Psych Management

Question 1

Psychological therapies (for psych)?

Answer 1

Primary care:
Counselling
Psychoeducation (group/individual)
CBT
DBT - dialectical behavioural therapy (for personality disorders)

Secondary care:
Group therapy
Family therapy 
Psychoanalytic psychotherapy
Refferal to CMHT

Question 2

Examples for Bio-Psych-Social managment approach in psych?

Answer 2

Bio - DRUGS
Psych - CBT, Psychoeducation, Counselling, Group therapy, DBT (for personality disorders)
Social - Support (family/carer), Work/Education, Support with engagement/benefits

Referral to CMHT - community mental health team

Question 3

Hypnotics? (3 classes)

Answer 3

Benzos - Lorazepam, diazepam, midazolam, chlordiazepoxide

Z-Drugs - zopiclone, zolpidem

Melatonin - (over 55s short term only)

Withdrawal effects - resp depression, seizures, irritability

Question 4

Antidepressants? (5 classes) SEs for each pls

Answer 4

SSRIs - sertralline, fluoxetine, citalopram, paroxetine

SNRIs - venlafaxine, duoloxetine

TCAs - amytriptilline, clomipramine

MAOIs - phenalazine

NaSSA (tetracyclic / noradrenergic + specific serotonin antidepressant)
-Mirtazepine

SEs
SS/SNRIs - suicidility, sexual dysfunction, serotonin syndrome

NaSSA - weight gain/increased appetite

TCAs - sedation, cardiac arrhythmias, anticholinergic effects (dry mouth, urinary retention, long QT, blurred vision)

MAOIs - hypertensive crises linked to tyrosine in cheese/red wine/fish

Question 5

Antipsychotics and SEs. 2 classes

Why clozapine of note?

Answer 5

Typical/1st gen - Haloperidol, Chlorpromazine
SEs - more EPSE + NMS + High prolactin

Atypical/2nd gen - Olanzapine, Risperidone, Quetiapine, Aripiprazole, Clozapine
SEs - more metabolic - DM, weight gain, lipids, NMS
HIGH PROLACTIN - tuberoinfundibular pathway
Aripiprazole = best SE profile

Clozapine - agranulocytosis, TDP, weight gain

Question 6

Mood stabilisers? SEs/risks?

Answer 6

Lithium
SEs - tremor, confusion, weight gain, thyroid dysfunction, renal impairment. EBSTEINs ANOMALY

Antipsychotics - olanzapine

Anticonvulsants - sodium valproate, carbemazepine, lamotrigine
N.B - risk in pregnancy

Question 7

EPSE mx?

Answer 7

Procycladine - acute dystonia/parkinsonism
Propanolol +/- cyproheptidine - akathisia
Tetrabenazine - tardive dyskinesia

Question 8

NMS + Serotinin syndrome Mx?

Answer 8

NMS

• Bromocriptine
• Dantrolene (reduce muscle spasms)

SS
-Cyproheptidine (5HT-2a antagonist)

Question 9

Alcohol Dependance Mx - NOT WITHDRAWAL

Answer 9

Acamposate
Disulfuram
Naltrexone

Support groups/CBT

Question 10

Withdrawal Mx

Answer 10

Chlordiazepoxide
IV Pabrinex
(Thiamine - alcohol only?)

Question 11

Opioid overdose acute Mx

Dependance Mx after?

Answer 11

Naloxone - IV/IM (opioid antagonist)

Methadone
Buprenorphrine

Question 12

Delirium Mx?

Answer 12

AVOID sedation unless needed - haloperidol/olanzapine
Benzos - chlordiazepoxide - only if alcohol

Side-room, sleep hygeine, adequate lights, clock/calendar

Question 13

GAD mx?

Answer 13

step1
education, stop smoking/drinking, exercise
time off work?

step2
guided-help, low intensity psych support, psychoeducational groups

step3
Meds
CBT / relaxation techniques - high intensity psych support

step4
psych referral

MEDS
1st line - Sertralline
2nd -TCA - clomipramine
Benzo = short term - if really hyper. Can use diazepam long-term

Question 14

Panic Disorder Mx?

Answer 14

Step1
recognition + diagnosis

step2
Meds - same as Anxiety
CBT

step3
Review + consider alternative tx
step4
review + referral 
step5
care in specialist MH service

Question 15

Phobia Mx

Answer 15

Same as Anxiety Meds (+beta-blockers - to help wth autonomic arousal)

CBT - Graded Exposure therapy

Question 16

OCD Mx

Answer 16

Same as anxiety!!!!

CBT - exposure !

Question 17

PTSD Mx

Answer 17

CBT
EMDR - eye movement desentisation + reprocessing

Meds - 2nd Line
SSRI - sert

-target specf symps:
-anything goes!
antipsychs - for psych symptsom
Benzos/Beta-Bs - for anxiety +autonomic
Mirtazepine - sleep issues

Question 18

Eating disorders. Specific for each bulaemia/anorxia

Answer 18

ED-CBT
MANTRA (anorexia specific)

SSRI - sert (bulaemia)

Question 19

Depression Mx. Mild/Moderate/Severe? Meds - 1st/2nd/3rd line?

Answer 19

Mild
Lifestyle - sleep hygeine, meditation, yoga
Computerised CBT, IAPT

Mod
Meds + IAPT (CBT)

Severe
Psych ward
?ECT

Meds
1st line - SSRI
2nd - another SSRI
3rd - SNRI / NaSSA
4th - TCAs / MAOIs

Question 20

Postnatal depression

Answer 20

CBT

Sertralline!!! all others excreted in breastmilk

Question 21

Puerperal psychosis?

Answer 21

Hospital admission

Mood stabliser, ECT, antidepressant
Psychotic symptoms - antipsych/benzo

Question 22

Bipolar?

Answer 22

Mood stabilisers - Lithium 1st line!

CBT
ECT - severe mania (as psychosis)

Question 23

Dementia? Lewy body? Vascular dementia?

Answer 23

Cholinesterase inhibitors

• Donepazil
• Rivastigmine - in Lewy Body

Memantine - NMDA receptor antagonist
–> SEVERE alzheimers

Aspirin - vascular dementia (others don’t work unless mixed A+VD)

memory aids, instructions round house, label drawers, memory stimulating activites, helpers round house

Question 24

Schizophrenia Mx? what types / symptoms do antipsychs not work?

Answer 24

CBT - 3rd person audit halluc

Meds:
1st line - Atypicals
2nd line - Typicals
3rd line - Clozapine

ECT - for Catatonic

Simple/Residual/-VE symps = antipsychs don’t work!

Question 25

Personality disorders? Borderline/Cluster B

Answer 25

DBT - borderline/ B cluster
CBT

Meds - don’t cure!
Benzos - short term crisis
Mood stabilisers / atypicals - comorbs

Question 26

Sleep disorders?

Answer 26

CBT

Sleep hygeine advice - limit coffe/alcohol/cigs, exercise, quiet/relax in evening. Less comp use/noise/light. reg sleep patterns

Meds
Z-drugs
Benzos - loraz
Malatonin - over 55s short term only

Question 27

Violence Mx? Why use one over the other (both class + route of admin)

Monitoring?

Answer 27

Try oral first!!!
Haloperidol / olanzapine - don’t combine - long QT
Lorazepam - if ALREADY ON ANTIPSYCH

IM = if risk to others/already tried 2 doses

Monitor vitals - every 5-10mins for 1hour, then every 30mins

Question 28

When to give ECT?

Answer 28

Severe depression (2core+4more)
Catatonic Schiz
Puerpural psychosis
Severe Mania