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MRCPsych Part B > Psychiatric Services > Flashcards

Psychiatric Services Flashcards

1
Q

Describe and differentiate primary secondary and tertiary prevention in Caplan’s model?

A
  • Primary prevention: treatments that are delivered BEFORE the onset of disease with a view to prevent disease incidence into those that are high risk (can be further subdivided into universal, selective and indicated)
  • Secondary prevention: aims to DETECT and treat disease that has yet become symptomatic therefore to reduce number of established cases. For example screening procedures or early intervention.
  • Tertiary prevention: treats ESTABLISHED disease to restore function, prevent negative effects and complications. To ensure individuals achieve highest level of functioning (relapse prevention and rehabilitation)
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2
Q

Differentiate universal prevention, selective prevention, indicated prevention? (The institute of medicine classification)

A

Universal prevention - for the whole population without risk stratification. Advantages if cheap, tolerated, low risk and effective.

Selective prevention - for those with biopsychosocial risk factors for lifetime/acute risk but not yet developed symptoms. Advantages if moderate cost and no side effects.

Indicated prevention - for groups who are high risk and have minimal but detectable signs/symptoms but do not meet threshold for diagnosis (i.e. symptoms or biomarker indicating predisposition). Often involve some risk of treatment but may be reasonable even if higher costs.

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3
Q

In TMS for unipolar depression where is the coil placed?

A

Left DLPFC

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4
Q

What is the indication for TMS or rTMS?

A

Unipolar depression that has not responded to conventional treatments and where ECT would be the next option

Delivered 4-5 x a week for 40 min sessions

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5
Q

What are the contraindications to TMS?

A
  • Epilepsy of organic brain pathology
  • Acute alcohol dependence
  • Sleep deprivation
  • Drugs that significantly lower the seizure threshold
  • Severe or recent heart disease
  • Ferromagnetic material - cochlear implant / metallic heart valves
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6
Q

What is the prevention paradox?

A

Described by Geoffrey Rose

Universal preventative strategies have significant benefit for the populaiton but less at individual level

High risk individuals who may get maximum benefit only contribute to a small proportion of disease level

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7
Q

Outline where ECT ranks in the treatment algorithm for the following conditions
a) Depressive illness
b) Mania
c) Schizophrenia
d) Catatonia
e) Parkinson’s disease

A

a) First line:
- Rapid response for emergency treatment of depression is needed rapid response is needed:
- Life threatening refusal to eat/drink
- High suicide risk
- TRD and has responded in a prior episode.
- Stupor/marked psychomotor retardation
- Pregnant with severe symptoms and health of foetus may be affected by disease/risk of teratogenic effects

Second line if not responding to medication

b) Life threatening physical exhaustion or prolonged and severe mania with lack of response to other drug treatments. May be first line if pregnant women and severe symptoms whose physical health or that of foetus is at serious risk

c) 4th line (two other antipsychotics + clozapine)

d) First line if life threatening malignant catatonia (usually after lorazepam challenge)

e) Used as an add on treatment if severe disability from motor, affective or psychotic symptoms despite medical treatment

Also occasionally used in NMS and intractable seizure disorders (acts to raise seizure threshold)

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8
Q

Name some relative contraindications to ECT

A
  • Acute respiratory infection
  • DVT until anti-coagulated as can cause PE
  • Unstable major fracture
  • High anaesthetic risk
  • Acute/impeding retinal detachment
  • Recent CVA (within 1 month)
  • Untreated cerebral aneurysm
  • Intracerebral haemorrhage
  • Raised ICP
  • Uncontrolled HF
  • Arrhythmias
  • Untreated pheochromocytoma
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9
Q

What is the risk of mortality in ECT?

A

2: 100,000 (same as anaesthetic risk for minor ops)

Generally death is due to ventricular fibrillation or myocardial infarction

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10
Q

How does anterograde amnesia and retrograde amnesia occur and recover in ECT?

A

Both arise during treatment and are more likely with bilateral ECT

Anterograde amnesia tends to resolve quickly once ECT stopped

Retrograde recovers more gradually and some patients may not recover certain retrograde memories. Older personal memories are more likely to be recovered.

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11
Q

What tests may be done as a workup for ECT?

A

Routine bloods
For some CXR and ECG
Pre-ECT memory assessment (after each session)

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12
Q
A
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13
Q

If an individual has not responded to the first BLANK NUMBER of sessions ECT should be re-considered as the chance of recovery is low?

A

If an individual has not responded to the first SIX of sessions ECT should be re-considered as the chance of recovery is low

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14
Q

Describe the electrode placement in ECT?

A

Bilateral - each electrode is placed 4cm above the perpendicular of the midpoint of a straight line drawn between the lateral of the eye and the external auditory meatus

Unilateral - one electrode is placed same as bilateral ECT the other is placed in the parietal region of the non-dominant hemisphere

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15
Q

How long is an effective seizure considered in ECT?

A
  • Motor seizure lasting at least 20 seconds (from end of ECT dose to last observable motor activity)
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16
Q

What are the four stages of EEG activity in ECT

A

4 phases
- build up of energies
- spike and wave
- slowing down of activity
- abrupt end

Usually lasts between 35 - 130 seconds

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17
Q

When should bilateral/unilateral ECT be considered?

A

Bilateral - use if speed of response is quicker, previous good response to bilateral without memory impairments, if unilateral has failed, if tricky to determine cerebral dominance

Unilateral - if speed or response less important, need to preserve memory, previous good response to unilateral

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18
Q

How do the following drugs interact with ECT
a) Benzodiazepines
b) AEDs
c) Antipsychotics
d) Lithium
e) Anti-D

A

a) Increase seizure threshold - avoid where possible
b) Increase seizure threshold - may elevate dose required. Try to reduce if possible
c) Generally ok - avoid Clozapine if 24hrs before
d) ?increase - may increase cognitive side effects and risk of neurotoxicity
e) SSRIs and Venlafaxine have minimal effect - avoid Moclobemide 24hrs before

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19
Q

What percentage of the population accessed secondary mental health services during 2021-2022

A

5.8%

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20
Q

In the adult psychiatric morbidity survey what percentage of individuals experienced an hallucination in the last year?

A

4.2%

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21
Q

From WHO data name some recognised factors that may delay seeking psychiatric treatment?

A
  • Being in a developing country
  • Being an older cohort
  • Male
  • Earlier age of onset of condition
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22
Q

Who devised the levels and filters model of MH care?

A

Goldberg and Huxley
Filters lie between different levels of care

Level 1 - THE COMMUNITY existing morbidity in the community. Filter 1 - consult GP
Level 2 - TOTAL PRIMARY CARE MORBIDITY (those who see GP but may not be detected). Filter 2 - GP detecting
Level 3 - CONSPICUOUS (detected by GP). Filter 3 - GP referring
Level 4 - REFERRED TO SECONDARY CARE. Filter 4 referral to inpatient bed.
Level 5 - PSYCHIATRIC inpatient bed

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23
Q

Outline the ONS socioeconomic professions

A
  1. High managerial/professional
  2. Low managerial professional
  3. Intermediate occupations (clerical/sales/service)
  4. Small employers and own account workers
  5. Lower supervisory and technical occupations
  6. Semi-routine occupations
  7. Routine occupations
  8. Never employed
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24
Q

How long is a course of rTMS

A

40-50 minutes a day for 4 weeks (4-5 days a week)

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25
Q

Where is the coil applied in rTMS?

A

Left DLPFC (BA 46 and 9)

Sometimes right DLPFC used - if more anxiety symptoms

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26
Q

What are the contraindications for rTMS?

A

Acute alcohol dependence
Epilepsy or organic brain pathology
Metallic cochlear impant/cardiac pacemaker
Severe or recent heart disease
Drugs that reduce the seizure threshold

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27
Q

What is the indication for rTMS?

A

Unipolar depression that has not responded to anti-depressants where ECT may be the next line but not appropriate (contraindicated or not chosen)

NNT 4 in individuals who fail to respond to a trial of anti-depressants
40% response rates in individuals who have failed on average 2.5 trials of anti-D. This response may last until 6 months with rescue rTMS

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28
Q

What are the side effects of rTMS?

A

Transient hearing changes/cognitive changes
Syncope
Acute transient mania
Seizure induction
Transient headache
Neck pain and stiffness

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29
Q

What are stereotactic methods used in psychosurgery?

A

MRI to establish target coordinates and stereotactic frame. Then radio-frequency thermocoagulation or gamma radiation to target the lesion.

30
Q

Outline the procedures used in psychosurgery?

A

Subcaudate tractotomy - beneath head of the caudate nucleus in the rostral orbital cortex - MOOD DISORDERS

Anterior cingulotomy - bilateral lesions in cingulate bundles

Limbic leucotomy - Combines subcaudate tractotomy and anterior cingulotomy - OCD

Anterior capsulotomy - bilateral lesions in limb of internal capsule - OCD

31
Q

Name some side effects of psychosurgery?

A

Headache and nausea post-op
Low incidence of personality changes 2-8%
Cognitive dysfunction tends not to occur
Post-op seizures 1%
Transient confusion post-op 10%
Weight gain 10%
Operative mortality 0.1%

Older techniques:
- Severe amotivational syndromes 4%
- Personality changes 60%
- Epilepsy 15%

For psychosurgery patients need to consent and have failed all other treatments for mood disorder/OCD

32
Q

What are the response rates from psychosurgery?

A

50-70% if carefully selected
3% may get worse

33
Q

Name some indications for DBS?

A

Parkinson’s disease - sub-thalamic nucleus and internal globus pallidus

OCD - internal capsule

Tourette’s disorder - may reduce abnormal motor movements

Also advantages in dystonia, major depression, neuropathic/phantom limb pain

34
Q

What are the neuropsychiatric effects of DBS?

A

Mood changes - mania/depression/anxiety
Impulsivity
Language/speech alteration
Decreased cognitive performance
Postural instability and falls

Surgical complications include: infection (0=15%), intracranial haemorrhage (0-4.5%), stroke, lead migration, post-op seizures, death

35
Q

What are the key competencies for MDT working? (Sainsbury 1997)

A

Assessment
Treatment and care management
Collaborative working
Team management and administration
Interpersonal skills

36
Q

Applying the necssary knowledge, skills and attitudes to a range of complex scenarios refers to

A

Capability

37
Q

What are the key functions of an MDT (Moss 1994)

A

Proactive and continued care to individuals with long term serious MH conditions
Organised response to GP requests
Uninterrupted access to information, support and treatment before/during/after a crisis

38
Q

Name some key policies on community psychiatric services?

A

National service framework for Mental Health (NSF):
- 1999 an agenda for improving MH care with focus on community
- 7 key standards for service development (1. promote MH reduce discrimination/stigma/exclusion, 2. + 3. better primary care tx, 4. + 5. better crisis care and safe places available close to homes, 6. addressing carer needs, 7. reduce suicide by 1/5th)

NHS plan for MH
- 2000 - provided targets and funds to realise NSF
- 50 early intervention teams by 2004
- 335 crisis resolution teams by 2004
- 220 assertive outreach teams

New MH strategy in 2011
1. More people will have good mental health
(starting well, developing well, working
well, living well and ageing well).
2. More people with mental health problems
will recover (improving quality of life)
3. More people with mental health problems
will have good physical health
4. More people will have a positive experience of care and support (offer timely evidence based
interventions)
5. Fewer people will suffer avoidable harm. (improving confidence on services).
6. Fewer people will experience stigma and discrimination. (improve public understanding)

39
Q

Outline some models of community care?

A

Brokerage model - worker coordinates services while not providing input

Case management - one worker responsible. One worker provides long term supportive care in all aspects akin to key worker model in building bridges document (1995). Less intensive and more non-specific than ACT.

Assertive community treatment - no brokerage, MDT working, each professional has caseload of 10-15. Continuous service with titrated input and backing away when needed. No time constraints to treatment and focus on functional recovery.

Intensive case management - akin to ACT but smaller caseloads for hard to engage patients

Personal strengths model - patient is primary driver. No goals imposed on patient. Also called acquisition development model

Rehabilitation model - patient directed and deficit focussed. Draws a comprehensive rehabilitation plan increasing personal autonomy and independence.

40
Q

Outline the basic requirements of a CPA

A
  1. Assessment of health and social needs
  2. Written care plan
  3. Patient is involved in the process of drafting care plan
  4. Patient has an appointed MH worker to coordinate care delivery
  5. The plan is reviewed regularly or necessary

Can be enhanced where organised MDT meetings take place to review care or standard where these meetings are not necessary

41
Q

What did modernising the CPA involve?

A
  • Abolish supervision registers
  • Change name of key worker to care coordinator
  • Appoint a key worker to work across all agencies
  • Integrate CPA with care management to form a single care coordination approach
  • Apply CPA as a framework for MH care delivery and not simply after care arrangement
42
Q

Name some tenets of early intervention services?

A
  1. Reducing duration of untreated psychosis
  2. Reducing psychosocial damage
  3. Reducing secondary morbidity and mortality
  4. Reducing co-morbidity and substance misuse
  5. Promoting recovery
  6. Promoting engagement early on to facilitate long term treatment
43
Q

Outline some criteria for early identification

A

PACE - UHR (Personal assistance and crisis evaluation service - UHR criteria):
- Close “in” strategy
- Specificity over sensitivity
- Ages 14 - 30 using attenuated positive symptoms or frank psychosis (brief limited psychotic symptoms) or having schizotypal personality or a FHx

Hillside criteria

Basic symptoms - cognitive, affective and social disturbances (depressed mood, irritability, aggression - Bonn Scale for Assessment of Basic Symptoms)

44
Q

What are the obstacles to for early intervention?

A

High false positive rate in identification from screening instruments - unnecessary treatment

Interventions at prodrome delay rather than prevent illness?

Would individuals recover naturally (Soteria project) exposure to treatments could be toxic

45
Q

Who identified DUP?

A

Wyatt identified duration of untreated psychosis:
- Suggested that the length may be a prognostic marker given untreated psychosis may be neurotoxic
- Time sensitive period to initiate treatment
- However DUP is confounded by personality, presence of negative symptoms, insidious disease onset, pre-mobid function affecting help seeking and delays initiating treatment
- May not correlate with secondary outcomes. In developing countries DUP can be 10-15 years however outcome may not be different once treated
- In UK median DUP is 52 days (Nottingham 2005) - aim to reduce under 3 months max 6 months

But is DUP neurotoxic:
- No gliosis/cell death on repeat episodes
- Cognitive changes may not be cumulative
- Number of episodes less important than age of onset

46
Q

How does recovery differ from remission

A

Recovery is free of any psychopathology - remission is loss of signs and symptoms so that they do not interfere with behaviour and initial diagnosis cannot be met

47
Q

Describe some vocational rehabilitation schemes/practices?

A

Skills training/prevocational training - often core of rehabilitation units with aim reducing clinical need and increase in employment

Transitional employment programmes - Club house model from Fountain House (1948). Individuals become members at a clubhouse that provides meaningful activities, educational opportunities, in house vocational training and social opportunities. Members can then move onto employment positions over a 6-month period on a part time basis before graduating to a competitive post

Sheltered employment - quota’s for mentally ill but results in segregated workforce

Supported employment - individual has an employment consultant who supports them getting a competitive post and retaining it. Aim is to get the individual into a job and support them as they perform their duties. Usually minimum prevocational training required. SE schemes have close integration with CMHTs

48
Q

Outline common articles of the European Convention for Human Rights that are relevant to individuals with MH disorders

A

Article 2 - right to life
State has a duty to protect life and any deaths in detention need investigation (inc. suicides)

Article 3 - prohibition of torture
Torture inhuman and degrading treatment cannot be justified in any circumstance
Issues arise with seclusions and detentions
Medical treatment even if intolerable side effects will not breach article 3

Article 5 - right to liberty
Detention for treating a mental disorder is acknowledged by ECHR. Often breaches are due to delays in tribunal reviews, detentions that do not comply with MHA 1983, MCA 2005, DOLS safeguards and seclusions/delayed discharges

Article 6 - right to a fair hearing
Cannot be interfered with
Mental health tribunals and court of protection

Article 8 - right to family/private life
Issues arise in relation to permitting family visits, home leaves, restricting correspondences and prohibiting activities e.g. smoking in care homes

Article 9 - freedom of thought & religion
It is qualified and can be breached to protect public safety, order. Relates to inability to provide a place of worship, right type of food or mixed wards

Article 10 - freedom of expression
Can be restricted for national security, territorial integrity and public safety
Proceedings from MHA tribunals and COP are private

Article 12 - right to marry
Mentally ill patients detained under MHA may not enter a marriage contract

Article 14 - right not to be discriminated against
Incudes gender, race and religion

49
Q

What are the common human rights violations experienced by the mentally ill? (Drew 2001)

A
  1. Exclusion, marginalisation, and discrimination in the community
  2. Denial or restriction of employment rights and educational opportunities
  3. Physical abuse/violence
  4. Inability to access effective mental health services
  5. Sexual abuse/violence
  6. Arbitrary detention
  7. Denial of opportunities for marriage/right to found a family
  8. Lack of means to enable people to live independently in the community
  9. Denial of access to general health/medical services
  10. Financial exploitation
50
Q

Outline the DVLA driving laws for psychiatric conditions of note

A

Acute psychotic episode, mania/hypomania:
- Group 1 drivers (cars/motorbikes) - must cease driving during acute illness. Can be relicensed when well and stable for 3 months, free from notable adverse effects of medication, have insight into mania/hypomania and a favourable report from specialist

  • Group 2 drivers (HGV) - Cease during medical enquiry. Person must be stable for 3 years and gain insight into their condition

For severe anxiety/depression
- Group 1 drivers cease when unwell medical enquiry and period of stability (length not cited)
- Group 2 drivers need to be well and stable for 6 months

For dementia
- Group 1 drivers - annual review
- Group 2 drivers - license revoked

51
Q

Outline the DVLA laws for epilepsy

a) Epileptic seizures while awake and lost consciousness
b) One-off seizure while awake and lost consciousness
c) Seizures while asleep and awake
d) Only seizures when asleep
e) Seizures that don’t affect consciousness

A

a) Reapply after 12 months if seizure free however if due to a medication change and back on old medication can reapply after 6 months

b) Reapply after 6 months if seizure free

c) May qualify for license if seizures in last 3 years have been asleep

d) May qualify if 12 months or more since seizure

e) May qualify is 12 months since last seizure (includes those that do not consciousness)

For Group 2 - needs 10 years seizure free if more than 1 previous seizure (not on AEDs) and 5 years seizure free if first seizure (not on AEDs)

52
Q

What are the 4D’s of medical negligence

A

Dereliction of duty directly resulting in damage to the patient

Bolam test the doctor is required to exercise the ordinary skills of a competent practitioner in the field (profession-based standard)

53
Q

What tool was designed in 1988 to assess a decision-making capacity for people in hospital with mental illness?

A

Mac-Arthur Treatment Competence Study
- Choosing
- Understanding
- Appreciating the nature of their own situation
- Reasoning with information

54
Q

Outline some duties to breach confidentiality (specifc)

A

Court order

To aid legal proceedings misuse of drugs, road traffic accident, police and criminal evidence act , terrorism prevention

Veneral disease regulation

Otherwise break with consent, on need to know basis, without identification, in public interest

Tarasoff case in USA highlights need to warm 3rd parties if important information comes to light (not legislated in UK)

55
Q

Name the six principles to safeguard adults?

A
  1. Empowerment to allow person-led decisions and consent
  2. Protection, support and representation for those in greatest need
  3. Prevention of harm or abuse
  4. Proportionality and least intrusive appropriate response to the risk
  5. Partnerships to provide local solutions through community-based services
  6. Accountability and transparency when safeguarding an abused person
56
Q

Define a vulnerable adult?

A

Due to disability, MH, age or illness a person cannot take care of him or herself and is at risk of significant harm or exploitation

57
Q

Name the 4 domains of factors for child maltreatment

A

Parent or caregiver factors
- Parent age - younger
- Parental expectations of developmental norms
- Parental personality traits - impulsivity/dissociality
- Parental MH or substance use
- Parental maltreatment as a child

Family factors
- Spouse maltreatment
- Single households
- Unemployment
- Financial stress
- Social isolation

Child factors
- Disability
- Age - birth - 3 years

Protective factors
- Emotionally satisfying relationship
- Social support
- Parental MH support and treatment of trauma related issues

58
Q

What is the traumagenic dynamics model?

A

Postulates that adverse effects of child sexual abuse depend on:
- Betrayal
- Traumatic sexualisation
- Stigmatisation
- Powerlessness

Proposed by Finkelhorr (1988)

59
Q

What is the child accommodation syndrome?

A

Proposes that families are susceptible to ongoing abuse without reporting them.

The elements are:
1. Secrecy related to the need to keep quiet due to the fear of the consequences
2. Helplessness with on-going threat of further abuse
3. Entrapment and accommodation with a destructive effect on personality development
4. Delayed and unconvincing disclosure at times of conflict with the family. This often results in
rejection of the child’s story and creates a damaging sense of being falsified if truth is revealed
5. Retraction of the disclosure due to a threat of disintegration of the family

60
Q

How many…

a) Adults experience a MH episode in their life
b) Individuals with depression have a chronic course
c) Individuals > 65 in the community have depression
d) Number of people living in UK with MH condition at any one time

A

a) 1 in 4
b) 10%
c) 1 in 7 (includes all severities)
d) 1 in 6

61
Q

What are the diagnostic criteria of bodily distress disorder?

A
  • Bodily symptoms that are distressing to the individual
  • Excessive attention paid to them:
    –> Preoccupation with them or their consequences
    –> Repeated contacts with medical services
  • Excessive attention to the bodily symptoms persists despite appropriate clinical examination and investigations or appropriate reassurance by health care providers.
  • Present on most days across several months
  • Disturbance to functioning
  • Symptoms are not explained by another mental disorder

n.b can be mild, moderate or severe depending on the narrowing of interests/attention paid to the symptoms and the degree of dysfynctioning

62
Q

What is body integrity dysphoria?

A

An ICD-11 condition where an individual has a persistent and severe desire to be disabled in some way accompanied by negative feelings. The individual may make attempts to disfigure self to become disabled and there is a preoccupation with his desire.

Symptoms typically arise during early adolescence.

63
Q

Which condition has a higher heritability - Anorexia or Bulimia?

A

Anorexia

  • MZ concordance is 55%, 5% for DZ
  • MZ concordance for Bulimia is 35% and 30% for DZ
64
Q

Outline the ICD-11 criteria for Bulimia?

A
  • Frequent or recurring binge eating episodes (at least once a week for a month). The individual feels a loss of control of eating
  • Repeated compensatory behaviours aimed at preventing weight gain
  • Excessive preoccupation with body weight/shape - checking with scales/mirrors/calorie counting. Or even refusal to wear tight fitting clothes/have mirrors at home

Marked distress is caused by the binge eating pattern - significant impairment due to compensatory behaviours

Symptoms don’t meet diagnostic criteria for anorexia nervosa

n.b onset of bulimia occurs at a younger age

65
Q

How does Bulimia differ from Binge eating disorder?

A

In binge eating disorder there are no compensatory behaviours that accompany

  • Time period states 1 month if frequent or severe otherwise needs to be for at least 3 months (ICD-11)
  • In both bulimia and binge eating disorder - the binges are a discrete period of time (e.g 2 hours)
66
Q

What is the male:female ratio of anorexia?

A

1M : 10F

67
Q

How is a diagnosis of ARFID made?

A

Avoidant or restriction in food intake that results in:

1) Intake of insufficient quantity or variety of food to meet sufficient energy intake or nutritional requirements - this results in clinically significant weight loss, nutritional deficiencies, need for oral supplementation or adverse outcome to physical health

2) Impairment in functioning or avoidance and distress related to participant in social experiences

  • The behaviour is not motivated body weight/shape concerns
68
Q

What are the aims of managing anorexia?

A
  • Weight restoration
  • Engagement
  • Psychological therapy - cognitive restructuring
  • If needed use compulsion
69
Q

Name some anti-D affected by CYP2D6 metabolism

A

Paroxetine, Fluoxetine, Clomipramine, Venlafaxine

Reboxetine is metabolised by CYP3A4

70
Q

What is the proposed mechanism behind antipsychotic mediated QTc prolongation?

A

Blocking cardiac potassium channels

71
Q

Peripheral neuropathy is a rare side effect of which class of depressants

A

MAO-I

MRCPsych Part B (13 decks)

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