Psychiatry Flashcards
How does ICD10 define mild, moderate, severe depression?
For 2 weeks:
mild = 2 core + 2 typical
mod = 3 core + 2 typical
severe = 4 core + 3 typical
What are the 10 core symptoms of depression?
For atleast 2 weeks
- Depressed mood for most of the day nearly everyday
- Anhedonia
- Fatigue or loss of energy
- Weight change associated with appetite change
- Disturbed sleep (insomnia ie early waking, or hypersomnia)
- Reduced libido
- Reduced ability to concentrate
- Psychomotor agitation or retardation
- Feelings of guilt/worthlessness
- Recurrent thoughts of death/suicide
How would you initially assess someone with depression?
Assess Suicide Risk!!!
Distress Thermometer for those with communication difficulties (investigate >4)
Depression questionnaires:
PHQ-9
HADS
BDI-II
What are some investigations you would do for depression?
Standard = FBC, U&Es, B12, Folate, ESR, LFTs, TFTs, Glucose, Ca2+
- Urine/Blood toxicology
- Breath/Blood alcohol
- ABG
- Thyroid antibodies
- Antinuclear Antibodies (SLE)
- Syphilis serology
- Electrolytes (Phosphate, Magnesium, Zinc)
- Dexamethasone Suppression Test (Cushings)
- Syncathen test or 9am cortisol (Addisons)
- LP
- CT/MRI/EEG
How would you initially manage mild depression
- Suicide risk? Contact Crisis Resolution and Home Treatment Team (CRHT)
- Safeguarding for their children etc
- Manage Comorbid
- Sleep hygiene advice for insomnia
Subthreshold =
- address concerns
- provide info (self help groups, support groups, organisations like MIND)
- follow up in 2 weeks if they don’t want treatment
Mild =
- 1st line = Low intensity psychosocial intervention (individual guided self-help based on CBT principles, Computerised CBT, Structured group-based physical activity programme)
- or Group based CBT
How would you initially manage mod-severe depression?
- Suicide risk? Contact Crisis Resolution and Home Treatment Team (CRHT)
- Safeguarding for their children etc
- Manage Comorbid
- Sleep hygiene advice for insomnia
Bio
- Antidepressant (1st line SSRI like citalopram, fluoxetine, paroxetine, sertraline + gastroprotection)
- Review effects in 2-4 weeks and enquire about adherence/adverse effects.
Psycho
- AND High intensity Psychological Intervention (individual CBT to recognise stressors, interpersonal therapy, couples therapy)
- OR Counselling and short-term psychodynamic therapy (if antidepressants + HIPI declined)
How would you manage an atypical depressive episode
1st line = Phenelzine
How would you manage SAD?
Bright Light Therapy
Pharm = SSRIs, Pre-Sunrise propranolol to suppress morning melatonin, Melatonin at night
Psych = Standard CBT
How is dysthymia different to depression?
depressed mood lasting over 2 years
(less severe, more chronic than depression)
Similar core symptoms, no suicidal ideation
What is the diagnostic criteria for the 2 types of bipolar?
ICD10 =
- at least 2 episodes of extreme mood, one of which must be hypomanic/manic/mixed
- (recovery usually complete between episodes but if not = rapid cycling)
- Type 1 = Mania +/- depressive episodes
- Type 2 = Hypomania +/- depressive episodes
What is the difference between mania and hypomania?
Mania
- grandiose plans and self regard
- increased energy, reduced sleep
- flight of ideas, pressured speech
- reduced attention
- irritation
- disinhibition (eg. over familiarity)
- impulsive risky behaviour
Hypomania is elated mood but not severe enough to interfere with social/occupational functioning like mania.
Hypomania does not include psychotic features.
How would you generally manage a severe acute bipolar episode?
Hospital admission if eg. high risk of suicide, severe psychotic/depressive/rapid cycling symptoms etc
Psychotic symptoms = antipsychotic with mood stabilising properties (eg. olanzapine or quetiapine)
Catatonic symptoms = admit, mood stabilising antipsychotic, BDZ, ECT
How would you manage a bipolar patient with mania longterm
Mood stabiliser = 1st line is Lithium
Can consider anticonvulsants for longterm mood stabilisers
(SV, Carbamazepine, Lamotrigine)
Can consider antipsychotics for episodes of mania/hypomania
(olanzapine, quetiapine, risperidone)
What would you have to do to start, monitor and stop lithium
Before
- Weight/BMI
- U&Es (eg. Ca2+)
- eGFR
- TFT
- FBC
- ECG for CVS risk
- Shared care arrangement with GP
- Info = maintain fluid intake, do not take NSAIDs
During
- Plasma Lithium 1 week after every dose change (12 hours after dose), then weekly until stable , then every 3 months for 1st year
- BMI, U&Es (eg. Ca2+), eGFR, TFT every 6 months
- monitor for neurotoxicity (paraesthesia, ataxia, tremor, cognitive impairment)
Stopping
- reduce over atleast 4 weeks - monitor for mania/depression
How would you manage a bipolar patient with depression longterm?
Bio
- Antidepressants eg. fluoxetine
- Mood stabiliser eg. lithium
-
Quetiapine if not already on antipsychotic
- (acts as antipsychotic, mood stabiliser, antidepressant)
Psycho
CBT to reduced relapses, interpersonal therapy and behavioural couples therapy
Social
Regular exercise
Define a panic attack
period of intense fear characterised by symptoms
(palpitations, sweating, SOB, chest pain, dizziness, feeling of imminent doom, numbness, feelings of detachment, etc)
that develop rapidly, reach a peak intensity in about 10 mins and generally do not last longer than 20-30 mins.
How would you manage panic disorder?
1st line Psych = CBT teaches you how to manage feelings that come on with a panic attack
Bio =
Antidepressants for atleast 6 months after optimal dose is reached
-
1st line = SSRI (escitalopram, sertraline, citalopram, paroxetine)
- OR SNRI (venlafaxine)
- 2nd line if SSRI unsuccessful after 12 weeks = imipramine or clomipramine (or an SNRI)
How would you manage simple/specific phobias?
Psych =
- Behavioural therapy (Exposure techniques)
- Reciprocal inhibition
- Modelling
- Cognitive methods
Pharm =
- Diazepam to allow patient to engage in exposure
- B Blocker can reduce sympathetic arousal
What is agoraphobia
Panic symptoms associated with places or situations where escape is difficult or embarrassing (eg. crowds, public places), resulting in avoidance
How would you manage agoraphobia?
- CBT = exposure techniques, relaxation training, etc
- Pharm = antidepressants like citalopram, escitalopram, paroxetine
Definition of GAD?
Generalised and persistent excessive worry about everyday issues, disproportionate to any inherent risk, causing distress or impairment for atleast 6 months
How would you manage a patient with GAD?
Initially
- GAD7 and Suicide Risk
1st line =
- Educate about GAD
- address environmental stressors and comorbid
- Monitor Sleep hygiene
- regular exercise
2nd line =
Low intensity Psychological Interventions eg. face to face/ telephone therapist sessions, psychoeducational groups and self-help manuals
3rd line =
- High intensity Psychological Intervention like CBT or applied relaxation
- OR Pharm
- 1st line = SSRI (sertraline, paroxetine, escitalopram)
- 2nd line = another SSRI or an SNRI (duloxetine, venlafaxine)
- 3rd line = Pregabalin
*** See within a week and then monitor weekly for first month in patients under 30 that have been started on SSRI/SNRI due to risk of suicide
What is adjustment disorder? (time span)
ICD10…
Must occur within 1 month of a psychosocial stressor and should not persist for longer than 6 months after the stressor is removed
ICD10 says a brief depressive reaction is >1 month but can result in a prolonged depressive reaction (>6 months but <2years)
How would you manage adjustment disorder?
Bio =
- antidepressants or anxiolytics/hypnotics if symptoms are too destressing
Psych =
- supportive psychotherapy
- specific support groups eg. bereavement
Social =
- practical support eg. carers/childcare
- financial support, benefits,
- OT assessment
What are the 3 clinical features of PTSD?
must persist at least 6 months after the traumatic event!!! so not adjustment disorder.
Re-experiencing
(flashbacks, nightmares, distressing images or sensory impressions that intrude in the waking day, reminders of the event provoke distress)
Avoidance
(suppress memories or avoid circumstances that remind them of the trauma)
OR
Rumination (prevent themselves from moving on or coming to terms with the event eg. excessively thinking about how it could have been prevented)
Hyperarousal
(Exaggerated startle response, sleep disturbance, irritable, problems concentrating)
OR
Emotional Numbing (feelings of detachment, giving up previously significant activities, etc)
How are children more likely to present in PTSD?
Nightmares and sleep disturbance
Avoidance symptoms
How would you manage a PTSD patient?
- Address comorbid (commonly substance misuse)
- Risk assess (may refer to CRHT)
Psych
- 1st line = Trauma focused CBT (evaluate thinking patterns)
- Consider EMDR in adults presenting 1-3 months after trauma
Pharm if patient prefers
- 1st line = Venlafaxine or SSRI (Sertraline)
- If unresponsive to other drugs/psych
- Antipsychotic like Risperidone + Psych therapies
- <1 month hypnotics for insomnia
How would you diagnose OCD?
Obsessional thoughts and Compulsive acts present on most days for atleast 2 weeks.
O&C must be…
- repetitive and unpleasant
- from the patients own mind and not be imposed by outside influences
- atleast one O/C must be acknowledged as excessive/unreasonable
- at least one must be unsuccessfully resisted
- they cause distress and interfere with daily functioning
What are the 6 screening questions for OCD?
- Do you wash or clean a lot?
- Do you check things a lot?
- Is there any thought that keeps bothering you that you would like to be rid of but cannot?
- Do your daily activities take a long time to finish?
- Are you concerned about putting things in a special order or are you very upset by mess?
- Do these problems trouble you?
How would you manage an OCD patient?
Initial =
- Yale-Brown Obsessive-Compulsive scale
- Safeguard children/vulnerable adults
Mild functional impairment =
- Low Intensity Individual CBT (including Exposure and Response Prevention)
- OR Group CBT+ERP
Mod
- SSRI (fluoxetine, fluvoxamine, paroxetine, sertraline)
- OR intensive CBT+ERP
Severe =
- SSRI AND intensive CBT+ERP
- If unresponsive, try Clomipramine alone.
What are features of EUPD?
- >18 years old
- unstable relationships and self image
- recurrent self harm and suicide threats
- depression
- bouts of anger
- impulsive behaviour
- transient psychotic symptoms
What are some psychological tests you can do for PD?
Diagnostic Interview for DSMIV Personality Disorders (DIPD-IV)
Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II)
Personality Assessment Schedule (PAS)
Standardised Assessment of Personality (SAP)
International Personality Disorder Examination (IPDE)
How would you manage a crisis in someone with EUPD?
by Community mental health services:
- short term drug treatment like sedative antihistamines (eg. promethazine)
- follow up after and plan to stop drugs within 1 week
- develop a crisis plan to identify triggers and find self management strategies
- provide support numbers for out of hours teams and crisis teams
How would you manage someone with EUPD Long term
by Community Mental Health Services or CAMHS
Bio =
- NICE only recommends drugs for comorbid
- Insomnia = sleep hygiene, zopiclone/zaleplon/zolpidem
Psych =
- psychotherapy for atleast 3 months.
- Can try Comprehensive Dialectical Behavioural Therapy Programme where reducing recurrent self harm is a priority
How would you diagnose Dissocial PD?
ICD10 - atleast 3 of the following
- callous unconcern for feelings of others
- gross and persistent disregard for social norms/rules/obligations
- incapacity to maintain enduring relationships, though no difficulty to establish them
- low tolerance to frustration, often aggression
- incapacity to experience guilt or profit from adverse experience eg. punishment
- blame others or offer rationalisations for behaviour bringing the patient into conflict with society
How would you manage a dissocial PD?
Psych
- group psychotherapy and CBT
- “Reasoning and rehabilitation” programmes that focus on reducing offending behaviour
When is the peak incidence of seizures and delirium tremens in alcohol withdrawal?
Peak incidence of seizures = 36 hours
Peak incidence of DT = 48-72 hours
How does delirium tremens present?
Coarse tremor, confusion, delusions, auditory/visual hallucinations, fever, tachycardia
How would you proceed with an uncomplicated assisted alcohol withdrawal?
1st line = long acting benzo (Chlordiazepoxide or Diazepam)
Lorazepam preferred in hepatic failure
Seizures = fast acting benzo like lorazepam
How would you manage delirium tremens?
1st line = Oral Lorazepam (aLcohol doesnt have a D in it)
or chlordiazepoxide
If oral declined, parenteral lorazepam or haloperidol as adjunct
How would you manage a patient who was alcohol dependent?
Mild =
- CBT
- or Pharm (acamprosate calcium or oral naltrexone hydrochloride)
Mod-Severe =
- CBT AND AC/NH
- Can use disulfiram if AC/NH unsuitable
- Alcohol related hepatitis = corticosteroids
- Alcohol related pancreatitis = nutritional support or enzyme supplements like Creon if patient is steatorrhoeac
How does Wernicke’s encephalopathy present?
Due to thiamine deficiency
Acute confusion, ocular (opthalmoplegia, nystagmus), ataxic gait
How would you manage Wernicke’s Encephalopathy?
-
Parenteral Thiamine followed by oral thiamine for those at risk
- (eg. risk of malnourishment or decompensated liver disease)
- Prophylactic oral thiamine for drinkers who are in acute withdrawal or before/during assisted withdrawal
-
Vitamin B like Pabrinex
- IV infusion for treatment
- Deep IM Injection for prophylaxis (eg. assisted alcohol withdrawal in inpatient setting)
What is Korsakoff Syndrome
Absence or significant impairment in the ability to lay down new memories, together with a variable length of retrograde amnesia
How would you manage Korsakoff Syndrome?
Oral Thiamine and Multivitamins for up to 2 years
OT Assessment
Cognitive Rehabilitation
How would you manage someone who was opioid dependent? (Bio)
Bio =
- Methadone (risk of cumulative toxicity due to long half life)
- or Buprenorphine (less sedation, risk of precipitated withdrawal)
- Symptom treatment
- loperamide for diarrhoea
- mebeverine for stomach cramps
- NSAIDs/ paracetamol for muscular pains and headaches
- Metoclopramide for nausea
- Zopiclone for insomnia
- Naloxone for accidental overdose
How would you manage someone who was opioid dependent? (Psycho and Social)
Psych
- motivational interviewing
- behavioural couples therapy if persons partner is a non-drug misuser
- CBT and psychodynamic therapy for comorbid depression/anxiety
Social
- community based programmes
- self help groups and support groups like SMART
- Drug services provide contingency management programmes
What is the difference between:
- Somatisation Disorder
- Hypochondriasis
- Dissociative/Conversion Disorders
- Factitious Disorder/ Munchausen’s
- Malingering
ICD10 Somatisation = Multiple recurrent and frequently changing unexplained physical symptoms present for atleast 2 years, before patient is referred to a psychiatrist
Hypochondriasis = Preoccupation with the fear of having a serious disease, persists despite negative investigations and reassurance
Conversion/Dissociative = Disturbance of motor/sensory/cognitive functions, attributed to a psychological cause eg. paralysis of limbs, loss of speech (although laryngeal exam and vocal cords are normal), sensory loss in lay distribution (not a dermatome), seizures generally infront of an audience, selective amnesia, fugue, etc.
Factitious = Patients intentionally falsify symptoms and past hx and fabricate signs of illness, with the aim of obtaining medical attention and treatment
Malingering = an act not a condition. Involves pretending to have a condition in order to gain a reward or avoid something eg. jury duty
What are some clinical features of Anorexia Nervosa? (NICE)
- Low Body Weight (BMI<18.5)
- intense fear of gaining weight
- self induced, not due to external factors
- behaviours that stop weight gain
- (vomiting, misusing laxatives, excess exercise, appetite suppressants, water loading, chewing gum, etc)
- Psychological disturbance
- eg. distortion of body image, drive for perfection, etc
- Denial of the serious impact on physical health
- eg. secrecy
- Hormonal disturbances
- eg. amenorrhoea, loss of libido and potency in males, physical development affected in children
what are some complications of AN?
- irregular periods/ amenorrhoea
- repeated voming and laxatives lowers K+ and Mg2+
- Osteoporosis due to lack of Ca2+ and Vit D
- Bowel problems like constipation
- Anaemia
- Increased infection risk
- CVS = risk of arrhythmias and cardiac arrest, muscle wasting and cardiomyopathy
- Hypokalaemia, low fsh, low lh, low oestrogens etc
- Hypercholesterolaemia, high cortisol, high gh
How would you manage a patient with Anorexia Nervosa as an outpatient?
Outpatient Psychological Treatment as 1st line
- Individual Eating Disorder focused CBT (CBT-ED)
- Maudsley Anorexia Treatment for Adults (MANTRA)
- Specialist Supportive Clinical Management If those arent available, try eating disorder focused Focal Psychodynamic Psychotherapy (FPT)
- Recommend age appropriate oral multi-vitamin and multi-mineral supplement
How would you manage an under 18 year old with Anorexia Nervosa?
1st line is Family Based Therapy in CAMHS
How would you manage an Anorexia Nervosa patient as an inpatient?
- Inpatient treatment for severe/complicated AN
- Refeeding syndrome can occur if severely malnourished (may need phosphate supplements)
-
Weight Restoration (mainly food, may need NG) =
- Psychotherapy is impossible due to neuropsychological deficits caused by malnutrition
- DEXA Bone Mineral Density scan (advise bisphosphonates in some women with low BMD)
- Refer to dietitian
What are some clinical features of Bulimia Nervosa (NICE)
- Recurrent episodes of binge eating at least once a week for 3 months
- (usually continued restriction between binges)
- Recurrent inappropriate compensatory behaviours to prevent weight gain at least once a week for 3 months
- (eg. vomiting, fasting, excess exercise, laxatives, diuretics, diet pills)
- Weight often normal or above
- Psychological features
- (eg. fear of gaining weight, guilt/shame over binging, anxiety/tension symptoms, preoccupation/craving for food)
- Physical features
- (eg. reflux, bloating, sore throat, Russell’s sign in severe cases (knuckle calluses), dental enamel erosion, salivary gland enlargement)
What would make you consider ASD in a preschool child?
- Language delay eg. echolalia, acquisition of fewer words than expected
- Reduced/negative response to others eg. unresponsive to name being called
- Reduced/absent interaction with others
- Reduced eye contact, pointing, gestures
- Reduced or absent i_magination and variety of pretend play_
- Unusual or r_estricted interests or rigid and repetitive behaviours_
What would make you suspect ASD in a primary-secondary school child?
(Same as preschool)
- Over/underreaction to sensory stimuli
- Unusual spoken language
- Eg. monotonous speech, speaking at people instead of sharing convo, inapprorpiate rude responses
- Rigid or repetitive behaviours Eg. excessive emotional distress to trivial incidents like change in routine that can lead to anxiety/aggression
How would you manage ASD?
Refer to autism team
Education
- inform parents how to request special education needs assessment for child
- Inform them the benefits they are entitled too
- Inform them how to arrange a carers assessment
Sleep
- paediatric sleep specialist or resp physician for OSA
- Sleep diary to identify problems over 2 weeks sleep hygiene
Reassess at 14 for if treatment needs to continue to adulthood
What two features characterise ASD?
Developmental impairments in social interaction and communication
Restricted repetitive patterns of behaviours, interests, activities
When would you suspect ADHD in a child?
at least 6 inattention symptoms and 6 hyperactivity and impulsivity symptoms that…
- start before they are 12
- occur in 2 or more settings eg. home and school
- have been present for at least 6 months
- interfere with social, academic, occupational functioning
- cannot be explained by mental disorder or psychotic disorder
How would you diagnose ADHD in an adult differently?
5 inattention symptoms and 5 hyperactivity-impulsivity symptoms…
Name some inattention symptoms of ADHD
- Failure to pay close attention to detail
- careless
- Difficulty maintaining concentration
- Appearing not to listen to what is said, mind is elsewhere
- Failing to follow through and finish tasks
- Disorganised
- Reluctance or avoidance of tasks that require sustained mental effort
- Losing items necessary for everyday activities like wallets
- Easily distracted
- Forgetful in everyday activities
Name some hyperactivity-Impulsivity symptoms of ADHD
- Fidgeting, tapping, squirming when seated
- Leaving seat where remaining seated is expected eg. classroom
- Running or climbing in situations where inappropriate - Restlessness in adults.
- Inability to engage in leisure activities quietly
- constantly being on the go, hard to keep up with
- Talking excessively
- Blurting out an answer before question has been completed difficulty waiting their turn
- Interrupting or intruding on others
How would you manage suspected ADHD in children?
Watchful waiting for 10 weeks
encouraging self-help and simple behavioural management
Group based ADHD focused support for parents
Then refer to CAMHS if problems persist
How would you manage ADHD in children?
GP =
- weight, height, bp, hr ever 6 months.
- suggest planned breaks in treatment over school holidays to allow “catch up” growth if it has been affected by medication
PreSchool =
1st line is ADHD focused group parent training programme
School age =
- Group or individual based support for parents
- liaison with school/college/uni if consented
- 1st line medication is Methylphenidate for severe impairment (can consider Lisdexamfetamine, dexamfetamine, atomoxetine)
- Can try CBT with drugs
How would you manage ADHD in adults?
Bio
medication for severe impairment = 1st line Lisdexamfetamine OR Methylphenidate
(consider dexamfetamine or atomoxetine as alternatives)
Psych can use in combo with meds
- Structured supportive psychological intervention focused on ADHD
- CBT
Social = Advise to eat normal diet and partake in regular exercise
What are some common presentations of Tourettes?
- Echolalia (copying words)
- Palilalia (repeating your own words)
- Coprolalia (obscene words)
- Copropraxia (obscene gestures)
- Echopraxia (copying movements)
- Difficulty concentrating, easily distracted
How would you diagnose Tourettes?
- Multiple motor tics and 1 or more vocal tics
- starting before 18 years old
- Presence for more than 1 year
- Tics lead to significant impairment in function
- Tics are not due to drugs or secondary causes
How would you assess for Tourettes?
- Full hx and MSE
- MOVES scale for tic severity
- TFT (hyperthyroidism)
- Throat swab for strep if rapid onset (strep induced autoimmune tourettes syndrome)
- EEG if concerns over epilepsy
- Urine drug screen (cocaine, amphetamines, lithium, antipsychotics, etc)
- Genetic causes (huntingtons chorea, Klinefelters syndrome, Wilsons)
How would you manage tourettes?
Mild =
- CBT like Habit Reversal Training (HRT) and Exposure with Response Prevention (ERP)
Mod-Severe
- specialist referral
- Pharm = risperidone or haloperidol
- Surgery = steroeotactic surgery
When should you suspect child maltreatment?
- marked changes in childs behaviour or emotional state
- Frequent or unusual attendance to healthcare services
- injuries with features that could suggest maltreatment
- harmful interaction between parent/child eg. exposure to traumatic experiences, rejection, etc
- child appears neglected eg. persistent infestation with scabies or head lice, failing to thrive, dirty
How would you manage a child with conduct disorder at different ages?
3-11 = parent training programmes
9-14 = child focussed programme
11-17 = multimodal intervention
What is a section 2
Allows you to be detained up to 28 days under the Mental health Act to be assessed or assessed then treated
What is a section 3
Allows you to be detained up to 6 months under the Mental Health Act to be admitted and treated
What is a section 5(4)
If you are in hospital, certain nurses can stop you leaving until the doctor in charge of your care decides whether to detain you there under Section 5(2)
Nurses can detain someone in hospital for up to 6 hours
What is a section 5(2)
Gives doctors the ability to detain someone in hospital for up to 72 hours
Patient should receive an assessment that decides whether further detention under Mental Health Act is necessary
What is a section 136?
If you are in public and appear to have a mental disorder and are in need of immediate care/control, you can be detained and taken to a place of safety (hospital/police station)
You’ll then be kept for up to 24 hours to be assessed by an approved MH professional and a doctor
How would ICD10 diagnose schizophrenia?
Over 1 month
At least 1 positive symptom…
- Thought echo/ insertion/ withdrawal/ broadcasting
- Delusions of Passivity/control/influence
- 2nd or 3rd person auditory hallucinations, running commentary, or other types of auditory hallucinations coming from some part of the body
- culturally inappropriate or implausible persistent Delusions
OR
At least 2 negative symptoms…
- persistent hallucinations in any modality
- breaks of insertions in train of thought resulting in incoherence or neologisms
- catatonic behaviour
- negative symptoms like marked apathy, paucity of speech, incongruity of emotional responses
- significant or consistent change in an aspect of personal behaviour eg. social withdrawal, loss of interest, etc
How would you manage a patients first episode of psychosis?
- Early Intervention in Psychosis (EIP) Services should be accessible to all people with a 1st presentation of psychosis.
-
Oral antipsychotic + CBT adapted for psychosis
- Before antipsychotic: weight, waist circumference, bp, fasting blood glucose, hba1c, blood lipid profile, prolactin levels, assessment of any movement disorders, assessment of nutritional status and level of physical activity, ecg if indicated
How would you manage subsequent acute episodes of schizophrenia
- 1st line support in community = CRHT (community psychiatric nurses educate and monitor patients for relapse)
- oral antipsychotics + CBT adapted for psychosis (fam intervention and individual CBT)
- consider art therapies for alleviation of negative symptoms
- Recommend community centres and organisations like SANE or Rethink for patients and carers
How would you manage unresponsive schizophrenia?
- review engagement with psychological treatments and compliance with medications (Dossette boxes especially for cognitive impairment)
- consider comorbid substance abuse (drug and alcohol services, nicotine substitution, opiate substitution, etc) or physical illness
- offer clozapine after trialling at least 2 different antispychotics (at least 1 should have been a 2nd gen antipsychotic like olanzapine, amisulpride, risperidone, quetiapine)
What is Schizoaffective disorder?
Schizophrenic and affective symptoms simultaneously present for at least 2 weeks (ICD10) and both equally prominent.
Excludes patients with separate episodes of schizophrenia and affective disorders and episodes due to substance misuse or medical disorders
What is schizotypal disorder?
Clinical features of schizophrenia but no delusions/hallucinations
Manage with risperidone, CBT, other antipsychotics
How would you assess someone with suspected postnatal depression?
- Edinburgh Postnatal Depression Scale (EPDS) Or PHQ9
- AUDIT if suspected alcohol misuse
- Ask about any confusion, abnormal behaviour, delusions, hallucinations (differential of postpartum psychosis)
- Ask about past psych hx, attitude towards pregnancy, relationship with baby, physical temperament
What do you do with a depressed patient who becomes pregnant?
Don’t stop antidepressant abruptly!
Mild + taking TCA/SSRI/SNRI = discuss gradually stopping
Mod + TCA/SSRI/SNRI = discuss switching to HIPI like CBT
Severe + TCA/SSRI/SNRI = continue current meds or switch to one with lower adverse effects.
Use meds + HIPI like CBT
What is the risk of SSRIs, TCAs and SNRIs in pregnancy?
SSRI =
- spontaneous abortion
- pulmonary HTN after 20 weeks gestation
- transient neonatal withdrawal syndrome if near delivery
SNRI =
- increased risk of pulmonary HTN
- similar to SSRI
TCA =
- cardiac malformations (clomipramine)
- increased risk of congenital malformations
- neonatal withdrawal symptoms
How would you manage postnatal depression?
Mild =
- refer for facilitated self help
Mod-Severe =
- refer for HIPI (CBT) +/- TCA/SSRI/SNRI
- If hx of severe depression who may initially present with mild = consider TCA/SSRI/SNRI
-
Monitor baby (for sedation, poor feeding, behavioural changes) if breastfeeding
- paroxetine and sertraline are the SSRIs most recommended
- If mental health problem presents within 12 months of childbirth, admit to a specialist mother baby unit
Give organic causes for:
- Depression/ Low mood
- Anxiety
- Schizophrenia
- Bipolar
- Depression = Hypothyroidism, Cushings
- Anxiety/ panic disorder = Hyperthyroidism (weight loss, heat intolerence), Phaeochryomocytoma (usually have htn and tachy, do 24 hour urinary metanephrines)
- Schizophrenia/Psychosis = substance misuse, bereavement, temporal lobe epilepsy
- Bipolar = Thyroid disorders, substance abuse, EUPD
How would you differentiate an acute stress response with PTSD?
An acute stress response is in the first 4 weeks of the event. PTSD is after 4 weeks.
Manage acute stress response with trauma focused CBT 1st line or benzodiazepines
