Hepatic Impairment: Recommended Drugs

Patients with hepatic impairment may experience reduced ability to metabolize drugs, toxicity, enhanced dose-related side effects, reduced ability to synthesize plasma proteins, and elevated levels of drugs subject to first-pass metabolism due to reduced hepatic blood flow. The Maudsley Guidelines 14th Ed recommends the following drugs for patients with hepatic impairment:

Antipsychotics: Paliperidone (if depot required), Amisulpride, Sulpiride

Antidepressants: Sertraline, Citalopram, Paroxetine, Vortioxetine (avoid TCA and MAOI)

Mood stabilizers: Lithium

Sedatives: Lorazepam, Oxazepam, Temazepam, Zopiclone 3.75mg (with care)

When it comes to treating atypical depression, tricyclic antidepressants (such as dosulepin) are the least effective type of antidepressant.

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.

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.

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

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.

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

Personality Disorder (Narcissistic)

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

Anhedonia is commonly regarded as a psychological manifestation of depression.

Depression (Biological Symptoms)

Depression can be classified into biological (physical) of psychological symptoms. The terms used to describe biological symptoms include somatic, vital, melancholic, and endogenomorphic. These terms are used interchangeably in exams, so it is important to be familiar with them.

Biological symptoms of depression include decreased appetite, weight loss, lack of emotional reactivity, anhedonia, early morning waking, depression worse in the mornings, psychomotor changes (retardation and agitation), fatigue, reduced libido, constipation, and insomnia.

Eating Disorders: Lab Findings and Medical Complications

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

The most significant risk factor for puerperal psychosis in individuals with a personal of family history of psychiatric illness is parity, with a higher incidence observed after the birth of the first child. However, the underlying cause for this increased risk remains uncertain.

Puerperal Psychosis: Incidence, Risk Factors, and Treatment

Postpartum psychosis is a subtype of bipolar disorder with an incidence of 1-2 in 1000 pregnancies. It typically occurs rapidly between day 2 and day 14 following delivery, with almost all cases occurring within 8 weeks of delivery. Risk factors for puerperal psychosis include a past history of puerperal psychosis, pre-existing psychotic illness (especially affective psychosis) requiring hospital admission, and a family history of affective psychosis in first of second degree relatives. However, factors such as twin pregnancy, breastfeeding, single parenthood, and stillbirth have not been shown to be associated with an increased risk. Treatment for puerperal psychosis is similar to that for psychosis in general, but special consideration must be given to potential issues if the mother is breastfeeding.

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

Schizotypal Personality Disorder: Symptoms and Diagnostic Criteria

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

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

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

Lithium – Clinical Usage

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

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

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

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

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

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

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

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.

The NICE guidelines for borderline personality disorder recommend that psychological treatment should be individualized to meet the specific needs of each patient. However, for women who experience recurrent self-harm and have BPD, dialectical behavioral therapy is recommended as a treatment option. These guidelines provide a framework for healthcare professionals to develop a personalized treatment plan for individuals with BPD.

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.

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.

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

When an imbalance in electrolytes is identified, the first step is to address the behavior causing it. In rare cases where supplementation is necessary to restore balance, oral administration is preferred over intravenous, unless there are issues with absorption in the gastrointestinal tract.

Eating Disorders: NICE Guidelines

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

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

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

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

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

Note: These guidelines are taken from NICE guidelines 2017.

According to the NICE guidelines of 2005 on post-traumatic stress disorder (PTSD), debriefing is not recommended.

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.

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.

Klerman identified bipolar VI as unipolar mania, which is characterized by manic episodes without any history of depression. However, determining the exact prevalence of unipolar mania is challenging. Studies suggest that individuals with unipolar mania tend to exhibit hyperthymic temperament, grandiosity, and psychotic symptoms before the onset of the illness. They also experience less rapid cycling, suicidality, comorbid anxiety disorder, and seasonality compared to those with bipolar mania. Unfortunately, unipolar mania does not respond well to lithium prophylaxis, and valproate may be a more effective treatment option for these patients.

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.

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

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

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

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

Self Harm in Older Adults

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

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

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

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.

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.

Both males and females are equally likely to experience OCD, according to most studies. While some discrepancies have been reported, the majority support a 1:1 ratio.

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

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 man’s symptoms suggest that he may be experiencing catatonia, as he is displaying immobility, echolalia, has a history of schizophrenia, and may have stopped taking clozapine. It is alarming that he is not consuming food of water, and urgent action is necessary to prevent a potentially fatal outcome. In cases of acute catatonia, antipsychotics are typically avoided, and benzodiazepines could be considered as a treatment option (although they are not listed as choices in the question). Given the man’s risk of dehydration and electrolyte imbalances, electroconvulsive therapy (ECT) may be a reasonable recommendation.

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.

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

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.

This scenario strongly indicates the presence of histrionic personality disorder, which often involves individuals displaying sexualized behaviors towards their partners and a constant desire for attention, leading to social alienation. While individuals with borderline personality disorder may also exhibit attention-seeking behaviors, their condition is typically characterized by self-destructive tendencies, tumultuous relationships, and persistent feelings of emptiness and identity disturbance, setting it apart from histrionic personality disorder.

Personality Disorder: Histrionic

A histrionic personality disorder, also known as a dramatic personality disorder, is a psychiatric condition characterized by a consistent pattern of attention-seeking behaviors and exaggerated emotional responses. To diagnose this disorder, the DSM-5 requires the presence of at least five of the following symptoms: discomfort when not the center of attention, seductive of provocative behavior, shallow and shifting emotions, using appearance to draw attention, vague and impressionistic speech, dramatic of exaggerated emotions, suggestibility, and considering relationships to be more intimate than they actually are. However, the ICD-11 has removed the diagnosis of histrionic personality disorder from its list of recognized disorders.

The frequently cited effectiveness rate of antidepressants is likely derived from the STAR*D study, which enrolled individuals with a history of recurrent depression and aimed to assess real-world outcomes.

STAR*D Study

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

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

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

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.

The primary distinction between PTSD and an acute stress reaction lies in the length of time that symptoms persist. If symptoms have not significantly diminished within a month, the diagnosis shifts to PTSD; prior to that point, it is classified as an acute stress reaction.

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.

Guaiacolate helps with coughing up phlegm, metoclopramide prevents nausea and vomiting, and lactulose aids in bowel movements. Although hydrogen peroxide can cause vomiting, it is not a popular choice for individuals with bulimia due to its unpleasantness and is more commonly used as a bleach.

Bulimia, a disorder characterized by inducing vomiting, is a serious health concern. One method used to induce vomiting is through the use of syrup of ipecac, which contains emetine, a toxic alkaloid that irritates the stomach and causes vomiting. While it may produce vomiting within 15-30 minutes, it is not always effective. Unfortunately, nearly 8% of women with eating disorders experiment with ipecac, and 1-2% use it frequently. This is concerning because ipecac is associated with serious cardiac toxicity, including cardiomyopathy and left ventricular dysfunction. Elevated serum amylase levels are a strong indication that a patient has recently been vomiting. It is important to seek professional help for bulimia and avoid using dangerous methods like ipecac to induce vomiting.

The primary metabolic pathway for cyclosporin involves the CYP3A3/4 isoenzymes. When this system is inhibited, toxic levels of cyclosporin can accumulate. Reports have shown that interactions with nefazodone and fluvoxamine can lead to cyclosporine toxicity. Vella (1998) published a study on the interactions between cyclosporine and newer antidepressant medications in the American Journal of Kidney Diseases, which supports these findings.

Interactions of Antidepressants with Cytochrome P450 System

Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), can have significant effects on the cytochrome P450 system. This can result in drug interactions that can affect the efficacy and safety of the medications.

One example of such interaction is between fluvoxamine and theophylline. Fluvoxamine is a potent inhibitor of CYP1A2, which can lead to increased levels of theophylline in the body. This can cause adverse effects such as nausea, vomiting, and tremors.

Another example is between fluoxetine and clozapine. Fluoxetine is a potent inhibitor of CYP2D6, which can increase the risk of seizures with clozapine. Clozapine is metabolized by CYP1A2, CYP3A4, and CYP2D6, and any inhibition of these enzymes can affect its metabolism and increase the risk of adverse effects.

It is important to be aware of these interactions and monitor patients closely when prescribing antidepressants, especially in those who are taking other medications that are metabolized by the cytochrome P450 system.

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.

Infants born to mothers with anorexia nervosa have significantly lower APGAR scores and birth weights compared to infants born to healthy women. Additionally, mothers with anorexia nervosa have higher rates of caesarean delivery, postnatal complications, and postpartum depression.

Paracetamol’s main byproduct is benzoquinoneimine, a highly reactive substance that typically binds with glutathione. However, when glutathione levels are low, it can bind to liver protein and result in liver damage.

Self-Harm and its Management

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

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

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

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

The patient has Wallenberg’s syndrome, which is caused by a blockage in the posterior inferior cerebellar artery. Symptoms typically appear suddenly and include severe dizziness, which can cause the patient to fall. Other common symptoms include nausea, vomiting, difficulty with coordination on the same side as the blockage, muscle stiffness, difficulty judging distance, and a tendency to lean to one side. The patient may also experience pain, tingling, of numbness on one side of the face, as well as involuntary eye movements, hiccups, difficulty swallowing, speaking, of breathing, and double vision. Horner’s syndrome, which affects the eye, is also common. Sensory changes may include a loss of pain and temperature sensation on one side of the face and reduced sensation on the opposite side of the body. This condition is most commonly seen in individuals over the age of 40.

Herbal Remedies for Depression and Anxiety

Depression can be treated with Hypericum perforatum (St John’s Wort), which has been found to be more effective than placebo and as effective as standard antidepressants. However, its use is not advised due to uncertainty about appropriate doses, variation in preparations, and potential interactions with other drugs. St John’s Wort can cause serotonin syndrome and decrease levels of drugs such as warfarin and ciclosporin. The effectiveness of the combined oral contraceptive pill may also be reduced.

Anxiety can be reduced with Piper methysticum (kava), but it cannot be recommended for clinical use due to its association with hepatotoxicity.

Antidepressants (Licensed Indications)

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

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

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.

The patient’s symptoms indicate possible HSV encephalitis, with specific damage to the temporal and orbitofrontal regions causing hallucinations, loss of smell, and significant memory problems. Immediate treatment with acyclovir and dexamethasone is necessary, and referral for decompression may be necessary depending on the severity of the condition.

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.

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

Self-Harm and its Management

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

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

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

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

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.

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.

Although CBT is effective in treating bulimia nervosa, it is not always successful in achieving full and lasting recovery for all patients. To address this, an enhanced form of CBT was developed by Fairburn. This treatment uses a range of strategies and procedures to improve treatment adherence and outcomes, and to identify and address obstacles to change. It has also been adapted to be suitable for all forms of eating disorders, not just bulimia, based on the transdiagnostic theory of the maintenance of eating disorders.

The enhanced CBT treatment comes in two forms: a focused form that concentrates solely on eating disorder psychopathology, and a broad form that also addresses external barriers to change, such as clinical perfectionism, core low self-esteem, and interpersonal difficulties. Eating disorders are often complex, with patients experiencing other problems such as mood disorders, substance misuse, personality disorders, and physical complications. Enhanced CBT is designed to manage these issues while providing treatment.

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.

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.

The inclination to prioritize one’s own desires over others, regardless of the consequences, is a shared characteristic of both antisocial and narcissistic personality disorders. Nevertheless, the conceitedness and exaggerated belief in one’s own significance are particularly indicative of narcissistic personality disorder.

Personality Disorder (Narcissistic)

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

One of the notable side effects of olanzapine is its potential to induce diabetes.

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.

Globus, a sensation of tightness of feeling of something stuck in the throat, can be caused by stress of anxiety. It is a common symptom that often improves after eating and is not considered a serious condition. Despite being bothersome, globus is generally harmless.

Generalised Anxiety Disorder: Symptoms and Diagnosis

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

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

Individuals with psychiatric illness may inquire about the criteria for being able to continue driving. Following an acute episode of uncomplicated mania of psychosis, a period of three months of stability is necessary before resuming driving.

The short half-life of paroxetine results in neonatal withdrawal when used during pregnancy.

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.

Factors that Increase the Risk of Recurrent Depression

Depression is a disorder that often recurs. Research shows that 50-85% of individuals who experience a single episode of depression will have a second episode, and of those, 80-90% will have a third episode (Forshall, 1999). Due to the high likelihood of recurrence, NICE recommends that individuals who have had two of more episodes of depression in the recent past should continue taking antidepressants for at least two years.

Several factors increase the risk of recurrent depression, including a family history of depression, recurrent dysthymia, concurrent non-affective psychiatric illness, female gender, long episode duration, chronic medical illness, and lack of a confiding relationship. It is important for individuals with a history of depression to be aware of these risk factors and to work with their healthcare provider to develop a plan for preventing future episodes.

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.

– 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.

Borderline personality disorder often presents with stress-related dissociation as a prominent symptom. Dissociation refers to a disturbance of interruption in the typical functioning of various cognitive processes, including consciousness, perception, attention, memory, and identity. This can manifest as feelings of detachment from oneself (depersonalization) of the surroundings (derealization), which may seem surreal, hazy, of insignificant. Memory disturbances can range from difficulty recalling information to complete dissociative amnesia.

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 recommended options for augmentation are olanzapine and quetiapine.

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.

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

Bipolar Disorder: Diagnosis and Management

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

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

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

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

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

The suicide rate in England is typically 1 in 10,000, while for individuals who use mental health services in England, the suicide rate is 1 in 1000.

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.

Paracetamol overdose can cause liver damage due to the production of a reactive metabolite called N-acetyl-p-benzoquinoneimine (NAPQI) by cytochrome P450 enzymes. Glutathione detoxifies NAPQI at therapeutic doses, but overdose depletes glutathione. Antidotes such as acetylcysteine and methionine provide a substrate for glutathione synthesis, reducing hepatotoxicity. IV acetylcysteine is the preferred option and more effective than oral acetylcysteine and methionine. Adverse reactions to IV acetylcysteine are rare but can include urticaria, pruritus, facial flushing, wheezing, dyspnoea, and hypotension. These reactions are not true anaphylaxis and do not require prior exposure to N-acetylcysteine. Patients should be observed for signs of anaphylactoid reactions, and management is supportive with temporary halting of slowing of the infusion and administration of antihistamines. Patients with a history of atopy and asthma may be at increased risk of developing an anaphylactoid reaction. (Benlamkadem, 2018).

Self-Harm and its Management

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

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

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

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

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.

In mania, there is a tendency for appetite to decrease.

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.

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.

The women’s symptoms are indicative of hyperprolactinemia, which is likely caused by venlafaxine. To avoid exacerbating this condition, mirtazapine is the recommended treatment option as it is thought to have no impact on prolactin levels.

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.

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.

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.

The most common disorder identified in the study was substance misuse, which encompassed both alcohol and drug use. This finding differs from the National Psychiatric Morbidity Survey, which reported neurotic disorders as the most prevalent. However, this discrepancy is likely due to differences in study design rather than actual differences in prevalence. The ECA study specifically identified high rates of alcohol dependence and illicit drug use, but presented these findings as distinct categories.

Epidemiological Catchment Area Study: A Landmark Community-Based Survey

The Epidemiological Catchment Area Study (ECA) was a significant survey conducted in five US communities from 1980-1985. The study included 20,000 participants, with 3000 community residents and 500 residents of institutions sampled in each site. The Diagnostic Interview Schedule (DIS) was used to conduct two interviews over a year with each participant.

However, the DIS diagnosis of schizophrenia was not consistent with psychiatrists’ classification, with only 20% of cases identified by the DIS in the Baltimore ECA site matching the psychiatrist’s diagnosis. Despite this, the ECA produced valuable findings, including a lifetime prevalence rate of 32.3% for any disorder, 16.4% for substance misuse disorder, 14.6% for anxiety disorder, 8.3% for affective disorder, 1.5% for schizophrenia and schizophreniform disorder, and 0.1% for somatization disorder.

The ECA also found that phobia had a one-month prevalence of 12.5%, generalized anxiety and depression had a prevalence of 8.5%, obsessive-compulsive disorder had a prevalence of 2.5%, and panic had a prevalence of 1.6%. Overall, the ECA was a landmark community-based survey that provided valuable insights into the prevalence of mental disorders in the US.

Depression Treatment Duration

It is recommended to treat a single episode of depression for 6-9 months after complete remission. Abruptly stopping antidepressants after recovery can lead to a relapse in 50% of patients within 3-6 months. For patients who have experienced 2 of more depressive episodes in recent history, NICE recommends a minimum of 2 years of antidepressant treatment. These guidelines are outlined in the Maudsley Guidelines 10th Edition.

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.

Psychiatric Issues in the Postpartum Period

The period following childbirth, known as the postpartum period, can be a time of significant psychiatric challenges for women. Many women experience a temporary mood disturbance called baby blues, which is characterized by emotional instability, sadness, and tearfulness. This condition typically resolves within two weeks.

However, a minority of women (10-15%) experience postpartum depression, which is similar to major depression in its clinical presentation. In contrast, a very small number of women (1-2 per 1000) experience postpartum psychosis, also known as puerperal psychosis. This is a severe form of psychosis that occurs in the weeks following childbirth.

Research suggests that there may be a link between puerperal psychosis and mood disorders, as approximately 50% of women who develop the condition have a family history of mood disorder. Puerperal psychosis typically begins within the first two weeks following delivery. It is important for healthcare providers to be aware of these potential psychiatric issues and to provide appropriate support and treatment to women during the postpartum period.

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 diagnosis would be coded as ARFID (Avoidant/Restrictive Food Intake Disorder) in the ICD-11, as it encompasses the three criteria mentioned above. Anorexia nervosa would require additional criteria, such as amenorrhea in females of a fear of gaining 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.

Stevens-Johnson syndrome is a rare but serious condition that affects the skin and mucous membranes. It is often caused by a reaction to medication of infection and can start with flu-like symptoms. The condition is characterized by a painful rash that spreads and blisters, leading to the shedding of the top layer of affected skin. Hospitalization is usually required as it is a medical emergency. Medications that have been known to cause Stevens-Johnson syndrome include lamotrigine, phenobarbital, sertraline, and certain types of NSAIDs such as meloxicam, piroxicam, and tenoxicam.

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.

This risk is purely hypothetical and can affect individuals of any gender.

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.

It appears that the individual in question may be exhibiting symptoms of obsessive compulsive personality disorder. This disorder is characterized by a preoccupation with orderliness, perfectionism, and control. Individuals with this disorder may have difficulty delegating tasks, may be excessively devoted to work, and may have rigid beliefs and values. They may also be overly conscientious and inflexible, and may struggle with decision-making.

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.

Antidepressants and Diabetes

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

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.

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

The patient’s symptoms do not suggest a physical cause, as the median nerve does not affect all fingers, and there is no clear connection between the fall and the onset of symptoms. There is no apparent motive for the patient to feign illness of adopt a sick role. It is probable that the patient is experiencing a conversion disorder, with the symptoms arising unconsciously in the context of therapy. The fact that the symptoms are affecting the patient’s left hand is noteworthy, as this is the hand that may have been used in the act of strangulation.

Although both mania and psychosis can exhibit similar symptoms and signs, individuals with mania are often psychotic and experience delusions of hallucinations. One distinguishing feature of mania is the presence of flight of ideas, which is characterized by rapid changes in topic.

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.

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.

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.

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.

Patients taking certain drugs, such as phenytoin, carbamazepine, barbiturates, rifampicin, and St John’s Wort, have a higher risk of liver damage due to the inducible metabolism of paracetamol. Phenytoin stands out as the only enzyme inducer in the list, which requires some lateral thinking to identify.

Self-Harm and its Management

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

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

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

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

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.

Skin Changes in Anorexia Nervosa

Anorexia nervosa is an eating disorder characterized by a distorted body image and an intense fear of gaining weight. In addition to the physical effects of malnutrition, anorexia can also cause various skin changes. These changes include xerosis of dry skin, cheilitis of inflammation of the lips, gingivitis of inflammation of the gums, hypertrichiosis of excess hair growth in areas that do not normally have hair, hyperpigmentation, Russell’s sign of scarring on knuckles and back of hand, carotenoderma of yellow/orange skin color, acne, nail changes, acrocyanosis of persistent blue, cyanotic discoloration of the digits, and seborrheic dermatitis. These skin changes can be a sign of underlying malnutrition and should be addressed as part of the treatment plan for anorexia nervosa.

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.

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.

The specific onset of puerperal psychosis is a topic of varying information from different sources. It is difficult to determine whether it is more common in the first two weeks of weeks 2-4. However, an article in Advances in Psychiatric Treatment by Brockington in 1998 suggests that the most common time period for onset is within the first two weeks. As this is a widely used resource in college, it is the source we have chosen to rely on.

Psychiatric Issues in the Postpartum Period

The period following childbirth, known as the postpartum period, can be a time of significant psychiatric challenges for women. Many women experience a temporary mood disturbance called baby blues, which is characterized by emotional instability, sadness, and tearfulness. This condition typically resolves within two weeks.

However, a minority of women (10-15%) experience postpartum depression, which is similar to major depression in its clinical presentation. In contrast, a very small number of women (1-2 per 1000) experience postpartum psychosis, also known as puerperal psychosis. This is a severe form of psychosis that occurs in the weeks following childbirth.

Research suggests that there may be a link between puerperal psychosis and mood disorders, as approximately 50% of women who develop the condition have a family history of mood disorder. Puerperal psychosis typically begins within the first two weeks following delivery. It is important for healthcare providers to be aware of these potential psychiatric issues and to provide appropriate support and treatment to women during the postpartum period.

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.

The HAMD is a tool used by clinicians to assess the severity of depression, whereas the Edinburgh Postnatal Depression Scale is primarily used for screening purposes.

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.

A key objective in the treatment of anorexia nervosa is to assist individuals in achieving a healthy body weight of BMI appropriate for their age. It is not recommended to rely solely on screening tools like SCOFF to diagnose eating disorders. While eating disorders can occur at any age, it is important to note that the risk is greatest for adolescents between the ages of 13 and 17, particularly young men and women. It is not advisable to use a single metric such as BMI of duration of illness to determine whether treatment for an eating disorder is necessary.

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.

Depression (Biological Symptoms)

Depression can be classified into biological (physical) of psychological symptoms. The terms used to describe biological symptoms include somatic, vital, melancholic, and endogenomorphic. These terms are used interchangeably in exams, so it is important to be familiar with them.

Biological symptoms of depression include decreased appetite, weight loss, lack of emotional reactivity, anhedonia, early morning waking, depression worse in the mornings, psychomotor changes (retardation and agitation), fatigue, reduced libido, constipation, and insomnia.

– Severe hypoglycemia can indicate infection and can be fatal
– Triiodothyronine levels are usually low
– Hypercortisolaemia does not result in Cushingoid features
– Primary and secondary amenorrhoea are common
– Insulin-like growth factor-1 is reduced

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.

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

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

Bipolar Disorder: Diagnosis and Management

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

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

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

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

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

Huntington’s disease is a degenerative disorder of the central nervous system that is inherited in an autosomal dominant manner. This means that if one parent has the disease, there is a 50% chance that their offspring will also develop the disease. The disease has complete penetrance, meaning that all individuals who inherit the disease-causing gene will eventually develop symptoms. Symptoms typically appear in the late 30s of early 40s. Inheritance patterns differ between maternal and paternal alleles, with paternal alleles exhibiting repeat expansion and earlier onset and severity of disease in successive generations. This phenomenon is known as genetic anticipation.