Psych Ix/Mx Flashcards

Question

What does the management of

Answer 1

Immediate • If high risk / lacking capacity admit to psych ward for own safety admit, discuss with senior • If lower risk: manage at home with close follow-up • Set up crisis plan for future suicidal ideation / thoughts of self-harm  Who will they tell and how will they get help? how to get help - Samaritans number • Educate on coping mechanisms when these thoughts appear: - Distraction, mood-raising activities (exercise etc), prevention (put away knives, tablets etc) if unavoidable talk about alternatives like using a cold ice cube • Arrange for psych liaison review before discharge Follow-up + Ongoing Mx: • 1w follow up at GP / Community mental health team, counseller • Treat underlying diagnosis eg depression – SSRIs, CBT, Support groups • If obvious social issues contributing – provide help advice about this as well eg. housing issues? Manage underlying causes: bio-psycho-social approach • Bio: SSRI - Consider ECT if life-threatening • Psychological: CBT or psychodynamic therapy • Social: support groups, encourage healthy diet and exercise, sleep hygiene • If lacerations – superficial cuts = sutures / steristrips, plastic surgery for deep cuts • Always provide adequate analgesia • If patient is insistent on leaving – assess their capacity Resources – mind.org.uk and Samaritans helplines which are available 24/7 MDT – Community mental health team, GP, Self-harm support groups, liaison psych team Safety net? – Crisis teams, Samaritans, A+E – if severe thoughts, seek help from community mental health or GP if symptoms persist

Answer 2

- How are you feeling? - Core symptoms: mood (rate it out of 10), energy - Biological: sleep, appetite - Cognition: memory, concentration - Disturbance of ADL, work - Shopping, gambling, driving, drugs and alcohol - Risk: to self, to others, from others - Episodes of low mood in past - Psychotic screen: What thoughts have you been having? Hallucinations

Answer 3

- Hypomania: at least 4 days, no psychotic features - Bipolar - Schizoaffective disorder - Organic causes: hypothyroidism (myxoedema madness), frontal lobe disease, drug induced (cocaine, amphetamine), delirium

Answer 4

- Collateral history, physical exam - Urinary toxicology screen - Bloods: FBC, CRP, TFT - Consider CT head

Answer 5

Acute • Consider admission or CMHT (mania v hypomania) (persuade them for an informal admission however may require sectioning) • Stop any precipitating meds e.g. SSRIs • Start atypical antipsychotic e.g. Olanzapine ± benzo (if agitated / insomniac) Long term • Mood stabilisers: lithium (will be give a lithium information book and alrt card – monitoring, measure lithium 1w after and 3m after, every 6m = U+E & TFTs), carbamazepine, sodium valproate • Psychological: CBT, psychodynamic therapy • Social: financial and occupational support, support groups, family therapy, charities such as MIND and Bipolar UK can provide lots of useful support • If carer present may find carers assessment useful and referral to support groups • Psychoeducation + identification of relapse signature • Cannot drive for 3m following acute episode • Lithium will require regular monitoring

Answer 6

Pre-lithium measurement of FBC, U+E, Ca (can increase risk of hyperparathyroid), ECG if known risk factors / cardiac disease Measure serum lithium 1 week after starting/changing dose • 12 hours post-dose • Aim for 0.4 - 1 mmol/L • Monitored weekly, then every 3 months TFT and U+E: every 6 months CK every year Warn patients about medications that can trigger toxicity and to consult doctors advice if ever concerned about starting new medication

Answer 7

Precipitants: • Dehydration, D+V, renal failure • Reduced excretion due to drugs: thiazide diuretics, ACEi, NSAIDs • Overdose Presentation: • GI disturbance: nausea, vomiting, diarrhoea • Coarse tremor • Severe: arrhythmias (palpitations), confusion, seizures, coma, renal failure Management • Stop lithium and precipitating drugs • Supportive: osmotic diuresis (fluid resus and rehydrate) • Consider haemodialysis esp if severe features

Answer 8

* Recent stress (precipitant) * Depression / anxiety screen (comorbid) * Obsessions: are these your thoughts or do you believe someone has put them in your mind? * Screen for psychosis: irrational delusions * Impact on QOL * Family history of OCD

Answer 9

- Anankastic personality disorder: lifelong personality of rigidity, orderliness and hygiene - Anxiety disorder - Depression, can occur in 50% of patients with OCD - Schizophrenia: beliefs are delusional not obsessional - Organic causes e.g. Sydenham chorea

Answer 10

* Collateral history – get better insight into how the condition is affecting the pt * Physical examination to rule out organic causes of sx – can also do urine dip, FBC (anaemia), TFTs (hyperthyroidism), glucose (hypoglycaemia) * Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)

Answer 11

Education, self help Mild: CBT w/ ERP -> self referral / GP referral to IAPT • Use hierarchy of feared situations • Encouraged to resist compulsive behaviours and experience anxiety Moderate: SSRIs or more intense CBT w/ ERP Severe: both SSRIs and CBT w/ ERP About the meds: • SSRIs e.g. Fluoxetine, citalopram • Usually higher doses needed than for depression so titrate up quickly • Continue for at least 12 months after remission • If not responding after 12 weeks: switch to alternative SSRI or consider Clomipramine TCA

Answer 12

* Mild = guided self help + psychoeducation for family | * Mod / severe = CAMHS

Answer 13

* Do you ever feel particularly worried about certain scenarios? – If any specific triggers may point towards a specific phobia * Do you ever feel your heart racing more than usual? * Have you ever had a panic attack? – difficulty breathing, sweating, heart beating out of your chest, GI discomfort * How long for? – GAD = 6 months * Do not have to ask all 3, just do a quick screen * Ask about drug, alcohol and caffeine use * Medications which can cause anxiety – salbutamol, theophylline, B-blockers, steroids, st johns wart * Triggers for anxiety * Recent life events * Disturbance on ADL * Sleep, appetite, weight * Thoughts: what are you thinking about when you get nervous? * Panic attacks * OCD symptoms * Hyperthyroidism features: irregular periods, weight changes, tremor * Mood * Risks * Caffeine intake, drugs and alcohol

Answer 14

* Collateral history * Bedside – Full physical examination, 12 lead ECG and basic obs * Bloods – FBC, U+Es, TFTs (Hyperthyroidism), Pulmonary function tests? * Urine -Tox screen if indicated? * Special tests – GAD7, HAD (if in hospital), Beck Anxiety Inventory (BAI), Consider doing PHQ9 as well? * Social and occupational assessments for affect on QOL

Answer 15

MDT: Community mental health team, GP, support groups, liaison psych team Stepped care model – Start w/ low intensity self help CBT if no functional impairment Biological: • SSRIs first line: sertraline, paroxetine, escitalopram = Higher doses than for depression and responses take longer 6-8 weeks, Continue for 12 months after remission • Second line: change to SNRIs Venlafaxine if no effect after 2-3 months • 3rd line: Pregabalin Psychological: CBT, applied relaxation also available • Reduce expectation of threat, and behaviours that maintain threat-related beliefs • Explore likelihood and impact of feared situation • Test feared situation and belief in outcome using behavioural experiments • Increase confidence in ability to cope For agoraphobia: exposure therapy, testing feared situations ``` Social: • Self-help books • Relaxation and breathing techniques • Sleep hygiene, exercise • Support groups, mind website ``` Charities – Anxiety UK, mind.org.uk Note if pregnant: High intensity CBT should be offered first -------------------------------Other drugs--------------------------------- Benzodiazepines • Short-term treatments e.g. whilst waiting for SSRIs to work or during acute crisis • Otherwise, should not be offered in primary care • Tolerance builds rapidly and dependence is issue • Must not be used for >4 weeks • Side-effects: amnesia, ataxia, respiratory depression • NOTE: Never give a benzodiazepine to anyone with anxiety because of high risk of dependence (it may be given for specific phobia in the short term (e.g. dental phobia)) Beta Blockers • E.g. propranolol • Sometimes used to treat adrenergic symptoms e.g. tremor, palpitations • Consider contraindications e.g. asthmatic

Answer 16

• S – Do you make yourself sick because you feel uncomfortably full? • C – Do you worry you have lost control over how much you eat? • O – Have you lost one stone (6kg) in a 3 month period • F – Do you believe yourself to be fat when others say you are too thin? • F – Would you say that food dominates your life ----------------------------------------- - Behaviours to control weight Diet restriction, fasting Excessive exercise Self-induced vomiting Diuretics, laxatives, appetite-suppressants e.g. caffeine - Distorted body image: how do you view yourself and your body? - Binging episodes (suggests BN) - Physical problems: Sleep, constipation, weak muscles, recurrent infections Periods - Psychological problems: Mood, concentration, memory, irritability - Effect on daily life and relationships - Support - ICE, risk - Past history: major life events, mental health

Answer 17

- Anorexia, bulimia, atypical anorexia (BMI >17.5) - Medical causes of weight loss: hyperthyroidism, malignancy, IBD - Depression - Body dysmorphic disorder

Answer 18

- Collateral history - Physical exam: Lanugo hair, parotid enlargement, dry skin, brittle nails Russel’s sign: callous/cuts on knuckles due to vomiting Basic Obs BMI Squat test for proximal myopathy - Bloods: FBC, U+E, LFT, TFT, B12 and Folate levels Glucose, CK, other electrolytes Identify nutritional risk - ECG: bradycardia, arrhythmias, long QT

Answer 19

- Bio-psycho-social approach: Social – Dieticans? CEDS? (aim for 0.5/1kg pw) Psychological therapy: CBT-ED, SSCM and MANTRA – in children that present family therapy or CBT should be offered) - Discussing thoughts that drive our behaviours - Setting eating plan and feasible weight gain target - Refer to CEDS community eating disorder service = specialist service which can help with Nutritional advice and support Bio: - Treat medical complications - Admit into hospital if high suicide risk, serious physical compromise (long QT, HR <40, electrolyte abnormality), very rapid weight loss / BMI <13 - Manage comorbidities, may use SSRIs if also depressed - Support: BEAT, support groups

Answer 20

DOPT (Duration, Onset, Progression, Triggers) o Short v long term o Fluctuating levels, gradual or step-wise decline? Establish Functional Level o Do they live alone? A o Are they able to cook, wash and dress themselves? Risk Assessment o Self – wandering, leaving iron / cooking on, self-neglect, driving o Others – aggression, risk behaviours, driving? ICE o Do they have insight into their condition? o What are the concerns of the pt’s relative? Specific Symptoms o Tremor, hallucinations, parkinsonian symptoms – Lewy body? Ask about temporal relationship to distinguish LBD vs Parkinsons Disease Dementia? o Ask about cardiovascular RFs – Vascular dementia? o Changes to personality / executive function – FTD? o Rapid progression of symptoms? – Consider creutsfeldt-Jakob o Altered consciousness – May suggest delirium instead o Low mood? – May suggest depressive pseudodementia o Falls / FLAWS ? – Hydrocephalus or SOL

Answer 21

* Bedside – Full physical examination (check for neurological signs) and basic obs, collateral hx * Bloods – FBC (Anaemia, U+Es (renal failure?), TFTs (Hypothyroidism), CRP, glucose, B12 and folate levels, syphilis VDRL if concerned about tertiary syphilis infection * Urine – Urinalysis and Tox screen? * Imaging – MRI Head (Can do CT instead) * Special tests – MMSE, AMTS, can also do PHQ9 * Consider CT /MRI, refer to neurologist / memory clinic

Answer 22

General - Bio-psycho-social approach - Optimise physical health (review meds), treat sensory impairment e.g. glasses - Psychological therapy: e.g. reminiscence therapy, art therapy - Support / Social: Personal care, meal prep, med prompting Suggest adaptations (carrying ID, dosset boxes, visible clocks etc Day centres for activities Patterned carpets can increase likelihood of hallucinations Consider OT Alzheimer’s: - Reversible anticholinesterases: increase choline (E.g. Donepezil, Rivastigmine), For mild-moderate, Cholinergic side effects e.g. vomiting, diarrhoea, usually settles within days - Memantine: severe Non-competitive NMDA antagonist - Consider antipsychotics for behavioural changes Vascular: control vascular risk factors e.g. Aspirin LBD: - Acetylcholinesterase inhibitors - Avoid antipsychotics MDT – Community mental health team, GP, Dementia support groups, old age psychiatrists, occupational therapists, carers?

Answer 23

- Psychotic features Auditory and visual hallucinations Delusions, thought disorder: someone stealing your thoughts etc - Insight: do you believe these people/voices/things are real - Mood - Biological: sleep, appetite, weight - Risks - Social history: committed crime, smoked cannabis

Answer 24

* Collateral history * Bedside – Full physical examination and basic obs * Bloods – FBC, U+Es, LFTs (alcohol intox), CRP (infection) * Urine -Tox screen * Imaging – CT / MRI Brain – if concerned about SOL * Lipids before starting treatment * Social work assessment: housing, activities of daily living, finances

Answer 25

* Refer to early intervention service (EIS) * Biological: first- or second-generation antipsychotics * Psychological: CBT, family therapy, concordance therapy * Social: consider admission, social skills training, education/occupation, financial, housing

Answer 26

- Quantification of drinking - CAGE Have you tried to cut down? How did you feel? Do you get annoyed when others criticise your drinking habits? Do you feel guilty about how much you drink? Do you need to have alcohol every morning to get you up? - Job - Relationship - Dependence symptoms Crave it Difficult to control how much you drink Do you know it’s harmful Are you still eating well and keeping healthy diet / neglect of hobbies (salience) Increasing in frequency / volume of drinking than in the past E.g. 6 weeks ago were you drinking this much Have you tried to go without alcohol and how did you feel - Mood Including thoughts of self-harm or suicide - Psychotic symptoms / features of delirium tremens - Risks Have you been under the influence of alcohol around children? Have you driven whilst under the influence of alcohol?

Answer 27

Rating scales AUDIT to identify use disorder, 10 item scoring system SADQ: determines severity of dependence APQ: alcohol problems questionnaire: assess problems arising from alcohol CIWA: withdrawal assessment Physical exam: establish baseline physical state ``` Bloods: FBC: macrocytic anaemia, low platelets LFTs: high GGT B12, folate, glucose U+E - dehydration Clotting ``` Urine drug screen, breathalyser or blood alcohol conc BAC

Answer 28

General: - Biopsychosocial approach - Motivational interviewing, establish goal, encourage abstinence - Warn about risks and complications - Advise about healthy diet and lifestyle Biological - Assisted withdrawal - Either community or inpatient - Inpatient indications: Complex withdrawal history e.g. delirium tremens, seizures Very severe dependency: 30+ units/day, 30+ score on SADQ Concurrent withdrawal of alcohol + benzo - Community based: refer to Drugs and Alcohol service, 2-4 meetings in first week - Fixed-dose drug regimen with long-acting benzo e.g. chlordiazepoxide or diazepam Titrate based on severity of dependence Gradually reduce dose over 7-10 days Use lorazepam if liver impairment or seizures - Thiamine supplement - Warn about withdrawal symptoms Worse within first 48 hours Takes up to 7 days since last drink to completely disappear - After successful treatment: relapse prevention Acamprosate: weak NMDA antagonist, anti-craving Naltrexone: opioid antagonist, blocks euphoric feeling Use for 6 months If unsuccessful / unsuitable: Disulfiram = flush-reaction Psychological - CBT, couples therapy - Focus on alcohol-related cognitions - 12 weeks - Refer to self-help resources and support groups Alcoholics Anonymous, SMART recovery Social - Rehabilitation centre including day centre or residential programmes Skills-based programmes for jobs - Direct to services for legal and financial support - Job centre - Driving: inform DVLA because cannot drive during treatment Follow-up and safety net: - Arrange appointment for after withdrawal complete - Safety net, if symptoms become severe → A+E

Answer 29

- Physical examination (cardio + neuro) - Urine tox screen - Bloods – FBC, U+Es, LFTs + screening for blood borne infections eg RPR – syphilis antibodies, hep serology and HIV test

Answer 30

Acute rapid + accelerated detox: - Actively precipitated by opioid antagonist (eg naltrexone or naloxone) – rapid = 1-5d w/ moderate sedation, accelerated = no sedation Longer process: - Psycho – motivational interviewing, can offer residential rehab if homeless for upto 3m - Bio – Long term detox (methadone, liquid – opioid agonist w/ longer ½ life – long withdrawal but mild OR buprenorphine – sublingual tablet, partial agonist – blocks eurphoric effects), important to appoint key worker that can support them through the detox process  Can be inpatient (4w) or in the community (12w), after detox can offer naltrexone to prevent relapse as it stops the euphoric effects - Social – pragmatic harm reduction approach – improving safety of drug use via needle exchanges and vaccination for blood borne viruses and also offering practical solutions to environmental stressors such as employment and housing - Can also get support from narcotics anonymous

Psych Ix/Mx Flashcards

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