Psychiatry

Psychosis is the misrepresentation of thoughts and perceptions that originate from a patient’s own mind which are experienced as reality. It is a symptom, not a diagnosis in itself and affects about 3% of the population.   Causes: With most psychiatric conditions, the aetiology of psychosis is seen with a biopsychosocial model: Biological: Genetics –> Twin studies have shown schizophrenia has 50% concordance rate in MZ  twins Dopamine–> Antipsychotics block D2 receptors whereas L-Dopa induces psychosis Neurodevelopmental –> Higher in people with low birth weight, developmental delay etc.   Psychological: Prodrome –> Often preceded by patients exhibiting anxiety, depression and ideas of reference –

  Acute stress reaction This is an acute reaction which occurs rapidly (minutes to hours) after a sudden and stressful event. – This can include sexual assault, an injury, a near-death experience etc. – This leads to several symptoms in response which usually arise very quickly and terminate within 3 days   Symptoms: – Initial state of being dazed and confused – Purposeless overactivity and withdrawal – Intense brief anxiety – Autonomic arousal –> sweating, dry mouth, vomiting   Management – Help patient to re-orientate with trauma-focussed CBT Prognosis – Most cases resolve rapidly within 3 days. If symptoms persist > 1

Affective (mood disorders) are characterised by emotional disturbances resulting in functional impairment.   Causes: The aetiology of affective disorders can be seen using a biopsychosocial model:  Biological: 5-HT–> Low levels of endogenous 5-HT and Na are thought to decrease mood Cortisol –> Overactivation of the HPA axis increases both risk and persistence of low  mood   Psychological: Beck’s triad –> Negative views about the self, the world and the future seen in depression Attributional style –> Higher incidence in people who blame themselves for life events   Social: Stress –> Linked to negative life events, adversity and childhood stress.   Depression This is a mental

  Somatisation Disorder (SYMPTOMS) This is a disorder where patients believe that have physical symptoms present for at least 2 years, despite no physical or organic explanation – The most common symptoms mentioned usually involve the GI tract (abdominal pain) or the skin – Patients don’t accept negative test results and instead feel great distress and worry over their symptoms – It is more common in young women and can lead to multiple operations/investigations despite absence of disease   Hypochondrial Disorder (DISEASE) This is a disorder where patients believe they have a serious underlying disease e.g. cancer, HIV, AIDS –

Affective (mood disorders) are characterised by emotional disturbances resulting in functional impairment.   Causes: The aetiology of affective disorders can be seen using a biopsychosocial model:  Biological: 5-HT–> Low levels of endogenous 5-HT and Na are thought to decrease mood Cortisol –> Overactivation of the HPA axis increases both risk and persistence of low  mood   Psychological: Beck’s triad –> Negative views about the self, the world and the future seen in depression Attributional style –> Higher incidence in people who blame themselves for life events   Social: Stress –> Linked to negative life events, adversity and childhood stress.   Depression This is a mental

This is an acute confusional state which is characterised by rapid onset of a global but fluctuating dysfunction of the CNS due to a variety of insults on the brain. – It is more commonly seen in people aged >65 and those with diffuse brain disease (dementia) – However, it can be experienced by anyone in hospital and is an important thing to keep watch out for   Causes – The main causes can be remembered using the acronym PINCH-ME: P – Pain In – Infection (often a UTI in elderly) C – Constipation H – Hydration M – Medication (drugs) E – Electrolytes (e.g. hyponatraemia) E – Environment

  Eating disorders refer to a group of conditions which are characterised by a disorganised pattern of food consumption which causes physical and emotional distress. – They are more common in females than males (3:1) with an onset around age 15-30. – The two most common are anorexia nervosa and bulimia nervosa, which share similar features.   Causes: With most psychiatric conditions, the aetiology can be considered using a biopsychosocial model. Biological: Genetics –> Twin studies have shown that eating disorders share a large genetic component 5-HT –> Altered brain serotonin contributes to dysregulation of appetite, mood and impulsivity   Psychological: Personality –> Higher

Personality is “the range of characteristic behavioural responses that a person deploys in order to negotiate the challenges produced by the outside world and their internal feelings.” – It is composed of 4 main components: cognition, impulse control, social communication and affect/emotions – As these components are continuous, psychiatrists assign cut-offs indicating when they become abnormal.   A personality disorder is where one or more of these components of personality has reached an abnormal level: i) The trait has to be pathological, pervasive and persistent (3P’s) ii) It must lead to stereotyped responses which can be traced to childhood iii)

  Affective (mood disorders) are characterised by emotional disturbances resulting in functional impairment.   Causes: The aetiology of affective disorders can be seen using a biopsychosocial model:  Biological: 5-HT–> Low levels of endogenous 5-HT and Na are thought to decrease mood Cortisol –> Overactivation of the HPA axis increases both risk and persistence of low  mood   Psychological: Beck’s triad –> Negative views about the self, the world and the future seen in depression Attributional style –> Higher incidence in people who blame themselves for life events   Social: Stress –> Linked to negative life events, adversity and childhood stress.   Depression This is a

Affective (mood disorders) are characterised by emotional disturbances resulting in functional impairment.   Causes: The aetiology of affective disorders can be seen using a biopsychosocial model:  Biological: 5-HT–> Low levels of endogenous 5-HT and Na are thought to decrease mood Cortisol –> Overactivation of the HPA axis increases both risk and persistence of low  mood   Psychological: Beck’s triad –> Negative views about the self, the world and the future seen in depression Attributional style –> Higher incidence in people who blame themselves for life events   Social: Stress –> Linked to negative life events, adversity and childhood stress.   Depression This is a mental

Eating disorders refer to a group of conditions which are characterised by a disorganised pattern of food consumption which causes physical and emotional distress. – They are more common in females than males (3:1) with an onset around age 15-30. – The two most common are anorexia nervosa and bulimia nervosa, which share similar features.   Causes: With most psychiatric conditions, the aetiology can be considered using a biopsychosocial model. Biological: Genetics –> Twin studies have shown that eating disorders share a large genetic component 5-HT –> Altered brain serotonin contributes to dysregulation of appetite, mood and impulsivity   Psychological: Personality –> Higher association

Alcohol Alcohol abuse is defined as the regular or binge consumption of alcohol which can lead to physical, neuropsychiatric or social damage. – 1 unit (10mL) of alcohol is about equivalent to a small glass of wine, or a single peg of spirits. – Units = Volume (L) * ABV (%) – e.g. a 750ml bottle of wine, strength 12% has 750/1000 *12 = 9 units – Both men and women should drink no more than 14 units a week. If you do, it is best to spread this evenly over 3 days or more. There are several problems of

ADHD This is a disorder which is characterised by inattention, hyperactivity and impulsivity – It is much more common in boys than girls and diagnosed in the primary school years – In order to distinguish this condition from simply bad behaviour, there are 3 key things that must be present in order to satisfy the diagnostic criteria: –> Persistent – This means that the disruptive behaviour must be constant – If behaviour does fluctuate, then this could simply be an acute reaction to a change in the environment of the child.   –> Pervasive – This means that the disruptive behaviour must be seen

  ADHD This is a disorder which is characterised by inattention, hyperactivity and impulsivity – It is much more common in boys than girls and diagnosed in the primary school years – In order to distinguish this condition from simply bad behaviour, there are 3 key things that must be present in order to satisfy the diagnostic criteria: –> Persistent – This means that the disruptive behaviour must be constant – If behaviour does fluctuate, then this could simply be an acute reaction to a change in the environment of the child.   –> Pervasive – This means that the disruptive behaviour must be

  Somatisation Disorder (SYMPTOMS) This is a disorder where patients believe that have physical symptoms present for at least 2 years, despite no physical or organic explanation – The most common symptoms mentioned usually involve the GI tract (abdominal pain) or the skin – Patients don’t accept negative test results and instead feel great distress and worry over their symptoms – It is more common in young women and can lead to multiple operations/investigations despite absence of disease   Hypochondrial Disorder (DISEASE) This is a disorder where patients believe they have a serious underlying disease e.g. cancer, HIV, AIDS –

Alcohol Alcohol abuse is defined as the regular or binge consumption of alcohol which can lead to physical, neuropsychiatric or social damage. – 1 unit (10mL) of alcohol is about equivalent to a small glass of wine, or a single peg of spirits. – Units = Volume (L) * ABV (%) – e.g. a 750ml bottle of wine, strength 12% has 750/1000 *12 = 9 units – Both men and women should drink no more than 14 units a week. If you do, it is best to spread this evenly over 3 days or more. There are several problems of

  Eating disorders refer to a group of conditions which are characterised by a disorganised pattern of food consumption which causes physical and emotional distress. – They are more common in females than males (3:1) with an onset around age 15-30. – The two most common are anorexia nervosa and bulimia nervosa, which share similar features.   Causes: With most psychiatric conditions, the aetiology can be considered using a biopsychosocial model. Biological: Genetics –> Twin studies have shown that eating disorders share a large genetic component 5-HT –> Altered brain serotonin contributes to dysregulation of appetite, mood and impulsivity   Psychological: Personality –> Higher

The commonest aetiologies of dementia are: Alzheimer’s disease, Vascular and Lewy body dementia. – These conditions are difficult to diagnose and there are many assessment tools e.g. GPCOG, abbreviated mental test score (AMTS) and the mini-mental state examination (MMSE)   Investigation pathway: – 1st do a cognitive assessment e.g. MOCA – Exclude reversible causes – do FBC, U&E, LFTs, calcium, glucose, TFT, Vit B12 and folate (2) – Imaging – CT head (structural causes) and MRI (vasculature changes)    Alzheimer’s disease The number one cause of dementia in the UK is Alzheimer’s disease. The disease is characterised by a progression degeneration

  This is an acute confusional state which is characterised by rapid onset of a global but fluctuating dysfunction of the CNS due to a variety of insults on the brain. – It is more commonly seen in people aged >65 and those with diffuse brain disease (dementia) – However, it can be experienced by anyone in hospital and is an important thing to keep watch out for   Causes – The main causes can be remembered using the acronym PINCH-ME: P – Pain In – Infection (often a UTI in elderly) C – Constipation H – Hydration M – Medication (drugs) E – Electrolytes (e.g. hyponatraemia) E –

  Psychosis is the misrepresentation of thoughts and perceptions that originate from a patient’s own mind which are experienced as reality. It is a symptom, not a diagnosis in itself and affects about 3% of the population.   Causes: With most psychiatric conditions, the aetiology of psychosis is seen with a biopsychosocial model: Biological: Genetics –> Twin studies have shown schizophrenia has 50% concordance rate in MZ  twins Dopamine–> Antipsychotics block D2 receptors whereas L-Dopa induces psychosis Neurodevelopmental –> Higher in people with low birth weight, developmental delay etc.   Psychological: Prodrome –> Often preceded by patients exhibiting anxiety, depression and ideas of reference

Acute stress reaction This is an acute reaction which occurs rapidly (minutes to hours) after a sudden and stressful event. – This can include sexual assault, an injury, a near-death experience etc. – This leads to several symptoms in response which usually arise very quickly and terminate within 3 days   Symptoms: – Initial state of being dazed and confused – Purposeless overactivity and withdrawal – Intense brief anxiety – Autonomic arousal –> sweating, dry mouth, vomiting   Management – Help patient to re-orientate with trauma-focussed CBT Prognosis – Most cases resolve rapidly within 3 days. If symptoms persist > 1 month,

  Affective (mood disorders) are characterised by emotional disturbances resulting in functional impairment.   Causes: The aetiology of affective disorders can be seen using a biopsychosocial model:  Biological: 5-HT–> Low levels of endogenous 5-HT and Na are thought to decrease mood Cortisol –> Overactivation of the HPA axis increases both risk and persistence of low  mood   Psychological: Beck’s triad –> Negative views about the self, the world and the future seen in depression Attributional style –> Higher incidence in people who blame themselves for life events   Social: Stress –> Linked to negative life events, adversity and childhood stress.   Depression This is a

The mental state examination is a way of observing and describing a patient’s current state of mind. – The purpose of the MSE is to get a cross-sectional description of the patient’s mental state – It is a time-specific snapshot of the patient’s current mental state (allows comparison to before) – This is combined with the psychiatric history, allowing clinicians to get the overall sense of the patient’s condition   Mental State Exam Acronym = A Brilliant Scientist Makes All Theories Too Perfectly Complicated “In-it”   Appearance This is a general description of the patient’s general look and appearance. Important to include the following: – An opening sentence summarising

Psychotherapy works by helping people understand why they feel as they do. It uses a combination of reflecting about past events, learning new coping strategies and building a therapist-patient relationship. – There are 3 main areas of psychological therapy, each with its advantages and disadvantages: i) Supportive therapies e.g. Counselling + Supportive Psychotherapy This is the least intense level of psychotherapy which is used for mild depression and anxiety – The sessions are unstructured but allow the patient to establish rapport, reflect and get reassurance – It is a non-direct way of solving the problem –> works for stress, bereavement,

The main piece of mental health legislation in England is the Mental Health Act 1983. This was amended by the Mental Health Act 2007.   Who it applies to? The Mental Health act applies to people with a “mental disorder” – any disorder/disability of mind – However, it excludes anyone with dependence on drugs or alcohol – Also excludes patients with learning disability, unless their condition causes abnormally aggressive or seriously irresponsible conduct – Applies to people of any age, but children are usually treated with consent of their parent.   Sectioning (compulsory admission to hospital) This part allows admission

Mental Capacity can be defined as the ability to make your own decisions. – This is very important as it gives patients autonomy and the right to make choices about their own healthcare – It becomes complicated when people lack capacity, as others have to make decisions about patients – The Mental Capacity act applied to people aged 16 and over. If the child is younger than 16, they only have capacity to make decisions provided that they are Gillick Competent.   5 key principles of mental capacity: i) A person is assumed to have capacity is assumed until it

Disease = the objective physical pathology and known aetiology Illness = the patient’s subjective distress caused by a condition   A big problem in psychiatry is that many conditions have no known or understood pathophysiological cause. – This makes it very difficult to diagnose diseases, since there is no demonstrable pathology. – Therefore, psychiatry talks about mental illness – this is a level of subjective distress which is greater in severity or duration than occurs in normal human experience – This allows us to diagnose patients regardless of our understanding of the condition and provide treatment   A diagnosis is the art

Overview Wernicke-Korsakoff syndrome refers to two distinct neurological syndromes resulting from thiamine (Vitamin B1) deficiency. Wernicke-Korsakoff syndrome (WKS) refers to a disease spectrum causing two classical neurological syndromes as a result of thiamine (vitamin B1) deficiency: Wernicke’s encephalopathy (WE): an acute encephalopathy characterised by a triad of confusion, ataxia, and oculomotor dysfunction Korsakoff syndrome (KS): a chronic amnesic syndrome characterised by defects in both anterograde and retrograde memory The syndromes are most commonly observed in chronic alcoholism because of poor dietary intake, although other factors are involved including a possible genetic element. WKS is not restricted to chronic alcoholism and may be observed in other conditions

Introduction Substance abuse or misuse is a repetitive harmful pattern of substance use that leads to negative consequences Substance abuse is a major problem both in the UK and more broadly across the world. Common substances of abuse, which can lead to dependence, include alcohol, opioids, cocaine, and a variety of legal substances such as nicotine and caffeine. In this article, we go over the general principles for substance misuse. For more specific information regarding a single substance, please see the relevant notes in our Psychiatry section. Substance abuse or misuse Substance abuse or misuse is a repetitive harmful pattern of substance use

Introduction In phobias, the fear response is excessive, irrational, and can have debilitating consequences for individuals. Fear is an uncomfortable emotion that occurs in response to threatening situations. The purpose of fear is to motivate an individual to protect themselves and avoid harm. Fear is therefore a rational reaction to a real threat or danger. In phobias, the fear response is excessive, irrational, and can have debilitating consequences for the individual. There is an exaggerated or unrealistic sense of danger about the phobic situation or object, which persists despite evidence to the contrary. In some cases, even thinking about the phobic object

Introduction In social anxiety disorder, the fear of social situations is overwhelming and disproportionate. It is normal to feel nervous in some social situations, such as attending a job interview or going on a date. However, in social anxiety disorder, the fear of social situations is overwhelming and disproportionate. The individual is fearful of being negatively judged by others in a variety of social settings including everyday social interactions, being observed by others, and performing in front of others. There may be a fear of humiliation, embarrassment, or social rejection. Individuals with social anxiety disorder therefore strive to avoid these social

Overview Serotonin syndrome can be a life-threatening neurological disorder due to increased serotonergic activity in the central nervous system. Serotonin syndrome (SS) is a potentially life-threatening disorder that is characterised by altered mental status (i.e. confusion), autonomic hyperactivity, and neuromuscular abnormalities (e.g. rigidity, clonus, hyperreflexia). It is due to increased serotonergic activity in the central nervous system (CNS) that can be induced by a range of medications that increase serotonergic transmission by altering the neurotransmitter serotonin. There is a wide clinical spectrum and the prognosis is generally favourable although severe cases may require treatment in intensive care. Epidemiology The incidence of SS has been increasing due to

Overview Schizophrenia, a form of psychosis, is characterised by distortion to thinking and perception and inappropriate or blunted affect. Schizophrenia is the most common form of psychosis with an onset that is typically early in life (15 to 35). It is a chronic condition with a course characterised by episodes of acute psychosis. Features that are common to psychoses are: Hallucinations: hallucinations can be defined as perceptions in the absence of stimuli. Most commonly auditory but may be visual or affect smell, taste, or tactile senses. Delusions: a fixed, false belief not in keeping with cultural and educational background. Thought and speech disorder:

Introduction Post-traumatic stress disorder (PTSD) describes a constellation of symptoms and experiences that an individual develops after exposure to a traumatic event or multiple events Many people who experience a traumatic event will struggle with negative emotions, thoughts, and unpleasant memories of the event. These symptoms are often transient and ease over time but for some, symptoms will persist and intensify. Post-traumatic stress disorder (PTSD) describes a constellation of symptoms and experiences that an individual develops after exposure to a traumatic event or multiple events. These include: Re-experiencing the traumatic event (e.g. memories, flashbacks, nightmares). Avoiding thoughts and memories: individuals typically try to

Introduction Pica is a mental health condition where a person compulsively swallows non-food items. Pica refers to the eating or craving of things that are not food and do not contain significant nutritional value. The term is derived from “pica-pica” the Latin word for the magpie; a bird with a tendency for gathering and eating an odd assortment of items. PICA is classified as an eating disorder but can also be the result of an existing mental disorder, or occur in the context of pregnancy or vitamin deficiencies. There are different types of pica, which can be characterised by the non-food

Introduction Personality is described as the “combination of characteristics or qualities that form an individual’s distinctive character“. Personality describes an individual’s enduring personal characteristics, including their unique patterns of thinking, feeling, and behaving. Personalities are thought to be formed from a combination of a person’s innate temperament, environmental factors, and life experiences. Personality disorders, commonly abbreviated to “PD”, occur when personality traits deviate significantly from the norm and manifest in harmful patterns of thinking, feeling, behaving, and interacting with others. Personality disorders tend to become evident during late adolescence or early adulthood but are not usually diagnosed under the age

Introduction Opioid is a broad term used to describe naturally occurring or synthetic substances that bind to opioid receptors. Opioids are naturally occurring or synthetic substances that bind to opioid receptors. They may have agonist, partial agonist, or mixed agonist and antagonist activity at opioid receptors. An opiate is a natural derivative of the flowering opium poppy plant that has activity at opioid receptors. All opiates are opioids but not all opioids are opiates. In these notes we will use the term opioids of which there are several types: Naturally occurring opioids (i.e. opiates): codeine, morphine, and heroin. Synthetic opioids: fentanyl, methadone,

Introduction Obsessive compulsive disorder is characterised by the presence of obsessions and/or compulsions. It is a relatively common disorder with a wide clinical spectrum. It may significantly impact an individual’s daily life and be a cause of profound functional impairment. NICE reports that anywhere between 1-3% of the UK population are affected. It is characterised by two features: Obsessions: intrusive thoughts, urges and images that cause anxiety and distress. Compulsions: repetitive behaviours that one feels compelled to perform, these may be observable or occur in the mind (e.g. repeating a phrase). Epidemiology OCD is a leading cause of global disease burden. It

Overview Neuroleptic malignant syndrome is a life-threatening neurological disorder characterised by confusion, fever, and rigidity. Neuroleptic malignant syndrome (NMS), is a rare, life-threatening disorder that is associated with the use of antipsychotic drugs (previously known as neuroleptic medications) but the exact cause is unknown. The condition is characterised by altered mental status (i.e. confusion), fever, muscular rigidity, and dysautonomia (i.e. autonomic instability). It is associated with high mortality (~10-20%) and requires a low index of suspicion in patients presenting with characteristic symptoms (i.e. fever or rigidity) whilst taking antipsychotics. Treatment is largely supportive and most episodes will resolve within two weeks

Introduction Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by persistent symptoms of inattention, hyperactivity and impulsivity. Attention deficit hyperactivity disorder (ADHD) is considered one the neurodevelopmental disorders such as Autism spectrum disorder. It is characterised by persistent symptoms of inattention, hyperactivity, and impulsivity. Inattention: may manifest as forgetfulness, being easily distracted, difficulty organising and prioritising tasks, seeming not to listen, and losing belongings. Hyperactivity: may present as excessive fidgeting, difficulty sitting still, restlessness, and being overly talkative. Impulsivity: may manifest as difficulty waiting their turn and interrupting others. These three hallmark symptoms are present across several settings (e.g.

Introduction ARFID is known as avoidant/restrictive food intake disorder, which is characteristed by a pattern of eating leading to avoidance and/or restriction of food. Avoidant/restrictive food intake disorder (ARFID) is characterised by a pattern of eating where there is avoidance and/or restriction of the food type or quantity of food eaten. This tends to have negative consequences for an individual’s physical health leading to weight loss, and nutritional deficiencies. The avoidance and/or restriction of foods in ARFID can occur for several reasons including: Sensory-based avoidance of food: the individual may dislike the smell, texture, taste, or look of certain foods.

Introduction Anorexia nervosa is an eating disorder characterised by restriction of energy intake resulting in low body weight and an intense fear of weight gain. Though anorexia nervosa may occur at any age, the risk is highest in young people between the ages of 13-18 years old. Management is typically with talking therapies and supervised weight gain. However those at-risk of significant complications may require urgent admission and inpatient management. It follows a variable course, but less than half of patients fully recover and mortality is 5 times that of the general population. Epidemiology It is estimated that the lifetime prevalence of anorexia nervosa is 2-4% in women.

Introduction Alcohol dependence develops after a period of regular alcohol consumption and is characterised by craving, tolerance, loss of control, withdrawal symptoms, and persistent use despite negative harm. Alcohol is a psychoactive substance that has been widely used in different cultures for centuries. Excessive and harmful use of alcohol can have negative individual consequences (e.g. physical, psychological, economic, and social). There are also wider harmful consequences to society at large. Alcohol intoxication is typically referred to as being “drunk” or inebriated. Desirable effects of alcohol intoxication include relaxation, euphoria, and social disinhibition. Other effects range from mild (e.g. impairments in balance, coordination,

Introduction Agoraphobia is derived from the Greek “agora” meaning a place of assembly or market-place and “phobia” meaning fear. Agoraphobia is an anxiety disorder characterised by an excessive fear of situations where escape might be difficult or help might not be readily available. This can include situations such as using public transportation, being in crowds, and being out of the home alone. There is a fear that a panic attack or other incapacitating/embarrassing physical symptoms may occur in these situations. Individuals with agoraphobia therefore strive to avoid these situations or endure them with intense feelings of anxiety or fear. This fear

Introduction An acute stress reaction refers to intense, or prolonged, mental or psychological distress that can develop after exposure, or in response, to a stressful event. Many people who experience a traumatic event will struggle with negative emotions, thoughts, and memories of the event. In the first month following the traumatic event, they may experience an acute stress reaction, symptoms of which include: Intrusion symptoms: reexperiencing the traumatic event (memories, flashbacks, nightmares). Negative mood: inability to experience positive emotions, such as happiness. Dissociative symptoms: an altered sense of one’s surroundings or oneself, difficulty remembering the trauma. Avoidance symptoms: avoidance of thoughts and memories of