1. Psychiatry

2. Background Info on Mental Health
1 in 4 people experience some kind of MH problem in 1 year
Mixed anxiety & depression is the most common MH disorder in Britain
Women are more likely to have been treated for a MH problem than men
10% children have a mental health problem
Depression affects 1 in 5 older people
The UK has one of the highest self-harm rates in Europe (400/100000 population)
9/10 prisoners have a mental disorder

3. Mental Health & The
Law

4. Human Rights Act
‘Everyone has the right to liberty and security of the person.’
‘No-one shall be subjected to torture or to inhuman or degrading
treatment or punishment.’
‘Everyone has the right to respect for his private and family life, his
home, and his correspondence.’

5. Mental Capacity Act
Assume capacity unless established that he/she doesn’t
Do not treat as unable to make a decision unless all practicable steps to do help
have been taken without success
Do not treat as unable to make a decision just because it is unwise
Any act or decision made under the MCA for or on behalf of someone who lacks
capacity must be done in his/her best interests
Before anything is done, you must consider whether the purpose can be
achieved in a way that is less restrictive of a persons right’s and freedom’s

6. Assessing Capacity
MUST have a diagnosis that may impair functioning
Need to assessed as to whether they can make a decision on a SPECIFIC matter
◦ Understand the information
◦ Retain the information
◦ Use and weigh the information to make a choice
◦ Communicate the decision

7. Mental Health Act
1983 Act of UK Parliament, revised in 2007
Covers reception, care and treatment of mentally disordered persons
Also covers detention of people (AKA sectioning)

8. People Defined in the Act
Approved Mental Health Professional
Section 12 Approved Doctors
Approved Clinicians
Responsible Clinicians

9. Civil Sections
Section 2
Section 3
Section 4
Section 5(2)
Section 5(4)
Section 135
Section 136

10. Examination &
Investigations

11. Mental State Exam
Appearance
Attitude
Behaviour
Mood & Affect
Speech
Thought Process
Thought Content
Perception
Cognition
Insight

12. ASSESS
CAPACITY

13. Assessing Suicide Risk
Male Gender
Age
Unemployed
Concurrent mental disorder
Treatment and care received after a
previous suicide attempt
Alcohol and drug abuse
Physically disabling or painful illness
Low socio-economic status
Previous psychiatric treatment
Professions
Low social support/living alone
Significant Life events
Institutionalisation
Bullying

14. PATHOS scoring
Have you had PROBLEMS for longer than 1 month?
Were you ALONE in the house when you attempted suicide?
Did you plan the suicide for more than THREE hours?
Are you feeling HOPELESS about the future and that things will not get much better?
Were you feeling SAD for most of the time before the attempt?

15. Medication Specific
Points

16. SSRIs
INDICATION: Moderate-severe depression. MAY be effective in bulimia nervosa.
EXAMPLES: Citalopram, Fluoxetine, Sertraline
MECHANISM: Increase 5-HT neurotransmission by blocking 5-HT reuptake
SIDE-EFFECTS: GI, side effects, agitation, sexual dysfunction
SPECIAL INSTRUCTIONS: Dyscontinuation syndrome if sertraline/citalopram stopped suddenly.
Fluoxetine has longer half-life therefore safer.

17. SNRIs
INDICATION: Major depression
EXAMPLES: Venlafaxine
MECHANISM: Increase noradrenaline & serotonin availability by blocking re-uptake
SIDE-EFFECTS: loss of appetite, weight and sleep. Sexual dysfunction.
SPECIAL INSTRUCTIONS: More dangerous in overdose than SSRIs

18. TCAs
INDICATION: Depression with anxiety and/or agitation
EXAMPLES: Amitriptyline, clomipramine, dothiepi
MECHANISM: Increase 5-HT, NA and DA availability by non-elective blockade of mono-amine
reuptake
SIDE-EFFECTS: dry mouth, constipation, sedation. Cardiotoxic in overdose
SPECIAL INSTRUCTIONS: Treat overdose with activated charcoal

19. MAOIs
INDICATION: Depression resistant to SSRIs/TCAs
EXAMPLES: Moclobemide, Isocarboxazid, Phenelzine
MECHANISM: block the monoamine oxidase enzymes responsible for intracellular metabolism of
monoamine neurotransmitters
SIDE-EFFECTS: serotonin syndrome!! Hypertensive crisis due to interaction with
sympathomimetic amines.
SPECIAL INSTRUCTIONS: when starting MAOIs ensure SSRIs/TCAs have been stopped for 2 weeks

20. Anxiolytics
INDICATION: Short-term treatment of severe, disabling anxiety/
EXAMPLES: Benzodiazapines, beta blockers, buspirone, SSRIs
MECHANISM: Increase the effect of GABA. Benzodiazapines increase GABAergic activity. Beta
blockers act on sympathetic nervous system and busprione is a 5-HT agonist.
SIDE-EFFECTS: Dependence, withdrawal, daytime sedation
SPECIAL INSTRUCTIONS: Decrease slowly and make sure only on them short term. Don’t drink on
them (increased sedative effect)

21. Hypnotics
INDICATION: Short-term treatment of insomnia causing significant distress/disability
EXAMPLES: Benzodiazapines, zopiclone, barbituates (but not really), antihistamines
MECHANISM: Increase effect of GABA
SIDE-EFFECTS: Dependence & tolerance. Withdrawal, daytime sedation,
SPECIAL INSTRUCTIONS: Same as anxiolytics

22. Lithium
INDICATION: Bipolar disorder
MECHANISM: Unclear.
SIDE-EFFECTS: Nausea, thirst, polyuria, hypothyroidism, tremor, ataxia and teratogenicity.
Toxicity – dysrhythmias, renal impairment, convulsions.
SPECIAL INSTRUCTIONS: Titrate dose to achieve plasma conc of 06-1.0mmol/L. Narrow
therapeutic range. Treat toxicity with fluid resuscitation, haemodialysis. Do not withdraw
abruptly.

23. Typical Antipsychotics
INDICATION: Acute treatment of psychotic states, schizophrenia & chronic psychoses
EXAMPLES: Chlorpromazine, promazine, prochlorperazine, haloperidol
MECHANISM: Dopamine receptor antagonists. Primarily affect D2 receptors.
SIDE-EFFECTS: Sedation, extra-pyramidal side effects of parkinsonism, dry mouth, drowsiness,
postural hypotension, weight gain, photosensitivity. NEUROLEPTIC MALIGNANT SYNDROME =
hyperthermia, loss of consciousness and autonomic dysfunction.
Chlorpromazine associated with raised prolactin & galactorrhoea
SPECIAL INSTRUCTIONS: Do NOT give haloperidol in parkinsons. Contraindicated in
cardiovascular disease, epilepsy, coma patients, bone marrow disorders.

24. Atypical Antipsychotics
INDICATION: Psychoses as in typical. Behavioural challenges in Alzheimer’s, controlling tics in
tourettes.
EXAMPLES: Clozapine, olanzapine, quetiapine, risperidone
MECHANISM: Affect D3 and D4 receptors.
SIDE-EFFECTS: Increased appetite and weight gain. Metabolic syndrome. Clozapine causes
agranulocytosis.
SPECIAL INSTRUCTIONS: Clozapine = last resort, monitor FBC on all atypical antipsychotics.

25. Cognitive Enhancers
INDICATION: Treatment of cognitive symptoms in Alzheimer’s disease.
EXAMPLES: Donepizil, galantamine, rivastigmine, memantine
MECHANISM: Acetylcholinesterase inhibitors.
SIDE-EFFECTS: Nausea, vomiting, diarrhoea, headache, insomnia, dizziness.
SPECIAL INSTRUCTIONS: Do NOT prescribe in asthmatics or COPD. Nor in patients with a history
of gastric/duodenal ulcers.

26. CNS stimulants
INDICATION: Narcolepsy and ADHD.
EXAMPLES: Methylphenidate (Ritalin), atomoxetine, dexamfetamine
MECHANISM: Increase availability of monoamines by stimulating release into synapse and/or
blocking reuptake
SIDE-EFFECTS: Insomnia, restlessness, tremors, anxiety, anorexia, dependence, psychosis.
Growth retardation in children.
SPECIAL INSTRUCTIONS: Do not prescribe in patients with cardiovascular disease or in
pregnancy/breastfeeding women.

27. Organic Mental
Disorders

28. Dementia
Describes the symptoms that occur when the brain is affected
◦ Memory loss
◦ Confusion & mood changes
◦ Problems with speech & understanding
NOT a natural part of growing old.
Various types. ALL are progressive.

29. Alzheimer’s
A woman attends surgery with her 72-year old mother. She reports that her mother
has recently been misplacing everyday things such as keys and has missed a few bill
payments and she demands you test her memory. Her mother feels there isn’t a
problem at that her daughter is exaggerating everything that has happened, she
then begins to tell you about the builder who knocked on her door two weeks ago
saying she needed her kitchen renovated under new council laws.

30. Vascular
An 81-year old male presents with his wife to the GP. He had a stroke 8 months ago
and, despite recovering reasonably well, he has found his memory just isn’t the same
as it used to be and he sometimes struggles to understand what people are saying.
Four months later he has another stroke. This time his wife brings him in post-
recovery saying she has noticed he drastically worsened. He is now unable to
remember what he has said, constantly repeating himself, and is often very agitated
due to struggling to communicate and understand what is being said.

31. Dementia with Lewy Bodies
A 65-year old male presents to the surgery informing you he thinks he has a memory
problem. It started about 6 months, he has noticed he has been increasingly
forgetful misplacing objects, and the other day he couldn’t recognise his wife. This is
very distressing for him and he is scared about what will happen. Observing him you
notice a resting tremor in his right hand and that the movements are quite slow. He
informs you the tremor has been going on for about 2 months.
Two years later he is being assessed by a psychiatrist and reports that he often see’s
people that aren’t there and hears dogs barking that his wife can’t hear.

32. Investigating Potential Dementia
Routine haematology
U&Es, Serum Calcium, Glucose, LFTs
TFTs
Vitamin B12 and folate levels
Refer to a MEMORY ASSESSMENT SERVICE

33. At the memory clinic…
History &
Examination
Medication
Review
Clinical
Cognitive
Assessment

34. Subtyping
MRI
Single-Photon Emission Computed Tomography

35. Management
EDUCATION PATIENTFAMILY
PROMOTE
INDEPENDENCE
OCCUPATIONAL
THERAPY
COGNITION BEHAVIOUR DEPRESSION

36. Other considerations
In-patient care
◦ Psychiatric inpatient admission if severely disturbed
◦ If in for medical reasons ALWAYS liaise and assess impact on
dementia
Palliation

37. Mental and Behavioural
Disorders
DUE TO PSYCHOACTIVE SUBSTANCE USE

38. Substance Abuse Histories
How long?
How much? How strong?
What time in the day/week?
Has it interfered with daily life?
Do you need more to create the same effect?
Do you get withdrawal symptoms?
If so, are these relieved by having more of the substance?

39. Alcohol Use
A 32-year old woman comes to you feeling depressed and complaining of work,
housing and financial stresses. She admits she is struggling to cope and her children
are being very difficult to handle at the moment.
When you question about how she is coping she reluctantly tells you she has started
drinking a bit more than usual, but it’s just because of the stress and it isn’t causing
her any problems. Her boss has caught her drunk after lunch once though.

40. Quick Scores for Alcohol Use
CAGE
Have you ever felt you needed to CUT down on your drinking?
Have people ANNOYED you by criticising your drinking?
Have you ever felt GUILTY about drinking?
Have you ever felt you needed a drink first thing in the morning (EYE-OPENER) to steady your
nerves or get rid of a hangover?
FAST Test
1:- MEN: How often do you have EIGHT or more drinks on one occasion?
WOMEN: How often do you have SIX or more drinks on one occasion?
NEVER LESS THAN MONTHLY MONTHLY WEEKLY DAILY
2:- How often during the last year have you been unable to remember what happened the
night before because you had been drinking?
NEVER LESS THAN MONTHLY MONTHLY WEEKLY DAILY
3:- How often during the last year have you failed to do what was normally expected of you
because of drinking?
NEVER LESS THAN MONTHLY MONTHLY WEEKLY DAILY
4:- In the last year has a relative, or friend, or a doctor or other health worker been
concerned about your drinking or suggested you cut down?
No YES, ON ONE OCCASION YES, ON MORE THAN ONE OCCASION

41. AUDIT
10 point questionnaire
Scored out of 40
8 or more is considered an indicator of hazardous and harmful use

42. Assessment
Bombard the patients with questionnaires
◦ Severity of Alcohol Dependence Questionnaire
◦ Alcohol Problems Questionnaire
Motivational intervention
◦ Identify drinking problem
◦ Resolve ambivalence and encourage positive change
◦ Be persuasive rather than confrontational
Refer Children and
Young People
Triage Adults
Assess co-morbidities,
patterns of use and
other problems
INTERVENE

43. Assessment
Advice to Adults re safe alcohol consumption
◦ Potential harm
◦ Barriers to change
◦ Practical strategies to reduce alcohol consumption
◦ Create a set of goals
Brief interventions for young adults and adults
◦ Motivational interviewing
Refer to specialist services ONLY IF NEEDED
◦ Show signs of moderate or severe alcohol dependence
◦ Failed to benefit from structured brief interventions
◦ Show signs of alcohol-related impairment

44. Planned Alcohol Withdrawal
ASSESS
SAFETY
INPATIENT/
OUTPATIENT
DRUG
REGIME

45. If Withdrawal is Unsuccessful…
Consider offering alternatives
◦ Acamprosate
◦ Oral Naltrexone
◦ +- CBT
◦ Disulfiram

46. Physical Complications
Acute alcohol withdrawal
Wernicke’s encephalopathy
Wernicke-Korsakoff syndrome
Alcohol-related liver disease
Alcohol-related pancreatitis

47. Prevention IS Better…
School programmes to educate children
Increasing the cost of alcohol
Limiting the licences on places selling alcohol
Encouraging companies to place warnings on the alcohol containers

48. Opioids Use
How to recognise…
◦ Physical signs :- miosis, needle marks, respiratory depression, increased sphincter tone, hypovolaemia
◦ Request specific opioids
◦ Unresponsive to the medication, always insisting they need a higher dose
◦ Malingering
◦ Failure to do what is expected of them

49. Treating Intoxication
A – clear if needed
B – provide ventilation if needed
C – IV fluids
OBSERVATIONS
IV Naloxone

50. Mechanism of Tolerance & Withdrawal
Internalisation of Mu and Delta opioid receptors
Down regulation of secondary messengers such as cAMP
Therefore need larger amount of opioid to create same effect
Withdrawal occurs when endogenous opioid cannot activate the remaining receptors

51. Recognising Withdrawal
Autonomic symptoms
CNS Arousal
Pain
Cravings

52. Treating Withdrawal
INFORMATION
CREATE A PLAN WITH GOALS
OFFER SUPPORT TO FAMILIES AND CARERS
METHADONE OR BUPRENORPHINE = FIRST LINE
LOFEXIDINE = OPTION FOR SHORT-TERM DETOXIFICATION
DETOXIFICATION LASTS 4 WEEKS IF INPATIENT
◦ 12 WEEKS IF IN COMMUNITY

53. CAN ALSO OFFER ‘ULTRA-
RAPID’ OR ‘RAPID’ DETOX

54. Cannabinoids
Recognised using CAGE for dependence
May have: -
◦ Miosis
◦ Loss of balance
◦ Impaired cognitive functioning
◦ Loss of sensory perceptions

55. Schizophrenia &
Delusional Disorders

56. Aetiology
Genetics
Development
Brain abnormalities
Neurotransmitter abnormalities
Life events
High expressed emotion environment

57. Epidemiology
Onset
◦ Between 17 & 30 in men
◦ 20 and 40 in women
Lifetime risk between 0.7 and 0.9%
Increased prevalence in urban areas and lower social classes

58. Schneider’s First Rank Symptoms
Auditory hallucinations
Thought withdrawal, insertion and interruption
Thought broadcasting
Somatic hallucinations
Delusional perceptions
Feelings/actions experienced as if made or influenced by external agents

59. General Clinical Features
Schizophrenic Thought Disorder
Disorders of Stream of Thought
Delusions
Abnormalities of Mood
Hallucinations

60. Paranoid Schizophrenia
An 24-year old male comes into GP. He has been feeling especially stressed since a
van parked outside his house has started watching him. He claims it is because they
know about his mission. Half-way through the consultation he becomes incredibly
aggressive towards you claiming you’re colluding with them and storms out.

61. Hebephrenic Schizophrenia
A 39-year old female is bought to the GP by her concerned husband. Both of them
lost their jobs a year ago and had to move into council housing. He says recently
she’s changed drastically, sometimes talking about one thing then going off on a
tangent and he struggles to keep up. She’s also started rhyming her words a lot and
on other occasions it’s very hard to get anything out of her. They were also at a
funeral the other day and she just began laughing uncontrollably and wouldn’t stop.

62. Catatonic Schizophrenia
A psychiatrist attends a home visit to see a patient that has been referred to him.
Upon arrival at the property he is met by a mother who shows him her son. He is
standing at the window on one leg, with the other slightly flexed and one finger
pointing upwards. She tells you he will wake up at 8.30 in the morning and maintain
this position for the entire day. If ever he does talk it’s intelligible words that make
no sense.

63. Treating Schizophrenia
Early referral
Pharmacological Intervention

64. Treating Schizophrenia
BUT WHICH DRUG?
POSITIVE NEGATIVE
ATYPICALTYPICAL

65. Treating Schizophrenia
Psychological Interventions
◦ CBT
◦ Family Based Therapies
◦ Arts therapy
Social Interventions
◦ Education
◦ Housing
◦ Finance

66. Delusional Disorder
Patient expresses idea with unusual persistence/force
Idea is exerting influence on patients life
Quality of secretiveness/suspicion
Humorless and sensitive about the belief
No matter how unlikely patient believes it fully and completely
Any contradiction to the idea is met with force
Belief is out of keeping with patients cultural and social background
Others who observe the behaviour believe it to be abnormal

67. Delusional Disorder
Stable disorder characterised by delusions that are clung to
Chronic illness
Delusions are logical and have internal consistency
Delusions do not interfere with logic unless related to the delusion

68. Types of Delusions
Erotomania
Grandiose
Jealous
Persecutory
Somatic
Mixed
Unspecified

69. Schizoaffective disorder
Mixture of Schizophrenia & Mood Disorders
Bipolar Type or Depressive Type
Treat symptoms of mood disorders and of schizophrenia

70. Mood disorders

71. Manic Episodes
“An episode where mood is higher than the person’s situation warrants and may vary from
relaxed high spirits to barely controllable exuberance, accompanied by hyperactivity, a
compulsion to speak, a reduced sleep requirement, difficulty sustaining attention and, often,
increased distractability”
PSYCHOLOGICAL
• Pressured speech
• Flight of ideas
• Grandiose delusions
• Expanded self-esteem
• Preoccupying thoughts
• Over-indulgence in behaviours with high risk
PHYSICAL
• Sweating
• Pacing
• Weight loss

72. Bipolar Affective Disorder
A 23-year old man walks into your practice. He stands out wearing brightly coloured
clothing and wearing shorts and flip-flops despite the snow. He talks incredibly
quickly and you struggle to keep up with him, but understand a few words about
‘living on mars’ and ‘communicating with the Gods for his mission.’ When you try to
get him to slow down he gets irritable telling you there’s no time and that he is of
vital importance to all their plans.

73. Bipolar Affective Disorder
Occurrence of at least one manic episode
◦ If hypomanic episode (without full manic episode) occurs then bipolar II disorder
Major social complications
◦ Marital
◦ Financial
◦ Social
Medical complications
◦ Increased mortality
◦ Substance abuse tends to occur concomitantly

74. Investigations
CT/MRI of brain
◦ Brain tumour
◦ Head injury
FBC, LFTs, U&Es, Haematinics
◦ Anaemia
◦ Hepatic/renal failure
◦ Pernicious anaemia
Endocrinology assessments
◦ Thyroid dysfunction
◦ Addison’s/Cushing’s
◦ Hypoglycaemia

75. Treatment
ACUTE MANIA DISCUSSED LATER
Mood stabilisers
◦ Lithium
◦ Semisodium valproate
Second-line
◦ Add carbamazepine or lamotrigine

76. Lithium Treatment
Before starting treatment
◦ TFTs
◦ Renal function
◦ ECG
◦ Avoid if in first trimester/advocate reliable contraception in women of child-bearing age
Check levels 12 hours after latest dose
◦ Therapeutic range = 0.7-1.0 mmol/L if dose is taken once daily
◦ Twice daily dose = 0.4-0.8 mmol/L at 12 hours
When starting check 1 week after commencing and 1 week after every dose change
Monitor monthly in first 6 months then every 3 months if lithium levels are stable and adherence is
good
Check TFTs & U&Es every 6 months

77. Lithium Toxicity
Occurs at levels above 1.4mmol/L
Symptoms
◦ Diarrhoea
◦ Vomiting
◦ Ataxia
◦ Nystagmus
◦ Dysarthria
Management
◦ Isotonic saline fluids
◦ Haemodialysis if renal failure
o Confusion
o Epileptic Seizures
o Hypereflexia
o Hypertonia
o AV Heart Block

78. Depression
A 33-year old woman comes to see her GP. It takes her a while to start talking, but
she reports symptoms of insomnia and early morning waking. She denies feeling of
low mood, but on further probing she has lost interest in her gardening and does feel
tired a lot of the time. She has been losing weight steadily over the past few months,
and has struggled to get the energy for her job.

79. Persistent sadness or low mood
Loss of interests or pleasure
Fatigue or low energy
+/-
◦ Disturbed sleep
◦ Poor concentration or indecisiveness
◦ Low self-confidence
◦ Poor or increased appetite
◦ Suicidal thoughts or acts
◦ Agitation or slowing of movements
◦ Guilt or self blame

80. Management
Refer if there is psychosis, a risk of suicide or a history of bipolar
Mild – moderate depression
◦ Watchful waiting
◦ Exercise
◦ Self Help
◦ Psychological therapies
Moderate depression
◦ SSRIs
◦ CBT
Consider need for ECT in severe depression

81. Neurotic, stress &
somatoform disorders

82. Specific Phobias
Irrational fear
Provokes physical response
Usually purely behavioural conditioned response
Treat with:-
◦ Counselling
◦ Psychotherapy
◦ CBT
◦ Desensitisation
◦ Medication

83. Panic Disorder
Characterised by panic attacks
◦ Sudden, overwhelming, discrete episodes of anxiety
◦ Patients think they might die, collapse or lose control
◦ Psychosomatic symptoms
◦ Palpitations Sweating Trembling Shortness of breath Choking Chest pain Nausea Dizziness
Derealisation/Depersonalisation Fear of losing control Fear of dying Paraesthesias Chills
Hot Flushes
Initial attacks sudden, later associated with environments

84. Generalised Anxiety Disorder
Anxiety towards everything
Constant worrying
Interferes with daily life

85. Management of Anxiety Disorders
SSRIs = first line along with CBT
Increase dose
Tricyclics second-line
Hypnotics third-line
If still no response reconsider diagnosis

86. Post-Traumatic Stress Disorder
Direct response to extreme stress or life-threatening event
Characteristics
◦ Recurrent reliving of the traumatic experience
◦ Nightmares/flashbacks
◦ Phobic avoidance of stimuli associated with trauma
◦ Persistent arousal
◦ Hypervigilance & abnormal startle response
Offer trauma focussed CBT
Eye movement desensitisation & reprocessing
Drugs are NOT first-line

87. Obsessive Compulsive Disorder
Recurrent obsessions &/OR compulsions
Unpleasant, intrusive repetitive thought
Recognised to be the patients own
Cause a degree of anxiety to patient
Treat same as other anxieties

88. Conversion Disorders
Typically involves loss of motor or sensory function
Symptoms aren’t consciously feigned or for material gain
Patients may be indifferent to symptoms (La Belle Indifference)

89. Somatisation Disorders
Multiple physical SYMPTOMS present for at least 2 years
Multiple investigations but patient refuses to accept reassurances or test results

90. Hypochondriacal Disorder
Persistent belief in the presence of an underlying DISEASE

91. Body Dysmorphic Disorder
DEPRESSION DELUSIONS
ANXIETY LOW SELF-ESTEEM
INABILITY TO
WORK
BEHAVIOURAL
PROBLEMS

92. Behavioural Syndromes
with Physiological
Disturbance/Physical
Factors

93. Anorexia Nervosa
Behavioural disturbance leading to marked weight loss or lack of weight gain
BMI <17.5
A morbid fear of fatness
An endocrine disorder
◦ Amenorrhoea
◦ Loss of sexual interest
May employ drastic means for weight control
◦ Laxative abuse
◦ Excessive exercise
◦ Self-induced vomiting

94. PHYSICAL
◦ Poor Peripheral Circulation
◦ Hypotension
◦ Bradycardia
◦ Electrolyte Disturbances
◦ Dehydration
◦ Lanugo hair
PSYCHOLOGICAL
◦ Depression
◦ Anxiety
◦ Irritability
◦ Social Withdrawal
◦ Low self-esteem
◦ Obsessional Thoughts

95. Bulimia Nervosa
Recurrent episodes of binge eating with loss of control
Extreme compensation (purging)
◦ Self-induced vomiting
◦ Laxative abuse
Morbid fear of fatness

96. Managing Eating Disorders
Anorexia
◦ Motivational interviewing
◦ CBT
◦ Family therapies
◦ DO NOT USE MEDICATION
Bulimia
◦ CBT
◦ Interpersonal therapy
◦ SSRIs

97. Postnatal Mental Health
'Baby-blues' Postnatal depression Puerperal psychosis
Seen in around 60-70% of women
Typically seen 3-7 days following birth
and is more common in primips
Mothers are characteristically anxious,
tearful and irritable
Affects around 10% of women
Most cases start within a month and
typically peaks at 3 months
Features are similar to depression seen
in other circumstances
Affects approximately 0.2% of women
Onset usually within the first 2-3 weeks
following birth
Features include severe swings in mood
(similar to bipolar disorder) and
disordered perception (e.g. auditory
hallucinations)
Reassurance and support, the health
visitor has a key role
As with the baby blues reassurance and
support are important
Cognitive behavioural therapy may be
beneficial. Certain SSRIs such as
sertraline and paroxetine may be used if
symptoms are severe - whilst they are
secreted in breast milk it is not thought
to be harmful to the infant
Admission to hospital is usually required
There is around a 20% risk of recurrence
following future pregnancies

98. Disorders of adult
personality and
behaviour

99. Paranoid Personality Disorder
Paranoia
Long-standing suspiciousness
Mistrust of others

100. Schizoid Personality Disorder
Lack of interest in social relationships
Tendency towards secretiveness, emotional coldness and apathy

101. Antisocial Personality Disorder
Disregard for the rights of others
Begins in childhood/adolescence and continues into adulthood
History of legal problems
Poor moral sense/conscience

102. Emotinally Unstable Personality Disorder
Variability and depth of moods
Affects interpersonal relationships
Impulsive behaviour
Unstable self-image and relationships
Feelings of abandonment

103. Psychiatric Emergencies

104. Acute Psychosis
Characterised by the presence of delusions, hallucinations, thought disorder and affective
disorder
May occur secondary to organic brain disorders, substance abuse, as an acute psychotic episode
or part of a chronic mental health issue
Assessment
◦ Evidence of Organic Brain Disorder
◦ Presence of Substance Abuse
◦ Risk of Self-Harm/Harm to Others
◦ Physical complications such as self-neglect
May need Rapid Tranquilisation
Consider oral antipsychotics or IM depo injection

105. Severe Depression
1. Organic cause?
2. Mini mental state exam
3. Psychosis?
4. Psychomotor retardation
5. History of bipolar?
6. Medical complications of neglect/self-harm?
7. Physical complications
8. SUICIDE RISK/RISK OF HARM TO OTHERS
ADMIT UNDER
MHA IF NECESSARY
CONSIDER NURSING
REQUIREMENT
TREAT
PHARMACOLOGICALLY
ECT FIRST-LINE

106. Management of Suicidal Behaviour
1. Is there evidence of a psychiatric disorder?
2. Is there evidence of medical
consequences?
3. Has there been a previous suicide attempt?
4. Is there evidence of a social crisis?
5. What social and financial support is
available?
6. Is there on-going suicidal intent?
7. Does the patient intend to harm others?
1. To what extent was the act planned?
2. Were there final acts (e.g. note/will)?
3. How dangerous was the act of self harm?
4. How dangerous was it perceived by the
patient?
5. Were any precautions to avoid discovery
taken?
6. Did the patient seek help?
SYMPATHY
TREAT PHYSICAL
CONSEQUENCES
TREAT PSYCHIATRIC
CONDITIONS
IDENTIFY
PRECIPITATING
FACTORS
CONSTANT
REVIEW &
REASSESSMENT

107. Acute Mania
ORGANIC
SUBSTANCE ABUSE
RISK TO SELF AND OTHERS
PHYSICAL COMPLICATIONS

108. Acute Mania
Pure Mania Rapid CyclingMixed
Lithium OR atypical
OR semisodium
valproate
Semisodium
Valproate
Olanzapine OR
semisodium
valproate
Add Benzodiazapine Add Benzodiazapine
Add Lithium/
Carbamazapine
Add Atypical Add Atypical Add Atypical
ASSESS RESPONSE

109. Severe Anorexia Nervosa
Severe defined as:-
◦ Bradycardic/hypotensive
◦ Glucose <4mmol/L
◦ Electrolyte imbalance – HYPOKALAEMIA
◦ WCC <2
◦ Hypothermia
◦ Dehydration
◦ Muscle weakness
◦ Hepatic, renal or CVS impairment
◦ BMI <13

110. Severe Anorexia Nervosa
Multidisciplinary Approach Required
◦ Refer to local psychiatric services
◦ Refer to eating disorder service
◦ Refer to local endocrinologist/gastroenterologist for medical evaluation
◦ Refer to a dietician
Motivational interviewing
Physical monitoring
Nutritional therapy with psychological support
MONITOR FOR RE-FEEDING SYNDROME
Treat any depression

111. Rapid Tranquilisation
RISKS vs BENEFITS
CAUTIONS
CONSULTATIONS & PATIENT CHOICE
MEDICATION
Over-sedation & airway problems
CVS & Respiratory Collapse
Interaction with prescribed/illicit medications
Damage to therapeutic relationship
Underlying physical/psychological disorders
Congenital prolonged QT syndrome
Hypo/hyperthermia
Stress
Physical exertion
Advanced Directive if possible
ORAL
IM
IV
Lorazepam/antipsychotics
Lorazepam+-Haloperidol
Benzodiazapines/Haloperidol

112. Acute Violence
MAINTAIN YOUR SAFETY
DO NOT BE ALONE WITH THE PATIENT
USE PERSONAL ALARMS
SUMMON THE POLICE IF NECESSARY
CONSIDER ESCAPE ROUTES
IDENTIFY POTENTIAL WEAPONS
IDENTIFY PARTICULARLY AT RISK INDIVIDUALS
ATTEMPT TO TALK TO PATIENT & CALM THEM
MAINTAIN DISTANCE
GIVE SIMPLE SHORT POSITIVE INSTRUCTIONS
ASK THE PATIENT WHAT THEY WANT AND MEET NEEDS IF POSSIBLE
DEPERSONALISE THE SITUATION
GAIN CONSENT FOR TREATMENT
AIM TO TRANSFER PATIENT TO A SAFE PLACE
TREAT APPROPRIATELY
CONSIDER RAPID TRANQUILISATION
SUGGESTED USE IM OLANZAPINE OR LORAZEPAM
MONITOR VITAL SIGNS
CONSIDER DIAGNOSIS POST-EVENT
CONTINUE TO MONITOR PATIENT
CONSTANT RISK ASSESSMENTS
REVIEW THE INCIDENT AND PROCEDURES TAKEN
ENSURE ADEQUATE COUNSELLING AND SUPERVISION OF INDIVIDUALS INVOLVED

113. Delirium
Disordered thinking
Euphoric, fearful, depressed or angry
Language impaired
Illusions/delusions/hallucinations
Reversal of sleep-awake cycle
Inattention
Unaware/disorientated
Memory deficits

114. Delirium
Systemic Infection
Intracranial Infection
Drugs
Alcohol Withdrawal
Metabolic
Hypoxia
Vascular
Head Injury
Epilepsy
Nutritional

115. Tests in Delirium
FBC – INFECTION, ANAEMIA
U&Es – ELECTROLYTE IMBALANCES
LFTs – LIVER FAILURE, ALCOHOL WITHDRAWAL
Blood Glucose - HYPOGLYCAEMIA
ABG - HYPOXIA
Sepsis Screen - INFECTION
ECG – CARDIAC CHANGES
Lumbar Puncture – CNS INFECTION, CSF PRESSURE
CT/MRI – BLEEDING, MASSES
Malaria Films – IF SUSPICIOUS OF MALARIA AS SOURCE OF INFECTION
EEG – POST-ICTAL

116. Management of Delirium
TREAT UNDERLYING CAUSE AS APPROPRIATE
Reduce distress, prevent accidents, encourage family to stay with patient
Nurse in a moderately lit, quiet room
Same staff in attendance
Do not use physical restraints, try not to cathetrise
Augment self-care, discourage passive dependency & napping
3M’s of delirium. Music, Massage, Muscle relaxation
Minimise medication