Psych Flashcards
Questions to think of in depression
Low mood?
Interest in things?
Energy levels?
Poor concentration?
Sleep?
Slow thoughts?
Appetite?
Anything that could have caused it?
Initial work up of depression
PHQ-9 to categorise
Bloods- FBC, U&Es, Calcium, TFTs
Questions to think of in anxiety
What worry about?
Related to any specific places or situations?
Feel heart racing?
Sleep?
Stiff in your muscles?
How manage these thoughts?
OCD questions to ask
Do you ever get uncomfortable thoughts you cant get rid of?
Where do these thoughts come from?
Do you believe them?
Do you have any rituals used to ease the anxiety?
If yes how many times? And often?
Questions to ask if manic?
Do you feel like on top of the world?
Is this normal for you?
Do you feel like can do things could not do?
Do you feel like can do things others cant?
Do you feel special?
Been sleeping much?
Have you made any purchases recently?
Explain CBT to a patient
Talking therapy where will speak to a specialist who is expert in dealing with people like yourself
Helps you by changing the way you think and behave. Wont help problems but it can helo you deal with them in a positive way
Management of a patient who is in middle of grief/adjustment disorder
Investigations
- PHQ9 to assess if depression present
Bio
- none
Psycho
- discuss CBT as an option but more if other methods do not work
Social
- grief counselling
- support helplines (SAMARITANS and CALM for men)
Counselling for adjustment disorder
Based off what have told me today I think suffering from what we call an adjustment disorder which is an extreme reaction to a life event which has caused a lot of distress to you and presents with a lot of the symptoms you have discussed today. Of course some of these feelings are normal in response to something like that which you cared about but its good youve come to seek medical help as we can help you work through how feeling
In terms of how we do this with situations like this its very much up to you on what you think suits you best so I can go through some options
Have you thought about what you would like to get out of today?
- go away today and read up some more about it and then come back in a few weeks and we can assess again
- grief counselling
- support helplines
- CBT
Investigations for depression
PHQ9
?GAD7
Bloods
- FBC anaemia
- TFTs
Counselling for depression
Based off what have told me today and looking at the questionnaire it looks like you are suffering from depression at the moment.
Do you know much about that?
Depression is when you have a persistently low mood which can impact your day to day functioning whether than be eg your lack of concentration, your lack of energy
Does that sound like what been experiencing?
Yes so its a good thing you came in today and as there are lots of options of things we can do to help you
Options include talking therapies and medications
Questions for depression
Subjective mood?
Enjoying things?
Feeling tired?
Concentration?
Sleep?
Appetite?
Sex interest?- are you sexually active at the moment? interest in sexual relationships?
Risk assess
Questions for dementia?
Memory short term and long term?
Confusion?
How affected daily function?
Doing crossword?
Behaving differently?
Incidences with tap or oven?
Drive?
Physical symptoms?
Investigations for dementia
In all
- AMTS
- MMSE or MOCA
- refer to dementia clinic where will get CT
If vascular dementia picture look at BP and metabolic syndrome bloods with urine dip
Questions for eating disorder
What does a typical day of eating look like for you? Add on about exercise, pills etc
Do you ever make yourself sick after eating?
Do you think you can’t control these feelings?
How much weight have you lost recently?
Do you think food dominates your life?
Have you ever thought that you were fat when someone has said you were thin?
Ask about periods and interest in sex
Screen for OCD, depression and anxiety
Investigations for eating disorders
Examination of abdomen, mouth and hands
Weigh and height for BMI
Squat test
Obs
ECG
Bloods
-FBC
- U&Es
- LFTS
- TFTS
If indicated
- PHQ9
- Yale and brown questionnaire
Counselling for eating disorders
Based off what youve told me today we think that you are siffering from what is called anorexia nervosa
Do you know what this is?
In anorexia people have an intense fear of putting on weight and disturbance in the way in which they see their body. as a result of this they restrict how much they eat which reduces their body weight. What is concerning to us is that this can have serious phyiscal side effects such as the irregular periods, electrolyte disturbances and on the heart. What we want to do is be able to support you in returning to a normal pattern of eating which will help restore body weight
What happens in anorexia focussed family therapy
Attending will involve showing your family how to support her in returning to a normal pattern of behaviour
What happens in MANTRA
Over 20 sessions with a psycologist
MANTRA aims to address the cognitive, emotional, relational and biological factors which tend to maintain AN by working out what keeps people stuck in their anorexia, and gradually helping them to find alternative and more adaptive ways of coping.
What happens in SSCM (specialist supportive clinical management)
Allocated a therapist whith whom create goals for treatment of your anorexia. Then over a period of sessions you will work together to build on your own skills to help achieve your goals. This is different as psychologist works more as a facilitator and is far more flexible to what you want to do as opposed to following a set rigid plan
Physical complications of AN
Bradycardia and hypotension
GI upset
Amenorrhoea and infertility
Osteoporosis
Peripheral neuropathy
Counselling for a psychosis
Based off what youve said today and after speaking to my seniors we think that the voices/beliefs that you have been having are because your mind can sometimes play tricks on us. This is as a result of some chemicals in the brain. Normally when you hear/see something it triggers a change in the chemicals in the brain to let you know its there however when these become unbalanced, it can cause you to hear or see things which are not there
What we can do is give you a drug to help balance out these chemicals
Investigations for psychosis
Examination
- FBC
- U&Es
- LFTs
- glucose
Lipids and Hba1c is starting an antipsychotic
Management of schizophrenia
Bio- atypical antipsychotic
Psycho- CBT to help deal with these hallucinations, coping mechanisms
Social- OT to assess living conditions, money
Difference in time taken to work between SSRIs in depression and GAD
Depression- 2-4 weeks
GAD- 6-8 weeks
How to counsel a patient with mania?
We believe that you’re experiencing something called mania- this is when a chemical change in the brain can lead to a very increased mood. I know this sounds like a good thing as you probably feel great right now however we are concerned as it can be very damaging in the long run
When our mood is elevated we are more likely to carry out very risky behaviour that we wouldnt normally do if we were being ourselves whether this be spending all of your money or putting yourself in physical danger
Managment of mania
Biological- antiphsycotic, mood stabiliser
Psycho- CBT
Social- help sort out work, finances etc
Purpose of CBT in mania
Help identify relapse indicators and how to manage these
How to manage a delirium patient
Keep on ward as even though may be lucid now it does fluctuate
Identify source
- stool culture
- urine dip
- CXR
Treat source
What drugs can cause psychosis (recreational and medicinal)
Steroids
Ethambutol
Cannabis
Cocaine
Counselling on delirium
Based off what have told me and the investigations that we have done, we think that you are experiencing delirium. This is a change in mental state from a physical cause which can affect your mood, your thinking and then also cause your mind to play tricks on you.It has most likely been caused by …… therefore what we are going to do is keep you on the ward and try and find the source … then when we do we can treat this. In the meantime we think it would be best if kept on the ward
Safety net about feeling a change in behaviour
Questions for OCD
Where do these thoughts come from? Are they your own?
What do you do when you get these thoughts?
Have you ever acted on them?
Does acting on them help?
How often do you do?
Does this affect your day to day function?
Job, socials, relationships?
Management plan for someone who has just attempted to commit suicide
Assess using PHQ9 and GAD7
Bio
- sertraline
- add anti-psychotic if affective psychotic symptoms
Psycho
- CBT longer term
Social
- consider admitting if high risk of committing suicide again
- if not manage under crisis team
Counselling for GAD
Based off what you have said to me today and speaking to my seniors it seems like you have been suffering from a generalised anxiety disorder
Do you know much about this?
So essentially what it does is it caues you to feel anxious about a wide range of things like in your case theres the worrying about x and y. Obviously it is completely normal to be feeling anxious about certain things in your life which everyone does however when the worrying begins to take up so much of your life and affects your functioning we tend to think about diagnosing a generalised anxiety disorder. So it is very good you came in today as there a wide range of things we can do to help you feel more relaxed
Investigations for anxiety
ECG
Bloods
- FBC
- TFTs
GAD 7
PHQ9
Questions for anxiety
What have been worrying about?- explore whether a range of things
Anything in particular?
Could anything have caused this?
- places
- social phobia
Panic attacks?
Palpitations?
Tremor?
Muscle stiffness?
Sleep
Diarrhoea?
Questions for PTSD/ acute stress disorder
Explore trauma
How has it been affecting you?
Figure out how to ask about how avoiding it
Hyperarousal
- on edge
- sleep
- concentration
Screen for depression
Management of PTSD or acute stress disorder
GAD7
PHQ9
1st line- Trauma focused CB
- can use sertraline
2nd line- EMDR
- can also use risperidone
Counselling for PTSD/acute stress disorder
From what you have told me today and speaking to my seniors it sounds like you may be suffering from PTSD/acute stress disorder. Have you heard about this?
It is a condition which occurs in response to suffering a major traumatic event. It is characterised by episodes of where can relive the event as well as times of feeling extremely anxious
On top of this it can lead us to avoiding anything which can remind you of what happened
It is defeinetely a good thing you have come in today as there are things we can do to help reduce some of these episodes and help you feel more in control
Truma cased cognitive therapy- where can talk through how have been feeling and understand why have been feeling it in response to the event
Traumatic events can also shatter some of our beliefs surrounding the world, therapy can help challenge these
Can also offer SSRI- may reduce symptoms while awaiting therapy
Questions for neurosis histories
SEDATED
Symptoms of anxiety- palpitations etc
Episodic- is it all the time or in specific scenarios
Drink and drugs
Avoidance- avoid particular things
Timing- how long
Effect on life
Depression screen
Questions for alcoholism on top of CAGE
Ask screening questions for dependance- Drinking not problematic without three criteria
Desire- do you ever crave
Neglect- do you miss out on stuff because of drinking
Pervasive- has it caused problems in life
Withdrawal- what happens if do not drink
Tolerance- do you feel that tolerance increased
Control- have you lost control
What questions need to ask about a suicide
Had been planning
What did you think would happen
Do you have anymore of the pills etc left
Regret
Write a note
Sorted out finanical affairs
Avoiding discovery
Strategies for avoiding thoughts of suicide/self harm
Distraction techniques
Things to help mood- activities enjoy
Avoidance strategies
- put tablets and sharp objects away
- stay in public and with people
- call friend
- squeeze ice cubes
- bite into a strongly flavoured food like lemon
- dont drink
How deal with an alcohol dependance- outline principles
Risk assess- driving, suicide, child care
Establish goals
Questions for autism
Social interactions
- how does he interact with other children
- eye contact?
- teachers at school say?
Language
- concerns about hearing or language
Routines
- particular toys he likes
- does he have a particular routine
- how does he react to change
Management of autism
MDT
- speech and language therapy
- doctor who can prescribe medicines for any particular needs- sleep or attention problems
- parent training and education programmes
- school involvement
National Autistic Society website
Medications used in autism
Aggression- risperidone
Obsessions- SSRI
Sleep problems- melatonin
Inattention- methylphenidate
Investigations for autism
Hearing test
Speech and language assessment
Cognitive testing- IQ through interview and school report
Questions for ADHD
Inattention
- does he get easily distracted
- is he forgetful
Hyperactivity
- fidgety
- restless
Impulsive
- interrupts others
- cant wait in turns
2 settings?
Investigations for ADHD
Conners rating scale- one for all ages
Stroop test
Investigations for alcogol dependance
Bedside
- examination- liver disease
- AUDIT and SADQ
Bloods
- FBC, U&Es, LFTs, B12, B1, glucose, HbA1c, blood alcohol level
Management of alchol dependance
Mild
- reassurance and support groups
Moderate
- CBT and thiamine
- outpatient detox
Severe
- in patient detox
- IV pabrinex
Long term- CBT, acamprosate, naltrexone and disulfiram
Investigations for mania
Bedside
- collateral history
- examination
- urinary drugs sceren
- young mania rating scale
- risk assessment
- ECG
Bloods
- FBC, TFTS, LFTs
Questions for mania
Cognitive
- mood
- confident and on top of world
- ever felt low
- delusions and hallucinations
Biological
- sleep
- appetite
- sex
Extra
- spending
- drugs and alcohol
- whos at home with you
- do you work
Explaining lack of capacity
So today we asked you some questions about your understanding and views on this medical procedure. Here we were trying to assess whether you have the ability to make a decision on consenting for this procedure
When we asked you blah blah you were unable to provide an answer which prompted us to question whether you have the ability to make an informed decision which is in your best interests.
Im afraid that in this case we are concerned you are not able to do this and so in this instance the mental capacity act says that someone else can make this decision
Moving forward I think there are 2 main things to consider
- firstly this decision will always be in your best interests and that also just because we didnt think you were able to make a decision here, the next time this happens you wont be able to make one again
Will keep you informed
Delirium questions
What happened?
Do you feel sleepy?
Fever or pain?
When start?
Is it always there? Worse at night?
MSE
Investigations for delirium
Bedside
- physical examination looking for signs of infection or neuro injury
- MMSE and collateral history from nurse, family member
- urine dip
Bloods
- FBC, U&Es, LFTs, CRP and ESR, Calcium, B12 and B1
Acute management of stress in delirium
1- non-verbal de-escalation techniques and isolate them in a side room
2. oral lorazepam
3. IM lorazepam
If haloperidol use ECG to monitor long QT
Preventative management of delirium
- Maximise orientation – sensory impairments, clear signage, clocks,
calendar and clear lighting, and staff explaining who they are - Prevention – decrease polypharmacy, decrease constipation and
dehydration, avoid catheters, assess O2 sats and hypoxia - Promotion of wellbeing – encourage mobilisation, good pain control,
sleep hygiene, healthy diet, social interaction
Investigations for dementia
Bedside
- AMTS then MMSE and then Addenbrookes Cognitive examination
- delirium screen if indicated
Bloods
- FBC, U&Es, LFTs, calcium
- syphyllis and HIV
Imaging- CT/MRI/ SPECT
Single photon emission computerised topography in certain cases like LBD
Medications for lewy body dementia
Confusion and hallucinations- ACEi
Movement- levodopa but need to balance as can worsen psychotic sx
Sleep- clonazepam
Depression- SSRI
AMTS
Monarch
Year
Address (ask patient to memorise an address e.g. 42 West Street)
Recognise person
Age
Birthday
WW1 date
Enumeration- COUNT BACKWARDS
Location
Time
Questions to make sure to ask in psychosis
Hallucinations and delusions screen
THOUGHT INTERFERENCE- do you feel like your thoughts are your own, do you feel like your thoughts are ever withdrawn or broadcasted to others
Do you ever feel like your body is being controlled or your emotions
Ask about COGNITION and feeding to assess RISK to self
Questions for insight
Do you feel like you have been yourself?
Your damily seem concerned- do you think that is reasonable
What goes into appearance of MSE
Clothing
Physical signs of underlying difficulties like scars
Have they brought any objects
What goes into behaviour of MSE
Rapport and engagement
Eye contact
Restless or agitated
Akathisia or involuntary movements
What goes into speech in MSE
Rate
Quantity- blunted or expansive
Tone and volume
Fluency
What goes into emotion in MSE
Mood- described by patient
Affect- how appear
- apparent to you
- range (labile or restricted
- intensity
- was it mood congruent
What goes into thought in MSE
Thought disorder
Delusions
Worries
Obsessions or compulsions
What goes into perception in MSE
Hallucinations
Depersonalisation
Derealisation
Illusions
How can assess cognition in MSE for dementia
Asking about what would do if smelt gas in the house
Questions for risk to self
Harm and suicide
Feeding self
Substance abuse
What to consider in risk
To self
- self harm and suicide
- neglect
- sexual exploitation
- substance abuse
To others
- harming others
From others
- sexual exploitation
What goes into MSE
ABSEPTIC- R
RISK!
What goes into insight for MSE
Insight into own condition and judgement on situations- ie about oral intake and dangerous scenarios
Presenting a depressive MSE
Brief intro to case and presentation
On examination the patient appeared kempt and did not appear restless or agitated. I was able to build good rapport with the patient and they engaged with my questions throughout
The patients speech was slow and monotonous
In terms of their mood they said they felt lowin mood and objectively she appeared down
There were no delusions apparent and described no abnormal perceptions
They had insight to their condition and although cognition was not formally assessed, she appeared oriented to time and place
Presenting a schizophrenia MSE
Brief intro
On examination the patient appeared dishevelled and unkempt. They were apprehensive about talking to me and were distracted throughout- responding to unknown perceptions. They appeared restless and agitated
Their speech was monotonous and restricted in their answer
Described mood as low and objectively appeared anxious.
The patient described persecutory delusions of MI6 trying to kill her. There was no evidence of thought interference
They also described third person auditroy hallucinations however no other perceptual abnormalities were present
The patient lacked insight into their condition and was oriented to time and place
Presenting a manic MSE
Brief intro
On examination the patient appeared kempt and was appropriately dressed
The patient was pacing around the room and seemed restless
The patients speech was fast and pressured, speaking quite loudly throughout
The patient described their mood as elated and this was consistent with their affect which appeared euphoric.
The patient described grandiose delusions and flight of ideas was present
The patient described no hallucinations or other perceptual abnormalities
The patient lacked insight to their condition
In terms of the patients risk they described no thoughts of self harm or suicideal ideation. they appeared at risk from others from sexual exploitation and to themselves due to an expansive history of substance abuse over the past week
What is examination for anorexia
Sit up squat test
Somatisation counselling
As you know we have done a lot investigations for your pain and they have all come back as negative which is obviously very reassuring. More investigations may end up doing more harm than good
Its very clear to me you have a lot of pain which is interfering with your life so for us as the medical teams its about figuring out how we can best support you
One of the things that we would like to discuss with you is the possibility of this pain being what we call somatisation- have you heard of this
This occurs when our emotional and mental state can sometimes present with physical symptoms.
Just like when people become very stressed they can have severe headaches or when anxious heart rate goes ujp
Autism counselling
Based off what youve described with these behaviours of ….. it sounds like your child may have autism. have you heard of this before
I will start off by saying that autism is not a disease or a condition, it means that their brain works in a different way to others, for example they may like to do the same things over and over or find it hard to communicate with people and understand how they feel
I mentioned earlier it is not a condition which requires a treatment or a cure, but instead what we find is that some people may need support with certain aspects of their life and that is where us the medical team and you his family come in to help do this
What we can do is refer you to a specialist autism team which is made up of a whole host of different professionals such as speech and language therapist who can help with communication, occupational therapist who can look at how they look after themselves and play with others
Counselling for oppositional defiant disorder or conduct disorder
Based off what told me today is that it sounds like your son is expressing consistently these behaviours of angriness and being argumentative with people of authority
now these can be extremely normal behaviours for someone of his age however what concerns us is when these become persistent for a long time and start to disrupt their daily life
in terms of how to manage this going forward what we can do if make a referral to a specialist team who are experts in dealing with children with these behaviours. there will be two main ways with which these can be managed
- talking therapies- helping son come up with ways to maange his cope and understand why has been feeling this way
- family education to improve interactions between those at home and strategies to positively alter their behaviour
MUST DO IN HISTORY FOR CONDUCT DISORDER/ADHD IN OLDER CHILD
MENTAL HEALTH SCREEN
Spiel for safety netting
Ok so thank you for talking to me today in terms of the next steps…..
In the mean time I can give you some information leaflets which can be used etc
In the mean time if over next few weeks you ever…. make sure you come back to see us ASAP or go straight to A&E
If you dont hear back from them soon then contact us and we can chase them for you
