Psychiatry

schizphasia. Completely incoherent speech where real words are strung together into nonsense sentences

total absence of emotion

Thought disorder where there are abrupt leaps from one topic to another [there may be a link]. Seen in mania

when a sentence is suddenly stopped for no obvious reason. Px starts speaking again, they will talk about something different

persistent repetition of words / ideas, even when another person attempts to change the topic

lengthy pauses between brief utterances. speech may be normal, but conveys little information as phrases are vague, empty etc.

frenzied speech at rapid rate and increased volume. difficult to interpret

thought insertion, thought broadcast, thought withdrawal

belief that a patients thought have been placed in their mind by someone else

belief that others can hear the patients thoughts

belief that a patients thoughts are being taken away from them, without their control

perception in the absence of stimulus [perceived in objective space w/ qualities of normal perceptions]

misperceptions of external stimuli, often when general level of sensory stimulation is reduced

hallucination where patient has insight that it isnt real [often auditory]. Often originating from within the patients head

unshakable false beliefs held with absolute conviction, out of keeping with patients cultural, social and religious beliefs

patient has misplaced belief that ordinary objects or events refer to them [e.g. believe that the music on the radio is played for them]

misplaced idea that the patient believes their thoughts or body parts are being controlled by an external force

misplaced idea where the px believes they have committed an awful sin / crime

deeply held personal convictions which are understandable when considering px’s background [important to delineate from delusions]

Predisposing: often early life / genetic factors, delivery related factors, previous emotional stress

Precipitating: triggers that may be physical, psychological or social

Perpetuating: maintain the disorder once triggered, may be physical / psychological / social

behaviour adoptd by ill people: dont fill social obligations, only see doc, treated with sympathy by others

Somatisation disorder [px experience psychological distress in the from of somatic illness]

Hypochondriasis [px complaint is of illness ]

Beforehand: ask some with experience of px whether it is safe to interview px alone

Access to others: interview in view / hearing of others OR accompanied with other member of staff

Setting: conduct interview in quiet room for confidentiality

Seating: sit inbetween the door and the px

Alarm: learn how to use one

do they recognise their illness?

Do they think their medical therapies would help?

Ability to recognise when they experience an unusual mental event?

mood state characterised by disinhibition and euphoria BUT shorter-lived than mania AND not accompanied by psychotic sx

abnormal state of mind, creates difficulty in determing what is real or not

will see hallucinations / delusions

patterns of behaviour which manifest as inflexible responses to personal and social situations. Often an acquired aetiology during childhood / adolescence

if sx interfere with normal functioning

if sx are qualitatively different and pervasive

in depressive illness, sx should last for 2 weeks or longer AND cause significant incapacity [trouble working or relating to others]

wandering from a topic without returning to it

inability to answer a question without giving excessive, unnecessary detail. This differs from tangentiality as the px does eventually return to the original point

Ideas are related to each other only by the fact they sound similar or rhyme

severe type of loosening of assocations where there are unexpected and illogical leaps from one idea to another. A feature of schizophrenia

repetition of someone elses speech, including the question that was asked

FHx, birth, head injury

head injury, alcohol and drugs

early separation, abuse, depressed mother [attachment] loss

life events like bereavement, divorce and redundancy

extended court proceedings, relationship difficulties

low SEC, poverty, debt, single parent, no confidante

housing, debt, isolation, drugs / alcohol

housing, debt, poverty, unemployment, drugs and alcohol

NOTEPAD: nature, onset, triggers, exacerbating / relieving factors, progression, associated sx, disability

Any previous contact with services / couselling / MHA admission. Ask about Tx outcomes, length, route, their thoughts on the medication

Get collateral history from someone close

Personal history starting from birth, school life, university, employment / relationships, short sexual history as well. Screen for abuse

Forensic history, any contact with the history

Important to ICE and summarise

Appearance and behaviour,
Speech [tone, rate, volume, pressure]
Affect and Mood
Thought [connections, neologisms, obsessions]
Perception [delusion, hallucinations]
Insight and judgement [sensible or not]
Coginitive state [orientated, concentration, memory problems]

Suicide risk assessment [any plan, duration, affairs in order, how did they feel after]

Dopamine D2 receptor antagonists

SEs: EPSE and hyperprolactinaemia

Haloperidol, Chlorpromazine

acts on variety of receptors [D2, D3, D4, 5HT]

SEs: EPSE and hyperprolactinaemia are less common. Metabolic effects

Clozapine, Risperidone, Olanzapine , Aripiprazole [most tolerable SE profile]

increased risk of stroke and VTE

Anti-muscarinic [dry mouth, blurred vision, constipation, urinary retention]
Sedation
Hyperprolactinaemia [suppresses GnRH so amenorrhoea and sexual dysfunction]
Metabolic [hyperplipidaemia, weight gain, impaired glucose tolerance]
Neuroleptic malignant syndrome
EPSE

Haloperidol

Parkinsonism [bilateral tremor]
Acute dystonia [sustained muscle contraction, manage via procyclidine]
Akathisia [severe restlessness]
Tardive dyskinesia [late onset of choreoathetoid, abnormal, involuntary movements]

usually only used in px resistant to other medication [2 or more medications trialled in last 6-8 weeks]

mostly indicated for schizophrenia

weight gain, lower seizure threshold, constipation, myocarditis, hypersalivation

*Agranulocytosis and neutropenia *

regular FBCs for agranulocytosis, seizure monitoring, cardiac monitoring for myocarditis, metabolic monitoring [weight, BG, lipids]

agranulocytosis Hx
Myeloproliferative disorder
Px with uncontrolled epilepsy [due to lower seizure threshold]

if longer than 48hrs since last dose, too long of a break so must restart from low dose and build up

mood stabilising drug commonly used prophactically in bipolar disorder. Very narrow therapeutic index

LITHIuM

Leucocytosis
Insipdus
fine TREMOR
Hypothyoidism
Increased weight
Metallic disease

n / v, diarrhoea

before Tx: U&Es, ECG, TFTs, BMI, FBC. Then check these every 6 months

Lithium levels checked 12hrs post dose and then weekly until concentrations are stable. Then check every 3 months

Addisons
Rhythmic cardiac disorders
Personal / FHx of Brugada syndrome, low sodium diets, untreated hypothyroidism

Renal impairment due to narrow therapeutic index

coarse tremor, hyperreflexia, acute confusion, seizure, coma, polyuria

mild-moderate: volum resusc, seizure control, monitor electrolyes

Severe: haemodialysis

1st line for depression. Indicated for generalised anxiety disorder, OCD, PTSD. Fluoxetine for children and adolescents. Sertraline for post-MI px

Inhibits reuptake of serotonin to increase seratonergic activity

NSAIDs with SSRIs causes increased GI bleeding

for people using warfarin / heparin, use mirtazapine instead

Increased serotonin syndrome risk with triptans and MAOIs

decreased libido, GI sx, hyponatraemia, suicidal ideation in young px

Review at 2 weeks

If younger than 25yrs or risk of suicide, review at 1 week instead

if ok, continue tx for at least 6 months after sx are repressed, to prevent withdrawal

gradually reduce over a 4 week period

not needed for fluoxetine

increased mood change
restlessness
sleeping difficulties
unsteadiness
sweating
GI sx [pain, vomiting, diarrhoea]
Paraesthesia

citalopram

40mg daily is max for adults.

20mg is max for over 65yr olds or px with hepatic impaiment

duloxetine, venlafaxine

neuropathic pain, migraine prophylaxis, used less now for depression due to SEs

Amitriptyline is more sedative

less sedative is imipramine and lofepramine

QT prolonging, drowsiness, blurred vision, constipation, urinary retention [overflow]

dry mouth / weight gain [anti cholinergic]
Weight gain [antihistamine]

suicidal px, px with arrhythmias / heart block / recently had MI

Px experiencing manic phase of bipolar disorder

antidepressant that blocks alpha 2 adrenergic receptors. Take at night because it is a sedative. Used for older px due to less SEs

status epilepticus, short term anxiety, muscle spasm, insomnia sedation

diazepam, lorazepam, midazolam

dependence / tolerance
withdrawal sx [seizures, insomnia, tremor, anxiety]
drowsiness, confusion, hypoventilation
falls in elderly

acute pulmonary insufficiency, neuromuscular respiratory weakness, obsessional status, phobia states, sleep apnoea, unstable m gravis

Flumazenil BUT can induce seizures

A oxidises serotonin and noradrenaline
B oxidises phenylethylanine

discharge home with no follow up from MH services + safety plan [family and friends, recognise stressors, avoid harmful alcohol use, possible support contacts]

Educate px on where to seek help from like GP, A&E, local MH services

discuss with px if they can manage safely at home with support of an intensive home Tx team OR will accept voluntary admission to a psychiatric hospital

MH act assessment needed ASAP

male, older, widowed / separated, social isolation, unemployed / low income, certain occupations, FHx

If the px carries out final acts beforehand, researched methods, precaution against being found, resists help, px dowplays the seriousness of the attempt

Applies only to mental health disorders.
Determine the nature and degree of their mental health disorder
Ensures that individuals with SMI which threaten their health / safety / public safety, can be detained irrespective of their consent

Cannot use MHA to treat physical illnesses UNLESS:
patient consents or the px lacts capacity to consent [MCA]

or to the extent that such Tx is part of or ancillary to Tx for mental disorder [self harm scars]

anorexia nervosa is classed as mental illness so refeeding is allowed

not considered to be a mental disorder UNLESS it is associated with abnormally aggressive or seriously irresponsible conduct by that person

done anywhere. need one approved mental health profressional [AMHP] AND 2 section 12 approved doctors [independent usually]

Person cannot be deemed to be suffering from a mental disorder by reasonal alone of alcohol / drug dependance.

2007 took out promiscuity and sexual deviancy

Assessment order, given for short term, up to 28 days. Nearest relative needs to notified and Tx cannot be renewed

Must document nature, degree, risks then detail Tx plan

a Tx order, usually for px with pre-existing known MH disorder

can last up to 6 months initially. Nearest relative can object this

Must document nature, degree, risks then detail Tx plan

Allows for emergency detainment for the purpose of assessment for a duration of up to 72hrs. It is recommended when section 2 detainment would invovle unacceptable delay.

Doctors holding power where a px tried to leave hospital and you prevent this. Further assessment must occur within 72hrs.

Nurses holding power is 6hrs long

no tx unless doing so out of immediate necessity like tranquilisation

magistrates order, when person refuses to allow health profressionals into their residence. Allows police warrant to enter property and take person to “place of safety”

applies to person found in public place suspected by police of having mental health risk. Assessment by Duty Psychiatrist

MH review tribunals to appeal against detention under the act.

Automatic review of capacity, consent, Tx after 3 months

allows px to “go on leave” from hospital. Allows rehabilitation in a non-hospital environment where the doctor can place conditions if needed

must have all 3 elements:
px lacks capacity
px is under continous supervision
px is not free to leave

legal safeguards put into place when MHA is not applicable. Ensures deprivation of liberty to be reviewed and monitored regularly

genetic / environmental factors

Hx of previous MH issues, physical illness, social challenges

Rule out organic causes like FBC / TFT/ U&E / LFT / glucose / B12 / cortisol / toxicology and CVS imaging

Hospital anxiety and depression scale
Px health questionnaire [PHQ-9]

During the last month, have you often been bothered by feeling down, depressed or hopeless?

During the last month, have you often been bothered by having little interest or pleasure in doing things

14 questions: 7 for anxiety and depression

Score from 0-3. 11 or more needs more investigations

9 questions, asks px over the last 2 weeks if they have been vothered by these problems.

less than 16 = less severe
16 or more = more severe

5 or more of the following sx present during the same 2 week period and represent a change from previous functioning:

depressed mood most of the day, diminished interest in activities, significant weight loss or gain, decrease / increase in appetite, insomnia / hypersomnia, psychomotor agitation or retardation, fatigue / loss of energy, anhedonia, diminished ability to think, recurrent suicidal ideation

psychotic features: delusions and hallucinations

Depressive stupor: profound immobility, mutism, refusal to eat / drink

least intrusive and least resource intensive first:

guided self-help
group CBT or behavorial activation
Individual CBT or behavourial activation
Group exercises, meditation
Interpersonal psychotherapy
SSRIs
Counselling

CBT + SSRIs [sertraline or venlafaxine is first line]

ECT

Short term SEs: short term memory loss, headache, cardiac arrhythmia, oral damange

Impaired memory in longer term

withdraw first one fully before starting

withdraw, leave a gap of 4-7 days due to longer half life, then start low dose alternative SSRI

cross tapering [lower old dose whilst increasing new drug].

Fluoxetine should be fully withdrawn

cross tapering. 37.5mg daily venlafaxine before slowly increasing

chronic mental health disorder characterised by periods of mania / hypomania alongside episodes of depression

Characterised by at least 2 episodes

Type 1 is mania, type 2 is hypomania

both relate to abnoramlly elevated mood / irritability

Mania includes psychotic sx like delusions or auditory hallucinations whilst hypomania does not contain psychotic sx

Genetic factors [inheritable]
Triggers: stress, physical illness, illicit substance misuse

Medication induced like a “manic switch” which can be induced by SSRIs when treating a depressive episode

Depressive phase

Manic phase: irritable mood, inflated self esteem, sleep disturbance, pressured speech, impulsivity

Psychotic sx

Risk taking behaviour [sexual disinhibition, spending / gambling, violence]

Must rule out organic causes like substance disorder via urine toxicology and amphetamine levels. Delirium can be secondary to infection, thyroid dysfunction, vitamin deficiencies

Prominent affective episodes with marked disturbance of mood

Manic / hypomanic episodes characterised by persistantly elevated, irritable mood

Conservative: hypomania sx, refer to community mental health team [CMHT]. Urgent referral to CMHT if there is mania or severe depression

Lithium is the mood stabiliser of choice, alternative is a valproate

Antidepressant of choice is fluoxetine but consider stopping antidepressants if the px has started on one recently or is also on antipsychotic therapy

IM BZDPs + / - psychiatric admission

oral antipsychotic monotherapy [haloperidol / olanzapine]. Can add mood stabilisers if unsuccessful.

ECT is last resort

chronic mood fluctuations over 2 years with episodes of hypomania and depression

an acute stress reaction that occurs in the first 4 weeks after a person has been exposed to a traumatic event

intrusive thoughts [flashbacks / nightmares]
Dissociation
Negative mood, avoidance
Emotional reactions: overwhelming anxiety, sense of unreality
Physiological manifestations: palpitations, hypervigilance

Direct / indirect to a traumatic event, resulting in intense emotional distress

Sx: dissociation, intrusive memories, -ve mood, arousal, avoidance

Duration: 3 days to 4 weeks post event

1st line: Trauma focused CBT

BZDPs can be used for acute sx like agitation and sleep disturbance, caution for addictive potential

Denial [numbness, pseudohallucinations, might focus on objects or prepare meals for passed ones]
Anger
Bargaining
Depression
Acceptance

Female, sudden / unexpected death, problematic relationship before death, px has not had much social support

delayed grief > 2 weeks after event.
Prolonged grief

Depression that predominantly occurs around winter months. Treated the same as depression. Should not give sleeping tablets

male, hx of self harm, alcohol / drug misuse, hx of mental illness, hx of chronic disease, increasing age, social factors [unemployment, social isolation, living alone], alone / divorced / widowed

can develop at any age following a traumatic event, usually classified as lasting for more than 1 month

Intrusion: flashbacks, nightmares, repetitive images
Avoidance: of situation, circumstances resembling the event
-ve Alterations in mood and cognition
Arousal and reactivity sx: hypervigilance, exaggerated startle response, concentration difficulties, sleep disturbances

Depression, anger, unexplained physical sx, drug / alcohol misuse

Exposure to traumatic event
Clusters of sx
Duration longer than 6 months

mild: sx are manageable and social / occupational functioning are not significantly impaired

Moderate: sx are affecting social functioning but no significant risk of suicide, self-harm or harm to others

Severe: sx are unmanageable, significant impairment to life, significant risk of suicide / self harm / harm to others

if mild sx < 4 weeks = watchful waiting

Severe cases: trauma focused CBT or eye movement desensitisation and reprocessing therapy [EMDR]

Pharmocological management is not 1st line but usually involves an SSRI or venlafaxine

hallucinations [sensory experience]
Delusions [fixed false belief]
Thought disorganisation [tangentiality, word salad, alogia]

agitation / aggression
neurocognitive impairment [memory, attention, executive]
Depression
Thoughts of self harm

Schizophrenia, depression, bipolar disorder, puerperal psychosis, parkinsons, drug use like corticosteroids, illicit drugs like cannabis

most common type

paranoid delusions + auditory hallucinations

usually detected in young adults

mood changes, unpredictable behaviour, shallow affect, fragmentary hallucinations

-ve outlook as -ve sx develop rapidly

-ve sx, px never experienced +ve sx

psychomotor features [posturing, rigidity, stupor]

sx unable to fit into other categories

-ve sx when +ve sx ‘burn out’

FHx
Black-Caribbean
Migration
Urban / stressful environment
Cannabis use

auditory hallucinations [thoughts aloud, hearing voices referring to them 3rd person, commentary hallucinations]
Thought disorder [insertion, withdrawal, broadcasting]
Passivity phenomena [bodily sensations being controlled by external influence. Actions / impulses / feelings imposed on the px]
Delusional perceptions
Somatic hallucinations

incongruity / blunting of affect
anhedonia
alogia
Avolition [poor motivation]
social withdrawal

impaired insight, neologisms, catatonia

urine culture to rule out UTI and urine drug screen for intoxication

Full bloods + HIV / syphilis testing

CT head if organic neurological cause is suspected

A first rank +ve sx or persistent delusion present for at least 1 month
+
No other causes of psychosis like intoxication, brain disease or extensive depressive / manic sx

Care programme approach: assess their health and social needs, make a care plan, appoint a key worker to be a 1st point of contact and review Tx

1st line is atypical antipsychotics with CBT offered to all people

Include early intervention team, community mental health team, crisis resolution team

CVS RFs due to high rates of CVD in schizophrenic px

strong FHx, gradual onset, low IQ, prodromal phase of social withdrawal, lack of obvious precipitant

px believes that they are either dead or non-existant. difficult to treat and can result in significant problems due to px’s taking part in tx. Associated w / severe depression and psychotic disorders

subtype of delusion where individuals deny existence of parts of their body or the whole world around them.

involves treating underlying psychiatric conditions

CBT / ECT have been effective

there is a high risk of self-harm and suicide ideation

age-related macular degeneration, glaucoma, cataract

increasing age, peripheral visual impairment, social isolation, sensory deprivation, early cognitive impairment

vivid visual hallucinations in a partially sighted person. Px maintains insight into the unreality

Must occur in the absence of any other significant neuropsychiatric disturbance via rulling out other causes of visual hallucinations via neurological and opthalmic examinations

manage associated visual impairment with psychological support and pharmacological tx

neuropsychiatric disorder caused by thiamine deficiency usually seen in alcoholics. Alcohol absorbs thiamine.

alcoholism, persistent vomiting, stomach cancer, dietary deficiencies

Triad: confusion, ataxia, opthalmoplegia

Peripheral sensory neuropathy, hypotension, memory disturbance, hypothermia, reduced consciousness

urgent replacement of thiamine via oral supplementation 100mg + abstain from alcohol

If hypoglycaemiac, give thiamine first due to glucose can precipitate wernickes

if untreated, can lead to Korsakoffs syndrome where there is anterograde and retrograde memory loss, which is irreversible.

serious mental health disorder characterised by self-imposed starvation, and a relentless pursuit of extreme thinness. Individuals will have a distorted body image, viewing themselves as overwight when they are normal or dangerously overweight

minimal food intake and excessive exercise

episodic binge eating followed by behaviours like laxative use or induced vomiting

pre occupation with food and calories
Starvation via restriction, purging, excessive exercise
Poor insight
Overvalued, intrusive obsession with weight / shape / fear of being fat
Weight / calorie goals in mind regardless of their impact on physical health

BMI < 17.5 [in bulimia, BMI is normal]
Hypotension
Bradycardia
Enlarged salivary glands
Lanugo hair [fine hair over skin]
Secondary Amenorrhoea

Hypokalaemic hypochloraemic metabolic alkalosis
Pitted teeth / dental erosion
Parotid Swelling
Scarring of dorsum of hand [Russels]

Vomiting complications: Boerhaave and Mallory-Weiss tear

Deranged electrolytes [hypo Ca, K, Mg]
Hypogonadism
Leukopenia
High GH and cortisol
Hypercholesterolaemia
Metabolic alkalosis

Restriction of energy intake relative to requirements
Intense fear of gaining weight / becoming fat, even though underweight
Body weight / shape distortion or denial of the seriousness of the current low body weight

1st line: anorexia focused family therapy
2nd line: CBT

Individual eating disorder focused CBT
MANTRA or specialist supportive clinical management [SSCM]

SSRIs can be given for comorbid MH issues

Can be admitted under MHA if px life is at immediate risk

severe / rapid weight loss
Significant suicide risk
Unable to perform SUSS test
Proximal muscle weakness

sit up, squat and stand

When nutrient intake occurs too rapidly after a period of low caloric intake. Will see oedema, confusion, tachycardia

The exposure to food after starvation leads to a rapid increase in insulin levels which leads to a shift of potassium and magnesium into the cell, leading to a depletion. Will see cardiac arrythmias possibly

Prevented via high dose vitamins [Pabrinex] before feeding commences. Monitor bloods and replenish electrolytes early. No more than 50% caloric requirement given at first in px who have starved for more than 5 days

binge eating [loss of control, high caloric food urgently],
purging
body image distortion

At least once a week for 3 months:

Recurrent episodes of binge eating
Sense of lack of control over eating during the episode
Recurrent inappropriate compensatory behaviour in order to prevent weight gain
Body image distortion

Specialist referral:
Bulimia nervosa focused self-help [targeting eating behaviours, body image, thought patterns and self-esteem]
If unsuccessful, CBT-ED

In children, bulimia nervosa focused family therapy. High dose fluoxetine in some cases

Paranoid, schizoid, schizotypal

antisocial, borderline [emotionally unstable], histrionic, narcissistic

Obsessive-Compuslive, Avoidant, Dependent

Hypersensitive, unforgiving
Unwarranted tendency to question loyalties, generally distrustful and suspicious of others
Preoccupation with conspirational beliefs and hidden meaning
Superficial relationships and lives in isolation

lack of desire for companionship or physical contact [sexual contact, holding hands]
Indifferent to praise / criticism
Emotional coldness / emotional blunting
Few interests
Social isolation

Paranoid ideation and suspiciousness
Odd, eccentric behaviour
Magical thinking / everything relates to destiny
Poor at gauging others perception of them
Lack of close friends other than family members BUT have a strong desire to have relationships

Disregard for moral values and societal norms
Impulsivessness, failure to plan ahead
Irritability and aggressiveness
Deceptive / charming to manipulate for personal gain
Little empathy, willing to hurt others if it helps them
Sociopath or psychopath

Unstable interpersonal relationships which alternate between idealisation and devaluation
Impulsivity and unstable moods from intense joy to rage
Recurrent suicidal behaviour, difficulty controlling temper, affective instability
Terrified of abandonment

attention-seeking, excessive emotionality to manipulate to draw attention
Shallow expression of emotions
Superifical relationships and self-dramatization

Grandiose self image
Chronic envy
Arrogant / haughty attitude
Fragile self-esteem
Exploitative of others
Lacks empathy

Occupied with details, rules, order, agenda to the point where the key part of the activity is gone
Perfectionism
Extremely dedicated to work / efficiency to the elimination of spare-time activities
Umwilling to pass on tasks to others
Stiffness / stubborness

Preoccupied that they are being criticised / rejected in social sitatuions
Avoid occupational activities due to fears of criticism / rejection
Unwilling to be involved unless certain of being liked
Fear of embarassment
Views self as inept and inferior to others

needs excessive reassurance from others
Lack of initiative
Difficulty making decisions, expressing disagreement
Unrealistic fears of being left to care for themselves
Urgent search for relationships as a source of care and support

difficult
Dialectical behaviour therapy
Tx of any co-existing psychiatric conditions

Multiple physical sx for over 2 years. Px refuses to accept reassurance or -ve test results

Persistent belief in the presence of an underlying serious diseases. Px refused to accept reassurance and -ve results

loss of motor / sensory function

Px does not fake the sx or seek material gain

process of separating off certain memories from normal consciousness

Involves psychiatric sx like amnesia, fugue, stupor

Dissociative identity disorder is a severe from

intentional production of physical / psychological s

fraudulent simulation / exaggeration of sx with the intention of financial or other gains

FHx, age 10-20yrs, pregnancy / post-natal period, history of abuse / bullying / neglect

obsessions [intrusive unwanted thoughts]

compulsions [repetitive behaviours / mental acts to reduce anxiety]

via Yale-Brown obsessive-compulsive scale

8-15 = mild
16-23 = moderate
24-31 = severe
32-40 = extremely severe

obsessions + / - compulsions
Time consuming or causes significant impairment
No other medical / mental cause

low intensive CBT with exposure and response prevention [ERP]

can give SSRI or more intensive CBT if needed

offer SSRI or more intensive CBT + ERP

Consider TCA like clomipramine

refer to secondary care MH team for assessment

whilst waiting, SSRI + CBT + ERP

excessive worry about a number of different events, associated with heightened tension. Can make potential metabolic cause

lower socioeconomic status, umemployment, divorce, renting a home, lack of educational qualifications, urban living

hyperthyroidism, cardiac disease, medication-induced anxiety [salbutamol, theophylline, coricosteroids, antidepressant, caffeine]

Psychological: fears / worries, poor concentration, irritability, depersonalisation, derealisation, insomnia

Motor sx: restlessness, fidgeting, feeling on edge

Neuromuscular: tremor, tension headache, muscle ache, dizziness, tinnitus

GI: dry mouth, dysphagia, nausea, indigestions, flatulence, loose bowel movements

Chest discomfort and palpitation
SOB, tight chest
Increased urine frequency, erectile dysfunction, amenorrhoea

Excessive worry and apprehension
Difficulty controlling worry

Associated sx: restlessness, muscle tension, fatigue for longer than 6 months

1. Educate about GAD + active monitoring
2. low intensity psychological intervention [self-help / psychoeducational groups]
3. high intesity psychological interventions like CBT or drug Tx
4. highly specialist input

1st line drug is sertraline SSRI or an SNRI like duloxetine / venlafaxine

Breathing difficulties
Chest discomfort / palpitations
Hyperventilation [hypocalcaemia leading to tingling at extremities or mouth, carpopedal spasm if extreme]
Shaking, sweating, dizziness
Depersonalisation / derealisation
Can lead to agoraphobia

Recurrent, unexpected panic attacks
At least one attack followed by persistant concern of a future attack
Avoidance behaviours related to attack

1. recognition and diagnosis
2. Tx in primary care through CBT or SSRI
3. review and consider alternative tx
4. review / referral to specialist MH services
5. care in specialist MH services

Part of cluster of anxiety disorders characterised by excessive and irrational fears. may be specific to a certain object or situation, leading to avoidance behaviour

usually apparent in early adulthood.
Leads to avoidance behaviour
Phobias of blood or bodily injury can lead to bradycardia / hypotension upon exposure
Severity is dependent on the effect on QOL
Always rule out comorbid depression

fear of open spaces / presence of crowds OR the perceived difficulty of immediate easy escape to safe space.

fear of scrutiny by others in relatively small groups [5-6 people], resulting in the avoidance of social situations. Can be specific like public speaking.

Can be precipitated by stressful / humiliating experiences, parental death, separation, chronic stress

May lead to alcohol / drug abuse

1st line is CBT: uses exposure techniques, aiming for systematic desensitisation

Flooding: exposing a px with phobia of heights to a tower

Modelling: individual observes therapist interacting with phobic stimulus

if ineffective or severe functional impairment, give SSRIs

transient paralysis of skeletal muscles which occurs when awakening from sleep or while falling alseep

Will see paralysis and hallucinations during paralysis

Give clonazepam if troublesome

typically related to a life event and resolves without tx

trouble falling asleep or staying asleep at least 3 nights a week for 3 months or more

Difficulty initiating / maintaining sleep OR early-morning awakening, leading to dissatisfaction with sleep quantity / quality

Despite adequate time / opportunity for sleep and results in impaired daytime functioning

alcohol / substance abuse
stimulant usage
poor sleep hygiene
Corticosteroids
Chronic pain or illness
Psychiatric illness

reduced daytime functioning
decreased periods of sleep
increased accidents due to poor concentration
Partner’s sleep will also suffer
Daytime napping
Enlarge tonsils / tongue
Micrognathia [small jaw]
lateral narrowing of oropharynx

sleep diaries, clinical diagnosis, actigraphy to aid diagnosis

polysomnography is not routinely recommended unless px is suspected OSA

identify cause
advise not to drive
advise good sleep hygiene: no screen, limit caffeine intake

only consider hypnotics if daytime impairment is severe

short acting BZDPs or non-BZDPs like zopiclone or zolpidem

Use at the lowest effective dose for the shortest period possible. Repeated presciptions are not usually given. Review after 2 weeks and consider CBT referral

SEs: daytime sedation, poor motor coordination, cognitive impairment, accidents / injuries, development of tolerance

Either can predispose a greater risk for the other. Fundamentally, if there has been an acute change in px cognitive baseline = delirium. Will see features like inattention, distractibility, disorganised thinking

An acute onset of altered consciousness, fluctuating cognitive impairment and attentional deficits. Can co-exist with dementia / depression = harder to diagnose.
Usually in >65yrs, pre-existing cognitive disorders, sensory impairment, co-morbidities.
Precipated via infections, drugs, surgery / anaesthesia, metabolic abnormalities. Unknown pathophysiology (neurotransmitter imbalance, inflammation, oxidative stress, neuroendocrine alterations

Sudden onset of fluctuating cognitive function and altered consciousness. Attention deficits, easily distracted, concentration problems. Illusions / hallucinations, agitation / fear, delusions

2nd most common cause. Refers to a group of syndromes of cognitive impairment caused by ischaemia / haemorrhage secondary to cerebrovascular disease.
RFs: Hx of stroke / TIA, AF, HPTN, DM, hyperlipidaemia, smoking, obesity, FHx of stroke / CVS disease, coronary heart disease

Stroke-related VD, Subcortical VD (small vessel disease Aetx), Mixed dementia (VD + Alzheimers).
Can also be inherited in CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and lymphadenopathy)

Progressive but with sudden deteriations following strokes / TIA, Hx of deteoriation of cognitive function. Focal neurological abnormalities (visual, sensory, motor disturbances), attention / concentration difficulties, seizures, memory / gait / speech / emotional disturbances

Hx + examination, formal screen of cognitive impairment, medical review, MRI scan to see possible infarcts / white matter changes

NICE recommend NINDS-AIREN criteria for probable VD

Support px, address invididual sx, reduce CVS RFs to slow progression.
Cognitive stimulation therapy, music / art therapy, animals, manage challenging behaviour.
No approved pharmacological medications so far. Consider ACHesterase inhibitors

Usually > 50yrs old, will see rapidly progressive, death within 7yrs of diagnosis. Characteristic is ALPHA-SYNUCLEIN cytoplasmic inclusions (Lewy bodies) in substantia nigra. Often linked with Parkinson and Alzheimers.

Progressive cognitive impairment, typically occurs before Parkinsonism. May be fluctuating. Early impairments in attention / executive function rather than memory loss. May also see delusions / non-visual hallucinations

Clinical usually. SPECT (single photon emission computed tomography) can be used to view alpha-synuclein bodies via using [123-I FP-CIT] as radioisotope

ACHesterase inhibitors like donepezil or rivastigmine used first line. Avoid antipsychotics as patients are extremely sensitive and may develop irreversible parkinsonism

Most common cause of dementia. Widerspread cerebral atrophy in cortex / hippocampus. Microscopic cortical plaques due to deposition of beta amyloid proteins and neurofibrillary tangles due to abnormal tau protein aggregation + hyperphosphorylation of tau proteins. Deficits of ACh seen from damage.
Amyloid plaques and tau tangles + phosphorylation leads to impairment of tubulin assembly into microtubules leading to less information transmission and death to brain cells and abnormal depositions.

age> 60yrs, first degree relative of Alzheimers, autosomal dominant trait inheritance in Chr 21, Downs syndrome, caucasion ethnicity

usually develops > 60yrs, affects all areas of the brain. Presents with memory loss with evidence of varying changes in planning, reasoning, speech, orientation. Anosognosia [px unaware of their own condition], mood disturbances, behaviourial changes, psychosis, agnosis. Eventually px become sedentary and take little interest in anything

lack of insight into problems (miss appointments, misunderstand conversations, mishandle money)

cognitive testing, blood tests to rule out reversible causes, brain imaging, CSF fluid analysis. Amyloid PET imaging

Activities to promote wellbeing tailored to px preference. Cognitive stimulation therapy, cognitive rehab.
Donepezil, rivastigmine, galantamine are all AChesterase inhibitors that can be used, Memantine is an NMDAr antagonist and is used 2nd line.

no preventative measures but can detect beta-amyloid changes and its deposition 15 years prior, along with tau proteins.

neuron damage / death in frontotemporal lobes due to tau proteins and genetic causes (MAPT).
Will see personality changes, increase in appetite, more childlike amusements, obsessions, rituals. Earlier onset < 65yrs, usually preserves memory but has personality changes.
Will see atrophy of frontotemporal lobes, focal gyral atrophy with knife blade appearance, Pick bodies (spherical aggregates of tau), gliosis, neurofibrillary tangles, senile plaques
AChesterase inhibitors / memantine are NOT used here

14 units a week max and should be spread over 3 days or more

Unit = [volume / ABV] / 1000

Oral thiamine if diet is deficient

BZDPs for acute withdrawal
Disulfram promotes abstinence
Acamprosate reduces craving, weak NMDA antagonist

inhibition of acetaldehyde dehydrogenase

even small amounts of alcohol from foods / mouthwash, will produce severe sx

CI: Ichaemic heart disease, psychosis

will see delirium tremens at 48-72hrs with psychosis, tremor, fever, tachycardia

first line: diazepam or lorazepam for px with liver cirrhosis.

Carbamazepine can also be used

erotomania, a paranoid delusion with an amorous quality. Px believes that a famous person is in love with her

rare condition where a px has a delusion that they are infested by bugs / parasites / worms / fungi.

occurs + / - psychiatric conditions

pathological jealousy where a person is convinced their partner is cheating on them without any real proof. Accompanied by socially unacceptable behaviour linked to these claims

seen after even minor head trauma

headache, fatigue, anxiety / depression, dizziness