Individuals with obsessive compulsive personality disorder tend to be hesitant to delegate tasks to others unless they conform to their specific methods and preferences.

Personality Disorder (Obsessive Compulsive)

Obsessive-compulsive personality disorder is characterized by a preoccupation with orderliness, perfectionism, and control, which can hinder flexibility and efficiency. This pattern typically emerges in early adulthood and can be present in various contexts. The estimated prevalence ranges from 2.1% to 7.9%, with males being diagnosed twice as often as females.

The DSM-5 diagnosis requires the presence of four of more of the following criteria: preoccupation with details, rules, lists, order, organization, of agenda to the point that the key part of the activity is lost; perfectionism that hampers completing tasks; extreme dedication to work and efficiency to the elimination of spare time activities; meticulous, scrupulous, and rigid about etiquettes of morality, ethics, of values; inability to dispose of worn-out of insignificant things even when they have no sentimental meaning; unwillingness to delegate tasks of work with others except if they surrender to exactly their way of doing things; miserly spending style towards self and others; and rigidity and stubbornness.

The ICD-11 abolished all categories of personality disorder except for a general description of personality disorder, which can be further specified as “mild,” “moderate,” of “severe.” The anankastic trait domain is characterized by a narrow focus on one’s rigid standard of perfection and of right and wrong, and on controlling one’s own and others’ behavior and controlling situations to ensure conformity to these standards. Common manifestations of anankastic include perfectionism and emotional and behavioral constraint.

Differential diagnosis includes OCD, hoarding disorder, narcissistic personality disorder, antisocial personality disorder, and schizoid personality disorder. OCD is distinguished by the presence of true obsessions and compulsions, while hoarding disorder should be considered when hoarding is extreme. Narcissistic personality disorder individuals are more likely to believe that they have achieved perfection, while those with obsessive-compulsive personality disorder are usually self-critical. Antisocial personality disorder individuals lack generosity but will indulge themselves, while those with obsessive-compulsive personality disorder adopt a miserly spending style toward both self and others. Schizoid personality disorder is characterized by a fundamental lack of capacity for intimacy, while in obsessive-compulsive personality disorder, this stems from discomfort with emotions and excessive devotion to work.

CATIE Study: Comparing Antipsychotic Medications for Schizophrenia Treatment

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

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

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

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

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

If the patient’s prolactin levels have not decreased even after switching to a different antipsychotic medication that has a lower likelihood of increasing prolactin levels, it is possible that there is an underlying cause within the body. One potential cause of hyperprolactinemia is a tumor in the anterior pituitary gland. Therefore, if the patient’s prolactin levels are greater than 118 ng/ml, it is recommended to undergo an MRI to investigate this possibility. It is important to note that a gadolinium-enhanced MRI is necessary to confirm the diagnosis of a prolactinoma, as CT scans do not provide sufficient visualization of the pituitary gland.

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.

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

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

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

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.

Compared to the other options, bupropion is classified as high risk for individuals with epilepsy. The remaining options are considered low risk of likely low risk.

Psychotropics and Seizure Threshold in People with Epilepsy

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

The AESOP study provides the latest evidence that being a migrant significantly increases the likelihood of developing schizophrenia, as it is a well-established risk factor.

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.

There is often confusion between hypochondriasis and somatisation disorder, which have been renamed illness anxiety disorder and somatic symptom disorder in the DSM-5. Hypochondriasis involves a preoccupation with a specific condition, while somatisation disorder is characterized by a focus on symptoms rather than a particular illness.

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.

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.

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.

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.

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.

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.

Personality Disorder (Obsessive Compulsive)

Obsessive-compulsive personality disorder is characterized by a preoccupation with orderliness, perfectionism, and control, which can hinder flexibility and efficiency. This pattern typically emerges in early adulthood and can be present in various contexts. The estimated prevalence ranges from 2.1% to 7.9%, with males being diagnosed twice as often as females.

The DSM-5 diagnosis requires the presence of four of more of the following criteria: preoccupation with details, rules, lists, order, organization, of agenda to the point that the key part of the activity is lost; perfectionism that hampers completing tasks; extreme dedication to work and efficiency to the elimination of spare time activities; meticulous, scrupulous, and rigid about etiquettes of morality, ethics, of values; inability to dispose of worn-out of insignificant things even when they have no sentimental meaning; unwillingness to delegate tasks of work with others except if they surrender to exactly their way of doing things; miserly spending style towards self and others; and rigidity and stubbornness.

The ICD-11 abolished all categories of personality disorder except for a general description of personality disorder, which can be further specified as “mild,” “moderate,” of “severe.” The anankastic trait domain is characterized by a narrow focus on one’s rigid standard of perfection and of right and wrong, and on controlling one’s own and others’ behavior and controlling situations to ensure conformity to these standards. Common manifestations of anankastic include perfectionism and emotional and behavioral constraint.

Differential diagnosis includes OCD, hoarding disorder, narcissistic personality disorder, antisocial personality disorder, and schizoid personality disorder. OCD is distinguished by the presence of true obsessions and compulsions, while hoarding disorder should be considered when hoarding is extreme. Narcissistic personality disorder individuals are more likely to believe that they have achieved perfection, while those with obsessive-compulsive personality disorder are usually self-critical. Antisocial personality disorder individuals lack generosity but will indulge themselves, while those with obsessive-compulsive personality disorder adopt a miserly spending style toward both self and others. Schizoid personality disorder is characterized by a fundamental lack of capacity for intimacy, while in obsessive-compulsive personality disorder, this stems from discomfort with emotions and excessive devotion to work.

The Beck’s depression inventory consists of 21 questions with a maximum score of 63. Each question is scored from 0 to 3 and is used to evaluate the severity of depression. It is a self-rated assessment that covers the two weeks leading up to the evaluation.

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

Schizophrenia and Mortality

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

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.

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 question is misleading as it suggests starting clozapine without following the clear guidance. According to the guidance, two antipsychotics (one of which must be an atypical) must be tried before considering clozapine. However, in the given scenario, both antipsychotics are typicals, which does not meet the criteria for starting clozapine.

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

Prescribing benzodiazepines for individuals with panic disorder is not recommended as it is linked to a poorer long-term outcome.

Anxiety (NICE guidelines)

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

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

Anxiety (NICE guidelines)

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

St John’s Wort, like other antidepressants, can lead to hypomania. While it is generally better tolerated than SSRIs, it is not recommended due to uncertainty about its active ingredient. There are potential risks associated with its use, including early macular degeneration and a risk of bleeding. Common side effects include dry mouth, nausea, constipation, fatigue, dizziness, headache, and restlessness. These considerations are outlined in the Maudsley Guidelines 10th Edition.

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.

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

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.

For patients with HIV who experience psychosis, atypical antipsychotics are the preferred first-line treatment. Among these medications, risperidone has the strongest evidence base, while quetiapine, aripiprazole, and olanzapine are also viable options. However, if clozapine is used, patients must be closely monitored.

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.

Biochemical Changes Associated with Psychotropic Drugs

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

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

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

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

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

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

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

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

Patients who have a history of repeated DSH are at a significantly higher risk for suicide. While high suicidal intent is associated with greater risk of suicide, it is not a reliable predictor for individual patients, particularly in the first year following DSH. DSH remains the strongest risk factor for suicide.

Suicide Rates Following Self-Harm

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

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

The effectiveness of non trauma-focused psychological therapies (such as relaxation therapy, hypnosis, and supportive therapy) in treating PTSD has not been supported by any evidence.

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 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 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.

All of the options, except for reserpine, are MAOIs that are used to treat depression. Reserpine, on the other hand, is a second-line antihypertensive drug that was previously used as a neuroleptic in the 1950s. It is derived from the root of Rauvolfia serpentina, which has been used in India for centuries to treat various ailments, including insanity, fever, and snakebites. Despite its historical use, reserpine fell out of favor due to reports of it causing depression in the 1950s.

Organic Causes of Depression

Depression can have various organic causes, including medications, drug abuse, metabolic disorders, nutritional deficiencies, neurological conditions, haematological disorders, infections, and carcinomas. The following table provides a list of some of the organic causes of depression.

Category: Medications
Causes: Reserpine, interferon alpha, beta blockers, levodopa, digoxin, anabolic steroids, H2 blockers, oral contraceptives

Category: Drug abuse
Causes: Alcohol, amphetamine, cocaine, hypnotics

Category: Metabolic
Causes: Hyperthyroidism, hypothyroidism, Cushing’s syndrome, Addison’s disease, hypercalcemia, hyponatremia, diabetes mellitus

Category: Nutritional
Causes: Pellagra, vitamin B12 deficiency

Category: Neurological
Causes: Stroke, MS, brain tumour, Parkinson’s disease, Huntington’s disease, epilepsy, syphilis, subdural hematoma

Category: Haematological
Causes: Anemia, leukaemia

Category: Other
Causes: Infection, carcinoma

It is important to note that depression can have multiple causes, and a thorough evaluation by a healthcare professional is necessary to determine the underlying cause and appropriate treatment.

EMDR: A Trauma-Focused Therapy for PTSD

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

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.

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

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

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

Personality Disorder (Obsessive Compulsive)

Obsessive-compulsive personality disorder is characterized by a preoccupation with orderliness, perfectionism, and control, which can hinder flexibility and efficiency. This pattern typically emerges in early adulthood and can be present in various contexts. The estimated prevalence ranges from 2.1% to 7.9%, with males being diagnosed twice as often as females.

The DSM-5 diagnosis requires the presence of four of more of the following criteria: preoccupation with details, rules, lists, order, organization, of agenda to the point that the key part of the activity is lost; perfectionism that hampers completing tasks; extreme dedication to work and efficiency to the elimination of spare time activities; meticulous, scrupulous, and rigid about etiquettes of morality, ethics, of values; inability to dispose of worn-out of insignificant things even when they have no sentimental meaning; unwillingness to delegate tasks of work with others except if they surrender to exactly their way of doing things; miserly spending style towards self and others; and rigidity and stubbornness.

The ICD-11 abolished all categories of personality disorder except for a general description of personality disorder, which can be further specified as “mild,” “moderate,” of “severe.” The anankastic trait domain is characterized by a narrow focus on one’s rigid standard of perfection and of right and wrong, and on controlling one’s own and others’ behavior and controlling situations to ensure conformity to these standards. Common manifestations of anankastic include perfectionism and emotional and behavioral constraint.

Differential diagnosis includes OCD, hoarding disorder, narcissistic personality disorder, antisocial personality disorder, and schizoid personality disorder. OCD is distinguished by the presence of true obsessions and compulsions, while hoarding disorder should be considered when hoarding is extreme. Narcissistic personality disorder individuals are more likely to believe that they have achieved perfection, while those with obsessive-compulsive personality disorder are usually self-critical. Antisocial personality disorder individuals lack generosity but will indulge themselves, while those with obsessive-compulsive personality disorder adopt a miserly spending style toward both self and others. Schizoid personality disorder is characterized by a fundamental lack of capacity for intimacy, while in obsessive-compulsive personality disorder, this stems from discomfort with emotions and excessive devotion to work.

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.

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

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

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

Confabulation is the creation of false memories while being fully aware, often due to an organic amnesia. Ganser’s syndrome is a disputed diagnosis that includes symptoms such as approximate answers, clouded consciousness, somatic conversion, pseudohallucinations, and amnesia for the time when the symptoms were present. It is commonly observed in incarcerated individuals awaiting trial and may be seen as a simulation of a psychotic disorder. Some experts argue that it is a type of malingering, and it is classified as a dissociative disorder.

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

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

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

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.

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 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.

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.

A consistent finding is that the male to female ratio is 3:1.

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.

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.

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.

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.

Sedatives and Liver Disease

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

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 information provided is valuable because the CATIE study was conducted in a real-world setting, making the estimate potentially applicable to the UK.

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.

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

Psychotropics and Seizure Threshold in People with Epilepsy

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

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

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

In order to diagnose acute and transient psychotic disorder, it is crucial that the individual does not exhibit negative symptoms such as affective flattening, alogia, avolition, asociality, of anhedonia during the psychotic episode. Despite the severity of symptoms being comparable to those seen in schizophrenia, there is typically no prodrome and symptoms can fluctuate rapidly in both frequency and intensity.

– 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.

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

Generalised Anxiety Disorder: Symptoms and Diagnosis

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

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

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.

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 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.

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

Paroxetine Use During Pregnancy: Is it Safe?

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

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.

The term Bouffée délirante is a distinct and historical French diagnosis used to describe a brief episode of psychosis characterized by sudden and severe psychotic symptoms that fully resolve. The oneiroid state refers to a dreamy mental state. Latent schizophrenia is an outdated term that was previously used to describe individuals with borderline, schizoid, and schizotypal personality disorders.

– 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.

Biochemical Changes Associated with Psychotropic Drugs

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

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

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

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

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

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

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

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

Antipsychotics can be classified in different ways, with the most common being typical (first generation) and atypical (second generation) types. Typical antipsychotics block dopamine (D2) receptors and have varying degrees of M1, Alpha-1, and H1 receptor blockade. Atypical antipsychotics have a lower propensity for extrapyramidal side-effects and are attributed to the combination of relatively lower D2 antagonism with 5HT2A antagonism. They are also classified by structure, with examples including phenothiazines, butyrophenones, thioxanthenes, diphenylbutylpiperidine, dibenzodiazepines, benzoxazoles, thienobenzodiazepine, substituted benzamides, and arylpiperidylindole (quinolone). Studies have found little evidence to support the superiority of atypicals over typicals in terms of efficacy, discontinuation rates, of adherence, with the main difference being the side-effect profile. The Royal College also favors classification by structure.

Flumazenil is not authorized for treating benzodiazepine overdose in the UK, despite its widespread use. It works by competitively inhibiting the benzodiazepine binding site on the GABAA receptor, reversing the effects of benzodiazepines. Due to its brief half-life of approximately 10 minutes, it is important to note that multiple doses may be required in cases of benzodiazepine overdose.

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.

Age is the primary factor contributing to agranulocytosis, and recent dose increase and smoking status are not significant factors. The risk factors for agranulocytosis and neutropenia differ, suggesting distinct underlying mechanisms for each disorder. Agranulocytosis is more prevalent in women and Asians, with a higher incidence in older individuals. In contrast, neutropenia is more common in black individuals, but not associated with race of age.

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

Consider prescribing olanzapine of quetiapine as prophylactic medication for women with bipolar disorder who stop taking lithium during pregnancy of plan to breastfeed, according to the Maudsley Prescribing Guidelines 13th edition. These medications can also be considered for post-partum initiation.

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.