PSYCHIATRY (Medicalstudyzone - Com)

PassMedicine Psychiatric Notes
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PASSMEDICINE PSYCHIATRY NOTE 2021
Acute stress disorder
Acute stress disorder is defined as an acute stress reaction that occurs in the first 4 weeks after
a person has been exposed to a traumatic event (threatened death, serious injury e.g. road
traffic accident, sexual assault etc). This is in contrast to post-traumatic stress disorder (PTSD)
which is diagnosed after 4 weeks.
Features include:
• intrusive thoughts e.g. flashbacks, nightmares

• dissociation e.g. 'being in a daze', time slowing
• negative mood
• avoidance
• arousal e.g. hypervigilance, sleep disturbance
Management
• trauma-focused cognitive-behavioural therapy (CBT) is usually used first-line

• benzodiazepines
o sometimes used for acute symptoms e.g. agitation, sleep disturbance
o should only be used with caution due to addictive potential and concerns that
they may be detrimental to adaptation
Agoraphobia
Agoraphobia is primarily describes a fear of open spaces but also includes related aspects, e.g.
the presence of crowds or the difficulty of escaping to a safe place
Alcohol withdrawal
Mechanism
• chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to
benzodiazepines) and inhibits NMDA-type glutamate receptors
• alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and
increased NMDA glutamate transmission)
Features
• symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety

• peak incidence of seizures at 36 hours
• peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion,
delusions, auditory and visual hallucinations, fever, tachycardia
Management
• patients with a history of complex withdrawals from alcohol (i.e. delirium tremens,
seizures, blackouts) should be admitted to hospital for monitoring until withdrawals
stabilised
• first-line: long-acting benzodiazepines e.g. chlordiazepoxide or
diazepam. Lorazepam may be preferable in patients with hepatic failure. Typically given
as part of a reducing dose protocol
• carbamazepine also effective in treatment of alcohol withdrawal
• phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures
•
Anorexia nervosa: features
Anorexia nervosa is associated with a number of characteristic clinical signs and physiological
abnormalities which are summarised below
Features
• reduced body mass index

• bradycardia
• hypotension
• enlarged salivary glands
Physiological abnormalities
• hypokalaemia
• low FSH, LH, oestrogens and testosterone
• raised cortisol and growth hormone
• impaired glucose tolerance
• hypercholesterolaemia
• hypercarotinaemia
• low T3
Antipsychotics
Antipsychotics are a group of drugs used in the management of schizophrenia and other forms
of psychosis, mania and agitation. They are usually divided into typical and atypical
antipsychotics. The atypical antipsychotics were developed due to the problematic
extrapyramidal side-effects which are associated with the first generation of typical
antipsychotics.
Typical antipsychotics Atypical antipsychotics

Mechanism Dopamine D2 receptor antagonists, Act on a variety of receptors
of action blocking dopaminergic transmission in (D2, D3, D4, 5-HT)
the mesolimbic pathways
Adverse Extrapyramidal side-effects and Extrapyramidal side-effects
effects hyperprolactinaemia common and hyperprolactinaemia less
common
Metabolic effects
Examples Haloperidol Clozapine
Chlopromazine Risperidone
Olanzapine
The rest of this section will focus on typical antipsychotics, with atypical antipsychotics covered
elsewhere.
Extrapyramidal side-effects (EPSEs)
• Parkinsonism
• acute dystonia
o sustained muscle contraction (e.g. torticollis, oculogyric crisis)
o may be managed with procyclidine
• akathisia (severe restlessness)
• tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary,
may occur in 40% of patients, may be irreversible, most common is chewing and pouting
of jaw)
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when
antipsychotics are used in elderly patients:
• increased risk of stroke

• increased risk of venous thromboembolism
Other side-effects
• antimuscarinic: dry mouth, blurred vision, urinary retention, constipation

• sedation, weight gain
• raised prolactin
o may result in galactorrhoea
o due to inhibition of the dopaminergic tuberoinfundibular pathway
• impaired glucose tolerance
• neuroleptic malignant syndrome: pyrexia, muscle stiffness
• reduced seizure threshold (greater with atypicals)
• prolonged QT interval (particularly haloperidol)
Aphonia
Aphonia describes the inability to speak. Causes include:
• recurrent laryngeal nerve palsy (e.g. Post-thyroidectomy)

• psychogenic
Atypical antipsychotics
Atypical antipsychotics should now be used first-line in patients with schizophrenia, according
to 2005 NICE guidelines. The main advantage of the atypical agents is a significant reduction in
extrapyramidal side-effects.
Adverse effects of atypical antipsychotics
• weight gain
• clozapine is associated with agranulocytosis (see below)

• hyperprolactinaemia
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when
antipsychotics are used in elderly patients:
• increased risk of stroke

• increased risk of venous thromboembolism
Examples of atypical antipsychotics
• clozapine
• olanzapine: higher risk of dyslipidemia and obesity
• risperidone
• quetiapine
• amisulpride
• aripiprazole: generally good side-effect profile, particularly for prolactin elevation
Clozapine
Clozapine, one of the first atypical agents to be developed, carries a significant risk
of agranulocytosis and full blood count monitoring is therefore essential during treatment. For
this reason, clozapine should only be used in patients resistant to other antipsychotic
medication. The BNF states:
Clozapine should be introduced if schizophrenia is not controlled despite the sequential use of
two or more antipsychotic drugs (one of which should be a second-generation antipsychotic
drug), each for at least 6–8 weeks.
Adverse effects of clozapine

• agranulocytosis (1%), neutropaenia (3%)

• reduced seizure threshold - can induce seizures in up to 3% of patients
• constipation
• myocarditis: a baseline ECG should be taken before starting treatment
• hypersalivation
Dose adjustment of clozapine might be necessary if smoking is started or stopped during

treatment.
Benzodiazepines
Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric

acid (GABA) by increasing the frequency of chloride channels. They therefore are used for a
variety of purposes:
• sedation
• hypnotic
• anxiolytic
• anticonvulsant
• muscle relaxant
Patients commonly develop a tolerance and dependence to benzodiazepines and care should
therefore be exercised on prescribing these drugs. The Committee on Safety of Medicines
advises that benzodiazepines are only prescribed for a short period of time (2-4 weeks).
The BNF gives advice on how to withdraw a benzodiazepine. The dose should be withdrawn in
steps of about 1/8 (range 1/10 to 1/4) of the daily dose every fortnight. A suggested protocol
for patients experiencing difficulty is given:
• switch patients to the equivalent dose of diazepam

• reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg
• time needed for withdrawal can vary from 4 weeks to a year or more
If patients withdraw too quickly from benzodiazepines they may experience benzodiazepine
withdrawal syndrome, a condition very similar to alcohol withdrawal syndrome. This may occur
up to 3 weeks after stopping a long-acting drug. Features include:
• insomnia
• irritability
• anxiety
• tremor
• loss of appetite
• tinnitus
• perspiration
• perceptual disturbances
• seizures
GABAA drugs
• benzodiazipines increase the frequency of chloride channels

• barbiturates increase the duration of chloride channel opening
Frequently Bend - During Barbeque
...or...
Barbidurates increase duration & Frendodiazepines increase frequency
Body dysmorphic disorder
Body dysmorphic disorder (sometimes referred to as dysmorphophobia) is a mental disorder

where patients have a significantly distorted body image
Diagnostic and Statistical Manual (DSM) IV criteria:
• Preoccupation with an imagine defect in appearance. If a slight physical anomaly is

present, the person's concern is markedly excessive
• The preoccupation causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning
• The preoccupation is not better accounted for by another mental disorder (e.g.,
dissatisfaction with body shape and size in Anorexia Nervosa)
Bulimia nervosa
Bulimia nervosa is a type of eating disorder characterised by episodes of binge eating followed
by intentional vomiting or other purgative behaviours such as the use of laxatives or diuretics or
exercising.
DSM 5 diagnostic criteria for a diagnosis of bulimia nervosa:
• recurrent episodes of binge eating (eating an amount of food that is definitely larger
than most people would eat during a similar period of time and circumstances)
• a sense of lack of control over eating during the episode
• recurrent inappropriate compensatory behaviour in order to prevent weight gain, such
as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or
excessive exercise.
• the binge eating and compensatory behaviours both occur, on average, at least once a
week for three months.
• self-evaluation is unduly influenced by body shape and weight.
• the disturbance does not occur exclusively during episodes of anorexia nervosa.
Management
• referral for specialist care is appropriate in all cases

• NICE recommend bulimia-nervosa-focused guided self-help for adults
• If bulimia-nervosa-focused guided self-help is unacceptable, contraindicated, or
ineffective after 4 weeks of treatment, NICE recommend that we consider individual
eating-disorder-focused cognitive behavioural therapy (CBT-ED)
• children should be offered bulimia-nervosa-focused family therapy (FT-BN)
• pharmacological treatments have a limited role - a trial of high-dose fluoxetine is
currently licensed for bulimia but long-term data is lacking
Charles-Bonnet syndrome
Charles-Bonnet syndrome (CBS) is characterised by persistent or recurrent complex

hallucinations (usually visual or auditory), occurring in clear consciousness. This is generally
against a background of visual impairment (although visual impairment is not mandatory for a
diagnosis). Insight is usually preserved. This must occur in the absence of any other significant
neuropsychiatric disturbance.
Risk factors include:
• Advanced age
• Peripheral visual impairment
• Social isolation
• Sensory deprivation
• Early cognitive impairment
CBS is equally distributed between sexes and does not show any familial predisposition. The
most common ophthalmological conditions associated with this syndrome are age-related
macular degeneration, followed by glaucoma and cataract.
Well-formed complex visual hallucinations are thought to occur in 10-30 per cent of individuals
with severe visual impairment. Prevalence of CBS in visually impaired people is thought to be
between 11 and 15 per cent.
Around a third find the hallucinations themselves an unpleasant or disturbing experience. In a

large study published in the British Journal of Ophthalmology, 88% had CBS for 2 years or more,
resolving in only 25% at 9 years (thus it is not generally a transient experience).
Cox (2014) Negative outcome Charles Bonnet Syndrome. Br J Ophthalmol.
Cotard syndrome
Cotard syndrome is a rare mental disorder where the affected patient believes that they (or in
some cases just a part of their body) is either dead or non-existent. This delusion is often
difficult to treat and can result in significant problems due to patients stopping eating or
drinking as they deem it not necessary.
Cotard syndrome is associated with severe depression and psychotic disorders.
De Clerambault's syndrome
De Clerambault's syndrome, also known as erotomania, is a form of paranoid delusion with an

amorous quality. The patient, often a single woman, believes that a famous person is in love
with her.
Delusional parasitosis
Delusional parasitosis is a relatively rare condition where a patient has a fixed, false belief
(delusion) that they are infested by 'bugs' e.g. worms, parasites, mites, bacteria, fungus. This
may occur in conjunction with other psychiatric conditions or may present by itself, with
patients often otherwise quite functional despite the delusion.
Depression in older people
Older patients are less likely to complain of depressed mood
Features
• physical complaints (e.g. hypochondriasis)

• agitation
• insomnia
Management
• SSRIs are first line (adverse side-effect profile of TCAs more of an issue in the elderly)
Depression vs. dementia
Factors suggesting diagnosis of depression over dementia
• short history, rapid onset

• biological symptoms e.g. weight loss, sleep disturbance
• patient worried about poor memory

• reluctant to take tests, disappointed with results
• mini-mental test score: variable
• global memory loss (dementia characteristically causes recent memory loss)
Depression: screening and assessment
Screening
The following two questions can be used to screen for depression
• 'During the last month, have you often been bothered by feeling down, depressed or
hopeless?'
• 'During the last month, have you often been bothered by having little interest or
pleasure in doing things?'
A 'yes' answer to either of the above should prompt a more in depth assessment.
Assessment
There are many tools to assess the degree of depression including the Hospital Anxiety and
Depression (HAD) scale and the Patient Health Questionnaire (PHQ-9).
Hospital Anxiety and Depression (HAD) scale
• consists of 14 questions, 7 for anxiety and 7 for depression

• each item is scored from 0-3
• produces a score out of 21 for both anxiety and depression
• severity: 0-7 normal, 8-10 borderline, 11+ case
• patients should be encouraged to answer the questions quickly
Patient Health Questionnaire (PHQ-9)

• asks patients 'over the last 2 weeks, how often have you been bothered by any of the
following problems?'
• 9 items which can then be scored 0-3
• includes items asking about thoughts of self-harm
• depression severity: 0-4 none, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-
27 severe
NICE use the DSM-IV criteria to grade depression:
• 1. Depressed mood most of the day, nearly every day

• 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the
day, nearly every day
• 3. Significant weight loss or weight gain when not dieting or decrease or increase in
appetite nearly every day
• 4. Insomnia or hypersomnia nearly every day
• 5. Psychomotor agitation or retardation nearly every day
• 6. Fatigue or loss of energy nearly every day
• 7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day
• 8. Diminished ability to think or concentrate, or indecisiveness nearly every day
• 9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a
suicide attempt or a specific plan for committing suicide
Subthreshold
depressive symptoms Fewer than 5 symptoms
Mild depression Few, if any, symptoms in excess of the 5 required to make the
diagnosis, and symptoms result in only minor functional impairment
Moderate depression Symptoms or functional impairment are between 'mild' and 'severe'
Severe depression Most symptoms, and the symptoms markedly interfere with
functioning. Can occur with or without psychotic symptoms
Electroconvulsive therapy
Electroconvulsive therapy is a useful treatment option for patients with severe depression
refractory to medication (e.g. catatonia) those with psychotic symptoms. The only absolute
contraindications is raised intracranial pressure.
Short-term side-effects
• headache
• nausea
• short term memory impairment
• memory loss of events prior to ECT
• cardiac arrhythmia
Long-term side-effects
• some patients report impaired memory
Generalised anxiety disorder and panic disorder
Anxiety is a common disorder that can present in multiple ways. NICE define the central feature
as an 'excessive worry about a number of different events associated with heightened tension.'
Always look for a potential physical cause when considering a psychiatric diagnosis. In anxiety
disorders, important alternative causes include hyperthyroidism, cardiac disease and
medication-induced anxiety (NICE). Medications that may trigger anxiety include salbutamol,
theophylline, corticosteroids, antidepressants and caffein
Management of generalised anxiety disorder (GAD)
NICE suggest a step-wise approach:
• step 1: education about GAD + active monitoring

• step 2: low-intensity psychological interventions (individual non-facilitated self-help or
individual guided self-help or psychoeducational groups)
• step 3: high-intensity psychological interventions (cognitive behavioural therapy or
applied relaxation) or drug treatment. See drug treatment below for more information
• step 4: highly specialist input e.g. Multi agency teams
Drug treatment
• NICE suggest sertraline should be considered the first-line SSRI

• if sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline
reuptake inhibitor (SNRI)
o examples of SNRIs include duloxetine and venlafaxine
• If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin
• interestingly for patients under the age of 30 years NICE recommend you warn patients
of the increased risk of suicidal thinking and self-harm. Weekly follow-up is
recommended for the first month
Management of panic disorder
Again a stepwise approach:
• step 1: recognition and diagnosis

• step 2: treatment in primary care - see below
• step 3: review and consideration of alternative treatments
• step 4: review and referral to specialist mental health services
• step 5: care in specialist mental health services
Treatment in primary care
• NICE recommend either cognitive behavioural therapy or drug treatment

• SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or
clomipramine should be offered
Grief reaction
It is normal for people to feel sadness and grief following the death of a loved one and this does
not necessarily need to be medicalised. However, having some understanding of the potential
stages a person may go through whilst grieving can help determine whether a patient is having
a 'normal' grief reaction or is developing a more significant problem.
One of the most popular models of grief divides it into 5 stages.
• Denial: this may include a feeling of numbness and also pseudohallucinations of the
deceased, both auditory and visual. Occasionally people may focus on physical objects
that remind them of their loved one or even prepare meals for them
• Anger: this is commonly directed against other family members and medical
professionals
• Bargaining
• Depression
• Acceptance
It should be noted that many patients will not go through all 5 stages.
Abnormal, or atypical, grief reactions are more likely to occur in women and if the death is
sudden and unexpected. Other risk factors include a problematic relationship before death or if
the patient has not much social support.
Features of atypical grief reactions include:
• delayed grief: sometimes said to occur when more than 2 weeks passes before grieving
begins
• prolonged grief: difficult to define. Normal grief reactions may take up to and beyond 12
months
Hypomania vs. mania
Mania Hypomania
• Lasts for at least 7 days - Causes A lesser version of mania
severe functional impairment in Lasts for < 7 days, typically 3-4 days. Can
social and work setting be high functioning and does not impair
• May require hospitalization due functional capacity in social or work setting
to risk of harm to self or others Unlikely to require hospitalization
• May present with psychotic Does not exhibit any psychotic symptoms
symptoms
Therefore, the length of symptoms, severity and presence of psychotic symptoms (e.g.
delusions of grandeur, auditory hallucinations) helps differentiates mania from hypomania.
The following symptoms are common to both hypomania and mania
Mood
• predominately elevated
• irritable
Speech and thought
• pressured
• flight of ideas: characterised by rapid speech with frequent changes in topic based on
associations, distractions or word play
• poor attention
Behaviour
• insomnia
• loss of inhibitions: sexual promiscuity, overspending, risk-taking
• increased appetite
Korsakoff's syndrome
Overview
• marked memory disorder often seen in alcoholics

• thiamine deficiency causes damage and haemorrhage to the mammillary bodies of the
hypothalamus and the medial thalamus
• in often follows on from untreated Wernicke's encephalopathy
Features
• anterograde amnesia: inability to acquire new memories

• retrograde amnesia
• confabulation
Lithium
Lithium is mood stabilising drug used most commonly prophylactically in bipolar disorder but
also as an adjunct in refractory depression. It has a very narrow therapeutic range (0.4-1.0
mmol/L) and a long plasma half-life being excreted primarily by the kidneys.
Mechanism of action - not fully understood, two theories:
• interferes with inositol triphosphate formation

• interferes with cAMP formation
Adverse effects
• nausea/vomiting, diarrhoea
• fine tremor
• nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
• thyroid enlargement, may lead to hypothyroidism
• ECG: T wave flattening/inversion
• weight gain
• idiopathic intracranial hypertension
• leucocytosis
• hyperparathyroidism and resultant hypercalcaemia
Monitoring of patients on lithium therapy
• inadequate monitoring of patients taking lithium is common - NICE and the National
Patient Safety Agency (NPSA) have issued guidance to try and address this. As a result it
is often an exam hot topic
• when checking lithium levels, the sample should be taken 12 hours post-dose
• after starting lithium levels should be performed weekly and after each dose change
until concentrations are stable
• once established, lithium blood level should 'normally' be checked every 3 months
• after a change in dose, lithium levels should be taken a week later and weekly until the
levels are stable.
• thyroid and renal function should be checked every 6 months
• patients should be issued with an information booklet, alert card and record book
Monoamine oxidase inhibitors
Overview
• serotonin and noradrenaline are metabolised by monoamine oxidase in the presynaptic

cell
Non-selective monoamine oxidase inhibitors
• e.g. tranylcypromine, phenelzine

• used in the treatment of atypical depression (e.g. hyperphagia) and other psychiatric
disorder
• not used frequently due to side-effects
Adverse effects of non-selective monoamine oxidase inhibitors
• hypertensive reactions with tyramine containing foods e.g. cheese, pickled herring,
Bovril, Oxo, Marmite, broad beans
• anticholinergic effects
Obsessive-compulsive disorder
Obsessive-compulsive disorder (OCD) is characterised by the presence of either obsessions or

compulsions, but commonly both. The symptoms can cause significant functional impairment
and/ or distress.
An obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters
the person's mind. Compulsions are repetitive behaviours or mental acts that the person feels
driven to perform. A compulsion can either be overt and observable by others, such as checking
that a door is locked, or a covert mental act that cannot be observed, such as repeating a
certain phrase in one's mind.
It is thought that 1 to 2% of the population have OCD, although some studies have estimated 2
to 3%.
The aetiology is multifactorial but possible factors include:
• genetic
• psychological trauma
• pediatric autoimmune neuropsychiatric disorder associated with streptococcal
infections (PANDAS)
Associations
• depression (30%)
• schizophrenia (3%)
• Sydenham's chorea
• Tourette's syndrome
• anorexia nervosa
Management
• If functional impairment is mild

o low-intensity psychological treatments: cognitive behavioural therapy (CBT)
including exposure and response prevention (ERP)
o If this is insufficient or can’t engage in psychological therapy, then offer choice of
either a course of an SSRI or more intensive CBT (including ERP)
• If moderate functional impairment
o offer a choice of either a course of an SSRI (any SSRI for OCD but fluoxetine
specifically for body dysmorphic disorder) or more intensive CBT (including ERP)
• If severe functional impairment

o offer combined treatment with an SSRI and CBT (including ERP)
Notes on treatments
• ERP is a psychological method which involves exposing a patient to an anxiety

provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping
them engaging in their usual safety behaviour (e.g. washing their hands). This helps
them confront their anxiety and the habituation leads to the eventual extinction of the
response
• if treatment with SSRI is effective then continue for at least 12 months to prevent
relapse and allow time for improvement
• If SSRI ineffective or not tolerated try either another SSRI
Othello's syndrome
Othello's syndrome is pathological jealousy where a person is convinced their partner is

cheating on them without any real proof. This is accompanied by socially unacceptable
behaviour linked to these claims.
Personality disorders
Disorder Features
Antisocial • Failure to conform to social norms with respect to lawful behaviors as
indicated by repeatedly performing acts that are grounds for arrest;
• More common in men;
• Deception, as indicated by repeatedly lying, use of aliases, or conning
others for personal profit or pleasure;
• Impulsiveness or failure to plan ahead;
• Irritability and aggressiveness, as indicated by repeated physical fights
or assaults;
• Reckless disregard for safety of self or others;
Disorder Features
• Consistent irresponsibility, as indicated by repeated failure to sustain
consistent work behavior or honor financial obligations;
• Lack of remorse, as indicated by being indifferent to or rationalizing
having hurt, mistreated, or stolen from another
Avoidant • Avoidance of occupational activities which involve significant

interpersonal contact due to fears of criticism, or rejection.
• Unwillingness to be involved unless certain of being liked
• Preoccupied with ideas that they are being criticised or rejected in
social situations
• Restraint in intimate relationships due to the fear of being ridiculed
• Reluctance to take personal risks doe to fears of embarrassment
• Views self as inept and inferior to others
• Social isolation accompanied by a craving for social contact
Borderline • Efforts to avoid real or imagined abandonment

• Unstable interpersonal relationships which alternate between
idealization and devaluation
• Unstable self image
• Impulsivity in potentially self damaging area (e.g. Spending, sex,
substance abuse)
• Recurrent suicidal behaviour
• Affective instability
• Chronic feelings of emptiness
• Difficulty controlling temper
• Quasi psychotic thoughts
Dependent • Difficulty making everyday decisions without excessive reassurance

from others
• Need for others to assume responsibility for major areas of their life
• Difficulty in expressing disagreement with others due to fears of losing
support
• Lack of initiative
• Unrealistic fears of being left to care for themselves
• Urgent search for another relationship as a source of care and support
when a close relationship ends
• Extensive efforts to obtain support from others
• Unrealistic feelings that they cannot care for themselves
Disorder Features
Histrionic • Inappropriate sexual seductiveness
• Need to be the centre of attention
• Rapidly shifting and shallow expression of emotions
• Suggestibility
• Physical appearance used for attention seeking purposes
• Impressionistic speech lacking detail
• Self dramatization
• Relationships considered to be more intimate than they are
Narcissistic • Grandiose sense of self importance

• Preoccupation with fantasies of unlimited success, power, or beauty
• Sense of entitlement
• Taking advantage of others to achieve own needs
• Lack of empathy
• Excessive need for admiration
• Chronic envy
• Arrogant and haughty attitude
Obsessive- • Is occupied with details, rules, lists, order, organization, or agenda to

compulsive the point that the key part of the activity is gone
• Demonstrates perfectionism that hampers with completing tasks
• Is extremely dedicated to work and efficiency to the elimination of
spare time activities
• Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics,
or values
• Is not capable of disposing worn out or insignificant things even when
they have no sentimental meaning
• Is unwilling to pass on tasks or work with others except if they
surrender to exactly their way of doing things
• Takes on a stingy spending style towards self and others; and shows
stiffness and stubbornness
Paranoid • Hypersensitivity and an unforgiving attitude when insulted

• Unwarranted tendency to questions the loyalty of friends
• Reluctance to confide in others
• Preoccupation with conspirational beliefs and hidden meaning
• Unwarranted tendency to perceive attacks on their character
Disorder Features
Schizoid • Indifference to praise and criticism
• Preference for solitary activities
• Lack of interest in sexual interactions
• Lack of desire for companionship
• Emotional coldness
• Few interests
• Few friends or confidants other than family
Schizotypal • Ideas of reference (differ from delusions in that some insight is

retained)
• Odd beliefs and magical thinking
• Unusual perceptual disturbances
• Paranoid ideation and suspiciousness
• Odd, eccentric behaviour
• Lack of close friends other than family members
• Inappropriate affect
• Odd speech without being incoherent
Management
• PDs are often thought to be 'untreatable' by definition

• however, a number of approaches have been shown to help patients, including:
o psychological therapies: dialectical behaviour therapy
Post-concussion syndrome
Post-concussion syndrome is seen after even minor head trauma
Typical features include
• headache
• fatigue
• anxiety/depression
• dizziness
Post-partum mental health problems
Post-partum mental health problems range from the 'baby-blues' to puerperal psychosis.
The Edinburgh Postnatal Depression Scale may be used to screen for depression:
• 10-item questionnaire, with a maximum score of 30

• indicates how the mother has felt over the previous week
• score > 13 indicates a 'depressive illness of varying severity'
• sensitivity and specificity > 90%
• includes a question about self-harm
'Baby-blues' Postnatal depression Puerperal psychosis

Seen in around 60-70% Affects around 10% of women Affects approximately 0.2%
of women of women
Most cases start within a month and
Typically seen 3-7 days typically peaks at 3 months Onset usually within the
following birth and is first 2-3 weeks following
more common in Features are similar to depression birth
primips seen in other circumstances
Features include severe
Mothers are swings in mood (similar to
characteristically bipolar disorder) and
anxious, tearful and disordered perception (e.g.
irritable auditory hallucinations)
'Baby-blues' Postnatal depression Puerperal psychosis

Reassurance and As with the baby blues reassurance Admission to hospital is
support, the health and support are important usually required
visitor has a key role
Cognitive behavioural therapy may be There is around a 25-
beneficial. Certain SSRIs such 50% risk of recurrence
as sertraline and paroxetine* may be following future
used if symptoms are severe** - whilst pregnancies
they are secreted in breast milk it is
not thought to be harmful to the
infant
*paroxetine is recommended by SIGN because of the low milk/plasma ratio

**fluoxetine is best avoided due to a long half-life
Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) can develop in people of any age following a traumatic
event, for example, a major disaster or childhood sexual abuse. It encompasses what became
known as 'shell shock' following the first world war. One of the DSM-IV diagnostic criteria is that
symptoms have been present for more than one month.
Features
• re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images

• avoidance: avoiding people, situations or circumstances resembling or associated with
the event
• hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems,
irritability and difficulty concentrating
• emotional numbing - lack of ability to experience feelings, feeling detached
from other people
• depression
• drug or alcohol misuse
• anger
• unexplained physical symptoms
Management
• following a traumatic event single-session interventions (often referred to as debriefing)

are not recommended
• watchful waiting may be used for mild symptoms lasting less than 4 weeks
• military personnel have access to treatment provided by the armed forces
• trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation
and reprocessing (EMDR) therapy may be used in more severe cases
• drug treatments for PTSD should not be used as a routine first-line treatment for adults.
If drug treatment is used then venlafaxine or a selective serotonin reuptake inhibitor
(SSRI), such as sertraline should be tried. In severe cases, NICE recommends that
risperidone may be used
Schizophrenia: epidemiology
The strongest risk factor for developing a psychotic disorder (including schizophrenia) is family
history. Having a parent with schizophrenia leads to a relative risk (RR) of 7.5.
Risk of developing schizophrenia
• monozygotic twin has schizophrenia = 50%

• parent has schizophrenia = 10-15%
• sibling has schizophrenia = 10%
• no relatives with schizophrenia = 1%
Other selected risk factors for psychotic disorders include:
• Black Caribbean ethnicity - RR 5.4

• Migration - RR 2.9
• Urban environment- RR 2.4
• Cannabis use - RR 1.4
Schizophrenia: features
Schneider's first rank symptoms may be divided into auditory hallucinations, thought disorders,
passivity phenomena and delusional perceptions:
Auditory hallucinations of a specific type:
• two or more voices discussing the patient in the third person

• thought echo
• voices commenting on the patient's behaviour
Thought disorder*:
• thought insertion
• thought withdrawal
• thought broadcasting
Passivity phenomena:
• bodily sensations being controlled by external influence

• actions/impulses/feelings - experiences which are imposed on the individual or
influenced by others
Delusional perceptions
• a two stage process) where first a normal object is perceived then secondly there is a
sudden intense delusional insight into the objects meaning for the patient e.g. 'The
traffic light is green therefore I am the King'.
Other features of schizophrenia include
• impaired insight
• incongruity/blunting of affect (inappropriate emotion for circumstances)
• decreased speech
• neologisms: made-up words
• catatonia
• negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive
pleasure), alogia (poverty of speech), avolition (poor motivation)
*occasionally referred to as thought alienation
Schizophrenia: management
NICE published guidelines on the management of schizophrenia in 2009.
Key points:
• oral atypical antipsychotics are first-line

• cognitive behavioural therapy should be offered to all patients
• close attention should be paid to cardiovascular risk-factor modification due to the high
rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic
medication and high smoking rates)
Schizophrenia: prognostic indicators
Factors associated with poor prognosis
• strong family history

• gradual onset
• low IQ
• prodromal phase of social withdrawal
• lack of obvious precipitant
Seasonal affective disorder
Seasonal affective disorder (SAD) describes depression which occurs predominately around the
winter months. SAD should be treated the same way as depression, therefore as per the NICE
guidelines for mild depression, you would begin with psychological therapies and follow up with
the patient in 2 weeks to ensure that there has been no deterioration. Following this an SSRI
can be given if needed. In seasonal affective disorder, you should not give the patient sleeping
tablets as this can make the symptoms worse. Finally, the evidence for light therapy is limited
and as such it is not routinely recommended.
Selective serotonin reuptake inhibitors
Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for the
majority of patients with depression.
• citalopram (although see below re: QT interval) and fluoxetine are currently the
preferred SSRIs
• sertraline is useful post myocardial infarction as there is more evidence for its safe use
in this situation than other antidepressants
• SSRIs should be used with caution in children and adolescents. Fluoxetine is the drug of
choice when an antidepressant is indicated
Adverse effects
• gastrointestinal symptoms are the most common side-effect

• there is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton
pump inhibitor should be prescribed if a patient is also taking a NSAID
• patients should be counselled to be vigilant for increased anxiety and agitation after
starting a SSRI
• fluoxetine and paroxetine have a higher propensity for drug interactions
Citalopram and the QT interval
• the Medicines and Healthcare products Regulatory Agency (MHRA) released a warning
on the use of citalopram in 2011
• it advised that citalopram and escitalopram are associated with dose-dependent QT
interval prolongation and should not be used in those with: congenital long QT
syndrome; known pre-existing QT interval prolongation; or in combination with other
medicines that prolong the QT interval
• the maximum daily dose is now 40 mg for adults; 20 mg for patients older than 65 years;
and 20 mg for those with hepatic impairment
Interactions
• NSAIDs: NICE guidelines advise 'do not normally offer SSRIs', but if given co-prescribe a
proton pump inhibitor
• warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering
mirtazapine
• aspirin: see above
• triptans - increased risk of serotonin syndrome
• monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome
Following the initiation of antidepressant therapy patients should normally be reviewed by a

doctor after 2 weeks. For patients under the age of 30 years or at increased risk of suicide they
should be reviewed after 1 week. If a patient makes a good response to antidepressant therapy
they should continue on treatment for at least 6 months after remission as this reduces the risk
of relapse.
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not
necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.
Discontinuation symptoms
• increased mood change

• restlessness
• difficulty sleeping
• unsteadiness
• sweating
• gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
• paraesthesia
SSRIs and pregnancy

- BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
- Use during the first trimester gives a small increased risk of congenital heart defects
- Use during the third trimester can result in persistent pulmonary hypertension of the newborn
- Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
Serotonin and noradrenaline reuptake inhibitors
Serotonin and noradrenaline reuptake inhibitor (SNRI's) are a class of relatively new
antidepressants. Inhibiting the reuptake increases the concentrations of serotonin and
noradrenaline in the synaptic cleft leading to the effects. Examples

include venlafaxine and duloxetine. They are used to treat major depressive disorders,
generalised anxiety disorder, social anxiety disorder and panic disorder and menopausal
symptoms.
Sleep paralysis
Sleep paralysis is a common condition characterized by transient paralysis of skeletal muscles

which occurs when awakening from sleep or less often while falling asleep. It is thought to be
related to the paralysis that occurs as a natural part of REM (rapid eye movement) sleep. Sleep
paralysis is recognised in a wide variety of cultures
Features
• paralysis - this occurs after waking up or shortly before falling asleep

• hallucinations - images or speaking that appear during the paralysis
Management
• if troublesome clonazepam may be used
SSRI: side-effects
Adverse effects
• gastrointestinal symptoms are the most common side-effect

• there is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton
pump inhibitor should be prescribed if a patient is also taking a NSAID
• hyponatraemia
• patients should be counselled to be vigilant for increased anxiety and agitation after
starting a SSRI
• fluoxetine and paroxetine have a higher propensity for drug interactions
Citalopram and the QT interval
• the Medicines and Healthcare products Regulatory Agency (MHRA) released a warning
on the use of citalopram in 2011
• it advised that citalopram and escitalopram are associated with dose-dependent QT
interval prolongation and should not be used in those with: congenital long QT
syndrome; known pre-existing QT interval prolongation; or in combination with other
medicines that prolong the QT interval
• the maximum daily dose is now 40 mg for adults; 20 mg for patients older than 65 years;
and 20 mg for those with hepatic impairment
Interactions
• NSAIDs: NICE guidelines advise 'do not normally offer SSRIs', but if given co-prescribe a
proton pump inhibitor
• warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering
mirtazapine
• aspirin: see above
• triptans: avoid SSRIs
Following the initiation of antidepressant therapy patients should normally be reviewed by a

doctor after 2 weeks. For patients under the age of 30 years or at increased risk of suicide they
should be reviewed after 1 week. If a patient makes a good response to antidepressant therapy
they should continue on treatment for at least 6 months after remission as this reduces the risk
of relapse.
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not
necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.
Discontinuation symptoms
• increased mood change

• restlessness
• difficulty sleeping
• unsteadiness
• sweating
• gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting

• paraesthesia
Suicide: risk factors
The risk stratification of psychiatric patients into 'high', 'medium' or 'low risk' is common in
clinical practice. Questions based on a patient's suicide risk are therefore often seen. However,
it should be noted that there is a paucity of evidence addressing the positive predictive value of
individual risk factors. An interesting review in the BMJ (BMJ 2017;359:j4627) concluded that
'there is no evidence that these assessments can usefully guide decision making' and noted that
50% of suicides occur in patients deemed 'low risk'.
Whilst the evidence base is relatively weak, there are a number of factors shown to be
associated with an increased risk of suicide
• male sex (hazard ratio (HR) approximately 2.0)

• history of deliberate self-harm (HR 1.7)
• alcohol or drug misuse (HR 1.6)
• history of mental illness
o depression
o schizophrenia: NICE estimates that 10% of people with schizophrenia will
complete suicide
• history of chronic disease
• advancing age
• unemployment or social isolation/living alone
• being unmarried, divorced or widowed
If a patient has actually attempted suicide, there are a number of factors associated with an
increased risk of completed suicide at a future date:
• efforts to avoid discovery

• planning
• leaving a written note
• final acts such as sorting out finances
• violent method
Protective factors
There are, of course, factors which reduce the risk of a patient committing suicide. These
include
• family support
• having children at home
• religious belief
Tricyclic antidepressants
Tricyclic antidepressants (TCAs) are used less commonly now for depression due to their side-
effects and toxicity in overdose. They are however used widely in the treatment of neuropathic
pain, where smaller doses are typically required.
Common side-effects
• drowsiness
• dry mouth
• blurred vision
• constipation
• urinary retention
• lengthening of QT interval
Choice of tricyclic
• low-dose amitriptyline is commonly used in the management of neuropathic pain and

the prophylaxis of headache (both tension and migraine)
• lofepramine has a lower incidence of toxicity in overdose
• amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose
More sedative Less sedative

Amitriptyline Imipramine
Clomipramine Lofepramine
Dosulepin Nortriptyline
Trazodone*
*trazodone is technically a 'tricyclic-related antidepressant'
Unexplained symptoms
There are a wide variety of psychiatric terms for patients who have symptoms for which no
organic cause can be found:
Somatisation disorder
• multiple physical SYMPTOMS present for at least 2 years

• patient refuses to accept reassurance or negative test results
Illness anxiety disorder (hypochondriasis)
• persistent belief in the presence of an underlying serious DISEASE, e.g. cancer

• patient again refuses to accept reassurance or negative test results
Conversion disorder
• typically involves loss of motor or sensory function

• the patient doesn't consciously feign the symptoms (factitious disorder) or seek material
gain (malingering)
• patients may be indifferent to their apparent disorder - la belle indifference - although

this has not been backed up by some studies
Dissociative disorder
• dissociation is a process of 'separating off' certain memories from normal consciousness

• in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue,
stupor
• dissociative identity disorder (DID) is the new term for multiple personality disorder as is
the most severe form of dissociative disorder
Factitious disorder
• also known as Munchausen's syndrome

• the intentional production of physical or psychological symptoms
Malingering
• fraudulent simulation or exaggeration of symptoms with the intention of financial or

other gain

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PassMedicine Psychiatric Notes

Furthermore You can also request a specific

Acute stress disorder

• intrusive thoughts e.g. flashbacks, nightmares

• trauma-focused cognitive-behavioural therapy (CBT) is usually used first-line

• symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety

Anorexia nervosa: features

• reduced body mass index

Typical antipsychotics Atypical antipsychotics

Extrapyramidal side-effects (EPSEs)

• increased risk of stroke

• antimuscarinic: dry mouth, blurred vision, urinary retention, constipation

Aphonia describes the inability to speak. Causes include:

• recurrent laryngeal nerve palsy (e.g. Post-thyroidectomy)

Adverse effects of atypical antipsychotics

• clozapine is associated with agranulocytosis (see below)

• increased risk of stroke

Examples of atypical antipsychotics

Adverse effects of clozapine

• agranulocytosis (1%), neutropaenia (3%)

Dose adjustment of clozapine might be necessary if smoking is started or stopped during

Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric

• switch patients to the equivalent dose of diazepam

• benzodiazipines increase the frequency of chloride channels

Frequently Bend - During Barbeque

Barbidurates increase duration & Frendodiazepines increase frequency

Body dysmorphic disorder

Body dysmorphic disorder (sometimes referred to as dysmorphophobia) is a mental disorder

Diagnostic and Statistical Manual (DSM) IV criteria:

• Preoccupation with an imagine defect in appearance. If a slight physical anomaly is

DSM 5 diagnostic criteria for a diagnosis of bulimia nervosa:

• referral for specialist care is appropriate in all cases

Charles-Bonnet syndrome (CBS) is characterised by persistent or recurrent complex

Risk factors include:

Around a third find the hallucinations themselves an unpleasant or disturbing experience. In a

Cox (2014) Negative outcome Charles Bonnet Syndrome. Br J Ophthalmol.

Cotard syndrome is associated with severe depression and psychotic disorders.

De Clerambault's syndrome, also known as erotomania, is a form of paranoid delusion with an

Depression in older people

Older patients are less likely to complain of depressed mood

• physical complaints (e.g. hypochondriasis)

Depression vs. dementia

Factors suggesting diagnosis of depression over dementia

• short history, rapid onset

• patient worried about poor memory

Depression: screening and assessment

The following two questions can be used to screen for depression

Hospital Anxiety and Depression (HAD) scale

• consists of 14 questions, 7 for anxiety and 7 for depression

Patient Health Questionnaire (PHQ-9)

NICE use the DSM-IV criteria to grade depression:

• 1. Depressed mood most of the day, nearly every day

contraindications is raised intracranial pressure.

• some patients report impaired memory

Generalised anxiety disorder and panic disorder

Management of generalised anxiety disorder (GAD)

NICE suggest a step-wise approach:

• step 1: education about GAD + active monitoring

• NICE suggest sertraline should be considered the first-line SSRI