Psychiatry - Management + Pharmacology Flashcards

Question

List examples of psychological treatment in BPAD

Answer 1

• CBT o Identify relapse indicators o relapse prevention strategies o help patients to test out their excessively positive thoughts to gain a sense of perspective • Psychodynamic psychotherapy o Useful if mood stabilised

Answer 2

* Family support and therapy * Aiding return to education or work * Interpersonal and social rhythm therapy (IPSRT) – incorporates aspects of IPT for depression with attention to circadian rhythms

Answer 3

• Primary care referral o Symptoms of hypomania – routine referral to CMHT o Symptoms of mania or severe depression – urgent referral to CMHT

Answer 4

Step 1: All known and suspected presentations of depression ``` Assessment Support Psychoeducation Active monitoring Referral for further assessment and interventions ```

Answer 5

Step 2: Persistent subthreshold depressive symptoms, mild to moderate depression Low-intensity psychosocial interventions Psychological interventions Medication Referral for further assessment and interventions

Answer 6

Step 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate to severe depression High-intensity psychological interventions Medication Combined treatments Collaborative care* Referral for further assessment and interventions • Collaborative care = only for depression where the person has a chronic physical heath problem and associated functional impairment

Answer 7

Step 4: Severe and complex depression; risk to life; severe self-neglect ``` High-intensity psychological interventions Medication Combined treatments ECT Crisis service Multiprofessional and inpatient care ```

Answer 8

o Active monitoring, asses again normally within 2 weeks o Sleep hygiene o Low intensity psychosocial intervention Individual-guided self-help based on principles of CBT Computerised CBT Structured group physical activity programme Relaxation therapy o Group CBT - if low-intensity psychological intervention is declined o Do not use anti-depressants routinely to treat persistent subthreshold depressive symptoms or mild depression but consider them for people with:  A past hx of moderate or severe depression  Initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least 2 years)  Subthreshold depressive symptoms or mild depression that persists after other interventions

Answer 9

a) combination of anti-depressant medication and a high-intensity psychosocial intervention (CBT or IPT) b) Antidepressant medication (normally SSRI) or High intensity psychological treatment (CBT, IPT, behavioural activation, behavioural couples therapy) ``` Antidepressants - 1st line --> SSRI High intensity psychosocial intervention Individual CBT (16-20 sessions over 3-4 months) Interpersonal therapy (16-20 sessions over 3-4 months) ``` o ECT – fast + short-term improvement of severe symptoms after all other treatment options have failed or when the situation is life-threatening

Answer 10

o Crisis resolution + home treatment teams to manage crises o Develop a crisis plan that identified potential triggers and strategies to manage triggers – share with GP and any other people involved in the patient’s care o Consider inpatient treatment if significant risk of suicide, self-harm or self-neglect o Consider ECT for acute treatment of severe depression + when rapid response is required

Answer 11

``` o Add an antipsychotic o Antipsychotics (aripiprazole, olanzapine, quetiapine, risperidone) ```  Augmentation of an antidepressant with buspirone, carbamazepine, lamotrigine, valproate should not be used routinely - insufficient evidence for their use

Answer 12

``` o Review medication concordance + diagnosis – Check medication adherence, side effects, carefully titrate to an effective dose o Consider a higher dose, different medication (initially switch often to alternative SSRI), different class of antidepressants (e.g. Mirtazapine, Venlafaixine, TCAs, MAOIs) ``` o Augmentation strategies (adding something to the antidepressant)  Lithium  Second-generation antipsychotics (SGAs) – lower doses than for psychosis  Combining 2 anti-depressants e.g. Mirtazapine + SSRI (greater risk of hyponatraemia, serotonin syndrome etc)  ECT  Buspirone – anxiolytic drug that acts on 5HT1a (no antidepressant action alone but may have a synergistic effect when combined with SSRIs)

Answer 13

o Sertaraline preferred (lower risk of drug interactions) | o Can rarely cause hypoglycaemia

Answer 14

Stopping anti-depressants should be done over a period of 4 weeks to prevent discontinuation symptoms ``` Discontinuation syndrome:  GI sx  Flu like sx  Sweating  Restlessness  Problems sleeping  Vivid dreams  Unsteadiness  Tinnitus  Altered sensations (electric shock sensations in the head)  Altered feelings (irritability, anxiety, confusion) ```

Answer 15

• Antidepressants can be combined/augmented with o Lithium (mood stabilizer) o Antipsychotics (aripiprazole, olanzapine, quetiapine, risperidone) o Antidepressants (mirtazapine, mianserin) o Benzodiazepines  Augmentation of an antidepressant with buspirone, carbamazepine, lamotrigine, valproate should not be used routinely  insufficient evidence for their use  Augmentation of an antidepressant with a benzodiazepine for more than 2 weeks should not be used routinely  risk of dependence))

Answer 16

```  GI sx  Flu like sx  Sweating  Restlessness  Problems sleeping  Vivid dreams  Unsteadiness  Altered sensations (electric shock sensations in the head)  Altered feelings (irritability, anxiety, confusion) ```

Answer 17

``` o Potentially fatal o Restlessness o Sweating o Myoclonus o Confusion o Fits ```

Answer 18

Seasonal Affective/Depressive disorder (SAD) that occurs in autumn/winter Typical symptoms of SAD: Hypersomnia and hyperphagia

Answer 19

Biological - anti-depressants, ECT, rTMS, light therapy, exercise Psychological - psychosocial interventions e.g. CBT, psychodynamic psychotherapy, ITP, MBCT Social interventions - sleep hygiene, exercise, healthy diet, psychoeducation, support groups, social network support

Answer 20

``` Citalopram Escitalopram Fluoxetine Fluvoxamine Paroxetine Sertraline ``` Fluoxetine, fluvoxamine, paroxetine - associated with a higher propensity for drug interactions than other SSRIs Paroxetine - associated with a higher propensity for drug interactions than other SSRIs (very short half life, 24h)

Answer 21

Venlafaxine | Duloxetine

Answer 22

``` Amitriptyline Clomipramine Imipramine Lofepramine Nortriptyline ```

Answer 23

Phenelzine Tranylcypromine Moclobemide

Answer 24

Moclobemide

Answer 25

Mirtazapine

Answer 26

Agomelatine

Answer 27

Paroxetine is an SSRI Has a very short half-life (24h) therefore delaying a tablet can cause discontinuation symptoms

Answer 28

Avoid venlafaxine if risk of arrhythmia Slowly withdraw venlafaxine - discontinuation symptoms are common due to its short half-life

Answer 29

Infrequently used due to cardiotoxicity - even small overdoses can be fatal QT prolongation (torsades de points, VT, normal QT: 0.44ms-0.47ms, if QT>0.50ms - dangerous), ST elevation, AV block except lofepramine

Answer 30

Can precipitate a hypertensive crisis "the cheese reaction" Therefore rarely used as tyramine rich foods can cause NA build-up and hypertensive crisis ``` Hypertensive crisis:  Tachycardia  Flushing  Severe throbbing headache  Pallor  Stroke  Death ```

Answer 31

Severe headache Moclobemide is a RIMA (reversible inhibitor of monoamine oxidase A) Hypertensive crisis still possible therefore avoid tyramine-rich foods and report severe headache immediately

Answer 32

Attend hospital if priapism Trazodone is a SARI (serotonin antagonist and reuptake inhibitor)

Answer 33

Monitor LFTs early in treatment Can stop abruptly without discontinuation symptoms

Answer 34

``` N+V Dyspepsia, diarrhoea, constipation (effect bc of serotonin receptors in the gut) Anxiety/Agitation Insomnia Vivid dreams advise to take it in the morning Tremor Headache Sweating Sexual dysfunction in about 70% of patients Hyponatraemia Suicidality Discontinuation syndrome ``` GI bleeding Especially in older people or in people taking other drugs that have the potential to damage the GI mucosa or interfere with clotting consider prescribing a gastroprotective drug in older people who are taking NSAIDs or aspirin

Answer 35

``` Same as SSRIs N+V Dyspepsia, diarrhoea Anxiety/Agitation Insomnia Vivid dreams Tremor Headache Sweating Sexual dysfunction ``` GI bleeding Hyponatraemia Suicidality Discontinuation syndrome PLUS ``` Constipation HTN Raised cholesterol Dry mouth Dizziness Drowsiness ```

Answer 36

Anticholinergic side effects ``` Dry mouth Blurred vision Constipation Urinary retention Arrhythmia Postural hypotension Sedation Sexual dysfunction ``` Weight gain ``` Cardiotoxicity QT prolongation (torsades de points, VT, normal QT: 0.44ms-0.47ms, if QT>0.50ms - dangerous), ST elevation, AV block ``` lethal in overdose - cardiac monitor the patient potential for postural hypotension and arrhythmias except lofepramine ``` Rare side effects include: Urinary retention Convulsions Cardiac dysrhythmias Weight gain Precipitation of glaucoma Hyponatremia Hepatic impairment ```

Answer 37

``` Hypertensive crisis - cheese reaction:  Tachycardia  Flushing  Severe throbbing headache  Pallor  Stroke  Death ``` ``` Nausea Drowsiness Postural hypotension Insomnia Sexual dysfunction ```

Answer 38

``` Nausea Agitation/anxiety Sleep disturbance Throbbing headache Sexual dysfunction ``` ``` *Hypertensive crisis (cheese reaction) still possible - avoid tyramine-rich foods, report severe headache immediately:  Tachycardia  Flushing  Severe throbbing headache  Pallor  Stroke  Death ```

Answer 39

``` Sedation Increased Appetite/weight gain Oedema Dry mouth Headache Dizziness ``` Sexual side effects relatively uncommon

Answer 40

``` Sedation Dizziness, postural hypotension Headache Tachycardia Nausea/Vomiting Tremor ``` Priapism Sexual dysfunction *Attend hospital if priapism Good sedative effect and used in older adults

Answer 41

``` Nausea Dizziness Headache/migraine Insomnia Drowsiness ``` Hepatotoxicity

Answer 42

Vortioxetine Good SE profile GI SE dizziness skin reactions

Answer 43

Bupropion Licensed for smoking cessation in the UK

Answer 44

• For people started on antidepressants who are not considered to be at increased risk of suicide o See them after 2 weeks o Regularly thereafter e.g. at intervals of 2-4 weeks in the first 3 months o At longer intervals if response is good • Person with depression started on antidepressants who is considered to present an increased risk of suicide and <30  seen after 1 week and frequently thereafter

Answer 45

• Careful when switching o From fluoxetine/paroxetine to TCA  Both of these drugs inhibit the metabolism of TCAs  Lower starting dose of TCA required, particularly if switching from fluoxetine because of its long half-life o From fluoxetine to other anti-depressants  Fluoxetine has a long half-life o From a non-reversible MAOI – 2 week washout period required, do not prescribe other antidepressants o To a new serotoninergic antidepressant or MAOI – risk of serotonin syndrome

Answer 46

Once well, recommended at the same dose for 6-12 months and for 2 years for those at greatest risk of relapse e.g. multiple recent episodes or significant hx

Answer 47

Fluoxetine SSRis

Answer 48

Irreversable - phenelzine, tranylcypromine, isocarboxazid reversible - moclobemide

Answer 49

``` a)SSRI o Bleeding (esp in elderly, gastric ulcers, hyponatraemia) – NSAIDs should be given with PPI ``` b) Drug interaction – fluoxetine, fluvoxamine, paroxetine c) Discontinuation symptoms – paroxetine d) Death from overdose – venlafaxine, TCAs except lofepramine e) Stopping treatment due to side-effects – venlafaxine, duloxetine, TCAs f) BP monitoring needed – venlafaxine g) Worsening hypertension – venlafaxine, duloxetine h) Postural hypotension and arrhythmia – TCAs

Answer 50

o Severe cases managed in hospital o Stop offending meds o Supportive measures (ABCDE) – airway management, renal care, IVF, temp control (paracetamol) o ?Cyproheptadine – antihistamine + serotonin antagonist

Answer 51

A first episode of depression should be treated for a minimum of 6 months after remission per NICE. There are suggestions that older patients may benefit from a minimum of 1 year’s treatment. A 2nd episode of depression should be treated for at least 2 years following remission.

Answer 52

Response to antidepressant treatments is usually seen within 2-4 weeks. At least 4 weeks at an effective dose is needed before deciding that the patient has failed to respond.

Answer 53

• Contraindications to the presribing of amitryptyline o Known allergy o Immediately post MI o Cardiac arrhythmias o Complete heart block o (acute porphyria is not a contraindication but note that amitriptyline is metabolised in the liver and can therefore precipitate an acute crisis in those with porphyria)

Answer 54

* Alcohol increases the sedative effect of amitriptyline * MOAIs exacerbate all the actions of amitriptyline * Amitriptyline lowers the convulsant threshold in epileptics * Amitriptyline increases the risks of hypotension and ventricular arrhythmias during GA * Amitriptyline increases the risk of ventricular arrhythmias when combined with a beta blocker * Amitriptyline has an unpredictable effect on the INR in patients taking concurrent warfarin * TCAs + SSRIs should never be combined with MAOIs  high risk of serotonin syndrome

Answer 55

Long term side effects of lithium therapy • Hypothyroidism • Irreversible nephrogenic Diabetes Insipidus • Other SE: Hyperglycaemia, ?hyperthyroidism, hyperparathyroidism

Answer 56

``` • Sodium valproate at therapeutic level o Diarrhoea o N+V o Ataxia o Tremor o Hair loss with curly re-growth o Weight gain ``` ``` • Sodium valproate at overdose o Hypotonia o Hyporeflexia o CNS depression/coma o Constriction of pupils o Impaired respiratory function o Metabolic acidosis ```

Answer 57

Extrapyramidal symptoms e.g. tremor

Answer 58

Carbamazepine | Clozapine

Answer 59

o The service aims to engage patients with very early symptoms, from adulthood till 35 years o Psychosis is toxic  the longer the patient is psychotic, the more it will affect their cognitive abilities, insight and social situation => the sooner effective treatment can be started, the better the prognosis o DUP – the time from the first clear-cut psychotic symptom until the start of effective treatment o Patients offered antipsychotics + psychosocial interventions - early intervention in psychosis aims to keep the duration of untreated psychosis (DUP) under 3 months o Service can be used in children >14 y/o  CAMHS can deal with psychosis in children up to 17 y/o o If urgent intervention is necessary  crisis resolution team, home treatment team

Answer 60

• Atypical (2nd generation antipsychotics) o Olanzapine, risperidone, quetiapine, aripiprazole, clozapine, amisulpride • Poor response - switch to another atypical antipsychotic o Psychological interventions (e.g. family intervention, individual CBT) o CBT should be offered to all patients

Answer 61

• Clozapine o Atypical antipsychotic o SE: weight gain, hypersalivation, agranulocytosis (fatal 0.03%), regular WBC monitoring o Small but significant risk of agranulocytosis o Weekly blood tests to detect early signs of neutropenia o Requirement to register with a monitoring service  CPMS (clozapine monitoring system) – national service in the UK that gives advise on the drug dosage to use, depending on the blood test results you send to them. Compulsory for anyone on clozapine. Only consultant psychiatrists can prescribe clozapine • If lack of response to clozapine  augmentation with another antipsychotic

Answer 62

• Treatment resistance = failure to respond to 2 or more antipsychotics, at least one of which is atypical, each given at a therapeutic dose for at least 6 weeks

Answer 63

• CBT – 16 or more one-to-one sessions over 6 months o Should be offered to all schizophrenic patients o Offered to anyone experiencing psychosis or at an increased risk of developing psychosis (i.e. ARMS) o CBT has been shown to help positive symptoms  Emphasis placed on reality testing  “here and now” focus on normalization of the psychotic experience (stigma)  Coping skills for managing voices  Exploring evidence for unusual or distressing beliefs  Explore the role that the interpretation + behaviour may have in managing negative emotions  Also helps improve self-esteem and problem-solving, helps people live their lives productively even if still experiencing some hallucinations and delusions • Family therapy – at least 10 sessions over 6-12 months o Educates the family to recognise the early signs of an attack + to be more supportive, + to remove any precipitating factors from the patients direct environment e.g. criticism o Patient encouraged to talk to their family about what is helpful and unhelpful o Aims to improve relationships by encouraging people to listen to each other + negotiate potential solutions o Can reduce the effects of high EE through communication skills training, education about psychosis and problem-solving techniques o Improves understanding + empathy on both sides  can help reduce conflict o Can reduce relapse rates • Arts therapy – alleviation of negative symptoms o Can help people discover new forms of expression and communication with others o Provided as group therapies o Can be effective during an acute episode or for negative symptoms in chronic illness • Concordance therapy – collaborative approach where the patient is encouraged to consider the pros and cons of the management

Answer 64

* Care-coordination – monitoring mental and physical health, medication, drug use, identifying and solving social problems * Assertive outreach – maintaining contract with patients who may not want contact with services * Early intervention in Psychosis * Structured weekly activities to reduce negative symptoms * May include admission to hospital for observation, treatment or refuge • Psychoeducation - vital to reduce relapse o Collaborative approach where people are encouraged to ask + find out more about their illness o Important part of the therapeutic alliance  encouraging people to consider the pros + cons of their treatment, improving insight into their needs • Social skills training – primarily aimed at improving interpersonal skills. Using methods such as role-play people develop improved confidence and skills in their day-to-day functioning • Rehabilitation psychiatry – focuses on quality of life, over-coming disability where possible and accepting limitations where not. It’s a long-term approach, addressing varied needs incl: (social workers, benefits advisors, occupational therapists) o Education, training, employment – vocational workers o Skills (e.g. budgeting, cooking) o Housing (e.g. supported accommodation, independent flats) o Accessing social activities o Developing personal skills and pursuing interests (e.g. creative writing) • Mental health organizations (e.g. Rethink, Mind) o Provide patient resources o Carry out important work in promoting social inclusion + helping tackle stigma at a personal + societal level * Recovery – the process of getting well + finding a way to live with psychosis that allows a person to have a fulfilling and meaningful life * Carer support – all carers should have their needs assessed. Formal support from social services or may benefit from carer’s groups

Answer 65

• General advice – continue medication for up to 3 years after the first episode of psychosis

Answer 66

o Response to treatment + SE o Adherence o Emergence of movement disorders o Waist circumference o BMI o Overall physical health o FBC, LFT, U&Es, lipid profile, CBG (followed by a glucose tolerance test and HbA1c if abnormal) ``` o Weight  Weekly for 6 weeks  At 12 weeks  At 1 year  Annually thereafter ``` o Pulse + BP  At 12 weeks  1 year  Annually thereafter o some people need monitoring of  prolactin levels – if hyperprolactinaemia is suspected or likely (e.g. risperidone)  ECGs – important in older people + those on high-dose antipsychotics or clozapine – to monitor the QTc interval;

Answer 67

o Healthy eating + physical activity programme o Interventions for metabolic complications of antipsychotics o Smoking cessation (nicotine replacement therapy or bupropion or varenicline)  Bupropion + valenicline - inreased risk of adverse neuropsychiatric symptoms - should be monitored closely for the first 2-3 weeks o Regularly monitor weight + other CV/metabolic parameters o Consider peer support (support from someone who has recovered from psychosis) Aripiprazole can help

Answer 68

``` Chlorpromazine Haloperidol Zuclopenthixol Flupenthixol Trifluoperazine Fluphenazine ```

Answer 69

``` Clozapine Olanzapine Quetiapine Risperidone Amisulpride Asenapine Lurasidone Ziprasidone Aripiprazole ```

Answer 70

``` Extrapyramidal side effects Parkinsonism Dystonias Dyskinesias Akathisia ``` • Parkinsonism o Tremor o Rigidity o Bradykinesia o Postural instability, mask-like expression, gait abnormalities Mx: o Anticholinergic medication – procyclidine PO/IM  Do not give too late in the evening so that pt can sleep  Can make pt feel high o Consider reducing antipsychotic dose o Consider changing to an atypical antipsychotic • Dystonias o Sustained or repetitive muscle contractions resulting in twisting and repetitive movements and posture o Can present as oculogyric crisis and torticollis (painful muscular contraction affecting the SCM muscle in the neck) o Occurs shortly after administration of antipsychotic  Occurs due to DA blockade causing an imbalance between dopaminergic and cholinergic transmission) o Typically in young/antipsychotic naïve (in SBAs, after depot/rapid tranquilisation etc) o Can be life threatening e.g. laryngeal dystonia Mx o Anticholinergic medication – procyclidine IM o Consider reducing antipsychotic dose o Consider changing to an atypical antipsychotic • Dyskinesias o Tardive dyskinesias = repetitive and stereotypical jerking movements of the face and mouth o Lip smacking, tongue protrusion, eye blinking o Idiosyncratic reaction o Choreo-athetoid movements o Can be irreversible o Made worse by anti-cholinergics Mx: o Carefully reduce dose of antipsychotic o Consider changing to an atypical antipsychotic Tetrabenazine • Akathisia o Subjective feeling of restlessness (mental and/or physical) e.g. constantly crossing and uncrossing legs, pacing up and down, rocking from foot to foot Mx: o Short-term benzodiazepines o Consider reducing antipsychotic dose o Consider changing to an atypical antipsychotic Propranolol Hyperprolactinaemia

Answer 71

Weight gain dyslipidaemia glucose metabolism • Metabolic syndrome o Especially with atypical antipsychotics o Olanzapine causes central obesity o Schizophrenia is already an independent CV RF o Metabolic side effects: HTN, central obesity, raised fasting plasma glucose, hyperTGaemia, low HDL ``` o NICE recommends regular monitoring of  BMI  Waist circumference  BP  Bloods (FBC, U+Es, LFTs (check for fatty liver), HbA1c, lipids) ``` Management: o Refer to dietician + to exercise programs o Counsel on smoking cessation – smoking cessation nurse o Aripiprazole is an anti-psychotic than can potentially help with the metabolic syndrome + diabetic profile

Answer 72

On the mesolimbic pathway Mesolimbic pathway – hyperactivity (D2 receptors) causes the positive symptoms/psychosis in schizophrenia

Answer 73

• QTc prolongation o <0.44s men, <0.47s women o Risk with all antipsychotics o NICE recommends an ECG prior to commencing antipsychotic medication + regular monitoring o Can develop torsades de pointes, VT, cardiac arrest • Sedation • Typical antipsychotics - EPSEs (e.g. Parkinsonism, dystonia, akathisia, tardive dyskinesia) o Extrapyramidal side-effects (EPSEs) can occur at higher concentrations of ALL antipsychotics, less common with atypical ones * Atypical antipsychotics - Weight gain (esp. olanzapine + clozapine), increased risk of DM (olanzapine) * Hyperprolactinaemia (galactorrhoea, amenorrhoea, gynaecomastia, hypogonadism, sexual dysfunction, infertility increased risk of osteoporosis) * Anticholinergic SE (dry mouth, blurred vision, constipation, urinary retention, tachycardia) * Arrythmias * Seizures (decrease seizure threshold) * Neuroleptic malignant syndrome

Answer 74

o Agranulocytosis – rare + potentially fatal idiosyncratic reaction - regular FBC testing o Weekly blood tests to detect early signs of neutropenia o Requirement to register with a monitoring service  CPMS (clozapine monitoring system) – national service in the UK that gives advice on the drug dosage to use, depending on the blood test results you send to them. Compulsory for anyone on clozapine. Only consultant psychiatrists can prescribe clozapine o Excessive sedation o Hypersalivation – hyoscine patch o Postural hypotension (dizziness) o Weigh gain + metabolic syndrome o Anti-cholinergic effects – particularly constipation [when you start clozapine, start a prophylactic laxative as well] o Cardiomyopathy and fatal myocarditis  [patients usually develop tachycardia after given clozapine – do ECT, Bloods to see CK and troponins to rule out myocarditis] o Seizures – reduces seizure threshold

Answer 75

* ABCDE * A+E * Stop all antipsychotics • Supportive: o IVF o Antipyretics/cooling devices o Dialysis • Potential treatments: o Muscle relaxant (Dantrolene) o DA replacement (e.g. Amantadine, bromocriptine) o ECT

Answer 76

Haloperidol

Answer 77

* Can be caused by all anti-depressants, particularly in SSRI use * Usually within 30 days * Dizziness, drowsiness. Confusion, nausea, muscle cramps, seizures * Stop anti-depressant + manage symptoms

Answer 78

o Usually, most people see an effect after 2 weeks o If the person’s depression shows no improvement after 2-4 weeks, check that the medication is being taken regularly and at prescribed dose, and ask about side effects (compliance screening) o If absent/minimal response after 3-4 weeks with therapeutic dose:  Increase support (weekly face to face or telephone contact)  Increase dose if no significant side effects  Consider switching to another antidepressant (SSRI if not on this already, or TCA if on SSRI) if the current drug is causing side effects or if the person would prefer a different drug o If there is some improvement by 4 weeks, continue for 2-4 weeks and consider switching if:  Response still not adequate  Still side effects  Person prefers to change

Answer 79

1st line – Mild functional impairment • Low-intensity psychological therapies o Brief individual CBT (incl. exposure and response prevention, RP) using structured self-help materials o Brief individual CBT (incl. ERP) by telephone o Group CBT (incl. ERP) o Should be done for up to 10 therapist hours per patient

Answer 80

2nd line – moderate functional impairment OR mild functional impairment but low intensity psychological therapies not effective/inadequate OR BDD with moderate functional impairment • SSRI OR more intensive CBT (including ERP, more than 10 therapist hours per patient) o SSRI possible agents: fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram  This is an off-label use of citalopram o Continue SSRI treatment for at least 12 months after remission of symptoms

Answer 81

3rd line – severe functional impairment or if inadequate response with an SSRI alone (within 12 weeks) or CBT (incl. ERP) alone (>10 therapist hours per patient) • Combined treatment with an SSRI + CBT (incl. ERP)

Answer 82

4th line (after 12 weeks) – if inadequate response after 12 weeks of combined treatment with an SSRI + CBT (incl. ERP) OR no response to SSRI alone OR patient has not engaged in CBT • Different SSRI or Clomipramine o Clomipramine considered only if: a) at least one SSRI has been ineffective or poorly tolerated or b) the patient prefers clomipramine or has had a previous good response to it

Answer 83

• Psychoeducation o Explain the dx o Reassure that the physical symptoms are not a sign of any underlying physical problem * Avoid exacerbating lifestyle factors (caffeine, nicotine) * Advise regular exercise (150 mins of moderate intensity exercise per week) ``` • Stress reduction techniques o Breathing techniques o Yoga o Mindfulness o Get enough sleep o Learn to mediate o Listen to music o Make time for things that you enjoy o Consider getting a pet ``` * Sleep hygiene * Encourage close interpersonal relationships with trusted family and friends • Carer education o Friends and family are often recruited in SSB or may facilitate escape avoidance, believing they are protecting the anxious person from harm and distress (go opposite to the principles in exposure therapy)

Answer 84

1st line – low-intensity CBT incl. ERP [mild functional impairment start from here] 2nd line – SSRI or more intensive CBT [moderate functional impairment start from here] 3rd line – SSRI + intensive CBT incl. ERP [severe functional impairment start from here] 4th line – different SSRI or Clomipramine (very rare but just have it in mind – psychosurgery – anterior cingulotomy)

Answer 85

* 1st line: SSRI * 2nd line: Clomipramine (TCA) * Those on medications need to understand that there is a lag time between medication initiation + response (6-8 weeks but can be up to 3 months) * The focus of treatment should be for improvement in symptoms, and not complete remission * Important to set up a patient’s expectations of how much improvement they will have on medications – patients can expect a maximum of 30-35% reduction * An “adequate trial” for one medication is between 12-15 weeks, with at least 6 weeks at the maximum dose * Symptoms should always be monitored via a scale like Y-BOCS

Answer 86

• CBT incl. ERP • ERP – Exposure and Response Prevention o Compulsions are analogous to escape in phobias o In ERP patients are exposed to situations that trigger obsessions + are thought strategies to prevent the compulsive response that would temporarily relieve their anxiety o Patients gradually become desensitized to the fear stimulus - improved OCD symptoms o Exposure = exposing the patient to the thoughts, images, objects, situations that make them anxious and/or trigger obsessions o Response Prevention = teaching the patient to not perform those compulsive behaviors once those anxiety or obsessions have been triggered; instead, they are taught to perform an opposite action. o A hierarchy of feared situations is used o Effective in well-motivated patients • Those doing therapy need to understand there is an extensive time commitment involved as well • Relapse is more likely with discontinuation of SSRI therapy compared to CBT/ERP o Patients must also be treated longer (at least 3 months) with doses near the maximum recommended doses (resulting in increased rates of adverse effects)

Answer 87

* Exercise - emerging evidence that exercise is a feasible + clinically impactful treatment for OCD * Psychoeducation through self-help literature and online resources * Carer education – friends + family are often recruited in SSB and may facilitate escape and avoidance, believing they are protecting the anxious person from harm or distress

Answer 88

• Support, reassurance, problem solving Psychological • CBT, ITP * Supportive therapy * Family/Group therapy – may reinforce positive coping strategies * Individual therapy – must be time limited to prevent dependence * Crisis counselling – is of doubtful benefit except in those with no other supports * Psychodynamic psychotherapy • Mindfulness based therapy o Problem solving: analyse stressors, determine if they can be eliminated/minimised o To clarify and interpret the meaning the patient gives to the stressor o To reframe the meaning of the stressor o To illuminate the concerns and conflicts the patient experiences o To identify a means of reducing the stressor o To maximize the patient’s coping skills (emotional self-regulation, avoidance of maladaptive coping, especially substance misuse) o To help patients gain perspective on the stressor, establish relationships, mobilize support, and manage themselves and the stressor

Answer 89

• TCA +/- ITP

Answer 90

* Debriefing is not recommended * Watchful waiting may be used for mild symptoms lasting <1m * Trauma focused CBT or EMDR may be used in more severe cases * Drug treatment not routinely recommended (meded says paroxetine and mirtazapine are recommended if drug treatment is used)

Answer 91

1st line – Mild functional impairment • Low-intensity psychological therapies o Brief individual CBT (incl. exposure and response prevention, RP) using structured self-help materials o Brief individual CBT (incl. ERP) by telephone o Group CBT (incl. ERP) o Should be done for up to 10 therapist hours per patient

Answer 92

2nd line – moderate functional impairment OR mild functional impairment but low intensity psychological therapies not effective/inadequate OR BDD with moderate functional impairment • SSRI or more intensive CBT (including ERP, more than 10 therapist hours per patient) o SSRI possible agents: fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram  This is an off-label use of citalopram o Continue SSRI treatment for at least 12 months after remission of symptoms

Answer 93

3rd line – if inadequate response with an SSRI alone (within 12 weeks) or CBT (incl. ERP) alone (>10 therapist hours per patient) • Combined treatment with an SSRI + CBT (incl. ERP)

Answer 94

4th line (after 12 weeks) – if inadequate response after 12 weeks of combined treatment with an SSRI + CBT (incl. ERP) OR no response to SSRI alone OR patient has not engaged in CBT • Different SSRI or Clomipramine o Clomipramine considered only if: a) at least one SSRI has been ineffective or poorly tolerated or b) the patient prefers clomipramine or has had a previous good response to it

Answer 95

• Combined treatment with an SSRI + CBT (incl. ERP)

Answer 96

1st line – low-intensity CBT incl. ERP [mild functional impairment start from here] [up to 10 h per patient] 2nd line – SSRI or more intensive CBT [moderate functional impairment start from here] 3rd line – SSRI + intensive CBT incl. ERP [severe functional impairment start from here] >=[>10h per patient] 4th line – different SSRI or Clomipramine (very rare but just have it in mind – psychosurgery – anterior cingulotomy)

Answer 97

* 1st line: SSRI * 2nd line: Clomipramine (TCA) * Those on medications need to understand that there is a lag time between medication initiation + response (6-8 weeks but can be up to 3 months) * The focus of treatment should be for improvement in symptoms, and not complete remission * Important to set up a patient’s expectations of how much improvement they will have on medications – patients can expect a maximum of 30-35% reduction * An “adequate trial” for one medication is between 12-15 weeks, with at least 6 weeks at the maximum dose * Symptoms should always be monitored via a scale like Y-BOCS

Answer 98

• CBT incl. ERP • ERP – Exposure and Response Prevention o Compulsions are analogous to escape in phobias o In ERP patients are exposed to situations that trigger obsessions + are thought strategies to prevent the compulsive response that would temporarily relieve their anxiety o Patients gradually become desensitized to the fear stimulus  improved OCD symptoms o Exposure = exposing the patient to the thoughts, images, objects, situations that make them anxious and/or trigger obsessions o Response Prevention = teaching the patient to not perform those compulsive behaviors once those anxiety or obsessions have been triggered; instead, they are taught to perform an opposite action. o A hierarchy of feared situations is used o Effective in well-motivated patients • Those doing therapy need to understand there is an extensive time commitment involved as well • Relapse is more likely with discontinuation of SSRI therapy compared to CBT/ERP o Patients must also be treated longer (at least 3 months) with doses near the maximum recommended doses (resulting in increased rates of adverse effects)

Answer 99

• Exercise  emerging evidence that exercise is a feasible + clinically impactful treatment for OCD o Increased levels of BDNF, improved cerebral flow, increased volume to the hippocampus, enhanced cognitive + neuropsychological functioning, improved resilience + overall well-being • Psychoeducation through self-help literature and online resources • Carer education – friends + family are often recruited in SSB and may facilitate escape and avoidance, believing they are protecting the anxious person from harm or distress

Answer 100

• Support, reassurance, problem solving Psychological • CBT, ITP • Supportive therapy • Family/Group therapy – may reinforce positive coping strategies • Individual therapy – must be time limited to prevent dependence • Crisis counselling – is of doubtful benefit except in those with no other supports • Psychodynamic psychotherapy • Mindfulness based therapy o Problem solving: analyse stressors, determine if they can be eliminated/minimised o To clarify and interpret the meaning the patient gives to the stressor o To reframe the meaning of the stressor o To illuminate the concerns and conflicts the patient experiences o To identify a means of reducing the stressor o To maximize the patient’s coping skills (emotional self-regulation, avoidance of maladaptive coping, especially substance misuse) o To help patients gain perspective on the stressor, establish relationships, mobilize support, and manage themselves and the stressor Pharmacotherapy • Short courses of medication for brief symptom relief e.g. insomnia, anxiety, dysphoria o BZD, SSRI/SNRI (only if symptoms last more than a few weeks) o Sedating antihistamine

Answer 101

• TCA +/- ITP

Answer 102

• Short courses of medication for brief symptom relief e.g. insomnia, anxiety, dysphoria o BZD, SSRI/SNRI (only if symptoms last more than a few weeks) o Sedating antihistamine

Answer 103

• Exclude injury • Support and reassurance • Trauma focused CBT o Highly trained therapist exploring the thoughts around he traumatic event and linking them to behaviours or symptoms which are developing because of them o It aims to give control over thoughts ad behaviours back to the individual • Benzodiazepines may alleviate short-term distress but do not prevent later PTSD

Answer 104

Step 1 – recognition and diagnosis Step 2 – treatment in primary care (self-help) Step 3 – review and consideration of alternative treatments Step 4 – review and referral to specialist MHS Step 5 – care in specialist MHS

Answer 105

* Self-help * CBT + SSRI * If no response after 12 weeks – TCA (imipramine or clomipramine)

Answer 106

• Low-intensity interventions o Individual non-facilitated self-help (6 weeks) o Individual facilitated self help (6 weeks, weekly therapist appointment)

Answer 107

* High intensity psychological intervention +/- medication * CBT or • Anti-depressant o If the disorder is long-standing o If the person has not benefitted/has declined psychological intervention

Answer 108

• Psychoeducation o Carers and families o About nature of their condition + treatment options available o Information on the use and likely side-effect profile of medication • Support and self-help groups o Offer information about them, where they are available etc. o To address the emotional, social and economic costs o Can also promote understanding and collaboration between people who have panic disorders o Support groups may provide face-to-face meetings, telephone conference support groups (which can be based on CBT principles) or additional information on all aspects of anxiety disorders plus other sources of help) • Self-help monitoring o Individuals receiving self-help interventions should be offered contact with primary health care professionals so that progress can be monitored and alternative interventions can be considered if appropriate o Between every 4 to 8 weeks • Exercise

Answer 109

• Antidepressants o Should be the only pharmacological intervention used in the longer-term management of panic disorder • SSRIs – escitalopram, sertraline, citalopram, paroxetine (1st line) • SNRIs – venlafaxine (1st line) o If no improvement after 12 weeks  TCAs • TCA – imipramine, clomipramine (2nd line) o TCA – if there is no improvement after a 12 week course and if further medication is appropriate o Highest risk of deliberate self-harm by overdose or otherwise out of the 3 • Monitoring and follow up o Review efficacy + side effects  Within 2 weeks of starting treatment  Again at 4, 6, 12 weeks o Assess effectiveness of the treatment at the end of 12 weeks  Decision should be made as to whether to continue or consider an alternative intervention o If medication is to be continued beyond 12 weeks, review individual at

Answer 110

• Where available, consideration should be given to providing psychotherapies in the person’s own language if this is not English • CBT should be used o Should be delivered only by suitably trained and supervised people o Should be offered in the optimal range of duration  7-14 hours in total o Weekly sessions of 1-2 hours o Should be completed within maximum of 4 months of commencement o Should be supplemented with appropriate focused information and tasks o Briefer CBT – 7 hours, designed to integrate with structured self-help materials o For a few people, more intensive CBT over a short period of time might be appropriate

Answer 111

• If there have been 2 interventions provided (any combination of psychological intervention, medication or bibliotherapy) and the person still has significant symptoms • Options in secondary care o Treatment of co-morbid conditions o CBT with an experienced therapist if not offered already (incl. home based CBT if attendance at clinic is difficult) o Full exploration of pharmaco-therapy o Day support to relieve carers and family members o Referral for advice, assessment or management to tertiary centres

Answer 112

* Usually present with chest pain * Do not necessarily constitute a dx of panic disorder • key management o ask if they are already receiving treatment for panic disorder o undergo the minimum investigations necessary to exclude acute physical problems o be referred to primary care for subsequent care o be given appropriate written information about panic attacks + why they are being referred to primary care o be offered appropriate written information about sources of support incl. local and national voluntary and self-help groups

Answer 113

Assessment in primary care: PACES • Current or previous violence (incl. severity, circumstances, precipitants, victims) • Presence of comorbid metal disorders and/or substance misuse • Contact with the criminal justice system (incl. convictions, periods of imprisonment) • Current life stressors, relationships, life events • Collateral history Assessment in secondary care • Antisocial behaviours • Personality functioning, coping strategies, strengths, vulnerabilities • Comorbid mental disorders • The need for psychological treatment, social care, support, occupational rehabilitation or development • Domestic violence and abuse Psychological • Screen for alcohol misuse, depression, anxiety • Group-based cognitive and behavioural interventions o To address problems such as impulsivity, interpersonal difficulties and antisocial behaviour o Programmes to reduce offending • Other psychological interventions (contingency management programmes) if misuse of drugs, alcohol misuse Social • Support groups for families and carers • YoungMind, Carers UK • Safeguarding for family members

Answer 114

Crisis management in primary care PACES • Assess risk to others and self • Ask about previous episodes + effective management in the past • Enhance coping skills/help to focus on current problems • Encourage identifying manageable changes that will enable them to deal with current problems • Offer follow up • Refer to CAMHS if – a) there is increasing distress/risk to themselves, b)they requires further help, c) risk has not subsided despite attempts to reduce anxiety + improve coping skills Crisis management in secondary care PACES • Crisis management plan o Be calm + non-threatening o Understand the person’s POV o Explore reasons for distress o Empathetic open questioning – onset + course o Stimulate reflection about solutions o Avoid minimising reasons for crisis o Do not offer solutions before receiving full clarification of the problems o Explore other options vs admission to crisis unit/inpatients o Offer follow up • Short term sedatives – no longer than 1 week o E.g. sedative antihistamine (?promethazine) – low SE profile, low addictive properties, minimum potential for misuse, safe in overdose ``` Treating a crisis • Provide contact numbers for o Community mental health nurse o Out-of-hours social worker o Local crisis resolution team ``` Follow up after a crisis • Review o Crisis + causes (environmental, personal relationship) o Drug treatment, benefits, SE, safety concern, role o Psychological treatments incl. their role in the overall treatment strategy and their possible role in precipitating the crisis • Stop drugs within a week Insomnia • Sleep hygiene • Bedtime routine • Avoid caffeine • Reduce activities likely to defer sleep • Consider sedative antihistamines (promethazine) or z-drugs (z-drugs have potential to be misused)

Answer 115

Management of personality disorders For all consider: At risk of harming themselves or other s/unable to attend basic self-needs: • Partial hospitalisation or inpatient hospitalisation referral • Referral for substance abuse assessment * Patient communication and relationship management (maintain good relationship with patient) * Refer for substance abuse: treatment with naltrexone, acamprosate, disulfiram may be of benefit to patients attempting to abstain from alcohol use o Antipsychotics – may reduce impulsivity + aggression (e.g. risperidone) o Antidepressants – may reduce impulsivity + anxisety o Mood stabilisers – may reduce labile affect (effects aren’t evidence based) • Treat comorbid problems o Substance misuse, affective + anxiety disorders require management

Answer 116

* Low-dose antipsychotics for schizotypal | * Anti-depressants may help self-injurious behaviour and depressive or psychotic-like symptoms

Answer 117

• BPD – DBT, MBT * Antipsychotics -  impulsivity, aggression – BPD, paranoid, schizoid * Anti-depressants – may have general effects at reducing impulsivity + anxiety (BPD, cluster c) * Mood stabilisers – e.g. lithium for lability * Treat comorbid problems e.g. substance misuse, affective and anxiety disorders

Answer 118

* CBT * DBT * CAT – cognitive analytical therapy * MBT – develop empathy, understand what people think and feel * Psychodynamic and psychoanalytical psychotherapy * Social skills training * Dynamic psychotherapy * Therapeutic community • Most approaches are related to CBT (focusing on the interaction between thoughts, moods and behaviours right now) + psychoanalysis (explores how the past relates to interpersonal difficulties) o DBT  Type of CBT that has been adapted for people who experience emotions very intensely  Used to treat EUPD/BPD  Focuses on changing unhelpful behaviours + accepting who you are at the same time o Cognitive analytical therapy (CAT) o Mentalisation  Integrative form of psychotherapy that brings together aspects of psychodynamic, CBT and systemic approaches o Therapeutic communities  Group-based approach to long-term mental illness  Housing placements where the residents make their own rules o Psychodynamic and psychoanalytical psychotherapy

Answer 119

* Psychoeducation * Carer education * Therapeutic community – consciously designed social environment + programme within residential/day unit * Challenge/modify interpersonal behaviours

Answer 120

Psychotherapy • NICE – Group based cognitive and behavioural interventions (e.g. group CBT) – To address impulsivity, interpersonal difficulties, challenging/antisocial behaviours • Peer therapy settings more effective than individual therapy • Psychodynamic therapy is not recommended • Contingency management treatment ( a behavioural therapy where adaptive behaviours are rewarded) may be used General therapy principles - Set firm limits using mentalizing based approaches - Therapist must understand + process their own countertransference Medications • NICE – Pharmacological interventions should not be routinely used for the treatment of antisocial PD or associated behaviours of aggression, anger and impulsivity

Answer 121

``` Psychotherapy • NICE – DBT – most commonly used, especially in women with recurrent self-harm • TFP (transference focused therapy) • MBT (mentalization based therapy) • SFT (schema focused therapy) ``` Medications • NICE – Drug treatment should not be used specifically for BPD or for the individual symptoms or behaviour associated with the disorder • NICE – Short-term use of sedative medication can be considered in a crisis (should not be longer than 1 week) • NICE recommends that antipsychotics should not be used for the medium- and long term treatment of BPD Crisis • NICE – Short term treatment – consider a drug e.g. a sedative antihistamine (?promethazine) that has low SE profile, low addictive properties, minimum potential for misuse and relative safety in overdose Insomnia – NICE • Advice about sleep hygiene • Z-drugs (zalepon, zolpidem, zopiclone) (potential for misuse) • Sedative antihistamines (promethazine (less potential for misuse)

Answer 122

Psychotherapy with a particular focus on therapeutic alliance

Answer 123

``` For significant self-destructive behaviours • MBT • TFP • SFT • DBT ``` Higher functioning narcissistic personalities • Psychodynamic/psychoanalytic psychotherapy • Supportive psychotherapy • Individual psychotherapy

Answer 124

Psychotherapy CBT (similar approach for social phobia) Psychodynamic therapy Therapists should encourage gradual exposures into the world, and stay aware of threats to patient’s self-esteem SSRIs Venlafaxine

Answer 125

CBT – can be used to challenge negative thoughts + encourage independent behaviours

Answer 126

CBT – best validated treatment of OCPD (addressing core beliefs e.g. “If I’m not in control, things will fall apart”) Psychodynamic therapy – may be appropriate when feelings are more accessible

Answer 127

DBT Focuses on the factors contributing to emotional instability Being emotionally vulnerable and sensitive to stress Growing up in a environment where your emotions were dismissed by those around you Vicious cycle: intense + upsetting emotions  make you feel guilty + worthless  lead to actions that can make you feel upset again Goal: helps learn to manage difficult emotions by letting yourself experience, recognize and accept them Aims to introduce 2 important concepts Validation – accepting that your emotions are acceptable Dialectics – showing you that things in life are rarely black or white and helping you be open to ideas and opinions that contradict your own * As you learn to accept/regulate emotions  more able to change harmful behaviour * Learn more effective ways of dealing with distress * Replace harmful behaviours with ones that can help you move forward with your life * Mindfulness – set of skills helping you focus your attention and live your life in the present, rather than being distracted by worries about the past or future * Distress tolerance * Interpersonal effectiveness – teaching you how to ask for things + say no to other people, while maintain your self-respect and important relationships * Emotion regulation

Answer 128

Mentalisation-Base therapy • Mentalisation is the ability to think about thinking – examining your own thoughts and assessing them based on reality • Teaches you how to take a step back and scrutinise your thoughts and impulses • Teaches you how to recognise other peoples’ thought patterns and accept that your interpretation may not be correct • Usually lasts around 18 months • Some places recommend staying as an inpatient

Answer 129

Psychological therapy • 2/7 psychological treatments may be considered • Women for whom reducing self-harm is a priority – comprehensive DBT * Other psychological therapies: MBT, therapeutic communities, arts therapies * Other options: CBT, CAT ``` • Monitor the effect of treatment on a broad range of outcomes o Personal functioning o Drug + alcohol use o Self-harm o Depression o Symptoms of PTD ``` * DBT * Mentalisation-Base therapy • Art therapies o Useful for people who struggle to express their feelings verbally

Answer 130

Social • Psychoeducation • Carer education • Therapeutic communities o Involves teaching social skills to groups of people with complex psychological conditions o Includes tasks that improve your social skills and self-confidence (e.g. household chores, meal preparation) Specialties guide SSRIs may be useful to reduce impulsive behaviour

Answer 131

• Prescribing anti-depressants o SE on the initiation of antidepressants may be minimised by starting at a low dose + increasing the dose slowly until a satisfactory therapeutic response is achieved o If the person is showing improvement with an antidepressant, the medication should be continued for at least 6 months after the optimal dose is reached, after which the dose can be tapered • When prescribing SSRIs be aware of o Cocaine use (drug-drug interactions) o The need to avoid concurrent use of multiple serotonergic drugs

Answer 132

• All people who are prescribed antidepressants should be informed at the time that the treatment is initiated of o Potential SE (incl. transient increase in anxiety at the start of treatment) o Drugs are not associated with tolerance and craving o Risk of discontinuation/withdrawal symptoms if treatment is stopped abruptly or in some instances on reducing the dose of the drug  Most commonly experienced – dizziness, numbness, tingling, GI disturbances (N+V), headache, sweating, anxiety, sleep disturbance  To minimise this risk, the dose should be reduced gradually over an extended period of time  Pt should seek advice from their medical practitioner if they experience significant discontinuation/withdrawal symptoms  Mild – reassurance  Severe – consider reintroducing the drug or prescribing another from the same class with a longer half-life + gradually reducing the dose while monitoring symptoms o The delay in onset of effect, time course of treatment, need to take medication as prescribed

Answer 133

* Physical exercise * Tobacco cessation * Reduce harmful drinking * Lose excess weight in midlife * Adhere to healthy diet (a Mediterranean-style diet) * Cognitive training * Social participation and support throughout life * HTN, DM, depression should be managed

Answer 134

o Conduct a physical examination and o Undertake appropriate blood + urine tests to exclude reversible causes of cognitive decline and o Use cognitive testing but do not rule out dementia solely because the person has a normal score on a cognitive instrument  10-point cognitive screener (10-CS)  6-item cognitive impairment test (6CIT)  6-item screener  Memory Impairment Screen (MIS)  Mini-Cog  Test your memory (TMT) o Tests that characterize global impairment  MMSE  <10 – severe  10-20 – moderate  21-26 – mild  MoCA • Assess risk o ADLs – personal care (bathing, dressing, continence), housework, preparing meals, shopping, managing finances, taking drug treatments as prescribed o Safety in home + outside o Social functioning + support o Driving • Refer the person to a specialist dementia diagnostic service e.g. memory clinic, community old age psychiatry service if o Reversible causes of cognitive decline have been investigated and  Delirium, depression, sensory impairment (e.g. sight or hearing loss), cognitive impairment from medicines associated with  anticholinergic burden) o Dementia is still suspected • Refer to a specialist neurological service if o <65 o Focal neurological signs on examination o Rapid cognitive decline o Genetic cause likely o Learning difficulties

Answer 135

* Ensure that the pt + family/carers have access to a memory service * Assess for any emerging dementia-related needs during primary care appointments • Care coordination – provide people living with dementia a single named health or social care professional who is responsible for coordinating their care offer the person and their families oral + written information that explains • Dementia subtypes + changes to expect as condition progresses • Which HCP + social care teams will be involved in their care + how to contact them • How dementia affects driving + what they need to tell the DVLA + car insurer about their dx o MCI + no driving impairment – may drive, do not need to notify DVLA o MCI + possible impairment of driving – must not drive, should notify the DVLA o Dementia – must inform DVLA * Legal rights + responsibilities * Right to reasonable adjustments if they are working or looking for work • How the following groups can help and how to contact them o Local support groups, online forums, national charities o Financial and legal advice services o Advocacy services ``` Advanced care planning Discuss • The benefits of planning ahead • LPA • Advance statement about their wishes/preferences/beliefs/values re their future car • Advance decisions to refuse treatment • Their preferences for place of care and place of death • Wills ```

Answer 136

* Always carry ID, address and contact number in case they get lost * Dossett boxes/blister packs to aid medication compliance * Reality orientation (visible clocks, calendars) * Environmental modifications (e.g. patterned carpets can predispose to hallucinations) * Assistive technology (e.g. door mat buzzers) * Do a home safety assessment and ensure that adaptations are made to home (fires, floods, falls)

Answer 137

* Discuss dx * Arrange F/U 6/12 + if symptoms worsen re-refer to mental health team * Suggest healthy brain exercises – regular exercise, word games, socialisation

Answer 138

* Discuss dx + give written information * Commence F/U in primary care * Assessment + treatment – community based unless severely disturbed or complex physical/psychiatric problems * Treat identified RF * Treat sensory impairment – glasses, hearing aids * Treat comorbid psychiatric illness (e.g. depression) * Review medication * Exclude delirium * Consider referral to social services, SALT, OP, physiotherapy

Answer 139

* Admit if severely disturbed * Might need to section under the MHA * Drug treatments should only be initiate by specialists – cannot be started in primary care * Start low, go slow – older people are very sensitive to drug side-effects

Answer 140

• Mild to moderate dementia – 3 anticholinesterase inhibitors (AChE inhibitor) o Donepezil o Galantamine o Rivastigmine o SE – fatigue, dizziness, muscle craps • Memantine monotherapy for managing AD for people with o NMDA receptor antagonist o Moderate AD who are intolerant / have a contraindication to AChE inhibitors or o Severe AD • Established diagnosis of AD o If people are not taking an AChE inhibitor or memantine  Only start treatment with these on the advice of a clinician who has the necessary knowledge and skills  Once a decision has been made to start an AChE inhibitor or memantine, the first prescription may be made in primary care o If people are already taking an AChE inhibitor  Moderate/Severe disease – memantine in addition to an AChE inhibitor  Memantine can be prescribed by primary care prescribers without taking advice frm a specialist clinician  Do not stop AChE inhibitors in people with AD because of disease severity alone

Answer 141

• Only consider AChE inhibitors or memantine for people with vascular dementia if they have suspected comorbid AD, PDD, or LBD

Answer 142

• 1st line = AChE inhibitors (to treat hallucinations + agitation) o Mild moderate dementia  1st line = Donepezil or rivastigmine  2nd line = Galantamine o Severe dementia  Donepezil or rivastigmine • 2nd line = memantine • (for REM sleep disorder – low dose melatonin or clonazepam) * Parkinson’s medications could relieve the tremors but worsen the psychosis * Antipsychotics are dangerous and should not be used (they cause severe reactions – confusion, Parkinsonism, death) • Other (psychosocial) o Adaptations for patient (with an occupational therapist)  Reality orientation, environmental modifications o Social support/support carers o Optimising physical health (review medications) o Psychological therapies (reminiscence therapy)

Answer 143

• Do not offer AChE inhibitors or memantine – may exacerbate behavioural symptoms o This is because unlike AD, cholinergic neurons are relatively preserved in FTD • Behavioural symptoms may respond to antidepressants o Trazodone – good evidence for treatment of behavioural symptoms related to FTD o SSRIs – citalopram, fluoxetine, sertraline • Antipsychotics + anti-epileptics may be effective in the management of behavioural symptoms but are limited in use due to their SE profile

Answer 144

* 1st line – donepezil, rivastigmine | * Galantamine has less evidence

Answer 145

• Encourage and enable people living with dementia to give their own views and opinions about their care • Care plans for people with dementia should include o Details on dx + treatment – non-pharmacological + pharmacological methods o Environmental modifications o Sources of information, review plans • Psychoeducation – symptoms, treatment, prognosis • Mild-moderate dementia o Offer group cognitive stimulation therapy – for cognitive symptoms and maintaining function e.g. word association, categorization, number games, discussing news o Consider group reminiscence therapy – encourage someone to talk about their life, often using prompts from the past e.g. music, photographs, objects o Behavioural approaches – identify + modify triggers for difficult/risky behaviours (e.g. wandering may be due to disorientation, boredom, anxiety) o Validation therapy – reassure and validate emotion behind what is said o Multisensory therapy – as dementia progresses + speech is lost  easier to respond to touch, music etc. o Consider cognitive rehabilitation or occupational therapy

Answer 146

• Planning o MHOA teams explore the person’s wishes for the future, supporting them to formalize theses .e.g. writing an advanced decision (e.g. living will), appointing a LPA to manage financial/health decisions, should they lose capacity to make these o Discuss driving – independence must be balanced against safety • Offer a range of activities to promote wellbeing that are tailored to the person’s preferences • Identify and modify underlying triggers for difficult or risky behaviours o Wandering due to disorientation/boredom/anxiety/pain/hunger/needing toilet  provide regular food/calm environment • Mild-moderate dementia o Consider cognitive rehabilitation or occupational therapy to support functional ability • Home support – practical interventions o Dosette boxes/blister packs – aid medication concordance o Orientation aids – clearly visible clocks, calendars, written reminders o Environmental modifications – remove patterned rugs (tigger visual illusions), change gas to electric hobs o Helpcards – essential information people carry in case of getting lost (e.g. their name, that they have memory problems, carer/GP contact details) o Care packages – help at home e.g. personal care, meal preparation, medication supervision o Assistive technology – sensor alerts carer if one leaves home overnight, tracker watches with panic alarms can help people who get lost or anxious while out and about • Day centres – enjoyable day activities + social contact • Day hospitals – daily psychiatric care and rehabilitation for those with greater needs • Care homes o When people cant live safely or comoftably at home o GPs + MHOA support teams can optimise residential + nursing home care • Social support o Personal care, meal preparation, medication prompting o Day centres provide enjoyable daytime activities and social contact o Day hospitals enable daily psychiatric care for more complex patients • Carer support, psychoeducation, skills training, psychological therapy incl. CBT + training in stress reduction, communication and problem solving o Offer carer’s assessment o Emotional support o Educate about dementia o Train to manage common problems o Provide respite care = Respite care is designed to give carers a break for a limited period of time. Someone else provides care so the carer can go on holiday, attend to everyday activities or just relax. ``` • Dementia support services o The Alzheimer’s society o NHS choices o National institute on ageing o Family caregiver alliance, carer’s UK o The lewy body society o Frontotemporal dementia support group ```

Answer 147

• Before starting non-pharmacological or pharmacological treatment for distress in people living with dementia o Explore possible reasons for their distress o Check for and address clinical or environmental causes (pain, delirium, inappropriate care) • Offer psychological + environmental interventions to reduce distress + while people are taking the antipsychotics + after they have stopped taking them • Behavioural disturbance may require sedatives as last resort (e.g. trazadone, haloperidol) • Antipsychotics: o For people living with dementia only if they are either  At risk of harming themselves or others or  Experience agitation, hallucinations or delusions that are causing them severe distress o LBD, PDD  High potency antipsychotics are contraindicated in LBD!!  Can worsen the motor features of the condition, result in cognitive impairment, sedation, increased/irreversible acute onset of parkinsonism, or symptoms resembling neuroleptic malignant syndrome  Antipsychotics can cause severe antipsychotic sensitivity reactions in some cases – can lead to death  Symptoms of sensitivity – worsening of extra-pyramidal signs, changes in consciousness (acute and severe physical deterioration)  If an antipsychotic must be used (severely distressed, immediate risk of harm to the person or others), then low potency atypical antipsychotics like clozapine or quetiapine should be used o When using antipsychotics  Use the lowest effective dose + for the shortest possible time  Reassess the person at least every 6 weeks to check whether they still need medication o Stop treatment with antipsychotics if  The person is not getting a clear ongoing benefit from taking them and  After discussion with the person taking them + their family members/carers o Do not offer valproate o Avoid using olanzapine + risperidone – increased risk of stroke • If at increased risk of harming others/themselves o Advise moving the person to a safe, low-stimulation environment away from others o Verbal + non-verbal de-escalation techniques o Short term use of drugs for behavioural control (haloperidol, lorazepam, olanzapine) o Oral medication offered before parenteral medication o IM preferred to IV o Rapid tranquillisation – IM haloperidol and IM lorazepam o IM haloperidol (or any other IM conventional antipsychotic) – monitor closely for dystonia and other EPSEs o If SE become distressing especially in acute dystonic reaction  consider use of anticholinergic agents o If using anti-cholinergic agents  monitor for deteriorating cognitive function

Answer 148

* Mild-moderate dementia + mild-moderate depression  psychological treatments * Do not routinely offer antidepressants to manage mild/moderate depression in people living with mild/moderate dementia unless they are indicated for a pre-existing severe mental health problem * LBD – SSRIs – sertraline, citalopram * Note – SSRIs may cause hyponatraemia in the elderly, so remember to check sodium levels

Answer 149

* Do not offer melatonin in AD * Sleep hygiene education, exposure to daylight, exercise, personalised activities * LBD with REM sleep behavioural disorder – clonazepam, melatonin

Answer 150

* Key is to prevent further cerebrovascular disease by optimal control of major risk factors in people with a history of stroke or TIA * Anti-platelets (aspirin or aspirin/dipyridamole) + lifestyle modification * If carotid stenosis >70% - carotid endarterectomy/angio + stenting * If concomitant AD – cholinesterase inhibitors or memantine * Hypertension – BP control * Elevated LDL – statins * DM – optimise glycaemic control

Answer 151

* Encourage people living with dementia to have eye tests every 2 years * Take into account the increased risk of delirium in people with dementia during hospital admission * Consider involving a SALT if there are concerns about a person’s safety when eating and drinking * Beware that carer interventions are likely to be most effective when provided in group sessions * Beware that carers of people living with dementia are at an increased risk of depression * LBD – Extrapyramidal symptoms – levodopa, carbidopa

Answer 152

``` • Rivastigmine o N+V o Diarrhoea o Weight loss o Anorexia o Treatment should be stopped if GI symptoms (dyspepsia  gastric/duodenal ulcers) occur and then reiterated on resolution if necessary ``` • Donepezil o All of the above o Vivid dreams • Galantamine o Similar to rivastigmine o Warn patients of serious skin reactions (SJS, acute generalised exanthematous pustulosis, erythema multiforme) – stop drug immediately if symptoms occur, seek advice ``` • Memantine o Headaches o Somnolence o Dizziness o Agitation/confusion o Caution if history of convulsions or epilepsy ```

Answer 153

• Behavioural management o Frequent reorientation (e.g. clocks, calendars, verbal reminders) o Good lighting (gloomy conditions increase risk of hallucinations/illusions) o Address sensory problems (e.g. hearing aids, glasses) o Avoid over or under stimulation (side-room if the main ward is disruptive)  Silence unnecessary noises (e.g. bleeping alarms) o Minimise change  Don’t keep moving the patient  People at risk of delirium should be cared for by a team of HCP who are familiar to the person at risk – one staff member to engage the patient each shift  Establish a routine – regular toileting + sleep hygiene o Remove things that can be thrown or tipped over o Allow safe and supervised monitoring o Facilitate regular visits from family and friends • Address o dehydration +/or constipation o Infection o Immobility or limited mobility o Pain o Poor nutrition o Sensory impairment o Urinary retention • Assess for hypoxia + optimise oxygen saturation • Promote good sleep patterns and sleep hygiene • Daily observations for recent changes or fluctuations in usual behaviour

Answer 154

• Consider referral o Geriatrics o Psychiatry • If there is difficulty distinguishing between the diagnoses of delirium, dementia or delirium superimposed on dementia, treat for delirium first • Reorientation – explain where the person is, who they are, what your role is + reassurance • Manage the cause of delirium • First consider the non-medical issues that could be causing an altered level of consciousness – pain, vision deficits, hearing deficits, hunger, constipation, urinary retention • Then consider the medical aetiologies – DIMS-R o Drugs – intoxication/withdrawal (alcohol,benzodiazepines), sedatives (benzodiazepines, barbiturates, antihistamines), anticholinergics (oexybutynin, tolterodine, anti-naudeants, promotlity agents, TCA, antipsychotics), anti-convulsant (mysoline, phenobarbitone phenytoin), anti-parkinsonian agents (DA agonsits, levodopa-carbidopa, amantadine, benztropine), alcohol – stop unnecessary medications o Infections – genitourinary, chest, skin/soft-tissue, blood o Metabolic – glucose/electrolytes/Cr/LFTs, VBG CO2, TSH, B12  Clinical evidence of changes in hydration status present – e.g. hx of GI losses, signs of hypovolaemia/dehydration, signs of volume overload o Structural – intracranial pathologies (stroke, haemorrhage, seizures, neoplasms) o Sensory/environmental – pre-existing dementia, significant auditory/visual disturbances, environmental changes, night o Retention – fecal impaction or urinary retention – abdominal x-rays, palpation, DRE, disimpaction

Answer 155

• Pharmacological management should only be used if the symptoms of delirium threaten the patient’s own safety, the safety of others or would result in the interruption of essential therapy • Small night time benzodiazepines could promote sleep • Distressed pt at risk of harming themselves or others o Verbal + non verbal descalation techniques o Short-term low dose haloperidol (<1 week) [NICE] or benzodiazepines (specialties guide) o Baseline ECG for a QTc prolongation monitoring if pt is on haloperidol o Other first line antipsychotics (psychdb) – risperidone, olanzapine quetiapine  PD, LBD – atypical antipsychotics are preferred o Second line (psychdb) – lorazepam  Can worsen or prolong delirium  Should only be used for patients with alcohol withdrawal or patients with antipsychotic sensitivity (e.g. PD, LBD) • Antipsychotic drugs o Use with caution o Not suitable for all pt e.g. pt with PD or LBD • New delusions or hallucinations, particularly nonauditory, in middle age or later deserve evaluation for delirium or another medical cause

Answer 156

• Information and support o Delirium is common and usually temporary o Describe people’s experience of delirium o Encourage people at risk + their families and/or carers to tell their healthcare team about any sudden changes/fluctuations in behaviours o Encourage pt to share their experience of delirium with the HCP during recovery o Advise the person of any support groups o Ensure that the information provided meets the cultural, cognitive and language needs of the person

Answer 157

• Biological o SSRIs (e.g. citalopram)  SSRIs may cause hyponatraemia in the elderly so remember to check sodium levels o ECT – sometimes used in psychotic or life-threatening depression • Psychological o CBT o Psychodynamic therapy o Group therapy o Family therapy o Couple therapy • Social o Age UK o Consider social workers, community nurses, carers o Problem solving, increasing socialisation and day-time activities • F/U people who suffer pseudodementia – at higher risk of developing actual dementia

Answer 158

• Management is usually psychological (CBT) although SSRIs can be useful exercise etc

Answer 159

* Reduction of sensory impairment * Exclusion of organic cause or LBD * Low-dose antipsychotics

Answer 160

• Early intervention in psychosis services o The service aims to engage patients with very early symptoms, from adulthood till 35 years o Psychosis is toxic  the longer the patient is psychotic, the more it will affect their cognitive abilities, insight and social situation => the sooner effective treatment can be started, the better the prognosis o DUP – the time from the first clear-cut psychotic symptom until the start of effective treatment o Patients offered antipsychotics + psychosocial interventions  aim of keeping the duration of untreated psychosis (DUP) under 3 months o Service can be used in children >14 y/o  CAMHS can deal with psychosis in children up to 17 y/o o If urgent intervention is necessary  crisis resolution team, home treatment team • Offer crisis resolution + home treatment teams o Consider acute community treatment within crisis resolution and home treatment teams before admission to an inpatient unit • Primary care  do not start antipsychotic medication for a first presentation of sustained psychotic symptoms in primary care unless it is done in consultation with a consultant psychiatrist • Treatment options o Oral antipsychotic + o Psychological interventions (e.g. family intervention, individual CBT) • Baseline investigations before starting antipsychotics – weight, waist circumference, pulse, BP, fasting blood glucose, HBA1c, blood lipid profile, prolactin levels, assessment of any movement disorders, assessment of nutritional status, diet and level of physical activity

Answer 161

• Treat comorbid psychiatric illness – depression, OCD, substance misuse ] • Nutritional management + weight restoration o Realistic weekly weight gain target (usually 0.5-1kg/week) o Set eating plan • Ultimate goal of increasing person’s confidence in making positive decisions when coping with stress that do not include food or eating o Disentangle the emotional factors from the eating behaviour o That emotional problems no longer affect the eating behaviour o i.e. still depressed and anxious but no link with eating therefore no eating disorder

Answer 162

Medication • Do not offer medication as the sole treatment for anorexia nervosa • Encourage people with anorexia nervosa to take age-appropriate oral multi-vitamin + multi-mineral supplement until their diet includes enough to meet their dietary reference values • If they need SSRI – give one with a long half life (fluoxetine has the longest half life) – less likely to be affected/get withdrawal symptoms by purging behaviours Bone health • Incremental physiological doses of oestrogen – women 13-17 with AN who have delayed puberty, long-term low body weight and low BMD with a bone age under 15 • Transdermal 17-β oestradiol (with cyclic progesterone) – women 13-17 with AN who have long-term low body weight + low bone mineral density with a bone age over 15 • Bisphosphonates – women 18 and over with AN who have long-term low body wright and low BMD. Teratogenic • Avoid high impact physical activity that increases the change of falls or fractures

Answer 163

First line o Individual CBT-ED  40 sessions over 40 weeks – biweekly sessions in the first 2-3 weeks  A type of talking therapy to help you manage your feelings about food and eating so that you are able to eat enough to be healthy  It aims to enhance self-efficacy  Addresses control, low self-esteem, perfectionism  Encourages healthy eating + reaching a healthy body weight  Creates a personalised treatment plan based on the processes that appear to be maintaining the eating problem o MANTRA – Maudsley AN treatment for adults  20 sessions  Helps pt understand the cause of their anorexia  Encourages the person to develop a non-anorexic identity  Can involve family members o SSCM – specialist supportive clinical management  >20 weekly sessions  Aims to assess, identify and regularly review key problems  Help people recognise the link between their symptoms + their abnormal eating behaviour  Encourage reaching a healthy body weight + healthy eating Second line • Consider one of these 3 treatments that the person has not had before or o FPT – ED focused psychodynamic therapy  40 sessions over 40 weeks  Patient centred focal hypothesis that is specific to the individual + addresses • What the symptoms mean to the person • How the symptoms affect the person • How the symptoms influence the person’s relationships with others and with the therapist o Motivational interviewing  For patients who lack insight into their disorders or who think that their illness is a good thing o ITP  Aims at improving social functioning + interpersonal skills  Better for patients with alter onset/longer duration of illness

Answer 164

o FT- AN – AN focused family therapy  18-20 sessions over 1 year  Psychoeducation  Emphasise role of family in helping person to recover – support carers to take a central role in helping the person manage their eating (temporary role)  Offer option to children for some sessions to be w/o carers o Individual CBT-ED  40 sessions over 40 weeks – biweekly sessions in the first 2-3 weeks – 8-12 additional family sessions  Family sessions – identify anything in the person’s home life that could make it difficult for the to change their behaviour, discuss meal plans o AFP-AN – adolescent focused psychotherapy for AN  32-40 sessions over 12-18 months – 8-12 additional family sessions  Focus on the person’s self-image, emotions and interpersonal processes + how these affect their eating disorder  Develop a formulation of the person’s psychological issues + how they use anorexic behaviour as a coping strategy  Address fears about weight gain + emphasise that weight gain + healthy eating is a critical part of therapy  Find alternative strategies for the person to manage stress

Answer 165

• Psychoeducation o advice on nutrition and health o on effects of starvation on the body and mind o regulating body wright, dieting o adverse effects of attempting to control weight with self-induced vomiting, laxatives or other compensatory behaviours • Carer education + support • SEED support group, beateatingdisorders.org.uk • BEAT  eating disorder charity

Answer 166

o May be necessary if  BMI <13  BMI <75% ideal or median for age  Extremely rapid weight loss >1kg/week  Serious physical complications  High suicide risk o Should occur before the onset of medical instability as manifested by abnormalities in vital signs  Orthostatic hypotension (<80/50mmHg) with an increase in pulse of 20bpm  Drop in standing BP of 20mmHg  Bradycardia <40 bpm or Tachycardia >110 bpm  Inability to sustain core body temperature • Cold peripheries • Core body temperature <34.5 • Hypothermia  ECG abnormalities – prolonged QT interval  Electrolyte abnormalities – K+ <2.5, Na+ <130, PO4 <0.5  Renal failure/significant dehydration  Hypoglycaemia  Medical complications e.g. syncope, seizure, pancreatitis, heart failure etc  Uncontrolled bingeing and/or purging  Acute food refusal  Inadequate social support, unreliable or inadequate F/U care o Other markers of nutritional decompensation requiring urgent medical treatment  Squat test – inability to stand from squatting without using arms for leverage  Purpuric rash

Answer 167

• Severe – urgent referral to CEDS (community eating disorder service) o BMI <15, rapid weight loss, evidence of system failure • Moderate – routine referral to CEDS o BMI 15-17, no evidence of system failure • Mild – monitor/advice/support for 8 weeks, recommend support from BEAT, routine referral to CEDS if failure to respond o BMI >17, no additional co-morbidity

Answer 168

* Blocks D1 + D4 receptors | * Considered the most effective antipsychotic

Answer 169

* Previous or current neutropenia * Previous myocarditis * Active or progressive liver disease * Only consultant psychiatrists can prescribe clozapine

Answer 170

* Agranulocytosis, neutropenia * Myocarditis * Reduced seizure threshold * Sedation * Metabolic syndrome * Weight gain * Hypersalivation GI (swallowing problems, constipation)

Answer 171

* Nicotine is an enzyme inducer | * Smoking cessation can lead to a decrease in CYP450 resulting in  clozapine levels

Answer 172

• Risk of Agranulocytosis • FBC to detect early signs of neutropenia o Weekly for the first 18 weeks o Every 2 weeks for weeks 18-52 o Monthly thereafter o Monitoring must continue throughout treatment and for at least 4 weeks after discontinuation • Clozaril patient monitoring service (CPMS) o Provides for centralised monitoring of leukocyte + neutrophil counts which is a mandatory requirement for all patients in the UK who are treated with clozapine o National service in the UK that gives advice on the drug dosage to use, depending on the blood test results you send to them o Compulsory for anyone on clozapine o Also maintains a database which includes all patients who have developed abnormal leucocyte or neutrophil findings and who should not be re-exposed to Clozapine

Answer 173

* Response to treatment + SE * Adherence * Emergence of movement disorders ``` • Waist circumference • BMI • FBC, LFT (?fatty liver), U&Es, lipid profile, CBG (followed by a glucose tolerance test and HbA1c if abnormal) • Weight o Weekly for 6 weeks o At 12 weeks o At 1 year o Annually thereafter • Pulse + BP o At 12 weeks o 1 year o Annually thereafter • some people need monitoring of o prolactin levels – if hyperprolactinaemia is suspected or likely (e.g. risperidone) o ECGs – important in older people + those on high-dose antipsychotics or clozapine – to monitor the QTc interval; o Children – height every 6m ```

Answer 174

* Procyclidine PO/IM (anti-cholinergic) * Consider  anti-psychotic dose * Consider switching to atypical antipsychotic

Answer 175

* Tetrabenazine (drug which depletes monoamines – DA, histamine, serotonin * Consider  anti-psychotic dose * Consider switching to atypical antipsychotic *made worse by anti-cholinergics

Answer 176

* Procyclidine PO/IM (anti-cholinergic) * Consider  anti-psychotic dose * Consider switching to atypical antipsychotic

Answer 177

* Short term BZD * Propranolol * Consider  anti-psychotic dose * Consider switching to atypical antipsychotic