psyc Flashcards

Question

what is first line for treatment resistant schizophrenia?

Answer 1

Lithium requires careful monitoring because it has a narrow therapeutic range (0.4–1 mmol/l). Routine serum lithium monitoring should be performed weekly after initiation and after each dose change until a therapeutic level has been achieved. It should then be checked every 3 months thereafter

Answer 2

(LITHIUM) Leucocytosis * Insipidus (nephrogenic) * Tremor * Hypothyroidism * Increased urine output * Mothers (teratogenic)

Answer 3

1 week risk of suicide - higher in younger patientsanhe

Answer 4

Anhedonia is the lack of enjoyment or pleasure. Apathy is a lack of energy or motivation to do things.

Answer 5

alzheimers

Answer 6

neural tube defect lamotrigine and carbamazpine is better

Answer 7

hypophosphataemia this is the hallmark symptom of refeeding syndrome may result in significant muscle weakness, including myocardial muscle (→ cardiac failure) and the diaphragm (→ respiratory failure) also get: hypokalaemia hypomagnesaemia: may predispose to torsades de pointes abnormal fluid balance

Answer 8

any CAMHS patient with an eating disorder the first line treatment will be family-focused treatment unless there are any contraindications or if family therapy is not possible/feasible The aim of family therapy is to support the young person around meals and to support them at home so that their eating can be managed without hospital admission

Answer 9

not an affective disorder

Answer 10

flight of ideas

Answer 11

mild - moderate= Acetylcholinesterase inhibitors: donepezil, rivastigmine, galantamine 1st line for severe= Memantine (NMDA antagonist)

Answer 12

< 18 y/o then its conduct disorder in the question be careful - can't be antisocial personality disorder if under 18

Answer 13

borderline / emotionally unstable personality disorder

Answer 14

borderline personality disorder

Answer 15

dialectical behaviour therapy form of CBT this is high yeild

Answer 16

histrionic

Answer 17

narcisitic

Answer 18

avoidant = they want conection but they are too afriad of rejection / they feel inadequate schizoid = they really not interested in social stuff. they don't want it...

Answer 19

anorexia nervosa bulimia nervosa binge eating disroder

Answer 20

BMI < 15 you need to hospitalise (associated with mortality)

Answer 21

reduced GnRH secretion from hypothalamus reduced LH / FSH functional hypothalamic amenorhheara

Answer 22

nutrional rehap strcutrued meals + daily calories goals psychotherapy Can give olanzapine (O = obesity, this drug helps you gain weight)

Answer 23

low urinary chlorde

Answer 24

scar on knucles from sticking hand in mouth

Answer 25

psychtherapy / CBT

Answer 26

1. somatic sx disorder- sx are uninentional / motivation is uninetional conversion disorder - this is usually following a stressor event (death/divorse) 3. factitious disorder - "munchausen" - falsified medical sx / "munchhausen by proxy" 4. malingering - "faking an injury so you dont have to go to work"

Answer 27

1. Appearance and behaviour - Provide some clues as to their lifestyle, current mental state and ability to care for themselves. a. Age, gender, ethnicity and occupation – e.g. “Mrs X is a middle-aged Caucasian female who reported to be the lead singer of the Spice Girls” b. Dress and self-care – dressing provocatively could be a sign of sexual disinhibition/bipolar disorder, whereas a disheveled appearance may be consistent with depression or schizophrenia. Note if the clothing is appropriate for the weather/circumstances and if the clothes have been put on correctly. c. Manner - hostile/helpful, aggressive/amiable? Were they appropriately behaved with you during the consultation? d. Posture and movement - were they tense, relaxed or overactive, or were there any side effects of antipsychotic use evident, e.g. tardive dyskinesia e. Rapport - easy or difficult to establish, distracted or if they appear to be engaging with hallucinations (e.g. replying to auditory hallucinations in schizophrenia) “This patient appeared well-kempt with adequate eye contact, a good level of personal hygiene and did not appear to be guarded.”

Answer 28

2. Speech - describe in terms of rate, rhythm, tone and volume. Comment on whether there was any pressure or poverty of speech and whether they were coherent or incoherent. Think of speech as a train and thoughts as passengers – normal speech and thought would be a train travelling at normal speed, reasonably full of passengers and it takes a logical route from station A to station B. NB: Formal thought disorder should be presented here, not in the Thought section, as it presents as abnormal speech patterns e.g. word salad "The patient spoke coherently at a normal rate, and rhythm. However, their voice was quiet and monotonous. No obvious thought disorder."

Answer 29

is the inability to answer a question without giving excessive, unnecessary detail. However, this differs from tangentiality in that the person does eventually return to the original point.

Answer 30

refers to wandering from a topic without returning to it.

Answer 31

is the repetition of ideas or words despite an attempt to change the topic.

Answer 32

is the repetition of someone else's speech, including the question that was asked.

Answer 33

is a severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another. It is a feature of schizophrenia.

Answer 34

a feature of mania, is a thought disorder where there are leaps from one topic to another but with discernible links between them.

Answer 35

describes completely incoherent speech where real words are strung together into nonsense sentences.

Answer 36

are new word formations, which might include the combining of two words.

Answer 37

are when ideas are related to each other only by the fact they sound similar or rhyme

Answer 38

3. Emotion/Mood - represents a patient’s predominant subjective internal state at any one time as described by patient a. Subjective – quote the patient directly e.g. “10/10” or “never felt better” b. Objective – what you think their mood is e.g. “depressed,” “elated,” “euthymic” flat affect = depressed blunted affect = schizophrenia c. Affect is what you observe of how the patient is presenting during the consultation in terms of emotions. Congruency means patient’s affect appears in keeping with the content of their thoughts. It is “incongruent” if the person’s report doesn’t match their presentation (i.e. they laugh while saying they have suicidal thoughts). If the affect varies appropriately, you can describe it as “reactive” d. Risk assessment! See (8) but this is a common place to ask about risk to self, risk to others and risk from others "Patient was feeling well and optimistic. He was having disturbed sleep which has recently resolved. Good appetite and has been motivated to go to the gym although he feels fatigue. No anhedonia, no evidence of worthlessness nor risks to self. Objectively, patient appeared to be euthymic but was blunted in affect"

Answer 39

4. Perception - hallucinations, pseudo-hallucinations, illusions, depersonalisation or derealisation.

Answer 40

a. Content - thought insertion, thought withdrawal or thought broadcasting b. Preoccupations (recurrent thoughts which the person is able to put aside), worries and overvalued ideas, obsessions, thoughts of harm c. Delusions – grandiose, persecutory, hypochondriacal, nihilistic, of guilt, of reference, of infidelity, amorous, of control d. Form - pressure or poverty of thought, thought blocking, loosening of associations, knight’s move, neologisms, perseveration, circumstantial or flight of ideas. "On direct questioning, the patient denied paranoid thoughts and grandiose beliefs. No current auditory or visual hallucinations but in the past, he had omnipotent, threatening 2nd person auditory hallucinations which were distressing, as well as visual hallucinations of shadows" If patient isn't disclosing their hallucinations (e.g. if they're paranoid): "On questioning, they denied experiencing any auditory or visual hallucinations but the patient was responding to unseen stimuli and seemed distracted"

Answer 41

6. Insight a. Does the patient consider themselves unwell in psychological terms? b. Does the patient feel in need of treatment?

Answer 42

7. Cognition a. Orientation - to time, place and person. b. Attention and concentration - subjective report, serial 7s, WORLD backwards c. Memory - subjective report and: i. Immediate memory ii. Recent memory iii. Remote memory d. Grasp – e.g. current monarch/prime minister. “Cognition wasn't formally assessed but patient was oriented to time, place and person"

Answer 43

Mania A: Increased energy and distractibility S: Pressure of speech E: Objectively elated and labile, subjectively elated P: Grandiose delusions, paranoia and auditory hallucinations T: Flight of ideas, content: optimistic ideation I: No insight C: Orientated to time, place and person

Answer 44

Generalised anxiety disorder A: Fleeting eye contact. Neatly dressed man with no evidence of self-neglect. Appears to be restless and tense but settles down as the interview progresses. S: Answers all the questions appropriately and there is no abnormality in speech. E: Mood is euthymic and no thoughts of self-harm P: No evidence of hallucinations T: No evidence of delusions I: Able to recognise the impact of the symptoms on social and occupational functioning and is keen to seek help. C: Orientated to time, place and person. Keeps up with the conversation with no lapses in concentration or memory.

Answer 45

Delirium A: Agitated, plucking at curtains, fearful expression, smells of urine, hitting out with stick S: Screaming, incoherent mumbling E: (S) refuses to comment, (O) frightened, irritable, suspicious P: Visual hallucinations; insects on bed & illusions, misinterpret curtains as ghosts T: Persecutory delusions e.g. feeling experimented on I: Refuse all interventions and do not believe they are ill C: Does not engage in MMSE. Disorientated to time, place and person. Poor attention and concentration. Unable to retain simple facts.

Answer 46

Panic disorder A: Drenched in sweat, hyperventilating. Dressed appropriately. S: Answers all the questions appropriately and there is no abnormality in speech. E: Mood is euthymic and no thoughts of self-harm P: No evidence of hallucinations T: No evidence of delusions I: Is keen to seek help because she recognizes the impact that these episodes are having on her life C: Orientated to time, place and person. Keeps up with the conversation with no lapses in concentration or memory.

Answer 47

Postnatal depression A: Dressed appropriately, difficult to maintain eye contact/build rapport S: Speech was articulate, slow, monotonous E: Mood was subjectively low, objectively patient had a low affect. Mood congruent P: Normal in all modalities tested. No evidence of delusions or hallucinations. T: Patient did not appear thought disordered, with no experiences of thought insertion, withdrawal or broadcasting I: Patient has full insight into condition and appears willing to try treatment/is looking for support C: Cognition was not formally assessed but appears grossly intact

Answer 48

NICE updated its depression guidelines in 2022. It now favours a simple classification of depression severity 'less severe' depression: encompasses what was previously termed subthreshold and mild depression a PHQ-9 score of < 16 'more severe' depression: encompasses what was previously termed moderate and severe depression a PHQ-9 score of ≥ 16

Answer 49

NICE use the DSM-IV criteria to grade depression: 1. Depressed mood most of the day, nearly every day 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day 3. Significant weight loss or weight gain when not dieting or decrease or increase in appetite nearly every day 4. Insomnia or hypersomnia nearly every day 5. Psychomotor agitation or retardation nearly every day 6. Fatigue or loss of energy nearly every day 7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day 8. Diminished ability to think or concentrate, or indecisiveness nearly every day 9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

Answer 50

 After starting antidepressant medication, review after 2 weeks (if low suicide risk), then every 2-4 weeks thereafter for 3 months  Patients 18-25 years old or at increased risk of suicide should be followed-up after 1 week  Review response to treatment after 3-4 weeks

Answer 51

Summary Mild depression or subthreshold depressive symptoms: - Consider a period of active monitoring - Provide information about depression - Arrange follow-up within 2 weeks Persistent subthreshold depressive symptoms or mild to moderate depression: - Consider psychological intervention (patients can self-refer through IAPT) - Avoid routine use of antidepressants (but consider if they have a history of moderate to severe depression, subthreshold depressive symptoms lasting a long time (usually >2 years) or mild depression that is complicating care of chronic physical health problems Moderate or Severe Depression - Offer an antidepressant and a high-intensity psychological intervention First Episode of Depression - Consider an SSRI (e.g. citalopram, sertraline) Recurrent Episode of Depression - Consider an antidepressant that the patient has previously had a good response to - Avoid antidepressants that have previously failed If co-existing chronic physical health problem - Sertraline is preferred (lower risk of drug interactions) * If they develop psychosis: add the antipsychotic earlier on (whenever the psychosis comes on) * Stopping antidepressants: dose should be tapered down over a period of 2-4 weeks

Answer 52

mood stabalisers o Lithium o Sodium valproate o Carbamazepine antipsychotic sometimes used is olanzapine

Answer 53

o Stop all medications that may induce symptoms (e.g. anti-depressants, recreational drugs, steroids and dopamine agonists) o Monitor food and fluid intake to prevent dehydration if not currently on tx with olanzapine + benzodiazepines

Answer 54

o Depression in BPAD  Difficult because antidepressants can cause a switch to mania  To reduce this risk, antidepressants should only be given with a mood stabiliser or antipsychotic * 1st line: fluoxetine + olanzapine/quetiapine * 2nd line: lamotrigine can also offer talking therpies (CBT)

Answer 55

* 1st line: atypical antipsychotic (e.g. quetiapine) * CBT should be offered to all patients * Close attention should be paid to cardiovascular risk factor modification due to the high rates of cardiovascular disease in schizophrenic patients (due to medication and high smoking rates) Treatment Resistance in Schizophrenia * 1st line: Clozapine * Treatment Resistance: failure to respond to two or more antipsychotics, at least one of which is atypical, each given at a therapeutic dose for at least 6 weeks * NB: there is a small but significant risk of agranulocytosis (0.7%) * Requires weekly blood tests to detect early signs of neutropaenia * If there is a lack of response to clozapine, consider augmentation with another antipsychotic

Answer 56

- Primary Care Referral o Symptoms of hypomania → routine referral to CMHT (community mental health team) o Symptoms of mania or severe depression → urgent referral to CMHT

Answer 57

Positive symptoms: hallucinations, delusions, and disorganized speech or behaviour Negative symptoms: social withdrawal, reduced emotional expression, and anhedonia. Cognitive deficits: impaired attention, memory, and executive functioning. Other features of schizophrenia include: * impaired insight * incongruity/blunting of affect (inappropriate emotion for circumstances) * decreased speech * neologisms: made-up words * catatonia * negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation)

Answer 58

Risk Assessment * Thoughts about hurting themselves again * Thoughts of hurting others * Concerns about being hurt by others * Specific features of increased risk: o Careful planning o Final acts in anticipation of death (e.g. writing wills) o Isolation at the time of the act o Precautions taken to prevent discovery (e.g. locking doors) o Writing a suicide note o Definite intent to die o Believing the method to be lethal (even if it wasn't) o Violent method (e.g. shooting, hanging, jumping in front of a train) o Ongoing wish to die/regret that the attempt failed * If the patient is insistent on leaving you need to assess their capacity

Answer 59

Sx must be present for at least a month

Answer 60

1. pabrinex 2. a benzodiazepine (e.g. lorazepam) or carbamazepine in the acute phase o Switch to long-acting benzodiazepines (e.g. chlordiazepoxide or diazepam) in the outpatient setting o Alternatives: Clomethiazole or carbamazepine 3. acamprosate to help with cravinngs

Answer 61

Features * symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety * peak incidence of seizures at 36 hours * peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

Answer 62

rhinorrhoea * needle track marks * pinpoint pupils * drowsiness * watering eyes * yawning

Answer 63

IV or IM naloxone: has a rapid onset and relatively short duration of action

Answer 64

Features of withdrawal: * Restlessness * Anxiety * Sweating * Yawning * Diarrhoea * abdominal cramps * nausea and vomiting * palpitations generalised muscle and joint pains, abdominal cramps, fever, and ‘everything runs’ (i.e. diarrhoea, vomiting, lacrimation, and rhinorrhoea). These patients often appear agitated with dilated pupils and goosebumps. Symptoms usually start within 12 hours of last heroin use and within 30 hours of last methadone use

Answer 65

Normal pressure hydrocephalus is a reversible cause of dementia seen in elderly patients. It is thought to be secondary to reduced CSF absorption at the arachnoid villi. These changes may be secondary to head injury, subarachnoid haemorrhage or meningitis. Normal Pressure Hydrocephalus (NPH) is characterised by the triad of symptoms including gait disturbance, cognitive impairment, and urinary incontinence. Whilst these classic features provide a foundation for clinical recognition, variations and additional symptoms can be present, confounding the diagnostic process.

Answer 66

o Memantine (NMDA antagonist)

Answer 67

o Mild AD: 21-26 o Moderate AD: 10-20 o Severe AD: < 10

Answer 68

1. CBT (low intesnity) 2. sertraline 3. highly specialist input

Answer 69

donepezil or rivastigmine

Answer 70

* Excessive and persistent worry about various events or activities, occurring more days than not for at least 6 months * Difficulty controlling the worry * Restlessness or feeling keyed up or on edge * Fatigue * Difficulty concentrating or mind going blank * Irritability * Muscle tension * Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep) * The anxiety and worry are associated with significant distress or impairment in social, occupational, or other important areas of functioning

Answer 71

Panic disorder is a type of anxiety disorder characterized by recurrent and unexpected panic attacks. Panic attacks are sudden episodes of intense fear or discomfort that peak within minutes and are accompanied by physical symptoms such as palpitations, sweating, trembling, and shortness of breath. The diagnosis of panic disorder is based on the presence of recurrent panic attacks and the persistent fear of having additional attacks

Answer 72

1. CBT + sertraline 2. clomipramine 3. refer (specilist mental health service)

Answer 73

1. CBT -> exposure and response prevention (you'll be encouraged to experience the anxiety and discuss with therapist) 2. fluoxetine (continue for 12 months after remission of sx) 3. clomipramine (after 12 weeks and no improvement )

Answer 74

1. trauma focused CBT + Eye movement desensitisation and reprocessing (EMDR) 2. paroxetine and sertraline (licensed)) or venlafaxine for adults with PTSD

Answer 75

Children with Anorexia Nervosa o 1st line: Family Therapy * Some sessions should be for the whole family and others should be separate * Usually, 18-20 sessions over 1 year * Review 4 weeks after treatment, then every 3 months o 2nd line: if Family Therapy unacceptable, consider Individual CBT-ED or AFP-AN

Answer 76

Referral Pathways * Severe → Urgent referral to CEDS (community eating disorder service) o Features: BMI < 15, rapid weight loss, evidence of system failure * Moderate → Routine referral to CEDS o Features: 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 Features: BMI > 17, no additional co-morbidity

Answer 77

* Same as depression but take care with drugs used in breastfeeding mothers o Antidepressants can be secreted in breast milk, therefore certain medications are avoided and others are preferred o Recommended SSRIs are sertraline and paroxetine

Answer 78

* Consider Bulimia Nervosa-Focused Guided Self-Help Programme for adults * Children: offer family therapy (FT-BN) * CBT-ED with nutrition and meal support * SSRIs (Fluoxetine) or SNRI o Reduce bingeing and purging by enhancing impulse control o Should not be offered as sole treatment for bulimia * Treat comorbid psychiatric illness o Depression, self-harm and substance misuse are common

Answer 79

Lithium has a teratogenic effect in pregnancy and can cause Ebstein’s anomaly — a heart malformation in which the tricuspid valve is displaced towards the apex of the heart resulting in atrialisation of the right side of the heart. The risk is particularly high if lithium is used in the first trimester.

Answer 80

fluoxetine

Answer 81

* Defined as difficulty getting to sleep or maintaining sleep on 3 or more nights of the week for 3 months mx = zopiclone

Answer 82

 NOTE: smoking cessation can lead to a decrease in CYP450 activity resulting in raised clozapine levels

Answer 83

Serotonin syndrome is a constellation of symptoms caused by high levels of serotonin usually due to misuse of drugs that cause an increase in serotonin concentration (e.g. SSRIs). It typically causes a fever, hypertension, tachycardia, agitation, diarrhoea, hyperreflexia, and myoclonus. It tends to happen when two or more drugs that raise serotonin levels are taken together (in this case, sertraline and cocaine). Other drugs that can cause serotonin syndrome include all classes of antidepressants, triptans, St John’s wort, lithium, metoclopramide, and other illicit drugs (e.g. ecstasy).

Answer 84

* Allows leave for a specified period of time from a current section * Certain conditions will have to be met (e.g. returning at a certain time, staying with a particular person)

Answer 85

* Side-Effects o GI upset o GI bleeding (if NSAIDs are being used, it should be given with a PPI) o Increased anxiety and agitation soon after starting -Usually occurs in first 2 weeks, then tends to settle but must warn patient and arrange follow-up during this period o Fluoxetine and paroxetine have higher propensity for drug interactions * QT Interval o Citalopram and Escitalopram are associated with a dose-dependent increase in QTc and should not be used in those with pre-existing QT prolongation or in combination with other medicines that prolong the QT interval o Maximum daily dose of citalopram: 40 mg for adults; 20 mg for > 65 years, 20 mg for hepatic impairment * Interactions o NSAIDs and aspirin: if used, give with a PPI o Warfarin/heparin: avoid SSRIs and consider mirtazapine o Triptans: avoid SSRIs

Answer 86

* Side-Effects o Nausea/vomiting and diarrhoea o Fine tremor o Nephrotoxicity: polyuria (secondary to nephrogenic DI) o Thyroid enlargement (and hypothyroidism) o ECG: T wave flattening/inversion o Weight gain o Idiopathic intracranial hypertension * Monitoring o After starting, lithium levels should be performed weekly and after each dose change until concentrations are stable o Once established, lithium blood levels should be routinely checked every 3 months (levels should be taken 12 hours post-dose) o Thyroid and renal function should be checked every 6 months o Patients should be given an information booklet, alert card and record book

Answer 87

o Side-Effects: sedation, weight gain, reduced seizure threshold, myocarditis, metabolic syndrome, hypersalivation, GI (swallowing problems, constipation)  NOTE: smoking cessation can lead to a decrease in CYP450 activity resulting in raised clozapine levels o Register patient with Clozaril patient monitoring service, Dezapine monitoring system or Zaponex treatment access system o Ensure normal leucocyte count and ECG before starting treatment o FBC Monitoring:  Weekly for 18 weeks  Fortnightly for 1 year  Monthly thereafter Side-Effects * Agranulocytosis, neutropaenia * Reduced seizure threshold * Constipation * Myocarditis (baseline ECG should be taken before starting treatment) * Hypersalivation

Answer 88

* Switching from citalopram, escitalopram, sertraline or paroxetine to another SSRI o First should be withdrawn before the alternative is started * Switching from fluoxetine to another SSRI o Withdraw then leave a gap of 4-7 days (fluoxetine has a long half-life) before starting a low-dose of the new SSRI * Switching from SSRI to TCA o Cross-tapering is recommended o Exception: fluoxetine should be withdrawn before TCAs are started * Switching from citalopram, escitalopram, sertraline or paroxetine to venlafaxine o Cross-taper cautiously (start venlafaxine 37.5 mg OD and increase very slowly) * Switching from fluoxetine to venlafaxine o Withdraw then start venlafaxine at 37.5 mg OD and increase very slowly * Take home message: fluoxetine takes longer to switch because it has a long half-life

Answer 89

* Any score > 24/30 is considered normal * Cognitive Impairment o Mild: 18-23 * May require some supervision, support or assistance o Moderate: 10-17 * Clear impairment, may require 24-hour supervision o Severe: 0-9 * Marked impairment, likely to require 24-hour supervision and assistance with ADLs