Unexplained symptoms

 Somatisation = Symptoms
 hypoChondria = Cancer

Somatisation disorder is the correct answer as the patient is concerned about persistent,
unexplained symptoms rather than an underlying diagnosis such as cancer (hypochondrial
disorder). Munchausen's syndrome describes the intentional production of symptoms, for
example self poisoning

There are a wide variety of psychiatric terms for patients who have symptoms for which no
organic cause can be found:
Somatisation disorder

 multiple physical SYMPTOMS present for at least 2 years

 patient refuses to accept reassurance or negative test results

Hypochondrial disorder

 persistent belief in the presence of an underlying serious DISEASE, e.g. cancer

 patient again refuses to accept reassurance or negative test results

Conversion disorder

 typically involves loss of motor or sensory function

 the patient doesn't consciously feign the symptoms (factitious disorder) or seek material
gain (malingering)
 patients may be indifferent to their apparent disorder - la belle indifference - although
this has not been backed up by some studies

Dissociative disorder

 dissociation is a process of 'separating off' certain memories from normal consciousness

 in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue,
stupor
 dissociative identity disorder (DID) is the new term for multiple personality disorder as
is the most severe form of dissociative disorder

Munchausen's syndrome

 also known as factitious disorder

 the intentional production of physical or psychological symptoms

Malingering

 fraudulent simulation or exaggeration of symptoms with the intention of financial or

other gain

1
Paroxetine has a higher incidence of discontinuation symptoms than other selective serotonin
reuptake inhibitors.

Lithium
Lithium is mood stabilising drug used most commonly prophylatically in bipolar disorder
but also as an adjunct in refractory depression. It has a very narrow therapeutic range (0.4-
1.0 mmol/L) and a long plasma half-life being excreted primarily by the kidneys.
Mechanism of action - not fully understood, two theories:

 interferes with inositol triphosphate formation

 interferes with cAMP formation

Adverse effects

 nausea/vomiting, diarrhoea
 fine tremor
 polyuria (secondary to nephrogenic diabetes insipidus)
 thyroid enlargement, may lead to hypothyroidism
 ECG: T wave flattening/inversion
 weight gain

Monitoring of patients on lithium therapy

 inadequate monitoring of patients taking lithium is common - NICE and the National
Patient Safety Agency (NPSA) have issued guidance to try and address this. As a result
it is often an exam hot topic
 lithium blood level should 'normally' be checked every 3 months. Levels should be taken
12 hours post-dose
 thyroid and renal function should be checked every 6 months
 patients should be issued with an information booklet, alert card and record book

Lithium toxicity
Both sodium bicarbonate and aminophylline may reduce plasma concentrations of lithium.
Diuretics, ACE-inhibitors and angiotensin II receptor antagonists may cause lithium toxicity.
The BNF advises that neurotoxicity may be increased when lithium is given with diltiazem
or verapamil but there is no significant interaction with amlodipine. Alpha-blockers are not
listed as interacting with lithium but they would not be first-line treatment for hypertension.

The NICE hypertension guidelines suggest amlodipine wouldn't be a bad first choice, even if
we ignore his lithium treatment.
Lithium is mood stabilising drug used most commonly prophylatically in bipolar disorder
but also as an adjunct in refractory depression. It has a very narrow therapeutic range (0.4-
2
1.0 mmol/L) and a long plasma half-life being excreted primarily by the kidneys. Lithium
toxicity generally occurs following concentrations > 1.5 mmol/L.

Toxicity may be precipitated by dehydration, renal failure, diuretics (especially

bendroflumethiazide), ACE inhibitors and metronidazole.

Features of toxicity

 coarse tremor (a fine tremor is seen in therapeutic levels)

 acute confusion
 seizure
 coma

Management

 mild-moderate toxicity may respond to volume resuscitation with normal saline

 haemodialysis may be needed in severe toxicity
 sodium bicarbonate is sometimes used but there is limited evidence to support this. By
increasing the alkalinity of the urine it promotes lithium excretion.

Post-partum mental health problems

Post-partum mental health problems range from the 'baby-blues' to puerperal psychosis.

The Edinburgh Postnatal Depression Scale may be used to screen for depression:

 10-item questionnaire, with a maximum score of 30

 indicates how the mother has felt over the previous week
 score > 13 indicates a 'depressive illness of varying severity'
 sensitivity and specificity > 90%
 includes a question about self-harm

'Baby-blues' Postnatal depression Puerperal psychosis

Seen in around 60- Affects around 10% of women Affects approximately
70% of women 0.2% of women
Most cases start within a month and
Typically seen 3-7 typically peaks at 3 months Onset usually within the
days following birth first 2-3 weeks following
and is more common Features are similar to depression birth
in primips seen in other circumstances
Features include severe
Mothers are swings in mood (similar to
characteristically bipolar disorder) and
anxious, tearful and disordered perception (e.g.
irritable auditory hallucinations)
3
Reassurance and As with the baby blues reassurance Admission to hospital is
support, the health and support are important usually required
visitor has a key role
Cognitive behavioural therapy may be There is around a 20% risk
beneficial. Certain SSRIs such as of recurrence following
sertraline and paroxetine* may be future pregnancies
used if symptoms are severe** -
whilst they are secreted in breast milk
it is not thought to be harmful to the
infant

paroxetine is recommended by SIGN because of the low milk/plasma ratio*

fluoxetine is best avoided due to a long half-life**

Depression: screening and assessment

Early morning waking is a classic somatic symptom of depression and often develops earlier
than general insomnia.

Palpitations and nausea and more common with anxiety. Excessive gambling may suggest
either a simple gambling addiction or be part of a hypomanic/manic disorder.

Flash-backs are common in post-traumatic stress disorder.

Screening

The following two questions can be used to screen for depression

 'During the last month, have you often been bothered by feeling down, depressed or
hopeless?'
 'During the last month, have you often been bothered by having little interest or pleasure
in doing things?'

A 'yes' answer to either of the above should prompt a more in depth assessment.

Assessment
There are many tools to assess the degree of depression including the Hospital Anxiety and
Depression (HAD) scale and the Patient Health Questionnaire (PHQ-9).

Hospital Anxiety and Depression (HAD) scale

 consists of 14 questions, 7 for anxiety and 7 for depression

 each item is scored from 0-3
 produces a score out of 21 for both anxiety and depression
 severity: 0-7 normal, 8-10 borderline, 11+ case
 patients should be encouraged to answer the questions quickly

4
Patient Health Questionnaire (PHQ-9)

 asks patients 'over the last 2 weeks, how often have you been bothered by any of the
following problems?'
 9 items which can then be scored 0-3
 includes items asking about thoughts of self-harm
 depression severity: 0-4 none, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-
27 severe

NICE use the DSM-IV criteria to grade depression:

 1. Depressed mood most of the day, nearly every day

 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the
day, nearly every day
 3. Significant weight loss or weight gain when not dieting or decrease or increase in
appetite nearly every day
 4. Insomnia or hypersomnia nearly every day
 5. Psychomotor agitation or retardation nearly every day
 6. Fatigue or loss of energy nearly every day
 7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day
 8. Diminished ability to think or concentrate, or indecisiveness nearly every day
 9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a
suicide attempt or a specific plan for committing suicide

Subthreshold Fewer than 5 symptoms

depressive 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
Moderate depression Symptoms or functional impairment are between 'mild' and
'severe'
Severe depression Most symptoms, and the symptoms markedly interfere with
functioning. Can occur with or without psychotic symptoms

Depression: switching antidepressants

The following is based on the Clinical Knowledge Summaries depression guidelines, which
in turn are based on the Maudsley hospital guidelines.

Switching from citalopram, escitalopram, sertraline, or paroxetine to another SSRI

 the first SSRI should be withdrawn* before the alternative SSRI is started

Switching from fluoxetine to another SSRI

5
  withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low-
dose of the alternative SSRI

Switching from a SSRI to a tricyclic antidepressant (TCA)

 cross-tapering is recommend (the current drug dose is reduced slowly, whilst the dose of
the new drug is increased slowly)

- an exceptions is fluoxetine which should be withdrawn prior to TCAs being started

Switching from citalopram, escitalopram, sertraline, or paroxetine to venlafaxine

 cross-taper cautiously. Start venlafaxine 37.5 mg daily and increase very slowly

Switching from fluoxetine to venlafaxine

 withdraw and then start venlafaxine at 37.5 mg each day and increase very slowly

In this situation NICE recommend 'for people with moderate or severe depression, combine
antidepressants with a high-intensity psychological intervention (CBT or IPT)'. Please see
the guidelines for more details.

Depression: management of subthreshold depressive symptoms or mild depression

NICE only recommend behavioural couples therapy for patients with moderate or severe
depression.
NICE produced updated guidelines in 2009 on the management of depression in primary and
secondary care. Patients are classified according to the severity of the depression and
whether they have an underlying chronic physical health problem.

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

Persistent subthreshold depressive symptoms or mild to moderate depression

General measures

 sleep hygiene
 active monitoring for people who do want an intervention

Drug treatment
6
  do not use antidepressants routinely but consider them for people with:
 a past history of moderate or severe depression or
 initial presentation of subthreshold depressive symptoms that have been present for a
long period (typically at least 2 years) or
 subthreshold depressive symptoms or mild depression that persist(s) after other
interventions
 if a patient has a chronic physical health problem and mild depression complicates the
care of the physical health problem

The following 'low-intensity psychosocial interventions' may be useful:

Individual guided self-help Interventions should:

based on CBT principles
(Includes behavioural
activation and problem-
solving techniques)
 include written materials (or alternative media)
 be supported by a trained practitioner who
reviews progress
 consist of up to 6-8 sessions (face-to-face and by
telephone) over 9-12 weeks, including follow-up

Computerised CBT Interventions should:

 explain the CBT model, encourage tasks between

sessions, and use thought-
 challenging and active monitoring of behaviour,
thought patterns and outcomes
 be supported by a trained practitioner who reviews
progress and outcome typically take place over 9-12
weeks, including follow-up

A structured group physical Interventions should:

activity programme
 typically consist of 3 sessions per week (lasting 45
minutes to 1 hour) over 10-14 weeks

An alternative is group-based CBT

 be based on a model such as 'Coping with depression'

 be delivered by two trained and competent practitioners
 consist of 10-12 meetings of 8-10 participants
 typically take place over 12-16 weeks, including follow-up

For patients with chronic physical health problems NICE also recommend considering a
group-based peer support programme:

7
  focus on sharing experiences and feelings associated with having a chronic physical
health problem
 consist typically of 1 session per week over 8-12 weeks

Depression: management of unresponsive, moderate and severe depression

NICE produced updated guidelines in 2009 on the management of depression in primary and
secondary care. Patients are classified according to the severity of the depression and
whether they have an underlying chronic physical health problem.

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

Persistent subthreshold depressive symptoms or mild to moderate depression with

inadequate response to initial interventions, and moderate and severe depression

For these patients NICE recommends an antidepressant (normally a selective serotonin

reuptake inhibitor, SSRI)
The following 'high-intensity psychological interventions' may be useful:

Individual CBT  typically 16-20 sessions over 3-4 months

 consider 3-4 follow-up sessions over the next 3-6 months
 for moderate or severe depression, consider 2 sessions
per week for the first 2-3 weeks

Interpersonal therapy  typically 16-20 sessions over 3-4 months

(IPT)  for severe depression, consider 2 sessions per week for the
first 2-3 weeks

Behavioural  typically 16-20 sessions over 3-4 months

activation  consider 3-4 follow-up sessions over the next 3-6 months
 for moderate or severe depression, consider 2 sessions per
week for the first 3-4 weeks

Behavioural couples  typically 15-20 sessions over 5-6 months

therapy

For people who decline the options above, consider:

 counselling for people with persistent subthreshold depressive symptoms or mild to

moderate depression; offer 6-10 sessions over 8-12 weeks
 short-term psychodynamic psychotherapy for people with mild to moderate depression;
offer 16-20 sessions over 4-6 months

8
For patients with chronic physical health problems the following should be offered:

 group-based CBT
 individual CBT

ICD-10 diagnostic criteria of Depressive Episodes

The correct answer is 2 weeks. The ICD-10 criteria for depressive illness are as follows:
In typical depressive episodes, individuals usually suffer from depressed mood, loss of
interest in things you would normally find pleasure in (anhedonia), and reduced energy
levels (anergia). Other common symptoms include:

 Reduced concentration and attention

 Decreased self-esteem and confidence
 Feelings of guilt and unworthiness
 Bleak and pessimistic views of the future
 Ideas or acts of self-harm or suicide
 Disturbed sleep
 Diminished appetite and weight loss
 Psychomotor agitation or retardation
 Marked loss of libido

Diagnostic criteria for Depressive Episodes

Mild Depressive Episode:

 At least 2 of the main 3 symptoms of depression, and at least two of the other
symptoms, should be present for a definite diagnosis. None of the symptoms should be
present to an intense degree
 Minimum duration of the whole episode is about 2 weeks
 Individuals may be distressed by symptoms, but should be able to continue work and
social functioning

Moderate Depressive Episode:

 At least 2 of the main 3 symptoms of depression, and at least three (and preferably
four) of the other symptoms, should be present for a definite diagnosis
 Minimum duration of the whole episode is about 2 weeks
 Individuals will usually have considerable difficulty continuing with normal work and
social functioning

Severe Depressive Episode:

9
  All three of the typical symptoms should be present, plus at least four other symptoms,
some of which should be of severe intensity
 The minimum duration of the whole episode should last at least 2 weeks, but if the
symptoms are particularly severe then it may be appropriate to make an early
diagnosis
 Can also experience psychotic symptoms with severe depressive episodes
 Individuals show severe distress and/or agitation.

Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) can develop in people of any age following a
traumatic event, for example a major disaster or childhood sexual abuse. It encompasses
what became known as 'shell shock' following the first world war. One of the DSM-IV
diagnostic criteria is that symptoms have been present for more than one month

Features

 re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images

 avoidance: avoiding people, situations or circumstances resembling or associated with
the event
 hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems,
irritability and difficulty concentrating
 emotional numbing - lack of ability to experience feelings, feeling detached

from other people

 depression
 drug or alcohol misuse
 anger
 unexplained physical symptoms

Management

 following a traumatic event single-session interventions (often referred to as debriefing)

are not recommended
 watchful waiting may be used for mild symptoms lasting less than 4 weeks
 military personnel have access to treatment provided by the armed forces
 trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation
and reprocessing (EMDR) therapy may be used in more severe cases
 drug treatments for PTSD should not be used as a routine first-line treatment for adults.
If drug treatment is used then paroxetine or mirtazapine are recommended

10
Generalised anxiety disorder and panic disorder

Anxiety is a common disorder that can present in multiple ways. NICE define the central
feature as an 'excessive worry about a number of different events associated with heightened
tension.'

Management of generalised anxiety disorder (GAD)

NICE suggest a step-wise approach:

 step 1: education about GAD + active monitoring

 step 2: low intensity psychological interventions (individual non-facilitated self-help or
individual guided self-help or psychoeducational groups)
 step 3: high intensity psychological interventions (cognitive behavioural therapy or
applied relaxation) or drug treatment. See drug treatment below for more information
 step 4: highly specialist input e.g. Multi agency teams

Drug treatment

 NICE suggest sertraline should be considered the first-line SSRI

 interestingly for patients under the age of 30 years NICE recommend you warn patients
of the increased risk of suicidal thinking and self-harm. Weekly follow-up is
recommended for the first month

Management of panic disorder

Again a stepwise approach:

 step 1: recognition and diagnosis

 step 2: treatment in primary care - see below
 step 3: review and consideration of alternative treatments
 step 4: review and referral to specialist mental health services
 step 5: care in specialist mental health services

Treatment in primary care

 NICE recommend either cognitive behavioural therapy or drug treatment

 SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or

Tricyclic antidepressants
Dosulepin - avoid as dangerous in overdose

11
Tricyclic antidepressants (TCAs) are used less commonly now for depression due to their
side-effects and toxicity in overdose. They are however used widely in the treatment of
neuropathic pain, where smaller doses are typically required.

Common side-effects

 drowsiness
 dry mouth
 blurred vision
 constipation
 urinary retention

Choice of tricyclic

 low-dose amitriptyline is commonly used in the management of neuropathic pain and

the prophylaxis of headache (both tension and migraine)
 lofepramine has a lower incidence of toxicity in overdose
 amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose

More Less sedative

sedative
Amitriptyline Imipramine
Clomipramine Lofepramine
Dosulepin Nortriptyline
Trazodone*

*trazodone is technically a 'tricyclic-related antidepressant'

Hypomania vs. mania

Cannnabis and alcohol related problems are very unlikely given how long ago he used those
substances.

The presence of psychotic symptoms differentiates mania from hypomania

Psychotic symptoms

 delusions of grandeur
 auditory hallucinations

The following symptoms are common to both hypomania and mania

Mood

12
  predominately elevated
 irritable

Speech and thought

 pressured
 flight of ideas
 poor attention

Behaviour

 insomnia
 loss of inhibitions: sexual promiscuity, overspending, risk-taking
 increased appetite

Sleep paralysis
Sleep paralysis is a common condition characterized by transient paralysis of skeletal
muscles which occurs when awakening from sleep or less often while falling asleep. It is
thought to be related to the paralysis that occurs as a natural part of REM (rapid eye
movement) sleep. Sleep paralysis is recognised in a wide variety of cultures

Features

 paralysis - this occurs after waking up or shortly before falling asleep

 hallucinations - images or speaking that appear during the paralysis

Management

 if troublesome clonazepam may be used

Selective serotonin reuptake inhibitors

Sertraline is the preferred antidepressant following a myocardial infarction as there is more
evidence for its safe use in this situation than other antidepressants

Fluoxetine is the SSRI of choice in children and adolescents

Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for the
majority of patients with depression.

 citalopram (although see below re: QT interval) and fluoxetine are currently the
preferred SSRIs
 sertraline is useful post myocardial infarction as there is more evidence for its safe use in
this situation than other antidepressants

13
  SSRIs should be used with caution in children and adolescents. Fluoxetine is the drug of
choice when an antidepressant is indicated

Adverse effects

 gastrointestinal symptoms are the most common side-effect

 there is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton
pump inhibitor should be prescribed if a patient is also taking a NSAID
 patients should be counselled to be vigilant for increased anxiety and agitation after
starting a SSRI
 fluoxetine and paroxetine have a higher propensity for drug interactions

Citalopram and the QT interval

 the Medicines and Healthcare products Regulatory Agency (MHRA) released a warning
on the use of citalopram in 2011
 it advised that citalopram and escitalopram are associated with dose-dependent QT
interval prolongation and should not be used in those with: congenital long QT
syndrome; known pre-existing QT interval prolongation; or in combination with other
medicines that prolong the QT interval
 the maximum daily dose is now 40 mg for adults; 20 mg for patients older than 65 years;
and 20 mg for those with hepatic impairment

Interactions

 NSAIDs: NICE guidelines advise 'do not normally offer SSRIs', but if given co-
prescribe a proton pump inhibitor
 warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering
mirtazapine
 aspirin: see above
 triptans: avoid SSRIs

Following the initiation of antidepressant therapy patients should normally be reviewed by a

doctor after 2 weeks. For patients under the age of 30 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 continue on treatment for at least 6 months after remission as this
reduces the risk of relapse.

When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not
necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.

Discontinuation symptoms

14
  increased mood change
 restlessness
 difficulty sleeping
 unsteadiness
 sweating
 gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
 paraesthesia.

Atypical antipsychotics
Clozapine - check FBC

The most important complication of clozapine therapy to exclude is agranulocytosis. Weight

gain is common in patients taking an antipsychotic
Atypical antipsychotics should now be used first-line in patients with schizophrenia,
according to 2005 NICE guidelines. The main advantage of the atypical agents is a
significant reduction in extra-pyramidal side-effects.

Adverse effects of atypical antipsychotics

 weight gain
 clozapine is associated with agranulocytosis (see below)

The Medicines and Healthcare products Regulatory Agency has issued specific warnings
when antipsychotics are used in elderly patients:

 increased risk of stroke (especially olanzapine and risperidone)

 increased risk of venous thromboembolism

Examples of atypical antipsychotics

 clozapine
 olanzapine
 risperidone
 quetiapine
 amisulpride

Clozapine, one of the first atypical agents to be developed, carries a significant risk of
agranulocytosis and full blood count monitoring is therefore essential during treatment. For
this reason clozapine should only be used in patients resistant to other antipsychotic
medication
15
Adverse effects of clozapine

 agranulocytosis (1%), neutropaenia (3%)

 reduced seizure threshold - can induce seizures in up to 3% of patients

Antipsychotics

Antipsychotics in the elderly - increased risk of stroke and venouso thrombo-embolism

Antipsychotics act as dopamine D2 receptor antagonists, blocking dopaminergic

transmission in the mesolimbic pathways. Conventional antipsychotics are associated with
problematic extrapyramidal side-effects which has led to the development of atypical
antipsychotics such as clozapine

Extrapyramidal side-effects

 Parkinsonism
 acute dystonia (e.g. torticollis, oculogyric crisis)
 akathisia (severe restlessness)
 tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may
occur in 40% of patients, may be irreversible, most common is chewing and pouting of
jaw)

The Medicines and Healthcare products Regulatory Agency has issued specific warnings
when antipsychotics are used in elderly patients:

 increased risk of stroke

 increased risk of venous thromboembolism

Other side-effects

 antimuscarinic: dry mouth, blurred vision, urinary retention, constipation

 sedation, weight gain
 raised prolactin: galactorrhoea, impaired glucose tolerance
 neuroleptic malignant syndrome: pyrexia, muscle stiffness
 reduced seizure threshold (greater with atypicals)
 prolonged QT interval (particularly haloperidol


16
 Sexual dysfunction can be caused by antipsychotic medication. As these drugs are
dopamine antagonists, they often cause high prolactin, which causes reduced libido. In
addition some antipsychotics are alpha1- adrenoreceptor antagonists which can cause
ejactulatory failure and erectile dysfunction. 

Risperidone and haloperidol are commonly associated with sexual dysfunction.

Treatment options are lowering the dose or changing to a different antipsychotic.
(Source BNF)

Antipsychotics: monitoring
The monitoring requires for patients taking antipsychotic medication are extensive. This is
on top of the clinical follow-up that such patients clearly require. The BNF advises the
following*:
Test Frequency
Full blood count (FBC), urea and  at the start of therapy
electrolytes (U&E), liver function tests  annually
(LFT)  clozapine requires much more
frequent monitoring of FBC (initially
weekly)

Lipids, weight  at the start of therapy

 at 3 months
 annually

Fasting blood glucose, prolactin  at the start of therapy

 at 6 months
 annually

Blood pressure  baseline

 frequently during dose titration

Electrocardiogram  baseline

Cardiovascular risk assessment  annually

Schizophrenia: epidemiology
Risk of developing schizophrenia

 monozygotic twin has schizophrenia = 50%

 parent has schizophrenia = 10-15%
 sibling has schizophrenia = 10%
 no relatives with schizophrenia = 1%

Schizophrenia: features
17
Schneider's first rank symptoms may be divided into auditory hallucinations, thought
disorders, passivity phenomena and delusional perceptions:

Auditory hallucinations of a specific type:

 two or more voices discussing the patient in the third person

 thought echo
 voices commenting on the patient's behaviour

Thought disorder*:

 thought insertion
 thought withdrawal
 thought broadcasting

Passivity phenomena:

 bodily sensations being controlled by external influence

 actions/impulses/feelings - experiences which are imposed on the individual or
influenced by others

Delusional perceptions

 a two stage process) where first a normal object is perceived then secondly there is a
sudden intense delusional insight into the objects meaning for the patient e.g. 'The traffic
light is green therefore I am the King'.

Other features of schizophrenia include

 impaired insight
 incongruity/blunting of affect (inappropriate emotion for circumstances)
 decreased speech
 neologisms: made-up words
 catatonia
 negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive
pleasure), alogia (poverty of speech), avolition (poor motivation)

*occasionally referred to as thought alienation

Schizophrenia: management

18
NICE published guidelines on the management of schizophrenia in 2009.

Key points:

 oral atypical antipsychotics are first-line

 cognitive behavioural therapy should be offered to all patients
 close attention should be paid to cardiovascular risk-factor modification due to the high
rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic
medication and high smoking rates)

Schizophrenia: prognostic indicators

A gradual, rather than acute, onset is associated with a poor prognosis

Factors associated with poor prognosis

 strong family history

 gradual onset
 low IQ
 premorbid history of social withdrawal
 lack of obvious precipitant

Alzheimer's disease
Alzheimer's disease is a progressive degenerative disease of the brain accounting for the
majority of dementia seen in the UK

Genetics

 most cases are sporadic

 5% of cases are inherited as an autosomal dominant trait
 mutations in the amyloid precursor protein (chromosome 21), presenilin 1 (chromosome
14) and presenilin 2 (chromosome 1) genes are thought to cause the inherited form
 apoprotein E allele E4 - encodes a cholesterol transport protein

Pathological changes

 macroscopic: widespread cerebral atrophy, particularly involving the cortex and

hippocampus
 microscopic: cortical plaques due to deposition of type A-Beta-amyloid protein and
intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein
 biochemical: there is a deficit of acetylecholine from damage to an ascending forebrain
projection

19
Neurofibrillary tangles

 paired helical filaments are partly made from a protein called tau
 in AD are tau proteins are excessively phosphorylated

Management

 NICE now recommend the three acetylcholinesterase inhibitors (donepezil, galantamine

and rivastigmine) as options for managing mild to moderate Alzheimer's disease
 memantine (a NMDA receptor antagonist) is reserved for patients with moderate -
severe Alzheimer's

Grief reaction
It is normal for people to feel sadness and grief following the death of a loved one and this
does not necessarily need to be medicalised. However, having some understanding of the
potential stages 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.

One of the most popular models of grief divides it into 5 stages.

 Denial: this may include a feeling of numbness and also pseudohallucinations of the
deceased, both auditory and visual. Occasionally people may focus on physical objects
that remind them of their loved one or even prepare meals for them
 Anger: this is commonly directed against other family members and medical
professionals
 Bargaining
 Depression
 Acceptance

It should be noted that many patients will not go through all 5 stages.
Abnormal, or atypical, grief reactions are more likely to occur in women and if the death is
sudden and unexpected. Other risk factors include a problematic relationship before death or
if the patient has not much social support.

Features of atypical grief reactions include:

 delayed grief: sometimes said to occur when more than 2 weeks passes before grieving
begins
 prolonged grief: difficult to define. Normal grief reactions may take up to and beyond 12
months

Post-concussion syndrome

20
In post-traumatic stress disorder the onset of symptoms is usually delayed and it tends to run
a prolonged course
Post-concussion syndrome is seen after even minor head trauma
Typical features include

 headache
 fatigue
 anxiety/depression
 dizziness

Anorexia nervosa
Anorexia nervosa is the most common cause of admissions to child and adolescent
psychiatric wards.

Epidemiology

 90% of patients are female

 predominately affects teenage and young-adult females
 prevalence of between 1:100 and 1:200

Diagnosis (based on the DSM-IV criteria)

 person chooses not to eat - BMI < 17.5 kg/m^2, or < 85% of that expected
 intense fear of being obese
 disturbance of weight perception
 amenorrhoea = 3 consecutive cycles

The prognosis of patients with anorexia nervosa remains poor. Up to 10% of patients will
eventually die because of the disorder

Anorexia nervosa: features

Anorexia features

 most things low

 G's and C's raised: growth hormone, glucose, salivary glands, cortisol, cholesterol,
carotinaemia

Anorexia nervosa is associated with a number of characteristic clinical signs and

physiological abnormalities which are summarised below

Features

 reduced body mass index

 bradycardia
21
  hypotension
 enlarged salivary glands

Physiological abnormalities

 hypokalaemia
 low FSH, LH, oestrogens and testosterone
 raised cortisol and growth hormone
 impaired glucose tolerance
 hypercholesterolaemia
 hypercarotinaemia
 low T3

Alcohol - problem drinking: management

NICE recommend 'For people who misuse alcohol and have comorbid depression or anxiety
disorders, treat the alcohol misuse first as this may lead to significant improvement in the
depression and anxiety. If depression or anxiety continues after 3 to 4 weeks of abstinence
from alcohol, undertake an assessment of the depression or anxiety and consider referral
and treatment in line with the relevant NICE guideline for the particular disorder.'

Nutritional support

 SIGN recommends alcoholic patients should receive oral thiamine if their 'diet may be
deficient'

Drugs used

 benzodiazepines for acute withdrawal

 disulfram: promotes abstinence - alcohol intake causes severe reaction due to inhibition
of acetaldehyde dehydrogenase. Patients should be aware that even small amounts of
alcohol (e.g. In perfumes, foods, mouthwashes) can produce severe symptoms.
Contraindications include ischaemic heart disease and psychosis
 acamprosate: reduces craving, known to be a weak antagonist of NMDA receptors,
improves abstinence in placebo controlled trials

 clomipramine should be offered

Alcohol - problem drinking: detection and assessment

Screening

AUDIT
22
  10 item questionnaire, please see the link
 takes about 2-3 minutes to complete
 has been shown to be superior to CAGE and biochemical markers for predicting alcohol
problems
 minimum score = 0, maximum score = 40
 a score of 8 or more in men, and 7 or more in women, indicates a strong likelihood of
hazardous or harmful alcohol consumption
 a score of 15 or more in men, and 13 or more in women, is likely to indicate alcohol
dependence
 AUDIT-C is an abbreviated form consisting of 3 questions

FAST

 4 item questionnaire
 minimum score = 0, maximum score = 16
 the score for hazardous drinking is 3 or more
 with relation to the first question 1 drink = 1/2 pint of beer or 1 glass of wine or 1 single
spirits
 if the answer to the first question is 'never' then the patient is not misusing alcohol
 if the response to the first question is 'Weekly' or 'Daily or almost daily' then the patient
is a hazardous, harmful or dependent drinker. Over 50% of people will be classified
using just this one question

1 MEN: How often do you have EIGHT or more drinks on one occasion?
WOMEN: How often do you have SIX or more drinks on one occasion?
2 How often during the last year have you been unable to remember what happened
the night before because you
had been drinking?
3 How often during the last year have you failed to do what was normally expected of
you because of drinking?
4 In the last year has a relative or friend, or a doctor or other health worker been
concerned about your drinking or
suggested you cut down?

CAGE

 well known but recent research has questioned it's value as a screening test
 two or more positive answers is generally considered a 'positive' result

C Have you ever felt you should Cut down on your drinking?
A Have people Annoyed you by criticising your drinking?
G Have you ever felt bad or Guilty about your drinking?
E Have you ever had a drink in the morning to get rid of a hangover (Eye opener)?

23
Diagnosis

ICD-10 definition - 3 or more needed

 compulsion to drink
 difficulties controlling alcohol consumption
 physiological withdrawal
 tolerance to alcohol
 neglect of alternative activities to drinking

persistent use of alcohol despite evidence of harm.

Alcohol withdrawal

Mechanism

 chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar
to benzodiazepines) and inhibits NMDA-type glutamate receptors
 alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA
and increased NMDA glutamate transmission)

Features

 symptoms start at 6-12 hours

 peak incidence of seizures at 36 hours
 peak incidence of delirium tremens is at 72 hours

Management

 benzodiazepines
 carbamazepine also effective in treatment of alcohol withdrawal
 phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures.

Suicide
The following is a list of suicide risk factors taken from the Preventing suicide in
England paper from the Government:

 Gender - males are three times as likely to take their own life as females
 Age - people aged 35-49 years now have the highest suicide rate
 Mental illness
 The treatment and care they receive after making a suicide attempt
 Physically disabling or painful illnesses including chronic pain
 Alcohol and drug misuse
 The loss of a job
 Debt
24
  Living alone - becoming socially excluded or isolated;
 Bereavement
 Family breakdown and conflict including divorce and family mental health problems
 Imprisonment

Factors associated with risk of suicide following an episode of deliberate self harm:

 efforts to avoid discovery

 planning
 leaving a written note
 final acts such as sorting out finances
 violent method

These are in addition to standard risk factors for suicide

 male sex
 advancing age
 unemployment or social isolation
 divorced or widowed
 history of mental illness (depression, schizophrenia)
 history of deliberate self harm
 alcohol or drug misuse.

25
 studies show that any history of deliberate self harm significantly increases the risk of
suicide. Employment is a protective factor.
St John's Wort
St John's Wort is a known inducer of the P450 system

Overview

 shown to be as effective as tricyclic antidepressants in the treatment of mild-moderate

depression
 mechanism: thought to be similar to SSRIs (although noradrenaline uptake inhibition
has also been demonstrated)
 NICE advise 'may be of benefit in mild or moderate depression, but its use should not be
prescribed or advised because of uncertainty about appropriate doses, variation in the
nature of preparations, and potential serious interactions with other drugs'

Adverse effects

 profile in trials similar to placebo

 can cause serotonin syndrome
 inducer of P450 system, therefore decreased levels of drugs such as warfarin,
ciclosporin. The effectiveness of the combined oral contraceptive pill may also be
reduced

Seasonal affective disorder

Seasonal affective disorder (SAD) describes depression which occurs predominately around
the winter months. Bright light therapy has been shown to be more effective than placebo for
patients with SAD
Neuroleptic malignant syndrome
Neuroleptic malignant syndrome is typically seen in patients who have just commenced
treatment. Renal failure may occur secondary to rhabdomyolysis

Neuroleptic malignant syndrome is a rare but dangerous condition seen in patients taking
antipsychotic medication. It carries a mortality of up to 10% and can also occur with atypical
antipsychotics. It may also occur with dopaminergic drugs (such as levodopa) for Parkinson's
disease, usually when the drug is suddenly stopped or the dose reduced.

Features

 more common in young male patients

 onset usually in first 10 days of treatment or after increasing dose
 pyrexia
 rigidity
 tachycardia
26
  A raised creatine kinase is present in most cases. A leukocytosis may also be seen

Management

 stop antipsychotic
 IV fluids to prevent renal failure
 dantrolene* may be useful in selected cases
 bromocriptine, dopamine agonist, may also be used

*thought to work by decreasing excitation-contraction coupling in skeletal muscle by

binding to the ryanodine receptor, and decreasing the release of calcium from the
sarcoplasmic reticulum.

Benzodiazepines
Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric
acid (GABA) by increasing the frequency of chloride channels. They therefore are used for
a variety of purposes:

 sedation
 hypnotic
 anxiolytic
 anticonvulsant
 muscle relaxant

Patients commonly develop a tolerance and 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 period of time (2-4 weeks).

The BNF gives advice on how to withdraw a benzodiazepine. The dose should be withdrawn
in steps of about 1/8 (range 1/10 to 1/4) of the daily dose every fortnight. A suggested
protocol for patients experiencing difficulty is given:

 switch patients to the equivalent dose of diazepam

 reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg
 time needed for withdrawal can vary from 4 weeks to a year or more

If patients withdraw too quickly from benzodiazepines they may experience benzodiazepine
withdrawal syndrome, a condition very similar to alcohol withdrawal syndrome. This may
occur up to 3 weeks after stopping a long-acting drug. Features include:

 insomnia
 irritability
 anxiety
27
  tremor
 loss of appetite
 tinnitus
 perspiration
 perceptual disturbances
 seizures

Electroconvulsive therapy
Although electroconvulsive therapy, by definition, causes a controlled seizure there is no
increased risk of epilepsy in the long-term.
Electroconvulsive therapy is a useful treatment option for patients with severe depression
refractory to medication or those with psychotic symptoms. The only absolute
contraindications is raised intracranial pressure.

Short-term side-effects

 headache
 nausea
 short term memory impairment
 memory loss of events prior to ECT
 cardiac arrhythmia

Long-term side-effects

 some patients report impaired memory

Bulimia nervosa

 referral to secondary care

 high-dose fluoxetine

Clinical Knowledge Summaries recommend referring all people with an eating disorder to
secondary care. This is most important for patients with anorexia nervosa where there is a
significant associated morbidity and mortality. However, services across the UK are
sometimes patchy and treatment within primary care may be appropriate
Bulimia nervosa is a type of eating disorder characterised by episodes of binge eating
followed by intentional vomiting

Management

 referral for specialist care is appropriate in all cases

 cognitive behaviour therapy (CBT) is currently consider first-line treatment
 interpersonal psychotherapy is also used but takes much longer than CBT

28
  pharmacological treatments have a limited role - a trial of high-dose fluoxetine is
currently licensed for bulimia but long-term data is lacking

Whilst arm cutting may sometimes be characterised as attention-seeking or 'releasing the

pain' studies show that any history of deliberate self harm significantly increases the risk of
suicide. Employment is a protective factor.

Attention Deficit Hyperactivity Disorder

NICE recommend a normal balanced diet unless a food diary has demonstrated a link
between behaviour and certain foods.
Attention Deficit Hyperactivity Disorder (ADHD) is characterised by

 extreme restlessness
 poor concentration
 uncontrolled activity
 impulsiveness

ADHD is diagnosed in about 5% of American children, In the UK, where the term
hyperkinetic syndrome is preferred, only 0.1% of children are diagnosed with the condition.
The male:female ratio is 5:1

Management

 specialist assessment is required in all cases

 unless a food diary has shown a link between diet and behaviour there is no basis for
recommending the avoidance of artificial colourings or the use of fatty acid supplements
 methylphenidate (Ritalin) - side-effects include abdominal pain, nausea, dyspepsia.
Growth is not usually affected but it is advised to monitor growth during treatment every
6 months. The BNF also advises monitoring for psychiatric disorders and checking
blood pressure/pulse every 6 months
 atomoxetine

Acute confusional state

A 75-year-old lady is admitted in an acute confusional state secondary to a urinary tract

infection. Despite antibiotic therapy, reassurance and environmental modification she
remains agitated. You are considering prescribing haloperidol. Which one of the following
conditions may be significantly worsened if haloperidol is prescribed?

All antipsychotics may worsen the symptoms of Parkinson's disease and should be avoided if
possible. A small dose of oral lorazepam may be an alternative in such a situation.

Acute confusional state is also known as delirium or acute organic brain syndrome. It affects
up to 30% of elderly patients admitted to hospital.

29
Features - wide variety of presentations

 memory disturbances (loss of short term > long term)

 may be very agitated or withdrawn
 disorientation
 mood change
 visual hallucinations
 disturbed sleep cycle
 poor attention

Management

 treatment of underlying cause

 modification of environment
 the 2006 Royal College of Physicians publication 'The prevention, diagnosis and
management of delirium in older people: concise guidelines' recommended haloperidol
0.5 mg as the first-line sedative
 the 2010 NICE delirium guidelines advocate the use of haloperidol or olanzapine

Aphonia
Psychogenic aphonia is considered to be a form of conversion disorder.
Aphonia describes the inability to speak. Causes include:

 recurrent laryngeal nerve palsy (e.g. Post-thyroidectomy)

 psychogenic

Parkinson's disease: features

Rigidity and rest tremor are uncommon in drug-induced parkinsonism. Masked face and
flexed posture can be seen in both conditions. Bilateral symptoms are more common in drug-
induced parkinsonism. Restlessness of arms and legs (akathisia) is a common side-effect of
antipsychotics.

Parkinson's disease is a progressive neurodegenerative condition caused by degeneration of

dopaminergic neurons in the substantia nigra.. This results in a classic triad of features:
bradykinesia, tremor and rigidity. The symptoms of Parkinson's disease are characteristically
asymmetrical.

Epidemiology

 around twice as common in men

 mean age of diagnosis is 65 years

Bradykinesia

30
  poverty of movement also seen, sometimes referred to as hypokinesia
 short, shuffling steps with reduced arm swinging
 difficulty in initiating movement

Tremor

 most marked at rest, 3-5 Hz

 worse when stressed or tired
 typically 'pill-rolling', i.e. in the thumb and index finger

Rigidity

 lead pipe
 cogwheel: due to superimposed tremor

Other characteristic features

 mask-like facies
 flexed posture
 micrographia
 drooling of saliva
 psychiatric features: depression is the most common feature (affects about 40%);
dementia, psychosis and sleep disturbances may also occur
 impaired olfaction
 REM sleep behaviour disorder

Drug-induced parkinsonism has slightly different features to Parkinson's disease:

 motor symptoms are generally rapid onset and bilateral

 rigidity and rest tremor are uncommon

Therapeutic drug monitoring

Lithium

 range = 0.4 - 1.0 mmol/l

 take 12 hrs post-dose

Ciclosporin

 trough levels immediately before dose

Digoxin

 at least 6 hrs post-dose

31
Phenytoin

trough levels immediately before.

Drug monitoring

Once established on treatment patients who are taking lithium should have their renal
function monitored every 6 months. 

The following paragraph is from the NICE guidelines 2014 - Bipolar disorder: the
assessment and management of bipolar disorder in adults, children and young people in
primary and secondary care

'Measure the person's weight or BMI and arrange tests for urea and electrolytes including
calcium, estimated glomerular filtration rate (eGFR) and thyroid function every 6 months,
and more often if there is evidence of impaired renal or thyroid function, raised calcium
levels or an increase in mood symptoms that might be related to impaired thyroid function.

The tables below show the monitoring requirements of common drugs. It should be noted
these are basic guidelines and do not relate to monitoring effectiveness of treatment (e.g.
Checking lipids for patients taking a statin)

Cardiovascular drugs

Main monitoring
Drug parameters Details of monitoring

Statins LFT LFTs at baseline, 3 months and 12

months

ACE U&E U&E prior to treatment

inhibitors U&E after increasing dose
U&E at least annually

Amiodarone TFT, LFT TFT, LFT, U&E, CXR prior to

treatment
TFT, LFT every 6 months

32
Rheumatology drugs

Main
monitoring
Drug parameters Details of monitoring

Methotrexate FBC, LFT, The Committee on Safety of Medicines

U&E recommend 'FBC and renal and LFTs before
starting treatment and repeated weekly until
therapy stabilised, thereafter patients should be
monitored every 2-3 months'

Azathioprine FBC, LFT FBC, LFT before treatment

FBC weekly for the first 4 weeks
FBC, LFT every 3 months

Neuropsychiatric drugs

Main monitoring
Drug parameters Details of monitoring

Lithium Lithium level, TFT, TFT, U&E prior to treatment

U&E Lithium levels weekly until stabilised
then every 3 months
TFT, U&E every 6 months

Sodium LFT LFT, FBC before treatment

valproate LFT 'periodically' during first 6 months

Endocrine drugs

Drug Main monitoring parameters Details of monitoring

Glitazones LFT LFT before treatment

33
Drug Main monitoring parameters Details of monitoring

LFT 'regularly' during treatment

Charles Bonnet syndrome

Charles Bonnet syndrome (CBS) is characterised by persistent or recurrent complex

hallucinations (usually visual or auditory), occurring in clear consciousness. This is generally
against a background of visual impairment (although visual impairment is not mandatory for
a diagnosis). Insight is usually preserved. This must occur in the absence of any other
significant neuropsychiatric disturbance.

Risk factors include:

 Advanced age
 Peripheral visual impairment
 Social isolation
 Sensory deprivation
 Early cognitive impairment

CBS is equally distributed between sexes and does not show any familial predisposition. The
most common ophthalmological conditions associated with this syndrome are age-related
macular degeneration, followed by glaucoma and cataract.

Well-formed complex visual hallucinations are thought to occur in 10-30 percent of

individuals with severe visual impairment. Prevalence of CBS in visually impaired people is
thought to be between 11 and 15 percent.

Around a third find the hallucinations themselves an unpleasant or disturbing experience. In

a large study published in the British Journal of Ophthalmology, 88% had CBS for 2 years or
more, resolving in only 25% at 9 years (thus it is not generally a transient experience).
Sectioning under the Mental Health Act
This is used for someone over the age of 16 years who will not be admitted voluntarily.
Patients who are under the influence of alcohol or drugs are specifically excluded

Section 2
34
  admission for assessment for up to 28 days, not renewable
 an Approved Mental Health Professional (AMHP) or rarely the nearest relative (NR)
makes the application on the recommendation of 2 doctors
 one of the doctors should be 'approved' under Section 12(2) of the Mental Health Act
(usually a consultant psychiatrist)

Section 3

 admission for treatment for up to 6 months, can be renewed

 AMHP along with 2 doctors, both of which must have seen the patient within the past 24
hours

Section 4

 72 hour assessment order

 used as an emergency, when a section 2 would involve an unacceptable delay
 a GP and an AMHP or NR
 often changed to a section 2 upon arrival at hospital

Section 5(2)

 a patient who is a voluntary patient in hospital can be legally detained by a doctor for 72
hours

Section 5(4)

 similar to section 5(2), allows a nurse to detain a patient who is voluntarily in hospital
for 6 hours

Section 17a

 Supervised Community Treatment (Community Treatment Order)

Section 135

 a court order can be obtained to allow the police to break into a property to remove a
person to a Place of Safety

Section 136

 someone found in a public place who appears to have a mental disorder can be taken by
the police to a Place of Safety

The police have a legal duty to ensure a sectioned patient is taken to a place of safety.
Metformin would not cause hypoglycaemia.

What would you do if the patient was inside her own home? The police could not
remove the patient using a Section 136. One option would be for the police to obtain a
35
 Section 135 to allow them to enter the patient's property, although this could take time.
Regardless, the police should be contacted given the patient's apparent mental health
disorder and threats of violence - it is difficult to conceive of a practical way forward
without involving them.
Dementia
Neuroimaging is required to diagnose dementia
NICE do not recommend routine testing for syphilis and HIV in Dementia.

Dementia is thought to affect over 700,000 people in the UK and accounts for a large amount
of health and social care spending. The most common cause of dementia in the UK is
Alzheimer's disease followed by vascular and Lewy body dementia. These conditions may
coexist.

Features

 diagnosis can be difficult and is often delayed

 the mini-mental state examination is widely used. A score of 24 or less out of 30
suggests dementia

Management

 in primary care a blood screen is usually sent to exclude reversible causes (e.g.
Hypothyroidism). NICE recommend the following tests: FBC, U&E, LFTs, calcium,
glucose, TFTs, vitamin B12 and folate levels. Patients are now commonly referred on to
old-age psychiatrists (sometimes working in 'memory clinics').
 in secondary care neuroimaging is performed* to exclude other reversible conditions
(e.g. Subdural haematoma, normal pressure hydrocephalus) and help provide
information on aetiology to guide prognosis and management

*in the 2011 NICE guidelines structural imaging was said to be essential in the
investigation of dementia.

Delirium vs. dementia

Factors favouring delirium over dementia

 impairment of consciousness
 fluctuation of symptoms: worse at night, periods of normality
 abnormal perception (e.g. illusions and hallucinations)
 agitation, fear
 delusions

36
Janet is a 93 year old lady with severe dementia. She has been relatively settled over the past
two years with a gradual decline in cognition. The nursing home call to say she has been
more aggressive, swearing and hitting staff over the past month and asks for a review. What
would be the most appropriate management

Janet appears to have developed a decline in her behaviour in the short-term, and although
this may be a progression of her dementia it is vital to ensure that any physical causes
including delirium are considered. This is also vital due to the high mortality risk associates
 .with delirium if left untreated
The Alzheimer's Society suggests the following causes to be considered when investigating
:challenging behaviour in the elderly

 Infections including chest infections and urinary tract infections (UTIs)

 Existing injuries such as cuts or bruises
 Constipation
 Pain
 Existing conditions such as arthritis
 Being in an uncomfortable position or being moved in an uncomfortable way
 Toenails or fingernails that need cutting
. Toothache, earache or problems with dentures

OCD
The following guidance is from the 'Obsessive-compulsive disorder: Core interventions in
the treatment of obsessive-compulsive disorder and body dysmorphic disorder' 2005 NICE
Guidance.

For adults with OCD, the initial pharmacological treatment should be one of the following
SSRIs: fluoxetine, fluvoxamine, paroxetine, sertraline or citalopram.

Pathophysiology

 some research suggest childhood group A beta-haemolytic streptococcal infection may

have a role

Associations

 depression (30%)
 schizophrenia (3%)
 Sydenham's chorea
 Tourette's syndrome
 anorexia nervosa.

:ICD-10 Diagnostic Criteria for Depression

37
The correct answer is 2 weeks. The ICD-10 criteria for depressive illness are as follows:

In typical depressive episodes, individuals usually suffer from depressed mood, loss of
interest in things you would normally find pleasure in (anhedonia), and reduced energy
levels (anergia). Other common symptoms include:

 Reduced concentration and attention

 Decreased self-esteem and confidence
 Feelings of guilt and unworthiness
 Bleak and pessimistic views of the future
 Ideas or acts of self-harm or suicide
 Disturbed sleep
 Diminished appetite and weight loss
 Psychomotor agitation or retardation
 Marked loss of libido

Diagnostic criteria for Depressive Episodes

Mild Depressive Episode:

 At least 2 of the main 3 symptoms of depression, and at least two of the other
symptoms, should be present for a definite diagnosis. None of the symptoms should be
present to an intense degree
 Minimum duration of the whole episode is about 2 weeks
 Individuals may be distressed by symptoms, but should be able to continue work and
social functioning

Moderate Depressive Episode:

 At least 2 of the main 3 symptoms of depression, and at least three (and preferably
four) of the other symptoms, should be present for a definite diagnosis
 Minimum duration of the whole episode is about 2 weeks
 Individuals will usually have considerable difficulty continuing with normal work and
social functioning

Severe Depressive Episode:

 All three of the typical symptoms should be present, plus at least four other symptoms,
some of which should be of severe intensity

38
  The minimum duration of the whole episode should last at least 2 weeks, but if the
symptoms are particularly severe then it may be appropriate to make an early
diagnosis
 Can also experience psychotic symptoms with severe depressive episodes
 Individuals show severe distress and/or agitation

MY Notes

:Agranulocytosis caused by Clonazipine

Agranulocytosis is a condition where an individual has a severe leukopaenia (decreased

white blood cell count), most commonly caused by a neutropaenia (decreased neutrophil
count). This makes individuals extremely susceptible to serious infections due to their
immunosuppression.

Individuals with agranulocytosis can present as asymptomatic, or with clinical features such
as fever, rigors and sore throat. Infection of any organ can be rapid, e.g. pneumona, urinary
tract infection, and sepsis may also develop.

There are a lot of drugs that can cause agranulocytosis. These include:

 Antipsychotics (predominantly Clozapine)

 Antiepileptics
 Antithyroid Drugs (Carbimazole)
 Antibiotics (Penicillin, Chloramphenicol and Co-Trimoxazole)
 Cytotoxic Drugs
 Gold
 NSAIDs (Naproxen, Indomethacin)
 Allopurinol
 Mirtazapine

The diagnosis is made using a full blood count, which will show an absolute neutrophil
count < 500 cells/mm³. The main treatment of agranulocytosis consists of the removal of the
offending drug, in this case clozapine.

Drugs increasing Lithium Toxicity:

Diuretics, ACE-inhibitors and angiotensin II receptor antagonists may cause lithium toxicity.
The BNF advises that neurotoxicity may be increased when lithium is given with diltiazem
or verapamil but there is no significant interaction with amlodipine. Alpha-blockers are not
listed as interacting with lithium but they would not be first-line treatment for hypertension.

The NICE hypertension guidelines suggest amlodipine wouldn't be a bad first choice, even if
we ignore his lithium treatment.
39
** Fluoxetine is the SSRI of choice in children and adolescents
** Alcohol withdrawal

 symptoms: 6-12 hours

 seizures: 36 hours
 delirium tremens: 72 hours

40
41