Validity in statistics refers to how accurately something measures what it claims to measure. There are two main types of validity: internal and external. Internal validity refers to the confidence we have in the cause and effect relationship in a study, while external validity refers to the degree to which the conclusions of a study can be applied to other people, places, and times. There are various threats to both internal and external validity, such as sampling, measurement instrument obtrusiveness, and reactive effects of setting. Additionally, there are several subtypes of validity, including face validity, content validity, criterion validity, and construct validity. Each subtype has its own specific focus and methods for testing validity.

Hopwood (1927) and Meyer and Oberman (2001) focused on maternal filicide, while Resnick (1969) examined filicide committed by both genders and identified five motives. Guileyardo (1999) expanded on Resnick’s work to include a wider range of motives. Scott (1973) created the initial classification of filicide based on a sample of fathers exclusively.

Charles Bonnet syndrome (CBS) is a condition where mentally healthy individuals experience vivid and recurring visual hallucinations, also known as fictive visual percepts. These hallucinations are typically small in size, known as lilliputian hallucinations. CBS is commonly found in individuals who have visual impairments due to old age of damage to the eyes of optic pathways. However, not all individuals with such deficits develop CBS. In some cases, CBS may be triggered by a combination of central vision loss due to conditions like macular degeneration and peripheral vision loss from glaucoma. In this context, bilateral lenticular opacities refer to cataracts. For more information on CBS, please refer to the Royal National Institute of Blind People (RNIB).

The man is experiencing depression. The initial step would be to assess if an elevated dosage of semi-sodium valproate could alleviate his symptoms. The typical dosage of semi-sodium valproate is 1-2G per day, divided into multiple doses. It is recommended to avoid doses exceeding 45 mg/kg, of at least monitor closely. However, considering his weight of 65kg, he could tolerate 1G twice daily. It is advisable to avoid introducing additional medications whenever possible, as each new medication carries the risk of potential side effects.

Bipolar Disorder: Diagnosis and Management

Bipolar disorder is a lifelong condition characterized by episodes of mania or hypomania and episodes of depressed mood. The peak age of onset is 15-19 years, and the lifetime prevalence of bipolar I disorders is estimated to be around 2.1%. The diagnosis of bipolar disorder is based on the presence of manic or hypomanic episodes, which are characterized by elevated of expansive mood, rapid speech, and increased activity of energy. Psychotic symptoms, such as delusions and hallucinations, may also be present.

Bipolar depression differs from unipolar depression in several ways, including more rapid onset, more frequent episodes, and shorter duration. Rapid cycling is a qualifier that can be applied to bipolar I of bipolar II disorder and is defined as the presence of at least four mood episodes in the previous 12 months that meet the criteria for a manic, hypomanic, of major depressive episode.

The management of bipolar disorder involves acute and long-term interventions. Acute management of mania or hypomania may involve stopping antidepressants and offering antipsychotics of mood stabilizers. Long-term management may involve psychological interventions and pharmacological treatments such as lithium, valproate, of olanzapine.

It is important to note that valproate should not be offered to women of girls of childbearing potential for long-term bipolar disorder unless other options are ineffective of not tolerated and a pregnancy prevention program is in place. Aripiprazole is recommended as an option for treating moderate to severe manic episodes in adolescents with bipolar I disorder.

Overall, the diagnosis and management of bipolar disorder require a comprehensive approach that takes into account the individual’s symptoms, history, and preferences.

Stevens suggested that scales can be categorized into one of four types based on measurements.

Scales of Measurement in Statistics

In the 1940s, Stanley Smith Stevens introduced four scales of measurement to categorize data variables. Knowing the scale of measurement for a variable is crucial in selecting the appropriate statistical analysis. The four scales of measurement are ratio, interval, ordinal, and nominal.

Ratio scales are similar to interval scales, but they have true zero points. Examples of ratio scales include weight, time, and length. Interval scales measure the difference between two values, and one unit on the scale represents the same magnitude on the trait of characteristic being measured across the whole range of the scale. The Fahrenheit scale for temperature is an example of an interval scale.

Ordinal scales categorize observed values into set categories that can be ordered, but the intervals between each value are uncertain. Examples of ordinal scales include social class, education level, and income level. Nominal scales categorize observed values into set categories that have no particular order of hierarchy. Examples of nominal scales include genotype, blood type, and political party.

Data can also be categorized as quantitative of qualitative. Quantitative variables take on numeric values and can be further classified into discrete and continuous types. Qualitative variables do not take on numerical values and are usually names. Some qualitative variables have an inherent order in their categories and are described as ordinal. Qualitative variables are also called categorical of nominal variables. When a qualitative variable has only two categories, it is called a binary variable.

Premenstrual dysphoric disorder is a condition where symptoms such as mood, somatic, of cognitive changes occur a few days before the start of menstruation, improve within a few days after menstruation begins, and disappear within a week. On the other hand, dysmenorrhea is characterized by pelvic or abdominal pain that occurs during of before menstruation and interferes with daily activities. Unlike premenstrual dysphoric disorder, dysmenorrhea does not involve mood symptoms and starts at the same time as menstruation. Symptoms of both conditions can improve during the suppression of the ovarian cycle, such as during pregnancy, lactation, of menopause induced by natural of medical means.

There is currently no evidence to support the use of vitamin supplements for the treatment of premenstrual dysphoric disorder. However, lifestyle changes such as regular exercise, a healthy diet, and stress reduction techniques may be helpful in managing symptoms. It is important to consult with a healthcare provider to determine the best course of treatment for individual cases of PMDD.

The only symptom that indicates hypoactive delirium is facial inexpression, while the rest of the symptoms suggest hyperactive delirium.

Delirium (also known as acute confusional state) is a condition characterized by a sudden decline in consciousness and cognition, with a particular impairment in attention. It often involves perceptual disturbances, abnormal psychomotor activity, and sleep-wake cycle impairment. Delirium typically develops over a few days and has a fluctuating course. The causes of delirium are varied, ranging from metabolic disturbances to medications. It is important to differentiate delirium from dementia, as delirium has a brief onset, early disorientation, clouding of consciousness, fluctuating course, and early psychomotor changes. Delirium can be classified into three subtypes: hypoactive, hyperactive, and mixed. Patients with hyperactive delirium demonstrate restlessness, agitation, and hyper vigilance, while those with hypoactive delirium present with lethargy and sedation. Mixed delirium demonstrates both hyperactive and hypoactive features. The hypoactive form is most common in elderly patients and is often misdiagnosed as depression of dementia.

A long-acting version of methylphenidate is Medikinet XL, which is recommended for ADHD cases where stimulant use leads to complications with tics.

ADHD (Diagnosis and Management in Children)

ADHD is a behavioural syndrome characterised by symptoms of inattention, hyperactivity, and impulsivity. The DSM-5 and ICD-11 provide diagnostic criteria for the condition, with both recognising three subtypes: predominantly inattentive, predominantly hyperactive-impulsive, and combined.

Treatment for children under 5 involves offering an ADHD-focused group parent-training programme as a first-line option. Medication should only be considered after obtaining advice from a specialist ADHD service. For children and young people aged 5-18, advice and support should be given, along with an ADHD-focused group parent-training programme. Medication should only be offered if ADHD symptoms persist after environmental modifications have been implemented and reviewed. Cognitive behavioural therapy may also be considered for those who have benefited from medication but still experience significant impairment.

NICE advises against elimination diets, dietary fatty acid supplementation, and the use of the ‘few foods diet’. Methylphenidate of lisdexamfetamine is the first-line medication option, with dexamphetamine considered for those who respond to lisdexamfetamine but cannot tolerate the longer effect profile. Atomoxetine of guanfacine may be offered for those who cannot tolerate methylphenidate of lisdexamfetamine. Clonidine and atypical antipsychotics should only be used with advice from a tertiary ADHD service.

Drug holidays may be considered for children and young people who have not met the expected height for their age due to medication. However, NICE advises that withdrawal from treatment is associated with a risk of symptom exacerbation.

Chlorpromazine: Photosensitivity Reactions and Patient Precautions

Chlorpromazine, the first drug used for psychosis, is a common topic in exams. However, it is important to note that photosensitivity reactions are a known side effect of its use. Patients taking chlorpromazine should be informed of this and advised to take necessary precautions. Proper education and awareness can help prevent potential harm from photosensitivity reactions.

Understanding Specific Phobia: Diagnosis, Course, and Treatment

A specific phobia is a type of anxiety disorder characterized by an intense fear of anxiety about a particular object of situation that is out of proportion to the actual danger it poses. This fear of anxiety is evoked almost every time the individual comes into contact with the phobic stimulus, and they actively avoid it of experience intense fear of anxiety if they cannot avoid it. Specific phobias usually develop in childhood, with situational phobias having a later onset than other types. Although most specific phobias develop in childhood, they can develop at any age, often due to traumatic experiences.

Exposure therapy is the current treatment of choice for specific phobias, involving in-vivo of imaging approaches to phobic stimuli of situations. Pharmacotherapy is not commonly used, but glucocorticoids and D-cycloserine have been found to be effective. Systematic desensitization, developed by Wolpe, was the first behavioral approach for phobias, but subsequent research found that exposure was the crucial variable for eliminating phobias. Graded exposure therapy is now preferred over flooding, which is considered unnecessarily traumatic. Only a small percentage of people with specific phobias receive treatment, possibly due to the temporary relief provided by avoidance.

Personality Disorder: Avoidant

Avoidant Personality Disorder (AVPD) is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. According to the DSM-5, individuals with AVPD exhibit at least four of the following symptoms: avoidance of occupational activities that involve interpersonal contact, unwillingness to be involved unless certain of being liked, restraint in intimate relationships due to fear of ridicule, preoccupation with being criticized of rejected in social situations, inhibition in new interpersonal situations due to feelings of inadequacy, viewing oneself as inept and inferior to others, and reluctance to take personal risks of engage in new activities due to potential embarrassment.

In contrast, the ICD-11 does not have a specific category for AVPD but instead uses the qualifier of detachment trait. The Detachment trait domain is characterized by a tendency to maintain interpersonal and emotional distance. Common manifestations of Detachment include social detachment (avoidance of social interactions, lack of friendships, and avoidance of intimacy) and emotional detachment (reserve, aloofness, and limited emotional expression and experience). It is important to note that not all individuals with Detachment will exhibit all of these symptoms at all times.

Distinguishing Cortical and Subcortical Dementia: A Contested Area

Attempts have been made to differentiate between cortical and subcortical dementia based on clinical presentation, but this remains a contested area. Some argue that the distinction is not possible. Cortical dementia is characterized by impaired memory, visuospatial ability, executive function, and language. Examples of cortical dementias include Alzheimer’s disease, Pick’s disease, and Creutzfeldt-Jakob disease. On the other hand, subcortical dementia is characterized by general slowing of mental processes, personality changes, mood disorders, and abnormal movements. Examples of subcortical dementias include Binswanger’s disease, dementia associated with Huntington’s disease, AIDS, Parkinson’s disease, Wilson’s disease, and progressive supranuclear palsy. Despite ongoing debate, questions on this topic may appear in exams.

Understanding ROC Curves and AUC Values

ROC (receiver operating characteristic) curves are graphs used to evaluate the effectiveness of a test in distinguishing between two groups, such as those with and without a disease. The curve plots the true positive rate against the false positive rate at different threshold settings. The goal is to find the best trade-off between sensitivity and specificity, which can be adjusted by changing the threshold. AUC (area under the curve) is a measure of the overall performance of the test, with higher values indicating better accuracy. The conventional grading of AUC values ranges from excellent to fail. ROC curves and AUC values are useful in evaluating diagnostic and screening tools, comparing different tests, and studying inter-observer variability.

Drug Misuse (Law and Scheduling)

The Misuse of Drugs Act (1971) regulates the possession and supply of drugs, classifying them into three categories: A, B, and C. The maximum penalty for possession varies depending on the class of drug, with Class A drugs carrying a maximum sentence of 7 years.

The Misuse of Drugs Regulations 2001 further categorizes controlled drugs into five schedules. Schedule 1 drugs are considered to have no therapeutic value and cannot be lawfully possessed of prescribed, while Schedule 2 drugs are available for medical use but require a controlled drug prescription. Schedule 3, 4, and 5 drugs have varying levels of restrictions and requirements.

It is important to note that a single drug can have multiple scheduling statuses, depending on factors such as strength and route of administration. For example, morphine and codeine can be either Schedule 2 of Schedule 5.

Overall, the Misuse of Drugs Act and Regulations aim to regulate and control the use of drugs in the UK, with the goal of reducing drug misuse and related harm.

If someone ingests more than 75 mg/kg of paracetamol, serious toxicity can occur. This means that a 75 kg male would need to ingest approximately 5.5 g (equivalent to 11-12 tablets) for significant harm to occur. Immediate action is necessary in this case. If someone ingests more than 150 mg/kg, they require immediate treatment. In cases of staggered overdoses, IV acetylcysteine should be administered regardless of the plasma paracetamol level.

Self-Harm and its Management

Self-harm refers to intentional acts of self-poisoning of self-injury. It is prevalent among younger people, with an estimated 10% of girls and 3% of boys aged 15-16 years having self-harmed in the previous year. Risk factors for non-fatal repetition of self-harm include previous self-harm, personality disorder, hopelessness, history of psychiatric treatment, schizophrenia, alcohol abuse/dependence, and drug abuse/dependence. Suicide following an act of self-harm is more likely in those with previous episodes of self-harm, suicidal intent, poor physical health, and male gender.

Risk assessment tools are not recommended for predicting future suicide of repetition of self-harm. The recommended interventions for self-harm include 4-10 sessions of CBT specifically structured for people who self-harm and considering DBT for adolescents with significant emotional dysregulation. Drug treatment as a specific intervention to reduce self-harm should not be offered.

In the management of ingestion, activated charcoal can help if used early, while emetics and cathartics should not be used. Gastric lavage should generally not be used unless recommended by TOXBASE. Paracetamol is involved in 30-40% of acute presentations with poisoning. Intravenous acetylcysteine is the treatment of choice, and pseudo-allergic reactions are relatively common. Naloxone is used as an antidote for opioid overdose, while flumazenil can help reduce the need for admission to intensive care in benzodiazepine overdose.

For superficial uncomplicated skin lacerations of 5 cm of less in length, tissue adhesive of skin closure strips could be used as a first-line treatment option. All children who self-harm should be admitted for an overnight stay at a pediatric ward.

Obsessional Neurosis: A Term Coined by Freud for Obsessive Compulsive Disorder

Obsessional neurosis is a term coined by Sigmund Freud to describe what is now commonly known as obsessive compulsive disorder. This condition typically begins in early adulthood and is often observed in individuals with average of above-average intelligence.

Jungian analytical psychology involves the study of archetypes. Interpersonal therapy is used to identify interpersonal problems, while CBT focuses on identifying negative automatic thoughts. CAT, on the other hand, aims to identify reciprocal role procedures (RRP’s).

Understanding Cognitive Analytic Therapy

Cognitive Analytic Therapy (CAT) is a form of therapy that combines psychodynamic and cognitive approaches. It is a brief therapy that typically lasts between 16-24 sessions. Developed by Anthony Ryle, CAT aims to identify the useful parts of psychotherapy and make it more efficient. It also aims to create a therapy that can be easily researched.

CAT focuses on identifying key issues early on and conceptualizing them as repeated unsuccessful strategies. These strategies are categorized into traps, dilemmas, and snags. Traps are flawed thinking patterns that result in a vicious cycle of negative assumptions and actions. Dilemmas occur when a person believes their choices are restricted to opposite actions, neither of which is satisfactory. Snags are thinking patterns that restrict actions due to a perception of potential harm of failure.

CAT follows a procedural sequence model, where the problem is appraised, options are discussed, a plan is created and put into place, and consequences are evaluated. The therapist often summarizes the problem and plan in a letter to the client.

CAT also identifies reciprocal role procedures (RRPs), which are patterns observed in the way we related to others. These patterns are visually presented using a sequential diagrammatic reformulation. For example, a client who rebelled against a stern, dominating father may be dismissive of therapy because they see the therapist as a demanding authority figure.

Overall, CAT is a useful therapy that combines psychodynamic and cognitive approaches to identify and address maladaptive patterns. Its procedural sequence model and use of RRPs make it an efficient and effective therapy.

Suicide Risk in Epilepsy

Several studies have shown that individuals with epilepsy have an increased risk of suicide. A large study published in the Lancet in 2007 found that individuals with epilepsy were three times more likely to commit suicide compared to those without epilepsy. This risk remained high even after excluding those with a history of psychiatric disease and adjusting for socioeconomic factors.

The highest risk of suicide was found in individuals with epilepsy and comorbid psychiatric disease, with a risk of 13.7 times higher than controls. The risk of suicide was also highest during the first six months after diagnosis, especially in those with a history of comorbid psychiatric disease.

These findings highlight the importance of addressing mental health concerns in individuals with epilepsy, particularly during the early stages of diagnosis. Healthcare providers should be aware of the increased risk of suicide in this population and provide appropriate support and resources to prevent suicide.

Making a false positive conclusion by rejecting the null hypothesis.

Understanding Hypothesis Testing in Statistics

In statistics, it is not feasible to investigate hypotheses on entire populations. Therefore, researchers take samples and use them to make estimates about the population they are drawn from. However, this leads to uncertainty as there is no guarantee that the sample taken will be truly representative of the population, resulting in potential errors. Statistical hypothesis testing is the process used to determine if claims from samples to populations can be made and with what certainty.

The null hypothesis (Ho) is the claim that there is no real difference between two groups, while the alternative hypothesis (H1 of Ha) suggests that any difference is due to some non-random chance. The alternative hypothesis can be one-tailed of two-tailed, depending on whether it seeks to establish a difference of a change in one direction.

Two types of errors may occur when testing the null hypothesis: Type I and Type II errors. Type I error occurs when the null hypothesis is rejected when it is true, while Type II error occurs when the null hypothesis is accepted when it is false. The power of a study is the probability of correctly rejecting the null hypothesis when it is false, and it can be increased by increasing the sample size.

P-values provide information on statistical significance and help researchers decide if study results have occurred due to chance. The p-value is the probability of obtaining a result that is as large of larger when in reality there is no difference between two groups. The cutoff for the p-value is called the significance level (alpha level), typically set at 0.05. If the p-value is less than the cutoff, the null hypothesis is rejected, and if it is greater or equal to the cut off, the null hypothesis is not rejected. However, the p-value does not indicate clinical significance, which may be too small to be meaningful.

Eating Disorders: NICE Guidelines

Anorexia:
For adults with anorexia nervosa, consider individual eating-disorder-focused cognitive behavioural therapy (CBT-ED), Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), of specialist supportive clinical management (SSCM). If these are not acceptable, contraindicated, of ineffective, consider eating-disorder-focused focal psychodynamic therapy (FPT). For children and young people, consider anorexia-nervosa-focused family therapy (FT-AN) of individual CBT-ED. Do not offer medication as the sole treatment.

Bulimia:
For adults, the first step is an evidence-based self-help programme. If this is not effective, consider individual CBT-ED. For children and young people, offer bulimia-nervosa-focused family therapy (FT-BN) of individual CBT-ED. Do not offer medication as the sole treatment.

Binge Eating Disorder:
The first step is a guided self-help programme. If this is not effective, offer group of individual CBT-ED. For children and young people, offer the same treatments recommended for adults. Do not offer medication as the sole treatment.

Advice for those with eating disorders:
Encourage people with an eating disorder who are vomiting to avoid brushing teeth immediately after vomiting, rinse with non-acid mouthwash, and avoid highly acidic foods and drinks. Advise against misusing laxatives of diuretics and excessive exercise.

Additional points:
Do not offer physical therapy as part of treatment. Consider bone mineral density scans after 1 year of underweight in children and young people, of 2 years in adults. Do not routinely offer oral of transdermal oestrogen therapy to treat low bone mineral density in children of young people with anorexia nervosa. Consider transdermal 17-β-estradiol of bisphosphonates for women with anorexia nervosa.

Note: These guidelines are taken from NICE guidelines 2017.

Individuals who smoked cannabis regularly at the age of 15 have a 4.5 times higher risk of developing schizophrenia at the age of 26, whereas those who did not report regular use until the age of 18 have a 1.65 times higher risk.

Schizophrenia and Cannabis Use

The relationship between cannabis use and the risk of developing schizophrenia is a topic of ongoing debate. However, research suggests that cannabis use may increase the risk of later schizophrenia of schizophreniform disorder by two-fold (Arseneault, 2004). The risk of developing schizophrenia appears to be higher in individuals who start using cannabis at a younger age. For instance, regular cannabis smokers at the age of 15 are 4.5 times more likely to develop schizophrenia at the age of 26, compared to those who did not report regular use until age 18 (Murray, 2004).

A systematic review published in the Lancet in 2007 found that the lifetime risk of developing psychosis increased by 40% in individuals who had ever used cannabis (Moore, 2007). Another meta-analysis reported that the age at onset of psychosis was 2.70 years younger in cannabis users than in non-users (Large, 2011). These findings suggest that cannabis use may have a significant impact on the development of schizophrenia and related disorders.

Flupentixol as an Antidepressant

Flupentixol is a conventional antipsychotic medication that works by strongly blocking D1 and D2 receptors, as well as having some weak antagonistic effects on 5-HT2A receptors. It is commonly used as an antidepressant at doses ranging from 0.5 to 3 mg per day. The British National Formulary (BNF) has approved flupentixol for the treatment of depression. In the 13th edition of the Maudsley Prescribing Guidelines, intramuscular flupentixol is recommended as an alternative route of administration for patients who are unable of unwilling to take oral antidepressants.

Parkinson’s Disease: Presentation, Aetiology, Medical Treatment, and Psychiatric Aspects

Parkinson’s disease is a degenerative disease of the brain that is characterised by motor symptoms such as rigidity, bradykinesia, and tremor. It has a long prodromal phase and early symptoms generally present asymmetrically. The tremor associated with Parkinson’s disease is classically described as ‘pill rolling’. The principle abnormality is the degeneration of dopaminergic neurons in the pars compacta of the substantia nigra, which leads to an accumulation of alpha-synuclein in these abnormal dopaminergic cells. The majority of cases of Parkinson’s disease are idiopathic, but single gene mutations occur in a minority of cases. Pesticide, herbicide, and heavy metal exposures are linked to an increased risk of Parkinson’s disease in some epidemiologic studies, whereas smoking and caffeine use are associated with decreased risks.

Treatment for Parkinson’s disease predominantly focuses on symptomatic relief with drugs aiming to either restore the level of dopamine in the striatum of to act on striatal postsynaptic dopamine receptors. However, as dopamine is not the only neurotransmitter involved in Parkinson’s disease, many other drugs are also being used to target specific symptoms, such as depression of dementia. Psychiatric symptoms are common in Parkinson’s disease and range from mild to severe. Factors associated with severe symptoms include age, sleep disturbance, dementia, and disease severity. Hallucinations are common in Parkinson’s disease and tend to be visual but can be auditory of tactile. In the majority of patients, psychotic symptoms are thought to be secondary to dopaminergic medication rather than due to the Parkinson’s disease itself. Anticholinergics and dopamine agonists seem to be associated with a higher risk of inducing psychosis than levodopa of catechol-O-methyltransferase inhibitors. Medications used for psychotic symptoms may worsen movement problems. Risperidone and the typicals should be avoided completely. Low dose quetiapine is the best tolerated. Clozapine is the most effective antipsychotic drug for treating psychosis in Parkinson’s disease but its use in clinical practice is limited by the need for monitoring and the additional physical risks.

Tolerance in Opiate Abuse

Tolerance is a common phenomenon that occurs in opiate abuse. It develops regarding the analgesic, euphoric, sedative, respiratory depressant, and nauseating effects of opioids. However, it does not develop to their effects on miosis and bowel motility, which can cause constipation. This means that individuals who abuse opioids may require higher doses to achieve the desired effects, leading to an increased risk of overdose and other adverse effects. Understanding the mechanisms involved in tolerance can help in developing effective interventions to prevent and treat opiate abuse.

The most prevalent method of suicide in prisons across the country is hanging of self-strangulation. As a result, the prison service places a high priority on eliminating ligature points. For more information on this topic, refer to the National Clinical Survey on Suicide by Prisoners conducted by Shaw et al. in 2004, which can be found in the British Journal of Psychiatry.

Anorexia is a serious mental health condition that can have severe physical complications. These complications can affect various systems in the body, including the cardiac, skeletal, hematologic, reproductive, metabolic, gastrointestinal, CNS, and dermatological systems. Some of the recognized physical complications of anorexia nervosa include bradycardia, hypotension, osteoporosis, anemia, amenorrhea, hypothyroidism, delayed gastric emptying, cerebral atrophy, and lanugo.

The Royal College of Psychiatrists has issued advice on managing sick patients with anorexia nervosa, recommending hospital admission for those with high-risk items. These items include a BMI of less than 13, a pulse rate of less than 40 bpm, a SUSS test score of less than 2, a sodium level of less than 130 mmol/L, a potassium level of less than 3 mmol/L, a serum glucose level of less than 3 mmol/L, and a QTc interval of more than 450 ms. The SUSS test involves assessing the patient’s ability to sit up and squat without using their hands. A rating of 0 indicates complete inability to rise, while a rating of 3 indicates the ability to rise without difficulty. Proper management and treatment of anorexia nervosa are crucial to prevent of manage these physical complications.

Disruptive Behaviour of Dissocial Disorders

Conduct disorders are the most common reason for referral of young children to mental health services. These disorders are characterized by a repetitive and persistent pattern of antisocial, aggressive, of defiant conduct that goes beyond ordinary childish mischief of adolescent rebelliousness. Oppositional defiant disorder (ODD) shares some negative attributes but in a more limited fashion.

ICD-11 terms the disorder as ‘Conduct-dissocial disorder’, while DSM-5 recognizes three separate conditions related to emotional/behavioral problems seen in younger people: conduct disorder, oppositional defiant disorder, and intermittent explosive disorder. Conduct disorder is about poorly controlled behavior, intermittent explosive disorder is about poorly controlled emotions, and ODD is in between. Conduct disorders are further divided into childhood onset (before 10 years) and adolescent onset (10 years of older).

The behavior pattern of conduct disorders must be persistent and recurrent, including multiple incidents of aggression towards people of animals, destruction of property, deceitfulness of theft, and serious violations of rules. The pattern of behavior must result in significant impairment in personal, family, social, educational, occupational, of other important areas of functioning.

Oppositional defiant disorder represents a less severe form of conduct disorder, where there is an absence of more severe dissocial of aggressive acts. The behavior pattern of ODD includes persistent difficulty getting along with others, provocative, spiteful, of vindictive behavior, and extreme irritability of anger.

The prevalence of conduct disorders increases throughout childhood and is more common in boys than girls. The most frequent comorbid problem seen with conduct disorder is hyperactivity. The conversion rate from childhood conduct disorder to adult antisocial personality disorder varies from 40 to 70% depending on the study.

NICE recommends group parent-based training programs of parent and child training programs for children with complex needs for ages 3-11, child-focused programs for ages 9-14, and multimodal interventions with a family focus for ages 11-17. Medication is not recommended in routine practice, but risperidone can be used where other approaches fail and they are seriously aggressive.

Lithium – Clinical Usage

Lithium is primarily used as a prophylactic agent for bipolar disorder, where it reduces the severity and number of relapses. It is also effective as an augmentation agent in unipolar depression and for treating aggressive and self-mutilating behavior, steroid-induced psychosis, and to raise WCC in people using clozapine.

Before prescribing lithium, renal, cardiac, and thyroid function should be checked, along with a Full Blood Count (FBC) and BMI. Women of childbearing age should be advised regarding contraception, and information about toxicity should be provided.

Once daily administration is preferred, and various preparations are available. Abrupt discontinuation of lithium increases the risk of relapse, and if lithium is to be discontinued, the dose should be reduced gradually over a period of at least 4 weeks.

Inadequate monitoring of patients taking lithium is common, and it is often an exam hot topic. Lithium salts have a narrow therapeutic/toxic ratio, and samples should ideally be taken 12 hours after the dose. The target range for prophylaxis is 0.6–0.75 mmol/L.

Risk factors for lithium toxicity include drugs altering renal function, decreased circulating volume, infections, fever, decreased oral intake of water, renal insufficiency, and nephrogenic diabetes insipidus. Features of lithium toxicity include GI and neuro symptoms.

The severity of toxicity can be assessed using the AMDISEN rating scale.

Interpersonal Therapy: A Structured Approach to Addressing Social Functioning Problems

Interpersonal therapy (IPT) is a structured form of psychotherapy that is often used to treat depression. It is based on the belief that social functioning problems have a significant impact on psychological problems. IPT is a time-limited therapy that typically runs for 10-16 one hour sessions. The therapy is organized into three phases, with the first phase involving data collection and formulation. The remaining sessions explore the formulation in more detail.

IPT focuses on four areas of social functioning problems: grief, role transitions, interpersonal deficits, and interpersonal disputes. The therapy aims to intervene at the level of social functioning, rather than focusing on personality. The therapy has been found to be effective in treating depression, particularly in patients with severe depression. However, it may be less effective in treating people with depression and comorbid personality disorders.

The evidence base for IPT is most developed for eating disorders, and the intervention is recommended in NICE guidelines for eating disorders. Overall, IPT is a structured approach to addressing social functioning problems that can be effective in treating depression and other psychological problems.

According to NICE 2018 guidelines, the recommended treatment options for PTSD are either SSRI of venlafaxine.

Stress disorders, such as Post Traumatic Stress Disorder (PTSD), are emotional reactions to traumatic events. The diagnosis of PTSD requires exposure to an extremely threatening of horrific event, followed by the development of a characteristic syndrome lasting for at least several weeks, consisting of re-experiencing the traumatic event, deliberate avoidance of reminders likely to produce re-experiencing, and persistent perceptions of heightened current threat. Additional clinical features may include general dysphoria, dissociative symptoms, somatic complaints, suicidal ideation and behaviour, social withdrawal, excessive alcohol of drug use, anxiety symptoms, and obsessions of compulsions. The emotional experience of individuals with PTSD commonly includes anger, shame, sadness, humiliation, of guilt. The onset of PTSD symptoms can occur at any time during the lifespan following exposure to a traumatic event, and the symptoms and course of PTSD can vary significantly over time and individuals. Key differentials include acute stress reaction, adjustment disorder, and complex PTSD. Management of PTSD includes trauma-focused cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and supported trauma-focused computerized CBT interventions. Drug treatments, including benzodiazepines, are not recommended for the prevention of treatment of PTSD in adults, but venlafaxine of a selective serotonin reuptake inhibitor (SSRI) may be considered for adults with a diagnosis of PTSD if the person has a preference for drug treatment. Antipsychotics such as risperidone may be considered in addition if disabling symptoms and behaviors are present and have not responded to other treatments. Psychological debriefing is not recommended for the prevention of treatment of PTSD. For children and young people, individual trauma-focused CBT interventions of EMDR may be considered, but drug treatments are not recommended.

Flooding as a Treatment for Phobias

Flooding is a treatment method for phobias that involves directly confronting the fear and remaining in the situation until the anxiety subsides. This process is called habituation and is different from systematic desensitization. However, flooding can be challenging for patients as it produces high levels of anxiety, which can cause them to leave the situation before the fear response is extinguished. As a result, desensitization is generally preferred over flooding as a treatment method for phobias.

Narcissistic personality disorder typically involves a very delicate sense of self-esteem.

Personality Disorder (Narcissistic)

Narcissistic personality disorder is a mental illness characterized by individuals having an exaggerated sense of their own importance, an intense need for excessive attention and admiration, troubled relationships, and a lack of empathy towards others. The DSM-5 diagnostic manual outlines the criteria for this disorder, which includes a pervasive pattern of grandiosity, a need for admiration, and a lack of empathy. To be diagnosed with this disorder, an individual must exhibit at least five of the following traits: a grandiose sense of self-importance, preoccupation with fantasies of unlimited success, belief in being special and unique, excessive admiration requirements, a sense of entitlement, interpersonal exploitation, lack of empathy, envy towards others, and arrogant of haughty behaviors. While the previous version of the ICD included narcissistic personality disorder, the ICD-11 does not have a specific reference to this condition, but it can be coded under the category of general personality disorder.

Epidemiology of Mental Health Disorders in Children and Adolescents

The Department of Health (DoH) survey titled The Mental Health of Children and Young People in England is the primary source of epidemiological data on children and adolescents aged 2-19. The latest survey was conducted in 2017 and involved over 9000 participants. The data was collected through interviews with the child, their parent, and their teacher (if school-aged).

The survey found that 1 in 8 children aged 5-19 had a mental disorder, with emotional disorders being the most common, followed by behavioural, hyperactivity, and other disorders such as ASD, eating disorders, and tic disorders. The prevalence of mental disorders has slightly increased over recent decades, with a rise in emotional problems since 2004.

Rates of mental disorders tend to be higher in older age groups, but there is some inconsistency with behavioural and hyperactivity types. For preschool children, 1 in 18 had at least one mental disorder, while for primary school children, 1 in 10 had at least one mental disorder, with behavioural and emotional disorders being the most common. Rates of emotional disorders were similar in boys and girls, while other types of disorders were more common in boys.

For secondary school children, 1 in 7 had at least one mental disorder, with emotional disorders being the most common. Among those aged 17-19, 1 in 6 had at least one mental disorder, with emotional disorders being the most common, mainly anxiety. Girls aged 17-19 had the highest likelihood of having a mental disorder, with nearly one in four having a mental disorder and 22.4% having an emotional disorder.

In summary, the epidemiology of mental health disorders in children and adolescents in England highlights the need for early intervention and support for emotional and behavioural problems, particularly in older age groups and among girls.

Maudsley Guidelines: Antipsychotics for Postural Hypotension

When postural hypotension is a concern, it may be necessary to switch to an antipsychotic that is less likely to cause this side effect. The following antipsychotics are recommended by the Maudsley Guidelines:

– Amisulpride
– Aripiprazole
– Haloperidol
– Sulpiride
– Trifluoperazine

These medications have a lower risk of causing postural hypotension compared to other antipsychotics such as risperidone, clozapine, olanzapine, paliperidone, quetiapine, and ziprasidone. It is important to discuss any concerns about side effects with a healthcare provider before making any changes to medication.

Eating Disorders: Lab Findings and Medical Complications

Eating disorders can lead to a range of medical complications, including renal failure, peripheral edema, sinus bradycardia, QT-prolongation, pericardial effusion, and slowed GI motility. Other complications include constipation, cathartic colon, esophageal esophagitis, hair loss, and dental erosion. Blood abnormalities are also common in patients with eating disorders, including hyponatremia, hypokalemia, hypophosphatemia, and hypoglycemia. Additionally, patients may experience leucopenia, anemia, low albumin, elevated liver enzymes, and vitamin deficiencies. These complications can cause significant morbidity and mortality in patients with eating disorders. It is important for healthcare providers to monitor patients for these complications and provide appropriate treatment.

Infection may be indicated by low serum albumin levels, as the body shifts its production from albumin to acute phase proteins. It is important to note that normal albumin levels should not be relied upon as a marker of nutritional status, as patients with anorexia may still have normal levels despite electrolyte imbalances. Additionally, eGFR may overestimate renal function in these patients due to low muscle mass. Binge-purge anorexia carries a higher risk of electrolyte disturbance, particularly hypokalaemia and hypomagnesaemia, due to induced vomiting and subsequent loss of hydrogen ions and potassium in the urine.

Anorexia is a serious mental health condition that can have severe physical complications. These complications can affect various systems in the body, including the cardiac, skeletal, hematologic, reproductive, metabolic, gastrointestinal, CNS, and dermatological systems. Some of the recognized physical complications of anorexia nervosa include bradycardia, hypotension, osteoporosis, anemia, amenorrhea, hypothyroidism, delayed gastric emptying, cerebral atrophy, and lanugo.

The Royal College of Psychiatrists has issued advice on managing sick patients with anorexia nervosa, recommending hospital admission for those with high-risk items. These items include a BMI of less than 13, a pulse rate of less than 40 bpm, a SUSS test score of less than 2, a sodium level of less than 130 mmol/L, a potassium level of less than 3 mmol/L, a serum glucose level of less than 3 mmol/L, and a QTc interval of more than 450 ms. The SUSS test involves assessing the patient’s ability to sit up and squat without using their hands. A rating of 0 indicates complete inability to rise, while a rating of 3 indicates the ability to rise without difficulty. Proper management and treatment of anorexia nervosa are crucial to prevent of manage these physical complications.

Likert scales are a type of ordinal scale used in surveys to measure attitudes of opinions. Respondents are presented with a series of statements of questions and asked to rate their level of agreement of frequency of occurrence on a scale of options. For instance, a Likert scale question might ask how often someone prays, with response options ranging from never to daily. While the responses are ordered in terms of frequency, the intervals between each option are not necessarily equal of quantifiable. Therefore, Likert scales are considered ordinal rather than interval scales.

Scales of Measurement in Statistics

In the 1940s, Stanley Smith Stevens introduced four scales of measurement to categorize data variables. Knowing the scale of measurement for a variable is crucial in selecting the appropriate statistical analysis. The four scales of measurement are ratio, interval, ordinal, and nominal.

Ratio scales are similar to interval scales, but they have true zero points. Examples of ratio scales include weight, time, and length. Interval scales measure the difference between two values, and one unit on the scale represents the same magnitude on the trait of characteristic being measured across the whole range of the scale. The Fahrenheit scale for temperature is an example of an interval scale.

Ordinal scales categorize observed values into set categories that can be ordered, but the intervals between each value are uncertain. Examples of ordinal scales include social class, education level, and income level. Nominal scales categorize observed values into set categories that have no particular order of hierarchy. Examples of nominal scales include genotype, blood type, and political party.

Data can also be categorized as quantitative of qualitative. Quantitative variables take on numeric values and can be further classified into discrete and continuous types. Qualitative variables do not take on numerical values and are usually names. Some qualitative variables have an inherent order in their categories and are described as ordinal. Qualitative variables are also called categorical of nominal variables. When a qualitative variable has only two categories, it is called a binary variable.

Maudsley Guidelines

First choice: SSRI of clomipramine (SSRI preferred due to tolerability issues with clomipramine)

Second line:

– SSRI + antipsychotic
– Citalopram + clomipramine
– Acetylcysteine + (SSRI of clomipramine)
– Lamotrigine + SSRI
– Topiramate + SSRI

The likelihood of developing PTSD is greater for females. Additionally, experiencing significant distress and dissociation during the initial traumatic event are also linked to the development of PTSD.

Stress disorders, such as Post Traumatic Stress Disorder (PTSD), are emotional reactions to traumatic events. The diagnosis of PTSD requires exposure to an extremely threatening of horrific event, followed by the development of a characteristic syndrome lasting for at least several weeks, consisting of re-experiencing the traumatic event, deliberate avoidance of reminders likely to produce re-experiencing, and persistent perceptions of heightened current threat. Additional clinical features may include general dysphoria, dissociative symptoms, somatic complaints, suicidal ideation and behaviour, social withdrawal, excessive alcohol of drug use, anxiety symptoms, and obsessions of compulsions. The emotional experience of individuals with PTSD commonly includes anger, shame, sadness, humiliation, of guilt. The onset of PTSD symptoms can occur at any time during the lifespan following exposure to a traumatic event, and the symptoms and course of PTSD can vary significantly over time and individuals. Key differentials include acute stress reaction, adjustment disorder, and complex PTSD. Management of PTSD includes trauma-focused cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and supported trauma-focused computerized CBT interventions. Drug treatments, including benzodiazepines, are not recommended for the prevention of treatment of PTSD in adults, but venlafaxine of a selective serotonin reuptake inhibitor (SSRI) may be considered for adults with a diagnosis of PTSD if the person has a preference for drug treatment. Antipsychotics such as risperidone may be considered in addition if disabling symptoms and behaviors are present and have not responded to other treatments. Psychological debriefing is not recommended for the prevention of treatment of PTSD. For children and young people, individual trauma-focused CBT interventions of EMDR may be considered, but drug treatments are not recommended.

The EAT, of Eating Attitudes Test, is a commonly used screening tool for diagnosing eating disorders. It is a self-rated test that evaluates attitudes towards food and eating. The test has been extensively studied and has been found to have good psychometric properties. For more information, see Garner et al.’s 1982 article in Psychol Med of visit the EAT-26 website.

The use of medical treatment for osteoporosis in individuals with anorexia is not advisable. Additionally, administering oestrogen as a solution for bone density issues in children should not be a standard practice. While there are no specific medications recommended for anorexia, they may be useful in addressing concurrent conditions like depression.

Eating Disorders: NICE Guidelines

Anorexia:
For adults with anorexia nervosa, consider individual eating-disorder-focused cognitive behavioural therapy (CBT-ED), Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), of specialist supportive clinical management (SSCM). If these are not acceptable, contraindicated, of ineffective, consider eating-disorder-focused focal psychodynamic therapy (FPT). For children and young people, consider anorexia-nervosa-focused family therapy (FT-AN) of individual CBT-ED. Do not offer medication as the sole treatment.

Bulimia:
For adults, the first step is an evidence-based self-help programme. If this is not effective, consider individual CBT-ED. For children and young people, offer bulimia-nervosa-focused family therapy (FT-BN) of individual CBT-ED. Do not offer medication as the sole treatment.

Binge Eating Disorder:
The first step is a guided self-help programme. If this is not effective, offer group of individual CBT-ED. For children and young people, offer the same treatments recommended for adults. Do not offer medication as the sole treatment.

Advice for those with eating disorders:
Encourage people with an eating disorder who are vomiting to avoid brushing teeth immediately after vomiting, rinse with non-acid mouthwash, and avoid highly acidic foods and drinks. Advise against misusing laxatives of diuretics and excessive exercise.

Additional points:
Do not offer physical therapy as part of treatment. Consider bone mineral density scans after 1 year of underweight in children and young people, of 2 years in adults. Do not routinely offer oral of transdermal oestrogen therapy to treat low bone mineral density in children of young people with anorexia nervosa. Consider transdermal 17-β-estradiol of bisphosphonates for women with anorexia nervosa.

Note: These guidelines are taken from NICE guidelines 2017.

According to NICE, it is recommended to gradually decrease the dose of lithium over a period of at least 4 weeks, and ideally up to 3 months, when discontinuing it, even if the individual has begun taking another antimanic medication.

Bipolar Disorder: Diagnosis and Management

Bipolar disorder is a lifelong condition characterized by episodes of mania or hypomania and episodes of depressed mood. The peak age of onset is 15-19 years, and the lifetime prevalence of bipolar I disorders is estimated to be around 2.1%. The diagnosis of bipolar disorder is based on the presence of manic or hypomanic episodes, which are characterized by elevated of expansive mood, rapid speech, and increased activity of energy. Psychotic symptoms, such as delusions and hallucinations, may also be present.

Bipolar depression differs from unipolar depression in several ways, including more rapid onset, more frequent episodes, and shorter duration. Rapid cycling is a qualifier that can be applied to bipolar I of bipolar II disorder and is defined as the presence of at least four mood episodes in the previous 12 months that meet the criteria for a manic, hypomanic, of major depressive episode.

The management of bipolar disorder involves acute and long-term interventions. Acute management of mania or hypomania may involve stopping antidepressants and offering antipsychotics of mood stabilizers. Long-term management may involve psychological interventions and pharmacological treatments such as lithium, valproate, of olanzapine.

It is important to note that valproate should not be offered to women of girls of childbearing potential for long-term bipolar disorder unless other options are ineffective of not tolerated and a pregnancy prevention program is in place. Aripiprazole is recommended as an option for treating moderate to severe manic episodes in adolescents with bipolar I disorder.

Overall, the diagnosis and management of bipolar disorder require a comprehensive approach that takes into account the individual’s symptoms, history, and preferences.

In the case of a child with nocturnal enuresis who has already tried lifestyle measures and a reward chart without success, the next step in treatment would be to consider either prescribing desmopressin of trying an enuresis alarm. However, as the child is under 7 years old, the current first-line treatment would be to try an enuresis alarm before considering other options. Therefore, the best course of action in this scenario would be to try an enuresis alarm.

Elimination Disorders

Elimination disorders refer to conditions that affect a child’s ability to control their bladder of bowel movements. Enuresis, of lack of control over the bladder, typically occurs between the ages of 1-3, while control over the bowel usually occurs before that of the bladder for most toddlers. Toilet training can be influenced by various factors, including intellectual capacity, cultural determinants, and psychological interactions between the child and their parents.

Enuresis is characterized by involuntary voiding of urine, by day and/of by night, which is abnormal in relation to the individual’s age and is not a result of any physical abnormality. It is not normally diagnosed before age 5 and may be primary (the child never having achieved continence) of secondary. Treatment options include reassurance, enuresis alarms, and medication.

Encopresis refers to repeated stool evacuation in inappropriate places in children over the age of four. The behavior can be either involuntary of intentional and may be due to unsuccessful toilet training (primary encopresis) of occur after a period of normal bowel control (secondary encopresis). Treatment generally involves bowel clearance, prevention of impaction, and behavioral therapy.

Before a diagnosis of encopresis is made, organic causes must be excluded. Hirschsprung’s disease is a condition that results from an absence of parasympathetic ganglion cells in the rectum, colon, and sometimes the small intestine. It leads to a colonic obstruction and is diagnosed in at least half of all cases in the first year of life. It is twice as common in boys than in girls.

The Maudsley Guidelines recommend trying Donepezil. Melatonin is only recommended for sleep disturbances, while Diazepam, Amitriptyline, and Valproate are not recommended.

Management of Non-Cognitive Symptoms in Dementia

Non-cognitive symptoms of dementia can include agitation, aggression, distress, psychosis, depression, anxiety, sleep problems, wandering, hoarding, sexual disinhibition, apathy, and shouting. Non-pharmacological measures, such as music therapy, should be considered before prescribing medication. Pain may cause agitation, so a trial of analgesics is recommended. Antipsychotics, such as risperidone, olanzapine, and aripiprazole, may be used for severe distress of serious risk to others, but their use is controversial due to issues of tolerability and an association with increased mortality. Cognitive enhancers, such as AChE-Is and memantine, may have a modest benefit on BPSD, but their effects may take 3-6 months to take effect. Benzodiazepines should be avoided except in emergencies, and antidepressants, such as citalopram and trazodone, may have mixed evidence for BPSD. Mood stabilizers, such as valproate and carbamazepine, have limited evidence to support their use. Sedating antihistamines, such as promethazine, may cause cognitive impairment and should only be used short-term. Melatonin has limited evidence to support its use but is safe to use and may be justified in some cases where benefits are seen. For Lewy Body dementia, clozapine is favored over risperidone, and quetiapine may be a reasonable choice if clozapine is not appropriate. Overall, medication should only be used when non-pharmacological measures are ineffective, and the need is balanced with the increased risk of adverse effects.

Based on the information provided, the most likely diagnosis is bulimia nervosa. Anorexia nervosa is not applicable as the individual’s BMI is not significantly low (less than 18.5). Binge eating disorder is also not applicable as the individual engages in compensatory behaviors such as induced vomiting. It is important to note that binge eating episodes can be either objective of subjective, but the key feature is the loss of control overeating.

Eating disorders are a serious mental health condition that can have severe physical and psychological consequences. The ICD-11 lists several types of eating disorders, including Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, Avoidant-Restrictive Food Intake Disorder, Pica, and Rumination-Regurgitation Disorder.

Anorexia Nervosa is characterized by significantly low body weight, a persistent pattern of restrictive eating of other behaviors aimed at maintaining low body weight, excessive preoccupation with body weight of shape, and marked distress of impairment in functioning. Bulimia Nervosa involves frequent episodes of binge eating followed by inappropriate compensatory behaviors to prevent weight gain, excessive preoccupation with body weight of shape, and marked distress of impairment in functioning. Binge Eating Disorder is characterized by frequent episodes of binge eating without compensatory behaviors, marked distress of impairment in functioning, and is more common in overweight and obese individuals. Avoidant-Restrictive Food Intake Disorder involves avoidance of restriction of food intake that results in significant weight loss of impairment in functioning, but is not motivated by preoccupation with body weight of shape. Pica involves the regular consumption of non-nutritive substances, while Rumination-Regurgitation Disorder involves intentional and repeated regurgitation of previously swallowed food.

It is important to seek professional help if you of someone you know is struggling with an eating disorder. Treatment may involve a combination of therapy, medication, and nutritional counseling.

Dementia: Types and Clinical Characteristics

Dementia is a progressive impairment of cognitive functions occurring in clear consciousness. There are over 100 different causes of dementia, and a detailed knowledge is required for the more common types. The following are some of the subtypes of dementia, along with their early features, neuropathology, and proportion:

– Alzheimer’s disease: Impaired memory, apathy, and depression; gradual onset; cortical amyloid plaques and neurofibrillary tangles; 50-75% proportion.
– Vascular dementia: Similar to AD, but memory less affected, and mood fluctuations more prominent; physical frailty; stepwise onset; cerebrovascular disease; single infarcts in critical regions, of more diffuse multi-infarct disease; 20-30% proportion.
– Frontotemporal dementia: Personality changes, mood changes, disinhibition, language difficulties; no single pathology – damage limited to frontal and temporal lobes; 5-10% proportion.
– Dementia with Lewy Bodies: Marked fluctuation in cognitive ability, visual hallucinations, Parkinsonism (tremor and rigidity); cortical Lewy bodies (alpha-synuclein); <5% proportion. Other types of dementia include Pick’s disease, Huntington’s disease, pseudodementia, and progressive supranuclear palsy. Each subtype has its own unique clinical characteristics and neuropathology. It is important to accurately diagnose the type of dementia in order to provide appropriate treatment and care.

Pellagra (niacin deficiency) is associated with diarrhea instead of constipation.

Pellagra: A Vitamin B3 Deficiency Disease

Pellagra is a disease caused by a lack of vitamin B3 (niacin) in the body. The name pellagra comes from the Italian words pelle agra, which means rough of sour skin. This disease is common in developing countries where corn is a major food source, of during prolonged disasters like famine of war. In developed countries, pellagra is rare because many foods are fortified with niacin. However, alcoholism is a common cause of pellagra in developed countries. Alcohol dependence can worsen pellagra by causing malnutrition, gastrointestinal problems, and B vitamin deficiencies. It can also inhibit the conversion of tryptophan to niacin and promote the accumulation of 5-ALA and porphyrins.

Pellagra affects a wide range of organs and tissues in the body, so its symptoms can vary. The classic symptoms of pellagra are known as the three Ds: diarrhea, dermatitis, and dementia. Niacin deficiency can cause dementia, depression, mania, and psychosis, which is called pellagra psychosis. The most noticeable symptom of pellagra is dermatitis, which is a hyperpigmented rash that appears on sun-exposed areas of the skin. This rash is usually symmetrical and bilateral, and it is often described as Casal’s necklace when it appears on the neck.

Case-control studies are useful in studying rare diseases as it would be impractical to follow a large group of people for a long period of time to accrue enough incident cases. For instance, if a disease occurs very infrequently, say 1 in 1,000,000 per year, it would require following 1,000,000 people for ten years of 1000 people for 1000 years to accrue ten total cases. However, this is not feasible. Therefore, a case-control study provides a more practical approach to studying rare diseases.

Types of Primary Research Studies and Their Advantages and Disadvantages

Primary research studies can be categorized into six types based on the research question they aim to address. The best type of study for each question type is listed in the table below. There are two main types of study design: experimental and observational. Experimental studies involve an intervention, while observational studies do not. The advantages and disadvantages of each study type are summarized in the table below.

Type of Question Best Type of Study

Therapy Randomized controlled trial (RCT), cohort, case control, case series
Diagnosis Cohort studies with comparison to gold standard test
Prognosis Cohort studies, case control, case series
Etiology/Harm RCT, cohort studies, case control, case series
Prevention RCT, cohort studies, case control, case series
Cost Economic analysis

Study Type Advantages Disadvantages

Randomized Controlled Trial – Unbiased distribution of confounders – Blinding more likely – Randomization facilitates statistical analysis – Expensive – Time-consuming – Volunteer bias – Ethically problematic at times
Cohort Study – Ethically safe – Subjects can be matched – Can establish timing and directionality of events – Eligibility criteria and outcome assessments can be standardized – Administratively easier and cheaper than RCT – Controls may be difficult to identify – Exposure may be linked to a hidden confounder – Blinding is difficult – Randomization not present – For rare disease, large sample sizes of long follow-up necessary
Case-Control Study – Quick and cheap – Only feasible method for very rare disorders of those with long lag between exposure and outcome – Fewer subjects needed than cross-sectional studies – Reliance on recall of records to determine exposure status – Confounders – Selection of control groups is difficult – Potential bias: recall, selection
Cross-Sectional Survey – Cheap and simple – Ethically safe – Establishes association at most, not causality – Recall bias susceptibility – Confounders may be unequally distributed – Neyman bias – Group sizes may be unequal
Ecological Study – Cheap and simple – Ethically safe – Ecological fallacy (when relationships which exist for groups are assumed to also be true for individuals)

In conclusion, the choice of study type depends on the research question being addressed. Each study type has its own advantages and disadvantages, and researchers should carefully consider these when designing their studies.

Intellectual disability is estimated to affect around 1-3% of the overall population, with Down syndrome being the most prevalent cause. Fragile X is believed to occur in about 1 out of every 3600 males and 1 out of every 4000-6000 females.

Classification of Intellectual Disability

Intellectual disability affects approximately 2% of the general population, with an estimated 828,000 adults aged 18 of older affected in England alone. Those with an IQ below 70 are considered to have an intellectual disability, with the average IQ being 100. The severity of intellectual disability is categorized based on IQ scores, with mild intellectual disability being the most common (85% of cases) and profound intellectual disability being the least common (1-2% of cases). People with intellectual disability may require varying levels of support in their daily lives, depending on their individual needs. It is important to use the preferred term ‘people with intellectual disability’ when referring to individuals with this condition.

According to current evidence, there is no connection between autism spectrum disorder (ASD) risk and various environmental factors such as vaccination, maternal smoking, thimerosal exposure, and assisted reproductive technologies (Modabbernia, 2017).

Autism Spectrum Disorder (ASD) is a lifelong disorder characterized by deficits in communication and social understanding, as well as restrictive and repetitive behaviors. The distinction between autism and Asperger’s has been abandoned, and they are now grouped together under the ASD category. Intellectual ability is difficult to assess in people with ASD, with an estimated 33% having an intellectual disability. ASD was first described in Europe and the United States using different terms, with Leo Kanner and Hans Asperger being the pioneers. Diagnosis is based on persistent deficits in social communication and social interaction, as well as restricted, repetitive patterns of behavior. The worldwide population prevalence is about 1%, with comorbidity being common. Heritability is estimated at around 90%, and both genetic and environmental factors seem to cause ASD. Currently, there are no validated pharmacological treatments that alleviate core ASD symptoms, but second-generation antipsychotics are the first-line pharmacological treatment for children and adolescents with ASD and associated irritability.

If we consider the above example as 60 separate experiments, we would anticipate that 3 variables would show a connection purely by chance. This is because a p-value of 0.05 indicates that there is a 5% chance of obtaining the observed result by chance, of 1 in every 20 times. Therefore, if we multiply 1 in 20 by 60, we get 3, which is the expected number of variables that would show an association by chance alone.

Institutional Racism in Psychiatry

There has been growing concern that institutional racism may be contributing to the overrepresentation of Black patients in mental health settings. Despite ethnic minorities making up only 9% of the UK population, the 2010 ‘Count me in Census’ found that 23% of inpatients and those on CTOs were from Black and minority ethnic groups. Black minority groups also had higher rates of admission, detention, and seclusion.

While patient factors, such as higher rates of mental illness in Black minority groups, may contribute to these findings, there is also a suggestion of inherent racism within psychiatry. This may manifest in perceptions of Black and minority ethnic patients being at greater risk, as well as systemic factors that disadvantage these groups.

It is important to address these issues and work towards a more equitable and just mental health system for all patients, regardless of their ethnicity.

The majority of Down syndrome cases are not passed down through inheritance. Trisomy 21, which causes the condition, typically occurs randomly during nondisjunction. Mosaic Down syndrome also arises randomly during early fetal development. However, Translocation Down syndrome can be inherited. A person without the condition may carry a balanced translocation, which involves a rearrangement of genetic material between chromosome 21 and another chromosome. This type of translocation does not result in extra material from chromosome 21, and carriers do not exhibit Down syndrome symptoms. Nevertheless, they have a higher likelihood of having children with the condition.

Down Syndrome: Causes and Risk Factors

Down syndrome is a genetic disorder caused by the presence of extra genetic material from chromosome 21. There are three different types of Down syndrome, each with its own cause and inheritance pattern. The most common form, full trisomy 21, is not inherited and accounts for 95% of cases. It occurs when there is a failure of chromosome 21 to separate properly during cell division, resulting in an extra copy of the chromosome. This can happen randomly, with the extra chromosome coming from the mother 88% of the time and from the father 12% of the time.

The second type, translocation Down syndrome, is inherited and accounts for 2-3% of cases. It occurs when a piece of chromosome 21 breaks off and attaches to another chromosome, resulting in extra genetic material. This type of Down syndrome is caused by a balanced translocation, which means that the parent carrying the translocation has no signs of symptoms of the disorder.

The third type, mosaic Down syndrome, is not inherited and also accounts for 2-3% of cases. It occurs as a random event during cell division early in fetal development, resulting in some cells having an extra copy of chromosome 21 while others do not.

The risk of having a child with Down syndrome increases as a mother gets older. At age 35, the risk is 1 in 385; at age 40, the risk is 1 in 106; and at age 45, the risk is 1 in 30. It is important for women to be aware of these risk factors and to discuss them with their healthcare provider if they are planning to have a child.

Cholinesterase Inhibitors are the preferred medication for treating visual hallucinations in LBD, but if they don’t work, antipsychotic drugs may be necessary. For Lewy Body psychosis, clozapine is the most effective option, although quetiapine is also a viable alternative. In Parkinson’s disease dementia with psychosis, a review by the Movement Disorder Society found that clozapine was effective and had an acceptable risk with proper monitoring. Quetiapine was considered investigational due to a lack of supporting evidence, while olanzapine was deemed unlikely to be effective and had an unacceptable risk due to its demonstrated worsening of motor function.

Management of Non-Cognitive Symptoms in Dementia

Non-cognitive symptoms of dementia can include agitation, aggression, distress, psychosis, depression, anxiety, sleep problems, wandering, hoarding, sexual disinhibition, apathy, and shouting. Non-pharmacological measures, such as music therapy, should be considered before prescribing medication. Pain may cause agitation, so a trial of analgesics is recommended. Antipsychotics, such as risperidone, olanzapine, and aripiprazole, may be used for severe distress of serious risk to others, but their use is controversial due to issues of tolerability and an association with increased mortality. Cognitive enhancers, such as AChE-Is and memantine, may have a modest benefit on BPSD, but their effects may take 3-6 months to take effect. Benzodiazepines should be avoided except in emergencies, and antidepressants, such as citalopram and trazodone, may have mixed evidence for BPSD. Mood stabilizers, such as valproate and carbamazepine, have limited evidence to support their use. Sedating antihistamines, such as promethazine, may cause cognitive impairment and should only be used short-term. Melatonin has limited evidence to support its use but is safe to use and may be justified in some cases where benefits are seen. For Lewy Body dementia, clozapine is favored over risperidone, and quetiapine may be a reasonable choice if clozapine is not appropriate. Overall, medication should only be used when non-pharmacological measures are ineffective, and the need is balanced with the increased risk of adverse effects.

A study that has a greater sample size is considered to have higher power, meaning it is capable of detecting a significant difference of effect that is clinically relevant.

The Importance of Power in Statistical Analysis

Power is a crucial concept in statistical analysis as it helps researchers determine the number of participants needed in a study to detect a clinically significant difference of effect. It represents the probability of correctly rejecting the null hypothesis when it is false, which means avoiding a Type II error. Power values range from 0 to 1, with 0 indicating 0% and 1 indicating 100%. A power of 0.80 is generally considered the minimum acceptable level.

Several factors influence the power of a study, including sample size, effect size, and significance level. Larger sample sizes lead to more precise parameter estimations and increase the study’s ability to detect a significant effect. Effect size, which is determined at the beginning of a study, refers to the size of the difference between two means that leads to rejecting the null hypothesis. Finally, the significance level, also known as the alpha level, represents the probability of a Type I error. By considering these factors, researchers can optimize the power of their studies and increase the likelihood of detecting meaningful effects.

Self Harm in Older Adults

Self harm in older adults should be taken very seriously as it often indicates suicidal intent. The NICE guidelines on Self Harm (2004) recommend that all acts of self-harm in people over 65 years of age should be regarded as evidence of suicidal intent until proven otherwise. This is because the number of older adults who complete suicide is much higher than in younger adults.

Unfortunately, many individuals who self-harm never receive psychiatric care and are discharged from emergency departments without any psychosocial needs assessment. This is contrary to the 2004 recommendations by the UK’s National Institute for Health and Clinical Excellence (NICE) for those who self-harm.

Self harm can take many forms, including overdose, cutting, burning, hitting of mutilating body parts, and attempted hanging of strangulation. It is important to recognize the signs of self harm and provide appropriate support and care to those who engage in this behavior.

Interpersonal Therapy: A Structured Approach to Addressing Social Functioning Problems

Interpersonal therapy (IPT) is a structured form of psychotherapy that is often used to treat depression. It is based on the belief that social functioning problems have a significant impact on psychological problems. IPT is a time-limited therapy that typically runs for 10-16 one hour sessions. The therapy is organized into three phases, with the first phase involving data collection and formulation. The remaining sessions explore the formulation in more detail.

IPT focuses on four areas of social functioning problems: grief, role transitions, interpersonal deficits, and interpersonal disputes. The therapy aims to intervene at the level of social functioning, rather than focusing on personality. The therapy has been found to be effective in treating depression, particularly in patients with severe depression. However, it may be less effective in treating people with depression and comorbid personality disorders.

The evidence base for IPT is most developed for eating disorders, and the intervention is recommended in NICE guidelines for eating disorders. Overall, IPT is a structured approach to addressing social functioning problems that can be effective in treating depression and other psychological problems.

Depression in Young People: NICE Guidelines

The NICE Guidelines for depression in young people are limited to those between the ages of 5-18. For mild depression without significant comorbid problems of active suicidal ideas of plans, watchful waiting is recommended, along with digital CBT, group CBT, group IPT, of group non-directive supportive therapy. For moderate to severe depression, family-based IPT, family therapy, psychodynamic psychotherapy, individual CBT, and fluoxetine may be used for 5-11 year olds, while individual CBT and fluoxetine may be used for 12-18 year olds. Antidepressant medication should not be used for initial treatment of mild depression, and should only be used in combination with concurrent psychological therapy for moderate to severe depression. Fluoxetine is the only antidepressant for which clinical trial evidence shows that the benefits outweigh the risks, and should be used as the first-line treatment. Paroxetine, venlafaxine, tricyclic antidepressants, and St John’s wort should not be used for the treatment of depression in children and young people. Second generation antipsychotics may be used for depression with psychotic symptoms, and ECT should only be considered for those with very severe depression and life-threatening symptoms.

For exams, it is important to be aware that Efavirenz, an antiretroviral, has been associated with both mania and fatal suicide.

HIV and Mental Health: Understanding the Relationship and Treatment Options

Human immunodeficiency virus (HIV) is a blood-borne virus that causes cellular immune deficiency, resulting in a decrease in the number of CD4+ T-cells. People with severe mental illness are at increased risk of contracting and transmitting HIV, and the prevalence of HIV infection among them is higher than in the general population. Antiretroviral drugs are used to manage HIV, but they are not curative.

Depression is the most common mental disorder in the HIV population, and it can result from HIV of the psycho-social consequences of having the condition. HIV-associated neurocognitive disorder (HAND) is the umbrella term for the spectrum of neurocognitive impairment induced by HIV, ranging from mild impairment through to dementia. Poor episodic memory is the most frequently reported cognitive difficulty in HIV-positive individuals.

Treatment options for mental health issues in people with HIV include atypical antipsychotics for psychosis, SSRIs for depression and anxiety, valproate for bipolar disorder, and antiretroviral therapy for HAND. It is important to avoid benzodiazepines for delirium and MAOIs for depression. Understanding the relationship between HIV and mental health and providing appropriate treatment options can improve the quality of life for people living with HIV.

Vega (1997) conducted a study that has been replicated multiple times, leading to this discovery.

Schizophrenia Epidemiology

Prevalence:
– In England, the estimated annual prevalence for psychotic disorders (mostly schizophrenia) is around 0.4%.
– Internationally, the estimated annual prevalence for psychotic disorders is around 0.33%.
– The estimated lifetime prevalence for psychotic disorders in England is approximately 0.63% at age 43, consistent with the typically reported 1% prevalence over the life course.
– Internationally, the estimated lifetime prevalence for psychotic disorders is around 0.48%.

Incidence:
– In England, the pooled incidence rate for non-affective psychosis (mostly schizophrenia) is estimated to be 15.2 per 100,000 years.
– Internationally, the incidence of schizophrenia is about 0.20/1000/year.

Gender:
– The male to female ratio is 1:1.

Course and Prognosis:
– Long-term follow-up studies suggest that after 5 years of illness, one quarter of people with schizophrenia recover completely, and for most people, the condition gradually improves over their lifetime.
– Schizophrenia has a worse prognosis with onset in childhood of adolescence than with onset in adult life.
– Younger age of onset predicts a worse outcome.
– Failure to comply with treatment is a strong predictor of relapse.
– Over a 2-year period, one-third of patients with schizophrenia showed a benign course, and two-thirds either relapsed of failed to recover.
– People with schizophrenia have a 2-3 fold increased risk of premature death.

Winter Births:
– Winter births are associated with an increased risk of schizophrenia.

Urbanicity:
– There is a higher incidence of schizophrenia associated with urbanicity.

Migration:
– There is a higher incidence of schizophrenia associated with migration.

Class:
– There is a higher prevalence of schizophrenia among lower socioeconomic classes.

Learning Disability:
– Prevalence rates for schizophrenia in people with learning disabilities are approximately three times greater than for the general population.

The use of mianserin for post-stroke depression has been found to be ineffective.

Depression is a common occurrence after a stroke, affecting 30-40% of patients. The location of the stroke lesion can play a crucial role in the development of major depression. Treatment for post-stroke depression must take into account the cause of the stroke, medical comorbidities, and potential interactions with other medications. The Maudsley guidelines recommend SSRIs as the first-line treatment, with paroxetine being the preferred choice. Nortriptyline is also an option, as it does not increase the risk of bleeding. If the patient is on anticoagulants, citalopram and escitalopram may be preferred. Antidepressant prophylaxis has been shown to be effective in preventing post-stroke depression, with nortriptyline, fluoxetine, escitalopram, duloxetine, sertraline, and mirtazapine being effective options. Mianserin, however, appears to be ineffective.

The prevalence of schizophrenia may be higher in urban areas due to the social drift phenomenon, where individuals with severe and enduring mental illnesses tend to move towards urban areas. However, a reduced incidence of schizophrenia in urban areas could explain why there is an increased prevalence of the condition in rural settings. It is important to note that prevalence is influenced by both incidence and duration of illness, and can be reduced by increased recovery rates of death from any cause.

STAR*D Study

The STAR*D trial, conducted in the USA, aimed to evaluate the effectiveness of treatments for major depressive disorder in real-world patients. The study involved four levels of treatment, with patients starting at level 1 and progressing to the next level if they did not respond. The outcome measure used was remission, and the study entry criteria were broadly defined to ensure results could be generalized to a wide range of patients.

A total of 4,041 patients were enrolled in the first level of treatment, making STAR*D the largest prospective clinical trial of depression ever conducted. In level 1, one-third of participants achieved remission, and a further 10-15% responded but not to the point of remission. If treatment with an initial SSRI fails, then one in four patients who choose to switch to another medication will enter remission, regardless of whether the second medication is an SSRI of a medication of a different class. If patients choose to add a medication instead, one in three will get better.

Overall, the STAR*D study provides valuable insights into the effectiveness of different treatments for major depressive disorder and highlights the importance of considering alternative treatments if initial treatment fails.

Conduct disorders are defined by a consistent and recurring pattern of behavior that is defiant, aggressive, of dissocial. This behavior should be severe enough to violate social expectations that are appropriate for the individual’s age, and should not be mistaken for typical adolescent rebellion of childish mischief. The diagnosis is not based on isolated criminal of dissocial acts, but rather on a persistent pattern of behavior.

Guidance for Registered Medical Practitioners on the Notification of Deaths Regulations 2019

If there is reason to suspect that the deceased died from self-inflicted poisoning, the coroner should be informed. The Notification of Deaths Regulations 2019 provides national guidance for registered medical practitioners on reporting deaths. This guidance supersedes any local protocols. There are several causes of death that must be referred to the coroner, including death from poisoning, violence of trauma, self-harm, neglect, medical procedures, employment-related injury of disease, unnatural death, unknown cause of death, death in state detention, and unidentified individuals. This does not include patients recently detained under the Mental Health Act of subject to DOLS, unless one of the above reasons applies.

The individual in the image is displaying symptoms consistent with early onset Alzheimer’s disease, which can affect individuals in their 40s. This form of the disease is often inherited in an autosomal dominant pattern, and mutations in the presenilin 1 and 2 genes have been linked to its development.

Individuals who have ingested PCP often exhibit difficulty with coordination and speech. The hallucinations experienced are typically intricate rather than straightforward. It is more likely for them to have excessive saliva production rather than a dry mouth.

PCP Intoxication: A Dangerous Hallucinogenic

Phencyclidine (PCP), also known as angel dust, is a hallucinogenic drug that is popular for inducing feelings of euphoria, superhuman strength, and social and sexual prowess. It is a NMDA receptor antagonist that has dissociative properties, similar to ketamine. PCP was previously used as an anesthetic and animal tranquilizer, but was soon recalled due to its adverse effects, including psychosis, agitation, and dysphoria post-operatively.

PCP is available in various forms, including white crystalline powder, tablets, crystals, and liquid. It can be snorted, smoked, ingested, of injected intravenously or subcutaneously. People who have taken PCP often present with violent behavior, nystagmus, tachycardia, hypertension, anesthesia, and analgesia. Other symptoms include impaired motor function, hallucinations, delusions, and paranoia.

PCP intoxication is best managed with benzodiazepines along with supportive measures for breathing and circulation. Antipsychotics are not recommended as they can amplify PCP-induced hyperthermia, dystonic reactions, and lower the seizure threshold. However, haloperidol may be useful for treating PCP-induced psychosis in patients who are not hyperthermic. Most deaths in PCP-intoxicated patients result from violent behavior rather than direct effects of the drug.

Extensive research has been conducted on the endocrine alterations linked to anorexia nervosa, revealing compelling evidence of hypothalamic dysfunction. These changes are all secondary and can be reversed through weight gain. Additional changes associated with anorexia nervosa include decreased levels of gonadotropins (FSH and LH), normal of elevated cortisol levels, reduced sex hormones, and imbalanced thyroid hormones characterized by low T3, high reverse T3, and an elevated T4:T3 ratio.

The question is specifically inquiring about the physical symptom, which is also known as the somatic symptom. The term ‘somatic’ pertains to bodily sensations of experiences, rather than mental of emotional ones.

Generalised Anxiety Disorder: Symptoms and Diagnosis

Generalised anxiety disorder is a condition characterized by persistent symptoms of anxiety that last for several months and occur on most days. The symptoms can be either general apprehension of excessive worry about multiple everyday events, such as family, health, finances, and work of school. In addition to these symptoms, individuals with generalised anxiety disorder may experience muscular tension, motor restlessness, sympathetic autonomic overactivity, nervousness, difficulty concentrating, irritability, of sleep disturbance.

To diagnose generalised anxiety disorder, healthcare professionals look for specific essential features. These include marked symptoms of anxiety that are not restricted to any particular environmental circumstance, and are accompanied by additional characteristic symptoms such as muscle tension, autonomic overactivity, nervousness, difficulty concentrating, irritability, and sleep disturbances. The symptoms must persist for at least several months, for more days than not, and cannot be better accounted for by another mental disorder of medical condition. The symptoms must also result in significant distress of impairment in personal, family, social, educational, occupational, of other important areas of functioning.

Based on the patient’s history, it appears that they are experiencing pathological crying. In such cases, medications such as amitriptyline or fluoxetine are recommended. However, it is important to note that if the pathological laughing/crying is a result of a stroke, citalopram or sertraline may be more appropriate.

Psychiatric Consequences of Multiple Sclerosis

Multiple sclerosis (MS) is a neurological disorder that affects individuals between the ages of 20 and 40. It is characterized by multiple demyelinating lesions in the optic nerves, cerebellum, brainstem, and spinal cord. MS presents with diverse neurological signs, including optic neuritis, internuclear ophthalmoplegia, and ocular motor cranial neuropathy.

Depression is the most common psychiatric condition seen in MS, with a lifetime prevalence of 25-50%. The symptoms of depression in people with MS tend to be different from those without MS. The preferred diagnostic indicators for depression in MS include pervasive mood change, diurnal mood variation, suicidal ideation, functional change not related to physical disability, and pessimistic of negative patterns of thinking. Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for depression in patients with MS.

Suicide is common in MS, with recognized risk factors including male gender, young age at onset of illness, current of previous history of depression, social isolation, and substance misuse. Mania is more common in people with MS, and mood stabilizers are recommended for treatment. Pathological laughing and crying, defined as uncontrollable laughing and/of crying without the associated affect, occurs in approximately 10% of cases of MS. Emotional lability, defined as an excessive emotional response to a minor stimulus, is also common in MS and can be treated with amitriptyline and SSRIs.

The majority of cases of neuropsychiatric side effects from corticosteroids fit an affective profile of mania and/of depression. Psychotic symptoms, particularly hallucinations, are present in up to half of these cases. Glatiramer acetate has not been associated with neuropsychiatric side-effects. The data regarding the risk of mood symptoms related to interferon use is conflicting.

In conclusion, MS has significant psychiatric consequences, including depression, suicide, mania, pathological laughing and crying, emotional lability, and neuropsychiatric side effects from treatment. Early recognition and treatment of these psychiatric symptoms are essential for improving the quality of life of individuals with MS.

Depression in Young People: NICE Guidelines

The NICE Guidelines for depression in young people are limited to those between the ages of 5-18. For mild depression without significant comorbid problems of active suicidal ideas of plans, watchful waiting is recommended, along with digital CBT, group CBT, group IPT, of group non-directive supportive therapy. For moderate to severe depression, family-based IPT, family therapy, psychodynamic psychotherapy, individual CBT, and fluoxetine may be used for 5-11 year olds, while individual CBT and fluoxetine may be used for 12-18 year olds. Antidepressant medication should not be used for initial treatment of mild depression, and should only be used in combination with concurrent psychological therapy for moderate to severe depression. Fluoxetine is the only antidepressant for which clinical trial evidence shows that the benefits outweigh the risks, and should be used as the first-line treatment. Paroxetine, venlafaxine, tricyclic antidepressants, and St John’s wort should not be used for the treatment of depression in children and young people. Second generation antipsychotics may be used for depression with psychotic symptoms, and ECT should only be considered for those with very severe depression and life-threatening symptoms.

The treatment nomogram for acetylcysteine is applicable for a duration of 4-24 hours, but it is important to note that the reliability of the levels decreases beyond 15 hours, as indicated by the dotted line. It is recommended to consider administering acetylcysteine to patients who have overdosed within 24 hours, even if their plasma paracetamol levels are below the treatment threshold on the graph, provided that biochemical tests indicate acute liver injury.

Self-Harm and its Management

Self-harm refers to intentional acts of self-poisoning of self-injury. It is prevalent among younger people, with an estimated 10% of girls and 3% of boys aged 15-16 years having self-harmed in the previous year. Risk factors for non-fatal repetition of self-harm include previous self-harm, personality disorder, hopelessness, history of psychiatric treatment, schizophrenia, alcohol abuse/dependence, and drug abuse/dependence. Suicide following an act of self-harm is more likely in those with previous episodes of self-harm, suicidal intent, poor physical health, and male gender.

Risk assessment tools are not recommended for predicting future suicide of repetition of self-harm. The recommended interventions for self-harm include 4-10 sessions of CBT specifically structured for people who self-harm and considering DBT for adolescents with significant emotional dysregulation. Drug treatment as a specific intervention to reduce self-harm should not be offered.

In the management of ingestion, activated charcoal can help if used early, while emetics and cathartics should not be used. Gastric lavage should generally not be used unless recommended by TOXBASE. Paracetamol is involved in 30-40% of acute presentations with poisoning. Intravenous acetylcysteine is the treatment of choice, and pseudo-allergic reactions are relatively common. Naloxone is used as an antidote for opioid overdose, while flumazenil can help reduce the need for admission to intensive care in benzodiazepine overdose.

For superficial uncomplicated skin lacerations of 5 cm of less in length, tissue adhesive of skin closure strips could be used as a first-line treatment option. All children who self-harm should be admitted for an overnight stay at a pediatric ward.

Clozapine is an effective antipsychotic drug used in the management of treatment-resistant schizophrenia (TRS). It was reintroduced in the 1990s with mandatory blood monitoring due to the risk of agranulocyte

The rate is considerably greater than that of adults who are of working age.

Suicide Rates Following Self-Harm

Most individuals who engage in self-harm do not go on to commit suicide, which makes risk assessment challenging. A study conducted in the UK in 2015 by Hawton found that 0.5% of individuals died by suicide in the first year following self-harm, with a higher rate among males (0.82%) than females (0.27%). Over the two-year period following self-harm, 1.6% died by suicide, with more occurrences in the second year. Interestingly, a study by Murphy in 2012 found that the rate of suicide following self-harm was higher in the elderly (those over 60), with a rate of 1.5 suicides in the first 12 months. The only significant risk factor for suicide following self-harm in this study was the use of a violent method in the initial episode.

A major benefit of using cost-effectiveness analysis is that the results are immediately understandable, such as the cost per year of remission from depression. When conducting economic evaluations, costs are typically estimated in a standardized manner across different types of studies, taking into account direct costs (e.g. physician time), indirect costs (e.g. lost productivity from being absent from work), and future costs (e.g. developing diabetes as a result of treatment with clozapine). The primary variation between economic evaluations lies in how outcomes are evaluated.

Methods of Economic Evaluation

There are four main methods of economic evaluation: cost-effectiveness analysis (CEA), cost-benefit analysis (CBA), cost-utility analysis (CUA), and cost-minimisation analysis (CMA). While all four methods capture costs, they differ in how they assess health effects.

Cost-effectiveness analysis (CEA) compares interventions by relating costs to a single clinical measure of effectiveness, such as symptom reduction of improvement in activities of daily living. The cost-effectiveness ratio is calculated as total cost divided by units of effectiveness. CEA is typically used when CBA cannot be performed due to the inability to monetise benefits.

Cost-benefit analysis (CBA) measures all costs and benefits of an intervention in monetary terms to establish which alternative has the greatest net benefit. CBA requires that all consequences of an intervention, such as life-years saved, treatment side-effects, symptom relief, disability, pain, and discomfort, are allocated a monetary value. CBA is rarely used in mental health service evaluation due to the difficulty in converting benefits from mental health programmes into monetary values.

Cost-utility analysis (CUA) is a special form of CEA in which health benefits/outcomes are measured in broader, more generic ways, enabling comparisons between treatments for different diseases and conditions. Multidimensional health outcomes are measured by a single preference- of utility-based index such as the Quality-Adjusted-Life-Years (QALY). QALYs are a composite measure of gains in life expectancy and health-related quality of life. CUA allows for comparisons across treatments for different conditions.

Cost-minimisation analysis (CMA) is an economic evaluation in which the consequences of competing interventions are the same, and only inputs, i.e. costs, are taken into consideration. The aim is to decide the least costly way of achieving the same outcome.

Costs in Economic Evaluation Studies

There are three main types of costs in economic evaluation studies: direct, indirect, and intangible. Direct costs are associated directly with the healthcare intervention, such as staff time, medical supplies, cost of travel for the patient, childcare costs for the patient, and costs falling on other social sectors such as domestic help from social services. Indirect costs are incurred by the reduced productivity of the patient, such as time off work, reduced work productivity, and time spent caring for the patient by relatives. Intangible costs are difficult to measure, such as pain of suffering on the part of the patient.

Non-drug approaches should be the first line of defense in managing aggression in Alzheimer’s disease, including identifying triggers and utilizing behavioral techniques. However, in some cases, drug treatment may be necessary. Atypical neuroleptics like quetiapine and haloperidol are not recommended due to increased risk of death of stroke and potential cognitive decline. Risperidone is licensed for short-term treatment of persistent aggression in moderate to severe Alzheimer’s disease if non-pharmacological alternatives have been tried and there is a risk of harm. Valproate has been used for calming effects, but evidence of its efficacy is limited. Benzodiazepines are not recommended due to increased risk of falls and worsening cognitive decline.

If rapid cycling bipolar disorder occurs, propranolol should be discontinued as it is believed to be a contributing factor.

Bipolar Disorder Diagnosis

Bipolar and related disorders are mood disorders characterized by manic, mixed, of hypomanic episodes alternating with depressive episodes. The lifetime risk of suicide in individuals with bipolar disorder is estimated to be at least 15 times that of the general population. Under the ICD-11, there are three subtypes of bipolar disorder: Bipolar I, Bipolar II, and Cyclothymic disorder.

Bipolar I disorder is diagnosed when an individual has a history of at least one manic of mixed episode. The typical course of the disorder is characterized by recurrent depressive and manic of mixed episodes. Onset of the first mood episode most often occurs during the late teen years, but onset of bipolar type I can occur at any time through the life cycle. The lifetime prevalence of bipolar I disorder is estimated to be around 2.1%.

Bipolar II disorder is diagnosed when an individual has a history of at least one hypomanic episode and at least one depressive episode. The typical course of the disorder is characterized by recurrent depressive and hypomanic episodes. Onset of bipolar type II most often occurs during the mid-twenties. The number of lifetime episodes tends to be higher for bipolar II disorder than for major depressive disorder of bipolar I disorder.

Cyclothymic disorder is diagnosed when an individual experiences mood instability over an extended period of time characterized by numerous hypomanic and depressive periods. The symptoms are present for more days than not, and there is no history of manic or mixed episodes. The course of cyclothymic disorder is often gradual and persistent, and onset commonly occurs during adolescence of early adulthood.

Rapid cycling is not a subtype of bipolar disorder but instead is a qualifier. It is defined as the presence of at least four mood episodes in the previous 12 months that meet the criteria for a manic, hypomanic, of major depressive episode. Rapid cycling is associated with an increased risk of suicide and tends to be precipitated by stressors such as life events, alcohol abuse, use of antidepressants, and medical disorders.

Overall, the diagnosis of bipolar disorder requires careful evaluation of an individual’s symptoms and history. Treatment typically involves a combination of medication and psychotherapy.

PTSD in People with Learning Disability

People with learning disability are just as likely to develop PTSD as those without when exposed to trauma. The symptoms of PTSD in people with learning disability often include aggression, disruptive behavior, self-harm, agitation, distractibility, sleep problems, and depressed mood. Behavioral problems, particularly aggression, are the most common presenting symptoms in this population, while sleep problems and jumpiness are more common in the general population.

Treatment interventions for PTSD in people with learning disability are similar to those used in the general population. Historically, psychological interventions have been the primary approach, but more recently, pharmacological interventions have also been considered. Overall, it is important to recognize and address PTSD in people with learning disability to improve their quality of life and overall well-being.

The development of Alzheimer’s disease is most strongly associated with increasing age.

Alzheimer’s Association: Risk Factors

The Alzheimer’s Association has identified several risk factors for the development of Alzheimer’s disease. These include age, family history, head trauma (especially if associated with loss of consciousness), hypertension, heart disease, diabetes, CVA, high cholesterol, lower educational level, and female gender. Increasing age is a significant risk factor, as is having a family history of the disease. Head trauma, particularly if it results in loss of consciousness, can also increase the risk of developing Alzheimer’s. Other medical conditions such as hypertension, heart disease, and diabetes have also been linked to an increased risk of Alzheimer’s. Additionally, individuals with lower levels of education and females may be at higher risk. It is important to be aware of these risk factors and take steps to reduce them where possible.

ADHD is a prevalent disorder worldwide, with a prevalence of 7% in those under 18 and 3.5% in those over 18. It is more common in males, with a male to female ratio of 2:1 in children and 1.6:1 in adults. While some improvement in symptoms is seen over time, the majority of those diagnosed in childhood continue to struggle with residual symptoms and impairments through at least young adulthood, with an estimated persistence rate of 50%.

Measures of Effect in Clinical Studies

When conducting clinical studies, we often want to know the effect of treatments of exposures on health outcomes. Measures of effect are used in randomized controlled trials (RCTs) and include the odds ratio (of), risk ratio (RR), risk difference (RD), and number needed to treat (NNT). Dichotomous (binary) outcome data are common in clinical trials, where the outcome for each participant is one of two possibilities, such as dead of alive, of clinical improvement of no improvement.

To understand the difference between of and RR, it’s important to know the difference between risks and odds. Risk is a proportion that describes the probability of a health outcome occurring, while odds is a ratio that compares the probability of an event occurring to the probability of it not occurring. Absolute risk is the basic risk, while risk difference is the difference between the absolute risk of an event in the intervention group and the absolute risk in the control group. Relative risk is the ratio of risk in the intervention group to the risk in the control group.

The number needed to treat (NNT) is the number of patients who need to be treated for one to benefit. Odds are calculated by dividing the number of times an event happens by the number of times it does not happen. The odds ratio is the odds of an outcome given a particular exposure versus the odds of an outcome in the absence of the exposure. It is commonly used in case-control studies and can also be used in cross-sectional and cohort study designs. An odds ratio of 1 indicates no difference in risk between the two groups, while an odds ratio >1 indicates an increased risk and an odds ratio <1 indicates a reduced risk.

The Rapid Assessment Interface and Discharge (RAID) psychiatric liaison service at Birmingham’s City Hospital was evaluated by the London School of Economics, which found that the benefit:cost ratio was over 4:1. The evaluation showed that the service resulted in savings of £3.55 million per year in general hospital bed use, at a cost of £0.8 million.

Linguistic Development and Risk Factors for Delayed Speech and Language

The development of language skills is an important aspect of a child’s growth. The prelinguistic period, from birth to 12 months, is marked by crying, babbling, and echolalia. From 6 to 12 months, a child responds to their name and can differentiate between angry and friendly tones. By 18 to 24 months, a child can use up to 40-50 words, mainly nouns, and starts to combine words in short phrases. By 36 to 48 months, a child has a vocabulary of 900-1000 words, can use plurals and past tense, and can handle three-word sentences easily.

However, there are risk factors associated with delayed speech and language development. These include a positive family history, male gender, twins, lower maternal education, childhood illness, being born late in the family order, young mother at birth, and low socioeconomic status. of these, a positive family history is considered the most reliable risk factor. It is important to monitor a child’s language development and seek professional help if there are concerns about delayed speech and language.

Negative predictive value = 172 / 177

Clinical tests are used to determine the presence of absence of a disease of condition. To interpret test results, it is important to have a working knowledge of statistics used to describe them. Two by two tables are commonly used to calculate test statistics such as sensitivity and specificity. Sensitivity refers to the proportion of people with a condition that the test correctly identifies, while specificity refers to the proportion of people without a condition that the test correctly identifies. Accuracy tells us how closely a test measures to its true value, while predictive values help us understand the likelihood of having a disease based on a positive of negative test result. Likelihood ratios combine sensitivity and specificity into a single figure that can refine our estimation of the probability of a disease being present. Pre and post-test odds and probabilities can also be calculated to better understand the likelihood of having a disease before and after a test is carried out. Fagan’s nomogram is a useful tool for calculating post-test probabilities.

Antidepressants and Diabetes

Depression is a prevalent condition among patients with diabetes. It is crucial to select the appropriate antidepressant as some may have negative effects on weight and glucose levels. The first-line treatment for depression in diabetic patients is selective serotonin reuptake inhibitors (SSRIs), with fluoxetine having the most supporting data. Serotonin-norepinephrine reuptake inhibitors (SNRIs) are also likely to be safe, but there is less evidence to support their use. Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) should be avoided. These recommendations are based on the Maudsley Guidelines 10th Edition.

Teratogens and Their Associated Defects

Valproic acid is a teratogen that has been linked to various birth defects, including neural tube defects, hypospadias, cleft lip/palate, cardiovascular abnormalities, developmental delay, endocrinological disorders, limb defects, and autism (Alsdorf, 2005). Lithium has been associated with cardiac anomalies, specifically Ebstein’s anomaly. Alcohol consumption during pregnancy can lead to cleft lip/palate and fetal alcohol syndrome. Phenytoin has been linked to fingernail hypoplasia, craniofacial defects, limb defects, cerebrovascular defects, and mental retardation. Similarly, carbamazepine has been associated with fingernail hypoplasia and craniofacial defects. Diazepam has been linked to craniofacial defects, specifically cleft lip/palate (Palmieri, 2008). The evidence for steroids causing craniofacial defects is not convincing, according to the British National Formulary (BNF). Selective serotonin reuptake inhibitors (SSRIs) have been associated with congenital heart defects and persistent pulmonary hypertension (BNF). It is important for pregnant women to avoid exposure to these teratogens to reduce the risk of birth defects in their babies.

The use of SSRIs and tricyclics is not recommended for individuals under the age of 18 who engage in deliberate self-harm. Instead, family therapy and counseling are preferred options. The Committee on Safety of Medicines has advised against the use of citalopram, escitalopram, paroxetine, and sertraline due to an unfavorable balance of risks and benefits for treating depressive illness in this age group. While fluoxetine has shown some benefit, there are concerns about an increased risk of self-harm and suicidal thoughts.

Common Biases and Errors in Research

Reverse causality occurs when a risk factor appears to cause an illness, but in reality, it is a consequence of the illness. Information bias is a type of error that can occur in research. Two examples of information bias are observer bias and recall bias. Observer bias happens when the experimenter’s biases affect the study’s findings. Recall bias occurs when participants in the case and control groups have different levels of accuracy in their recollections.

There are two types of errors in research: Type I and Type II. A Type I error is when a true null hypothesis is incorrectly rejected, resulting in a false positive. A Type II error is when a false null hypothesis is not rejected, resulting in a false negative. It is essential to be aware of these biases and errors to ensure accurate and reliable research findings.

Qualitative research is a method of inquiry that seeks to understand the meaning and experience dimensions of human lives and social worlds. There are different approaches to qualitative research, such as ethnography, phenomenology, and grounded theory, each with its own purpose, role of the researcher, stages of research, and method of data analysis. The most common methods used in healthcare research are interviews and focus groups. Sampling techniques include convenience sampling, purposive sampling, quota sampling, snowball sampling, and case study sampling. Sample size can be determined by data saturation, which occurs when new categories, themes, of explanations stop emerging from the data. Validity can be assessed through triangulation, respondent validation, bracketing, and reflexivity. Analytical approaches include content analysis and constant comparison.

Antipsychotics: Minimum Effective Doses

The Maudsley Guidelines provide a table of minimum effective oral doses for antipsychotics in schizophrenia. The following doses are recommended for first episode and relapse (multi-episode) cases:

– Chlorpromazine: 200mg (first episode) and 300mg (relapse)
– Haloperidol: 2mg (first episode) and 4mg (relapse)
– Sulpiride: 400mg (first episode) and 800mg (relapse)
– Trifluoperazine: 10mg (first episode) and 15mg (relapse)
– Amisulpride: 300mg (first episode) and 400mg (relapse)
– Aripiprazole: 10mg (first episode and relapse)
– Olanzapine: 5mg (first episode) and 7.5mg (relapse)
– Quetiapine: 150mg (first episode) and 300mg (relapse)
– Risperidone: 2mg (first episode) and 4mg (relapse)

The minimum effective doses may vary depending on individual patient factors and response to treatment. It is important to consult with a healthcare professional before making any changes to medication dosages.

Choosing the right statistical test can be challenging, but understanding the basic principles can help. Different tests have different assumptions, and using the wrong one can lead to inaccurate results. To identify the appropriate test, a flow chart can be used based on three main factors: the type of dependent variable, the type of data, and whether the groups/samples are independent of dependent. It is important to know which tests are parametric and non-parametric, as well as their alternatives. For example, the chi-squared test is used to assess differences in categorical variables and is non-parametric, while Pearson’s correlation coefficient measures linear correlation between two variables and is parametric. T-tests are used to compare means between two groups, and ANOVA is used to compare means between more than two groups. Non-parametric equivalents to ANOVA include the Kruskal-Wallis analysis of ranks, the Median test, Friedman’s two-way analysis of variance, and Cochran Q test. Understanding these tests and their assumptions can help researchers choose the appropriate statistical test for their data.

Psychotropics and Seizure Threshold in People with Epilepsy

People with epilepsy are at an increased risk for various mental health conditions, including depression, anxiety, psychosis, and suicide. It is important to note that the link between epilepsy and mental illness is bidirectional, as patients with mental health conditions also have an increased risk of developing new-onset epilepsy. Psychotropic drugs are often necessary for people with epilepsy, but they can reduce the seizure threshold and increase the risk of seizures. The following tables provide guidance on the seizure risk associated with different classes of antidepressants, antipsychotics, and ADHD medications. It is important to use caution and carefully consider the risks and benefits of these medications when treating people with epilepsy.

Body Dysmorphic Disorder is a condition where individuals are preoccupied with one of more perceived flaws in their appearance, which may not be noticeable to others. They may feel excessively self-conscious and believe that others are judging them based on these flaws. This can lead to repetitive behaviors such as examining the perceived flaw, attempting to hide of alter it, of avoiding social situations that trigger distress. In contrast, Body Integrity Dysphoria is a rare condition where individuals experience discomfort of negative feelings about a specific body part, often leading to a desire to amputate of remove it, rather than improve its appearance.

Somatoform and dissociative disorders are two groups of psychiatric disorders that are characterized by physical symptoms and disruptions in the normal integration of identity, sensations, perceptions, affects, thoughts, memories, control over bodily movements, of behavior. Somatoform disorders are characterized by physical symptoms that are presumed to have a psychiatric origin, while dissociative disorders are characterized by the loss of integration between memories, identity, immediate sensations, and control of bodily movements. The ICD-11 lists two main types of somatoform disorders: bodily distress disorder and body integrity dysphoria. Dissociative disorders include dissociative neurological symptom disorder, dissociative amnesia, trance disorder, possession trance disorder, dissociative identity disorder, partial dissociative identity disorder, depersonalization-derealization disorder, and other specified dissociative disorders. The symptoms of these disorders result in significant impairment in personal, family, social, educational, occupational, of other important areas of functioning. Diagnosis of these disorders involves a thorough evaluation of the individual’s symptoms and medical history, as well as ruling out other possible causes of the symptoms.

Transsexualism is a condition where an individual desires to live and be accepted as a member of the opposite sex, often accompanied by discomfort with their own biological sex and a desire for gender reassignment treatment. This desire is usually present from an early age, before puberty.

Fetishistic transvestism involves wearing clothes of the opposite sex primarily for sexual arousal. The individual experiences a strong desire to remove the clothing once sexual arousal subsides.

Dual role transvestism involves wearing clothes of the opposite sex to temporarily experience membership of the opposite sex, without any desire for a permanent sex change of sexual arousal.

Egodystonic sexual orientation refers to an individual who wishes their gender identity of sexual orientation were different due to associated psychological and behavioral disorders. They may seek treatment to change it.

Voyeurism is a recurring tendency to observe people engaging in sexual of intimate behavior, such as undressing, without their knowledge. This behavior often leads to sexual excitement and masturbation.

– Schizophrenia and other primary psychotic disorders are characterized by impairments in reality testing and alterations in behavior.
– Schizophrenia is a chronic mental health disorder with symptoms including delusions, hallucinations, disorganized speech of behavior, and impaired cognitive ability.
– The essential features of schizophrenia include persistent delusions, persistent hallucinations, disorganized thinking, experiences of influence, passivity of control, negative symptoms, grossly disorganized behavior, and psychomotor disturbances.
– Schizoaffective disorder is diagnosed when all diagnostic requirements for schizophrenia are met concurrently with mood symptoms that meet the diagnostic requirements of a moderate or severe depressive episode, a manic episode, of a mixed episode.
– Schizotypal disorder is an enduring pattern of unusual speech, perceptions, beliefs, and behaviors that are not of sufficient intensity of duration to meet the diagnostic requirements of schizophrenia, schizoaffective disorder, of delusional disorder.
– Acute and transient psychotic disorder is characterized by an acute onset of psychotic symptoms, which can include delusions, hallucinations, disorganized thinking, of experiences of influence, passivity of control, that emerge without a prodrome, progressing from a non-psychotic state to a clearly psychotic state within 2 weeks.
– Delusional disorder is diagnosed when there is a presence of a delusion of set of related delusions, typically persisting for at least 3 months and often much longer, in the absence of a depressive, manic, of mixed episode.

A Historical Note on the Development of Zimelidine, the First Selective Serotonin Reuptake Inhibitor

In 1960s, evidence began to emerge suggesting a significant role of serotonin in depression. This led to the development of zimelidine, the first selective serotonin reuptake inhibitor (SSRI). Zimelidine was derived from pheniramine and was marketed in Europe in 1982. However, it was removed from the market in 1983 due to severe side effects such as hypersensitivity reactions and Guillain-Barre syndrome.

Despite its short-lived availability, zimelidine paved the way for the development of other SSRIs such as fluoxetine, which was approved by the FDA in 1987 and launched in the US market in 1988 under the trade name Prozac. The development of SSRIs revolutionized the treatment of depression and other mood disorders, providing a safer and more effective alternative to earlier antidepressants such as the tricyclics and MAO inhibitors.

Methods of Economic Evaluation

There are four main methods of economic evaluation: cost-effectiveness analysis (CEA), cost-benefit analysis (CBA), cost-utility analysis (CUA), and cost-minimisation analysis (CMA). While all four methods capture costs, they differ in how they assess health effects.

Cost-effectiveness analysis (CEA) compares interventions by relating costs to a single clinical measure of effectiveness, such as symptom reduction of improvement in activities of daily living. The cost-effectiveness ratio is calculated as total cost divided by units of effectiveness. CEA is typically used when CBA cannot be performed due to the inability to monetise benefits.

Cost-benefit analysis (CBA) measures all costs and benefits of an intervention in monetary terms to establish which alternative has the greatest net benefit. CBA requires that all consequences of an intervention, such as life-years saved, treatment side-effects, symptom relief, disability, pain, and discomfort, are allocated a monetary value. CBA is rarely used in mental health service evaluation due to the difficulty in converting benefits from mental health programmes into monetary values.

Cost-utility analysis (CUA) is a special form of CEA in which health benefits/outcomes are measured in broader, more generic ways, enabling comparisons between treatments for different diseases and conditions. Multidimensional health outcomes are measured by a single preference- of utility-based index such as the Quality-Adjusted-Life-Years (QALY). QALYs are a composite measure of gains in life expectancy and health-related quality of life. CUA allows for comparisons across treatments for different conditions.

Cost-minimisation analysis (CMA) is an economic evaluation in which the consequences of competing interventions are the same, and only inputs, i.e. costs, are taken into consideration. The aim is to decide the least costly way of achieving the same outcome.

Costs in Economic Evaluation Studies

There are three main types of costs in economic evaluation studies: direct, indirect, and intangible. Direct costs are associated directly with the healthcare intervention, such as staff time, medical supplies, cost of travel for the patient, childcare costs for the patient, and costs falling on other social sectors such as domestic help from social services. Indirect costs are incurred by the reduced productivity of the patient, such as time off work, reduced work productivity, and time spent caring for the patient by relatives. Intangible costs are difficult to measure, such as pain of suffering on the part of the patient.

Insomnia Treatment: Sleep Hygiene

Before resorting to medication, it is important to try sleep hygiene approaches to treat insomnia. These approaches include increasing daily exercise (but not in the evening), avoiding large meals in the evening, ensuring exposure to natural light during the day, reducing of stopping daytime napping, reducing alcohol and stimulant (caffeine and nicotine) intake, associating the bed with sleep (not using it for TV, radio, of reading), using anxiety management and relaxation techniques, and developing a regular routine of rising and retiring at the same time each day (regardless of the amount of sleep taken). By implementing these strategies, individuals can improve their sleep quality and quantity without the use of medication.

Stages of Change Model

Prochaska and DiClemente’s Stages of Change Model identifies five stages that individuals go through when making a change. The first stage is pre-contemplation, where the individual is not considering change. There are different types of precontemplators, including those who lack knowledge about the problem, those who are afraid of losing control, those who feel hopeless, and those who rationalize their behavior.

The second stage is contemplation, where the individual is ambivalent about change and is sitting on the fence. The third stage is preparation, where the individual has some experience with change and is trying to change, testing the waters. The fourth stage is action, where the individual has started to introduce change, and the behavior is defined as action during the first six months of change.

The final stage is maintenance, where the individual is involved in ongoing efforts to maintain change. Action becomes maintenance once six months have elapsed. Understanding these stages can help individuals and professionals in supporting behavior change.

Cognitive Analytic Therapy (CAT) was developed by Anthony Ryle.

Interpersonal Therapy: A Structured Approach to Addressing Social Functioning Problems

Interpersonal therapy (IPT) is a structured form of psychotherapy that is often used to treat depression. It is based on the belief that social functioning problems have a significant impact on psychological problems. IPT is a time-limited therapy that typically runs for 10-16 one hour sessions. The therapy is organized into three phases, with the first phase involving data collection and formulation. The remaining sessions explore the formulation in more detail.

IPT focuses on four areas of social functioning problems: grief, role transitions, interpersonal deficits, and interpersonal disputes. The therapy aims to intervene at the level of social functioning, rather than focusing on personality. The therapy has been found to be effective in treating depression, particularly in patients with severe depression. However, it may be less effective in treating people with depression and comorbid personality disorders.

The evidence base for IPT is most developed for eating disorders, and the intervention is recommended in NICE guidelines for eating disorders. Overall, IPT is a structured approach to addressing social functioning problems that can be effective in treating depression and other psychological problems.

Concussion is categorized as a sane automatism since it is caused by an external factor.

Criminal Responsibility and Age Limits

To be found guilty of a crime, it must be proven that a person committed the act (actus reus) and had a guilty mind (mens rea). In England and Wales, children under the age of 10 cannot be held criminally responsible for their actions and cannot be arrested or charged with a crime. Instead, they may face other punishments such as a Local Child Curfew of a Child Safety Order. Children between the ages of 10 and 17 can be arrested and taken to court, but are treated differently from adults and may be dealt with by youth courts, given different sentences, and sent to special secure centers for young people. Young people aged 18 are treated as adults by the law.

Not Guilty by Reason of Insanity and Other Defenses

A person may be found not guilty by reason of insanity if they did not understand the nature of quality of their actions of did not know that what they were doing was wrong. Automatism is a defense used when the act is believed to have occurred unconsciously, either from an external cause (sane automatism) of an internal cause (insane automatism). Diminished responsibility is a defense used only in the defense of murder and allows for a reduction of the normal life sentence to manslaughter.

Rapid Risk Assessment for Sex Offence Recidivism (RRASOR)

The Rapid Risk Assessment for Sex Offence Recidivism (RRASOR) is a well-known actuarial tool that is used to predict the likelihood of sex offence recidivism. It comprises of four items that have been proven to have predictive accuracy for sex offence recidivism. These items include the number of past sex offence convictions of charges, the age of the offender being less than 25, the offender being unrelated to the victim, and the gender of the victim.

According to a NICE Health Technology Assessment, buprenorphine maintenance therapy is more effective in retaining individuals in treatment compared to placebo of no therapy. However, buprenorphine can be abused if injected and is more expensive than methadone. Methadone may be more suitable for individuals who use large amounts of heroin, as they may not respond as well to high dose buprenorphine. On the other hand, buprenorphine may be a better option for individuals on long-term treatment with drugs that induce of inhibit liver enzymes, as it is less affected by these enzymes compared to methadone.

Opioid Maintenance Therapy and Detoxification

Withdrawal symptoms can occur after as little as 5 days of regular opioid use. Short-acting opioids like heroin have acute withdrawal symptoms that peak in 32-72 hours and last for 3-5 days. Longer-acting opioids like methadone have acute symptoms that peak at day 4-6 and last for 10 days. Buprenorphine withdrawal lasts up to 10 days and includes symptoms like myalgia, anxiety, and increased drug craving.

Opioids affect the brain through opioid receptors, with the µ receptor being the main target for opioids. Dopaminergic cells in the ventral tegmental area produce dopamine, which is released into the nucleus accumbens upon stimulation of µ receptors, producing euphoria and reward. With repeat opioid exposure, µ receptors become less responsive, causing dysphoria and drug craving.

Methadone and buprenorphine are maintenance-oriented treatments for opioid dependence. Methadone is a full agonist targeting µ receptors, while buprenorphine is a partial agonist targeting µ receptors and a partial k agonist of functional antagonist. Naloxone and naltrexone are antagonists targeting all opioid receptors.

Methadone is preferred over buprenorphine for detoxification, and ultra-rapid detoxification should not be offered. Lofexidine may be considered for mild of uncertain dependence. Clonidine and dihydrocodeine should not be used routinely in opioid detoxification. The duration of detoxification should be up to 4 weeks in an inpatient setting and up to 12 weeks in a community setting.

Pregnant women dependent on opioids should use opioid maintenance treatment rather than attempt detoxification. Methadone is preferred over buprenorphine, and transfer to buprenorphine during pregnancy is not advised. Detoxification should only be considered if appropriate for the women’s wishes, circumstances, and ability to cope. Methadone or buprenorphine treatment is not a contraindication to breastfeeding.

Wernicke’s Encephalopathy: Symptoms, Causes, and Treatment

Wernicke’s encephalopathy is a serious condition that is characterized by confusion, ophthalmoplegia, and ataxia. However, the complete triad is only present in 10% of cases, which often leads to underdiagnosis. The condition results from prolonged thiamine deficiency, which is commonly seen in people with alcohol dependency, but can also occur in other conditions such as anorexia nervosa, malignancy, and AIDS.

The onset of Wernicke’s encephalopathy is usually abrupt, but it may develop over several days to weeks. The lesions occur in a symmetrical distribution in structures surrounding the third ventricle, aqueduct, and fourth ventricle. The mammillary bodies are involved in up to 80% of cases, and atrophy of these structures is specific for Wernicke’s encephalopathy.

Treatment involves intravenous thiamine, as oral forms of B1 are poorly absorbed. IV glucose should be avoided when thiamine deficiency is suspected as it can precipitate of exacerbate Wernicke’s. With treatment, ophthalmoplegia and confusion usually resolve within days, but the ataxia, neuropathy, and nystagmus may be prolonged of permanent.

Untreated cases of Wernicke’s encephalopathy can lead to Korsakoff’s syndrome, which is characterized by memory impairment associated with confabulation. The mortality rate associated with Wernicke’s encephalopathy is 10-20%, making early diagnosis and treatment crucial.

Psychotic Depression

Psychotic depression is a type of depression that is characterized by the presence of delusions and/of hallucinations in addition to depressive symptoms. This condition is often accompanied by severe anhedonia, loss of interest, and psychomotor retardation. People with psychotic depression are tormented by hallucinations and delusions with typical themes of worthlessness, guilt, disease, of impending disaster. This condition affects approximately 14.7-18.5% of depressed patients and is estimated to affect around 0.4% of community adult samples, with a higher prevalence in the elderly community at around 1.4-3.0%. People with psychotic depression are at a higher risk of attempting and completing suicide than those with non-psychotic depression.

Diagnosis

Psychotic depression is currently classified as a subtype of depression in both the ICD-11 and the DSM-5. The main difference between the two is that in the ICD-11, the depressive episode must be moderate of severe to qualify for a diagnosis of depressive episode with psychotic symptoms, whereas in the DSM-5, the diagnosis can be applied to any severity of depressive illness.

Treatment

The recommended treatment for psychotic depression is tricyclics as first-line treatment, with antipsychotic augmentation. Second-line treatment includes SSRI/SNRI. Augmentation of antidepressant with olanzapine or quetiapine is recommended. The optimum dose and duration of antipsychotic augmentation are unknown. If one treatment is to be stopped during the maintenance phase, then this should be the antipsychotic. ECT should be considered where a rapid response is required of where other treatments have failed. According to NICE (ng222), combination treatment with antidepressant medication and antipsychotic medication (such as olanzapine or quetiapine) should be considered for people with depression with psychotic symptoms. If a person with depression with psychotic symptoms does not wish to take antipsychotic medication in addition to an antidepressant, then treat with an antidepressant alone.

A negative prognosis in head injury can be indicated by various factors, including advanced age, history of prior head injury, post traumatic amnesia lasting longer than seven days, dependence on alcohol, severity of the head injury requiring neurosurgical intervention, and presence of the APOE4 gene.

Testamentary Capacity

Testamentary capacity is a crucial aspect of common law that pertains to a person’s legal and mental ability to create a will. To meet the requirements for testamentary capacity, there are four key factors that a testator must be aware of at the time of making the will. These include knowing the extent and value of their property, identifying the natural beneficiaries, understanding the disposition they are making, and having a plan for how the property will be distributed.

Clozapine is an effective antipsychotic drug used in the management of treatment-resistant schizophrenia (TRS). It was reintroduced in the 1990s with mandatory blood monitoring due to the risk of agranulocyte

Supportive Psychotherapy: An Overview

Supportive psychotherapy is a widely used approach in psychiatry, often reserved for clients who are not suitable for other forms of therapy. It aims to provide emotional support and encouragement to help people cope with overwhelming stress and restore them to their previous level of functioning. This therapy is not based on any specific psychological theory and is eclectic in approach.

Supportive psychotherapy is generally used with two different patient groups: those who were otherwise functioning well but have become symptomatic due to stress, and those who are not suitable for other forms of therapy. The goal of therapy is to help the patient get on with their life as best as possible, without disrupting reasonable defenses of generating conflicts.

The therapist avoids confrontation and transference issues are rarely analyzed. However, the therapeutic aims of long-term supportive psychotherapy include establishing a therapeutic alliance, holding and containing, promoting awareness of transference issues, promoting stability, facilitating the maturation of defenses, and promoting better adaptation to reality.

Supportive psychotherapy has been dismissed as ‘hand holding,’ but it should not be underestimated. It is suitable for most patients and is often the only therapy that can help when others have failed. Much of the work doctors do in outpatient clinics could be classified as supportive psychotherapy.

Priapism: A Painful and Persistent Erection

Priapism is a condition characterized by a prolonged and painful erection, which can occur in males and even in the clitoris. Although rare, certain medications such as antipsychotics and antidepressants have been known to cause priapism. The primary mechanism behind this condition is alpha blockade, although other mechanisms such as serotonin-mediated pathways have also been suggested. Some of the drugs most commonly associated with priapism include Trazodone, Chlorpromazine, and Thioridazine. Treatment involves the use of alpha-adrenergic agonists, which can be administered orally of injected directly into the penis. Priapism is a serious condition that can lead to complications such as penile amputation, although such cases are extremely rare.

Clozapine is an effective antipsychotic drug used in the management of treatment-resistant schizophrenia (TRS). It was reintroduced in the 1990s with mandatory blood monitoring due to the risk of agranulocyte

Schizoid Personality Disorder: A Description of Symptoms

Schizoid personality disorder is a type of personality disorder that falls under cluster A. People with this disorder are often seen as distant, isolated, and emotionally detached. They tend to have a restricted range of emotions and struggle to form close relationships with others. Symptoms typically begin in early adulthood and can be observed in various contexts. To be diagnosed with schizoid personality disorder, an individual must exhibit at least four of the following symptoms:

1. Lack of desire for close relationships
2. Preferring solitary activities
3. Little interest in sexual experiences
4. Finding pleasure in few activities
5. Lack of close friends of confidants
6. Indifference to praise of criticism
7. Emotional coldness, detachment, of flattened affectivity
8. Symptoms cannot be attributed to another medical condition and do not occur in the context of schizophrenia, manic depression, autism spectrum disorder, of another affective disorder with psychotic features.

It is important to note that the ICD-11 does not have a specific category for schizoid personality disorder. Instead, it has adopted a dimensional approach to diagnosis.

Klinefelter’s syndrome is a condition that occurs when a male has one of more extra copies of the X chromosome in their cells. This extra genetic material interferes with male sexual development, causing the testes to function abnormally and reducing testosterone levels. This can lead to delayed of incomplete puberty, genital abnormalities, gynecomastia, reduced facial and body hair, and infertility. Additionally, individuals with Klinefelter’s syndrome may experience learning disabilities, delayed speech and language development, and a shy personality. The syndrome is typically caused by one extra X chromosome in each cell, but can also be caused by two of three extra X chromosomes. The severity of symptoms increases with the number of extra sex chromosomes. Some individuals with Klinefelter’s syndrome have the extra X chromosome in only some of their cells, which can result in milder symptoms. Lyonization, which occurs when there are multiple X chromosomes in a cell, is present to some degree in all individuals with Klinefelter’s syndrome.

Lyonization: The Process of X-Inactivation

The X chromosome is crucial for proper development and cell viability, containing over 1,000 essential genes. However, females carry two copies of the X chromosome, which can result in a potentially toxic double dose of X-linked genes. To address this imbalance, females undergo a process called Lyonization, of X-inactivation, where one of their two X chromosomes is transcriptionally silenced. The silenced X chromosome then condenses into a compact structure known as a Barr body, which remains in a silent state.

X-inactivation occurs randomly, with no preference for the paternal or maternal X chromosome. It takes place early in embryogenesis, soon after fertilization when the dividing conceptus is about 16-32 cells big. This process occurs in all somatic cells of women, but not in germ cells involved in forming gametes. X-inactivation affects most, but not all, genes on the X chromosome. If a cell has more than two X chromosomes, the extra Xs are also inactivated.

Approximately 16% of individuals who visit an emergency department after self-harm will engage in self-harm again within the next year.

Self-Harm and its Management

Self-harm refers to intentional acts of self-poisoning of self-injury. It is prevalent among younger people, with an estimated 10% of girls and 3% of boys aged 15-16 years having self-harmed in the previous year. Risk factors for non-fatal repetition of self-harm include previous self-harm, personality disorder, hopelessness, history of psychiatric treatment, schizophrenia, alcohol abuse/dependence, and drug abuse/dependence. Suicide following an act of self-harm is more likely in those with previous episodes of self-harm, suicidal intent, poor physical health, and male gender.

Risk assessment tools are not recommended for predicting future suicide of repetition of self-harm. The recommended interventions for self-harm include 4-10 sessions of CBT specifically structured for people who self-harm and considering DBT for adolescents with significant emotional dysregulation. Drug treatment as a specific intervention to reduce self-harm should not be offered.

In the management of ingestion, activated charcoal can help if used early, while emetics and cathartics should not be used. Gastric lavage should generally not be used unless recommended by TOXBASE. Paracetamol is involved in 30-40% of acute presentations with poisoning. Intravenous acetylcysteine is the treatment of choice, and pseudo-allergic reactions are relatively common. Naloxone is used as an antidote for opioid overdose, while flumazenil can help reduce the need for admission to intensive care in benzodiazepine overdose.

For superficial uncomplicated skin lacerations of 5 cm of less in length, tissue adhesive of skin closure strips could be used as a first-line treatment option. All children who self-harm should be admitted for an overnight stay at a pediatric ward.

The Significance of Containment in Therapeutic Relationships

Containment is a term coined by Bion to describe the process of emotional containment, which is best exemplified by the relationship between a mother and her infant. Infants often project their unbearable feelings onto their mothers, who receive and accommodate them for a while, making them tolerable and acceptable again to the child.

In therapeutic relationships, containment plays a crucial role. It occurs when one person receives and comprehends the emotional communication of another without being overwhelmed by it. The receiver then processes the information and communicates understanding and recognition back to the other person. This process can help restore the other person’s capacity to think.

Overall, containment is an essential aspect of therapeutic relationships, as it allows individuals to express their emotions without fear of being judged of rejected. It creates a safe space for individuals to explore their feelings and thoughts, leading to greater self-awareness and personal growth.

The Stages of Change Model does not view relapse as a stage in the process.

Stages of Change Model

Prochaska and DiClemente’s Stages of Change Model identifies five stages that individuals go through when making a change. The first stage is pre-contemplation, where the individual is not considering change. There are different types of precontemplators, including those who lack knowledge about the problem, those who are afraid of losing control, those who feel hopeless, and those who rationalize their behavior.

The second stage is contemplation, where the individual is ambivalent about change and is sitting on the fence. The third stage is preparation, where the individual has some experience with change and is trying to change, testing the waters. The fourth stage is action, where the individual has started to introduce change, and the behavior is defined as action during the first six months of change.

The final stage is maintenance, where the individual is involved in ongoing efforts to maintain change. Action becomes maintenance once six months have elapsed. Understanding these stages can help individuals and professionals in supporting behavior change.

Cotard’s syndrome is a delusion where an individual believes they do not exist of have lost their blood, internal organs, of soul. It is commonly seen in depression, schizophrenia, and bipolar disorder, and can also occur after trauma. The condition is more prevalent in females and the elderly.

Understanding Hypothesis Testing in Statistics

In statistics, it is not feasible to investigate hypotheses on entire populations. Therefore, researchers take samples and use them to make estimates about the population they are drawn from. However, this leads to uncertainty as there is no guarantee that the sample taken will be truly representative of the population, resulting in potential errors. Statistical hypothesis testing is the process used to determine if claims from samples to populations can be made and with what certainty.

The null hypothesis (Ho) is the claim that there is no real difference between two groups, while the alternative hypothesis (H1 of Ha) suggests that any difference is due to some non-random chance. The alternative hypothesis can be one-tailed of two-tailed, depending on whether it seeks to establish a difference of a change in one direction.

Two types of errors may occur when testing the null hypothesis: Type I and Type II errors. Type I error occurs when the null hypothesis is rejected when it is true, while Type II error occurs when the null hypothesis is accepted when it is false. The power of a study is the probability of correctly rejecting the null hypothesis when it is false, and it can be increased by increasing the sample size.

P-values provide information on statistical significance and help researchers decide if study results have occurred due to chance. The p-value is the probability of obtaining a result that is as large of larger when in reality there is no difference between two groups. The cutoff for the p-value is called the significance level (alpha level), typically set at 0.05. If the p-value is less than the cutoff, the null hypothesis is rejected, and if it is greater or equal to the cut off, the null hypothesis is not rejected. However, the p-value does not indicate clinical significance, which may be too small to be meaningful.

Methods of Economic Evaluation

There are four main methods of economic evaluation: cost-effectiveness analysis (CEA), cost-benefit analysis (CBA), cost-utility analysis (CUA), and cost-minimisation analysis (CMA). While all four methods capture costs, they differ in how they assess health effects.

Cost-effectiveness analysis (CEA) compares interventions by relating costs to a single clinical measure of effectiveness, such as symptom reduction of improvement in activities of daily living. The cost-effectiveness ratio is calculated as total cost divided by units of effectiveness. CEA is typically used when CBA cannot be performed due to the inability to monetise benefits.

Cost-benefit analysis (CBA) measures all costs and benefits of an intervention in monetary terms to establish which alternative has the greatest net benefit. CBA requires that all consequences of an intervention, such as life-years saved, treatment side-effects, symptom relief, disability, pain, and discomfort, are allocated a monetary value. CBA is rarely used in mental health service evaluation due to the difficulty in converting benefits from mental health programmes into monetary values.

Cost-utility analysis (CUA) is a special form of CEA in which health benefits/outcomes are measured in broader, more generic ways, enabling comparisons between treatments for different diseases and conditions. Multidimensional health outcomes are measured by a single preference- of utility-based index such as the Quality-Adjusted-Life-Years (QALY). QALYs are a composite measure of gains in life expectancy and health-related quality of life. CUA allows for comparisons across treatments for different conditions.

Cost-minimisation analysis (CMA) is an economic evaluation in which the consequences of competing interventions are the same, and only inputs, i.e. costs, are taken into consideration. The aim is to decide the least costly way of achieving the same outcome.

Costs in Economic Evaluation Studies

There are three main types of costs in economic evaluation studies: direct, indirect, and intangible. Direct costs are associated directly with the healthcare intervention, such as staff time, medical supplies, cost of travel for the patient, childcare costs for the patient, and costs falling on other social sectors such as domestic help from social services. Indirect costs are incurred by the reduced productivity of the patient, such as time off work, reduced work productivity, and time spent caring for the patient by relatives. Intangible costs are difficult to measure, such as pain of suffering on the part of the patient.

It is common for women to experience the baby-blues, which affects approximately two-thirds of them. Although lack of sleep can be a symptom of depression, it is a normal occurrence for new mothers.

Perinatal Depression, Baby Blues, and Postpartum Depression

Perinatal depression, also known as postpartum depression, is a common mood disorder experienced by new mothers after childbirth. The term baby blues is used to describe the emotional lability that some mothers experience during the first week after childbirth, which usually resolves by day 10 without treatment. The prevalence of baby blues is around 40%. Postpartum depression, on the other hand, refers to depression that occurs after childbirth. While neither DSM-5 nor ICD-11 specifically mention postpartum depression, both diagnostic systems offer categories that encompass depression during pregnancy of in the weeks following delivery. The prevalence of postpartum depression is approximately 10-15%.

Various factors have been shown to increase the risk of postnatal depression, including youth, marital and family conflict, lack of social support, anxiety and depression during pregnancy, substance misuse, previous pregnancy loss, ambivalence about the current pregnancy, and frequent antenatal admissions to a maternity hospital. However, obstetric factors such as length of labor, assisted delivery, of separation of the mother from the baby in the Special Care Baby Unit do not seem to influence the development of postnatal depression. Additionally, social class does not appear to be associated with postnatal depression.

Puerperal psychosis, along with severe depression, is thought to be mainly caused by biological factors, while psychosocial factors are most important in the milder postnatal depressive illnesses.

Asthenic personality disorder, which used to be a common term, is now referred to as dependent personality disorder. It is important to be aware of this older term as it may still appear in older records.

Dependent Personality Disorder is a type of personality disorder where individuals excessively rely on others for support and fear abandonment. This disorder falls under Cluster C personality disorders. The DSM-5 criteria for this disorder includes exhibiting five of more of the following behaviors: difficulty making decisions without input from others, requiring others to take on responsibilities, fear of disagreement, difficulty starting projects without support, excessive need for nurturance and support, feeling vulnerable and helpless when alone, seeking new relationships when one ends, and having an unrealistic fear of being left alone and unable to care for oneself. The ICD-11 removed the specific diagnosis of Dependent Personality Disorder, but individuals can still be diagnosed with a general personality disorder if they exhibit dependent features.

Alcohol withdrawal is characterized by overactivity of the autonomic nervous system, resulting in symptoms such as agitation, tremors, sweating, nausea, vomiting, fever, and tachycardia. These symptoms typically begin 3-12 hours after drinking stops, peak between 24-48 hours, and can last up to 14 days. Withdrawal seizures may occur before blood alcohol levels reach zero, and a small percentage of people may experience delirium tremens (DT), which can be fatal if left untreated. Risk factors for DT include abnormal liver function, old age, severity of withdrawal symptoms, concurrent medical illness, heavy alcohol use, self-detox, previous history of DT, low potassium, low magnesium, and thiamine deficiency.

Pharmacologically assisted detox is often necessary for those who regularly consume more than 15 units of alcohol per day, and inpatient detox may be needed for those who regularly consume more than 30 units per day. The Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar) can be used to assess the severity of withdrawal symptoms and guide treatment decisions. Benzodiazepines are the mainstay of treatment, as chronic alcohol exposure results in decreased overall brain excitability and compensatory decrease of GABA-A neuroreceptor response to GABA. Chlordiazepoxide is a good first-line agent, while oxazepam, temazepam, and lorazepam are useful in patients with liver disease. Clomethiazole is effective but carries a high risk of respiratory depression and is not recommended. Thiamine should be offered to prevent Wernicke’s encephalopathy, and long-acting benzodiazepines can be used as prophylaxis for withdrawal seizures. Haloperidol is the treatment of choice if an antipsychotic is required.

Schizophrenia in children is rare compared to adults, with a prevalence estimate of 0.05% for those under 15 years old. There are two classifications based on age of onset: early onset schizophrenia (EOS) when symptoms appear between 13-18 years old, and very early onset schizophrenia (VEOS) when symptoms appear at of before 13 years old. EOS and VEOS have atypical features compared to adult-onset schizophrenia, including insidious onset, more severe neurodevelopmental abnormalities, terrifying visual hallucinations, constant inappropriate of blunted affects, higher rates of familial psychopathology, minor response to treatment, and poorer outcomes. Preliminary data suggests that VEOS and EOS may be due to greater familial vulnerability from genetic, psychosocial, and environmental factors. Poor outcomes are most reliably linked to a positive history of premorbid difficulties, greater symptom severity (especially negative symptoms) at baseline, and longer duration of untreated psychosis. Age at psychosis onset and sex are not consistent predictors of outcome.

The death instinct is known as Thanatos, while the life instinct is represented by Eros.

Freud’s Concepts of Thanatos and Eros

Freud’s theories introduced two fundamental concepts: thanatos and eros. Thanatos, also known as the death instinct, refers to the innate drive that each person possesses to cause destruction and death. On the other hand, eros, also known as the life instinct, refers to the opposite drive towards life. These concepts are essential to understanding Freud’s theories on human behavior and the unconscious mind. By acknowledging the presence of both thanatos and eros, Freud believed that individuals could better understand their motivations and desires. The concepts of thanatos and eros continue to be studied and debated in the field of psychology today.

Depression in the Elderly

Depression in the elderly is similar to depression in younger people, but there is a type of depression called vascular depression that has more cognitive impairment and apathy than depressive ideation. It can be difficult to distinguish between depression and dementia, but there are some key differences. Dementia has a rapid onset, while depression has symptoms of short duration. Mood and behavior fluctuate in dementia, while depression has consistently depressed mood. Patients with dementia often give don’t know answers, while those with depression give near miss answers. Patients with dementia try to conceal their forgetfulness, while those with depression highlight it. Cognitive impairment is relatively stable in dementia, while it fluctuates greatly in depression. Higher cortical dysfunction is evident in dementia, while it is absent in depression.

Stages of Change Model

Prochaska and DiClemente’s Stages of Change Model identifies five stages that individuals go through when making a change. The first stage is pre-contemplation, where the individual is not considering change. There are different types of precontemplators, including those who lack knowledge about the problem, those who are afraid of losing control, those who feel hopeless, and those who rationalize their behavior.

The second stage is contemplation, where the individual is ambivalent about change and is sitting on the fence. The third stage is preparation, where the individual has some experience with change and is trying to change, testing the waters. The fourth stage is action, where the individual has started to introduce change, and the behavior is defined as action during the first six months of change.

The final stage is maintenance, where the individual is involved in ongoing efforts to maintain change. Action becomes maintenance once six months have elapsed. Understanding these stages can help individuals and professionals in supporting behavior change.

Amphetamine induces the direct release of dopamine by stimulating it, while also causing the internalization of dopamine transporters from the cell surface. In contrast, cocaine only blocks dopamine transporters and does not induce dopamine release.

Mechanisms of action for illicit drugs can be classified based on their effects on ionotropic receptors of ion channels, G coupled receptors, of monoamine transporters. Cocaine and amphetamine both increase dopamine levels in the synaptic cleft, but through different mechanisms. Cocaine directly blocks the dopamine transporter, while amphetamine binds to the transporter and increases dopamine efflux through various mechanisms, including inhibition of vesicular monoamine transporter 2 and monoamine oxidase, and stimulation of the intracellular receptor TAAR1. These mechanisms result in increased dopamine levels in the synaptic cleft and reuptake inhibition.

While quantitative methods are typically used for treatment evaluation, qualitative studies can also provide valuable insights by interpreting, qualifying, of illuminating findings. This is especially beneficial when examining unexpected results, as they can help to test the primary hypothesis.

Qualitative research is a method of inquiry that seeks to understand the meaning and experience dimensions of human lives and social worlds. There are different approaches to qualitative research, such as ethnography, phenomenology, and grounded theory, each with its own purpose, role of the researcher, stages of research, and method of data analysis. The most common methods used in healthcare research are interviews and focus groups. Sampling techniques include convenience sampling, purposive sampling, quota sampling, snowball sampling, and case study sampling. Sample size can be determined by data saturation, which occurs when new categories, themes, of explanations stop emerging from the data. Validity can be assessed through triangulation, respondent validation, bracketing, and reflexivity. Analytical approaches include content analysis and constant comparison.

EMDR: A Trauma-Focused Therapy for PTSD

EMDR, of eye movement desensitisation and reprocessing, is a therapy developed by Francine Shapiro in the 1980s that focuses on processing traumatic memories. While the exact way it works is not fully understood, it involves reliving traumatic memories while experiencing bilateral alternating stimulation, often through a light source. EMDR is recommended by the NICE Guidelines as a treatment for PTSD, along with trauma-focused cognitive-behavioral therapy.

According to the Maudsley 14th, Risperidone is approved for a maximum dosage of 1 mg twice daily, but the recommended of optimal dose is 500 µg.

Management of Non-Cognitive Symptoms in Dementia

Non-cognitive symptoms of dementia can include agitation, aggression, distress, psychosis, depression, anxiety, sleep problems, wandering, hoarding, sexual disinhibition, apathy, and shouting. Non-pharmacological measures, such as music therapy, should be considered before prescribing medication. Pain may cause agitation, so a trial of analgesics is recommended. Antipsychotics, such as risperidone, olanzapine, and aripiprazole, may be used for severe distress of serious risk to others, but their use is controversial due to issues of tolerability and an association with increased mortality. Cognitive enhancers, such as AChE-Is and memantine, may have a modest benefit on BPSD, but their effects may take 3-6 months to take effect. Benzodiazepines should be avoided except in emergencies, and antidepressants, such as citalopram and trazodone, may have mixed evidence for BPSD. Mood stabilizers, such as valproate and carbamazepine, have limited evidence to support their use. Sedating antihistamines, such as promethazine, may cause cognitive impairment and should only be used short-term. Melatonin has limited evidence to support its use but is safe to use and may be justified in some cases where benefits are seen. For Lewy Body dementia, clozapine is favored over risperidone, and quetiapine may be a reasonable choice if clozapine is not appropriate. Overall, medication should only be used when non-pharmacological measures are ineffective, and the need is balanced with the increased risk of adverse effects.

When conducting a systematic review, restricting the selection of studies to those published only in English may introduce a bias known as the Tower of Babel effect. This occurs because studies conducted in non-English speaking countries that report positive results are more likely to be published in English language journals, while those with negative results are more likely to be published in non-English language journals.

Schizophrenia: Understanding the Risk Factors

Social class is a significant risk factor for schizophrenia, with people of lower socioeconomic status being more likely to develop the condition. Two hypotheses attempt to explain this relationship, one suggesting that environmental exposures common in lower social class conditions are responsible, while the other suggests that people with schizophrenia tend to drift towards the lower class due to their inability to compete for good jobs.

While early studies suggested that schizophrenia was more common in black populations than in white, the current consensus is that there are no differences in rates of schizophrenia by race. However, there is evidence that rates are higher in migrant populations and ethnic minorities.

Gender and age do not appear to be consistent risk factors for schizophrenia, with conflicting evidence on whether males of females are more likely to develop the condition. Marital status may also play a role, with females with schizophrenia being more likely to marry than males.

Family history is a strong risk factor for schizophrenia, with the risk increasing significantly for close relatives of people with the condition. Season of birth and urban versus rural place of birth have also been shown to impact the risk of developing schizophrenia.

Obstetric complications, particularly prenatal nutritional deprivation, brain injury, and influenza, have been identified as significant risk factors for schizophrenia. Understanding these risk factors can help identify individuals who may be at higher risk for developing the condition and inform preventative measures.

The high concordance rate of 50% among monozygotic twins and the 10% likelihood of offspring being affected indicate a significant genetic component in the development of schizophrenia.

The relative risk (RR) of the event of interest in the exposed group compared to the unexposed group is 2.5.

RR = EER / CER
EER = 10 / 200 = 0.05
CER = 10 / 500 = 0.02
RR = EER / CER
= 0.05 / 0.02 = 2.5

This means that the exposed group has a 2.5 times higher risk of experiencing the event compared to the unexposed group.

Measures of Effect in Clinical Studies

When conducting clinical studies, we often want to know the effect of treatments of exposures on health outcomes. Measures of effect are used in randomized controlled trials (RCTs) and include the odds ratio (of), risk ratio (RR), risk difference (RD), and number needed to treat (NNT). Dichotomous (binary) outcome data are common in clinical trials, where the outcome for each participant is one of two possibilities, such as dead of alive, of clinical improvement of no improvement.

To understand the difference between of and RR, it’s important to know the difference between risks and odds. Risk is a proportion that describes the probability of a health outcome occurring, while odds is a ratio that compares the probability of an event occurring to the probability of it not occurring. Absolute risk is the basic risk, while risk difference is the difference between the absolute risk of an event in the intervention group and the absolute risk in the control group. Relative risk is the ratio of risk in the intervention group to the risk in the control group.

The number needed to treat (NNT) is the number of patients who need to be treated for one to benefit. Odds are calculated by dividing the number of times an event happens by the number of times it does not happen. The odds ratio is the odds of an outcome given a particular exposure versus the odds of an outcome in the absence of the exposure. It is commonly used in case-control studies and can also be used in cross-sectional and cohort study designs. An odds ratio of 1 indicates no difference in risk between the two groups, while an odds ratio >1 indicates an increased risk and an odds ratio <1 indicates a reduced risk.

Bipolar Disorder Diagnosis

Bipolar and related disorders are mood disorders characterized by manic, mixed, of hypomanic episodes alternating with depressive episodes. The lifetime risk of suicide in individuals with bipolar disorder is estimated to be at least 15 times that of the general population. Under the ICD-11, there are three subtypes of bipolar disorder: Bipolar I, Bipolar II, and Cyclothymic disorder.

Bipolar I disorder is diagnosed when an individual has a history of at least one manic of mixed episode. The typical course of the disorder is characterized by recurrent depressive and manic of mixed episodes. Onset of the first mood episode most often occurs during the late teen years, but onset of bipolar type I can occur at any time through the life cycle. The lifetime prevalence of bipolar I disorder is estimated to be around 2.1%.

Bipolar II disorder is diagnosed when an individual has a history of at least one hypomanic episode and at least one depressive episode. The typical course of the disorder is characterized by recurrent depressive and hypomanic episodes. Onset of bipolar type II most often occurs during the mid-twenties. The number of lifetime episodes tends to be higher for bipolar II disorder than for major depressive disorder of bipolar I disorder.

Cyclothymic disorder is diagnosed when an individual experiences mood instability over an extended period of time characterized by numerous hypomanic and depressive periods. The symptoms are present for more days than not, and there is no history of manic or mixed episodes. The course of cyclothymic disorder is often gradual and persistent, and onset commonly occurs during adolescence of early adulthood.

Rapid cycling is not a subtype of bipolar disorder but instead is a qualifier. It is defined as the presence of at least four mood episodes in the previous 12 months that meet the criteria for a manic, hypomanic, of major depressive episode. Rapid cycling is associated with an increased risk of suicide and tends to be precipitated by stressors such as life events, alcohol abuse, use of antidepressants, and medical disorders.

Overall, the diagnosis of bipolar disorder requires careful evaluation of an individual’s symptoms and history. Treatment typically involves a combination of medication and psychotherapy.

Out of the given options, Amitriptyline (TCA) is classified as high risk while the others are categorized as either moderate of low risk.

Psychotropics and Seizure Threshold in People with Epilepsy

People with epilepsy are at an increased risk for various mental health conditions, including depression, anxiety, psychosis, and suicide. It is important to note that the link between epilepsy and mental illness is bidirectional, as patients with mental health conditions also have an increased risk of developing new-onset epilepsy. Psychotropic drugs are often necessary for people with epilepsy, but they can reduce the seizure threshold and increase the risk of seizures. The following tables provide guidance on the seizure risk associated with different classes of antidepressants, antipsychotics, and ADHD medications. It is important to use caution and carefully consider the risks and benefits of these medications when treating people with epilepsy.

Bipolar Disorder Diagnosis

Bipolar and related disorders are mood disorders characterized by manic, mixed, of hypomanic episodes alternating with depressive episodes. The lifetime risk of suicide in individuals with bipolar disorder is estimated to be at least 15 times that of the general population. Under the ICD-11, there are three subtypes of bipolar disorder: Bipolar I, Bipolar II, and Cyclothymic disorder.

Bipolar I disorder is diagnosed when an individual has a history of at least one manic of mixed episode. The typical course of the disorder is characterized by recurrent depressive and manic of mixed episodes. Onset of the first mood episode most often occurs during the late teen years, but onset of bipolar type I can occur at any time through the life cycle. The lifetime prevalence of bipolar I disorder is estimated to be around 2.1%.

Bipolar II disorder is diagnosed when an individual has a history of at least one hypomanic episode and at least one depressive episode. The typical course of the disorder is characterized by recurrent depressive and hypomanic episodes. Onset of bipolar type II most often occurs during the mid-twenties. The number of lifetime episodes tends to be higher for bipolar II disorder than for major depressive disorder of bipolar I disorder.

Cyclothymic disorder is diagnosed when an individual experiences mood instability over an extended period of time characterized by numerous hypomanic and depressive periods. The symptoms are present for more days than not, and there is no history of manic or mixed episodes. The course of cyclothymic disorder is often gradual and persistent, and onset commonly occurs during adolescence of early adulthood.

Rapid cycling is not a subtype of bipolar disorder but instead is a qualifier. It is defined as the presence of at least four mood episodes in the previous 12 months that meet the criteria for a manic, hypomanic, of major depressive episode. Rapid cycling is associated with an increased risk of suicide and tends to be precipitated by stressors such as life events, alcohol abuse, use of antidepressants, and medical disorders.

Overall, the diagnosis of bipolar disorder requires careful evaluation of an individual’s symptoms and history. Treatment typically involves a combination of medication and psychotherapy.

Antidepressants (Licensed Indications)

The following table outlines the specific licensed indications for antidepressants in adults, as per the Maudsley Guidelines and the British National Formulary. It is important to note that all antidepressants are indicated for depression.

– Nocturnal enuresis in children: Amitriptyline, Imipramine, Nortriptyline
– Phobic and obsessional states: Clomipramine
– Adjunctive treatment of cataplexy associated with narcolepsy: Clomipramine
– Panic disorder and agoraphobia: Citalopram, Escitalopram, Sertraline, Paroxetine, Venlafaxine
– Social anxiety/phobia: Escitalopram, Paroxetine, Sertraline, Moclobemide, Venlafaxine
– Generalised anxiety disorder: Escitalopram, Paroxetine, Duloxetine, Venlafaxine
– OCD: Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline, Clomipramine
– Bulimia nervosa: Fluoxetine
– PTSD: Paroxetine, Sertraline

The available evidence regarding high-dose antipsychotic therapy is mixed and generally unfavorable.

Schizophrenia Treatment

When it comes to treating schizophrenia, there are several consistent findings that have been discovered. One of these is that clozapine is more effective than other antipsychotics for neuroleptic-refractory positive symptoms. Additionally, transcranial magnetic stimulation (TMS) has been found to be effective, while cognitive behavioural therapy can reduce psychotic symptoms. Family and patient psychoeducation can also reduce relapses, and social skills training has been shown to improve outcomes. Finally, early intervention during the first episode of psychosis has been found to improve outcomes as well.

Achieving a level of 1.1 mmol/L indicates that the appropriate therapeutic level of lithium has been reached, and any further increase in dosage would be unsafe (as per the Maudsley 14th guidelines, which recommend a level between 1.0-1.2). To address this, the guidelines suggest adding an antipsychotic medication, preferably one that is licensed for bipolar disorder, such as olanzapine, risperidone, quetiapine, of aripiprazole.

Bipolar Disorder: Diagnosis and Management

Bipolar disorder is a lifelong condition characterized by episodes of mania or hypomania and episodes of depressed mood. The peak age of onset is 15-19 years, and the lifetime prevalence of bipolar I disorders is estimated to be around 2.1%. The diagnosis of bipolar disorder is based on the presence of manic or hypomanic episodes, which are characterized by elevated of expansive mood, rapid speech, and increased activity of energy. Psychotic symptoms, such as delusions and hallucinations, may also be present.

Bipolar depression differs from unipolar depression in several ways, including more rapid onset, more frequent episodes, and shorter duration. Rapid cycling is a qualifier that can be applied to bipolar I of bipolar II disorder and is defined as the presence of at least four mood episodes in the previous 12 months that meet the criteria for a manic, hypomanic, of major depressive episode.

The management of bipolar disorder involves acute and long-term interventions. Acute management of mania or hypomania may involve stopping antidepressants and offering antipsychotics of mood stabilizers. Long-term management may involve psychological interventions and pharmacological treatments such as lithium, valproate, of olanzapine.

It is important to note that valproate should not be offered to women of girls of childbearing potential for long-term bipolar disorder unless other options are ineffective of not tolerated and a pregnancy prevention program is in place. Aripiprazole is recommended as an option for treating moderate to severe manic episodes in adolescents with bipolar I disorder.

Overall, the diagnosis and management of bipolar disorder require a comprehensive approach that takes into account the individual’s symptoms, history, and preferences.

Although sertraline can be used to treat depression during pregnancy, it is important to note that no psychotropic medication is completely safe. Therefore, it is recommended to avoid medication if possible and carefully consider the risk versus benefit. In cases of mild depression, it may be reasonable to explore non-medication options.

Paroxetine Use During Pregnancy: Is it Safe?

Prescribing medication during pregnancy and breastfeeding is challenging due to the potential risks to the fetus of baby. No psychotropic medication has a UK marketing authorization specifically for pregnant of breastfeeding women. Women are encouraged to breastfeed unless they are taking carbamazepine, clozapine, of lithium. The risk of spontaneous major malformation is 2-3%, with drugs accounting for approximately 5% of all abnormalities. Valproate and carbamazepine are associated with an increased risk of neural tube defects, and lithium is associated with cardiac malformations. Benzodiazepines are associated with oral clefts and floppy baby syndrome. Antidepressants have been linked to preterm delivery and congenital malformation, but most findings have been inconsistent. TCAs have been used widely without apparent detriment to the fetus, but their use in the third trimester is known to produce neonatal withdrawal effects. Sertraline appears to result in the least placental exposure among SSRIs. MAOIs should be avoided in pregnancy due to a suspected increased risk of congenital malformations and hypertensive crisis. If a pregnant woman is stable on an antipsychotic and likely to relapse without medication, she should continue the antipsychotic. Depot antipsychotics should not be offered to pregnant of breastfeeding women unless they have a history of non-adherence with oral medication. The Maudsley Guidelines suggest specific drugs for use during pregnancy and breastfeeding. NICE CG192 recommends high-intensity psychological interventions for moderate to severe depression and anxiety disorders. Antipsychotics are recommended for pregnant women with mania of psychosis who are not taking psychotropic medication. Promethazine is recommended for insomnia.

Individuals with epilepsy are at a low risk when taking sertraline.

Psychotropics and Seizure Threshold in People with Epilepsy

People with epilepsy are at an increased risk for various mental health conditions, including depression, anxiety, psychosis, and suicide. It is important to note that the link between epilepsy and mental illness is bidirectional, as patients with mental health conditions also have an increased risk of developing new-onset epilepsy. Psychotropic drugs are often necessary for people with epilepsy, but they can reduce the seizure threshold and increase the risk of seizures. The following tables provide guidance on the seizure risk associated with different classes of antidepressants, antipsychotics, and ADHD medications. It is important to use caution and carefully consider the risks and benefits of these medications when treating people with epilepsy.

Stats: Correlation and Regression

Correlation and regression are related but not interchangeable terms. Correlation is used to test for association between variables, while regression is used to predict values of dependent variables from independent variables. Correlation can be linear, non-linear, of non-existent, and can be strong, moderate, of weak. The strength of a linear relationship is measured by the correlation coefficient, which can be positive of negative and ranges from very weak to very strong. However, the interpretation of a correlation coefficient depends on the context and purposes. Correlation can suggest association but cannot prove of disprove causation. Linear regression, on the other hand, can be used to predict how much one variable changes when a second variable is changed. Scatter graphs are used in correlation and regression analyses to visually determine if variables are associated and to detect outliers. When constructing a scatter graph, the dependent variable is typically placed on the vertical axis and the independent variable on the horizontal axis.

Paranoid personality disorder and schizotypal personality disorder share some common traits such as suspiciousness, interpersonal aloofness, and paranoid ideation. However, schizotypal personality disorder also includes symptoms like magical thinking, unusual perceptual experiences, and odd thinking and speech. In this particular case, the individual’s inappropriate affect and ideas of reference suggest schizotypal personality disorder rather than paranoid personality disorder. Individuals with schizoid personality disorder are often perceived as strange, eccentric, cold, and aloof, but they do not usually exhibit prominent paranoid ideation. Interestingly, research has shown that schizotypal personality disorder is a significant predictor of belief in conspiracy theories (March, 2019).

Schizotypal Personality Disorder: Symptoms and Diagnostic Criteria

Schizotypal personality disorder is a type of personality disorder that is characterized by a pervasive pattern of discomfort with close relationships, distorted thinking and perceptions, and eccentric behavior. This disorder typically begins in early adulthood and is present in a variety of contexts. To be diagnosed with schizotypal personality disorder, an individual must exhibit at least five of the following symptoms:

1. Ideas of reference (excluding delusions of reference).
2. Odd beliefs of magical thinking that influences behavior and is inconsistent with subcultural norms.
3. Unusual perceptual experiences, including bodily illusions.
4. Odd thinking and speech.
5. Suspiciousness of paranoid ideation.
6. Inappropriate or constricted affect.
7. Behavior of appearance that is odd, eccentric, of peculiar.
8. Lack of close friends of confidants other than first-degree relatives.
9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.

It is important to note that the ICD-11 does not have a specific category for schizotypal personality disorder, as it has abandoned the categorical approach in favor of a dimensional one.

Munchausen’s syndrome by proxy, also known as fabricated or induced illness, is a rare form of child abuse where a caregiver, usually the mother, falsifies illness in a child by fabricating of producing symptoms and presenting the child for medical care while denying knowledge of the cause. It is most commonly seen in children under the age of 4, with symptoms including apnoea, anorexia, feeding problems, and seizures. The disorder is now recognized as ‘Factitious Disorder Imposed on Another’ in the DSM-5, with criteria including falsification of physical of psychological signs of symptoms, presentation of the victim as ill, and evident deceptive behavior. The perpetrator, not the victim, receives this diagnosis. Presenting signs of symptoms can take the form of covert injury, fabrication of symptoms, of exaggeration of existing symptoms. Symptoms are often subjective and easy to fake.

In cases of paracetamol overdose, it is recommended to measure the levels of the drug in the patient’s system 4 hours after the incident, if possible. Treatment should be based on the results of this test. However, in this particular case, since the patient has sought medical attention early, there is sufficient time to obtain the test results before initiating treatment. Blind treatment is only considered when the levels cannot be measured within 8 hours, of when the patient has ingested more than 150 mg/kg of paracetamol, of when the overdose was taken in a staggered manner of the timing is uncertain, as the test results may not be reliable in such cases.

Self-Harm and its Management

Self-harm refers to intentional acts of self-poisoning of self-injury. It is prevalent among younger people, with an estimated 10% of girls and 3% of boys aged 15-16 years having self-harmed in the previous year. Risk factors for non-fatal repetition of self-harm include previous self-harm, personality disorder, hopelessness, history of psychiatric treatment, schizophrenia, alcohol abuse/dependence, and drug abuse/dependence. Suicide following an act of self-harm is more likely in those with previous episodes of self-harm, suicidal intent, poor physical health, and male gender.

Risk assessment tools are not recommended for predicting future suicide of repetition of self-harm. The recommended interventions for self-harm include 4-10 sessions of CBT specifically structured for people who self-harm and considering DBT for adolescents with significant emotional dysregulation. Drug treatment as a specific intervention to reduce self-harm should not be offered.

In the management of ingestion, activated charcoal can help if used early, while emetics and cathartics should not be used. Gastric lavage should generally not be used unless recommended by TOXBASE. Paracetamol is involved in 30-40% of acute presentations with poisoning. Intravenous acetylcysteine is the treatment of choice, and pseudo-allergic reactions are relatively common. Naloxone is used as an antidote for opioid overdose, while flumazenil can help reduce the need for admission to intensive care in benzodiazepine overdose.

For superficial uncomplicated skin lacerations of 5 cm of less in length, tissue adhesive of skin closure strips could be used as a first-line treatment option. All children who self-harm should be admitted for an overnight stay at a pediatric ward.

Schizophrenia and Mortality

Schizophrenia is associated with a reduced life expectancy, according to a meta-analysis of 37 studies. The analysis found that people with schizophrenia have a mean SMR (standardised mortality ratio) of 2.6, meaning that their risk of dying over the next year is 2.6 times higher than that of people without the condition. Suicide and accidents contribute significantly to the increased SMR, while cardiovascular disease is the leading natural cause of death. SMR decreases with age due to the early peak of suicides and the gradual rise in population mortality. There is no sex difference in SMR, but patients who are unmarried, unemployed, and of lower social class have higher SMRs. The majority of deaths in people with schizophrenia are due to natural causes, with circulatory disease being the most common. Other linked causes include diabetes, epilepsy, and respiratory disease.

The recommended initial treatment for opioid detoxification is methadone of buprenorphine.

Opioid Maintenance Therapy and Detoxification

Withdrawal symptoms can occur after as little as 5 days of regular opioid use. Short-acting opioids like heroin have acute withdrawal symptoms that peak in 32-72 hours and last for 3-5 days. Longer-acting opioids like methadone have acute symptoms that peak at day 4-6 and last for 10 days. Buprenorphine withdrawal lasts up to 10 days and includes symptoms like myalgia, anxiety, and increased drug craving.

Opioids affect the brain through opioid receptors, with the µ receptor being the main target for opioids. Dopaminergic cells in the ventral tegmental area produce dopamine, which is released into the nucleus accumbens upon stimulation of µ receptors, producing euphoria and reward. With repeat opioid exposure, µ receptors become less responsive, causing dysphoria and drug craving.

Methadone and buprenorphine are maintenance-oriented treatments for opioid dependence. Methadone is a full agonist targeting µ receptors, while buprenorphine is a partial agonist targeting µ receptors and a partial k agonist of functional antagonist. Naloxone and naltrexone are antagonists targeting all opioid receptors.

Methadone is preferred over buprenorphine for detoxification, and ultra-rapid detoxification should not be offered. Lofexidine may be considered for mild of uncertain dependence. Clonidine and dihydrocodeine should not be used routinely in opioid detoxification. The duration of detoxification should be up to 4 weeks in an inpatient setting and up to 12 weeks in a community setting.

Pregnant women dependent on opioids should use opioid maintenance treatment rather than attempt detoxification. Methadone is preferred over buprenorphine, and transfer to buprenorphine during pregnancy is not advised. Detoxification should only be considered if appropriate for the women’s wishes, circumstances, and ability to cope. Methadone or buprenorphine treatment is not a contraindication to breastfeeding.

Individuals with antisocial personality disorder were more likely to have a history of aggression, unemployment, and promiscuity than to have committed serious crimes.

Personality Disorder (Antisocial / Dissocial)

Antisocial personality disorder is characterized by impulsive, irresponsible, and often criminal behavior. The criteria for this disorder differ somewhat between the ICD-11 and DSM-5. The ICD-11 abolished all categories of personality disorder except for a general description of personality disorder. This diagnosis can be further specified as “mild,” “moderate,” of “severe.” Patient behavior can be described using one of more of five personality trait domains; negative affectivity, dissociality, anankastic, detachment, and disinhibition. Clinicians may also specify a borderline pattern qualifier.

The core feature of dissociality is a disregard for the rights and feelings of others, encompassing both self-centeredness and lack of empathy. Common manifestations of Dissociality include self-centeredness and lack of empathy. The DSM-5 defines antisocial personality disorder as a pervasive pattern of disregard for and violation of the rights of others, occurring since age 15, as indicated by three (of more) of the following: failure to conform to social norms with respect to lawful behaviors, deceitfulness, impulsivity of failure to plan ahead, irritability and aggressiveness, reckless disregard for safety of self of others, consistent irresponsibility, and lack of remorse.

Prevalence estimates are between 1%-6% in men and between 0.2-0.8% in women. Antisocial behaviors typically have their onset before age 8 years. Nearly 80% of people with ASPD developed their first symptom by age 11 years. Boys develop symptoms earlier than girls, who may not develop symptoms until puberty. An estimated 25% of girls and 40% of boys with Conduct Disorder will later meet criteria for ASPD.

The 2009 NICE Guidelines essentially make two recommendations on treatment: consider offering group-based cognitive and behavioral interventions and pharmacological interventions should not be routinely used for the treatment of antisocial personality disorder of associated behaviors of aggression, anger, and impulsivity. A Cochrane review found that there is not enough good quality evidence to recommend of reject any psychological treatment for people with a diagnosis of AsPD.

The term psychopathy has varied meanings. Some use the term synonymously with APD and consider it to represent the severe end of the spectrum of APD. Others maintain a clear distinction between psychopathy and APD. Psychopathy has been said to be a richer (broader) concept than APD. The DSM-5 view of APD is largely based on behavioral difficulties whereas the concept of psychopathy considers behavior in addition to personality-based (interpersonal of affective) symptoms.

– Avunculicide: murder of one’s uncle
– Familicide: murder of murder-suicide of at least one spouse and one of more children
– Filicide: murder of a child (under the age of 18) by its parent
– Infanticide: killing of a child aged less than 12 months, can only be committed by the mother in English Law
– Uxoricide: murder of one’s wife
– Matricide: act of killing one’s husband