Psychiatry Flashcards
(192 cards)
1
Q
Describe step 1 of the stepped care model for depression
A
Step 1: all known and suspected presentation of depression
assess, support, psychoeducational, active monitoring and referral for further assessment and interventions
2
Q
Describe step 2 of the stepped care model
A
persistent subthreshold depressive symptoms, mild to moderate depression
low intensity psychological intervention, psychological interventions, medication, referral for further assessment and interventions
3
Q
Describe step 3 of the stepped care model
A
Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial intervention, moderate to severe depression
medication, high intensity psychological intervention, combined treatments, collaborative care and referral for further assessment and interventions
4
Q
Describe step 4 of the stepped care model
A
Severe and complex depression, risk to life, severe self-neglect
medication, high-intensity psychological interventions, ECT, crisis service, combined treatments, multi-professional and inpatient care
5
Q
How is mild to moderate depression managed?
A
sleep hygiene
follow up in two weeks
low intensity psychosocial intervention
group CBT
6
Q
What different types of low intensity psychosocial interventions are available?
A
individual guided self help based on the principles of CBT:
- written materials from a professionals
- 6-8 sessions face-to-face or telephone usually over 9-12 weeks with a follow up
computerised CBT:
- explain CBT model
- supported by a trained professional
- over 9-12 weeks
Structured group physical activity program:
- 3 sessions per week over 10-14 weeks
7
Q
How does group CBT work?
A
considered if low intensity is declines
should be based on a structured model e.g. ‘coping with depression’
delivered by 2 trained practitioners
10-12 meetings with 8-10 people
12-16 weeks
8
Q
When is medication considered in mild to moderate depression?
A
medication only if Hx of moderate / severe depression, symptoms lasting over 2 years, persistent symptoms despite other interventions
do not recommend St John’s wort due to uncertainty of dosing and drug interactions
9
Q
How is moderate to severe depression managed?
A
combination of antidepressant medication and high intensity psychological intervention e.g. CBT / interpersonal therapy
10
Q
What medication does St John’s wort affect?
A
warfarin
11
Q
What are some of the risks of SSRIs?
A
Bleeding, especially in elderly, ulcers and hyponatraemia
drug interaction
discontinuation syndrome
death from overdose
overdose
stopping treatment due to side effects
blood pressure monitoring needed
worsening hypertension
postural hypertension and arrhythmia
12
Q
Which SSRIs can interact with other drugs?
A
fluoxetine
paroxetine
fluvoxamine
13
Q
Which SSRIs can cause discontinuation syndrome?
A
paroxetine (shortest half life)
14
Q
Which SSRI can cause death from overdose?
A
venlafaxine
15
Q
Which SSRI can be used to overdose?
A
TCAs (except lofepramine)
16
Q
Which SSRI can cause people to stop the treatment due to the side effects?
A
venlafaxine, duloxetine, TCAs
17
Q
Which SSRI required regular blood pressure monitoring?
A
venlafaxine
18
Q
Which SSRI can cause worsening hypertension?
A
venlafaxine and duloxetine
19
Q
Which SSRI ca cause hypotension and arrhytmia?
A
TCAs
20
Q
How should a patient be monitored after starting an SSRI?
A
review after 2 weeks if no particular risk of suicide, then every 2-4 weeks after for 3 months
if < 30 or at increased risk of suicide, follow up in a week
review response to treatment every 3-4 weeks
21
Q
How are SSRIs continued after an improvement in symptoms?
A
continue at the same dose for 6-12 months or 2 years if high risk
22
Q
What are some high intensity psychological interventions?
A
individual CBT:
- 16-20 sessions over 12-16 weeks
- consider 2 sessions per week for the first 2-3 weeks
- consider follow up sessions over the following 3-6 months
interpersonal therapy:
- 16-20 sessions over 12-16 weeks
- consider 2 sessions per week for the first 2-3 weeks
- helps to identify how interactions with others are affecting the patients mood and ways of improving these interactions
23
Q
How do monoamine oxidase inhibitors work?
A
increase serotonin and noradrenaline in the cleft, beware of CHEESE REACTION
24
Q
How do SARIs (serotonin antagonist reuptake inhibitors) work?
A
antagonist at the post synaptic cleft e.g. trazodone
25
Give 4 examples of new anti depressants
agomelatine: melanin agonist and serotonin antagonist
bupoprion: noradrenaline and dopamine reuptake inhibitor
roboxetine: noradrenaline reuptake inhibitor
Vortioxetine: serotonin modulator stimulator
26
Which anti depressant might be used in elderly people or those who need to gain weight?
NASSAs (mirtazapine)
helps with sleep and appetite
27
Which antidepressant do you need to be careful with when switching?
from fluoxetine to other antidepressant as it has a long half life
from fluoxetine or paroxetine to a TCA (both inhibit the metabolism of TCA so may need a lower starting dose)
to a new serotoninergic antidepressant or MAOI (risk of serotonin syndrome)
from non-reversible MAOI: a 2 weeks washout period is required
28
How is complex and severe depression managed?
use crisis resolution and gome treatment teams
develop a crisis plan that identifies potential triggers and strategies to manage triggers
consider inpatient treatment if a significant risk of suicide, self harm or neglect
consider ECT for acute treatment of severe depression when a rapid response is required
29
What is the catch up phenomena?
if someone recovers from depression due to treatment, treatment is stopped, if they have depression again they will experience it worse
30
How should antidepressant be stopped?
over a period of 4 weeks otherwise discontinuation syndrome may occur (headache, flu symptoms, electric shocks)
31
PACES: depression
explain it is a persistently low mood that impacts on day to day functioning
explain that it is very common, about 1/4 people
address any social needs
explain the role of CBT, a talking therapy based on the principle that thoughts, mood and behaviour are all linked
explain the role of medication and that it takes a few weeks to work
arrange to review in 1-2 weeks and warn about initial side effects (lower libido, GI upset)
warn about sleep disturbance so to take in the morning
advise about the crisis resolution teams ane home treatment team
support: mind UK and samaritans
32
What are the three main mood stabilisers?
lithium - bipolar
carbamazepine
valproate - mania
33
What is the therapeutic range for lithium and when does it become toxic?
0.6-1
toxic after 1.2
34
How is lithium monitored?
1 weeks after starting / changing dose and weekly until a steady therapeutic level is achieved
then every 3 months
U&E and TFTs every 6 months (can cause renal impairment and hypothyroidism)
35
How does lithium toxicity present?
```
GI disturbance
polyuria
polydipsia
sluggishness
giddiness
ataxia
gross tremor
fits
renal failure
```
36
What are some triggers for lithium toxicity?
salt imbalance e.g. diarrhoea and vomiting or dehydrations
drugs interfering e.g. diuretics
accidental or deliberate overdose
37
How is lithium toxicity managed?
check level
stop lithium dose (beware of sudden precipitation of mania or depression)
transfer for medical care with rehydration and osmotic diuresis
if severe, may require gastric lavage or dialysis
38
Describe the use of valporate as a mood stabiliser
anticonvulsant and can be used to treat acute mania
prophylaxis in BPAD
no requirement for monitoring
no accepted therapeutic range
given as sodium valproate because of reduced side effects
39
Describe the use of carbamazepine as a mood stabiliser
```
anticonvulsant
can cause toxicity at high doses
induces liver enzymes
need to monitor levels closely
check for drug interactions before prescribing
can cause hyponatraemia
```
40
What are teratongenic effects of lithium?
Ebstein's anomaly
41
What are the teratogenic effects of valproate and carbamazepine?
spina bifida
if using valproate, women of childbearing age should be given contraception and prescribed a foalte supplement
closely monitor the foetus if any of these medications are used in pregnancy
42
What drug is used as second line prophylaxis for BPAD II?
lamotrigine
43
How is acute mania / hypomania treated?
stop all medications that may induce symptoms (e.g. anti-depressant, drugs of abuse, steroids and dopamine agonists)
monitor food and fluid intake to prevent dehydration
if treatment free - give an antipsychotic and short course of a benzo e.g. olanazpine and lorazepam
if already on treatment:
- optimised medication
- check compliance
- adjust doses
- consider adding another agent
- short term benzo
ECT if unresponsive to medication
44
What is the long term treatment of BPAD?
mood stabilisers
45
How is depression in BPAD managed?
talking therapies
anti-depressant may increase the risk of mania
therefore, anti-depressants should be given with anti-psychotics or mood stabilisers:
1. fluoxetine and olanzapine / quetiapine
2. lamotrigine
monitor closely for any signs of mania nad stop if present
46
What psychological treatment can be offered in BPAD?
CBT:
- dientify relapse indicators and prevent these .e.g routine, sleep hygiene, exercise, drug compliance
psychodynamic therapy: useful once mood is stabilised
47
What social interventions can be offered in BPAD?
family support and therapy, aiding return to education or work
48
What should be stopped during an acute manic episode?
anti depressant if they are on one
49
Describe the primary care referral in BPAD
hypomania - routine referral to CMHT
| mania - urgent referral to CMHT
50
PACES: BPAD
consider admission and section if at risk
Explain that this is a condition where you have a tendency to experience the extremes of emotion for variable lengths of time
explain the importance of controlling it (both extremes can lead to you making decisions that you otherwise would not make)
explain that there are medications available that helps to balance the chemical in the brain
advise about risis resolution team and samaritans
51
What are some immediate intervention if a patient is at high risk of attempting suicide again or lacks capacity?
need to be admitted to a psychiatric ward
crisis plan for future if they feel they want to do again: who will they call and how will they get help?
52
What are some long term interventions offered to people who are low to medium risk of attempting suicide again?
discahrge home
follow up within 1 weeks e.g. community mental health team, outpatient clinic, GP or counsellor
53
What psychological therapies can be offered to people who have tried to commit suicide?
CBT e.g. dialectical based therapy
mentalisation based treatment
transference focused therapy
54
What percentage of suicides occur within 3 months of discharge from psychiatric wards?
30%
55
What is the ideal time within which a patient with psychosis should be treated?
need Duration of Untreated Psychosis < 3 months
56
Who can be treated with the early intervention service?
children > 14, CAMHS can deal with psychosis in children up to 17 years
57
Which medications can be used to treat schizophrenia?
typical or atypical antipsychotics
| Dopamine antagonists
58
Which chemical is involved in the reward pathway?
dopamine
59
What are some examples of typical antipsychotics?
chlorpromazine, haloperidol and flupentixol
60
What side effects do typical antipsychotics cause?
extra pyramidal side effects
dystonia
akathisia
parkinsonism
tardive dyskinesia
61
What are some examples of atypical antipsychotics?
```
olanzapine
risperidone (available as a depot)
quetiapine
apriprazole
clozapine
amisulpride
```
these block dopamine and serotonin
62
What are some side effects of atypical antipsychotics?
hypermetabolic e.g. weight gain
increased risk of diabetes (olanzapine)
EPSE
hyperprolactinaemia (increased risk of osteoporosis, amenorrhoea / subfertility, sexual dysfunction, gynaecomastia)
```
sedation
dyslipidaemia
anti cholinergic effects e.g. dry mouth and blurred vision
arrhythmias
seizures
neuoleptic malignant syndrome
```
63
What psychological treatments are available for schizophrenia?
CBT at least 16 sessions
family therapy at least 10 sessions - respite for families and lower relapse rate
concordance therapy: patient is encouraged to think of pros and cons of the management
64
What are the aspects of social management in schizophrenia?
```
may need admission for observation
education
skills
housing
employment
accessing social activities
developing personal skills
```
psychoeduation is vital in reducing relapse
65
Which baseline measurements are required before starting an anti-psychotic?
weight
waist circumference
pulse and bp
fasting BM, HbA1c, lipid profile and prolactin
assess any movement disorders
ECG
children should have height measured every 6 months
66
What needs to be monitored after starting an anti-psychotic?
```
response to treatment
side effects
emergence of movement disorders
waist circumference
adherence
overall physical health
```
weight: weekly for 6 weeks, at 12 weeks and 1 year, then annually
pulse and BP at 12 weeks, 1 year, then annually
67
What other management is offered in schizophrenia?
physical health e.g. lifestyle and smoking cessation (can given buproprion and varenicline, need to be monitored as these increase risk of adverse neuropsychiatric conditions)
carer support, inform of their right to carer's assment
68
What medication is given in treatment resistant schizophrenia?
clozapine
-small but singificant risk of agranulocytosis so needs weekly blood tests to detect neutropaenia
if still no response, augment with another anti psychotic
69
Define treatment resistant schizophrenia
failure to respond to two or more anti psychotics, one of which is atypical, given at the therapeutic dose for at least 6 weeks
70
summarise the treatment of schizophrenia
1st line: atypical antipsychotic e.g. quetiapine
CBT
monitr, especially cardiovascular health due to high rates of CVD (due to medication and smoking)
71
PACES: schizophrenia
Explain it is a condition where your brain processes information differently, leading to you seeing and hearing things that are not there
Some of the thoughts or voices can be quite distressing so it is important you have a good social network and call for help if you feel like this is happening
I will refer you to a specialist who can help in a lot of different ways e.g. housing and employment
will start on cognitive behaviour therapy and medication
support: samaritans
72
Which rating scales are used in alcohol misuse and what are they for?
AUDIT - screens for hazardous and haermful alcohol consumption e.g. addiction (like CAGE) > 15 requires more assessment
CIWA-Ar - severity of alcohol withdrawal
APQ - determines the extent of problems caused by alcohol
SADQ - severity of alcohol dependence
73
What medical investigations are done in alcohol abuse?
FBC, LFT, B12, folate, UE, clotting and glucose
blood alcohol level
urine drug screen
74
What can be offered to family memebrs of people with alcohol dependence?
carer's assessment if necessary
consider offering guided self help for families and provide resources about support groups
family meetings can be considered, at least 5 meetings,over 5 weeks (one a week)
75
When would people with alcohol dependence and comorbid mental health conditions be referred to a specialist?
if issues do not improve within 3-4 weeks of abstinence
76
If a homeless person with alcohol dependece presents, what is the maximum amount of time they may remain at an inpatient rehabilitation programme?
3 months
77
What are the principles of intervention in alcohol dependence?
carry out a motivational interview
offer interventions to promote abstinence as part of intensive structured inpatient based intervention for people with moderate - severe dependence, esp if they have limited social support, complex comorbidities and have not responded to community-based programmes
monitor outcomes routinely
provide information on alcoholic anonymous, SMART recovery and 'change, grow, live'
78
Waht interventions are given to harmful drinkers and mild alcohol dependence?
CBT , behavioural therapy based on alcohol related cognitions (weekly 1 hour sessions for 12 weeks)
behaviour couples therapy if partner is present
if no response, offer acamprosate and naltrexone alongside psychological treatment
79
What is given for assisted withdrawl?
pabrinex if at risk of wernicke's encephalopathy
withdrawal symptoms are worst 48h after last drink and takes about 3-7 days to completely disappear
80
How are people drinking > 15 units a day or with an AUDIT score > 20 managed?
community based withdrawal is the best option
through organisations like CGL, 2-4 meetings in the first week and if complex 4-7 meetings over a 3 week period
manage in specialist alcohol services if there are concerns about safety
81
When would inpatient assisted withdrawal be considered?
any one of the following
30+ units in a day
30+ on SADQ
history of epilepsy, delirium tremends or withdrawal related seizures
need concurrent withdrawal of alcohol and benzodiazepines
significant psychiatric comorbidity or learning disability
lower threshold for inpatient if vulnerable e.g. homeless
children (10-17), should also have family therapy for 3 months
82
Outline the drug regimens in alcohol misuse
fixed dose or syptoms triffered regimen (chlordiazepoxide or diazepam, lroazepam in significant liver impairment
tritrate initial dose based on severity of dependence / consumption
gradually reduce the dose over 7-10 days (long ifer concurrent benzo withdrawal needed - over 3 weeks)
no more than 2 days medication at a time
83
What is given after successful withdrawal to prevent relapse?
acamprosata / naltrexone with individualised psychologica intervention
usually prescribed for up to 6 months
needs thorough baseline medical assessment before starting, including LFTs and UE
consider disulfiram if acamprosate / naltrexone not successful are not successful
84
PACES: alcohol misuse
establish risks: driving, suicide, dependents
assess social issues and advise accordingly
establish goals (elimination or moderation)
explain that symptoms of withdrawal are worst in the first 48h and last about 3-7 days
do not recommend stopping abrupty
explain referral to drugs and alcohol service and the process of assessed withdrawal
85
How is acute alcohol withdrawal treated?
IV chlordiazepoxide and Pabrinex
if hepatic impairment - lorazepam
or carbamazepine
alternative: clomethiazole
86
How is delirium tremens treated?
1st: oral lorazepam
if symptoms persist, IV lorazepa or haloperidol
alternative: chlordiazepoxide
IV thiamine also
87
How are acute alcohol withdrawal seizures treated
consider a fast acting benzodiazepine e.g. lorazepam to reduce the likelihood of future seizures
88
What medication is used for detoxification in opiate misuse?
appoint a key worker
| 1st: methadone (liquid) or buprenorphine (sublingual) decision is based on patient preference
89
When should opioid withdrawal treatment NOT be offered?
concurrent medical problem requiring urgent treatment
in police custody
presenting in acute or emergency settings
be wary with pregnant women
90
When is lofexidine given?
if methadone / buprenorphine are not acceptable, only mild dependence or they are keen to detoxify over a short period
91
What is the duration of ipiate detox as an in patient and in the community?
inpatient: 4 weeks
community: 12 weeks
92
What medication can be given to help with opiate withdrawal symptoms?
lofexidine or clonidine (alpha 2 agonist)
also things like anti diarrhoeals
93
What is ultra-rapid / rapid / accelerated detoxification?
rapid: 1-5 days with moderate sedation, given if patient requests it
accelerated: no sedation
ultra-rapid: under GA, do not offer
94
What is the second stage of managing opiate detoxification
promote abstinence from illicit drugs, prevent relapse, reduce HIV and HCV risk,
consider long acting opioid agonists e.g. methadone and buprenorphine
and long acting opioid antagonists (injectable, extended release naltrexone)
95
How is opioid detoxification followed up?
refer to drugs ad alcohol service for at least 6 months
offer a talking therapy e.g. CBT
appoint a key worker
offer contingency management
96
What is a contingency management for opioid detoxification?
offer incentives for every drug negative test
screening could be frequent at first and then reduce
urinalysis is the preferred method
97
PACES: opioid misuses, detox and withdrawal
explain that it is worth getting a test for blood borne disease and getting vaccinated
explain the features of withdrawal (restlessness, anxiety, sweating, yawning, diarrhoea, cramps, nausea, vomiting and palpitations)
advise that these usually begin with 24 hours, peaks after 2-3 days and should be better by 1 week
explain the detoxification regime (give a substitute that should lessen the symptoms
explain that symptomatic treatments will be given to reduce nausea, diarrhoea and autonomic symptoms
explain the role of psychological therapies and key worker
support: narcotics anonymous and SMART recovery
98
What are some uses of benzodiazepines?
sedation, hypnotic, anxiolytic anticonvulsant, muscle relaxant
only give for a short time
99
What are the risks of using benzodiazepines?
short term: drowsiness, reduced concentration
long term: cognitive impairment, worsening anxiety and depression and sleep disturbance
100
What are some clinical features of benzodiazepine withdrawal?
```
insomnia
irritability
anxiety
tremor
loss of appetite
tinnitus
excessive sweating
seizures
```
101
How should benzodiazepines be withdrawn?
ideally reduce by 1/8th of the dose every fortnight (in reality reduce according to the severity of the withdrawal symptoms)
consider switching them to the equivalent dose of diazepam (oxazepam if liver failure)
duration: can take 3 months to a year
DO NOT DRIVE IF FEELING DROWSY
102
PACES: benzodiazepine misuse
explain that benzodiazepines can cause worsening of long term psychiatric symptoms
explain that these can be reduced very gradually, in consideration of the symptoms the patient is experiencing
explain the role of CBT and what it is
advise that they should not drive if feeling drowsy
103
How is delirium treated?
treat the cause e.g. infection / constipation
stop any unnecessary medications
behavioural management
104
What is the behavioral management of delirium?
frequent reorientation (clocks and calendars)
good lighting
address any sensory problems
avoid over / under stimulation
minimise change and do not keep moving the patient, one staff member per shift
remove things they might trip over
allow safe and supervised wandering
105
What medication can be given in delirium?
small night time dose of benzodiazepine could help with sleep
short term sedation, can use low dose typical antipsychotics e.g. haloperidol
106
How can delirium be prevented?
good sleep hygiene without medication
minimal moves around hospital
encourage mobility
proactive management (minimise dehydration, pain, UTI risk)
107
how is normal pressure hydrocephalus managed?
a ventriculoperitoneal shunt
108
How can depression in the elderly be treated?
problem solving activities, socializing and day time activities
psychological therapies e.g. CBT, group therapy, family therapy, couple therapy
SSRIs first line e.g. citalopram
ECT if severe of life threatening
consider social workers, community nurses and carers
AGE UK
109
how is psychosis in the elderly managed?
reduction of sensory impairment
exclusion of organic causes or LBD
low-dose antipsychotics
110
What are the aspects of dementia managed?
```
adaptations for patients
social support
support carers
optimize physical health
psychological therapies
psychotropic medications
```
111
What adaptions can be made for patients with dementia?
```
always carry ID
dosset box
reality orientation
environmental modifications
assistive technology
home safety assessment e.g. electric instead of gas hob
```
112
What social support is available for people with dementia?
personal care, meal prep and medication prompting
day centres provide enjoyable daytime activities and social contact
day hospitals enable daily psychiatric care for more complex patients
113
What support can be offered for carers of dementia patients?
```
emotional support
education about the condition
advise against them telling pt what to do as this can aggravate them
train to manage common problems
provide respite care
```
114
How can the physical health of a patients with dementia be optimised?
treat sensory impairment e..g hearing aids
exclude superimposed delirium
treat underlying risk factors
review all medication
115
What psychological therapies can be offered to patients with dementia?
group cognitive stimulation (memory training and relearning)
group reminiscence therapy
consider rehabilitation or occupational therapy
behavioral approaches (identify triggers for behaviour)
validation therapy
multisensory therapy
116
Which psychotropic medications can be offered for dementia?
acetylcholinesterase inhibitors, used in mild to moderate Alzheimers - offers symptomatic relief but will not slow progression
memantine (NMDA antagonist) - used in severe alzheimers or if ACHEi is contraindicated
117
How is MMSE used to determine the severity of alzhimers?
Mild AD: 21-26
Moderate: 10-20
Severe<10
118
What medications can and cannot be given in lewy body dementia?
CAN give donepazil or rivastigmine (galantamine if not tolerated or contraindicated)
DO NOT GIVE ANTI PSYCHOTICS
119
What medications cannot be given in frontotemporal dementia?
ACHEi
120
When can ACHEi be given in vascular dementia?
if they have comorbid alzheimers, lewy boyd or parkinsons dementia
121
What is the first step in managing GAD?
CBT over 4-12 weeks
low intensity e.g. individualised non facilitated self help or individual guided self help)
explores patients thinking and likelihood of threat, test prediction of worry with behavioural experiments and looking at errors in thinking
can also do applied relaxation therapy, meditation, sleep hygiene and exercise)
122
What is panic disorder?
panic is triggered by misiinterpreting physical anxieety symptoms as signs of a major catastrophe
123
What is exposure therapy in GAD?
used as part of them CBT approach when there are strong elements of avoidance and escape
usually after 45 mins habituation occurs and leads to extinction
this is achieved through a gradual a process of desensitization
124
What is the second step of GAD management?
pharmacological:
sertraline (follow up at 1 week if < 30 due to increased risk of suicide)
SSRI / SNRI
pregablin
do not routinely use benzodiazepine due to risk of addiction
125
What is step 3 in GAD management?
specialist assessmnet of needs and risks and support for family and carers
126
What other pharmacological options are there for GAD?
TCAs e.g. clompiramine
buspirone (serotoning partial agonist)
Beta blockers but consider the contraindications
127
PACES: GAD
propanolol helps with physcial symptoms such as sweating
never give benzo
128
How is Panic disorder managed?
1. recognition and diganosis
2. treatment in primary care (CBT and SSRI)
3. review, if no response after 12 weeks consider impiramine and clompiramine
4. review and referral to specialist mental health services
5. care in specialist mental health services
129
What is OCD?
characterised by obsessions (unwanted thoughts that are distressing, centred around infection and contamination and aggression and morality)
compulsions to 'reduce' the tension: repeated stereotyped actions with no obvious link to the obsession and irrational
patients identify the thoughts as their own and may begin to avoid triggers
130
What are some differentials for OCD?
GAD, depressions, anakastic personality disorder and schizophrenia
131
What questionnaire can be used for OCD?
Yale-Brown
132
How is OCD managed?
CBT - exposure response prevention self help or group
SSRI - fluoxetine or paroxetine,
3rd: clopiramine or alternative SSRI if no response after 12 weeks
133
How long should people with OCD be treated for?
12 months after remission of symptoms
134
Describe an acute stress reaction
occurs minutes to hours after an event, lasts less than a month
135
How is an acute stress reaction managed?
exclude injury a provide support
| 2-4 week trial of benzodiazepine may alleviate short term distress (does not prevent later PTSD)
136
What are the core features of PTSD?
hyperarousal, reliving and avoidance
occurs within 6 months and lasting longer than a month
137
How is PTSD treated?
watchful waiting if subthreshold symptoms of PTSD within 1 month of traumatic event (F/U within a month)
Trauma focused CBT (8-12 sessions) offered to all PTSD if >1 month
EMDR - ONLY IN NON COMBAT TRAUMA, if >3 of symptoms
SSRI - paroxetine (licensed) or venlafaxine (unlicensed)
138
Paces: PTSD
explain it is a condition after a traumatic life event, characterised by hyperarousal, avoidance and reliving
trauma focused CBT is first line 8-12 sessions computer or face to face
pharmacological treatment includes SSRIs e.g. paroxetine
Consider group therapy and offer a follow up
139
What is an adjustment disorder?
When a person's adaption or reaction to change is much great than expected commonly in new uni students
140
How is adjustment disorder managed?
support and reasure and problem solving techniques
141
How are medically unexplained symptoms managed?
```
explain and reassure,
reattribution model
avoid unecessary Ix
Emotional support
Encourage normal function
Anti depressants
Treat comorbid illnesses
CBT
Graded exercise
```
142
How is chronic fatigue syndrome managed?
CBT
| graded exercise
143
How are conversion disorders managed?
psychotherapy and CBT
144
What are the 4 key aspects of anorexia nervosa?
BMI < 17.5
deliberate avoidance of food
endocrine dysfunction
distorted body image
145
What are some exmination findings of Anorexia?
```
bradycardia
hypotension
hypothermia
FAILED SQUAT TO STAND TEST
peripheral neuropathy
amennorhoea
```
146
What are some differentials for Anorexia?
```
Bulimia
organic cause e.g. hyperthyroidism
malignancy
depression
body dysmorphic disorder
```
147
What investigations need to be done in Anorexia?
```
height weight and BMI
squat to stand test
FBC
TFTs
ECG
```
148
How is anorexia managed?
Determine engagement and educate regarding nutrition
refer to CEDS
treat comorbid conditions
Psycho: ED-CBT, SSCM or MANTRA, Interpersonal
2nd - EDF FPT
149
What is the first line management for anorexia in children?
Family therpay
150
When is medical management indicated in anorexia (i.e. admission)?
```
BMI < 13.
Temperature < 34
Sodium < 130
Potassium < 2.5
High risk of suicide
>1kg / week weight loss
```
151
What are the characteristic findings of refeeding syndrome?
hypophophataemia
hypomagnesiumaemia
hypokalaemia
152
Describe the referral pathways in anorexia
urgent to CEDS if BMI < 15
routine if 15-17
mild - monitor for 8 weeks and recommend BEAT
153
PACES: anorexia
explain it is a condition that is characterised by being underweight and having a morbid aversion to food
NOT BASED ON OPINION BUT BASED ON NUMBERS
psycho therapy: CBT-ED, SSCM, MANTRA or Family therapy for children
set a realistic weight gain plan (0.5kg-1kg/week)
if depressed - fluoxetine
charity - BEAT
154
What are the characteristic feature of bulimia nervosa?
binge eating
purging
BMI > 17.5
body dysmorphia
155
How is Bulimia managed?
Bulimia nervosa focused guided self help programme for adults
children: family therapy bulimia nervosa
CBT-ED with nutrition and meal support
Fluoxetine (reduces purgin ideas)
treat comorbid psych conditions
156
Describe the referral pathways in bulimia nervosa
urgent (daily purgin and significant electrolyte imbalance)
moderate (monitor for 8 weeks, recommend self help consider SSRI and routine referral (purgin >2 weekly but no significant electrolyte imbalance )
mild - BEAT and monitor for 3 months
157
How is binge eating disorder managed?
BED focused guided self help for adults
if ineffective or unacceptable (after 4 weeks) group CBT)
progress to individual CBT
158
How is low libido managed?
establish if there are organic causes e.g. SSRI
treatment is mainly psychological
sensate focus therapy - ban intercourse, non genital caressing, genital touching to arouse and eventually intercourse
timetabling sex - helps partners with different libidos reach a compromise
159
How is hypersexuality treated?
exclude causes such as mania, substance and brain tumours
CBT
160
What are some causes of erectile dysfunction?
diabetes, neurological, vascular problems
anti depressants, anti psychotics, beta blockers and iduretics
depression and performance anxiety
161
How is erectile dysfunction manged?
modify risk factors such as smoking, increase exercise and reduce weight and alcohol
treated diabetes or HTN
psychological approach e.g. exploring anxiety
physical treatment e.g. viagra (phosphodiesterase-5 inhibitor)
intercavernosal prostaglandin self injection
vacuum pumps
surgery
topical therapy
162
How are disorders of gender identify managed?
Hormone therapy and gender reassignment
patient has to show they can live successfully in the other gender before surgery can be considered
163
How long must postnatal depression last to be diagnosed as postnatal depression
ONLY after 2 weeks after childbirth (before this is baby blues) What proportion of women have baby blues?
164
What proportion of women have baby blues?
75%
165
What proportion of women get PND
10%
166
What proportion of women get pueperal psychosis?
0.1%
167
What scale is used to assess postnatal depression?
Edinburgh postnatal depression (examines the last 7 days)
168
How is postnatal depression managed?
SSRIs: sertraline and paroxetine
valporate MUST be avoided
avoid lithium if possible
ALWAYS CHECK WHERE BABY IS
169
When should a mother be admitted to the mother and baby unit?
if ideas of infanticide or self harm and suicide
170
How long does post natal depression take to resolve?
1 month
171
PACES: post natal depression
CHECK WHERE BABY IS
consider admitting if severe
explain that it is quite common about 10%
address concerns e.g. guilt and provide home support
1st - CBT
2nd- SSRI (safe with breastfeeding)
will likely resolve in a month
safety net: samaritans
172
How is Pueperal Psychosis managed?
```
antipsychoitcs, anti depressants or lithium may be needed
CHECK WHERE BABY IS AND ADMIT
severe: ECT
usually recover within 6-12 weeks
exclude organic causes e.g. insomnia
```
173
PACES: Pueperal psychosis
```
CHECK WHERE BABY IS
explain the diagnosis
approx 0.1% of women get it
linked to hormonal changes
admit to M&B Unit
recovery 6-12 weeks
30% recurrence rate
```
174
How is BPAD manged in pregnancy?
avoid lithium and valproate
lithium can lead to ebstein anomaly and is secreted through the milk
monitor every 4 weeks and weekly from 36 week
will need to reduce dose following birth due to fall in GFR
175
Define the classifications of learning disability
50-70 mild
35-49 moderate
20-34 severe
<20 profound
176
What are the aspects of managing learning disability?
treat physical comorbidity
psychological suport (ABC antecedants, behaviour and consequences)
Education - statement of special education needs
carers support
177
How is Autism Spectrum Disorder managed?
applied behavioural analysis
early start denver model
more than words (hanen programme)
support for parents
CBT (occasionally mood stabilisers)
special education
National Autistic Society
178
What are the key features of autism spectrum disorder?
reciprocal socail interaction
communication problems
restricted behaviours and routine
179
How is Asperger's syndrome managed?
support (school GP / nurse)
routine
social skills training
advice
180
How is depressionin chidlren managed?
CBT first
| fluoxetine is the ONLY licensed drug for children
181
How is school refusal managed?
encourage rapid return
182
How is encoparesis managed?
```
laxatives if constipated
reassures and adress stress
and toilet training
pelvic floor exercise
star charts
```
183
What is conduct disorder?
<18
animal cuelty
bullying
socialised (as part of a group)
unsocialized (loner)
184
How is conduct disorder managed?
family education of needs
psychological therapy to encourage emotional expression
parent management training to help them reinforce positive behaviours
family therapy
education support
anger management
185
How are Tic disorders managed?
reasure
clonidiine (alpha 2 agonist)
atypical antipsychotics
186
How is ADHD managed?
first is parent training programme
> 6 methyphenidate for 6 weeks, if ineffective or they develop a tic --> atomoxetine
187
What forms of therpay are available for personality disorders?
```
CBT
CBT
CAT
transferance
psychodynamic psychotherapy
therapeutic arts
mentalisation
```
188
How is EUPD managed?
1. dialectical based therapy
2. formulate long and short term goals and a crisis plan
mentalisation based therapy, arts, therapeutic communities
SSRIs to reduce impulsivity
provide number for out of hours social worker, community mental health workers and local crisis resolution team
189
PACES: EUPD
explain they are more sensitive to emotions
personality disorders are often undiagnosed
explain DBT will help to understand emotions and validate emotions
recommend therapeutic communities
crisis management: provide numbers for crisis resolution team, community mental health nurse, out of hours social worker and samaritans
190
Define Insomnia
problems getting to sleep or staying asleep for 3 nights a week for 3 months
191
How is Chronic insomnia managed?
investigate using sleep diary or actigraphy
identify potential causes such as anxiety
advise on sleep hygiene and not to drive when tired
CBT-I for insomnia
hypnotics if major day time symptoms
short acting benzos or z drugs
lowest possible dose for max 2-4 weeks
192
Which questionnaires can be used for Schizophrenia?
Positive and NEgative Syndrome Scale
| Brief Impression Questionnaire
