Psych Flashcards
What is the definition of ADHD?
Attention Deficit Hyperactivity Disorder
Is a neuro-developmental disorder characterised by features relating to inattention and/or hyperactivity/impulsivity that are persistent.
What is the epidemiology of ADHD?
- More common in Boys (M:F 4:1)
- Persists to adult hood in 30-50% of cases.
What are the causes/risk factors for ADHD?
Multifactorial
- Genetics 74% heritability
- 3-4x risk if siblings suffer
- Environment
- Pregnancy issues: Alcohol, Smoking, Prematurity, Infections, Low birth weight
What are the criteria on the ICD-11 for a diagnosis of ADHD?
- Symptoms of Inattention, Hyperactivity or impulsivity (DSM says 6/9 Sx)
- Present for at least 6 months
- Onset should occur during Childhood (typically before 12 years)
- Significant Functional impairment in personal, social, academic or occupational functioning
- Impairment present in 2 or more settings
- Not better explained by an alternative mental health or neurodevelopmental disorder
What are some differentials for ADHD?
Learning Disabilities:
Characterised by difficulties in reading, writing, mathematics or other learning skills, often with normal attention span.
Conduct Disorder:
Presents with persistent pattern of antisocial behaviour, such as aggression or destructiveness.
Autism Spectrum Disorder:
Mood Disorders:
E.g. depression and bipolar disorder, can cause concentration problems and impulsivity
What investigations are done for ADHD?
Diagnosis is done primarily done using the ICD-11/DSM-5 criteria. But the following can also help:
- Comprehensive history and physical examination (Clinical Interview)
- 10 week watch and wait Observation of the individual’s behaviour and see if Sx resolve
- Teacher and parent reports or rating scales
- Nurse observation in classrooms
- Neuropsychological testing
What is the management of ADHD?
What is first line
What referral may be made?
What medications can be used?
What monitoring is required for the medications?
Non-Pharmacological
- Watchful waiting for up to 10 weeks
- Healthy diet and exercise.
- Behaviour management - including reward charts, positive redirection.
- Behavioural Therapies - CBT, Psychoeducation, interpersonal therapy is first line for management
If symptoms persist
- Referral to CAMHS
Pharmacological: Stimulant Medications (Amphetamines/Methylphenidate)
- First Line in children in Severe/uncontrolled Sx: Methylphenidate on 6 week trial basis
- Second line in children: Dexamfetamine or Atomoxetine
- Cannot be given to children <5 years
- Children should have weight and height monitored every 6 months
- First Line in Adults: Either Methylphenidate/Lisdexamfetamine
- Second line: Lisdexamfetamine
What is the definition of Major Depressive Disorder?
Major Depressive Disorder
It’s a common mental health disorder typified by persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable
What is the epidemiology of depression?
- Lifetime risk is around 1 in 8 (12%)
- Increased prevalence in Females (F:M 2:1)
- Mean age of onset is 40 years (but becoming more present in younger people)
What causes/risk factors depression?
Genetics
- Family history of depression
- High concordance in twins
- Personal history of depression
Environmental:
- Stressful life events
- Childhood abuse
- Substance abuse
- Medical conditions
What is the Diasthesis-Stress Model?
A Stressful event in a person with pre-existing vulnerability has a greater likelihood of developing depression.
Therefore 2 people experiencing the same stressful event: one without pre-existing vulnerability may not develop depression whilst the other individual does.
What are the main differentials for depression?
Bipolar Disorder
Anxiety Disorders
Substance/Medication-Induced Mood Disorder
Mood disturbance associated with intoxication or withdrawal from substances or side effects of medications.
Adjustment Disorders
Development of emotional or behavioural symptoms in response to identifiable stressors.
Various organic causes also need to be considered:
Neurological disorders
E.g. Parkinson’s disease, dementia, and multiple sclerosis.
Endocrine disorders especially thyroid dysfunction and hypo/hyperadrenalism (e.g., Cushing’s and Addison’s disease).
Substance use or medication side effects
e.g. steroids, isotretinoin, alcohol, beta-blockers, benzodiazepines, and methyldopa.
Chronic conditions
like diabetes and obstructive sleep apnea.
Long-standing infections
Neoplasms and cancers
low mood can theoretically be a presenting complaint in any cancer, with pancreatic cancer being a notable example.
What investigations are done for Depression?
Depression is primarily a clinical diagnosis using DSM-5 or ICD-11, with patients fulfilling the diagnostic criteria outlined above. Other investigations that are done can be:
- Patient Health Questionaire - 9 (PHQ-9)
- Hospital Anxiety and Depression Scale (HAD)
- FBC
- TFTs
- U+Es
- LFTs
- Blood glucose
- B12/Folate Levels
- Cortisol levels
- Toxicology Screen
- CNS Imaging
What is the Non-Pharmacological Management of Depression?
Lifestyle Changes:
- Exercise and Diet changes
- Reduce alcohol and stop smoking
- Stop drug use
- Regular Schedule
Psychotherapies:
Less severe depression:
- Guided self-help
- Group Cognitive Behavioural Therapy (CBT)
- Interpersonal Therapy
More severe depression:
- Individual CBT (with medication)
- individual behavioural activation
What is the Pharmacological management of depression?
First-line pharmacological treatment:
- Selective Serotonin Reuptake Inhibitor (SSRI): Sertraline, Citalopram, Fluoxetine
- Fluoxetine is first line in children
- Selective Noradrenaline Reuptake Inhibitors (SNRI): Duloxetine, Venlafaxine (Work well in patients with associated pain disorders)
2nd line pharmacological treatment
- Atypical Anti-depressants: Mirtazapine
- Tricyclic Antidepressants (TCAs): Amitriptyline
- Monoamine Oxidase Inhibitors: Selegiline
What is the definition of Refractory Depression?
Its defined as a failure to demonstrate an adequate response to an adequate treatment trial
How is Refractory Depression Managed?
- Antipsychotics: Olanzepine, Quetiapine
- Lithium
Electroconvulsive Therapy (ECT) (After all other approaches have been tried). is safe and effected for Severe medication resistant and psychotic depression
- Requires a GA
- Electrodes trigger a short generalised seizure
- Side effects include: Headache, Muscle Ache, Memory loss (short term)
What is the definition of Austistic Spectrum Disorders (ASDs)?
ASDs are a set of complex neuro-developmental disorders, characterised by a spectrum of impaired social, communication, and behavioural deficits. and restrictive or repetitive patterns or interests
What is the epidemiology of Autistic Spectrum Disorders?
- Higher prevalence in Males (M:F 3/4:1)
- Prevalence of 1-2%
- Features normally present by age 3
- Around 50% of children with ASD have intellectual disability
What are some risk factors for developing an ASD?
Genetics:
- Male sex
- Advanced parental age at the time of conception
- Certain genetic mutations
- Maternal exposure to specific drugs or infections during pregnancy
Environment:
- No current clear risk factors
What deficits in social interaction might someone with Autism show?
- Lack of eye contact
- Delay in smiling
- Avoids physical contact
- Unable to read non-verbal cues
- Difficulty establishing friendships
- Not displaying a desire to share attention (i.e. not playing with others)
What deficits in communication might someone with Autism show?
- Delay, absence or regression in language development
- Lack of appropriate non-verbal communication such as smiling, eye contact, responding to others and sharing interest
- Difficulty with imaginative or imitative behaviour
- Repetitive use of words or phrases
What behavioural traits may someone with Autism show?
- Greater interest in objects, numbers or patterns than people
- Stereotypical repetitive movements. There may be self-stimulating movements that are used to comfort
themselves, such as hand-flapping or rocking. - Intensive and deep interests that are persistent and rigid
- Repetitive behaviour and fixed routines
- Anxiety and distress with experiences outside their normal routine
- Extremely restricted food preferences
What are some differentials for ASDs?
Intellectual Disability
Characterised by generalised deficits in intellectual functioning and adaptive behaviour, typically lacking the social deficits seen in ASD.
Attention Deficit Hyperactivity Disorder (ADHD)
Exhibits symptoms of inattention, hyperactivity, and impulsivity, but does not exhibit significant social or language communication deficits as seen in ASD.
Specific Language Impairment
Characterised by difficulties in language acquisition in the absence of cognitive impairment. Unlike ASD, social interaction is not typically affected.
Childhood Schizophrenia
Characterised by hallucinations, delusions, and disorganised speech or behaviour, which are not typical in ASD.
How is an ASD diagnosed?
Diagnosis should be made through a multidisciplinary assessment completed by a specialist in autism.
This can involve:
- Psychological evaluation
- Speech and language assessment
- Cognitive assessment
- Thorough review of the child’s behaviour in different settings (home, school, etc.).
What are the risk factors for developing Bipolar Disorder?
Genetics:
- First degree family member = 10x risk
- 1 parent affected = 15-30% risk
- 2 parents affected = 50-75% risk
Environment:
- Stressors such as death, illness, relationships or financial problems
What is the clinical presentation of Bipolar Disorder?
It depends on the phase of the disorder:
Depressive Phase
- Withdrawal
- Tearfulness
- Low mood
- Poor sleep
- Anhedonia
- Potential suicidal ideation or attempts.
Manic Phase
- Elevated mood
- Irritability
- Disinhibition and sexual inappropriateness
- Impulsivity
- Reduced need for sleep
- Mood congruent delusions
- Pressured speech
- Flight of ideas.
What are some differentials for Bipolar Disorder?
Major Depressive Disorder
Characterised by low mood, loss of interest or pleasure, feelings of worthlessness, impaired concentration, and possible suicidality.
Schizoaffective Disorder
Presents with hallucinations, delusions, disorganised speech, disorganised behaviour, and symptoms of depression or mania.
Generalised Anxiety Disorder
Chronic and excessive worry, restlessness, fatigue, impaired concentration, and sleep disturbance.
Substance-Induced Mood Disorder
Mood disturbances caused by substance misuse or withdrawal.
How is Bipolar Disorder diagnosed?
ICD 10/11
- At least 2 episodes of significant mood disturbance
ICD10
- Where there is at least one or more episode of mania/hypomania
- and one or more depressive episodes
ICD 11
- Where each of the two episodes includes both Mania/hypomania and Depressive episodes
AND
- Significant impairment in social, occupational or other important areas of functioning
What is the acute management for Bipolar Disorder?
Acute manic episode (what else must be remembered)
Acute Depressive Episode
Acute Manic Episode:
- First Line: Antipsychotic medications: Olanzapine, Haloperidol, Risperidone
- Existing antidepressants are Tapered and stopped
- Other options: lithium, Sodium Valproate
Acute Depressive Episode:
- First Line: Olanzapine PLUS Fluoxetine
- Lamotrigine
- Psychotherapy: CBT
What is the chronic management for Bipolar Disorder?
Long-term maintenance therapy is crucial due to high relapse risk:
Mood stabilisers
- First line: Lithium
- Alternatives: Anti-epileptics (Sodium Valproate, Lamotrigine, Carbamazepine), Olanzapine
High-intensity Psychotherapies
- CBT, interpersonal therapy, or couples/family therapy better for managing depressive features
Resistant cases/very severe Bipolar disorder:
- Electroconvulsive therapy
- Transcranial Magnetic Stimulation
What is the definition of a Generalised Anxiety Disorder (GAD)?
Generalised anxiety disorder (GAD) is defined as at least 6 months of excessive worry about everyday issues that is disproportionate to any inherent risk, causing distress or impairment.
What is the epidemiology of GAD?
Higher prevalence in Females
Higher prevalence in younger age groups (age of onset after 35 is more indicative of depressive disorder or organic disease).
What are some risk factors for GAD?
Comorbid anxiety disorders
Females (F:M 2:1)
Genetics: first degree relative
Childhood adversity
- Maltreatment (e.g. sexual or physical abuse), neglect.
- Maternal depression, family disruption (e.g. divorce).
- Domestic violence, parental alcoholism, or drug use.
Physical, sexual, or emotional trauma
- Physical or sexual abuse or assault.
- Motor vehicle accident.
- Sudden bereavement.
Sociodemographic factors
- Separated, widowed, divorced.
- Unemployment.
- Low socioeconomic status.
- Low education levels.
- Substance dependence or exposure to organic solvents
Chronic physical condition
What is the criteria to diagnose GAD?
DSM-5 Criteria where symptoms last for 6 months with the anxiety being disproportionate to threat which has an impact on the individuals ability to function and these symptoms are not due to another medical condition or substance use
3 of the following 6 key symptoms are required for a diagnosis (only 1 in kids)
- Restlessness or nervousness
- Being easily fatigued
- Poor concentration
- Irritability
- Muscle tension
- Sleep disturbance
in combination with an inability to manage their worry
What are some differentials for GAD?
- Hyperthyroidism
- Substance abuse/withdrawal
- Panic disorder
- Depression
- Medications - Salbutamol, theophylline, corticosteroids, antidepressants and caffeine
- Avoidant personality disorder
How is GAD managed?
NICE suggest Step-wise approach:
- Step 1 (Mild GAD): Psychoeducation about Lifestyle (sleep, diet, exercise, smoking, alcohol, drugs) .Psychoeducation about GAD + active monitoring
- Step 2 (Mild GAD): low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
- Step 3 (Moderate-severe GAD): high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment.
- Step 4 (Severe GAD): highly specialist input e.g. Multi agency teams
What is the definition of Obsessive Compulsive Disorder (OCD)?
Obsessive-compulsive disorder (OCD) is a mental health disorder characterised by the presence of persistent obsessions and/or compulsions
These are time consuming (i.e. take more than 1 hour per day) and/or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
What are Obsessions?
Obsessions are unwanted and uncontrolled thoughts and intrusive images that the person finds it very difficult to ignore.
E.g. an overwhelming fear of contamination with dirt or germs; or violent or explicit images that keep appearing in their mind.
What are Compulsions?
Compulsions are repetitive actions the person feels they must do, generating anxiety if they are not done. Often these compulsions are a way for the person to handle the obsessions.
E.g. checking that all electrical equipment is turned off to settle the anxiety of obsessing about the house burning down.
Describe the cycle of anxiety seen in OCD?
Obsessions lead to anxiety, which leads to the compulsive behaviour, which leads to a temporary relief in the anxiety.
Shortly after the temporary improvement in anxiety the obsession reappears, leading to further anxiety, further compulsive behaviour with a temporary relief.
This cycle continues and each time gets more engrained in the person’s behaviour. Without doing the compulsions, the person feels they cannot get relief from their anxiety.
What is the epidemiology of OCD?
It affects Males and Females equally (although presents earlier and more severely in males)
Affects around 3% of population
More common in pregnant and post-partum women
Bimodal age of onset, peaking at 10 and 21 years
What are the risk factors for developing OCD?
- Family history
- Age: peak onset is between 10-20 years
- Pregnancy/postnatal period
- History of abuse, bullying, neglect
- History of anxiety disorders
What is the diagnostic criteria for OCD?
OCD is a clinical diagnosis and according to the DSM-5 or ICD-11:
- Presence of obsessions, compulsions or both
- Time consuming (>1 hour a day) which causes clinically significant distress or functional impairment
- Cannot be attributed to substance use or medical condition
- Not better explained by another mental disorder
What scale is used to assess the severity of OCD symptoms?
Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
What is the management for OCD?
Always give education and self help resources
Mild OCD
- First Line: CBT with exposure and response prevention ERP)
- Second Line: Offer SSRI or more intensive CBT
Moderate OCD
- Referral to CAMHS in children
- First line: Offer either SSRI (Sertraline, Fluoxetine, Paroxetine) or intensive CBT including ERP
- Second line: consider Clomipramine (if patient has previously had good response to it or SSRI is contraindicated
Severe OCD:
- Referral to Secondary Care Mental Health Team for assessment
- Offer combined treatment with SSRI and CBT (including ERP)
What is the definition of Postpartum depression?
It’s a significant mood disorder that can develop at any time up to one year after the birth of a baby.
This condition represents a considerable aspect of maternal mental health and extends beyond the common “baby blues”.
Typically presenting with persistent depressive symptoms that may interfere with daily functioning and parenting.
What causes Postpartum depression?
Development of postpartum depression is multifactorial with a combination of Biological, Psychological, and Social factors all contributing.
What biological factors contribute to the development of postpartum Depression?
- Hormonal fluctuations post-delivery, including sudden drops in progesterone, estrogen, and thyroid hormones.
- Alterations in melatonin and cortisol rhythms and immune-inflammatory processes
- Genetic predispositions
What Psychological factors contribute to the development of postpartum Depression?
- A history of mood or anxiety disorders
- Previous episodes of postpartum depression
- Certain personality traits such as neuroticism
- Psychological stress from the transition to parenthood
- Unrealistic expectations of motherhood
What Social Factors contribute to the development of postpartum depression?
- Lack of social support
- Relationship issues,
- Life stressors
- Low socioeconomic status
What are the signs and symptoms of postpartum depression?
- Persistent lowering of mood and reduced enjoyment or interest in activities.
- Lowering of energy levels.
- Biological symptoms of depression like poor appetite and disturbed sleep patterns (not associated with normal disturbed sleep patterns with a baby)
- Concerns related to bonding with the baby, caring for the baby, and in extreme circumstances, thoughts about harming oneself or the baby.
What are some differentials for postpartum depression?
Baby blues
Characterised by mild mood swings, irritability, anxiety, and tearfulness. However, these symptoms usually present within the first two weeks after birth and resolve spontaneously.
Postpartum Psychosis
Adjustment disorders
These disorders may develop in response to a major life change or stressor, such as having a baby, but the emotional or behavioural symptoms are less severe than in depression.
Generalized Anxiety Disorder (GAD)
What is the main screening tool for Postpartum depression?
Edinburgh Postnatal Depression Scale (EPDS)
A cutoff score of over 10 is used as a positive result.
What is the management of postpartum depression?
First-line treatments:
- Self-help strategies and psychological therapies e.g. Cognitive Behavioural Therapy (CBT) or Interpersonal Therapy (IPT).
Pharmacological treatments
- Antidepressants considered in high risk cases
In severe cases admission to a mother and baby inpatient mental health unit might also be necessary.
What is the definition of Postpartum Psychosis?
It’s a serious psychiatric disorder that typically develops within the first two weeks following childbirth.
It is characterised by a range of psychological symptoms, including paranoia, delusions, hallucinations, mania, depression, and confusion.
What are the risk factors for Postpartum Psychosis?
- Prior history of severe mental illnesses such as schizophrenia or bipolar affective disorder
- Family history of postpartum psychosis
- Previous episode of postpartum psychosis
What is the clinical presentation of Postpartum Psychosis?
Paranoia
Delusions
Hallucinations
Manic episodes
Depressive episodes
Confusion
What is the main differential for Postpartum Psychosis?
Postpartum depression with psychotic features
How is Postpartum depression diagnosed?
Diagnosis is predominantly clinical, based on the presenting signs and symptoms.
It requires a thorough psychiatric evaluation.
Consideration should be given to other medical conditions that may cause similar symptoms, such as thyroid disorders or sepsis.
How is Postpartum psychosis managed?
Pharmacotherapy with:
- Antipsychotic medications
- Mood stabilisers in some instances
Potential referral to a specialist mother and baby inpatient mental health unit in very severe cases (when the mother experiences command hallucinations, thoughts of self-harm or suicide, or delusional beliefs regarding the baby’s role or identity).
What needs to be considered when prescribing medications for Postpartum Psychosis?
The mother’s breastfeeding status and the potential for the transfer of drugs to the nursing infant.
What is the definition of Post Traumatic Stress Disorder (PTSD)?
A relatively common mental health condition resulting from traumatic experiences, with ongoing distressing symptoms and impaired function.
What are some Risk Factors for PTSD?
- Type of Trauma: Assault based > Natural disaster base trauma
- Females > Males
- Pre-existing mental health conditions
- Childhood adversity
- Lack of social support
HARD
What is the clinical features of PTSD?
Hyperarousal/Hypervigilance: Poor sleep, irritability, poor concentration
Avoidance behaviours: avoiding people, places, events
Re-experiencing: Flashbacks, Nightmares, Repetitive and distressing intrusive images
Dull/emotional numbing: Feeling detached.
When is usually the time of onset for PTSD?
PTSD tends to develop soon after the event. It may be delayed, but delayed onset greater than a year post-trauma is very rare.
What are some differentials for PTSD?
Acute Stress reaction
Prolonged grief disorder
Depression
Adjustment disorders
Enduring personality change after catastrophic experience
What screening questionnaires are there for PTSD (1st line investigations)
Trauma Screening Questionnaire (TSQ)
A set of 10 items covering re-experiencing and arousal symptoms.
DSM-5 PTSD Checklist
A 20 item checklist assessing the symptoms of PTSD according to DSM-5.
What are the Non-Pharmacological managements of PTSD?
- watchful waiting for 4 weeks if traumatic event happened within the last month
- Psychotherapies:
- Trauma Focused Cognitive Behavioural therapy (TF-CBT)
- Narrative/Prolonged exposure therapy
- Eye Movement Desensitisation and Reprocessing (EMDR) Therapy
First Line for PTSD is TF-CBT
EMDR offered to patients presenting >3 months after non-combat related trauma
What is the Pharmacological management of PTSD?
First line:
- SSRI (e.g. sertraline/paroxetine)
- Venlafaxine
In serious cases that haven’t responded to previous drug or psychological therapies:
- Antipsychotics (like risperidone) in addition to psychological therapies
Define the term Learning Disability
Give some examples of LDs
It’s a general umbrella term encompassing a range of different conditions that affect the ability of the child to develop new skills.
Examples include:
- Dyslexia
- Dysgraphia refers to a specific difficulty in writing.
- Dyspraxia
- Auditory processing disorder
- Non-verbal learning disability
- Profound and multiple learning disability
They can vary from very mild to severe
What is the definition of Dyslexia?
It refers to a specific difficulty in reading, writing and spelling.
What is the definition of Dysgraphia?
It refers to a specific difficulty in writing.
What is the definition of Dyspraxia?
Also known as developmental co-ordination disorder.
It refers to a specific type of difficulty in physical co-ordination.
More common in boys.
It presents with delayed gross and fine motor skills and a child that appears clumsy.
What is the definition of Auditory processing disorder?
It refers to a specific difficulty in processing auditory information.
What is the definition of a Non-verbal learning disability?
It refers to a specific difficulty in processing non-verbal information, such as body language and facial expressions.
What is the definition of a Profound and multiple learning disability?
It refers to severe difficulties across multiple areas, often requiring help with all aspects of daily life.
How are Learning disabilities classified?
The severity of the learning disability is based on the IQ (intelligence quotient): < 70
55 – 70: Mild
40 – 55: Moderate
25 – 40: Severe
Under 25: Profound
What are the risk factors for Learning Disabilities?
- Family history of learning disability
- Abuse
- Neglect
- Psychological trauma
- Toxins
- Certain conditions
What conditions are associated with learning disabilities?
- Genetic disorders such as Downs syndrome
- Antenatal problems, such as foetal alcohol syndrome and maternal chickenpox
- Problems at birth, such as prematurity and hypoxic
- ischaemic encephalopathy
- Problems in early childhood, such as meningitis
- Autism
- Epilepsy
What does the management of learning disabilities involve?
The key is a multidisciplinary approach to support the parents and child:
Health visitors
Social workers
Schools
Educational psychologists
Paediatricians, GPs and nurses
Occupational therapists
Speech and language therapists
Define Psychosis
Psychosis is a term used to describe a person experiencing things differently from those around them as they have lost contact with reality
What are the 2 main causes of Phychosis?
Psychosis can be due to:
- Primary (“non-organic”) psychiatric disorders
- Secondary to substance use or specific medical (“organic”) aetiologies
Give some examples of primary psychotic disorders
Schizophrenia (most common)
Delusional disorder
Schizoaffective disorder
Schizophreniform disorder
Brief psychotic disorder
Bipolar disorder
Puerperal Psychosis
What are the clinical psychotic features?
- Hallucinations (e.g. auditory)
- Delusions
- Thought disorganisation
- Alogia: little information conveyed by speech
- Tangentiality: answers diverge from topic
- Clanging
- Word salad: linking real words incoherently → nonsensical content
What are some common associated features of psychosis?
- Agitation/aggression
- Neurocognitive impairment (e.g. in memory, attention or executive function)
- Depression
- Thoughts of self-harm
How is Psychosis investigated?
- Physical examination
(detailed neurological examination and a complete mental status examination) - Complete psychiatric and medical history
(review of head injury, seizures, cerebrovascular disease, sexually transmitted infections, and new or worsening headaches) - Laboratory work-up
What lab work should be done for a Psychosis investigation?
FBC
Comprehensive metabolic profile
TFTs
Urine toxicology
Parathyroid hormone
calcium
vitamin B12
folate
niacin
Based on clinical suspicion, testing for HIV infection and hepatitis C,
What is the management of psychosis?
It depends on the underlying cause.
If Schizophrenia:
1st line is (2nd gen) atypical antipsychotics e.g. Risperidone or Olanzapine
Haloperidol is also still used
What is the definition of Schizophrenia?
It’s a severe mental disorder characterised by chronic or relapsing episodes of psychosis.
It involves altered perceptions of reality, disordered thinking, and social dysfunction.
What are the risk factors for Schizophrenia?
-
Family History
- 10% if either a parent or sibling is affected
- 50% if both parents or a monozygotic twin
- Childhood trauma, like poor maternal bonding, poverty, or exposure to natural disasters
- Heavy cannabis use in childhood
- Maternal health issues, including malnutrition and infections like rubella and cytomegalovirus
- Birth trauma, particularly hypoxia and blood loss
- Urban living and immigration to more developed countries
What are Schneider’s First Rank Symptoms?
- Auditory hallucinations
- Thought disorders
- Passivity phenomena
- Delusional perceptions
What are some differentials for Schizophrenia?
- Schizoaffective Disorder
- schizophreniform Disorder
Others:
- Mania
- Psychotic depression
- Drugs (e.g., hallucinogens and cannabis)
- Stroke
- Brain tumours
- Cushing’s syndrome (e.g., patients taking systemic steroids)
- Hyperthyroidism
- Huntington’s disease
What investigations may be done to rule out other potential differentials in Schizophrenia?
- Brain imaging (CT/MRI) to rule out structural abnormalities
- Blood tests to exclude infectious (e.g.,HIV, syphilis) or metabolic causes (e.g., thyroid function tests)
- Drug screening to identify substance misuse
What is the management of Schizophrenia?
1st line
acute episodes
resistant to therapy
Other
1st Line:
- Second-generation (atypical) antipsychotics e.g. Risperidone
In acute episodes:
- Sedatives (e.g. lorazepam, promethazine, or haloperidol) to manage dangerous behaviour.
when schizophrenia is resistant to other antipsychotics (2 have been tried)
- Clozapine is considered (Due to its potential lethal side effects, it requires intensive monitoring.)
Psychotherapy, such as cognitive-behavioural therapy offered to all patients
What is the definition of Schizoaffective disorder?
Schizoaffective disorder combines the symptoms of schizophrenia with bipolar disorder. Patients have psychosis and symptoms of depression and mania.
Define Somatisation Disorder
Somatic symptom disorder or Briquet’s Syndrome
- A psychiatric condition characterized by the presence of multiple, recurrent and clinically significant somatic complaints that cannot be fully explained by any underlying medical conditions
- Present for at least 2 years
What are the risk factors for Somatisation Disorders?
- History of IBS
- History of PTSD
- History of sexual or physical abuse
What is the typical presentation of Somatic Syndrome?
Symptoms that are generally severe enough to affect work and relationships and lead the person to consult a doctor and take medication.
A lifelong history of ‘sickliness’ is often present:
Stress often worsens the symptoms.
Examples include:
- Cardiac (SOB, Palpitations, Chest Pain)
- GI (Vomiting, Abdominal pain, nausea, diarrhoea)
- MSK ( Back pain, Joint pain)
- Neurological (Headaches, dizziness, amnesia, vision changes, paralysis or muscle weakness)
- Urogenital (Pain during urination, low libido, dyspareunia, impotence).
How is Somatic Syndrome Diagnosed?
Somatisation is often a diagnosis of exclusion but it’s much more effective to pursue a positive diagnosis when the patient presents with typical features:
- multiple symptoms, often occurring in different organ systems.
- Symptoms are vague or that exceed objective findings.
At least 6 months
cause significant distress and impairment
not attributed to specific medical or other psychiatric conditions
What is the management of Somatic Syndrome?
1st Line treatment is Psychotherapy, and Cognitive behavioural therapy shows the best outcomes
Pharmacological interventions show little effect on the disease although psychiatric disorders associated with somatisation like anxiety and depression can be treated with antidepressants which will often improve somatic symptoms.
What are the main atypical antipsychotics?
Clozapine
Risperidone
Olanzapine
Quetiapine
What are the side effects of atypical antipsychotics?
Metabolic Conditions
Weight gain
Hyperprolactinaemia
Glucose intolerance
Drowsiness
Hyperprolactinaemia
Increased appetite
Dyslipidaemia
Galactorrhoea
Why is Clozapine a high risk medication?
What are sin some other adverse effects?
Has many side effects
It can only be started after two other antipsychotics have been trialled.
Causes Agranulocytosis which can lead to severe infections
Adverse Effects:
C - constipation
Lo - lower seizure threshold
Z - zzz sedation
A - agranulocytosis
P - phat weight gain
I - increased salivation
N - neutropenia
E - ECG changes (myocarditis/cardiomyopathy)
What are the side effects relevant to all anti-psychotics?
- Sedation
- Antimuscarinic effects
- Hyperprolactinaemia
- Sexual dysfunction
- Impaired glucose tolerance
- Cardiac Arrhythmias
- Reduction of seizure threshold
- Prolonged QT (particularly Haloperidol)
What is the most common first generation antipsychotic and what is a common cardiac side effect
Haloperidol
Prolonged QT
What is the definition of Delusions?
Delusions are fixed, false beliefs that are maintained despite contradictory evidence. They are a prominent feature of numerous psychiatric conditions
E.g.
Schizophrenia, bipolar disorder, and psychotic depression.
What are these specific types of Delusions:
- Nilhilistic
- Grandeur
- Control
- Capgras
- Persecutory
- Somatic
Nihilistic delusions
- Negative delusions typically congruent with the individual’s depressed mood. Patients may believe that they are dead or that the world has ended.
Delusions of grandeur
- Patients believe they possess extraordinary traits or powers. Common in manic phases of bipolar disorder.
Delusions of control
- The individual experiences a sensation that an external entity is controlling their thoughts or actions. Frequently observed in psychotic conditions.
Capgras Delusions
- Misidentification syndrome characterised by the belief by the patient that the close person is replaced by an imposter who looks physically the same
Persecutory delusions
- The patient believes they are being persecuted or conspired against. Common in conditions like paranoid schizophrenia.
Somatic delusions
- Patients are convinced they have a physical, medical, or biological problem despite no medical evidence supporting their claim. These delusions can manifest as a wide range of physical symptoms.
How are delusions classified?
Bizarre Vs non-bizarre
(very strange or highly unusual) Vs (plausible but incorrect)
Mood-congruent (consistent with the individual’s emotional state) Vs mood-neutral
What are some differentials for Delusions?
Mood disorders with psychotic features
Delusions often mood-congruent. In depressive episodes, these might be nihilistic delusions; in manic episodes, they might be grandiose.
Neurocognitive disorders
Delusions can occur in conditions such as Alzheimer’s disease or Parkinson’s disease dementia. The delusions often involve theft or persecution.
Substance-induced psychotic disorder
Delusions might be part of a broader psychotic syndrome due to intoxication or withdrawal from substances such as alcohol, hallucinogens, or amphetamines.
What investigations are done for delusions?
Clinical interview
Comprehensive psychiatric history, including onset, duration, and the impact of symptoms on functioning.
Mental state examination (MSE)
Evaluation of appearance, behaviour, speech, mood, affect, thought process, thought content, perception, cognition, insight, and judgment.
Neuropsychological assessment
To rule out neurocognitive disorders or to assess for any cognitive impairment.
What is the management of delusions?
Pharmacological
Antipsychotic medication is the mainstay of treatment. The choice of medication depends on the underlying disorder.
Psychotherapy
Cognitive behavioral therapy (CBT) can be beneficial.
Psychoeducation
Providing information to the patient and their family about the nature and management of the disorder.
Define Personality Disorder
Personality disorders are a group of mental health conditions where a person’s thoughts, feelings, and behaviors differ significantly from what is typically expected, leading to difficulties in relationships and everyday functioning.
What are the 3 Categories of personality disorders?
Class A: Suspicious
Class B:Emotional or Impulsive
Class C Anxious
What are the different Class A personality disorders?
Suspicious, Odd, Eccentric disorders:
- Paranoid
- Schizoid
- Schizotypal
What are the different Emotional / Impulsive personality disorders?
Dramatic, Emotional or Erratic Disorders:
- Antisocial
- Borderline (Emotionally unstable)
- Histrionic
- Narcissistic
What are the different Anxious personality disorders?
Anxious or fearful disorders:
- Obsessive-Compulsive
- Avoidant
- Dependent
What are the risk factors for personality disorders?
BioPsychoSocial
- History of abuse
- Family history of schizophrenia
- Negative parenting interactions
- Emotional/disruptive disorder in childhood
What is the 1st line investigation for personality disorders?
Clinical Interview
Diagnosis of personality disorders is often difficult as as these patients don’t come to the doctor for help with their personality difficulties, and may have little or no insight into their personality issues.
Diagnosis will be based on symptoms detected in talks with the patient or present in their history, whether obtained from the patient him/herself or from others who know the patient (collateral sources).
What is the management of personality disorders?
Dialectical Behavioural Therapy, CBT and psychotherapy is the key management option of choice.
Risk Management: such as ongoing self-harm, suicide or harm to others
Medications are not usually used unless in CRISIS where Sedatives may be used.
What are the key side effects of SSRIs?
SSRIs
Stomach issues - Diarrhoea, nausea, vomiting, increased risk of GI bleeding
Sexual dysfunction - loss of libido, ED, orgasms
Risk of suicidal thoughts and actions increased
Irritability, agitation, anxiety (in first weeks)
SIADH leading to hyponatraemia
What are the side effects of TCAs?
What receptors do TCAs block?
Serotonin and Noradrenaline reuptake
- similar side effects to SSRI/SNRIs
Antagonism of histamine receptors
- Drowsiness
Antagonism of muscarinic receptors
- dry mouth
- blurred vision
- constipation
- urinary retention
Antagonism of adrenergic receptors
- postural hypotension
- lengthening of QT interval
Contraindicated in CVD due to causing
- Arrhythmias,
- Tachycardia
- Prolonged QT
- Bundle branch block
What conditions are TCAs contraindicated in?
- Those with previous heart disease
- Can exacerbate schizophrenia
- May exacerbate long QT syndrome
- May alter blood sugar in T1 and T2 diabetes mellitus
- May precipitate urinary retention, so avoid in men with enlarged prostates
- Those on CP450 medications or those with liver damage (as it uses the CP450 metabolic pathway)
What conditions are SNRIs (Serotonin and norepinephrine re-uptake inhibitors) contraindicated in?
Those with a history of heart disease and high blood pressure
What is Electroconvulsive Therapy (ECT)?
It is a extreme treatment method that induces a generalised seizure.
What conditions is Electroconvulsive Therapy indicated for?
Its indicated for:
- Severe depressive illness or refractory depression.
- Catatonia.
- A prolonged or severe episode of mania that does not respond to other treatments
What does Electroconvulsive Therapy involve?
- Electrodes are placed on the skull. Either on both side or only one side.
- Patients are given a general anaesthetic and a muscle relaxant.
- Subsequently, an electrical current is delivered to induce a generalised seizure.
- The patient has about 6-12 sessions (twice a week). If the patient responds, then sessions are stopped.
What are the possible complications of Electroconvulsive Therapy?
Immediate:
- Cardiovascular instability - eg, arrhythmias and hypotension.
- Status epilepticus.
- Laryngospasm.
- Peripheral nerve palsies.
- Headache.
- Nausea.
Long term
Possible issues with short and long term memory
What is the definition of specific Phobias?
Phobia: an intense, irrational fear of an object, situation, place or person that is recognised as excessive or unreasonable.
Agoraphobia and Social anxiety are classified as their own disorder
What are the general features of Phobias?
- Irrational excessive and persistant fear
- Immediate anxeity response when exposed
- Recognition the fear is excessive
- Avoiding the phobia
- Symptoms arent transient
- Symptoms not accounted for by another medical or mental health condition
- Significant functional impairment
What is the definition of Agoraphobia?
Fear of being in a situation or place that an individual perceives as being unsafe with no escape
- Open space
- Closed space
- Crowds
- Public Transport
Closely liked to panic and social anxiety disorder
What is the definition of Social Anxiety Disorder?
When does it typically develop?
Fear/anxiety of social or performance situations where they are exposed to potential scrutiny due to fear of humiliation and embarrassment.
- Typically develops in late childhood/adolescence Often following a specific triggering event where there was embarrassment
What are the symptoms of Social Anxiety Disorder?
- Significant Avoidance of social situations
- Blushing
- Fear of vomiting
- Palpitations
- Trembling
- Sweating.
What other features of Social anxiety disorder are there?
It can be specific (public speaking) or generalised (any social setting)
Can be precipitated by stressful or humiliating experiences, parental death, separation, chronic stress.
May lead to alcohol or drug abuse (perpetuating the problem).
Mental state examination: may appear relaxed as the phobic object or situation is not present.
What is the management of Phobias
1st Line: Cognitive Behavioural Therapy with graded eposure therapy for all Phobias:
- Exposure techniques are the most widely used, aiming for systematic desensitization
- Flooding (exposing someone with a fear of heights to a tower)
- Modelling (individual observes therapist interacting with phobic stimulus).
If ineffective/severe functional impairment
SSRIs are first-line medical management
What is the definition of Substance Misuse?
Refers to using a substance in a way that is not recommended or prescribed, but not necessarily to the level of causing harm or addiction. Misuse might involve taking higher doses, using medication for non-medical purposes, or using illegal substances recreationally.
What is the definition of Substance Abuse?
use of a substance results in harm or significantly interferes with daily functioning, social obligations, or responsibilities. Abuse implies a pattern of use that leads to negative outcomes or risk of dependency.
What is the difference between Drug misuse and Drug abuse?
The key difference between a person who misuses drugs and a person who abuses drugs is their intent.
Someone who misuses a drug, takes the drug to treat a specific ailment.
Whereas the latter uses a drug to elicit certain feelings.
What are the features of Opioid misuse?
vs
Features of Opioid Withdrawal
Misuse:
- Low BP
- Pinpoint pupils
- Needle Trackmarks
- Rhinorrhoea
Withdrawal
- Dilated Pupils
- High BP
- Muscle Aches/Cramps
- Sweating
What are the clinical features of cannabis intoxication?
Drowsiness
Impaired memory
Slowed reflexes and motor skills
Bloodshot eyes
Increased appetite
Dry mouth
Increased heart rate
Paranoia
Cannabis acts at cannabinoid receptors.
What are the Psychoactive symptoms of LSD intoxication?
(Lysergic Acid Diethylamide)
Variable subjective experiences
Impaired judgements which can lead to injury
Amplification of current mood which leads to euphoria or dysphoria
Agitation, appearing withdrawn - especially in inexperienced users
Drug-induced psychosis
What are the clinical features of stimulant intoxication (e.g. Cocaine)?
- Euphoria
- Increased blood pressure
- Increased heart rate
- Increased temperature
- A feeling of increased concentration and focus.
What is the management for cannabis, hallucinogen and stimulant abuse (including cocaine)?
Psychosocial Interventions are the main treatment.
These can include:
Counselling
Cognitive behavioural therapy
Supportive help (for example with housing and benefits).
What are the risk factors for substance abuse/misuse?
- History of alcohol or other drug misuse
- History of mental illness
- Male Sex
- Family history of addiction
- Unemployment/Homelessness
What investigations are done for substance abuse/misuse?
- Comprehensive history to establish the extent of the drug abuse problem / dependence.
- Urine Toxicology
- Blood tests - FBC, LFTs, U+Es, etc…
What investigations are done for an opioid overdose?
1st Line:
- Therapeutic Trial of Naloxone (Overdose patients will show improvement of symptoms)
- ECG (can show things like QRS prolongation and evidence of myocardial ischaemia)
What are some differentials for opioid overdose?
GHB or GBL overdose
Very closely mimic an opioid overdose, but will show little / no responce to naloxone.
Clonidine/Imidazolines overdose
Presents with more profound bradycardia and hypotension than opioid overdose. And will also show only limited responce to naloxone.
Antipsychotic Overdose
Presents with hypotension and tachycardia, but will not have the profound bradypnoea seen in opioid overdose. No response to naloxone.
What is the definition of harmful drinking?
It’s defined as a pattern of alcohol consumption causing health problems directly related to alcohol.
This could include psychological problems such as depression, alcohol-related accidents or physical illness such as acute pancreatitis.
What is the criteria for alcohol dependence syndrome?
ICD 10 Criteria for diagnosis requires 3 of the following:
- Craving (desire or compulsion to take the substance)
- Difficulties in controlling intake
- Physiological withdrawal
- Tolerance (more needed to achieve the same effect)
- Priority is given to substance, with neglect to other aspects of life
- Persistence despite being aware of the harm the substance causes
Patients can be dependent but have no physiological dependence on alcohol (no withdrawal or tolerance)
What is the definition of an Alcohol use disorder?
It’s defined as clinically significant impairment or psychosocial stress in the previous 12 months as a direct result from alcohol?
This term encompasses both harmful drinking and alcohol dependence.
What are the risk factors for developing an alcohol use disorder?
- Family history of alcohol-use disorder
- Antisocial behaviour (pre-morbid)
- High trait anxiety level
- Low response to the effects of alcohol
- Depression
How can Alcohol Use Disorders be screened for?
AUDIT Questionnaire
- 10 questions with multiple choice
- Score of 8 or more indicates harmful use
CAGE Questionnaire
- CUT DOWN? Do you ever think you should cut down?
- ANNOYED? Do you get annoyed at others commenting on your drinking?
- GUILTY? Do you ever feel guilty about drinking?
- EYE OPENER? Do you ever drink in the morning to help your hangover or nerves?
TWEAK Questionnaire
When do Alcohol Withdrawal Symptoms typically present?
6-12 hours: tremor, sweating, headache, craving and anxiety, palpitations
36 hours: seizures
48-72 hours: delirium tremens
What is the clinical presentation of Alcohol Withdrawal?
due to overactivation of the adrenergic system but glutamate upregulation following GABA downregulation
Simple Withdrawal
Insomnia
Tremors
Anxiety
Agitation
Nausea and vomiting
Sweating
Palpitations
What is Alcohol Hallucinosis and when does it present?
It’s a rare complication of alcohol withdrawal characterised predominantly by auditory hallucinations
It typically presents 12-24 hours post drink
What is the presentation of Delirium Tremens?
Is another rare complication of alcohol withdrawal and typically presents 48-72 hours post drink
It is caused by the overactivation of the adrenergic system from glutamate up-regulation and GABA depression
Symptoms
- Severe agitation
- Delusions and hallucinations
- Formication Hallucinations feeling like bugs are crawling under the skin
- Lilliputian Hallucinations (small people or objects)
- Confusion
- Coarse Tremor
- Seizures
Signs
- Ataxia
- Tachycardia
- Hypertension
- Hyperthermia
- Arrhythmias
What are some differentials of alcohol withdrawal?
Benzodiazepine withdrawal
Similar symptoms to alcohol withdrawal, but may also include perceptual changes, depersonalization, derealization, hypersensitivity to light and sound, and numbness/tingling in extremities.
Drug-induced delirium
Characterised by fluctuating mental status, inattention, and a disturbed sleep-wake cycle.
Other conditions causing delirium
What are the indications for inpatient withdrawal treatment?
- Patients drinking >30 units per day
- Scoring over 30 on the SADQ score
- High risk of alcohol withdrawal seizures (previous alcohol withdrawal seizures or delirium tremens, or history of epilepsy)
- Concurrent withdrawal from benzodiazepines
- Significant medical or psychiatric comorbidity
- Vulnerable patients
- Patients under 18
What Screening tools are used to assess for Alcohol Dependence?
What screening tools are used to assess the severity of alcohol dependence if identified?
Screening for dependence
- AUDIT Questionnaire (AUDIT-C in time limited scenarious)
- CAGE Questionnaire
Screening for Severity
- SADQ (Severity of Alcohol Dependence Questionnaire)
- Leeds Dependence Questionnaire (LDQ
What is the management for Alcohol Withdrawal?
What tool is used to assess withdrawal symptoms in patients?
CIWA-Ar (Clinical institute Withdrawal Assessment for Alcohol, Revised)
-
Chlordiazepoxide (Diazepam is a less commonly used alternative) is a benzodiazepine used to combat the effects of alcohol withdrawal.
It is given orally as a reducing regime - High-dose B vitamins (Pabrinex) are given intramuscularly or intravenously, followed by long-term oral thiamine. This is used to prevent Wernicke-Korsakoff syndrome.
What is the management for Delerium Tremens?
Oral Benzodiazepines as the first-line treatment for delirium tremens.
Chlordiazepoxide, Lorazepam, Diazepam
With parenteral lorazepam offered if oral treatment is declined or symptoms persist.
What is the definition of Self-Harm?
Self-harm refers to an intentional act of self-poisoning or self-injury without suicidal intent, irrespective of the motivation or apparent purpose of the act.
It is an expression of emotional distress
What different methods of Self-Harm are there?
- A behaviour (eg, self-cutting) intended to cause self-harm.
- Ingesting a substance in excess of the prescribed or generally recognised therapeutic dose.
- Ingesting a recreational or illicit drug that was an act that the person regarded as self-harm.
- Ingesting a non-ingestible substance or object.
What is the epidemiology of Self-Harm?
It’s most common among younger people, especially younger / teenage girls.
Self-harm increases the likelihood that the person will eventually die by suicide by between 50- and 100-fold.
What are the risk factors for self-harm?
- Younger age <25 years
- Females
- Psychiatric problems like borderline personality disorder, depression, bipolar disorder, schizophrenia, eating disorders, drug misuse and alcohol abuse
- Domestic violence
- Socio-economic disadvantage
What is the initial management of Self-Harm?
Safety netting, a Safety Plan and follow up must be considered
Safeguarding issues may be considered
- Urgent referral to the emergency department if required. Once there they will be seen by the Mental Health Team
- For drugs taken in overdose / poisoning; Activated charcoal is the first line management (preferably within one hour of ingestion) for many substances
What further interventions should be offered to those who self-harm?
Assessment of needs
Includes an evaluation of the social, psychological and motivational factors specific to the act of self-harm, current suicidal intent and hopelessness, as well as a full mental health and social needs assessment.
Suicide Risk Assessment
Psychological Intervention
NICE recommends 3-12 sessions specifically structured for self-harm
Dialectical behaviour therapy (DBT)
It’s based on cognitive behavioural therapy (CBT), but is specially adapted for people who feel emotions very intensely.
What is the epidemiology of a paracetamol overdose?
Paracetamol is the most common agent for intentional self-harm in the UK.
Paracetamol overdose accounts for 44% of all adult self-poisoning cases in the UK.
What is the pathophysiology of a paracetamol overdose?
A paracetamol overdose involves the buildup of a toxic substance called NAPQI (N-acetyl-p-benzoquinone-imine).
Normally, NAPQI is inactivated by glutathione, but during an overdose, glutathione stores are rapidly depleted, leaving NAPQI unmetabolised and resulting in liver and kidney damage.
What are the clinical features of a paracetamol overdose?
No symptoms
Nausea and vomiting
Loin pain
Haematuria and proteinuria
Jaundice
Abdominal pain
Coma
Severe metabolic acidosis
What are some differentials of a paracetamol overdose?
Acute gastritis/gastroenteritis
Renal colic
Liver diseases
Metabolic acidosis
What investigations are done for a paracetamol overdose?
Paracetamol level
Full Blood Count (FBC)
Urea and Electrolytes
Clotting Screen
Liver Function Tests
Venous Blood Gas
Decisions on treatment are guided by a nomogram which plots paracetamol levels.
What is the definition of Suicide?
It can be described as a fatal act of self-harm initiated with the intention of ending one’s own life
What are some factors that increase the risk of someone attempting suicide?
- Male sex
- History of deliberate self-harm/suicide attempts
- History of alcohol or drug misuse
- History of mental illness: Depression, Schizophrenia
- History of chronic disease
- Advancing age
- Unemployment or social isolation/living alone
- Being unmarried, divorced or widowed
What are the factors that increase the risk of someone completing a suicide attempt in the future?
- Previous Suicide attempts
- Efforts to avoid discovery
- Planning/preparation
- Leaving a written note
- Final acts such as sorting out finances
- Violent method
- Feelings of hopelessness, impulsiveness
What are some protective factors for Suicide?
- A strong religious faith.
- Family support to find alternative solutions to their problems.
- Having children at home.
- Access to mental health support
- A sense of responsibility for others.
- Resilience, Coping mechanisms, Problem-solving skills.
What is the best way of establishing whether a patient has suicidal intent?
A comprehensive clinical interview
(NICE recommends that no score systems should be used)
What does a suicide risk assessment involve?
Introduction
Establish rapport, develop a trusting relationship.
Establish current anxieties or problems.
Observe behaviour and be alert to any mismatch between words and behaviour. Suicidal intent be denied.
Assess Risk Factors
Assess Current Plans and Intent
‘Red flags’ to consider may include a sense of hopelessness, a feeling of entrapment, well-formed plans, perception of no social support, distressing psychotic phenomena and significant pain/physical chronic illness.
Assess Needs
Social problems.
Untreated mental health disorders.
Physical symptoms and disorders.
Coping strategies.
Skills, strengths and assets.
Psychosocial and occupational functioning.
Personal and financial difficulties.
Needs of dependants.
What does the management of suicidal patients involve?
Once a risk assessment has been performed, subsequent action will depend on the level of risk believed to be present.
Formulate a Care Plan (including a risk management and crisis plan)
Specific treatment e.g.
Medication
Counselling
Cognitive behavioural therapy (CBT)
Dialectical behaviour therapy (DBT)
Provide follow up at regular intervals
What is the 1983 Mental Health Act (MHA)?
It provides legal structures to define and manage procedures associated with the treatment and rights of people with mental health disorders.
What is the definition of ‘Involuntary Commitment’ or Sectioning?
It is a legal process through which an individual who is deemed by a qualified agent to have symptoms of severe mental disorder is detained in a psychiatric hospital where they can be treated involuntarily.
What is in Section 2 of the MHA?
Compulsory admission for mental health assessment for up to 28 days,
- Non-renewable - must end in either discharge or detainment under section 3
- For assessment (may be followed by treatment)
- Requires 2 doctors and an AMHP
What is in Section 3 of the MHA?
Compulsory admission for Treatment
- Maximum period of 6 months
- Can then be renewed if requiring further treatment
- Nearest Relative can object
What is in Section 4 of the MHA?
Used to detain patients for up to 72 hours in urgent scenarios
- Used where other procedures cannot be arranged in time.
- It requires an AMHP and one doctor.
- It is followed by a Mental Health Act assessment.
Designed for emergencies when applying Section 2 would cause an unnecessary delay.
What is in Section 5(2) of the MHA?
What is a Section 5(4) of the MHA?
Enables a doctor to legally detain a patient who attended the hospital voluntarily (already in hospital)
- For a period of 72 hours.
- Only requires 1 Doctor
Section 5(4) enables 1 nurse to do the same for 6 hours
These are followed by a MHA Assessment
What is in Section 17 of the MHA?
Allows for a Supervised Community Treatment (also known as a Community Treatment Order).
What is in Section 135 of the MHA?
Court order enabling the police to enter a property to escort a person to a Place of Safety (either the police station or, more commonly, an Accident and Emergency Department (A&E)).
