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Psychiatry
👩⚕️ Assessment
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Core:
- ↓ mood, anhedonia, anergia
Additional:
- Biological: ↓ sleep, ↓ appetite, ↓ libido
- Psychological: ↓ concentration, social isolation, self-worth
- Harm: Self/others
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- Triggers
- OCD: Obsessions or compulsions?
- PTSD: Re-experiencing, avoidance, hyper-arousal, emotional numbing
Symptoms:
- Constant or in short attacks: GAD vs panic
- Physiological: Tachycardia (palpitations/chest pain), excessive sweating, headaches
- Psychological: Social isolation, depressive symptoms
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- Mania vs hypomania: Do they have psychosis? (Delusions, hallucinations, thought disorders)
Symptoms:
- Increased energy
- Little sleep
- Disinhibition: Sexual or financial
- Thought: Flight of ideas
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Any odd or unusual happenings recently? Do you hear anything in an empty room? See things that aren't there?
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- Auditory: Key voices are third person commenting / talking behind back
- Visual
- Somatic
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- Knight's move: Random jumps between topics that aren't related
- Neologisms
- Flight of ideas: Jumping between related topics: 'You're a doctor, doctor who? Great programme, etc.'
- Tangential
- Confabulation: Made-up stories fill gaps in memory
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Delusions: Fixed, false belief not fitting with their social, cultural or educational background. Needs to be affecting their daily life.
- Persecutory
- Grandiose
- Jealousy (Othello syndrome)
- Love with somebody of importance/higher social class (De Clérambault syndrome). Erotomania - Similar but more sexualised
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- Thought broadcasting, insertion, withdrawal
- Being controlled by someone else
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- Risk: Self / others
- Past psychiatic history
- Forensic history
- Personal history
- Review of Systems: Depression (mood, anhedonia), schizophrenia (TAPD)
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For the following sections, what is the description of normal and what factors do you need to consider in each?
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- Describe clothing: Dishevelled, appropriately dressed
- Body language
- Hygiene
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- Normal: Behaviour was appropriate for the consultation and we developed a good rapport and maintained good eye contact
- Abnormal:
- Distracted/fidgeting
- Psychomotor retardation (slow)
- Poor eye contact
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- Normal: Speech was congruent with their emotions and of a normal speed.
- Abnormal:
- Speed: Slow/normal/fast
- Tone: monotonous/congruent]
- Volume
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- Normal: Both objectively and subjectively euthymic
- Objective (my impression):
- Mood: Low/euthymic/high
- Affect: Flat/normal
- Subjective (patient’s impression):
- Low/euthymic/high
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- Normal: Patient did not respond to any stimuli that weren't present
- Hallucinations: Auditory/visual/somatic
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- Normal: Patient did not have any disorders of thought formation, content or possession
Comment on:
- Content: Delusions (thought formation, content or posession)
- Form: Neologisms, flight of ideas, tangential
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- Present or not at this given time
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- Normal: Cognition grossly intact but not formally assessed (memory, orientation)
- Assess using Addenbrooke’s Cognitive Examination (ACE-III) - attention, memory, fluency, language, visuospacial
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What are the requirements for the following sections & what do they permit?
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- Requirements: 1 AMHP & 2 doctors (that know the patient, one section 12(2) approved)
- Permit: 28 days for assessment (non-renewable)
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- Requirements: 1 AMHP (approved mental health practitioner) & 2 doctors (that know the patient)
- Permit: 6 months for treatment (renewable)
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- Requirements: Doctor
- Permit: 72 hours detainment in hospital for assessment
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- Requirements: Nurse
- Permit: 6 hours detainment in hospital
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- Requirements: Consultant psychiatrist
- Permit: CTO (community treatment order) - Release from hospital to treat in community
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- Requirements: Police
- Permit: Court order to enter a property to bring a patient to a place of safety
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- Requirements: Police
- Permit: Detain a patient in a public place to bring them to a place of safety
👩🎤 Diseases / Disorders
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A mental health condition in which a person’s perception, thoughts, mood, and behaviour are significantly altered; characterised by ‘positive’ and ‘negative’ symptoms.
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- Auditory (commonly third person & can be commenting) & somatic hallucinations
- Thought:
- Formal thought disorder - Loosening of associations
- Content - Delusions
- Possessional thought disorder - Thought insertion, withdrawal, broadcasting
- Negative symptoms - Emotional blunting, social withdrawal
- Behaviour - Distracted by the high volume of stimuli, threatened fom voices
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- Paranoid: Well organised persecutory delusions & hallucinations
- Hebephrenic: Behaviour, mood and thought disturbance are predominant
- Catatonic: Motor symptoms, lack of eating, drinking and speaking
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- Schizoaffective disorder: Combination of schizophrenia and mood disorder (manic auditory hallucinations are usually second person and make more sense than the schizophrenic hallucinations)
- Mood stabiliser: Lithium
- Antipsychotic: Olanzapine
- Bipolar disorder
- Organic cause → Delirium
- Depression: Negative symptoms can mimic depression
- Charles Bonnet syndrome: Visual hallucinations (insight preserved)
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- Low IQ
- Strong family history
- Gradual onset
- Lack of clear precipitant
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- Antipsychotics (discussed below)
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Chronic, excessive worry for at least six months that causes distress or impairment.
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At least three key symptoms out of a possible six are required to make a diagnosis of GAD in adults (only one is required to make the diagnosis in children):
- Restlessness or nervousness
- Being easily fatigued
- Poor concentration
- Irritability
- Muscle tension
- Sleep disturbance
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- Lifestyle: Education & reassurance. Exercise & meditation.
- Psychoeducational groups, individual-guided self-help.
- CBT / serotonergic antidepressants, or a combination of these approaches.
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Recurring unexpected panic attacks over a 1-month period.
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- Family history: Higher risk among first-degree relatives.
- Stress.
- Comorbidities: Anxiety, mood, and substance-use disorders.
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- Self-help.
- Cognitive behavioural therapy.
- SSRI / SNRI.
- Long-term management includes relapse prevention after treatment is complete.
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PTSD may develop following a traumatic event or a situation involving threatened death, serious injury, or sexual violence. It is characterised by the features discussed below.
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The following symptoms must persist for > 1 month and cause impairment in function for a diagnosis to be made:
- Intrusions (re-experiencing)
- Avoidance
- Negative alterations in mood and cognition (emotional blunting)
- Alterations in arousal or reactivity (hypervigilance for threat)
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- Symptoms < 3 months (mild – moderate) → Active monitoring
- Symptoms < 3 months (severe) → Trauma-focused cognitive behavioural therapy (TFCBT)
- Symptoms ≥ 3 months:
- Eye movement desensitisation and reprocessing (EMDR)
- People are made ready to attend to the memory and associations while their attention is also engaged by a bilateral physical stimulation (e.g., eye movements, taps, or tones).
- Selective serotonin-reuptake inhibitors (SSRIs)
- CBT
Case:
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Acute stress reaction.
- < 1 month → Acute stress rather than PTSD
- He is exhibiting dissociative symptoms
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- Hyperthyroidism
- Cardiac chest pain
- Medication-induced: Salbutamol, theophylline, steroids, caffeine
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A mental state characterised by persistent low mood, loss of interest and enjoyment in everyday activities, and reduced energy, causing social and occupational dysfunction.
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'Depression identification questions'
- During the last month, have you often been bothered by feeling down, depressed, or hopeless?
- During the last month, have you often been bothered by having little interest or pleasure in doing things?
If the symptoms have been present most days, most of the time, for at least 2 weeks - ask about associated symptoms:
- Disturbed sleep (decreased or increased compared to usual)
- Appetite and/or weight
- Fatigue or loss of energy
- Agitation or slowing down of movements and thoughts
- Poor concentration
- Feelings of worthlessness or guilt.
- Recurrent thoughts of death, recurrent suicidal ideas, or a suicide attempt or specific plan.
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DSM-V does not state the number of MDD symptoms required for each severity level:
- Anhedonia discriminated severe depression from moderate depression based on discriminant analysis.
DSM-IV classified the severity of depression as follows:
- Mild: 2 core, ≥ 2 additional
- Moderate: 2 core, ≥ 3 additional
- Severe: 3 core, ≥ 4 additional
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- ≥ 2 weeks
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Mild/moderate depression:
- Antidepressant, likely SSRI (e.g. citalopram, escitalopram, fluoxetine, paroxetine, sertraline)
- Cognitive behavioural therapy (CBT)
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Severe depression (psychotic, suicidal, severe psychomotor retardation impeding activities of daily living, catatonia, or severe agitation):
- Psychiatric referral ± hospitalisation + antidepressant.
- Suicide risk management is critical.
- Antidepressant therapy is usually the first-line option.
- Electroconvulsive therapy (ECT) is the first-line treatment in some severe cases, but when immediate ECT is either not indicated or not an option, antidepressant pharmacotherapy is crucial.
- Immediate symptom management with benzodiazepine ± antipsychotic.
Case:
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- Differentials: Dementia & depression.
- Diagnosis: Depression because short history and global memory loss is key.
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An episodic mood disorder characterised by manic, or hypomanic, episodes.
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- Family history of bipolar disorder or suicide
- Early age of mood disorder onset
- Highly recurrent mood episodes
- Poor or limited response to traditional antidepressants
- Comorbid anxiety or substance misuse disorders
- A pattern of psychosocial instability
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- Mood: ↑ mood & energy
- Speech & thought: Pressured, flight of ideas, poor attention
- Behaviour: Insomnia, loss of inhibitions (sexual, financial)
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- Bipolar I (Manic): Psychosis & symptoms ≥ 7 days
- Distinct periods of abnormally, persistently elevated or irritable mood, with abnormally increased energy, lasting for at least 1 week.
- Most people will experience a major depressive episode at some point during their lives
- Bipolar II (Hypomanic): No psychosis & symptoms < 7 days
- A current or past hypomanic episode and a current or past major depressive episode.
- Hypomanic episodes present with similar symptoms as mania but cause less impairment and are of shorter duration, lasting for at least 4 consecutive days.
Management:
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- Mania: Urgent referral to the CMHT
- Hypomania: Routine referral to the CMHT
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- Start oral antipsychotic/mood stabiliser: Lithium / sodium valproate / risperidone
- Stop antidepressant (exacerbates manic symptoms)
- Consider: Rapid-acting non-oral antipsychotic or benzodiazepine
- IM olanzapine / IM lorazepam
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- Start oral antipsychotic: Lithium / sodium valproate / risperidone
- Switch to alternative first-line drug if the first isn’t effective
- Consider ECT
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- β-amyloid plaques - Build up of β-amyloid around neurons
- APP gene is linked to Alzheimer's and it's found on chromosome 21
- May present around 40 years
- Neurofibrillary tangles - Phosphate added to TAU proteins → Dysfunctional microtubules → Apoptosis
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- Mild/moderate: Acetylcholinesterase inhibitors
- Rivastigmine, donepezil
- Severe: Memantine
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- AchEi: Insomnia (most common), diarrhoea, N&V, bradycardia, increased salivary production
- Memantine: Constipation
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- ɑ-synuclein build up → Lewy body formation → Neuronal dysfunction
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- Parkinsonism (Motor): Differentiate whether dementia started first or parkinsonism as could be parkinson's dementia
- Visual hallucinations
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- Acetylcholinesterase inhibitors
- Levodopa (for Parkinsonism)
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- Small microvascular infarcts → Brain necrosis → ↓ Memory
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- Step-wise decline in cognitive function that doesn't return to baseline
- Abnormal neurological signs
- Vascular RFs: Metabolic syndrome, hypertension
- Previous stroke/TIA
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- Lifestyle: Improve vascular RFs
- Acetylcholinesterase inhibitors
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- Behavioural/personality changes
- Early onset: 45-65 years
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- AchEI make this worse and it's commonly used to manage all of the rest.
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- Infection
- Toxic: Substance misuse
- Metabolic: Electrolyte imbalance
- CNS: Space occupying lesion
- Vascular: Stroke/TIA
Differentiating:
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Delirium | Dementia | |
Onset | Hours – Days | Months – Years |
Cause | Commonly infective / metabolic | Degenerative |
Course | Temporary and reversible | Permanent and worsens |
Duration | Hours – Weeks | Months – Years |
Behaviour | Agitated, withdrawn or depressed | Intact early |
Attention & orientation | Impaired | Generally preserved, can be altered in later stages. |
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- Substance misuse
- Sensory impairment
- Hypothyroidism
- Depression
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- 18 years - Personality needs to have fully developed
Based on the following descriptions, what is the personality disorder?
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- Antisocial
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- Avoidant
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- Borderline
- Often childhood trauma
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- Dependent
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- Histrionic
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- Narcissistic
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- Obsessive complusive personality disorder
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- Paranoid
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- Schizoid
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- Schizotypal
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What disorder do the following patients have:
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- Hypochondrial disorder → Cancer
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- Somatisation → Symptoms
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- Conversion disorder, two types:
- Factitious (Muchhausen's) → Not seeking material gain
- Malingering → Seeking material gain
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- Munchhausen's syndrome (factitious disorder)
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- Alcohol → ↑ GABA inhibition in the brain → Tolerance to GABA
- Withdrawal → ↓ GABA inhibition → Sympathetic effects
- Symptoms: Tremor, tachycardia, sweating, dry mouth
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- DT: 48 hours after stopping alcohol → Delusions, hallucinations, fever, tremor, tachycardia
- Seizures can occur around 36 hours after withdrawal
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- Lifestyle: Advice, support from community team and referral to alcohol services
- Chlordiazepoxide reducing regime
- Acamprosate is another option
- Pabrinex (B1)
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- Produces an acute sensitivity to ethanol: Used in management of chronic alcohol misuse
Acute thiamine deficiency:
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- Wernicke's encephalopathy
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Triad:
- Confusion
- Ataxia
- Ophthalmoplegia
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- Korsakoff's psychosis
- Irreversible anterograde amnesia
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- µ-opioid receptor agonist
- Better because it has a longer onset of action and half life (less addictive) and less crosses the BBB causing less of a high
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- Buprenorphine (partial opioid antagonist)
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- Attempting to stop relapse of addiction
- Full opioid antagonist causing the individual to get less of a high from heroin
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A girl presents with a BMI of 15.5.
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- HR
- BP
- FSH & LH (infertility)
- T3 (hypothyroid)
- K⁺
- WCC
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G's & C's:
- Growth hormone
- Glucose
- Salivary glands (hypersalivation)
- Cholesterol
- Cortisol
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- Bulimia
- Laxatives
- Diuretics
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Rapid insulin production → Intracellular shift of ions
- ↓ PO₄³⁻
- ↓ Mg²⁺
- ↓ K⁺
- ↑ Glucose
💊 Management
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- Fluoxetine
- Citalopram
- ECG because can cause prolonged QT → Risk of Torsades
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- Sertraline
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- Normal for mood to fall first before starting to feel better, takes 4-6 weeks to feel full effects
- ↑ suicidal risk early as motivation is increased but mood is still the same
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- Congenital heart defects
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- NSAIDs: ↑ risk of peptic ulcers & GI bleed → Prescribe PPI
- Warfarin: Avoid completely
- Triptans: Risk of serotonin syndrome. Avoid completely
Monitoring:
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- No. Minimum course is 6 months.
- If stopped earlier: ↑ risk of relapse.
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- Review 2 weeks after initiation
- Continue monthly until they are stable
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- No, they need to be reduced over 4 weeks. If not they may get discontinuation symptoms
- Fluoxetine can be stopped immediately due to long half-life
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- Diarrhoea & vomiting
- Abdominal pain
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- Venlafaxine
- Duloxetine
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- ɑ-2-adrenoceptor blocker → ↑ serotonin & noradrenaline
- Causes sedation & ↑ appetite at low doses and these effects are less prominent in high doses
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- IV sodium bicarbonate
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Antimuscarinic:
- Blurred vision
- Dry mouth
- Overflow incontinence
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- Monoamine oxidase is the enzyme that metabolises serotonin & noradrenaline in the presynaptic neuron → MOAs stop this action
- Avoid cheese as it causes a hypertensive reaction
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- Withdraw citalopram, when completely off introduce the sertraline
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- Withdraw fluoxetine, wait 7 days, introduce paroxetine
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- As you withdraw the citalopram, increase the amitryptyline
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- Fluoxetine - Long half life therefore needs more time to get out of the system
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Atypicals:
- Olanzapine
- Quetiapine
- Risperidone
- Aripiprazole
- Clozapine
Typicals:
- Haloperidol
- Chlorpromazine
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- Dopamine (D₂) receptor antagonists
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- FBC → Risk of agranulocytosis
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- Smoking cessation → Significant ↑ clozapine levels
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- Risk of myocarditis
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- ↓ seizure threshold
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Increasing dopamine has effects on both the nigrostriatal pathway (movement) and mesocorticolimbic system (pleasure/mood).
- Parkinsonism
- Acute dystonia
- Torticollis (wry neck) - Unilateral pain & deviation of the neck
- Oculogyric crisis - Upward deviation of the eyes
- Procyclidine
- Tardive dyskinesia
- Late-onset choreoathetoid movements (kinesia = movements)
- Lip smacking
- Excessive blinking
- Pouting of jaw
- Tetrabenazine
- Akathisia
- Restless leg - Severe reselessness and inability to stay still
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Dopamine → Prolactin inhibition
- ↓ Dopamine → ↑ Prolactin secretion → Galactorrhoea
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- Olanzapine
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- Aripiprazole
Cases:
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- Trial olanzapine/risperidone for 4-6W
- Try a different antipsychotic (one not tried above) for 4-6W
- Consider clozapine
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- Neuroleptic malignant syndrome
- IV fluids
- Dantrolene/bromocriptine
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- IV magnesium sulphate (Torsades)
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- ↑ GABA inhibition within the brain
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'I bend frequently during barbeque'
- Benzodiazepines - ↑ chloride channel frequency
- Barbituates - ↑ chloride channel duration of opening
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- Diazepam
- Lorazepam
- Midazolam
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- Convert the current dose to the equivalent of diazepam
- Slowly decrease the diazepam by approx. 1/8 every fortnight (can take between 1 month to 1 year)
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- Flumazenil (although management with flumazenil is controversial). Follow local guidelines.
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- Bipolar affective disorder
- Refractory depression
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- 0.4 – 1 mmol/litre (lower end of the range for maintenance therapy and elderly patients).
- 0.8 – 1 mmol/litre (acute episodes of mania, and for patients who have previously relapsed or have sub-syndromal symptoms).
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- Kidneys: Keep in mind for patients with AKI / CKD.
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- Coarse tremor
- CNS disturbance: Seizures, impaired co-ordination, dysarthria
- Arrhythmias
- Visual disturbance
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Every 3 months:
- Lithium levels (when dose starts/changes, check levels weekly until stable).
Every 6 months:
- U&E: Nephrotoxic.
- TFTs: Risk of hypothyroidism.
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- Refractory depression
- Treatment-resistant schizophrenia
- Catatonia due to either of the above
- Waxy flexibility → Move the pillow from behind the patients head and the head stays in the same place.
- Posturing → Patient holds odd positions for prolonged periods.
- Often will not eat, drink or speak.
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- ↑ intracranial pressure
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- Headache
- Nausea
- Amnesia (mainly retrograde but can be anterograde)
- Cardiac arrhythmia
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