Psychiatry + Geriatrics Flashcards
A 23-year-old man presents to his GP surgery asking to be referred to a plastic surgeon. He is concerned that his ears are too big in proportion to his face. He now seldom leaves the house because of this and has lost his job. On examination his ears appear to be within normal limits. What is the most appropriate description of this behaviour?
Body dysmorphic disorder (sometimes referred to as dysmorphophobia) is a mental disorder where patients have a significantly distorted body image
What is the first line tx for a 14 year old girl with anorexia?
Family based therapy
Name two common features of sleep paralysis?
1) Paralysis - this occurs after waking up or shortly before falling asleep
2) Hallucinations - images or speaking that appear during the paralysis
What is sleep paralysis and what treatment can be used?
Sleep paralysis is a common condition characterized by transient paralysis of skeletal muscles which occurs when awakening from sleep or less often while falling asleep.
Tx: If needed clonazepam
What is the cut off for clozapine with regards to missed doses and needing to restart?
If clozapine doses are missed for more than 48 hours the dose will need to be restarted again slowly
What is the general summary of investigation results for patients with anorexia?
Most blood results are low
Anything beginning with GorC is high (Growth hormone, cortisol, glucose etc)
What is the minimum length of symptoms that ICD-10 criteria can be used to diagnose depression?
2 weeks
A 64-year-old woman presents as she is feeling down and sleeping poorly. After speaking to the patient and using a validated symptom measure you decide she has moderate depression. She has a past history of ischaemic heart disease and currently takes aspirin, ramipril and simvastatin. What is the most appropriate course of action?
Start sertraline (first line SSRI if heart disease) \+ lanzoprozole
As she is already taking aspirin, any NSAID + SSRI can give risk of GI bleed so needs cover with PPI
What are the main risks of using an SSRI (a) in the 1st trimester and (b) in the 3rd trimester
Use during the first trimester gives a small increased risk of congenital heart defects
Use during the third trimester can result in persistent pulmonary hypertension of the newborn
A 30-year-old female patient with previously diagnosed depression managed with fluoxetine presents to her GP having had terrifying hallucinations at night occurring most nights in the past week. These have been mainly auditory and woken her from sleep. They comprise of aggressive male voices which last for around 10 minutes after she is fully awake. What is the most likely diagnosis?
Hypnogogic (occurring from wakefulness to sleeping) and hypnopompic (occurring from sleeping to waking) hallucinations can occur as a normal physiological phenomenon, however there is a recognised association with depression and anxiety. They can also be associated with sleep paralysis. As these hallucinations have only been occurring at night over a one week period they are not a manifestation of psychosis associated with schizoaffective disorder or schizophrenia.
In what year was the Mental Health Act written and what year was it ammended?
Written 1983
Amended 2007
In what year did the mental capacity act come into place?
2005
When would a section 2 be used? How long does it last for?
Who approves it?
Detained in hospital for ASSESSMENT of mental health
Up-to 28 days
Approved by two doctors, one specialist?
Can a patient appeal a section 2, can it be renewed?
Can appeal in first 14 days
Can’t be renewed, but can be moved to a section 3
What is a section 3 used for?
How long does it last? Can it be renewed?
Detained in hospital for TREATMENT
- Up to 6 months
Renewed for periods of up to 1 year at a time
What is a section 4 used for and how long does it last? Who approves it?
Detained for emergency assessment
Up-to 72 hours
(needs only one doctor, but must have seen in last 24 hours)
When is a section 5 used? What are the subsections and how long does it last?
Stopped from leaving hospital for up to 72 hours
Done by doctor = Section 5 (2) - 72hrs
Done by nurse = Section 5 (4) - 6 hours
Of MHA sections 2/3/4/5, which can a patient be treated without consent, when can’t a patient be treated without consent?
Section 2 + 3 = Can treat without consent
Section 4+5 = Can’t treat without consent
What is a section 135 used for?
Warrant to gain access to premesis to remove patient to place of safety
One doctor + one police
- Assessment only, no tx
- Can only be used once
What is a section 136 used for?
Allow police to remove a person from public place to safety
- Police power only
- Assessment not tx
Name 3 risk factors for depression?
Female Past Hx Significant physical illness Other mental health conditions Afro-Caribbean or Asian
What are the depressive symptoms which should be covered in a hx?
Sad (mood) Apathy (loss of enjoyment) Guilty Concentration Loss of appetite Agitation or slow movements Sleep changes + fatigue Suicide
BAP (Bipolar, alcohol/ drugs, psychosis)
How should mild/moderate depression be treated?
1) Watchful waiting (assess every 2 weeks)
2) Low intensity psychological i.e. online CBT, relaxation therapy
3) Only offer medication if persists after this
How should moderate to severe depression be treated?
Medication + high intensity psychological tx
What is first line medication for depression?
1) SSRI
- Sertraline, fluoxetine, citalopram etc
What is first line antidepressant medication in children or young people?
Fluoxetine
Name 3 common side effects of SSRI’s?
GI upset + nausea (often resolve in 2 weeks) Dry mouth Drowsiness Decreased sex drive Agitation
Name 3 symptoms of SSRI withdrawal syndrome?
Mood changes Restlessness Sleeping problems GI (pain, cramping, D+V) Parasthesia, sweating, unsteadiness
Give 3 example questions you could use to risk assess someone with depression?
- Often when people feel down they can feel like life is no longer worth living, have you ever felt like this?
- Have you ever had any thoughts of taking your life?
- – If so, have you made any plans?
- Have you ever thought about or tried to hurt yourself in anyway?
- Are you managing to eat and drink as normal?
- Has your alcohol intake changed at all?
What is the average length of a depressive episode?
6-8 months
How long do SSRI’s take for the patient to start feeling the benefit?
Up to 4 weeks
In an OSCE situation how would you assess capacity?
Informal conversation to check can the cover the 4 main domains
(understand decision, weight it up, retain it and communicate it back)
- Always say you’d get a second opinion from a doctor who specialises in Care of the Elderly.
It’s Friday afternoon and you have a safeguarding concern about a patient on a home visit, name five steps you’d take?
SMACK S- Safety of patient M- Medical problems A- Ask a senior C- Contact social care (i.e. rapid access team) K- Keep clear notes
If you have a safeguarding concern about a px and a relative is being obstructive, what do you do?
Explore reasons for being obstructive
Raise safeguarding concern
Name two risk factors for GAD?
Divorced/ separate
Living alone or as lone parent
What is the ICD-10 definition of GAD?
Excessive anxiety and worry occurring more days than not for at least 6 months, about a wide range of activities or events
What symptoms must be present to meet the diagnostic criteria for GAD?
Three or more of:
- Restlessness/ on edge/ easy fatigued/ difficulty concentrating
- Irritability, muscle tension, sleep disturbance
+ 4 physical manifestations
(SOB, fast HR, palpitations, sweating, trembling, dry mouth, nausea etc)
How do you distinguish between GAD and ‘panic disorder’?
Panic disorder has obvious triggers
What investigations should be performed in suspected GAD?
PHQ-9 for depression
Bloods (FBC to r/o anaemia, TFT’s to rule out hypothyroid, cortisol, B12 and folate)
What are the first three lines of management of GAD?
1) Identify + educate (avoid caffeine, alcohol, drugs, stimulants). Practice breathing exercises and do physical exercise
2) Low intensity pyschological support (guided self help or groups)
3) Offer CBT, if doesn’t work can offer SSRI (sertraline)
When starting sertraline for anxiety, name three factors the patient should be counselled on?
- Inform patient about transient increase in anxiety on starting meds
- Council on delayed onset of effect (4weeks or so), and likely to stay on for a year or so, don’t stop the drug abruptly
- Review every 2-4 weeks for first three months then three-monthly thereafter
- Side effects
(GI for first 2 weeks, then dry mouth, drowsiness, low sex drive)