psych Flashcards
PHQ-9 score - what are NICE cut-offs for
(a) less severe depression
(b) more severe depression
and first-line Rx
(a) <16 - refer to CBT
(b) > or = 16 - SSRI and refer to CBT
what needs to be checked before starting venlafaxine
blood pressure
A patient taking chlorpromazine develops a bilateral resting tremor. What side-effect of antipsychotic medication is this an example of?
Parkinsonism
sustained muscle contraction (e.g. torticollis, oculogyric crisis) is what side effect
acute dystonia
what is the treatment of acute dystonia (sustained muscle contraction - torticollis, oculogyric crisis)
procyclidine
severe restlessness caused by anti-psychotics is called what?
akathisia
Abnormal, involuntary choreoathetoid movements e.g. chewing and pouting of jaw
tardive dyskinesia
2 adverse effects/warnings of increased risk of when antipsychotics are used in elderly patients
Increased risk of stroke and VTE
acute stress disorders has a timeframe of what period after the traumatic event
acute stress reaction in first 4 weeks
PTSD is after 4 weeks
acute stress disorder management
trauma-focused CBT first line
benzodiazepines for acute symptoms
SSRIs are associated with what electrolyte abnormality
hyponatraemia
what is the most common side effect of SSRIs
GI symptoms
What should be prescribed if a patient is taking SSRIs and NSAID
PPIs
Which two SSRIs have a higher propensity for drug interactions
Fluoxetine
Paroxetine
Citalopram main adverse effect
Prolongs QT interval
Interaction between warfarin/heparin and SSRIs
What other medication can be considered instead
NICE advises avoiding SSRIs
Consider mirtazapine
What 4 medications should you be cautious of with SSRIs
- NSAIDs - give PPI
- Triptans - avoid SSRIs
- Aspirin
- Warfarin/heparin - give mirtazapine instead
After starting antidepressant therapy, patients should be reviewed after…
2 weeks
For patients under age of 30 or increased risk of suicide after 1 week
If a patient makes a good response to antidepressant therapy they should continue on treatment for at least how long
6 months to reduce risk of relapse
When stopping SSRI, dose should be gradually reduced over how long?
4 week period
What SSRI has the highest incidence of discontinuation symptoms
Paroxetine
Somatisation definition
Multiple physical SYMPTOMS
At least for 2 years
Patient refuses to accept reassurance or negative test results
Conversion disorder definition
Loss of motor or sensory function
Patients may be indifferent - la belle indifference
Muchausen’s syndrome is also known as
Factitious disorder
ICD-10 criteria requires depressive symptoms to be present for at least..
2 weeks
HAD scale - what are the score thresholds
0-7 normal
8-10 borderline
11+ anxiety/depression
PHQ-9 scoring thresholds
<16 less severe depression
>16 severe depression
Cluster A personality disorder
Odd or eccentric
Paranoid
Schizoid
Schizotypal
Cluster B personality disorder
Dramatic, emotional, erratic
Antisocial
Borderline
Narcissistic
Cluster C personality disorder
Anxious and fearful
Obsessive-compulsive
Avoidant
Dependent
Management of personality disorders
Dialectal behaviour therapy
jealousy where a person is convinced their partner is cheating on them
what condition
Othello syndrome
3 adverse effects of atypical antipsychotics
- weight gain
- clozapine - agranulocytosis
- hyperprolactinaemia
what is the first line SSRI for generalised anxiety disorder
sertraline
Generalised anxiety disorder, first line treatment is sertraline. If this is ineffective, what can be offered?
- offer alternative SSRI or SNRI (duloxetine, venlafaxine)
- if cannot tolerate SSRIs or SNRIs, offer pregabalin
- weekly follow up is recommended for under 30s for the first month
management of panic disorder
- CBT or drug treatment
- SSRIs are first line.
- If contraindicated or no response after 12 weeks then imipramine or cloipramine should be offered
5 factors associated with poor schizophrenia prognosis
- Strong family history
- Gradual onset
- Low IQ
- Prodromal phase of social withdrawal
- Lack of obvious precipitant
first-line treatment for children and young people with anorexia nervosa
family based therapy
diagnosis of anorexia is now based on the DSM5 criteria and BMI and amenorrhoea are no longer specifically mentioned.
what are the 3 criteria?
- restriction of energy intake relative to requirements leading to low body weight
- intense fear of gaining weight or becoming fat even though underweight
- disturbance in way weight or shape is experienced or denial of seriousness of current low body weight
NICE recommend adults with anorexia should have one of which three treatments
- individual eating disorder focused CBT (CBT-ED)
- Maudsley anorexia treatment for adults (MANTRA)
- specialist supportive clinical management (SSCM)
To screen for depression, which two questions are most useful to ask?
‘During the past month, have you been bothered by ….’
feeling down, depressed, or hopeless
and
having little interest or pleasure doing things
when checking lithium levels, the sample should be taken how many hours post-dose
12 hours
how often should lithium levels be monitored?
weekly, after starting lithium or after each dose change, until concentrations are stable
In patients who take lithium, what other things need to be checked (other than lithium levels) and how often?
BMI, serum electrolytes, eGFR, (renal function) and thyroid function every 6 months
Venlafaxine and other SNRIs are associated with the development of what condition
Hypertension
what needs to be monitored at initiation and dose titration of venlafaxine and other SNRIs ?
Blood pressure
associated with hypertension!
For people presenting with mild to moderate symptoms of PTSD of less than 4 weeks duration, what management may be appropriate
Period of watchful waiting
What are the 4 features of PTSD
- Flashbacks
- Avoidance
- Hyperarousal
- Emotional numbing
Management of PTSD
- Debriefing is NOT recommended
- Watchful waiting if <4 weeks symptoms
- Military personnel have access to treatment by armed forces
- Trauma focused CBT or EMDR
- Venlafaxine or SSRI or risperidone
NICE recommend classifying OCD impairment with what scale and into what categories
Y-BOCS scale
Mild, moderate or severe
Management of OCD - mild, moderate, severe
- Mild - first-line = CBT, exposure and response prevention (ERP). After that, SSRI or more intensive CBT can be offered.
- Moderate = SSRI (fluxoetine for body dysmorphia) or intensive CBT. Consider clomipramine if cannot have SSRI
- Severe = refer to mental health team. While awaiting assessment, offer combined SSRI (or clomipramine) + CBT
If treatment with SSRI for OCD is effective, then how long should it be continued for at least to prevent relapse and allow time for improvement
AT LEAST 12 months
Compared to depression, the regime for SSRI for OCD differs how?
Requires a higher dose
Longer duration of treatment (at least 12 weeks) for initial response
Patient must continue it for at least 12 months to prevent relapse + allow time for improvement
Benzodiazepines mechanism of action
Enhance effect of GABA by increasing frequency of chloride channels
Committee on Safety of Medicines advises that benzodiazepines are only prescribed for what period of time
2-4 weeks
How should you withdraw a benzodiazepine
- Withdraw in steps of about 1/8 range of daily dose every 2 weeks
- Switch patients to equivalent dose of diazepam
- Reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5mg
- Time needed for withdrawal can vary from 4 weeks to a year or more
Patients who withdraw too quickly from benzodiazepines can experience withdrawal - similar to alcohol withdrawal. This may occur up to how long after stopping?
Up to 3 weeks after stopping
side effects of tricyclic anti-depressants
Dry mouth
Blurred vision
Urinary retention
Constipation
Postural hypotension
Prolonged QT interval
Low dose amitriptyline is commonly used in the management of what 2 things
Neuropathic pain
Prophylaxis of headache (migraine + tension)
Clozapine monitoring requires what and when
FBC every week for 18 weeks
Then every 2 weeks after
Until 1 year of treatment
What is required before starting haloperidol
ECG
Which syndrome is characterised by a person believing they are dead or non-existent?
Cotard syndrome
Difference between mania vs hypomania
Mania - lasts for 7 days. Has psychotic symptoms
Hypomania - less than 7 days. No psychotic symptoms
What is the commonest eye condition associated with Charles-Bonnet syndrome
Age-related macular degeneration
circumstantiality
what is this
long-winded answer
seen in hypomania or anxiety
Risk of developing schizophrenia when the following has schizophrenia:
(a) monozygotic twin
(b) parent
(c) sibling
(d) no relatives
(a) monozygotic twin = 50%
(b) parent = 10-15%
(c) sibling = 10%
(d) no relatives = 1%
Switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI
Withdraw first SSRI before the alternative is started
Switching from fluoxetine to another SSRI
withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low-dose of the alternative SSRI
Switching from a SSRI to a tricyclic antidepressant (TCA)
cross-tapering is recommend (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)
EXCEPT fluoxetine - withdraw prior to starting TCA
Switching from fluoxetine to TCA
Withdraw fluxetine first
Then start TCA
Switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine
cross-taper cautiously. Start venlafaxine 37.5 mg daily and increase very slowly
Switching from fluoxetine to venlafaxine
withdraw and then start venlafaxine at 37.5 mg each day and increase very slowly
Adverse effects of clozapine
Agranulocytosis
Neutropenia
Reduces seizure threshold
Constipation
Myocarditis
Hypersalivation
Section 2
Up to 28 days
AMHP + 2 doctors
Section 3
6 months
AMHP + 2 doctors
Section 4
72 hours
GP + AMHP + NR
Section 5(2)
72 hours on inpatient
Doctor
Section 5(4)
6 hours
Nurse
Section 17a
Community treatment order
Supervised community treatment
Section 135
Police take patient from home to place of safety
Section 136
Police take patient from public place to place of safety
24 hours
Schneider’s first rank symptoms may be divided into what 4 components
- auditory hallucinations
- thought disorders
- passivity phenomena
- delusional perceptions
Anorexia features
including Gs and Cs
Most things are low - hypokalaemia, LH, FSH, testosterone, BP, HR
Gs and Cs are raised: growth hormone, glucose, salivary Glands, cortisol, cholesterol, carotinaemia
delusion that a famous is in love with them, with the absence of other psychotic symptoms
Erotomania a.k.a De Clerambault’s syndrome
alogia is included in thought disorganisation - what is this?
little information conveyed by speech, speaking less
factors that increase risk of suicide
- male sex (HR 2.0)
- history of self-harm (1.7)
- alcohol or drug misuse (1.6)
- age
- history of mental illness
- chronic disease
- unemployment or social isolation
- unmarried or widowed or divorced
3 factors which reduce the risk of a patient committing suicide
- family support
- children at home
- religion
management of sleep paralysis if troublesome
clonazepam
Mirtazapine may be prescribed due to useful side effects which include what?
Sedation - good for patients with insomnia
Increased appetite
n.b. also reduces alcohol intake
What is the SSRI of choice post myocardial infarction
Sertraline
What is the SSRI of choice in children and adolescents
fluoxetine
Management of schizophrenia
Oral atypical antipsychotics
CBT!
Once a stable dose of lithium has been achieved after weekly monitoring, how often should levels be checked?
Every 3 months
Depression in older people are less likely to attend with depressed mood. They tend to present with physical complaints e.g. hypochondriasis, agitation and insomnia. What is first-line treatment?
SSRIs
If a patient makes a good response to antidepressant therapy they should continue on treatment for at least how long after remission?
6 months to reduce the risk of relapse.
Schizophrenia: management
- Oral atypical antipsychotics
- CBT
- Review cardiovascular risk factors
Depression (variable appetite, poor sleep) with excess alcohol use may benefit from which antidepressant
Mirtazapine
Differencer between type 1 and type 2 bipolar disorder
Type 1 - mania (>7 days) and depression
Type 2 - hypomania (4-7 days) and depression
patients with bipolar disease - DVLA rules
bipolar disease patients must inform DVLA of their diagnosis. manic episodes - must stop driving for at least 6 months.
What things other than blood tests are monitored for anti-psychotics and how often?
- Weight - start of therapy, 3 months, annually
- Fasting blood glucose - at the start of therapy, 6 months, annually
- Blood pressure - baseline, frequently during dose titration
- ECG - baseline
- CVS risk - annually
What blood tests are monitored with antipsychotics?
FBC
U+Es
LFTs
These three are at the start, then annually. Clozapine is more frequent (weekly for first 18 weeks)
Prolactin - at the start, at 6 months, annually
How often is ECG done with antipsychotics
At baseline
When is cardiovascular risk assessment done with antipsychotics
Annually
When is BP monitored in antipsychotics
At baseline
Frequently during dose titration
When is fasting blood glucose and prolactin monitored with antipsychotics?
At the start of therapy
6 months
Annually
When are lipids and weight monitored in antipsychotics?
Start of therapy
3 months
Annually
When are FBC, U+Es. LFTs monitored in antipsychotics?
Start of therapy
Annually
Clozapine needs weekly FBCs for first 18 weeks
What tricyclic antidepressant is most dangerous in overdose
dosulepin
seasonal affective disorder treatment is the same as what other disorder
depression
- psych therapy and SSRI if needed
alcohol withdrawal timeframe for:
- symptoms
- seizures
- delirium tremens
- symptoms: 6-12 hours
- seizures: 36 hours
- delirium tremens: 72 hours
management of alcohol withdrawal
- long-acting benzodiazepines e.g. chlordiazepoxide or diazepam
- carbamazepine
