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Focused 1 > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

Unresponsive, moderate and severe depression Rx?

A

SSRI + High intensity psychological intervention

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2
Q

High intensity psychological interventions?

A
  1. Individual CBT
  2. Interpersonal therapy (IPT)
  3. Behavioural activation
  4. Behavioural couples therapy
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3
Q

How often do high intensity sessions usually happen?

A

16-20 sessions over 3-4 months

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4
Q

People who decline the above?

A
  1. Counselling
  2. Short term psychodynamic psychotherapy
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5
Q

Pt with poor oral compliance to antipsychotics?

A

Monthly IM depot injections

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6
Q

Advantage of atypical antipsychotics (AAs)?

A

Significant reductions in EPSEs

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7
Q

AA s/es?

A
  1. Weight gain
  2. Hyperprolactinaemia
  3. Clozapine associated with agranulocytosis
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8
Q

AA warnings in elderly patients?

A

Increased risk of stroke and VTE

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9
Q

Atypical antipsychotic examples?

A

AA CORQ
1. Aripiprazole
2. Amisulpride
3. Clozapine
4. Olanzapine (higher risk of dyslipidaemia and obesity)
5. Risperidone
6. Quetiapine

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10
Q

When should clozapine be used?

A

If schizophrenia not controlled despite sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each at least 6-8 weeks

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11
Q

Clozapine side effects?

A
  1. Agranulocytosis (1%), neutropenia (3%)
  2. Reduced seizure threshold (seizures in 3%)
  3. Constipation
  4. Myocarditis (need baseline ECG)
  5. Hypersalivation
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12
Q

When is dose adjustment of clozapine required?

A

If smoking is started or stopped during treatment

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13
Q

PTSD features?

A

For more than one month
1. Re-experiencing
2. Avoidance
3. Hyperarousal
4. Emotional numbing

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14
Q

PTSD management?

A
  1. Watchful waiting for mild symptoms <4 weeks
  2. Trauma-focused CBT or EMDR therapy in more severe cases
  3. Drugs not first line, if needed then venlafaxine or SSRI, risperidone in severe cases
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15
Q

Strongest RF for developing psychotic disorder?

A

FHx

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16
Q

Familial of developing schizophrenia?

A
  1. Monozygotic twin = 50%
  2. Parent = 10-15%
  3. Sibling = 10%
  4. No relatives = 1%
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17
Q

Selected RFs for psychotic disorders?

A
  1. Black Caribbean = RR 5.4
  2. Migration = RR 2.9
  3. Urban environment = RR 2.4
  4. Cannabis use = RR 1.4
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18
Q

Mania features?

A
  1. At least 7 days, causing severe functional impairment in social and work setting
  2. May require hospitalisation due to risk of harm to self or others
  3. May present with psychotic symptoms
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19
Q

Hypomania features?

A
  1. A lesser version of mania
  2. <7 days, typically 3-4 days, can be high functioning and does not impair functional capacity in social or work setting
  3. Unlikely to require hospitalisation
  4. No psychotic symptoms
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20
Q

Increased risk of suicide factors?

A
  1. Male
  2. DSH
  3. Alcohol or druh misuse
  4. Hx of mental illness
  5. Hx of chronic disease
  6. Advancing age
  7. Unemployment or social isolation/living alone
  8. Being unmarried, divorced or widows
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21
Q

What % of people with schizophrenia will commit suicide?

A

10%

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22
Q

Increased risks of completed suicide at a later date after an attempt?

A
  1. Efforts to avoid discovery
  2. Planning
  3. Leaving a written note
  4. Final acts e.g. sorting out finances
  5. Violent method
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23
Q

Protective factors for suicide?

A
  1. Family support
  2. Children at home
  3. Religious belief
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24
Q

Somatisation disorder?

A
  1. Multiple physical symptoms present for at least 2 years
  2. Patient refuses to accept reassurance or negative test results
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25
Q

Illness anxiety (hypochondriasis)?

A
  1. Persistent belief in the presence of an underlying disease e.g. cancer
  2. Pt refused to accept reassurance or negative test results
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26
Q

Conversion disorder?

A
  1. Typically involves loss of motor or sensory function
  2. Pt doesnt consciously feign symptoms or seek material gain
  3. La belle indifference
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27
Q

Dissociative disorder?

A
  1. Separating off certain memories from normal consciousness
  2. In contrast to conversion disorder, involves psychiatric symptoms e.g. amnesia, fugue, stupor
  3. DID (dissociative identity disorder) is new term for multiple personality disorder as is the most severe form of dissociative disorder
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28
Q

Factitious disorder?

A
  1. AKA Munchausen’s
  2. Intentional production of physical or psychological symptoms
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29
Q

Malingering?

A

Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain

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30
Q

Alcohol withdrawal mechanism?

A
  1. Chronic alcohol consumption enhances GABA mediation inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
  2. Alcohol withdrawal is though to lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
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31
Q

Alcohol withdrawal features?

A
  1. Sx start at 6-12 hours = tremor, sweating, tachycardia, anxiety
  2. Peak incidence of seizures at 36 hours
  3. Peak incidence of delirium tremens at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
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32
Q

Alcohol withdrawal management?

A
  1. Admission
  2. Long acting benzodiazepines e.g. chlordiazepoxide or diazepam as part of reducing dose protocol (lorazepam preferable in pts with hepatic failure)
  3. Carbamazepine also effective
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33
Q

Who is excluded from sectioning under the MHA?

A

Pts under influence of alcohol or drugs

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34
Q

Section 2 mushkies?

A

1.Admission for assessment up to 28 days, not renewable
2. AMHP or NR makes the application on the recommendation of 2 doctors
3. One of the doctors should be ‘approved’ under Section 12(2) of the MHS (usually consultant)
4. Treatment can be given against a patient’s wishes

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35
Q

Section 3 mushkies?

A
  1. Admission for treatment up to 6 months, can be renewed
  2. AMHP along with 2 doctors, both of which must have seen the pt with the past 24 hours
  3. Treatment can be given against a pt’s wishes
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36
Q

Section 4 mushkies?

A
  1. 72 hour assessment order
  2. Used as an emergency, when a Section 2 would involve an unacceptable delay
  3. a GP and an AMHP or NR
  4. Often changed to a Section 2 upon arrival at hospital
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37
Q

Section 5(2) mushkies?

A

A patient who is a voluntary patient in hospital can be legally detained by a doctor for 72 hours

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38
Q

Section 5(4)?

A

Similar to 5(2), allows nurse to detain a pt who is voluntarily in hospital for 6 hours

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39
Q

Section 17a?

A
  1. Supervised Community Treatment (Community Treatment Order)
  2. Can be used to recall a patient to hospital for treatment if they do not comply with conditions of the order in the community, such as complying with medication
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40
Q

Section 135?

A

A court order can be obtained to allow pt to break into a property to remove a person to a place of safety

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41
Q

Section 136?

A

Someone found in a public place who appears to have a mental disorder can be taken by the police to a place of safety, can only be used for up to 24 hours whilst a MHA is arranged

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42
Q

When is a second opinion sought for a section 3?

A

After 3 months, if a pt still does not consent to treatment, from an impartial psychiatrist

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43
Q

Agranulocytosis definition?

A

Absolute neutrophil count <500 cells/mm^3

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44
Q

When are antidepressants recommended?

A
  1. Moderate-severe depression
  2. Subthreshold depressive symptoms that have persisted for a long period (typically at least 2 years).
  3. Subthreshold symptoms or mild depression that persists after other interventions.
  4. Mild depression that is complicating the care of a chronic physical health problem
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45
Q

4 SSRIs?

A
  1. Sertraline
  2. Fluoxetine
  3. Citalopram
  4. Paroxetine
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46
Q

Lithium uses?

A
  1. Prophylactically in bipolar disorder
  2. Adjunct in refractory depression
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47
Q

Lithium therapeutic range?

A

0.4-1.0mmol/L

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48
Q

Lithium excretion?

A

Kidneys, has long plasma half life

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49
Q

Lithium MOA?

A

Not fully understood, two theories
1. Interferes with inositol triphosphate formation
2. Interferes with cAMP formation

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50
Q

Lithium adverse effects?

A
  1. N&V&D
  2. Fine tremor
  3. Nephrotoxicity, nephrogenic DI
  4. Thyroid enlargement, hypothyroidism
  5. Weight gain, IIH
  6. Leukocytosis
  7. Hyperparathyrodism and hypercalcaemia
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51
Q

Lithium ECG?

A

T wave flattening/inversion

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52
Q

Lithium monitoring?

A
  1. 12 hours post-dose
  2. Weekly after commencement and after each dose change until concentrations are stable
  3. Once established, every 3m
  4. Thyroid and renal function every 6m
  5. Pt should have information booklet, alert card and record book
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53
Q

Mirtazapine s/e?

A

Sedation and weight gain

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54
Q

Olanzapine s/e?

A

Dyskinetic tremore

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55
Q

Sertraline s/e?

A

Altered sleep-wake cycles, weight gain, sexual dysfunction, tremor

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56
Q

Flight of ideas?

A

Rapid speech with requent changes in topic based on associations, distractions or word play

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57
Q

Knights move thinking?

A

No apparent link between topics

58
Q

Tangentiality?

A

Veers off topic

59
Q

Circumstantiality?

A

Similar to tangentiality but patient, after giving excessive details, eventually returns to the topic

60
Q

SAD?

A

Treat as per NICE guidelines for NICE depression (begin with psychological therapies and f/up in 2w to ensure no deterioration, following this an SSRI can be given if needed)

61
Q

What should you not give in SAD?

A

Sleeping tablets as can make symptoms worse

62
Q

Typical antipsychotic MOA?

A

D2 receptor antagonist, blocking transmission in mesolimbic pathways

63
Q

Typical antipsychotic adverse effects?

A

EPSEs and hyperprolactinaemia commona

64
Q

Typical antipsychotic examples?

A

Haloperidol, chlopromazine

65
Q

EPSEs?

A

DAPT
1. Dystonia = torticollis, oculogyric crisis
2. Akathisia = severe restlessness
3. Parkinsonism
4. Tardive dyskinesia = 40% with typical, may be irreversible, most commonly chewing and pouting of jaw

66
Q

Acute dystonia management?

A

Procyclidine

67
Q

Typical antipsychotic s/e?

A
  1. Antimuscarinic = dry mouth, blurred vision, urinary retention, constipation
  2. Sedation, weight gain, impaired glucose tolerance
  3. Raised prolactin = may galactorrhoea, due to inhibition of dopaminergic tuberoinfundibular pathway
  4. NMS = pyrexia, muscle stiffness
  5. Reduced seizure threshold (greater with atypicals)
  6. Prolonged QT interval (particularly haloperidol)
68
Q

Which are preferred SSRIs?

A

Citalopram and Fluoxetine

69
Q

What SSRI is useful post-MI?

A

Sertraline

70
Q

Antidepressant for children?

A

Fluoxetine

71
Q

SSRI S/e?

A
  1. GI
  2. Increased risk of bleeding, PPI if taking NSAID
  3. Pt to stay vigilant for anxiety and angitation
72
Q

SSRIs with higher propensity for drug interactions?

A

Fluoxetine and paroxetine

73
Q

Which SSRI elongates QT interval?

A

Citalopram, dose dependent

74
Q

Citalopram maximum daily doses?

A
  1. 40mg for adults
  2. 20mg for >65 y/o and hepatic impairment
75
Q

SSRI interactions?

A
  1. NSAIDs (plz prescribe PPI)
  2. Warfarin
  3. Aspirin
  4. Triptans
  5. MAOis
76
Q

Alternative to SSRI if on warfarin?

A

Mirtazapine

77
Q

SSRI + Triptan?

A

Increased risk of serotonin syndrome

78
Q

SSRI + MAOi?

A

Increased risk of serotonin syndrome

79
Q

F/up after initiating antidepressant?

A
  1. Review after 2 weeks
  2. If <30 y/o / increased risk of suicide after 1 weeks
80
Q

How long antidepressant continued after remission?

A

6 months, reduces risk of relapse

81
Q

How to stop SSRI?

A

Dose gradually reduced over 4 week period

82
Q

Which SSRI has higher incidence of discontinuation symptoms?

A

Paroxetine

83
Q

Which SSRI can be stopped suddenly?

A

Fluoxetine

84
Q

SSRI discontinuation symptoms?

A
  1. Increased mood change
  2. Restlessness, difficulty sleeping
  3. Unsteadiness, sweating
  4. GI = pain, cramping, D&V
  5. Paraesthesia
85
Q

SSRIs in pregnancy?

A
  1. 1st trimester = increased risk CHD
  2. 3rd trimester = PPH of newborn
  3. Paroxetine has increased risk of congenital malformations, esp. in 1st trimester
86
Q

Main use of TCAs?

A

Neuropathic pain

87
Q

TCA s/e?

A
  1. Drowsiness
  2. Dry mouth, blurred vision, constipation, urinary retention
  3. QT prolongation
88
Q

Amitryptiline uses?

A
  1. Neuropathic pain
  2. Headache prophylaxis (tension and migraine)
89
Q

More sedative TCAs?

A
  1. Amitryptiline
  2. Clomipramine
  3. Dosulepin
  4. Trazodone
90
Q

Less sedative TCAs?

A
  1. Imipramine
  2. Lofepramine
  3. Nortryptiline
91
Q

Benzodiazepine MOA?

A

Enhance effect of inhibitory GABA by increasing the frequency of chloride channels

92
Q

Benzodiazepine uses?

A
  1. Sedation
  2. Hypnotic
  3. Anxiolytic
  4. Anticonvulsant
  5. Muscle relaxant
93
Q

How long show BZDs be prescribed for?

A

2-4 weeks

94
Q

How to withdraw BZDs?

A
  1. Switch pt to equivalent dose of diazepam
  2. Reduce diazepam every 2-3 weeks in steps of 2-2.5mg
  3. Time needed for withdrawal can vary from 4 weeks to a year or more
  4. (Dose should be withdrawn in steps of about 1/8 of the daily dose every fortnight)
95
Q

Benzodiazepine withdrawal syndrome symptoms?

A
  1. Insomnia
  2. Irritability
  3. Anxiety
  4. Tremor
  5. Loss of appetite
  6. Tinnitus
  7. Perspiration
  8. Perceptual disturbance
  9. Seizures
96
Q

How long after stopping long acting BZDs can withdrawal occur?

A

Up to 3 weeks

97
Q

Barbiturate MOA?

A

Increase duration of chloride channel opening (Barbidurates increase duration, frenzodiazepines increase frequency)

98
Q

Personality disorder definition?

A

Series of maladaptive personality traits that interfere with normal function in life

99
Q

Personality disorder prevalence?

A

1 in 20

100
Q

Personality disorder clusters?

A
  1. Cluster A = Weird
  2. Cluster B = Wild
  3. Cluster C = Worried
101
Q

Cluster A personality disorder types?

A
  1. Paranoid = Accusatory
  2. Schizoid = Aloof
  3. Schizotypal = Awkward
102
Q

Cluster B personality disorder types?

A
  1. Antisocial
  2. Borderline
  3. Histrionic
  4. Narcissistic
103
Q

Cluster C personality disorder types?

A
  1. Avoidant = cowardly
  2. Obsessive-compulsive = compulsive
  3. Dependent = clingy
104
Q

Personality disorder Rx?

A
  1. DBT
  2. Treatment of coexistent psychiatric conditions
105
Q

Schizophrenia poor prognosis indicators?

A
  1. Strong FHx
  2. Gradual onset
  3. Low IQ
  4. Prodromal phase of social withdrawal
  5. Lack of obvious precipitant
106
Q

TCA OD Rx?

A
  1. Hypertonic sodium bicarbonate
  2. Acidosis correction, hypoxia, electrolyte imbalance correction
107
Q

Procyclidine MOA?

A

Anticholinergic

108
Q

Contraindication to ECT?

A

Raised ICP

109
Q

ECT short term side effects?

A
  1. Headache
  2. Nausea
  3. Short term memory impairment
  4. Memory loss of events prior to ECT
  5. Cardiac arryhthmia
110
Q

Long term side effects of ECT?

A

Impaired memory

111
Q

Schizophrenia management?

A
  1. Oral atypical antipsychotic
  2. CBT to all pts
  3. Close attention paid to CVS risk (linked to antipsychotic medication and high smoking rates)
112
Q

Dizziness, electric shock sensations and anxiety?

A

SSRI discontinuation syndrome (esp. paroxetine)

113
Q

TCA causes what type of urinary incontinence?

A

Overflow incontinence due to anticholinergic effect

114
Q

Sleep paralysis definition?

A

Sleep paralysis is a common condition characterized by transient paralysis of skeletal muscles which occurs when awakening from sleep or less often while falling asleep. It is thought to be related to the paralysis that occurs as a natural part of REM (rapid eye movement) sleep. Sleep paralysis is recognised in a wide variety of cultures

115
Q

Sleep paralysis features?

A
  1. Paralysis = short before falling asleep or after waking up
  2. Hallucinations
116
Q

Sleep paralysis management?

A

If troublesome clonazepam may be used

117
Q

Death under MHA?

A

Referral to coroner

118
Q

What to do instead of prolonged manual restraint (>10mins)?

A

Rapid tranquilisation or seclusion

119
Q

Psychosis definition?

A

A person experiencing things differently from those around them

120
Q

Psychotic features?

A
  1. Hallucinations
  2. Delusions
  3. Thought disorganisation (alogia, tangentiality, clanging, word salad)
121
Q

Peak age of first episode of psychosis?

A

15-30 years

122
Q

Hoover’s sign?

A

In non-organic paresis, pressure is felt under the paretic leg when lifting the non-paretic leg against pressure, this is due to involuntary contralateral hip extension

123
Q

What kind of amnesia can BZDs cause?

A

Anterograde

124
Q

Rapid tranquilisation medication of acutely disturbed pts?

A
  1. IM Lorazepam
  2. IM haloperidol + IM promethazine
125
Q

Anorexia nervosa features?

A
  1. Reduced BMI
  2. Bradycardia
  3. Hypotension
  4. Enlarged salivary glands
126
Q

Anorexia nervosa bloods?

A

Most things low, Gs and Cs raised
1. Low = hypokalaemia, FSH, LH, oestrogens, testosterone, T3
2. High = GH, glucose, (glands (salivary), cortisol, cholesterol, carotinaemia

127
Q

Antipsychotic monitoring?

A
  1. FBC, U&E, LFT = start, annual
  2. Lipids, weight = start, 3m, annual
  3. Fasting glucose, prolactin = start, 6m, annual
  4. BP = start, during dose titration
  5. ECG = baseline
  6. CVS = annual
128
Q

Section 17a AKA?

A

Community Treatment Order (CTO)

129
Q

SSRI sodium levels?

A

Hyponatraemia

130
Q

Schneider’s first rank symptoms?

A
  1. Delusional perception
  2. Auditory hallucinations
  3. Passivity
  4. Thought disorders
131
Q

Negative schizophrenia symptoms?

A
  1. Affect blunting
  2. Anhedonia
  3. Alogia
  4. Avolition
132
Q

Perfectionism at the expense of completing tasks?

A

Obsessive-compulsive personality (anankastic personality disorder)

133
Q

Anxiety central feature?

A

Excessive worry about a number of different events associated with heightened tension

134
Q

GAD management?

A
  1. Education + active monitoring
  2. Low intensity psychological intervention
  3. High intensity psychological intervention (CBT or drug treatment)
  4. Highly specialist input e.g. multi agency teams
135
Q

GAD medications?

A
  1. Sertraline 1st line
  2. If ineffective another SSRI or SNRI (duloxetine/venlafaxine)
  3. If cannot tolerate SSRI/SNRI, then pregabalin
  4. Weekly f/up for 1st month
136
Q

Panic disorder management?

A
  1. Recognition and diagnosis
  2. Treatment in primary care (CBT or drugs)
  3. Review and consideration of alternative treatment
  4. Review and referral to specialist mental health services
  5. Care in specialist mental health services
137
Q

Panic disorder in primary care?

A
  1. CBT or drug treatment
  2. SSRIs 1st line, if contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
138
Q

Section 136 duration?

A

24 hours

139
Q

Depression assessment tools?

A
  1. HAD
  2. PHQ-9
  3. DSM-IV
140
Q

HAD scale?

A
  1. 14 questions, 7 for anxiety and 7 for depression
  2. Each scored 0-3
  3. Produces score out of 21 for each
  4. Severity: 0-7 normal, 8-10 borderline, 11+ case
  5. Encourage pt to answer questions quickly
141
Q

PHQ-9 scale?

A
  1. Over last 2 weeks, how often bothered by the following problems?
  2. 9 items scored 0-3
  3. Depression severity: 0-4 = none, 5-9 mild, 10-14 moderate, 15-19 moderatley severe, 20-27 severe

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