Psychiatry Flashcards
1
Q
When is the onset of postnatal depression
A
Peripartum onset (from any time during pregnancy to 1 year after delivery)
2
Q
Sx of Asperger’s
A
Associated with marked clumsiness
Psychotic episodes occasionally
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
4
Q
How long must depressive symptoms last for a diagnosis of a major depressive episode? (ID-10)
A
At least 2 weeks
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
6
Q
Define cyclothymia
A
History of hypomanic symptoms with periods of depression that do not meet the criteria for major depressive disorder
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
8
Q
Features of agoraphobia
A
Depressive and obsessional symptoms and social phobias
Avoidance of phobic situation
9
Q
What is a potential complication of bulimia?
A
Electrolyte disturbance due to repeated vomiting
10
Q
Cluster A Personality Disorders
A
Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder
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
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
13
Q
What are the three areas of psychopathology?
A
Reciprocal social interaction
Communication
Restricted, stereotypes, repetitive behaviour
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
15
Q
Define Mania
A
Elevated mood out of keeping with patient’s circumstances and may vary from carefree joviality to almost uncontrollable excitement
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
17
Q
Cluster C Personality Disorders
A
Anxious (Avoidant) personality Disorder
Dependent Personality Disorder
Anakastic Personality Disorder
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
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
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
21
Q
What is the criteria for diagnosis of postnatal depression?
A
Same as non-childbirth depression
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
23
Q
Define Bipolar 2 disorder
A
At least one hypomanic episode
At least one major depressive episode
24
Q
Concurrent disorder in adjustment disorder
A
Conduct disorder (mainly in adolescents)
25
Define autism
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
26
DDx of acute stress reaction?
Consider diagnosis of PTSD if >1 month
27
Define delusional disorder
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
28
What is the difference between ODD and conduct disorder
Oppositional defiant disorder does not include delinquent acts or aggressive/dissocial behaviour
The child is specifically defiant against being controlled by others
29
Sx of generalised anxiety disorder
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
30
Key features of generalised anxiety disorder
Apprehension
Motor tension
Autonomic overactivity
31
Define PTSD
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
32
Characteristics of Anakastic Personality Disorder
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
33
What is noteworthy about Panic Disorder diagnosis?
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
34
Sx of Panic Disorder
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)
35
Key features of OCD
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
36
Subtypes of dissociative (conversion) disorders
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
37
Cluster B Personality Disorders
Dissocial (antisocial) Personality Disorder
Emotionally Unstable Personality Disorder
Histrionic Personality Disorder
38
Characteristics of Dependent Personality Disorder
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
39
What occurs in a small proportion of PTSD sufferers?
The disease will follow a chronic course over many years, resulting in enduring personality change
40
Key features of acute stress reaction?
```
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
```
41
What hallucinations are present in delusional disorder?
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
42
Characteristics of body dysmorphic disorder
Appearance preoccupations
Repetitive, compulsive behaviours
Can cause clinically significant distress or impairment of functioning
43
What are the requirements of Sx for a diagnosis of ADHD?
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
44
What is the general definition of personality disorder?
Pervasive: Occurs in all/most areas of life
Persistent
Pathological
45
Defined Baby Blues
Tearfulness, irritability and low mood occurring within a few days of childbirth
Spontaneously resolves after a few days
46
Define adjustment disorder
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
47
What is the difference between autism and Asperger's syndrome?
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
48
WHat are the biological ICD-10 symptoms of depression
Sleep disturbance (aprticularly early morning waking)
Appetite/weight disturbance
Low libido
Psychomotor agitation
49
What are the characteristics of anorexia nervosa?
Deliberate weight loss
Morbid dread of being fat (intrusive overvalued idea)
Disturbance of bodily function (endocrine and metabolic)
50
Key features of adjustment disorder
Depressed mood
Anxiety
Worry
Feeling of inability to cope; plan ahead, or continue with the present situation
Disability in the performance of daily routine
51
What are the 3 patterns of puerperal psychosis?
Delirium
Affective (like psychotic depression or mania)
Schizophreniform
52
How long do symptoms have to last for diagnosis of ADHD?
at least 6 months
53
What are the characteristics of Schizoid Personality Disorder?
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
54
Define acute stress reaction
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
55
3 subtypes of ADHD
ADHD predominantly inattentive
ADHD predominantly hyperactive-impulsive
ADHD-combination
56
DSM-IV depressive criteria
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
57
Symptoms of mania
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
58
What are the characteristics of Schizotypal Personality Disorder?
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
59
What are the core ICD-10 symptoms of depression?
Low mood
Anergia
Anhedonia
60
Characteristics of Antisocial Personality Disorder
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
61
What symptoms may severely depressed individuals concurrently experience?
Psychotic symptoms
62
How is severe depression diagnosed based on ICD-10 criteria?
All 3 core symptoms
At least 4 other symptoms
Major impact on QoL and social functioning
May show distress and/or agitation
63
Define panic disorder
Recurrent attacks of severe anxiety (panic) which are not restricted to any particular situation or set of circumstances and are therefore unpredictable.
64
What are the criteria for diagnosis of a learning disability?
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
65
What are the characteristics of bulimia nervosa?
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
66
What are the subtypes of conduct disorder?
Conduct disorder confined to the family context
Unsocialised conduct disorder
Socialised conduct disorder: individuals are well-integrated into the peer group
67
Why do some agoraphobics experience little anxiety?
Able to avoid phobic situations
68
What are some non-specific symptoms of autism?
Phobias
Sleeping and eating disturbances
Temper tantrums
(self-directed) aggression
69
What are the characteristics of Paranoid Personality Disorder?
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
70
Define Bipolar 1 disorder
At least one manic episode
| Depressive episodes are common, but not necessary for diagnosis
71
Key features of PTSD
```
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
```
72
Subtypes of Emotionally Unstable Disorder
IMpulsive: Characterised predominantly by emotional instability and lack of impulse control
Borderline: Characterised by disturbances in self-image, aims and internal preferences. Chronic feelings of emptiness, unstable interpersonal relationships and a tendency to self-destructive behaviour (including suicide gestures and attempts)
73
What factors increase the risk of developing PTSD?
Previous history of neurotic illness
| Certain personality traits (e.g. compulsive)
74
Characteristics of schizophrenia
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)
75
What are the First-rank symptoms?
```
Thought insertion, withdrawal, broadcasting
Delusional perceptions (and passivity phenomena)
Auditory hallucinations (3rd person, thought echo, running commentary)
```
76
When should a diagnosis of schizophrenia be reconsidered?
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
77
How long should schizophrenic symptoms last for a diagnosis according to DSM-V criteria?
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
78
Signs of social disturbance present between 1-6 months?
Schizophreniform disorder
79
Psychotic symptoms lasting <1 month?
Brief psychotic disorder
80
Subtypes of schizophrenia
```
Paranoid
Hebephrenic
Catatonic
Undifferentiated
Residual
Simple
```
81
Characteristics of paranoid schizophrenia
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
82
Characteristics of hebephrenic schizophrenia
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)
83
In what demographic is hebephrenic schizophrenia more commonly diagnosed?
Normally, hebephrenia should only be diagnosed in adolescents or young adults
84
Characteristics of catatonic schizophrenia
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
85
Define undifferentiated schizophrenia
Psychotic conditions meeting the general diagnostic criteria for schizophrenia but not conforming to any of the subtypes
86
Define residual schizophrenia
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)
87
Define simple schizophrenia
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)
88
What are the key features of simple schizophrenia?
Characteristic negative features of residual schizophrenia (e.g blunted affect, loss of volition) develop without being preceded by any over psychotic symptoms
89
What is a potential associated illness with schizophrenia?
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
90
Define schizoaffective disorder
Episode disorders in which both affective and schizophrenic symptoms are prominent but do not justify a diagnosis of either schizophrenia or depressive/manic episodes
91
What are the subtypes of schizoaffective disorder?
Manic and depressive
92
How long must schizoaffective symptoms last for a diagnosis (DSM-5)?
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
93
Define acute intoxication
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)
94
Define harmful use
A pattern of psychoactive substance use that is causing damage to health
The damage might be physical or mental
95
Key features of dependence syndrome
```
Craving
Control (difficulties controlling use)
Persistent use (despite knowledge of harmful consequences)
Priority
Tolerance
Withdrawal
```
96
Define withdrawal state
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
97
What can complicate withdrawal state?
Convulsions
98
Define psychotic disorder
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
99
Characteristic features of psychotic disorder
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
100
Define amnesia syndrome
A syndrome associated with chronic prominent impairment of recent and remote memory
101
Key features of amnesia syndrome
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
102
Define residual/late-onset psychotic disorder
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
103
How can you distinguish residual psychotic disorder from psychotic state?
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
104
Define somatisation disorder
Multiple, recurrent and frequently changing physical symptoms of at least two years duration
105
Key features of somatisation disorders
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
106
How do somatisation disorders present?
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
107
Undifferentiated somatoform disorder
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
108
Hypochondrial disorder
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
109
Key features of hypochondrial disorder
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
What is somatoform autonomic dysfunction?
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
What types of symptoms are present in somatoform autonomic dysfunction?
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
What are the subtypes of somatisation disorders?
Undifferentiated somatoform disorder
Hypochondrial disorder
Somatoform autonomic dysfunction
Persistent somatoform pain disorder
113
What is the key complaint in persistent somatoform pain disorder?
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
Outline the investigations required in suspected depression
```
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
What must be explored in an individual suspected of being depressed?
Previous episodes of depression and mood elevation
| Suicide risk
116
Outline Step 1 of the Stepped Care Model
All known and suspected presentations of depression
Assessment, support, psycho education, active monitoring and referral for further assessment and interventions
117
Outline Step 2 of the Stepped Care Model
Persistent subthreshold depressive symptoms, mild-to-moderate depression
Low-intensity psychological interventions, psychological interventions, medication, referral for further assessment and interventions
118
Outline Step 3 of the Stepped Care Model
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
Outline Step 4 of the Stepped Care Model
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
What is it important to make the patient aware of when starting treatment for depression?
Symptoms may get worse soon after starting treatment
| Give clear advice on how to seek help
121
How to assess an individual with mild-to-moderate depression?
Sleep hygiene
| Arrange further assessment within 2 weeks
122
Outline 3 low-intensity psychological interventions
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
Group CBT
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
When should antidepressant medication be considered, in mild-to-moderate depression?
Past history of moderate or severe depression
Symptoms have been present >2 years
Symptoms persist despite other interventions
125
Treatment of moderate-to-severe depression
Combination of:
Antidepressant medication
High-intensity psychological intervention (CBT or interpersonal therapy (IPT))
126
What is the first-line antidepressant medication used in moderate-to-severe depression?
SSRI (e.g Sertraline)
127
What risks are associated with antidepressant medication use?
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
When should antidepressant medication be reviewed?
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
What high intensity psychological interventions are available for depression?
Individual CBT
Interpersonal therapy: helps identify how interactions with others are affecting the patients mood, and ways of improving these interactions
130
Exercise particular caution when switching the following antidepressants:
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
What management options are available for complex and severe depression?
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
Why is sertraline preferred in individuals with a co-existing chronic physical health problem?
Lower risk of drug interactions
| Non-sedative
133
Outline the counselling process for someone diagnosed with depression (PACES)
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
When is citalopram contraindicated?
In any condition that prolongs QTc
135
What is the second-line pharmacological treatment option for depression?
Taper down SSRI and switch to SNRI
| E.g. venlafaxine, duloxetine
136
When does SNRI pharmacology switch from SSRI to SNRI effect?
At maximum dose
137
What needs to be checked if antidepressant medication is not effective?
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
What treatment options are available for treatment resistant depression (3rd line)?
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
What is the 4th line treatment option for depression?
ECT
140
What is catch-up phenomena?
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
Over what time period should antidepressants be stopped?
Over four weeks
142
Outline the clinical features of serotonin syndrome
```
Fever
Agitation
Confusion
Hyper reflexes
Tremor
Dilated pupils (onset within hours)
Hypertension
Clonus
Diarrhoea
```
143
Treatment for serotonin syndrome
Withdraw offending drug
Supportive care
Benzodiazepines to control agitation
Some may benefit from cyproheptadine (antihistamine)
Mild cases resolve within 1-3 days
144
Investigations for mania and BPAD
```
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
What are the three types of mood stabilisers?
Lithium
Sodium valproate
Carbamazepine
146
What is the mechanism of action of mood stabilisers?
Unclear
| ?something to do with sodium channels or GABA
147
What is the therapeutic range of lithium?
0.6-1.0mmol/L
148
How often should lithium levels be checked?
1 week after starting or changing dose and monitored weekly until a steady therapeutic level is achieved; every 3 months from then on
149
What is a side-effect of lithium treatment?
Hypothyroidism and renal impairment
U+E and TFTs should be monitored every 6 months
150
At what level is lithium toxic?
Above 1.2mmol/L
151
Outline the presentation of lithium toxicity
Life-threatening
```
GI disturbance
Polyuria/polydipsia
Sluggishness
Giddiness
Ataxia
Gross tremor
Fits
Renal failure
```
152
What are the triggers for lithium toxicity?
Salt balance changes (e.g. dehydration, D+V)
Drugs interfering with lithium excretion (e.g. diuretics)
Accidental or deliberate overdose
153
Management for lithium toxicity
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
Why is valproate given as sodium valproate?
Reduced side-effects
155
What is the therapeutic range of valproate?
No known therapeutic range
| Dose-related toxicity not usually an issue
156
What is valproate used for?
Anticonvulsant
Treats acute mania
Prophylaxis in BPAD
Plasma levels do not need monitoring
157
Carbamazepine
Anticonvulsant
Can cause toxicity at high doses
Induces liver enzymes
Close monitoring of carbamazepine levels is essential
Check for drug interactions before prescribing
158
What risks do mood stabilisers pose in pregnancy?
They are teratogenic
Lithium- Ebstein’s anomaly
Valproate and carbamazepine- spina bifida
159
What countermeasures should be provided to a woman of child bearing age taking valproate?
Contraceptive advice
Folate supplement
Closely monitor foetus if medications are used during pregnancy
160
Why are the antipsychotics given in mania/BPAD atypical? (E.g. olanzapine, dispersions, quetiapine)
Fewer side-effects
161
What anticonvulsant is 2nd line treatment for prophylaxis in BPAD type II?
Lamotrigine
162
How to treat acute mania/hypomania if not on treatment already?
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
How to treat acute mania/hypomania if already on treatment?
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
When can ECT be considered for acute manic/hypomania patients?
If unresponsive to other treatments
165
Why is depression difficult to manage in BPAD?
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
What psychological treatments are available for BPAD.?
```
CBT
Psychodynamic psychotherapy (useful if mood stabilised)
```
167
Outline the strategies used in CBT for BPAD
```
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
Outline the prognosis of BPAD
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
Outline the primary care approach to referring for BPAD
Symptoms of hypomania —> routine referral to CMHT
| Symptoms of mania or severe depression —> urgent referral to CMHT
170
Outline the counselling approach to a BPAD diagnosis (PACES)
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
What class of antimanic is given for acute manic phase treatment?
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
What drugs are given to stabilise BPAD?
Mood stabilisers or atypical antipsychotics
| Both work equally well
173
Treatment for bipolar depression
SSRI (1st line: fluoxetine) with an atypical antipsychotic (olanzapine or quetiapine)
Always check lithium levels if the lithium appears to be ineffective
174
What physical treatment is available for an overdose of antidepressant?
```
Activated charcoal (decreases absorption)
Needs to be taken <1hour after ingestion
```
175
What is the treatment for an acute overdose of paracetamol?
N-acetylcysteine
176
Outline specific features of increased risk of suicide
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
What should be done if a suicidal patient is insistent on leaving hospital?
Assess their capacity
178
What immediate interventions should be taken in a suicidal individual?
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
Follow-up interventions for suicidal patient discharged from hospital
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
What psychological therapies are available for discharged suicidal patients?
CBT-based therapies (e.g. dialectical behaviour therapy)
Mentalisation-based treatment
Transference-focused psychotherapy
181
Coping strategies to prevent self-harm
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
Investigations for first-line psychosis in schizophrenia
```
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
What is the aim for schizophrenia treatment?
EIP
Patients are offered antipsychotic and psychosocial interventions with the aim of keeping duration of untreated psychosis under 3 months
184
Up to what age can CAMHS deal with psychosis in children?
Up to 17 years
| EIP can be used in children >14
185
If urgent treatment is necessary in schizophrenia, what measures should be taken?
Use the crisis resolution and home treatment teams
186
List examples of typical antipsychotics
Chlorpromazine
Haloperidol
Flupentixol decanoate
187
What side effects are associated with typical antipsychotics and at what dose?
EPSEs
Normal dose
However, are effective, cheap and provide depot options
188
What is the mechanism of action of atypical antipsychotics?
As well as blocking dopamine receptors, they also block serotonin 5-HT2 receptors.
189
List some examples of atypical antipsychotics
```
Olanzapine
Risperidone (available as depot)
Quetiapine
Aripiprazole
Clozapine
Amisulpride
```
190
When should starting an atypical antipsychotic be considered?
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
What are side effects associated with antipsychotic use in general?
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
What are the types of EPSEs caused by antipsychotic use?
Dystonia
Akathisia
Parkinsonism
Tardive dyskinesia
193
What are the symptoms of dystonia (EPSE), and how can it be treated?
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
What are the symptoms of akathisia (EPSE), and how can it be treated?
Restlessness
Decrease dose/ hangs antipsychotic
Add propanolol or benzodiazepines
195
What are the symptoms of Parkinsonism (EPSE), and how can it be treated?
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
What are the symptoms of tardive dyskinesia (EPSE), and how can it be treated?
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
What is a notable side effect of clozapine?
Agranulocytosis
198
What psychological treatment options are available for schizophrenia?
CBT: 16 sessions
Family therapy: 10 sessions
Concordance therapy
199
Outline CBT use in schizophrenia
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
Outline the use of family therapy in schizophrenia
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
What is concordance therapy?
Collaborative approach where the patient is encouraged to consider the pros and cons of the management
202
What is the benefit of arts therapy in schizophrenia?
Alleviation of negative symptoms
203
What needs have to be addressed, for social management of schizophrenia?
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
What is the issue with use of bupropion or varenicline for smoking cessation aid?
Increased risk of neuropsychiatric symptoms, so should be monitored for the first 2-3 weeks
205
What should schizophrenic careers be informed of?
Right to a formal carers assessment
206
What parameters should be measured in an individual about to start on an antipsychotic?
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
Define treatment resistance in schizophrenia
Failure to respond to two or more antipsychotics, at least one of which is atypical, each given at a therapeutic dose for at least 6 weeks
208
What is the first-line treatment for treatment resistant schizophrenia?
Clozapine
209
What is a potential side effect of clozapine treatment?
Agranulocytosis
Requires weekly blood tests to detect early signs of neutropenia
210
How to treat treatment resistant schizophrenia if clozapine is not inducing a response?
Consider augmentation with another antipsychotic
211
Outline antipsychotic management for schizophrenia
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
Outline the treatment of schizoaffective disorder.
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
What treatment options are available for rapid tranquilisation in schizophrenia?
```
Lorazepam
Lorazepam (1mg) + haloperidol (5mg)
```
214
Outline the mechanism of neuroleptic malignant syndrome
Sympathetic hyperactivity as a result of dopaminergic antagonism (onset over 1-3 days)
215
Outline the clinical features of neuroleptic malignant syndrome
```
Muscle rigidity
Fever
Sweating
Confusion
Autonomic dysfunction
```
216
What investigations should be performed for neuroleptic malignant syndrome?
```
High CK
High WCC
Altered LFTs
U+E (can cause AKI)
Creatinine
```
217
Outline the treatment of neuroleptic malignant syndrome
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
Investigations for alcohol misuse
```
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
Needs of family/carers in alcohol misuse
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
Assessment of alcohol misuse
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
If comorbid mental health issues don’t improve within 3-4 weeks of abstinence from alcohol, what should be considered?
Referral for specific treatment
222
Outline the available interventions for harmful drinkers and mild alcohol dependency
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
Outline the key points of assisted alcohol withdrawal
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
When should impatient assisted withdrawal of alcohol be considered? (One or more of the following)
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
What are the preferred medications given to aid in alcohol dependence?
Chlordiazepoxide or diazepam
| Lorazepam if liver impairment, as it is associated with limited hepatic metabolism
226
How long should drug regimens be titrated for in alcohol dependence treatment?
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
Post successful alcohol withdrawal treatment?
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
Outline the steps taken to counsel an individual who misuses alcohol (PACES)
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
How to treat acute alcohol withdrawal?
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
How to treat delirium tremens
1st line: oral lorazepam —> if symptoms persist, offer IV lorazepam or haloperidol (chlordiazepoxide as alternative)
IV thiamine
231
How to treat alcohol withdrawal seizures
Consider fast-acting benzodiazepine (e.g. lorazepam) to reduce the likelihood of future seizures
232
Investigations for opiate misuse
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
Outline the approaches to harm reduction in opiate misuse
Improving safety of drug use
Needle exchange for IVDU
Vaccination and testing for blood-borne viruses for sex workers and IVDU
234
When should opioid withdrawal treatment NOT be recommended?
Concurrent medical problem requiring urgent treatment
In police custody
Presenting in acute or emergency settings
Be careful with pregnant women
235
General recommendations for opiate misuse treatment
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
Outline the steps taken for detoxification in opiate misuse
```
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
Duration of opiate detoxification?
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
What medications can be given to treat the symptoms of withdrawal in opiate detoxification?
Clonidine
Lofexidine
Medications to help manage symptoms (e.g. anti-diarrhoeals, anti-emetics, pain killers)
239
Ultra-rapid, rapid and accelerated opiate detoxification
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
Outline the steps taken at follow-up after opiate detoxification
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
What is the preferred screening method in opiate use?
Urinalysis
242
Outline the counselling given to someone about to undergo opiate detoxification (PACES)
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
Outline some uses of benzodiazepines
```
Sedation
Hypnotic
Anxiolytics
Anticonvulsant
Muscle relaxant
```
Should only be used for a short time (2-4 weeks)
244
What are the short and long term risks of benzodiazepines?
Short-term: drowsiness, reduced concentration
| Long-term: cognitive impairment, worsening anxiety and depression, sleep disruption
245
What are the clinical features of benzodiazepine withdrawal?
```
Insomnia
Irritability
Anxiety
Tremor
Loss of appetite
Tinnitus
Excessive sweating
Seizures
Perception disturbance
```
246
What underlying issues require benzodiazepines?
Anxiety
Sleep
Depression
247
How to withdraw from benzodiazepine use?
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
How long does benzodiazepine withdrawal treatment last?
May take 3 months to a year or more
249
Outline the steps used in counselling an individual abusing benzodiazepines (PACES)
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
Investigations for delirium
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
Behavioural management for delirium
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
Medication for delirium?
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
Where can a delirious patient be referred to?
Geriatrics
| Psychiatry
254
Steps to prevent delirium?
Good sleep hygiene without medication
Minimal moves around the hospital
Encouraging mobility
Proactive management (minimise dehydration, pain, constipation, urinary retention and sensory problems)
255
What does delirium indicate for the prognosis of an individual?
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
What is a potential treatment option for normal pressure hydrocephalus?
A ventriculoperitoneal shunt may allow CSF drainage from the brain ventricles into the heart
257
Management of depression in the elderly?
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
Management of psychosis in the elderly?
Reduction of sensory impairment
Exclusion of organic cause or LBD
Low-dose antipsychotics
259
Investigations for suspected dementia
```
Cognitive screen (AMTS, MMSE, ACE-R, MoCA)
Delirium screen
Consider structural imaging
```
260
Tools for differentiating dementia from delirium?
Long Confusion Assessment Method (CAM)
| Observational Scale or Level of Arousal (OSLA)
261
What adaptations can be made available for patients with dementia, for ease of treatment?
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
Support for carers in dementia
```
Emotional support
Offer carers assessment
Educate about dementia
Train to manage common problems
Provide respite care
```
263
Measures to optimise physical health in dementia?
Treat sensory impairment (hearing aids, glasses)
Exclude superimposed delirium
Treat underlying risk factors
Review all medication
264
Psychological therapies for dementia?
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
What psychotropic medications are available for Alzheimer’s?
```
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
MMSE in Alzheimer’s
Mild AD:21-26
Moderate: 10-20
Severe: <10
267
Pharmacology for non-Alzheimer’s dementia
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
Treatment for Lewy body dementia
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
Outline how CBT is used in anxiety disorders
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
Outline the principles of CBT in GAD
The main feature is worry
| Therapy involves testing predictions of worry with behavioural experiments and looking at errors in thinking
271
Outline the principles of CBT in panic disorder
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
Outline the principles of exposure therapy
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
