Psychiatry Flashcards

Question

When is ECT offered for treatment of depression?

Answer 1

Patient has strong preference - usually have responded well before Rapid treatment required - life-threatening depression where patient is not eating/drinking, while waiting for effects of antidepressant therapy Multiple other treatments have been trialled unsuccessfully

Answer 2

Indications - first-line for moderate-severe depression, may be used in mild depression if long-term/other interventions failed Also used in EDs, anxiety disorders Contraindications: Bipolar affective disorder, manic episode or history of mania Poorly controlled epilepsy Known QT prolongation, congenital long QT or concurrent use of drugs which prolong QT (citalopram and escitalopram) Severe hepatic impairment (sertraline)

Answer 3

Rare adverse effect of all antipsychotics Fever Sweating Rigidity Confusion Fluctuating consciousness Fluctuating blood pressure Tachycardia Raised CK Leucocytosis LFT derangement

Answer 4

Sedatives e.g. sedating antihistamines Drugs which cause hypotension Drugs which prolong QT e.g. erythromycin Azole antifungals - increase levels of some antipsychotics (e.g. haloperidol) Carbamazepine - decreases levels of antipsychotics Grapefruit juice - increases levels of pimozide SSRI - increase levels of some antipsychotics (e.g. haloperidol and fluoxetine) Smoking cessation - increases level of olanzapine and clozapine

Answer 5

Fluoxetine Sertraline Citalopram Escitalopram Paroxetine

Answer 6

Cardiac - palpitations, QT prolongation (citalopram and escitalopram), torsade de pointes GI - reduced appetite, diarrhoea, nausea, constipation, vomiting, weight changes, hepatitis (rare) CNS - sleep disorders (insomnia common), headache, dizziness, reduced seizure threshold, drowsiness, serotonin syndrome (rare) Psychiatric - anxiety, memory problems, suicidal thoughts Skin - hyperhidrosis (common) Other - menstrual cycle abnormalities, sexual dysfunction, hyponatraemia (especially in elderly), impaired diabetic control, bleeding

Answer 7

Genetic: Very heritable - 5x greater lifetime risk if first degree relative with bipolar disorder Environmental: Maternal infections - toxoplasma gondii Premature birth Early life stress - childhood abuse/trauma Cannabis and cocaine use

Answer 8

Bipolar I - has had at least one episode of mania Bipolar II - has had at least one episode of hypomania (but never an episode of mania), and at least one episode of major depression

Answer 9

Mania - >7 days, usually begin abruptly, caused marked impairment of social/occupational functioning Abnormally elevated mood, extreme irritability, increased energy or activity, restlessness, decreased need for sleep Pressure of speech, flight of ideas, racing thoughts, poor concentration Increased libido, disinhibition, sexual indiscretions Psychotic symptoms - delusions (usually grandiose) or hallucinations (usually voices) Hypomania - not severe enough to cause functional impairment, no psychotic features, 4-7 days Mild elevation or mood or irritability Increased energy and activity, may lead to increased performance at work/socially Increased sociability Depression - persistent low mood, anhedonia, low energy (+ other features)

Answer 10

Unipolar depression - no manic/hypomanic episodes Cyclothymia - chronic disturbance of mood where symptoms do not meet criteria for bipolar disorder or depression Schizophrenia - absence of prominent mood symptoms, auditory hallucinations usually 3rd person rather than 2nd person Mood disorder due to underlying medical condition e.g. thyroid Substance misuse - symptoms subside within 7 days Personality disorders - rapid mood changes, do not occur in cycles

Answer 11

Risk assessment - include potential consequences of poor judgement/actions during acute episodes (employment, relationships, finance, sexual activity, alcohol/drug use) Acute phase management: Mania - antipsychotic (haloperidol, olanzapine, quetiapine or risperidone), if two antipsychotics are tried and do not give response may add lithium or sodium valproate (unless pre-menopausal woman) Depression - antipsychotic +/- antidepressant (fluoxetine), lamotrigine Long-term management: Relapse prevention - continue treatment for mania, start long term lithium or add valproate if lithium alone not effective Psychological therapies specifically for bipolar depression Important to take measures e.g. appointing power of attorney, advance statement to ensure wishes are known during possible future episodes

Answer 12

Female sex Comorbid anxiety disorder e.g. social phobia Childhood adversity - maltreatment, neglect, domestic violence, bullying History of physical, sexual or emotional trauma Sociodemographic factors - divorce, unemployment, low socioeconomic status, low education level Chronic physical condition e.g. cancer

Answer 13

Psychological symptoms: Chronic, excessive feelings of worry not related to particular circumstances Restlessness Sense of dread Feeling constantly on edge Difficulty concentrating, easily distracted Feelings of detachment - derealisation, depersonalisation Fear of losing control Fear of dying Panic attacks Sleep disturbance Physical symptoms: Chest/abdo - Nausea/churning stomach Palpitations Chest pain Tachypnoea Lightheadedness Arousal symptoms - Sweating Dry mouth Difficulty swallowing Muscle stiffness/aches Tremor

Answer 14

Situational anxiety - controllable, no pathological symptoms, related to particular situation Adjustment disorder - temporary anxiety in response to a life stressor, <6 months Depression Panic disorder - recurrent episodes of sudden onset anxiety, absence of multi-themed worry, physical symptoms during episodes, avoidance behaviours (often comorbid) Social phobia - limited to social situation, avoidance behaviour common Obsessive-compulsive disorder - anxiety due to compulsions/obsessions Post-traumatic stress disorder - anxiety caused by exposure to reminders of past trauma, flashbacks and nightmares Anorexia nervosa - anxiety related to fear of gaining weight Substance or drug-induced anxiety disorder, or withdrawal related anxiety

Answer 15

Step 1 - education about GAD and treatment options, active monitoring Step 2 - low-intensity psychological interventions (individual self-help, psychoeducational groups) Step 3 - high-intensity psychological intervention (e.g. CBT) or drug treatment (SSRI - sertraline usually offered first, other SSRI or SNRI if ineffective) Step 4 - complex drug and/or psychological treatment regimen, inpatient care

Answer 16

Anxiety evoked only/predominantly by a specific external situation, e.g. Agoraphobia - crowds, public places, leaving home Social phobia - low self esteem, fear of criticism/embarrassment Claustrophobia Anticipatory anxiety - about exposure to precipitant and anxiety itself Somatic symptoms - palpitations, sweating etc.

Answer 17

Recurrent unpredictable episodes of severe acute anxiety, not restricted to particular stimuli or situations Crescendo of anxiety Somatic symptoms Secondary fear of dying/losing control - often related to somatic symptoms

Answer 18

Develops following exposure to extremely traumatic event/series of events Features - HARD: Hyperarousal - persistently heightened perception of current threat Avoidance of situations reminiscent of events or memories of events Re-experiencing events - intrusive memories, flashbacks, nightmares Distress - strong/overwhelming fear and physical sensations when re-experiencing

Answer 19

Prevention (for those with acute stress disorder or symptoms of PTSD within 1 month exposure to traumatic events) - psychological interventions e.g. cognitive processing therapy >1 month from traumatic events - treatment Psychological treatment - trauma-focused CBT Eye movement densensitisation and reprocessing (EDMR) Drug treatment - SSRI or venlafaxine, antipsychotics only if no response to other treatments and psychotic symptoms

Answer 20

CBT SSRI - escitalopram or sertraline

Answer 21

Step 1 - Low intensity psychological treatment - brief individual CBT, group CBT Step 2 - SSRI Step 3 - Combined CBT + SSRI

Answer 22

Lithium Carbamazepine Sodium valproate

Answer 23

Acute treatment of mania or hypomania in bipolar disorder Prophylaxis/maintenance in bipolar disorder and schizoaffective disorder Prophylaxis in recurrent depressive illness Augmentation of antidepressants in acute depressive illness Treatment of depression in bipolar disorder

Answer 24

Addison's disease Cardiac disease associated with rhythm disorder - ECG required prior to treatment Cardiac insufficiency Dehydration Family or personal history of Brugada syndrome Low sodium diet Untreated hypothyroidism - TFTs required prior to treatment Pregnancy - causes tricuspid deformity

Answer 25

LITHIUM - L - lethargy I - insipidus (diabetes insipidus - increased thirst, excessive urination) T - tremor H - hypothyroidism, hyperparathyroidism I - insides (GI - nausea, vomiting, diarrhoea) U - urine (increased) M - metallic taste, muscle weakness Others - Weight gain Renal tubular necrosis - renal failure Confusion, drowsiness, feeling dazed Seizures

Answer 26

LITHIUM - L - lethargy I - insipidus (diabetes insipidus - increased thirst, excessive urination) T - tremor H - hypothyroidism, hyperparathyroidism I - insides (GI - nausea, vomiting, diarrhoea) U - urine (increased) M - metallic taste, muscle weakness Others - Weight gain Renal tubular necrosis - renal failure Confusion, drowsiness Seizures Toxicity

Answer 27

Initially - Fine tremor Nausea/vomiting Dizziness Progresses to - Course tremor Ataxia Dysarthria Drowsiness Confusion Seizures Coma Death Serum level >1.2mmol/L

Answer 28

Investigations - serum lithium level, U&Es, ECG Management - Increase clearance via IV fluids Reduce absorption via gastric lavage, whole bowel irrigation

Answer 29

Neurological - myoclonus, nystagmus, headache, tremor, rigidity, seizures Mental state - irritability, confusion, agitation, hypomania, coma Other - hyperpyrexia, sweating, diarrhoea, cardiac arrhythmias, death

Answer 30

Thiazide (and loop to a lesser extent) diuretics, ACE inhibitors - increase lithium levels by reducing clearance, can cause toxicity NSAIDs - increase lithium levels Haloperidol, carbemazepine, serotonergic antidepressants - can cause severe neurotoxicity

Answer 31

Serum lithium levels measured one week after starting treatment/changing dose and once weekly until levels stable, then usually every 3 months (12 hours post-dose) 6 monthly - Weight/BMI U&Es including eGFR Calcium Thyroid function tests

Answer 32

When lithium is ineffective/poorly tolerated in long-term prophylaxis for bipolar disorder As an alternative to antipsychotic/lithium for mania/hypomania (valproate only) 1st line - valproate (unless woman of childbearing age) Other options - lamotrigine, carbemazepine

Answer 33

Active liver disease Personal or family history of severe, drug-related hepatic dysfunction Acute porphyria Mitochondral disorders of polymerase gamma enzyme e.g. Alpers-Hutternlocher syndrome

Answer 34

Gastric irritation, nausea Lethargy/confusion Weight gain Hair loss, curly regrowth Peripheral oedema Rarely hepatic failure Hyperandrogenism in women - menstrual cycle abnormalities, PCOS, fertility dysfunction Thrombocytopaenia, leucopaenia, red cell hypoplasia Pancreatitis Seizures Suicidal thoughts

Answer 35

Myoclonic seizures - may exacerbate Parkinson's disease - may exacerbate Brugada syndrome

Answer 36

Skin rash - can be severe e.g. Stevens-Johnson syndrome/TEN GI - nausea, vomiting, diarrhoea Aggression, agitation Diplopia, blurred vision, conjunctivities Confusion, nightmares, hallucinations Suicidal thoughts

Answer 37

Acute porphyrias AV conduction abnormalities (unless paced) History of bone marrow depression Acute liver disease Some HLA alleles predispose to cutaneous reactions e.g. Stevens-Johnson syndrome

Answer 38

GI discomfort, nausea Dizziness Drowsiness, fatigue Headache Leucopaenia, thrombocytopaenia Skin reactions Weight gain Movement disorders e.g. ataxia

Answer 39

Similar to bipolar disorder with periods of depression and hypomania, but no episodes which meet criteria for a major depressive episode or manic episode Symptoms >2 years

Answer 40

Usually underlying diagnosis of psychiatric illness - will present with worsening depression, mania or psychosis and catatonic symptoms Motor disturbance - reduction in movement, agitation or mixture of both Repetitive or purposeless movements and mannerisms Rigidity, waxy flexibility Mutism, echolalia (repetition of others speech), verbigeration (repeating meaningless phrases) Refusal to eat/drink Malignant catatonia - life-threatening autonomic dysfunction including fever, abnormalities in blood pressure, heart rate, respiratory rate, sweating, delirium

Answer 41

Multiple depressive episodes (low mood, anhedonia, lack of energy, sleep and appetite problems, poor concentration, decreased libido) which have occurred during the same season in different years, usually winter

Answer 42

Progressive, irreversible clinical syndrome with impairment of more than one aspect of higher brain function (concentration, memory, language, personality, emotion), without impairment of consciousness Range of cognitive and behavioural symptoms including memory loss, problems in reasoning and communication, change in personality and reduction in ability to carry out daily activities Not attributable to normal ageing

Answer 43

Alzheimer's dementia - amyloid plaques and tau neurofibrillary tangles Vascular dementia - multiple small cerebrovascular infarcts Lewy body dementia - Lewy body protein (alpha-synuclein) deposits Fronto-temporal dementia (including Pick's disease) - deposition of abnormal proteins (often tau) in frontal and temporal lobes Prion protein diseases (CJD) - eating cattle meat infected with bovine spongiform encephalopathy HIV-related dementia Parkinson's disease dementia - loss of dopaminergic neurons in substantia nigra

Answer 44

Usually insidious onset with non-specific signs/symptoms Cognitive impairment - memory loss, problems with reasoning and communication, difficulty making decisions, dysphagia, difficult carrying out coordinated movements, disorientated and unawareness of time and place, impairment of executive function (planning, judgement, problem solving) Behavioural and psychological symptoms - psychosis (delusions, hallucinations), agitation and emotional lability, depression and anxiety, withdrawal or apathy, disinhibition, motor disturbance, sleep cycle disturbance and insomnia

Answer 45

Alzheimer's - loss of short term and episodic memory, difficulty with executive dysfunction, aphasia, apraxia, agnosia Vascular dementia - stepwise increases in severity of symptoms, may have focal neurological signs e.g. hemiparesis Dementia with Lewy bodies - fluctuating cognition, recurrent visual hallucinations, features of Parkinsonism (bradykinesia, rest tremor, rigidity) Frontotemporal dementia - personality change and behavioural disturbance with other cognitive functions relatively preserved initially

Answer 46

History from patient and collateral e.g. from family member Blood tests to exclude reversible causes - FBC, ESR, CRP, U&Es, calcium, HbAlc, LFTs, TFTs, serum B12 and folate May need urinalysis, CXR, ECG, syphilis serology, HIV testing Assess cognition with scoring system e.g. 10-point cognitive screener or memory impairment screen Specialist diagnosis of dementia subtype - can do further testing e.g. CSF analysis, PET scanning Structural imaging e.g. MRI/CT

Answer 47

Involve family members and make care plan early Non-pharmacological interventions - cognitive stimulation therapy, group reminiscence therapy, cognitive rehabilitation, occupational therapy Pharmacological management - acetylcholinesterase inhibitors +/-memantine for mild to moderate Alzheimer's, vascular dementia with Alzheimer's and Lewy body dementia Management of behavioural symptoms - attempt non-pharmacological first, give antipsychotics if risk of harm/severe distress

Answer 48

Three acetylcholinesterase inhibitors - donepezil, galantamine, rivastigmine Memantine - glutamate receptor antagonist Acetylcholinesterase inhibitors are first line for mild - moderate Alzheimer's and mild, moderate or severe Lewy body dementia Memantine for those intolerant/contraindication to AChE inhibitors, first line for severe Alzheimer's AChE + memantine for moderate - severe disease

Answer 49

AChE inhibitors contraindications: Galantamine - severe renal/hepatic impairment, urinary outflow obstruction, GI obstruction All - hypersensitivity to drugs, pregnancy/breastfeeding, history of bradycardia/heart block Adverse effects: Vomiting, nausea, anorexia, weight loss Dizziness, drowsiness Arrhythmias Headache Hallucinations Rarely - neuroleptic malignant syndrome

Answer 50

Contraindications - severe hepatic/renal impairment, history of seizures/predisposing factors for epilepsy, hypersensitivity Adverse effects - Constipation Hypertension Dyspnoea Headache Dizziness Impaired balance Drowsiness Rarely - seizures, depression, suicidal ideation

Answer 51

Acute, fluctuating, transient disturbance in level of consciousness, attention, global cognition and perception with an organic, reversible cause

Answer 52

Predisposing: Older age Cognitive impairment e.g. dementia Frailty/multi-morbidity Significant injuries Functional impairment History of, or current, alcohol excess Sensory impairment Poor nutrition Precipitating: Infection e.g. UTI, pneumonia Metabolic disturbance e.g. hypoglycaemia Cardiovascular, respiratory or neurological disorders - MI, PE, stroke Urinary retention Hepatic failure, constipation Severe pain Alcohol intoxication or withdrawal Medication - opioids, benzodiazepines, antihistamines, antipsychotics Psychosocial factors - sleep deprivation, emotional stress, change of environment

Answer 53

Acute - hours - days Evidence of precipitating factor e.g. infection Fluctuating symptoms - usually worse at night Altered cognitive function - disorientated, memory/language impairment, poor concentration, confusion Inattention Disorganised thinking Altered perception - delusions, visual/auditory hallucinations Altered social behaviour - mood changes, inappropriate behaviour Altered level of consciousness, sleep-cycle disturbance

Answer 54

Identify and manage underlying cause Gentle reorientation and reassurance Short-term haloperidol for distress only if other measures have failed and patient is a risk to themselves or others

Answer 55

Symptoms of schizophrenia (usually psychosis) and a mood disorder - usually bipolar disorder and depression Have to have episodes of mood disorder-free psychosis in the context of a long term mood disorder (If only psychotic symptoms during mood episode it is mood disorder with psychotic features not schizoaffective disorder) Psychosis including delusions, hallucinations, disorganised thinking/speech/behaviour and negative symptoms Mood symptoms - mania, hypomania, mixed or depression

Answer 56

Cluster A - 'odd or eccentric' Paranoid personality disorder Schizoid personality disorder Schizotypal personality Cluster B - 'dramatic, emotional or erratic' Antisocial personality disorder Borderline personality disorder Histrionic personality disorder Narcissistic personality disorder Cluster C - 'anxious or fearful' Avoidant personality disorder Dependent personality disorder Obsessive-compulsive personality disorder

Answer 57

Suspicious Hypersensitivity, easily offended Unforgiving Questions loyalty Preoccupation with conspiratorial beliefs and hidden meaning Perceives attacks on their character

Answer 58

Socially withdrawn Preference for solitary activities No emotional pleasure from activities Emotional coldness Indifferent to praise or criticism Little interest in sexual interactions Few friends/confidants

Answer 59

Odd beliefs and magical thinking Inappropriate affect Odd speech but coherent Unusual perceptual disturbances Paranoid ideation and suspiciousness Social and interpersonal deficits

Answer 60

No regard for social norms, rules and obligations e.g. the law Unable to maintain relationships, consistent work, honour financial obligations Lack of remorse Deception - repeated lying, conning others Impulsiveness Irritability and aggressiveness Reckless disregard for safety of self or others Unable to experience guilt, no concern for others feelings

Answer 61

Intense, unstable relationships Impulsivity Unstable mood, angry outbursts Unstable self imaging Avoidance of real or imagined abandonment Self harm, suicidal behaviour Feelings of emptiness Quasi-psychotic thoughts - short-lived, less bizarre than real psychosis

Answer 62

Dramatic/theatrical Inappropriately seductive Need to be the centre of attention Easily influenced Preoccupied with physical appearance

Answer 63

Grandiose sense of self importance Sense of entitlement Lack of empathy Very sensitive Preoccupied with fantasies of success, power, beauty Belief they are 'special' and 'unique' Need for admiration Envious of others Interpersonally exploitative Arrogant/haughty attitude

Answer 64

Feelings of being socially inhibited, criticised or rejected Reluctance to take risks due to fear of embarrassment Views self as inferior or inadequate to others Tense and apprehensive Restraint in intimate relationships due to fear of being ridiculed

Answer 65

Pervasive need to be cared for by others Difficulty making decisions without reassurance and advice Unrealistic fears of being left to care for themselves Uncomfortable/helpless alone

Answer 66

Preoccupied with details, rules, lists, order, organisation Perfectionism that hampers with completing tasks Meticulous, scrupulous and rigid about ideas of morality, ethics and values Unwilling to pass on tasks to others Dedicated to work and efficiency, no time for leisurely activities Displays stiffness and stubbornness

Answer 67

Assess and manage risk Psychotherapy interventions - individual, family, group CBT Pharmacotherapy - Antipsychotics - may be helpful in schizotypal, borderline Antidepressants - borderline Mood stabilisers - borderline Cluster A - poor prognosis Cluster B - high risk for suicide, antisocial particularly poor prognosis, variable response for others Cluster C - better prognosis

Answer 68

Reaction to life stressor/traumatic event which is greater than the expected normal or significantly impairs their functional ability Usually begin within 3 months of event, do not last longer than 6 months after the event Can have features of depression, anxiety, PTSD, misconduct Can have prominent suicidal behaviour

Answer 69

Psychotherapy e.g. CBT Pharmacotherapy e.g. antidepressants, benzodiazepines only with severe symptoms

Answer 70

Self-harm - usually cutting, can also be self-poisoning (usually with OTC, less often with illicit drugs), burning, hanging, drowning, swallowing objects, jumping from height/in front of vehicles Self harm can include suicide attempts as well as acts with little or no suicidal intent - to communicate distress, release internal tension, feel relief when overwhelmed Self harm rates peak in 16-24 year old females, 25-34 year old males Suicide rates highest in both aged 45-49 Associated with: Low socioeconomic status Social isolation Stressful life events Bereavement Mental health disorders Chronic physical health problems Alcohol/drug misuse Involvement with criminal justice system

Answer 71

Examine physical injuries Assess emotional and mental state, risk assessment - suicidal intent Likely to need emergency department assessment if self-poisoned May require treatment/admission against their wishes under Mental Health Act Referral to community mental health team

Answer 72

Psychological interventions e.g. CBT Harm minimisation strategies - use less harmful methods of self-injury e.g. pinching, ice cubes, rubber bands Manage mental health problems e.g. anxiety, depression, addiction Prevent access to means of self-harm - least dangerous drugs prescribed (e.g. SSRIs) and few tablets once

Answer 73

Final acts e.g. making a will, saying goodbye to family/friends Planning of method (premeditation) - buying tablets, rope etc. Measures to prevent interruption e.g. lonely spot, timing when others out of house Patient's perception of method most likely to be successful/lethal - even if this is not medically accurate it is the patient's intent which matters Active symptoms of mental illness especially severe depressive disorder Absence of intoxicants at time of act (doesn't mean attempt is less dangerous) Regret over failure, indifference to being found/alive Continuing means to commit suicide Hopelessness Ongoing intent

Answer 74

Admission to psychiatry ward if necessary Diagnosis and treatment of mental illness and substance misuse problems After acute crisis: Discharge planning - follow-up in secondary care (community psychiatry, outpatient psychiatry) or primary care

Answer 75

History: Previous violence, known to criminal justice system Poor concordance with treatment, discontinuation of disengagement Impulsivity Alcohol and substance use Triggers, changes in behaviour or mental state which have occurred prior to previous violence or relapse Anything which is likely to occur to change risk Evidence of recent stressors or losses Factors which have stopped them acting violently in the past History of domestic violence Lack of empathy Environment: Access to potential victims - children or other vulnerable people, caring for someone, occupation Risk of harm via neglect - dependents Access to weapons, violent means Involvement in radicalisation Mental state: Delusions of persecution by others Passivity - mind or body controlled by external forces Voicing emotions related to violence or emotional arousal Specific threats or ideas of retaliation Thoughts linking violence and suicide (homicide-suicide) Thoughts of sexual violence Restricted insight What do they think they are capable of? Do they think they could kill? Consult other sources - carers, criminal record, police, probation reports Formulating risk: How serious is the risk? How immediate is the risk? Is the risk specific or general? What are the signs of increasing risk? Which specific management plan can best reduce the risk?

Answer 76

Dependent on level of risk, patient capacity, patient willingness to engage, patient support e.g. family etc. May require detainment, tranquillisation, restraint if imminent serious risk, patient lacking capacity and not willing to engage May be able to agree a safety plan with patient with some level of observation, management of mental illness/substance use issues

Answer 77

1. Current episode of self-harm: Was there a precipitant? Were precautions taken against discovery? Did they do any final acts? Were they intoxicated? What method of self harm was used? What was the intention of the self harm - to end life? Who were they found by? How do they feel about the attempt now, do they regret it? Do they still feel suicidal? What would prevent them doing it again - do they feel they have anything to live for? 2. Screen for other mental health disorders which increase the risk of suicide - depression, psychosis, anorexia (diagnosed or undiagnosed) 3. Previous episodes of self-harm 4. Past psychiatric history - diagnoses, previous admissions 5. Past medical history 6. Drug history 7. Family history - any family members with psychiatric conditions, suicidal behaviours 8. Social history - living situation (children?), occupation, financial, alcohol, illicit drugs

Answer 78

Stages of change: Pre-contemplation - patient is not thinking about stopping, doesn't acknowledge there is a problem (likely to be defensive, may not be receptive to intervention, encourage reflection without pushing) Contemplation - patient is thinking about stopping, acknowledges there is a problem (likely to be more receptive to intervention, reinforce decision through evaluating pros and cons) Preparation - patient is making plans to stop (identify obstacles, support system) Action - patient tries to stop (likely to require close support, emphasise benefits and deal with obstacles) Maintenance - patient remains abstinent (continuing follow-up, think about coping with relapse) Relapse - resumption of old behaviours (evaluate triggers, reassess motivation and barriers, plan future coping strategies)

Answer 79

Factitious disorder (Munchausen's) - intentionally feigns, exaggerates or produces symptoms in order to attain care from medical professionals Malingering - intentionally feigns, exaggerates or produces symptoms for the intention of financial or other gain, e.g. relief from work Conversion disorder (functional neurological disorder) - genuine neurological symptoms (not fabricated by patient) without an organic cause Somatic symptom disorder - obsessive thoughts and anxiety over symptoms without an identifiable cause e.g. pain, weakness, fatigue, symptoms present >2 years Hypochondriasis (illness anxiety disorder) - persistent belief in the presence of an underlying serious disease, refuses to accept reassurance or negative test results

Answer 80

Investigate for physical cause Provide reassurance that symptoms are real and explain how psychological stresses can manifest as physical symptoms Antidepressants often helpful CBT

Answer 81

Harmful use - pattern of substance use which causes damage to physical health, mental health or social circumstances Dependence - physiological, behavioural and cognitive phenomena where the use of a substance takes on a higher priority than other behaviours which previously had greater value, central is the strong/overpowering desire to take the substance

Answer 82

A strong desire or sense of compulsion to take the substance Difficulties in controlling substance-taking behaviour in terms of onset, termination or levels of use A physiological withdrawal state when substance has ceased or been reduced Progressive neglect of alternative pleasures or interests because of substance use Persisting with substance use despite clear evidence of overtly harmful consequences

Answer 83

Anxiety Agitation Irritability Diaphoresis Confusion Nausea Palpitations Insomnia Seizures Hallucinations Psychosis

Answer 84

Rhinitis Lacrimation Yawning Dilated pupils Diaphoresis Insomnia Diarrhoea Nausea & vomiting Piloerection Abdominal cramps Dysphoria Tachycardia Hypertension

Answer 85

Hx of Alcohol Confusion - Nocturnal worsening Hallucinations - Lilliputian Illusions - Insects Anxiety/Fear Tremulousness Hypertension Tachycardia Tachypnoea Seizures

Answer 86

Motivational interviewing Brief interventions - useful in misuse/harmful use not dependence CBT - relapse prevention, anxiety management, coping skills 12-step programmes - AA, NA Peer support Therapeutic community/residential rehabilitation

Answer 87

Detox - lofexidine or buprenophine (high relapse rates) Opioid replacement therapy - methadone or buprenorphine Effective in reducing heroin use, injecting and sharing injecting equipment Long half life Respiratory depression in overdose Prolonged QTc Rapid loss of tolerance - high risk OD if missed doses and restarted at usual dose

Answer 88

Low, gradual reduction and withdrawal in licit dependence Little evidence for use of other anxiolytics or psychological therapies No evidence to support maintenance prescribing for illicit use

Answer 89

Psychological interventions - CBT, contingency management No effective pharmacological treatment

Answer 90

Delusional parasitosis - skin infected with insects

Answer 91

High consumption in teenage years linked to onset of schizophrenia Long term use - cognitive impairment affecting memory, concentration Amotivational syndrome

Answer 92

'Baby blues' - 60-70% of women, typically in the first 3-7 days after birth, especially in primips Postnatal depression - 10% of women, most cases within a month of birth, peak at 3 months, last >2 weeks Puerperal psychosis - 0.2% of women, occurs 2-3 weeks after birth

Answer 93

'Baby blues' - anxious, tearful, irritable, mood swings Postnatal depression - classical depression features (low mood, anhedonia, low energy)

Answer 94

Delusions Hallucinations Depression Mania Confusion Thought disorder

Answer 95

Past psychiatric history Psychological problems during pregnancy Poor relationship - domestic violence Lack of social support Stressful life events Low socioeconomic status Previous miscarriage or termination Difficult pregnancy/delivery Unintended pregnancy

Answer 96

History of postpartum psychosis History of bipolar affective disorder Family history of either Primiparity Obstetric complications during delivery Discontinuing mood stabilisers

Answer 97

Advise not to stop taking antidepressants abruptly If taking TCAs, SSRI or SNRI for mild-moderate depression can consider gradually stopping and monitoring response Can switch to high intensity psychological intervention e.g. CBT If severe depression need to consider risk of medication vs risk of depressive symptoms to mother and baby - can switch to lower risk drug, stop during 1st trimester only (highest risk teratogenicity) add or switch to CBT

Answer 98

Valproate - organ dysgenesis (craniofacial and cardiac abnormalities), IUGR, neonatal toxicity, neurobehavioural toxicity (SHOULD BE AVOIDED IF POSSIBLE) SSRIs - cardiac malformations (paroxetine), prematurity, low birth weight, persistent pulmonary hypertension, neonatal withdrawal symptoms (generally mild) MAOIs - not much info, venlafaxine may be higher risk in overdose and withdrawal Fluoxetine first line in pregnancy Sertraline first line for breast feeding

Answer 99

Good prognosis from episode High risk recurrence - puerperally and non-puerperally Higher risk if personal or family history of PP or bipolar affective disorder

Answer 100

Teratogenic - 4-12% risk of congenital abnormalities including cardiac malformation (Ebstein's anomaly) Highest risk 1st trimester IUG - increased weight Neonatal toxicity - floppy baby syndrome, hypothyroidism, prematurity Neurobehavioural toxicity Management during pregnancy: Early USS and echo Increase frequency of lithium checks Increased dose usually required as pregnancy progresses If stopped during pregnancy restart immediately on delivery if high risk Very effective for prevention of puerperal psychosis in high risk

Answer 101

Monitoring of mother and baby Usually require admission to mother and baby unit CBT Pharmacological - antidepressants, antipsychotics, mood stabilisers ECT

Answer 102

Mild - reassurance and support, self-help, follow-up with GP Moderate - antidepressants (e.g. SSRI, paroxetine recommended for breast feeding) and CBT Severe - may need inpatient care on mother and baby unit

Answer 103

Edinburgh postnatal depression scale 10-item questionnaire, indicates how the mother has felt over the previous week >10 indicates depressive illness

Answer 104

IQ <70 Impairment in social and adaptive functioning, understanding new or complex information, learning new skills Reduced ability to cope independently Onset before 18 years old

Answer 105

By IQ Mild - 50-69 Moderate - 35-49 Severe - 20-34 Profound - <20

Answer 106

Genetic e.g. Down syndrome, PKU, fragile X Infective e.g. rubella (antenatal), meningitis, encephalitis (postnatal) Trauma e.g. birth asphyxia, head trauma

Answer 107

Increased prevalence of mental health disorders - depression, schizophrenia, anxiety, delirium and dementia, ADHD May present in different ways compared to general population Behaviour (e.g. physical aggression) may be a sign of physical, mental or environmental problem

Answer 108

Epilepsy GORD Constipation Hearing and vision impairments Problems related to underlying condition e.g. heart abnormalities, endocrine problems

Answer 109

Same core symptoms but can present differently Classical biological symptoms relatively rare Somatic symptoms Social withdrawal Psychotic symptoms rare Mood - irritable, argumentative, defiant, aggression, angry Sleep - insomnia and hypersomnia > early morning wakening Declining school performance/attendance Slow, insidious onset of symptoms

Answer 110

Greater emphasis on collateral history - seek permission from patient Can get collateral from parents, school, social services Focus on social history - relationships (peer, family, love life), school, alcohol/drugs, life events/stressors Protective factors - family relationships, external support (e.g. teachers), individual strengths Comorbidity - ASD, ADHD, learning difficulties (e.g. dyslexia), learning difficulties

Answer 111

Suicidal thoughts Self-harm Risky behaviours e.g. alcohol, drug abuse, peer groups Impulsivity, ambivalence Risk of exploitation/abuse

Answer 112

Greater school/social services/family involvement Psycho-education Psychological therapies - CBT, family therapy, play/art therapy Pharmacotherapy - fluoxetine only licensed anti-depressant

Answer 113

Usually identifiable <3 years old Social: Lack of eye contact Delay in smiling Avoids physical contact Unable to read non-verbal cues Difficulty establishing friendships Not playing with others Communication: Delay or regression in language development Lack of appropriate non-verbal communication e.g. smiling, eye contact, responding t others Difficulty with imaginative or imitative behaviour Repetitive use of words or phrases Behaviour: Greater interest in objects, numbers or patterns than people Stereotypical repetitive movements e.g. self-stimulating movements used for comfort Intensive and deep interests that are persistent and rigid Repetitive behaviour and fixed routines Anxiety and distress with experiences outside of normal routine Restricted food preferences

Answer 114

Epilepsy Bowel disorders Schizophrenia Sleep disorders ADHD Intellectual impairment

Answer 115

Non-pharmacological: Specialist education Occupational therapy Speech therapy Psychological interventions Pharmacological: Depression/anxiety - SSRIs Sleep difficulties - melatonin

Answer 116

Symptoms present in childhood (<12) Significantly impair functioning Present in multiple settings Inattention: Difficulty sustaining attention, avoids sustaining attention Distracted easily Misplaces things Organisation problems Makes mistakes Finds listening difficult Forgetful in daily activities Difficulty completing tasks Hyperactive/impulsive: Loud in quiet situations Fidgets Restless or overactive On the go all the time Seating difficulty Talks excessively Finds waiting difficult Interrupts or intrudes Blurts out prematurely Other: Affective instability Constant mental activity Mind wandering - restlessness, unrelated spontaneous thoughts, multiple thoughts at the same time Hyperfocus Paradoxical reaction to stimulant drugs

Answer 117

Chaotic, disorganised, late, loses things Multiple jobs and relationships Makes careless mistakes Avoids books/films/queues Restless, fidgets Can't relax Rude, impatient, can't wait Loses train of thought

Answer 118

Normal behaviour Malingering or drug seeking Hyperthyroidism Substance abuse Mania Cyclothymia Agitated depression Anxiety disorder ASD Tourette's syndrome

Answer 119

Watchful waiting for up to 10 weeks to observe change/resolution of symptoms Referral to CAMHS/paediatrician/child psychiatrist if severe symptoms Non-pharmacological management: Healthy diet (food diary), exercise Behavioural management Parent training CBT Pharmacological management (>5 only usually): CNS stimulants - methylphenidate, lisdexamfetamine, dexamfetamine, atomoxetine

Answer 120

Healthy diet and exercise Self-help CBT Occupational therapy Medication offered if symptoms causes significant impairment after environmental modifications made

Answer 121

Children >5 - methylphenidate Adults - lisdexamfetamine or methylphenidate

Answer 122

Reduced appetite - weight loss Insomnia Headache Irritability Tachycardia, arrhythmias Tics Seizures

Answer 123

Stimulants e.g. methylphenidate, dexamfetamine Dopamine/noradrenaline reuptake inhibitors Immediate action Positive effect on attention even without ADHD More potential for abuse/diversion (Controlled drugs) Non-stimulant e.g. atomoxetine Noradrenaline reuptake inhibitor Delayed onset of action No positive effect on attention in those without ADHD (may help with comorbid conditions e.g. anxiety) Preferable if concern about diversion, unresponsive/intolerant to stimulant Non-controlled drugs

Answer 124

Reduced appetite Nausea Insomnia Dizziness Constipation Sweating Sexual dysfunction Seizures Acute liver failure Suicidality Contraindication - phaemochromocytoma

Answer 125

Highest prevalence in 13-17 year olds, F>M Restriction of energy intake resulting in low body weight - BMI <18.5 or less than 5th percentile on growth chart Intense fear of gaining weight/pursuit of thinness - preoccupation with food and weight, repeated weighing, measuring and checking in the mirror Behaviour that interferes with weight gain - self-induced purging, excessive exercise, use of appetite suppressant medication Psychological disturbance - distortion of body imagine, low self-esteem, drive for perfection Denial of seriousness of malnutrition and impact on physical health

Answer 126

Hormonal disturbance - amenorrhoea, loss of libido, delayed onset of puberty Dry skin Abdominal pain Pallor Hair loss Bradycardia Orthostatic hypotension Hypothermia Loss of muscle strength Oedema Constipation Fainting Dizziness Fatigue Lanugo hair - fine, soft hair across body Hypokalaemia Hypoglycaemia Osteoporosis Anaemia Atypical dental wear e.g. erosion Cardiac complications - arrhythmias, cardiac atrophy, sudden cardiac death

Answer 127

Psychoeducation - nutrition and affects of malnutrition Psychological interventions - eating-disorder-focused CBT, Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), SSCM If these are unacceptable can use focused focal psychodynamic therapy

Answer 128

Anorexia nervosa focused family therapy for children and young people - single and family sessions If not acceptable for the patient can consider CBT-ED or adolescent focused psychotherapy

Answer 129

Recurrent episodes of binge eating occurring on average at least once a week for 3 months - consuming an excessive amount of food in a discreet time period with a sense of loss of control over eating at that time Recurrent inappropriate compensatory behaviour to prevent weight gain - vomiting, fasting, excessive exercise, laxative, diuretic or diet pill use Weight often within normal limits or above normal weight range for age Psychological features - fear of gaining weight, mood disturbance, symptoms of anxiety, persistent preoccupation and craving for food, feelings of guilt and shame about binge eating, self harm

Answer 130

Russel's sign - knuckle calluses from inducing vomiting Dental enamel erosion Salivary gland enlargement Alkalosis - vomiting Hypokalaemia Mouth ulcers GORD Mallory-Weiss tears Aspiration pneumonitis

Answer 131

Adults: Bulimia-nervosa-focused guided self help programmes OR CBT-ED Children: Bulimia-nervosa-focused family therapy (FT-BN) OR CBT-ED

Answer 132

Recurrent episodes of binge eating (at least once per week for 3 months) in the absence of compensatory behaviours (no purging/over-exercising etc.) Binge = consuming an excessive amount of food in a discreet time period accompanied by a feeling of loss of control where the person cannot stop eating or control the amount of food they eat May eat more quickly than normal, eat until uncomfortably full or when not hungry, and experience significant distress and feelings of guilt and shame Body weight may be normal, overweight or obese

Answer 133

Binge-eating-disorder-focused guided self-help programme or group CBT-ED (weight loss is not a treatment!)

Answer 134

Aka Other Specified Feeding and Eating Disorders (OFSED) or Eating Disorder Not Otherwise Specified (EDNOS) Eating disorder which does not fit exactly into a diagnostic category - can have features of anorexia, bulimia or binge eating disorder but not meet diagnostic criteria No evidence to guide management - follow guidance on treatment of ED which most closely resembles the patient's presentation

Answer 135

Monitor and treat fluid and electrolyte balance abnormalities May require ECG monitoring (caffeine, electrolyte imbalance etc.) Dental care if vomiting - regular dental view, avoid brushing immediately after, rinse with non-acid mouthwash, avoid highly acidic foods and drinks Monitor weight or BMI Low bone mineral density - can give oestrogen +/- bisphosphonates Recognise those at risk of refeeding syndrome and manage appropriately

Answer 136

BMI <16 Weight loss >15% within last 3-6 months Little or no nutritional intake for >10 days Low levels of potassium, phosphate, magnesium prior to feeding History of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics Presence of purging behaviours e.g. vomiting, laxative misuse

Answer 137

Starvation - catabolic state, lack of carbohydrate so use of protein and fat metabolism, intracellular minerals (particularly phosphate) become severely depleted, although can have normal serum levels, insulin secretion suppressed, glucagon secretion increased Refeeding - rapid switch to anabolism, insulin secretion resulting in increased glycogen, fat and protein synthesis Requires phosphate, magnesium and potassium which are already depleted Also have tissue ischaemia, intracellular movement of serum electrolytes Hyperglycaemia Low thiamine levels Metabolic disturbances = Hypophosphataemia Hypokalaemia Hypomagnesaemia Thiamine deficiency Salt and water retention Causes arrhythmia, heart failure, fluid overload

Answer 138

Immediately before and during the first 10 days of feeding: oral thiamine 200-300mg daily, vit B Co Strong 1-2 tabs tds and a balanced multivitamin/ trace element eg. Forceval 1 tab once daily Re-feeding plan prescribed by nutrition support team or dietician, starting at 20kcal/kg/day and gradually increasing based on daily bloods (may be less if high risk for refeeding syndrome but should avoid underfeeding syndrome)

Answer 139

Daily Bloods: U&Es, LFTs, Bone Profile, Glucose Close monitoring of Mg, K+ & phosphate Daily ECG Fluid Balance Bowels Monitor for oedema, BP, pulse, Ox sats

Answer 140

1:1 observation by experienced nurse to avoid sabotage of care Bed rest with DVT prophylaxis Supervised washes Tissue viability assessment Fluid input/output charts Access to toilets/taps restricted Meal and snack supervision, post-meal and snack supervision More frequent observations and BMs

Answer 141

Psychosis - particularly first episode Antisocial personality disorder Alcohol/drug use Medication non-compliance Undiagnosed or untreated mental illness Socio-economic factors - unemployment, homelessness Cognitive impairment

Answer 142

Treatment resistant depression Acutely depressed - risk to life through suicidality or not eating/drinking Catatonia Prolonged/severe mania Life-threatening mental illness during pregnancy Postpartum psychosis Occasionally schizophrenia

Answer 143

Given twice weekly EEG monitoring throughout Pre-oxygenation General anaesthetic (induction) and muscle relaxant given Electrodes (usually bitemporal) deliver electric current to brain, which induces seizure - unconscious for approximately 5 minutes Monitored after treatment to ensure recovery from anaesthetic

Answer 144

Phaeochromocytoma Increased intracranial pressure with mass effect Recent MI, stroke Uncontrolled HTN Arrhythmia Glaucoma History of cerebral or aortic aneurysm High-risk pregnancy

Answer 145

Anaesthetic complications Cardiovascular complications - arrhythmias, hypo/hypertension, stroke Respiratory complications - tachypnoea, airway spasm, pneumonia, hypoxia, pulmonary oedema Prolonged seizure - >2 minutes, requires IV lorazepam or midazolam, can progress to status epilepticus Dental trauma - use bite block to minimise risk Headache, muscle ache, nausea Confusion - post-ictal usually short-lived Cognitive side effects - memory loss, learning impairment ?

Answer 146

Most can consent themselves If severely unwell and lacking capacity but ECT is clinically indicated and likely to benefit them - need local second opinion (agree that ECT would be beneficial) then formal second opinion from designated medical practitioner (DMP) DMP is completely separate from team looking after patient

Answer 147

Bloods - U&Es, FBC, glucose, LFTs, TFTs Urinalysis ECG - QTc CXR Lithium level INR if on warfarin Pregnancy test COVID-19 test

Answer 148

Anterior capsulotomy - OCD Subcaudate tractotomy - anxiety, depression, OCD Limbic leucotomy - OCD, depression Deep brain stimulation - movement disorders e.g. Parkinson's, OCD Anterior cingulotomy - OCD, depression

Answer 149

All - haemorrhage, stroke, infection, breathing issues, nausea, seizures Anterior capsulotomy - weight gain, executive function disorder, apathy, disinhibition Limbic leucotomy - transient hallucination, amnesia, mania Anterior cingulotomy - headache, nausea, vomiting, seizures Deep brain stimulation - paraesthesias, speech/balance problems, mood swings, visual disturbance

Answer 150

Depression Anxiety, panic and phobia disorders Bipolar affective disorder Eating disorders OCD PTSD Psychosis Schizophrenia Sleep issues Alcohol and drug misuse Also used in chronic conditions with psychological aspect e.g. IBS, ME, fibromyalgia, chronic pain

Answer 151

Explore connections between thoughts, feelings, physical sensations and behaviours Identify negative/unhelpful thoughts, feelings and actions and how to change them Unhelpful thinking styles e.g. all or nothing thinking, over-generalisation, jumping to conclusions which are more frequent/harder to challenge in conditions e.g. anxiety and depression Specific strategies for change and how to implement them

Answer 152

Pros Can be done quickly Highly structured - can be given as group, books, online Teaches practical strategies which can be used after treatment finished Different versions tailored to specific conditions e.g. ED-CBT Cons Patient needs to be willing to commit to process get something out of it May not be suitable for more complex issues or those with learning difficulties Doesn't address underlying causes of conditions (e.g. childhood events), problems in family which may have significant impact on mental health

Answer 153

Mild to moderate major depressive disorder Dysthymic disorder Mild to moderate anxiety disorder Somatic symptoms with significant psychological component (with some patient insight) Severe/chronic depression - as adjunct to pharmacotherapy Bipolar affective disorder (to some extent)

Answer 154

Idea that past relationships are recreated in current relationships - including relationship between therapist and patient Aims: Improve insight - identify unhelpful conscious processes and defence mechanisms (e.g. projection, repression, rationalisation) Improvement of management of distress

Answer 155

Aims to help patient become clearer about problems, and be able to come up with their own answers Therapist avoids giving answers/advice Strengthen existing coping strategies

Answer 156

Mild - moderate depression, anxiety, eating disorder Mental distress due to physical health condition e.g. infertility or stressful life event e.g. bereavement, work-related stress Self-esteem or anger issues Sexual identity

Answer 157

Psychiatrist Community psychiatric nurse Social worker Occupational therapist Clinical psychologist Pharmacists Responsible medical officer - usually psychiatrist Mental health officer Support worker May also have advocate who is not part of team

Answer 158

Community mental health teams Day centres Residential care - hostels, residential care homes, supported housing schemes Crisis intervention and home treatment team

Answer 159

Venlafaxine Desvenlafaxine Duloxetine Milnacipran Levomilnacipran

Answer 160

Major depression Generalised anxiety disorder Social anxiety disorder Panic disorder

Answer 161

Uncontrolled hypertension Hepatic/renal impairment - duloxetine Caution in: Bleeding disorders Epilepsy Personal or family history mania/bipolar Cardiac disease, high risk arrhythmias Diabetes - may affect glucose levels

Answer 162

Cardiac - palpitations, tachycardia, hypertension GI - decreased appetite, nausea (very common), constipation, vomiting, diarrhoea, abdominal pain, GI haemorrhage, hepatitis, pancreatitis CNS - headache, sleepiness (common), tremor, paraesthesia (common), movement disorders, sleep disorder, seizure Psychiatric - insomnia, confusion, anxiety, agitation, suicidal thoughts Skin - rash Other - menstrual cycle irregularities, sexual dysfunctino, hyponatraemia, neuroleptic malignant syndrome, serotonin syndrome

Answer 163

If co-prescribe an SSRI or other 5-HT potentiating drugs with St John's wort can induce serotonergic syndrome

Answer 164

Disulfram - aldehyde dehydrogenase inhibitor, produces acute sensitivity to alcohol e.g. flushing, headache, nausea, vomiting, palpitations, tachycardia, hypotension, anxiety Acamprosate - manages alcohol cravings, used with psychosocial support Opiate antagonists: Nalmefene - alcohol (reduced enjoyment) Naltrexone - opiate or alcohol abuse, reduces cravings and enjoyment

Answer 165

Amitriptyline Clomipramine Dosulepin Imipramine Lofepramine Nortriptyline

Answer 166

Acute porphyrias Arrhythmias Heart block Severe hepatic/renal impairment Manic episode in bipolar Immediate period after MI With MAOI

Answer 167

Cardiac - palpitations, arrhythmias, tachycardia, AV block, bundle branch block, QT prolongation, MI, sudden cardiac death Vision - accommodation disorder, mydriasis, blurred vision GI - reduced appetite, constipation, nausea, diarrhoea, vomiting, abdominal pain, paralytic ileus CNS - tremor, dizziness, reduced concentration, drowsiness, movement disorders, peripheral neuropathy, seizure Psychiatric - aggression (very common), confusion, anxiety, delirium, hallucinations, suicidality Other - bone marrow depression, hyponatraemia, neuroleptic malignant syndrome, sexual dysfunction Dangerous in overdose

Answer 168

Phenelzine, isocarboxazid, tranylcypromine - inhibit MAOA and B irreversibly Moclobemide - inhibits MAOA reversibly Inhibit monoamine oxidase, enzyme which breaks down neurotransmitters A - noradrenaline, serotonin, dopamine, tyramine B - dopamine, tyramine etc.

Answer 169

Cerebrovascular disease Manic episodes Phaeochromocytoma Severe cardiovascular disease Caution in elderly

Answer 170

CNS - confusion, dizziness, drowsiness, hallucination, headache, insomnia, paraesthesias, tremor, blurred vision Psychiatric - suicidal GI - appetite increased, weight increased, vomiting, constipation, jaundice Cardiovascular - arrhythmia, postural hypotension, hypertensive (tyramine) reaction Tyramine reactions - high levels of tyramine in fish, some meats, overripe fruits including avocados, bananas, raisins, figs, cheeses, alcohol, fava beans MAO usually breaks down tyramine in the gut, high levels cause hypertensive reaction which can trigger cerebral haemorrhage

Answer 171

Primary action is serotonin and noradrenaline reuptake inhibition More minimal action as dopamine reuptake inhibitors, acetylcholine and antihistamine antagonists

Answer 172

Gradually decrease dose over 4 weeks (except fluoxetine - can be stopped immediately) Prevent discontinuation symptoms: Mood change Restlessness Insomnia Unsteadiness Sweating GI symptoms - pain, cramping, diarrhoea, vomiting Paraesthesia

Answer 173

Increase activity of GABA through increasing frequency of chloride channels

Answer 174

Short-term relief (2-4 weeks) of severe, disabling anxiety causing the patient unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic, or psychotic illness Inappropriate to treat 'mild' anxiety Insomnia only if severe, disabling, causing extreme distress

Answer 175

Diazepam Lorazepam Loprazolam Temazepam

Answer 176

Dependence - long term use >4 weeks, even with low doses Withdrawal occurs one day - 3 weeks after stopping (3 weeks if long acting) Symptoms: Insomnia Anxiety Loss of appetite/weight loss Tremor Sweating Tinnitus Abrupt withdrawal can produce confusion, toxic psychosis, convulsions - should be withdrawn gradually

Answer 177

Zolpidem tartrate and zopiclone Non-benzodiazepine hypotics - act to modify the GABA receptor Used for insomnia

Answer 178

Acute pulmonary insufficiency Neuromuscular respiratory weakness Not for use alone to treat chronic psychosis, depression, obsessional state, phobic states, sleep apnoea syndrome, unstable myasthenia gravis Caution in elderly, history of alcohol/drug dependence

Answer 179

Sedative effect - drowsiness, ataxia, fatigue, impaired motor ability, confusion, deceased alertness (may impair ability to drive) Enhanced sedation when prescribed with opioids, taken with alcohol Paradoxical effects - agitation, aggression, antisocial behaviour Headache Vertigo Tremor Slurred speech Decreased libido Gynaecomastia Sleep apnoea Tolerance and dependence Withdrawal syndrome

Answer 180

Includes - mental illness, learning disability, personality disorder Excludes - sexual orientation, sexual deviancy, gender identify, dependence on/use of alcohol of drugs, behaviour that causes harassment, alarm or distress to another person, acting as no prudent person would act

Answer 181

Emergency detention - to keep/bring patient to hospital for assessment, lasts up to 72 hours, any full registered doctor but should be reviewed by senior psychiatrist ASAP, should have MHO consent if possible but not mandatory if essential, treatment not covered, cannot be appealed Short term detention - to keep/bring patient to hospital for assessment and treatment, approved medical practitioner only, lasts up to 28 days, MHO consent essential, can be appealed, must be reviewed and revoked timeously Compulsory treatment order - to bring/keep patient to hospital for treatment or to continue treatment in the community, two medical recommendations (one must be AMP), lasts up to six months and is renewable, MHO is the applicant, can be appealed, must be reviewed and revoked timeously

Answer 182

Mental disorder Significant risk to health, safety or welfare of the patient or safety of another person Detainment is necessary to determine what medical treatment should be given or to give medical treatment Seriously impaired decision making ability (SIDMA) in relation to medical treatment

Answer 183

Artificial feeding ECT Treatments which directly act on the brain Medications where the purpose is to reduce sex drive Cannot be given without consent without a second opinion from a designated medical practitioner

Answer 184

Have to: Take past and present wishes into account Take views of carer, named person, guardian or welfare attorney into account Make sure patients get the information and support needed to take part in decisions Look at the full range of options for care Give treatment that provides maximum benefit Take account of background, beliefs and abilities Make sure any restrictions on freedom are the minimum necessary in the circumstances Carers needs taken into account Make sure they are not treated less favourably than other patients Take special care of welfare if <18

Answer 185

Presenting complaint History of presenting complaint RISK ASSESSMENT Past psychiatric history - diagnoses, previous admissions, detention/treatment under Mental Health Act, care in community Past medical history Drug history - *compliance* Family psychiatric history Social history - living situation, employment, finances, family/relationships, alcohol/drugs Personal history - birth, developmental milestones, school, friends, criminal justice system involvement, work Pre-morbid personality/functional level - how would you describe yourself, how would others describe you?

Answer 186

Appearance Behaviour Mood and affect Speech Thoughts - form and content, passivity Perception Cognition - MMSE, AMTS, ACE-III, MoCA Insight and judgement

Answer 187

The Mental Health (Care and Treatment) (Scotland) Act 2003

Answer 188

Assume all adults (>16) have capacity Can: Understand information relevant to the decision Retain the information Use the information to make decision Communicate decision

Answer 189

Adults with Incapacity (Scotland) Act 2000

Answer 190

Reboxetine - major depressive disorder Atomoxetine - ADHD

Answer 191

Phaeochromocytoma Severe cardiovascular disease Severe cerebrovascular disease

Answer 192

GI - decreased appetite, constipation, nausea, vomiting Cardiovascular - palpitations, tachycardia Neurological - headache, insomnia, paraesthesia Other - sexual dysfunction, urinary disorders, urinary tract infection

Answer 193

Caused by thiamine deficiency, most commonly seen in alcoholics Wernicke's Oculomotor dysfunction - nystagmus, ophthalmoplegia Gait ataxia Encephalopathy - confusion, disorientation, indifference, inattentiveness Peripheral sensory neuropathy Can develop Korsakoff's if not treated - Antero- and retrograde amnesia Confabulation

Answer 194

Restriction of eating to small amounts or avoidance of certain foods or food groups - without altered beliefs about size/shape of body, not for specific purpose of losing weight, no behaviours associated with anorexia/bulimia e.g. over-exercising Triggers - choking or vomiting episodes, anxiety disorders, ADHD, ASD

Psychiatry Flashcards

(218 cards)