Psychiatry

What is schizoaffective disorder? How is it different from schizophrenia?

(a mixture of first rank symptoms and mood symptoms). Schizoaffective disorder is diagnosed when the patient has features of both schizophrenia and a mood disorder but does not strictly meet the diagnostic criteria for either illness alone. In ICD-10, schizoaffective disorder is diagnosed by simultaneous and equally prominent mood and psychotic symptoms, particularly the occurrence of Schneiderian first-rank symptoms in the context of prominent mood disturbance. The term should not be applied to patients who exhibit schizophrenic symptoms and mood symptoms only in different episodes of illness.

Antipsychotics also increase the risk of developing metabolic syndrome. What comprises metabolic syndrome and which antipsychotics are more likely to increase the risk?

(olanzapine, clozapine). The features of a metabolic syndrome are: Central obesity Insulin resistance Impaired glucose regulation Hypertension Raised plasma triglycerides Raised LDL cholesterol level, and/or low HDL cholesterol level The presence of a metabolic syndrome can affect morbidity and mortality. Thus, as a clinician you must be able to carry out a risk:benefit analysis before starting antipsychotic treatment, then subsequently monitor for evidence of a metabolic syndrome.

How is delusional disorder diagnosed?

(the main symptom is non-first rank delusional belief with minimal hallucination). Illness duration must be >3 months for delusional disorder to be diagnosed using ICD-10 diagnostic criteria.

Describe some different types of hallucinations

-auditory - characteristic of schizophrenia. The more simple, the more likely the cause is organic. Elementary ones are just like rattling, whistling etc -visual - more common in organic states eg drug withdrawal, dementias, encephalitis, epilepsies, occipital lobe tumours. Less common in schizophrenia. Visual hallucinations of delirium tremens are often Lilliputian (little animals/men) -tactile - Superficial - heat, light touch (haptic hallucination), tingling and so on Kinaesthetic - to do with joint or muscle position sense - the limbs feel as though they are being twisted or muscles squeezed Visceral - false perceptions of inner organs Where hallucinations occur in schizophrenia there is often a delusional elaboration for the phenomenon, relating to a delusion of control from an outside agent (i.e. somatic passivity) Olfactory/gustatory Very difficult to tell apart Olfactory hallucinations appear in epilepsy and some other organic states and, more rarely, in schizophrenia In epilepsy, this often has a temporal lobe focus and may occur during the aura

How do you tell the difference between hallucinations and pseudohallucinations? Why is this important?

-hallucination - coming from outside the head like a normal voice, can't stop it -pseudohallucinations - not quite a real voice, inside head, more vivid if concentrate on it -patient knows what they experienced wasn't real Hallucinations are more likely to be treated (and are much more amenable to treatment). If we treat all people who are complaining of, for example, 'voices' (including pseudohallucinations), with long-term spsychotics, then that becomes a very significant burden of weight gain, hyperlipidaemia, hyperglycaemia and other side effects, which often shortens the patient's life. If the drugs are not going to produce a significant benefit in terms of efficacy, this becomes unsupportable.

Where are the different places that schizophrenia can be managed?

-psychiatric ward - If urgent/immediate concerns regarding risk that cannot be managed in community (may need to use mental health act) -the Crisis Resolution and Home Treatment (CRHT) Team - if can be managed in community. Liaise with community mental health team [CMHT] or other specialist teams · Early Intervention in Psychosis Team (EIP) if it is available. Sometimes, this function is provided by Community Mental Health Team (CMHT). - if first episode of psychosis and between 18-35 -Community Rehabilitation Service - If no urgent concerns but patient has an established psychotic illness (e.g. schizophrenia) and need a period of intensive psychiatric rehabilitation to improve his/her functioning -community mental health team (CMHT) - If no urgent concerns, not first episode and not 18-35, does not need intensive psychiatric rehab and patient does not have multiple previous psychiatric admissions and does not have tendency to not engage with services -Assertive Outreach (AO) team - if often doesn't engage with services

What is the difference between typical and atypical antipsychotics?

-typicals were the first made -typicals MOA: Dopamine receptor 2 (D2) antagonism atypicals -atypicals have a different side effect profile -no difference in efficacy -atypicals more frequently used Mode of action: D2 antagonism +/- 5-HT receptor antagonism

What are the outcomes of schizophrenia? What are the risks?

20% after first episode never have another episode 30% continuous illness, not free of symptoms 25% improved, but require extensive support network Risk of premature death due to suicide (10-15%), cardiovascular disease and type 2 diabetes.

What is a nihilistic delusion?

A belief that the patient has died or no longer exists or that the world has ended

What is a delusion of reference?

A delusional belief that external events or situations have been arranged so that a message is conveyed to the individual, or there is some other special significance.

What is a persecutory delusion?

A delusional belief that one's life is being interfered with in a harmful way

What is a grandiose delusion? What is grandiosity?

A delusional belief that the patient has special powers. These might include: Extreme wealth Exceptional intelligence Powers such as a super-hero might have This might occur in any psychotic illness, but would be characteristic in a manic illness, where the delusion could be described as 'mood congruent' = An inflated sense of one's own abilities or importance

What is delusional perception?

A delusional perception is a real percept that leads immediately to a delusional belief: e.g. 'the traffic lights turned red and I knew I was the King of England'. In this case, the traffic lights are real and were seen, but the belief is clearly delusional. We say the delusion is primary as it arose 'out of nowhere' as a result if the unrelated stimulus.

What is a delusion?

A fixed, (usually) false, unshakeable belief which is out of keeping with the patient's educational, cultural and social background and held despite all evidence to the contrary absolute subjective certainty and cannot be rationalised away no external proof - held even with contradictory evidence personal significance cannot be understood as part of the subjects cultural or religious background

What is formal thought disorder?

A pattern of disordered language use that reflects disordered thought form. Can sometimes be difficult to describe E.g. loosening of association (derailment), flight of ideas, circumstantial thoughts, tangential thoughts, thought block

What are Schneider's first rank symptoms?

ABCD: Auditory hallucinations, Broadcasting of thought, Controlled thought (delusions of control, thought withdrawal/insertion/interruption, somatic hallucinations), Delusional perception.

What is an obsession? What is a compulsion?

An idea, impulse or image, recognised by the patient as their own, but experienced as repetitive, distressing or intrusive = A behaviour or action that is purposeless or unnecessary, that the patient feels a subjective urge to perform. The drive to perform the behaviour or action is recognised as originating in the patient.

How is treatment resistant schizophrenia defined? How is it treated?

An insufficient response to two clinical trials of 4 or 6 weeks' duration using monotherapy with two different antipsychotics, at least one of which should be a second generation if available. Treatment-resistant schizophrenia is estimated to affect 30% of those with schizophrenia. Clozapine in the only efficacious and licenced antipsychotic for treatment-resistant schizophrenia. However, clozapine treatment will still only improve symptoms in 40-70% of these patients. Before diagnosing with TRS: review diagnosis (is the diagnosis correct?) rule out co-morbid substance misuse ensure dose, duration and compliance with previous treatment

What is a hallucination?

An internal percept without a corresponding object, perceived in external space and outside of conscious control

what is depersonalisation?

An unpleasant subjective report that the patient feels they are 'unreal'

What are the 7 parts of the mental state examination?

Appearance and behaviour Speech Mood and affect Thoughts Perceptions Cognitive examination Insight

Name atypical antipsychotics. What is their mode of action?

Aripiprazole - generally good side-effect profile, particularly for prolactin elevation Amisulpride Olanzapine - higher risk of dyslipidemia and obesity Quetiapine Risperidone Clozapine Mode of action: D2 antagonism +/- 5-HT receptor antagonism Adverse effects of atypical antipsychotics weight gain clozapine is associated with agranulocytosis (see below) hyperprolactinaemia

What are the 11 First Rank symptoms of schizophrenia? (4 categories)

Auditory hallucinations 1. 3rd person voices 2. Thought echo (repeating patient's thoughts) 3. Running commentary Delusions of though ownership 4. Thought withdrawal (thoughts being taken away by external agency) 5. Thought broadcast (thoughts transmitted to others) 6. Thought insertion (external thoughts being put in patient's mind) Passivity/delusions of control 7. Somatic passivity - delusions of control with somatic hallucinations. - Patient reports experiencing sensations on their body and believed being controlled by an external force 8. Made volition (acts) - The patient reports his will to be under the control of an external force 9. Made impulse (drives) 10. Made affect (feelings) Primary delusion 11. Delusional perception

Outline the components of a psychiatric history

Before the history Some demographics: e.g. sex, age, occupation and ethnicity of the patient Mode of referral and the reason of referral - it is important PC: Record patient's main problem briefly in their own words Past psychiatric HPC: when did problem start any precipitating events how did it develop any associated symptoms how the problem affects day to day functioning has any help or treatment been sought for it and the response of these interventions temporal relationships between symptoms and any physical disorder, psychological or social problems Past psychiatric history Details of past problems including psychiatric admissions (informal/ under the Mental Health Act) and treatments (drug and psychosocial) Any history of under the mental health service or psychiatric treatment in primary care Also need to include any past self-harm and suicide attempt what interventions were helpful and which were not, benefits, side effects and doses of medication used, concordance to treatment plan If the diagnosis is in doubt, record symptoms of previous episodes and how they have changed over time. What led to episodes of illness? predisposing, precipitating and perpetuating factors as well as protective factors and positive coping strategies FH age, health, employment, psychiatric history and relationships with patient Medical history This should include any major illness and any current treatments including current medications- also to consider concordance to medications Any known allergy Substance misuse and alcohol Consider tobacco, alcohol, illicit drugs - pattern of use, past and current use, effects (including withdrawal symptoms, dependence features) and how substance use relates to mental health difficulties Personal history This is an opportunity to document a brief biographical history including the followings:Childhood - birth, developmental milestones, family atmosphereSchool & education - primary and secondary schooling, relationship with teachers and peers, problems at school (academic, behavioural e.g. truancy, school refusal), age when left school, any further training or coursesOccupations - job taken, for how long, why left, and for how long being unemployedPsychosexual and relationship history - past and current relationship, marital history, any children (ages and contact - remember children safeguarding), sexual orientation and difficulties if relevant Past history of emotional, sexual and physical abuse if appropriate Forensic history Consider all offences whether convicted or not - especially any violence, sexual offences and persistent offending Premorbid personality At times, patients may not know how to answer as they may have been unwell for so long. Make sure to focus on the patient's personality BEFORE they become unwell Premorbid personality includes attitudes to others in relationships attitudes to oneself (self-esteem)any predominant mood and stabilityleisure activities and interests reaction pattern to stressreligious and cultural issuesindividual's strengths and abilities It may be necessary to get information from others and it needs to state that what information is from patient and what information is from other people These questions may help:"How would you describe your normal self?""How would other people describe you?""How do you cope when.... (e.g. stress)?" Social circumstances This describes briefly where the person is living, whom they are living with, whether there are any children in the house, the financial situation and the patient's support network (personal and professional). Consider any debt and what benefits the person is receiving Any carer identified and support to the carer

Describe the factors contributing to aetiology of schizophrenia

Biological Genetic - Family history (possible multiple genes) Obstetric complication - increased risk Dopamine theory - how antipsychotic medication works Neurodevelopmental theory The strongest risk factor for developing a psychotic disorder (including schizophrenia) is family history. Having a parent with schizophrenia leads to a relative risk (RR) of 7.5. Risk of developing schizophrenia monozygotic twin has schizophrenia = 50% parent has schizophrenia = 10-15% sibling has schizophrenia = 10% no relatives with schizophrenia = 1% Cannabis use - RR 1.4 Psychological Cognitive errors - jumping to conclusions (especially in delusions and paranoia) Premorbid personality - schizotypal disorder Social Urban living (x2 to x3 - consistent research finding) Migration (x3) Life events (including physical and sexual abuse) Ethnicity (x4 in Afro-Caribbeans in the UK; higher incidence also in South Asians)

Name typical antipsychotics. What is their mode of action?

Chlorpromazine Fluphenazine Flupentixol Haloperidol Pipothiazine Sulpiride Trifluoperazine Zuclopenthixol Mode of antipsychotic action: Dopamine receptor 2 (D2) antagonism

Describe the types of thought disorder

Circumstantiality is the inability to answer a question without giving excessive, unnecessary detail. However, this differs from tangentiality in that the person does eventually return the original point. Tangentiality refers to wandering from a topic without returning to it. Neoligisms are new word formations, which might include the combining of two words. Clang associations are when ideas are related to each other only by the fact they sound similar or rhyme. Word salad is completely incoherent speech where real words are strung together into nonsense sentences. Knight's move thinking is a severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another. It is a feature of schizophrenia. Flight of ideas, a feature of mania, is thought disorder where there are leaps from one topic to another but with discernible links between them. Perseveration is the repetition of ideas or words despite an attempt to change the topic. Echolalia is the repetition of someone else's speech, including the question that was asked.

What 4 things should you note about appearance and behaviour?

Clothes - Colourful and loud clothes may suggest mania Dirty and crumpled clothes may suggest self-neglect Weight Evidence of rapid weight loss increases the possibility of self-neglect - consider ill-fitting or new belt holes Low weight may be an indication of anorexia Obesity could be a side effect of medication Facial appearance Depression - turned down corners of mouth, furrowed brow Anxiety - creases on forehead and dilated pupils Anger and irritability - characteristics Posture Depression - hunched posture Anxiety - sitting on edge of seat, restless

What psychological therapies are useful for schizophrenia? PSYCHO

Cognitive Behavioural Therapy - everyone with psychosis/ schizophrenia should be offered CBTp (cognitive behavioural therapy for psychosis). Family Intervention Therapy (FIT) - to family members and the service user where appropriate, and offering carers education and support programmes. Psychoeducation relapse signature/ early relapse signs crisis plans relapse prevention WRAP (Wellness, Recovery and Action Plans) Coping strategies Maastricht interview (a specific assessment for voice hearers) Concordance Therapy

Outline the different community psychiatric services and their functions

Community Mental Health Teams (CMHT) multidisciplinary, multi-agency teams offering specialist assessment, treatment and care to adults with mental health problems, both in their own homes and in the community. CMHTs aim to provide the day-to-day support needed that allows a person to live in the community. They work with people often described as having complex needs - for example, in relation to housing and homelessness, benefits, unemployment, use of drugs or alcohol, or those who have had contact with the criminal justice system. They also provide keyworkers/care coordinators for the CPA function. Crisis Resolution and Home Treatment Team (CRHT) These are teams of mental health professionals who treat people with mental illness when they are very unwell or in mental health crisis or have tried to take their own life, for example. CRHT aims to avoid admission to a psychiatric ward by offering people intensive, community-based support at home. They can offer a 24-hour, 7-day-a-week service. The teams consist of CPNs, psychiatrists and support workers who can prescribe and monitor medicine, help resolve practical difficulties, offer talking therapies and support family members. CRHT also 'gate keep' - they assess people who are in crisis and decide whether they can offer appropriate support or whether that individual needs to be admitted to hospital. After the crisis has passed, CRHT members are also responsible for planning what happens next in terms of the ongoing care and support offered to an individual. They may offer support when the individual is first discharged from hospital. Early Intervention for Psychosis Team (EIP) These specialist teams of mental health professionals work with people who are experiencing symptoms of psychosis for the first time. usually offer service to people aged 14-35 (differ in different locality) Intensive medium-term follow-up (~3 years), then referral to other services, as appropriate Work closely with primary care mental health teams/ CAMHS/CMHT Focus on the reduction of Duration of Untreated Psychosis (DUP) Assertive Outreach Team (AOT) The assertive outreach team aims to help people who have a history of serious mental health problems, poor engagement with mental health services and increased risks. The AO teams provide more intensive contact with patients aimed to enhance engagement. Assertive outreach teams will visit people at home, at flexible times, or at a location of an individual's choice, and encourage them to accept support and treatment from mental health services again. Liaison Psychiatry team This team deals with medical and surgical in-patients with psychiatric presentations in general hospital. They receive referrals from emergency department/ acute assessment units/medical/surgical ward and their role is to provide advice and consultation to relevant medical/surgical teams in general hospital. Members of the team can assess and treat patients who may be experiencing mental health problems while they are in hospital for a physical health problem. They work with older people who are experiencing dementia or delirium, for example, or with people who have come to casualty because they have self-harmed or are in crisis. Perinatal Psychiatry team Perinatal psychiatric services support women who experience mental health problems around the time of pregnancy. Perinatal specialists - including psychiatrists and mental health nurses - may be based within the 'liaison perinatal psychiatric services' in general hospitals where they work closely with antenatal services and maternity unit. In some parts of England, there are perinatal psychiatric community teams offering support to pregnant women and/or new mothers in their own home. There are also mother and baby units staffed by specialist perinatal mental health professionals and other team members who can help care for newborn babies. The Mother and Baby units provide special risk management and strive to avoid mother-baby separation. Eating disorders team Eating disorder services are there to help adults and children who have moderate to severe eating disorders. They are multidisciplinary teams of psychiatrists, psychologists, psychotherapists, nurse specialists, dietitians, support workers and administrative staff. Based in the community, they offer services such as assessment, treatment and counselling for individuals and their families and carers. Some services also offer help with meal planning and shopping. Eating disorder clinics often provide a combination of occupational and talking therapies, as well as feeding for patients with serious malnutrition. Staff in clinics include doctors, dietitians, psychotherapists, occupational therapists, social workers, family and relationship therapists, and specialist nurses. Personality Disorders Team The personality disorder service provides assessment and psychological treatment to patients with personality difficulties. They are largely community-based and sometimes run day programmes.

What things need to be considered in the social treatment of schizophrenia? SOCIAL

Daytime activities/ occupation/ employment/ education/ leisure hobbies Family Accommodation Benefits Relationships Cultural needs Safeguarding Often interventions are referred to as Psychosocial interventions as they incorporate both psychological and social aspects e.g social skills training

What are the organic causes of psychosis?

Delirium - is another syndrome and there are many causes of delirium (e.g. sepsis) Medication-induced (e.g. corticosteroids, stimulants, dopamine agonists) Endocrine disorders (e.g. Cushings, hypothyroidism, hyperthyroidism) Neurological disorder (e.g. temporal lobe epilepsy, multiple sclerosis, movement disorders, Wilson's disease, Huntington's disease) Other systemic diseases (e.g porphyria, SLE)

Which psychotic symptoms may also be present in depression?

Delusions Tend to be mood congruent i.e. their content is in line with low mood Worthlessness, guilt, ill health, poverty, imminent disaster Nihilistic delusions Persecutory delusions Hallucinations 2nd person auditory - often accusatory or defamatory Olfactory - e.g. filth, or rotting/decomposing flesh

What is the mode of action and side effects of aripiprazole?

Dose usually 5 - 30mg mane Long half life Side-effects Nausea Restlessness Insomnia may initial exacerbation of psychosis least weight gain minimal metabolic effect not sedating The mode of action is partial dopamine agonist - limits the maximal response rather than shifts dose-response curve to the right.

What baseline investigations need to be done prior to starting antipsychotics?

ECG Weight/height BP FBC U&Es LFT Prolactin Glucose/HbA1c Fasting lipids

What is Expressed Emotion (EE)? How does it affect relapse?

Expressed emotion (EE) refers to the carers emotional reaction to the individual with schizophrenia There are 3 different domains: criticism hostility over-involvement. High EE leads to increased risk of relapse in schizophrenia

What is first episode psychosis and how is it managed?

First-episode psychosis is a heterogeneous group of diagnoses that is not synonymous with a diagnosis of schizophrenia. Typically, within a group of these patients, around 25% will have bipolar disorder or psychotic depression, and only 30-40% will meet criteria for schizophrenia at presentation, although this proportion will increase over time. Approximately 50-60% of individuals with first-episode psychosis will eventually be diagnosed with schizophrenia, but others present with acute and transient psychotic disorders, substance-induced psychosis and psychotic mood disorders. Low-dose antipsychotic medication is a recommended first-line pharmacotherapeutic intervention. Robust psychosocial interventions, delivered in an assertive outreach model of care, in conjunction with antipsychotic medication, have been shown to be effective in first-episode psychosis. Cognitive-behavioural therapy, vocational rehabilitation, a consistent key worker for the patient, family support, support with reducing/controlling substance and alcohol use, and supporting the patient in developing relapse prevention strategies are all key components of an effective early intervention service for first-episode psychosis

What are the core and additional symptoms of depression and how is a diagnosis made?

For depressive episodes, a duration of at least 2 weeks is usually required for diagnosis, but shorter periods may be reasonable if symptoms are unusually severe and of rapid onset. Core - low mood, anhedonia, reduced energy (anergia) Additional - reduced concentration, reduced confidence/self-esteem, ideas of guilt and unworthiness, pessimism about the future, ideas/acts of self harm or suicide, disturbed sleep, changes in appetite

When is thought content important for diagnosis (congruence)?

For some diagnoses, the content of the experience is especially important. For example, in a patient with delusions, the degree to which they might be described as 'mood congruent' is vital. In a patient who appears flat and depressed, one might expect a delusion to be 'mood congruent' - there might be delusions of guilt of a serious crime, poverty or lack of bodily function. If the delusions are not of this type and are more 'bizarre' it might lead you away from a diagnosis of 'depressive episode with psychotic features' and towards one of the other psychotic illnesses

What is the difference between thought form and thought content?

Form = the structure or type of the phenomenon. For example, it could be a fixed, false belief (which may be a delusion), or it could be an unusual perceptual experience, described as being in a particular modality - visual, auditory, tactile - and having a particular relationship to reality - for example, in internal or external subjective space. Content = This is usually what the patient is more concerned about. The content may have a meaning for the patient in the context of their past life. Although it is usually the form that is most important to the diagnostic category, enquiring as to the content is often beneficial for building a therapeutic relationship

A 24-year-old male who was diagnosed with paranoid schizophrenia 2 years ago, this has been complicated by intermittent amphetamine usage. During this time he has had three short admissions under the MHA, the last 2 admissions were precipitated by non-concordance with medication. He has been treated with Olanzapine up to a dose of 20mg nocte and Risperidone up to a dose of 3mg BD. He has just been admitted to your ward under a Section 3 MHA.

From the limited information, you have about this case the main issue here is probably non-concordance and substance misuse rather than ineffective treatment. Therefore, Clozapine is probably not appropriate and you should be considering a depot. Risperidone Consta (i.e. Risperidone long-acting injection) would probably be the best option, as it would appear that oral risperidone has previously been tolerated. Alternatives include typical antipsychotics depot (such as zuclopenthixol depot or haloperidol depot) and aripiprazole depot. So: haloperidol, risperidone, zuclopenthixol

What monitoring is required for patients on antipsychotic medication?

Full blood count (FBC), urea and electrolytes (U&E), liver function tests (LFT) - at the start of therapy annually clozapine requires much more frequent monitoring of FBC (initially weekly) Lipids, weight - at the start of therapy at 3 months annually Fasting blood glucose, prolactin at the start of therapy at 6 months annually BP baseline frequently during dose titration ECG - baseline CV risk assessment - annually

Are antipsychotics effective in the long term?

Further important factors for you to consider: 60-70% with chronic symptoms will relapse within one year of stopping medication vs 10-30% who continue on treatment Continue medication for at least 1-2 years following recovery from an acute episode Do not stop medication abruptly

What are the good and bag prognostic factors for psychosis?

Good Female Married Family history of affective disorder Acute onset Good Premobid personality Early treatment Prominent mood symptoms Good response to treatment improved social integration at onset; and less social disadvantage at onset. Bad Generally opposite of the "good outcome" factors Eg Insidious onset Plus Family history of schizophrenia High expressed emotion (more later) Substance misuse Prominent negative symptoms Early onset Lack of insight/non-compliance Pre-morbid social withdrawal lower iq lack of an obvious precipitant.

What are the symptoms of neuroleptic malignant syndrome?

Hyperthermia Muscle rigidity Confusion Tachycardia Hyper/hypotension Tremor Raised Creatine Kinase (CK) Low pH - metabolic acidosis incidence of 0.07-0.2% per year, with a mortality of 5-20%. This most frequently occurs when initiating treatment but can occur at any time. This should be treated as a medical emergency, all antipsychotics should be stopped immediately and the involvement of a physician is required

What is the difference between the ICD-10 and the DSM-5?

ICD-10 - Contains all diseases and has a chapter for mental and behavioural disorders. Has 10 sections for clinical diagnoses DSM-5 - Only contains psychiatric illnesses. Section II contains all the diagnoses, including personality disorders and intellectual disability

What are overvalued ideas?

Ideas that are understandable and reasonable in themselves come to dominate the patient's life

If doses of clozapine are missed, what should you do?

If doses are missed for more than 2 consecutive days (48 hours), you will need to restart their clozapine slowly (like when they first started on it). This restart of treatment needs to be under the direction of a Psychiatrist. This is because when you start Clozapine after a break of >48 hours, it can make side effects worse, such as blood pressure changes, drowsiness and dizziness. If there is a gap in treatment of 3 days (72 hours) then you may also require more frequent blood tests for a short period.

What are the side effects of olanzapine? What can it be used for (situation)?

In addition to treating psychosis, it can also be used in rapid tranquillisation - intramuscular (i.m.) Usual oral dose 5-20mg nocte Side-effects Sedation +++ Weight gain ++++ Risk of metabolic disturbance +++ Raised triglycerides Proglycaemic Dizziness Anticholinergic side-effects

SMR (standardised mortality rate) is nearly 5 times higher in schizophrenia. Why is this? What are contributing factors? What monitoring is needed?

Increased risk of cardiovascular disease, diabetes and stroke. Contributing factors include - poor diet reduced physical activity smoking not engaging with physical health monitoring antipsychotics increase the risk of metabolic syndrome Monitoring needed Baseline and at least every year smoking and drinking status personal/ family history of diabetes/ coronary heart disease BP, BMI blood for FBC, RFT, LFT, glucose and lipid ECG Monitor more closely for certain antipsychotics e.g. olanzapine

What are the side effects of clozapine? What is its mode of action and uses?

Indicated in treatment resistant schizophrenia Improved efficacy over other antipsychotics Positive effect on symptomatology and suicide risk Mode of action: D4 blockade in addition to other sites (though the reason for its improved efficacy is not entirely clear) Serious side-effects Myocarditis/Cardiomyopathy - a baseline ECG should be taken before starting treatment Orthostatic hypotension AGRANULOCYTOSIS - Neutropenia and fatal Agranulocytosis - Need weekly full blood counts for 18 weeks, then every 2 weeks for a year, then every 4 weeks. A benign fever can occur in patients during the initial phase of clozapine treatment. This fever is not usually related to blood dyscrasias. However, a persistent rise in temperature raises concern about the possibility of agranulocytosis and infection. A full blood count with a white blood cell count and differential should be requested as a first-line investigation to rule out neutropenia. reduced seizure threshold - can induce seizures in up to 3% of patients constipation hypersalivation Other Sedation ++++ Weight gain ++++ risk of metabolic disturbance ++++ Raised triglycerides Proglycaemic Hypersalivation Reduced seizure threshold Initiation requires careful dose titration, usually in hospital Dose adjustment of clozapine might be necessary if smoking is started or stopped during treatment. Clozapine should be introduced if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each for at least 6-8 weeks.

What are the risk factors for self neglect?

Interest in self-care Appetite, oral/fluid intake Social support Particular clinical pictures associated with increased risk of self-neglectSchizophrenia (particularly negative symptoms)Severe depression with psychotic symptoms (e.g. related to nihilistic delusions)Diogenes syndrome (picture of self-neglect, social isolation, hoarding)Substance misuseObsessive compulsive disorder (where rituals prevent self-care)

What questions should you ask yourself when assessing insight?

Is the patient aware that there is anything wrong? If there is anything wrong, does the patient think it is due to an illness? If an illness, is it physical or mental illness? If it is a mental illness, can it be helped? Is the patient willing to accept help or treatment?This may include hospital admission - will the patient agree? You should present the insight as if you are answering these 5 questions rather than saying it is 'present' or 'absent' or "partial".

Which antipsychotic should you prescribe? A 19 year old male who was diagnosed with paranoid schizophrenia 18 months ago. He has had 3 admissions each lasting over 3 months. He has been treated with Quetiapine, Olanzapine and Aripiprazole to BNF limits, however he has not been free of psychotic symptoms nor returned to his premorbid level of functioning.

It is clear that this person has not been free of symptoms despite adequate trials of three antipsychotics. You should therefore be considering Clozapine, which can only be given orally.

What is the epidemiology of schizophrenia?

Lifetime risk roughly one in a hundred M=F Very rare below age 14 Rare 16-18 Peak incidence 23 yrs male26 yrs female (second peak between 30-40) Urban > rural Lower social class

What do you need to note regarding mood and affect?

Mood is the pervasive and sustained emotional state (i.e. longer term) whereas affect is the observable behaviour associated with changing emotions. (mood = climate, affect = weather) Subjective mood - How does the patient describe their mood? Objective mood - What is your impression of the mood? - elated/irritable, depressed, anxious, labile Affect is the observable behaviour associated with changing emotions such as fear, sadness, or joy. blunted or flattened affect - dulling of normal emotional response labile affect - sudden rapid and often marked shifts of affect inappropriate or incongruent affect - can be inappropriate to the thought content (e.g. laughter upon recounting the death of loved one) or inappropriate to the magnitude of events (e.g. emotional outburst after a small and insignificant event)

List (categorise) side effects of antipsychotics

Neurological Neuroleptic malignant syndrome Seizure threshold lowered -> fits Sedation Extrapyramidal side-effects - most widely reported SE Autonomic Blood pressure Temperature Hypersensitivity reactions Liver Bone marrow Skin Endocrine Raised Prolactin - may result in galactorrhoea due to inhibition of the dopaminergic tuberoinfundibular pathway Impaired glucose tolerance Psychiatric Apathy Confusion Depression Peripheral autonomic nervous system Muscarinic receptor blockade - dry mouth, blurred vision, urinary retention, constipation Alpha-1-adrenoceptor blockade Cardiac Arrhythmia Weight gain neuroleptic malignant syndrome: pyrexia, muscle stiffness reduced seizure threshold (greater with atypicals) prolonged QT interval (particularly haloperidol)

What are objective signs of depression?

Objective evidence of depression might be: characteristic facial changes that we could all recognise as exhibiting 'sadness' or hopelessness less animation in terms of speech or movement than we would expect (if significant, we might call this 'psychomotor retardation') a lessened emotional response to a particular event or situation (we might say they had 'reduced affect' - affect should always be commented on in addition to the 'objective' assessment of mood)

What is Othello syndrome?

Othello syndrome is pathological jealousy, most commonly the belief that their partner is not faithful, and can be isolated delusion or secondary to an affective state, schizophrenia or a personality disorder.The patient often obsessively searches for evidence, but is not satisfied when none is found. Can then result in violent behaviour.

List the types of schizophrenia

Paranoid Disorganised Catatonic Undifferentiated Residual

What are the risk factors for abuse, harassment or exploitation by others

Particular clinical pictures associated with increased risk of vulnerability to othersLearning disabilityDementiaSubstance misuse

Which factors do you need to consider when choosing an antipsychotic?

Personal or family history of Type II diabetes Personal or family history of a metabolic syndrome Current obesity Concerns about weight gain Potential impact of sedation

What investigations do you do for schizophrenia and what are the purposes of doing these?

Physical examination (neurological, BMI) Blood tests -FBC, LFT, RFT, TFT, blood glucose, blood lipids, cholesterol;other blood tests to look for organic causes if indicated Urine for drug screen (probably the most important investigation) ECG Others if indicated - brain scan, EEG Aim of physical investigations: to establish any organic cause to prepare for treatment with antipsychotic medications

After taking a psychiatric history and doing a mental state examination, what are the next steps - other examinations/investigations?

Physical examination - Individuals with mental illness have a higher chance of various physical illnessSome physical illness can also present with psychiatric symptoms ("organic causes"): physical examination will help to look for any Investigations - Physical investigations: blood tests, ECG, urine tests, brain scan, EEG etc. Help exclude organic causes of psychiatric symptomsScreen for psychical health difficulties Act as a baseline, especially when initiating medication Psychosocial investigations: informant history with patient's consent (which can be difficult at times), review medical records, social assessment, occupational therapy assessment for functioning, etc. Risk assessment Risk assessment is not a separate assessment from history and mental state: what you do is to identify any concerning risk factors which increased patient's risk to themselves or to others.

How should you document initiation of an antipsychotic?(what are the counselling points?)

Prior to initiation, check FBC, U&Es, LFT, Prolactin, HbA1c, fasting lipids Check ECG, weight and BP Commence e.g. Olanzapine 5mg nocte Side-effects explained including metabolic syndrome, sedation and effects on driving Review efficacy in e.g. 4 weeks Patient advised to seek advice if they develop any side-effects If longer-term treatment required will need monitoring of weight, BP and bloods

List some indications for ychoticssychotics (aka neuroleptics) (though not always 1st line or a licensed indication)

Psychosis Mood disorders Anxiety disorders Insomnia Rapid tranquillisation Nausea and vomiting Hiccups Tics including in Tourette's syndrome

What is psychosis?

Psychosis is defined as a state in which there is a loss of contact with reality and includes: Delusions Hallucinations Formal thought disorder

What elements of the patient's speech should you note?

Rate (fast, slow) Quantity (e.g.. poverty of speech) Volume Flow of Speech (e.g. pressure of speech - if you cannot interrupt, consider this) Spontaneity

Can women of child bearing age have antipsychotics?

Remember women will often not realise they are pregnant until several weeks after conception Advice should be given about contraception, preferably long-acting reversible contraceptives (LARCs) Evidence base continues to change, current evidence favours typicals in pregnancy If uncertain seek advice

What are the side effects and uses of quetiapine?

Requires titration Usual dose 300-600mg/day in two divided doses Also available as once daily XL (extended release) preparation In addition to psychosis, quetiapine has also been shown to be effective in bipolar depression Side-effects Sedation ++ Weight gain ++ Less metabolic disturbance than olanzapine Possible QT prolongation

Name 4 other causes of psychosis

Schizotypal Disorder Acute and transient psychotic disorder (symptoms less than 28 days) Mood disorder (Mania, Severe depression) Substance misuse - e.g. alcohol withdrawal, intoxication with stimulants, cannabis

What are 3 things you need to ask about relating to perceptions?

Sensory distortion - includes distortions of intensity, colour, form and proportions. Depersonalisation - an alteration in the perception or experience of the self, leading to a sense of detachment from one's mental process or body. Derealisation - an alteration in the perception or experience of the environment, leading to a sense that it is strange or unreal. Illusions are misinterpretations of a real stimulus. A false perception - the perception of a real object is combined with internal imagery to produce a false internal percept. It can happen in individuals without mental illness - e.g. in heightened emotion. For example, misinterpret a branch of a tree as an arm of a person. Hallucinations are perceptions in the absence of a stimulus auditory hallucinations - 2nd person, 3rd person, commentary, commands

What symptoms make up the somatic syndrome?

Some 'biological' symptoms of depression are regarded as having particular clinical significance Markedly reduced appetite Weight loss (>5% of normal body weight in 1 month) Early morning wakening (at least 2 hours before usual time) Diurnal variation in mood (depression worse in the morning, improving through the day) Psychomotor retardation/agitation Loss of libido Marked anhedonia Lack of emotional reactivity

What is a pseudo hallucination?

Some hallucinations can happen in normal individuals - e.g. hypnopompic hallucination (visual or auditory hallucination upon awaking) hypnagogic hallucination (visual or auditory hallucination upon falling asleep)

What is the epidemiological link between depression and suicide?

Studies suggest that between 36 and 90% of those who die by suicide have a diagnosis of depression. Between 5 and 15% of those with a diagnosis of depression will die by suicide. Those people who do die by suicide and have a diagnosis of depression, are more likely than other depressed patients to have a history of self-harm, and to have experienced a sense of hopelessness.As such, hopelessness and self-harm are important risk factors for suicide.

What features suggest psychosis is being caused by schizophrenia?

Symptoms present for longer than 28 days (some classification system needs longer duration) No "organic" cause First rank symptoms present or persistent hallucinations and delusions May also have negative and cognitive symptoms

What is a CPA (Care Programme Approach)? Who gets it and what do they get? When is it stopped?

The CPA is a way of writing a care plan for patients who are under secondary mental health services. CPA guidance states it is for people for whom the following things apply: Severe Mental Illness Significant problems in looking after themselves - significant risk of harm to self or others, not wanting help or being particularly vulnerable Significant Intellectual Disability Those receiving services from a number of agencies - housing, physical care, criminal justice or voluntary agencies Recent detention under the Mental Health Act Commonly when the patient is under care of one of the following teams: Community Mental Health Teams (CMHTs) Assertive Outreach Teams Early Intervention Teams Occasionally Crisis and Home Treatment Teams (this is less common) A Care Coordinator (CCO or Keyworker) who will look at: Medication Therapy Help with money problems, advice and support, employment and training Help with housing difficulties Any voluntary sector support that might be useful Physical health, especially with respect to side effects from psychiatric medications Risk to the patient or others Problems with drugs or alcohol A written copy of the care plan, to be shared with the GP and, if the patient agrees, carers and relatives Regular reviews The assessments should take into consideration age, disability, gender, sexual orientation, race, ethnicity and religious beliefs When is it stopped? · This will be regularly assessed · It will not stop just because of 'stability', if the stability is brought about by the extra support of the CPA · There will need to be an assessment of needs and a risk assessment · There will need to be a handover to another professional - usually GP or psychiatrist · There will need to be a plan for follow up and, if needed, how to get in contact if the patient's health deteriorates

What are the 4 extra pyramidal side effects (EPSEs)? Which is the most concerning? How are these treated?

There are 4 EPSEs, the most concerning of these is tardive dyskinesia, as this may be irreversible. Akathisia - subjective feelings of restlessness, often associated with objective signs (pacing, rocking, repeatedly crossing legs). It has been suggested that akathisia often exacerbates psychotic agitation and that the diagnosis should be considered whenever a patient develops impulsive suicidal ideation after a change in neuroleptic treatment. Propranolol is useful for akathisia (restlessness). Parkinsonism - antipsychotic and idiopathic parkinsonism are clinically identical (tremor, rigidity and bradykinesia). Usually develops after several days to weeks. Acute Dystonia - involuntary muscle spasms which produce briefly sustained abnormal postures. Usually occurs within 48hrs of initiation. (e.g. torticollis, oculogyric crisis) Procyclidine and benztropine are useful for acute dystonia (eg after admin of haloperidol for rapid tranquilisation). Tardive dyskinesia (TD) - abnormal involuntary hyperkinetic movements. TD is potentially irreversible. Abnormal movements include abnormal tongue movements (fly catching sign, bon-bon sign), pouting/smacking of lips, chewing, head nodding, grimacing, rocking movements. (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw) If severe, tetrabenazine. EPSEs may be managed with procyclidine

What are depot antipsychotics? Which antipsychotics are available in the form?

There are situations when an intramuscular form of an antipsychotic is preferred to oral preparations. This is most frequently due to non-concordance with treatment but may also be due to patient choice. They are usually given between weekly to monthly. There is a limited range of antipsychotics available in depot preparation' including: Typicals Haloperidol Flupentixol Zuclopenthixol Fluphenazine Atypicals Risperidone Olanzapine Aripiprazole

What to note about thoughts?

Thought form - it is the train of thought. Some patients (e.g. schizophrenia) may have formal thought disorder (i.e. disorder of thought form) flight of ideas loosening of associations/derailment thought block poverty of thought Thought content Overvalued ideas Phobia (i.e. irrational fear) Obsessions/ruminations Delusions "I would like to ask you some questions that may seem a little strange. These are questions that we put to all of our patients. Is that OK? Do you have any beliefs that your friends and family do not share?" "Is anything bothering or weighing on you at the moment?"

What risk factors are there for harm to others? What disorders increase the risk?

Thoughts of harming others Thoughts that other may cause harm History of harm to others - Previous police involvement/charges/convictions, Age at time of first violent act (Younger age of onset of violence suggests higher risk) Access to weapons Particular clinical pictures associated with increased risk to others Command hallucinations, passivity phenomenaDelusional jealousyDissocial personality disorderFrontal lobe damageSubstance misuse

What are the principles for investigating and managing schizophrenia?

To establish a diagnosis: history and mental state examinationinvestigations (physical and psychosocial) To manage the condition: where to manage? Likely to depend on level of risk who to manage? ie. which service bio-psycho-social management support for carer follow up

What are the general guidelines when prescribing antipsychotics?

Use lowest effective dose Start low and go slow (it can take up to six weeks for a response) Prescribe one antipsychotic at a time Monitor for side-effects Assess concordance before making any changes

What are the side effects of risperidone? In what other preparation does it come?

Usual dose usually 4-6mg (maximum BNF doses are higher) Depot preparation available - Risperidone Consta Side effects Sedation + Weight gain ++ Hyperprolactinaemia Sexual dysfunction ++ EPSE ++

A 29 year old male, with a BMI of 31 and a FH of Type II Diabetes, presents with first onset psychosis requiring treatment with antipsychotic medication.

When prescribing antipsychotics to patients with either a personal or family history of obesity or diabetes, you must be mindful when using antipsychotics which are more liekly to be associated with a metabolic syndrome. Antipsychotics should be administered oral unless there exist specific indications. You should avoid olanzapine if possible, as well as clozapine unless it is treatment resistance. So could prescribe: aripiprazole, chlorpromazine, haloperidol, quetiapine, risperidone, zuclopenthixol

How can you assess someone's cognition in a mental state exam?

You need to include the following items as minimum: Orientation in time, place and person Attention and concentration (serial-7 test or backwards spelling) Memory - immediate recall, delayed recall, long-term memory/knowledge If you discover cognitive impairment, a more detailed cognitive examination is necessary. Mini-mental state examination (MMSE - don't confuse with mental state examination MSE!) by Folstein Maximum score 30 does not test any frontal lobe abnormality​ takes about 5-10 minutes depending on patient Montreal Cognitive Assessment (MOCA) A full version and a basic version (for illiterate or with low education - less than 5 years) Maximum score 30 Covers most of cognitive domains including executive (e.g. frontal)

Where are patients with schizophrenia followed up? What is considered at follow up?

depending on the illness, usually need secondary mental health service follow-up (e.g. community mental health team, or other specialist teams - assertive outreach, early intervention), although some patients with more stable illness can be monitored and followed up GP. During follow-up, these needs to be considered: Monitor mental state Monitor treatment effectiveness and side effects Monitor risk Monitor support system Further psychoeducation

Which drugs are used for schizophrenia/psychosis? BIO

generally, second generation atypical antipsychotics. Clozapine for treatment-resistant schizophrenia.

In what condition are pseudo hallucinations often experienced?

in Emotionally Unstable Personality Disorder. In this case, they tend to be pejorative, in the second person "you are worthless", and may be related to past abuse. Psychologically they are sometimes explained as being an 'internalisation' of a past aggressor/abuser Also in grief

What are common reasons for noncompliance to antipsychotics and how is this combatted?

lack of insight side effects of medication delusions about medication/ prescriber patient feels better when "ill" patient gains remission from symptoms and thinks medication is no longer required Depot preparations are often used for individuals where compliance is an issue.

When can individuals be detained under the Mental Health Act?

o Individuals can only be detained under the MHA for psychiatric admission if they meet the following criteria: o There is a mental disorder (or significant symptoms to suggest a mental disorder even there is not a firm diagnosis) o There is a significant risk to patient himself/herself and/or to others o Informal psychiatric admission is not possible, which can be because of: The patient is not able to provide a valid consent because

Divide psychosis symptoms into positive and negative

positive thought disorder hallucinations disorganised behaviour delusions negative reduced attention avolition blunted affect poverty speech social withdrawal

Split symptoms of schizophrenia into positive, negative and motor/catatonic symptoms

positive - hallucination, formal thought disorder, delusion negative - lack of volition, blunting of affect, apathy, anhedonia motor/catatonic - posturing (voluntary assumption of inappropriate or bizarre postures), negativism (motiveless resistance to attempts to move the patient/movement in opposite direction), waxy flexibility (patient's limbs can be moved to any posture which will then be held for prolonged period of time), mutism

What is the mode of action of antipsychotics?

postsynaptic competitive receptor antagonism. The antagonist pushes the dose-response curve to the right. mode of action is antagonism of the mesocortical/mesolimbic pathway. positive symptoms such as delusions, hallucinations and thought disorder might be caused by an overactivity of mesolimbic pathway dysfunction of the mesocortical pathway may be part of the neurobiology of negative and cognitive symptoms However, antagonism of the tuberoinfundibular and nigrostriatal pathways is responsible for some of the more common side-effects. Blockade of the tuberoinfundibular pathway can result in hyperprolactinaemia and the nigrostriatal pathway can result in extrapyramidal side-effects. (all dopamine pathways)

Name and describe the people involved in mental health services

primary care: GP, advanced nurse practitioners, counsellors and therapists psychiatrist · Social worker - They have a qualification approved by the Health and Care Professions Council (HCPC). As well as being able to give emotional support and practical help with accessing money, housing and other entitlements, some may provide psychological treatments · Approved Mental Health Professionals (AMHPs) - They can be any member of the mental health team. They will usually be a social worker although they can be other allied health professionals etc. They have had further training in assessing if someone needs to be admitted to the hospital using the Mental Health Act. In the past, they are called Approved Social Worker (ASW). · Community psychiatric nurse (CPN) - Registered mental health nurses who work outside hospitals and visit patients in their own homes, outpatient departments or GP surgeries (NB: Inpatient nurses are generally called Staff Nurse or if more senior, Ward Sister/Charge Nurse) · Occupational therapist - Help patients get back to doing practical everyday things - to assess what the patient can or can't do; give advice on appropriate accommodation; find meaningful activities; rebuild confidence; promote independence · Clinical psychologist - Have a degree in psychology and undertake a further 3 years training in order to work with clients, give psychological therapies and help other members of the team work psychologically · Healthcare assistant - Sometimes known as nursing assistants, they will work usually under the supervision of nurses, but also doctors and other healthcare workers. Closely related to Clinical Support Workers (CSWs) · Independent Mental Capacity Advocate (IMCA) - Someone with specialist training who helps someone lacking capacity make decisions around serious medical treatment or a change of accommodation. A legal right for people over 16 who lack mental capacity and do not have an appropriate family member or friend to represent their views · Independent Mental Health Advocate (IMHA) - Someone specially trained to support people to understand their rights under the Mental Health Act and to help them participate in their care and treatment. A legal right for anyone detained under Sections 2 or 3 of the Mental Health Act, as well as some other parts of the Act Care coordinator/keyworker - A member of the team (usually a Nurse, OT or social worker) who will fully assess the patient's needs, write a care plan which shows how the NHS and other organisations will meet those needs and regularly review the plan to check on progress

Outline the different components of a risk assessment

risk of self harm and suicide risk of neglect risk of being exploited by others risk of further deterioration of mental and physical health eg do they lack insight, won't comply to meds risk of aggression and violence to other people risk of children risk to property and risk of driving

What are the key side effects and benefits of each atypical antipsychotic?

the only notable drug that reduces seizure threshold is clozapine. Clozapine is an effective medication but carries a number of serious side effects which you must be aware of: agranulocytosis, neutropenia, reduced seizure threshold, and myocarditis. All atypical antipsychotics can cause weight gain and hyperprolactinemia. However, generally speaking, aripiprazole has a good side effect profile and is less likely to increase prolactin levels or cause other side effects. Olanzapine is notorious for its associations with dyslipidemia and weight gain, and is also associated with diabetes and sedation. It is for this reason that some patients are purposefully given olanzapine if they are underweight and cannot sleep. Quetiapine is also associated with weight gain and dyslipidemia. However, one of the most notable side effects of this drug is postural hypotension. Risperidone can increase the likelihood of developing extrapyramidal side effects, as well as cause postural hypotension and sexual dysfunction.

What is the prodrome of schizophrenia?

the period of time when the individual is gradually developing symptoms but has not yet met the criteria for diagnosis. These symptoms include: non-specific negative symptoms emotion distress/ agitation without reason transient psychotic symptoms The longer the DUP (duration of untreated psychosis) the worst the outcome. Average DUP is over a year.

Describe the following delusional disorders: De Clerambault's syndrome, Cotard syndrome, Capgras syndrome, Fregoli syndrome

· De Clerambault's syndrome - A delusion where the patient believes another individual is in love with them and they are destined to be together; aka 'erotomania' · Cotard syndrome - Psychotic depressive presentation with nihilistic delusions (the patient has died or no longer exists or the world has ended and no longer exists) and hypochondriacal delusions (especially that their organs do not work, they are 'hollow') · Capgras syndrome - A delusional misidentification syndrome where a person well-known to the patient is replaced by an identical 'double' who is not the 'real person' · Fregoli syndrome - A delusional misidentification syndrome where the patient believes that strangers have been replaced by (usually) one familiar person who changes appearance or takes on disguises

What risk factors are there for self harm and suicide? What disorders increase the risk?

· Thoughts of harm to self · Thoughts of death/dying/ending own life · Hopes or plans for the future · 5-15% of people with depression will die by suicide Previous deliberate self-harm or attempts to end own life · How many times? · Methods (e.g. Cutting, overdoses, ligature etc.) · Intention (What did you think would happen? Sleep, injury, death?) · Precipitants (Was there something that triggered this? Was it planned?) · Location (Were attempts made to avoid discovery? Did you contact help?) · Final acts (Was a note left, or a will made etc?) · Feelings afterwards (Were you glad to have lived? Did you regret what happened?) Particular clinical pictures associated with increased risk of deliberate self-harm or suicide · Depression, bipolar affective disorder · Schizophrenia (Particularly in early stages of recovery from acute episode) · Emotionally unstable personality disorder · Obsessive-compulsive disorder