Psychiatry Peer Teaching - PowerPoint Presentation

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Psychiatry Peer Teaching

Will MannersBen Sharples

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What is in the teaching

Psychiatric history and MSE

Depression disordersAnxiety disordersBipolar disorderSchizophreniaMental Health ActPsychiatric emergenciesPersonality disordersSubstance misuseDementia and delirium

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Pyschiatric history and MSE

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Psychiatric history

HPC – onset -> duration -> stressors

PMH – physical and mental health

FH:History of mental health

Relationship with familySH:

Housing

Money and employment

Substance abuse – alcohol, drugs

Personal history:

Developmental milestones

School participation/enjoyment

Previous abuse

Forensic history – offender/prison or victim

Premorbid history:

Friend descriptionsStrengths and assets – hobbies, future plans

During the psychiatric history, do the MSE

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Mental state examination

Appearance and behaviour

Speech – rate, tone, volume

Mood and affect:Current mood +/- variation

Congruent/incongruent affect

Thoughts:

Content – delusions, obsessions, compulsions

Form – loosening of association, thought block

Perception – hallucinations

Orientation – date, place, time

Insight

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Depressive disorders

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Depression

Criteria

Symptoms >2 weeks

Symptoms not 2’ to alcohol, drugs, medication or bereavement

Patient experiencing ≥5 symptoms, which must include either depressed mood AND/OR anhedonia.

Core symptoms

Persistently depressed mood and anhedonia (somatic) – must have at least 1 of these

Weight change, psychomotor agitation/retardation and fatigue/anergia

Feelings of worthlessness or excessive/inappropriate guilt

Inability to concentrate

Suicidal thoughts/acts

N.B. Symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

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Depression

Somatic symptoms

Loss of emotional reactivity, diurnal mood variation, anhedonia, early morning waking

Psychotic symptoms

Delusions, e.g., poverty, personal inadequacy, guilt over presumed misdeeds, responsibility for world events, deserving of punishment and other nihilistic delusions

Hallucination, e.g., auditory (defamatory/accusatory and cries for help/screaming), olfactory (bad smells) and visual (tormentors, demons and The Devil etc.)

Catatonic symptoms

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Depression

Grading severity (DSM-5)

Mild depression: 5 core symptoms + minor social/occupational impairment

Moderate depression: ≥5 core symptoms + variable degree of social/occupational impairment

Severe depression: ≥5 core symptoms + significant social/occupational impairment - can occur with or without psychotic symptoms.

At least 1 core symptom must be depressed mood OR anhedonia.

Subthreshold depression is diagnosed if the person has at least 2, but fewer than 5 core symptoms of depression. 

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Depression

Indirect presentations

Insomnia, fatigue, or other somatic symptoms OR

Elderly pts presenting with agitation, confusion and decline in normal function (i.e., pseudodementia)

Children presenting with irritability, decline in school performance, or social withdrawal

Subtypes of depression

Dysthymic disorder

Post-natal depression

Seasonal affective disorder

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Depression

Initial assessment

Psychiatric Hx + MSE

Patient Health Questionnaire-9 (PHQ-9),

Hospital Anxiety & Depression Scale (

HADS) or Becks Depression Inventory-2 (BDI-II)

Baseline

Ix

:

FBC, ESR, B

12

/folate, U&Es, LFTs, TFTs, glucose and Ca

2+

Focused

Ix

:

Urine/blood toxicology, ABG, thyroid antibodies, antinuclear antibodies, dexamethasone suppression test (Cushing’s disease), syphilis serology, LP (VDRL and Lyme antibody) and CT/MRI head

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Depression

Treatment

Cognitive behavioural therapy (CBT)

Antidepressants

First line: SSRIs, e.g., paroxetine,

citalopram, fluoxetine or sertraline (consider gastroprotection i.e., PPI)

SNRIs: duloxetine and venlafaxine 

TCAs: Sedating (e.g., amitriptyline or clomipramine) and non-sedating (e.g., imipramine and lofepramine)

Alpha

2

-adrenoreceptor antagonist: Mirtazapine

MAOi: Isocarboxazid or Phenelzine sulphate

Information to patient: vigilant for worsening depressive symptoms, usually takes 2–4 weeks for symptoms to improve

Interpersonal therapy (IPT)

Risk assessment

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Dysthymic disorder

Chronic (>2yrs), low-grade depressive symptoms

Clinical features similar to depression

Epidemiology: 1:2 M:F, usually early age onset (<20yrs)

Course: less severe, more chronic

Management: SSRI/TCA, CBT may be useful

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Seasonal affective disorder

Clinical features

Clear seasonal pattern to recurrent depressive episodes

Usually January/February (‘winter depression’)

Low self- esteem, hypersomnia, fatigue, increased appetite/weight gain

Decreased social and occupational functioning

Symptoms mild-moderate

Management

Light therapy, then SSRI

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Post-natal depression

Definition:

Significant depressive episode related to childbirth (<6month post-partum)

Risk factors

FHx

depression, older age

Single mother, poor maternal relationship

Ambivalence to pregnancy, poor social support and severe baby blues

Additional clinical features

Worries about baby’s health or ability to cope adequately with the baby

Assessment

Psychiatric screen + MSE + and Edinburgh Postnatal Depression Scale (EPDS)

Treatment

SSRI (e.g., paroxetine, sertraline or citalopram) ± CBT

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Anxiety disorders

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Anxiety disorders

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Generalised

anxiety disorder

Definition: Excessive worry/feelings of apprehension about everyday events/problems leading to significant distress/functional impairment.Criteria for DxExcessive anxiety and worry about everyday events/activities and difficulty controlling the worry on most days for 6 monthsShould cause clinically significant distress/impairment in social, occupational or other important areas of functioningAt least 3 associated symptoms

Associated symptomsRestlessness or feeling keyed up or on edgeBeing easily fatiguedDifficulty concentrating or ‘mind going blank’IrritabilityMuscle tensionSleep disturbance

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1. Generalised anxiety disorder

Assessment

Psychiatric history + MSE + GAD-7 questionnaireNICE stepwise care modelEducation about GAD and treatment options with active monitoringIndividual non-facilitated or guided self-help and psychoeducational groupsCBT ± SSRI (sertraline first-line)

CBT + SSRI (± input from multi-agency teams, crisis services, day hospitals or inpatient care)Risk assessment

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2. Panic disorder

Definition:

Recurrent, episodic, severe panic attacks that are unpredictable and NOT restricted to particular situation/circumstanceClinical presentationSymptoms peak within 10minsDiscrete episodes of intense fear Autonomic arousal (PANICS Disorder)P – PalpitationsA – Abdominal distress N – Numbness/nauseaI – Intense fear of death

C – Choking/chest pain S – Sweating/shaking/SOBD – depersonalization/derealization

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2. Panic disorder

AssessmentPsychiatric Hx + MSE

Bloods: FBC, TFTs and glucoseECG: sinus tachycardiaRule out GAD with GAD-7TreatmentSSRIs (e.g., sertraline) > TCA (e.g. imipramine)Don’t give BDZ!CBT and self-help methods

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3. Phobic anxiety

Definition: ‘Recurring excessive and unreasonable psychological or autonomic symptoms of anxiety in the (anticipated) presence of specific feared objects, situation, place or person leading, wherever possible to avoidance’

5 subtypesAnimals, aspects of natural environment, blood/injection/injury, situation and ‘other’E.g. Zoophobia, arachnophobia, aviophobia etc.ManagementBehavioural therapy i.e., graded exposure therapyEducation/anxiety management

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4. Post-traumatic stress disorder

Definition:

Intense, prolonged, delayed reaction following exposure to an exceptionally traumatic eventClinical presentation (classic quadrad)Reliving the situationAvoidanceHyperarousal Emotional numbingDissociative amnesia:

inability to remember an important aspectCriteria for diagnosisExposure to traumatic event, above features present within 6 months of event, features last > 1 month.

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4. Post-traumatic stress disorder

AssessmentPsychiatric history + MSE

Trauma Screening Questionnaire (TSQ)TreatmentFirst-line: Trauma-focused CBT + Eye movement desensitization and reprocessing (EMDR)Sertraline/venlafaxine Zopiclone

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5. Obsessive-compulsive disorder

Definition:

chronic condition, associated with marked anxiety and depression, characterized by ‘obsessions’ and/or ‘compulsions’Obsession: an idea, image or impulse recognised by patient as their own, but which is experienced as repetitive, intrusive and distressingE.g., Aggressive impulses, contamination, need for order, repeated doubts, sexual imagery etc.Compulsion: behaviour or action recognised by patient as unnecessary and purposeless but which they cannot resist performing repeatedly

E.g., Checking, cleaning (overt), mental acts (covert), ordering etc.

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5. Obsessive-compulsive disorder

Aetiology:

Developmental factors, psychological factors and stressorsCriteria for diagnosisPresence of either obsessions, compulsions, or both.Obsessions/compulsions are time-consuming or cause clinically significant distress/functional impairmentAt some point patient recognises the symptoms to be excessive/unreasonableTreatment

CBT + exposure and response prevention (ERP)Behavioural therapy/psychotherapy (supportive)Pharmacological approach: SSRI (first-line), clomipramine (second-line)

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Bipolar disorder

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Bipolar disorder

Aetiology:

Personality, childhood experiences, life events, biochemical/endocrine correlates of depression

Definition:

Depression

+ mania/hypomania occurring in episodes usually with months separating them.

Diagnosis requires

at least 1 episode of mania or hypomania

Mania:

Elevated, expansive, euphoric, or irritable mood with ≥3 characteristic symptoms of mania on most days for 1 week

Elevated mood and increased energy

Pressure of thought, flight of ideas, pressure of speech and word salad

Increased self-esteem and reduced attention

Tendency to engage in risky behaviour

Other: excitement, irritability, aggressiveness and suspiciousness

Marked disruption of work, social activities and family life

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Bipolar disorder

Psychotic symptoms

Occur in up to 75% of manic episodes

Grandiose delusions e.g., special powers

Persecutory delusions may develop from suspiciousness

Auditory and visual hallucinations

Catatonia i.e., manic stupor

Total loss of insight

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Bipolar disorder

Hypomania:

≥3 characteristic symptoms lasting

≥4 days and be present most of the day, almost every day

Shares mania symptoms

Symptoms evident to lesser degree

N

ot severe enough to interfere with social or occupational functioning

Does not result in hospital admission

No psychotic features

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Bipolar disorder

Bipolar I disorder:

characterised by episodes of depression, mania or mixed states separated by periods of normal mood

Bipolar II disorder: 

do not experience mania but have periods of hypomania, depression or mixed states

Cyclothymic disorder:

characterised by recurring depressive and hypomanic states, lasting for at least 2 years, that do not meet the diagnostic threshold for a major affective episode

N.B. Medication induced mania/hypomania

TCAs/NSRIs > SSRIs, benzodiazepines, antipsychotics, lithium, anti-Parkinsonian medications

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Bipolar disorder

Pharmacological treatment

Manic episode: lithium ± benzodiazepine (e.g., clonazepam or lorazepam)

Depressive episode: SSRI

Maintenance:

Lithium

Lithium adverse effects:

weight gain, subclinical/clinical hypothyroidism, renal impairment and teratogenic

Psychotherapeutic interventions

Psychoeducation

CBT

IPT

Support groups

Risk assessment

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Schizophrenia

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Schizophrenia – risk factors

Bimodal age distribution

Family history of schizophrenia

Pre-morbid schizoid personalityAbuse

Delayed developmental milestonesObstetric risk factors

Substance abuse

Significant life event

Cerebral injury

Acute psychosis

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Schizophrenia - symptoms

Appearance and behaviour – bizarre, disorganised, catatonic

Mood:

Anhedonia, depression, blunting/incongruity of affectNegative symptoms tend to be prodromal

Speech:Pressured and

distractible

Phenomenology – verbigeration, perseveration, word salad

Thoughts:

Content:

D

elusions - persecutory, grandiose, nihilistic, religious, referential, perceptive

Thought alienation - insertion, withdrawal, broadcast

Form – tangentiality, loosening of association, circumstantiality

Perception – auditory hallucinations:

2nd or 3rd personCommand, derogatory, running commentaryPassivity - feelings, impulses or actsInsight – present or absentSchneiderian ranks1st – thought alienation, delusional perception, passivity, 3rd person auditory hallucinations2nd – other delusions, 2nd person auditory hallucinations, negative symptoms

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Schizophrenia – investigations

Full history and MSE

Exclude differentials:Psychotic depression:Depressive featuresDelusions – derogatory and nihilisticPsychomotor changes

Schizoaffective disorder - mood disorder + schizophreniaPersonality disorderBipolar disorderSubstance abuseExclude physical cause:Scans – CT/MRI head

Toxicology screenBloods – FBC, U&E, LFT

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Schizophrenia - pharmacological

Antipsychotics (PO or depot):

Atypical:Risperidone QuetiapineAripiprazoleOlanzapine

ClozapineTypical:HaloperidolChlorpromazineSide effects:Extra-pyramidal –

akathisia, tardive dyskinesia, dystonia, NMSMetabolic – weight gain, diabetes, liver dysfunctionGeneral – dry mouth, constipation, sexual dysfunction, ECG changesSpecific:

Risperidone – hyperprolactinaemia

Clozapine – agranulocytosis, cardiomyopathy

Monitoring – FBC, prolactin, U&E, LFT, ECG, HbA1c, weight measurement

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Schizophrenia – non-pharmacological

Manage mental health co-morbidities

CBTFamily therapyArt therapyLifestyle changesECT

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Mental Health Act 1983

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Section 2

Duration:

28 days

Non-renewablePurpose – assessment and treatment

Professionals:TWO doctors (ONE S12)

ONE approved mental health professional (AMHP)

Evidence:

Patient is suffering from mental disorder

Being detained for their own health/safety or others protection

S12

AMHP

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Section 3

Duration:

6 months

Renewable

Purpose – long term treatmentProfessionals:

TWO doctors (ONE S12)

1 AMHP

Evidence:

Section 2 rationale

A

ppropriate treatment is available

S12

AMHP

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Section 4

Duration – 72 hours, non-renewable

Purpose – to hold patient until assessment by S12 doctor

Professionals;ONE doctor

ONE AMHPEvidence – Section 2 rationale

AMHP

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Section 5

Purpose – patient is in hospital but wants to leave, cannot be treated coercively

Types:

5(4):Duration -

6 hoursInitiated by nurse

5(2):

72 hours

Initiated by doctor in charge of patient’s care

Slide44

Police orders

135:

Duration – 36 hours

Purpose - police allowed to enter patient’s home to move to a place of safety

136:Duration – 24 hours

Purpose – police can move patient with mental disorder in a public place to place of safety

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Psychiatric emergencies

Slide46

Neuroleptic malignant syndrome

Pathophysiology:

Adverse reaction to dopamine receptor agonists - anti-psychotics

Abrupt withdrawal of dopaminergic medication

Symptoms:Altered mental state

Hypertonia

Autonomic dysfunction

Hyperthermia

Investigations:

Bloods – FBC, CK, U and Es

Imaging – CT/MRI head

Infection screen - urine/blood culture, LP

Management:

Withdraw anti-psychotic medication

Supportive treatment

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Serotonin syndrome

Pathophysiology -

increased intrasynaptic serotonin concentration

Causes:Antidepressants – SSRI and SNRI

Others – opioid analgesics, MAOI, lithiumSymptoms:

Altered mental state

Neuromuscular dysfunction

Autonomic

dysregulation

Investigations – look for other causes

Management:

Withdraw offending medication

Supportive treatment

If recent overdose – activated charcoal

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Personality disorders

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Personality disorders

Definition:

An enduring pattern of inner experience and behaviour that deviated markedly from the expectations of the individual’s culture.

Pattern manifests in 2 or more areas

Cognition

Affectivity

Interpersonal functioning

Impulse control

Enduring pattern

Inflexible and pervasive across a broad range of personal and social situations AND

Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Aetiology

Socioeconomic status

Family history

Parenting/deprivation

Abuse

Slide50

Personality disorders

Description

Cluster A

Paranoid

Sensitive, suspicious, unforgiving of others, spouse fidelity questioned, perceives attack, jealous, criticism not liked, distrust of others, preoccupied with conspiratorial explanations and self-referential

Schizoid

Emotionally cold, detached affect, lack of interest in others, indifferent to praise/criticism, tasks done alone, sexual drive low

Schizotypal

Interpersonal discomfort with peculiar ideas, perceptions, appearance, eccentric behaviour, speech and beliefs are odd, inability to maintain friendships, lack of companionship, emotionally cold

Cluster B

Antisocial

Callous lack of concern for others, disregard to rules and responsibility, irritability, aggression, incapacity to maintain relationships and evidence of childhood conduct disorder

Emotionally unstable personality disorder

1. Impulsive type: violent, impulsive and poor response to criticism

2. Borderline type: Self-image and chronic feelings of emptiness, intense and unstable relationships, self-harm and suicidal attempts profoundHistrionicSelf-dramatisation, shallow affect, egocentricity, craving attention and excitement and manipulative behaviourNarcissisticGrandiosity, lack of empathy and need for admirationCluster CAvoidantTension, self-consciousness, fear of negative evaluation by others, timid, social inhibition and insecureDependant

Reassurance required, expressing disagreement is difficult, lack of self-confidence, abandonment fears, needs others to assume responsibility, companionship sought and exaggerated fears

Obsessive-compulsive disorders (ICD refer to as ‘Anankastic’)

Doubt, indecisiveness, caution, pedantry, rigidity, perfectionism and preoccupation with orderliness and control

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Personality disorders

Investigations

Psychiatric history + MSEPersonality diagnostic questionnaire (PDQ-IV)Minnesota multiphasic personality inventoryMRI/CT headDiagnosis typically made >18yrs when personality has developedManagementRisk assessmentNo specific pharmacological treatmentDialectical behavioural therapy (DBT)

Mentalisation-based therapy (MBT)/CBT/psychodynamic therapyCrisis team

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Substance abuse

Slide53

Substance (drug) abuse

Physiological dependence

Signs of toleranceWithdrawal symptomsThree or more of the following must occur for >1mthDesire for substancePreoccupation with substance useWithdrawal state Incapability to control substance

Tolerance to substanceEvidence of harmful effectsComplicationsDeath, infection (e.g., IE), DVT, PE etc.

Slide54

Substance (drug) abuse

Assessment

Psychiatric Hx + MSEPhysical exam: weight, dentition, signs of IVDUSigns of withdrawalBloods: FBC, U&Es, LFTs, clotting profile, drug level and screen for blood-borne infectionsUrinalysis: toxicologyECG, echocardiogram and CXR

Slide55

Substance (drug) abuse

ManagementSelf-help groups

Motivational interviewing/CBTPharmacological intervention: opioid dependenceSubstitute prescribing/detoxification: Methadone, buprenorphine or dihydrocodeineWithdrawal symptom relief: LofexidineRelapse prevention: NaltrexoneOverdose: Naloxone

Slide56

Alcohol misuse

Recommended units:

14 units/weekUnits =

Clinical presentation (intoxication)

Impaired speech, labile affect, impaired judgement, poor coordination, hypoglycaemia, stupor and comaAlcohol dependence (SAW

DRINk

)

S – Subjective awareness of compulsion to drink

A – avoidance or relief of withdrawal by further drinking

W – Withdrawal symptoms

D – Drink-seeking behaviour

R – Reinstatement of drinking after attempted abstinence

I – Increased tolerance

N – Narrowing of drinking repertoire

 

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Alcohol misuse

Alcohol withdrawal

Symptoms appear 6-12hrs after last drinkMalaise, tremor, nausea, insomnia, transient hallucination and autonomic hypersensitivityAt 36 hoursSeizuresAt 72 hoursDelirium tremensDelirium tremens (DT)Dehydration ± electrolyte disturbancesCognitive impairmentHallucinations/illusions

Paranoid delusionsMarked tremorAutonomic arousal

Slide58

Alcohol misuse

Wernicke’s encephalopathy

Thiamine deficiencyClinical presentationAtaxiaDeliriumHypothermiaNystagmusOphthalmoplegiaIV Pabrinex (thiamine)Korsakoff’s syndromeInability to lay down new memories

Working memory impaired with confabulationAnte/retrograde amnesia Disorientation to time

Slide59

Alcohol misuse

Assessment

Psychiatric Hx + MSE Physical examQuestionnaires: AUDIT, CAGE, SADQ and FASTClinical Institute Withdrawal Assessment (CIWA) CT head ECGBloods: FBC, U&Es, LFTs (gamma-GT^), TFTs, vitamin B12/folate, blood alcohol level, amylase/lipase, glucose and hepatitis serologyTreatment

First-line: Chlordiazepoxide + IV ThiamineMaintenance and relapse prevention: Acamprosate, naltrexone or disulfiramMotivational interviewing/CBT Alcoholics anonymous

Slide60

Dementia

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Dementia – pathophysiology

Definition -

progressive neurological disorder impacting cognition that leads to functional impairmentTypes:Alzheimer’s disease

Vascular dementiaLewy body dementia

Others:Frontotemporal

Parkinson’s related

A

lcohol related

M

ixed (

Alzh

+

vasc

)

Slide62

Dementia – risk factors

Age

Family history

GeneticsDown’s syndrome

Cerebrovascular diseaseHyperlipidaemia

Lifestyle – smoking, obesity, high fat diet, alcohol

Poor education

Slide63

Dementia - symptoms

General:

Memory decline

Disoriented in time and placeNominal dysphasiaVisuospatial dysfunction

Change in emotionsChange in personality

Prosopagnosia

Specific:

Alzheimer’s:

Gradual onset + progressive

No insight to condition

Vascular:

Stepwise progression

Insight into condition

Lewy body:

Hallucinations commonParkinsonian signs

Slide64

Dementia - investigations

Full history – personal and collateralCognitive screening tools:

MMSEACE IIIMoCARule out medical cause:Bloods – FBC, metabolic panel, B12, LFT, BMUrinalysisCT/MRI headDifferential diagnosis:DeliriumDepression

Slide65

Dementia - management

Advance care plan –

LPA, advance statement, preferred place of care

Pharmacological:Acetylcholinesterase inhibitors:

DonepezilGalantamine

Rivastigmine

Other psychiatric disturbances – antipsychotics/antidepressants/anxiolytic

Non-pharmacological:

Lifestyle changes - diet, exercise, maintain social contacts

Cognitive rehabilitation/occupational therapy

Slide66

Delirium

Pathophysiology:

Definition – acute, fluctuating change in mental state

Types:Hyperactive

Hypoactive Mixed

Causes = PINCH ME:

Pain

Infection

Nutrition

Constipation

Hydration

Medication

Environment

MANAGEMENT = TREAT THE CAUSE

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Questions?

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Quiz

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Question 1

John is a 21-year-old student who has presented to his GP surgery with unspecified mental health problems. After describing his symptoms, the GP suspects John may be suffering from schizophrenia. Which of the following symptoms that John describes is least likely to point to a diagnosis of schizophrenia?

‘The government are definitely listening to my thoughts and stealing the good ones’

‘Sometimes I feel like someone else is in control of my body, I’m just a passenger’

‘The presenter on the TV told me to come and see you today, otherwise I wouldn’t have come’‘There are days when I feel on top of the world and I can do anything, and there are days when I can’t leave my bed because I feel so low’

‘Can you hear those voices? They keep talking about me and saying the worst things’

Slide70

Question 1

John is a 21-year-old student who has presented to his GP surgery with unspecified mental health problems. After describing his symptoms, the GP suspects John may be suffering from schizophrenia. Which of the following symptoms that John describes is least likely to point to a diagnosis of schizophrenia?

‘The government are definitely listening to my thoughts and stealing the good ones’

A is an example of thought broadcast and withdrawal

‘Sometimes I feel like someone else is in control of my body, I’m just a passenger’ B is an example of passivity

‘The presenter on the TV told me to come and see you today, otherwise I wouldn’t have come’

C is an example of a referential delusion

‘There are days when I feel on top of the world and I can do anything, and there are days when I can’t leave my bed because I feel so low’

D is more descriptive of bipolar disorder, consisting of extreme mood swings

‘Can you hear those voices? They keep talking about me and saying the worst things’

E is an example of a 3

rd

person derogatory auditory hallucination

Slide71

Question 2

Which of the following is the least suitable treatment for post-traumatic stress disorder?

Selective serotonin reuptake inhibitor

Cognitive behavioural therapy

Eye movement desensitisation and reprocessing

Benzodiazepine

Atypical antipsychotic

Slide72

Question 2

Which of the following is the least suitable treatment for post-traumatic stress disorder?

Selective serotonin reuptake inhibitor

Cognitive behavioural therapy

Eye movement desensitisation and reprocessing

Benzodiazepine

Benzodiazepines are not recommended for the treatment of PTSD

Atypical antipsychotic

Slide73

Question 3

You are working as an F1 in Accident and Emergency and are called to see a patient previously diagnosed with Emotionally Unstable Personality Disorder. Over the course of the consultation it becomes clear that the patient is suicidal and is at high risk of committing suicide if they leave the department. The patient is now requesting to leave and is becoming aggressive. You speak to the consultant in charge and they decide to detain the patient under Section Four of the Mental Health Act. Which of the following statements applies to Section Four?

This section lasts for 24 hours

One S12 approved doctor is sufficient to approve this section

This section cannot be renewed

The police are the main profession who use this order

You cannot be given treatments against your will during this section

Slide74

Question 3

You are working as an F1 in Accident and Emergency and are called to see a patient previously diagnosed with Emotionally Unstable Personality Disorder. Over the course of the consultation it becomes clear that the patient is suicidal and is at high risk of committing suicide if they leave the department. The patient is now requesting to leave and is becoming aggressive. You speak to the consultant in charge and they decide to detain the patient under Section Four of the Mental Health Act. Which of the following statements applies to Section Four?

This section lasts for 24 hours

S

ection 4 lasts for 72 hoursOne S12 approved doctor is sufficient to approve this section

One S12 doctor AND one approved mental health professional (AMHP) is required to approve the section

This section cannot be renewed

The section can not be renewed but a second S12 doctor can progress the order to a Section two or three if there is clinical need

The police are the main profession who use this order

Section 4 is most often used in healthcare settings like an A and E departments; Sections 135 and 136 are used most often by police

You cannot be given treatments against your will during this section

T

here are certain situations in which a patient can be treated against their will

Slide75

Question 4

Peter is a 45-year male with a long- standing diagnosis of schizophrenia. He changed his anti-psychotic medication three months ago, and he has not attended a GP appointment since that change. He presents to his local emergency department with fever and chills, and his observations show tachycardia, tachypnoea and severe hypotension. He does not have any neurological signs. Which of the following investigations will be most useful to determine the cause of Peter’s symptoms?

Full blood count

Creatinine kinase

Liver function testsEEG

Lithium levels

Slide76

Question 4

Peter is a 45-year male with a long- standing diagnosis of schizophrenia. He changed his anti-psychotic medication three months ago, and he has not attended a GP appointment since that change. He presents to his local emergency department with fever and chills, and his observations show tachycardia, tachypnoea and severe hypotension. He does not have any neurological signs. Which of the following investigations will be most useful to determine the cause of Peter’s symptoms?

Full blood count

Peter is presenting with agranulocytosis after switching his anti-psychotic medication to clozapine. A is therefore the diagnostic test to confirm clozapine-induced agranulocytosis. This is a similar presentation to neuroleptic malignant syndrome; however, the delayed onset and lack of extra-pyramidal symptoms suggest that NMS is not the cause of Peter’s symptoms

Creatinine kinase

Liver function tests

EEG

Lithium levels

Slide77

Question 5

Which of the following phenomena would be classed as a nihilistic delusion?

Charles-Bonnet syndrome

Fregoli syndrome

Lilliputian syndromeCapgras syndrome

Cotard’s

syndrome

Slide78

Question 5

Which of the following phenomena would be classed as a nihilistic delusion?

Charles-Bonnet syndrome

Charles Bonnet syndrome is a visual hallucination related to loss of sight

Fregoli syndromeFregoli

syndrome is persecutory delusion in which people are constantly changing their appearance around you

Lilliputian syndrome

Lilliputian syndrome is a visual hallucination where things seem smaller than they are

Capgras syndrome

Capgras syndrome is a persecutory delusion in which the people close to you have been replaced by imposters

Cotard’s

syndrome

Cotard’s

syndrome is a nihilistic delusion in which the patient believes they are dead or rotting

Slide79

Question 6

Which of the following would be most useful in determining whether a patient has an alcohol abuse problem?

MoCA test

Folstein test

CAGE questionnaireAUDIT-C score

PAWS scale

Slide80

Question 6

Which of the following would be most useful in determining whether a patient has an alcohol abuse problem?

MoCA test

Screening tool for cognitive declineFolstein

testAnother name for the mini mental state examination

CAGE questionnaire

Alcohol screening tool

AUDIT-C score

Alcohol screening tool

, more comprehensive than CAGE

PAWS scale

U

sed to determine the severity of alcohol withdrawal

Slide81

Question 7

Which of the following side-effects of atypical antipsychotics is most likely to result in the cessation of the antipsychotic treatment?

Tardive dyskinesia

Akathisia

Hyperprolactinaemia Sexual dysfunction

Increased risk of diabetes

Slide82

Question 7

Which of the following side-effects of atypical antipsychotics is most likely to result in the cessation of the antipsychotic treatment?

Tardive dyskinesia

All are side-effects of atypical anti-psychotics; however, A is the only symptom that calls for the cessation of the treatment as soon as possibleAkathisia

Hyperprolactinaemia

Sexual dysfunction

Increased risk of diabetes

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Question 8

A 55-year-old man presents to Accident and Emergency with global confusion and agitation, and you take his observations to find the following: Temp: 39.1

oC, HR: 115, BP: 190/110. As you take a history you find out that the man is homeless and has recently decided to stop drinking after 25 years. As you start taking a thorough alcohol consumption history, he becomes more agitated and attempts to leave the room. When you ask the patient what the problem is, he is surprised that you cannot see all the rats crawling on the floor. What is the most appropriate initial treatment for this patient?

IM lorazepam

Section under the Mental Health Act

PO lorazepam

IV thiamine

IM haloperidol

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Question 8

A 55-year-old man presents to Accident and Emergency with global confusion and agitation, and you take his observations to find the following: Temp: 39.1

o

C, HR: 115, BP: 190/110. As you take a history you find out that the man is homeless and has recently decided to stop drinking after 25 years. As you start taking a thorough alcohol consumption history, he becomes more agitated and attempts to leave the room. When you ask the patient what the problem is, he is surprised that you cannot see all the rats crawling on the floor. What is the most appropriate initial treatment for this patient?

IM lorazepamT

he patient should be offered voluntary medication initially

Section under the Mental Health Act

T

he patient does not yet meet the criteria for sectioning

PO lorazepam

The first line treatment for delirium tremens

IV thiamine

A

n important step in treatment to prevent the onset of Wernicke’s encephalopathy, however it is not the most appropriate initial treatment

IM haloperidolShould be used if lorazepam is not suitable

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Question 9

Which of the following is the correct definition of an obsession?

A false, unshakeable belief not in keeping with the social, cultural or religious background of a patient

An unwanted intrusive thought, image or urge that repeatedly enters a patient’s mind

Repetitive behaviours or actions that the patient feels driven to performA perception in the absence of external stimuli

An action initiated in the moment without forethought that may cause harm to the patient

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Question 9

Which of the following is the correct definition of an obsession?

A false, unshakeable belief not in keeping with the social, cultural or religious background of a patient

Definition of delusion

An unwanted intrusive thought, image or urge that repeatedly enters a patient’s mind

Definition of obsession

Repetitive behaviours or actions that the patient feels driven to perform

Definition of compulsion

A perception in the absence of external stimuli

Definition of a hallucination

An action initiated in the moment without forethought that may cause harm to the patient

Definition of impulsivity

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Question 10

Which of the following pharmacological interventions is first line for opioid detoxification?

Bupropion

Acamprosate

VareniclineDisulfiram

Buprenorphine

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Question 10

Which of the following pharmacological interventions is first line for opioid detoxification?

Bupropion

Acamprosate

VareniclineDisulfiram

Buprenorphine

A and C are used in smoking cessation programs. B and D are used during alcohol detoxification.