Psychiatry

Question 1

Depression investigations

Answer 1

Bedside
• Collateral history
• PHQ-9
• Hospital anxiety and depression scale

Bloods and imaging, can be helpful to rule out organic causes
• Blood glucose, FBC, U&E, TFT, Calcium
• HIV/syphilis, drug screen
• MRI/CT if atypical presentation

Question 2

Depression management

Answer 2

I would like to care for this patient under the MDT within a community setting following a biopsychosocial, stepped-care approach

• Initially conservative by recommending sleep hygiene and actively monitoring
• Could recommend self-help based on CBT principles
• cCBT
• Assess again in 2 weeks

Bio - SSRIs (-> SSRI -> SNRI e.g. venlafaxine -> mirtazepine)

Psycho - high-intensity CBT or interpersonal therapy

Social - encourage support from family and friends, occupational therapist can help find strategies to help with effects of depression

Question 3

BPAD investigations

Answer 3

Can do blood tests if worried about organic influences
Collateral history
PHQ-9 if depressive episode
PRIME-MD in primary care (primary care evaluation of mental disorders)
MDQ (mood disorder questionnaire)

Question 4

BPAD management

Answer 4

I would like to care for this patient using the MDT following a biopsychosocial approach

*admit whilst giving initial treatment if acute mania

Bio
• Stop antidepressant if taking one
• Acute mania - atypical antipsychotic e.g. olanzapine, adjunctive benzodiazepine can be considered
• Mood stabiliser - lithium (monitor weekly until stable, then monitor every 3 months)

Psycho - psychoeducation, family therapy, CBT

Social - supported employment programmes, adapting in education systems, regular engagement

Question 5

Acute manic relapse management

Answer 5

1. Increase mood stabiliser dose
2. Antipsychotic augmentation e.g. add haloperidol
3. Consider ECT

Question 6

Bipolar depression management

Answer 6

Limited evidence but can try olanzapine with fluoxetine

Question 7

Schizophrenia investigations

Answer 7

Bedside, bloods, imaging approach to exclude organic causes

• Collateral history
• Neurological exam
• Cardiovascular exam
• Urine drug screen
• Blood test - FBC, U&E, TFT
• MRI/CT

Question 8

Schizophrenia management

Answer 8

I would like to care for this patient under the MDT in secondary care where they would follow a biopsychosocial approach.

(GP - consult senior GP partner for consideration of admission)

MHA and encourage voluntary assessment, otherwise section.

Bio - atypical antipsychotics e.g. olanzapine, consider benzodiazepine first if agitated

Psycho - CBTp, family therapy

Social - care-coordination (monitor health, social problems), assertive outreach (maintain contact). Refer to early intervention service if first-episode psychosis in young person.

Question 9

If you decide not to admit a patient but they are at risk of suicidal behaviours in the future (e.g. they are self-harming), what safety plan would you formulate?

Answer 9

• Avoid alcohol when stressed
• Ask patient who they can tell if they are stressed
• If they feel like this again, suggest seeking help from GP, A&E, local support line e.g. Samartians
• Signpost counselling services, alcohol and drugs services, housing services, HR helpline

Question 10

Alcohol withdrawal investigations

Answer 10

Bedside and bloods approach

• FAST screening (if 3+, complete AUDIT)
• AUDIT (16+ higher risk, 20+ dependence)
• Obs
• Neurological examination

• Bloods e.g. FBC, U&E, LFT, clotting, albumin, glucose

Question 11

Alcohol withdrawal management

Answer 11

Admit and later management by the alcohol substance misuse team using a biopsychosocial approach

Bio - chlordiazepoxide (give lorazepam if hx of seizures), pabrinex

Psycho - refer to community alcohol team and motivational coaching after stabilised

Social - occupational therapist, family support

Question 12

Opioid withdrawal investigations

Answer 12

• Physical examination
• PHQ-9/GAD-7/HADS
• Urine drug screen
• Bloods - FBC (anaemia due to malnutrition, infection), U&E (malnutrition), LFT (impact medication dosing)
• Blood borne infections

Question 13

Opioid long-term withdrawal management

Answer 13

Conservative
• Needle exchange
• Vaccination
• HIV test etc.
• Healthy lifestyle
• Naloxone
• Self-help groups

Detoxification
• Appoint key worker to support patients during this process
1. Methadone (liquid) or buprenorphine (sublingual) - patient preference
2. Lofexidine (a2-agonist) if mild dependence or detoxify over short time, also helps with withdrawal symptoms

• 12 weeks in community
• 4 weeks inpatient (significant health problems or detox of other substances)
• Refer to drugs and alcohol services
• Offer CBT

Question 14

Delirium investigations

Answer 14

Bedside, bloods, imaging approach
MoCA
Urine dipstick
Bloods (FBC, U&E, CRP, ABG)
CXR

Question 15

Delirium management

Answer 15

• Modify risk factors e.g. change in environment (familiar staff, family, good lighting), nutrition
• Early diagnosis and exclude other factors
• Treat causes e.g. pain, hypoxia, hyponatraemia, constipation, urinary retention, dehydration, liver/renal impairment, infection
• Minimal evidence for antipsychotics

Question 16

Dementia investigations

Answer 16

Bedside, bloods, imaging approach

• Collateral history
• Neurological examination
• Bloods (confusion profile - FBC, U&E, TFT, B12, calcium, glucose, HIV)
• CT/MRI

Question 17

Dementia general management PACES answer

Answer 17

Referally to memory clinic for MDT approach, which includes psychiatrists, neurologists, or geriatricians working with nurses, OT, psychologists and social workers

There, they will be cared for following the biopsychosocial model

Question 18

Alzheimer’s, Lewy body dementia, and vascular dementia specific management

Answer 18

Bio (none for vascular)

1. Acetylcholinesterase inhibitors e.g. donepezil, rivastigmine, galantamine
2. NMDA-R antagonist e.g. memantine

Psycho
• Group cognitive stimulation therapy
• Offer activities to promote wellbeing

Social
• Social support e.g. meal preparation
• Inform DVLA
• Patient adaptations e.g. dossett box, reality orientation with clocks, carry ID

Question 19

GAD/panic disorder investigations

Answer 19

Collateral history
Obs
Urine drug screen
GAD-7
PHQ-9

Consider organic cause; bloods - FBC, TFT. ECG

Question 20

GAD management

Answer 20

I would like to care for this patient within a community setting following a biopsychosocial, stepped-care approach

1. Initially recommend education and active monitoring e.g. sleep hygiene, exercise, reduce caffeine, come back in 2 weeks
2. Low intensity psychiatric intervientions e.g. self-help, psycho-educational groups
3. High intensity CBT / applied relaxation. Consider sertraline (SSRI) -> duloxetine/venlafaxine (SNRI) -> pregabalin
4. Combination therapy in MDT

Question 21

Panic disorder management

Answer 21

I would like to care for this patient within a community setting following a biopsychosocial approach

Bio
1. SSRI
2. TCA e.g. imipramine if no response after 12 weeks
• No benzos

Psycho
• CBT
• Relaxation training

Social
• Support from family and friends

Question 22

Phobias management

Answer 22

SSRI/SNRI

Beta-blockers

Question 23

OCD management

Answer 23

I would like to care for this patient within a community setting following a biopsychosocial, stepped-care approach

Mild - low-intensity CBT and ERP, SSRI if not engaging

Moderate - SSRI or intensive CBT + ERP

Severe - SSRI + CBT + ERP

Question 24

PTSD investigations and management

Answer 24

Collateral history
PHQ-9
GAD-7
Check body for trauma
PTSD checklist

I would like to care for this patient within a community setting following a biopsychosocial approach

Bio
• SSRI -> SNRI -> Mirtazepine
• Antipsychotic e.g. risperidone

Psycho
• Trauma focused CBT
• EMDR (eye movement desensitisation and reprocessing)

Social
• Social prescriber for finances
• Mind.co.uk for psychoeducation

Question 25

Anorexia specific questions

Answer 25

SCOFF Sick - do you make yourself sick? Control - do you worry you have lost control over how much you eat? One - have you recently lost 1 stone in a 3 month period Fat - do you find that you tell yourself that you're fat when others say you're thin? Food - would you say that food dominates your life?

Question 26

Anorexia investigations

Answer 26

Bedside, bloods approach * Obs * Physical examination - muscle tone, hair, hydration * BMI * Squat test - difficulty standing from squatting * ECG * FBC * U&E * TFT

Question 27

Anorexia management

Answer 27

I would like to care for this patient under an MDT (medical, psychology, dietician, OT) Adults • CBT-ED • MANTRA (Maudsley anorexia nervosa treatment for Adults) • SSCM (specialist supportive clinical management) Children • Anorexia-focused family therapy • CBT

Question 28

Anorexia explanation in counselling

Answer 28

You have a condition called anorexia nervosa, which is characterised by a resctricted energy intake leading to low body weight, an intense fear of gaining weight, and a disturbance in the way people perceive their body. This can lead to various health problems, which is why we would like to treat you.

Question 29

Bulimia management

Answer 29

I would like to care for this patient under an MDT (medical, psychology, dietician, OT) Adults 1. Bulimia-nervosa-focused guided self-help 2. CBT-ED Children • Bulimia-nervosa-focused family therapy Trial of fluoxetine currently licensed but no long-term data

Question 30

Perinatal red flag questions

Answer 30

* New disturbing feelings and thoughts that you've never had before? * Thoughts of suicide or harming yourself in violent ways? * Feeling incompetent or estranged from your baby? * Do you feel you might or are getting worse?

Question 31

Perinatal psychiatry investigations

Answer 31

Dependent on history * Collateral history * Edinburgh Postnatal Depression scale (>13/30 - depressive illness)

Question 32

Postpartum psychosis (present within 2-3 weeks of birth) management

Answer 32

I would like to admit this patient to the mother and baby unit where she would be cared for under an MDT. * Treat with antipsychotics e.g. olanzapine or quetiapine * May require rapid tranq e.g. lorazepam * Enhanced nursing supervision and help orientate the patient * Consider acute psych admission if severe and even ECT

Question 33

Management for BPAD in pregnancy

Answer 33

Consult the psychiatrist and obstetrician * Avoid medications, and prescribe the lowest effective dose if required * Lithium increases risk of Ebstein anomaly - if they require it, carefully monitor dose and serum levels throughout pregnancy, delivery and postnatal * Consider ECT if med risk > ECT risk

Question 34

Different levels of intellectual disability

Answer 34

Mild • Difficulty with complex language concepts and academic skills • Basic activities normal • Independent living but may require support Moderate • Difficulty with complex language concepts and academic skills • Some fine with basic activities • Require considerable and consistent support to be independent Severe • Limited language and academic skills • May acquire basic skills with intensive training • May have motor impairments • Require daily support in supervised environment Profound • 'Adaptive' behaviour differences from severe

Question 35

Intellectual disability assessment

Answer 35

* WAIS IV (Wechsler Adult Intelligence Scale) = verbal IQ + performance IQ * ABAS II (adaptive behaviour assessment system) * Historical medical information + school reports

Question 36

Intellectual disability

Answer 36

I would like to care for this patient under the MDT in where they would follow a biopsychosocial approach. ``` This would involve: • Community LD nurses • Psychiatrists • Psychologists • OT • SALT • Physio • Dieticians ``` Bio • Concurrent psychiatric problems e.g. melatonin for sleep ``` Psycho • Antecedent-behaviour-consequence behavioural treatment • CBT • Family therapy • Creative therapy ``` Social • Skills training - develop independent living • Environmental change - level of stimulation, abuse/neglect

Question 37

ASD assessment

Answer 37

Specialist paediatrician / psychiatrist diagnosis • Revised ADI-R (autism diagnostic inventory) • ADOS (autism diagnostic observatory schedule) • Diagnostic interview for social and communication disorders (DISCO)

Question 38

ASD management

Answer 38

I would like to care for this patient under the MDT in where they would follow a biopsychosocial approach. Bio • Comorbid conditions e.g. risperidone for challenging behaviour, SSRI for obsession Psycho • Positive behaviour support Social • Family education • Social skills training • SALT assessment

Question 39

ADHD assessment

Answer 39

* ADHD rating scale (based on DSM criteria) 6+ features need to be present from DSM-V. * Vanderbilt Scale (Conners Adult ADHD rating scale in adults) * Full developmental history * Consider neuropsychological testing to rule out intellectual disabilities * Baseline ECG if considering ADHD medical treatment * Physical examination to rule out other problems e.g. hyperthyroidism

Question 40

ADHD management

Answer 40

Hollistic approach e.g. parent training and behaviour classroom intervention first. Then watch and wait for 10 weeks. If this doesn't help, I would like to refer this patient to secondary care where they would follow a biopsychosocial approach and managed under an MDT (school nurse, OT, neurologists, SALT, paediatrics, psychiatrist). Bio (last resort) 1. Stimulants e.g. methylphenidate (ritalin) - pre-synaptic DA transporter antagonist + postnaptic DRD4 agonist • 6 week trial basis, monitor weight and height every 6 months • Titrate over 4-6 weeks 2. Non-stimulants e.g. atomoxetine (NA reuptake inhibitor) Psycho • Education • Parents skills training e.g. Webster Stratton • ABC-CBT Social • School interventions • Environmental change • Special education needs statement should be obtained

Question 41

ADHD pre-drug assessment

Answer 41

* Cardio history + FHx * HR, BP * Weight

Question 42

Personality disorder assessment

Answer 42

``` Dependent on hx • SAPAS (standardised assessment of Personality-Abbreviated Scale) • Urine drug screen • PHQ-9 • GAD-7 ```

Question 43

Personality disorder management

Answer 43

I would like manage this patient following the biopsychosocial model. Bio (cluster A: odd/eccentric) • Low-dose antipsychotics e.g. aripiprazole • Antidepressants e.g. sertraline Bio (cluster B: dramatic) • Mood stabilisers e.g. lithium • Anticonvulsants e.g. valproate Bio (cluster C: anxious) • SSRI e.g. sertraline Psycho • Dialectical behavioural therapy • Mentalisation-based therapy • Psychotherapy for bordeline Social - dependent • Help with social circumstances e.g. mitigating circumstances at uni • Subtance use disorder treatment programme referral • Provide contact number for community mental health nurse / crisis team

Question 44

Lithium toxicity management

Answer 44

Stop lithium - one of the few times it can be stopped abruptly Mild-moderate • Volume resuscitation with normal saline • Recheck levels every 6-12 hours Severe • Haemodialysis

Question 45

Lithium toxicity precipitation

Answer 45

* Dehydration * Renal failure * Diuretics e.g. thiazides, ACEi, NSAIDs

Question 46

How to withdraw benzodiazepine and what happens if withdrawn too quickly?

Answer 46

Reduce 1/8 of a dose every 2 weeks If having difficulty: • Switch to long-acting BDZ like diazepam if not on that • Reduce every 2 weeks in steps of 2mg Can take from 1 month up to 1 year May consider anticonvulsants Consider psychotherapy Refer to specialist addiction service ``` If withdraw too quickly: • Insomnia • Irritability • Tinnitus • Perspiration • Seizures ```

Question 47

Benzodiazepine OD investigations

Answer 47

* O2 sats * ECG (heart block) * ABG - ?hypoxia ?metabolic acidosis * FBC, U&e (?AKI), LFT (?paracetamol) * CK (?elevated) * Plasma paracetamol

Question 48

Benzodiazepine overdose management

Answer 48

I would like to carry out an A-E assessment • Call for help from crash team including anaesthetist and emergency medical team • Insert wide-bore IV cannula A - check airways is patent if they can't talk, insert an airway B - check RR, O2, and auscultate for other pathology C - check BP, cap refill, cardiac rhythm and fluid balance. BDZ may be hypotensive and require fluid resus. D - check pupils, glucose E - exposure, hypothermia, inspect for injuries etc. * Flumazenil not licences but could be considered with expert advice if benefits>risks * Consider activated charcoal if <1 hour

Question 49

Paracetamol overdose investigations

Answer 49

• Obs * Serum paracetamol * LFT * Clotting * Glucose - ?hypo * ABG - ?lactic acidosis * FBC

Question 50

Paracetamol overdose management

Answer 50

Explain this is damaging to the liver, could lead to death, and may need a transplant in the future. Acute • Activated charcoal <1 hour • IV N-acetylcysteine (replenishes glutathione to break down NAPQI) dependent on time + serum paracetamol • Consult TOXBASE for management Sub-acute • Explain need for admission informally • Consider assessment for section 2 under MHA if refused Long-term: biopsychosocial Bio - SSRI (review within 1 week due to suicidal ideation) Psycho - CBT Social - potentially involve family and social services

Question 51

Antipsychotic monitoring

Answer 51

``` Start • FBC, U&E, LFT • Lipids, weight • Fasting blood glucose, prolactin • BP • ECG ``` Weekly • FBC for clozapine Titration • BP At 3 months • Lipids, weight 6 months • Fasting blood glucose, prolactin ``` Annually • FBC, U&E, LFT • Lipids, weight • Fasting blood glucose, prolactin • Cardio risk assessment ```