Psychiatry Flashcards
Which drugs can be used for augmentation if SSRI/SNRI was ineffective?
Atypical antipsychotic (e.g. quetiapine)
Lithium
Thyroxine
Buspirone
What guides the prescription of acetylcholinesterase inhibitors for patients with Alzheimer’s dementia?
MMSE 10-20 (moderately severe)
What is the optimum dose of venlfaxine recommended for GAD?
75 mg
By what age does autism start to impair function/manifest as abnormal development?
3 years
Outline the risks of SSRIs in pregnancy.
1st trimester: congenital heart defects
3rd trimester: persistent pulmonary hypertension
Paroxetine has an increased risk of congenital malformations, particularly in the 1st trimester
Sertraline, fluoxetine and citalopram are generally considered safe
Which agent is often used for rapid tranquillisation of an agitated patient?
Lorazepam
Alternative: olanzapine, haloperidol
How long do high-intensity psychological interventions go on for?
16-20 sessions over 3-4 months
What proportion of patients diagnosed with anorexia nervosa will make a full recovery?
20%
Name a tool used to assess the severity of alcohol withdrawal.
Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)
What is a particularly important aspect of the management of depression in the elderly?
Problem-solving
Increased socialisation and day-time activities
How long do low-intensity psychosocial interventions go on for?
Roughly 9-12 weeks with follow-up
Describe how you should switch from citalopram, escitalopram, sertraline or paroxetine to another SSRI.
First should be withdrawn before the alternative is started
How long do symptoms of depression need to be present to be diagnostic?
2 weeks
How is the MMSE score interpreted?
24 or more = normal
18-23 = mild
10-17 = moderate
< 9 = severe
NOTE: raw score should be corrected based on educational attainment and age
Outline the behavioural management approach for delirium.
Frequent reorientation (clocks, calendars)
Good lighting
Address sensory problems (e.g. hearing aids)
Minimise change (don’t keep moving the patient, one staff member per shift, establish routine)
Allow safe and supervised wandering
How should delirium tremens be managed?
Reducing benzodiazepine (chlordiazepoxide) regime IV pabrinex
NOTE: lorazepam may be used in hepatic failure
How are conversion disorders managed?
Encourage a return to normal activities and avoid reinforcing symptoms
Provide support for addressing stressors
What are some medical management options for preventing relapse in alcohol abuse?
Acamprosate (anti-craving)
Disulfiram
What is the FAST screening tool?
Consists of a subset of questions from AUDIT
A score of 3 or more is FAST positive
Which service should be involved in the care of a young person with first episode psychosis?
Early intervention service (EIS)
What is a major side-effect of chlorpromazine?
Skin photosensitivity (requires sunscreen)
What is treatment resistance schizophrenia?
Failure to respond to two or more antipsychotics, at least one of which is atypical, each given at a therapeutic dose for at least 6 weeks
State the duration of the following types of section. 2 3 4 5(2) 5(4) 35 37 135 136
2 - 28 days 3 - 6 months 4 - 72 hours 5(2) - 72 hours 5(4) - 6 hours 35 - 28 days 37 - 6 months 135 - 24 hours (up to 36) 136 - 24 hours (up to 36)
Which SSRI has a long half-life?
Fluoxetine
Define somatisation disorder.
• The main features are multiple, recurrent and frequently changing physical symptoms of at least 2 YEARS duration.
NOTE: if it has been going on for < 2 years, it is an undifferentiated somatoform disorder
What are the components of an AMTS?
How old are you?
What is the time to the nearest hour?
Give an address and ask them to recall it at the end
What is the year?
What is the name of the hospital or place you are currently at?
Can you recognise two people (doctor and nurse)?
What is your date of birth (day and month)?
In which year did WW2 begin?
Name the current prime minister.
Count backwards from 20 to 1
What is the first-line SSRI used for generalised anxiety disorder?
Sertraline
Paroxetine is the only licensed SSRI for GAD
List some transcultural psychiatric disorders.
Amox - Malaysia - frenzied killing spree
Koro - Asian - fear of penis disappearing
Piblokto - Inuits - sudden-onset hysteria (screaming)
Dhat - Indian - semen lost in urine
Latah - North Africa/Far East - exaggerated startle, echolalia or obeying commands, amnesia
Susto - South America - severe depressive episode after a traumatic event (often accompanied by diarrhoea and tics)
Windigo - North America - body is possessed by spirit that craves human flesh
List some physical/pharmacological treatments for erectile dysfunction.
Sildenafil
Intracavernosal prostaglandin self-injection
Vacuum pumps
How long do symptoms of PTSD have to last to be diagnostic?
> 1 month
Which benzodiazepine has the shortest half-life and what are the clinical implications?
Lorazepam - leads to worse withdrawal symptoms
Patients withdrawing may be switched from lorazepam to diazepam
Which medication can be used to prevent relapse in patients with opiate misuse?
Naltrexone
Which SSRI would be best to use in anorexia nervosa?
Fluoxetine (stable in terms of weight)
NOTE: you don’t want to give these patients anything that will make them gain weight too rapidly
Which tools are used to distinguish dementia from delirium?
Long Confusion Assessment Method (CAM)
Observational Scale of Level of Arousal (OSLA)
Which medications can be used for alcohol detoxification?
Chlordiazepoxide
Diazepam
NOTE: lorazepam can be used in cases of liver failure
What are the treatment approaches for emotionally unstable personality disorder?
Dialectical behavioural therapy Mentalisation-based therapy Therapeutic communities Arts therapy Transference focused therapy
Which social aspects of a patient with schizophrenia require management?
Social skill training Education, training and employment Skills (e.g. cooking, budgeting) Housing Accessing social activities Developing personal skills (e.g. creative writing)
List some triggers for lithium toxicity.
Salt balance changes (e.g. dehydration, D&V)
Drugs interfering with lithium excretion (e.g. diuretics)
Accidental or deliberate overdose
What is the Young Mania Rating Scale?
Uses 11 questions with a total score of 60
Scores
Outline the aspects of managing autism spectrum disorder.
Support and advice for families (National Autistic Society)
Behaviour therapy
Speech and language therapy
Special education
Treat comorbid problems (e.g. epilepsy)
Antipsychotics and mood stabilisers are occasionally used
List some side-effects of clozapine.
- Agranulocytosis, neutropaenia
- Reduced seizure threshold
- Constipation
- Myocarditis (baseline ECG should be taken before starting treatment)
- Hypersalivation
List the side-effects of SNRIs.
Constipation
Hypertension
Raised cholesterol
They also have all the SSRI side-effects
If a patient with postnatal depression required admission, where should she be admitted?
Mother and Baby Unit
Which investigations/further management should a GP recommend for a patient with suspected Alzheimer’s disease?
Physical examination
Blood tests
Refer to old age psychiatry outpatient clinic (memory clinic)
How should benzodiazepines be withdrawn?
Reduce by 1/8 of the dose every fortnight
List some symptoms of refeeding syndrome.
Weakness Fatigue Rhabdomyolysis Leucocyte dysfunction Respiratory failure Cardiac failure Hypotension Arrhythmia Seizure Coma This phenomenon usually occurs within four days of starting to feed again.
Which receptors are blocked by typical and atypical antipsychotics?
Typical = dopamine (D2) Atypical = dopamine and 5HT2
What is overshadowing?
When a patient’s presenting symptoms are assumed to be due to an underlying learning disability rather than another, potentially treatable, cause
Which forms of psychological therapy may be useful in schizophrenia?
CBT (for all patients)
Family therapy (particularly useful if high expressed emotion)
Concordance therapy
Describe the features of benzodiazepine withdrawal.
Nausea and vomiting Autonomic hyperactivity insomnia Delirium Seizures
How long do features of conduct disorder need to occur to be diagnostic?
6 months
How long does postnatal depression and puerperal psychosis usually take to recover?
Depression: 1 month
Psychosis: 6-12 weeks
What counts as a ‘brief intervention’ for alcohol dependence?
5-10 mins of information
2-3 sessions of motivational interviewing
What are the aspects of management of learning disabilities?
Treat physical comorbidity
Treat psychological comorbidity
Statement of Special Educational Needs (maximise potential)
Psychological therapy (group therapy, counselling)
What is the oestrogen hypothesis?
Potential explanation for why women respond better to TYPICAL antipsychotics (like haloperidol)
Describe the features of amphetamine withdrawal.
Dysphoric mood
Fatigue
Agitation
What criteria need to be fulfilled to be able to discharge a patient with puerperal psychosis?
Developed some insight into the nature of the illness and is adherent with medication
No longer a risk to herself or the baby
Outline the interpretation of the HAD.
7 questions for anxiety and 7 for depression (maximum 21 points for each)
Normal: 0-7
Borderline: 8-10
Anxiety/Depression: 11-14
What counts as mild, moderate and severe depression?
Mild
• 2 or 3 core symptoms
• At least 2 other symptoms
• The patient is distressed about the symptoms but can still continue with most activities
Moderate
• 2 or 3 core symptoms
• At least 3 other symptoms
• The patient has considerable difficulty continuing with ordinary activities and social functioning
Severe
• All 3 core symptoms
• At least 4 other symptoms, some of which are intense
• Major impact on quality of life and social functioning
• May show distress and/or agitation
NOTE: All symptoms must be present for at least 2 weeks
How should depression in BPAD be managed?
Antidepressant + mood stabiliser OR antipsychotic
Risk of precipitating mania
What are the features of alcohol withdrawal syndrome and how long after the last drink will it occur?
4-12 hours after the last drink Coarse tremor Sweating Insomnia Tachycardia Nausea and vomiting Psychomotor agitation Generalised anxiety
Where can detoxification for alcohol be given?
Inpatient detox
Community detox
What are the risks of using benzodiazepines in pregnancy?
1st trimester exposure is associated with cleft palette
Outline how a score from AUDIT is interpreted.
20+ = possible dependence 16-19 = high risk 8-15 = moderate risk 0-7 = low risk
Max = 40
What are the aspects of management of medically unexplained symptoms?
Reattribution model Avoid unnecessary investigations Emotional support Antidepressants CBT Graded exercise
What is the difference between Fregoli and Capgras syndromes?
Fregoli: delusion that a persecutor is able to change into many forms and disguise themselves to look like different people
Capgras: delusional belief that a close acquaintance has been replaced by an identical double
Which psychological therapies are available for patients with dementia?
Reminiscence therapy
Validation therapy
Multisensory therapy
Cognitive stimulation therapy (memory training)
What are the stages of change model?
Pre-contemplation Contemplation Preparation Action Maintenance Relapse
What are some psychological therapy options for alcohol abuse?
CBT
Problem-solving therapies
Group therapy (alcoholics anonymous)
Which mood stabiliser is considered safest to use in pregnancy?
Lamotrigine
Lithium –> Ebstein anomaly
Valproate and Carbamazepine –> NTD
Which SSRIs are associated with a dose-dependent increase in QTc?
Citalopram
Escitalopram
Which SSRIs have a high propensity for drug interactions?
Fluoxetine and paroxetine
What is an IMHA?
Independent Mental Health Advocate
Advocate who helps the patient find out their rights under the MHA and provide support whilst detained
NOTE: patients on section 4, 5, 135 and 136 cannot have an IMHA
Which agents may be used as substitutes in opiate misuse?
Methadone (liquid, full agonist) or buprenorphine (sublingual tablet, partial agonist)
NOTE: these are taken in a supervised environment
Buprenorphine causes less sedation so allows patients to work better, but taking heroin with buprenorphine is dangerous so it’s preferred for patients with mild/moderate dependence
What is the antidepressant of choice to treat the depressive phase of BPAD?
Fluoxetine
List some indications for ECT.
Catatonia
Prolonged or severe manic episode
Severe depression that is life-threatening
Which treatment option is best for children with eating disorders?
Family therapy (eating disorder-focused)
Which features distinguish personality disorders from personality traits?
Pervasive: occurs in all/most areas of life
Persistent: evident in adolescence and continues through adulthood
Pathological: causes distress to self or others, impairs function
List some clinical signs of anorexia nervosa.
Constipation
Bradycardia
Hypothermia
Sensitivity to the cold
What are two psychological therapies that are used to treat PTSD?
Trauma Focused CBT
EMDR (eye movement desensitisation and reprocessing)
Describe how you would switch from fluoxetine to venlfaxine.
Withdraw then start venlafaxine at 37.5 mg OD and increase very slowly
What is the most common cause of maternal death during pregnancy and the 1st year postpartum?
Suicide
NOTE: within 6 weeks postpartum it is VTE
Describe the features of benzodiazepine use.
Loss of coordination Slurred speech Decreased attention and memory Disinhibition Aggression Hypotension Respiratory depression
How is tardive dyskinesia treated?
Tetrabenzene
What is the main pharmacological treatment option for patients with dementia?
Acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine)
How is schizoaffective disorder treated?
Same treatment as schizophrenia
You may add a mood stabiliser or antidepressant for the affective component
How long do symptoms of generalised anxiety disorder have to last in order to be diagnostic?
6 months
Which high-intensity psychological therapies may be offered to patients with moderate-to-severe depression?
Individual CBT
Interpersonal Therapy
List some complications of bulimia nervosa.
Hypokalaemia Dehydration Enlargement of parotid glands Dental caries Mallory-Weiss tears Osteoporosis Russell's sign
Which antipsychotics are particularly associated with weight gain?
Olanzapine and clozapine
Who should be offered group CBT?
Individuals with mild-to-moderate depression who decline low intensity psychological therapies
What are the main risks of using antipsychotics in the elderly?
Stroke and VTE
Why should antipsychotics be avoided in Lewy Body dementia?
They precipitate parkinsonism
How is Asperger’s syndrome managed?
Advice and support
Social skills training
Which pre-existing conditions can be worsened by acetylcholinesterase inhibitors?
Peptic ulcer disease
COPD
Asthma
Cardiac arrhythmias
Describe the features of amphetamine intoxication.
Euphoria Insomnia Agitation Hallucination Hypertension Tachycardia
List some features that suggest the patient is at high risk of attempting suicide again.
Careful planning
Final acts in anticipation of death (e.g. writing wills)
Isolation at the time of the act
Precautions taken to prevent discovery (e.g. locking doors)
Writing a suicide note
Definite intent to die
Believing the method to be lethal (even if it wasn’t)
Violent method (e.g. shooting, hanging, jumping in front of a train)
Ongoing wish to die/regret that the attempt failed
How often should a patient with newly diagnosed depression be followed-up after starting an antidepressant?
Review after 2 weeks (if no particular risk of suicide), then every 2-4 weeks thereafter for 3 months
What criteria must be fulfilled for a diagnosis of chronic insomnia?
Diagnosed if a person has trouble falling asleep or staying asleep at least 3 nights per week for 3 months
How does the pattern of BPAD change with age?
Remissions become shorter and depressive episodes become more frequent
How is depression in children managed?
CBT
Antidepressants (fluoxetine) may be used in severe cases
List some discontinuation symptoms of SSRIs.
Flu-like symptoms
Electric shock sensations
Headaches
Vertigo
When is section 48 used?
For the transfer of an unsentenced prisoner to hospital for detention
Section 49 is a restriction order that can be applied by the Ministry of Justice
What is considered treatment resistance depression?
Failure to respond to 2 adequate trials of different classes of antidepressants at adequate doses and for a period of 6-8 weeks
What is the therapeutic range for lithium?
0.6-1.0 mmol/L
Becomes toxic > 1.2 mmol/L
Over what period of time should antidepressants be stopped?
4 weeks
Not necessary with fluoxetine due to the long half life
According to DSM-V, how long do psychotic symptoms in schizoaffective disorder need to last to be diagnostic?
Psychosis must be sustained for > 2 weeks without affective symptoms
Requires 2 episodes of psychosis to qualify: 1 without affective symptoms, 1 with affective symptoms
Under what conditions can activated charcoal be used for drug overdoses?
Oral drugs
Within 1 hour of consumption
How can normal pressure hydrocephalus be treated?
Ventriculoperitoneal shunt
What should be done if a clozapine dose is missed for > 48 hours?
The dose should be carefully retitrated up (as if starting therapy from scratch)
What is applied relaxation therapy?
Used for anxiety disorders
Teaches patients how to spot the signs of tension, relax their muscles to relieve tension and apply these techniques to stressful situations
12-15 weekly sessions
What is the main aim of CBT in schizophrenia?
Emphasis on reality testing
Encourage the patient to think about evidence and alternative explanations
What needs to be monitored after a patient is started on lithium and how regularly should this happen?
Lithium levels - at 1 week after starting, then weekly until therapeutic level is reached. Then every 3 months (12 hours post dose).
U&E - every 3 months
TFTs - every 6 months
Creatinine clearance - annually
Which low-intensity psychotherapies may be offered to patient with mild-to-moderate depression?
Individual-guided self-help based on the principles of CBT
Computerised CBT
Structured group physical activity programme
What type of drug is mianserin?
Tetracyclic antidepressant
Define 1 unit of alcohol.
8 g of pure ethanol
10 ml of pure ethanol
Amount of alcohol that an adult can metabolise in 1 hour
What are the steps in the management of generalised anxiety disorder?
1) education about GAD + active monitoring
2) low-intensity psychological intervention (individual non-facilitated self-help or individual-guided self-help or psychoeducational groups)
3) high-intensity psychological intervention (CBT or applied relaxation) or drug treatment
4) highly specialist input
What are the criteria for diagnosing ADHD?
Age 6-12 years
Occurring in > 1 environment
Clear evidence of academic or social problems
Duration of at least 6 months
What are the clinical features of the cheese reaction (in patients taking MAOi)?
Severe hypertension
Tachycardia
Pyrexia
Tyramine is found in red wine, cheese, Marmite, broad beans)
What are some treatment options for low libido?
Sensate Focus Therapy (ban intercourse, then progress to genital caressing and eventually intercourse)
Timetabling sex
Which class of antihypertensive drugs are associated with causing a low mood?
Beta-blockers
Outline how the GAD7 is interpreted.
Asks about 7 questions and their frequency Mild: 5-10 Moderate: 10-15 Severe: 15+ Maximum = 21
NOTE: it can also be used for PTSD, panic disorder and social anxiety
Describe the clinical features of opiate withdrawal.
Appear 6-24 hours after the last dose Lasts 5-7 days Dilated pupils Sweating Tachycardia Hypertension Piloerection (hairs on end) Watering eyes/nose Yawning Cool, clammy skin (cold turkey)
List some side-effects of SSRIs.
GI upset
GI bleeding (if using NSAIDs, give with a PPI)
Increased anxiety/agitation soon after starting
List some psychotherapy options that may be used for anorexia nervosa.
Eating Disorder CBT
Specialist Supportive Clinical Management (SSCM)
Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
Family Therapy (best for children)
Interpersonal Therapy
Which antidepressant is recommended in patients with comorbid medical conditions due to low risk of drug interactions?
Sertraline
What are the criteria for diagnosis of bipolar I disorder?
At least one manic episode
Depressive episodes are common (more than 90% chance) but not necessary to make the diagnosis
Name two forms of nicotine replacement therapy.
Varenicline
Bupropion
List some side-effects of lithium.
o Nausea/vomiting and diarrhoea
o Fine tremor
o Nephrotoxicity: polyuria (secondary to nephrogenic DI)
o Thyroid enlargement (and hypothyroidism)
o ECG: T wave flattening/inversion
o Weight gain
o Idiopathic intracranial hypertension
o Hyperparathyroidism -> features of hypercalcaemia
What are the two main subtypes of emotionally unstable personality disorder?
Impulsive: characterised predominantly by emotional instability and lack of impulse control
Borderline: characterised by disturbances in self-image, aims and internal preferences. Chronic feelings of emptiness, unstable interpersonal relationships and a tendency to self-destructive behaviour (including suicide gestures and attempts).
What are the aspects of managing tic disorders?
Reassure and stress management Habit reversal training Exposure and response prevention Clonidine (alpha-2 agonist) Haloperidol (antipsychotic)
What is interpersonal therapy?
Examines how the patient interacts with other people and teaches social skills and improves social functioning
List some features of lithium toxicity.
- GI disturbance
- Sluggishness
- Giddiness
- Ataxia
- Gross tremor
- Fits
- Renal failure
Briefly outline the step by step pharmacological management for depression.
STEP 1: SSRI (e.g. sertraline)
STEP 2: Taper down SSRI, start SNRI (e.g. venlafaxine)
STEP 3: Add augmentation - either atypical antipsychotics (e.g. quetiapine) or another antidepressant (e.g. mirtazapine)
STEP 4: ECT
What advice should you provide to a patient who is being started on SSRIs?
- Can cause hyponatraemia
- Can cause reduced libido/sexual dysfunction
- Lower seizure threshold (careful in epilepsy)
- Avoid in mania or hypomania
- Do not drink alcohol (increased sedation)
- Never drive if feeling drowsy on antidepressants
- Explain that the onset of action is delayed
What type of drug is zopiclone?
Cyclopyrrolone
Which medications can be used for acute alcohol withdrawal?
Chlordiazepoxide
Diazepam
NOTE: carbamazepine is an alternative
What are some side-effects of drugs used in ADHD?
Insomnia Reduced appetite (and growth)
How is acute dystonia treated?
Procyclidine
List some examples of MAO inhibitors.
Selegiline
Phenylzine
Moclobemide (reversible)
List some symptoms of serotonin syndrome.
Triad of altered mental state (agitation), neuromuscular changes (hyperreflexia, myoclonus, tremor) and autonomic dysfunction (sweating, dilated pupils, diarrhoea)
Describe how you should switch from SSRI to a TCA.
Cross-taper
Except with fluoxetine (withdraw completely before starting TCA)
How soon after an episode of self-harm should the patient be followed-up?
1 week
This can be in outpatient clinic, CMHT, GP or counsellor
What are the main components of mental capacity?
Understanding information
Retaining information
Weighing up the options
Communicating their thoughts
Describe how you should switch from fluoxetine to another SSRI.
Withdraw then leave a gap of 4-7 days (fluoxetine has a long half-life) before starting a low-dose of the new SSRI
How is neuroleptic malignant syndrome managed?
Stop antipsychotics immediately
Get urgent medical treatment (usually ITU)
Treat hyperthermia (cooling blankets, ice packs)
Dantrolene may be used for muscle rigidity
Benzodiazepines may be necessary for agitation
High myoglobin can cause AKI (IV fluids and dialysis may be required)
If a patient has a mild cognitive impairment, who is responsible for informing the DVLA about the diagnosis?
If mild, the patient should be encouraged to inform the DVLA
If the patient continues to drive despite advice to inform the DVLA, the doctor can breach confidentiality
What are the management options for panic disorder?
CBT and SSRI
Offer TCA (e.g. clomipramine, imipramine) if SSRI is contraindicated or no response after 12 weeks
Which medication can be used for symptomatic relief during opiate withdrawal?
Lofexidine (alpha agonist)
What is HoNOS?
Used to measure behaviour impairment, symptoms and social functioning
Used in severe mental illness
NOTE: GAS (global assessment scale) is a similar sale that assesses overall functioning in people with mental health problems
What is a carer’s assessment?
A free assessment that can be done by social services that conducts an interview with the carer and helps improve their ability to care for the patient
What is the maximum score for a MoCA and what score would warrant further cognitive assessment?
Max = 30
Refer for further assessment if 25 or less
Outline how the PHQ-9 is interpreted.
9 questions each worth 3 points None: 0-4 Mild: 5-9 Moderate: 10-14 Moderately Severe: 15-19 Severe: 20-27
What is the main difference between anorexia nervosa and bulimia nervosa?
Anorexia nervosa BMI < 17.5 or weight loss of > 15%
What are the three classes of personality disorder?
A - odd (paranoid, schizoid)
B - dramatic (histrionic, emotionally unstable, dissocial)
C - anankastic, dependent, anxious
What are the aspects of managing conduct disorder?
Family education Family therapy (take a problem-solving approach) Parent management training Educational support Anger management for children
Which high-intensity psychological therapies should be offered for GAD?
CBT
Applied relaxation
What are the steps in the pharmacological management of generalised anxiety disorder?
1) SSRI
2) switch to SNRI
3) Add pregabalin
4) consider quetiapine (not licensed)
Which low-intensity psychological therapies should be offered for GAD?
Individual non-facilitated self-help
Individual guided self-help
Psychoeducational groups
What required monitoring during clozapine treatment and how regularly?
FBC o Weekly for 18 weeks o Then every 2 weeks up to 1 year o Then monthly Lipids and Weight o Baseline o Every 3 months for 1 year o Annually Fasting BM o Baseline o 1 month o Every 4-6 months Prolactin o Baseline o 6 months o Annually U&E and LFT o At the start of therapy o Annual Blood Pressure o Baseline o Frequently during dose titration ECG o Baseline Cardiovascular Risk Assessment o Annually
Outline the management of lithium toxicity.
Stop lithium
Transfer for medical care (rehydration, osmotic diuresis)
If overdose is severe, the patient may need gastric lavage or dialysis
List some biochemical consequences of bulimia nervosa.
Hypokalaemia
Hypocalcaemia
Hypotension
Reduced red cell count
Which investigations should be considered in a patient presenting with mania/BPAD?
o Collateral history
o Physical examination (establish baseline state)
o Bloods: FBC, TSH, U&E, LFT, ECG
o Urine drug screen
o Rating scale: Young Mania Rating Scale
o Risk assessment
Which pharmacological treatments may be used in PTSD?
Venlafaxine or an SSRI is first-line ONLY IF drug therapy is required
NOTE: risperidone may be used in severe cases
NOTE: mirtazapine is good if they are having problems getting to sleep
What is the first line antipsychotic medication used for the treatment of a psychotic illness?
Olanzapine (usually starting with 10 mg)
Maximum dose: 20 mg (minimum therapeutic dose is 7.5-1 mg)
Which mood stabiliser does not need monitoring of drug levels?
Sodium valproate
What are some management options for chronic fatigue syndrome?
Graded exercise (scheduled and gradually increasing activity) - recently been scrapped by NICE CBT - treats anxiety surrounding the illness but not the illness itself
Outline the classification of learning disability based on IQ.
o 50-70 = Mild
o 35-49 = Moderate
o 20-34 = Severe
o < 20 = Profound
List which antidepressants are associated with the following risks: • Drug Interaction • Discontinuation Symptoms • Death from Overdose • Overdose • Stopping treatment due to side-effects • Blood Pressure Monitoring Needed • Worsening Hypertension • Postural Hypotension and Arrhythmia
- Drug Interaction: fluoxetine, fluvoxamine, paroxetine
- Discontinuation Symptoms: paroxetine
- Death from Overdose: venlafaxine
- Overdose: TCAs (except lofepramine)
- Stopping treatment due to side-effects: venlafaxine, duloxetine, TCAs
- Blood Pressure Monitoring Needed: venlafaxine
- Worsening Hypertension: venlafaxine, duloxetine
- Postural Hypotension and Arrhythmia: TCA
According to DSM-V, how long do symptoms last in acute stress reactions?
At least 3 days
Should disappear within 1 month
What are some coping strategies that can be used for patients with thoughts of self-harm?
Distraction techniques
Mood-raising activities (e.g. exercise)
Prevention of self-harm (put tablets and sharp objects away, stay in public places with supportive people, call a friend/support line, avoid drugs and alcohol)
Transitions between which antidepressants must you be particularly careful with?
From fluoxetine to other antidepressants (as fluoxetine has a long half-life)
From fluoxetine or paroxetine to a TCA (both drugs inhibit TCA metabolism so a lower starting dose may be needed)
To a new serotoninergic antidepressant or MAOI (because of risk of serotonin syndrome)
From non-reversible MAOI: a 2-week washout period is required (other antidepressants should not be prescribed during this period)
What are the defining features of dependence syndrome?
Craving
Control (difficulties controlling use)
Persistent Use (despite knowledge of harmful consequences)
Priority (higher priority given to drug use than other normal activities)
Tolerance (increased)
Withdrawal
Which SSRIs are recommended for postnatal depression?
Sertraline and paroxetine
Which medication is most commonly used for the treatment of OCD?
Fluoxetine 60 mg (high dose)
What is the mechanism of action of memantine?
NMDA receptor antagonist
Which medications may be used for ADHD?
Methylphenidate, lisdexamphetamine
Atomoxetine (non-stimulant)
How is postnatal depression managed?
Same as normal depression (CBT + SSRI)
List some environmental adaptations that can be recommended for a patient with dementia.
Always carry ID, address and contact number in case they get lost
Dossett boxes/blister packs to aid medication compliance
Change gas to electricity
Reality orientation (visible clocks, calendars)
Environmental modifications (e.g. patterned carpets can predispose to hallucinations)
Assistive technology (e.g. door mat buzzers)
Which assessment tool is used to assess for the presence of psycopathy in patients?
PCL-R
List some causes of delirium.
Infection (e.g. UTI) Hypoxia Electrolyte disturbance Constipation Drugs CNS disease
Describe the pathophysiology of refeeding syndrome.
In starvation the secretion of insulin is decreased in response to a reduced intake of carbohydrates
Instead fat and protein stores are catabolised to produce energy
This results in an intracellular loss of electrolytes, in particular phosphate
Malnourished patients’ intracellular phosphate stores can be depleted despite normal serum phosphate concentrations
When they start to feed, a sudden shift from fat to carbohydrate metabolism occurs and secretion of insulin increases
This stimulates cellular uptake of phosphate, which can lead to profound hypophosphataemia
Give an example of an anxiety disorder that is treated with exposure therapy.
Agoraphobia
What is the risk of a patient presenting with mania developing a depressive episode in the future?
> 90%
What are the symptoms of neuroleptic malignant syndrome?
Pyrexia
Muscle stiffness
Which services should be used to manage mental health crises?
Crisis resolution
Home treatment team
When does postnatal depression occur?
From anytime during pregnancy to within 1 year of delivery
How are anxiety disorders in children managed?
Psychological therapies (CBT)
What are the criteria for diagnosis of bipolar II disorder?
At least one hypomanic episode (lasting at least 4 days)
At least one major depressive episode
What are some harm reduction approaches that are used for opiate misuse?
Needle exchange
Vaccination and testing for blood-borne viruses for sex-workers and IVDU
Describe how you should switch from citalopram, escitalopram, sertraline or paroxetine to venlafaxine.
Cross-taper cautiously (starting on 37.5 mg OD venlafaxine and tapering upwards slowly)
What do rehabilitation programmes for alcohol-abuse involve?
May be residential or day programmes
Allow a break for people submerged in a drinking community
May be skills-based courses to help find employment
Which psychological therapies for patients who have self-harmed?
CBT
Mentalisation-based therapy
Transference-focused psychotherapy
Which medications can be used for the treatment of acute mania?
Acute management = atypical antipsychotic (olanzapine is 1st line)
Long term management = mood stabilisers (lithium, valproate)
Which investigations should be considered in a patient presenting with depression?
o Collateral history o Physical examination o Bloods: FBC, TFT, U&E o Rating Scale: PHQ9, HAD, CDI (children) o Risk Assessment
List some side-effects of TCAs.
Anti-cholinergic side-effects + QT prolongation
Tachycardia, arrhythmias Dry mouth Blurred vision Constipation Urinary retention Postural hypotension Sedation Nausea Weight gain
List some screening tools used for alcohol misuse.
CAGE
Alcohol Use Disorders Identification Test (AUDIT)
Which investigations are used in neuroleptic malignant syndrome?
CK (high)
WCC (high)
What are the main approaches to managing OCD?
CBT (exposure and response prevention)
SSRIs (most commonly fluoxetine)
2nd line: SNRI
3rd line: add atypical antipsychotic
What is the a community treatment order (CTO)?
Allows being discharged from a previous section but on the agreement that certain conditions are met such as:
Living in a certain place
Going somewhere for medical treatment
Which class of drugs may be beneficial in bulimia nervosa and why?
SSRIs (e.g. high-dose fluoxetine)
Improves impulse control and reduces bingeing/purging behaviour
According to DSM-V, how long do psychotic symptoms need to be present to diagnose schizophrenia?
At least two diagnostic criteria present over much of the time for > 1 month
Significant impact on social and occupational functioning for > 6 months
NOTE: disorder lasting 1-6 months is schizophreniform disorder
Which investigations may be used for ADHD?
Questionnaires (Conner’s Rating Scale)
Classroom observation
Educational psychological assessment
Which drugs should not be used with SSRIs?
Warfarin
Triptans
MAOI
Which assessment tool is used to assess the risk of violence?
HCR-20
What is mentalisation-based therapy?
Used for emotionally unstable personality disorder and self-harm
Teaches how to take a step back and assess their mental state and the mental state of others
Give some examples of TCAs that causes high sedation and low sedation.
High Sedation: amitriptyline, clomipramine, dosulepin, trazadone
Low Sedation: imipramine, lofepramine, nortriptyline
How is puerperal psychosis treated?
Antipsychotics
ECT may be required if severe
Admission to a mother and baby unit
How long should SSRIs be used for in a patient with depression?
Until 6 months after the patient’s depression has ended
This can be extended to 1 year for elderly patients
Who can make a section 2?
Made by an AMHP or nearest relative (NR) on behalf of TWO doctors, one or whom should be section 12 approved (usually SpR or consultant) and one of whom should know the patient in professional capacity (e.g. GP)
