Psychology

Question 1

Schizophrenia

Answer 1

Bio:

• 1st line = Atypical antipsychotic - Quetiapine
• Treatment resistance = Clozapine (if at least 2 antipsychotics dont work)
• Baseline measurements before starting Tx:
  
  • Urine drug screen
  • Height/weight + BMI
  • Waist circumference
  • Blood - FBC, U&Es, HbA1c, lipid profile, TFTs,
  • ECG

Psycho:

• CBT - 16+ sessions over 6months
• Family therapy
  
  • encouraged to talk to their family about what helps and what doesn’t

Social:

• Psychoeducation
• Education/employment? Housing?

Other:

• Smoking cessation
• MONITOR CARDIOVASCULAR
• Support for carers

Question 2

Depression

Answer 2

ICD-10 Definition = Depressive episode lasting AT LEAST 2 WEEKS

• Mild-moderate
  
  • Watchful waiting 2wks
  • IAPT
    
    • NHS ‘Talking therapy’
    • Effective, confidential treatments delivered by trained professionals
    • Help with common mental health problems like stress, anxiety, depression
    • FREE, self-referral online. Someone will be in touch with you online
  • Samaritans - call if you need to speak to someone straight away, 24-7.
• Moderate-severe
  
  • SSRI - sertraline
    
    • Usually takes 2-6wks to work
    • F/U Re-assess efficacy in 2 wks
    • Length of Tx = 6-9 months after resolution of current episode
    • SEs: N+V, Hyponatraemia, Sexual side-effects
  • Individual CBT
    
    • Based on principle that our thoughts/behaviour/emotions are all linked
    • 16-20 sessions over 3-4 months

Question 3

Bipolar Affective Disorder

Answer 3

BPAD Type 1 = One epidode of mania ± episode of depression

BPAD Type 2 = One episode of HYPONMANIA ± episode of depression

BPAD is a condition where you tend to experience the 2 extremes of emotion for varying lengths of time

Hypomania = weaker version of mania

Difference is degree of functional impairment.

BioPsychoSocial

• Acute mania de novo
  
  1. STOP any anti-depressants
  2. 1st line = Anti-psychotic (Quetiapine)
  3. For agitation/insomnia = BDZ (Clonazepam)
• Acute mania known patient
  
  1. 1st line = ​Increase plasma lithium levels
  2. Anti-psychotic (Quetiapine)
• Bipolar Depression
  
  • SSRI + Anti-psychotic
  • Fluoxetine + Olanzapine
• Lithium carbonate
  
  • BMI, FBC, U&Es, TFTs before starting
  • Check plasma lithium level 1wk after starting, then monitor weekly until therapeutic level achieved (0.6-0.8)
  • Mild SEs:
    
    • Fine tremor
    • Mild GI upset
    • Metallic taste in mouth
    • Sedation

Question 4

Self-harm + suicide

Answer 4

• Antidotes
  
  • Paracetamol = NAC
  • Opioid = Naloxone
  • Anti-depressant = Activated charcoal
• Adequate analgesia + treat cuts/lacerations
• Risk assessment
• HIGH RISK + lacks capacity
  
  • ADMIT to psych ward
  • Crisis plan
• F/U 1wk community mental health team or outpatient clinic
• Treat underlying disorder (e.g. depression)

Question 5

Delirium

Answer 5

AMTS + MoCA

• Exclude dementia
• Treat the cause
• Single room, well lit
• Avoid under & overstimulation
• Address sensory problems (hearing aids, glasses)
• Minimise change
  
  • One staff member attending
  • Don’t keep moving patient
  • Establish routine (toilet + sleep)
• Remove anything that can trip him over

Question 6

Dementia

Answer 6

• Alzheimer’s
  
  • MILD-MODERATE = AChE inhibitor - Donepezil, rivastigmine
  • SEVERE = Memantine (NMDA antagonist)
• Dementia with Lewy Bodies
  
  • AChEi
• Vascular = NONE

Psycho

• Group cognitive stimulation - memory training/re-learning
• Occupational therapy

Social

• Social support
• Support carers - emotional support, train to manage common problems
  *

Question 7

Generalised Anxiety Disorder

Answer 7

NO trigger + >6months

Ix:

• Exclude organic causes - durgs, hyperthyroid
• Urine drug screen
• ECG
• Collateral Hx
• GAD-7

1. Low intensity CBT 4-12wks
   
   • Aims to reduce expectations of threat, and behaviours that maintain threat-related beliefs
2. Biological
   
   • SSRI (Sertraline)
   • Propranolol - for tremors/sweating
3. Specialist assessment

Question 8

OCD

Answer 8

Obsessions = recurrent, intrusive in mind despite attempts to resist them

?RITUALS

Sx present on most days for at least 2 wks

1. CBT with ERP (Exposure and Response Prevention)
   
   • Aims to prevent compulsive behavior - encourage experience of anxiety and discuss with therapist, slowly building tolerance
2. SSRI - Fluoxetine
   
   • ​​Continue for at least 12 months after remission
3. Alternative SSRI or Clomipramine

Question 9

PTSD

Answer 9

Triad of:

1. Flashbacks (Reliving)
2. Hyperarousal/Vigilance
3. Avoidance due to fear of re-exposure

Management:

1. Sx <1 month = watchful waiting + F/U
2. Trauma-focused CBT
   
   • Explores how trauma has affected belief systems/outlook
   • Computer or F2F
   • 8-12 sessions
3. Eye Movement Desensitisation and Reprocessing (EMDR)
   
   • Original trauma experience re-simulated with therapist
4. Group therapy
   
   • Meeting with other people with similar experiences
5. Consider medication (Sertraline, Mirtazapine)

Question 10

Bulimia Nervosa

Answer 10

Binge eating + Purging (vomiting, laxative)

NORMAL weight

1. Referral for specialist care
2. Bulimia-focused Guided self-help programme
3. If not working after 4wks, CBT-ED
4. Consider trial of Fluoxetine

Question 11

Lewy-Body Dementia