Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

FINALS > Psych > Flashcards

Psych Flashcards

REFEEDING SYNDROME WHEN DO ANOREXIA; prader willi

1
Q

Patients ≤ 25 years who have been started on an SSRI should be reviewed when?

A

after 1 week

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is flight of ideas?

A

Jumping from idea to idea with links between these

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is Knights move?

A

Jumping from idea to idea with no links between these

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is the risk of SSRI in third trimester?

A

Persistent pulmonary HTN

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is a C/I to triptans for migraines?

A

Patients taking SSRI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Patients under 25 starting an SSRI should be reviewed when?

A

After 1 week

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

When do you get alcohol withdrawal symptoms, seizures and delirium?

A

symptoms: 6-12 hours
seizures: 36 hours
delirium tremens: 72 hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Management of OCD?

A
  1. SSRI
  2. Clomipramine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

OCD vs OCPD?

A

OCD must have functional component/impact of daily life

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Management of SSRIs before ECT?

A

Dose should be reduced but not stopped

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

When should lithium levels be checked after a change in dose?

A

One week after change and then weekly until levels are stable

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Signs of alcohol addiction

A

Attempted and failure of abstinence, compulsion to drink, narrowing of drinking repertoire, increased tolerance to alcohol, alcohol is priority over oth e r aspects of life, physical withdrawal when alcohol is stopped

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Why can antipsychotics cause elevated prolactin?

A

Prolactin release from lactotrophs is inhibited by dopamine released from the hypothalamus. Therefore, when this inhibition is lifted, prolactin release is increased

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

How can patients appeal against being sectioned?

A

Appeal must be applied for in writing to a mental health tribunal within 14 days o f detention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

How does activated charcoal work?

A

Activated charcoal works by providing a large surface area to absorb a potential poison and stop it from being absorbed by the GI tract;

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Lithium toxicity may be precipitated by what?

A

NSAIDs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Management of PTSD?

A
  • Trauma focused CBT
  • EMDR
  • Venlafaxine/SSRI
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Triggers for lithium toxicity

A

Dehydration
Infection
Renal failure
ACE/ARB
NSAID
Diuretic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

How long should symptoms be present for with PTSD?

A

4 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What is the management of lithium toxicity?

A

Mild/Moderate: IV Fluid resus
Severe: Haemodialysis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Bipolar I vs Bipolar II

A

Bipolar I - mania and depression
Bipolar II - hypomania and depression

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Purposefully causing symptoms such as hypoglycaemia?

A

Munchausen syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Hypomania in the community?

A

Routine referral to community mental health

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

How do you define chronic insomnia?

A

Trouble falling asleep/staying asleep for 3 months or longer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What are risk factors for insomnia?

A
  • Increasing age
  • Female gender
  • Lower educational attainment
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Which medications can cause insomnia?

A

Corticosteroids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

OCD vs psychosis?

A

OCD will have a level of insight of their actions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What can be protective factors against completed suicide ideation?

A
  • Social support
  • Religious beliefs
  • Having children at home
  • Regretting an attempt
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What are common PTSD symptoms?

A
  • Flashbacks/nightmares
  • Avoiding people or situations
  • Hypervigilance/Sleep problems
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Schizoid vs schizotypal PD?

A

Schizotypical will also have unusual beliefs/magical thinking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

How should SSRI dose be stopped?

A

Over a 4 week period

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

What ophthalmic feature is associated with Charles Bonnet?

A

Age related MD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Flight of idea vs tangentiality?

A

In flight of ideas, they would answer the question then jump to another idea whereas in tangentiality, they would not answer the question

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Sweating, tremor, confusion and hyperreflexia?

A

Serotonin syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Which medications can cause serotonin syndrome?

A
  • MAO
  • SSRIs + Tramadol/St Johns Wort
  • Ecstasy
  • Amphetamines
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Which medications can be used as mood stabilizers?

A
  • Lithium
  • Sodium valproate
  • Carbamazepine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

5 stages of grief

A
  • Denial
  • Anger
  • Bargaining
  • Depression
  • Acceptance
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

What is an hallucination?

A

Abnormal perception in the absence of external stimulus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Which deaths should be referred to coroner?

A
  • Unknown cause of death
  • Death was violent or suspicious
  • Accidental death
  • Death due to self neglect
  • Death related to employment/industrial disease
  • Death during operation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

What are risk factors for NMS?

A
  • Use of neuroleptic medication
  • High dose medication
  • Depot
  • Previous NMS
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Which receptor is blocked in NMS?

A

Dopamine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

What are principles of the mental capacity act?

A
  • Assume capacity
  • Decisions made in best interests
  • Help can be provided to make decision for themselves
  • People with capacity can make unwise decisions
  • Decisions made should be with the least restrictive option
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Who can be a representative party for patients when no relatives during mental capacity discussions?

A

Independent Mental Capacity Advocates

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

What is an advanced decision?

A

Legally bound document allowing someone to state treatment they would not want in the future if they lack capacity to make the decision

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

What is panic disorder?

A

Regular, sudden or unexpected attacks of panic or fear

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

What questionnaires can be used for anxiety?

A
  • Beck Anxiety Inventory
  • Hamilton Anxiety scale
  • General health questionnaire
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Signs of anorexia on examination

A
  • Bradycardia
  • Lanugo hair
  • Dry skin
  • Evidence of self harm
  • Acid erosion
  • Hypotension
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

What is a community treatment order?

A

Service user has to meet certain supervised conditions in the community, if they fail to do this, they may be recalled to hospital

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Risk of using antipsychotics in elderly?

A
  • Stroke
  • VTE
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Recurrent vomiting can cause what?

A
  • Russell sign
  • Erosion of teeth
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Clozapine S/E

A
  • Agranulocytosis
  • Reduced seizure threshold
  • Constipation
  • Dose must be adjusted if smoking if started/stopped
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

What assessment tools can be used for depression?

A
  • HAD scale
  • PHQ-9 scale
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Section 2

A
  • Admission for upto 28 days
  • AMHP
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Section 3

A

Treatment for 6 months
- 2 doctors and AMHP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

Section 4

A
  • 72 hours order
  • GP and AMHP
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Section 5(2)

A

Detained for 72 hours by doctor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Section 5(4)

A

Detained for 6 hours by nurse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Section 17(A)

A

Community treatment order

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Section 135

A

Police order to retrieve someone from home to place of safety

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

Section 136

A

Police order to bring someone from public place to a place of safety

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

What is the most important prognostic indicator in paracetamol overdose?

A

Arterial PH

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

What is indication for liver transplant in paracetamol overdose?

A

pH < 7.3 more than 24 hours after transplant

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

What kind of reaction does N-acetylcysteine cause?

A

Anaphylactoid - non-IgE mediated mast cell release

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

What is high in anorexia?

A
  • Growth hormone
  • Glucose
  • Salivary glands -> parotidomegaly
  • Cortisol
  • Cholesterol
  • Carotenaemia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

When can paracetamol overdose become high risk to develop liver failure?

A
  • Chronic alcoholic
  • HIV
  • Anorexia
  • Taking P450 inducers
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

Lead pipe rigidity is a sign of what?

A

Neuroleptic malignant syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

What is a Fregoli delusion?

A

Belief that everyone is the same person/strangers are familiar

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

What is a capgras delusion?

A

Relative/Friend has been replaced by an imposter

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

What are C/I to using anti-cholinesterase inhibitors?

A
  • prolonged QT
  • 2nd/3rd degree heart block
  • Sinus bradycardia

Use Cognitive stimulation therapy instead

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
70
Q

What is logoclonia?

A

Where the patient gets stuck on a particular word and repeats it

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
71
Q

What is Ekbom syndrome?

A

Believe they are infested with parasites

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
72
Q

What test is used to assess muscle wasting in patients with anorexia?

A

Sit-up-squad-stand test

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
73
Q

Postpartum depression has to be within when?

A

12 months after birth

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
74
Q

Stopping of voluntary movement or staying still in an unusual position

A

Catatonia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
75
Q

Serotonin syndrome vs NMS

A

Serotonin: faster onset, increased reflexes, dilated pupils
NMS: slower onset, decreased reflexes, normal pupils

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
76
Q

Social phobia vs agoraphobia

A

Agoraphobia - fear of open spaces + crowds / difficulty of immediate easy escape to a safe place
Social Phobia - feat of scrutiny in small groups e.g. public speaking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
77
Q

Lithium can cause a benign what?

A

Leucocytosis - raised WCC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
78
Q

Antipsychotics can increase the risk of what?

A

Stroke

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
79
Q

Symptoms of aspirin overdose?

A
  • Hyperventilation
  • Tinnitus
  • Sweating
  • N+V
  • Seizures
  • Causes respiratory alkalosis then metabolic acidosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
80
Q

Conversion disorder?

A

Neuro symptoms without any underlying cause

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
81
Q

Tahycardia, HTN, CNS stimulate, GI upset?

A

Think opioid withdrawal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
82
Q

What is agnosia?

A

Inability to recognise people, objects or places which were once known

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
83
Q

Confusion screen bloods

A

FBC, U&E, LFTs, CRP/ESR, Ca2+, TFTs, B12, folate, syphilis, HIV

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
84
Q

ophthalmoplegia, ataxia, and confusion

A

Wernickes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
85
Q

Personality disorders

A

Cluster A - Paranoid, schizoid, schizotypal
Cluster B - Antisocial, EUPD, Histrionic, Narcissistic
Cluster C - OCPD, Avoidant, Dependent

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
86
Q

Fregoli delusion

A

Different people are the same person

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
87
Q

How long should treatment for SSRI be continued before thinking about switching?

A

4 weeks - younger
6 weeks - elderly

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
88
Q

What is schizoaffective disorder?

A

Schizophrenia with mood disturbance e.g. depression/mania

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
89
Q
A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
90
Q

What should be considered in elderly patients with new onset psychosis?

A

Organic cause -> CT head

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
91
Q

Acute stress disorder?

A

acute stress reaction that occurs in 1st 4w after person has been exposed to a traumatic event eg. threatened death, serious injury (road traffic accident, sexual assault ect)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
92
Q

PTSD vs acute stress disorder?

A

Acute stress disorder= occurs in 1st 4w after exposed to traumatic event

PTSD= diagnosed after 4w

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
93
Q

Features of acute stress disorder?

A

intrusive thoughts e.g. flashbacks, nightmares

dissociation e.g. ‘being in a daze’, time slowing

negative mood

avoidance

arousal e.g. hypervigilance, sleep disturbance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
94
Q

Examples of intrusive thoughts in acute stress disorder?

A

flashbacks, nightmares

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
95
Q

Examples of dissociation in acute stress disorder?

A

being ‘in a daze’, time slowing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
96
Q

Mx for acute stress disorder?

A

1st= trauma focused CBT

acute symptoms (eg. agitations, sleep disturbance)= benzodiazepines (should only be used with caution due to addictive potential and concerns that they may be detrimental to adaptation)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
97
Q

DSM-V defines ADHD as what?

A

condition incorporating features relating to inattention and/or hyperactivity/impulsivity that are persistent

has to be an element of developmental delay (like many paeds conditions)

=<16yrs= need 6 features
17yrs+= 5 features

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
98
Q

Who is ADHD more common in?

A

males

most diagnosed 3-7yrs

possible genetic component

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
99
Q

Diagnostic features of ADHD (need 6 features if =<16yrs or 5 if 17yrs+)?

A

Inattention:
- does not follow through on instructions
- reluctant to enage in mentally-intense tasks
- easily distracted
- finds it difficult to sustain tasks
- finds difficult to organise tasks/activities
- forgetful in daily activities
- often lose things
- often does not seem to listen when spoken to directly

Hyperactivity/Impulsivity:
- unable to play quietly
- talks XSly
- does not wait their turn easily
- will spontaneously leave their seat when expected to sit
- is often ‘on the go’
- interruptive or intrusive to others
- will answer prematurely before a question has been finished
- will run and climb in situations not appropriate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
100
Q

ADHD is a behavioural syndrome characterised by what?

A

hyperactivity, impulsivity and inattention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
101
Q

When does ADHD typically appear?

A

3-7yrs but may not be recognised until after 7yrs esp if hyperactivity not present

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
102
Q

Assessing ADHD?

A
  • core symptoms= hyperactivity, inattention and/or impulsivity present since childhood
  • result in signif psycho, social and/or educational impairment
  • symptoms present at least 6m
  • symptoms at least in 2 settings eg. home, school, social situations
  • other causes excluded
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
103
Q

Suspect ADHD if at least 5 (6 in adults) inattention symptoms and/or 6 (5 in adults) hyperactivity-impulsivity symptoms that have….

A
  • started <12yrs old
  • occurred in 2+ setting
  • present for at least 6m
  • interfered with or reduced quality of social, academic or occupational functioning
  • not explained by another disorder eg. oppositional defiant disorder or conduct disorder
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
104
Q

Ix for ADHD?

A
  • formal diagnosis and Tx carried out by specialist
  • if only moderate impairment can be initially Mx in primary care with self-help, behavioural Mx or parent support programmes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
105
Q

What to do if ADHD is suspected in a child?

A

1) assess social and educational impact of their symptoms

2) if adverse effects on life then= watch and wait up to 10w with self help and behavioural Mx; parent support group

3) Refer children to CAMHS, specialist paeds or child psychiatrist if severe, watching not acceptable or problems persist

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
106
Q

What to do if ADHD is suspected in a adult?

A

1) assess psych, social, educational or occupational impact of symptoms

2) refer pt without prior diagnosis for assessment by specialist
2) if previously Tx for ADHD then refer to general adult psych services for assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
107
Q

How to assess social and educational impact of ADHD in child?

A

School-age children= extent of impairment should be judged in the context of self-care (for example, eating, or hygiene), travelling independently, making and keeping friends, achieving in school, forming positive relationships with other family members, developing a positive self-image, avoiding criminal activity, avoiding substance misuse, maintaining emotional states free of excessive anxiety and unhappiness, and understanding and avoiding common hazards.

For adolescents, difficulties may extend to cover occupational or educational underachievement, dangerous driving, and difficulties in carrying out daily activities (such as shopping and organizing household tasks), in making and keeping friends, and intimate relationships (for example, excessive disagreement).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
108
Q

Suspected ADHD= in addition to assessing social and educational impact of their symptoms in children, primary care practitioners with appropriate training/expertise may wish to augment this assessment using what?

A

Strengths and Difficulties questionnaire or the Conners’ rating scale.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
109
Q

Mx of ADHD is initiated and coordinated by who?

A

Specialists

Depending on locally-agreed shared care arrangements, drug treatments initiated and titrated by a specialist may be continued and monitored in primary care.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
110
Q

What should be documented in pts notes if they have ADHD and on treatment?

A

1) weight= every 3m if 10yrs and younger; 3m & 6m when starting Tx and every 6m after in children >10yrs; every 6m in adults (BMI)

2) height= every 6m

3) BP and HR= before and after each dose change and every 6m

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
111
Q

When to seek specialist advice for pt who has ADHD and is managed in primary care using shared care arrangement?

A

if drug treatment results in sustained resting tachycardia (>120 bpm), arrhythmia, or systolic blood pressure greater than the 95th percentile (or a clinically significant increase) measured on two occasions, or other significant adverse effects develop.

Specialist advice should also be sought if a child or young person’s height over time is significantly affected by medication (that is, they have not met the height expected for their age), as a planned break in treatment over school holidays may be required to allow ‘catch-up’ growth.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
112
Q

ADHD: what to give advice on if adult is prescribed an amfetamine eg. dexamfetamine or lisdexamfetamine) for ADHD?

A

They should not drive if they feel drowsy, dizzy, unable to concentrate or make decisions, or if they have blurred or double vision.

It is now an offence to drive if they have more than a specified amount of amfetamines in their body, whether driving is impaired or not. It may be helpful for the person to keep evidence (such as the other half of their prescription) in the car to show that they are taking the amfetamine in accordance with medical advice.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
113
Q

Diet and exercise advise for pt with ADHD?

A

normal healthy diet and regular exercise

if appears to be a link between certain food/drink advise to keep food diary; ?refer to dietician before dietary elimination considered

if weight a problem= take ADHD meds with or after food not before; additional meals/snacks in morning or late evening when drugs worn off

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
114
Q

Secondary care Mx for preschool children with ADHD?

A

1st line= ADHD focused group parent-training programme

  • if still impairment after environmental modifications been implemented, advise from ADHD service specialist
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
115
Q

Secondary care Mx for school aged children and young people with ADHD?

A
  • group support to pt and parents= education and info; liaison with school/uni if consent
  • individual parent-training programmes if can’t attend group or too complex for group
  • Still not improved= methylphenidate
  • if insomnia= melatonin 6-17yrs
  • if medication effective but still impairment eg. social skills, self control= CBT
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
116
Q

Secondary care Mx for adults with ADHD?

A
  • environmental modifications
  • no improved= medication
  • meds effective but still impairment= structured supportive psychological intervention, regular follow up and/or CBT
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
117
Q

Medication for ADHD?

A

methylphenidate

contraindicated/ineffective= Lisdexamfetamine, dexamfetamine or atomoxetine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
118
Q

Following presentation with suspected ADHD, immediate Mx?

A

watch and wait for 10w to observe if symptoms change or resolve

if persists then refer to secondary care= CAMHS or specialist paeds for tailored plan of action

holistic approach= parents attending education and training programmes; medication last resort if this fails or if severe

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
119
Q

When is drug therapy used for ADHD?

A

last resort and only in pts aged 5yrs+

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
120
Q

1st line drug for ADHD?

A

methylphenidate
initially 6w trial

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
121
Q

MOA of methylphenidate for ADHD?

A

CNS stimulant which acts as a dopamine/norepinephrine reuptake inhibitor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
122
Q

Side effects of methylphenidate for ADHD?

A

abdo pain, nausea, dyspepsia, stunted growth in children, weight loss

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
123
Q

What should be monitored every 6m if on methylphenidate for ADHD?

A

height and weight

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
124
Q

What if methylphenidate not effective for ADHD Mx?

A

switch to lisdexamfetamine;

Dexamfetamine should be started in those who have benefited from lisdexamfetamine, but who can’t tolerate its side effects.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
125
Q

1st line ADHD meds in adults?

A

Methylphenidate or lisdexamfetamine are first-line options;

Switch between these drugs if no benefit is seen after a trial of the other.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
126
Q

What should be done before starting pt on ADHD drugs?

A

baseline ECG before starting treatment, and refer to a cardiologist if there is any significant past medical history or family history, or any doubt or ambiguity.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
127
Q

Why is baseline ECG done before starting ADHD drugs?

A

all ADHD drugs potentially cardiotoxic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
128
Q

Autism?

A

pattern of qualitative differences and impairments in reciprocal social interaction and social communication, combined with restricted interests and rigid and repetitive behaviours, often with lifelong impact

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
129
Q

When do features of autism usually present?

A

in early childhood

persistent

may not become apparent until a change in the child or young person’s life eg. transition to school

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
130
Q

Difficulties in autism can affect what?

A

personal, social, educational, occupational or other functioning

usually observable in all settings

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
131
Q

Autism spectrum disorder?

A

broad, heterogeneous neurodevelopmental disorder which is behaviourally defined, with different levels of severity, that encompasses autism, Asperger’s syndrome, and atypical autism.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
132
Q

Cause of autism?

A

unknown

genetic, neurobiological and environmental factors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
133
Q

Autism may be associated with range of coexisting problems such as what?

A

neurodevelopmental= learning disability, severe visual & hearing impairments, motor or co-ordination disorders, speech & language disorders, epilepsy, ADHD

Mental health= anxiety, depression, conduct disorder, Tourettes

Functional= sleep, diet, nutrition, bladder and bowel

Other= social isolation, exclusion, bullying, child exploitation and maltreatment, carer stress

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
134
Q

Assessment for suspected autism in child?

A
  • developmental history and behaviour, speech, language and communication; social skills; sensory difficulties; severity and duration of features and presence in different settings; impact on the person and family/carers; family history; risk factors for autism; coexisting physical, mental health, and behavioural problems; educational history; safeguarding issues, any previous assessments and treatments.

Examination of general appearance, developmental stage, growth, eye contact, vocabulary and language skills, social interaction and communication, behaviour; neurological, vision and hearing assessment.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
135
Q

Ix/Mx for suspected autism?

A
  • referral to local team/paeds/psych depending on age, RFs, level of concern
  • if suspect genetic/chromosomal anomaly= refer to clinical genetics specialist
  • review after watchful waiting and gathering info about development and behaviour from other health, social and educational professionals if uncertain
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
136
Q

Mx of child with confirmed autism?

A
  • liasise with allocated key worker and local autism team for ongoing care and support= social and communication skills, physical and mental health, behaviour that challenges, sleep, safeguarding concerns
  • info and support
  • advise about making reasonable adjustments or adaptations, structuring time and activities, carer support and future planning
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
137
Q

When to suspect autism in preschool child? (features consistently present across different settings)

A
  • language delay or regression, unusual characteristics of spoken language, reduced/infrequent use of language
  • reduced or absent interaction with others
  • reduced eye contact, pointing and other gestures
  • reduced or absent imagination and variety of pretend play
  • unusual or restricted interests and/or rigid and repetitive behaviours eg. hand flapping, body rocking while standings, spinning
  • over or under reaction to sensory stimuli eg. sounds, smells, taste, textures; extreme food fads
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
138
Q

When may diagnosing autism be challenging?

A
  • <24m
  • child developmental age of <18m
  • child where lack of info about early life eg. adopted
  • severe sensory impairment eg. hearing or vision or motor disorder eg. cerebral palsy
  • milder symptoms and/or average or above intelligence
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
139
Q

When to suspect autism in primary school/secondary school child? (features consistently present across different settings)

A
  • unusual speech eg. limited, repetitive, monotonous
  • reduced, absent or negative response to others eg. reduced/absent response to facial expressions; reduced/no response to name but normal hearing
  • reduced or absent interaction with others
  • reduced or absent eye contact, pointing or other gestures
  • reduced or absent ideas and imagination
  • unusual or restricted interests and/or rigid and repetitive behaviours eg. strong preference for for familiar routines and dislike of change
  • over or under reaction to sensory stimuli
  • unusual profile of skills or deficits eg. skills or knowledge advanced for chronological or mental age
  • social development more immature eg. XS trusting
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
140
Q

ASD?

A

autism spectrum disorder

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
141
Q

Prognosis of autism?

A

no cure for ASD, early diagnosis and intensive educational and behavioural management may improve outcomes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
142
Q

Around 50% of children with ASD have what

A

intellectual disability

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
143
Q

Autism: when may features present?

A

Social communication impairments and repetitive behaviours are present during early childhood (typically evident before 2-3 years of age), or maybe manifested later.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
144
Q

Clinical features of autism can be classified as what?

A
  • impaired social communication and interaction
  • repetitive behaviours, interests and activities
  • often associated with intellectual impairment or language impairment
  • may also have ADHD (35%) and epilepsy (18%)
  • associated with higher head circumference to brain volume ratio
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
145
Q

What conditions are associated with autism?

A

ADHD (35%) and epilepsy (18%)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
146
Q

Clinical features of autism= examples of impaired social communication and interaction?

A

Children frequently play alone (younger children may not play alongside other children) and maybe relatively uninterested in being with other children.

They may fail to regulate social interaction with nonverbal cues like eye gaze, facial expression, and gestures.

Fail to form and maintain appropriate relationships and become socially isolated.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
147
Q

Clinical features of autism= examples of repetitive behaviours, interests and activities?

A

Stereotyped and repetitive motor mannerisms, inflexible adherence to nonfunctional routines or rituals are often seen.

Children are noted to have particular ways of going about everyday activities.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
148
Q

Mx for autism should be what?

A

initiated early, involves educational and behavioural Mx, medical therapy and family counselling

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
149
Q

Goal in the Mx of autism?

A

The goal is to increase functional independence and quality of life through:

  • Learning and development, improved social skills, and improved communication
  • Decreased disability and comorbidity
  • Aid to families
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
150
Q

Non-pharmacological therapy for autism?

A

Early educational and behavioural interventions:
- Applied behavioural analysis (ABA).
- ASD preschool program.
- Treatment and Education of Autistic and Communication related handicapped CHildren (TEACCH)/Structured Teaching method.
- Early Start Denver Model (ESDM).
- Joint Attention Symbolic Play Engagement and Regulation (JASPER).

Family support and counselling:
- Parental education on interaction with the child and acceptance of his/her behaviour.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
151
Q

Pharmacological interventions for autism?

A

no consistent evidence

may need methylphenidate if also have ADHD

self-injury, aggression= antipsychotic drugs

anxiety, aggression, repetitive behaviours= SSRIs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
152
Q

What was bipolar previously known as?

A

manic depression

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
153
Q

Bipolar?

A

serious long term mental illness, characterised by episodic depressed and elated moods, and increased activity (hypomania or mania)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
154
Q

Manic episode in bipolar according to NICE?

A

period during which there is abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week, accompanied by at least three additional symptoms, and which is severe enough to cause marked impairment in social or occupational functioning or necessitate hospitalization, or which includes psychotic features.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
155
Q

Hypomanic episode in bipolar according to NICE?

A

similar to a manic episode except that a diagnosis only requires that symptoms have lasted for 4 days, is not severe enough to cause marked impairment in social or occupational functioning or necessitate hospitalization, and there are no psychotic features.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
156
Q

Depressive episode in bipolar according to NICE?

A

period of at least 2 weeks during which there is either depressed mood or loss of interest or pleasure in nearly all activities (or irritability in children and adolescents), accompanied by at least four additional depressive symptoms.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
157
Q

What is a mixed episode in bipolar according to NICE?

A

A mixture or rapid alternation of manic and depressive symptoms, or

A period of time (at least 1 week) in which the criteria are met for either a manic or hypomanic episode and at least three symptoms of depression are present during the majority of the days of the current or most recent episode of mania or hypomania, or

A period of time (at least 2 weeks) in which the criteria for a major depressive episode are met and at least three manic or hypomanic symptoms are present during the majority of days of the current or most recent episode of depression.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
158
Q

What is rapid-cycling bipolar disorder?

A

defined as the experience of at least four depressive, manic, hypomanic, or mixed episodes within a 12-month period.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
159
Q

Most important Cx of bipolar?

A

suicide and deliberate self-harm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
160
Q

Cx of acute episodes in bipolar?

A
  • suicide and self-harm
  • Financial difficulties from overspending.
  • Traumatic injuries and accidents.
  • Sexually transmitted infections and unplanned pregnancy from disinhibition and increased libido.
  • Damage to reputation, income and occupation, and relationships.
  • Self-neglect, exhaustion, and dehydration.
  • Exploitation by others.
  • Alcohol and substance misuse.
  • Harm to others.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
161
Q

When to suspect bipolar in someone?

A

present with symptoms suggestive of mania, hypomania, depression and a history of previous episodes of possible mania or hypomania, or a mixture of both manic and depressive symptoms.

162
Q

What to do if suspect bipolar disorder?

A
  • refer for specialist mental health assessment, Mx, follow up
  • risk assessment to determine urgency of referral
  • if considered a danger to themselves or other then arrange hospital admission

-Tx in secondary care but can be transferred to primary care for ongoing Mx once stabilised

163
Q

Diagnostic criteria for bipolar disorder in children and young people state that…

A
  • Mania must be present.
  • Euphoria must be present on most days and for most of the time, for at least 7 days.
  • Irritability is not a core diagnostic criterion.
164
Q

Suspect bipolar if pt has or has had any symptoms of what?

A
  • mania
  • hypomania
  • depression and history of previous episodes of mania or hypomania
  • mixture of both manic and depressive symptoms
165
Q

List symptoms of mania in bipolar?

A
  • abnormally elevated mood, extreme irritability, aggression
  • increased activity/energy, restlessness, decreased need for sleep eg. feel rested after 3hrs sleep
  • pressure of speech or incomprehensible speech
  • flight of ideas or racing thoughts
  • distractibility, poor conc
  • increased libido, disinhibition, sexual indiscretion
  • extravagant or impractical plans eg. spending sprees
  • psychotic symptoms eg. delusions (grandiose) or hallucinations (usually voices)
166
Q

Diagnosis of manic episode in bipolar requires symptoms of mania lasting how long?

A

at least 7 days which usually begin abruptly

167
Q

examples of psychotic symptoms in manic episode in bipolar?

A

delusions (usually grandiose) or hallucinations (usually voices)

168
Q

What suggests hypomania in bipolar?

A

symptoms of mania that are not severe enough to cause marked impairment and the absence of psychotic features

  • mild elevation of mood/irritability
  • increased energy & activity which may lead to increased performance at work/socially
  • feeling of well-being, physical and mental efficiency
  • increased sociability, talkativeness and over familiarity
169
Q

Diagnosis of hypomanic episode in bipolar requires what?

A

symptoms to last at least 4d

170
Q

Mixed episode in bipolar?

A

mixture or rapid alternation (usually within few hrs) of manic/hypomanic and depressive symptoms

171
Q

Are symptoms of depression required to diagnose bipolar?

A

no

but at onset, most people with bipolar disorder present with a depressive episode, and a proportion of people with a diagnosis of unipolar depression will actually have bipolar disorder.

172
Q

Symptoms and signs that may help distinguish bipolar disorder from unipolar depression include:

A

Hypersomnia, lability, and weight instability (experienced by around 90% of people with bipolar disorder and around around 50% of people with unipolar depression).

Earlier age of onset (peak age 15 to 19 years), abrupt onset (possibly triggered by stressor).

More frequent episodes of shorter duration.

Comorbid substance misuse.

Higher post-partum risk.

Psychosis, psychomotor retardation, and catatonia.

Lower likelihood of somatic symptoms.

FHx bipolar

173
Q

When diagnosing bipolar, what is it important to do?

A

be aware of differential diagnoses to determine whether TFTs, FBC, vit D or other bloods (incl. toxicology screen) are required

174
Q

How is bipolar diagnosed in secondary care?

A

adults= refer to specialist mental health

children= made after intensive monitoring by specialist:
<14yrs= refer to CAMHS
14-18yrs= specialist early intervention in psychosis or CAMHS

175
Q

Differential diagnosis for autism (may be misdiagnosed or comorbid also)?

A
  • unipolar depression
  • cyclothymia
  • schizophrenia
  • mood disorders due to stroke, thyroid disease or MS
  • substance misuse
  • organic brain disease
  • iatrogenic= antidepressents, levodopa, corticosteroids, methylphenidate
  • metabolic disorders= hyperthyroidism, Cushings, Addisions, vit B12 def, end-stage kidney disease
  • personality disorders
  • anxiety disorders
  • OCD
  • PTSD
  • ADHD
  • sexual, emotional or physical abuse
  • learning difficulties
176
Q

most common comorbidities in people with bipolar disorder include

A

anxiety disorders, alcohol and substance misuse, and personality disorders. Comorbidity occurs in two-thirds of people with bipolar disorder throughout their lifetimes.

177
Q

Onset of mania in later life may be indicative of what?

A

underlying medical comorbidity

178
Q

Mx of bipolar in the acute phase?

A

therapeutic trial of oral antipsychotic eg. haloperidol, olanzapine, quetiapine or risperidone

if 1st not effective, can add 2nd, if still not can add lithium

mixed episodes Tx same as mania

Tx of depression= Quetiapine alone, or
Fluoxetine combined with olanzapine

  • 4w after acute episode resolved then secondary care Mx long term
179
Q

Chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression

A

bipolar disorder

180
Q

Epidemiology of bipolar?

A

typically develops in late teen years

181
Q

2 types of bipolar disorder?

A

Type I= mania and depression (most common)

Type II= hypomania and depression

182
Q

What is hypomania and mania?

A

both terms relate to abnormally elevated mood or irritability

with mania, there is severe functional impairment or psychotic symptoms for 7 days or more

hypomania describes decreased or increased function for 4 days or more

183
Q

Hypomania vs mania?

A

psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) suggest mania

no psychotic symptoms= hypomania

184
Q

Mx for bioplar?

A
  • psychological interventions
  • mood stabiliser= lithium; alternative is valproate
  • Mx of mania/hypomania= consider stopping antidepressant if the patient takes one; antipsychotic therapy e.g. olanzapine or haloperidol
  • Mx of depression= talking therapies; fluoxetine antidepressant of choice
  • adress co-morbidities= 2-3 times increased risk of diabetes, cardiovascular disease and COPD
185
Q

Mx of mania/hypomania in bipolar?

A

consider stopping antidepressant if the patient takes one; antipsychotic therapy e.g. olanzapine or haloperidol

186
Q

Mx of depression in bipolar?

A

talking therapies; fluoxetine is the antidepressant of choice

187
Q

Mood stabiliser of choice in bipolar?

A

lithium

valproate alternative

188
Q

Primary care referral for bipolar?

A

if symptoms suggest hypomania then NICE recommend routine referral to the community mental health team (CMHT)

if there are features of mania or severe depression then an urgent referral to the CMHT should be made

189
Q

Pts with bipolar may have what to help with Mx of relapse?

A

advanced care plan

190
Q

Advice to pt with bipolar to prevent relapse?

A

Encouraging compliance with treatment.
Maintaining an adequate amount of sleep.
Avoidance, if possible, of shift work, night flying and flying across time zones, or routinely working excessively long hours.
Establishing a regular routine in the morning.
Structuring the day with some activity and social contact.
Self-monitoring of symptoms (including triggers and early warning signs) and coping strategies.
Avoiding caffeinated drinks such as tea, coffee, or cola.
Smoking — advise the person to stop, or if this is not possible cut down (nicotine is a stimulant).
Avoiding alcohol and drug misuse.

191
Q

Lithium?

A

mood stabilising drug used most commonly prophylactically in bipolar disorder but also as an adjunct in refractory depression

192
Q

Therapeutic range and half life for lithium?

A

very narrow therapeutic range (0.4-1.0 mmol/L) and a long plasma half-life being excreted primarily by the kidneys.

193
Q

MOA of lithium?

A

not fully understood, two theories:
- interferes with inositol triphosphate formation
- interferes with cAMP formation

194
Q

Adverse effects of lithium?

A

nausea/vomiting, diarrhoea

fine tremor

nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus

thyroid enlargement, may lead to hypothyroidism

ECG: T wave flattening/inversion

weight gain

idiopathic intracranial hypertension

leucocytosis

hyperparathyroidism and resultant hypercalcaemia

195
Q

Lithium ECG changes?

A

T wave flattening/inversion

196
Q

When to check lithium levels to monitor, when should the sample be taken?

A

12hrs post dose

197
Q

When should lithium be monitored when starting?

A

after starting, levels should be performed weekly and after each dose change until concentrations are stable

198
Q

When should lithium blood levels be monitored?

A

every 3m

199
Q

When should lithium levels be checked after a change in dose?

A

1w after changing and weekly until levels are stable

200
Q

Monitoring lithium= what should be checked every 6m?

A

thyroid and renal function

201
Q

What should pts with bipolar be given when started on lithium?

A

info booklet, alert card and record book

202
Q

Monitoring of lithium in bipolar?

A
  • when checking levels, take sample 12hrs post dose
  • check weekly after starting until concentrations are stable
  • check levels weekly after change in dose
  • once levels stable check levels every 3m
  • every 6m check thyroid and renal function
203
Q

How is depression classified?

A

less severe and more severe depresson

204
Q

‘Less severe’ depression?

A

PHQ-9 score <16

previously termed subthreshold and mild depression

205
Q

‘More severe’ depression?

A

PHQ-9 score >=16

previously termed moderate and severe depression

206
Q

Mx of less severe depression (in order of preference)?

A

1) guided self-help
2) group CBT
3) group behavioural activation (BA)
4) Individual CBT
5) Individual BA
6) group exercise
7) group mindfulness and meditation
8) interpersonal psychotherapy (IPT)
9) SSRIs
10) counselling
11) short-term psychodynamic psychotherapy (STPP)

(order of preference)

207
Q

Are antidepressants offered 1st line for less severe depression?

A

no, unless that is the pts preference

208
Q

How is Tx approached in less severe depression?

A

discuss Tx options with pts to reach shared decision; least intrusive and least resource intensive Tx 1st

209
Q

Mx for more severe depression (in order of preference)?

A

1) combined CBT and antidepressant
2) individual CBT
3) Individual behavioural activation
4) Antidepressants= SSRI or SNRI or other
- individual problem-solving
counselling
- short-term psychodynamic psychotherapy (STPP)
- interpersonal psychotherapy (IPT)
- guided self-help
- group exercise

210
Q

What 2 questions can be used to screen for depression?

A

‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’

‘During the last month, have you often been bothered by having little interest or pleasure in doing things?’

if yes to either then more depth assessment needed

211
Q

Name 2 tools to assess degree of depression?

A

Hospital Anxiety and Depression (HAD) scale

and

Patient Health Questionnaire (PHQ-9)

212
Q

Assessing depression: Hospital Anxiety and Depression (HAD) scale?

A

consists of 14 questions, 7 for anxiety and 7 for depression

each item is scored from 0-3

produces a score out of 21 for both anxiety and depression

severity: 0-7 normal, 8-10 borderline, 11+ case

patients should be encouraged to answer the questions quickly

213
Q

Assessing depression: Patient Health Questionnaire (PHQ-9)?

A

asks patients ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’
9 items which can then be scored 0-3
includes items asking about thoughts of self-harm

214
Q

How is severity of depression grouped?

A

2 groups= less severe and more severe

used to be subthreshold, mild, moderate and severe

215
Q

Score <16 on PHQ-9?

A

less severe depression

216
Q

Score of 16 or more on PHQ-9?

A

more severe depression

217
Q

What provides a criteria for diagnosing major depressive disorder (MDD) aka depression?

A

DSM-5

218
Q

How many symptoms needed to diagnose depression (major depressive disorder) according to DSM-5 criteria?

A

Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

219
Q

Symptoms in the DSM-5 criteria to diagnose depression include what?

A
  • Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
  • Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
  • Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
  • Insomnia or hypersomnia nearly every day.
  • Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
  • Fatigue or loss of energy nearly every day.
  • Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
  • Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
  • Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
220
Q

Depression meds= can you switch from from citalopram, escitalopram, sertraline, or paroxetine to another SSRI?

A

direct switch possible

221
Q

Depression meds= switching between fluoxetine to another SSRI?

A

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

222
Q

Depression meds: switching from SSRI to tricyclic antidepressant (TCA)?

A

cross-tapering is recommended (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly)

  • an exception is fluoxetine which should be withdrawn, the leave a gap of 4-7 days prior to TCAs being started at a low dose
223
Q

Depression meds: switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine?

A

direct switch is possible (caution if paroxetine used)

224
Q

Depression meds: switching from fluoxetine to venlafaxine?

A

withdraw and then start venlafaxine at a low dose 4–7 days later

225
Q

SSRI stands for?

A

selective serotonin reuptake inhibitors

226
Q

1st line medical Mx for depression?

A

SSRIs

227
Q

Examples of SSRIs?

A
  • citalopram
  • sertraline
  • fluoxetine
228
Q

What SSRI is useful post MI?

A

sertraline

229
Q

SSRIs should be used in caution in what population?

A

children and adolescents

230
Q

SSRI of choice when indicated in a child or adolescent with depression?

A

fluoxetine

231
Q

Adverse effects of SSRIs?

A
  • GI symptoms (most common)
  • increased risk GI bleeding so PPI if also taking NSAIDs
  • increased anxiety after starting
  • fluoxetine and paroxetine have a higher propensity for drug interactions
232
Q

When first starting SSRI, what should you warn pts?

A

anxiety and agitation may increase at first

233
Q

SSRIs: citalopram and escitalopram are associated with what? So do not use in who?

A

dose-dependent QT interval prolongation

those with= congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval

234
Q

Citalopram max daily dose (due to dose-dependent QT interval prolongation)?

A

40 mg for adults; 20 mg for patients older than 65 years; and 20 mg for those with hepatic impairment

235
Q

Interactions with SSRIs?

A
  • NSAIDs (do not offer SSRIs but if do then give PPI too)
  • warfarin and heparin= consider mirtazapine not SSRI
  • aspirin
  • triptans
  • monoamine oxidase inhibitors (MAOIs)
236
Q

Why to avoid SSRIs in pts taking triptans or MAOIs?

A

increased risk of serotonin syndrome

237
Q

When to review pt by a doctor after starting antidepressant therapy?

A

after 2w

but if <25yrs or at risk of suicide then review after 1w

238
Q

How long should pt be on antidepressants?

A

if good response then be on at least 6m after remission (symptoms better) to reduce risk of relapse

(don’t stop as soon as feel better)

239
Q

How to stop SSRI antidepressants?

A

the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.

240
Q

SSRI discontinuation symptoms?

A

increased mood change
restlessness
difficulty sleeping
unsteadiness
sweating
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia

241
Q

SSRIs and pregnancy?

A
  • weigh up benefits and risk when deciding whether to use in pregnancy.
  • Use during the first trimester gives a small increased risk of congenital heart defects
  • Use during the third trimester can result in persistent pulmonary hypertension of the newborn
  • Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
242
Q

Risk of SSRIs in 1st trimester of pregnancy?

A

small increased risk of congenital heart defects

243
Q

Use of SSRIs during 3rd trimester of pregnancy?

A

can result in persistent pulmonary HTN of the newborn

244
Q

Paroxetine (SSRI) and pregnancy?

A

increased risk of congenital malformations, esp in 1st trimester

245
Q

Features of beta-blocker overdose?

A

bradycardia
hypotension
heart failure
syncope

246
Q

Mx of beta blocker overdose?

A
  • bradycardic= atropine
  • resistant then give glucagon

haemodialysis NOT effective

247
Q

Drugs that can be cleared with haemodialysis in overdose?

A

BLAST

Barbiturate
Lithium
Alcohol (inc methanol, ethylene glycol)
Salicylates
Theophyllines (charcoal haemoperfusion is preferable)

248
Q

Drugs that cannot be cleared with haemodialysis in overdose?

A

tricyclics
benzodiazepines
dextropropoxyphene (Co-proxamol)
digoxin
beta-blockers

249
Q

Cx of iron overdose?

A
  • metabolic acidosis
  • erosion of gastric mucosa= GI bleeding
  • shock
  • hepatotoxicity and coagulopathy
250
Q

Iron overdose= Mx is guided by what?

A

total amount of iron ingested (elemental iron/kg) and the presence/absence of symptoms (abdominal pain, diarrhoea, vomiting, lethargy)

251
Q

Mx of iron overdose= ingested <40mg/kg elemental iron and are symptomatic?

A

observed at home

252
Q

Mx of iron overdose= ingested >40mg/kg iron or symptomatic?

A

medical assessment with serum iron levels measured 2-4 hours post-ingestion and abdominal x-ray

253
Q

Iron overdose= Mx for all patients presenting within 4 hours who have ingested > 60mg/kg elemental iron or have undissolved tablets on abdominal x-ray?

A

Whole bowel irrigation

if not effective or iron is adhered to gastric wall then endoscopy or surgery

254
Q

Can you use activated charcoal in iron poisoning?

A

no

255
Q

Drug used in iron overdose?

A

Desferrioxamine

256
Q

When is desferrioxamine indicated in iron overdose?

A

Patients with serum iron level > 90umol/l,

Patients with serum iron level 60-90umol/l, who are symptomatic or have persistent iron on abdominal x-ray despite whole bowel irrigation

Any patient with shock, coma or metabolic acidosis

257
Q

When is lithium used?

A

prophylactically in bipolar disorder but also as an adjunct in refractory depression

258
Q

Half-life of lithium?

A

long plasma half-life

excreted by kidneys

259
Q

Lithium toxicity generally occurs following concentrations of what?

A

> 1.5mmol/L

260
Q

Lithium toxicity may be precipitated by what?

A

dehydration

renal failure

drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.

261
Q

Features of lithium toxicity?

A

coarse tremor (a fine tremor is seen in therapeutic levels)
hyperreflexia
acute confusion
polyuria
seizure
coma

262
Q

Mx of lithium toxicity?

A

mild-moderate= may respond to volume resuscitation with normal saline:
- IV fluids with isotonic saline, until euvolemic, then typically twice maintenance rate
- monitor serum sodium closely (every 4 hours with serial lithium concentrations) if there is a concern about lithium-induced nephrogenic diabetes insipidus

haemodialysis may be needed in severe toxicity

sodium bicarbonate is sometimes used but there is limited evidence to support this (by increasing the alkalinity of the urine it promotes lithium excretion)

263
Q

Paracetamol overdose= minority of pts that present within 1hr may benefit from what?

A

activated charcoal to reduce absorption of the drug

264
Q

Drug for the Mx of paracetamol overdose?

A

N-Acetylcysteine

265
Q

When should acetylcysteine be given in paracetamol overdose?

A

the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity

there is a staggered overdose or there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration

patients who present 8-24 hours after ingestion of an acute overdose of more than 150 mg/kg of paracetamol even if the plasma-paracetamol concentration is not yet available

patients who present > 24 hours if they are clearly jaundiced or have hepatic tenderness, their ALT is above the upper limit of normal
- acetylcysteine should be continued if the paracetamol concentration or ALT remains elevated whilst seeking specialist advice

266
Q

What rate is aceytlcysteine infused over in paracetamol overdose?

A

1hr (used to be 15mins)

267
Q

Why in paracetamol overdose, is acetylcysteine infused over 1hr and not 15mins?

A

reduce the number of adverse effects.

Acetylcysteine commonly causes an anaphylactoid reaction (non-IgE mediated mast cell release).

Anaphylactoid reactions to IV acetylcysteine are generally treated by stopping the infusion, then restarting at a slower rate.

268
Q

Anaphylactoid reactions to IV acetylcysteine are generally treated by

A

stopping the infusion, then restarting at a slower rate.

269
Q

Paracetamol overdose= King’s College Hospital criteria for liver transplantation (paracetamol liver failure)?

A

Arterial pH < 7.3, 24 hours after ingestion

or all of the following:
- prothrombin time > 100 seconds
- creatinine > 300 µmol/l
- grade III or IV encephalopathy

270
Q

When is an overdose considered as staggered?

A

if all the tablets were not taken within 1hr

271
Q

Pathophysiology behind paracetamol overdose?

A

The liver normally conjugates paracetamol with glucuronic acid/sulphate. During an overdose the conjugation system becomes saturated leading to oxidation by P450 mixed function oxidases*. This produces a toxic metabolite (N-acetyl-B-benzoquinone imine)

Normally glutathione acts as a defence mechanism by conjugating with the toxin forming the non-toxic mercapturic acid. If glutathione stores run-out, the toxin forms covalent bonds with cell proteins, denaturing them and leading to cell death. This occurs not only in hepatocytes but also in the renal tubules

*this explains why there is a lower threshold for treating patients who take P450 inducing medications e.g. phenytoin or rifampicin

272
Q

Pathophysiology behind paracetamol overdose= why is N-acetyl cysteine used?

A

as it is a precursor of glutathione and hence can increase hepatic glutathione production

273
Q

The following groups of patients are at an increased risk of developing hepatotoxicity following a paracetamol overdose:

A

1) patients taking liver enzyme-inducing drugs (rifampicin, phenytoin, carbamazepine, chronic alcohol excess, St John’s Wort)

2) malnourished patients (e.g. anorexia nervosa) or patients who have not eaten for a few days

Acute alcohol intake, as opposed to chronic alcohol excess, is not associated with an increased risk of developing hepatotoxicity and may actually be protective.

274
Q

Salicylate overdose leads to what results on ABG?

A

mixed respiratory alkalosis and metabolic acidosis.

Early stimulation of the respiratory centre leads to a respiratory alkalosis whilst later the direct acid effects of salicylates (combined with acute renal failure) may lead to an acidosis. In children metabolic acidosis tends to predominate.

275
Q

Features of salicylate overdose?

A

hyperventilation (centrally stimulates respiration)
tinnitus
lethargy
sweating, pyrexia
nausea/vomiting
hyperglycaemia and hypoglycaemia
seizures
coma

276
Q

Why may pt get pyrexia with salicylate overdose?

A

salicylates cause the uncoupling of oxidative phosphorylation leading to decreased adenosine triphosphate production, increased oxygen consumption and increased carbon dioxide and heat production

277
Q

Tx for salicylate overdose?

A

general (ABC, charcoal)

urinary alkalinization with intravenous sodium bicarbonate - enhances elimination of aspirin in the urine

haemodialysis

278
Q

Indications for haemodialysis in salicylate overdose?

A

serum concentration > 700mg/L

metabolic acidosis resistant to treatment

acute renal failure

pulmonary oedema

seizures

coma

279
Q

Causes of serotonin syndrome?

A

monoamine oxidase inhibitors

SSRIs
- St John’s Wort, often taken over the counter for depression, can interact with SSRIs to cause serotonin syndrome
- tramadol may also interact with SSRIs

ecstasy

amphetamines

280
Q

Features of serotonin syndrome?

A

neuromuscular excitation= hyperreflexia, myoclonus, rigidity

autonomic nervous system excitation= hyperthermia, sweating

altered mental state= confusion

281
Q

Mx of serotonin syndrome?

A

supportive including IV fluids

benzodiazepines

more severe cases are managed using serotonin antagonists such as cyproheptadine and chlorpromazine

282
Q

Serotonin syndrome vs Neuroleptic maligant syndrome?

A

SS= caused by SSRIs, MAOIs, ecstasy/novel psychoactive stimulants; faster onset (hrs); increased reflexes, clonus, dilated pupils; Mx of severe= cyproheptadine, chlorpromazine

NMS= caused by antipsychotics; slower onset (hrs-d); decreased reflexes, ‘lead pipe’ rigidity, normal pupils; Mx of severe= dantrolene

Both= drug reactions often in young pts; tachycardia, HTN; pyrexia, diaphoresis; rigidity; increased CK (more in NMS); IV fluids, benzodiazepines

283
Q

Serotonin syndrome or neuromalignant syndrome= increased reflexes, clonus , rigidity and dilated pupils?

A

Serotonin syndrome

NMS= decreased reflexes, lead pipe rigidity, normal pupils

284
Q

What tricyclics are particularly dangerous in overdose?

A

amitriptyline and dosulepin (dothiepin)

285
Q

Early features of tricyclic overdose?

A

anticholingeric= dry mouth, dilated pupils, agitation, sinus tachy and blurred vision

286
Q

Features of severe tricyclic overdose?

A

arrhythmias
seizures
metabolic acidosis
coma

287
Q

ECG changes in tricyclic overdose?

A

sinus tachycardia
widening of QRS
prolongation of QT interval

288
Q

Tricyclic overdose= widening of QRS and prolonged QT means what?

A

Widening of QRS > 100ms is associated with an increased risk of seizures whilst QRS > 160ms is associated with ventricular arrhythmias

289
Q

Mx for tricyclic overdose?

A
  • IV bicarbonate= first-line therapy for hypotension or arrhythmias; indications include widening of the QRS interval >100 msec or a ventricular arrhythmia
  • other drugs for arrhythmias
  • correction of acidosis is the first line in the management of tricyclic-induced arrhythmias
  • intravenous lipid emulsion is increasingly used to bind free drug and reduce toxicity
290
Q

What is ineffective in tricyclic overdose?

A

dialysis

291
Q

What is contraindicated in tricyclic overdose?

A

+ class 1a (e.g. quinidine) and class Ic antiarrhythmics (e.g. Flecainide) are contraindicated as they prolong depolarisation

class III drugs such as amiodarone should also be avoided as they prolong the QT interval

response to lignocaine is variable and it should be emphasized that correction of acidosis is the first line in the management of tricyclic-induced arrhythmias

292
Q

Antidotes can be given in overdose why?

A

to prevent the poison from working or reverse the effects of the poison

293
Q

Antidote for paracetamol overdose?

A

acetylcysteine

294
Q

Antidote for digoxin overdose?

A

Digoxin-specific antibody fragments

295
Q

Antidote for benzodiazepine overdose?

A

Flumazenil injection

reverses the central nervous system and respiratory depression.

if the person has also taken a tricyclic antidepressant or has epilepsy, there must be caution, as flumazenil can cause seizures and arrhythmias.

296
Q

Antidote for insulin, BB or CCB overdose?

A

Glucagon injection

297
Q

Antidote for morphine, heroin or opiate overdose?

A

naloxone injection

In people with reduced consciousness due to suspected opioid poisoning, administration which leads to significant improvement in the person’s condition within 1-2 minutes is highly suggestive of opioid poisoning.

298
Q

Antidote for iron overdose?

A

Desferrioxamine mesilate

299
Q

Antidote for ethylene glycol or methanol overdose?

A

fomepizole

300
Q

Most common cause of admission to child and adolescent psychiatric wards?

A

anorexia nervosa

301
Q

Epidemiology of anorexia nervosa?

A

90% female

teens and young-adults mainly

302
Q

Diagnosis of anorexia nervosa based on what criteria?

A

DSM-5 (BMI and amenorrhoea no longer specifically mentioned)

303
Q

DSM-5 criteria for diagnosis of anorexia nervosa?

A
  1. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
  2. Intense fear of gaining weight or becoming fat, even though underweight.
  3. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
304
Q

Mx of anorexia nervosa?

A

one of:
individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)

Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)

specialist supportive clinical management (SSCM).

305
Q

1st line Mx of anorexia nervosa in children and young people?

A

‘anorexia focused family therapy’

The second-line treatment is cognitive behavioural therapy.

306
Q

Prognosis of anorexia?

A

poor

Up to 10% of patients will eventually die because of the disorder.

307
Q

Features of anorexia nervosa?

A

reduced body mass index
bradycardia
hypotension
enlarged salivary glands

308
Q

Physiological abnormalities in anorexia?

A

hypokalaemia

low FSH, LH, oestrogens and testosterone

raised cortisol and growth hormone

impaired glucose tolerance

hypercholesterolaemia

hypercarotinaemia

low T3

309
Q

Mx of binge eating disorder?

A

‘binge-eating-disorder-focused’ guided self-help programme

if guided self-help is unacceptable, contraindicated, or ineffective after 4 weeks, NICE recommend that we offer group eating-disorder-focused cognitive behavioural therapy (CBT-ED)

310
Q

Bulimia nervosa?

A

type of eating disorder characterised by episodes of binge eating followed by intentional vomiting or other purgative behaviours such as the use of laxatives or diuretics or exercising.

311
Q

DSM-5 diagnostic criteria for bulimia nervosa?

A

1) recurrent episodes of binge eating (eating an amount of food that is definitely larger than most people would eat during a similar period of time and circumstances)

2) a sense of lack of control over eating during the episode

3) recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.

  • recurrent vomiting may lead to erosion of teeth and Russell’s sign - calluses on the knuckles or back of the hand due to repeated self-induced vomiting

4) the binge eating and compensatory behaviours both occur, on average, at least once a week for three months.

5) self-evaluation is unduly influenced by body shape and weight.

6) the disturbance does not occur exclusively during episodes of anorexia nervosa.

312
Q

Pt with bulimia nervosa may have what physical signs?

A

recurrent vomiting may lead to erosion of teeth and Russell’s sign - calluses on the knuckles or back of the hand due to repeated self-induced vomiting

313
Q

Mx for bulimia nervosa?

A

referral for specialist care is appropriate in all cases

NICE recommend bulimia-nervosa-focused guided self-help for adults

If bulimia-nervosa-focused guided self-help is unacceptable, contraindicated, or ineffective after 4 weeks of treatment, NICE recommend that we consider individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)

children should be offered bulimia-nervosa-focused family therapy (FT-BN)

pharmacological treatments have a limited role - a trial of high-dose fluoxetine is currently licensed for bulimia but long-term data is lacking

314
Q

Eating disorders?

A

complex mental health conditions characterised by abnormal eating habits that negatively affect an individual’s physical and psychological well-being.

315
Q

Types of eating disorder?

A

anorexia nervosa, bulimia nervosa, and binge eating disorder, though there are other specified and unspecified feeding or eating disorders (OSFED/UFED)

316
Q

Aetiology of eating disorders?

A

multifactorial, encompassing biological, psychological, and sociocultural factors.

317
Q

Criteria for anorexia nervosa (AN)?

A

Restriction of food intake leading to a weight that is significantly below that which is expected.

Intense fear of gaining weight or persistent behaviour to avoid it.

Disturbance in the perception of body weight or shape, undue influence of body weight on self-worth, or persistent denial of the seriousness of the current low body weight.

318
Q

Criteria for bulimia nervosa (BN)?

A

Recurrent episodes of binge eating: consuming an abnormally large amount of food in a short time frame with a sense of lack of control.

Recurrent inappropriate compensatory behaviours to prevent weight gain.

Binge eating and compensatory behaviours both occur, on average, at least once a week for three months.

Self-worth is overly influenced by body shape and weight.

319
Q

Binge eating disorder (BED)?

A

Binge eating disorder is similar to bulimia nervosa in terms of the binge eating episodes, but differs in that individuals with BED do not consistently engage in inappropriate compensatory behaviours.

320
Q

Binge eating disorder (BED) criteria?

A

Recurrent episodes of binge eating.

Binge eating episodes are associated with at least three of the following: eating more rapidly than normal, eating until feeling uncomfortably full, eating large amounts when not feeling physically hungry, eating alone due to embarrassment, and feeling disgusted, depressed, or guilty after the episode.

Marked distress regarding binge eating.

Binge eating occurs, on average, at least once a week for three months.

321
Q

Diagnosis of eating disorders?

A

Diagnosis of eating disorders is based on clinical evaluation, which should consider medical history, physical examination, and diagnostic criteria. It is essential to rule out other medical conditions or psychiatric disorders.

322
Q

Mx of eating disorders?

A

Early detection and multidisciplinary intervention, encompassing medical, psychological, and nutritional support, are crucial for optimal outcomes.

323
Q

Cx of eating disorders?

A

Untreated eating disorders can lead to severe physical and psychological complications, including cardiac arrhythmias, electrolyte imbalances, osteoporosis, and increased risk of mortality.

Psychological complications might include depression, anxiety, and an increased risk of self-harm or suicide.

324
Q

Atypical eating disorders?

A

closely resemble anorexia nervosa, bulimia nervosa, and/or binge eating but do not meet the precise diagnostic criteria.

325
Q

Most common eating disorders?

A

Atypical eating disorders are most common, followed by binge eating disorders, then bulimia nervosa. Anorexia nervosa is the least common.

326
Q

Anorexia nervosa definition?

A

low body weight due to restriction of food intake or persistent behaviour which interferes with weight gain and intense fear of gaining weight.

327
Q

Bulimia nervosa definition?

A

recurrent episodes of uncontrolled eating of an abnormally large amount of food over a short time period (binge eating) followed by compensatory behaviour such as self-induced vomiting, laxative abuse, or excessive exercise.

328
Q

Binge eating disorder definition?

A

recurrent episodes of binge eating in the absence of compensatory behaviours. Episodes are marked by feelings of lack of control.

329
Q

When to consider emergency admission for eating disorders?

A

Severely compromised physical health — BMI or body weight below a safe range, cardiovascular instability, hypothermia, reduced muscle power, concurrent infection, overall ill health or abnormal blood tests.

Risk of refeeding syndrome.

Lack of support at home.

Acute mental health risk — risk of suicide attempt or serious self-harm.

330
Q

What to do if suspect pt has eating disorder?

A

Referral of all people with a suspected eating disorder to an age-appropriate eating disorder service.

While awaiting assessment by the eating disorder team:
- Arranging regular reviews to monitor the level of physical and mental health risk.
- Seeking advice from an appropriate specialist for people with co-morbidities (such as diabetes) and pregnant women.
- Considering the impact of malnutrition and compensatory behaviour on medication effectiveness and risk of side effects.

331
Q

Mx of confirmed eating disorder involves what?

A

Ensuring there is a clear agreement between primary and secondary care about responsibility for monitoring a person with an eating disorder.

Monitoring ongoing levels of risk to the person’s mental and physical health and managing complications — specialist input may be indicated.

Placing an alert in the person’s prescribing record to highlight the potential risk of adverse drug effects.

Giving advice on contraceptive use and pregnancy to women with eating disorders.

Ensuring the person and their family/carers have access to information and support.

332
Q

Central feature of anxiety?

A

‘excessive worry about a number of different events associated with heightened tension.’

333
Q

When considering a psychiatric diagnosis, always consider what?

A

a potential physical cause

334
Q

What physical causes is it important to eliminate before diagnosing generalised anxiety disorder?

A

hyperthyroidism, cardiac disease and medication-induced anxiety

335
Q

What meds might trigger anxiety?

A

salbutamol, theophylline, corticosteroids, antidepressants and caffeine

336
Q

GAD?

A

generalised anxiety disorder

337
Q

Mx of GAD?

A

step 1: education about GAD + active monitoring

step 2: low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)

step 3: high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment.

step 4: highly specialist input e.g. Multi agency teams

regular follow up

338
Q

Drug Tx for GAD?

A

1st line= sertraline (SSRI)
2nd= alternative SSRI or SNRI eg. duloxetine
3rd= pregabalin

339
Q

Pts under 30 starting SSRI for anxiety, warn them of what?

A

warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month

340
Q

Mx of panic disorder?

A

step 1: recognition and diagnosis

step 2: treatment in primary care

step 3: review and consideration of alternative treatments

step 4: review and referral to specialist mental health services

step 5: care in specialist mental health services

341
Q

Tx of panic disorder in primary care?

A

cognitive behavioural therapy or drug treatment

SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered

342
Q

Criteria for GAD?

A

excessive worry about every day issues that is disproportionate to any inherent risk.

At least three of the following symptoms are present most of the time= restlessness or nervousness, being easily fatigued, poor concentration, irritability, muscle tension, or sleep disturbance.

Symptoms are present for at least 6 months and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

343
Q

Prognosis of GAD?

A

chronic condition that may fluctuate in severity, with low rates of remission over the short- and medium-term.

344
Q

GAD is defined, and its severity categorized, by one of two main classification systems:

A

American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), or the World Health Organization (WHO) International Classification of Diseases (ICD-11).

345
Q

Most common psychiatric disorder?

A

anxiety disorders

346
Q

RFs for GAD?

A

Female sex.
Comorbid anxiety disorders.
Family history of anxiety disorders.
Childhood adversity.
History of sexual or emotional trauma.
Sociodemographic factors.

347
Q

Cx of GAD?

A

Distress, substantial disability, and impaired quality of life.
Impaired social and occupational functioning.
Comorbidities.
Suicidal ideation and attempts.

348
Q

Suspect GAD in who?

A

person who reports chronic, excessive worry which is not related to particular circumstances, and symptoms of physiological arousal such as restlessness, insomnia, and muscle tension.

Attend primary care frequently and=
- Have a chronic physical health problem.
- Do not have a physical health problem, but are seeking reassurance about somatic symptoms (particularly older people and people from minority ethnic groups).
- Are repeatedly worrying about a wide range of different issues.

349
Q

How to assess/determine the severity of GAD?

A

GAD-2 or GAD-7 questionnaires

350
Q

Referral for specialist Tx for GAD in who?

A

if GAD is complex, if the person has treatment-refractory GAD, if there is very marked functional impairment, or a if there is a high risk of self-harm.

351
Q

What does OCD stand for?

A

Obsessive-compulsive disorder

352
Q

OCD?

A

characterised by the presence of either obsessions or compulsions, but commonly both. The symptoms can cause significant functional impairment and/ or distress.

353
Q

Obsession definition?

A

an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind

354
Q

Compulsions definition?

A

repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one’s mind.

355
Q

RFs for OCD?

A

family history
age: peak onset is between 10-20 years
pregnancy/postnatal period
history of abuse, bullying, neglect

356
Q

How to classify OCD?

A

classigy impairment into mild, moderate or severe
they recommend the use of the Y-BOCS scale

an example of ‘severe’ OCD would be someone who spends > 3 hours a day on their obsessions/compulsions, has severe interference/distress and has very little control/resistance

357
Q

Mx of OCD if functional impairment is mild?

A

low-intensity psychological treatments: cognitive behavioural therapy (CBT) including exposure and response prevention (ERP)

If this is insufficient or can’t engage in psychological therapy, then offer a choice of either a course of an SSRI or more intensive CBT (including ERP)

358
Q

Mx of OCD if moderate functional impairment?

A

offer a choice of either a course of an SSRI (any SSRI for OCD but fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP)

consider clomipramine (as an alternative first-line drug treatment to an SSRI) if the person prefers clomipramine or has had a previous good response to it, or if an SSRI is contraindicated

359
Q

Mx of OCD if severe functional impairment?

A

refer to the secondary care mental health team for assessment

whilst awaiting assessment - offer combined treatment with an SSRI and CBT (including ERP) or consider clomipramine as an alternative as above

360
Q

OCD Mx= what is ERP?

A

psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands).

helps them confront their anxiety and the habituation leads to the eventual extinction of the response

361
Q

OCD= what if Tx with SSRI is effective?

A

continue for at least 12 months to prevent relapse and allow time for improvement

362
Q

OCD= SSRI use in OCD compared to depression?

A

SSRI usually requires a higher dose and a longer duration of treatment (at least 12 weeks) for an initial response in OCD

363
Q

Why is OCD undertreated?

A

People with OCD often fear stigmatization and fail to disclose their symptoms spontaneously, leading to low rates of recognition and, consequently, undertreatment.

364
Q

Diagnosis of OCD?

A

Screening people with symptoms of depression, anxiety, alcohol or substance misuse, body dysmorphic disorder, or an eating disorder.

Excluding other conditions including body dysmorphic disorder, illness anxiety disorder, and autism.

Assessing the severity of functional impairment as mild, moderate, or severe.

Assessing the risk of self-harm and suicide and the impact of compulsive behaviours on others.

365
Q

Mx of OCD?

A

depends on the level of functional impairment and includes:

  • Cognitive-behavioural therapy, ideally including exposure and response prevention.
  • SSRI or clomipramine. SSRIs should only be prescribed to people under 18 years of age following assessment and diagnosis by a child and adolescent psychiatrist.
  • Specialist referral (depending on factors including the person’s age, severity of symptoms, and previous treatment failures).
366
Q

OCD= when to refer for urgent psychiatric assessment?

A

people with a suspected high risk of self-harm or suicide.

367
Q

Personality disorders (PD)?

A

group of mental health conditions characterised by persistent patterns of thinking, feeling, and behaving that are significantly different from cultural expectations. These patterns can lead to distress or problems in personal, social, and occupational functioning

368
Q

How are people with personality disorder diagnosed?

A

For many years patients were diagnosed with a specific ‘named’ personality disorder, such as narcissistic or paranoid.

This approach was changed significantly with the introduction of the ICD-11 classification which marked a shift towards a more dimensional model, such as severity and specific problems.

This allows for a more flexible and comprehensive understanding of personality pathology.

369
Q

Most pts with personality disorders will be…

A

‘labelled’ using the previous classification system rather than the more modern way that just focuses on severity and specific problems

370
Q

4 Key features of personality disorder (ICD-11)?

A

1) Persistent Pattern: The individual’s patterns of cognition, emotional experience, behaviour, and interpersonal functioning deviate from cultural expectations. These patterns are stable over time and span across various personal and social situations.

2) Impairment: The deviation results in significant problems or dysfunctions in the person’s life, especially in relationships, work, or social functioning.

3) Duration: These characteristics are stable over time, beginning in adolescence or early adulthood, and are not transient.

4) Distress or Dysfunction: The impairment may result in distress to the individual or others. These patterns are not explained by another mental disorder, a medical condition, or substance misuse.

371
Q

In the ICD-11 personality disorders are classified how? This provides a broader and more flexible approach.

A

Mild
Moderate
Severe

Also trait domains

372
Q

Mild personality disorder?

A

Some impairments in functioning, often limited to specific areas of life (e.g., intimate relationships or work).

Symptoms may be noticeable to others but do not cause pervasive distress or dysfunction.

The individual may still maintain relatively stable relationships and occupational roles.

373
Q

Moderate personality disorder?

A

More significant impairments in multiple areas of life (personal, social, and work).

The individual may struggle with maintaining close relationships, and there may be greater interpersonal difficulties.

More distressing symptoms are present, but the individual can manage day-to-day functioning with some effort or support.

374
Q

Severe personality disorder?

A

Profound impairments in all areas of life.

Individuals may experience pervasive difficulties in interpersonal relationships, self-identity, and coping mechanisms.

Significant distress, dysfunction, and reduced quality of life are common.

Individuals may require intensive and long-term therapeutic interventions.

375
Q

Key features of personality disorder (ICD-11)= persistent pattern?

A

The individual’s patterns of cognition, emotional experience, behaviour, and interpersonal functioning deviate from cultural expectations. These patterns are stable over time and span across various personal and social situations.

376
Q

Key features of personality disorder (ICD-11)= impairment?

A

The deviation results in significant problems or dysfunctions in the person’s life, especially in relationships, work, or social functioning.

377
Q

Key features of personality disorder (ICD-11)= duration?

A

These characteristics are stable over time, beginning in adolescence or early adulthood, and are not transient.

378
Q

Key features of personality disorder (ICD-11)= distress or dysfunction?

A

The impairment may result in distress to the individual or others. These patterns are not explained by another mental disorder, a medical condition, or substance misuse.

379
Q

In addition to severity, ICD-11 also characterises personality disorders how?

A

trait domains that represent the predominant problematic areas in the individual’s personality

380
Q

Name the Personality Disorder Trait Domains?

A

1) Negative Affectivity
2) Detachment
3) Dissociality
4) Disinhibition
5) Anankastia
6) Borderline Pattern

381
Q

Personality Disorder trait domains= negative affectivity?

A

Tendency to experience a wide range of negative emotions such as anxiety, depression, guilt, and anger.

Individuals may be prone to mood swings, insecurity, and emotional lability.

382
Q

Personality Disorder trait domains= Disinhibition?

A

Impulsiveness, risk-taking, and difficulty controlling behaviours.

Individuals may struggle with planning and foresight, leading to reckless or irresponsible actions.

382
Q

Personality Disorder trait domains= Detachment?

A

Avoidance of social interactions, emotional withdrawal, and limited pleasure from relationships.

Individuals may appear cold, aloof, and isolated.

382
Q

Personality Disorder trait domains= Dissociality?

A

Disregard for the rights and feelings of others, lack of empathy, and difficulty forming prosocial relationships.

Impulsivity and manipulative behaviours are common traits.

383
Q

Personality Disorder trait domains= Anankastia?

A

Preoccupation with orderliness, control, and perfectionism.

Individuals may be rigid, stubborn, and excessively focused on rules and details.

384
Q

Personality Disorder trait domains= Borderline Pattern?

A

An additional qualifier for those showing emotional instability, intense and unstable interpersonal relationships, a fluctuating sense of identity, and impulsivity.

This pattern is akin to borderline personality disorder as recognised in ICD-10 and DSM-5.

385
Q

Previous classification of personality disorders= used to be categorised how?

A

as 3 clusters:

Cluster A= odd or eccentric

Cluster B= dramatic, emotional or erratic

Cluster C= anxious and fearful

386
Q

Previous classification of personality disorders= Cluster A?

A

Odd or Eccentric

  • Paranoid
  • Schizoid
  • Schizotypal
387
Q

Previous classification of personality disorders= Cluster B?

A

Dramatic, emotional or erratic

  • antisocial
  • borderline (emotionally unstable)
  • histrionic
  • narcissistic
388
Q

Previous classification of personality disorders= Cluster C?

A

anxious and fearful

  • obsessive-compulsive
  • avoidant
  • dependent
389
Q

Previous classification of personality disorders= Cluster A (odd or eccentric)- Paranoid?

A

Hypersensitivity and an unforgiving attitude when insulted

Unwarranted tendency to questions the loyalty of friends

Reluctance to confide in others

Preoccupation with conspirational beliefs and hidden meaning

Unwarranted tendency to perceive attacks on their character

390
Q

Previous classification of personality disorders= Cluster A (odd or eccentric)- Schizoid?

A

Indifference to praise and criticism

Preference for solitary activities

Lack of interest in sexual interactions

Lack of desire for companionship

Emotional coldness

Few interests

Few friends or confidants other than family

391
Q

Previous classification of personality disorders= Cluster A (odd or eccentric)- Schizotypal?

A

Ideas of reference (differ from delusions in that some insight is retained)

Odd beliefs and magical thinking

Unusual perceptual disturbances

Paranoid ideation and suspiciousness

Odd, eccentric behaviour

Lack of close friends other than family members

Inappropriate affect

Odd speech without being incoherent

392
Q

Previous classification of personality disorders= Cluster B (dramatic, emotional or erratic)- Antisocial?

A

Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest;

More common in men;

Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
Impulsiveness or failure to plan ahead;

Irritability and aggressiveness, as indicated by repeated physical fights or assaults;

Reckless disregard for the safety of self or others;

Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations;

Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

393
Q

Previous classification of personality disorders= Cluster B (dramatic, emotional or erratic)- Borderline (Emotionally Unstable)?

A

Efforts to avoid real or imagined abandonment

Unstable interpersonal relationships which alternate between idealization and devaluation

Unstable self image

Impulsivity in potentially self damaging area (e.g.
Spending, sex, substance abuse)

Recurrent suicidal behaviour

Affective instability

Chronic feelings of emptiness

Difficulty controlling temper

Quasi psychotic thoughts

394
Q

Previous classification of personality disorders= Cluster B (dramatic, emotional or erratic)- Histrionic?

A

Inappropriate sexual seductiveness

Need to be the centre of attention

Rapidly shifting and shallow expression of emotions

Suggestibility

Physical appearance used for attention seeking purposes

Impressionistic speech lacking detail

Self dramatization

Relationships considered to be more intimate than they are

395
Q

Previous classification of personality disorders= Cluster B (dramatic, emotional or erratic)- Narcissistic?

A

Grandiose sense of self importance

Preoccupation with fantasies of unlimited success, power, or beauty

Sense of entitlement

Taking advantage of others to achieve own needs

Lack of empathy

Excessive need for
admiration

Chronic envy

Arrogant and haughty attitude

396
Q

Previous classification of personality disorders= Cluster C (anxious and fearful)- Obsessive-compulsive?

A

Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone

Demonstrates perfectionism that hampers with completing tasks

Is extremely dedicated to work and efficiency to the elimination of spare time activities

Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values

Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning

Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things

Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness

397
Q

Previous classification of personality disorders= Cluster C (anxious and fearful)- Avoidant?

A

Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection.

Unwillingness to be involved unless certain of being liked

Preoccupied with ideas that they are being criticised or rejected in social situations

Restraint in intimate relationships due to the fear of being ridiculed

Reluctance to take personal risks due to fears of embarrassment

Views self as inept and inferior to others

Social isolation accompanied by a craving for social contact

398
Q

Previous classification of personality disorders= Cluster C (anxious and fearful)- Dependent?

A

Difficulty making everyday decisions without excessive reassurance from others

Need for others to assume responsibility for major areas of their life

Difficulty in expressing disagreement with others due to fears of losing support

Lack of initiative

Unrealistic fears of being left to care for themselves

Urgent search for another relationship as a source of care and support when a close relationship ends

Extensive efforts to obtain support from others

Unrealistic feelings that they cannot care for themselves

399
Q

Mx of personality disorders?

A

difficult to treat and in the past have been considered ‘untreatable’ by definition.. However, a number of approaches have been shown to help patients, including:

psychological therapies: dialectical behaviour therapy

treatment of any coexisting psychiatric conditions

400
Q
A

FINALS (37 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions