CP2 - PSYCH

List possible differential diagnoses for patients with psychiatric symptoms

-new onset psychosis - 1) primary - schizophrenia spectrum (symptoms for >28 days, no "organic" cause, 1st rank symptoms or persistent hallucinations & delusions), other psych illnesses (eg/ delusional disorder, schizoaffective disorder) 2) secondary - dementia, delirium, medical illness, toxins, drugs, meds 3) medical illnesses - a) endocrine - hypo or hyper-thyroidism, Cushing's, insulinomas, pheochromocytoma b) metabolic - acute intermittent porphyria (AIP) c) autoimmune - SLE, Hashimoto encephalopathy, paraneoplastic syndromes d) infections - cerebral malaria, toxoplasmosis, neurocysticercosis, sleeping sickness, HIV e) neurological eg/ temporal lobe epilepsy, MS, Wilson's, Huntington's 4) meds - steroids, stimulants, dopaminergic eg/ L-dopa, amantadine, anticholinergics -depression - 1) CNS eg/ Parkinson's, Huntington's, dementia, MS, neoplastic lesions, CVA 2) endocrine eg/ hypo & hyper-thyroidism, Cushing's, Addison's 3) drugs eg/ cocaine (opiates), SE of some CNS depressants, steroids, L-dopa 4) infections eg/ mononucleosis, HIV, syphilis, herpes 5) other - sleep related disorders, malignancy, SLE, RA, renal failure, porphyria 6) psych - schizophrenia, anxiety disorder, eating disorder, dementia -dementia - delirium, depression, amnesia, learning difficulties, psychotic disorders, normal ageing -schizophrenia - 1) substance induced psychotic disorder eg/ alcohol, stimulants, hallucinogens 2) medical eg/ brain disease, metabolic (hypernatremia), endocrine (Cushing's) 3) mood disorders with psychotic features 4) acute psychotic disorder & schizophreniform disorder 5) sleep related 6) dementia & delirium 7) delusion disorder & body dysmorphic disorder

Recommended limit of alcohol consumption

1) 1 unit = 10ml or 8g of pure alcohol, around the amount of alcohol the average adult can process in an hour a) number of units in a drink based on size of drink & alcohol strength 2) men and women advised not to drink more than 14 units a week on a regular basis a) drinking should be spread over three or more days if regularly drinking as much as 14 units a week b) try to have several drink-free days each week 3) calculating units - standard measure ABV = alcohol by volume a) ABV measures amount of pure alcohol as % of total volume of liquid in a drink eg/ wine that says "12% ABV" or "alcohol volume 12%" means 12% of volume of drink is pure alcohol b) work out how many units there are in any drink by multiplying total volume of a drink (in ml) by ABV (in %) and dividing the result by 1,000 eg/ to work out units in a pint (568ml) of strong lager (ABV 5.2%): 5.2 (%) x 568 (ml) ÷ 1,000 = 2.95 units c) 750ml bottle of red, white or rosé wine (ABV 13.5%) contains 10 units d) small glass wine = 1.5 units e) standard glass wine = 2 units f) large glass wine = 3 units g) pint lower strength beer/lager/cider = 2 units h) higher strength beer/lager/cider = 3 units i) bottle or can of beer/lager/cider = 2 units j) alcopop bottle = 1.5 units k) small shot of spirits = 1 unit (25ml)

Psychiatric disorders in children & adolescence - ADHD, dyslexia, assessment (including risk assessment), and management

1) ADHD - a) epidemiology - I) prevalence 1-5% (variable depending on diagnostic criteria) II) boys:girls 3:1 III) onset < 7 years IV) persistent: in more than 1 setting e.g. home & school b) presentation - core symptoms: inattention, hyperactivity, impulsivity. maladaptive and inconsistent with child's developmental level c) aetiology: I) genetic II) biological, neurotransmitters, brain injury, ? certain foods III) psychological/social 2) dyslexia - a) epidemiology - I) prevalence - most severe = 4%, widest possible definition = 10% II) boys: girls 4:1 b) presentation - often presents to CAMHS with secondary behaviour problems I) persistent difficulties processing & producing written material out of keeping with pt's other abilities - modern disorder as reading/ writing only recently become universally required skills c) aetiology: I) genetic II) biological, neurotransmitters, brain injury, III) psychological/ social factors affect problem presents & how pt copes with it 3) adolescence & mental health - adolescence is a modern, culturally determined concept a) special challenge in social development b) indices for full maturity - I) identity formation II) high priority for human relationships III) comfortable alone or with others IV) empathy and appreciation for needs of others V) formation of reciprocal, meaningful and mutually dependent relationships c) adolescents can develop mental illnesses such as mood disorder, anxiety disorder, substance misuse, eating disorder and psychosis: they share similar features as adult disorders d) self-harm & stigma is also common among adolescents 4) assessment - principles similar to adult assessment - history, mental state examination and risk assessment. remember the following: a) always include family (unless young person refuses) - especially for older children, you may want to speak to the child before their parents b) remember to consider risk and any underlying mental illness c) social context more vital than in adults, children can't choose where they live or go to school, they get what the adults around them supply 5) risk assessment - a) remember risk to self and risk to others b) one particular concern is child protection/safeguarding children - physical, sexual, emotional abuse & neglect c) abuse may underlie presenting symptoms d) duty of all professionals to protect children & role of social/children services in safeguarding 6) mx - bio-psychosocial model a) biological - I) generally less common as first-line II) fewer treatments, limited evidence base III) nice guidelines: depression in adolescents (only fluoxetine licenced), hyperactivity (ADHD) in children b) psychological - depending on disorders, commonly used: CBT, family therapy c) social - very important, links to wider network especially education, social services 7) ADHD - a) biological - meds (needs titration and monitoring): I) stimulants - methylphenidate (ritalin, concerta etc.) II) non-stimulants - atomoxetine b) psychological parenting course social - liaison with education (e.g. special need NB/ psychiatric disorders may have different aetiology & present differently in different age groups NB2/ importance of relationships on children's mental health, also need to consider views of each family member when working with families

Basic structure and delivery of psychiatric services in the UK

1) How secondary mental health care provided and monitored in the UK: a) Psychiatric services in the UK have broadly similar structures, but names of various teams will differ from area to area 2) Local mental health service usually provided by secondary care mental health NHS Trust a) It's commissioned to provide services by a small number of Clinical Commissioning Groups (CCGs) that have replaced Primary Care Trusts (PCTs) b) CCGs made up of consortia of GPs (i.e. Primary Care) c) almost all services psychiatry provides are commissioned by CCG, depending on the needs they perceive exist

Definition, classification & epidemiology of anxiety disorders (GAD, panic disorder, phobia, OCD, PTSD)

1) anxiety is a part of the normal emotional range of humans - normal physiological response to stressful situations = adaptive response to experience of threat or danger. Behavioural response can be "fight or flight" = respiratory, CV & other changes that prepare for flight from, or confrontation of danger. Anxiety is adaptive at lower levels & disabling at high levels 2) following features distinguish pathological anxiety from 'normal' anxiety: a) autonomy: no or minimal environmental trigger b) intensity: exceeds pt's capacity to bear discomfort c) duration: symptoms are persistent d) behaviour: anxiety impairs functioning +/- results in disabling behaviours 3) normal fears at each stage in development: a) birth to six months - loud noises, rapid position changes b) 7-12 months - strangers, looming objects, unexpected object c) 1-5 years - strangers, storms, animals, dark, separation from parents d) 6-12 years - supernatural, bodily injury, disease, burglars, failure, criticism e) 12-18 years - performance in school, peer scrutiny, appearance 4) basic classification of anxiety - a) symptoms constant = GAD (3% prevelance) b) symptoms episodic - I) phobias (eg/ agoraphobia, social, specific - 8% prevelance) II) panic disorder (3% prevelance) III) PTSD (4% prevelance) IV) OCD (2% prevelance)

Ethical & legal principles of mental health legislations in managing psychiatric emergency, including the Mental Health Act and the Mental Capacity Act

1) section 4 used in emergency situations a) pt detained in hospital for an assessment of mental health for a shorter period of time b) needs the recommendation of 1 doctor (unlike section 2) 2) pt detained under a section 4 if: a) pt needs an assessment or possible medical treatment; and b) pt needs to be detained in interests of their own health, own safety or to protect other people; and c) it's urgent and necessary that pt is admitted and detained under section 2; and d) using section 2 would involve an "undesirable delay" 3) pt can be detained for up to 72 hours 4) 2nd doctor should assess pt ASAP after detained to decide whether section 4 should be changed to a section 2 5) under a section 4 pt can refuse treatment. You must give consent before any treatment is given to you. 6) sometimes treatment can be given without pt's consent if: a) pt doesn't have capacity to make a decision about tx & tx in pt's best interests b) pt needs tx in an emergency to prevent serious harm to yourself or others eg/ I) pt attempting and threatening suicide II) victims of serious assaults III) casualties of major incidents IV) pts with serious injuries who decline medical aid

Possible family reactions to intellectual disability

1) shock - panic - denial 2) grief - overprotection/rejection 3) projection of grief - a) guilt - valid (isolation) or invalid (chronic sorrow) b) anger - relatives (disharmony) or professionals (scapegoating) 4) bargaining - late rejection 5) acceptance - infantilization 6) ego-centred work - over-identification

Normal & abnormal psychological and behavioural responses to physical illness health such as sick role and illness behaviours

1) sick role - a term used in medical sociology regarding sickness and the rights and obligations of the affected a) Talcon Parsons who argued that being sick means the sufferer enters a role of 'sanctioned deviance', because, from a functionalist perspective, a sick individual is not a productive member of society. This deviance needs to be policed, which is the role of the medical profession. Genuinely, Parsons argued the best way to understand illness sociologically is to view it as a form of deviance which disturbs the social function of the society b) general idea is that pt who has fallen ill is not only physically sick, but now adheres to specifically patterned social role of being sick. 'Being Sick' is not simply a 'state of fact' or 'condition', it contains within itself customary rights and obligations based on the social norms that surround it. The theory outlined two rights of a sick person and two obligations: I) rights: sick pt is exempt from normal social roles, sick pt is not responsible for their condition II) obligations: sick pt should try to get well, sick pt should seek technically competent help and cooperate with the medical professional c) 3 versions of sick role: 1) conditional 2) unconditionally legitimate 3) illegitimate role: condition stigmatised by others 2) illlness behaviours - describes the ways pts respond to bodily indications & conditions under which they come to view them as abnormal. Illness behaviour involves the manner in which persons monitor their bodies, define & interpret their symptoms, take remedial action, and utilize various sources of help as well as the more formal health-care system. Also concerned with how people monitor & respond to symptoms and symptom change over course of illness and how this affects behaviour, remedial actions taken, and response to treatment. Different perceptions, evaluations and responses to illness have, at times, dramatic impact on the extent to which symptoms interfere with usual life routines, chronicity, attainment of appropriate care and co-operation of pt in treatment. Variables affecting illness behaviour usually come into play well before any medical scrutiny and treatment

Indications & practical implementation of social interventions in psychosis

1) social work & housing involvement often necessary 2) community psychiatric nurses may help provide information/education & monitor for early signs of relapse 3) for pts of depot, non-attendance at GP/CPN appointment may indicate problem 4) drop-in community centers & other support by non-statutory & other voluntary organisations can be helpful 5) consider interventions by other professions when needed eg/ OT, physios etc 6) refer pts to SANE, Rethink, MIND etc

Anorexia nervosa: prognosis, common co-morbidity, physical, psychiatric and social consequences, and management

1) tx of anorexia nervosa a) biological - I) weight restoration is key - input from Specialist Dietician (monitor intake & re-feeding syndrome) II) regular weight & blood monitoring, frequency depends on severity eg/ FBC, U&E, LFT, glucose, phosphate, Mg, Ca, Ck, zinc, B12 and folate III) Dexa bone density scan if indicated IV) ECG, looking for QTC prolongation, rate<50, heart block, arrhythmias V) admission if blood tests are severely out of range - MARSIPAN b) psychological - I) Motivational Interviewing, CBT, Interpersonal therapy, Compassion Focused Therapy, Mindfulness, Arts Psychotherapy II) family therapy (systemic) common if pt under 18 years of age III) therapeutic relationship are most important factor in recovery IV) formal psychological therapy unlikely to be effective if BMI <13 c) social - I) advise to inform a loved one for extra support, carer support, inc flexibility & participation in social plans and lifestyle goals eg/ hobbies 3) complications: a) hypokalaemia: common and may cause fatal arrhythmias b) hypotension c) cardiac eg/ arrhythmias, mitral valve prolapse, peripheral oedema, death d) anaemia and thrombocytopenia e) hypoglycaemia f) osteoporosis: restoring pt's weight is best treatment g) constipation h) lack of growth in teenagers, and lack of secondary sexual characteristics - infertility i) Infections j) renal calculi, AKI, CKD k) anxiety and mood disorders l) social difficulties 4) prognosis: a) slow recovery rates - 1/3 up to 3 years, another 1/3 3-6 years II) recovery less likely after 15 years - focus on improvement on QOL III) after 10 years, 50% recovered, 10% mortality (1/3 due to suicide), 40% ongoing eating problem (many cross-over to BN) IV) poor prognostic indicators: v low weight, bulimic features, family difficulties, personality difficulties, longer illness duration

Bulimia nervosa: prognosis, common co-morbidity, physical, psychiatric and social consequences, and management

1) tx of bulimia nervosa a) biological - I) SSRIs, most commonly Fluoxetine II) cessation of laxatives & excess alcohol III) regular weight & blood monitoring eg/ U&E (check for hypokalaemia) b) psychological - I) psycho-education regarding coping mechanisms II) CBT (20 sessions), Interpersonal Therapy, Compassion Focused Therapy, Mindfulness, Arts Psychotherapy III) therapeutic relationships most important factor in recovery IV) input from Specialist Dietician - psycho-education on balanced eating c) social - I) advise to inform a loved one for extra support, carer support II) focus on encouraging regular intake, cessation of restrict, binge, purge cycle III) inc involvement with social plans and lifestyle goals eg/ hobbies 4) complications - a) haematemesis, and metabolic complications (eg, hypokalaemia), following excessive self-induced vomiting b) dental erosions c) painless enlargement of the salivary glands, tetany and seizures d) around 10-15% go on to develop anorexia 5) comorbidity with bulimia nervosa - needs consideration within mx plan as dec binge/purge behaviour can lead to inc in other coping mechanisms eg/ alcohol misuse, illicit substances misuse, self-harm 6) prognosis - 70% recover in 10 years, 1% mortality rate, poor prognostic indicators: low body weight, comorbid depression

Indications, mechanism of action and side effects of mood stabilisers

1) types - Lithium, Valproate, Lamotrigine, Carbamazepine, atypical antipsychotics eg/ Quetiapine, Olanzapine and Aripiprazole 2) indications - a) prophylaxis for bipolar, tx of an acute mania/hypomania (not 1st line), tx of bipolar depression, treatment-resistant depression 3) lithium - a) mechanism - remains unclear b) therapeutic range - narrow, so too little is ineffective and too much gives toxicity. Titrate lithium dosing and monitor levels, aim for 0.4-1.2 mmol/L d) SE - I) GI upset II) fine tremor III) polyuria & polydipsia IV) metallic taste in mouth V) weight gain VI) oedema e) toxicity - associated with low sodium diets, dehydration, drug interactions (NSAIDS, ACEI, diuretics), Addison's disease. Toxicity occurs with plasma concentrations >1.5 mmol/L. Symptoms: I) diarrhoea II) course tremor III) ataxia, dysarthria, convulsions IV) nystagmus V) confusion f) monitoring - due to narrow therapeutic range check lithium level once every 3 months, U&Es (every 6 months), TFTs (every 6 months) g) pregnancy - lithium is a known teratogen, should be withdrawn prior to conception. Mostly ASD, VSD, Ebstein's anomaly (abnormality of the tricuspid valve) 4) valproate - a) mechanism of action - inhibits catabolism of GABA, alters synaptic plasticity, promotes BDNF expression and dec protein kinase C. c) pregnancy - known teratogen, so adequate contraception. Inc risk of congenital malformation by 10%, NTD, low verbal IQ, autism, valproate syndrome 5) lamotrigine (depression) a) SE - I) generally well tolerated, dose needs to be titrated to prevent SJS II) least teratogenic, but inc risk of cleft lip/palate if first-trimester exposure 6) carbamazepine - blocks voltage-dependent sodium channels 7) choice of mood stabiliser - wherever possible choice made with pt a) special consideration if women with childbearing potential - all teratogens so essential that adequate contraception is in place

Overview of the classification of psychiatric disorders and how these may present clinically contd.

4) main categories of in DSM are: a) disorders diagnosed in infancy, childhood or adolescence eg/ mental retardation, ADHD b) delirium, dementia and amnesia & other cognitive disorders eg/ Alzheimer's c) schizophrenia & psychotic disorders eg/ delusional disorder d) mental disorder due to general medical condition eg/ AIDS-related psychosis e) substance related disorders eg/ alcohol abuse f) mood disorders eg/ major depressive disorder, bipolar g) anxiety disorders eg/ GAD, social anxiety disorder h) somatoform disorders eg/ somatization disorder i) factitious disorders eg/ Munchausen syndrome j) dissociative disorders eg/ dissociative identity disorder k) sexual & gender identity disorders eg/ dyspareunia, gender identity disorder l) eating disorders eg/ anorexia nervosa, bulimia nervosa m) sleep disorders eg/ insomnia n) impulse control disorders eg/ kleptomania o) adjustment disorders eg/ adjustment disorder p) personality disorder eg/ narcissistic personality disorder q) other conditions that may be a focus of clinical attention eg/ tardive dyskinesia, child abuse

Clinical features and management of emergency related to substance misuse including delirium tremens and Wernicke encephalopathy

delirium tremens - 1) medical emergency, typically occurs 1-7 days after last drink 2) occurs in 5% pts with AWS 3) symptoms include (in addition to symptoms of uncomplicated withdrawal): clouding of consciousness & disorientation to time, place and person; amnesia for recent events; hallucinations (visual, tactile, auditory) & delusions; severe psychomotor agitation & tremor; fever; autonomic disturbances & electrolyte 4) mortality up to 40% if left untreated 5) differential: alternative cause of delirium, head injury, hepatic/Wernicke encephalopathy 6) mx - a) meds (Benzodiazepines) for symptomatic relief b) nutritional & vitamin supplementation - thiamine & mulitvitamins prescribed as standard to pts with alcohol dependence c) close monitoring for severe physical and psychiatric complications throughout withdrawal period d) outpatient tx - preferred as relatively inexpensive, outcomes (eg/ pt concordance and abstinence at 6 months following tx) are comparable to inpatient detoxification treatment e) inpatient tx considered for pts with - past history of severe and complicated withdrawals (eg/ seizures, delirium), current psychiatric symptoms: delirium, confusion, psychosis, suicidality, co-morbid physical illness, severe malnutrition or frailty, severe N+V or biochemical abnormalities f) pharmacological mx - consider a reducing regime of benzodiazepines for pts with: active symptoms of withdrawal; hx of dependence syndrome; consumption >10 units/day over previous 10 days Wernicke-Korsakoff syndrome - Wernicke's encephalopathy and Korsakoff psychosis respectively represent acute & chronic phases of a single disease process. Caused by neuronal degeneration secondary to thiamine (vitamin B1), most commonly seen in heavy drinkers 1) Wernicke encephalopathy a) aetiology - I) occurs secondary to thiamine (vitamin B1) deficiency II) alcohol dependent individuals particularly susceptible to thiamine deficiency for 3 reasons - tend to have poor dietary habits & vitamin intake is poor; chronic alcohol intake dec thiamine absorption from GI tract; many heavy drinkers have liver disease & capacity for hepatic storage of thiamine is dec III) chronic alcohol misuse is most common cause of thiamine deficiency in UK. Rarer: anorexia, post-GI surgery, hyperemesis gravidarum b) symptoms - classic symptom triad in Wernicke's encephalopathy: I) acute confusional state + II) ocular-motor signs (ophthalmoplegia, nystagmus) + III) ataxic gait IV) associated symptoms: peripheral neuropathy, resting tachycardia, stigmata of nutritional deficiency V) complete triad of symptoms is only seen in 10% cases. Confusion is most common presenting symptom (seen in 80% of cases) c) pathophysiology - brain imaging may show haemorrhages and secondary gliosis in periventricular and periaqueductal grey matter particularly involving mamillary bodies, hypothalamus and tegmentum of the midbrain d) tx - I) all pts who have symptoms or at high risk of developing WE should be given parenteral vitamin replacement - high potency vit B1 replacement - IV Pabrinex - 2 ampoules over 30 mins 2x/day for 3-7 days II) don't rehydrate with glucose solutions before giving thiamine III) treat co-existing alcohol withdrawal syndrome e) prognosis - if WE left untreated, ~80% cases progress to Korsakoff syndrome, mortality is ~15% if left untreated 2) Korsakoff syndrome a) aetiology - I) usually the result of thiamine deficiency (most commonly due to heavy alcohol use) II) Rarer: head injury, encephalitic processes, CO poisoning III) Korsakoff syndrome not necessarily preceded by WE & can present in a "chronic" form b) symptoms - I) absence or significant impairment in ability to lay down new memories (anterograde amnesia) II) may be some retrograde amnesia (usually less marked) III) confabulation - pt may describe false memories for a period for which they have amnesia IV) apathy: pts lose interest in things quickly, & indifferent to change c) tx - I) aggressively treat initial Wernicke's encephalopathy if present II) continue oral thiamine & multivitamins for up to 2 years III) appropriate psychosocial interventions for cognitive impairment (eg/ OT, carer support etc.) d) prognosis - 20% cases show complete recovery and 25% show significant recovery over time with the remainder largely showing no improvement

Ethical & legal principles of mental health legislations in clinical practice, including the Mental Health Act

1) act of Parliament of UK which applies to people in England and Wales. Covers reception, care and treatment of mentally disordered persons, mx of their property & other related matters. Provides legislation by which people diagnosed with a mental disorder can be detained in hospital or police custody and & be assessed or tx against their wishes ("sectioning") 2) section 2 - assessment, up to 28 days, 2 Doctors + AMHP (eg/ social workers, nurses, clinical psychologists and OTs) a) used when no clear psychiatric diagnosis at the time - allows doctor to hold & treat someone against their will for up to 28 days. After this need to implement Section 3 order or begin treating the patient informally b) cannot implement two Section 2 orders back-to-back 3) section 3 - tx, lasts up to 6 months, need 2 Doctors + AMPH a) used when definitive psychiatric diagnosis or prognosis - allows doctor to hold & treat someone against their will up to 6 months. If the section is renewed it lasts a further 6 months, and any further renewal from then on lasts for 1 year 4) section 4 - emergency, lasts up to 72 hrs, needs 1 Doctor + 1 AMPH a) once in hospital, a further medical recommendation from 2nd doctor would convert from a section 4 to a Section 2 assessment order. Rare 5) section 5(2) - emergency, lasts up to 72 hrs, needs 1 Doctor a) can be used for patients who fall into the following categories: I) in-patient with a mental illness II) if pt is at risk III) if informal admission is no longer appropriate, i.e. pt wants to leave IV) if pt needs an assessment for Section 2 or 3 b) allows Doctor to hold pt for Mental Health Act assessment - can't: I) give treatment II) do another 5(2) back-to-back III) use in A&E or Outpatients c) can't be signed by F1 6) section 5(4) - emergency, up to 6 hrs, needs 1 MH nurse 7) section 135 - power of entry & removal to Place of Safety, up to 72 hours, needs a magistrate 8) section 136 - place of safety, lasts up to 72 hours, needs a police officer a) order which gives police power to remove a person who they consider to have a mental disorder to a "Place of Safety". Once pt taken to a "Place of Safety" they can be assessed, & Section 2 or 3 order can be implemented 9) pt may be treated under Mental Health Act and still live in community on Community Treatment Order - order only relates to pt's psychiatric care

Some of the practical and ethical issues for people with an intellectual disability

1) adaptive behavior, or adaptive functioning often lacking - skills needed to live independently (or at minimally acceptable level for age). To assess adaptive behavior, professionals compare functional abilities of a child to those of other children of similar age. To measure adaptive behavior, professionals use structured interviews, with which they systematically elicit info about pts' functioning in community from people who know them well. Certain skills are important to adaptive behavior, such as: daily living skills eg/ getting dressed, using the bathroom, feeding oneself communication skills eg/ understanding what is said & being able to answer social skills with peers, family members, spouses, adults, and others 2) society - pts with intellectual disabilities often not seen as full citizens of society. Person-centered planning and approaches are seen as methods of addressing labeling & exclusion of socially devalued people, encouraging a focus on pt as someone with capacities and gifts as well as support needs a) until middle of 20th century, pts with intellectual disabilities were routinely excluded from public education, or educated away from other typically developing children

Aetiology, differential diagnosis and treatment of psychosis

1) aetiology - a) biological - fmx, obstetric complications, dopamine theory, neurodevelopmental theory b) psychological - cognitive errors (jumping to conclusions), premorbid personality (schizotypal disorder) c) social - urban living & migration (x3), life events (eg/ abuse), ethnicity (x4 in afro-caribbeans, south Asians) d) other - substance abuse 2) differential diagnoses - a) psychological - substance-induced psychosis, delirium, mood disorder eg/ major depression or bipolar, schizophrenia spectrum (also - dissociative disorders, delusional disorder, personality disorders, severe stress or anxiety, lack of sleep) b) medical conditions - seizures, Cushing's, hypoglycaemia, brain problems (eg/ MS, tumour, Parkinson's), infection (eg/ HIV, syphilis, malaria) c) substance misuse - excess intake or withdrawal eg/ cocaine, amphetamine, methamphetamine, mephendrone, MDMA, cannabis, LSD (acid) d) malingering & factitious disorders NB/ if psychosis for > 1 month think schizo-, delusional or mood disorder. Rapidly changing delusions & mood differentiate brief psychosis from schizophrenia 2) mx - important to recognise & manage 1st episode of psychosis correctly, as delay in diagnosis may adversely affect prognosis a) tx underlying cause b) antipsychotics + psychological therapies + social support c) if 1st psychotic episode refer to early intervention team (if 18-35) d) admission to psychiatric unit e) if symptoms disabling, antipsychotic given 1st line for <1 month: I) typical (1st-gen) antipsychotics: haloperidol, flupentixol, fluphenazine, chlorpromazine II) if adverse SE use atypical (2nd-gen) antipsychotics: olanzapine, quetiapine, ziprasidone, risperidone, aripiprazole III) dec feelings of anxiety within hours, may take weeks to dec psychosis IV) oral or injection - slow-release antipsychotics = 1 injection every 2-6 weeks f) psychological treatment - dec intensity & anxiety caused by psychosis I) CBT - 1-1 over 16+ sessions. Help pt achieve goals meaningful & important to them eg/ dec distress, returning to work, regaining a sense of control II) family intervention - helping both pt & family cope with condition III) self-help groups - may help to be around others going through same thing g) violence and aggression - uncommon in psychosis - more likely to be victims of violence than perpetrators h) social - I) daytime activities/ occupation/ employment/ education/ leisure hobbies II) family & relationships & safeguarding III) accomodation & benefits

Aetiology, differential diagnosis, comorbidities, management, physical, psychiatric and social consequences and prognosis of anxiety disorders (GAD, panic disorder, phobia, OCD, PTSD)

1) aetiology - combo of genetics & environmental a) risk factors - genetics, child abuse, fmx of mental disorders, poverty, caffeine or alcohol or benzo or cannabis dependence (also acute withdrawal phase of alcohol), chronic exposure to organic solvents eg/ painting, varnishing, stress, medical conditions - SE of an underlying endocrine disease, low levels of GABA, amygdala 2) comorbidities - a) endocrine - thyroid dysfunction, phaeochromocytoma b) metabolic - acidosis (eg/ DKA), hyperthermia or hypothermia c) hypoxia - congestive heart failure, angina, COPD, anaemia d) neurological - seizures, vestibular dysfunction e) cardiac - arrhythmias e.g. Supraventricular Tachycardia (SVT) f) drugs - alcohol, opiates, caffeine, amphetamines, cocaine etc 3) mx - flight-fight-freeze response is a natural human defence mechanism to counter normal anxiety. Some maladaptive defence mechanisms are also 'naturally employed by humans to treat their anxiety' NB/ pts can manage their own anxiety through avoidance & safety behaviours, but these behaviours feed into anxiety & worsen illness a) 1st-line tx for anxiety disorder = psychological tx - psychoeducation + CBT + social interventions I) CBT - systematic desensitisation or graded exposure (phobia); exposure & response prevention (OCD) 4) 1st-line tx of mild to moderate anxiety = psychological treatment: antidepressants, B-blocker - sometimes used to dec HR & autonomic arousal of anxiety, benzos 4) tx for PTSD according to NICE: a) during therapy, original trauma is re-experienced in as much detail as possible eg/ pt narrating or imagining every step. While doing this, they fix their eyes on therapist's finger as it quickly passes from side to side in front of them = eye movement desensitization and reprocessing NB/ antipsychotics - not routinely used, but can be beneficial in severe cases

Role of different medications in treating substance misuse

1) alcohol - recommended by NICE to treat alcohol misuse: a) acamprosate (Campral) - used to help prevent relapse when successfully achieved abstinence from alcohol - dec alcohol craving I) affects levels of GABA (partly responsible for inducing craving for alcohol) II) course starts as soon as pt begins withdrawal & can last 6 months b) disulfiram (Antabuse) - used if trying to achieve abstinence but concerned pt may relapse, or if had previous relapses I) deters drinking by causing unpleasant physical reactions eg/ N+V, chest pain, dizziness II) as well as alcoholic drinks pt to avoid all sources of alcohol eg/ aftershave, mouthwash, some vinegars, perfume, paint thinners and solvents III) lasts for 1 week after use IV) at start see healthcare team every 1-2 weeks (for 2 months), then monthly c) naltrexone - prevent relapse or limit amount of alcohol pt drinks I) blocks opioid receptors, stopping effects of alcohol - also stops painkillers that contain opioids working, including morphine and codeine II) course of naltrexone can last up to 6 months d) nalmefene (Selincro) - prevents relapse or limit amount of alcohol drunk I) works by blocking opioid receptors in brain to dec cravings for alcohol II) recommended for alcohol dependence if still drinking >7.5 units a day (men) or >5 units a day (women); no physical withdrawal symptoms; pt doesn't need to stop drinking immediately or achieve total abstinence 2) illicit drugs - a) opioid meds eg/ methadone & buprenorphine treat addiction and dependence on other opioids such as heroin, morphine or oxycodone I) dec cravings for opiates, both may be used as maintenance meds (taken for an indefinite period of time), or used as detoxification aids b) naltrexone - long-acting opioid antagonist I) blocks euphoric effects of alcohol and opiates - cuts relapse risk during first 3 months, but far less effective in helping pts maintain abstinence c) ibogaine - hallucinogenic drug promoted by certain fringe groups to interrupt both physical dependence and psychological craving to a many drugs including narcotics, stimulants, alcohol and nicotine

Epidemiology, clinical presentation, aetiology and prognosis of common psychiatric disorders during pregnancy and after childbirth

1) all women should be screened at antenatal booking for previous hx of or current psychiatric disorder 2) women with a hx of serious affective disorder or other psychoses should be referred in pregnancy for psychiatric assessment & mx even if well 3) psychiatric services should have priority care pathways for pregnant & postpartum women. 4) who to refer - all women with previous or current: a. schizophrenia or psychosis b) bipolar disorder c) postpartum psychosis d) severe depression e) all woman on mood stabilisers. f) any women with fmx of bipolar affective disorder or schizoaffective disorder AND a personal history of any psychiatric disorder 5) perinatal psychiatric service provides care for women with psychiatric disorders complicating pregnancy, childbirth & postpartum period. Includes not only women who develop illnesses during perinatal period but also women with pre-existing psychiatric illness 6) psychiatric disorders in pregnancy - psychiatric disorders common in pregnancy, disorders slightly inc in 1st trimester in comparison to general population a) disorders usually mild and likely to improve b) milder psychiatric disorders respond to psychosocial interventions c) 1st onset of serious mental illness rare in pregnancy d) depression & anxiety in 3rd trimester may continue in postpartum as postnatal depression e) up to 1/3 deliveries complicated by psychiatric morbidity - 15-20% depression, 10% depressive episode, 3-5% moderate/severe depressive episode, 2% referred psychiatry, 0.2% psychosis f) 'pinks' - normal phenomena which occur in first 48 hours postpartum, characterised by excitement and a sense of euphoria. Woman may also present as mildly over talkative and overactive with some insomnia, though slight risk of exhaustion, 'pinks' will resolve without any intervention g) 'blues' - common occurrence in postpartum period, 50-80%. Most frequently present about Day 5 but usually present between Day 3-10. Blues attributed to hormonal changes in combination with physical & emotional exhaustion. Typical symptoms of Blues are emotional lability, tearfulness, mild anxiety and irritability. Though presentation of Blues can be varied, symptoms are generally mild and not pervasive. Blues generally last 48 hours and no specific tx required 7) depressive illnesses occurring in postpartum period are similar to illnesses occurring at other times, with guilt and concerns about parental ability commonplace a. peak onset of depressive illnesses is between 2-4 weeks postpartum, however there's a secondary peak at around 3 months postpartum b) with prompt & appropriate tx 2/3 pts illnesses will resolve within 2-3 months. Without treatment can take 6 months or longer to recover c) if woman has suffered from previous severe depressive illness or postnatal depressive illness, risk of developing further illness following this delivery is around 50% 8) postpartum psychosis aka puerperal psychosis - risk of postpartum psychosis is 0.2% a. postpartum psychosis characterised by sudden onset of behavioural disturbances, hallucinations, delusions, fear and perplexity b) 50% present by day 7, 75% present by day 16, 95% present by day 90 c) due to early & sudden onset of postpartum psychosis, it is essential that wherever possible at-risk women are identified antenatally, so can effectively manage the risks d) 99% of postpartum psychoses are either bipolar or schizoaffective disorder e) 50% risk if: Bipolar Affective Disorder or previous postpartum psychosis f) prognosis - postpartum psychosis has good short-term progress, however associated with significant morbidity and mortality. Postpartum psychosis generally requires admission to a Mother and Baby Unit for high intensity physical and psychological care, however, can only offer high level of care to women with serious mental illness if can identify these cases or preferably identify at-risk women prior to the onset of the illness

Perform a mental state examination

1) appearance and behavior: a) clothes - I) colourful and loud clothes suggest mania II) dirty & crumpled clothes suggest self-neglect III) appropriate for the time of year? b) weight - I) rapid weight loss - self-neglect? anorexia? II) obesity - SE of meds? c) facial appearance - I) depression - turned down corners of mouth, furrowed brow II) anxiety - creases on forehead & dilated pupils d) posture - I) depression - hunched posture II) anxiety - on edge of seat, restless e) movements eg/ non-voluntary (SE of some meds), agitated, restless f) socially appropriate behavior g) eye contact h) rapport 2) speech: a) rate, rhythm, tone, volume, quantity, fluency b) monotonous? c) can you understand what pt is saying? if not why not? 3) mood: a) describe mood - subjectively (what pt says) & objectively (what you see) b) affect - reactive, blunted/flattened, congruent or incongruent NB/ mood = past 2/3 weeks, affect = right now 4) thought: a) form - I) flight of ideas - connection between ideas II) formal thought disorder- no connection between ideas III) can they keep train of thoughts or 'derails' b) content - I) delusional beliefs (no insight eg/ (I am king) - primary (out of blue), or secondary (due to something eg/ depression) II) overvalued ideas (understood in terms of cultural beliefs) III) obsessional thoughts (recurrent & intrusive thoughts that cause distress, patients know these thoughts are nonsensical) 5) perceptual abnormalities: a) hallucination - perception without an object b) illusion - misinterpretation of a percept 6) cognitive function: a) alertness b) orientation - time, person, place c) attention and concentration d) memory e) specific tests eg/ agnosias, frontal, speech 7) insight - 5 questions: a) is the patient aware that there is anything wrong? b) if there is anything wrong, does the patient think it is due to an illness? c) if an illness, is it physical or mental illness? d) if it is a mental illness, can it be helped? e) will pt accept help or treatment - may include hospital admission

Recognise possible presentation of mental illness in patients with intellectual disability

1) autism & ID - >66% individuals with autism have intellectual disabilities a) 3 classical impairments in autism: social interaction, communication, imagination/repetition/routines b) possible presenting features: aloof, repetitive movements, little /no interaction with mother, don't bring toys to show to mother or run to greet parents or follow mother around the house, little eye contact c) speech: 49% no speech, exact repetition, pronoun reversal, difficulty with abstraction, poor non-verbal communication, no imaginative play, carry same object around, can be agile, but clumsy at copying movements, cannot understand world: temper tantrums 2) Asperger's - classical features of Asperger's syndrome include: a) good speech, but long winded and literal - long monologues, regardless of response, monotonous b) good memories, but not interested in wider applications c) lack of common sense in social interactions d) physically clumsy e) intelligence - variable but usually at least average, but sometimes highly intelligent f) mx of autism - I) sufficient personal space & quiet location II) each day to be organised and explained with planned space for their rituals III) organised physical activities can dec challenging behaviour IV) graded change to deal with obsessions: aim to dec frequency gradually eg/ remove an item at a time in the case of obsessive collection of items V) +ve reinforcers (eg/ reward) - immediate, appropriate, consistent VI) setting limits - mainly for challenging behaviours, avoid 'no' : use positive direction, use short and concrete explanation, allow tantrum to run itself out VII) education - can provide a framework for order, routines and structure VIII) counselling of parents is important IX) medication: not very useful. Excitability may be dec by antipsychotics X) aggressive outbursts usually understood in terms of environmental factors h) prognosis - life-long, normal life expectancy, some improvement with age, does not develop into schizophrenia, better prognosis if early speech and higher intelligence 3) ID & mental illness - risk of mental illness 3x higher than in general population. Individuals with ID may present differently as well a) depression - I) fmx of depression II) observed behaviour eg/ diurnal mood or activity variation, agitation may lead to wandering, loss of appetite, sleep disturbance, speech or motor retardation III) observed anxiety IV) exaggeration of a need for sameness V) depressive ideas and suicidal ideas rare and poorly planned b) mania/bipolar - I) fmx of bipolar disorder (may help to distinguish from schizophrenia) II) challenging behaviour III) giggling, overactivity and excitement IV) inappropriate masturbation or exposure (disinhibition) V) delusions are not as elaborate c) schizophrenia - I) difficult to diagnose below IQ of 45 II) commoner with more severe intellectual disability III) poverty of thought IV) delusions: less elaborated V) hallucinations: simpler and repetitive, may respond to unseen stimuli VI) distinguish -ve symptoms from developmental history (deterioration from previous level of functioning) VII) persecutory delusions and thought disorder less common VIII) earlier age of onset IX) can present with: fear, withdrawal, challenging behaviour (in particular out of character), sleep disturbances 4) challenging behaviour - general term used in ID to describe undesirable behaviour in pts a) can be caused by different reasons eg/ social / environmental factor (new environment, new carer), mental illness, SE of meds, physical illness eg/ ear infections, dental problems, UTIs, respiratory infections, thyroid problems 5) capacity in decision making - ID may affect capacity in decision making (use MCA) 6) epilepsy in ID - more likely in severe intellectual disability a) prevalence: school children: 0.6 %, mild ID: 5%, at least moderate ID: 44 % b) M:F = 4: 1 c) compliance can be an issue - inadequate control of fits d) education of pt & carer is important eg/ emergency treatment of prolonged fits e) social implications

Alcohol withdrawal syndrome

1) can occur in any pt dependent on alcohol who abruptly stops drinking 2) symptoms can be mild & short-lived or severe and life-threatening 3) severity of withdrawal symptoms tends to correlate with amount of alcohol consumed & length of time of heavy drinking 4) other risk factors for more severe withdrawal include - intercurrent medical illness (e.g. infection); advanced liver disease; previous withdrawal episodes 5) AWS has potential to cause serious physical and psychiatric harm 6) syndrome should be anticipated & prophylactically treated in any pt who has: a) known alcohol dependence b) history of alcohol withdrawal c) consumed >10 units alcohol for >10days d) current withdrawal symptoms 7) progress - a) severe, day 1 = seizures b) mild withdrawal = anxiety, perspiration, insomnia, nausea, inc PR/BP c) sever withdrawal (later on) = acute confusion, amnesia, psychomotor agitation, psychosis, DTs 8) mild/uncomplicated - I) occurs 4-12 hours after the last alcoholic drink, lasts 2-5 days II) features: coarse tremor, sweating, insomnia, tachycardia, N+V, psychomotor agitation, anxiety. Pt may occasionally experience transient hallucinations III) intense cravings for alcohol 9) seizures - I) 5-15% cases of alcohol withdrawal complicated by grand-mal seizures occurring 6-48 hours after the last drink II) risk factors for seizures: heavy, prolonged alcohol consumption, previous withdrawal seizures, idiopathic epilepsy & hx of head injury III) if seizures only occur during withdrawal they do not indicate primary diagnosis of epilepsy

Overview of the classification of psychiatric disorders and how these may present clinically

1) classification of mental disorders done by 2 widely established systems: chapter V of International Classification of Diseases (ICD-10) or Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 2) ICD-10 - chapter V focuses on "mental and behavioural disorders" and consists of 10 groups: F0: Organic mental disorders F1: Mental & behavioural disorders due to psychoactive substances F2: Schizophrenia, schizotypal & delusional disorders F3: Mood [affective] disorders F4: Neurotic, stress-related & somatoform disorders F5: Behavioural syndromes associated with physiological disturbances and physical factors F6: Disorders of personality & behaviour F7: Mental retardation F8: Disorders of psychological development F9: Behavioural and emotional disorders with onset in childhood and adolescence NB/ within each group are more specific subcategories 3) DSM-IV - 5 axes (domains) on which disorders can be assessed Axis I: Clinical Disorders Axis II: Personality Disorders & Mental Retardation Axis III: General Medical Conditions (connected to a Mental Disorder) Axis IV: Psychosocial and Environmental Problems (eg/ limited social support network) Axis V: Global Assessment of Functioning (Psychological, social and job-related functions)

Explain basic Cognitive Behavioural Therapy (CBT)

1) cognitive refers to mental processes like thinking. Everything that goes on in the mind including dreams, memories, images, thoughts, and attention are all cognitive processes 2) behaviour refers to all the things we do- our actions (AND inactions). Hailing a taxi, running to the next bus stop or giving up and going back home are all plausible behavioural responses to missing a bus 3) basic premise of CBT is that you feel the way you think eg/ you might miss the bus at the bus stop and you might think "This always happens to me - I am always late - I am so hopeless". This is likely to make you feel a bit negative and down. On the other hand, you might think "Oh well - let me listen to some music and send some texts to my friends while I wait for the next bus - it won't be long" - this thought is unlikely to make you feel as hopeless and down as the previous thought might 4) CBT is about finding the cognitions that link the events & the emotional reactions - ABC: Antecedent - Belief - Consequences 5) indications - depression, anxiety disorders eg/ GAD, OCD, PTSD, phobias, or adjuncts for: schizophrenia, bipolar 6) sources - a) CBT therapists based in primary care (Integrated Access to Psychological Therapy - IAPT) are the main source of CBT provision in the UK b) computerised CBT c) self-help books d) use of mobile phone apps such as Mood Gym 7) initial session - spent building a therapeutic relationship. Therapist explains the model and its rationale to ensure pt has a good understanding of CBT model, including ABC analysis. Therapist & pt may spend time analysing events using the ABC model together 8) ongoing - sessions take place weekly or fortnightly & last 50-60 mins. Pts complete homework between sessions. Pts need to be able to write or otherwise record their thoughts, feelings and behaviours. Focus is on challenging and correcting cognitive errors, and replacing maladaptive with more adaptive coping mechanisms 9) identifying cognitive errors: a) arbitrary inference - my girlfriend is out, she might be enjoying herself with someone else b) overgeneralisation - I missed the bus this morning. I am always late and I am so hopeless c) selective abstraction - although Tom said he likes me, he did say once that he did not like the dress I was wearing that day, which means Tom does not like me like how he says d) magnification - if I do not submit this assignment today then the lecturer will think I am completely useless e) minimisation - lecturer said that "well done" only because she was in a good mood f) personalisation - my team did not get a prize in the quiz. It's all my fault - I am the one to blame g) dichotomous thinking - if I do not get an "A" in class, that means I have failed h) therapist will ask the patient to record a brief description of the following in a table: triggering event; automatic thought that follows (verbatim if possible); feelings generated & their intensity; behavioural responses; cognitive errors involved; any challenges to those cognitive errors 10) behavioural experiments - therapist & pt choose a belief to challenge, and brainstorm various ways in which the belief can be challenged through an experiment. Important to record pt's thoughts/beliefs about what they think is likely to happen eg/ Jane is convinced she might have a heart attack if she is on her own outside the house. She has become agoraphobic. She agrees to set up a behavioural experiment with her therapist to walk up the street for 50 yards while her therapist watches her. She records her thoughts - "I might die and have no help available", "People will laugh at me for being such a sissy". Experiment allows her to test her hypotheses (and disprove them). This allows them to set up further behavioural experiments, gradually extending the repertoire of her activities 11) explaining CBT - a) check prior knowledge/experience of CBT b) explain why CBT is being considered (its effectiveness) to instil hope c) explain mechanism of action - relating specifically to symptoms your pt is experiencing d) explain the process - number/time of sessions, location, homework e) mention possible SE eg/ inc agitation, restlessness etc f) explain whether medications need to continue concurrently g) explain what might happen once therapy ends or if therapy is not successful h) check understanding i) signpost to self-help resource (e.g. Royal College of Psychiatrists' leaflets)

Comorbidities, aetiology, and differential diagnosis of bipolar

1) comorbid conditions - psych eg/ OCD, substance abuse, eating disorders, ADHD, social phobia, premenstrual syndrome, panic disorder 2) aetiology - ?cause a) genetics - risk of bipolar 10x inc if 1st degree-relative affected, no single gene is responsible, inc paternal age linked to inc chance of bipolar disorder in offspring (inc new genetic mutations) b) environment - recent life events and interpersonal relationships contribute to onset & recurrence of bipolar eg/ abuse in childhood, PTSD, prolonged stress c) neurological - less common, may be result of stroke, traumatic brain injury, HIV infection, MS, porphyria, temporal lobe epilepsy etc d) physiological - dec volume in L rostral anterior cingulate cortex(ACC), fronto-insular cortex, ventral prefrontal cortex, and claustrum. Inc in volume of lateral ventricles, globus pallidus, subgenual anterior cingulate, and amygdala e) brain components proposed to play a role are mitochondria & sodium ATPase pump. Circadian rhythms & regulation of melatonin seem to be altered f) neurochemical - dopamine has inc transmission during manic phase. Dopamine hypothesis - inc dopamine = secondary homeostatic down regulation of receptors eg/ inc in dopamine mediated G protein-coupled receptors = dec dopamine transmission characteristic of depressive phase. Depressive phase ends with homeostatic up regulation potentially restarting cycle over again g) substance misuse - precipitating factor in episodes of illness 3) differential diagnosis - a) psych - schizophrenia, major depressive disorder, ADHD, personality disorders eg/ borderline personality disorder b) neurologic diseases eg/ MS, complex partial seizures, strokes, brain tumors, Wilson disease, traumatic brain injury etc c) endocrine eg/ hypothyroidism, hyperthyroidism, and Cushing's disease d) connective tissue disease, SLE e) infections (mania) eg/ herpes encephalitis, HIV, influenza, or neurosyphilis f) vitamin deficiencies eg/ pellagra (niacin deficiency), B12 deficiency, folate deficiency, and Wernicke Korsakoff syndrome (thiamine deficiency) g) meds eg/ antidepressants, prednisone, Parkinson's meds, thyroid hormone, stimulants (cocaine and methamphetamine), and certain antibiotics NB/ diagnosis - for bipolar affective disorder: need to elicit current symptoms and past episodes. 1 episode of mania = acute mania, 2 episodes of mania or 1 mania + 1 depression = bipolar affective disorder, 2 episodes of depression = recurrent depressive disorder

Somatoform disorders: definition, epidemiology, aetiology, clinical presentation

1) definition - chronic condition with many physical complaints which can last for years and result in substantial impairment. Somatisation - process by which "psychological distress is expressed through physical symptoms & subsequent medical help-seeking", aka MUS a) 5 main types - hypochondriasis, conversion disorder (neurological s/s), body dysmorphic disorder (nose or ears), pain disorder (headache, lower back ache), Somatisation disorder 2) somatisation diagnosis a) hx of 2+ yrs complaints of multiple & variable physical symptoms that cannot be explained by any detectable physical disorder b) preoccupation with symptoms causes persistent distress & leads pt to seek repeated consultations or ix; or persistent self-medication c) persistent refusal to accept medical reassurance that no cause d) must be a number of symptoms from 2+ separate groups: I) GI: abdo pain, N+V, bloating, bad taste in mouth, loose bowel motions II) CV: breathlessness without exertion, chest pains III) GU: dysuria, unpleasant sensation around genitals, unusual vaginal discharge IV) skin and pain: blotchiness, discoloration, pain in limbs, numbness or tingling 3) hypochondriacal disorder diagnosis, either of: a) persistent belief >6 months, of presence of a maximum of 2 serious physical diseases (at least 1 must be specifically named by pt) b) persistent preoccupation with a presumed deformity or disfigurement (body dysmorphic disorder) c) preoccupation with belief & symptoms causes persistent distress or interference with personal functioning in daily living, & leads pt to seek medical tx or ix d) persistent refusal to accept medical reassurance that no physical cause 4) factitious disorder aka Munchausen's - a) pt feigns or exaggerates symptoms for no obvious reason b) pt may even inflict self-harm in order to produce symptoms or signs c) internal motivation with aim of adopting the sick role d) Munchausen syndrome by proxy - pt imposes symptoms to other 5) malingering - conscious manufacturing or exaggerating of symptoms for a secondary gain eg/ benefits, housing, other than assuming the sick role 6) epidemiology - a) F:M ratio 10:1 for somatization disorder, 2:1 for conversion disorder b) 0.1% prevalence, usually begins before 30 7) aetiology - a) inc prevalence in pts with: IBS, chronic pain, or PTSD b) antisocial personality disorder associated with a risk for SSD c) somatising pt seems to seek sick role, which affords relief from stressful or interpersonal expectations ('primary gain') - provides attention, caring and sometimes even monetary reward ('secondary gain'), not malingering as pt not aware of process through which symptoms arise, cannot will them away and genuinely experiences symptoms d) association between somatisation & hx of sexual or physical abuse e) neuroendocrine genes may be implicated 5) presentation - symptoms severe enough to affect work and relationships and lead pt to consult a doctor and take meds. Lifelong history of 'sickliness' is often present: pts may have a combination of symptoms for which an organic cause can be found and symptoms for which there is no underlying cause. Stress often worsens symptoms 6) diagnosis: a) multiple symptoms, often occurring in different organ systems b) symptoms vague or that exceed objective findings c) chronic course d) presence of a psychiatric disorder e) hx of extensive diagnostic testing f) rejection of previous physicians

Dissociative disorders: epidemiology, aetiology, clinical presentation, prognosis, common co-morbidity, physical, psychiatric and social consequences, and management

1) definition - conditions that involve disruptions or breakdowns of memory, awareness, identity, or perception. Pts use dissociation as a defence mechanism, pathologically and involuntarily. Some triggered by trauma, but dissociative disorders such as depersonalization/derealization disorder may be preceded only by stress, psychoactive substances, or no identifiable trigger - may also show a lack of concern for the disability (la belle indifference) 2) aetiology - a) dissociative identity disorder (multiple personality disorder) - caused by childhood trauma before age of 9. Pts usually have close relatives with DID b) dissociative amnesia - a way to cope with trauma c) dissociative fugue - stressful event in adulthood d) depersonalisation disorder - usually develop to cope with childhood trauma, but can also be acute due to severe traumas eg/ death of a loved one 3) presentation of dissociative disorder - a) amnesia b) fugue (sudden, unexpected journey that may last a few months, together with memory loss, confusion about personal identity) c) stupor d) trance or possession disorders e) motor disorders (eg/ paralysis of limbs) f) anaesthesia/sensory loss g) convulsions ("pseudo-seizures" or "psychogenic non-epileptic seizure") 4) epidemiology - 10% in general population 5) tx - many people make a full recovery with treatment and support a) physical therapies may be used to address specific physical symptoms, such as paralysis, speech loss and walking difficulties b) psychological - CBT: aim is to help pt cope with the underlying cause of your symptoms, and to learn and practise techniques to manage the periods of feeling disconnected c) meds - SSRIs may be prescribed to treat associated conditions like depression, anxiety and panic attacks

Bulimia nervosa: definition, epidemiology, aetiology, clinical presentation

1) definition - eating disorder characterised by repeated episodes of uncontrolled overeating (binges) followed by weight loss behaviours. Features: a) excess preoccupation with body weight and shape b) undue emphasis on weight in self-evaluation c) feeling of lack of control over eating d) compensatory weight control mechanisms eg/ vomiting, fasting, intense exercise, abuse of meds eg/ laxatives, diuretics, thyroxine or amfetamines 2) epidemiology - a) incidence 10/1,000 females per year, prevalence = 1%, lifetime prevalence in women is 2% b) F:M = 10:1 c) more common in adolescence and young adulthood 3) aetiology - multifactorial biopsychosocial: a) biological - changes in levels of serotonin with disease, ?genetics b) psychological - low self esteem, hx of abuse, impulsive personality traits, personality disorder, high value placed on food and eating behaviour, hx of being over-weight (factual or perceived) c) social - exposure to culture of dieting, family/ social culture of categorizing food as good or bad, healthy or naughty 4) presentation a) head/CNS - poor concentration, irritability, seizure secondary to electrolytes imbalance b) mouth & teeth - tooth decay, erosion, horse voice, bleeding from mouth or throat, swollen parotid glands ("chipmunk" faces) c) heart - hypokalemia can cause cardiac arrhythmias and can be fatal, caused by diuretics, diarrhoea, vomiting and excessive use of laxatives d) abdomen - stomach: swollen, pain, delayed gastric emptying; rectal - constipation, rectal prolapse; oesophageal tears/oesophagitis, renal failure, UTI e) hand - Russell sign f) feet and ankles - swollen feet and ankles & cold extremities g) other complications: dehydration & electrolytes imbalance, muscle paralysis 5) DSM-5 Diagnostic criteria of bulimia nervosa a) recurrent episodes of binge eating - eating more than most would in a certain amount of time b) recurrent inappropriate compensatory behaviour to prevent weight gain eg/ self-induced vomiting, laxatives, diuretics, fasting or excessive exercise c) binge eating & compensatory behaviours occur at least 1/week for 3 months d) self-evaluation is unduly influenced by body shape and weight e) disturbance does not occur exclusively during episodes of anorexia nervosa

Definition, epidemiology, aetiology, risk factors, management and prognosis of suicide

1) definition - fatal act of self-harm initiated with intention of ending one's own life. Although often seen as impulsive, it may be associated with years of suicidal behaviour including suicidal ideation or acts of deliberate self-harm 2) epidemiology - a) >800,000 deaths/year worldwide b) highest suicide rate in men 40-44 - 25.9 deaths/100,000 population (3:1 ratio) c) 2nd leading cause of death in 15-29 year olds d) most common methods - hanging, strangulation and suffocation, followed by poisoning 3) aetiology - despite being a leading cause of death, both in UK and worldwide, there is little hard evidence to explain why some people attempt suicide. Most who choose to do so for complex reasons a) in UK, many people who die by suicide have a mental illness, most commonly depression or an alcohol problem. In many, suicide linked to feelings of hopelessness & worthlessness b) vulnerability to suicide - I) antidepressants and suicide risk, especially if <25 II) genetics and suicide - suicide & some mental health problems can run in families. This has led to speculation that certain genes may be associated with suicide 4) risk factors - a) people with mental illness have a higher suicide risk than general population (10x inc): ~90% of pts who die by suicide have mental illness, most common with - affective disorders (40%) particularly depression, schizophrenia (18%), alcohol dependence (13%), personality disorder eg/ borderline PD (10%), drug dependence (6%), bipolar (20x more likely than general population), anorexia (20% chance) b) previous suicide attempt is biggest risk factor for suicide - up to 50% people who take their own lives have previously attempted to harm themselves c) male gender (3x more likely than women) d) unemployment & low socio-economic status & debt e) homelessness, low social support f) alcohol and drug abuse g) physically disabling or painful illness, including chronic pain h) certain professions - historically, professions with means/knowledge to kill themselves (vets, doctors, dentists, pharmacists, farmers, war veterans) had highest rates of suicide. More recently, rates in these professions have reduced significantly (although remaining comparatively high) and higher numbers seen amongst manual occupations eg/ construction workers and plant/machine operatives i) significant life events - bereavement, family breakdown j) institutionalised eg/ prisons, army k) bullying (sometimes a factor in children and adolescents where social media and/or pro-suicide websites play a part) 5) mx - a) do a general assessment of pt & form a summary and a risk assessment - subsequent action depends on level of risk present & will be guided by specific risk factors identified eg/ non-stable relationships, mental health, access to lethal methods etc b) aim to be supportive, empathetic and reassuring in developing a relationship c) remove access to preferred means of suicide where possible d) care plans - form and agree a care plan. Aims may include: I) prevent self-harm or suicide attempts, or escalation of either behaviour II) dec level of injury from self-harming behaviour III) improve QOL IV) improve social or occupational functioning V) improve mental health conditions VI) improve physical symptoms e) care plans should: be multidisciplinary (& shared with pts GP if not involved), be developed collaboratively with pt, identify short- and long-term goals, steps to achieve them, and professionals responsible for helping achieve them, include a risk management plan: I) address specific identified risk factors where these can be modified II) include a crisis plan (self-management strategies & how to access services in crisis) f) specific treatment options may include: I) medication II) counselling III) CBT IV) dialectical behaviour therapy (DBT) - specific type of CBT which has largest evidence base. DBT focuses on acceptance techniques, and change techniques, helping people change damaging patterns of behaviour g) follow-up at regular intervals, depending on level of risk, but probably within 24 hours h) high-risk individuals - ensure safety with 24-hour support through crisis team of local mental health service. Consider grounds for psychiatric evaluation & detention under Mental Health Act if pt refuses. Involuntary detention cannot be used in UK if mental state due to alcohol or drug intoxication alone 6) prognosis - a) many who attempt suicide & survive eventually die by their own hands, many within a year of index attempt b) hx of multiple past attempts inc risk of eventual suicide c) short-term intensive treatment, often with psychiatric hospitalization dec immediate risk, but the standard of care often requires more than just a few days of generic inpatient care

Definition, epidemiology, aetiology and risk factors of self-harm

1) definition - intentional act of self-poisoning or self-injury, irrespective of motivation or apparent purpose of the act. It is an expression of emotional distress a) deliberate self-harm may be caused by one or more of the following: I) a behaviour (eg, self-cutting) intended to cause self-harm II) ingesting a substance in excess of prescribed or generally recognised therapeutic dose III) ingesting a recreational or illicit drug that was an act the person regarded as self-harm IV) ingesting a non-ingestible substance or object b) deliberate self-harm is not an attempt at suicide in majority of cases - usually an attempt to maintain control in stressful situations or emotional pressures eg/ bullying, abuse, academic pressure or work pressure. Self-harm is usually done in private and hidden from anyone else 2) epidemiology - a) male:female 1:2 b) divorced > single > widowed > married c) 2/3 people who harm themselves <35 years of age c) overdoses and cutting are most common methods d) self-harm inc likelihood person will eventually die by suicide by between 50-100x above rest of the population in a 12-month period 3) aetiology - in most cases pts self-harm to help them cope with overwhelming emotional issues, which may be caused by: a) social problems eg/ being bullied, difficulties at work or school, difficult relationships with friends or family, coming to terms with their sexuality if they think they might be gay or bisexual, or coping with cultural expectations, such as an arranged marriage, genetics, substance misuse b) trauma eg/ physical or sexual abuse, death of a close family member or friend, having a miscarriage c) psychological causes eg/ repeated thoughts or voices telling them to self-harm, disassociating, or borderline personality disorder, crisis of faith d) these issues can lead to a build-up of intense feelings of anger, guilt, hopelessness and self-hatred. The person may not know who to turn to for help and self-harming may become a way to release these pent-up feelings e) self-harm linked to anxiety and depression 4) risk factors - a) psychiatric problems eg/ borderline personality disorder, depression, bipolar disorder, schizophrenia, drug misuse and alcohol abuse are associated with self-harm b) other risk factors include victims of domestic violence, socio-economic disadvantage, and those with eating disorders c) inc risk in South Asian women, prisoners, asylum seekers, veterans d) strong suicidal intent, high lethality, precautions against being discovered, and psychiatric illness are indicators of high suicide risk

Anorexia nervosa: definition, epidemiology, aetiology, clinical presentation

1) definition - maintenance of low body weight as preoccupation with weight, construed as a fear of fatness or pursuit of thinness. In spite of this, they believe they are fat & are terrified of gaining weight 2) epidemiology - a) 9/1,000 during their life, prevalence = 1% b) affects women more than men (ratio 10:1) c) typically onset is during early to mid-adolescence d) 3rd most common chronic illness in adolescent females 3) aetiology - multifactorial biopsychosocial: a) biological - ?genetics, dec weight causes neuro/endocrine changes (disturbance of hypothalamus, inc serotonin levels, brain atrophy) b) psychological - perfectionism, low self-esteem (weight loss = achievement), sexual development (early development), hx of abuse, personality disorder c) social - possible: parental overprotection and family enmeshment 4) presentation - low body weight, rapid weight loss, weight loss measures (particularly extreme dieting), and psychological features (including distorted body image) + physical & endocrine sequelae. Clinical features include: a) hair and skin - dry and brittle, hair can thin and drop out, lanugo hair may grow over skin on face and body aiming to aid warmth b) head/psychiatric - thinking becomes inflexible, difficult to make a decision, poor concentration, obsessions, difficulty being spontaneous, interest centered around food eg/ cookery books, irritated mood, 'flattened affect' b) heart - BP & pulse dec, inc risk of heart arrhythmias & heart failure c) reproductive system - lack libido, reproductive system ceases to function - often function returns with weight restoration and regular eating d) bones - osteopenia/osteoporosis e) muscles - muscle wastage, muscle cramp (sit up and squat test can asses this) f) feet and ankles - swelling, cold extremities (hypothermia), broken skin g) others complications: infections, metabolic disturbance (hypoglycaemia, hyponatraemia, hypokalemia, vitamin deficiency, hypercholesterolaemia, deranged liver function) 5) DSM-5 Diagnostic criteria of anorexia nervosa a) BMI <17.5 b) persistent restriction of energy intake = significantly low body weight c) either intense fear of gaining weight/being fat, or persistent behaviour that interferes with weight gain d) disturbance in way one's body weight or shape & weight on self-evaluation, or persistent lack of recognition of the seriousness of current low body weight e) subtypes: restricting type or binge-eating/ purging type

Definition, epidemiology, aetiology and presentation of schizophrenia

1) definition - most common form of psychosis, lifelong - either chronic or with relapsing and remitting episodes of acute illness 2) epidemiology - incidence of 15/100,000 person-years, prevalence of 7/1,000 persons a) can develop at any age but mostly 15-30. Peak age of onset is later in women. Men are more likely to have -ve symptoms & more serious schizophrenia 3) aetiology - multiple factors involved eg/ genetic, environmental, social a) short-lived paranoid schizophrenia = cocaine, amfetamines and cannabis - cannabis use associated with inc future risk of schizophrenia c) risk factors - I) fmx II) intrauterine and perinatal complications eg/ premature birth, low birth weight, intrauterine infection, particularly viral III) abnormal early cognitive/neuromuscular development IV) social isolation, migrants V) abnormal family interactions eg/ hostile or overly critical parents 4) presentation a) acute symptoms - hallmark symptoms of a psychotic illness are: delusions + hallucinations + thought disorder + lack of insight b) 'first rank' (+ve) symptoms of schizophrenia rare in other psychotic illnesses (eg/ mania). Presence of 1+ strongly predictive of diagnosis: I) lack of insight II) A: auditory hallucinations: thought echo, running commentary, people talking about them III) B: thought broadcasting, insertion, removal IV) C: control of thoughts V) D: delusional perceptions eg/ 'The rainbow came out and I realised I was the son of God.' NB/ can have somatic passivity - thoughts, sensations and actions are under external control c) chronic or 'negative' symptoms: underactivity (also affects speech), low motivation, social withdrawal, flattened affect, self-neglect d) pts may manifest symptoms of other psychiatric diseases (eg/ depression, anxiety, obsessions and compulsions), co-morbidity with substance misuse f) signs - in mental state exam be alert for: I) appearance and behaviour - withdrawal, suspicion II) speech - thought blocking, loosening of associations III) mood/affect - flattened, incongruous or 'odd' IV) abnormal beliefs - delusional percepts, thought control or broadcasting, passivity experiences V) abnormal experiences - hallucinations, especially auditory VI) cognition - attention, concentration, orientation and memory assessed (significant impairment suggests delirium or severe dementia)

Definition, epidemiology, presentation and investigations in psychosis

1) definition - severe mental disorder in which there is loss of contact with reality, includes delusions + hallucinations + formal thought disorder a) occurs in many serious mental illnesses eg/ schizophrenia, depression, bipolar, puerperal psychosis, substance abuse (can be neuro conditions or meds) b) psychosis interferes with ADL & can be very debilitating c) delusion - false, fixed, strange, or irrational belief that is firmly held. Belief is not normally accepted by other members of same culture or group. Delusions of paranoia, grandeur, somatic (false belief in having a terminal illness) d) hallucination - sensory perception (seeing, hearing, feeling, smelling) without an appropriate stimulus eg/ hearing voices when no one is talking e) formal thought disorder - pattern of disordered language use that reflects disordered thought form eg/ loosening of association (derailment), flight of ideas, circumstantial thoughts, tangential thoughts, thought block 2) epidemiology - a) 80% pts between the ages of 16-30, peaks at mid-20s (then 30-40) b) inc rates in black & minority ethnicity, urban and deprived communities c) incidence: 32/1000 people, prevalence: 4/1000, lifetime risk - 1/100 3) presentation ICD-10: a) positive symptoms = Schneider's First Rank Symptoms (exams) - A - Auditory hallucinations: thought echo (hearing thoughts aloud), 3rd person (voices talking about pt), running commentary B - Broadcasting of thought: also thought insertion & withdrawal C - Controlled thought D = Delusional perception: eg/ "I heard the church bells and knew I would win Wimbledon" also - formal thought disorder & disorganised behaviour b) negative symptoms - social withdrawal, poverty of speech, avolition, blunted affect, dec attention 4) ix - a) FBC & LFTs: abnormal LFTs & macrocytosis on FBC = alcohol abuse b) serological tests for syphilis, possibly for HIV c) urine screen for drugs of abuse (see recreational cannabis for 14/7, heavy & chronic gives +ve result for months) d) CT brain eg/ for space-occupying lesion or cerebral atrophy if focal signs

Definition, epidemiology, aetiology, comorbidities, presentation, management and prognosis of adjustment disorder

1) definition - stress-related, short-term (<1 month), nonpsychotic disturbance. Psychological reaction to adapting to a new set of circumstances eg/ new job/home, divorce, etc a) starts within 3 months & related to and in proportion to stressful event b) criteria often met with bereavement, onset of terminal illness or sexual assault 2) epidemiology - a) affects 12% population, 70% of pts with adjustment disorder in adult medical settings of general hospitals receive comorbid psychiatric diagnoses 3) aetiology - a) risk factors - genetics, personality, past hx, stage of development, psychological qualities (cognitive capacities, typical coping patterns,), and overall constitution b) 4 factors that may contribute to development of adjustment disorders in children: I) intrinsic factors - age, sex, intellectual, emotional, and ego development, coping skills, temperament, and past experiences II) extrinsic factors - support systems, expectations, understanding, skills, maturity III) most important factor in a child is their degree of vulnerability - depends on characteristics of both child & child's environment 4) comorbidities - personality disorders, organic mental disorders, and psychoactive substance abuse disorders 5) presentation - a) symptoms of anxiety and worry, depression, irritability b) physical symptoms caused by autonomic arousal eg/ palpitations & tremor c) occasional outbursts of dramatic or aggressive behaviour, sometimes abuse of alcohol or drugs, social functioning impaired d) onset more gradual than acute stress reaction & more prolonged course 6) mx - a) if possible, help resolve change of circumstances eg/ support to make changes at work b) prevent avoidance & denial, encourage problem-solving c) psychotherapy 7) prognosis - a) most last a few months, a few last a few years b) adults generally do well, adolescents have inc risk of developing psychiatric illness in adult life

Delirium - definition, epidemiology, presentation, aetiology, ix, mx

1) definition - transient, potentially reversible cerebral dysfunction with acute or sub- acute onset, manifested clinically by a wide range of fluctuating mental status abnormalities. Common & can be potentially lethal (aka acute brain failure, acute confusional state, acute organic syndrome, cerebral insufficiency, encephalopathy, postoperative psychosis and toxic psychosis) 2) epidemiology - delirium very common - in hospital has prevalence of 10-30% a) 10-15% elderly population have delirium on admission to acute hospital & further b) 10-40% develop delirium during their stay c) in up to two-thirds of delirium is superimposed on dementia 3) clinical features - a) abrupt onset & fluctuating course typical and highly suggestive b) ICD 10 criteria for Delirium: clouding of consciousness (dec clarity of awareness of environment, with dec ability to focus, sustain or shift attention); disturbed cognition, with impaired immediate recall and recent memory but relatively intact remote recall, and disorientation in time, place or person + I) at least one of: variable activity levels, inc reaction time, altered flow of speech or enhanced startle reaction + II) at least another one of: insomnia, daytime drowsiness, reversal of sleep-wake cycle, nocturnal worsening of symptoms or disturbing dreams & nightmares 4) types of delirium - a) hyperactive delirium: pts who have inc arousal, can be restless, agitated or aggressive b) hypoactive delirium: pts who become withdrawn, quiet and sleepy c) delirium d) delirium superimposed on Dementia e) persistent delirium 5) ix - a) infection: cultures, urinalysis, FBC, CRP, CXR etc b) review all meds c) metabolic/endocrine: U&Es, LFTs, calcium, glucose, TFTs d) others: cardiac - ECG, hypoxia - O2 saturation, neurological - CT/MRI Brain 6) mx - a) identify & treat precipitating cause b) provide a calm environment & supportive measures I) education off all who interact with pts (doctors, nurses, family etc) II) reality orientation techniques - improve communication by use of calendar, clock III) correct sensory impairments (eg/ hearing aids, glasses) IV) optimize pts condition - attention to hydration, nutrition, adequate pain control V) environment that optimises stimulation (eg/ adequate lighting), dec unnecessary noise VI) make environment safe (remove objects with which pts could harm self or others) VII) avoid moving people between wards or rooms VIII) avoid constipation, unnecessary catheterisation c) involve family and carer d) consider referral to psychiatric team (especially if hx of mental health issues, suspected dementia, depression, persistent delirium, aggression etc) e) avoid sedation unless severely agitated 7) aetiology of delirium - I WATCH DEATH I - infection: HIV, sepsis, pneumonia W - withdrawal: Alcohol, barbiturate, sedative e.g. hypnotic A - acute metabolic: Acidosis, alkalosis, electrolyte disturbance, hepatic failure, renal failure T - trauma : Closed-head injury, heat stroke, postoperative, severe burns C - CNS pathology: Abscess, haemorrhage, hydrocephalus, subdural hematoma, Infection, seizures, stroke, tumours, metastases, vasculitis, encephalitis, meningitis, syphilis H - hypoxia: anaemia, carbon monoxide poisoning, hypotension, pulmonary or cardiac failure D - deficiencies: Vitamin B12, folate, niacin, thiamine E - endocrinopathies: Hyper/hypoadrenocorticism, hyper/hypoglycemia, myxedema, hyperparathyroidism A - acute vascular: Hypertensive encephalopathy, stroke, arrhythmia, shock T - toxins or drugs: Prescription drugs, illicit drugs, pesticides, solvents H - heavy metals: lead, manganese, mercury

Different settings and modalities of psychotherapy

1) definition - umbrella term that includes a range of talking therapies. Aims: a) removing, modifying or retarding existing symptoms b) mediating disturbed patterns of behaviour c) promoting personal growth and development 2) range of techniques based on relationship building, dialogue, communication and behaviour change designed to improve the mental health of an individual patient or group. Focus may be on an individual or family 3) some therapies focus on the here and now and behavioural change (eg/ CBT); others focus on past events & their impact on current behaviour (eg/ psychodynamic therapy) 4) psychodynamic psychotherapy (insight oriented psychotherapy) - a) model - our feelings & behaviours are influenced by unconscious motives that are the result of early childhood experiences. Contrast this with CBT where feelings and behaviours are considered to derive from thoughts and core beliefs b) Freud postulated that delving into the unconscious mind could offer a window into one's early childhood which could help explain current feelings & behaviours (and indeed symptoms) c) eg/ dream analysis, free association (pt speaking whatever comes to the mind - accesses unconscious), transference & counter-transference - in establishing a therapeutic relationship, therapist & pt bring (unconsciously) their own beliefs, values, previous experiences etc. to the interaction. Analysis of this interaction can offer another window into the unconscious - unconscious redirection of one's feelings from those towards significant others in one's childhood to the therapist = transference, slips of the tongue d) psychodynamic triad - establish a therapeutic relationship with pt that helps draw links between pt's early childhood experiences, defence mechanisms and current symptoms e) 1-2 sessions/week, 1hr, can last 1-2 years, brief = 14-20 sessions f) indications - personality disorders 5) defence mechanisms - coping mechanisms to negotiate conflicts/traumas encountered in early childhood. Some defence mechanisms are mature; others neurotic or less mature. Under stress, pts tend to use less mature defence a) mature - I) altruism - deal with stress or conflict through devotion to charitable endeavours to help others II) anticipation - anticipate possible adverse events and prepare for them III) humour - deal with stress by seeing lighter side IV) sublimation - channel potentially maladaptive impulses into socially acceptable behaviour (eg/ competitive sports channelling aggression) V) suppression - distract (consciously) to avoid thinking about stressor VI) affiliation - seek support from others b) neurotic - I) displacement - transfer negative feelings about one person to another II) externalization - blame others III) intellectualization - avoid painful emotions but stuck on details IV) repression - dispel disturbing thoughts/feelings from consciousness (unconsciously) V) reaction formation - express unconscious unacceptable impulse in the opposite - more acceptable form c) primitive - I) denial - refuse to acknowledge some aspect of reality II) autistic fantasy - day-dreaming to avoid reality III) passive-aggressive - expressing hostility whilst not openly aggressive IV) acting out - inappropriate behaviour without considering consequences V) splitting - black or white thinking VI) projection - falsely attribute unacceptable feelings to others 6) psychoanalysis - a) quite rigorous, indicated for long-term personality difficulties b) 3-5 times/week, 50-60 mins/session, expensive and time-intensive c) pts need to be able to tolerate intensive self-reflection and not become dependent or impulsive. Focus on developing insight through clarification and interpretation of unconscious conflict 7) dialectical behavioural therapy (BPD) (emotionally unstable personality disorder)- a) DBT aims to help pt manage difficult emotions by letting them experience, recognise and accept them. Model says that, with acceptance, people become more able to change damaging behaviours b) course of DBT typically lasts for about a year and has 4 elements I) individual therapy - weekly 1-1 therapy with a DBT therapist lasting about an hour II) skills training in groups - focussing on developing practical skills (tolerating distress, managing personal relationship issues, mindfulness) III) telephone crisis coaching - gives service receivers telephone contact with their therapist outside of therapy sessions IV) therapists' consultation groups - members of the team of people providing DBT may meet together weekly to discuss issues that have come up in treatment sessions c) although based on CBT, it better meets the needs of people who experience particularly intense emotional responses d) like CBT, DBT focuses on changing unhelpful behaviours. However, while CBT enables challenging of unhelpful thoughts, DBT allows acceptance of whole person - including those thoughts e) relationship between pt & DBT therapist is key - relationship used to actively motivate change a) problem solving therapy - provided mainly by primary-care based counsellors, involves step-wise approach. Elicit practical problems; explain emotional symptoms; reassure; clarify the problem and collaboratively identify possible solutions; pt chooses most likely solution; review and repeat as necessary 8) interpersonal therapy (IPT) - based on hypothesis that disorders eg/ depression can be explained as disorders arising from interpersonal relationship difficulties a) using principles of active listening, empathy, facilitation of emotional expression in context of inter-personal relationships, pt is encouraged to reframe and rebuild their relationships 9) supportive therapy - based on Carl Rogers' principles of person-centred therapy viz. a) empathy b) unconditional positive regard and c) genuineness, the aim of supportive therapy is to: a) actively listen to patient's concerns & emotions; develop therapeutic relationship; identify and utilise pt's strengths & promote self-management; involve and support carers 10) family therapy - focuses on the "system" rather than individual hence the focus on the family. Allows multiple perspectives to emerge. Can have individual/family sessions. Used primarily in Child and Adolescent Mental Health Services, also effective in other settings

Legal framework in child and adolescent psychiatry

1) definitions: a) children - according to GMC = younger children who lack the maturity and understanding to make important decisions for themselves b) young person/people - older or more experienced children who can make important decisions themselves c) adults - aged above 18 d) legally presumed that people >16 have the ability to make decisions about their own care 2) respect for young people's views is important in making decisions about their care. If they refuse treatment, particularly if life-saving or that prevents serious deterioration in their health, this presents a challenge a) parents cannot override the competent consent of a young person to treatment that you consider is in their best interests. But you can rely on parental consent when a child lacks the capacity to consent. Law on parents overriding young people's competent refusal is complex - seek legal advice if think tx is in best interests of a competent young person who refuses b) carefully weigh up harm to the rights of children and young people of overriding their refusal against benefits of treatment, so that decisions can be taken in their best interests. In these circumstances, consider involving other members of the MDT, an independent advocate, or a named or designated doctor for child protection. Legal advice may be helpful in deciding whether to apply to the court to resolve disputes about best interests that cannot be resolved informally 3) no age restriction for Mental Health Act but can only be used for tx of mental disorder (not physical illness unless manifests with mental health symptoms) 4) Mental Capacity Act generally only applies to individuals >16 (few exceptions but more related to social care). However, assessing capacity as in Mental Capacity Act can be used at any age. If consent is needed below aged 16, consider parental consent - remember Fraser/Gillick competency 5) confidentiality & disclosure - same duties of confidentiality apply when using, sharing or disclosing information about children and young people as about adults a) if child or young person does not agree to disclosure there are still circumstances in which you should disclose information: I) when there is an overriding public interest in the disclosure II) when you judge thatisclosure is in the best interests of a child or young person who does not have the maturity or understanding to make a decision about disclosure III) when disclosure is required by law b) occasionally, children who lack the capacity to consent will share information with you on the understanding that their parents are not informed - try to persuade child to involve a parent. If they refuse & you consider it is necessary in child's best interests for information to be shared (eg/ to enable a parent to make an important decision, or to provide proper care for the child), you can disclose information to parents or appropriate authorities

Acute stress reaction definition, symptoms, management and prognosis

1) definiton - brief response (up to a month) to severely stressful events a) almost everyone will experience an acute stress reaction during their life, whether to failing an exam, a break up in a relationship or an accident. Most utilise normal coping strategies & recover without any need for intervention b) those who seek help from medical professionals are more likely to have a poor pre-existing support network & nowhere else to go for support, more likely to have pre-existing mental health problems so coping more difficult, & also likely to have suffered a more serious trauma to have come to the attention of medics early on after the trauma eg/ after surviving mass shooting 2) symptoms - a) include symptoms of anxiety and depression b) possibly numbness, detachment, poor concentration, derealisation, insomnia, restlessness, anger, autonomic symptoms c) pts may already be using coping strategies - avoidance of talking or thinking about the event, denial of events/not being able to remember d) unhelpful strategies such as alcohol excess are also common 3) mx - a) dec emotional response - talking to friends/family or professionals b) encouraging, but not forcing, recall (debriefing) c) learning effective coping skills d) anxiolytic only if severe anxiety (addictive potential of benzodiazepines) e) hypnotics if severe sleep disturbance 4) prognosis - vast majority get better with no intervention or formal diagnosis. If formally diagnosed, 78% go on to develop PTSD

Common co-morbidity & prognosis of psychosis

1) depression - affects 70% pts in acute phase of psychosis, often resolves a) occurs in 1/3rd pts in maintenance phase (post-psychotic or post-schiziophrenic) - TCAs eg/ impiramine 2) substance abuse - consider clopazine, psychosocial approaches, possibly pharmacotherpy eg/ nicotine substitution, opiate substitution 3) prognosis - a) 20% after 1st episode never have another episode b) 30% continuous illness, not free of symptoms c) 25% improved, but require extensive support network d) risk of premature death from suicide (10-15%), CV disease & T2DM e) good prognostic factors - female, married, acute onset, early & effective tx, prominent mood symptoms f) poor factors - opposite to above + fmx of schizophrenia, substance misuse, prominent -ve symptoms, early onset, lack of insight

Carry out a basic motivational interview

1) develop discrepancy - a) motivation for change created when pt perceives a discrepancy between their present behaviour & important personal goals b) identifying pt's own goals (need to be those of pt not those of health care provider) - objective of MI is to help pt recognise the discrepancy between their behaviour and their personal goals c) various techniques used to help develop discrepancy eg/ ask pt what is good or positive about a particular behaviour and what is not so good about it. Reflecting back and examining +ve & -ve will help discrepancy emerge. MI changes pt's perceptions of discrepancy without creating a sense of being pressured 2) express empathy - MI relies to a great extent on establishing and maintaining rapport with pt. Ability to express empathy is critical. Requires skilful, reflective listening to understand pt's feelings and perspectives without judging, criticising, or blaming. Attitude of acceptance and respect contributes to development of an effective, helping relationship and enhances pt's self-esteem. Empathic responses demonstrate the health care provider understands pt's point of view and provides an important basis for engaging pt in a process of change 3) support self-efficacy - self-efficacy is a pt's belief or confidence in their ability to carry out a target behaviour successfully. General goal of MI is to enhance pt's confidence in their ability to overcome barriers and succeed in change. Health care providers can support self-efficacy by recognising small +ve steps pt is taking to change their behaviour. Even when pt is simply contemplating a change, there is an opportunity to provide recognition and support. Setting reasonable and reachable goals the pt can actually accomplish will help build confidence. Important that pt is involved in setting the goal 4) roll with resistance - resistance can take several forms eg/ negating, blaming, excusing, minimising, arguing, challenging, interrupting, and ignoring. Don't directly oppose resistance but roll or flow with it. Direct confrontation creates additional barriers to make change more difficult. Pt's resistance during MI is expected and should not be viewed as a negative outcome - pts who resist are providing information about factors that foster or reduce motivation to adhere to behavioural change. Rolling with resistance includes involving pt actively in process of problem-solving

Clinical presentation, including an understanding of the ICD-10 diagnostic criteria, of substance misuse (intoxication, withdrawal state, harmful use and dependence syndrome)

1) diagnosis - ICD-10 2 step approach: a) specify substance or class of substance - alcohol, opioids, cannabinoids, sedatives or hypnotics, cocaine, stimulants (inc caffeine), hallucinogens, solvents, multiple drug use b) specify type of disorder - I) acute intoxication - transient physical & mental abnormalities occurring shortly after administration & caused by direct effects of psychoactive substance. Acute intoxication may cause disturbances in consciousness, cognition, perception, affect, behaviour or other psychophysiological functions. Effects are specific & characteristic for each substance (eg/ disinhibition with alcohol, visual and sensory distortions with LSD) II) harmful use - continuation of substance use despite evidence of damage to user's physical or mental health or to their social, occupational or familial well-being. Damage may be denied or minimised by the individual concerned III) dependence syndrome IV) withdrawal state (+/- delirium) - when physical dependence on a drug, abrupt cessation or partial withdrawal of substance generally leads to withdrawal symptoms. Particular symptoms experienced & their severity and persistence usually related to type of substance & quantity being used prior to cessation. Some drugs not associated with any withdrawal symptoms. Clinically significant withdrawal symptoms recognised in dependence on alcohol, opiates, benzodiazepines, cocaine and amphetamines. Withdrawal syndromes can be simple or complicated by development of seizures, delirium or psychosis V) psychotic disorder VI) amnestic disorder VII) other mental & behavioural disorders (eg/ dementia) 2) tolerance - over time, user finds more of the drug must be taken to achieve the same intensity of pleasurable effects. May attempt to combat inc tolerance by choosing a more rapidly acting route of administration (eg/ IV rather than smoking). Tolerant individuals able to consume large quantities of substance while showing no or few signs of intoxication 3) dependence syndrome - a) comprises a cluster of physiological, behavioural and cognitive phenomena relevant to a pt's relationship with particular substance or class of substance b) core features of dependence syndrome include: I) primacy - drug & need to obtain it becomes most important things in pt's life taking priority over all other responsibilities, activities and interests. Relationships, employment, financial stability, physical health & individual's sense of morality may all be diminished as a consequence I) continued use despite negative consequences - pt continues with substance use even when threatened with significant losses as a direct consequence of continued use II) loss of control of consumption - subjective sense of inability to control or restrict further consumption once the drug is taken III) narrowing of repertoire - user moves from using a range of psychoactive substances to a single drug taken in preference to all others. Over time, user takes drug in same setting with same individuals and uses the same route of administration IV) rapid reinstatement of dependent use after abstinence - characteristically, when user relapses to drug use after a period of abstinence they are at risk of rapidly returning to pattern of dependent use in a much shorter period of time V) tolerance and withdrawal - features of the dependence syndrome

Psychiatric disorders in children and adolescents - epidemiology, aetiology, attachment theory and autistic spectrum disorder

1) epidemiology - a) mental health difficulties affect 10% children b) up to 50% presentations to GPs d) 30% new presentations to paediatricians e) only 1:10 of these are in contact with specialists 2) aetiology - a) risk factors: I) parental mental illness, child as carer II) sibling mental illness III) family difficulties IV) adversity/poverty V) domestic violence/abuse 3) attachment theory - mary ainsworth "strange situation" procedure to observe infant exploring toys for 20 minutes while mother & stranger entering and leaving room a) 3 categories: secure attachment, anxious-ambivalent insecure attachment, anxious-avoidant insecure attachment b) attachment in infants is important as it can lead to an internal model of the self as unlovable and inadequate, and of others as unresponsive and punitive c) it may also predict a person's reaction to loss or adversity, and his pattern of relating to peers, engaging in relationships and parenting children d) development of attachment - I) newborn - lack of selective attachments and stranger anxiety II) 9-month - stranger anxiety, selective attachments begin III) 18-month - peak of proximity seeking with distressed/anxious behavior IV) 3-4 years - separates more easily from parents V) 5-year - more stable "internal representations" of parents/relationships VI) adolescent - culturally dependent; western culture-minimal dependency needs 4) autistic spectrum disorder - a) epidemiology - I) prevalence - some debate II) most severe (kanner autism) 10 in 10,000 III) widest possible definition (complete spectrum) 1 in a 100 IV) boys: girls 4:1 V) may present to services at any age b) presentation - persistent triad of deficits: socialisation, communication, repetitive behaviour c) aetiology: I) genetic II) biological, neurotransmitters, brain injury, III) psychological/social factors affect how presents & how pt copes with it

Differential diagnosis, comorbidities, physical, psychiatric and social consequences and prognosis of schizophrenia

1) differential diagnosis a) organic disorders: drug or alcohol induced psychosis, temporal lobe epilepsy, enchepalitis, dementia, delirium, cerebral syphilis b) psychiatric: mania, psychotic depression, personality disorders, panic disorders, dissociative identity disorder c) associated conditions: depression, anxiety, PTSD, substance misuse, obesity, DM, infection, CV disease, continuing disability 2) mx - a) social - help with housing, vocational support, social isolation, employment and financial aid b) psychological support - psychoeducation, support groups, art/music therapy I) CBT for tx c) drugs - I) 1st line in newly diagnosed = atypicals eg/ risperidone or olanzapine II) depot considered if pt prefers this or non-compliance with meds III) benzos only if pt is violent or aggressive and refuses admission IV) aripiprazole if 15-17 years & intolerant of risperidone V) tx should continue for 1-2 yrs after initial event, then gradually dec VI) SE - typicals = EPSE, atypicals = weight gain & sedation d) electroconvulsive therapy (ECT) - if resistant to meds 3) prognosis and recovery - recovery: "being able to live a meaningful and satisfying life, in the presence or absence of symptoms" a) 80% recover after 1st episode. Early intervention and more effective treatment needed b) good prognostic factors: no fmx, good premorbid function - stable personality, stable relationships, clear precipitant, acute onset, mood disturbance, prompt treatment c) poor prognostic factors: slow, insidious onset, -ve symptoms prominent d) dec life expectancy linked to CV disease, respiratory disease and cancer e) suicide risk 9x higher than general population f) 50% have a substance misuse problem. High rates of cigarette smoking

Definition of the concept of intellectual disability

1) disability characterised by significant limitations in both intellectual functioning & in adaptive behaviour (taking into account pt's age), which covers many everyday social and practical skills. This disability originates before the age of 18 2) intellectual functioning (aka intelligence) - refers to general mental capacity, such as learning, reasoning, problem solving etc a) can be measured by IQ test - generally score around 70 (up to 75) indicates a limitation in intellectual functioning 3) adaptive behaviour - collection of conceptual, social, and practical skills learned & performed by people in everyday lives a) conceptual skills—language and literacy; money, time, and number concepts; and self-direction b) social skills—interpersonal skills, social responsibility, self-esteem, gullibility, naïveté (i.e., wariness), social problem solving, and the ability to follow rules/obey laws and to avoid being victimized c) practical skills—activities of daily living (personal care), occupational skills, healthcare, travel/transportation, schedules/routines, safety, use of money, use of the telephone d) standardised tests can determine limitations in adaptive behaviour 4) when defining and assessing intellectual disability, additional factors must be taken into account eg/ community environment typical of individual's peers & culture. Professionals should also consider linguistic diversity and cultural differences in the way people communicate, move, and behave 5) severity of learning difficulties a) mild LD - IQ score 50-69 I) prevalence: 1.5-3% (account about 85% of all IDs) II) often not recognised as learning disabled, only need help if problems arise, often can sustain relationships, and hold a routine job b) moderate LD - IQ score 35-49 I) prevalence: 0.5% (with severe LD) II) often capable of substantial autonomy in ADL with some supervision, able to communicate adequately, to do simple household jobs III) may need a supervised environment and work in a sheltered workshop c) severe LD - IQ score 20-34 I) prevalence: 0.5% (with moderate LD) II) need help with ADL, can be able to wash & usually continent; often physically disabled III) capable of only limited communication often not by speech IV) usually need continuous care d) profound LD - IQ score <20 I) prevalence: 0.05% II) usually need extensive or total help with ADL, minimal ability of communication III) needs continuous care

Common psychiatric co-morbidity of substance misuse and the concept of dual diagnosis

1) dual diagnosis - term used when a person has a mood disorder eg/ depression or bipolar disorder & a problem with alcohol or drugs. A person who has a dual diagnosis has two separate illnesses, and each illness needs its own treatment plan 2) anxiety & depressive disorders - a) symptoms eg/ low mood, generalised anxiety, social phobia and panic attacks frequently reported in substance abusers. 2-way relationship between alcohol/drugs and these psychiatric disorders b) pts may have a primary mood or neurotic illness and be using alcohol/drugs to self-medicate c) chronic alcohol use has a direct depressogenic effect & cycle of drinking and withdrawal can provoke and exacerbate symptoms of anxiety 3) suicide - alcohol/drug misuse associated with inc risk of suicide I) psychiatric co-morbidity, social isolation and repeated failed attempts at abstinence inc risk schizophrenia - rates of harmful use and dependence on alcohol/drugs inc among people with schizophrenia as compared to the general population. Alcohol misuse in those with schizophrenia is a risk factor for psychotic relapse, re-hospitalisation, non-concordance with treatment and violence

Epidemiology, aetiology and prognosis of alcohol misuse

1) epidemiology - a) 9 million people in England regularly drink > recommended daily limits b) younger people tend to drink more heavily (>8 units for men and 6 units for women) on a single occasion than older people c) older people tend to drink more frequently than younger people d) ~9% of UK adult men and 4% of UK adult women are dependent on alcohol e) 65% hospital admissions due to alcohol related diseases, injuries and conditions are men f) alcohol estimated to cost NHS £3.5 billion per year - £120 per tax payer 2) aetiology a) biological - I) genes play a role in determining pt's risk of developing alcohol misuse disorder - 1st degree relatives of alcohol-dependent persons have 7x risk of developing alcohol problems themselves II) genetic factors also determine pt's capacity to metabolise alcohol eg/ South-east Asians have inactive form of aldehyde dehydrogenase enzyme = accumulation of acetaldehyde = flushing reaction to alcohol b) psychological - I) mental illness (eg/ depression, anxiety disorders and schizophrenia) inc pt's risk of developing alcohol or substance misuse disorder II) stress, high social anxiety levels & low self-esteem associated with alcohol misuse III) psychological theories of -ve & +ve reinforcement can be applied to alcohol misuse IV) -ve reinforcement: stressful situation = drink alcohol = dec unpleasant feelings = drink alcohol V) +ve reinforcement: social situation= drink alcohol = inc in pleasant feelings = drink alcohol c) social/occupational - I) heavy drinking more common in men II) alcohol-related mortality inc in more deprived socio-economic classes III) other social risk factors: social isolation, loss of spouse IV) certain professions have inc risk eg/ bartending and farming V) many jobs in healthcare system can be highly stressful with unsociable working hours - may inc potential for to develop alcohol and illicit substance misuse disorders 3) prognosis - up to 30% pts with alcoholism stop drinking. Even a pt with cirrhosis might have a favorable prognosis if alcohol cessation is achieved

Epidemiology, presentation, risk factors, comorbidities, pathophysiology and ix of depression

1) epidemiology - a) lifetime prevalence: depression = 15% (major = 3%), bipolar = 2%, any mood disorder = 10% (2x more in women) b) 5% adults with major depression die by suicide c) most likely to develop 1st depressive episode at 30-40, 2nd peak at 50-60 2) presentation of major depressive disorder - a) core symptoms - low mood + anhedonia + anergia + apathy b) additional symptoms - dec concentration, dec self-esteem, guilt or worthlessness, ideas/acts of self-harm/suicide, disturbed sleep, changes in appetite c) somatic syndrome - markedly dec appetite & weight loss (>5% in 1 month), early morning wakening (at least 2hrs before usual time), diurnal variation in mood (depression worse in morning), psychomotor retardation/agitation d) depression with psychosis - can happen in severe cases of depression: delusions (mood congruent i.e. content is in line with low mood): persecutory or nihilistic delusions - belief that self, part of self, part of body etc has ceased to exist I) also hallucinations: 2nd person auditory - accusatory or defamatory, olfactory eg/ filth, or rotting/decomposing flesh e) severity - I) mild: 5 symptoms II) moderate: at least 6 symptoms III) severe: all 3 core symptoms + additional symptoms giving at least 8 IV) severe with psychotic symptoms: as above + delusions, hallucinations 3) risk factors - fmx of depression, major life changes, certain meds, chronic health problems, substance abuse. 40% risk related to genetics 4) comorbidities - a) major depression frequently co-occurs with other psychiatric problems eg/ anxiety, PTSD b) inc rates of alcohol and drug abuse & dependence c) medical problems eg/ ADHD, pain 5) pathophysiology - current theories center around monoaminergic systems, circadian rhythm, immunological dysfunction, HPA axis dysfunction and structural or functional abnormalities of emotional circuits a) monoamine theory - insufficient activity of monoamine neurotransmitters b) immune system abnormalities - inc cytokines generate sickness behavior c) HPA axis abnormalities - association of CRHR1 with depression & inc frequency of dexamethasone test non-suppression in depressed pts d) "Limbic Cortical Model": hyperactivity of paralimbic regions & hypoactivity of frontal regulatory regions in emotional processing; "Corito-Striatal model": abnormalities of prefrontal cortex in regulating striatal and subcortical structures results in depression 6) ix - a) bloods: TSH, U&E, Ca2+, FBC, ESR, testosterone, vit D b) cognitive testing & brain imaging to distinguish depression from dementia, & CT for brain pathology if psychotic, rapid-onset or unusual symptoms

Psychological interventions in substance misuse including motivational interviewing

1) harm reduction - refers to policies, programmes and practices that aim to dec harms associated with use of psychoactive drugs in people unwilling or unable to achieve abstinence. Based on recognition that many people throughout the world continue to use illicit substances despite strong efforts to discourage the initiation and continuation of use. Harm Reduction strategies focus on prevention of harmful consequences of drug use rather than of drug use itself a) models - re-use or share uncleaned equipment; re-use of share cleaned equipment; use only sterile equipment & don't share; don't inject - use in other ways; don't use b) strategies - needle distribution/exchange programmes and advice regarding safer injecting practice; "Take home naloxone" programmes to provide individuals with means to reverse opiate overdose; substitute prescribing (e.g. methadone programmes); assessment & tx of comorbid physical and mental illness; education about safe-sex practice c) community strategies eg/ prescription of methadone may dec criminality in an opiate-dependent individual with a consequent wider community benefit 2) stages of change - tx of pts with alcohol and drug misuse disorders can be challenging. Pts often have marked ambivalence towards achieving behaviour change, habit reduction and abstinence. Stages-of-Change model recognises different people are at different stages of "readiness for change". By identifying a person's stage in the change process a healthcare worker may more appropriately match interventions to the individual's needs a) 6 stages - pre-contemplation (no intention on changing behaviour) - contemplation (aware problem exists but no commitment to action) - preparation (intent on taking action to address problem) - action (active modification of behaviour) - maintenance (sustained change, new behaviour replaces old) - relapse (fall back to old patterns of behaviour) b) positive prognostic factors - motivated to change; supportive family or relationship; in employment; treatable co-morbid mental illness (eg/ depression, anxiety disorder); alcoholic or drug service c) negative prognostic factors - ambivalent about change; unstable accommodation or homelessness; absence of pro-social relationships; unemployment; primacy (limited pursuits outside alcohol or drug use); repeated tx failures; cognitive impairment motivational interviewing

Health anxiety

1) health anxiety - umbrella term that encompasses a wide range of: a) excessive health-related concerns (eg/ ruminations on having an illness, suggestibility if one reads about a disease, unrealistic fear of infection) b) somatic perceptions (eg/ preoccupation with bodily sensations or functioning) c) behaviours (eg/ repeated reassurance seeking, avoidance of medications or medical personnel) d) can also apply to pt with a medical illness - their reaction will be out of proportion with what would be expected 2) normal and abnormal illness behaviours - a) normal - wanting to get better, to seek help, to co-operate with tx, adopting the sick role, expected to be exempted from responsibilities b) abnormal illness behaviour - going to doctor's too often, not wanting to get better, denial of problem, not going to doctors or taking medical advice, illness behaviour continuing beyond appropriate timescale, taking too many tablets/using too many aids 3) health anxiety subtypes - a) cognitive type: health anxiety with high cognitive awareness and more pronounced fear of disease eg/ Nick developed a fear of having HIV after having an extramarital affair 1 year ago. Fearing transmission to his wife, Nick has refrained from any sexual relations with his wife for 12 months, leading to severe marital discord. Inc tearfulness, sleep disruption & loss of appetite. Been tested 11 times for HIV; all came back negative, but his worries persist b) somatising type: health anxiety with high symptom awareness and more pronounced bodily preoccupation eg/ Andy reports a prior hx of depression & fmx of somatoform disorder. Worrying much of the day about having a heart attack. Reports frequent SOB, nauseous, dizziness, tingling, and palpitations. Feels so poorly he stopped going for his daily run over the past year and gained 30 lb c) behavioural type: health anxiety with high disease conviction and avoidance eg/ Sue has significant worries about having breast cancer that is interfering with her social and occupational functioning. Reports checking a lump she found in her armpit for the past year. Although her sister and mother repeatedly assured her it was an ingrown hair, she is unable to stop checking the site on her body several times a day, so site has swelled to an even greater degree and developed some discoloration and bruising 4) aetiology of health anxiety a) predisposing factors - fmx of OCD or health anxiety or somatisation disorder, early life trauma (sexual, trauma, violence, parental upheaval) b) precipitating factors - personal experience of previous illness - misinterpret bodily sensation, fear of relapse, significant illness of a loved one c) perpetuating factors - inc sensitivity in certain brain area (anterior cingulate, prefrontal cortex), somatosensory amplification - paying too much focus on minor body sensations

Indications, mechanism of action and side effects of ECT & be able to describe to a patient or carer how ECT is administered

1) indications a) treatment-resistant depression or mania, life-threatening depression, catatonia, depressed pregnant women 2) pt receives 4-12 sessions in a course of ECT, sessions usually 2x/week a) ?mechanism of action of ECT, likely to be a combination of: I) modulation of neurotransmitter functioning II) changes in regional blood/activity III) modulation of neuronal connectivity IV) alterations of neuronal structures, including hippocampal neurogenesis b) electrode placement - 2 options: bilateral and unilateral I) bilateral placement (most used) - more effective but may give rise to more cognitive SE c) during 1st session a dose titration is carried out to establish seizure threshold - effective tx dose can then be calculated d) to determine whether an effective seizure achieved, an EEG is used - seizures are electrically induced in pts to provide relief from psychiatric illnesses e) administered under anesthetic with a muscle relaxant 3) efficacy - ECT is one of the most effective tx for depression (better than antidepressants), "80% pts who receive ECT recover from clinical depression" 4) contraindications - a) absolute: cochlear implant b) relative: inc ICP, intracranial aneurysm, hx of cerebral haemorrhage, recent MI (<3 months), aortic aneurysm, uncontrolled cardiac arrhythmias, cardiac failure, DVT, acute respiratory infection 5) SE: most resolve on completion of the course of ECT - a) common: headache, confusion, dec cognitive function, temporary amnesia b) longer-term: a specific component of retrograde memories before ECT may be effected longer term, usually related to autobiographical memories

Indications, mechanism of action and side effects of antidepressants and benzodiazepines

1) indications - a) depressive illness, anxiety disorders, neuropathic pain, insomnia, bulimia nervosa, impulsivity, migraines, chronic fatigue syndrome, IBS, narcolepsy NB/ antidepressants are not addictive 2) mechanim of action - Serotonin, noradrenalin and dopamine are all neurotransmitters implicated in depression and anxiety. Antidepressants work mainly through serotonin (raphe nuclei) & noradrenaline (locus coeruleus) systems a) serotonin released from presynaptic membrane, crosses synaptic cleft & binds with postsynaptic receptors. Serotonin then taken back into presynaptic synapse b) SSRIs, TCAs and SNRIs inhibit reuptake of serotonin, noradrenaline or both = enhancement of neurotransmission 3) SSRI SE - transient nausea, exacerbation of anxiety, inc suicidal ideation with initiation, insomnia, apathy and fatigue, diarrhoea, dizziness, sweating, akathesia 4) SNRIs - 2nd or 3rd line eg/ Venlafaxine, Duloxetine, SE similar to SSRIs 5) TCAs - 3rd line, toxic in overdose, not teratogenic so often used in pregnancy eg/ Amitriptyline, Imipramine, Clomipramine, Dosulepin, Lofepramine a) SE - majority due to antimuscarinic side-effects: dry mouth, blurred vision, constipation, urinary retention, sedation, weight gain

Indication, mechanism of action and side effects of antipsychotics

1) indications - a) psychological - psychosis, mood disorders, anxiety disorders, Tourettes (tics) b) medical problems - insomnia, rapid tranquillisation, N+V, hiccups 2) mode of action - postsynaptic competitive receptor antagonism for dopamine a) 3 dopaminergic pathways: tuberoinfundibular, mesocortical/mesolimbic and nigrostriatal b) antipsychotics - antagonism of mesocortical/mesolimbic pathway (blockage of other pathways = common SE - blockade of tuberoinfundibular = hyperprolactinaemia, nigrostriatal = extrapyramidal SE) c) typical antipsychotics: Chlorpromazine, Fluphenazine, Flupentixol, Haloperidol = dopamine receptor 2 (D2) antagonism d) atypicals: Aripiprazole, Olanzapine, Quetiapine, Risperidone, Clozapine = D2 antagonism +/- 5-HT receptor antagonism 3) SE of aripiprazole - nausea, restlessness, insomnia a) least weight gain & minimal metabolic effect 4) SE of olanzapine - +++ sedation & weight gain, inc TG, proglycaemic, anticholinergic SE - big metabolic disturbance 5) SE of quetiapine - ++ sedation & weight gain, QT prolongation 6) SE of risperidone - ++ sedation & weight gain & sexual dysfunction & EPSE, hyperprolactinaemia 7) SE of clozapine - treatment-resistant schizophrenia, D4 blockade a) myocarditis/cardiomyopathy b) orthostatic hypotension c) agranulocytosis (regular blood monitoring - initially weekly FBC) d) ++++ sedation & weight gain & TG e) proglycaemic 8) SE of typicals - a) neurological - neuroleptic malignant syndrome, seizure threshold lowered b) autonomic - BP + temperature c) hypersensitivity reactions - liver, BM, skin d) endocrine - inc prolactin e) psychiatric - apathy, confusion, depression f) peripheral ANS - muscarinic + a-1-adrenoceptor blockade g) cardiac - arrhythmia 9) extrapyramidal SE - most widely reported SE of typicals, most concerning is tardive dyskinesia, as may be irreversible: a) akathisia - subjective feelings of restlessness + objective signs b) Parkinsonism - tremor, rigidity and bradykinesia c) acute dystonia - involuntary muscle spasms = brief abnormal posture d) tardive dyskinesia (TD) - abnormal involuntary hyperkinetic movements eg/ abnormal tongue movements, pouting/smacking of lips 10) Depot antipsychotics - IM antipsychotic when non-concordance with tx, weekly-monthly eg/ 1st gens, Risperidone, Olanzapine, Aripiprazole NB/ Neuroleptic Malignant Syndrome (NMS) - potentially fatal SE of all antipsychotics. Idiosyncratic reaction to antipsychotics. S/S - hyperthermia, muscle rigidity, confusion, tachycardia, hyper/hypotension, tremor, inc CK, low pH - metabolic acidosis

Obtain a relevant history from a patient and/or carer

1) introduction 2) demographics - age, sex, marital status etc. (identifies risk factors) 3) consent 4) reason for referral: a) what is pts understanding of referral? Why are they here? b) what are they expecting? 5) presenting complaint: a) pt may not have a complaint! b) look for usual w's - what, when, where, why 6) hx present illness - for each problem list: a) when did the problem start b) precipitating events c) how did it develop d) associated symptoms e) how problem affects day to day functioning f) has any help or tx been sought & response of these interventions g) temporal relationships between symptoms & any physical, psychological or social problems h) what makes it better or worse? 7) hx of psychiatric illnesses: a) hospital admissions? use of MHA b) what was helpful/unhelpful with previous tx c) hx of deliberate self-harm or attempted suicide? d) predisposing, precipitating & perpetuating factors + protective factors & +ve coping strategies 8) fmx - psych hx & relationships with patient 9) mx - illness & surgery 10) dx including allergies 11) illicit drug & alcohol history a) pattern of use b) withdrawal, dependence, physical sequelae c) drinking or using drugs every day = dependence d) alcohol - double what pt says (shame), drugs - half what pt says 12) personal history: a) childhood I) birth and early development problems II) adversity, separation, abuse, quality of relationships III) academic performance, school, bullying b) adulthood I) relationships, marital, children, social support II) occupations - unemployed how long 13) forensic hx a) trouble with the police b) convictions (current and spent), time in prison, on probation? 14) pre-morbid personality a) how would you describe yourself before you became ill & how would others have described you before you became ill? c) includes: attitudes to others, self-esteem, any predominant mood and stability, interests, reaction to stress, individual's strengths and abilities 15) current social circumstances - a) where are they living & with who (dependants?) b) finances c) current occupation inc education d) other services involves 16) ICE 17) summary 18) finish the consultation

Common causes of psychiatric emergencies including agitation and acute confusion contd.

1) lithium toxicity - lithium only taken orally & excreted almost entirely by kidneys (need to check renal function tests before commencing Lithium as very narrow therapeutic range - check blood levels weekly then once in every 3 months) a) upper therapeutic limit for 12-hour post-dose serum lithium level is 1.2mmol/l, with levels >1.5mmol/L most pts experience some symptoms of toxicity, if >2.0mmol/L, life-threatening toxic effects occur b) diuretics (especially thiazides), NSAIDs, ACEI can also inc serum lithium levels and should ideally be avoided c) early symptoms - marker tremor, anorexia, N+V+D, dehydration & lethargy d) later symptoms - neurological complications, restlessness, muscle fasciculations, myoclonic jerks, choreo-athetoid movements, marked hypertonicity, may progress to ataxia, dysarthria, inc lethargy, drowsiness, confusion, hypotension, arrhythmias, emerging seizures, stupor and coma e) untreated lithium toxicity is fatal 2) serotonin syndrome - rare but potentially life-threatening condition occurring in context of initiation or dose inc of a serotonergic medication a) potential mechanisms of serotonin syndrome (SS) include: inc serotonin synthesis or release, dec serotonin uptake or metabolism, direct serotonin receptor activation b) common cause - pts are being: switched over from one antidepressant to another; combination of antidepressants used; if pts taking antidepressants & other meds & supplements eg/ Triptans for migraine, herbal supplements like St. John's wort or illegal substances like LSD, Cocaine, amphetamines etc c) symptoms - clinical manifestations of serotonin syndrome highly variable. Symptoms can present within few hours after taking new meds that can inc serotonin activity in CNS. No clinical investigations to diagnose SS - diagnosed mainly based on hx I) psychiatric - restlessness, confusion, agitation II) autonomic - hyperthermia (could be related to prolong seizure activity, rigidity or muscular hyperactivity), GI upset, tachycardia, hypo or hypertension, mydriasis III) neuromuscular - myoclonus, rigidity, tremors, hyperreflexia, ataxia, convulsions IV) untreated serotonin syndrome can be fatal 3) differentiating against NMS & serotonin syndrome - a) associated tx - antipsychotics (NMS) vs serotonergic medications (SS) b) onset - slow (days to weeks - NMS) vs rapid (SS) c) progression - slow (24-72 hours, NMS) vs rapid (SS) d) muscle rigidity - severe (lead pipe - NMS) vs less severe (SS) activity - bradykinesia (NMS) vs hyperkinesia (SS)

Understand the impact of stigma in mental illness

1) medical - collection of s/s by which a disease can be recognised 2) modern - collective disproval & -ve perceptions attached to people, trait, condition, or lifestyle 3) 3 stages: a) individual marked out as different by actions or appearance b) society develops a series of beliefs about the affected individual c) society changes its behaviour towards these individuals in a way consistent with those beliefs, often to detriment of stigmatised individuals d) stigma can be self-reinforcing as associated with avoidance of stigmatised individuals, leaving no opportunity for society to change its beliefs e) fear of unknown, contamination, and death have led to stigmatisation of many diseases - esp with mental disorders 4) for people affected, name of condition & their abnormalities of experience & behaviour marks them out as different - root cause of distress. Stigmatisation adds to burden & may prolong condition eg/ belief it is 'all in the mind' & individual should 'pull themselves together' - people don't understand condition so pt suffers, can also mean pts get better at a slower rate as don't have support needed

Physical, psychiatric and social consequences of alcohol misuse including stigma

1) medical complications a) CNS - I) cognitive & memory impairment (dec brain weight and volume) II) Wernicke-Korsakoff Syndrome III) central pontine myelinolysis (pseudobulbar palsy and quadriplegia) IV) cerebellar degeneration b) PNS - I) alcoholic peripheral neuropathy and myopathy II) optic atrophy and visual changes c) resp - inc susceptibility to infections and aspiration pneumonia d) CV - I) alcoholic cardiomyopathy II) arrhythmias (especially atrial fibrillation) III) HTN IV) cerebrovascular events (especially haemorrhagic strokes) e) hepatic - I) alcoholic liver disease is most common cause of liver disease II) fatty liver changes >90% heavy drinkers & can emerge after a single heavy binge. May be asymptomatic or have non-specific symptoms eg/ lethargy and malaise III) alcoholic hepatitis IV) cirrhosis = end-stage of above processes. Female drinkers at inc risk of progressing to cirrhosis. Co-morbid hep B or C infection also inc risk V) chronic alcohol misuse significantly inc risk of hepatocellular carcinoma f) renal - I) cirrhosis can predispose to the hepato-renal syndrome II) chronic alcohol misuse and binge drinking may cause HTN & contribute to CKD g) pancreas - I) alcohol misuse is commonest cause of chronic pancreatitis. If left untreated can lead to malabsorption & predisposes to DM II) acute pancreatitis can also occur h) spleen - splenomegaly secondary to hepatic cirrhosis and portal HTN i) bowel - I) alcohol can cause malabsorption and chronic diarrhoea II) risk factor for lower GI carcinoma j) oesophageal - I) Mallory-Weiss tears secondary to vomiting II) oesophageal varices +/- haemorrhage III) Barretts oesophagus and oesophageal carcinoma k) gastric - I) gastritis and gastric erosions II) peptic ulcer disease +/- haemorrhage III) gastric carcinoma l) female reproduction - I) chronic alcohol misuse can cause sexual dysfunction in women & thought to be a risk factor for fertility problems II) heavy drinking during pregnancy potentially harmful to unborn foetus & inc risk of foetal alcohol syndrome m) male reproduction - erectile dysfunction & hypogonadism 2) psychiatric complications 1) alcoholic hallucinosis - I) hallucinosis = substance-induced psychotic illness, rare complication of prolonged heavy alcohol use. Pt experiences hallucinations (usually auditory) in clear consciousness while sober. Auditory hallucinations may begin as "elemental hallucinations" eg/ banging or murmuring sounds but, with ongoing alcohol use, progress to formed voices II) differential diagnosis includes acute psychotic episode and delirium tremens (delirium tremens - in a confusional state) III) in 95% pts, there is a spontaneous resolution of symptoms after cessation of alcohol use 2) alcohol related brain damage (ARBD) - I) alcohol-related cognitive impairment & dementia recognised in diagnostic classification system ICD-10 II) 60% chronic heavy drinkers display some degree of cognitive impairment on cognitive testing while sober III) impairment of short-term memory, long-term recall, new skill acquisition, executive functioning, but preservation of IQ & language IV) CT/MRI brain imaging in heavy drinkers reveals cortical and subcortical atrophy with prominent white matter loss V) direct neurotoxic effects exacerbated by thiamine deficiency which can lead to Wernicke-Korsakoff syndrome 3) pathological jealousy - I) monosymptomatic delusional disorder seen most commonly secondary to current or previous heavy alcohol misuse. Pt presents with primary delusion that his partner or spouse has or is being unfaithful II) pt may go to great lengths to obtain "evidence" of infidelity eg/ following their partner to work, examining the partner's clothing III) significant association with violence & homicide towards supposedly unfaithful partner 4) social complications - I) marital disharmony & divorce II) domestic violence III) missed days of work & poor work performance IV) financial & legal problems V) risky sexual activity psychological harm to family members

Relationship between physical illness and psychiatric disorders

1) mental health & physical health are fundamentally linked - a) people living with a serious mental illness are at inc risk of experiencing a wide range of chronic physical conditions b) people living with chronic physical health conditions 2x as likely to experience depression & anxiety compared to general population c) co-existing mental and physical conditions can dec QOL and lead to longer illness duration and worse health outcomes. Also generates economic costs to society due to lost work productivity & inc health service use 2) people with mental illnesses experience a range of physical symptoms from illness itself & consequence of treatment. Mental illnesses can alter hormonal balances & sleep cycles, while many psychiatric meds have SE eg/ from weight gain to irregular heart rhythms - these symptoms create inc vulnerability to a range of physical conditions 3) the way pts experience their mental illnesses can inc susceptibility of developing poor physical health. Mental illness can impact social and cognitive function and dec energy levels - can negatively impact adoption of healthy behaviours. People may lack motivation to take care of their health, or may adopt unhealthy eating & sleeping habits, smoke or abuse substances, as a consequence or response to their symptoms, contributing to worse health outcomes eg/ Canadians who report symptoms of depression also report experiencing 3x as many chronic physical conditions as the general population eg2/ Canadians with chronic physical conditions have 2x chance of also experiencing a mood or anxiety disorder when compared to those without a chronic physical condition 4) pts with mental illnesses often face inc rates of poverty, unemployment, lack of stable housing, and social isolation - inc vulnerability of developing chronic physical conditions 5) some chronic physical conditions can cause high blood sugar levels & disrupt blood circulation, which can impact brain function. People living with chronic physical conditions often experience emotional stress and chronic pain, both associated with development of depression & anxiety. Experiences with disability can cause distress & isolate people from social supports. Some evidence the more symptomatic the chronic physical condition, the more likely a person will also experience mental health problems 6) diabetes rates inc among pts with mental illnesses. Depression & schizophrenia are risk factors for T2DM due to impact on body's resistance to insulin. Antipsychotics shown to cause weight gain. People with diabetes experience emotional stress which can negatively affect mental health. Biological impact of high blood sugar associated with development of depression 7) heart disease and stroke - pts with serious mental illnesses often experience inc BP & stress hormones & adrenaline which inc HR. Antipsychotics linked with development of abnormal heart rhythm. These changes interfere with CV function & inc risk of developing heart disease among pts with mental illnesses. Pts with serious mental illnesses have inc rates of risk factors for heart disease eg/ poor nutrition & obesity. Inc rates of depression in pts with heart disease 8) resp - pts with serious mental illnesses have inc likelihood of developing a range of chronic respiratory conditions eg/ COPD, chronic bronchitis and asthma. Pts with mental illnesses have high smoking rates, due to: impact of nicotine on symptom control, positive social aspects of smoking. Pts with chronic respiratory diseases experience inc rates of anxiety and depression. 9) arthritis - dec rate of arthritis in people with serious mental illnesses, but pts with arthritis are at inc risk of developing mood and anxiety disorders

Mx and prognosis of personality disorders

1) mx - a) general - I) pts can be challenging to manage - they provoke strong, often negative, reactions in other people including health care professionals II) clear boundary is important (knowing when to "draw the line") III) demonstrate you are reliable & consistent rather than promising something you cannot deliver IV) remember splitting - "you are the best doctor!...(next day) you are the worst doctor!" Common reaction from pts with personality disorder and another reason why working closely as a team is essential V) beware transference (how pt feels about you - don't take it personally) & counter-transference (how you feel about them - don't let it affect your professionalism) VI) pts may need to take responsibility for their actions VII) beware the "admission trap"- sometimes admission may be counter-productive, fostering dependence and disempowering individuals from adopting safer coping strategies - needs to be balanced against risk. Decision to admit pt with a personality disorder is often difficult & if you are in any doubt you should seek senior advice and supervision as early in the process as possible. Rule of thumb is that the purpose of admission needs to be clear b) short-term: I) think about any ongoing risks - is pt suicidal or still attempting to harm themselves? If pt has already harmed themselves is this being treated appropriately eg/ tx of physical injuries or drug overdose. Is pt still intoxicated with drink or drugs? II) consider comorbidity - is their presentation just the consequence of personality problems or is there another, comorbid, mental illness that needs treating as well? III) often pts can be safely managed in community by primary care or by secondary services eg/ crisis teams or community mental health teams IV) if risks are significant, it can be appropriate to admit personality disorder pts, either informally or under MHA (personality disorder is considered a "mental disorder" in Mental Health Act) c) long-term: I) variety of longer-term tx for pts with personality disorder. Mainly talking therapies eg/ CBT, Dialectical Behavioural Therapy (DBT), Cognitive Analytical Therapy (CAT), therapeutic communities II) settings can vary, but usually occur on an outpatient basis III) good engagement from pt is vital to success of therapies & poor engagement and / or poor insight into their problems the most common reason for the failure of treatment IV) social interventions may also be appropriate eg/ support around stigma, social inclusion activities, finance, housing etc. etc. V) in a small minority psychological tx for personality disorder is carried out on an inpatient basis. Occurs when risks posed by pt (usually risks to others) are so extreme that they cannot be treated safely in the community. Pts in this group are commonly involved with criminal justice system as well and inpatient treatment of personality disorder is often carried out by forensic psychiatrists d) medication: I) place of meds in tx of personality disorder is controversial - NICE doesn't recommend pharmacological treatment for either emotionally unstable or dissocial personality disorder II) often use meds to address complicating comorbid problems eg/ mood disorder, psychosis or ADHD. In many cases meds used "off-licence" and treatment should only be initiated by a specialist after careful consideration of the risks and benefits III) eg/ antipsychotics: for transient psychotic experiences, reduction of impulsivity and agitation; antidepressants for comorbid illness such as anxiety and depression; mood stabilisers for mood instability 2) prognosis - a) personality disorders, particularly cluster B disorders, appear to be linked with inc rate of suicide, likely from impulsivity & emotional instability seen cluster B disorders seem to be less common with inc age, may reflect the fact that some of the characteristics eg/ impulsivity appear to naturally diminish with age. Whether or not the underlying personality disorder has disappeared is more difficult to say, but pt's presentation may change so that they no longer meet the diagnostic criteria

Management and prognosis of self-harm

1) mx - a) pts who have self-poisoned should be referred urgently to nearest ED b) pts should have an initial assessment of physical health, mental state, safeguarding concerns, social circumstances and risks of repetition or suicide c) receive a comprehensive psychosocial assessment d) emetics eg/ ipecac (ipecacuanha), should not be used in the management of self-poisoning e) gastric lavage should not be used unless specifically recommended by TOXBASE or NPIS f) pts should be fully involved in decision-making about tx & care - I) integrated and comprehensive psychosocial assessment of needs and risks to understand and engage people who self-harm and to initiate a therapeutic relationship II) mx includes forming a trusting relationship with pt, jointly identifying problems, ensuring support is available in a crisis and treating psychiatric illness vigorously III) family and friends may also provide support g) self-harm is a way of expressing distress - often pts don't know why they self-harm - means of communicating & described as expressing an inner scream. Important all people who have self-harmed be properly assessed by local mental health services and appropriately managed and supported by all health professionals involved in their care h) care plans agreed with pt should include short & long-term goals & risk management plan i) assessment of needs: evaluation of social, psychological and motivational factors specific to the act of self-harm, current suicidal intent and hopelessness, as well full mental health & social needs assessment j) assessment of risk: identification of main clinical & demographic features known to be associated with risk of further self-harm and/or suicide, and identification of key psychological characteristics associated with risk, especially depression, hopelessness and continuing suicidal intent k) psychological intervention structured for people who self-harm should be offered, with the aim of reducing self-harm. NICE recommends 3-12 sessions of a psychological intervention specifically structured for people who self-harm, with the aim of reducing self-harm l) psychological, pharmacological and psychosocial interventions should be used for any associated mental health conditions m) drug treatment should not be offered as a specific intervention to reduce self-harm n) tx that focus on inc protective factors eg/ parent support and positive affect, as well as promotion of alcohol and illicit drug avoidance and healthy sleep, may be beneficial with regard to prevention of recurrent suicidal ideation, attempts, or self-harm in adolescents o) for pts at risk of self-poisoning, meds prescribed should be least dangerous in overdose and prescribed as a small number of tablets at any one time - same for relatives who live with pt 2) prognosis - a) risk of repetition of self-harm & of later suicide is high - >5% pts who have been seen at a hospital after self-harm will have committed suicide within nine years b) some young people self-harm on a regular basis while others do it just once or a few times c) for some it is part of coping with a specific problem & they stop once problem has resolved d) others self-harm for years whenever certain kinds of pressures or feelings arise e) many risk factors for repetition of self-harm but most consistent evidence for inc risk of repetition comes from long-standing psychosocial vulnerabilities, rather than characteristics of the index episode f) physical health & life expectancy severely compromised in people who self-harm

Management, prognosis and stigma of bipolar

1) mx - can be challenging as pts can be in different phase and stages of their bipolar disorder (eg/ acute mania, bipolar depressive, or prevention) a) secondary mental health services eg/ community mental health team, crisis team, EIP. Inpatient admission may be indicated 2) acute mania - a) biological - I) 1st line = antipsychotic eg/ haloperidol, olanzapine (best), risperidone II) stop prescribed antidepressants III) consider lithium or valproate IV) consider benzos eg/ lorazepam or diazepam for behavioural difficulties b) psychological - I) formal psychological approaches unlikely to be appropriate in acute phase II) psychoeducation c) social - I) calming, low stimulus environment (consider admission) II) advise to maintain relationships with carers III) advise not to make any serious decisions whilst unwell 3) bipolar depression - a) tx depends on severity of depressive episode b) biological - I) consider atypical antipsychotics eg/ olanzapine, quetiapine - can add SSRI II) consider mood stabiliser eg/ lithium, valproate, lamotrigine d) psychological - I) CBT especially if mild to moderate + psychoeducation e) social - a) social inclusion, carer support, support with education, training, employment 4) prevention of relapse - a) biological - I) lithium (discuss risks & benefits), then valproate - both associated with foetal abnormalities so if women of child-bearing age give antipsychotic II) olanzapine III) avoid antidepressants (unless with mood stabiliser) b) psychological - I) CBT + family therapy + psychoeducation c) social - I) support with housing, benefits, education, training, employment, CPN NB/ pts should be offered a healthy eating/physical activity programme. Weight & CV & metabolic indicators of morbidity monitored, at least annually 2) prognosis - lifelong condition with relapse & remission. Inc rates of disability & premature mortality a) average length of a manic episode, treated or untreated, is 6 months - after which 90% will have a further episode of mood disturbance b) pts with bipolar disorder have ~10 episodes of mood disturbance, over a 25-year follow-up period c) recovery from acute episodes is good, but long term prognosis poor - <20% have 5 yrs of clinical stability, with good social/occupational performance d) pts 25x times more likely to die by suicide e) relapse - non-concordance with meds; life events, stress; disruption of circadian rhythm; substance misuse; childbirth (puerperal psychosis) 3) stigma - widespread problems with social stigma, stereotypes, and prejudice against individuals with bipolar disorder

Somatoform disorders: prognosis, common co-morbidity, physical, psychiatric and social consequences, and management

1) mx - make the link between physical symptoms & psychological factors & broaden the agenda from purely physical cause to include psychological a) goal of treatment is to help pt learn to control symptoms - often an underlying mood disorder which can respond to antidepressants b) attempts to 'take away symptom' may cause pt to substitute another symptom as a result of the need-to-be-sick phenomenon c) interventions directed at dec specific sources of stress are most helpful eg/ advice about dealing with marital conflict d) physical exercise is important e) importance of pleasurable private time eg/ yoga, hobbies etc f) psychotherapy - psychoeducation & CBT: I) challenges pt's beliefs & maladaptive behaviours in a caring manner II) short course intervention (8-16 sessions) III) sessions combine general advice eg/ stress management, problem solving and training in social skills, with specific interventions targeted at amplification & need-to-be-sick features of somatisation, modifying dysfunctional thoughts in response to symptoms g) pharmacological - psych disorders associated with somatisation eg/ anxiety and depression, respond well to tx eg/ antidepressants h) supportive relationship with a sympathetic healthcare provider is the most important aspect of treatment. Regular appointments maintained 2) complications - result from invasive testing, dependency on pain relievers or sedatives, poor relationship with healthcare provider worsens condition 3) prognosis - a) hypochondriasis - in mild form usually benign, responding to simple re-assurance. In severe form, may become depression, anxiety or schizophrenia b) conversion disorder - persists throughout life, with pts experiencing episodes of neurological symptoms that require repeated re-assurance by doctor c) body dysmorphic disorder - many pts seek surgical correction of imagined deformity. Few will find satisfaction with plastic surgery, resulting in multiple procedures & inc potential for complications. Depression usually occurs d) pain disorder - poor prognosis, many pts complaining of pain throughout life. Long-term use of pain-killers inc risk of kidney and liver disease & inc accidental death e) somatisation disorder - poorest prognosis, long-term, patients carrying "imagined" symptoms for much of their lives. Depression may develop 4) stigma - SSD can be associated with a great deal of stigma; risk pts may be dismissed by physicians as having problems that are 'all in their head'

Management, prognosis & stigma of depression

1) mx - psychotherapy, medication, electroconvulsive therapy & social a) psychotherapy is tx of choice if <18 or mild depression: CBT - teaches pts to challenge self-defeating, enduring ways of thinking, change counter-productive behaviors b) antidepressants + psychosocial interventions if moderate or severe depression I) antidepressants continued at least 6 months after remission to dec relapse II) SSRIs 1st line (mild SE & less toxic in overdose) III) SE - mood gets worse in first 2 weeks, nausea, inc appetite & weight gain, loss of libido, erectile dysfunction, fatigue & drowsiness, insomnia, dry mouth, blurred vision, constipation, dizziness, agitation, irritability, anxiety c) lifestyle - exercise, smoking cessation, good sleep and diet d) electroconvulsive therapy e) transcranial magnetic stimulation (or deep transcranial magnetic stimulation) - noninvasive method used to stimulate small regions of brain f) bright light therapy 2) prognosis - a) 50% will recover within 1yr b) chronic depression (>2 years) occurs in 15% c) after 1 year, 25% will have had a further episode, after 10 years, 75% d) 5-15% will die by suicide e) median duration of episode = 6 months, inc rate of recovery in first 3 months f) poor outcome associated with: inappropriate tx, severe initial symptoms, early age of onset, previous episodes, incomplete recovery after 1 year, pre-existing severe mental or medical disorder, and family dysfunction 3) stigma - pts can be reluctant to discuss or seek treatment for depression due to social stigma about condition

Principles of management of psychiatric emergencies including agitation and acute confusion

1) mx of acute behavioural disturbances - a) 3 important basic principles of mx of acute behavioural disturbance: predictions of risk of agitation, prevention of behaviour escalating once ps become disturbed, use of interventions to ensure safety of pts & staff b) key issues - need for admission, including use of MHA or MCA, level of security needed (police?) c) warning signs - angry facial expression, restless or pacing, shouting, pronged direct eye contact, refusal to cooperate, presence of delusions or hallucination with violent content, verbal threats or reports thoughts of violence, blocking escape routes, evidence of arousal (SNS activation) 2) rapid tranquilisation - a) non-pharmacological techniques 1st-line but when fails, consider medications, physical restraint or seclusion b) aim of meds is to calm agitated pt without sedating them & dec risk of violence & harm c) choose meds with rapid onset, short acting, minimal SE & easily reversible eg/ Lorazepam, Midazolam, Diazepam d) antipsychotics can be used to dec agitation eg/ Haloperidol, Olanzapine. Drawbacks - pts might become drowsy & may not be suitable for further psychiatric assessment under MHA 3) SE of meds - a) acute dystonia - severe painful muscular stiffness (spasmodic torticolis) - give procyclidine or benzotropine b) hypotension - dec BP (orthostatic or <50mmHg diastolic) - lie pt flat & raise legs c) neuroleptic malignant syndrome d) respiratory depression - dec consciousness & RR - give O2, raise legs; If RR <10 in pt with benzodiazepines (Flumazenil 200microgram IV) e) arrhythmias - irregular pulse or pulse rate< 50/min - monitor closely, liaise with medical team 4) tx of NMS - a) withdraw antipsychotics b) monitor temperature, BP and pulse c) consider benzodiazepine for sedation d) rehydration e) dopamine agonist like Bromocriptine or dantrolene may be used f) consult psychiatrist before starting antipsychotics in any pts who might have had NMS 5) tx of acute dystonia - dystonia usually well responds to anticholinergic meds eg/ Procyclidine 5-10 mg. With IM, response ~ 20 mins, within 5 minutes with IV 6) tx of lithium toxicity - a) prevention - education of pts to maintain adequate hydration and salt intake b) if suspect Lithium toxicity, immediately stop c) in severe toxicity: pt may require forced diuresis or haemodialysis 7) tx of serotonin syndrome - a) stop medication which might be the precipitating cause b) symptomatic treatment with rehydration c) benzodiazepines can be used for agitation d) if symptoms are severe transfer immediately to ED e) if overdose - consider gastric lavage

Develop a structured targeted management plan for an individual patient with substance misuse including managing withdrawal

1) mx of alcohol & substance misuse - basic principles a) attention should be focused not only on achieving but also maintaining change b) many pts find initial change (moving to abstinence or dec consumption) surprisingly easy but find it much more difficult to maintain change c) relapse is a common component of the "change process" & strategies should be in place to anticipate and minimise length & harm of these d) dependence on alcohol or illicit drugs is not sufficient grounds to for detaining a person in hospital under a Section of MHA. However, alcohol or drug misuse may be accompanied by or associated with mental disorders for which MHA may be used (e.g. drug-induced psychosis) 2) alcohol mx - a) biological - I) detoxification II) maintenance tx - pharmacological maintenance tx for alcohol misuse include medications that aim to i) deter pt from drinking or ii) dec pt's craving for alcohol III) disulfiram - medication used as a deterrent to alcohol abuse. Causes irreversible inhibition of acetaldehyde dehydrogenase (ALDH) which converts alcohol to CO2 and water. If alcohol is consumed there is a build up of acetaldehyde in the bloodstream causing unpleasant symptoms including flushing, headache, tachycardia, N+V IV) Acamprosate - can be prescribed to help dec cravings for alcohol for pts trying to maintain abstinence. Acts through enhancing GABA transmission in brain 3) illict substances mx - a) biological opiate detoxification - I) symptomatic medication - several non-opiate, oral meds effective in ameliorating symptoms of opiate withdrawal. Unlike substitute-opiates (eg/ methadone) they not liable to abuse or diversion to the black market II) Lofexidine = a-adrenergic agonist effective in dec many unpleasant symptoms of opiate withdrawal. Effective detoxification can be achieved in 3 days III) Loperamide and Metoclopramide (or other anti-emetic) often prescribed to treat diarrhoea and N+V commonly seen in withdrawal IV) substitute prescribing - methadone used in detoxification & maintenance regimes - methadone is a long-acting synthetic opioid, has a half-life of 24 hours so suitable for once daily dosing. Taken orally as a coloured liquid b) biological opiate maintenance - I) opiate maintenance tx involves medium & long term prescribing of substitute opiate medications (eg/ methadone) as an alternative to illicit opiate drug that pt is dependent on (eg/ heroin). Methadone is the maintenance drug of choice in the UK II) methadone associated with dec in: use of other opioids; drug related mortality; injection drug-related risk behaviours and transmission of blood-borne viruses; criminal activity III) after stabilisation and complete abstinence from street opiates, a decision should be made as to whether the aim is dose reduction or maintenance IV) rapid reduction regimes dec dose over 14-21 days although dec usually more gradual (weeks to months) c) psychosocial illicit substance I) drug & alcohol services II) narcotics anonymous III) individual counselling (social skills & assertiveness training - learning to say no) IV) self help V) social support - housing, child care/social services, financial/employment VI) motivational interviewing & CBT

Mechanisms of action and effects of commonly used illicit drugs

1) opiates - potent analgesics, cause euphoria & sedation eg/ heroin, morphine, opium, methadone, dipipanone and pethidine. Heroin is most frequently abused 2) depressants - substances that suppress CNS activity causing relief from anxiety eg/ alcohol, cannabis, barbiturates and benzodiazepines 3) stimulants - act on CNS & associated with feelings of extreme well-being, inc mental and motor activity eg/ cocaine, crack cocaine, amphetamines, MDMA 4) hallucinogens (psychedelics) - natural & synthetic substances which produce altered sensory & perceptual experiences eg/ cannabis, Lysergic acid diethylamide (LSD), Phenylcyclidine (PCP), Ketamine, Psilocybin (magic mushrooms) 5) heroin (diamorphine, darks, horse, brown) - derived from morphine (extracted from opium poppy) a) very strong painkiller & gives pt a feeling of warmth, sedation and well-being b) class A illicit drug c) heroin most commonly smoked ("chasing"), otherwise IV, oral or inhaled d) mechanism of action - heroin crosses blood-brain barrier & acts as a powerful agonist at mu opioid receptor subtype to inhibit release of GABA from nerve terminal, reducing inhibitory effect of GABA on dopaminergic neurones = inc release of dopamine into synaptic cleft & continued activation of dopaminergic reward pathway leading to feelings of euphoria e) harmful effects - acute medical problems: I) any route: N+V, constipation, respiratory depression and loss of consciousness (with risk of aspiration) II) IV: adds risk of local abscesses, cellulitis, osteomyelitis, bacterial endocarditis, septicaemia & transmission of viral infections including Hepatitis B, C and HIV III) opiate dependency develops after weeks of regular use & associated with unpleasant (but not medically dangerous) withdrawal syndrome 6) cocaine (flake, charlie, pebbles) - a) potent and highly addictive stimulant drug - user typically feels a greatly elevated sense of well-being, alertness, energy & confidence b) signs of cocaine use: pupil dilation, aggression and risk taking behaviour c) class A drug d) cocaine undergoes rapid 1st-pass hepatic metabolism so not usually consumed orally. Usually taken by inhalation (snorting) but may be injected e) crack ("freebase") cocaine - cocaine that can be smoked. Usually sold in crystal form ("rocks"). Rapidity of onset & peak blood levels similar to IV f) stimulant effects of cocaine relatively short-lived (last 20-30 mins). When effects begin to diminish there is a strong craving to take more g) mechanism of action - inhibition of reuptake of monoamines (blocks necessary proteins) eg/ dopamine, NA + serotonin. Reuptake inhibited = inc levels of neurotransmitters in synaptic cleft. Rewarding & compulsive effects of cocaine mainly due to inc dopamine (mesocortical limbic dopamine pathway) h) harmful effects: I) acute - CV effects eg/ tachycardia, HTN, vasoconstriction, which inc risk of CVA, MI, cardiac arrhythmias. May also cause acute anxiety, panic attacks, impaired judgement & impulsivity II) chronic - necrosis of nasal septum & sinuses; CKD secondary to HTN; inc risk of miscarriage & placental abruption; pysch complications eg/ panic disorder, generalised anxiety, psychosis i) withdrawal - when cocaine used regularly for prolonged period tolerance & dependence may occur. Abrupt cessation in dependent users leads to withdrawal symptoms (unpleasant but rarely medically serious, resolve in <14 days) j) typical withdrawal symptoms include: dysphoria and anxiety; fatigue and difficulty concentrating; craving for cocaine; muscle aches and tremors 7) cannabis (green, blaze, dope) - most widely used illegal drug in UK. Produced from dried leaves, seeds and stems of weed Cannabis Sativa. Active chemical is tetrahydrocannabinol (THC) a) THC causes pt to feel very relaxed and happy. Can cause hallucinations - so categorised as a depressant and a hallucinogen b) Skunk - slang term used to refer to stronger forms of cannabis c) cannabis is a Class B drug d) distributed as a herbal material ("grass" or marijuana), as a resin ("hash") or as cannabis oil. Majority of users smoke often after combining with tobacco. Can also be eaten directly or incorporated into other foodstuffs (e.g. cakes) e) effects apparent within mins if smoked, peaking at 30 mins & lasts 2-5 hours f) onset of action if orally consumed cannabis is slower & effect more prolonged g) mechanism of action - THC binds to & activates cannabinoid CB1 receptors on pre-synaptic nerve terminals in brain. CB1 receptors in parts of brain associated with memory, concentration, time perception, coordination & executive functioning h) physical effects - inc HR, dizziness, inc appetite, inc risk of respiratory disease and other smoking-related pathology i) psychological effects - cannabis use may provoke acute anxiety, panic attacks. Some users may develop acute psychotic symptoms. j) chronic harmful use may cause dysthymia, dec motivation & anxiety disorders k) cannabis and schizophrenia - those who use cannabis particularly at a younger age have inc risk of developing schizophrenia (dose-related) 8) MDMA (skittles, molly) - 3,4-methylenedioxy-methamphetamine (MDMA) is a synthetic drug that alters mood and perception producing feelings of inc energy, pleasure, emotional warmth, and distortions in sensory and time perception a) users feel euphoric and "in tune" with surroundings & inc feelings of affection for others around them b) structural similarities to both amphetamine & mescaline so categorised as stimulant & hallucinogen. c) MDMA is a Class A drug d) almost always taken orally, usually sold in tablet form although crystal and powder preparations increasingly being distributed, half-life ~ 7 hours e) effects on serotonergic, noradrenergic and dopaminergic systems in CNS. Physical & psychological effects primarily due to action on serotonin - causes serotonin release & blocks its reuptake from the synaptic cleft f) harmful effects - I) acute - jaw clenching & teeth grinding; nausea; blurred vision; inc body temperature = dehydration; come down effects begin 12-48hrs after consumption & include fatigue & depression II) chronic - pts develop tolerance to MDMA but dependence syndrome doesn't occur; depression & anxiety with chronic use 9) LSD - Lysergic acid diethylamide (LSD). Occurs naturally in Morning Glory Plant a) pt experiences sense of euphoria, detachment and " sense of novelty in the familiar and a sense of wonder at the normal" b) perceptual distortions may occur in all sensory modalities and synasthesia (stimulus usually perceived in 1 sensory modality is experienced in another e.g. "tasting colours", "seeing sounds") c) LSD is a Class A drug d) very soluble, sold either impregnated onto paper, as a powder or in tablet e) LSD is an indolealkylamine & structurally very similar to serotonin molecule. Acts as an agonist on most of serotonin receptor subtypes in brain. Also has indirect effects on the dopaminergic pathways f) harmful effects - I) acute - dilated pupils, tachycardia, HTN, acute intoxication can be associated with perceptual disorders & high-risk behaviour, bad trip may be associated with terrifying delusions & hallucinations II) chronic - not associated with physiological dependence or withdrawal, regular use can cause long-term psych complications eg/ chronic psychosis, depressive & anxiety disorders 10) benzodiazepines - used in clinical practice as anxiolytics and anti-convulsants a) feeling of euphoria & marked dec in anxiety eg/ Diazepam, Lorazepam, Clonazepam, Midazolam, Temazepam and Oxazepam b) benzodiazepines only prescribed if essential. Prescriptions at lowest therapeutic dose, short-term & pt kept under regular review for signs of addiction or dependence c) may be taken orally as a tablet of a liquid. Less commonly IM or IV d) mechanism of action - benzodiazepines potentiate effects of Gamma-aminobutyric (GABA) at GABAa receptor e) harmful effects - I) acute - intoxication, drowsiness, dizziness & blurred vision, impaired concentration, impaired coordination, hypotension & respiratory depression in OD or IV use II) chronic - impaired memory & concentration, depression, tolerance & dependence within 3-6 weeks of regular use, dependence associated with unpleasant withdrawal syndrome (agitation, anxiety, insomnia), withdrawal may be complicated by seizures, delirium, psychosis, may need medical mx, may be fatal 11) new psychoactive substances (NPS aka "legal highs") - heterogeneous group of plant-based and synthetic substances that mimic effects of more established illicit substances such as cocaine, cannabis and MDMA

Presentation of personality disorders

1) paranoid personality disorder - SUSPECT a) Sensitive b) Unforgiving c) Suspicious d) Possessive and jealous of partners e) Excessive self-importance f) Conspiracy theories g) Tenacious sense of rights 2) schizoid personality disorder - ALL ALONE a) Anhedonic b) Limited emotional range c) Little sexual interest d) Apparent indifference to praise or criticism e) Lack of close relationships f) One-player activities g) Normal social conventions ignored h) Excessive fantasy world 3) dissocial personality disorder - FIGHTS a) Forms but cannot maintain relationships b) Irresponsible c) Guiltless d) Heartless e) Temper easily lost f) Someone else's fault 4) emotionally unstable personality disorder a) 2 types (ICD-10): borderline type & impulsive type b) common features for both types: I) affective instability II) explosive behaviours III) impulsive IV) outbursts of anger V) unable to plan or consider consequences c) borderline type - SCARS I) Self-image unclear II) Chronic "empty" feelings III) Abandonment fears IV) Relationships are intense and unstable V) Suicide attempts and self-harm NB/ occasionally experience fleeting psychotic features (pseudohallucinations) d) impulsive type - LOSE IT I) Lacks impulse control II) Outbursts or threats of violence III) Sensitivity to being criticised or let down IV) Emotional instability V) Inability to plan ahead VI) Thoughtless of consequences 5) histrionic personality disorder - ACTORS a) Attention Seeking b) Concerned with own appearance c) Theatrical d) Open to suggestion e) Racy and seductive f) Shallow affect 6) anankastic personality disorder - DETAILED a) Doubtful b) Excessive detail c) Tasks not completed d) Adheres to rules e) Inflexible f) Likes own way g) Excludes pleasure and relationships h) Dominated by intrusive thoughts 7) anxious/avoidant personality disorder - AFRAID a) Avoids social contact b) Fears rejection / criticism c) Restricted lifestyle d) Apprehensive e) Inferiority f) Doesn't get involved unless sure of acceptance 8) dependant personality disorder - SUFFER a) Subordinate b) Undemanding c) Feels helpless when alone d) Fears abandonment e) Encourages others to take decisions Reassurance needed

Personality disorder: definition, aetiology, epidemiology, comorbidity, classification

1) personality - set of consistent thoughts, feelings and behaviours shown across time in a variety of settings 2) hallmarks of a problem caused by dysfunctional personality: a) pervasive - occurs in all/most areas of life b) persistent - evidence from adolescence & continues into adulthood c) pathological - causes distress to self or others; impairs function (occupation/social/relationships) 3) personality develops in childhood and adolescence and, if a problem is rooted in personality, there should be evidence of its presence reaching back to these developmental stages 4) aetiology - a) genetics b) childhood temperament (pt's innate basic disposition to an emotional response, thought to manifest from birth onwards). Distinguished from personality which develops during later developmental stages c) other emotional difficulties in childhood - attachment problems, conduct disorders etc. - may impact on the later development of personality disorder d) childhood experience - neglect, trauma or abuse in childhood. Particularly common association in emotionally unstable personality disorder or PTSD e) neurochemical imbalance - eg/ impulsive behaviour/aggression & serotonin. May explain some links between genetics & PD & why they are heritable 5) epidemiology - a) community survey = 10% prevalence, primary care & psych outpts = 20% prevalence, 50% prevelance in prisons 6) comorbidity - inc chance of having other mental illness concurrently eg/ anxiety, depression, PTSD, substance, adjustment disorder/ stress reaction 7) classification of personality disorder (DSM-5/ICD-10) a) cluster A = odd and eccentric: schizoid, paranoid, schizotypal b) cluster B = dramatic and emotional: antisocial/dissocial, histrionic, borderline/emotionally unstable (impulsive or borderline), narcissistic cluster C = anxious and fearful: obsessive compulsive/anakastic, avoidant/anxious, dependent

Treatment of common psychiatric disorders during pregnancy and after childbirth

1) postnatal depression - a) 3 main types of treatment: self-help strategies, therapy and medication, b) self-help - I) talk to partner, friends and family - try to help them understand how you're feeling and what they can do to support you II) don't try to be a "supermum" - accept help from others when it's offered & ask loved ones if they can help look after the baby and do tasks such as housework, cooking and shopping III) make time for yourself - try to do activities you find relaxing and enjoyable eg/ going for a walk, listening to music, reading a book IV) rest when you can - although it can be difficult, try to sleep whenever you can, follow good sleeping habits, ask partner to help with night-time work V) exercise regularly VI) eat regular, healthy meals, don't go for long periods without eating VII) don't drink alcohol or take drugs VIII) health visitor may be able to put you in touch with a social worker, counsellor or local support group c) psychological treatments - 1st line for women with postnatal depression I) guided self-help - involves working through a book or online course on your own or with some help from a therapist, for 9-12 weeks II) CBT - eg/ some women have unrealistic expectations about what being a mum is like and feel they should never make mistakes. As part of CBT, they're encouraged to see these thoughts are unhelpful and discuss ways to think more positively. III) interpersonal therapy - talking to a therapist about problems you're experiencing. Aims to identify problems in your relationships with family, friends or partners and how they might relate to your feelings of depression. Tx lasts 3-4 months d) antidepressants - for moderate or severe depression if don't want to try psychological treatment or psychological treatment doesn't help. May also be used if have mild postnatal depression & previous hx of depression I) can help ease symptoms such as low mood, irritability, lack of concentration and sleeplessness, allowing pt to function normally & cope better with new baby II) usually need to take them for ~6 months after start to feel better e) severe postnatal depression - more intensive CBT, other psychological treatments eg/ psychotherapy, therapies such as baby massage to help pt bond better with baby, if this has become a problem, different meds, ECT f) if thought that pt's depression is so severe they're at risk of harming themselves or others, may be admitted to hospital or mental health clinic g) charities and support groups - Association for Post Natal Illness (APNI), Pre and Postnatal Depression Advice and Support (PANDAS), National Childbirth Trust (NCT), Mind 2) postpartum psychosis aka puerperal psychosis a) most women need to be treated in hospital. Ideally in mother & baby unit (MBU) b) medication - may be prescribed one or more of the following: I) antidepressants - to help ease systems of depression II) antipsychotics - to help with manic and psychotic symptoms eg/ delusions or hallucinations III) mood stabilisers (eg/ lithium) - to stabilise mood & prevent symptoms recurring psychological therapy - CBT, ECT (rare - for severe depression or mania)

Effects of mental illness and its treatment (e.g. medication) on the developing foetus and the infant including possible risk

1) psychiatric disorders during pregnancy associated with poor maternal health & inadequate prenatal care 2) also associated with adverse outcomes for offspring eg/ etal growth and development, poor cognitive development and behavior during childhood and adolescence, -ve nutritional and health effects 3) antidepressants during pregnancy - a) SSRIs: citalopram, fluoxetine & sertraline; SNRIs: duloxetine & venlafaxine; TCAs: amitriptyline and nortriptyline b) risks include: I) possible birth defects eg/ SSRIs early in pregnancy - inc risk of heart defects, spina bifida, cleft lip II) inc risk of miscarriage and premature birth III) withdrawal symptoms in newborn baby if antidepressants in late pregnancy IV) when breastfeeding, drug could be passed to baby through breast milk (not sertraline) V) unknown risks - drugs not clinically tested in pregnant women VI) all risks likely to be higher during first three months & last few weeks of your pregnancy 4) antipsychotics - a) risks to baby in 1st trimester - eg/ prochlorperazine, & in 3rd trimester eg/ risk of temporary muscle disorder b) breastfeeding risk if 2nd gen c) drugs not clinically tested in pregnant women

Common causes of psychiatric emergencies including agitation and acute confusion

1) psychiatric emergency - any disturbance in thought, feeling or actions for which immediate therapeutic intervention is necessary 2) psych emergencies classified as major, minor & emergencies related to medical causes 3) ~30% psychiatric emergency pts are suicidal, ~10% are violent & ~40% require admission to hospitals 4) major - suicidal patients; agitated & violent patients 5) minor - grief reaction; rape; disaster; panic attacks 6) medical emergencies in psychiatry - delirium; Neuroleptic Malignant Syndrome; serotonin syndrome; overdose of psych meds; overdose & withdraw from addicting substance 7) acute behavioural disturbance - a) acute behavioural disturbances can develop in pts suffering from mental health issues at any time during course of their mental illness or can be a manifestation of underlying systemic organic illness (eg infection) b) causes - pts can become agitated or aggressive during an acute episode of illness such as mania or schizophrenia: I) maybe directly due to psychotic symptoms such as delusion or hallucinations II) due to non-psychotic symptoms such as high levels of anxiety or arousal III) use of illicit substances such as cannabis, amphetamines 8) Neuroleptic Malignant syndrome (NMS) - rare, but potentially serious and fatal adverse effect of all antipsychotics, due to dopamine blockade leading to sympathetic hyperactivity a) epidemiology - incidence & mortality rate of NMS difficult to establish. Estimated <1% pts treated with typical antipsychotic meds will experience NMS b) risk factors for NMS - I) hx: previous NMS, cerebral compromise or organic brain damage, alcohol II) mental state: agitation, over activity, catatonia III) physical state: dehydration IV) tx-related factors: IM therapy; recent or rapid antipsychotics dose inc; rapid dose dec/abrupt withdrawal of anticholinergics; high doses of antipsychotics; high potency neuroleptic medication like haloperidol c) symptoms - presentation varies significantly I) pts can present with fever, rigidity, confusion & fluctuating consciousness II) autonomic instability - fluctuating BP, tachycardia, diaphoresis, salivation and incontinence III) ix - no blood tests pathognomonic of NMS, CK frequently inc & often >1000units/litre, pts can also have leucocytosis and deranged LFTs 9) acute dystonia - a) acute dystonic reactions are reversible extrapyramidal SE that occur after administration of antipsychotics - muscle spasm occurring anywhere in body b) symptoms can begin immediately or delayed for few hours to days c) intermittent spasmodic or sustained involuntary contractions of muscles of face, neck (torticollis), trunk, pelvis, extremities and even larynx d) can cause significant distress to pts & can be life threatening if includes laryngeal muscles e) although dystonic reactions occasionally dose related, more often idiosyncratic & unpredictable f) most meds cause dystonic reactions by Dopamine D2 receptor blockade in nigrostriatal pathway = excess striatal cholinergic output - high potency D2 receptor medications like haloperidol more likely to causes acute dystonia g) atypical antipsychotic medications are less likely to cause dystonia h) prevalence - ~10%, more common: in young men; those who are neuroleptic naïve; with high potency Dopamine receptor D2 blocker such as Haloperidol (dystonic reactions rare in the elderly)

Presentation of anxiety disorders (GAD, panic disorder, phobia, OCD, PTSD)

1) psychological arousal - a) worrying thoughts, fearful anticipation b) irritability, restlessness c) sensitivity to noise d) poor concentration e) sleep disturbance - insomnia, night terrors f) muscle tension - tremors, aches g) autonomic arousal - dry mouth, difficulty breathing, palpitations, chest discomfort, frequent and urgent micturition, diarrhoea h) consequences of hyperventilation - dizziness, tingling numbness 2) cycle of anxiety - thoughts - behaviour - emotion - bodily responses 3) ICD-10 criteria of GAD: a) generalised & persistent somatic (physical) + psychological symptoms of anxiety on most days for at least several weeks at a time b) anxiety symptoms usually involve - apprehension, motor tension, autonomic overactivity 4) ICD-10 criteria of panic disorder - several attacks within 1 month in circumstances with no objective danger, not confined to known or predictable situations with comparative freedom from anxiety symptoms between attacks, panic attacks short-lived & last <10 mins 5) ICD-10 criteria of agoraphobia - a) symptoms restricted to fearful situations or contemplation of feared situation = avoidance b) can occur with or without panic disorder c) anxiety restricted to at least 2 of: crowds, public places, leaving home 6) ICD-10 criteria of social phobia - a) marked fear of being focus of attention, of embarrassment or humiliation b) symptoms restricted to fearful situations or contemplation of feared situation - avoidance when possible c) psychological, behavioural or autonomic symptoms must be primarily manifestations of anxiety & not secondary to other conditions 7) specific (isolated) phobia - a) marked fear of a specific object or situation not included in agoraphobia or social phobia or marked avoidance of such objects or situations b) eg/ animals, birds, insects, heights, thunder, flying, small enclosed spaces 8) OCD - disorder characterised by obsessive symptoms (thoughts, impulses, images) +/- compulsive acts or rituals, present on most days for 2+ weeks, causing distress and interfering with activities a) symptoms common in childhood, and at this age, this is considered normal (9 years delay between onset of symptoms to diagnosis) b) frequently symptoms coexist with: schizophrenia, Tourette's, depression c) at severe end of a spectrum pt has OCD, other end = Anankastic Personality Disorder d) in some situations & professions, obsessive traits can be an advantage & considered eg/ pharmacists, military 9) obsessions vs compulsions - a) both - acknowledged as excessive or unreasonable, repetitive, intrusive & resisted by pt, unpleasant (thought gives no pleasure), originate in mind of pt & not imposed by outside persons or influences, cause distress & interfere with functioning b) obsessions - eg/ desire to line thigs up so they're straight & symmetrical; feeling hands are dirty even when washed; intrusive images of child being dead even though they're well c) compulsion - physical act which: causes distress & interferes with functioning, usually due to wasting time, magical thinking can occur eg/ "if I touch this door frame five times, no harm will come to my family" eg/ checking door is locked; washing hands repeatedly; touching door handle 5x to prevent yourself getting sick; getting up & checking on child to see they're ok

Produce differential diagnoses for patient with medically unexplained symptoms and somatisation

1) pts who somatically express psychological disturbances may have a wide variety of psychiatric disorders and/or medical disease states, apart from somatisation disorder or hypochondriacal disorder: a) depression & anxiety disorders may be exhibited with multiple somatic complaints - anxiety and depression v common in high utilizers of medical care b) personality disorder may also complicate diagnostic evaluation of MUS c) organic conditions eg/ MS, lupus or porphyrias - medical disorders that present initially with vague and diffuse complaints d) dissociative disorders - presence unconsciously produced symptoms that affect voluntary sensory or motor functions e) rarely, pt with psychosis or schizophrenia can also present with hypochondriacal delusion 2) rare organic diseases eg/ Wilson's 3) MUS also must be distinguished from 2 rare psychiatric disorders: factitious disorder (FD) and malingering a) for the sole purpose of assuming the sick role pts with FD intentionally produce organic disease eg/ Munchausen, or feign psychological symptoms. Pts with FD have obvious organic diseases - self-induced eg/ bleeding secondary to surreptitious anticoagulant ingestion b) malingering pts do not induce organic diseases, but feign or grossly exaggerate physical or psychological symptoms for some external incentive eg/ financial compensation or obtaining drugs d) MUS pts don't intentionally produce or feign symptoms & don't have obvious external incentives

Develop a structured targeted management plan for an individual patient with medically unexplained symptoms

1) reassurance from GP - most pts improve without any specific tx, particularly when GP gives an explanation for symptoms that makes sense, removes any blame from pt & generates ideas about symptoms mx 2) treat the treatable - specific tx that will help acute or chronic conditions a) use pain ladders b) maximise tx of long-term conditions and pain c) screen for depression and treat appropriately d) CBT helps with MUS & chronic pain, also dec fatigue in Chronic Fatigue Syndrome e) physiotherapy and exercise therapies help and should be encouraged f) communicate with other clinicians involved - shared plan agreed with pt & professionals

Justify the selection of appropriate investigations for common psychiatric presentations

1) screen broadly - a) FBC, glucose, LFTs, U&Es, ESR, ANA, calcium 2) exclude specifically - abnormal levels of TSH, B12, folate, ceruloplasmin, HIV, FTA-Abs 3) investigate further as clinically indicated - a) CXR, lumbar puncture, blood & urine cultures, ABG, ECG b) serum cortisol levels c) toxin search (eg/ urine), drug levels d) genetic testing e) tumour markers 4) others such as EEG, CT or MRI if diagnostic need a) EEG - suspect epilepsy, assess atypical patterns of cognitive impairment, aid diagnosis of certain dementia, sleep disorders b) brain imaging - if possible neurological problem eg/ head injury, epilepsy

Appropriate services for people with an intellectual disability

MDT - psychiatrists & psychologists, community nurses, speech and language therapists, social workers, OTs, physiotherapists, music therapist, support staff

Ethical & legal principles of mental health legislations in clinical practice, including the Mental Capacity Act

Mental capacity act 1) Mental Capacity Act 2005 is statute law. Act assumes all adults have capacity unless proven otherwise a) all practicable steps taken to help pt to have capacity before a person is deemed to not have capacity b) if pt makes an unwise decision, that doesn't mean they lack capacity c) decisions made under MCA needs to be in pt's best interests & least restrictive of pt's rights 2) capacity - There are 4 components to the process of capacity: a) Understand - information relevant to decision b) Retain - information long enough to make decision c) Deliberate - information as part of process of making the decision d) Communicate - decision (talking, sign language etc) 3) 2 stage tests - if suspect a pt does not have capacity, need to be able to assess him/her to ascertain if he/she has capacity or not a) Stage 1: a pt lacks capacity if unable to make a specific decision due to a disturbance in functioning of the mind or brain. Needs to be evidence pt has a disturbance of mind or brain affecting functioning of mind or brain. May be temporary or permanent due to physical or psychological or other reasons b) Stage 2: pt unable to make a decision if cannot: Understand, Retain, Deliberate, Communicate (UR Deciding Care) c) if both stages are not met, pt does not have capacity on that specific decision 4) capacity is time & decision specific 5) having established pt lacks capacity in a specific situation, doctor can then act in best interests of pt under MCA. All decisions need to be a proportionate response to the situation. a) best interests in short is what would this pt in this situation want given their upbringing, background, beliefs and expressed wishes? 6) restraint - situation happens quickly & clear action is helpful to all. Most common scenario is someone with some risk behaviour wanting to leave the ward. Can restrain (including physical restraint) pt using MCA as long as they lack capacity & restraint is required to protect pt in question from harm. Restraint needs to be proportionate to the situation 7) Lasting Power of Attorney (LPA) - legal mechanism that allows someone to specify another adult to look after their affairs - financial and/or medical should they lack capacity in the future 8) advance decisions - made by pt when he/she has capacity, come into effect when pt no longer has capacity, state what tx patient wants to refuse in a specific situation 9) Deprivation of Liberty Safeguards (DoLS) - human rights act: everyone has a right to liberty, except in specific circumstances (eg/ detained under Mental Health Act or sent by a court of law to prison). DoLS created by MCA and apply to people being deprived of liberty in hospital or care homes when pt lacks capacity

Bereavement & PTSD

bereavement 1) duration of 'normal' grief reaction varies depending on circumstances of loss, pt & their physical & emotional wellbeing 2) only medical issue if lasts >6 months & is significantly affecting pt's relationships and ability to function 3) symptoms eg/ poor energy, low mood, lack of enjoyment, disturbed sleep and appetite or symptoms of anxiety are all common after a bereavement 4) abnormal grief symptoms - a) guilt about things other than actions taken or not taken by survivor at time of death b) thoughts of death other than survivor feeling they would be better off dead or should have died with deceased person c) morbid preoccupation with worthlessness d) significant psychomotor retardation (eg/ it's hard to get moving, and what movements there are slow) e) prolonged and serious functional impairment f) hallucinations other than focused on deceased PTSD 1) delayed or protracted response to stressful event or situation of an exceptionally threatening or catastrophic nature, likely to cause pervasive distress in almost anyone eg/ natural disasters, combat, victim of torture or rape 2) onset of symptoms usually with a latency period of weeks to few months, but rarely >6 months. Symptoms persist >6 months after event, less than this = normal response to severe trauma 3) PTSD symptoms sometimes arise much later in life (secondary trauma) 4) 5-10% lifetime prevalence. Female victims of domestic violence up to 45% a) more common if internal perceived control, i.e. if traumatic event caused by someone or could have been prevented (eg/ a victim of a stabbing) rather than an act of nature (eg/ hit by lightening) 5) symptoms - a) core triad of symptoms: I) hyperarousal - persistent anxiety, irritability, insomnia, poor concentration II) re-experiencing - 'flashbacks', recurrent distressing dreams III) avoidance - of reminders, detachment, numbness, anhedonia b) depressive & guilt symptoms common c) substance use as a coping strategy common 6) mx a) psychological tx - psychoeducation, trauma-focused CBT , Eye Movement Desensitization and Reprocessing (EMDR) b) biological - antidepressants (e.g. SSRI) c) social - educate family, support in reintegration to environment, avoid alcohol 7) prognosis a) 50% recover within 1st year b) poorer prognosis if: co-morbid mental illness, long duration, hx of psychiatric illness, fmx of mental illness, poor social support, pre-morbid functioning

Classification & aetiology of depression (mood disorders)

mood (affective) disorders - conditions where a disturbance in pt's mood is main feature. Either: elevated mood eg/ mania; depressed mood eg/ major depressive disorder (MDD); and moods which cycle between them = bipolar disorder (BD) 1) classification of depressive disorders - Hamilton Rating Scale for Depression or Beck Depression Inventory a) major depressive disorder (MDD) - 1+ major depressive episodes. Depression without periods of mania sometimes referred to as unipolar depression (mood remains at bottom & doesn't climb to manic as in bipolar disorder) I) pts at inc risk for suicide. Affects 9% people. No age group exempt b) atypical depression (AD) - mood reactivity (paradoxical anhedonia) & positivity, inc weight or appetite ("comfort eating"), excessive sleep or somnolence (hypersomnia), a sensation of heaviness in limbs (leaden paralysis), significant social impairment c) melancholic depression - anhedonia in most or all activities, failure of reactivity to pleasurable stimuli, depressed mood more pronounced than that of grief or loss, a worsening of symptoms in morning hours, early-morning waking, psychomotor retardation, excessive weight or excessive guilt d) psychotic major depression - major depressive episode of melancholic nature, wherein pt experiences psychotic symptoms eg/ delusions, hallucinations. Mostly mood-congruent (content coincident with depressive themes) e) catatonic depression - rare and severe form of major depression with disturbances of motor behaviour. Pt is mute & almost stuporose, immobile or exhibits purposeless or even bizarre movements f) postpartum depression (PPD) - intense, sustained and sometimes disabling depression in women after giving birth, affecting 10-15% of women, typically within 3 months of labour, and lasts as long as 3 months g) premenstrual dysphoric disorder (PMDD) - severe & disabling form of premenstrual syndrome affecting 5% menstruating women. Cluster of affective, behavioral and somatic symptoms that recur monthly during luteal phase. Tx = SSRI, & contraception that dec ovulation h) seasonal affective disorder (SAD) - pts have a seasonal pattern, with depressive episodes in autumn or winter, resolving in spring. Need 2+ episodes in colder months with none at other times over 2+ year period. Tx - light therapy. i) dysthymia - related to unipolar depression as same physical and cognitive problems evident, but not as severe and tend to last longer (at least 2 years) j) double depression - fairly depressed mood (dysthymia) for 2+ years & punctuated by periods of major depression k) recurrent brief depression (RBD) - depressive episodes once per month, with iepisodes lasting <2 weeks (typically <3 days) n) minor depressive disorder - depression that doesn't meet full criteria for major depression but 2+ symptoms present for 2 weeks 2) aetiology - a) biopsychosocial model: biological, psychological, and social factors all play a) biological - I) genetics eg/ 5-HTTLPR (serotonin transporter promoter), CRHR1, FKBP5, BDNF II) hormonal changes III) substance misuse - alcohol or psychoactive drugs or benzodiazepines IV) another medical condition eg/ dementia, electrolyte disturbances, GI diseases, thyroid abnormalities, COPD, cancer, RA, HIV V) iatrogenic eg/ interferon therapy, B-blockers, isotretinoin, contraceptives, cardiac agents, anticonvulsants, antimigraine drugs, antipsychotics b) psychological - -ve thoughts, learned helplessness, psychodynamic defence mechanisms c) social - life events, social isolation & adversity, bereavement, abuse or trauma

Classification, epidemiology & presentation of bipolar disorder (mood disorder)

periods of depression & periods of elevated mood (mania or hypomania) 1) classification of bipolar disorders a) bipolar disorder - unstable emotional condition with cycles of abnormal, persistent high mood (mania) and low mood (depression). Subtypes: a) bipolar I - manic episodes & major depressive episodes b) bipolar II - hypomanic & depressive episodes c) cyclothymia - hypomanic & dysthymic episodes 2) epidemiology a) 1% adults have bipolar I, 1% have bipolar II or cyclothymia, and 3% have "sub-threshold" bipolar. Lifetime prevelance = 3% I) fmx - risk if 1 parent diagnosed is 25%, if both parents = 65%, sibling risk = 20%, M=F b) late adolescence & early adulthood are peak years for onset of bipolar 3) presentation - a) symptoms for 4 days (diagnose hypomania), or >1 week (mania) a) mania - I) mood is elevated, expansive, irritable II) inc activity III) reckless behaviour & disinhibition IV) marked distractibility V) markedly inc sexual energy VI) sleep severely impaired or absent VII) grandiosity VIII) flight of ideas NB/ for both need 3+ symptoms, hypomania = no functional impairement (is in mania) b) mania with psychotic symptoms - diagnostic criteria for mania +: I) delusions - mood congruent eg/ inflated self-esteem & ideation become grandiose beliefs; suspiciousness becomes delusions of persecution II) hallucinations less frequent - 2nd person auditory hallucinations c) bipolar commonly diagnosed during adolescence or early adulthood, but onset can occur throughout the life cycle