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Psych Flashcards

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1
Q

Reason for patient with major mental illness to be re referred to psych services

A

Poor response to treatment
Non adherence
Intolerable side effects
Comorbid alcohol or substance misuse
Risk to self or others

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2
Q

Difference between school refusing and school truancy

A

School refuses are sensitive sometimes bullied children who may have a background of unhappiness. Somatic symptoms would commonly occur in this group.
By contrast school truants on the other hand are more likely to come from poorer backgrounds, sometimes dysfunctional, and have antisocial tendencies

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3
Q

Symptoms of compassion fatigue

A

Mood swings lack of concentration lack of empathy and problems with patients and carers

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4
Q

Red flags for patient with anorexia nervosa

A

Hypothermia, BMI <15, bradycardia, peripheral oedema and intercuttent infection

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5
Q

Management of patient with psychotic symptoms

A

Refer to early intervention in psychosis service for immediate assessment.
If service not able to assess, for CRHTT

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6
Q

Lithium monitoring

A

Lithium levels weekly on initiation or after dose change until levels stable, then every 3 months for first year then 6 monthly.
3 monthly if older, or drugs that interact, or renal thyroid issues, or poor symptoms control, or high previous level.
Also measure: weight BMI, u&E, calcium, thyroid all every 6 months.

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7
Q
A
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8
Q

What is clozapine used for?

A

Licenced for treatment of schizophrenia only in patients unresponsive to or intolerant of, conventional antipsychotic drugs, or psychosis in parkinsons disease. It can cause agranulocytosis. Patients need to be registered to the clozapine patient monitoring service

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9
Q

Which patients are at a high risk of post partum psychosis

A

Women with history of bipolar affective disorder or schizophrenia are at high risk of post partum psychosis. They should have a plan for their pregnancy and post natal Psychiatry management

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10
Q

Difference between eating disorders and feeding disorders

A

Eating disorder - abnormal eating behaviour and preoccupation with food as well as prominent body weight and shape concerns. Includes AN and BN.
Feeding disorder - behavioural disturbances without associated weight, body shape or shape concerns - Includes pica, Avoidant restrictive food intake disorder, or rumination regurgitation disorder.

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11
Q

Common precipitants of lithium toxicity

A

Dehydration, electrolyte imbalance.

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12
Q

How to prescribe lithium and side effects

A

By brand name.
Aim for 0.6-1 (0.6-0.8 if new on lithium).
Contraindications are cardiac disease, renal impairment, hypothyroid, low sodium, Addison disease, brudaga. Not in DI, breastfeeding. Caution in elderly, epilepsy, cardiac disease, QT prolongation.
Initial effects- nausea, diarrhoea, vertigo, muscle weakness, dazed (resolve). Polydispia and polyuria may persist.
Can cause thyroid and parathyroid problems, so measure TFTs and Ca.
Reduces EGFR in 20%, which is OK, small number get AIN.

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13
Q

Drug interactions with lithium

A

Thiazide diuretics increase levels
NSAIDs increase levels due to fluid balance effects.
Dapaglifozin reduce levels.
Antidepressants can cause CNS toxicity with lithium.
Acei increase levels and can cause renal failure so need to carefully monitor renal fx and lithium level.
Lithium increases QTc.

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14
Q

When to take lithium level

A

12 hrs after dose

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15
Q

Lithium toxicity

A

Diarrhoea, vomiting, anorexia, muscle weakness, lethargy, dizziness, ataxia, poor coordination, blurred vision, course tremor of extremities and lower jaw, drowsiness.
Normally if lithium level more than 1.5
No specific antidote, supportive treatment, osmotic or forced alkaline diuresis or even dialysis if severe.

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16
Q

Advice to give to people on lithium

A

Regular blood tests
Symptoms of lithium toxicity
Not to take NSAIDS
Episodes of D&V will increase lithium levels by depleting sodium.
Maintain fluid intake especially if sweating.
Good adherence.
Women to use contraception

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17
Q

When to refer in eating disorders

A

As soon as suspected - don’t wait for trigger bmi etc. Early intervention is important

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18
Q

What is Scoff

A

Used in eating disorders
So full make yourself SICK
Ever worry you have lost CONTROL
Recently lost or gained ONE stone in 3 m
Believe yourself to be FAT when others think thin
Does FOOD dominate your life
Don’t use in isolation

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19
Q

What does MEED look at

A

Medical emergencies in eating disorders
Looks at weight loss, bmi, heart rate, blood pressure, hydration, sit up squat test, blood tests, ecg, other clinical states, behaviour, and self harm and suicide. Any meeting threshold should be admitted.

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20
Q

Can a person with an eating disorder be sectioned

A

Yes, if they don’t consent, MHA does provide for this. Provision of nutrion and insulin for diabetes can be considered medical treatments for a mental disorder.

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21
Q

Management of anorexia nervosa

A

CBT, refeeding to a healthy weight, olanzipine may be initiated by specialist.

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22
Q

Management of bulimia

A

Cbt to address purging behaviours
Fluoxetine may be initiated by specialist

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23
Q

Management of binge eating

A

Cbt. No evidence for meds unless comorbid other mental health condition.

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24
Q

Management of eating disorder in children

A

Family therapy first line.
Cbt and other psych therapies sometimes offered.
Medicine not good evidence. Occasionally olanzapine and fluoxetine used.

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25
Physical conditions in eating disorder
Increased fracture risk - assess bone density after 2 yrs then yrly if remaining underweight. Can use bisphos or oestrogen but weight restoration is the important thing. If purging - need dental checks.use non acid mouthwash. Advise against medication misuse eg laxatives, don't help weight loss anyway.
26
T1DM and eating disorde
ED twice as common in T1DM Consider at all reviews with these patients. Tend to loss weight by omitting insulin, but can also reduce carbohydrates, so risk of hyper or hypo. May present as high hba1c, recurrent dka, poor engagement with health care, infrequent glucose monitoring, omission of quick acting insulin.
27
Pregnancy and eating disorder
Eating disorder usually better while pregnant but relapse risk high after birth. Increased risk iron def anaemia. Adverse obstetric outcomes. Good health visitor support needing for infants.
28
Yearly review for eating disorder should include
Weight and BMI, BP and pulse, ECG if weight change or purging, daily functioning, bloods including fbc haematinics, renal, liver, albumin, calcium, phosphate, bicarb, CK, lipids, TFTs. Review bone health, carer support..
29
What other psych conditions are linked to eating disorder
Autism (30% Personality disorder 30% Ocd Depression Anxiety Trauma
30
symptoms of lithium toxicity
tremor, ataxia, dysarthria, nystagmus, renal impairment and convulsions. commonly prescribed drugs that interact with lithium include NSAIDs, ACEis, ARBs, diuretics, and antidepressants .
31
What is the only licensed antidepressant for children
Fluoxetine
32
First line antidepressants in pregnancy
Sertaline and citalopram due to large data sets showing well tolerated and small risks. Avoid paroxetine.
33
What is section 135
Allows police to enter patients home to bring you to a place of safety (or keep you in a place of safety) so you can have a mental health assessment. Must have warrant for this - approved mental health professional needs to apply for the warrant. Need to have MH disorder. Lasts 24hrs and can be extended for 12 hrs.
34
What is section 136
Allows policy to take you or keep you in a place of safety. They can do this without a warrant if you have a mental disorder, you are in a public place, and you are in need of immediate care or control. Must consult health professional before doing this if practicable. Can be hospital, care home, your home, someone elses home. Can also be police station if behaviour poses imminent risk of serious injury or death to you or another person. (police stations should never be used as place of safety to someone under 18).
35
What is a panic attack
Discrete episodes of intense fear. Start rapidly, peak within 10 minutes, usually last 20-40 minutes. Often have other physical symptoms such as palpitations, sweating, trembling, shortness of breath, chest pain, dizziness or lightheadedness.
36
Features in history for panic disorder
High use of medical services Comorbidities as described above. Presentations for somatic symptoms. Catastrophic misinterpretations of harmless often anxiety related physical symptoms.
36
Difference between panic disorder and phobias
Panic disorder is current panic attacks but arise unpredictably. No specific stimuli or situation. May also get attacks at night. Phobias may experience panic attacks in specific situations eg social phobia.
36
Risk factors for panic disorder
Peak onset 20s More common in women. 2/3s people with panic disorder also have agorophobia (therefore can classify panic disorder as with or without agorophobia). Worse outcomes if high level of agorophobic avoidance. Other associated disorders - anxiety, depression, substance misuse. Outcomes poorer if comorbidities. Also more common in people with GI and CV disease.
37
How to assess for panic disorder
GAD2 screening Rule out physical causes eg thyroid. Ask about drug causes Use timeline if complex conditions, to clarify sequence of events which can prioritise treatment choices.
38
Mx of panic disorder
NB 1 panic attack is not panic disorder- watch and wait. Physical exercise good adjunct - reduces anxiety symptoms Lifestyle eg good sleep, regular meals, limiting drug and alcohol intake. Reduce substances that worsen anxiety. If drug or alcohol misuse, treat that first! mild/mod panic disorder - fascilitated or non fascilitated self help mod/severe panic disorder- CBT first line. Consider antidepressant if disease longstanding or person not benefitted from psych intervention or declined it.
39
Which antidepressant for panic disorder
SSRIs most benefit and least adverse events. Sertraline and escitalopram most effective agents - use first line. (paroxetine, citalopram and venlafaxine also licenced for panic disorder). Warn about transient increase in anxiety and slow onset of action. Review 2-4 weeks. Continue for at least 6-12months. Second line SNRI or TCA. (If risk of self harm, avoid TCA as most harm in overdose). NB: beta blockers NOT recommended by NICE. propranolol can be highly toxic in overdose. benzodiazepines also should NOT be px, as poor long term outcomes. no medication should be used PRN for attacks as this reinforces fears of dangers of panic attacks. Refer if 2 interventions have been ineffective.
39
Natural history of depression
Most people recover in 3 months, 75% recover in 1 yr, 20% get chronic course lasting 2 or more years. Longer duration more likely if more severe depression or comorbid dysthymia. recurrence common, especially in old or young people.
39
Risk factors for depression
Stressful life event, especially loss, hx of depression or other mental health problems, psychosocial problems, chronic physical health problems, perinatal period, Fhx suicide or depression, ACE, drugs (antihypertensives, antidepressants!! hormones, steroids).
40
How does PHQ9 split depression
Score <16 is less severe Score >16 is more severe (the PHQ9 tests the DSM criteria for depression).
41
what to do if depression and anxiety co exist
first priority is to treat the depression.
42
Treatment options for less severe depression PHQ<16
Guided self help Group CBT Group behavioural activation Individual CBT Individual behavioural action Group exercise Group mindfulness and meditation Interpersonal psychotherapy SSRIs Counselling Short term dynamic psychotherapy. Active monitoring is also an option for less severe depression.
43
Options for management of more severe depression
Individual CBT and antidepressants Individual CBT Individual behavioural activation Antidepressants Individual problem solving Counselling Short term psychodynamic psychotherapy Interpersonal psychotherapy Guided self help Group exercise Top is most clinical and cost effective.
44
When can we stop antidepressants
Continue at effective dose until patient is well plus another 6 months (unless compelling reason to reduce dose eg side effects). (or often longer if high risk relapse).
45
Side effects of SSRIs
nausea and diarrhoea sleep disturbances bleeding risk, sexual dysfunction, withdrawal effects. headache, dry mouth, sweating, agitation
46
Can psychological therapy be used for relapse prevention
Yes - CBT group or individual aimed at developing relapse prevention skills.
47
typical antipsychotic monitoring
FBC U&E LFT prolactin monitoring Annual weight, HbA1c and lipids Physical health is very important in those with major mental illness!
48
What is season affective disorder
Depression occuring annually in the winter (or more rarely over the summer). Much more common in women. Physical symptoms very common. Treat in same way as normal depression.
49
What is a screening test for depression in young people
Mood and feelings questionnaire.
50
Most frequent age of onset of bipolar
15-19YO
51
What electrolyte disorder does SSRIs typically cause
Hyponatraemia Consider this as cause if patient becomes drowsy, confused or convulsions while taking SSRI.
52
What antidepressants are licenced for use in PTSD
Sertraline and paroxetine
53
Which SSRI has the most risk of disconitnuation symptoms
Paroxetine. Symptoms of abrupt withdrawal or reduction in dose include GI disturbance, headache, anxiety, dizziness, paraesthesia, electric shock sensations in head, neck and spine, tinnitus, sleep disturbance, fatigue, flu like symptoms, sweating.
54
Which antidepressant is the first line treatment for post herpetic neuralgia
amitriptyline
55
What type of person cannot be an approved mental health practitioner
registered medical practitioners (doctors)
56
What medications are recommended if someone with bipolar disorder develops depression
Fluoxetine with olanzipine
57
First line management of psychotic depression
Antidepressant with antipsychotic ECT if patient preference or life threatening.
58
Management of medically unexplained symptoms - what approach?
Collaborative care involves working with patient and family to define solutions to problems. Shown to improve symptoms and health care utilisation costs for patients with medically unexplained symptoms.
59
What is the first line management for binge eating disorder
Guided self help focusing on the binge eating disorder. If unacceptable or ineffective after 4 weeks then refer for group CBT.
60
What drugs have licenses for insomnia
Melatonin licensed for insomnia short term use over 55YO. Clomethiazole for severe insomnia for short term use in the elderly. Zopiclone licensed for short term treatment of insomnia. Promethazine licensed for short term use in insomnia. Daridorexant licensed for short term treatment of insomnia of at least 3 months duration. Amitriptyline is not licensed for insomnia.
61
Drugs for dementia
Donepezil, galantamine, rivastigmine. All similar efficacy. All for mild-mod Alzeimers. Rivastigmine can also be used for behavioural change in LBD.
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