psyc Flashcards
OCD management
1st line: CBT with Exposure and response prevention (ERP)
2nd line: fluoxetine (SSRI) (continue for 12 months after remission)
3rd line (after 12 weeks no improvement): clomipramine or alternative SSRI
3 types of thought alienation
- thought withdrawal (thoughts
are being removed from the patient’s head) - thought insertion (thoughts are
being placed into the patient’s head) - thought broadcasting (thoughts are
heard by others)
learning difficulty vs learning disability
difficulty = IQ unaffected
(dyslexia eg.)
disibility = IQ affected
50–70: Mild
35–49: Moderate
20–34: Severe
Less than 20: Profound
(intellectual functioning, maladaptive behaviour across several environments)
chronic insomnia define
Chronic Insomnia: diagnosed if a person has trouble falling asleep or staying asleep at least 3 nights per week for 3 months
manage insomnia with severe daytime impairment
Hypnotics that are recommended
- short-acting
benzodiazepines (e.g. temazepam) and non-benzodiazepine ‘Z-drugs’ (e.g. zopiclone).
(Diazepam can be used if insomnia is associated with daytime anxiety)
If a hypnotic is prescribed, the lowest possible dose should be used for
the shortest possible time, and the patient should be reviewed after 2 weeks
examples of typical and atypical antipsychotics
typicals= haloperidol, chlorpromazine
atypical = clozapine, olanzapine, risperidone, quetiapine, apriprazole, amisulphide
outline dystonia (onset, sx, tx)
onset = early / sometimes hours
sx = painful sustained muscle contractions/spasms
e.g. oculogyric spasm, torticollis
tx = procyclidine (anti-cholinergic)
outline akathisia (onset, sx, tx)
onset = hours to weeks
sx = restlessness, jiggle legs , patient paces about
tx = decrease dose / change
propanolol or benzodiazepine
outline parkinsonism onset sx tx
days to weeks
resting tremour, cogwheel rigidty, bradykinesia
tx = decrease dose / change
procyclidine
outline tardive dyskinesia
months to years
rhythmic invol movements, grimace, chewing, sucking, blinkning, often irreversible
tx = stop reduce/ reduce dose
- switch to clozapine (atypical)
- avoid procyclidine –> makes it worse
- tetrabenazine for moderate/severe
name of that person for sectioning
Approved Mental health professional
indications for the 4 different depression drugs (SSRI/SNRI’s/NaSSA)
Sertraline is considered safest in patients who have comorbid medical
conditions (especially if they have a history of ischaemic heart disease)
fluoxetine is the SSRI of choice in children and adolescents.
Mirtazapine is a noradrenergic and specific serotoninergic antidepressant (NaSSA) which has a sedating effect that helps improve sleep and stimulate appetite.
Venlafaxine is a serotonin– noradrenaline reuptake inhibitor (SNRI) which is usually used if SSRIs are ineffective or unacceptable.
how to manage paracetamol overdose
if presenting < 2 hours of digestion = give activated charcoal
otherwise measure serum paracetamol level at 4 hours after digestion on normogram to see if treatment with N acetylcysteine is necessary
a new drug or an increase in dose. It presents with rigidity, altered consciousness, and disturbed autonomic function
neuroleptic malignant syndrome
neuroleptic malignant syndrome- how does it present and what ix do you do
It presents with rigidity, altered consciousness, and disturbed autonomic function
ix = measure creatine kinase
ptsd management
- Debriefing is not recommended
- Watchful waiting may be used for mild symptoms lasting < 4 weeks
- Trauma-focused CBT or EMDR may be used in more severe cases
- Drug treatment is not routinely recommended, but if it is used, paroxetine and mirtazapine are recommended
- Note: mirtazapine is a NaSSA (alpha-2 antagonist, serotonin antagonist and histamine antagonist)
first line tx to prevent relapse of alcohol
first 7-10 days give benzo (chlorodiazepoxide / diazepam)
next can give = acamprosate and naltrexone, which have an anti-craving effect.
what is associated with SSRI use in pregnancy ?
congenital heart
disease (if used in the first trimester)
persistent
pulmonary hypertension (if used in the third trimester).
Paroxetine, in particular, is associated with an increased
risk of congenital malformations.
SSRIs that are generally considered safer in
pregnancy include sertraline, citalopram, and fluoxetine
Paroxetine and sertraline are considered safe
to use during breastfeeding.
how to manage adhd ?
present for > 6 months
1st line = parent training programme
2nd line = methylphenidate (ritilin)
scale used to assess post natal depression
The severity can be assessed using the Edinburgh
Postnatal Depression scale.
where to admit a crazy mum
mother and baby unit
maternity blues vs post natal depression
maternity blues is < 2 weeks
post nat depress is longer, can even be up to a year after birth
what to give to someone who wants to get off heroin (and delivery routes)
methadone (oral liquid)
or
buprenorphine (sublingual)
triad of lewy body dementia
This patient is exhibiting the classical triad of Dementia with Lewy Bodies
(DLB):
- confusion
- vivid visual hallucinations, 3. Parkinsonian signs (e.g.
tremor).
Parkinsonism is a late sign and may also include rigidity, bradykinesia,
and postural instability
what is first line for treatment resistant schizophrenia?
clozapine
how to monitor lithium ?
Lithium requires careful monitoring because it has a narrow therapeutic range
(0.4–1 mmol/l).
Routine serum lithium monitoring should be performed weekly
after initiation and after each dose change until a therapeutic level has been
achieved.
It should then be checked every 3 months thereafter
how to remember lithium side effects ?
(LITHIUM)
Leucocytosis
*
Insipidus (nephrogenic)
*
Tremor
*
Hypothyroidism
*
Increased urine output
*
Mothers (teratogenic)
after starting someone on antidepressants how long do you wait to follow them up ?
1 week
risk of suicide - higher in younger patientsanhe
anhedonia vs apathy ?
Anhedonia is the lack of enjoyment or pleasure. Apathy is a lack of energy or motivation to do things.
downs syndrome person gets dementia - what is it ?
alzheimers
sodium valproate in pregnancy ?
neural tube defect
lamotrigine and carbamazpine is better
refeeeding syndrome electrolyte changes ?
hypophosphataemia
this is the hallmark symptom of refeeding syndrome
may result in significant muscle weakness, including myocardial muscle (→ cardiac failure) and the diaphragm (→ respiratory failure)
also get:
hypokalaemia
hypomagnesaemia: may predispose to torsades de pointes
abnormal fluid balance
first line for eating disorder in CAHMS ?
any CAMHS patient with an eating disorder the first line treatment will be family-focused treatment unless there are any contraindications or if family therapy is not possible/feasible
The aim of family therapy is to support the young person around meals and to support them at home so that their eating can be managed without hospital admission
if an exam question says its euthymic … what is it not ?
not an affective disorder
you’re a doctor, doctor who, he’s a doctor… - what is this thought disorder ??
flight of ideas
meds for alzeihmers
severe and moderate
mild - moderate= Acetylcholinesterase inhibitors:
donepezil, rivastigmine, galantamine
1st line for severe= Memantine (NMDA antagonist)
projection, deep seated distrust, suspicious
what personality disorder?
paranoid
what is antisocial disorder related to in young people
< 18 y/o then its conduct disorder
in the question be careful - can’t be antisocial personality disorder if under 18
unstable relationships
borderline / emotionally unstable personality disorder
which perosnality is self harm / suicide attempts most common?
borderline personality disorder
tx for borderline personality disorder
dialectical behaviour therapy
form of CBT
this is high yeild
inappropriate sexually provocative behaviour / centre of attention
which personality disorder is this ?
histrionic
grandiosity / inflated sense of self / lack empathy /
narcisitic
avoidant vs schizoid personality disorder
avoidant = they want conection but they are too afriad of rejection / they feel inadequate
schizoid = they really not interested in social stuff. they don’t want it…
delusion where someone has been replaced by an imposter ?
capgras
same person that is wearing mask / changing their appearance to be different people
fregoli
delution that you belive you are dead / does not exist /
cotard
delution that you’re infested with pathogens
ekbom
3 typees of eating disorders
anorexia nervosa
bulimia nervosa
binge eating disroder
what is classfied as severe anorexia and what do you need to do ?
BMI < 15
you need to hospitalise (associated with mortality)
physiological effects of anorexia
reduced GnRH secretion from hypothalamus
reduced LH / FSH
functional hypothalamic amenorhheara
tx for anorexia nervosa
nutrional rehap
strcutrued meals + daily calories goals
psychotherapy
Can give olanzapine (O = obesity, this drug helps you gain weight)
what can you find in the urine for someone who does surreptitious vomtiing ?
low urinary chlorde
russell’s sign?
scar on knucles from sticking hand in mouth
best tx for binge eating disorder ?
psychtherapy / CBT
3 types of unexplained symptoms categories
- somatic sx disorder-
sx are uninentional / motivation is uninetional
conversion disorder - this is usually following a stressor event (death/divorse) - factitious disorder - “munchausen” - falsified medical sx / “munchhausen by proxy”
- malingering - “faking an injury so you dont have to go to work”
what are some things to cover in A for ASEPTIC in psych
- Appearance and behaviour - Provide some clues as to their lifestyle, current mental state and ability to care for themselves.
a. Age, gender, ethnicity and occupation – e.g. “Mrs X is a middle-aged Caucasian female who reported to be the lead singer of the Spice Girls”
b. Dress and self-care – dressing provocatively could be a sign of sexual disinhibition/bipolar disorder, whereas a disheveled appearance may be consistent with depression or schizophrenia. Note if the clothing is appropriate for the weather/circumstances and if the clothes have been put on correctly.
c. Manner - hostile/helpful, aggressive/amiable? Were they appropriately behaved with you during the consultation?
d. Posture and movement - were they tense, relaxed or overactive, or were there any side effects of antipsychotic use evident, e.g. tardive dyskinesia
e. Rapport - easy or difficult to establish, distracted or if they appear to be engaging with hallucinations (e.g. replying to auditory hallucinations in schizophrenia)
“This patient appeared well-kempt with adequate eye contact, a good level of personal hygiene and did not appear to be guarded.”
give things you would include in S for aseptic in psych
- Speech - describe in terms of rate, rhythm, tone and volume. Comment on whether there was any pressure or poverty of speech and whether they were coherent or incoherent.
Think of speech as a train and thoughts as passengers – normal speech and thought would be a train travelling at normal speed, reasonably full of passengers and it takes a logical route from station A to station B.
NB: Formal thought disorder should be presented here, not in the Thought section, as it presents as abnormal speech patterns e.g. word salad
“The patient spoke coherently at a normal rate, and rhythm. However, their voice was quiet and monotonous. No obvious thought disorder.”
Circumstantiality
is the inability to answer a question without giving excessive, unnecessary detail. However, this differs from tangentiality in that the person does eventually return to the original point.
Tangentiality
refers to wandering from a topic without returning to it.
Perseveration
is the repetition of ideas or words despite an attempt to change the topic.
Echolalia
is the repetition of someone else’s speech, including the question that was asked.
Knight’s move thinking
is a severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another. It is a feature of schizophrenia.
Flight of ideas,
a feature of mania, is a thought disorder where there are leaps from one topic to another but with discernible links between them.
Word salad
describes completely incoherent speech where real words are strung together into nonsense sentences.
Neologisms
are new word formations, which might include the combining of two words.
Clang associations .
are when ideas are related to each other only by the fact they sound similar or rhyme
what to include in E for ASEPTIC in p[sych
- Emotion/Mood - represents a patient’s predominant subjective internal state at any one time as described by patient
a. Subjective – quote the patient directly e.g. “10/10” or “never felt better”
b. Objective – what you think their mood is e.g. “depressed,” “elated,” “euthymic”
flat affect = depressed
blunted affect = schizophrenia
c. Affect is what you observe of how the patient is presenting during the consultation in terms of emotions. Congruency means patient’s affect appears in keeping with the content of their thoughts. It is “incongruent” if the person’s report doesn’t match their presentation (i.e. they laugh while saying they have suicidal thoughts). If the affect varies appropriately, you can describe it as “reactive”
d. Risk assessment! See (8) but this is a common place to ask about risk to self, risk to others and risk from others
“Patient was feeling well and optimistic. He was having disturbed sleep which has recently resolved. Good appetite and has been motivated to go to the gym although he feels fatigue. No anhedonia, no evidence of worthlessness nor risks to self. Objectively, patient appeared to be euthymic but was blunted in affect”
WHat is teh P for in ASEPTC
- Perception - hallucinations, pseudo-hallucinations, illusions, depersonalisation or derealisation.
what is the T for in aseptic in psych
a. Content - thought insertion, thought withdrawal or thought broadcasting
b. Preoccupations (recurrent thoughts which the person is able to put aside), worries and overvalued ideas, obsessions, thoughts of harm
c. Delusions – grandiose, persecutory, hypochondriacal, nihilistic, of guilt, of reference, of infidelity, amorous, of control
d. Form - pressure or poverty of thought, thought blocking, loosening of associations, knight’s move, neologisms, perseveration, circumstantial or flight of ideas.
“On direct questioning, the patient denied paranoid thoughts and grandiose beliefs. No current auditory or visual hallucinations but in the past, he had omnipotent, threatening 2nd person auditory hallucinations which were distressing, as well as visual hallucinations of shadows”
If patient isn’t disclosing their hallucinations (e.g. if they’re paranoid): “On questioning, they denied experiencing any auditory or visual hallucinations but the patient was responding to unseen stimuli and seemed distracted”
what is the i for in ASEPTIC in psych
- Insight
a. Does the patient consider themselves unwell in psychological terms?
b. Does the patient feel in need of treatment?
what is the C for in aseptic in psych
- Cognition
a. Orientation - to time, place and person.
b. Attention and concentration - subjective report, serial 7s, WORLD backwards
c. Memory - subjective report and:
i. Immediate memory
ii. Recent memory
iii. Remote memory
d. Grasp – e.g. current monarch/prime minister.
“Cognition wasn’t formally assessed but patient was oriented to time, place and person”
give a classic MSE for mania
Mania A: Increased energy and distractibility
S: Pressure of speech
E: Objectively elated and labile, subjectively elated
P: Grandiose delusions, paranoia and auditory hallucinations
T: Flight of ideas, content: optimistic ideation
I: No insight
C: Orientated to time, place and person
give a classic MSE for GAD
Generalised anxiety disorder A: Fleeting eye contact. Neatly dressed man with no evidence of self-neglect. Appears to be restless and tense but settles down as the interview progresses.
S: Answers all the questions appropriately and there is no abnormality in speech.
E: Mood is euthymic and no thoughts of self-harm
P: No evidence of hallucinations
T: No evidence of delusions
I: Able to recognise the impact of the symptoms on social and occupational functioning and is keen to seek help.
C: Orientated to time, place and person. Keeps up with the conversation with no lapses in concentration or memory.
give a classic mental state exam for delirum
Delirium
A: Agitated, plucking at curtains, fearful expression, smells of urine, hitting out with stick
S: Screaming, incoherent mumbling
E: (S) refuses to comment, (O) frightened, irritable, suspicious
P: Visual hallucinations; insects on bed & illusions, misinterpret curtains as ghosts
T: Persecutory delusions e.g. feeling experimented on
I: Refuse all interventions and do not believe they are ill
C: Does not engage in MMSE. Disorientated to time, place and person. Poor attention and concentration. Unable to retain simple facts.
give a classic mental state exam for panic disorder
Panic disorder A: Drenched in sweat, hyperventilating. Dressed appropriately.
S: Answers all the questions appropriately and there is no abnormality in speech.
E: Mood is euthymic and no thoughts of self-harm
P: No evidence of hallucinations
T: No evidence of delusions
I: Is keen to seek help because she recognizes the impact that these episodes are having on her life
C: Orientated to time, place and person. Keeps up with the conversation with no lapses in concentration or memory.
give a classic mental state exam for post natal depression
Postnatal depression A: Dressed appropriately, difficult to maintain eye contact/build rapport
S: Speech was articulate, slow, monotonous
E: Mood was subjectively low, objectively patient had a low affect. Mood congruent
P: Normal in all modalities tested. No evidence of delusions or hallucinations.
T: Patient did not appear thought disordered, with no experiences of thought insertion, withdrawal or broadcasting
I: Patient has full insight into condition and appears willing to try treatment/is looking for support
C: Cognition was not formally assessed but appears grossly intact
objective way to classify depression
NICE updated its depression guidelines in 2022. It now favours a simple classification of depression severity
‘less severe’ depression: encompasses what was previously termed subthreshold and mild depression
a PHQ-9 score of < 16
‘more severe’ depression: encompasses what was previously termed moderate and severe depression
a PHQ-9 score of ≥ 16
features of depression - what to ask in hx
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
follow up for starting SSRI’s
After starting antidepressant medication, review after 2 weeks (if low suicide risk), then every 2-4 weeks thereafter for 3 months
Patients 18-25 years old or at increased risk of suicide should be followed-up after 1 week
Review response to treatment after 3-4 weeks
outline depression managmeent `
Summary
Mild depression or subthreshold depressive symptoms:
- Consider a period of active monitoring
- Provide information about depression
- Arrange follow-up within 2 weeks
Persistent subthreshold depressive symptoms or mild to moderate depression:
- Consider psychological intervention (patients can self-refer through IAPT)
- Avoid routine use of antidepressants (but consider if they have a history of moderate to severe depression, subthreshold depressive symptoms lasting a long time (usually >2 years) or mild depression that is complicating care of chronic physical health problems
Moderate or Severe Depression
- Offer an antidepressant and a high-intensity psychological intervention
First Episode of Depression
- Consider an SSRI (e.g. citalopram, sertraline)
Recurrent Episode of Depression
- Consider an antidepressant that the patient has previously had a good response to
- Avoid antidepressants that have previously failed
If co-existing chronic physical health problem
- Sertraline is preferred (lower risk of drug interactions)
- If they develop psychosis: add the antipsychotic earlier on (whenever the psychosis comes on)
- Stopping antidepressants: dose should be tapered down over a period of 2-4 weeks
drugs for bipolar
mood stabalisers
o Lithium
o Sodium valproate
o Carbamazepine
antipsychotic sometimes used is olanzapine
Acute Treatment of Mania or Hypomania
o Stop all medications that may induce symptoms (e.g. anti-depressants, recreational drugs, steroids and dopamine agonists)
o Monitor food and fluid intake to prevent dehydration
if not currently on tx with olanzapine + benzodiazepines
how to manage depression in BPAD ?
o Depression in BPAD
Difficult because antidepressants can cause a switch to mania
To reduce this risk, antidepressants should only be given with a mood stabiliser or antipsychotic
* 1st line: fluoxetine + olanzapine/quetiapine
* 2nd line: lamotrigine
can also offer talking therpies (CBT)
mx for schizophrenia
- 1st line: atypical antipsychotic (e.g. quetiapine)
- CBT 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 (due to medication and high smoking rates)
Treatment Resistance in Schizophrenia
* 1st line: Clozapine
* Treatment Resistance: failure to respond to two or more antipsychotics, at least one of which is atypical, each given at a therapeutic dose for at least 6 weeks
* NB: there is a small but significant risk of agranulocytosis (0.7%)
* Requires weekly blood tests to detect early signs of neutropaenia
* If there is a lack of response to clozapine, consider augmentation with another antipsychotic
if you’re in the GP where do you refer someone with suspected BPAD ?
- Primary Care Referral
o Symptoms of hypomania → routine referral to CMHT (community mental health team)
o Symptoms of mania or severe depression → urgent referral to CMHT
features of scizophrenia
Positive symptoms: hallucinations, delusions, and disorganized speech or behaviour
Negative symptoms: social withdrawal, reduced emotional expression, and anhedonia.
Cognitive deficits: impaired attention, memory, and executive functioning.
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)
risk assessment questions for self harm / suicide
Risk Assessment
* Thoughts about hurting themselves again
* Thoughts of hurting others
* Concerns about being hurt by others
- Specific features of increased risk:
o Careful planning
o Final acts in anticipation of death (e.g. writing wills)
o Isolation at the time of the act
o Precautions taken to prevent discovery (e.g. locking doors)
o Writing a suicide note
o Definite intent to die
o Believing the method to be lethal (even if it wasn’t)
o Violent method (e.g. shooting, hanging, jumping in front of a train)
o Ongoing wish to die/regret that the attempt failed - If the patient is insistent on leaving you need to assess their capacity
how long must sciz features be prestn for ?
Sx must be present for at least a month
alcohol withdrawl hiow to manage
- pabrinex
- a benzodiazepine (e.g. lorazepam) or carbamazepine in the acute phase
o Switch to long-acting benzodiazepines (e.g. chlordiazepoxide or diazepam) in the outpatient setting
o Alternatives: Clomethiazole or carbamazepine - acamprosate to help with cravinngs
acute alcohol withdrawal going cold turkey timelines
Features
* symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
* peak incidence of seizures at 36 hours
* peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
Features of opioid misuse
*
rhinorrhoea
* needle track marks
* pinpoint pupils
* drowsiness
* watering eyes
* yawning
emergency management of opioid overdose
*
IV or IM naloxone: has a rapid onset and relatively short duration of action
features of opiod withdrawal
Features of withdrawal:
- Restlessness
- Anxiety
- Sweating
- Yawning
- Diarrhoea
- abdominal cramps
- nausea and vomiting
- palpitations
generalised muscle and joint pains, abdominal cramps, fever, and ‘everything runs’ (i.e. diarrhoea, vomiting, lacrimation, and rhinorrhoea). These patients often appear agitated with dilated pupils and goosebumps.
Symptoms usually start within 12 hours of last heroin use and within 30 hours of last methadone use
gait disturbance, cognitive impairment, and urinary incontinence
Normal pressure hydrocephalus
is a reversible cause of dementia seen in elderly patients. It is thought to be secondary to reduced CSF absorption at the arachnoid villi. These changes may be secondary to head injury, subarachnoid haemorrhage or meningitis.
Normal Pressure Hydrocephalus (NPH) is characterised by the triad of symptoms including gait disturbance, cognitive impairment, and urinary incontinence. Whilst these classic features provide a foundation for clinical recognition, variations and additional symptoms can be present, confounding the diagnostic process.
severe alzihmers first line drug ?
o Memantine (NMDA antagonist)
- Using MMSE in Alzheimer’s Disease
what are the thresholds ?
o Mild AD: 21-26
o Moderate AD: 10-20
o Severe AD: < 10
GAD MX
- CBT (low intesnity)
- sertraline
- highly specialist input
drugs for demenita with lewy bodies
donepezil or rivastigmine
features to elicit for Generalised anxiety disorder
- Excessive and persistent worry about various events or activities, occurring more days than not for at least 6 months
- Difficulty controlling the worry
- Restlessness or feeling keyed up or on edge
- Fatigue
- Difficulty concentrating or mind going blank
- Irritability
- Muscle tension
- Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
- The anxiety and worry are associated with significant distress or impairment in social, occupational, or other important areas of functioning
what is panic disorder ?
Panic disorder is a type of anxiety disorder characterized by recurrent and unexpected panic attacks. Panic attacks are sudden episodes of intense fear or discomfort that peak within minutes and are accompanied by physical symptoms such as palpitations, sweating, trembling, and shortness of breath.
The diagnosis of panic disorder is based on the presence of recurrent panic attacks and the persistent fear of having additional attacks
panic disorder mx
- CBT + sertraline
- clomipramine
- refer (specilist mental health service)
OCD mx
- CBT -> exposure and response prevention (you’ll be encouraged to experience the anxiety and discuss with therapist)
- fluoxetine (continue for 12 months after remission of sx)
- clomipramine (after 12 weeks and no improvement )
PTSD MX
- trauma focused CBT + Eye movement desensitisation and reprocessing (EMDR)
- paroxetine and sertraline (licensed)) or venlafaxine for adults with PTSD
mx for < 18 with anorexia
Children with Anorexia Nervosa
o 1st line: Family Therapy
* Some sessions should be for the whole family and others should be separate
* Usually, 18-20 sessions over 1 year
* Review 4 weeks after treatment, then every 3 months
o 2nd line: if Family Therapy unacceptable, consider Individual CBT-ED or AFP-AN
referral pathways for anorexia nervosa
Referral Pathways
* Severe → Urgent referral to CEDS (community eating disorder service)
o Features: BMI < 15, rapid weight loss, evidence of system failure
* Moderate → Routine referral to CEDS
o Features: BMI 15-17, no evidence of system failure
* Mild → Monitor/advice/support for 8 weeks, recommend support from BEAT, routine referral to CEDS if failure to respond
o Features: BMI > 17, no additional co-morbidity
mx for post natal depression
- Same as depression but take care with drugs used in breastfeeding mothers
o Antidepressants can be secreted in breast milk, therefore certain medications are avoided and others are preferred
o Recommended SSRIs are sertraline and paroxetine
mx for bullimia nervosa
- Consider Bulimia Nervosa-Focused Guided Self-Help Programme for adults
- Children: offer family therapy (FT-BN)
- CBT-ED with nutrition and meal support
- SSRIs (Fluoxetine) or SNRI
o Reduce bingeing and purging by enhancing impulse control
o Should not be offered as sole treatment for bulimia - Treat comorbid psychiatric illness
o Depression, self-harm and substance misuse are common
what happens if you give lithium in pregancy ?
Lithium has a teratogenic effect in pregnancy and can cause Ebstein’s anomaly
— a heart malformation in which the tricuspid valve is displaced towards the
apex of the heart resulting in atrialisation of the right side of the heart. The risk
is particularly high if lithium is used in the first trimester.
which SSRI in kids
fluoxetine
define chronic isomnia + how to mx
- Defined as difficulty getting to sleep or maintaining sleep on 3 or more nights of the week for 3 months
mx = zopiclone
psych patients stops smoking whats gonna happen ?
NOTE: smoking cessation can lead to a decrease in CYP450 activity resulting in raised clozapine levels
what is serotinnin syndrome and when does it happen?
Serotonin syndrome is a constellation of symptoms caused by high levels of serotonin usually due to misuse of drugs that cause an increase in serotonin concentration (e.g. SSRIs).
It typically causes a fever, hypertension, tachycardia, agitation, diarrhoea, hyperreflexia, and myoclonus.
It tends to happen when two or more drugs that raise serotonin levels are taken together (in this case, sertraline and cocaine).
Other drugs that can cause serotonin syndrome include all classes of antidepressants, triptans, St John’s wort, lithium, metoclopramide, and other illicit drugs (e.g. ecstasy).
what is Section 17
- Allows leave for a specified period of time from a current section
- Certain conditions will have to be met (e.g. returning at a certain time, staying with a particular person)
side effects of SSRI’s
- Side-Effects
o GI upset
o GI bleeding (if NSAIDs are being used, it should be given with a PPI)
o Increased anxiety and agitation soon after starting
-Usually occurs in first 2 weeks, then tends to settle but must warn patient and arrange follow-up during this period
o Fluoxetine and paroxetine have higher propensity for drug interactions - QT Interval
o Citalopram and Escitalopram are associated with a dose-dependent increase in QTc and should not be used in those with pre-existing QT prolongation or in combination with other medicines that prolong the QT interval
o Maximum daily dose of citalopram: 40 mg for adults; 20 mg for > 65 years, 20 mg for hepatic impairment - Interactions
o NSAIDs and aspirin: if used, give with a PPI
o Warfarin/heparin: avoid SSRIs and consider mirtazapine
o Triptans: avoid SSRIs
side effects of lithium and monitoring to bear in mind
- Side-Effects
o Nausea/vomiting and diarrhoea
o Fine tremor
o Nephrotoxicity: polyuria (secondary to nephrogenic DI)
o Thyroid enlargement (and hypothyroidism)
o ECG: T wave flattening/inversion
o Weight gain
o Idiopathic intracranial hypertension - Monitoring
o After starting, lithium levels should be performed weekly and after each dose change until concentrations are stable
o Once established, lithium blood levels should be routinely checked every 3 months (levels should be taken 12 hours post-dose)
o Thyroid and renal function should be checked every 6 months
o Patients should be given an information booklet, alert card and record book
clozapine side effects ?
o Side-Effects: sedation, weight gain, reduced seizure threshold, myocarditis, metabolic syndrome, hypersalivation, GI (swallowing problems, constipation)
NOTE: smoking cessation can lead to a decrease in CYP450 activity resulting in raised clozapine levels
o Register patient with Clozaril patient monitoring service, Dezapine monitoring system or Zaponex treatment access system
o Ensure normal leucocyte count and ECG before starting treatment
o FBC Monitoring:
Weekly for 18 weeks
Fortnightly for 1 year
Monthly thereafter
Side-Effects
* Agranulocytosis, neutropaenia
* Reduced seizure threshold
* Constipation
* Myocarditis (baseline ECG should be taken before starting treatment)
* Hypersalivation
things to bear in mind when switching anti depressants
- Switching from citalopram, escitalopram, sertraline or paroxetine to another SSRI
o First should be withdrawn before the alternative is started - Switching from fluoxetine to another SSRI
o Withdraw then leave a gap of 4-7 days (fluoxetine has a long half-life) before starting a low-dose of the new SSRI - Switching from SSRI to TCA
o Cross-tapering is recommended
o Exception: fluoxetine should be withdrawn before TCAs are started - Switching from citalopram, escitalopram, sertraline or paroxetine to venlafaxine
o Cross-taper cautiously (start venlafaxine 37.5 mg OD and increase very slowly) - Switching from fluoxetine to venlafaxine
o Withdraw then start venlafaxine at 37.5 mg OD and increase very slowly - Take home message: fluoxetine takes longer to switch because it has a long half-life
MMSE interpreation
- Any score > 24/30 is considered normal
- Cognitive Impairment
o Mild: 18-23 - May require some supervision, support or assistance
o Moderate: 10-17 - Clear impairment, may require 24-hour supervision
o Severe: 0-9 - Marked impairment, likely to require 24-hour supervision and assistance with ADLs
