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YEAR 5: Specialties (Laz) > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

Which drugs can be used for augmentation if SSRI/SNRI was ineffective?

A

Atypical antipsychotic (e.g. quetiapine)
Lithium
Thyroxine
Buspirone

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2
Q

What guides the prescription of acetylcholinesterase inhibitors for patients with Alzheimer’s dementia?

A

MMSE 10-20 (moderately severe)

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3
Q

What is the optimum dose of venlfaxine recommended for GAD?

A

75 mg

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4
Q

By what age does autism start to impair function/manifest as abnormal development?

A

3 years

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5
Q

Outline the risks of SSRIs in pregnancy.

A

1st trimester: congenital heart defects
3rd trimester: persistent pulmonary hypertension

Paroxetine has an increased risk of congenital malformations, particularly in the 1st trimester
Sertraline, fluoxetine and citalopram are generally considered safe

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6
Q

Which agent is often used for rapid tranquillisation of an agitated patient?

A 
1st = IM Lorazepam 
2nd = IM haloperidol
3rd = promethazine (sedating antihistamine)
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7
Q

How long do high-intensity psychological interventions go on for?

A

16-20 sessions over 3-4 months

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8
Q

What proportion of patients diagnosed with anorexia nervosa will make a full recovery?

A

20%

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9
Q

Name a tool used to assess the severity of alcohol withdrawal.

A

Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)

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10
Q

What is a particularly important aspect of the management of depression in the elderly?

A

Problem-solving
Increased socialisation and day-time activities
cbt, psychodynamic therapy, group therapy
ssris - citalopram

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11
Q

How long do low-intensity psychosocial interventions go on for?

A

Roughly 9-12 weeks with follow-up

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12
Q

Describe how you should switch from citalopram, escitalopram, sertraline or paroxetine to another SSRI.

A

First should be withdrawn before the alternative is started

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13
Q

How long do symptoms of depression need to be present to be diagnostic?

A

2 weeks

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14
Q

How is the MMSE score interpreted?

A

24 or more = normal
18-23 = mild
10-17 = moderate
< 9 = severe

NOTE: raw score should be corrected based on educational attainment and age

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15
Q

Outline the behavioural management approach for delirium.

A

Frequent reorientation (clocks, calendars)
Good lighting
Address sensory problems (e.g. hearing aids)
Minimise change (don’t keep moving the patient, one staff member per shift, establish routine)
Allow safe and supervised wandering

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16
Q

How should delirium tremens be managed?

A

1st = oral lorazepam
alternative chlordiazepoxide
IV thiamine

NOTE: lorazepam may be used in hepatic failure

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17
Q

How are conversion disorders managed?

A

Encourage a return to normal activities and avoid reinforcing symptoms
Provide support for addressing stressors
cbt and psychotherapy

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18
Q

What are some medical management options for preventing relapse in alcohol abuse?

A

Acamprosate (anti-craving)
Disulfiram - aversion therapy –> unpleasant sensation in response to alcohol

for up to 6 months

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19
Q

What is the FAST screening tool?

A

Consists of a subset of questions from AUDIT

A score of 3 or more is FAST positive

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20
Q

Which service should be involved in the care of a young person with first episode psychosis?

A

Early intervention service (EIS)

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21
Q

What is a major side-effect of chlorpromazine?

A

Skin photosensitivity (requires sunscreen)

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22
Q

What is treatment resistance schizophrenia?

A

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

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23
Q 
State the duration of the following types of section.
2
3
4
5(2)
5(4)
35
37
135
136
A 
2 - 28 days 
3 - 6 months
4 - 72 hours 
5(2) - 72 hours 
5(4) - 6 hours 
35 - 28 days 
37 - 6 months 
135 - 24 hours (up to 36)
136 - 24 hours (up to 36)
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24
Q

Which SSRI has a long half-life?

A

Fluoxetine

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25
Q

Define somatisation disorder.

A

• The main features are multiple, recurrent and frequently changing physical symptoms of at least 2 YEARS duration.

NOTE: if it has been going on for < 2 years, it is an undifferentiated somatoform disorder

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26
Q

What are the components of an AMTS?

A

How old are you?
What is the time to the nearest hour?
Give an address and ask them to recall it at the end
What is the year?
What is the name of the hospital or place you are currently at?
Can you recognise two people (doctor and nurse)?
What is your date of birth (day and month)?
In which year did WW2 begin?
Name the current prime minister.
Count backwards from 20 to 1

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27
Q

What is the first-line SSRI used for generalised anxiety disorder?

A

Sertraline

Paroxetine is the only licensed SSRI for GAD

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28
Q

List some transcultural psychiatric disorders.

A

Amox - Malaysia - frenzied killing spree
Koro - Asian - fear of penis disappearing
Piblokto - Inuits - sudden-onset hysteria (screaming)
Dhat - Indian - semen lost in urine
Latah - North Africa/Far East - exaggerated startle, echolalia or obeying commands, amnesia
Susto - South America - severe depressive episode after a traumatic event (often accompanied by diarrhoea and tics)
Windigo - North America - body is possessed by spirit that craves human flesh

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29
Q

List some physical/pharmacological treatments for erectile dysfunction.

A 
Sildenafil (viagra) = phosphodiesterase-5 inhibitor 
Intracavernosal prostaglandin self-injection before intercourse
Vacuum pumps (plastic dome and pump placed over the penis creating a vacuum to produce an erection. maintained by slipping a tight ring around the base of the penis)
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30
Q

How long do symptoms of PTSD have to last to be diagnostic?

A

> 1 month

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31
Q

Which benzodiazepine has the shortest half-life and what are the clinical implications?

A

Lorazepam - leads to worse withdrawal symptoms

Patients withdrawing may be switched from lorazepam to diazepam

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32
Q

Which medication can be used to prevent relapse in patients with opiate misuse?

A

Naltrexone

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33
Q

Which SSRI would be best to use in anorexia nervosa?

A

Fluoxetine (stable in terms of weight)

NOTE: you don’t want to give these patients anything that will make them gain weight too rapidly

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34
Q

Which tools are used to distinguish dementia from delirium?

A

Long Confusion Assessment Method (CAM)

Observational Scale of Level of Arousal (OSLA)

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35
Q

Which medications can be used for alcohol detoxification?

A

Chlordiazepoxide
Diazepam
NOTE: lorazepam can be used in cases of liver failure

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36
Q

What are the treatment approaches for emotionally unstable personality disorder?

A 
Dialectical behavioural therapy 
Mentalisation-based therapy 
Therapeutic communities 
Arts therapy 
Transference focused therapy
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37
Q

Which social aspects of a patient with schizophrenia require management?

A 
Social skill training 
Education, training and employment 
Skills (e.g. cooking, budgeting) 
Housing 
Accessing social activities 
Developing personal skills (e.g. creative writing)
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38
Q

List some triggers for lithium toxicity.

A

Salt balance changes (e.g. dehydration, D&V)
Drugs interfering with lithium excretion (e.g. diuretics)
Accidental or deliberate overdose

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39
Q

What is the Young Mania Rating Scale?

A

Uses 11 questions with a total score of 60

Scores

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40
Q

Outline the aspects of managing autism spectrum disorder.

A

Support and advice for families (National Autistic Society)

Behaviour therapy - applied behavioural analysis for young children

Speech and language therapy

Special education

need for education health and care (EHC) plan assessment with nursery, school, gp

Treat comorbid problems (e.g. epilepsy)
Antipsychotics and mood stabilisers are occasionally used

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41
Q

List some side-effects of clozapine.

A
  • Agranulocytosis, neutropaenia
  • Reduced seizure threshold
  • Constipation
  • Myocarditis (baseline ECG should be taken before starting treatment)
  • Hypersalivation
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42
Q

List the side-effects of SNRIs.

A

Constipation
Hypertension
Raised cholesterol

They also have all the SSRI side-effects

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43
Q

If a patient with postnatal depression required admission, where should she be admitted?

A

Mother and Baby Unit

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44
Q

Which investigations/further management should a GP recommend for a patient with suspected Alzheimer’s disease?

A
  1. history
  2. collateral history
  3. Physical examination
  4. Blood tests - to exclude reversible causes of cognitive decline: FBC, U&Es, glucose, CRP, urine dip, TFTs, LFTs
  5. Cognitive testing
  6. Refer to old age psychiatry outpatient clinic (memory clinic)
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45
Q

How should benzodiazepines be withdrawn?
how long will it take
what warning do u give them

A

Reduce by 1/8 of the dose every fortnight
consider switching patients to equivalent dose of diazepam
may take 3 months to a year
do not drive if feeling drowsy

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46
Q

List some symptoms of refeeding syndrome.

A 
Weakness 
Fatigue 
confusion
hypertension
Arrhythmia
Seizure
Cardiac failure 
Rhabdomyolysis
Leucocyte dysfunction 
Respiratory failure 
peripheral oedema 
Coma

This phenomenon usually occurs within four days of starting to feed again.

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47
Q

Which receptors are blocked by typical and atypical antipsychotics?

A 
Typical = dopamine (D2) 
Atypical = dopamine and 5HT2
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48
Q

What is overshadowing?

A

When a patient’s presenting symptoms are assumed to be due to an underlying learning disability rather than another, potentially treatable cause

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49
Q

Which forms of psychological therapy may be useful in schizophrenia?

A

CBT (for all patients)

Family therapy (effects of high expressed emotions can be improved through communication sills, education about schizophrenia, problem solving and helping patients expand their social network)

Concordance therapy = collaborative approach where the pt is encouraged to consider the pros and cons of the mx

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50
Q

Describe the features of benzodiazepine withdrawal.

A 
insomnia
irritability
anxiety
tremor
loss of appetite
tinnitus
excessive sweating
seizures
perception disturbance
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51
Q

How long do features of conduct disorder need to occur to be diagnostic?

A

6 months

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52
Q

How long does postnatal depression and puerperal psychosis usually take to recover?

A

Depression: 1 month
Psychosis: 6-12 weeks

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53
Q

What counts as a ‘brief intervention’ for alcohol dependence?

A

5-10 mins of information

2-3 sessions of motivational interviewing

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54
Q

What are the aspects of management of learning disabilities?

A
  1. Treat physical and psychiatric comorbidity
  2. Statement of Special Educational Needs (maximise potential)
  3. Psychological therapy (group therapy, counselling)
  4. behavioural therapy: avoid triggers, reinforce positive behaviours, prevent reinforcing negative behaviours, help people to understand the consequences of their actions
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55
Q

What is the oestrogen hypothesis?

A

Potential explanation for why women respond better to TYPICAL antipsychotics (like haloperidol)

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56
Q

Describe the features of amphetamine withdrawal.

A

Dysphoric mood
Fatigue
Agitation

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57
Q

What criteria need to be fulfilled to be able to discharge a patient with puerperal psychosis?

A

Developed some insight into the nature of the illness and is adherent with medication
No longer a risk to herself or the baby

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58
Q

Outline the interpretation of the HAD.

A

7 questions for anxiety and 7 for depression (maximum 21 points for each)
 Normal: 0-7
 Borderline: 8-10
 Anxiety/Depression: 11-14

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59
Q

What counts as mild, moderate and severe depression?

A

Mild
• 2 or 3 core symptoms
• At least 2 other symptoms
• The patient is distressed about the symptoms but can still continue with most activities
Moderate
• 2 or 3 core symptoms
• At least 3 other symptoms
• The patient has considerable difficulty continuing with ordinary activities and social functioning
Severe
• All 3 core symptoms
• At least 4 other symptoms, some of which are intense
• Major impact on quality of life and social functioning
• May show distress and/or agitation

NOTE: All symptoms must be present for at least 2 weeks

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60
Q

How should depression in BPAD be managed?

A

Antidepressant + mood stabiliser OR antipsychotic

e.g fluoxetine and onlazapine
2nd line - lamotrigine

Risk of precipitating mania

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61
Q

What are the features of alcohol withdrawal syndrome and how long after the last drink will it occur?

A 
4-12 hours after the last drink 
Coarse tremor 
Sweating 
Insomnia 
Tachycardia 
Nausea and vomiting 
Psychomotor agitation 
Generalised anxiety
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62
Q

Where can detoxification for alcohol be given?

A

Inpatient detox

Community detox

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63
Q

What are the risks of using benzodiazepines in pregnancy?

A

1st trimester exposure is associated with cleft palette

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64
Q

Outline how a score from AUDIT is interpreted.

A 
20+ = possible dependence 
16-19 = high risk 
8-15 = moderate risk 
0-7 = low risk

Max = 40

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65
Q

What are the aspects of management of medically unexplained symptoms?

A
  1. Reattribution model = ensure they feel understood, broaden the agenda from a physical and psychological cause, make a link bt sx and psychological factors
  2. Avoid over-investigating = reinforces physical illness beliefs and increases anxiety
  3. Emotional support = encourage pt to discuss emotional difficulties. support them in dealing w stress
  4. encourage normal function = patients may avoid normal activities bcos they think it will exacerbate problems
  5. Antidepressants = may be useful even w/o depression (e.g tension headache, IBS)
  6. Treat comorbid illness = esp anxiety or depression
  7. CBT
  8. Graded exercise = helpful in CFS and fibromyalgia
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66
Q

What is the difference between Fregoli and Capgras syndromes?

A

Fregoli: delusion that a persecutor is able to change into many forms and disguise themselves to look like different people
Capgras: delusional belief that a close acquaintance has been replaced by an identical double

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67
Q

Which psychological therapies are available for patients with dementia?

A

Group cognitive stimulation therapy (memory training and re-learning)
Group reminiscence therapy
Validation therapy (reassure and validate the emotion behind what is said)
Multisensory therapy

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68
Q

What are the stages of change model?

A 
Pre-contemplation
Contemplation 
Preparation 
Action 
Maintenance 
Relapse
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69
Q

What are some psychological therapy options for alcohol abuse?

A

CBT
Problem-solving therapies
Group therapy (alcoholics anonymous)

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70
Q

Which mood stabiliser is considered safest to use in pregnancy?

A

Lamotrigine

Lithium –> Ebstein anomaly
Valproate and Carbamazepine –> NTD

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71
Q

Which SSRIs are associated with a dose-dependent increase in QTc?

A

Citalopram

Escitalopram

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72
Q

Which SSRIs have a high propensity for drug interactions?

A

Fluoxetine and paroxetine

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73
Q

What is an IMHA?

A

Independent Mental Health Advocate
Advocate who helps the patient find out their rights under the MHA and provide support whilst detained
NOTE: patients on section 4, 5, 135 and 136 cannot have an IMHA

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74
Q

Which agents may be used as substitutes in opiate misuse?

A

Methadone (liquid, full agonist) or buprenorphine (sublingual tablet, partial agonist)

NOTE: these are taken in a supervised environment

Buprenorphine causes less sedation so allows patients to work better, but taking heroin with buprenorphine is dangerous so it’s preferred for patients with mild/moderate dependence

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75
Q

What is the antidepressant of choice to treat the depressive phase of BPAD?

A

Fluoxetine

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76
Q

List some indications for ECT.

A

Catatonia
Prolonged or severe manic episode
Severe depression that is life-threatening

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77
Q

Which treatment option is best for children with eating disorders?

A

Family therapy (eating disorder-focused)

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78
Q

Which features distinguish personality disorders from personality traits?

A

Pervasive: occurs in all/most areas of life
Persistent: evident in adolescence and continues through adulthood
Pathological: causes distress to self or others, impairs function

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79
Q

List some clinical signs of anorexia nervosa.

A

Constipation
Bradycardia
Hypothermia
Sensitivity to the cold

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80
Q

What are two psychological therapies that are used to treat PTSD?

A

Trauma Focused CBT

EMDR (eye movement desensitisation and reprocessing)

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81
Q

Describe how you would switch from fluoxetine to venlfaxine.

A

Withdraw then start venlafaxine at 37.5 mg OD and increase very slowly

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82
Q

What is the most common cause of maternal death during pregnancy and the 1st year postpartum?

A

Suicide

NOTE: within 6 weeks postpartum it is VTE

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83
Q

Describe the features of benzodiazepine use.

A 
Loss of coordination 
Slurred speech 
Decreased attention and memory 
Disinhibition 
Aggression 
Hypotension 
Respiratory depression
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84
Q

How is tardive dyskinesia treated?

A

Tetrabenzene

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85
Q

What is the main pharmacological treatment option for patients with dementia?

A

Acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine)

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86
Q

How is schizoaffective disorder treated?

A

Same treatment as schizophrenia

You may add a mood stabiliser or antidepressant for the affective component

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87
Q

How long do symptoms of generalised anxiety disorder have to last in order to be diagnostic?

A

6 months

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88
Q

Which high-intensity psychological therapies may be offered to patients with moderate-to-severe depression?

A

Individual CBT

Interpersonal Therapy

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89
Q

List some complications of bulimia nervosa.

A 
Hypokalaemia 
Dehydration 
Enlargement of parotid glands 
Dental caries
Mallory-Weiss tears 
Osteoporosis 
Russell's sign
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90
Q

Which antipsychotics are particularly associated with weight gain?

A

Olanzapine and clozapine

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91
Q

Who should be offered group CBT?

A

Individuals with mild-to-moderate depression who decline low intensity psychological therapies

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92
Q

What are the main risks of using antipsychotics in the elderly?

A

Stroke and VTE

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93
Q

Why should antipsychotics be avoided in Lewy Body dementia?

A

They precipitate parkinsonism

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94
Q

How is Asperger’s syndrome managed?

A

Advice and support - discuss EHC plan

Social skills training

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95
Q

Which pre-existing conditions can be worsened by acetylcholinesterase inhibitors?

A

Peptic ulcer disease
COPD
Asthma
Cardiac arrhythmias

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96
Q

Describe the features of amphetamine intoxication.

A 
Euphoria
Insomnia
Agitation 
Hallucination 
Hypertension 
Tachycardia
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97
Q

List some features that suggest the patient is at high risk of attempting suicide again.

A

 Careful planning
 Final acts in anticipation of death (e.g. writing wills)
 Isolation at the time of the act
 Precautions taken to prevent discovery (e.g. locking doors)
 Writing a suicide note
 Definite intent to die
 Believing the method to be lethal (even if it wasn’t)
 Violent method (e.g. shooting, hanging, jumping in front of a train)
 Ongoing wish to die/regret that the attempt failed

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98
Q

How often should a patient with newly diagnosed depression be followed-up after starting an antidepressant?

A

Review after 2 weeks (if no particular risk of suicide), then every 2-4 weeks thereafter for 3 months

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99
Q

What criteria must be fulfilled for a diagnosis of chronic insomnia?

A

Diagnosed if a person has trouble falling asleep or staying asleep at least 3 nights per week for 3 months

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100
Q

How does the pattern of BPAD change with age?

A

Remissions become shorter and depressive episodes become more frequent

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101
Q

How is depression in children managed?

A

CBT

Antidepressants (fluoxetine) may be used in severe cases

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102
Q

List some discontinuation symptoms of SSRIs.

A

Flu-like symptoms
Electric shock sensations
Headaches
Vertigo

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103
Q

When is section 48 used?

A

For the transfer of an unsentenced prisoner to hospital for detention

Section 49 is a restriction order that can be applied by the Ministry of Justice

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104
Q

What is considered treatment resistance depression?

A

Failure to respond to 2 adequate trials of different classes of antidepressants at adequate doses and for a period of 6-8 weeks

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105
Q

What is the therapeutic range for lithium?

A

0.6-1.0 mmol/L

Becomes toxic > 1.2 mmol/L

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106
Q

Over what period of time should antidepressants be stopped?

A

4 weeks

Not necessary with fluoxetine due to the long half life

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107
Q

According to DSM-V, how long do psychotic symptoms in schizoaffective disorder need to last to be diagnostic?

A

Psychosis must be sustained for > 2 weeks without affective symptoms
Requires 2 episodes of psychosis to qualify: 1 without affective symptoms, 1 with affective symptoms

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108
Q

Under what conditions can activated charcoal be used for drug overdoses?

A

Oral drugs
Within 1 hour of consumption

• Decreases intestinal absorption of some substances

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109
Q

How can normal pressure hydrocephalus be treated?

A

Ventriculoperitoneal shunt

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110
Q

What should be done if a clozapine dose is missed for > 48 hours?

A

The dose should be carefully retitrated up (as if starting therapy from scratch)

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111
Q

What is applied relaxation therapy?

A

Used for anxiety disorders
Teaches patients how to spot the signs of tension, relax their muscles to relieve tension and apply these techniques to stressful situations
12-15 weekly sessions

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112
Q

What is the main aim of CBT in schizophrenia?

A

Emphasis on reality testing

Encourage the patient to think about evidence and alternative explanations

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113
Q

What needs to be monitored after a patient is started on lithium and how regularly should this happen?

A

Lithium levels - at 1 week after starting, then weekly until therapeutic level is reached. Then every 3 months (12 hours post dose).
U&E - every 3 months
TFTs - every 6 months
Creatinine clearance - annually

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114
Q

Which low-intensity psychotherapies may be offered to patient with mild-to-moderate depression?

A

patients can self refer through IAPT
Individual-guided self-help based on the principles of CBT
Computerised CBT
Structured group physical activity programme

115
Q

What type of drug is mianserin?

A

Tetracyclic antidepressant

116
Q

Define 1 unit of alcohol.

A

8 g of pure ethanol
10 ml of pure ethanol
Amount of alcohol that an adult can metabolise in 1 hour

117
Q

What are the steps in the management of generalised anxiety disorder?

A

1) education about GAD + active monitoring
2) low-intensity psychological intervention (individual non-facilitated self-help or individual-guided self-help or psychoeducational groups)
3) high-intensity psychological intervention (CBT or applied relaxation) or drug treatment
4) highly specialist input

118
Q

What are the criteria for diagnosing ADHD?

A
  1. > 6 months
  2. Inattention and/or hyperactivity-impulsivitity
  3. Pervasive across different situations – manifests in multiple environments
  4. Onset < 12 years
  5. Significant distress or social impairment
119
Q

What are the clinical features of the cheese reaction (in patients taking MAOi)?

A

Severe hypertension
Tachycardia
Pyrexia
Tyramine is found in red wine, cheese, chicken/beef liver, pickled herring, fermented soya beans

120
Q

What are some treatment options for low libido?

A
  1. Establish there are no physical health problems
  2. Encourage communication
  3. Sensate Focus Therapy = ban intercourse –> non genital caressing (focus on pleasure and relaxation) –> genital touching (to achieve arousal and subsequent orgasm) –> eventually intercourse)
  4. Timetabling sex - helps partners with different libidos to reach a compromise
121
Q

Which class of antihypertensive drugs are associated with causing a low mood?

A

Beta-blockers

122
Q

Outline how the GAD7 is interpreted.

A 
Asks about 7 questions and their frequency
	Mild: 5-10
	Moderate: 10-15
	Severe: 15+ 
	Maximum = 21

NOTE: it can also be used for PTSD, panic disorder and social anxiety

123
Q

Describe the clinical features of opiate withdrawal.

A 
Appear 6-24 hours after the last dose 
Lasts 5-7 days 
Dilated pupils
Sweating 
Tachycardia 
Hypertension 
Piloerection (hairs on end)
Watering eyes/nose 
Yawning 
Cool, clammy skin (cold turkey)
124
Q

List some side-effects of SSRIs.

A

GI upset
sexual dysfunction
GI bleeding (if using NSAIDs, give with a PPI)
Increased anxiety/agitation soon after starting

125
Q

List some psychotherapy options that may be used for anorexia nervosa.

A

1st line =
- Eating Disorder CBT
- Specialist Supportive Clinical Management (SSCM)
- Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
Family Therapy (best for children)

2nd line =
- Eating disorder focused focal psychodynamic therapy (FPT)

Other treatment =

  • Motivational Interviewing
  • Interpersonal Therapy
126
Q

Which antidepressant is recommended in patients with comorbid medical conditions due to low risk of drug interactions?

A

Sertraline

127
Q

What are the criteria for diagnosis of bipolar I disorder?

A

At least one manic episode

Depressive episodes are common (more than 90% chance) but not necessary to make the diagnosis

128
Q

Name two forms of nicotine replacement therapy.

A

Varenicline

Bupropion

129
Q

List some side-effects of lithium.

A

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
o Hyperparathyroidism -> features of hypercalcaemia

130
Q

What are the two main subtypes of emotionally unstable personality disorder?

A

Impulsive: characterised predominantly by emotional instability and lack of impulse control
Borderline: characterised by disturbances in self-image, aims and internal preferences. Chronic feelings of emptiness, unstable interpersonal relationships and a tendency to self-destructive behaviour (including suicide gestures and attempts).

131
Q

What are the aspects of managing tic disorders?

A

Reassure, education and stress management
Clonidine (alpha-2 agonist)
Atypical antipsychotic

132
Q

What is interpersonal therapy?

A

Examines how the patient interacts with other people and teaches social skills and improves social functioning

133
Q

List some features of lithium toxicity.

A
  • GI disturbance
  • Sluggishness
  • Giddiness
  • Ataxia
  • Gross tremor
  • Fits
  • Renal failure
134
Q

Briefly outline the step by step pharmacological management for depression.

A

STEP 1: SSRI (e.g. sertraline)
STEP 2: Taper down SSRI, start SNRI (e.g. venlafaxine)
STEP 3: Add augmentation - either atypical antipsychotics (e.g. quetiapine) or another antidepressant (e.g. mirtazapine)
STEP 4: ECT

135
Q

What advice should you provide to a patient who is being started on SSRIs?

A
  • Can cause hyponatraemia
  • Can cause reduced libido/sexual dysfunction
  • Lower seizure threshold (careful in epilepsy)
  • Avoid in mania or hypomania
  • Do not drink alcohol (increased sedation)
  • Never drive if feeling drowsy on antidepressants
  • Explain that the onset of action is delayed
136
Q

What type of drug is zopiclone?

A

Cyclopyrrolone

137
Q

Which medications can be used for acute alcohol withdrawal?

A

Chlordiazepoxide
Diazepam

NOTE: carbamazepine is an alternative

138
Q

What are some side-effects of drugs used in ADHD?

A 
Insomnia 
Reduced appetite (and growth)
139
Q

How is acute dystonia treated?

A

Procyclidine

140
Q

List some examples of MAO inhibitors.

A

Selegiline
Phenylzine
Moclobemide (reversible)

141
Q

List some symptoms of serotonin syndrome.

A

Triad of altered mental state (agitation), neuromuscular changes (hyperreflexia, myoclonus, tremor) and autonomic dysfunction (sweating, dilated pupils, diarrhoea)

142
Q

Describe how you should switch from SSRI to a TCA.

A

Cross-taper

Except with fluoxetine (withdraw completely before starting TCA)

143
Q

How soon after an episode of self-harm should the patient be followed-up?

A

1 week

This can be in outpatient clinic, CMHT, GP or counsellor

144
Q

What are the main components of mental capacity?

A

Understanding information
Retaining information
Weighing up the options
Communicating their thoughts

145
Q

Describe how you should switch from fluoxetine to another SSRI.

A

Withdraw then leave a gap of 4-7 days (fluoxetine has a long half-life) before starting a low-dose of the new SSRI

146
Q

How is neuroleptic malignant syndrome managed?

A

Stop antipsychotics immediately
Get urgent medical treatment (usually ITU)
Treat hyperthermia (cooling blankets, ice packs)
Dantrolene may be used for muscle rigidity
Benzodiazepines may be necessary for agitation
High myoglobin can cause AKI (IV fluids and dialysis may be required)

147
Q

If a patient has a mild cognitive impairment, who is responsible for informing the DVLA about the diagnosis?

A

If mild, the patient should be encouraged to inform the DVLA
If the patient continues to drive despite advice to inform the DVLA, the doctor can breach confidentiality

148
Q

What are the management options for panic disorder?

A

CBT and SSRI

Offer TCA (e.g. clomipramine, imipramine) if SSRI is contraindicated or no response after 12 weeks

149
Q

Which medication can be used for symptomatic relief during opiate withdrawal?

A

Lofexidine (alpha agonist)

150
Q

What is HoNOS?

A

Used to measure behaviour impairment, symptoms and social functioning
Used in severe mental illness

NOTE: GAS (global assessment scale) is a similar sale that assesses overall functioning in people with mental health problems

151
Q

What is a carer’s assessment?

A

A free assessment that can be done by social services that conducts an interview with the carer and helps improve their ability to care for the patient

152
Q

What is the maximum score for a MoCA and what score would warrant further cognitive assessment?

A

Max = 30

Refer for further assessment if 25 or less

153
Q

Outline how the PHQ-9 is interpreted.

A 
9 questions each worth 3 points 
	None: 0-4
	Mild: 5-9
	Moderate: 10-14
	Moderately Severe: 15-19
	Severe: 20-27
154
Q

What is the main difference between anorexia nervosa and bulimia nervosa?

A

Anorexia nervosa BMI < 17.5 or weight loss of > 15%

155
Q

What are the three classes of personality disorder?

A

A - odd (paranoid, schizoid)
B - dramatic (histrionic, emotionally unstable, dissocial)
C - anankastic, dependent, anxious

156
Q

What are the aspects of managing conduct disorder?

A
  1. Family education = help the family understand CD and how they may accidentally reinforce the behaviours
  2. Psychological therapy = talk about feelings and thoughts and how these affect behaviour and wellbeing to a therapist
  3. Parent management training = teaches parents to reward good behaviour and deal constructively with negative behaviours
  4. Family therapy (take a problem-solving approach)
  5. Educational support
  6. Anger management for children
  7. Treact comorbid problems (e.g ADHD)
157
Q

Which high-intensity psychological therapies should be offered for GAD?

A

CBT

Applied relaxation

158
Q

What are the steps in the pharmacological management of generalised anxiety disorder?

A

1) SSRI
2) switch to SNRI
3) Add pregabalin

159
Q

Which low-intensity psychological therapies should be offered for GAD?

A

Individual non-facilitated self-help
Individual guided self-help
Psychoeducational groups

160
Q

What required monitoring during clozapine treatment and how regularly?

A
  1. FBC
    - Weekly for 18 weeks
    - Fortnightly for 1 year
    - Then monthly
  2. Lipids and Weight
    - Baseline
    - Every 3 months for 1 year
    - Annually
  3. Fasting blood sugar and prolactin
    - Baseline
    - 6 months
    - Annually
  4. U&E and LFT
    - At the start of therapy
    - Annual
  5. Blood Pressure and pulse
    - Baseline
    - At 12 weeks
    - Annually
    - Frequently during dose titration
  6. ECG
    - Baseline
  7. Cardiovascular Risk Assessment
    - Annually
161
Q

Outline the management of lithium toxicity.

A
  1. Check lithium level
  2. Stop lithium dose- warning stopping lithium abruptly could precipiate symptoms of mania/depression
  3. Transfer for medical care (rehydration, osmotic diuresis)
  4. If overdose is severe, the patient may need gastric lavage or dialysis
162
Q

List some biochemical consequences of bulimia nervosa.

A 
hypochloraemic hypokalaemic metabolic alkalosis 
hyponatraemia
Hypocalcaemia 
Hypotension
Reduced red cell count
163
Q

Which investigations should be considered in a patient presenting with mania/BPAD?

A

o Collateral history
o Physical examination (establish baseline state)
o Bloods: FBC, TFT, U&E, LFT, ECG
o Measure BMI
o Urine drug screen
o Rating scale: Young Mania Rating Scale
o Risk assessment

164
Q

Which pharmacological treatments may be used in PTSD?

A

Venlafaxine or an SSRI is first-line ONLY IF drug therapy is required

NOTE: risperidone may be used in severe cases
NOTE: mirtazapine is good if they are having problems getting to sleep

165
Q

What is the first line antipsychotic medication used for the treatment of a psychotic illness?

A

Olanzapine (usually starting with 10 mg)

Maximum dose: 20 mg (minimum therapeutic dose is 7.5-1 mg)

166
Q

Which mood stabiliser does not need monitoring of drug levels?

A

Sodium valproate

167
Q

What are some management options for chronic fatigue syndrome?

A

Graded exercise - scheduled and gradually increasing activity
patients need realistic goals and should not do more activity than planned
CBT - improves fatigue and physical functioning

168
Q

Outline the classification of learning disability based on IQ.

A

o 50-70 = Mild
o 35-49 = Moderate
o 20-34 = Severe
o < 20 = Profound

169
Q 
List which antidepressants are associated with the following risks:
•	Drug Interaction
•	Discontinuation Symptoms
•	Death from Overdose
•	Overdose
•	Stopping treatment due to side-effects
•	Blood Pressure Monitoring Needed
•	Worsening Hypertension
•	Postural Hypotension and Arrhythmia
A
  • Drug Interaction: fluoxetine, fluvoxamine, paroxetine
  • Discontinuation Symptoms: paroxetine
  • Death from Overdose: venlafaxine
  • Overdose: TCAs (except lofepramine)
  • Stopping treatment due to side-effects: venlafaxine, duloxetine, TCAs
  • Blood Pressure Monitoring Needed: venlafaxine
  • Worsening Hypertension: venlafaxine, duloxetine
  • Postural Hypotension and Arrhythmia: TCA
170
Q

According to DSM-V, how long do symptoms last in acute stress reactions?

A

At least 3 days

Should disappear within 1 month

171
Q

What are some coping strategies that can be used for patients with thoughts of self-harm?

A

Distraction techniques
Mood-raising activities (e.g. exercise)
Prevention of self-harm (put tablets and sharp objects away, stay in public places with supportive people, call a friend/support line, avoid drugs and alcohol)

172
Q

Transitions between which antidepressants must you be particularly careful with?

A

 From fluoxetine to other antidepressants (as fluoxetine has a long half-life)
 From fluoxetine or paroxetine to a TCA (both drugs inhibit TCA metabolism so a lower starting dose may be needed)
 To a new serotoninergic antidepressant or MAOI (because of risk of serotonin syndrome)
 From non-reversible MAOI: a 2-week washout period is required (other antidepressants should not be prescribed during this period)

173
Q

What are the defining features of dependence syndrome?

A

Craving
Control (difficulties controlling use)
Persistent Use (despite knowledge of harmful consequences)
Priority (higher priority given to drug use than other normal activities)
Tolerance (increased)
Withdrawal

174
Q

Which SSRIs are recommended for postnatal depression?

A

Sertraline and paroxetine

175
Q

Which medication is most commonly used for the treatment of OCD?

A

Fluoxetine 60 mg (high dose)

176
Q

What is the mechanism of action of memantine?

A

NMDA receptor antagonist

177
Q

Which medications may be used for ADHD?

A

Methylphenidate, lisdexamphetamine

Atomoxetine (non-stimulant)

178
Q

How is postnatal depression managed?

A

Same as normal depression (CBT + SSRI)

ssri is safe for breastfeeding

involve the home treatment team and health visitor

post natal community menta health team will be involved

179
Q

List some environmental adaptations that can be recommended for a patient with dementia.

A

Always carry ID, address and contact number in case they get lost
Dossett boxes/blister packs to aid medication compliance
Change gas to electricity
Reality orientation (visible clocks, calendars)
Environmental modifications (e.g. patterned carpets can predispose to hallucinations)
Assistive technology (e.g. door mat buzzers)

180
Q

Which assessment tool is used to assess for the presence of psycopathy in patients?

A

PCL-R

181
Q

List some causes of delirium.

A

CHIMPS PHONED
Constipation, Change of location (ITU, HDU, ward), CNS pathology e.g. raised ICP

Hydration Status = Dehydration, Urine retention

Infection, Intracranial e.g. encephalitis, Systemic e.g. septicaemia, UTI is a common cause in elderly. Cellulitis

Metabolic disturbance e.g. liver failure, renal failure, electrolyte imbalance

Pain

Sleeplessness, Surgery, Stroke

Prescriptions e.g. anticholinergics, opiates, steroids

Hypothermia/pyrexia, Hypoxia: cardiovascular /respiratory

Organ dysfunction: Liver/renal impairment

Nutritional e.g. Wernicke’s encephalopathy

Endocrine e.g. hypoglycaemia

Drugs and alcohol: intoxication and withdrawal

Trauma e.g. head injury, burns

182
Q

Describe the pathophysiology of refeeding syndrome.

A

In starvation the secretion of insulin is decreased in response to a reduced intake of carbohydrates
Instead fat and protein stores are catabolised to produce energy
This results in an intracellular loss of electrolytes, in particular phosphate
Malnourished patients’ intracellular phosphate stores can be depleted despite normal serum phosphate concentrations
When they start to feed, a sudden shift from fat to carbohydrate metabolism occurs and secretion of insulin increases
This stimulates cellular uptake of phosphate, which can lead to profound hypophosphataemia

183
Q

Give an example of an anxiety disorder that is treated with exposure therapy.

A

Agoraphobia

184
Q

What is the risk of a patient presenting with mania developing a depressive episode in the future?

A

> 90%

185
Q

What are the symptoms of neuroleptic malignant syndrome?

A

Pyrexia

Muscle stiffness

186
Q

Which services should be used to manage mental health crises?

A

Crisis resolution

Home treatment team

187
Q

When does postnatal depression occur?

A

From anytime during pregnancy to within 1 year of delivery

188
Q

How are anxiety disorders in children managed?

A

Psychological therapies (CBT)

189
Q

What are the criteria for diagnosis of bipolar II disorder?

A

At least one hypomanic episode (lasting at least 4 days)

At least one major depressive episode

190
Q

What are some harm reduction approaches that are used for opiate misuse?

A

Needle exchange

Vaccination and testing for blood-borne viruses for sex-workers and IVDU

191
Q

Describe how you should switch from citalopram, escitalopram, sertraline or paroxetine to venlafaxine.

A

Cross-taper cautiously (starting on 37.5 mg OD venlafaxine and tapering upwards slowly)

192
Q

What do rehabilitation programmes for alcohol-abuse involve?

A

May be residential or day programmes
Allow a break for people submerged in a drinking community
May be skills-based courses to help find employment

193
Q

Which psychological therapies for patients who have self-harmed?

A

CBT
Mentalisation-based therapy
Transference-focused psychotherapy

194
Q

treatment of acute mania?

A

stop all medications that may induce symptoms

monitor food and fluid intake to prevent dehydration

if not currently on treatment = atypical antipsychotic (olanzapine is 1st line)

if already on treatment: optimise medication, check compliance, adjust doses, consider adding another medication

ECT if unresponsive

195
Q

Which investigations should be considered in a patient presenting with depression?

A 
o	Collateral history 
o	Physical examination 
o	Bloods: FBC, TFT, U&E 
o	Rating Scale: PHQ9, HAD, CDI (children)
o	Risk Assessment
196
Q

List some side-effects of TCAs.

A

Anti-cholinergic side-effects + QT prolongation

	Tachycardia, arrhythmias 
	Dry mouth 
	Blurred vision 
	Constipation 
	Urinary retention 
	Postural hypotension 
	Sedation 
	Nausea
	Weight gain
197
Q

List some screening tools used for alcohol misuse.

A

CAGE - screening
AUDIT (Alcohol Use Disorders Identification Test - screening)
CIWA-Ar (severity of withdrawal)

198
Q

Which investigations are used in neuroleptic malignant syndrome?

A

CK (high)

WCC (high)

199
Q

What are the main approaches to managing OCD?

A

1st line: low intensitity CBT with ERP (exposure and response prevention) for up to 10 hours
2nd line = SSRIs (fluoxetine) - continue for at least 12 months after remission
3nd line: clomipramine or alternative SSRI - if first SSRI is ineffective after 12 weeks

200
Q

What is the a community treatment order (CTO)?

A

Allows being discharged from a previous section but on the agreement that certain conditions are met such as:
 Living in a certain place
 Going somewhere for medical treatment

201
Q

Which class of drugs may be beneficial in bulimia nervosa and why?

A

SSRIs (e.g. high-dose fluoxetine)

Improves impulse control and reduces bingeing/purging behaviour

202
Q

According to DSM-V, how long do psychotic symptoms need to be present to diagnose schizophrenia?

A

At least two diagnostic criteria present over much of the time for > 1 month
Significant impact on social and occupational functioning for > 6 months

NOTE: disorder lasting 1-6 months is schizophreniform disorder

203
Q

Which investigations may be used for ADHD?

A

Questionnaires (Conner’s Rating Scale)
Classroom observation
Educational psychological assessment

204
Q

Which drugs should not be used with SSRIs?

A

Warfarin
Triptans
MAOI

205
Q

Which assessment tool is used to assess the risk of violence?

A

HCR-20

206
Q

What is mentalisation-based therapy?

A

Used for emotionally unstable personality disorder and self-harm
Teaches how to take a step back and assess their mental state and the mental state of others

207
Q

Give some examples of TCAs that causes high sedation and low sedation.

A

High Sedation: amitriptyline, clomipramine, dosulepin, trazadone
Low Sedation: imipramine, lofepramine, nortriptyline

208
Q

How is puerperal psychosis treated?

A

Antipsychotics
ECT may be required if severe
Admission to a mother and baby unit

209
Q

How long should SSRIs be used for in a patient with depression?

A

Until 6 months after the patient’s depression has ended

This can be extended to 1 year for elderly patients

210
Q

Who can make a section 2?

A

Made by an AMHP or nearest relative (NR) on behalf of TWO doctors, one or whom should be section 12 approved (usually SpR or consultant) and one of whom should know the patient in professional capacity (e.g. GP)

211
Q

when to give medication in mild-moderate depression

A

past history of moderate or severe depression
symptoms have been present for a long time >2 years
symptoms persist after other interventions

212
Q

which drugs can interact with antidepressants

A

oral contraceptives, anticonvuldants and anticonvulsants

213
Q

management of moderate to severe depression

A

antidepressant medication and high intensity psychological intervention (CBT or interpersonal therapy)

214
Q

when to follow up a depessed patient <30 years old or at increased suicide risk

A

after 1 week

215
Q

how to manage complex and severe depresson

A

use crisis resolution and home treatment teams to manage crises
develop a crisis plan that identifies triggers and strategies to manage triggers (share with the GP and other people involved in the patient’s care)
consider inpatient treatment if significant risk of suicide, self harm or neglect
consider ECT for acute treatment for depression that is life threatening and when a rapid response is needed or when other treatments have failed

216
Q

what charities for depression

A

mind.co.uk and samaritans

217
Q

what do mood stabilisers do

A

even out the highs of mania and profound lows of deression

218
Q

sodium valproate is an anticonvulsant used for

A

acute mania and prophylaxis

219
Q

Holmes-Rahe Social adjustment top 5

A
  • death of a spouse
  • divorce
  • marital separation from mate
  • detention in jail
  • death of a close family member
220
Q

what is becks model of depression

A

negative cognitive triad of views on the self, the world, and the future.

negative thinking can depress mood, which generates negative thoughts

typical pattern of depression involves distorted and negative thoughts –> this alters mood –> this alters behavior e.g. will avoid people and social events –> this causes positive reinforcement of thoughts as nobody is around to challenge the –ve thoughts –> cycle repeats

221
Q

Differential diagnosis for DEPRESSION

A 
Physical/organic causes
	Hypothyroidism
	Hypercalcaemia
	Cushing’s 
	Addison’s
adjustment disorder
normal grief
dementia
substance misuse
222
Q

step 1 management of depression

A

active monitoring for 2 weeks
psychoeducation: advise on sleep hygiene: establish regular sleep and wake times, avoid excess eating smoking or alcohol before bed

223
Q

what is ECT

A

Uses electrodes to produce a generalised tonic-clonic seizure while the patient is anaesthetised

224
Q

side effects of ECT

A

 Short term side effect: headache, nausea, memory impairment, arrhythmias
 May get memory issues long term

225
Q

management of Seasonal affective disorder

A

Treat in same away as other types of depression +/- light therapy and lifestyle advice

226
Q

depression prognosis

A

o Approx 50% will have at least 1 more episode
o Each episode lasts ~ 8-9 months but treatment can reduce to 2-3 months
o Up to 15% of people with major depression eventually take their own lives

227
Q

how long to treat second episode of depression

A

• A 2nd episode of depression should be treated for at least 2 years following remission.

228
Q

what is psychodynamic psychotherapy

A

o A good relationship between the therapist and the patient is essential
o The patient applies unconscious templates of relationships, derived from past experiences, to the new situation with the therapy (e.g. ‘I will be rejected’)
o These distorted perceptions are known as transferences

229
Q

organic causes of mania

A

 Drug-induced e.g. amphetamines, cocaine
 Dementia
 Frontal lobe disease

230
Q

cyclothymia

A

 This is persistent mood instability with many episodes of mild low mood and mild elation for at least 2 years
 None of the episodes are sufficiently severe or prolonged to meet criteria for even mild depression or hypomania

231
Q

long term management of bpad

A

to be discussed by secondary care four weeks after acute episode resolved
start long term lithium

232
Q

psychological treatment for mania

A

CBT -Identify relapse indicators
o Relapse prevention strategies: e.g. developing routine, sleep hygiene

Psychodynamic psychotherapy - useful if mood stablised

233
Q

social interventions for bpad

A
  • Family support and therapy

* Aiding return to education or work

234
Q

 Primary care referral of mania

A
  • Symptoms of hypomania  routine referral to CMHT

* Symptoms of mania/severe depression  urgent referral to CMHT

235
Q

Primary care management of mania: first presentation

A

 Refer all suspected of BPAD to specialist mental health service to confirm diagnosis, treat acute episode and establish care plan
• Urgent MHA if mania, severe depression or danger to themselves/others

236
Q

risk factors for suicide

A

male, history of mental illness, previous attempt, social support lacks

237
Q

charity for family of suicide victims

A

survivors of bereavement by suicide (SOBS)

238
Q

why do people self harm

A

o Self-punishment
o overcoming numbness
o Substituting psychological distress with physical pain

239
Q

benzodiazepine overdose tx

A

• Flumazenil f

240
Q

treatment of self harm lacerations

A

 Superficial cuts: sutures or Steristrips
 Plastic surgery for deep cuts
 Adequate analgesia should be given

241
Q

immediate intervention for suicide

A

o If at high risk of suicide and lacking capacity, they need to be admitted to a psychiatric ward for their own safety

o Patients at lower risk may be managed at home (depending on home circumstance (e.g. if they have a supportive family))

o A crisis plan should be made to deal with future suicidal ideation or thoughts of self-harm
 Who they will tell
 How they will get help (e.g. coming straight to hospital)

242
Q

investigations for schizophrenia

A

• 1st = Detailed history and mental state exam
• 2nd = Full physical examination and investigations to exclude an organic cause
o Blood tests (FBC, TFTs, U&E, LFTs, CRP, fasting blood glucose)
o Consider HIV, syphilis serology (VDRL)
o Lipids should be checked before starting antipsychotics
o MSU
o Urine analysis, urine drug screen
 Rule out drug induced psychosis
o MRI
o CT scan (rule out organic pathology if suspected)
o EEG (if epilepsy or other organic cause suspected)
• 3rd = obtain collateral history
• 4th = refer to psychiatric team

symptom rating scale

243
Q

For those in crisis and need URGENT INTERVENTION in schizophrenia

A

• refer to a crisis resolution and home treatment team

o Community mental health team
 Provide day to day support and treatment
 CPN – community psychiatric nurse

o Crisis resolution team
 For patients experiencing an acute psychotic episode

244
Q

 Care Programme approach (CPA)  Has 4 stages:

A
  • Assessing health and social needs
  • Creating a care plan
  • Appointing a key worker to be the first point of contact (care coordinator)
  • Reviewing treatment
245
Q

physical health management for schizophrenia

A

o Offer combined healthy eating and physical activity programme
o Offer interventions for metabolic complications
o Monitor cardiovascular risk factor: high rates of cvd due to antipsychotic medication and high smoking rates
o Help with smoking cessation

246
Q

what is harmful use substance

A

o Consuming substances that has consequences but occurs without dependence.

still functioning to a relative degree

247
Q

what is substance abuse/misuse

A

o The continued misuse of any psychoactive substance that severely affects person’s physical and mental health, social situation and responsibilities

248
Q

symptoms of delirium tremens

A

confusion, hallucination, formications, gross tremor, autonomic disturbance, affective changes, delusions
peaks at 48-72 hours and lasts 3-4 days

249
Q

physical complications of alcoholism

A

cirrhosis, pancreatitis, hypertension

250
Q

investigations for alcoholic

A 
FBC
LFTs 
B12/Folate
U+E
clotting screen
glucse
ECG
urine drug screen
251
Q

first thing to do in alcohol misuse management

A

establish their goals - do you want to abstinence

252
Q

• Principles of interventions for alcohol abuse

A

o Carry out a motivational interview: explore problems related to drinking, encourage belief in ability to change
o Offer interventions to promote abstinence as part of intensive structured community-based intervention for people with moderate-severe alcohol dependence who have limited social support, complex physical/psychiatric comorbidities or not responded to initial community-based interventions
o If homeless, offer residential rehabilitation services for maximum of 3 months
o Routinely monitor outcomes
o Provide information about Alcoholics Anonymous, SMART Recovery and Change, Grow, Live (CGL)

253
Q

interventions for harmful drinkers and mild alcohol dependence

A

offer psychological intervention - cbt
offer behavioural couples therapy
if no response to aboive if want meds –> acamprosate and naltrexone

254
Q

assisted alcohol withdrawal if > 15 units/day or >20 on AUDIT, consider offering

A

 Community-based assisted withdrawal (best option)
• Can be done through organisations like Change, Grow, Live
• Usually 2-4 meetings in first week
• If complex, may need up to 4-7 days per week over a 3 week period
 Management in specialist alcohol services if there are safety concerns

255
Q

inpatient assisted withdrawal if 1 or more of

A

 30+ units/day
 30+ on SADQ
 History of epilepsy, delirium tremens or withdrawal-related seizures
 Need concurrent withdrawal of alcohol and benzodiazepines
 Significant psychiatric comorbidity or significant learning disability
 Lower threshold for inpatient treatment in vulnerable groups e.g. homeless, older people
 Children 10-17
• Should also receive family therapy for ~3 months

256
Q

what to explain for withdrawal from alcohol

A

worst in first 48 hours and should pass after 3-7 days

advise against stopping drinkin abruptly

257
Q

investigations for opiate misuse

A 
•	Physical examination (establish baseline physical state)
•	Urine drug screen
•	U&Es (malnutrition)
•	FBC 
o	Anaemia due to malnutrition
o	Signs of infection
•	LFTs
•	Blood borne infections: RPR, hepatitis serology, HIV test
258
Q

general recommendations for opiate misuse

A

o Counsel on aspects of a healthy lifestyle e.g. sleep hygiene, diet
o Provide information about self-help groups - e.g 12 step groups ~ soho recovery centre
o Offer assessment for family members and carers

259
Q

duration of opiate detoxifcation

A

 Inpatient: up to 4 weeks

Community: up to 12 weeks

o Withdrawal symptoms: clonidine and lofexidine can help the symptoms

260
Q

rapid detoxification from opiates

A

1-5 days with moderate sedation = naltrexone or naloxone

261
Q

follow up for opiate misuse

A

o Refer to Drugs and Alcohol Service
o For at least 6 months
o Offer talking therapy (CBT) to prevent relapse
o Appoint a key worker - support u through detox
o Consider contingency management after completed detoxification
 Offer incentives for every drug-negative test
 Screening could be frequent at first (3/week) and then reduce
 Urinalysis is preferred method of screening

262
Q

depression in elderly charity

A

age uk

263
Q

psychosis in elderly tx

A

reduce sensory impairment
exclude organic cause or lewy body dementia
low dose antipsychotics

264
Q

social support for dementia

A

personal care, meal preparation and medication promping

day centres provide enjoyable daytime activities and social contacts

day hospitals enable daily psychiatric care for more complex patients

265
Q

investigations for delirium

A

● Physical examination
● Collateral history: is this patient usually forgetful?
● AMTS (abbreviated mental test)
● Check drug chart for recently added drugs
● Basic observations
o Early warning scores
o BP and pulse, Temperature, RR and SaO2
● If delirium suspected, carry out specialist clinical assessment
o o Short Confusion Assessment Method (short CAM)
t
● Bloods: FBC, U&E, LFTs. TFTs, CRP
o CA2+: hypercalcaemia can cause confusion
o B12/folate
o Glucose: hypoglycaemia can cause confusion
● Urine dipstick/culture
● ECG
● CXR: rule out pneumonia, congestive heart failure, other potential causes of hypoxia
● Urine drug screen
● ABG

266
Q

investigations for dementia

A

history and collateral history

confusion profile - fbc, u+e, tft, b12, folate, calcium, glucose, lipids, vdrl, hiv to rule out reversible causes

cognitive testing - MMSE
ct brain

refer to memory clinic for mdt approach (old age psychiatrists, neurologists or geriatricians)

267
Q

first step in dementia management

A

appoint a care coordinator

268
Q

what is trauma focused cbt

A

o A traumatic event can shatter previous belief systems (e.g. the world is an unsafe place, I am vulnerable)
o These thoughts can be examined and tested
o Exposure therapy is important (support the patient to work through their memories)
o WARNING: talking about the experience can make the patient feel re-traumatised
o Usually 8-12 regular sessions (can be computerised)

269
Q

initial treatment for anorexia nervosa if medically stable and suitable for outpatient

A
  1. advice on nutrion and health
  2. treat comorbid psychiatric illness
  3. nutritional management and weight restoration
    - Realistic weekly weight gain target (usually 0.5-1 kg/week)
    - Set eating plan
270
Q

investigations for anorexia and bulimia

A
  • Height, weight and BMI
  • FBC, U+E, TFT, LFT, urine dip, ESR , glucose,
  • Squat test - Ask the patient to squat down and rise without using their arms –> Tests proximal myopathy

• ECG: Bradycardia
o arrhythmias and prolonged QT interval
 Due to low potassium (caused by repeated vomiting)  metabolic alkalosis

Other tests as indicated: DEXA to assess bone density

271
Q

when to consider inpatient treatment for anorexia

A
  1. BMI < 13 or extremely rapid weight loss
  2. Serious physical complications
  3. High suicide risk

Mental Health Act may be needed to enable compulsory feeding

272
Q

referral pathways for anorexia nervosa

A

Mild: monitor/advice/support for 8 weeks, recommend support from BEAT, routine referral to community eating disorder service (CEDS) if failure to respond
 Features: BMI > 17, no additional co-morbidity

Moderate: routine referral to CEDS
 Features: BMI 15-17, no evidence of system failure
o Severe: urgent referral to CEDS
 Features: BMI <15, rapid weight loss, evidence of system failure

273
Q

bulimia clinical presentation

A

binge eating
purging
body image distortion
bmi > 17.5

at least once a week for 3 months <

274
Q

referral pathways for bulimia

A

Mild: recommend self-help, recommend BEAT, monitor/advice/support for 3 months, routine referral to CEDS if no improvement/deterioration

Moderate: monitor/advice/support for 8 weeks, recommend self-help, consider SSRI, routine referral to CEDS if failure to response
 Features: frequent binging and purging (>2/week), no significant electrolyte abnormality, some medical consequences e.g. chest pain

o Severe: urgent referral to CEDS
 Features: daily purging with significant electrolyte imbalance, comorbidity

275
Q

bulimia management

A
  1. treat medical complications and comorbid psychiatric illness
  2. BN-focused guided self-help –> if ineffective after 4 weeks: CBT-ED
  3. SSRIs

o Encourage those who are vomiting to
 Have regular dental and medical reviews
 Avoid brushing teeth immediately after vomiting
 Rise with non-acid mouthwash after vomiting
 Avoid highly acidic food and drinks

276
Q

binge eating dirsoder

A
  • Offer BED focussed self guided self-help programme for adults
  • If unacceptable or ineffective after 4 weeks: consider group CBT-ED
  • If unacceptable or ineffective, consider individual CBT-ED
277
Q

hypersexuality management

A

cbt

278
Q

disorders of gender identity management

A

hormone therapy

gender reassignment surgery

279
Q

bipolar disorder in pregnancy management

A

consider stopping lithium gradually over 4 weeks and switch to antipsychotic instead

antipsychotic is safe to use in pregnancy and breastfeeding

monitor every 4 weeks, weekly from the 36th week

ensure the woman gives birth in hosptial

280
Q

aspergers triad

A

normal intelligence, no delay in language development, impaired social and communication skills and narrow range obsessional interests

281
Q

management of encopresis

A 
o	Laxatives (if constipated)  
o	Reassure, address stress and review toilet training  
o	Star charts
282
Q

what is dialectical behavioural therapy

A

cbt for people who experience emotions very intensely

validation: accepting that your emotions are acceptable
dialectics: showing you that things in life are rarely black or white and helping you to be open to ideas and opinions that contradict your own

283
Q

crisis management for eupd

A 
provide contact numbers for:
community mental health nurse
out of hours social worker
local crisis resolution team 
mind.co.uk
284
Q

management for chronic insomnia

A

identify potential causes

advise on sleep hygiene and not to drive when tired

CBT-I for insomnia

hypnotics if major day time impairments - lorazepam or zopiclone
use the lowest dose for the shortest possible time

YEAR 5: Specialties (Laz) (19 decks)

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