Psychiatry Flashcards

Question

Mirtazapine SE

Answer 1

Often used 2nd life after SSRI SE: Drowsiness (can help sleep) Weight gain Rare cases of neutropenia

Answer 2

Often used 2nd/3rd line agent / treatment resistant depression Care in pts with CVS problems - Increased BP at higher doses + may exacerbate cardiac arrhythmias

Answer 3

Advise people with depression to continue antidepressants for atleast 2 years. Maintain the level of medication at which acute treatment was effective (unless there is a good reason to reduce dose, eg. unacceptable adverse effects) --> lithium should not be used as a sole agent to prevent recurrence

Answer 4

``` Increased mood change Restlessness Difficulty sleeping Unsteadiness Sweating Abdominal symptoms Altered sensations ``` Appears 1-14 days after cessation, last 7-14 days --> When stopping, gradually reduce dose, normally over atleast a 4 week period

Answer 5

Most antidepressants cause this Risk factors – old age, female LBW, low baseline Na, concurrent medication, hypothyroidism, diabetes, warm weather May need to be clinically managed SSRIs are more likely to cause it Lofepramine, reboxetine and moclobemide are less likely.

Answer 6

Mood: Irritable, euphoria, lability Cognition: grandiosity, flight of ideas, racing thoughts, distractibility, confusion, lack of insight Behaviour: rapid speech, hyperactivity, lack of sleep, hypersexuality, extravagance Psychotic symptoms: delusions, hallucinations, hypomania

Answer 7

Elevated/irritable mood sustained for atleast 4 days Atleast 3 of following, leading to some interference with personal function: ``` Increased activity or restlessness Increased talkativeness Distractibility Decreased need for sleep Increased sexual energy Mild reckless or irresponsible behaviour Increased sociability ```

Answer 8

Predominately elevated or irritable mood sustained for atleast 1/52. Atleast 3 of the following - leading to severe interference with personal function: - increased activity/restlessness - Increased talkativeness - Flight of ideas - Loss of normal social inhibitions - Decreased need for sleep - Inflated self-esteem or gradiosity - Distractibility or constant changes in activity - Behaviour that is foolhardy or reckless - Marked sexual energy or sexual indiscretions

Answer 9

Hx or mild hypomania interspersed with periods of depression that do not meet the criteria for major depressive episodes. low grade cycling of mood, which appears to the observer as a personality trait, and interferes with functioning

Answer 10

A major affective disorder marked by severe mood swings (manic or major depressive episodes) and a tendency to remission and recurrence.

Answer 11

``` Mania/hypomania Lithium Valproate Atypical antipsychotic (olanzapine, risperidone) Combinations ``` ``` Bipolar depression Valproate Quetiapine Lamotrigine Olanzapine SSRIs ```

Answer 12

``` Lithium - first line (NICE Guidelines September 2014) Valproate Olanzapine Lamotrigine Risperidone Aripiprazole Quetiapine Combinations ```

Answer 13

Not fully understood Alters Na+ transport across cell membranes Alters metabolism of neurotransmitters including catecholamines and serotonin Reduces PKC activity, possibly affecting genomic expression associated with neurotransmission

Answer 14

Levels 0.4-1mmol/L ``` Abdominal Pain Nausea Metallic taste in mouth Fine tremor Thirst Polyuria Weight gain Oedema Leukocytosis - Advice to seek medical attentino if they develop D/V or become acutely ill for any reason ``` Long term effects: - hypothyroidism - Hyperparathyridism - hypercalcaemia - Renal failure - Nephrogenic diabetes insipidus 'Fine tremor is fine, coarse tremor is not (Toxicity)'

Answer 15

Levels >1.5mmol ``` Anorexia D+V drowsiness Apathy Restlessness Dysarthria Ataxia Muscle twiches Coarse tremor Blackouts/coma ```

Answer 16

Pre-lithium work up: ECG, TFTs, U+Es, Renal function tests Monitoring: - Start at 400mg once daily (200mg in elderly) - -> Plasma level after 5-7 days - Then every 5-7 days until required level reached (0.6-1mmol/L) --> Toxicity occurs at > 1.5mmol/L) - Bloods taken at 12 hours post dose (trough) - Once stable - levels every 3 months, U+Es and TFTs every 6 months

Answer 17

``` Abnormal eye movements blood/marrow problems confusion deafness EPSE agitation N+D hair loss headaches liver problems... Paraesthesiae Osteoporosis ``` Basically a Fuck tonne

Answer 18

CI: Women of child bearing potential - teratogenic. Work-up - TFTs, FBC, RFTs, BM, LFTs, Lipid profile, Weight + height, ECG Monitoring: FBC, LFTs, Weight + height every 6/12 Dose monitoring - only useful to ensure adequate dosing and compliance

Answer 19

Very common: - Postural hypotension, abnormal gait, appetite gain, falls, metabolic syndrome, sedation, lethargy, weight gain, worsening of parkinson's Common: Constipation, decreased libido, dry mouth, erectile dysfunction, joint pain

Answer 20

Psychoeducation - sleep hygiene, identifying relapsing markers, managing stress, mood monitoring CBT - some evidence in reduction in severity of symptoms, but only early on in course of illness - Psychopharmacology remains mainstay of treatment

Answer 21

Bipolar I - mania has occurred on atleast one occasion Bipolar II - hypomania has occurred on atleast one occasion

Answer 22

Pretreatment, measure and record: - Weight/BMI - Pulse, BP - Fasting bloods, HbA1c - Blood lipid profile - offer ECG if known cardiovascular risk, FH Monitoring - HR + BP after each dose change - Weight/BMI weekly for first 6 weeks, then at 12 weeks - Blood glucose, HbA1c and lipid profile at 12 weeks - Response to treatment including changes in symptoms and behaviour

Answer 23

Reduce dose gradually over at least 4 weeks, preferably up to 3 months during dose reduction + 3 months after, monitor closely for signs of mania/depression

Answer 24

Decreased Na+ intake/increased sodium excretion (low Na+ diet, diuretics, ACEis, AR2b, excessive sweating, D+V) Decreased water intake/increased water excretion (dehydrating, diuretics, fever, illness) Renal disease - Renal dysfunction - NSAIDs

Answer 25

Fluoxetine + Olanzapine OR Quietiapine

Answer 26

Skin rash including SJS or Toxic epidermal necrolysis

Answer 27

Offer lithium 1st line --> Most effective long term tx If ineffective/poorly tolerate, consider valproate or olanzapine

Answer 28

Inner ring: Circumstances of the attempt What happened that day? Were things normal to begin with? Were there any preparations made e.g. making a will or giving things away? Was there a last act (e.g. suicide note)? What happened after the attempt? Middle ring: Background to the event How have things been over the preceding months? Has the patient thought about attempting suicide in the last few months? What relationships were important over this time? Outer ring: Family and personal history What was the intention behind the attempt? What are the present feelings and intentions? If the patient was to leave hospital today how would they cope?

Answer 29

Agree a contract offering help by negotiation Discuss confidentiality and then talk with family Anti-depressants Problem solving therapy Follow up with preventative strategies

Answer 30

anxiety, depression, fatigue, insomnia, irritability, worry, obsessions, compulsions, somatisation, agitation, feelings of impending doom, trembling, sense of collapse, insomnia, poor concentration, goose flesh, butterflies in the stomach, hyperventilation, headaches, sweating, palpitations, poor appetite, nausea, lump in the throat (globus hystericus), difficulty getting to sleep, excessive concern, repetitive thoughts and activities

Answer 31

Anxiety + 3 somatic symptoms; present for > 6 months

Answer 32

``` GAD Panic disorder Phobia PTSD Social anxiety disorder Obsessive compulsive disorder ```

Answer 33

Symptom control: reassurance, listening Regular exercise meditation CBT Meds: - Benzo eg.diazepam - SSRI eg. paroxetine - Antihistamines eg. hydroxyzine - B-blockers - others: pregabalin, venlafaxine Progressive relaxation training Hypnosis

Answer 34

Anxiety in specific situations – leads to avoidance Elicit the exact phobic stimulus Mx: CBT; paroxetine

Answer 35

Compulsions: senseless, repeated rituals Obsessions: stereotyped, purposeless words, ideas or phrases that come into the mind Perceived by the patient as nonsensical and originating from themselves E.g. rambler who cannot do a long walk because every few paces they wonder if they have really locked the car and has to return repeatedly to ensure this has been done; repetitive cleaning, counting and dressing rituals Pathophysiology: orbitofrontal and caudate nucleus Mx: behavioural or cognitive therapy; clomipramine or fluoxetine

Answer 36

Fearful, horrifeid, dazed, helpless, numb, detached, decreased emotional responsiveness, intrusive thoughts, hypervigilance, depersonalisation, dissociative amnesia, reliving of events, autonomic arousal , headaches, abdo pain

Answer 37

DSM-IV: symptoms have been present for more than one month: - Re-living: flashbacks, nightmares, repetitive and distressing intrusive images - hyperarousal (hypervigilance, exaggerated startle, sleep problems, irritability, difficulty concentrating) - Avoidance - Emotional numbing ``` from other people: - Depression - Druh or alcohol misuse Anger - Unexplained physical symptoms ```

Answer 38

- watchful waiting for mild symptoms

Answer 39

Compulsive need to control eating Low self-worth Weight loss becomes an over-valued idea - achieved by over-exercising, induced vomiting, laxative abuse, diuretics or appetite suppressants. May also have episodes of binge following by remorse, vomiting and concealment

Answer 40

Reduced BMI Bradycardia Hypotension Enlarged salivary glands

Answer 41

Hypokalaemia Low FSH, LH, oestrogens and testosterone Impaired glucose tolerance Low T3 ------------------ Raised cortisol/growth hormone Hypercholesterolaemia Hypercarotinaemia

Answer 42

SCOFF Do you ever make yourself SICK because you feel too full? Do you worry you've lost CONTROL over eating Have you recently lost more than ONE stone in 3 months? Do you believe you are FAT when others say you are thin? Does FOOD dominate your life?

Answer 43

Restore nutritional balance Treat complications of starvation Severe anorexia: - BMI 17.5 Encourage use of self help books and a food diary - If no response within 8 weeks, consider referral to secondary care Therapy: cognitive, analytic, interpersonal, supportive or family therapy Meds: Fluoextine, olanzapine

Answer 44

Complication of metabolic disturbances that occur when reintroducing normal calorific intake to pts who have been severe starved/malnutritioned for a prolonged period: Signs: rhabdo, resp/cardiac failure, decreased BP, arrhytmias, seizures, comas and sudden death - Acute gastric dilatation if poorly nourished pt binges - Monitor PO3-, glucose, potassium and magnesium

Answer 45

Recurrent episodes of binge eating characterised by uncontrolled overeating Preoccupation with control of body weight Regular use of starvation, vomit-induction, laxatives or overexercise to overcome effects of binges BMI >17.5 Mx: Mild: support, self-help books, food diary Moderate/severe: refer to community mental health team or eating disorder unit Medication: antidepressants e.g. fluoxetine Cognitive therapy

Answer 46

Acute confusional state with disorientation in time, place or person. Memory disturbances Difficulty concentration Agitated/withdrawn Mood change Visual hallucination Disturbed sleep cycle Poor attention

Answer 47

1) Infection 2) Metabolic: U+Es, glucose, decreased PaO2, Increased PaC02 3) Drugs: Benzodiazepines, opiates, anticonvulsants, digoxin, L-DOPA), Alcohol / withdrawal 4) Trauma 5) Surgery

Answer 48

MEDIC HAT PINE ``` Metabolic Endocrine Degenerative Inflammatory Congenital Haematological Autoimmune Trauma Psychological/Neurological Iatrogenic Neoplastic Enviromental ```

Answer 49

Treat cause Calm patient - place in quiet sideroom , music, muscle relaxation and massage. If does not work, try haloperidol/ risperidone

Answer 50

Behaviour: restless, repetitive, no initiative, purposelessness activity, sexual disinhibition, social gaffes, shoplifting, rigid routines Speech: syntax errors, dysphasia, mutism Thinking: slow, muddled, delusions, poor memory, no insight Perception: illusions, hallucinations Mood: irritable, depressed, blunted affect, emotional incontinence

Answer 51

Bloods: FBC, b12, folate, ESR, U+E, LFT, yGT, Ca2+ , TSH Serology: Syphilis, HIV CT/MRI: excludes tumours, hydrocephalus, subdural haematoma, stroke

Answer 52

Stage I: amnesia and spatial disorientation Stage II: personality disintegration (aggression, psychosis, agitation, depression) and focal parietal signs (dysphasia, apraxia, agnosia and acalculia); parkinsonism Stage III: neurovegetative changes with apathy, akathisia, wasting, immobility, seizures and spasticity

Answer 53

Anti-AchE: Donepezil, rivastigmine, galantamine NMDA Antagonists: Memantine

Answer 54

increased HR, decreased BP, tremor, fits, visual or tactile hallucinations Admit and monitor vital signs Give diazepam or chlordiazepoxide for 1st three days

Answer 55

Explore whether patient wants to change – abstinence or controlled intake Treat co-existing depression Self-help/group therapy/12-step programme Disulfiram Naltrexone – reduces pleasure that alcohol brings Acamprosate – can increase abstinence rates

Answer 56

Odd or eccentric behaviour: - -> Paranoid - --> Schizoid - -> Schizotypal

Answer 57

Dramatic or emotional behaviour: - Antisocial (Psychopathic) - Borderline - Histrionic - Narcissistic

Answer 58

Unstable affect regulation, poor impulse control, poor interpersonal relationships/self-image, repeated self-injury, suicidality and difficult life course trajectory Tendency to form intese relationships and rapid fluctuations in mood, with impulsivity, unstable relationships Associated with ADHD and learning difficulties Mx: dialectical behaviour therapy, inpatient hospital programmes and medication

Answer 59

Anxious or avoidant behaviour - -> Avoidant - -> dependent - -> Obsessive-compulsive

Answer 60

The self-centred, sexually provocative (but frigid) person who enjoys (but does not feel) angry scenes; can maintain relationships; episodic outbursts of rage; less impulseve Schizoid personality: Cold, aloof, introspective, misanthropic

Answer 61

Belief that someone or something is interfering with the person in a Malicious or destructive way Examples: Someone (or an organisation e.g. MI5) is trying to kill or harm them The neighbours are harassing them People are monitoring their movements or following them Asking about delusions of persecution: Are there times when you worry that people are against you/ trying to harm you? Do you have any concerns for your safety?

Answer 62

Belief of being famous, having supernatural powers, having enormous wealth Suggestions for interview: “Do you have any exceptional abilities or talents?”

Answer 63

Belief that actions of other people, events, media etc. are either directly referring to the person or are communicating a message Suggestions for interview: Have there been times when you have overheard people talking about you? Do you ever see things on the TV or hear things on the radio which you think are about you?

Answer 64

Capgras syndrome: someone close has been replaced by an identical looking impostor Fregoli’s syndrome: belief that strangers are actually familiar people in disguise

Answer 65

“Passivity phenomena”: made actions, feelings or impulses The boundaries between self and the world are broken Thoughts, actions or feelings are subject to outside influences Thought insertion, withdrawal, broadcasting Often accompanied by delusional explanations Asking about delusions of control: Thought interference: Have you ever felt that your thoughts were being directly interfered with or controlled by another person? Was this just because people were distracting you or being persuasive, or did it come about in a way many people would find hard to believe, for instance through telepathy? Passivity: Have you ever felt that another person was able to control what you did directly, as if they were pulling the strings of a puppet?

Answer 66

Beliefs about body Including: Illnesses (hypochondriacal delusions) Infestations (Ekbom’s syndrome)

Answer 67

In flight of ideas, there are links between phrases but they are clang associations. Clang associations are associations of words similar in sound but not in meaning. Links may be rhymes or puns This occurs in mania and hypomania and usually with pressure of speech. “You come in here swinging your stethoscope…….telling me about my horoscope” In loosening of association there is no link between phrases. Knight’s move thinking is a type of loosening of association where there is an abrupt jump from one idea to another midway through the first thought e.g. “Inferior schools! Inferior schools! Preferably Dr Sims? Your tablets have been a miserable failure. I have had to sit with these mad surgeries. With regard to these tablets it will depend what the lord wants. With these women it is certainly destiny humph” In word salad, there is no link between words e.g. “blue does runs shaky lovely very

Answer 68

Overinclusion of details and parenthetical remarks | Takes a long time to get to the desired point

Answer 69

Inability to have goal-directed associations of thought | Never gets from desired point to desired goal

Answer 70

Repeating of words or phrases of another person | Can occur in schizophrenia, mental retardation or dementia

Answer 71

Persisting response to a prior stimulus after the new stimulus has been presented

Answer 72

Abrupt interruption in train of thinking before a thought or idea is finished After a brief pause the person indicates no recall of what was being said or what was going to be said May be explained by the patient as thought withdrawal

Answer 73

They do not appear to the patient to be real and instead located in the mind (i.e. in subjective inner space) e.g. visual pseudohallucinations - seen by ‘inner eye’ and auditory pseudohallucinations - ‘voice in my head’ Or they seem to occur in the outside world but patient views it as unreal. They may occur in, for example, borderline personality disorder, fatigue, bereavement

Answer 74

Generalized impairment of cognitive functions (perception, thinking, memory, orientation), emotion, psychomotor activity and sleep-wake cycle

Answer 75

Organic: - Infection (sepsis, encephalitis) - Cerebral neoplasm, trauma, stroke - Neurological disorderss: parkinson's, epilepsy - Psychoactive drug use - Alcohol: withdrawl, intoxication, hallucinosis Psychiatric: - Schizophrenia spectrum disorders - Mood disorders (bipolar/depression

Answer 76

``` Elementary hallucinations (noises) Visual or olfactory hallucinations = ?organic conditions (LBD) Episodic delusions and hallucinations = ?epilepsy, substance abuse Delusions / hallucinations + altered level of consciousness = delirium Bizarre delusions and hallucinations = ? Schizophrenia spectrum disorders Mood congruent delusions and hallucinations = ? Mood disorders ```

Answer 77

- Auditory hallucinations - Thought withdrawal, insertion & broadcast - Somatic hallucinations - Delusional perception - feelings or actions experienced as made or influenced by external agents (passivity phenomena)

Answer 78

Atleast 1 of: - Thought echo, insertion, withdrawal, broadcast - Delusions of control, influence, passivity, clearly referred to body or limb movements or thoughts, actions and sensations - Voices giving a running commentary or discussing - Persistent delusions or atleast 2 of: - Other hallucinations which occur every day for weeks on end - Thought disorder - Catatonic behaviour eg. excitement, posturing, wavy flexibility, negativism, mutism, echopraxia - Negative symptoms - Significant and consistent change in behaviour FOR atleast 1 month, in absence of intoxication, brain disease or extensive manic/depressive symptoms. Symptoms have to be present for 6 months for diagnosis of schizophrenia to be made

Answer 79

Hallucinations Delusions Ideas of reference

Answer 80

Under activity Anhedonia Apathy Sexual problems Lethargy Social withdrawal - Reduced speech - Reduced motivation - Reduced responsiveness (flat affect)

Answer 81

Paranoid schizophrenia - stable delusions, usually + hallucinations Hebephrenic schizophrenia - fleeting delusions & hallucinations Behaviour & thought disorganized Residual schizophrenia – after a period of positive symptoms, negative symptoms predominate Simple schizophrenia – negative symptoms, no initial positive symptoms (rare) ``` Catatonic schizophrenia Rare Disturbances of voluntary motor activity including Stupor Periods of over-activity Rigidity Posturing “Waxy flexibility” (maintenance of limbs and body in externally imposed positions) ```

Answer 82

Volume of lateral ventricles is increased Volume of brain decreased – Especially Temporal lobe, Amygdala / hippocampal complex Same changes found in newly diagnosed patients as chronic schizophrenics Appear to be non-progressive Neuropathological changes suggestive of neuronal degeneration

Answer 83

Volume of lateral ventricles is increased Volume of brain decreased – Especially Temporal lobe, Amygdala / hippocampal complex Same changes found in newly diagnosed patients as chronic schizophrenics Appear to be non-progressive Neuropathological changes suggestive of neuronal degeneration

Answer 84

Increased dopamine Reduced glutamate activity Increased 5-HT activity

Answer 85

``` Male Insidious onset Long duration of untreated psychosis Drug use Family environment Non-compliance Neuro-cognitive deficits ```

Answer 86

Both affective and psychotic symptoms are prominent within illness episode, simultaneously or within a few days of each other Therefore criteria for schizophrenia and depressive/ manic episode not met Usually less impairment between episodes and social impairment than for schizophrenia (but more than in bipolar affective disorder)

Answer 87

``` Risk assessment Care Programme approach: - Assess health & social needs - Agreed carer plan - Named Care Co-ordinator Regular monitoring and review meetings - Interagency and MDT working - Early intervention in psychosis services ``` These are being set up in many areas Specialist teams who treat people experiencing their first episode of psychosis (aged 18-35) Aim to reduce the Duration of Untreated Psychosis, because shorter time to treatment associated with better outcome Therefore focus on early detection and treatment and maintaining contact to try to prevent relapse Anti-psychotic medicine CBT for psychosis

Answer 88

Typical antipsychotics: chlorpromazine, haloperidol Atypical antipsychotics: risperidone, olanzapine, quetiapine, amisulpiride, aripiprazole, clozapine Antipsychotic medication are started at low dose and increased gradually They take affect after 1-6 weeks They should be continued for a minimum of a year after a person is asymptomatic. There is probably benefit in continuing for up to 5 years, but many people are reluctant to do so. Adherence to medication is key 1st episode Schizophrenia Start agreed antipsychotic Titrate if necessary 1st onset of antipsychotic action – 2/52 Assess at optimum dosage over 4-6 weeks. If successful, continue for at least 1-2 years. If withdrawal, undertake gradually. After withdrawal monitor for at least two years If not, change to another antipsychotic & as above. If not successful, consider clozapine

Answer 89

Recommended by NICE as a treatment in addition to medication for people with persistent positive symptoms of psychosis Typically, around 50-65% of people who receive therapy benefit in some way Identify a client’s main difficulties, how they arose, and what they understand about them. The aim is not necessarily to get rid of symptoms, but to alleviate distress and disability, by helping them find: New ways to reframe their experiences New strategies to cope with their symptoms

Answer 90

If possible, including: Provide information and discuss the likely benefits and possible side effects of each medicine including: Metabolic (including weight gain and diabetes) EPSEs (including akathisia, dyskinesia and dystonia) cardiovascular (including prolonging the QT interval) Hormonal (including increasing plasma prolactin) Other (including unpleasant subjective experiences)

Answer 91

Before starting: - weight, waist circumference - Pulse and BP - Fasting BM, HbA1c, blood lipid profile and proclactin - Assessment of any movement disorders - ECG if CVS risk Monitor and record the following throughout treatment: - Response to treatment, including changes in symptoms and behaviour - Side effects of treatment, taking into account overlap between certain side effects and symptoms e.g. the overlap between akathisia and agitation or anxiety, and impact on functioning - Emergence of SEs- EPSEs, anticholinergic SEs Weight, waist circumference, pulse and blood pressure, fasting blood glucose, HbA1c and blood lipid levels Hyperprolactinaemia, drowsiness, postural hypotension

Answer 92

Dystonia: - Sustained involuntary muscle contractions, twisting of neck, limbs, trunk or face. Acute form more likely in younger Parkinsonian: - Rigidity, coarse tremor (no pill rolling), akinesia Akathisia: - Uncontrolled restlessness with feelings of inability to sit still - -> Consider propanoll Tardive dyskinesia: - Involuntary hyperkinesia, increases with anxiety and relieved with sleep. - Symptoms include tics, choreas and dystonias. - Repetitive involuntary purposeless movements of jaw, neck and tongue. --> Switch onto atypicals or consider procyclidine IM/IV for acute episode

Answer 93

- Dry Mouth - Blurred vision - GI disturbance - Constip. - Urinary retention - Tachycardia - Mental confusion

Answer 94

Rigidity, fever, confusion, fluctuating BP, tachycardia Elevated creatine kinase ? Dopamine deficiency Risk factors including high potency drugs, rapid dose changes, agitation, dehydration, abrupt withdrawal of anticholinergics, concurrent lithium Treatment - Life threatening - Withdraw antipsychotic immediately - Monitor TPR - May need to be admitted to A&E - Rehydrate, artificial ventilation - Sedate with benzodiazepines - Dantrolene – muscle relaxant - Bromocriptine – dopamine agonist - ECT for psychosis No antipsychotics for at least 5 days. Wait for symptoms to resolve including CPK. Use small doses of an unrelated antipsychotic, preferably not a long acting one and one with low dopamine affinity. Monitor for symptoms of NMS –TPR, CPK

Answer 95

- indicated for treatment resistance. - Reversible neuropenia (3%) - Agranulocytosis (0.8%) - -> Higher risk in elder and those with lower WBC counts - Myocarditis - Reduce seizure threshold Blood tests during tx - -> weekly for 18 weeks - -> fornightly for 52 weeks - -> Monthly ever after ``` Sore throat, fever Hypersalivation – must be treated. Constipation – must be treated. Seizures – must be treated. Urinary incontinence Drowsiness Hypotension Tachycardia – investigate and treat if necessary. Weight gain – potential long term problems Raised glucose and cholesterol levels Pulmonary embolism Myocarditis Cardiomyopathy ```

Answer 96

- Carbamazepine and various meds which cause neutropenia are CI - Fluovoxamine may increase clozapine levels - Smoking

Answer 97

Antipsychotic: haloperidol PO/IM, atypical antipsychotics, aripiprazole IM Promethazine PO/IM Benzodiazepines: lorazepam PO/IM Combination Some evidence that this works synergistically Also can mean giving less of more toxic antipsychotics

Answer 98

``` Drugs of abuse Tolerance Hangover effect Disinhibition, Confusion Resp. depression Do not discharge with this unless longterm ```

Answer 99

Exposure/flooding/implosion therapy (phobias - pt stays with anxiety provoking stimuli until habituation/ avoidance response extinguished) Relaxation training Systematic desensitisation Response Prevention --> obsessions. Thought stopping Aversion therapy Social skills training Token economy CBT

Answer 100

Helps change how pt thinks and feels by consideration interaction between our thoughts, feelings in a particular situation and the action taken. CBT lets use see how thoughts and feelings interact. BY changing thoughts, the cycle is broken or turned into a virtuous cycle Indication General: The patient prefers to use psychological interventions, either alone or in addition to medication. The target problems for CBT (extreme, unhelpful thinking; reduced activity; avoidant or unhelpful behaviours) are present. No improvement or only partial improvement has occurred on medication. Side effects prevent a sufficient dose of medication from being taken over an adequate period. Significant psychosocial problems (e.g. relationship problems, difficulties at work or unhelpful behaviours such as self-cutting or alcohol misuse) are present that will not be adequately addressed by medication alone.

Answer 101

Arbitrary inference—conclusions drawn with little or no evidence to support them Selective abstraction—dwelling on insignificant (negative) detail while ignoring more important features or stimuli Overgeneralization—drawing global conclusions about worth/ability/performance on the basis of single facts Magnification/minimization—Gross errors of evaluation with small bad events magnified and large good events minimized.

Answer 102

Patient can be confronted by the effect his behaviour and beliefs have on others and be protected during his first attempts to change Specific: Personality disorders Addictions: drug and alcohol dependence Victims of childhood sexual abuse People with difficulties in socialisation Major medical illnesses e.g. breast cancer

Answer 103

Individual dynamic psychotherapy is based on the premise that a person’s behaviour is influenced by unconscious factors (thoughts, feelings, fantasies).

Answer 104

Aimed to provide a legal framework for detention of people suffering from mental disorders against their will

Answer 105

To ensure that people with serious mental disorders which threaten their health or safety or the safety of the public can be treated irrespective of their consent where it is necessary to prevent them from harming themselves or others Details the circumstances in which a person with a mental disorder can be detained for treatment with or without his or her consent Outlines the processes that must be followed Introduces new safeguards for patients Aims to ensure that patients are not inappropriately detained or treated without consent

Answer 106

MHA 1983 does not provide legal framework for assessment or treatment of physical illness Can only treat concurrent physical illness if: Patient consents Patient lacks capacity to consent/refuse to treatment for physical illness (under MCA) MHA allows treatment to alleviate or prevent a worsening of a mental disorder (or one or more of its symptoms or manifestations) This includes “treatment of physical health problems only to the extent that such treatment is part of, or ancillary to treatment for mental disorder (e.g. treating wounds self-inflicted as a result of mental disorder)”

Answer 107

Anorexia nervosa is classed as mental illness: re-feeding allowed under MHA

Answer 108

A person with LD shall not be considered by reason of that disability to be: Suffering from a mental disorder for purposes of the Act Requiring treatment in hospital for mental disorder Unless that disability is associated with abnormally aggressive or seriously irresponsible conduct by that person

Answer 109

New definitions “Mental disorder” refers to any disorder or disability of the mind ``` Omitted definitions from MHA 1983 Severe mental impairment Mental impairment Mentally impaired Psychopathic disorder ``` Exclusions MHA 1983: a person cannot be deemed to be suffering from a mental disorder “by reason only of promiscuity or other immoral conduct, sexual deviancy or dependence on alcohol or drugs” MHA 2007: alcohol/drug dependency retained; promiscuity etc. removed Appropriate treatment test Is appropriate treatment for this patient’s mental disorder going to be available to them when they are detained?

Answer 110

This is used for someone over the age of 16 years who will not be admitted voluntarily. Patients who are under the influence of alcohol or drugs are specifically excluded Can take place anywhere Approved Mental Health Professional (AMHP) 2 x Section 12 Approved Doctors Sometimes Psychiatrist and GP joint assessment ``` -------- Patient is suffering from a mental disorder that is of a NATURE and DEGREE to merit detention Risks: Patient’s health and safety Risk to self Protection of others Refuses to go to hospital No alternative to hospital admission Medical Recommendation Form completed and given to AMHP Patient is transported to hospital ```

Answer 111

Admission for assessment for up to 28 days, not renewable An Approved Mental Health Professional (AMHP) or rarely the nearest relative (NR) makes the application on the recommendation of 2 doctors One of the doctors should be 'approved' under Section 12(2) of the Mental Health Act (usually a consultant psychiatrist)

Answer 112

Admission for treatment up to 6 months, can be renewed for 1 month at a time. AMHP, along with 2 doctors, both of which must have seen the pt within the past 24hrs - Cannot be detained under section 3 if NR objects - Most Tx can be given, including psychotropic meds - -> Safeguards for ECT

Answer 113

For pts on section 3 (or 37) --> Enforce treatment in community Power to bring pt back to hospital if does not comply with treatment plan - Allows them to go home under supervision of senior psych

Answer 114

72 hour assessment order Used as an emergency, when a section 3 would involve an unacceptable delay A GP and an AMHP or NR

Answer 115

A pt who is a voluntary pt in hospital can be legally detained by a doctor for 72 hours ``` When an informal inpt tries to leave: Any registered doctor Any ward (can't be used in A&E) ``` Further assessment must occur within 72 hrs: can be released from 5(2) by senior psych - Discharge if not detainable, or detention under S2 or S3

Answer 116

Same as 5(2) - Allows a nurse to detain a pt voluntarily in hospital for 6 hours

Answer 117

A court order can be obtained to break into a property to remove a person to a place of safety MAgistrate's order - Applied for by AMHP where person refusing to allow mental health professionals into residence

Answer 118

Someone found in a public place who appears to have a mental disorder can be taken by the police to a place of safety Assessment by duty psych - -> Discharge - -> Admit under S2 or S3, or discharge if not detainable

Answer 119

Appeals against detention under the Act Members appointed by Lord Chancellor Members include an independent doctor, a lawyer and a lay person Detained person has right to be represented by a solicitor 2007 Act introduces one MHRT for the whole of England

Answer 120

Understand information relevant to decision Retain information Weigh up information Communicate decision

Answer 121

Arose following a case involving DOL of a man with severe autism and LD People with who lack capacity with mental disorders/disabilities may need to be deprived of liberty for treatment or care Not necessarily detainable under MHA Human rights act demands people who lack capacity and are Deprived of Liberty in “best interests” have safeguards in place, as with MHA Not detainable under MHA No acute deterioration – do not fulfil ‘degree’ criteria Deprivation necessary to reside in an institution to receive care, not assessment / treatment People with dementia living in long-stay institutions Learning disability not a detainable disorder under MHA

Answer 122

Provides legal safeguards for mentally ill patients deprived of liberty when MHA not applicable Who is covered by DoLS? Adults (18+) in hospitals or care homes, Mental disorder/disability not covered by MHA Lack capacity to make decision on care/placements Deprivation of Liberty is necessary to provide appropriate care (in their best interests) At times during care, liberty may need to be restricted in for clinical reasons in individual’s best interests For people who lack capacity this is done under the Mental Capacity Act. When does restriction of liberty become deprivation of liberty? (Requiring DoL Safeguards) What constitutes “Deprivation” of liberty?

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DoLS process Patient identified as needing restraint to receive care Authority for DoL requested from Supervisory Body (usually PCT) 6 DoLS assessments (≥2 different trained assessors) Patient representative appointed Review process DoL last for 12 months. Review at 3 months to check detention still in patient’s best interests. Elements of care that could introduce more ‘liberty’

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MHA: - Mental health disorders only - 3 professionals' decision - Formalised and standard application procedure - Appeal to MHRT after decision made - Not related to capacity MCA: - Applies to any decision - Trumped by MHA - Assessment procedure depends on complexity of decision - Also depends on how restrictive the treatment is

Answer 125

1) Reassurance.support 2) CBT 3) certain SSRIs, Paroxetine preferred due to low milk/plasma ratio, but also sertaline

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Increased risk of stroke (especially olanzapine and risperidone) Increased risk of VTE

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Multiple physical SYMPTOMS present for atleast 2 years Pt refuses to accept reassurance or negative test results

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Persistent belief in the presence of an underlying serious DISEASE eg. CANCER PT refuses to accept reassurance or -ve test results

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Typically involves LOSS OF MOTOR OR SENSORY FUNCTION Pt doesn't consciously fign the symptoms (Factitious disorder) or seek material gain (malingering) Pt may be indifferent to their apparent disorder - le belle indifference

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Dissociation - a process of separating off certain memories from normal consciousness - In contrast to conversion disorder, involves psychiatric symptoms eg. amnesia, fugue, stupor DID - new term for multiple personality disorder

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Factitious disorder | - The intentional production of physical or psychological symptoms

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

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Sertaline following MI as more evidence for its safe use than other antidepressants

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NSAIDs: NICE guidelines advise 'do not normally offer SSRIs', but if given co-prescribe a proton pump inhibitor warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine aspirin: see above triptans: avoid SSRIs

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Raised ICP

Answer 136

Factors suggesting diagnosis of depression over dementia short history, rapid onset biological symptoms e.g. weight loss, sleep disturbance patient worried about poor memory reluctant to take tests, disappointed with results mini-mental test score: variable global memory loss (dementia characteristically causes recent memory loss) Next question

Answer 137

NICE suggest a step-wise approach: step 1: education about GAD + active monitoring step 2: low intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups) step 3: high intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information step 4: highly specialist input e.g. Multi agency teams Drug treatment NICE suggest sertraline should be considered the first-line SSRI interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month

Answer 138

Again a stepwise approach: step 1: recognition and diagnosis step 2: treatment in primary care - see below step 3: review and consideration of alternative treatments step 4: review and referral to specialist mental health services step 5: care in specialist mental health services Treatment in primary care NICE recommend either cognitive behavioural therapy or drug treatment SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered

Answer 139

Imipramine

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Most things low G's and C's raised: Growth hormone, Glucose, salivary Glands, Cortisol, Cholesterol, Carotinaemia

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Inducer of P450 system - therefore decreased levels of drugs such as warfarin, ciclosporin and COCP.

Answer 142

Neuroleptic malignant syndrome is a rare but dangerous condition seen in patients taking antipsychotic medication. It carries a mortality of up to 10% and can also occur with atypical antipsychotics. It may also occur with dopaminergic drugs (such as levodopa) for Parkinson's disease, usually when the drug is suddenly stopped or the dose reduced. ``` Features more common in young male patients onset usually in first 10 days of treatment or after increasing dose pyrexia rigidity tachycardia ``` A raised creatine kinase is present in most cases. A leukocytosis may also be seen Management stop antipsychotic IV fluids to prevent renal failure dantrolene* may be useful in selected cases bromocriptine, dopamiqne agonist, may also be used

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Alpha-synuclein cytoplasmic inclusions (lewy bodies) in the substantia nigra, paralimbic and neocortical areas

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Neuroleptics as LBD pts are extremely sensitive and may develop irreversible parkinsonism

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Progressive cognitive impairment Parkinsonism Visual hallucinations Autonomic dysfunction Dx with SPECT/DAT scan

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1) motor symptoms generally rapid onset/ bilateral | 2) Rigidity/rest tremor uncommon

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Switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI the first SSRI should be withdrawn* before the alternative SSRI is started Switching from fluoxetine to another SSRI withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low-dose of the alternative SSRI Switching from a SSRI to a tricyclic antidepressant (TCA) cross-tapering is recommend (the current drug dose is reduced slowly, whilst the dose of the new drug is increased slowly) - an exceptions is fluoxetine which should be withdrawn prior to TCAs being started Switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine cross-taper cautiously. Start venlafaxine 37.5 mg daily and increase very slowly Switching from fluoxetine to venlafaxine withdraw and then start venlafaxine at 37.5 mg each day and increase very slowly *gradually reduce dose then stop

Answer 148

Risk of developing schizophrenia monozygotic twin has schizophrenia = 50% parent has schizophrenia = 10-15% sibling has schizophrenia = 10% no relatives with schizophrenia = 1%

Answer 149

Dose should be withdrawn in steps of about 1/8 of the daily dose every fornight. A suggested protocal is: - switch patients to the equivalent dose of diazepam - reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg - time needed for withdrawal can vary from 4 weeks to a year or more

Answer 150

If patients withdraw too quickly from benzodiazepines they may experience benzodiazepine withdrawal syndrome, a condition very similar to alcohol withdrawal syndrome. This may occur up to 3 weeks after stopping a long-acting drug. Features include: ``` insomnia irritability anxiety tremor loss of appetite tinnitus perspiration perceptual disturbances seizures ```

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Symptoms: 6-12 hrs Seizures: 36 hrs Delirium tremens: 72 hrs

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Mechanism chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission) Mx: - Benzos - Carbemazepine also effective

Answer 153

Dosulepin Amitryptaline

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NICE guidelines advice to consider stopping antidepressant (As some evidence SSRI may precipitate acute psychotic episode) before starting anti-psychotic

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Don't do normally, only do it if suspecting toxicity or sub-therapeutic levels --> trough levels - 12 hrs after last dose

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Serotonin: Altered mental state. NM problems and autonomic nervous system excitiation (SEE SLIDES) . Risk factors: SSRI, MAOs, REcreational drugs, ecstacy and amphetamines NMS: Presents similar to SS. Associated with antipsychotic use and dopaminergic drugs. Classically found in young men. A raised CK and leukocytosis (as well as Dhx) are best way to differentiate from SS nb. Malignnant hyperthermia: Associated with anaesthetic agents Cocaine toxicity: chest pain, convulsions, psychosis GBH: stiffness, stiff muscles, collapse

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a man thinks he's pregnant

Answer 158

Erotomania - Delusion that a person of high-standing is in love with them.

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Infestations

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belief that strangers are actually familiar people in disguise

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Morbid jealous obsession their partner is cheating Associated with alcoholism

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A shared delusion between two family members

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someone close has been replaced by an identical looking impostor

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Fregoli’s syndrome: belief that strangers are actually familiar people in disguise

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OP: Oral thiamine + reducing dose chlordiazepoxide Inpatient: IV pabrinex bags 1+2 (NOT ORAL THIAMINE), oral chlordiazepoxide - If high risk of seizures, cover with diazepam (quicker onset of action than chlordiazepoxide)

Answer 166

men: 14 units, over atleast 3 days Binge = 8 units for a man, 6 for awomen - Hazardous drinking = exceeding recommendations Harmful drinking = physical or mental harm caused by exceeding recommendations

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Modifying unacceptable desires to become acceptable

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internal issues becomes external

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Unacceptable behaviours in response to conflict (eg. self harm following conflict)

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Having the opposite reaction to your true feelings

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Patients attitude towards their therapist eg. pt thinks their psychiatrist is their father they don't like

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Answer 173

People are either all good or all bad