lOMoARcPSD|6265699

Psychiatry Notes

Medicine (Queen Mary University of London)

StuDocu is not sponsored or endorsed by any college or university

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)
 lOMoARcPSD|6265699

Alcohol withdrawal say you are thing? Does food dominate your
life? Yes >2 = AN or bulimia
Mechanism - Features: Due to starvation or vomiting:
chronic alcohol consumption enhances Fatigue, reduced cognition, altered sleep cycle,
GABA mediated inhibition in the CNS sensitivity to cold, enlarged salivary glands,
hypotension
(similar to benzodiazepines) and inhibits - Red flags: BMI <13 or below 2nd centile, wt loss
NMDA-type glutamate receptors >1kg/wk, temp <34.5, BP <80/50, pulse <40,
alcohol withdrawal is thought to be lead O2 < 92%, limbs = blue and cold, no muscle
strength, ECG: long QT, flat T waves, purpura,
to the opposite (decreased inhibitory K<2.5, Na<130, PO4 <0.5
GABA and increased NMDA glutamate o Refer to EDU, re-feed
transmission) - Tx: Individual eating-disorder-focused cognitive
behavioural therapy (CBT-ED), wight gain
0.5kg-1kg, final BMI = 20-25, Maudsley
Features Anorexia Nervosa Treatment for Adults
symptoms start at 6-12 hours: tremor, (MANTRA), specialist supportive clinical
management (SSCM), fluozetine
sweating, tachycardia, anxiety - In children and young people, NICE
peak incidence of seizures at 36 hours recommend 'anorexia focused family therapy'
peak incidence of delirium tremens is at as the first-line treatment. The second-line
treatment is cognitive behavioural therapy.
48-72 hours: coarse tremor, confusion,
delusions, auditory and visual
Bulimia nervosa
hallucinations, fever, tachycardia - Episodes of binge eating then vomiting or
using laxatives or diuretics or exercising, BMI
Management >17.5, preoccupation with body weight
control.
patients with a history of complex - Episodes occur on average once a week for
withdrawals from alcohol (i.e. delirium three months.
tremens, seizures, blackouts) should be - Tx = Mild: Supportive (CBT-ED, FT-BN), refer to
EDU if no response, moderate/severe: SSRI
admitted to hospital for monitoring until (fluoxetine), CBT
withdrawals stabilised
first-line: benzodiazepines e.g. chlordiazep
oxide. Lorazepam may be preferable in Antipsychotics
patients with hepatic failure. Typically
given as part of a reducing dose protocol Antipsychotics are a group of drugs used in the
carbamazepine also effective in treatment management of schizophrenia and other forms of
of alcohol withdrawal psychosis, mania and agitation. They are usually
divided into typical and atypical antipsychotics. The
phenytoin is said not to be as effective in
atypical antipsychotics were developed due to
the treatment of alcohol withdrawal the problematic extrapyramidal side-effects which
seizures are associated with the first generation of typical
antipsychotics.

Typical antipsychotics
Anorexia nervosa
- Common cause of admission to children and
Mechanism of Dopamine D2 receptor antagonists, blocking dopam
adolescent psych wards. F>M action transmission in the mesolimbic pathways
- DSM5 criteria: Adverse effects Extrapyramidal side-effects and hyperprolactinaemia
o Weight <85% of predicted
o Intense fear of gaining weight with
behaviour that interferes with
Examples Haloperidol
weight gain
Chlopromazine
o Feeling fat when thin
- SCOFF questionnaire: Make yourself sick? Lost
control over eating? Lost more than one stone
in 3 months? Believe you are fat hen others The rest of this section will focus on typical
antipsychotics, with atypical antipsychotics covered

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

elsewhere. top of the clinical follow-up that such patients

clearly require. The BNF advises the following*:
Extrapyramidal side-effects (EPSEs)
Test
Full blood count (FBC), urea and electrolytes (U&E), liver
 Parkinsonism function tests (LFT) 
 acute dystonia 
o sustained muscle 
contraction (e.g. torticollis, oculo
gyric crisis)
o may be managed with
procyclidine Lipids, weight
 akathisia (severe restlessness) 
 tardive dyskinesia (late onset of 
choreoathetoid movements, abnormal, 
involuntary, may occur in 40% of
patients, may be irreversible, most Fasting blood glucose, prolactin
common is chewing and pouting of jaw) 



The Medicines and Healthcare products Regulatory

Blood pressure
Agency has issued specific warnings when

antipsychotics are used in elderly patients:


Electrocardiogram
 increased risk of stroke
 increased risk of venous 
thromboembolism
Cardiovascular risk assessment

Other side-effects

*please see the BNF for more details. There are a

 antimuscarinic: dry mouth, blurred number of specific recommendations for individual
vision, urinary retention, constipation drugs, the above is a general summary
 sedation, weight gain
 raised prolactin
o may result in galactorrhoea Atypical antipsychotics
o due to inhibition of the
dopaminergic tuberoinfundibular
pathway Atypical antipsychotics should now be used first-
 impaired glucose tolerance line in patients with schizophrenia, according to
 neuroleptic malignant syndrome: pyrexia, 2005 NICE guidelines. The main advantage of the
muscle stiffness atypical agents is a significant reduction in
 reduced seizure threshold (greater with extrapyramidal side-effects.
atypicals)
 prolonged QT interval (particularly Adverse effects of atypical antipsychotics
haloperidol)

Antipsychotics: monitoring  weight gain

 clozapine is associated
with agranulocytosis (see below)
The monitoring requires for patients taking  hyperprolactinaemia
antipsychotic medication are extensive. This is on

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

The Medicines and Healthcare products Regulatory Dose adjustment of clozapine might be necessary
Agency has issued specific warnings when if smoking is started or stopped during treatment.
antipsychotics are used in elderly patients:
Benzodiazepines

 increased risk of stroke

Benzodiazepines enhance the effect of the
 increased risk of venous
inhibitory neurotransmitter gamma-aminobutyric
thromboembolism
acid (GABA) by increasing the frequency of
chloride channels. They therefore are used for a
variety of purposes:
Examples of atypical antipsychotics

 sedation
 clozapine
 hypnotic
 olanzapine: higher risk of dyslipidemia
 anxiolytic
and obesity
 anticonvulsant
 risperidone
 muscle relaxant
 quetiapine
 amisulpride
 aripiprazole: generally good side-effect
Patients commonly develop a tolerance and
profile, particularly for prolactin elevation
dependence to benzodiazepines and care should
therefore be exercised on prescribing these drugs.
The Committee on Safety of Medicines advises that
benzodiazepines are only prescribed for a short
Clozapine period of time (2-4 weeks).

Clozapine, one of the first atypical agents to be The BNF gives advice on how to withdraw a
developed, carries a significant risk benzodiazepine. The dose should be withdrawn in
of agranulocytosis and full blood count monitoring steps of about 1/8 (range 1/10 to 1/4) of the daily
is therefore essential during treatment. For this dose every fortnight. A suggested protocol for
reason, clozapine should only be used in patients patients experiencing difficulty is given:
resistant to other antipsychotic medication. The
BNF states:
 switch patients to the equivalent dose of
diazepam
Clozapine should be introduced if schizophrenia is  reduce dose of diazepam every 2-3 weeks
not controlled despite the sequential use of two or in steps of 2 or 2.5 mg
more antipsychotic drugs (one of which should be  time needed for withdrawal can vary from
a second-generation antipsychotic drug), each for 4 weeks to a year or more
at least 6–8 weeks.

Adverse effects of clozapine If patients withdraw too quickly from

benzodiazepines they may experience
benzodiazepine withdrawal syndrome, a condition
 agranulocytosis (1%), neutropaenia (3%) very similar to alcohol withdrawal syndrome. This
 reduced seizure threshold - can induce may occur up to 3 weeks after stopping a long-
seizures in up to 3% of patients acting drug. Features include:
 constipation
 myocarditis: a baseline ECG should be
taken before starting treatment  insomnia
 hypersalivation  irritability
 anxiety
 tremor

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

 loss of appetite  hypomania describes decreased or

 tinnitus increased function for 4 days or more
 perspiration  from an exam point of view the key
 perceptual disturbances differentiation is psychotic symptoms
 seizures (e.g.delusions of grandeur or auditory
hallucinations) which suggest mania

GABAA drugs
Management

 benzodiazipines increase the frequency of

chloride channels  psychological interventions specifically
 barbiturates increase the duration of designed for bipolar disorder may be
chloride channel opening helpful
 lithium remains the mood stabilizer of
choice. An alternative is valproate
Frequently Bend - During Barbeque  management of mania: consider stopping
antidepressant if the patient takes one;
...or... antipsychotic therapy e.g. olanzapine or
haloperidol
Barbidurates increase duration  management of depression: talking
& Frendodiazepines increase frequency therapies (see above); fluoxetine is the
antidepressant of choice
 address co-morbidities - there is a 2-3
Bipolar disorder times increased risk of diabetes,
cardiovascular disease and COPD

Bipolar disorder is a chronic mental health disorder

characterised by periods of mania/hypomania Primary care referral
alongside episodes of depression.

Epidemiology
 if symptoms suggest hypomania then
NICE recommend routine referral to the
community mental health team (CMHT)
 typically develops in the late teen years  if there are features of mania or severe
 life time prevalence: 2% depression then an urgent referral to the
CMHT should be made

Two types of bipolar disorder are recognised:

Charles-Bonnet syndrome
 type I disorder: mania and depression
(most common)
 type II disorder: hypomania and Charles-Bonnet syndrome (CBS) is characterised by
depression persistent or recurrent complex hallucinations
(usually visual or auditory), occurring in clear
consciousness. This is generally against a
background of visual impairment (although visual
What is mania/hypomania?
impairment is not mandatory for a diagnosis).
Insight is usually preserved. This must occur in the
absence of any other significant neuropsychiatric
 both terms relate to abnormally elevated disturbance.
mood or irritability
 with mania there is severe functional Risk factors include:
impairment or psychotic symptoms for 7
days or more

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

 Advanced age Factors suggesting diagnosis of depression over

 Peripheral visual impairment dementia:
 Social isolation  Short history, rapid onset
 Sensory deprivation  Biological symptoms e.g. Weight
 Early cognitive impairment loss, sleep disturbance
 Patient worried about poor memory
 Reluctant to take tests, disappointed with
CBS is equally distributed between sexes and does results
not show any familial predisposition. The most  Mini-mental test score: variable
common ophthalmological conditions associated  Global memory loss (dementia
with this syndrome are age-related macular characteristically causes recent memory
degeneration, followed by glaucoma and cataract. loss)

Well-formed complex visual hallucinations are Depression: management of subthreshold

thought to occur in 10-30 per cent of individuals depressive symptoms or mild depression
with severe visual impairment. Prevalence of CBS
in visually impaired people is thought to be
between 11 and 15 per cent. NICE produced updated guidelines in 2009 on the
management of depression in primary and
Around a third find the hallucinations themselves secondary care. Patients are classified according to
an unpleasant or disturbing experience. In a large the severity of the depression and whether they
study published in the British Journal of have an underlying chronic physical health
Ophthalmology, 88% had CBS for 2 years or more, problem.
resolving in only 25% at 9 years (thus it is not
generally a transient experience). Please note that due to the length of the 'quick'
reference guide the following is a summary and we
Cox (2014) Negative outcome Charles Bonnet would advise you follow the link for more detail.
Syndrome. Br J Ophthalmol.

Cotard syndrome Persistent subthreshold depressive symptoms or

mild to moderate depression

Cotard syndrome is a rare mental disorder where

General measures
the affected patient believes that they (or in some
cases just a part of their body) is either dead or
non-existent. This delusion is often difficult to treat
and can result in significant problems due to  sleep hygiene
patients stopping eating or drinking as they deem  active monitoring for people who do want
it not necessary. an intervention

Cotard syndrome is associated with severe

depression and psychotic disorders. Drug treatment

De Clerambault's syndrome  do not use antidepressants routinely but

consider them for people with:
 a past history of moderate or severe
De Clerambault's syndrome, also known as
depression or
erotomania, is a form of paranoid delusion with an
 initial presentation of subthreshold
amorous quality. The patient, often a single
depressive symptoms that have been
woman, believes that a famous person is in love
present for a long period (typically at least
with her.
2 years) or
 subthreshold depressive symptoms or
Depression vs. Dementia
mild depression that persist(s) after other
interventions

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

 if a patient has a chronic physical health  focus on sharing experiences and feelings
problem and mild depression complicates associated with having a chronic physical
the care of the physical health problem health problem
 consist typically of 1 session per week
over 8-12 weeks
The following 'low-intensity psychosocial
interventions' may be useful:
Depression: management of unresponsive,
Intervention moderate and severe depression
Individual guided self-help based on CBT Interventions should:
principles NICE produced updated guidelines in 2009 on the
management of depression in primary and
(Includes behavioural activation and  include written materials
secondary (or alternative
care. Patients media) according to
are classified
problem-solving techniques)  be supported by a trained
the severity of thepractitioner
depressionwhoand reviews
whetherprogress
they
 consist ofhave
up toan6-8 sessions (face-to-face
underlying andhealth
chronic physical by telephone) over 9-12
weeks, including
problem.follow-up

Computerised CBT Please note that due to the length of the 'quick'
Interventions should:
reference guide the following is a summary and we
would advise you follow the link for more detail.

 explain the CBT model, encourage tasks between sessions, and use
thought-
Persistent subthreshold depressive symptoms or
 challenging and active monitoring of behaviour, thought patterns and
mild to moderate depression with inadequate
outcomes
response to initial interventions, and moderate
 be supported by a trained practitioner who reviews progress and outcome
and severe depression
typically take place over 9-12 weeks, including follow-up

A structured group physical activity For these patients NICE recommends an

Interventions should:
programme antidepressant (normally a selective serotonin
reuptake inhibitor, SSRI)

 typically consist of 3 sessions

The following per weekpsychological
'high-intensity (lasting 45 minutes to 1 hour) over
10-14 weeks
interventions' may be useful:

An alternative is group-based CBT

 typicall
 be based on a model such as 'Coping with  consider 3-4 fol
depression'  for moderate or severe dep
 be delivered by two trained and
competent practitioners
Individual CBT
 consist of 10-12 meetings of 8-10
participants Interpersonal therapy (IPT) Delivery
 typically take place over 12-16 weeks,
including follow-up
 typically 16-20 sessions over 3-
 for severe depression, consider
For patients with chronic physical health problems
NICE also recommend considering a group-based Behavioural activation Delivery
peer support programme:

 typically 16-20 sessions over 3-

 consider 3-4 follow-up sessions

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

A 'yes' answer to either of the above should

prompt a more in depth assessment.

 consider 3-4 follow-up sessions over the next 3-6 months

 Assessment
for moderate or severe depression, consider 2 sessions per week for the first 2-3

Individual CBT There are many tools to assess the degree of

 depression
for moderate or severe including
depression, the
consider Hospital per
2 sessions Anxiety
weekand
for the first 3-4 weeks
Depression (HAD) scale and the Patient Health
Questionnaire (PHQ-9).
Behavioural couples Delivery
therapy
Hospital Anxiety and Depression (HAD) scale

 typically 15-20 sessions over 5-6 months

 consists of 14 questions, 7 for anxiety and
7 for depression
For people who decline the options above,  each item is scored from 0-3
consider:  produces a score out of 21 for both
anxiety and depression
 severity: 0-7 normal, 8-10 borderline, 11+
 counselling for people with persistent case
subthreshold depressive symptoms or  patients should be encouraged to answer
mild to moderate depression; offer 6-10 the questions quickly
sessions over 8-12 weeks
 short-term psychodynamic psychotherapy
for people with mild to moderate Patient Health Questionnaire (PHQ-9)
depression; offer 16-20 sessions over 4-6
months
 asks patients 'over the last 2 weeks, how
often have you been bothered by any of
For patients with chronic physical health problems the following problems?'
the following should be offered:  9 items which can then be scored 0-3
 includes items asking about thoughts of
self-harm
 group-based CBT  depression severity: 0-4 none, 5-9 mild,
 individual CBT 10-14 moderate, 15-19 moderately
severe, 20-27 severe

Depression: screening and assessment

NICE use the DSM-IV criteria to grade depression:

Screening
 1. Depressed mood most of the day,
The following two questions can be used to screen nearly every day
for depression  2. Markedly diminished interest or
pleasure in all, or almost all, activities
most of the day, nearly every day
 'During the last month, have you often  3. Significant weight loss or weight gain
been bothered by feeling down, when not dieting or decrease or increase
depressed or hopeless?' in appetite nearly every day
 'During the last month, have you often  4. Insomnia or hypersomnia nearly every
been bothered by having little interest or day
pleasure in doing things?'  5. Psychomotor agitation or retardation
nearly every day

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

 6. Fatigue or loss of energy nearly every

day Switching from citalopram, escitalopram,
 7. Feelings of worthlessness or excessive sertraline, or paroxetine to venlafaxine
or inappropriate guilt nearly every day
 8. Diminished ability to think or
concentrate, or indecisiveness nearly  cross-taper cautiously. Start venlafaxine
every day 37.5 mg daily and increase very slowly
 9. Recurrent thoughts of death, recurrent
suicidal ideation without a specific plan,
or a suicide attempt or a specific plan for
Switching from fluoxetine to venlafaxine
committing suicide

 withdraw and then start venlafaxine at

Subthreshold depressive
37.5 mg each day and increase very slowly
symptoms
Mild depression Few, if any, symptoms in excess of the 5 required to make the diagnosis, and symptoms result in
only minor functional impairment
*this means gradually reduce the dose then stop
Moderate depression Symptoms or functional impairment are between 'mild' and 'severe'
Severe depression Most symptoms, and the symptoms markedly interfere
Electroconvulsive therapywith functioning. Can occur with or
without psychotic symptoms

Depression: switching antidepressants Electroconvulsive therapy is a useful treatment

option for patients with severe depression
refractory to medication (e.g. catatonia) those with
The following is based on the Clinical Knowledge psychotic symptoms. The only absolute
Summaries depression guidelines, which in turn contraindications is raised intracranial pressure.
are based on the Maudsley hospital guidelines.
Short-term side-effects
Switching from citalopram, escitalopram,
sertraline, or paroxetine to another SSRI
 headache
 nausea
 the first SSRI should be withdrawn*  short term memory impairment
before the alternative SSRI is started  memory loss of events prior to ECT
 cardiac arrhythmia

Switching from fluoxetine to another SSRI

Long-term side-effects

 withdraw then leave a gap of 4-7 days (as

it has a long half-life) before starting a  some patients report impaired memory
low-dose of the alternative SSRI

Generalised anxiety disorder

Switching from a SSRI to a tricyclic antidepressant
(TCA)
Management

 cross-tapering is recommend (the current

drug dose is reduced slowly, whilst the  SSRI anti-depressants
dose of the new drug is increased slowly)  buspirone (5-HT1A partial agonist)
 beta-blockers
- an exceptions is fluoxetine which should be  benzodiazepines: use longer acting
withdrawn prior to TCAs being started preparations e.g. diazepam, clonazepam
 cognitive behaviour therapy

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

thinking and self-harm. Weekly follow-up

Generalised anxiety disorder and panic disorder is recommended for the first month

Anxiety is a common disorder that can present in

multiple ways. NICE define the central feature as
Management of panic disorder
an 'excessive worry about a number of different
events associated with heightened tension.'
Again a stepwise approach:
Always look for a potential physical cause when
considering a psychiatric diagnosis. In anxiety
disorders, important alternative causes include  step 1: recognition and diagnosis
hyperthyroidism, cardiac disease and medication-  step 2: treatment in primary care - see
induced anxiety (NICE). Medications that may below
trigger anxiety include salbutamol, theophylline,  step 3: review and consideration of
corticosteroids, antidepressants and caffeine alternative treatments
 step 4: review and referral to specialist
mental health services
Management of generalised anxiety disorder  step 5: care in specialist mental health
(GAD) services

NICE suggest a step-wise approach:

Treatment in primary care

 step 1: education about GAD + active

monitoring  NICE recommend either cognitive
 step 2: low intensity psychological behavioural therapy or drug treatment
interventions (individual non-facilitated  SSRIs are first-line. If contraindicated or no
self-help or individual guided self-help or response after 12 weeks then imipramine
psychoeducational groups) or clomipramine should be offered
 step 3: high intensity psychological
interventions (cognitive behavioural
therapy or applied relaxation) or drug Grief reaction
treatment. See drug treatment below for
more information
 step 4: highly specialist input e.g. Multi It is normal for people to feel sadness and grief
agency teams following the death of a loved one and this does
not necessarily need to be medicalised. However,
having some understanding of the potential stages
Drug treatment a person may go through whilst grieving can help
determine whether a patient is having a 'normal'
grief reaction or is developing a more significant
problem.
 NICE suggest sertraline should be
considered the first-line SSRI One of the most popular models of grief divides it
 if sertraline is ineffective, offer into 5 stages.
an alternative SSRI or a serotonin–
noradrenaline reuptake inhibitor (SNRI)
o examples of SNRIs include
duloxetine and venlafaxine  Denial: this may include a feeling of
 If the person cannot tolerate SSRIs or numbness and also pseudohallucinations
SNRIs, consider offering pregabalin of the deceased, both auditory and visual.
 interestingly for patients under the age of Occasionally people may focus on physical
30 years NICE recommend you warn objects that remind them of their loved
patients of the increased risk of suicidal one or even prepare meals for them

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

 Anger: this is commonly directed against

other family members and medical Speech and thought
professionals
 Bargaining
 Depression  pressured
 Acceptance  flight of ideas: characterised by rapid
speech with frequent changes in topic
based on associations, distractions or
It should be noted that many patients will not go word play
through all 5 stages.  poor attention

Abnormal, or atypical, grief reactions are more

likely to occur in women and if the death is sudden Behaviour
and unexpected. Other risk factors include a
problematic relationship before death or if the
patient has not much social support.
 insomnia
Features of atypical grief reactions include:  loss of inhibitions: sexual promiscuity,
overspending, risk-taking
 increased appetite

 delayed grief: sometimes said to occur

when more than 2 weeks passes before
Insomnia
grieving begins
 prolonged grief: difficult to define. Normal
grief reactions may take up to and beyond
Insomnia is one of the most commonly reported
12 months
problems in primary care, and can be associated
with other physical and mental health complaints.
In the DSM-V, insomnia is defined as difficulty
Hypomania vs. mania initiating or maintaining sleep, or early-morning
awakening that leads to dissatisfaction with sleep
quantity or quality. This is despite adequate time
Mania and opportunity for sleep and results in impaired
daytime functioning.
 Lasts for at least 7 days - Causes severe
functional impairment in social and work setting Insomnia may be considered acute or chronic.
 May require hospitalization due to risk of harm Acute insomnia is more typically related to a life
to self or others event and resolves without treatment. Chronic
 May present with psychotic symptoms insomnia may be diagnosed if a person has trouble
falling asleep or staying asleep at least three nights
per week for 3 months or longer.
Therefore, the length of symptoms, severity and
Patients typically present with decreased daytime
presence of psychotic symptoms (e.g. delusions of
functioning, decreased periods of sleep (delayed
grandeur, auditory hallucinations) helps
sleep onset or awakening in the night) or increased
differentiates mania from hypomania.
accidents due to poor concentration. Often the
partner's rest will also suffer. It is important to
The following symptoms are common to both
identify the aetiology of the insomnia, as
hypomania and mania
management can differ.
Mood
The following features are associated with
insomnia:

 predominately elevated
 irritable
 Female gender
 Increased age

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

 Lower educational attainment  Identify any potential causes e.g. mental/

 Unemployment physical health issues or poor sleep
 Economic inactivity hygiene.
 Widowed, divorced, or separated status  Advise the person not to drive while
sleepy.
 Advise good sleep hygiene: no screens
Other risk factors include: before bed, limited caffeine intake, fixed
bed times etc.
 ONLY consider use of hypnotics if daytime
impairment is severe.
 Alcohol and substance abuse
 Stimulant usage
 Medications such as corticosteroids
 Poor sleep hygiene There is good evidence for the efficacy of hypnotic
 Chronic pain drugs in short-term insomnia. However, there are
 Chronic illness: patients with illnesses many adverse effects e.g. daytime sedation, poor
such as diabetes, CAD, hypertension, motor coordination, cognitive impairment and
heart failure, BPH and COPD have a higher related concerns about accidents and injuries. In
prevalence of insomnia than the general addition, tolerance to the hypnotic effects of
population. benzodiazepines may be rapid (within a few days
 Psychiatric illness: anxiety and depression or weeks of regular use).
are highly correlated with insomnia.
People with manic episodes or PTSD will Guidance on using hypnotics:
also complain of extended periods of
sleeplessness.
 The hypnotics recommended for treating
insomnia are short-acting
Less common diagnostic factors may include: benzodiazepines or non-benzodiazepines
(zopiclone, zolpidem and zaleplon).
 Diazepam is not recommended but can be
useful if the insomnia is linked to daytime
 Daytime napping
anxiety.
 Enlarged tonsils or tongue
 Use the lowest effective dose for the
 Micrognathia (small jaw) and retrognathia
shortest period possible.
 Lateral narrowing of oropharynx
 If there has been no response to the first
hypnotic, do not prescribe another. You
should make the patient aware that
Investigations: repeat prescriptions are not usually given.
 It is important to review after 2 weeks and
consider referral for cognitive behavioural
 Diagnosis is primarily made through therapy (CBT).
patient interview, looking for the presence
of risk factors.
 Sleep diaries and actigraphy may aid Other sedative drugs (such as antidepressants,
diagnosis. Actigraphy is a non-invasive antihistamines, choral hydrate, clomethiazole and
method for monitoring motor activity. barbiturates) are not recommended for managing
 Polysomnography is not routinely insomnia.
indicated. It may be considered in patients
with suspected obstructive sleep apnoea Lithium
or periodic limb movement disorder, or
when insomnia is poorly responsive to
conventional treatment. Lithium is mood stabilising drug used most
commonly prophylactically in bipolar disorder but
also as an adjunct in refractory depression. It has a
Short-term management of insomnia: very narrow therapeutic range (0.4-1.0 mmol/L)
and a long plasma half-life being excreted primarily
by the kidneys.

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

Mental state examination

Mechanism of action - not fully understood, two
theories:
Thought disorders

Circumstantiality is the inability to answer a

 interferes with inositol triphosphate
question without giving excessive, unnecessary
formation
detail. However, this differs from tangentiality in
 interferes with cAMP formation
that the person does eventually return the original
point.
Adverse effects
Tangentiality refers to wandering from a topic
without returning to it.

 nausea/vomiting, diarrhoea Neoligisms are new word formations, which might

 fine tremor include the combining of two words.
 nephrotoxicity: polyuria, secondary to
nephrogenic diabetes insipidus Clang associations are when ideas are related to
 thyroid enlargement, may lead each other only by the fact they sound similar or
to hypothyroidism rhyme.
 ECG: T wave flattening/inversion
 weight gain Word salad is completely incoherent speech where
 idiopathic intracranial hypertension real words are strung together into nonsense
 leucocytosis sentences.
 hyperparathyroidism and resultant
hypercalcaemia Knight's move thinking is a severe type of
loosening of associations, where there are
unexpected and illogical leaps from one idea to
Monitoring of patients on lithium therapy another. It is a feature of schizophrenia.

Flight of ideas, a feature of mania, is thought

disorder where there are leaps from one topic to
 inadequate monitoring of patients taking
another but with discernible links between them.
lithium is common - NICE and the
National Patient Safety Agency (NPSA)
Perseveration is the repetition of ideas or words
have issued guidance to try and address
despite an attempt to change the topic.
this. As a result it is often an exam hot
topic
Echolalia is the repetition of someone else's
 when checking lithium levels, the sample
speech, including the question that was asked.
should be taken 12 hours post-dose
 after starting lithium levels should be
Mirtazapine
performed weekly and after each dose
change until concentrations are stable
 once established, lithium blood level
Mirtazapine is an antidepressant that works by
should 'normally' be checked every 3
blocking alpha2-adrenergic receptors, which
months
increases the release of neurotransmitters.
 after a change in dose, lithium levels
should be taken a week later and weekly
Mirtazapine has fewer side effects and interactions
until the levels are stable.
than many other antidepressants and so is useful
 thyroid and renal function should be
in older people who may be affected more or be
checked every 6 months
taking other medications. Two side effects of
 patients should be issued with an
mirtazapine, sedation and an increased appetite,
information booklet, alert card and record
can be beneficial in older people that are suffering
book
from insomnia and poor appetite.

It is generally taken in the evening as it can be

sedative.

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

Monoamine oxidase inhibitors The aetiology is multifactorial but possible factors

include:

Overview
 genetic
 psychological trauma
 serotonin and noradrenaline are  pediatric autoimmune neuropsychiatric
metabolised by monoamine oxidase in disorder associated with streptococcal
the presynaptic cell infections (PANDAS)

Non-selective monoamine oxidase inhibitors Associations

 e.g. tranylcypromine, phenelzine  depression (30%)

 used in the treatment of atypical  schizophrenia (3%)
depression (e.g. hyperphagia) and other  Sydenham's chorea
psychiatric disorder  Tourette's syndrome
 not used frequently due to side-effects  anorexia nervosa

Adverse effects of non-selective monoamine Management

oxidase inhibitors

 If functional impairment is mild

 hypertensive reactions with tyramine o low-intensity psychological
containing foods e.g. cheese, pickled treatments: cognitive
herring, Bovril, Oxo, Marmite, broad behavioural therapy (CBT)
beans including exposure and response
 anticholinergic effects prevention (ERP)
o If this is insufficient or can’t
engage in psychological therapy,
Obsessive-compulsive disorder then offer choice of either a
course of an SSRI or more
intensive CBT (including ERP)
Obsessive-compulsive disorder (OCD) is  If moderate functional impairment
characterised by the presence of either obsessions o offer a choice of either a course
or compulsions, but commonly both. The of an SSRI (any SSRI for OCD but
symptoms can cause significant functional fluoxetine specifically for body
impairment and/ or distress. dysmorphic disorder) or more
intensive CBT (including ERP)
An obsession is defined as an unwanted intrusive  If severe functional impairment
thought, image or urge that repeatedly enters the o offer combined treatment with
person's mind. Compulsions are repetitive an SSRI and CBT (including ERP)
behaviours or mental acts that the person feels
driven to perform. A compulsion can either be
overt and observable by others, such as checking Notes on treatments
that a door is locked, or a covert mental act that
cannot be observed, such as repeating a certain
phrase in one's mind.
 ERP is a psychological method which
It is thought that 1 to 2% of the population have involves exposing a patient to an anxiety
OCD, although some studies have estimated 2 to provoking situation (e.g. for someone
3%. with OCD, having dirty hands) and then
stopping them engaging in their usual

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

safety behaviour (e.g. washing their Disorder Features

hands). This helps them confront their Physical appearance used for attention seeking purposes
anxiety and the habituation leads to the Impressionistic speech lacking detail
eventual extinction of the response Self dramatization
 if treatment with SSRI is effective then Relationships considered to be more intimate than they are
continue for at least 12 months to preventNarcissistic Grandiose sense of self importance
relapse and allow time for improvement Preoccupation with fantasies of unlimited success, power, or beauty
 If SSRI ineffective or not tolerated try Sense of entitlement, taking advantage of others to achieve own needs
Lack of empathy
either another SSRI
Excessive need for admiration
Chronic envy
Arrogant and haughty attitude
Othello's syndrome Obsessive- Is occupied with details, rules, lists, order, organization, or agenda to the
compulsive Demonstrates perfectionism that hampers with completing tasks
Is extremely dedicated to work and efficiency to the elimination of spare ti
Othello's syndrome is pathological jealousy where Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, o
a person is convinced their partner is cheating on Is not capable of disposing worn out or insignificant things even when the
them without any real proof. This is accompanied Is unwilling to pass on tasks or work with others except if they surrender t
by socially unacceptable behaviour linked to these Takes on a stingy spending style towards self and others; and shows stiffn
claims. Paranoid Hypersensitivity and an unforgiving attitude when insulted
Unwarranted tendency to questions the loyalty of friends
Reluctance to confide in others
Personality Disorders Preoccupation with conspirational beliefs and hidden meaning
Disorder Features Unwarranted tendency to perceive attacks on their character
Antisocial Failure to conform to social norms with respect to lawful behaviorsIndifference
Schizoid as indicatedtobypraise
repeatedly performing acts that are grounds for
and criticism
arrest; Preference for solitary activities
More common in men; Lack of interest in sexual interactions
Deception, as indicated by repeatedly lying, use of aliases, or conning
Lackothers for personal
of desire profit or pleasure;
for companionship
Impulsiveness or failure to plan ahead; Emotional coldness
Irritability and aggressiveness, as indicated by repeated physical fights
Feworinterests
assaults;
Reckless disregard for safety of self or others; Few friends or confidants other than family
Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations;
Schizotypal Ideas of reference (differ from delusions in that some insight is retained)
Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
Odd beliefs and magical thinking
Avoidant Avoidance of occupational activities which involve significant interpersonal
Unusual contact duedisturbances
perceptual to fears of criticism, or rejection.
Unwillingness to be involved unless certain of being liked Paranoid ideation and suspiciousness
Preoccupied with ideas that they are being criticised or rejected in social situationsbehaviour
Odd, eccentric
Restraint in intimate relationships due to the fear of being ridiculedLack of close friends other than family members
Reluctance to take personal risks doe to fears of embarrassment Inappropriate affect
Views self as inept and inferior to others Odd speech without being incoherent
Social isolation accompanied by a craving for social contact - Tx: TT, dialectical behavioural therapy,
Borderline Efforts to avoid real or imagined abandonment mentalization, therapeutic communities
Unstable interpersonal relationships which alternate between idealization and devaluation
Unstable self image
Impulsivity in potentially self damaging area (e.g. Spending, sex,Post-concussion
substance abuse)syndrome
Recurrent suicidal behaviour
Affective instability
Chronic feelings of emptiness Post-concussion syndrome is seen after even minor
Difficulty controlling temper head trauma
Quasi psychotic thoughts
Dependent Difficulty making everyday decisions without excessive reassurance Typical
fromfeatures
others include
Need for others to assume responsibility for major areas of their life
Difficulty in expressing disagreement with others due to fears of losing support
Lack of initiative
Unrealistic fears of being left to care for themselves  headache
Urgent search for another relationship as a source of care and support fatigue
 when a close relationship ends
Extensive efforts to obtain support from others  anxiety/depression
Unrealistic feelings that they cannot care for themselves  dizziness
Histrionic Inappropriate sexual seductiveness
Need to be the centre of attention
Rapidly shifting and shallow expression of emotions Post-traumatic stress disorder
Suggestibility

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

Post-traumatic stress disorder (PTSD) can develop

in people of any age following a traumatic event, Pseudohallucinations
for example, a major disaster or childhood sexual
abuse. It encompasses what became known as
'shell shock' following the first world war. One of ICD10 definition of hallucination: false sensory
the DSM-IV diagnostic criteria is that symptoms perception in the absence of an external stimulus.
have been present for more than one month. Maybe organic, drug-induced or associated with
mental disorder.
Features
The definition of a pseudohallucination is harder to
pin down. There is no mention of
pseudohallucinations in either the ICD10 nor the
 re-experiencing: flashbacks, nightmares,
DSM-5. However, there is a generally accepted
repetitive and distressing intrusive images
definition that a pseudohallucination is a false
 avoidance: avoiding people, situations or
sensory perception in the absence of external
circumstances resembling or associated
stimuli when the affected is aware that they are
with the event
hallucinating.
 hyperarousal: hypervigilance for threat,
exaggerated startle response, sleep
There is disagreement among specialists about not
problems, irritability and difficulty
only the definition but also the role in the
concentrating
treatment of pseudohallucinations. Many
 emotional numbing - lack of ability to
specialists feel that it is more appropriate to think
experience feelings, feeling detached
about hallucinations on a spectrum from mild
sensory disturbance to hallucinations to prevent
from other people
symptoms from being mistreated or misdiagnosed.

An example of a pseudohallucination is a
 depression hypnagogic hallucination which occurs when
 drug or alcohol misuse transitioning from wakefulness to sleep. These are
 anger experienced vivid auditory or visual hallucinations
 unexplained physical symptoms which are fleeting in duration and may occur in
anyone. These are pseudohallucinations as the
affected person is able to determine that the
Management hallucination was not real.

The relevance of pseudohallucinations in practice

is that patients may need reassurance that these
 following a traumatic event single-session
experiences are normal and do not mean that they
interventions (often referred to as
will develop a mental illness.
debriefing) are not recommended
 watchful waiting may be used for mild
Pseudohallucinations commonly occur in people
symptoms lasting less than 4 weeks
who are grieving.
 military personnel have access to
treatment provided by the armed forces
Psychosis
 trauma-focused cognitive behavioural
therapy (CBT) or eye movement
desensitisation and reprocessing (EMDR)
Psychosis is a term used to describe a person
therapy may be used in more severe cases
experiencing things differently from those around
 drug treatments for PTSD should not be
them.
used as a routine first-line treatment for
adults. If drug treatment is used
Psychotic features include:
then venlafaxine or a selective serotonin
reuptake inhibitor (SSRI), such as
sertraline should be tried. In severe cases,
NICE recommends that risperidone may  hallucinations (e.g. auditory)
be used  delusions
 thought disorganisation

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

o alogia: little information  parent has schizophrenia = 10-15%

conveyed by speech  sibling has schizophrenia = 10%
o tangentiality: answers diverge  no relatives with schizophrenia = 1%
from topic
o clanging
o word salad: linking real words Other selected risk factors for psychotic disorders
incoherently → nonsensical include:
content

 Black Caribbean ethnicity - RR 5.4

Associated features:  Migration - RR 2.9
 Urban environment- RR 2.4
 Cannabis use - RR 1.4
 agitation/aggression
 neurocognitive impairment (e.g. in
memory, attention or executive function) Schizophrenia: epidemiology
 depression
 thoughts of self harm
The strongest risk factor for developing a psychotic
disorder (including schizophrenia) is family history.
Psychotic symptoms may occur in a number of Having a parent with schizophrenia leads to a
conditions: relative risk (RR) of 7.5.

Risk of developing schizophrenia

 schizophrenia
 depression (psychotic depression, a
subtype more common in elderly  monozygotic twin has schizophrenia =
patients) 50%
 bipolar disorder  parent has schizophrenia = 10-15%
 puerperal psychosis  sibling has schizophrenia = 10%
 brief psychotic disorder: where symptoms  no relatives with schizophrenia = 1%
last less than a month
 neurological conditions e.g. Parkinson's
disease, Huntington's disease Other selected risk factors for psychotic disorders
 prescribed drugs e.g. corticosteroids include:
 certain illicit drugs e.g. cannabis,
phencyclidine
 Black Caribbean ethnicity - RR 5.4
 Migration - RR 2.9
The peak age of first-episode psychosis is around  Urban environment- RR 2.4
15-30 years.  Cannabis use - RR 1.4

Schizophrenia: epidemiology
Schizophrenia: features

The strongest risk factor for developing a psychotic

disorder (including schizophrenia) is family history. Schneider's first rank symptoms may be divided
Having a parent with schizophrenia leads to a into auditory hallucinations, thought disorders,
relative risk (RR) of 7.5. passivity phenomena and delusional perceptions:

Risk of developing schizophrenia Auditory hallucinations of a specific type:

 monozygotic twin has schizophrenia =  two or more voices discussing the patient
50% in the third person

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

 thought echo NICE published guidelines on the management of

 voices commenting on the patient's schizophrenia in 2009.
behaviour
Key points:

Thought disorder*:
 oral atypical antipsychotics are first-line
 cognitive behavioural therapy should be
 thought insertion offered to all patients
 thought withdrawal  close attention should be paid to
 thought broadcasting cardiovascular risk-factor modification
due to the high rates of cardiovascular
disease in schizophrenic patients (linked
Passivity phenomena: to antipsychotic medication and high
smoking rates)

 bodily sensations being controlled by

Schizophrenia: prognostic indicators
external influence
 actions/impulses/feelings - experiences
which are imposed on the individual or
Factors associated with poor prognosis
influenced by others

Delusional perceptions  strong family history

 gradual onset
 low IQ
 prodromal phase of social withdrawal
 a two stage process) where first a normal  lack of obvious precipitant
object is perceived then secondly there is
a sudden intense delusional insight into
the objects meaning for the patient e.g.
Seasonal affective disorder
'The traffic light is green therefore I am
the King'.
Seasonal affective disorder (SAD) describes
depression which occurs predominately around
Other features of schizophrenia include the winter months. SAD should be treated the
same way as depression, therefore as per the NICE
guidelines for mild depression, you would begin
 impaired insight with psychological therapies and follow up with
 incongruity/blunting of affect the patient in 2 weeks to ensure that there has
(inappropriate emotion for circumstances) been no deterioration. Following this an SSRI can
 decreased speech be given if needed. In seasonal affective disorder,
 neologisms: made-up words you should not give the patient sleeping tablets as
 catatonia this can make the symptoms worse. Finally, the
 negative symptoms: incongruity/blunting evidence for light therapy is limited and as such it
of affect, anhedonia (inability to derive is not routinely recommended.
pleasure), alogia (poverty of speech),
avolition (poor motivation) Sectioning under the Mental Health Act

*occasionally referred to as thought alienation This is used for someone over the age of 16 years
who will not be admitted voluntarily. Patients who
Schizophrenia: management are under the influence of alcohol or drugs are
specifically excluded

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

Section 2
Section 17a

 admission for assessment for up to 28

days, not renewable  Supervised Community Treatment
 an Approved Mental Health Professional (Community Treatment Order)
(AMHP) or rarely the nearest relative (NR)  can be used to recall a patient to hospital
makes the application on the for treatment if they do not comply with
recommendation of 2 doctors conditions of the order in the community,
 one of the doctors should be 'approved' such as complying with medication
under Section 12(2) of the Mental Health
Act (usually a consultant psychiatrist)
 treatment can be given against a patient's Section 135
wishes

 a court order can be obtained to allow the

Section 3 police to break into a property to remove
a person to a Place of Safety

 admission for treatment for up to 6

months, can be renewed Section 136
 AMHP along with 2 doctors, both of which
must have seen the patient within the
past 24 hours
 someone found in a public place who
 treatment can be given against a patient's
appears to have a mental disorder can be
wishes
taken by the police to a Place of Safety
 can only be used for up to 24 hours, whilst
a Mental Health Act assessment is
Section 4 arranged

 72 hour assessment order Selective serotonin reuptake inhibitors

 used as an emergency, when a section 2
would involve an unacceptable delay
 a GP and an AMHP or NR Selective serotonin reuptake inhibitors (SSRIs) are
 often changed to a section 2 upon arrival considered first-line treatment for the majority of
at hospital patients with depression.

Section 5(2)  citalopram (although see below re: QT

interval) and fluoxetine are currently the
preferred SSRIs
 a patient who is a voluntary patient in  sertraline is useful post myocardial
hospital can be legally detained by a infarction as there is more evidence for its
doctor for 72 hours safe use in this situation than other
antidepressants
 SSRIs should be used with caution
Section 5(4) in children and adolescents. Fluoxetine is
the drug of choice when an
antidepressant is indicated
 similar to section 5(2), allows a nurse to
detain a patient who is voluntarily in
Adverse effects
hospital for 6 hours

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

 gastrointestinal symptoms are the most continue on treatment for at least 6 months after
common side-effect remission as this reduces the risk of relapse.
 there is an increased risk of
gastrointestinal bleeding in patients taking When stopping a SSRI the dose should be gradually
SSRIs. A proton pump inhibitor should be reduced over a 4 week period (this is not necessary
prescribed if a patient is also taking a with fluoxetine). Paroxetine has a higher incidence
NSAID of discontinuation symptoms.
 patients should be counselled to be
vigilant for increased anxiety and agitation Discontinuation symptoms
after starting a SSRI
 fluoxetine and paroxetine have a higher
propensity for drug interactions  increased mood change
 restlessness
 difficulty sleeping
Citalopram and the QT interval  unsteadiness
 sweating
 gastrointestinal symptoms: pain,
 the Medicines and Healthcare products cramping, diarrhoea, vomiting
Regulatory Agency (MHRA) released a  paraesthesia
warning on the use of citalopram in 2011
 it advised that citalopram and
escitalopram are associated with dose- SSRIs and pregnancy
dependent QT interval prolongation and - BNF says to weigh up benefits and risk when
should not be used in those with: deciding whether to use in pregnancy.
congenital long QT syndrome; known pre- - Use during the first trimester gives a small
existing QT interval prolongation; or in increased risk of congenital heart defects
combination with other medicines that - Use during the third trimester can result
prolong the QT interval in persistent pulmonary hypertension of the
 the maximum daily dose is now 40 mg for newborn
adults; 20 mg for patients older than 65 - Paroxetine has an increased risk of congenital
years; and 20 mg for those with hepatic malformations, particularly in the first trimester
impairment
Serotonin and noradrenaline reuptake inhibitors

Interactions
Serotonin and noradrenaline reuptake inhibitor
(SNRI's) are a class of relatively new
antidepressants. Inhibiting the reuptake increases
 NSAIDs: NICE guidelines advise 'do not
the concentrations of serotonin and noradrenaline
normally offer SSRIs', but if given co-
in the synaptic cleft leading to the effects.
prescribe a proton pump inhibitor
Examples include venlafaxine and duloxetine. They
 warfarin / heparin: NICE guidelines
are used to treat major depressive disorders,
recommend avoiding SSRIs and
generalised anxiety disorder, social anxiety
considering mirtazapine
disorder and panic disorder and menopausal
 aspirin: see above
symptoms.
 triptans - increased risk of serotonin
syndrome
Sleep paralysis
 monoamine oxidase inhibitors (MAOIs) -
increased risk of serotonin syndrome
Sleep paralysis is a common condition
characterized by transient paralysis of skeletal
Following the initiation of antidepressant therapy muscles which occurs when awakening from sleep
patients should normally be reviewed by a doctor or less often while falling asleep. It is thought to be
after 2 weeks. For patients under the age of 30 related to the paralysis that occurs as a natural
years or at increased risk of suicide they should be part of REM (rapid eye movement) sleep. Sleep
reviewed after 1 week. If a patient makes a good paralysis is recognised in a wide variety of cultures
response to antidepressant therapy they should

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

Features Interactions

 paralysis - this occurs after waking up or  NSAIDs: NICE guidelines advise 'do not
shortly before falling asleep normally offer SSRIs', but if given co-
 hallucinations - images or speaking that prescribe a proton pump inhibitor
appear during the paralysis  warfarin / heparin: NICE guidelines
recommend avoiding SSRIs and
considering mirtazapine
Management  aspirin: see above
 triptans: avoid SSRIs

 if troublesome clonazepam may be used

Following the initiation of antidepressant therapy
patients should normally be reviewed by a doctor
after 2 weeks. For patients under the age of 30
SSRI: side-effects
years or at increased risk of suicide they should be
reviewed after 1 week. If a patient makes a good
response to antidepressant therapy they should
Adverse effects
continue on treatment for at least 6 months after
remission as this reduces the risk of relapse.

 gastrointestinal symptoms are the most When stopping a SSRI the dose should be gradually
common side-effect reduced over a 4 week period (this is not necessary
 there is an increased risk of with fluoxetine). Paroxetine has a higher incidence
gastrointestinal bleeding in patients taking of discontinuation symptoms.
SSRIs. A proton pump inhibitor should be
prescribed if a patient is also taking a Discontinuation symptoms
NSAID
 hyponatraemia
 patients should be counselled to be
 increased mood change
vigilant for increased anxiety and agitation
 restlessness
after starting a SSRI
 difficulty sleeping
 fluoxetine and paroxetine have a higher
 unsteadiness
propensity for drug interactions
 sweating
 gastrointestinal symptoms: pain,
cramping, diarrhoea, vomiting
Citalopram and the QT interval
 paraesthesia

 the Medicines and Healthcare products Suicide: risk factors

Regulatory Agency (MHRA) released a
warning on the use of citalopram in 2011
 it advised that citalopram and The risk stratification of psychiatric patients into
escitalopram are associated with dose- 'high', 'medium' or 'low risk' is common in clinical
dependent QT interval prolongation and practice. Questions based on a patient's suicide
should not be used in those with: risk are therefore often seen. However, it should be
congenital long QT syndrome; known pre- noted that there is a paucity of evidence
existing QT interval prolongation; or in addressing the positive predictive value of
combination with other medicines that individual risk factors. An interesting review in the
prolong the QT interval BMJ (BMJ 2017;359:j4627) concluded that 'there is
 the maximum daily dose is now 40 mg for no evidence that these assessments can usefully
adults; 20 mg for patients older than 65 guide decision making' and noted that 50% of
years; and 20 mg for those with hepatic suicides occur in patients deemed 'low risk'.
impairment

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

Whilst the evidence base is relatively weak, there used widely in the treatment of neuropathic pain,
are a number of factors shown to be associated where smaller doses are typically required.
with an increased risk of suicide
Common side-effects

 male sex (hazard ratio (HR) approximately

2.0)  drowsiness
 history of deliberate self-harm (HR 1.7)  dry mouth
 alcohol or drug misuse (HR 1.6)  blurred vision
 history of mental illness  constipation
o depression  urinary retention
o schizophrenia: NICE estimates  lengthening of QT interval
that 10% of people with
schizophrenia will complete
suicide Choice of tricyclic
 history of chronic disease
 advancing age
 unemployment or social isolation/living  low-dose amitriptyline is commonly used
alone in the management of neuropathic pain
 being unmarried, divorced or widowed and the prophylaxis of headache (both
tension and migraine)
 lofepramine has a lower incidence of
If a patient has actually attempted suicide, there toxicity in overdose
are a number of factors associated with an  amitriptyline and dosulepin (dothiepin)
increased risk of completed suicide at a future are considered the most dangerous in
date: overdose

 efforts to avoid discovery More sedative

 planning
Amitriptyline Im
 leaving a written note
Clomipramine Lof
 final acts such as sorting out finances
Dosulepin No
 violent method
Trazodone*

*trazodone is technically a 'tricyclic-related

antidepressant'

Unexplained symptoms
Protective factors

There are, of course, factors which reduce the risk There are a wide variety of psychiatric terms for
of a patient committing suicide. These include patients who have symptoms for which no organic
cause can be found:

Somatisation disorder
 family support
 having children at home
 religious belief
 multiple physical SYMPTOMS present for
at least 2 years
 patient refuses to accept reassurance or
Tricyclic antidepressants
negative test results

Tricyclic antidepressants (TCAs) are used less

commonly now for depression due to their side- Illness anxiety disorder (hypochondriasis)
effects and toxicity in overdose. They are however

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

 persistent belief in the presence of an Z drugs have similar effects to benzodiazepines but
underlying serious DISEASE, e.g. cancer are different structurally. They act on the α2-
 patient again refuses to accept subunit of the GABA receptor.
reassurance or negative test results
They can be divided into 3 groups:

Conversion disorder
 Imidazopyridines: e.g. zolpidem
 Cyclopyrrolones: e.g. zopiclone
 typically involves loss of motor or sensory  Pyrazolopyrimidines: e.g. zaleplon
function
 the patient doesn't consciously feign the
symptoms (factitious disorder) or seek Adverse effects
material gain (malingering)
 patients may be indifferent to their
apparent disorder - la belle indifference -  similar to benzodiazepines
although this has not been backed up by  increase the risk of falls in the elderly
some studies

Dissociative disorder Acute confusional state (Delirium)

 dissociation is a process of 'separating off' Acute confusional state is also known as delirium
certain memories from normal or acute organic brain syndrome.
consciousness
 in contrast to conversion disorder involves Predisposing factors include:
psychiatric symptoms e.g. Amnesia,  Age > 65 years
fugue, stupor  Background of dementia
 dissociative identity disorder (DID) is the  Significant injury e.g. Hip fracture
new term for multiple personality  Frailty or multimorbidity
disorder as is the most severe form of  Polypharmacy
dissociative disorder
The precipitating events are often multifactorial
and may include:
Factitious disorder  Infection: particularly urinary tract
infections
 Metabolic: e.g. Hypercalcaemia,
hypoglycaemia, hyperglycaemia,
 also known as Munchausen's syndrome
dehydration
 the intentional production of physical or
 Change of environment
psychological symptoms
 Any significant cardiovascular, respiratory,
neurological or endocrine condition
 Severe pain
Malingering  Alcohol withdrawal
 Constipation

 fraudulent simulation or exaggeration of Features - a wide variety of presentations

symptoms with the intention of financial  Cognitive functions:
or other gain o memory disturbances (loss of
short term > long term)
 Perception - Auditory or visual
Z drugs hallucination
 Physical function - reduced morbidity,
reduce movement, restlessness, agitation
changes in appetite, sleep disturbance

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

 Social behaviour - may be very agitated or point cognitive screener (10-CS), 6-Item
withdrawn, Lack of cooperation cognitive impairment test (6CIT)
 assessment tools not recommended by
Management NICE for the non-specialist setting include
- treatment of the underlying cause the abbreviated mental test score (AMTS),
- modification of the environment General practitioner assessment of
- the 2006 Royal College of Physicians cognition (GPCOG) and the mini-mental
publication 'The prevention, diagnosis and state examination (MMSE) have been
management of delirium in older people: widely used. A MMSE score of 24 or less
concise guidelines' out of 30 suggests dementia
recommended haloperidol 0.5 mg as the
first-line sedative
- the 2010 NICE delirium guidelines Management
advocate the use of haloperidol or
olanzapine IM (SE - alteration in blood
pressure, stroke, insomnia, dyspepsia)
 in primary care, a blood screen is usually
- management can be challenging in
sent to exclude reversible causes (e.g.
patients with Parkinson's disease, as
Hypothyroidism). NICE recommend the
antipsychotics can often worsen
following tests: FBC, U&E, LFTs, calcium,
Parkinsonian symptoms
glucose, TFTs, vitamin B12 and folate
- careful reduction of the Parkinson
levels. Patients are now commonly
medication may be helpful
referred on to old-age psychiatrists
- if symptoms require urgent treatment
(sometimes working in 'memory clinics').
then the atypical
 in secondary care, neuroimaging is
antipsychotics quetiapine and clozapine
performed* to exclude other reversible
are preferred
conditions (e.g. Subdural haematoma,
normal pressure hydrocephalus) and help
differential diagnosis:
provide information on aetiology to guide
- withdrawal from alcohol or drugs
prognosis and management
- mania
- psychosis or anxiety

Dementia vs Delirium *in the 2011 NICE guidelines structural imaging

was said to be essential in the investigation of
dementia
Factors favouring delirium over dementia
 Impairment of consciousness
 Fluctuation of symptoms: worse at night, Dementia: causes
periods of normality
 Abnormal perception (e.g. Illusions and
hallucinations) Common causes
 Agitation, fear
 Delusions
 Alzheimer's disease
Dementia  cerebrovascular disease: multi-infarct
dementia (c. 10-20%)
 Lewy body dementia (c. 10-20%)
Common cause of dementia in the UK is
Alzheimer's disease followed by vascular and Lewy
body dementia. These conditions may coexist. Rarer causes (c. 5% of cases)

Features
 Huntington's
 diagnosis can be difficult and is often
 CJD
delayed
 Pick's disease (atrophy of frontal and
 assessment tools recommended by NICE
temporal lobes)
for the non-specialist setting include: 10-

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

 HIV (50% of AIDS patients)

Risk factors

Important differentials, potentially treatable

 History of stroke or transient ischaemic
attack (TIA)
 hypothyroidism, Addison's  Atrial fibrillation
 B12/folate/thiamine deficiency  Hypertension
 syphilis  Diabetes mellitus
 brain tumour  Hyperlipidaemia
 normal pressure hydrocephalus  Smoking
 subdural haematoma  Obesity
 depression  Coronary heart disease
 chronic drug use e.g. Alcohol, barbiturates  A family history of stroke or
cardiovascular
Vascular dementia

Rarely, VD can be inherited as in the case of

Vascular dementia (VD) is the second most CADASIL (cerebral autosomal dominant
common form of dementia after Alzheimer arteriopathy with subcortical infarcts and
disease. It is not a single disease but a group of leukoencephalopathy.
syndromes of cognitive impairment caused by
different mechanisms causing ischaemia or Patients with VD typically presents with
haemorrhage secondary to cerebrovascular
disease. Vascular dementia has been increasingly
recognised as the most severe form of the  Several months or several years of a
spectrum of deficits encompassed by the term history of a sudden or stepwise
vascular cognitive impairment (VCI). Early deterioration of cognitive function.
detection and an accurate diagnosis are important
in the prevention of vascular dementia.
Symptoms and the speed of progression vary but
Epidemiology
may include:

 VD is thought to account for around 17%

 Focal neurological abnormalities e.g.
of dementia in the UK
visual disturbance, sensory or motor
 Prevalence of dementia following a first
symptoms
stroke varies depending on location and
 The difficulty with attention and
size of the infarct, definition of dementia,
concentration
interval after stroke and age among other
 Seizures
variables. Overall, stroke doubles the risk
 Memory disturbance
of developing dementia.
 Gait disturbance
 Incidence increases with age
 Speech disturbance
 Emotional disturbance

The main subtypes of VD:

Diagnosis is made based on:

 Stroke-related VD – multi-infarct or single-

infarct dementia
 A comprehensive history and physical
 Subcortical VD – caused by small vessel
examination
disease
 Formal screen for cognitive impairment
 Mixed dementia – the presence of both
 Medical review to exclude medication
VD and Alzheimer’s disease
cause of cognitive decline

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

 MRI scan – may show infarcts and There is no specific pharmacological


extensive white matter changes treatment approved for cognitive
symptoms
 Only consider AChE inhibitors or
National Institute for health and care excellence memantine for people with vascular
(NICE) recommends that diagnosis be made using dementia if they have suspected
the NINDS-AIREN criteria for probable vascular comorbid Alzheimer’s disease, Parkinson’s
dementia disease dementia or dementia with Lewy
bodies.
Presence of cognitive decline that interferes with activities of daily living, not due to secondary effects of the
cerebrovascular event  There is no evidence that aspirin is
effective in treating patients with a
diagnosis of vascular dementia.
 No randomized trials found evaluating
 established using clinical examination and neuropsychological testing
statins for vascular dementia

Cerebrovascular disease Lewy body dementia

 defined by neurological signs and/or brain imaging Lewy body dementia is an increasingly recognised
cause of dementia, accounting for up to 20% of
cases. The characteristic pathological feature is
A relationship between the above two disorders inferred by:
alpha-synuclein cytoplasmic inclusions (Lewy
bodies) in the substantia nigra, paralimbic and
neocortical areas.
 the onset of dementia within three months following a recognised stroke
 an abrupt deterioration in cognitive functions The relationship between Parkinson's disease and
 fluctuating, stepwise progression of cognitive deficits
Lewy body dementia is complicated, particularly as
dementia is often seen in Parkinson's disease. Also,
up to 40% of patients with Alzheimer's have Lewy
General management bodies.

Features
 Treatment is mainly symptomatic with the
aim to address individual problems and
provide support to the patient and carers  progressive cognitive impairment
 Important to detect and address o in contrast to Alzheimer's, early
cardiovascular risk factors – for slowing impairments in attention and
down the progression executive function rather than
just memory loss
o cognition may be fluctuating, in
Non-pharmacological management contrast to other forms of
dementia
o usually develops before
parkinsonism
 Tailored to the individual
 parkinsonism
 Include: cognitive stimulation
 visual hallucinations (other features such
programmes, multisensory stimulation,
as delusions and non-visual hallucinations
music and art therapy, animal-assisted
may also be seen)
therapy
 Managing challenging behaviours e.g.
address pain, avoid overcrowding, clear
communication Diagnosis

Pharmacological management  usually clinical

 single-photon emission computed
tomography (SPECT) is increasingly used.

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

It is currently commercially known as a by personality change and impaired social conduct.

DaTscan. Dopaminergic iodine-123- Other common features include hyperorality,
radiolabelled 2-carbomethoxy-3-(4- disinhibition, increased appetite, and
iodophenyl)-N-(3-fluoropropyl) perseveration behaviours.
nortropane (123-I FP-CIT) is used as the
radioisotope. The sensitivity of SPECT in Focal gyral atrophy with a knife-blade appearance
diagnosing Lewy body dementia is around is characteristic of Pick's disease.
90% with a specificity of 100%
Macroscopic changes seen in Pick's disease
include:-
Management

 Atrophy of the frontal and temporal lobes

 both acetylcholinesterase inhibitors (e.g.
donepezil, rivastigmine) and memantine
can be used as they are in Alzheimer's. Microscopic changes include:-
NICE have made detailed
recommendations about what drugs to
use at what stages. Please see the link for  Pick bodies - spherical aggregations of tau
more details protein (silver-staining)
 neuroleptics should be avoided in Lewy  Gliosis
body dementia as patients are extremely  Neurofibrillary tangles
sensitive and may develop irreversible  Senile plaques
parkinsonism. Questions may give a
history of a patient who has deteriorated
following the introduction of an
Management
antipsychotic agent

Frontotemporal lobar degeneration

 NICE do not recommend that AChE
inhibitors or memantine are used in
Frontotemporal lobar degeneration (FTLD) is the people with frontotemporal dementia
third most common type of cortical dementia after
Alzheimer's and Lewy body dementia.

There are three recognised types of FTLD CPA

Here the chief factor is non fluent speech. They

 Frontotemporal dementia (Pick's disease) make short utterances that are agrammatic.
 Progressive non fluent aphasia (chronic Comprehension is relatively preserved.
progressive aphasia, CPA)
 Semantic dementia
Semantic dementia

Common features of frontotemporal lobar dementias

Here the patient has a fluent progressive aphasia.
Onset before 65 The speech is fluent but empty and conveys little
Insidious onset meaning. Unlike in Alzheimer's memory is better
Relatively preserved memory and visuospatial skills for recent rather than remote events.
Personality change and social conduct problems
Alzheimer's disease: management

Pick's disease
Alzheimer's disease is a progressive degenerative
disease of the brain accounting for the majority of
This is the most common type and is characterised dementia seen in the UK

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)

 lOMoARcPSD|6265699

 is relatively contraindicated in patients

Non-pharmacological management with bradycardia
 adverse effects include insomnia

 NICE recommend offering 'a range of

activities to promote wellbeing that are
tailored to the person's preference'
 NICE recommend offering group cognitive
stimulation therapy for patients with mild
and moderate dementia
 other options to consider include group
reminiscence therapy and cognitive
rehabilitation

https://passmedicine.com/database/dbnotes.php
Pharmacological management

 NICE updated it's dementia guidelines in

2018
 the three acetylcholinesterase inhibitors
(donepezil, galantamine and rivastigmine)
as options for managing mild to moderate
Alzheimer's disease
 memantine (an NMDA receptor
antagonist) is in simple terms the 'second-
line' treatment for Alzheimer's, NICE
recommend it is used in the following
situation reserved for patients with
o moderate Alzheimer's who are
intolerant of, or have a
contraindication to,
acetylcholinesterase inhibitors
o as an add-on drug to
acetylcholinesterase inhibitors
for patients with moderate or
severe Alzheimer's
o monotherapy in severe
Alzheimer's

Managing non-cognitive symptoms

 NICE does not recommend

antidepressants for mild to moderate
depression in patients with dementia
 antipsychotics should only be used for
patients at risk of harming themselves or
others, or when the agitation,
hallucinations or delusions are causing
them severe distress

Donepezil

Downloaded by Noman Ajmal (nomanbutt8895@gmail.com)