Psychiatry

Insomnia

>3d/w for >3mo, difficulty falling, maintaining, or poor quality sleep. Genereally excessively concerned, distressed, with social/occupational impairment Psychophysiological: difficulty initiating and maintaining, with somatasised tension anxiety, over-concern and learned sleep prevention Paradoxical insomnia: 'sleep state misperception' - pt thinks little-no sleep, but actually normal Adjustment sleep disorder: related to emotional arousal from stress, conflict, environmental change - resolution of stressor cures Inadequate sleep hygiene: late nights, caffeiene consumption, etc Idiopathic insomnia: rare, lifelong insufficient sleep Environmental sleep disorder: transient sleep disturbance due to heat, cold, noise, light, excessive partner movement, danger, allergens, unfamiliar surroundings Altitude insomnia: unusual, accompanied by headache, loss of appetite, fatigue without O2. Most above 4k, 25% above 2k Food allergy insomnia: rare, difficulty initiating and maintaining due to allergic response to food Behavioural insomnia of childhood Limit-setting sleep disorder: 5-10% of kids, inadequate enforcement of bedtimes by caregiver - refusal to go to bed Sleep-onset association disorder: 6mo-3y, sleep impaired by absence of object (toy) or circumstance (routine, night-light), sometimes inability to fall asleep w/o eating/drinking (nocturnal eating/drinking syndrome) SECONDARY Sleep-related breathing, circadian and movement disorders Medical: pain, resp (COPD, CF, asthma), DM, parkinson;s, Addison's/Cushing's Psych: major affective, anxiety, borderline personality, eating, scitzophrenia, dementia disorders Drugs: antidepressants (MAOI, SSRI, SNRI), antiParkinsons, phyllines, CVS (bblocker, clonidine, digoxin, verapamil), chemo, steroids, NSAIDs, stimulants (amfetamine, cocaine, caffiene, nicotine), thyroxine, withdrawal/dependency (hypnotics, opiates, alcohol, cannabis) Sleep hygiene Environment: noise, light, temperature Behaviour: 1h wind-down to distract from stress (read, watch TV, music, warm bath). Regular exercise, not late at night. avoid naps (if needed early afternoon <40min). Set aside time to reflect on problems or stresses Drugs: avoid caffiene after 16:00, no smoking <1h before bed. Tryptophan snack (eg warm milk) Stimulus control: only go to bed when sleepy, avoid non-sleep, non-sexual activities whilst in bed. If sleep does not occur, do not remain in bed >10-20min - get up, go to other room w/o turning on lights, return to bed when sleepy. Establish regular time to get up with <1h variation (even weekends/holidays) Sleep restriction: for fragmented sleep. Tries to compress sleep onto one continuous segment Hypnotics: last resort, short term. 5 nights/w <4w to avoid tolerance and rebound insomnia. BDZs, Z-drugs (zopiclone, zolpidem, zapeplon - 1st line), chloral hydrate, sedating antidep (trazodone, mirtazapine), sedating antipsychotic, melatonin agonists

Antidepressant discontinuation syndrome

Abrupt onset within days of stopping antidepressant, quick resolution when restarted. 1/3 of pts Sensory: paraesthesias, visual disturbances, shock-like sensations/numbness Disequilibrium: dizziness, vertigo, light-headedness General: flu-like symptoms, fatigue, headache, sweating, tremor GI: V+D+N Affective: irritability, anxiety, low mood, tearfulness Sleep: nightmares, vivid dreams, insomnia If mild-moderate, supportive treatment If severe, reintroduce antidepressant then taper slowly or switch (fluoxetine has long t1/2 so resistant to discontinuation syndromes

Alcohol misuse

Acute: 60min to reach max conc, equally distributed, 1h/u breakdown. Elevation of mood, increased socialisation/disinhibition -> labile mood, impaired judgement, aggression, slurred speech, ataxia Toxicity: >300mg%. LOC/coma, aspiration, hypoglycaemia, AKI Psych: delerium tremens, alcohol-induced amnesia, alcoholic hallucinosis, alcohol-induced delusional disorder, WK syndrome, pathological jealousy, alcohol-related cognitive impairment, alcoholic dementia CAGE questionairre: (CAGE + 2 - most drunk in day? in week?), >2/4 indicates further assessment AUDIT: or abbreviated version AUDIT-C FAST, PAT, SASQ MCV: raised for 3-6mo gammaGT: raised for 2-3w Carbohydrate-deficient transferrin (CDT): highly specific, rises with 7-10d heavy drinking, stays raised for 2-3w Urinary ethyl glucoronide: raised for days after ingestion of only 1-2 drinks 14u/w over >=3d/w Alcoholic brief intervention (ABI): low intensity short intervention at GP level to reduce hazardous drinking Controlled drinking: set weekly/daily alcohol limits, don't drink alone/with heavy drinkers, pace drinking to lightest/slowest drinker alternating between soft and alcoholic drinks with meal, rehearse rejecting drink, plan enjoyable non-drinking activities For some controlled drinking not feasible, complete abstinence required Maintenance: initial change easy, staying hard. Individual counselling, group therapy (AA), residentially-assisted abstinence, relapse planning Pharma (once abstinent) Disulfiram: irreversible ALDH inhibitor, causing acetaldehyde buildup if drinks (flushing, n+v, tachycardia). ADRs halitosis, headache, rarely hepatotoxic, psychotic reaction. Usually taking is monitored by spouse Acamprosate: enhances GABA transmission. Reduces craving. ADRs GI upset, pruritus, rash, altered libido. Discontinue if relapse>1 Nalmefene: opiate receptor modulator, reduces craving in active drinkers. ADR nausea, dizziness, insomnia, headaches Naltrexone: modulates opiate receptors, reduces craving in active drinkers. ADR GI upset, anxiety, headache, fatigue, sleep disturbance, flu-like symptoms

Emergencies

Attempted hanging: support pt's weight, loosen/cut ligature, lower pt to flat service then basic resuscitation, transfer to emergency services. Beware cervical spinal # in attempted judicial hanging, and of impending resp obstruction from soft tissue injuries/oedema Severe behavioural disturbance: shouting, screaming, hyperactivity, aggressive outbursts, threatening violence (ACS, intoxication, psychosis, LD, PD). Try to come to peaceful resolution. If physical cause suspected, Rx as delerium. If psychiatric cause suspected: 1st - lorazepam, haloperidol, chlorpromazine PO. 2nd- IM lorazepam. 3rd IM lorazepam AND haloperidol, IM olanzapine, IM chlorpromazine, IM depot zuclopenthixol acetate. Immediate effect needed (exceptional circumstances): IV diazepam (w/ IV flumazenil available for resp depression), IV haloperidol (high risk of dystonia). If no cause suspected, call police Catatonia: BDZs (lorazepam PO/IM), barbituates, ECT should relieve symptoms. May mimic SS and NMS

Anorexia nervosa

Condition of young women with marked distortion of body image, pathological desire for thinness, and self-induced weight loss. Some genetic RF but not associated with childhood abuse CRITERIA Low body weight: >15% below expected, BMI <17.5 (<2nd centile in kids) Self-induced weight loss: avoidance of fattening foods, vomiting/purging, excessive exercise, appetite suppressant use Body image distortion: dread of fatness - over valued idea with low weight threshold Endocrine (HPA axis): amenorrhoea (can persist after weight gain), reduced libido/impotence, raised GH/cortisol, altered TFTs, abnormal insulin secretion Delayed/arrested puberty: if onset prepubertal Signs: russel sign, hypercarotinaemia (yellow skin/sclera), breast atrophy, parotid/submandibular swelling, swollen tender abdo (reduced motility -> intestinal dilation), brittle hair/nails COMPLICATIONS Oral: dental caries CVS: hypotension, ECG changed (sinus brady, STE, T flattening, RAD, low voltage, prolonged QT - risk of life threatening arrhythmias), cardiomyopathy (reduced heart size/LV mass, MVP - recovers on feeding). Most common cause of death GI: prolonged GI transit, constipation (prokinetic agents may accelerate gastric emptying, resolve gastric bloating helping with renormalisation of eating habits) Endocrine/Met: hypokalaemia/natraemia/glycaemia/thermia, arrested growth, osteoporosis Renal: renal calculi Reproductive: infertility, low birth-weight infant Derm: dry scaly skin, brittle hair, alopecia, lanugo (fine downy) body hair Neuro: peripheral neuropathy, loss of brain volume, ventricular enlargement, sulcal widening, cerebral pseudoatrophy (will correct with weight gain) Haem: anaemia, leukopenia, thrombocytopenia FBC, U+E, LFT, ESR, glucose, TFT (sick euthyroid syndrome), endocrine panel, cholesterol (may be dramatically increased) VBG/ABG: metabolic alkalosis (excess vomiting) or metabolic acidosis (laxative abuse) Pharma: fluoxetine Psych: family therapy, CBT/behavioural therapy Education: nutritional education challenging overvalued ideas, bibliotherapy (self-help manuals) Admission: if extreme weight loss, severe electrolyte imbalance, CVS complications, psychosis, risk of suicide, failure of outpt Rx Re-feeding: in first 2w cardiac decompensation can occur due to increased metabolic demand (excessive bloating, oedema, rarely CCF). To prevent, correct U+Es before refeeding, then recheck every 3d for 1w after refeeding, then weekly until recovery. Increase caloric intake by 200-300kCal every 3-5d until sustained 1-2lb/w weight gain achieved Highest mortality of all psych disorders (10-15% 2/3 from med complications). with Rx 1/3 full recovery, partial recovery, chronic problems

Hypersomnia

EDS. Can be sleep attacks, sleep drunkness (prolonged transition to awake), lengthening of night time sleep. Epsworth sleepiness score SECONDARY Neuro: brainstem lesions (ICP, diencephalic tumours/infarcts, Parkinson's, AC malformation, post-traumatic hypersomnia), myotonic dystrophy ID: EBV, viral pneumonia, HBV, GBS, viral encephalitis, sleeping sickness Endo/met: hypothyroidism Drug: alcohol, hypnotics, opiates, heavy metals, vit A, CO, anticonvulsants, antidepressants, antiemetics, antiH, antipark, antipsych, anxiolytics/hypnotics Psych causes: bipolar, SAD, adjustment disorder, PD. May have clinophilia OSA/CPA NARCOLEPSY classic but rare tetrad of excessive sleepiness, cataplexy, sleep paralysis, hypnagogic hallucinations (or hypnopompic). Cataplexy brought on by laughter or anger, usually partial (eg dysarthria with jaw, grimacing with face, knee unlocking with thigh), last s-mins, frequency highly variable (rarely status cataplecticus. Cataplexy and excessive sleepiness (irresistable and refreshing sleep attacks often in dangerous situations)are the only required symptoms. May have fequent awakenings, disturbing dreams, sleep-talking, REM-related sleep behaviours. Can rarely occur w/o cataplexy, or secondary to drugs PSG+MSLT: sleep onset REM period (SOREMP), with sleep latency <10min, REM latency <20min CSF hypocretin-1 levels reduced (v. sensitive + specific), HLA type associations Daytime somnolence: regular naps, stimulants (modafenil, methylphenidate, dexamfetamine), possibly Na oxybate (GHB) Cataplexy: TCA (clomipramine) or SSRI, also improve REM symptoms (hallucinations, paralysis). Withdrawal causes status catalepticus Kleine-Levin syndrome Rare syndrome of periodic somnolence and morbid hunger in male adolescents. Episodes decrease in frequency over years until cessation. Last 1d-weeks, occuring every 1-6mo. May have megaphagia, sexual disinhibition, confusion, irritability, restlessness, euphoria, hallucinations/delusions, schizophreniform states. Between episodes completely normal Hypersomnia: stimulants Prophylaxis: if major social/occupational impact. Mood stabilisers (Li, valpr, carb) Menstrual-related hypersomnia: EDS during periods, stimulants if symptomatic Idiopathic hypersomnia polysymptomatic: prolonged nocturnal sleep (>10h), with sleep drunkenness and constant EDS w/ frequent unrefreshing naps monosymptomatic: EDS alone PSG normal, MSLT <8min but longer than narco. Rx as for narco but naps don't help Behaviourally induced insufficient sleep syndrome: failing to sleep enough to maintain daytime alertness. Common in new parents, doctors, students. Typically hypersomnia in afternoon/early evening, with long sleeps + napping on rest days. Reduced conc/attention, low mood, irritability, GI/MSK somatic symptoms

Antipsychotics

FGA Aliphatic phenothiazines: anti-adrenergic + antiH causing sedation, antimuscarinic ADRs and EPS. Eg chlorpromazine, promazine (haemolytic anaemia) Piperidine phenothiazides: antimuscarinic ADRs, fewer EPS. eg Pericyazine Piperazine phenothiazides: mainly antiD ADRs, limited sedation, potent but prominent EPS. Trifluoperazine, fluphenazine, perphenazine, flupenthixol, zuclopenthixol, haloperidol, pimozide, sulpiride SGA (less EPS, prolactinaemia) Olanzapine: no EPS or prolactin. Sedation, weight gain, dizziness, dry mouth, constipation, glucose dysregulation. Post-injection syndrome may cause excessive sedation for 1-6h after depot injection, with acute confusion, EPS, dysarthria/ataxia, seizure Risperidone/paliperidone (active metabolite): low EPS, but dystonias, akathisia, prolactinaemia, weight gain Quetiapine: no EPS or prolactin. Sedation, dizziness, constipation, dry mouth, weight gain, dyslipidaemia Amisulpride: less weight gain, but at high doses EPS and prolactin Aripiprazole: low EPS, prlactin or weight gain. Akathisia in first 2-3w + insomnia Lurasidone: no QTc, wieght or lipid issues Clozapine: Great for resistant scitzo, but big risk of agranulocytosis. Anticholinergic, antihistaminergic and antiadrenergic ADRs. First pass metabolism by liver highly variable, takes several weeks to have effect. CI with lithium, Hx of neutropenia/blood dyscrasias, renal/cardiac/liver disease, AChEis. Smoking increases clearance, caffiene raises conc. Beware of CP450 Monitoring: register pt with monitoring service. Normal FBC pre-rx. Repeat and send to service weekly for 18w, then 2weekly until 1y, then monthly indefinitely. GREEN - normal, continue. AMBER - WBC 3-3.5k neut 1.5-2k. Check twice weekly until stabilise/recover. RED - WCC<3k neut<1.5k, STOP clozapine, FBC daily until resolves, monitor for infection, consult haem. Check serum levels if concern about compliance. 12.5mg->25-50mg then increase daily by 25-50mg. Reverse if discontinuing. May have psychosis recurrence, or cholinergic rebound (diaphoresis, headache, N+V+D) ADRs: Constipation, nausea, hypersalivation, nocturnal enuresis. Fever, agranulocytosis. HTN, hypotension. Sedation, weight gain, seizure (withhold 24h). Fatal myocarditis, PE, NMS sedation: NOT (chlor)promazine. Haloperidol, risperidone, amisulpride Weight gain: NOT phenothiazines, olanzapine, clozapine. Haloperidol, fluphenazine EPS: NOT FGA. SGA postural hypotension: NOT phenothiazines. Haloperidol, amisulpride, trifluoperazine EPSE Acute dystonia: maximal contraction of muscle group (eg SCM, tongue. May include oculogyric crisis). Rx procyclidine 10mg IM Parkinsonism: Rx procyclidine/amantidine Akathisia: restlessness of lower limbs, drive to move. Rx propranolol, BZDs. Difficult Tardive dyskinesia: continuous slow writhing athetosis or sudden involuntary movements typically of oro-lingual region (chorea). Irreversible. Rx none. Vit E prevents deterioration

XLR LD

Hunter syndrome: MPS - iduronate sulphatase deficiency (male Ashkenazi jews). GAG accumulation. Short stature, gargoylism, prominent forehead, enlarged tongue, flattened nose bridge, enlarged head, degenerative hip disease, joint stiffness, claw hand, chest deformities, cervical cord compression, hepatosplenomegaly, hearing loss, breathing obstruction, developmental delay, eye (RP, papilloedema, hypertrichosis), umbilical/inguinal hernia Lesch-Nyhan syndrome: HPRT deficiency -> hyperuricaemia. Healthy at birth, then dystonias, developmental delay -> spasticity, choreoform movements, transient hemiparesis, variable LD, microcephaly, epilepsy (50%), behaviour (2yo onset - self-mutilation, verbal/physical aggression. Rx SSRI Oculocerebrorenal syndrome of Lowe: v. rare. LD (25% normal IQ), short stature, hypotonia, epilepsy, eye (congenital catarcts), renal (tubular dysfunction), behaviour (temper tantrums, hand-waving, self-injury)

ADRs

Paradoxical BDZ reaction (1%): characterised by acute excitement and altered mental state with increased anxiety, vivid dreams, hyperactivity, sexual disinhibition, aggressive dyscontrol. Exacerbated by higher doses/misuse Rx: Nurse in safe environment w/ constant supervision, sedative antipsychotic if required and IV flumazenil in severe cases Parkinsonism: always b/l, generally gets better over time. Rx reduce dose/switch, or antiCh agent (amantadine if older as less tolerant of antiCh ADRs) - withdraw slowly after acute phase Akathisia: subjective feeling of inner restlessness, with repetitive movements (pacing, unable to stand/sit/lie still, rocking, crossing/uncrossing legs). Acute (h-w), acute persistent (chronic), tardive (onset >=3mo after Rx, poorly responsive to antiCh), pseudo (old male schizophrenics) Rx: lower dose/switch or try anti-akathisia agent (1st: propranolol, mirtazapine. 2nd: mianserine, cyproheptadine. Alternatives BDZs, amantadine, clonidine) which should then be slowly withdrawn after resolution Tardive dyskinesia: late onset (7y) involuntary, repetitive, purposeless movements due to longterm antipsychotic Rx (may be triggered by cessation), antiCh is RF. Pt often unaware of movements, noticed by others. Perioral movements most common (tongue, lips, jaw), followed by axial/trunk twisting, torticollis, shoulder shrugging, pelvic thrusting, rapid limb movement, hand clenching, choreoathetoid movement. Can be consciously supressed, worse with distraction, exacerbated by stress/antiCh, disappear during sleep. Improves with time (50% resolve in 5y) Rx: reduce dose, slowly reduce/stop antiCh. If severe, switch or raise dose of antipsychotic to alleviate symptoms Specific Rx: 1st - tetrabenazine. Also dopamine agonists, BDZs, CCB, anticonvulsants, vitE Dystonic reaction: sustained painful muscular spasms producing repetitive twisting movements/abnormal postures due to antipsychotics. Usually young, lasting minutes to hours. Head and neck most common (torticollis, trismus, jaw opening, forceful protrusion of tongue, blepharospasm, grimacing, oculogyric spasm, opisthotonus). Trunk/limbs less common, involvement of pharynx/larynx causes dysphagia and laryngospasm. More generalised in kids (confused with seizures). Can be tardive Rx: discontinue agent, emergency IM (IV if life-threatening) antiCh (eg procyclidine), continuing for 1w then tapered for 2-3w. Alternative amantadine. Resistant oculogyric crisis can be treated with clonazepam. If tardive - botox, ECT, DBS

Alcohol disorders

Pathological intoxication (mania a potu): idiosyncratic reaction to small amount of alcohol. Severe agitation, beligerence, violent behaviour followed by collapse, profoundly deep sleep, amnesia. Highly dubious/controversial diagnosis Palimpsest: alcohol-induced amnesia, usually hours-long gap in memory (partial or global/'En bloc') Alcoholic hallucinosis: auditory hallucination in alcohol misuser, whilst conscious and sober. Start as elemental (bang/murmuring) -> derogatory voices (if alcohol use continued). Worsens during detox. 95% rapidly resolve with drinking cessation, 5% develop more chronic schizo symptomatology Alcohol-induced psychotic disorder with delusions: persecutory or grandiose delusions w/ Hx of heavy drinking. Also pathological jealousy/Othello syndrome (strongly associated with homicide) Alcohol related cognitive impairment/brain damage (ARBD): 50-60% have near-global cognitive impairment while sober (not IQ). CT/MRI shows atrophy. Exacerbated by thiamine deficiency, improves with cessation. Includes alcohol dementia and WK syndrome Affect: 50% depressed, 75% anxiety disorders. Can be self-medicative, or causative Medical: ALD (fatty, hepatitis, cirrhosis - female, HB/CV), GI (gastritis/Barrett's, Mallory-Weiss tears, chronic pancreatitis), cancer (HCC, oesophageal, gastric, oropharyngeal), CVS (HTN, dilated cardiomyopathy, AF/arrhythmias, CVA), resp (TB, Kleb/strep pneumo), neuro (WK, peripheral neuropathy, central pontine myelinosis, Marchiafava-Bignami, cerebellar degeneration, Optic atrophy, myopathy), Other (ED, hypogonadism, FAS, gout, osteoporosis) LOSS OF LICENSE Alcohol misuse: 6mo(group1) or 1y (2) abstinence/controlled drinking w/ normalisation of blood Alcohol dependence: 1y (1) or 3y (2) abstinence with normalisation of blood Cannabis/amfetamines/MDMA/LSD/hallucinogens: 6mo (1) or 1y (2) abstinence Heroin/morphine/cocaine/methadone: 1y (1) or 3y (2) abstinence + favourable consultant report. Can be licensed with fully supervised methadone programme

Central sleep apnoea

Primary CSA w/o CSB: idiopathic recurrent sleep apnoea w/o resp effort. EDS, insomnia. PSG no hypercapnia, >5 apnoea episodes/h CSA w/ CSB: recurrent apnoea followed by prolonged hyperpnoea (CSB) pattern in NREM. Associated with heart/renal failure and cerebrovascular disorders CSA due to drugs: usually longterm opiate use High altitude breathing pattern: >2.5k, 30s cycles of apnoea or hyperpnoea Med: brain stem pathology Primary sleep apnoea of infancy: developmental, eg Ondine's curse

Depression

RF: FHx, childhood (parental loss/alcoholism, sexual abuse), personality (anxiety, impulsivity, obsessionality - high neuroticism), social (divorce, unemployment, loss), organic illness (parkinsons, MS, MI). Intelligence and marriage protective Typical triad: Depressed mood, anhedonia, fatigue. In elderly can present as pseudodementia (may have islands of normality, with excessive apathy to easy cognitive tests) Somatic: Loss of emotional reactivity, diurnal mood variation (worst in morning, then improving), sleep (early wakening, insomnia, hypersomnia), psychomotor agitation/retardation (loss of conc), loss of appetite/weight, loss of libido Psychotic Delusions: poverty, personal inadequacy, guilt over presumed misdeeds, responsibility for world events, deserving of punishment Hallucinations: auditory (defamatory/accusatory voices, cries for help), olfactory (bad smells), visual (tormentors, demons, devil, dead bodies, scenes of death and torture) Catatonia: depressive stupor ICD-10 Mild: 2 typical + 2 somatic Moderate: 2 typical + >=3 somatic Severe: 3 typical + >=4 somatic Non-melancholic: no somatic or psychotic symptoms. can be irritable/hostile depression with aggression, acting out, DSH (generally younger), OR anxious depression - highly anxious and withdrawn, may have substance misuse, frequent DSH/suicide attempts, respond well to SSRI Melancholic: somatic symptoms (but no psychotic). Usually have psychomotor signs. Better SSRI response With psychotic symptoms: usually v. severe non-reactive depression with near catatonic psychomotor disturbance and psychotic symptoms. Often have constipation with delusion of bowels being sewn up Episodes last 4-30w for mild/moderate and ~6mo for severe. Recurrence common but shorter In pregnancy, most suicides between 6-12w postpartum Ratings: Hamilton depression rating scale (HAM-D), Beck depression inventory (BDI) FBC, U+E, LFT, ESR, haematinics, TFT, glucose, Ca MIld (CAMHS tier 1-2): Start with CBT/talking therapies (CAMHS tier 2-4). Only antidepressants if long insidious Hx Moderate/severe: antidepressants + IPT. review every 1-4w until established (suicide risk increased in early stages, due to psychomotor restrictions on suicide being lifted). adequate trial=4w at max dose. If partially respond, may benefit from addition of lithium (or tryptophan/T3). Continue effective dose/Rx for 6mo-1y before gradual discontinuation (although if pt wants, can stay on it indefinitely). If severe and recurrent, maintain for at least 5y/indefinitely ECT: first line for severe biological features (eg marked weight loss or psychomotor retardation), hish risk of harm to self or others, psychotic features, refractory disease ADMIT if significant risk of harm to self, others, self neglect (esp weight loss) or severe depressive/psychotic symptoms Depression with psychotic symptoms: ECT first line (although practical concerns mean usually 2nd). Start antipsychotic, then a few days later antidepressant (sometimes antipsychotic enough, and antidepressants can worsen untreated psychosis) - commonly olanzapine-fluoxetine (Symbyax). If ECT resolves, maintain on antidepressants. If dual therapy resolves, mainatain same but lowest effective dose of antipsychotic. Maintenance indefinite

Depersonalisation disorder

Rare. Persistent or recurrent episodes of unreality (derealisation syndrome) or detatchment from own body/thoughts/feelings/behaviour (depersonalisation syndrome) Feel like passive observer of their actions/surroundings, emotional numbness, impression on dream/trance-like state, alteration of perceptions. Insight preserved, pt finds phenomenon distressing. Usually in context of acute stressor Cambridge depersonalisation scale CBT: only Rx with evidence Pharma: no licensed drugs. SSRI, lamotrigibe, BDZs may have benefit

Paediatric terms

Resilience: ability to resist adversity, cope with uncertainty and recover more successfully from trauma. High IQ, sense of humour, empathy, loving family environment, successful at school, extra-curricular activity, religious/faith communities Level of attunement with caregiver permanently influences HPA axis (ie baseline stress) and establishes attitude towards relationships (attachment) as below Secure: values relationships, confident of self-worth Insecure avoidant: emotionally independent, does not value relationships Insecure anxious: self-worth depends on approval of others, attention seeking Insecure ambivalent: values relationships, but cautious about safety Disorganised: neither self-sufficient nor able to use relationships Reactive attachment disorder: disturbed social relations diagnosed <5yo Rx: although working with child helps (eg behavioural management), most effective is modification of primary relationships

Perception

Sensory distortion: eg hyperacusis, micropsia Affect illusions: heightened emotion (eg at night thinking waving tree is attacker) Completion illusions: eg optical illusion, from brain filling in blanks Pareidolic illusions: poorly defined stimulus (seeing face in fire/clouds) Pseudohallucination: patient recognises is in their head, and that others cannot sense it Auditory hallucination: narrating thoughts/actions, 2+ arguing Visual hallucination: usually organic, eg delerium tremens (Liliputian hallucinations) Olfactory hallucination: Hypnagogic/hypnopompic hallucination: on falling asleep (hypnagogic) or waking (hypnopompic), normal Elemental hallucinations: usually organic, flashing lights/unstructured noise - simple hallucinations Extracampine hallucinations: object beyond normal range of sense Functional hallucinations: only heard when stimulated (eg voices when hearing fans) Charles-Bonnet syndrome: due to reduced VA, complex visual hallucinations Delusion: pathological belief of absolute certainty (cannot be rationalised away), held in the face of contradictory evidence and not understandable as part of cultural/religious background Overvalued ideas: not delusions or obsessions. Eg weight in anorexia Accelerated tempo of thought: may have pressured speech. Can present as flight of ideas (or prolixity, less severely) where each thought is associated with the next, but highly accelerated with no goal Decelerated tempo of thought: eg depression, may have low speech rate, no spontaneous speech SCITZO thought disorder Snapping off: sudden unintentional stop in train of thought (explained as thought withdrawal) Derailment: Knight's move thinking - total break in chain of associations of thoughts Fusion: 2+ related ideas come together to form 1 Muddling: mixture of fusion and derailment - Drivelling Catatonia: stupor, catalepsy, waxy flexibility/rigidity, mutism, negativism (opposition to stimuli/instructions), posturing, echopraxia/lalia, agitation, mannerisms/stereotypy

Other paed

Speech and language delay: slower development, but in correct sequence SAL disorder: not in correct sequence. For both, see SALT Learning disorders Reading disorders (dyslexia): difficulty reading with phonological processing deficit (4% of school kids, male) Rx 1:1 remedial teaching + parental involvement Disorder of written expression: often coexists w/ dyslexia, difficulties spelling, syntax, grammar, composition. Difficulty with narrative->expository shift in writing assignments Mathematics disorder: female, associated with visuospatial deficits (R parietal dysfunction) Developmental co-ordination disorder (DCD): aka dyspraxia - difficulties with organisation, planning and execution of physical movement. Can be part of DAMP syndrome (Deficits in Attention, Motor control and Perception) ELIMINATION DISORDERS Enuresis: psychoeducation (ERIC) Nocturnal: enuresis alarms, night lifting, reward systems/star charts, medication (desmopressin, imipramine, oxybutynin) Diurnal: body alarms, meds, psych (eg anxiety managemnt if due to fear of toilet) Encopresis: 95% have functional constipation with retention and overflow. Physical (loss of sensation) and psych (fear of toilet/pain on defecation) factors. Rx psychoeducation, family therapy (Sneaky Poo), star charts, meds (laxatives) Pica: >1mo eating non-nutritive substances at >1yo (dirt, stones, hair, faeces, plastic, paper, wood, string). Associated with developmental disability, may cause toxicity, infection, GIT obstruction/ulceration Rumination: voluntary or involuntary regurgitation and rechewing of partially digested food. Start mins post-prandial, lasts 1-2h, appears effortless preceded by belching. Onset 3-6mo age, lasts months then spontaneously remits. Weight loss, halitosis, dental decay, aspiration, recurrent RTIs, asphyxiation and death (10%). Rx behavioural methods, nutritional advice EATING DISORDERS Food avoidance emotional disorder: food avoidance + weight loss w/o abnormal cognitions about weight/shape. Usually know they are underweight, want to get heavier but can't Selective eating: long-standing restriction of types of food eaten Pervasive refusal: rare - profound and pervasive refusal to eat, walk, talk or engage in self care. Rx inpt admission Paediatric autoimmune neurological disorder associated with streptococcus (PANDAS): associated with OCD/tic disorders. Orepubertal onset of episodic exacerbation of symptoms with evidence of GAS

Psychoanalysis

Topographical model of the mind: unconscious (censored thoughts), preconscious (subconscious) and conscious (only one we have awareness of) - quickly moved on to Structural model of the mind: the id ("the it")- wishes to persue desires regardless of consequences (unconscious), the ego ("the me") - emerges in infancy, mostly conscious, negotiates desire of Id, hold of reality and superego. the superego ("the conscience") - conscious and unconscious internalisation of morals/strictures of parents/society, informing acceptability of behaviours. Disease comes from inability of ego to balance id and superego Drive theory: basic drives. Libido (sexual drive), eros (drive to live), thanatos (drive to die). Pleasure principle (drive to avoid pain and experience pleasure) Transference: unconscious development of feelings/thoughts/behaviour from pt towards therapist which recapitulate early life relationships (most commonly w/ parents) to defend against reality of relationship w/ others Countertransference: equivalent reaction of therapist towards pt - now used to describe all preconceived notions therapists have about pts Dreams: mix of daytime memories, nocturnal stimuli and primary process thinking - accessing subconscious which has no negation, no sense of time, and many concepts expressed symbolically Secondary process thinking: (pre)conscious mind, linear, word-oriented, oriented to time Parapraxis: Freudian slip revealing unconscious desires Free association: therapists says word, pt says first thing that comes to mind, then association explored - trying to access unconscious Resistance: blocks to free association (forgetting/changing subject) demonstrate where psych problems present - then try to make unconscious conscious (where it is, let ego be) Evenly suspended attention: required for therapist during free association. No response is more important than any other Theory of psychosexual development (how libido develops) Oral phase (0-1.5y): pleasure from suckling/oral investigation of objects. Conflict - love of breast, urge to bite Anal phase (1.5-3y): pleasure from anal sensations, production and withholding of faeces. Conflict - avoid shame of encopresis, avoid faecal retention Phallic phase (3-4y): pleasure by manipulation of penis. Girl conflict - "penis envy" leading to feelings of inferiority Oedipal phase (4-6y): sex with opposite parent, killing other. Boys oedipus complex (love for mother v fear of castration by father - castration anxiety), girls Electra complex (attachment to father due to desire for baby) Latency phase (6y-puberty): quiescence of sexual thoughts Genital phase (from puberty onwards): fully developed sexual drive. Improper resolution of previous conflicts manifest now. Object relations theory: relationships are mor important than drives. Early relationships (esp w/ mother) drive psychological development. Therapist must be a blank page to allow transference - and so an understanding of pt's early relationships - to occur

Sex chromosomes LD

Turner's syndrome: 45XO female, LD rare (usually normal IQ) Trisomy X: 47 XXX female. Increased height, LD. ?reduced fertility, increaased schizo risk Klinefelter's XYY: "supermale", higher incidence in prison, IQ lower than average, behavioural problems

Bipolar affective disorder

aka manic depression Mania: elevated mood and >=3 of increased energy (overactivity, reduced need for sleep), thought disorder (pressured speech, flight of ideas, racing thoughts), increased self esteem (overoptimistic ideation, grandiosity, reduced social inhibitions, over-familiarity, facetiousness), reduced attention/distractibility, risk behaviour (extravagant impracticable schemes - preoccupation can lead to self neglect, reckless spending, inappropriate sex), behaviour (excitement, irritability, aggressiveness, suspiciousness), marked social/occupational disruption, psychosis (grandiose/persecutory delusions, manic stupor, loss of insight) Hypomania: >=3 for 4d, not requiring admission, no psychosis, not interfering with social/occupational functioning. Mildly elevated/irritable mood, increased energy/activity, marked well-being/physical+mental efficiency, increased self esteem, sociability/talkativeness/overfamiliarity, increased sex drive, reduced need for sleep, difficulty in focusing (tasks started but not finished) Mixed: both (hypo)manic + depressive symptoms simultaneouslu. eg depression + pressured speech, mania + agitation/loss of libido, dysphoria + manic symptoms (-elevated mood), rapid cycling Bipolar spectrum disorder: >=1 major depressive episode with FHx of bipolar or antidepressant-induced (hypo)mania, but not spontaneous. Rx anti-depressants bad, try mood-stabiliser (valproate) Cycothymia: numerous periods of mild depression and elation, not severe/prolonged enough for bipolar/depression, with no normal state inbetween (sine wave), usually young adult. Rx psychoeducation, psychotherapy. Consider trial of mood stabiliser (lithium, valproate, carbamezapine, lamotrigine) Bipolar affective disorder 1: >=2 episodes with complete recovery inbetween. >=1 manic episode BAD 2 (have to be adult): >=1 depressive episode, >=1 hypomanic episode 70% heritability Originally takes >5y between episodes, but then episodes accelerate with age. 7% don't recur w/ Rx, 45% reduced, 40% resistant. DDx thyroid, substance abuse, ADHD, PD Rx: maintain regular sleep patterns, try to identify pre-episode prodrome. Admit if risk of harm to self (indirect through overspending, sex, substance abuse) or others, severe symptoms Psychotic symptoms: antipsychotic with mood stabilising properties (olanzapine, quetiapine) or + mood stabiliser (valproate, lithium). ECT if severe Manic stupor: admit, ECT/BZD with mood stabilising antipsychotic Mania: 1st line SGA (particularly risperidone, haloperidol, olanzapine), 2nd line mood stabiliser (valproate, lithium - takes 3w to have effect), 3rd line anticonvulsants (lamotrigine, carbamezapine, topiramate) Depression: 1st line quetiapine (if not already on antipsychotic) or SSRI, 2nd line other antidepressants. If severe/lifethreatening, ECT 1st. Taper after 8-12w Maintenance: 1st line Lithium. Not great for rapid cycling of mixed episodes. 2nd line Carbamezapine. 3rd Aripiprazole/quetiapine (if used successfully to manage acute mania, but lowest effective dose). Valproate v. commonly used off license, along with lamotragine/other anticonvulsants, antipsychotics, etc. Maintenance is indefinite Non-pharma: psychoeducation (v important), CBT, interpersonal and social rhythm therapy (IPT/SRT - helps maintain regular pattern of activities), family-focused therapy (FFT), support groups

Functional syndromes

Body dysmorphic disorder: preoccupation w/ belief that some aspect of physical appearance markedly abnormal, unattractive or diseased - overvalued idea. Commonly face, head, 2ndary sexual characteristics - believe that is noticable to others, may become delusional. May have skin picking, rubbing, topical applications of affected area, causing more problems. Onset early adolescence. Rx don't operate (plastic surgery generally leads to new preoccupation about scar/other tissue). SSRI, if delusional antipsychotic. CBT Chronic fatigue syndrome/myalgic encephalomyelitis: severe fatigue unrelated to exertion/triggered by minimal activity. Also myalgias, arthralgias, headaches, sleep disturbance, difficulty concentrating. May have onset with viral infection (pharyngitis, fever, tender cervical lymphadenopathy) Factitious disorder (Munchausen's): intentionally falsify symptoms/signs of mental/physical disorder to obtain medical attention Wandering: males moving from hospital to hospital with dramatic and fantastic stories Non-wandering: female paramedics, less dramatic By proxy: female mothers/carers/nursing staff simulate/prolong illness in dependants - emergency, prevent harm to dependant Malingering: purposefully made up for benefit (eg controlled drugs, compensation, avoiding service) Commonly self-induced infection, self-medication. Rx try to challenge w/ evidence, if doesn't work put on Munchausen's register

Other mood procedures

ECT: for severe depression, catatonia and mania. Safe in pregnancy During: gastric aspiration, dental injury due to masseter stimulation (bite block used), cortisol release (beware DM), raised IOP (glaucoma) Early: short-term retrograde amnesia, usually resolves. Headache, temporary confusion, N+V, clumsiness, muscle aches Late: loss of long term memory. Can be limited by using unilateral therapy on non-dominant lobes and pulse instead of sine wave admnisitration Neurosurgery for mental disorder (NMD): severe mood/anxiety disorders, OCD. Pt must provide informed consent and all other Rx must be tried and failed. Done with stereotactic RFA. Stereotactic subcaudate tractotomy (SST), anterior cingulotomy (ACING), stereotactic limbic leucotomy (SLL - SST + ACING), anterior capsulotomy (ACAPS). Can cause post-op confusion, incontinence, apathy, weight gain, seizures EXPERIMENTAL repetitive transcranial magnetic stimulation (rTMS): experimental therapy for refractory depression Magneto-convulsive therapy (MCT): ECT but using magnetic field, so reduced memory impairment Vagus nerve stimulation (VNS): low evidence Rx for depression DBS: experimental Rx for OCD (anterior limb of internal capsule - ACAPS) and depression (subgenual cingulate gyrus - ACING). May cause jaw tingling, throbbing/buzzing sensations, nausea. Promising

Male dysfunction

Erectile failure: inability to develop/maintain erection, leading to failure of intercourse. Primar (never had), Secondary (was able to before), Situational (sometimes), Total (never) Rx: exclude physical causes. Education, self-help exercises (ideally with partner). Meds/surgery found elsewhere Orgasmic dysfunction: rare. Reduce performance anxiety, increase arousal/physical stimulation, sensate focus, education Premature ejaculation: immediately after penetration or before achieving erection. Rx Education, reduce performance anxiety, self-help (stop-start or squeeze technique within sensate focus) Non-organis dyspareunia: usually physical cause. If not, reassurance, education, CBT Paraphilias: Encourage to develop normal relationships/fantasies, address any feelings of sexual inadequacy, develop interests/activities/relationships to fill time previously taken up by paraphilia. Ix: penile plethysmography, polygraphy, visual reaction times Rx: SSRIs, hormonal therapies, psychoanalysis, CBT

Paediatric therapies

FAMILY THERAPY Structural: deals with disruption to hierarchies, subsystems, boundaries Strategic: Problems with interpersonal interactions between family members, family given tasts Milan systemic: emphasis on family beliefs (no objective truth), team behind screen, therapist takes non-expert stance Brief solution focused: focus on goals and solutions Narrative: changing narrative about life, facilitating new perspective. May get team to act out a previously described situation to give family new perspective Parent management training (PMT): Parents taught to use positive reinforcement contingently, frequently and immediately in response to good child behaviours, and mild punishment for bad. Hands-on practices/rehearsals are used. Main component in OBD Rx

Female dysfunction

Failure of genital response: vaginal dryness due to psych (anxiety), physical (infection), oestrogen def (post-men), or due to loss of sexual desire. Rx increasing arousal during sex, lubes, addressing secondary factors Orgasmic dysfunction: most common, orgasm delayed or does not occur at all, despite normal arousal/excitement. Primary (never had), secondary (previously able, not now), situational (only sometimes) or total (always). Simple cases can be sent for directed self-help program (directed masturbation, sensate focus for couples, Kegel's pelvic floor exercises, use of sexual fantasy). For more complex, specialist sex therapist Non-organic vagismus: pelvic floor muscle spasm making penetration painful or impossible. Due to anxiety or fears (of pain, sexual assault, sex, judgement from parents, pregnancy/labour) - pain reinforces fear, vicious circle Rx: expert. Education, relaxation techniques, self-exploration, Kegel's exercises, graded trainers, sensate focus exercises with graded attempts at intercourse Non-organic dyspareunia: superficial or deep. Rx educate (positions that avoid deep penetration), relaxation techniques (Kegel exercises), positive self-talk. If complex, specialist. If PMS-like symptoms after sex, may be pelvic congestion syndrome (due to preorgasmic accumulation of blood, relieved by orgasm)

Non-genetic LD

Fetal alcohol syndrome (FAS): major cause of LD (10-20%). Postnatal alcohol withdrawal syndrome, microcephaly, face (small eye fissures, epicanthic folds, short palpebral fissure, small maxilla/mandible, underdeveloped philtrum, cleft palate, thin upper lip, small overall length, joint deformities, mild LD, behaviour (hyperactivity, sleep problems), optic nerve hypoplasia, hearing loss, receptive + expressive language deficits, ASD, VSD, renal hypoplasia, bladder diverticuli Iodine deficiency disease: most common cause of LD Congenital hypothyroidism: cretinism. Screened for, but if untreated -> lethargy, difficult feeding, constipation, macroglossia, umbilical hernia Toxins: cocaine, lead bilirubin, coumarin anticoagulants, phenytoin Infections: ToRCH, syphilis Hypoxic damage: placental insufficiency, pre-eclampsia, birth trauma, severe prematurity, multiple pregnancy CNS: micro/macrocephaly, spina bifida, hydrocephalus, craniostenosis, callosal agenesis, lissencephalies, holoprosencephaly

Hyperventilation syndrome

HVS. Emotional distress, lactate, caffeine, cholecystokinin, CO2. 35% have panic disorder. Use accessory muscles to breathe, (hyperinflation), so when stressor comes they feel dyspnoeic (no reserve), leading to anxiety - viscious cycle Cardiac: CP (may last hours, relieved by exercise not GTN), ECG changes (prolonged QT, ST depression/elevation, T wave inversion) Resp: tachypnoea, wheeze (low PCO2 causes bronchospasm) CNS (hypercapnea -induced low CBF): dizziness, weakness, confusion, depersonalisation, visual hallucinations, paraesthesias, peri-oral numbness, syncope, seizure GI: bloating, belching, flatus, epigastric pressure (aerophagia), dry mouth (mouth breathing, anxiety) Metabolic (metabolic alkalosis): acute hypocalcaemia, hypokalaemia, hypophosphataemia Acute: reassure (most spontaneously resolve within 30min), BDZ, establish normal breathing pattern Further: education/formal breathing changes, bbclockers and/or BDZs

Mental hospitals

High security hospitals: 5 in total, most have committed offences, 500 beds ea. Pts must pose immediate grave danger to public E+W: broadmoor (south), ashworth, rampton (north) NI+S: Carstairs RoI: Dundrum Medium security unit: locked ward with secure perimeter, <2y admission. Many in E+W, but fewer in NI+S (may be sent to Carstairs) Low security unit: ward with locked door. Intensive psychiatric care unit (IPCU) are short stay low security wards for care of acutely disturbed psychiatric pts Local prison: remand or <2y sentence Training prison: >2y sentence Prisoners categorised A-D (D lowest risk), sex segregated

Other substances

Injection: local abscess, cellulitis, osteomyelitis, endocarditis, sepsis, BBV (HBV, HCV, HIV). Rx new needles+syringes each time (local needle exchange, if not possible flush with bleach), sterile water (eg cold tap), rotate injection site avoiding infected skin/neck/groin/breast, ensure drug completely dissolved and injected with direction of blood flow Heroin: £50-100/g, use 0.25-2g/d. Smoked (chasing), occassionally snorted or taken parenterally (IV/IM/SC). Intense relaxation, euphoria. N+V, constipation, resp depression, LOC w/ aspiration (most common cause of mortality). Dependency after weeks, withdrawal unpleasant (sweating, mydriasis, tachycardia, HTN, piloerection (goose flesh), watering eyes/nose, yawning, abdo cramping, N+V, diarrhoea, tremor, arthralgia/myalgia) but not dangerous (6-24h after last dose, peak 2-3d, last 1w) Opioid Rx: for withdrawal - lofexidine (alpha agonist), loperamide, metaclopramide, ibuprofen. Substitute - methadone (>80mg completely saturates receptors - no further effect. coloured liquid), buprenorphine (partial opiate agonist), relapse prevention - naltrexone If travelling abroad with >500mg, license needed from home office BDZ: usually temazepam, diazepam or flunitrazepam (Rohypnol). Forgetfulness, drowsiness, impaired concentration/coordination, limb ischaemia (IV melted tablets). Chronically impaired conc + memory, depressed mood. Dependency in 3-6w, withdrawl (anxiety, insomnia, tremor, agitation, headache, nausea, diaphoresis, depersonalisation, seizures, delerium) Rx: substitute - diazepam. No role for maintenance, must be dose reducing (max 30mg/d) GHB: intrinsic neurotransmitter. dissociation, euphoria, intoxication. N+V, resp depression, seizures. Dependency rare (require multiple/d) but withdrawal causes emergency (delerium, severe behavioural distubrance, psychosis, autonomic instability, AKI) Rx reducing BDZ and baclofen reigime Cocaine: Blocks D,5HT,NA reuptake. Cocaine hydrochloride inhaled, freebase (crack/alkalinised to remove hydrochloride) cocaine smoked. Inhaled due to rapid first pass liver metabolism. Energy, confidence, euphoria, diminished need for sleep, but rapid fall-off of effects due to liver metabolism -> addiction. Arrhythmias, intense anxiety, HTN -> CVA, acute impulsivity, impaired judgement. Chronically necrosis of nasal septum, fetal damage (crack baby), panic/anxiety disorders, persecutory delusions, psychosis. Not generally associated with dependence Amfetamines: Similar to NA and dopamine. longer acting, milder version of cocaine. tachycardia, arrhythmias, hyperpyrexia, irritability, post-use depression, quasi-psychotic state w/ hallucinations. No dependency, but psychological addiction rife MDMA/ecstacy: Causes serotonin release, blocks uptake. PO, ~30min after taking - increased camaraderie/closeness to others, pleasurable agitation relieved by dancing, decreased fatigue - lasts 3h, then hangover 24-48h after (fatigue, anorexia, low mood). Sweating, N+V, reduced potency despite increased libido. Mortality with dehydration and hyperthermia. Chronically neuro/hepatotoxicity. Tolerance but no dependency LSD: Similar to serotonin. Hofman accidently ingested at Sandoz pharmaceuticals, found in Morning Glory seeds. Within 15-30min initial euphoria, detachment, sense of novelty in familiar/wonder at normal, visual distortions, misperceptions, synaesthesia, distorted body image, dizziness, tremors. Acutely behavioural toxicity (believe they can fly, so jump out of building), bad trips. Chronically flashbacks (many years after tripping), post-hallucinogenic perceptual disorder, persistent psychosis/anxiety/depression. No danger of OD or dependence, if admitted psychotic BDZs to calm PCP: Rarely seen in UK. opioid and aspartate agonist causing serotinergic and cholinergic effects (confusion, visual distortions, aggression, sudden severe violence Magic mushrooms: several varieties, most common liberty cap (Psilocybe semilanceata). Eaten raw, cooked, dried, or as drink. Possession and consumption of unrefined shrooms is legal. Small doses cause euphoria, >25 shrooms cause perceptual abnormalities similar to LSD. No dependence, tolerance develops quickly (continuous use impossible). N+V, dizziness, diarrhoea, abdo cramps, behavioural toxicity Ketamine: PCP-like, anaesthetic but no RAS depression, just prevents cortical awareness of pain. Sniffed, small amounts - dissociation, large - LSDlike synaesthesia/hallucinations. N+V, ataxia/slurred speech, rarely flashbacks, psychosis, amnesic syndromes Cannabis: Cannabis Sativa herbal material (grass/marijuana), resin (hash) or oil. THC agonist of canabinoid receptors (anandamine endogenous version). Mild euphoria (the giggles), sense of enhanced wellbeing, subjective enhanced sensation, relaxation, altered time sense, increased appetite (the munchies), tachycardia, dysarthria, ataxia. Acutely mild paranoia, panic attacks, delayed reaction time. Chronic dysthymia, anxious/depressive illness, amotivational syndrome (disputed). Can precipitate episode/relapse of schizophrenia. No dependency but mild withdrawal (insomnia, anxiety, irritability)Urine test stays +ve for 4w Volatile substances: acetone, toluene, xylene, butane. Found in variety of common things (petrol, glue, lighter fluid, etc). Euphoria, disinhibition, slurred speech, blurred vision with misperceptions. Acutely headache, arrhythmia, acute suffocation (bag or laryngeal oedema), LOC, aspiration, sudden death. Chronically liver/kidney damage, memory/concentration impairment. Withdrawal similar to alcohol Anabolic steroids: nandrolone, stanozolol. Increased muscle mass/strength, increased training time, reduced recovery time, euphoriant effects, sense of increased energy levels. HTN, hypogonadism, gynaecomastia, amenorrhoea, liver damage, impotence, alopecia, acute emotional instability (roid rage), aggression, persecutory/grandiose delusions, depression Legal highs: eg mephadrone (M-CAT, meow-meow), now illegal Substitute prescriptions: must have daily use w/ dependence syndrome, +ve urine >twice >1w apart, and must have symptoms of withdrawal syndrome at time of prescribing

Interpersonal therapy`

Interpersonal therapy (IPT): focuses on interpersonal functioning. 12-16 1h sessions. Focuses on one of: role transitions, interpersonal disputes, grief or interpersonal deficits (long-standing difficulties with unfulfilling relationships and impoverished social environment). Different techniques for each focus set out in IPT manual. Use of psychotropic medication is encouraged. NOT FOR PD OR SUBSTANCE ABUSE Dialectical behaviour therapy (DBT): Rx for BPD (usually due to invalidating environment - child's experiences and emotions consistently disqualified or invalidated by others, so original difficulties w/ problem solving and self control aren't sorted. Later in life this leads to setting unrealistic goals, then not achieving them, causing shame and DSI. Complex Rx involving CBT-esque and eastern meditative (mindfulness) components. Can be individual or group Stage 1: focus on life-threatening behaviour (DSI, suicide ideation), then on therapy-interfering behaviour (DNAs, overuse of telephone clinic), then on QoL-interfering behaviour (substance misuse, interpersonal conflicts) Stage 2: focus on emotional processing of previous traumatic experiences Stage 3: develop self-esteem, establish future goals Cognitive analytic therapy (CAT): attempts to explain psychoanalytic ideas in cognitive terms. Traumatic experiences in early life give way to coping mechanisms which are maintained into adulthood by neurotic repetition (3 patterns: traps - negative assumptions drive behaviour which causes -ve consequences so reinforce, Dilemmas - forms false dichotomy so resists change, Snags - goals/role abandoned as others would oppose or 'forbidden'). To solve, 3 Rs (recognition, reformulation, revision) Solution-focused therapy: empower pts to recognise and capitulate on own strengths (aka brief, can be 1 session) to overcome current difficulties. Tries to avoid in-depth discussion about current problems, just asks about best potential future and how to get there Supportive/Counselling: 3 components - psychoeducation, active listening and problem solving advice (may be borrowed from others eg CBT). Only difference is risk counselling, where the counsellor must be an expert (not just a listener)

Learning disability

LD, IQ <70 is indicator. Defect in intellectual function confirmed by IQ and conceptual (language, reading, writing, maths, reasoning, knowledge, memory), social (empathy, social judgement, communication skills, friendships), practical (personal care, job responsibilities, money management) deficits Subcultural: normal for family and culture (low SEC), no dysmorphic features, no functional impairment Minor: delay in acquiring speech but eventually able to use everyday speech, can self-care and sometimes work but academically challenged, most no organic aetiology Moderate: permanent deficit in language/numeracy and comprehention, sometimes can do simple supervised occupation, most organic Severe: marked motor impairment, low visuospatial, language, social skills Profound: severe neuro and physical disability, almost no skills, comprehension or language Improve sensory deficits (glasses, HAs) and communication (PECS, Makaton, sign language). Generally try to keep at home/mainstream schools but may require admission to specialist environments Behavioural and cognitive therapies (CBT)

Mood stabilisers

Lithium Dose-related ADRs: DI, weight gain, cognitive problems (dulling, impaired memory, poor conc), tremor, sedation, ataxia, GI distress (N+V+D, dyspepsia), hair loss, acne, oedema. Lower or split dose. On ECG causes T wave changes, QRS widening, can exacerbate arrhythmia Long-term ADRs: Renal (interstitial fibrosis), hypothyroidism, teratogenic (Ebstein anomaly, DI, floppy baby syndrome. May be maintained during pregnancy if severe risk of relapse, otherwise stop) Monitoring: 12h post-dose serum lithium. <1.2mmol/L, >1.5 toxic, >2 life threatening Toxicity: tremor, anorexia, N+V+D (bloody). Then severe neuro (myoclonic jerks/fasciculation, choreoathetoid movements, hypertonicity) progressing to ataxia, dysarthria, drowsiness and confusion. Finally arrhythmia, hypotension, seizures, stupor, coma, death. If severe toxicity, forced diuresis with IVNS, or haemodialysis Carbamezapine toxicity: diziness, ataxia, sedation diplopia. Then nystagmus, ophthalmoplegia, EPS, LOC, seizures, circulatory collapse. >6g fatal

Normal sleep variants

Long sleeper: >10h, may have EDS w/ less Short sleeper: <5h Snoring Somniloquy: sleep talking. Uttering words or sounds w/o awareness, usually devoid of meaning PSG: brief partial arousal during NREM (rarely during REM if dream-related) Hypnic jerks (sleep starts): sleep onset, sudden abrupt muscle contraction wakening pt with siderealism (sensation of falling in space). Prevalence 60-70% Benign sleep myoclonus of infancy: myoclonic jerks <6mo old, resolves spontaneously Hypnagogic foot tremor and alternating leg muscle activation Propriospinal myoclonus at sleep onset: recurrent sudden muscular jerks in wake->sleep transition, can cause severe sleep-onset insomnia Excessive fragmentary myoclonus: small muscle twitches in fingers, toes, corner of mouth, not enough for joint movement, incidental PSG finding

CBT

COGNITIONS Automatic thoughts: most superficial and accessible - plausible but distorted. My friend cancelled, she must not like me Underlying assumptions: 'rules' for behaving (I can't enjoy myself w/o other people) Schema/core belief: most fundamental beliefs about pt and world (eg "I am unloveable") COGNITIVE ERRORS Selective abstraction: drawing conclusion from isolated part of information (dessert went wrong, so dinner disaster) Arbitrary inference: drawing unjustified conclusion (my partner is stressed - she's about to leave me) All or nothing thinking: seeing in extremes of black and white (must win or else I'm a failure) Magnification/minimisation: emphasising negatives, playing down positives Disqualifying positives: I only came first by chance Personalisation: assuming responsibility for all negative events (sister in bad mood, I must have angered her) Catastrophic thinking: "I embarrassed myself, I'll never show my face to them again" Over-generalisation: single -ve event as norm (made mistake, so I'm incompetent) Emotional reasoning: using emotions as evidence (I'm anxious, so that spider must be dangerous) Jumping to conclusions: mindreading/fortune telling (I know the exam will ask the topics I haven't had time to study) SPECIFIC TECHNIQUES Depression: activity/thoughts diary with scheduled activity/pleasant event scheduling Anxiety: anxiety diary, relaxation techniques (eg breathing), graded exposure (systemic desensitisation) General: identify cognitive errors in automatic thoughts and challenge them (can even do behavioural experiments - eg ask pt to have coffee w/ friend and ask if they really don't want anything to do with them, or trap pt in stressful situation to show anxiety won't continue to rise), present rational alternative thought patterns

Medically unexplained symptoms

(MUS) Somatisation disorder: repeated MUS affecting multiple organ systems, onset <40yo. Chronic in adults, less so in children. If v serious Briquet's syndrome. Fat file, pts life revolves around illness - usually one organ system, then investigations exhausted, then switch to next. 2/3 psychiatric comorbidity (depression/anxiety most common - may attribute to pain). RF: FHx, childhood abuse Somatoform pain disorder: persistent severe unexplained pain. many psychiatric comorbidity Conversion/dissociative disorders: unexplained loss/disturbance of normal sensory or motor function. Paralysis (flaccid, but synergistic movement intact - eg +ve Hoover's), aphonia (loss of speech, may be able to whisper, comprehension/writing fully intact), sensory loss (matching pts beliefs about anatomy), Seizures (non-epileptiform), amnesia (generally patchy and selective, recovery w/ realisation of forgotten trauma), Fugue (dissociative amnesia + travel to far away place with amnesia of journey - although functioned normally during trip. May forget many personal details, associated with recovery and realisation of trauma) Hypochondriasis: preoccupation with idea of having a serious medical condition. Normal variants/minor ailments interpreted as signs. Not a delusion! Pt can accept fears are groundless - overvalued idea. If delusional treat for delusional disorder. >50% have GAD Rx Psych: behavioural therapy, CBT, IPT, FT, biofeedback Pharma: some weak evidence for antidepressants

Scitzophrenia

1% prevalence RF: pregnancy/neonatal complications, neurodevelopmental/behavioural childhood difficulties, severe maternal malnutrition/influenza during pregnancy, urbanisation at birth, use of cannabis during adolescence May have prodrome of non-specific or negative symptoms. Then have first acute episode late adolescence/early adult requiring admission. Then relapse (can be spontaneous, but usually non-compliance, substance misuse or life stress) Positive: delusions, hallucination, thought disorder Negative: loss of volition motivation and spontaneous behaviour, social awareness. Social withdrawal, blunting of mood/affect, anhedonia FIRST RANK Auditory hallucinations: voices arguing, thought echo, running commentary Delusions of Thought interference: thought insertion/withdrawal/broadcasting Control: passivity of affect/impulse/volition/somatic Perception SCITZO TYPES Paranoid: delusions + hallucinations Hebephrenic: disorganised speech, flat/inappropriate affect Catatonic: psychomotor disturbance Simple: only negative, gradual onset, no acute episodes Residual: previous positive, but now gone and left with negative Post-schizo depression Undifferentiated: no subtype predominates PO antipsychotic (depot if Hx of recurrences due to non-compliance). Discuss risk (EPS, weight gain, others) and benefits. Don't combine. If >2 don't work (1 must be SGA), try clozapine Usually either SGA (olanzapine, amisulpride, risperidone, quetiapine) and BDZ (diazepam), OR a sedating FGA (chlorpromazine, not trifluoperazine, flupenthixol, haloperidol) which will also sedate. Anticholinergics (procyclidine) or amantadine for Parkinsonian ADRs. 70% have acute depression, TCA>SSRI ONCE acute phase has passed (3-9mo), find minimal effective dose for maintenance 15-20% only have first episode (no recurrence) 55% show good social functioning at 13y f/u

Cognitive tests

6-item cognitive impairment test (6CIT): used in EASYCare standard assessment of elderly wellbeing for GPs. Score>8/28 cognitive impairment Abbreviated mental state test (AMT): rapid screening for cognitive impairment MMSE/MOCA: detailed <23/30 cognitive impairment Addenbrooke's cognitive examination (ACE-III): 100-item test with 94% sensitivity for dementia Frontal assessment battery (FAB): 10min executive function test. <12/18 = frontotemporal (not AD) Wisconsin card sorting task: allocate cards according to some rule Digit span: repeat digits back. 6+/-1 for forward, 5+/-1 for backwards Trail making test: eg q1 on MOCA. Can be simple number sequence or numbers and letters Cognitive estimate testing: q that requires abstract reasoning, not in semantic memory (how many camels in the UK?)

Generalised anxiety disorder

>=3 of restlessness/feeling keyed up/on edge, easy fatigueability, concentration difficulty/mind going blank, irritability, muscle tension, sleep disturbance. Present most days for >6mo. May also have classic panic symptoms Children: headache, stomach pain, tachycardia, SOB, nail biting, hair pulling, school refusal Psychotherapy (CBT) less effective due to lack of situational triggers Psycho: buspirone Somatic: BDZ Depressive: TCA, trazodone, SNRI, SSRI CVS/autonomic: bblocker (pregabalin alternative) V. rarely NMD if severe and intractable Prognosis poor, chronic and disabling with low remission rates

Substance misuse disorders

Acute intoxication At-risk use: eg drunk driving Harmful use: use despite damage to pt's physical/mental/social wellbeing Dependence: physical and psychological addiction. Primacy of drug-seeking behaviour (salience, drug becomes most important in life), narrowing of range of drugs taken, tolerance, loss of control of consumption, withdrawal signs (with drug taking to avoid), continued harmful use, rapid reinstatement of behaviour with relapse Substance-induced psychotic disorder: hallucinations and/or delusions associated with withdrawal or toxicity Cognitive impairment syndromes: temporary (during intoxication) or permanent chronic (alcohol, volatile chemicals, BDZ, ?cannabis) Withdrawal: alcohol, opiates, nicotine, BDZ, amfetamines, cocaine Residual disorders: alcoholic hallucinosis, persisting drug-induced psychosis, LSD flashbacks - continuing symptoms despite abstinence Rx precontemplation -> contemplation -> decision -> action -> maintenance -> relapse -> precontemplation (cycle, w/ each cycle new methods learnt so maintenance becomes longer) Harm reduction: if abstinence not feasible, advice safer sex/injecting practice, or provide maintenance BZD/opiates Drug testing and treatment orders (DTTO): form of community sentence forcing offenders to attend drug-treatment service, monitored by urine sampling

Phobias

Agoraphobia: anxiety/panic symptoms associated with places/situations where escape would be difficult/embarrassing. May be 2ndary to med problems (eg incontinence) Rx as for panic disorder, but BDZ not used as may reinfornce avoidance. Behavioural methods (exposure techniques, relaxation training) Phobias: recurring excessive unreasonable anxiety in the presence of specific feared object/situation. 80% will develop another psychiatric disorder. Rx behavioural (exposure - Wolpe's systematic desensitisation, VR exposure), cognitive (anxiety education/management, coping skills), pharma not used unless exposure absolutely necessary before psycho has time to work (BZDs) Social phobia: symptoms of incapacitating anxiety 2ndary to particular social situations. Blushing, trembling, dry mouth, perspiration, excessive fear of humiliation, embarassment, and others noticing anxiety. Usually pts self critical and perfectionist. May lead to poor social, educational and occupational functioning. Rx CBT (relaxation training, exposure), bblockers (autonomic arousal), SSRI, SNRI/MAOI. RIMA/BDZ are alternatives. 90% respond, indefinite maintenance Separation anxiety: normal at certain stages of development, but if older abnormal. Anxiety about actual/anticipated separation from attachment figure, sleep disturbances/nightmares, somatisation, school refusal Selective mutism (SM): consistent failure to speak in social situations when expected, but normal speech otherwise. Difficult to treat, behavioural therapy, CBT, SRRIs, psychotherapy

Sleep - drugs

Alcohol: sedative, at first reduces sleep latency, increases N3 but then increases REM in 2nd half with sleep disruption and intense dreams/nightmares. Withdrawal causes high sleep latency, reduced sleep duration with loss of N3 and increased REM Nicotine: insomnia, increased REM with intense dreams (esp patches) Cannabis: hypnotic Opiates: hypnotic, but sleep disruption with misuse Stimulants: disturb sleep. MDMA causes daytime sedation and disturbed sleep Antidepressants: TCA/TeCA sedate (nortriptyline least sedating), agomelatine promotes sleep. MAOI/SSRI/NARI/DARI/SNRI all alert, so take in morning for hypersomnolence Antipsychotics: most sedating chlorpromazine, clozapine, levomepromazine, pericyazine. Least - amisulpride, aripiprazole Li: sedates Carbamezapine/valproate: may have mild drowsiness at start, quickly resolves BDZ: sedative, but hypnotic effects cause tolerance and rebound on cessation Psychostimulants: dexamfetamine, methylphenidate, methamphetamine, mazindol, pemolie, modafinil. Disturb sleep, take in morning

Depression-like syndromes

Atypical depressive episode: depressed but reactive mood (can enjoy experiences), hypersomnia (>10h/d, >3d/w, >3mo), hyperphagia (weight gain >3kg in 3mo), leaden paralysis (heaviness of limbs, >1h/d >3d/w >3mo), oversensitivity to perceived rejection. Can have reversed diurnal variation (better in morning). Usually late teens, early 20s, FHx of affective disorders. Rx phenelzine. RIMA, SSRI, NARI are alternatives Seasonal affective disorder (SAD): January/February, annual mild low self esteem, hypersomnia, fatigue, increased appetite, weight gain, reduced social/occupational functioning. Rx light therapy (2h on waking). Response seen in 2w, then maintenance 30min every 1-2d. Can try buproprion or SSRI Dysthymia/dysthymic disorder: chronic lowgrade depressive symptoms. Rx antidepressnats (SSRI), CBT

circadian rhythm sleep disorder

Delayed sleep phase syndrome (DSPS): sleep comes late (02:00) but normal sleep time, leading to difficulty waking/insomnia. Presents in adolescence, runs to old age. Commonly take night jobs Advanced sleep phase syndrome (ASPS): early sleep onset 18:00-20:00) with evening sleepiness and early morning wakening. Common in elderly Irregular sleep wake pattern: Sleep onset and waking highly variable. Associated with AD, head injury, developmental disorders, hypothalamic tumours Non-entrained type (free running): more frequent in blind or schitzoid PD. >24h cycle, so shifts forward 1-2h/d. In phase period every few weeks with no symptoms Jet lag type: moving between timezones. Insomnia, EDS Reduced conc/attention, low mood, irritability, GI/MSK somatic symptoms Shift work type: same as jet lag, but due to shift changes. Takes 1-2w to adapt. Generally somatic complaints Ix: sleep diary, actigraphy. PSG rarely needed Lifestyle: as for insomnia. For shift workers, maintain regular sleep and mealtimes, nap to limit sleep loss Chronotherapy: establish regular schedule, phase-advance/delay methods to reset circadian rhythm, particularly for ASPS/DSPS Light therapy: DSPS (after waking), ASPS (at 16:00 to delay sleep). Suppresses sleep-promoting melatonin Pharma: appropriately timed BDZs or melatonin to entrain cardiac rhythm are effective, especially if travelling >5 eastern time zones

Idiopathic LD

Disintegrative disorder: normal development til 4yo, then profound regression - disintegration of behaviour, loss of all acquired skills (eg language), impaired social relationships, stereotypies. Prognosis severe LD Cornelia de Lange/Brachmann de Lange syndrome: Hypertrichosis (hirsutism, synophyrs, long eyelashes), face (depressed nasal bridge, eye abnormalities, prominent philtrum, thin lips, downturned mouth, anteverted nostrils, blue tinge around eyes/nose/mouth, widely spaced teeth, high arched palate, lowset ears, micrognathia, short neck), limb deformities, cryptorchidism/hypoplastic genitals, small umbilicus/nipples, low-pitched cry, GI/visual/hearing/skin problems, CHD, epilepsy, death in infancy PDDs: not Asperger's, which shows normal or raised IQ (male predominance) and normal language. High functioning autism has normal IQ but language difficulties. Normal autism LD.

Delerium

MSK: trauma/PAIN Infective: UTI, chest infection, wound abscess, cellulitis, SABE Metabolic: anaemia, electrolyte disturbance, hepatic encephalopathy, uraemia, cardiac failure, hypothermia Intracranial: CVA, head injury, encephalitis, tumour/raised ICP Endo: pituitary, (para)thyroid, adrenal disease, hypoglycaemia, DM, vit deficiencies Drugs: alcohol, BDZs, antiCh, psychotropics, lithium, antiHTN, diuretics, anticonvulsants, digoxin, steroids, NSAIDs Hypoxia: any cause Stereotyped brain response to insult. Acute onset fluctuating cognitive impairment/deterioration + behavioural abnormalities. Can be characterised as "acute brain failure" (dementia = "chronic brain failure") Impaired ability to direct, sustain, shift attention; global impairment of cognition with disorientation, recent memory and abstract thinking impairment; Sleep-wake cycle disturbance w/ nocturnal worsening; psychomotor agitation, emotional lability; perceptual distortions/illusion, characteristically visual hallucinations; rambling incoherent speech, disordered thought; poorly developed paranoid delusions; rapid onset w/ fluctuation within mins-hours. Hyperactive: prominent psychomotor agitation, increased arousal, inappropriate behaviour, hallucinations, delusions Hypoactive: psychomotor retardation, lethargy, excess somnolence Mixed: features from both 4 steps Identify cause and Rx - mortality 20% on admission, 50% within 1y, may trigger dementia Support: educate family. Adequate lighting, reduce unnecessary noise, mobilise pt when possible, correct vision/hearing, reality orientation techniques (firm clear communication + clocks and calendars) Sedation: avoid unless absolutely necessary. If needed - halperidol, lorazepam or risperidone - AVOID BDZ (worsen delerium). Start low go slow Regular review and f/u

CNS infections

Mumps, VZV, arbovirus, rubella: learning difficulties, behavioural problems, ADHD-like symptoms HSV1: encephalitis - TLE, delerium, hallucinations. Chronically Korsakoff psychosis, dementia, Kluwer-Bucy syndrome EBV: CFS/myalgic encephalitis Measles: SSPE - behavioural problems, deteriorating IQ, movement problems (ataxia, myoclonus), seizures, dementia TB meningitis: apathy, withdrawal, personality change, delerium, hallucinations, chronic behavioural problems Syphilis: GPI - grandiosity, euphoria, mania with mood-congruent delusions, disinhibition, personality change, memory impairment. Argyll robertson pupils, trombone tongue, tremor, ataxia, dysarthria, myoclonus, hyperreflexia/spasticity, EPS Encephalitis lethargica: 20y post-influenza encephalitis. Parkinsonism, oculogyric crises, pupillary abnormalities, psychoses

Parasomnia

NREM sleep/arousal Confusional arousals (sleep drunkenness): confusion during/following arousals from first cycle of deep sleep. Individuals disoriented, incoherent, hesitant, slow but walk, get dressed, perform complex motor behaviours. Violence, assault, even homicide may occur. Universal <5yo, becoming less common with age. In adults, associated with sleep deprivation, alcohol/depressant drugs. PSG shows early arousal, Rx prevent prolonged NREM sleep, restrict drug use, sleep hygeine Sleep terrors (parvor nocturnes/incubus): sudden awakening with loud terrified screaming, pt sits up rapidly, marked autonomic arousal (tachycardia/pnoea, diaphoresis, mydriasis), frenzied activity with injury. Lasts 10-15min, increased muscle tone, resistance to physical contact. If wakened incoherent, fall asleep with no memory of event. Can be precipitated by sleep deprivation, fever, depressants PSG: abrupt wakening from N3 in first third of night (children, adults whenever), with alpha activity Rx: reassure benign. If frequent, treat as sleepwalking Nocturnal panic attacks (NP): no trigger, waking from sleep in intense fear/discomfort, with autonomic arousal. May cause sleep avoidance and insomnia. Commonly have panic disorder. May be sleep deprived, withdrawing from alcohol/drugs, MVP, stimulant use PSG: N2->N3 transition awakening. Nocturnal Panic Screen Rx: CBT, pharma (no evidence, maybe TCA/alprazolam Sleepwalking (somnambulism): complex, automatic behaviours (automatisms - aimless wandering, attempting to (un)dress, carrying objects, eating/urinating in unusual places, even driving cars (usually due to Z drugs) and sex (sexomnia), with eyes wide open, glassy, incoherent talking and sometimes injury (stairs/window). Easily returned to bed and falls asleep, if awoken become confused and disoriented. Usually due to sleep deprivation/increased stress. Episodes start 15-120min after sleep onset. Precipitants as for confusional arousal PSG: episodes preceded by hypersynchronous high voltage delta waves Rx: reassure. Lock doors/windows, sleep downstairs. Avoid stress/sleep deprivation, sleep hygiene. If frequent/high risk, pre-sleed lowdose BDZ/antidepressant REM SLEEP REM sleep behavioural disorder (RSBD): vivid intense action packed violent dreams/nightmares, with dream-enacting behaviour and sleep injury/general sleep disruption. Associated with Parkinson's and narcolepsy. Rarely other psychiatric illness, drugs (TCA/MAOI/SSRI) or REM-supressor withdrawal (alcohol, amfetamine, cocaine) PSG: EMG twitching during REM Rx: ensure safe sleeping environment, Rx cause/aggravators, if problematic symptoms clonazepam controls behaviour and dreams (alternatives carb, melatonin, Ldopa, imipramine) Nightmare disorder: frightening dreams awakening from REM w/o confusion. May be preceded by irl traumatic event PSG: increased REM density lasting 10min terminated by awalening in second half of night Rx: avoid stress/drugs (baclofen, bblockers, clonidine, digoxin, verapamil)/withdrawal (alcohol, BDZ, opiates, hypnotics), sleep hygiene, pharma with REM-suppressing antidepressants (cessation will cause rebound) Recurrent isolated sleep paralysis: not able to move - hypnagogic or hypnopompic PSG: atonia in muscles despite desynchronised EEG with eye movements and blinking Rx: sleep hygiene, avoid sleep deprivation, REM suppressor (clomipramine, SSRI) OTHER Sleep-related eating disorder (SRED): 20-30yo women, recurrent episodes of involuntary eating during partial arousal. May have pica or eat toxic food (eg raw meet, pet food). Sleep disrupted with unexplained weight gain PSG: multiple confusional arousals from all phases (mainly N3) Rx: treat comorbid sleep disorders, stop precipitating drugs (zolpidem, olanzapine, risperidone), pharma (topiramate, dopaminergics, clonazepam, fluoxetine) Sleep-related dissociative disorders: Hx of physical/sexual abuse, with daytime dissociation and SHB PSG: complex behaviours - tend to be reenactmet of previous abuse - during wakefulness after a sleep cycle Rx: treat dissociative disorder. BDZs exacerbate, CI

Neuroleptic malignant syndrome

Neuroleptic malignant syndrome: rare lifethreatening idiosyncratic reaction to antipsychotics (and some antidepressants, antiCh/amantadine/LDopa and others). 5-20% mortality due to rhabdomyolysis, aspiration pneumonia, seizures, DIC Slow onset (days-weeks) Hyperthermia >38deg, muscular (lead pipe) rigidity, confusion/agitation/altered LOC, tachycardia, tachypnoea, Hyper/otension, diaphoresis, sialorrhoea, tremor, incontinence/retention/obstruction, CK, urinary myoglobin, leukocytosis, metabolic acidosis. Lasts 7-10d Stop causative drug/restart any stopped drug Acute behavioural disturbance: BDZs Support: O2, fluids for hypotension, reduce temperature Rhabdomyolysis: rapid hydration + IV NaCO3 to alkalise urine and prevent myoglobinuric renal failure Rigidity: 1st - dantrolene, lorazepam. 2nd - bromocriptine, amantidine. 3rd - nifedipine, ECT

Autosomal dominant LD

Noonan's syndrome: Many different genes (PTPN11, SOS1, KRAS). LD, short stature, CHD, hepatosplenomegaly, distinctive facies, anterior chest wall deformities (pectus carinatum/excavatum) PHAKOMATOSES (only VHL not associated w/ LD) TSC NF Sturge-Weber: Port-wine stain covering part of forehead + >=1 eyelid, angiomas of meninges on ipsilateral temporal/occipital lobe, LD, epilepsy, sometimes c/l hemiparesis. Ipsilateral buphthalmos, glaucoma

Obsessive-compulsive disorder

OCD. Associated with marked anxiety and depression, Sydenham's chorea, Tourette's. In order of prevalence: checking, washing, contamination, doubting, bodily fears, counting, insistence on symmetry, aggressive thoughts. Obsessions/compulsions must cause distress/interfere with life. Average age 20yo sudden onset after stressful event CBT: exposure and response prevention (ERP) Pharma: SSRIs first line, clomipramine 2nd line. Antipsychotics if tics, psychosis or schizotypal traits. Maintenance indefinite If suicidal/severely incapacitated ECT NMD: stereotactic cingulotomy (65% success) DBS: experimental 1/3 improve significantly, moderately or chronic worsening HOARDING DISORDER persistent difficulties in discarding possessions regardless of value. starts st 11-15yo, interferes with functioning by 20yo, clinically significant impairment by 30yo. Rx CBT, SSRI

Elderly psychosis

Old: previously stable schizo, but doc messed with drugs causing relapse NEW Paraphrenia: delusions + hallucinations, but no changes in affect, thought form or personality. Persecutory commonplace delusions (neighbours spying, entering home + moving items). Can also be referential, misidentification, hypochondriacal, religious. Hallucinations mostly auditory. Schneiderian first rank symptoms common Rx: Rx isolation/sensory deficits, hospital admission often required. Low-dose antipsychotic (elderly sensitive to ADRs) Diogenes syndrome: senile squalor syndrome. Extreme self neglect, domestic squalor, social withdrawal, apathy, compulsive hoarding (garbage or animals), lack of shame BEWARE, parasuicide usually failed suicide in elderly Elderly much more sensitive to drugs, require lower doses. Particularly sensitive to EPSEs and anti-cholinergic ADRs

Delusional disorder

Only non-bizarre delusions for >1mo Erotomanic (De Clerambault syndrome, mostly female): some important person is secretly in love with pt Grandiose: have special role/relationship/abilities Jealous (Othello syndrome, mostly male): spouse/partner has been unfaithful Persecutory: most common, others trying to harm pt Somatic: varying symptoms/requesting medical/surgical Rx. Bodily infestation, dysmorphophobia, olfactory reference syndrome Cotard: delusion that pt is dead/do not exist, usually as explanation for depersonalisation Mixed Unspecified Pts generally reticent about delusions, very difficult to interview/assess Admit if risk of harm Separate from source of delusional ideas Pharma: antipsychotics, SSRIs Psychotherapy: eg social training to not discuss delusions in public, reframe delusions as symptoms 50% remit 40% resist, 10% improve. Beware of post-psychotic depression after remission INDUCED DELUSIONAL SYNDROME (folie a deux) Folie imposee: delusions of primary psychotic pt adopted by healthy individual. Rx separation Folie simultanee: 2 psychotic pts develop same delusions at same time Folie communique: Folie imposee but with initial resistance Folie induite: pre-existing psychosis in both pts, but one adopts the other's delusions DELUSIONAL MISIDENTIFICATION SYNDROME Capgras: everyone has been replaced by identical imposter Fregoli: unknown person is someone pt knows in disguise Intermetamotphosis: can see others change form Subjective doubles: doppleganger of pt that exists and functions independently Autoscopic: doubles of pt projected onto nearby objects/people Reverse subjective double: pt is an imposter about to be physically and psychologically replaced Reverse Fregoli syndrome: others have misidentified pt Rx antipsychotics/anticonvulsants

Defense mechanisms

PRIMITIVE DEFENCE MECHANISMS Denial: pushing difficult events/subjective truths to unconscious Introjection: perception of significant figures form part of personality (eg having then becoming critical dad) Projection: attributing unacceptable internal ideas to external target (eg angry child accuses dog of being angry) Projective identification: making another take on internal unacceptable ideas (eg angry kid making mum angry) Idealisation and denigration: only good or bad (respectively) seen in people to avoid anxiety of ambivalence Splitting: separating contradictory perceptions of self or others to avoid anxiety of considering them simultaneously (pt believes doctor is amazing at one point, then terrible the next time) Acting out: acting in ways that reveal unconscious desires (eg self-harm due to disgust) Regression: stress response - revert to previous level of maturation (teenager sucking thumb around exam time NEUROTIC DEFENSE MECHANISMS Repression: preventing unacceptable aspects of internal reality from entering conscious (eg no conscious awareness of childhood abuse) Identification: taking on characteristics of another as your own (eg assaulted man may become aggressive) Intellectualisation: focus on abstract concepts, logic, intellectual reasoning to avoid painful emotions Isolation of affect: separating experience from painful emotions associated with it (eg talking about trauma w/ flat affect) Rationalisation: justify feelings/behaviour with acceptable explanation, despite knowing true explanation in unconscious (eg gone to a better place in mourners) Reaction formation: expressing behaviours opposite to unacceptable internal feelings (being extra polite to hated person) Undoing and magical thinking: undoing - action cancels out unacceptable internal impulse/previous experience. Magical thinking - attribute magical properties to behaviours (eg if I touch this 10 times I'll pass my exams - OCD) Displacement: transferring emotional response from one person to another that resembles the first (eg anger at person who looks like dad) MATURE DEFENSE MECHANISMS Humour: finding aspects of unpleasant experience funny to avoid painful emotions Altruism: attending others' needs above your own Compensation: developing abilities in one area to compensate for lack in another Sublimation: expressing unacceptable internal impulses in socially acceptable ways

Organic disease

PSYCHOSIS Neuro: epilepsy, head trauma/tumour, dementia, encephalitis, neurosyphilis, CVA Endo: thyroid imbalance, hyperparathyroidism, Cushings, Addisons Metabolic: uraemia, sodium imbalance, porphyria SLE (Lupus psychosis) Meds: steroids, levodopa, isoniazid Drugs: cocaine, LSD, canabis, PCP, amfetamines, opioids DEPRESSION Neuro: CVA, epilepsy, head tumour/trauma, dementia, MS, HUntington's, Parkinson's Infection: HIV, EBV, brucellosis Endo/Met: hypothyroidism, Cushing, Addisons, parathyroid disease, B12/folate def, porphyria Cardiac: MI, CCF Rheum: SLE, RA, cancer Meds: COCP, steroids, cimetidine, salbutamol, dopamine Drugs: alcohol, BDZ, cannabis, cocaine, opioids MANIA Neuro: CVA, epilepsy, brain tumour/trauma, MS Endo: hyperthyroidism Meds: steroids, mefloquine, interferon, isoniazid Drugs: cannabis, cocaine, amfetamines ANXIETY Neuro: epilepsy, head trauma/tumour, dementia, CVA, MS, Parkinson's CRS: COPD, CCF, angina, MVP, arrhythmias Hyperthyroidism Meds: flumazenil, fenfluramine Drugs: alcohol, BDZ, caffeine, cannabis, cocaine, LSD, MDMA, amfetamines AMNESIA Dementia/delerium Wernicke's/Korsakoff's CVA Post-traumatic amnesia (PTA): temporal lobe hits temporal bone, causing anterograde amnesia that recovers if lasts <1w HSV encephalitis/temporal lobe surgery: inability to store STM Hypoxic brain damage MS Palimpsest: alcoholic amnesia during intoxication on b/g of chronic misuse ECT: several hours of antero and retrograde amnesia Transient global amnesia (TGA): transient ischaemia of temporal lobes/diencephalon causes 6-24h amnesia. RF: >50yo, HTN, migraine Trauma: PTA, retrograde amnesia from time of injury, acute post-traumatic delerium (PTD - prolonged confusion, behavioural problems, anxiety, paranoid delusions, hallucinations), chronic (cognitive impairment, personality/behavioural change), psychosis, PTSD, CTE, post-concussional syndrome

AR LD

Phenylketonuria: Phenylalanine hydroxylase deficiency causing phenylalaninaemia + phenylketonuria. Fair hair/skin, blue eyes, neuro (stooped posture, broad-based gait, hypertonia/reflexia, tremor, stereotypies), behaviour (hyperactivity, temper tantrums, perseveration, echolalia. Dx: postnatal "Guthrie" test. Rx dietary (severe LD if untreated) Sanfilipo disease: Dysfunctional heparin sulphate breakdown. Severe LD, claw hand, dwarfism, hypertrichosis, hearing loss, hepatosplenomegaly, biconvex lumbar vertebrae, joint stiffness, behavioural (restlessness, sleep problems, challenging behaviour). Poor prognosis, most die <20yo RTI Hurler syndrome: MPS - A-L-iduronidase deficiency. Progressive LD, MSK (short stature, kyphosis, flexion deformities, claw hand, long head, characteristic facies), hearing loss, resp/cardiac issues, hepatosplenomegaly, umbilical/inguinal hernia. Poor prognosis Laurence-Moon-Beidl syndrome: Bedouins of Kuwait and Newfoundland. LD, short stature, spastic paraparesis, hypogenitalism, nyctalopia (red cone dystropy), T2DM, DI, CKD Joubert syndrome: v. rare. Severe LD, characteristic hyperpnoea ("dog panting"), cerebellar dysgenesis, hypotonia, ataxia, tongue protrusion, facial spasm, abnormal eye movements, cystic kidneys, syndactyly/polydactyly, self-injury Gaucher's: most common lysosomal storage disease - glucocerebrosidase deficiency -> glucosylceramide accumulation. LD, Rx enzyme replacement, BMTx (but no Rx for neuro effects/LD)

Child abuse

Physical: hitting, shaking, poisoning, burning, drowning, suffocating Neglect: failure to meet basic physical/psychological needs (food, clothing, shelter, supervision, protection from harm, access to medical care) including substance misuse during pregnancy Emotional: denigration, rejection, developmentally inappropriate expectations, repeated separations Sexual abuse: forcing or enticing child into sexual activities (including looking at/producing sexual images) Muchausen's syndrome by proxy: aka factitious or induced illness syndrome (FIIS) - inducing illness in child to obtain medical attention, difficult to detect as perpetrating parent usually denies and disguises behaviour Looked-after-child (LAC): child in public care. Usually due to abuse, poor educational/social outcomes Follow local child protection procedures, discuss with child and parents, carefully document everything. DO NOT investigate allegations/ask leading questions as may jeopardise police investigation

Deletion/duplication LD

Prader-Willi syndrome: 75% paternal deletion, 25% maternal uniparent disomy (mUPD). Massive hyperphagia w/ marked obesity. Neonatal - hypotonia, sleepiness, narrow BFD, triangular mouth (feeding difficulties). Childhood: short stature, hypogenitalism, self-injurous behaviour, LD, speech abnormalities, sleep disorders. Small hands/feet, cleft palate, almond shaped eyes, strabismus, talipes dorsalis, DDH, knee/ankle/spine (scoliosis) abnormaities. Have GI, CVS, resp (asthma), renal calculi, hearing deficits, hypothermia Angelman ("happy puppet") syndrome: 80% maternal deletion, 2% pUPD, 18% direct mutation. Ataxia, epilepsy, paroxysms of laughter, absence of speech, severe LD, behavioural issues (hand flapping, tongue thrusting, mouth movements), URTIs, ear infections, obesity. Blonde hair, blue eyes, microcephaly, flat occiput, long face, prominent jaw, wide mouth + widely spaced teeth, thin upper lip, mid-facial hypoplasia B-thalassaemia mental retardation: deletion causing LD Cri du Chat: Partial monosomy (loss of 5p). Cat-like cry, microcephaly, rounded face, hypertelorism, micrognathia, dental malocclusion, epicanthic folds, low-set ears, hypotonia, severe LD DiGeorge (Velocardiofacial) syndrome: microdeletion. 50% LD, cardiac issues (ToF, VSD, interrupted aortic arch, pulmonary atresia, TA). Microcephaly, cleft palate/submucous cleft, small mouth, long face, prominent tubular nose, adenoid hypoplasia - nasal speech, bulbous nasal tip, narrow palpebral fissure, minor ear abnormalities, small discs + tortuous retinal vessels + cataracts. Hypocalcaemia (seizures, renal/hearing problms, inguinal/umbilical hernia), hypospadias, long thin hands w/ hyperextensible fingers, associated with schizo, blunt affect Rubenstein-Taybi syndrome: microdeletion. LD + dysgenesis of corpus callosum. broad thumbs + great toes, persistent foetal finger pads, face (short upper lip, pouting lower lip, maxillary hypoplasia, beaked nose,slanted palpebral fissure, long eyelashes, ptosis, epicanthic fold, strabismus, glaucoma, iris coloboma), CVS (PS, PHTN, MR, PDA), keloid formation, GU (hypoplastic kidneys, cryptorchidism, shawl scrotum), GI (constipation, megacolon), collapsable larynx (OSA), epilepsy (25%), sleep problems, stereotypies (rocking, self-injurous behaviour) Smith-Magenis syndrome: deletion. LD, face (brachycephaly, broad face, flattened midface, strabismus), myopia, short broad hands, upper limb deformity, insensitivity to pain, behaviour (self-hugging posturing, aggression, self injury, hyperactivity, severe sleep problems) William's syndrome: deletion, may be related to escess aternal vit D intake. Hypercalcaemia, supravalvular aortic stenosis, elfin facies. Neonates- irritable, feeding problems, failure to thrive. Child - growth retardation, hoarse voice, premature wrinkling/sagging of skin, CVS (AS, pulmonary artery stenosis), GU (asymmetrical kidneys, nephrocalcinosis, bladder diverticuli, urethral stenosis), LD, abnormal attachment (either anxiety/poor relationships/hypersensitivity or poor social inhibition/excessive friendliness Wolf-Hirschhorn syndrome: 4p monosomy, severe LD

Menstrual disorders

Premenstrual symptoms: abdo bloating, breast tenderness, headaches not interfering with function. Rx low salt/fat/sugar/caffiene diet, restrict alcohol/tobacco, exercise, reduce stress. If no response in 2-3mo, trial SSRI Premenstrual syndrome (PMS): both physical and behavioural (fatigue, labile mood, irritability, tension, depressed mood, increased appetite, forgetfulness, conc difficulty) symptoms in second half of menstrual cycle (beginning of menses) impairing social/occupational functioning. Predisposes to affective and anxiety disorders Premenstrual dysphoric disorder (PMDD): premenstrual dysphoric and labile mood, irritability, anxiety, relieved at onset of menses, with distress and functional impairment Ix: 2mo symptom chart to confirm Rx: antidepressants, esp fluoxetine. Can do luteal phase therapy (start 14d before start of menses, stop at onset). 2nd line alprazolam, 3rd line medical oophoriectomy with GnRH agonist. OCP DOES NOT WORK

MHA

Principles: Least restrictive (the least restrictive option), purpose (to minimize harm done to pt, safety and health of pts and protection of public), respect (respect pt, religion, race, etc), participation (pts, carers and family members should be involved in decision making), effectiveness (best use of resources to meet needs of pt) Nearest relative (NR): spouse -> child -> parent -> sibling -> grandparent/other relatives. If living with relative, they are NR. If 2 of same, eldest is NR Mental health review tribunal (MHRT): pt or NR appeals here against detention. Consists of legally qualified chair, medical practitioner and lay member Mental health act commission (MHAC): monitors MHA/pts under detention, investigates complaints, appoints second opinion appointed doctors (SOAD) Section 2 (admission for assessment): made by NR or appointed mental health practitioner (AMHP), requiring 2 medical recommendations (one from MHAC approved doctor). Duration 28d Section 3 (admission for Rx): similar application process to section 2, lasts 6mo, renewed for further 6mo, then yearly thereafter Section 4 (emergency admission): v. rare, for those not admitted (eg A+E, outpt, day hospitals). Made by NR or AMHP, requiring recommendation from one registered medical practitioner Section 5(2) (emergency detention of informal pt): v. rare, for admitted pt. Medical recommendation by responsible clinician or their deputy. NR or AMHP not required For sections 4, 5(2) duration is 72h, assessment for section 2/3 must be made in this time Section 5(4): allows certain nurses to hold informal admitted pts in hospital for up to 6h to allow medical assessment Section 58: pt detained under section 2/3 may be given medication for mental disorder for up to 3mo w/o consent. For over 3mo or ECT, pt consent (form 38) or if no/incapable of consent, agreement of SOAD (form 39) Section 62: Urgently necessary Rx can be authorised by responsible clinician w/o consent or SOAD (generally used for 1st ECT in severely ill/at-risk pts, while awaiting SOAD) Section 57: Pt's consent and agreement of SOAD required for NMD or surgical implantation of hormones to reduce male sex drive Section 17: allows responsible clinician to grant leave of absence Section 18: pt can be taken into custody and returned to hospital if they abscond Section 19: allows pts to be transferred between hospitals pts under sections 2,3, or 7 (local guardianship order) may appeal to MHRT, NR can appeal for sections 3, 7. Both limited to one appeal per period of compulsion Section 117: duty of aftercare after detention from sections 3, 37/47/48 (equivalent of section 3 for various stages of court proceedings). Done via Care Programme Approach (CPA), which starts well before discharge, with an assigned care coordinator (CPN, social worker or psychiatrist). Can be standard of enhanced CPA, depending on likelihood of adherence/attendance. Pt cannot be compelled to accept/participate in CPA Section 32: Community treatment order (CTO) discharges a pt from section 3 subject to being liable to recall. Authorised by responsible clinician with agreement of AMHP. CTO must be in writing, and pt must require Rx for his health or safety of others. Recall powers under section 17E(1). Duration 6mo, then 6mo, then yearly. Responsible clinician determines criteria for recall

Pregnancy/parturition

Pseudocyesis: woman firmly believes she is pregnant, even develops objective signs (abdo enlargement, menstrual disturbance, apparent foetal movements, nausea, breast changes, labour pains, uterine enlargement, cervical softening, urinary frequency, +ve preg test). Rx supportive/insight-oriented psychotherapy + antidepressant trial Baby blues: 75% of mums have short-lived tearfulness and emotional lability, onset 2-3d postpartum, lasting 1-2d. Rx reassurance Postnatal depression (PND): 10-15% of women within 6mo (peak 3-4w), 90% last <1mo. Significant depressive episode, often with anxiety component and worries about baby's health/her ability to cope with baby Rx: Early identification/monitoring with Edinburgh Postnatal Depression Scale (EPDS). Education, support, usual depression Rx (antidep, CBT, admit if severe of risk of harm to self or baby) Postpartum psychosis: acute psychotic episode ~2w post-partum. 3 pres: prominent affective symptoms (80%, mania or depression with psychosis), schizophreniform disorder (15%), acute organic psychosis (5%). Usually labile symptoms with insomnia, perplexity/bewilderment, disorientation, thoughts of suicide/infanticide Prevention: identification, education, support, Rx if at risk (eg PMHx) Rx: admit to specialist mother-baby unit. For affective systems ECT + mood stabilisers (esp carbamezapine) + antidepressants. Antipsychotics for psychosis

Sleep

R (REM): desynchronised EEG with muscle atonia to stop acting out vivid dreams, rapid eye movements N1 (light sleep): reduced alpha activity with slow theta waves. Lasts a few mins, may have sudden twitches/jerks/hypnagogic hallucinations N2: sleep spindles with K-complexes. conscious awareness disappears, lasts 15-30min N3: SWS, >20% delta waves. This is when parasomnias occur. 30-45min, then reversion to N2 4-5 cycles 90-110min long. As cycles go on, N3/delta time reduces, whilst REM time increases Sleep diary: 2w, day activities, drug consumption, exercise, napping Video recording: good if no poly Actigraphy: collects sleep-wake patterns by motion detection (wristband with peizoelectric crystal) Polysomnography: EEG, EOG, EMG required. May also have ECG, resp monitoring (airflow/diaphragm EMG), pulse ox, actigraphy, penile tumescence, oesophageal pH (for reflux). Generally one night followed by MSLT Multiple sleep latency test (MSLT): assessment of daytime somnolence/REM sleep (eg OSA/narcolepsy). pt put to bed every 2h from 8am, sleep latency measured. >10min normal, <5min = excessive daytime somnolence

Serotonin syndrome

Rare, potentially fatal result of initiating/increasing serotonergic agent. Rapid onset Sternbach's diagnostic criteria Psych: confusion, agitation, coma Neuromuscular: myoclonus, rigidity, tremors (inc shivering), hyperreflexia (LL>UL), ataxia Autonomic: hyperthermia, GI upset (N+D), mydriasis, tachycardia, hyper/hypotension. Hyperkinesia vs bradykinesia in NMS Most resolve within 24-36h Immediate transfer to emergency department, activated charcoal if OD Rhabdo: aggressive IV fluids + IV NaCO3, temp reduction agitation, seizures, muscular rigidity: IV lorazepam Serotonin receptor antagonists: selected cases - cyproheptadine, chlorpromazine, mirtazepine, methysergide, propranolol - mild 5HT antagonist

Sleep related movement disorders

Restless leg syndrome (Ekbom's syndrome): 10% prevalence. Unpleasant painful sensation in legs, particularly at and preventing sleep onset. Exacerbated by caffiene, fatigue, stress Rx: move or stimulate (rub, squeeze, heat) legs. Many meds inc clonazepam, cabergoline, levodopa, ropinirole Periodic limb movement disorder (PLMS): periodic repetitive stereotyped limb movements usually reported by partner, wth EDS, >60yo 34% Sleep-related cramps: typically calf/foot, during sleep awakening pt. 16%, common in elderly. Rx if severe - heat, massage, stretch, quinine sulphate Sleep-related bruxism: clenching/grinding of teeth, can arouse, may lead to TMJS, wearing of teeth, severe tongue/mouth injury. Rx sleep hygiene, occlusal splints/night-time bite guard, clonazepam Sleep-related rhythmic movement disorder: stereotyped repetitive movements of large muscles (eg head banging - jactatio capitis nocturna, head rolling, body rocking) immediately prior to -> light sleep, can cause head injury. Young boys, declines w/ age, associated with psychodevelopmental issues Rx: usually not needed, should resolve by 18mo. Lowdose BDZ/antidepressant if injuries

Schitzoid disorders

Schitzoaffective disorder: both scitzophrenia and affective symptoms (major depressive/manic/mixed episode) in equal measure. Rx for sctizo and bipolar Schitzotypal disorder: 3% prevalence. Partial expression of scitzo phenotype (common in sctizo relatives). Ideas of reference, social anxiety, odd behaviour/beliefs/appearance/speech. Suspicious/paranoid ideas, illusions, inappropriate affect, no close friends. Rx risperidone Schitzophreniform disorder: scitzophrenia that doesn't reach duration criteria (1mo-6mo, returning to baseline after, 60-80% progress to sctizophrenia). Rx as for scitzo Acute psychotic disorder: sudden onset, <1mo resolution, sometimes due to acute stressor, personality disorder is RF. Admit if needed, with BDZs for support. Prophylaxis with antidepressants or mood stabilisers (relapse common)

Confidentiality

Seek pts' consent to disclosure wherever possible Anonymise data as much as possible Keep disclosures to minimum necessary Always document decisions Caldicott guardians overlook how confidential pt records are shared, ensuring they are kept on a need-to-know basis If asked by an organisation to disclose information from medical records, ensure: pt understands scope and purpose of disclosure, and that relevant facts cannot be "redacted", obtain written evidence of this. Disclose only information relevant to request, only factual information, and check whether pt wants to see report before sending it BREAKING CONFIDENTIALITY Document and be prepared to justify decision, tell pt To protect pt/others: eg colleague putting pts at risk due to illness, pt continuing to drive when unfit to do so (disclose to DVLA immediately), prevention/detection of a serious crime or suspected child abuse Judicial/statutory proceedings: Notification of notifiable diseases, ordered by judge or presiding officer of a court (unless irrelevant to case), to assist coroner/procurator fiscal or other similar in connection with inquest/fatal accident inquiry, official request from statutory regulatory body of any health care profession when necessary in interests of justice and safety of other pts Difficult situations: if lack competence (eg children), try to persuade to allow parent in consultation. Document and inform pt and carers/family when breaking confidentiality. Any breaks should be legally required or in pt's best interests When confidentiality is broken, inform pt before and after disclosure made

DVLA requirements

Severe anxiety/depression: driving should cease pending outcome of medical enquiry. G2 needs stable period of 6mo Hypomania/mania: cease. G1 - stable 3mo (if isolated) or 6mo (if >=4 mood swings in previous y), compliant, insight, no ADRs affecting driving, subject to specialist favourable report. G2 - outcome of medical inquiry, stable 3y + insight, no likelihood of recurrence, no ADRs affecting driving Acute psychosis: cease. G1 - stable for 3mo, compliant, no ADRs interfering w/ driving, subject to favourable specialist report. G2 as for mania Dementia/organic brain syndrome: G1 - if sufficient skills retained w/ slow progression, license issued subject to annual review. G2 - refuse/revoke license Learning disability: severe refuse, mild-moderate may be possible but must demonstrate adequate functional ability at wheel Persistent behaviour disorder: Refusal/revocation if seriously disturbed and behavioural disturbance likely to make pt danger at wheel

Sexual dysfunction

Subclinical: no diagnosis, but supportive therapy with sensate focus v effective Loss of libido: check not secondary. Sensate focus group therapy Sexual aversion/lack of enjoyment: usually due to previous traumatic sexual experience. Requires senior therapists Excessive sexual desire: women - nymphomania, male - satyriasis. Late teenage/early adulthood, 2ndary to mood disorder (mania), or dementia/brain trauma Paraphilias: Encourage to develop normal relationships/fantasies, address any feelings of sexual inadequacy, develop interests/activities/relationships to fill time previously taken up by paraphilia. Ix: penile plethysmography, polygraphy, visual reaction times Rx: SSRIs, hormonal therapies, psychoanalysis, CBT Transsexualism: MTF>FTM. Identity must be present >2y, not associated with psych disorder (delusion of being opposite gender) or any intersex conditions. Associated with many mental illnesses. Confirm diagnosis, refer to specialist gender services. Invite family/friends to discuss for supporting evidence and to support them through transition. Can change birth cirtificate to change gender. Evidence of change must be presented to Gender Recognition Panel after 2y Rx: 1y real-life test (lives, finds employment, changes name, all in new gender). Hormones (oestrogen + antiandrogen (eg finasteride, cyproterone acetate) produce breasts, change hips, soften skin, redistribute fat. Testosterone causes muscle development, hirsutism, lowered vocal pitch, growth of clittoris) Surgery: MTF - orchidectomy + penectomy w/ vaginoplasty using penile skin. Can have good cosmetic results, but orgasmic ability varies. Also breast augmentation, facial feminisation, thyroid chondroplasty. FTM - b/l mastectomy, hysterectomy, salpingooopherectomy. <50% have phalloplasty as neither functional nor cosmetically acceptable Transvestism: stress relieveing Fetishistic transvestism: sexually gratifying Dual role transvestism: spends time split between f and m Dysmorphobia: dissatisfied with primary/secondary sexual characteristics, not with gender Third sex: identifies with neither sex, may want to be neutered

Psychotherapy

Supportive: guided, problem-solving discussion with venting of emotions. Eg counselling, regular psych f/u Psychodynamic: childhood experience, the unconscious mind, relationships in past and present. Requires good insight/abstract thought and good impulse control/emotional resilience. Psychoanalysis: 1-5 50min sessions/week for years, very intensive. 2 therapists in room (for 3rd viewpoint) Psychodynamic psychotherapy: 1-2 sessions/w for 16 sessions. Therapist more involved, with direct eye contact (c/f lying on couch with therapist behind in psychoanalysis) and much more verbal input/countertransference (c/f evenly suspended attention to facilitate transference in psychoanalysis) CBT: thoughts, feelings and actions are interrelated. Therefore, challeging and changing current thought patterns will change behaviour and feelings, and improve symptoms. Delivered 'by the book' via established protocols. Initial assessment, then 6-20 1h sessions w/ review after 6 sessions Group: can be supportive, CBT or psychoanalytical Brief: short, solution-oriented interventions Psychotherapy CI in: acute psychosis, severe depression (psychomotor retardation), dementia/delerium, acute suicide risk

Antidepressants

TCA: SN(D)RI. ADRs: antiACh (dry mouth, blurred vision, constipation, urinary retention, drowsiness, confusion in elderly, palpitations), a1 agonist (postural hypotension, tachycardia, impotence), antiH (sedation, weight gain), anti5HT (anxiolytic), toxic in overdose, slow cardiac conduction (CI in MI, arrhythmias/av block, IHD, severe liver disease, pregnancy). Amitriptyline, clomipramine, dosulepin, doxepin, imipramine, lofepramine, nortriptyline, trimipramine MAOI/RIMA: RIMA=reversible inhibitor of MOA-A (MAOI irreversible and both A/B). ADRs: cheese reaction/HTNcrisis, antiACh, hepatotoxicity, insomnia, anxiety, appetite suppression, weight gain, postural hypotension, ankle oedema, sexual dysfunction. Many interactions, must be 'washed out' before starting other Rx. MAOI - isocarboxazid, phenelzine, tranylcypromine. RIMA - moclobemide SSRI: action through 5HT1a. ADRs: 5HT2 (agitation, akathisia, insomnia, sexual dysfunction), 5HT3 (nausea, GI upset, diarrhoea, headache). Inhibits P450, CI in mania. Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, St johns wart (Hypericum perforatum) SNRI: nausea, GI upset, constipation, loss of appetite, dry mouth, dizziness, agitation, insomnia, sexual dysfunction, headache, nervousness, sweating, weakness. Venlafaxine, Duloxetine TeCA: like TCA, but less antiACh ADRs and more blood dyscrasias. Mianserin SARI: sedating, orthostatic hypotension, weight gain. Also TCA SEs, rarely (but severely) priapism NaSSA: a1 antagonist (orthostatic hypotension), antiACh (as above), anti5HT3 (no GI affects), antiH (sedation, weight gain). Rarely transaminitis, agranulocytosis. Mirtazepine NARI: insomnia, sweating, postural hypotension, tachycardia, sexual dysfunction, dysuria, urinary retention, dry mouth, constipation, hypokalaemia. Reboxetine NDRI: agitation, insomnia, dry mouth, GI upset (N+V, constipation, abdo pain), HTN (esp + nicotine), 0.4% seizures, taste disturbance. Bupropion MaSSA: nausea, dizziness, headache, somnolence, insomnia, migraine, diarrhoea, constipation, abdo pain, sweating, back pain, fatigue, anxiety, transaminitis. Rarely rash, hepatitis, suicidal behaviour. Agomelatine

Legal

Treatment w/o consent Common law: emergency sedation of ACS pt, also defence against assault. Allows non-consensual Rx in emergencies when consent is not possible. Also requires all medical decisions to abide by Bolam (considered suitable by a professional body) and Bolitho (and logically defensible under circumstances) tests Incapacity act: best interests decisions allowed by MCA Mental health: MHA detention, ONLY Rx FOR MENTAL, not physical comorbidities Court: generally non-urgent controversial cases with no precedent MCA (>=16yo) 5 principles: presumption of capacity, all practical steps to facilitate capacity, allow unwise decisions, act in best interests, and with the least restrictive option 2 stage test: 1 - permanent/temporary impairment in functioning of the mind, 2 - unable to understand, retain, weigh-up, communicate decision. Judgment made on balance of probabilities Marriage, divorce, consent to sex and casting ballots cannot be done under this act LPA: must be registered with the Office of the Public Guardian Court-appointed deputies: from court of protection, appointed if no LPA and court anticipates many decisions, but cannot refuse life-sustaining Rx ADs: if against life-sustaining Rx must be signed, witnessed and in writing containing "even if life is at risk"

Attention deficit hyperactivity disorder (ADHD)

Triad of inattention, hyperactivity and impulsiveness (can have inattentive only and hyperactive impulsive subtypes). 5% meet criteria. Large genetic component Inattention: careless w/ detail, appears not to listen, not finishing tasks, poor self-organisation, loses things, forgetful, easily distracted Hyperactivity: seen in structured situations. Fidgets w/ hands or feet, leaves seat in class, runs/climbs about, cannot play quietly, always moving Impulsiveness: talks excessively, blurts out answers, cannot wait turn, interrupts/intrudes on others 50-80% have mental comorbidities, 30% persist in adults, 60% have >=1 symptom (usually inattention) Connor's rating scale, SDQ Psychoeducation, behavioural/school interventions, dietary changes Pharma prescription by experts only, 70% effective. Regularly monitor and discontinue at intervals Methylphenidate (Ritalin): CNS stimulant, >6yo. ADR abdo pain, n+v, dry mouth, anxiety, insomnia, dysphoria, headaches, anorexia, reduced weight gain Atomoxetine: non-stimulant NRI, up to 6w for effect. ADR anorexia, dry mouth, n+v, headache, fatigue, dysphoria Dexamfetamine: CNS stimulant similar to methyphenidate

Down's

Trisomy 21, most common genetic cause of LD. IQ<50. Can be full (95%) or robertsonian translocation (5%), rarely mosaicism (IQ in 70s, physical abnormalities less marked) RF: mum >40yo, FHx Short, overweight, brachycephaly, maxillary hypoplasia, underdeveloped bridge of nose, eyes close together, Brushfield's spots, epicanthic folds, low-set ears, high arched palate, protruding tongue, atlanto-occipital instability CVD: ASD/VSD/AVD, MVD, PDA GI: Oesophageal/duodenal atresia, Hirschsprung, umbilical/inguinal hernia Hands: short broad hands with single (simian) palmar crease, syndactyly, clinodactyly, altered dermatoglyphics Eye: strabismus, myopia, blocked tear ducts, nystagmus, late-life cataracts, keratoconus Ear: structural anomalies -> recurrent otitis media, SNHL Immuno: raised IgG/IgM, low T cells Endo: hypothyroid (20%), DM CNS: reduced brain weight/gyru, cortical thinning. Alzheimer's desease Male: delayed puberty, abnormal spermatogenesis Female: Problems with ovulation/follicular growth, early menopause 30% will have psych comorbidity (usually depression)

Alcohol withdrawal syndrome

Uncomplicated: 4-12h after last drink. Coarse tremor, sweating, insomnia, tachycardia>100, n+v, psychomotor agitation, generalised anxiety. Rarely transitory hallucinations/illusions. Peak at 48h, last 2-5d With seizures: 5-15%, generalised T-C seizure 6-48h after last drink Delirium tremens: acute confusional state due to withdrawal (75%) 1-7d (48h) after last drink. Uncomplicated withdrawal + LOC/disorientation, recent amnesia, marked psychomotor agitation, lilliputian (small animals/humans) visual auditory and tactile hallucinations, fluctuating severity (worst at night). If severe heavy diaphoresis, fear, paranoid delusions, suggestibility, fever, sudden CVS collapse. Mortality 5-10% CIWA-Ar: 10 item tool to detect and monitor withdrawal Rx can be done as outpatient if detoxing voluntarily Pabrinex Reducing regime of BDZs: enough to cover period of danger/symptoms, but rapidly reducing dose (over 5d) to prevent iatrogenic dependence syndromes. Chlordiazepoxide used for outpatients due to lower abuse potential, diazepam for inpatient as faster acting Symptom-triggered regimen: BDZ given in accordance with CIWA score, used in inpatient settings Post-alcohol detox 1st: acamprosate and naltrexone 2nd: disulfiram

Behaviour therapy

Using basic learning theory (Classical Pavlovian conditioning and Operant Skinnerian conditioning) Systematic desensitisation: Phobia Rx based on Pavlovian extinction (if conditioned stimulus does not come with unconditioned stimulus multiple times). Identify fear, create hierarchy of increasing anxiety, train in relaxation techniques, start at lowest (repeating until no anxiety), then moving onto next level Flooding/implosive therapy: cannot maintain high level of anxiety for long time, so if expose to phobic object (in vivo - flooding, in imagination - implosion) and prevent escape, dissociation of CS and US occurs Behaviour modification: Rx for behavioural disturbance in children/LD pts, based on operant conditioning. Small intermediate steps towards desired behaviour are rewarded by positive reinforcement (eg 'token economy'). Can be used for less voluntary things (eg star charts for encopresis/enuresis Aversion therapy: used to be used to Rx homosexuality. Now partially effective in the form of disulfiram

Bulimia nervosa

Young women, recurrent episodes of binge eating, overvalued ideas about ideal body shape/weight, often with normal BMI and Hx of anorexia nervosa. Mid-adolescent onset, present mid 20s CRITERIA persistent preoccupation with eating Irresistible craving for food Binges: episodes of overeating Attempts to counter fattening effects of food: vomiting, purgative abuse, periods of fasting, appetite suppressants, thyroxine, diuretics PURGING COMPLICATIONS Arrhythmias, cardiac failure/sudden death, electrolyte disturbance Oesophageal/gastric erosions/perforations/ulcers Pancreatitis, constipation, steatorrhoea Dental erosion, leukopenia, lymphocytosis SCOFF questionaire: screening for eating disorders. Sick, lose Control, >One stone in 3mo, Fat when others think thin, Food dominates life? Pharma: fluoxetine Psycho: CBT best, IPT takes longer, bibliotherapy, education, group support Admission: pregnant (increased risk of spontaneous abortion), suicide risk, physical problems, extreme refractory Binge-eating disorder: w/o compensatory bulimic behaviours

Conduct disorder

a repetitive and persistent pattern of antisocial, aggressive or defiant behaviour violating age-appropriate social norms with impact on family/peer relationships and schooling Conduct Disorder (CD) Aggression/cruelty to people/animals, destruction of property, deceitfulness, theft, fire-setting, truancy, running from home, severe provocative/disobedient behaviour Oppositional Defiant Disorder (ODD) enduring negative, hostile and defiant behaviour w/o violation of social norms. Can be angry/irritable, argumentative/defiant or vindictiveness Parent management training: eg Webster-Stratton incredible years programme, positive parenting programme (triple P) Functional family therapy Child interventions: last resort 50% will receive diagnosis of antisocial PD as adults. Poor schooling and societal prognosis

Autism spectrum disorder (ASD)

aka pervasive developmental disorder (triad of abnormal reciprocal social interaction, communication and langage impairment, and restricted interests) Umbrella term containing autism, Asperger's syndrome and pervasive developmental disorder not otherwise specified (PDD-NOS) Relationships: few/no sustained relationships, persistent aloofness/awkward interaction with peers, unusually egocentric with little concern/awareness of viewpoint of others, lack of social awareness Communication: odd voice (monotonous, unusual volume, talking at people w/ little awareness of response), language too fomal/stilted/pedantic with no non-literal comprehension, limited nonverbal (impassive appearance, few gestures, abnormal gaze, awkward odd posture/body language) Interests: obsessively pursued interests, set approach to everyday life with unusual routines/rituals, change is upsetting May have seizures, motor tics, unusually intense sensory responsiveness w/o typical pain response ADI-R, DISCO, 3di Multidisciplinary approach. Parenting programs, visual timetabling, communication interventions (SALT) Risperidone for short-term Rx of aggression Melatonin for behavioural therapy-resistant sleep disturbance

XLD

fragile X syndrome: common cause of LD, trinucleotide repeat (CGG). Usually undetectable until adulthood. Large testicles/ears, smooth skin, hyperextensible fingers, flat feet, MVP, inguinal/hiatus hernia, face (long/narrow w/ underdeveloped midface, macrocephaly), epilepsy, variable LD, behaviour (delayed language development, conversational rigidity, perseveration, echolalia, palilalia, cluttering, overdetailed/circumstantial speech), psych (prominent depression/anxiety). MRI brain - reduced posterior cerebeallr vermis, enlarged hippocampus + causate nuclei, enlarged ventricles Rett's syndrome: females only, MECP3 mutation. Early onse/developmental arrest (6-18mo age, delayed motor skills, low eye contact/toy interest. Classically hand wringing, reduced head growth), Rapid destructive/regressive (1-4yo, loss of purposeful hand movement/speech, stereotypies (hand wringing, washing, clapping, tapping), ASD, worsening gait), plateu/pseudo-stationary (4yo-onwards, seizures+motor problems prominent, but rest improves slightly), late motor deterioration (gradual worsening mobility, scoliosis, spasticity and muscle weakness) Aicardi syndrome: rare, female - dysgenesis of corpus callosum and cerebrum + severe LD, usually death in infancy. Microcephaly, facial asymmetry, lowset ears, chorioretinal lacunae, hypotonia, scoliosis, epilepsy, behaviour (aggression, lack of communication, sleep problems, self-injury)

PD

not a mental disorder, just bad personality! Normal personality described by Costa and McCrae's five-factor model (neuroticism, extraversion, openness, agreeableness, conscientiousness) Paranoid: sensitive, suspicious, preoccupied with conspiracies, self-referential, distrust others Schizoid: emotionally cold, detachment, lack of interest in others, excessive introspection and fantasy Schizotypal: interpersonal discomfort with peculiar ideas, perceptions, appearance, behaviour. ~50% develop schizophrenia Dissocial/antisocial: callous lack of concern for others, irresponsibility, irritability, aggression, inability to maintain enduring relationships, disregard/violation of others rights, childhood conduct disorder Emotionally unstable - impulsive type: inability to control anger or plan, unpredictable affect/behaviour Emotionally unstable - borderline type/Borderline: unclear identity, intense unstable relationships, unpredictable affect, threats/acts of self harm, impulsivity Histrionic: self-dramatisation, shallow affect, egocentricity, craving attention/excitement, manipulative behaviour Narcissistic: grandiosity, lack of empathy, need for admiration Anxious/avoidant: tension, self-consciousness, fear of -ve evaluation by others, timid, insecure Anankastic/Obsessive-compulsive: doubt, indecisiveness, caution, pedantry, rigidity, perfectionism, preoccupation with orderliness and control Dependent: clinging, submissive, excess need for care, feels helpless when not in relationship Psychopathy: defined by psychopathy checklist revised (PCL-R). Strongly correlated with future violence. May have 'immature' EEG with fMRI and autonomic (galvanic skin test) abnormalities Rx: medication doesn't work. Therapeutic community (residential unit for social retraining), Dialectical behavioural therapy (DBT), cognitive analytic therapy, modified psychodynamic approaches, CBT (more longterm than other CBTs)

Impulse control disorders

pt cannot resist acting on a specific potentially harmful impulse, with increased sens of arousal and tension before committing the act, and pleasure/gratification/release of tension after Intermittent explosive disorder (IED): extreme explosive behaviours out of proportion to trigger (eg emma apple). Typically young men. Episodes infrequent, lasting <20min. May have tingling, tremor, palpitations, chest tightness, head pressure, echo. Rx some evidence for mood stabilisers, SSRIs, bblockers Kleptomania: can't resist stealing items not needed for personal use/monetary value. Rx SSRI, CBT/FT Pyromania: multiple episodes of deliberate firesetting leading to property damage, legal consequences, loss of life. Male adolescents w/ learning/social difficulties . May have fascination/attraction to fire, indifferent to consequences, no discernable reason. Rx CBT Gambling disorder: recurrent gambling behaviour leading to personal/family/occupational difficulties. Criteria - preoccupation with gambiling, need to gamble larger sums of money for same feeling, unsuccessful attempts to cut down, restlessness/irritability when cuts down, chasing losses, lies/jeopardises relationship with family/friends, illegal acts to fund gambling. Rx SSRI, lithium, clomipramine, naltrexone, CBT Trichotillomania: recurrent pulling of hair, exacerbated by stress or relaxation, usually involving scalp (but can be any hair), leading to hair loss. May use teeth, trichophagia, examine hair root, bite nails. Rx CBT. some evidence for SSRIs, lithium, antipsychotics Excoriation disorder: recurrent skin picking causes skin lesions, associated with repeated attempts to stop, significant distress or social/occupational impairment

Panic disorder

recurrent panic attacks with no 2ndary cause. Genetic component (50% heritability) Panic attack: palpitations, sweating, trembling/shaking, dyspnoea, globus hstericus, CP, nausea+GI issues, presyncope, depersonalisation, angor animi, paraesthesiae, chills/hot flushes. 50-60% have HVS 1st line: SSRI ((es)citalopram, sertraline, paroxetine). May at first increase panic symptoms, takes 12w at high dose to work 2nd line: SNRI, TCA, MAOi. BDZs not recommended due to dependence Psycho: CBT, emotion-focused psychodynamic psychotherapy Maintenance: continue for 12-18mo, then taper over 2-4mo. Can continue indefinitely

Trauma

type I: single unexpected event type II: repeated sustained events Grief: associated with bereavement. Disbelief, shock, numbness, anger, guilt, sadness, tearfulnes, insomnia, anorexia, weight loss, hallucination (visual or auditory) of deceased. Gradually reduce, lasts up to 12mo. can use benzos for autonomic arousal and insomnia shortterm ACUTE STRESS REACTION transient, lasting hours or days, onset within 1h of type I trauma Initial daze, then depression, GAD-like anxiety, anger, despair Severity: social withdrawal, narrowed attention, disorientation, aggression, hopelessness, overactivity, excessive grief. Mild none, moderate 2, severe 4 or dissociative stupor. Rx none, max 3d Acute stress disorder: onset within 4w, lasts 3d-4w. PTSD-like symptoms. Rx: supportive (advise about police procedures, insurance claims), CBT (2w post-event), pharma (TCA, SSRI, BDZs). Either self limiting or progresses to PTSD PTSD 2 or more persistent symptoms of increased psychological sensitivity + arousal: insomnia, irritability/outbursts of anger, reckless/self-destructive behaviour, conc difficulties, hypervigilance, exaggerated startle response Other: persistent remembering/reliving stressor in intrusive flashbacks, vivid memories, recurring dreams, distress when exposed to/avoidance of situations resembling/associated with stressor, partial/complete amnesia of stressor Protective: high IQ/SEC, male white, psychopathic traits, seeing dead body of person Rx CBT: education, anxiety management, exposure to anxiety-inducing stimuli, imaginal reliving Eye movement desensitisation and reprocessing (EMDR): voluntary multi-saccadic eye movements to treat anxiety Other: psychodynamic therapy, stress management, hypnotherapy Pharma: only used if ongoing severe threat, or psycho fails. SSRI (paroxetine, sertraline) licensed for PTSD, can try others (TCA, MAOI). insomnia/nightmares - hypnotics, mirtazapine, prazosin. Anxiety - BDZs, propranolol. Psychosis - antipsychotics. Intrusive thoughts - mood stabilisers 50% recover in first year, 30% become chronic Adjustment disorder: sub-traumatic problematic difficulties cause depressive or anxious symptoms within 1-3mo. Rx supportive psychotherapy/OT to help adaptation, pharma (antidepressants/anxiolytics) if unsuccessful. 45% adolescents will develop major psychiatric problems