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122 Cards in this Set
- Front
- Back
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What is included in a psychiatric history? (15 points) |
- Introduction and presenting complaint - History of presenting complaint - Collateral history - Past Psychiatric history - Past medical/surgical history - Drug history and allergies - Family history - Personal history - educational history - occupational history - relationship history - Substance use - Forensic history - Social history - Premorbid personality |
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The psychiatric history and mental state assessment are taken when? |
Psychiatric interview |
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In the mental state assessment - what do you look out for in Speech? |
tone --> pitch, rate of speech, volume, pressure and whether or not they don't pause |
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Describe circumstantial speech |
Patient takes longer to get to the point |
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Preservation - the repetition of words is an indication of what? |
Frontal Lobe Impairment |
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What are neologisms? And in what disorder are they most common? |
Neologisms are made up words (neo =new, logism = word). It is common in schizophrenia. Ex. headshoe to mean hat |
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What is the difference between mood and affect? |
Mood: Underlying emotion Affect: what is observed - so the physical/external manifestation of the emotion. |
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What are the aims of classifications in psychiatry? |
identify similar client groups improve reliability and validity [cause science] |
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What are discriminating symptoms? What are characteristic symptoms? |
Discriminating - occur commonly in a defined syndrome. But is not so common in other syndromes. (discriminating because with this symptom you can remove all other diagnoses) Characteristic - frequent in the defined syndrome, but can also occur in others. |
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Mental disorders are classified into 3. What are they and what are their features? |
1. Learning disability - features of the disorder are from birth 2. Personality disorder - usually develop through childhood or adolescence and are clearly evident from early adulthood with no period of abnormal adult functioning 3. mental illness - there is no identifiable onset of illness |
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Classification systems can be either dimensional or categorical. Define them. |
Dimensional -use a continuum and have been used mainly to classify personality. Categorical - describe a group of entirely discrete conditions. The two main current systems of classification, the DSM (American Psychiatric Association) and the ICD are categorical. |
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How do you manage violent patients ? |
BE CAREFUL Breakaway Evaluate and talk down Control and restraint Assess need for medication to sedate and/or treat disorder Re-Evaluate setting (is higher level of security needed?) Fully review care plan |
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How do you evaluate the safety of a vulnerable adult? ex. elderly |
HOW SAFE? HOme safety (e.g. leaving gas on) WanderingSelf neglect (e.g. poor self care) Abuse, neglect, crime vulnerability Falls Eating (malnutrition) [these acronyms suck] |
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What is the protocol used to prevent risk to yourself or others when working with a possibly violent person? |
WARN Write risk incidents in notes Assess in a safe environment Read documentation before you assess Notify professionals involved of risks [this is an acceptable acronym] |
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What is the difference between suicide and deliberate self harm? |
Suicide - intentional infliction of death on oneself DSH - it's non-fatal injuries to oneself. |
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What are Durkheim's types of suicide? |
Anomic suicide: reflects a society’s disintegration and loss of common values. This is demonstrated by positive correlations between suicide rates and unemployment and homicide rates, and reductions in suicide in wartime and other moments of social unity in adversity – rates dropped in New York after the terrorist attack of September 2001. Egoistic suicide: involves individuals’ separation from otherwise cohesive social groups. Demonstrated by higher suicide rates following bereavement and moving house, in immigrants and people living alone, and the divorced or single, compared with people who are married (but social isolation is also frequently the consequence of major mental illnesses). --> the person cannot regulate into their new routine. Altruistic suicide: for the good of society (e.g. Kamikaze pilots in the Second World War). |
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How do you manage DSH (deliberate self harm)? |
MEDIATE Medically stabilise Establish rapport Diagnose and treat mental illness Iatrogenic risk – prescribe safely Assess likelihood of recurrence: Thoughts might return – make a plan Evaluate social problems |
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If a person DSH's and they have suicidal ideation, who can you refer them to? |
Crisis Resolution Team |
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What is psychosis? |
Psychosis describes the misperception of thoughts and perceptions that arise from the patient’s own mind/imagination as reality, and includes delusions and hallucinations. This is a symptom, not a diagnosis |
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Mention some psychotic disorders |
Psychotic disorders include: ° schizophrenia ° schizoaffective disorder ° delusional disorder ° brief psychotic episodes ° psychotic depression ° bipolar affective disorder ° drug-induced psychoses. |
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Define 'manic depression' and 'dementia praecox' [said: pre-cox] |
manic depression - where normal function is regained between periods of relapse, dementia praecox - characterised by irreversible deterioration of mental functions. It corresponds broadly to current concepts of schizophrenia. |
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What are first-rank symptoms? Mention a few of these for schizophrenia |
First-rank symptoms are strong indicators of a disorder, but are not exclusive to it. Ex. Third-person auditory hallucinations (discussing/giving running commentary) Thought echo (hear own thoughts out loud) Delusional perception (delusion arises from a real perception, e.g. from ‘a bunch of flowers’ to ‘I therefore knew terrorists were after me’) Thought insertion/withdrawal/ broadcast (thoughts interfered with) Passivity (actions, feelings or impulses interfered with) and somatic passivity (body controlled by others) |
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How would you ask a schizophrenic patient if their thoughts are inserted/withdrawn or broadcast (thoughts which are being interfered with) |
Are your thoughts being interfered with or controlled? Are they known to others, e.g. through telepathy?` |
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What are the sub-types of schizophrenia? |
- Paranoid - Catatonic - Hebephrenic (disorganised) - Residual (chronic) - Undifferentiated (simple) |
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How do you ask about a suicidal intent? What do you ask if patient says he will not commit suicide? |
Do you think you would actually do this? (if not) What stops you from acting on your plan? |
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What is insight? (not INSITE – an amazing media organization which used to be headed by a very attractive person) |
The patient’s understanding of their condition and its cause as well as their willingness to accepttreatment. |
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What is the difference between a disease and an illness? |
A distinction is made between ‘disease’ (objective physical pathology and known aetiology) and‘illness’ (subjective distress). |
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What are the 5 types of mental disorders? |
Organic, psychotic, mood, anxiety and personality |
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What do you include in a risk-assessment ? |
Risk of self-harm Risk of harm to others Risk of self-neglect and accidental harmVulnerability to abuse |
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Current diagnostic criteria for schizophrenia are still mainly based on Schneider’s First Rank Symptoms. What do they require? |
First Rank Symptom or persistent delusions which need to be present for at least a month (ICD-10)or 6 months (DSM). Patient must not be under drug intoxication, withdrawal, overt brain disease or prominent affective symptoms. |
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What are first rank symptoms as devised by Schneider? Hint: they are used to diagnose schizophrenia |
3rd personal auditory hallucinations, thought echoing, delusional perception, thought insertion/withdrawal/broadcast, passivity. |
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What are good prognostic factors in schizophrenia? |
- Female - In a relationship or has good social support - No negative symptoms - Adheres to medication - Is more educated - No stress [HA!] - Good premorbid personality - Paranoid subtype - Late onset - Acute onset - No substance misuse - Scans (CT/MRI head) are normal |
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What are the 3 core symptoms in ICD-10 which are needed to diagnose depression? |
Low mood Anhedonia (no longer finding activities which patient used to enjoy, pleasurable) Decreased energy/easier to fatigue |
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What other symptoms, except for the 3 core symptoms described within ICD-10 can beused to diagnose depression? |
Reduced concentration and attention Reduced self-esteem and self-confidence Ideas of guilt and worthlessness Feelings of hopelessness regarding the futureThoughts of self harm Decreased sleep and/or appetite |
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How many and for how long should symptoms be present for a person to be diagnosedwith depression (ICD-10)? |
2 core symptoms for at least 2 weeks. |
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What kind of hallucinations can be present within a person with depression? Describethem. |
Auditory – usually in the second person (you) and accusatory, condemning or urging the patient tocommit suicide. |
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What is atypical depression characterised by? |
Initial anxiety-related insomnia, followed by oversleeping [me every week insomma :P], increased appetite and a relatively bright, reactive mood. More common in adolescence. |
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What is the lifetime risk of depression? Which gender is most vulnerable to depression? |
The lifetime risk of depression is about 10–20%. Women are the most vulnerable. |
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Is depression genetic? |
Possibly.
A genetic contribution is evident in both twin and adoption studies, but less markedly for unipolar than bipolar depression. Current theories implicate gene-environment interactions – i.e. a genetic predisposition to depression if exposed to adverse life events. |
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How to detect depression in the elderly? |
Biological symptoms (e.g. reduced sleep, appetite and libido) may be particularly prominent in older people, who less often complain of disturbed mood. There is often a sleep pattern of early waking (more than two hours before usual) and maximal lowering of mood in the morning (diurnal variation). Poor appetite is often associated with weight loss; in severe cases food and fluid may be refused. |
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What treatment is needed for depression? |
Psychological therapy should be given together with antidepressants for moderate or severe depression. These can have a 60–70% response rate, but often fail because of inadequate dosage, duration or adherence. |
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What treatment could be used to reduce relapse in bipolar depression? |
mood stabilisers (e.g. lithium) are preferable. CBT or mindfulness-based cognitive therapy can also help prevent relapse. • |
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What can be used in severe cases? Especially if the patient is refusing food/liquids? |
Electroconvulsive therapy (ECT) is very effective in severe cases, particularly where psychosis or stupor is present, and can be life- saving if fluids and food are being refused |
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What factors can cause a person to experience depression? |
Psychosocial factors implicated are recent adverse life events (e.g. bereavement or deteriorating physical health) and adverse current social circumstances, especially unemployment and lack of a confiding relationship. Parental loss and major childhood stress or abuse appear to increase vulnerability to depression in adult- hood. Stress leads to increased cortisol levels, which may cause depressed mood through decreasing expression of BDNF |
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You have been referred with a depressed case. How do you manage the case? What do you treat? What do you look out for? |
• Depressed patients often present with other conditions. • Always assess risk of self-neglect and suicide. [they will generally have a suicide risk to be referred to the psychiatrist] • Treat comorbid physical illnesses or substance misuse problems. • For mild depression, self-help groups, structured physical activity groups, guided self-help or computerised cognitive behavioural therapy (CBT) are often helpful • If these less intensive therapies do not help, individual CBT or interpersonal therapy (IPT) may be recommended. Behavioural activation or, where appropriate, behavioural couples therapy can also be of use. |
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What characterises bipolar affective disorder? (general) |
Bipolar affective disorder (previously called manic depression) is characterised by recurrent episodes of altered mood and activity, involving both upswings and downswings. |
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What are individual episodes of bipolar affective disorder classified as? (4 answers) |
Individual episodes are classified as: • depressive • manic • hypomanic (less severe and without psychotic symptoms) • mixed (less usual) where features of both mania and major depression are present or alternate rapidly |
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If you're following the ICD-10 method of classification, what does the patient need to experience before they can be classified as having BAD (bipolar affective disorder) |
In ICD-10, bipolar affective disorder is defined as at least two episodes, including at least one hypomanic or manic episode |
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If you're following the DSM method of classification, what does the patient need to experience before they can be classified as having BAD (bipolar affective disorder) |
In DSM-IV-TR, patterns of recurrence can be classified as: ° bipolar I disorder – one or more manic or mixed episodes and usually one or more major depressive episodes ° bipolar II disorder – recurrent major depressive and hypomanic but not manic episodes ° cyclothymic disorder – chronic mood fluctuations over at least two years, with episodes of depression and hypomania (but notmania) of insufficient severity to meet diagnostic criteria. |
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Irrespective of medication, what does a patient with bipolar affective disorder need? (Management) |
A coordinated care programme, with rapid access to support at times of crisis, is essential. Hospitalisation is required for those at significant risk of harm. Since patients often lose insight early, detention without consent may be required under the Mental Health Act [in the Maltese Mental Health Act - detention is only allowed when there is a risk of harm to self or others]. |
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What (generally) medication is required for the treatment of bipolar affective disorder? |
The treatment of bipolar disorder is based primarily on psychotropic medication to reduce the severity of symptoms, stabilise mood and prevent relapse. |
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How do you treat manic or hypomanic episodes? |
anti-manic drugs: lithium; valproate atypical antipsychotics: olanzapine; risperldone; aripiprazole; quetiapine |
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What can you use for short term acute behaviour disturbance in bipolar affective disorder? What can you use for rapid tranquilisation? |
Benzodiazepines may be used short term for acute behavioural disturbance. Lorazepam and antipsychotics may be useful for rapid tranquillisation |
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How to treat depressive episodes in bipolar? |
Episodes of depression in bipolar disorder are treated similarly to unipolar depression, but, since antidepressants may precipitate mania or ‘rapid cycling’ (with four or more episodes a year), their role in maintenance treatment is limited and they should not be prescribed without an antimanic/mood-stabilising agent. If a patient is taking an antidepressant at the onset of an acute manic episode, the antidepressant should be stopped. |
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How to treat bipolar affective disorder? (medication and treatment). What do you use to reduce suicide risk? |
Effective prophylactic drugs for bipolar disorder are: ° antimanic drugs (lithium, valproate, carbamazepine and lamotrigine) ° atypical antipsychotics such as olanzapine, quetiapine and aripiprazole. • Lithium reduces the risk of suicide; it may also be useful in cyclothymia. Lithium therapy requires blood monitoring. • The teratogenic toxicity associated with valproate severely limits its use in women of child-bearing potential. Lithium and car- bamazepine are also teratogenic. • Structured psychological treatment focusing on depressive symptoms, problem solving, promoting social functioning and education about medication can be helpful. • Patients should have an annual physical health review including blood lipids and glucose, blood pressure, weight, and review of smoking and alcohol status. |
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NICE guidelines (2009) state that all people with schizophrenia should be offered what kind of therapy? |
CBT (cognitive behavioral therapy) |
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Most cases of depression can be dealt with at what level of care? |
Primary, but many go undetected. |
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When should cases of depression be referred to psychiatric help? [5 points] |
Suicide risk is high severe depression unresponsive to initial treatment bipolar recurrent |
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What can be done in cases of mild depression? [4] |
For mild depression, self-help groups, structured physical activity groups, guided self-help or computerised cognitive behavioural therapy (CBT) are often helpful |
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Psychological therapy should be given together with antidepressants for moderate or severe depression. These can have a 60–70% response rate, but often fail because..... |
....of inadequate dosage, duration or adherence. |
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How long should the usage of antidepressants continue in order to reduce relapse? |
6 months |
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What should you do when discontinuing antidepressants? |
taper it off slowly to avoid withdrawal symptoms |
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What can you use in cases of resistant depression? (medication-wise) |
Resistant depression may respond to combining an antidepressant (augmenting) with lithium, an atypical antipsychotic (aripiprazole, olanzapine, risperidone, quetiapine) or another anti- depressant (e.g. mirtazipine) |
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What could be done in cases of severe depression? Which could also be potentially life-saving |
Electroconvulsive therapy (ECT) is very effective in severe cases, particularly where psychosis or stupor is present, and can be life- saving if fluids and food are being refused |
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How would you manage a bipolar patient? (not medication). Think about what can be done in times of crisis. |
A coordinated care programme, with rapid access to support at times of crisis, is essential. Hospitalisation is required for those at significant risk of harm |
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Bipolar patients are (more/less) likely to lose insight early on. [which is the correct answer] |
MORE! so involuntary admission into hosp may be an option to consider, |
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What are effective treatments for acute mania? [2 main types - of 2 drugs and 4 drugs respectively - try remember them] |
Anti-manic drugs : lithium and valproate atypical antipsychotics: olanzapine • risperidone • aripiprazole • quetiapine |
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1) What can you use for acute behavioural disturbance [in bipolar]? 2) What can you use for rapid tranquillisation of a bipolar patient? |
Benzodiazepines may be used short term for acute behavioural disturbance. Lorazepam and antipsychotics may be useful for rapid tranquillisation |
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How to treat depressive episodes in bipolar patients? |
antidepressants may precipitate mania, and so must only be used in conjunction with antimanic/mood-stabilising agents. If patient is on antidepressants already these need to be stopped. Otherwise patient is treated in a similar manner as unipolar depressed patients are. |
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Why is lithium used? What can you do to reduce risk associated with this drug? |
Lithium reduces the risk of suicide; it may also be useful in cyclothymia. Lithium therapy requires blood monitoring |
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Which drugs should have limited use with woman of 'child-bearing potential' [jaqq what a phrase]. |
Valproate, Lithium and carbamazepine are teratogenic |
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What non-medicinal management can you give a patient with bipolar affective disorder? |
Structured psychological treatment focusing on depressive symptoms, problem solving, promoting social functioning and education about medication can be helpful. Patients should have an annual physical health review including blood lipids and glucose, blood pressure, weight, and review of smoking and alcohol status.Prognosis |
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What is the lifetime prognosis [recurrence] for someone who experienced ONE manic episode? |
90% |
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What is the prognosis of patients who develop rapid cycling? Which drug(s) are they responsive and unresponsive to? |
A minority who develop rapid cycling have a particularly poor prognosis and seldom respond to lithium. However they respond better to antiepileptic mood stabilisers. |
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What management can you suggest with someone who has an adjustment disorder? |
Initial management may involve encouragement to ventilate feelings and to develop appropriate problem-solving strategies. Sometimes formal CBT is required. |
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What is the first line of treatment for someone with a panic disorder? |
Selective serotonin re-uptake inhibitors (SSRIs) and cognitive behavioural therapy (CBT) or self-help materials based on CBT principles are recommended first-line treatments. |
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When SSRI's are inadequate for someone with a panic disorder, what can be used instead? The use of which drug is not recommended? |
• Tricyclic antidepressants (imipramine and clomipramine) may be helpful where SSRIs are ineffective. • Benzodiazepines are not recommended. |
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What first line treatment can be offered someone with Generalized Anxiety Disorder? |
CBT and SSRIs are the recommended first-line treatments |
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What is the aim of CBT in Generalized Anxiety Disorder? |
CBT (self-help material or face to face) for GAD seeks to:° identify morbid anticipatory thoughts and replace them with more realistic cognitions° distraction, breathing and relaxation exercises. |
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Benzo's should not be used in patients who have GAD for more than 2-4 weeks. What other medical treatments can be used? |
Other pharmacological treatments include:° serotonin noradrenaline reuptake inhibitors (SNRIs) ° buspirone ° pregabalin.Phobic |
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how to treat someone suffering from agoraphobia? |
CBT is considered the mainstay of treatment and usually involves graded exposure to avoided situations SSRIs are also effective. Treatment response depends on the patient’s engagement with treatment and motivation for change |
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How would you manage someone experiencing social phobia? |
Management includes CBT, self-help materials, graded self- exposure and social skills training. Drug treatments should not be first line, but, if psycho-social treatment fails or the patient does not want it, may help. SSRIs are most commonly used. |
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How to manage OCD and BDD (body dysmorphic disorder) ? |
Psychoeducation helps people understand their disorder. • First-line treatment is with cognitive behavioural therapy (CBT), together with medication. |
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What does CBT with patients experiencing OCD or BDD involve? |
CBT involves exposure followed by response prevention; the patient is encouraged not to perform the unwanted compulsive behaviour (e.g. hand-washing) while simultaneously being exposed to a situation associated with it (e.g. wiping a toilet seat). CBT can be self-help, group or individual therapy. |
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What drug treatments can be offered someone with OCD or BDD? |
Drug treatment is with selective serotonin reuptake inhibitors (SSRIs) or clomipramine. These drugs are effective even in the absence of coexistent depressive symptomatology. They may take up to 12 weeks to have an effect |
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What is the first line of treatment for adolescents with anorexia? |
family interventions |
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What is the first line of treatment for adults with anorexia? |
effective psychological therapies include cognitive– behavioural therapy (CBT), interpersonal psychotherapy (IPT), focal psychodynamic therapy and family therapy [MUST HAVE GOOD RAPPORT WITH PATIENT!] |
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What can be done in SEVERE cases of anorexia? |
nasogastric feeding - this can be done under the mental health act since patient was in risk of death. |
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How to treat a bulimic patient? |
medical stabilisation
psychotherapy (usually CBT or IPT) to establish a regular eating programme, re-establish control of diet and address underlying abnormal cognitions antidepressants; these are effective, best established for fluoxetine (60 mg), but less effective than CBT. |
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How to treat someone with a binge-eating disorder or obesity? |
Management involves CBT, exercise and educational pro- grammes. Anti-obesity medications such as orlistat (reduces absorption of dietary fat) are of short-term benefit. Surgery (e.g. gastric banding or bypass surgery) is indicated in severe cases |
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What is important to set up with patients with a personality disorder? |
Structure, consistency and clear boundaries (i.e. agreement of behaviour that is acceptable and unacceptable) are critical. Multi- disciplinary and multi-agency work is often required. |
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How can you manage a person who is borderline? |
Adapted cognitive–behavioural therapy (CBT), dialectical behaviour therapy (DBT) and mentalisation-based treatments can help patients may find change in treatment or service difficult. Keep this in mind. |
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What can do with patients who are antisocial, who also have a history of offenses? |
Psychological therapies require patient cooperation, and motivation to engage in treatment predicts success. For those with a history of offending behaviour, group-based cognitive and behav- ioural interventions focused on reducing offending and other anti- social behaviour can be effective |
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How to manage someone with a psychosexual disordeR? [also include drugs - if any] |
- treat the underlying psychological or medical problem - Drugs which can be prescribed: ° Oral phosphodiesterase inhibitors such as sildenafil (Viagra) are the drugs of choice for erectile dysfunction.° Low-dose antidepressant drugs, which have a side-effect of delaying time to ejaculation, are also commonly prescribed tomen with premature ejaculation |
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What can be prescribed (drug and non-drug) to a male experiencing erectile dysfunction? |
Other treatments for erectile dysfunction include mechanical devices (vacuum pumps, penile bands and intracavernosal use of drugs e.g. alprostadil) |
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What psychological treatments can be offered to someone with a psychosexual disorder? |
Cognitive–behavioural-based therapies, which aim to facilitate communication, decrease anxiety about performance failure, and identify and explore underlying developmental and person- ality problems. ° Education, particularly dispelling myths about what is consid- ered appropriate or normal sexual behaviour. ° Traditional sex or couples therapy, which (irrespective of the presenting dysfunction) involves the setting of a hierarchy ofsexual ‘assignments’, structured on behavioural principles |
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What (in general) can be done to manage someone with substance abuse? |
Can be in residential rehabilitation, hospital or community. Contingency management programmes are evidence based. Drug users receiving methadone or who misuse stimulants are offered rewards (e.g. vouchers for goods or services) for negative drug tests or harm reduction (e.g. hepatitis and HIV tests). • Effective psycho-social interventions include cognitive– behavioural therapy, motivational interviewing and self-help groups. • Medication can be useful • Infection (HIV and hepatitis C) is the greatest risk associated with injecting drug use; harm-reduction strategies aim to minimise infection (e.g. needle exchange) and improve safety. |
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How to manage an opiate addiction? |
Methadone (opioid agonist) or buprenorphine (opioid partial agonist) are first line; they are less euphoriant and have a relatively long half-life than opioids of abuse. ° Lofexidine is sometimes used for short detoxification treatments or where abuse is mild or uncertain. ° Consider a contingency management programme, with psychosocial support for at least six months. Naltrexone (opioid antagonist) blocks the euphoric effects and is occasionally used to help prevent relapse. • In maintenance therapy, methadone or buprenorphine is pre- scribed at a dose higher than required to prevent withdrawal symptoms. |
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How to manage alcohol substance abuse? |
Achieving abstinence requires acute detoxification: ° This should be in hospital if there is a risk of delirium tremens or withdrawal seizures, or the person is a child or vulnerable (e.g.cognitively impaired or lacking support). ° Initially high but rapidly tailing sedation (almost always a benzodiazepine, such as chlordiazepoxide or diazepam) usually needed to control withdrawal symptoms and prevent seizures. ° Treatment of delirium tremens is usually with lorazepam or antipsychotics (e.g. haloperidol or olanzapine). ° Treatment also includes rehydration, correction of electrolyte disturbance, and oral or parenteral thiamine. |
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motivational interviewing can be used with patients who are alcoholics/dependency on alcohol. What is this? And what specific types of patients would this be used on? |
Motivational interviewing is client-centred counselling that explores ambivalence to seeking treatment, drinking cessation, or both. It may help problem drinkers in denial achieve insight and a desire to change |
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What medication can be used in the management of alcoholics? |
Medication may help maintain abstinence after detoxification: ° Disulfiram blocks alcohol metabolism, inducing acetaldehyde accumulation if alcohol is ingested, with resultant flushing,headache, anxiety and nausea. ° Acamprosate acts on the γ-aminobutyric acid (GABA) system to reduce cravings and risk of relapse. ° Naltrexone, an opioid-receptor antagonist, has similar therapeutic effects (licensed in the USA but not the UK) [dunno about Malta] |
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Mention some signs of conduct disorder (8 possible signs) |
disobedience, damage to property, truancy, lying, stealing, fighting, use of force, and weaponsarson |
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What management can you suggest for conduct disorders? |
• Management involves sessions (typically 8–12) of group or individual parent-training/education programmes Cognitive–behavioural and social skills therapies may target the child’s aggressive behaviour or poor social interactions. |
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In general, how can you treat emotional disorders in children? |
Treatment involves behavioural and family therapy |
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How would you manage OCD in children? |
CBT (ovja, ghax dejjem CBT) - family should cooperate for this to be a success. Fluoxetine may be described - but cautiously. |
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How would you manage enuresis in children? |
- first cancel out the possibility of a UTI or other physical pathologies - Check if the child intakes an excessive amount of fluids (particularly at night should it be bed wetting) - reward systems (e.g. star charts) used to reinforce success, but the emphasis should be on adherence to the programme ratherthan to dryness - enuresis alarms: these devices are activated by moisture; alarms achieve dryness over time by training the child to recog- nise the need to pass urine and to wake to go to the toilet or hold on - medication: desmopressin (synthetic antidiuretic hormone) or imipramine (a tricyclic antidepressant) are sometimesprescribed. |
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How would you manage encopresis in children? |
Physical causes for constipation (e.g. Hirschsprung’s disease) or pain on defecation must be ruled out. • Encopresis is associated with emotional disturbance; intelligence is usually average or below average. There may be underlying parental marital conflicts, punitive potty training and/or sexual abuse. • Treatment aims both to restore normal bowel habits and to improve parent/child relationships. Parents should be encouraged to ignore the soiling and in particular not to punish the child. More specific treatments include behaviour modification (e.g. star chart) and family therapy. Drug treatments are of very little use, except the use of laxatives if constipation is present. |
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How would you manage a young patient with an autism spectrum disorder? |
Treatment is with specialist, intensive (>25 hours a week) behavioural treatments. These typically: ° break down skills (such as communication and cognitive skills) into small tasks, then teach those tasks in a highly structuredway ° reward and reinforce positive behaviour ° discourage and redirect inappropriate behaviour. Family support and counselling are crucial. |
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How would you manage an adolescent with conduct disorder? |
Psycho-social intervention should be the first line of treatment, along with treating comorbid disorders. • If problems are severe, medication may be used cautiously. ° Atypical antipsychotics (in particular risperidone, which is licensed for conduct disorder) may reduce aggressive behaviours, especially if there are coexisting neurodevelopmental disorders, such as autistic spectrum disorder. ° Selective serotonin reuptake inhibitors (SSRIs) may reduce impulsivity, irritability and lability of mood. |
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What interventions can be used with adolescents with mood disorders? |
Interventions may include: ° family therapy° individual psychotherapy (particularly cognitive behavioural therapy; ° antidepressants may be indicated where biological features are prominent. Because of concerns that SSRIs may increase the risk of suicidal thoughts and self-harm, only fluoxetine is generally recommended for depression under the age of 18. |
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How would you manage someone with a learning disability? |
- at-home-care - Specialist multidisciplinary community teams coordinate local services, assess and manage any concurrent mental illness, social skills and problem-solving training, and support with finances and accommodation. - People with LD need written information to be accessible (in a format they can understand). Those with more severe LD some- times use Makaton, a communication system of signs and gestures. |
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How to manage a woman with postpartum depression ? |
Management involves full psycho-social assessment (including possible risk to mother and the baby). • First line of treatment for mild to moderate perinatal depression is psychological therapy and not antidepressants because of the potential for adverse effects in the foetus or breastfeeding baby |
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How would you manage depression in older patients? |
Both physical and psychological treatments are effective, but are underused in older people. • Reducing social and sensory isolation may be important (through, for example, hearing aids and glasses, and day centre referral). • Cognitive–behavioural therapy may need to be modified to the needs of an older group but is effective in group as well as individual settings. In dementia, the focus may be on behavioural management and working with carers. • Antidepressants with a relative lack of contraindications and favourable side-effect profiles, including selective serotonin reuptake inhibitors (SSRIs), venlafaxine and mirtazapine, There is new evidence that antidepressants are not effective in dementia (so consider other treatment first unless severe depres- sion/risk of suicide). • Electroconvulsive therapy (ECT) is very effective in more severe depression, particularly in patients with delusions or psychomotor retardation and those refusing food or fluid, in whom the risk of irreversible physical deterioration is high |
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how would you manage dissociative disorders in the elderly? |
Management involves ensuring that there really is no organic basis, treating any underlying mood disorder and exploring with the patient and the family any ‘secondary gain’ (such as sympathy or avoidance of family conflict) that might be maintaining symptoms. |
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Define Munchausen’s syndrome. Hint: it affects elderly |
When a patient fakes or induces illness in themselves. Can be to gain nurture/affection or to avoid persecution from the law. Also called factituous disorder |
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How can you manage pain and fatigue in an elderly patient? |
- depression may be underlying the pain/fatigue - Chronic pain may respond to psychological therapy and antidepressants even in the absence of clear-cut depression - first-line treatment for fatigue (which can be caused by myalgic encephalomyelitis) is CBT or graded exercise therapy. |
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What treatment can you suggest for someone with epilepsy? |
Treatment includes careful use of antidepressants. ° Selective noradrenaline and serotonin reuptake inhibitors (SNRIs) and selective serotonin reuptake inhibitors (SSRIs) arerecommended as least likely to lower the seizure threshold. ° Citalopram is also least likely to interact with anti-epilepsy drugs. • Electroconvulsive therapy (ECT) may be given if necessary. • Carbamazepine and lamotrigine are anti-epileptic agents that may also improve mood |
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How to treat a patient with huntington's? |
answer: with respect! Book answer: Treatment is symptomatic, and depression and psychoses should be treated with standard medications. Atypical antipsychotics are preferred because they are less likely to exacerbate motor symptoms |
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How can you investigate for delirium? |
obtain an informant history, focusing particu- larly on premorbid level of functioning, onset and course of the confusion, and use/abuse of drugs or alcohol. • In the mental state assessment, particular attention should be paid to cognitive function (alertness, memory, language, visuo- spatial ability) and to fluctuation in behaviour. • Physical examination is crucial in identifying focal neurological signs and evidence of infection or trauma. • Appropriate blood investigations - midstream urine (MSU) - Chest x-ray (CXR) may be informative. • Structural brain imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) can identify many intracranial causes. • Consider electroencephalography (EEG) if epilepsy is a differential. |
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What blood investigations can you make for possible cases of delirium? |
full blood count (FBC) (to exclude anaemia, macrocytosis, leucocytosis) ° erythrocyte sedimentation rate (ESR) (infection) ° urea and electrolytes (U&E) (dehydration, electrolyte imbalance) ° glucose ° thyroid function tests (TFT) ° liver function tests (LFT) ° calcium ° folate and B12 ° VDRL (i.e. syphilis serology). |
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how can you manage a patient with delirium? |
Specific management should be targeted at detection of the confusional state itself, and at identification and subsequent treatment of underlying pathology. Patients should therefore usually be managed on general hospital (i.e. not psychiatric) wards. • Taking preventive measures • If a person with delirium is distressed or considered a risk to him/herself or others and non-pharmacological measures are insufficient, medication may be needed. ° Consider short-term (<1 week) antipsychotic (e.g. haloperidol, risperidone [not recommended in dementia]) or short-actingbenzodiazepines (e.g. lorazepam). ° Medication is preferable to physical restraint, but should be used sparingly. ° Hypotensive and anticholinergic side-effects may precipitate falls or exacerbate the confusion. ° Longer acting benzodiazepines (e.g. diazepam or chlor- diazepoxide) are used when the patient is withdrawing from alcohol or drug abuse |
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How to manage a patient with dementia? What drugs can you use to treat underlying dementia? |
Patients should have a full assessment to exclude treatable causes and identify specific problems The possibility of superimposed and treatable acute confusional states (commonly iatrogenic or secondary to infection) should be considered if a patient suddenly deteriorates. • Depression sometimes precedes or complicates established dementia and has a poor response to antidepressants. Controlling vascular risk factors in patients with vascular dementia and prescribing low-dose aspirin reduce the risk of further stroke-related deterioration. • Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) can arrest or temporarily reverse cognitive and functional decline in people with mild to moderate AD and DLB, and may also improve behaviour. • Memantine, which modulates glutamate neurotransmission, is used in moderate to severe AD. • No currently available drugs can treat the underlying dementia, although these are targets of current research. Social support may include home care, day centres and intermit- tent respite organised by Social Services. Patients with severe dementia may require residential, nursing or continuing care (in hospital or other appropriate facility). • Psychological techniques such as cognitive stimulation (group activities to actively stimulate and engage people with dementia) or teaching behavioural management techniques (see Glossary) to carers may improve cognition and behaviour. |
