Psych

Question 1

Questions to ask a suicidal patient who has not attempted suicide

Answer 1

• Do you still get pleasure out of life?
• Are you able to face each day?
• Do you feel life is a burden?
• Do you wish it will all end?
• Have you ever thought about ending your own life?
• What is stopping you from trying to commit suicide?
• Have you thought about how you would do it?

Question 2

Questions to ask a patient who has attempted suicide

Answer 2

• Was it premeditated?
• Did you make any attempts to stop people from finding you?
• Did you tell anyone about it?
• Did you write a suicide note/ change your will Violent act?
• Did you think it would be final/ reversible?
• Do you have any regrets?
• Did you try and get help after the attempt? Previous attempts?
• Alcohol/ drugs involved?

Question 3

Questions for a depressed patient

Answer 3

• Low mood?
  
  • Duration?
• Anhedonia
  
  • Loss of interest in hobbies?
• Anergia
  
  • Diurnal variation (worse in mornings?)
• Poor concentration/ memory
• Poor sleep?
• Appetite/ weight Guilt/ worthlessness
• Suicidal ideation?

Question 4

Questions for the manic patient?

Answer 4

• Excessive spending?
• Decreased sleep?
• Ambitions?
• Grandiose ideas
• Disinhibition
• Sexual energy/ libido
• Flight of ideas
• Pressure of speech

Question 5

Questions for the delusional patient

Answer 5

• Has anything been worrying you lately?
• What’s been on your mind?
• Has anything odd been happening to you lately that others are finding it difficult to believe?

Question 6

Questions for a patient with hallucinations

Answer 6

• Has anything unusual happened to you recently?
• Did you hear voices which no one else can hear?
• Did you ever see things that are strange or that other people cannot see?

Question 7

First rank symptoms of schizophrenia

Answer 7

• Thought possession (insertion, withdrawal. broadcasting)
• Passivity phenomena (somatic, thoughts, emotions, acts)
• Auditory hallucinations (usually 3 rd person, thought echo or commentary)
• Delusional perception

Question 8

What is a delusion?

Answer 8

A false belief which is kept despite proof to the contrary and out of keeping with the patient’s social, cultural and educational backgrounds

Question 9

Questions to ask the anxious patient?

Answer 9

• Feelings of worry/ apprehension?
• Irritability
• Restlessness
• Depersonalisation
• Insomnia
• Psychogenic symptoms
• Memory problems

Question 10

Questions to ask about panic attacks?

Answer 10

• Fear/ feeling of threat, panic or doom which is out of proportion to the perceived danger
• Avoidance of anything that may trigger the panic attack
• What triggers it?
• How severe is the panic attack?

Question 11

Questions about phobias

Answer 11

• How often?
• Trigger avoidance
• Safe at home?
• Do they need anyone to be at home with them?
• How well do you do in crowds? anonymous or not?
• Affect on a day to day relationships

Question 12

OCD questions

Answer 12

• An intrusive thought
• Recognition it’s their own Irrational feeling?
• The resistance of these thoughts?

Question 13

PTSD Questions

Answer 13

• Flashbacks
• Panic attacks
• Emotional numbing
• Avoidance
• Nightmares
• Over arousal
• Depression
• Substance misuse

Question 14

Features of dependence

Answer 14

• Stereotypes pattern
• Primacy
• Tolerance
• Withdrawal
• Relief drinking (to stop withdrawal symptoms)
• Compulsion to drink
• Relapse after abstinence

Question 15

Questions to ask an alcoholic patient

Answer 15

• What is drunk?
• How much?
• How often?
• Where?
• When?
• Triggering?
• Binges?
• When did this start?
• Abstinent?
• Have you sought help before?
• FH?

Question 16

SCOFF Questionnaire

Answer 16

• Sick: do you make yourself feel sick?
• Control: do you worry you have lost control over what you eat?
• One stone: loss in the last three months?
• Fat: do you think you are too fat when others think you are too thin?
• Food: Do you think food dominates your life?

Question 17

Eating disorder questions

Answer 17

• How would you feel if you gained weight?
• How do you see yourself when you look in the mirror?
• Amenorrhea?

Question 18

Eating disorder Biological symptoms

Answer 18

• Lanugo hair
• Breast atrophy
• Skin looks rough
• Low BP
• Extremities cold

Question 19

What is CBT?

Answer 19

• Based on Beck’s model of depression
• Negative thinking can depress mood which generates negative thoughts
• Resulting in a downward spiral
• The therapist helps the patient to notice negative automatic thoughts (NATs)

Question 20

Symptoms of depression?

Answer 20

• Core symptoms:
  
  • Low mood
  • Anhedonia
  • Anergia
• Cognitive symptoms:
  
  • worthless
  • feelings of guilt
  • pessimistic view of the future
  • poor concentration
• Biological:
  
  • insomnia
  • early morning waking
  • fatigue, hyperphagia, weight gain
  • reduced libido

Question 21

Ix for Depression

Answer 21

• 1. Collateral history
• 2. Physical examination
• 3. Blood tests (include others as suggested by history and examination):
     * TFT (to rule out hypothyroidism)
     * FBC (anaemia causes fatigue)
     * G or HbA1c (diabetes causes fatigue)
• 4. Rating scales can measure severity or monitor treat- ment response,
     * e.g. Beck Depression Inventory (BDI), Hospital Anxiety and Depression Scale (HADS)
• 5. CT or MRI head are never routine but may help to rule out suspected cerebral pathology

Question 22

Psychological Therapy for depression

Answer 22

• IAPT talking therapies
  
  • if mild then computer based or self-help
• Cognitive Behavioural Therapy: focusing on the now
• Psychodynamic psychotherapy: talking to a therapist, allows you to put into words how you feel with the prompts of the therapist
• Interpersonal Therapy: focuses on unresolved loss, psychosocial transitions, relationship conflicts

Question 23

Common side effects of SSRIs

Answer 23

• Insomnia
• Tremor
• dizziness
• Headache
• Sweating
• Sexual dysfunction

Question 24

Presentation of MSE

Answer 24

• A - Appearance/Behaviour
• S - Speech
• E - Emotion (Mood and Affect)
• P - Perception (Auditory/Visual Hallucinations)
• T - Thought Content (Suicidal/Homicidal Ideation) and Process
• I - Insight and Judgement
• C - Cognition

Question 25

Biological management of depression

Answer 25

• 1st line: SSRI
• 2nd line:
  
  • SNRI (venlafaxine)
  • NASSAS (mirtazapine)
  • NARI (reboxetines)
  • MAOI (Phenelzine)
  • RIMA (Moclebemide)

Question 26

Physical causes of depression

Answer 26

• Cushing’s syndrome
• Hypothyroidism
• Addison’s disease
• Dementia
• Head injury
• Stroke
• PD
• MS

Question 27

Management of suicide

Answer 27

• Admit if at high risk of suicide
• Same as per depression
• Could also consider discharging with HTT
• Suicide hotlines given
• Establish a plan for what the patient will do if they feel this way again

Question 28

Management of puerperal psychosis

Answer 28

• If severe admit to mother and baby unit
• Treat psychosis with atypical antipsychotic (olanzapine and quetiapine are safe in breastfeeding)
• Treat depression with SSRIs (paroxetine and sertraline are safe in breastfeeding)
• Severe cases may need ECT

Question 29

RF for puerperal psychosis

Answer 29

• Personal or family history of puerperal psychosis
• BPAD
• Puerperal infection
• Obstetric complications

Question 30

Features of lithium toxicity

Answer 30

• GI disturbance (diarrhoea and vomiting)
• Sluggishness
• Giddiness
• Ataxia
• Gross tremor Fits
• Renal failure

Question 31

What are the teratogenic effects of mood stabilisers in pregnancy?

Answer 31

• Lithium – Ebstein’s anomaly
• Valproate and Carbamazepine – spina bifida

Question 32

Management of psychosis

Answer 32

• Can be managed at home with HTT support • If <30 can refer to EIS
• If at risk then admit under section
• Biological
  
  • Acute: Consider IM lorazepam
  • Chronic:
    
    • 1st line atypical antipsychotic (olanzapine, risperidone (can be depot), quetiapine, clozapine, aripiprazole) o
    • 2nd line typical antipsychotic (e.g. chlorpromazine, haloperidol- these are better as depot injections
• Psychological
  
  • CBT: reality testing, as these patients tend to jump to conclusions
  • Family therapy: especially preventing relapse in high expressed emotional families •
  • Concordance therapy: collaborative approach where the patient decides the pros and cons of their treatment
• Social
  
  • Social skills training to improve interpersonal skills
  • Education
  • Rehabilitation accommodation
  • Social services
  • Creative writing

Question 33

Management of acute mania in patients with BPAD

Answer 33

• Stop anti-depressants, steroids and dopamine agonists
• Check lithium levels
• IM atypical anti-psychotic à olanzapine/quetiapine/risperidone
• BDZ for agitation
• For patients already on medication try combining medication (i.e. antipsychotic + mood stabiliser + benzo)
• Stabilise using mood stabiliser
• ECT may be considered if medication is ineffective

Question 34

Management of Dementia

Answer 34

Social

• Referral to memory clinic
• Environmental control: always carry ID with address, dossett boxes for medication, change gas to electricity, reality orientation
• Social Support: personal care, meal preparation, day centres, day hospitals
• Support for carers:
  
  • Carer support (Alzheimer’s Association, National institute on Aging)
  • Written instructions

Psychological Therapies:

• Reminiscence therapy
• Validation therapy
• Multisensory Therapy
• Cognitive Stimulation Therapy
• Regular follow up with an old age psychiatrist

Biological therapies: not to be used long-term

• Acetylcholinesterase inhibitors e.g. donepezil, galantamine and rivastigmine
• NMDA agonist – memantine
• SSRIs in those with depression

Question 35

List some key differences between DLB, AD and VD

Answer 35

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

Question 36

Eating Disorder Management

Answer 36

• 1^stline: Anorexia-focused family therapy with dietician involvement
• 2^ndline: ED-CBT
• Other options: specialist supportive clinical management (SSCM), Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
• If co-morbid depression à fluoxetine
• Possible long-term follow up for complications e.g. osteoporosis

Question 37

When would you consider the admission of a patient with anorexia?

Answer 37

• BMI < 13 or extremely rapid weight loss >1 kg/week
• Serious physical complications → Hypotension, Bradycardia, Electrolytes, Hypothermia
• High suicide risk
• NOTE: MHA may be used to enforce compulsory feeding

Question 38

What are some physical complications of anorexia nervosa?

Answer 38

• Bradycardia and hypotension (risk of sudden death)
• GI upset (constipation, abdominal pain, ulcers)
• Amenorrhoea and infertility
• Osteoporosis
• Peripheral neuropathy

Question 39

Alcohol rating scales

Answer 39

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

CIWA Ar alcohol to determine severity of withdrawal

Question 40

Management of addiction

Answer 40

Bio – Assisted Withdrawal

• Community-based - Drug and Alcohol Service
• Fixed-dose drug regimen (chlordiazepoxide or diazepam)
  
  • Titrate based on severity of alcohol dependence
  • Gradually reduce the dose over 7-10 days (give 2 days of medication at a time)
• After successful withdrawal, consider acamprosate or naltrexone (for 6 months) with individualised psychological intervention
• Thiamine supplementation
• Expectations: withdrawal symptoms are worst within the first 48 hours, and takes about 3-7 days after the last drink to completely disappear

Psychological

• CBT, behavioural or social network and environment-based
• Focus on alcohol-related cognitions
  
  • Weekly 1-hour sessions for 12 weeks
• Refer to self-help resources and support groups (Alcoholics Anonymous, SMART Recovery)

Social

• Direct to the relevant services regarding legal and financial support (e.g. benefits)
  
  • Direct to services that can help find a new job (e.g. job centres)
  • Driving – DVLA will need to be informed about you receiving treatment (can’t drive during treatment)
• Follow-Up
  
  • Arrange an appointment for any time after you finish withdrawal
  • Safety Net: if symptoms become very severe, go to A&E

Question 41

SSRI discontinuation syndrome

Answer 41

• Symptoms can include diarrhoea, nausea and vomiting.
• Flu-like symptoms such as headaches and sweating may also be seen, and in some cases, patients can present with symptoms of vertigo

Question 42

Physiological changes in anorexia

Answer 42

• hypokalaemia
• low FSH, LH, oestrogens and testosterone
• raised cortisol and growth hormone
• impaired glucose tolerance
• hypercholesterolaemia
• hypercarotinaemia
• low T3

Most things low

• G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia

Question 43

Interpret the MMSE

Answer 43

• 24-30- no cognitive impairment
• 18-23- mild cognitive impairment
• 0-17- Severe cognitive impairment

Question 44

Drugs to help with alcohol dependence

Answer 44

• Disulfiram: makes you throw up after having alcohol (
• Acamprosate: tablet taken three times a day which reduces craving

Question 45

How does serotonin syndrome present?

Answer 45

Serotonin syndrome presents with the triad of:

• altered mental status (e.g. agitation, confusion, coma)
• autonomic dysfunction (e.g. hyperthermia, hypertension, tachycardia)
• neuromuscular abnormalities (e.g. tremor, clonus, hyperreflexia).