Psych management

Question 1

Depression

Answer 1

• Assessment of suicide risk and identifying safeguarding concerns.
• Consider any other mental or psychical comorbidity.
• Psychoeducation: sleep hygiene, diet, avoiding smoking and alcohol, exercise.
• Validated depression questionnaire (Beck Depression Inventory, PHQ9, BDI-II or Hospital Anxiety and Depression Scale).
• Arrange further assessment within 2w.
• Give advice about MIND, Depression Alliance, Depression UK, Samaritans.

Persistent subthreshold symptoms or mild-moderate depressive symptoms
1. Low intensity therapy: 8 sessions of self-help CBT, computerised CBT, structured group programme. Accessed through IAPT or referral.
2. Medication is not routinely used but may be considered for patients with a history of moderate or severe depression, subthreshold symptoms present for 2y, mild depression complicating care of a chronic physical condition.
3. Consider antidepressants if low-intensity therapy fails.
• If symptoms are subthreshold, provide information about the natural history of depression and arrange follow-up within 2w.

Persistent moderate-severe depressive symptoms

1. High intensity intervention: 16 sessions over 3m of CBT, interpersonal therapy, behavioural couples therapy.
2. SSRI (sertraline) until 6m after remission. Consider suicide risk and toxicity.
3. Treatments can be combined.
4. Arrange an initial review within 2w and every 4w for the first 3m before considering longer intervals.
5. If symptoms do not respond within 4w, check adherence and side effects and either increase dose or change drug. Switching should be done by cross tapering.

Severe and complex depression

1. High intensity intervention: 16 sessions over 3m of CBT, interpersonal therapy, behavioural couples therapy.
2. SSRI (sertraline) for at least 2y at effective dose. Consider suicide risk and toxicity.
3. Crisis resolution and home treatment team involvement.
4. Crisis plan to identify triggers and strategies.
5. Treatments can be combined.
6. Inpatient care.
7. Consider ECT for acute treatment. Absolutely contraindicated if patient has phaeochromocytoma. Relatively contraindicated if patient has had MI/stroke in past 3m, raised ICP, SOL, arterial hypertension, acute glaucoma, narcotic intolerance, cerebral aneurysm/angioma.
8. Arrange an initial review within 1w and frequently thereafter until the risk is not clinically important.
9. If symptoms do not respond within 4w, check adherence and side effects and either increase dose or change drug. Switching should be done by cross tapering.

Question 2

Mania and bipolar affective disorder

Answer 2

Management
1. Refer all suspected BPAD (including hypomania) to CMHT to confirm, treat and establish a care plan. Consider urgent referral if person presents with mania, severe depression or risk to self/others.
• While awaiting assessment, consider tapering antidepressants on specialist advice if mania develops.
• Advise person to stop driving during acute illness.
2. If admission is required, persuade them to go voluntarily. Compulsory admission may be used if person requires assessment/treatment in hospital and needs to be admitted in interests of themselves or others.
3. For the mania: in secondary care, offer therapeutic trial of antipsychotic PO (haloperidol, olanzapine, quetiapine, risperidone). If one is ineffective, use a second.
4. For the mania: If a second is ineffective, add lithium or sodium valproate. Avoid sodium valproate in pre-menopausal women. If already taking lithium, check dose and compliance and consider adding an antipsychotic.
5. For the depression: offer fluoxetine with olanzapine/quetiapine first then lamotrigine alone as second-line. Quetiapine alone or olanzapine alone may be considered. Monitor closely for mania and withdraw cautiously if symptom-free for a sustained period.
6. Secondary care team should discuss the long-term plan. Patient can continue treatment or start long-term treatment with lithium +/- valproate. Valproate or olanzapine alone may be considered.
7. High-intensity CBT for depression or psychodynamic psychotherapy for BPAD may be offered.
8. A care plan should include social and emotional recovery goals, assessment of mental state, a crisis plan, medication plan, an advanced statement for future treatment, a statement of financial affairs, care of pets or at-risk relatives and key contacts in case of emergency.
9. Monitor patient for at least 12m or until condition stabilised. Re-refer to secondary care if function declines, adherence is poor, substance misuse is suspected or a woman is planning to conceive.

• Benzodiazepines may be useful in the acute treatment of manic episodes.

Question 3

Psychosis and schizophrenia

Answer 3

Management

1. For first episode of psychosis, offer assessment in primary care including risk to self (self-harm, suicidal ideation and attempts, substance abuse, accidental or non-accidental injury), potential for neglect of dependent persons, risk to public, risk from others.
2. Arrange same day assessment by Early Intervention in Psychosis team. If unavailable, refer to a crisis resolution and home treatment team. Do not start anti-psychotics.
3. Consider use of sections 2 or 4 of MHA for admission.
4. Offer family therapy (10 sessions over 1y), individual CBT (16 sessions), arts therapies (for negative symptoms). Treat any co-existing anxiety, depression, substance misuse or emergency personality disorder.
5. Offer a trial of oral antipsychotic in conjunction. Titrate the dose up to optimum dosage over 4-6w.
6. A care plan should include social and emotional recovery goals, assessment of mental state, a crisis plan, medication plan, an advanced statement for future treatment, a statement of financial affairs, care of pets or at-risk relatives and key contacts in case of emergency.
7. Monitor patient for at least 12m or until condition stabilised in secondary care. Then responsibility may be transferred to primary care. Assess symptom control, deterioration at work/school/socially, anxiety/depression, adherence and side effects, alcohol and substance misuse. Measure weight (weekly for 6w, then 12w, then annually), waist circumference (annually), HR and BP (12w, 1y then annually) and fasting glucose, HbA1c, lipids, U&E, FBC, LFT, prolactin (12w, 1y then annually). Perform an ECG if person is taking haloperidol, pimozide or sertindole.
8. People that do not have a clear diagnosis of a psychotic disorder should be monitored in secondary care for up to 3y.
9. Give advice about MIND, British Association for Supported Employment.
10. Re-refer to secondary care if function declines, adherence is poor, side effects are intolerance, substance abuse is suspected, a woman is planning to conceive or there is potential risk to the person or others.
11. When stopping, withdraw gradually and monitor regularly for relapse signs. Continue monitoring for 2y.

• Inform patient that they must not drive during an acute episode and must inform the DVLA.

Question 4

Postnatal depression

Answer 4

Management
1. Consider referral for high-intensity psychological intervention. Assess within 2w of referral.
2. Consider medication: TCA (imipramine, nortriptyline), SSRI (paroxetine, sertraline) or SNRI. Monitor baby for sedation, poor feeding and behavioural effects. Do not prescribe valproate and avoid lithium where possible.
3. Consider hospital admission for severe depression with suicidal or infanticidal ideation. A Mother and Baby Unit it ideal for this.
• For subthreshold symptoms, consider referral for facilitated self-help. Consider medical treatment if there is a previous history of severe depression.

Question 5

Puerperal psychosis

Answer 5

Management

1. Encourage women to breastfeed unless they are taking carbamazepine, clozapine or lithium. If she chooses to breastfeed on these medications, advise the woman to give her baby a formula feed at night after taking medication and breastfeed in the daytime.
2. Consider the use of TCAs, SSRIs or SNRIs.
3. Assess and discuss the nature of the mother-baby relationship.
4. Arrange admission to the Mother and Baby Unit.
5. Benzodiazepines may be used in the short term for sedation.
6. ECT may be used in severe psychosis.
7. Arrange for midwives to visit daily until 14-28w postpartum.
8. When stopping, gradually reduce antipsychotic.

Question 6

Autism

Answer 6

Management

1. Use play-based strategies with parents and teachers to increase attention and communication. Adjust the environment as needed.
2. Treat physical or co-existing mental health problems.
3. Use psychosocial interventions as first line: applied behavioural analysis (a reward system for children <3y), Early Start Denver model, More Than Words programme (for children <6 with social and communication difficulties).
4. Develop sleep plan for sleep hygiene. Refer to paediatric sleep specialist if sleep is disturbed. Offer respite breaks for carers.
5. Use pharmacological interventions second-line: consider antipsychotics if severe behavioural challenges starting at low dose for 6w. Stop if no response.
6. Refer parents to the National Autistic society and National Autistic Society schools.

Question 7

Attention deficit-hyperactivity disorder

Answer 7

Management
• Behavioural management with clear expectations and rewards.
• Use drug holidays to limit growth retardation.

Children <5y

1. Refer child to paediatric psychiatrist.
2. Offer ADHD-focused group parent-training programmes without awaiting a formal diagnosis. If ineffective, obtain advice from a specialist ADHD service.
3. Do not start medication without a second specialist opinion.

Children >5y

4. Offer children >5y ADHD-focused group parent-training programmes. Consider individual programmes if symptoms of conduct disorder or oppositional defiance disorder.
5. Offer medication if ADHD symptoms are causing persistent significant impairment in at least one domain after environmental changes have been implemented and reviewed.
6. Carry out baseline assessment of past medical history, drug history, height, weight, HR, BP and cardiovascular exam.
7. Use methylphenidate first line for 6w. Titrate slowly up to adequate dose.
8. Use lisdexamfetamine second line for 6w if this is ineffective.
9. Use dexamfetamine is the long-acting effects of lisdexamfetamine are not tolerated.
10. Use non-stimulant noradrenaline reuptake inhibitors atomoxetine or guanfacine.
11. Monitor height, HR and BP every 6m, monitor weight every 3m if <10 and every 6m thereafter, plot growth. Do not perform ECG routinely. Stop medication if it precipitates an acute psychotic or manic episode.
12. Consider a course of CBT for young people who have benefited from medication but whose symptoms still cause significant impairment.

Adults

1. Structured supportive psychological intervention for ADHD, possibly with CBT.
2. Methylfenidate or lisdexamfetamine.
3. Atomoxetine.

Question 8

Alcohol misuse

Answer 8

Management

1. Motivational interviewing and structured brief to empower the person to change.
2. If homeless, offer residential rehabilitation for a maximum of 3m. Uncomplicated dependency may be managed in the community but a history of withdrawal fits, comorbid medical or psychiatric illness or lack of support necessitates inpatient detoxification.
3. Urgently admit patients with signs of delirium tremens or Wernicke’s encephalopathy. Offer chlordiazepoxide for detoxification using a fixed-dosage reducing regimen over 5-7d. Consider the use of lorazepam instead of chlordiazepoxide for patients in acute withdrawal. Use lorazepam in patients with hepatic impairment.
4. Offer prophylactic PO pabrinex to patients with mild dependence. Offer IV or IM thiamine for 5d to patients with signs of delirium tremens or Wernicke’s encephalopathy.
5. Refer patients with co-morbid mental health conditions to mental health services.
6. Consider offering CBT, group therapy or social network therapy. Children should receive family therapy for 3m.
7. Offer acomprosate 2000mg OD and disulfiram 200mg OD to promote abstinence following detoxification for 6m. Consider the use of naltrexone starting at 25mg OD aiming for a maintenance dose of 50mg OD.
8. Offer supported independent living for those with Wernicke-Korsakoff syndrome.
9. Advise patients that they should notify the DVLA and surrender their license for a period.

Question 9

Opiate misuse

Answer 9

Management

1. Provide information about self-help groups.
2. Offer opioid detoxification and withdrawal treatment unless the patient has a concurrent medical problem requiring urgent treatment, is in police custody or is pregnant.
3. Appoint a key worker to support the person. Use PO methadone or sublingual buprenorphine for detoxification. For mild dependence or patients keen to detoxify over a shorter period, consider lofexidine. Inpatient admission for patients with significant comorbidities is for 4w, community detoxification takes 12w.
4. Promote abstinence, prevent relapse and reduce the risk of HIV and HCV transmission. Consider naltrexone to prevent relapse.
5. Refer to Drugs and Alcohol Service for 6m and offer CBT to prevent relapse.
6. Consider contingency management: offer incentives for each negative drug test and reduce frequency of screening over time.

Question 10

Anorexia nervosa

Answer 10

Management
1. Psychoeducate the person on nutrition and health. Offer dietary counselling and encourage multivitamin and mineral supplement.
2. Treat comorbid psychiatric illness.
3. Set realistic weekly weight gain targets (0.5-1kg weekly) and set an eating plan.
4. Offer psychotherapy such as motivational interviewing, FT-AN (20 sessions over 1y), IPT, MANTRA (20 sessions for adults) or CBT-AN (4o sessions over 4w).
5. Consider medical treatment if the person has physical complications, is rapidly losing weight or has BMI <13.5. Consider inpatient treatment if BMI <13, there are serious physical complications or a high suicide risk. The MHA may be necessary for compulsory feeding.
6. Do not offer medication as sole treatment for AN.
7. Monitor person and involve family in helping them achieve a healthy body weight.
8. Alert the patient’s record to highlight the potential risks of adverse drug effects.
Mild anorexia nervosa

If BMI >17 with no additional comorbidity, monitor and support for 8w, give advice about BEAT and refer routinely to community Eating Disorder Service if conservative measures are ineffective.

Moderate anorexia nervosa
If BMI 15-17 but without evidence of system failure, urgently refer to EDS.

Severe anorexia nervosa
If BMI <15 with rapid weight loss, evidence of system failure (purpuric rash, cold peripheries, hypotension <80/50, bradycardia <40bpm, electrolyte imbalance or proximal myopathy) or high suicide risk, consider inpatient admission. Avoid rapid increases in daily caloric intake and closely monitor inpatients for refeeding syndrome.

Question 11

Bulimia nervosa

Answer 11

Management

1. Psychoeducate the person on nutrition and health. Offer dietary counselling and encourage multivitamin and mineral supplement.
2. Treat comorbid psychiatric illness.
3. Encourage those who are vomiting to have regular dental and medical reviews, avoid brushing teeth immediately after vomiting, rinse with non-acidic mouthwash after vomiting and avoid highly acidic food and drinks.
4. Advise them that laxatives and diuretics do not reduce calorie absorption and do not help with weight loss — laxative or diuretic use should be gradually reduced and stopped.
5. Admit those with severe compromise to a medical inpatient or day patient service for stabilisation and refeeding if these cannot be done in an outpatient setting.
6. Alert the patient’s record to highlight the potential risks of adverse drug effects.

Mild bulimia nervosa
• Recommend BN-focused self-help and BEAT, monitor and support for 3m. Refer routinely to EDS if ineffective. Consider individual CBT-ED for adults. Offer FT-BN for children and, if ineffective, offer CBT-ED.

Moderate bulimia nervosa
• Monitor and support for 8w, recommend BN-focused self-help, consider use of SSRI (fluoxetine) for impulse control. Refer routinely to EDS if ineffective.

Severe bulimia nervosa
• Urgent referral to EDS.

Question 12

Binge eating disorder

Answer 12

Management

1. Offer BED-focused self-help.
2. If unacceptable or ineffective after 4w, consider group CBT-ED.
3. If unacceptable or ineffective, consider individual CBT-ED.

Question 13

Delirium

Answer 13

Management

1. Identify underlying cause and treat/stop it. Have a low threshold for diagnosis in patients >65y, cognitive impairment, current hip fracture or with severe illness.
2. Effectively communicate and orientate the person with family’s help eg lighting, clocks, hearing aids and glasses, minimise change, allow supervised wandering, facilitate visitation.
3. If patients are a risk to themselves or others, first use verbal and non-verbal de-escalation techniques. Distress may be less evident in hypoactive delirium.
4. If ineffective, use the lowest clinically effective dose of haloperidol and titrate cautiously. Discontinue haloperidol after 1w. Do not use haloperidol in PD or DLB.
5. Consider the use of a small nocturnal dose of benzodiazepine to correct the sleep-wake cycle.
6. If delirium does not resolve, re-evaluate for underlying causes and assess for dementia.

Question 14

Generalised anxiety disorder

Answer 14

Management

1. Follow a stepped care model. Identify and communicate the diagnosis. Consider GAD in people presenting with anxiety and people who attend primary care frequently with a chronic health problem.
2. Have a high suspicion of GAD in patients with somatic symptoms or patients that are repeatedly worrying about a wide range of issues.
3. Assess severity and the presence of comorbid depression, substance misuse, physical health conditions and a history of mental health conditions. Monitor the person and provide education about triggers and coping techniques.
4. If diagnosed, offer low-intensity therapies such as individual non-facilitated self-help and psychoeducational groups based on CBT.

Marked functional impairment
• If unimproved or with marked functional impairment, offer a choice of high-intensity individual therapy such as CBT or applied relaxation (12-15 weekly sessions) or drug treatment with an SSRI (sertraline). If ineffective, offer an alternative SSRI or SNRI and advise the patient of the initial worsening of anxiety. Monitor suicide risk for the first month. If SSRI/SNRI is not tolerated, offer pregabalin. Monitor every 2-4w for the first 3m then every 3m thereafter. If there is no response to psychology therapy, switch to medication and vice versa. If there is a partial response with medication, add a psychological intervention.
• Do not offer benzodiazepines except as a short-term measure (2-4w) during crises until long-term medications take effect.

Complex and treatment-refractory GAD
• For complex, treatment-refractory GAD with marked function impairment or high risk of self-harm, refer for specialist assessment. Combination psychological and drug treatments should be commenced by the specialist.

Anxiety in children

1. Psychoeducation regarding lifestyle changes and managing stressors.
2. Psychological therapy: CBT, counselling with family involvement.
3. Consider fluoxetine or sertraline (for OCD) alongside psychological therapy.

Question 15

Social anxiety disorder

Answer 15

Management

1. Individual CBT based on Clark and Wells model or Heimberg model (14 sessions). Do not offer group CBT. If declined, offer CBT-based self-help.
2. Offer SSRI (sertraline or escitalopram).
3. If partially responsive, offer individual CBT in addition to SSRI. If ineffective after 12w, offer alternative SSRI or SNRI (venlafaxine).
4. If ineffective, offer MAOi (phenylzine).
5. For patients who decline all the above, consider short-term psychodynamic therapy of 30 sessions over 8m.

Children
1. Individual or group CBT (12 sessions). Do not offer medication without specialist advice.

Question 16

Panic disorder

Answer 16

Management
1. Follow a stepped care model. Recognise and communicate the diagnosis. Educate about the benefits of exercise.

Mild-moderate
• Individual non-facilitated or facilitated self-help
• Offer support groups with meetings.
• Follow up every 4-8w.

Moderate-severe
• Offer CBT (1 session weekly for 3m). If panic disorder is longstanding or CBT ineffective, offer SSRI. Review in 2w, then 4, 6, 12w and decide on effectiveness. Monitor suicide risk for the first month for people <30 and review in 1w. If continued, monitor every 3m.
• If ineffective after 12w, offer imipramine or clomipramine.
• If after two interventions the person still has significant symptoms, refer to mental health services.
• Undertake a holistic assessment of previous treatments, comorbid depression, substance misuse, physical health conditions. Assess functioning and social networks and formulate a shared care plan with specialist.

Question 17

Obsessive compulsive disorder

Answer 17

Management
1. Follow a stepped care model. Identify and communicate the diagnosis. Educate about the benefits of exercise.

Mild functional impairment
• Low-intensity structured self-help or group CBT (including exposure and response prevention) for 10 sessions.

Moderate functional impairment

1. If above ineffective or unacceptable, offer high-intensity CBT including ERP or an SSRI (sertraline, fluoxetine, escitalopram). If <30, assess in 1w. Assess all others in 2w then every 2-4w for 3m then every 3m thereafter. If effective continue for at least 1y. Monitor suicide risk for the first month.
2. Consider clomipramine as an alternative or if previously effective or if SSRI is ineffective after 12w. Monitor for psychiatric symptoms. If effective continue for at least 1y.

Severe functional impairment

1. Refer to mental health team for assessment.
2. While awaiting assessment consider combined SSRI/clomipramine and CBT with ERP. Monitor suicide risk for the first month.

Children

1. Offer guided self-help CBT for mild OCD.
2. Offer individual or group CBT (and ERP) for moderate CBT or if self-help is ineffective.
3. Consider SSRI (fluoxetine). Clomipramine may be used if SSRI is ineffective.

Question 18

Post-traumatic stress disorder

Answer 18

Management

1. Monitor and provide social support for people with subthreshold symptoms of PTSD within 1m of a traumatic event. This includes cognitive processing therapy, cognitive therapy for PTSD, narrative exposure therapy and prolonged exposure therapy.
2. Offer all patients with symptoms >1m trauma-focused CBT (12 sessions).
3. Offer all adults with a diagnosis of PTSD or clinically important symptoms presenting more than 3m after non-combat related trauma eye movement desensitisation and reprocessing. Consider EMDR for adults with non-combat related trauma presenting after 1-3m. Consider trauma-focused computerised CBT as an alternative as long as they do not have severe symptoms and are not at risk of harm to themselves or others.
4. Consider drug treatments if preferred. Offer SSRI (sertraline) or SNRI (venlafaxine).
5. Consider antipsychotics such as risperidone with psychological therapy if symptoms are disabling and person has not responded to other drugs or psychological treatments.
6. If comorbid depression is present, treat PTSD first as this will usually relieve the depression unless the depressive symptoms are severe enough to make PTSD treatment difficult.

Post-traumatic stress disorder in children

1. Monitor and provide individual trauma-focused CBT within 1m of a traumatic event for children with a diagnosis of PTSD or clinically important symptoms. Consider group CBT if a large-scale shared trauma.
2. Consider individual CBT for people aged 5-6y presenting >1m after event and people aged 7-17y presenting 1-3m after event. Offer individual CBT for people aged 7-17y presenting >3m after event.
3. Consider EMDR for people aged 7-17y if CBT is ineffective.

Question 19

Alzheimer’s dementia

Answer 19

Management

1. Refer to community Old Age service. Ensure access to tests for CJD if rapidly progressive.
2. If diagnosed, investigate dementia subtype using validated criteria (International Consensus for DLB, International FTD, NINDS-AIREN for VD, NIA for AD, Movement Disorders Society for PD, International for CJD).
3. Offer CT or MRI to rule out reversible causes and assist with subtype diagnosis. Do not rule out AD based on these.
4. Consider FDG-PET or perfusion SPECT if AD is suspected. Consider CSF assessment for tau and/or beta-amyloid if it will aid diagnosis and alter management.
5. Offer group CST, reminiscence therapy, multisensory therapy or validation therapy.
6. Offer acetylcholinesterase inhibitors (donepezil, galantamine, rivastigmine) in secondary care for mild to moderate AD. Perform a baseline ECG before prescribing donepezil.
7. Offer memantine in moderate AD where acetylcholinesterase inhibitors are contraindicated. If already on acetylcholinesterase inhibitors, add memantine in severe disease (the primary care prescriber may do this without specialist advice).
8. Only offer antipsychotics if patients are at risk of harm to themselves or others, are agitated or experience hallucinations or delusions that cause them severe distress. Use the lowest clinically effective dose of haloperidol and titrate cautiously. Risperidone may be used for up to 6w in patients with persistent aggression with moderate-severe AD unresponsive to non-pharmacological interventions. Do not offer valproate to manage agitation in dementia unless indicated for another condition.
9. Treat conditions that may worsen cognition and discontinue medications that may worsen cognition such as anticholinergic drugs.
10. Offer a carer’s assessment and develop a coordinated care plan.
11. Recommend adaptations such as carrying ID, using dossett boxes, changing the gas stove to electric and using assistive technology. Advise carers to enable reality orientation.
12. Advise patient of the importance of an Advanced Directive or appointed Lasting Power of Attorney.

• Offer points 9-12 to all patients with dementia of any subtype.

Question 20

Vascular dementia

Answer 20

Management

Atherosclerotic ischaemic disease

1. Offer lifestyle modification advice and antiplatelet therapy.
2. Offer endarterectomy for carotid stenosis >70%.
3. Therapeutically optimise blood pressure, LDL cholesterol and diabetes mellitus control.
4. Offer group CST, reminiscence therapy, multisensory therapy or validation therapy.

Embolic disease

1. Offer lifestyle modification advice and anticoagulation or antiplatelet therapy.
2. Therapeutically optimise blood pressure, LDL cholesterol and diabetes mellitus control.
3. Offer group CST, reminiscence therapy, multisensory therapy or validation therapy.

• Only consider acetylcholinesterase inhibitors or memantine in patients with comorbid AD, PD or DLB.

Question 21

Dementia with lewy bodies

Answer 21

Management

1. Treat acute behavioural disturbance with short-acting benzodiazepines (lorazepam).
2. For ongoing treatment offer acetylcholinesterase inhibitors. Use donepezil or rivastigmine for mild-moderate DLB. If not tolerated, use galantamine in mild-moderate DLB and memantine in severe DLB.
3. Consider donepezil or rivastigmine for people with severe DLB.
4. An SSRI may be added if there is comorbid depression. Clonazepam may be added if there is REM sleep disorder. Levodopa or cabidopa may be added if motor symptoms are present.
5. Offer group CST, reminiscence therapy, multisensory therapy or validation therapy.

Question 22

Frontotemporal dementia

Answer 22

Management

1. Do not offer acetylcholinesterase inhibitors or memantine.
2. Offer supportive care with benzodiazepines used short-term for acute restlessness/irritability.

Question 23

Parkinson’s disease

Answer 23

Management

1. Refer to community Old Age service.
2. Offer levodopa for motor symptoms. Consider a choice of dopamine agonists (bromocriptine, cabergoline), levodopa or MAO-B inhibitors for people in the early stages of PD without significant motor symptoms.
3. If the patient develops dyskinesia with levodopa, offer a choice of non-ergot derived dopamine agonists (ropinerol), MAO-B inhibitors or COMT inhibitors as an adjunct to levodopa. Only consider ergot-derived dopamine agonist as an adjunct to levodopa is a non-ergot derived dopamine agonist is ineffective.
4. If impulse control disorder develops, offer specialist CBT.
5. Offer acetylcholinesterase inhibitors for severe PD. If ineffective, consider memantine. Consider acetylcholinesterase inhibitors in mild-moderate PD.
6. Advise the patient to avoid driving if experiencing sleepiness and consider modafinil (not for use in pregnant women). Review every 12m.
7. Offer clonazepam or melatonin to treat REM sleep behavioural disorders after excluded pharmacological causes.
8. Offer levodopa or dopamine agonists for nocturnal akinesia. If ineffective, consider rotigotine.
9. Do not treat psychotic symptoms unless they cause distress. Consider low-dose quetiapine to treat psychotic symptoms without cognitive impairment. If ineffective, offer low-dose clozapine. Do not use olanzapine.
10. For drooling saliva, refer to SALT. Consider subsequent use of glycopyrronium bromide and then botulinum toxin A.

Question 24

Borderline personality disorder

Answer 24

Management

1. Refer to community mental health services for assessment. If <18y refer to CAMHS.
2. If a person with an established diagnosis presents in a crisis, assess the current level of risk and ask about previous episodes and effective management. Help them manage anxiety by enhancing coping skills and identify modifiable factors that may help. Offer a follow-up appointment.
3. Do not use brief psychological interventions. Use an integrated approach on a twice-weekly basis. Consider DBT for women with BPD for whom reducing recurrent self-harm is a priority.
4. Consider short-term use of sedative medication as part of overall treatment in a crisis. Consider the use of antipsychotics to reduce impulsivity and aggression, antidepressants to reduce anxiety, mood stabilisers for labile affect.
5. Treat comorbid problems.

Question 25

Antisocial personality disorder

Answer 25

Management

1. Identify young people at risk of APD, in particular young children with conduct disorder.
2. Assess antisocial behaviours, coping strategies, comorbid mental health conditions, domestic violence and abuse. Measure severity using PCL-R or PCL-SV. Use HCR-20 to develop a risk management strategy.
3. Consider group CBT and behavioural interventions. Offer interventions specifically aimed at young offenders.
4. Do not routinely use pharmacological interventions.
5. Use inpatient admission only for crisis management or treatment of comorbid conditions.

Question 26

Rapid tranquilisation protocol

Answer 26

Adults of all ages without dementia

Neuroleptic naïve or unknown

1. PO lorazepam. Allow 1h for response.
2. If ineffective, give IM lorazepam and allow 30m for response. Repeat if partial response. If no response, give IM olanzapine 1h later OR IM haloperidol + IM promethazine/lorazepam (confirm no cardiac disease by ECG).

Confirmed antipsychotic use
1. PO lorazepam OR PO olanzapine OR PO haloperidol + promethazine. Allow 1h for response.
2. No cardiac disease: IM haloperidol + promethazine/lorazepam. Repeat if partial response. If ineffective, IM lorazepam OR IM olanzapine.
Cardiac disease suspected: IM lorazepam and wait 30m OR IM olanzapine (repeat if partial response). If ineffective, IM lorazepam OR IM olanzapine.

Adults with dementia

Neuroleptic naïve or unknown

1. PO lorazepam or PO promethazine. Allow 1h for response.
2. If ineffective, give IM lorazepam and allow 30m for response. Repeat if partial response.

Confirmed antipsychotic use
1. PO lorazepam OR PO haloperidol + promethazine. Allow 1h for response.
2. No cardiac disease: IM haloperidol + promethazine and wait 30m. Repeat if partial response. If no response, IM lorazepam.
Cardiac disease suspected: IM lorazepam and wait 30m. Repeat if partial response.

Children

Neuroleptic naïve or unknown

1. PO lorazepam or PO promethazine. Allow 1h for response.
2. If ineffective, give IM lorazepam and allow 30m for response. Repeat if partial response. If no response, allow further 30m then give IM promethazine.

Confirmed antipsychotic use

1. PO olanzapine +/- PO lorazepam OR PO promethazine. Allow 1h for response.
2. If ineffective, give IM lorazepam and allow 30m for response. Repeat if partial response. If no response, allow further 30m then give IM olanzapine OR IM promethazine.

People with a learning disability

Neuroleptic naïve or unknown

1. PO lorazepam. Allow 1h for response.
2. If ineffective, give IM lorazepam and allow 30m for response. Repeat if partial response. If no response, give IM olanzapine 1h later OR IM haloperidol + IM promethazine/lorazepam (confirm no cardiac disease by ECG).

Confirmed antipsychotic use
1. PO olanzapine OR PO lorazepam +/- haloperidol. Allow 1h for response.
2. No cardiac disease: IM haloperidol + promethazine. Repeat if partial response. If ineffective, IM lorazepam OR IM olanzapine.
Cardiac disease suspected: IM lorazepam and wait 30m (repeat if partial response) OR IM olanzapine. Repeat if partial response. If ineffective, IM lorazepam OR IM olanzapine.