Psychiatry Flashcards
Depression investigations
Bedside
• Collateral history
• PHQ-9
• Hospital anxiety and depression scale
Bloods and imaging, can be helpful to rule out organic causes
• Blood glucose, FBC, U&E, TFT, Calcium
• HIV/syphilis, drug screen
• MRI/CT if atypical presentation
Depression management
I would like to care for this patient under the MDT within a community setting following a biopsychosocial, stepped-care approach
- Initially conservative by recommending sleep hygiene and actively monitoring
- Could recommend self-help based on CBT principles
- cCBT
- Assess again in 2 weeks
Bio - SSRIs (-> SSRI -> SNRI e.g. venlafaxine -> mirtazepine)
Psycho - high-intensity CBT or interpersonal therapy
Social - encourage support from family and friends, occupational therapist can help find strategies to help with effects of depression
BPAD investigations
Can do blood tests if worried about organic influences
Collateral history
PHQ-9 if depressive episode
PRIME-MD in primary care (primary care evaluation of mental disorders)
MDQ (mood disorder questionnaire)
BPAD management
I would like to care for this patient using the MDT following a biopsychosocial approach
*admit whilst giving initial treatment if acute mania
Bio
• Stop antidepressant if taking one
• Acute mania - atypical antipsychotic e.g. olanzapine, adjunctive benzodiazepine can be considered
• Mood stabiliser - lithium (monitor weekly until stable, then monitor every 3 months)
Psycho - psychoeducation, family therapy, CBT
Social - supported employment programmes, adapting in education systems, regular engagement
Acute manic relapse management
- Increase mood stabiliser dose
- Antipsychotic augmentation e.g. add haloperidol
- Consider ECT
Bipolar depression management
Limited evidence but can try olanzapine with fluoxetine
Schizophrenia investigations
Bedside, bloods, imaging approach to exclude organic causes
- Collateral history
- Neurological exam
- Cardiovascular exam
- Urine drug screen
- Blood test - FBC, U&E, TFT
- MRI/CT
Schizophrenia management
I would like to care for this patient under the MDT in secondary care where they would follow a biopsychosocial approach.
(GP - consult senior GP partner for consideration of admission)
MHA and encourage voluntary assessment, otherwise section.
Bio - atypical antipsychotics e.g. olanzapine, consider benzodiazepine first if agitated
Psycho - CBTp, family therapy
Social - care-coordination (monitor health, social problems), assertive outreach (maintain contact). Refer to early intervention service if first-episode psychosis in young person.
If you decide not to admit a patient but they are at risk of suicidal behaviours in the future (e.g. they are self-harming), what safety plan would you formulate?
- Avoid alcohol when stressed
- Ask patient who they can tell if they are stressed
- If they feel like this again, suggest seeking help from GP, A&E, local support line e.g. Samartians
- Signpost counselling services, alcohol and drugs services, housing services, HR helpline
Alcohol withdrawal investigations
Bedside and bloods approach
- FAST screening (if 3+, complete AUDIT)
- AUDIT (16+ higher risk, 20+ dependence)
- Obs
- Neurological examination
• Bloods e.g. FBC, U&E, LFT, clotting, albumin, glucose
Alcohol withdrawal management
Admit and later management by the alcohol substance misuse team using a biopsychosocial approach
Bio - chlordiazepoxide (give lorazepam if hx of seizures), pabrinex
Psycho - refer to community alcohol team and motivational coaching after stabilised
Social - occupational therapist, family support
Opioid withdrawal investigations
- Physical examination
- PHQ-9/GAD-7/HADS
- Urine drug screen
- Bloods - FBC (anaemia due to malnutrition, infection), U&E (malnutrition), LFT (impact medication dosing)
- Blood borne infections
Opioid long-term withdrawal management
Conservative • Needle exchange • Vaccination • HIV test etc. • Healthy lifestyle • Naloxone • Self-help groups
Detoxification
• Appoint key worker to support patients during this process
1. Methadone (liquid) or buprenorphine (sublingual) - patient preference
2. Lofexidine (a2-agonist) if mild dependence or detoxify over short time, also helps with withdrawal symptoms
- 12 weeks in community
- 4 weeks inpatient (significant health problems or detox of other substances)
- Refer to drugs and alcohol services
- Offer CBT
Delirium investigations
Bedside, bloods, imaging approach MoCA Urine dipstick Bloods (FBC, U&E, CRP, ABG) CXR
Delirium management
- Modify risk factors e.g. change in environment (familiar staff, family, good lighting), nutrition
- Early diagnosis and exclude other factors
- Treat causes e.g. pain, hypoxia, hyponatraemia, constipation, urinary retention, dehydration, liver/renal impairment, infection
- Minimal evidence for antipsychotics
Dementia investigations
Bedside, bloods, imaging approach
- Collateral history
- Neurological examination
- Bloods (confusion profile - FBC, U&E, TFT, B12, calcium, glucose, HIV)
- CT/MRI
Dementia general management PACES answer
Referally to memory clinic for MDT approach, which includes psychiatrists, neurologists, or geriatricians working with nurses, OT, psychologists and social workers
There, they will be cared for following the biopsychosocial model
Alzheimer’s, Lewy body dementia, and vascular dementia specific management
Bio (none for vascular)
- Acetylcholinesterase inhibitors e.g. donepezil, rivastigmine, galantamine
- NMDA-R antagonist e.g. memantine
Psycho
• Group cognitive stimulation therapy
• Offer activities to promote wellbeing
Social
• Social support e.g. meal preparation
• Inform DVLA
• Patient adaptations e.g. dossett box, reality orientation with clocks, carry ID
GAD/panic disorder investigations
Collateral history Obs Urine drug screen GAD-7 PHQ-9
Consider organic cause; bloods - FBC, TFT. ECG
GAD management
I would like to care for this patient within a community setting following a biopsychosocial, stepped-care approach
- Initially recommend education and active monitoring e.g. sleep hygiene, exercise, reduce caffeine, come back in 2 weeks
- Low intensity psychiatric intervientions e.g. self-help, psycho-educational groups
- High intensity CBT / applied relaxation. Consider sertraline (SSRI) -> duloxetine/venlafaxine (SNRI) -> pregabalin
- Combination therapy in MDT
Panic disorder management
I would like to care for this patient within a community setting following a biopsychosocial approach
Bio
1. SSRI
2. TCA e.g. imipramine if no response after 12 weeks
• No benzos
Psycho
• CBT
• Relaxation training
Social
• Support from family and friends
Phobias management
SSRI/SNRI
Beta-blockers
OCD management
I would like to care for this patient within a community setting following a biopsychosocial, stepped-care approach
Mild - low-intensity CBT and ERP, SSRI if not engaging
Moderate - SSRI or intensive CBT + ERP
Severe - SSRI + CBT + ERP
PTSD investigations and management
Collateral history PHQ-9 GAD-7 Check body for trauma PTSD checklist
I would like to care for this patient within a community setting following a biopsychosocial approach
Bio
• SSRI -> SNRI -> Mirtazepine
• Antipsychotic e.g. risperidone
Psycho
• Trauma focused CBT
• EMDR (eye movement desensitisation and reprocessing)
Social
• Social prescriber for finances
• Mind.co.uk for psychoeducation
Anorexia specific questions
SCOFF
Sick - do you make yourself sick?
Control - do you worry you have lost control over how much you eat?
One - have you recently lost 1 stone in a 3 month period
Fat - do you find that you tell yourself that you’re fat when others say you’re thin?
Food - would you say that food dominates your life?
Anorexia investigations
Bedside, bloods approach
- Obs
- Physical examination - muscle tone, hair, hydration
- BMI
- Squat test - difficulty standing from squatting
- ECG
- FBC
- U&E
- TFT
Anorexia management
I would like to care for this patient under an MDT (medical, psychology, dietician, OT)
Adults
• CBT-ED
• MANTRA (Maudsley anorexia nervosa treatment for Adults)
• SSCM (specialist supportive clinical management)
Children
• Anorexia-focused family therapy
• CBT
Anorexia explanation in counselling
You have a condition called anorexia nervosa, which is characterised by a resctricted energy intake leading to low body weight, an intense fear of gaining weight, and a disturbance in the way people perceive their body. This can lead to various health problems, which is why we would like to treat you.
Bulimia management
I would like to care for this patient under an MDT (medical, psychology, dietician, OT)
Adults
- Bulimia-nervosa-focused guided self-help
- CBT-ED
Children
• Bulimia-nervosa-focused family therapy
Trial of fluoxetine currently licensed but no long-term data
Perinatal red flag questions
- New disturbing feelings and thoughts that you’ve never had before?
- Thoughts of suicide or harming yourself in violent ways?
- Feeling incompetent or estranged from your baby?
- Do you feel you might or are getting worse?
Perinatal psychiatry investigations
Dependent on history
- Collateral history
- Edinburgh Postnatal Depression scale (>13/30 - depressive illness)
Postpartum psychosis (present within 2-3 weeks of birth) management
I would like to admit this patient to the mother and baby unit where she would be cared for under an MDT.
- Treat with antipsychotics e.g. olanzapine or quetiapine
- May require rapid tranq e.g. lorazepam
- Enhanced nursing supervision and help orientate the patient
- Consider acute psych admission if severe and even ECT
Management for BPAD in pregnancy
Consult the psychiatrist and obstetrician
- Avoid medications, and prescribe the lowest effective dose if required
- Lithium increases risk of Ebstein anomaly - if they require it, carefully monitor dose and serum levels throughout pregnancy, delivery and postnatal
- Consider ECT if med risk > ECT risk
Different levels of intellectual disability
Mild
• Difficulty with complex language concepts and academic skills
• Basic activities normal
• Independent living but may require support
Moderate
• Difficulty with complex language concepts and academic skills
• Some fine with basic activities
• Require considerable and consistent support to be independent
Severe
• Limited language and academic skills
• May acquire basic skills with intensive training
• May have motor impairments
• Require daily support in supervised environment
Profound
• ‘Adaptive’ behaviour differences from severe
Intellectual disability assessment
- WAIS IV (Wechsler Adult Intelligence Scale) = verbal IQ + performance IQ
- ABAS II (adaptive behaviour assessment system)
- Historical medical information + school reports
Intellectual disability
I would like to care for this patient under the MDT in where they would follow a biopsychosocial approach.
This would involve: • Community LD nurses • Psychiatrists • Psychologists • OT • SALT • Physio • Dieticians
Bio
• Concurrent psychiatric problems e.g. melatonin for sleep
Psycho • Antecedent-behaviour-consequence behavioural treatment • CBT • Family therapy • Creative therapy
Social
• Skills training - develop independent living
• Environmental change - level of stimulation, abuse/neglect
ASD assessment
Specialist paediatrician / psychiatrist diagnosis
• Revised ADI-R (autism diagnostic inventory)
• ADOS (autism diagnostic observatory schedule)
• Diagnostic interview for social and communication disorders (DISCO)
ASD management
I would like to care for this patient under the MDT in where they would follow a biopsychosocial approach.
Bio
• Comorbid conditions e.g. risperidone for challenging behaviour, SSRI for obsession
Psycho
• Positive behaviour support
Social
• Family education
• Social skills training
• SALT assessment
ADHD assessment
- ADHD rating scale (based on DSM criteria) 6+ features need to be present from DSM-V.
- Vanderbilt Scale
(Conners Adult ADHD rating scale in adults)
- Full developmental history
- Consider neuropsychological testing to rule out intellectual disabilities
- Baseline ECG if considering ADHD medical treatment
- Physical examination to rule out other problems e.g. hyperthyroidism
ADHD management
Hollistic approach e.g. parent training and behaviour classroom intervention first. Then watch and wait for 10 weeks.
If this doesn’t help, I would like to refer this patient to secondary care where they would follow a biopsychosocial approach and managed under an MDT (school nurse, OT, neurologists, SALT, paediatrics, psychiatrist).
Bio (last resort)
1. Stimulants e.g. methylphenidate (ritalin) - pre-synaptic DA transporter antagonist + postnaptic DRD4 agonist
• 6 week trial basis, monitor weight and height every 6 months
• Titrate over 4-6 weeks
2. Non-stimulants e.g. atomoxetine (NA reuptake inhibitor)
Psycho
• Education
• Parents skills training e.g. Webster Stratton
• ABC-CBT
Social
• School interventions
• Environmental change
• Special education needs statement should be obtained
ADHD pre-drug assessment
- Cardio history + FHx
- HR, BP
- Weight
Personality disorder assessment
Dependent on hx • SAPAS (standardised assessment of Personality-Abbreviated Scale) • Urine drug screen • PHQ-9 • GAD-7
Personality disorder management
I would like manage this patient following the biopsychosocial model.
Bio (cluster A: odd/eccentric)
• Low-dose antipsychotics e.g. aripiprazole
• Antidepressants e.g. sertraline
Bio (cluster B: dramatic)
• Mood stabilisers e.g. lithium
• Anticonvulsants e.g. valproate
Bio (cluster C: anxious)
• SSRI e.g. sertraline
Psycho
• Dialectical behavioural therapy
• Mentalisation-based therapy
• Psychotherapy for bordeline
Social - dependent
• Help with social circumstances e.g. mitigating circumstances at uni
• Subtance use disorder treatment programme referral
• Provide contact number for community mental health nurse / crisis team
Lithium toxicity management
Stop lithium - one of the few times it can be stopped abruptly
Mild-moderate
• Volume resuscitation with normal saline
• Recheck levels every 6-12 hours
Severe
• Haemodialysis
Lithium toxicity precipitation
- Dehydration
- Renal failure
- Diuretics e.g. thiazides, ACEi, NSAIDs
How to withdraw benzodiazepine and what happens if withdrawn too quickly?
Reduce 1/8 of a dose every 2 weeks
If having difficulty:
• Switch to long-acting BDZ like diazepam if not on that
• Reduce every 2 weeks in steps of 2mg
Can take from 1 month up to 1 year
May consider anticonvulsants
Consider psychotherapy
Refer to specialist addiction service
If withdraw too quickly: • Insomnia • Irritability • Tinnitus • Perspiration • Seizures
Benzodiazepine OD investigations
- O2 sats
- ECG (heart block)
- ABG - ?hypoxia ?metabolic acidosis
- FBC, U&e (?AKI), LFT (?paracetamol)
- CK (?elevated)
- Plasma paracetamol
Benzodiazepine overdose management
I would like to carry out an A-E assessment
• Call for help from crash team including anaesthetist and emergency medical team
• Insert wide-bore IV cannula
A - check airways is patent if they can’t talk, insert an airway
B - check RR, O2, and auscultate for other pathology
C - check BP, cap refill, cardiac rhythm and fluid balance. BDZ may be hypotensive and require fluid resus.
D - check pupils, glucose
E - exposure, hypothermia, inspect for injuries etc.
- Flumazenil not licences but could be considered with expert advice if benefits>risks
- Consider activated charcoal if <1 hour
Paracetamol overdose investigations
• Obs
- Serum paracetamol
- LFT
- Clotting
- Glucose - ?hypo
- ABG - ?lactic acidosis
- FBC
Paracetamol overdose management
Explain this is damaging to the liver, could lead to death, and may need a transplant in the future.
Acute
• Activated charcoal <1 hour
• IV N-acetylcysteine (replenishes glutathione to break down NAPQI) dependent on time + serum paracetamol
• Consult TOXBASE for management
Sub-acute
• Explain need for admission informally
• Consider assessment for section 2 under MHA if refused
Long-term: biopsychosocial
Bio - SSRI (review within 1 week due to suicidal ideation)
Psycho - CBT
Social - potentially involve family and social services
Antipsychotic monitoring
Start • FBC, U&E, LFT • Lipids, weight • Fasting blood glucose, prolactin • BP • ECG
Weekly
• FBC for clozapine
Titration
• BP
At 3 months
• Lipids, weight
6 months
• Fasting blood glucose, prolactin
Annually • FBC, U&E, LFT • Lipids, weight • Fasting blood glucose, prolactin • Cardio risk assessment
