Psychiatry - Finals

Mental state in which reality is greatly disordered. Sx = hallucinations, delusions, thought disorder, and disorders of self. Episodes begin sudden or gradually, and can last days/weeks/months. 20% have no further eps in 5 years. Complications = suicide, CVS disease, T2DM, cancer, smoking-related illness.

May be preceded by prodromal period (few days - 18 months) in which emotional and behavioural changes occur causing decline in personal functioning and social withdrawal.

Hallucination = perception w/o stimulus. Hypnogogic (falling asleep) and hypnopompic (on waking up) can occur in general population.

• Auditory are most common. 1st person = audible thoughts, 2nd person = hear voices talking to them, 3rd person = hear voices speaking about them (running commentary)
• Olfactory can be due to frontal lobe pathology e.g. medial meningioma that compresses olfactory nerve

Pseudohallucination = perception w/o stimulus, but is considered by the person as subjective and unreal (occur inside head - inner subjective space)

Delusions = fixed, firmly held abnormal belief outside social and cultural norms, that cannot be reasoned away and is held despite evidence to the contrary.

Delusion examples = grandiose, control (believe others are controlling them), reference (believe ordinary events/objects/behaviours have a specific meaning just for them), eratomanic (believe everyone is in love with them), persecutory, Othello syndrome (delusional jealousy - believe partner is unfaithful), nihilistic (believe they are dead/ have lost their internal organs or that they don't exist). Delusions are primary (no previous psychopathological state) or secondary (previous psychiatric disorder), mood congruent/incongruent, bizarre (completely impossible) or non-bizarre.

Encapsulated delusion = delusion in the absence of other signs/Sx of psychiatric illness.

Formal thought disorder = impairment in ability to form thoughts from logically connected ideas, so thoughts are confused and disturbed.

• flight of ideas (rapidly shift from one topic to another, discernible links between ideas), loosening of association (knight's move thinking - move from one topic to another with no links), alogia (poverty of speech - little info conveyed by speech, may only talk if prompted), thought blocking (cessation of thought, stop mid-sentence), circumstantiality (excessive irrelevant details but return to point), tangentiality (go off on tangents and don't return to point), perseveration (initially correct response is innapropriately repeated), echolalia (repeat words spoken around them)

Disorders of self = individual can't ditinguish between themselves and the world.

RFs = BAME, FHx, recreational drugs, Hx of traumatic life events, pregnancy/birth complications, neurodevelopmental delay, high-dose corticosteroids, Toxoplasma gondii exposure, migration 

Psychotic disorders ICD-10:

• Schizophrenia 
• Schizotypal disorder - eccentric behaviour, suspiciousness, unusual speech, deviations of thinking and affect, no hallucinations/delusions
• Persistent delusional disorder - delusional disorder (development of single/set of delusions for at least 3 months e.g. paraphrenia), other persitent delusional disorders
• Acute and transient psychotic disorder - psychotic episode similar to schizophrenia but lasting <1 month. Usually no prodromal period. Often caused by life stress.
• Induced delusional disorder - presence of similar delusions in 2+ individuals with close emotional links
• Schizoaffective disorder - symptoms of schizophrenia and mood disorder (mania or depression) in same episode of illness. Delusions/hallucinations are present for 2+ weeks without mood disorder.

Mood disorder with psychosis - delusions/hallucinations are NOT present without mood disorder.

Non-organic (functional psychosis) = schizophrenia, psychotic disorders, mood disorders (psychotic features occur at same time as mood symptoms, and are mood-congruent), personality disorders (never achieve normal baseline), postpartum psychosis, drug-induced

Organic causes = neuro conditions (Parkinson's, dementia, temporal lobe epilepsy), delirium, metabolic derangements (hyperthyroidism, hypocalcaemia, hypoglycaemia), autoimmune (SLE, MS), Cushing's, malignancy (ovarian teratoma, SCLC), infections (syphilis, HIV, malaria), drug-induced (corticosteroids, recreational drugs)

Ix = MSE, full neuro exam, bloods (FBC, LFTs, U+Es, blood borne virus screen, TFTs, autoimmune antibodies), bedside (BM, urine dipstick), urine screen for drug abuse, imaging (CT/MRI head, EEG)

Mx: (early intervention is psychosis team coordinate care if 1st ep)

• bio = atypical antipsychotics e.g. risperidone. Depot if non-compliance. Annual GP review.
• psycho = assess risk (high - need EIIP same-day mental health assessment), counselling, CBT, family therapy, crisis team involvement if high risk
• social = carers, suitable accomodatioon, involvement of CPN/SW, EIIP team for support and monitoring, driving advice (ok if stable for 3 months, no Tx effects, favourable specialist report)

Prodromal illness - community-based e.g. allocated keyworker, psychiatrist.

Recurrent complex hallucinations (usually visual/auditory) occuring in clear consciousness.

Usually occurs in people who are visually impaired - occurs in 11-15%. Caused by age-related macular degeneration, followed by glaucoma and cataracts.

RFs = old age, peripheral visual impairment, social isolation, sensory deprivation, early cognitive impairment

Insight is preserved. Occurs in absence of other significant neuropsychiatric disease.

Most common psychotic condition, characterised by hallucinations, delusions and thought disorder which cause functional impairment. Consists of psychotic episodes (+ve Sx - add to pt) and -ve Sx (take away from pt).

ICD-10:

• Paranoid - delusions/hallucinations are prominent. Most common
• Simple - only experience -ve Sx, no hallucinations/delusions. Decline in social/academic/work performance
• Hebephrenic - disorganised speech behaviour (aimless and disjointed), flat or incongruent affect. Hallucinations/delusions must not dominate 
• Catatonic - psychomotor disturbance causes catatonic Sx
• Undifferentiated - meet general criteria but no specific subtype predominates
• Residual - 1 year history of -ve Sx. Usually occurs when +ve Sx have 'burnt out'
• Post-schizophrenic depression - some residual Sx following schizophrenic illness but depression predominated

RFs = 15-35 years, FHx, pregnancy/birth complications, abnormal early cognitive/neuro development, parental age at extremes (>40 or <20), cannabis used, low SES, social isolation, adverse life events, migrants

Most common psychotic condition, characterised by hallucinations, delusions and thought disorder which cause functional impairment. Consists of psychotic episodes (+ve Sx - add to pt) and -ve Sx (take away from pt).

ICD-10:

• Paranoid - delusions/hallucinations are prominent. Most common
• Simple - only experience -ve Sx, no hallucinations/delusions. Decline in social/academic/work performance
• Hebephrenic - disorganised speech behaviour (aimless and disjointed), flat or incongruent affect. Hallucinations/delusions must not dominate 
• Catatonic - psychomotor disturbance causes catatonic Sx
• Undifferentiated - meet general criteria but no specific subtype predominates
• Residual - 1 year history of -ve Sx. Usually occurs when +ve Sx have 'burnt out'
• Post-schizophrenic depression - some residual Sx following schizophrenic illness but depression predominated

RFs = 15-35 years, FHx, pregnancy/birth complications, abnormal early cognitive/neuro development, parental age at extremes (>40 or <20), cannabis used, low SES, social isolation, adverse life events, migrants

Catatonia = >2 weeks of 1+ of:

• stupor/mutism 
• posturing 
• negativism (involuntary resistance to passive movement/ act in ways that are contrary to commands)
• rigidity 
• waxy flexibility (reduced response to stimuli and tendency to remain in immobile posture)
• command automatism (instructions carried out regardless of consequences)
• excitement

It is seen in schizophrenia, psychosis, drug withdrawal, mood disorders, pervasive developmental disorders, NMS. Also caused by cerebrovascular disease, Parkinsonism, tumours, hydrocephalus, head injury, infections, medical conds e.g. hyperthyroidism/SLE/DKA.

Can be treated with benzodiazepines or ECT.

Dopamine hypothesis - overactivity of dopamine at D2 receptors in mesolimbic pathway and underactivity of mesocortical pathway.

• Mesolimbic = reward, motivation, pleasure. From ventral tegemental area to limbic structures (amygdala, hippocampal formation, septal area) and nucleus accumbens. Increased dopamine acting at D2 receptors causes +ve Sx.
• Mesocortical = cognition, motivation, emotional response. From ventral tegmental area to prefrontal cortex and cingulate cortex. Decreased dopamine acting at D2 receptors causes -ve Sx.

Abnormal immune function e.g. prenatal viral infections may contribute.

Brain changes:

• enlarged ventricles 
• reduced: hippocampal formation (learning, memory), aygdala (processing fear, emotion), parahippocampal gyrus (spatial memory and navigation), prefrontal cortex (executive functions e.g. immpulse control and goal setting)

For diagnosis, need at least 1 very clear Sx from Group A or 2+ from Group B, for at least 1 month +. No organic brain disease.

Group A -

• thought echo (hear thoughts aloud shortly after thhinking them), insertion, withdrawal or broadcast
• delusions of control, or passivity phenomena (believe thoughts/actions are controlled by others)
• running commentary (3rd person) auditory hallucinations 
• bizarre persistent delusions

Group B -

• hallucinations in other modalitiies that occur every day for at least 1 month + delusions 
• thought disorganisation (loosening of association, neologisms, incoherence)
• catatonic Sx
• negative Sx - avolition, social withdrawal, flat affect, self-neglect, apathy (lack of interest/enthusiasm), alogia, anhedonia

8 A's = flat affect, autism (self-absorbed, in own world), ambivalence (two opposing ideas are held about the same thing at the same time), loosening of association, avolition (decreased motivation), asocial behaviouor, anhedonia, alogia (poverty of speech)

Schneider's first rank (+ve Sx) - these are rare in other psychoses:

• 3rd person auditory hallucinations (running commentary)
• somatic hallucinations (mimic feeling from inside body e.g. 'there is a snake inside mmy stomach')
• thought interference - thought withdrawal, thought insertion, thought broadcast
• passivity experiences 
• delusional preception

Negative Sx also present.

In children/adolescents - prodromal period is common in which subtle behavioural/personality changes occur. Transient or attenuated first rank Sx may occur.

DDs = organic (anti-NMDA encephalitis, drug-induced psychosis, temporal lobe epilepsy, alcoholoic hallucinosis, dementia, delirium), psychiatric (mania, psychotic depression, PD, panic disorder, depression, anxiety, PTSD), substance abuse

MSE

• schizophrenia - A (normal or poor self-care), B (suspicious, restless, withdrawn, reduced eye contact, apathy), M + A (flat affect, incongruent affect), T (delusions, thought interference, thought disorder), P (hallucinations), C (attention and concentration often impaired), insight generally poor 

Bloods - FBC, LFTs, vitamin B12/folate, serological tests e.g. syphilis, blood borne virus screen, autoimmune screen, TFTs, blood alcohol concentration 

Bedside - BM, urine dipstick +/- MSU, ECG (before considering antipsychotics - long QT)

Urine screen (drug abuse)

CT/MRI, EEG - rule out organic neuro cause

Bio:

• manage psychosis - EIIP team to coordinate care if 1st episode. Give PO atypical antipsychotic e.g. risperidone or olanzapine. Benzodiazepines if violent/aggressive.
• yearly check ups at GP 
• CVD and DM RF modification 

Psycho:

• inpatient care if high suicide/homicide risk (do risk assessment), severe Sx, lack capacity to cooperate with Tx, Tx non-compliance, failure of outpatient Tx, need to address co-morbid conds 
• refer to specialist services in pts who are distressed with declining social function and: transient/attenuated psychotic Sx, other behaviour suggestive of possible psychosis, 1st degree relative with psychosis/schizophrenia. Children <17 - CAMHS, If >14 then can refer to EIIP.
• CBT, family interventions in psychosis teams (10 sessions over 3 months-1 year), art therapy for -ve Sx

Social:

• smoking cessation support, support groups (Rethink and SANE), peer support, supported employment programmes 
• care plan

Good prognostic factors - no FHx, clear precipitant, acute, prompt Tx

Poor prognostic factors - gradual onset, FHx, male, -ve Sx, low IQ, prodromal phase with social withdrawal, psych history

Complications = die 9-15 years earlier, suicide risk x9 higher, increased CVS/resp/cancer risk, higher incidence of smoking, 50% have substane abuse problem

Increased suicide risk if - +ve Sx, young and male, first decade of illness, social isolation, good insight

ICD-10:

• manic episode (hypomania, mania +/- psychotic Sx)
• bipolar disorder 
• depressive episode
• recurrent depressive episode (mild, mod, severe +/- psychotic Sx)
• persistent mood disorders - cyclothymia/dysthymia
• other mood disorder 
• unspecified mood disorder

Cyclothymia - numerous periods of elation/deoression, none of which are severe enough for a diagnosis of bipolar disorder, and need to be present for 2+ years. Early onset and chronic course. Common in relatives of pts with bipolar.

Dysthmia - chronic low mood (at least several years) not fulfilling criteria of recurrent depressive disorder (as they're not sufficienctly severe/prolonged)

Factors increasing risk of suicide in someone with mood diisorders - self-neglect, hoplessness, alcohol abuse, Hx of suicidal behaviours 

Negative affect +/- absence of positive affect. Most common psych disorder.

RFs = female, FHx, post-natal period, chronic health problems, poor coping mechanisms, mental health co-morbidities, stressful life event, low SES, adverse childhood experiences

Pathophysiology = monoamine hypothesis (NT changes in NA and 5HT)

Presentation:

• Core = low mood, anhedonia, low energy 
• Somatic Sx = low appetite, sleep changes (hypersomnia in young, insomnia in older, EMW), diurnal variation in mood (worse in morning), poor libido, poor concentration, weight loss, psychomotor retardation 
• Cognitive Sx = low self-esteem, guilt/self-blame, hoplessness, hypoochondrial thoughts, poor concentration, suicidal thoughts/DSH
• Beck's cognitive triad = negative views about onself, the world and the future

Psychotic depression - depressions with hallucinations (often auditory) and mood-congruent delusions (hypochondrial, guilt, nihiilistic, persecutory)

Mild = 2 core Sx + 2 others 

Moderate = 2 core Sx + 3-4 others 

Severe = 3 core Sx + 4+ others (+/- psychotic Sx)

Each Sx should be present for most of each day, and for 1 month +.

Core = low mood (most of the day, almost every day, for at least 2 weeks), anhedonia, low energy

Additional =

• loss of confidence/self-esteem
• unreasonable feelings of guilt
• recurrent thoughts of death/suicide 
• complaints/evidence of diminished ability to think/concentrate
• change in psychomotor activity
• sleep disturbance 
• change in appetite with corresponding weight change 

Adjustment reaction = sudden Sx, Sx fluctuate, time limited, pt is preoccupied with event, energy normal, no sleep disturbance, feelings of anger/frustration 

Depression = gradual onset of Sx, continuous Sx, lack of interest, low energy, sleep disturbance, loss of appetite/weight, low self-esteem, feeling of guilt

Screening questions:

• During the last month, have you often been bothered by feeling down/depressed/hopeless?
• During the last month, have you often been bothered by having little interest or pleasure in doing things?

MSE - self-neglect, thin, unkept, tearful, poor eye contact, psychomotor retardation, slow speech, low volume, low mood, auditory hallucinations, impaired concentration, insight good

Screening tools - PHQ-9, HADS

Bloods - FBC (anaemia, infection), U+Es (hyponatraemia, renal functoin), LFTs (alcohol abuse), TFTs, bone profile (hypercalcaemia), vitamin B12/folate 

HIV/syphilis serology 

MRI/CT to look for cerebrovascular cause

Drug screen 

Autoantibody screen

Risk assessment

Medical - anaemia, cancer, chronic fatigue syndrome, hypo/hyperthyroidism, IBD, stroke, SOL, SLE

Medication use - antipsychotics, beta-blockers, contraceptives, corticosteroids, isotretinoin 

Psychiatric disorder - adjustment disorder with depressive features, AN, anxiety disorders, ADHD, bipolar, BN, coonduct disorder, PDs, psychotic disorders, substance use 

Step 1 (all known/suspected presentations) = bio (advice on sleep hygeine and lifestyle), psycho (psycho-education, self-help books, online info e.g. MIND or depression UK), social (active monitoring, encourage volunteering - opportunities in local area shown on Timebanking UK website, exercise classes)

Step 2 (persistent subthreshold depressive Sx or mild/mod depression) = bio (advice on sleep hygeine and lifestyle, medication), psycho (psycho-education, low intensity psychological intervention), social (active monitoring, support groups, benefits, occupation advice)

• Low intensity psychological intervention - self-help CBT/computerised CBT/physical activity programmes/counselling

Step 3 (mild/mod depression with inadequate response to initial interventions, mod/severe depression) = bio (advice on sleep hygeine and lifestyle, medication), psycho (psycho-education, high intensity psychological interventions), social (active monitoring, support groups, benefits, occupation advice)

• High intensity psychological intervention - CBT, interpersonal therapy, behavioural activation 

Step 4 (severe and complex depression) = bio (advice on sleep hygeine and lifestyle, medication, ECT), psycho (psycho-education, high intensity psychological interventions), social (active monitoring, support groups, benefits, occupation advice)

Antidepressant prescribing: 1st line = SSRI (Sertraline). If major weight loss/sleep difficulties then Mirtazapine. If SSRI not working after 4 weeks then switch. SEs should go away within 2 weeks. Give for 6 months after Sx resolution.

• Other options = SNRIs, TCAs, MAOIs
• Psychiatrist referral if increased suicide risk, severe depression, recurrent depression, unresponsive to Tx

Suicide risk - check on pt within 2 weeks of starting antidepressant. If at risk of suicide or <30 then check within 1 week.

Complications = suicide, CVS disease risk, exacerbates pain, substance abuse. 80% have further ep. 10% have severe unremitting depression.

Seasonal affective disorder = depression in winter months. Tx same.

Cotard syndrome = rare mental disorder, pt believes that they/part of their body is dead or non-existent. Delusion is difficult to treat - patient may stop eating/drinking as they feel it isn't necessary. Associated with severe depression/psychotic disorders.

Mania = significantly elevated mood for 7+ days. Need 3 of following: inflated self-esteem, decreased need for sleep, pressure of speech, flight of ideas, easily distracted, psychomotor agitation, excessive involvement in pleasurable activities w/o thought for consequences. Psychotic features can be present (mood congruent delusions/hallucinations).

Hypomania = elevated mood (but less so than mania) for 4+ days (usually <10). No psychotic features. Sx are less serious, not serious enough to need hospitalisation. Do not harm/put lives of others in danger. 

Mixed affective state = mixture or a rapid alternation (usually within a few hours) of hypomanic, manic and depressive Sx.

RFs = early 20s, FHx, substance misuse, anxiety disorders, stressful life events

ICD-10: currently hypomanic, currently manic +/- psychotic Sx, currently depressed (mild, mod, severe +/- psychotic Sx), mixed disorder, in remission

ICD-10 diagnostic criteria:

• current episode of mania +/- psychotic Sx, hypomania, depression +/- psychotic Sx, mixed/rapid alternation 
• at least 1 episode in the past

Bipolar 1 - 1 or more manic episodes +/- 1+ depressive episodes. Psychotic Sx can be present.

• Mania must be present when diagnosing BD in children. 

Bipolar 2 - no episodes of mania, only hypomania. Can be more subtle, no psychotic Sx. 1 or more depressive episodes with at least 1 hypomanic episode.

Bipolar 3 - iatrogenic. Meds cause mania.

DDs = normal mood fluctuations, hyper/hypothyroidism, AN, cerebrovascular event, dementia, schizophrenia, schizoaffective disorder, PDs, meds (steroids, L-Dopa), CKD, acute drug withdrawal

Schizoaffective disorder - psychotic Sx can occur at different times to mood disorder Sx.

Bipolar - psychotic Sx occur at the same time as mood disorder Sx, and are mood-congruent.

Depression with psychotic Sx - psychotic Sx occur at the same time as mood disorder Sx, and are mood-congruent.

Ix = mood diary, Beck Depression Inventory, HADS, bloods to rule ouot organic cause, urine drug screen, EEG, CT/MRI head

Bio:

• mood stabilisers e.g. lithium (+ sodium valproate if lithium ineffective on own/ or as an alternative). If Sx still persist then refer for specialist consideration of other meds e.g. carbamazepine. Avoid giving antidepressants (and never give in a mixed episode) - if needed, prescribe mood stabiliser alongside.
• mania Mx - urgent referral to CMHT, often need admission. Risk assess. Stop antiepressants. Give antipsychotics (aripiprazole in adolescents >13yrs with BPD1 for up to 12 weeks)
• hypomania/non-severe depression - routine referral to CMHT.
• ECT when antipsychotics ineffective.

Psycho:

• psychoeducation, CBT, family therapy, CPN support

Social:

• benefits/occupation support
• social support groups

80% relapse within 5-7 years.

Anxiety = feeling of worry/nervousness/unease about something with an uncertain outcome. Normal physiological response (stress response) to potential threat. Increasing anxiety increases performance up to a point.

• Physiologic reaction to anxiety = decreased blood flow to gut, gut SM contraction, increased blood flow to skeletal muscles, increased muscle tension, pupil dilatation, nausea, increased HR and BP

Stress response (and general adaptation syndrome) - when someone experiences a stressful event, the amygdala sends a distress signal to the hypothalamus. The hypothalamus then activates the SNS (fight/flight response - alarm reaction of GAS) which sends signals to adrenal glands via autonomic nerves. This causes NA and adrenaline to be released.

• Adrenaline causes increased HR/BP/RR, senses become sharper, increased glucose and fat from body stores

Once initial surge of adrenaline subsides then the HPA axis is activated, which causes cortisol release (inhibits insulin production, increases glucose in blood, causes vasoconstriction). Action of cortisol is longer than adrenaline, which allows maintenance of the stress response (resistance stage). Prolonged stress causes continued cortisol secretion which leads to muscle wastage, immune suppression and hyperglycaemia (exhaustion stage).

In anxiety disorders, the perceived danger doesn't exist, and the response is psychological. Overactivity of ascending noradrenergic neurones innervating the limbic system occurs (amygdala is part of limbic system - keeps sending out distress signal to hypothalamus so maintenance of stress response)

Reduced functional connectivity between prefrontal cortex and limbic system causes increased conscious control and awareness of emotional states.

Single nucleotide polymorphisms in 5-HT transporter causes decreased 5-HT signalling (monoamine hypothesis of anxiety and depression). 5-HT transporter is responsible for serotonin reuptake into presynaptic terminal, hence terminates action of serotonin.

Dysregulation of HPA axis causes increased cortisol release.

Phobic anxiety disorders = irrational and intense fear of a specific object/situation. Leads to anticipatory anxiety and avoidance. 

RFs = adverse experiences, stress, other anxiety disorders, mood disorders, substance misuse disorders, FHx

Pathophysiology:

• genetics 
• psychoanalytic theory - fear is the symbolic representation of an unconscious conflict, which has been repressed and displaced into phobic Sx 
• learning theory - conditioned fear response related to traumatic situation, with learned avoidance

ICD-10:

Either of the following - fears manifest in social situations 

• marked fear of being the focus of attention or behaving in an embarassing/humiliating way
• marked avoidance of being the focus of attention or of situations in which there is fear of behaving in an embarassing/humiliating way

At least 2 Sx of anxiety in feared situation, + one of the following:

• blushing or shaking, fear of vomiting, urgency/ fear of micturition or defaecation

Significant emotional distress due to Sx or avoidance, and the individual recognises that they are excessive/unreasonable

Sx are restricted to/predominate in the feared situations, or when thinking about the feared situations.

Mx = individual CBT, meds (SSRI). If meds and CBT are declined, then short-term psychodynamic psychotherapy.

Fear of public spaces.

ICD-10:

Marked and consistent far/avoidance of at least 2 of: crowds, public places, travelling alone, travelling away from home 

Sx of anxiety in feared situation, with at least 2 Sx present together, at least 1 autonomic arousal Sx

Significant emotional distress due to avoidance/anxiety Sx, and recognition that these are excessive/unreasonable 

Sx are restricted to/predominate in feared situation or when thinking about situation

Mx = antidepressants. Exposure techniques, relaxation training, CBT.

5 types - animal, aspects of natural environment, blood/injection/injury, situational, other.

ICD-10:

Either -

• marked fear of specific object/situation (not social/agoraphobia)
• marked avoidance of objects/situations 

Sx of anxiety in feared situation 

Significant emotional stress due to Sx/avoidance and recognition that these are excessive/unreasonable

Sx are restricted to feared situation/when thinking about it 

Mx = exposure therapy, CBT, SSRIs

Attacks must occur for >1 month, there must be persisting anxiety about the recurrence of attacks, the consequences of attacks, or significant behavioural changes associated with them. Can co-exist with agoraphobia (panic disorder can --> agoraphobia).

ICD-10:

Recurrent panic attacks that are not consistently associated with specific situation/object and are spontaneous. No trigger, occur randomly.

Panic attack is characterised by all of -

• discrete episode of intense fear/discomfort 
• starts abruptly
• reaches a crescendo withing a few mins, and lasts at least a few mins 
• at least 4 anxiety Sx, at least 1 autonomic arousal Sx

Panic attacks can occur in other anxiety disorders. Panic disorder is when panic attacks occur suddenly and randomly without a specific trigger.

Pathophysiology = reduced GABA levels in cortex causes excitatory effect.

Mx:

1. Recognition and diagnosis 

2. Tx in primary care = avoid anxiety-producing substances e.g. caffeine, CBT or meds (SSRIs 1st line. If no response after 12 weeks, then give TCAs imipramine or clomipramine)

3. If this fails, then review and consider alternative Tx. Can use pregabalin (GABA analogue)

4. If 2x interventions fail then refer to specialist mental health services 

5. Inpt care in specialist mental health services

Mx of acute panic attack - sit down, try to relax, control breathing rate (count to 4 between breathing in and out)

Ongoing anxiety and worry about many things, pt recognises as excessive and inappropriate. May have panic attacks on top. Type 1 worries = everday worries that change. Type 2 worries = worry about their worries). Often maintained by belief that worry is useful (motivates)

ICD-10:

6 months with prominent tension/worry about everyday events and problems, with 4 of the following (1+ in children), at least 1 being an autonomic arousal Sx:

• autonomic arousal - palpitations, sweating, trembling/shaking, dry mouth
• chest and abdomen - SOB, feeling of choking, chest pain, nausea, abdo distress
• brain and mind - dizzy/light-headed, derealisation/depersonalisation, fear of losing control or passing out, fear of dying
• general - hot flushes, cold chills, numbness/tingling 
• tension - muscle tension/aches/pains, restlessness/inability to relax, feeling on edge, sensation of lump in throat/diffiiculty swallowing 
• non-specific - easily startled, difficulty concentrating/mind blank, persistent irritability, difficulty sleeping

RFs = aged 35-54, divorced/separated, living alone, FHx, female, substance abuse, adverse childhood experiences, unemployment, low SES

DDs:

• SOB - CCF, PE, asthma 
• Autonomic arousal Sx - hypoglycaemia, phaeochromocytoma 
• intoxicatiion/withdrawal - alcohol, caffeine, recreational drugs, BDZs
• organic causes - Cushing's, hyperthyroidism, temporal lobe epilepsy

Ix =

• MSE - A+B (look worried, restless, tremor, sweat hands, increased RR< pallor, tense posture), S (tremulous), M (anxious), T (repetitive worrying thoughts), C (poor memory, reduced concentration), may/may not have insight
• GAD-7 questionnaire, HADS, Beck's anxiety inventory
• bloods (TFTs to rule out thyrotoxicosis, blood glucose to rule out hypoglycaemia)
• CAGE questoinnaire (alcohol withdrawal can mimic anxiety Sx)
• dementia screening e.g. MMSE and 6CIT
• special tests e.g. 24 hour urinary metanephrine collection (rule out phaeochromocytoma)

Step 1 (any case of suspected GAD) - active monitoring (review every 4-8 weeks), psychoeducation 

Step 2 - low-intensity psychological interventions (self-help, psychoeducational groups)

Step 3 - medication or high-intensity psychological interventions (CBT, applied relaxation)

• 1st line = SSRI (sertraline). If no improvement after 12 weeks, then offer another SSRI or SNRI (duloxetine or venlafaxine). 
• Beta-blockers for Sx management
• Must warn about potential SEs, withdrawal Sx, delay in onset of effect, time course of Tx, increased risk of suicidal thoughts and DSH in first 2-3 weeks.
• If pt can't tolerate SSRIs/SNRIs then pregabalin 

**For a pt on meds, follow up weekly for first month if <30, then every 2-4 weeks for first 3 months. 

Step 4 - medication +/- high-intensity psychological interventionsm involve specialist services, consider inpt care

ICD-10:

Obsessions/compulsions need to be present on most days for a period of at least 2 weeks. Obsessions/compulsions cause distress, or intefere with social/individual functioning (mostly by wasting time).

Obessional Sx have the following characteristics:

• originate in mind of pt
• repetitive and unpleasant 
• acknowledged as excessive/unreasonable
• pt tries to resist but at least one obsession/compulsion is unsuccessfully resisted

Carrying out obsessive thought or compulsive act is not pleasurable, but reduces anxiety

Obsession = thought that persists and dominates an individual's thinking despite their awareness that the thought is either entirely without purpose, or that it has persisted in their thinking beyond point of relevance or usefulness. They are unpleasant, and ego dystonic (opposite of what they would normally do) e.g. contaminating, sexual imagery, aggression

Compulsion = obsessional motor acts or mental behaviours that a person feels driven to perform (= neutralising behaviours that reduce anxiety) e,g, ordering, washing, checking

Pathophysiology (unknown, suggested theories): re-entry circuits in basal ganglia, reduced serotonin levels. Genetics. PANDAS. Psychoanalytic theory - filling the mind with obsessional thoughts to prevent undesirable ideas entering consciousness. Behavioural theory - compulsive behaviour is learned and maintained by operant conditiong (anxiety created by obsession is reduced by performing the compulsion, so the need to perform the compulsion increases)

DDs:

• obsessions and compulsions - EDs, anakastic PD, BDD
• primarily obsessions - anxiety disorders, depressive disorders, hypochondrial disorders, schizophrenia 
• primarily compulsions - Tourette's/kleptomania
• organic DDs - dementia, epilepsy, head injury

PANDAS = paediatric autoimmune neuropsychiatric disorder associated with Streptococcal infection. Causes sudden onset of OCD/tics after infection with group-A Beta-haemolytic strep. Thought to be due to antibodies cross-reacting with neurones in basal ganglia. Give Abx.

History:

• Do you have any thoughts that go round and round in your mind, depsite trying hard to resist them? 
• Do you have certain rituals or actions that you feel you need to perform? Are you able to resist performing these actions?
• Do you worry about contamination with dirt even after washing? Do you repeatedly check things you have already done? Do you find yourself having to count/rearrange things many times?

MSE - may demonstrate increasing anxiety if unable to succumb to compulsion, thoughts are unwanted/intrusive/uncomfortable for pt, obsessions can lead to poor concentration, insight is usually very good

Yale-brown obsessive-compulsive scale (Y-BOCS)

Mild functional impairment - low-intensity psychological Tx (group CBT, self-help CBT). If this is insufficient then either SSRi, or CBT + Exposure and Response prevention.

• SSRI given high dose - fluoxetine, sertraline, citalopram

Moderate functional impairment - SSRI or CBT + ERP. If SSRI is effective then continue for at least 12 months to prevent relapse. An alternative to SSRI is the antipsychotic clomipramine. 

Severe functional impairment - SSRI + CBT + ERP

Deep brain stimulation can also be trialled - stops re-entry circuit in basal ganglia (between globus pallidus and substantia nigra to the caudate nucleus and putamen)

**ERP = prevent repetitive behaviour. Involves exposing a pt to an anxiety provoking situation and stopping them engaging in their safety behaviour.

Physiological and maladaptive reaction to sudden stressful event. Immediate onset of Sx.

Transient disorder that develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress. Usually subsides within hours (lasts up to 2-3 days). Individual vulnerability and coping capacity affect occurence/severity.

Presentation = initial dazed state, narrowing of attention, apparent disorientation, aggression, hopelessness, uncontrollable/XS gried, autonomic Sx of panic, hyperarousal. May have partial/complete amnesia.

No Tx required. If Sx are more severe and prolonged then trauma-focused CBT/EMDR.

Significant distress out ot proportion to initial stressor that impairs social/occupational functioning. 

ICD-10: Experience of identifiable psycho-social stressor within 1 month of Sx onset. Sx or behaviour disturbance include those found in any affective disorder/anxiety disorder/somatoform disorder/conduct disorder. Sx are present for <6 months.

Only diagnose when pt doesn't meet criteriia for more specific diagnoses e.g. anxiety disorders.

Mx = counselling, family therapy, crisis intervention

ICD-10:

Exposure to stressful event or situation of exceptionally threatening/catastrophic nature 

Persistent remembering/reliving stressor by intrusive flashbacks, vivid memories, recurring dreams or experiencing distress when exposed to circumstances that are similar/associated with stressor

Avoidance of circumstances that are similar/associated with stressor

Either -

• Inability to recall some important aspects of period of exposure to stressor
• Persistent Sx of hyperarousal. 2+ of following: difficulty sleeping, irritability/anger outbursts, difficulty concentrating, hyper-vigilance (increased alertness), exaggerated startle response

Occur within 6 months of stressful event

Pathophysiology = hyperactivity of amygdala causes exaggerated response to perceived threats. Cortisol inhibits traumatic memory retrieval and controls sympathetic response - PTSD pts have reduced cortisol levels.

RFs = majoor traumatic event, Hx of mental illness, refugees/asylum seekers, first responders, low SES, childhood abuse, concurrent life stressors, absence of social support

Presentation = re-experiencing (flashbacks, vivid memories, nightmares, repetitive distressing intrusive images), avoidance (of reminders of trauma, excessive rumination about trauma, inability to recall aspects), hyperarousal, emotional numbing (feeling detached from others, giving up previously enjoyed activities, -ve thoughts about onseld)

Mx:

Within 3 months of trauma -

• watchful waiting if Sx present for <4 weeks
• trauma focussed CBT or Eye movement desensitisation and reprocessing (EMDR)
• Short-term meds e.g. zopiclone for sleep

>3 months after trauma -

• trauma-focussed CBT or EMDR
• if CBT/EMDR are ineffective/pt preference/co-morbid depression/severe hyperarousal then meds (SSRIs or venlafaxine)

Class of disorders whose Sx suggest/take form of physical illness, but in absence of physiological illnes. This leads to the presumption that Sx are due to psychological factors. Prevalence is 0.1-2%. F>M.

RFs = genetics, PTSD, physical/sexual abuse

DDs = Sx directly related to psychiatric disorders e.g. depression, dissociative disorders, factitious disorder, malingering, organic disease

Somatization disorder (Briquet's syndrome):

• at least 2 years duration of physical Sx that cannot be explained by a physical disorder
• preoccupation with Sx causes physical diress which leads to them seeking repeated medical consultations/requesting Ix
• continuous refusal to accept reassurance from doctors that there is no physical cause
• a total of 6+ Sx.

Somatoform autonomic dysfunction: objective evidence of autonomic arousal e.g. sweating, and more subjective Sx e.g. pains/burnings/bloating. Patients attribute these to a particular organ that is largely under autonomic control e.g. GI (IBS), resp (psychogenic hyperventilation), CVS (Da costa syndrome - chest pain that mimics angina)

Persistent somatoform pain disorder: severe and persistent pain >6 months that can't be fully explained by physical illness.

Hypochondrial disorder: Patients misinterpret normal bodily sensations which lead them to believe that they have a serious and progressive physical disease. Refuse to accept reassurance/negative test results.

• Body dysmorphic disorder - variant of hypochondiral disorder, in which patients are preoccupied with an imagined/minor defect in their physical appearance. Leads to time consuming behaviouors e.g. mirror gazing.

Malingering = patient seeks advantageous consequences of being diagnosed with a medical condition e.g. receiving benefits, being given a certain drug or evading criminal prosecution (secondary gain). Fradulent simulation or exaggeration of Sx.

Factitious disorder (Munchausen's syndrome) = individual wishes to adopt the 'sick role' in order to receive the care of a patient for internal emotional gain (primary gain). Intentional production of physical or psychological Sx.

Munchausen's by proxy = caregiver makes up an injury or illness for a person under their care.

Sx which cannot be explained by a medical disorder, in which there are convincing associations in time between Sx and stressfull events/problems/needs. Unpleasant events are converted into Sx. Prevalence = 2-6/100.

Dissociation is the process of 'separating off' certain memories from normal consciousness (psychological defence mechanism - prevents emotional conflict from entering their mind). Sx tend to pass after a few weeks/months, particularly if onset is associated with traumatic life event.

Dissociative amnesia - partial/complete memory loss for events of a traumatic or stressful nature, not due to forgetfulness/organic brain disorders/intoxication.

Dissociative fugue - amnesia for personal identify, including memories and personality. Self-care and social interaction are maintained. Usually only lasts hours-days. 

Dissociative stupor - decreased/absence of voluntary movement and normal responsiveness to external stimuli.

Dissociative anaesthesia and sensory loss - cutaneous/visual sensory loss that doesn't correspond to anatomic dermatomes or neurological patterns.

Trance and possession disorders - trance (= temporary alteration in state of consciousness) and posession (=absolute conviction that they have been taken over by spirit/power/person)

Dissociative motor disorders - partial/complete paralysis of 1+ muscle groups that are under voluntary control, not due to any physical cause.

Dissociative convulsions (psychogenic non-epileptic seizures) - present similarly to epileptic seizures but no tongue-biting, serious injury or UI.

Dissociative identity disorder (Multiple personality disorder):

• covert - sudden and dramatic shifts in the way they perceive, think and feel. Usually aware that the experience is unusual 
• overt - assume 2+ distinct identities which talk and act differently compared to original person. Have different political views, age, gender and nationality. Don't always have insight. Forget portions of the day, and have periods of fugue. Suicide high.

• MSE
• Physical examination 
• Bloods - FBC (anaemia, infection), U+Es (electrolyte disturbance), LFTs, CRP, TFTs
• If GI Sx - AXR, stool culture, OGD, colnoscopy, diagnostic laparoscopy
• CVS Sx - ECG, ECHO, angiogram 
• Resp Sx - CXR
• GU Sx - urine dipstick, MSU, cystoscopy

Biological:

• SSRIs for underlying mood disorder 
• encourage physical exercise 

Psychological:

• CBT
• coping strategies
• Psychoeducation - physical Sx that we can't find a reason for, but there are other ways we can help. We often find that physical illnesses get worse if the pt feels tense/stressed/down, so if we help on this front it should help make you feel a bit better too.

Social:

• encourage hobbies 
• stress-relieving activities 
• involve family member if appropriate

Personality = individual differences in characteristic patterns of thinking/feeling/behaving. Personality disorder = maladaptive patterns of behaviour, cognition and inner experience, that deviate markedly from those accepted by individual culture. They do not involve psychosis/persistent mood alterations. They are persistent, problematic and pervasive (across different contexts). Diagnosed once adaptive behaviours become fixed (around 18 years).

ICD-10:

Characteristic and enduring patterns of inner experience/behaviour deviate markedly from culturally expected and accepted range/norm. Deviation manifests in 1+ of:

• cognition, control over impulses/need gratification, relating to others/manner of handling interpersonal situations, affectivity (degree of person's response to pain/pleasure/emotional stimuli)

Deviation manifests pervasively as behaviour that is inflexible/maladaptive/otherwise dysfunctional cross broad range of personal/social situations (pervasive)

Personal distress/adverse impact on social environment attributable to behaviour (problematic)

Evidence that deviation is stable and long duration (persistent)

Deviation cannot be explained byy other mental disorders/organic disease

Paranoid (SUSPECT) - suspicious of others, unforgiving (bears grudges), spouse fidelity questioned, perceives attack, envious (jealous), criticism not liked, trust in other reduced

Schizoid (DISTANT) - detached (from others), indifferent to praise/criticism, sexual drive reduced, tasks done alone (prefers solitary activities), absence of close friends, no emotion (limited capacity to express feelings), takes pleasure in few activities. Also no desire for close or sexual relationships

Schizotypal (classified as clinical disorder associated with schizophrenia in ICD-10, classified as PD in DSM-V) - eccentric behaviour, odd beliefs or magical thinking, unusual beliefs and perceptual experiences, ideas of reference, paranoid ideas, vague or circummstantial thinking, social withdrawal, inappropriate affect, lack close friends. Can --> schizophrenia.

Emotionally unstable (borderline - AM SUICIDE) = abandonment feared, mood instability, suicidal behaviour, unstable relationships, intense relationships, control of anger poor, impulsivity, disturbed sense of self, emptiness (chronic). May experience pseudohallucinations. PD that is most likely to lead to suicide.

• Impulsive type - need 3+ of: tendency to act without consideration of consequences, tendency to quarrelsome behaviour, liability to outburts of anger/violence, difficulty maintaining course of action that doesn't offer immediate award, unstable mood
• Borderline type - need 3 Sx of impulsive type and 2 of: disturbances in/uncertainty about self-image/aims/internal preferences, liability to become involved in intense and unstable relationships, excessive efforts to avoid abandonment, recurrent threats/acts of DSH, chronic feelings of emptiness

Antisocial (dissocial - CORRUPT) = callous (insensitive/cruel disregard for others), others blamed, reckless disregard for safety/rules/obligations, remorseless (lack of guilt), underhanded (deceitful), poor planning (impulsive), temper/tendency to violence. More common in men. Also incapable of maintaining enduring relationships (no difficulty establishing them)

Histrionic (PRAISE) = provocative behaviour, real concern for physical attractiveness, attention seeking, influenced easily, shallow/seductive (innapropriately), egocentric (vain), exaggerated emotions (dramatic)

Narcissistic = grandiose sense of self-importance, need for admiration, degrade others, preoccupation with fantasies of unlimited success/power/beauty, lack of empathy, arrogant

Anakastic (obsessive compulsive - LAW FIRMS) = loses point of activity due to preoccupation with detail, ability to complete tasks is compromised (due to perfectionism/ preoccupation with orderliness and rules), workaholic at expense of leisure, fussy (excessively concerned with minor details), inflexible, rigidity (about morals/ethics/values), meticulous attention to detail, stubborn

Dependent (RELIANCE) = reassurance required, expressing disagreement is difficult, lack of self-confidence, initiating projects is difficult (lack of initiative), abandonment feared, needs others to assume responsibility/make decisions for them, companionship sought (urgent search for another relationship as source of care/support when a close relatioonship ends), exaggerated fears

Avoidant (anxious - CRIES) = certainty of being liked is needed before becoming involved with people, restriction to lifestyle in order to maintain security, inadequacy felt (believe that they are socially inferior), embarassment potential prevents involvement in new activities, social isolation with craving for social contact. Also hypersensitivie to critical remarks or rejection, and avoid intimate relationships due to fear of being ridicules unless acceptance guaranteed.

Ix = toxicology screen (substance abuse common), STI and HIV screen (poor impulse control), psychological testing (international PD examination (IPDE), PDQ-4 is used in Leics)

Mx:

• bio (meds only for Sx, don't affect maladaptive personality traits) - treat comorbidities, can give SSRIs (anakastic, DSH behaviour, depressive Sx), mood stabilisers (aggression, impulsivity and mood instability. Antipsychotics can be given in a crisis
• psycho - psychoeducation, CBT, psychodynamic psychotherapy, dialectical behavioural therapy (cognitive and behavioural therapy, some relaxation techniques), crisis team assessment in a crisis to assess need for admission, crisis Mx plan, harm minimisation techniques e.g. holding ice cubes/elastic bands on wrists
• social - support groups, substance misuse services, assistance with social problems

In primary care, refer to CMHT for EUPD assessment, to CAMHS if <18.

Complications = DSH, MSK injuries from assaults/accidents, substance abuse, suicide, relationship difficulties

AN = intense fear of gaining weight, leading to the refusal to maintain/achieve normal body weight. 

• Restrictive type or binge eating/purging type (in latter, they also severely restrict intake and BMI <17.5)

ICD-10: 

Must be present for 3+ months with the absence of recurrent episodes of binge eating or preoccupation with eating/craving to eat. Criteria = FEEDD

• intense fear of gaining weight (=overvalued idea)
• emancipated, refusal to maintain/achieve normal body weight, BMI <17.5
• endocrine disturbance e.g. amenorrhoea, impotency
• deliberate weight loss
• distorted body image

Unlike most psychiatric illnesses, AN is ego syntonic ('feels right') which makes it more difficult to treat.

DDs = BN, OSFED, depression, OCD, schizophrenia (delusions aboout food), organic causes of weight loss, alcohol/substance misuse

Fear of gaining weight --> rules: calorie limits, foods/food groups avoided, rules around eating (always less than others, eat alone, eat at exact times). 

Distorted body image --> constant comparisons with others, body checking. They ignore hunger and compensate for what is eaten. Diabetics may omit or reduce insulin dose.

Physical features = fatigue, hypothermia, low HR, peripheral oedema (secondary to low albumin), lanugo hair, weak proximal muscles, rapid weight loss, amenorrhoea, feel cold a lot, feel bloated 

RFs:

• bio - genetics, FHx, female, early menarche 
• psycho - sexual abuse, dieting behaviours starting in adolescence, low self-esteem, anxiety/depression, anakastic personality
• social - western society, bullying about weight in school, stressful life events, occupational pressure

• MSE - A+B (thin, weak, slow, baggy clothes, dry skin, lanugo hair), S (may be slow/slurred), M (can be low if co-morbid depression, or euthymic), T (preoccupied with food, weight/appearance are overvalued ideas), C (can be poor), insight often poor 
• Hx - "Do you ever find yourself being concerned about your weight?" "What would be your ideal target weight?" "What methods do you use to lose weight?" "When women lose a lot of weight, their periods can stop. Has this happened to you?"
• Bloods - FBC (anaemia, low platelets, low WCC), U+Es (raised urea and creatinine if dehydrated, hypokalaemia, low phosphate, low magnesium), increased cholesterol, TFTs (low T3/4), LFTs (low albumin), increased cortisol, low sex hormones (LH and FSH), low glucose, increased growth hormone 
• VBG - metabolic alkalosis if vomiting, metabolic acidosis if taking laxatices 
• DEXA scan - rule out osteoporosis
• EXG - identify bradycardia and prolonged QT if BMI <15
• Sit-up and squat-stand test (SUSS) to assess muscle power

Follow MARSIPAN guidelines (Mx of Really Sick Pts With AN) - when to admit, advice on assessment and Mx

Hospitalisation if: 

• BMI <13
• HR <40
• low BP
• Core temp <35 degrees
• Electrolyte/ECG abnormalities 

Bio - SSRIs if comorbid depression, Tx of complications 

Psycho - risk assessment. One of MANTRA therapy (Maudsley AN Tx for Adults), SSCM (Specialist Support Clnical Mx), CBT-ED (indiividual eating-disorder-focused CBT). Also psychoeducation about nutrition, cognitive analytic therapy, IPT.

• In children/adolescents, 1st line = AN focused family therapy. 2nd line = CBT.

Social - self-help groups, voluntary organisation e.g. BEAT

Metabolic:

• Hypokalaemia, hyponatraemia, low phosphate, low magnesium, low albumin (causes peripheral oedema)
• Raised cholesterol, raised urea and creatinine if dehydrated

Endocrine:

• Raised cortisol, raised growth hormone
• Low sex hormones (FSH + LH), low testosterone
• Amenorrhoea 
• Sick euthyroid syndrome (low T4, normal TSH)

GI:

• delayed gastric emptying and reduced gut motility --> constipation
• hepatitis
• fatty liver
• pancreatitis
• PUD

MSK - osteopenia/osteoporosis

CVS:

• Low HR, low BP
• arrythmias
• cardiomyopathy
• mitral valve prolapse 
• HF

Renal:

• renal failure
• renal stones 

Neuro:

• Seizures 
• Peripheral neuropathy

Blood:

• BM suppression --> low WCC, low platelets, IDA

Metabolic disturbance that results from food intake after prolonged starvation/malnourishment. 

Pathophysiology = low blood glucose causes a drop in circulating insulin. A sudden increase in blood glucose on feeding causes a surge in insulin. Reduced phosphate intake and sudden insulin increase --> abrupt decrease in serum phosphate.

Biochemical features = hypokalaemia, low magnesium, low phosphate, abnormal fluid balance. Low phosphate can cause cardiac failure.

Mx:

• Start by feeding up to 10kcal/kg/day, then increase to full needs over 4-7 days
• Give PO thiamine
• Daily bloods to monitor U+Es.

BN = recurrent binge eating followed by innapropriate compensatory behaviour. Normal BMI (potential for increased weight after binge is counteracted by purge). Common alongside depression, anxiety, DSH, substance abuse, EUPD.

• Purging type (vomiting/laxative use) and non-purging type (exercise/fasting)

ICD-10: (Bulimia Pts Fear Obesity)

• Behaviours to prevent weight gain (compensatory)
• Persistent preoccupation with eating and strong desire to eat 
• Fear of fatness - self-perception of being too fat
• Recurrent episodes of overeating - at least x2 a week over 3+ months

Binge = subjective loss of control, large amounts (high calorie/forbidden foods), associated guilt afterwards, secretive/often hide the evidence 

Signs - repeated vomiting = Parotid gland swelling, Russel's sign (calloused knuckles), erosions of inner surface of front teeth, Mallory-Weiss tear

Also show signs of dehydration = low BP, reduced skin turgor, increased cap refill, dry mucous membranes, sunken eyes

RFs:

• bio = female, FHx, early onset of puberty, childhood obesity, co-morbidities
• psycho = physical/sexual abuse, childhood bullying, parental obesity, pre-morbid mental health disorder, high parental expectations, low self-esteem
• social = western society/developed country, profession, environmental stressors/life events, family dieting 

DDs = AN, OSFED, Kleine-Levin syndrome, depression, binge eating disorder, OCD, organic causes of vomiting 

Kleine-Levin syndrome = sleep disorder in adolescent males, recurrent episodes of binge eating and hypersomnia

History  Q's - "Do you ever feel that your eating is getting out of control?" "After an episode of eating what you later feel is too much, do you ever make yourself sick/use meds to make yourself feel better?" "Do you ever feel a strong craving to eat?" (preoccupation with food) "Do you ever get muscle aches/very fast HR?" (hypokalaemia)

MSE - A+B (normal weight, parotid swelling, sunken eyes, Russel's sign), S (slow or normal), M (low), T (pre-occupied with body size/shape/eating), C (normal or poor), insight usually good

Bloods:

• FBC - anaemia 
• U+Es - low sodium, low magnesium, low potassium, low phosphate
• low glucose 
• TFTs
• amylase - raised in 30% of pts with significant vomiting due to salivary gland hypersecretion

VBG - hypokalaemic metabolic acidosis with vomiting, metabolic acidosis with laxative use

ECG - signs of hypokalaemia (raised PR interval, flatted T wave, U waves)

EAT (Eating Attitudes Test) questionnaire 

Pregnancy test if amenorrhoea

Bio:

• trial of antidepressant - usually high dose Fluoxetine (60mg) as this can help reduce frequency of binge eating/purging
• treat complications e.g. hypokalaemia 

Psycho:

• psychoeducation about nutrition
• risk assessment 
• 1st line in adults = BN focused guided self-help. If this is ineffective after 4 weeks, then CBT-BN. IPT is an alternative to CBT-BN.
• 1st line in adolescents = focused family therapy (FT-BN)
• inpt Tx if suicide risk/electrolyte abnormalities

Social:

• food diary to monitor binge eating/purging patterns 
• techniques to avoid bingeing - eat in company, mindful eating 
• self-help programmes 
• online resources e.g. beat

CVS:

• arrhythmias 
• mitral valve prolapse
• peripheral oedema 

GI:

• MW tear
• increased salivary gland size 

Dental - erosion of enamel by gastric acid 

Endocrine:

• irregular periods
• hypoglycaemia 
• osteopenia 

Dermatological - Russel's sign

Pulmonary - aspiration pneumonitis 

Neuro:

• cognitive impairment 
• peripheral neuropathy 
• seizures

Atypical AN - fulfil some features of AN but not enough --> diagnosis. E.g. one of they key Sx such as amenorrhoeoa or fear of being fat may be absent, but there is weight loss/ weight loss behaviour.

Atypical BN - fulfil some features of BN but not enough for diagnosis e.g. there may be recurrent binges and purges without typical overconcern of body shape/weight

Psychogenic overeating - stressful event --> eating too much 

Psychogenic vomiting - occurs in dissociative disorders and hypochondrial disorders

Pica - regularly eat things that aren't food and have no nutritional value

Binge eating disorder (diagnosis only in DSM-V, comes under 'other eating disorder in ICD-10) - recurrent binges that can lead to weight gain. Eat more rapidly than usual, eat until uncomfortably full, eat large amounts even when not hungry, eat alone due to embarassment, feel disgusted afterwards.

Eating disorder unspecified - EDs that don't meet diagnostic criteria.

Aetiology:

• environmental - unsafe community, low quality childcare, lack of resources in community, 

Low mood may not be pervasive.  Can be masked by anger in boys. Presentation – low mood, anhedonia, low energy, clinginess, irritability, avoiding social situations, hopelessness, poor sleep, poor appetite/overeating, poor concentration, physical Sx e.g. abdo pain. Biological symptoms may not be consistent – e.g. appetite/sleep not affected, concentration/motivation wors

Mx:

If mild/associated with a single negative event – watchful waiting and advice about healthy habits. Follow up in 2 weeks.

If mod/severe refer to CAMHS. CAMHS can initiate: full assessment and diagnosis, psychological therapy, medications.

• 1^st line = psychological therapy with CBT, non-directive supportive therapy (counselling, involves listening and empathy), IPT, family therapy
• Antidepressants (SSRIs) – fluoxetine is 1^st line in kids (start at 10mg, max dose of 20mg), sertraline and citalopram are 2^nd line. If child responds to Tx, continue for 6 months after remission is achieved.

Monitoring via mood and feelings questionnaire (MFQ)

Admission if risk of self-harm, suicide or self-neglect, or immediate safeguarding issue

Conduct disorder - more common in boys and urban populations. P/w aggression/cruelty to people/animals, destruction of property, deceitfulness, theft, fire-setting, running away, severe provocative or disobedient behaviour. Most common psychiatric disorder of childhood. Socialised (less serious, phasic in nature) and unsocialised (more serious, can lead to criminality and a later diagnosis of antisocial PD)

RFs = child abuse, rejection, comorbid learning/developmental difficulties, male, low socioeconomic status, parental psychiatric disorders, inconsistent/critical parenting style, low IQ, neurodevelopmental disorders

Oppositional defiant disorder – enduring pattern of negative, hostile and defiant behaviour, without serious violations of societal norms or the rights of others. Behaviour may occur in one situation only e.g. at home, and tends to be most evident in interactions with familiar adults or peers.

Mx – help child and family understand the thoughts and feelings lead to behaviour (to help reduce negative interpretations of behaviour), consistent care/parenting, parent management training (group-based if child <12 years e,g, Webster-Stratton incredible years programme), family therapy, behavioural therapy, school-based interventions, community interventions, treat comorbidity, address any safeguarding concerns

GAD - more common as child gets older. Influenced by parents having anxiety and levels of reassurance. Fears of death, loss of child/parents, somatic manifestations (N+V, sweating), panic attacks (sudden onset, extreme fear and physical Sx).

• Mild – watchful waiting, self-help strategy advice e.g. meditation
• Mod/severe – refer to CAMHS to initiate counselling, CBT, medical Mx (SSRI – fluoxetine most commonly given in children)

Separation anxiety disorder – anxiety manifest upon separation from attachment figures. PTSD. May have somatic manifestations, nightmares with separation themes, school refusal.

Obsessive compulsive disorders – often starts in children and presents later on. Related to anxiety, depression, ED, ASD, phobias.

• Mild OCD – education and self-help
• Mod/severe OCD – refer to CAMHS, patient and carer education, CBT, SSRIs

PTSD – persistently re-experiencing trauma, avoidance of associated stimuli, ­ arousal e.g. sleep disturbance and poor concentration.

Characterised by the development of tics that are persistent for over a year.Tics = involuntary movements or sounds that are performed repetitively throughout the day. Tics become more prominent when the person is under pressure/excited. Often present around 5 years of age, can be associated with OCD and ADHD.

• Examples of simple tics = clearing throat, blinking, head jerking, sniffing, grunting, eye rolling.
• Examples of complex tics = copropraxia (making obscene gestures), coprolalia (saying obscene words), echolalia (repeating other people’s words). 

Premonitory sensations = uncomfortable feelings/sensations preceding tics that are relieved by a particular movement. The urge to perform a tic increases the more they supress it.

Mx = tics usually improve over time. Mild cases may only need reassurance and monitoring.

• Troublesome tics need specialist referral and may benefit from habit reversal training, exposure with response prevention, medications (if v severe, usually antipsychotics)

Rare in pre-adolescence, ↑prevalence in adolescence, similar symptoms to adult presentation. Also causes delayed puberty/growth issues. Worse prognosis if younger/male. Strong correlation with personality disorders, OCD and anxiety.

AN = excessive weight loss, amenorrhoea, lanugo hair, low K+, low BP, hypothermia, changes in mood. Can cause cardiac complications e.g. arrhythmias, cardiac atrophy and sudden cardiac death.

BN = normal weight, alkalosis, low K+, teeth erosion, swollen salivary glands, mouth ulcers, GORD, Russell’s sign

Binge eating disorder = planned binge, eating very quickly, unrelated to whether they’re hungry or not, becoming uncomfortably full, eating in a “dazed state”

Mx = self-help resources, counselling, CBT, admission if refeeding syndrome, SSRI can be started by specialist. Refer to CAMHS if mod/severe.

Rare before puberty. Need to consider substance misuse.

Schizophrenia - often a prodromal period occurs in which family and friends may notice subtle changes in behaviour and personality. Transient or attenuated first-rank symptoms may occur but these are not pathognomonic.

• If transient/attenuated Sx, refer to CAMHS. If >14, then can refer to early intervention in psychosis services

Pervasive developmental disorder characterised by a triad of impairment in social interaction, impairment in communication, and repetitive stereotyped behaviour, interests/behaviours. Affects 1.1% of populatiion. 4:1 M>F. Caused by abnormal Purkinje cells in the cerebellar vermis.

RFs = male, genetics, advancing parental age, parental psychiatric disorders, prematurity, mothers taking sodium valproate in pregnancy

Aetiology:

• Prenatal causes = genetics (fragile X, tuberous sclerosis), parental age >40, intrauterine exposure to drugs e.g. sodium valproate, intrauterone viral infection e.g. Rubella 
• Antenatal causes = obstetric complications e.g. low birth weight, prematurity, hypoxia 
• Postnatal causes = exposure to toxins e.g. lead, pesticide exposure (if genetically predisposed)

Oneset of autism is <3 years. Atypical autism can be diagnosed >3 years. 

Conditions associated with ASD = epileptic seizures (20%), visual impairment, hearing impairment, infections, Pica, sleep disorders, constipation, underlying medical conditions (congenital rubella, fragile X, TS), psychiatric (ADHD, depression, bipolar, anxiety, psychosis, OCD, DSH)

Clinical picture is not attributable to other pervasive developmental disorders.

Presence of abnormal/impaired development before the age of 3 in at least one of:

• Receptive/expressive language
• Development of selective social attachments/reciprocal social interactions
• Functional/symbolic play

Qualitative abnormalities in social interaction, in at least one of:

• Failure to use eye-to-eye gaze, facial expression, body posture and gestures to regulate social interaction
• Failure to develop peer relationships that involve sharing of interests/activities/emotions
• Lack of socio-emotional reciprocity, shown by impairment/deviant response to other’s emotions, lack of modulation of behaviour, or weak integration of social/emotional/communicative behaviours

Qualitative abnormalities in communication, in at least 2 of:

• Delay in/total lack of development of spoken language that is not accompanied by attempt to compensate through use of gesture/mine
• Relative failure to initiate/sustain conversational interchange
• Stereotyped and repetitive use of language/idiosyncratic use of words/phrases
• Abnormalities in pitch, stress, rate, rhythm, intonation of speech

Restrictive, repetitive, stereotyped interests and activities, in at least 2 of:

• Apparent compulsive adherence to specific, non-functional routines/rituals
• Stereotyped and repetitive motor mannerisms
• Preoccupation with part-objects/non-functional elements of play materials
• Distress over changes in small, non-functional, details of environment

Many people with ASD are oversensitive to the senses which leads to sensory overload (especially with sound). They may display behaviours e.g. sensory blocking or tune outs. 

Comorbidities = LD, depression, anxiety, bipolar, OCD, ADHD, epilepsy, visual/hearing impairment, constipation, sleep disorders, Pica

Ix:

• MSE 
• observation of child
• screening tools - Autism Diagnostic Interview-Revised (ADI-R), Checklist for Autism in Toddlers (CHAT), Diagnostic Interview for Social and Communication Disorders (DICSO)
• SALT and OT assessment 
• educational psychologsit assessment - can provide support at school to improve children's learning experiences 
• MRI brain - shows increased brain size, and increased lateral and 4th ventricles

DDs = Asperger’s, Rett’s, childhood disintegrative disorder, LD, deafness, childhood schizophrenia

Asperger’s Syndrome – abnormalities in social interaction and restricted stereotyped, repetitive interests and behaviours, but no impairment in language, cognition or intelligence. More common in boys.

Rett’s Syndrome – severe, progressive disorder starting in early life. Results in language impairment, repetitive stereotyped hand movements, loss of fine motor skills, irregular breathing and seizures. Almost exclusive in girls.

Childhood Disintegrative Disorder (Heller’s Syndrome) – two years of normal development followed by loss of previously learned skills (language, social, motor). Also associated with repetitive, stereotyped interests and behaviours as well as cognitive deterioration.

Social:

• Good structure and routine – they need a physical presentation of time, as don’t necessarily understand concept
• Family support and counselling – education on interaction with the child and acceptance of his/her behaviour
• Inform about additional sources of info and support e.g. National Autistic Society
• Social-communication intervention e.g. play-based strategies

Psychological - CBT, psychoeducation for carers/families. Early education and behaviuoral interventions:

• Applied behavioural analysis (ABA) - identifies problem behaviour, helps students replace inappropriate behaviour with behaviour that is more helpful, helps students work on skills that will help them become more independent in the future
• ASD preschool program
• Teachment and Educaition of Autistic and Communication Handicapped Children (TEACCH) – academic program that is based on the idea that autistic individuals are visual learners. Teachers must adapt their teaching style accordingly
• Early Start Denver Model (ESDM) – behavioural therapy for children for children of 1-2 years. It is based on methods of ABA. Parents and therapists use play to boost language, social and cognitive skills.

• Joint Attention Symbolic Play Engagement and Regulation (JASPER) – designed for preschool and school age children. Sessions are play-based.

Biological interventions (only for challenging behaviour, not core Sx of ASD):

• SSRIs - for Sx like repetitive stereotyped behaviour, anxiety and aggression
• Antipsychotics e.g. risperidone - for Sx like aggression, self-injury
• Methylphenidate – if comorbid ADHD

3 core symptoms = inattention, hyperactivity and impulsiveness. Also known as hyperkinetic disorder.

There are 3 subtypes: Combined subtype (all 3 core Sx present), Inattentive subtype (attention deficit disorder), and a hyperactive-impulsive subtype.

Symptoms should be present for at least 6 months and develop before the age of 7.

ADHD is highly common alongside other conditions e.g. learning difficulties, ASD, tic disorders, bipolar disorder conduct disorder, dyspraxia. 3x more common in males. Age of onset commonly between 3 and 7 years.  Affects 2.4% of children in UK.

RFs = genetics, low birthweight, mothers who smoke/drink/take drugs during pregnancy, head injury, male

DDs = attachment disorder, hearing impairment, learning difficulty, high IQ child insufficiently stimulated in school, behavioural disorder, anxiety disorder, medication SEs e.g. antihistamines, oppositional defiant disorder, conduct disorder, bipolar 

Causes = genetics, abnormality in dopaminergic pathways, neurodevelopmental abnormalities of pre-frontal cortex, social deprivation, family contact, parental cannabis and alcohol exposure.

ICD-10 criteria:

Abnormality of attention/activity/impulsivity at home for age and developmental level of child:

• 3 inattention - short activity duration, leaves play unfinished, over-frequent changes of activities, lack of persistence at tasks, high distractibility during study
• 3 hyperactivity - runs/climbs excessively where inappropriate, excessive fidgeting/restlessness, excessive activity in situations of stillness, leaves seat when sitting is expected, difficulty playing quietly (excessive talking/noises)
• 1 impulsivity – difficulty awaiting turn, interrupts/intrudes on others, answers questions before questions completed

Abnormality of attention/activity at school/nursery for age and developmental level of child:

• 2 attention - lack of persistence at tasks, high distractibility, over-frequent changes between activities, excessively short duration of activities
• 3 hyperactivity – continuous/excessive restlessness in situations of free activity, excessive fidgeting and wriggling in structured situations, excessive levels of off-task activity during tasks, out of seat when required to be sitting, difficulty playing quietly

ICD-10 criteria continued:

Directly observed abnormality of attention/activity for child’s age and developmental level:

• Direct observation of criteria G1/G2
• Observation of abnormal levels of motor activity, off-task behaviour, lack of persistence in activities
• Significant impairment of performance on psychometric tests of attention

Doesn't meet criteria for a pervasive developmental disorder, mania, depressive, anxiety disorder

Onset before 7yrs

Duration at least 6mths

IQ above 50

Ix:

• Collateral Hx from school and carers
• Observe child - at school, at home
• MSE 
• Questionnaires - Conners rating scale (screening, evaluates severity, monitors Sx of ADHD), Strengths and Difficulties questionnaire (SDQ - measures psychological adjustment and aims to detect any emotional/behavioural problems)
• Physical examination - screen for comorbidity: Blood tests, hearing tests.

Mx:

Following presentation, 10-week 'watch and wait' period to see if Sx change or resolve. If persist then refer to paediatrician with interest in behavioural disorders, or to CAMHS

Psychological:

• In pre-school age children, parent-training and psychoeducation are 1^st line. Keep food diary to see if there is a clear link between food and drink consumed and behaviour.
• Behavioural interventions – positive reinforcement of desired behaviours, reduce distraction at school, encourage realistic expectations
• Education and training programmes
• Psychoeducation + CBT – 1^st line in school age children

Social - voluntary organisations e.g. ADDISS (ADD info and support service), Add+Up

Biological Mx - last resort, if 5+, if severe Sx in school age kids, if fail to respond to education programmes:

• 1st line = Methylphenidate (Ritalin) - trial for 6 weeks 
• 2nd line = Lisdexamfetamine.
• Can also give Atomoxetine (NA re-uptake inhibitor) - according to pt preference

Introduction:

• wash hands
• introduce self
• confirm patient's name/DOB/hospital number/what they like to be called
• explain that you would like to ask them a few questions and obtain consent 

Presenting complaint:

• Start by using open questions - What has brought you to see me today? How have youo been feeling recently? Can you tell me more about this?
• Who prompted them to come in?
• Onset 
• Duration - "how long has this been going on for?"
• Progression - "have you had any fluctuations in the way you have been feeling? or do you feel like this all the time?"
• Severity - "how has this affected your life?"
• Triggers - "has anything happened in your life recently that could explain how you are feeling?"
• Aggravating/relieving factors?
• Did they come to hospital voluntarily or were they detained?

Psychiatric systems review: (keep it short, ask about key Sx)

Depression -

Screen for low mood, anhedonia, low energy. If Sx suggest depression, ask about sleep, appetite, weight changes (and how much), concentration, libido. Also ask how they feel about themself (do they blame/criticise themself a lot), about life at the moment and about the future.

"How has your mood been recently?" "Have you felt little interest in doing things you would normally enjoy? "Have you nootices any changed in your sleep or appetite?" "Have you had any difficulty concentrating?" "How do you view yourself/the world/the future?"

GAD - 

"Do you feel you worry about things?" "What do you worry about?" "Do you worry about anything and everything, or one or two things in particular?" "When you're feeling worried, do you experience any other Sx?"

Panic attacks -

"Do you ever experience panic attacks, where you feel sudden feelings of worry that are quite uncomfortable, as well as physical symptoms such as SOB and dizziness?" "Does anything in particular trigger these panic attacks, or do they occur randomly?" (randomly - think panic disorder)

OCD -

"Do you have any thoughts that go round and round in your head that you can't stop thinking about?" "Do you have any distressing thoughts that enter you mind, despite trying hard to resit them?" "Do you feel there are certain actions or rituals you have to do, such as repeatedly checking things or rearranging things many times? Do these take up a lot of time in your day?"

PTSD -

"Is there a difficult event that has happened to you, that you find it hard to stop thinking about?" "Do you have nightmares related to the event?" Do you ever have flashbacks, where you get the sense that you're back there in the situation?" "Do you avoid things that remind you of the event?" "Have you had any difficulty sleeping/concentrating?" "Do you feel that you're often on edge?"

Social phobia - 

"Do you ever experience feelings of worry in social situations/ when thinking about social situations?" "Are you able to go to social situations where you may have to interact with people you don't know well, or is this very daunting for you?" "Do your social fears get in the way of your life?" "Do you find you avoid social situations?"

Mania - 

"Have you ever had a period where you've felt particuarly high in mood, energetic or euphoric?"

Psychosis -

"Have you ever heard voices when there is no one else around?" "How many voices can you hear?" "Who's voice is it?" "What do they say?" "Do they ever tell you to do things, and if so, are you able to resist them?" "Have you ever seen them?" "Do you have any evidence?" "Can you hear the voices inside your head or outside?"

"Has anything more unusual been happening at the moment?""Do you ever feel that people are out to harm you?" "Have you ever felt that the TV/radio plays messages for you?"

"Do you feel that your thoughts are your own?" "Do you feel that anyone is interfering with your thoughts?" "Is anyone able to put thoughts in your head/take them away?" 

"Do you ever feel that someone or something is touching you, when there is nobody there?"

"Do you feel that you are being controlled by someone/something?" "Are your thoughts, moods and actions under you control?" "Do you feel that someone or something is making you behave a certain way?"

Assess risk:

"Sometimes, when people are in a similar situation to you and are feeling down, they feel that life is no longer worth living. Have you ever felt like this?" 

"Have you ever thought about taking your own life?" "How often do you think about taking your life?" "When was the last time you thought about ending things?" "Have you thought about how you would end your life?" "Have you made any plans to end your life?" "Is there anything that stops you from ending your life?" (suicidal thoughts)

"Have you ever had thoughts about hurting yourself?" "Have you tried to hurt yourself?" "What happened?" "Have you ever hurt yourself in the past?" (thoughts of DSH)

"Have you ever had thoughts about hurting other people?" (risk to others)

"Are you coping ok at home?" "Are you eating well, exercising, sleeping enough?" (risk of self-neglect)

Past psychiatric history: 

Other psychiatric diagnoses

Previous admissions - when? why? for how long? under MHA or informally? diagnosis? Tx started?

Previous Tx - name, dose, duration, was it effective? compliant?

PMHx: any other health conditions? are they well managed? any allergies (and if so, reactions)?

DHx: what medications are they on? what dose and how often do they take them? have they been taking them as they should be? any side effects?

FHx: any conditions in the family (particularly psych ones)? do they feel close to/get on well with their family? (explore any reasons for discord) 

Personal history:

I would like to ask you a few more personal questions now, as this helps me to get a better understanding of who you are and perhaps why you are feeling this way, and it can give me a better idea of how I can best help you too. 

Infancy - any complications in pregnancy/birth? can they remember if they met the developmental milestones ("Did you walk and talk at the right ages?)? did they have any serious illnesses as a child? what was their childhood like? any siblings? do they get on well? were their parents married when they had them? as a child did they ever unusually aggressive or struggle with social interaction? have they ever had any unpleasant experiences as a child?

Education - where did they go to school? how was school for them? did they have a good experience? did they have friends, and what were their friendships like? were they bullied? how did they do academically? 

Occupation - are they currently working? what past jobs have they had (in chronological order)? why did they change job? what were their relationships like with their boss/co-workers?

Sexual - are they currently in a relationship? how would they describe their current relationship? have they had previous relationships? what were their previous relationships like?

Forensic - have they ever been arrested/gone to prison? what types of crimes? longest prison sentence? any domestic abuse?

Current social history - who do they live with? do they have any children? how old are the children/are they dependent on the pt? do they have a good relationship? how is everything financially? do they have a good support network? where do they live (house/flat)? are they coping at home?

Alcohol and drugs - current consumption per week? have they ever had a period of heavy consumption? have they ever taken recreational drugs? have they ever injected drugs? record route and years/frequency of use

Pre-morbid personality: how would people have described them before? would they describe them differently now? what did they used to be interested in/do in their spare time? what was their mood like? how would they describe their character e.g. shy/confident? what were their relationships like socially?

ICE: do they have any thoughts as to what could be making them feel thihs way? is there anything in particular concerning/worrying them at the moment? do they have any thoughts as to the best way in which they feel we can help them?

Summarise. Thank the pt.

Appearance:

• distinguishing features e.g. scars, tattoos, IVDU
• weight 
• well/poorly kempt
• appropriate clothing
• personal hygeine 
• objects they have with them e.g. stress ball 

Behaviour:

• engagement and rapport 
• eye contact
• facial expression - relaxed, angry, disengaged
• body language - threatening, withdrawn
• psychomotor activity 
• abnormal movements/postures - involuntary movements, tremor, tiks, akathisia 

Speech:

• rate - pressure of speech (tendency to speak rapidly - mania, schizophrenia, severe anxiety), slow speech (psychomotor retardation in major depression and depressive phase of bipolar)
• quantity - minimal, excessive (mania, schizophrenia)
• tone - monotonous (depression, schizophrenia, ASD), tremulous (anxiety)
• fluency - stuttering/slurred (psychomotor retardation)
• volume - increased (mania), decreased (depression, anxiety)

Mood (predominant subjective internal state) - low, anxiuos, angry, euphoric, guilty

Affect (immediately expressed and objectively observed emotion):

• apparent emotion - sad, angry, hostile, euphoric
• intensity of affect - heightened (mania), blunted (decreased signs of emotion - schizophrenia, PTSD, depression), flat (no signs of emotion - schizophrenia, depression, PTSD)
• range and mobility of affect (does affect change at the appropriate rate)- fixed (same regardless of topic), restricted (affect changes slightly but doesn't demonstrate normal range of emotional expression), labile (exaggerated changes in emotion - mania, EUPD, anxiety)
• incongruent affect (affect isn't in keeping with content of thoughts - schizophrenia)

Thought:

Thought form (processing and organisation)

• speed (fast - mania, slow - depression)
• formal thought disorder 

Thought content 

• delusions 
• obsessions 
• compulsions
• overvalued ideas
• suicidal/homicidal thoughts 

Thought possession - insertion, withdrawal, broadcast

Loose associations/knight's move thinking - move rapidly from one topic to another, no connection between topics (psychosis)

Poverty of speech - reduced quantity, brief responses to Q's (bipolar, depression, dementia, brain injury)

Circumstantial thoughts - lots of irrelevant details, eventually get to the point slowly (mania with psychosis, schizophrenia)

Tangential thoughts - digression from main conversation topic, introduce thoughts that are unrelated and irrelevant (psychosis, dementia, delirium)

Flight of ideas - accelerated tempo of speech, rapidly shift from one topic to another, discernible links between ideas (bipolar, schizophrenia, ADHD, anxiety, OCD, mania)

Thought blocking - sudden cessation of thought typically mid-sentence, can't recover what was previously said (schizophrenia, anxiety, dissociation disorders, dementia, delirium)

Perseveration - repetition of a particular response e.g. word/phrade despite absence or removal of stimulus (psychosis, dementia, epilepsy, brain trauma, stroke)

Echolalia - repeat words spoken around them (ASD, SOL, dementia, Tourette's, schizophrenia)

Clanging - words rhyme/sound similar (bipolar, schizophrenia)

Neologisms - made up words (psychotic disorrders, stroke, head injury)

Word salad/incoherence - no pattern or structure to sentence with random words or phrases (advanced schizophrenia, dementia, brain injury)

Perception:

• hallucinations - psychosis, drug abuse, neurological conditions e.g. Alzheimer's, Charles Bonnet syndrome
• pseudo-hallucinations - EUPD, taking hallucinogenic drugs, PTSD
• illusions - reduced consciousness
• depersonalisatioon (pt feels they are no longer their true self, and are someone different) - depression, anxiety, stress, drugs, traumatic events 
• derealisation (pt believes the world around them isn't a true reality) - dementia, drug abuse, schizophrenia, depression

Cognition - orientation to time, place and person. Formal testing (if didn't do MMSE or AMTS, then say that you did not conduct formal testing).

Insight - do they feel they are unwell? do they feel they need help? do they understand the purpose of Tx? (ask about in ICE)

Capacity = ability to make a decision. It is time and decision specific: time (may lack capacity at one point in time but have capacity at another), decision (may have capacity to consent to one decision but not for another).

Mental capacity act 2005 principles:

1. Pt has capacity until proven otherwise 

2. Individuals must be supported to make their own decisions 

3. Pt with capacity can make an unwise decision 

4. If decision is made on behalf of someone who lacks capacity, it must be made in their best interests

5. If decision is made on behalf of someone who lacks capacity, the least restrictive option should be chosen 

Capacity threshold = if at the time a person is unable to make a decision for themself due to impaired functioning of mind, then they lack capacity

2 stage capacity test:

1. Does the impairment cause the brain/mind to not function efficiently?

2. Does the impairment prevent the person from making a decision when they need to?

If a pt can't do 1+ of the following, then they lack capacity according to the mental capacity act:

• understand info 
• retain info long enough to make a decision 
• use/weigh-up info
• communicate the decision (either verbally or non-verbally)

If they lack capacity, then consider whether it is likely to be temporary.

• If temporary then reassess later 
• If not temporary, then see if they have an advance directive or LPA (and use these determine Tx). If they don't have either, then appoint an IMCA and treat pt in their best interests.

When to suspect a lack of capacity (CARD) - cognitive impairment, abnormal behaviouor, refusing treatment, delirium

Consent = patient voluntarilyy agrees to the proposal of another. Needs to be informed and voluntary. Can be expressed (verbal or written permission is explicitly asked for and recorded), or implied (consent through actions of pt. Pt does not object to and co-operates with the procedure)

Lasting power of attorney - this allows a person with capacity to appoint an attorney to make future decisions on their behalf if they lose capacity. There are 2 types - LPA for property and affairs, LPA for personal welfare.

Advance decisions:

• advance decision/directive - legal document with a specific refusal of Tx in a predefined situation (where the person would have lost capacity), that is signed by the pt and witnessed. Advance decisions permit a person to refuse Tx, but not demand it. They don't allow pts to refuse basic care needs. Need to have capacity at point of writing it.
• advance statement (verbally or written) - allows patients to make general statements about their wishes and preferences for the future, if they were to lose capacity. Not legally binding.

Deprivation of Liberty Safeguard (DoLS) - aims to make sure that people in care homes/hospitals/supported living who lack capacity, are looked after in a way that does not inappropriately restrict their freedom. When a hospital/care home identifies a person who lacks capacity is being/or risks being deprived of their liberty, they must apply for an authorisation of deprivation of liberty.

Independent Mental Capacity Advocate (IMCA) - someone appointed to support a person who lacks capacity but has no one to speak on their behalf e.g. no next of kin/LPA. They make representations about the person's wishes, feelings, beliefs and values. 

When to use MHA: (Revise Our Mental Health Act)

• Refusal of voluntary Tx
• Other options have been considered but not appropriate 
• Mental disorder 
• Harm (self-harm, self-neglect, harm to others)
• Appropriate Tx - needs to be an option available to pt

Section 2 = allows for admission, for assessment and response to Tx. Lasts up to 28 days. Can appeal to a tribunal during the first 14 days, and to hospital managers at any time. Done by 2 doctors, at least 1 is Section 12(2) approved, and 1x approved mental health practitioner. 

Section 3 = allows for Tx of a mental disorder. Lasts 6 months, can be renewed for a further 6 months, then renewed for further periods of one year at a time. Can appeal to tribunal at any time in the first 6 months (only once). Pts can be treated against their will for 3 months, then they need to be seen by a second opinion appointed doctor (SOAD) if they lack capacity to consent/or are refusing Tx. SOAD carries out assessment to see if they think Tx is needed. Pts can refuse ECT if they are under section but still have capacity. Free aftercare is provided for pts when discharged from S3 (S117 aftercare)

Pts have the right to applyy for discharge to the Mental Health Act managers, and an IMCA can be sought.

Section 17 = pt can leave hoospital under S17 whilst detained in hospital under S2/3

Section 4 = used as an emergency when S2 would involve an unacceptable delay. Often changed to S2 on arrival to hospital. It can be done by 1 doctor with an AMHP or nearest relative. No right to appeal.

Section 5(2) = urgent detention of inpatients on any ward excluding A+E, by an approved clinician. Lasts up to 72 hours. They must then be assessed for S2/3 or discharge from S5(2) to become an informal pt. There is no right to appeal. 

Section 5(4) = urgent detention of an inpatient (voluntary) for up to 6 hours. It is carried out by a registered mental health nurse when a doctor is unable to attend immediately. Therre is no right to appeal. 

Section 135 = allows a police officer/authorised person with a magistrate's warrant to enter a person's premises (who is suspected of suffering from a mental disorder) and remove them to a place of safety

Section 136 = allows a police officer to remove an individual who appears to suffer from a mental disorder, from a public place to a place of safety for assessment 

Community treatment order = allows pts on S3 who are well enoough, to leave the hospital for Tx in the community. Decision is made by the responsible clinician with the agreement of the AMHP (approved mental health professional - person that makes an application for the pt to be sectioned. SWs, nurses, psychologists or OTs, not doctors). Pt can be recalled to hospital if they do not comply with Tx/attend appointments. Once they are recalled they can be detained for up to 72 hours for assessment. 

Section 62 = concerns urgent Tx e.g. ECT for life-threatening depression

Cognitive behavioural therapy - identify and tackle negative thoughts, either in groups or individually

Interpersonal therapy - identify and solve relationship problems 

Behavioural activation - encourages depressed pts to develop more positive behaviour/activities they usually avoid 

Counselling - enables pts to explore problems and Sx. Counsellors offer support and guide pts to help themselves

Psychodynamic psychotherapy - explore and understand dynamics/difficulties of a pts life by bringing the unconscious mind into consciousness

Dialectical behaviooural therapy - type of CBT, that helps pts understand and accept their feelings and learn skills to manage them. It teaches that it is possible for pts to accept themselves and change their behaviour (an idea that seems contradictory)

Acute intoxication = disturbances in consciousness, cognition, perception and behaviour after taking a psychoactive substance. Pattern of changes are reversible and specific to each substance.

Harmful use = recurrent misuse associated with physical, psychological and social consequences to health.

Dependence syndrome = prolonged, compulsive substance use that leads to addiction, tolerance and the potential for withdrawal Sx.

Withdrawal state = physical +/- psychological effects from complete/partial cessation of substance after prolonged, repeated or high level use.

Psychotic disorder = onset of psychotic Sx within 2 weeks of substance use, persisting for >48 hours. Includes hallucinosis, jealousy, paranoia and psychosis.

Amnesic syndrome = memory impairment in recent memory (impaired learning of new material) and ability to recall past experiences. Also defect in recall, clouding of consciousness and global intellectual decline.

Residual disorder = specific features (flashbacks, personality disorder, affective disorder, dementia, persisting cognitive impairment) subsequent to substance misuse.

Biological:

• genetics (variations in enzymes that metabolise drugs)
• neurochemical abnormalities in GABA/dopamine 

Environmental:

• peer pressure 
• life stressors 
• parental drug use
• cultural acceptibility 
• personal vulnerability 

Bio + environmental factors --> person taking a substance (influenced by cost and availability)

--> +ve reinforcement (from peers, pleasurable effects, biological via mesolimbic pathway)

--> dependence over time.

Groups of chemicals derived from opium poppy. Morphine (PO, IV), diamorphine (heroin - IN, IV), codeine (PO).

Psychological effects:

• apathy (lack of interest/enthusiasm)
• disinhibition 
• psychomotor retardation 
• impaired judement/ attention
• drowsiness
• slurred speech 

Physical effects:

• respiratory depression 
• hypoxia
• low BP
• hypothermia
• coma 
• pupillary constriction 
• needle sharing --> infection

Withdrawal:

• early (12 hours) = sweating, clammy, persisting yawning, rhinorrhoea, increased HR, restless, dilated pupils, goose bumps, lacrimation 
• late (2-3d) = N+V, diarrhoea, insomnia, abdo/muscle cramps

Overdose = extreme drowsiness, hypoxia, respiratory depression, pinpoint pupils, low HR, coma, death 

• Overdose Mx = IM or IV Naloxone for 7-10d. Naloxone = opioid antagonist with a high affinity for Mu (μ) opioid receptors, so in overdose it causes dissociation of other drugs bound to these receptors 

Opioid dependence Mx = PO methadone or buprenorphine (community based detox, can also be used as maintenance therapy). These are both competitive agonists at opioid receptors - they still cause a 'high', but dose can be gradually reduced to decrease withdrawal symptoms. This helps reduce the number of receptors slowly (as these increase in dependence so more of the drug is needed for the same affect)

Maintaining opioid abstinence once no longer dependent (maintenance) = Naltrexone (opioid antagonist)

Naturally occuring compounds found in the Cannabis sativa plant. Cannabis (PO, smoked), cannabidiol oil (sublingual), black mamba, spice.

Psychological effects: (peak at 30 mins, last 2-5 hours)

• euphoria, disinhibition, agitation 
• paranoiod ideation 
• temporal slowing (time passes slowly)
• impaired judgement/attention/reaction time 
• illusions and hallucinations 

Physical effects:

• increased appetite
• dry mouth
• conjunctival injection - hyperaemia due to enlargement of conjunctival vessels 
• increased HR
• cannabinoid hyperemesis syndrome 
• low sperm and infertility 
• irregular periods

Withdrawal - anxiety, irritability, tremor when hands are outstretched, sweating, myalgia, insomnia 

Overdose = fatigue, poor coordination, panic attack, paranoia, psychosis 

Acute intoxication Mx: short-acting BDZs e.g. lorazepam to reduce anxiety Sx

Regular use - urine tests remain +ve for up to 4 weeks after regular use has ceased (as absorbed into fat).

Regular use also causes dose-related paranoid ideation, and increases the risk of psychosis.

Includes benzodiazepines and barbiturates e.g. phenobarbital. BDZs are used as anxiolytics, hyponotics, anticonvulsants and muscle relaxants. Usually PO, sometimes given by IV injection. Tolerance develops rapidly. Enhance GABA transmission.

Psychological effects:

• euphoria, disinhibition
• apathy 
• anterograde amnesia
• labile mood, aggression

Physical affects:

• unsteady gait, difficulty standing 
• slurred speech 
• nystagmus 
• erythematous skin lesions
• low BP
• hypothermia 
• reduced gag reflex 
• coma

Withdrawal = tremor of hands/tongue/eyelids, increased HR, postural hypotension, headache, agitation, hallucinations, paranoid ideation, grandmal convulsions (generalised tonic-clonic)

BDZ dependency syndrome - develops after 3-6 weeks of regular use. 

BDZ overdose = breathing difficulty, cyanosis, blurred vision, severe weakness, tremor, stupor, coma

• Mx: supportive, reduce dose gradually. Give Flumazenil if severe (BDZ antagonist)

Flunitrazepam (Rohypnol) = short-acting potent BDZ, '*********' drug. Causes impaired judgement and anterograde amnesia. Tasteless solution.

Dissociative anaesthetic. Does not depress the reticular activating system (unlike most anaesthetics), but instead prevents cortical awareness of painful stimuli. Usually IN, also IV injection or PO.

Small amounts - relaxation, sense of detachment.

Large amounts - hallucinations, euphoria, sense of wonder, dizziness, tremors, ataxia, slurred speech, flashbacks, psychosis 

Overdose = atypical behaviour, psychosis, N+V, seizures, LOC, loss of coordination 

• Mx = often supportive (remove sensory stimulatioin, quiet calm room), BDZ if agitated

Potentiate neurotransmissioin and increase cortical excitability. Cocaine (IN, smoked, IV), crack cocaine (IN, smoked, IV), amfetamines (PO, IV, IN, smoked), MDMA/ecstasy (PO), caffeine (PO).

Psychological effects:

• euphoria, labile mood 
• increased energy 
• grandiose beliefs
• aggression, argumentative 
• illusions and hallucinations (but intact orientation)
• paranoid ideation 

Physical effects:

• increased HR and BP, sweating, N+V
• arrythmias, chest pain
• pupillary dilatation
• psychomotor agitation 
• muscular weakness 
• convulsions

Withdrawal state = dysphoric mood (intense feelings of discontent/depression - must be present), lethargy, psychomotor agitation, craving, insomnia, increased appetite, bizarre/unpleasant dreams

Stimulant overdose = jerking/rigid limbs, LOC, hyperthermia, increased HR, seizures, chest pain, severe headaches, sweating, psychosis, palpitations, dilated pupils (react slowly)

• Mx = BDZs if sedation needed, IV fluids, ECG monitoring 

All stimulants are psychotogenic - can cause psychotic Sx.

Cocaine - also causes stroke, MI, seizures, nasal cartilage damage, miscarriage, prematurity, low birth weight infants. Metabolites will cause a +ve urine test for 2-3d after use.

Produce altered sensory and perceptual experiences. Lysergic acid diethylamide (LSD), phenylcyclidine (PCP), magic mushrooms - all PO. LSD can cause 'bad trips' (dissociation, frightening perceptions) and long-term use can cause acute hallucinogen-induced psychosis. No risk of overdose, withdrawal Sx don't occur. 

Psychological effects:

• anxiety
• illusions and hallucinations 
• depersonalisation and derealisation 
• paranoia
• ideas of reference 
• hyperactivity, impulsivity and inattention 

Physical effects:

• increased HR, palpitations 
• sweating, tremor
• blurred vision, pupillary dilatation
• incoordination 

Aerosols, paint, glue, petrol - all inhaled. Increase permeability of nerve cell membranes. Chronic use can cause liver/kidney damage, cognitive impairment. Usually no withdrawal Sx.

Psychological effects:

• apathy, lethargy
• aggression 
• impaired attention and judgement 
• psychomotor retardation
• euphoria

Physical effects:

• unsteady gait 
• diplopia
• nystagmus 
• decreased consciousness
• muscle weakness 
• headache
• arrhythmias

Synthetic testosterone. Danazol, nandrolone - PO or IM. No withdrawal Sx. Overdose is rare.

Psychological effects:

• euphoria, depression or mood swings 
• aggression 
• hyperactivity
• hallucinations and delusions 

Physical effects:

• increased muscle mass
• reduces fat
• acne 
• male pattern baldness
• reduce sperm count/infertility 
• stunted growth 
• HTN
• gynaecomastia 

ICD-10: (Drug problems Will Continue To Harm)

• Strong desire/compulsion to take substance 
• Preoccupation with substance use leads to neglect of other pleasures/interests 
• Withdrawal state when ingestion decreases or use of closely related/same substance to reduce withdrawal Sx
• Impaired ability to control substance-taking behaviour 
• Tolerance
• Persistent use despite harmful effects

"Have you ever taken recreational drugs? How often do you take them, how long have you done this?"

"What are the effects when you take the drug?"

"What impact has the drug had on your life?"

"Do you feel that the drug is always at the forefront of your mind?" (preoccupation)

"Have you ever tried to reduce the amount you're taking? Did you have any problems with this?" (withdrawal)

"Are you able to control your consumption?"

"Do you recently feel that you have to take more to get the same effect?"

"Are you aware of the harmful effects?"

DDs = psychosis, mood disorders, anxiety disorders, delirium. Hyperthyroidism, CVA, intracranial haemorrhage, neurological disorders e.g. SOL.

Ix:

• full systems examination 
• bloods (including HIV, Hep B+C screen) - U+Es (renal function), LFTs and clotting (hepatic function), drug levels in blood 
• urinalysis for drug testing 
• ECG - arrythmias 
• ECHO if IE suspected 
• Obs (including neuro)

Detoxification = effects of drug eliminated in a safe manner to reduce withdrawal Sx in attempt to cause abstinence. Maintenance therapy = aim is to minimise harm, abstinence isn't the priority

Bio:

• Meds can be prescribed to aid detox - either give a substitute drug that can be gradually reduced e.g. methadone/buprenorphine for opioid dependence, or to ameliorate Sx e.g. loperamide for diarrhoea and metaclopramide for N+V
• Hep B immunisatioon 

Psycho:

• self-help groups e.g. Narcotics anonymous, Cocaine anonymous 
• motivational interviewing - guides pts and helps them say why and how they might change 
• CBT - co-morbid depression/anxiety
• contingency Mx - focuses on chaning behaviours by offering incentives (rewards +ve behaviours e.g. -ve urine drug test --> receive vouchers for goods/services)

Social - housing/financial/employment supprot, review DVLA guidelines for driving, refer to Turning point in Leicestershire (provide psychological support), rehabilitation (occurs after detox. Spend 6 months in a therapeutic community to try prevent relapse)

Active ingredient = ethyl alcohol.

Alcohol effects:

• enhance GABA-A transmission --> anxiolytic effects
• release of dopamine in mesolimbic system --> reward/pleasurable and stimulant effects
• inhibits NMDA-mediated glutaminergic transmission --> amnesic effects

Long-term use --> down-regulation of inhibitory GABA receptors (as a result of chronic exposure to XS GABA) and up-regulation of NMDA-type glutamate receptors.

• Alcohol withdrawal --> decreased inhibitory GABA and increased glutamate transmission, which in turn causes hyperexcitation of CNS

Alcohol is oxidised by alcohol dehydrogenase to acetaldehyde. Acetaldehyde is converted to acetate by aldehyde dehydrogenase. Acetate is converted into acetyl-CoA and is used in TCA cycle or for FA synthesis. 

25% of males and 15% of females drink over recommended limit in UK. Alcohol dependence affects 4% of 16-65 year olds in England. 

RFs for alcohol abuse = male, younger adults, genetics, antisocial behaviour, lack of facial flushing, life stressors

ICD-10:

A) General criteria for acute intoxication met: 

• clear evidence of psychoactive substance use at high dose levels 
• disturbance in consciousness/cognition/perception/behaviour
• not accounted for by medical/mental disorder 

B) Evidence of dysfunctional behaviour (disinhibition, argumentative, aggressive, labile mood, decreased attention, interference with personal functioning), and one of the following signs:

• unsteady gait 
• slurred speech
• difficulty staniding 
• nystagmus 
• flushing 
• reduced consciousness
• conjunctival injection

Screen for alcohol dependence - CAGE questionnaire:

• "Have you ever felt you should cut down?"
• "Have people ever annoyed you by criticising your drinking?"
• "Have you ever felt guilty about you drinking?"
• "Do you ever drink in the early morning to wake you up/ steady your nerves?"

Establish drinking pattern and quantity consumed: what drinks do they have in a typical day? how many units/wk? how much money do they spend on alcohol? do they drink steadily or binge?

Features of alcohol dependence: when/where do they drink (narrowing of repertoire)? does it have less effect on them now than in the past (tolerance)? have they ever felt shaky/anxious if they haven't had a drink? have they ever tried to stop drinking, and if so what happened (withdrawal)? is alcohol the first thing that comes to mind when planning a social gathering (drink seeking behaviour)?

Establish impact: has alcohol affeced their mental/physical health? has alcohol caused any problems with work/relationships/the law?

Explore RFs: FHx, financial difficulty, relationship issues 

Intoxication MSE - poor coordination , slurred speech, labile affect, mood up/down, impaired judement/concentration, poor insight 

ICD-10:

A) General criteria for withdrawal met:

• clear evidence of recent cessation/ decrease in substance after prolonged or high level usage
• not accounted for by medical/mental disorder 

B) Any 3 of the following: tremor, sweating, N+V, increased HR and BP, headache, psychomotor agitation, insomnia, malaise, transient hallucinatioons, grand mal convulsions

Withdrawal MSE - agitated, sweaty, confused speech, anxious mood, paranoid delusions, visual hallucinations/illusions, delirium, inattention, poor insight

6-12 hours = uncomplicated alcohol withdrawal syndrome (Sx of autonomic hyperactivity - tremor, sweating, headache, anxiety)

12-24 hours = hallucinations 

24-48 hours = seizures (peak at 36 hours)

24-72 hours = delirium tremens 

Edward and gross criteria for alcohol dependence: (SAW DRINK)

• Subjective awareness of compulsion to drink 
• Avoiodance or relief of withdrawal Sx by further drinking
• Withdrawal Sx
• Drink-seeking behaviour predominates
• Reinstatement of drinking after attempted abstinence 
• Increased tolerance 
• Narrowing of drinking repertoire (fixed drinking times)

Ix:

Bloods:

• blood alcohol level 
• FBC and MCV (anaemia, macrocytosis)
• U+Es (dehydration, low urea)
• LFTs (gamma GT raised)
• vit B12/folate (rule out deficiency as a cause of macrocytosis)
• amylase (pancreatitis is a consequence)
• hepatitis serology
• low glucose 

Alcohol Use questionnaires - Alcohol Use Disorders Identification Test (AUDIT), FAST screening tool

CT head if suspected head injury 

ECG - arrhythmias 

DDs: psychosism mood disorders, anxiety disorders, delirium, head injury, cerebral tumour, CVA.

Emergency. Results from reduced GABA and increased glutamate transmission once alcohol is stopped --> extreme excitability of CNS. Peak incidence at 48 hours.

Physical illness is a predisposing factor.

Presentation = acute confusion, severe agitation, delusions (usually paranoid), hallucinations, ataxia, arrhythmias, cognitive impairment, dehydration

• Signs = tremor, increased HR, HTN, hyperthermia, electrolyte disturbance

Mx: admit, PO lorazepam 1st line, IV fluids

Bio:

• WITHDRAWAL - Alcohol detoxification regimen in the community, or as an inpatient if high suicide risk/poor social support/ hx of severe withdrawal Sx. 1st line for detox = high dose chloriazepoxide (BDZ) that is tapered down over 5-9 days. Give lorazepam instead if hepatic failure. PO/IV thiamine 
• DEPENDENCE (given once abstinence achieved) - disulfiram (inhibits aldehyde dehydrogenase, CI in IHD and psychosis), acamprosate (enhances GABA transmission to reduce craving), naltrexone (antagonist at opioid receptors so decreases pleasurable effects)
• Prophylactic 50mg PO OD thiamine if malnourished/ decompensated liver disease

Psycho:

• alcohol dependence - motivational interviewing, CBT

Social = Alcoholics anonymoous, social support.Pts responsibility to contact DVLA. Drinking advice (12 units/wk spread over at least 3 days). Advice on techniques to control drinking (set a weekly limit, don't drink alone, don't drink with other heavy drinkers)

Medical:

• hepatic - fatty liver, hepatitis, cirrhosis, HCC
• GI - PUD, oesophageal varices, pancreatitis, oesophageal carcinoma 
• CVS - HTN, cardiomyopathy, arrhythmias 
• haematological - anaemia, thrombocytopenia
• neuro - seizures, peripheral neuropathy, cerebellar degeneration, Wernicke's encephalopathy, Korsakoff's psychosis 
• obstetrics - fetal alcohol syndrome 

Psychiatric: morbid jealousy, DSH and suicide, anxiety disorders, alcohol-related dementia, alcoholic hallucinosis, delirium tremens. Social: domestic violence, drink driving, financial problems, homelessness, relationship problems

Wernicke's encephalopathy = acute encephalopathy due to thiamine deficiency. Most commonly due to alcoholism, rarer causes include persistent vomiting, stomach cancer and dietary deficiency. Petechial haemorrhages occur in the brain (including mamillary bodies and ventricle walls). Presents with a triad of opthalmoplegia/nystagmus, ataxia and confusion. Ix = reduced red cell transketolase. Can cause Korsakoff's psychosis. Tx = IV thiamine 250-500mg + IV magnesium 2-4g/d.

Korsakoff's psychosis = triad in WE + antero/retrograde amnesia + confabulation. Tx = PO thiamine and multivitamins for up to 2 years.

Alcoholic hallucinosis = hallucinations (usually auditory) that occur while sober. Worse on detox. Antipsychotics if persisting Sx.

Deliberate self-harm = behaviour that is self-initiated, and the intent is to cause harm or injury to self. Affects 2/1000 people in UK. Peark at 15-19yrs in females, 20-24 yrs in males. Female:male 1.5:1

• Self-injury = cutting, burning, hanging, jumping 
• Self-poisoning = meds, illicit drugs, household substances

DSH RFs (DSH Largely Comes Via Self-Poisoning) = divorced/single/living alone, severe life stressors, harmful drug/alchol use, less than 35yrs, chronic physical health condition, violence (domestic) or childhood maltreatment, socioeconomic disadvantage, psychiatric illness

Motives = death wish, temporary relief from problems, influencing others (trying to make another change their views/behaviour e.g. make spouse feel guilty for not caring enough), punish oneself, seek attention 

DDs for self-poisoning = head trauma, intracranial haemorrhage, intracranial infection, metabolic abnormalities, liver disease

DDs for self-injury = clotting abnormality, abuse, anaemia

MSE - selef-inflicted injuries, may show signs of neglect, behaviour may reflect an underlying mental disorder, thoughts of guilt/worthlessness/helplessness, DSH may be triggered by command hallucinations in schizophrenia/depression with psychosis 

Ix:

• bloods - drug levels, U+Es (renal function), LFTs and clotting (hepatic function)
• urinalysis - toxicology analysis 
• CT head - rule out intracranial cause for altered consciousness

Complications = permanent scarring, nerve/tendon damage, liver failure in overdose

Bio:

• Treat any overdose in self-poisoning (activated charcoal within 1st hour after ingestion to reduce absorption)
  • Paracetamol - N-acetylcysteine 
  • Opiates - Naloxone 
  • BDZs - Flumazenil 
  • Warfarin - Vitamin K
  • Beta-blockers - Glucagon
  • TCAs - sodium bicarbonate
• skin suturing for deep laceratioons
• antidepressants for co-morbid depression

Psycho:

• counselling
• CBT
• psychodynamic psychotherapy if underlying PD
• refer to drug/alcohol services if needed 

Social: voluntary organisations e.g. Samaritans or MIND, financial/occupational rehabilitation advice

Suicide = fatal act of self-harm with the intention of ending one's own life. 

• Risk increases with age, act may be planned meticulously, act is more often violent, physical/psychiatric illness is common 
• With DSH, more common in younger people, act is impulsive, usually overdose/cutting, physical/psychiatric illness is less common

Para-suicide = act of intentionally trying to end one's life with the intent of dying but failing to succeed. 

13th leading cause of death worldwide. 18.2/100,000 males, 5.2/100,000 in females.

RFs (I'M A SAD PERSON): institutionalised, mental health disorders, alone (lack of social support), sex (male), age 40-44yrs, depression, previous attempts, ethanol use, rational thinking lost, sickness (disabling, painful, terminal, chronic), occupation (vets, doctors, nurses, farmers), no job. Also childhood abuse, FHx, marital status, recent liife crisis

Presentation = preoccupation with death, sense of isolation/withdrawal from society, emotional distance from others, distraction ('in own world'), lack of pleasure, focus on past, feelings of hopelessness/helplessness, feel the world would be better off without them

Protective factors = children at home, pregnancy, strong religious beliefs, strong social support, supportive living arangements, life satisfaction, fear of physical act of suicide, fear of dissaproval by society, responsibility for others, hope

Collateral Hx

Risk assessment:

• suicidal thoughts?
• how do they view themself/the world/the future?
• explore recent DSH - intent to end life? what happend before/during/after? any triggers? any final acts? how do they feel now?
• screen for other mental health disorders
• past psych Hx, PMHx, DHx, FHx, SHx

Questionnaires - Tool for Assessment of suicide risk (TASR)

NB if any of the following are present, risk is increased following recent DSH: note left, planned attempt, attempts to avoid discovery, violent method, final acts

Individual:

• admission to hospital if high risk
• treat any psychiatric disorders 
• involve crisis team 
• safety plan (avoid stressors, family/friend support, avoid alcohol when stressed, advise where they can seek help from/who they can tell if they feel this way again)

General:

• public education 
• reduce means of suicide e.g. safer prescribing and safety rails in high places
• reduce social stressors e.g. signpost to housing services
• reduce substance misuse

Depression during pregnancy = 15% of women. Core Sx of low mood, lethargy and anhedonia. Need urgent referral to specialist mental health services if severe/risk or self-harm/self-neglect/psychotic Sx. Also consider referral if FHx of severe mental illness or suicide. Mx = social support and psychological Tx. Can try SSRIs.

Baby blues = period of low mood and irritability that starts 3-4d after birth, and lasts around 7d. Doesn't require Tx. More common in primips.

Postnatal depression = depressive episode within first 12 months post-partum. Sx similar to depression, may have -ve thoughts about motherhood/coping skills. Use Edinburgh postnatal depression scale (>13 = depression). Sx typically peak at 3 months. Consider urgent referral to specialist mental health services if severe/risk of DSH or suicide, or if FHx of severe mental illness. Mx = social and psychological support e.g. CBT. Meds can be given but caution if breastfeeding (Paroxetine is recommended as not harmful to baby).

Postpartum (puerperal) psychosis = develops rapidly over a few hours, starts within first 2 weeks. 1/1000. More common in women with bipolar/previous psychotic illness. If PP in previous pregnancy then 50% chance of it recurring. Can cause confusion, mother is quiet/withdrawn or agitated/distressed, sleep disturbance. Severe Sx for 2-12 weeks, can take up to 12 months to recover. Tx as inpatient in specialist mother and baby unit. Need assessment by specialist mental health services. May need an antipsychotic.