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FFP Mental Health Flashcards

1
Q

Mental State Examination

A

Appearance and behaviour: Clothes, Evidence of Self-neglect?, Facial expression, Movements, Socially appropriate behavior, Eye contact,Rapport

Speech: Rate, volume, quantity, fluency

Mood: low, anxious, elated
Subjectively (what the patients says)
Objectively (what the examiner sees/considers)
Affect – reactive, blunted/flattened, inappropriate

Thought:
Form – the train of thought
Flight of ideas – connection between ideas
Formal thought disorder- no connection between ideas
Content; Delusional beliefs, Overvalued ideas, Obsessional thoughts

Perceptual abnormalities: Hallucination, illusions

Cognitive function

Insight

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2
Q

CBT explanation

A

The “hot cross bun” illustrates that four aspects are all interconnected. A change in one area (like changing your thoughts) can lead to changes in the others (like feeling less anxious, your body relaxing, and being more motivated to act).

Thoughts: What we think in response to a situation (e.g., “I’m going to fail”).

Emotions: How we feel as a result of our thoughts (e.g., anxiety, sadness).

Physical Sensations: How our body reacts (e.g., heart racing, sweating).

Behaviors: What we do in response (e.g., avoiding a task, procrastinating).

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3
Q

Dialectal behavioural therapy

A

Adaptation of CBT:
Incorporates CBT techniques but adds specific strategies for managing extreme emotions and improving relationships.

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4
Q

Risk Assessment domains

A

To Self
Self harm and suicide
Self neglect
Further deterioration of mental health or physical health
Being exploited by others (vulnerable adult)

To other people
Aggression and violence

Risk to children

To property

Driving

Pets

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5
Q

Risk assessment outcomes

A

Low (unlikely, requires standard care)
Moderate (real risk of unwanted outcome occurring, requires active management)
High (likely to occur, may require more resources allocated to manage)

Immediate
Short term (days/weeks)
Medium (weeks/months)
Long term (months/years)

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6
Q

Mental health act - Section 2

A

28 day admission for treatment/triage
2 doctors + 1 approved mental health professional

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7
Q

Mental health act - Section 3

A

6 month stay for ongoing treatment
2 doctors + 1 approved mental health professional

Can be blocked by closest relative

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8
Q

Mental health act - Section 4

A

Emergency 72 hour treatment order
1 doctors + 1 approved mental health professional

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9
Q

Mental health act - Section 5 (2)

A

Emergency holding order for a general hospital inpatient for assessment for 72 hours
1 doctors

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10
Q

Mental health act - Section 5 (4)

A

Emergency holding order for a general hospital inpatient for assessment for 6 hours
1 approved mental health professional

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11
Q

Mental health act - Section 135

A

Allows entry into a persons home and detainment for 24 hours for assessment
Magistrate

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12
Q

Mental health act - Section 136

A

Holding for 24 hours in a police setting for assessment regarding section 2/3
Police

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13
Q

Capgras syndrome

A

Among us

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14
Q

Fregoli syndrome

A

Pt thinks they know strangers

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15
Q

Nilhistic delusions

A

World is ending

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16
Q

Ekbom’s syndrome

A

Body is infested

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17
Q

Circumstantial thought disorder

A

Speech goes off topic before returning

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18
Q

Tangential thought disorder

A

Speech goes off topic

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19
Q

Flight of ideas

A

Pt fires off many ideas in short timeframe

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20
Q

Schizophrenia; first rank sx and other sx and poor prognostic indicators

A

Delusional perceptions, thought disorder, thought control, auditory hallucination
Negative sx, catatonia, disorganised speech

Poor prognostic indicators: Pre-morbid social withdrawal, low IQ, family history of schizophrenia, gradual onset of symptoms and lack of an obvious precipitant.

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21
Q

Schizophrenia treatment

A

MDT - CBT, family therapy, social care arrangements

Atypical antipsychotics 1st line: Olanzapine, Quetiapine, Risperidone, Aripiprazole (least side effects, best for hyperprolactinemia)

Typical 2nd line: Haloperidol, Levomepromazine, flupentixol

Clozapine for treatment resistant

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22
Q

What to check before antipsychotics started

A

ECG for long QT

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23
Q

Antipsychotics side effects - generally and specifics

A

Parkinsonisms

Acute dystonia - involuntary spasms; Jaw = trismus, Neck = torticollis, acute oculogyric crisis (tongue out, eyes up)
Treated with anticholinergic - benzotropine, procyclidine

Akathisia

Tardive dyskinesia

Hyperprolactinaemia - galactorrhoea, ED, amenorrhea

Aripiprazole (least side effects, best for hyperprolactinemia)
Olanzapine: higher risk of dyslipidemia and obesity
Clozapine: agranulocytosis, weight gain, sedation, constipation

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24
Q

Treatment of acute dystonia e.g. antipsychotic side effect

A

Treated with anticholinergic - benzotropine, procyclidine

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25
Q

Treatment of tardive dyskinesia

A

Tetrabenazine may be used to treat moderate/severe tardive dyskinesia

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26
Q

Catatonia treatment

A

I.v. 2mg lorazepam -> if improvement 4-12mg/day

if not ECT

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27
Q

Schizophrenia differentials

A

Schizoaffective disorder - equal negative and schizo sx at the same time
Psychotic depression - initial depression with psychosis
Delusional disorder - 3 months of delusions (non bizarre grandiose, persecutory) but not thought control and no other sx

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28
Q

Organic causes of psychosis

A

Delirium - infection
Medication - steroids, dopamine agonists
Endocrine - Cushings, thyroid
Neuro - huntingtons, temporal lobe epilepsy
SLE, porphyria
Pyschoactive substances - cocaine, amphetamines
Alcohol withdrawal

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29
Q

Neuroleptic malignant syndrome

A

Life threatening reaction to antipsychotics
Insidious onset (4-14 days)
Altered consciousness
Severe lead pipe rigidity
Autonomic dysfunction - hyperthermia, sweating, labile BP
Hyporeflexia

Increased WCC, CK, Liver transaminases

Stop antipsychotics
Benzos if needed
Cool the pt +- fluids
i.v. bromocriptine/dantrolene

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30
Q

Serotonin syndrome

A

1-2 days onset
Altered consciousness
Severe lead pipe rigidity
Autonomic dysfunction - hyperthermia, sweating, labile BP
Hyperreflexia, tremor, clonus

Increased CK

Stop serotonergic drugs
Benzos if needed
Cool the pt +- fluids
I.v. Cyproheptadine (antihistamine)

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31
Q

Depression key sx + more

A

2 weeks<
Low mood, anhedonia, low energy
Early awakening, diurnal variation in mood, decreased appetite, psychomotor agitation
Decreased conc, decreased self esteem, guilt, hopelessness

If v severe, delusions/hallucinations e.g. cotord’s syndrome

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32
Q

cotord’s syndrome

A

Pt believes they are already dead, nilhistic, grandiose

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33
Q

Disorders to check for in ?depression

A

hypothyroid, hypoadrenalism, anaemia

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34
Q

Depression management

A

CBT, lifestyle, social support

SSRIs - Citalopram, Fluoxetine (U18s), Sertraline

SNRIs - Duloxetine, Venlafaxine

NaSSAs - Mirtazapine

TCAs - Amitriptyline 1st line in pregnancy

MAOIs - phenelzine, isocarboxacid

ECT

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35
Q

Depression questionnaire and results

A

0-4: No depression

5-9: Mild depression

10-14: Moderate depression

15-19: Moderately severe depression - active therapy

20-27: Severe depression

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36
Q

Antidepressant specific indications, contraindications and side effects
U18s
Pregnancy
Teratogenic
QT prolongation
Atypical depression (insomnia/overeating)

A

U18s - Fluoxetine
Pregnancy - Amitriptyline
Teratogenic - Paroxetine in 1st trimester
QT prolongation - TCAs (CI in CVD, Liver disease) and Citalopram
Atypical depression (insomnia/overeating) - MAOIs - phenelzine, isocarboxacid

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37
Q

Antidepressant side effects

A

SSRIs - Citalopram, Fluoxetine, Sertraline:
GI, inital anxiety/suicidality
decreased appetite, akathisia, insomnia, sweating, ED

SNRIs - venlafaxine, duloxitine
As above but more severe

NaSSAs - Mirtazapine
Increased appetite and sedation

TCAs - amitriptyline, lofepramine
Anticholinergic, antihistamine; wt gain, sedation, anti-a; postural hypotension. QT prolongation

MAOIs - phenelzine, isocarboxacid
Hypertensive crisis: cheese affect
Serotonin syndrome

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38
Q

2 types of Bipolar affective disorder

A

Type I: Manic episodes + Major depression
Type II: Hypomania + Major depression

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39
Q

Mania presentation

Hypomania

A

Elevated self esteem, accelerated thinking, impaired judgement, poor concentration
Decreased need for sleep, increased energy
Disorder thought form, abnormal beliefs, perceptual disturbances

Hypomania - milder form less delusions

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40
Q

Acute mania management

A

Admission
Stop antidepressants
Antimanic drugs = antipsychotics: risperidone, olanzapine, quetiapine

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41
Q

Acute depression in bipolar management

A

Check level of mood stabiliser (lithium/valproate/olanzapine) and increase if possible
Add SSRI/Olanzapine/Lamotrigine
CBT

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42
Q

Bipolar maintenance therapy
side effects/contraindications/monitoring

A

Lithium
GI, dry mouth, metallic taste
Not suitable in renal impairment
Cardiotoxic, Thyrotoxic

Toxicity => tremor, seizures, coma. AKI, Nephrotic syndrome, diabetes insipidus. QT, sinus node dysfunction.
Teratogenic

3 monthly plasma levels, TFTs every 6 months

Valproate
wt gain, hair loss, sedation, tremor, blood dyscrasias, liver failure
teratogen

Olanzapine
As per antipsychotics

43
Q

General anxiety disorder criteria/sx + management

A

6 months, impairs day to day functioning
Heart racing, sweating, hyperventilation, etc.
Persistent worrisome thoughts, poor conc.
irritability, avoids socialisation

CBT
Beta blockers PRN
SSRIs

44
Q

Phobia management

A

CBT
SSRIs if agora/social phobia

45
Q

OCD criteria/sx and management

A

2 weeks< affecting functioning:
Obsessions: involuntary thoughts, against own resistance and good insight
Compulsions: repetitive mental operations e.g. handwashing, compelled to perform them

CBT with exposure and response prevention (ERP
SSRIs if moderate-severe
social input

46
Q

Acute stress reaction/disorder criteria/sx

A

After significant trauma; >3 days, but <4 weeks (PTSD if longer)

Dissociative sx - emotionally numb, physical dissociation, amnesia of event details
Vivid recollection
Avoidance of stimuli
State of hyperarousal

47
Q

PTSD criteria/sx

A

After significant trauma; >4 weeks (Acute stress reaction if shorter)

Dissociative sx - emotionally numb, physical dissociation, amnesia of event details
Vivid recollection
Avoidance of stimuli
State of hyperarousal

48
Q

PTSD management

A

Eye movement desensitisation and reprocessing

CBT
SSRIs, venlafaxine, antipsychotics

49
Q

When is grief abnormal and management

A

if more than 1 year (5 if child)

CBT, guided mourning

50
Q

Somatization disorder (Briquet’s)

A

“S for symptom concern”
For 2 years
Multiple, recurrent, frequently changing sx e.g. GI, sexual, urinary, neuro
With no belief it is psychological
Seeking sx relief

51
Q

Persistent somatoform pain disorder

A

Similar to Somatization disorder (Briquet’s), but severe and persistent pain is the overriding presenting complaint

52
Q

Hypochondrial disorder

A

C (chondrial) cancer
Irrational fear for own health; asks for many many investigations despite normal results

53
Q

Management of somatoform disorders

A

Psychotherapy
Regular arranged GP appts to support pt.

54
Q

factitious disorder munchausen’s syndrome

A

Faking sx to gain access to “sick role”

55
Q

munchausen’s by proxy

A

Faking sx in a child to gain sick role

56
Q

Malingering

A

Faking sx for own gain e.g. avoid prosecution, obtaining drugs

57
Q

Anorexia nervosa criteria/sx, findings/investigations, management

A

self induced Low body weight (15% below normal), overvalued ideas about body image, endocrine disturbance (amenorrhea, impotency)

Lanugo (fine hair over body), bradycardia, constipation, cardiomyopathy, oesophageal tears, scarring over knuckles, dental defects

Deranged LFTs, increased urea cortisol GH, decreased T3, hypoglycaemia, decreased FSH/LH, normocytic anaemia

Weekly visits to boost weight
Hospitalisation if BMI <13.5, rapid wt loss, syncope, electrolytes; risk of refeeding syndrome (hypophosphatemia hallmark sign)
CBT - 40 sessions
Maudsley anorexia nervosa treatment for adults - 20 sessions

58
Q

When to hospitalise anorexia nervosa pts

A

Hospitalisation if BMI <13.5, rapid wt loss, syncope, electrolytes; risk of refeeding syndrome (hypophosphatemia hallmark sign)

59
Q

Bulimia nervosa criteria and management

A

Binge eating, strong food cravings -> methods to counteract wt gain; vomiting, diuretics, excessive exercise, fasting
normal or increased weight

CBT-ED
self help guidance
SSRIs

60
Q

Paranoid personality disorder

A

“SUSPECT”

Sensitive
Unforgiving
Suspicious
Possessive & jealous
Excessive self importance
Conspiracy theories
Tenacious sense of rights

61
Q

Schizoid personality disorder

A

“ALL ALONE”

Anhedonia
Limited emotion
Little sexual interest
Apparent indifference to praise
Lacks relationships
One player activities
Normal social conventions ignored
Excessive fantasy world

62
Q

Schizotypal personality disorder

A

“UFO AIDER”

Unusual perceptions
Friendless
Odd beliefs
Affect is inappropriate
Ideas of reference
Doubtful
Eccentric
Reluctant to socialise

63
Q

Emotionally unstable personality disorder (overall + 2 types)

A

AEIOU

Affective instability
Explosive behaviours
Impulsive
Outbursts of anger
Unable to plan ahead

Borderline type: SCARS

Self image unclear
Chronic emptiness
Abandonment fears
Relationships unstable
Self harm and suicidal

Impulsive type: LOSE IT

Lack control
Outbursts
Sensitivity to criticism
Emotional instability
Inability to plan
Thoughtless of consequences

64
Q

Dissocial personality disorder

A

“FIGHTS”

Forms but cannot maintain relationships
Irresponsible
Guiltless
Heartless
Temper
Someone else’s fault

65
Q

Histrionic personality disorder

A

“ACTORS”

Attention seeking
Concerned with appearance
Theatrical
Open to suggestion
Racy
Shallow affect

66
Q

Narcissistic personality disorder

A

A FAME GAME

Admiration required
Fantasises about success
Arrogant
Manipulative
Envious
Grandiose sense of importance
Associates with special people
Me first attitude
Empathy lacking

67
Q

Obsessive compulsive/Anankastic personality disorder

A

DETAILED

Doubtful
Excessive detail taken
Tasks not completed
Adheres to rules
Inflexible
Likes own way
Excludes pleasure
Dominated by intrusive thoughts

68
Q

Anxious/avoidant personality disorder

A

AFRAID

Avoids social contact
Fears criticism
Restricted lifestyle
Apprehensive
Inferiority
Doesnt get involved without acceptance

69
Q

Dependant personality disorder

A

SUFFER

Subordinate
Undemanding
Feels helpless when alone
Fears abandonment
Encourages others to make decisions
Reassurance needed

70
Q

Management of personality disorders

A

Psychotherapy - Dialectal behavioural therapy

71
Q

Substance dependence criteria

A

3< of the following:
Strong desire, difficulty controlling substance use, withdrawal sx, tolerance, neglect of other interest

72
Q

Alcohol dependence syndrome criteria/sx

A

Narrowing of repertoire, prioritising drinking, tolerance, withdrawal, awareness of compulsions to drink, rapid dependence after abstinence

73
Q

Uncomplicated alcohol withdrawal syndrome

A

4-12 hours after stopping
tremors, sweats, GI upset, autonomic hyperactivity, mood disturbance

“Complicated” if perceptual disturbances

74
Q

Severe alcohol intoxication symptoms

A

respiratory depression, aspiration, hypoglycaemia, hypothermia, trauma

75
Q

Alcoholic withdrawal seizures

A

6-48 hours after alcohol cessation
GTC
treat as per normal seizures - 4mg iv lorazepam

76
Q

Delirium tremens sx and management

A

1-7 days after cessation alcohol - most common 48 hours
Delirium with cognitive impairment
vivid hallucinations
Paranoid delusions
Extreme autonomic hyperarousal: HTN, fever, tachycardia, sweats, marked tremor

High dose benzodiazepines (+ antipsychotics if severe)
High dose IV thiamine (pabrinex)
Fluids and electrolytes

77
Q

Alcohol withdrawal management

A

None if low risk
If higher risk, titrated Chlordiazepoxide over 24 hours (as per CIWA score)
Thiamine supplementation

78
Q

Wernicke’s encephalopathy and management

A

Chronic vitamin B1 (thiamine) deficiency:

Delirium
Ocular palsy: nystagmus, CNVI palsy or gaze palsy
Ataxia

High dose benzodiazepines (+ antipsychotics if severe)
Very high dose IV thiamine (2 pairs pabrinex TDS)
Fluids and electrolytes

If untreated => Korsakoff’s psychosis

79
Q

Korsakoff’s psychosis

A

Untreated B1 deficiency and Wernicke’s encephalopathy

Anterograde amnesia
Frontal lobe dysfunction
Psychosis

80
Q

Imaging signs of alcoholic dementia

A

cortical atrophy and ventricular enlargement

81
Q

Post-alcohol withdrawal management options

A

Disulfiram:
aldehyde dehydrogenase blocker
Unpleasant after effect after alcohol consumption

Acamprosate:
Enhances GABA to decrease cravings

Naltrexone:
opioidR blocker
Reduces cravings and nice effects.

CBT, motivational interviewing, social support

82
Q

Opiate abuse - Heroin
Sx from use, withdrawal and overdose

A

Effects:
Euphoria, intense relaxation, miosis, drowsiness, nausea, itching

Withdrawal:
Not life threatening; insomnia, tachycardia, muscle pains (helped with lofexadine), dilated pupils, sweating, GI

Overdose:
Respiratory depression, bradycardia, coma
Pinpoint pupils unreactive

Management:
i.v. Naloxone

Substitution therapy for controlled withdrawal:
Methadone - long acting agonist
Buprenorphine - long acting partial agonist
Naltrexone - blocks future opioid use euphoria

83
Q

Opiate overdose management and controlled substitution management

A

Overdose management:
i.v. Naloxone

Substitution therapy for controlled withdrawal:
Methadone - long acting agonist
Buprenorphine - long acting partial agonist
Naltrexone - blocks future opioid use euphoria

84
Q

Cocaine - Sx from use and overdose

A

Effects:
Increased energy, alertness, mydriasis, increased impulsivity, decreased need for sleep
Anxiety, htn, arrhythmias, cocaine bugs (hallucination)

Overdose:
Tremor, confusion, seizures, panic and agitation
Tachycardia, HTN, hyperthermic

85
Q

MDMA symptoms

A

Euphoria, sociability, intimacy
Increased BP, HR, Temp
jaw clenching, appetite

86
Q

LSD symptoms

A

Euphoria, detachment, synaesthesia
behavioural toxicity

87
Q

Benzodiazepine recreational use
Sx from use, withdrawal and overdose

A

Effects:
Anxiolytic

Withdrawal:
Anxiety, tremor, seizures

Overdose:
Respiratory depression, coma, death

88
Q

Solvent misuse sx

A

Euphoria, disinhibition, visual illusions
Headache, MI
Cognition, renal, hepatic injury long term

89
Q

ADHD criteria and management

A

Impaired attention and hyperactivity for 6 months in multiple environments

Parental, CBT, Social skills
Methylphenidate, Atomoxetine

90
Q

Autism spectrum disorder criteria and management

A

Impaired social interaction
Impaired communication
Restricted, stereotyped interests
Aggressiveness, impulsivity, self injurious
75% intellectual disability, 25% epilepsy

Social skills and support plans

Asperger’s is the same but language and cognitive development is normal; monotonous but good quality speech

91
Q

Conduct disorder criteria/sx and management

A

6 months, persistent and repetitive:
Aggression, destruction, deceitfulness, violation of age related social expectations

Psychosocial
Risperidone if very severe

92
Q

Intellectual disability IQ levels and sx

A

Mild: IQ 50-69
Deficits may be subtle, children require increased academic support but are generally able to live independently in adulthood.

Moderate: IQ 35-49
Limited language / comprehension skills, rarely able to live independently in adulthood.

Severe: IQ 20-34
Marked motor impairment, may learn to speak only at school age, capable of elementary self-care only.

Profound IQ <20
Severe motor and communication impairment, lack of continence, and need for constant care.

93
Q

When to complete a psychiatric referral for pregnant women

A

History of current mental disorder, FH of bipolar, schizoaffective

94
Q

The “pinks”

A

Normal sense of euphoria in the first 48 hours after giving birth

95
Q

The “blues”

A

Day 3-10 post-partum
48 hours of emotional lability, tearfulness, mild anxiety, irritability

96
Q

Post natal depression sx and management

A

2-4 weeks postpartum most common, then after 3 months
Depressive sx; parental ability may be affected, reduced affection for baby, intrusive thoughts

Mild-moderate - CBT, mother-baby groups, counselling, visits
Severe - SSRIs; paroxetine, sertraline

Admission if suicidal/infanticidal

97
Q

Puerperal psychosis and management

A

Behavioural disturbances: insomnia, restlessness, perplexity
Hallucinations, delusions, fear

Mother-baby units
atypical antipsychotics for 12 months after remission

98
Q

Delirium criteria and types

A

Acute confusion, rapid onset, fluctuating intensity:

Disturbances of consciousness, worsening confusion, fluctuating levels of new sx, evidence of underlying cause

Hypoactive - apathy, withdrawal, lethargy
Hyperactive - increased motor activity, agitation, hallucinations
Mixed - ^^^

99
Q

Cognition tests in delirium (and other presentations?)

A

AMT then CAM if abnormal:
Assess acute changes, inattention, disorganised thinking, altered consciousness.

100
Q

Investigating delirium (tests)

A

GCS, infection screen, bloods, hydration and nutrition status, bladder scan, bowels checked, neurology, cognition, CXR, urine MC+S

101
Q

Alcohol withdrawal complications and timing

A

symptoms: 6-12 hours
seizures: 36 hours
delirium tremens: 72 hours

102
Q

After a change in dose, lithium levels should be checked when?

A

After a change in dose, lithium levels should be taken a week later and weekly until the levels are stable

103
Q

Clozapine monitoring

A

White blood cell monitoring weekly for 18 weeks, then fortnightly for up to one year, and then monthly.

Blood lipids and weight should be measured at baseline, every 3 months for the first year, then yearly.

Fasting blood glucose tested at baseline, after one months’ treatment, then every 4–6 months.

104
Q

Lithium monitoring

A

After a change in dose, lithium levels should be taken a week later and weekly until the levels are stable

Then, 3 monthly plasma levels, TFTs every 6 months,

GEM (18 decks)

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