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PACES management > Laz Psych Histories > Flashcards

Laz Psych Histories Flashcards

1
Q

differential diagnosis of normal bereavement

A
  • depression
  • adjustment disorder
  • substance misuse
  • BPAD
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2
Q

Investigations for normal bereavement

A
  • PHQ9 to assess baseline level of depression

- investigations for physical causes: FBC (anaemia), TFTs, cortisol

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3
Q

management of normal bereavement

A
  • assess risk
  • grief counselling
  • offer support helplines (e.g. Samaritans, Campaign Against Living Miserably (CALM - only for men)
  • CBT
  • Antidepressants (SSRIs e.g. sertraline)
  • IAPT
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4
Q

what are some features of abnormal grief?

A
  • extreme/ intense (disabling)
  • lasting >6 months
  • delayed
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5
Q

what are some physical causes of depression?

A
  • Cushing’s syndrome
  • Hypothyroidism
  • Addison’s disease
  • Dementia
  • Head injury
  • Stroke
  • MS
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6
Q

what are some cognitive symptoms of depression?

A
  • selective memory for negative events
  • pathological guilt
  • feeling of guilt about being a burden on others
  • pessimism
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7
Q

what are the components of Beck’s cognitive triad?

A
  • Negative views about the self (worthless)
  • Negative views about the world (helpless)
  • Negative views about the future (hopeless)
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8
Q

Features of Lewy Body dementia

A
  • confusion (mixing up names etc)
  • falls
  • hallucinations
  • fluctuating
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9
Q

potential other differentials for Lewy Body dementia

A
  • vascular dementia
  • Alzheimer’s disease
  • derlirium
  • pseudodementia
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10
Q

investigations for Lewy Body Dementia

A
  • physical exam: resting tremor, cogwheel rigidity in wrist
  • AMTS: 5/10
  • MMSE: 21/30
  • FBC, U&Es, glucose, TFTs (NAD)
  • CT/ MRI (mild atrophy)
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11
Q

management of lewy body dementia

A
  • adaptations for patient (with an OT): reality orientation, environmental modifications
  • social support/ support carers
  • optimising physical health (review meds)
  • psychological therapies (e.g. reminiscence therapy)
  • Acetylcholinesterase inhibitors may provide symptomatic relief
  • Parkinsonian symptoms can be treated with Parkinson’s drugs but this can make hallucinatiosn worse
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12
Q

reversible causes of dementia

A
  • brain (subdural haematoma, SOL, NPH)
  • endocrine (Addison’s, Cushing’s disease)
  • Vitamin deficiency (B12, folate, thiamine (Wernicke’s), niacin (pellagra)
  • Neurosyphilis
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13
Q

key differences between between DLB, AD and VD

A
  • VD has stepwise decline, DLB and AD has a more gradual decline
  • AD has insidious onset, VD is sudden and DLB varies
  • DLB causes parkinsonism, hallucinations and syncope
  • short term memory is less affected than in VD and AD
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14
Q

risk factors for VD

A
  • vascular risk factors (CVD, HTN, high cholesterol, diabetes)
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15
Q

CT changes in AD, VD and DLB

A

AD - gernealised atrophy
DLB - mild atrophy
VD - multiple lucencies

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16
Q

name a congenital condition that increases the risk of developing AD

A

Down syndrome

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17
Q

differential diagnoses for anorexia nervosa

A
  • bulimia nervosa
  • physical cause (e.g. hyperthyroidism, GI disease)
  • depression
  • eating disorder not otherwise specified
  • body dysmorphic disorder
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18
Q

investigations in anorexia nervosa

A
  • physical exam: emaciated, lanugo hair, very thin
  • height and weight, BMI
  • squat test: difficulty standing from squatting without help
  • TFTs (NAD)
  • FBC: low Hb
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19
Q

management of anorexia nervosa

A
  • speak to child directly and figure out stressors
  • explore the possibility of OCD
    1st: Anorexia-focused family therapy
    2nd: ED-CBT
  • other options: specialist supportive clinical management (SSCM), Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
  • treat co-morbid OCD if necessary: education and self help, ERP
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20
Q

how do you counsel a patient with anorexia nervosa

A
  • condition characterised by restriction of energy intake leading to low body weight, an intense fear of gaining weight and a disturbance in the way an individual perceived their body shape/weight
  • this can lead to several physical health problems so want to help you get to a healthy weight
  • involve attending anorexia-focused family therapy (involved showing you how you can support your daughter in returning to normal pattern of behaviour)
  • also possible to have some features of OCD (obsessions and compulsions) which is something we’d like to explore further and see whether treatment is necessary
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21
Q

difference between anorexia nervosa and bulimia nervosa

A

bulimia is characterised by periods of bingeing followed by purging (using laxatives, forced vomiting, diuretics)

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22
Q

physical complications of anorexia nervosa?

A
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23
Q

physical complications of anorexia nervosa

A
  • bradycardia and hypotension (risk of sudden death)
  • GI upset (constipation, abdo pain, ulcers)
  • amenorrhoea and infertility
  • osteoporosis
  • peripheral neuropathy
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24
Q

medical causes of weight loss

A
  • hyperthyroidism
  • malignancy
  • GI diseasse (e.g. coeliac disease)
  • Addison’s
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25
Q

mortality rate of anorexia nervosa

A

10%

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26
Q

when might inpatient treatment of anorexia nervosa be needed?

A
  • BMI < 13 or rapid weight loss
  • serious physical complications
  • high suicide risk
  • MHA may be used to enforce compulsory feeding
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27
Q

Paranoid schizophrenia features to ask about

A
  • auditory hallucinations
  • visual hallucinations
  • delusional beliefs and thought disorder
  • risk
  • insight
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28
Q

investigations to investigate paranoid schizophrenia

A
  • physical exam: assess baseline, rule out organic causes
  • FBC, TFTs, U&Es and glucose
  • lipids: before starting anti-psychotics
  • urine drugs screen
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29
Q

differential diagnosis of paranoid schizophrenia

A
  • substance misuse
  • FEP
  • mood disorder
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30
Q

management of paranoid schizophrenia

A
  • biopsychosocial model
  • biological therapies: antipsychotics
  • psychological therapies: CBT, family therapy, concordance therapy
  • social interventions: admission, social skills training, education, mood disorder
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31
Q

how would you counsel a schizophrenic patient?

A
  • voices you are hearing and feelings you have been feeling are due to an imbalance in the chemicals in your brain
  • normally when you see something in life it will trigger a change in chemicals in your brain to help you understand what is going on
  • if chemicals are unbalanced, it can cause you to see/ hear things that other people don’t see and hear
  • can give medication that can help balance these chemicals and make these symptoms go away
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32
Q

what is the MOA of atypical antipsychotics?

A

blocks dopamine receptors and serotonin receptors

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33
Q

side effects of anti-psychotics

A
  • extra-pyramidal: dystonia, akathisia, parkinsonism, tardive dyskinesia, hyperprolactinaemia (galactorrhoea)
  • weight gain
  • sedation
  • dyslipidaemia
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34
Q

what are Schneider’s First-Rank Symptoms?

A
  • delusional perception
  • passivity
  • delusions of thought interference (insertion, withdrawal, broadcasting)
  • auditory hallucinations (thought echo, 3rd person voices, running commentary)
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35
Q

what is schizoid personality disorder?

A
  • lack of interest in social or intimate relationships
  • difficulty with expressing emotions
  • prefer solitary lifestyle
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36
Q

differential diagnoses for delirium

A
  • FEP
  • intoxication
  • dementia
  • if taking steroids = steroid induced psychosis
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37
Q

management of delirium

A
  • admit: delirium fluctuates so even if they are lucid right now, they could deteriorate if they go home
  • identify source of infection (CXR, stool culture) or cause of delirium
  • treat cause
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38
Q

define delirium

A

acute confusional state resulting from physical cause e.g. infection

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39
Q

name some drugs that can cause psychosis

A
  • steroids
  • ethambutol
  • cannabis
  • cocaine
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40
Q

Management of OCD

A
  • 1st: CBT

- 2nd: SSRI (usually at high dose)

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41
Q

how do you counsel someone with OCD?

A

the symptoms described are suggestive of OCD, have you heard much about this before?
it is a condition in which you have recurrent intrusive thoughts to do something and it can really disturb your life
This can be managed using something called CBT (explain CBT)

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42
Q

what are the key differences between an obsession and a delusional belief?

A
  • thoughts are identified as your own
  • thoughts are repetitive and intrusive
  • evidence of resistance by the patient (as least in early stages)
  • signs of avoidance
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43
Q

co-morbidities associated with OCD

A
  • depression

- eating disorders

44
Q

investigations for OCD

A

physical exam (get idea of baseline state and rule out organic causes)
PHQ9 and GAD7 to assess baseline
admit pt if think they are at high risk of suicide

45
Q

management of depression

A

Biopsychosocial
Biological: SSRI - follow up closely and explain that they take time to work
Psychological: CBT or psychodynamic therapy
Social: recommend taking part in more activities day day, occupy time with stimulating activities

46
Q

main symptoms of depression

A
  • anergia
  • anhedonia
  • low mood
  • sleep change
  • appetite change
  • concentration change
  • memory deficits
47
Q

list 3 classes of anti-depressants and give an example of each

A
  • SSRI: sertraline, citalopram, escitalopram, fluoxetine
  • SNRI: duloxetine, venlafaxine
  • NaSSA: mirtazapine
  • TCA: imipramine, amitriptyline
48
Q

how might the treatment be different if the patient has psychotic depression?

A
  • start anti-psychotic (e.g. quetiapine) alongside anti-depressant
49
Q

how is psychosis in depression different from psychosis in schizophrenia?

A
  • psychosis is mood congruent in psychotic depression

- psychosis tends not to be mood congruent in schizophrenia as patients have blunted affect

50
Q

investigations in GAD

A
  • GAD7 questionnaire to assess baseline state
51
Q

differential diagnosis for GAD

A
  • substance misuse (caffeine)
  • depression
  • anxious personality disorder
  • hyperthyroidism
52
Q

management of GAD

A

1st: CBT + self help methods, encourage reliance on supportive contacts, problem-solving (to help identify and deal with stressors)
Propranolol is CONTRAINDICATED (because of asthma) but relaxation techniques and breathing exercises may be helpful

53
Q

pharmacological treatment for GAD

A

1st: SSRI (e.g. sertraline) - usually required higher doses (200mg), takes longer to act (6-8 weeks)
2nd: taper SSRI and switch to SNRI (e.g. venlafaxine)
3rd: add pregabalin
4th: quetiapine (off label)

54
Q

support charity for GAD

A

mind.co.uk

55
Q

how long do SSRIs take to act in GAD?

A

6-8 weeks

56
Q

what’s the difference between GAD and panic disorder?

A
  • GAD is not triggered by specific stimulus, it is continuous and generalised
  • Panic disorder is characterised by sudden attacks of extreme anxiety lasting <30 minutes and relatively free of anxiety in between attacks
57
Q

what is agoraphobia?

A

fear of being unable to easily escape to a safe place (usually home)

58
Q

fear of social phobia

A

fear of being scrutinized or criticized by other people

59
Q

what is the prognosis of anxiety disorders?

A

1/3 recover completely
1/3 improve partially
1/3 fare poorly and suffer considerable disability

60
Q

differential diagnoses of PTSD

A
  • anxiety disorder
  • depression
  • adjustment disorder
61
Q

management of PTSD

A

1st: Trauma focused CBT (trauma can shatter previous belief systems, these new beliefs can be examined and tested, helps pt to understand link between current feelings and trauma)
Adjunct: SSRI (helps with sleep and low mood)
2nd line: EMDR

62
Q

how you counsel a patient with PTSD

A

PTSD is a condition that occurs after someone has gone through a major traumatic event
it is characterised by episodes where you feel like you are vividly reliving the trauma as well as times when you feel like you’re particularly anxious/ high alert
can affect your behaviour e.g. avoid anything that may trigger you to feel all these emotions again

63
Q

cardinal features of PTSD

A
  • flashback and reliving
  • hyperarousal
  • avoidance
64
Q

what is adjustment disorder?

A

a person’s reaction to life changes that require adaptation to cope (e.g. moving to uni) is greater than usually expected
not severe enough to diagnose disorder or depression

65
Q

physical manifestations of anxiety

A

tremor
palpitations
sweating
hyperventilation

66
Q

differential diagnosis of acute mania

A
  • BPAD type 1
  • drug induced state
  • FEP
  • schizophrenia (grandiose)
  • delusional disorder
  • schizoaffective disorder
67
Q

management of acute mania

A

Biological: pharmacological management of acute mania and BPAD
Psychological: CBT (identify relapse indicators, relapse prevention strategies)
Social: family support, aiding return to work, deal with financial issues resulting from overspending
Risk: admit if risky

68
Q

Pharm management of acute mania

A
  • atypical antipsychotic (e.g. aripiprazole, quetiapine, olanzapine, risperidone)
    if fails, add mood stabiliser
  • mood stabiliser (e.g. lithium, carbamazepine, sodium valproate)
69
Q

Long term management of mania

A
  • mood stabiliser is mainstay

- Lithium and monitoring

70
Q

how do you counsel a patient with mania

A
  • we believe you are experiencing mania
  • get a chemical change in your brain and can lead to very increased mood
  • may not seem like a bad thing but it can actually be very damaging in long run
  • can lead you to make risky decisions that you wouldn’t otherwise make
  • can cause you serious harm (financial, physical, emotional)
  • we would like to keep you in hospital to give you some treatment that can normalise chemicals in your brain and help you think clearer
  • when you are feeling back to normal, we can discuss how we can help you get back to regular work
71
Q

what are 2 types of bipolar affective disorder?

A

1: characterized by episodes of main interspersed with depressive episodes
2: mainly recurrent depressive episodes with less prominent hypomanic episodes

72
Q

what are some features of lithium toxicity?

A
  • GI disturbance (D&V)
  • sluggishness
  • giddiness
  • ataxia
  • gross tremor
  • fits
  • renal failure
73
Q

what are some long term consequences of lithium use?

A
  • hypothyroidism

- renal impairment

74
Q

what are the teratogenic effects of mood stabilisers in pregnancy?

A
  • Lithium: Ebstein’s anomaly

- Valproate and carbamazepine: spina bifida

75
Q

if this patient was in depressive phase of BPAD, how would you manage him?

A
  • anti-depressant (e.g. SSRI) with an atypical antipsychotic (e.g. arirprazole, quetiapine) to prevent triggering mania
76
Q

potential differential diagnoses for puerperal psychosis

A
  • BPAD with psychosis
  • schizophrenia
  • FEP
  • psychotic depression
  • substance misuse
77
Q

management of puerperal psychosis

A
  • admit to a mother and baby unit for treatment
  • take collateral history from husband
  • treat psychosis with atypical antipsychotic (e.g. quetiapine)
  • other agents used for treatment: antidepressants, mood stabilisers
  • investigate possibility of underlying BPAD
  • severe cases: ECT may ne requried
  • most pt require in 6-12 weeks
78
Q

risk factors for puerperal psychosis

A
  • personal or FH of puerperal psychosis or BPAD
  • puerperal infection
  • obstetric complications
79
Q

what is incidence of puerperal psychosis?

A

1 in 1000 births

80
Q

how is puerperal psychosis different from postnatal depression and baby blues?

A
  • postnatal depression does not tend to have psychotic symptoms or if it does they tend to be mood congruent
  • baby blues tend to occur within few days of birth. Characterized by tearfulness and low mood which swiftly recover
81
Q

describe Dialectical Behavioural Therapy (DBT)

A
  • focuses on factors contributing to emotional instability (being emotionally vulnerable and sensitive to stress, growing up where emotions were dismissed by those around)
  • there factors lead to viscous cycle where you experience intense and upsetting emotions
  • make you feel guilty and worthless
  • leads to actions that can make you feel upset again
  • DBT aims to introduce 2 important concepts (Validation and Dialectics)
  • Validation: accepting that your emotions are acceptable
  • Dialectics: showing you that things in life are rarely black or white, help you be open to ideas/ opinions that contradict your own
82
Q

what is mentalisation-based therapy?

A
  • mentalisation is ability to think about thinking
  • examining your own thoughts and assessing them based on reality
  • teaches you how to take a step back and scrutinise your thoughts and impulses
  • teaches you how to recognise other people’s thought patterns and accept your interpretation may not be correct
83
Q

what other therapies can be used in personality disorder?

A
  • therapeutic communities: teaching social skills to groups of people with complex psychological conditions, inc tasks that improve social skills and self confidence
  • art therapies if pt suffer to express feelings verbally
84
Q

when treating a crisis, what useful contact numbers should be given?

A
  • community mental health nurse
  • out of hours social worker
  • local crisis resolution team
85
Q

what are the 3 clusters of personality disorder?

A

A: odd, eccentric = schizoid, schizotypal, paranoid
B: dramatic = histrionic, narcissistic, antisocial, emotionally unstable
C: anxious = avoidant, dependent, anakastic

86
Q

what distinguishes a personality disorder from a personality trait?

A
  • pervasive: all/ most areas of life
  • persistent: evident in adolescence and continues into adult life
  • pathological: causes distress to self or others
87
Q

what is the difference between schizoid and schizotypal personality disorder?

A
  • Schizoid: odd, loner, little interest in forming relationships, no interest in sexual experiences, cold affect
  • Schizotypal: bizarre beliefs, magical thinking, strange behaviour
88
Q

what are the big 5 personality traits?

A
  • openness
  • conscientiousness
  • extraversion
  • agreeableness
  • neuroticism
89
Q

things to ask about in alcohol history

A
  • CAGE
  • dependence symptoms
  • mood
  • psychotic symptoms (to exclude delirium tremens)
  • safeguarding issues
  • driving
90
Q

rating scales in alcohol dependence

A
  • AUDIT to identify use disorder
  • SADQ to determine severity of dependence
  • APQ to assess nature of problems arising from alcohol
91
Q

management of alcohol dependence - BIO

A
  • motivational interviewing and encourage abstinence
  • advise healthy diet/lifestyle
    BIO: assisted withdrawal. if community based = Drug and Alcohol Service
  • chlordiazepoxide or diazpam, after successful withdrawal = acamprosate or naltrexone with psychological intervention
  • thiamine supplementation
    EXPLANATIONS: withdrawal symptoms worst within first 48 hours, takes about 3-7 days after last drink to disappear
92
Q

management of alcohol dependence - PSYCH

A
  • CBT, behavioural, social network and environment based
  • focus on alcohol-related cognitions (weekly 1 hour sessions for 12 weeks)
  • refer to self help resources and support groups (AA, SMART recovery)
93
Q

management of alcohol dependence - SOCIAL

A
  • direct to relevant services regarding legal/ financial support
  • direct to services that can help find new job
  • Driving: DVLA will need to be informed, can’t drive during treatment
  • arrange follow up for any time after you finish withdrawal
94
Q

what are some risks associated with excessive drinking?

A
  • liver disease
  • CV disease
  • malnutrition
95
Q

what are the symptoms of delirium tremens?

A
  • nightmares
  • agitation
  • confusion
  • disorientation
  • visual and auditory hallucinations
  • tactile hallucinations
  • fever
  • high BP
  • sweating
96
Q

what drugs are used for alcohol detox?

A
  • chlordiazepoxide or diazepam

lorazepam if liver failure

97
Q

what is the rout of admin of drugs used for opiate withdrawal?

A
  • methadone (oral liquid)

- buprenorphine (sublingual tablet)

98
Q

MoA of methadone and buprenorphine

A

Methadone: full mu receptor agonist
Buprenorphine: partial mu receptor agonist

99
Q

which medications can be given for prevention of relapse?

A
  • naltrexone
  • acamprosate
  • disulfiram
100
Q

how would you counsel a somatoform disorder to a patient?

A
  • validate the pain is real

- explain the root cause is psychological

101
Q

management of a somatoform disorder?

A
  • Bio: SSRI, counsel mood may get worse before it gets better, follow up in 1 week
  • Psycho: CBT
  • Social: if stress caused by work, can offer a note
102
Q

what is somatisation?

A

manifestation of multiple, recurrent and frequently changing physical symptoms
>2 years duration
results from psychological distress

103
Q

how is somatisation different from hypochondrial disorder?

A
  • Hypochondriasis is characterised by a persistent preoccupation with the possibility of having one or more serious and progressive physical disorder
  • focused on one disease rather than cluster of symptoms
104
Q

give some examples of medically-explained symptoms

A
  • stomach pains
  • conversion disorder
  • chronic fatigue syndrome
  • fibromyalgia
105
Q

what are some side effects of SSRIs?

A
  • N&V
  • appetite change and weight change
  • anxiety/agitation
  • headache
  • sweating
  • hyponatraemia
106
Q

which medications should not be used in patients who are on SSRIs?

A
  • NSAIDs and aspirin
  • Triptans
  • Warfarin/heparin

PACES management (7 decks)

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