Indicators of learning Flashcards
Psychiatric assessment-
What knowledge is required-
What skills need to be able to be performed (psych assessment)
Knowledge:
- Define signs and symptoms found in patients presenting with psychiatric and common medical disorders.
- Recognise the importance of historical data from multiple sources e.g. clinical file, collateral sources.
- Demonstrate an understanding of factors that influence the aetiology and course of mental disorder, including social deprivation and, if relevant, trauma.
Skills:
- Elicit a complete clinical history, including psychiatric history, that identifies the main or chief complaint, the history of the present illness, the past psychiatric history, medications, general medical history, review of systems, substance abuse history, forensic history, family history, personal, social, trauma history and developmental history.
Answers:
Conducting a psychiatric assessment
- Intro and consent
-
Basic demographics
- Age, sex, ethnicity
- Consider collateral history
-
Presenting complaint
- How and why the patient is presenting to services
-
History of presenting complaint
- Ask about time frames, severity, recurrence
- Mood disorder
- Screen for anxiety and depression
- Ask about related problems e.g. mania, PTSD, psychosis
- Suicidal ideation/attempt
- SADPERSONS
- Was it impulsive or planned? Signs of saying goodbye e.g. note writing?
- Specifics of attempt e.g. drug or prescription OD, paracetamol
- Psychosis
- Hallucinations: number, sex and age of voices. What are they saying? Inside or outside the head?
- Delusions: nature of delusions
- Negative symptoms: avolition, anhedonia, amotivation
-
Psychiatric history
- Prior diagnoses, symptoms when previously unwell
- History of suicide attempts or self harm, violence to others
- Prior contact with mental health services
- Management in the past: what worked well, what didn’t
-
Medical history
- Consider organic causes of psychiatric presentation e.g. delirium
-
Development history
- Birth: maternal health and substance use during pregnancy, birth
- Childhood: milestones, illness, relationships to parents and siblings, trauma (sexual, emotional, verbal, physical)
- Education: attention and performance at school, bullying, being bullied, expulsion and suspension, social groups
- Employment: number and type of jobs held
- Interpersonal relationships
-
Family history
- Genogram of family psychiatric disease
-
Substance abuse
- Coffee, tobacco, alcohol, prescription and OTC drugs, illicit drugs
- First use, current use, route of use, prior attempts to cease, tolerance, withdrawal
-
Forensic history
- Juvenile justice history
- Adult police contacts and incarceration
- Mental state examination
Appearance and behaviour
Appearance: age, sex, race, build, neat/dishevelled, appropriately groomed/not groomed, malodorous, tattoos, piercings, style
Behaviour: alertness, normal/avoids/excessive/intense eye contact, posture and body language, tics, cooperative/superficially cooperative/uncooperative/hostile
Speech
Rate: fast/slow, pressure of speech
Tone: monotonous, normal range, loud/quiet
Spontaneous/talkative/monosyllabic/poverty of speech/mute
Emotion and affect
Affect: labile/constricted, range blunted/flat/reactive, appropriateness for situation, consistency with emotion
Emotion: predominant mood, mood /10
Perception
Hallucinations: visual, auditory, tactile
Illusions
Passivity phenomenon
Depersonalisation: I’m not real, detachment from self
Derealisation: the world isn’t real, detachment from environment
Thoughts
Stream and form: Coherent, logical, relevant, goal-directed, loose associations, circumferential, racing thoughts, flight of ideas, tangential , word salad, thought blocking, thought perseveration, though insertion
Content: thoughts of hurting or killing self, thoughts of hurting or killing others, delusions, obsessions, magical thinking, ideas of reference, overvalued ideas
Insight and judgement
Into disease symptoms, admission to in-patient or community clinic, on need to take medications
Intact/partial/no insight
Locus of control internal/external
Judgement and decision-making capacity intact or impaired
Cognition
Assess with MMSE or other tool
Level of consciousness: alert, drowsy, delirium, stupor
Orientated to time/place/person, confusion
Attention: attentive or easily distracted
Memory: immediate, short-term, long-term memory function
Intellect
-
Risk assessment
- Suicide
- Psychosis
- Drug use
- Impulsive behaviour
- Physical examination
-
Formulation and impression
- Predisposing
- Precipitating
- Prolonging
- Protective
- Effect on the patient’s level of functioning
- Management plan
Mental state examination
What knowledge is required regarding MSE? Define components of MSE?
Recognise physcial signs and symptoms that accompany psychiatric disorder
What skills are needed? e.g elicit and record components of MSE, make a clear and concise presentation)
Knowledge:
Define the components of mental state examination:
- Appearance and behaviour
- Speech
- Mood and affect
- Thought form and content
- Perceptions
- Cognition
- Insight and judgement
Recognise physical signs and symptoms that accompany psychiatric disorders.
- Physical signs and symptoms may indicate: - an aetiological factor influencing the presentation e.g. appearance of weight loss in hyperthyroidism presenting with mania -
- a physical consequence of the illness e.g. appearance of dehydration in severe depression -
- a consequence of treatment e.g. abnormal movements due to EPSE caused by antipsychotic treatments - any signs of intoxication, overdose, delirium or head injury
Skills:
- Elicit and record the components of mental state examination. Make a clear and concise case presentation.
Answer:
Appearance and behaviour
Appearance: age, sex, race, build, neat/dishevelled, appropriately groomed/not groomed, malodorous, tattoos, piercings, style
Behaviour: alertness, normal/avoids/excessive/intense eye contact, posture and body language, tics, cooperative/superficially cooperative/uncooperative/hostile
Speech
Rate: fast/slow, pressure of speech
Tone: monotonous, normal range, loud/quiet
Spontaneous/talkative/monosyllabic/poverty of speech/mute
Emotion and affect
Affect: labile/constricted, range blunted/flat/reactive, appropriateness for situation, consistency with emotion
Emotion: predominant mood, mood /10
Perception
Hallucinations: visual, auditory, tactile
Illusions
Passivity phenomenon
Depersonalisation: I’m not real, detachment from self
Derealisation: the world isn’t real, detachment from environment
Thoughts
Stream and form: Coherent, logical, relevant, goal-directed, loose associations, circumferential, racing thoughts, flight of ideas, tangential , word salad, thought blocking, thought perseveration, though insertion
Content: thoughts of hurting or killing self, thoughts of hurting or killing others, delusions, obsessions, magical thinking, ideas of reference, overvalued ideas
Insight and judgement
Into disease symptoms, admission to in-patient or community clinic, on need to take medications
Intact/partial/no insight
Locus of control internal/external
Judgement and decision-making capacity intact or impaired
Cognition
Assess with MMSE or other tool
Level of consciousness: alert, drowsy, delirium, stupor
Orientated to time/place/person, confusion
Attention: attentive or easily distracted
Memory: immediate, short-term, long-term memory function
Intellect
Depression on examination:
Examination
- There are no definitive findings of depression on physical examination, although most patients will have a depressed affect, as well as a downcast gaze, furrowed brow, psychomotor slowing, speech latency, and expressions of guilt or self-blame. The physical examination and cognitive screening may be useful in ruling out common conditions that are often confused with depression (e.g., hypothyroidism, dementia) and in looking for commonly co-occurring illnesses (including obesity, cancer, stroke)
Hyper thyroidism + weight loss + Mania (from case study)
Backgroud information
- The link between psychiatric disturbance and thyrotoxicosis was first described by von Basedow in the 19th century.1 Although overt psychotic features are not often seen in patients with thyrotoxicosis, it is important to recognise the phenomenon. It is very rare for psychosis to be the presenting symptom of Graves’ disease.2 The estimated incidence of psychosis as the presenting feature of Graves’ is 1% according to a New Zealand-based case series.3 Equally it is rare for thyrotoxicosis to be the underlying cause of a new psychiatric presentation.
- Initiation of thionamides plus beta-blockade to treat agitation, anxiety and sympathomimetic symptoms is of paramount importance.
- While patients presenting with hypomania often receive treatment with antipsychotic medications, when thyrotoxicosis is the cause of mental health deterioration, treatment with thionamides with or without beta-blockers may be all that is required.
- Those patients who have antipsychotics administered as primary treatment may be misdiagnosed or left on long-term antipsychotic medication inappropriately
- Nevertheless, there will be situations where management of psychosis requires a combination of antipsychotic therapy and thionamide drugs.
Antipsychotics and EPSEs
- Acute dystonia from antipsychotics is thought to occur through this pathway seen in Parkinson’s.
- Normally, dopaminergic neurons in the nigrostriatal pathway have an inhibitory effect on cholinergic interneurons that regulate motor movements in the body.
- When dopamine antagonists (i.e. - antipsychotics) are given, this decreases endogenous dopamine.
- Since antipsychotics reduce dopamine’s inhibitory effects, this results in increased firing of cholinergic interneurons, and increased release of acetylcholine.
- This combination of decreased dopamine (postsynaptic nigrostriatal dopamine blockade) and excessive acetylcholine is thought to create a dopaminergic-cholinergic imbalance that leads to development of extrapyramidal symptoms
Treatment of acute dystonia:
–> Benzotropine (anticholinergic)
Akathisia (Greek: “Inability to sit”) is a neuropsychiatric syndrome characterized by the subjective feeling of anxiety, restlessness, and an irresistible urge to move
- Akathisia is an acute reaction, and occurs within hours to days of starting the offending agent. Individuals may feel compelled to pace and do tasks; for some, this can cause severe agitation, irritability, outbursts, and may place individuals at higher suicide risk
Treatment: Benzotropine
Tardive dyskinesias
- (TD) are involuntary movements of the muscles of the face, mouth, and tongue that are referred to as orofacial dyskinesias. These are repetitive oral, facial, and tongue movements that can resemble grimacing, chewing, lip smacking, tongue protrusion. The estimated prevalence of TD from exposure to antipsychotics is estimated to be 30% with first-generation antipsychotics, and 20% with second-generation antipsychotics.
Hyperprolactaemia and antipyshcotics
Hyperprolactinemia is a side effect most commonly associated with antipsychotic use. Hyperprolactinemia can be completely asymptomatic or be very distressing to patients when they experience associated symptoms such as amenorrhea, galactorrhea, infertility, or sexual dysfunction. The most significant consequence of hyperprolactinemia is hypogonadism that results in estrogen or testosterone deficiency. Elevation of prolactin levels can occur as soon as 6 days after initiation of treatment.[1]
Mechanism
- The mechanism of action is thought to be at the anterior pituitary gland, which resides outside the blood brain barrier. Consistent D2 antagonism contributes to elevated prolactin levels.
Typical antipsychotics
- All typical antipsychotics are associated with hyperprolactinaemia to varying degrees.
Atypical antipsychotics
- Initially, it was thought that because of the 5-HT2A receptor affinity of atypical antipsychotics this would prevent them increasing prolactin levels. However, risperidone and paliperidone both increase prolactin levels much like typical antipsychotics. Prolactin levels have been found to correlate with blood levels of paliperidone rather than risperidone
Metabolic Syndrome
- is a group of conditions (including increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels) that occur together. This increases the risk of heart disease, stroke and diabetes. Of psychotropic medications, the risk is greatest with antipsychotics.
Mechanism
Antipsychotics are thought to cause metabolic syndrome through a variety of etiologies, including histamine (H1) antagonism, increased appetite, and/or the alteration of insulin sensitivity which then directly impairs metabolic regulation.
Psychiatric differential diagnosis and formulation
E.g Need to know DDx for common groups of MH conditions
What are common signs and symptoms of the following conditions?
- Affective disorder
- Anxiety disorder
- Psychotic disorders
- Personality disorders
- Eating disorders
- Substance misuse disorders
- Organic disorders
Describe the various biological, psychological, cultural and social factors involved in psychiatric disorders and recovery utilzing the “5 ps”
- Presenting
- predisposing
- Precipitating
- Perpetuating
- Protective factors
Knowledge:
Skills Be able to use a diagnostic system (DSM V ) to construct a differential diagnosis for common presenting problems?
Neurocognitive disorders
- Intellectual disability
- Communication disorders
- Autism spectrum disorder
- ADHD
- Learning disorders
- Motor disorders
- Tic disorders
Psychotic disorders
- Brief psychotic disorder
- Delusional disorder
- Schizophreniform disorder
- Schizophrenia
- Schizoaffective disorder
- Catatonia
Bipolar disorder
Depressive disorders
- Disruptive mood dysregulation disorder
- Major depressive disorder
- Dysthymia
Anxiety disorders
- Separation anxiety disorder
- Selective mutism
- Specific phobia
- Social anxiety disorder
- Panic disorder
- Agoraphobia
- Generalized anxiety disorder
- Obsessive-compulsive and related disorders
- Obsessive-compulsive disorder
- Body dysmorphic disorder
- Hoarding disorder
Trauma and stressor-related disorders
- Reactive attachment disorder
- PTSD
- Adjustment disorder
Feeding and eating disorders
- Anorexia nervosa
- Bulimia nervosa
- Binge eating disorder
Conduct disorders
- Oppositional defiant disorder
- Conduct disorder
- Pyromania
- Kleptomania
Personality disorders
- Paranoid personality disorder
- Schizoid personality disorder
- Schizotypal personality disorder
- Antisocial personality disorder
- Borderline personality disorder
- Histrionic personality disorder
- Narcissistic personality disorder
- Avoidant personality disorder
- Dependent personality disorder
- Obsessive-compulsive personality disorder
Give an example of using the biopsychosocial model with the 5 ps to create a formulation
Form a basic Clinical management plan – including investigations and treatments
Knowledge needed:
- Define the indications for the key investigations that are used in psychiatric practice.
- Knowledge of lifestyle interventions and strategies for instituting sleep hygiene, healthy diet, regular exercise, addressing smoking and alcohol and substance misuse.
- Basic understanding and indications for the most common psychotherapy modalities, including CBT, DBT and psychodynamic therapies.
- Indications, major side effects and monitoring requirements of psychiatric medications and physical treatments particularly:
- SSRIs, First and Second-generation
- Antipsychotic medications including specific considerations regarding Clozapine, Lithium, ECT
Skills:
- Explain treatments and their side-effects
- Advise on environment and lifestyle changes
Physical examination / Investigations: - - - - -
Bloods
- FBC
- eLFTs at discretion – think elderly, eating disorders, catatonia, substance abuse, polydipsia. Normally done on admission to rule out organicity.
- Thyroid Function Tests (thyroid dysfunction can produce mood/psychotic symptoms; lithium can cause thyroid dysfunction)
- Vitamin B12/folate/iron studies (can influence mood)
- +/- prolactin level (certain antipsychotics can cause hyperprolactinaemia)
- Infectious screen - Syphilis serology, HIV, Hep B/C.
- Fasting glucose/lipids (prior to commencing an antipsychotic, and at regular intervals thereafter)
- Calcium/Magnesium/Phosphate (especially if poor oral intake/underweight)
- Baseline weight (for metabolic monitoring if starting antipsychotic)
- Drug levels (lithium, valproate, clozapine) to check compliance / toxicity Urine
- Mid Stream Urine M/C/S if ?infection/delirium o Urine Drug Screen if indicated (good to have evidence of substances being present or absence to clarify diagnosis)
- ECG (especially if going to commence an antipsychotic or antidepressant with potential to effect heart)
- Head CT (to rule out space-occupying lesion in first episode psychosis, especiall in first episode psychosis, especially if focal neurological signs are present).
- Weight, Height and BMI – for eating disorders or metabolic monitoring
Specific investigations to rule out a physical disorder Consider whether any investigations are required to rule out other organic causes for depression.
Also consider what opportunistic testing might be appropriate according to risks identified (family history, sexual activity etc.) and screening recommendations.
Testing will depend on a thorough history, including the psychological assessment, as well as physical examination findings and specific risk factors. If the young person is presenting with a clear mental health or psychosocial issue, with an absence of red flags, then a period of monitoring without any investigations is usually appropriate.
Laboratory testing in the absence of clinical indictors or red flags may have negative consequences including: a low yield; anxiety and; a risk of false positives.
Where indicated testing should be targeted to the history and examination.
Baseline investigations to consider include:
- Full blood count (FBC)
- Urea, electrolytes and creatinine (UE&C)
- Liver function tests (LFTs)
- Thyroid stimulating hormone (TSH)
- Blood sugar level (BSL)
It may also be worth considering the following:
- Iron (ferretin)
- Vitamin D
- Vitamin B12
- Folic acid
Where the predominant symptom is severe fatigue, general malaise or where there are also other symptoms identified there are a number of other investigations that may be considered, for example:
- EBV serology
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
- Autoimmune serology for rheumatologic symptoms
- Coeliac screen, haemachromotosis screen and/or referral to a gastroenterologist for gastrointestinal symptoms
- Referral to a neurologist for other neurological symptoms (eg multiple sclerosis)
Substance use
Knowledge:
- Demonstrate an understanding of the effects of alcohol and illicit drugs on health and psychosocial wellbeing.
- Be aware of dual diagnosis (comorbid mental illness and substance use disorder) and the link between risk and substance misuse.
- Demonstrate an understanding of support services and agencies e.g. AA, Alcohol and Drug Foundation, Family Drug Support, Salvation Army Recovery Services.
Skills:
- Screen for alcohol use disorders through use of screening tools e.g. AUDIT, CAGE, ASSIST.
- Offer advice on the effects of alcohol and illicit drugs on health and psychosocial wellbeing
Assess and document patient’s potential for self-harm or harm to others:
Knowledge:
- Explain the process of risk assessment and management.
Skills:
- Assess immediate and long-term risks to patients and others during assessment and treatment with consideration of relevant static and dynamic factors.
Self-harm is a risk factor for suicide, but many patients who self-harm do not report having an intention to die. The management of patients who deliberately self-harm is beyond the scope of these guidelines.
- Assessing suicide risk is a standard and crucial component of psychiatric assessments and mental health plans, but it is inherently difficult to reliably predict an individual’s risk of suicide.
- For examples of risk factors associated with suicide, see Table 8.24—this is not an exhaustive list of risk factors or a ‘check list’ for assessing suicide risk.
- Use the risk factors for suicide as a prompt to inform discussions with the patient.
Risk factors for suicide can be:
- Static—fixed or historic (eg history of self-harm or psychiatric disorder, gender, minority groups, family history of suicide)
- Dynamic—can fluctuate in duration and intensity (eg psychosocial stress, suicidal thoughts, active psychological symptoms, feelings of hopelessness).
Questions to ask when assessing suicide risk
- When people feel like you are/have been feeling, they sometimes think that life is not worth living—have you been thinking like that or have you ever thought like that?
- Have you been thinking of harming yourself?
- Are you thinking of suicide?
- If yes, how often are you having these thoughts?
- Have you thought about how you would act on these (is there a plan)? Do you have easy access to a weapon? (Consider whether the plan seems feasible, the methods are available and whether it is likely to be lethal.)
- Do you think you would or could act on this plan?
- Have you thought about when you might act on this plan?
- Are there any things/reasons that stop you from acting on these thoughts?
- Have you tried to harm yourself in the past?
- If yes, how many times?
- When was the most recent time?
- Do you know anyone who has recently tried to harm themselves?
- Do you feel safe at the moment?
If a suicide attempt has been made
- What did you hope would happen as a result of your attempt? (Distinguish whether the intent was to die or to end their pain.)
- Do you regret that the attempt was not successful?
- Do you still have access to the method used?
- Did you use alcohol or drugs before the attempt? What did you use?
Assessing risk (risk assessment and management)
- Assessment of risk involves making enquiry into the extent of the young person’s thinking, intent and behaviour around self-harm or suicide, including those listed below:
- If thinking about self-harm or suicide is present, how frequent, distressing and persistent is it?
- If the person has a plan, how detailed and realistic is it?
- What method has the person chosen, and how lethal is it?
- It is also important to clarify the young person’s understanding of the lethality (e.g. they may not understand that a paracetamol overdose may be lethal).
- It is important to ask about the young person’s intention to carry out the plan including their intention to die.
- Does the person have the means to carry out the method?
- Has the person ever planned or attempted suicide or self-harmed?
If so: What was the context (stressors, planned or impulsive, substance use)?
- What was their intention?
- How were they prevented from acting (did they ask for help, were they discovered acting)?
- How do they feel about that attempt now?
- Has someone close to the person attempted or completed suicide?
Suicide risk assessment should always be followed by a comprehensive mental health status examination.
From RACGP
Ten steps in the assessment and initial management of a suicidal adolescent
- Assess the adolescent’s risk profile.
- Assess the adolescent’s mental state.
- Consider involving the parents if at all possible
- Offer psycho-education about suicide risk and underlying psychological condition
- Consider the need for hospitalisation.
- Consider involvement of other health professionals and services (eg. crisis assessment team/public mental health service, private psychologist or psychiatrist, school counsellor)
- Develop a safety plan or refer to a mental health clinician who can provide this.
- Consider psychotropic medication or psychosocial intervention to treat underlying mental illness (eg. cognitive behaviour therapy and/or antidepressants for major depression).
- Document the risk assessment, mental state, safety plan and people contacted.
- Arrange for review.
MHA legislation:
Knowledge:
- Describe the applications of QLD mental health legislation in the care of patients who are experiencing mental illness.
Interpret and use key terminology associated with the Mental Health Act:
- Least restrictive
- Capacity to consent to be treated
- Supported decision making
- Advanced Health Care Directives
- Emergency Examination Authorities
- Recommendation for Assessment
- Treatment Authority
- Treatment criteria
- Forensic Order
- Mental Health Review Tribunal (MHRT) function – independent review to protect rights of people receiving involuntary treatment for mental illness
- Classified patient (involuntary and voluntary)
- Seclusion Mechanical restraint
- Authority to transport absent patient
Documentation of the clinical assessment and management plan
Skills:
Record concisely, accurately and confidentially appropriate elements of the history, examination, investigation, differential diagnosis, risk assessment and management plan.
Communication skills:
Knowledge:
- Describe how to structure the clinical interview to identify the patients concerns and priorities, their expectations and their understanding using communication skills including: establishment of rapport, the appropriate use of open ended and closed questions, techniques for asking difficult questions (e.g. flag posting), the appropriate use of facilitation, empathy, clarification, reassurance, silence and summary statements.
- Understand the ways in which patients may communicate that are not directly verbal and may have unconscious elements.
Skills:
- Demonstrate interviewing skills, including the appropriate initiation of the interview, the establishment of rapport, the appropriate use of open ended and closed questions, techniques for asking difficult questions, the appropriate use of facilitation, empathy, clarification, reassurance, silence and summary statements.
- Solicit and acknowledge expression of the patients’ ideas, concerns, questions and feelings.
- Communicate information to patients in a clear fashion.
- Avoid jargon and use familiar language when talking to patients and their families.
Team work
Knowledge:
- Demonstrate an understanding of the roles and responsibilities of team members
- e.g. Doctors, Nurses, Occupational Therapists, Social Workers, Psychologists, Cultural Liaison Officers, Peer workers, Speech and Language Pathologists, Administrative officers, and Operations assistants.
Skills:
- Communicate effectively with members of the multi-professional team, as well as patients, carers and relevant others where appropriate.
- Be willing to consult and work as part of a team.
Cultural Diversity:
- Recognise and incorporate the needs of culturally and linguistically diverse populations
- Awareness of the need for interpreters and culturally appropriate health workers
Health advocate
- Awareness of the health inequalities and disparities for people with severe mental illness
- Identify the impact of cultural beliefs and stigma of mental illness on patients, families and carers
- Describe the scope and role of local consumer and carer organisations within mental health care
Mood Disorders
- Major Depressive disorder
- Bipolar affective Disorder
- Presenting features (DSM 5 Diagnostic criteria) Major Depressive Disorder,Bipolar Affective Disorder
- Management First line treatments for Depression:
- Biological – SSRIs should be known about in detail, awareness of other antidepressant treatments including SNRIs, Mirtazapine, Tricyclic antidepressants, MAOIs
- Psychological – CBT: Be able to convey basic information about what this involves, duration, frequency of sessions.
- Awareness of other psychotherapies including ACT
- Physical Treatments: Knowledge of major indications for ECT and common side effects
- Social and Lifestyle – sleep advice, substance use, diet and exercise, social support
- First line treatments for Bipolar Depression
- Biological – awareness of relative contraindication for antidepressant medications, knowledge of use of lithium, commonly used antiepileptics (valproate and lamotrigine) and second generation antipsychotics alone or in combination with antidepressants.
- Psychological – CBT
- Social and Lifestyle – sleep, substance use, diet and exercise, social support
- First line treatments for Mania Setting – inpatient admission usually, consider risks and need for HDU setting - Behavioural disturbance – benzodiazepines - Treatment of mania – Second generation antipsychotics +/- anti-epileptic or lithium
- First line treatments for Bipolar
- prophylaxis Lithium – detailed knowledge of narrow therapeutic window, common side effects, presentation of toxicity (signs and symptoms), common interactions (NSAIDs, ACE inhibitors etc), monitoring requirements, awareness of perinatal concerns
- Sodium Valproate – awareness of relative contraindication in women of child bearing age, common side effects
- SGAs – awareness that they are used for this indication, often alongside a mood stabilising agent (lithium or antiepileptic)
Psychosis
Knowledge:
- Name and be able to describe common psychotic experiences
- Delusions – grandiose, persecutory, jealous, poverty, nihilistic, somatic, delusions of reference, delusions of control (including thoughts i.e. withdrawal, insertion, broadcast/ emotions or actions – passivity phenomena)
- Hallucinations – auditory (awareness of tactile, somatic, olfactory, visual, gustatory and the relevance of these)
- Awareness of major conditions that may present with psychotic features:
- Organic – neuropsychiatric consequences of intoxication, withdrawal, delirium, neurological conditions including encephalitis, Parkinson’s disease
- Psychotic Disorders in Psychiatry – Schizophrenia, Schizoaffective disorder, Delusional Disorder
- Major presenting features of each (DSM5
- Other Disorders in Psychiatry that may present with psychotic features – Depression, Bipolar Affective Disorder
- Awareness of concept of non-psychotic hallucinations which may include dissociative experiences, unusual perceptions experienced in the context of borderline personality disorder and attachment trauma.
- Treatments Knowledge of indications and major side effects of Antipsychotic medications -
- The major side effects of antipsychotic medications by class OFGA – (commonly used e.g. Haloperidol, chlorpromazine, zuclopenthixol, flupenthixol) extra pyramidal side effects, sedation, QTc prolongation, raised prolactin O
- SGA – (commonly used e.g. Risperidone, Quetiapine, Olanzapine, aripiprazole, lurasidone, ziprasidone) metabolic side effects and monitoring, sedation, QTc prolongation, raised prolactin O
- Awareness of propensity for Olanzapine and Quetiapine to cause rapid weight gain
- Risperidone to increase prolactin
- Clozapine – knowledge of indication (treatment resistant Schizophrenia); major side effects and adverse events associated including haematological (neutropenia and agranulocytosis), cardiac (myocarditis, cardiomyopathy), neurological (sedation and seizures), metabolic, gastrointestinal (constipation), hypersalivation; statutory monitoring requirements (I.e. regular FBC
- required for pharmacy to dispense); recommended metabolic monitoring; awareness of need for slow titration and re-titration in the event the medication is stopped for greater than 72 hours;
- awareness of low propensity for extra pyramidal side effects
- Awareness of psychological treatments used in Psychosis – CBT for psychosis
- Awareness of importance of the MDT in management of long term psychiatric conditions e.g. - Occupational therapy (identification and support in finding meaningful activities, promote ability and engagement in ADLs/ other living skills)
- Social workers – ensure appropriate accommodation, support with finances, navigate benefits systems
Anxiety disorders:
Knowledge:
- Major distinguishing features of DSM5 anxiety disorders including panic disorder, agoraphobia, social phobia, generalised anxiety disorder
- First line treatments for anxiety disorder
- Psychological – CBT, with emphasis on graduated exposure techniques
- Pharmacological – SSRIs (including understanding of major side effects and monitoring)
- Management of lifestyle factors associated with anxiety disorders, particularly diet, exercise, sleep and substance use
