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Psychiatry Notes
Psychiatry History
 Introduction
 Name, age, DOB and employment status
 Remember MSE and safety
Presenting complaint
 What has brought you here?
 Why are you here?
(Keep this open and obscure in case of delusions)
HPC
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When did the problem start (timeline)
When did you last feel well?
Did anything precede the problem? (Bereavement, relationship problems)
How did it develop? (Symptoms)
Associated Sx
o Psych - (Anhedonia, poor concentration, guilt)
o Physical - (sleep, appetite etc)
Impact on daily living?
Any help or Rx, were they useful?
Screen for any other problems
Depression screen, delusional or obsessional thoughts, unusual perceptions or experiences, suicidal
thoughts, changes in social contact, sleep probs and anxiety?
Past Psychiatric History
 Have you seen a psychiatrist in the past? Admissions?
 What were your reasons (for Rx, Sucide, Self-harm, stopping meds etc)
 How have you been between episiodes? (Work, socially)
PMH
 Keep this brief and probe Psych related conditions (e.g Thyrotoxicosis, Medications etc)
FH
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Can I ask about your family?
Relationships, employment and social circumstances
FH of psych conditions
Alcohol or drug misuse at home
Personal Hx
 Can I ask you questions about your past?
o Childhood
o School
o Occupations
o Relationships and Sexual history
 Habits and Dependencies
Forensic Hx
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Any trouble with the police?
Social Hx
 Housing - type, state, who do you live with?
 Support - friends, relatives, neighbours, CAMS
 Daily activities - describe a typical day, social activities
 Finances - do they manage them, debts or worries, benefits, recent spending spree?
Personality
 How would people describe you?
 Attitude to self
 Religious and moral beliefs
 Activities and interests
Anything else you would like to tell me?
Mental StateExamination
 Appearance
 Behaviour
 Mood (Objective and Subjective)
 Speech (Rate, Rhythm and Volume)
 Affect (Correct for consultation)
 Thoughts (Insertion, broadcast,)
 Perception (Delusions, Illusions, Hallucinations)
 Cognition (cognitive abilities)
 Insight (do they know they have a problem)
Mental Health Act
Section
Ground
Application
2
Assessment
ASW or Relative
3
Treatment
ASW or Relative
4
5(2)
Emergency
Detention of
inpatient
Detention of in
patient
Magistrate - police
to enter home
Admission by
police
ASW or Relative
ASW or relative
5(4)
135
136
Max. Duration
MH Nurse
Med
Recommendation
2 Dr’s (1 is section
12 approved)
2 Dr’s (1 is section
12 approved)
Any Dr
Dr in charge of pt
care
None
Magistrate
None
72 hrs
Police
None
72 hrs
28 days
6 months
72 hrs
72 hrs
6 hrs
Schizophrenia
Schneider’s First Rank Symptoms
 Auditory Hallucinations
o Thought echo
o Running commentary
o 3rd person reference
 Thought alienation
o Thought insertion
o Thought withdrawal
o Thought broadcasting
Negative Sx
 Low mood
 Flattened affect
 Low IQ
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Somatic passivity
Somatic Phenomena
o Made feelings
o Made impulses
o Made actions
Delusional Perception
o Religious, Grandiose, Nihilistic etc
Lack of energy
Sleep disturbances
Loss of motivation/drive
Management
 Antipsychotics
o Olanzapine, Risperidone – 2nd generation antipsychotics
 Psychosocial
o Family therapy
o CBT
o Social skills rehabilitation
Schizoaffective Disorder
Schizophrenic Sx + Sx of mood (affective) disorders in same episode
 Schizoaffective disorder, manic type
 Schizoaffective disorder, depressive type
Management: Treat acute symptoms with antipsychotics and antidepressants
Paranoid Disorders
More common in females, Onset 40-55 years
Othello Syndrome
 Delusional belief that one’s partner is cheating
 High risk of violence
De Clerambault’s Syndrome
 Delusional belief that someone of higher status is in love with the patient
Persecutory Delusions
 Delusional belief that others are constantly plotting against the patient
Cotard’s Syndrome
 Nihilistic delusional belief
Capgras’ Syndrome
 Delusional belief that a familiar person has been replaced by an identical double
Fregoli’s Syndrome
 Delusional belief that a familiar persona has taken on the appearance of another person
Folie a duex
 A delusional belief adopted by someone close to a patient suffering from a psychotic disorder
Depression
 Core Symptoms:
o Pervasive lowering of mood
o Anhedonia
o Reduced energy
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Further Symptoms:
o Reduced self-esteem/confidence
o Reduced concentration &
attention
o Ideas of guilt & worthlessness
o Feelings of hopelessness
o Thoughts of self-harm
o Biological symptoms
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Pschological:
o CBT
o Interpersonal Psychotherapy
Social: Financial, Housing problems etc
Admit to hospital
Mild: 2 core + 2 further
Moderate: 2 core + 4 further
Severe: 3 core + 5 further (or pyshchosis)
Management
Address underlying co-morbidities
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Biological:
o SSRIs e.g. Fluoxetine
o TCAs e.g. Amitriptyline
o MAOIs e.g. Phenelzine
o ECT-psychosis, catatonic state,
refractory
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Postnatal Depressive Disorder’s
Baby blues: occurs in 50-70% of deliveries, peaks at 3-5 days. Educate & Reassure
Postpartum depression: 10-15%, Family Hx of depression, CBT & antidepressants
Postpartum psychosis: 0.1%. Onset 2-4 weeks postnpartum. Depression>Mania + 1st rank symptoms.
Bipolar affective disorder
History of at least 2 episodes of mood disturbance, at least one of which should have been mania (or
hypomania)
Types:
Bipolar I disorder:
 One or more manic or mixed episodes and one or more major depressive episodes
Bipolar II disorder:
 Recurrent major depressive and hypomanic but not manic episodes
Cyclothymia:
 Hx of at least 2 years’ of instability of mood involving mild depression and hypomania of lesser
degree than BPAD
Management of Mania
 Treatment
o Antipsychotic’s
o Benzodiazepine
o Lithium
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Prophylaxis
o Lithium
o Carbamazepine & Sodium
Valproate (if Lithium fails)
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Psychological
o Family therapy
o Social worker involvemnt
o Support groups
Management of Depression
 As for unipolar
Somatoform Disorders
 Physical symptoms truly experienced by the patient
 Extensive investigation by many physicians from different specialities
Subtypes:
 Somatisation disorder
 Hypochondriasis
 Somatoform autonomic dysfunction disorder
Management
 Build up a good relationship and trust with one doctor e.g. GP
 Regular appointments to keep their behaviour and presentation under control
Dissociative disorders
 Patients present with a true dysfunction
 Often triggered by a psychological trauma
 Signs may follow the patient’s understanding of the body rather than true clinical signs
Subtypes:
 Disscociative amnesia/fugue
 Dissociative stupor
 Dissociative convulsions
 Dissociative motor disorder
 Dissociative anaesthesia and sensory loss
Management
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Psychotherapy
Address underlying issues
Factitious disorders
Munchausen’s syndrome
 The patient invents his or her symptoms in order to gain admission and care in hospital – need to
fulfil the ‘sick role’
Malingering
 Symptoms are made up in order to fulfil another primary gain e.g. avoid going to court
Dysmorphophobia
Persistent concern about the appearance of body or conviction that part of the body is not part of the self
Personality Disorders
Classification
Paranoid PD
Schizoid PD
Schizotypal PD
Dissocial (antisocial) PD
Emotionally
unstable PD
Features
 Suspicious
 Jealous
 Bears grudges
 Self-important
 Emotionally cold
 Detached
 Lacking enjoyment
 Prone to fantasy
 Don’t make intimate relationships
Classified with Schizophrenia in ICD-10
 Callous
 Transient shallow relationships
 Grossly irresponsible
 Lack guilt
 Fail to accept responsibility
 Low frustration and aggression
threshold
Borderline
 Uncertain self-image,
 Intense, unstable relationships
 Recurrent threat of self-harm
Impulsive
 Impulsiv,
 Liability to anger and violence
 Quarrelsome
Treatment
 Supportive to prevent
accumulation of problems
caused by suspiciousness or
angry responses to others
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Often drop out after few
sessions
Therapy to help them to be
more aware of their problems
and respond to them
Fluoxetine can reduce
measures of aggression
Individual psychotherapy can
be useful
Group therapy
Therapeutic community
Problem-solving counselling:
focus on dealing with everyday
probs.
SSRIs may ↓ impulsive
behaviour in some and small
dose of anti-psychotics may ↓
aggression short-term.
MAOIs may be helpful
Group psychotherapy
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Histrionic PD
Anakastic PD
Avoidant
(anxious) PD
Dependent PD
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Difficulty maintaining course of
action
Self-dramatization
Suggestibility
Labile affect
Seek attention and excitement
Over-concern with physical
attractiveness
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Preoccupied with details and rules
Inhibited by perfectionism
Rigid and stubborn
Excessively doubting and cautious
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Tension
Feel socially inferior/inadequate
Preoccupation with rejection or
criticism
Avoidance of risk
Avoidance of social activity
Let others take responsibility for
important decisions
Unduly compliant with wishes of
others
Feel unable to care for self and fear
having to do so
Needs excessive advice to make
decisions
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May attempt to impose
impractical conditions on
treatment
Set clear limits
Treatment focuses on
responding to stressful
situations.
Medication of little value
Do not respond well to
psychotherapy
Treatment directed to
avoiding situations that
increase the pts difficulties
and to coping with stressful
situations.
Providing a therapeutic
relationship in which they feel
valued
Be alert to co-morbid
depressive disorder.
Problem-solving
Should not be seen too
frequently to avoid
dependence.
Avoid meds unless associated
depression.
Generalized Anxiety Disorder
Often present as somatic symptoms:
 Gastrointestinal (dry mouth, dysphagia, abdo discomfort, wind, diarrhoea)
 Respiratory (chest tightness, hyperventilation)
 Cardiovascular (palpitations, chest pain)
 Genitourinary (frequent/urgent micturation, erectile dysfunction)
 Neuromuscular (tremor, parathesiae, dizziness, headache)
 Sleep disturbance (insomnia, night terrors)
 Psychological (fearfulness, irritability, restlessness, poor concentration)
Management
 Supportive measures using reassurance
 Benzodiazepines (severe episodes)
 Relaxation training
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Futher sx control:
o TCAs
o SSRIs
o MAOIs
o Beta-Blocker (for palpitations)
Phobic Disorders
Symptoms are almost identical to generalized anxiety except:
 Only in specific circumstances
 Avoidance of these circumstances
 Anticipatory anxiety of circumstances
Simple Phobia
 Due to particular situations or circumstances
 Treatment is usually by exposure to the stimulus ( behaviour therapy)
Social Phobia
 Inappropriate anxiety due to being observed or criticised by others
 Symptoms include blushing, trembling and alcohol use
 Treatment may be anxiolytic medication, MAOIs, SSRIs, CBT and psychodynamic therapy
Agoraphobia
 Inappropriate anxiety caused by being away from home or in crowds
 Anxiety may be reduced when accompanied by trusted companions or objects
 Treatment is graded exposure and anxiety management (medication and relaxation)
Panic Disorder
 Features include the physical symptoms of generalized anxiety and can occur with other anxiety
disorders
 Treatment is supportive therapy followed by medication (benzodiazepines and antidepressants)
 Cognitive therapy can also be used
Obsessive-Compulsive Disorder
 These disorders are characterised by obsessional thinking and/or compulsive behaviour.
 There may be slowness due to the necessity to perform obsessional rituals and symptoms of
depression and depersonalisation.
 May be precipitated by stressful life-events
 Treatment is reassurance, SSRIs, anxiolytics and tricyclics.
 Behaviour therapy may also be considered.
Dementia
Disease
Alzheimer’s Disease
Symptoms
 Memory loss (short term)
 Dysphasia and Dyspraxia
 Persecutory beliefs
 Personality change
 Labile mood
 Preserved insight
 Flucuating Cognition
 Visual Hallucinations
 Parkinsonism
 Frontal lobe/executive
function impairment
 Preserved memory
 Personality change
 SZ-like psychosis
 Depression
 Abnormal movements
 Dementia occurs later
 Seizures
 Cerebellar ataxia
 Myoclonic jerks
Vascular Dementia
Lewy Body Dementia
Pick’s Disease
Huntington’s Disease
CJD
Other Features
 Relentless progression
 5-10 year survival
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Stepwise progression
CVA risk factors
Neuro sx
Worsened by anti-psychotics
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FH
Slow progression
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20-40 yrs
Strong FH
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Often presenile
Rapid onset and progression
Child & Adolescent Psychiatry
Early Childhood (0-5yrs)
Disorder
Behaviour Disorders
Sleep Disorders
Temper Tantrums
Enuresis / Encopresis
Autism
Features
 Active, attention-seeking, disobedient children
 Often found with negative parent attitudes and incongruous discipline
 Management is usually with support and behavioural advice or therapy
 Night-waking and severe sleep problems are relatively common
 Illness, stress and maternal depression contribute
 Management by behavioural techniques
 Medication is seldom used
 Outbursts are common and peak in year 2 of life
 Causes include frustration over speech delay, difficulties in parent-child
relationship and anxiety in new situations
 Behavioural therapy can be used
 Involuntary urinary or faecal incontinence may be linked to events during
toilet training or current stress
 Behavioural programmes, including bell and pad, may help
 Drug treatments may be used in bedwetting
 Affects 2-4 per 10,000 M>F and usually seen by age 3
 There are severe problems with understanding speech and grammar as
well as social interaction and relationships
 Ritualistic routines are common
 Treatment is supportive
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Hyperkinetic Disorder
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Also known as ADD, characterised by overactivity
Problems with attention and can cause learning difficulty, low selfesteem and relationship problems.
High incidence of familial disharmony.
Treatment is by structured daily routine, behavioural therapy and
possibly medication (eg amphetamines)
Middle Childhood (5-12yrs)
Disorder
Features
 Most common symptom is anxiety in
anticipation of an unpleasant event
 Associated with tension, physical complaints,
Emotional
bed-wetting and soiling
 Association with introvert personality
 Linked to over-protective parenting
 More common in boys
 Antisocial behaviour usually with aggression
Conduct
 Lying and disobedience
 Linked to social deprivation and broken homes
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Psychosomatic
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School Refusal
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Recurrent abdominal pain and headaches are
the most common
May be due to other physical illness, concern
over academic issues and is linked to highachievers.
More common in single and youngest children
who are passive and introvert
Usually due to separation anxiety and may be
influenced by overprotection
Adolescence (12-16yrs)
The common psychiatric problems are:
 Depressive disorder
 Suicide and deliberate self-harm
Substance Misuse
Alcohol
 Light/Moderate/Heavy
 Men 21/35/50
 Women 14/25/35
Features
 Acute Intoxication
 Harmful Use (social / psychiatric / psychological / physical)
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Treatment
Stress reduction
Improving understanding of
anxiety a
Enhancing coping
mechanisms
Counselling or
psychotherapy
Behaviour modification
through feedback
Rarely tranquillisers
Joint psychiatric and
paediatric management
Mainly dealt with by
parents and teachers.
Firmness and
encouragement
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Dependence
Withdrawal
o 2h-4d
o tremor / sweating / vomit [GABA hyperactivity]
o Delerium tremens
 Long term use
o Cerebellar atrophy
o Dementia
o Wernicke’s (acute confusion, lateral rectus palsy, peripheral neuropathy, horiz nystagmus,
ataxia + encelphelopathy)
o Korsakoffs
Management
 Acute Withdrawal:
o Monitor + Correct
Hydration/Electrolytes
o Reassure
o Benzos if req
o Parenteral thiamine
o Prophylactic anticonvulsant if Hx of
seizures
Opiates
Features
 Toxicity
o Coma
o CNS + resp depression 4-6bpm
o Pupillary miosi
o Bradycardia
o Hypotension
o Constipation
o Analgesia
 Withdrawal
o Dilated pupils
o Insomnia
o Ttachycardia
o Hypertension
o Piloerection
o Lacrimation
o Yawning
Management
 Acute intoxication
o Urine drug screen
o Establish on detox
 Withdrawal
o Symptomatic treatment
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Detox supervised patient contract
Psychiatric Medications
Anxiolytic medication
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Delirium Tremens:
o Parenteral Thiamine
o Rehydrate
o Electrolyte Balance
o Underlying Infection
o Benzos if req
Wernicke (MEDICAL EMERGENCY)
o Parenteral Thiamine
o Rehabilitation
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Reduced anxiety
Euphoria
Ventricular arrhythmia
Seizures
Hallucinations
Psychosis
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Sweating
Rhinorrhea
Nasal congestion
Myalgia
Emesis
Diarrhoea
Abdominal crampin
o Intubate, Restrain & titrate up
Naloxone
o Opioids should be avoided
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Reduce anxiety and at higher doses induce drowsiness (sedatives) and sleep (hypnotics)
Prescribed for short periods to avoid tolerance and dependence
Gradual withdrawal to prevent withdrawal effects
o Buspirone
o Beta-blockers (eg propanolol)
o Benzodiazepines
Antipsychotic Medication
Group
Examples
Haloperidol
Chlorpromazine
Clozapine
Olanzepine
‘Typical’
‘Atypical’
Unwanted Effects
More
Less
Extrapyramidal side-effects:
 Acute dystonia (eg tongue protrusion, grimace, ocular spasm)
 Akathisia (inability to remain still)
 Parkinsonism (expressionless face, akinesia, rigidity, tremor)
 Tardive dyskinesia (chewing and sucking, grimacing)
Antidepressant Medication
Type
Examples
Tricyclic Antidepressants
(TCAs)
Amitriptyline
Imipramine
Selective Serotonin Reuptake
Inhibitors (SSRIs)
Paroxetine
Fluoxetine
Fluvoxamine
Sertraline
Monoamine Oxidase
Inhibitors (MAOIs)
Phenelzine
Isocarboxazid
Unwanted Effects
Dry mouth
Constipation
Drowsiness
Arrhythmia
GI disturbance
Insomnia
Agitation
Sexual dysfunction
Dry mouth
Constipation
Headache
Tremor
TCAs - toxicity in overdose
MAOIs - complex interactions with various chemicals and foods
Mood Stabilisers
 Lithium
 Carbamazepine
 Sodium valproate
Use
Moderate/severe
depression
Mild/moderate
depression
Started by specialist