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).

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.

St John’s Wort is recognized as a substance that stimulates the P450 system.

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.

According to the Maudsley Guidelines, there is insufficient evidence to support the use of olanzapine as an addition to treatment, and it may worsen metabolic side effects.

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

Sialadenosis is the term used to describe the enlargement of the salivary glands, particularly the parotids, without any inflammation. This condition is typically recurrent and is commonly linked to an underlying systemic disorder such as alcoholism, diabetes, malnutrition, bulimia, and anorexia nervosa.

Eating Disorders: Lab Findings and Medical Complications

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

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.

According to ICD-11, a BMI between 18.5 and 14.0 is considered significantly low for adults, while a BMI under 14.0 is classified as dangerously low. Therefore, it is important to remember that a BMI of 14 is the threshold for dangerously low BMI in adults.

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

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

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

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

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

Schizophrenia is associated with advanced paternal age, as well as cannabis use, which is a separate risk factor (Rajiv, 2008; Semple, 2005).

Schizophrenia Epidemiology

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

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

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

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

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

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

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

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

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

Antipsychotics: Minimum Effective Doses

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

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

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

It is important to take clozapine levels as trough samples, which means they should be taken 11-13 hours after the last dose. Samples taken outside of this time frame may produce inaccurate results. If the levels are taken too early (before 11 hours), the clozapine levels may be artificially high, resulting in high ratios. Conversely, if the levels are taken too late (after 11 hours), the clozapine levels may be artificially low, resulting in low ratios.

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

Bipolar Disorder: Diagnosis and Management

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

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

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

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

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

The occurrence of constipation caused by clozapine is dependent on the dosage.

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

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.

It is important to note that the question is asking for the option that is the most suggestive of a diagnosis of personality disorder with borderline pattern in the ICD-11. The correct answer is ‘transient, psychotic-like features’ as this is a qualifying element of the diagnosis. While the other options may also be present in individuals with this condition, they are not defining features.

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.

While 7am falls within the 10-14 hour range for taking lithium levels, it is not the preferred time as lithium is typically prescribed to be taken at night. Therefore, it is recommended to take the levels in the morning, 10-14 hours after the nighttime dose.

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.

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

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

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.

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.

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.

Drug-Induced Mania: Evidence and Precipitating Drugs

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

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

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

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.

Bipolar disorder with psychosis typically displays noticeable mood symptoms, including heightened mood and restlessness, accompanied by delusions that align with the mood, such as grandiose delusions. In contrast, schizophrenia typically exhibits non-prominent mood symptoms and delusions that do not align with the mood, often being neutral of opposite to it.

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.

Dissociative disorders involve an involuntary disturbance of interruption in the usual integration of various aspects such as identity, sensations, perceptions, emotions, thoughts, memories, bodily movements, of behavior. This disruption can be complete of partial and may vary in intensity over time. The condition usually develops suddenly.

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.

Self Harm in Older Adults

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

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

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

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

Self-Harm and its Management

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

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

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

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

Drug-Induced Mania: Evidence and Precipitating Drugs

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

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

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

Bipolar Disorder: Diagnosis and Management

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

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

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

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

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

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

Suicide Risk in Epilepsy

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

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

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

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

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

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.

When taken with clozapine, many SSRIs can cause an increase in its levels. However, citalopram and escitalopram are considered safe as they do not affect the cytochrome system. Although paroxetine is believed to interact, it has been proven safe when used at normal clinical doses alongside clozapine. Sertraline has minimal impact on clozapine levels.

Interactions of Antidepressants with Cytochrome P450 System

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

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

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

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

Theophylline levels may be elevated by Fluvoxamine due to its inhibition of CYP1A2, while Fluoxetine does not affect CYP1A2.

Interactions of Antidepressants with Cytochrome P450 System

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

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

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

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

Vigabatrin, an AED, is recognized for its ability to decrease AST and ALT levels, but it is also associated with the development of visual field impairments.

Biochemical Changes Associated with Psychotropic Drugs

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

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

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

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

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

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

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

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

Eating Disorders: NICE Guidelines

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

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

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

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

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

Note: These guidelines are taken from NICE guidelines 2017.

According to a Cochrane review, while Ginkgo biloba may have the potential to decrease TD, there is insufficient evidence to support its regular use as a recommended treatment. Additionally, it should be noted that reducing medication dosage may initially exacerbate TD symptoms.

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).

Perinatal Depression, Baby Blues, and Postpartum Depression

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

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

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

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

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

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

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

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.

Schizophrenia and Sleep

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

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.

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

Antipsychotics: Common Side Effects and Relative Adverse Effects

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

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

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

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

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

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

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

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

Transient global amnesia is a condition that is characterized by a temporary lack of blood flow to both hippocampi, typically occurring in individuals over the age of 50. Although rare, it is a temporary condition that lasts for less than 24 hours, during which the affected individual retains their personal identity and normal cognitive abilities.

Symptoms related to inadequate performance of the autonomic nervous system, such as difficulties with sleep, exhaustion, and reduced energy levels, are referred to as neurovegetative symptoms.

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.

Valproate Use During Pregnancy Can Cause Birth Defects and Developmental Problems in Children

Valproate is a medication that is commonly used to treat epilepsy and bipolar disorder. However, when taken by pregnant women, it can cause serious birth defects in their babies. Studies have shown that around 1 in 10 babies born to women who took valproate during pregnancy will have a birth defect. These defects can include malformations of the spine, face, skull, limbs, heart, kidney, urinary tract, and sexual organs.

In addition to birth defects, children exposed to valproate in the womb may also experience developmental problems. About 3-4 children in every 10 may have issues with learning to walk and talk, lower intelligence than their peers, poor speech and language skills, and memory problems. There is also evidence to suggest that these children may be at a higher risk of developing autism or autistic spectrum disorders, as well as symptoms of attention deficit hyperactivity disorder (ADHD).

It is important for women who are pregnant of planning to become pregnant to discuss the risks and benefits of taking valproate with their healthcare provider. Alternative medications of treatment options may be available that are safer for both the mother and the developing baby.

Bipolar Disorder: Diagnosis and Management

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

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

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

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

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

The symptoms displayed by the man suggest that he may be suffering from psychotic depression. However, since he is still able to eat and drink, ECT should not be considered as a treatment option at this point. Instead, other approaches should be explored and if they prove ineffective, ECT may be considered later on.

Psychotic Depression

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

Diagnosis

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

Treatment

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

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 2017 NICE Guidelines advise clinicians to inform individuals with binge eating disorder that psychological treatments focused on addressing binge eating may not have a significant impact on body weight and that weight loss is not the primary goal of therapy. However, it is important to clarify that while CBT-ED does not specifically target weight loss, it can lead to weight reduction in the long run by addressing binge eating behaviors.

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.