontal and/or temporal lobes at an earlier stage than a CT
or MRI scan might show structural changes.
Further tests may include a lumbar puncture, which involves collecting and
analysing fluid from the spine and is carried out mainly in younger people. Where a
strongly inherited form of frontotemporal dementia is suspected, genetic testing
may confirm the diagnosis and potentially allow family members to find out
whether they will go on to develop frontotemporal dementia in their lifetime. The
decision to find out is up to the individual and support is available.
After a person dies, it is possible to make a pathological diagnosis of

frontotemporal dementia as the changes to the brain can be directly seen at a
post-mortem.
Treatment and support
Researchers are working to find effective new treatments for frontotemporal

dementia, but there is currently no cure and the progression of the disease cannot
be slowed. Approaches to treatment look to ease symptoms or help people cope
with them.
Supporting a person with frontotemporal dementia usually requires input from a

team of professionals. These can include a GP, community nurse, psychiatrist and
speech and language therapist. When someone has problems with movement or
coordination, support from a physiotherapist or occupational therapist is often
needed.
Caring for someone with frontotemporal dementia can be particularly challenging,

because of the young age of onset, and changes in behaviour and communication.
Where a gene mutation which causes frontotemporal dementia is identified, birth

relatives will face additional issues of whether to have genetic counselling and
testing themselves.
Specialist support groups for younger people with dementia or those with
frontotemporal dementia and their carers can provide invaluable practical and
emotional support (see 'Other useful organisations'). Social interaction can also
help if the affected person seems to lose motivation in things or appears bored or
lonely.
Behavioural changes
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Many people with frontotemporal dementia continue to lead an active social life
for some years following diagnosis, but changes in behaviour can begin to make
social situations more challenging. It can be less stressful for carers to try to accept
potentially embarrassing behavioural symptoms as part of the disease, rather than
to confront or correct the person, unless the behaviour poses a risk of harm. The
person with dementia will generally lack insight into their condition or the impact
of their behaviour on others. They will generally not have much control over their
actions.
So long as the behaviour is harmless, it may be easier for a carer to allow someone
to carry on with it. The person may prefer to follow a fixed routine or pursue an
obsession (eg with jigsaws).
When a person with frontotemporal dementia behaves inappropriately in public, it

can be useful for the carer to try to remove any triggers or distract the person with
something else. Some carers or people with dementia carry a small card that
explains to members of the public that the person has dementia. (Helpcards for
people with dementia are available from Alzheimer's Society.)
Many carers offer support to help minimise the opportunity for compulsive eating -
for example, by offering food only at mealtimes and in suitable portions. The
person's use of alcohol may also need to be closely monitored.
It is important to try to manage restlessness, agitation or aggressive behaviour

without drugs initially, where possible. This behaviour might result from a person
trying to communicate an unmet need, such as the person feeling frustrated or in
pain. Physical exercise and enjoyable, tailored activities carried out within a
structured routine can help.
There is evidence that certain antidepressant drugs improve apathy (little interest
in people and things) and behavioural symptoms.
If antipsychotic drugs are being considered for a person with frontotemporal

dementia, advice from a specialist on the risks and benefits is recommended.
There have been a few small trials in people with frontotemporal dementia of the
Alzheimer's disease drugs (donepezil, rivastigmine, galantamine and memantine)
with mixed results. In some cases these drugs made symptoms worse. They are
also not licensed for use in frontotemporal dementia and not widely prescribed

C
Huntington’s disease- What is Huntington disease?
Huntington disease is a progressive brain disorder that causes uncontrolled
movements, emotional problems, and loss of thinking ability (cognition).
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Adult-onset Huntington disease, the most common form of this disorder, usually
appears in a person's thirties or forties.
Early signs and symptoms can include irritability, depression, small involuntary
movements, poor coordination, and trouble learning new information or making
decisions.
Many people with Huntington disease develop involuntary jerking or twitching
movements known as chorea.
As the disease progresses, these movements become more pronounced. Affected
individuals may have trouble walking, speaking, and swallowing.
People with this disorder also experience changes in personality and a decline in
thinking and reasoning abilities.
Individuals with the adult-onset form of Huntington disease usually live about 15 to
20 years after signs and symptoms begin.
A less common form of Huntington disease known as the juvenile form begins in
childhood or adolescence.
It also involves movement problems and mental and emotional changes. Additional
signs of the juvenile form include slow movements, clumsiness, frequent falling,
rigidity, slurred speech, and drooling.
School performance declines as thinking and reasoning abilities become impaired.
Seizures occur in 30 percent to 50 percent of children with this condition. Juvenile
Huntington disease tends to progress more quickly than the adult-onset form;
affected individuals usually live 10 to 15 years after signs and symptoms appear.
How common is Huntington disease?

Huntington disease affects an estimated 3 to 7 per 100,000 people of European
ancestry. The disorder appears to be less common in some other populations,
including people of Japanese, Chinese, and African descent.
What genes are related to Huntington disease?

Mutations in the HTT gene cause Huntington disease. The HTT gene provides
instructions for making a protein called huntingtin. Although the function of this
protein is unknown, it appears to play an important role in nerve cells (neurons) in
the brain.
The HTT mutation that causes Huntington disease involves a DNA segment known
as a CAG trinucleotide repeat. This segment is made up of a series of three DNA
building blocks (cytosine, adenine, and guanine) that appear multiple times in a
row. Normally, the CAG segment is repeated 10 to 35 times within the gene. In
people with Huntington disease, the CAG segment is repeated 36 to more than 120
times. People with 36 to 39 CAG repeats may or may not develop the signs and
symptoms of Huntington disease, while people with 40 or more repeats almost
always develop the disorder.
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An increase in the size of the CAG segment leads to the production of an
abnormally long version of the huntingtin protein. The elongated protein is cut into
smaller, toxic fragments that bind together and accumulate in neurons, disrupting
the normal functions of these cells. The dysfunction and eventual death of neurons
in certain areas of the brain underlie the signs and symptoms of Huntington
disease.

How do people inherit Huntington disease?

This condition is inherited in an autosomal dominant pattern, which means one
copy of the altered gene in each cell is sufficient to cause the disorder. An affected
person usually inherits the altered gene from one affected parent. In rare cases, an
individual with Huntington disease does not have a parent with the disorder.
As the altered HTT gene is passed from one generation to the next, the size of the
CAG trinucleotide repeat often increases in size. A larger number of repeats is
usually associated with an earlier onset of signs and symptoms. This phenomenon
is called anticipation. People with the adult-onset form of Huntington disease
typically have 40 to 50 CAG repeats in the HTT gene, while people with the juvenile
form of the disorder tend to have more than 60 CAG repeats.
Individuals who have 27 to 35 CAG repeats in the HTT gene do not develop
Huntington disease, but they are at risk of having children who will develop the
disorder. As the gene is passed from parent to child, the size of the CAG
trinucleotide repeat may lengthen into the range associated with Huntington
disease (36 repeats or more).

D Alzheimer’s disease- Typical early symptoms of Alzheimer’s include:
• Regularly forgetting recent events, names and faces.

• Becoming increasingly repetitive.
• Regularly misplacing items or putting them in odd places.
• Confusion about the time of day.
• Disorientation, especially away from your normal surroundings.
• Getting lost.
• Problems finding the right words.
• Mood or behaviour problems such as apathy, irritability, or losing confidence.
Alzheimer’s gets worse over time, but the speed of change varies from person to
person

E Vascular dementia- Vascular dementia is the second most common type of
dementia (after Alzheimer's disease), affecting around 150,000 people in the UK.
The word dementia describes a set of symptoms that can include memory loss and
difficulties with thinking, problem-solving or language. In vascular dementia, these
symptoms occur when the brain is damaged because of problems with the supply
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of blood to the brain. This factsheet outlines the causes, types and symptoms of
vascular dementia. It looks at how it is diagnosed and the factors that can put
someone at risk of developing it. It also describes the treatment and support that
are available.
Causes
Vascular dementia is caused by reduced blood supply to the brain due to diseased
blood vessels.
To be healthy and function properly, brain cells need a constant supply of blood to
bring oxygen and nutrients. Blood is delivered to the brain through a network of
vessels called the vascular system. If the vascular system within the brain becomes
damaged - so that the blood vessels leak or become blocked - then blood cannot
reach the brain cells and they will eventually die.
This death of brain cells can cause problems with memory, thinking or reasoning.
Together these three elements are known as cognition. When these cognitive
problems are bad enough to have a significant impact on daily life, this is known as
vascular dementia.
Types of vascular dementia
There are several different types of vascular dementia. They differ in the cause of
the damage and the part of the brain that is affected. The different types of
vascular dementia have some symptoms in common and some symptoms that
differ. Their symptoms tend to progress in different ways.
Stroke-related dementia
A stroke happens when the blood supply to a part of the brain is suddenly cut off.
In most strokes, a blood vessel in the brain becomes narrowed and is blocked by a
clot. The clot may have formed in the brain, or it may have formed in the heart (if
someone has heart disease) and been carried to the brain. Strokes vary in how
severe they are, depending on where the blocked vessel is and whether the
interruption to the blood supply is permanent or temporary.
Post-stroke dementia
A major stroke occurs when the blood flow in a large vessel in the brain is suddenly
and permanently cut off. Most often this happens when the vessel is blocked by a
clot. Much less often it is because the vessel bursts and bleeds into the brain. This
sudden interruption in the blood supply starves the brain of oxygen and leads to
the death of a large volume of brain tissue.
Not everyone who has a stroke will develop vascular dementia, but about 20 per
cent of people who have a stroke do develop this post-stroke dementia within the
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following six months. A person who has a stroke is then at increased risk of having
further strokes. If this happens, the risk of developing dementia is higher.
Single-infarct and multi-infarct dementia
These types of vascular dementia are caused by one or more smaller strokes. These
happen when a large or medium-sized blood vessel is blocked by a clot. The stroke
may be so small that the person doesn't notice any symptoms. Alternatively, the
symptoms may only be temporary - lasting perhaps a few minutes - because the
blockage clears itself. (If symptoms last for less than 24 hours this is known as a
'mini-stroke' or transient ischaemic attack (TIA). A TIA may mistakenly be dismissed
as a 'funny turn'.)
If the blood supply is interrupted for more than a few minutes, the stroke will lead
to the death of a small area of tissue in the brain. This area is known as an infarct.
Sometimes just one infarct forms in an important part of the brain and this causes
dementia (known as single-infarct dementia). Much more often, a series of small
strokes over a period of weeks or months lead to a number of infarcts spread
around the brain. Dementia in this case (known as multi-infarct dementia) is
caused by the total damage from all the infarcts together.
Subcortical dementia
Subcortical vascular dementia is caused by diseases of the very small blood vessels
that lie deep in the brain. These small vessels develop thick walls and become stiff
and twisted, meaning that blood flow through them is reduced.
Small vessel disease often damages the bundles of nerve fibres that carry signals
around the brain, known as white matter. It can also cause small infarcts near the
base of the brain.
Small vessel disease develops much deeper in the brain than the damage caused by
many strokes. This means many of the symptoms of subcortical vascular dementia
are different from those of stroke-related dementia.
Subcortical dementia is thought to be the most common type of vascular

dementia.
Mixed dementia (vascular dementia and Alzheimer's disease)
At least 10 per cent of people with dementia are diagnosed with mixed dementia.
This generally means that both Alzheimer's disease and vascular disease are
thought to have caused the dementia. The symptoms of mixed dementia may be
similar to those of either Alzheimer's disease or vascular dementia, or they may be
a combination of the two.
Symptoms
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How vascular dementia affects people varies depending on the different underlying
causes and more generally from person to person. Symptoms may develop
suddenly, for example after a stroke, or more gradually, such as with small vessel
disease.
Some symptoms may be similar to those of other types of dementia. Memory loss
is common in the early stages of Alzheimer's, but is not usually the main early
symptom of vascular dementia.
The most common cognitive symptoms in the early stages of vascular dementia
are:
• problems with planning or organising, making decisions or solving problems

• difficulties following a series of steps (eg cooking a meal)
• slower speed of thought
• problems concentrating, including short periods of sudden confusion.
A person in the early stages of vascular dementia may also have difficulties with:
• memory - problems recalling recent events (often mild)

• language - eg speech may become less fluent
• visuospatial skills - problems perceiving objects in three dimensions.
As well as these cognitive symptoms, it is common for someone with early vascular
dementia to experience mood changes, such as apathy, depression or anxiety.
Depression is common, partly because people with vascular dementia may be
aware of the difficulties the condition is causing. A person with vascular dementia
may also become generally more emotional. They may be prone to rapid mood
swings and being unusually tearful or happy.
Other symptoms that someone with vascular dementia may experience vary
between the different types. Post-stroke dementia will often be accompanied by
the obvious physical symptoms of the stroke. Depending on which part of the brain
is affected, someone might have paralysis or weakness of a limb. Or if a different
part of the brain is damaged they may have problems with vision or speech. With
rehabilitation, symptoms may get a little better or stabilise for a time, especially in
the first six months after the stroke.
Symptoms of subcortical vascular dementia vary less. Early loss of bladder control
is common. The person may also have mild weakness on one side of their body, or
become less steady walking and more prone to falls. Other symptoms of
subcortical vascular dementia may include clumsiness, lack of facial expression and
problems pronouncing words.
Progression and later stages
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Vascular dementia will generally get worse, although the speed and pattern of this
decline vary. Stroke-related dementia often progresses in a 'stepped' way, with
long periods when symptoms are stable and periods when symptoms rapidly get
worse. This is because each additional stroke causes further damage to the brain.
Subcortical vascular dementia may occasionally follow this stepped progression,
but more often symptoms get worse gradually, as the area of affected white
matter slowly expands.
Over time a person with vascular dementia is likely to develop more severe
confusion or disorientation, and further problems with reasoning and
communication. Memory loss, for example for recent events or names, will also
become worse. The person is likely to need more support with day-to-day activities
such as cooking or cleaning.
As vascular dementia progresses, many people also develop behaviours that seem
unusual or out of character. The most common include irritability, agitation,
aggressive behaviour and a disturbed sleep pattern. Someone may also act in
socially inappropriate ways.
Occasionally a person with vascular dementia will strongly believe things that are
not true (delusions) or - less often - see things that are not really there
(hallucinations). These behaviours can be distressing and a challenge for all
involved.
In the later stages of vascular dementia someone may become much less aware of
what is happening around them. They may have difficulties walking or eating
without help, and become increasingly frail. Eventually, the person will need help
with all their daily activities.
How long someone will live with vascular dementia varies greatly from person to
person. On average it will be about five years after the symptoms started. The
person is most likely to die from a stroke or heart attack.
Who gets vascular dementia?
There are a number of things that can put someone at risk of developing vascular
dementia. These are called risk factors. Most of these are things that contribute to
underlying cardiovascular diseases. Some of these risk factors (eg lifestyle) can be
controlled, but others (eg age and genes) cannot. For more information see
factsheet 450, Am I at risk of developing dementia?
Age is the strongest risk factor for vascular dementia. A person's risk of developing
the condition doubles approximately every five years over the age of 65. Vascular
dementia under the age of 65 is uncommon and affects fewer than 8,000 people in
the UK. Men are at slightly higher risk of developing vascular dementia than
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February 17, 2016

women.
A person who has had a stroke, or who has diabetes or heart disease, is
approximately twice as likely to develop vascular dementia. Sleep apnoea, a
condition where breathing stops for a few seconds or minutes during sleep, is also
a possible risk factor. Someone can reduce their risk of dementia by keeping these
conditions under control, through taking prescribed medicines (even if they feel
well) and following professional advice about their lifestyle.
There is some evidence that a history of depression also increases the risk of
vascular dementia. Anyone who thinks they may be depressed should seek their
doctor's advice early.
Cardiovascular disease - and therefore vascular dementia - is linked to high blood

pressure, high cholesterol and being overweight in mid-life. Someone can reduce
their risk of developing these by having regular check-ups (over the age of 40), by
not smoking, and by keeping physically active. It will also help to eat a healthy
balanced diet and drink alcohol only in moderation.
Aside from these cardiovascular risk factors, there is good evidence that keeping
mentally active throughout life reduces dementia risk. There is some evidence for
the benefits of being socially active too.
Researchers think there are some genetic factors behind the common types of
vascular dementia, and that these are linked to the underlying cardiovascular
diseases. Someone with a family history of stroke, heart disease or diabetes has an
increased risk of developing these conditions. Overall, however, the role of genes
in the common types of vascular dementia is small.
People from certain ethnic groups are more likely to develop cardiovascular
disease and vascular dementia than others. Those from an Indian, Bangladeshi,
Pakistani or Sri Lankan background living in the UK have significantly higher rates of
stroke, diabetes and heart disease than white Europeans. Among people of
African-Caribbean descent, the risk of diabetes and stroke - but not heart disease -
is also higher. These differences are thought to be partly inherited but mainly due
to lifestyle factors such as diet, smoking and exercise.
Diagnosis
Anyone who is concerned that they may have vascular dementia (or any other type
of dementia) should seek help from their GP. If someone does have dementia, an
early diagnosis has many benefits: it provides an explanation for the person's
symptoms; it gives access to treatment, advice and support; and it allows them to
prepare for the future and plan ahead. For vascular dementia, treatments and
lifestyle changes may also slow down the progression of the underlying disease.
There is no single test for vascular dementia. The GP will first need to rule out
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February 17, 2016

conditions that can have similar symptoms, particularly depression. Symptoms
could also be caused by infections, vitamin and thyroid deficiencies (diagnosed
from a blood test) and side effects of medication.
The doctor will also talk to the person about their medical history (eg high blood
pressure or diabetes). This will include questions about dementia or cardiovascular
disease in close family members. The doctor will probably do a physical
examination and will ask about how the person's symptoms are currently affecting
their life. The GP or a practice nurse may ask the person to do some tests of mental
abilities. It is often helpful if a close friend or family member accompanies the
person to medical appointments. They may be able to describe subtle changes that
the person themselves has not noticed, such as starting to struggle with daily
activities.
The GP may feel able to make a diagnosis of vascular dementia at this stage. If not,
they will generally refer the person to a specialist. This might be an old-age
psychiatrist (who specialises in the mental health of older people) based in a
memory service, or a geriatrician (who specialises in the physical health of older
people) in a hospital. For more information see factsheet 426, Assessment and
diagnosis.
The specialist will assess the person's symptoms in more detail. The way that
symptoms developed - in steps or more gradually - may suggest different
underlying diseases. The person's thinking and other mental abilities will also be
assessed further with a wider range of tests. In someone with vascular dementia,
the test might show slowness of thought and difficulties thinking things through,
which are often more common than memory loss.
A person suspected of having vascular dementia will generally have a brain scan to
look for any changes that have taken place in the brain. A scan such as CT
(computerised tomography) or MRI (magnetic resonance imaging) may rule out a
tumour or build-up of fluid inside the brain. These can have symptoms similar to
those of vascular dementia. A CT scan may also show a stroke or an MRI scan may
show changes such as infarcts or damage to the white matter. If this is the case,
the brain scan will be very helpful in diagnosing the dementia type, rather than
simply ruling out other causes.
If the person has dementia, and the circumstances mean it is best explained by
vascular disease in the brain, a diagnosis of vascular dementia will be made. For
example, the dementia may have developed within a few months of a stroke, or a
brain scan may show a pattern of disease that explains the dementia symptoms.
The diagnosis should be communicated clearly to the person and usually also those
closest to them, along with a discussion about the next steps. For more information
see factsheet 426, Assessment and diagnosis.
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There is currently no cure for vascular dementia: the brain damage that causes it
cannot be reversed. However, there is a lot that can be done to enable someone to
live well with the condition. This will involve drug and non-drug treatment, support
and activities.
The person should have a chance to talk to a health or social care professional
about their dementia diagnosis. This could be a psychiatrist or mental health nurse,
a clinical psychologist, occupational therapist or GP. Information on what support is
available and where to go for further advice is vital in helping someone to stay
physically and mentally well.
Control of cardiovascular disease
If the underlying cardiovascular diseases that have caused vascular dementia can
be controlled, it may be possible to slow down the progression of the dementia.
For example, after someone has had a stroke or TIA, treatment of high blood
pressure can reduce the risk of further stroke and dementia. For stroke-related
dementia in particular, with treatment there may be long periods when the
symptoms don't get significantly worse.
In most cases, a person with vascular dementia will already be on medications to

treat the underlying diseases. These include tablets to reduce blood pressure,
prevent blood clots and lower cholesterol. If the person has a diagnosed heart
condition or diabetes they will also be taking medicines for these. It is important
that the person continues to take any medications and attends regular check-ups
as recommended by a doctor.
Someone with vascular dementia will also be advised to adopt a healthy lifestyle,
particularly to take regular physical exercise and, if they are a smoker, to quit. They
should try to eat a diet with plenty of fruit, vegetables and oily fish but not too
much fat or salt. Maintaining a healthy weight and keeping to recommended levels
of alcohol will also help. The GP should be able to offer advice in all these areas
KEY
Additional
Information
Reference
Dr Khalid/Rabia National Institute of Neurological and Communicative Disorders and Stroke and the
Alzheimer's Disease and Related Disorders Association (NINCDS/ADRDA) diagnostic
criteria be used for the assessment of Alzheimer's disease. Alternatives are the ICD-
10 or DSM-IV (now DSM-5 since the guidelines were written) criteria.[10][11]

The NINCDS/ADRDA criteria were proposed in 1984 and revised in 2011.[12] Core
features for diagnosis of Alzheimer's disease include:

Probable Alzheimer's disease
Dementia established by clinical examination and neuropsychological tests.
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February 17, 2016

Deficits in two or more areas of cognition.
Insidious onset over months to years, and progressive worsening of memory and
other cognitive functions.
No disturbance of consciousness.
Onset between ages of 40 and 90. (Criterion removed in latest revision.)
Absence of systemic disorders or other brain diseases that could account for the
symptoms.
Possible Alzheimer's disease
Dementia with an atypical onset or course (ie sudden onset or insufficient
documentation of progressive decline); OR
Aetiologically mixed presentation (ie other criteria fit the diagnosis, but features of
other brain disorders or causes of dementia are present).
Mild cognitive impairment due to Alzheimer's disease
Newer diagnostic criteria have attempted to classify the symptomatic, pre-
dementia stage of Alzheimer's disease. The work group which revised the
NINCDS/ADRDA criteria in 2011 refers to this stage as "mild cognitive impairment"
with clinical diagnostic criteria as follows:[13]

Concern regarding a change in cognition (from patient, informer or clinician)
Impairment of one or more cognitive domains
Preservation of independence in functional abilities
Not having the features of dementia

Q:433 A 30yo man complains of episodes of hearing music and sometimes
threatening voices within a
couple of hours of heavy drinking. What is the most likely dx?
a. Delirium tremens
b Wernicke’s encephalopathy
c. Korsakoff’s psychosis
d. Alcohol hallucinosis
e. Temporal lobe dysfunction

Clincher(s)
A Delerium Tremens - Symptoms of visual, auditory, and tactile hallucinations
are indicative of late-stage withdrawal (36-72 h), the stage associated with
delirium tremens and a mortality rate of 5-15%.
B Wernick’s Encephalopathy- Thiamine deficiency – Confusion Ataxia ,
Opthalmoplegia.
C Korsakoff’s psychosis- Complication of WE ( Glucose administered after
Thiamine if needed)
D Alcoholic Hallucinosis- In withdrawal, auditory hallucinations can be indicative
of early-stage withdrawal (6-24 h), the stage associated with withdrawal
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seizures
E Temporal Lobe Dysfunction- 1) disturbance of auditory sensation and
perception, 2) disturbance of selective attention of auditory and visual input,
3) disorders of visual perception, 4) impaired organization and categorization
of verbal material, 5) disturbance of language comprehension, 6) impaired
long-term memory, 7) altered personality and affective behavior, 8) altered
sexual behavior.
Causes- Traumatic brain injury
• Infections, such as encephalitis or meningitis, or history of such infections

• A process that causes scarring (gliosis) in a part of the temporal lobe called
the hippocampus
• Blood vessel malformations in the brain
• Stroke
• Brain tumors
• Genetic syndromes

Mayo Clinic
KEY D
Additional OHCM- 728Wernick’s Encephalopathy-
Information
Reference
Dr Khalid/Rabia *Alcohol withdrawal presents in the following stages:
-Minor withdrawal symptoms- [Appear 6-12 hours after alcohol has stopped.]
Insomnia, tremors, mild anxiety, mild agitation or restlessness, nausea,
vomiting, headache, excessive sweating, palpitations, anorexia, depression and
craving.

-Alcohol hallucinosis- Visual, auditory or tactile hallucinations that can occur
either during acute intoxication or withdrawal. During withdrawal, they [occur
12-24 hours after alcohol has stopped.]

-Withdrawal seizures are generalized tonic-clonic seizures that [appear 24-48
hours after alcohol has stopped.]

-Delirium tremens appears [48-72 hours after alcohol has stopped]. Altered
mental status in the form of confusion, delusions, severe agitation and
hallucinations. Seizures can occur. Examination might reveal stigmata of
chronic alcoholic liver disease.

• Investigation: FBC, LFTs, clotting, ABG to look for metabolic acidosis,
Glucose, blood alcohol levels, U&E, creatinine, amylase, CPK and blood
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February 17, 2016

culture. CXR to check for aspiration pneumonia. CT scan if seizures or
evidence of head trauma. ECG-arrhythmia.

• Management of alcohol withdrawal-
6. ABC
7. Treat hypoglycemia
8. Sedation: Benzodiazepine (chlordiazepoxide). Alternative- diazepam.
9. Carbamezapine or Mg if history of withdrawal seizures.
10. IV Thiamine to prevent or treat Wernicke’s encephalopathy that might
lead to korsakoff syndrome. Give THIAMINE FIRST.

*Wernicke’s encephalopathy- Triad of ataxia, ophthalmoplegia and mental
confusion). If left untreated, leads to Korsakoff’s syndrome (Wernicke’s plus
confabulation, antero or retrograde amnesia and telescoping of events)
>Investigations: FBC (^MCV), LFTs, Glucose, U&E (^Na, ^Ca, ^Uricaemia), ABG
(^Carbia and Hypoxia), Serum thiamine (low).

Q:436 A schizophrenic pt hears people only when he is about to fall asleep. What is
the most likely dx?
a. Hypnopompic hallucinations
b. Hyponogogic hallucinations
c. Hippocampal hallucinations
d. Delirious hallucinations
e. Auditory hallucinations

Clincher(s)
A Hypnopompic hallucinations- While waking up
B Hyponogogic hallucinations- While falling asleep
C Hippocampal hallucination- Photographic, animated or film-like clarity of
people, animals, faces, flowers, insects etc
D
E Auditory hallucinations- hearing voices that aren’t present

KEY B
Additional
Information
Reference
Dr Khalid/Rabia IN KEYS

Q: 450 A 32yo man has OCD. What is the best tx?
a. CBT
b. SSRI
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c. TCA
d. MAO inhibitors
e. Reassure

Clincher(s)
A CBT
B SSRI
C TCA
D MAO inhibitors
E Reassure
KEY B ( WRONG KEY) CORRECT SEEMS A
Additional OCD is treated initially with individual CBT (Cognitive Behavioural therapy) plus
Information exposure and response prevention. If symptoms become severe or do not
improve, SSRIs like fluoxetine or Citalopram etc are introduced. Recent studies
have shown that there is no superiority of one over the other (CBT over SSRIs),
but CBT remains the initial management plan, This question is quite deficient,
and the original key is B. SSRI, but I’m sure in the exam, it will be more
detailed; but this is how OCD is managed. Reference: Patient.co.uk. Link-
http://patient.info/doctor/obsessive-compulsive-disorder-pro
Obsessive-compulsive disorder (OCD) may be characterised by the presence of

• Obsessions are unwanted intrusive thoughts, images or urges that

repeatedly enter the person's mind.
• Compulsions are repetitive behaviours or mental acts that the person
feels driven to perform. They can be overt (observable by others) - eg,
checking a door is locked; or they can be covert - eg, a mental act that
cannot be observed, such as repeating a certain phrase in one's mind.
Epidemiology[1]
Studies vary but the figure for prevalence ranges from 0.8-3% in adults and
0.25-2% in children and adolescents. Onset is most commonly in late
adolescence and early twenties but can occur at any age.
Aetiology[2]
Aetiology seems to be multifactorial, involving several possible components:
• Genetic. Twin studies suggest a genetic predisposition.[3]

• Developmental factors. Abuse or neglect, social isolation, teasing or
bullying may predispose.
• Psychological factors. Personality characteristics maintain OCD.
• Stressors/triggers. A common stressor is pregnancy or the postnatal
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period.
• Neurological conditions. Occasionally OCD is a presenting sign of a
neurological condition such as a tumour or frontotemporal dementia,
or the result of trauma to the brain.
Presentation
Diagnostic criteria
The International Classification of Diseases 10th Edition (ICD-10) definition of

OCD applies the following criteria:[4]
• Either obsessions or compulsions (or both) must be present on most

days for a period of at least two weeks.
• They are acknowledged as originating in the mind of the patient and
are not imposed by outside persons or influences.
• They are repetitive and unpleasant and at least one obsession or
compulsion must
be present that is acknowledged as excessive or unreasonable.
• The subject tries to resist them (but if very long-standing, resistance to
some obsessions or compulsions may be minimal). At least one
obsession or compulsion must be present which is unsuccessfully
resisted.
• Carrying out the obsessive thought or compulsive act is not in itself
pleasurable.
• The obsessions or compulsions cause distress or interfere with the
subject's social or individual functioning, usually by wasting time.
Associated diseases[2]
There are frequently comorbid conditions, namely one of the following:
• Depression.
• Social and other phobias.
• Alcohol misuse.
• General anxiety disorder.
• Body dysmorphic disorder (BDD).
• Eating disorders.
• Schizophrenia.
• Tourette's syndrome.
• Autistic spectrum disorder.
Assessment[5]
People with OCD often do not volunteer their symptoms spontaneously and it
is likely that there is under-diagnosis of this condition. Assessment should
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February 17, 2016

include the following elements:
• Identify cases - for patients at risk of OCD (depression, anxiety, BDD,

substance misuse or eating disorder), ask the following questions:
o Do you wash or clean a lot?
o Do you check things a lot?
o Is there any thought that keeps bothering you that you would
like to get rid of but cannot?
o Do your daily activities take a long time to finish?
o Are you concerned about putting things in a special order or are
you very upset by mess?
o Do these problems trouble you?
• Assess severity, ie how much it is affecting the patient's ability to
function in everyday life. National Institute for Health and Care
Excellence (NICE) guidance bases management guidelines on degree of
severity but does not specify how this should be assessed. Essentially
assess the effect the condition has on quality of life, school or work,
relationships and social life. Rating scales such as the Yale-Brown
Obsessive Compulsive Scale may be used.[1]
• Assess the risk of self-harm or suicide and the presence of comorbidity
such as depression.
• Arrange referral to appropriate secondary care provision.
• Ensure continuity of care to avoid multiple assessments, gaps in service
and a smooth transition from child to adult services (many patients
have lifelong symptoms).
• Promote understanding - make patients/families aware of the
involuntary nature of symptoms. Consider patient information leaflets,
contact numbers of self-help groups, etc.
• Consider the bigger picture - cultural, social, emotional and mental
health needs.
• If the patient is a parent, consider child protection issues.
Management in adults[1][5]
NICE recommends referral to a specialist multidisciplinary team offering age-

appropriate care.
Mild functional impairment
People with mild functional impairment can be successfully managed with low-
intensity psychological treatment. A psychological intervention should be
recommended as first-line therapy. This is accessed by referral or self-referral
to the Improving Access to Psychological Therapies (IAPT) scheme. Options for
therapy include:
• Individual cognitive behavioural therapy (CBT) plus exposure and

response prevention (ERP).
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• Individual CBT and ERP by telephone or internet.
• Group CBT.
• A couples-based course, which has been developed for patients in long-
term relationships.[6]
If the person has been unable to engage in low-intensity CBT (including ERP) or
the response is inadequate then offer the choice of a selective serotonin
reuptake inhibitor (SSRI) or higher-intensity psychological therapy. (Higher
intensity essentially refers to the level of hours of input of therapy.)
Moderate functional impairment
Those with moderate functional impairment should be offered a choice

between high-intensity CBT and ERP (more than 10 hours per patient) or an
SSRI. Clomipramine may also be used as an alternative to an SSRI.
Severe functional impairment
Those with severe functional impairment should be offered high-intensity

psychological therapy plus an SSRI.
Evidence comparing treatment options
• Cochrane reviews have determined psychological therapies to be

effective in OCD, although have not been able to recommend one
specific technique.[7] Likewise, SSRIs have been shown to have efficacy
over placebo but no evidence supports one over another or shows
superiority between SSRIs and psychological therapies.[8]
• Studies show psychological therapies such as CBT delivered by phone
or internet to be effective.[9][10]
• One randomised comparative trial concluded that group CBT was an
effective treatment but did not exclude the possibility that individual
therapy was superior.[11]
• One study found that two prominent features of OCD - overestimations
of danger and inflated beliefs of personal responsibility - benefited
equally from CBT.[12]
• Inference-based treatment (IBT) is a method of psychological treatment
sometimes used as an adjunct to CBT in OCD patients with obsessional
doubt.[13]
• ERP is a technique in which patients are repeatedly exposed to the
situation causing them anxiety (eg, exposure to dirt) and are prevented
from performing repetitive actions, which lessens that anxiety (eg,
washing their hands). Efficacy has been demonstrated in
studies.[14][15] This method is only used after extensive counselling and
discussion with the patient who knows fully what to expect. After an
initial increase in anxiety, the level gradually decreases. The patient
feels that they have confronted their worst fears without anything
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February 17, 2016

terrible happening. One study found that, providing there was
adherence to a standardised treatment manual, the experience (or
inexperience) of the therapist did not affect the outcome.
Management in children[1][5]
• Mild dysfunction : offer guided self-help along with support and

information for the family or carers. If this fails, or if it is unavailable
locally, refer to Children and Adolescents Mental Health Services
(CAMHS).
• Moderate-to-severe: refer to CAMHS. Psychological therapy will be
with CBT/ERP as for adults but should involve family/carers. It may be
individual or group therapy, depending on the preference of the
patient. CBT has been shown to be effective in children for OCD and
other associated disorders.[16][17] Furthermore, CBT may be more
effective than SSRI treatment.[18]
• If psychological treatment fails, factors which might require other
interventions may be involved - eg, co-existence of comorbid
conditions, learning disorders, persisting psychosocial risk factors such
as family discord, presence of parental mental health problems.
• Pharmacotherapy: in children over the age of 8, adding an SSRI might
be appropriate, following a multidisciplinary review. In children under
the age of 18, an SSRI should only be prescribed after assessment by a
specialist psychiatrist for this age group (but see below concerning
safety issues).
Using selective serotonin reuptake inhibitors[5]
See also the separate Selective Serotonin Reuptake Inhibitors article.
SSRIs in adults
• There is a range of potential side-effects (see individual drugs),

including worsening anxiety, suicidal thoughts and self-harm, which
need to be carefully monitored, especially in the first few weeks of
treatment. Caution is advised in view of increased risk of suicidal
thoughts and self-harm in people with depression.
• In high-risk patients, prescribe limited quantities, keep in contact
especially during the first few weeks and actively monitor for akathisia
(restlessness and the urge to move), suicidal ideation, agitation and
increased anxiety.
• NICE recommends fluoxetine, fluvoxamine, paroxetine, sertraline or
citalopram. There are no significant differences in efficacy.
• There is commonly a delay in onset of up to 12 weeks, although
depressive symptoms improve more quickly.
• When prescribing, provide written supporting material.
• If there is no response to a standard dose, check compliance, check
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interaction with drugs and alcohol, then consider titrating to a
maximum dose according to the Product Characteristics.
• Monitor all patients around the time of dosage changes.
• Continue for at least twelve months from remission and withdraw
gradually.
• There is a risk of discontinuation/withdrawal symptoms on stopping
the drug, missing doses, or reducing the dose.
• Clomipramine may be used as an alternative if the person is intolerant
of SSRIs, if at least one SSRI has been ineffective, or if they have
previously responded successfully to clomipramine.
SSRIs in children and young people (8-18 years)
• Caution is advised, as there is a risk of self-harm or suicide in patients

with depression. Only prescribed by specialists, in conjunction with
psychological therapy following assessment by a child and adolescent
psychiatrist who should also be involved in dosage changes and
discontinuation.
• Sertraline and fluvoxamine are the only SSRIs licensed for this use,
unless significant co-existing depression is evident, in which case
fluoxetine should be used.
• Discuss adverse effects, dosage, monitoring, etc with the
patient/family/carers, as per adults (see above).
• SSRIs should only be prescribed in conjunction with CBT.
Treatment failures[14]
The following are in conjunction with specialist assessment and

multidisciplinary review:
• Try another SSRI.

• Consider change to clomipramine; however, there is a greater tendency
to produce adverse effects. Do baseline ECG and check BP. Start with a
small dose, titrate according to response and monitor regularly.
• Antipsychotics are sometimes used to augment the effect of an SSRI.
There is evidence for haloperidol, risperidone and aripiprazole.
• Intensive inpatient therapy or residential/supportive care may
occasionally be needed for people with chronic severe dysfunction.
• Neurosurgery may be considered for severely ill patients who do not
respond to CBT and medication. Risks, benefits, long-term
postoperative management and patient selection should all be carefully
considered before embarking on treatment. Patient selection can be
improved by the use of neuroimaging.[19] Anterior capsulotomy is the
traditional procedure.
• Deep brain stimulation is currently being explored and has shown
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promise.[20]

Reference
Dr Khalid/Rabia REF ABOVE

Q:451 A 65yo woman says she died 3m ago and is very distressed that nobody has
buried her. When she is outdoors, she hears people say that she is evil and
needs to be punished. What is the most likely explanation for her symptoms?
a. Schizophrenia
b. Mania
c. Psychotic depression
d. Hysteria
e. Toxic confusional state

Clincher(s)
A Schizophrenia- People with other mental illnesses, such as schizophrenia, also
experience psychosis. But those with psychotic depression usually have
delusions or hallucinations that are consistent with themes about depression
(such as worthlessness or failure), whereas psychotic symptoms in
schizophrenia are more often bizarre or implausible and have no obvious
connection to a mood state (for example, thinking strangers are following
them for no reason other than to harass them). People with psychotic
depression also may be humiliated or ashamed of the thoughts and try to hide
them. Doing so makes this type of depression very difficult to diagnose.
B Mania- IRRITABILITY , EUPHORIA, LABILITY, COGNITION, BEHAVIOUR,
PSYCHOTIC SYMPTOMS, HYPOMANIA,BPD, CYCLOTHYMIA, Bipolar mania,
hypomania, and depression are symptoms of bipolar disorder. The dramatic
mood episodes of bipolar disorder do not follow a set pattern -- depression
does not always follow mania. A person may experience the same mood state
several times -- for weeks, months, even years at a time -- before suddenly
having the opposite mood. Also, the severity of mood phases can differ from
person to person.
Hypomania is a less severe form of mania. Hypomania is a mood that many

don't perceive as a problem. It actually may feel pretty good. You have a
greater sense of well-being and productivity. However, for someone with
bipolar disorder, hypomania can evolve into mania -- or can switch into serious
depression

C Psychotic depression- Psychotic depression is a subtype of major depression
that occurs when a severe depressive illness includes some form of psychosis.
The psychosis could be hallucinations (such as hearing a voice telling you that
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you are no good or worthless), delusions (such as, intense feelings of
worthlessness, failure, or having committed a sin) or some other break with
reality. Psychotic depression affects roughly one out of every four people
admitted to the hospital for depression
D Hysteria- Types of dissociation Amnesia is the commonest type: see BOX.
Depersonalization:Feeling of being detached from one’s body or ideas, as if
one were an outsider, observing the self; “I’m in a dream” or “I’m an
automaton” (unrelated to drugs/alcohol) eg from stress.
Dissociative identity disorder: The patient has multiple personalities which
interact in complex ways. It is present in 3% of acute psychiatric inpatients.
Fugue: Inability to recall one’s past .loss of identity or formation of a new
identity, associated with unexpected purposeful travel (lasts hours to
months, and for which there is no me)
E Toxic confusional state-
KEY C
Additional
Information Psychotic depression consists of a major depressive episode plus psychotic
symptoms like hallucinations or delusions (in this case nihilistic delusions).
Toxic confusional state can be eliminated since there is no history of infection.

Reference
Dr Khalid/Rabia REF

Q: 462 An 18yo previously well student is in his 1st year at uni. He has been brought
to the ED in an agitated, deluded and disoriented state. What is the most
probable reason for his condition?
a. Drug toxicity
b. Delirium tremens
c. Infection toxicity
d. Electrolyte imbalance
e. Head injury
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Clincher(s)
A Drug toxicity- TEENAGE, FIRST YEAR AT UNI
B Delirium tremens- ALCOHOL RELATED
C Infection toxicity- NO HISTORY, The symptoms of toxic shock syndrome (TSS)
normally begin with a sudden high fever (body temperature rises above
38.9C/102F).
Other symptoms then rapidly develop, normally in the course of a few hours.
They may include:
• flu-like symptoms including headache, muscle aches, sore throat and

cough
• nausea and vomiting
• diarrhoea
• fainting or feeling faint
• dizziness or confusion
A widespread sunburn-like skin rash may also occur, with the whites of the
eyes, lips and tongue becoming more red than usual.
One or two weeks after the rash appears, it is common that the skin begins to
shed in large sheets, especially from the palms of the hands and soles of the
feet.
People with streptococcal TSS may also have the symptoms of a serious
streptococcal infection. For example, pain in the muscles, abdominal pain
(such as after childbirth) or cough

D Electrolyte imbalance- NO ILLNESS
E Head injury NOT IN HISTORY
KEY A
Additional
Information Clinchers are teenage, and 1st year of university, where students tend to
experiment with drugs.
Infection toxicity can be ruled out due to lack of any signs of infection like
fever. Lack of history of trauma rules out head injury, and delirium tremens is
due to alcohol withdrawal.

Reference
Dr Khalid/Rabia

Q:470 . A 40yo woman has had intermittent tension, dizziness and anxiety for
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February 17, 2016

4months. Each episode usually resolves after a few hours. She said she takes
alcohol to make her calm. She is in a loving relationship and has no probs at
work or home. What is the next step in her management?

Clincher(s)
A Collateral info (panic disorder?)/ something is missing here: to investigate
more

B CT brain

C CBC

D LFT

E TFT

KEY KEY- A Collateral info. Likely diagnosis is panic disorder. Collateral info from
family, friends & other peers should be asked to find out the cause for her
anxiety
Additional Classifying anxietyDSM-IV
Information • Generalized anxiety disorder (GAD): anxiety +3 somatic symptoms and
present for ≥6 months
• Panic disorder
• Phobia, eg agoraphobia
• Post-traumatic stress disorder
• Social anxiety disorder
• Obsessive–compulsive disorder
Reference
Dr Khalid/Rabia Ref OHCS-361

Q:472 A 71yo woman looks disheveled, unkempt and sad with poor eye contact. She
has recently lost her husband. Which of the following describes her condition?
a. Anxiety
b. Hallucination
c. Mania
d. High mood
e. Low mood

Clincher(s)
A Anxiety
B Hallucination
C Mania
D High mood
E Low mood
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February 17, 2016

KEY E
Additional Dx- Depression. Disheveled and unkempt because she doesn’t take care of
Information herself, plus the loss of her husband, points towards depression

Reference
Dr Khalid/Rabia REF

Q:480 A 23yo man comes to the ED with a hx of drug misuse. He recognizes that he
has a prb and is willing to see a psychiatrist. Which of the following terms best
describes this situation?

Clincher(s)
A Judgement
B Thought insertion
C Thought block
D Mood
E Insight
KEY E
Additional Insight is the patient's awareness and understanding of the origins and
Information meaning of his attitudes, feelings, and behavior and of his disturbing
symptoms, basically, he is aware that he has a problem
Reference
Dr Khalid/Rabia REF

Q: 492. A 40yo woman presents to the GP with low mood. Of note, she has an
increased appetite and has gone up a dress sizes. She also complains that she
can not get out of bed until the afternoon.

Clincher(s)
A Pseudo depression
B Moderate depression
C Severe depression
D Dysthymia
E Atypical depression
KEY
Additional Atypical depression is a subtype of major depression or dysthymic disorder
Information that involves several specific symptoms, including increased appetite or weight
gain, hypersomnia, marked fatigue or weakness, moods that are strongly
reactive to environmental circumstances, and feeling extremely sensitive to
rejection, or feeling of being weighed down, paralyzed, or "leaden”.

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February 17, 2016

Reference
Dr Khalid/Rabia

Q:501 A 20yo boy is brought by his parents suspecting that he has taken some drug.
He is agitated, irritated and can’t sleep. Exam: perforated nasal septum. Which
of the following is the most likely to be responsible for his symptoms?

With heroin/opioids> everything will be low, e,g bp, HR;
With cocaine/ecstacy > everything will be high
Clincher(s)
A Heroine-pinpoint pupils, decreased consciousness, bradycardia, respiratory
depression, hypoxia. antidote: naloxone
B Cocaine- Nasal Septal Perforation
C Ecstasy/MDMA/amphetamine- agitation, anxiety, confusion, ataxia,
tachycardia, hypertension, hyponatraemia, hyperthermia, rhabdomyolysis
D Alcohol
E Opioids
KEY
Additional Causes of septal perforation After septal surgery trauma; nose picking; body
Information piercings; nasal prongs (O2 delivery); sniffing chrome salts or cocaine;
malignancies (eg rodent ulcer); nasal steroid/decongestant sprays, any chronic
mucosal infl ammation/granuloma—eg TB; syphilis; HIV, extra-GI Crohn’s;
sarcoidosis; SLE; granulomatosis with polyangiitis; relapsing polychondritis
(chondritis in auricles, nose and trachea } non-erosive polyarthritis, eye infl
ammation, and vestibular or cochlear damage; it may be fatal).Perforations
irritate, whistle, crust, and bleed.
Reference Ohcs 577
Dr Khalid/Rabia

Q:511 A 26yo woman had bipolar disorder for 10yrs and is on Lithium for it. She is
symptom free for the past 4 years. She is now planning her pregnancy and wants to
know whether she should continue taking lithium. What is the single most
appropriate advice?
a. Continue lithium at the same dose and stop when pregnancy is confirmed
b. Continue lithium during pregnancy and stop when breast feeding
c. Reduce lithium dosage but continue throughout pregnancy
d. Reduce lithium gradually and stop when pregnancy is confirmed
e. Switch to sodium valproate

Clincher(s)
A Continue lithium at the same dose and stop when pregnancy is confirmed
B Continue lithium during pregnancy and stop when breast feeding
C Reduce lithium dosage but continue throughout pregnancy
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D Reduce lithium gradually and stop when pregnancy is confirmed
E Switch to sodium valproate (it is teratotgeic)
KEY D
Additional symptom free for last 4 years. Lithium is teratogenic.
Information Adverse effects
• nausea/vomiting, diarrhoea
• fine tremor
• polyuria (secondary to nephrogenic diabetes insipidus)
• thyroid enlargement, may lead to hypothyroidism
• ECG: T wave flattening/inversion
• weight gain

Monitoring of patients on lithium therapy
• inadequate monitoring of patients taking lithium is common - NICE and the
National Patient Safety Agency (NPSA) have issued guidance to try and
address this. As a result it is often an exam hot topic
• lithium blood level should 'normally' be checked every 3 months. Levels
should be taken 12 hours post-dose
• thyroid and renal function should be checked every 6 months
• Pregnancy: avoid in first the trimester (teratogenic). Only use in the second
and third trimester if considered essential, ie a severe risk to the patient,
and monitor levels closely, as dose requirements may alter.
• Breast-feeding: avoid, as present in milk, and there is risk of toxicity in an
infant. Bottle-feeding is advisable.
Withdrawal
Abrupt withdrawal (both because of poor compliance or rapid change in dose) can
precipitate relapse. Withdraw lithium slowly over several weeks, watching for
relapse.

Reference
Dr Khalid/Rabia REF
Q:526 A 34yo man with MS has taken an OD of 100 tablets of paracetamol with intent to
end his life. He has been brought to the ED for tx but is refusing all intervention.

Clincher(s)
A Assessment
B Evaluate pt’s capacity to refuse tt
C Establish if pt has a prv mental illness
D
E
KEY B
Additional Consent not needed when urgent treatment is required:
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February 17, 2016

Information · To save the patient's life.
· To prevent a serious deterioration in the patient's condition, so long as the
treatment is not irreversible.
· To alleviate serious suffering so long as the treatment is neither irreversible nor
hazardous.
· To prevent the patient from behaving violently or being a danger to self or others
so long as the treatment is neither irreversible nor hazardous, and represents the
minimum interference necessary.

Reference
Dr Khalid/Rabia
Q: 521 A 22yo man has rushed into the ED asking for help. He describes recurrent
episodes of fearfulness, palpitations, faintness, hyperventilation, dryness of the
mouth with peri-oral tingling and cramping of the hands. His symptoms last 5-10
mins and have worsened since their onset 3months ago. He is worried he may be
having a heart attack. An ECG shows sinus tachycardia. What is the single most
appropriate immediate intervention?
a. High flow oxygen
b. IV sedation
c. Rebreathe into a paper bag
d. Refer for anxiety management course
e. Refer for urgent cardiology opinion

Clincher(s) HYPERVENTILATION (panic attack)> leads to co2> hypocalcemia (ca moves into
cells)> spasm . Bag helps to rebreathe co2.
A High flow oxygen
B IV sedation
C Rebreathe into a paper bag
D Refer for anxiety management course
E Refer for urgent cardiology opinion
KEY
Additional Symptoms of anxiety: Tension, agitation; feelings of impending doom, trembling; a
Information sense of collapse; insomnia; poor concentration; ‘goose fl esh’; ‘butterfl ies in the
stomach’; hyperventilation (so tinnitus, tetany, tingling,
chest pains); headaches; sweating; palpitations; poor appetite; nausea; ‘lump in
the throat’ unrelated to swallowing (globus hystericus); diffi culty in getting to
sleep; excessive concern about self and bodily functions; repetitive
thoughts and activities (p346). Children’s symptoms: Thumb-sucking; nail-biting;
bed-wetting; foodfads.

Symptoms HYPERVENTILATION
• The complaint is usually of a paroxysmal rather than a continuous nature,

although chronic hyperventilation can occur.
• The patient may complain of shortness of breath when an attack occurs.
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February 17, 2016

• Pain or discomfort in the chest is common.
• Paraesthesiae usually affects both arms. The complaint is often of
numbness or tingling in the fingers and sometimes toes.
• Other symptoms include:
o Dizziness.
o Perioral tingling.
o Weakness.
o Tinnitus.
o Palpitations.
o Feeling of choking or suffocation.
o Wheezing.
o Sweating.
o Loss of consciousness (uncommon
Management
Anxiety can cause hyperventilation, producing symptoms that are interpreted as

indicating serious physical illness. This causes more hyperventilation, worse
symptoms and a vicious circle. Careful explanation of the nature of the condition is
needed. Patients may find it difficult to accept the aetiology. Reproducing
symptoms with voluntary hyperventilation may be useful.
• Rebreathing into a paper bag can be used to help build up the pCO2 but this
should only be used where the diagnosis is certain, as it may be dangerous
if there is physical disease.
• Relaxation techniques may be helpful.
• Breathing exercises are frequently used to treat dysfunctional breathing
and hyperventilation syndrome. However, there is currently no strong
evidence of benefit either in children or adults.[9][10]
• Treating asthmatics with dysfunctional breathing, using a brief
physiotherapy intervention (teaching breathing retraining exercises),
improves quality of life but this is only maintained in a quarter of patients
six months on.[11]

Reference http://patient.info/doctor/hyperventilation
Dr Khalid/Rabia
Q:1083 A 24yo lady has been low after the death of her husband and had stopped
contacting her family. She was started on SSRI tx and starts feeling better after a
few months. On discontinuing the meds she starts feeling that she has developed
cancer just like her husband. What is the most appropriate next step?
a. Continue SSRI
b. Add TCA
c. Neuropsychiatric analysis
d. CBT
e. Antipsychotics

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February 17, 2016

Clincher(s)
A Continue SSRI.
B Add TCA.
C Neuropsychiatric analysis
D CBT
E Antipsychotics
KEY C (answer is refer to psychiatrist)
Additional Delusion of hypochondriasis is the diagnosis. Lady requires a neuropsychiatric
Information analysis. All the other options are wrong. Hypochondriasis
This is a disorder where people fear that minor symptoms may be due to a serious
disease. For example, that a minor headache may be caused by a brain tumour, or
a mild rash is the start of skin cancer. Even normal bodily sensations such as
'tummy rumbling' may be thought of as a symptom of serious illness. People with
this disorder have many such fears and spend a lot of time thinking about their
symptoms.
This disorder is similar to somatisation disorder. The difference is that people with
hypochondriasis may accept the symptoms are minor but believe or fear they are
caused by some serious disease. Reassurance by a doctor does not usually help, as
people with hypochondriasis fear that the doctor has just not found the serious
disease
Reference
Dr Khalid/Rabia REF
Q: 1085 A person doesn’t go outside the home because he thinks that people will look at
him and talk about him. He finds it difficult to associate with his peers in a
restaurant or under social settings.
a. Agoraphobia
b. GAD
c. Panic disorder
d. Adjustment disorder
e. Social phobia

Clincher(s)
A Agoraphobia- agora, Greek for market place) is fear of crowds, travel, or situations
away from home
B GAD
C Panic disorder
D Adjustment disorder
E Social phobia- social phobias (where we might be minutely observed, eg small
dinner parties);
KEY E
Additional Phobic disorders involve anxiety in specifi c situations only, and leading to their
Information avoidance. These are labelled according to specifi c circumstance: agoraphobia
away from home; social phobias (where we might be minutely observed, eg small
dinner parties); simple phobias, eg to dentists, intercourse, Friday the 13th
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(triskaidecophobia), spiders (arachnophobia, p372), beetles (paint them red
with black spots on and they are charming ladybirds). There may also be
freefloating ‘fear of fear’, or fear of disgracing oneself by uncontrollable
screaming.Elicit the exact phobic stimulus. It may be specifi c, eg travelling by car,
not bicycle. Why are some situations avoided? If deluded (“I’m being
followed/persecuted”), paranoia rather than phobia is likely. For panic attacks, try
cognitive-behaviour therapy175 (p373, } eg paroxetine 20–50mg/day PO).
Reference
Dr Khalid/Rabia
Q:1138 A 33yo lady who is a drug addict wants to quit. She says she is ready to stop the
drug abuse. She is supported by her friends and family. What drug tx would you
give her?
a. Benzodiazepines
b. Diazipoxide
c. Lithium
d. Methadone
e. Disulfiram

Clincher(s)
A Benzodiazepines
B Diazipoxide
C Lithium
D Methadone
E Disulfiram
KEY D
Additional The choice of medication for detoxification
Information
Methadone or buprenorphine should be offered as the first-line treatment in
opioid detoxification. When deciding between these medications, healthcare
professionals should take into account:
• whether the service user is receiving maintenance treatment with

methadone or buprenorphine; if so, opioid detoxification should normally
be started with the same medication
• the preference of the service user.
Ultra-rapid detoxification
• Ultra-rapid detoxification under general anaesthesia or heavy sedation

(where the airway needs to be supported) must not be offered. This is
because of the risk of serious adverse events, including death.
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The choice of setting for detoxification
Staff should routinely offer a community-based programme to all service users

considering opioid detoxification. Exceptions to this may include service users who:
• have not benefited from previous formal community-based detoxification
• need medical and/or nursing care because of significant comorbid physical

or mental health problems
• require complex polydrug detoxification, for example concurrent

detoxification from alcohol or benzodiazepines
•are experiencing significant social problems that will limit the benefit of
community-based detoxification
http://www.nice.org.uk/guidance/cg52/chapter/Key-priorities-for-
implementation
Reference
Dr Khalid/Rabia reason :methadone is used to treat opioid withdrawal symptoms
Methadone or buprenorphine can be used in opioid dependance treatment
NICE recommends that, if both drugs are equally suitable, methadone should be
prescribed as first choice
- Methadone is used as a pain reliever and as part of drug addiction detoxification

and maintenance programs.
- For detoxification during withdrawals Methadone is the first choice.
- Methadone is also used for maintenance.
- Benzodiazepines, Diazepoxide and Disulfiram are specifically used in alcohol

withdrawal.
- Lithium is used in Mania and Bipolar Affective Disorder.

Q:1170 A 68yo woman has been admitted with poor appetite, weight loss, poor
concentration and self neglect for 3wks. She has not been eating or drinking
adequately and has rarely left her bed. She is expressive suicidal ideas and is
convinced that people are out to kill her. She has been on
antidepressant therapy for the past 3m with no improvement. What is the most
appropriate tx?
a. Anti depressants
b. CBT
c. Interpersonal therapy
d. ECT
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February 17, 2016

e. Antipsychotics

Clincher(s)
A Anti depressants
B CBT
C Interpersonal therapy
D ECT
E Antipsychotics
KEY D
Additional REASON : suicidal thought is an indication of ECT specially after treatment failure
Information
Indications of ECT
• Severe depressive illness or refractory depression.
• Catatonia.
• A prolonged or severe episode of mania.
• It should only be used if other treatment options have failed or the

condition is potentially life-threatening (eg, personal distress, social
impairment or high suicide risk).
ECT is not useful in schizophrenia

Reference
Dr Khalid/Rabia AS ABOVE
Q: 1171. A 78yo retired teacher was admitted for a hernioplasty procedure. After the
operation he became agitated, aggressive and confused. What is the most
appropriate management?
a. Diazepam
b. Chlordiazepoxide
c. Vit B
d. Clozapine
e. Thiamine

Clincher(s)
A Diazepam
B Chlordiazepoxide
C Vit B
D Clozapine
E Thiamine
KEY ????? HALOPERIDOL (will need correction)-
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February 17, 2016

Additional Treatment of POD has remained constant—identification of underlying medical
Information issues, optimization of environment and pain control, and pharmacological
treatment for refractory cases. It is important to stress that pharmacological
treatment is not first line. However, it may be necessary when agitation puts the
patient and caregivers at risk of harm or prevents normal postoperative care. The
drug of choice remains haloperidol. It is an antipsychotic D2 dopamine receptor
antagonist and is administered at a dose of 0.5–1 mg i.v. every 10–15 min until the
behaviour is controlled. I.M. dosing is possible as well, but much less desirable. The
dosage is 2–10 mg and interval for titration is 60–90 min. Careful titration is
important to avoid oversedation and prolonged effects secondary to its long (up to
72 h) half-life. Newer antipsychotics have been shown to be effective in acute
agitation when administered as i.m. injections, but have not been tested in medical
and surgical patients.3 Physical restraints are undesirable except in the most severe
cases and then only as a temporary measure while pharmacological and other
interventions have failed. Treatment of POD is summarized in Table 3
http://bja.oxfordjournals.org/content/103/suppl_1/i41.full

Pharmacologic treatment of delirium is required in many elderly patients following
major operations. Neuroleptic agents, particularly haloperidol, are the medication
of choice to treat delirium (Kalisvaart et al 2005; Inouye 2006) (see Figure 1G).
Prospective placebo controlled data has established the superiority of haloperidol
over benzodiazepines (Breitbart et al 1996). Atypical antipsychotics, most notably
respiridone, have been compared with haloperidol for the treatment of delirium,
but have not shown superiority (Han and Kim 2004). Dosing recommendations vary
depending on the severity of the delirium as well as clinical setting of the ICU or
surgical ward.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2546478/
Reference
Dr Khalid/Rabia reason :delirium tremens >>> first line >>> chlordiazepoxide
second line >>> diazepam
Delirium tremens:
Delirium tremens usually begins 24-72 hours after alcohol consumption has been
reduced or stopped,,there are signs of altered mental status eg, Hallucinations
,Confusion, Delusions ,Severe agitation , Seizures can also occur.
Q: 1178. A 57yo man who had MI a few months ago has been having a low mood. A dx
of moderate depression has been established. Which medication is the best tx for
him?
a. SSRI
b. TCA
c. MAOi
d. Benzodiazepam
e. Mood stabilizer

Clincher(s)
A SSRI (citalopram)
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February 17, 2016

B TCA
C MAOi
D Benzodiazepam
E Mood stabilizer
KEY A
Additional
Information
Reference
Dr Khalid/Rabia . SSRI
Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment
for the majority of patients with moderate depression.
• citalopram (re: QT interval) and fluoxetine are currently the preferred SSRIs
• sertraline is useful post myocardial infarction as there is more evidence for
its safe use in this situation than other antidepressants
• SSRIs should be used with caution in children and adolescents. Fluoxetine is
the drug of choice when an antidepressant is indicated

Q:1515 A 71yo man with no prv immediate hx is brought to the ED by his wife who says he
has become progressively more forgetful, tends to lose his temper and is
emotionally liable. There is no hx of infectious disease of trauma. What’s the single
most likely dx?
a. Pitt’s dementia (fronto temporal)
b. Fronto-temporal dementia (younger age group)
c. Huntington’s disease
e. Vascular dementia
Key- Alzheimer’s ?
Clincher(s) Age, progressive,
A Pitt’s dementia- Pick’s dementia Prevalence: 15:100,000 aged 45–64yrs. Signs:
Before cognitive
loss, look for: 111 character change, frontal lobe signs, eg tactless disinhibition
} stealing, practical jokes, callousness, sexual (mis)adventures, fatuous
euphoria/depression, odd eating habits/impaired satiety, 112 jargon dysphasia.
Delusions (rare).113 Tests: MRI. : Drugs, eg memantine et al, often fail. 114
B Fronto-temporal dementia- Frontotemporal dementia is one of the less common
forms of dementia. The term covers a range of specific conditions. It is sometimes
called Pick's disease or frontal lobe dementia.
The word frontotemporal refers to the two lobes of the brain that are damaged in
this form of dementia. The frontal lobes of the brain - situated behind the forehead
- control behaviour and emotions, particularly on the right side of the brain. They
also control language, usually on the left. The temporal lobes - on either side of the
brain - have many roles. On the left side, these lobes control the understanding of
words.
This damage to the brain causes the typical symptoms of frontotemporal dementia,
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which include changes in personality and behaviour, and difficulties with language.
As frontotemporal dementia is a less common form of dementia, many people

(including some health professionals) may not have heard of it.
Frontotemporal dementia and younger people
Frontotemporal dementia occurs much less often than other forms of dementia
(such as Alzheimer's disease or vascular dementia). However, it is a significant
cause of dementia in younger people (under the age of 65). Frontotemporal
dementia is probably the third most common cause for people in this age group. It
affects men and women about equally.
Frontotemporal dementia is most often diagnosed between the ages of 45 and 65,
but it can also affect younger or older people. This is considerably younger than the
age at which people are most often diagnosed with the more common types of
dementia such as Alzheimer's disease.
Symptoms
In frontotemporal dementia, a variety of symptoms are caused by damage to

different areas of the frontal and temporal lobes. Based on these symptoms and
the lobes that are affected, a person may have one of three types of
frontotemporal dementia:
• behavioural variant frontotemporal dementia

• progressive non-fluent aphasia
• semantic dementia.
As with most forms of dementia, the initial symptoms can be very subtle, but they
slowly get worse as the disease progresses over several years.
Behavioral variant frontotemporal dementia
This form is diagnosed in about two thirds of people with frontotemporal

dementia. During the early stages, changes are seen in the person's personality and
behavior.
A person with behavioral variant frontotemporal dementia may:
• lose their inhibitions - behave in socially inappropriate ways and act in an

impulsive or rash manner; this could include making tactless or
inappropriate comments about someone's appearance
• lose interest in people and things - lose motivation but (unlike someone
with depression) they are not sad
• lose sympathy or empathy - become less responsive to the needs of others
and show less social interest or personal warmth; this can make the person
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February 17, 2016

appear selfish and unfeeling
• show repetitive, compulsive or ritualised behaviours - this can include
repeated use of phrases or gestures, hoarding and obsessions with
timekeeping
• crave sweet or fatty foods, lose table etiquette, or binge on 'junk' foods,
alcohol or cigarettes.
It is common for a person with behavioural variant frontotemporal dementia to

struggle with planning and organising or making decisions. These difficulties may
first appear at work or with managing finances.
In contrast to Alzheimer's disease, people with early-stage behavioural variant

frontotemporal dementia tend not to have problems with day-to-day memory or
with visuospatial skills (judging relationships and distances between objects).
It is unusual for a person with behavioural variant frontotemporal dementia to be

aware of the extent of their problems. Even early on, people generally lack control
over their behaviour or insight into what is happening to them. The symptoms are
more often noticed by the people close to them.
Language variants of frontotemporal dementia
In the other two types of frontotemporal dementia, the early symptoms are
progressive difficulties with language. These difficulties become apparent slowly,
often over two or more years.
In progressive non-fluent aphasia, initial problems are with speech. (Aphasia means
loss of language.) Common early symptoms may include:
• slow, hesitant speech - speech may seem difficult to produce and a person
may stutter before they can get the right word out, or may mispronounce it
when they do
• errors in grammar - a person may have 'telegraphic speech', leaving out
small link words such as 'to', 'from' or 'the'
• impaired understanding of complex sentences, but not single words.
In semantic dementia, speech is fluent but people begin to lose their vocabulary
and understanding of what objects are. Common early symptoms may include:
• asking the meaning of familiar words (eg, 'What is knife?')

• trouble finding the right word, leading to less precise descriptions instead
(eg 'the thing for opening tins'), or use of generalised words such as 'animal'
instead of 'cat'
• difficulty recognising familiar people or common objects.
In both of the language forms of frontotemporal dementia, other aspects of mental

function (memory, visuospatial skills, planning and organising) tend to be well
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preserved in the early stages.
Later stages
The rate of progression of frontotemporal dementia varies greatly, from less than
two years to 10 years or more. Research shows that on average, people live for
about eight years after the start of symptoms.
As frontotemporal dementia progresses, differences between the three types

become much less obvious. People with the behavioural variant tend to develop
language problems and may eventually lose all speech, like a person with one of
the language variants.
Similarly, over several years a person with semantic dementia or progressive non-
fluent aphasia will generally develop the behavioural problems typical of
behavioural variant frontotemporal dementia.
In the later stages of all forms of frontotemporal dementia, damage to the brain
becomes more widespread. Symptoms are often then similar to those of the later
stages of Alzheimer's disease. The person may become increasingly less
interested in people and things and have limited communication. They may show
restlessness or agitation, or behave aggressively. At this late stage someone may
no longer recognise friends and family, and is likely to need full-time care to meet
their needs.
Overlapping motor disorders
About 10-20 per cent of people with frontotemporal dementia also develop a
motor disorder, before or after the start of dementia. A motor disorder is one that
causes difficulties with movement. These motor disorders - which are generally
uncommon but more likely in this form of dementia - are:
• motor neurone disease

• progressive supranuclear palsy
• corticobasal degeneration.
Their symptoms are similar but can include twitching, stiffness, slow movements
and loss of balance or coordination. In the later stages there are often difficulties
with swallowing. The three motor disorders share some symptoms with
Parkinson's disease.
These motor disorders are all degenerative diseases of the nervous system,
meaning that they will get worse over time. The condition of a person with
frontotemporal dementia and motor neurone disease can deteriorate quite
quickly. On average, a person with both conditions will live for two or three years
after diagnosis.
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Causes
The cause of frontotemporal dementia is not known. Experts assume that the
disease reflects a mixture of genetic, medical and lifestyle factors. Unlike
Alzheimer's disease or vascular dementia, it doesn't seem that frontotemporal
dementia becomes much more common in older age.
Autopsy studies show that the death of nerve cells in the frontal and temporal
lobes is linked to clumps of abnormal proteins inside the cells, including one called
tau. The tau protein may take the form of Pick bodies, which gave frontotemporal
dementia its original name of Pick's disease.
Frontotemporal dementia runs in families much more often than in the more
common forms of dementia. About one third of people with it have some family
history of dementia.
About 10-15 per cent of people with frontotemporal dementia have a strong family
history of it, with several close relatives in different generations affected. In
contrast, strongly inherited early-onset Alzheimer's disease affects less than 1 in
1,000 people with Alzheimer's. Typically in these cases, frontotemporal dementia is
inherited from a parent as a defect (mutation) in one of three genes: MAPT, GRN or
C9ORF72.
The children or siblings of someone with one of the mutations known to cause
frontotemporal dementia are at 50 per cent risk of carrying the same defective
gene. Families with a known mutation should be offered a referral to a specialist
genetics service for counselling. Diagnosis
Frontotemporal dementia can be hard to diagnose, because it is uncommon and

does not initially cause memory problems. Doctors may also not suspect dementia
in a middle-aged person.
Frontotemporal dementia may be misdiagnosed as atypical Alzheimer's disease (a

form of Alzheimer's disease without early memory loss). Behavioural symptoms
may be mistaken for depression, schizophrenia or obsessive-compulsive disorder.
Problems with language or movement may be misdiagnosed as stroke.
Blood tests and a thorough physical examination are important to rule out other
possible causes of symptoms. A specialist may suspect a diagnosis of
frontotemporal dementia after questioning the affected person and someone who
knows them well. The specialist will take a detailed history of their symptoms and
gather information to gain a wider picture of the person's behaviour and
functioning in their daily life.
Standard cognitive tests, which tend to focus on memory loss, can be less helpful in
the diagnosis of frontotemporal dementia. More specialised tests of social
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awareness or behaviour may be needed.
CT (computerised tomography) and MRI (magnetic resonance imaging) brain scans

should be used to assess the pattern of damage to the brain. They can also rule out
other possible causes of symptoms such as stroke or tumour. If further tests are
needed, more specialised brain scans will be carried out such as PET (positron
emission tomography) and SPECT (single photon emission computerised
tomography) to measure brain activity. These scans are useful as they may detect
reduced activity in the frontal and/or temporal lobes at an earlier stage than a CT
or MRI scan might show structural changes.
Further tests may include a lumbar puncture, which involves collecting and
analysing fluid from the spine and is carried out mainly in younger people. Where a
strongly inherited form of frontotemporal dementia is suspected, genetic testing
may confirm the diagnosis and potentially allow family members to find out
whether they will go on to develop frontotemporal dementia in their lifetime. The
decision to find out is up to the individual and support is available.
After a person dies, it is possible to make a pathological diagnosis of

frontotemporal dementia as the changes to the brain can be directly seen at a
post-mortem.
Researchers are working to find effective new treatments for frontotemporal

dementia, but there is currently no cure and the progression of the disease cannot
be slowed. Approaches to treatment look to ease symptoms or help people cope
with them.
Supporting a person with frontotemporal dementia usually requires input from a

team of professionals. These can include a GP, community nurse, psychiatrist and
speech and language therapist. When someone has problems with movement or
coordination, support from a physiotherapist or occupational therapist is often
needed.
Caring for someone with frontotemporal dementia can be particularly challenging,

because of the young age of onset, and changes in behaviour and communication.
Where a gene mutation which causes frontotemporal dementia is identified, birth

relatives will face additional issues of whether to have genetic counselling and
testing themselves.
Specialist support groups for younger people with dementia or those with
frontotemporal dementia and their carers can provide invaluable practical and
emotional support (see 'Other useful organisations'). Social interaction can also
help if the affected person seems to lose motivation in things or appears bored or
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lonely.
Behavioural changes
Many people with frontotemporal dementia continue to lead an active social life
for some years following diagnosis, but changes in behaviour can begin to make
social situations more challenging. It can be less stressful for carers to try to accept
potentially embarrassing behavioural symptoms as part of the disease, rather than
to confront or correct the person, unless the behaviour poses a risk of harm. The
person with dementia will generally lack insight into their condition or the impact
of their behaviour on others. They will generally not have much control over their
actions.
So long as the behaviour is harmless, it may be easier for a carer to allow someone
to carry on with it. The person may prefer to follow a fixed routine or pursue an
obsession (eg with jigsaws).
When a person with frontotemporal dementia behaves inappropriately in public, it

can be useful for the carer to try to remove any triggers or distract the person with
something else. Some carers or people with dementia carry a small card that
explains to members of the public that the person has dementia. (Helpcards for
people with dementia are available from Alzheimer's Society.)
Many carers offer support to help minimise the opportunity for compulsive eating -
for example, by offering food only at mealtimes and in suitable portions. The
person's use of alcohol may also need to be closely monitored.
It is important to try to manage restlessness, agitation or aggressive behaviour

without drugs initially, where possible. This behaviour might result from a person
trying to communicate an unmet need, such as the person feeling frustrated or in
pain. Physical exercise and enjoyable, tailored activities carried out within a
structured routine can help.
There is evidence that certain antidepressant drugs improve apathy (little interest
in people and things) and behavioural symptoms.
If antipsychotic drugs are being considered for a person with frontotemporal

dementia, advice from a specialist on the risks and benefits is recommended.
There have been a few small trials in people with frontotemporal dementia of the
Alzheimer's disease drugs (donepezil, rivastigmine, galantamine and memantine)
with mixed results. In some cases these drugs made symptoms worse. They are
also not licensed for use in frontotemporal dementia and not widely prescribed
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C
Huntington’s disease- What is Huntington disease?
Huntington disease is a progressive brain disorder that causes uncontrolled
movements, emotional problems, and loss of thinking ability (cognition).
Adult-onset Huntington disease, the most common form of this disorder, usually
appears in a person's thirties or forties.
Early signs and symptoms can include irritability, depression, small involuntary
movements, poor coordination, and trouble learning new information or making
decisions.
Many people with Huntington disease develop involuntary jerking or twitching
movements known as chorea.
As the disease progresses, these movements become more pronounced. Affected
individuals may have trouble walking, speaking, and swallowing.
People with this disorder also experience changes in personality and a decline in
thinking and reasoning abilities.
Individuals with the adult-onset form of Huntington disease usually live about 15 to
20 years after signs and symptoms begin.
A less common form of Huntington disease known as the juvenile form begins in
childhood or adolescence.
It also involves movement problems and mental and emotional changes. Additional
signs of the juvenile form include slow movements, clumsiness, frequent falling,
rigidity, slurred speech, and drooling.
School performance declines as thinking and reasoning abilities become impaired.
Seizures occur in 30 percent to 50 percent of children with this condition. Juvenile
Huntington disease tends to progress more quickly than the adult-onset form;
affected individuals usually live 10 to 15 years after signs and symptoms appear.
How common is Huntington disease?

Huntington disease affects an estimated 3 to 7 per 100,000 people of European
ancestry. The disorder appears to be less common in some other populations,
including people of Japanese, Chinese, and African descent.
What genes are related to Huntington disease?

Mutations in the HTT gene cause Huntington disease. The HTT gene provides
instructions for making a protein called huntingtin. Although the function of this
protein is unknown, it appears to play an important role in nerve cells (neurons) in
the brain.
The HTT mutation that causes Huntington disease involves a DNA segment known
as a CAG trinucleotide repeat. This segment is made up of a series of three DNA
building blocks (cytosine, adenine, and guanine) that appear multiple times in a
row. Normally, the CAG segment is repeated 10 to 35 times within the gene. In
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people with Huntington disease, the CAG segment is repeated 36 to more than 120
times. People with 36 to 39 CAG repeats may or may not develop the signs and
symptoms of Huntington disease, while people with 40 or more repeats almost
always develop the disorder.
An increase in the size of the CAG segment leads to the production of an
abnormally long version of the huntingtin protein. The elongated protein is cut into
smaller, toxic fragments that bind together and accumulate in neurons, disrupting
the normal functions of these cells. The dysfunction and eventual death of neurons
in certain areas of the brain underlie the signs and symptoms of Huntington
disease.

How do people inherit Huntington disease?

This condition is inherited in an autosomal dominant pattern, which means one
copy of the altered gene in each cell is sufficient to cause the disorder. An affected
person usually inherits the altered gene from one affected parent. In rare cases, an
individual with Huntington disease does not have a parent with the disorder.
As the altered HTT gene is passed from one generation to the next, the size of the
CAG trinucleotide repeat often increases in size. A larger number of repeats is
usually associated with an earlier onset of signs and symptoms. This phenomenon
is called anticipation. People with the adult-onset form of Huntington disease
typically have 40 to 50 CAG repeats in the HTT gene, while people with the juvenile
form of the disorder tend to have more than 60 CAG repeats.
Individuals who have 27 to 35 CAG repeats in the HTT gene do not develop
Huntington disease, but they are at risk of having children who will develop the
disorder. As the gene is passed from parent to child, the size of the CAG
trinucleotide repeat may lengthen into the range associated with Huntington
disease (36 repeats or more).

D Alzheimer’s disease- Typical early symptoms of Alzheimer’s include:
• Regularly forgetting recent events, names and faces.

• Becoming increasingly repetitive.
• Regularly misplacing items or putting them in odd places.
• Confusion about the time of day.
• Disorientation, especially away from your normal surroundings.
• Getting lost.
• Problems finding the right words.
• Mood or behaviour problems such as apathy, irritability, or losing confidence.
Alzheimer’s gets worse over time, but the speed of change varies from person to
person

E Vascular dementia- Vascular dementia is the second most common type of
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dementia (after Alzheimer's disease), affecting around 150,000 people in the UK.
The word dementia describes a set of symptoms that can include memory loss and
difficulties with thinking, problem-solving or language. In vascular dementia, these
symptoms occur when the brain is damaged because of problems with the supply
of blood to the brain. This factsheet outlines the causes, types and symptoms of
vascular dementia. It looks at how it is diagnosed and the factors that can put
someone at risk of developing it. It also describes the treatment and support that
are available.
Causes
Vascular dementia is caused by reduced blood supply to the brain due to diseased
blood vessels.
To be healthy and function properly, brain cells need a constant supply of blood to
bring oxygen and nutrients. Blood is delivered to the brain through a network of
vessels called the vascular system. If the vascular system within the brain becomes
damaged - so that the blood vessels leak or become blocked - then blood cannot
reach the brain cells and they will eventually die.
This death of brain cells can cause problems with memory, thinking or reasoning.
Together these three elements are known as cognition. When these cognitive
problems are bad enough to have a significant impact on daily life, this is known as
vascular dementia.
Types of vascular dementia
There are several different types of vascular dementia. They differ in the cause of
the damage and the part of the brain that is affected. The different types of
vascular dementia have some symptoms in common and some symptoms that
differ. Their symptoms tend to progress in different ways.
Stroke-related dementia
A stroke happens when the blood supply to a part of the brain is suddenly cut off.
In most strokes, a blood vessel in the brain becomes narrowed and is blocked by a
clot. The clot may have formed in the brain, or it may have formed in the heart (if
someone has heart disease) and been carried to the brain. Strokes vary in how
severe they are, depending on where the blocked vessel is and whether the
interruption to the blood supply is permanent or temporary.
Post-stroke dementia
A major stroke occurs when the blood flow in a large vessel in the brain is suddenly
and permanently cut off. Most often this happens when the vessel is blocked by a
clot. Much less often it is because the vessel bursts and bleeds into the brain. This
sudden interruption in the blood supply starves the brain of oxygen and leads to
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the death of a large volume of brain tissue.
Not everyone who has a stroke will develop vascular dementia, but about 20 per
cent of people who have a stroke do develop this post-stroke dementia within the
following six months. A person who has a stroke is then at increased risk of having
further strokes. If this happens, the risk of developing dementia is higher.
Single-infarct and multi-infarct dementia
These types of vascular dementia are caused by one or more smaller strokes. These
happen when a large or medium-sized blood vessel is blocked by a clot. The stroke
may be so small that the person doesn't notice any symptoms. Alternatively, the
symptoms may only be temporary - lasting perhaps a few minutes - because the
blockage clears itself. (If symptoms last for less than 24 hours this is known as a
'mini-stroke' or transient ischaemic attack (TIA). A TIA may mistakenly be dismissed
as a 'funny turn'.)
If the blood supply is interrupted for more than a few minutes, the stroke will lead
to the death of a small area of tissue in the brain. This area is known as an infarct.
Sometimes just one infarct forms in an important part of the brain and this causes
dementia (known as single-infarct dementia). Much more often, a series of small
strokes over a period of weeks or months lead to a number of infarcts spread
around the brain. Dementia in this case (known as multi-infarct dementia) is
caused by the total damage from all the infarcts together.
Subcortical dementia
Subcortical vascular dementia is caused by diseases of the very small blood vessels
that lie deep in the brain. These small vessels develop thick walls and become stiff
and twisted, meaning that blood flow through them is reduced.
Small vessel disease often damages the bundles of nerve fibres that carry signals
around the brain, known as white matter. It can also cause small infarcts near the
base of the brain.
Small vessel disease develops much deeper in the brain than the damage caused by
many strokes. This means many of the symptoms of subcortical vascular dementia
are different from those of stroke-related dementia.
Subcortical dementia is thought to be the most common type of vascular

dementia.
Mixed dementia (vascular dementia and Alzheimer's disease)
At least 10 per cent of people with dementia are diagnosed with mixed dementia.
This generally means that both Alzheimer's disease and vascular disease are
thought to have caused the dementia. The symptoms of mixed dementia may be
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similar to those of either Alzheimer's disease or vascular dementia, or they may be
a combination of the two.
Symptoms
How vascular dementia affects people varies depending on the different underlying
causes and more generally from person to person. Symptoms may develop
suddenly, for example after a stroke, or more gradually, such as with small vessel
disease.
Some symptoms may be similar to those of other types of dementia. Memory loss
is common in the early stages of Alzheimer's, but is not usually the main early
symptom of vascular dementia.
The most common cognitive symptoms in the early stages of vascular dementia
are:
• problems with planning or organising, making decisions or solving problems

• difficulties following a series of steps (eg cooking a meal)
• slower speed of thought
• problems concentrating, including short periods of sudden confusion.
A person in the early stages of vascular dementia may also have difficulties with:
• memory - problems recalling recent events (often mild)

• language - eg speech may become less fluent
• visuospatial skills - problems perceiving objects in three dimensions.
As well as these cognitive symptoms, it is common for someone with early vascular
dementia to experience mood changes, such as apathy, depression or anxiety.
Depression is common, partly because people with vascular dementia may be
aware of the difficulties the condition is causing. A person with vascular dementia
may also become generally more emotional. They may be prone to rapid mood
swings and being unusually tearful or happy.
Other symptoms that someone with vascular dementia may experience vary
between the different types. Post-stroke dementia will often be accompanied by
the obvious physical symptoms of the stroke. Depending on which part of the brain
is affected, someone might have paralysis or weakness of a limb. Or if a different
part of the brain is damaged they may have problems with vision or speech. With
rehabilitation, symptoms may get a little better or stabilise for a time, especially in
the first six months after the stroke.
Symptoms of subcortical vascular dementia vary less. Early loss of bladder control
is common. The person may also have mild weakness on one side of their body, or
become less steady walking and more prone to falls. Other symptoms of
subcortical vascular dementia may include clumsiness, lack of facial expression and
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problems pronouncing words.
Progression and later stages
Vascular dementia will generally get worse, although the speed and pattern of this
decline vary. Stroke-related dementia often progresses in a 'stepped' way, with
long periods when symptoms are stable and periods when symptoms rapidly get
worse. This is because each additional stroke causes further damage to the brain.
Subcortical vascular dementia may occasionally follow this stepped progression,
but more often symptoms get worse gradually, as the area of affected white
matter slowly expands.
Over time a person with vascular dementia is likely to develop more severe
confusion or disorientation, and further problems with reasoning and
communication. Memory loss, for example for recent events or names, will also
become worse. The person is likely to need more support with day-to-day activities
such as cooking or cleaning.
As vascular dementia progresses, many people also develop behaviours that seem
unusual or out of character. The most common include irritability, agitation,
aggressive behaviour and a disturbed sleep pattern. Someone may also act in
socially inappropriate ways.
Occasionally a person with vascular dementia will strongly believe things that are
not true (delusions) or - less often - see things that are not really there
(hallucinations). These behaviours can be distressing and a challenge for all
involved.
In the later stages of vascular dementia someone may become much less aware of
what is happening around them. They may have difficulties walking or eating
without help, and become increasingly frail. Eventually, the person will need help
with all their daily activities.
How long someone will live with vascular dementia varies greatly from person to
person. On average it will be about five years after the symptoms started. The
person is most likely to die from a stroke or heart attack.
Who gets vascular dementia?
There are a number of things that can put someone at risk of developing vascular
dementia. These are called risk factors. Most of these are things that contribute to
underlying cardiovascular diseases. Some of these risk factors (eg lifestyle) can be
controlled, but others (eg age and genes) cannot. For more information see
factsheet 450, Am I at risk of developing dementia?
Age is the strongest risk factor for vascular dementia. A person's risk of developing
the condition doubles approximately every five years over the age of 65. Vascular
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dementia under the age of 65 is uncommon and affects fewer than 8,000 people in
the UK. Men are at slightly higher risk of developing vascular dementia than
women.
A person who has had a stroke, or who has diabetes or heart disease, is
approximately twice as likely to develop vascular dementia. Sleep apnoea, a
condition where breathing stops for a few seconds or minutes during sleep, is also
a possible risk factor. Someone can reduce their risk of dementia by keeping these
conditions under control, through taking prescribed medicines (even if they feel
well) and following professional advice about their lifestyle.
There is some evidence that a history of depression also increases the risk of
vascular dementia. Anyone who thinks they may be depressed should seek their
doctor's advice early.
Cardiovascular disease - and therefore vascular dementia - is linked to high blood

pressure, high cholesterol and being overweight in mid-life. Someone can reduce
their risk of developing these by having regular check-ups (over the age of 40), by
not smoking, and by keeping physically active. It will also help to eat a healthy
balanced diet and drink alcohol only in moderation.
Aside from these cardiovascular risk factors, there is good evidence that keeping
mentally active throughout life reduces dementia risk. There is some evidence for
the benefits of being socially active too.
Researchers think there are some genetic factors behind the common types of
vascular dementia, and that these are linked to the underlying cardiovascular
diseases. Someone with a family history of stroke, heart disease or diabetes has an
increased risk of developing these conditions. Overall, however, the role of genes
in the common types of vascular dementia is small.
People from certain ethnic groups are more likely to develop cardiovascular
disease and vascular dementia than others. Those from an Indian, Bangladeshi,
Pakistani or Sri Lankan background living in the UK have significantly higher rates of
stroke, diabetes and heart disease than white Europeans. Among people of
African-Caribbean descent, the risk of diabetes and stroke - but not heart disease -
is also higher. These differences are thought to be partly inherited but mainly due
to lifestyle factors such as diet, smoking and exercise.
Diagnosis
Anyone who is concerned that they may have vascular dementia (or any other type
of dementia) should seek help from their GP. If someone does have dementia, an
early diagnosis has many benefits: it provides an explanation for the person's
symptoms; it gives access to treatment, advice and support; and it allows them to
prepare for the future and plan ahead. For vascular dementia, treatments and
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lifestyle changes may also slow down the progression of the underlying disease.
There is no single test for vascular dementia. The GP will first need to rule out
conditions that can have similar symptoms, particularly depression. Symptoms
could also be caused by infections, vitamin and thyroid deficiencies (diagnosed
from a blood test) and side effects of medication.
The doctor will also talk to the person about their medical history (eg high blood
pressure or diabetes). This will include questions about dementia or cardiovascular
disease in close family members. The doctor will probably do a physical
examination and will ask about how the person's symptoms are currently affecting
their life. The GP or a practice nurse may ask the person to do some tests of mental
abilities. It is often helpful if a close friend or family member accompanies the
person to medical appointments. They may be able to describe subtle changes that
the person themselves has not noticed, such as starting to struggle with daily
activities.
The GP may feel able to make a diagnosis of vascular dementia at this stage. If not,
they will generally refer the person to a specialist. This might be an old-age
psychiatrist (who specialises in the mental health of older people) based in a
memory service, or a geriatrician (who specialises in the physical health of older
people) in a hospital. For more information see factsheet 426, Assessment and
diagnosis.
The specialist will assess the person's symptoms in more detail. The way that
symptoms developed - in steps or more gradually - may suggest different
underlying diseases. The person's thinking and other mental abilities will also be
assessed further with a wider range of tests. In someone with vascular dementia,
the test might show slowness of thought and difficulties thinking things through,
which are often more common than memory loss.
A person suspected of having vascular dementia will generally have a brain scan to
look for any changes that have taken place in the brain. A scan such as CT
(computerised tomography) or MRI (magnetic resonance imaging) may rule out a
tumour or build-up of fluid inside the brain. These can have symptoms similar to
those of vascular dementia. A CT scan may also show a stroke or an MRI scan may
show changes such as infarcts or damage to the white matter. If this is the case,
the brain scan will be very helpful in diagnosing the dementia type, rather than
simply ruling out other causes.
If the person has dementia, and the circumstances mean it is best explained by
vascular disease in the brain, a diagnosis of vascular dementia will be made. For
example, the dementia may have developed within a few months of a stroke, or a
brain scan may show a pattern of disease that explains the dementia symptoms.
The diagnosis should be communicated clearly to the person and usually also those
closest to them, along with a discussion about the next steps. For more information
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see factsheet 426, Assessment and diagnosis.
There is currently no cure for vascular dementia: the brain damage that causes it
cannot be reversed. However, there is a lot that can be done to enable someone to
live well with the condition. This will involve drug and non-drug treatment, support
and activities.
The person should have a chance to talk to a health or social care professional
about their dementia diagnosis. This could be a psychiatrist or mental health nurse,
a clinical psychologist, occupational therapist or GP. Information on what support is
available and where to go for further advice is vital in helping someone to stay
physically and mentally well.
Control of cardiovascular disease
If the underlying cardiovascular diseases that have caused vascular dementia can
be controlled, it may be possible to slow down the progression of the dementia.
For example, after someone has had a stroke or TIA, treatment of high blood
pressure can reduce the risk of further stroke and dementia. For stroke-related
dementia in particular, with treatment there may be long periods when the
symptoms don't get significantly worse.
In most cases, a person with vascular dementia will already be on medications to

treat the underlying diseases. These include tablets to reduce blood pressure,
prevent blood clots and lower cholesterol. If the person has a diagnosed heart
condition or diabetes they will also be taking medicines for these. It is important
that the person continues to take any medications and attends regular check-ups
as recommended by a doctor.
Someone with vascular dementia will also be advised to adopt a healthy lifestyle,
particularly to take regular physical exercise and, if they are a smoker, to quit. They
should try to eat a diet with plenty of fruit, vegetables and oily fish but not too
much fat or salt. Maintaining a healthy weight and keeping to recommended levels
of alcohol will also help. The GP should be able to offer advice in all these areas
KEY
Additional
Information
Reference
Dr Khalid/Rabia National Institute of Neurological and Communicative Disorders and Stroke and the
Alzheimer's Disease and Related Disorders Association (NINCDS/ADRDA) diagnostic
criteria be used for the assessment of Alzheimer's disease. Alternatives are the ICD-
10 or DSM-IV (now DSM-5 since the guidelines were written) criteria.[10][11]

The NINCDS/ADRDA criteria were proposed in 1984 and revised in 2011.[12] Core
features for diagnosis of Alzheimer's disease include:
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Probable Alzheimer's disease
Dementia established by clinical examination and neuropsychological tests.
Deficits in two or more areas of cognition.
Insidious onset over months to years, and progressive worsening of memory and
other cognitive functions.
No disturbance of consciousness.
Onset between ages of 40 and 90. (Criterion removed in latest revision.)
Absence of systemic disorders or other brain diseases that could account for the
symptoms.
Possible Alzheimer's disease
Dementia with an atypical onset or course (ie sudden onset or insufficient
documentation of progressive decline); OR
Aetiologically mixed presentation (ie other criteria fit the diagnosis, but features of
other brain disorders or causes of dementia are present).
Mild cognitive impairment due to Alzheimer's disease
Newer diagnostic criteria have attempted to classify the symptomatic, pre-
dementia stage of Alzheimer's disease. The work group which revised the
NINCDS/ADRDA criteria in 2011 refers to this stage as "mild cognitive impairment"
with clinical diagnostic criteria as follows:[13]

Concern regarding a change in cognition (from patient, informer or clinician)
Impairment of one or more cognitive domains
Preservation of independence in functional abilities
Not having the features of dementia

Q: 1629 1629. An 83yo woman admitted with a chest infection becomes confused with impaired
attention and poor concentration. She is restless and frightened. She is verbally abusive
and has perceptual abnormalities. There is no significant prv psychiatric hx. What is the
SINGLE most likely dx?
a. Delirium
b. Drug induced psychosis
c. Lewy body dementia
d. Multi-infarct dementia
e. Psychotic depression


A No sig previous history/ delirium
B
C
D
E
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KEY A
Additional
information Points in favour = Reason: Drug induced psychosis would require a drug history,
dementia and psychotic depression would have a significant previous psychiatric history.
Delirium or Acute Confusional States happen in the elderly in response to stressors like
acute infections and this is most likely brought on by the chest infection that has
developed.

Q:1633 1633. A 38yo man has disturbing thoughts about his house being infected by germs. He
is anxious about safety and checks the locks of his doors repeatedly before going to bed.
For the last 8wks he has been washing his hands every time he touches the lock, 20-30
times a day. What is the SINGLE most appropriate management?
a. Antidepressant
b. Antipsychotic
c. Anxiolytic
d. CBT
e. Psychodynamic psychotherapy

Clincher(s)
A
B
C
D
E
KEY D
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Additional

information Reason: This scenario describes a case of OCD for which the best management is CBT
followed by SSRIs or TCAs. The first line treatment is always CBT, not pharmacological
therapy. Psychotherapy is indicated in depression, psychosomatic disorders, dissociative
or conversion disorders, personality disorders, relationship problems or grief
Q: 1651 1651. A 59yo man has shown a change in his mood and personality over a 9m period.
He has subsequently developed difficulty with memory and conc, and then progressive
fidgety movements of his limbs and facial musculature. By the time of medical
assessment he has frank choreiform movements and a mini-mental state exam of 21/30.
Other exam is normal. He was adopted and therefore no information on his famhx is
available. He has 3 adult children (27, 30,33) of whom the 2 youngest are asymptomatic.
However, the oldest son has recently been inv by the neurology dept for slightly erratic
behavior and fidgety restless movements of both legs. Based on the likely clinical dx,
which one of the following genetic patterns is most likely?
a. AD inheritance with anticipation
b. AD with variable penetrance
c. AR
d. X-linked
e. Mitochondrial disorder


A Patient is suffering from Huntingtons disease and that is autosomal dominant
with anticipation which means a genetic disorder is passed on to the next
generation, the symptoms of the genetic disorder become apparent at an
earlier age with each generation.
Huntingtons Disease:
· It is an inherited (genetic) condition that affects the brain and nervous
system. It can interfere with movements of your body, can affect your
reasoning, awareness, thinking and judgement (cognition) and can lead to a
change in your behavior
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· This faulty gene is carried on chromosome 4.
· HD affects between 5-10 people per 100,000 in the UK.
Presentation
The symptoms of HD can be grouped into three main areas:
· Problems with movement
· Problems with cognition
· Mood and behavioural problems
Treatment:
· At present there is no cure for HD. Also, there is no treatment that has been
found to delay the onset of symptoms or to delay the progression of
symptoms.

B
C
D
E
KEY a
Q: 1652 1652. A 35yo pt has been dx with schizophrenia. He mimics the doctors and attendants –
doing the same physical actions as them. What symptom does this pt have?
a. Echopraxia
b. Echolalia
c. Perseveration
d. Apraxia
e. Anosognosia


A Echopraxia is the involuntary repetition or imitation of another person's (action)
B . Similar to echolalia, which is the involuntary repetition of sounds and language. Echopraxia
has long been recognized as a core feature of Tourette syndrome, and is considered a
complex tic, but it also occurs in autism spectrum disorders, schizophrenia and catatonia
(verbal)
C
D Apraxia is a motor disorder caused by damage to the brain (specifically the posterior
parietal cortex), in which someone has difficulty with the motor planning to perform
tasks or movements when asked, provided that the request or command is understood
and he/she is willing to perform the task. Apraxia is an acquired disorder of motor
planning, but is not caused by incoordination, sensory loss, or failure to comprehend
simple commands (which can be tested by asking the person to recognize the correct
movement from a series
E Anosognosia is a deficit of self-awareness, a condition in which a person who suffers a
certain disability seems unaware of the existence of his or her disability
KEY a
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Additional
Echopraxia is involuntary imitation of the movements and is a feature for the
information diagnosis of schizophrenia.
Schizophrenia:
· Schizophrenia is a serious mental health condition that causes disordered
ideas, beliefs and experiences. In a sense, people with schizophrenia lose
touch with reality and do not know which thoughts and experiences are true
and real and which are not.
· Schizophrenia develops in about 1 in 100 people. It can occur in men and
women. The most common ages for it first to develop are 15-25 in men and 25-
35 in women.
Presentation:
· Delusions
· Hallucinations.
· Disordered thoughts.
Q: 1656 1656. A 65yo pt who had MI 1yr ago now comes to the ED complaining that his neighbor
is conspiring against him. When his son is asked, he denies it and also narrates that
sometimes his father says that everybody in his office is always talking about him, which
is not the case. What is the most appropriate med?
a. TCA
b. Clozapine
c. Olanzapine
d. Lorazepam


A
B
C
D
E
KEY C (atypical antipsychotics)
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February 17, 2016

Additional
information TCA is not given at this age
Clozapine needs strict monitoring and can only be given under the supervision of
a psychiatrist
Olanzapaine is antipsychotic which is most suitable in this case
He is psychotic. Delusion of reference.

Clazipeine was fatal MI/agranulocytosis- last resort, Lorazepine is short acting
Q: 1693 1693. A young girl with a psychiatric hx on med tx is brought to the dermatologist by her
mother
because of recurrent patchy hair loss. Exam: the hair shafts revealed twisting and
fractures. This
suggests the following pathology:
a. Infection with Trichophyton
tonsurans
b. Infection with Microsporum
canis
c. Alopecia areata
d. Telogen Effluvium
e. Androgenetic Alopecia
f. Lichen planus
g. Traction Alopecia
h. Alopecia totalis
i. Trichorrhexis nodosa
j. Trichotillomania


A
B
C
D
E
KEY Trichotillomania (she is pulling her hair), which is a psychotriac disprder. others are
infection.
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Additional
information
Q: 1701 1701. A 45yo woman presents with easy fatigability, even on no exertion, chronic
headaches and body aches and severe physical and mental exhaustion. She has no
underlying conditions and all inv are non-conclusive. What is the most likely dx?
a. Somatization (symptoms utpo 2 years with no positive findings)
b. Chronic fatigure syndrome (diag of exclusion)
c. Polymyalgia rheumatic (unknown pain)
d. GCA (one sided pain in elderly men)
e. Depression


A One character: will be from different systems.
B
C investigation
D GCA- giant cell arthritis- will have finings
E
KEY B (diagnosis of exclusion- easy fatiguability – without underlying condition)

Q:1234 . A 22yo man keeps having persistent and intrusive thoughts that he is a dirty
thief. No matter what he tries these thoughts keep coming to him. Any attempt
to avoid these thoughts leads to serious anxiety. What is the most likely dx?
a. Schizophrenia
b. OCD
c. PTSD
d. Mania
e. Psychotic depression
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February 17, 2016

Clincher(s)
A Schizophrenia-Schizophrenia is a common chronic/relapsing
condition often presenting in
late teens/early 20s with psychotic symptoms
(hallucinations, delusi ons); disorganization
symptoms (incongruous mood, abnormal speech and
thought);
negative symptoms (apathy, self-neglect, blunted mood,
motivation, withdrawal);
and, sometimes, cognitive impairment.It has major
implications
for patients, work and families
B Ocd
C Ptsd
D Mania
E Psychotic depression
KEY OCD (B)
Symptoms typically include recurring thoughts and repetitive actions in
response to the recurring thoughts. A common example is recurring thoughts
about germs and dirt, with a need to wash your hands repeatedly to "clean off
the germs".
-

Additional Treatment
Information The usual treatment for OCD is:
- Cognitive behavioural therapy (CBT)
- Medication, usually with an Clomipramine or SSRI antidepressant
medicine; or
- A combination of CBT plus an SSRI antidepressant medicine
Reference

Dr Khalid/Rabia

Q:1236 A 30yo man is becoming concerned about the safety of his family. He has been
checking the locks of the door every hour during the night. He becomes very
anxious if his wife tries to stop him. What is the most likely dx?
a. Paranoid delusion
b. PTSD
c. Social phobia
d. OCD
e. GAD
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February 17, 2016

Clincher(s)
A Paranoid delusion
B PTSD
C Social phobia
D OCD
E GAD
KEY OCD (D)
Described in 1234

Additional
Information
Reference
Dr Khalid/Rabia

Q:1244 1244. A pt presents with a mask face. He also has gait prbs. Which class of drug is
causing this?
a. Anti-depressant
b. Antipsychotic
c. Anti-HTN
Mask face and gait problems suggest Parkinsonism which is caused by deficiency of
Dopamine and anti-psychotic medications are known to deplete Dopamine and
cause Parkinsonism
Clincher(s)
A Anti depressant-anti –muscarinic effects like
B Anti psychotic – typical have more
C Anti HTN
D
E
KEY Anti-Psychotics Side-effects (B)
-.
- The other medications mentioned do not cause the symptoms such as in this
patient.
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February 17, 2016

Additional
Information

Anti-depressant side effects :
• Dry mouth
• Urinary retention
• Blurred vision
• Constipation
• Sedation (can interfere with driving or operating machinery)
• Sleep disruption
• Weight gain
• Headache
• Nausea
• Gastrointestinal disturbance/diarrhea
• Abdominal pain
• Inability to achieve an erection
• Inability to achieve an orgasm (men and women)
• Loss of libido
• Agitation
• Anxiety

Reference http://www.clinical-depression.co.uk/dlp/treating-depression/side-effects-of-
antidepressants/
Rang & dale pharmaco
Dr Khalid/Rabia All antipsychotic treamtents cause extra pirimidal symptoms

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February 17, 2016

Q:18-25 A 22yo girl unhappy about her weight with BMI=22. She likes to have her
dinner in an expensive restaurant. She does excessive shopping. K+=3.3.
What is the dx?
a. Anorexia nervosa
b. Bipolar
c. OCD
d. Bulimia

18-25 N
Clincher(s) YOUNG AGE , bmi=22, low potassium (k= 3.5-5 normal) , unhappy abt her wt
A . Anorexia Nervosa: BMI = LESS THAN 17.5
People with anorexia nervosa maintain a low body weight as a result of a
preoccupation with weight, construed as either a fear of fatness or a pursuit of
thinness. In spite of this, they believe they are fat and are terrified of becoming
what is, in reality, a normal weight or shape. A diagnosis of anorexia nervosa is
based on low body weight, weight loss measures (particularly extreme dieting),
psychological features (usually including distorted body image), along with physical
and endocrine sequelae
B . Bipolar Disorder:
Bipolar disorder is a chronic episodic illness associated with behavioural
disturbances. It used to be called manic depression. It is characterised by episodes
of mania (or hypomania) and depression. Either one can occur first and one may
be more dominant than the other but all cases of mania eventually develop
depression.

C OCD
D Bulimia nervosa ( BMI GREATER THAN 17.5) is an eating disorder characterised
by repeated episodes of uncontrolled overeating (binges) followed by
compensatory weight loss behaviours.
D
KEY Answer: D. Bulimia. Patient likes to have dinner in expensive restaurant,
normal BMI ( as patient after eating go for self induced vomiting) and low
potassium point towards the diagnosis. Bulimia nervosa is a type of eating
disorder characterised by episodes of binge eating followed by intentional vomiting
Features include:
• Excessive preoccupation with body weight and shape

• Undue emphasis on weight in self-evaluation
• Feeling of lack of control over eating
• Compensatory weight control mechanisms which can be:
o Self-induced vomiting
o Fasting
o Intensive exercise
o Abuse of medication such as laxatives, diuretics, thyroxine
or amphetamines
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February 17, 2016

Presentation
The history often dates back to adolescence. The core features include:
o Regularbinge eating. Loss of control of eating during

binges.
o Attempts to counteract the binges - eg, vomiting, using
laxatives, diuretics, dietary restriction and excessive
exercise.
o Preoccupation with weight, body shape, and body image.
o Preoccupation with food and diet. This is often rigid or
ritualistic, and deviations from a planned eating
programme cause distress. The affected person therefore
starts to avoid eating with others and becomes isolated.
o Mood disturbance and anxiety are common, as are low
self-esteem, and self-harm.
o Severe comorbid conditions may be present - eg,
depression and substance abuse.
o Periods may be irregular.
Investigations
• These are usually normal apart from serum potassium, which is often
low.
• Renal function and electrolytes should be checked in view of frequent
self-induced vomiting.
Management:
• referral for specialist care is appropriate in all cases
• cognitive behaviour therapy (CBT) is currently considered first-line

treatment
• interpersonal psychotherapy is also used but takes much longer than CBT
• pharmacological treatments have a limited role - a trial of high-dose
fluoxetine is currently licensed for bulimia but long-term data is lacking

Additional
Information
Reference
Dr Khalid/Rabia

Q:1253 A 22yo girl had a fight with her boyfriend and then took 22 tabs of paracetamol.
She was commenced on N-acetyl cysteine and she was medically fit to go
home the following day. Which
of the following does she require?
a. OPD referral to relationship counselor
b. OPD referral to psychiatrist
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February 17, 2016

c. Inpatient referral to psychiatrist
d. Inpatient referral to psychologist.

Clincher(s) Attempt to suicide
A
B
C
D
E
KEY Answer: C. inpatient referral to psychiatrist. In this case the patient is suicidal
so we can not discharge the patient and patient should be admitted in
psychiatry department
Additional
Information
Reference
Dr Khalid/Rabia

Q:1268 A 36yo pregnant woman comes for evaluation with her husband. Her husband
has been complaining of morning sickness, easy fatigability and even
intermittent abdominal pain. What
is the husband suffering from?
a. Ganser syndrome
b. Couvade syndrome
c. Pseudo-psychosis
d. Stockholm syndrome
e. Paris syndrome

Clincher(s)
A Ganser syndrome is a type of factitious disorder, a mental illness in
which a person deliberately and consciously acts as if he or she has a
physical or mental illness when he or she is not really sick.

B Couvade syndrome, also called sympathetic pregnancy, is a proposed
condition in which a partner experiences some of the same symptoms
and behavior of an expectant mother. These most often include minor
weight gain, altered hormone levels, morning nausea, and disturbed
sleep patterns.

C Stockholm syndrome, or capture-bonding, is a psychological
phenomenon in which hostages express empathy and sympathy and
have positive feelings toward their captors, sometimes to the point of
defending and identifying with the captors.
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D Pseudo Psychosis: As the name itself says, pseudo (psychosis), which means
false, is not a form of psychosis, but instead, pseudo psychosis is when someone
is convinced that they are suffering from psychosis when they are not. This doesn’t
mean that the person is pretending or faking the symptoms of psychosis such as
hallucinations, “hearing voices” or other forms of being completely detached from
reality.

E Paris Syndrome: is a transient psychological disorder exhibited by some
individuals visiting or vacationing in Paris or elsewhere in Western Europe. It is
characterized by a number of psychiatric symptoms such as acute delusional
states, hallucinations, feelings of persecution (perceptions of being a victim of
prejudice, aggression, or hostility from others), derealization, depersonalization,
anxiety, and also psychosomatic manifestations such as dizziness, tachycardia,
sweating, and others. The have hallucinations while in those countries.

KEY Couvades syndrome
Additional
Information
Reference
Dr Khalid/Rabia

Q:1283 1283. A 77yo publican was admitted for an appendectomy. Post-op he
becomes confused, agitated and starts to pick at things. He is then given an IV
drug which settles this confusion. Which of the following drugs was given for
his confusion?
a. Diazepam
b. Chlordiazepoxide
c. Thiamine
d. Vit B

Clincher(s)
A Diazepam is 2nd line. Benzodiazepines are the recommended drugs for
detoxification. They have a slower onset of action and therefore are less likely
to lead to abuse

B
C
D
E
KEY B-Chlordiazepoxide
For alcohol withdrawal, chlordiazepoxide is 1st line. Diazepam is 2nd line.
e. A reducing dose of chlordiazepoxide over 5-7 days is commonly used.

Additional Diazepam is an alternative.
Information
• Symptoms typically present about eight hours after a significant fall in
blood alcohol levels. They peak on day 2 and, by day 4 or 5, the
symptoms have usually improved significantly.
• Minor withdrawal symptoms (can appear 6-12 hours after alcohol has
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February 17, 2016

stopped)
o Insomnia and fatigue.
o Tremor.
o Mild anxiety/feeling nervous.
o Mild restlessness/agitation.
o Nausea and vomiting.
o Headache.
o Excessive sweating.
o Palpitations.
o Anorexia.
o Depression.
o Craving for alcohol.
• Alcoholic hallucinosis (can appear 12-24 hours after alcohol has
stopped)
o Includes visual, auditory or tactile hallucinations.
• Withdraw
• al seizures (can appear 24-48 hours after alcohol has stopped)
o These are generalised tonic-clonic seizures.
• Alcohol withdrawal delirium or 'delirium tremens' (can appear 48-72
hours after alcohol has stopped).
OHCS 363

OHCM 282

Reference
Dr Khalid/Rabia

Q:620 A 36yo woman was recently admitted to a psychiatric ward. She believes that
the staff and other pts know exactly what she is thinking all the time. What is
the most likely symptom this pt is suffering from?
a. Thought insertion
b. Thought withdrawal
c. Thought block
d. Though broadcasting
e. Hallucination

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February 17, 2016

Where exclusions not discussed: they have been discussed in other questions
Clincher(s)
A
B
C
D
E
KEY d. Though broadcasting

Additional
Information
Reference
Dr Khalid/Rabia
Thought insertion, removal or interruption - delusions about external control
of thought: The delusion that thoughts are being placed into one's mind
by an outsider; often a symptom of schizophrenia.

Thought broadcasting - the delusion that others can hear one's thoughts

thought withdrawal is the delusional belief that thoughts have been 'taken
out' of the patient's mind, and the patient has no power over this. It often
accompanies thought blocking.

Thought blocking is a thought condition usually caused by a mental health
condition such as schizophrenia. During thought blocking, a person stops
speaking suddenly and without explanation in the middle of a sentence.

hallucination is a perception in the absence of external stimulus that has
qualities of real perception.

Q:621 A 60yo woman is admitted to the hospital after a fall. She is noted to have
poor eye contact. When asked how she is feeling, she admits to feeling low in
mood and losing enjoyment in all her usual hobbies. She has also found it
difficult to concentrate, feels that she is not good at anything, feels guilty over
minor issues and feels very negative about the future. What is the most likely
dx?
a. Mild depression
b. Moderate depression
d. Psychosis
e. Seasonal depression

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February 17, 2016

Clincher(s) Low mood, difficult to concentrate, not feeling good, feeling guilty and
negative
A See Dr Khalid’s note below
B
C
D
E
KEY a. Mild depression

Additional (FB-Khalid/Fb discussions)
Information
Mild depression: i)Low mood ii) Anhedonia (inability to feel pleasure) iii) Guilt
iv) Hopelessness v) Worthlessness vi) Inability to concentrate. Tx CBT

Moderate depression: Features of mild + vii) Poor sleep viii) Poor Appetite ix)
Poor libido x) Easy fatiguability. Tx Antidepressants [signs of self neglect
/biological features of depression]

Severe depression: Features of moderate + xi) Suicidal intensions. Tx ECT

Psychotic depression: Features of severe + xii) Hallucinations xiii) Delusions
xiv) Guilt xv) Nihilism. Tx ECT

FB: At least 5 of the following must be present for at least 2 weeks for severe
depression:

Sleep – increased or decreased (if decreased, often early morning awakening)
Interest – decreased
Guilt/worthlessness
Energy – decreased or fatigued
Concentration/difficulty making decisions
Appetite and/or weight increase or decrease
Psychomotor activity – increased or decreased
Suicidal ideation
• (no need to learn everything below)

• The severity of depression is based on:
o The number, duration, and severity of symptoms, and their
impact socially and functionally. The severity of depression is
classified as:
" Subthreshold depression — less than the five symptoms
required to make a diagnosis of major depression.
" Mild depression — few, if any, symptoms in excess of
the five required to make the diagnosis, and only minor
functional impairment.
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" Moderate depression — symptoms or functional
impairment between mild and severe. Some symptoms
would be expected to be marked.
" Severe depression — several symptoms in excess of
those required to make the diagnosis. Some symptoms
would be expected to be severe and markedly interfere
with functioning.
• A depression questionnaire. This may be used as well to give an
indication of the severity of depression and to help assess
improvement over time.
• The three recommended questionnaires, which are validated for use in
primary care, are PHQ-9 (Patient Health Questionnaire 9), HADS
(Hospital Anxiety and Depression Scale), and BDI-II (Back Depression
Inventory-II). [Details in NICE]
Reference FB/NICE
Dr Khalid/Rabia Rabia:

NICE use the DSM-IV criteria to grade depression:
• 1. Depressed mood most of the day, nearly every day
• 2. Markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day
• 3. Significant weight loss or weight gain when not dieting or decrease
or increase in appetite nearly every day
• 4. Insomnia or hypersomnia nearly every day
• 5. Psychomotor agitation or retardation nearly every day
• 6. Fatigue or loss of energy nearly every day
• 7. Feelings of worthlessness or excessive or inappropriate guilt nearly
every day
• 8. Diminished ability to think or concentrate, or indecisiveness nearly
every day
• 9. Recurrent thoughts of death, recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for committing
suicide

The above in additional information in table form by Rabia:
Subthreshold
depressive symptoms Fewer than 5 symptoms
Mild depression Few, if any, symptoms in excess of the 5 required to make the
diagnosis, and symptoms result in only minor functional
impairment
Moderate depression Symptoms or functional impairment are between 'mild' and

'severe'
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Severe depression Most symptoms, and the symptoms markedly interfere with
functioning. Can occur with or without psychotic symptoms

Q: 626 A 19yo man presents for the 1st time with a firm and unshakable belief that he
is being followed by terrorists who are plotting against him. What is the single
best term for this man’s condition?
b. Delusion of grandeur
c. Delusion of control
d. Delusion of reference
e. Delusion of nihilism

Clincher(s)
A Delusion of persecution most common types of delusions, centering around a
person's fixed, false belief that others aim to obstruct, harm, or kill him/her.

B
C
D
E
KEY a. Delusion of persecution

Additional
Information
Reference
Dr Khalid/Rabia
Delusion of grandeur fixed, false belief that one possesses superior qualities
such as genius, fame, omnipotence, or wealth.

Delusion of control false belief that another person, group of people, or
external force controls one's general thoughts, feelings, impulses, or behavior.

Delusion of reference A neutral event is believed to have a special and
personal meaning. For example, a person with schizophrenia might believe a
billboard or a celebrity is sending a message meant specifically for them.

Delusion of nihilism the delusion that things (or everything, including the self)
don't exist. a sense that everything is unreal.

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Q: 627 A 19yo female is brought in by her parents. They are concerned about her BMI
which is 12. She is satisfied with it. What is the next step?
a. Psychiatric referral for admission
b. Family counselling
c. Social service
d. Start antidepo
e. Medical admission

Clincher(s) BMI 12, She is happy about it.
A
B
C
D
E bmi s 12. Anorexic and she doesn’t think its harmful. so next step is medical
admission.
need for urgent referral and appropriate medical intervention

• Nutrition: BMI below 14; weight loss more than 0.5 kg per week.
• Circulation: systolic BP below 90; diastolic BP below 70; postural drop
greater than 10 mm Hg.
• Squat test: unable to get up without using arms for balance or leverage.
• Core temperature below 35°C.
• Blood tests: low potassium, sodium, magnesium or phosphate. Raised
urea or LFTs. Low albumin or glucose.
• ECG: pulse rate below 50; prolonged QT interval.

KEY e. Medical admission

Additional Below 17.5: anoxia, below 15 is dangerous, fatal BMI is less than 13 is red
Information flag sign: to admit instantly
Refeeding symptom: hypophosphatemia

Reference OHCM:
Dr Khalid/Rabia The defining clinical features are:
• Refusal to maintain a normal body weight for age and height.
• Weight below 85% of predicted. This means in adults a body mass
index (BMI) below 17.5 kg/m2.
• Having a dread of gaining weight.
• Disturbance in the way weight or shape is experienced, resulting in
over-evaluation of size.
• Amenorrhoea for three months or longer
• fatigue, hypothermia, hypotension, peripheral oedema, gaunt face,
lanugo hair, scanty pubic hair, acrocyanosis (hands or feet are red or
purple), and bradycardia
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February 17, 2016

• Enhanced weight loss by over-exercise, diuretics, laxatives and self-
induced vomiting
•

Q: 638 A 30yo woman has been feeling low and having difficulty in concentrating
since her mother passed away 2m ago. She feels lethargic and tends to have
breathlessness and tremors from time to time. What is the most likely dx?
a. Adjustment disorder
b. PTSD
c. Panic disorder
d. GAD
e. Bereavement

Clincher(s) Major life event, 2 m, symptoms

A
Adjustment disorder also known as situational depression involves symptoms
of anxiety and depression such as a feeling of hopelessness, low mood, weight
loss, palitation in a non previously psychiatric patient in which a major life
event (external stressor) has been found. it does not usually improve with
supportive therapy..

Adjustment disorder = depression + Anxiety (emotional or behavioral
symptoms in response to an identifiable stressor)

Since this woman is not able to adjust to the loss and is having physical
symptoms it's adjustment disorder.

Features of atypical grief reactions include:
• delayed grief: sometimes said to occur when more than 2 weeks passes
before grieving begins
• prolonged grief: difficult to define. Normal grief reactions may take up to and
beyond 12 months

Adjustment disorder is a short-term condition that occurs when a person has
great difficulty coping with, or adjusting to, a particular source of stress, such
as a major life change, loss, or event.
adj disorder starts within 3 m of the stress and does not last more than 6 m
while bereavement starts w the stress and does not last more than 2 months

Unlike major depression, however, an adjustment disorder doesn't involve as
many of the physical and emotional symptoms of clinical depression (such as
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February 17, 2016

changes in sleep, appetite and energy) or high levels of severity (such as
suicidal thinking or behavior).

B Ptsd, one must have flash backs, nightmares, nothing like that ..

C Panic . Unprovoked attack. This lady has source of provocation. . So can't be c

D Gad, multiple worry for over 6 month period in multiple aspect of life . None in
this

E Bereavement is a natural response to a sad life event like loss of a loved one it
includes tearfulness and generally a low mood which improves with support
from family and friends. bereavement should not extend 2 months and
breathless and tremors point more towards adjustment disorder .

Bereavement is the time spent adjusting to loss. It has four stages accepting
that your loss really happened:
1) experiencing the pain that comes with grief
2 )trying to adjust to life without the person who died
3) putting less emotional energy into your grief and
4) finding a new place to put it i.e. moving on.

Since this woman is not able to adjust to the loss and is having physical
symptoms, it's adjustment disorder.

KEY a. Adjustment disorder

Additional
Information
Reference FB discussions/afsan/Khalid etc
Dr Khalid/Rabia
It is not PTSD as in aetiology death of near one is not included and given case
doesn't have the diagnostic feature of repeated memory flashbacks or dream.
Panic disorder does not occur in response to any external or internal stress! So
it is not panic disorder. Similarly GAD is chronic anxiety which is not directly
related to any object or situation. Which also does not explain death as a point
in its favour! Beyond 2 months bereavement is considered to be either
pathological bereavement or major depression. So given time period of 2
months indicates it is no more normal bereavement. So by exclusion I think it
is a case of adjustment disorder (of which death of near one is considered as
an etiologic factor). (Dr Khalid)

Bereavement is the time spent adjusting to loss. It has four stages accepting
that your loss really happened
experiencing the pain that comes with grief
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February 17, 2016

trying to adjust to life without the person who died
putting less emotional energy into your grief and finding a new place to put it
i.e. moving on.

Q: 639 639. A 32yo man on psychiatric medications complains of inability to ejaculate.
Which drug is most likely to cause these symptoms?
a. Lithium
b. Haloperidol
c. Chlorpromazine
d. Fluoxetine
e. Clozapine

Clincher(s) Psychiatric drug, inability to ejaculate
A
B Erectile Dysfunction is associated with Haloperidol.

C
D SSRI's (fluoxetine ) cause sexual dysfunction (age of patient so clozapine can’t
be given probably)

gastrointestinal symptoms are the most common side-effect
Suicide ideation is also associated with Fluoxetine.

E
KEY d. Fluoxetine

Additional
Information
Reference FB/Rabia
Dr Khalid/Rabia
FB discussion: (claim that key is wrong)

Key is wrong.

E will be the answer Clozapine (for inability to ejaculate- BUT not documented)
fluoxetine decreases Libido
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February 17, 2016

Fluoxetine is an antidepressant not an anti psychotic. Although fluoxetine also
causes sexual dysfunction but in question it's mentioned that pt is on anti
psychotic drug. Haloperidol n chlorpromazine are also antpsychtics but both
belong to typical antpsychtics alongwith thioridazine so can't choose one of
these as they share same side effects. So i m left with Clozapine which is
atypical antpsychtic.
SAMI: “BNF mentions NOTHING about sexual/ejaculation SE of clozapine, for GMC, that what
matters
http://www.evidence.nhs.uk/.../second.../clozapine”

Q: 640 640. A 4yo boy is brought by his parents with complains of wetting his bed at
night and whenever he gets excited. What would be the most appropriate
management for this child?
a. Desmopressin
b. Oxybutynin
c. Behavioural therapy
d. Tamsulosin
e. Restrict fluid intake

Clincher(s) 4 years, nocturnal enuresis, daytime wetting
A Sami: “BNF: Desmopressin, Primary nocturnal enuresis, ADULT (under 65 years)
and CHILD over 5 years 200 micrograms at bedtime, “
Desmopressin should be offered first-line to children aged over 7 where rapid
control is needed or an alarm is inappropriate. Otherwise it should be used
second-line after an alarm has been tried. It may be used in children aged 5-7 if
treatment is required under the same circumstances.

B Although anticholinergic monotherapy is ineffective, it can improve treatment
response when combined with other established treatments, including
imipramine, desmopressin, or enuresis
alarms, especially in the treatment of resistant cases.

C ? Sleep alarm training & Rewarding agreed behaviour (eg, drinking adequately,
voiding before sleep, and engaging in management) may be more effective
than rewarding dry nights, which are out of the child's conscious control.

D Tamsulosin (Flomax) is an alpha-blocker that relaxes the muscles in the
prostate and bladder neck, making it easier to urinate. Tamsulosinis used to
improve urination in men with benign prostatic hyperplasia (enlarged
prostate).
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E In patient UK fluid restriction is discouraged
KEY c. Behavioural therapy

Additional Reassurance if under 5 (and if given)
Information
Children below 7yrs : sleep alarm training or behavioural therapy
Children above 7yrs : Desmopressin
Alarm training is a first-line treatment for nocturnal enuresis and is the most
effective long-term strategy (can be good or better than desmopressin).

Second line is alarm training + pharma

Imipramine and other tricyclic antidepressants reserved for treating resistant
cases only due to side effects (eg, cardiac arrhythmias, hypotension,
hepatotoxicity, central nervous system depression, interaction with other
drugs, and the danger of intoxication by accidental overdose

Reference http://patient.info/doctor/nocturnal-enuresis-in-children
Dr Khalid/Rabia
FB: Desmopressin could be offered for 5 ys child but it's recommended to start
with alarm training for the most effective long term strategy but if the child is
7 ys old desmopressin is the first line where rapid control is needed or an
alarm is inappropriate. Otherwise it should be used second-line after an alarm
has been tried

218

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Psychiatry-System

Wise 1700-by Sush and Team. 2016

Praziquantel is the drug of choice

In a depressive psychosis the comments from the auditory hallucination may be

This type of auditory hallucination is particularly associated with schizophrenia, but

Gedankenlautwerden is a hallucination where a patient hears voices which anticipate

It is a symptom suggestive of schizophrenia.

Gedankenlautwerden literally means thoughts becoming loud.

Cardiac symptoms: Temperature symptoms:

Gastrointestinal symptoms: General symptoms:

tightness around the chest fast breathing

tingling (e.g. in fingers, arms, mouth) muscle stiffness

dizziness blurred vision faintness headaches

tachycardia (rapid heart beat)

warm feeling in the head

sickness abdominal pain

Practice your breathing when sitting or lying in a comfortable position.

• phobias – an extreme or irrational fear of an object, place, situation,

You may experience an overwhelming sense of fear, apprehension

Traumatic life experiences

Increased sensitivity to carbon dioxide

Many people assume that agoraphobia is simply a fear of open

• travelling on public transport

If someone with agoraphobia finds themselves in a stressful

• serious road accidents

• depression – where you feel very low and lethargic

Bipolar disorder can occur at any age, although it often develops

What are the signs and symptoms of dysthymia?

• Persistent sad or empty feeling

Borderline personality disorder is a type of “personality disorder” which essentially means

Onset and Duration of Mood Episodes

The two main symptoms of psychosis are:

• hallucinations – where a person hears, sees and, in some

What causes psychosis?

It's sometimes possible to identify the cause of psychosis as a

• schizophrenia – a condition that causes a range of

They are psychosis caused by:

• psychological (mental) conditions

• hallucinations – hearing or seeing things that do not exist

B. Bipolar: Depression alternating with mania.

Bipolar affective disorder

2. Low energy level

4. Anhedonia – loss of interest in daily activities

5. Early morning waking

8. Reduced self esteem

10. Fatigability – feeling tired

11. Loss of libido

It is characterized by the mild depressive illness that lasts intermittently

C. SEASONAL AFFECTIVE DISORDER

It is characterized by the recurrent episodes of depressive illness occurring

• Low mood, anhedonia

• Increased appetite and weight gain

Management: Light therapy, Pscho-therapy and antidepressants.

D.POST NATAL DEPRESSION

• Occurs after delivery

• Poor sleep, low confidence, anhedonia

• Loss of appetite & weight

• Feeling that she is not capable of looking after her child

• Guilt feeling that she is not a good mother

• Occurs in the first 3 months after delivery

• Mother feels as if someone/partner wants to harm her baby

• Occurs in 50% women after giving birth

• Poor sleep, anxiety, irritability, tearful, crying for no reason