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Specialties Mx 2021 > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

Describe step 1 of the stepped care model for depression

A

Step 1: all known and suspected presentation of depression

assess, support, psychoeducational, active monitoring and referral for further assessment and interventions

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2
Q

Describe step 2 of the stepped care model

A

persistent subthreshold depressive symptoms, mild to moderate depression

low intensity psychological intervention, psychological interventions, medication, referral for further assessment and interventions

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3
Q

Describe step 3 of the stepped care model

A

Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial intervention, moderate to severe depression

medication, high intensity psychological intervention, combined treatments, collaborative care and referral for further assessment and interventions

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4
Q

Describe step 4 of the stepped care model

A

Severe and complex depression, risk to life, severe self-neglect

medication, high-intensity psychological interventions, ECT, crisis service, combined treatments, multi-professional and inpatient care

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5
Q

How is mild to moderate depression managed?

A

sleep hygiene

follow up in two weeks

low intensity psychosocial intervention

group CBT

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6
Q

What different types of low intensity psychosocial interventions are available?

A

individual guided self help based on the principles of CBT:

  • written materials from a professionals
  • 6-8 sessions face-to-face or telephone usually over 9-12 weeks with a follow up

computerised CBT:

  • explain CBT model
  • supported by a trained professional
  • over 9-12 weeks

Structured group physical activity program:
- 3 sessions per week over 10-14 weeks

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7
Q

How does group CBT work?

A

considered if low intensity is declines

should be based on a structured model e.g. ‘coping with depression’

delivered by 2 trained practitioners

10-12 meetings with 8-10 people

12-16 weeks

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8
Q

When is medication considered in mild to moderate depression?

A

medication only if Hx of moderate / severe depression, symptoms lasting over 2 years, persistent symptoms despite other interventions

do not recommend St John’s wort due to uncertainty of dosing and drug interactions

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9
Q

How is moderate to severe depression managed?

A

combination of antidepressant medication and high intensity psychological intervention e.g. CBT / interpersonal therapy

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10
Q

What medication does St John’s wort affect?

A

warfarin

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11
Q

What are some of the risks of SSRIs?

A

Bleeding, especially in elderly, ulcers and hyponatraemia

drug interaction

discontinuation syndrome

death from overdose

overdose

stopping treatment due to side effects

blood pressure monitoring needed

worsening hypertension

postural hypertension and arrhythmia

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12
Q

Which SSRIs can interact with other drugs?

A

fluoxetine

paroxetine

fluvoxamine

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13
Q

Which SSRIs can cause discontinuation syndrome?

A

paroxetine (shortest half life)

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14
Q

Which SSRI can cause death from overdose?

A

venlafaxine

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15
Q

Which SSRI can be used to overdose?

A

TCAs (except lofepramine)

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16
Q

Which SSRI can cause people to stop the treatment due to the side effects?

A

venlafaxine, duloxetine, TCAs

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17
Q

Which SSRI required regular blood pressure monitoring?

A

venlafaxine

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18
Q

Which SSRI can cause worsening hypertension?

A

venlafaxine and duloxetine

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19
Q

Which SSRI ca cause hypotension and arrhytmia?

A

TCAs

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20
Q

How should a patient be monitored after starting an SSRI?

A

review after 2 weeks if no particular risk of suicide, then every 2-4 weeks after for 3 months

if < 30 or at increased risk of suicide, follow up in a week

review response to treatment every 3-4 weeks

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21
Q

How are SSRIs continued after an improvement in symptoms?

A

continue at the same dose for 6-12 months or 2 years if high risk

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22
Q

What are some high intensity psychological interventions?

A

individual CBT:

  • 16-20 sessions over 12-16 weeks
  • consider 2 sessions per week for the first 2-3 weeks
  • consider follow up sessions over the following 3-6 months

interpersonal therapy:

  • 16-20 sessions over 12-16 weeks
  • consider 2 sessions per week for the first 2-3 weeks
  • helps to identify how interactions with others are affecting the patients mood and ways of improving these interactions
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23
Q

How do monoamine oxidase inhibitors work?

A

increase serotonin and noradrenaline in the cleft, beware of CHEESE REACTION

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24
Q

How do SARIs (serotonin antagonist reuptake inhibitors) work?

A

antagonist at the post synaptic cleft e.g. trazodone

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25
Q

Give 4 examples of new anti depressants

A

agomelatine: melanin agonist and serotonin antagonist
bupoprion: noradrenaline and dopamine reuptake inhibitor
roboxetine: noradrenaline reuptake inhibitor

Vortioxetine: serotonin modulator stimulator

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26
Q

Which anti depressant might be used in elderly people or those who need to gain weight?

A

NASSAs (mirtazapine)

helps with sleep and appetite

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27
Q

Which antidepressant do you need to be careful with when switching?

A

from fluoxetine to other antidepressant as it has a long half life

from fluoxetine or paroxetine to a TCA (both inhibit the metabolism of TCA so may need a lower starting dose)

to a new serotoninergic antidepressant or MAOI (risk of serotonin syndrome)

from non-reversible MAOI: a 2 weeks washout period is required

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28
Q

How is complex and severe depression managed?

A

use crisis resolution and gome treatment teams

develop a crisis plan that identifies potential triggers and strategies to manage triggers

consider inpatient treatment if a significant risk of suicide, self harm or neglect

consider ECT for acute treatment of severe depression when a rapid response is required

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29
Q

What is the catch up phenomena?

A

if someone recovers from depression due to treatment, treatment is stopped, if they have depression again they will experience it worse

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30
Q

How should antidepressant be stopped?

A

over a period of 4 weeks otherwise discontinuation syndrome may occur (headache, flu symptoms, electric shocks)

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31
Q

PACES: depression

A

explain it is a persistently low mood that impacts on day to day functioning

explain that it is very common, about 1/4 people

address any social needs

explain the role of CBT, a talking therapy based on the principle that thoughts, mood and behaviour are all linked

explain the role of medication and that it takes a few weeks to work

arrange to review in 1-2 weeks and warn about initial side effects (lower libido, GI upset)

warn about sleep disturbance so to take in the morning

advise about the crisis resolution teams ane home treatment team

support: mind UK and samaritans

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32
Q

What are the three main mood stabilisers?

A

lithium - bipolar
carbamazepine
valproate - mania

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33
Q

What is the therapeutic range for lithium and when does it become toxic?

A

0.6-1

toxic after 1.2

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34
Q

How is lithium monitored?

A

1 weeks after starting / changing dose and weekly until a steady therapeutic level is achieved

then every 3 months

U&E and TFTs every 6 months (can cause renal impairment and hypothyroidism)

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35
Q

How does lithium toxicity present?

A 
GI disturbance 
polyuria 
polydipsia 
sluggishness
giddiness
ataxia
gross tremor 
fits
renal failure
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36
Q

What are some triggers for lithium toxicity?

A

salt imbalance e.g. diarrhoea and vomiting or dehydrations

drugs interfering e.g. diuretics

accidental or deliberate overdose

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37
Q

How is lithium toxicity managed?

A

check level

stop lithium dose (beware of sudden precipitation of mania or depression)

transfer for medical care with rehydration and osmotic diuresis

if severe, may require gastric lavage or dialysis

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38
Q

Describe the use of valporate as a mood stabiliser

A

anticonvulsant and can be used to treat acute mania

prophylaxis in BPAD
no requirement for monitoring
no accepted therapeutic range
given as sodium valproate because of reduced side effects

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39
Q

Describe the use of carbamazepine as a mood stabiliser

A 
anticonvulsant
can cause toxicity at high doses 
induces liver enzymes 
need to monitor levels closely 
check for drug interactions before prescribing 
can cause hyponatraemia
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40
Q

What are teratongenic effects of lithium?

A

Ebstein’s anomaly

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41
Q

What are the teratogenic effects of valproate and carbamazepine?

A

spina bifida

if using valproate, women of childbearing age should be given contraception and prescribed a foalte supplement

closely monitor the foetus if any of these medications are used in pregnancy

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42
Q

What drug is used as second line prophylaxis for BPAD II?

A

lamotrigine

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43
Q

How is acute mania / hypomania treated?

A

stop all medications that may induce symptoms (e.g. anti-depressant, drugs of abuse, steroids and dopamine agonists)

monitor food and fluid intake to prevent dehydration

if treatment free - give an antipsychotic and short course of a benzo e.g. olanazpine and lorazepam

if already on treatment:

  • optimised medication
  • check compliance
  • adjust doses
  • consider adding another agent
  • short term benzo

ECT if unresponsive to medication

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44
Q

What is the long term treatment of BPAD?

A

mood stabilisers

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45
Q

How is depression in BPAD managed?

A

talking therapies
anti-depressant may increase the risk of mania

therefore, anti-depressants should be given with anti-psychotics or mood stabilisers:

  1. fluoxetine and olanzapine / quetiapine
  2. lamotrigine

monitor closely for any signs of mania nad stop if present

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46
Q

What psychological treatment can be offered in BPAD?

A

CBT:
- dientify relapse indicators and prevent these .e.g routine, sleep hygiene, exercise, drug compliance

psychodynamic therapy: useful once mood is stabilised

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47
Q

What social interventions can be offered in BPAD?

A

family support and therapy, aiding return to education or work

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48
Q

What should be stopped during an acute manic episode?

A

anti depressant if they are on one

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49
Q

Describe the primary care referral in BPAD

A

hypomania - routine referral to CMHT

mania - urgent referral to CMHT

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50
Q

PACES: BPAD

A

consider admission and section if at risk

Explain that this is a condition where you have a tendency to experience the extremes of emotion for variable lengths of time

explain the importance of controlling it (both extremes can lead to you making decisions that you otherwise would not make)

explain that there are medications available that helps to balance the chemical in the brain

advise about risis resolution team and samaritans

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51
Q

What are some immediate intervention if a patient is at high risk of attempting suicide again or lacks capacity?

A

need to be admitted to a psychiatric ward

crisis plan for future if they feel they want to do again: who will they call and how will they get help?

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52
Q

What are some long term interventions offered to people who are low to medium risk of attempting suicide again?

A

discahrge home

follow up within 1 weeks e.g. community mental health team, outpatient clinic, GP or counsellor

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53
Q

What psychological therapies can be offered to people who have tried to commit suicide?

A

CBT e.g. dialectical based therapy
mentalisation based treatment
transference focused therapy

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54
Q

What percentage of suicides occur within 3 months of discharge from psychiatric wards?

A

30%

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55
Q

What is the ideal time within which a patient with psychosis should be treated?

A

need Duration of Untreated Psychosis < 3 months

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56
Q

Who can be treated with the early intervention service?

A

children > 14, CAMHS can deal with psychosis in children up to 17 years

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57
Q

Which medications can be used to treat schizophrenia?

A

typical or atypical antipsychotics

Dopamine antagonists

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58
Q

Which chemical is involved in the reward pathway?

A

dopamine

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59
Q

What are some examples of typical antipsychotics?

A

chlorpromazine, haloperidol and flupentixol

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60
Q

What side effects do typical antipsychotics cause?

A

extra pyramidal side effects

dystonia

akathisia

parkinsonism

tardive dyskinesia

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61
Q

What are some examples of atypical antipsychotics?

A 
olanzapine
risperidone (available as a depot) 
quetiapine 
apriprazole 
clozapine 
amisulpride

these block dopamine and serotonin

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62
Q

What are some side effects of atypical antipsychotics?

A

hypermetabolic e.g. weight gain
increased risk of diabetes (olanzapine)

EPSE

hyperprolactinaemia (increased risk of osteoporosis, amenorrhoea / subfertility, sexual dysfunction, gynaecomastia)

sedation 
dyslipidaemia 
anti cholinergic effects e.g. dry mouth and blurred vision 
arrhythmias 
seizures 
neuoleptic malignant syndrome
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63
Q

What psychological treatments are available for schizophrenia?

A

CBT at least 16 sessions

family therapy at least 10 sessions - respite for families and lower relapse rate

concordance therapy: patient is encouraged to think of pros and cons of the management

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64
Q

What are the aspects of social management in schizophrenia?

A 
may need admission for observation
education 
skills
housing
employment 
accessing social activities 
developing personal skills

psychoeduation is vital in reducing relapse

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65
Q

Which baseline measurements are required before starting an anti-psychotic?

A

weight
waist circumference
pulse and bp
fasting BM, HbA1c, lipid profile and prolactin
assess any movement disorders
ECG
children should have height measured every 6 months

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66
Q

What needs to be monitored after starting an anti-psychotic?

A 
response to treatment 
side effects
emergence of movement disorders 
waist circumference 
adherence 
overall physical health

weight: weekly for 6 weeks, at 12 weeks and 1 year, then annually

pulse and BP at 12 weeks, 1 year, then annually

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67
Q

What other management is offered in schizophrenia?

A

physical health e.g. lifestyle and smoking cessation (can given buproprion and varenicline, need to be monitored as these increase risk of adverse neuropsychiatric conditions)

carer support, inform of their right to carer’s assment

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68
Q

What medication is given in treatment resistant schizophrenia?

A

clozapine

-small but singificant risk of agranulocytosis so needs weekly blood tests to detect neutropaenia

if still no response, augment with another anti psychotic

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69
Q

Define treatment resistant schizophrenia

A

failure to respond to two or more anti psychotics, one of which is atypical, given at the therapeutic dose for at least 6 weeks

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70
Q

summarise the treatment of schizophrenia

A

1st line: atypical antipsychotic e.g. quetiapine
CBT
monitr, especially cardiovascular health due to high rates of CVD (due to medication and smoking)

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71
Q

PACES: schizophrenia

A

Explain it is a condition where your brain processes information differently, leading to you seeing and hearing things that are not there

Some of the thoughts or voices can be quite distressing so it is important you have a good social network and call for help if you feel like this is happening

I will refer you to a specialist who can help in a lot of different ways e.g. housing and employment

will start on cognitive behaviour therapy and medication

support: samaritans

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72
Q

Which rating scales are used in alcohol misuse and what are they for?

A

AUDIT - screens for hazardous and haermful alcohol consumption e.g. addiction (like CAGE) > 15 requires more assessment

CIWA-Ar - severity of alcohol withdrawal

APQ - determines the extent of problems caused by alcohol

SADQ - severity of alcohol dependence

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73
Q

What medical investigations are done in alcohol abuse?

A

FBC, LFT, B12, folate, UE, clotting and glucose
blood alcohol level
urine drug screen

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74
Q

What can be offered to family memebrs of people with alcohol dependence?

A

carer’s assessment if necessary
consider offering guided self help for families and provide resources about support groups
family meetings can be considered, at least 5 meetings,over 5 weeks (one a week)

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75
Q

When would people with alcohol dependence and comorbid mental health conditions be referred to a specialist?

A

if issues do not improve within 3-4 weeks of abstinence

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76
Q

If a homeless person with alcohol dependece presents, what is the maximum amount of time they may remain at an inpatient rehabilitation programme?

A

3 months

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77
Q

What are the principles of intervention in alcohol dependence?

A

carry out a motivational interview

offer interventions to promote abstinence as part of intensive structured inpatient based intervention for people with moderate - severe dependence, esp if they have limited social support, complex comorbidities and have not responded to community-based programmes

monitor outcomes routinely

provide information on alcoholic anonymous, SMART recovery and ‘change, grow, live’

78
Q

Waht interventions are given to harmful drinkers and mild alcohol dependence?

A

CBT , behavioural therapy based on alcohol related cognitions (weekly 1 hour sessions for 12 weeks)

behaviour couples therapy if partner is present

if no response, offer acamprosate and naltrexone alongside psychological treatment

79
Q

What is given for assisted withdrawl?

A

pabrinex if at risk of wernicke’s encephalopathy

withdrawal symptoms are worst 48h after last drink and takes about 3-7 days to completely disappear

80
Q

How are people drinking > 15 units a day or with an AUDIT score > 20 managed?

A

community based withdrawal is the best option

through organisations like CGL, 2-4 meetings in the first week and if complex 4-7 meetings over a 3 week period

manage in specialist alcohol services if there are concerns about safety

81
Q

When would inpatient assisted withdrawal be considered?

A

any one of the following

30+ units in a day
30+ on SADQ
history of epilepsy, delirium tremends or withdrawal related seizures
need concurrent withdrawal of alcohol and benzodiazepines
significant psychiatric comorbidity or learning disability
lower threshold for inpatient if vulnerable e.g. homeless
children (10-17), should also have family therapy for 3 months

82
Q

Outline the drug regimens in alcohol misuse

A

fixed dose or syptoms triffered regimen (chlordiazepoxide or diazepam, lroazepam in significant liver impairment

tritrate initial dose based on severity of dependence / consumption

gradually reduce the dose over 7-10 days (long ifer concurrent benzo withdrawal needed - over 3 weeks)

no more than 2 days medication at a time

83
Q

What is given after successful withdrawal to prevent relapse?

A

acamprosata / naltrexone with individualised psychologica intervention

usually prescribed for up to 6 months

needs thorough baseline medical assessment before starting, including LFTs and UE

consider disulfiram if acamprosate / naltrexone not successful are not successful

84
Q

PACES: alcohol misuse

A

establish risks: driving, suicide, dependents
assess social issues and advise accordingly
establish goals (elimination or moderation)
explain that symptoms of withdrawal are worst in the first 48h and last about 3-7 days
do not recommend stopping abrupty
explain referral to drugs and alcohol service and the process of assessed withdrawal

85
Q

How is acute alcohol withdrawal treated?

A

IV chlordiazepoxide and Pabrinex

if hepatic impairment - lorazepam

or carbamazepine

alternative: clomethiazole

86
Q

How is delirium tremens treated?

A

1st: oral lorazepam

if symptoms persist, IV lorazepa or haloperidol
alternative: chlordiazepoxide

IV thiamine also

87
Q

How are acute alcohol withdrawal seizures treated

A

consider a fast acting benzodiazepine e.g. lorazepam to reduce the likelihood of future seizures

88
Q

What medication is used for detoxification in opiate misuse?

A

appoint a key worker

1st: methadone (liquid) or buprenorphine (sublingual) decision is based on patient preference

89
Q

When should opioid withdrawal treatment NOT be offered?

A

concurrent medical problem requiring urgent treatment
in police custody
presenting in acute or emergency settings
be wary with pregnant women

90
Q

When is lofexidine given?

A

if methadone / buprenorphine are not acceptable, only mild dependence or they are keen to detoxify over a short period

91
Q

What is the duration of ipiate detox as an in patient and in the community?

A

inpatient: 4 weeks
community: 12 weeks

92
Q

What medication can be given to help with opiate withdrawal symptoms?

A

lofexidine or clonidine (alpha 2 agonist)

also things like anti diarrhoeals

93
Q

What is ultra-rapid / rapid / accelerated detoxification?

A

rapid: 1-5 days with moderate sedation, given if patient requests it
accelerated: no sedation

ultra-rapid: under GA, do not offer

94
Q

What is the second stage of managing opiate detoxification

A

promote abstinence from illicit drugs, prevent relapse, reduce HIV and HCV risk,

consider long acting opioid agonists e.g. methadone and buprenorphine

and long acting opioid antagonists (injectable, extended release naltrexone)

95
Q

How is opioid detoxification followed up?

A

refer to drugs ad alcohol service for at least 6 months

offer a talking therapy e.g. CBT

appoint a key worker

offer contingency management

96
Q

What is a contingency management for opioid detoxification?

A

offer incentives for every drug negative test

screening could be frequent at first and then reduce

urinalysis is the preferred method

97
Q

PACES: opioid misuses, detox and withdrawal

A

explain that it is worth getting a test for blood borne disease and getting vaccinated

explain the features of withdrawal (restlessness, anxiety, sweating, yawning, diarrhoea, cramps, nausea, vomiting and palpitations)

advise that these usually begin with 24 hours, peaks after 2-3 days and should be better by 1 week

explain the detoxification regime (give a substitute that should lessen the symptoms

explain that symptomatic treatments will be given to reduce nausea, diarrhoea and autonomic symptoms

explain the role of psychological therapies and key worker

support: narcotics anonymous and SMART recovery

98
Q

What are some uses of benzodiazepines?

A

sedation, hypnotic, anxiolytic anticonvulsant, muscle relaxant

only give for a short time

99
Q

What are the risks of using benzodiazepines?

A

short term: drowsiness, reduced concentration

long term: cognitive impairment, worsening anxiety and depression and sleep disturbance

100
Q

What are some clinical features of benzodiazepine withdrawal?

A 
insomnia
irritability 
anxiety
tremor
loss of appetite 
tinnitus
excessive sweating 
seizures
101
Q

How should benzodiazepines be withdrawn?

A

ideally reduce by 1/8th of the dose every fortnight (in reality reduce according to the severity of the withdrawal symptoms)

consider switching them to the equivalent dose of diazepam (oxazepam if liver failure)

duration: can take 3 months to a year

DO NOT DRIVE IF FEELING DROWSY

102
Q

PACES: benzodiazepine misuse

A

explain that benzodiazepines can cause worsening of long term psychiatric symptoms

explain that these can be reduced very gradually, in consideration of the symptoms the patient is experiencing

explain the role of CBT and what it is

advise that they should not drive if feeling drowsy

103
Q

How is delirium treated?

A

treat the cause e.g. infection / constipation

stop any unnecessary medications

behavioural management

104
Q

What is the behavioral management of delirium?

A

frequent reorientation (clocks and calendars)
good lighting
address any sensory problems
avoid over / under stimulation
minimise change and do not keep moving the patient, one staff member per shift
remove things they might trip over
allow safe and supervised wandering

105
Q

What medication can be given in delirium?

A

small night time dose of benzodiazepine could help with sleep

short term sedation, can use low dose typical antipsychotics e.g. haloperidol

106
Q

How can delirium be prevented?

A

good sleep hygiene without medication

minimal moves around hospital

encourage mobility

proactive management (minimise dehydration, pain, UTI risk)

107
Q

how is normal pressure hydrocephalus managed?

A

a ventriculoperitoneal shunt

108
Q

How can depression in the elderly be treated?

A

problem solving activities, socializing and day time activities
psychological therapies e.g. CBT, group therapy, family therapy, couple therapy

SSRIs first line e.g. citalopram
ECT if severe of life threatening
consider social workers, community nurses and carers
AGE UK

109
Q

how is psychosis in the elderly managed?

A

reduction of sensory impairment
exclusion of organic causes or LBD
low-dose antipsychotics

110
Q

What are the aspects of dementia managed?

A 
adaptations for patients 
social support 
support carers
optimize physical health 
psychological therapies 
psychotropic medications
111
Q

What adaptions can be made for patients with dementia?

A 
always carry ID
dosset box 
reality orientation
environmental modifications 
assistive technology 
home safety assessment e.g. electric instead of gas hob
112
Q

What social support is available for people with dementia?

A

personal care, meal prep and medication prompting
day centres provide enjoyable daytime activities and social contact
day hospitals enable daily psychiatric care for more complex patients

113
Q

What support can be offered for carers of dementia patients?

A 
emotional support 
education about the condition 
advise against them telling pt what to do as this can aggravate them 
train to manage common problems 
provide respite care
114
Q

How can the physical health of a patients with dementia be optimised?

A

treat sensory impairment e..g hearing aids
exclude superimposed delirium
treat underlying risk factors
review all medication

115
Q

What psychological therapies can be offered to patients with dementia?

A

group cognitive stimulation (memory training and relearning)
group reminiscence therapy
consider rehabilitation or occupational therapy
behavioral approaches (identify triggers for behaviour)
validation therapy
multisensory therapy

116
Q

Which psychotropic medications can be offered for dementia?

A

acetylcholinesterase inhibitors, used in mild to moderate Alzheimers - offers symptomatic relief but will not slow progression

memantine (NMDA antagonist) - used in severe alzheimers or if ACHEi is contraindicated

117
Q

How is MMSE used to determine the severity of alzhimers?

A

Mild AD: 21-26
Moderate: 10-20
Severe<10

118
Q

What medications can and cannot be given in lewy body dementia?

A

CAN give donepazil or rivastigmine (galantamine if not tolerated or contraindicated)

DO NOT GIVE ANTI PSYCHOTICS

119
Q

What medications cannot be given in frontotemporal dementia?

A

ACHEi

120
Q

When can ACHEi be given in vascular dementia?

A

if they have comorbid alzheimers, lewy boyd or parkinsons dementia

121
Q

What is the first step in managing GAD?

A

CBT over 4-12 weeks

low intensity e.g. individualised non facilitated self help or individual guided self help)

explores patients thinking and likelihood of threat, test prediction of worry with behavioural experiments and looking at errors in thinking

can also do applied relaxation therapy, meditation, sleep hygiene and exercise)

122
Q

What is panic disorder?

A

panic is triggered by misiinterpreting physical anxieety symptoms as signs of a major catastrophe

123
Q

What is exposure therapy in GAD?

A

used as part of them CBT approach when there are strong elements of avoidance and escape

usually after 45 mins habituation occurs and leads to extinction

this is achieved through a gradual a process of desensitization

124
Q

What is the second step of GAD management?

A

pharmacological:

sertraline (follow up at 1 week if < 30 due to increased risk of suicide)
SSRI / SNRI
pregablin

do not routinely use benzodiazepine due to risk of addiction

125
Q

What is step 3 in GAD management?

A

specialist assessmnet of needs and risks and support for family and carers

126
Q

What other pharmacological options are there for GAD?

A

TCAs e.g. clompiramine
buspirone (serotoning partial agonist)
Beta blockers but consider the contraindications

127
Q

PACES: GAD

A

propanolol helps with physcial symptoms such as sweating

never give benzo

128
Q

How is Panic disorder managed?

A
  1. recognition and diganosis
  2. treatment in primary care (CBT and SSRI)
  3. review, if no response after 12 weeks consider impiramine and clompiramine
  4. review and referral to specialist mental health services
  5. care in specialist mental health services
129
Q

What is OCD?

A

characterised by obsessions (unwanted thoughts that are distressing, centred around infection and contamination and aggression and morality)

compulsions to ‘reduce’ the tension: repeated stereotyped actions with no obvious link to the obsession and irrational

patients identify the thoughts as their own and may begin to avoid triggers

130
Q

What are some differentials for OCD?

A

GAD, depressions, anakastic personality disorder and schizophrenia

131
Q

What questionnaire can be used for OCD?

A

Yale-Brown

132
Q

How is OCD managed?

A

CBT - exposure response prevention self help or group

SSRI - fluoxetine or paroxetine,

3rd: clopiramine or alternative SSRI if no response after 12 weeks

133
Q

How long should people with OCD be treated for?

A

12 months after remission of symptoms

134
Q

Describe an acute stress reaction

A

occurs minutes to hours after an event, lasts less than a month

135
Q

How is an acute stress reaction managed?

A

exclude injury a provide support

2-4 week trial of benzodiazepine may alleviate short term distress (does not prevent later PTSD)

136
Q

What are the core features of PTSD?

A

hyperarousal, reliving and avoidance

occurs within 6 months and lasting longer than a month

137
Q

How is PTSD treated?

A

watchful waiting if subthreshold symptoms of PTSD within 1 month of traumatic event (F/U within a month)

Trauma focused CBT (8-12 sessions) offered to all PTSD if >1 month

EMDR - ONLY IN NON COMBAT TRAUMA, if >3 of symptoms

SSRI - paroxetine (licensed) or venlafaxine (unlicensed)

138
Q

Paces: PTSD

A

explain it is a condition after a traumatic life event, characterised by hyperarousal, avoidance and reliving

trauma focused CBT is first line 8-12 sessions computer or face to face

pharmacological treatment includes SSRIs e.g. paroxetine

Consider group therapy and offer a follow up

139
Q

What is an adjustment disorder?

A

When a person’s adaption or reaction to change is much great than expected commonly in new uni students

140
Q

How is adjustment disorder managed?

A

support and reasure and problem solving techniques

141
Q

How are medically unexplained symptoms managed?

A 
explain and reassure, 
reattribution model 
avoid unecessary Ix
Emotional support 
Encourage normal function 
Anti depressants 
Treat comorbid illnesses
CBT
Graded exercise
142
Q

How is chronic fatigue syndrome managed?

A

CBT

graded exercise

143
Q

How are conversion disorders managed?

A

psychotherapy and CBT

144
Q

What are the 4 key aspects of anorexia nervosa?

A

BMI < 17.5
deliberate avoidance of food
endocrine dysfunction
distorted body image

145
Q

What are some exmination findings of Anorexia?

A 
bradycardia
hypotension
hypothermia
FAILED SQUAT TO STAND TEST 
peripheral neuropathy 
amennorhoea
146
Q

What are some differentials for Anorexia?

A 
Bulimia
organic cause e.g. hyperthyroidism 
malignancy
depression
body dysmorphic disorder
147
Q

What investigations need to be done in Anorexia?

A 
height weight and BMI
squat to stand test
FBC
TFTs
ECG
148
Q

How is anorexia managed?

A

Determine engagement and educate regarding nutrition
refer to CEDS

treat comorbid conditions

Psycho: ED-CBT, SSCM or MANTRA, Interpersonal
2nd - EDF FPT

149
Q

What is the first line management for anorexia in children?

A

Family therpay

150
Q

When is medical management indicated in anorexia (i.e. admission)?

A 
BMI < 13.
Temperature < 34
Sodium < 130 
Potassium < 2.5 
High risk of suicide
>1kg / week weight loss
151
Q

What are the characteristic findings of refeeding syndrome?

A

hypophophataemia
hypomagnesiumaemia
hypokalaemia

152
Q

Describe the referral pathways in anorexia

A

urgent to CEDS if BMI < 15
routine if 15-17
mild - monitor for 8 weeks and recommend BEAT

153
Q

PACES: anorexia

A

explain it is a condition that is characterised by being underweight and having a morbid aversion to food

NOT BASED ON OPINION BUT BASED ON NUMBERS

psycho therapy: CBT-ED, SSCM, MANTRA or Family therapy for children
set a realistic weight gain plan (0.5kg-1kg/week)

if depressed - fluoxetine

charity - BEAT

154
Q

What are the characteristic feature of bulimia nervosa?

A

binge eating
purging
BMI > 17.5
body dysmorphia

155
Q

How is Bulimia managed?

A

Bulimia nervosa focused guided self help programme for adults
children: family therapy bulimia nervosa
CBT-ED with nutrition and meal support

Fluoxetine (reduces purgin ideas)
treat comorbid psych conditions

156
Q

Describe the referral pathways in bulimia nervosa

A

urgent (daily purgin and significant electrolyte imbalance)

moderate (monitor for 8 weeks, recommend self help consider SSRI and routine referral (purgin >2 weekly but no significant electrolyte imbalance )

mild - BEAT and monitor for 3 months

157
Q

How is binge eating disorder managed?

A

BED focused guided self help for adults

if ineffective or unacceptable (after 4 weeks) group CBT)

progress to individual CBT

158
Q

How is low libido managed?

A

establish if there are organic causes e.g. SSRI
treatment is mainly psychological

sensate focus therapy - ban intercourse, non genital caressing, genital touching to arouse and eventually intercourse

timetabling sex - helps partners with different libidos reach a compromise

159
Q

How is hypersexuality treated?

A

exclude causes such as mania, substance and brain tumours

CBT

160
Q

What are some causes of erectile dysfunction?

A

diabetes, neurological, vascular problems

anti depressants, anti psychotics, beta blockers and iduretics

depression and performance anxiety

161
Q

How is erectile dysfunction manged?

A

modify risk factors such as smoking, increase exercise and reduce weight and alcohol

treated diabetes or HTN

psychological approach e.g. exploring anxiety

physical treatment e.g. viagra (phosphodiesterase-5 inhibitor)
intercavernosal prostaglandin self injection
vacuum pumps
surgery
topical therapy

162
Q

How are disorders of gender identify managed?

A

Hormone therapy and gender reassignment

patient has to show they can live successfully in the other gender before surgery can be considered

163
Q

How long must postnatal depression last to be diagnosed as postnatal depression

A

ONLY after 2 weeks after childbirth (before this is baby blues) What proportion of women have baby blues?

164
Q

What proportion of women have baby blues?

A

75%

165
Q

What proportion of women get PND

A

10%

166
Q

What proportion of women get pueperal psychosis?

A

0.1%

167
Q

What scale is used to assess postnatal depression?

A

Edinburgh postnatal depression (examines the last 7 days)

168
Q

How is postnatal depression managed?

A

SSRIs: sertraline and paroxetine
valporate MUST be avoided

avoid lithium if possible

ALWAYS CHECK WHERE BABY IS

169
Q

When should a mother be admitted to the mother and baby unit?

A

if ideas of infanticide or self harm and suicide

170
Q

How long does post natal depression take to resolve?

A

1 month

171
Q

PACES: post natal depression

A

CHECK WHERE BABY IS
consider admitting if severe
explain that it is quite common about 10%
address concerns e.g. guilt and provide home support
1st - CBT
2nd- SSRI (safe with breastfeeding)
will likely resolve in a month

safety net: samaritans

172
Q

How is Pueperal Psychosis managed?

A 
antipsychoitcs, anti depressants or lithium may be needed
CHECK WHERE BABY IS AND ADMIT
severe: ECT
usually recover within 6-12 weeks 
exclude organic causes e.g. insomnia
173
Q

PACES: Pueperal psychosis

A 
CHECK WHERE BABY IS
explain the diagnosis 
approx 0.1% of women get it 
linked to hormonal changes
admit to M&B Unit
recovery 6-12 weeks
30% recurrence rate
174
Q

How is BPAD manged in pregnancy?

A

avoid lithium and valproate

lithium can lead to ebstein anomaly and is secreted through the milk
monitor every 4 weeks and weekly from 36 week
will need to reduce dose following birth due to fall in GFR

175
Q

Define the classifications of learning disability

A

50-70 mild
35-49 moderate
20-34 severe
<20 profound

176
Q

What are the aspects of managing learning disability?

A

treat physical comorbidity
psychological suport (ABC antecedants, behaviour and consequences)
Education - statement of special education needs

carers support

177
Q

How is Autism Spectrum Disorder managed?

A

applied behavioural analysis

early start denver model

more than words (hanen programme)

support for parents

CBT (occasionally mood stabilisers)
special education

National Autistic Society

178
Q

What are the key features of autism spectrum disorder?

A

reciprocal socail interaction
communication problems
restricted behaviours and routine

179
Q

How is Asperger’s syndrome managed?

A

support (school GP / nurse)
routine
social skills training
advice

180
Q

How is depressionin chidlren managed?

A

CBT first

fluoxetine is the ONLY licensed drug for children

181
Q

How is school refusal managed?

A

encourage rapid return

182
Q

How is encoparesis managed?

A 
laxatives if constipated
reassures and adress stress
and toilet training 
pelvic floor exercise
star charts
183
Q

What is conduct disorder?

A

<18
animal cuelty
bullying

socialised (as part of a group)
unsocialized (loner)

184
Q

How is conduct disorder managed?

A

family education of needs
psychological therapy to encourage emotional expression
parent management training to help them reinforce positive behaviours
family therapy
education support
anger management

185
Q

How are Tic disorders managed?

A

reasure
clonidiine (alpha 2 agonist)
atypical antipsychotics

186
Q

How is ADHD managed?

A

first is parent training programme

> 6 methyphenidate for 6 weeks, if ineffective or they develop a tic –> atomoxetine

187
Q

What forms of therpay are available for personality disorders?

A 
CBT
CBT
CAT
transferance
psychodynamic psychotherapy 
therapeutic arts 
mentalisation
188
Q

How is EUPD managed?

A
  1. dialectical based therapy
  2. formulate long and short term goals and a crisis plan

mentalisation based therapy, arts, therapeutic communities

SSRIs to reduce impulsivity

provide number for out of hours social worker, community mental health workers and local crisis resolution team

189
Q

PACES: EUPD

A

explain they are more sensitive to emotions
personality disorders are often undiagnosed
explain DBT will help to understand emotions and validate emotions
recommend therapeutic communities

crisis management: provide numbers for crisis resolution team, community mental health nurse, out of hours social worker and samaritans

190
Q

Define Insomnia

A

problems getting to sleep or staying asleep for 3 nights a week for 3 months

191
Q

How is Chronic insomnia managed?

A

investigate using sleep diary or actigraphy
identify potential causes such as anxiety
advise on sleep hygiene and not to drive when tired
CBT-I for insomnia
hypnotics if major day time symptoms

short acting benzos or z drugs
lowest possible dose for max 2-4 weeks

192
Q

Which questionnaires can be used for Schizophrenia?

A

Positive and NEgative Syndrome Scale

Brief Impression Questionnaire

Specialties Mx 2021 (4 decks)

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