High yield

Psychiatry
Utkarsh Ojha
Imperial College School of Medicine

Utkarsh Ojha
Introduction

I am delighted that you have chosen this guide to aid you in your psychiatry revision. The following guide is
tailored for year 5 MBBS students at Imperial College London. However, I believe the information presented
here is useful for all students revising psychiatry.

With the introduction of Sofia at Imperial College School of Medicine, it has become much more straightforward
to understand which conditions you are expected to learn and are examinable. The information presented in
this guide is all high yield for the specialties exam and the most important topics are covered and explained.

Here, I begin by providing an overview of useful resources. Next, the information is presented as categorized
on sofia under “Skills”, “Professionalism” and “Knowledge”.

I have used a plethora of medical textbooks, peer reviewed papers and websites to provide the most accurate
and detailed explanations of the pharmacology of psychiatric drugs and treatments.

What follows next is a list of conditions and treatments from Sofia and the relevant information you are required
to learn for them. The notes are made using Rapid Psychiatry by Oakley and Malik. Each condition is presented
in a specific format, as seen on Sofia:

• Definition

• Aetiology

• Epidemiology

• Signs on physical examination

• Investigations

• Management

• Complications

• Prognosis

I suggest the best way to use this guide is to print it off, bind it (this can be done from your university library,
for Imperial students please visit: http://www.imperial.ac.uk/finance/purchasing/recommended-suppliers/by-
product-type/thesis-binding-and-printing/) and annotate as you read PRN Psychiatry (Stringer et al), Crash
Course in Psychiatry (Marwick and Birrell) and any other specialties question book.

Please don’t use this guide solely on its own, as attending firms, clerking patients and learning on the job itself
is paramount and the best way to study and understand clinical specialties.

I wish you all the best of luck in your revision and exams.

Utkarsh Ojha, BSc (Hons)

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Useful resources

Information books

Websites

Passmed: https://passmedicine.com/

Royal College of Psychiatrist: http://www.rcpsych.ac.uk/discoverpsychiatry/acareerinpsychiatry.aspx

Revise psych: http://www.revisepsych.co.uk/

MRCPsych: http://www.trickcyclists.co.uk/

Videos

CrashCourse (Psychology):

https://www.youtube.com/watch?v=vo4pMVb0R6M&list=PL8dPuuaLjXtOPRKzVLY0jJY-uHOH9KVU6

EMQ books

Psychiatry finals: EMQs and OSCEs (Iwata and Ali)

Masterpass. SBAs and EMQs in Psychiatry for Medical students (Sharma)

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ICD-10 classification of mental and behavioral disorders

The Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems
(ICD-10) is a medical classification list by the World Health Organization (WHO). In chapter V it includes a
detailed classification of over 300 mental and behavioral disorders. Its publication follows extensive field-testing
by more than 100 clinical and research centers in 40 countries.

There are two main versions available: Clinical Description and Diagnostic Guidelines and Diagnostic
Criteria for Research. The former provides clinical descriptions detailing the principal signs and symptoms of
each disorder, together with other important but less specific associated features, as well as comprehensive
guidelines for their diagnosis.

For more information, please refer to:

ICD-10 clinical description & diagnostic guidelines:

http://www.who.int/substance_abuse/terminology/ICD10ClinicalDiagnosis.pdf?ua=1

ICD-10 Diagnostic criteria for research:

http://www.who.int/substance_abuse/terminology/ICD10ResearchDiagnosis.pdf?ua=1

Diagnostic and Statistical Manual of Mental Disorders (DSM)

The DSM-5 is the handbook used by health care professionals in the United States and much of the world as
the authoritative guide to the diagnosis of mental disorders. DSM contains descriptions, symptoms and other
criteria for diagnosing mental disorders. The DSM was initially published in 1952. The American Psychiatric
Association (APA) recruited more than 160 of the top researchers and clinicians from around the world to
contribute to the development of the 5th edition.

The DSM-5 is a manual for assessment and diagnosis of mental disorders and does not include information
or guidelines for treatment of any disorder.

Relationship between DSM and the WHO’s ICD

DSM-5 and the ICD should be thought of as companion publications. DSM-5 contains the most up-to-date
criteria for diagnosing mental disorders, along with extensive descriptive text, providing a common language
for clinicians to communicate about their patients. The APA works closely with staff from the WHO to ensure
the two systems are maximally compatible.

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Skills
• History & Examination
• Patient Management

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History and Examination

Psychiatric history: demonstrate the ability to take, summarise and record a full psychiatric history including a
risk assessment covering risk to self, to others and that of neglect

Collateral history: demonstrate the ability to take, evaluate and integrate a collateral history as appropriate
from various sources (e.g. multidisciplinary team, GPs, families, carers, day centres, police)

Substance use history: demonstrate the ability to take, summarise and record a a comprehensive substance
use history, focusing on the extent of use, identification of problematic use (and its duration) and its impact
on psychosocial functioning and physical health

Eating disorder history: demonstrate the ability to take, summarise and record a focused eating disorder
history and assessment (incl. risk to self and that of neglect) This is covered later in “Knowledge;
Conditions and Procedures”

Forensic history: demonstrate the ability to take a forensic history (noting violent/aggressive incidents and
criminally offending behaviour)

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Taking Psychiatry History

Background Information

Establish the scene by introducing yourself, your role and confirming the patient’s name and age. Check if they
are at comfort and ok to talk to you. Reassure them everything they say is confidential within the medical team.

Presenting complaint

Ask open questions which allows the patient to talk, e.g. “What led up to you coming into hospital?” “So, have
you been having any problems recently, can you tell me about them?

NB: when reporting the presenting complaint, always use the patient’s own words. This keeps their story fresh
and stops you from misinterpreting their problem from the start. Also if the patient uses any medical or emotive
words ask them to clarify what they mean, e.g. “Doctor I think I’m manic” “Doctor, I’m going mad”.

History of presenting complaint

Build a vivid picture of exactly what happened leading up the patient coming into hospital. Use the mnemonic
NOTEPAD: Nature of problem, Onset, Triggers, Exacerbating/relieving factors, Progression (improving,
worsening or staying the same), Associated symptoms, Disability (effect on life)

The nature of the presenting complain is the form the problems takes, e.g. a worry, mood, delusion,
hallucination, physical ailment, social problem. Before finishing ask the patient “is there anything you think I
should know?”

Past psychiatric history

Ask about any contact with psychiatric services, mental health issues treated by the GP, and any times of
severe stress or depression which the patient handled alone, e.g. “Have you had any stress-related or mental
health problems before”. It is important to know when the first episode occurred, how long it lasted and whether
the patient required admission under the mental health act. Make note of any treatment they had for their
mental health condition, and any risky behavior (thoughts of self harm, suicide attempts, violence).

Past medical history

List past and present physical problems

Drug history

List the patient’s current medication, both prescribed and over the counter. Also at this point check for any
allergies.

Substance misuse

This follows on well from drug history. This should cover past and present use of illicit/recreational drugs,
cigarettes and alcohol. Take each drug individually and ask when it was first used, tracking forward from that
point. Ask about route of intake, amount used (any changes over time- increased amount over time indicates
tolerance).

Family history

Drawing a genogram can be very useful- however I doubt you’ll have time and the equipment in the PACES.

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For each relative ask about their age and occupation and any mental illnesses they suffered
e.g. “has anyone in your family suffered from stress or had to see the doctor for mental health problems”. Ask
about any physical health. If anyone in the family died and at what age and cause of death if applicable.

Personal history

“Now I would like to ask some more questions to get to know you better, let me know if it makes you feel
uncomfortable, but I assure you this will all be confidential within the medical team”

Birth and early development

• “Do you know if there were any problems with your mother’s pregnancy and your birth”
• “As far as you know, did you walk and talk at the normal ages?”

If there were any problems, find out the details, including: Prematurity, Labour complications/birth
trauma/ interventions, e.g. Caesarean section, time in special care/being unable to go home
immediately, need for pediatric follow up

Family background and early childhood

Record periods of serious or lengthy illness, separation from parents, and neglect or abuse.

• What was it like growing up in your family?

• What were your parents and siblings like? How did you get on with them?
• Was early childhood a happy or a difficult time?

Education

This section gives a lot of information about personality and social abilities, and some idea about
intelligence. You may want to make a note of the age and level of achievement on leaving education

• What was school like for you?

• Did you have any problems at school?

Also make note of more specific issues:

• What were your friendships like?

• Where you shy or outgoing?
• Were you bullied or anything traumatic ever happen?
• Were you ever in trouble for bullying or taunting?
• Did you get on with teachers?
• Were you near the top, middle, or bottom of the class?

Occupation

List patient’s jobs chronologically, including durations and reasons for leaving
(promotion/resignation/dismissal).

Psychosexual/ relationships

List relationship chronologically. Ask about:

• Age of first intercourse and number of sexual partners

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 • Long-term/ brief
• Heterosexual/homosexual/bisexual
• Quality of relationship (abusive, supportive)
• Marriages or civil partnerships

If currently in a relationship, ask about duration, partner’s name and occupation, and whether they
are content.

Forensic history

• “Have you ever been in trouble with the police?”

• “Have your ever broke the law being caught”
• Find out whether offences were committed while unwell

Premorbid personality

What was the person like before they became unwell?

• Before all this happened, what kind of person were you?

• How would your friends describe you?
• How do you cope under pressure?
• Do you have any strong religious or moral views?

Social history

The social history is the patient’s current day-to-day situation. It should cover:

• Housing (type, rented/owned, flatmates)

• Finances, including benefits
• Current employment/training
• Activities or interests
• Carer’s duties
• Social network

Collateral history

Can be useful- especially if patient can’t or won’t talk to you. Can give a good indication of premorbid
personality. (sources may include: MDT, GPs, families, carers, day centers, police) NB: People lie!

Mental state examination: demonstrate the ability to perform, summarise and record a detailed mental state
examination (e.g. AMTS, MMSE, frontal lobe testing), assess cognition and capacity and interpret clinical
findings (recognising and differentiating typical and atypical presentations of common psychopathology giving
due consideration to age, developmental stage, disability, normal stress response, life events and socio-
cultural background)

Mental state examination (MSE)

The past psychopathology belongs in the history; if it is present it goes in the MSE. There are 7 sections:
Appearance and behavior, Speech, Mood, Thought, Perception, Cognition, Insight.

NB: Most of the MSE is covered during the history, don’t repeat things from the history in the MSE just for the
sake of doing it- it doesn’t look slick at all.

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Appearance and behavior

You should be able to describe the patient so well that anyone who walks onto the wards can spot your patient
easily.

General appearance

Age, gender, build, ethnicity

• Hair, make-up, clothing

• Physical problems (e.g. hemiparesis, hearing aid, dehydration)
• Scars, piercings, tattoos
• Self-care: well-kempt or self-neglecting (e.g stained clothing, malodorous)

Body language

• Facial expression, e.g. smiling, scowling, fearful

• Eye contact, e.g. responsive and appropriate/ staring/ downcast/ avoidant/ distracted
• Posture, e.g. hunched shoulders in depression
• Activity level: overactive or underactive?
• Describe what they are doing, e.g. “pacing restlessly around the room”
• Movements may seem slowed (motor retardation) in depression, or speeded up in mania

Other movements

• Extrapyramidal side effects are caused by antipsychotics, e.g.

o Akathisia: unpleasant restlessness causing agitation
o Parkinsonism: Shuffling gait, ‘pill rolling’ tremor, slowed movements, and rigidity
o Tradive dyskinesia: rhythmic involuntary movements of the face, limbs, and trunk, e.g
grimacing, chewing
• Repeated movements
o Mannerism: appear goal-directed (e.g. sweeping hair from face)
o Stereotypies: not goal-directed (e.g. flicking fingers at air)
o Tics: Purposeless, involuntary movements involving a group of muscles (e.g blinking)
o Compulsions: rituals the patients feels compelled to undertake (e.g. hand-washing)
o Catatonic symptoms: Extreme negativism, lack of response to stimuli

Rapport

Is the patient withdrawn and cold; polite and friendly; rude or Guarded (suspicious or deliberately
withholding information); disinhibited (e.g. removing their clothing).

Other- Responding to hallucinations? Smells, e.g. body odour, urine, acholol

Speech

• Rate: fast, slow, or normal

• Volume: Loud, soft, or normal, e.g. shouting, whispering
• Tone: The emotional quality of speech, e.g. sarcastic, angry, glum, calm, neutral.
• Flow: Speech may be spontaneous, or only when prompted, hesitant, or with long pauses before answers;
garrulous and uninterruptible.

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Also note:

• Dysarthria- Impaired articulation.

• Dysphasia- Impaired ability to comprehend or generate speech
• Clang association- rhyming connections (e.g bang, sang)
• Punning (playing on words with the same sounds, but different meanings, e.g. tire, tyre)
• Neologisms (made-up words)
• Pressure of speech reflects underlying pressure of thought- will be hard to interrupt the patient
• Poverty of speech reflect underlying poverty of thought- typically seen in depression
• Thought block- Complete emptying off the mind of thoughts, shown in speech by a sudden halt.
Sometimes seen in Schizophrenia.
• Circumstantial speech- reflecting underlying over-inclusive thinking which adds excessive details and
subclauses to every sentence
• Flight of ideas- Patient’s ideas jump from one to another but may eventually come back to the pointr-
though they may be linked normally (i.e via rhymes, puns, sometimes new ideas arise from distractions in
the room)
• Derailment/Loosening of associations/Knight’s move thinking- Thoughts start at one place but end at
a completely unrelated place to the original route.
• Perseveration- Thoughts remain in one place. E.g “hello sir, what’s your name” Patient: “Morgan”. “How
old are you, sir?” patient “Morgan”, “Do you have children, sir?”, Patient: “Morgan”

Mood and affect

Mood is the pervasive experience of the patient. Mood can be divided into:

• Subjective: how the patient says they are feeling, recorded in their own words.
• Objective: what you think about the patient’s emotional state, e.g. low, elated, irritable, anxious,
perplexed etc. Mood can be Labile: fluctuating between extremes

Affect is assessed by observing patients’ posture, facial expression, emotional reactivity and speech. There
are two components to consider:

• Appropriateness or congruity: If a patient with schizophrenia is smiling and happy yet saying she is
feeling suicidal- this shows Incongruous affect
• Range of emotional expressivity: Within normal range, Blunted/flat (reduction in normal intensity)

Thoughts

Thought can be divided into: Thought form and Thought content

Thought form

Are the patient’s thought in order or disordered? Disordered thinking includes circumstantial and
tangential thinking, loosening of association, neologisms, flight of ideas, thought blocking.

Tips from a consultant: “If by the end of the patient’s sentence(s) you have no idea what they’re talking
about then that’s usually disorganized thoughts”

Thought content

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 The thought content is the patient’s beliefs and ideas. Important to asses if the
patient has any delusions and what kind

Delusions: Fixed belief, held despite rational argument or evidence to the contrary. It cannot be fully
explained by the patient’s cultural, religious, or educational background.

• Primary delusions: these arise completely out of the blue in someone without prior mental health problems
• Secondary delusions: follow another abnormal experience, such as an abnormal mood or hallucination
(e.g. hearing a disembodies voice, a patient then believes they are being stalked)
• Systematized delusions: occur when delusions grow and build on each other, connecting into a delusional
system. Delusions can be categorized by theme.
o Grandiose delusions: exaggerated beliefs of being special or important (e.g. being rich and
famous)
o Persecutory delusions: beliefs that others are trying to persecute or cause harm
o Nihilistic delusions: beliefs regarding the absence of something vitally important (e.g. the patient
is dead, homeless, or their organs are rotting)
o Delusions of reference: beliefs that ordinary objects, events, or other people’s actions have a
special meaning or significance for the patient (e.g. news reports related to them, objects are
arranged as a ‘sign’)
o Delusions of control: beliefs that outside forces control the patient in some way.
o Passivity: the belief that movement, sensation, emotion, or impulse are controlled by an outside
force, e.g. as if someone has a remote control for the patient’s actions
o Delusion of thought interference: these occur against the person’s will and feel like an invasion
of privacy:
§ Thought Withdrawal: the belief that someone/something is removing thoughts from the
patient’s head
§ Thought insertion: the belief that thoughts are being placed into the patient’s mind, so that
they are thinking someone else’s thoughts
§ Thought broadcasting: the belief that thoughts are broadcast to others. NB: this is different
from people guessing someone’s thoughts by reading their body language
o Delusions of jealousy: The patient thinks their partner is cheating, usually affects men
o Amorous (erotomanic) delusions: the belief that someone is in love with the patient. More
common in women
o Delusions of guilt: The belief of having committed an awful sin or crime
o Hypochondriacal delusions: patient believes they have an illness.
Perception

Perception relates to the patient’s sensory world. All five modalities should be explored. If they are normal,
then say “No illusions or hallucinations in any modality”

Illusions: misperception of a stimulus. Can occur if patient is drowsy, extremely emotional, can also
occur in delirium.

Hallucinations: a perception in the absence of a stimulus. Check all modalities: Auditory, Visual, Touch
(tactile- superficial feelings, deep- internal feelings e.g. feeling of heart being twisted), Olfactory,
Gustatory (e.g. tasting ‘poison’ in food)

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 Voices may be in the second person (addressing the patient directly as ‘you’) or the
third person (‘he/she’). Those particularly suggesting schizophrenia discuss or argue about the patient,
giving a running commentary of the patient’s actions.

Hallucinations can be normal, they can occur (briefly) when waking (Hypnopompic hallucinations) or
on falling asleep (Hypnagogic hallucination), or fowling a bereavement. Auditory hallucinations are
the most common; visual hallucinations suggest organic illness (e.g. brain tumour).

Depersonalization: the person feels unreal: detached, numb, emotionally distant “do you ever feel as
if you aren’t quite real?”

Derealization: the world feels unreal, e.g “like a film set”. Ask: “do you ever feel as if the world around
you is not quire real?”

Both depersonalization and derealization occur in many disorders, especially anxiety states.

Cognition

Cognition is the umbrella term covering thinking and remembering. It includes orientation, attention,
concentration, and memory, all of which are affected by the patient’s level of consciousness. Any concern
should lead to formal testing with the Mini mental State Examination (MMSE)

Insight

Refers to the patient’s own understanding and beliefs about their condition- there are different levels of
awareness that something is wrong.

• Awareness that behavior or symptoms are seen as abnormal by others: “Do you think your friends
would say you’re different to usual”
• Agreement that the behavior or symptoms are abnormal: Do you think there’s anything wrong with
you at the moment? Is this normal for you? How are you different to usual?
• Understanding that problems are due to mental illness: “What do you think is causing this? Could
it be stress or mental illness?
• Agreement that illness requires treatment: “do you think that the doctor’s treatment will help? Would
you be happy to try the treatment?”

Abbreviated Mental Test Score (AMTS)

AMTS is a quick way to assess confusion. Patient is scored out of ten, with (variations of) the following
questions:

1. How old are you?

2. What time is it? (to the nearest hour)
3. What Year is it?
4. Where are we?
5. I want you to remember this address: 42 West Register Street. Ask to recall later on in test.
6. Do you know who I am? Do you know who that is [point to nurse / family member]?
7. Do you know who the Prime Minister / President is?
8. What is your date of birth?
9. Can you tell me when the second world war ended / the first moon landing was / other memorable
date?
10. Can you count down from 20 to 1?

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Each question is worth 1 point. A score of <6 is significant for dementia or delirium.

Mini Mental State Examination

The test is marked out of 30. It is used to assess cognitive impairment – most commonly as a screening tool
for dementia, especially Alzheimer’s. It can also be used to asses a patient’s progress through a phase of
cognitive impairment, for example to assess the progression of Alzheimer’s disease. A typical patient, without
treatment, will have a declining score of about 3-4 points / year.

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Patient Management

Investigation: generate a plan for investigation of common psychiatric clinical cases (inc. taking into account
any existing physical and/or mental health co-morbidities and medications) and interpret their results

Management plan: demonstrate the ability to generate a management plan for clinical cases integrating risk
assessment as well as predisposing, precipitating and perpetuating factors within a bio-psycho-social
framework and manage any co-morbid mental health or physical disorders (making use of all available
statutory and non-statutory resources)

Differential diagnosis: interpret findings from the history, examination and investigations to formulate a
differential diagnosis in a patient presenting with psychiatric symptoms

Organic disorder: recognise the neuropsychiatric manifestations of organic disorders

Bio-psycho-social model: Aetiology and Management plans

• Biological treatments: antidepressants, antipsychotics, ECT, psychosurgery

• Psychological: Counselling, CBT, family therapy, couple therapy
• Social: See patient as a part of a wider system- work, family, society

Aetiology

Management

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Referral pathways: recognise referral pathways to and within psychiatric services and
between primary and secondary care services for patients of all ages

The Pathway

Psychological therapies: demonstrate the ability to explain the basic principles psychological therapies (incl.
cognitive behaviour therapy, computer aided CBT, family therapy, psychodynamic therapy, interpersonal
therapy, psychoeducation, counselling, motivational interviewing and group therapy) to patients

CBT

Cognitive behavioural therapy (CBT) is a talking therapy that can help you manage your problems by changing
the way you feel, think and act. CBT aims to find practical ways to help you deal with problems in a more
positive way by breaking them down into smaller parts.

Cognitive means the way we think about things. Cognitive therapy helps us to understand our thoughts so that
we can think about things more positively. Behavioural therapy helps us to change any of our actions that
cause us harm or are unhelpful (for example, staying at home all the time because of a fear of something
outside). Cognitive and behavioural therapies are often used together because how we behave often depends
on how we think about certain things or situations.

Computer aided CBT

CCBT is any computing system that aids cognitive–behavioural therapy by using patient input to make at least
some computations and treatment decisions. This definition excludes video conferencing and ordinary
telephone and electronic mail consultations, chat rooms and support groups, which expedite communication
and overcome the tyranny of distance but do not delegate any treatment tasks to a computer or other electronic

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device. It excludes, too, the electronic delivery of educational materials and electronic
recording of clinical state or behaviour where those allow no more interaction than do paper
leaflets and workbooks.

Computer-aided therapy may be delivered on a range of computing devices, such as stand-alone personal
computers, internet-linked computers, palmtops and personal digital assistants, telephone interactive voice
response systems, gaming machines, CD–ROMs, DVDs, cellphones and virtual reality devices.

Much CCBT aids the patient and clinician by taking over tasks and therapist time required in usual care. Used
in business and industry, sport and education for employee and student training. It allows for flexible, on-the-
spot training.

Family therapy

Family therapy is a type of psychological counseling (psychotherapy) that can help family members improve
communication and resolve conflicts.

Family therapy can help you improve troubled relationships with your partner, children or other family
members. You may address specific issues such as marital or financial problems, conflict between parents
and children, or the impact of substance abuse or a mental illness on the entire family.

Sessions typically take about 50 minutes to an hour. Family therapy is often short term — generally about 12
sessions. During family therapy, you can:

• Examine your family's ability to solve problems and express thoughts and emotions in a productive
manner
• Explore family roles, rules and behavior patterns to identify issues that contribute to conflict — and
ways to work through these issues
• Identify your family's strengths, such as caring for one another, and weaknesses, such as difficulty
confiding in one another

Psychodynamic therapy

Therapeutic process which helps patients understand and resolve their problems by increasing awareness of
their inner world and its influence over relationships both past and present. It differs from most other therapies
in aiming for deep seated change in personality and emotional development.

The therapist encourages the client to talk about the emotions they are feeling and helping the client to identify
recurring patterns in their thoughts, emotions, and behaviors. He or she will aid the client in finding the
significance of these patterns and discovering the effects they exert upon the client.

One of the most important roles of the therapist is to probe the client’s past. Discussion of the client’s childhood
and early life experiences will likely take up a large portion of psychodynamic sessions, as this form of therapy
assumes these experiences have a significant impact on the client’s current issues.

The therapist may also observe how the client interacts within the therapeutic relationship and add their own
insight on the client’s relationship habits to the discussion. Psychodynamic theory holds that how the client
acts in the relationship with the therapist usually mirrors how they act in other relationships, such as with a
parent or other important adult from their childhood/

In general, the therapist’s role is to aid the client in connecting the dots between their past experiences and
their current problems, and leveraging their internal resources to address these problems.

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Interpersonal therapy

interpersonal therapy is a structured, time-limited therapy that typically works intensely on established
interpersonal issues. The underlying belief of interpersonal therapy is that psychological symptoms (such as
depression) are often a response to difficulties we have interacting with others. The resulting symptoms can
then also affect the quality of these interactions, causing a cycle. The thought process behind the therapy is
that once a person is capable of interacting more effectively with those around them, the psychological
symptoms can improve.

The first few sessions of interpersonal therapy are typically used as a means of assessment - allowing the
therapist to gain a better understanding of what is concerning you and what you hope to gain from the therapy.
Together with your therapist you will then have the opportunity to identify any interpersonal issues you want to
address and rank them in order of importance. It will then be a case of working through the key issues raised.

The next few sessions will look to address these concerns in order to understand them better, learn how to
make adjustments and apply these adjustments outside of your therapy sessions. To help this process your
therapist will offer support in a number of ways, including the following:

• clarification of your issues

• communication analysis
• supportive listening.

Psychoeducation

The goal of Psychoeducation is to help people better understand (and become accustomed to living with)
mental health conditions.
All of the following may constitute psychoeducation:

• A therapist explaining to a person in therapy the ways a mental health condition might impact function
• A psychiatrist describing how a prescribed medication can counteract symptoms of a mental health
condition
• A psychiatric hospital providing support and education to family members of those receiving treatment
• Formal classes designed to educate the population about both specific mental health conditions and
mental health in general
• Classroom behavior management assistance for students diagnosed with behavioral concerns
• Self-help and support groups designed to encourage those diagnosed with mental health concerns to
share strategies and information with one another.

Counselling

Counselling is usually brief in duration and is recommended for patients with minor mental health or
interpersonal difficulties, or for those experiencing stressful life circumstances (e.g. grief counselling for
bereavement). Counselling helps patients utilize their own strengths, with the therapist being reflective and
empathic. The provision of relevant information and advice is also considered to be counselling, which is
undertaken by healthcare professionals of all specialties. In person-centred counselling, the therapist assumes
an empathic and reflective role, allowing patients to discover their own insights using the basic principle that
the client ultimately knows best. Problem solving counselling is more directive and focused as patients are
actively assisted in finding solutions to their problems.

Motivational interviewing

The motivational interview is defined as “a client-centered, directive method for enhancing intrinsic motivation
to change by exploring and resolving ambivalence” The clinician practices motivational interviewing with five
general principles in mind:

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 1. Express empathy through reflective listening.
2. Develop discrepancy between clients' goals or values and their current behavior.
3. Avoid argument and direct confrontation.
4. Adjust to client resistance rather than opposing it directly.
5. Support self-efficacy and optimism.

Group Therapy

Most groups meet once weekly for an hour and consist of one or two therapists and about 5–10 patients.
Therapy can run from months (CBT orientation) to years (psychodynamic orientation). Group therapy allows
patients (and therapists) the opportunity to observe and analyse their psychological and behavioural
responses to other members of the group in a ‘safe’ social setting.

Miscellaneous

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Lifestyle management: recognise the importance of lifestyle on mental health and its role
in management plans incl. sleep hygiene, nutrition, social interaction, fitness, activity,
education, occupation, and family and community involvement

Mental Health impact: evaluate the impact of mental health illness on the individual, their family and those
around them

Mental Health & Society: recognise the relevance of family, culture, spirituality, society and the individual’s
relationship with these factors; and the positive and negative effects of these on their mental health with an
appreciation of the current meaning of ‘mental illness’ to individuals and society

Factors affecting Mental Health: evaluate information about family/personal relationships and other relevant
social factors (including work, education and finances) and their impact on an individual patient, which may
involve gaining information from other sources and recognise their role in the presentation, course and
management of mental health illness using a bio-pscyho-social framework

Appreciate these components

Excellent review on Lifestyle and Mental health: https://www.apa.org/pubs/journals/releases/amp-66-7-

579.pdf

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Acutely unwell patients: demonstrate the ability to assess and manage psychiatric
emergencies which may occur in psychiatric, general medical or other settings. In particular,
be able to conduct a risk assessment (risk to self and others, incl. from abuse), act appropriately based on this
risk assessment; and to be competent in the management of acute behavioural disturbance

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Agitated patient: demonstrate the ability to utilise deesclation strategies to manage an
agitated patient, being mindful of routinely taking sensible precautions to protect your own
safety

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Psychiatric disorder in chronic illness: recognise and generate a management plan for the
mental health needs and problems of people with long-term medical conditions

Child psychiatric disorder: generate a management plan for childhood psychiatric disorder having considered
contributory predisposing, precipitating, perpetuating and protective/resilience factors and and outline how
developmental stage may have influenced behaviour and presentation

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Child/Adolescent centered care: explain the influence of the family unit on child
development, the impact of parental mental health on the individual and the importance of
considering their functioning in school as well as within their family

Child and Family Assessment: Perform an assessment of a child and family, considering who you might
involve; where you might assess; what observations you would make on the family; how you would evaluate
the family’s perspectives, ideas, concerns and beliefs

Mentally disordered offenders: recognise that mentally disordered offenders may have particular treatment
needs

In the UK, 66% of prisoners have personality disorder, 45% are dependent on illicit drugs, 30% are dependent
on alcohol, and 45% have neurotic disorder (depression or anxiety). Around 10% of prisoners may have some
form of psychotic disorder, and between 20-30% are thought to have intellectual disability.

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Diagnostic overshadowing: recognise 'diagnostic overshadowing' (symptoms are attributed
to a mental health, instead of a potentially treatable medical cause)

Diagnostic overshadowing described the tendency to attribute everything to the learning disability itself.
Changes in behaviour, mental state, or ability are dismissed, despite usually indicating physical or mental
illness in people without a learning disability. For example, dismissing someone with a learning difficulty who
cries and stops eating because: “That’s the way these people are sometimes”- when appendicitis is the
problem

Psychiatric disorder in old age: recognise how the physical, social and psychological consequences of aging,
sensory impairment and late life events may contribute to the presentation of psychiatric disorders in old age

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Professionalism
• Personal & Professional Development
• Communication, Partnership & Teamwork
• Medical Ethics & Law
• Safety, Quality & Management

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Personal & Professional Development

Mental Health significance: demonstrate an awareness that illnesses of the brain/mind are of equal
importance as illnesses of other parts of the body and view psychiatric patients as being as deserving of the
same high standard of medical care as patients with purely physical illness

Attitudes to Mental Health: demonstrate awareness of how your own attitudes to patients with mental health
problems might influence your approach to such patients

Reflection & Seeking help: demonstrate the ability to reflect on how working in mental health settings may
impact upon your own health and that of colleagues and understand the importance of seeking professional
help if you develop mental health problems and know how/where to access this help

Professional boundaries: demonstrate awareness of professional boundaries in relation to patients in a

mental health setting

Nothing to make notes on here- develop these skills and appreciate the impact of mental health in the
community by attending firms.

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Communication, Partnership & Teamwork

Mental Health communication: demonstrate your effective communication skills with patients of all ages and
backgrounds in a mental health setting (incl. patients with dementia, learning difficulties and their carers)

Supporting patients: demonstrate awareness for the need of additional enquiry, appropriate investigations
and careful examination of those unable to verbalise or describe symptoms (patients with learning disability,
cognitive impairment)

Nothing to make notes on. Think holistically about patients using Bio/Psycho/Socio model and understand
the importance of collateral histories.

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Medical Ethics and Law

Mental Capacity Act: demonstrate awareness of the sequential process for assessing capacity to make
decisions under the Mental Capacity Act 2005

Mental Capacity Act: demonstrate awareness of the principles underlying the Mental Capacity Act (MCA) –
(e.g. principle of presumption of capacity, decision and time specific nature of capacity, determining 'best
interests', least restrictive alternative)

Mental capacity is the ability to make a decision. The Mental Capacity Act became law in 2005 and provides
the legal framework for:

• People who lack capacity to make decisions for themselves

• People who have capacity and want to make provisions for when they might lose capacity in the
future

Principles of mental capacity

1. Mental capacity is decision and time specific, i.e. it is incorrect to say that an individual lacks mental
capacity generally; rather, one should state that an individual does/not lack capacity to make a
specific decision at a specific time
2. An individual must always be presumed to have capacity unless proven otherwise.
3. An assessor, whilst making an assessment of mental capacity, must do everything possible to
enhance an individual’s capacity to make the decision in question
4. Every adult has a right to make their own decision, if they have mental capacity to do so
5. In cases of individuals lacking capacity, those making decisions on their behalf must do so in their
best interest

Mental Capacity Act: perform a capacity assessment in a range of common clinical mental health scenarios
in accordance with legal requirements and the GMC’s guidance

Assessment of capacity is a two-stage process and must be undertaken keeping the above principles in
mind.

• Stage I: Does the person have an impairment of mind or brain?

• Stage II: If so, does the impairment mean that the person is unable to make the decision in question
at the time it needs to be made?

To assess whether an individual is able to make the decision, one must assess their ability to
understand, retain and weight up information relevant to the decision and then communicate their
decision by any means

Lasting power of attorney (LPA)

An LPA gives the chosen person (attorney or donee) authority to make decisions that are as valid as
ones made by the person (donor) themselves. An LPA can cover:

1. Property and affairs decisions

2. Welfare decisions

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Court of Protection

This is the special court set up to deal with decision making for adults who may lack capacity to make
specific decisions for themselves

Advance decision

An advance decision enables someone aged 18 or over, while still capable, to refuse specified medical
treatment for a time in the future, when they may lack capacity to consent to or refuse that treatment

Mental Health Act: recognise situations in which requesting a Mental Health Act assessment would be
appropriate and explain the procedure for requesting one

This legislation applies to any patient with a mental disorder who needs to be detained in hospital but some
sections (37,47,48,49 and 41) are more common in the practice of forensic psychiatry due to their relation to
the court.

Criteria for detention

• In order to be detained under the Mental Health Act (MHA), a person must be determined to be suffering
from a mental disorder. There is no definition in the legislation of ‘mental disorder’ other than that is a
disorder of disability of the mind. However, detention solely on the basis of dependence on alcohol or
drugs is not permitted
• It is also necessary to decide that the nature or degree of the mental disorder warrants detention in
hospital (for assessment or treatment depending on the section used)
• It must be necessary for the health and safety of the patient or the protection of others that the patient
be detained in hospital.
• For detention under section 3 or related treatment sections; appropriate medical treatment must be
available

Mental Health Act roles: explain the roles and responsibilities of the professionals involved in a mental
health act assessment

Professionals involved

The following professions may be involved in the process of detention under the MHA, depending on the
section under which the patient is detained:

• Section 12(2) approved doctor, who has been certified to have special expertise in mental health. Their
role is to provide a medical recommendation for detention
• In most cases a second medical recommendation is required and this must be independent of the first
and ideally someone who has prior knowledge of the patient (patient’s GP). If that is not possible, a
second section 12(2) approved doctor’s recommendation is usually used.
• Approved mental health practitioner (AMHP) is a role that can be taken on by mental health
professionals. AMHPs have received specific training relating to the application of the MHA. In relation
to civil sections (section 2,3,4 and Community Treatment Orders), AHMPs make the application for
detention to the hospital based on the medical recommendations and other relevant information.
• The responsible clinician (RC) is the approved clinician in charge of the patient’s care.

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Mental Health Act (Section 5-2): define the criteria that must be met for a patient to be
placed on Section 5(2) of the Mental Health Act 1983 as well as it's powers and limitations and demonstrate
how to complete a section 5(2) form

• Requires a recommendation by the RC or their nominated deputy who may be a doctor or an

approved clinician (often the on-call psychiatric trainee)
• Maximum duration 72 hours during which a full MHA assessment should take place

Mental Health Act (Section 2 & 3): recognise the criteria that must be met for a patient to be placed on
Section 2 or 3; the powers of detention and treatment given; the process by which a patient appeals against
it

Section 2
• Requires two medical recommendations (as described above) and the recommendation of an AMHP
• Maximum duration 28 days
• Is for assessment of a mental disorder (and treatment if required)

Section 3
• Requires two medical recommendations and the recommendation of an AMHP
• Initial duration is 6 months and can be extended by a further 6 months and then for periods of 1 year
at a time
• Is for treatment of a mental disorder

Mental health review tribunals

• Patients may appeal their detention under the MHA by appealing for a tribunal
• The tribunal consists of an independent panel of a psychiatrist (usually a consultant), a lawyer and a lay
person
• They may decide to discharge the patient from hospital if they are satisfied that the criteria for detention
are not met.

Community treatment orders

• Community Treatment Orders may be used for patients who have been detained under section 3 or 37
• They allow patients to live in the community whilst still being subject to the powers of the MHA for the
purpose of receiving medical treatment and they can be recalled to be hospital.

Mental Health Act (Section 135, 136): recognise the powers of access and detention given by Section 135
and 136
• Section 135: magistrate can issue a warrant allowing entry to private premises to search for and
remove patients thought to need urgent medical attention
• Section 136: police can detain people whom they believe to be mentally disordered in a public place
to a place of safety for up to 72 hours.
• Section 5(4): Nurses’ holding power for inpatients that lasts for up to 6 hours.
• Section 4: Emergency section of up to 72 hours requiring only one medical recommendation and
application by an AHMP
• Section 17 leave: Leave from the hospital for patients detained under the MHA that must be
approved by the RC

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Compulsory vs Autonomy: demonstrate awareness of the ethical issues raised by compulsory detention and
treatment versus the principle of 'autonomy'

Confidentiality & Consent: demonstrate the ability to comply with principles of confidentiality and consent
when taking collateral histories

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Safety, Quality and Management

Risk & Safeguarding: critique what may constitute risk to self (suicide, self harm and/or neglect, engaging in
high risk behaviour) and risk to and from others (incl. knowledge of safeguarding children and vulnerable
adults)

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Deliberate self-harm

Definition: Intentional self-inflicted injury/harm without fatal outcome.

Aetiology: ‘Cry for help’- to obtain relief, to escape a situation, to seek attention or to make someone feel
guilty, Impulsivity, poor coping strategies, self-punishment, failed suicide attempt

Association/Risk factors: Single/divorced, Lower social classes, previous history of child abuse,
unemployment, recent stressful event, e.g. loss of loved one, being in trouble with the law, borderline
personality disorder, depression, substance misuse

Epidemiology: Incidence of 3/1000 in the UK. More prevalent in lower social classes and those living in
crowded urban areas. More common in women and those under 35 years.

History: focus on obtaining a clear account of events and intentions in order to undertake a risk assessment
of future risk of self-harm and suicide.

Indications of serious suicidal intent

• A planned and premeditated attempt, e.g “I have been collecting the packets of paracetamol for
weeks”
• Attempt carried out in isolation and precautions taken to avoid discovery, e.g. “I locked my door so
nobody could get in”
• Final acts in anticipation of death, “I had written suicide notes and posted them to family/friends”
• Violent and dangerous methods
• Person thought the act would be final and irreversible
• They didn’t seek help after the act
• Person regrets surviving the event
• Numerous previous attempts

Examination: Mental state examination may reveal psychiatric disorder, which is of crucial importance in
determining future risk and should be suitable manage once identified

Investigations: None specifically

Managements: Treat as medically appropriate, full assessment, treat underlying psych disorder,

Complications: Unintentional suicide, suicide

Prognosis: One percent will commit suicide within the next 2 years.

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Suicide

Definition: Intentional self-inflicted death. Not all suicide attempts result in death.

Aetiology:

• Psychiatric disorder (90% of those who commit suicide have a psych condition)
o Depression (15% of patients commit suicide)
o Schizophrenia (10% of patients commit suicide)
o Substance misuse
o Personality disorder
o Anorexia nervosa
• Medical disorders- chronic pain and cancer patients
• Biochemical abnormalities- studies of CSF and brain show reduced 5-HIAA
• Social factors- loss of shared values and reduced social support

Association/ Risk factors:

• Previous deliberate self-harm

• Age- young men and elderly are at higher risk
• Sex M>F
• Loss of events (bereavement)
• Unemployment
• Living alone
• Single, divorced and widowed

Epidemiology: 1 in 10,000 per year in England and Wales. Highest rates in elderly, though rates rising in
young men.

Prevention:

• Individual level
o Detection of people at risk of psychiatric disorders
o Effective management of psychiatric disorders
• Population level
o Reduce ease (smaller packets of paracetamol)
o Provide support services (e.g. Samaritans)
o Reduce stressors (e.g. reduce unemployment)
o Reduce stigma of mental health (e.g. mental health campaigns with MIND)

Patient safety: demonstrate the ability to act safely towards patients giving due consideration to the potential
to do psychological harm to patients, incl. by providing untrained/unsupervised psychotherapeutic
interventions and fostering inappropriate doctor-patient attachments

Stigmatisation: demonstrate the ability to understand how patients’ opportunities may be affected by
stigmatisation of mental illness and demonstrate sensitivity to the concerns of patients and their families
about such stigmatisation

Nothing to make notes one- Do this by practicing PACES

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Knowledge
• Clinical Pharmacology & Therapeutics
• Conditions & Procedures

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Clinical pharmacology and therapeutics

Biological psychotropic medication: list the indications, contraindications, mechanism of action, side effects,
monitoring and adherence concerns for common biological psychotropic medication incl. antidepressants,
antipsychotics, mood stabilisers, sedative/hypnotics and medications for dementia

Antidepressants

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 Class of Examples Mechanism Indication Side-effects Contraindication Prescribing notes
antidepressants of actions

Selective • Citalopram Selective • Depressive illness GI: nausea, vomiting, • Mania- use with • Usually given
serotonin • Fluoxetine presynaptic (treatment of anoerxia, weight loss, caution in bipolar once a day
reuptake • Paroxetine blockade of prophylaxis in diarrhea disorder • Used as first line
inhibitor (SSRI) • Sertaline serotonin recurrent treatment for
reuptake episodes) Sexual: Low libido, depression
pumps • Anxiety (GAD, delayed orgasm • May take 2
panic disorder) weeks for any
• Bulimia effect and 6
(fluoxetine) Other: Headache, weeks for full
• OCD anxiety, sleep effect
• PTSD disturbance, restless • Withdrawal
symptoms,
especially with
paroxetine
• May cause initial
suicidal ideation
(especially with
citalopram in
younger adults)
Tricyclic • Amitriptyline Presynaptic • Depression Antimuscarinic: dry • Recent MI • Given in divided
antidepressants • Iofepramine blockade of • OCD(clomipramin mouth, blurred vision, • Arrhythmias doses or a single
(TCA) • Clomipramine both e) constipation, urinary • Severe liver dose at bedtime
• Imipramine noradrenaline • Neuropathic pain retention disease • May take 2
and serotonin (amitriptyline) • Mania- use with weeks before any
reuptake • Nocturnal Drowsiness caution with effect and 6
pumps (to a enuresis in bipolar disorder weeks for full
lesser extent children CVS: Postural effects
dopamine) (imipramine) hypotension (due to • May cause
also blockade reduced peripheral drowsiness-
of muscarinic, vasoconstriction), advise patients to
histaminergic arrhythmias avoid driving
and α- • AVOID IF HIGH
adrenergic Toxic in overdose: SUICIDE RISK!
receptors cardiotoxic, As lethal in
respiratory failure, overdose

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 seizures, convulsions, (lofepramine is
coma safest TCA in
overdose)
Monoamine • Phenelzine Non-selective • Refractory/atypical • Postural • Mania-use with • Patients must
oxidase • Moclobemide and depression hypotension caution in carry a card
inhibitors (MOAI) • Tranylcypromine irreversible • Antimuscarinic: bipolar patients indicating they
Isocarboxazid inhibition of dry mouth, blurred
• • Hepatic are taking MAOI
monoamine vision, urinary
oxidase A and impairment and must be
retention,
B constipation • Cerebrovascular educated and
• Increased disease given written
appetite and • Phaeo information
weight gain about diet
• Hepatoxicity • Foods to avoid:
• Hpyertensive cheese, non-
crisis: due to fresh fish, meat,
interaction poultry, broad
between MAOIs beans, Marmite,
and tyramine- Bovril and Oxo,
containing foods. acohol
Release of NA
causes • MAOIs should
tachycardia, be prescribed at
hypertension and least 1 week
vasoconstriction. after cessation
May lead to of other
intracerebral or antidepressants
subarachnoid • Other
haemorrhage. antidepressants
• Serotonin should not be
syndrome
prescribed until
(occurs because
MAOI ↑ 5-HT)- 2 weeks after
neuromuscular discontinuing
Hyperactivity, MAOIs
Autonomic
stimulation and
Agitation.
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 Serotonin- • Venlafaxine Presynaptic • Generalised • Constipation • High risk of • Can be given
noradrenaline blockade of anxiety disorder • Nausea cardiac once daily in a
reuptake both arrhythmia modified-
• Dizziness
inhibitor (SNRI) noradrenaline
• Sleep • Uncontrolled release
and serotonin
reuptake disturbances hypertension preparation
pumps (also • Hypertension • Pregnancy • Should be used
dopamine in as a second-
high doses) line treatment
but with under specialist
negligible supervision
effects on • Requires
muscarinic, monitoring of
histaminergic
BP
or α-
adrenergic
receptors
Noradrenergic • Mirtazapine Presynaptic • Depression • Increased • Don’t give it to • Given at
and specific alpha 2 appetite and patients with bedtimes as it
serotonergic receptor weight gain Hypersensitivity aids sleep
antidepressants blockade
• Oedema • Avoid patients • Few
(NaSSA) (results in
increased • Sedation on MAOIs antimuscarinic
release of side effects and
noradrenaline so can be
and serotonin useful in elderly
from patients
presynaptic
neurons)

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Antipsychotics

Mechanism of actions

The primary mechanism of action of all antipsychotics, with the

possible exception of clozapine, is antagonism of dopamine D2
receptors in the mesolimbic dopamine pathway. Clozapine is a
comparatively weak D2 antagonist but has a high affinity for
serotonin type 2 receptors (5-HT2) an D4 receptors, among
many other receptor targets.

Typical antipsychotics

These are older drugs, such as chlorpromazine, haloperidol and depot preparations like flupentixol decanoate.
They tend to cause distressing extrapyramidal side effects (EPSEs) at normal treatment doses. Despite this
they are still widely used because they are effective, cheap and provide depot options. Depots are long-acting
injections that are useful for patients who have difficulties taking daily tablets

Atypical antipsychotics

These cause fewer EPSEs and generally don’t increase prolactin levels. All atypical antipsychotics block
dopamine receptors, but they also block serotonin 5-HT2 receptors. Examples include: olanzapine, risperidone,
quetiapine, aripiprazole, amisulpride, and clozapine. Resperidone is available as depot injection

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 Class of Examples Indication Side-effects Contraindication Prescribing notes
Antipsychotics
Typical • Phenothiazine: • Schizophrenia EPSEs: • Monitor of BP,
Chlorpromazine, • Other psychotic Acute dystonia: pulse ECG
fluphenazine, illnesses • Presents with grimacing, • To increase
thioridazine • Mania abnormal movements compliance, a
• Butyrophenones: • Agitation and facial spasms, long-acting depot
haloperidol, droperidol especially masseter IM injection can
• Thioxanthine: muscles. May even lead be used (e.g
flupenthixol to jaw dislocation, haloperidol
• Benzamide: sulpiride torticollis, limb rigidity and decanoate: one
altered behavior. injection every 4
• Treat with weeks)
PROCYCLIDINE 5mg IM
bolus. Then continue oral
procyclidine 8-hourly if
necessary
Parkinsonism: Tremor,
Rigidity, Bradykinesia. Treat
with procyclidine or another
antimuscarinic drug
Akathisia (restlessness):
Review medication, consider
propranolol
Tardive dyskinesia

Neuroleptic malignant
syndrome
• A rare but potentially
fatal complication of
antipsychotic
treatments
• Presents with:
hyperthermia,
fluctuating levels of

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 consciousness,
muscular rigidity,
autonomic
dysfunction with
pallor, tachycardia,
labile BP, sweating
and urinary
incontinence
• Increased WBC and
creatine
phosphokinase
• Stop antipsychotics
and provide CVS and
respiratory support
(in ITU)
• Bromocriptine and
dantrolene (post
synaptic muscle
relaxant)
• Usually lasts 5-7
days after
discontinuation of
antipsychotics

Atypical • Olanzapine • Schizophrenia • Weight gain • Use with caution in • Monitoring is

• Risperidone • Other psychotic • Postural hypotension those with CVS, recommended
• Quetiapine illnesses • Drowsiness epilepsy, and the including: weight, BP,
• Aripiprazole • Mania • EPSEs (less common) elderly ECG, Lipids,
• Amisulpride • Prophylaxis in • Diabetes Glucsoe/HbA1c,
BAD FBC, U&Es, LFTs
• Agitation
Clozapine Clozapine Treatment-resistant • Agranulocytosis (rare • Severe cardiac • Very effective
schizophrenia but fatal) disease (reduces suicide rate)
(failure to respond to • Constipation (use • Acute liver disease • Manage
two antipsychotics, laxatives) • Severe renal agranulocytosis with
al least on of which • Tachycardia (Treat with impairment regular FBC (weekly
st
as an atypical) B-blockers) • History of bone for 1 18 weeks, then
• Hypersalivation (treat marrow disorders fortnightly, then
with hyoscine) monthly)
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 • Sedation • Initiate medication as
• Hypertension inpatient
• Weight gain • Monitor: weight,
• Diabetes lipids, ECG, LFTs.
• Convulsions • If patient misses > 2
• Myocarditis days then start
treatment again with
appropriate titration of
dose

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Mood stabilisers

These drugs ‘even out’ the extreme highs of mania and profound lows of depression, although they tend to be
most effective against mania. Three main drugs include: lithium, sodium valproate, carbamazepine. The
mechanism of action is currently uncertain, although anticonvulsants may act on sodium channels or GABA,
an inhibitory neurotransmitter in the nervous system

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Mood Examples Indication Side-effects Contraindication Prescribing notes
Stabilisers
Carbamazepine Carbamazepine • Prophylaxis in BAD • Erythematous rash may • Atrioventricular • May be useful in patients
• Treatment of occur in large number of conduction with rapid cycling (four or
epilepsy and patients and rarely may abnormalities more episodes in a year)
trigeminal neuralgia be serious (unless paced) • Pretreatment
• GI: diarrhea, nausea, • History of bone investigations: bloods-
vomiting, anorexia marrow FBC, LFT, U&Es,
• Neurological: Dizziness, depression pregnancy test, ECG
headache, ataxia, diplopia • Acute porphyria • Regular blood monitoring
• Haem: Leucopenia, • Pregnancy and is required throughout
thrombocytopenia, breastfeeding treatment to check FBC
agranulocytosis, aplastic
anaemia
• Biochem: hyponatraemia
Sodium Sodium Valproate • Mania in BAD • Nausea • Hepatic • It may be particularly
Valproate • Prophylaxis in BAD • Vomiting dysfunction useful in patients with
• Refractory • Weight gain • Porphyria rapid cycling (four or
depression • Hair loss • Pregnancy and more episodes in a year)
• Epilepsy • Hepatic failure (rare) breastfeeding • Liver function tests
• Pancreatitis should be checked
• Pancytopenia • TERATOGENIC- fetal
malformation= neural
tube defects.

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Lithium Lithium • Prophylaxis in BAD • General: weight gain, fine
• Augments tremor, muscle weakness
antidepressants in oedema, worsening acne
treatment of and psoriasis
refractory • GI: Diarrhoea, nausea,
depression vomiting, metallic taste
• Mania • Renal: nephrogenic
• Aggressive or self- diabetes insipidus,
mutilating impaired renal function
behaviours • Endocrine:
hypothyroidism,
hyperparathyroidism
• Cardiac: T-wave
inversion
• Haem: Leucocytosis
Lithium toxicity
Toxic over levels of
1.5mmol/l. antidepressants,
anticonvulsants,
antipsychotic, diuretics and
Ca channel blockers+
dehydration can precipitate.
Presentation: sever nausea,
vomiting, diarrhea,
disorientation, seizures,
drowsiness. STOP
TREATMENT+ CHECK Li
levels + FLUIDS
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• Pregnancy • Prescribed only on
• Caution in renal specialist advice
disease and • Narrow therapeutic index;
cardiac disease consider risk:benefit ratio
• Caution in (therapeutic range =
conditions 0.6-1.0mmol/l) increased
causing sodium side effects above
imbalance such 1.2mmol/l. Risk of toxic
as Addison’s effects about 1.5mmol/l.
disease • Need pretreatment
investigations: medication
review (NSAIDs and
ACEi interact), blood
tests: FBC, U&E, thyroid
screen, pregnancy test,
ECG
• Investigations during
treatment: lithium plasma
levels (every 3 months
after dose has stabilized),
regular monitoring of
FBC, U&Es, Ca and TFT
• Avoid women of child
bearing age.
Anxiolytic and Hypnotic drugs

A hypnotic drug is on that induces sleep. An anxiolytic/sedative drug is on that reduces anxiety. However, an
anxiolytic drug can induce sleep if given in high doses and hypnotic drugs can have a calming effect in lower
doses. Most important drugs in this group are Benzodiazepines (Oxazepam, Temazepam, Lorazepam,
Chlordiazepoxide, Diazepam), and ‘Z” drugs (Zaleplon, Zolpidem, Zopiclone).

Mechanism of action

Benzodiazepines potentiate the action of GABA, the main inhibitory neurotransmitter in the brain. They bind
to specific benzodiazepine receptors on the GABAA receptor complex, which results in an increased affinity
of the complex for GABA, and so an increased flow of chloride ions into the cell. This hyperpolarizes the
post-synaptic membrane and reduces neuronal excitability.

Z-drugs are a group of nonbenzodiazepine drugs with similar effects to benzodiazepines. They are believed
to modulate benzodiazepine specific subunit sites, as specific agonists of the GABAA receptors.

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Anxiolytic/Hypnotic Examples Indication Side-effects Contraindication Prescribing notes
Anxiolytic • Diazepam, • For short-term • Drowsiness • Respiratory depression • Care with alcohol and
(Benzodiazepine) Nitrazepam relief of sever • Paradoxical • Severe hepatic other minor tranquillizers
(prolonged anxiety agitation and impairment as they enhance the
action) • Insomnia aggression (benzodiazepines are sedative effect
• Temazepam, (hypnotic effect) • Confusion metabolized in liver, so • Flumazenil is a
Lorazepam • Alcohol • Dependence and accumulation of active benzodiazepine
(shorter action) withdrawl tolerance with metabolites can occur) antagonist that can be
• Status prolonged use given as an antidote in
epilepticus • Withdrawal overdose
(diazepam) syndrome after
• Premedication prolonged use:
before minor insomnia, anxiety,
surgery loss of appetite
and weight,
tremor, sweating,
perceptual
disturbances,
transfer patient to
equivalent daily
dose of diazepam
and withdraw in
gradual steps
Hypnotics (Z-drugs) • Zopiclone • Short-term • GI disturbances • Obstructive sleep • Before prescribing
• Zolpidem treatment of • Headache apnoea hypnotics, alternatives
• Zaleplon insomnia • Dependence • Respiratory failure methods should be tried,
• Memory • Myasthenia gravis e.g advice about sleep
disturbances • Pregnancy/breastfeeding hygiene
• Alcohol/drug abuse • Do it for short term (up to
• Hepatic/renal impairment 4 weeks)

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 • Effects of alcohol are
enhanced
• Drowsiness may persist
and can impair skilled
tasks, e.g driving

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Medication for Dementia

Acetylcholinesterase inhibitors

The symptoms associated with dementia are believed to be related to lack of acetylcholine in the brain,
which is responsible for sending messages between brain cells.

Acetylcholinesterase inhibitors: donepezil, galantamine, rivastigmine.

Mechanism of actions

Acetylcholinesterase inhibitors work by increasing amount of acetylcholine in the brain. These also benefit in
vascular dementia, though the evidence is less strong.

Memantine

The theory goes that excess glutamate (acting on NMDA receptor) leads to excitoxicity and cell death. The
appropriate amount of glutamate facilitates learning and storage of long-term receptors via NMDA receptors.
Excessive glutatmate causes excess calcium influx leading to excitoxicity. So a drug which modulates the
NMDA receptor may be of benefit in dementia.

Mechanism of actions

Memantine, an N-methyl-D-aspartate (NMDA) receptor antagonist, reduces excitotxic damage by blocking

NMDA receptors, preventing calcium influx.

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Dementia medication Examples Indication Side-effects Contraindication Prescribing notes
Acetylcholinesterase • Donepezil • Mild to moderate • GI: nausea, • Renal impairment • Start with the lowest
inhibitors • Galantamine dementia related vomiting, gastric (galantamine) dose and increase
• Rivastigmine to Alzheimer’s and duodenal gradually whilst
disease ulcers, GI • Caution in monitoring for side
• Mild to moderate hemorrhages cardiac disease effects
dementia related • CVS: dizziness, and those with • With
to Parkinson’s syncope, susceptibility to acetylcholinesterase
(Rivastigmine) bradycardia, AV peptic ulcers inhibitors, monitor
heart blocks, MI cognition and pulse
• Psych: regularly (at least
hallucinations, every 6 months)
agitation • Review
• Others: rash, appropriateness of
muscle cramps acetylcholinesterase
NMDA receptor • Memantine • Moderate to • Constipation • Caution in renal inhibitors in severe
antagonist severe dementia • Hypertension impairment and dementia (MMSE
related to • Seizures those with history <10)
Alzheimer’s • Dizziness of seizures
disease • Depression

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Polypharmacy: explain the complications from polypharmacy in patients with psychiatric
(and comorbid physical health) problems and prescribe psychotropic medication (if appropriate) safely,
effectively and economically

Psychiatric polypharmacy is the use of two or more psychiatric medications in the same patient, or using two
or more medications (of the same chemical class or same pharmacologic actions) to treat the same
condition.

The evidence for the added benefit of psychiatric polypharmacy is limited, there is growing evidence
regarding the increased adverse effects associated with such combinations.

Problems include:

• Cumulative toxicity
• Increased vulnerability to adverse events
• Adherence issues due to complex regimen
• Various unwanted pharmaco-dynamic and pharmaco-kinetic interactions
• High drug costs for patients
• Studies show polypharmacy is strongly associated with excessive dosing and early death
• Becomes a cycle of treating one condition, experiencing side effects, and treating the side effects,
until the patient and the clinician cannot remember where the cycle began

The review by Kukreja et al (2013) gives an excellent overall analysis of polypharmacy in psychiatry:

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3653237/

Psychoactive substances: list the mechanism of action, adverse effects and withdrawal syndromes of
common psychoactive drugs used recreationally incl. alcohol, cannabis, stimulants, opiates, sedative /
hypnotics (eg. benzodiazepines), ‘legal highs’ (NB: Sedatives/Hyponotics are covered earlier)

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Psychoactive Substance Mechanism of action Adverse effects Withdrawal syndromes

Alcohol Primary effect on CNS: • Cortical atrophy and Physical:

decreased volume of • Hand tremors
Alcohol affects GABA, both pre- and post- cerebral white matter à • Sweating
synaptically. It facilitates chloride ion influx and dementia • Nausea
therefore promotes the effects of GABA. It also • Cerebellar cortex • Visual hallucination
has an inhibitory effect pre-synaptically via the degenerationà ataxia • Seizures
generation of the neurotransmitter steroid • Wernick-korsakoff
called Alloprgenenolone, which has a syndrome Psychological:
stimulatory effect on release GABA. • Korsakoff’s psychosis • Depression
• Fatty liver • Anxiety
Alcohol may also bind to NMDA receptors and Hepatitis
• • Irritability
calcium channels to reduce function, and
• Restless
decrease the effects of excitatory
neurotransmitters. • Insomina

There is also dampening down of calcium

channel activity. NT release is calcium
dependent, therefore down-regulating calcium
entry shows a depressant effect.
Cannabis • Binds to CB1 receptors in the brain • Pychosis • Flu-like symptoms
(hippocampus, cerebellum, cerebral • Schizophrenia • Excessive sweating
cortex, basal ganglia) to produce • Profound memory loss • Decreased appetite
euphoric effects; (due to the effects on the
• CB2 receptors are found on white limbic regions of the
blood cells (immune cells) brain)
These are both G-protein coupled receptors, • Interferes with
and downstream signaling involves down psychomotor
regulation of adenylyl cyclase. Binding of performance
cannabis to its CB1 receptor results in the • Immunosuppressant
inhibition of GABA secretion, which increases
dopamine release in the nucleus accumbens

Stimulants Examples include Methylohenidate (Ritalin): • GI (nausea, vomiting, • Depression

Inhibits reuptake of dopamine and loss of appetite) • Disrupted sleep pattern
norepinephrine • Vision problems, • Fatigue
dizziness, mild headache
• Sweating, mild skin rash
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 • Weight loss

Opiates • Act via specific “opioid” receptors. • Depression of respiration • Nausea

Mediates action via µ receptors. Opioid (via action on medulla) • Muscle cramping
binds to their G-protein coupled • Nausea/Vomiting • Depression
receptorsà decrease adeynlate (stimulation of • Agitation
cyclase activity, which dampens down chemoreceptor trigger • Anxiety
the capacity of the neurone to produce zone) • Opiate cravings
cAMP, therefore cellular signaling is • GI effects
decreased • Pupillary constriction
• At the membrane level, they increase • Euphoria
the capacity for K+ to leave
(hyperpolarization), and decrease the
capacity for Ca2+ to enter the cell. This
decreases the ability to excite the
neurone and release transmitters. This
is a depressant effect.

Legal highs These are relatively new. Contains many Uncertain • Hallucination
different chemicals. Effects include: stimulants, • Psychosis • Aggression
sedatives, hallucinogens • Dizziness • Tachycardia
• Coma • Tachypnoea
• Seizures

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Pharmacology & physical dependence: list pharmacological approaches used to manage
physical dependence, incl. opiate substitute medication for opiate dependence, benzodiazepine detoxification
for alcohol withdrawal, and recognise the value of abstinence medications (eg. disulfiram and naltrexone)

Medication for alcohol dependence

85% of alcohol is metabolized in the liver, where alcohol dehydrogenase metabolizes alcohol to
Acetaldehyde. 15% of metabolism occurs in the gastrointestinal tract. Both the GI tract and liver metabolizes
Acetaldehyde to Acetic acid via Aldehyde Dehydrogenase.

Examples: Disulfiram (aversive)- inhibits aldehyde dehydrogenase, Acamprosate (anti-craving)

Indications: Maintenance of abstinence in alcohol dependence

Side Effects:

• Disulfiram: Fatigue, halitosis, reduced libido, rarely psychosis.

• Acamprosate: GI disturbances, rash

Contraindications:

• Disulfiram: Cardiac disease, hypertension, previous CVA, psychosis

• Acamprosate: Severe hepatic or renal impairment

Prescribing notes

• Consuming even a small amount of alcohol while taking disulfiram leads to a build-up of
acetaldyhyde, causing an extremely unpleasant reaction, including:
o Facial flushing
o Headache
o Palpitation
o Nausea and vomiting
• Compliance with disulfiram is increased if it is monitored by a spouse or family member
• Discontinue acamprosate if the patient returns to regular drinking

Medication for opioid dependence

Examples: Methadone, Buprenorphine (partial opioid agonist)

Indications: Substitute prescribing for opiates as a means of harm reduction

Side effects:

• Methadone: fatal overdose, QT prolongation

• Buprenorphine: Abdominal pain, fatigue, anxiety

Contraindications:

• Caution with methadone and buprenorphine in those using alcohol and benzodiazepines (increases
mortality)
• Caution with hepatic and renal impairment as this will reduce metabolism and elimination and so
increase risk of overdose

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 • Methadone is considered safer than buprenorphine in pregnancy and
breastfeeding

Prescribing notes

• Before prescribing, opioid dependence must be confirmed by positive urine results and objective
signs of withdrawal (lactorrhoea, rhinorrhea, agitation, sweating, yawning, dilated pupils)
• First 2 weeks of methadone are associated with increased death due to overdose therefore monitor
• Start initial dose low then increase gradually
• Supervised methadone consumption is recommended for 3 months
• METHDONE/BUPRENORPHINE OVERDOSE= NALOXONE

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Electroconvulsive Therapy

Define electroconvulsive therapy (ECT)

A medical procedure used under controlled conditions to treat some major

psychiatric disorder. It is generally used when an illness remains
unresponsive to other treatments or when a very rapid response is needed.
The patient is anaesthetized and given a muscle relaxant; seizures are then
induced by delivering brief electrical stimuli to the brain via scalp electrodes
Patients usually receive a total of 6-12 treatments, given twice weekly. Exact
mechanism unknown; neurotransmitter release and hormone secretion from
hypothalamus and pituitary may play a role.

Video: https://www.youtube.com/watch?v=LPBTEHYlZK4

Special preparations

• Mental Health ACT means ECT can only be given if:

o Patient understands the treatment and consents
o Patient lacks capacity to consent and second opinion approved doctor is consulted and agrees
that it doesn’t conflict with an advance directive by the patient
• Emergency ECT, can be given under section 62 while awaiting a second opinion if:
o It is immediately necessary to prevent serious suffering
o It is immediately necessary to prevent the patient causing harm to themselves/others
• Patients must have full preoperative work-up, including any necessary investigations, e.g ECG, U&E,
CXR and assessment by anesthetist
• Antiepileptic and benzodiazepines should be discontinued before treatment if possible as they increase
the seizure threshold

Special preparations: nurse to look after patient in recovery, anaesthetist to give muscle relaxant and
anesthetic, psychiatrist to administer the treatment

Summarise the indications for electroconvulsive therapy (ECT)

Predominantly used for depression, effective in older adults. Used for the following features of depression:
life-threatening poor fluid intake, strong suicidal intent, psychotic features or stupor, antidepressants are
ineffective or not tolerated.

Identify the possible complications of electroconvulsive therapy (ECT) and its management

Side effects include: confusion, headache short-term memory impairment

Complications include: anesthetic problems, status epilepticus, same risks for general anaesthetic/other
minor procedures

Contraindications: serious anaesthetic risk, raised ICP, risk of cerebral bleeding, heart disease

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Psychological Therapy

Cognitive behaviour therapy (CBT)

Define cognitive behaviour therapy

Cognitive-behavioural therapy (CBT) is structured, time limited

and problem and goal orientated. The emphasis is on current
problems rather than considering the past. Homework is
important and there is a focus on relapse prevention procedures.
CBT aims to ‘change the way you feel by changing the way you
think’. The rationale is that some distressing emotions and
behaviours are the result of cognitive errors. These cognitive
distortions relate to self, world and future (known as Beck’s
cognitive triad).

Cognitive methods

• The ABC method involves identifying the Antecedent, the Behaviour, and the Consequences. For
example, A= a panic attack in the supermarket, B= avoiding going to the supermarket, C= increasing
isolation and reinforcement of panic attack, C= increasing isolation and reinforcement of panick
attack.
• Identifying negative automatic thoughts:
o Selective abstraction: focusing on one minor aspect of the bigger picture
o All-or-nothing thinking: thinking of things in absolute terms
o Magnification/minimsation: faulty evaluation of relative significance of particular events
o Catastrophic thinking: anticipating the worse possible outcome for a situation
o Overgeneralisation: If one thing has gone wrong, all others will as well
o Arbitary interference: coming to a conclusion in the absence of any evidence to support it
• Thoughts diary to recognize connections between cognitions, emotions and behaviour
• Examine evidence for and against negative automatic thoughts and substitute other more realistic
interpretations

Behavioural methods

• Relaxation techniques
• Systematic desensitization involves constructing a hierarchy of anxiety-provoking situations and the
patient is exposed to these situations in a graded manner. The exposure can be in their imagination
or in real life or a combination of the two, depending on the availability of the phobic object. Patients
gradually habituate to the anxiety they experience and the anxiety will eventually be easier to tolerate
and subside.
• Flooding involves the patient being exposed to the phobic object without any attempt to reduce
anxiety beforehand and they are required to continue exposure until the associated anxiety reduces
• Activity scheduling (e.g. to combat poor motivation in depression)

Summarise the indications and contraindications for cognitive behaviour therapy

Good evidence for CBT from RCT results. Used for: depression, eating disorder, anxiety disorders, OCD,
PTSD, Chronic psychotic symptoms

Identify the possible complications of cognitive behaviour therapy and its management: Not much.

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Psychodynamic psychotherapy

Define psychodynamic psychotherapy

Psychodynamic theories were developed by Freud, Jung and Klein. The developmental model stresses that
early childhood experiences are crucial in shaping the personality. Treatment involves discussing past
experiences and how they have shaped the present situation. Unconscious conflicts are explored and the
insight gained aims to change patients’ maladaptive behaviour through exploration of the unconscious. There
is much emphasis on the relationship between the therapist and patient. Therapies can be offered on an
individual, couple, group and therapeutic residential community basis.

Trasnference and countertransference

Transference is the patient’s attitudes and feelings towards the therapist. It is the projection onto the therapist
of assumptions derived from a previous important relationship in the patient’s life (usually in childhood).
Transference is a very important way for a patient’s difficulties to be understood as these relationship problems
are re-enacted within therapy. Analysis and interpretation of this transference are the basis of the therapeutic
model of psychodynamic psychotherapy.

Countertransference is the therapist’s emotional response to the patient. If understood properly, it can allow
the therapist to gain valuable insight into the way the patient relates to others.

Defence mechanisms

Defence mechanisms are psychological strategies to protect people from emotional distress. They are utilized
unconsciously by everybody at some point to cope with stressful situations. Defence mechanisms are grouped
into 3 categories: mature, neurotic and immature. Mature defences have a better and more stable outcome.
Analysis of patient’s use of defence mechanisms can be a useful tool in therapy.

Mature: Altruism (meeting own needs by helping others), Humour (seeing the funny side of difficult situations),
Sublimation (modifying unacceptable desires to make them acceptable)

Neurotic: Displacement (transfer of negative feelings to someone/something else), Reaction formation

(opposite reaction to hide true feelings), Isolation (exclusion of others to protect self), Repression (thoughts
are prevented from being made conscious)

Immature: Splitting (people are either all good or all bad), Projection (internal issues are attributed to an
external cause), Acting out (unacceptable behaviour in response to conflict, e.g slef-harm), Passive aggression
(anger becomes passive resistance to co-operate)

Summarise the indications and contraindications for psychodynamic psychotherapy

Dissociative disorder, somatoform disorders, psychosexual disorders, certain personality disorders, chronic
dysthymia, recurrent depression

Identify the possible complications of psychodynamic psychotherapy and its management

Contraindicated in: Antisocial personality disorder, acute psychotic disorders, dependence on alcohol or
drugs, current depression with high suicide risk

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Family Therapy

Define family therapy

Instead of focusing on the individual patient, this form of therapy treats the family as a whole. It may include
just parents and siblings or extended family. It is hoped that improved family communication and conflict
resolution will result in an improvement in the patient’s symptoms.

Summarise the indications and contraindications for family therapy

• Couple relationship difficulties

• Child and adolescent mental health issues
• Adult mental health issues
• Child, adolescent and adult behaviour difficulties
• Parenting issues
• Illness and disability in the family
• Separation, divorce and step-family life
• Anorexia, bulimia and other eating disorders
• Fostering, adoption, kinship care and the needs of ‘looked after’ children
• Domestic violence and abuse
• Self-harm
• Drug and alcohol misuse
• The effects of trauma
• Difficulties related to ageing and other life cycle changes.

Identify the possible complications of family therapy and its management

Not much

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Conditions

Acute Stress Reaction

Define acute stress reaction (ICD-10/DSM-5)

A transient disorder of significant severity which develops in an individual without mental disorder in
response to a severe stressor.

Explain the aetiology of acute stress reaction using a bio-psycho-social approach

Occurs in response to a broad range of stressors of overwhelming importance e.g physical/sexual assault,
major road traffic accident, war.

Summarise the epidemiology of acute stress reaction with regard to age and socio-cultural background

May represent a maladaptive response to stress. There may be higher incidence in anxious patients.

Recognise the presenting symptoms of acute stress reaction and how these may differ according to age,
developmental stage and socio-cultural background

There must be a clear relationship between stressor and the symptoms. The onset of symptoms is usually
within minutes. Feelings of intense anxiety, accompanied by symptoms of autonomic arousal such as
sweating, palpitations and dry mouth. There may also be aggression, hopelessness and overactivity.

Recognise the signs of acute stress reaction on physical examination and 62omatizat how these may differ
according to age, developmental stage and socio-cultural background

Autonomic arousal- tachycardia, hypertension, sweating. Anxious, restless, may wander aimlessly or be
hyperactive. Fearful, disorientated and confused.

Identify appropriate investigations for acute stress reaction and interpret the results

Exclude other neuroses, psychoses or organic disorders producing delirium

Generate a management plan for acute stress reaction, using a bio-psycho-social approach with
consideration to risk assessment

Remove the stressor if possible. Reassurance. Short-term anxiolytics (e.g. benzodiazepines) may aid sleep
and help relieve symptoms

Identify the possible complications of acute stress reaction and its management

May progress to PTSD

Summarise the prognosis for patients with acute stress reaction. If the stressor is transient, then the
symptoms must resolve after 8 hours. If the exposure to the stressor continues then the symptoms must
continue to diminish after 48 hours. If they persist, this suggests the patient is at risk of developing PTSD.

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Adjustment disorder (including prolonged grief reaction)

Define adjustment disorder (incl. prolonged grief reaction) (ICD-10/DSM-5)

Prolonged severe abnormal response to stress beginning within 1 month of a stressful life event and lasting
no longer than 6 months.

Explain the aetiology of adjustment disorder (incl. prolonged grief reaction) using a bio-psycho-social
approach

Maladaptive psychological responses to stressful life events, e.g. divorce, being made redundant

Summarise the epidemiology of adjustment disorder (incl. prolonged grief reaction)

Any age of onset. It has been estimated that as many as 20% of patient attending a psychiatric outpatient
clinic could be diagnosed with an adjustment disorder.

Recognise the presenting symptoms of adjustment disorder (incl. prolonged grief reaction)

Precipitated by a psychological stressor. The patient has symptoms of anxiety and depression but not
severe enough to diagnose anxiety/depressive disorder. Symptoms of anxiety- irritability, increased
arousal, insomnia. Symptoms of depression- tearfulness, low mood. But no biological features of
depression (i.e decreased sleep and appetite). Adjustment to terminal illness may follow a similar course to
bereavement- shock and denial, anger, sadness, and finally acceptance.

Recognise the signs of adjustment disorder (incl. prolonged grief reaction) on physical examination

May have increased autonomic arousal (increased BP and pulse rate). Fearful, anxious, sweating. There
may be preoccupation with the event. Concentration may be poor.

Identify appropriate investigations for adjustment disorder (incl. prolonged grief reaction) and interpret the
results

None specifically

Generate a management plan for adjustment disorder (incl. prolonged grief reaction) using a bio-psycho-
social approach with consideration to risk assessment

Remove stressor if possible. Supportive psychotherapy, teaching about coping mechanisms and problem-
solving techniques.

Identify the possible complications of adjustment disorder (incl. prolonged grief reaction) and its
management

Short term disruption of work and social life

Summarise the prognosis for patients with adjustment disorder (incl. prolonged grief reaction)

Symptoms usually improve rapidly following resolution of the cause

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Anxiety disorder: Generalized

Define anxiety disorder (ICD-10/DSM-5)

Generalised and persistent anxiety, not restricted to, or predominating in, any particular circumstances
(free-floating)

Explain the aetiology of anxiety disorder using a bio-psycho-social approach

Genetic predisposition, Current stress, life events. Childhood experiences characterized by separations,
demands for high achievement and excessive conformity.

Summarise the epidemiology of anxiety disorder

Lifetime prevalence is 5% F> M. Onset in adolescence to early adulthood.

Recognise the presenting symptoms of anxiety disorder

The symptoms should be present most days for at least several weeks at a time. These symptoms should
involve elements of:

• Apprehension (worries about the future misfortunes, feeling on edge, difficulty concentrating)
• Motor tension (restlessness, fidgeting, tension headaches, trembling)
• Autonomic overactivity (lightheadedness, sweating, tachycardia or tachypnea, dizziness, dry mouth,
epigastric discomfort).

Recognise the signs of anxiety disorder on physical examination

Tachycardia and Tachypnoea

Identify appropriate investigations for anxiety disorder and interpret the results

FBC, U+Es, LFTs, Ca, TFTs

Generate a management plan for anxiety disorder using a bio-psycho-social approach with consideration to
risk assessment

• Anxiety management:
o Psychoeducation
o Distraction techniques
o Cognitive control
o Breathing/relaxation techniques
• Benzodiazepines may be useful in short term
• SSRIs or Venlafaxine (serotonin-noradrenaline reuptake inhibitor)

Identify the possible complications of anxiety disorder and its management

50% will develop a depressive illness. May misuse alcohol or illicit substances to cope with anxiety

Summarise the prognosis for patients with anxiety disorder

Course may be chronic, worse at times of stress. Poor prognosis is associated with longer duration of
illness, co-morbid psychiatric disorder and poor premorbid personality.

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Anxiety disorder: Obsessive compulsive disorder

Define obsessive compulsive disorder (ICD-10/DSM-5)

An anxiety disorder in which the patient suffers from time-consuming and obsession and compulsions that
interfere with normal everyday life.

Explain the aetiology of obsessive compulsive disorder using a bio-psycho-social approach

Genetics- 35% of first-degree relatives also have OCD, MZ:DZ= 50-80: 25%. Serotonin dysfunction. Frontal
cortex and basal ganglia abnormalities. Psychoanalytical models see symptoms as arising from conflicting
desires and drives.

Associations/ Risk factors

o Anankastic premorbid personality traits found in 70%

o Co-morbid depression is present in 30% of OCD patients
o 15% of patients with Schizophrenia have an additional diagnosis of OCD
o Some patients with OCD also have tics
o There are high rates of OCD in families with Tourette’s syndrome

Summarise the epidemiology of obsessive compulsive disorder

Lifetime prevalence 2-3%. M=F. Mean age of onset is early twenties.

Recognise the presenting symptoms of obsessive compulsive disorder

Obsession and compulsion are present on most days for a period of 2 weeks and are not accounted for by
the presence of another mental illness like schizophrenia. The obsession and compulsion share the
following features:

o Acknowledged as originating in the mind

o Persistent, repetitive, and intrusive
o Patient tries to resist them
o Not intrinsically pleasurable
o Cause distress and interfere with functioning

Obsession: may be persistent thoughts, images, doubts or impulses. Common content: contamination,
bodily fears, aggression, orderliness/symmetry

Compulsions are stereotyped acts, recognized as excessive, unreasonable or exaggerated. If the patient
tries to resist doing them, there is a sense of mounting tension that can be immediately relieved by yielding
to the compulsion. Often involve: cleaning, checking, counting, hoarding

Recognise the signs of obsessive compulsive disorder on physical examination

Poor concentration if distracted by unwanted thoughts. May show signs of increasing anxiety if prevented
from yielding to compulsions. Patients recognize that the thoughts are their own and excessive

Identify appropriate investigations for obsessive compulsive disorder and interpret the results

FBC, U+Es, LFTs, Ca, TFTs

Generate a management plan for obsessive compulsive disorder using a bio-psycho-social approach with
consideration to risk assessment

Behavioral therapy (exposure and response prevention and thought stopping) helps up to 90% of patients.
Clomipramine or SSRIs are efficacious in between 50% and 80% of patients. Often symptoms relapse
within weeks of discontinuing treatment. If there is a lack of response to SSRIs or clomipramine, an

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antipsychotic can be added. Psychosurgery can be used for severe OCD of at least 2
years duration with severe life disruption that is unresponsive to other treatments

Identify the possible complications of obsessive compulsive disorder and its management

Difficulty with relationships, work and social functioning. It may lead to alcohol and substance misuse.

Summarise the prognosis for patients with obsessive compulsive disorder

Worse prognosis if male, early onset, severe symptoms, premorbid obsessional personality disorder, life
stresses

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Anxiety disorder: Panic Disorder

Define panic disorder (ICD-10/DSM-5)

Presence of panic attacks that occur unpredictably and are not restricted to any particular situation or
objective danger.

Explain the aetiology of panic disorder using a bio-psycho-social approach

Summarise the epidemiology of panic disorder

Recognise the presenting symptoms of panic disorder

Anxiety is intermittent and without an obvious trigger. A panic attack is a sudden attack of extreme (100%)
anxiety with accompanying physical symptoms such as: breathing difficulties/choking, chest
discomfort/tightness, palpitations, tingling/numbness in hands, feet or around the mouth,
depersonalization/derealization, shaking, dizziness, sweating.

Recognise the signs of panic disorder on physical examination

Tachycardia and Tachypnoea, sweaty

Identify appropriate investigations for panic disorder and interpret the results

Good history. Rating scales of anxiety e.g. Beck Anxiety Inventory and the Hospital Anxiety and Depression
Scales (HADS). Social and occupational assessments for effect on quality of life. Collateral history. TFTs,
LFTs, Urine Drug screen, ECG/24-hour ECG, Glucose, 23 hour urine for catecholamine
(phaeochromocytoma)

Generate a management plan for panic disorder using a bio-psycho-social approach with consideration to
risk assessment

1) Advice and Reassurance- psychoeudcation, 2) Basic counselling 3) Problem solving approach to

identify and deal with stressors 4) Relaxation techniques and breathing

Identify the possible complications of panic disorder and its management

Development of specific phobias, social isolation

Summarise the prognosis for patients with panic disorder

Patients with good premorbid functioning and a brief duration of symptoms tend to have a good prognosis.
About 10-20% of patients continue to have significant symptoms. Overall, the long-term prognosis is
usually good, with almost 65% of patients with panic disorder achieving remission, typically within 6
months.

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Anxiety disorder: Agoraphobia

Define phobia (social, specific, agoraphobia) (ICD-10/DSM-5)

Anxiety associated with places or situations from which escape may be difficult, e.g crowds and public
places

Explain the aetiology of phobia (social, specific, agoraphobia) using a bio-psycho-social approach

Family and twin studies suggest that genetic factors are relevant. Onset of agoraphobia often follows a
precipitating event, which may be a panic attack, which leads to avoidance. It can occur following a major
life event in someone with dependent personality traits.

Associations/Risk factors: It is strongly associated with panic and ICD-10 classifies the disorder into
agoraphobia either with our without panic disorder

Summarise the epidemiology of phobia (social, specific, agoraphobia)

Average onset in late 20s. Females > Males.

Recognise the presenting symptoms of phobia (social, specific, agoraphobia)

Consistent and marked fear of: Crowds, public places, travelling alone, being away from home.

Anxiety symptoms: Palpitations, sweating, shaking, dry mouth, difficulty breathing, chest pain, nausea,
dizziness, hot flushes, fear of losing control, fear of dying. Avoidance of these features is a prominent
feature. The patient may feel better if accompanied by someone else.

Recognise the signs of phobia (social, specific, agoraphobia) on physical examination

Normal unless in that situation. May have a panic attack if exposed.

Identify appropriate investigations for phobia (social, specific, agoraphobia) and interpret the results

FBC, U&Es, LFTs, Ca, TFTs

Generate a management plan for phobia (social, specific, agoraphobia) using a bio-psycho-social approach
with consideration to risk assessment

Exposure therapy, gradually increasing, e.g. walking increasing distances from home each day. CBT.

Identify the possible complications of phobia (social, specific, agoraphobia) and its management

Isolation. Secondary depression. May misuse alcohol or illicit substances to cope with feared environment.

Summarise the prognosis for patients with phobia (social, specific, agoraphobia)

Fluctuating course. Condition may be sever and the person housebound.

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Anxiety disorder: Social Phobia

Define phobia (social, specific, agoraphobia) (ICD-10/DSM-5)

Persistent fear of social situations, that may lead to scrutiny, criticism or embarrassment (e.g eating,
drinking, speaking in public)

Explain the aetiology of phobia (social, specific, agoraphobia) using a bio-psycho-social approach

There is evidence from family studies of a genetic component

Summarise the epidemiology of phobia (social, specific, agoraphobia)

Female > Male. Onset gradual from late adolesnce

Recognise the presenting symptoms of phobia (social, specific, agoraphobia)

Situational anxiety in social groups: parties, meetings, classrooms. There is marked avoidance of these
situations. There will be anxiety symptoms and blushing, trembling, fear of vomiting and urgency/fear of
micturition

Recognise the signs of phobia (social, specific, agoraphobia) on physical examination

Normal unless exposed to social situation. Then blushing, shaking, restless, avoids eye contact. Fear of
scrutiny/humiliation. Fear of vomiting/fainting.

Identify appropriate investigations for phobia (social, specific, agoraphobia) and interpret the results

Generate a management plan for phobia (social, specific, agoraphobia) using a bio-psycho-social approach
with consideration to risk assessment

Graded exposure and desensitization. CBT. SSRIs.

Identify the possible complications of phobia (social, specific, agoraphobia) and its management

Social phobia may be secondary to a depressive illness when social performance declines. Secondary
alcohol and substance misuse is common

Summarise the prognosis for patients with phobia (social, specific, agoraphobia)

Generally present for life.

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Anxiety disorder: Specific Phobia

Define phobia (social, specific, agoraphobia) (ICD-10/DSM-5)

Persistent fear of a specific object or situation, out of proportion to the threat of the situation. The fear is
recognized as excessive, but cannot be reasoned away.

Explain the aetiology of phobia (social, specific, agoraphobia) using a bio-psycho-social approach

There is evidence for a familial pattern of phobias. Classical conditioning suggests that phobias arise as a
result of negative experience with the object or situation. Phobias may also develop by modelling (i.e
watching parents).

Association/Risk Factors: Biological vulnerability to anxiety. Hypervigilant individuals more at risk.

Summarise the epidemiology of phobia (social, specific, agoraphobia)

Females > Males. Blood/Needle/Injury phobia Females = Males. 12-month prevalence is about 10% of the
population. Onset usually in childhood, but may vary.

Recognise the presenting symptoms of phobia (social, specific, agoraphobia)

Symptoms of anxiety and panic when exposed to feared stimulus. Fear and avoidance of specific objects or
situations. Types of phobias include: animals, blood/injury/heights/illness

Anxiety symptoms include: sweating, trembling, dry mouth, nausea, difficulty breathing, choking sensation,
chill/hot flushes.

Most phobias cause tachycardia but blood/injury phobia causes an initial tachycardia followed by vasovagal
bradycardia and hypotension. This may cause nausea and fainting.

Recognise the signs of phobia (social, specific, agoraphobia) on physical examination

Normal unless exposed to feared stimulus. When exposed, sweating, restless, panic, distracted, fearful.

Identify appropriate investigations for phobia (social, specific, agoraphobia) and interpret the results

Generate a management plan for phobia (social, specific, agoraphobia) using a bio-psycho-social approach
with consideration to risk assessment

Systematic desensitization; relaxation therapy paired with graded exposure. Use of benzodiazepines in the
short term may allow the patient to engage more easily in systematic desensitization.

Identify the possible complications of phobia (social, specific, agoraphobia) and its management

Disruption of normal daily life if the phobic stimulus is something that must be routinely encountered

Summarise the prognosis for patients with phobia (social, specific, agoraphobia)

Good. Exposure therapy is often successful. Most phobias do not interfere with normal life if the stimulus
can be easily avoided.

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Anxiety disorder: Post-traumatic stress disorder

Define post-traumatic stress disorder (ICD-10/DSM-5)

An intense, delayed, prolonged reaction to an exceptionally stressful event. The event is likely to cause
pervasive distress in almost anyone and usually involves the threat of severe injury or death

Explain the aetiology of post-traumatic stress disorder using a bio-psycho-social approach

Traumatic events, e.g. being the victim of violence or personal attack, rape, observer/survivor of civilian
disaster, being involved in combat. Cognitive theories include: 1) The event challenges currently held
beliefs, which result in an inability to cognitively rationalize the event. 2) Normal processing of emotionally
charged information is overwhelmed so memories persist in an unprocessed form, which can intrude into
conscious awareness. 3) Negative appraisal of intrusive thoughts maintains experience of symptoms over
time. Association/Risk factors: Childhood trauma, borderline, paranoid or dependent personality traits,
inadequate support system, recent stressful life events, female gender, low social class and poor
education, past psych history.

Summarise the epidemiology of post-traumatic stress disorder

Between 10-25% of those exposed to an exceptionally threatening even will develop PTSD. Occurs at any
age. Life time prevalence between 1-3%. Prevalence in high-risk groups such as Iraq War veterans is
approximately 30%. High prevalence in asylum seekers and refugees.

Recognise the presenting symptoms of post-traumatic stress disorder

Occurs within 6 months of the event. 3 main group of symptoms:

• Hyperarousal: Persistent anxiety, hypervigilance, poor concentration, insomnia, irritability,

exaggerated startle response
• Intrusions: Flashbacks, nightmares, vivid memories, frequent thoughts of incident
• Avoidance: Avoid reminders, inability to recall some of the events, poor interest in everyday life,
emotional detachment, avoids discussing incident

Recognise the signs of post-traumatic stress disorder on physical examination

May be signs of neglect related to depression, may look anxious, hypervigilance. Poor eye contact, tearful.
Slow, non-spontaneous speech. Low mood and suicidal ideation. Poor concentration.

Identify appropriate investigations for post-traumatic stress disorder and interpret the results

FBC, U+Es, LFTs, Ca, TFTs

Generate a management plan for post-traumatic stress disorder using a bio-psycho-social approach with
consideration to risk assessment

• Screen for co-morbid psychiatric disorders and conduct risk assessment (suicide neglect)
• CBT involves identifying and challenging dysfunctional thoughts surrounding the traumatic incident
and is often combined with exposure
• Eye Movement-Desensitization and Reprocessing (EMDR) involves patient recalling traumatic
events while in a state of relaxation resulting from focusing their attention on the therapists voice
and following therapists rapid finger movements. SSRIs can treat all core symptoms of PTSD

Identify the possible complications of post-traumatic stress disorder and its management

Social withdrawal, suicide, alcohol and drug misuse

Summarise the prognosis for patients with post-traumatic stress disorder About half make good recovery
within 1 year of onset but rest may have lifelong symotoms.
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Attention Deficit Hyperactive Disorder (ADHD)

Define attention deficit hyperactivity disorder (ICD-10/DSM-5)

Also known as hyperkinetic disorder. Severe form of long-term overactivity associated with inattention and
impulsivity arising before the age of 6 years.

Explain the aetiology of attention deficit hyperactivity disorder using a bio-psycho-social approach

50% risk in MZ twins. There is increased conduct disorder and substance misuse in the parents. Functional
imaging shows frontal metabolism. There is dopamine and noradrenaline dysregulation in the prefrontal
cortex.

Association/Risk factors: Common co-morbidities are conduct disorder, learning difficulties, antisocial
behavior and depression

Summarise the epidemiology of attention deficit hyperactivity disorder

Prevalence 1-2% M:F= 3:1

Recognise the presenting symptoms of attention deficit hyperactivity disorder

Hyperactivity-impulsivity symptoms: Fidgeting, interrupts others, jumping the queue, Talking

excessively

Inattention symptoms: Easily distracted, does not listen, forgetful

Recognise the signs of attention deficit hyperactivity disorder on physical examination

Do development assessment and full neurological screen

Identify appropriate investigations for attention deficit hyperactivity disorder and interpret the results

Diagnosed by specialist assessment, including psychometric testing. Collect information from parents and
teachers to ensure the symptoms are present in more than one environment. Connor’s assessment scale
may be useful

Generate a management plan for attention deficit hyperactivity disorder using a bio-psycho-social approach
with consideration to risk assessment

• Information and support for parents and teachers

• Attend to educational deficits and environmental factors
• Behavioral modification. Educate parents and teachers about appropriate methods- reward good
behavior and discourage reinforcement of problem behavior
• Medication (Methylphenidate, atomoxetine) under specialist supervision.

Identify the possible complications of attention deficit hyperactivity disorder and its management

• Difficulties learning (child does not sit still and learn)

• Risk of accidents (due to impulsivity)
• Low self-esteem and peer rejection (behaviors upset other children)

Summarise the prognosis for patients with attention deficit hyperactivity disorder

Usually symptoms reduce by puberty. Severe cases persist into adulthood. Conduct disorder and other co-
morbidities give a a poorer prognosis and may persist.

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Autism Spectrum Disorder (Including Asperger’s Syndrome)

Define autism spectrum disorder (incl. Asperger’s syndrome) (ICD-10/DSM-5)

Autism is a pervasive developmental disorder. 70% of those affected have mild to moderate learning
difficulties (there is normal IQ in Asperger’s syndrome). Autism is characterized by a triad of features:

1) Language and communication difficulties

2) Abnormal social interaction
3) Restricted and repetitive behavior, interests and activities

Explain the aetiology of autism spectrum disorder (incl. Asperger’s syndrome) using a bio-psycho-social
approach

Unknown. No sound evidences for causal link between MMR vaccine and autism

Association/Risk factors: Associated with genetic disorders, obstetric complications, infections and
neurological disorders

Summarise the epidemiology of autism spectrum disorder (incl. Asperger’s syndrome)

Prevalence 5 per 1000 individuals. M:F= 4:1

Recognise the presenting symptoms of autism spectrum disorder (incl. Asperger’s syndrome)

• Onset < 36 months. 20% develop autistic features after a period of normal development
• Early symptoms: floppiness, poor eye contact, sluggist feeding
• Social impairment: aloofness, lack of interest in people, unresponsive to social cues, poor eye
contact, no capacity to share or understand emotions, failure to develop normal attachments
• Language abnormalities: distorted and delayed speech and language development, echolalia (,
stilted rate and rhythm of speech, impaired use of gestures and facial expressions
• Stereotyped or ritualized behavior: hand flapping, rocking, restricted and repetitive behavioral
repertoire, insistence on routines, resistance to change, obsessions/compulsions especially in
adolescence
• May have isolated exceptional abilities

Recognise the signs of autism spectrum disorder (incl. Asperger’s syndrome) on physical examination

A/B: Ritualised, stereotypical behavior. Poor eye contact, aloof. May attach to unusual items
Speech: Delayed, echolalia (meaningless repetition of another person’s spoken words as a symptom of
psychiatric disorder), stilted rate and rhythm of speech, impaired use of gestures and facial expression.
Mood: Normal
Thoughts: Obsession and compulsion
Perceptions; None
Cognition: Delated language development
Insight: poor

Identify appropriate investigations for autism spectrum disorder (incl. Asperger’s syndrome) and interpret
the results

Full multidisciplinary development assessment. Rating scales such as the Autism Diagnostic Interview
(ADI-R) and the Autism Diagnostic Observation Schedule (ADOS) may be used.

Generate a management plan for autism spectrum disorder (incl. Asperger’s syndrome) using a bio-
psycho-social approach with consideration to risk assessment

• Treatment of co-morbid problems, e.g. ADHD, epilepsy

• Speech therapy to improve language skills
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 • Behavioral approach to challenging behaviors
• Social skills training
• Education and support of family
• Educational and vocational interventions
• Medication as indicated for symptoms management

Identify the possible complications of autism spectrum disorder (incl. Asperger’s syndrome) and its
management

Social isolation. Inability to live independently in the majority

Summarise the prognosis for patients with autism spectrum disorder (incl. Asperger’s syndrome)

Lifelong disorder. Better prognosis with early speech acquisition, higher intelligence and signs of
diminishing impairments

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Postnatal mental disorders- baby blues

Define baby blues (ICD-10/DSM-5)

AKA postnatal blues/maternatity blues. Common psychological problem typically occurring around the third
day post partum. It is not a psychiatric disorder and should not be considered abnormal; however must be
distinguished from postnatal depression (which is a psychiatric issue).

Explain the aetiology of baby blues using a bio-psycho-social approach

Biological theories suggest hormonal changes after birth: sudden decrease in oestrogen and progesterone

Association/Risk factors: women who have previously suffered with premenstrual syndrome,
primigravidae, anxiety and depression during pregnancy, fear of labour, poor social adjustment, NOT
ASSOCIATED WITH OBSTETRIC FACTORS.

Summarise the epidemiology of baby blues

Between half and two-thirds of mothers.

Recognise the presenting symptoms of baby blues

Symptoms begin within the first 10 days post partum, typically from the third to fifth day. Lability of mood is
particularly characteristic, with rapid alterations between euphoria and misery. Women may complain of
feeling confused but cognitive function is normal. They are frequently tearful and feel tense and irritable.

Recognise the signs of baby blues

Tearfullness, irritability, emotional lability

Identify appropriate investigations for baby blues

Not appropriate

Generate a management plan for baby blues

Medication is not required. Reassurance, explanation and family support are key features. Antenatal
education that provides warning for women and their partners is helpful

Identify the possible complications of baby blues

May upset early bonding and breastfeeding

Summarise the prognosis for patients with baby blues

Excellent, resolves spontaneously within few days.

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Postnatal mental disorders- Postnatal depression

Define postnatal depression (ICD-10/DSM-5)

AKA puerperal depression. Depression arising in the months following childbirth. It is not qualitatively
different from depression occurring at other times

Explain the aetiology of postnatal depression using a bio-psycho-social approach

• Psychological factors play a major role e.g. lack of support

• Biological theories suggest hormonal changes; sudden drop in oestrogen and progesterone levels

Association/risk factors: past psychiatric history, especially depression. Psychological problems

during pregnancy. Family history of postnatal depression. Recent adverse life events

Summarise the epidemiology of postnatal depression

Affects 10-15% of mothers, usually within the first 3 months of childbirth

Recognise the presenting symptoms of postnatal depression

May have developed insidiously over several weeks or as an exacerbation of the baby blues. Similar
features to general depressive illness. Sleep disturbance, energy changes, and low libido are less sensitive
indicators as these can occur normally after child birth. Cognitive features are more sensitive indicators and
are usually based around motherhood, e.g. feels guilty for not coping as mother, gains no pleasure from the
child, feels angry with the child

Recognise the signs of postnatal depression on physical examination

Depressive features. There may be obsessional thoughts (often of causing harm to the baby).

Identify appropriate investigations for postnatal depression and interpret the results Same as depression

Generate a management plan for, postnatal depression using a bio-psycho-social approach with
consideration to risk assessment

Assess risk to mother and child, most cases will be mild and don’t require psychiatric intervention and
respond to additional support and counselling. Moderate depression can usually be managed at home,
although if severe, admit to a mother and baby unit (may need to use MHA).

Multidisciplinary care- liaise with GP and midwife/health visitor

Antidepressant medication. Screening for depression should be incorporated into a 6 week postnatal check

Identify the possible complications of, postnatal depression and its management

• Bonding failure
• Rejection/neglect of the baby
• Marital/relationship problem
• Detrimental effect on child’s language skills, social and emotional development in the first year of
life
• Insecure attachments at 18 months
• Maternal suicide
• Infanticide

Summarise the prognosis for patients with postnatal depression Untreated, 10% have a course lasting
longer than 6 months. 90% of cases last less than 1 month with treatment, 4% are still depressed 1 year
later.

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Postnatal mental disorders- Puerperal Psychosis

Define puerperal psychosis (ICD-10/DSM-5)

A psychotic disorder arising after childbirth

Explain the aetiology of puerperal psychosis using a bio-psycho-social approach

The strong association with bipolar affective disorder implies a genetic predisposition.

Association/Risk factors: Past history of puerperal psychosis, existing bipolar affective disorder family
history of bipolar affective disorder and puerperal psychosis, Primigravida

Summarise the epidemiology of puerperal psychosis

Arises after 1 in 500-1000 births

Recognise the presenting symptoms of puerperal psychosis

Unusually arises within a month of delivery and not uncommonly within the first 2 days. The majority of
cases are affective in nature. Typically, there are rapid fluctuations in mood and an abrupt onset of
disturbed 77omatiza

Recognise the signs of puerperal psychosis on physical examination

Usually marked restlessness and fear. Mixture of manic and depressive symptoms. Delusions and
hallucinations may be based around the baby, e.g. paranoid delusions that her baby has been swaped with
someone else’s and auditory command hallucinations instructing her to kill the baby. There is marked
perplexity but no detectable cognitive impairment

Identify appropriate investigations for puerperal psychosis and interpret the results

Rule out delirium due to infection

Generate a management plan for puerperal psychosis using a bio-psycho-social approach with
consideration to risk assessment

• Risk assessment of mother to child

• Admit to hospital (if appropriate using MHA), preferably a mother and baby unit. Rarely, can be
managed at home with frequent reviews from community psychiatric nurse (CPN)
• Medication as appropriate (antidepressants, mood stabilisers and antipsychotics)
• ECT may be useful if medication has failed
• Supportive psychotherapy may be helpful during recovery to help the woman come to terms and
understand the nature of the illness, and allow her to eliminate any feelings of guilt or failure

Identify the possible complications of puerperal psychosis and its management

• Harm or neglect of the child

• Suicide
• Infanticide

Summarise the prognosis for patients with puerperal psychosis

Most cases settle within 6 weeks and are fully recovered within 6 months. However, the recurrence rate is
over 50% for subsequent non-puerperal psychosis and 25% for subsequent puerperal psychosis, although
there is increased for those with a previous psychiatric history or family history.

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Bipolar affective disorder

Define bipolar affective disorder (incl. mania) (ICD-10/DSM-5)

AKA manic depression. Involves recurrent episodes of both depression and mania. The recovery between
episodes is usually complete and the frequency and pattern of episodes is variable.

Explain the aetiology of bipolar affective disorder (incl. mania) using a bio-psycho-social approach

Genetic factors have a strong contribution to bipolar affective disorder. Heritability is estimated at 85%.
MZ:DZ= 80:20%. Risk of bipolar illness in first-degree relatives of those with bipolar is approximately 8%

Summarise the epidemiology of bipolar affective disorder (incl. mania)

Lifetime risk 1% and 1-year prevalence 1%. M:F 1:1. First episode usually occurs during early 20s and is
more commonly mania than depression.

Recognise the presenting symptoms of bipolar affective disorder (incl. mania)

Hypomania

• Persistent mild elevation of mood (>3 days)

• Increased activity and energy
• Decreased sleep
• Talkative
• Overfamiliarity
• Increased libido

Mania without psychotic symptoms

• Elated mood (or irritability) > 1-week duration with complete disruption of work and social life
• Increased energy
• Pressure of speech
• Feelings of high creativity and mental efficiency can lead to grandiose ideas. Expenditure can be
excessive and lead to debts
• Sexual disinhibition
• Reduced sleep may lead to physical exhaustion

Mania with psychotic symptoms

• Manic symptoms as above

• Delusions are often mood congruent (grandiose)
• Auditory hallucinations may be present

Recognise the signs of bipolar affective disorder (incl. mania) on physical examination

A: Dress inappropriately/bright/outlandish. May be neglect of personal hygiene.

B: Overfamiliar, even flirtatious, increased psychomotor activity. Distractible, restless

S: Loud, pressure of speech, uninterruptible, flight of ideas, puns and rhymes

M: elated but can quickly turn to irritability and anger

T: Grandiose or persecutory delusions may be present

Perceptions: Auditory hallucinations, often mood congruent.

C: attention and concentration often impaired

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Insight: poor

Identify appropriate investigations for bipolar affective disorder (incl. mania) and interpret the results

Exclude other causes for a manic episode: substance misuse, space-occupying lesion, hyperthyroidism,
corticosteroids, anabolic androgenic steroids. FBC, U&Es, LFTs, Ca, TFTs, glucose, urine drug screen

Generate a management plan for bipolar affective disorder (incl. mania) using a bio-psycho-social
approach with consideration to risk assessment

Acute manic episode Prophylaxis

• Most patients will require hospital admission
use of MHA if poor insight
• Lithium is a mood stabilizer. It takes 3-7 days
to achieve therapeutic effect so antipsychotics
are required for rapid control of acute
behavioral disturbance
• A benzodiazepine may also be used as an
adjunct
• Olanzapine can also be used as a mood
stabilizer and has the benefit of sedating
patients in the acute phase
• ECT is used if exhaustion is becoming life-
threatening
• Many clinicians think that one episode of
mania at an early age is an indication for
prophylactic treatment
• Lithium and sodium valproate are mood
stabilizers and are the main treatments used
to prevent relapse. They help prevent both
depression and mania; effective for 80% of
sufferers
• Advise women regarding contraception
before starting lithium or sodium valproate
• Before lithium treatment is started check
renal function and TFTs. Lithium has a
narrow therapeutic range and therefore
levels must be carefully monitored

• Olanzapine is now increasingly being used

• Antidepressants can precipitate or aggravate for prophylaxis and has been shown to be
a manic episode, so are stopped effective

• Carbamazapine and lamotrigine are also

effective and may benefit some non-
responders

Identify the possible complications of bipolar affective disorder (incl. mania) and its management

• 10% of those with bipolar affective disorder commit suicide

• Alcohol and substance misuse can complicate the picture
• Non-compliance with prophylaxis is an important issue. Patients often don’t comply due to the side
effects or a prolonged period of well-being. Abrupt withdrawl of mood stabilizer carriers a high risk of
relapse of mania and/or depression (50% of patients relapse within 5 months if lithium is stopped)
• A minority of patients develop rapid cycling of four or more episodes a year

Summarise the prognosis for patients with bipolar affective disorder (incl. mania)

Most relapses are associated with poor compliance. The majority of those with bipolar affective disorder are
well for most of the time as recovery between episodes is usually complete. Even with prolonged

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prophylaxis, 90% of patients will have at least one recurrence of mania and/or depression
within 10 years. The median duration of an untreated manic episode lasts 4 months.
Depression lasts longer with a median duration of 6 months. Predictors of poor outcome: Early onset of
illness, poor compliance, persistent depressive symptoms, severe mania, family history of non-response,
co-morbid personality disorder, substance misuse, rapid cycling (four episodes a year)

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Conduct disorder

Define conduct disorder (ICD-10/DSM-5)

Disorder of childhood or adolescence (below age of 18) characterized by a repetitive and persistent pattern
of antisocial behaviors, which violate the basic right of others and are out of keeping with age-appropriate
social norms

Explain the aetiology of conduct disorder using a bio-psycho-social approach

Exact unknown. Theories suggested include the following:

Parental

• Violence
• Failure to set rules
• Alcoholism
• Antisocial PD
• Divorce
• Rejection

Child

• Difficult temperament
• Low IQ
• Neurological impairment

Association/Risk factors More common in those from deprived areas and children in the care system.
ADHD and substance misuse are common co-morbidities.

Summarise the epidemiology of conduct disorder

Prevalence 4% M:F = 3:1

Recognise the presenting symptoms of conduct disorder

One episode is not significant enough to make the diagnosis; there must be a 6-12-month history.
Problems reported by parents or teachers include; frequent bad tempers/irritability, disobedience, blaming
others for their own mistake, violence, bullying, problems with police, inappropriate sexual behavior.

Recognise the signs of conduct disorder on physical examination

MSE may be difficult as they may not engage in conversation. Their behavior may be disruptive during
interview

Identify appropriate investigations for conduct disorder and interpret the results

Check for educational difficulties. Developmental assessment

Generate a management plan for conduct disorder using a bio-psycho-social approach with consideration
to risk assessment

Psychotherapies: family, problem-solving skills, behavioral therapy and group therapies. Address
educational needs with remedial teaching. Provision of alternative peer group activities. Parent skill training

Summarise the prognosis for patients with conduct disorder

Half will develop antisocial personality disorder. Poor prognosis is predicted by early onset, low IQ, co-
morbidity, family criminality, low socio-economic status and poor parenting.

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Dementia

Definition

An organic syndrome characterized by deterioration of intellectual functioning in several cognitive domains

without impairment of consciousness and this deterioration has an impact on the individual’s daily living,
occupational and or social function.

Aetiology

Most common causes (accounting for more than 90% of all cases of dementia):

• Alzheimer’s disease
• Vascular dementia
• Diffuse lewy body dementia
• Pick’s disease
• Normal-pressure hydrocephalus
• Prion disease (CJD)

Association/Risk factors

Epidemiology

1% in 65-74 years, 10% in > 75 year age group, 25% in > 85 year age group

History

Often from a worried family member who has noticed changes in: Memory, e.g. ‘leaves the gas on and
loses the door keys; Behavior, e.g ‘doesn’t want to go out and visit friends any more like always used to’

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Personality, e.g ‘used to be a calm person, but now is very irritable and axious’. Mood
changes ‘used to be cheerful but nothing seems to give pleasure anymore.

Examination

MSE will depend on type of dementia. MMSE, ACE.

Investigations: Aimed at identifying aetiology

• Routine blood tests: FBC, U&E, B12 and folate, LFT

• More specialized blood tests: HIV, syphilis serology
• Brain imaging (CT or MRI) aids in diagnosis, especially in cases with sudden onset or atypical
presentation. Cerebral blood flow imaging tests can also help identify the areas of deficit
• Neuropsyschological testing highlights brain regions affected/severity and can aid in diagnosis, risk
assessment and management
• Lumbar Puncture: CSF infection screen and pressure (rarely indicated)
• Specialised tests: genetic tests for familial dementia and EEG for priod disease are carried out in
special circumstances

Management

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 • Explanation of nature of the illness and broad prognosis to both patients and carers
• MDT approach to diagnosis and assessment of specific needs involving psychologist, OT, pyshio
and counsellors in addition to psychiatrist
• Close working with social services; home help, day centres, respite residential stays.
• Support for carers including assessment of carer needs and information regarding support groups
• Risk management of issues arising as a result of cognitive impairment:
o Fire safety (cooking and smoking)
o Driving (patients diagnosed with dementia need to tell the DVLA about their diagnosis)
o Wandering or getting lost
o Risk of financial abuse
• Pharmacological treatments
o Acetylcholine esterase inhibitors: Can slow progression in Alzheimer’s disease with
maximum efficacy in moderate stages
o Antidepressants: to treat co-morbid and agitation
o Antipsychotics: can be used to manage behavioural and psychological symptoms of
dementia. They should be used with caution as they increase the risk of CVS in people with
dementia and should be used in the lowest possible dose for the shortest possible time to
target specific symptoms.

Complications

o Difficulty and distress for family

o Death often due to pneumonia
o Predisposition to delirium

Prognosis

o The prognosis depends on the underlying cause

o Younger age of onset usually means poorer prognosis
o Alzheimer’s disease is usually fatal within 10 years of diagnosis
o Vascular dementia has a worse prognosis, with sudden stepwise deterioration and risk of
sudden death from stroke

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Depression

Definition

Mood disorder characterized by a pervasive lowering of mood accompanied by psychosocial and biological
symptoms. A typical depressive episode is described in terms of core symptoms, plus additional features in
ICD-10. A depressive episode may be further classified as; mild, moderate, severe or severe with psychotic
features.

Aetiology

MZ: DZ= 55: 25%. Overall risk of mood disorder in first-degree relatives is 20%. Biochemical theories
include 5-HT dysfunction. Depressed patients can be viewed as having cognitive distortions (e.g
overgeneralization, personlisation, minimsation) and having negative views of themselves, the world and
the future. Most episodes are preceded by adverse life events.

Association/Risk Factors

• Chronic illness
• Divorce
• Unemployed
• Lack of confiding relationship
• Low self-esteem
• Poor social support
• Low social class

Co-morbidity with other psychiatric problems, e.g. alcohol misuse, anxiety disorders

Epidemiology

Lifetime risk: 10-20%. M:F = 1:2. Onset any time from childhood to old age but on average in thirties for
women and forties for men.

History

Symptoms are presents for at least 2 weeks.

Core: Low mood, anhedonia, Low energy

Additional: Reduced concentration and attention, reduced self-esteem and self-confidence, ideas of guilt
and worthlessness, pessimistic views of the future, ideas of acts of self-harm or suicide, disturbed sleep,
diminished appetite

Biological symptoms (four required for diagnosis for somatic syndrome): Anhedonia, lack of
emotional reactivity, Early morning wakening > 2 hours, diurnal variation of mood, psychomotor retardation
or agitation, marked loss of appetite, weight loss, marked loss of libido

Mild Depression- 2 core symptoms and 2 additional symptoms

Moderate Depression- 2 core symptoms and 3 additional symptoms

Severe depression- 3 core symptoms and 4 additional symptoms

Severe depression with psychotic symptoms- delusions, hallucinations or stupor (slowing of movement and
poverty of speech so extreme that the patient is motionless and mute).

Examination

A- Signs of neglect, e.g. weight loss, unkempt appearance

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 B- Poor eye contact, downcast eyes, tearful

S- Slow, non-spontaneous, reduced volume

M- Low, have have suicidal ideation

T- pessimistic, ideas of guilt and worthlessness. Nihilistic delusions or other delusions

P- second-person auditory hallucinations, often derogatory

Cognition- poor concentration

Insight- usually good

Investigations

Blood tests to exclude medical cause, e.g. TFT, FBC, LFT, U&Es, Ca, glucose

Management

• Risk assessment: risk of suicide, risk to others and self-neglect

• Minimize adverse life events
• Primary care if mild, psychiatric referral if severe, hospitalize if suicidal/psychotic
• Drug treatments: antidepressants (TCA, SSRIs); lithium if refractory
• Antidepressants should be continued for at least 6 months after symptoms have resolved; they may
be taken prophylactically following multiple episodes
• Antipsychotics to treat any psychotic symptoms in relation to the depressive episode
• ECT if severe or treatment resistant
• Psychotherapies: supportive, CBT, interpersonal therapy (IPT)

Complications

Social isolation, unemployment, self-harm/suicide, drug/alcohol abuse

Prognosis

• Lifetime suicide is 15%

• After an initial depressive episode, 90% recover but almost all will have a recurrence within 10 years
• 10% have a chronic unremitting course

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Dissociative disorders

Define dissociative disorder (ICD-10/DSM-5)

A physical or mental symptom that occur in the absence of a physical disorder to explain them.

Explain the aetiology of dissociative disorder using a bio-psycho-social approach

Used to be called hysteria. Psychodynamic theories suggest that dissociative symptoms are caused by the
repression of unconscious intrapsychic conflict and the conversion of the resulting anxiety into a physical
symptom. This results in the relief of emotional conflict (primary gain) and the advantages of assuming the
sick role.

Association/Risk factors: Time with stressful life events, insoluble problems and disturbed relationships.
Childhood abuse and other traumatic experiences.

Summarise the epidemiology of dissociative disorder

Rare disorder. Thought to be more common in women and younger adults.

Recognise the presenting symptoms of dissociative disorder

The patient often shows less distress than would be expected of someone with their symptoms, sometimes
called ‘belle indifference’. However, they often show exaggerated emotional reactions to other things.

NB: The condition must be distinguished from malingering, in which the patient consciously and deliberately
feigns illness in order to avoid a situation, e.g. Prison

Types of dissociative state include:

• Dissociative amnesia: Core feature is a patchy loss of memory, usually of recent traumatic events
• Dissociative fugue: same features as dissociative amnesia with an apparently purposeful journey
away from home. A new identity may be assumed
• Dissociative pseudo-dementia: The patient shows abnormality of intelligence, suggesting dementia,
but answers questions wrongly in a way that suggests they have the correct answer in mind
• Dissociative stupor: Motionless and mute, but they are aware of their surroundings
• Dissociative disorders of movement and sensation: The symptoms often resemble the patient’s
idea of a physical disorder. Core features is loss of function which doesn’t appear to be under
voluntary control.

Recognise the signs of dissociative disorder on physical examination

There must be NO EVIDENCE of a physical disease that can explain the symptoms of this disorder

Identify appropriate investigations for dissociative disorder and interpret the results

Exclude physical cause for the symptoms. This may be difficult

Generate a management plan for dissociative disorder using a bio-psycho-social approach with
consideration to risk assessment

Resolution is spontaneous- can give supportive therapy aimed at increasing insight and stress
management and coping skills. Reassure patient that no adverse affect on physical health. Minimize
advantage of sick role

Identify the possible complications of dissociative disorder and its management

Can become chronic due to secondary gain (i.e patient becomes excused from responsibilities)

Summarise the prognosis for patients with dissociative disorder- Excellent. But can become chronic
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Eating disorders: Anorexia Nervosa

Define anorexia nervosa (ICD-10/DSM-5)

Eating disorder characterized by deliberate weight loss resulting in weight 15% below expected or a BMI <
17.5, with secondary endocrine and metabolic disturbances

Explain the aetiology of anorexia nervosa using a bio-psycho-social approach

Genetic (MZ> DZ concordance, increased risk if family history). Dysfunction of 5-HT neurotransmitter
system. Sociocultural views that thinness is attractive. Family relationship, e.g over-involved parents.
Personality, e.g. perfectionism, low self-esteem, obsessive traits.

Association/Risk factors: It is associated with certain occupations, e.g. ballet and modelling. Co-morbid
depression, substance misuse and personality disorder are common.

Summarise the epidemiology of anorexia nervosa

95% are female. Peak age of onset is 15-19 years. Prevalence is approximately 1-2 per 1000 women.
Higher prevalence in higher socio-economic classes and western Caucasians

Recognise the presenting symptoms of anorexia nervosa

• Weight loss induced by diet restriction and one or more of:

o Self-induced vomiting
o Excessive exercise
o Appetite suppressants or diuretics
o Laxatives
• Morbid fear of fatness
• Body image distortion
• Loss of libido
• Fatigue
• Amenorrhoea
• Obsessional thoughts and rituals

Recognise the signs of anorexia nervosa on physical examination

MUST EXCLUSE MEDICAL CAUSES FOR WEIGHT LOSS. A patient with anorexia may:

• Be gaunt and emaciated

• Be dehydrated
• Have proximal myopathy
• Have cold extremities
• Have bradycardia and hypotension
• Have fine lanugo hair
• Exhibit peripheral oedema
• Have parotid gland enlargement and erosion of tooth enamel (secondary to vomiting)

They may be low in mood. There will be preoccupation with food and overvalued ideas about weight and
appearance. Insight is usually poor.

Identify appropriate investigations for anorexia nervosa and interpret the results

FBC, U&Es, LFT, amylase, lipid, glucose, TFTs, Ca, magnesium, phosphate. ECG due to electrolyte
abnormalities. Bone scan may be indicated if osteoporosis is suspected.

Generate a management plan for anorexia nervosa using a bio-psycho-social approach with consideration
to risk assessment
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 • Correct medical complications (may require admission to medical ward)
• Psychiatric admission if very low weight or suicide risk
• Refeeding via nasogastric tube if necessary
• Negotiate dietary aims
• Psychoeducation and supportive psychotherapy
• Monitor muscle power, BP, biochemistry, weight
• CBT
• Family therapy
• SSRIs

Identify the possible complications of anorexia nervosa (incl. refeeding syndrome) and its management

Osteoporosis, cardiac arrhythmias, renal failure, pancreatitis, hepatitis, seizures, peripheral neuropathies,
suicide

Summarise the prognosis for patients with anorexia nervosa

Variable. Some patients recover after a single episode, some relapse and some run a chronic deteriorating
course over many years. Mortality of 10% due to complications of the eating disorder and suicide. Poor
outcome is associated with older age of onset, long duration of illness, lower weight at presentation and
poor childhood social adjustment.

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Eating disorders: Bulimia Nervosa

Define bulimia nervosa (ICD-10/DSM-5)

Eating disorder characterized by uncontrolled binge eating with vomiting/laxative abuse. There is a
preoccupation with body weight and shape.

Explain the aetiology of bulimia nervosa using a bio-psycho-social approach

Those with bulimia are more likely to have a personal and family history of obesity, a family history of
affective disorders and a family history of substance misuse. Half have a previous history of anorexia
nevorsa and the aetiology of the two condition is similar.

Summarise the epidemiology of bulimia nervosa

Prevalence amongst adolescent and young adult females is 1-3%. Sex ratio F:M= 10:1. Average age of
onset is 18 years.

Recognise the presenting symptoms of bulimia nervosa

There is a persistent pre-occupation with eating and a craving for food. Binge eating of up to 20,000 kcal in
one session occurs. This is followed by self-loathing, vomiting, and/or laxative abuse and starvation.

Recognise the signs of bulimia nervosa on physical examination

Weight may be normal. Signs of vomiting: dental erosion, finger calluses, calluses on the dorsum of the
hand (Russell’s sign), parotid swelling. Menstrual abnormalities occur in 50%. Mood may be low, with self-
loathing. There will be preoccupation with body weight and shape. There is more insight that in anorexia
and patients are often keep for help.

Identify appropriate investigations for bulimia nervosa and interpret the results

FBC, U&Es, LFT, amylase, lipids, glucose, TFTs, Ca, Magnesium, phosphate, ECG due to electrolyte
abnormalities

Generate a management plan for bulimia nervosa using a bio-psycho-social approach with consideration to
risk assessment

• Nearly all patients can be managed as outpatients

• Medical stabilization
• CBT
• Interpersonal psychotherapy
• SSRI antidepressants have an antibulimic effect separate from their antidepressants effect e.g.
fluoxetine

Identify the possible complications of bulimia nervosa and its management

Cardiac arrhythmia, renal failure, Mallory-weiss tears, Esophagitis

Summarise the prognosis for patients with bulimia nervosa

Majority make full recovery. CBT is effective for more than half of patients. Poor outcome is associated with
depression, personality disturbance, longer duration of symptoms, greater severity of symptoms and
substance abuse.

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Learning Disability

Define learning disability (impairment, disability and handicap) (ICD-10/DSM-5)

Impairment of the CNS originating during the developmental period, which usually presents during early
childhood with a below-average intellectual performance and reduced ability to acquire life/adaptive skills
resulting in social handicap.

Explain the aetiology of learning disability using a bio-psycho-social approach

Causes of many cases of LD, especially mild LD, is unknown but they may be associated with the
following:

• Genetics:
o Chromosomal (Down’s syndrome)
o Autosomal dominant (neurofibromatosis, tuberous sclerosis)
o Autosomal recessive (phenylketonuria)
o Sex linked (fragile X)
• Structural developmental abnormalities: Hyrdocephalus
• Secondary to brain damage
o Antenatal (infection, toxic, hypoxic, maternal disease)
o Perinatal (birth asphyxia, intracranial bleed)
o Postnatal (infection, injury, epilepsy, hypothyroidism)

Association/Risk factors: Social and educational deprivation. Low parental intellect. Co-morbid conditions
include: epilepsy, autism, cerebral palsy, hearing, visual and physical impairments, psychiatric disorder.

Summarise the epidemiology of learning disability

Overall prevalence of LD is 2% of population. Of these, 80% are mild, 12% are moderate, 8% are
severe/profound.

Recognise the presenting symptoms of learning disability and demonstrate awareness of how psychiatric
and physical illness may present atypically in people with learning disability since they may have sensory,
communication and cognitive problems

PC in children: delay in usual development (e.g sitting up, walking, speaking, toilet training). Difficulty in
managing school work as well as other children. Behavioral problems.

PC in adolescents: Difficulties with peers, leading to social isolation. Inappropriate sexual behavior.
Difficulty in making the transition to adulthood.

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PC in adults: difficulties in everyday functioning, require extra support (e.g. cooking and
cleaning, filling in forms, handling money). Problems with normal social development and
establishing an independent life in adulthood (e.g. finding work, marriage, child-rearing).

During assessment: Collateral history from family/carer is essential. Enquire about problems
antenatally/perinatally/postnatally. Ask about family history of LD. Take thorough childhood history,
including developmental milestones. Assessment of functioning and life skills. Neuropsychological
assessment including IQ testing. Consider associated problems (epilepsy, neurological and physical
disabilities). Screen for co-morbid psychiatric problems.

Recognise the signs of learning disability on physical examination

In addition to MSE, conduct full physical examination, including sight and hearing

Identify appropriate investigations for learning disability and interpret the results

FBC, U&Es, LFTs, TFTs, glucose, infection screening and serology. EEG and neuroimaging may be
indicated. If genetic disorder suspected, arrange for karyotyping.

Generate a management plan for learning disability using a bio-psycho-social approach with consideration
to risk assessment (and involve statutory and non-statutory agencies that can support the patient and
family needs)

• MDT (psychiatrist, OT, SALT, nurse, educational support, social support including finance/housing)
• Treatment of co-morbid medical and psychiatric problems is essential, although unnecessary
medication should be avoided
• Give information to family and carers about support groups
• Behavioral treatments can be used to teach basic skills and alter maladaptive patterns of behavior
• Medication should be used with caution due to limited evidence of efficacy and the increased
potential for adverse reactions. Low-dose antipsychotics are sometimes used for aggressive or self-
injurious behaviours

Identify the possible complications of learning disability (incl. medical and educational consequences) and
its management

Patients with LD have a higher prevalence of psychiatric symptoms than the general population. There can
be difficulty in diagnosing psychiatric conditions due to language difficulties and atypical presentations (e.g.
schizophrenia may present with simple repetitive hallucinations and persecutory delusions)

Summarise the prognosis for patients with learning disability

Chronic problem but the handicap can be modified by social support

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Personality Disorder

Define personality disorder (ICD-10/DSM-5)

Characterized by enduring, deeply ingrained, pervasive and inflexible patterns of inner experience and
behvaviour, which are maladaptive in the individual’s culture and lead to distress or impairment of work of
social functioning. The patterns of behavior deviate from the norm and have their onset in late childhood.

Explain the aetiology of personality disorder using a bio-psycho-social approach

There is some evidence of a genetic contribution to personality disorder

Association/Risk factors: Early adversities that are commonly reported by patients with personality
disorder only lead to pathology in a minority of those in the population experiencing similar adversity. This
suggests an underlying vulnerability in those who develop personality disorders. Early adversities that are
commonly reported are social stressors, childhood abuse and dysfunctional families

Summarise the epidemiology of personality disorder

The symptoms begin in late childhood or adolescence but it is unusual for a diagnosis to be made before
adulthood. 5% of the adult population and 40% of the psychiatric inpatients have a personality disorder

Recognise the presenting symptoms of personality disorder

Maladaptions may manifest as:

• Cognition
• Affectivity
• Control over impulses and gratification of needs
• Manner of relating to others
• Handling of interpersonal situations
• Manner of handling stress

Personality disorders are divided into three clusters.

Cluster A= Odd/Eccentric

• Paranoid
o Sensitive to setbacks
o Suspiciousness and misinterprets people’s intentions
o Bears grudges
o Suspicious regarding loyalty of partner
o Stubborn sense of personal rights
o Excessive self-importance
o Conspiratorial view of events
• Schizoid
o Emotional coldness
o Few activities provide pleasure
o Limited capacity to express feelings
o Indifference to praise or criticism
o Little interest in sexual experience
o Preference for solitary activities
o Preoccupation with fantasy
o Insensitivity to social norms
o Uninterested in having close friends

Cluster B= Dramatic/Emotional

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 • Histrionic
o Shallow and labile affect
o Self-dramatization
o Suggestibility
o Seeks excitement and wants to be the center of attention
o Inappropriate seductiveness
o Very concerned with physical attractiveness
• Dissocial
o Blame others
o Callous unconcern for others
o Gross and persistent irresponsibility
o Unable to maintain enduring relationships
o Incapacity to experience guilt
o Low threshold for violence
• Emotionally unstable: Impulsive type
o Act impulsively without thought thought of consequences
o Unstable mood
o Inability to control anger
o Conflict with others
• Emotionally unstable: Borderline type
o Some of the features of impulsive type present
o Chronic feelings of emptiness
o Efforts to avoid abandonment
o Intense and unstable relationships
o Uncertainty about self-image
o Self-harm

Cluster C: Fear/Anxious

• Anankastic
o Preoccupation with detail
o Perfectionism interferes with completing tasks
o Feelings of excessive doubt
o Rigid and stubborn
• Dependent
o Allows others to make important decisions
o Unwillingness to make reasonable demands on others
o Feels helpless when alone
o Subordination of own needs to those of others
o Fear of being abandoned
• Anxious (avoidant)
o Feeling of tension and apprehension
o Preoccupation with being criticized
o Believe they are socially inept and inferior to others
o Restrictions in lifestyle because of the need for security

Recognise the signs of personality disorder on physical examination

MSE will vary depending on the features above

Identify appropriate investigations for personality disorder and interpret the results

• MRI may be indicated if organic causes of personality change are suspected, e.g. frontal lobe
tumour, subdural haematoma
• Careful and thorough assessment should be conducted- collateral history is essential
• Psychometric assessments such as the Millon Clinical Multiaxial Inventory may be useful

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Generate a management plan for personality disorder using a bio-psycho-social approach
with consideration to risk assessment

• Treatment of co-morbid psychiatric disorders, e.g. depression

• Psychotherapy
• Low-dose antipsychotics are sometimes used
• Antidepressants may be useful in emotionally unstable personality disorder
• Carbamazepine may be used for episodic behavioral dyscontrol and aggression
• Therapeutic communities

Identify the possible complications of personality disorder and its management

• Subjective distress
• Adverse effects on relationships/society
• Depressive illnesses
• Alcohol and substance abuse
• Deliberate self-harm and suicide
• Violence towards other and other criminal activities

Summarise the prognosis for patients with personality disorder

The personality disorders have a high morbidity and mortality. There is a similar standardized mortality ratio
for personality disorder and for psychosis. The behavior of those with personality disorders may improve
with increasing age but the cognitive and affective symptoms tend to remain.

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Delirium

Define psychotic disorder (incl. acute) (ICD-10/DSM-5)

An acute, transient, global organic disorder of CAN function resulting in impaired consciousness and
attention, thinking, memory, psychomotor, disturbances and sleep-wake cycle.

Explain the aetiology of psychotic disorder (incl. acute) using a bio-psycho-social approach

Many causes for delirium

• Cardiovascular: Congestive heart failure, TIA, stroke

• Endocrine: hypoglycaemia, DKA, thyroid dysfunction, cushing’s syndrome
• Metabolic: hypoxia, electrolyte imbalance, dehydration, renal/liver/respiratory failure
• Infection: Systemic (UTI, pneumonia, HIV), local (encephalitis, meningitis, syphilis, cellulitis)
• Trauma: Subdrual haematoma, post concussion
• Food/nutrition: Thiamine deficiency
• Malignancy: primary and secondary in the brain
• Drugs: anaesthetic (postoperative), analgesics (opiates), anticholinergics, benzodiazepines,
corticosteroids, digoxin, postictal states

Association/Risk factors: Extremes of age (old and young), pre-existing dementia, sensory deprivation,
unfamiliar environment.

Summarise the epidemiology of psychotic disorder (incl. acute)

10% of all hospital inpatients; 30% of elderly hospital inpatients.

Recognise the presenting symptoms of psychotic disorder (incl. acute)

• Often collateral history only. Previous mental state important

• Rapid onset, fluctuating levels of consciousness
• Symptoms of the underlying cause (see aetiology above)
• Hypo/hyperactivity (can fluctuate from one to the other)
• Sleep disturbances (insomnia, reversal of sleep-wake cycle)
• Hypersensitivity to light and sound
• Perceptual disturbance: misidentification, illusions and hallucinations (visual more common)
• Reduced ability to maintain attention to external stimuli
• Memory impairment, poor registration and retention of new material
• Anxiety, fear

Recognise the signs of psychotic disorder (incl. acute) on physical examination

MSE

A+B: Aggressive purposeless behavior or drowsy with reduced levels of activity

Speech: Incoherent, rambling
Mood: Labile, anxious, depressed, irritable
Thought: Disordered
Perception: Illusions, hallucinations and distortions
Cognition: Memory impairment, disorientation
Insight: Very limited
Physical: Autonomic signs- sweating, tachycardia, dilated pupils

Identify appropriate investigations for psychotic disorder (incl. acute) and interpret the results

• Thorough physical examination, urine screen for drugs, glucose and infection

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 • Blood: FBC, U&Es, glucose, LFT, TFT, CRP, blood cultures (if appropriate), ABG.
• EEG: generalized slowing of background activity (can be useful for differentiating from depression)
• Depending on clinical findings, other investigations: CXR, HIV test, MRI/CT, LP.

Generate a management plan for psychotic disorder (incl. acute) using a bio-psycho-social approach with
consideration to risk assessment

Treat underlying cause

Medical Management- Aimed at managing agitation to facilitate treatment of underlying cause

• Treat underlying cause

• Maintain adequate fluid and electrolyte balance
• Drugs: avoid benzodiazepines unless absolutely essential (as can add to confusion) or for
management of alcohol withdrawal
• Consider use of the MHA if necessary

Nursing Management

• Aimed at reassurance and reduction of disorientation

• Quiet and reassuring environment
• Good lighting
• Avoid frequent changes of staff
• Encourage relatives/friends to visit

Identify the possible complications of psychotic disorder (incl. acute) and its management

Develop drug and alcohol misuse. Self harm and suicide.

Summarise the prognosis for patients with psychotic disorder (incl. acute)

• Longer stay in hospital

• Increased mortality: 20-25% in elderly patients
• Depends on the rapid diagnosis, treatment and prognosis of the underlying cause

Important to distinguish between delirium and dementia, particularly in elderly. Dementia is a risk factor for
delirium, and the two conditions can co-exist.

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Schizophrenia

Define schizophrenia (ICD-10/DSM-5)

A psychotic disorder in the absence of organic disease, alcohol or drugs related dependence/withdrawal.
Not secondary to elevation or depression of mood. ICD-10 subgroups of schizophrenia: Paranoid,
hebephrenic, catatonic, simple, residual

Explain the aetiology of schizophrenia using a bio-psycho-social approach

Multifactorial. MZ:DZ = 48:4%

• Candidate genes have been identified

• Siblings of a patient with schizophrenia have a 10% chance of having schizophrenia
• If both parents have schizophrenia, their child has nearly a 50% chance of having the condition
• Hypoxic brain injury at birth has been associated with developing schizophrenia
• Cannabis use can contribute to the development of schizophrenia
• Neurochemical theories include abnormalities in glutamatergic neurotransmission which interacts
with dopamine pathways
• Imaging studies show decreased cortical volume, especially of the temporal lobe, and enlargement
of the lateral ventricle.

Association/Risk factors: Schizophrenic symptoms are more common in those with temporal lobe
epilepsy and Huntington’s chorea.

Summarise the epidemiology of schizophrenia

Lifetime risk is 1%. Prevalence: 0.5-1%. M:F= 1:1. Median age of onset: males 28 years, females 32 years.

Recognise the presenting symptoms of schizophrenia

The onset of symptoms may be preceded by a prodrome where the patient becomes withdrawn, anxious,
suspicious and irritable with a reduction in normal functioning

Symptoms must be present for at least a month

For a diagnosis to be made according to ICD-10, one of the following signs and symptoms must be
present:

• Thought echo, thought insertion, thought withdrawl, thought broadcast

• Delusions of control
• Running commentary or voices discussing the patient between themselves
• Persistent delusions

Or two of the following signs and symptoms

• Persistent hallucinations in any modality

• Thought disorder
• Catatonic behvaiour
• Negative symptoms

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Recognise the signs of schizophrenia on physical examination

Positive signs and symptoms Negative signs and symptoms

Appearance: normal or inappropriate dress, Appearance: poor self-care/unkempt

headgear etc.
Behaviour: withdrawn or restless and noisy Behaviour: Tardive dyskinesia/poor eye
contact/apathy

Mood: incongruent affect, guarded Mood: flattened/blunted

Speech: reflects underlying thought disorder Speech: Poverty of speech

Thought: Formal thought disorder. Derailment, Thought: may be formal thought disorder, may be
loosening of associations, thought blocking persistent delusion
Thought alienation: broadcasting, withdrawal,
insertion. Delusions:
persecutory/reference/control/grandiose

Perception: Third-person auditory hallucinations, Perception: may have persistent auditory

running commentary, hallucinations in other hallucinations
modalities

Cognition: orientation often normal, impaired Cognition: specific cognitive deficits

attention and concentration

Insight: Poor Insight: poor

Bleuler’s 4 As

• Autistic thoughts- inner world of fantasy

• Affective incongruity- e.g. similing when describing sad event
• Associations loosened- thought disorder
• Ambivalence- conflicting feelings

Identify appropriate investigations for schizophrenia and interpret the results

Exclude organic cause. FBC, TFTs, glucose, LFTs, U&Es, B12, and folate, VDRL (for syphilis). Urine drug
screen. Brain imaging if neurological symptoms/first episode. Neuropsychological testing.

Generate a management plan for schizophrenia using a bio-psycho-social approach with consideration to
risk assessment

• Risk assessment: risk of suicide, risk to others, self-neglect

• Consider need for hospital treatment, possibly under the MHA due to lack of insight
• Involve family/carers, as they need to be supported and educated about the illness
• Antipsychotics are the mainstay of treatment. A depot is given if compliance is a problem.
• Clozapine is used for treatment-resistant schizophrenia (two adequate trials of two different
antipsychotics, one of which is an atypical, have failed)
• CBT for persisting hallucinations/delusions
• Behavioral family therapy
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 • Social/rehabilitation: day centres (social skills training, vocational training,
education, help with benefits and housing, outings and recreation)
• Community care: GP, CMHT, crisis team, assertive outreach team

Identify the possible complications of schizophrenia and its management

Personal and social cost: hospitalization, strain on relationship, dropping out of education, time off work/job
loss.

Summarise the prognosis for patients with schizophrenia

• Variable and difficult to predict for any individual

• 10% chronic course
• 20% one episode only
• 35% several episodes with little functional impairment
• 35% increasing impairment with each of several episodes
• 15% lifetime risk of suicide

Schizoaffective disorder

There is considerable overlap between schizophrenia and bipolar disorder. Patients are diagnosed with
schizoaffective disorder only if they satisfy the criteria for schizophrenia and mood disorder occurring
DURING the same episode, but where psychosis is not secondary to mood disturbances. First-degree
relatives of patients with schizoaffective disorder have an increased risk for both mood disorders and
schizophrenia. Treat mood symptoms and schizophrenia symptoms, e.g. lithium and antipsychotics may be
used in combination.

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Somatisation

Define Somatization (ICD-10/DSM-5)

There is repeated presentation of physical symptoms with persistent requests for medical investigations
and no physical basis is found and attempts to discuss possible psychological causes are resisted

Explain the aetiology of Somatization using a bio-psycho-social approach

Patients tend to have a low threshold for worrying about symptoms and consulting doctors. Patients are
more likely to report parental physical illness and to have had more physical illness themselves during
childhood.

Association/Risk factors: A high proportion of patients with somatization disorder will also have a
personality disorder. Co-morbidity is also high with anxiety, depression and alcohol abuse

Summarise the epidemiology of Somatization

Lifetime prevalence is about 0.1%. More common in women. Onset usually before 30 years old. Onset after
the age of 40 may suggest depression

Recognise the presenting symptoms of Somatization

• Multiple, recurrent and frequently changing physical symptoms, e.g. abdominal pain, headache,
fatigue, dizziness, pins and needles
• Symptoms may affect any system but are most commonly: GI, skin, sexual, menstrual
• No physical explanation is found for the symptoms
• Symptoms are present for more than 2 years
• Multiple investigations/treatments by different specialists
• Persistent refusal to accept the advice and reassurance of several doctors
• Social or occupational functioning is impaired as a result of the 102omatiza

Recognise the signs of Somatization on physical examination

All patients require full physical examination to exclude physical illness

Identify appropriate investigations for Somatization and interpret the results

Refusal to accept reassurance leads to multiple investigations for organic aetiology of symptoms

Generate a management plan for Somatization using a bio-psycho-social approach with consideration to
risk assessment

Patient should be seen by same doctor each time. Treat an associated anxiety or depression. Be clear
about negative clinical findings. Don’t conduct further investigations. Acknowledge psychological distress.
Elicit childhood experience of illness. Encourage coping strategies and letting go of the inappropriate sick
role. Involve family who may be reinforcing the behavior.

Identify the possible complications of Somatization and its management

New symptoms may appear during times of stress

Summarise the prognosis for patients with somatization Chronic and fluctuating. Often resistant to
treatment
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Substance use disorder: Alcohol

Define harmful alcohol use and alcohol dependence (physical, psychological) (ICD-10/DSM-5)

Alcohol misuse: consumption of alcohol sufficient to cause physical, psychiatric or social harm. Levels of
alcohol consumption:

• Low risk: men <21 units/week; women <14 units/week

• Hazardous drinking (intake likely to increase the risk of alcohol-related harm): Men 22-50
units/week; women 15-35 units/week
• Harmful drinking (this is synonymous with alcohol misuse). A pattern of drinking associated with the
development of alcohol related harm. Men > 50 units/week; women > 35 units/week.

Explain the aetiology and maintenance of harmful alcohol use and alcohol dependence using a bio-psycho-
social approach (incl. factors relating to family and personal relationships)

Multifactorial. No specific cause.

Associations/Risk factors: Genetic factors, culture, religion, family history, availability and price of
alcohol, males.

Summarise the epidemiology of harmful alcohol use and alcohol dependence with regard to age and socio-
cultural background

In the UK, 0.5-1.0% drink harmfully. This number has been increasing over the past decade. Overall, 27%
of men and 13% of women drink over the recommended ‘low-risk’ level of 21 and 14 units/week. M:F= 2:1

Recognise the presenting symptoms of harmful alcohol use and/or alcohol dependence

SEE ASSESSMENT SECTION ABOVE

Recognise the signs of harmful alcohol use and/or alcohol dependence on physical examination

Physical examination for alcoholic stigmata and those of chronic liver disease; e.g palmar erythema, spider
naevi, gynaecomastia, peripheral neuropathy, signs of portal hyper-tension

MSE will depend on the state of intoxication

Acute intoxication

A+B: smell of alcohol, unco-ordinated, may have acute injuries

S: slurred

M: labile, may be excessively happy or sad

T: Variable

P: None

C: slow, impaired judgement

I: May be poor

Delirium tremens

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Usually starts with 48-72 hours after drinking cessation

A+B: Agitated, tremor, fearful, may have nausea and seizures

S: Confused

M: labile, may be anxious

T: Delusions

P: Hallucinations or illusioms- usually visual

C: confused, poor attention

I: poor

Identify appropriate investigations for harmful alcohol use and/or alcohol dependence and interpret the
results

Blood alcohol levels, GGT, glucose, LFTs, B12 and folate, FBC, U&Es

Generate a management plan for harmful alcohol use and/or alcohol dependence using a bio-psycho-social
approach (incl. addressing contributory factors related to family and personal relationships) with
consideration to risk assessment

• Detoxification if indicated
o Benzodiazepines to prevent seizures and control withdrawal symptoms
o Rehydration and correction of electrolyte disturbances
• Vitamin supplements: may need IV supplements (pabrinex) initially followed by oral vitamin B
tablets
• Motivational interviewing
• Self-help e.g. AA
• Address social issues
• Disulfiram- blocks alcohol dehydrogenase so leads to an unpleasant reatction on drinking
• Acamprosate- reduces conditioned aspects of drinking and prevents craving-induced relapses
• Naltrexone- opioid antagonist. Reduces reinforcing actions of alcohol (e.g the pleasure)
• Treat any co-morbid anxiety and depression

Identify the possible complications of harmful alcohol use and/or alcohol dependence and its management

• Mental
o Anxiety
o Depression
o Alcoholic hallucinosis
o Morbid jealousy
o Self-harm
o Memory loss
o Dementia
• Physical
o GI upsets (gastritis, ulcers, nausea)
o Hypertension
o Cardiac arrhythmias
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 o Cardiomyopathy
o Cirrhosis
o Hepatitis
o Jaundice
o Peripheral neuropathy
o Wernicke’s encephalopathy

Summarise the prognosis for patients with harmful alcohol use and/or alcohol dependence

Relapsing and remitting. High suicide risk. Depends on support and pre-morbid personality

Utkarsh Ojha
Utkarsh Ojha
Substance use disorder: Drugs

Define harmful drug use, drug dependence (physical, psychological) and drug withdrawal of common
psychoactive drugs (incl. cannabis, stimulants, opiates, sedative / hypnotics (e.g. benzodiazepines), 'legal
highs') (ICD-10/DSM-5)

Acute intoxication- transient disturbance of behavior, cognition or perception after taking a substance.
Misuse- maladaptive and recurrent use of substance leading to significant impairment or distress.
Dependence- Opioid dependence has the same features as alcohol dependence as outlines above

Explain the aetiology and maintenance of harmful drug use, drug dependence (physical, psychological) and
drug withdrawal using a bio-psycho-social approach

Multifactorial, possible neurobiological mechanism. Pre-existing psychiatric conditions, e.g. personality

disorder, may increase the likelihood of substance misuse

Association/Risk factor: Peer pressure, deprivation, availability of substances, iatrogenic factors, e.g.
prescription of benzodiazepines/analgesics long term.

Summarise the epidemiology of harmful drug use, drug dependence (physical, psychological) and drug
withdrawal with regard to age and socio-cultural background

Difficult to assess as people may not be honest about an illegal activity.

Recognise the presenting symptoms of harmful drug use, drug dependence (physical, psychological) and
drug withdrawal

SEE ASSESSMENT SECTION ABOVE

Recognise the signs of harmful drug use, drug dependence (physical, psychological) and drug withdrawal
on physical examination

Will depend on the substance being used (see table below for physical complications)

Identify appropriate investigations for harmful drug use, drug dependence (physical, psychological) and
drug withdrawal and interpret the results

Urine drug screen. HIV and hepatitis screening

Generate a management plan for harmful drug use, drug dependence (physical, psychological) and drug
withdrawal using a bio-psycho-social approach with consideration to risk assessment

Intervention is primarily focused around opioid dependence. However, psychological and social
interventions will be of benefit for all types of substance misuse

• Detoxification from opiates:

o Lofexidine
o Loperamide
o Buscopan
o Benzodiazepines
o Ibuprofen
o Metoclopramide
• Motivational interviewing

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 • Substitution prescribing: methadone, buprenorphine
• Treat any psychiatric co-morbidity

Identify the possible complications of harmful drug use, drug dependence (physical, psychological) and
drug withdrawal and its management

Physical complications given in table below. Substance abuse may worsen/precipitate psychological
conditions. Social problems- debts, crime, prison, isolation. Infection and blood borne viruses may be a
consequence of injecting drugs.

Summarise the prognosis for patients with harmful drug use, drug dependence (physical, psychological)
and drug withdrawal

Depends on the substance of misuse. Also depends on social support and levels of motivation

Utkarsh Ojha