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Year 5 > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

Define ‘psychosis’

A

Mental health problem that causes people to perceive or interpret things differently from those around them, which might involve hallucinations or delusions

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2
Q

Give 3 causes of psychosis

A 
Schizophrenia 
Bipolar affective disorder 
Delusional disorder 
Schizoaffective disorder 
Drugs 
Medical illness
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3
Q

Give 2 physical illnesses presenting with psychotic symptoms

A 
Temporal lobe epilepsy
Hyper/hypothyroidism 
Paraneoplastic syndrome 
Sensory impairment 
Brain tumours 
AVMs
Delirium
Drug induced/withdrawal
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4
Q

Give 3 acute features of psychosis

A 
Lack of insight
Auditory hallucination
Ideas of reference
Suspiciousness
Thought disorder
Flat affect
Voices speaking to patient
Delusional mood
Delusions of persecution
Thought alienation
Thoughts spoken aloud
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5
Q

Give 3 chronic features of psychosis

A 
Social withdrawal
Under activity
Lack of conversation
Few leisure interests
Slowness
Over activity
Odd ideas
Depression
Odd behaviour
Neglect of appearance
Odd postures and movements
Threats or violence
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6
Q

Define ‘illusion’

A

A misinterpretation of an external stimuli; no diagnostic significance

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7
Q

Define ‘delusion’

A

A belief that is firmly held on inadequate and irrational grounds
It is not a conventional belief to that person given their educational, cultural and religious background
It significantly affects the way a person behaves and how they feel

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8
Q

Give 2 types of delusion

A 
Persecutory
Grandiose
Guilt
Bizarre 
Reference
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9
Q

Define ‘hallucination’

A

An experience that occurs without the presence of an external stimuli
Can occur in healthy people, but generally are a sign of major mental illness

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10
Q

Give 2 types of hallucination

A 
Auditory
Visual
Olfactory
Gustatory
Somatic
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11
Q

What is the difference between 2nd and 3rd person auditory hallucination?

A

2nd person - when the voice is talking to the patient

3rd person - when the voice is talking about the patient

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12
Q

What are the 3 predominant features of acute schizophrenia?

A

Delusions
Hallucinations
Disordered thoughts

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13
Q

What are the first rank symptoms of schizophrenia?

A

Hallucinations (3rd person auditory, running commentary, thoughts spoken aloud)
Thought disturbance (insertion, withdrawal, broadcast)
Affective (violation, mood, affect)

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14
Q

How common is lack of insight in schizophrenia?

A

Very - 97%

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15
Q

How is schizophrenia diagnosed?

A

Emphasis on first rank symptoms

Symptoms must be present for at least 1 month

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16
Q

What patient population are at highest risk of schizophrenia?

A

Males in 20s

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17
Q

What is the aetiology of schizophrenia?

A

Biological - genetic, obstetric, neurochemical
Psychological - personality, cognitive deficit
Social - lower SE class, migration, isolation, trauma

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18
Q

What is the role of vulnerability in schizophrenia?

A

Combination of biological, psychological and social factors increase vulnerability

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19
Q

How is schizophrenia treated?

A

Pharmacological - antipsychotics (e.g. olanzapine)
Psychological - CBT, psychotherapy
Social - skills training, employment and housing help

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20
Q

Give 2 types of schizophrenia

A 
Paranoid (delusions and hallucinations)
Hebephrenic (thoughts and affect)
Catatonic 
Undifferentiated 
Residual (negative)
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21
Q

Give 2 brain changes in schizophrenia

A

Enlarged ventricles
Overall weight reduction
Loss of asymmetry
Redution in cortex and hippocampus

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22
Q

What is the prognosis of schizophrenia?

A

1/2 will experience relapsing and remitting with some persistent deficits
1/4 will have chronic with persistent functional disability
1/5 will experience 1-2 episodes will full recovery
Small fraction will result in suicide

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23
Q

Give 3 factors which contribute to a worse outcome in schizophrenia

A 
Male 
Drug misuse
Low IQ
Long duration untreated 
Severe symptoms 
Prominent negative symptoms 
Poor response to antipsychotics
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24
Q

Give 3 types of mood disorder

A 
Manic episode 
Bipolar affective disorder 
Depressive episode 
Recurrent depressive disorder 
Cyclothymia/dysthymia 
Schizoaffective disorder 
Seasonal affective disorder
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25
Q

Define ‘mood’

A

Pervasive and sustained; what the patient describes

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26
Q

Define ‘affect’

A

Variable in response to changing emotional states; what the observer sees

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27
Q

Give 4 symptoms of depression

A 
Markedly depressed mood
Loss of interest or enjoyment
Reduced self-esteem and self-confidence
Feelings of guilt and worthlessness
Bleak and pessimistic views of the future
Ideas or acts of self-harm or suicide
Disturbed sleep
Disturbed appetite
Decreased libido
Reduced energy leading to fatigue and diminished activity
Reduced concentration and attention
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28
Q

How is depression defined?

A

At least 2 of low mood, loss of interest/enjoyment, reduced energy/fatigue plus at least 2 other symptoms present for at least 2 weeks
3 grades of severity

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29
Q

Give 4 symptoms of mania

A 
Irritability
Grandiose ideas
Inflated self-esteem
Increased energy and activity
Flight of ideas
Rapid pressured speech (may be unintelligible)
Enhanced libido (often leading to disinhibition and inappropriate sexual activity)
Impaired judgement and impulsive behaviour (including gross over-spending and poor decision making)
Decreased need for sleep
Increased sociability
Impaired concentration and attention
Psychotic symptoms
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30
Q

What are the 3 degrees of severity of a manic episode?

A

Hypomania
Mania without psychotic symptoms
Mania with psychotic symptoms

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31
Q

How is depression treated?

A

SSRI

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32
Q

How is a manic episode treated?

A

Lithium

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33
Q

What are cyclothymia and dysthymia?

A

Cyclothymia - persistent instability of mood, not meeting criteria for BPAD
Dysthymia - long-standing depression of mood, not meeting criteria for depressive episode

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34
Q

What are mood congruent and non-mood congruent symptoms?

A

Mood congruent - concerned with the same themes as non-delusional thinking in moderate affective disorders
Non-mood congruent – if present with prominent affective symptoms, consider alternative diagnosis i.e. schizophrenia or schizoaffective disorder

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35
Q

What is post-schizophrenic depression?

A

Depressive symptoms can appear after psychotic symptoms begin to recede in schizophrenia

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36
Q

What is the lifetime risk of a depressive episode?

A

Men 12%

Women 25%

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37
Q

What are the treatment options for mood disorders?

A

Biological – antidepressants (augment monoamine neurotransmission), antipsychotics (psychotic symptoms and mania), ECT (severe psychotic depression), mood stabilisers (prevent fluctuations in BPAD and augment antidepressant)
Psychological – CBT, psychodynamic psychotherapy, family therapy, supportive psychotherapy/counselling
Social – help with debt/housing issues, increased socialisation

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38
Q

What does the Yerkes-Dodson curve show?

A

Performance increases with physiological/mental arousal until level of arousal becomes too high and performance decreases; intellectually demanding tasks require a lower level of arousal (to facilitate concentration), whereas tasks demanding stamina/persistence require higher levels of arousal (to increase motivation)

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39
Q

Define ‘neurosis’

A

Class of functional mental disorders involving chronic distress

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40
Q

Give 3 physical symptoms of anxiety disorder

A 
Sweating 
Chest pain 
Tremors
Dizziness
Decreased sex drive 
Irritability 
Increased muscle tension 
Tachypnoea
Breathlessness
Increased BP
Numbness
Diarrhoea
Chills/hot flashes
Weakness
Dry mouth 
Palpitations
Light headedness
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41
Q

Give 3 psychological symptoms of anxiety disorder

A 
Restlessness 
Sense of dread
Feeling on edge 
Difficulty concentrating 
Easily distracted
Detachment
Fear of losing control 
Fear of dying
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42
Q

What is the 5 areas model of cognitive behavioural therapy?

A

Situations, thoughts, emotions, physical feelings, actions

CBT is based on the concept of these 5 areas being interconnected and affecting each other

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43
Q

What factors are involved in the aetiology of anxiety disorder?

A

Biological - genetic, illness, injury, CNS changes
Psychological - childhood, vulnerable personality, stress, depressed mood, avoidance
Social - lack of support, stress

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44
Q

Give 3 types of anxiety bases disorders

A 
Specific phobias
Generalised anxiety disorder
Panic disorder
OCD
PTSD
Somatoform and dissociative disorders
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45
Q

What are specific phobias?

A

Anxiety provoked by specific situations or objects which are perceived to be more dangerous than they actually are, causing anticipatory anxiety and avoidance (e.g. animals, blood, heights)

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46
Q

How are specific phobias treated?

A

Exposure therapy

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47
Q

What is social phobia?

A

Shyness, fear of performance failure and negative evaluation (e.g. public speaking, eating in public, general social interactions)

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48
Q

Give 3 symptoms of social phobia

A 
Blushing
Muscle twitching
Anxiety about scrutiny
Self-focused attention
Avoidance
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49
Q

How is social phobia treated?

A

CBT
Short term benzo/propranolol
SSRIs
MAOIs

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50
Q

What is generalised anxiety disorder?

A

Free floating anxiety often with panic disorder

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51
Q

Give 2 features of GAD

A

Anxiety is free floating (not restricted to any circumstance)
Irrational worries
Motor tension
Autonomic overactivity

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52
Q

How is GAD treated?

A

Pharmacological - benzo, SSRI, beta-blocker, mirtazepine, duloxetine
Non-pharmacological - relaxation training, exposure therapy, CBT, physical exercise

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53
Q

What is the bimodal onset of panic disorder?

A

Late adolescence and mid-30s

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54
Q

How does panic disorder present?

A

Several severe attacks of autonomic anxiety within a month, fear of death/suffocating, urgent desire to flee

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55
Q

How is panic disorder treated?

A

SSRI
CBT
Relaxation training

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56
Q

What is agoraphobia?

A

Fear and avoidance of places/situations that might cause panic (e.g. crowds, public places, travelling away from home)

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57
Q

How is agoraphobia treated?

A

SSRI
Anxiolytic
CBT

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58
Q

What is PTSD?

A

Delayed (within 6 months of trauma) and protracted response to a stressful event/situation of exceptionally threatening/catastrophic nature

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59
Q

What are the symptoms of PTSD?

A

Episodes of repeated reliving of trauma in intrusive memories/flashbacks
Nightmares
Numbness and emotional detachment
Avoidance of activities/situations reminiscent of trauma
Autonomic hyper-arousal (may manifest as persistent anxiety, irritability, insomnia, poor concentration)
Hyper-vigilance

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60
Q

Give 2 associations of PTSD

A

Aggressive behaviour
Substance misuse
Deliberate self-harm

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61
Q

How is PTSD treated?

A

CBT
Eye movement desensitisation and reprocessing
High dose SSRI and TCA

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62
Q

What are the 3 main features of OCD?

A

Obsessions – recurrent, intrusive thoughts/images/ruminations/impulses
Compulsions – ritualistic motor acts
Ego-dystonic – acknowledged as unreasonable/excessive, attempts to resist

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63
Q

How is OCD treated?

A

CBT
High dose SSRI
Clomipramine

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64
Q

Define ‘somatoform’ disorder

A

Mental disorder characterised by physical symptoms which cannot be explained by a medical condition (not consciously fabricated)

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65
Q

Define ‘dissociative’ disorder

A

Break down in memory, awareness, identity and/or perception

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66
Q

How is somatoform and dissociative disorder treated?

A

Difficult to treat
Spontaneous over time
Psychotherapy
Medication unhelpful

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67
Q

Outline how to carry out a psychiatric history

A 
PC
HPC
Past psychiatric history 
PMH
DH
FH
SH
Personal history 
Forensic history 
Premorbid personality 
MSE
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68
Q

Outline how to carry out a MSE

A 
Appearance and behaviour 
Speech 
Mood 
Thought - content, form 
Perception 
Cognition 
Insight 
(Risk)
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69
Q

Give 2 advantages of ECT

A

Improves mood and psychotic symptoms
Few side effects
Fast acting
Life saving

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70
Q

Give 2 indications for ECT

A

Severe depression (suicidal ideation, psychomotor retardation)
Catatonia
Treatment resistant psychosis

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71
Q

How often is ECT delivered?

A

Twice a week for up to 12 sessions

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72
Q

Give 2 side effects of ECT

A 
Anaesthetic risk
Dental issues 
Headache
Muscle pain
Vomiting
Memory loss (long-term)
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73
Q

Give 3 types of psychosurgery

A

Lobotomy (no longer carried out)
Anterior cingulotomy
Transcranial magnetic stimulation
Vagal nerve stimulation

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74
Q

What is an anterior cingulotomy used for?

A

Treatment resistant mood disorder or OCD

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75
Q

Give 3 types of dementia

A 
Alzheimer's 
Vascular
Lewy body 
Parkinson's 
Pick's disease
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76
Q

How is dementia diagnosed?

A

History
Examination
Neuropsychiatric tests

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77
Q

What areas of the brain are primarily affected in Alzheimer’s dementia?

A

Medial temporal lobes

Hippocampi

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78
Q

In terms of signs/symptoms of Alzheimer’s dementia, what are the ‘5 As’?

A 
Amnesia
Aphasia
Apraxia
Agnosia 
Associated non-cognitive (e.g. mood problem, hallucination, delusions)
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79
Q

Give 2 genes implicated in Alzheimer’s dementia aetiology

A

APP
APOE
PS1

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80
Q

How is Alzheimer’s managed?

A 
Cholinesterase inhibitors (e.g. donepezil, rivastigmine) to slow decline/reduce non-cognitive symptoms 
Glutaminergic agent (e.g. memantine)
Education, support, OT, PT
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81
Q

Give 2 characteristics of vascular dementia

A

Patchy cognitive impairment
Stepwise deterioration
Localised neurological deficits
Cerebrovascular disease

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82
Q

How is vascular dementia managed?

A

Supportive - smoking cessation, aspirin, statin

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83
Q

Give 2 features of Lewy body dementia

A

Parkinsonism
Hallucinations
Fluctuating course

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84
Q

Give 2 associations of Lewy body dementia

A 
Neuroleptic sensitivity
REM sleep disorder
Low dopamine transmitter uptake in SPECT/DAT scan
Syncope
Repeated falls
Autonomic disturbance
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85
Q

How is Lewy body dementia managed?

A

Cholinesterase inhibitor (e.g. rivastigmine)
Supportive
Melatonin/clonazepam for REM sleep disorder

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86
Q

What type of medications should be avoided in Lewy body dementia?

A

Anticholinergics

Antipsychotics

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87
Q

Give 2 features of Pick’s disease/frontotemporal dementia

A 
Slow steady decline from middle age
Frontal lobe dysfunction mainly
Blunting of behaviours 
Disinhibition 
Apathy 
Restlessness
Aphasia
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88
Q

Give 3 differential diagnoses for dementia

A 
Depression 
Malnutrition 
Vitamin deficiencies 
Alcohol/substance misuse 
Delirium 
Polypharmacy
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89
Q

What treatment is recommended for mild cognitive impairment?

A

None

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90
Q

Give 2 features of delirium

A 
Acute onset 
Fluctuating course
Inattention 
Disorganised thinking 
Altered level of consciousness
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91
Q

Give 3 possible causes of delirium

A 
Infection
Pain
Nutrition
Constipation
Hydration
Medications
Environment
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92
Q

How is delirium managed?

A 
Reorientation
Involving carers
Limit sensory deprivation
Correcting reversible causes
Consider stopping anti-cholinergic or contributory medications
Mobilisation
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93
Q

What is risk?

A

Probability of a negative event (e.g. suicide, violence)

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94
Q

What is the most powerful predictor of risk?

A

Past behaviour

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95
Q

What are the most common methods of suicide?

A 
Hanging
Strangulation and suffocation 
Poisoning 
Drowning 
Jumping from height
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96
Q

Give 2 risk factors for suicide

A 
Mental health problems 
Self harm 
Substance misuse
Chronic illness
Personality issues/coping style
Work and employment 
Poverty
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97
Q

Give 2 protective factors for suicide

A 
Problem solving ability 
Self control of thoughts/emotions
Hopefulness 
Participating in sport
Family/marriage/social relationships
Religious faith 
Employment 
Social values
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98
Q

Give 2 correlates of suicide in major depression

A 
Severe illness
Self neglect
Impaired concentration and memory 
Hopelessness
Alcohol abuse
Mood cycling
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99
Q

Give 2 correlates of suicide in schizophrenia

A 
Young male 
Relapsing pattern 
Depression 
Recent discharge from inpatient care 
Social isolation 
Insight
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100
Q

What are the 2 vulnerability points in an episode of psychiatric illness?

A

Initial acute phase

Period of recovery

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101
Q

What are the most common methods of deliberate self harm?

A

Poisoning

Self-cutting

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102
Q

Give 2 risk factors for DSH

A

Alcohol
Trauma in childhood
Chaotic personal life

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103
Q

Give 2 circumstances which indicate serious intent to DSH

A

Final acts/premeditation (e.g. will, saying bye)
Measures to prevent interruption (e.g. isolated spot, knowing others will not be around)
Choosing method perceived to be most successful (e.g. hanging, pills)

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104
Q

Give 2 factors from the history which indicate serious intent to DSH

A 
Active mental illness
Absence of intoxicants 
Regret over failure/indifference to being alive 
Specific suicidal plans 
Hopelessness 
Ongoing intent
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105
Q

How can DSH/suicide be prevented?

A

No specific management
Teach problem solving skills, admission for mental illness, treat underlying substance misuse/mental illness, population approach

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106
Q

Give 2 population approaches to preventing DSH/suicide

A

Reducing availability of methods (e.g. catalytic converters, limit on tablet number)
Economic (e.g. increasing employment)
Educating GPs (e.g. better management of depression)
Educating public (e.g. anti-stigma towards mental illness)

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107
Q

How is risk of violence assessed?

A

Difficult to predict

Increased risk in schizophrenia and substance misuse

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108
Q

Which Act protects patients and society, and allows treatment of patients with a mental disorder?

A

The Mental Health (Care and Treatment) (Scotland) Act 2003

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109
Q

Which Act deals with capacity?

A

Adults with Incapacity (Scotland) Act 2000

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110
Q

What 3 Acts may be relevant in patients with a mental disorder?

A

Mental Health Act 2003
Criminal Procedures Act 1995
Criminal Justice and Licensing Act 2010

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111
Q

What are the Millan principles?

A

All treatment under the Mental Health Act must follow 10 principles, known as the Millan principles

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112
Q

What does the Detention and Mental Health (Scotland) Act 2003 cover?

A

Mental illness
Learning disability
Personality disorder

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113
Q

Give 3 types of detention used in psychiatry

A

Emergency (EDC)
Short-term detention (STDC)
Compulsory treatment order (CTO)

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114
Q

Give 3 features of an emergency detention certificate (EDC)

A

Keeps/brings patient in hospital for assessment
Any doctor FY2+
Lasts 72 hours
Best to have consent from mental health officer (MHO)
Must be reviewed by senior psychiatrist ASAP
Treatment is not covered
Cannot be appealed

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115
Q

Give 3 features of a short term detention certificate (STDC)

A

To keep/bring patient in hospital for assessment and treatment
Approved medical practitioner (AMP) only (Section 22) e.g. psychiatrist
Lasts up to 28 days
MHO consent essential
Can be appealed
Must be reviewed and revoked timeously

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116
Q

Give 3 features of a compulsory treatment order (CTO)

A

To bring/keep patient in hospital for treatment, or to continue treatment in the community
Two medical recommendations (one must be AMP)
Lasts up to six months and is renewable
MHO is the applicant
Can be appealed
Must be reviewed and revoked timeously

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117
Q

What are the criteria for detention of patients under the Mental Health Act?

A 
Mental disorder 
Significant risk 
Treatment 
Significantly impaired decision making ability 
Necessity
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118
Q

What is the dopamine hypothesis of schizophrenia?

A

Hyperactivity of the mesolimbic dopamine pathways - accounts for positive symptoms
Deficiency of dopamine in the mesocortical dopamine pathway - accounts for negative and cognitive symptoms

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119
Q

Give 2 typical antipsychotics

A 
Haloperidol 
Flupentixol
Chlorpromazine 
Sulpride
Clopixol
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120
Q

Give 2 atypical antipsychotics

A

Aripiprazole
Clozapine
Olanzapine
Risperidone

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121
Q

Give 2 indications for antipsychotic medications in psychiatry

A

Schizophrenia (and related disorders)

Bipolar affective disorder

122
Q

Give 3 side effects of antipsychotics

A 
Movement disorders (e.g. dystonia, akathisia)
Autonomic effects  (e.g. anti adrenergic/cholinergic)
Neuroleptic malignant syndrome 
Convulsant activity 
Pigmentation 
Metabolic effects (e.g. weight gain)
Endocrine effects 
Hypersensitivity reactions (e.g. skin)
123
Q

What is acute dystonia and who is most likely to suffer from it as a result of antipsychotic use?

A

Involuntary skeletal muscle contraction

Young males naive to medication

124
Q

What is tardive dyskinesia and when is it seen in psychiatry?

A

Late onset hyperkinetic involuntary movements

Side effect of antipsychotics

125
Q

What anti-adrenergic effects can be caused by antipsychotics?

A 
Postural hypotension
QTc prolongation and arrhythmias (e.g. Torsade des pointes)
Sexual dysfunction (e.g. ejaculatory failure)
126
Q

What anti-cholinergic effects can be caused by antipsychotics?

A 
Dry mouth
Blurred vision
Constipation
Difficulty micturating
Urinary retention
127
Q

What is neuroleptic malignant syndrome?

A

Life-threatening reaction that can occur in response to antipsychotic medication

128
Q

What are the signs/symptoms of neuroleptic malignant syndrome?

A 
Muscle rigidity 
Extreme extrapyramidal symptoms 
Severe hyperthermia
Hypertension 
Tachycardia
129
Q

Which antipsychotic can lower the seizure threshold?

A

Chlorpromazine

130
Q

Which antipsychotics cause weight gain?

A

Clozapine

Olanzapine

131
Q

What endocrine effect can antipsychotics have?

A

Hyperprolactinaemia

Causes reduced libido, sexual dysfunction (impotence), menstrual irregularities, lactation (non-pregnant females)

132
Q

What is clozapine used for?

A

Treatment resistant schizophrenia

133
Q

What is the method of action of clozapine?

A

Serotonin and dopamine antagonist

134
Q

What important side effect is clozapine associated with and what should be done to prevent this?

A

Agranulocytosis

Regular differential WBC monitoring

135
Q

What lifestyle factor needs to be taken into account for patients on clozapine?

A

Smoking induces hepatic enzymes which will cause a reduced plasma level of clozapine (which will increase if smoking stops)

136
Q

Define bipolar affective disorder

A

Repeated (i.e. at least two) episodes in which the patient’s mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of an elevation of mood and increased energy and activity (mania or hypomania), and on others of a lowering of mood and decreased energy and activity (depression)

137
Q

Give 3 signs/symptoms of BAD

A 
Elevated mood
Increased motor activity
Increased sexual interest
Sleep disturbance
Irritability
Aggression
Fast speech
138
Q

How is BAD managed?

A

Mood stabilisers
Antipsychotics
Benzodiazepines
ECT

139
Q

Name 2 mood stabilising drugs

A

Lithium
Carbamazepine
Valproate

140
Q

Give 2 indications for lithium

A

Acute treatment of mania/hypomania
Prophylaxis in bipolar disorder, schizoaffective disorder and recurrent depressive illness
Augmentation of antidepressants in acute depressive illness
Treatment of depression in bipolar disorder

141
Q

What investigations should be done before starting a patient on lithium?

A

Bloods - thyroid and kidney

ECG

142
Q

What is the main contraindication of lithium and why?

A

Pregnancy - crosses placenta and causes Epstein’s anomaly and affects thyroid function of baby

143
Q

Name a drug type which interacts with lithium

A

NSAIDs

Thiazide diuretics

144
Q

Give 5 adverse effects of lithium

A 
Nausea/vomiting
Diarrhoea
Metallic taste in mouth
Cognitive dulling
Tremor
Muscle weakness
Weight gain
Hypothyroidism 
Hyperparathyroidism
Renal tubular necrosis 
Kidney failure
Nephrogenic diabetes insipidus (thirst, polyuria, sleep disturbance)
145
Q

How does lithium cause hypothyroidism?

A

Competes with iodine for absorption into thyroid gland, reducing hormone production

146
Q

Give 3 signs/symptoms of lithium toxicity

A

Initially - fine tremor, nausea, vomiting and dizziness

Progressing to - course tremor, ataxia, dysarthria, drowsiness, confusion, fits, coma and death

147
Q

What is the Care Programme Approach?

A

Approach used in secondary mental health and learning disability services to; assess, plan, review and co-ordinate care, treatment and support for people with complex needs, relating to their mental health or learning disabilities

148
Q

Give 3 types of professional involved in the Care Programme Approach and their main duty

A 
Community psychiatry nurse - monitor mental state and medication adherence
Housing officer - monitor housing 
OT - assess ADL
GP - review physical health 
Social work - needs assessment
149
Q

How would a lithium overdose be managed?

A

Monitor - serum lithium, renal function, ECG
Reduce absorption and increase clearance to below 1 mmol/L - IV fluids, gastric lavage, whole bowel irrigation, national poisons information service

150
Q

How long should antidepressants be continued for a single episode?

A

4-6 months after resolution of symptoms

151
Q

Name a TCA

A

Amitriptyline

Imipramine

152
Q

Name an SSRI

A

Sertraline

Fluoxetine

153
Q

Name a selective noradrenaline and serotonin re-uptake inhibitor

A

Venlafaxine

154
Q

Name a MAOI

A

Phenalzine

Moclobemide

155
Q

What is the basic mechanism of action of antidepressants?

A

Enhance the functional activity of noradrenaline and/or dopamine in the brain

156
Q

How long should a patient be newly on antidepressants before reviewing?

A

6 weeks

157
Q

What drug is first line for depression?

A

Sertraline

158
Q

Give 3 side effects of SSRIs

A 
Nausea
Loss of appetite
Dry mouth
Diarrhoea
Constipation
Dyspepsia
Vomiting
Weight loss
Insomnia
Dizziness
Anxiety
Fatigue
Tremor
Somnolence
Extrapyramidal symptoms
Seizures
Mania
Sweating
Delayed orgasm/anorgasmia
Hyponatraemia
Alopecia
159
Q

What is hypericum perforatum?

A

St John’s wort

OTC remedy for anxiety and depression

160
Q

Why is it important to find out if a patient is taking St John’s wort before prescribing an antidepressant?

A

Co-prescribing with SSRI/dopamine potentiator may cause serotonergic syndrome/neurotoxicity

161
Q

Give 3 signs/symptoms of serotonin syndrome

A 
Myoclonus
Nystagmus
Headache
Tremor
Rigidity 
Seizures
Irritability
Confusion
Agitation
Hypomania
Coma
Hyperpyrexia
Sweating
Diarrhoea
Cardiac arrhythmias
Death
162
Q

What is the spectrum of substance use?

A

Recreational
Acute intoxication
Harmful use
Dependence syndrome

163
Q

What is acute intoxication?

A

Transient condition following use of alcohol or drugs, closely related to dose and following which recovery is usually complete

164
Q

What are the symptoms of acute intoxication?

A 
Stimulation, excitement or impaired judgement
Disinhibition
Reduced (or heightened) consciousness
Euphoria/dysphoria
Impaired motor co-ordination
Sensory disturbances 
Hyperthermia
Respiratory Depression
165
Q

What is harmful substance use?

A

A pattern of substance use that causes damage to physical/mental health or social circumstances

166
Q

What is dependence syndrome?

A

A cluster of physiological, behavioural, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours that once had greater value

167
Q

How is dependence syndrome diagnosed?

A

3 or more of:
A strong desire or sense of compulsion to take the substance
Difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use
A physiological withdrawal state when substance use has ceased or been reduced
Evidence of tolerance, such that increased doses of the psychoactive substances are required in order to achieve effects originally produced by lower doses
Progressive neglect of alternative pleasures or interests because of psychoactive substance use
Persisting with substance use despite clear evidence of overtly harmful consequences

168
Q

What is withdrawal state?

A

A group of symptoms occurring on withdrawal/reduction of a substance after repeated use; indicates dependence

169
Q

What are the symptoms of benzodiazepine withdrawal?

A 
Anxiety
Agitation
Irritability
Diaphoresis
Confusion
Nausea
Palpitations
Insomnia
Seizures
Hallucinations
Psychosis
170
Q

What are the symptoms of opioid withdrawal?

A 
Rhinitis
Lacrimation
Yawning
Dilated pupils
Diaphoresis
Insomnia
Diarrhoea
Nausea & vomiting
Piloerection
Abdominal cramps
Dysphoria
Tachycardia
Hypertension
171
Q

What condition can accompany withdrawal state? Give an example

A

Delirium

E.g. delirium tremens in alcohol withdrawal

172
Q

What are the signs/symptoms of delirium tremens?

A 
Confusion with nocturnal worsening
Hallucinations
Illusions
Anxiety/fear
Tremor
Hypertension 
Tachycardia
Tachypnoea
Seizures
173
Q

What are the signs/symptoms of psychotic disorder caused by substance misuse?

A

Vivid hallucinations, misidentifications, paranoid delusions, ideas of reference
Psychomotor disturbances
Abnormal affect

174
Q

What is the timing of psychotic disorder caused by substance misuse?

A

Symptoms occur during/within 48 hours of psychoactive substance use
Improves within 1 month, resolves within 6 months

175
Q

What substances can cause psychotic disorder?

A

Alcohol
Cocaine
Amphetamine

176
Q

What is amnesic syndrome? What is commonly implicated?

A

Memory impairment - absence or defect in immediate recall, impairment of consciousness and generalised cognitive impairment
Chronic use of alcohol or drugs

177
Q

What areas of the brain are involved in the dopamine reward pathway?

A

Vental tegmental area - dopaminergic neurons
Nucleus accumbens - dopamine sensitive cells
Amygdala and hippocampus - memory and desire
Prefrontal cortex - co-ordination of information, determination of behaviour

178
Q

Give 4 things which can activate the reward pathway

A

Natural - food, sex, nurturing, exercise

Chemical - drugs, alcohol, coffee, nicotine

179
Q

What factors are implicated in addiction?

A

Social learning/copying
Biological and neurological
Genetics

180
Q

How are substance use disorders assessed?

A 
Use 
Problems 
Physical adaptation 
Behavioural dependence 
Medical harm 
Cognitive impairment 
Motivation for change
181
Q

What is the cycle of change?

A 
Pre-contemplation 
Contemplation
Preparation
Action
Maintenance 
Relapse
182
Q

What psychosocial interventions can be useful in addiction?

A 
Motivational interview 
Brief interventions
CBT - relapse prevention, anxiety management and coping skills 
12 step programmes 
Peer support 
Rehabilitation
183
Q

What are the advantages of motivational interviewing for addiction?

A

Works on facilitating & engaging intrinsic motivation to change
Collaborative
Goal-orientated
Client-centred
Guides patient to examine & resolve ambivalence

184
Q

What brief interventions can be useful for addiction?

A 
F - Feedback of risks
R - Responsibility highlighted
A - Advice to abstain or cut down
M - Menu of alternative options and 	activities offered
E - Empathic interviewing
S - Self efficacy enhanced
185
Q

What empathetic techniques should be used in motivational counselling?

A

Express empathy
Avoid arguments
Roll with resistance
Support self efficacy

186
Q

What laws are in place for substance use?

A

Misuse of Drugs Act (1971)

Psychoactive Substances Act (2016)

187
Q

What is the strongest single predictor of suicide in substance misuse?

A

Alcohol

188
Q

What are the effects of opioids?

A 
Analgesia
Respiratory depression
Euphoria
Drowsiness
Constipation
189
Q

What drugs can be used for opioid detox and replacement?

A

Detox - lofexidine, buprenorphine

Replace - buprenorphine, methadone

190
Q

What are the issues with opioid replacement therapy?

A

Prolonged QT and respiratory depression at higher doses

Rapid loss of tolerance - high risk of OD if missed doses (need for re-titration after 3 days)

191
Q

What are the symptoms of opioid OD?

A

Respiratory depression
Pinpoint pupils
Decreased level of consciousness

192
Q

How is opioid OD treated?

A

Naloxone (competitive opioid antagonist)

193
Q

What are the symptoms of benzodiazepine OD?

A 
Sedation
Drowsiness
Ataxia
Slurred speech
Coma
Respiratory depression
194
Q

How is benzodiazepine OD treated?

A

Supportive

Flumazenil

195
Q

What are the effects of MDMA?

A

Stimulant

Hallucinogenic

196
Q

How can harm from MDMA be reduced?

A

Maintain hydration

Avoid overheating

197
Q

What are the effects of cocaine?

A 
Increased energy 
Increased confidence 
Euphoria
Diminished need for sleep
Psychological dependence
198
Q

What is cocaine associated with?

A

Psychosis

Sudden cardiac death

199
Q

What are the effects of cannabis?

A

Impaired cognitive and psychomotor performance
Euphoria, heightened perceptual sensitivity, depersonalisation and derealisation
Vasodilation, suffused sclerae, postural hypotension, syncope
Tolerance
Psychological dependence

200
Q

What are the symptoms of cannabis withdrawal?

A 
Restlessness
Insomnia
Anxiety
Aggression
Anorexia
Muscle tremor
Autonomic effects
201
Q

What is cannabis use in teenagers linked with?

A

Schizophrenia

202
Q

What are the dangers of volatile gases?

A 
Sudden cardiac death 
Asphyxiation 
Accidents whilst intoxicated 
Rapid intoxication
Rashes around nose & mouth
Occular or oropharangeal irritation
Chronic users may develop diffuse cerebral, cerebellar and brainstem atrophy with white matter changes & leukoencephalopathy
Hearing loss, cerebellar signs, peripheral neuropathy, lethargy, memory less
203
Q

What are the risks of ketamine use?

A

Cardiac problems
Accidental death
Unprotected sex
Cognitive deficits

204
Q

What is ketamine associated with?

A

Ketamine bladder - 30% of users have erosion of urothelium which causes revascularisation and leads to urge incontinence, decreased bladder compliance/volume, detrusor overactivity, painful haematuria, bilateral hydronephrosis and renal papillary necrosis

205
Q

How are learning disabilities defined?

A

IQ <70
Reduced ability to understand/learn
Impaired social and adaptive functioning
Onset before 18 years of age

206
Q

What is the age equivalent of mild, moderate, severe and profound learning disability?

A

Mild - 9-12 years
Moderate - 6-9 years
Severe - 3-6 years
Profound - <3 years

207
Q

Give 2 causes of learning disability

A

Genetic - Down’s syndrome, PKU, fragile X
Infective - rubella, meningitis, encephalitis
Trauma - birth asphyxia, head trauma

208
Q

What mental health conditions are more common in people with learning disability?

A 
Depression 
Schizophrenia 
Anxiety 
Delirium and dementia 
ADHD
209
Q

What effect can pregnancy have on mental illness?

A

May modify the presentation of illness or alter help-seeking behaviour (e.g. greater motivation to tackle issues before birth)
May alter the outcomes of pregnancy (e.g. poorer engagement with antenatal care, greater use of smoking, alcohol, drugs)

210
Q

What are the features of postnatal depression?

A

Onset 6-8 weeks
Varying severity
Symptoms similar to depression
Significant effects on child if left untreated

211
Q

What are the predictors of postnatal depression?

A 
Past psychiatric history 
Psychological problems during pregnancy 
Poor marital relationship
Lack of social support 
Stressful life events 
Low social status 
Single 
Previous miscarriage/termination 
Ambivalence about baby 
Lack of female confidante
Difficult pregnancy/delivery
212
Q

How is postnatal depression managed?

A

Social support and primary care counselling
Psychological therapies
Antidepressants

213
Q

When should a woman with postnatal depression be referred to psychiatry?

A

Significantly impaired function
Ideas of self harm/harm to baby
Unresponsive to medication

214
Q

What are the features of postpartum psychosis?

A

Onset in first 2 weeks
Dramatic presentation - labile mood, confusion, delusions
Good prognosis but 60% recurrence risk

215
Q

What are the predictors of postpartum psychosis?

A

History of postpartum psychosis
History of BAD
Family history of PPP or BAD

216
Q

What is the main difference between the predictors of postnatal depression and postpartum psychosis?

A

PD - psychosocial

PPP - biological

217
Q

What is PPP a variant of?

A

BAD

218
Q

How is PPP managed?

A

Usually require admission
Supervision of mother and baby
Antidepressant and neuroleptic +/- lithium +/- ECT

219
Q

How can PPP be prevented?

A

Identify risk
Communicate with GP and refer to mental health services
Lithium prophylaxis in immediate postpartum period

220
Q

What risks regarding pregnancy are increased in schizophrenia?

A 
Reduced fertility 
Unplanned/unwanted pregnancies 
Smoking and drinking during pregnancy 
Complications during pregnancy and delivery 
SIDS
221
Q

How should prescribing in pregnancy be done for women with psychiatric conditions?

A 
Pre-pregnancy decision making - contraception, risk of illness, risk of drugs 
Clear indication
Avoid first trimester if possible 
Lowest effective dose for shortest time 
Avoid polypharmacy 
Individual assessment of risks and benefits 
Involve partner 
Acknowledge uncertainty
222
Q

What are the risks of antidepressants in pregnancy?

A

Cardiac malformations (2% AR)
Persistent pulmonary hypertension of the newborn (0.5% AR)
Neonatal adaptation syndrome (10% AR)

223
Q

What are the effects of postnatal depression on the mother and child?

A

Disturbed mother-infant interaction

Poorer infant interactions and play, decreased sociability, cognitive delay

224
Q

What sex is more likely to develop depression in childhood and adolescence?

A

Childhood - equal

Adolescence - females (2:1)

225
Q

What percentage of adolescents with depression are likely to experience a second episode in early adulthood?

A

45%

226
Q

What are the 3 core symptoms of depression?

A

Low mood
Anhedonia
Lack of energy

227
Q

How does the presentation of depression in children/adolescents differ from adults?

A

Mood - irritable, argumentative, defiant, aggressive; may have periods of brightening
Sleep - insomnia and hypersomnia, early morning wakening
Behaviour - poor school performance, refusal to attend school, social withdrawal
Somatic complaints
Slow, insidious onset

228
Q

How should children/adolescents with depression be assessed?

A

Collateral history (seek permission from patient)
Speak with patient with and without parents
Focus on social history and protective factors
Consider co-morbidities (e.g. ASD)

229
Q

How should children/adolescents with depression be assessed for risk?

A

Same as adults
Ask about suicidal thoughts
Emphasis on - self-harm, risky behaviour, impulsivity, abuse

230
Q

How should children/adolescents with depression be managed?

A

Involvement of family/school
Psycho-education
Psychological therapies - CBT, family, art/play
Pharmacotherapy - fluoxetine only

231
Q

What are the 4 types of factors to consider in psychiatric conditions?

A

Predisposing
Precipitating
Perpetuating
Protective

232
Q

Name 2 neurodevelopmental disorders

A 
ADHD
ASD
Tourette's syndrome
Learning difficulties
Dyslexia
233
Q

What are the 3 core components of ADHD?

A

Inattention
Hyperactivity
Impulsivity

234
Q

What are the risk factors for ADHD?

A

Male
Genetics
Family history

235
Q

How does ADHD change with age?

A

Improvement is seen with age, but 2/3rds still have symptoms in adulthood

236
Q

What are the developmental impacts of ADHD?

A 
Behavioural disturbance 
Academic impairment 
Poor social interaction 
Impaired self-esteem 
Engaging in smoking/alcohol/drugs at young age and then abusing 
Antisocial behaviour 
Occupational difficulties/unemployed
Injury/accidents 
Inability to cope with daily tasks 
Mood instability 
Relationship difficulties
237
Q

How does ADHD present in adults?

A 
Chaotic
Disorganised
Always late
Losing things
Starts a lot, finishes little
Multiple jobs and relationships
Careless mistakes
Avoid books/films/queues
Others organise life
Restless
Fidgeting
Can’t relax or switch off
Rude
Can’t wait
Impatient
Conflicts at work
Lose train of thought
Forget question
Unthinking breaching of ‘rules’
238
Q

How is ADHD diagnosed?

A

Detailed psychiatric and developmental assessment
Collateral history
Diagnostic criteria (DSM or ICD)
Optional neuropsychiatric assessment

239
Q

What symptoms of inattention can occur in ADHD?

A

DADMOMLFC

Difficulty sustaining attention
Avoids sustaining attention
Distracted easily
Misplaces things
Organisation problems
Mistakes made
Listening difficult
Forgetful in daily activities
Completing tasks or jobs
240
Q

What symptoms of hyperactivity/impulsivity can occur in ADHD?

A

LFROST/WIB

Loud in quiet situations
Fidgetiness
Restless or overactive
On the go all the time
Seating difficult
Talks excessively

Waiting difficult
Interrupts or intrudes
Blurts out prematurely

241
Q

What are the ICD-10 diagnostic criteria for ADHD?

A

Hyperkinetic disorder: ≥6 symptoms of inattention, ≥3 of hyperactivity, ≥1 of impulsivity

Started before age 7
Present ≥ 6/12 months
Affecting ≥ 2 settings
Significant impairment in functioning
Symptoms not due to another cause
242
Q

What are the differential diagnoses for ADHD?

A

Normal behaviour
Malingering or seeking stimulant medication (mainly students)
Hyperthyroidism, substance abuse, mania, cyclothymia, agitated depression, anxiety disorders, EUPD, ASPD, LD, ASD, Tourette’s syndrome

243
Q

How can ADHD be managed?

A

Support groups, psychiatry, CBT, occupational therapy
Stimulants - methylphenidate, dexamfetamine
Non-stimulants - atomoxetine, clonidone, bupropion, modafinil

244
Q

How is the dose of methylphenidate for ADHD titrated?

A

Smallest dose at least 2 weekly and increase until adequate response/intolerable side effects or increased BP/HR

245
Q

What preparations of methylphenidate are available for ADHD?

A 
Immediate release (e.g. ritalin)
Slow release (e.g. concerta)
246
Q

What are the side effects of methylphenidate given for ADHD?

A 
Reduced appetite
Insomnia
Headache
Irritability 
Tachycardia
Tics
Seizures
247
Q

When would atomoxetine be considered for management of ADHD?

A

Unresponsive/intolerant to stimulant

Abuse/diversion of stimulants is a concern

248
Q

What are the side effects of atomoxetine?

A 
Acute liver failure
Suicidality
Reduced appetite
Nausea
Insomnia 
Dizziness
Constipation
Sweating
Sexual dysfunction 
Seizures
249
Q

When would atomoxetine be contraindicated?

A

Phaeochromocytoma

250
Q

How is response to management of ADHD monitored?

A

Monitor core and associated symptoms
Functioning (WFIRS scale)
Patient report/collateral

251
Q

In what psychiatric co-morbidities should prescribing for ADHD be done carefully?

A

Psychosis - non-stimulant preferred
Depression - check if on NA antidepressant
Mania - mood stabiliser/antipsychotic cover
Anxiety - atomoxetine preferred (stimulants can exacerbate)
Addiction - 6 months abstinence
Tourette’s - stimulants worsen tics

252
Q

What is the duration of drug treatment for ADHD?

A

6 monthly HR/BP
Drug holidays considered annually to assess if patient has ‘grown out’ of it
Gradual withdrawal with non-stimulants, rapid withdrawal with stimulants

253
Q

What is Asperger’s syndrome?

A

Similar to autism but no general delay in language or cognitive development and tend to have normal intelligence

254
Q

What are the 3 core symptoms of autism?

A

Abnormal reciprocal social interaction
Impaired communication/language
Restricted and repetitive interests/activities

255
Q

What are the risk factors for autism?

A 
FH
Male
Parental age 
Birth complications 
Environment
256
Q

What symptoms of abnormal social interaction may be seen in a patient with ASD?

A 
Indifference
Minimal shared enjoyment
Reciprocal interaction
Functional friendships
Only early life friends
Attachment to objects
Aloof or awkward
Egocentric
Limited empathy
Social rules
Insensitive
Lack of intuition
Emotional recognition
257
Q

What symptoms of communication/language impairment may be seen in a patient with ASD?

A 
Delayed or lack of speech
Prolonged or avoidant eye contact
Awkward posture or body language
Speech unusual volume
Formal, stilted, pedantic
Misinterpretation of literal/implied meanings
Advanced vocabulary ; poor conversational skills
Lack of prosody (monotonous)
Talking at rather than to
Few nonverbal gestures
258
Q

What symptoms of restricted/repetitive behaviours may be seen in a patient with ASD?

A 
Obsessive fixed interests
Motor mannerism (hand flapping, body rocking)
Compulsive / repetitive behaviours
Ritualistic daily activities
Repetitive self injury
Preference for sameness e.g. food
Change unsettling
Increased sensory responsiveness
259
Q

What other symptoms may be experienced by a patient with ASD?

A

Clumsiness
Difficulty expressing emotion
Increased pain threshold
Lack of empathy

260
Q

How is ASD assessed?

A

Psychiatry, SLT, OT, psychology

Standardised tools - autism behaviour checklist (ABC), childhood autism rating scale (CARS)

261
Q

What is the main difference between the ICD-10 and DSM-5 diagnostic criteria for ASD?

A

ICD-10 - 3 different autism subtypes (childhood autism, Asperger syndrome, pervasive developmental disorder)
DSM-5 - spectrum

262
Q

How is ASD managed?

A 
Education 
Adapt environment - routine, reduce interactions 
Communication aids 
Social skills training 
CBT, OT 
Parenting programmes 
Medication if symptomatic
263
Q

How is medication used in ASD?

A

Antipsychotics for stereotyped or aggressive behaviours
SSRIs for compulsive behaviours
Melatonin for insomnia

264
Q

What is adjustment disorder?

A

A group of feelings (e.g. stress, sadness, hopelessness) and physical symptoms in over-reaction to a stressful life event due to difficulty coping

265
Q

What is Russell’s sign?

A

Repeated contact of the fingers with teeth during self-induced vomiting (e.g. in bulimia) episodes can lead to characteristic abrasions, small lacerations, and calluses on the back of the hand overlying the knuckles

266
Q

What are the main characteristics of bulimia nervosa?

A

Recurrent episodes of overeating (twice a week for three months)
Self perception of being too fat and intrusive dread of fatness
Persistent preoccupation with food
Attempts to counteract the “fattening” aspects of food by one of the following; self induced vomiting, purgative abuse, alternating periods of starvation, or use of drugs

267
Q

How is bulimia nervosa managed in adults?

A

Focused self help programme using CBT

268
Q

What should CBT for bulimia nervosa in adults cover?

A 
20 sessions over 20 weeks 
Engagement and education
Establishing regular eating
Providing encouragement, advice and support 
Address psychopathology
Involve significant others
269
Q

How is bulimia nervosa managed in children/adolescents?

A

Focused family therapy

270
Q

What should family therapy for bulimia nervosa in children/adolescents cover?

A

20 sessions over 6 months
Establish relationship
Information about regulating weight and adverse effects of inducing vomiting
Individual involvement too

271
Q

How is binge eating disorder characterised?

A 
3/5 of: 
Eating much more quickly than usual
Eating until uncomfortably full
Eating a lot when not hungry
Eating alone because of embarrassment
Feeling very bad or guilty after eating
272
Q

How is binge eating disorder managed?

A

Self-help programme (CBT) and brief supportive sessions

273
Q

How is anorexia nervosa characterised?

A 
Weight loss (or in children lack of weight gain), leading to a body weight at least 15% below the normal or expected weight for age and height
Weight loss is self induced by avoidance of fattening foods
Self perception of being too fat, which leads to a self imposed low weight threshold
Widespread endocrine disorder involving the hypothalamic-pituitary-gonadal axis is manifest as amenorrhea or in men, loss of sexual interest and impotency
274
Q

What is the prognosis of anorexia nervosa?

A

50% recovery with treatment

275
Q

What are atypical eating disorders?

A

An eating disorder is called atypical if they do not fit exactly into the diagnostic categories. For example a person may have most of the symptoms of anorexia or bulimia but not all; or they may have symptoms of both conditions; or they may move from one condition to another.

276
Q

How are atypical eating disorders managed?

A

Considers following the guidance on the treatment of the eating problem that most closely resembles the individual patient’s eating disorder

277
Q

What are the cardiovascular physical complications of anorexia nervosa?

A 
Cardiomyopathy
Mitral valve prolapse
SVT
Long QT syndrome
Bradycardia
Orthostatic hypotension
278
Q

What are the hormonal physical complications of anorexia nervosa?

A 
Delayed puberty
Amenorrhea
Anovulation
Increased GH
Decreased ADH
Hypothermia
Hypokalemia
Hyponatremia
Hypoglycemia
Euthyroid sick syndrome
Hypercortisolism
Arrested growth
Osteoporosis
279
Q

What are the gastrointestinal physical complications of anorexia nervosa?

A

Constipation
Decreased intestinal mobility
Delayed gastric emptying
Gastric dilation and rupture

280
Q

What are the renal physical complications of anorexia nervosa?

A 
< eGFR
Oedema
Acidosis with dehydration
Hypokalemia
Hypochloremic alkalosis with vomiting
281
Q

What are the haematological and general physical complications of anorexia nervosa?

A 
Anaemia
Leucopenia
Thrombocytopenia
Dry skin and hair
Hair loss
Lanugo body hair
Infertility
Low birth weight infant
282
Q

What is refeeding syndrome?

A

Any individual who has had negligible nutrient intake for more than 20 consecutive days is at risk of refeeding syndrome. Refeeding syndrome usually occurs within 10 days of starting to feed. Patients can develop fluid and electrolyte disorders, especially hypophosphatemia, along with neurologic, pulmonary, cardiac, neuromuscular, and hematologic complications.

283
Q

How is anorexia nervosa managed in adults?

A

Self-help CBT programme - Aim to reduce the risk to physical health and any other symptoms of eating disorder
Encourage healthy eating and reach a healthy body weight
Consider nutrition, cognitive restructuring, mood regulation, social skills, body image concern, self esteem and relapse prevention, create a personalised treatment plan, explain risks of malnutrition, enhance self efficacy, self monitoring of intake and thoughts and feelings, homework

284
Q

How is anorexia nervosa managed in children/adolescents?

A

Family therapy - Emphasise the role of family in helping them recover
Psychoeducation about nutrition and malnutrition
Establish a good therapeutic alliance with the person
Latterly support the person to establish a level of independence
Relapse prevention

285
Q

What is MARSIPAN?

A

Management of Really Sick Patients with Anorexia Nervosa
Contains guidance for clinicians looking after MARSIPAN patients on acute medical wards and psychiatric wards, but also includes service recommendations e.g. most MARSIPAN patients should be admitted to a SEDU, treated by local expert physician with interest in nutrition/ nutrition team

286
Q

How is physical risk assessment carried out for eating disorders?

A 
BMI 
Rate of weight change 
CV risk (BP, pulse, ECG)
Glucose and albumin 
Electrolytes and renal function 
Liver function
Bone marrow function (WCC, Hb, platelets)
287
Q

What are the risk factors for developing refeeding problems in anorexia nervosa?

A

1 or more of:
BMI less than 16kg/m2
Weight loss greater than 15% within the last 3 – 6 months
Little or no nutritional intake for more than 10 days
Low levels of potassium, phosphate or magnesium prior to feeding
History of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics
The presence of purging behaviours, such as vomiting and /or laxative misuse

288
Q

How is refeeding managed?

A

Providing immediately before and during the first 10 days of feeding: oral thiamine 200-300mg daily, vit B Co Strong 1-2 tabs tds and a balanced multivitamin/ trace element eg. Forceval 1tab once daily
For most MARSIPAN patients, a re-feeding plan should be prescribed by a nutrition support team or dietitian (if necessary consulting with AEDS dietitian), starting at 20kcal/ kg/day and gradually increasing the caloric intake dependent on daily bloods (as previously detailed)

289
Q

What psychiatric issues need to be considered in MARSIPAN patients?

A

Patients may admit or deny eating disordered behaviours (but have a high index of suspicion)
Falsifying weight by means of drinking water, wearing weights etc.
Excessive exercise (including microexercise)
“Under” dressing to burn calories
Disposing of food/ feed or using purging behaviours
Patients who sabotage their care may be observed 1:1 by experienced nurses.
If staff e.g. agency are inexperienced in management of AN, provide a concise management plan to follow

290
Q

What additional considerations should there be when planning inpatient care for anorexia nervosa?

A

Consider bed rest (BMI<13) and DVT prophylaxis, partial bed rest (BMI 13-15)
Supervised washes only (BMI<13), supervised showers (BMI 13-15)
Tissue viability risk assessment, airflow mattress
Fluid input/ output charts
Access to toilets/ taps
Meal and snack supervision and post meal and snack supervision
Leave
Frequency of physical observations
Frequency of BMs
ALERT on Kardex regarding low BMI: For dose reductions for symptomatic relief and cautious use of sedative medication

291
Q

What is the most common type of patient seen by a forensic psychiatrist?

A

Male
Psychotic
Alcohol/drug misuse
Personality disorder

292
Q

How are patients managed in forensic psychiatry?

A 
Medical 
Education and risk factors 
Psychology 
Occupational therapy 
Emphasis on rehabilitation
293
Q

What are the symptoms of adjustment disorder?

A

Feeling sad, hopeless or not enjoying things you used to enjoy
Frequent crying
Worrying or feeling anxious, nervous, jittery or stressed out
Trouble sleeping
Lack of appetite
Difficulty concentrating
Feeling overwhelmed
Difficulty functioning in daily activities
Withdrawing from social supports
Avoiding important things such as going to work or paying bills
Suicidal thoughts or behavior

294
Q

What is the timing of adjustment disorder?

A

Occurs within 3 months of the triggering event and lasts no longer than 6 months after it ends (can be persistent/chronic)

295
Q

What is personality disorder?

A

A mental disorder in which there is a rigid and unhealthy pattern of thinking, functioning and behaving
A person with a personality disorder has trouble perceiving and relating to situations and people

296
Q

What are the risk factors for personality disorder?

A

Family history
Abuse/unstable childhood
Childhood conduct disorder diagnosis
Brain chemistry and structure

297
Q

What are the diagnostic criteria for personality disorder?

A

Long-term marked deviation from cultural expectations that leads to significant distress or impairment in at least two of these areas:

The way you perceive and interpret yourself, other people and events
The appropriateness of your emotional responses
How well you function when dealing with other people and in relationships
Whether you can control your impulses

298
Q

How is personality disorder managed?

A

Psychotherapy

Medication - antidepressants, mood stabilisers, antipsychotics, anxiolytics

299
Q

What is CBT?

A

Cognitive behavioural therapy (CBT) is a talking therapy that can help you manage your problems by changing the way you think and behave

300
Q

How does CBT work?

A

CBT is based on the concept that your thoughts, feelings, physical sensations and actions are interconnected, and that negative thoughts and feelings can trap you in a vicious cycle
CBT aims to help you deal with overwhelming problems in a more positive way by breaking them down into smaller parts.

You’re shown how to change these negative patterns to improve the way you feel.

Unlike some other talking treatments, CBT deals with your current problems, rather than focusing on issues from your past.

It looks for practical ways to improve your state of mind on a daily basis.

301
Q

What is psychotherapy?

A

Psychotherapy is a type of therapy used to treat emotional problems and mental health conditions
It involves talking to a trained therapist, either one-to-one, in a group or with your wife, husband or partner. It allows you to look deeper into your problems and worries, and deal with troublesome habits and a wide range of mental disorders

Year 5 (10 decks)

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