Psych Flashcards
Mary Thomas, a 52 year old bank worker, comes to see you. She is a new patient of the practice, having moved from Melbourne last year because of her husband’s work. She tells you that her husband recently left her for a younger woman, and she is worried that she ‘may have caught something from him’. She asks if you can do a check-up for this. When you talk to her, she hardly looks at you, looks very tired and drained and is very tearful. How would you assess and manage her?
Concern: reactive psych illness
PDx: depression
DDx: organic (disease, meds), schizoaffective, bipolar
Priorities
- Confirm depression and rule out DDx: K10, screen for organic symptoms/psychotic/manic symptoms, ask about time period of symptoms and change from baseline, MMSE, consider TFTs and FBC
- Risk assessment and MSE
- Formulation
- Reassure re: STI screen
- Start CBT
- Trial SSRI if CBT doesn’t work (if no contraindications eg epilepsy, bipolar, other serotonin drugs)
A 66 year old man presents with what appears to be Major Depression of 4 months duration. At the time you see him, he has already been treated with Sertraline for 6 weeks, at a dose of 50-100 mg/day, with no improvement. His lack of response makes you suspect that he may have an ‘organic depression’. Which physical disorders are most likely to present as depression in him, and how will you investigate him?
DDx:
- neuro: dementia (vascular etc), stroke, PD, Huntington’s, SOL
- endocrine: Cushing’s, Addisons, hypothyroidism
- autoimmune: SLE, GCA, vasculitis
- infections: syphilis, EBV
Priorities
- check depression and treatment: ask about symptomatology, treatment, adherence, issues
- ask about atypical presentation: late onset, hallucinations, severe and rapid onset, other neuro deficit, symptoms of other conditions, stroke RF
- risk assessment and MSE
- screen for organic disease: FBC, EUC, CMP, BSL, LFTs, vit B12 and folate, TFTs, MRI brain – if nothing found, dex suppression test, short synacthen, tox screen, EBV, autoantibodies
- formulation
- treat cause if found and wean SSRI
- optimise CV risk factors
Describe the screening tools at our disposal to aid in the early detection of depression arising in women in the perinatal period. What are the treatments (psychological and pharmacological) available for the treatment of depression at this time; please include a brief comment on the safety of antidepressants in pregnancy.
Routine screening (at first postnatal visit and 6-8 weeks after)
- Questioning about wellbeing, coping and stressors - HoPC and SHx
- Screen for anxiety and psychosis - consider K10
- Risk assessment
- EPDS
Referral to specialist psychiatrist
Treatments
- Mild: supportive measures, parenting skills, psycho-education, psychotherapy (CBT, IPT), diet and exercise
- Moderate: introduce pharm
- Severe: hospitalise, consider ECT
*Postnatal psychosis: has a prodrome, hospitalise and give antipsychotics and mood stabiliser (ie bipolar management) with long term psychotherapy
Antidepressants in pregnancy: not a lot of evidence
- SSRIs have most evidence - no increased risk of teratogenicity, miscarriages; slightly increased risk of prematurity, postpartum haemorrhage
- other agents: SNRIs are pretty much the same; mirtazapine preterm birth but not PPH; TCA there’s one to avoid and also has risks of hypertension and PPH
A 35 year old businessman is brought to you by his wife as his work colleagues have been concerned that he has become increasingly irritable, demanding, talkative and is starting new schemes and investments which they consider unwise. He does not think that he needs to see you. Discuss how you would manage this clinical situation.
PDx: bipolar (I or II)
DDx: organic (med-induced, substance use, organic brain disease) schizophrenia/schizoaffective, anxiety
Priorities
- Confirm diagnosis and rule out differentials: DSM V criteria
- Assess severity and risk assessment (incl MSE)
- Formulation
- Hospitalise if at risk - schedule 1 under MH Act (2007)
- Antipsychotic (olanzepine) + mood stabiliser (lithium) - baseline Ix pre-lithium are EUC, CMP, TFTs, ECG; measure lithium level 5-7 days after treatment
- ECT if refractory
- Regular outpatient psych F/U with psychotherapy: psychoeducation, family therapy
You are a general practitioner and a 22 year old man is referred to you for follow-up after being discharged from hospital where he was treated for an acute relapse of schizophrenia. His discharge medication is olanzapine 15 mg daily. Describe your ongoing management plan including your own role and that of other agencies whose help you may need to enlist.
Schizophrenia
Priorities
- Elucidate past psych history
- Determine current issues: psych illness management, family, social support, ADLs, vocation, cognition
- RISK ASSESSMENT, mse
- Formulation and plan
MANAGEMENT
- pharm: continue with olanzepine for 12 months, consider reducing dose, depot; monitor for s/e esp metabolic syndrome and EPSE (regular psychiatrist F/U)
- psych: psychotherapy - psychoeducation, CBT, family therapy, cognitive remediation therapy (via psychologist);
- social worker: housing - stepdown centre if ADLs not intact, ADL support and development; social support -programs to improve social skills, befriending; financial/vocational: training/Centrelink DSP
- GP: regular F/U incl physical/psych health screening and CV risk factor improvement
You have just seen a 33 year old woman who often attends with worries over her own health and the safety of her husband and children. She finds the worrying excessive and not easy to control. Describe your approach to discussing the likely diagnosis and management with the patient.
Anxiety disorder - likely GAD
DDx: OCD, panic disorder, depression/bipolar/psychosis, organic disease/med-induced
Approach
- confirm GAD
- rule out other anxiety or non-anxiety disorder (could be comorbid)
- rule out organic disease: substance/med use, PMHx, TFTs
- RISK ASSESSMENT
- formulation
- psychotherapy: CBT, ACT (or other as relevant eg graded exposure for specific phobia)
- consider SSRI - trial cessation after symptom-free for 6 months (benzos if severe and disabling)
Michael is 30 and for years has been afraid that electrical appliances, if not switched off, could cause a fire and harm his family or neighbours. He spends four hours a day checking that such dangerous appliances are safely switched off. What is the likely diagnosis? Design a graded exposure and response prevention program for him.
OCD: both obsessions and compulsions that are causing functional impairment
DDx: psychosis, mood disorder (rumination, obsessions)
RISK ASSESSMENT
Treatment: exposure and response prevention/thought stopping
0) patient ranks certain OCD situations in order of least to most threat
1) with empty powerpoints in therapist’s office - check once and then sit with you, talk through ways of coping rather than checking x number of times
2) with one device plugged in
3) with multiple devices plugged in
4) at home, without devices
5) at home, with one device
6) at home, with all devices
adjunct: pharm, hospitalisation (if suicide risk or self-care impaired)
A 28 year old woman has presented with a 15 minute episode of chest pain, dizziness and breathlessness. She has had 2 similar episodes in the past 4 months. Medical investigations performed at the hospital have excluded cardiac pathology. Discuss your approach to further assessment, possible diagnoses and management options.
Panic disorder +/- agoraphobia DDx: - specific phobia, social anxiety, GAD - somatic symptom disorder - organic disorder - substance use/withdrawal, hyperthyroidism
Priorities
- confirm diagnosis and rule out differentials: hx, MSE, TFTs
- treat with psychoeducation, ACT, CBT (including relaxation training), graded exposure therapy if agoraphobic/specific phobia
- consider SSRI (benzos for acute attack, consider ‘pill-in-pocket’
A 35 year old woman presents with severe symptoms of anxiety, irritability and difficulty concentrating which have been present for the past 6 months since her involvement in a motor vehicle accident. What additional features would need to be present for a diagnosis of post- traumatic stress disorder? What are the essential components of psychological treatment for this disorder?
PTSD
- Experience of trauma
- Symptoms: intrusive memories, dreams, dissociative reliving of trauma, psych/physiological reaction to cues
- Avoidance
- Cognition/mood affected
- Increased arousal/reactivity
- longer than a month, functional impairment, exclude other things
Assess: hx, MSE, formulation
Treatment
- prolonged exposure and cognitive processing
- EMDR
- consider pharm: SSRI
You have just started in your first position as a general medical practitioner in a large practice. You are told by the receptionist that you are to see a Mrs Smith who is regarded as an “impossible patient”. She attends the practice at least twice each week and has been seen by every doctor in the practice over the last 10 years. Mrs Smith has complained of a whole variety of symptoms over the years but no serious medical condition has ever been diagnosed. Describe how you would assess and manage Mrs Smith’s case.
?somatisation disorder
Priorities
- Elicit patient’s symptoms and concerns
- Confirm conversion/ somatisation/illness anxiety –> both symptoms and distressing worry present >6 months (Somatic Symptoms Scale-8)
- Rule out organic disease, depression, delusion, factitious disorder
- MSE, risk assessment
- Formulation
- Psych referral: psychoeducation, CBT
- Lifestyle modification
A 16 year-old girl presents with her mother with a recent history of weight loss and preoccupation with the size of her body. Outline how you would assess and manage her.
?anorexia nervosa
DDx: bulimia nervosa, normal dieting, physical causes of weight loss
Priorities ASSESSMENT - confirm the diagnosis and rule out differentials - assess risk factors - assess consequences, severity - risk assessment, MSE, formulation
MANAGEMENT
- hospitalisation if acutely unwell/BMI < 14
- dietetics: aim BMI 18-20
- family based treatment
- psychoeducation, individual psychotherapy (NOT CBT tho)
***DSM:
A. Restriction of energy intake -> significantly low body weight
B. Intense fear of gaining weight, persistent behaviour that interferes with weight gain even though at significantly low weight
C. Disturbance in way one’s body weight/shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight
A 28-year-old woman is BIBA, tearful and threatening self-harm. She denies having taken any drug overdoses. There are superficial lacerations to her right wrist. She is irritable and crying. How would you assess and manage her?
PDx: BPD
DDx: depression, mania, psychosis
Priorities ASSESSMENT - confirm BPD and rule out differentials - treat superficial lacerations - risk assessment, MSE, formulation
MANAGEMENT
- admit only if at risk to herself: schedule if necessary, minimise length of stay
- outpatient F/U with psych
- DBT (mostly to reduce self-harm): mindfulness, distress tolerance, emotional regulation, interpersonal effectiveness
- IPT: developing personal/interpersonal skills
- CBT
- family psychoeducation
***DSM: Labile identity, relationships, affect Suicidality Paranoia, emptiness, dissociation, impulsivity, anger Fear of abandonment
A 9 year old boy attends for interview with his mother. She reports that his school complains that he gets into fights at school, and is disruptive in class. Mother also reports that he is aggressive towards his 2 younger brothers. How would you approach the assessment of this child’s mental health and what diagnoses would you consider likely?
DDx:
- ADHD
- internalising: anxiety, depression
- behavioural: ODD, CD
- developmental: learning/language/sensory impairment
- environmental: family stressors, bullying, abuse
- organic: asthma meds, neuro conditions, hyperthyroid
Assessment
- symptomatology (in multiple environments)
- social issues: home, school, other environments
- rule out developmental/sensory issues
- refer to paed/child psych -> Connor Rating Scale
Management
- ADHD:
- –CHILD: behavioural intervention (especially for younger kids); stimulants (methylphenidate, dexamphetamine) -> ongoing monitoring (especially weight and growth), try to wean later
- –SCHOOL: educational support
A 7 year old boy is referred because of his antisocial and isolated behaviour at school, and non- compliance at home. He has a history of “being different”, few friends, and poor attention except for spending most of his time pre-occupied with his coin collection. His father is a computer expert and his mother is a maths teacher. The parents have difficulty communicating and are contemplating a trial separation. You are about to see the parents. What are the issues?
PDx: autism spectrum disorder DDz: internalising: depression, anxiety externalising: ADHD, ODD IDs: ID, GDD
Priorities
- Assess current symptomatology and development
- Elicit social history: home situation, school situation and potential issues
- Check for associated syndromes/dysmorphic features, growth
- Risk assessment, MSE, formulation
- Formal ASD assessment by ed and dev child psych eg ADOS; paeds to do neuro/genetics/metabolic assessment, SP to assess functional level and pragmatics, OT for motor and sensory
- Assess vision, hearing, speech, language, communication
- Treat (early intervention if possible) - behavioural and educational interventions: communication, social interaction; family: psychoeducation, financial, counselling, respite; school and community: education, support for programs, funding
(meds only if aggression and severe irritability)
Issues
- Socialisation development
- Language development
- Parental tension in home environment
**DSM:
- DSM V criteria
A. SOCIAL: persistent deficits in social communication and social interaction
i. Deficits in social-emotional reciprocity
ii. Deficits in nonverbal communicative behaviours
iii. Deficits in developing, maintaining and understanding relationships
B. BEHAVIOUR: restricted, repetitive patterns of behaviour, interests or activities
i. Stereotypes or repetitive motor movements, use of objects or speech
ii. Insistence on sameness, inflexible adherence to routines, ritualised patterns of verbal or nonverbal behaviour
iii. Highly restricted, fixated interests that are abnormal in intensity or focus
iv. Hyper/hyporeactivity to sensory input
C. Onset in early developmental period
D. Functional impairment
Exclude due to ID, global developmental delay
Discuss psychotherapy - what is it, what types are there, and what are the common ingredients of successful therapies?
Psychotherapy: use communication + personal-professional relationship to improve negative patterns of feeling/behaviour/thoughts
Types:
- IPT
- CBT
- Psychodynamic
- DBT
- Mentalisation-based
- Family/marital
- Group
- Problem-solving
Ingredients
- Patient: motivated, insight, supported
- Doctor: experienced, competent, empathetic, psychoeducation provided, encouraging
- Therapy: altering fundamental beliefs, enhancing coping mechanisms and problem-solving skills
