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Psychiatry Thursday 29th May By Dr Chantae Reid-Agboola & Dr Ololade TijaniSessionOutline ● Depression ● Anxiety disorders ● Psychosis: Schizophrenia ● Bipolar disorder: ● Eating disorders: Anorexia, bulimia ● Mental health crisisQuestion 1 A 30-year-old woman presents to her GP with a 3-month history of low mood, poor concentration, and disrupted sleep. She reports feelings of worthlessness and has lost interest in activities she once enjoyed. There are no signs of psychosis or suicidal ideation. Question: What is the most appropriate initial management for this patient? A. Initiate selective serotonin reuptake inhibitors (SSRIs) B. Refer for cognitive behavioural therapy (CBT) C. Offer a combination of CBT and antidepressant medication D. Provide information on self-help strategies and monitor E. Refer urgently to secondary mental health servicesAnswer 1 A 30-year-old woman presents to her GP with a 3-month history of low mood, poor concentration, and disrupted sleep. She reports feelings of worthlessness and has lost interest in activities she once enjoyed. There are no signs of psychosis or suicidal ideation. Question: What is the most appropriate initial management for this patient? A. Initiate selective serotonin reuptake inhibitors (SSRIs) B. Refer for cognitive behavioural therapy (CBT) C. Offer a combination of CBT and antidepressant medication D. Provide information on self-help strategies and monitor E. Refer urgently to secondary mental health servicesAnswer cont… Diagnosis ● Clinical Assessment: Diagnosis is primarily clinical, based on a comprehensive history and symptom criteria. ● Symptom Criteria: Depression is characterized by a persistently low mood and/or loss of interest or pleasure in activities, accompanied by at least four additional symptoms such as fatigue, sleep disturbances, changes in appetite, feelings of worthlessness, or thoughts of death or suicide. ● Screening Tools: In some cases, standardized tools like the Patient Health Questionnaire-9 (PHQ-9) may be used to assess the severity of symptoms. Treatment ● First-Line Interventions: ○ Psychological Therapies: Cognitive Behavioral Therapy (CBT) is recommended for individuals with moderate to severe depression. ○ Antidepressant Medications: Selective Serotonin Reuptake Inhibitors (SSRIs) are commonly prescribed.Answer cont… ● Second-Line Options: ○ Combination Therapy: Combining CBT with antidepressants may be considered if initial treatments are ineffective. ○ Alternative Medications: Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) or tricyclic antidepressants may be options if SSRIs are not suitable. Management ● Monitoring: Regular follow-up appointments to assess treatment efficacy and side effects. ● Long-Term Strategies: ○ Relapse Prevention: Continued treatment for at least 6 months after symptom resolution to prevent relapse. ○ Lifestyle Modifications: Encouraging physical activity, healthy diet, and adequate sleep. ● Special Considerations: ○ Electroconvulsive Therapy (ECT): Considered for severe or treatment-resistant depression. ○ Lithium Augmentation: May be used in treatment-resistant cases.Question 2 A 25-year-old man presents with excessive worry occurring more days than not for at least six months. He finds it difficult to control the worry and experiences restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance. Question: What is the most appropriate first-line treatment for this patient? A. Initiate selective serotonin reuptake inhibitors (SSRIs) B. Refer for cognitive behavioural therapy (CBT) C. Offer a combination of CBT and SSRIs D. Prescribe benzodiazepines for short-term use E. Provide information on self-help strategies and monitorAnswer 2 A 25-year-old man presents with excessive worry occurring more days than not for at least six months. He finds it difficult to control the worry and experiences restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance. Question: What is the most appropriate first-line treatment for this patient? A. Initiate selective serotonin reuptake inhibitors (SSRIs) B. Refer for cognitive behavioural therapy (CBT) C. Offer a combination of CBT and SSRIs D. Prescribe benzodiazepines for short-term use E. Provide information on self-help strategies and monitorAnswer 2 cont… Diagnosis ● Clinical Evaluation: Thorough assessment to identify symptoms such as excessive worry, restlessness, fatigue, difficulty concentrating, irritability, and sleep disturbances. ● Differential Diagnosis: Excluding other medical conditions or psychiatric disorders that may mimic anxiety symptoms. Treatment ● Step 1: Low-Intensity Interventions: ○ Self-Help Strategies: Providing information and resources for self-management. ○ Guided Self-Help: Structured programs with minimal therapist contact. ● Step 2: High-Intensity Interventions: ○ Cognitive Behavioral Therapy (CBT): A structured, time-limited therapy focusing on changing unhelpful thought patterns. ○ Antidepressant Medications: SSRIs or SNRIs may be prescribed, especially if symptoms are moderate to severe.Answer 2 cont… ● Step 3: Complex or Treatment-Resistant Anxiety: ○ Specialist Psychological Interventions: Intensive CBT or other therapies tailored to individual needs. ○ Medication Adjustments: Considering alternative medications or augmenting current treatment. Management ● Monitoring: Regular assessments to gauge treatment response and adjust as necessary. ● Supportive Measures: ○ Psychoeducation: Educating patients and families about anxiety and its management. ○ Lifestyle Advice: Encouraging stress management techniques, regular exercise, and healthy sleep habits. ● Crisis Intervention: Providing immediate support during acute anxiety episodes.Question 3 A 28-year-old man presents with auditory hallucinations, delusions of persecution, and disorganized speech. These symptoms have been present for over a month and are affecting his social and occupational functioning. Question: What is the most appropriate first-line pharmacological treatment for this patient? A. Olanzapine B. Clozapine C. Haloperidol D. Aripiprazole E. RisperidoneAnswer 3 A 28-year-old man presents with auditory hallucinations, delusions of persecution, and disorganized speech. These symptoms have been present for over a month and are affecting his social and occupational functioning. Question: What is the most appropriate first-line pharmacological treatment for this patient? A. Olanzapine B. Clozapine C. Haloperidol D. Aripiprazole E. RisperidoneAnswer 3 cont… Diagnosis ● Clinical Criteria: Presence of characteristic symptoms such as delusions, hallucinations, disorganized speech, and negative symptoms (e.g., flat affect, social withdrawal) for a significant portion of time during a one-month period. ● Exclusion of Other Conditions: Ruling out other psychiatric disorders or medical conditions that could explain the symptoms. ● Functional Impairment: Symptoms cause significant impairment in social, occupational, or other important areas of functioning. Treatment ● First-Line Pharmacotherapy: ○ Second-Generation Antipsychotics: Medications like risperidone are commonly prescribed due to their efficacy and more favorable side effect profile compared to first-generation antipsychotics.Answer 3 cont… Second-Line Options: ○ Clozapine: Considered for treatment-resistant schizophrenia after trials of at least two different antipsychotic medications. ○ Augmentation Strategies: Combining antipsychotics or adding other medications if there is inadequate response. Management ● Monitoring: Regular assessments to monitor for side effects, adherence, and overall treatment response. ● Psychosocial Interventions: ○ Cognitive Behavioral Therapy (CBT): Helps patients understand and manage symptoms. ○ Family Intervention: Involves family members in treatment to improve outcomes. ● Community Support: ○ Supported Employment and Education: Assisting patients in returning to work or education. ○ Social Skills Training: Improving interpersonal skills and community integrationQuestion 4 A 35-year-old man with a 15-year history of schizophrenia presents to the psychiatric outpatient clinic. His current treatment regimen includes clozapine 300 mg daily. Despite adherence to this regimen, he continues to experience persistent auditory hallucinations and delusions. A recent full blood count (FBC) shows a white blood cell count of 3.0 × 10⁹/L, with an absolute neutrophil count of 1.2 × 10⁹/L. He denies any symptoms of infection. Question: Given the patient's current presentation and laboratory findings, what is the most appropriate next step in management? A. Increase the dose of clozapine to 400 mg daily B. Initiate a second antipsychotic medication to augment clozapine C. Temporarily withhold clozapine and repeat FBC in one week D. Discontinue clozapine and switch to an alternative antipsychotic E. Initiate electroconvulsive therapy (ECT)Answer 4 A 35-year-old man with a 15-year history of schizophrenia presents to the psychiatric outpatient clinic. His current treatment regimen includes clozapine 300 mg daily. Despite adherence to this regimen, he continues to experience persistent auditory hallucinations and delusions. A recent full blood count (FBC) shows a white blood cell count of 3.0 × 10⁹/L, with an absolute neutrophil count of 1.2 × 10⁹/L. He denies any symptoms of infection. Question: Given the patient's current presentation and laboratory findings, what is the most appropriate next step in management? A. Increase the dose of clozapine to 400 mg daily B. Initiate a second antipsychotic medication to augment clozapine C. Temporarily withhold clozapine and repeat FBC in one week D. Discontinue clozapine and switch to an alternative antipsychotic E. Initiate electroconvulsive therapy (ECT)Answer 4 cont… Regular monitoring of FBC is essential during clozapine therapy due to the risk of agranulocytosis. If neutropenia persists or worsens, alternative antipsychotic medications should be considered. Diagnosis: ● Clinical Presentation: Persistent psychotic symptoms despite adequate clozapine dosing. ● Laboratory Findings: Absolute neutrophil count (ANC) below 1.5 × 10⁹/L. Treatment: ● Immediate Action: Withhold clozapine administration. ● Monitoring: Repeat FBC weekly until ANC returns to a safe level Management: ● If ANC Normalizes: Reassess the risk-benefit ratio of resuming clozapine. ● If Neutropenia Persists: Consider alternative antipsychotic medications, such as risperidone or aripiprazole. ● Long-Term Strategy: Implement regular FBC monitoring as per NICE guidelines to detect early signs of hematological abnormalities.Question 5 A 32-year-old woman presents to the emergency department 6 days postpartum with her first child. She exhibits rapid mood swings, disorganized speech, and reports hearing voices instructing her to protect her baby from harm. Her family notes that she has been increasingly agitated and has difficulty sleeping. She has no prior history of psychiatric illness. On examination, she is disheveled and appears confused. Question: What is the most appropriate next step in management? A. Initiate treatment with an atypical antipsychotic and observe for 72 hours B. Administer intravenous hydration and monitor in a low-stimulation environment C. Prescribe a benzodiazepine for sedation and discharge home D. Obtain a CT head scan to rule out structural abnormalities E. Refer to a specialist perinatal mental health service for immediate inpatient careQuestion 5 A 32-year-old woman presents to the emergency department 6 days postpartum with her first child. She exhibits rapid mood swings, disorganized speech, and reports hearing voices instructing her to protect her baby from harm. Her family notes that she has been increasingly agitated and has difficulty sleeping. She has no prior history of psychiatric illness. On examination, she is disheveled and appears confused. Question: What is the most appropriate next step in management? A. Initiate treatment with an atypical antipsychotic and observe for 72 hours B. Administer intravenous hydration and monitor in a low-stimulation environment C. Prescribe a benzodiazepine for sedation and discharge home D. Obtain a CT head scan to rule out structural abnormalities E. Refer to a specialist perinatal mental health service for immediate inpatient care Question 5 cont… Diagnosis: ● Clinical Features: Sudden onset of psychotic symptoms such as hallucinations, delusions, mood instability, and confusion within the first two weeks postpartum. ● Risk Factors: Personal or family history of bipolar disorder or schizophrenia; previous episode of postpartum psychosis. ● Differential Diagnosis: Distinguish from other causes of postpartum psychiatric symptoms, including postpartum depression and delirium. Treatment: ● Pharmacotherapy: Initiate antipsychotic medications (e.g., haloperidol, olanzapine) and consider mood stabilizers such as lithium. ● Electroconvulsive Therapy (ECT): Consider if there is no response to medications or if the patient's condition is life-threatening. ● Benzodiazepines: May be used for short-term sedation in the acute setting. Management: ● Inpatient Care: Admission to a specialist perinatal mental health unit is recommended. ● Mother and Baby Units (MBUs): Provide integrated care for both mother and infant, supporting bonding and recovery. ● Monitoring: Regular assessment of psychiatric symptoms and adjustment of treatment as necessary. ● Prophylaxis: For women with a history of postpartum psychosis, consider prophylactic treatment with lithium during subsequent pregnanciesQuestion 6 A 21-year-old male is brought to ED by his friend who is worried about his lack of sleep in the last 1 week. He is very irritable when you ask him to confirm his name and date of birth as he expected you to realise he is the prime minister. He tells you he has spent over £2.500 since yesterday because his riches are obviously never going to end. His friend tells you that this is very different to his struggle with low mood last year. Question: What is the most appropriate initial management for this patient? A. Initiate Lithium B. Refer for dialectical behavioural therapy (DBT) C. Rapid tranquilization with haloperidol D. Start sertraline E. Refer to liaison psychiatryQuestion 6 A 21-year-old male is brought to ED by his friend who is worried about his lack of sleep in the last 1 week. He is very irritable when you ask him to confirm his name and date of birth as he expected you to realise he is the prime minister. He tells you he has spent over £2,500 since yesterday because his riches are obviously never going to end. His friend tells you that this is very different to his struggle with low mood last year. Question: What is the most appropriate initial management for this patient? A. Initiate Lithium B. Refer for dialectical behavioural therapy (DBT) C. Rapid tranquilization with haloperidol D. Start sertraline E. Refer to liaison psychiatryBipolarAffective Disorder Chronic episodic mood disorder, characterised by at least one episode of mania (or hypomania) and a further episode of mania or depression. Psychiatry: a clinical handbook. M.Azam, M.Qureshi, D.KinnairBipolarAffective Disorder Psychiatry: a clinical handbook. M.Azam, M.Qureshi, D.KinnairBipolarAffective Disorder Beware of the depressed patient in OSCEs: - Always screen for previous manic episodesBipolarAffective DisorderBipolarAffective Disorder Lithium monitoring - Side effects - Signs of toxicity - Lithium monitoringQuestion 7 A 17 year old presents to her GP with her dad. He is worried about her tiredness and occasional complaints of palpitations and tingling/burning sensations. Her nails are more brittle and she reports going to the gym twice a day every day. The GP takes a detailed history and proceeds to examine the patient who complains that she feels conscious about how fat she is although her BMI is 18 kg/m2. She has not had a period in the last 6 months. The GP proceeds to do an ECG. Question: What is the most likely finding on the ECG associated with her diagnosis? A. Sinus Tachycardia B. Sinus bradycardia and QTc >460 C. S1Q3T3 D. Atrial fibrillation E. Widespread ST depressionQuestion 7 A 17 year old presents to her GP with her dad. He is worried about her tiredness and occasional complaints of palpitations and tingling/burning sensations. Her nails are more brittle and she reports going to the gym twice a day every day and only eating 1 meal on alternate days. The GP takes a detailed history and proceeds to examine the patient who complains that she feels conscious about how fat she is although her BMI is 17 kg/m2. She has not had a period in the last 6 months. The GP proceeds to do an ECG. Question: What is the most likely finding on the ECG associated with her diagnosis? A. Sinus Tachycardia B. Sinus bradycardia and QTc >460 C. S1Q3T3 D. Atrial fibrillation E. Widespread ST depressionAnorexia Nervosa: Characterised by: - Fear of weight gain - Endocrine disturbance resulting in amenorrhoea in females and loss of sexual interest and potency in males - Emaciated (abnormally low body weight): >15% below expected weight or BMI <17.5 kg/m2 - Deliberate weight loss with ↓ food intake or ↑ exercise - Distorted body image Features must be present for at least 3 months No recurrent episodes of binge eating; preoccupation with eating/craving to eat.Anorexia Nervosa: Bedside: ECG: Arrhythmias such as sinus bradycardia and prolonged QT are common Blood tests: FBC (anaemia, thrombocytopenia, leukopenia), U&Es (↑ urea and creatinine if dehydrated, ↓ potassium, phosphate, magnesium and chloride), TFTs (↓ T3 and T4 ), LFTs (↓ albumin), lipids (↑ cholesterol), cortisol (↑), sex hormones (↓ LH, FSH, oestrogens and progestogens), glucose (↓), amylase (pancreatitis is a complication). VBG: Metabolic alkalosis (vomiting), metabolic acidosis (laxatives) Imaging/special tests: DEXA scan: To rule out osteoporosis Questionnaires: e.g. eating attitudes test (EAT).Anorexia Nervosa: Management: Risk assessment for suicide and medical complications Treat medical issues/ SSRIs for comorbidities Psychological treatments: at least 6 months’ duration CAT, CBT, Family therapy Social: Support groups - BEAT Aim of treatment as an inpatient: weight gain of 0.5–1 kg/week vs outpatient 0.5 kg/week Risk of refeeding syndrome which causes metabolic disturbances Hospitalization is necessary for medical (severe anorexia with BMI <14 or severe electrolyte abnormalities) and psychiatric (suicidal ideation) reasonsAnorexia Nervosa:Question 8 A 70 year old with a history of AF for which he is rate controlled with bisoprolol is brought to ED by his daughter who found him on the floor when she came to visit him. She mentions she only brought his new pack of medications yesterday and is shocked to find the pack empty next to him. She admits he has been low in mood since his wife died last year but refused antidepressant medication and talking therapies. Question: What is the best course of action? A. Reversal with N-acetylcysteine B. Reversal with naloxone C. Reversal with Vitamin K D. Reversal with glucagon E. Reversal with flumazenilQuestion 8 A 70 year old with a history of AF for which he is rate controlled with bisoprolol is brought to ED by his daughter who found him on the floor when she came to visit him. She mentions she only brought his new pack of medications yesterday and is shocked to find the pack empty next to him. She admits he has been low in mood since his wife died last year but refused antidepressant medication and talking therapies. Question: What is the best course of action? A. Reversal with N-acetylcysteine B. Reversal with naloxone C. Reversal with Vitamin K D. Reversal with glucagon E. Reversal with flumazenilDSH/Self-poisoningQuestion 9 A 30 year old male with schizoaffective disorder has been threatening to harm his neighbours. He recently went on holiday without his medications and since being back, he has felt the need to protect himself from his neighbour by buying a hammer which he wanted to use to attack him. However, the neighbour saw him coming via his CCTV and called the police which led to the crisis team being contacted. They arranged a psychiatry inpatient admission as he lives alone and lacks insight but evidently needs treatment which he is refusing. Question: Which of the following is most appropriate? A.Section 2 B.Section 3 C.Section 5(4) D Section 136 E.Section 135Question 9 A 30 year old male with schizoaffective disorder has been threatening to harm his neighbours. He recently went on holiday without his medications and since being back, he has felt the need to protect himself from his neighbour by buying a hammer which he wanted to use to attack him. However, the neighbour saw him coming via his CCTV and called the police which led to the crisis team being contacted. They arranged a psychiatry inpatient admission as he lives alone and lacks insight but evidently needs treatment which he is refusing. Question: Which of the following is most appropriate? A.Section 2 B.Section 3 C.Section 5(4) D Section 136 E.Section 135Mental HealthAct Sections Source: In2MedQuestion 10 A 45 year old male presents to ED with a fever, hallucinations and excessive sweating. He is able to tell you his name but is not oriented to place or time. He has a significant tremor and is very tachycardic. His pupils are dilated but reactive to light and he begins to respond to stimuli not seen by others and is very suspicious of the doctors. What is the diagnosis? Collateral hx revealshe last consumed alcohol 3 days ago before deciding to go ‘cold turkey’ Question: Which of the following is most appropriate? A.Chlordiazepoxide, IV pabrinex +/- haloperidol B.Lorazepam C.Load with phenytoin D Load with levetiracetam + IV pabrinex E.Urgent CT headQuestion 10 A 45 year old male presents to ED with a fever, hallucinations and excessive sweating. He is able to tell you his name but is not oriented to place or time. He has a significant tremor and is very tachycardic. His pupils are dilated but reactive to light and he begins to respond to stimuli not seen by others and is very suspicious of the doctors. What is the diagnosis? Collateral hx revealshe last consumed alcohol 3 days ago before deciding to go ‘cold turkey’ Question: Which of the following is most appropriate? A.Chlordiazepoxide, IV pabrinex +/- haloperidol B.Lorazepam C.Load with phenytoin D Load with levetiracetam + IV pabrinex E.Urgent CT headAlcohol DependenceAlcohol Dependence Wernicke’s encephalopathy: acute encephalopathy due to thiamine deficiency. Features include:delirium, nystagmus, ophthalmoplegia, hypothermia and ataxia. Requires urgent treatment with parenteral thiamine. Korsakoff’s psychosis: memory loss with confabulation and disorientation to timeAlcohol Dependence Rx: Chlordiazepoxide + thiamine Disulfiram, Naltrexone, Acamprosate Motivational interviewing + CBT Social: AA SEEYOUNEXT https://linktr.ee/medtic.teaching THURSDAY! Sign up to our next session on MedAll Take part in our research survey See all our upcoming events www.medticteaching.com | Email: medticteaching@gmail.com | Youtube @medtic | Instagram @medtic.teaching | Tiktok @medticteaching