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Year 5 Specialties > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

When is the onset of postnatal depression

A

Peripartum onset (from any time during pregnancy to 1 year after delivery)

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2
Q

Sx of Asperger’s

A

Associated with marked clumsiness

Psychotic episodes occasionally

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3
Q

Define Generalised Anxiety Disorder

A

Anxiety that is generalised and persistent but not restricted to, or even strongly predominating in, any particular environment (free-floating)
>6months

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4
Q

How long must depressive symptoms last for a diagnosis of a major depressive episode? (ID-10)

A

At least 2 weeks

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5
Q

Define conduct disorder

A

Disorders characterised by a repetitive and persistent pattern of dissocial, aggressive or defiant conduct

Should violate age-appropriate social expectations
Should imply an enduring pattern of behaviour (>6 months)
Examples include excessive fighting, bullying, cruelty to people and animals, destruction of property, fire-setting, stealing, repeated lying, truancy and severe temper tantrums

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6
Q

Define cyclothymia

A

History of hypomanic symptoms with periods of depression that do not meet the criteria for major depressive disorder

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7
Q

Sx of ADHD

A

Inattention: difficulty paying close attention to details, trouble holding attention on tasks, trouble organising tasks and activities, appears forgetful in daily activities, loses things necessary for tasks, shorter attention span and is easily distracted, difficulty with structured schoolwork, difficulty completing tasks that are tedious or time-consuming

Hyperactivity-impulsivity: unable to sit still, fidgest+squirms in seat, leaves seat in inapproprate situations, takes risks with little thoughts for the dangers, “driven by a motor”, talking more than others, often answers quickly, trouble waiting their turn, interrupts or intrudes on conversations

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8
Q

Features of agoraphobia

A

Depressive and obsessional symptoms and social phobias

Avoidance of phobic situation

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9
Q

What is a potential complication of bulimia?

A

Electrolyte disturbance due to repeated vomiting

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10
Q

Cluster A Personality Disorders

A

Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder

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11
Q

Characteristics of Histrionic Personality Disorder

A 
Shallow and labile affectivity
Self-dramatisation
Theatricality
Exaggerated expression of emotions
Suggestibility
Egocentricity
Self-indulgence
Lack of consideration for others
Easily hurt feelings
Continuous seeking of appreciate, excitement and attention
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12
Q

What are the cognitive ICD-10 symptoms of depression?

A 
Impaired memory
Reduced concentration and attention
Guilt and worthlessness
Low self-esteem and confidence
Bleak view for the future
Ideas or acts of self-harm or suicide
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13
Q

What are the three areas of psychopathology?

A

Reciprocal social interaction
Communication
Restricted, stereotypes, repetitive behaviour

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14
Q

Puerperal psychosis

A

Not defined by ICD-10 or DSM-5
Onset of psychotic symptoms after childbirth (usually from around 2 weeks)
Symptoms deteriorate and fluctuate rapidly
Most patients recover within 6-12 weeks

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15
Q

Define Mania

A

Elevated mood out of keeping with patient’s circumstances and may vary from carefree joviality to almost uncontrollable excitement

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16
Q

Characteristics of emotionally unstable personality disorder

A

Definite tendency to act impulsively and without consideration of the consequences
Mood is unpredictable and capricious
Liable to outbursts of emotion and an incapacity to control the behavioural explosions
Tendency to quarrelsome behaviours and to conflicts with others

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17
Q

Cluster C Personality Disorders

A

Anxious (Avoidant) personality Disorder
Dependent Personality Disorder
Anakastic Personality Disorder

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18
Q

Define binge eating disorder

A

Frequent, recurrent episodes of binge eating (once a week or more over a period of several months) which are not regularly followed by inappropriate compensatory behaviours aimed at preventing weight gain

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19
Q

Symptoms of hypomania

A

Increased sociability, talkativeness and overfamiliarity
Increased sexual energy
Decreased need for sleep
Does NOT lead to severe disruption of work or result in social rejection
Can manifest as irritability, conceit or boorish behaviour
No hallucinations or delusion

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20
Q

Key features of social phobia

A

Low self-esteem and fear of criticism
May present with complaints of blushing, hand tremor, nausea or urinary urgency in social situations
Can progress to panic attacks

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21
Q

What is the criteria for diagnosis of postnatal depression?

A

Same as non-childbirth depression

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22
Q

Characteristics of Avoidant/Anxious Personality Disorder

A

Feelings of tension and apprehension
Insecurity and inferiority
Continuous yearning to be liked and accepted
Hypersensitivity to rejection and criticism with restricted personal attachments
Tendency to avoid certain activities by habitual exaggeration of the potential dangers or risks in everyday situations

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23
Q

Define Bipolar 2 disorder

A

At least one hypomanic episode

At least one major depressive episode

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24
Q

Concurrent disorder in adjustment disorder

A

Conduct disorder (mainly in adolescents)

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25
Q

Define autism

A

A pervasive developmental disorder defined by presence of abnormal or impaired development that manifests before the age of 3 years, as well as abnormal functioning in all 3 areas of psychopathology

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26
Q

DDx of acute stress reaction?

A

Consider diagnosis of PTSD if >1 month

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27
Q

Define delusional disorder

A

A disorder characterised by the development either or a single delusion or of a set of related delusions that are usually persistent and sometimes lifelong

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28
Q

What is the difference between ODD and conduct disorder

A

Oppositional defiant disorder does not include delinquent acts or aggressive/dissocial behaviour

The child is specifically defiant against being controlled by others

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29
Q

Sx of generalised anxiety disorder

A

Autonomic: palpitations, sweating, trembling, dry mouth

Chest/abdo: breathing difficulty, choking feeling, chest pain, nausea/abdo distress

Brain/mind: dizziness, light headedness, derealisation/depersonalisation, fear of losing control, fear of dying (common fear: they or family member will shortly become ill/have an accident)

General: hot flushes/cold chills, numbness or tingling sensation

tension: muscle tension/aches/pains, restlessness, mental tension, lump in throat

Other: irritability, exaggerated startle response, difficulty concentrating, difficulty sleeping

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30
Q

Key features of generalised anxiety disorder

A

Apprehension
Motor tension
Autonomic overactivity

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31
Q

Define PTSD

A

Delayed or protracted response to a stressful life event or situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone
>1 month

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32
Q

Characteristics of Anakastic Personality Disorder

A

feelings of doubt
Perfectionism
Excessive conscientiousness
Checking and preoccupation with details, stubbornness, caution and rigidity
Insistent and unwelcome thoughts or impulses that do not attain the severity of OCD

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33
Q

What is noteworthy about Panic Disorder diagnosis?

A

Should not be the main diagnosis in a patient with a depressive disorder at the time of the attack - most likely secondary to the depression

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34
Q

Sx of Panic Disorder

A

Sudden onset palpitations
Chest pain
Choking sensations
Dizziness
Feelings of unreality (depersonalisation or derealisation)
Fear of dying, losing control, or going mad (and fear if when panic attack might recur)

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35
Q

Key features of OCD

A

Ideas, images, impulses

Recognised as own thoughts, which are distressing (attempts to resist)
Compulsive acts or rituals are repeated again and again - not enjoyable and do not result in completion of a useful task - believed to prevent some objectively unlikely event
Behaviour is recognised as pointless, but leads to worsening anxiety if resisted

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36
Q

Subtypes of dissociative (conversion) disorders

A

Dissociative amnesia
Dissociative fugue
Dissociative stupor
Trance and possession disorders
Dissociative motor disorders
Dissociative convulsions (tongue-biting, brusing due to falling and urinary incontinence are uncommon; consciousness is maintained or replaced by a state of stupor or trance)
Dissociative anaesthesia: associated patient’s ideas aboiut bodily functions, rather than medical knowledge

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37
Q

Cluster B Personality Disorders

A

Dissocial (antisocial) Personality Disorder
Emotionally Unstable Personality Disorder
Histrionic Personality Disorder

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38
Q

Characteristics of Dependent Personality Disorder

A

Pervasive passive reliance on other people to make one’s major and minor life decisions
Great fear of abandonment
Feelings of helplessness and incompetence
Passive compliance with the wishes of elders and others
Weak response to the demands of daily life
Lack of vigour may show itself in the intellectual or emotional spheres
Often a tendency to transfer responsibility to others

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39
Q

What occurs in a small proportion of PTSD sufferers?

A

The disease will follow a chronic course over many years, resulting in enduring personality change

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40
Q

Key features of acute stress reaction?

A 
Initial state of daze
Narrowing of attention
Constriction of field of consciousness
Inability to comprehend stimuli
Disorientation
Severe withdrawal from surrounding situation could manifest as stupor
Flight reaction - agitation and over-reactivity
Autonomic signs of panic
Partial/complete amnesia
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41
Q

What hallucinations are present in delusional disorder?

A

There should NOT be any auditory hallucinations, delusions of control, blunting of affect of other schizophrenic symptoms (BUT presence of the occasional hallucination does not rule out diagnosis, assuming this is only a small part of the clinical picture

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42
Q

Characteristics of body dysmorphic disorder

A

Appearance preoccupations
Repetitive, compulsive behaviours

Can cause clinically significant distress or impairment of functioning

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43
Q

What are the requirements of Sx for a diagnosis of ADHD?

A

Symptoms must have appeared:
By the age of 6-12 years
Occurring in >1 environment (e.g home and school)
Clear evidence of causing social, school or work-related problems
Last>6 months

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44
Q

What is the general definition of personality disorder?

A

Pervasive: Occurs in all/most areas of life
Persistent
Pathological

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45
Q

Defined Baby Blues

A

Tearfulness, irritability and low mood occurring within a few days of childbirth
Spontaneously resolves after a few days

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46
Q

Define adjustment disorder

A

States of subjective distress and emotional disturbance, usually interfering with social functioning and performance, arising in the period of adaptation to a significant life change or a stressful life event

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47
Q

What is the difference between autism and Asperger’s syndrome?

A

Asperger’s features no general delay in language or retardation in language or in cognitive development

However, does feature abnormalities of reciprocal social interaction, as well as restricted, stereotyped, repetitive repertoire of interests and activities

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48
Q

WHat are the biological ICD-10 symptoms of depression

A

Sleep disturbance (aprticularly early morning waking)
Appetite/weight disturbance
Low libido
Psychomotor agitation

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49
Q

What are the characteristics of anorexia nervosa?

A

Deliberate weight loss
Morbid dread of being fat (intrusive overvalued idea)
Disturbance of bodily function (endocrine and metabolic)

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50
Q

Key features of adjustment disorder

A

Depressed mood
Anxiety
Worry
Feeling of inability to cope; plan ahead, or continue with the present situation
Disability in the performance of daily routine

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51
Q

What are the 3 patterns of puerperal psychosis?

A

Delirium
Affective (like psychotic depression or mania)
Schizophreniform

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52
Q

How long do symptoms have to last for diagnosis of ADHD?

A

at least 6 months

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53
Q

What are the characteristics of Schizoid Personality Disorder?

A

Withdrawal from affectional, social and other contacts
Preference for fantasy, solitary activities and introspection
Limited capacity to express feelings and to experience pleasure

ICD-10 features:
Few, if any, activities provide pleasure
Emotional coldness, detachment or flattened affectivity
Limited capacity to express warm, tender feelings for others as well as anger
Appears indifferent to praise or criticism
Little interest in sexual experience with another person
Almost always chooses solitary activities
Excessive preoccupation with fantasy and introspection
Neither desires, nor has, any close friends or confiding relationships
Marked insensitivity to prevailing social norms and conventions

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54
Q

Define acute stress reaction

A

A transient disorder that develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress and that usually subsides within hours or days

DSM-IV states must last at least 3 days

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55
Q

3 subtypes of ADHD

A

ADHD predominantly inattentive
ADHD predominantly hyperactive-impulsive
ADHD-combination

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56
Q

DSM-IV depressive criteria

A

Depressed mood most of the day, nearly every day
Anhedonia
Weight/appetite change
Sleep disturbance nearly every day
Psychomotor agitation/retardation nearly every day
Fatigue
Feelings of worthlessness or excessive/inappropriate guilt
Diminished ability to think or concentrate, or indecisiveness nearly every day
Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt of a specific plan for committing suicide

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57
Q

Symptoms of mania

A

Increased energy leading to overactivity, pressure of speech and decreased need for sleep
Distractability
Inflated self-esteem with grandiose ideas and over confidence
Loss of normal social inhibitions may result in behaviour that is reckless, foolhardy, inappropriate or out of character

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58
Q

What are the characteristics of Schizotypal Personality Disorder?

A

Eccentric behaviour
Anomalies of thinking and affect that resemble schizophrenia
Cold or inappropriate affect
Anhedonia
Odd or eccentric behaviour
Tendency to social withdrawal
Paranoid or bizarre ideas not amounting to true delusions
Obsessive ruminations
Thought disorder and perceptual disturbances
Occasional transient quasi-psychotic episodes with intense illusions, auditory or other hallucainations and delusion-like ideas
No definite onset or evolution

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59
Q

What are the core ICD-10 symptoms of depression?

A

Low mood
Anergia
Anhedonia

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60
Q

Characteristics of Antisocial Personality Disorder

A

Disregard for social obligations and callous unconcern for the feelings of others
Gross disparity between behaviour and prevailing social norms
Behaviour is NOT readily modifiable by adverse experience (e.g. punishment)
Low tolerance to frustration and a low threshold for aggression including violence
Tendency to blame others or offer plausible rationalisations for the behaviour bringing the patient into conflict with society

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61
Q

What symptoms may severely depressed individuals concurrently experience?

A

Psychotic symptoms

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62
Q

How is severe depression diagnosed based on ICD-10 criteria?

A

All 3 core symptoms
At least 4 other symptoms
Major impact on QoL and social functioning
May show distress and/or agitation

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63
Q

Define panic disorder

A

Recurrent attacks of severe anxiety (panic) which are not restricted to any particular situation or set of circumstances and are therefore unpredictable.

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64
Q

What are the criteria for diagnosis of a learning disability?

A

Significant limitation in general mental abilities (intellectual functioning)
Significant limitations in one or more areas of adaptive behaviour across multiple environments (as measured by an adaptive behaviour rating scale)
Evidence that the limitations became apparent in childhood or adolescence
IQ <70

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65
Q

What are the characteristics of bulimia nervosa?

A

Repeated episodes of bingeing
Excessive preoccupation with control of bodyweight, leading to a pattern of overeating followed by vomiting or using purgatives
Overconcern with body shape and weight

Often a history of an earlier episode of anorexia nervosa

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66
Q

What are the subtypes of conduct disorder?

A

Conduct disorder confined to the family context
Unsocialised conduct disorder
Socialised conduct disorder: individuals are well-integrated into the peer group

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67
Q

Why do some agoraphobics experience little anxiety?

A

Able to avoid phobic situations

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68
Q

What are some non-specific symptoms of autism?

A

Phobias
Sleeping and eating disturbances
Temper tantrums
(self-directed) aggression

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69
Q

What are the characteristics of Paranoid Personality Disorder?

A

Excessive sensitivity to setbacks
Unforgiveness to insults
Suspiciousness
Tendency to sitrort experience by misconstruing the neutral or friendly actions of others as hostile or contemptuous
Recurrent suspicions without justification regarding sexual fidelity of the spouse or sexual partner
Combative and tenacious sense of personal rights
May be excessive self-importance and excessive self-reference

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70
Q

Define Bipolar 1 disorder

A

At least one manic episode

Depressive episodes are common, but not necessary for diagnosis

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71
Q

Key features of PTSD

A 
Re-experiencing: flashbacks, dreams or nightmares
Avoidance of activities and situations reminiscent of the trauma
Autonomic hyperarousal (hypervigilance, enhanced startle reflex, insomina)
Sense of numbness and emotional blunting
Detachment from other people
Unresponsiveness to surroundings
Anhedonia
Depression and suicidal ideation
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72
Q

Subtypes of Emotionally Unstable Disorder

A

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)

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73
Q

What factors increase the risk of developing PTSD?

A

Previous history of neurotic illness

Certain personality traits (e.g. compulsive)

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74
Q

Characteristics of schizophrenia

A

Fundamental and characteristic distortions of thinking and perception
Affects are inappropriate or blunted
Clear consciousness and intellectual capacity are usually maintained (although cognitive deficits may evolve)
First-rank symptoms
Negative symptoms (e.g. social isolation)

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75
Q

What are the First-rank symptoms?

A 
Thought insertion, withdrawal, broadcasting
Delusional perceptions (and passivity phenomena)
Auditory hallucinations (3rd person, thought echo, running commentary)
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76
Q

When should a diagnosis of schizophrenia be reconsidered?

A

In the presence of extensive depressive or manic symptoms (unless it is clear that schizophrenic symptoms came first)

In the presence of overt brain disease or during states of drug intoxication or withdrawal

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77
Q

How long should schizophrenic symptoms last for a diagnosis according to DSM-V criteria?

A

2 diagnostic criteria met over much of the time for a period of at least one month with a significant impact on social or occupational functioning for at least six months

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78
Q

Signs of social disturbance present between 1-6 months?

A

Schizophreniform disorder

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79
Q

Psychotic symptoms lasting <1 month?

A

Brief psychotic disorder

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80
Q

Subtypes of schizophrenia

A 
Paranoid 
Hebephrenic
Catatonic
Undifferentiated
Residual
Simple
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81
Q

Characteristics of paranoid schizophrenia

A

Dominated by relatively stable, often paranoid delusions, usually accompanied by hallucinations (often auditory) and perceptual disturbances

Uncommon features include disturbances of affect, volition, speech and catatonia

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82
Q

Characteristics of hebephrenic schizophrenia

A

Affective changes
Fleeting and fragmentary delusions and hallucinations
Irresponsible and unpredictable behaviour
Mannerisms are common
Disorganised thought and incoherent speech
Tendency to social isolation

Poor prognosis because of rapid development of negative symptoms (flattening of affect and loss of volition)

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83
Q

In what demographic is hebephrenic schizophrenia more commonly diagnosed?

A

Normally, hebephrenia should only be diagnosed in adolescents or young adults

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84
Q

Characteristics of catatonic schizophrenia

A

Dominated by psychomotor disturbances that may alternate between extremes (hyperkinesis and stupor),automatic obedience and negativism

Episodes of violent excitement may be a striking feature

Catatonic phenomena may be combined with a dream-like state with vivid scenic hallucinations

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85
Q

Define undifferentiated schizophrenia

A

Psychotic conditions meeting the general diagnostic criteria for schizophrenia but not conforming to any of the subtypes

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86
Q

Define residual schizophrenia

A

A chronic stage in the development of a schizophrenic illness in which there has been a clear progression from an early stage to a later stage characterised by long-term negative symptoms (e.g. blunting affect, passivity,lack of initiative, poverty of speech, poor facial expression and eye contact, poor self-care and social performance)

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87
Q

Define simple schizophrenia

A

Insidious but progressive development of oddities of conduct, inability to meet the demands of society and a decline in total performance

Characteristic negative features of residual schizophrenia (e.g. blunted affect, loss of volition) develop without being preceded by any over psychotic symptoms)

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88
Q

What are the key features of simple schizophrenia?

A

Characteristic negative features of residual schizophrenia (e.g blunted affect, loss of volition) develop without being preceded by any over psychotic symptoms

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89
Q

What is a potential associated illness with schizophrenia?

A

Post-schizophrenic depression

Some schizophrenic symptoms may still be present, but they do not dominate the clinical picture
These depressive episodes are associated with increased suicide risk
If there are no schizophrenic symptoms, a depressive episode can be diagnosed

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90
Q

Define schizoaffective disorder

A

Episode disorders in which both affective and schizophrenic symptoms are prominent but do not justify a diagnosis of either schizophrenia or depressive/manic episodes

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91
Q

What are the subtypes of schizoaffective disorder?

A

Manic and depressive

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92
Q

How long must schizoaffective symptoms last for a diagnosis (DSM-5)?

A

Requires psychotic symptoms to persist in a sustained fashion for 2 weeks or longer without concurrent affective symptoms

Requires 2 episodes of psychosis to qualify:
One episode must last >2weeks without mood disorder symptoms (but the patient can be mild/moderately depressed whilst psychotic)
One episode requires obvious overlap of mood and psychotic symptoms

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93
Q

Define acute intoxication

A

A condition that follows the administration of a psychoactive substance resulting in disturbances in level of consciousness, cognition, perception, affect or behaviour, or other psycho-physiological functions and responses

The disturbances are directly linked wto the acute pharmacological effects of the substance and resolve with time with a complete recovery (except in the case of tissue damage)

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94
Q

Define harmful use

A

A pattern of psychoactive substance use that is causing damage to health

The damage might be physical or mental

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95
Q

Key features of dependence syndrome

A 
Craving
Control (difficulties controlling use)
Persistent use (despite knowledge of harmful consequences)
Priority
Tolerance 
Withdrawal
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96
Q

Define withdrawal state

A

A group of symptoms of variable clustering and severity occurring on absolute or relative withdrawal of a psychoactive substance after persistent use of that substance

Onset and course of the withdrawal state are time-limited and are related to the type of psychoactive substance and dose

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97
Q

What can complicate withdrawal state?

A

Convulsions

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98
Q

Define psychotic disorder

A

A cluster of psychotic phenomena that occur during or following psychoactive substance use that are not explained on the basis of acute intoxication alone and do not form part of the withdrawal state

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99
Q

Characteristic features of psychotic disorder

A

Hallucinations (usually auditory)
Perceptual distortions
Delusions (often of a paranoid or persecutory nature)
Psychomotor disturbance (excitement or stupor)
Abnormal affect (ranging from intense fear to ecstasy)
There may be some degree of clouding of consciousness

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100
Q

Define amnesia syndrome

A

A syndrome associated with chronic prominent impairment of recent and remote memory

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101
Q

Key features of amnesia syndrome

A

Immediate recall is usually preserved, and recent memory is characteristically more disturbed than remote memory

Disturbances of time sense and ordering of events are usually evident, as there are difficulties learning new material

Confabulation may be marked but is not invariably present

Other cognitive functions are well preserved

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102
Q

Define residual/late-onset psychotic disorder

A

A disorder in which alcohol- or psychoactive substance-induced changes of cognition, affect, personality or behaviour persist beyond the period during which a direct psychoactive substance-related effect might be assumed to be operating

Onset is directly related to the use of a psychoactive substance

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103
Q

How can you distinguish residual psychotic disorder from psychotic state?

A

Flashbacks in late-onset psychotic disorder are episodic in nature (short duration) and by their duplication of previous alcohol- or other psychoactive substance-related experiences

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104
Q

Define somatisation disorder

A

Multiple, recurrent and frequently changing physical symptoms of at least two years duration

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105
Q

Key features of somatisation disorders

A

Most patients have a complicated history of contact with medical care, during which many negative investigations or fruitless exploratory operations may have been carried out

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106
Q

How do somatisation disorders present?

A

Symptoms can be referred to any system or part of the body

The disorder is chronic and fluctuating, and is often associated with disruption of social, interpersonal and family behaviour

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107
Q

Undifferentiated somatoform disorder

A

When somatoform complains are multiple, varying and persistent but the complete and typical clinical picture of somatisation disorder is not fulfilled

Usually when features of somatisation disorder have been going on for <2 years

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108
Q

Hypochondrial disorder

A

Persistent preoccupation with the possibility of having one or more serious and progressive physical disorders
Patients have persistent somatoform complaints or a persistent preoccupation with their physical appearance

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109
Q

Key features of hypochondrial disorder

A

Preoccupation with physical appearance

Normal or commonplace sensations are interpreted by the patients as abnormal or distressing, and attention is usually focused on one or two organs/systems

Marked depression and anxiety are often present

110
Q

What is somatoform autonomic dysfunction?

A

Symptoms are presented as if they were due to a physical disorder of a system/organ that is largely of completely under autonomic inner arion and control (e.g cariovasculad, GI, respiratory)

111
Q

What types of symptoms are present in somatoform autonomic dysfunction?

A

Complaints based on onbjective signs of autonomic arousal (e.g, palpitations, sweating, flushing, tremor)

Subjective complaints of a non-specific or changing nature (e.g. fleeting aches and pains, sensations of burning, heaviness, bloating)

112
Q

What are the subtypes of somatisation disorders?

A

Undifferentiated somatoform disorder
Hypochondrial disorder
Somatoform autonomic dysfunction
Persistent somatoform pain disorder

113
Q

What is the key complaint in persistent somatoform pain disorder?

A

The predominant complaint is of persistent, severe and distressing pain which cannot be fully explained by a physiological process or a physical disorder, and which occurs in association with emotional conflict or psychosocial problems

The result is usually a marked increase in support and attention.

114
Q

Outline the investigations required in suspected depression

A 
Collateral history
Physical examination
Bloods: FBC, U+Es, TFTs
Rating scale: PHQ9, HAD, CDI (children)
Risk assessment

Assess severity of depression, considering the number of symptoms, degree of functional impairment and/or disability and duration of the episode

115
Q

What must be explored in an individual suspected of being depressed?

A

Previous episodes of depression and mood elevation

Suicide risk

116
Q

Outline Step 1 of the Stepped Care Model

A

All known and suspected presentations of depression

Assessment, support, psycho education, active monitoring and referral for further assessment and interventions

117
Q

Outline Step 2 of the Stepped Care Model

A

Persistent subthreshold depressive symptoms, mild-to-moderate depression

Low-intensity psychological interventions, psychological interventions, medication, referral for further assessment and interventions

118
Q

Outline Step 3 of the Stepped Care Model

A

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

Medication, high-intensity psychological interventions, combined treatments, collaborative care and referral for further assessment and interventions

119
Q

Outline Step 4 of the Stepped Care Model

A

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

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

120
Q

What is it important to make the patient aware of when starting treatment for depression?

A

Symptoms may get worse soon after starting treatment

Give clear advice on how to seek help

121
Q

How to assess an individual with mild-to-moderate depression?

A

Sleep hygiene

Arrange further assessment within 2 weeks

122
Q

Outline 3 low-intensity psychological interventions

A

Individual-guided self-help based on the principles of CBT (written materials and supported by a trained practitioner who reviews progress and outcomes, 6-8 sessions over 9-12 weeks)

Computerised CBT (encourage tasks between sessions, use thought-challenging and active monitoring of behaviour and thought patterns, supported by trained practitioner, 9-12 weeks)

Structured group physical activity programme (3 sessions per week, 10-14 weeks)

123
Q

Group CBT

A

Considered if low-intensity psychological intervention is declined
Should be based on a structured model such as “coping with depression”
Should be delivered by 2 trained practitioners
Consists of 10-12 meetings of 8-10 participants
Normally lasts 12-16 weeks

124
Q

When should antidepressant medication be considered, in mild-to-moderate depression?

A

Past history of moderate or severe depression
Symptoms have been present >2 years
Symptoms persist despite other interventions

125
Q

Treatment of moderate-to-severe depression

A

Combination of:
Antidepressant medication
High-intensity psychological intervention (CBT or interpersonal therapy (IPT))

126
Q

What is the first-line antidepressant medication used in moderate-to-severe depression?

A

SSRI (e.g Sertraline)

127
Q

What risks are associated with antidepressant medication use?

A

Bleeding (particularly in the elderly, gastric ulcers, hyponatremia) => NSAIDs should be given with a PPI

Drug interactions: paroxetine, fluoxetine, fluvoxamine

Discontinuation symptoms: paroxetine

Death from overdose: venlafaxine

Overdose: TCAs (except lofepramine)

Stopping treatment due to side-effects: venlafaxine, duloxetine, TCAs

Blood pressure monitoring required: venlafaxine

Worsening hypertension: venlafaxine, duloxetine

Postural hypotension and arrhythmia: TCA

128
Q

When should antidepressant medication be reviewed?

A

After starting antidepressant medication, review after 2 weeks (if no particular risk of suicide), then every 2-4 weeks thereafter for 3 months

Patients <30 years or at risk of suicide should be followed-up after 1 week

Review response to treatment after 3-4 weeks

129
Q

What high intensity psychological interventions are available for depression?

A

Individual CBT
Interpersonal therapy: helps identify how interactions with others are affecting the patients mood, and ways of improving these interactions

130
Q

Exercise particular caution when switching the following antidepressants:

A

From fluoxetine to other antidepressants (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 a non- reversible MAOI: a 2-week washout period is required (other antidepressants should not be prescribed in this time)

131
Q

What management options are available for complex and severe depression?

A

Crisis resolution and home treatment teams

Develop a crisis plan that identifies potential triggers and strategies to manage triggers (share with GP and any other people involved in patient’s care)
Consider inpatient treatment if significant risk of suicide, self-harm or self-neglect
Consider ECT for acute treatment of severe depression and when a rapid response is required

132
Q

Why is sertraline preferred in individuals with a co-existing chronic physical health problem?

A

Lower risk of drug interactions

Non-sedative

133
Q

Outline the counselling process for someone diagnosed with depression (PACES)

A

Explain the diagnosis of depression (persistently low mood that impacts ok day to day functioning)
Explain that it is very common (every year, 1 in 4 people suffer from a mental health problem)
Address social needs
Explain the role of psychological therapy
Explain the role of medication (takes a number of weeks to work, follow-up in 1 or 2 weeks, warn about side-effects)
Advise about the crisis resolution and home treatment teams
Support: mind.co.uk, Samaritans

134
Q

When is citalopram contraindicated?

A

In any condition that prolongs QTc

135
Q

What is the second-line pharmacological treatment option for depression?

A

Taper down SSRI and switch to SNRI

E.g. venlafaxine, duloxetine

136
Q

When does SNRI pharmacology switch from SSRI to SNRI effect?

A

At maximum dose

137
Q

What needs to be checked if antidepressant medication is not effective?

A

Are the drugs being taken correctly?
Check the diagnosis (could be BPAD or psychosocial depression)
Check drug interactions
Check perpetuating factors (e.g. alcohol)

138
Q

What treatment options are available for treatment resistant depression (3rd line)?

A

Augmentation (e.g. atypical antipsychotic like quetiapine 150-300mg)
Lithium (aim for blood level of 0.4-0.8)
Another antidepressant (e.g. mirtazapine or mianserin)

139
Q

What is the 4th line treatment option for depression?

A

ECT

140
Q

What is catch-up phenomena?

A

If someone recovers from depression due to treatment, treatment is stopped. Then if they experience depression again they will be in a worse state.

If they develop psychosis, you add the antipsychotic earlier on (whenever the psychosis comes on)

141
Q

Over what time period should antidepressants be stopped?

A

Over four weeks

142
Q

Outline the clinical features of serotonin syndrome

A 
Fever
Agitation
Confusion
Hyper reflexes
Tremor
Dilated pupils (onset within hours)
Hypertension
Clonus
Diarrhoea
143
Q

Treatment for serotonin syndrome

A

Withdraw offending drug
Supportive care
Benzodiazepines to control agitation
Some may benefit from cyproheptadine (antihistamine)

Mild cases resolve within 1-3 days

144
Q

Investigations for mania and BPAD

A 
Collateral history
Physical examination (establish a baseline state)
Bloods: FBC, TSH, U+E, LFT, ECG
Urine drug screen
Rating scale: Young Mania Rating Scale
Risk assessment
145
Q

What are the three types of mood stabilisers?

A

Lithium
Sodium valproate
Carbamazepine

146
Q

What is the mechanism of action of mood stabilisers?

A

Unclear

?something to do with sodium channels or GABA

147
Q

What is the therapeutic range of lithium?

A

0.6-1.0mmol/L

148
Q

How often should lithium levels be checked?

A

1 week after starting or changing dose and monitored weekly until a steady therapeutic level is achieved; every 3 months from then on

149
Q

What is a side-effect of lithium treatment?

A

Hypothyroidism and renal impairment

U+E and TFTs should be monitored every 6 months

150
Q

At what level is lithium toxic?

A

Above 1.2mmol/L

151
Q

Outline the presentation of lithium toxicity

A

Life-threatening

GI disturbance
Polyuria/polydipsia
Sluggishness
Giddiness
Ataxia
Gross tremor
Fits
Renal failure
152
Q

What are the triggers for lithium toxicity?

A

Salt balance changes (e.g. dehydration, D+V)
Drugs interfering with lithium excretion (e.g. diuretics)
Accidental or deliberate overdose

153
Q

Management for lithium toxicity

A

Check lithium level
Stop lithium dose (NB. Stopping lithium abruptly could precipitate symptoms of mania/depression)
Transfer for medical care (rehydration, osmotic diuresis)
If overdose is severe, the patient may need gastric lovage or dialysis

154
Q

Why is valproate given as sodium valproate?

A

Reduced side-effects

155
Q

What is the therapeutic range of valproate?

A

No known therapeutic range

Dose-related toxicity not usually an issue

156
Q

What is valproate used for?

A

Anticonvulsant
Treats acute mania
Prophylaxis in BPAD

Plasma levels do not need monitoring

157
Q

Carbamazepine

A

Anticonvulsant
Can cause toxicity at high doses
Induces liver enzymes
Close monitoring of carbamazepine levels is essential
Check for drug interactions before prescribing

158
Q

What risks do mood stabilisers pose in pregnancy?

A

They are teratogenic

Lithium- Ebstein’s anomaly
Valproate and carbamazepine- spina bifida

159
Q

What countermeasures should be provided to a woman of child bearing age taking valproate?

A

Contraceptive advice
Folate supplement

Closely monitor foetus if medications are used during pregnancy

160
Q

Why are the antipsychotics given in mania/BPAD atypical? (E.g. olanzapine, dispersions, quetiapine)

A

Fewer side-effects

161
Q

What anticonvulsant is 2nd line treatment for prophylaxis in BPAD type II?

A

Lamotrigine

162
Q

How to treat acute mania/hypomania if not on treatment already?

A

Stop all medications that may induce symptoms (e.g. antidepressants, steroids, drugs of abuse and dopamine agonists)
Monitor food and fluid intake to prevent dehydration

Give an antipsychotic OR mood stabilisers (can be given together if not responding)
A short course of benzodiazepines is often added for sedation (sleep deprivation can exacerbate mania)

163
Q

How to treat acute mania/hypomania if already on treatment?

A

Stop all medications that may induce symptoms (e.g. antidepressant,s drugs of abuse, steroids and dopamine agonists)
Monitor food and fluid intake to prevent dehydration

Optimise the medication
Check compliance
Adjust doses
Consider adding another agent (e.g. antipsychotic as well as mood stabilisers)
Short-term benzodiazepines may help
164
Q

When can ECT be considered for acute manic/hypomania patients?

A

If unresponsive to other treatments

165
Q

Why is depression difficult to manage in BPAD?

A

Antidepressants can cause a switch to mania

To reduce this risk, antidepressants should only be given with a mood stabilisers or antipsychotic:

1) fluoxetine+olanzapine/quetiapine
2) lamotrigine

Monitor closely for signs of mania and immediately stop antidepressants if signs are present
Medication can be cautiously withdrawn if the patient is symptom-free for a sustained period

166
Q

What psychological treatments are available for BPAD.?

A 
CBT
Psychodynamic psychotherapy (useful if mood stabilised)
167
Q

Outline the strategies used in CBT for BPAD

A 
Identify relapse indicators and prevent relapse by:
Developing routine 
Ensuring good-quality sleep 
Promoting a healthy lifestyle
Avoiding excessive stimulation/stress
Addressing substance misuse 
Ensuring drug compliance

Helps patients test out their excessively positive thoughts to gain a sense of perspective

168
Q

Outline the prognosis of BPAD

A

Manic episodes begin abruptly and are often shorter than depressive episodes (usually 2 weeks - 5 months)
Recovery is usually complete between episodes
Remissions become shorter with age and depressions become more frequent
15% of people with BPAD will commit suicide. Lithium reduces this to the same levels as the general population.

169
Q

Outline the primary care approach to referring for BPAD

A

Symptoms of hypomania —> routine referral to CMHT

Symptoms of mania or severe depression —> urgent referral to CMHT

170
Q

Outline the counselling approach to a BPAD diagnosis (PACES)

A

Consider admission and section if at risk
Explain the diagnosis (condition where patients have a tendency to experience the extremes of emotion for variable lengths of time)
Explain the importance of controlling it (both extremes can lead to making certain decisions and taking risks that you would otherwise regret)
Explain that there are medications available (helps balance the chemicals in the brain)
Advise about crisis resolution team and Samaritans

171
Q

What class of antimanic is given for acute manic phase treatment?

A

Atypical antipsychotic > mood stabilisers

Atypical antipsychotics work very quickly, are safe and are more effective in the acute manic phase

Mood stabilisers are best used when the patient is already stable

172
Q

What drugs are given to stabilise BPAD?

A

Mood stabilisers or atypical antipsychotics

Both work equally well

173
Q

Treatment for bipolar depression

A

SSRI (1st line: fluoxetine) with an atypical antipsychotic (olanzapine or quetiapine)

Always check lithium levels if the lithium appears to be ineffective

174
Q

What physical treatment is available for an overdose of antidepressant?

A 
Activated charcoal (decreases absorption) 
Needs to be taken <1hour after ingestion
175
Q

What is the treatment for an acute overdose of paracetamol?

A

N-acetylcysteine

176
Q

Outline specific features of increased risk of suicide

A

Careful planning
Final acts in the 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 isn’t
Violent method
Ongoing wish to die/regret that the attempt failed

177
Q

What should be done if a suicidal patient is insistent on leaving hospital?

A

Assess their capacity

178
Q

What immediate interventions should be taken in a suicidal individual?

A

Admit to a psychiatric ward if at high risk and lacking capacity
Patients are lower risk may be managed at home (depending on home circumstance (e.g. if they have a supportive family))
A crisis plan should be made to deal with future suicidal ideation or thoughts of self-harm: who they will tell, how they will get help (eg. Coming straight to hospital)

179
Q

Follow-up interventions for suicidal patient discharged from hospital

A

Follow-up within 1 week of the self-harm or discharge from inpatient ward (could be CMHT, GP, Counsellor, outpatient clinic)

Underlying disorders should be treated (e.g. depression): SSRIs are first-line, but prescriptions should be short and reviewed regularly to prevent stockpiling for OD

180
Q

What psychological therapies are available for discharged suicidal patients?

A

CBT-based therapies (e.g. dialectical behaviour therapy)
Mentalisation-based treatment
Transference-focused psychotherapy

181
Q

Coping strategies to prevent self-harm

A

Distraction techniques
Mood-raising activities (e.g. exercise, writing)
Put tablets and sharp objects away
Avoid triggering images
Stay in public places or with supportive people when tempted to self-harm
Call a friend or support line
Avoid drugs and alcohol
Squeeze ice cubes
Snap a rubber band around wrist
Bite into something strongly flavoured (e.g. lemon)

182
Q

Investigations for first-line psychosis in schizophrenia

A 
Collateral history
Physical examination
Bloods (FBCs, U+Es, lipids, LFTs, VDRL)
Urine drugs screen
Rating scale - Brief Psychiatric Rating Scale
ADL Assessment and Housing and Finance
183
Q

What is the aim for schizophrenia treatment?

A

EIP
Patients are offered antipsychotic and psychosocial interventions with the aim of keeping duration of untreated psychosis under 3 months

184
Q

Up to what age can CAMHS deal with psychosis in children?

A

Up to 17 years

EIP can be used in children >14

185
Q

If urgent treatment is necessary in schizophrenia, what measures should be taken?

A

Use the crisis resolution and home treatment teams

186
Q

List examples of typical antipsychotics

A

Chlorpromazine
Haloperidol
Flupentixol decanoate

187
Q

What side effects are associated with typical antipsychotics and at what dose?

A

EPSEs
Normal dose

However, are effective, cheap and provide depot options

188
Q

What is the mechanism of action of atypical antipsychotics?

A

As well as blocking dopamine receptors, they also block serotonin 5-HT2 receptors.

189
Q

List some examples of atypical antipsychotics

A 
Olanzapine
Risperidone (available as depot)
Quetiapine
Aripiprazole
Clozapine
Amisulpride
190
Q

When should starting an atypical antipsychotic be considered?

A

Choosing first line treatment in newly diagnosed schizophrenia
Unacceptable side-effects from typical antipsychotics
Relapse occurs on a typical antipsychotic

Avoid using more than 1 antipsychotic

191
Q

What are side effects associated with antipsychotic use in general?

A

EPSES
Hyperprolactinaemia: galactorrhoea, gyanecomastia, hypogonadism, sexual dysfunction, increased risk of osteoporosis
Weight gain (especially olanzapine and clozapine)
Sedation
Increased risk of diabetes
Dyslipidaemia
Anticholinergic side effects (dry mouth, blurred vision, constipation, urinary retention, tachycardia)
Arrhythmia
Seizures (reduces seizure threshold)
Neuroleptic malignant syndrome

192
Q

What are the types of EPSEs caused by antipsychotic use?

A

Dystonia
Akathisia
Parkinsonism
Tardive dyskinesia

193
Q

What are the symptoms of dystonia (EPSE), and how can it be treated?

A

Involuntary, painful and sustained spasm e.g. torticollis: neck twists to one side; oculogyric crisis: eyes twist up and can’t look down

Anticholinergic

194
Q

What are the symptoms of akathisia (EPSE), and how can it be treated?

A

Restlessness

Decrease dose/ hangs antipsychotic
Add propanolol or benzodiazepines

195
Q

What are the symptoms of Parkinsonism (EPSE), and how can it be treated?

A

Resting tremor, rigidity and bradykinesia
Patients may have mask-like faces and a shuffling gait

Decrease dose/change antipsychotic
Try an anticholinergic (e.g. procyclidine),but review frequently and do not prescribe prophylactically

196
Q

What are the symptoms of tardive dyskinesia (EPSE), and how can it be treated?

A

Rhythmic involuntary movements of the mouth, face, limbs and trunk which are very distressing
Patients may grimace, or make chewing and sucking movements with their mouth and tongue

Stop antipsychotic or reduce dose if possible (though problems may worsen initially)
Avoid anticholinergic since they often worsen the problem
Switch to an atypical or clozapine
Often irreversible

197
Q

What is a notable side effect of clozapine?

A

Agranulocytosis

198
Q

What psychological treatment options are available for schizophrenia?

A

CBT: 16 sessions
Family therapy: 10 sessions
Concordance therapy

199
Q

Outline CBT use in schizophrenia

A

Should be offered to ALL patients
Particular emphasis on reality testing: gently challenge patient’s beliefs, aiding awareness of illogical thinking. The patient is encouraged to think about the evidence and considered alternative explanations.
CBT can also help patients cope with troublesome hallucinations and delusions

200
Q

Outline the use of family therapy in schizophrenia

A

Can reduce relapse rates
Effects of high expressed emotion can be ameliorated through communication skills, education about schizophrenia, problem-solving and helping patients expand their social network
Can offer respite for the families

201
Q

What is concordance therapy?

A

Collaborative approach where the patient is encouraged to consider the pros and cons of the management

202
Q

What is the benefit of arts therapy in schizophrenia?

A

Alleviation of negative symptoms

203
Q

What needs have to be addressed, for social management of schizophrenia?

A

Education, training and demployment
Skills (e,g, budgeting, cooking)
Housing (e.g. supported accommodation, independent flats)
Accessing social activities (social skills training can improve interpersonal skills)
Developing personal skills (e.g creative writing)

May consider admission to hospital for observation, treatment or refuge

204
Q

What is the issue with use of bupropion or varenicline for smoking cessation aid?

A

Increased risk of neuropsychiatric symptoms, so should be monitored for the first 2-3 weeks

205
Q

What should schizophrenic careers be informed of?

A

Right to a formal carers assessment

206
Q

What parameters should be measured in an individual about to start on an antipsychotic?

A

Waist circumference
Fasting BM, HbA1c, lipid profile, prolactin
Assessment of any movement disorders
Assessment of nutritional status, diet and physical activity
Children should have their height measured every 6 months
Weight: weekly for 6 weeks, at 12 weeks, at 1 year, annually thereafter
Pulse and blood pressure: at 12 weeks, 1 year, annually

207
Q

Define treatment resistance in schizophrenia

A

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

208
Q

What is the first-line treatment for treatment resistant schizophrenia?

A

Clozapine

209
Q

What is a potential side effect of clozapine treatment?

A

Agranulocytosis

Requires weekly blood tests to detect early signs of neutropenia

210
Q

How to treat treatment resistant schizophrenia if clozapine is not inducing a response?

A

Consider augmentation with another antipsychotic

211
Q

Outline antipsychotic management for schizophrenia

A

Start with an atypical antipsychotic: aripiprazole (initial akathisia) and quetiapine (sedation and weight gain) have a better side-effect profile than the stronger olanzapine (mainly weight gain and metabolic syndrome) and risperidone (hyperprolactinaemia, EPS and sedation)

Aripiprazole (10mg) —> quetiapine (needs to be raised from 50mg to 750mg —> olanzapine (10mg) and risperidone (3 to 6mg per day)

Max dose of quetiapine in mania is 800mg

If this doesn’t work after 2-4 weeks, try another class. If there is still no response, consider clozapine

212
Q

Outline the treatment of schizoaffective disorder.

A

Same medication as schizophrenia but add a mood stabilisers when there seems to be an affective component that is not being controlled.
May use an anti-depressant.

213
Q

What treatment options are available for rapid tranquilisation in schizophrenia?

A 
Lorazepam
Lorazepam (1mg) + haloperidol (5mg)
214
Q

Outline the mechanism of neuroleptic malignant syndrome

A

Sympathetic hyperactivity as a result of dopaminergic antagonism (onset over 1-3 days)

215
Q

Outline the clinical features of neuroleptic malignant syndrome

A 
Muscle rigidity
Fever
Sweating
Confusion
Autonomic dysfunction
216
Q

What investigations should be performed for neuroleptic malignant syndrome?

A 
High CK
High WCC
Altered LFTs
U+E (can cause AKI)
Creatinine
217
Q

Outline the treatment of neuroleptic malignant syndrome

A

Stop antipsychotics immediately
Get urgent medical treatment (usually ITU)
Treat hyperthermia (cooling blankets, ice packs)
Consider bromocriptine
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)

218
Q

Investigations for alcohol misuse

A 
Bloods: FBC, U+E, LFT, B12, folate, clotting screen, glucose
Blood alcohol level or breathalyser
Urine drug screen
SADQ
Rating scale: AUDIT, CIWA-Ar, APA
219
Q

Needs of family/carers in alcohol misuse

A

Offer a carer’s assessment if necessary
Consider offering guided self-help for families and provide resources about support groups
Consider offering family meetings, usually at least 5 weekly meetings

220
Q

Assessment of alcohol misuse

A

AUDIT- alcohol use disorders identification test (>15 requires comprehensive assessment)
SADQ- severity of dependence
CIWA-Ar - clinical institute withdrawal assessment of alcohol scale (for severity of withdrawal)
APQ- alcohol problems questionnaire (assess the nature and extent of the problems arising from alcohol misuse)

221
Q

If comorbid mental health issues don’t improve within 3-4 weeks of abstinence from alcohol, what should be considered?

A

Referral for specific treatment

222
Q

Outline the available interventions for harmful drinkers and mild alcohol dependency

A

Psychological intervention (CBT, behavioural therapy, social network and environment based, focused on alcohol related cognition): weekly 1 hour sessions for 12 weeks
Offer behavioural couples’ therapy
Acamprosate (for cravings)
Naltrexone

223
Q

Outline the key points of assisted alcohol withdrawal

A

Pabrinex if at risk of Wernicke’s encephalopathy

If >15 units/day, or >20 on AUDIT, consider offering:
Community-based assisted withdrawal (e.g. CGL; usually 2-4 meetings in the first week; if complex, may need up to 4-7 days per week over a 3-week period)
Management in specialist alcohol services if there are safety concerns

224
Q

When should impatient assisted withdrawal of alcohol be considered? (One or more of the following)

A

30+ units a day
30+ on SADQ
History of epilepsy, delirium tremens or withdrawal-related seizures
Need concurrent withdrawal of alcohol and benzodiazepines
Significant psychiatric comorbidity or significant learning disability
Lower threshold for inpatient treatment in vulnerable groups (e.g. homeless, older people)
Children (10-17): should also receive family therapy for about 3 months

225
Q

What are the preferred medications given to aid in alcohol dependence?

A

Chlordiazepoxide or diazepam

Lorazepam if liver impairment, as it is associated with limited hepatic metabolism

226
Q

How long should drug regimens be titrated for in alcohol dependence treatment?

A

Gradually reduce the dose over 7-10 days (longer if concurrent benzodiazepine withdrawal treatment (up to 3 weeks))
Give no more than 2 days medication at a time

227
Q

Post successful alcohol withdrawal treatment?

A

Consider acamprosate or naltrexone with individualised psychological intervention
Usually prescribed for up to 6 months
Carry out thorough medical assessment to establish baseline before stating medication (including U+E and LFT)

Consider disulfiram if above options are unacceptable/unsuccessful

228
Q

Outline the steps taken to counsel an individual who misuses alcohol (PACES)

A

Establish risks (driving, suicide)
Assess social issues and advise accordingly
Establish goals (elimination or moderation)
Explain that symptoms of withdrawal (worst in the first 48 hours and should pass after 3-7 days)
Advise against stopping drinking abruptly
Explain referral to drugs and alcohol service and the process of assisted withdrawal (benzodiazepines, psychological treatment and relapse prevention)

229
Q

How to treat acute alcohol withdrawal?

A

Offer pharmacotherapy to treat the symptoms of withdrawal as follows;
Consider offering a benzodiazepine e.g. lorazepam, or carbamazepine (clomethiazole as an alternative)

Offer advice on local support services (Alcoholics Anonymous, SMART recovery)

230
Q

How to treat delirium tremens

A

1st line: oral lorazepam —> if symptoms persist, offer IV lorazepam or haloperidol (chlordiazepoxide as alternative)
IV thiamine

231
Q

How to treat alcohol withdrawal seizures

A

Consider fast-acting benzodiazepine (e.g. lorazepam) to reduce the likelihood of future seizures

232
Q

Investigations for opiate misuse

A

Physical examination (establish baseline)
Urine drugs screen
U+E (malnutrition)
FBC (anaemia due to malnutrition or signs of infection)
LFTs (may impact medication dosing)
Blood borne infections (RPR, HIV test, hepatitis serology)

233
Q

Outline the approaches to harm reduction in opiate misuse

A

Improving safety of drug use

Needle exchange for IVDU
Vaccination and testing for blood-borne viruses for sex workers and IVDU

234
Q

When should opioid withdrawal treatment NOT be recommended?

A

Concurrent medical problem requiring urgent treatment
In police custody
Presenting in acute or emergency settings
Be careful with pregnant women

235
Q

General recommendations for opiate misuse treatment

A

Counsel on aspects of a healthy lifestyle (e.g. sleep hygiene, diet)
Provide information about self-help groups (e.g. 12-Step programmes)
Offer assessment for family members and carers

236
Q

Outline the steps taken for detoxification in opiate misuse

A 
Appoint a key worker (provides support)
1st line: methadone (liquid) or buprenorphine (sublingual)- decision largely based on patient preference
Consider lofexidine (alpha-2 agonist) is above options are unacceptable, mild dependence or keen to detoxify over a short period of time
Decisions about the dosing regimen should be based on severity of dependence, stability of patient and the setting of detoxification
237
Q

Duration of opiate detoxification?

A

Inpatient: up to 4 weeks (residential detoxification tends to be limited to patients with significant comorbid physical and mental health problems or require concurrent detox of other substances)
Community: up to 12 weeks

238
Q

What medications can be given to treat the symptoms of withdrawal in opiate detoxification?

A

Clonidine
Lofexidine

Medications to help manage symptoms (e.g. anti-diarrhoeals, anti-emetics, pain killers)

239
Q

Ultra-rapid, rapid and accelerated opiate detoxification

A

Withdrawal is actively precipitated by using high doses of opioid antagonists (e.g. naltrexone or naloxone)

Ultra-rapid: 24 hours under GA oR heavy sedation (not offered)
Rapid: 1-5 days with moderate sedation (can be considered if patient specifically requests it)
Accelerated detoxification: no sedation

240
Q

Outline the steps taken at follow-up after opiate detoxification

A

Refer to Drugs and Alcohol Service for at least 6 months
Offer talking therapy (CBT) to prevent relapse and address underlying mental health issues
Appoint a key worker
Consider contingency management after completed detoxification (incentives, screening 3/week)

241
Q

What is the preferred screening method in opiate use?

A

Urinalysis

242
Q

Outline the counselling given to someone about to undergo opiate detoxification (PACES)

A

Explain that it would be worth getting tests done for blood-borne diseases and offer vaccinations
Explain the features of withdrawal (restlessness, anxiety, sweating, yawning, diarrhoea, abdo cramps, nausea and vomiting, palpitations): manage expectations and explain timescale (begin with 24 hours, peaks after 2-3 days, should be significantly better by 1 week)
Explain detoxification regime (giving a substitute that should lessen the symptoms of withdrawal)
Explain that symptomatic treatments will be given to reduce nausea, diarrhoea and autonomic symptoms
Explain the role of psychological therapies in preventing relapse
Explain the role of the key worker
Support: Narcotic Anonymous, SMART Recovery

243
Q

Outline some uses of benzodiazepines

A 
Sedation
Hypnotic
Anxiolytics
Anticonvulsant 
Muscle relaxant

Should only be used for a short time (2-4 weeks)

244
Q

What are the short and long term risks of benzodiazepines?

A

Short-term: drowsiness, reduced concentration

Long-term: cognitive impairment, worsening anxiety and depression, sleep disruption

245
Q

What are the clinical features of benzodiazepine withdrawal?

A 
Insomnia
Irritability
Anxiety
Tremor
Loss of appetite
Tinnitus
Excessive sweating
Seizures
Perception disturbance
246
Q

What underlying issues require benzodiazepines?

A

Anxiety
Sleep
Depression

247
Q

How to withdraw from benzodiazepine use?

A

Withdraw in steps of about 1/8 of the daily dose every fortnight (but in reality, the dose is reduced according to the severity of the withdrawal symptoms)
Consider switching to the equivalent dose of diazepam (oxazepam may be considered instead in patients with liver failure)

248
Q

How long does benzodiazepine withdrawal treatment last?

A

May take 3 months to a year or more

249
Q

Outline the steps used in counselling an individual abusing benzodiazepines (PACES)

A

Explain the harmful effects of benzodiazepines (long-term worsening of psychiatric symptoms)
Explain that benzodiazepines can be reduced very gradually, considering the symptoms the patient is experiencing
Explain the role of CBT
Advise against driving if feeling drowsy

250
Q

Investigations for delirium

A

Collateral history
MMSE (>24 is normal)
Physical examination (checking for localising signs of infection)
Bloods (FBC, WCC, neutrophils, CRP and ESR, U+E, blood glucose, TFT, LFTS, Calcium, folate, B12, VDRL)
Urine dip and MSU
CXR if indicated

251
Q

Behavioural management for delirium

A

Frequent reorientation (e.g. clocks, calendars, verbal reminders)
Good lighting (gloomy lighting increases risk of hallucination/illusions)
Address sensory problems (e.g. hearing aids, glasses)
Avoid over- or understimulation (side-room if the main ward is disruptive)
Minimise change (don’t keep moving the patient, one staff member to engage the patient each shift, establish a routine)
Remove things that can be thrown or tripped over
Silence unnecessary noises (e.g. bleeping alarms)
Allow safe or unsupervised wandering

252
Q

Medication for delirium?

A

Small night-time dose or benzodiazepines could promote sleep

If short-term sedation is needed, low-dose typical antipsychotics (e.g. haloperidol) or benzodiazepines can be used

253
Q

Where can a delirious patient be referred to?

A

Geriatrics

Psychiatry

254
Q

Steps to prevent delirium?

A

Good sleep hygiene without medication
Minimal moves around the hospital
Encouraging mobility
Proactive management (minimise dehydration, pain, constipation, urinary retention and sensory problems)

255
Q

What does delirium indicate for the prognosis of an individual?

A

Increased mortality
Longer admissions
Higher readmissions rates
Subsequent nursing home placement

May take days to weeks to resolve
Some patients do not return to premorbid levels

256
Q

What is a potential treatment option for normal pressure hydrocephalus?

A

A ventriculoperitoneal shunt may allow CSF drainage from the brain ventricles into the heart

257
Q

Management of depression in the elderly?

A

Problem-solving, increasing socialisation and day-time activities
Psychological therapies (e.g. CBT, psychodynamic therapy, group therapy, family therapy, couple therapy)
Antidepressants: SSRIs are first line (e.g. citalopram)
ECT is sometimes used in psychotic or life-threatening depression
Consider social workers, community nurses, and carers
Recommend Age UK

258
Q

Management of psychosis in the elderly?

A

Reduction of sensory impairment
Exclusion of organic cause or LBD
Low-dose antipsychotics

259
Q

Investigations for suspected dementia

A 
Cognitive screen (AMTS, MMSE, ACE-R, MoCA)
Delirium screen
Consider structural imaging
260
Q

Tools for differentiating dementia from delirium?

A

Long Confusion Assessment Method (CAM)

Observational Scale or Level of Arousal (OSLA)

261
Q

What adaptations can be made available for patients with dementia, for ease of treatment?

A

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)

262
Q

Support for carers in dementia

A 
Emotional support
Offer carers assessment 
Educate about dementia 
Train to manage common problems
Provide respite care
263
Q

Measures to optimise physical health in dementia?

A

Treat sensory impairment (hearing aids, glasses)
Exclude superimposed delirium
Treat underlying risk factors
Review all medication

264
Q

Psychological therapies for dementia?

A

Range of activities
Group cognitive stimulation (memory training and re-learning)
Consider group reminiscence therapy
Consider cognitive rehabilitation or occupational therapy
Behavioural approaches (identify and modify underlying triggers for difficult/risky behaviours (e.g. wandering may be due to disorientation, boredom or anxiety)
Validation therapy (reassure and validate the emotion behind what is said)
Multi sensory therapy

265
Q

What psychotropic medications are available for Alzheimer’s?

A 
Acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamime)- used in mild/moderate AD, can cause symptomatic relief, no effect on progression of disease 
Memantine (NMDA antagonist)- used in severe AD, or if there is intolerance/contraindication for acetylcholinesterase inhibitors 
Behavioural disturbances may require sedatives as a last resort (e.g. trazodone, sodium valproate, haloperidol)
266
Q

MMSE in Alzheimer’s

A

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

267
Q

Pharmacology for non-Alzheimer’s dementia

A

Offer donepezil or rivastigmine for Lewy body dementia (galantamine if not tolerated)
Only consider acetylcholinesterase inhibitors in people with vascular dementia if there is suspected comorbid Alzheimer’s, Parkinson’s dementia or dementia with Lewy bodies.
Do NOT offer to patients with frontotemporal dementia
Antipsychotics can be used acutely I’m agitated patients who are at risk of harming themselves, but can worsen Lewy body dementia

268
Q

Treatment for Lewy body dementia

A

Adaptations for patient with an OT (reality orientation, environmental modifications)
Social support/support carers
Optimising physical health (review medications)
Psychological therapies (e.g. reminiscence therapy)
Acetylcholinesterase inhibitors may provide symptomatic relief
Parkinson’s medications could relieve the tremors but could worsen the psychosis
Antipsychotics are dangerous and should not be used (they cause severe reactions - confusion, Parkinsonism, death)

269
Q

Outline how CBT is used in anxiety disorders

A

Aims to reduce patient’s expectations of threat, and the behaviours that maintain threat-related beliefs
Often begins with teaching techniques for managing arousal (relaxation and controlled breathing)
Explore the actual likelihood and impact or the anticipated catastrophe
Test the feared situation and their belief in a catastrophic outcome using behavioural experiments
This gradually increases the patient’s confidence in their capacity to cope with the feared situation

270
Q

Outline the principles of CBT in GAD

A

The main feature is worry

Therapy involves testing predictions of worry with behavioural experiments and looking at errors in thinking

271
Q

Outline the principles of CBT in panic disorder

A

Panic may be triggered by misinterpretation of physical anxiety symptoms as signs of major catastrophe
Safety behaviours may be adopted which reinforce beliefs (e.g. avoiding situations)
CBT educated the patient on the true meaning of the symptoms (I.e. panic not perish)
Helps them test whether their behaviours keep them safe and whether their beliefs are true or misinterpretations

272
Q

Outline the principles of exposure therapy

A

Habituation occurs around 45 mins after exposure, resulting in a decrease in anxiety until fear dies out (extinction)
Exposure is usually through a gradual or graded approach called desensitisation
The patient identifies a goal and constructs a hierarchy of feared situations, which are gradually tackled
The aim is to stay in the situation until the anxiety has subsided to induce learning and challenge existing thoughts
Agoraphobia can be treated using this strategy

Year 5 Specialties (7 decks)

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