Psychiatry Flashcards
What are the three classes of personality disorder?
A - odd (paranoid, schizoid)
B - dramatic (histrionic, emotionally unstable, dissocial)
C - anankastic, dependent, anxious
List which antidepressants are associated with the following risks: • Drug Interaction • Discontinuation Symptoms • Death from Overdose • Overdose • Stopping treatment due to side-effects • Blood Pressure Monitoring Needed • Worsening Hypertension • Postural Hypotension and Arrhythmia
- Drug Interaction: fluoxetine, fluvoxamine, paroxetine
- Discontinuation Symptoms: paroxetine
- Death from Overdose: venlafaxine
- Overdose: TCAs (except lofepramine)
- Stopping treatment due to side-effects: venlafaxine, duloxetine, TCAs
- Blood Pressure Monitoring Needed: venlafaxine
- Worsening Hypertension: venlafaxine, duloxetine
- Postural Hypotension and Arrhythmia: TCA
How often should a patient with newly diagnosed depression be followed-up after starting an antidepressant?
Review after 2 weeks (if no particular risk of suicide), then every 2-4 weeks thereafter for 3 months
Which low-intensity psychotherapies may be offered to patient with mild-to-moderate depression?
Individual-guided self-help based on the principles of CBT
Computerised CBT
Structured group physical activity programme
Who should be offered group CBT?
Individuals with mild-to-moderate depression who decline low intensity psychological therapies
Which high-intensity psychological therapies may be offered to patients with moderate-to-severe depression?
Individual CBT
Interpersonal Therapy
Transitions between which antidepressants must you be particularly careful with?
From fluoxetine to other antidepressants (as fluoxetine has a long half-life)
From fluoxetine or paroxetine to a TCA (both drugs inhibit TCA metabolism so a lower starting dose may be needed)
To a new serotoninergic antidepressant or MAOI (because of risk of serotonin syndrome)
From non-reversible MAOI: a 2-week washout period is required (other antidepressants should not be prescribed during this period)
Briefly outline the step by step pharmacological management for depression.
STEP 1: SSRI (e.g. sertraline)
STEP 2: Taper down SSRI, start SNRI (e.g. venlafaxine)
STEP 3: Add augmentation - either atypical antipsychotics (e.g. quetiapine) or another antidepressant (e.g. mirtazapine)
STEP 4: ECT
Over what period of time should antidepressants be stopped?
4 weeks
What needs to be monitored after a patient is started on lithium and how regularly should this happen?
Lithium levels - at 1 week after starting, then weekly until therapeutic level is reached. Then every 3 months (12 hours post dose).
U&E - every 3 months
TFTs - every 6 months
Creatinine clearance - annually
Which mood stabiliser does not need monitoring of drug levels?
Sodium valproate
How soon after an episode of self-harm should the patient be followed-up?
1 week
This can be in outpatient clinic, CMHT, GP or counsellor
Which psychological therapies for patients who have self-harmed?
CBT
Mentalisation-based therapy
Transference-focused psychotherapy
What are some coping strategies that can be used for patients with thoughts of self-harm?
Distraction techniques
Mood-raising activities (e.g. exercise)
Prevention of self-harm (put tablets and sharp objects away, stay in public places with supportive people, call a friend/support line, avoid drugs and alcohol)
Which service should be involved in the care of a young person with first episode psychosis?
Early intervention service (EIS)
Which receptors are blocked by typical and atypical antipsychotics?
Typical = dopamine (D2) Atypical = dopamine and 5HT2
Which antipsychotics are particularly associated with weight gain?
Olanzapine and clozapine
What is the main aim of CBT in schizophrenia?
Emphasis on reality testing
Encourage the patient to think about evidence and alternative explanations
Which forms of psychological therapy may be useful in schizophrenia?
CBT (for all patients)
Family therapy (particularly useful if high expressed emotion)
Concordance therapy
Which social aspects of a patient with schizophrenia require management?
Social skill training Education, training and employment Skills (e.g. cooking, budgeting) Housing Accessing social activities Developing personal skills (e.g. creative writing)
What is treatment resistance schizophrenia?
Failure to respond to two or more antipsychotics, at least one of which is atypical, each given at a therapeutic dose for at least 6 weeks
How is schizoaffective disorder treated?
Same treatment as schizophrenia
You may add a mood stabiliser or antidepressant for the affective component
Which investigations are used in neuroleptic malignant syndrome?
CK (high)
WCC (high)
How is neuroleptic malignant syndrome managed?
Stop antipsychotics immediately
Get urgent medical treatment (usually ITU)
Treat hyperthermia (cooling blankets, ice packs)
Dantrolene may be used for muscle rigidity
Benzodiazepines may be necessary for agitation
High myoglobin can cause AKI (IV fluids and dialysis may be required)
How should delirium tremens be managed?
Reducing benzodiazepine (chlordiazepoxide) regime IV pabrinex
NOTE: lorazepam may be used in hepatic failure
What are the stages of change model?
Pre-contemplation Contemplation Preparation Action Maintenance Relapse
Where can detoxification for alcohol be given?
Inpatient detox
Community detox
What are some psychological therapy options for alcohol abuse?
CBT
Problem-solving therapies
Group therapy (alcoholics anonymous)
What are some medical management options for preventing relapse in alcohol abuse?
Acamprosate (anti-craving)
Disulfiram
What do rehabilitation programmes for alcohol-abuse involve?
May be residential or day programmes
Allow a break for people submerged in a drinking community
May be skills-based courses to help find employment
What are some harm reduction approaches that are used for opiate misuse?
Needle exchange
Vaccination and testing for blood-borne viruses for sex-workers and IVDU
Which agents may be used as substitutes in opiate misuse?
Methadone (liquid) or buprenorphine (sublingual tablet)
NOTE: these are taken in a supervised environment
Which medication can be used to prevent relapse in patients with opiate misuse?
Naltrexone
Outline the behavioural management approach for delirium.
Frequent reorientation (clocks, calendars)
Good lighting
Address sensory problems (e.g. hearing aids)
Minimise change (don’t keep moving the patient, one staff member per shift, establish routine)
Allow safe and supervised wandering
Which agent is often used for rapid tranquillisation of an agitated patient?
Lorazepam
Alternative: olanzapine, haloperidol
How can normal pressure hydrocephalus be treated?
Ventriculoperitoneal shunt
What is a particularly important aspect of the management of depression in the elderly?
Problem-solving
Increased socialisation and day-time activities
What are the main risks of using antipsychotics in the elderly?
Stroke and VTE
List some environmental adaptations that can be recommended for a patient with dementia.
Always carry ID, address and contact number in case they get lost
Dossett boxes/blister packs to aid medication compliance
Change gas to electricity
Reality orientation (visible clocks, calendars)
Environmental modifications (e.g. patterned carpets can predispose to hallucinations)
Assistive technology (e.g. door mat buzzers)
Which psychological therapies are available for patients with dementia?
Reminiscence therapy
Validation therapy
Multisensory therapy
Cognitive stimulation therapy (memory training)
What is the main pharmacological treatment option for patients with dementia?
Acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine)
Give an example of an anxiety disorder that is treated with exposure therapy.
Agoraphobia
What are the steps in the management of generalised anxiety disorder?
1) education about GAD + active monitoring
2) low-intensity psychological intervention (individual non-facilitated self-help or individual-guided self-help or psychoeducational groups)
3) high-intensity psychological intervention (CBT or applied relaxation) or drug treatment
4) highly specialist input
What is the first-line SSRI used for generalised anxiety disorder?
Sertraline
Paroxetine is the only licensed SSRI for GAD
What are the steps in the pharmacological management of generalised anxiety disorder?
1) SSRI
2) switch to SNRI
3) Add pregabalin
4) consider quetiapine (not licensed)
What are the management options for panic disorder?
CBT and SSRI
Offer TCA (e.g. clomipramine, imipramine) if SSRI is contraindicated or no response after 12 weeks
What are the main approaches to managing OCD?
CBT (exposure and response prevention)
SSRIs (most commonly fluoxetine)
2nd line: SNRI
3rd line: add atypical antipsychotic
What are two psychological therapies that are used to treat PTSD?
Trauma Focused CBT
EMDR (eye movement desensitisation and reprocessing)
Which pharmacological treatments may be used in PTSD?
SSRIs (paroxetine and mirtazapine)
NOTE: mirtazapine is good if they are having problems getting to sleep
What are the aspects of management of medically unexplained symptoms?
Reattribution model Avoid unnecessary investigations Emotional support Antidepressants CBT Graded exercise
What are some management options for chronic fatigue syndrome?
Graded exercise (scheduled and gradually increasing activity) CBT
How are conversion disorders managed?
Encourage a return to normal activities and avoid reinforcing symptoms
Provide support for addressing stressors
What is the main difference between anorexia nervosa and bulimia nervosa?
Anorexia nervosa BMI < 17.5 or weight loss of > 15%
List some psychotherapy options that may be used for anorexia nervosa.
Eating Disorder CBT
Specialist Supportive Clinical Management (SSCM)
Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
Family Therapy (best for children)
Interpersonal Therapy
Which SSRI would be best to use in anorexia nervosa?
Fluoxetine (stable in terms of weight)
NOTE: you don’t want to give these patients anything that will make them gain weight too rapidly
What is interpersonal therapy?
Examines how the patient interacts with other people and teaches social skills and improves social functioning
Which class of drugs may be beneficial in bulimia nervosa and why?
SSRIs (e.g. high-dose fluoxetine)
Improves impulse control and reduces bingeing/purging behaviour
Which treatment option is best for children with eating disorders?
Family therapy (eating disorder-focused)
What are some treatment options for low libido?
Sensate Focus Therapy (ban intercourse, then progress to genital caressing and eventually intercourse)
Timetabling sex
List some physical/pharmacological treatments for erectile dysfunction.
Sildenafil
Intracavernosal prostaglandin self-injection
Vacuum pumps
How is postnatal depression managed?
Same as normal depression (CBT + SSRI)
Which SSRIs are recommended for postnatal depression?
Sertraline and paroxetine
If a patient with postnatal depression required admission, where should she be admitted?
Mother and Baby Unit
How is puerperal psychosis treated?
Antipsychotics
ECT may be required if severe
Admission to a mother and baby unit
How long does postnatal depression and puerperal psychosis usually take to recover?
Depression: 1 month
Psychosis: 6-12 weeks
Which mood stabiliser is considered safest to use in pregnancy?
Lamotrigine
Lithium –> Ebstein anomaly
Valproate and Carbamazepine –> NTD
What are the aspects of management of learning disabilities?
Treat physical comorbidity
Treat psychological comorbidity
Statement of Special Educational Needs (maximise potential)
Psychological therapy (group therapy, counselling)
Outline the aspects of managing autism spectrum disorder.
Support and advice for families (National Autistic Society)
Behaviour therapy
Speech and language therapy
Special education
Treat comorbid problems (e.g. epilepsy)
Antipsychotics and mood stabilisers are occasionally used
How is Asperger’s syndrome managed?
Advice and support
Social skills training
How is depression in children managed?
CBT
Antidepressants (fluoxetine) may be used in severe cases
How are anxiety disorders in children managed?
Psychological therapies (CBT)
Which investigations may be used for ADHD?
Questionnaires (Conner’s Rating Scale)
Classroom observation
Educational psychological assessment
Which medications may be used for ADHD?
Methylphenidate, lisdexamphetamine
Atomoxetine (non-stimulant)
What are some side-effects of drugs used in ADHD?
Insomnia Reduced appetite (and growth)
What are the aspects of managing conduct disorder?
Family education Family therapy (take a problem-solving approach) Parent management training Educational support Anger management for children
What are the aspects of managing tic disorders?
Reassure and stress management Habit reversal training Exposure and response prevention Clonidine (alpha-2 agonist) Haloperidol (antipsychotic)
What are the treatment approaches for emotionally unstable personality disorder?
Dialectical behavioural therapy Mentalisation-based therapy Therapeutic communities Arts therapy Transference focused therapy
List some side-effects of SSRIs.
GI upset
GI bleeding (if using NSAIDs, give with a PPI)
Increased anxiety/agitation soon after starting
Which SSRIs have a high propensity for drug interactions?
Fluoxetine and paroxetine
Which SSRIs are associated with a dose-dependent increase in QTc?
Citalopram
Escitalopram
Which drugs should not be used with SSRIs?
Warfarin
Triptans
MAOI
Outline the risks of SSRIs in pregnancy.
1st trimester: congenital heart defects
3rd trimester: persistent pulmonary hypertension
Paroxetine has an increased risk particularly in the 1st trimester
Sertraline, fluoxetine and citalopram are generally considered safe
How is acute dystonia treated?
Procyclidine