Psych Flashcards
Delirium vs Dementia
Delirium is acute onset, fluctuating with impaired consciousness and abnormal sleep wake cycles
Dementia is gradual onset cognitive decline that is non-fluctuant. Delirium can be caused by steroids
Dementia Screen and Management
Screen: FBC, U+E, LFT, TFT, B12, Folate, Bone Profile, CRP, ESR. Urine dip, Imagine of the brain
Also get a collateral history, regular follow up over a period of time to confirm diagnosis. Do a cognitive assessment such as ACE as well.
Management:
Bio-Ache inhibitors such as donepezil or NMDA antagonists such as memantine only for Alzheimers. Levodopa for Parkinson’s dementia. Give dosset boxes if required and get pharmacy to drop them off.
Psychosocial- Memory clinic, refer for counselling, CBT, help with writing advanced directives, involve MDT, social workers and OT to ensure home is fit for purpose. Design home so that it is dementia friendly. For vascular dementia, reduce risk factors. Physiotherapist maybe for Parkinson’s. Give carer support if required.
Dementia Different Types
Alzheimers-Steady cognitive decline
Vascular-Stepwise decline
Lewy Body-Visual hallucinations
Parkinson’s- Tremor, rigidity, bradykinesia
Pick’s Disease-Personality Changes and disinhibition
Huntington’s-Family Hx
Pseudodementia-Not really dementia
AMTS
Age Time 45 West Street Year Location Identify 2 people DOB WW1 Monarch Count backwards
Delirium Management
Can be caused by drugs, infection, metabolic, trauma, oxygen and poisoning. (DIMTOP).
Treat underlying cause, 1:1 nursing and sideroom in hospital setting, support with orientation to TPP.
Consider benzodiazepines as last resort if significant risk to self or others. (Haloperidol?)
Alcohol/Substance Misuse Management
ABCDE Approach. Give oxygen, fluids, analgesia as required. Consider possibility of delirium tremens in an inpatient. Especially if post-op.
Acutely, give reducing regimen of chlordiazepoxide and IV pabrinex to prevent Wernicke’s encephalopathy or Korsakoff syndrome.
Long term, do through substance use history and establish dependence and misuse. Management is biopsychosocial. Refer to specialist for detoxification regime. Can be done as an inpatient.
Bio- For alcohol, can give reducing dose initially and then give disulfiram which makes people sick and/or naltrexone which reduces cravings for it. Naltrexone can be used for opioids too.
Psychosocial- CBT, motivational interviewing therapy, consider social group support such as alcoholics anonymous. Possible family therapy, look at underlying issues of alcohol use such as possible recent lack of employment or difficulties with relationships.
Schizophrenia Investigations and Management
ABCDE Approach. Ensure patient is stable and give oxygen, fluids and analgesia as required. Do full investigations and try to rule out an organic cause for psychotic episode. So consider urine drug screen and possible imaging. Get a collateral history.
Schizophrenia requires a MDT approach in terms of management. Involve psychiatrist, GP, care co-ordinator, psychologist, home treatment team, OT and social worker.
Bio- Antipsychotics can be given. Two are tried (ie risperidone and olanzapine) before clozapine is used. Aripiprazole can be used if side effects of anti-psychotics are not tolerated. ECT can be used in severe catatonic patients.
Psychosocial- CBT, Psychoeducation, Family therapy, Support with getting to work, consider involvement with OT and social workers as patients may require supported accommodation.
Avoid triggers that induce psychotic episodes. So comply with medication and minimise social isolation risks.
Monitoring requirement includes: FBC, U+E, LFT, TFT, Blood glucose, BP and weight to see effects the drugs can have on the patient. Treat and monitor any underlying medical conditions.
Depression Diagnosis and Management
Core Symptoms: Low mood, low energy, loss of pleasure
Other Symptoms: Change in sleep, change in appetite, change in concentration, change in libido, presence of guilt, increased risks of suicide. Do risk assessment.
Management: Rule out any organic causes that may be causing or exacerbating the depression. Symptoms need to also be present for 2 weeks most of the time. Do FBC, U+E, LFT, TFT, CRP, ESR, Bone Profile, B12, Vit D. Do thorough risk assessment for suicide and self harm. Follow up in one week after starting on anti-depressant. Must take for at least 6 months.
Bio- Sertraline can be considered. If under 18, fluoxetine can be used. Sertraline is generally considered safe in breast feeding and in those with other medications. If taking NSAID’s, add lansoprazole.
Psychosocial- CBT, computerised motivational interviewing, group therapy, increase exercise, good sleep hygiene, healthy balanced diet, avoid alcohol and substance misuse and consider help with improving any possible social isolation. Consider self-help books
Acute Manic Episode Management
ABCDE Approach- Ensure patient is stable. Give oxygen, fluids and analgesia as required. If patient is aggressive, try to de-escalate the situation. If that does not work, call for senior help or consider haloperidol dependant on the situation. Take a full history, get a collateral history and examine the patient. Do through risk assessment for suicide and self-harm
Do a urine drug screen and blood tests such as FBC, U+E, LFT, TFT, CRP, ESR, Bone Profile. Ensure an MDT approach with psychiatrist, GP, care co-ordinator, psychologist, OT, social worker as needed.
Management:
Bio- Initially, consider a benzodiazepine as patients may be significantly sleep deprived and having some sleep alone should improve symptoms. Generally, they will need to be put on a mood stabiliser such as Lithium or sodium valproate. In pregnancy, lamotrigine is the drug of choice. If on an anti-depressant, that will likely need to be removed.
Psychosocial- Psychoeducation, CBT, Help with work schemes, family therapy, counselling, lifestyle changes
GAD Diagnosis
Always anxious, no known trigger, episodes last for at least an hour. There is presence of physical symptoms that are medically unexplained. This includes palpitations, abdominal pains, nausea, intense fear of death, chest pains and sweating. The anxiety is present for most days at most times for most things for at least six months with the presence of somatic symptoms. Can co-exist with depression and substance misuse. Do thorough risk assessment for suicide and self-harm. Can be medication induced. Look for organic causes.
Management is
Bio- Not indicated initially. Can consider sertraline drug treatment if psychosocial treatment alone is not working.
Psychosocial- Psychoeducation, CBT, counselling, self-help therapies are all useful. Consider family therapies if appropriate. Social support groups can also be considered as well.
The target is to build a non-judgemental relationship with the patient and work together with the patient on a plan that they are amenable to. Give information appropriate to the level that the patient requires (not too little and not too much). Ensure to answer any questions that they may have and address their ideas, concerns and expectations.
Panic Disorders Diagnosis
There is the presence of triggers. They can have symptoms of palpitations, abdominal pain, nausea, intense fear of death, chest pain and sweating. Must rule out organic causes. Do TFT’s, consider endocrine causes such as a phaeochromocytoma. Patients have somatic symptoms as a result of a trigger and the trigger can be due to agoraphobia, social phobias and specific phobias. Symptoms resolve within an hour in most cases. Can co-exist with depression and substance misuse. Rule out psychosis so patient is not hearing someone tell them that they must do this for example, patient should have insight.
Management:
Bio- Not indicated first line. Maybe consider something like SSRI
Psychosocial- Psychoeducation, low intensity therapies, group therapies, psychotherapies, CBT, graded exposure therapy can all be considered. Family therapy and social support groups as appropriate.
The target is to build a non-judgemental relationship with the patient; answer their questions and give them information that is appropriate to the level that they require (not too much or too little). Work together with the patient on a plan that they are amenable to. Ensure you address their ideas, concerns and expectations.
OCD Diagnosis + Management
Obsessive- Intrusive thoughts that are unpleasant, involuntary and recurrent.
Compulsive- Ritualistic behaviour as a result of the intrusive thoughts. Not doing the ritualistic behaviour is unpleasant and brings about anxiety.
During history, must rule out depression, substance abuse, psychosis and GAD/Panic disorder. Do thorough risk assessment and check for risks of self harm and suicide.
Management
Bio- Not indicated first line. Second line can consider an anti-depressant such as Sertraline
Psychosocial- Psychoeducation, low intensity intervention talking therapies and self help can be initiated. Then move on to CBT, group therapies, look at social support groups, graded exposure therapies and family therapies if appropriate.
Treat any underlying conditions, such as with hands, you want to treat any possible eczema/dry skin or infections.
PTSD Diagnosis and Management
Hypervigilance, re-experiencing flashbacks nightmares, avoidant behaviour, emotional numbing, others see patient as depressed. May also be depressed at the same time. Rule out depression, substance misuse, psychosis and adjustment disorder. Do thorough risk assessment for suicide and self harm. Symptoms must be present for over one month after the traumatic event.
Management:
Bio- Not recommended as first line. But if used, paroxetine or mirtazapine can be used. If there is acute sleep disturbance, hypnotic medication can be considered for short term. But if longer term, mirtazapine can actually help with the sleep anyway.
Psychosocial- Consider EMDR, trauma based CBT, counselling, talking therapies, family therapies, social support groups.
Anorexia Diagnosis
Low body weight
Self-induced weight loss
Disturbed body image
Everything low except: GH, Cortisol, Glands, Glucose tolerance, Cholesterol and Carotinaemia
Bulimia Diagnosis
Low BMI, Binge eating, purging food, distorted body image
Anorexia and Bulimia Management
Fluoxetine, Psychoeducation, CBT, psychotherapy, social support, dietician involvement, support with eating plans, family therapy and support
Puerporal Psychosis Management
ABCDE Approach, ensure patient is stable and baby is safe. Consider admission to mother and baby unit, try informal, if not, may require MHA. Consider drug screen as that may be underlying it. Do thorough risk assessment for both baby and mother. If patient is high risk, they should have a MDT approach and tailored care plan working with the patient on designing it.
Management
Bio- Patient may be need to be put on an antipsychotic, mood stabiliser or both.
Psychosocial- CBT, admission to mother and baby unit, support bonding with mother and baby, family therapy, support for father if around, consider complications of breast feeding (not okay with carbamezapine, lithium and valproate), psychoeducation
Suicide Attempt Risks (Also, talk about paracetamol OD and management)
Planned, hoarding of pills, wills and letters left, attempts made to avoid being found, under the influence of alcohol or drugs, perceived lethality and brutality of method, regret of actions and how they were found and if they’re willing to comply with management.
Assess capacity, take biopsychosocial approach
Treat underlying medical condition too. If suicidal with plan, admit. If without plan, urgent psychiatric referral. Depression screen Look at any substance misuse Formalise a plan with the patient that they agree to and ensure to bring them in ASAP. Long term consider anti-depressants CBT Lifestyle changes
PV Bleed in a Post Menopausal Woman with Delusions of Pregnancy
Take a full history, do MSE
This patient may need to be sectioned under the MHA for assessment and then treatment for whatever the diagnosis is. Probably schizophrenia, do full baseline investigations to rule out any possible organic causes.
Patient needs to be seen by a senior consultant with an MDT to determine suitability for investigating her PV bleed. Can be hyperplasia, malignancy, trauma, atrophic vaginitis, PID, polyps, endometrial atrophy. Cannot be done under Mental Health Act, maybe done under Mental Capacity Act
LD and Contraception
Assess capacity Understand information Retain it Weigh up pros and cons Convey decision back to you If she can do that, you can in theory give it providing there are no other contraindications. Refer to senior for advice
Depressed inpatient not wanting to go back to care home because of abuse
Depression History, risk assessment, safeguarding involvement. Patient not safe to be discharged, involve social services and senior members of staff. Consider police involvement. Ensure documentation is thorough
Lithium Monitoring
FBC, UE, LFT, TFT, INR, Blood pressure, weight, pregnancy test (Ebsteins anomaly)
Nephrotoxic
Diabetes Insipidus
Narrow therapeutic range
Monitor levels of lithium in blood
Symptoms include dry mouth, polyuria, nausea, weight gain, tremor, hypothyroidism
Lamotrigine can caused blurred vision and Stevens Johnson syndrome.
EPSE’s
Dystonia
Tardive dyskinesia
Parkinsonism
Akathisia
Other Side effects for aytpical
Weight gain
clozapine-neutropenia and agranulocytosis
Risk of violence
Previous history of violence (circumstances, frequency, who the victims were, severity, weapons, injuries, were they sober) Antisocial Personality disorder Male Lower SE Background Substance Misuse Mental Illness Childhood Physical Abuse Parental Substance Misuse Criminal record School and employment problems
Mild Cognitive Impairment
Cognitive decline that is serious enough to be noticed by others but it’s not quite dementia yet. Medication can cause MCI and it may be reversible. Must rule out dementia however.
Do thorough screening including bloods and imaging.
Exercise, control CVD risk factors, keep stimulating brain. and regular follow up.
Refer to memory clinic, take a holistic approach, psychosocial support, family support, consider OT involvement so MDT approach
Differentials for OCD
Depression GAD Panic Disorder Schizophrenia Substance Abuse Personality Disorder
Depression often co-exists with OCD
