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

Dysthymia is a type of mood disorder characterized by persistent low-grade depressive symptoms that last for at least two years. Although there may be brief periods without symptoms, there has never been a prolonged period of two months of more without symptoms since the onset of the disorder. While treatment for dysthymia can be effective, the results may be modest and short-lived, and the course of the disorder can be challenging. Dysthymia often begins in childhood of adolescence and is associated with a higher likelihood of substance misuse and co-occurring personality disorders, particularly when onset occurs before the age of 21. Co-occurring disorders are common in individuals with dysthymia.

Depression is diagnosed using different criteria in the ICD-11 and DSM-5. The ICD-11 recognizes single depressive episodes, recurrent depressive disorder, dysthymic disorder, and mixed depressive and anxiety disorder. The DSM-5 recognizes disruptive mood dysregulation disorder, major depressive disorder, persistent depressive disorder, and premenstrual dysphoric disorder.

For a diagnosis of a single depressive episode, the ICD-11 requires the presence of at least five characteristic symptoms occurring most of the day, nearly every day during a period lasting at least 2 weeks. The DSM-5 requires the presence of at least five symptoms during the same 2-week period, with at least one of the symptoms being either depressed mood of loss of interest of pleasure.

Recurrent depressive disorder is characterized by a history of at least two depressive episodes separated by at least several months without significant mood disturbance, according to the ICD-11. The DSM-5 requires at least two episodes with an interval of at least 2 consecutive months between separate episodes in which criteria are not met for a major depressive episode.

Dysthymic disorder is diagnosed when a person experiences persistent depressed mood lasting 2 years of more, according to the ICD-11. The DSM-5 requires depressed mood for most of the day, for more days than not, for at least 2 years, along with the presence of two or more additional symptoms.

Mixed depressive and anxiety disorder is recognized as a separate code in the ICD-11, while the DSM-5 uses the ‘with anxious distress’ qualifier. The ICD-11 requires the presence of both depressive and anxiety symptoms for most of the time during a period of 2 weeks of more, while the DSM-5 requires the presence of both depressive and anxious symptoms during the same 2-week period.

Overall, the criteria for diagnosing depression vary between the ICD-11 and DSM-5, but both require the presence of characteristic symptoms that cause significant distress of impairment in functioning.

The sudden appearance of symptoms without a preceding prodrome indicates an acute and temporary psychotic disorder, rather than the milder experiences observed in schizotypal disorder.

– 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.

Bipolar Disorder: Historical Subtypes

Bipolar disorder is a complex mental illness that has been classified into several subtypes over the years. The most widely recognized subtypes are Bipolar I, Bipolar II, and Cyclothymia. However, there have been other classification systems proposed by experts in the field.

In 1981, Gerald Klerman proposed a classification system that included Bipolar I, Bipolar II, Bipolar III, Bipolar IV, Bipolar V, and Bipolar VI. This system was later expanded by Akiskal in 1999, who added more subtypes such as Bipolar I 1/2, Bipolar II 1/2, and Bipolar III 1/2.

Bipolar I is characterized by full-blown mania, while Bipolar II is characterized by hypomania with depression. Cyclothymia is a milder form of bipolar disorder that involves cycling between hypomania and mild depression.

Other subtypes include Bipolar III, which is associated with hypomania of mania precipitated by antidepressant drugs, and Bipolar IV, which is characterized by hyperthymic depression. Bipolar V is associated with depressed patients who have a family history of bipolar illness, while Bipolar VI is characterized by mania without depression (unipolar mania).

Overall, the classification of bipolar disorder subtypes has evolved over time, and different experts have proposed different systems. However, the most widely recognized subtypes are still Bipolar I, Bipolar II, and Cyclothymia.

The Maudsley Guidelines recommend the use of diazepam and clonazepam in their treatment plan for antipsychotic induced akathisia, likely because of their extended duration of action.

Benzodiazepines are a class of drugs commonly used to treat anxiety and sleep disorders. It is important to have a working knowledge of the more common benzodiazepines and their half-life. Half-life refers to the amount of time it takes for half of the drug to be eliminated from the body.

Some of the more common benzodiazepines and their half-life include diazepam with a half-life of 20-100 hours, clonazepam with a half-life of 18-50 hours, chlordiazepoxide with a half-life of 5-30 hours, nitrazepam with a half-life of 15-38 hours, temazepam with a half-life of 8-22 hours, lorazepam with a half-life of 10-20 hours, alprazolam with a half-life of 10-15 hours, oxazepam with a half-life of 6-10 hours, zopiclone with a half-life of 5-6 hours, zolpidem with a half-life of 2 hours, and zaleplon with a half-life of 2 hours. Understanding the half-life of these drugs is important for determining dosages and timing of administration.

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.

If a patient taking clozapine experiences chest pain, it is important to consider myocarditis as a potential cause. Conducting a troponin test can aid in confirming the presence of this condition.

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

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.

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.

Paranoid Personality Disorder is a type of personality disorder where individuals have a deep-seated distrust and suspicion of others, often interpreting their actions as malevolent. This disorder is characterized by a pattern of negative interpretations of others’ words, actions, and intentions, leading to a reluctance to confide in others and holding grudges for long periods of time. The DSM-5 criteria for this disorder include at least four of the following symptoms: unfounded suspicions of exploitation, harm, of deception by others, preoccupation with doubts about the loyalty of trustworthiness of friends of associates, reluctance to confide in others due to fear of malicious use of information, reading negative meanings into benign remarks of events, persistent grudges, perceiving attacks on one’s character of reputation that are not apparent to others and reacting angrily of counterattacking, and recurrent suspicions of infidelity in a partner without justification. The ICD-11 does not have a specific category for paranoid personality disorder but covers many of its features under the negative affectivity qualifier under the element of mistrustfulness.

Children experience a particular symptom more frequently than adults do.

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.

Based on the case, it appears that the patient is experiencing bipolar I with rapid cycling. According to NICE guidelines, there is no specific treatment recommended for rapid cycling. However, one possible approach would be to add an antipsychotic medication to the patient’s current lithium treatment. Alternatively, the Maudsley Guidelines suggest that combining different mood stabilizers, such as lithium and valproate, may be considered as an alternative treatment option.

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.

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.

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.

Vigabatrin has the potential to cause permanent visual field constriction, leading to tunnel vision and disability. It may also harm the central retina and reduce visual acuity. The risk of vision loss increases with higher doses and prolonged use. The onset of vision loss is unpredictable and can occur shortly after starting treatment of at any point during treatment, even after several months of years. Unfortunately, once vision loss is detected, it cannot be reversed.

Antiepileptic drugs (AEDs) are commonly used for the treatment of epilepsy, but many of them also have mood stabilizing properties and are used for the prophylaxis and treatment of bipolar disorder. However, some AEDs carry product warnings for serious side effects such as hepatic failure, pancreatitis, thrombocytopenia, and skin reactions. Additionally, some AEDs have been associated with an increased risk of suicidal behavior and ideation.

Behavioral side-effects associated with AEDs include depression, aberrant behaviors, and the development of worsening of irritability, impulsivity, anger, hostility, and aggression. Aggression can occur before, after, of in between seizures. Some AEDs are considered to carry a higher risk of aggression, including levetiracetam, perampanel, and topiramate. However, data on the specific risk of aggression for other AEDs is lacking of mixed. It is important for healthcare providers to carefully consider the potential risks and benefits of AEDs when prescribing them for patients with epilepsy of bipolar disorder.

UK700 Trial on Assertive Community Treatment

Assertive community treatment was created to assist patients who have difficulty staying out of the hospital to live more successfully in the community. The UK700 case management trial aimed to determine if enhanced outcomes could be achieved under CPA by reducing case-load size. The trial tested the hypothesis that reducing CPA case-loads to 10-15 patients (intensive case management) would result in less hospitalization. However, the findings did not support the hypothesis.

Antipsychotics (Maximum Doses)

It is important to be aware of the maximum doses for commonly used antipsychotics. The following are the maximum doses for various antipsychotics:

– Clozapine (oral): 900 mg/day
– Haloperidol (oral): 20 mg/day
– Olanzapine (oral): 20 mg/day
– Quetiapine (oral): 750mg/day (for schizophrenia) and 800 mg/day (for bipolar disorder)
– Risperidone (oral): 16 mg/day
– Amisulpride (oral): 1200 mg/day
– Aripiprazole (oral): 30 mg/day
– Flupentixol (depot): 400 mg/week
– Zuclopenthixol (depot): 600 mg/week
– Haloperidol (depot): 300 mg every 4 weeks

It is important to keep these maximum doses in mind when prescribing antipsychotics to patients.

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.

Although hyperprolactinemia is a rare side effect of antidepressant use, it typically does not cause any symptoms. However, if symptoms do occur, it is suggested that the patient be prescribed mirtazapine instead.

Management of Hyperprolactinaemia

Hyperprolactinaemia is often associated with the use of antipsychotics and occasionally antidepressants. Dopamine inhibits prolactin, and dopamine antagonists increase prolactin levels. Almost all antipsychotics cause changes in prolactin, but some do not increase levels beyond the normal range. The degree of prolactin elevation is dose-related. Hyperprolactinaemia is often asymptomatic but can cause galactorrhoea, menstrual difficulties, gynaecomastia, hypogonadism, sexual dysfunction, and an increased risk of osteoporosis and breast cancer in psychiatric patients.

Patients should have their prolactin measured before antipsychotic therapy and then monitored for symptoms at three months. Annual testing is recommended for asymptomatic patients. Antipsychotics that increase prolactin should be avoided in patients under 25, patients with osteoporosis, patients with a history of hormone-dependent cancer, and young women. Samples should be taken at least one hour after eating of waking, and care must be taken to avoid stress during the procedure.

Treatment options include referral for tests to rule out prolactinoma if prolactin is very high, making a joint decision with the patient about continuing if prolactin is raised but not symptomatic, switching to an alternative antipsychotic less prone to hyperprolactinaemia if prolactin is raised and the patient is symptomatic, adding aripiprazole 5mg, of adding a dopamine agonist such as amantadine of bromocriptine. Mirtazapine is recommended for symptomatic hyperprolactinaemia associated with antidepressants as it does not raise prolactin levels.

Effectiveness of Antidepressants

In clinical trials, a response to antidepressants is typically defined as a 50% reduction in depression rating scores. For patients with moderate depression, the number needed to treat (NNT) for antidepressants over placebo is 5, while the NNT for antidepressants over true no-treatment is 3. These findings are outlined in the Maudsley Guidelines 14th Edition.

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.

Atypical Depression: Symptoms and Treatment

Atypical depression is a subtype of major depressive disorder that is characterized by low mood with mood reactivity and a reversal of the typical features seen in depression. This includes hypersomnia, hyperphagia, weight gain, and libidinal increases. People with atypical depression tend to respond best to MAOIs, while their response to tricyclics is poor, and SSRIs perform somewhere in the middle.

The DSM-5 defines atypical depression as a subtype of major depressive disorder ‘with atypical features’, which includes mood reactivity, significant weight gain of increase in appetite, hypersomnia, leaden paralysis, and a long-standing pattern of interpersonal rejection sensitivity that results in significant social of occupational impairment. However, this subtype is not specifically recognized in ICD-11.

If you of someone you know is experiencing symptoms of atypical depression, it is important to seek professional help. Treatment options may include therapy, medication, of a combination of both. MAOIs may be the most effective medication for atypical depression, but it is important to work with a healthcare provider to determine the best course of treatment.

According to the NICE Guidelines, if women discontinue treatment during pregnancy, the likelihood of relapse is increased, and therefore, it is recommended to continue with the antipsychotic medication.

Bipolar Disorder in Women of Childbearing Potential

Prophylaxis is recommended for women with bipolar disorder, as postpartum relapse rates are high. Women without prophylactic pharmacotherapy during pregnancy have a postpartum relapse rate of 66%, compared to 23% for women with prophylaxis. Antipsychotics are recommended for pregnant women with bipolar disorder, according to NICE Guidelines (CG192) and the Maudsley. Women taking valproate, lithium, carbamazepine, of lamotrigine should discontinue treatment and start an antipsychotic, especially if taking valproate. If a woman with bipolar disorder is taking lithium and becomes pregnant, she should gradually stop lithium over a 4 week period and start an antipsychotic. If this is not possible, lithium levels must be taken regularly, and the dose adjusted accordingly. For acute mania, an antipsychotic should be considered. For mild depressive symptoms, self-help approaches, brief psychological interventions, and antidepressant medication can be considered. For moderate to severe depressive symptoms, psychological treatment (CBT) for moderate depression and combined medication and structured psychological interventions for severe depression should be considered.

Reference: Wesseloo, R., Kamperman, A. M., Munk-Olsen, T., Pop, V. J., Kushner, S. A., & Bergink, V. (2016). Risk of postpartum relapse in bipolar disorder and postpartum psychosis: a systematic review and meta-analysis. The American Journal of Psychiatry, 173(2), 117-127.

Mania: Features and Characteristics

Mania is a mental state characterized by a range of symptoms that can significantly impact an individual’s behavior, thoughts, and emotions. Some of the key features of mania include an elated of irritable mood, restlessness, and overactivity. People experiencing mania may also exhibit disinhibited and reckless behavior, such as excessive spending of engaging in risky activities. They may have over-ambitious plans for the future and experience a flight of ideas and pressured speech. Additionally, mania can involve mood congruent delusions, increased libido, and a decreased need for sleep. Overall, mania can be a challenging and disruptive condition that requires professional treatment and support.

Hepatolenticular degeneration is another name for Wilson’s disease.

Understanding Wilson’s Disease: A Disorder of Copper Storage

Wilson’s disease, also known as hepatolenticular degeneration, is a genetic disorder that affects copper storage in the body. This condition is caused by a defect in the ATP7B gene, which leads to the accumulation of copper in the liver and brain. The onset of symptoms usually occurs between the ages of 10 and 25 years, with liver disease being the most common presentation in children and neurological symptoms in young adults.

The excessive deposition of copper in the tissues can cause a range of symptoms, including hepatitis, cirrhosis, basal ganglia degeneration, speech and behavioral problems, asterixis, chorea, dementia, Kayser-Fleischer rings, renal tubular acidosis, haemolysis, and blue nails. Diagnosis is based on reduced serum ceruloplasmin, reduced serum copper, and increased 24-hour urinary copper excretion. However, the majority of patients exhibit low levels of both ceruloplasmin and total serum copper.

The traditional first-line treatment for Wilson’s disease is penicillamine, which chelates copper. Trientine hydrochloride is an alternative chelating agent that may become first-line treatment in the future. Tetrathiomolybdate is a newer agent that is currently under investigation. Early diagnosis and treatment are crucial to prevent irreversible damage to the liver and brain.

Narcissistic personality disorder may be indicated by an excessive desire for admiration.

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.

The practice of reducing the dosage of antipsychotics is outdated and no longer recommended, as per Cochrane’s 2006 findings. Instead, a more effective approach is to switch to an antipsychotic medication that has a lower risk of causing the condition.

Tardive Dyskinesia: Symptoms, Causes, Risk Factors, and Management

Tardive dyskinesia (TD) is a condition that affects the face, limbs, and trunk of individuals who have been on neuroleptics for months to years. The movements fluctuate over time, increase with emotional arousal, decrease with relaxation, and disappear with sleep. The cause of TD remains theoretical, but the postsynaptic dopamine (D2) receptor supersensitivity hypothesis is the most persistent. Other hypotheses include the presynaptic dopaminergic/noradrenergic hyperactivity hypothesis, the cholinergic interneuron burnout hypothesis, the excitatory/oxidative stress hypothesis, and the synaptic plasticity hypothesis. Risk factors for TD include advancing age, female sex, ethnicity, longer illness duration, intellectual disability and brain damage, negative symptoms in schizophrenia, mood disorders, diabetes, smoking, alcohol and substance misuse, FGA vs SGA treatment, higher antipsychotic dose, anticholinergic co-treatment, and akathisia.

Management options for TD include stopping any anticholinergic, reducing antipsychotic dose, changing to an antipsychotic with lower propensity for TD, and using tetrabenazine, vitamin E, of amantadine as add-on options. Clozapine is the antipsychotic most likely to be associated with resolution of symptoms. Vesicular monoamine transporter type 2 (VMAT2) inhibitors are agents that cause a depletion of neuroactive peptides such as dopamine in nerve terminals and are used to treat chorea due to neurodegenerative diseases of dyskinesias due to neuroleptic medications (tardive dyskinesia).

Schizophrenia presents differently in men and women. Women tend to have a later onset and respond better to treatment, requiring lower doses of antipsychotics. Men, on the other hand, have an earlier onset, poorer premorbid functioning, and more negative symptoms and cognitive deficits. They also have greater structural brain and neurophysiological abnormalities. Females display more affective symptoms, auditory hallucinations, and persecutory delusions, but have a more favorable short- and middle-term course of illness with less smoking and substance abuse. Families of males are more critical, and expressed emotion has a greater negative impact on them. Certain neurological soft signs may be more prevalent in males. There are no clear sex differences in family history, obstetric complications, and minor physical anomalies.

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.

Differential Diagnosis for Anorexia Nervosa

Anorexia nervosa is a disorder characterized by an abnormal perception of body image. However, there are other conditions that may present with similar symptoms. This test aims to assess your knowledge of differential diagnoses and features that may indicate an alternative diagnosis.

Patients with anorexia nervosa often feel well despite others’ concerns about their appearance. They may also be highly motivated and successful in their academic of professional pursuits. However, the absence of delusions about food being poisoned may suggest a different diagnosis, such as a psychotic illness.

Heavy drinking is another factor that may indicate a different diagnosis, such as alcoholism. On the other hand, if the patient is secretly abusing laxatives, this would support a diagnosis of anorexia nervosa rather than the use of anabolic agents.

In summary, it is important to consider other potential diagnoses when evaluating a patient with symptoms of anorexia nervosa. Factors such as delusions, heavy drinking, of the use of anabolic agents may suggest a different underlying condition.

Cerebral Dysfunction: Lobe-Specific Features

When the brain experiences dysfunction, it can manifest in various ways depending on the affected lobe. In the frontal lobe, dysfunction can lead to contralateral hemiplegia, impaired problem solving, disinhibition, lack of initiative, Broca’s aphasia, and agraphia (dominant). The temporal lobe dysfunction can result in Wernicke’s aphasia (dominant), homonymous upper quadrantanopia, and auditory agnosia (non-dominant). On the other hand, the non-dominant parietal lobe dysfunction can lead to anosognosia, dressing apraxia, spatial neglect, and constructional apraxia. Meanwhile, the dominant parietal lobe dysfunction can result in Gerstmann’s syndrome. Lastly, occipital lobe dysfunction can lead to visual agnosia, visual illusions, and contralateral homonymous hemianopia.

CATIE Study: Comparing Antipsychotic Medications for Schizophrenia Treatment

The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Study, funded by the National Institute of Mental Health (NIMH), was a nationwide clinical trial that aimed to compare the effectiveness of older and newer antipsychotic medications used to treat schizophrenia. It is the largest, longest, and most comprehensive independent trial ever conducted to examine existing therapies for schizophrenia. The study consisted of two phases.

Phase I of CATIE compared four newer antipsychotic medications to one another and an older medication. Participants were followed for 18 months to evaluate longer-term patient outcomes. The study involved over 1400 participants and was conducted at various treatment sites, representative of real-life settings where patients receive care. The results from CATIE are applicable to a wide range of people with schizophrenia in the United States.

The medications were comparably effective, but high rates of discontinuation were observed due to intolerable side-effects of failure to adequately control symptoms. Olanzapine was slightly better than the other drugs but was associated with significant weight gain as a side-effect. Surprisingly, the older, less expensive medication (perphenazine) used in the study generally performed as well as the four newer medications. Movement side effects primarily associated with the older medications were not seen more frequently with perphenazine than with the newer drugs.

Phase II of CATIE sought to provide guidance on which antipsychotic to try next if the first failed due to ineffectiveness of intolerability. Participants who discontinued their first antipsychotic medication because of inadequate management of symptoms were encouraged to enter the efficacy (clozapine) pathway, while those who discontinued their first treatment because of intolerable side effects were encouraged to enter the tolerability (ziprasidone) pathway. Clozapine was remarkably effective and was substantially better than all the other atypical medications.

The CATIE study also looked at the risk of metabolic syndrome (MS) using the US National Cholesterol Education Program Adult Treatment Panel criteria. The prevalence of MS at baseline in the CATIE group was 40.9%, with female patients being three times as likely to have MS compared to matched controls and male patients being twice as likely.

The APMS has a significant drawback in that it solely relies on household data and does not incorporate data from institutions like prisons.

Adult Psychiatric Morbidity Survey

The Adult Psychiatric Morbidity Survey (APMS), also known as the National Psychiatric Morbidity Survey, is conducted every 7 years to monitor the prevalence of mental illness and access to treatment in the general population of England. The survey obtains a stratified random sample representative of the population living in private households by using postcodes. The information is gathered through questionnaires and interviews to screen for a range of mental disorders and risk factors. However, the survey does not collect data on individuals under the age of 16. The study does not include people living in institutional settings such as prisons of care homes, of those who are homeless of living in temporary housing.

The main requirement is a mismatch between an individual’s biological sex and their gender identity, which causes significant distress.

Gender identity is the person’s identification of lived role in society, which is separate from their biological sex. Gender can include non-binary and pangender identities, and cisgender refers to people whose gender is congruent with their biological sex. Gender identity is not the same as sexual preference, which is covered by separate diagnostic categories. The ICD-11 has redefined gender identity-related health, replacing diagnostic categories like “transsexualism” and “gender identity disorder of children” with “gender incongruence of adolescence and adulthood” and “gender incongruence of childhood”, respectively. The DSM-5 uses the term ‘gender dysphoria’ to cover the whole range of gender identity disorders, which is characterized by a marked incongruence between one’s experienced/expressed gender and their assigned gender, lasting at least 6 months, and associated with clinically significant distress of impairment in social, occupational, of other important areas of functioning.

Bipolar Disorder in Women of Childbearing Potential

Prophylaxis is recommended for women with bipolar disorder, as postpartum relapse rates are high. Women without prophylactic pharmacotherapy during pregnancy have a postpartum relapse rate of 66%, compared to 23% for women with prophylaxis. Antipsychotics are recommended for pregnant women with bipolar disorder, according to NICE Guidelines (CG192) and the Maudsley. Women taking valproate, lithium, carbamazepine, of lamotrigine should discontinue treatment and start an antipsychotic, especially if taking valproate. If a woman with bipolar disorder is taking lithium and becomes pregnant, she should gradually stop lithium over a 4 week period and start an antipsychotic. If this is not possible, lithium levels must be taken regularly, and the dose adjusted accordingly. For acute mania, an antipsychotic should be considered. For mild depressive symptoms, self-help approaches, brief psychological interventions, and antidepressant medication can be considered. For moderate to severe depressive symptoms, psychological treatment (CBT) for moderate depression and combined medication and structured psychological interventions for severe depression should be considered.

Reference: Wesseloo, R., Kamperman, A. M., Munk-Olsen, T., Pop, V. J., Kushner, S. A., & Bergink, V. (2016). Risk of postpartum relapse in bipolar disorder and postpartum psychosis: a systematic review and meta-analysis. The American Journal of Psychiatry, 173(2), 117-127.

Depression Treatment Guidelines by NICE

The National Institute for Health and Care Excellence (NICE) provides guidelines for the treatment of depression. The following are some general recommendations:

– Selective serotonin reuptake inhibitors (SSRIs) are preferred when prescribing antidepressants.
– Antidepressants are not the first-line treatment for mild depression.
– After remission, continue antidepressant treatment for at least six months.
– Continue treatment for at least two years if at high risk of relapse of have a history of severe or prolonged episodes of inadequate response.
– Use a stepped care approach to depression treatment, starting at the appropriate level based on the severity of depression.

The stepped care approach involves the following steps:

– Step 1: Assessment, support, psychoeducation, active monitoring, and referral for further assessment and interventions.
– Step 2: Low-intensity psychosocial interventions, psychological interventions, medication, and referral for further assessment and interventions.
– Step 3: Medication, high-intensity psychological interventions, combined treatments, collaborative care, and referral for further assessment and interventions.
– Step 4: Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care.

Individual guided self-help programs based on cognitive-behavioral therapy (CBT) principles should be supported by a trained practitioner and last 9 to 12 weeks. Physical activity programs should consist of three sessions per week of moderate duration over 10 to 14 weeks.

NICE advises against using antidepressants routinely to treat persistent subthreshold depressive symptoms of mild depression. However, they may be considered for people with a past history of moderate or severe depression, initial presentation of subthreshold depressive symptoms that have been present for a long period, of subthreshold depressive symptoms of mild depression that persist after other interventions.

NICE recommends a combination of antidepressant medication and a high-intensity psychological intervention (CBT of interpersonal therapy) for people with moderate of severe depression. Augmentation of antidepressants with lithium, antipsychotics, of other antidepressants may be appropriate, but benzodiazepines, buspirone, carbamazepine, lamotrigine, of valproate should not be routinely used.

When considering different antidepressants, venlafaxine is associated with a greater risk of death from overdose compared to other equally effective antidepressants. Tricyclic antidepressants (TCAs) except for lofepramine are associated with the greatest risk in overdose. Higher doses of venlafaxine may exacerbate cardiac arrhythmias, and venlafaxine and duloxetine may exacerbate hypertension. TCAs may cause postural hypotension and arrhythmias, and mianserin requires hematological monitoring in elderly people.

The review frequency depends on the age and suicide risk of the patient. If the patient is over 30 and has no suicide risk, see them after two weeks and then at intervals of 2-4 weeks for the first three months. If the patient is under 30 and has a suicide risk, see them after one week.

Drug-Induced Mania: Evidence and Precipitating Drugs

There is strong evidence that mania can be triggered by certain drugs, according to Peet (1995). These drugs include levodopa, corticosteroids, anabolic-androgenic steroids, and certain classes of antidepressants such as tricyclic and monoamine oxidase inhibitors.

Additionally, Peet (2012) suggests that there is weaker evidence that mania can be induced by dopaminergic anti-Parkinsonian drugs, thyroxine, iproniazid and isoniazid, sympathomimetic drugs, chloroquine, baclofen, alprazolam, captopril, amphetamine, and phencyclidine.

It is important for healthcare professionals to be aware of the potential for drug-induced mania and to monitor patients closely for any signs of symptoms. Patients should also be informed of the risks associated with these medications and advised to report any unusual changes in mood of behavior.

There is no association between the risk of agranulocytosis and either the dose of plasma concentration of clozapine, according to Bishara (2014).

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 presence of self-destructive cutting behavior is a strong indicator for a diagnosis of borderline personality disorder.

Bipolar Disorder Versus BPD

Bipolar disorder and borderline personality disorder (BPD) can be distinguished from each other based on several factors. Bipolar disorder is characterized by psychomotor activation, which is not typically seen in BPD. Additionally, self-destructive cutting behavior is rare in bipolar disorder but common in BPD. BPD is often associated with sexual trauma, while bipolar disorder has a lower prevalence of sexual trauma. Other BPD features such as identity disturbance and dissociative symptoms are not typically seen in bipolar disorder. Finally, bipolar disorder is highly heritable, while BPD has a lower genetic loading. Understanding these differences is important for accurate diagnosis and treatment.

2021 National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) report reveals key findings on suicide rates in the UK from 2008-2018. The rates have remained stable over the years, with a slight increase following the 2008 recession and another rise since 2015/2016. Approximately 27% of all general population suicides were patients who had contact with mental health services within 12 months of suicide. The most common methods of suicide were hanging/strangulation (52%) and self-poisoning (22%), mainly through prescription opioids. In-patient suicides have continued to decrease, with most of them occurring on the ward itself from low lying ligature points. The first three months after discharge remain a high-risk period, with 13% of all patient suicides occurring within this time frame. Nearly half (48%) of patient suicides were from patients who lived alone. In England, suicide rates are higher in males (17.2 per 100,000) than females (5.4 per 100,000), with the highest age-specific suicide rate for males in the 45-49 years age group (27.1 deaths per 100,000 males) and for females in the same age group (9.2 deaths per 100,000). Hanging remains the most common method of suicide in the UK, accounting for 59.4% of all suicides among males and 45.0% of all suicides among females.

Budesonide is a type of steroid that is often administered through an inhaler to manage asthma symptoms. However, it has been noted that the use of inhaled steroids can trigger episodes of hypomania and mania. This information was reported in a study by E Brown et al. titled The psychiatric side effects of corticosteroids, which was published in the Annals of Allergy, Asthma & Immunology in 1999.

Drug-Induced Mania: Evidence and Precipitating Drugs

There is strong evidence that mania can be triggered by certain drugs, according to Peet (1995). These drugs include levodopa, corticosteroids, anabolic-androgenic steroids, and certain classes of antidepressants such as tricyclic and monoamine oxidase inhibitors.

Additionally, Peet (2012) suggests that there is weaker evidence that mania can be induced by dopaminergic anti-Parkinsonian drugs, thyroxine, iproniazid and isoniazid, sympathomimetic drugs, chloroquine, baclofen, alprazolam, captopril, amphetamine, and phencyclidine.

It is important for healthcare professionals to be aware of the potential for drug-induced mania and to monitor patients closely for any signs of symptoms. Patients should also be informed of the risks associated with these medications and advised to report any unusual changes in mood of behavior.

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.

Sedatives and Liver Disease

Sedatives are commonly used for their calming effects, but many of them are metabolized in the liver. Therefore, caution must be taken when administering sedatives to patients with liver disease. The Maudsley Guidelines recommend using low doses of the following sedatives in patients with hepatic impairment: lorazepam, oxazepam, temazepam, and zopiclone. It is important to note that zopiclone should also be used with caution and at low doses in this population. Proper management of sedative use in patients with liver disease can help prevent further damage to the liver and improve overall patient outcomes.

Based on the symptoms described, the most likely diagnosis is severe depression with psychosis. This is indicated by the nihilistic delusions, which are commonly seen in people with psychotic depression. Late onset schizophrenia is typically associated with persecutory delusions, whereas people with psychotic depression tend to report hypochondriacal and somatic delusions. These findings are supported by research on the clinical approaches to late-onset psychosis (Kim, 2022) and an international consensus on late-onset schizophrenia and schizophrenia-like psychosis (Howard, 2000).

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.

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.

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.

Conversion disorder is a type of somatic symptom disorder, which involves physical symptoms that cannot be explained by a medical condition and are often related to psychological distress.

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.

While stress has been found to worsen schizophrenia and other mental illnesses, it is not considered a direct cause. It is important to note the distinction between exacerbating factors and causative factors. For more information on causality, refer to the Bradford Hill criteria.

Precipitating Factors of Schizophrenia

Schizophrenia is a mental disorder that can be triggered by various factors. Stress is one of the factors that can cause relapse in individuals who are genetically predisposed to developing schizophrenia. Stressful life events and expressed emotion can also contribute to the onset of the condition. Substance misuse is another factor that can precipitate schizophrenia in vulnerable individuals. However, there is no direct evidence to support its role as a causal factor in the disorder. Despite the increase in cannabis consumption over the last three decades, the rates of schizophrenia have not increased, indicating that it is not a significant causal factor.

Topiramate is a medication used for epilepsy and bipolar affective disorder. It works by inhibiting voltage gated sodium channels and increasing GABA levels. Unlike most psychotropic drugs, it is associated with weight loss.

Consider administering clozapine via the intramuscular route in cases where patients are noncompliant with oral medications, provided that two different antipsychotics (at least one of which is an atypical) have been tried at effective doses and with adequate compliance.

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 AESOP study is a first-presentation study of schizophrenia and other psychotic disorders that identified all people presenting to services with psychotic symptoms in well-defined catchment areas in South London, Nottingham and Bristol. The study aimed to elucidate the overall rates of psychotic disorder in the 3 centres, confirm and extend previous findings of raised rates of psychosis in certain migrant groups in the UK, and explore in detail the biological and social risk factors in these populations and their possible interactions. The study found that the incidence of all psychoses was higher in African-Caribbean and Black African populations, particularly in schizophrenia and manic psychosis. These groups were also more likely to be compulsorily admitted to hospital and come to the attention of mental health services via police of other criminal justice agencies, and less likely to come via the GP.

NICE’s stance is that medication should not be prescribed to individuals under 18 with PTSD. Antipsychotics should only be considered as a last resort after other methods, such as SSIs, have been attempted and proven ineffective.

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 SCOFF Questionnaire for Screening Eating Disorders

The SCOFF questionnaire is a tool used to screen for eating disorders. It consists of five questions that aim to identify symptoms of anorexia nervosa or bulimia. The questions include whether the individual makes themselves sick because they feel uncomfortably full, worries about losing control over how much they eat, has recently lost more than one stone in a three-month period, believes themselves to be fat when others say they are too thin, and whether food dominates their life.

A score of two or more positive responses indicates a likely case of anorexia nervosa or bulimia. The questionnaire has a sensitivity of 84.6% and specificity of 98.6% when two or more questions are answered positively. This means that if a patient responds positively to two of more questions, there is a high likelihood that they have an eating disorder. The negative predictive value of the questionnaire is 99.3%, which means that if a patient responds negatively to the questions, there is a high probability that they do not have an eating disorder.

Overall, the SCOFF questionnaire is a useful tool for healthcare professionals to quickly screen for eating disorders and identify individuals who may require further assessment and treatment.

Out of all the atypical antipsychotics, aripiprazole has the smallest impact on the lipid profile.

Antipsychotics and Dyslipidaemia

Antipsychotics have been found to have an impact on lipid profile. Among the second generation antipsychotics, olanzapine and clozapine have been shown to have the greatest effect on lipids, followed by quetiapine and risperidone. Aripiprazole and ziprasidone, on the other hand, appear to have minimal effects on lipids.

Maudsley Guidelines 10th Edition

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.

Agranulocytosis is characterized by a decrease in the number of granulocytes, specifically neutrophils, basophils, and eosinophils. When clozapine is used, the primary focus is on monitoring the neutrophil count.

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

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 levels of clozapine can be significantly impacted by smoking.

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

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

If a patient is experiencing mania, it is important to avoid administering antidepressants such as dosulepin, moclobemide, and tranylcypromine as they may exacerbate the condition. Instead, the Maudsley recommends the use of quetiapine and other appropriate medications.

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.

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.

Ganser’s syndrome is a disputed diagnosis that typically involves vague responses, confusion, physical symptoms without a clear medical explanation, false perceptions, and memory loss for the time when the symptoms were present. It is commonly observed in incarcerated individuals awaiting trial and seems to be a manifestation of their perception of what a mental illness entails. As a result, some experts argue that it is a type of feigning illness. Ganser’s syndrome is classified as a dissociative disorder.

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.

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.

Olanzapine was found to have the highest duration of treatment before discontinuation due to inadequate efficacy, the longest period of successful treatment, and the lowest number of hospitalizations caused by worsening of schizophrenia among the patients.

CATIE Study: Comparing Antipsychotic Medications for Schizophrenia Treatment

The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Study, funded by the National Institute of Mental Health (NIMH), was a nationwide clinical trial that aimed to compare the effectiveness of older and newer antipsychotic medications used to treat schizophrenia. It is the largest, longest, and most comprehensive independent trial ever conducted to examine existing therapies for schizophrenia. The study consisted of two phases.

Phase I of CATIE compared four newer antipsychotic medications to one another and an older medication. Participants were followed for 18 months to evaluate longer-term patient outcomes. The study involved over 1400 participants and was conducted at various treatment sites, representative of real-life settings where patients receive care. The results from CATIE are applicable to a wide range of people with schizophrenia in the United States.

The medications were comparably effective, but high rates of discontinuation were observed due to intolerable side-effects of failure to adequately control symptoms. Olanzapine was slightly better than the other drugs but was associated with significant weight gain as a side-effect. Surprisingly, the older, less expensive medication (perphenazine) used in the study generally performed as well as the four newer medications. Movement side effects primarily associated with the older medications were not seen more frequently with perphenazine than with the newer drugs.

Phase II of CATIE sought to provide guidance on which antipsychotic to try next if the first failed due to ineffectiveness of intolerability. Participants who discontinued their first antipsychotic medication because of inadequate management of symptoms were encouraged to enter the efficacy (clozapine) pathway, while those who discontinued their first treatment because of intolerable side effects were encouraged to enter the tolerability (ziprasidone) pathway. Clozapine was remarkably effective and was substantially better than all the other atypical medications.

The CATIE study also looked at the risk of metabolic syndrome (MS) using the US National Cholesterol Education Program Adult Treatment Panel criteria. The prevalence of MS at baseline in the CATIE group was 40.9%, with female patients being three times as likely to have MS compared to matched controls and male patients being twice as likely.

If the patient’s depression history was only mild to moderate, NICE would suggest considering stopping paroxetine and using facilitated self-help. However, since the patient’s depression history is more severe, it would not be wise to discontinue antidepressant treatment. The Maudsley recommends continuing with the same antidepressant if it is effective, except for MAOIs, to prevent relapse. Although some studies have linked paroxetine to cardiac malformations, other studies have not replicated this finding and have implicated other SSRIs. While paroxetine may increase the likelihood of neonatal withdrawal effects compared to alternatives with a longer half-life, these effects are typically mild and self-limiting.

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.

Schizophrenia and Sleep

Sleep disturbances are a common feature of schizophrenia, as research has shown. Specifically, individuals with schizophrenia tend to have a shorter amount of time until the onset of rapid eye movement (REM) sleep, known as decreased REM latency. Additionally, they have a lower proportion of slow wave sleep. These findings were reported in a 2008 article by Rajiv T. titled Schizophrenia, ‘Just the facts’, What we know in 2008 in the journal Schizophrenia Research.

Complex PTSD includes all the necessary criteria for PTSD, but it also involves severe challenges in regulating emotions, persistent negative self-beliefs, and ongoing struggles in maintaining relationships. While some individuals with Complex PTSD may also meet the criteria for a personality disorder, it is not considered a personality disorder itself.

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.

Biochemical Changes Associated with Psychotropic Drugs

Psychotropic drugs can have incidental biochemical of haematological effects that need to be identified and monitored. The evidence for many of these changes is limited to case reports of information supplied by manufacturers. The Maudsley Guidelines 14th Edition summarises the important changes to be aware of.

One important parameter to monitor is ALT, a liver enzyme. Agents that can raise ALT levels include clozapine, haloperidol, olanzapine, quetiapine, chlorpromazine, mirtazapine, moclobemide, SSRIs, carbamazepine, lamotrigine, and valproate. On the other hand, vigabatrin can lower ALT levels.

Another liver enzyme to monitor is ALP. Haloperidol, clozapine, olanzapine, duloxetine, sertraline, and carbamazepine can raise ALP levels, while buprenorphine and zolpidem (rarely) can lower them.

AST levels are often associated with ALT levels. Trifluoperazine and vigabatrin can raise AST levels, while agents that raise ALT levels can also raise AST levels.

TSH levels, which are associated with thyroid function, can be affected by aripiprazole, carbamazepine, lithium, quetiapine, rivastigmine, sertraline, and valproate (slightly). Moclobemide can lower TSH levels.

Thyroxine levels can be affected by dexamphetamine, moclobemide, lithium (which can raise of lower levels), aripiprazole (rarely), and quetiapine (rarely).

Overall, it is important to monitor these biochemical changes when prescribing psychotropic drugs to ensure the safety and well-being of patients.

The rates of PTSD vary depending on the type of traumatic event experienced.

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.

Insomnia is a sleep disorder characterized by difficulty falling asleep, staying asleep, waking up too early, of feeling unrefreshed after sleep. The management of insomnia depends on whether it is short-term (lasting less than 3 months) of long-term (lasting more than 3 months). For short-term insomnia, sleep hygiene and a sleep diary are recommended first. If severe daytime impairment is present, a short course of a non-benzodiazepine hypnotic medication may be considered for up to 2 weeks. For long-term insomnia, cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment.

Pharmacological therapy should be avoided, but a short-term hypnotic medication may be appropriate for some individuals with severe symptoms of an acute exacerbation. Referral to a sleep clinic of neurology may be necessary if another sleep disorder is suspected of if long-term insomnia has not responded to primary care management. Good sleep hygiene practices include establishing fixed sleep and wake times, relaxing before bedtime, maintaining a comfortable sleeping environment, avoiding napping during the day, avoiding caffeine, nicotine, and alcohol before bedtime, avoiding exercise before bedtime, avoiding heavy meals late at night, and using the bedroom only for sleep and sexual activity.

2021 National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) report reveals key findings on suicide rates in the UK from 2008-2018. The rates have remained stable over the years, with a slight increase following the 2008 recession and another rise since 2015/2016. Approximately 27% of all general population suicides were patients who had contact with mental health services within 12 months of suicide. The most common methods of suicide were hanging/strangulation (52%) and self-poisoning (22%), mainly through prescription opioids. In-patient suicides have continued to decrease, with most of them occurring on the ward itself from low lying ligature points. The first three months after discharge remain a high-risk period, with 13% of all patient suicides occurring within this time frame. Nearly half (48%) of patient suicides were from patients who lived alone. In England, suicide rates are higher in males (17.2 per 100,000) than females (5.4 per 100,000), with the highest age-specific suicide rate for males in the 45-49 years age group (27.1 deaths per 100,000 males) and for females in the same age group (9.2 deaths per 100,000). Hanging remains the most common method of suicide in the UK, accounting for 59.4% of all suicides among males and 45.0% of all suicides among females.

Insomnia is a sleep disorder characterized by difficulty falling asleep, staying asleep, waking up too early, of feeling unrefreshed after sleep. The management of insomnia depends on whether it is short-term (lasting less than 3 months) of long-term (lasting more than 3 months). For short-term insomnia, sleep hygiene and a sleep diary are recommended first. If severe daytime impairment is present, a short course of a non-benzodiazepine hypnotic medication may be considered for up to 2 weeks. For long-term insomnia, cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment.

Pharmacological therapy should be avoided, but a short-term hypnotic medication may be appropriate for some individuals with severe symptoms of an acute exacerbation. Referral to a sleep clinic of neurology may be necessary if another sleep disorder is suspected of if long-term insomnia has not responded to primary care management. Good sleep hygiene practices include establishing fixed sleep and wake times, relaxing before bedtime, maintaining a comfortable sleeping environment, avoiding napping during the day, avoiding caffeine, nicotine, and alcohol before bedtime, avoiding exercise before bedtime, avoiding heavy meals late at night, and using the bedroom only for sleep and sexual activity.

Epidemiological surveys and prevalence estimates have been conducted to determine the prevalence of various mental health conditions. The Epidemiological Catchment Area (ECA) study was conducted in the mid-1980s using the Diagnostic Interview Schedule (DIS) based on DSM-III criteria. The National Comorbidity Survey (NCS) used the Composite International Diagnostic Interview (CIDI) and was conducted in the 1990s and repeated in 2001. The Adult Psychiatric Morbidity Survey (APMS) used the Clinical Interview Schedule (CIS-R) and was conducted in England every 7 years since 1993. The WHO World Mental Health (WMH) Survey Initiative used the World Mental Health Composite International Diagnostic Interview (WMH-CIDI) and was conducted in close to 30 countries from 2001 onwards.

The main findings of these studies show that major depression has a prevalence of 4-10% worldwide, with 6.7% in the past 12 months and 16.6% lifetime prevalence. Generalised anxiety disorder (GAD) has a 3.1% 12-month prevalence and 5.7% lifetime prevalence. Panic disorder has a 2.7% 12-month prevalence and 4.7% lifetime prevalence. Specific phobia has an 8.7% 12-month prevalence and 12.5% lifetime prevalence. Social anxiety disorder has a 6.8% 12-month prevalence and 12.1% lifetime prevalence. Agoraphobia without panic disorder has a 0.8% 12-month prevalence and 1.4% lifetime prevalence. Obsessive-compulsive disorder (OCD) has a 1.0% 12-month prevalence and 1.6% lifetime prevalence. Post-traumatic stress disorder (PTSD) has a 1.3-3.6% 12-month prevalence and 6.8% lifetime prevalence. Schizophrenia has a 0.33% 12-month prevalence and 0.48% lifetime prevalence. Bipolar I disorder has a 1.5% 12-month prevalence and 2.1% lifetime prevalence. Bulimia nervosa has a 0.63% lifetime prevalence, anorexia nervosa has a 0.16% lifetime prevalence, and binge eating disorder has a 1.53% lifetime prevalence.

These prevalence estimates provide important information for policymakers, healthcare providers, and researchers to better understand the burden of mental health conditions and to develop effective prevention and treatment strategies.

While depression and anxiety rates tend to rise during pregnancy, rates of bipolar disorder and schizophrenia remain unchanged. However, individuals who stop taking medication during pregnancy are more likely to experience a relapse. Interestingly, pregnancy appears to be a protective factor against suicide, with decreased rates observed.

Suicide Risk Factors

Risk factors for completed suicide are numerous and include various demographic, social, and psychological factors. Men are at a higher risk than women, with the risk peaking at age 45 for men and age 55 for women. Being unmarried and unemployed are also risk factors. Concurrent mental disorders are present in about 90% of people who commit suicide, with depression being the most commonly associated disorder. Previous suicide attempts and substance misuse are also significant risk factors. Co-existing serious medical conditions and personality factors such as rigid thinking, pessimism, and perfectionism also increase the risk of suicide. It is important to identify and address these risk factors in order to prevent suicide.

Extrapyramidal side-effects (EPSE’s) are a group of side effects that affect voluntary motor control, commonly seen in patients taking antipsychotic drugs. EPSE’s include dystonias, parkinsonism, akathisia, and tardive dyskinesia. They can be frightening and uncomfortable, leading to problems with non-compliance and can even be life-threatening in the case of laryngeal dystonia. EPSE’s are thought to be due to antagonism of dopaminergic D2 receptors in the basal ganglia. Symptoms generally occur within the first few days of treatment, with dystonias appearing quickly, within a few hours of administration of the first dose. Newer antipsychotics tend to produce less EPSE’s, with clozapine carrying the lowest risk and haloperidol carrying the highest risk. Akathisia is the most resistant EPSE to treat. EPSE’s can also occur when antipsychotics are discontinued (withdrawal dystonia).

The Beck Depression Inventory consists of 21 questions, with a maximum score of 63. Each question is scored on a scale of 0 to 3, and the assessment is used to determine the severity of depression. It is a self-rated questionnaire.

In psychiatry, various questionnaires and interviews are used to assess different conditions and areas. It is important for candidates to know whether certain assessment tools are self-rated of require clinical assistance. The table provided by the college lists some of the commonly used assessment tools and indicates whether they are self-rated of clinician-rated. For example, the HAMD and MADRS are clinician-rated scales used to assess the severity of depression, while the GDS is a self-rated scale used to screen for depression in the elderly. The YMRS is a clinician-rated scale used to assess the severity of mania in patients with bipolar disorder, while the Y-BOCS is used to measure both the severity of OCD and the response to treatment. The GAF provides a single measure of global functioning, while the CGI requires the clinician to rate the severity of the patient’s illness at the time of assessment. The CAMDEX is a tool developed to assist in the early diagnosis and measurement of dementia in the elderly.

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.

Clozapine exhibits significant anticholinergic effects, resulting in both xerostomia and excessive salivation.

Antipsychotics: Common Side Effects and Relative Adverse Effects

Antipsychotics are medications used to treat various mental health conditions, including schizophrenia and bipolar disorder. However, they can also cause side effects that can be bothersome of even serious. The most common side effects of antipsychotics are listed in the table below, which includes the adverse effects associated with their receptor activity.

Antidopaminergic effects: These effects are related to the medication’s ability to block dopamine receptors in the brain. They can cause galactorrhoea, gynecomastia, menstrual disturbance, lowered sperm count, reduced libido, Parkinsonism, dystonia, akathisia, and tardive dyskinesia.

Anticholinergic effects: These effects are related to the medication’s ability to block acetylcholine receptors in the brain. They can cause dry mouth, blurred vision, urinary retention, and constipation.

Antiadrenergic effects: These effects are related to the medication’s ability to block adrenaline receptors in the body. They can cause postural hypotension and ejaculatory failure.

Histaminergic effects: These effects are related to the medication’s ability to block histamine receptors in the brain. They can cause drowsiness.

The Maudsley Guidelines provide a rough guide to the relative adverse effects of different antipsychotics. The table below summarizes their findings, with +++ indicating a high incidence of adverse effects, ++ indicating a moderate incidence, + indicating a low incidence, and – indicating a very low incidence.

Drug Sedation Weight gain Diabetes EPSE Anticholinergic Postural Hypotension Prolactin elevation
Amisulpride – + + + – – +++
Aripiprazole – +/- – +/- – – –
Asenapine + + +/- +/- – – +/-
Clozapine +++ +++ +++ – +++ +++ –
Flupentixol + ++ + ++ ++ + +++
Fluphenazine + + + +++ ++ + +++
Haloperidol + + +/- +++ + + +++
Olanzapine ++ +++ +++ +/- + + +
Paliperidone + ++ + + + ++ +++
Pimozide + + – + + + +++
Quetiapine ++ ++ ++ – + ++ –
Risperidone + ++ + + + ++ +++
Zuclopenthixol ++ ++ + ++ ++ + +++

Overall, it is important to discuss the potential side effects of antipsychotics with a healthcare provider and to monitor for any adverse effects while taking these medications.

This vignette is most indicative of a diagnosis of anorexia nervosa, characterized by low body weight, excessive exercise, and distorted body image. Unlike in avoidant-restrictive food intake disorder, individuals with anorexia nervosa have a strong desire for thinness of fear of weight gain. This disorder can be distinguished from bulimia nervosa by the very low body weight. Binge eating disorder, on the other hand, does not typically involve compensatory behaviors to maintain weight and does not necessarily involve low body weight.

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.

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

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.

The ICD-11 and DSM-5 both allow for a diagnosis of recurrent depression if there is continued mood disturbance between depressive episodes. However, the ICD-11 requires that the mood disturbance during the intervening period is not significant, while the DSM-5 requires that the symptoms are below the diagnostic threshold. Both classifications require at least two episodes, including the current one, for a diagnosis of recurrent depression. The ICD-11 specifies that the two episodes must be separated by several months, while the DSM-5 requires an intervening time period of at least two months.

Depression is diagnosed using different criteria in the ICD-11 and DSM-5. The ICD-11 recognizes single depressive episodes, recurrent depressive disorder, dysthymic disorder, and mixed depressive and anxiety disorder. The DSM-5 recognizes disruptive mood dysregulation disorder, major depressive disorder, persistent depressive disorder, and premenstrual dysphoric disorder.

For a diagnosis of a single depressive episode, the ICD-11 requires the presence of at least five characteristic symptoms occurring most of the day, nearly every day during a period lasting at least 2 weeks. The DSM-5 requires the presence of at least five symptoms during the same 2-week period, with at least one of the symptoms being either depressed mood of loss of interest of pleasure.

Recurrent depressive disorder is characterized by a history of at least two depressive episodes separated by at least several months without significant mood disturbance, according to the ICD-11. The DSM-5 requires at least two episodes with an interval of at least 2 consecutive months between separate episodes in which criteria are not met for a major depressive episode.

Dysthymic disorder is diagnosed when a person experiences persistent depressed mood lasting 2 years of more, according to the ICD-11. The DSM-5 requires depressed mood for most of the day, for more days than not, for at least 2 years, along with the presence of two or more additional symptoms.

Mixed depressive and anxiety disorder is recognized as a separate code in the ICD-11, while the DSM-5 uses the ‘with anxious distress’ qualifier. The ICD-11 requires the presence of both depressive and anxiety symptoms for most of the time during a period of 2 weeks of more, while the DSM-5 requires the presence of both depressive and anxious symptoms during the same 2-week period.

Overall, the criteria for diagnosing depression vary between the ICD-11 and DSM-5, but both require the presence of characteristic symptoms that cause significant distress of impairment in functioning.

If an SSRI is not appropriate of proves ineffective for treating panic disorder, imipramine of clomipramine may be recommended as alternative options.

Anxiety (NICE guidelines)

The NICE Guidelines on Generalised anxiety disorder and panic disorder were issued in 2011. For the management of generalised anxiety disorder, NICE suggests a stepped approach. For mild GAD, education and active monitoring are recommended. If there is no response to step 1, low-intensity psychological interventions such as CBT-based self-help of psychoeducational groups are suggested. For those with marked functional impairment of those who have not responded to step 2, individual high-intensity psychological intervention of drug treatment is recommended. Specialist treatment is suggested for those with very marked functional impairment, no response to step 3, self-neglect, risks of self-harm or suicide, of significant comorbidity. Benzodiazepines should not be used beyond 2-4 weeks, and SSRIs are first line. For panic disorder, psychological therapy (CBT), medication, and self-help have all been shown to be effective. Benzodiazepines, sedating antihistamines, of antipsychotics should not be used. SSRIs are first line, and if they fail, imipramine of clomipramine can be used. Self-help (CBT based) should be encouraged. If the patient improves with an antidepressant, it should be continued for at least 6 months after the optimal dose is reached, after which the dose can be tapered. If there is no improvement after a 12-week course, an alternative medication of another form of therapy should be offered.

Restless Leg Syndrome, also known as Wittmaack-Ekbom syndrome, is a condition that causes an irresistible urge to move in order to alleviate uncomfortable sensations, primarily in the legs but sometimes in other areas of the body. The symptoms are exacerbated by rest and tend to worsen at night. Treatment options for this condition include dopamine agonists, opioids, benzodiazepines, and anticonvulsants. Sibler (2004) has developed an algorithm for managing Restless Leg Syndrome.

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.

NICE recommends against the use of dosulepin due to the higher risk of cardiac complications and overdose toxicity, which outweigh any potential benefits in terms of tolerability compared to other antidepressants.

Depression Treatment Guidelines by NICE

The National Institute for Health and Care Excellence (NICE) provides guidelines for the treatment of depression. The following are some general recommendations:

– Selective serotonin reuptake inhibitors (SSRIs) are preferred when prescribing antidepressants.
– Antidepressants are not the first-line treatment for mild depression.
– After remission, continue antidepressant treatment for at least six months.
– Continue treatment for at least two years if at high risk of relapse of have a history of severe or prolonged episodes of inadequate response.
– Use a stepped care approach to depression treatment, starting at the appropriate level based on the severity of depression.

The stepped care approach involves the following steps:

– Step 1: Assessment, support, psychoeducation, active monitoring, and referral for further assessment and interventions.
– Step 2: Low-intensity psychosocial interventions, psychological interventions, medication, and referral for further assessment and interventions.
– Step 3: Medication, high-intensity psychological interventions, combined treatments, collaborative care, and referral for further assessment and interventions.
– Step 4: Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care.

Individual guided self-help programs based on cognitive-behavioral therapy (CBT) principles should be supported by a trained practitioner and last 9 to 12 weeks. Physical activity programs should consist of three sessions per week of moderate duration over 10 to 14 weeks.

NICE advises against using antidepressants routinely to treat persistent subthreshold depressive symptoms of mild depression. However, they may be considered for people with a past history of moderate or severe depression, initial presentation of subthreshold depressive symptoms that have been present for a long period, of subthreshold depressive symptoms of mild depression that persist after other interventions.

NICE recommends a combination of antidepressant medication and a high-intensity psychological intervention (CBT of interpersonal therapy) for people with moderate of severe depression. Augmentation of antidepressants with lithium, antipsychotics, of other antidepressants may be appropriate, but benzodiazepines, buspirone, carbamazepine, lamotrigine, of valproate should not be routinely used.

When considering different antidepressants, venlafaxine is associated with a greater risk of death from overdose compared to other equally effective antidepressants. Tricyclic antidepressants (TCAs) except for lofepramine are associated with the greatest risk in overdose. Higher doses of venlafaxine may exacerbate cardiac arrhythmias, and venlafaxine and duloxetine may exacerbate hypertension. TCAs may cause postural hypotension and arrhythmias, and mianserin requires hematological monitoring in elderly people.

The review frequency depends on the age and suicide risk of the patient. If the patient is over 30 and has no suicide risk, see them after two weeks and then at intervals of 2-4 weeks for the first three months. If the patient is under 30 and has a suicide risk, see them after one week.

According to NICE, paroxetine has a greater likelihood of causing discontinuation symptoms compared to other SSRIs.

Depression Treatment Guidelines by NICE

The National Institute for Health and Care Excellence (NICE) provides guidelines for the treatment of depression. The following are some general recommendations:

– Selective serotonin reuptake inhibitors (SSRIs) are preferred when prescribing antidepressants.
– Antidepressants are not the first-line treatment for mild depression.
– After remission, continue antidepressant treatment for at least six months.
– Continue treatment for at least two years if at high risk of relapse of have a history of severe or prolonged episodes of inadequate response.
– Use a stepped care approach to depression treatment, starting at the appropriate level based on the severity of depression.

The stepped care approach involves the following steps:

– Step 1: Assessment, support, psychoeducation, active monitoring, and referral for further assessment and interventions.
– Step 2: Low-intensity psychosocial interventions, psychological interventions, medication, and referral for further assessment and interventions.
– Step 3: Medication, high-intensity psychological interventions, combined treatments, collaborative care, and referral for further assessment and interventions.
– Step 4: Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care.

Individual guided self-help programs based on cognitive-behavioral therapy (CBT) principles should be supported by a trained practitioner and last 9 to 12 weeks. Physical activity programs should consist of three sessions per week of moderate duration over 10 to 14 weeks.

NICE advises against using antidepressants routinely to treat persistent subthreshold depressive symptoms of mild depression. However, they may be considered for people with a past history of moderate or severe depression, initial presentation of subthreshold depressive symptoms that have been present for a long period, of subthreshold depressive symptoms of mild depression that persist after other interventions.

NICE recommends a combination of antidepressant medication and a high-intensity psychological intervention (CBT of interpersonal therapy) for people with moderate of severe depression. Augmentation of antidepressants with lithium, antipsychotics, of other antidepressants may be appropriate, but benzodiazepines, buspirone, carbamazepine, lamotrigine, of valproate should not be routinely used.

When considering different antidepressants, venlafaxine is associated with a greater risk of death from overdose compared to other equally effective antidepressants. Tricyclic antidepressants (TCAs) except for lofepramine are associated with the greatest risk in overdose. Higher doses of venlafaxine may exacerbate cardiac arrhythmias, and venlafaxine and duloxetine may exacerbate hypertension. TCAs may cause postural hypotension and arrhythmias, and mianserin requires hematological monitoring in elderly people.

The review frequency depends on the age and suicide risk of the patient. If the patient is over 30 and has no suicide risk, see them after two weeks and then at intervals of 2-4 weeks for the first three months. If the patient is under 30 and has a suicide risk, see them after one week.

The primary diagnosis for the individual would be panic disorder due to the ongoing evidence of unexpected panic attacks. As panic disorder progresses, panic attacks may become more expected as they become associated with certain stimuli of contexts. This can lead to anticipatory anxiety and the development of agoraphobic symptoms over time. If the individual also meets all other diagnostic requirements for agoraphobia, an additional diagnosis may be assigned.

Understanding Panic Disorder: Key Facts, Diagnosis, and Treatment Recommendations

Panic disorder is a mental health condition characterized by recurrent unexpected panic attacks, which are sudden surges of intense fear of discomfort that reach a peak within minutes. Females are more commonly affected than males, and the disorder typically onsets during the early 20s. Panic attacks are followed by persistent concern of worry about their recurrence of negative significance, of behaviors intended to avoid their recurrence. The symptoms result in significant impairment in personal, family, social, educational, occupational, of other important areas of functioning.

To diagnose panic disorder, the individual must experience recurrent panic attacks that are not restricted to particular stimuli of situations and are unexpected. The panic attacks are followed by persistent concern of worry about their recurrence of negative significance, of behaviors intended to avoid their recurrence. The symptoms are not a manifestation of another medical condition of substance use, and they result in significant impairment in functioning.

Panic disorder is differentiated from normal fear reactions by the frequent recurrence of panic attacks, persistent worry of concern about the panic attacks of their meaning, and associated significant impairment in functioning. Treatment recommendations vary based on the severity of the disorder, with mild to moderate cases recommended for individual self-help and moderate to severe cases recommended for cognitive-behavioral therapy of antidepressant medication. The classes of antidepressants that have an evidence base for effectiveness are SSRIs, SNRIs, and TCAs. Benzodiazepines are not recommended for the treatment of panic disorder due to their association with a less favorable long-term outcome. Sedating antihistamines of antipsychotics should also not be prescribed for the treatment of panic disorder.

Approximately, what percentage of individuals are estimated to experience OCD at some point in their lifetime?

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

To diagnose bulimia, weight reduction methods are necessary, but vomiting is not the only method used. Some individuals with bulimia may opt for laxatives of excessive exercise instead. The SCOFF questionnaire is utilized to screen for both anorexia and bulimia, rather than the CAGE questionnaire.

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.

Electroconvulsive therapy may be considered for severe depression if the patient presents with attempted suicide, strong suicidal ideation of plans, life-threatening illness due to refusal of food of fluids, stupor, marked psychomotor retardation, of depressive delusions of hallucinations. However, in the case of refractory depression, the Maudsley Guidelines suggest that lithium of ECT are the only options, and ECT may not be indicated at this stage based on the patient’s overall presentation.

Depression (Refractory)

Refractory depression is a term used when two successive attempts at treatment have failed despite good compliance and adequate doses. There is no accepted definition of refractory depression. The following options are recommended as the first choice for refractory depression, with no preference implied by order:

– Add lithium
– Combined use of olanzapine and fluoxetine
– Add quetiapine to SSRI/SNRI
– Add aripiprazole to antidepressant
– Bupropion + SSRI
– SSRI (of venlafaxine) + mianserin (of mirtazapine)

These recommendations are taken from the 13th edition of the Maudsley Guidelines.

When treating catatonia, the preferred initial treatment is benzodiazepines such as lorazepam. If this approach is unsuccessful, electroconvulsive therapy (ECT) should be considered.

Catatonia Treatment

Catatonia can lead to complications such as dehydration, deep vein thrombosis, pulmonary embolism, and pneumonia. Therefore, prompt treatment is essential. The first-line treatment is benzodiazepines, particularly lorazepam. If this is ineffective, electroconvulsive therapy (ECT) may be considered. The use of antipsychotics is controversial and should be avoided during the acute phase of catatonia.

There is limited evidence suggesting that fluoxetine, paroxetine, and venlafaxine may be effective in treating PTSD, while SSRIs as a whole were found to be more effective than placebo. However, trials involving sertraline did not show any evidence of efficacy, and there is no evidence supporting the use of other drug treatments. Additionally, brofaromine is a type of reversible MAOi.

According to the MARSIPAN guidelines, individuals with anorexia and a BMI below 13 should be placed on 24-hour bed rest and given careful consideration for prophylaxis against deep vein thrombosis. This recommendation is outlined in the October 2010 College Report CR 162, which was jointly produced by the Royal College of Psychiatrists and the Royal College of Physicians in London.

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.

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 CATIE study did not include haloperidol, which is a commonly used typical antipsychotic, due to its high likelihood of causing EPSEs. Instead, perphenazine, an older antipsychotic that is effective and less likely to cause EPSEs, was used.

CATIE Study: Comparing Antipsychotic Medications for Schizophrenia Treatment

The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Study, funded by the National Institute of Mental Health (NIMH), was a nationwide clinical trial that aimed to compare the effectiveness of older and newer antipsychotic medications used to treat schizophrenia. It is the largest, longest, and most comprehensive independent trial ever conducted to examine existing therapies for schizophrenia. The study consisted of two phases.

Phase I of CATIE compared four newer antipsychotic medications to one another and an older medication. Participants were followed for 18 months to evaluate longer-term patient outcomes. The study involved over 1400 participants and was conducted at various treatment sites, representative of real-life settings where patients receive care. The results from CATIE are applicable to a wide range of people with schizophrenia in the United States.

The medications were comparably effective, but high rates of discontinuation were observed due to intolerable side-effects of failure to adequately control symptoms. Olanzapine was slightly better than the other drugs but was associated with significant weight gain as a side-effect. Surprisingly, the older, less expensive medication (perphenazine) used in the study generally performed as well as the four newer medications. Movement side effects primarily associated with the older medications were not seen more frequently with perphenazine than with the newer drugs.

Phase II of CATIE sought to provide guidance on which antipsychotic to try next if the first failed due to ineffectiveness of intolerability. Participants who discontinued their first antipsychotic medication because of inadequate management of symptoms were encouraged to enter the efficacy (clozapine) pathway, while those who discontinued their first treatment because of intolerable side effects were encouraged to enter the tolerability (ziprasidone) pathway. Clozapine was remarkably effective and was substantially better than all the other atypical medications.

The CATIE study also looked at the risk of metabolic syndrome (MS) using the US National Cholesterol Education Program Adult Treatment Panel criteria. The prevalence of MS at baseline in the CATIE group was 40.9%, with female patients being three times as likely to have MS compared to matched controls and male patients being twice as likely.

Understanding Panic Disorder: Key Facts, Diagnosis, and Treatment Recommendations

Panic disorder is a mental health condition characterized by recurrent unexpected panic attacks, which are sudden surges of intense fear of discomfort that reach a peak within minutes. Females are more commonly affected than males, and the disorder typically onsets during the early 20s. Panic attacks are followed by persistent concern of worry about their recurrence of negative significance, of behaviors intended to avoid their recurrence. The symptoms result in significant impairment in personal, family, social, educational, occupational, of other important areas of functioning.

To diagnose panic disorder, the individual must experience recurrent panic attacks that are not restricted to particular stimuli of situations and are unexpected. The panic attacks are followed by persistent concern of worry about their recurrence of negative significance, of behaviors intended to avoid their recurrence. The symptoms are not a manifestation of another medical condition of substance use, and they result in significant impairment in functioning.

Panic disorder is differentiated from normal fear reactions by the frequent recurrence of panic attacks, persistent worry of concern about the panic attacks of their meaning, and associated significant impairment in functioning. Treatment recommendations vary based on the severity of the disorder, with mild to moderate cases recommended for individual self-help and moderate to severe cases recommended for cognitive-behavioral therapy of antidepressant medication. The classes of antidepressants that have an evidence base for effectiveness are SSRIs, SNRIs, and TCAs. Benzodiazepines are not recommended for the treatment of panic disorder due to their association with a less favorable long-term outcome. Sedating antihistamines of antipsychotics should also not be prescribed for the treatment of panic disorder.

The Cochrane review in 2011 found that both comprehensive and non-comprehensive psychotherapies can have beneficial effects for individuals with borderline personality disorder (BPD) core pathology and associated general psychopathology. Dialectical Behaviour Therapy (DBT) was found to be particularly helpful, with results indicating a decrease in inappropriate anger, a reduction in self-harm, and an improvement in general functioning. However, there were generally too few studies to draw firm conclusions about the value of other types of psychotherapeutic interventions. Overall, more research is needed in this area.

Personality Disorder (Borderline)

History and Terminology

The term borderline personality disorder originated from early 20th-century theories that the disorder was on the border between neurosis and psychosis. The term borderline was coined by Adolph Stern in 1938. Subsequent attempts to define the condition include Otto Kernberg’s borderline personality organization, which identified key elements such as ego weakness, primitive defense mechanisms, identity diffusion, and unstable reality testing.

Features

The DSM-5 and ICD-11 both define borderline personality disorder as a pervasive pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity. Symptoms include efforts to avoid abandonment, unstable relationships, impulsivity, suicidal behavior, affective instability, chronic feelings of emptiness, difficulty controlling temper, and transient dissociative symptoms.

Abuse

Childhood abuse and neglect are extremely common among borderline patients, with up to 87% having suffered some form of trauma. The effect of abuse seems to depend on the stage of psychological development at which it takes place.

comorbidity

Borderline PD patients are more likely to receive a diagnosis of major depressive disorder, bipolar disorder, panic disorder, PTSD, OCD, eating disorders, and somatoform disorders.

Psychological Therapy

Dialectical Behavioral Therapy (DBT), Mentalization-Based Treatment (MBT), Schema-Focused Therapy (SFT), and Transference-Focused Psychotherapy (TFP) are the main psychological treatments for BPD. DBT is the most well-known and widely available, while MBT focuses on improving mentalization, SFT generates structural changes to a patient’s personality, and TFP examines dysfunctional interpersonal dynamics that emerge in interactions with the therapist in the transference.

NICE Guidelines

The NICE guidelines on BPD offer very little recommendations. They do not recommend medication for treatment of the core symptoms. Regarding psychological therapies, they make reference to DBT and MBT being effective but add that the evidence base is too small to draw firm conclusions. They do specifically say Do not use brief psychotherapeutic interventions (of less than 3 months’ duration) specifically for borderline personality disorder of for the individual symptoms of the disorder.

The presence of a family history of schizophrenia is not relevant to this case and may lead to a false conclusion.

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.

Sexual side effects are rare when using aripiprazole.

Antipsychotics: Common Side Effects and Relative Adverse Effects

Antipsychotics are medications used to treat various mental health conditions, including schizophrenia and bipolar disorder. However, they can also cause side effects that can be bothersome of even serious. The most common side effects of antipsychotics are listed in the table below, which includes the adverse effects associated with their receptor activity.

Antidopaminergic effects: These effects are related to the medication’s ability to block dopamine receptors in the brain. They can cause galactorrhoea, gynecomastia, menstrual disturbance, lowered sperm count, reduced libido, Parkinsonism, dystonia, akathisia, and tardive dyskinesia.

Anticholinergic effects: These effects are related to the medication’s ability to block acetylcholine receptors in the brain. They can cause dry mouth, blurred vision, urinary retention, and constipation.

Antiadrenergic effects: These effects are related to the medication’s ability to block adrenaline receptors in the body. They can cause postural hypotension and ejaculatory failure.

Histaminergic effects: These effects are related to the medication’s ability to block histamine receptors in the brain. They can cause drowsiness.

The Maudsley Guidelines provide a rough guide to the relative adverse effects of different antipsychotics. The table below summarizes their findings, with +++ indicating a high incidence of adverse effects, ++ indicating a moderate incidence, + indicating a low incidence, and – indicating a very low incidence.

Drug Sedation Weight gain Diabetes EPSE Anticholinergic Postural Hypotension Prolactin elevation
Amisulpride – + + + – – +++
Aripiprazole – +/- – +/- – – –
Asenapine + + +/- +/- – – +/-
Clozapine +++ +++ +++ – +++ +++ –
Flupentixol + ++ + ++ ++ + +++
Fluphenazine + + + +++ ++ + +++
Haloperidol + + +/- +++ + + +++
Olanzapine ++ +++ +++ +/- + + +
Paliperidone + ++ + + + ++ +++
Pimozide + + – + + + +++
Quetiapine ++ ++ ++ – + ++ –
Risperidone + ++ + + + ++ +++
Zuclopenthixol ++ ++ + ++ ++ + +++

Overall, it is important to discuss the potential side effects of antipsychotics with a healthcare provider and to monitor for any adverse effects while taking these medications.

Studies have indicated that belonging to an ethnic minority group increases the likelihood of being at risk. However, it is important to note that race alone is not a determining factor. The correlation is believed to be influenced by various factors, including social stress and discrimination. It is noteworthy that this trend appears to persist across multiple generations.

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.