Psych

Question 1

Schizophrenia Mx

Answer 1

DDx: Organic - drugs, alcohol.
dementia, delirium. temp lobe epilepsy, steroids/dopamine agonists SEs.
Brain tumour, stroke, HIV. wilsons, porphyria, neurosyphillis.
Acute transient psychotic episode.
Mood disorder
schizoaffective disorder
Delusional disorder.(no hallucinations).

Ix: Physical exam
Bloods: FBC, TFT, U+E, LFT, CRP, fasting glucose, HIV, syphilius, Lipids. 
MSU, Urine drug screen, 
CT scan, EEG. 
Symptom rating scales.
OT
Social work asessment
collateral hx. 

1. Refer to Early intervention in Psychosis service
2. If urgent - Crisis resolution team and Home treatment team.

Bio: Oral atypical antipsychotic
Olanzapine/risperidone/amisulpride/quetiapine.
alternative: Chlorpromazine (typical)
- Get weight, plot weekly for 6w,then12w,then annually
-pulse and bp
-Fasting blood glucose, HbA1c, lipids, prolactin
-assess movement disorders
-assess nutrition/activity.
ECG

Psycho: CBT (16 sessions) + Family therapy (10 sessions) work on high expressed emotion) Concordance therapy - pt to consider pros and cons of mx.

Social: Maybe admit for observation, treatment or refuge.
Psychoeducation - reduce relapse
-eduation, training, employment, skills, housing, social activities, personal skills.

Other:
Physical health- stop smoking (bupropion/varenicline)
Arts therapy
Carers support

Monitoring.

Question 2

Depression Dx

Answer 2

At least one of (low mood, anhedonia) for 2 weeks most days, most of the time.

Associated symptoms

• sleep disturbance
• appetite loss/gain
• fatigue
• agitation/slow movements
• poor concentration/indecisiveness
• worthlessness/excess guilt
• suicidal thoughts/acts.

Subthreshold:
2-5 symptoms
Mild: <5symptoms -> minor functional impairment
Moderate: between,
severe:most symptoms -> marked functional impairment

Glucose, u+e, cr, LFTs, TFTs, Ca
FBC, ESR.

Question 3

Depression mx

Answer 3

Mild/subthreshold - active monitoring.
-info, 2w FU

Mild/Mod:
Sleep hygiene
2 week F/U
Individual Self help 6-8 sessions for 9-12weeks.
Computerised CBT
Structured group physical activity programme
Group CBT

Mod-severe
1. SSRI
rv in 2w <30 -> 1w. 
review tx response in 3-4w. 
\+ 
High intensity individual CBT/Interpersonal therapy. 

Complex/severe
Crisis resolution team 
Home treatment team 
Crisis plan 
Inpt tx if self harm/suicide risk/self neglect. 
ECT -  when rapid response needed. 

persistent subthreshold -> IAPT

support: mind.co.uk
Samaritans.

Question 4

SSRI side effects

Answer 4

• Bleeding
  -drug interactions
  -Discontinuation symptoms
  -death OD (venlafaxine)
  Overdose (TCAs)
  -Stopping due to side effects
  -BP monitoring - venlafaxine
  -Postural Hypotension
  -arrythmias - TCA

Question 5

Mania mx

Answer 5

Consider admission/section if at risk.
otherwise routine/urgent CMHT referral.

Tx free:

1. Stop antidepressants, drugs of abuse, steroids, dopamine agonists.
2. Monitor food/fluid intake
3. Give Antipsychotic + benzo

already on tx:

• optimise meds
• check compliance
• add antipsychotic
• benzos

ECT if unresponsive

Psychosocial:
Education 
Treatment and side effects
self help
support
CBT
Cognitive interpersonal therapy
ne
crisis resolution team ,
samaritans.

Question 6

Long term mx BPAD

Answer 6

Hypomania -> routine CMHT referraal
Mania/severe depression -> urgent to CMHT.
consider admission if at risk.

1. Mood stabiliser
   -Lithium - check levels in 1 week. monitor every 3 months.
   -monitor U+Es and TFTs every 6m
   -do preg test, ecg >50/fhx heart disease
   Valproate if preg.

Mx of depression in BPAD:
-Fluoxetine + olanzapine/quetiapine.

CBT - relapse prevention
Psychodynamic psychotherapy

Family support/therapy
address comorbidities.

Crisis resolution team
samaritans

Question 7

Side effects of lithium

Answer 7

GI disturbance
Polyuria/polydipsia
hypothyroid
tremor
weight gain
acne/psoriasis
neurotoxic coma/renal failure.

Triggers: salt balance changes - D+V, Dehydration

Mx: Check lithium level, (>1.2) stop dose.
Transfer for rehydration, osmotic diuresis.
severe oD-> gastric lavage/dialysis.

Question 8

Suicide

Answer 8

high risk; admit to psych ward
Lower risk: home - crisis plan. (who tell/how get help)

Physical tx of overdose.

Follow up interventions 1 week.
Tx underlying depression.
CBT, DBT, mentalisation, trasferance focused psychotherapy.
coping strategies - distraction/mood raising activities, avoid self harm

Question 9

Anorexia Nervosa

Answer 9

Mild: >17 BMI
monitor/advice/support 8 weeks. BEAT support.
Mod:15-17. Routine CEDS refferal
Severe<15, rapid wt loss, system failure- > URgent CEDS.

1. Psychoeducation- advice.
2. Treat comorbid psych illness.
3. Weight restoration - 0.5 -1kg a week.
   set eating plan.
4. Psychotherapies.
   - CBT ED - address control, self esteem, perfectionism. 40 sessions.
   - Specialist supportive clinical mx (SSCM) - 20 sessions.
   - Maudsley anorexia treatment for adults - MANTRA - 20 sessions - understand cause.

2nd lie - Eating disorder focussed focal psychodynamic therapy

Motivational interviewing
Interpersonal therapy

Children
1. Family therapy
2.CBT
2. Medical tx
3. inpatient - BMI <13/ extreme rapid wt loss
high suicide risk.

Question 10

Refeeding syndrome

Answer 10

Intracellular shift of ions due to switching to cho metabolism.

• Low phosphate, magnesium, potassium, thiamine, salt and water retention.
• Fatigue, weaknes, confusion, high bP, seizures, arrythmias, HF

Question 11

Schizo mx

Answer 11

Psycho- CBT
Family therapy
Concordance therapy

Social management:
Psychoeducation
?admission

Support for carers
Physical health support
Monitoring - response to tx, SEs.

Biological management: Atypical antipsychotic
Typical antipsychotic
clozapine -weekly blood tests

Question 12

Depression:

Answer 12

Explain sx may get worse initially
PHq9

Social - mild refer - Active monitoring. 2 week
Sleep hygiene
Mind.co.uk
samaritans

Psycho: Individual Self help
Computerised CBT
Group physical activity programme
Group CBT

Modsev:
Individual CBT
Interpersonal therapy

SSRI: bleeding, discontinuation. overdose, interactions
BP mx.

Complex severer: crisis resolution/HTT
ECT

Question 13

Self harm/suicide

Answer 13

high risk (planning, wills, isolation, prevent discovery, intent, violent, ongoing wish to die): Admit
lower risk
-> crisis plan. who they will tell, how they will get elp?

1 week FU
CMHT, OP, GP, counseller
tx depression/psychosis
CBT - dialectical behavioural therapy. 
Mentalisation
Transference focused psychotherapy.

COping strategies.

Question 14

Mania

Answer 14

antipsychotic and benzo

Long term
mood stabilisers
give SSRIs with antipsychotic/mood stabiliser

CBT
Psychodynamic psychotherapy.
family support and therapy

CMHT refferral - mania - urgent
hypomania - routine
crisis resoluton team/samaritans.

Question 15

Alcohol

Answer 15

Ix: bloods, urine drugs, blood alcohol, audit, ciwa, apq

Carers assessment
family meetings
abstincence
motivational interview
ALcoholics anonymous, 
SMART recovery 
change grow live

CBT, behavioural couples therapy.
Acamrosate
naltrexone

Pabrinex
Chlordiaepixode

assited withdrawala