AKT Psychiatry

1. A 33-year-old man comes for review of his depression. He has now been taking citalopram for 12 weeks with minimal effect on his symptoms. It is decided to switch him to venlafaxine. How should this be done?

A. 2 week period of overlapping the drugs
B. Withdraw citalopram with the commencement of venlafaxine once citalopram has been stopped
C. Wait 1 week after withdrawing citalopram before commencing venlafaxine
D. Wait 2 weeks after withdrawing citalopram before commencing venlafaxine
E. 1 week period of overlapping the drugs

Answer: B

The following is based on the Clinical Knowledge Summaries depression guidelinesSwitching from one SSRI to another SSRI
the first SSRI should be withdrawn before the second is started
if switching from fluoxetine then leave a gap of 4-7 days as it has a long half-life
Switching from a SSRI to a tricyclic antidepressant (TCA)
cross-tapering is recommend (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)
- exceptions include fluoxetine (should be withdrawn prior to TCAs being started) and clomipramine (should not be given with a SSRI)Switching from a SSRI to venlafaxine
withdraw the SSRI
start venlafaxine the next day (unless fluoxetine - wait 4-7 days as above)

2. A 34-year-old man confides in you that he experienced childhood sexual abuse. Which one of the following features is not a characteristic feature of post-traumatic stress disorder?

A. Hyperarousal
B. Emotional numbing
C. Nightmares
D. Loss of inhibitions
E. Avoidance

Answer: D

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. One of the DSM-IV diagnostic criteria is that symptoms have been present for more than one monthFeatures
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
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
trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more 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

3. A 24-year-old male is admitted to the Emergency Department complaining of severe abdominal pain. On examination he is shivering and rolling around the trolley. He has previously been investigated for abdominal pain and no cause has been found. He states that unless he is given morphine for the pain he will kill himself. This is an example of:

A. Hypochondrial disorder
B. Conversion disorder
C. Malingering
D. Munchausen's syndrome
E. Somatisation disorder

Answr: C

Somatisation disorder
multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results
Hypochondrial disorder
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
Conversion disorder
typically involve loss of motor or sensory function
some patients may experience secondary gain from loss of function
patients may be indifferent to their apparent disorder
Dissociative disorder
dissociation is a process of 'separating off' certain memories from normal consciousness
in contrast to conversion disorder involves psychiatric symptoms e.g. amnesia, fugue, stupor
dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder
Munchausen's syndrome
also known as factitious disorder
the intentional production of physical or psychological symptoms
Malingering
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain

4. Which one of the following statements regarding cognitive behavioural therapy is incorrect?

A. May be useful in the management of generalised anxiety disorder
B. Can be used for patients already taking antidepressants
C. Usually consists of one to two hour sessions once per week
D. Should be completed within 4 months
E. Patients usually get around 35-40 hours in total

Answer: E

Main points
useful in the management of depression and anxiety disorders
usually consists of one to two hour sessions once per week
should be completed within 4 months
patients usually get around 16-20 hours in total

5. Which one of the following is not a first-rank symptom of schizophrenia?

A. Thought broadcasting
B. Visual hallucinations
C. Thought withdrawal
D. Delusional perceptions
E. Auditory hallucinations

Schneider's first rank symptoms may be divided into auditory hallucinations, thought disorders, passivity phenomena and delusional perceptions:Auditory hallucinations of a specific type:
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
Passivity phenomena:
bodily sensations being controlled by external influence
actions/impulses/feelings - experiences which are imposed on the individual or influenced by others
Delusional perceptions
a two stage process) where first a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient e.g. 'The traffic light is green therefore I am the King'.
Other features of schizophrenia include
impaired insight
incongruity/blunting of affect (inappropriate emotion for circumstances)
decreased speech
neologisms: made-up words
catatonia
negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation)
*occasionally referred to as thought alienation