Crash Course Psychiatry Xiu 5 Ed 2019

Psychiatry
First and second edition authors:

Darran Bloye
Simon Davies
Alisdair D Cameron
Third edition authors:

Julius Bourke
Matthew Castle
Fourth edition authors:

Katie Marwick
Steven Birrell
5 th Edition
CRASH COURSE
SERIES EDITORS
Philip Xiu
MA, MB BChir, MRCP
GP Registrar
Yorkshire Deanery
Leeds, UK
Shreelata Datta
MD, MRCOG, LLM, BSc (Hons), MBBS
Honorary Senior Lecturer
Imperial College London,
Consultant Obstetrician and Gynaecologist
King's College Hospital
London, UK
FACULTY ADVISOR
Steven Birrell
MBChB, MRCPsych, PGCertClinEd, AFHEA
Consultant Psychiatrist
Queen Margaret Hospital, Dunfermline, Fife, UK
Psychiatry
Katie Marwick
MA (Hons), MB ChB (Hons), MRCPsych, PhD
Honorary Specialty Registrar in General Adult Psychiatry,
NHS Lothian
Clinical Lecturer in Psychiatry, University of Edinburgh
Edinburgh, UK
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Content Development Specialist: Alexandra Mortimer
Project Manager: Andrew Riley
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© 2019, Elsevier Limited. All rights reserved.
First edition 1999

Second edition 2004
Third edition 2008
Reprinted 2010
Fourth edition 2013
Updated Fourth edition 2015
Fifth edition 2019
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Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information,
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ISBN: 978-0-7020-7383-0
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Series Editors’ foreword
The Crash Course series was conceived by Dr Dan Horton-Szar who as series
editor presided over it for more than 15 years – from publication of the first
edition in 1997, until publication of the fourth edition in 2011. His inspiration,
knowledge and wisdom lives on in the pages of this book. As the new series
editors, we are delighted to be able to continue developing each book for the
twenty-first century undergraduate curriculum.
The flame of medicine never stands still, and keeping this all-new fifth series
relevant for today's students is an ongoing process. Each title within this new
fifth edition has been re-written to integrate basic medical science and clinical
practice, after extensive deliberation and debate. We aim to build on the success
of the previous titles by keeping the series up-to-date with current guidelines for
best practice, and recent developments in medical research and pharmacology.
We always listen to feedback from our readers, through focus groups and
student reviews of the Crash Course titles. For the fifth editions we have
reviewed and re-written our self-assessment material to reflect today's ‘single-
best answer’ and ‘extended matching question’ formats. The artwork and layout
of the titles has also been largely re-worked and are now in colour, to make it
easier on the eye during long sessions of revision. The new on-line materials
supplement the learning process.
Despite fully revising the books with each edition, we hold fast to the principles
on which we first developed the series. Crash Course will always bring you all
the information you need to revise in compact, manageable volumes that still
maintain the balance between clarity and conciseness, and provide sufficient
depth for those aiming at distinction. The authors are junior doctors who have
recent experience of the exams you are now facing, and the accuracy of the
material is checked by a team of faculty editors from across the UK.
We wish you all the best for your future careers!
Shreelata Datta and Philip Xiu
v
Preface
Author
The ability to diagnose and manage mental health problems is an increasingly
valued skill. Greater scientific understanding of mental illness is reducing the
stigma associated with it, in turn allowing its impact to be greater recognised:
mental illness is the single largest cause of disability in the UK (28%), the leading
cause of sickness absence, costs the UK economy 4.5% of GDP, and the life
expectancy of people with severe mental illness is reduced by 15–20 years.
Despite its importance, mental illness is typically under-recognised and
undertreated: around three quarters of people with a mental illness in England
receive no treatment (compared with around a quarter of people with a physical
illness). Mental and physical health problems are frequently comorbid and
exacerbate each other, meaning you will have the opportunity to improve the
lives of people with mental illness in almost any branch of medicine you choose.
This book is designed to equip you with the core knowledge and skills you need
to help people with mental health problems, both to pass your exams and to be a
holistic and skilled future doctor. The already popular 4th edition has been updated to
be in line with contemporary guidelines, classification systems and self-assessment
formats. This edition also includes two brand new chapters on neurodevelopmental
disorders, an increasingly common clinical presentation in children and adults.
Psychiatry can be a challenging speciality but it is also one where you can make
a real difference to people’s lives – old or young, rich or poor, in hospital or at
home. Psychiatry is also a rapidly changing speciality, however, I have done my
best to ensure this book will provide a solid foundation to help you effectively
diagnose and treat mental illness in the patients and people you care for in the
future. I wish you the best of luck!
Katie Marwick
Faculty Advisor
As a proud co-author of the fourth edition of the book, it has been a privilege to
work in an advisory role on this title. The fifth edition of Crash Course: Psychiatry
builds upon the success of previous incarnations of the book, being fully up to date
with regards contemporary psychiatric practice, the current classification systems,
evidence base and guidelines, and medico-legal information. It also includes
an expanded and improved self-assessment section. As with all titles within
the Crash Course series, the perfect balance of attention to detail and concise
accessibility means this book will be perfect for you whether you are a medical
student on placement or studying for exams, a junior doctors hoping to refresh their
knowledge, or indeed anyone interested in a career in psychiatry. Enjoy!
Steven Birrell
vi
Acknowledgements
I would firstly like to thank my faculty advisor, Dr Steve Birrell, who has provided
consistently sound and sensible advice on all topics as well as being a
supportive and kind colleague.
This textbook has drawn strength from expert feedback on specialist chapters
on a goodwill basis; I have done my best to accurately convey the reviewers’
expertise and judgement. I am very grateful to: Dr Lucy Stirland (Clinical
Research Fellow in Older Adult Psychiatry, University of Edinburgh),
Dr Rebecca Lawrence (Consultant Psychiatrist in Addictions, NHS Lothian),
Dr Rachel Petrie (Consultant Psychiatrist in Addictions, NHS Lothian), Dr Premal
Shah (Consultant Psychiatrist, Adult ADHD and ASD team, NHS Lothian),
Dr Rob Stewart (Consultant Perinatal Psychiatrist, NHS Lothian), Dr Leah Jones
(ST5 in Forensic Psychiatry, NHS Lothian) and Dr Senem Sahin (ST4 General
Adult Psychiatry, Camden & Islington NHS Foundation Trust). I am particularly
grateful to Dr Jennifer Cumming (ST6 in Child and Adolescent Psychiatry,
NHS Lothian) who also co-authored the Child and Adolescent Mental Health
chapter. Representatives of the Royal College of Psychiatrists (RCPsych) were
very helpful in providing detailed advice on some specific aspects of UK Mental
Health Acts (Dr Gerry Lynch, Consultant Psychiatrist, Chair of RCPsych in
Northern Ireland and Vice President of RCPsych, and Helen Phillips, Senior
Policy Administrator, RCPsych). I am also grateful to Dr Liana Romaniuk
(CT1 Psychiatry, NHS Lothian) who provided early input into the book’s
reorganisation.
This is the first edition of this textbook to contain Objective Structured Clinical
Exams (see accompanying resources on studentconsult.com). I have been
greatly helped in crafting their structure and content by the other members of the
Edinburgh University Psychiatry Undergraduate OSCE writing team (2015-2017),
in particular my co-chair Dr Chris O’Shea (Clinical Teaching Fellow, NHS Lothian)
and Dr Jennie Higgs (Clinical Teaching Fellow, NHS Lothian).
I am also grateful to those who have taught me, those whom I have taught, and
patients I have met. I hope I have distilled some of their wisdom and outlook into
the clinical cases and tips throughout the book.
I am deeply thankful to my husband, Jonathan Shutt, and to my family, for

their support and understanding during the epic process of writing a
textbook - again.
Katie Marwick
vii
Dedication
Author
To my mother, Dr Helen Marwick (Developmental Psychologist and Senior Lecturer,
University of Strathclyde), who helped to shape my early interest in understanding
people and neuroscience and who has been much in my thoughts during the
preparation of this book.
Katie Marwick
Faculty Advisor
To my wife, children, family, friends, colleagues, and patients who all continue to
inspire, challenge, and support me.
Steven Birrell
viii
Series Editors’ acknowledgements
We would like to thank the support of our colleagues who have helped in the
preparation of this edition, namely the junior doctor contributors who helped
write the manuscript as well as the faculty editors who check the veracity of the
information.
We are extremely grateful for the support of our publisher, Elsevier, whose staffs’
insight and persistence has maintained the quality that Dr Horton-Szar has
set-out since the first edition. Jeremy Bowes, our commissioning editor, has
been a constant support. Alex Mortimer and Barbara Simmons our development
editors has managed the day-to-day work on this edition with extreme patience
and unflaggable determination to meet the ever looming deadlines, and we are
ever grateful for Kim Benson’s contribution to the online editions and additional
online supplementary materials.
Shreelata Datta and Philip Xiu
Contributor:
Jennifer Cumming
Dr Jennifer Cumming BSc (Hons) MBChB MRCPsych AFHEA
ST6 Child and Adolescent Psychiatry & NHS Lothian Clinical Educator
Royal Edinburgh Hospital
Edinburgh, UK
Chapter 30. Child and Adolescent Psychiatry
ix
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Contents
Series Editors’ foreword . . . . . . . . . . . . . . . . . . . . . . . . v Patient management following self-harm

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi or attempted suicide.................................................56
Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . vii Discussion of case study.............................................56
Dedication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii 7 The patient with impairment of consciousness,
Series Editors’ acknowledgements. . . . . . . . . . . . . . . . ix memory or cognition . . . . . . . . . . . . . . . . . . . . . . . . 59
Definitions and clinical features...................................59
Common cognitive disorders.......................................61
Section 1 General . . . . . . . . . . . . . . . . . . . . 1
Differential diagnosis....................................................66
1 Psychiatric assessment and diagnosis. . . . . . . . . . . 3 Assessment..................................................................69
Interview technique........................................................3 Discussion of case study.............................................70
Psychiatric history..........................................................4
8 The patient with alcohol or substance
Mental state examination...............................................7
use problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Risk assessment............................................................9
Physical examination...................................................10
Alcohol-related disorders.............................................75
The formulation: presenting the case..........................10
Alcohol-related cognitive disorders.............................78
Classification in psychiatry..........................................12
Other substance-related disorders..............................80
2 Pharmacological therapy and electroconvulsive Differential diagnosis....................................................80
therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Assessment..................................................................83
Antidepressants...........................................................15 Discussion of case study.............................................84
Mood stabilizers...........................................................19 Further reading.............................................................85
Antipsychotics.............................................................21
9 The patient with psychotic symptoms . . . . . . . . . . 87
Anxiolytic and hypnotic drugs.....................................25
Other drugs used in psychiatry....................................27
Differential diagnosis....................................................93
Electroconvulsive therapy............................................27
Algorithm for the diagnosis of psychotic
3 Psychological therapy . . . . . . . . . . . . . . . . . . . . . . . 29 disorders...................................................................96
Psychotherapeutic approaches...................................29 Assessment..................................................................96
Indications for psychological therapy..........................35 Discussion of case study.............................................97
4 Mental health and the law . . . . . . . . . . . . . . . . . . . . 37 10 The patient with elated or irritable mood. . . . . . . . 99
Mental Health Act 1983 as amended by Definitions and clinical features...................................99
the Mental Health Act 2007.......................................37 Differential diagnosis..................................................101
Mental Health (Care & Treatment) (Scotland) Assessment................................................................103
Act 2003....................................................................39 Algorithm for the diagnosis of mood
Mental Health (Northern Ireland) Order 1986...............41 disorders.................................................................104
Capacity to consent to treatment................................41 Discussion of case study...........................................104
Common law................................................................43
11 The patient with low mood. . . . . . . . . . . . . . . . . . . 107
Human rights legislation..............................................43
Definitions and clinical features.................................107
Fitness to drive.............................................................44
Differential diagnosis..................................................109
5 Mental health service provision. . . . . . . . . . . . . . . . 47 Assessment................................................................111
History..........................................................................47 Discussion of case study...........................................112
Primary care.................................................................47
12 The patient with anxiety, fear or avoidance. . . . . 115
Secondary care............................................................47
Definitions and clinical features.................................115
Section 2 Presenting Complaints. . . . . . 51 Differential diagnosis..................................................116
6 The patient with thoughts of suicide or self-harm. 53 Assessment................................................................120
Definitions and clinical features...................................53 Discussion of case study...........................................120
Assessment of patients who have inflicted harm 13 The patient with obsessions and compulsions . . 123
upon themselves.......................................................53 Definitions and clinical features.................................123
xi
Contents
Differential diagnosis..................................................124 24 Eating disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 205

Discussion of case study...........................................127 Anorexia and bulimia nervosa....................................205
14 The patient with a reaction to a stressful event. . 129 25 The sleep–wake disorders. . . . . . . . . . . . . . . . . . . 209
Definitions and clinical features.................................129 Definitions and classification.....................................209
Bereavement..............................................................133 Further reading...........................................................214
Differential diagnosis..................................................133 26 The psychosexual disorders . . . . . . . . . . . . . . . . . 215
Discussion of case study...........................................134 Sexual dysfunction.....................................................215
Further reading...........................................................134 Disorders of sexual preference (paraphilias)..............219
15 The patient with medically unexplained Gender identity..........................................................219
physical symptoms. . . . . . . . . . . . . . . . . . . . . . . . . 135 27 Disorders relating to the menstrual cycle,
Definitions and clinical features.................................135 pregnancy and the puerperium. . . . . . . . . . . . . . . 221
Differential diagnosis..................................................137 Premenstrual syndrome.............................................221
Assessment................................................................139 Menopause................................................................221
Discussion of case study...........................................139 Psychiatric considerations in pregnancy...................222
16 The patient with eating or weight problems. . . . . 141 Puerperal disorders....................................................223
Definitions and clinical features.................................141 28 The personality disorders. . . . . . . . . . . . . . . . . . . . 227
Assessment................................................................142 The personality disorders...........................................227
Differential diagnosis of patients with low weight......145
29 The neurodevelopmental disorders . . . . . . . . . . . 231
Discussion of case study...........................................145
Intellectual disability...................................................231
17 The patient with personality problems. . . . . . . . . 147 Autism spectrum disorders........................................232
Definitions and clinical features.................................147 Attention deficit hyperactivity disorders....................233
Classification..............................................................147 Tourette syndrome.....................................................235
Assessment................................................................149
30 Child and adolescent psychiatry. . . . . . . . . . . . . . 237
Differential diagnosis..................................................150
Child and Adolescent Mental Health
Discussion of case study...........................................151
Services...................................................................237
18 The patient with neurodevelopmental problems. 153 Attachment.................................................................237
Definitions..................................................................153 Epidemiology.............................................................237
Clinical features and differential diagnosis................154 Mental illness in children and adolescents................239
Assessment................................................................160 Child abuse................................................................242
Discussion of case study...........................................162 Assessment considerations in young people............242
Section 3 Cause and management. . . . 163 Further reading...........................................................243
19 Dementia and delirium. . . . . . . . . . . . . . . . . . . . . . 165 31 Older adult psychiatry . . . . . . . . . . . . . . . . . . . . . . 245

Dementia....................................................................165 Mental illness in older adults......................................245
Delirium......................................................................170 Assessment considerations in older adults...............247
Treatment considerations in older adults...................248
20 Alcohol and substance-related disorders. . . . . . .173
Alcohol disorders.......................................................173 32 Forensic psychiatry. . . . . . . . . . . . . . . . . . . . . . . . . 251
Other psychoactive substances................................178 Mental disorder and crime.........................................251
Assessing and managing risk of violence..................252
21 The psychotic disorders: schizophrenia. . . . . . . . 183
Considerations in court proceedings.........................253
Schizophrenia............................................................183
22 The mood (affective) disorders . . . . . . . . . . . . . . . 191 Self-Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Depressive disorders.................................................191 Single best answer (SBA) questions . . . . . . . . . . . . . . 257
Bipolar affective disorder...........................................194 Extended-matching questions (EMQs). . . . . . . . . . . . 275
Dysthymia and cyclothymia.......................................196 SBA answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
23 The anxiety and somatoform disorders . . . . . . . . 199 EMQ answers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Anxiety disorders.......................................................199 Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
Dissociative and somatoform disorders....................203 Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
xii
GENERAL
Chapter 1
Psychiatric assessment and diagnosis�� 3

Chapter 2
Pharmacological therapy and electroconvulsive therapy �� 15

Chapter 3
Psychological therapy�� 29
Chapter 4
Mental health and the law �� 37

Chapter 5
Mental health service provision �� 47

Psychiatric assessment and
diagnosis 1
The psychiatric assessment is different from a medical • Chairs should be at the same level and arranged at an
or surgical assessment in that: (1) the history taking is of- angle, so that you are not sitting directly opposite the
ten longer and requires understanding each patient’s unique patient.
background and environment; (2) a mental state examina- • Establishing rapport is an immediate priority and
tion (MSE) is performed; and (3) the assessment can in itself requires the display of empathy and sensitivity by the
be therapeutic. Fig. 1.1 provides an outline of the psychiat- interviewer.
ric assessment, which includes a psychiatric history, MSE, • Notes may be taken during the interview; however,
risk assessment, physical examination and formulation. explain to patients that you will be doing so. Make sure
that you still maintain good eye contact.
• Ensure that both you and the patient have an
unobstructed exit should it be required.
INTERVIEW TECHNIQUE • Carry a personal alarm and/or know where the alarm
in the consulting room is, and check you know how to
• Whenever possible, patients should be interviewed in work the alarms.
settings where privacy can be ensured – a patient who • Introduce yourself to the patient and ask them how
is distressed will be more at ease in a quiet office than they would like to be addressed. Explain how long the
in an accident and emergency cubicle. interview will last. In examination situations, it may
Psychiatric history
• Identifying information
• Presenting complaint
• History of presenting complaint
• Past psychiatric history
• Past medical history
• Current medication
• Family history
• Personal history
• Social circumstances
Psychiatric history • Alcohol and substance use
Mental state examination • Forensic history
• Premorbid personality
Physical examination
Risk assessment
Mental state examination

• Appearance
Formulation • Behaviour and psychomotor function
• Rapport
• Speech
• Mood and affect
• Thought form and content
• Perception
• Cognition
• Insight
Risk assessment
Formulation • Self: self-harm, self-neglect, exploitation
• Description of the patient • Others: aggression, sexual assault, children
• Differential diagnosis
• Aetiology
• Management
• Prognosis
Fig. 1.1 Outline of the psychiatric assessment procedure.
3
Psychiatric assessment and diagnosis
prove helpful to explain to patients that you may need Identifying information
to interrupt them due to time constraints.
• Keep track of and ration your time appropriately. • Name
• Flexibility is essential (e.g. it may be helpful to put • Age
a very anxious patient at ease by talking about their • Marital status and children
background before focusing in on the presenting • Occupation
complaint). • Reason for the patient’s presence in a psychiatric setting
(e.g. referral to out-patient clinic by family doctor,
admitted to ward informally having presented at casualty)
HINTS AND TIPS • Legal status (i.e. if detained under mental health
legislation)
Arrange the seating comfortably, and in a way that
For example:
allows everyone a clear exit, before inviting the
Mrs LM is a 32-year-old married housewife with two chil-
patient into the room.
dren aged 4 and 6 years. She was referred by her family doctor
to a psychiatric out-patient clinic.
Make use of both open and closed questions when Presenting complaint
appropriate:
Closed questions limit the scope of the response to one- or Open questions are used to elicit the presenting complaint.
two-word answers. They are used to gain specific informa- Whenever possible, record the main problems in the pa-
tion and can be used to control the length of the interview tient’s own words, in one or two sentences, instead of using
when patients are being over-inclusive. For example: technical psychiatric terms. For example:
Mrs LM complains of ‘feeling as though I don’t know who
• Do you feel low in mood? (Yes or no answer)
I am, like I’m living in an empty shell’.
• What time do you wake up in the morning? (Specific
Patients frequently have more than one complaint, some of
answer)
which may be related. It is helpful to organize multiple pre-
Note that closed questions can be used at the very begin- senting complaints into groups of symptoms that are related;
ning of the interview, as they are easier to answer and help for instance, ‘low mood’, ‘poor concentration’ and ‘lack of en-
to put patients at ease (e.g. ‘Do you live locally?’; ‘Are you ergy’ are common features of depression. For example:
married?’; see Identifying information later). Mrs LM complains firstly of ‘low mood’, ‘difficulty sleeping’
Open questions encourage the patient to answer freely and ‘poor self-esteem’, and secondly of ‘taking to the bottle’
with a wide range of responses and should be used to elicit associated with withdrawal symptoms of ‘shaking, sweating
the presenting complaint, as well as feelings and attitudes. and jitteriness’ in the morning.
For example: It is not always easy to organize patients’ difficulties into
• How have you been feeling lately? a simple presenting complaint in psychiatry. In this case,
• What has caused you to feel this way? give the chief complaint(s) as the presenting complaint, and
cover the rest of the symptoms or problems in the history of
the presenting complaint.
COMMUNICATION
Rapport building is vital when working in History of presenting complaint

mental health. Always think why a patient may
have difficulty establishing one with you (e.g.
This section is concerned with eliciting the nature and devel-
opment of each of the presenting complaints. The following
persecutory delusions, withdrawal, apathy). Failure
headings may be helpful in structuring your questioning:
to establish rapport should never be due to the
• Duration: when did the problems start?
interviewer.
• Development: how did the problems develop?
• Mode of onset: suddenly, or over a period of time?
• Course: are symptoms constant, progressively
worsening or intermittent?
PSYCHIATRIC HISTORY • Severity: how much is the patient suffering? To what
extent are symptoms affecting the patient’s social and
The order in which you take the history is not as impor occupational functioning?
tant as being systematic, making sure you cover all the • Associated symptoms: certain complaints are associated
essential subsections. A typical format for taking a psy- with clusters of other symptoms that should be
chiatric history is outlined in Fig. 1.1 and is described in enquired about if patients do not mention them
detail below. spontaneously. This is the same approach as in other
4
Psychiatric history 1
Table 1.1 Typical questions used to elicit specific

• Delusions and hallucinations (psychosis)
psychiatric symptoms
• Free-floating anxiety, panic attacks or phobias
Questions used to elicit… Chapter (anxiety disorders)
Suicidal ideas 6 • Obsessions or compulsions (obsessive-
Depressive symptoms 11 compulsive disorder)
Mania/hypomania 10 • Alcohol or substance abuse
Delusions 9
Hallucinations 9
Symptoms of anxiety 12
Dissociative symptoms 14 HINTS AND TIPS
Obsessions and 13 Depression and obsessive-compulsive
compulsions
symptoms often coexist (>20%), with onset
Somatoform disorders 15 of obsessive-compulsive symptoms occurring
Memory and cognition 7 before, simultaneously with or after the onset of
Problem drinking 8 depression. You may find it useful to have a set of
Symptoms of anorexia and 16 screening questions ready to use.
bulimia
Symptoms of insomnia 25
specialties; for example, enquiring about nausea,

Past psychiatric history
diarrhoea and distension when someone reports This is an extremely important section, as it may provide
abdominal pain. When ‘feeling low’ is a presenting clues to the patient’s current diagnosis. It should include:
complaint, biological, cognitive and psychotic features • Previous or ongoing psychiatric diagnoses
of depression, as well as suicidal ideation, should be • Dates and duration of previous mental illness episodes
asked about. You can also ask about symptom clusters • Previous treatments, including medication,
for psychosis, anxiety, eating problems, substance use psychotherapy and electroconvulsive therapy
and cognitive problems, among others. Also, certain • Previous contact with psychiatric services (e.g.
symptoms are common to many psychiatric conditions, referrals, admissions)
and these should be screened for (e.g. a primary • Previous assessment or treatment under mental health
complaint of insomnia may be a sign of depression, legislation
mania, psychosis or a primary sleep disorder). • History of self-harm, suicidal ideas or acts
• Precipitating factors: psychosocial stress frequently
precipitates episodes of mental illness (e.g.
bereavement, moving house and relationship Past medical history
difficulties). Enquire about medical illnesses or surgical procedures. Past
Table 1.1 directs you to the relevant chapters with ex- head injury or surgery, neurological conditions (e.g. epi-
ample questions for different components of the history lepsy) and endocrine abnormalities (e.g. thyroid problems)
and MSE. are especially relevant to psychiatry.
Current medication
HINTS AND TIPS Note all the medication patients are using, including psy-
chiatric, nonpsychiatric and over-the-counter drugs. Also
It is useful to learn how to screen patients for
enquire how long patients have been on specific medication
common symptoms. This is especially so with and whether it has been effective. Nonconcordance, as well
patients who are less forthcoming with their as reactions and allergies, should be recorded.
complaints. Remember to ask about:
• Low mood (depression) Family history
• Elevated mood and increased energy
(hypomania and mania) • Enquire about the presence of psychiatric illness
(including suicide and substance abuse) in family
members, remembering that genetic factors are
5
implicated in the aetiology of many psychiatric

conditions. A family tree may be useful to summarize COMMUNICATION
information. A history of childhood abuse is important to detect,
• Enquire whether parents are still alive and, if not,
but it can feel awkward to ask about. Most people
causes of death. Also ask about significant physical
respond well to being straightforwardly asked
illnesses in the family.
• Ask whether the patient has any siblings and, if so, ‘Would you say you were ever abused in any way
where they are in the birth order. when you were growing up?’ In young people, or
• Enquire about the quality of the patient’s relationships those you are struggling to build a rapport with,
with close family members. a more graded approach may be preferable (e.g.
‘When was your first relationship? When was your
Personal history first sexual experience? Have you ever had an
unpleasant sexual experience? Sometimes such
The personal history consists of a brief description of the
experiences are unpleasant because they are
patient’s life. Time constraints will not allow an exhaustive
unwanted or because the person is too young to
biographical account, but you should attempt to include
significant events, perhaps under the following useful understand …?’) Leaving the question open allows
headings: the patient room to answer freely, rather than
simply answering ‘yes’ or ‘no’.
Infancy and early childhood
(until age 5 years)
• Pregnancy and birth complications (e.g. prematurity, Social circumstances
foetal distress, caesarean section)
• Developmental milestones (e.g. age of crawling, This includes accommodation, social supports and relation-
walking, speaking, bladder and bowel control) ships, employment and financial circumstances and hobbies
• Childhood illnesses or leisure activities. It is important to identify if the patient
• Unusually aggressive behaviour or impaired social has current frequent contact with children, in case their pre-
interaction sentation raises any child protection concerns.
Later childhood and adolescence Alcohol and substance use

(until completion of higher education) This section should never be overlooked, as alcohol/
• History of physical, sexual or emotional abuse
substance-related psychiatric conditions are very common.
• School record (e.g. academic performance, number
The CAGE questionnaire (see Chapter 8) is a useful tool
and type of schools attended, age on leaving, final
to screen for alcohol dependence. If a patient answers af-
qualifications)
firmatively to two or more questions, regard the screen as
• Relationships with parents, teachers and peers. Victim
positive and go on to check if they meet criteria for alcohol
or perpetrator of bullying
dependence syndrome (see Chapter 8). Try to elicit a patient’s
• Behavioural problems, including antisocial behaviour,
typical drinking day, including daily intake of alcohol in
drug use or truancy
units, type of alcohol used, time of first drink of the day and
• Higher education and training
places where drinking occurs (e.g. at home alone or in a pub).
If recreational drugs have been or are being used, record
Occupational record the drug names, routes of administration (intravenous, in-
• Details of types and duration of jobs haled, oral ingestion) and the years and frequency of use.
• Details of and reasons for unemployment and/or Also enquire about possible dependence (Chapter 8).
dismissal
Forensic history
Relationship, marital and sexual history
• Puberty: significant early relationships and experiences, Enquire about the details and dates of previous offences
as well as sexual orientation and antisocial behaviour, including prosecutions, convic-
• Details and duration of significant relationships tions and prison sentences. It is important to ask specifi-
Reasons for break-ups cally about violent crime, the age of the patient’s first violent
• Marriage/divorce details. Children. offence and whether the patient has any charges pending.
• Ability to engage in satisfactory sexual relationships. Pending charges may be a source of stress for the patient,
Sexual dysfunction, fetishes or gender identity and in some cases a reason to report mental health symp-
problems (only enquire if problem is suspected). toms with a view to secondary gain.
6
Mental state examination 1
Premorbid personality By the time you have finished the psychiatric history, you
should have completed many aspects of the MSE, and you
The premorbid personality is an indication of the patient’s should just need to ask certain key questions to finish this
personality and character before the onset of mental illness. process off. The individual aspects of the MSE, which
It can be difficult to ascertain retrospectively. Indirect evi- are summarized in Fig. 1.1, are discussed in more detail
dence of it can be provided from the personal history (e.g. below.
Have they ever been able to hold down a job or been in a There is some variation in the order in which the MSE is
long-term relationship? Have their interests changed?). reported (e.g. speech is sometimes described before mood,
Patients may be asked directly about their personality be- and sometimes before thought form). As long as you in-
fore they became ill, or it may be useful to ask a close family clude the information, the exact order is not important.
member or friend about a patient’s premorbid personality.
For example:
A young man with schizophrenia, with prominent negative HINTS AND TIPS
symptoms of lack of motivation, lack of interest and poverty
Don’t just ask questions and write down answers!
of thought, was described by his mother as being outgoing,
intelligent and ambitious before becoming ill. Appearance and behaviour are vital to the mental
state examination, especially with less communicative
patients. Posture, facial expression, tone of voice,
COMMUNICATION
spontaneity of speech, state of relaxation and
One way to explore premorbid personality in a movements made are all important. You may find
patient with some insight is to ask questions it helpful to practise with a colleague – try writing
such as: ‘How would people have described you down 10 points that describe their appearance and
before?’ ‘How about now?’ behaviour.
MENTAL STATE EXAMINATION Appearance

• Physical state: how old does the patient appear? Do they
The MSE describes an interviewer’s objective impression of appear physically unwell? Are they sweating? Are they
many aspects of a patient’s mental functioning at a certain too thin or obese?
point in time. Whereas the psychiatric history remains rela- • Clothes and accessories: are clothes clean? Are
tively constant, the MSE may fluctuate from day to day or hour accessories appropriate (e.g. wearing sunglasses
to hour. It is useful to try and gather as much evidence as possi- indoors)?
ble about the MSE while doing the psychiatric history, instead • Do clothes match? Are clothes appropriate to the
of viewing this as a separate section. In fact, the MSE begins weather and circumstances, or are they bizarre? Is the
the moment you meet the patient. In addition to noting their patient carrying strange objects?
appearance, you should observe how patients first behave on • Self-care and hygiene: does the patient appear to have
meeting you. This includes their body language and the way been neglecting their appearance or hygiene (e.g.
that they respond to your attempts to establish rapport. unshaven, dirty tangled hair, malodorous, dishevelled)?
Is there any evidence of injury or self-harm (e.g. cuts to
COMMON PITFALLS wrists or forearms)?
The MSE, like a physical examination, is a snap-

shot of a person’s presentation during the interview.
Behaviour and psychomotor
Only record what the patient demonstrates or function
experiences during the interview (e.g. if a patient This section focuses on all motor behaviour, including ab-
reports having had a hallucination 5 minutes before normal movements such as tremors, tics and twitches; dis-
you entered the room, that would be described in plays of suspiciousness, aggression or fear; and catatonic
the history, not the MSE – much as you wouldn’t features. Documenting patients’ behaviour at the start of,
record that someone had had abdominal pain and during, the interview is an integral part of the MSE, and
prior to but not during your physical examination). should be done in as much detail as possible. For example:
Including history in the MSE is a very common Mrs LM introduced herself appropriately, although only
made fleeting eye contact. She sat rigidly throughout the first
mistake in student case reports.
half of the interview, mostly staring at the floor and speaking
very softly. She became tearful halfway through the interview
7
when talking about her lack of self-esteem. After this her pos-
ture relaxed, her eye contact improved and there were mo- COMMON PITFALLS
ments when she smiled. There were no abnormal movements.
Note that disorganized, incoherent or bizarre
The term ‘psychomotor’ is used to describe a patient’s
speech (e.g. flight of ideas) is usually regarded as
motor activity as a consequence of their concurrent mental
processes. Psychomotor abnormalities include retardation a thought disorder and is described later in the
(slow, monotonous speech; slow or absent body move- thought form section.
ments) and agitation (inability to sit still; fidgeting, pacing
or hand-wringing; rubbing or scratching skin or clothes).
Note whether you can establish a good rapport with pa-
tients. What is their attitude towards you? Do they make
good eye contact, or do they look around the room or at
Mood and affect
the floor? Patients may be described as cooperative, cor- Mood refers to a patient’s sustained, subjectively experi-
dial, uninterested, aggressive, defensive, guarded, suspi- enced emotional state over a period of time. Affect refers to
cious, fearful, perplexed, preoccupied or disinhibited (that the transient ebb and flow of emotion in response to stimuli
is, a lowering of normal social inhibitions; e.g. being over- (e.g. smiling at a joke or crying at a sad memory).
familiar or making sexually inappropriate comments), Mood is assessed by asking patients how they are feel-
amongst many other adjectives. ing and might be described as depressed, elated, anxious,
guilty, frightened, angry, etc. It is described subjectively
(what the patient says they are feeling) and objectively
HINTS AND TIPS (what your impression of their prevailing mood is during
Observations of appearance and behaviour the interview) For example, her mood was subjectively ‘rock
bottom’ and objectively low. Affect is assessed by observing
may also reveal other useful information (e.g.
patients’ posture, facial expression, emotional reactivity
extrapyramidal side-effects from antipsychotic
and speech. There are two components to consider when
medication). It is useful to remember to look for: assessing affect:
• Parkinsonism: drug-induced signs are most
1. The appropriateness or congruity of the observed
commonly a reduced arm swing and unusually affect to the patient’s subjectively reported mood (e.g.
upright posture while walking. Tremor and a woman with schizophrenia who reports feeling
rigidity are late signs, in contrast to idiopathic suicidal but has a happy facial expression would be
parkinsonism. described as having an incongruous affect).
• Acute dystonia: involuntary sustained muscular 2. The range of affect or range of emotional expressivity.
contractions or spasms. In this sense, affect may be:
• Akathisia: subjective feeling of inner restlessness • Within the normal range
and muscular discomfort, often manifesting • Blunted/flat: a noticeable reduction in the normal
with an inability to sit still, ‘jiggling’ of the legs
intensity of emotional expression, as evidenced by a
monotonous voice and minimal facial expression
(irregularly, as opposed to a tremor, which would
Note that a labile mood refers to a fluctuating mood state
be regular) or apparent psychomotor agitation.
that alternates between extremes (e.g. a young man with
• Tardive dyskinesia: rhythmic, involuntary a mixed affective episode alternates between feeling over-
movements of head, limbs and trunk, especially joyed, with pressure of speech, and miserable, with suicidal
chewing, grimacing of mouth and making ideation).
protruding, darting movements with the tongue.
Thoughts
Problems with thinking are considered under two headings:
Speech thought form (abnormal patterns of thinking) and thought
Speech should be described in terms of: content (abnormal beliefs).
• Rate of production: pressure of speech in mania; long
pauses and poverty of speech in depression Thought form
• Quality and flow of speech: volume, dysarthria Disordered thinking includes circumstantial and tangen-
(articulation difficulties), dysprosody (unusual speech tial thinking, loosening of association (derailment/knight’s
rhythm, melody, intonation or pitch), stuttering move thinking), flight of ideas and thought blocking (see
• Word play: punning, rhyming, alliteration (generally Chapter 9 for the definitions of these terms). Whenever
seen in mania) possible, record patients’ disorganized speech word for
8
Risk assessment 1
word, as it can be very difficult to label disorganized think- listening or quizzically looking at hallucinatory objects
ing with a single technical term, and written language may around the room.
be easier to evaluate than spoken language.
RED FLAG
Thought content: delusions, obsessions
Elementary hallucinations are more common
and overvalued ideas
in delirium, migraine and epilepsy than in primary
It is diagnostically significant to classify delusions as:
psychiatric disorders.
• Primary or secondary
• Mood congruent or mood incongruent
• Bizarre or nonbizarre
• According to the content of the delusion (summarized
in Table 9.1)
Cognition
See Chapter 9 for a detailed description of these terms. The cognition of all patients should be screened by check-
An obsession is an involuntary thought, image or im- ing orientation to place and time. Depending on the cir-
pulse that is recurrent, intrusive and unpleasant and enters cumstances, a more thorough cognitive assessment may
the mind against conscious resistance. Patients recognize be required. Cognitive tests, including tests of generalized
that the thoughts are a product of their own mind. See cognitive abilities (e.g. consciousness, attention, orienta-
Chapter 13 for more information. tion) and specific abilities (e.g. memory, language, exec-
utive function, praxis, perception), are discussed fully in
Chapter 7. Figure 7.1 and Tables 7.1, 7.2 and 7.6 describe
COMMUNICATION methods of testing cognition.
Some psychiatrists include thoughts of self-harm,
suicide or harm to others under thought content, Insight
while others mention it only under risk assessment. Insight is not an ‘all or nothing’ attribute. It is often de-
As long as you mention it, it doesn’t matter where. scribed as good, partial or poor, although patients really
lie somewhere on a spectrum and vary over time. The key
questions to answer are:
• Does the patient believe they are unwell in any way?
Perception • Do they believe they are mentally unwell?
Hallucinations are often mentioned during the history. • Do they think they need treatment (pharmacological,
However, this is not always the case, so it is important that psychological or both)?
you specifically enquire about abnormal perceptual experi- • Do they think they need to be admitted to hospital (if
ences (perceptual abnormalities are defined and classified relevant)?
in Chapter 9). If patients admit to problems with percep-
tion, it is important to ascertain:
• Whether the abnormal perceptions are
hallucinations, pseudohallucinations, illusions or RISK ASSESSMENT
intrusive thoughts
• From which sensory modality the hallucinations Although it is extremely difficult to make an accurate as-
appear to arise (i.e. are they auditory, visual, olfactory, sessment of risk based on a single assessment, clinicians are
gustatory or somatic hallucinations – see Chapter 9) expected, as far as is possible, to establish some idea of a
• Whether auditory hallucinations are elementary (a patient’s risk to:
very simple abnormal perception; e.g. a flash or a • Self: through self-harm, suicide, self-neglect or
bang) or complex. If complex, are they experienced exploitation by others. Chapter 6 explains the
in the first person (audible thoughts, thought echo), assessment of suicide risk in detail.
second person (critical, persecutory, complimentary • Others: includes violent or sexual crime, stalking and
or command hallucinations) or third person (voices harassment. Chapter 32 discusses key principles in
arguing or discussing the patient, or giving a running assessing dangerousness.
commentary)? • Children: includes physical, sexual or emotional
It is also important to note whether patients seem to be abuse, as well as neglect or deprivation. Child abuse is
responding to hallucinations during the interview, as evi- discussed in more detail in Chapter 30.
denced by them laughing inappropriately as though they are • Property: includes arson and physical destruction of
sharing a private joke, suddenly tilting their head as though property.
9
• Relevant background details (e.g. past psychiatric

RED FLAG history, positive family history)
Risk assessment is a vital part of psychiatric • Positive findings in the MSE and physical
assessment. You should always assess risk to self examination
and others. Table 1.2 shows a case summary as a formulation.
HINTS AND TIPS
When presenting your differential diagnosis,

PHYSICAL EXAMINATION remember that two or more psychiatric disorders
can coexist (e.g. depression and alcohol abuse).
The psychiatric examination includes a general physical In this event, it is important to ascertain whether
examination, with special focus on the neurological and the conditions are independent or related (e.g.
endocrine systems. Always remember to look for signs alcohol abuse that has developed secondary to the
relevant to the psychiatric history (e.g. signs of liver dis- depressive symptoms of emptiness and difficulty
ease in patients who misuse alcohol, ophthalmoplegia or
sleeping).
ataxia in someone withdrawing from alcohol (indicating
Wernicke encephalopathy), signs of self-harm in patients
with a personality disorder and signs of intravenous drug
use (track marks) in patients who use drugs). Also, ex-
amine for side-effects of psychiatric medication (e.g. Differential diagnosis
parkinsonism, tardive dyskinesia, dystonia, hypotension,
obesity and other cardiometabolic sequelae, signs of lith- The differential diagnosis is mentioned in order of decreas-
ium toxicity). It may not be possible to complete a de- ing probability. Only mention conditions that you have ob-
tailed physical examination in an exam situation, but you tained evidence about in your assessment, as you should be
should always recommend that it should be done. Always able to provide reasons for and against all the alternatives
make a point of mentioning your positive physical find- on your list. Table 1.2 provides an example of a typical dif-
ings when summarizing the case. ferential diagnosis.
Aetiology
The exact cause of most psychiatric disorders is often un-
THE FORMULATION: PRESENTING known, and most cases seem to involve a complex interplay
THE CASE of biological, social and psychological factors. In clinical
practice, psychiatrists are especially concerned with the
‘Formulation’ is the term psychiatrists use to describe the question: ‘What factors led to this patient presenting with
integrated summary and understanding of a particular pa- this specific problem at this specific point in time?’ That is,
tient’s problems. The formulation usually includes: what factors predisposed to the problem, what factors pre-
• Description of the patient cipitated the problem, and what factors are perpetuating the
• Differential diagnosis problem? Table 1.2 illustrates an aetiology grid that is very
• Aetiology helpful in structuring your answers to these questions in
• Management terms of biological, social and psychological factors – the
• Prognosis emphasis should be on considering all the blocks in the grid,
not necessarily on filling them.
Description of the patient
The patient may be described: (1) in detail by recounting
Management
all the information obtained under the various headings Investigations
in the psychiatric history and MSE; or (2) in the form of Investigations are considered part of the management plan
a case summary. The case summary consists of one or two and are performed based on findings from the psychiatric
paragraphs and contains only the salient features of a case, assessment. Appropriate investigations relevant to specific
specifically: conditions are given in the relevant chapters. Familiarize
• Identifying information yourself with these, as you should be able to give reasons for
• Main features of the presenting complaint any investigation you propose.
10
The formulation: presenting the case 1
Table 1.2 Example of a case formulation (differential diagnosis, aetiology, management)

Differential diagnosis
Diagnosis Comments
1. Schizophrenia For: symptoms present for more than 1 month
For: ICD-10 and first-rank symptoms of delusions of control or passivity
(thought insertion); delusional perception; and third person running
commentary hallucinations
For: clear and marked deterioration in social and work functioning
2. Schizoaffective disorder For: typical symptoms of schizophrenia
Against: no prominent mood symptoms
3. Mood disorder (either manic or depressive Against: on mental state examination, mood was mainly suspicious (as
episode) with psychotic features opposed to lowered or elevated) and appeared secondary to delusional
beliefs
Against: no other prominent features of mania or depression
Against: mood-incongruent delusions and hallucinations
4. Substance-induced psychotic disorder Against: long duration of symptoms
Against: no evidence of illicit substance or alcohol use
5. Psychotic disorder secondary to a medical Against: no signs of medical illness or abnormalities on physical
condition examination
Aetiology
Biological Psychological Social
Predisposing Family history of - -
(what made the patient prone to this schizophrenia
problem?)
Precipitating The peak of onset for - Break-up of
(what made this problem start now?) schizophrenia for men relationship Recently
is between 18 and started college
25 years
Perpetuating Poor concordance with High expressed Lack of social support
(what is maintaining this problem?) medication due to lack emotion family
of insight
Management
1. Investigations
2. Management plan below
Term Biological Psychological Social
Immediate to Antipsychotic Establish therapeutic Admission to hospital
short-term medication, with relationship Allocation of care coordinator (care programme
benzodiazepines if Support for family approach)
necessary (carers) Help with financial, accommodation and social
problems
Medium- to long-term Review progress in out- Relapse prevention Regular review under care programme approach
patient clinic work Consider day hospital
Consider another Consider cognitive Vocational training
antipsychotic behavioural therapy and
then clozapine for family therapy
non-response
Consider depot
medication for
concordance problems
Prognosis
Assuming Mr PP has a diagnosis of schizophrenia, it is likely his illness will run a chronic course, showing a relapsing
and remitting pattern. Being a young man with a high level of education, Mr PP is particularly at risk for suicide,
especially following discharge from hospital. Good prognostic factors include a high level of premorbid functioning and
the absence of negative symptoms.
11
Organization). The eleventh revision, ICD-11, is close

CASE SUMMARY to completion at the time of writing (https://icd.who.
Mr PP is a 23-year-old, single man in full-time
int/browse11/l-m/en).
2. DSM-5: the fifth edition of the Diagnostic and
education who recently agreed to informal
Statistical Manual of Mental Disorders (published by
hospital admission. He presented with a 6-month
the American Psychiatric Association, 2013).
history of hearing voices and maintaining
Both the ICD-10 and the DSM-5 make use of a categorical
bizarre beliefs that he was being subjected to
classification system, which refers to the process of dividing
government experiments. During this time, his
mental disorders into discrete entities by means of accurate
college attendance had been uncharacteristically descriptions of specific categories. In contrast, a dimensional
poor, he had terminated his part-time work, and approach rejects the idea of separate categories, hypothesiz-
he had become increasingly socially withdrawn. ing that mental conditions exist on a continuum that merges
He has no history of psychiatric illness and into normality. This better reflects reality but is harder to put
denies the use of alcohol or illicit substances; into clinical practice; for example, would someone whose
however, he did mention that his maternal uncle mood is ‘one standard deviation lower than normal’ be likely
suffers from schizophrenia. On mental state to benefit from treatment with an antidepressant?
examination, he appeared unkempt and behaved The ICD-10 categorizes mental disorders according to de-
scriptive statements and diagnostic guidelines. The DSM-5
suspiciously. He had delusions of persecution,
categorizes mental disorders according to operational defi-
reference and thought control, as well as
nitions, which means that mental disorders are defined by
delusional perception. He also described second
a series of precise inclusion and exclusion criteria. Note that
person command hallucinations and third person the research version of the ICD-10 (Diagnostic Criteria for
running commentary hallucinations. He appeared Research) also makes use of operational definitions.
to have no insight into his mental illness, as he In general, both the ICD-10 and the DSM-5 propose a
refused to consider that he might be unwell. hierarchical diagnostic system, whereby disorders higher on
There were no abnormalities on physical the hierarchical ladder tend to be given precedence. As a
examination. broad rule, symptoms related to another medical condition
or substance use take precedence over conditions such as
schizophrenia and mood disorders, which take precedence
over anxiety disorders. This does not mean that patients
Specific management plan may not have more than one diagnosis (which they may);
It may help to structure your management plan by consider- rather, it means that clinicians should:
ing the biological, social and psychological aspects of treat- • Always consider a medical or substance-related cause
ment (the biopsychosocial approach) in terms of immediate of mental disorder symptoms before any other cause.
to short-term and medium- to long-term management. See • Remember that certain conditions have symptoms
Table 1.2 for an example of this method. in common. For example, schizophrenia commonly
presents with features of depression and anxiety, and
Prognosis depression commonly presents with features of anxiety;
in both cases, the treatment of the primary condition
The prognosis is dependent on two factors: results in resolution of the symptoms – a separate
1. The natural course of the condition, which can be diagnosis for every symptom is not needed.
predicted based on studies of patient populations; these The ICD-10 and the DSM-5 share similar diagnostic cate-
are discussed for each disorder in the relevant chapters. gories and are fairly similar for the most part, with further
2. Individual patient factors (e.g. social support, convergence planned between DSM-5 and ICD-11.
concordance with treatment, comorbid substance abuse) The DSM-5 and the current draft of ICD-11 (not yet pub-
See Table 1.2 for an example. lished) take a lifespan approach to diagnoses. Classification
begins with neurodevelopmental disorders (autism, psy-
chotic disorders), followed by disorders that often present
in early adulthood (bipolar, depression, anxiety) and ending
CLASSIFICATION IN PSYCHIATRY with neurocognitive disorders (dementia).
These classification systems are evolving over time as new ev-
There are two main categorical classification systems in idence about the aetiology of mental disorders arises. Currently,
psychiatry: psychiatric disorders are classified by clustering symptoms, signs
1. ICD-10: the tenth revision of the International and behaviours into syndromes. As yet, they are not based on a
Classification of Diseases, Chapter V (F) – Mental and clear understanding of pathogenesis. As this develops, classifi-
behavioural disorders (published by the World Health cation systems will continue to change and, hopefully, improve.
12
Classification in psychiatry 1
Chapter Summary
• A psychiatric history is like any other history, except that more attention is given to
personal and social circumstances, and a mental state examination is conducted during it.
• A mental state examination, like a physical examination, is a snapshot of how the person
presents at the time you meet them.
• Physical examination is still important, even in patients who don’t report physical
symptoms.
• Psychiatric diagnostic systems are evolving in light of new understanding of mental
disorder aetiology.
13
Pharmacological therapy and
electroconvulsive therapy 2
Psychotropic (mind-altering) medications can be divided 5-HT2C (serotonin 2C) receptor antagonist, but neither of
into the following groups: these actions alone have an antidepressant effect. Fig. 2.1
• Antidepressants illustrates the mechanism of action of antidepressants at
• Mood stabilizers synapses, and Table 2.1 summarizes their classification
• Antipsychotics and pharmacodynamics.
• Anxiolytics and hypnotics The latest research has focused on monoamine neu-
• Other rotransmitter activation of ‘second messenger’ signal
Despite its simplicity, this method of grouping drugs by transduction mechanisms. This results in the production
the disorder they were first used to treat is flawed, because of transcription factors that lead to the activation of genes
many drugs from one class are now used to treat disorders controlling the expression of downstream targets such as
in another class (e.g. antidepressants are first-line therapies brain-derived neurotrophic factor (BDNF). BDNF is neu-
for many anxiety disorders, and some antipsychotics also roprotective, and might be a key target of antidepressant
have mood stabilizing and antidepressant effects). action.
HINTS AND TIPS

ANTIDEPRESSANTS When recommending antidepressants to trial in
a patient with treatment-resistant depression,
History it makes sense to try those with different
Antidepressants were first used in the late 1950s, with the pharmacodynamic properties to antidepressants
appearance of the tricyclic antidepressant (TCA) imip- that have been trialled before. See Table 2.1.
ramine and the monoamine oxidase inhibitor (MAOI)
phenelzine. Research into TCAs throughout the 1960s
and 1970s resulted in the development of many more tri-
cyclic agents and related compounds. A major develop-
ment in the late 1980s was the arrival of the first selective Indications
serotonin reuptake inhibitor (SSRI) fluoxetine (Prozac).
There has since been considerable expansion of the SSRI SSRIs are used in the treatment of:
class, as well as the development of antidepressants such • Depression
as mirtazapine and agomelatine that have other mecha- • Anxiety disorders
nisms of action. • Obsessive-compulsive disorder
Mirtazapine is used in the treatment of:
Classification and mechanism • Depression (particularly where sedation or increased
oral intake is desirable)
of action
TCAs are used in the treatment of:
At present, antidepressants are classified according to
• Depression
their pharmacological actions, as there is not yet an ad-
• Anxiety disorders
equate explanation as to what exactly makes antidepres-
• Obsessive-compulsive disorder (clomipramine)
sants work. Although there are many different classes of
• Other: chronic pain, nocturnal enuresis,
antidepressants, their common action is to elevate the lev-
narcolepsy
els of one or more monoamine neurotransmitters in the
synaptic cleft. Some predominantly influence serotonin, MAOIs are used in the treatment of:
some noradrenaline and some dopamine, with many in- • Depression (especially atypical depression, which
fluencing the transporters or receptors for multiple neu- is characterized by hypersomnia, overeating and
rotransmitters. It is likely that the combination of effects anxiety)
on multiple neurotransmitter pathways acts synergisti- • Anxiety disorders
cally in causing the antidepressant effect. For example, • Other: Parkinson disease, migraine prophylaxis,
agomelatine is both a melatonin receptor agonist and a tuberculosis
15
Pharmacological therapy and electroconvulsive therapy
SEROTONERGIC OR NORADRENERGIC
NERVE TERMINAL
Monoamine oxidase inhibitors (MAOI)
• Phenelzine
• Tranylcypromine
Metabolites
Reversible inhibitors of monoamine
oxidase A (RIMA)
• Moclobemide Noradrenergic
and specific
serotonergic
– antidepressant
MONOAMINE SYNTHESIS
Degradation (NaSSA)
Tryptophan Tyrosine • Mirtazapine
Specific serotonin reuptake Monoamine DOPA
inhibitors (SSRI) oxidase A
• Fluoxetine Dopamine
• Sertraline
–
• Paroxetine Serotonin (5-HT) Noradrenaline
• Citalopram
– –
no rece
–
rad pt
α2 nalin
re or
e
Serotonin reuptake pump
Noradrenaline Noradrenaline (norepinephrine)

(norepinephrine) – reuptake pump
reuptake inhibitor
(NRI)
• Reboxetine
SYNAPTIC CLEFT
–
Tricyclic antidepressants (TCA)

• Amitriptyline
• Clomipramine
• Imipramine
• Lofepramine
Serotonin-noradrenaline (norepinephrine) Serotonin Noradrenaline
reuptake inhibitor (SNRI) (5-HT) receptor
• Venlafaxine receptor
• Duloxetine
Bupropion (noradrenaline and dopamine POSTSYNAPTIC CELL
reuptake inhibitor)
Note: the serotonin and noradrenaline (norepinephrine) pathways are presented together for convenience;
they do not occur in the same nerve terminal
Fig. 2.1 Mechanism of action of antidepressants at the synaptic cleft.
16
Antidepressants 2
Table 2.1 Classification and pharmacodynamics of the antidepressants

Class of antidepressant Examples Mechanism of action
Commonly used
Selective serotonin reuptake Fluoxetine, sertraline, paroxetine, Selective presynaptic blockade of serotonin
inhibitor (SSRI) citalopram, fluvoxamine reuptake pumps.
Serotonin and noradrenaline Venlafaxine, duloxetine Presynaptic blockade of both noradrenaline
reuptake inhibitor (SNRI) (norepinephrine) and serotonin reuptake
pumps (also dopamine in high doses),
but with negligible effects on muscarinic,
histaminergic or α-adrenergic receptors (in
contrast to tricyclic antidepressants).
Noradrenergic and specific Mirtazapine Presynaptic alpha 2 receptor blockade
serotonergic antidepressant (NaSSA) (results in increased release of noradrenaline
(norepinephrine) and serotonin from
presynaptic neurons). Also 5-HT2A/C and 3
receptor antagonist and histamine 1 receptor
antagonist.
5-HT2A/C antagonist/serotonin Trazodone Also antagonist at alpha 1 adrenergic
reuptake inhibitor (SARI) receptors, histamine type 1 receptors and
T-type calcium channels. Which of its actions
is important in inducing its sedative and
anxiolytic effects is unclear.
Tricyclic antidepressant Amitriptyline, lofepramine, Presynaptic blockade of both noradrenaline
clomipramine, imipramine (norepinephrine) and serotonin reuptake
pumps (to a lesser extent - dopamine). Also,
blockade of muscarinic, histaminergic and
α-adrenergic receptors.
Less commonly used
Monoamine oxidase inhibitor (MAOI) Phenelzine, tranylcypromine, Nonselective and irreversible inhibition of
isocarboxazid monoamine oxidase A and B.
Reversible inhibitor of monoamine Moclobemide Selective and reversible inhibition of
oxidase A (RIMA) monoamine oxidase A.
Noradrenaline and dopamine Bupropion Dopamine and noradrenaline reuptake pump
reuptake inhibitor inhibitor.
Dopamine agonist Pramipexole, ropinirole Dopamine receptor agonist (D2, D3, D4).
Selective noradrenaline reuptake Reboxetine Selective presynaptic blockade of
inhibitor (NRI) noradrenaline (norepinephrine) reuptake
pumps.
Melatonin agonist and serotonin Agomelatine Melatonin receptor 1 and 2 agonist and
antagonist 5-HT2C receptor antagonist.
Serotonin modulator and stimulator Vortioxetine Selective serotonin reuptake inhibitor, plus
varied effects on different 5-HT receptor
subtypes (1A agonist, 1B partial agonist, 1D,
3 and 7 antagonist).
Side-effects and contraindications in young people). Due to their low cardiotoxicity, SSRIs are
the antidepressant of choice in patients with cardiac dis-
SSRIs and SNRIs ease and in those who are at risk for taking an overdose.
SSRIs have fewer anticholinergic effects than the TCAs and However, they do have their own side-effects that may be
are not sedating. The majority of patients find them alert- unacceptable to some patients. These are summarized in
ing, so they are prescribed to be taken in the morning. Soon Box 2.1. Selective serotonin and noradrenaline reuptake
after initiation, or when taken at high doses, some patients inhibitors (SNRIs) such as venlafaxine have similar side-
can feel alerted to the point of agitation/anxiety. This may effects to SSRIs, but they tend to be more severe.
be associated with an increased risk for suicide, particularly Contraindications: mania, poorly controlled epilepsy and
in adolescents (see Chapter 30 for recommendations on use prolonged QTc interval (for citalopram and escitalopram).
17
Trazodone
BOX 2.1 COMMON SIDE-EFFECTS OF SSRIs
Trazodone is a relatively weak antidepressant but a good
Gastrointestinal disturbance (nausea, vomiting, sedative. It is relatively safe in overdose and has negligible
diarrhoea, pain) – earlya anticholinergic side-effects. It is often used as an adjunctive
antidepressant in those receiving a nonsedative primary an-
Anxiety and agitation – earlya
tidepressant (e.g. an SSRI).
Loss of appetite and weight loss (sometimes
Contraindications: as TCAs (closely related structurally).
weight gain)
Insomnia
Sweating
RED FLAG
Sexual dysfunction (anorgasmia, delayed
ejaculation) Antidepressants should be used with caution in
a
Gastrointestinal and anxiety symptoms occur on initiation of patients with epilepsy, as they can increase seizure
treatment and resolve with time. frequency, either by directly lowering the seizure
threshold or by interacting with the metabolism of
antiepileptics. However, depression is common
and often undertreated in patients with epilepsy,
Mirtazapine so it is important not to avoid antidepressants if
Mirtazapine is very commonly associated with increased they are indicated. SSRIs or SNRIs are usually
appetite, weight gain and sedation (via histamine antago- recommended as first-line treatments.
nism). These side-effects can be used to advantage in many
patients. It is also associated with headache, dry mouth and,
less commonly, dizziness, postural hypotension, tremor and
peripheral oedema. It has negligible anticholinergic effects.
Contraindications: mania. MAOIs/RIMAs
Due to the risk for serious interactions with certain foods
and other drugs, the MAOIs have become second-line an-
Tricyclic antidepressants tidepressants. Their inhibition of monoamine oxidase A
Table 2.2 summarizes the common side-effects of TCAs, most
results in the accumulation of amine neurotransmitters
of which are related to the multireceptor blocking effects of
and impairs the metabolism of some amines found in cer-
these drugs. The sedative side-effect can be useful if patients
tain drugs (e.g. decongestants) and foodstuffs (e.g. tyra-
have insomnia. TCAs with prominent sedative effects include
mine). Because MAOIs bind irreversibly to monoamine
amitriptyline and clomipramine. Those with less sedative ef-
oxidase A and B, amines may accumulate to dangerously
fects include lofepramine and imipramine. Due to their car-
high levels, which may precipitate a life-threatening hy-
diotoxic effects, TCAs are dangerous in overdose, although
pertensive crisis. An example of this occurs when the in-
lofepramine (a newer TCA) has fewer antimuscarinic effects,
gestion of dietary tyramine results in a massive release of
and so is relatively safe compared with other TCAs.
noradrenaline (norepinephrine) from endogenous stores.
Contraindications: recent myocardial infarction, ar-
This is termed the ‘cheese reaction,’ because some mature
rhythmias, acute porphyria, mania and high risk for
cheeses contain high levels of tyramine. Box 2.2 lists the
overdose.
drugs and foodstuffs that should be avoided in patients
taking MAOIs.
Table 2.2 Common side-effects of tricyclic
antidepressants
Mechanism Side-effects RED FLAG
Anticholinergic: muscarinic Dry mouth An early warning sign of a hypertensive crisis is

receptor blockade Constipation a throbbing headache. Check blood pressure in
Urinary retention
someone taking a MAOI who feels unwell.
Blurred vision
α-Adrenergic receptor Postural hypotension
blockade (dizziness, syncope)
Histaminergic receptor Weight gain The reversible inhibitor of monoamine oxidase A (RIMA)
blockade Sedation moclobemide reversibly inhibits monoamine oxidase A.
Cardiotoxic effects QT interval prolongation Therefore the drug will be displaced from the enzyme as
ST segment elevation amine levels start to increase. So, although there is a small
Heart block risk for developing a hypertensive crisis if high levels of tyra-
Arrhythmias mine are ingested, dietary restrictions are much less onerous.
18
Mood stabilizers 2
BOX 2.2 DRUGS AND FOODS THAT MAY HINTS AND TIPS

PRECIPITATE A HYPERTENSIVE CRISIS IN
COMBINATION WITH MAOIS The abrupt withdrawal of any antidepressant
may result in a discontinuation syndrome with
Tyramine-rich foods symptoms such as gastrointestinal disturbance,
Cheese – especially mature varieties (e.g. Stilton) agitation, dizziness, headache, tremor and
Degraded protein: pickled herring, smoked fish, insomnia. SSRIs with short half-lives (e.g.
chicken liver, hung game paroxetine, sertraline) and venlafaxine are particular
Yeast and protein extract: Bovril, Oxo, Marmite culprits. Therefore all antidepressants (with the
Chianti wine, beer exception of fluoxetine, which has a long half-life
Broad bean pods and many active metabolites) should be gradually
Soya bean extract tapered down before being withdrawn completely.
Overripe or unfresh food
Medication or Substances
Adrenaline (epinephrine), noradrenaline
(norepinephrine) COMMUNICATION
Amphetamines
Cocaine Although certain antidepressants may cause a
Ephedrine, pseudoephedrine, phenylpropanolamine discontinuation syndrome, they do not cause
(cough mixtures, decongestants) a dependence syndrome or ‘addiction,’ in that
L-dopa, dopamine patients do not become tolerant to them or
Local anaesthetics containing adrenaline crave them.
(epinephrine)
Note: the combination of MAOIs and antidepressants or opiates
(especially pethidine or tramadol) may result in serotonin
syndrome. Opiates have some serotonin reuptake inhibitory MOOD STABILIZERS
activity.
These include lithium and the anticonvulsants valproate,

carbamazepine and lamotrigine. Antipsychotics such as
quetiapine and olanzapine are also increasingly used in
treating episodes of mania and in prophylactic mood sta-
bilization (these are covered in the next section; see also
Chapter 22).
RED FLAG
When other antidepressants that have a strong History
serotonergic effect (e.g. SSRIs, clomipramine,
In 1949, John Cade discovered that lithium salts caused
imipramine) are administered simultaneously with
lethargy when injected into animals, and later reported
an MAOI, the risk for developing the potentially lithium's antimanic properties in humans. Trials in the
lethal ‘serotonin syndrome’ is increased (see 1950s and 1960s led to the drug entering mainstream prac-
Table 2.8). Therefore antidepressant wash-out tice in 1970.
periods are required if starting or stopping an Valproate was first recognized as an effective anticonvul-
MAOI – check guidance for the specific switch you sant in 1962. Along with carbamazepine and lamotrigine,
are considering. it was later shown to be effective in treating patients with
bipolar affective disorder.
Mechanism of action
It is not known how any of the mood stabilizers work.
MAOIs may have further side-effects similar to those Lithium appears to modulate the neurotransmitter-
induced by TCAs, including postural hypotension and an- induced activation of second messenger systems. Valproate,
ticholinergic effects. carbamazepine and lamotrigine all inhibit the activity
Contraindications (MAOIs): phaeochromocytoma, voltage-gated sodium channels, and also enhance GABA-
cerebrovascular disease and mania. ergic neurotransmission.
19
Indications Table 2.3 Side-effects and signs of toxicity of lithiuma

Lithium is used in the treatment of: Side-effects Signs of toxicity
• Acute mania Thirst, polydipsia, polyuria, 1.5–2 mmol/L: nausea and
• Prophylaxis of bipolar affective disorder (prevention of weight gain, oedema vomiting, apathy, coarse
relapse) Fine tremor tremor, ataxia, muscle
Precipitates or worsens weakness
• Treatment-resistant depression (lithium augmentation) skin problems >2 mmol/L: nystagmus,
Valproate is used in the treatment of: Concentration and dysarthria, impaired
memory problems consciousness, hyperactive
• Epilepsy
Hypothyroidism tendon reflexes, oliguria,
• Acute mania Hyperparathyroidism hypotension, convulsions,
• Prophylaxis of bipolar affective disorder Impaired renal function coma
(second-line) Cardiac: T-wave flattening
Carbamazepine is used in the treatment of: or inversion
Leucocytosis
• Epilepsy Teratogenicity
• Prophylaxis of bipolar affective disorder (third-line) a
The treatment of lithium toxicity is supportive, ensuring
Lamotrigine is used in the treatment of: adequate hydration, renal function and electrolyte balance.
Anticonvulsants may be necessary for convulsions and
• Epilepsy haemodialysis may be indicated in cases of renal failure.
• Prophylaxis of depressive episodes in bipolar affective
disorder (third-line) synergistically increase lithium-induced neurotoxicity;
this is important, as lithium and antipsychotics are often
coadministered in acute mania. Table 2.3 summarizes the
HINTS AND TIPS side-effects and signs of toxicity of lithium.
Valproate is available in formulations as sodium RED FLAG

valproate, valproic acid and semisodium valproate
Lithium toxicity can arise rapidly in someone who
(Depakote), which comprises equimolar amounts
becomes dehydrated for any reason (e.g. vomiting,
of sodium valproate and valproic acid. Different
diarrhoea, inadequate fluid intake). Always check a
formulations have different equivalent doses, so
random lithium level in someone who takes lithium
prescribe by brand.
and is physically unwell.
It follows that the following investigations are needed prior

Side-effects and contraindications to initiating therapy:
• Full blood count
Lithium • Urea and electrolytes
Lithium has a narrow therapeutic window between non- • Calcium
therapeutic and toxic blood levels. Lower levels can be toxic • Thyroid function
in older patients. • Pregnancy test (in women of childbearing age)
• Therapeutic levels: 0.4–0.8 mmol/L when used • Electrocardiogram (if cardiac disease or risk factors)
adjunctively for depression; 0.6–1.0 mmol/L for Blood levels are monitored weekly after starting treatment
treatment of acute mania and for bipolar disorder until a therapeutic level has been stable for 2 consecutive
prophylaxis weeks. Lithium blood levels should then be monitored ev-
• Toxic levels: >1.5 mmol/L ery 3 months for the first year, then every 6 months (unless
• Dangerously toxic levels: >2 mmol/L the patient is at high risk for complications from lithium or
Lithium is only taken orally and is excreted almost entirely has poor concordance). Renal function, calcium and thy-
by the kidneys. Clearance of lithium is decreased with renal roid function should be monitored every 6 months or more
impairment (e.g. in older adults, dehydration) and sodium frequently if there is any evidence of impairment.
depletion. Certain drugs such as diuretics (especially thi- Contraindications/cautions: untreated hypothyroidism,
azides), nonsteroidal antiinflammatory drugs (NSAIDs) heart failure, cardiac arrhythmia.
and angiotensin-converting enzyme (ACE) inhibitors can
also increase lithium levels and should ideally be avoided Valproate, carbamazepine and lamotrigine
or prescribed with caution and frequent checks of lithium Table 2.4 summarizes the side-effects of carbamazepine,
levels during initiation. Furthermore, antipsychotics may valproate and lamotrigine. It is important to check liver
20
Antipsychotics 2
Table 2.4 Side-effects of valproate, carbamazepine and lamotrigine

Valproatea Carbamazepineb Lamotriginec
Increased appetite and weight gain Nausea and vomiting Nausea and vomiting
Sedation and dizziness Skin rashes Skin rashes (consider
Ankle swelling Blurred or double vision (diplopia) withdrawal)
Hair loss Ataxia, drowsiness, fatigue Headache
Nausea and vomiting Hyponatraemia and fluid retention Aggression, irritability
Tremor Haematological abnormalities (leucopenia, Sedation and dizziness
Haematological abnormalities (prolongation of thrombocytopenia, eosinophilia) Tremor
bleeding time, thrombocytopenia, leucopenia) Raised liver enzymes (hepatic or
Raised liver enzymes (liver damage very uncommon) cholestatic jaundice, rarely)
a
Serious blood and liver disorders do occur, but are rare.
b
Serious blood and liver disorders do occur, but are rare.
c
Stevens-Johnson syndrome can occur, but it is rare.
and haematological functions prior to and soon after start-

ing valproate or carbamazepine, due to the risk for serious ANTIPSYCHOTICS
blood and hepatic disorders.
History and classification
RED FLAG Antipsychotics or neuroleptics (originally known as
‘major tranquillizers’) appeared in the early 1950s with
Valproate should not be prescribed in women of the introduction of the phenothiazine chlorpromazine.
childbearing age, unless alternative treatments A number of antipsychotics with a similar pharmaco-
are ineffective or not tolerated, because of its high dynamic action soon followed (e.g. the butyrophenone
teratogenic risk (see Chapter 27). If valproate is to haloperidol in the 1960s). Their ability to treat psychotic
be prescribed, ensure the patient is aware of the symptoms had a profound impact on psychiatry, acceler-
risk for developmental disorders (approximately ating the movement of patients out of asylums and into
the community. However, serious motor side-effects (ex-
a third of births) and congenital malformations
trapyramidal side-effects (EPSEs)) soon became appar-
(approximately 1 in 10 babies), is using adequate
ent with all these drugs.
contraception and knows to consult promptly if Clozapine was the first antipsychotic with fewer EPSEs,
she does become pregnant. and thus was termed ‘atypical’. It led to the introduction of
several other atypical (or ‘second generation’) antipsychotics,
including risperidone, olanzapine and quetiapine. The older
antipsychotics such as haloperidol and chlorpromazine be-
RED FLAG came known as ‘conventional’, ‘first generation’ or ‘typical’
antipsychotics. However, this distinction is increasingly
Carbamazepine is a potent CYP450 enzyme viewed as artificial – all antipsychotics can induce EPSEs if
inducer. Before prescribing new medication for given at high enough doses. Clozapine is the only ‘true’ atyp-
someone taking carbamazepine, check a drug ical antipsychotic, in that it has a distinct receptor binding
interactions reference (e.g. Appendix 1 in the profile and can be effective in two-thirds of the patients for
British National Formulary). whom other antipsychotics have failed. Table 2.5 lists com-
mon antipsychotics.
Table 2.5 Commonly used antipsychotics

RED FLAG
First generation Second generation
Lamotrigine can, rarely, be associated with
Chlorpromazine Clozapine
Stevens-Johnson syndrome, particularly in the first
Haloperidola Olanzapinea
8 weeks of use. Patients should be advised to stop
immediately if there is development of a rash, and Sulpiride Quetiapine
reintroduction of lamotrigine at a later date should Flupentixol (Depixol)a Risperidonea
be considered only by a specialist. Zuclopenthixol (Clopixol) a
Aripiprazolea
a
Can be given in long-acting intramuscular injection (depot) form.
21
Mechanism of action and cardiovascular mortality, so it is important to monitor and

manage the components of this syndrome.
side-effects Clozapine is associated with some rare serious side-effects
The primary mechanism of action of all antipsychotics, such as agranulocytosis, myocarditis and cardiomyopathy,
with the possible exception of clozapine, is antagonism of which means it is reserved for treatment-resistant cases.
dopamine D2 receptors in the mesolimbic dopamine path-
way. Clozapine is a comparatively weak D2 antagonist, but HINTS AND TIPS
has a high affinity for serotonin type 2 receptors (5-HT2A
receptors) and D4 receptors, among many other receptor If you can remember the side-effects of tricyclic
targets. Most second generation antipsychotics also block antidepressants, you can remember many of the side-
5-HT2 receptors. effects of antipsychotics, as both are multireceptor
Unfortunately, blockade of dopamine D2 receptors oc- blockers. Both groups are anticholinergic (dry
curs throughout the brain, resulting in diverse side-effects. mouth, constipation, blurred vision, urinary
In addition, antipsychotics also cause side-effects by block-
retention), antiadrenergic (postural hypotension) and
ing muscarinic, histaminergic and α-adrenergic receptors
antihistaminergic (sedation, weight gain).
(as do TCAs). Fig. 2.2 and Table 2.6 summarize both the
useful and troublesome clinical effects of D2-receptor an-
tagonism, as well as the side-effects caused by the blockage
of other receptors. Learn this table well; these effects have HINTS AND TIPS
a big impact on patients’ quality of life and concordance
(and as such are frequently asked exam questions). See also ‘Extrapyramidal’ symptoms are motor symptoms
Table 21.1 for the relative frequency of side-effects for some arising from dysfunction of the striatum (part of the
commonly used antipsychotics. basal ganglia). The striatum provides input to the
The risk for metabolic syndrome (obesity, diabe- motor cortex and hence the upper motor neurons
tes, hypertension and dyslipidaemia) is particularly high (corticospinal and corticobulbar tracts), which
with clozapine and other second generation antipsychot-
ics. Metabolic syndrome is associated with increased
Striatum
Nucleus
Accumbens
Prefrontal
Cortex
Hypothalamus
Anterior pituitary
Ventral
Tegmental
Area
Pathways
Substantia Chemoreceptor
Mesolimbic Nigra
Trigger zone
Mesocentral
(Detects
Nigrostriatal substances
Tuberoinfundibular in blood
(Dopamine synthesized in and CSF)
Infundibular (arcuate)
Nucleus in tuberal region
of hypophyseal portal
region to reach anterior
pituitary)
Fig. 2.2 Dopaminergic pathways.

See Table 2.6 for consequences of D2 receptor blockade in each of these regions.
22
Antipsychotics 2
Table 2.6 The clinical effects and side-effects of conventional antipsychotics

Dopamine D2-receptor antagonism
Location of dopamine D2 Clinical effect of dopamine
receptors (see Fig. 2.2) Function D2-receptor antagonism
[1] Mesolimbic pathway Involved in delusions/hallucinations/ Treatment of psychotic symptoms.
thought disorders, euphoria and drug
dependence
[2] Mesocortical pathway Mediates cognitive and negative Worsening of negative and cognitive
symptoms of schizophrenia symptoms of schizophrenia.
[3] Nigrostriatal pathway (basal Controls motor movement Extrapyramidal side-effects (see
ganglia/striatum) Fig. 2.10):
• Parkinsonian symptoms
• Acute dystonia
• Akathisia
• Tardive dyskinesia
• Neuroleptic malignant syndrome
[4] Tuberoinfundibular pathway Controls prolactin secretion – Hyperprolactinaemia
dopamine inhibits prolactin release • Galactorrhoea (breast milk
production)
• Amenorrhoea and infertility
• Sexual dysfunction
Chemoreceptor trigger zone Controls nausea and vomiting Antiemetic effect: some phenothiazines
(e.g. prochlorperazine (Stemetil)) are
very effective in treating nausea and
vomiting.
Other side-effects
Anticholinergic: muscarinic receptor blockade Dry mouth, constipation, urinary
retention, blurred vision
α-Adrenergic receptor blockade Postural hypotension (dizziness,
syncope)
Histaminergic receptor blockade Sedation, weight gain
Cardiac effects Prolongation of QT-interval,
arrhythmias, myocarditis, sudden death
Metabolic effects Increased risk for metabolic syndrome
Dermatological effects Photosensitivity, skin rashes
(especially chlorpromazine: blue–grey
discolouration in the sun)
Other Lowering of seizure threshold,
hepatotoxicity, cholestatic jaundice,
pancytopenia, agranulocytosis
HINTS AND TIPS

travel from cortex to spinal cord (or cranial nerve
nuclei). As these tracts pass through the brainstem, The particular extrapyramidal side-effects
they form a bulge, which is termed the medullary (EPSEs) of parkinsonism and dystonia are due
pyramids. The term ‘extrapyramidal’ emphasizes to a relative deficiency of dopamine and an
that different symptoms arise from disruption to excess of acetylcholine induced by dopamine
the striatum (e.g. Table 2.7) than from disruption to antagonism in the nigrostriatal pathway. This is
motor cortex (e.g. hemiparesis following a stroke); why anticholinergic drugs are effective treatments
however, in both cases, the motor control signals (but not for akathisia, which has a different
descend via the pyramids. mechanism).
23
Table 2.7 summarizes the antipsychotic-induced EPSEs and Contraindications/cautions: severely reduced conscious-
treatment. See also Table 2.8. ness level (sedating), phaeochromocytoma, basal ganglia
Certain antipsychotics are available in a slow-release disorders (e.g. Parkinson disease or Lewy Body dementia
form as an intramuscular depot preparation that can be (can exacerbate)), arrhythmias (can prolong QTc, consider
administered every 1–12 weeks (e.g. flupentixol (Depixol), baseline electrocardiogram).
zuclopenthixol (Clopixol) and paliperidone). They are used
for patients who are poorly concordant with oral therapy or
who prefer the simplicity of an infrequent injection. Indications
• Schizophrenia, schizoaffective disorder, delusional
disorder
RED FLAG
• Prophylaxis in bipolar affective disorder
Clozapine is a very effective antipsychotic, but is • Depression or mania with psychotic features
only used in treatment-resistant schizophrenia, • Psychotic episodes secondary to a medical condition or
due to the life-threatening risk for bone marrow psychoactive substance use
suppression with agranulocytosis (0.8% of • Delirium
• Behavioural disturbance in dementia (caution is
patients). Patients should be registered with
recommended, as there is an increased risk for
a clozapine monitoring service and have a full
cerebrovascular events)
blood count (FBC) prior to starting treatment. • Severe agitation, anxiety and violent or impulsive
This is followed by weekly FBCs for several behaviour
weeks, followed by monthly FBCs for the duration • Tics (Tourette syndrome)
of treatment. With monitoring, fatalities from • Nausea and vomiting (e.g. prochlorperazine)
agranulocytosis are very rare (less than 1 in 5000 • Intractable hiccups and pruritus (e.g. chlorpromazine,
patients on clozapine). haloperidol)
Table 2.7 Antipsychotic-induced extrapyramidal side-effects and treatment

Extrapyramidal
side-effect Description Treatment
Parkinsonism Muscular rigidity, bradykinesia (lack of or Anticholinergics (e.g. procyclidine (i.v. or
slowing of movement), resting tremor i.m. if unable to swallow, oral otherwise))
Generally occurs within a month of starting Consider reducing dose of antipsychotic
antipsychotic or switching to antipsychotic with fewer
Dystonia Involuntary sustained muscular contractions or extrapyramidal side-effects (e.g. atypical)
spasms (e.g. neck (spasmodic torticollis), clenched
jaw (trismus), protruding tongue, eyes rolling upwards
(oculogyric crisis))
More common in young men
Usually occurs within 72 hours of treatment
Akathisia Subjective feeling of inner restlessness and Propranolol or short-term
muscular discomfort benzodiazepines
Occurs within days to weeks of starting an Consider reducing dose of antipsychotic
antipsychotic or switching to antipsychotic with fewer
extrapyramidal side-effects (e.g. atypical)
Tardive dyskinesia Rhythmic, involuntary movements of head, limbs No effective treatment
and trunk, especially chewing, grimacing and making Withdraw antipsychotic if possible
protruding, darting movements with the tongue Clozapine might be helpful
Develops in up to 20% of patients who receive long- Consider benzodiazepines
term treatment with conventional antipsychotics Do not give anticholinergics (may worsen
tardive dyskinesia)
Neuroleptic malignant syndrome – see Table 2.8
24
Anxiolytic and hypnotic drugs 2
Table 2.8 Distinguishing neuroleptic malignant syndrome from serotonin syndrome

Neuroleptic malignant syndrome Serotonin syndrome
Defining features Both conditions characterized by triad of neuromuscular abnormalities, altered consciousness
level and autonomic dysfunction (hyperthermia, sweating, tachycardia, unstable blood pressure)
Neuromuscular Reduced activity: severe rigidity Increased activity: myoclonus or clonus,
abnormalities (‘lead pipe’); stiff pharyngeal and thoracic hyperreflexia, tremor, muscular rigidity
muscles may lead to dysphagia and (less severe than neuroleptic malignant
dyspnoea; bradyreflexia syndrome)
Onset Insidious Acute
Medication history Usually occurs within 4–11 days of initiation Usually occurs after one or two doses of
or dose increase of dopamine antagonist new serotonergic medication; the most
(any antipsychotic, metoclopramide) common cause is concurrent SSRI and
MAOI
Typical blood results Elevated creatinine kinase, white cell count and hepatic transaminases; metabolic acidosis
General treatment for Discontinue offending drugs. Cool the patient. Monitor and manage hydration and
all patients haemodynamics (e.g. intravenous fluids). Consider intensive care for monitoring and/or
ventilation. Monitor for complications (e.g. pneumonia, renal failure). Use benzodiazepines for
sedation if agitated.
Specific treatment Bromocriptine (to reverse dopamine blockade) Cyproheptadine (5HT2A antagonist)
options to consider Dantrolene (to reduce muscle spasm)
(depending on Electroconvulsive therapy
severity of illness)
Mortality 20% untreated Low
MAOI, Monoamine oxidase inhibitor; SSRI, selective serotonin reuptake inhibitor.
ANXIOLYTIC AND HYPNOTIC because: (1) these drugs are not pharmacologically
DRUGS related; (2) the antipsychotics do far more than just
tranquillize; and (3) the effect and use of anxiolytics
A hypnotic drug is one that induces sleep. An anxiolytic is in no way minor.
drug is one that reduces anxiety. This differentiation is not
particularly helpful, as anxiolytic drugs can induce sleep
when given in higher doses, and hypnotics can have a calm-
ing effect when given in lower doses (e.g. the benzodiaz- History
epines, which are anxiolytic in low doses and hypnotic in
high doses). This is reflected in the term ‘sedative,’ which In the 1960s, the benzodiazepines replaced the
refers to both these effects and is generally used to refer to a often-abused barbiturates as the drugs of choice for the
drug with hypnotic and/or anxiolytic effects. All such drugs treatment of anxiety and insomnia. However, this initial
can result in tolerance, dependence and withdrawal symp- enthusiasm was tempered by the observations that they
toms. Furthermore, their effects, when used in combination were associated with serious dependence and withdrawal
or with alcohol, are additive. The most important drugs in syndromes and had gained a market as drugs of abuse.
this group are the benzodiazepines and ‘Z drugs’ (zopiclone, Z drugs were introduced in the 1990s and were initially
zolpidem and zaleplon), which have very similar actions thought to be less likely to cause dependence – this is
and indications. not true. Today, benzodiazepines and Z drugs are recog-
nized as highly effective and relatively safe drugs when
prescribed judiciously, for short periods and with good
patient education.
HINTS AND TIPS
Classification
In the past, the antipsychotics have been referred
to as the ‘major tranquillizers,’ and the anxiolytics From a clinical perspective, it is useful to group benzodiaze-
as the ‘minor tranquillizers’. This is misleading pines and Z drugs according to their duration of action and
route of administration. Table 2.9 summarizes these quali-
ties in some common drugs.
25
Table 2.9 Classification of the benzodiazepines and Z drugs

Dose equivalent to Time to peak Routes of
Drug 5 mg diazepam (mg) Duration of action effect Half-life (h) administration
Benzodiazepines
Midazolam 2.5 Short 5–10 min 2 Oromucosal
solution, s.c., i.v.
Temazepam 10 Short 2–3 h 11 Oral
Lorazepam 0.5 Short 1–4 h 15 Oral, i.m.a, i.v.
Nitrazepam 2.5 Medium 1–2 h 30 Oral
Chlordiazepoxide 15 Long 1–4 h 100 Oral
Diazepam 5 Long 5–10 h 100 Oral, per rectum,
i.v.; i.m. only if no
alternative
Z drugs
Zaleplon 5 Very short 1 h 1 Oral
Zolpidem 5 Short 1 h 2 Oral
Zopiclone 3.75 Short 2 h 5 Oral
a
Lorazepam is the only benzodiazepine that has predictable absorption when given intramuscularly.
Mechanism of action • Patients should be warned about the potential dangers

of driving or operating machinery due to drowsiness,
Benzodiazepines potentiate the action of GABA (γ- ataxia and reduced motor coordination
aminobutyric acid), the main inhibitory neurotransmitter in • Use with great caution in older adults where
the brain. They are GABAA-positive allosteric modulators: drowsiness, confusion and ataxia can precipitate falls or
they bind to specific benzodiazepine modulatory sites on delirium
the GABAA receptor complex, which results in an increased • Use with caution in patients with chronic respiratory
affinity of the complex for GABA, and so an increased flow disease (e.g. chronic obstructive pulmonary disease,
of chloride ions into the cell. This hyperpolarizes the post- sleep apnoea), as they may depress respiration
synaptic membrane and reduces neuronal excitability. Z
drugs are also GABAA-positive allosteric modulators, bind-
ing to a different but neighbouring site to benzodiazepines. RED FLAG
Benzodiazepines or Z drugs (zopiclone, zolpidem
Indications of benzodiazepines and zaleplon), are seldom fatal in overdose if taken
alone, but can be when taken in combination with
• Insomnia, especially short-acting benzodiazepines
other sedatives. Flumazenil is an antagonist at the
(short-term use only)
benzodiazepine site and can reverse the effects
• Anxiety disorders (short-term use only)
• Alcohol withdrawal, especially chlordiazepoxide of both benzodiazepines and Z drugs (which bind
• Acute mania or psychosis (sedation) close by).
• Akathisia – see Table 2.7.
• Other: epilepsy prophylaxis, seizures, muscle spasm
(diazepam) and anaesthetic premedication
RED FLAG
Indications of Z drugs Alcohol, opiates, barbiturates, tricyclic

antidepressants, antihistamines and other
• Insomnia (short-term use)
sedatives may all enhance the effects of
benzodiazepines and Z drugs; therefore moderate
Side-effects of benzodiazepines doses of benzodiazepines in combination with
and Z drugs some of these substances can result in respiratory
depression.
• Risk for developing dependence, especially with
prolonged use and shorter acting drugs
26
Electroconvulsive therapy 2
Other hypnotic and anxiolytic Indications

agents ECT is predominantly used for depression and can be par-
• Pregabalin is used to treat generalized anxiety ticularly effective in older adults. Although antidepressants
disorder. It is structurally related to GABA, but are usually tried first, ECT is considered for the following
does not act directly on receptors or enzymes that features of depression:
recognize GABA. Rather, it reduces the release of a • Life-threatening poor fluid intake
range of neurotransmitters through binding to an • Strong suicidal intent
auxiliary subunit of voltage-gated calcium channels. • Psychotic features or stupor
Gabapentin’s mechanism is very similar. • When antidepressants are ineffective or not tolerated
• Buspirone is a 5-HT1A receptor agonist that is used ECT is an effective treatment for severe mania (although
to treat generalized anxiety disorder. It is unrelated in rare cases it can precipitate a manic episode in patients with
to the benzodiazepines; does not have hypnotic, bipolar affective disorder). ECT is also an effective treatment
anticonvulsant or muscle relaxant properties; and is for certain types of schizophrenia: catatonic states, positive
not associated with dependence or abuse. Response psychotic symptoms and schizoaffective disorder. ECT is also
to treatment may take up to 2 weeks, unlike the used for puerperal psychosis (see Chapter 27) with prominent
benzodiazepines, which have an immediate anxiolytic mood symptoms or severe postnatal depression where a rapid
effect. improvement is necessary to reunite the mother with her baby.
• Sedating antihistamines (diphenhydramine (Nytol))
are available for insomnia without a prescription.
Unfortunately, their long duration of action may lead to
Administration and mechanism
drowsiness the following day. of action
ECT is administered 2–3 times per week. Most patients need
between 4 and 12 treatments. An anaesthetist administers a
short-acting induction agent and muscle relaxant that en-
OTHER DRUGS USED sure about 5 minutes of general anaesthesia. During this
IN PSYCHIATRY time, a psychiatrist applies two electrodes to the patient's
scalp, in a bilateral or unilateral placement, and delivers an
• Alcohol dependence: acamprosate, disulfiram electric current of sufficient charge to cause a generalized
• Opiate dependence: methadone, buprenorphine, seizure of at least 15 seconds in duration.
lofexidine, naltrexone It is still not clear how ECT works. It causes a release
• Dementia: cholinesterase inhibitors (donepezil, of neurotransmitters, as well as hypothalamic and pituitary
rivastigmine, galantamine), memantine hormones; it also affects neurotransmitter receptors and
• Attention deficit hyperactivity disorder: stimulants: second messenger systems, and results in a transient in-
methylphenidate, dexamfetamine; and nonstimulants: crease in blood-brain barrier permeability.
atomoxetine
Side-effects
The mortality rate associated with ECT is the same as that
ELECTROCONVULSIVE THERAPY for any minor surgical procedure under general anaesthe-
sia (i.e. around 1 in 100 000). Loss of memory is a com-
mon complaint, particularly for events surrounding the
History ECT. Some patients also report some impairment of auto-
The possibility that seizures could improve psychiatric biographical memory. Unfortunately, studies that exam-
symptoms arose from the observation that convulsions ap- ine the long-term effects of ECT are difficult to perform.
peared to lead to an improvement of psychotic symptoms Memory impairment can be reduced by unilateral electrode
in patients with comorbid epilepsy and schizophrenia. This placement (as opposed to bilateral).
led to seizures being induced pharmacologically with intra- Minor complaints such as confusion, headache, nau-
muscular camphor in the early 1930s. An electric stimulus sea and muscle pains are experienced by 80% of patients.
was later discovered to be an effective way of inducing sei- Anaesthetic complications (e.g. arrhythmias, aspiration)
zures. Modern-day anaesthetic induction agents and mus- can be reduced by good preoperative assessment. Prolonged
cle relaxants make electroconvulsive therapy (ECT) a highly seizures may occur, especially in patients who are on drugs
safe and nondistressing procedure. ECT is a highly effective that lower the seizure threshold (e.g. antidepressants and
and often life-saving treatment for patients with serious antipsychotics). In contrast, benzodiazepines increase the
mental illness. It is the most effective treatment known for seizure threshold, making it more difficult to induce a sei-
severe depression (with an effect size of 0.9). zure of adequate length.
27
Contraindications ETHICS
There are no absolute contraindications to ECT. Relative
contraindications include: Media portrayals of ECT have included its use as
a punishment, given without patient consent. In
• Heart disease (recent myocardial infarction, heart
modern practice, a patient with capacity will make
failure, ischaemic heart disease)
• Raised intracranial pressure his or her own decision about commencing ECT
• Risk for cerebral bleeding (hypertension, recent stroke) or not. A patient who lacks capacity may be given
• Poor anaesthetic risk. ECT without his or her consent if it is felt to be in
his or her best interests; however, this requires a
second opinion from an independent psychiatrist.
Chapter Summary
• Psychotropic medications are classed by the indication for which they were first licensed,
but many medications are of benefit in other disorders.
• Antidepressants influence the serotonin, noradrenaline and dopamine systems.
• Many antidepressants are well tolerated.
• Lithium requires regular monitoring of blood levels because high levels are toxic.
• Antipsychotics antagonize dopamine D2 receptors.
• Antipsychotics often have unpleasant and debilitating side-effects.
• Benzodiazepines and Z-drugs both increase the activity of GABAA receptors.
• Medications with shorter half-lives are more likely to cause discontinuation symptoms.
• Electroconvulsive therapy is a highly effective and safe treatment for severe mental
illness.
28
Psychological therapy
3
Psychological therapy describes the interaction between
a therapist and a client that aims to impart beneficial in the management of less severe psychological
changes in the client’s thoughts, feelings and behaviours. difficulties or as an adjunct to other forms of
Psychological therapy, which is often known as ‘psycho- treatment. Group-based peer support is a form
therapy’ or ‘talking therapy,’ may be useful in alleviating of self-help delivered to groups of patients with
specific symptoms (e.g. social phobia) or in helping a client shared symptoms, during which experiences can
improve their overall sense of well-being. be shared and progress reviewed by a facilitator.
Members of different professional disciplines, including
clinical psychologists, psychiatrists, occupational therapists,
mental health nurses, art and drama therapists and counsel-
lors, may all practise psychotherapy, provided they have had
adequate training and supervision.
HINTS AND TIPS
The single factor most commonly associated with

PSYCHOTHERAPEUTIC a good therapeutic outcome is the strength of the
client-therapist relationship (therapeutic alliance),
APPROACHES
regardless of the modality of therapy. In some
There are many different approaches to psychotherapy. cases, it may be beneficial to use a mixture of
Research has shown efficacy for many different types of psy- modalities (e.g. psychodynamic, interpersonal and
chotherapies for many conditions. This has led to the idea cognitive-behavioural therapy) uniquely tailored to
that the success of psychotherapy might be due to certain understanding and treating the patient (known as
common therapeutic factors, as opposed to specific theo- ‘eclectic therapy’).
ries or techniques. A comprehensive review of psychother-
apy research showed that common factors (occurring in any
model of therapy) account for 85% of the therapeutic ef-
fect, whereas theoretical orientation only accounts for 15%.
Therefore the use of a modality with which the patient can
Counselling and supportive
identify, and work may be more important than the theoret- psychotherapy
ical basis of the therapy itself. Common therapeutic factors Psychotherapy is sometimes distinguished from counsel-
include client factors (personal strengths, social supports), ling, although they exist on a continuum from counselling
therapist-client relationship factors (empathy, acceptance, and supportive psychotherapy (least complex) to psychody-
warmth) and the client’s expectancy of change. namic psychotherapy and sophisticated cognitive therapy
(more complex and requiring more specialist training).
Counselling is usually brief in duration and is recom-
HINTS AND TIPS mended for patients with minor mental health or inter-
personal difficulties, or for those experiencing stressful
‘Self-help’ is the umbrella term used to describe
life circumstances (e.g. grief counselling for bereavement).
the process of self-guided improvement. Often,
Counselling helps patients utilize their own strengths, with
self-help resources utilize psychological techniques the therapist being reflective and empathic. The provision
(especially cognitive-behavioural therapy) and of relevant information and advice, which is undertaken by
educational materials. Self-help may involve health care professionals of all specialties, is also considered
books, DVDs, interactive websites and discussion to be counselling.
groups (including Internet-based forums). Self-help In person-centred counselling, the therapist assumes
materials may be provided from, and progress an empathic and reflective role, allowing patients to dis-
followed and reviewed by, health care professionals cover their own insights using the basic principle that the
(known as ‘facilitated’ or ‘guided’ self-help), and client ultimately knows best. Problem-solving counselling
can be incredibly useful for some people, either is more directive and focused, as patients are actively as-
sisted in finding solutions to their problems. These types
of counselling may provide some benefit for patients with
29
mild anxiety and depression; however, they tend not to be patients are unaware), and to facilitate their understand-
as useful for more severe mental disorders. ing of unconscious processes in the context of a safe, car-
ing relationship. Historically, various methods have been
used (free association; hypnosis; interpretation of dreams
Psychodynamic psychotherapy and fantasy material; analysis of defence mechanisms –
Psychoanalysis and psychodynamic therapy have changed see Table 3.1). However, modern psychodynamic psycho-
substantially since Sigmund Freud introduced psychoan- therapy mainly relies on the analysis of transference and
alytic theory in the late 19th century. Fig. 3.1 summarizes counter-transference:
some of his ideas regarding personality. The contributions • Transference is the theoretical process by which
of many other influential theorists (e.g. Melanie Klein, Carl the patient (inappropriately and unconsciously)
Jung, Alfred Adler, John Bowlby, Donald Winnicott), along- transfers feelings or attitudes experienced in an earlier
side the introduction of evidence-based practice, has meant significant relationship onto the therapist (e.g. a male
the continued evolution of theory and technique. However, patient becomes angry with his therapist, whom he sees
the basic assumptions of psychoanalytic theory remain con- as cold and uncaring, unconsciously reminding him of
sistent: namely, that it is mainly unconscious thoughts, feel- his mother).
ings and fantasies that give rise to distressing symptoms, and • Counter-transference refers to the feelings that are
that these processes are kept unconscious by defence mecha- evoked in the therapist during the course of therapy.
nisms (which are employed when anxiety-producing aspects The therapist pays attention to these feelings, as they
of the self threaten to break through to the conscious mind, may be representative of what the patient is feeling,
potentially giving rise to intolerable feelings (Table 3.1)). and so help the therapist to empathize with the patient.
The essential aim of psychoanalysis or psychodynamic Often, therapists have undergone therapy themselves as
psychotherapy is to facilitate conscious recognition of part of their training – this helps them to separate out
symptom-causing unconscious processes. It is the thera- what feelings belong to them and what feelings belong
pist’s role to identify and interpret these processes (of which to the patient.
Ego (’the actual’):

Conscious In touch with reality. Mediates
between the demands of the Id,
SUPEREGO
Preconscious EGO the superego and external reality.
Unconscious
Id
Id (’the pleasurable’):
Governed by the pleasure
principle. Demands immediate
Superego (’the ideal’):
satisfaction. Primitive, instinctive,
Ethical and moral part that
animalistic, hedonistic.
sets rigid standards for
behaviour. Usually internalized
from the parents’ moral code and
gives rise to feelings of guilt.
Often referred to as
‘the conscience’.
Fig. 3.1 The ‘iceberg metaphor,’ summarizing some of Freud’s ideas of personality. The iceberg itself represents the
‘structural’ model of the mind, while the sea represents the ‘topographical model.’
30
Psychotherapeutic approaches 3
Table 3.1 Some examples of psychoanalytic defence mechanisms

Defence
Type mechanism Description Example
Pathological Denial Failure to acknowledge the existence A man who was badly assaulted
of an aspect of reality that is obvious reports that it did not happen.
to others.
Projection Attribution of unconscious feelings to A man who strongly dislikes his
others. neighbour states that his neighbour
hates him.
Splitting Rigid separation of two extremes. A woman is convinced that her boss is
an evil man after she was disciplined
at work.
Immature Fantasy Use of imagination to avoid A schoolboy thinks about killing a
acknowledging a difficult or distressing bully, rather than taking action to stop
reality. the bullying.
Somatization The transformation of negative A man stuck in an unhappy marriage
feelings towards others into physical develops medically unexplained back
symptoms. pain.
Neurotic Repression Blocking painful memories from An adult child who has no memory of
consciousness. being beaten by a beloved parent.
Reaction formation The switching of unacceptable A man who hates his job works extra
impulses into opposites. hard and performs incredibly well.
Intellectualization Concentrating on intellectual aspects A woman diagnosed with terminal
to avoid emotional aspects of a cancer develops an intense interest in
difficult situation. the classification process of tumour
staging.
Mature Humour Using comedy to avoid provoking A woman laughs and mocks herself
discomfort in self or others. after arriving at a formal dinner
dressed in casual clothes.
Sublimation Redirecting energy from unacceptable An angry man vigorously works out at
impulses into socially acceptable the gym.
activities.
Suppression Consciously avoiding thinking about A student cleans the kitchen while
disturbing problems. waiting on exam results.
• Although the terms psychoanalytic and psychodynamic minutes per session, during which time the patient
are often used interchangeably, they differ in the and therapist sit face-to-face. Duration of therapy
following ways: varies depending on the patient’s individual needs,
• Psychoanalysis describes the therapy where but it can range from a few months to several
clients see their analyst several times per week years. Psychodynamic psychotherapy may be
for a nonspecified period of time. Psychoanalysis conducted on an individual basis or in a group
is conducted with clients lying on a couch, with setting.
the analyst sitting behind them out of view. The
analyst may be quieter than in psychodynamic Due to the time- and resource-intensive nature (for both
therapy, and there is space for the patient to the health service and the patient) of classical psycho-
explore what comes into their mind and for the analysis, this is very seldom offered within the National
analyst to help the client understand how they Health System, with weekly psychodynamic therapy being
relate to the therapist (the transference) and to favoured. However, psychoanalysis is still practised within
others. the private sector.
• Psychodynamic psychotherapy is based on Mentalization-based therapy is one example of a therapy
psychoanalytical theory; however, it tends to be derived from psychodynamic psychotherapy and is summa-
more interactive and occurs once weekly for 50 rized in Table 3.4.
31
HINTS AND TIPS Cognitive-behavioural therapy

Attachment refers to the bond between an infant Cognitive-behavioural therapy (CBT) is based on the assump-
and their primary caregiver (see Chapter 30). How tion that the way in which individuals think about things (i.e.
a person was treated by their primary caregiver their cognitions) subsequently determines how they feel and
during their early years sets the tone for that behave. Likewise, physical or psychological feelings can influ-
ence the way in which an individual thinks and behaves.
person’s expectations of the rest of their life:
Automatic thoughts involuntarily enter an individual’s
how others are likely to behave towards them,
mind in response to specific situations (e.g. ‘He doesn’t like
and how they should behave in return. Disrupted me’; ‘I’m such an idiot’; ‘I’m so boring’). Dysfunctional assump-
attachment during early childhood often contributes tions are the faulty ‘rules’ that individuals live by that underlie
to problems with mood, anxiety and self-esteem in what automatic thoughts occur. When these rules are broken
adulthood, and attachment difficulties often emerge (as they inevitably are), the result is normally psychological
during psychological treatment (consciously or distress (e.g. ‘If I don’t come first, then I am completely
unconsciously). useless’; ‘If I hurt someone, then I am evil’). The rules them-
selves may be inherently problematic (e.g. ‘If I tell people how I
feel, this means I’m weak’). The patient is often encouraged to
keep a diary of automatic thoughts, and from this the patient’s
COMMUNICATION thinking styles (technically called ‘cognitive distortions’) can
be identified. Some examples are given in Table 3.3.
Transference and counter-transference are
unconscious processes that often occur in
settings outside psychodynamic psychotherapy. COMMUNICATION
Patients may inappropriately react to health care
One way of explaining the process of cognitive-
professionals as if they were some significant
behavioural therapy to patients is that it aims to
figure from the past. An example is when patients
help them notice and change ‘mental bad habits’
express unwarranted anger towards doctors
which we all have to a greater or lesser degree.
or nurses when they do not receive immediate
attention: this may be considered anger that was
initially experienced towards neglectful parents.
The process of therapy draws on the principle that auto-
Similarly, health workers may misplace feelings
matic thoughts and dysfunctional assumptions may be
from their own earlier relationships onto patients.
challenged (and changed) by behavioural experiments (test-
ing dysfunctional thoughts against reality).
Using an example, Fig. 3.2 illustrates the relationship
Behaviour therapy between thoughts, feelings and behaviours; how automatic
thoughts and dysfunctional assumptions may affect this re-
Behaviour therapy is concerned with changing maladaptive lationship; and how challenging these may result in change.
behaviour patterns that have arisen through learning (classi- CBT differs from psychodynamic psychotherapy in
cal or operant conditioning). The premise is that if a patient that: it is time-limited (12–24 sessions); it is goal-oriented
changes his or her behaviour to make it more adaptive, this will and predominantly focuses on present problems (less con-
have positive effects on how they think about things. Table 3.2 cerned with the details of how problems developed or un-
summarizes some of the techniques used in behaviour therapy. conscious factors); the therapeutic relationship is strongly
collaborative (deciding together on the session’s agenda and
case formulation); it involves patients doing ‘homework as-
COMMUNICATION
signments’. Also, due to its structured format, CBT is more
Avoidance increases anxiety. Many of the amenable to efficacy studies.
Some other forms of therapy that incorporate elements
behavioural techniques used to treat anxiety
of CBT are summarized in Table 3.4.
disorders involve systematic exposure to anxiety-
inducing thoughts or situations, supporting the
Interpersonal therapy
patient to realize that they can tolerate and, in
due course, reduce their fear. It can be helpful to Interpersonal therapy (IPT) is based on the assumption
explain to patients that they will have to experience that problems with interpersonal relationships and social
some anxiety in order to overcome it. functioning are significant contributors to the d evelopment
of mental illness, as well as being a consequence of men-
tal illness (particularly depression). IPT attempts to enable
32
Psychotherapeutic approaches 3
Table 3.2 Some techniques used in behaviour therapy

Behavioural
technique Clinical uses Description
Exposure Phobias and avoidance, Graded exposure: a hierarchy of increasingly threatening situations is
posttraumatic stress created (e.g. spider in another room → spider in the same room → spider
disorder near the patient → spider on the patient’s hand). Patient exposed to (or
imagines) the least threatening situation and stays in the situation until
their anxiety reduces towards normal levels. When anxiety relief has been
achieved, patients are then exposed to increasingly threatening situations.
Flooding: patient instantly exposed to the highest level of their anxiety
hierarchy until their anxiety diminishes, (e.g. throwing a patient with a fear
of water in the deep end of a swimming pool) (flooding by imagination is
termed implosion therapy).
Exposure Obsessive-compulsive Patients are encouraged to resist carrying out compulsions until the urge
with response disorder diminishes. They are then exposed to more severe compulsion-evoking
prevention situations.
Relaxation Anxiety Progressive relaxation of muscle groups; breathing exercises; visualizing
relaxing images and situations (guided imagery).
Modelling Phobias and avoidance Patients observe the therapist being exposed to the phobic stimulus,
then attempt the same.
Activity Depression Patients are encouraged to structure their day with certain activities, as
scheduling and reduced activity can lead to further lowering of mood, due to reduced
target setting stimulation and fewer opportunities for positive experiences.
Table 3.3 Some examples of types of cognitive distortion

Cognitive distortion Description Example
All-or-nothing thinking Evaluating experiences using extremes ‘If I don’t get this job, I’ll never work again.’
such as ‘amazing’ or ‘awful.’
Mind reading Assuming a negative response without ‘Because she didn’t reply to my text
relevant evidence. message, she hates me.’
Personalization Blaming self for an event. ‘It’s all my fault that the relationship ended.’
Overgeneralization Drawing negative conclusions on the ‘Because I spelt a word wrong in my essay,
basis of one event. I’ll get a lower grade.’
Fortune telling Assuming knowledge of the future ‘Now I’ve been told off by my boss, he is
going to be on my back forever.’
Emotional reasoning Confusing feelings with facts. ‘I feel so anxious: air travel must be dangerous.’
Labelling Using unhelpful labels to describe self. ‘I’m so horrible.’
Magnification Blowing things out of proportion. ‘I forgot to buy milk: my husband is going to
be so angry with me.’
atients to evaluate their social interactions and improve

p with participants attending one individual and one group
their interpersonal skills in all social roles, from close family therapy session each week. Clear, well-boundaried treat-
and friendships to community and work-related roles. One ment contracts are drawn up regarding missing sessions and
of the following areas is chosen as the main focus: (1) role self-harming. Patients need to be stabilized (not recently in
disputes; (2) role transitions; (3) interpersonal deficits; and crisis) before embarking on the treatment course. DBT can be
(4) loss or grief. IPT tends to focus on current problems and helpful in reducing self-harm and improving functioning in
is brief in duration (12–16 sessions). individuals with emotionally unstable personality disorders.
Dialectical behavioural therapy Motivational interviewing

Dialectical behaviour therapy (DBT) uses a combination of Motivational interviewing (MI) is commonly used to help
cognitive and behavioural therapies, with some relaxation people with substance dependence, but it can be applied to
techniques and mindfulness skills. It generally lasts for 2 years, help anyone change their behaviour (e.g. smoking c essation,
33
Situation: sitting an exam

Thoughts
• ‘I am going to fail’
• ‘If I don’t pass, I’m
completely useless
Physical symptoms Feelings

• Stomach churning • Anxiety
• Trembling hands • Unable to concentrate
Behaviour
• Underperforming
Cognitive behavioural therapy

to help challenge irrational
and unhelpful automatic
thoughts and dysfunctional
assumptions
Thoughts (more balanced)

• ‘I am going to try my best’
• ‘If I fail, it is not the end
of the world’.
Feelings
Physical symptoms
• Confident
• None
• Less anxious
Behaviour
• Performing well
Fig. 3.2 Cognitive-behavioural formulation and the process of therapeutic change.
weight loss). MI aims to strengthen the patient’s own motiva- to psychodynamic approaches. Most groups meet once weekly
tion and desire to change (making progress along the ‘Stages for an hour and consist of one or two therapists and about 5–10
of change’ model – see Fig. 20.3). It avoids being directive (tell- patients. Therapy can run from months (CBT orientation) to
ing the patient what to do), as that can provoke the opposite years (psychodynamic orientation). Group therapy allows pa-
reaction in someone who is ambivalent. Instead, the counsel- tients (and therapists) the opportunity to observe and analyse
lor takes a curious and collaborative stance, allowing the pa- their psychological and behavioural responses to other mem-
tient to voice in their own words what their reasons for change bers of the group in a ‘safe’ social setting. It is thought that group
might be, what the first steps should be and what they can do therapy owes its effectiveness to a number of ‘curative factors’
to overcome barriers to change. Key skills are asking open (e.g. universality, which describes the process of patients real-
questions, practising reflective listening and summarizing. izing that they are not alone in having particular problems).
Group therapy Family therapy

Group therapy may be practised according to different theo- Instead of focusing on the individual patient, this form of
retical orientations, from supportive to cognitive-behavioural therapy treats the family as a whole. It may include just
34
Indications for psychological therapy 3
Table 3.4 Some therapies derived from cognitive-behavioural therapy (CBT) and psychodynamic therapy
Therapy type Description
Eye movement At the same time as giving attention to difficult (usually traumatic) memories, the therapist
desensitization and encourages the patient to attend to another sensory stimulus (e.g. lights or beeps). Eye
reprocessing movements are no longer thought necessary to the therapy. Rather, the gradual exposure to the
memory in a relaxed environment seems important.
Mentalization-based Developed from psychodynamic therapy, this form of therapy focuses on allowing patients to
therapy better understand what is going on both in their own minds and in the minds of others. It can
utilize both individual and group components. It can involve asking ‘How does my outside
appear to other people’s insides?’
Cognitive analytic Cognitive analytic therapy aims to help the patient understand the problematic roles that they
therapy repeatedly find themselves and others in, and the (dysfunctional) ways they cope with this. The
aim is to increase the patient’s flexibility in ways of relating, and to find ‘exits’ from dysfunctional
patterns. The focus is on helping with present circumstances, while understanding from the
past how things have arisen.
Mindfulness-based Utilizes traditional CBT methods in conjunction with mindfulness and meditation. Mindfulness
cognitive therapy focuses on becoming aware of thoughts and feelings and accepting them, rather than reacting
to them.
arents and siblings or may also include extended family.

p
It is hoped that improved family communication and con-
INDICATIONS FOR
flict resolution will result in an improvement in the patient’s PSYCHOLOGICAL THERAPY
symptoms. Similar to group therapy, there are many differ-
ent orientations, most notably the psychodynamic, struc- The psychological treatment options for specific conditions
tural and systemic approaches. have been discussed in each of the relevant chapters on these
conditions. The main treatment options with the strongest
evidence bases, along with relevant cross-references, are
Therapeutic community summarized in Table 3.5.
(milieu therapy)
Therapeutic communities are cohesive residential commu-
nities that consist of a group of about 30 patients who are
resident for between 9 and 18 months. During this time,
residents are encouraged to take responsibility for them-
selves and others (e.g. by allowing them to be involved in
running the unit). These communities may be useful for
patients with personality disorders (especially borderline
personality disorder) and behavioural problems.
HINTS AND TIPS
Mindfulness is an increasingly common component

of a range of psychological therapies. It is also
something that many people in the general
population choose to explore. In essence,
mindfulness is keeping one’s attention on the
present moment. While trying to do this, it
is common for a lot of thoughts and feelings
unrelated to the present moment to come
into consciousness: mindfulness aims to
nonjudgmentally acknowledge these without
shifting attention onto them.
35
Table 3.5 Main indications for psychological treatments

Psychiatric condition Main psychological treatment used
Stressful life events, illness, bereavement Counselling
Depression Cognitive-behavioural therapy
Mindfulness-based cognitive therapy
Psychodynamic therapy
Group therapy
Anxiety disorders Cognitive-behavioural therapy
Mindfulness-based cognitive therapy
Exposure and response prevention (for obsessive-compulsive disorder)
Systematic desensitization (for phobias)
Posttraumatic stress disorder Cognitive-behavioural therapy
Eye movement desensitization and reprocessing
Schizophrenia Cognitive-behavioural therapy
Family therapy
Eating disorders Cognitive-behavioural therapy
Focused psychodynamic psychotherapy
Family therapy
Emotionally unstable personality disorder Dialectical behaviour therapy
Mentalization-based therapy
Psychodynamic therapy
Cognitive-behavioural therapy
Cognitive analytic therapy
Therapeutic communities
Alcohol dependence Cognitive-behavioural therapy
Group therapy
Motivational interviewing
Chapter Summary
• Psychological therapies are first-line treatments for mild to moderate mood disorders,
stress-related disorders, anxiety disorders, eating disorders and personality disorders.
• The therapeutic relationship is more important than the modality of psychological
treatment used.
• Self-help is often sufficient for milder problems.
• Counselling is unstructured, allowing the patient to generate their own solutions to
problems.
• Psychodynamic psychotherapy aims to facilitate conscious recognition of unconscious
processes causing problematic symptoms.
• Cognitive-behavioural therapy aims to help the patient identify and change the links
between how they think, feel, sense and behave.
36
Mental health and the law
4
A fundamental principle of medicine is that patients who
are capable of doing so are free to make decisions about HINTS AND TIPS
their treatment, even if those decisions seem imprudent, Note that the Mental Health Act 1983 does not
and this is no different in psychiatry. However, the very
regard dependence on alcohol or drugs alone as
nature of mental disorders can affect some patients’ ability
evidence of a mental disorder. However, mental
to make decisions regarding their care and treatment: in
these instances, decisions may need to be made without the disorders that arise secondary to substance
informed consent or agreement of the patient. Treatment intoxication or withdrawal (e.g. delirium tremens,
against patients’ wishes is usually only considered when the drug-induced psychosis) are covered by the MHA.
patient would otherwise be at significant risk to themselves
(through self-harm, suicide, self-neglect, exploitation) or
may place others at risk. Mental health legislation is there- Part II: Civil Sections
fore in place to protect patients and the public.
Differing legal systems within the UK mean that there Part II of the MHA relates to compulsory assessment and
are differences in mental health legislation across the home treatment, both in hospital and in the community. Table 4.2
nations. This book will focus on mental health legislation summarizes the most important sections in this part.
applicable in England and Wales. Normally, the process starts because concerns are raised
about an individual's mental health. Following assessment
by the appropriate professionals, the patient may be admit-
ted to hospital under Section 2 or 3 of the MHA.
MENTAL HEALTH ACT 1983 AS In an emergency, it may not be possible to arrange a re-
view for consideration of a Section 2 or 3. In these cases,
AMENDED BY THE MENTAL there are various options available, depending on circum-
HEALTH ACT 2007 stances. When any emergency measure is used to detain a
patient, this should be reviewed as soon as possible by the
In England and Wales, the Mental Health Act 1983 as appropriate professionals and compulsory measures either
amended by the Mental Health Act 2007 (MHA) provides revoked, or a Section 2 or 3 granted.
a legal framework for the care and treatment of individuals Under Section 135, an Approved Mental Health
with mental disorders. The MHA is divided into a number Professional (AMHP) may apply to a magistrate for a war-
of parts, each of which is divided into ‘Sections’ (groups of rant, which allows the police to enter private premises in
paragraphs). order to remove someone with a possible mental disorder
and take them to a ‘place of safety’ (usually a police station
or hospital) for further assessment. An amendment (2017)
Part I: Definitions also allows the mental health assessment to occur in the pri-
The term ‘mental disorder’ is defined as any disorder or vate premises if the occupiers consent. Section 136 applies
disability of the mind. However, the Learning Disability when a police officer has concerns about an individual’s
Qualification states that a person with a learning disability mental health in a place that is not the person’s dwelling.
(intellectual disability) alone can only be detained for treat- However, the police officer need not apply for a warrant.
ment or be made subject to Guardianship if that learning dis- Patients admitted to hospital on an involuntary basis are
ability (intellectual disability) is associated with abnormally informed of their detention and their rights. They may ap-
aggressive or seriously irresponsible conduct. ply to have their case reviewed by a Mental Health Review
The Appropriate Medical Treatment test stipulates Tribunal or by the Mental Health Act Manager within the
that for long-term powers of compulsion (i.e. longer than hospital, both of whom have the power to remove the deten-
28 days) it is not possible for patients to be compulsorily de- tion. Patients may also be discharged from their detention
tained or treated unless ‘medical treatment’ is available and by the Responsible Clinician (RC) or by their nearest rela-
appropriate. Medical treatment includes not only medica- tive (unless the right to do this is blocked by the RC).
tion but also psychological treatment, nursing and specialist For patients liable to be detained under Section 3, it may
mental health habilitation and rehabilitation. be appropriate to consider the use of a Community Treatment
Certain officials and bodies are designated to carry out Order (CTO) under Section 17 of the MHA. This can be use-
specific duties related to implementation of the MHA. Some ful when treatment in the community is an option (i.e. when
of these are summarized in Table 4.1. the associated risks of the mental disorder do not necessitate
37
Table 4.1 Mental Health Act officials

Official or body Description
Approved Mental A mental health professional (nurse, social worker, occupational therapist, clinical
Health Professional psychologist) with specialist training in mental health assessment and legislation, approved
(AMHP) by the local authority. Duties of an AMHP include assessing patients, and (if appropriate)
making an application for Mental Health Act 2007 (MHA) detention.
Section 12 approved A doctor approved under Section 12 of the Mental Health Act (MHA) as having expertise in
doctor the diagnosis and treatment of mental disorders. Section 12 doctors are responsible for the
assessment of patients and for recommending MHA detention if appropriate.
Approved Clinician A health care professional (usually a doctor, but can also be a nurse, social worker,
(AC) and Responsible occupational therapist, clinical psychologist) who has received specialist training and is
Clinician (RC) responsible for the treatment of individuals with mental disorders detained under the MHA.
An AC in charge of the care of a specific patient is known as Responsible Clinician (RC) for
that patient. Their responsibility is to oversee the care and treatment of a patient detained
under the MHA and to remain responsible for administrative duties of the MHA pertinent to
the patient.
Second Opinion Appointed by the Care Quality Commission (CQC – see later), the role of the SOAD is to
Approved Doctor provide an independent second medical opinion regarding treatment in patients subject to
(SOAD) prolonged compulsory treatment who are unable to consent to their treatment, or when a
patient refuses electroconvulsive therapy (ECT; not applicable in emergency situations, see
‘Consent to Treatment’).
Nearest Relative (NR) The spouse, child, parent, sibling or other relative of a patient detained under the MHA.
This sometimes varies from ‘next of kin.’ It is the duty of the AMHP to appoint the nearest
relative, although this decision can be appealed in court. AMHPs have a duty to inform
the NR of the application for MHA detention. NRs can – in some instances – apply for the
patient to be discharged from compulsory measures.
Independent Mental Advocacy is a process of supporting and enabling people to express their views and
Health Advocates concerns, access information and services, defend and promote their rights and
(IMHA) responsibilities, and explore choices and options. Most patients detained under the MHA
have the right to access an independent mental health advocate.
Care Quality An independent health and social care regulatory body that oversees the use of the MHA
Commission and ensures standards are maintained. All NHS and social care providers involved with the
care of patients detained under the MHA must be registered with the CQC.
Mental Health Tribunal MHTs hear appeals against detention under the MHA. Their members include a lawyer, a
(MHT) doctor and a layperson. MHTs have the authority to discharge patients from compulsory
measures when they determine that the conditions for detention are not met.
Mental Health Act Represent the hospital responsible for a detained patient. Hospital managers will hear
Managers (‘hospital appeals from patients against their detention and review renewals of lengthy detentions.
managers’) Cases are heard in similar settings to those heard by MHRTs, and Mental Health Act
Managers have the authority to discharge patients.
ngoing hospital admission). Conditions such as attending ap-

o
pointments may be enforced. However, specific treatment can- HINTS AND TIPS
not be forcibly given. A CTO allows the Responsible Clinician
Section 5(2) – doctor’s holding power – may be
to recall the patient to hospital should the patient become non-
concordant with treatment or should they become unwell. enacted by any hospital doctor provided they
are either the responsible clinician or another
doctor nominated by them (e.g. a specialist
HINTS AND TIPS
registrar or senior house officer). This means
Note that the term ‘informal’ applies to hospital that a psychiatrist need not see suspected
patients who not are detained under the Mental mentally ill patients on a medical or surgical
Health Act 2007 (i.e. patients who have agreed to ward before they can be detained under this
voluntary admission). Section.
38
Mental Health (Care & Treatment) (Scotland) Act 2003 4
Table 4.2 Civil sections enabling compulsory admission

Section Aim Duration Application
Section 35 To prepare a report on the mental 28 days, with Crown or Magistrates’ Court, on
Remand to hospital condition of an individual who is option to extend evidence of one doctor, who must
for report on charged with an offence that could to 12 weeks be Section 12 approved
mental condition lead to imprisonment
Section 36 To treat an individual who is charged 28 days, with Crown Court, on evidence of two
Remand to hospital with an offence that could lead to option to extend medical doctors (one of whom
for treatment imprisonment to 12 weeks must be Section 12 approved)
Section 37 Detention and treatment of Initially 6 months, Crown or Magistrates’ Court, on
Hospital order an individual convicted of an with option to evidence of two medical doctors
imprisonable offence (similar to extend (one of whom must be Section 12
Section 3) approved)
Section 41 Leave and discharge of Section 37 As for Section 37 Crown Court only, on evidence of
Restriction order patients may only be granted with one medical doctor (who must be
approval of the Home Office (recorded Section 12 approved)
as 37/41) – applied to serious
persistent offenders
Part III: Forensic Sections In circumstances where urgent treatment is required to save
the patient's life or to prevent serious suffering or deteri-
Part III of the MHA incorporates Sections 35–55 and relates oration, it may be appropriate to use Section 62 to waive
to mentally ill patients involved in criminal proceedings or the second opinion requirements of Sections 57 and 58 (e.g.
under sentence. Table 4.3 summarizes the most important emergency ECT for a patient who is not eating or drink-
sections in this part. It should be noted that patients who ing). Section 62 is only used until a second opinion can be
are detained under certain forensic Sections and who are obtained.
not ‘restricted’ patients (see Table. 4.3) can be considered
for supervised community treatment (CTO) if appropriate.
MENTAL HEALTH (CARE &

Part IV: Consent to treatment
TREATMENT) (SCOTLAND)
This part of the MHA clarifies the extent to which treat- ACT 2003
ments can be imposed on patients subject to compulsory
measures. Patients detained under Section 3 or 37 (long- Compulsory measures in Scotland are legislated for by the
term treatment orders) may be treated with standard psy- Mental Health (Care & Treatment) (Scotland) Act 2003.
chiatric medication for 3 months with or without their They can be used when a patient is suffering (or thought to
consent. However, after 3 months and in other special cases, be suffering) from a mental disorder (mental illness, intel-
an extra Section from a Second Opinion Approved Doctor lectual disability, personality disorder), by virtue of which
(SOAD) is required for treatment. Such cases include: the individual’s ability to make decisions about treatment of
• Psychosurgery and surgical implants of hormones to their mental disorder is significantly impaired, when treat-
reduce sex drive: these require the informed consent ment for the mental disorder (including medication, nurs-
of a patient with capacity to make such a decision, as ing and psychosocial care) is available, and if there would
well as the approval of a SOAD, under Section 57 of the be considerable risk to the health, safety or welfare of the
MHA. Neither of these procedures can be carried out on individual, or to the safety of others, without treatment. The
a patient who lacks capacity to make these decisions. use of compulsory powers must be considered necessary
• Administration of medical treatment in a patient and lesser restrictive options must be deemed inappropri-
who cannot provide, or refuses to provide, informed ate. The use of the Act is overseen by the Mental Welfare
consent: this requires the approval of a SOAD, under Commission for Scotland. Under civil law, the following
Section 58 of the MHA. orders are frequently used:
• ECT: if the patient is ‘capable of understanding the
nature, purpose and likely effects of the treatment’
then electroconvulsive therapy (ECT) cannot be given
Emergency Detention Certificate
without his consent. If the patient lacks capacity, then An Emergency Detention Certificate (EDC) allows an in-
ECT must be certified as ‘appropriate’ by a SOAD, dividual with a mental disorder (or suspected mental dis-
under Section 58A of the MHA. order) to be detained in hospital for up to 72 hours, where
39
Table 4.3 Forensic sections

Section Aim Duration Application Recommendation
Section 2 Compulsory detention for assessment. 28 days Approved Two doctors (at least
Admission for Used when diagnosis and response Mental one of whom must be
assessment to treatment are unknown. May be Health Section 12 approved)
converted to a Section 3 if longer Professional
admission needed. Medication may be (AMHP)
given as part of the assessment process.
Section 3 Compulsory detention for treatment. Used 6 months AMHP Two doctors (at least
Admission for when diagnosis and treatment response one of whom must be
treatment is established. May be extended. Section 12 approved)
Section 4 Emergency admission to hospital for 72 h AMHP One doctor, with full
Emergency assessment when there is no time to GMC registration
admission for wait for Section 2 procedures in the (usually FY2 or above)
assessment community
Section 5(2) Detention of a hospital inpatient receiving 72 h – Doctor responsible for
Doctor’s any form of treatment (not necessarily patient’s care or other
holding power psychiatric) in order to give time to nominated doctor (with
arrange review for a Section 2 or 3 full GMC registration;
usually FY2 or above)
Section 5(4) Urgent detention of an inpatient receiving 6 h - Registered Mental
Nurse’s holding treatment for a mental disorder, to allow Health Nurse
power for review by doctor
Section 17 Allows for supervised treatment in the 6 months Responsible AMHP and RC
Community community in patients liable to detention Clinician (RC)
Treatment Order under Section 3: stipulates that patient
must attend appointments. May be
recalled to hospital if nonconcordant with
treatment or if they become unwell.
Section 135 Allows police to enter private premises 72 h AMHP Magistrate
to remove someone with a suspected
or known mental disorder to a place of
safety for further assessment or to allow
an assessment to occur in the private
premises if the occupiers agree.
Section 136 Allows a police officer to remove 24 h – Police officer (following
someone with a suspected or known consultation with
mental disorder from a place that is not a mental health
their dwelling to a place of safety in their professional if
best interests or for the protection of practicable)
others. If the person is already in a place
of safety, a police officer can keep them
there or transfer them to another place of
safety.
hospital admission is required urgently for assessment and Mental Health (Care & Treatment, Scotland, Act 2003) and
when application for a Short-Term Detention Certificate should either be revoked or converted to an STDC.
(STDC) would cause undesirable delay. Any doctor (with
full GMC registration) can implement an EDC. Wherever
possible, the agreement of a mental health officer (MHO –
Short-term detention certificate
usually a social worker specially trained in mental health) An STDC allows an individual with a mental disorder (or
should also be obtained. Patients may not be treated against suspected mental disorder) to be detained in hospital for up
their will under an EDC, but emergency treatment is pos- to 28 days. It can only be applied by an Approved Medical
sible under common law. It should be reviewed as soon as Practitioner in agreement with a MHO. Patients may be
practical by an Approved Medical Practitioner; a psychi- given treatment for their mental disorder under an STDC.
atrist with special training and approval in the use of the Patients have the right to appeal the STDC at any time, with
40
Capacity to consent to treatment 4
their appeal being heard at a tribunal. The STDC may be be examined by a consultant psychiatrist within 48
revoked or an application for a CTO may be made. hours of admission and during the second 7 days of the
assessment period.
Compulsory treatment order The Mental Capacity Act (Northern Ireland, 2016) is due to
come into force in 2020. This new legislation will supersede
A CTO usually follows an STDC. An MHO applies to the the 1986 Mental Health Order. Innovatively, it combines
Mental Health Tribunal for Scotland, asking them to con- legislation regarding treatment for mental health problems
sider granting a CTO. This requires two written medical with treatment for those who lack capacity for any reason.
reports, usually completed by the Responsible Medical
Officer (the Approved Medical Practitioner responsible for
the care of the patient) and the patient’s general practitioner
(GP). It also requires a proposed care plan, detailing medi- CAPACITY TO CONSENT TO
cal treatment that would be provided if the CTO is granted. TREATMENT
The tribunal consists of a lawyer, a doctor and a layperson.
They decide whether the application is appropriate before Mental capacity is defined by the Mental Capacity Act 2005
granting the CTO, refusing the CTO, or suggesting an in- (MCA) as the ability of an individual to make their own de-
terim order while further information is gathered. A CTO cisions. An individual (aged 16 years or older) has the ca-
lasts for 6 months initially; however, applications can be pacity to make a specific decision if they can:
made to the Mental Health Tribunal to extend this. Patients • communicate their decision,
have the right of appeal. CTOs can be used to treat patients • understand information given to them to make a
in the community as well as in hospital. particular decision,
• retain that information, and
• balance or weigh up the information to make the
decision.
MENTAL HEALTH (NORTHERN
IRELAND) ORDER 1986
HINTS AND TIPS
The Mental Health (Northern Ireland) Order 1986 is simi-
lar to the Mental Health Act of England and Wales, although Capacity assessment can be remembered
there are some noteworthy differences: by almost the same acronym as the common
pneumonia severity assessment: ‘CURB’
• Unlike other UK mental health legislation, the order
defines mental illness: ‘Mental illness’ means ‘a state (Communicate, Understand, Retain, Balance).
of mind which affects a person’s thinking, perceiving,
emotion or judgement to the extent that he requires
care or medical treatment in his own interests or the If an individual is unable to do one or more of the above,
interest of other persons’. they lack the capacity to make the particular decision in
• The various paragraphs are referred to as Articles, not question.
Sections. It should be noted that ‘capacity’ is not a blanket term
• The order does not allow for the detention of and it should be considered according to the decision to
individuals with a personality disorder (or sexual be made. For example, a woman with a moderate intel-
deviancy or dependence on alcohol or drugs), although lectual disability may have the capacity to decide to buy
individuals may be detained when a personality music by her favourite singer. However, she may lack the
disorder coexists with mental illness or severe mental capacity to make a decision to take out a mortgage to buy
impairment. a house.
• There is only one procedure for admission to hospital: Under the MCA, an individual:
all patients compulsorily admitted to hospital will be
• Must be assumed to have capacity until it is established
held for a period of assessment lasting up to 14 days.
that they lack capacity
Following this, they may be detained under Article
• Should not be treated as incapable until all practical
12, which allows detention for treatment for up to
steps to help them have been taken without success
6 months beginning with the date of admission. The
• Must not be treated as incapable merely on the basis of
application for assessment is made either by the nearest
wishing to make an unwise decision
relative or, more commonly, by an approved social
worker. This application is founded upon a medical Any act done or decision made under the MCA:
recommendation, which must be made by a registered • Must be in the best interests of the individual
medical practitioner, usually the person’s GP. The order • Must be undertaken in a manner that is least restrictive
stipulates that a patient admitted for assessment should to the individual’s rights
41
they were to become incapable of making decisions on these

ETHICS matters in the future. The individual must be over the age
A patient should by default be assumed to have
of 18 years and must have capacity to make the statement.
The Advance Decision can become valid when the individ-
capacity unless it has been demonstrated they do
ual loses capacity to consent to (or refuse) treatment in the
not. Making an unwise decision does not by itself
future. Advance Decisions are legally enforceable under the
demonstrate incapacity. MCA in England and Wales.
In Scotland and Northern Ireland, the equivalent of
an Advance Decision is called an ‘Advance Directive’.
The framework used to assess mental capacity in Scotland Respecting the advance refusal of a competent adult is also
is the Adults with Incapacity (Scotland) Act 2000 and in a requirement of Articles 5 and 8 of the Human Rights Act
Northern Ireland, the Mental Capacity Act (Northern 1998. A principle underlying decision-making on behalf
Ireland) 2016. of all those without capacity is that the previously known
With regard to medical treatment, clinicians should pro- wishes of the individual should be taken into consideration,
vide patients with a clear explanation of the nature and likely whether or not they are written down.
benefits of a treatment as well as its potential risks and side
effects. An adult who has capacity has the right to refuse Proxy decision-making
treatment, even if this refusal results in death or serious dis-
ability. When patients refuse essential treatment, clinicians A Power of Attorney is a legal document that enables an in-
should ascertain whether they have the capacity to consent dividual (who has capacity and is over the age of 18 years)
to treatment and have made a free decision without coercion. to nominate another person (‘Attorney’) to make decisions
When making decisions about capacity, you should not on their behalf in the event that they become incapable of
hesitate to discuss the case with colleagues, or even a med- doing so in the future. The type of decisions may be specified
icolegal defence organization. The process of assessment and may include health care, welfare and financial matters.
should be clearly and comprehensively documented in the If the individual lacks capacity and has not made a Power of
medical notes. Attorney, it is possible for the courts to appoint these powers
to individuals. Laws regarding Power of Attorney vary be-
tween England and Wales, Scotland and Northern Ireland.
RED FLAG
An adult who has capacity has the right to refuse ETHICS
treatment, even if this refusal results in death or
serious disability. In such cases it is important to Having a serious mental illness does not preclude
document carefully the assessment of capacity a patient from having the capacity to consent to
and to discuss with senior colleagues. physical treatment, as long as their illness does
not interfere with their understanding of relevant
information and the decision-making process.
Deprivation of liberty safeguards

The ‘deprivation of liberty safeguards’ is an amendment to the
Mental Capacity Act (2005), which applies only in England
and Wales. These safeguards do not apply to someone de- COMMON PITFALLS
tained under the Mental Health Act. If a person who lacks The Mental Health Acts make provision for the
capacity in a care home or hospital needs to have their lib-
compulsory treatment of mental disorders only, not
erty restricted (i.e. they are not free to leave or are subject to
for the compulsory treatment of physical disorders.
continuous supervision and control), then an application to
the local authority needs to be made for a ‘standard authori- Therefore a patient can never be detained under
zation.’ Issuing such an authorization ensures that safeguards the Mental Health Act 2007 to treat a physical
for the patient are in place (including appointing a patient’s disorder, and patients can refuse physical
representative, the right of appeal and access to advocacy). treatment unless they are assessed as lacking
capacity. Patients who require urgent physical
Advance Decisions treatment, but who do not have capacity, may
be treated without their consent (but in their best
An Advance Decision (or ‘living will’) is a statement of an interests) under the Mental Capacity Act 2005.
individual’s wishes regarding the health care and medical
treatment they would wish to have (or not wish to have), if
42
Human rights legislation 4
(ECHR) in 1953. These are considered to be international

COMMON LAW law. The UK has introduced its own statute law, the Human
Rights Act 1998 (HRA).
Common law refers to law that is based on previous court
There are some fundamental incompatibilities be-
decisions (case law), rather than laws made in Parliament
tween the Human Rights Act 1998 and mental health
(statute law). The Mental Health Act is an example of
legislation. The Mental Health Act 2007 has gone some
statutory law, whereas providing immediate life-saving
way to address these. However, it is still important to
treatment to an unconscious patient (unable to consent)
be aware of some important aspects of human rights
is justified under common law. The common law doctrine
legislation and to interpret mental health legislation in
of necessity allows for treatment in emergency situations
a way compatible with the Human Rights Act as far as
of physical or mental disorders in adults who are unable
possible.
to consent. Treatment must be in the best interests of the
Article 3 of the ECHR states that ‘no one shall be sub-
individual and must be necessary to sustain life, to prevent
jected to torture or to inhuman or degrading treatment
serious deterioration or to alleviate severe pain or suffering.
or punishment.’ This is an absolute right and is always
The doctrine of necessity is applicable only in emergency
applicable. When a patient is in hospital (whether de-
situations, and – if necessary – treatment should be contin-
tained or not), practices that could be considered to be
ued under statute law (e.g. MHA, MCA) as soon as practi-
‘inhuman or degrading’ may include the use of excessive
cally possible.
force during restraint, maintaining high levels of seda-
Many doctors and nurses who are not familiar with
tion to compensate for staff shortages, a lack of privacy
mental health legislation are often concerned about in-
or adequate sanitation, or treatment without consent in
fringing patients’ rights and may not act at all (e.g. a
cases where it is not medically necessary (under common
man with a life-threatening alcohol withdrawal delirium
law or under the MHA). Public authorities have a duty
is allowed to leave the ward with no one attempting to
under the HRA to protect the human rights of patients
stop him). When considering an action under common
in their care.
law, always ask yourself whether your actions would be
Article 8 of the ECHR protects the right to respect
defensible in court. Your actions should be consistent
for private and family life, home and correspondence. It
with what most individuals with your level of training
also sets out, in general terms, circumstances when an
would do in the same situation. Choosing not to act
interference (also known as a restriction) with this right
when you should is indefensible and would be construed
is acceptable. However, interference must be lawful, nec-
as negligent.
essary and proportionate. Under mental health legisla-
tion, seclusion (keeping and supervising a patient alone
in a room that may be locked) can occasionally be used.
COMMON PITFALLS However, if this is not justified as being lawful, necessary
and proportionate, it may be a violation of the human
It is permissible under common law to restrain and rights of the patient.
medicate patients who are mentally disordered and Article 5 of the ECHR protects the right to liberty.
who present an imminent danger to themselves However, it also sets out specific circumstances in which
or others. However, it is not legal to impose this can be limited. Inappropriate use of the MHA (includ-
psychiatric medication repeatedly on informal ing undue delays in tribunal or appeal processes) can result
patients. Anyone who has required emergency in an unlawful restriction of liberty, which may be in viola-
tion of Article 5 of the ECHR.
restraint and treatment under common law should
There are also instances when failure to use mental
be promptly assessed by a senior doctor for
health legislation appropriately may be considered to be in
treatment under the appropriate Section of the violation of an individual's human rights. Article 2 of the
Mental Health Act. ECHR is an absolute right to life, and professionals or au-
thorities who fail to protect life may be considered to be
in violation of the law (e.g. failing to detain a severely de-
pressed and suicidal patient who later committed suicide
was considered by the UK Supreme Court to be a violation
HUMAN RIGHTS LEGISLATION of Article 2 of the ECHR).
The interface between mental health legislation and
Human rights are commonly understood as ‘inalienable human rights legislation is incredibly complex and beyond
fundamental rights to which a person is inherently entitled the scope of this book to discuss in detail. However, it is
simply because she or he is a human being.’ The Universal important to be mindful of human rights law and these
Declaration of Human Rights was established in 1948 and potential difficulties and to seek advice from an expert if
subsequently the European Convention on Human Rights in doubt.
43
FITNESS TO DRIVE • It is the driver’s responsibility to inform the DVLA

of any condition that may impair his/her driving
Driving is a complex skill requiring good sensory abilities ability.
(vision, hearing), good motor control (power, coordination, • A patient with a condition requiring notification
reaction time), good memory and good executive function should not drive until they hear back from the DVLA
(attention and concentration, judgement, planning and and must not drive during an acute illness.
organization, ability to self-monitor). It follows that many • It is the doctor’s responsibility to advise patients
mental illnesses and psychiatric medications can impair fit- to inform the DVLA of any condition that may
ness to drive. Clinicians should be aware of the following interfere with their driving (e.g. psychotic episode,
legal provisions: manic episode, dementia). Table 4.4. Doctors may
• It is the responsibility of the Driver and Vehicle be contacted by the DVLA for further clinical
Licensing Agency (DVLA) to make the decision as to information or may be invited to prepare a medical
whether an individual is fit to continue driving. report.
Table 4.4 Common mental health conditions about which the DVLA should be notified
Condition Likely licensing outcomea
Anxiety or depression, mild-moderate (without Can continue to drive, no notification required
suicidal thoughts, agitation or significant memory or
concentration problems)
Depression or anxiety, severe (causing significant Licence revoked until a period of stability has been achieved
memory or concentration problems, agitation or (typically 3 months)
suicidal thoughts)
Acute psychotic episode Licence revoked until stable with good insight for 3 months
Hypomania or mania Licence revoked until stable with good insight for 3 months
Schizophrenia Must not drive during acute illness. After 3 months of stability,
licensing can be considered even if continuing symptoms, as
long as these are unlikely to affect concentration, memory or
cause distraction while at wheel.
Neurodevelopmental disorders (e.g. ADHD) May be able to drive but must notify DVLA
Dementia May be able to drive but must notify DVLA. Early dementia
may be licensed with annual review. Impairment in short-term
memory, disorientation or lack of insight suggests unfit to
drive.
Learning disability Mild: may be able to drive but must notify DVLA (a driving
assessment may be required). Moderate–severe: should not
drive.
Personality disorders with severe behavioural May be able to drive but must notify DVLA.
disturbance
Persistent harmful use of alcohol or alcohol Licence revoked until a minimum of 6 months or 1 year free
dependence of alcohol problems (depending on severity of use).
Persistent harmful use of substances or dependence Licence revoked until a minimum of 6 months or 1 year
free of substance use, depending on substance. If multiple
substances used, unlikely to be licensed. Methadone or
buprenorphine use can be compatible with driving.
Any other psychiatric condition that impairs Case specific, likely that a period of stability required.
concentration or awareness, increases distractibility
or in any other way is likely to affect safe driving of the
vehicle
a
Note, although the DVLA provides examples of likely outcomes, each case is assessed individually and may differ from the above. The
licensing outcome is not decided by the doctor treating the patient, but by DVLA medical advisors. Standards are much stricter for those
with licences to drive buses or lorries. DVLA, Driver and Vehicle Licencing Agency.
44
Fitness to drive 4
• Medications that can influence safety to drive

are those that impair alertness, concentration or ETHICS
coordination. Many medications used in psychiatry
In order to protect the public, doctors have a duty
are sedating (e.g. tricyclic antidepressants) and/or can
to break confidentiality and inform the Driver and
affect motor control (e.g. antipsychotics) and patients
should be advised not to drive immediately after Vehicle Licencing Agency if they become aware
starting or increasing the dose of such a medication. that a patient is continuing to drive or is likely to
Those who are not adversely affected can continue to continue to drive, against medical advice.
drive. This is particularly important for professional
drivers.
• Doctors have a duty to breach confidentiality
considerations and contact the DVLA medical
advisor themselves if patients fail to take this advice
and the potential impairment is serious. The same
applies to patients who, due to their illness (e.g.
dementia, psychosis), are unable or unlikely, to contact
the DVLA.
Chapter Summary
• Patients who have capacity are free to make good or bad decisions about their health
care.
• Patients who lack capacity may need decisions to be made for them in their best interests.
Legislation exists to ensure this is done only when necessary and in a way that protects
patients’ rights.
• Mental health legislation in the UK allows people with significantly impaired decision-
making ability to be detained in hospital for assessment and to be given treatment for a
mental disorder against their will.
• Mental capacity legislation in the UK allows people who lack capacity to be given
treatment for physical disorders and to be accommodated against their will.
• Common law allows immediate treatment to be given to people who cannot consent in
emergency situations in order to prevent serious deterioration, severe pain or death.
• Severe mental health problems often impair driving and require the Driver and Vehicle
Licencing Agency to be notified; a licence is often returned after a period of stability.
45
Mental health service provision
5
Some patients will continue to receive intervention at a pri-
HISTORY mary care level and others will require secondary care. The
following box lists the common reasons for referral from
Until the 18th century, the mentally ill in the UK received
primary to secondary mental health care.
no formal psychiatric care and those who were not looked
after by their families were kept in workhouses and private
institutions. In 1845, the Lunatics Act led to the building
REASONS FOR REFERRAL TO SECONDARY
of an asylum in every county so that those patients with
MENTAL HEALTH SERVICES
severe mental illness could be cared for in large remote
asylum communities. Since the introduction in the 1950s • Moderate to severe mental illness (e.g.
of chlorpromazine, the first effective medication for schizo- schizophrenia, bipolar affective disorder, severe
phrenia, there has been a significant decline in the number
depression or anxiety disorder)
of patients in psychiatric hospitals. The attempts to reduce
• Patients who pose a serious risk for harm to
the cost of inpatient care, as well as the criticism levelled at
asylums regarding the ‘institutionalization’ of patients and self, others or property
the loss of patient autonomy, led to the closure of the large • Uncertainty regarding diagnosis
asylums and the rise of community care. Today, most men- • Poor response to standard treatment, despite
tally ill patients are assessed and managed in the commu- adequate dose and concordance
nity and hospital admission, when indicated, is usually only • Specialist treatment required (e.g. psychological
brief in duration. therapy, specialist medication regimens)
PRIMARY CARE
Up to 95% of mental illness is seen and managed exclusively SECONDARY CARE
in primary care by general practitioners (GPs), with mild
to moderate mood and anxiety disorders and alcohol mis- Community mental health teams
use being the most common conditions. Depression, which
In the UK, specialist psychiatric care in the community is
is the most common mental illness treated, is frequently
mostly coordinated by regional community mental health
associated with symptoms of anxiety as well as physical
teams (CMHTs), which consist of a multidisciplinary team
complaints.
of psychiatrists, CPNs, social workers, psychologists, occu-
It is important to note that up to half of all mentally
pational therapists and support workers. Team members
ill patients go undetected in primary care. This is because
usually operate from a base that is easily accessible to the
many of these patients present with physical, rather than
community they serve, although local GP surgeries are also
psychological, symptoms. Also, some patients are reluctant
used to see patients. Patients who are unable to come to the
to discuss emotional issues with their doctor, due to feel-
CMHT location are often seen at home.
ings of embarrassment or uncertainty about how they will
be received.
Some GPs have the option of referring patients with mild Care programme approach
symptoms or those going through a life crisis (e.g. bereave-
ment) to a practice counsellor (see Chapter 3). Practice and The approach taken by some secondary care psychiatric ser-
district nurses may be helpful in screening for, and educat- vices is called the care programme approach (CPA), intro-
ing patients about, mental illness. duced by the Department of Health in 1991. This approach
Primary care liaison teams exist in many areas. These applies to all patients under specialist psychiatric care and
act as a single point of contact for GPs to refer to. Referrals includes patients based in the community, in hospitals and
are allocated to psychiatrists, psychologists, community in prisons. The key components of the CPA are:
psychiatric nurses (CPNs) or occupational therapists as ap- • The systematic assessment of patients’ health and social
propriate. This means the GP does not have to work out care needs
which professional is best placed to help the patient before • The formation of an agreed care plan that addresses
referring; the team can discuss this among themselves. these identified needs
47
Mental health service provision
• The allocation of a care coordinator (previously called used for patients who have just been discharged from hos-
‘key worker’) to keep in touch with the patient to pital, but who still need a high level of support, as a form
monitor and to coordinate the care of these needs. This of ‘partial hospitalization.’ They are now mainly used for
is usually a CPN, social worker or psychiatrist. older adults.
• Regular review meetings, which include all relevant
professionals, patients and their carers, to adjust the Assertive outreach teams
care plan, if necessary
Patients may be placed on a standard or an enhanced CPA These are like CMHTs and involve a multidisciplinary
according to the severity of their needs. team but provide a more intensive service, providing more
flexible and frequent patient contact. They are targeted at
challenging patients who have not engaged well with main-
stream mental health services in the past. Patients who
HINTS AND TIPS
use this service often have histories of severe and endur-
The diverse and multiple needs of patients with ing mental illness, significant social problems and complex
mental health problems make a multidisciplinary needs, and are usually considered relatively high risk in
some regard (e.g. self-harm or suicide, violence to others,
approach indispensable in psychiatry. A
self-neglect, or vulnerable). The nature of their illness re-
multidisciplinary team consists of members with
quires more focused and intensive input.
medical, psychological, social and occupational
therapy expertise.
Home treatment teams
There is increasing emphasis on treating patients at home,
thus avoiding expensive and disruptive inpatient admis-
Outpatient clinics sions. A hospital admission can be very challenging for
Psychiatric outpatient clinics take place in CMHT centres, anyone, particularly someone with an acute mental illness.
GP surgeries and hospitals. Types of clinics include psy- Treatment at home also allows practical problems with hous-
chiatrists’ clinics for new referrals and follow-up patients ing and activities of daily living to be better identified and
and special purpose clinics (e.g. depot antipsychotic in- addressed. Most regions now have home treatment teams
jection clinics, clozapine monitoring clinics). Some areas (also called crisis teams) who can provide short periods of
offer regional assessment services for neurodevelopmental support (from a few days to weeks) to people who might
disorders. otherwise have to be admitted. They can also facilitate ear-
lier discharge than would otherwise be possible. Such teams
include similar professionals to a CMHT but generally are
Liaison psychiatry available out of hours and can visit patients more often (e.g.
Liaison psychiatrists work in general hospitals. They pro- multiple times per day, if required). Medication, practical
vide psychiatric opinions for people who attend a general help and psychological therapy can be offered.
hospital with physical health problems, with or without a
preexisting mental health problem. Common referrals are Early intervention in psychosis
for assessment following self-harm, advice on management
of delirium and distinguishing depression from symptoms
teams
of physical health disorders. People with intellectual dis- There is some evidence that the longer a psychotic epi-
ability can find hospital admissions particularly challenging sode goes untreated, the poorer the prognosis, suggesting
and therefore some hospitals provide an intellectual disabil- that early treatment is preferable. However, not all mild or
ity liaison nurse who can advise on strategies to manage dis- vague symptoms of possible psychosis become a definite
tress and challenging behaviour. psychotic episode, meaning it can be hard to know when
to start treatment (e.g. a person who is suspicious of others,
Day hospitals but not holding a certain belief of persecution). Specialist
teams exist in many regions to manage such cases, offering
Day hospitals are nonresidential units that patients attend assessment, medication, psychological strategies and educa-
during the day. They are an alternative to inpatient care for tion for patients and families. Teams are open to psychosis
patients who, although needing intensive support, are able secondary to any diagnosis (e.g. schizophrenia, bipolar dis-
to go home in the evening and at weekends. Having a sup- order, substance-induced) and generally accept people aged
portive family is helpful in such cases. They may also be 14–35 years.
48
Secondary Care 5
Inpatient units and baby units provide care to women who have recently
given birth and eating disorder units provide care to those
Occasionally, community care is not possible and hospital with severe physical complications resulting from anorexia
admission is necessary. Reasons for admission include the nervosa.
following:
• To provide a safe environment when there is: (1) high
risk for harm to self or others or (2) grossly disturbed Rehabilitation units
behaviour. These units aim to reintegrate patients whose social and liv-
• A period of inpatient assessment is needed (e.g. ing skills have been severely handicapped by the effects of
of response to treatment or when the diagnosis is severe mental illness and institutionalization into the com-
uncertain). munity. Admissions are often for months or even years. The
• It is necessary to institute treatment in hospital (e.g. approach taken is holistic and uses the ‘Recovery Model’
electroconvulsive therapy, clozapine therapy – although (i.e. learning to live well with ongoing symptoms, rather
both of these can be initiated as outpatients if the than aim for complete remission of symptoms).
patient is at low risk for complications).
There are various types of inpatient units. These range Accommodation
from a general adult acute ward for uncomplicated admis-
sions to psychiatric intensive care units (PICUs) for se- Certain patients, who are unable to live independently due
verely disturbed patients who cannot be adequately looked to severe and enduring mental illness, may need supported
after on an open ward. High security units (also called ‘spe- accommodation. Types of supported accommodation range
cial hospitals’ (e.g. Broadmoor, Rampton)) are for mentally from warden-controlled property to residential homes with
ill offenders who pose a significant risk to others. Mother trained staff on hand 24 hours a day.
Chapter Summary
• Most mental health conditions are managed in primary care.

• Patients with severe and enduring mental illness can benefit from input from a community
mental health team.
• Many services exist to manage acutely unwell patients at home.
• High-risk patients are likely to need hospital admission.
49
PRESENTING
COMPLAINTS
Chapter 6
The patient with thoughts of suicide or self-harm . . . 53

Chapter 7
The patient with impairment of consciousness,

memory or cognition . . . . . . . . . . . . . . . . . . 59
Chapter 8
The patient with alcohol or substance use problems . 73
Chapter 9
The patient with psychotic symptoms . . . . . . . . . 87

Chapter 10
The patient with elated or irritable mood . . . . . . . . 99

Chapter 11
The patient with low mood�� 107

Chapter 12
The patient with anxiety, fear or avoidance . . . . . . 115

Chapter 13
The patient with obsessions and compulsions �� 123

Chapter 14
The patient with a reaction to a stressful event �� 129

Chapter 15
The patient with medically unexplained physical

symptoms�� 135
Chapter 16
The patient with eating or weight problems �� 141

Chapter 17
The patient with personality problems�� 147

Chapter 18
The patient with neurodevelopmental problems �� 153

The patient with thoughts of
suicide or self-harm 6
experience into a discrete physical sensation. Suicide is the
CASE SUMMARY act of intentionally and successfully ending one’s own life.
The duty psychiatrist is asked for their opinion on Mr Attempted suicide refers to an unsuccessful suicide bid.
SA, a 28-year-old unemployed, recently divorced man,
who was brought in by his landlord. The landlord had HINTS AND TIPS
called round to discuss payment arrears, only to find
the door unlocked and Mr SA asleep on his bed with an Self-harm is one of the top five reasons for acute
empty box of paracetamol tablets and several empty cans medical admissions for both men and women in the
of lager littered around the floor. He also found a hastily UK. Further, it is estimated that a large number of
scribbled suicide note on the bedside table, addressed to people do not attend hospital following self-harm.
Mr SA’s children. Mr SA was easily roused but was upset
to have been found and initially refused the landlord’s
pleas that they go to the hospital. Only when he was vi-
olently sick did Mr SA finally agree. The doctor in the
accident and emergency (A&E) department reports that,
ASSESSMENT OF PATIENTS WHO
other than the smell of alcohol on his breath, Mr SA’s HAVE INFLICTED HARM UPON
medical examination was normal. Blood tests revealed THEMSELVES
raised paracetamol levels, but these were not sufficiently
high to require medical treatment. The A&E doctor is Compared with the general population, which has an annual
concerned because Mr SA is ambivalent about further suicide rate of 0.01%, patients who present with self-harm
acts of self-harm or suicide, saying that his ‘life is a fail- have a 50- to 100-fold greater chance of completing suicide
ure’ and that ‘there is nothing worth living for’. Before in the following year (resulting in about 1% of people dying
coming to see the patient, the duty psychiatrist checks by suicide), emphasizing the need for comprehensive risk as-
Mr SA’s past medical and psychiatric history. sessment. It is incredibly difficult to predict suicide reliably,
(For a discussion of the case study see the end of the but numerous studies have shown that certain epidemiolog-
chapter). ical and clinical variables are more prevalent among those
who have completed suicide (Box 6.1) and it is important to
bear these in mind when assessing risk. No patient question-
naire or suicide risk-scoring system has been shown to be
While many psychiatric illnesses can be associated with better than thorough clinical assessment.
self-harm or suicidal intent (both as a presenting feature The key areas to assess are:
and a chronic symptom), many patients who self-harm or
1. Suicide risk factors
attempt suicide are not previously known to mental health
2. Suicidal intent (including circumstances surrounding
services. Assessments of these patients are often made by
the act)
nonpsychiatric staff, so it is vital that all doctors are able to
3. Mental state examination
detect and manage any underlying mental illness, and have
4. Current social supports
a sound approach to assessing and managing risk.
RED FLAG
DEFINITIONS AND CLINICAL Suicidal thoughts and actions are common. In
FEATURES the general population within the last year, around 1
in 20 people will have had suicidal thoughts, around
Self-harm is a blanket term used to describe any intentional 1 in 200 will have attempted to kill themselves,
act done with the knowledge that it is potentially harmful. It and around 1 in 10 000 will have died by suicide.
can take the form of self-poisoning (e.g. overdosing) or self- Suicide is the commonest cause of death in men
injury (e.g. cutting, burning, hitting). The motives for self- and women under the age of 35 years, and the 13th
harm are vast and include emotional relief, self-punishment,
commonest cause of years of life lost worldwide.
attention seeking, and can even be a form of self-help (albeit
maladaptive) by way of channelling an intolerable emotional
53
The patient with thoughts of suicide or self-harm
BOX 6.1 RISK FACTORS FOR SUICIDE COMMUNICATION
Epidemiological factors: Every patient with suicidal ideas should be asked

Male of any age (younger females more likely to about alcohol or substance misuse, no matter how
self-harm but less likely to complete suicide) unlikely it seems. Taking a nonjudgemental stance
Being lesbian, gay, bisexual or transgender is likely to enhance the therapeutic relationship and
(particularly younger people) help the patient feel understood.
Prisoners (especially remand)
Being unmarried (single, widowed, divorced)
Unemployment
Physical illness
Working in certain occupations (farmer, vet, nurse, Many disabling or unpleasant medical conditions can be
doctor) associated with self-harm and suicide. Often, a patient may
Low socioeconomic status have comorbid depression that will respond to treatment.
Living alone, social isolation However, a minority of patients have no mental illness and
make a capacitous decision to die. The most common ex-
Clinical factors: amples are:
Psychiatric illness or personality disorder (see • Chronic illnesses which cause a lot of functional
Table 6.1) impairment or pain (e.g. chronic obstructive
Previous self-harm pulmonary disease, asthma, stroke, epilepsy)
Alcohol dependence • Life-limiting illnesses (e.g. cancer, Huntington disease)
Physical illness (especially debilitating, chronically
painful, or terminal conditions) Recent adverse life events
Family history of depression, alcohol dependence, Stressful life events are more common in the 6 months prior
or suicide to a suicide attempt, and include relationship break-ups,
Recent adverse life-events (especially health problems, legal/financial difficulties, or problems at
bereavement) home or within the family.
Suicidal intent
Suicidal intent, which is commonly defined as the serious-
COMMUNICATION ness or intensity of the wish of a patient to terminate their
life, is suggested by the following:
Suicidal patients often feel distressed and guilty.
One of the most important therapeutic aspects
The attempt was planned in advance
of the assessment is to convey empathy and A lethal suicide attempt typically involves days or weeks
optimism. of planning. It is rarely an impulsive, spur-of-the-moment
idea (the exception is the psychotic patient who impul-
sively responds to hallucinations or delusions). Planning
is strongly suggested by the evidence of final acts. These
Suicide risk factors include the writing of a will or suicide note.
Box 6.1 summarizes the most important epidemiological
and clinical risk factors for suicide. Precautions were taken to avoid
discovery or rescue
Psychiatric illness For example, a patient might check into a hotel room in a
About 90% of patients who commit suicide have a diag- distant town or ensure that no friends or family will be vis-
nosed or retrospectively diagnosable mental disorder; how- iting over the ensuing hours or days.
ever, only around a quarter of these patients have contact
with mental health services in the year before completing
suicide. Patients recently released from inpatient psychiat- A dangerous method was used
ric care are at a significantly elevated risk for suicide, par- Violent methods (hanging, jumping from heights, firearm
ticularly during the first couple of weeks after discharge. use) are suggestive of lethal intent. That said, use of an ap-
Table 6.1 summarizes the most important psychiatric con- parently ineffective method (e.g. taking six paracetamol
ditions associated with suicide. tablets) might reflect lack of knowledge of the lethal dose
54
Assessment of patients who have inflicted harm upon themselves 6
Table 6.1 Association between psychiatric disorders and suicide

Psychiatric disorder Risk relative to general population Comments
Personality disorders Approximately 40-fold Highest in borderline personality disorder. Also, strong
association with antisocial and narcissistic personality
disorders. Often have comorbid depression or substance
misuse.
Unipolar depression 20-fold Risk greatest in patients with anxiety/agitation or severe
insomnia and higher in patients having received inpatient
treatment in the past. Risk greatest in first 3 months of
diagnosis.
Substance use Cocaine dependence 17-fold Highest risk when comorbid depression.
Alcohol dependence 12-fold
Opioid dependence 7-fold
Amphetamine dependence 5-fold
Schizophrenia 13-fold Highest risk is young, intelligent, unemployed males with
good insight and recurrent illness.
Eating disorders Anorexia nervosa 8-fold Mortality in anorexia nervosa is also increased due to
Bulimia lower risk than anorexia complications of malnutrition.
Bipolar affective 6-fold More common in depressive phase but can also happen
disorder in manic or mixed affective episodes.
Anxiety disorders 3-fold Increased risk in GAD, panic disorder and PTSD even
without comorbid depression. OCD not associated with
increased risk.
GAD; Generalized anxiety disorder; OCD, obsessive-compulsive disorder; PTSD, posttraumatic stress disorder.
needed, rather than a lack of intent to die. Therefore it • Current suicidality: is the act now regretted, or is there
should be ascertained whether the method used was seen as strong intent to die? What does the patient plan to do if
dangerous from the patient’s perspective. discharged?
• Protective factors: what aspects of the patient’s life
No help was sought after the act (family, children and dependents) would guard against
Patients who immediately regret their action and seek further acts? Lack of protective factors, or dismissal of
help are less at risk than those who do not seek help and their importance, is a worrying sign.
wait to die. The person communicated with is often of The following questions might be helpful when asking
significance – they may be someone whose behaviour the about suicidal ideation:
patient is seeking to influence by their act of self-harm, • Have you been feeling that life isn’t worth living?
and/or they may be someone who provides support to the • Do you sometimes feel like you would like to end it all?
patient. • Have you given some thought as to how you might
do it?
• How close are you to going through with
Mental state examination your plans?
• Is there anything that might stop you from attempting
This should ideally be conducted in a calm, quiet and confi-
suicide?
dential setting, preferably when the patient has had a chance
to rest and is not under the influence of drugs or alcohol.
Check specifically for:
HINTS AND TIPS
• Current mood state: does the patient appear to be
suffering from a depressive illness? Assess for features Patients who are tired, emotionally upset or
of hopelessness, worthlessness or agitation (all of intoxicated may appear to be at greater risk for
which are associated with a higher risk for completed imminent self-harm. Allowing some time to sober
suicide). up and reflect can be of great therapeutic value.
• Other psychiatric illness: does the patient appear However, this will always be a matter of clinical
to be preoccupied, delusional or responding to
judgment.
hallucinations? Is there evidence of eating disorder,
substance abuse or cognitive impairment?
55
The patient with thoughts of suicide or self-harm
• Crisis planning (relaxation or distraction techniques,

PATIENT MANAGEMENT telephone counselling services, information on
FOLLOWING SELF-HARM OR accessing emergency psychiatric services).
ATTEMPTED SUICIDE
Management planning should follow assessment of risk
factors and mental state. It is important to remember that DISCUSSION OF CASE STUDY
self-harm and suicidality are not discrete illnesses; instead
they are symptoms reflecting a complex interplay of men-
Self-harm risk assessment
tal disorders, personality types and social circumstances.
Rather than taking the form of a prescribed care pathway, Mr SA’s epidemiological risk factors are that he is a young
management of the suicidal or self-harming patient re- man, recently divorced, unemployed and lives alone in so-
quires clinical judgement, taking into consideration the cial isolation. His clinical risk factors are that he may have
needs of the individual patient and the availability of local alcohol problems and has recently experienced adverse life
resources. This can often be anxiety-provoking for health events (divorce, financial difficulties). The evidence of final
care workers. acts (suicide note) and the failure of Mr SA to seek help after
Formulation of a management plan should be made after the act suggest strong suicide intent. The fact that he would
a thorough review of any available past history, including not have been discovered but for the landlord’s timely ar-
care programmes or crisis plans if relevant. It is always de- rival indicates a degree of forward planning, although his
sirable to obtain a collateral history from a family member leaving the door unlocked and his willingness to go to hos-
or close friend. A good plan should include both short- and pital after vomiting suggest some ambivalence. Mr SA had
long-term management strategies. consumed a significant quantity of alcohol at the time of
Immediate management considerations include the the overdose, which could have clouded his judgement and
following: increased his impulsivity. On mental state examination, Mr
• Is the patient in need of inpatient psychiatric care to SA has ongoing suicidal ideation and cognitive features of
ensure their safety? If so, can this be achieved on a worthlessness and hopelessness, which are associated with
voluntary basis, or is the use of mental health legislation suicide.
required?
• Would the patient benefit from the input of home Further management
treatment, outreach or crisis teams (see Chapter 5)?
The duty psychiatrist should ask about all the epidemi-
• Does the patient have existing social supports that
ological and clinical risk factors, specifically about: past
could be called upon?
or current mental illness (is Mr SA known to mental
• Reducing access to means of self-harm: does the
health services?); previous episodes of self-harm; alcohol
patient have a collection of tablets or rope remaining
or substance dependence; physical illness; family history
in their home they could dispose of? Should their
of depression, alcohol dependence or suicide; and recent
prescription medication be dispensed weekly (or more
adverse life events. The duty psychiatrist will also be in-
frequently)?
terested in Mr SA’s current social support in order to try
Longer-term management involves the modification of fac- and help him formulate the most appropriate manage-
tors that could increase the risk for further acts of self-harm ment plan.
or suicidality, and may include: As this is a complex risk assessment, the duty psychiatrist
• Treatment of psychiatric illness (medication, self-help, will probably have to reassess the patient himself, especially
psychological therapies, community mental health as regards detecting mental illness on mental state exam-
team, outpatient appointments, GP follow-up). ination. The psychiatrist might ask the A&E doctor to keep
• Avoidance of substance use (highlighting Mr SA overnight, so that a mental state examination can
association with suicide to patient, encouraging be performed in the morning when he is refreshed and no
patient to attend voluntary organisations and/or longer under the influence of alcohol. A hospital admission
addictions services) or follow-up by a high-intensity support mental health team
• Optimizing social functioning (social work, Citizens (e.g. crisis team) seems to be the most likely outcome.
Advice Bureau, community groups and activities,
encouragement of family support, voluntary support
agencies).
56
Discussion of case study 6
Chapter Summary
Self-harm is a very common presentation with many different causes.

Self-harm increases the risk for completed suicide, but the vast majority of people who self-
harm will not die by suicide.
Assess risk for suicide in all those who have self-harmed, by identifying:
• risk factors for suicide (epidemiological and clinical),
• degree of suicidal intent,
• evidence of mental disorder,
• use of alcohol or other substances and
• social support and protective factors.
Management is very specific to the individual but should include crisis planning for all.
57
The patient with impairment
of consciousness, memory
or cognition 7
CASE SUMMARY DEFINITIONS AND CLINICAL
FEATURES
Mr DD, aged 78 years, lived at home with his
wife with carers visiting twice daily. His general
practitioner (GP) had referred him to a psychiatrist
Consciousness
6 years earlier, after he started experiencing To be conscious is to be aware, both of the environment
difficulty remembering things. At first, he would and of oneself as a subjective being. It is a global cognitive
forget things like the social arrangements he had function. It is a poorly understood, complex phenomenon
made. Later he started forgetting activities he with multiple vaguely defined terms for its abnormali-
ties. It is best to avoid terms such as ‘confused,’ ‘obtunded,’
had engaged in only the day before. His wife had
‘clouding of consciousness’ and ‘stupor’ as they are not well
noticed a gradual change in his personality in that
defined and mean different things to different specialties.
he became increasingly withdrawn and sullen Clinically, the key question is whether someone has a nor-
and, at times, verbally aggressive. His language mal or altered conscious level. This is assessed at a practical
deteriorated to the point where he would ramble level by observing arousal level (hyperaroused or lowered)
incoherently, even when there was no one else in (Fig. 7.1).
the room. Despite having smoked for many years,
Mr DD seemed unable to recognize his pipe and Cognition
would stare at it quizzically for hours. He lost
the ability to dress himself or complete simple
This chapter considers ‘cognition’ in its broadest sense as
meaning all the mental activities that allow us to perceive,
multistep tasks such as making a cup of coffee.
integrate and conceptualize the world around us. These in-
His wife contacted their GP when Mr DD was clude the global functions of consciousness, attention and
too sleepy to get out of bed one morning. The orientation and the specific domains of memory, executive
GP arranged hospital admission for further function, language, praxis and perception. The term ‘cog-
investigation. Nurses were concerned because nition’ is also used more narrowly in cognitive psychology
his consciousness level was fluctuating from and cognitive therapy where individual thoughts or ideas
hour to hour. He slept through most of the day, are also referred to as ‘cognitions’.
but would wander around the ward at night Impairments in cognition can be generalized (multiple
looking very agitated and appeared to have visual domains) or specific (one domain only). An altered level of
consciousness is generally associated with a generalized im-
hallucinations. The senior nurse pointed out that he
pairment in all aspects of cognition, as it is difficult to con-
had developed a productive cough.
centrate on any tasks when feeling very agitated or drowsy.
(For a discussion of the case study see the end of the A large number of specific cognitive impairments exist
chapter). (Table 7.1). These can be isolated impairments, for example,
if they are developmental or secondary to a small stroke or
occur together in disorders of generalized cognitive impair-
ment such as dementia.
Cognitive impairment is common and important, but of-

Memory
ten underdiagnosed and underinvestigated. It is associated Memory is one of the commonest cognitive domains to
with a high morbidity and mortality, and you are likely to be impaired. There are two main ways to categorize mem-
frequently encounter people with cognitive impairment in ory: the duration of storage (working or long-term) or the
most specialties of medical practice. type of information stored (implicit or explicit). Explicit
59
The patient with impairment of consciousness, memory or cognition
Is the patient awake?
NO YES
Are they agitated/hypervigilant/

Are they easily rousable?
unable to sleep?
NO YES NO YES
Lowered Normal Hyperaroused
Consider Do they remain alert

ABC, GCS throughout assessment?
NO YES
Lowered Normal
Fig. 7.1 Assessment of conscious level. ABC, Airway, Breathing, Circulation; GCS, Glasgow Coma Scale.
Table 7.1 Specific cognitive impairments

Cognitive domain Term(s) for impairment Description
Language Dysphasia/aphasia Loss of language abilities despite intact sensory and motor
function (e.g. difficulty in understanding commands or other
words (receptive dysphasia) or difficulty using words with correct
meaning (expressive dysphasia)). Not being able to name items
correctly despite knowing what they are (nominal dysphasia) is a
subtype of expressive dysphasia
Praxis Dyspraxia/apraxia Loss of ability to carry out skilled motor movements despite intact
motor function (e.g. inability to put a letter in an envelope, use a
tinopener, button up a shirt)
Perception Dysgnosia/agnosia Loss of ability to interpret sensory information despite intact
sensory organ function (e.g. not able to recognize faces as
familiar)
Memory Amnesia Loss of ability to learn or recall new information (e.g. not able to
recall time or recent events, not able to learn new skills)
Executive function Many terms, including: Loss of ability to plan and sequence complex activities, or
(umbrella term for Disinhibition, perseveration, to manipulate abstract information (e.g. not able to plan the
many abilities) apathy, dysexecutive preparation of a meal, not able to return to a task once distracted)
syndrome
60
Common cognitive disorders 7
memory (sometimes called declarative memory) includes all Retrograde amnesia results in the patient being unable to
stored material of which the individual is consciously aware retrieve memories, although the ability to store new mem-
and can thus ‘declare’ to others. Implicit memory (some- ories may remain unaffected. Retrograde amnesia usually
times called procedural memory) includes all material that is results from damage to the frontal or temporal cortex.
stored without the individual’s conscious awareness (e.g. the
ability to speak a language or ride a bicycle). HINTS AND TIPS
Explicit memory is the most common type of mem-
ory to be disrupted. It can be further subdivided into Implicit memory (procedural memory) is typically
semantic and episodic memory. Semantic memory preserved despite severe disruptions to explicit
is knowledge of facts (e.g. Edinburgh is the capital of (declarative) memory, probably due to its
Scotland). Episodic memory is knowledge of autobi- independent neural location. Implicit memory is
ographical events (e.g. remembering a trip to Edinburgh associated with basal ganglia circuitry. Explicit
when you were 10 years old). See Table 7.2 for the char-
memory is associated with the hippocampal,
acteristics of different durations of explicit memory and
diencephalic and cortical structures.
how to test them.
COMMUNICATION COMMON COGNITIVE DISORDERS

There are different ways of classifying memory,
and different terms have similar or overlapping
Delirium
meanings. For example, some clinicians use the Delirium can be thought of as acute brain failure. It is a syn-
term ‘short-term memory’ to mean recent long- drome manifesting as acute or fluctuating cognitive impairment
term memory whereas others mean working associated with altered consciousness and impaired attention. If
memory. When speaking to colleagues it can be someone is newly disorientated and is drowsy or agitated, they
useful to define the type of memory referred to by are very likely to have delirium. Psychotic features such as hal-
lucinations or persecutory delusions are often present but are
the name of the test used to measure it.
not essential to make the diagnosis. Delirium often fluctuates,
so a patient may appear normal on the morning ward round but
cognitively impaired and agitated in the evening.
Delirium is a final common pathway of severe injury to
Amnesia refers to the loss of the ability to store new the brain or body and is a marker of severity of illness (e.g.
memories or retrieve memories that have previously been the ‘C’ in the CURB65 score for severity of community-
stored. Anterograde amnesia is when the patient is unable acquired pneumonia). It is usually multifactorial and often
to store new memories (impaired learning of new ma- arises from illnesses that do not directly affect the brain
terial), although the ability to retrieve memories stored (Box 7.1). It has a high mortality, with around a third of
before the event or onset of disorder may remain unim- people with delirium dying during the presentation. It is
paired. Anterograde amnesia usually results from damage therefore a medical emergency and the cause should be thor-
to the medial temporal lobes, especially the hippocampal oughly investigated and treated. It is particularly common
formation. in those with ‘at risk’ brains, such as those with pre-existing
dementia. In individuals with vulnerable brains a relatively
Table 7.2 Explicit memory types, disorders and tests

Explicit memory type Capacity duration Key brain regions Tests
Working/short-term 7 ± 2 items Frontal cortex Recall of unrelated words (e.g. ‘lemon, key,
15–30 s ball’)
Long-term (recent) Unlimited Hippocampus Anterograde: delayed recall of an address or
Minutes to months Mamillary bodies objects
Retrograde: questions about recent events
(e.g. what did you have for breakfast?)
Long-term (remote) Unlimited Frontal and temporal Questions about past important events.
Lifetime cortex Ask about personal events (episodic; e.g.
what school did you attend?) and general
knowledge (semantic; e.g. which US
president was assassinated in the 1960s?)
61
BOX 7.1 CAUSES OF DELIRIUM

Trauma
(ANYTHING THAT DISRUPTS HOMEOSTASIS)
• Any fracture, but frequently hip fracture
Environmental change or stress Intracranial causes
• Hospital admission, particularly intensive care Space-occupying lesions
• Urinary catheterisation
• Tumours, cysts, abscesses, haematomas
• Use of physical restraint
• Major surgery Head injury (especially concussion)
• Sleep deprivation Infection
Drugs (use or discontinuation) • Meningitis
Prescribed (plus many more) • Encephalitis
• Anticholinergics Epilepsy
• Benzodiazepines Cerebrovascular disorders
• Opiates • Transient ischaemic attack
• Antiparkinsonian drugs • Cerebral thrombosis or embolism
• Steroids • Intracerebral or subarachnoid haemorrhage
Recreational • Hypertensive encephalopathy
• Alcohol (delirium tremens, see Chapter 8) • Vasculitis (e.g. from systemic lupus
• Opiates erythematosus)
• Cannabis
• Amphetamines
Poisons
• Heavy metals (lead, mercury, manganese) minor insult can result in delirium (e.g. dehydration or a new
• Carbon monoxide medication). Delirium is also a risk factor for development or
Systemic illness worsening of dementia. Delirium usually resolves when the
cause is treated, but sometimes can be prolonged for weeks or
Infections and sepsis months. The terms ‘acute confusional state’ and ‘encephalop-
Hypoxia athy’ have roughly the same meaning as delirium. Prominent
• Respiratory failure symptoms of delirium are described further below. There are
• Heart failure three main subtypes: hyperactive, hypoactive and mixed.
• Myocardial infarction
Metabolic and endocrine HINTS AND TIPS
• Dehydration
• Electrolyte disturbances Key risk factors for delirium are an abnormal
• Renal impairment brain (e.g. dementia, previous serious head
• Hepatic encephalopathy injury, alcohol misuse), age (children, adults over
• Porphyria 65 years), polypharmacy and sensory impairment.
• Hypoglycaemia
• Hyper- and hypothyroidism
• Hyper- and hypoparathyroidism HINTS AND TIPS
• Hyper- and hypoadrenocorticism (Cushing
syndrome, Addison disease) The four key diagnostic features of delirium are:
• Hypopituitarism (1) impaired consciousness, (2) impaired attention
and (3) impaired cognition, all with (4) acute or
Nutritional
fluctuating onset. Supportive diagnostic features
• Thiamine (Wernicke encephalopathy), vitamin
are perceptual and thought disturbance, sleep-
B12, folic acid or niacin deficiency
wake cycle disturbance and mood disturbance.
62
Impaired consciousness
Patients may have a reduced level of consciousness ranging RED FLAG
from drowsiness to coma (hypoactive delirium), or they can Medication is one of the easiest causes of delirium
be hypervigilant and agitated (hyperactive delirium). to reverse. Always check the patient’s prescription.
The top three drug classes which precipitate delirium
Impaired attention are benzodiazepines, anticholinergics and opiates.
Ability to sustain attention is reduced and patients are easily
distractible. Assess attention using tests such as serial sevens
or months of the year backwards.
Dementia
Impaired cognitive function Dementia is a syndrome of acquired progressive general-
Short-term memory and recent memory are impaired with ized cognitive impairment associated with functional de-
relative preservation of remote memory. Patients with decline. Conscious level is nearly always normal. Symptoms
lirium are almost always disorientated to time and often to should be present for 6 months before a diagnosis can be
place. Orientation to self is seldom lost. Language abnor- confirmed. The following text describes the general catego-
malities such as rambling, incoherent speech and an im- ries of impairment in dementia.
paired ability to understand are common.
Functional impairment
Perceptual and thought disturbance Functional impairment must be present to make a diagno-
Patients may have perceptual disturbances ranging from sis of dementia. Functional impairment means difficulties
misinterpretations (e.g. a door slamming is mistaken for an with basic or instrumental activities of daily living (ADL).
explosion) to illusions (e.g. a crack in the wall is perceived as Basic ADLs refer to self-care tasks such as eating, dressing,
a snake) to hallucinations (especially visual and, to a lesser washing, toileting, continence and mobility (being able to
extent, auditory). Transient persecutory delusions and delu- make crucial movements such as from bed to chair to toi-
sions of misidentification may occur. let). Instrumental ADLs refer to tasks which are not crucial
to life, but which allow someone to live independently, such
Sleep–wake cycle disturbance as cooking, shopping and housework. As well as being di-
Sleep is characteristically disturbed and can range from day- agnostically important, someone’s ability to perform ADLs
time drowsiness and night-time hyperactivity to a complete re- determines what level of support they need (home carers or
versal of the normal cycle. Nightmares experienced by patients 24-hour residential care).
with delirium may continue as hallucinations after awakening.
Memory impairment
Mood disturbance Impairment of memory is a common feature of demen-
Emotional disturbances such as depression, euphoria, anxi- tia. Recent memory is first affected (e.g. forgetting where
ety, anger, fear and apathy are common. objects are placed, conversations and events of the previ-
ous day). With disease progression, all aspects of mem-
ory are affected, although highly personal information
RED FLAG (name, previous occupation, etc.) is usually retained un-
til late in the disease. Note that memory is essential for
A physical illness should always be sought when
orientation to person, place and time and this will also
a patient presents with visual hallucinations in
be gradually affected (e.g. patients may lose their way in
isolation because patients with schizophrenia or their own house).
psychotic mood disorders usually also experience
auditory hallucinations. Other cognitive symptoms (aphasia,
apraxia, agnosia, impaired executive
functioning)
See Table 7.1.
RED FLAG
Delirium is a medical emergency. Around a third of
Behavioural and psychological
people with delirium die during an episode of delirium. symptoms of dementia
Thoroughly assess for and treat the probable cause. ‘Behavioural and psychological symptoms of dementia’
(BPSD) is an umbrella term for noncognitive symptoms
associated with dementia, including changes in behaviour,
63
mood and psychosis. Behavioural symptoms are very or vascular disease. Table 7.4 describes the distinguishing
common and include pacing, shouting, sexual disinhibi- clinical features of the various types of dementias although
tion, aggression and apathy. Depression and anxiety may clinically, it is often difficult to tell what form of dementia is
occur in up to 50% of all those with dementia. Delusions, present and definitive diagnosis can normally only be made
especially persecutory, may occur in up to 40% of patients. by postmortem examination. It is important to establish the
Hallucinations in all sensory modalities (visual is more likely underlying type of dementia because:
common) occur in up to 30% of patients. BPSD can be • A secondary dementia-causing process (e.g. brain
similar to symptoms of delirium, but generally has a more tumour) may be detected and possibly treated.
gradual onset and conscious level is normal. See Table 7.3 • The progress of certain types of dementia may be
for more ways to differentiate BPSD from delirium. slowed with specific medication (e.g. cholinesterase
inhibitors in Alzheimer dementia).
Neurological symptoms • Certain drugs may be contraindicated in some
Between 10% and 20% of patients will experience seizures. dementias (e.g. antipsychotics can cause a catastrophic
Primitive reflexes (e.g. grasp, snout, suck) and myoclonic parkinsonian reaction in patients with dementia with
jerks may also be evident. Lewy bodies).
• The prognoses of the various dementias differ; this
may have practical implications for patients and their
COMMUNICATION families as regards final arrangements (e.g. wills).
• The patient’s relatives may enquire about genetic
When seeing a new patient with a likely diagnosis
counselling (e.g. Huntington disease, early-onset
of dementia, always take a collateral history as Alzheimer dementia).
patients may have poor insight and recall of their
In a minority of cases the distinction will be obvious,
difficulties. based on other symptoms produced by the disease process
(e.g. jerky movements of the face and body (chorea)) and a
positive family history would be suggestive of Huntington
disease. In the majority of cases, the different dementias
Distinguishing the type of dementia may be distinguished to some degree based on a detailed
Dementia can result from a primary neurodegenerative history from the patient and an informant, physical exam-
process or be secondary to substance use or another med- ination, relevant investigations and follow-up over time.
ical condition. Early onset dementia begins before age However, the definitive diagnosis of a dementia subtype
65 years. A small number of cases are due to treatable, can only be established with absolute certainty on detailed
potentially reversible causes (Box 7.2). However, the most microscopic examination of the brain at autopsy, and even
common causes of dementia are neurodegeneration and/ then, a conclusive diagnosis may not be possible.
Table 7.3 Factors differentiating delirium from dementia

Feature Delirium Dementia
Onset Acute Gradual
Duration Hours to weeks Months to years
Attention Impaired Normal
Course Fluctuating Progressive deterioration
Consciousness Altered Normal
Context New illness/medication Health unchanged
Perceptual disturbance Common Occurs in late stages
Sleep−wake cycle Disrupted Usually normal
Orientation Usually impaired for time and unfamiliar Impaired in late stages
people/places
Speech Incoherent, rapid or slow Word finding difficulties.
Things you may think ‘Why aren’t they listening?’, ‘Why won’t ‘Why do they keep telling me about the
they wake up properly?’, or ‘They need to past?’, ‘Why do they keep asking me the
calm down’ same question?’
64
Table 7.4 Distinguishing clinical features of the

BOX 7.2 DISEASES THAT MAY CAUSE
DEMENTIA commonest types of dementia
Dementia type Distinguishing clinical features
Neurodegenerative
Alzheimer Gradual onset with progressive
• Alzheimer disease dementia cognitive decline
• Frontotemporal dementia (includes Pick disease) (62%) Early memory loss
• Dementia with Lewy bodies (DLB) Vascular dementia Focal neurological signs and
• Parkinson disease (multi-infarct symptoms
dementia) Evidence of cerebrovascular disease
• Huntington disease (17%) or stroke
• Progressive supranuclear palsy May be uneven or stepwise
Cerebrovascular disease deterioration in cognitive function
Mixed Features of both Alzheimer and
• Vascular dementia
(10%) vascular dementia
• Mixed Alzheimer and vascular dementia
Lewy body Core:
Space-occupying lesions dementia Day-to-day (or shorter)
• Tumours, cysts, abscesses, haematomas (4%) fluctuations in cognitive
performance
Trauma Recurrent visual hallucinations
Motor signs of parkinsonism
• Head injury
(rigidity, bradykinesia, tremor)
• Dementia pugilistica (not drug-induced)
(sometimes called ‘punch-drunk syndrome’) Supporting:
REM sleep behaviour disorder
Infection Recurrent falls and syncope
• Creutzfeldt–Jakob disease Transient disturbances of
(including ‘new variant CJD’) consciousness
Extreme sensitivity to
• HIV-related dementia antipsychotics (induces
• Neurosyphilis parkinsonism)
• Viral encephalitis Frontotemporal Behavioural variant:
• Chronic bacterial and fungal meningitides dementia (including Early decline in social and
Pick disease) personal conduct (disinhibition,
Metabolic and endocrine (2%) tactlessness)
• Chronic renal impairment Dietary changes (preference for
(also called ‘dialysis dementia’) sweet food)
Early emotional blunting and loss
• Liver failure of insight
• Wilson disease Primary progressive aphasia
• Hyper- and hypothyroidism (nonfluent and semantic variants):
• Hyper- and hypoparathyroidism Attenuated speech output,
echolalia, perseveration, mutism
• Cushing syndrome and Addison disease Loss of semantic knowledge and
Nutritional naming
Relative sparing of other cognitive
• Thiamine, vitamin B12, folic acid or niacin functions
deficiency (pellagra)
Parkinson disease Diagnosis of Parkinson disease
Drugs and toxins with dementia (motor symptoms over a year prior
(2%) to cognitive symptoms)
• Alcohol (see Chapter 8), benzodiazepines, Dementia features very similar to
barbiturates, solvents those of Lewy body dementia
Chronic hypoxia Percentages are prevalence of dementia subtypes in UK
population (Dementia UK report, 2007).
Inflammatory disorders
• Multiple sclerosis To aid the clinical distinction of dementia, some authors
• Systemic lupus erythematosus differentiate cortical, subcortical and mixed dementias
Normal pressure hydrocephalus based on the predominance of cortical or subcortical dys-
function, or a mixture of the two (see Table 7.5 for the fea-
tures of cortical and subcortical dementias). Unfortunately,
65
Table 7.5 Features of cortical and subcortical dementias

Characteristic Cortical dementia Subcortical dementia
Language Aphasia early Normal
Speech Normal until late Dysarthric
Praxis Apraxia Normal
Agnosia Present Usually absent
Calculation Early impairment Normal until late
Motor system Usually normal posture/tone Stooped or extended posture, increased tone
Extra movements None (may have myoclonus in Tremor, chorea, tics
Alzheimer disease)
Cortical:
Alzheimer disease and the frontotemporal dementias (including Pick disease)
Subcortical:
Parkinson disease, dementia with Lewy bodies, Huntington disease, progressive supranuclear palsy, Wilson disease,
normal pressure hydrocephalus, multiple sclerosis, HIV-related dementia
Mixed:
Vascular dementias, infection-induced dementias (Creutzfeldt–Jakob disease, neurosyphilis and chronic meningitis)
there is often a considerable overlap of symptoms in ad- • Which cognitive domains are impaired? (one or many?)
vanced dementia of whatever type. • Is the impairment stable, fluctuating or progressive?
• Is the cognitive impairment causing functional
HINTS AND TIPS impairment?
• Are there any other associated symptoms? (e.g. mood
At this point you might find it helpful to read up on change, personality change, perceptual disturbance).
the aetiology and neuropathology of the various Chronic impairment in multiple cognitive domains is due
neurodegenerative dementias in Chapter 19. most often to dementia, mild cognitive impairment or de-
pression (see Box 7.3 for more differentials). Sometimes a
patient has an isolated impairment (see Table 7.1 for ex-
amples), most often due to a head injury or stroke. Causes
DIFFERENTIAL DIAGNOSIS of isolated amnesia (amnesic syndrome) are considered in
more detail at the end of the section.
There are four key questions when a patient presents with
possible cognitive impairment: RED FLAG
• Is there objective evidence of cognitive impairment on
Lewy body dementia and multi-infarct dementia
a standardized test?
are the only dementias that feature transient
• If so, is it acute, chronic, or acute-on-chronic? (this
may require a collateral history) episodes of impaired consciousness as a typical
• Is the patient’s conscious level normal or abnormal? feature. All other dementias do not feature an
• What impact is the cognitive impairment having on the impairment of consciousness unless complicated
patient’s functioning? by a delirium.
See Fig. 7.2 for a diagnostic algorithm and Box 7.3 for a
summary of differential diagnosis.
Dementia
Acute, acute-on-chronic or fluctuating See Common cognitive disorders section, above, for clinical
cognitive impairment: delirium features.
See Common cognitive disorders section earlier for clinical Older adults presenting with both physical health
features of delirium. problems and generalized cognitive impairment are very
common, and it is imperative that you understand how
Chronic cognitive impairment to differentiate between dementia and delirium. Table 7.3
Key questions when a patient presents with chronic cogni- summarizes the factors differentiating delirium from de-
tive impairment: mentia – learn it well.
66
Differential diagnosis 7
Cognitive symptoms
Normal score on YES Subjective

standardized testing cognitive impairment
NO
YES
Acute or fluctuating Likely delirium
NO
YES Depression
Depressive symptoms (reassess cognition
once treated)
NO
Activities of daily living YES Mild

unaffected cognitive impairment
NO
Progressive worsening YES

Dementia
over at least 6 months
NO
YES Stable
Stable impairment
cognitive impairment
Note: Other differentials of cognitive impairment include intellectual

disability, psychotic illness, amnesic syndrome, dissociative disorders,
factitious disorder and malingering (see Box 7.3)
Fig. 7.2 Diagnostic algorithm for cognitive symptoms.
HINTS AND TIPS

BOX 7.3 DIFFERENTIAL DIAGNOSIS
OF COGNITIVE IMPAIRMENT Dementia and delirium are by far the most common
causes of generalized cognitive impairment. A
Delirium key question in differentiating them is the duration
Dementia of impairment: is it acute, chronic or acute-on-
Mild cognitive impairment chronic? The patient may not be able to tell you,
Subjective cognitive impairment but their notes or a collateral history from a relative
Stable cognitive impairment post insult (e.g. stroke, or GP can be invaluable.
hypoxic brain injury, traumatic brain injury)
Depression (‘pseudodementia’)
Psychotic disorders
Mood disorders Mild cognitive impairment
Intellectual disability Mild cognitive impairment is objective cognitive impairment
Dissociative disorders (confirmed with a standardized test) that does not interfere
Factitious disorder and malingering notably with activities of daily living. Mild cognitive impair-
ment is a risk state for dementia, with around 10% to 15% of
Amnesic syndrome
patients developing dementia each year. However, in some
cases the impairment remains stable or even improves. All the
67
processes that cause dementia can also cause mild cognitive delirium: around 50% of people with Down Syndrome will
impairment, so it is normally investigated in the same way. develop Alzheimer dementia, often early-onset.
Subjective cognitive impairment Dissociative disorders

Subjective cognitive impairment is when a patient com- Memory loss and altered conscious levels can occur in the
plains of cognitive problems but scores normally on stan- dissociative disorders (e.g. dissociative amnesia, fugue and
dardized tests. It can reflect anxiety or depression, but can stupor; see Chapter 14, Table 14.1). These usually occur in
also represent early deterioration in a highly educated in- younger adults; however, there is no evidence of a physical
dividual that is unidentifiable using standard tests. People cause and they are usually precipitated by a psychosocial
with subjective memory impairment are at increased risk stressor.
for later developing mild cognitive impairment or dementia.
Factitious disorder and malingering
Stable cognitive impairment See Chapter 15.
Some ‘one off ’ insults to the brain can impair one or more
aspects of cognition but not cause progressive deterioration
Amnesic syndrome
(e.g. following a stroke, hypoxic brain injury, traumatic
While dementia is the most common cause of chronic
brain injury or viral encephalitis). Improvement post-
memory dysfunction overall, certain brain diseases can
insult can occur over several months, so it is important
cause a severe disruption of memory with minimal or no
not to make a firm diagnosis of stable chronic impairment
deterioration in other cognitive functions. This is termed
too soon. Often someone who has had one cerebrovascu-
‘amnesic syndrome’ and usually results from damage to the
lar event continues to have further episodes, so an initially
hypothalamic–diencephalic system or the hippocampal re-
stable post-stroke cognitive impairment can evolve into
gion (see Box 7.4 for the causes of amnesic syndrome). The
vascular dementia.
amnesic syndrome is characterized by all of the following:
Depression • Anterograde and retrograde amnesia. The impairment
Depressive ‘pseudodementia’ is a term sometimes used of memory for past events is in reverse order of their
when patients present with clinical features resembling a occurrence (i.e. recent memories are the most affected).
dementia that result from an underlying depression. Both • There is no impairment of attention or consciousness
depression and dementia can be associated with a grad- or global intellectual functioning. There is also no
ual onset of low mood, anorexia, sleep disturbance and defect in working memory as tested by digit span.
generalized cognitive and functional impairment, and
they can be very difficult to distinguish. If there is un-
certainty, treatment for depression is trialled and cogni- BOX 7.4 CAUSES OF AMNESIC SYNDROME
tion rechecked after mood has improved. Unfortunately,
depression presenting with cognitive impairment is a risk Diencephalic damage
factor for later developing dementia.
Vitamin B1 (thiamine) deficiency (i.e. Korsakoff
syndrome):
Psychosis
Chronic alcohol abuse
Patients with schizophrenia often have multiple cognitive
deficits, particularly relating to memory, but unlike de- Gastric carcinoma
mentia, the age of onset is earlier and psychotic symptoms Severe malnutrition
are present from the start. An acute psychotic state may Hyperemesis gravidarum
resemble a delirium due to disturbed behaviour, vivid hal- Bilateral thalamic infarction
lucinations, distractibility and thought disorder. However, Multiple sclerosis
patients generally remain orientated and symptoms do not Post subarachnoid haemorrhage
fluctuate to the same degree as in delirium. Third ventricle tumours/cysts
Intellectual disability Hippocampal damage

Patients with intellectual disability have an IQ below 70 Bilateral posterior cerebral artery occlusion
with an impaired ability to adapt to their social environ- Carbon monoxide poisoning
ment. Unlike dementia, intellectual disability manifests Closed head injury
in the developmental period (before age 18 years) and the Herpes simplex virus encephalitis
level of cognitive functioning tends to be stable over time,
Transient global amnesia
not progressively deteriorating (see Chapter 29). However,
intellectual disability can be comorbid with dementia or
68
Assessment 7
• There is strong evidence of a brain disease known to To the informant:

cause the amnesic syndrome. • Are they repetitive in conversation?
Although there is no impairment of global cognitive func- • Has their personality changed?
tioning, patients with the amnesic syndrome are usually • Are they having difficulty with aspects of their day-to-
disorientated in time due to their inability to learn new ma- day life?
terial (anterograde amnesia). Other associated features are • Do you have any concerns about their safety?
confabulation (filling of gaps in memory with details which
are fictitious, but often plausible), lack of insight and apathy. Examination
The commonest cause of amnesic syndrome is thiamine
deficiency resulting in Wernicke encephalopathy followed Cognitive examination
by Korsakoff syndrome. See Chapter 8 for details. The key when assessing cognition is to use a standardized
test and avoid vague descriptions such as ‘alert and orien-
tated’. Many patients maintain a good social veneer, making
HINTS AND TIPS it surprisingly easy to miss cognitive impairment if it is not
formally assessed. There is a wide range of tests available
Due to their unimpaired intellectual functioning, of varying comprehensiveness, length and generalizability
maintained communication and language skills, across cultures. The one you choose depends on the time
tendency to confabulate and lack of insight, available and degree of concern about a patient’s cognition.
patients with an amnesic syndrome can present In the UK, it is recommended that all hospital inpatients
as problem-free. Therefore, as in dementia, a aged more than 65 years have their cognition screened
whether or not they appear impaired. Table 7.6 lists the ad-
collateral history is crucial.
vantages and disadvantages of some widely used screening
tests. There are many more cognitive tests which may be
useful for specific disorders (e.g. the Wisconsin card test to
assess frontal lobe function). Assessment of conscious level
is described in Fig. 7.1.
ASSESSMENT
History
HINTS AND TIPS
The following questions may be helpful in eliciting symp-
toms of cognitive impairment: Try to ensure the result of a cognitive assessment
To the patient: reflects cognitive abilities rather than other
• Do you find yourself forgetting familiar people’s difficulties as far as possible: check for medications
names? which may be influencing cognition, ensure the
• Do you get lost more easily than you used to? patient has their glasses and/or hearing aid, is not
• Are you able to handle money confidently? hungry, needing the toilet or exhausted.
• Do you feel being forgetful is stopping you from doing
anything?
Table 7.6 Standardized tests of cognition: advantages and disadvantages

Test Acronym Time to perform (min) Advantages Disadvantages
Abbreviated Mental AMT 3 Fast Not sensitive to mild to
Test moderate impairment
Montreal Cognitive MoCA 10 Tests all cognitive Influenced by premorbid IQ,
Test domains language and culture
Sensitive to mild Tester needs to practice
impairment prior to administration
Addenbrooke’s ACE-III 20 Tests all cognitive Lengthy
Cognitive domains Influenced by premorbid IQ,
Examination – III Sensitive to mild language and culture
impairment
In the past, the MMSE (mini mental state exam) was commonly used but is less so now because of both licensing
restrictions and availability of more comprehensive tests.
69
Physical examination Table 7.8 Typical CT appearances for the main forms of

A physical examination, including a neurological examina- dementia
tion, is important in everyone with cognitive impairment as
Condition CT appearance
it may provide evidence of:
Normal ageing Progressive cortical atrophy
• Reversible causes of impairment such as and increasing ventricular
hypothyroidism or a space occupying lesion size
• Risk factors for dementia (e.g. hypertension or atrial
Alzheimer disease Generalized cerebral
fibrillation). atrophy
• Differential diagnosis of dementia (e.g. a hemiparesis Widened sulci
or visual field defect suggestive of a stroke and hence Dilated ventricles
increased risk for vascular dementia) Thinning of the width of the
• Complications of impairment such as self-neglect or medial temporal lobe (in
injuries from falls temporal lobe-oriented CT
scans)
• Factors that may influence future prescribing
decisions (e.g. bradycardia should lead to caution with Vascular dementia Single/multiple areas of
cholinesterase inhibitors) infarction
Cerebral atrophy
Dilated ventricles
Investigations Frontotemporal dementia Greater relative atrophy of
The main aim of investigation in cognitive impairment is to (including Pick disease) frontal and temporal lobes
exclude reversible causes (Table 7.7). In delirium, additional Knife-blade atrophy
investigations for acute illness are likely to be appropriate, (appearance of atrophied
including an electrocardiogram (ECG) and a septic screen gyri)
in the presence of infective symptoms or pyrexia. Huntington disease Dilated ventricles
Although some types of dementia have characteristic ra- Atrophy of caudate nuclei
diological findings (Table 7.8), these differences are not yet (loss of shouldering)
robust enough to be diagnostic. In some rarer forms of de- Creutzfeldt–Jakob disease Usually appears normal
mentia, genetic testing may be useful (Huntington disease (CJD)
and early onset Alzheimer; see Chapter 19). If the diagnosis nvCJD (new variant CJD) nvCJD has a characteristic
MRI picture: a bilaterally
evident high signal in the
pulvinar (post-thalamic)
region
Note that an MRI scan is generally preferable to a CT scan
Table 7.7 Investigations recommended in chronic for aiding in the diagnosis of dementia because more
cognitive impairment detailed images can be obtained. CT findings are provided
here because MRI is less commonly available.
Investigation Potentially treatable cause
CT, Computed tomography; MRI, magnetic resonance imaging.
Vitamin B12/folate level Nutrient deficiency/
malabsorption
Thyroid function tests, Hypothyroidism,
calcium, glucose, urea and hypercalcaemia, Cushing, or
electrolytes (U&E) Addison disease is in doubt or atypical, a more detailed cognitive assessment
CT/MRI head scan Subdural haematoma, by a neuropsychologist may be of benefit (usually accessed
tumour, normal pressure via a ‘memory clinic’).
hydrocephalus
The above investigations are recommended by NICE
(2006) as a minimum for excluding reversible causes
of dementia in the UK. Other investigations may also DISCUSSION OF CASE STUDY
be appropriate depending on features in the history or
examination (e.g. HIV or syphilis serology, heavy metal
Mr DD first presented with memory loss for recent events.
screen, autoantibodies).
His personality gradually changed (withdrawn, prone to
CT, Computed tomography; MRI, magnetic resonance imaging.
verbal aggression) and he also developed numerous other
70
cognitive deficits: aphasia (rambling incoherently), agnosia sleep–wake cycle, psychomotor agitation and apparent
(unable to recognize his pipe), apraxia (unable to dress him- perceptual disturbances (visual hallucinations). It is crucial
self) and impaired executive functioning (unable to make that the cause of the delirium is diagnosed and treated. In
a cup of coffee). This 6-year deterioration in cognitive and this case, it could be pneumonia as Mr DD had developed
functional abilities associated with a normal level of con- a productive cough.
sciousness suggests the diagnosis of dementia. Now go on to Chapter 19 to read about delirium and de-
Mr DD then developed a delirium as evidenced by mentia and their management.
the rapid onset of a fluctuating conscious level, disturbed
Chapter Summary
• Cognitive impairment is common and associated with high morbidity and mortality, but is
often under-recognized.
• Delirium is a syndrome of impaired consciousness, impaired attention and impaired
cognition, all with acute or fluctuating onset.
• Dementia is a syndrome of acquired, gradually progressive, generalized cognitive
impairment associated with functional decline.
• Always assess cognition using a standardized cognitive test.
• A collateral history is often crucial to establish the temporal pattern of cognitive
difficulties and degree of functional impairment.
• Always screen for treatable causes of delirium and dementia.
71
The patient with alcohol or
substance use problems 8
FEATURES
Mr AD, aged 42 years, presented to his general
practitioner (GP) smelling of alcohol and The term ‘psychoactive’ refers to any substance that has an
complaining of depression, anxiety, relationship effect on the central nervous system. This includes recre-
difficulties and erectile dysfunction. He admitted ational drugs, alcohol, nicotine, caffeine, prescribed or
to drinking up to a bottle and a half of whisky per over-the-counter medication and poisons or toxins.
day. He reported drinking increasing amounts This section will introduce five concepts in relation to psy-
over the past year as the same amount no longer choactive substance use: intoxication, hazardous use, harmful
gave him the same feeling of well-being. Recently, use, dependence and withdrawal. Fig. 8.1 provides an over-
view of these and some other substance-related disorders.
he noticed that he had to drink in order to avoid
shaking, sweating, vomiting and feeling ‘on edge’.
These symptoms meant having to take two glasses Substance intoxication
of whisky before breakfast, just to feel better. Mr Substance intoxication describes a transient, substance-
AD admitted that he had neglected his family and specific condition that occurs following the use of a psy-
work because of his drinking. Whereas in the past, choactive substance. Symptoms can include disturbances
he would vary what and when he drank, he now of consciousness, perception, mood, behaviour and physi-
tended to drink exactly the same thing at the same ological functions. Severity of intoxication is normally pro-
time each day, irrespective of his mood or the portional to dose or levels.
occasion. He found himself craving alcohol and felt
unable to walk home past the pub without going HINTS AND TIPS
in. He continued to drink although he knew it was
harming his liver. He was also concerned about Hazardous use of a substance
his mental health because, on more than one ‘Hazardous use’ is a widely used term introduced
occasion, he thought he saw a witch, about the by the World Health Organization and National
same height as the kitchen kettle, walking around Institute for Health and Care Excellence but is not
the room. He decided to contact his GP after he in ICD-10. Hazardous use of a substance is defined
was charged with drink-driving by the police. Mr as a quantity or pattern of substance use that
AD had no previous psychiatric history or family places the user at risk for adverse consequences,
history of psychiatric illness and was not taking without dependence. For example, drinking alcohol
any medication. above the recommended limits (see Fig 8.2) is
(For a discussion of the case study see the end of hazardous use, whether or not the person feels
the chapter). they have come to any harm.
Psychoactive substances have been used for centuries, and

their use is seen in many cultures as entirely acceptable.
Harmful use of substance
They have many beneficial effects including relief of pain Harmful use of a substance is defined as a quantity or pat-
and distress; without them, life would be grim for some. tern of substance use that actually causes adverse conse-
However, psychoactive substances may cause symptoms quences, without dependence. It may result in difficulties
and behaviour changes which are damaging to the individ- within interpersonal relationships (e.g. domestic violence,
ual or those around them, particularly when the substance erectile dysfunction); problems meeting work or educa-
is used regularly or to excess. Initial use of a substance can tional obligations (e.g. absenteeism); impaired physical
lead to a cycle of further use even when the person wishes health (e.g. alcohol-related liver disease, trauma); worsen-
to stop, as many recreational substances are associated with ing of mental health problems (e.g. low mood or anxiety); or
dependence, and withdrawal can be unpleasant and, with a legal difficulties (e.g. arrest for disorderly conduct, stealing
minority of substances, fatal. to fund habit, drink-driving).
73
The patient with alcohol or substance use problems
Patient reports psychoactive substance use

Transient behavioural, perceptual or cognitive
symptoms shortly after use
Intoxication
Can present as delirium if severe
If use places at high risk for harm

Hazardous use
If use causes harm but not dependent Substance-related cognitive disorder

Harmful use
May be Substance-related psychotic disorder
If dependence syndrome (Box 8.4) associated with
Dependence Substance-related mood disorder
Substance-related anxiety disorder

If stopped abruptly
No symptoms
depending on substance and extent of use:
e.g. hallucinogens, inhalants
Withdrawal syndrome
Mild-severe, substance-specific
Withdrawal with delirium

e.g. Delirium tremens in alcohol withdrawal
Notes on classification: This diagram is primarily based on ICD-10. Hazardous use is a widely used term introduced by the WHO
but is not in ICD-10. ICD-10 does not specify substance-induced mood or anxiety disorder, but these are included in the current draft
of ICD-11 (not yet published). ICD-10 refers to substance-induced ‘amnestic disorder’ (see Chapter 7) rather than cognitive disorder.
Fig. 8.1 Diagnostic algorithm for a person presenting with psychoactive substance use.
Limit weekly consumption
You should drink no more than 14 units/week, male or female

Regularly drinking more than this means your lifetime risk of dying from
an alcohol-related condition is >1%
1
2.7 3.5
40% spirit 4.8% lager 14% wine

25 mL Pint (568 mL) 250 mL
Spread out weekly consumption
Avoid bingeing: spread intake evenly over 3 or more days

(or fewer days if drinking less than 14 units/week)
Reduce risk during single-episode consumption
Limit the total amount consumed on a single occasion

No maximum daily limit suggested due to large variation between individuals
and contexts. Groups particularly vulnerable to risks of acute intoxication
include people at risk for falls, on interacting medication, or people with
existing physical or mental health problems.
Drink slowly, with food, and alternate with water
Plan ahead to protect yourself from problems while intoxicated

e.g. plan transport home, drink around people you trust
Fig. 8.2 How to keep health risks from drinking alcohol to a low level. (Modified with permission from UK Chief Medical
Officers’ Low Risk Drinking Guidelines, 2016.)
74
Alcohol-related disorders 8
COMMUNICATION BOX 8.1 ICD-10 CRITERIA FOR DEPENDENCE

ON A SUBSTANCE
Remember the ‘four Ls’ (love, livelihood, liver, law)
as a framework for assessing harm arising from 1. A strong desire or compulsion to take the
substance use. substance
2. Difficulties in controlling substance-taking
behaviour (onset, termination, levels of use)
3. Physiological withdrawal state when substance
Substance dependence use has reduced or ceased; or continued use
of the substance to relieve or avoid withdrawal
HINTS AND TIPS symptoms
4. Tolerance where increased quantities of the
The confusion regarding use of the term
substance are required to produce the same
‘addiction’ led the World Health Organization
effect originally produced by lower amounts
(1964) to recommend that the term be abandoned
5. Priority given to substance with neglect of
in scientific literature in favour of the term
other interests and activities due to time spent
‘dependence’.
acquiring and taking substance, or recovering
from its effects
6. Persistence despite harm where use of
the substance is continued despite a clear
COMMUNICATION
awareness of its harmful consequences
Substance ‘misuse’ is a general term used to (physical or mental)
refer to substance use without legal or medical
guidelines. It includes both harmful or dependent
use of substances. Substance ‘abuse’ has the
same meaning but is usually avoided because it ALCOHOL-RELATED DISORDERS
has negative connotations.
Many people who drink alcohol come to no apparent harm.
However, drinking even a small amount of alcohol without
overt harm at the time increases the risk for many subsequent
Substance dependence describes a syndrome that incorpo- illnesses (e.g. cancer, stroke, heart disease, liver disease) and
rates physiological, psychological and behavioural elements also death through accidents (e.g. head injuries, fractures,
(Box 8.1). If patients exhibit either tolerance or withdrawal, facial injuries). This increase in mortality far outweighs the
they may be specified as having physiological dependence. potential health benefits of moderate consumption (which
However, patients can meet the criteria for the dependence are limited to a small reduction in risk for ischaemic heart
syndrome without having developed tolerance or with- disease in women over 55 years old who drink around 5
drawal. The dependence syndrome (ICD-10 criteria) is di- units per week). The Chief Medical Officer (2016) advised
agnosed if three or more of the criteria in Box 8.1 have been that ‘there is no safe level of alcohol consumption’. However,
present together at some time during the previous year. for many people alcohol is a large part of their social lives
and they may feel the benefits of consumption outweigh the
HINTS AND TIPS risks (similar decisions are made by those who choose to
partake in high-risk sports). For those who choose to drink
Patients are physiologically dependent on a alcohol, a number of steps can be taken to keep the associ-
psychoactive substance when they exhibit signs of ated harms to a low level: see Fig. 8.2 and Box 8.8.
tolerance and/or withdrawal.
HINTS AND TIPS

Substance withdrawal One unit of alcohol = 8 g/10 mL of pure alcohol
Substance withdrawal describes a substance-specific syn- (note this varies between countries)
drome that occurs on reduction or cessation of a psycho- One unit is approximately equivalent to the amount
active substance that has generally been used repeatedly, in of alcohol metabolized in 1 hour. For example, if
high doses, for a prolonged period. It is one of the criteria of
the dependence syndrome.
75
you drink a large glass of wine (usually containing RED FLAG

around three units) it will typically be at least 3
Alcohol intoxication can cause dangerous
hours before blood alcohol concentration returns
disinhibition, increasing a person’s likelihood of
to zero.
having and acting upon thoughts of self-harm
Alcohol metabolism follows zero-order kinetics; it or suicide. Seven out of ten men who complete
cannot be speeded up (e.g. by drinking coffee). suicide are intoxicated.
You can calculate units by multiplying alcohol by
volume (ABV) in percent by volume in litres: ABV ×
vol = units (e.g. a pint (568 mL) of 5.3% lager would
contain 5.3 × 0.568 = 3 units Alcohol intoxication can be a potentially life-threatening
condition due to the risk for respiratory depression, aspi-
ration of vomit, hypoglycaemia, hypothermia and trauma
(e.g. head injury, fractures or blood loss following accidents
or assaults).
COMMUNICATION
HINTS AND TIPS
The Chief Medical Officer’s advice on alcohol
consumption can be summarized as: Patients may report drinking alcohol in order to
• There’s no safe level at which to drink alcohol sleep better. This is counterproductive. It is true
• Drinking at most 14 units/week keeps risks low that alcohol reduces sleep latency and leads to
(but some people will be harmed by less) increased slow-wave (deep) sleep during the first
• Don’t drink all 14 units in one night half of the night. However, alcohol also inhibits the
time to onset and duration of REM sleep, causing
disruption to sleep architecture during the second
half of the night and overall reduced quality sleep.
Acute intoxication
Ingestion of alcohol results in transient psychological, be-
havioural and neurological changes, the severity of which Harmful use of alcohol
are roughly correlated to the alcohol concentration in the Harmful use of alcohol is when drinking causes physical,
blood and brain. Initially, this may produce an enhanced psychological or social harm to the patient or others around
sense of well being, greater confidence and relief of anxiety, them. People who harmfully drink are not dependent on alco-
which may lead to individuals becoming disinhibited, talk- hol; if features of dependence are present, the patient has alco-
ative and flirtatious. As blood levels increase, some drinkers hol dependence syndrome (Box 8.1). Box 8.2 lists the adverse
may exhibit inappropriate sexual or aggressive behaviour physical, psychological and social consequences of drinking.
whereas others might become sullen and withdrawn, with
labile mood and possibly self-injurious behaviour. As lev-
els rise further, drinkers can suffer incoordination, slurred COMMUNICATION
speech, ataxia, amnesia (see later) and impaired reaction
It is frequently useful to explain that, although
times, and at very high concentrations, a lowered level of
a patient may not be suffering from alcohol
consciousness, respiratory depression, coma and death.
dependence, they are drinking at harmful levels,
and are likely to benefit from support to reduce
their consumption.
HINTS AND TIPS
Extreme alcohol intoxication states can cause

impaired concentration, inability to sustain
attention and global cognitive impairment, and
Alcohol dependence
can meet diagnostic criteria for delirium (see After a significant time of heavy, regular drinking, users may
Chapter 7). However, this should not be confused develop dependence (Box 8.1). Alcohol dependence does
with delirium tremens, associated with alcohol not just mean physical dependence (although that is an im-
withdrawal. portant part of it), but describes a heterogeneous collection
of symptoms, signs and behaviours which are determined by
biological, psychological and sociocultural factors. There is a
76
Alcohol-related disorders 8
BOX 8.2 COMPLICATIONS OF EXCESSIVE ALCOHOL USE
Mental health Cancers: oropharynx, larynx, oesophagus, liver,

• Substance-related disorders (Fig. 8.1) breast, colon and pancreas.
• Self-harm or suicidal behaviour • Cardiovascular system
Hypertension
Social
Arrhythmias
• Absenteeism from, or poor performance at, work Ischaemic heart disease (in heavy drinkers)
or education Alcoholic cardiomyopathy
• Victim of theft (e.g. wallet, phone, keys) • Immune system
• Unprotected sex with risk for sexually transmitted Increased risk for infections (especially meningitis
disease or unplanned pregnancy and pneumonia)
• Legal problems (increased risk for violent crime, • Metabolic and endocrine system
drink-driving, alcohol-related disorderly conduct, Hypoglycaemia
child abuse) Hyperlipidaemia/hypertriglyceridemia
• Interpersonal problems (arguments with friends or Hyperuricaemia (gout)
family due to alcohol) Hypomagnesaemia, hypophosphatemia,
• Financial problems (expense of drinking, hyponatraemia
unemployment) Alcohol-induced pseudo−Cushing syndrome
• Homelessness • Haematological system
Physical health Red cell macrocytosis
• Nervous system Anaemia
Intoxication delirium Neutropenia
Withdrawal delirium (delirium tremens) Thrombocytopenia
Withdrawal seizures • Musculoskeletal system
Cerebellar degeneration Acute and chronic myopathy
Haemorrhagic stroke Osteoporosis
Peripheral and optic neuropathy • Reproductive system
Wernicke–Korsakoff syndrome Intrauterine growth retardation
Alcohol-related cognitive impairment Fetal alcohol syndrome
• Gastrointestinal system Erectile dysfunction
Alcoholic liver disease (fatty liver, alcoholic Infertility
hepatitis, alcoholic cirrhosis) • Increased incidence of trauma (fractures, head
Acute and chronic pancreatitis injury, soft tissue injury following accidents or
Peptic ulceration and gastritis assaults).
range in the severity of dependence; one dependent drinker states are potentially life-threatening, if they are associated
may experience a mild tremor and anxiety while at work with autonomic hyperactivity or perceptual disturbances
(‘the fear’) whereas another may shake so much after waking which may cause a person to engage in risky behaviour.
that he is unable to drink a cup of tea in the morning without
spilling it.
RED FLAG
Alcohol withdrawal (including
Always check whether previous episodes of
delirium) alcohol withdrawal have been complicated by
The development of withdrawal symptoms upon discontin- medical problems (such as delirium tremens
uation of substance use is part of the dependence syndrome. or seizures) or psychiatric problems (such as
Box 8.3 summarizes the continuum of clinical features of suicidality). These points will be important in
alcohol withdrawal, from uncomplicated withdrawal to determining where detoxification takes place.
life-threatening delirium tremens (‘the DTs’). However,
‘uncomplicated’ does not mean not serious. All withdrawal
77
BOX 8.3 CLINICAL FEATURES OF ALCOHOL WITHDRAWAL
Uncomplicated alcohol withdrawal Withdrawal delirium (delirium tremens)

syndrome • Develops 1–7 days after drinking cessation (mean
• Symptoms develop 4–12 hours after drinking = 48 hours)
cessation • Altered consciousness and marked cognitive
• Tremulousness (‘the shakes’) impairment (i.e. delirium; see Chapters 7 and 19)
• Sweating • Vivid hallucinations and illusions in any sensory
• Nausea and vomiting modality (patients often interact with or are
• Mood disturbance (anxiety, depression, horrified by them; Lilliputian visual hallucinations,
‘feeling edgy’) i.e. miniature humans/animals; formication, i.e.
• Sensitivity to sound (hyperacusis) sensation of insects crawling on the skin)
• Autonomic hyperactivity (tachycardia, • Marked tremor
hypertension, mydriasis, pyrexia) • Autonomic arousal (heavy sweating, raised pulse
• Sleep disturbance and blood pressure, fever)
• Psychomotor agitation • Paranoid delusions (often associated with intense
With perceptual disturbances fear)
• Mortality (5% to 15% of people with delirium
• Illusions or hallucinations (typically visual,
tremens die from cardiovascular collapse,
auditory, or tactile)
hypothermia/hyperthermia, infection)
With withdrawal seizures
• Predisposing factors such as physical illness
• Develop 6–48 hours after drinking (hepatitis, pancreatitis, pneumonia)
cessation
• Occurs in 5%–15% of all alcohol-dependent Withdrawal often precipitates Wernicke
drinkers encephalopathy
• Generalized and tonic–clonic • Triad of ataxia, ophthalmoplegia and acute
• Predisposing factors: previous history of cognitive impairment
withdrawal fits, concurrent epilepsy, low • Risk for long-term cognitive impairment
potassium or magnesium (Korsakoff syndrome)
now clear they represent a continuum, with Wernicke en-

ALCOHOL-RELATED COGNITIVE cephalopathy occurring during acute brain damage due to
DISORDERS thiamine deficiency and Korsakoff being the chronic state
that emerges later. Any disorder that is associated with low
Blackouts thiamine can cause Wernicke–Korsakoff syndrome, but
heavy drinkers are at particular risk. This is because of nu-
Episodes of anterograde amnesia (‘blackouts’) can occur
tritional deficiency secondary to poor dietary intake and
during acute alcohol intoxication. Memory loss may be
impaired absorption.
patchy, or for a discrete block of time during which noth-
Wernicke encephalopathy is characterized by the clas-
ing can be remembered. Blackouts are common and have
sical clinical triad of delirium, ophthalmoplegia (mainly
been experienced by two-thirds of dependent drinkers
nystagmus, sixth nerve palsy or conjugate gaze palsy), and
and one-third of young men in the general population.
ataxia (which can be impossible to distinguish from in-
Blackouts refer to amnesia, not collapsing or ‘passing
toxication). All three triad components are found in only
out’ at the end of the night. They are evidence of haz-
a minority of cases; the presence of any of them should
ardous use of alcohol as they place an individual at great
prompt treatment. Early treatment with parenteral thia-
vulnerability.
mine (Pabrinex) can reduce the likelihood of progression
to Korsakoff syndrome. Korsakoff syndrome is charac-
Wernicke–Korsakoff syndrome terized by extensive anterograde and retrograde amnesia,
Both Wernicke encephalopathy and Korsakoff syndrome frontal lobe dysfunction and psychotic symptoms occur-
occur because of thiamine (vitamin B1) deficiency. Although ring in the absence of delirium. See Chapter 20 for more
the two disorders were initially described separately it is details of treatment.
78
Alcohol-related cognitive disorders 8
from disorders associated with psychotic symptoms (e.g.

RED FLAG schizophrenia, bipolar affective disorder). Alcohol misuse
The classic triad of Wernicke encephalopathy is is also strongly (but rarely) associated with overvalued ideas
delirium (82% of cases), ophthalmoplegia (29% or delusions of infidelity (morbid jealousy, or ‘Othello syn-
of cases) and ataxia (23% of cases). However,
drome’; see Table 9.1). However, drinkers may experience
psychotic symptoms that resolve or significantly improve
all three features are only found in around 1 in
with abstinence from alcohol and can thus be directly at-
10 patients, and at presentation 1 in 5 patients
tributed to alcohol. These can range from fleeting percep-
have none of these features. In someone who is tual disturbances with retained insight, to more persistent
withdrawing from alcohol, treatment with parental auditory or visual hallucinations (‘alcoholic hallucinosis’), to
thiamine is required for: persecutory or grandiose delusions. These are distinguished
• Anyone who is detoxing as an inpatient from acute intoxication or alcohol withdrawal delirium by
• Anyone who is at high risk for Wernicke the absence of cognitive impairment and by clarifying when
encephalopathy someone last had a drink. Psychotic symptoms directly due
• The presence of any symptom consistent with to alcohol are far rarer than psychotic symptoms due to a
comorbid psychiatric disorder, so always carefully assess for
Wernicke encephalopathy
the presence of other psychiatric disorders even if a patient
Treatment can always be stopped if suspicions
is drinking heavily.
turn out to be unfounded.
Alcohol-related mood disorder

Again, the relationship between alcohol and depression
Dementia is complex. Heavy alcohol consumption may cause low
Long-term alcohol excess leads to impairment of mem- mood, and similarly, low mood may cause sufferers to
ory, learning, visuospatial skills and impulse control asso- drink heavily to ‘escape’ their difficulties. This problem is
ciated with cortical atrophy and ventricular enlargement often compounded by the social damage that alcohol can
(alcohol-related dementia). Withdrawal from alcohol is as- have on a patient’s personal life (relationships, marriage,
sociated with cognitive impairment, which often does not employment, finances, physical ill health, criminality, etc.).
fully recover. Alcohol-dependent people are also at risk for Differentiating low mood secondary to alcohol and true de-
brain damage due to years of poor nutrition, trauma (e.g. pressive disorder is very difficult, and usually starts with ab-
head injury) and comorbid physical illness (e.g. alcoholic stinence (following detoxification if necessary). Because of
liver disease). It is therefore important to screen for other the potent psychoactive depressant effects of alcohol, phar-
causes of cognitive impairment, particularly reversible macological treatment of depression with antidepressants
causes of dementia. Unlike with other dementias, subse- in a patient who continues to drink heavily is extremely
quent abstinence from alcohol often leads to stabilization or unlikely to work and potentially dangerous. The first step in
some improvement in cognitive functioning. See Chapters 7 treating low mood is abstinence.
and 19 for more on dementia.
Alcohol-related anxiety disorder
HINTS AND TIPS Up to a third of drinkers have significant anxiety symptoms. As
in depression, establishing whether alcohol is a cause or a con-
‘Alcohol related brain damage’ (ARBD) is an sequence of anxiety disorders is difficult. The anxiolytic prop-
umbrella term which includes alcohol-induced erties of alcohol often result in attempts at self-medication in
dementia, Wernicke-Korsakoff syndrome and patients with PTSD, agoraphobia and social phobia, and alco-
amnesic syndrome. Abstinence from alcohol hol withdrawal symptoms can mimic anxiety and panic symp-
is often associated with some improvement in toms. Patients often find it difficult to remember which came
cognition. first: the alcohol or the anxiety. Whatever the direction of the
relationship, reducing alcohol consumption will be of benefit.
RED FLAG
Alcohol-related psychotic disorder
Self-harm and suicide are strongly associated with
The interplay between alcohol excess and psychotic symp- alcohol misuse. Over 50% of patients who present
toms is complex, and is not as simple as ‘cause and effect’. to hospital after harming themselves have recently
While both hallucinations and delusions can occur in the drunk alcohol. Alcohol dependence is associated
context of heavy alcohol consumption, alcohol misuse is
also a common comorbidity in many patients who suffer
79
in psychiatric disorders such as psychosis. The effects of

with a 12-fold increase in the risk for completed common recreational drugs are described in Table 8.1.
suicide. This may be due to:
• Alcohol-related psychiatric disorders (mainly
low mood)
• Comorbid psychiatric illnesses and personality DIFFERENTIAL DIAGNOSIS
disorders
• Impaired judgement or disinhibition secondary Patients using psychoactive substances can present with
to alcohol features similar to primary psychiatric disorders, posing a
diagnostic challenge. The relationship between substance
use and psychiatric symptoms can be reduced to three di-
agnostic possibilities:
OTHER SUBSTANCE-RELATED 1. There is a primary psychiatric disorder (e.g. depression
or schizophrenia) and the patient is coincidentally
DISORDERS using drugs or alcohol (remember that patients
suffering from mental illness often use psychoactive
It is beyond the scope of this book to describe in detail the
substances to obtain relief from their symptoms).
individual psychiatric consequences of every recreational
2. The symptoms are entirely due to the direct effect of the
drug. Like alcohol, use can be harmful, dependent or result
substance and no primary psychiatric diagnosis exists.
Table 8.1 Effects of common recreational drugs

Mood and Associated
Common cognition Withdrawal psychiatric
a
Drug group examples effects Physical effects syndromeb disorders
Opioids Heroin, Euphoria, Miosis, Muscle aches, None typical
dihydrocodeine drowsiness, conjunctival nausea, piloerection,
(DF118), apathy, injection, sweating, mydriasis,
methadone, personality nausea, pruritus, lacrimation,
buprenorphine change constipation, rhinorrohea,
(Subutex), bradycardia, tachycardia, tremor,
fentanyl, respiratory anxiety/irritability
oxycodone depression, (rate using COWS)
coma, death Short acting opioids
within 12 hours,
long-acting within
2 days
Lasts around a week
Sedatives Temazepam, Drowsiness, Hypotension, Similar to alcohol Substance-
diazepam (Valium), disinhibition, impaired withdrawal with induced
flunitrazepam confusion, poor coordination, onset and duration cognitive
(Rohypnol) concentration, respiratory depending on impairment
Gamma- reduced anxiety, depression half-life: seizures,
hydroxybutyrate feeling of hallucinations,
(GHB), gamma- wellbeing sweating,
butyrolactone tachycardia, tremor,
(GBL) nausea
Stimulants Amphetamine, Alertness, Mydriasis, Within a few Substance-
cocaine, crack hyperactivity, tremor, hours to days of induced
cocaine, MDMA euphoria, hypertension, stopping heavy use: psychosis
(Ecstasy), irritability, tachycardia, dysphoria, fatigue, and/or mood
mephedrone, aggression, arrhythmias, hyperphagia, disorder
novel paranoid ideas, perspiration, nightmares, Trigger for manic
psychoactive hallucinations fever (especially insomnia or episode in those
substances (especially Ecstasy), hypersomnia, with BPAD
(commonly cocaine – convulsions, psychomotor
stimulants)c formication), perforated nasal retardation or
psychosis septum (cocaine) agitation
80
Table 8.1 Effects of common recreational drugs—cont’d

Mood and Associated
Common cognition Withdrawal psychiatric
Drug groupa examples effects Physical effects syndromeb disorders
Hallucinogens Lysergic acid Marked Mydriasis, No specific Substance-
diethylamide perceptual conjunctival withdrawal induced
(LSD), magic disturbances injection, syndrome psychosis
mushrooms including chronic hypertension,
flashbacks, tachycardia,
paranoid ideas, perspiration, fever,
suicidal and loss of appetite,
homicidal ideas, weakness,
psychosis tremors
Cannabinoids Cannabis, hashish, Euphoria, Impaired Generally Substance-
hash oil relaxation, coordination and mild−moderate induced
altered time reaction time, symptoms lasting psychosis and/or
perception, conjunctival 2−4 weeks mood disorder
psychosis injection, Irritability, anxiety, low Trigger for
nystagmus, dry mood, restlessness, schizophrenia
mouth insomnia,
tremulousness,
headaches
Dissociative Ketamine, Hallucinations, Mydriasis, No specific Substance-
anaesthetics phencyclidine paranoid tachycardia, withdrawal induced
(PCP) ideas, thought hypertension, syndrome psychosis
disorganization, ulcerative
aggression cystitis
Inhalants Aerosols, glue, Disinhibition, Similar to alcohol Existence of Substance-
lighter fluid, petrol, confusion, intoxication: withdrawal induced
toluene euphoria, headache, syndrome unclear. psychosis
hallucinations, nausea, slurred Around half of
stupor speech, loss heavy users
of motor may experience
coordination, hypersomnia, low
muscle mood and nausea
weakness, over the first days
nystagmus Also post-cessation.
arrhythmia and
pneumonitis.
Chronic use:
damage to brain/
liver/kidneys/
myocardium
BPAD, Bipolar affective disorder; COWS, Clinical Opiate Withdrawal Scale.
a
Many drugs affect a person in more than one way so one drug can fit into multiple categories. There are other ways to categorize drugs,
for example, as ‘empathogens’ (drugs which increase empathy) see Fig. 8.3.
b
Stopping any recreational drug that has been taken long-term is often associated with cravings and anxiety about discontinuation; this is
not the same as a specific physiological withdrawal syndrome.
c
Not all novel psychoactive substances are stimulants, they can occur in all classes (e.g. synthetic cannabis, ‘spice’.)
3. Psychiatric symptoms are due to a combination of the • There is a temporal relationship (hours or days)
above, as occurs when psychoactive substances are between the use of the suspected drug and the
used by those with a predisposing vulnerability to the development of psychiatric symptoms.
development of mental illness. • There is a complete recovery from all psychiatric
symptoms after termination and metabolic clearance of
The following features suggest a substance-related psychi-
the suspected drug.
atric disorder:
• There is an absence of evidence to suggest an
• The psychiatric symptoms are known to be associated alternative explanation for psychiatric symptoms (e.g.
with the specific drug in question (e.g. psychotic previous history of primary psychiatric illness or family
symptoms with amphetamine use). history of psychiatric illness).
81
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82
Assessment 8
3. Have you ever felt Guilty about your drinking?

COMMUNICATION 4. Have you ever needed an ‘Eye-opener’ (a drink first
thing in the morning to steady your nerves or get rid of
You cannot completely exclude the use of
a hangover)?
substances, or gauge the severity of established
misuse, without a collateral history (or in some The Alcohol Use Disorders Identification Test (AUDIT)
is a 10-item screening questionnaire for problem drink-
cases even with one). A urine or oral toxicology
ing developed by the WHO. It takes 3 minutes to complete
screen are useful in establishing recent use of
and score, and is recommended by NICE (2011). Severity
common recreational substances. of dependence can be rated using the ‘Severity of Alcohol
Dependence Questionnaire’ (SADQ).
ASSESSMENT RED FLAG
History Always ask about driving and the patient’s

responsibilities for caring for children. These are
The CAGE and AUDIT questionnaires (see later) can be common areas of risk to others caused by alcohol
helpful in screening for alcohol dependence. A thorough
or other substance use.
clinical history should pay particular attention to all sub-
stances used, the pattern of use, the route of use, features of
dependence, periods of abstinence or controlled use, rea-
sons for relapse, previous treatments, and consequences of
substance use (relationships, employment, physical health,
RED FLAG
criminality). History of psychiatric illness and substance
misuse, as well as family history of substance misuse should General Medical Council guidance states that
be explored. Mental state examination is important to estab- use of illegal substances and misuse of alcohol
lish psychiatric comorbidity or sequelae, current suicidality, are fitness to practice issues. This applies to
and insight into current substance misuse (e.g. whether the medical students as well as qualified doctors and
patient considers it to be a problem and what they would is intended to be supportive rather than punitive,
consider to be helpful).
aiming to protect patient safety while facilitating
the doctor or student to engage in treatment and
recovery. If you are misusing substances, contact
RED FLAG
your general practitioner and seek support from
Taking multiple substances at once is a your medical school. If you suspect a peer or
major risk factor for drug related death, with senior colleague is misusing substances in a way
recreational, prescribed and over the counter which may influence patient care, speak to a
drugs all implicated. The top four drugs senior doctor or your medical school.
involved in overdose are all depressants: heroin,
diazepam, alcohol, methadone. Always ask about
polydrug use, and whether the person has ever
unintentionally overdosed. All patients prescribed Examination
opioid substitution treatment should be offered
The physical examination requires an awareness of both the
a take home naloxone kit, and training in how to acute and chronic effects of alcohol or substance use and
recognize and treat an overdose. should focus on:
• Evidence of acute use or intoxication (e.g. pupil
constriction with opioid use; incoordination and
The CAGE questionnaire is a simple tool to screen for al- slurred speech with alcohol use)
cohol dependence. If patients answer yes to two or more • Signs of withdrawal (e.g. tremulousness, sweating,
questions, regard the screen as positive and go on to check nausea and vomiting, tachycardia and pupil dilatation
if they meet criteria for the alcohol dependence syndrome: with opioid withdrawal)
1. Have you ever felt you ought to Cut down on your • Immediate and short-term medical complications
drinking? of substance use (e.g. head injury following alcohol
2. Have people ever Annoyed you by criticizing your intoxication; infection caused by intravenous drug use
drinking? (always inspect injection sites))
83
• Long-term medical complications (e.g. alcohol-related consider the need to repeat testing after potential sero-
liver disease, hepatitis B or C or HIV infection with conversion). Signpost the patient to a needle exchange
intravenous drug use) where they will also get access to a wide variety of harm-
reduction information and education, including sexual
health issues.
Investigations
If the patient is suffering from a withdrawal delirium,
There is no investigation that is absolutely indicative of sub- brain imaging may be necessary to exclude an alternative
stance dependence. A urine or saliva drug-screening test cause or additional complication (e.g. infection, head in-
is essential whenever the use of psychoactive substances is jury, stroke).
suspected. Saliva testing is more dignified than urine test-
ing, and is now most commonly used. Hair testing is oc-
casionally used to get an accurate picture of drug use over HINTS AND TIPS
longer time periods. However, toxicology testing generally
is only set up to detect a limited number of well-known All patients, especially people presenting for the
drugs (and testing laboratories will often not yet be set up first time with psychotic symptoms, should have a
to detect drugs which are new to the black market). Breath urine or saliva drug-screening test. It is important
alcohol level (via a breathalyser) only detects recent alcohol to collect the sample as soon as possible because
use; however, a high reading in the absence of signs of intox- the half-lives (and hence detection windows) of
ication suggests some degree of tolerance, which is likely to some drugs are short. Urine dip-sticks are the
be indicative of chronic heavy drinking. fastest way to get a result.
Investigations are also useful to identify possible
longer-term complications of alcohol (see Table 8.1) and
include a full blood count (mean corpuscular volume, or
MCV, may be elevated), urea and electrolytes, liver function
tests (gamma glutamyl transpeptidase may be raised; ele-
vated aminotransferases (ALT or AST) indicate liver injury DISCUSSION OF CASE STUDY
and a high AST:ALT ratio suggests alcohol is the cause),
clotting screen (prolonged prothrombin time is a sensitive Mr AD has an alcohol dependence syndrome as evidenced
marker of liver function) and electrocardiogram. by his tolerance, withdrawal symptoms, relief of withdrawal
by drinking, strong desire to consume alcohol, and continued
drinking despite awareness of harmful consequences. He has
physical (sexual, possibly other systems), social (relationship
HINTS AND TIPS problems, neglect of family and work), legal (drink-driving
If a patient is drinking too much alcohol, check offence) and mental health (depression, anxiety, hallucina-
tions) complications of his alcohol use. The first priority is
their liver function. If a patient has abnormal liver
treating the alcohol dependence. Following detoxification, it
function tests (LFT), take an alcohol history. Alcohol
is important to reassess his mental health to ensure that his
can cause abnormalities in any LFT. depression, anxiety and hallucinations are not indicative of a
primary psychiatric disorder. The visual hallucinations may
be suggestive of a withdrawal syndrome or be one of the per-
ceptual disturbances sometimes caused by heavy alcohol use
If the patient has injected drugs ensure serology for (alcoholic hallucinosis), although the latter is much less likely.
blood-borne viruses has been performed (hepatitis B and Now go on to Chapter 20 to read about the alcohol and
C, HIV) subsequent to the most recent injection (and substance disorders and their management.
84
Further reading 8
Chapter Summary
Problematic psychoactive substance use can be classified as:

• Substance use disorders including
• intoxication, hazardous use, harmful use, dependent use, withdrawal states
• Substance-induced psychiatric disorders
• including cognitive impairment, psychosis, depressive episode, manic episode,
anxiety
Substance use is often comorbid with primary psychiatric disorders
Intoxication by and withdrawal from psychoactive substances can be life-threatening
When assessing substance misuse, don’t forget to assess for impact on physical health and
psychosocial function
FURTHER READING
Clinical Opiate Withdrawal Scale (COWS) https://www.drugabuse.
gov/sites/default/files/files/ClinicalOpiateWithdrawalScale.pdf
Alcohol Use Disorders Identification Test (AUDIT) https://www.
drugabuse.gov/sites/default/files/files/AUDIT.pdf
85
The patient with psychotic
symptoms 9
The patient with psychotic symptoms can present in many
CASE SUMMARY varied ways. It is often very difficult to elicit and describe
Mr PP, aged 23 years, was assessed by his
specific symptoms when a patient is speaking or behaving
in a grossly disorganized fashion. Therefore it is important
general practitioner (GP) because his family had
to approach the assessment in a logical and systematic fash-
become concerned about his behaviour. Over the
ion as well as to have a good understanding of the psycho-
last 6 months his college attendance had been pathology involved.
uncharacteristically poor and he had terminated his
part-time work. He had also become increasingly
reclusive, spending more time alone in his flat,
refusing to answer the door or see his friends. After DEFINITIONS AND CLINICAL
some inappropriate suspiciousness, he allowed the FEATURES
GP into his flat and then disclosed that government
scientists had started to perform experiments on The term ‘psychosis’ refers to a mental state in which re-
him over the last year. These involved the insertion ality is grossly distorted, resulting in symptoms such as
of an electrode into his brain that detected gamma delusions, hallucinations and thought disorder. However,
rays transmitted from government headquarters, patients with schizophrenia and other psychotic disorders
which issued him with commands and ‘planted’ often have other symptoms too (e.g. psychomotor abnor-
malities, mood/affect disturbance, cognitive deficits and
strange ideas in his head. When the GP asked how
disorganized behaviour).
he knew this, he replied that he heard the ‘men’s
There are many classifications that attempt to describe
voices’ as ‘clear as day’ and that they continually all the symptoms seen in schizophrenia and psychosis, but it
commented on what he was thinking. He explained is useful to approach psychotic psychopathology using five
that his suspicion that ‘all was not right’ was somewhat interrelated parameters:
confirmed when he heard the neighbour’s dog 1. Perception
barking in the middle of the night; at that point 2. Abnormal beliefs
he knew ‘for certain’ that he was being interfered 3. Thought disorder
with. Prompted by the GP, Mr PP also mentioned 4. Negative symptoms
that a man in his local pub knew of his plight and 5. Psychomotor function
had sent him a ‘covert signal’ when he overheard
the man conversing about the dangers of nuclear Perceptual disturbance
experiments. He also admitted to ‘receiving coded
information’ from the radio whenever it was turned Perception is the process of making sense of the physical in-
on. Mr PP found his experiences very disturbing
formation we receive from our sensory modalities.
Hallucinations are perceptions occurring in the absence
and had been considering suicide to escape his
of an external physical stimulus, which have the following
situation. The GP found no evidence of abnormal
important characteristics:
mood, incoherence of speech or disturbed
• To the patient, the nature of a hallucination is the same
motor function. Mr PP denied use of recreational
as a normal sensory experience (i.e. it appears real).
drugs and appeared physically well. After the GP
Therefore patients often have little insight into their
discussed the case with a psychiatrist, Mr PP was abnormal experience.
admitted to a psychiatric hospital for a period of • They are experienced as external sensations from any
assessment and to manage his risk to himself. Mr one of the sensory modalities (e.g. hearing, vision,
PP agreed to a voluntary admission, as he was smell, taste, touch) and should be distinguished from
now afraid of staying alone at home. ideas, thoughts, images or fantasies which originate in
(For a discussion of the case study see the end of the patient’s own mind.
the chapter). • They occur without an external stimulus and are not
merely distortions of an existing physical stimulus (see
Illusions).
87
The patient with psychotic symptoms
Elementary
First person
Auditory
Complex Second person
Third person
Visual
Tactile/haptic
Superficial Thermal
Somatic Visceral Hygric
Kinaesthetic
Olfactory
Gustatory
Extracampine
Special cases Functional
Reflex
Hypnopompic/hypnagogic
Fig. 9.1 Outline of classification of hallucinations.
According to which sense organ they appear to arise from, states (e.g. epilepsy, migraine, delirium). Complex halluci-
hallucinations are classified as auditory, visual, olfactory, nations occur as spoken phrases, sentences or even dialogue
gustatory or somatic. Special forms of hallucinations will that are classified as:
also be discussed. See Fig. 9.1 for an outline of the classifica- • Audible thoughts (first person): patients hear their own
tion of hallucinations. thoughts spoken out loud as they think them. When
Illusions are misperceptions of real external stimuli (e.g. patients experience their thoughts as echoed by a voice
in a dark room, a dressing gown hanging on a bedroom wall after they have thought them, it is termed thought echo.
is perceived as a person). Illusions often occur in healthy • Second person auditory hallucinations: patients hear
people and are usually associated with inattention or in- a voice or voices talking directly to them. Second
tense emotional state (e.g. situational anxiety). person hallucinations can be persecutory, highly
A pseudohallucination is a perceptual experience which critical, complimentary or can issue commands to the
differs from a hallucination in that it appears to arise in the patient (command hallucinations). Second person
subjective inner space of the mind, not through one of the hallucinations are often associated with mood disorders
external sensory organs. Although experienced in internal with psychotic symptoms and so will be critical or
space pseudohallucinations are not under conscious control persecutory in a depressed patient or complimentary in
(e.g. someone hearing a voice inside their own head telling a manic patient (i.e. mood-congruent hallucinations).
them to harm themselves or someone experiencing distress- • Third person auditory hallucinations: patients hear a
ing flashbacks in posttraumatic stress disorder). These are voice or voices speaking about them, referring to them
not viewed as true psychotic experiences. Note that some in the third person. This may take the form of two or
psychiatrists define pseudohallucinations to mean halluci- more voices arguing or discussing the patient among
nations that patients recognize as false perceptions (i.e. they themselves or one or more voices giving a running
have insight into the fact that they are hallucinating). The commentary on the patient’s thoughts or actions.
former definition is probably more widely used.
HINTS AND TIPS

Auditory hallucinations
These are hallucinations of the hearing modality and are the Particular types of auditory hallucination are highly
most common type of hallucinations in clinical psychiatry. suggestive of schizophrenia and known as ‘first-
Elementary hallucinations are simple, unstructured sounds rank symptoms’. See Box 9.7 for a list.
(e.g. whirring, buzzing, whistling or single words); this type
of hallucination occurs most commonly in acute organic
88
Definitions and clinical features 9
Visual hallucinations Special forms of hallucination

These are hallucinations of the visual modality. They occur Hypnagogic hallucinations are false perceptions in any mo-
most commonly in organic brain disturbances (delirium, dality (usually auditory or visual) that occur as a person
occipital lobe tumours, epilepsy, dementia) and in the con- goes to sleep; whereas, hypnopompic hallucinations occur
text of psychoactive substance use (lysergic acid diethylam- as a person awakens. These occur commonly and do not
ide, mescaline, petrol/glue-sniffing, alcoholic hallucinosis). indicate mental disorder.
An autoscopic hallucination is the experience of seeing an Extracampine hallucinations are false perceptions that
image of oneself in external space. Charles Bonnet syndrome occur outside the limits of a person’s normal sensory field
describes the condition where patients experience complex (e.g. a patient describes hearing voices from 100 miles
visual hallucinations associated with no other psychiatric away). Patients often give delusional explanations for this
symptoms or impairment in consciousness; it usually occurs phenomenon.
in older adults and is associated with loss of vision. Lilliputian A functional hallucination occurs when a normal sen-
hallucinations are hallucinations of miniature people or ani- sory stimulus is required to precipitate a hallucination in
mals and are associated with alcohol withdrawal. that same sensory modality (e.g. voices that are only heard
when the doorbell rings). A reflex hallucination occurs
Somatic hallucinations when a normal sensory stimulus in one modality precip-
These are hallucinations of bodily sensation and include itates a hallucination in another (e.g. voices that are only
superficial, visceral and kinaesthetic hallucinations. heard whenever the lights are switched on).
Superficial hallucinations describe sensations on or just
below the skin and may be:
• Tactile (haptic): experience of the skin being touched,
Abnormal beliefs
pricked or pinched. Formication is the unpleasant Abnormal beliefs include primary and secondary delusions
sensation of insects crawling on or just below the skin; and overvalued ideas.
it is commonly associated with long-term cocaine use
(cocaine bugs) and alcohol withdrawal.
• Thermal: false perception of heat or cold. Delusions
• Hygric: false perception of a fluid (e.g. ‘I can feel water A delusion is an unshakeable false belief that is not accepted
sloshing in my brain’). by other members of the patient’s culture. It is important
Visceral hallucinations describe false perceptions of the in- to understand the following characteristics of delusional
ternal organs. Patients may be distressed by deep sensations thinking:
of their organs throbbing, stretching, distending or vibrating. • To the patient, there is no difference between a
Kinaesthetic hallucinations are false perceptions of joint delusional belief and a true belief; they are the same
or muscle sense. Patients may describe their limbs vibrating experience. Therefore only an external observer can
or being twisted. The fleeting but distressing sensation of diagnose a delusion. A delusion is to ideation what an
free falling just as one is about to fall asleep is an example hallucination is to perception: both have the quality of
that most people have experienced (see Hypnagogic hallu- reality to the person experiencing them.
cinations later in this chapter). • The delusion is false because of faulty reasoning.
A man’s delusional belief that his wife is having
Olfactory and gustatory hallucinations an affair may actually be true (she may indeed be
These are the false perceptions of smell and taste. They unfaithful), but it remains a delusion because the
commonly occur together because the two senses are closely reason he gives for this belief is undoubtedly false
related. A classic example is mood-congruent hallucina- (e.g. she ‘must’ be having an affair because she is part
tions of rotting flesh or burning in depression. However, in of a top-secret sexual conspiracy to prove that he is a
patients with new olfactory or gustatory hallucinations, it is homosexual).
important to rule out epilepsy (especially of the temporal • A delusion is out of keeping with the patient’s
lobe) and other organic brain diseases. social and cultural background. It is crucial to
establish that the belief is not one likely to be
RED FLAG BOX held by that person’s subcultural group (e.g. a
belief in the imminent second coming of Christ
If a patient presents with visual, olfactory, or may be appropriate for a member of a religious
elementary hallucinations, consider the possibility group, but not for a formerly atheist, middle-aged
of brain disorders such as delirium, migraine, businessman).
epilepsy or cancer before attributing these It is diagnostically significant to classify delusions as:
symptoms to a primary psychiatric disorder.
• Primary or secondary
• Mood congruent or mood incongruent
89
• Bizarre or non-bizarre
• According to the content of the delusion COMMUNICATION
Primary delusions (autochthonous delusions) do not oc- Direct questioning about perceptual experience
cur in response to any previous psychopathological state; may alienate a nonpsychotic patient and raise
their genesis is not understandable. They may be preceded undue suspicion in a psychotic patient. To maintain
by a delusional atmosphere (mood) where patients have a
rapport with patients, begin these questions with a
sense that the world around them has been subtly altered,
primer such as: ‘I am now going to ask you some
often in a sinister or threatening way. In this state a fully
formed delusion has not yet developed and patients appear questions which may seem a little strange, but are
perplexed and apprehensive. Note that when a delusion routine questions which I ask all patients’.
occurs after a delusional atmosphere it is still regarded as
primary; the delusional atmosphere is probably a precur-
sor to the fully developed primary delusion. A delusional Overvalued ideas
perception is also a primary delusion and occurs when a An overvalued idea is a plausible belief that a patient becomes
delusional meaning is attached to a normal perception (e.g. preoccupied with to an unreasonable extent. The key feature
a patient believed he was a terrorist target because he heard is that the pursuit of this idea causes considerable distress to
an aeroplane flying in the distance). Primary delusions oc- the patient or those living around them (i.e. it is overvalued).
cur typically in schizophrenia and other primary psychotic Patients who hold overvalued ideas have usually had them for
disorders. Secondary delusions are the consequences of pre- many years and typically have abnormalities of personality.
existing psychopathological states, usually mood disorders They are distinguished from delusions by the lack of a gross
(see Chapters 10 and 11). Many interrelated delusions that abnormality in reasoning; these patients can often give fairly
are centred on a common theme are termed systematized logical reasons for their beliefs. They differ from obsessions in
delusions. that they are not experienced as recurrent intrusive thoughts.
In mood-congruent delusions, the contents of the However, one will frequently encounter beliefs that span defi-
delusions are appropriate to the patient’s mood and nitions. Typical disorders that feature overvalued ideas are an-
are commonly seen in depression or mania with psychotic orexia nervosa, hypochondriacal disorder, dysmorphophobia,
features. paranoid personality disorder and morbid jealousy (this can
Bizarre delusions are those which are extremely implau- also take the form of a delusion). See Table 13.1 for tips on
sible (e.g. the belief that aliens have planted radioactive det- how to distinguish different types of abnormal thoughts.
onators in the patient’s brain). They are considered to be
characteristic of schizophrenia.
Table 9.1 lists the classification of delusions by their con-
Thought disorder
tent. It is important that you can label a delusion according Thought disorder is when someone’s speech is so disorga-
to its content, so take some time to familiarize yourself with nized that it is difficult to follow what is meant. Many patients
this table. with delusions are able to communicate in a clear and coher-
ent manner; although their beliefs may be false, their speech
is organized (thus delusions are an abnormality of thought
HINTS AND TIPS content, not thought form). However, there is a subgroup
of psychotic patients who speak in such a disorganized way
Note that the term ‘paranoid’ refers to any that it becomes difficult to understand what they are saying.
delusions or ideas that are unduly self-referent, The coherency of patients with disorganized thinking varies
typically feelings of persecution, grandeur or from being mostly understandable in patients exhibiting cir-
reference. It should not be used synonymously with cumstantial thinking to being completely incomprehensible
in patients with a word salad phenomenon (see Fig. 9.2).
the term ‘persecutory’; (i.e. when a patient has a
Describing the disturbance of a patient’s thought form
false belief that people are trying to harm him), do
is one of the most challenging tasks facing clinicians. This
not say that he is paranoid, rather say that he has a problem is compounded by two factors: it is impossible
persecutory delusion. to know what patients are actually thinking (i.e. thought
form has to be inferred from their speech and behaviour);
the unfortunate situation has arisen where various authors
in psychiatry have described a different conceptual view
of thought disorder, which has resulted in conflicting and
Finally, beliefs that were previously held with delusional confusing classification systems. It is not essential to be able
intensity but then become held with less conviction are to identify all the subgroups of thought disorder, but it is
termed partial delusions. This occurs when patients are important that you are able to say when thought form is
recovering. or is not disordered. To describe the nature of the thought
90
Table 9.1 Classification of delusions by content

Classification Content
Persecutory delusions False belief that one is being harmed, threatened, cheated, harassed or is a victim of a
conspiracy
Grandiose delusions False belief that one is exceptionally powerful (including having ‘mystical powers’), talented
or important
Delusions of reference False belief that certain objects, people or events have intense personal significance and
refer specifically to oneself (e.g. believing that a television newsreader is talking directly
about one)
Religious delusions False belief pertaining to a religious theme, often grandiose in nature (e.g. believing that
one is a special messenger from God)
Delusions of love False belief that another person is in love with one (commoner in women). In one form,
(erotomania) termed ‘de Clérambault syndrome’, a woman (usually) believes that a man, frequently older
and of higher status, is in love with her
Delusion of infidelity False belief that one’s lover has been unfaithful. Note that morbid jealousy may also take
(morbid jealousy, Othello the form of an overvalued idea, that is, nonpsychotic jealousy
syndrome)
Delusions of Capgras syndrome: belief that a familiar person has been replaced by an exact double – an
misidentification impostor
Fregoli syndrome: belief that a complete stranger is actually a familiar person already
known to one
Nihilistic delusions False belief that oneself, others or the world is nonexistent or about to end. In severe
(see Cotard syndrome, cases, negation is carried to the extreme with patients claiming that nothing, including
Chapter 11.) themselves, exists
Somatic delusions False belief concerning one’s body and its functioning (e.g. that one’s bowels are rotting).
Also called ‘hypochondriacal delusions’ (to be distinguished from the overvalued ideas
seen in hypochondriacal disorder)
Delusions of infestation False belief that one is infested with small but visible organisms. May also occur secondary
(Ekbom syndrome) to tactile hallucinations (e.g. formication; see Chapter 8)
Delusions of control False belief that one’s thoughts, feelings, actions or impulses are controlled or ‘made’ by
(passivity or ‘made’ an external agency (e.g. believing that one was ‘made’ to break a window by demons)
experiences) Delusions of thought control include:
Note: these are all ‘Thought insertion’: belief that thoughts or ideas are being implanted in one’s head by an
first-rank symptoms of external agency
schizophrenia ‘Thought withdrawal’: belief that one’s thoughts or ideas are being extracted from one’s
head by an external agency
‘Thought broadcasting’: belief that one’s thoughts are being diffused or broadcast to others
such that they know what one is thinking
isorder you should have a clear understanding of the indi-

d The following are important signs of disorganized
vidual definitions you intend to use. To help describe thought thinking:
disorder, it is particularly helpful if you document and are able
to cite examples of the patient’s speech in their own words. Circumstantial and tangential thinking
See Chapter 10.
HINTS AND TIPS

Flight of ideas
Many people have mildly disordered See Chapter 10.
communication styles, particularly when tired or
stressed. Perhaps you can think of someone you Loosening of association (derailment/
know who is often mildly circumstantial in their knight’s move thinking)
story telling? To count as thought disorder, the This is when the patient’s train of thought shifts suddenly
patient’s thinking style should significantly impair from one very loosely or unrelated idea to the next. In its
worst form, speech becomes a mixture of incoherent words
effective communication.
and phrases and is termed ‘word salad’. Loosening of asso-
ciation is characteristic of schizophrenia. Note that some
91
A B
Normal thinking: relevant associations, goal directed
A B
Circumstantial/overinclusive thinking: less relevant associations, goal reached but by circuitous route
Tangential thinking/flight of ideas: less relevant associations, goal never reached

Normal speed = tangential, accelerated speed = flight of ideas C
Loosening of associations: poorly or unrelated concepts, unclear goal
Fig. 9.2 Thought disorder: simplified representation.
sychiatrists, but not all, use the term ‘formal thought dis-
p Negative symptoms
order’ synonymously with loosening of association.
Positive symptoms are those that are present when they
should not be and include delusions, hallucinations and
Special forms of thought disorder thought disorder. In contrast, negative symptoms are abili-
Thought blocking occurs when patients experience a sudden
ties that are absent when they should be present and include
cessation to their flow of thought, often in mid-sentence
marked apathy, poverty of thought and speech, blunting of af-
(observed as sudden breaks in speech). Patients have no re-
fect, social isolation, poor self-care and cognitive impairment.
call of what they were saying or thinking and thus continue
Patients can have positive and negative symptoms simulta-
talking about a different topic.
neously or, as often happens, develop a negative presentation
Neologisms are new words created by the patient, often
after initially presenting with predominantly positive symp-
combining syllables of other known words. Patients can also
toms. Remember that patients with a depressed mood or
use recognized words idiosyncratically by attributing them
those experiencing significant side-effects from psychotropic
with an unrecognized but related meaning (metonyms).
medication may also present with what appear to be negative
Perseveration is when an initially correct response is
symptoms, which often presents a diagnostic challenge.
inappropriately repeated (e.g. unnecessarily repeating a
previously expressed word or phrase). Palilalia describes
Psychomotor function
the repetition of the last word of a sentence; logoclonia de-
scribes the repetition of the last syllable of the last word. Although a relatively rare phenomenon in industrialized
Perseveration is highly suggestive of organic brain disease. countries, some patients with psychosis will present with
Echolalia is when patients senselessly repeat words or abnormalities of motor function. Motor system dysfunc-
phrases spoken around them by others (i.e. like a parrot). tion in schizophrenia is usually due to the e xtrapyramidal
Irrelevant answers is when patients give answers that are side-effects of neuroleptic medication (see Chapter 2).
completely unrelated to the original question. However, patients with psychosis can occasionally present
92
Table 9.2 Motor symptoms in schizophrenia

Catatonic rigidity Maintaining a fixed position and rigidly resisting all attempts to be moved
Catatonic posturing Adopting an unusual or bizarre position that is then maintained for some time
Catatonic negativism A seemingly motiveless resistance to all instructions or attempts to be moved; patients
may do the opposite of what is asked
Catatonic waxy flexibility Patients can be ‘moulded’ like wax into a position that is then maintained
(cerea flexibilitas)
Catatonic excitement Agitated, excited and seemingly purposeless motor activity, not influenced by external
stimuli
Catatonic stupor A presentation of ‘akinesis’ (lack of voluntary movement), ‘mutism’ and ‘extreme
unresponsiveness’ in an otherwise alert patient (there may be slight clouding of
consciousness)
Echopraxia Patients senselessly repeat or imitate the actions of those around them. Associated with
‘echolalia’; also occurs in patients with frontal lobe damage
Mannerisms Apparently goal-directed movements (e.g. waving, saluting) that are performed repeatedly
or at socially inappropriate times
Stereotypies A complex, identically repeated movement that does not appear to be goal-directed (e.g.
rocking to and fro, gyrating)
Tics Sudden, involuntary, rapid, recurrent, nonrhythmic motor movements or vocalizations
with striking motor signs that are not caused by p sychiatric

medication or a known organic brain disease. Although BOX 9.1 DIFFERENTIAL DIAGNOSIS OF
undoubtedly associated with the patient’s abnormal mental PSYCHOSIS
state, the cause of this psychomotor dysfunction is far from
Psychotic disorders
clarified. The term ‘catatonia’ literally means extreme mus-
cular tone or rigidity; however, it commonly describes any • Schizophrenia
excessive or decreased motor activity that is apparently pur- • Schizophrenia-like psychotic disorders
poseless and includes abnormalities of movement, tone or • Schizoaffective disorder
position. Note that catatonic symptoms are not diagnostic • Delusional disorder
of schizophrenia; they may also be caused by brain diseases, Mood disorders
metabolic abnormalities or psychoactive substances, and • Manic episode with psychotic features
can also occur in mood disorders. Table 9.2 describes the • Depressive episode, severe, with psychotic
common motor symptoms seen in schizophrenia. features
Secondary to a general medical condition
Secondary to psychoactive substance use
DIFFERENTIAL DIAGNOSIS Dementia/delirium
Personality disorder (schizotypal, borderline,
Psychotic symptoms are nonspecific and are associated with
many primary psychiatric illnesses. They can also present schizoid, paranoid)
secondary to a general medical condition or psychoactive Neurodevelopmental disorder (autistic spectrum)
substance use. See Box 9.1 for the differential diagnosis for
psychotic symptoms.
Psychotic disorders the preceding section (Box. 9.2). It is also important to es-
tablish that there has been a clear and marked deterioration
Schizophrenia in the patient’s social and work functioning.
There are no pathognomonic or singularly defining symp- In the past, psychiatrists used Schneider’s first-rank
toms of schizophrenia; it is a syndrome characterized symptoms to make the diagnosis of schizophrenia. Kurt
by a heterogeneous cluster of symptoms and signs. The Schneider suggested that the presence of one or more first-
International Statistical Classification of Diseases and rank symptoms in the absence of organic disease was of
Related Health Problems, 10th edition (ICD-10) has set pragmatic value in making the diagnosis of schizophrenia.
out diagnostic guidelines based on the most commonly First-rank symptoms are still referred to, so you should
occurring symptom groups, which have been discussed in familiarize yourself with them; they are presented in Box 9.3.
93
BOX 9.2 ICD-10 DIAGNOSTIC GUIDELINES HINTS AND TIPS

FOR SCHIZOPHRENIA
Memory aid: if you add ‘bizarre delusions’ and
One or more of the following symptoms: ‘hallucinations coming from a part of the body’ to
a. Thought echo, insertion, withdrawal or Schneider’s first-rank symptoms you will have the a
broadcast to d criteria of the ICD-10 diagnostic guidelines for
b. Delusions of control or passivity; delusional schizophrenia.
perception
c. Hallucinatory voices giving a running
commentary; discussing the patient among Schizophrenia subtypes
themselves or ‘originating’ from some part of Due to the differing presentations of schizophrenia, re-
the body searchers have tried to identify schizophrenia subtypes.
d. Bizarre delusions The importance of these subtypes is that they vary in their
OR prognosis and treatment response. The ICD-10 has coded
the following subtypes, which are not necessarily exclusive:
Two or more of the following symptoms:
• Paranoid schizophrenia: dominated by the presence of
e. Other hallucinations that either occur every
delusions and hallucinations (positive symptoms). Negative
day for weeks or that are associated with and catatonic symptoms as well as thought disorganization
fleeting delusions or sustained overvalued are not prominent. The prognosis is usually better and the
ideas onset of illness later (typically 18–25 years) than the other
f. Thought disorganization (loosening of subtypes.
association, incoherence, neologisms) • Hebephrenic (disorganized) schizophrenia: characterized
g. Catatonic symptoms by thought disorganization, disturbed behaviour and
h. Negative symptoms inappropriate or flat affect. Delusions and hallucination
i. Change in personal behaviour (loss of interest, are fleeting or not prominent. Onset of illness is earlier
aimlessness, social withdrawal) (15 to 25 years of age) and the prognosis poorer than
paranoid schizophrenia.
Symptoms should be present for most of the time
• Catatonic schizophrenia: a rare form characterized by
during at least 1 month one or more catatonic symptoms (see Table. 9.2).
Schizophrenia should not be diagnosed in the • Residual schizophrenia: 1 year of predominantly chronic
presence of organic brain disease or during drug negative symptoms which must have been preceded by
intoxication or withdrawal at least one clear-cut psychotic episode in the past.
Schizophrenia-like psychotic disorders

Some psychotic episodes with schizophrenia-like symptoms
seem to have an abrupt onset (without a prodromal phase),
precipitated by an acute life stress, or to have a shorter dura-
tion of symptoms than that usually observed in schizophre-
BOX 9.3 SCHNEIDER’S FIRST-RANK nia. The ICD-10 codes these as acute and transient psychotic
SYMPTOMS OF SCHIZOPHRENIA disorders. The Diagnostic and Statistical Manual of Mental
Disorders, 5th Edition, on the other hand, suggests diagnoses
• Delusional perception of schizophreniform disorder and brief psychotic disorder.
• Delusions of thought control: insertion, Often these diagnoses are superseded by a later diagnosis of
withdrawal, broadcast schizophrenia as the clinical picture evolves.
• Delusions of control: passivity experiences
of affect (feelings), impulse, volition and Schizoaffective disorder
somatic passivity (influence controlling Schizoaffective disorder describes the presentation of both
the body) schizophrenic and mood (depressed or manic) symptoms
• Hallucinations: audible thoughts (first that present in the same episode of illness, either simultane-
person or thought echo), voices arguing or ously or within a few days of each other. The mood symptoms
discussing the patient, voices giving a running should meet the criteria for either a depressive or manic ep-
commentary isode. Patients should also have at least one, p referably two,
of the typical symptoms of schizophrenia (i.e. symptoms (a)
to (d) as specified in the ICD-10 schizophrenia diagnos-
94
tic guidelines; see Box. 9.2). Depending on the particular

mood symptoms displayed, this disorder can be coded in BOX 9.4 MEDICAL AND SUBSTANCE-
RELATED CAUSES OF PSYCHOTIC SYMPTOMS
the ICD-10 as schizoaffective disorder, manic type or schi-
zoaffective disorder, depressed type. Medical conditions:
• Cerebral neoplasm, infarcts, trauma, infection,
HINTS AND TIPS inflammation (including HIV, CJD, neurosyphilis,
herpes encephalitis)
When psychiatrists talk about the typical symptoms • Endocrinological (thyroid, parathyroid, adrenal
of schizophrenia, they are generally referring to points disorders)
(a) to (d) of the ICD-10 criteria for schizophrenia (or • Epilepsy (especially temporal lobe epilepsy)
Schneider’s first-rank symptoms; e.g. delusions of • Huntington disease
control, running commentary hallucinations, etc). • Systemic lupus erythematosus
• Vitamin B12, niacin (pellagra) and thiamine
deficiency (Wernicke encephalopathy)
Delusional disorder • Acute intermittent porphyria
In this disorder, the development of a single or set of delu- Substances:
sions for the period of at least 3 months is the most prom-
• Alcohol
inent or only symptom. It usually has onset in middle age
• Cannabis
and may persist throughout the patient’s life. Delusions can
be persecutory, grandiose and hypochondriacal. Typically, • Novel psychoactive substances
schizophrenic delusions, such as delusions of thought control • Amphetamines
or passivity, exclude this diagnosis. Hallucinations, if present, • Cocaine
tend to be only fleeting and are not typically schizophrenic • Hallucinogens
in nature; brief depressive symptoms may also be evident. • Inhalants/solvents
Affect, speech and behaviour are all normal and these pa- Prescribed:
tients usually have well-preserved personal and social skills.
Rarely, patients may present with an induced delusional • Antiparkinsonian drugs
disorder (folie à deux), which occurs when a nonpsychotic • Corticosteroids
patient with close emotional ties to another person suffering • Anticholinergics
from delusions (usually a dominant figure) begins to share CJD, Creutzfeldt-Jakob disease; HIV, human immunodeficiency
those delusional ideas themselves. The delusions in the non- virus.
psychotic patient tend to resolve when the two are separated.
Mood (affective) disorders

previous psychotic episodes and absence of a family history of
Manic episode with psychotic features schizophrenia also supports this diagnosis.
See Chapter 10.
Delirium and dementia
Depressive episode, severe with
Visual hallucinations and delusions are common in delir-
psychotic features ium and may also occur in dementia, particularly diffuse
See Chapter 11.
Lewy body dementia (see Chapter 19).
Psychotic episodes secondary to a

Personality disorder
general medical condition or
In general, schizophrenia presents with a clear change in
psychoactive substance use behaviour and functioning, sometimes with a prodrome,
A medical or psychoactive substance cause of psychosis should whereas patients with a personality or neurodevelopmental
always be sought for and ruled out. Box 9.4 lists the medical and disorder have never achieved a normal baseline. Schizotypal
substance-related causes of psychotic episodes. The m edical (personality) disorder is characterized by eccentric be-
condition or substance use should predate the development haviour and peculiarities of thinking and appearance.
of the psychosis and symptoms should resolve with treatment Although there are no clear psychotic symptoms evident
of the condition or abstinence from the offending substance and its course resembles that of a personality disorder,
(although sometimes exposure to a recreational substance can the ICD-10 actually describes schizotypal disorder in the
precipitate a psychotic illness which never resolves). Absence of chapter on psychotic disorders. This is because it is more
95
prevalent among relatives of patients with schizophrenia Hallucinations

and, occasionally, it progresses to overt schizophrenia. • Do you ever hear strange noises or voices when there is
Borderline, paranoid and schizoid personality disorders no one else about?
also share similar features to schizophrenia without display- • Do you ever hear your own thoughts spoken aloud
ing clear-cut psychotic symptoms. Personality disorders are such that someone standing next to you might possibly
discussed in greater detail in Chapter 17. hear them? (audible thoughts; first person auditory
hallucinations)
Neurodevelopmental disorder • Do you ever hear your thoughts echoed just after you
have thought them? (thought echo)
Social difficulties and rigid thinking are found in both autis- • Do these voices talk directly to you or give you
tic spectrum disorders and schizophrenia. See Chapter 18. commands? (second person auditory hallucinations)
• Do these voices ever talk about you with each other
or make comments about what you are doing? (third
ALGORITHM FOR THE DIAGNOSIS person auditory hallucinations/running commentary)
OF PSYCHOTIC DISORDERS Delusions
• Are you afraid that someone is trying to harm or
See Fig. 9.3.
poison you? (persecutory delusions)
• Have you noticed that people are doing or saying things
that have a special meaning for you? (delusions of
ASSESSMENT reference)
• Do you have any special abilities or powers? (grandiose
delusions)
History • Does it seem as though you are being controlled or
The following questions may be helpful in eliciting psy- influenced by some external force? (delusions of control)
chotic phenomena on mental state examination: • Are thoughts that don’t belong to you being put into
your head? (thought insertion)
Psychotic symptoms
Organic psychotic
Secondary to a medical
YES disorder or
condition or psychoactive
substance-induced
substance use
psychotic disorder
NO
Schizophrenia-like
Duration shorter than 1 month YES psychotic disorder
(acute and transient
psychotic disorder)
NO
Presence of delusions only and
YES Delusional disorder
duration longer than 3 months
NO
Typical schizophrenic symptoms
in the absence of prominent mood YES Schizophrenia
symptoms (depression or mania)
NO
Typical schizophrenic
Schizoaffective
symptoms in the presence of YES
disorder
prominent mood symptoms
NO
Psychotic symptoms (usually Depression or mania
mood-congruent) in the presence YES with psychotic
of prominent mood symptoms features
Fig. 9.3 Algorithm for the diagnosis of a patient presenting with psychotic symptoms.
96
It is important to obtain collateral information from the pa-

tient’s GP, family and any other mental health professionals
DISCUSSION OF CASE STUDY
involved in their care to establish premorbid personality
Mr PP meets the ICD-10 criteria for schizophrenia, para-
and functioning, as well as pattern of deterioration.
noid subtype. He has had a marked deterioration in his so-
cial and work functioning. He has delusions of persecution
Examination (believing he was a victim of government experiments),
A basic physical examination including a thorough neuro- thought control (believing that ideas were being planted in
logical and endocrine system examination should be per- his head – thought insertion) and reference (believing that
formed on all patients with psychotic symptoms. the man in the pub was referring specifically to him). His
claim that he knew these things after hearing the neigh-
bour’s dog bark suggests delusional perception. He also has
Investigations second person command hallucinations and third person
Blood investigations are performed to: running commentary hallucinations. ‘Receiving coded
• Exclude possible medical or substance-related causes of information’ from the radio might be a hallucination or a
psychosis. delusion of reference depending on how Mr PP described
• Establish baseline values before administering this experience subjectively. Mr PP’s description that ‘all
antipsychotics and other psychotropic drugs. was not right’ could indicate the presence of a delusional
• Assess renal and liver functioning which may affect atmosphere, prior to the development of the full-blown
elimination of drugs that are likely to be taken long- delusions.
term and possibly in depot form. It is imperative that a substance-induced psychotic disor-
• If the patient presents with a first episode of psychosis, a der or psychotic disorder secondary to a medical condition is
good basic screen comprises full blood count, erythrocyte excluded. It would be important to ascertain the duration of
sedimentation rate, urea and electrolytes, thyroid Mr PP’s psychotic symptoms. It seems as though he has had
function, liver function tests, glucose, lipids, serum schizophrenic symptoms for over a month. If the duration of
calcium, and serology for any suspected infections. symptoms had been less than a month, it would be advisable
• A urine drug screen should always be done because to diagnose a schizophrenia-like psychotic disorder (e.g. acute
recreational drugs both cause and exacerbate psychosis. and transient psychotic disorder). It is important to rule out
• An electrocardiogram should be done in patients with a mood disorder with psychotic features. The presence of a
cardiac problems as many antipsychotics prolong the mood episode associated with simultaneous schizophrenic
QT interval and have the potential to cause lethal symptoms would suggest a schizoaffective episode. Prominent
ventricular arrhythmia. hallucinations militate against a diagnosis of delusional
• The use of a routine electroencephalogram, computed disorder.
tomography (CT) or magnetic resonance imaging Now go on to Chapter 21 to read more about the psy-
brain scan to help exclude an organic psychosis (e.g. chotic disorders and their management.
temporal lobe epilepsy, brain tumour) varies between
psychiatric units; they should always be considered
in atypical cases, cases with treatment resistance or if
there are cognitive or neurological abnormalities.
97
Chapter Summary
Psychosis is when the experience of reality is grossly distorted.

Psychotic symptoms comprise delusions, hallucinations and thought disorder.
• A delusion is a fixed, false, belief which arises through faulty reasoning, is not altered by
evidence to the contrary, and is outside cultural norms.
• A hallucination is a perception in the absence of a stimulus.
• Thought disorder is speech so disorganized that communication is impaired.
When assessing someone with psychotic symptoms, explore
• the nature and content of their abnormal experiences (their signs and symptoms)
• how these symptoms are affecting them, and their current and past social circumstances
(functional impact)
• their physical health and use of recreational substances
• obtain a collateral history from someone who knows them well (as lack of insight can
prevent the patient giving a full history)
The key differentials for someone presenting with psychotic symptoms are: schizophrenia,
mania with psychotic symptoms, drug-induced psychosis and psychosis secondary to a
general medical condition.
98
The patient with elated
or irritable mood 10
FEATURES
Feeling that she was no longer able to cope,
Mrs EM consulted her general practitioner (GP) In Chapter 11 we will observe how a disturbance in mood
about a Mental Health Act assessment for her in addition to various other cognitive, biological and psy-
husband, Mr EM, a 37-year-old freelance writer. chotic symptoms all contribute to the recognition of a de-
He had no psychiatric history other than a period pressive episode. A similar approach is taken to hypomanic
of depression 2 years ago. He had progressively and manic episodes; these occur on the opposite pole of the
needed less sleep over the past 2 weeks and mood disorder spectrum to depression.
had not slept at all for 48 hours. Recently, he had
started taking on increasing amounts of work and Core symptoms
seemed to thrive on this due to an ‘inexhaustible The International Statistical Classification of Diseases and
source of boundless energy’. He told his wife Related Health Problems, 10th edition (ICD-10) classifi-
and all his friends that he had a new lease of life, cation system specifies two core symptoms of a manic or
as he was ‘happier than ever’. Mrs EM became hypomanic episode:
concerned when he developed lofty ideas that • Sustained elated, irritable or expansive mood
he was a world expert in his field, remaining • Excessive activity or feelings of energy
convinced of this even when she tried to reason When manic and depressive symptoms rapidly alternate
with him, and would talk incessantly for hours (e.g. within the same day), this is termed a mixed affective
about elaborate and complicated writing schemes. episode.
Mr EM’s behaviour had become markedly
uncharacteristic over the past day or two, when he Mood
started making sexually inappropriate comments The hallmark of a hypomanic or manic episode is an ele-
to his neighbour’s wife and presented her with vated or irritable mood. Patients often enjoy the experience
reams of poetry which he had spent the night of elevated mood and might describe themselves as feeling:
writing. When Mrs EM suggested that he visit the ‘high’, ‘on top of the world’, ‘fantastic’ or ‘euphoric’. This
GP, Mr EM became verbally aggressive saying that mood has an infectious quality, although those who know
she was trying to bring him down because she was the patient well clearly see it as a deviation from normal.
However, some patients tend to become extremely irritable
threatened by his ‘irresistible sex appeal and wit’.
or suspicious when manic and do not enjoy the experience
Mrs EM was unable to reason with him and noticed
at all. They have a low frustration tolerance and any thwart-
that he struggled to keep to the point of the
ing of their plans can lead to a rapid escalation in anger or
conversation, often bringing up issues that seemed even delusions of persecution.
completely irrelevant. The GP noted that, other
than a recent bout of flu, Mr EM had no medical Increased energy
problems and was not using any prescribed This initially results in an increase in goal-directed activity
medication. He denied using drugs or alcohol. and, when coupled with impaired judgement, can have di-
(For a discussion of the case study see the end of sastrous consequences (e.g. patients may instigate numerous
the chapter). risky business ventures, go on excessive spending sprees, or
engage in reckless promiscuity that is unusual for them).
However, in severe episodes actions can become repetitive,
stereotyped and apparently purposeless, even progressing
Just as spells of feeling sad and miserable are quite normal to a manic stupor in the extremely unwell. If left untreated,
to the human experience, so too are periods where we feel excessive overactivity can lead to physical exhaustion, de-
elated, excited and full of energy. Although an irritable or hydration and sometimes even death. On mental state ex-
elevated mood is not in itself pathological, it can be when amination, increased energy can be seen as psychomotor
grossly and persistently so, and when associated with an- excitation: the patient is unable to sit still, frequently standing
other psychopathology. up, pacing around the room and gesticulating expansively.
99
The patient with elated or irritable mood
HINTS AND TIPS COMMUNICATION
Patients with mania experience irritability (80%) or Assessing manic patients can be made difficult by
labile or fluctuating mood (69%) just as often as their distractibility and disinhibition. Adopt a polite
euphoria (71%). but firm approach and redirect the patient back to
the questions you need to ask.
Biological symptoms
Impaired judgement and insight
Decreased need for sleep This is typical of manic illness and sometimes results in
This is a very important early warning sign of mania or hy- costly indiscretions that patients may later regret. Lack of
pomania. Sleep disturbance can range from only needing a insight into their illness can be a difficult barrier to over-
few hours of sleep a night to a manic patient going for days come when trying to engage patients in essential treatment.
on end with no sleep at all. Crucially, it is not associated
with fatigue.
Psychotic symptoms
Psychotic symptoms are far more common in manic than in
HINTS AND TIPS depressive episodes and include disorders of thought form,
thought content and perception.
Irrespective of how obvious the diagnosis might
appear, it is always important to routinely examine
Disordered thought form
for affective symptoms such as a decreased need Disordered thought form (see Chapter 9 and Fig. 9.2)
for sleep (81%), grandiosity (78%), racing thoughts commonly occurs in schizophrenia but is regularly seen in
(71%), distractibility (68%) and sexual disinhibition manic episodes with psychotic features and to a lesser de-
(57%). gree in psychotic forms of unipolar depression. The most
common thought form disorders in mania are circumstan-
tiality, tangentiality and flight of ideas. However, signs of
thought disorder most typical for schizophrenia can also be
Cognitive symptoms seen in manic episodes (e.g. loosening of association, neol-
ogisms and thought blocking).
Elevated sense of self-esteem or
grandiosity Circumstantiality and tangentiality
Hypomanic patients may overestimate their abilities and so- Circumstantial (over-inclusive) speech means speech that
cial or financial status. In severe cases, manic patients may is delayed in reaching its final goal because of the over-
have delusions of grandeur (see later). inclusion of details and unnecessary asides and diversions;
however, the speaker, if allowed to finish, does eventually
Poor concentration connect the original starting point to the desired destina-
Manic patients may find it difficult to maintain their focus tion. Circumstantiality need not be pathological – most
on any one thing as they struggle to filter out irrelevant families have at least one person who takes forever to fin-
external stimuli (background noise, other objects or peo- ish a story! Tangential speech, on the other hand, is more
ple in the room), making them, as a consequence, highly indicative of psychopathology and sees the speaker divert-
distractible. ing from the initial train of thought but never returning
to the original point, jumping tangentially from one topic
Accelerated thinking and speech to the next.
Manic patients may subjectively experience their
thoughts or ideas racing even faster than they can artic- Flight of ideas
ulate them. When patients have an irrepressible need to As described earlier, flight of ideas occurs when thinking
express these thoughts verbally, making them difficult to is markedly accelerated, resulting in a stream of connected
interrupt, it is termed pressure of speech. When thoughts concepts. The link between concepts can be as in normal
are rapidly associating in this way in a stream of con- communication where one idea follows directly on from the
nected (but not always relevant) concepts it is termed next or can be links that are not relevant to an overall goal.
flight of ideas. Some hypomanic patients express them- For example, links made through wordplay such as a pun or
selves by incessant letter writing, poetry, doodling or clang association; or through some vague idea which is not
artwork. part of the original goal of speech (e.g. ‘I need to go to bed
100
now. Have you ever smelt my bed of roses? Ah, but a rose
by any other name would smell just as sweet!’). Even though BOX 10.1 DIFFERENTIAL DIAGNOSIS FOR
PATIENT PRESENTING WITH ELEVATED OR
manic patients may appear to be talking gibberish, a written
IRRITABLE MOOD
transcript of their speech will usually reveal that their ideas
are related in some, albeit obscure, way. Mood disorders
As patients become increasingly manic, their associa- • Hypomania, mania, mixed affective episode
tions tend to loosen as they find it increasingly difficult to
(isolated episode or part of bipolar affective
link their thoughts. Eventually they approach the incoher-
disorder)
ent thought disorder sometimes seen in schizophrenia (see
Chapter 9). • Cyclothymia
• Depression (may present with irritable mood)
Abnormal beliefs Secondary to a general medical condition
Patients with elated mood will typically present with Secondary to psychoactive substance use
grandiose delusions in which they believe they have spe- Psychotic disorders
cial importance or unusual powers. Persecutory delusions • Schizoaffective disorder (may be similar to
are also common, especially in patients with an irritable
mania with psychotic features)
mood, and often feature them believing that others are
• Schizophrenia
trying to take advantage of their exalted status. When the
content of delusions matches the mood of the patient, Personality disorder (with prominent traits of
the delusions are termed mood-congruent. Very often, disinhibition, negative affect or dissocial features)
patients with elevated mood may have overvalued ideas Neurodevelopmental disorder (attention deficit
as opposed to true delusions, which are important to dis- hyperactivity disorder)
tinguish, as the former are not regarded as psychotic in Delirium/dementia
nature (see Chapter 9).
Perceptual disturbance
Some hypomanic patients may describe subtle distortions
of perception. These are not psychotic symptoms and
Mood (affective) disorders
mainly include altered intensity of perception such that Hypomanic, manic and mixed affective
sounds seem louder (hyperacusis) or colours seem brighter
and more vivid (visual hyperaesthesia). Psychotic percep-
episodes
The ICD-10 specifies three degrees of severity of a manic ep-
tual features develop when manic patients experience hallu-
isode: hypomania, mania without psychotic symptoms and
cinations. This is usually in the form of voices encouraging
mania with psychotic symptoms. All of these share the above-
or exciting them.
mentioned general characteristics, most notably: an elevated
or irritable mood and an increase in the quantity and speed of
mental and physical activity. If psychotic symptoms are present,
HINTS AND TIPS the episode is by definition mania. In those without psychotic
Always screen for psychotic symptoms in patients symptoms, the distinction between mania and hypomania can
be hard to judge and hinges on the degree of functional impair-
suffering from a manic episode. The prevalence
ment (Fig. 10.1) If the person is experiencing rapidly alternating
is very high – two-thirds report experiencing
(e.g. within a few hours of each other) manic and depressive
psychotic symptoms during such an episode. symptoms they are diagnosed with a mixed affective episode.
Interestingly, only one third report psychotic
symptoms during a depressive episode.
Bipolar affective disorder
Most patients who present with a hypomanic, manic or
mixed affective episode will have experienced a previous epi-
sode of mood disturbance (depression, hypomania, mania or
DIFFERENTIAL DIAGNOSIS mixed). In this case they should be diagnosed with bipolar af-
fective disorder. Most patients who experience hypomanic or
Like depression, an elevated or irritable mood can be sec- manic episodes also experience depressive episodes, hence,
ondary to a medical condition, psychoactive substance use the commonly used term: ‘manic-depression’. However, pa-
or other psychiatric disorder. These will have to be excluded tients who only suffer from manic or hypomanic episodes
before a primary mood disorder can be diagnosed. Box 10.1 with no intervening depressive episodes are also classified
shows the differential diagnosis for patients presenting with as having bipolar affective disorder, even though their mood
elevated or irritable mood. does not swing to the depressive pole. It is good practice to
101
Mood elevated, irritable or labile?
Functional impairment?
Minimal Considerable Complete disruption

interference with interference with to work or social
work or social work or social activities
activities activities (e.g. being admitted)
Psychotic symptoms?
NO YES
Consider Hypomania Mania Mania with

no mental illness, psychotic
cyclothymia, features
other differentials
Fig. 10.1 Distinguishing mania from hypomania.
record the nature of the current episode in a patient with

bipolar affective disorder (e.g. ‘bipolar affective disorder, cur-
rent episode manic without psychotic features’). BOX 10.2 MEDICAL AND SUBSTANCE
CAUSES OF MANIA
Cyclothymic disorder Medical conditions:

Cyclothymic disorder (or cyclothymia) is analogous to dys-
• Cerebral neoplasms, infarcts, trauma,
thymia (see Chapter 11) in that it usually begins in early
adulthood and follows a chronic course with intermittent infection (including HIV), autoimmune
periods of wellness in between. It is characterized by an in- encephalitis
stability of mood over at least 2 years resulting in alternating • Cushing disease
periods of mild elation and mild depression, none of which • Huntington disease
are sufficiently severe or long enough to meet the criteria • Hyperthyroidism
for either a hypomanic or a depressive episode. • Multiple sclerosis
• Renal failure
Depression • Systemic lupus erythematosus
There are three common scenarios where a patient with a • Temporal lobe epilepsy
primary depressive disorder may present with an elevated • Vitamin B12 and niacin (pellagra) deficiency
or irritable mood. An ‘agitated depression’ can present with a Substances:
prominent irritable mood, which, when coupled with psycho-
motor agitation, can be difficult to distinguish from a manic ep- • Amphetamines
isode; depressed patients who are responding to antidepressants • Cocaine
or electroconvulsive therapy may experience a transient period • Hallucinogens
of elevated mood; and a patient with a recently resolved depres- • Novel psychoactive substances
sive disorder might misidentify euthymia for hypomania. Prescribed:
• Anabolic steroids
Manic episodes secondary to a • Antidepressants
general medical condition or • Corticosteroids
psychoactive substance use • Dopaminergic agents (e.g. L-dopa, selegiline,
bromocriptine)
A medical or psychoactive substance cause of mania should
always be sought for and ruled out. Box 10.2 lists the medical
102
Assessment 10
and substance-related causes of mania. The medical condi- Table 10.1 Psychopathological distinctions between
tion or substance use should predate the development of the mania and schizophrenia (these are guidelines only;
mood disorder and symptoms should resolve with treatment typically schizophrenic symptoms can occur in mania
of the condition or abstinence from the offending substance. and vice versa)
Absence of previous manic episodes and lack of a family his- Psychopathology Mania Schizophrenia
tory of bipolar affective disorder also supports this diagnosis.
Thought form Circumstantiality, Loosening of
tangentiality, association,
Schizophreniform disorders flight of ideas neologisms,
thought
Schizoaffective disorder blocking
See Chapter 9. This can be very difficult to distinguish from Delusions Most often Delusions
a manic episode with psychotic features. mood-congruent unrelated to
(grandiose mood, bizarre
delusions or delusions,
Schizophrenia persecutory delusions
Patients with schizophrenia can present with an excited, delusions) of passivity
suspicious or agitated mood and therefore can be difficult to (e.g. thought
distinguish from manic patients with psychotic symptoms. insertion,
Table 10.1 compares relevant features that might act as clues withdrawal,
broadcast)
to the correct diagnosis.
Speech Pressured Speech is often
speech, difficult hesitant or
Personality/neurodevelopmental to interrupt halting
disorders Biological Significantly Sleep less
symptoms reduced need for disturbed, less
Patients with disorders of personality or neurodevelop- sleep, increased hyperactive
ment often report features similar to hypomania, e.g. physical and
impulsivity, displays of temper and lability of mood in mental energy
personality disorder with prominent features of negative Psychomotor Agitation Agitation,
affect, disinhibition or dissocial features or in attention function catatonic
deficit hyperactivity disorder. However, personality symptoms
and neurodevelopmental disorders involve stable and or negative
enduring behaviour patterns, unlike the more discrete symptoms
episodes of bipolar affective disorder, which are char-
acterized by a distinct, demarcated deterioration in
psychosocial functioning. Further, mood instability in
personality disorder or neurodevelopmental disorder • Do you sometimes feel as though you have too much
tends to fluctuate more rapidly (e.g. from hour to hour). energy compared with people around you?
See Chapters 17 and 18. • Do you find yourself needing less sleep but not getting
tired?
• Have you had any new interests or exciting ideas lately?
Delirium/dementia • Have you noticed your thoughts racing in your head?
Insomnia, agitation and psychotic symptoms in an older • Do you have any special abilities or powers?
adult can be a presentation of hyperactive delirium or of
behavioural and psychological symptoms of dementia. See Examination
Chapter 19.
A basic physical examination, including a thorough neuro-
logical and endocrine system examination, should be per-
formed on all patients with elevated mood.
ASSESSMENT
Investigations
History As for the depressive disorders (see Chapter 11), social,
psychological and physical investigations are normally
The following questions might be helpful in eliciting the key performed on manic patients to establish the diagnosis
symptoms of mania/hypomania: and to rule out an organic or substance-related cause (see
• Have you been feeling particularly happy or on top of Box 10.2). A urine drug screen is essential in anyone pre-
the world lately? senting with a first episode of elated mood.
103
ecause of the severe impairment in social and probably

b
ALGORITHM FOR THE DIAGNOSIS work functioning, and because of the psychotic features.
OF MOOD DISORDERS Although Mr EM denied using drugs or alcohol, intoxi-
cation with substances (e.g. a novel psychoactive substance)
See Fig. 10.2. is an important differential. A urine drug screen could ex-
clude amphetamines and a collateral history might help to
identify any existing pattern of substance use. However, the
long duration of symptoms (2 weeks) is less suggestive of
DISCUSSION OF CASE STUDY substance-induced manic symptoms, which would typically
resolve over a few days.
Mr EM appears to be suffering from a manic episode with The past psychiatric history is extremely important in
psychotic features. He has an elated mood and has developed this case. A previous mood episode (hypomanic, manic,
the grandiose delusion that he is a world expert (mood- depressive, mixed) is required in order to make the diag-
congruent psychotic symptom); note also the rapid switch nosis of bipolar affective disorder. Mr EM had a period of
to irritable mood when confronted. Biological symptoms depression 2 years prior to developing this manic episode,
include the reduced need for sleep and increased mental and suggesting the diagnosis is: bipolar affective disorder, current
physical energy with overactivity. Cognitive symptoms in- episode manic with psychotic features. Previous psychotic ep-
clude elevated sense of self-importance, poor concentration, isodes would add schizoaffective disorder and schizophre-
accelerated thinking with pressure of speech and impaired nia to the differential diagnosis. Now go on to Chapter 22
judgement and insight. The episode is classified as manic to read about the mood disorders and their management.
Depressed, elevated or irritable mood
YES Organic mood disorder or

Secondary to a medical condition or
substance-induced mood
psychoactive substance
disorder
NO
YES
Occurs simultaneously with schizophrenia-like
Schizoaffective disorder
symptoms
What is the nature of the current mood episode?
Depressive Hypomanic Manic Mixed affective Chronic low grade depression

episode episode episode episode or cycles of mild elation and
mild depression
Has there been a

previous
hypomanic, Has there been a previous depressive, hypomanic,
manic or mixed manic or mixed episode?
episode?
NO
Has there been a

previous YES
depressive
episode?
YES
Recurrent Dysthymia
depressive Bipolar affective disorder or
disorder cyclothymia
Fig. 10.2 Algorithm for the diagnosis of mood disorders.
104
Chapter Summary
• A manic episode is a sustained period (at least a week) of extremely elated or irritable
mood associated with increased activity and energy.
• A hypomanic episode has the same symptoms as a manic episode but without marked
impairment in functioning.
• A mixed affective episode is the rapid alternation between symptoms of mania and
depression over a sustained period (at least 2 weeks).
• Psychotic symptoms can occur in mania, generally mood-congruent.
• Bipolar affective disorder is diagnosed when episodes of mood disorder recur.
• The key differential diagnoses for an episode of elated mood are a substance use
disorder or psychotic disorder.
• When assessing someone with elated mood, ask about the four domains of: core
symptoms, biological symptoms, cognitive symptoms and psychotic symptoms.
105
The patient with low mood
11
Feeling sad or upset is a normal part of the human condi-
CASE SUMMARY tion; thus a patient presenting with emotional suffering does
Mrs LM, a 32-year-old married housewife with
not necessarily warrant a psychiatric diagnosis or require
treatment. However, psychiatrists agree that when patients
two children aged 4 and 6 years, presented to
present with a certain number of key depressive features,
her general practitioner stating that she was
they are probably suffering from some form of psychopa-
persistently unhappy and had been crying thology that will require, and usually respond to, specific
repeatedly over the past few weeks. She had no kinds of treatment.
previous psychiatric history or significant medical
history and her only regular medication was
oral contraception. She had moved to the area
3 years earlier when her husband was promoted DEFINITIONS AND CLINICAL
and, at first, appeared to have integrated well
FEATURES
into the neighbourhood by involving herself in the
organization of a toddlers’ group. Unfortunately,
the group had dissolved a few months ago when
Core symptoms
her co-organizer and only close confidante had Whereas feelings describe a short-lived emotional experi-
moved away. Deprived of her most important ence, mood refers to a patient’s sustained, subjectively expe-
social outlet, Mrs LM found herself increasingly rienced emotional state over a period of time. Patients may
dominated by her young children. Although describe a depressed mood in a number of ways, such as
feeling sad, dejected, despondent, ‘down in the dumps’, mis-
usually an outgoing person, she noticed that her
erable, ‘low in spirits’ or ‘heavy-hearted’. They are unable
motivation to keep in touch with other mothers
to just lift themselves out of this mood and its severity is
from the group had started to dwindle. At the same often out of proportion to the stressors in their surrounding
time, she started feeling persistently weary even social environment.
though her work schedule had not increased, and
often awakened 2–3 hours earlier in the morning.
Although her appetite had not increased, she HINTS AND TIPS
had turned to food for ‘comfort’ and had gained
over 14 pounds. in weight. Mrs LM also candidly At least 2 weeks of daily low mood, loss of interest
admitted that she was drinking more alcohol than or pleasure, and fatigability are the three core
usual. She described feeling incompetent because symptoms of depression.
she was always miserable and had become too
tired to look after the children. She felt guilty for
burdening her husband and started crying when The term ‘affect’ has two uses in psychiatry. It can be
talking about her loss of interest in sex and her used synonymously with mood or emotion, as in the af-
feelings of unattractiveness. Mrs LM maintained fective (mood) disorders. However, it is most often used
that no aspect of her life gave her pleasure and to describe the transient natural fluctuations of emotional
when asked specifically by her doctor, admitted state that occur from moment to moment. For example,
that she had started to wonder whether her you might notice a patient is tearful when discussing the
children and husband would be better off without death of their mother but smiles when discussing their hol-
her. iday plans. The range and appropriateness of a patient’s af-
fect is documented as part of the mental state exam. People
(For a discussion of the case study see the end of
with depression may have a reduced range of affect, with
the chapter).
a monotonous voice and minimal facial expression (see
Chapter 1).
107
The International Statistical Classification of Diseases sually, and then find it impossible to get back to sleep
u
and Related Health Problems, 10th edition (ICD-10) classi- again. Further disturbances of sleep in depression include:
fication system specifies three core symptoms of depression: difficulty falling asleep (initial insomnia), frequent awak-
• Depressed mood, which varies little from day to day ening during the night and excessive sleeping (hypersom-
and is unresponsive to circumstances (although diurnal nia). Although all of these contribute to the diagnosis of
variation may be present, with mood worse in the depression, only early morning wakening is a biological
mornings) symptom.
• Markedly reduced interest in almost all activities,
associated with the loss of ability to derive pleasure Depression worse in the morning
from activities that were formerly enjoyed (partial or Diurnal variation of mood means that a patient’s abnor-
complete anhedonia) mal mood is more pronounced at a specific time of day. A
• Lack of energy or increased fatigability on minimal depressive mood consistently and specifically worse in the
exertion leading to diminished activity (anergia) morning is an important biological symptom.
A range of other symptoms are also associated with a de-
pressive episode. They can be considered under the sub- Marked loss of appetite with weight loss
headings biological, cognitive and psychotic symptoms. Although some depressed patients have an increased
appetite and turn to ‘comfort eating’, only a dramatic re-
duction in appetite with weight loss (5% of body weight
HINTS AND TIPS in last month) is regarded as a biological symptom. Note
that the reversed biological features of overeating and
Remember the distinction between the terms
oversleeping are sometimes referred to as atypical depres-
‘mood’ and ‘affect’; they are not the same. One sive symptoms.
way to remember the difference is that mood is like
the climate and affect like the weather.
Psychomotor retardation or agitation
The term ‘psychomotor’ is used to describe a patient’s mo-
tor activity as a consequence of their concurrent mental
processes. Psychomotor changes in depression can include
HINTS AND TIPS retardation (slow, monotonous speech, long pauses before
answering questions, or muteness; leaden body movements
Know the biological symptoms of depression; they
and limited facial expression (i.e. blunted affect)) or con-
are often asked for in exams. The key ones relate versely, agitation (inability to sit still; fidgeting, pacing or
to sleep and appetite. hand-wringing; rubbing or scratching skin or clothes). Note
that psychomotor changes must be severe enough to be ob-
servable by others, not just the subjective experience of the
patient.
Biological (somatic) symptoms
In the past, psychiatrists distinguished between ‘endog- Loss of libido
enous’ or ‘reactive’ depression. ‘Endogenous’ depression Sensitive questioning will often reveal a reduction in sex
(also called somatic, melancholic, vital or biological depres- drive that may lead to guilt when the sufferer feels unable
sion) was assumed to occur in the absence of an external to satisfy their partner.
environmental cause and have a ‘biological’ clinical picture.
This is opposed to so-called ‘reactive’ or ‘neurotic’ depres-
sion where it is assumed that the patient is, to some degree,
Cognitive symptoms
understandably depressed, reacting to adverse psychosocial Cognition has two meanings in psychiatry: it refers broadly
circumstances. However, most depression is a mixture of to brain processing functions (e.g. concentrating, learning,
the two, and an ‘understandable depression’ does not re- making decisions) and also more specifically to the thoughts
quire any less treatment than a ‘spontaneous depression’. patients have about themselves and the world, which are
‘Biological’ symptoms are still important to enquire about conclusions arrived at by cognition (e.g. I failed my maths
as, if present, they suggest a more severe depression; how- exam, therefore I will fail all exams; (see Chapter 3)).
ever, they are no longer viewed as providing information
on aetiology. Reduced concentration and memory
Depressed patients report difficulty in sustaining attention
Early morning wakening while doing previously manageable tasks. They often appear
Although patients may get off to sleep at their normal easily distracted and may complain of memory difficulties.
time, they wake at least 2 hours earlier than they would They may feel indecisive.
108
of the psychotic symptoms is consistent with the patient’s

COMMUNICATION mood. Delusions and hallucinations in depression are gen-
erally mood congruent and so may involve an irrational
Questions about concentration can include asking
conviction of guilt or sin or the belief that parts of the body
if they can follow their favourite TV programme or
are dead or wasting away. Hallucinations may take the form
read a novel.
of accusatory or defamatory voices criticizing the patient in
the second person (auditory hallucination) or the smell of
rotting flesh (olfactory hallucination).
In severe episodes, psychomotor retardation may prog-
Poor self-esteem ress to the point of unresponsiveness, lack of voluntary
Self-esteem includes the interrelated concepts of personal
movement (akinesis) and near or total mutism. Severe mo-
efficacy and personal worth. Depressed patients may have
tor symptoms are probably more common in schizophrenia
thoughts that they are no longer competent to meet life’s
and bipolar affective disorder, but they can and do occur in
challenges and that they are no longer worthy of happiness
unipolar depression.
and the healthy assertion of their needs.
Guilt
Depressed patients often have guilty preoccupations about DIFFERENTIAL DIAGNOSIS
minor past failings. This guilt is often inappropriate and out
of proportion to the original ‘offence’. Patients often have Careful history taking and examination should reveal
guilty thoughts about the very act of developing the de- whether the patient presenting with low mood is suffering
pressed mood itself. from a primary mood disorder, or whether their depression
is secondary to a medical condition, psychoactive substance
Hopelessness or other psychiatric condition. Box 11.1 presents the differ-
Depressed patients can have bleak and pessimistic views of ential diagnosis. An algorithm for the diagnosis of mood
the future, believing that there is no way out of their current disorders is presented on.
situation.
Suicide or self-harm
Depressed patients frequently have thoughts of death and
harming themselves. In severe cases suicidal ideation may
lead to an actual suicide attempt. At these times, patients BOX 11.1 DIFFERENTIAL DIAGNOSIS OF LOW
may believe that they are faced with insurmountable diffi- MOOD
culties or are trying to escape a relentlessly painful emotional
state. Self-harm and suicide are discussed fully in Chapter 6. Mood disorders
• Depressive episode
• Recurrent depressive disorder
RED FLAG • Dysthymia
• Bipolar affective disorder
Risk needs to be assessed in every patient.
• Cyclothymia
During an assessment, the subject can be
Schizoaffective disorder
broached by saying that it is common for people
who are depressed to feel that life is not worth
Secondary to psychoactive substance use
living and asking the patient if this has occurred to
(including alcohol)
them. Suicidality can then be formally assessed as
Secondary to other psychiatric disorders
discussed in Chapter 6.
• Psychotic disorders
• Adjustment disorder (including bereavement)
• Eating disorders
Psychotic symptoms
• Personality disorders
In severe depressive episodes, patients may suffer from • Neurodevelopmental disorders (autism or
delusions, hallucinations or a depressive stupor; these are attention deficit hyperactivity disorder)
termed psychotic symptoms (see Chapter 9). Delusions • Delirium/dementia
and hallucinations can be classified as ‘mood congruent’ or
‘mood incongruent’, which describes whether the content
109
Mood (affective) disorders Dysthymia

This is a chronically depressed mood (lasting at least 2 years)
Depressive episode that usually has its onset in early adulthood and may re-
The ICD-10 has set out certain diagnostic guidelines for main throughout the patient’s life, with variable periods of
diagnosing a depressive episode (see Box 11.2). The min- wellness in between. The patient’s mood is seldom severe
imum duration of the episode is 2 weeks and at least two enough to satisfy the formal criteria for a depressive episode
of the three symptoms of depressed mood, loss of interest and does not present with discrete episodes as in recurrent
or pleasure and increased fatigability should be present. A depressive disorder. Sometimes dysthymia has its onset in
depressive episode can be graded mild, moderate or severe later adult life, often after a discrete depressive episode, and
depending on the number and severity of symptoms and is associated with bereavement or some other serious stress.
degree of functional impairment. A depressive episode oc- Note that patients may develop a depressive episode on a
curring with hallucinations, delusions or a depressive stu- baseline mood of dysthymia (so called ‘double depression’).
por is always coded as ‘severe with psychotic features’.
Bipolar affective disorder/cyclothymia
Recurrent depressive disorder Unipolar depression means that the patient’s mood varies
Around 80% of patients who have an episode of depres- between depressed and normal. When patients suffer from
sion will go on to have more episodes (the lifetime average episodes of either depressed or elated mood (often, but not
is five). Recurrent depressive disorder is diagnosed when a always, punctuated by periods of normal mood), the disor-
patient has another depressive episode after their first. der is termed bipolar, as the mood is considered to deviate
from normal to either a depressed or elated (manic) pole.
When this instability of mood involves only mild elation
and mild depression it is termed cyclothymia. Bipolar ill-
BOX 11.2 ICD-10 CRITERIA FOR DEPRESSIVE ness and cyclothymia are discussed in Chapter 10.
EPISODE
Depressive episode Schizoaffective disorder

Symptoms should be present for A diagnosis of schizoaffective disorder can be made when
at least 2 weeks patients present with both mood (depression or mania)
At least two of the following core symptoms: symptoms and schizophrenic symptoms within the same
episode of illness. It is important that these symptoms occur
• Depressed mood simultaneously, or at least within a few days of each other.
• Loss of interest and enjoyment
• Reduced energy or increased fatigability
COMMON PITFALLS
AND…
Some of the following: Schizoaffective disorder is a difficult diagnosis to
• Disturbed sleep establish, as it is not uncommon to have psychotic
• Diminished appetite symptoms in a severe episode of depression
• Psychomotor retardation or agitation (depressive episode with psychotic features);
• Reduced concentration and attention likewise, depressive symptoms often occur in
• Reduced self-esteem and self-confidence patients with schizophrenia. Schizoaffective
• Ideas of guilt disorder is discussed in more detail in Chapter 9.
• Bleak and pessimistic views of the future
• Ideas or acts of self-harm or suicide
Severity Anxiety disorders
Mild: Some difficulty in continuing with normal
Many anxiety disorders are associated with a degree of low
activities mood, because of their unpleasant and pervasive effects. If
Moderate: Considerable difficulty in continuing the low mood is severe enough to meet criteria for depression,
normal activities but still able to function in this should be diagnosed and treated first. See Chapter 12.
some domains
Severe: Unable to continue normal activities Adjustment disorder
Severe with psychotic symptoms: In cases with
delusions or hallucinations Low mood may be one of several symptoms that appear
when a patient has had to adapt to a significant change in
life (e.g. divorce, retirement, bereavement). If the symptoms
110
Assessment 11
are not severe enough to be diagnosed as depression but are Depression secondary to general
clearly related to a stressful life event, an adjustment disorder
can be diagnosed (see Chapter 14).
medical disorders, or to
psychoactive substances
Eating disorder Many general medical conditions are associated with an
increased risk for depression (Table 11.1). In some cases,
Eating disorders where nutrition is inadequate to maintain
this may be due to a direct depressant effect on the brain.
body weight are often associated with symptoms of starva-
However, any condition that causes prolonged suffering is a
tion such as low mood, low energy and poor concentration.
risk factor for depression (e.g. chronic pain).
See Chapter 16.
Both prescribed (Table 11.2) and illicit drugs can be
aetiologically responsible for symptoms of depression.
Personality/neurodevelopmental Remember that alcohol is the psychoactive substance
disorders that is probably most associated with substance-induced
depression.
Patients with disorders of personality (see Chapter 17) or
neurodevelopment (see Chapter 18) often report features
similar to depression (e.g. low self-esteem in autism spec-
trum disorders, feelings of hopelessness and thoughts of
self-harm and suicide in emotionally unstable personality ASSESSMENT
disorder). However, personality and neurodevelopmental
disorders involve stable and enduring behaviour patterns, History
unlike the more discrete episodes of a depressive disorder,
The following questions might be helpful in eliciting the key
which are characterized by a distinct, demarcated deteriora-
symptoms of depression:
tion in psychosocial functioning.
Core symptoms
Delirium/dementia • Have you been cheerful or quite low in mood or spirits
Low mood, apathy and hypersomnia in an older adult can lately?
be a presentation of hypoactive delirium. Depression can • Do you find that you no longer enjoy things the way
cause marked cognitive impairment, but if it persists for you used to?
more than a few months beyond the remission of low mood, • Do you find yourself often feeling very tired or
dementia may be the underlying diagnosis. See Chapter 7. worn out?
Table 11.1 General medical conditions associated with low mood

Neurological Endocrine Infections Others
Multiple sclerosis Cushing disease Hepatitis Malignancies (especially
Parkinson disease Addison disease Infectious mononucleosis pancreatic cancer)
Huntington disease Thyroid disorders Herpes simplex Chronic pain states
Spinal cord injury (especially hypothyroidism) Brucellosis Systemic lupus
Stroke (especially left Parathyroid disorders Typhoid erythematosus
anterior infarcts) Menstrual cycle-related HIV/AIDS Rheumatoid arthritis
Head injury Syphilis Renal failure
Cerebral tumours Porphyria
Vitamin deficiencies (e.g.
niacin)
Ischaemic heart disease
Table 11.2 Prescribed drugs causing low mood

Antihypertensives Steroids Neurological drugs Analgesics Other
β-blockers Corticosteroids L-dopa Opiates Antipsychotics
Methyldopa Oral contraceptives Carbamazepine Indometacin Interferon (alpha
and beta)
111
Biological symptoms • Vitamin B12 and folate (if deficiencies suspected).

• Do you find your mood is worse in the mornings or • Urine drug screen (if drug use is suspected).
evenings? • Electrocardiogram should be done in patients with
• What time did you wake up before your mood became cardiac problems as tricyclic antidepressants and
low? What time do you wake up now? lithium may prolong the QT interval and have the
• Has anyone mentioned you seem slowed up or restless? potential to cause lethal ventricular arrhythmia.
• Sometimes when people are depressed they have a poor • Electroencephalogram (if epileptic focus or other
sex drive. Has this happened to you? intracranial pathology is suspected).
• Computed tomography brain scan (if evidence of
Cognitive symptoms neurological or cognitive deficit).
• How do you see things turning out in the future?
• Do you ever feel that life’s not worth living?
• Are you able to concentrate on your favourite TV DISCUSSION OF CASE STUDY
programme?
Mrs LM meets the criteria for a depressive episode, at least
Psychotic symptoms moderate in severity. She has had both core symptoms of
• Do you hear people say bad things about you when depression for longer than 2 weeks: depressed mood and
there’s no one there? loss of interest. She also has biological symptoms of fati-
• Do you smell anything unpleasant which is hard to gability, early morning awakening and loss of libido. The
explain? GP has also elicited cognitive symptoms of feelings of in-
• Do you feel your body is healthy? competence (reduced self-esteem) and guilt and possible
A collateral history from the patient’s family, partner, carer, thoughts of self-harm. As this is a first episode, the diag-
community psychiatric nurse, or general practitioner (GP) nosis of recurrent depressive disorder is not appropriate.
is often helpful. Dysthymia is not a suitable diagnosis as the period of low
mood is far too short, the severity of the present episode
too great and the deterioration in functioning too marked.
Examination There appear to be no instances of elated mood or in-
A basic physical examination, including a thorough neuro- creased energy, excluding a diagnosis of bipolar affective
logical and endocrine system examination, should be per- disorder or cyclothymia.
formed on all patients with depression. In order to grade the severity of the depression it would
be useful to enquire about all the biological, cognitive and
psychotic components of depression, and to ask about
Investigations functional impairment. Assessing Mrs LM’s ability to care
Investigations are performed to: (1) exclude possible med- for her young children is crucial and is likely to require
ical or substance-related causes of depression; (2) establish a collateral history from her husband with consideration
baseline values before administering treatment that may of referral to social work if there are significant concerns.
alter blood chemistry (e.g. antidepressants may cause hypo- In all cases of suspected depression it is imperative to en-
natraemia, lithium may cause hypothyroidism); (3) assess quire about thoughts and/or plans of suicide or self-harm
renal and liver functioning, which may affect the elimina- (see Chapter 6 for a full discussion). It is also important
tion of medication; and (4) screen for the physical conse- to rule out secondary causes of depression; these include
quences of neglect, such as malnutrition. general medical conditions (Table 11.1), psychoactive
• Full blood count: check for anaemia (low haemoglobin), substance use (Table 11.2) and other psychiatric condi-
infection (raised white count), and a high mean cell tions. Mrs LM admitted to using increased quantities of
volume (a marker of high alcohol intake). alcohol subsequent to the onset of her low mood: advising
• Urea and electrolytes (hyponatraemia, renal her to abstain from alcohol is an important first step in
function). managing her mood. Patients often use alcohol as a form
• Liver function tests and γ-glutamyltranspeptidase (also of self-medication to alleviate feelings of dysphoria; how-
a marker for high alcohol intake). ever, alcohol can aggravate and in some cases even cause
• Thyroid function tests (hyperthyroidism or depressive symptoms. Mrs LM’s use of oral contraception
hypothyroidism) and calcium (hypercalcaemia). long before the onset of her depressive symptoms suggests
that it is unlikely that this prescribed drug is causing her
If indicated: depression.
• C reactive protein or erythrocyte sedimentation rate (if Now go on to Chapter 22 to read about the mood disor-
infection or inflammatory disease suspected). ders and their management.
112
Chapter Summary
• A depressive episode is a sustained period of low mood (at least 2 weeks) associated
with loss of interest or pleasure, fatigue and functional impairment.
• A depressive episode can be associated with impaired cognition and/or psychotic
symptoms.
• The key differential diagnoses for a depressive episode are a substance use disorder,
anxiety disorder, or personality disorder.
• When assessing someone for depression, ask about the four domains of: core
symptoms, biological symptoms, cognitive symptoms and psychotic symptoms.
• When assessing someone for depression, always ask about suicidal thoughts.
113
The patient with anxiety, fear
or avoidance 12
Good
CASE SUMMARY
Mrs PA, a 32-year-old divorced interior designer,

was referred to a primary care psychologist by
Performance
her family doctor because of a 6-month history of
sudden, dramatic anxiety attacks accompanied by
heart palpitations, profuse sweating, dizziness, a
choking sensation and a fear that she was going
to die. There appeared to be no logical reason for
the attacks and Mrs PA described them as coming Poor
on ‘out of the blue’. They reached their maximum Low High
Arousal
intensity within 2 minutes and seldom lasted longer
than 15 minutes, occurring two to three times a Fig. 12.1 Yerkes–Dodson law (1908).
week. Because of these attacks, which occurred
in any situation and at any time of day, Mrs PA
had stopped going into shops or crowded public inverted U: mild to moderate levels of anxiety improve
performance, but high levels impair it. Fig. 12.1 demon-
places for fear of having an attack and not being
strates the Yerkes–Dodson curve.
able to escape to a safe place and appearing
like a ‘blubbering fool’. She had started relying
on her mother to accompany her on ‘absolutely
necessary’ household excursions ‘just in case’ she DEFINITIONS AND CLINICAL
had another attack. Her general practitioner (GP) FEATURES
had booked her off work for the past 3 months,
as she was too frightened to visit potential clients’ Both anxiety and fear are alerting signals that occur in re-
houses in the event that she had another attack. sponse to a potential threat, either known or unknown.
Mrs PA told the psychologist that she had almost The experience of anxiety consists of two interrelated
become housebound and felt that she was ‘losing components: (1) thoughts of being apprehensive, nervous
her mind’. A full physical examination, routine or frightened and (2) the awareness of a physical reaction to
anxiety (autonomic or peripheral anxiety). Box 12.1 sum-
blood tests including: full blood count, urea and
marizes the physical signs of anxiety. The experience of
electrolytes, fasting glucose, liver function, thyroid
anxiety may lead to a change in behaviour, particularly an
function and calcium concentration as well as an
avoidance of the real or imagined threat.
electrocardiogram revealed no abnormalities. There are two patterns of pathological anxiety:
(For a discussion of the case study see the end of 1. Generalized (free-floating) anxiety does not occur
the chapter). in discrete episodes and tends to last for hours, days
or even longer and is of mild to moderate severity.
It is not associated with a specific external threat or
situation (i.e. free-floating); it is excessive worry or
Feelings of anxiety or fear are both common and essential apprehension about many normal life events (e.g. job
to the human experience. It is the very uncomfortable na- security, relationships and responsibilities).
ture of this experience that makes anxiety such an effective 2. Paroxysmal anxiety has an abrupt onset, occurs in
alerting, and therefore harm-avoiding, device. However, discrete episodes and tends to be quite severe. In its
for the same reasons, when anxiety is excessive and un- severest form, paroxysmal anxiety presents as panic
checked it can create an extremely debilitating condition. attacks. These are discrete episodes of short-lived
To distinguish between normal and pathological anxiety (usually less than 1 hour), intense anxiety. They have
it is important to observe the patient’s level of function- an abrupt onset and rapidly build up to a peak level of
ing. The Yerkes–Dodson law states that the relationship anxiety. They are accompanied by strong autonomic
between performance and anxiety has the shape of an symptoms (see Box. 12.1), which may lead patients
115
The patient with anxiety, fear or avoidance
to a specific imagined or external threat. The phobic disor-

BOX 12.1 PHYSICAL SIGNS OF ANXIETY ders are the most common cause of paroxysmal anxiety in
Tachycardia
response to a perceived threat.
A phobia is an intense, irrational fear of an object, activ-
Palpitations (abnormal awareness of the heart
ity or situation (e.g. flying, heights, animals, blood, public
beating)
speaking). Although patients may recognize that their fear
Hypertension is irrational, people characteristically avoid the phobic stim-
Shortness of breath/rapid breathing ulus or endure it with extreme distress. It is the degree of
Chest pain or discomfort fear that is irrational in that the feared objects or situations
Choking sensation are not inevitably dangerous and do not cause such severe
Tremors, shaking anxiety in most other people. In severe cases, phobic anxiety
Muscle tension may progress to frank panic attacks.
Dry mouth
Sweating
Cold skin
Nausea or vomiting DIFFERENTIAL DIAGNOSIS
Diarrhoea
Abdominal discomfort (‘butterflies’) When considering the differential diagnosis of anxiety you
should determine:
Dizziness, light-headedness, syncope
Mydriasis (pupil dilatation) • The rate of onset, severity and duration of the anxiety
(i.e. is the anxiety generalized or paroxysmal? Is it
lifelong or acquired?)
• Whether the anxiety is in response to a specific threat
to believe that they are dying, having a heart attack or arises spontaneously (unprovoked)
or going mad. This increases their anxiety level and • Whether the anxiety only occurs in the context of a
produces further physical symptoms, thereby creating pre-existing psychiatric or medical condition
a vicious cycle. Box 12.2 presents the differential diagnosis for patients
See Fig. 12.2 for a comparison of panic attacks and presenting with anxiety and Fig. 12.3 gives a diagnostic
free-floating (generalized) anxiety. Quite often the two algorithm.
co-occur: someone with a background moderately elevated
anxiety level can also have superimposed panic attacks.
Paroxysmal anxiety can further be subdivided into
Anxiety disorders
episodes of anxiety that occur seemingly spontaneously, It is useful to consider the primary anxiety disorders under
without a specific imagined or external threat (see Panic the headings: phobic disorders, nonsituational disorders,
disorder, later) and those episodes that occur in response reaction to stress and obsessive-compulsive disorder.
A B
Anxiety symptoms prevalent for long periods Discrete episode of symptoms

rather than appearing in discrete episodes starting abruptly and reaching
a peak quickly
Symptom
intensity
Symptom
intensity
Time Time
a Generalized anxiety b Panic attacks Minimal baseline
symptoms of anxiety
Slow rate of onset Acute onset between attacks
Mild to moderate severity Intense severity
Long duration Shorter duration
Fig. 12.2 Graphs comparing generalized (free-floating) anxiety (A) and panic attacks (B).
116
Classification of Diseases and Related Health Problems,

BOX 12.2 DIFFERENTIAL DIAGNOSIS FOR 10th edition (ICD-10) you can code agoraphobia as occur-
PATIENTS PRESENTING WITH ANXIETY
ring with or without panic disorder.
Anxiety disorders: Social phobia
• Phobic disorders Patients with social phobia fear social situations where they
• Agoraphobia (with or without panic disorder) might be exposed to scrutiny by others that might lead to
• Social phobia humiliation or embarrassment. This fear might be limited
• Specific phobia to an isolated fear (e.g. public speaking, eating in public,
• Nonsituational disorders fear of vomiting or interacting with the opposite sex) or may
• Generalized anxiety disorder involve almost all social activities outside the home.
• Panic disorder Specific phobia
• Reaction to stress Specific (simple) phobias are restricted to clearly specific
• Acute stress reaction and discernible objects or situations (other than those cov-
• Posttraumatic stress disorder ered in agoraphobia and social phobia). Examples from
• Adjustment disorder adult psychiatric samples in order of decreasing prevalence
• Obsessive-compulsive disorder include:
Secondary to (any) other psychiatric disorder • Situational: specific situations (e.g. public
• Depression transportation, flying, driving, tunnels, bridges,
• Psychosis elevators)
• Personality disorder • Natural environment: heights, storms, water, darkness
• Neurodevelopmental disorder • Blood-injection-injury: seeing blood or an injury, fear
of needles or an invasive medical procedure
• Other
• Animal: animals or insects (e.g. spiders, dogs, mice)
• Other: fear of choking or vomiting, contracting
Secondary to psychoactive substance use an illness (e.g. HIV), children’s fear of costumed
(especially alcohol use) characters
HINTS AND TIPS
Phobic disorders Even if a patient appears calm and denies

Remember that: troublesome anxiety symptoms, always screen
for phobias. This is because sufferers of phobic
• Phobic disorders are associated with a prominent
avoidance of the feared situation. disorders avoid their phobic stimulus. If this is the
• The situationally induced anxiety may be so severe as case, it is also important to establish how severely
to take the form of a panic attack. their lives are curtailed by avoidance.
Agoraphobia
Agoraphobia literally means ‘fear of the marketplace’ (i.e.
fear of public places). In psychiatry today, it has a wider Nonsituational anxiety disorders
meaning that also includes a fear of entering crowded These disorders, unlike the phobic disorders, are character-
spaces (shops, trains, buses, elevators) where an immedi- ized by primary anxiety symptoms that are not restricted to
ate escape is difficult or in which help might not be avail- any specific situation or circumstance.
able in the event of having a panic attack. At the worst
extreme, patients may become housebound or refuse to Generalized anxiety disorder
leave the house unless accompanied by a close friend or The key element of generalized anxiety disorder is
relative. long-standing, free-floating anxiety. Patients describe exces-
There is a close relationship between agoraphobia and sive worry about minor matters and should be apprehensive
panic disorder that occurs when patients develop a fear on most days for about 6 months. The ICD-10 diagnostic
of being in a place from where escape would be difficult guidelines suggest three key elements:
in the event of having a panic attack. In fact, studies have 1. Apprehension
shown that in a clinical setting, up to 95% of patients pre- 2. Motor tension (restlessness, fidgeting, tension
senting with agoraphobia have a current or past diagnosis headaches, inability to relax)
of panic disorder. Therefore in the International Statistical 3. Autonomic overactivity (see Fig. 12.2)
117
Anxiety Secondary to a general medical condition YES Organic Anxiety Disorder or

symptoms or psychoactive substance? Substance-induced Anxiety Disorder
NO
Secondary to another major psychiatric YES

Other Psychiatric Disorder
disorder? e.g. depression
Onset after Onset unrelated

life event to life event
Event stressful YES

but not Adjustment
Disorder Unpredictable Clear trigger
traumatic
TRAUMATIC
Symptoms YES Acute Stress

resolve within
Reaction
3 days Lengthy,
External
mild-moderate
event
NO GAD periods of Phobia
or
anxiety
situation
>6 months
Meets PTSD YES
PTSD
criteria
NO NO
NO
Short intense Intrusive
Adjustment Panic
periods of thought OCD
Disorder disorder
anxiety or image
Fig. 12.3 Diagnostic algorithm for anxiety and stress related disorders.
Remember that many patients with panic disorder will

HINTS AND TIPS also have concurrent agoraphobia, so in the ICD-10 you
can code agoraphobia as occurring with or without panic
Blood-injection-injury phobias differ from others
disorder.
in that they are characterized by bradycardia and
possibly syncope (vasovagal response), rather than
tachycardia.
COMMUNICATION
Panic disorder When asking a patient whether they suffer from

Panic disorder is characterized by the presence of panic at- panic attacks, always define panic attacks for
tacks that occur unpredictably and are not restricted to any them (i.e. short, discrete episodes of extremely
particular situation (phobic disorders) or objective danger. severe anxiety). This is because patients
Panic attacks are so distressing that patients commonly commonly use the term to describe nonspecific
develop a fear of having further attacks; this is known as anxiety.
anticipatory anxiety. Anticipatory anxiety apart, patients are
relatively free from anxiety symptoms between attacks.
118
Reaction to stress and obsessive- Generalized anxiety disorder and personality disor-
ders may both have symptoms from childhood onwards,
compulsive disorder a chronic course and cause significant distress and func-
The disorders associated with a reaction to stress and tional impairment. They can be distinguished by the fo-
obsessive-compulsive disorder are discussed in Chapters 14 cus of the anxiety and by the presence or absence of other
and 13, respectively. traits in personality disorder. For example, someone with
anancastic personality disorder will worry specifically
about not doing tasks well enough, and/or about lack of
HINTS AND TIPS orderliness and control. They are also likely to have a rigid
view of appropriate behaviour and find it difficult to devi-
Both agoraphobia and severe social phobia may ate from their principles. In contrast, someone with gen-
result in patients becoming housebound and eralized anxiety disorder may well worry about not doing
the two disorders can be difficult to distinguish. tasks well enough, but they will also worry about many
When in doubt, precedence should be given to other things (e.g. appearance, finances, personal safety)
agoraphobia. and they are no more likely than average to have a partic-
ularly fixed moral code.
Anxiety secondary to a general

Other psychiatric conditions
medical condition or psychoactive
Anxiety is a nonspecific symptom and can occur secondary
to other psychiatric conditions. See Table 12.1 for examples
substance use
of psychiatric problems commonly associated with anxiety. A medical or psychoactive substance cause of anxiety
Note that depression and anxiety are closely intertwined. should always be actively sought and ruled out. Table 12.2
Not only can anxiety occur secondary to a depressive dis- lists the medical- and substance-related causes of anxiety.
order and vice versa, but some authors have also suggested The medical condition or substance use should predate the
that the two disorders are aetiologically related. About 65% development of the anxiety and symptoms should resolve
of patients with anxiety also have depressive symptoms; with treatment of the condition or abstinence from the of-
therefore, when making a diagnosis, it is essential to de- fending substance. Anxiety during alcohol withdrawal is
cide which symptoms came first or were predominant and particularly important to exclude (see Chapter 8). Absence
which were secondary. If symptoms of anxiety occur only of previous anxiety or absence of a family history of anxiety
in the context of a depressive episode then depression takes disorder also supports this diagnosis. Often symptoms can
precedence and should be diagnosed alone. arise from a combination of a general medical condition
Table 12.1 Examples of psychiatric problems commonly associated with anxiety

Focus of anxiety Psychiatric problem
Gaining weight Eating disorder (see Chapter 16)
Having many physical complaints Somatization disorder (see Chapter 15)
Having a serious illness Hypochondriacal disorder (see Chapter 15)
Fear of being poisoned or killed Delusional beliefs in paranoid schizophrenia (see Chapter 9)
Ruminative thoughts of guilt or worthlessness Depression (see Chapter 11)
When having an obsessional thought or resisting a Obsessive-compulsive disorder (see Chapter 13)
compulsion
Separation or abandonment Personality disorder (emotionally unstable or dependent; see
Chapter 17)
Being rejected or inadequate Personality disorder (avoidant or dependent; see Chapter 17)
Not being perfect Personality disorder (anankastic; see Chapter 17)
Feeling restless, unable to concentrate Attention deficit hyperactivity disorder (see Chapter 18)
Not understanding others Autism spectrum disorder (see Chapter 18)
Not understanding what is going on Delirium or dementia (see Chapter 19)
119
Table 12.2 Medical conditions and substances that are associated with anxiety
Substances
Side-effects of prescribed
Medical conditions Intoxication Withdrawal drugs
Causing dyspnoea Alcohol Alcohol Antidepressants (e.g. SSRIs
Congestive cardiac failure Amphetamines Benzodiazepines and tricyclics in first 2 weeks
Pulmonary embolism Caffeine Caffeine of use or following rapid
Chronic obstructive Cannabis Cocaine discontinuation (particularly of
pulmonary disease Cocaine Gamma-hydroxybutyrate/ Paroxetine or Venlafaxine))
Asthma Hallucinogens gamma-butyrolactone Corticosteroids
Causing increased Inhalants Nicotine Sympathomimetics
sympathetic outflow Ketamine Other sedatives and Thyroid hormones
Hypoglycaemia Novel psychoactive hypnotics Compound analgesics
Pheochromocytoma substances Opiates containing caffeine
Causing pain Phencyclidine Anticholinergics
Malignancies Antipsychotics (akathisia)
Other
Cerebral trauma
Cushing disease
Hyperthyroidism
Temporal lope epilepsy
Vitamin deficiencies
SSRI, Selective serotonin reuptake inhibitor.
and anxiety, as each predispose to the other. For example, Examination

if someone is having an acute asthma attack they will natu-
rally feel anxious and breathe even faster. Helping them to A basic physical examination, including a thorough neuro-
calm down may be an important intervention. logical and endocrine system examination, should be per-
formed on all patients with symptoms of anxiety.
Investigations
ASSESSMENT
The anxiety disorders can only be diagnosed when the symp-
History toms are not due to the direct effect of a substance or med-
ical condition. It is impractical to test for each of the large
The following questions may be helpful in eliciting anxiety number of drugs and physical health conditions capable of
symptoms: producing anxiety symptoms (see Table 12.2). It is, however,
• Do you sometimes wake up feeling anxious and important to exclude any disease or substance that may be
dreading the day ahead? (any form of anxiety) implicated through any clues in the history (e.g. past medi-
• Do you worry excessively about minor matters on most cal history and drug history) and physical examination. For
days of the week? (generalized anxiety) example, a patient with a rapid pulse and heat intolerance
• Have you ever been so frightened that your heart was should have thyroid function tests in case thyrotoxicosis is
pounding and you thought you might die? (panic causing the anxiety symptoms. The possibility of withdrawal
attack) syndromes (e.g. alcohol, benzodiazepines, opiates) causing
• Do you avoid leaving the house alone because you are anxiety symptoms should always be considered.
afraid of having a panic attack or being in situations
(like being in a crowded shop or on a train) from
which escape will be difficult or embarrassing?
(agoraphobia) DISCUSSION OF CASE STUDY
• Do you get anxious in social situations, like speaking
in front of people or making conversation? (social Repeated, unexpected episodes of short-lived intense
phobia) anxiety of abrupt onset and rapidly building up to a peak
• Do some things or situations make you very scared? Do level of anxiety associated with palpitations, sweating,
you avoid them? (specific phobia) dizziness, a choking sensation and thoughts of being
120
about to die, with no medical cause, suggests a diagnosis tack indicates anticipatory anxiety; fear of having a panic
of panic disorder. attack in a situation from which escape will be difficult or
As is common in many patients with panic disorder, ag- humiliating, thus resulting in avoidance of those situations
oraphobia has developed as a super-added problem as evi- indicates agoraphobia—Mrs PA has both.
denced by a fear of going into situations from which escape It is important to rule out depression or other psychiatric
might be difficult or humiliating. Mrs PA is showing the im- conditions as well as medical conditions and psychoactive
portant sign of avoidance of the feared situation by refusing substance use.
to go out unless it is essential and then only accompanied Now go on to Chapter 23 to read about the anxiety dis-
by her mother. Note that fear of having another panic at- orders and their management.
Chapter Summary
• Anxiety has two main components: fearful thoughts, and physical symptoms of
autonomic arousal.
• Anxiety can be free floating or paroxysmal.
• The main anxiety disorders are phobias, panic disorder and generalized anxiety disorder.
• Many other psychiatric disorders can present with or cause anxiety.
• When assessing anxiety disorders it is important to exclude substance use, particularly
alcohol withdrawal, and general medical conditions such as hyperthyroidism.
121
The patient with obsessions
and compulsions 13
• They are recurrent and intrusive and are experienced as
CASE SUMMARY unpleasant or distressing.
Mr OC is a 22-year-old medical student and has
• They enter the mind against conscious resistance.
Patients try to resist but are unable to do so.
recently moved into his own flat. He describes a
• Patients recognize obsessions as being the product
5-month history of recurrent thoughts that he has
of their own mind (not from without as in thought
behaved in a sexually inappropriate way towards his insertion (see Chapter 9 and Table 13.1)) even though
mother. He says that even though on one level he they are involuntary and often repugnant.
knows that this is impossible, he is unable to push
Obsessions are not merely excessive concerns about nor-
these thoughts away despite trying ‘rigorous mental mal life problems, and patients generally retain insight
gymnastics’. The only way he is able to relieve the into the fact that their thoughts are irrational. In fact, pa-
distress he experiences is to actually contact his tients often see their obsessions as foreign to, or against,
mother for reassurance that his fears are not true. their ‘essence’ (ego-dystonic or ego-alien; e.g. a religious
On most days, he physically has to go and see man has recurrent thoughts that he has betrayed God).
his mother, and will spend up to 2 hours analysing Also, see case study.
his behaviour with her until he feels reassured.
Whenever he tries to stop himself from seeking COMMUNICATION
reassurance, he feels a rapid escalation in anxiety,
If a patient tells you they are suffering from
thinking that not contacting his mother is evidence
obsessional thinking, always clarify what they
that his thoughts ‘might be true’. He shudders in
mean by ‘obsession’ (a recurrent, intrusive,
horror when asked whether he has ever had any
unpleasant, resisted thought from within their own
sexual feelings for his mother but admits that these
mind). This is because, like many psychiatric terms,
distressing thoughts are ‘obviously’ his own. He is
‘obsession’ has other, less specific meanings.
heterosexual and has recently become engaged.
He is extremely embarrassed and was eventually
persuaded to see his general practitioner by his
mother and fiancée when he started falling behind Compulsions are repetitive mental operations (count-
with his studies. He says that the whole thing is ing, praying or repeating a mantra silently) or physical acts
(checking, seeking reassurance, handwashing, strict rituals)
starting to depress him and that he has lost weight.
that have the following unique characteristics:
• Patients feel compelled to perform them in response
the chapter).
to their own obsessions (see case study) or irrationally
defined ‘rules’ (e.g. ‘I must count to 10,000 four times
before falling asleep’).
Obsessions or compulsions are terms that are often used in ev- • They are performed to reduce anxiety through the
eryday language (e.g. ‘she has an obsession with shoes’ or ‘he is belief that they will prevent a ‘dreaded event’ from
a compulsive liar’). Psychiatrists, however, use these terms in a occurring, even though they are not realistically
very specific way and it is important to accurately elicit, recog- connected to the event (e.g. compulsive counting each
nize and understand obsessive-compulsive psychopathology. night to prevent ‘family catastrophe’) or are ridiculously
excessive (e.g. spending hours handwashing in
response to an obsessive fear of contamination).
Compulsions are experienced as unpleasant and serve no
DEFINITIONS AND CLINICAL realistically useful purpose despite their tension-relieving
FEATURES properties. Similar to obsessions, patients resist carrying
out compulsions. Resisting compulsions, however, causes
increased anxiety.
Obsessions and compulsions Obsessions and compulsions are often closely linked,
Obsessions are involuntary thoughts, images or impulses as the desire to resist or neutralize an obsession produces
which have the following important characteristics: a compulsive act (see Table 13.2 for examples of the most
123
The patient with obsessions and compulsions
Table 13.1 Differentiating types of repetitive or intrusive thoughts or images

Term Description
Obsession Unpleasant, recurrent, intrusive thought, image or impulse. Patient attributes origin within
self. Involuntary and resisted (ego-dystonic).
Hallucination Involuntary perception occurring in the absence of a stimulus experienced as
indistinguishable from a normal perception.
Pseudohallucination Involuntary perception in the absence of stimulus experienced in internal space.
Experienced vividly, as opposed to an obsessional image which may lack detail or
completeness. Not usually resisted.
Flashback Vivid reexperiencing of memory. Usually visual. Associated with strong affect. Patient
recognizes as memory, with origin from within self. Involuntary. Usually unpleasant and
resisted.
Rumination Repeatedly thinking about the causes and experience of previous distress and difficulties.
Voluntary, not resisted.
Thought insertion Intrusive thought, image or impulse. Patient attributes origin outside self. May or may not
be resisted.
Over-valued idea Plausible belief arrived at logically but held with undue importance. Not resisted or viewed
as abnormal.
Delusion Fixed belief arrived at illogically and not amenable to reason. Not culturally normal. May or
may not be plausible. Not resisted.
Table 13.2 Examples of the most commonly occurring

BOX 13.1 QUESTIONS USED TO ELICIT
obsessions and their associated compulsions in
OBSESSIONS AND COMPULSIONS
descending order
Obsession Compulsion Do you worry about contamination with dirt even
Fear of contamination Excessive washing and when you have already washed?
(feared object is usually cleaning. Do you have awful thoughts entering your mind
impossible to avoid, e.g. Avoidance of contaminated despite trying hard to keep them out?
faeces, urine, germs) object Do you repeatedly have to check things that you
Pathological doubt Exhaustive checking of the have already done (stoves, lights, taps, etc.)?
(‘Have I turned the stove possible omission
Do you find that you have to arrange, touch or
off?’ ‘Did I lock the
door?’) count things many times over?
Reprehensible violent, Act of ‘redemption’ (e.g.
blasphemous or sexual repeating ‘Forgive me, I
thoughts, images or have sinned’ 15 times) or
impulses (e.g. impulse seeking reassurance (see
to stab husband, having case study)
thoughts that one might DIFFERENTIAL DIAGNOSIS
be a paedophile)a
Need for symmetry or Repeatedly arranging Obsessions and compulsions may occur as a primary ill-
precision objects to obtain perfect ness as in obsessive-compulsive disorder (OCD) or may
symmetry be clinical features of other psychiatric conditions. If pa-
a
Patients often have these isolated obsessions without associated tients have genuine obsessions or compulsions without
compulsions other psychiatric symptoms, then the diagnosis is sim-
ply obsessive-compulsive disorder. The International
Statistical Classification of Diseases and Related Health
Problems, 10th edition (ICD-10) diagnostic guidelines are
commonly occurring obsessions and compulsions). It can shown in Box 13.2.
be difficult enquiring about obsessions and compulsions, Many other psychiatric conditions may also present
especially when patients do not offer them as a presenting with repetitive or intrusive thoughts, impulses, images or
complaint. Box 13.1 suggests some useful questions in elic- behaviours (see Table 13.1). However, it is usually possi-
iting these symptoms. ble to differentiate them from OCD by applying the strict
124
suggests a diagnosis algorithm that may be useful in dif-

BOX 13.2 ICD-10 DIAGNOSTIC GUIDELINES ferentiating OCD from other psychiatric conditions (see
FOR OBSESSIVE-COMPULSIVE DISORDER
also Fig. 12.3).
• Obsessions or compulsions must be present for
at least 2 successive weeks and are a source of HINTS AND TIPS
distress or interfere with the patient’s functioning
• They are acknowledged as coming from the A key differential for an obsession is a delusion.
patient’s own mind They can be distinguished by checking whether the
• The obsessions are unpleasantly repetitive patient knows the thought is false and a product of
• At least one thought or act is resisted their own mind (an obsession) or believes it to be
unsuccessfully (note that in chronic cases some true and representing external reality (a delusion).
symptoms may no longer be resisted)
• A compulsive act is not in itself pleasurable
(excluding the relief of anxiety) You should always consider depression in patients with
obsessions or compulsions because:
• Over 20% of depressed patients have obsessive-
compulsive symptoms, which occur at or after the onset
definition of obsessions and compulsions. Also, when of depression. They invariably resolve with treatment of
repetitive thoughts occur in the context of other mental the depression.
disorders, the contents of these thoughts are limited ex- • Over two-thirds of patients with OCD experience a
clusively to the type of disorder concerned (e.g. morbid depressive episode in their lifetime. Obsessions and
fear of fatness in anorexia nervosa, ruminative thoughts compulsions are present before and persist after the
of worthlessness in depression, fear of dreaded objects in treatment of depression.
phobias). Table 13.3 lists the differential diagnoses and • OCD is a disabling illness and patients often have
key distinguishing features of patients presenting with chronic mild depressive symptoms that do not fully
obsessive-compulsive symptomatology. OCD can also be meet the criteria for a depressive episode. These
comorbid with other psychiatric conditions, particularly symptoms usually resolve when the OCD is treated and
depression and, less commonly, schizophrenia. Fig. 13.1 the patient’s quality of life improves.
Table 13.3 Differential diagnosis for patients presenting with obsessions or compulsions
Diagnosis Diagnostic features

Obsessions and compulsions
Obsessive-compulsive disorder At least 2 weeks of genuine obsessions and compulsions (see Box 13.2)
Eating disordersa Morbid fear of fatness (over-valued idea)
(see Chapter 16) Thoughts and actions are not recognized by patient as excessive or
unreasonable and are not resisted (ego-syntonic)
Thoughts do not necessarily provoke, nor do actions reduce, distress
Obsessive-compulsive (anankastic) Enduring behaviour pattern of rigidity, doubt, perfectionism and pedantry
personality disorder Ego-syntonic
(see Chapter 17) No true obsessions or compulsions
Autism spectrum disorder Restricted, stereotyped interests, typically related to physical aspects
(see Chapter 18) of objects or to classification and collecting. Pleasurable, not viewed as
unreasonable, not resisted. Repetitive behaviours (e.g. rocking or hand-
flapping) are performed to gain or reduce sensory input, not to reduce anxiety
following an obsessional thought. Associated features are impairments in
communication and social understanding.
Mainly obsessions
Depressive disorder Obsessive-compulsive symptoms occur simultaneously with, or after the onset
(see Chapter 11) of, depression and resolve with treatment
Obsessions are mood-congruent (e.g. ruminative thoughts of worthlessness)
Continued
125
The patient with obsessions and compulsions
Table 13.3 Differentiating diagnosis for patients presenting with obsessions or compulsions—cont’d

Diagnosis Diagnostic features
Other anxiety disorders Phobias: provoking stimulus comes from external object or situation rather
(see Chapter 12) than patient’s own mind
Generalized anxiety disorder: excessive concerns about real-life circumstances
Absence of genuine obsessions or compulsions
Hypochondriacal disorder Obsessions only related to the fear of having a serious disease or bodily
(see Chapter 15) disfigurement
Schizophrenia Thought insertion: patients believe that thoughts are not from their own mind
(see Chapter 9) Delusion: patients to do not attempt to resist thought
Presence of other schizophrenic symptoms
Lack of insight
Mainly compulsions
Habit and impulse-control disorders: Repetitious impulses and behaviour (gambling, stealing, pulling out hair) with
pathological gambling, kleptomania, no other unrelated obsessions/compulsions
trichotillomania Concordant with the patient’s own wishes (therefore ego-syntonic)
Gilles de la Tourette syndrome Motor and vocal tics, echolalia, coprolalia
(see Chapter 18)b
a
There is a higher incidence of true obsessive-compulsive disorder in patients with anorexia nervosa.
b
35%–50% of patients with Gilles de la Tourette syndrome meet the diagnostic criteria for obsessive-compulsive disorder, whereas only
5%–7% of patients with obsessive-compulsive disorder have Tourette syndrome
Obsessive-compulsive symptoms for 2 weeks
Does the patient meet the criteria for another

psychiatric diagnosis?
Obsessive-compulsive
YES NO
disorder
Are the contents of the obsessions/compulsions restricted only to the other diagnosis
(e.g. preoccupation with food in anorexia/guilty ruminations in depression)?
YES NO
Diagnose other psychiatric condition only, e.g. Diagnose OCD and other condition.
• Depression It is best to diagnose depression alone
• Anorexia nervosa when obsessions or compulsions develop
• Hypochondriacal disorder only in the context of depressive episode,
• Pathological gambling even if they are mood-incongruent
Fig. 13.1 Algorithm for the diagnosis of obsessions and compulsions.
126
His most likely diagnosis is OCD; however, it is import-

DISCUSSION OF CASE STUDY ant to consider depression. In this case, the depressed mood
developed after the obsessive-compulsive symptoms. If Mr
Mr OC has genuine obsessions (recurrent, intrusive
OC now met the criteria for a depressive episode, then OCD
thoughts that are distressing, resisted and recognized as be-
and depression would be diagnosed. He most probably has
ing from his own mind) and compulsions (repeatedly and
mild ‘reactive’ depression, which will resolve when the
excessively seeking reassurance to relieve anxiety caused by
OCD is treated (see Fig. 13.1).
obsessions). He also describes symptoms of depression (de-
Now go on to Chapter 23 to read about obsessive-
pressed mood and weight loss).
compulsive disorder and its management.
Chapter Summary
• An obsession is a recurrent, intrusive, unpleasant, resisted thought experienced as

arising from within someone’s own mind.
• A compulsion is an irrational or excessive mental operation or physical action performed
to reduce anxiety triggered by an obsession.
• Obsession-like symptoms often arise in other psychiatric disorders: taking a careful
history of the nature of the recurrent thought is important.
• Depression is often comorbid with obsessive-compulsive disorder.
127
The patient with a reaction
to a stressful event 14
FEATURES
Mrs PT, a 28-year-old divorced woman, was
referred to a psychiatrist. She was well and When assessing someone who may have had a pathological
working as a cleaner until 3 months ago when, on response to a stressful event, it is important to explore two
her way to work one evening, two men cornered variables: (1) the nature and severity of the life event; and
her at a secluded bus shelter. They pushed her to (2) the nature and severity of the person’s reaction to the
the ground and attempted to rape her, threatening life event.
to ‘slit her throat’ if she screamed. The men ran off
when they heard someone approaching, leaving Nature and severity of the life event
Mrs PT shaken but with only superficial cuts and
bruises. She felt low in mood for a few days after
Stress
‘Psychosocial stressor’ is the term used for any life event,
the assault but attempted to carry on with her
condition or circumstance that places a strain on a person’s
job and forget what had happened. In the month
current coping skills. It is important to remember that what
that followed, Mrs PT avoided all attempts by constitutes a ‘stressor’ is subjective, and dependent on the
her family and friends to talk about the incident. specific person’s ability to adapt or respond to a specific life
She became socially withdrawn, only leaving the challenge. For example, one student may breeze through an
house to go to work. After a month, she started exam without experiencing any stress, whereas another may
having nightmares about the incident and would feel incredibly strained because of a perceived (or actual)
wake up drenched in sweat. Her work colleagues mismatch between their ability and the demands of the sit-
noticed that she had become ‘jumpy and quick- uation. Also note that the same person’s coping skills vary
tempered’ and that sudden movements or noises throughout their developmental life: the death of a distant
startled her. She had also started avoiding public
relative may be far more stressful for a middle-aged man
contemplating his own mortality than for an ‘invincible’
transportation and refused to watch television
adolescent.
for fear that something might remind her of the
attack. Mrs PT finally sought medical help after
her work supervisor found her lying on the floor, COMMUNICATION
seemingly in a trance, screaming ‘Leave me alone!’
Whenever a patient presents with low mood or
repeatedly. She recounted to her psychiatrist how
anxiety, always check for possible psychosocial
she ‘relived’ the attack in her mind and thought
stressors and establish how (if at all) they relate
she could hear the men threatening her, just like
to the onset of symptoms. If the stressor seemed
they did during the incident. The psychiatrist
insignificant, verify how it was perceived by
noticed that Mrs PT could not recall certain
the patient. Remember, a seemingly innocuous
important aspects of the assault.
life event may be a significant psychosocial
stressor for a vulnerable patient (e.g. a change of
the chapter).
accommodation for an elderly widow).
It is normal to have some psychological symptoms after a

stressful event or bereavement. However, in some cases, Traumatic stress
these symptoms may be more severe than expected, and im- A traumatic stressor occurs outside the range of nor-
pact upon everyday functioning. It is important to be able mal human experience, and its magnitude means that it
to distinguish a normal reaction to a difficult life event from would be experienced as traumatic by most people. This
a specific constellation of symptoms that denote psychopa- type of stress occurs in situations where a person feels
thology requiring clinical attention. that their own (or a loved one’s) physical or p
sychological
129
The patient with a reaction to a stressful event
integrity is under serious threat. These include natural Acute stress reaction
disasters, physical or sexual assaults, serious road traffic The symptoms of an acute stress reaction develop immedi-
accidents, terrorist attacks, torture and military combat. ately after, or within a few minutes of, a traumatic stressor.
Bereavement is a special case of traumatic stress that will Typically, sufferers will experience an initial ‘dazed’ state
be discussed later. followed by possible disorientation and a narrowing of at-
tention with inability to process external stimuli. In some
Nature and severity of patient’s cases, this may be followed either by a period of dimin-
ished responsiveness (to the extreme of a dissociative stu-
reaction por) or psychomotor agitation and overactivity. Patients
Some people seem to experience stressful or traumatic may also have amnesia for the episode (see Box 14.1 for
life events with minimal symptoms, while others seem dissociative amnesia and stupor). These symptoms nor-
more susceptible to developing a pathological response. mally begin to diminish after 24–48 hours and are usually
Depending on the severity of the stressor and the person’s minimal after 3 days.
underlying vulnerability, a patient may develop: (1) an ad- Because this diagnosis describes symptoms which are
justment disorder; (2) an acute stress reaction or posttrau- part of the spectrum of normal existence and do not require
matic stress disorder (PTSD); (3) a dissociative disorder; or any specific treatment, this diagnosis is little used and is
(4) another major mental illness such as a depressive, anxi- undergoing revision in psychiatric classification systems.
ety or psychotic disorder. DSM-5 now specifies that an acute stress reaction should
only be diagnosed if symptoms persist for longer than
Adjustment disorder 3 days, and at the time of writing, the latest draft of ICD-11
Feeling unable to cope is common at times of psychosocial no longer lists it as a mental disorder.
stresses to which we need to adapt or adjust (such as mov-
ing house, changing job or becoming a parent). However, Posttraumatic stress disorder
when symptoms are considered significant enough to be The symptoms of PTSD usually develop after 1 month but
out of proportion to the original stressor or cause distur- within 6 months of a traumatic stressor and lead to signif-
bance of social or occupational functioning, this can be icant distress or functional impairment. Symptoms include
described as an adjustment disorder. For this diagnosis to all of the following:
be made, the emotional and/or behavioural symptoms need 1. Repetitive reexperiencing of the traumatic event in the
to occur within 3 months (according to the Diagnostic and form of:
Statistical Manual of Mental Disorders, 5th Edition (DSM- • Flashbacks (intrusive, unwanted memories;
5); International Statistical Classification of Diseases and vivid mental images or dreams of the original
Related Health Problems, 10th edition (ICD-10) states experience)
1 month) of the original stressor. Although it is assumed • Distress caused by internal or external cues that
that the disorder would not have arisen without the orig- resemble the stressor (at times, patients may
inal stressor, an individual’s personality and vulnerability dissociate and experience the original event as
to stress play an important contributing role. Symptoms though it were happening at that moment)
usually fully resolve within 6 months of onset, and if this • Patients may also experience hallucinations and
is not the case, consideration should be given to a different illusions.
diagnosis. 2. Avoidance of stimuli associated with the stressor,
Usually, adjustment disorder is characterized by mood amnesia for aspects of the trauma, as well as emotional
and/or anxiety symptoms, and this can occasionally be of numbness and social withdrawal
severity sufficient to cause disturbances of conduct (e.g. 3. Increased arousal (insomnia, angry outbursts,
reckless driving, aggressive behaviour). Many people with hypervigilance, poor concentration, exaggerated startle
adjustment disorder also experience suicidal ideation. response)
The biggest risk factor for posttraumatic stress disorder is
experience of past trauma, particularly during childhood.
HINTS AND TIPS The latest draft of ICD-11 (not yet published) includes the
diagnosis of ‘complex posttraumatic stress disorder’ where
You should only diagnose an adjustment disorder people who experience a series of severe traumas (e.g. re-
when patients do not meet the criteria for a more peated childhood sexual abuse) develop persistent diffi-
specific diagnosis such as mood, psychotic or culties in regulating affect, relationships with others and
anxiety disorder (including posttraumatic stress feelings of worthlessness, guilt and shame. These symptoms
disorder), or a normal bereavement reaction. are closely related to those seen in reactive attachment dis-
order in childhood (see Chapter 30) and emotionally unsta-
ble personality disorder (see Chapter 17).
130
RED FLAG BOX 14.1 DIFFERENTIAL DIAGNOSIS FOR

PATIENTS PRESENTING WITH A REACTION TO
When assessing a patient with suspected STRESS OR TRAUMA
posttraumatic stress disorder (PTSD), remember
that head injuries and epilepsy are important Adjustment disorder
differential diagnoses that may present with similar Acute stress reaction
symptoms, and may also have been caused by the Posttraumatic stress disorder
initial trauma. Patients with PTSD also have a high Normal bereavement reaction
rate of comorbid substance misuse, and it is also Dissociative disorder
important to be vigilant for symptoms of alcohol or Exacerbation or precipitation of other psychiatric
drug intoxication/withdrawal. illness:
• Mood disorders
• Psychotic disorders (especially acute and
COMMUNICATION transient psychotic disorders)
Malingering (see Chapter 15)
Not everyone who tells you they are ‘traumatized’
has posttraumatic stress disorder (PTSD): PTSD
is only diagnosed following an event which the
majority of people would experience as life- with the onset of the dissociative symptoms; however, this
threatening or catastrophic to themselves or requirement is absent from the current draft of ICD-11 (not
to loved ones. For example, severe domestic yet published). DSM-5 classifies the memory symptoms in
violence, rather than a relationship break-up. Table 14.1 as dissociative disorders and the neurological
symptoms as somatic disorders. The shifting classification
system reflects shifts in understanding of the causes of these
syndromes. They are now falling more under the umbrella
Dissociation of ‘medically unexplained symptoms’ and of ‘functional
In psychiatry, ‘dissociation’ describes a disruption in the symptoms’ (see Chapter 15). It is now thought that dysfunc-
usually integrated functions of consciousness and cognition in high level cortical processing of motor and sensory
tion. In this phenomenon, memories of the past, awareness information can lead to symptoms which are genuinely ex-
of identity, thoughts, emotions, movement, sensation and/ perienced, involuntary and not necessarily related to pass
or control of behaviour become separated from the rest of or current trauma, even though no structural or physiolog-
an individual’s personality such that they function inde- ical abnormality is identified. Older terms such as ‘hysteria’
pendently and are not under voluntary control. Box 14.1 and ‘conversion disorder’ are now little used, as they imply a
describes the more common dissociative disorders. psychogenic causation which is now in doubt.
Dissociative disorders should not be diagnosed if there
is evidence of a physical or psychiatric disorder that plausi-
HINTS AND TIPS bly explains the symptoms. In addition to assessing for evi-
dence of known physical disorders, it is also useful to check
Depersonalization is feeling yourself to be for positive signs of functional neurological disorder (see
strange or unreal. Derealisation is feeling that Table 14.2). If present, these strengthen the evidence for a
external reality is strange or unreal. These can be functional (dissociative) neurological condition. However, if
considered as types of dissociation, and may be in doubt it is safest to ask a neurologist for their opinion too.
caused by psychiatric illness (e.g. depression,
anxiety, schizophrenia), physical illness (e.g.
epilepsy), psychosocial stress and substance
abuse. RED FLAG
Before accepting the diagnosis of a dissociative
disorder, a neurological or other psychiatric
Dissociative disorders are not well understood and are disorder should be carefully sought for and
undergoing revision in classification. The ICD-10 requires adequately excluded (see Fig. 15.1).
that there be some evidence of a psychological causation
(stressful events or disturbed relationships) in association
131
Table 14.1
Dissociation causing neurological symptoms (‘Functional neurological symptoms’)
Dissociative anaesthesia Cutaneous or visual sensory loss that does not correspond to anatomic dermatomes or
and sensory loss known neurological patterns
Dissociative motor disorders Partial or complete paralysis of one or more muscle groups not due to any physical
cause
Dissociative convulsions Used to be known as ‘pseudoseizures’; however, the name has been changed because
(psychogenic nonepileptic of concerns that the term ‘pseudo’ implies a degree of voluntary control (which is not
seizures) the case). May present similarly to epileptic seizures but tongue-biting, serious injury
and urinary incontinence are uncommon. There is also absence of epileptic activity on
the electroencephalogram.
Dissociation causing memory symptoms
Dissociative amnesia Partial or complete memory loss for events of a traumatic or stressful nature not due to
normal forgetfulness, organic brain disorders or intoxication
Dissociative fugue Rare disorder characterized by amnesia for personal identity, including memories and
personality. Self-care and social interaction are maintained. Usually short-lived (hours
to days), but can last longer. Very often involves seemingly purposeful travel beyond the
individual’s usual range, and in some cases, a new identity may be assumed.
Less common dissociative disorders
Dissociative stupor (trance) Severe psychomotor retardation characterized by extreme unresponsiveness, lack of
voluntary movement and mutism, not due to a physical or psychiatric disorder (that is,
not due to depressive, manic or catatonic stupor)
Dissociative identity disorder Apparent existence of two or more personalities within the same individual. This is a
(multiple personality rare and highly controversial diagnosis.
disorder
Table 14.2 Some positive signs of functional

HINTS AND TIPS
neurological disorders
Disorder Signs Although dissociative disorders are covered in this
Functional seizure Eyes shut, resisting opening. chapter, around one in three functional neurological
(dissociative convulsion) Ictal or postictal weeping. disorders arise in the absence of a stressor.
Long duration. Memory
of ictal events (e.g. ‘I was
shaking all over’)
Functional paresis Hoover sign. A ‘give way’
(dissociative motor quality to the weakness. HINTS AND TIPS
disorder) A limb that when left
suspended in the air The Hoover sign is weakness of hip extension
‘hovers’ for a moment which returns to normal with contralateral
before falling. hip flexion against resistance. This can be
Functional sensory Nondermatomal pattern of demonstrated to the patient to reassure them that
loss (dissociative sensory loss (e.g. sensory is a problem with muscle control, not structure,
anaesthesia) abnormalities that stop at
which is causing their leg weakness.
the groin or shoulder)
Functional tremor Entrainment (i.e. the tremor
frequency aligns with that
of a voluntary rhythmic
movement). Stops with Precipitation or exacerbation
distraction (e.g. mental of an existing mental illness
arithmetic). Worsens
when attempts made to The influence of a patient’s environment on their mental health
immobilize (e.g. if limb held cannot be overemphasized. Almost all forms of mental illness
onto by examiner) (e.g. depression, psychotic illness, anxiety) can be precipitated
132
or exacerbated by psychosocial (‘life events’) or traumatic stress- Although most people will meet the criteria for a de-
ors. However, unlike the above reactions in this group, there pressive episode at some stage during the grieving process,
need not be a direct aetiological link with the stressor involved. bereavement reactions are not pathological, so no psychiat-
ric diagnosis should be made. However, patients who have
been bereaved are at higher risk for developing a severe de-
pressive illness requiring treatment. DSM-5 now suggests
BEREAVEMENT that bereaved people meeting criteria for a depressive ep-
isode should be assessed and treated as normal. Although
Bereavement is a unique kind of stress experienced by most
the shift is away from defining ‘normal’ or ‘abnormal’ grief
people during their life and is a normal human experience.
reactions, both DSM-5 and the most recent draft of ICD-
A bereavement reaction usually occurs after the loss of a
11 (not yet published) do include an option to describe
loved person but can also result from other losses, like the
extremely prolonged and intense grief (causing significant
loss of a national figure or a beloved pet. The normal course
functional impairment) as a disorder. Table 14.3 compares
of grief after bereavement occurs in five phases (Fig. 14.1),
symptoms suggested by DSM-5 that may help to distinguish
although these should not be regarded as a rigid sequence
depression from bereavement.
that is passed through only once. Each response to bereave-
ment is unique to the individual, and will vary greatly in
severity, duration and content.
HINTS AND TIPS

DIFFERENTIAL DIAGNOSIS
The length of a bereavement reaction is variable Following thorough exploration of the nature and severity
and tends to be longer if the death was sudden of both the life event and patient’s reaction, the diagnosis
and unexpected. is usually clear (see Box 14.1 and Fig. 12.3 for a diagnos-
tic algorithm). Major mental illnesses are often triggered
by major stressors. Even if the onset of symptoms is clearly
Alarm
A highly stressed emotional state coupled with physiological arousal (increased heart rate and blood pressure)
Numbness
A state of being emotionally disconnected – a form of self-protection against the acute pain of loss
Pining
A state where the bereaved is constantly reminded of, and preoccupied with, the deceased. Marked by ‘pangs of grief’
and intense anxiety. Hypnagogic, hypnopompic, pseudohallucinations and illusions of the
deceased may occur; these are transient and always involve the dead person
Depression and despair

A state where the bereaved have a depressed and irritable mood, thoughts of being ‘better off dead’ or that
they should have died with the deceased, anhedonia, loss of appetite and weight, insomnia,
impaired concentration and short-term memory
Recovery and reorganization

Acceptance of loss; return of food, social, and sexual appetite; weight is regained; grief
diminishes but may return for a time at anniversaries associated with the deceased
Fig. 14.1 Parkes’s stages of normal bereavement.
133
Table 14.3 Distinguishing depression from grief If a patient presents with psychiatric symptoms after a
life-threatening event, always screen for features of depres-
Depression Bereavement
sion as well as features of PTSD. This is because the risk for
Mood Pervasively low Feeling empty developing depression increases sixfold in the 6 months that
symptoms and anhedonic and lost, but also follow a stressful event.
able to experience
positive emotions
Variation Diurnal, worse Triggered by
in morning reminders of
deceased
Cognitions Guilt, Self-esteem intact, Mrs PT experienced a traumatic stressor in which she
worthlessness preoccupied with
believed that her physical integrity was under i mmediate
deceased
threat. The event was outside the range of normal hu-
Suicidal With intent to With intent to join man experience and would have been experienced as
thoughts end a worthless, the deceased
traumatic by most people. She subsequently devel-
pointless or or end the pain
unbearable of unbearable oped avoidance of stimuli associated with the trauma
existence existence (avoided talking or thinking about it, avoided public
transportation and television), amnesia for aspects of the
Psychotic Mood- Transient
symptoms congruent, hallucinations of trauma and social withdrawal. Later on, she showed signs
persistent the deceased of increased arousal (startle response, being ‘jumpy and
quick-tempered’). Finally, Mrs PT repetitively reexperi-
Motor function Psychomotor Intact
retardation in enced the trauma through nightmares, flashbacks and
severe cases dissociation (reliving and behaving as though the trauma
were occurring at that moment through mental imagery
and hallucinations). All of the above suggest a diagnosis
linked with a stressor, diagnosis of a specific major mental of PTSD.
illness (mood disorder, psychotic disorder) should be given Now go on to Chapter 23 to read about the anxiety- and
if diagnostic criteria are met. stress-related disorders and their management.
Chapter Summary
• Unpleasant responses to stressful events such as bereavement are normal and generally
not pathological.
• Life-threatening or potentially catastrophic trauma can lead to posttraumatic stress
disorder (PTSD) in vulnerable individuals.
• The three core features of PTSD are: reexperiencing, avoidance and hypervigilance.
• Dissociative disorders are when the normal integration of consciousness with cognition is
disrupted.
• Dissociative disorders can disrupt motor, sensory and memory function. A subset are
now termed ‘functional neurological disorders’.
• Bereavement does not exclude the diagnosis of depression.
FURTHER READING
Good explanation and advice regarding functional neurological
symptoms www.neurosymptoms.org
Description of functional facial weakness: BBC Radio 4 Inside
Health 10th Oct 2012 along with a commentary www.bbc.co.uk/
programmes/b01n65zl
134
The patient with medically
unexplained physical
symptoms 15
CASE SUMMARY COMMUNICATION
Mrs SD, a 32-year-old mother of three, had Many of the terms used for medically unexplained
consulted her general practitioner (GP) at least symptoms are perceived as stigmatizing but the
once every 2 weeks for the past year. Her term functional symptoms is acceptable to most
GP had known her for just over a year since patients and colleagues. Functional symptoms are
she moved to the area after an acrimonious those without identifiable structural cause. They
divorce. Her medical history, part of which was can be likened to ‘software’ rather than ‘hardware’
obtained from her previous GP, was substantial, problems in the body.
and her health difficulties had precluded her
from employment. At menarche, she was
diagnosed with dysfunctional uterine bleeding
and dysmenorrhoea. Extensive investigations,
including three exploratory laparoscopies, DEFINITIONS AND CLINICAL
revealed no physical cause for persistent upper FEATURES
abdominal pain with alternating diarrhoea and
constipation. Three years ago, Mrs SD presented A structural or physical cause should always be considered
with urinary frequency and dysuria. Exhaustive in response to reported ‘physical symptoms’. However, in
investigations including cystoscopy, urodynamic certain cases, the reported symptoms are medically unex-
plained, that is they:
studies and radiography, were all normal. She
had also been referred to various specialists • Do not correspond to or are clearly not typical of any
known physical condition
including a rheumatologist due to chronic
• Are associated with an absence of any physical signs or
neck pain that she had described as: ‘the pain
structural abnormalities
that has ruined mine and my kids’ life!’ Again,
• Are associated with an absence of any abnormalities
physical examination and investigations revealed in comprehensive laboratory, imaging and invasive
no abnormalities. Mrs SD was taking up to 30 investigations
codeine tablets daily and could not sleep without Medically unexplained symptoms represent a large and di-
two different types of sleeping tablets. verse group of symptoms and underlying difficulties:
(For a discussion of the case study see the end of • It is likely that some disorders for which no medical
the chapter). cause can be found are still secondary to ‘physical
aetiology’ – subtle presentations of a disorder yet to
fully manifest or a vanishingly rare genetic disorder,
toxin or occult infection which can never be detected.
• Some symptoms are recognized to arise as part of a
Medically unexplained symptoms (symptoms where common syndrome, without associated structural
no cause can be found despite adequate investigation) abnormalities, but with unclear aetiology. These
are a common clinical problem, representing around are generally now termed ‘functional disorders’. For
a third of medical outpatient appointments and a large example, fibromyalgia, irritable bowel syndrome or
proportion of primary care appointments. Patients with dissociative disorders (see Chapter 14).
such symptoms are often stigmatized by health care pro- • Some symptoms are associated with undue distress,
viders, with their genuine difficulties being labelled ‘fat causing a high degree of anxiety and impairment
folder syndrome’, ‘all in the mind’ or ‘the worried well’. despite reassurance. These ‘somatoform disorders’ are
Understanding the psychiatric disorders leading patients the focus of this chapter.
to have unusual physical symptoms or an abnormal re- It is worth noting that even though no structural or phys-
sponse to physical symptoms is invaluable for all junior iological disease has been identified, it does not mean that
doctors. one does not exist – it may remain undiscovered thus far to
135
The patient with medically unexplained physical symptoms
Table 15.1 Functional disorders affecting individual recent draft of International Statistical Classification of
systems Diseases and Related Health Problems, 11th edition (ICD-
11; not yet published).
System Disorder
Cardiovascular Atypical chest pain
COMMUNICATION
Respiratory Hyperventilation
Gastrointestinal Irritable bowel syndrome It is important to acknowledge that even though no
Neurological Dissociative seizures, physical pathology has been found, the functional
weakness and sensory impairment and distress caused by somatoform
symptoms (see Chapter 14) disorders is genuine and that the symptoms are
Rheumatology Fibromyalgia neither under conscious control nor are they
Infectious diseases Chronic fatigue syndrome being feigned. Empathic acknowledgement and
explanation can be very therapeutic in itself.
medical science. For example: epilepsy, migraine, multiple Dismissing a patient by telling them that their
sclerosis and stomach ulcers were historically considered symptoms are ‘all in your mind’ is unhelpful and
‘functional’ illnesses. See Table 15.1 for a list of what are potentially harmful.
currently termed functional disorders.
It is also worth noting that many patients with medically
unexplained symptoms will be reassured by normal investi-
gations or an explanation that they are functional symptoms Somatization disorder
which are likely to get better. Those patients who are unable The central features of somatization disorder are multiple,
to accept reassurance may have a somatoform disorder. recurrent and frequently changing physical symptoms, with
the absence of identifiable physiological explanation. These
include:
Somatoform disorders
• Gastrointestinal: nausea, vomiting, diarrhoea,
Somatoform disorders are a class of disorders where pa- constipation, food intolerance, abdominal pain
tients are unduly concerned about physical symptoms or • Sexual or reproductive: loss of libido, ejaculatory or
illness. Obviously, it is normal to be concerned to some erectile dysfunction, irregular menses, menorrhagia,
extent about physical symptoms, and what they may indi- dysmenorrhoea
cate. However, in somatoform disorders, patients remain • Urinary: dysuria, frequency, urinary retention,
concerned even when examination and investigations show incontinence
no detectable structural or physiological abnormalities, or • Neurological: paralysis, paraesthesia, sensory loss,
show some abnormalities that are insufficient to account seizures, difficulty swallowing, impaired coordination
for the severity of the patient’s response. Patients are unable or balance
to accept reassurance and remain anxious and disabled by
To meet diagnostic criteria, patients should have numerous
their physical symptoms.
symptoms from almost all these systemic groups, not just
In somatoform disorder, symptoms are not under vol-
one or two isolated symptoms.
untary control: they occur unintentionally, as opposed to
For the diagnosis of somatization disorder, the ICD-10
the intentional feigning or production of symptoms in fac-
suggests that all the following be present:
titious disorder and malingering (see later section). Patients
may have a comorbid physical health condition (e.g. mild • At least 2 years of symptoms with no physical
asthma), but feel unduly preoccupied about the risks of this explanation found
to the point of having regular episodes of hyperventilation. • Persistent refusal by the patient to accept reassurance
The commonest somatoform disorders are somatization from several doctors that there is no physical cause for
disorder, hypochondriacal disorder and body dysmorphic the symptoms
disorder. Somatoform autonomic dysfunction and per- • Some degree of functional impairment due to the
sistent somatoform pain disorder are now generally sub- symptoms and resulting behaviour
sumed within functional disorders and are not covered Most patients with somatization disorder will have a long
further here. All of these diagnoses are undergoing classi- history of contact with medical services, during which
fication revision, with a move away from the requirement numerous investigations may have been conducted. This
for medically unexplained symptoms in the Diagnostic and often results in iatrogenic disease with physically explain-
Statistical Manual of Mental Disorders, 5th Edition (DSM- able symptoms (e.g. abdominal adhesions from frequent
5; instead emphasizing an abnormal response to symptoms, exploratory surgery). Due to frequent courses of medica-
medically explained or not) and the use of the term bodily tion, these patients are often dependent on analgesics and
distress disorder in place of somatoform disorder in the most sedatives.
136
Hypochondriacal disorder ciation. These patients can go undetected and may receive
In hypochondriacal disorder, patients misinterpret normal large doses of psychotropic medication. As well as feigning
bodily sensations, which lead them to believe that they have physical or psychiatric illness, these patients tend to pro-
a serious and progressive physical disease. These patients vide a fluent, plausible account of symptoms, described as
tend to ask for investigations to definitively diagnose or pseudologia fantastica (pathological lying).
confirm their underlying disease. However, despite repeated
normal examination and investigations, hypochondriacal Factitious disorder (Munchausen
patients refuse to accept the reassurance of numerous doc- syndrome)
tors that they do not suffer from a serious physical illness. The central feature of factitious disorder is focus on the pri-
This is in contrast to somatization disorder, where patients mary (internal) gain of assuming the sick role (the aim to
tend to seek relief from their symptoms. be cared for like a patient, usually in hospital). Although
symptoms are feigned, it is important to understand that
Body dysmorphic disorder this care-seeking behaviour is usually a manifestation of
Body dysmorphic disorder (dysmorphophobia) is a variant of psychological distress. Although the terms are still used
hypochondriacal disorder, in which patients are preoccupied synonymously and interchangeably, Munchausen syndrome
with an imagined or minor defect in their physical appear- refers to a subgroup of patients with factitious disorder who
ance. The symptoms should not be better accounted for by an- travel between hospitals and care providers (peregrination),
other disorder (e.g. concerns regarding weight and body shape often giving different names and details. The syndrome’s
are usually more accurately attributed to an eating disorder). name derives from Rudolf Erich Raspe’s literary character,
This imagined defect or deformity can concern any part of the Baron Munchausen, a well-known teller of fantastic and im-
body (e.g. a ‘crooked nose’ or ‘ugly hands’). The preoccupation plausible stories about his travels and adventures.
causes significant distress or impairment in functioning.
The psychopathology of both hypochondriacal disorder Malingering
and body dysmorphic disorder takes the form of an over- Malingering patients focus on secondary (external) gain of
valued idea (see Chapter 9). The belief is not delusional be- the secondary consequence of being diagnosed with an illness
cause patients are open to some explanation and their fears (avoidance of military service, evading criminal prosecution,
can be allayed, at least for a short while. A persistent delu- obtaining illicit drugs, obtaining benefits or compensation).
sional disorder (somatic delusional disorder) is diagnosed if
the belief is held with delusional intensity.
Munchausen syndrome by proxy
This is a form of abuse where a carer (classically a parent)
Functional, conversion and will seek help for fabricated or induced symptoms in a de-
dissociative disorders pendent (classically a child). The psychological aim of the
carer is for the dependent to be cared for like a patient. The
These three types of disorder are closely related, and their
induction of a factitious disorder can be dangerous (e.g. co-
classification is evolving rapidly. Conversion is a psychoana-
vert poisoning) and once a diagnosis has been made, the
lytical term that describes the hypothetical process whereby
dependent should be removed from the direct influence of
psychic conflict or pain undergoes ‘conversion’ into so-
the carer, and relevant authorities (most often child/adult
matic or physical form to produce physical symptoms. The
protection agencies) alerted (see Chapter 30). The affected
DSM-5 uses this term interchangeably with ‘functional
carer should be offered psychiatric help; however, because
neurological symptom disorder’, although a recent stressor
the disorder is rare, little is known about effective treatment.
is not required for the diagnosis, whereas ICD-10 considers
these to be dissociative disorders. This book describes these
in Chapter 14. See also Table 15.1. The details of these indi-
vidual conditions are not covered here.
Factitious disorder and malingering The differential diagnosis for patients presenting with
Both factitious disorder and malingering differ from soma- an abnormal response to physical symptoms is shown in
toform disorders in that physical or psychological symptoms Box 15.3. The flow chart in Fig. 15.1 can help with reaching
are produced intentionally or feigned. Patients may give the correct diagnosis.
convincing histories that fool even experienced clinicians An underlying physical condition should be ruled out
and often manufacture signs (e.g. warfarin may be ingested when patients present with physical symptoms. Somatization
to simulate bleeding disorders, insulin may be injected to disorder can resemble insidious multisystem diseases such
produce hypoglycaemia, urine may be contaminated with as systemic lupus erythematosus, multiple sclerosis, ac-
blood or faeces). Certain patients feign psychiatric symp- quired immune deficiency syndrome, h yperparathyroidism,
toms such as hallucinations, delusions, depression or disso- occult malignancy and chronic infections.
137
The patient with medically unexplained physical symptoms
Physical complaints often occur in the context of other

BOX 15.3 DIFFERENTIAL DIAGNOSIS FOR psychiatric conditions. Patients with schizophrenia may
PATIENTS PRESENTING WITH MEDICALLY
have somatic delusions or visceral somatic hallucinations.
UNEXPLAINED SYMPTOMS
However, the explanation of these symptoms is often quite
Undiagnosed unknown medical condition odd and there are usually other psychotic symptoms accom-
Undiagnosed known medical condition panying the physical complaints. Individuals with depressed
(e.g. insidious multi-system disease) mood often present with numerous somatic complaints;
these tend to be episodic and resolve with the treatment of
Functional disorders (also known as dissociative
the depression. Patients with panic disorder have multiple
disorders or conversion disorders)
somatic symptoms while having panic attacks, but these
Somatoform disorders resolve when the panic subsides. Patients with generalized
• Somatization disorder anxiety disorder may also have multiple somatic preoccupa-
• Hypochondriacal disorder tions, but their anxiety is not limited to physical symptoms.
• Body dysmorphic disorder Conversion and dissociative disorders (e.g. motor disorders,
Factitious disorder psychogenic nonepileptic seizures) can present with neuro-
Malingering logical symptoms without any evidence of an organic cause.
Other psychiatric conditions However, these symptoms are usually clearly defined and
• Anxiety disorders isolated as opposed to the ill-defined, multiple symptoms in
• Mood disorders somatization disorder. The difficulty in distinguishing other
mental disorders from somatization disorder is illustrated by
• Psychotic disorders
the observation that at least half of patients with somatiza-
tion disorder have another coexisting mental illness.
Medically unexplained symptoms
Physical disorder sufficient to No

Further examination and
cause symptoms adequately
investigation
excluded
For example:
• Fatigue in depression
• Paraesthesia in anxiety
• Somatic hallucinations in
Yes psychosis
Symptoms secondary to
another psychiatric disorder Other psychiatric disorder
Yes
For example:
• Hoover sign in neurological
symptoms
Yes
Positive evidence of • Pain relieved by defecation in Functional/dissociative
functional disorder irritable bowel syndrome disorder
• Tenderness at specific points in
fibromyalgia
Yes
Abnormal response to Undue concern over symptoms
Somatization disorder
symptoms
Undue concern over presence of Yes
underlying disorder
Hypochondriacal disorder
Undue concern over appearance Yes

Body dysmorphic disorder
Symptoms Gain is sick role

Factitious disorder
fabricated
Gain is external (e.g. benefits)

Malingering
Fig. 15.1 Diagnostic flow chart for medically unexplained physical symptoms.
138
and needless investigations to placate an anxious patient

RED FLAG can result in a vicious circle with worsening of symptoms.
Somatization disorder usually has its onset in early Invasive investigations can result in iatrogenic harm. See
adult life. The onset of multiple physical symptoms Chapter 23 for guidance on management.
late in life is more likely to be due to a physical
illness.

Mrs SD has a long history of multiple, recurrent, frequently
ASSESSMENT changing physical symptoms for which no physical causes
have been found despite extensive investigation. She is un-
History duly distressed by her symptoms (e.g. describing pain as ‘ru-
ining her life’). Her functioning has been impaired, and this
The following questions may be helpful in screening for so- has possibly impacted on her children’s lives. Because she
matoform disorders on mental state examination: is focused on symptoms, not the idea that she has a serious
• Do you often worry about your health? and progressive illness, Mrs SD has somatization disorder
• Are you bothered by many different symptoms? as opposed to hypochondriacal disorder. As is typical, Mrs
• Are you concerned you may have a serious illness? SD has a secondary (possibly iatrogenic) substance misuse
• Are you concerned about your appearance? problem (codeine and sleeping tablets). It would be import-
• Do you find it hard to believe doctors when they tell ant to exclude other mental illness, such as depression and
you that there is nothing wrong with you? anxiety, as causative factors. If there was evidence that Mrs
SD intentionally produced or feigned her symptoms, then
Examination factitious disorder or malingering should be considered.
Now go on to Chapter 23 to read about the somatoform
A thorough physical examination with special focus on the disorders and their management.
presenting problem is imperative when dealing with soma-
toform complaints.
Investigations
Clinicians dealing with patients with a somatoform disor-
der need to investigate physical complaints judiciously. It
is important to take all symptoms seriously, yet excessive
Chapter Summary
• Medically unexplained symptoms are common in all fields of medicine.

• In somatoform disorders, patients have an abnormal response to physical symptoms.
• In functional/dissociative disorders, the normal integration of consciousness with
cognition is disrupted, leading to disrupted sensory perception and motor control.
• In factitious disorder and malingering, patients feign physical symptoms.
139
The patient with eating or
weight problems 16
are significantly underweight, whereas weight in bulimia is
CASE SUMMARY generally normal, or slightly above normal.
Miss ED, a 19-year-old law student, eventually
agreed to see a psychiatrist after much persuasion Anorexia nervosa
from her mother and general practitioner (GP). Anorexia is characterized by overvalued ideas concerning
Her weight had fallen from 65 kg to 41 kg over the body shape and weight, preoccupation with being thin and
previous 6 months and she appeared emaciated. intrusive dread of fatness. As a result, a self-imposed low
Her GP had measured her height at 1.65 metres body weight is maintained at least 15% below what is ex-
and had calculated her body mass index (BMI) to pected for age and height. In adults, the body mass index
be 15 kg/m2. The psychiatrist saw Miss ED alone (BMI; Box 16.1) is 17.5 kg/m2 or less (in children and ado-
and spent some time putting her at ease. After lescents, growth charts should be consulted). There is also
an initial reluctance, she admitted that she was generalized endocrine disturbance of the hypothalamic–
pituitary–gonadal axis, as evidenced by amenorrhoea in
repulsed by the thought of being fat and felt that
post-menarcheal women; loss of sexual interest and impo-
she was still overweight and needed to lose ‘just a
tency in men; raised growth hormone and cortisol levels; and
few more pounds’. She had stopped menstruating reduced T3. In prepubertal sufferers of anorexia, expected
4 months ago and had also noted that she was weight gain during the growth period is impaired and puber-
feeling tired and cold all the time and was finding tal events (menarche, breast and genital development) may
it difficult to concentrate. The psychiatrist elicited be delayed or arrested. While not always present, self-induced
that she only ate one small meal a day and was purging, excessive exercise and use of appetite suppressants
exercising to the point of almost collapsing. She or diuretics are often used to enhance weight loss.
denied binge eating or self-induced vomiting but
did admit to using 20 senna tablets daily. She
reported symptoms of depression, but no suicidal BOX 16.1 THE BODY MASS INDEX
ideation. Physical examination revealed a pulse
rate of 50 beats per minute and fine downy hair The body mass index (BMI) relates weight to
covering her torso. height and is used as a crude test to assess
(For a discussion of the case study see the end of nutritional status in patients who are fully
the chapter). grown
weight ( kilograms )
BMI =
height ( metres )
2
Many people are concerned about what they eat and how Gross obesity: greater than 40 kg/m2
this affects their body weight and shape. However, some in-
dividuals become morbidly concerned with their body im- Obesity: greater than 30 kg/m2
age to the point that their life revolves around the relentless Normal: 20–25 kg/m2
pursuit of thinness. This life-threatening psychopathology
needs to be distinguished from other physical, psychiatric, Anorexia nervosa: less than or equal to
or substance-associated causes of weight loss. 17.5 kg/m2
High risk for medical less than 13.5 kg/m2
complications:
DEFINITIONS AND CLINICAL The ranges of values listed above relate
FEATURES to adults and differ during growth and
development. A BMI growth chart should be
Anorexia nervosa and bulimia nervosa are two psychiatric consulted for younger people
disorders characterized by conscious and deliberate efforts
to reduce body weight. Individuals with anorexia nervosa
141
The patient with eating or weight problems
Bulimia nervosa ASSESSMENT

In bulimia nervosa, patients usually have a normal body
weight (or weight may even be increased). In addition to History
sharing similar overvalued ideas with anorexia nervosa, bu-
It is important to define the extent of the eating disorder, yet
limia nervosa is characterized by a preoccupation with eat-
at the same time not alienate a patient who might be am-
ing and an irresistible craving for food that results in binge
bivalent about treatment. Focusing initially on the patient’s
eating. This is associated with a sense of lack of control and
life history, premorbid personality, social circumstances,
is invariably followed by feelings of shame and disgust. To
family, friendships, relationships and functionality can aid
counteract this caloric load, patients engage in purging
engagement and build rapport. These factors can also be
(self-induced vomiting, laxative and diuretic use), fasting or
very relevant to the aetiology of the disorder, and useful in
excessive exercise, but can employ a number of ingenious,
determining appropriate treatment (see Chapter 24). Later in
even dangerous, strategies (e.g. misuse of thyroid drugs, di-
the interview, it is important to focus on weight and eating.
abetic patients refusing to administer insulin).
Remember that direct questions may lead to confrontation
Box 16.2 summarizes the International Statistical
and denial, and a technique that can be helpful to avoid alien-
Classification of Diseases and Related Health Problems, 10th
ating the patient is to ‘normalize’ symptoms for the purposes
edition (ICD-10) criteria for anorexia and bulimia nervosa.
of the interview. The following questions may be useful:
HINTS AND TIPS Anorexic symptoms

Some patients with anorexia nervosa may also • Body weight and shape can be very important to some
people. Do you find that you are quite concerned about
engage in binge eating and purging behaviour,
your weight?
which is characteristic of bulimia nervosa. This does
• Do you think you are a healthy weight? (This is a key
not preclude the diagnosis of anorexia nervosa: diagnostic question: an underweight person who
the key diagnostic difference is that patients with recognizes they are too thin does not have anorexia
anorexia nervosa are significantly underweight and nervosa.)
have generalized endocrine abnormalities. • A common way of losing weight is to eat less or to
exercise a lot. Are these things that you do?
• Sometimes when women lose weight, their periods can
become irregular or stop. Has this happened to you?
BOX 16.2 ICD-10 CRITERIA FOR ANOREXIA
AND BULIMIA NERVOSA Bulimic symptoms
• Often when people try to lose weight, they have
Anorexia nervosa, all of the following: episodes when their eating seems excessive or out of
1. Low body weight: 15% below expected (body control. Has this ever happened to you?
mass index <17.5 kg/m2 in adults) • After eating a lot, some people can feel guilty and
2. Self-induced weight loss (poor caloric intake, uncomfortable and can vomit to make themselves feel
vomiting, exercise, etc.) better. Is this something that you have ever done?
3. Overvalued idea: dread of fatness, self- • Sometimes people might use prescribed or street drugs
to help control their weight. Have you ever tried this?
perception of being too fat; low target weight
4. Endocrine disturbance (hypothalamic–pituitary–
gonadal axis, resulting in amenorrhoea, raised Other psychiatric symptoms
Sufferers of eating disorders may report other psychiatric
cortisol, growth hormone, etc.
symptoms. Anxiety classically surrounds eating but may ap-
Prepubertal: failure to make expected weight gains; pear more generalized. If symptoms are sufficiently severe
delayed pubertal events to be disorders in their own right, then a comorbid psychi-
Bulimia nervosa, all of the following: atric illness may be present. Distinguishing depression from
1. Binge eating anorexia is discussed below (under differential diagnosis).
2. Strong cravings for food
3. Methods to counteract weight gain (vomiting, Physical symptoms
laxatives, fasting, exercise, etc.) Eating disorders are associated with a number of phys-
4. Overvalued idea: dread of fatness; self- ical sequelae, and therefore a thorough medical history is
perception of being too fat; low target weight required. Physical complications are listed in Box 16.3.
Important factors to ascertain include a menstrual history,
episodes of syncope or presyncope, palpitations, tiredness,
142
Assessment 16
BOX 16.3 PHYSICAL COMPLICATIONS OF EATING DISORDERS
Related to starvation Related to vomiting

• Emaciation • Permanent erosion of dental enamel; dental
• Amenorrhoea; infertility; reproductive system cavities
atrophy • Enlargement of salivary glands (especially
• Cardiomyopathy parotid)
• Constipation; abdominal pain • Calluses on the back of hands from repeated
• Cold intolerance; lethargy teeth trauma (Russell’s sign)
• Bradycardia; hypotension; cardiac arrhythmias; • Oesophageal tears; gastric rupture
heart failure
• Lanugo: fine, downy hair on trunk; loss of head hair
• Peripheral oedema
• Proximal myopathy; muscle wasting
• Osteoporosis; fractures
• Seizures; impaired concentration; depression
Laboratory tests: Laboratory tests:

• Normocytic anaemia • Hypokalemic, hypochloremic alkalosis
• Leukopenia • Hyponatraemia
• Acute kidney injury (dehydration) • Hypomagnesaemia
• Raised transaminases • Raised serum amylase (acute pancreatitis)
• Hypoglycaemia
• Raised cortisol
• Raised growth hormone
• Reduced T3
• Reduced follicle-stimulating hormone and
luteinizing hormone
• Hypercholesterolaemia
muscle weakness and sensitivity to cold. A history of syn- RED FLAG

cope or palpitations is very concerning and places the pa-
tient at high physical risk.
High-risk examination findings in patients
Examination with eating disorders
Both anorexia nervosa and bulimia nervosa cause medical • Extreme weight loss (body mass index 30%
sequelae, and a physical examination is essential to accurately below expected (<14 in adults)
assess the physical risk to the patient (See Box for red flags). • Bradycardia (<40 bpm)
Patients may be reluctant to be examined; however, this can • Marked postural hypotension (>20 mm Hg
be facilitated when preceded by a clinical interview in which systolic) or postural tachycardia (>30 bpm)
good rapport is established. Other than measuring height and • Prolonged QTc
weight and calculating BMI, important areas to examine are: • Severe dehydration (reduced urine output and
• Skin – ‘lanugo’ hair (fine, downy hair on body); loss skin turgor)
of head hair; calluses on knuckles (from self-induced • Hypothermia (<35.5°C)
vomiting: Russell’s sign) • Unable to get up from squatting position, or
• Dentition – abrasions; tooth decay from lying flat
• Cardiovascular – lying and standing blood pressure • Confusion
(postural hypotension may occur if dehydrated); pulse
• Abdomen – constipation
143
• Musculoskeletal – muscle wasting; ability to sit up from may be associated with long-term consequences or result
lying and rise from a squat without using hands (the ‘SUSS’ in sudden death. Investigations should therefore include:
test (sit-up, stand-squat test)); pathological fractures. electrocardiogram (ECG), urea and electrolytes, full blood
• Other – core temperature; mucous membranes count, liver function tests, serum glucose and lipids, thy-
(dehydration); facial glands (swollen parotid glands roid function tests and amylase. Changes in hormone levels
may suggest frequent vomiting). (cortisol, insulin, luteinizing hormone, follicle stimulating
hormone, growth hormone) have been described, but
these are of limited diagnostic value and are not routinely
Investigations measured. Bone density (DXA) scanning may be consid-
Numerous biochemical and metabolic changes are asso- ered for identification of osteopenia and osteoporosis.
ciated with being underweight and engaging in excessive Fig. 16.1 shows an algorithm which may help establish
purging as summarized in Box 16.3. These complications diagnosis in patients with a suspected eating disorder.
Does the patient have a

physical or medical cause
to account for their Unsure
presentation?
Investigate and
No manage as
Nil abnormal appropriate
Does the patient have

No another psychiatric cause
to account for their Unsure
presentation?
No Comprehensive psychiatric
assessment to exclude organic
psychiatric illness, substance misuse,
Nil abnormal psychosis, affective disorder, anxiety
Markedly abnormal
disorder
attitude to body weight,
size or shape?
Yes
Body mass index

<17.5, or weight <15%
Yes expected for height? No
Rapid weight
loss?
No
Purging after
Yes bingeing?
Yes
Anorexia Consider evolving Bulimia

nervosa anorexia nervosa nervosa
Fig. 16.1 Diagnostic approach for patients in whom eating disorder is suspected.
144
Poor nutrition often occurs due to self-neglect in patients

RED FLAG with alcohol or substance abuse and dementia. Patients with
Hypokalaemia is a life-threatening psychosis may not eat due to delusions about food or hal-
complication that can result from repeated lucinations commanding them not to. The negative symp-
vomiting, as well as laxative and diuretic abuse.
toms of schizophrenia can also result in substantial weight
loss due to self-neglect.
Gradual correction is safer than rapid correction,
Severe weight loss may occur in depression, but this is
so advise patients to eat high-potassium foods
usually associated with a marked loss of appetite and inter-
(e.g. bananas) or use potassium supplements. est in food. Patients with anorexia maintain their appetite
Severe hypokalaemia is an indication for until late in the disease and remain interested in food-
hospitalization. related subjects (e.g. low-calorie recipes). Note that patients
with anorexia and bulimia often have comorbid depression
and that depressive symptoms may be secondary to the bi-
ological consequences of starvation and thus resolve with
subsequent weight gain.
HINTS AND TIPS Patients with obsessive-compulsive disorder may lose
weight when time-consuming compulsions prevent an ade-
When weighing someone with a suspected eating
quate diet. Also, obsessions of contamination of food might
disorder, always ensure they remove their shoes curtail their caloric intake. As with depression, the issue is
and any outdoor clothing. It is common for patients clouded by the observation that patients with anorexia ner-
to attempt to artificially increase their weight by vosa have an increased incidence of obsessive-compulsive
wearing heavy clothing or accessories, and even to disorder, which should only be diagnosed when obsessions
drink a lot of water shortly before review. or compulsions are unrelated to food or body shape.
Binge eating disorder is a diagnosis in the Diagnostic
and Statistical Manual of Mental Disorders, 5th Edition,
and in the draft version of ICD-11 (not yet published). In
DIFFERENTIAL DIAGNOSIS OF this disorder, people binge eat at least weekly for several
months. They feel out of control, distressed and disgusted
PATIENTS WITH LOW WEIGHT during binges. However, they do not then purge themselves
or perform any other compensatory behaviours to avoid
Box 16.4 lists the other causes of significant weight loss that weight gain. Also, they are not preoccupied with body
should be considered, especially when the onset of illness is weight or shape.
later than adolescence or early adulthood.
It is very important to exclude physical causes of weight
loss, including malignancies, gastrointestinal disease, en- HINTS AND TIPS
docrine diseases (e.g. diabetes mellitus, hyperthyroidism),
chronic infections and chronic inflammatory conditions. In the differential diagnosis of weight loss,
Note that rare neurological syndromes associated with anorexia and bulimia nervosa are associated with
gross overeating include the Kleine-Levin, Klüver-Bucy and the overvalued idea of dread of fatness. Weight
Prader-Willi syndromes. loss occurring in depression results from loss of
appetite and lack of interest and enjoyment in food.
BOX 16.4 DIFFERENTIAL DIAGNOSIS FOR

PATIENT PRESENTING WITH WEIGHT LOSS
• Medical causes of low weight

• Alcohol or substance abuse
Miss ED’s body mass index is 15 kg/m2, which is more than
• Dementia 15% below what would be expected. She admits to a dread
• Psychotic disorders of fatness and consequently pursues a target weight signifi-
• Depression cantly below that which is normal or healthy. Her weight
• Obsessive-compulsive disorder loss methods include poor caloric intake, excessive exercise
• Anorexia nervosa and laxative abuse. Dread of fatness, low body weight and
• Bulimia nervosa endocrine disturbance (amenorrhoea) are characteristic
• Binge eating disorder of anorexia nervosa. The depressive symptoms may sig-
nify a comorbid disorder or be secondary to the biologi-
cal effects of malnutrition. Medical complications include
145
amenorrhoea, lethargy, bradycardia and lanugo (fine She will require urgent treatment to stabilize then increase
downy hair on torso). Her extremely low BMI, moderate weight.
bradycardia and history of almost collapsing while exercis- Now go on to Chapter 24 to read about the eating disor-
ing place her at moderate to high physical risk. She requires ders and their management.
a complete physical examination, and same day bloods and
ECG to assess for any acute life-threatening complications.
Chapter Summary
• The key psychopathology in eating disorders is the overvalued idea of being overweight.
• Anorexia nervosa is associated with a significantly reduced body mass index (BMI),
bulimia with a normal BMI.
• Purging behaviours are common in both disorders, including vomiting and laxative
misuse.
• Restrictive behaviours are common in anorexia nervosa, including over-exercise and
fasting.
• Anorexia nervosa can be associated with life-threatening physical complications, and it is
important to perform a full physical examination (including muscle power), blood tests
and electrocardiogram at presentation and frequently during treatment.
146
The patient with personality
problems 17
FEATURES
The on-call psychiatrist was asked to assess Miss
BP, a 27-year-old woman who had been known to Personality traits are enduring patterns of perceiving, think-
mental health services since the age of 17 years ing about, and relating to both self and the environment,
with symptoms that had been fairly consistent. She exhibited in a wide range of social and personal contexts.
lived with her mother, who had contacted services A personality disorder is when an individual has traits that
because Miss BP was threatening to jump in front are persistently inflexible and maladaptive, are stable over
of a bus. Her father had sexually abused her as a time, appeared in adolescence or early adulthood and that
child and she had a long history of self-harm that cause significant personal distress or functional impairment
included cutting and repeated overdoses. Her to the person or those around them.
Patients with a personality disorder tend not to regard
mother was inclined to challenge her promiscuous
their patterns of behaviour as inherently abnormal. Instead,
behaviour and binge drinking, which led to many
they usually present to health care services with a wide
heated arguments. At interview, Miss BP told the range of problems related or consequent to their abnor-
psychiatrist that she was feeling ‘more depressed mal personality traits (e.g. self-harm, feelings of depression
than ever’ because her mother had suggested or anxiety, violence or disorderly conduct, posttraumatic
that she move into her own house. With gentle stress disorder, eating disorders, dissociative or somato-
questioning, it transpired that she was afraid that form disorders). Having a major psychiatric illness such as
her mother would stop caring for her if she moved schizophrenia does not preclude patients from also having
out. The psychiatrist, who had known Miss BP a personality disorder.
for years, recognized that this behaviour was not A diagnosis of personality disorder can be stigmatizing.
unusual for her and was able to help her to see It is important to consider whether making the diagnosis is
useful, for example if it will direct the patient towards ap-
another perspective to her mother’s suggestion.
propriate therapy or direct them away from potential iat-
Miss BP’s mood quickly lifted and her suicidal
rogenic harm.
ideation resolved.
(For a discussion of the case study see the end of the
chapter).
CLASSIFICATION
The description and management of what has been arbi- Personality disorders can be classified into two groups
trarily designated ‘personality disorder’ is one of the most according to their aetiology. The first group includes ‘ac-
controversial subjects in psychiatry. They overlap substan- quired’ personality disorders where the disorder clearly
tially with the concept of neurodevelopmental disorders develops after, and is directly related to, a recognizable ‘in-
(see Chapter 18) but are currently considered separately. sult’. Organic personality disorder results when this ‘insult’ is
Classification changes are underfoot, with the draft version some form of brain damage or disease (e.g. a brain tumour
of the International Statistical Classification of Diseases and or stroke). A common example is seen in patients with
Related Health Problems, 11th edition (ICD-11; not yet frontal lobe lesions, which can be characterized by social
published) proposing substantial changes. People use the disinhibition (e.g. stealing, sexual inappropriateness) and
term ‘personality’ with varying meanings, even within the abnormalities of emotional expression (e.g. shallow cheer-
psychological and psychiatric specialties. Amid the lack of fulness, aggression, apathy). Patients can also develop en-
consensus on what defines personality, there is little doubt during personality changes after experiencing a catastrophic
that some people seem to experience and interact with the event (e.g. concentration camp or hostage situation leading
world in a manner markedly different to other individuals to posttraumatic stress disorder) or after the development
in their culture. Personality disorders are important: they of a severe psychiatric illness. In such cases, a mental illness
are common, associated with significant distress to the suf- rather than personality disorder should be diagnosed.
ferer and often with great cost to health care and social and The second group includes what is referred to in the
criminal justice agencies. ICD-10 as specific personality disorders (these are far more
147
The patient with personality problems
prevalent and therefore simply referred to as ‘personality disorders and is measured by personality inventories (e.g.
disorders’; this is the term that will be used for the rest of Minnesota Multiphasic Personality Inventory – MMPI).
this chapter). In this group of personality disorders, it is dif- The ICD-10 and the Diagnostic and Statistical Manual of
ficult to find a direct causal relationship between personality Mental Disorders, 5th Edition (DSM-5) use the categorical
traits and any one specific insult, although genetic and en- approach, which assumes the existence of distinct types of
vironmental factors have been implicated (see Chapter 28). personality disorder and therefore classifies patients into
The onset of personality disorders is in adolescence or early discrete categories as summarized in Table 17.1. Despite the
adulthood and any change in symptoms tends to occur very widespread use of the categorical approach in clinical prac-
gradually over a long period of time. tice, it seldom conforms to reality as there is a considerable
Personality disorders can be further classified according overlap of traits and most individuals do not fit perfectly
to clinical presentation, specifically regarding which par- into these described categories. People are often best de-
ticular maladaptive personality traits are present. In this scribed as having a ‘mixed personality disorder’, listing the
regard, there are two approaches: the dimensional and cate- specific traits that are causing difficulties.
gorical classifications: In an attempt to simplify further the classification of
The dimensional approach hypothesizes that the person- personality disorders, the DSM-5 has designated three
ality traits of patients with personality disorder differ from personality clusters based on general similarities. Cluster
the normal population only in terms of degree. Maladaptive A describes individuals who appear odd or eccentric and
personality traits can therefore be seen as existing on a con- includes paranoid, schizoid and schizotypal personality
tinuum that merges into normality. The dimensional ap- disorders. Cluster B describes individuals who appear dra-
proach is used predominantly in the research of personality matic, emotional or erratic and includes borderline (closest
Table. 17.1 Categorical classification of personality disorders (DSM-5)

Cluster A: ‘odd or eccentric’
Paranoid personality disorder Suspects others are exploiting, harming or deceiving them; doubts about
spouse’s fidelity; bears grudges; tenacious sense of personal rights; litigious
Schizoid personality disorder Emotional coldness; neither enjoys nor desires close or sexual relationships;
prefers solitary activities; takes pleasure in few activities; indifferent to praise or
criticism
Schizotypal personality disorder Eccentric behaviour; odd beliefs or magical thinking; unusual perceptual
experiences (e.g. ‘sensing’ another’s presence); ideas of reference; suspicious
or paranoid ideas; vague or circumstantial thinking; social withdrawal
Cluster B: ‘dramatic, emotional, erratic’
Borderline (emotionally unstable) Unstable, intense relationships (fluctuating between extremes of idealization
personality disorder and devaluation); unstable self-image; impulsivity (sex, binge eating, substance
abuse, spending money); chronic feelings of emptiness; repetitive suicidal
or self-harm behaviour; fluctuations in mood; frantic efforts to avoid (real or
imagined) abandonment; transient paranoid ideation; pseudohallucinations;
dissociation
Antisocial (dissocial) personality Repeated unlawful or aggressive behaviour; deceitfulness; lying; reckless
disorder irresponsibility; lack of remorse or incapacity to experience guilt
Histrionic personality disorder Dramatic, exaggerated expressions of emotion; attention seeking; seductive
behaviour; labile shallow emotions
Narcissistic personality disorder Grandiose sense of self-importance, need for admiration
Cluster C: ‘anxious or fearful’
Dependent personality disorder Excessive need to be cared for; submissive, clinging behaviour; needs others
to assume responsibility for major life areas; fear of separation
Avoidant (anxious) personality Hypersensitivity to critical remarks or rejection; inhibited in social situations;
disorder fears of inadequacy
Obsessive-compulsive (anankastic) Preoccupation with orderliness, perfectionism and control; devoted to work at
personality disorder expense of leisure; pedantic, rigid and stubborn; overly cautious
Note that the ICD-10 includes all the personality disorders described in the DSM-5 clusters above, except for schizotypal and narcissistic
personality disorder. However, schizotypal disorder (similar to the DSM-5’s schizotypal personality disorder) is included in the ICD-10’s
section on psychotic disorders. Note also that the draft ICD-11 classification of personality disorder includes some substantial changes.
DSM-5, Diagnostic and Statistical Manual of Mental Disorders, 5th Edition; ICD-10, International Statistical Classification of Diseases and
Related Health Problems, 10th edition.
148
Assessment 17
ICD-10 equivalent: emotionally unstable), antisocial (clos-

est ICD-10 equivalent: dissocial), histrionic and narcissistic
ASSESSMENT
personality disorders. Cluster C describes individuals who
appear anxious or fearful and includes avoidant, dependent History
and obsessive-compulsive (anankastic) personality dis- As with other mental illnesses, giving a patient a label of
orders. A hybrid categorical-dimensional approach is be- personality disorder gives those involved with their care
ing taken by the current draft of the ICD-11, which splits only a limited amount of information. In fact, the clinical
personality disorders into mild, moderate and severe and classification of personality disorders is often unreliable,
refers to five ‘prominent traits’ (anankastic, detached, disin- and although psychiatrists usually agree that a patient has a
hibited, dissocial, negative affect) rather than 10 individual personality disorder, there are often differing points of view
disorders. Someone may be considered to have one or more regarding the subtype of the disorder. Patients with a possi-
prominent traits, potentially improving the accuracy of the ble personality disorder often present at times of crisis and
personality description. distress, and therefore diagnosis at the first interview can
be difficult because of the quantity of background and col-
HINTS AND TIPS lateral information required and because diagnosis requires
the features to persist over time.
Everybody has a personality that, no matter A practical approach includes making a comprehensive
how ‘normal’, can have dysfunctional traits assessment of:
(e.g. anger, anxiety, idealization/devaluation, • Sources of distress (thoughts, emotions, behaviour and
obsessive-compulsive behaviour). These traits relationships) to self and others
often become much more prominent at times of • Any comorbid mental illness
psychological stress, such as mental or physical • Specific impairments of functioning at work, home or
illness, pain and discomfort, work-related stress in social circumstances
and even tiredness and hunger. It is important It is usually possible to establish some idea of a patient’s per-
to remember that personality disorders occur sonality by taking a detailed history of their life, focusing on
in many settings, remain stable over time and the areas of education, work, criminality, relationships and
cause significant personal distress or functional sexual behaviour. When patients are not able to describe as-
impairment. pects of their personality, it can be useful to ask how those
close to them might describe them. It is also useful – with
consent – to obtain collateral information from the patient’s
family, employer and general practitioner, all of whom
HINTS AND TIPS might be able to provide information to help distinguish
between transient and enduring patterns of behaviour.
The term ‘borderline personality disorder’ is derived It is important to recognize that patients with a personal-
from the early 20th century psychoanalysts, ity disorder may exhibit strong emotional reactions (trans-
who described a group of patients who were ‘on ference and countertransference – see Chapter 3) and that
the borderline’ between the neuroses and the they are often perceived as ‘difficult patients’ because of this.
psychoses. Being aware of your own emotions (often strong feelings of
anger or anxiety) and taking a nonjudgemental and em-
pathic stance during assessment can be greatly beneficial, as
well as providing insight into the diagnosis itself.
COMMUNICATION A number of self-rating questionnaires that focus on
personality traits are available. These can be helpful in the
Confusingly, the different classification systems
diagnosis of personality disorder; however, they should not
use slightly different terms for essentially the same
be used as a substitute for a comprehensive clinical history.
type of personality disorder. Borderline personality
Structured interviews are also available, although these
disorder (DSM-5) is very similar to emotionally tend to be used for research purposes and are seldom used
unstable personality disorder, borderline type in clinically.
ICD-10. Similarly, antisocial personality disorder
(DSM-5) is very similar to dissocial personality
Examination and investigation
disorder in ICD-10. The terms are often used
interchangeably – don’t be confused if both appear There are no specific physical signs that help in the diag-
in someone’s notes! nosis of personality disorders. However, the consequences
of associated behaviours may be seen on examination or
investigation (e.g. marks from self-inflicted lacerations or
149
The patient with personality problems
burns, musculoskeletal injuries from assaults or accidents, misuse or mania (see Table 17.2). The diagnostic task is also
the sequelae of drug or alcohol misuse and sexually trans- complicated by the observation that many patients with a
mitted infections following promiscuity). major mental illness or intellectual disability also have a con-
current personality disorder. A personality disorder should
only be diagnosed when the clinical features begin in ado-
COMMUNICATION lescence or early adulthood, are relatively stable over time
and do not only occur during an episode of a major mental
It is difficult to confirm or to exclude the diagnosis
illness (e.g. depressive, manic, psychotic episode).
of a personality disorder without taking a reliable When an individual develops a dramatic personality
collateral history to establish pervasiveness and change after a period of normal personality functioning,
stability of presentation. It can be difficult for consider an organic personality disorder or a personality
patients to comment on this objectively, especially change that occurs secondary to experiencing a catastrophic
if they are in a state of distress. event or developing a severe psychiatric illness.
HINTS AND TIPS
A personality disorder should not be diagnosed if symptoms
are better explained by a physical problem, substance misuse Remember that Cluster A personality disorders
or a mental illness. Almost all the mental illnesses d
escribed may present with features similar to the psychotic
in this book can feature some of the behaviours that char- disorders (e.g. suspiciousness, social withdrawal
acterize personality disorders. Examples include social and eccentric beliefs) but are differentiated by the
withdrawal, suspiciousness and odd ideas in schizophrenia;
absence of true delusions or hallucinations.
self-harm, low mood and poor self-image in depression;
aggression, irresponsibility and impulsivity in substance
Table. 17.2 Differential diagnosis for common presenting problems in personality disorder
Differentials to consider
(also consider ‘no psychiatric disorder’ in all
Presenting problem Potential personality disorder cases)
Cluster A
Suspiciousness Paranoid Schizophrenia
Difficulty forming Borderline (emotionally unstable), Autism spectrum disorder
relationships schizoid, paranoid, schizotypal
Intrusive images, voices or Borderline (emotionally unstable), OCD, schizophrenia, PTSD, substance abuse
thoughts schizotypal
Cluster B
Chronic mood problems Borderline (emotionally unstable) Recurrent depressive disorder, bipolar affective
disorder, dysthymia, cyclothymia, ADHD,
substance use (especially alcohol dependence)
Impulsivity Borderline (emotionally unstable), ADHD, substance abuse
antisocial (dissocial)
Frequent offending Borderline (emotionally unstable), ADHD
antisocial (dissocial)
Suicidal tendencies Borderline (emotionally unstable) Depressive episode
Grandiosity Narcissistic, histrionic Mania
Cluster C
Chronic anxiety Dependent, avoidant Generalized anxiety disorder, social anxiety,
recurrent depressive disorder, substance abuse
ADHD, attention deficit hyperactivity disorder; OCD, obsessive-compulsive disorder; PTSD, posttraumatic stress disorder.
150
unstable personality disorder, borderline type. It would be

DISCUSSION OF CASE STUDY important to exclude another mental illness that may co-
exist with the personality disorder, such as depression or
Miss BP has a chronic condition that first presented in ado-
harmful use/dependence on alcohol. Note that there is an
lescence and has changed little over time. She has a number
association between emotionally unstable personality dis-
of maladaptive and inflexible personality traits that mani-
order and childhood trauma, including physical, emotional
fest as repeated self-harm, suicidal behaviour, impulsivity
and sexual abuse.
(promiscuity, binge drinking), fluctuations in mood and a
Now go on to Chapter 24 which deals with personality
marked fear of abandonment by her mother. These char-
disorders and their management.
acteristics are consistent with a diagnosis of an emotionally
Chapter Summary
• A personality disorder is when someone has ways of thinking, feeling or behaving that:
• Are stable over time and context
• Manifest in adolescence or early adulthood
• Cause significant distress to the patient or those around them
• The classification of personality disorders is a controversial topic currently being
reviewed.
• Many people have both a personality disorder and a mental disorder.
• A personality disorder should not be diagnosed if symptoms are better explained by a
physical problem, substance abuse or a mental disorder.
151
The patient with
neurodevelopmental problems 18
psychiatry. They are disorders where abnormal develop-
CASE SUMMARY ment of the central nervous system leads to impairments
John, aged 9 years, was assessed by the child and
in brain function, for example, seizures (epilepsy), ab-
normal movements (tics) and abnormal learning and
adolescent mental health team after his teacher told
memory (intellectual disability). The severest neurodevel-
his parents she thought John might have Attention
opmental disorders tend to present early and are assessed
Deficit Hyperactivity Disorder (ADHD). She had and diagnosed by paediatricians. Disorders that primarily
noticed that he was a bright child but made a lot of influence subtle aspects of cognition are more likely to
careless mistakes in his homework, which he often present with behavioural difficulties in children of school
forgot to bring to school. He had always been very age and are assessed and diagnosed by psychiatry. Because
talkative, which initially endeared him to his peers, of increasing awareness of neurodevelopmental disor-
but lately he had fallen out with some friends as they ders in both the public and among health professionals,
said he never let them get a word in. He had also some people who had difficulties that were not assessed in
always been an active boy and had been picked childhood and that have persisted into adulthood are now
for his school football team. However, the coach
seeking assessment for neurodevelopmental disorders as
adults.
had dropped him after John failed to notice the ball
The concept of neurodevelopmental disorders is evolv-
coming in his direction on a number of occasions,
ing. Recent classification changes have given them increas-
seemingly staring off into space. His high activity ing precedence, with the Diagnostic and Statistical Manual
levels were becoming increasingly noticeable as he of Mental Disorders, 5th Edition (DSM-5) and the most
got older and his peers became better able than him recent draft of the International Statistical Classification of
to sit through a class. John’s parents were initially Diseases and Related Health Problems, 11th edition (ICD-
surprised by the suggestion but on reflection agreed 11; not yet published) including them as a diagnostic cat-
that he often did things without thinking (he broke egory in their own right. Some disorders not historically
an arm last year after leaping out of a tree) and they viewed as neurodevelopmental may be categorized as such
had never considered going to the cinema as a family in due course, for example, brain changes in schizophrenia
because they knew John would not be able to sit
and bipolar disorder probably occur from a young age, but
symptoms only manifest from adolescence or early adult-
through a film. There were no concerns that they were
hood. These disorders are covered in Chapters 9 and 10 in
not looking after John well. John told the psychiatrist
this book. Personality disorders also overlap conceptually
that he generally felt cheerful, had no physical with neurodevelopmental disorders: both describe dysfunc-
problems and did not have any problems seeing or tional patterns of behaviour with onset in childhood caus-
hearing. In fact, he thought he had extra good hearing ing significant impairment to the patient or others. These
because he seemed to notice things other people did are covered in Chapter 17.
not, such as bird calls outside the classroom. This chapter covers the common neurodevelopmental
(For a discussion of the case study see the end of problems that present to psychiatry: difficulties with learn-
the chapter). ing, socializing, paying attention and controlling move-
ments. In defining disorders involving these abilities, it is
crucial to recognize that performance in these areas varies
normally within the healthy population (see Fig. 18.1). A
disorder is only diagnosed if:
DEFINITIONS 1. The person has characteristics that are significantly
outwith the typical range.
Neurodevelopmental disorders are common and in- 2. These characteristics are associated with functional
creasingly identified throughout a normal life span. You impairment (i.e. problems in social, occupational or
will encounter patients with them in all branches of adaptive functioning).
153
The patient with neurodevelopmental problems
A: ability below average but not significantly so.

No diagnosis.
B: ability significantly below average AND

significant functional impairment. Diagnosis.
C: ability significantly below average but no

significant functional impairment. No diagnosis.
Ability
significantly
below average
Number of people
Poor C B A Ability Excellent

Fig. 18.1 Core criteria for a diagnosis of a neurodevelopmental disorder.
sensory, motor or communication difficulties may lead to

CLINICAL FEATURES AND patients obtaining falsely low IQ scores. Therefore patients
DIFFERENTIAL DIAGNOSIS obtaining IQ scores lower than 70 should not be diagnosed
as having intellectual disability if there is no evidence of
Problems with learning significant impairments in adaptive functioning.
In addition to the impairment of adaptive function-
Global ing, patients may have clinical features associated with
A generalized problem with learning new information and the specific cause of their intellectual disability (e.g. Down
skills can arise through physical or mental health problems, syndrome: epicanthic folds with oblique palpebral fissures,
sensory impairments or psychosocial adversity. If these are broad hands with single transverse palmar crease, flattened
excluded, a diagnosis of intellectual disability should be occiput, cardiac septal defects). Other features associated
considered. with intellectual disabilities include aggression, self-
Intellectual disability is an umbrella term used to de- injurious behaviour, repetitive stereotypical motor move-
scribe diverse difficulties that manifest as significant intel- ments and poor impulse control. Up to a third of people
lectual impairment associated with a diminished ability to with an intellectual disability have a comorbid psychiatric
adapt to the normal demands of daily living, arising during illness, most commonly schizophrenia (4%), which occurs
the developmental period (normally in early childhood). at a higher rate in individuals with learning disabilities than
These disorders are generally caused by an interruption in in the general population.
the normal development of the brain resulting from a vari- Intellectual disabilities are classified as mild, moderate,
ety of problems. Intellectual disability is a lifelong condition. severe and profound, according to the degree of intellec-
Adaptive functioning is a measure of how patients cope tual and adaptive impairment. Table 18.1 summarizes the
with activities of living such as communication, self-care, so- clinical features of the degrees of intellectual disabilities.
cial skills and academic and vocational skills. This is assessed However, this is simplified and difficulties experienced can
by a thorough developmental, psychiatric and medical his- vary from person to person.
tory from the patient’s parents and other care providers.
Intellectual functioning is usually defined by the intel-
ligence quotient (IQ). This can be assessed by standard- HINTS AND TIPS
ized intelligence tests (e.g. Wechsler Intelligence Scales for
Children – WISC). An IQ of 70 or below, which is two Whereas dementia describes a loss of cognitive
standard deviations below the mean (IQ = 100), represents ability already acquired, intellectual disability
sub-average intellectual functioning. It is important to re- describes the failure to develop a normal level of
member the limitations of using standardized testing in- cognitive functioning. However, individuals with
struments. Many standardized tests tend to be aimed at Down syndrome are also at very high risk for
people of (or around) average intelligence and may be developing Alzheimer disease in later life.
unsuitable for patients with more severe difficulties. Also,
differences in native language and background, as well as
154
Clinical features and differential diagnosis 18
COMMUNICATION
Problems with social interaction
and communication
The terms ‘intellectual disability’ and ‘learning
Social interaction is one of the most complex tasks the
difficulty’ are often confused. A learning difficulty
brain has to negotiate and many factors can influence social
refers in general to any condition that impairs
ability.
learning and is most often not associated with
a global reduction in IQ. A specific learning
difficulty is impairment in one particular type Children
of learning (e.g. dyslexia, dyscalculia). An Parents, health visitors or teachers may raise concerns
about a child’s ability to communicate and interact so-
‘intellectual disability’ is where learning difficulties
cially. It is important to exclude an influence of physical
are also associated with IQ <70 and impairments
or mental health problems, sensory impairments or psy-
in adaptive functioning. chosocial adversity. Intellectual disability reduces social
abilities, but if the social impairments are more marked
than would be expected for the degree of intellectual dis-
ability, they can be diagnosed separately. Differentials are
shown in Box 18.1 and clinical features of the neurodevel-
Specific opmental causes of social difficulty are described below.
Some disorders are characterized by the disturbed acquisi- Selective mutism and reactive attachment disorder are
tion of a specific cognitive or motor function during a child’s described in Chapter 30.
development (e.g. language, reading, spelling, arithmetical
ability and motor skills). If other areas of cognitive func- Autism spectrum disorder
tioning are normal, a child may have a specific reading The three characteristic features of autism manifest within
disorder (developmental dyslexia) but be of normal intel- the first 3 years of life and include:
ligence and have no problem with writing or mathematics. 1. Impairment in social interaction as evidenced by the
In some children, the consequences of the difficulty (e.g. poor use of nonverbal behaviour (e.g. eye contact,
school problems, bullying) might lead to secondary emo- facial expression, gestures) and a failure to develop and
tional or behavioural problems. to share in the enjoyment of peer relationships
Table 18.1 Degrees of intellectual disability

Degree of intellectual Intelligence quotient
disability (IQ) range Adaptive functioning
Mild 50–69 Difficulties may be subtle and difficult to identify.
(85% of cases) Often only identified at a later age.
Difficulties in academic work (reading and writing) but
greatly helped by educational programmes.
Usually capable of unskilled or semi-skilled manual labour.
May be able to live independently or with minimal support.
Moderate 35–49 Language and comprehension limited.
(10% of cases) Self-care and motor skills impaired, may need supervision.
May be able to do simple practical work with supervision.
Rarely able to live completely independently.
Severe 20–34 Marked degree of motor impairment.
(3%–4% of cases) Little or no speech during early childhood; may learn to talk
in school-age period.
Capable of only elementary self-care skills.
May be able to perform simple tasks under close
supervision.
Profound <20 Severely limited in ability to communicate their needs.
(1%–2% of cases) Often severe motor impairment with restricted mobility and
incontinence.
Little or no self-care.
Often require residential care.
155
X chromosome and can arise sporadically or from germ-

BOX 18.1 DIFFERENTIAL DIAGNOSIS FOR line mutations. It is initially characterized by an apparently
SOCIAL AND COMMUNICATION DIFFICULTIES
normal antenatal development with a normal head circum-
IN CHILDREN
ference at birth, followed by an apparently normal psycho-
Normal for age motor development in the first 5 months after birth. From
Secondary to sensory impairment (e.g. deafness) 6 months to 2 years of age, a progressive and destructive
Secondary to mental or physical health problem encephalopathy results in a deceleration of head growth;
loss or lack of development of language and loss of purpose-
(e.g. depression, childhood schizophrenia,
ful hand movements and fine motor skills, with subsequent
uncontrolled epilepsy)
development of stereotyped hand movements (e.g. midline
Secondary to psychosocial adversity (e.g. hand-wringing). After a decade, most girls are bound to a
emotional abuse) wheelchair with incontinence, muscle wasting and rigidity
Intellectual disability and almost no language ability.
Autism spectrum disorder
Rett syndrome Childhood disintegrative disorder (Heller
Childhood disintegrative disorder syndrome)
This disorder, which is more common in boys, is character-
Attention deficit hyperactivity disorder
ized by about 2 years of normal development, followed by a
Reactive attachment disorder
loss of previously acquired skills (language, social and adap-
Conduct disorder tive skills, play, bowel and bladder control and motor skills)
Selective mutism before age 10 years. It is also associated with an autism-like
Specific language impairment impairment of social interaction as well as repetitive, stereo-
Specific movement disorder typed interests and mannerisms. Thus, after the deteriora-
tion, these children may resemble autistic children.
2. Impairment in communication as evidenced by poor Adults

development of spoken language; extreme difficulty in In adults presenting with social difficulties, the main dif-
initiating or sustaining conversation; repetitive use of ferentials are shown in Box 18.2. It is paramount to take
idiosyncratic language and lack of imitative or make- a history of the time course of difficulties: have they been
believe play present from a young age or only since adulthood? Patients
3. Restricted, stereotyped interests and behaviours as
evidenced by intense preoccupations with interests
such as dates, phone numbers and timetables;
inflexible adherence to routines and rituals; repetitive, SOCIAL AND COMMUNICATION DIFFICULTIES
stereotyped motor movements such as clapping, IN ADULTS
rocking or twisting and an unusual interest in parts of
hard or moving objects Within normal range
In addition to these diagnostic features, patients may also Intellectual disability
exhibit behavioural problems such as aggressiveness, im- Autism spectrum disorder
pulsivity and self-injurious behaviour. Although children Personality disorder
with autism can be of normal intelligence, 50% have sig- • Schizoid
nificant intellectual disabilities. Epilepsy develops in about • Schizotypal
25%–30% of cases. • Anankastic (obsessive-compulsive)
Asperger syndrome (or ‘high functioning autism’) is a • Emotionally unstable
subtype of autism where there are no significant abnormal- • Dissocial
ities in language acquisition and ability or in cognitive de-
Secondary to other psychiatric disorder
velopment and intelligence. Although Asperger syndrome
• Social phobia
is a diagnosis in ICD-10, it is not included as a separate
diagnostic category in DSM-5 or in the latest draft of ICD- • Generalized anxiety disorder
11 (to be published). The term ‘pervasive developmental • Depression
disorder’ is now used synonymously with autism spectrum • Negative symptoms of schizophrenia
disorder. Brain injury (e.g. traumatic, cerebrovascular
accident, infection, inflammation)
Rett syndrome
Neurodegeneration (e.g. dementia)
Rett syndrome, which has almost only been seen in girls,
is caused by mutations in the gene MECP2 located on the
156
themselves usually struggle to provide an objective account (see Table 18.4) and a collateral history are crucial. Not ev-
of this, so it is essential to obtain a collateral developmental eryone who has difficulty in interacting has autism or any
history from someone who knew the patient well as a child. other psychiatric diagnosis!
This can be a parent, a teacher, an older sibling or in written
form, for example, school reports. The validity of any diag- Problems with attention
nosis of this sort in adulthood increases with the number of
sources of collateral information available. Children
If impairments in communication and social abilities In a child described as paying poor attention, it is import-
have had onset or significantly worsened in adulthood, then ant to exclude an influence of physical or mental health
it is important to exclude other conditions that could have problems, sensory impairments or psychosocial adversity.
caused this, for example, a traumatic brain injury, fronto- Intellectual disability reduces the ability to pay attention, but
temporal dementia, a depressive episode or schizophrenia. if this is more marked than would be expected for the de-
Anxiety and depression are often comorbid with au- gree of intellectual disability, it can be diagnosed separately.
tism in adults. A primary diagnosis of social anxiety can Differentials are shown in Box 18.3 and clinical features of
be distinguished from an autism spectrum disorder in that the key neurodevelopmental cause of inattention (attention
there should be no associated problems in communication deficit hyperactivity disorder; ADHD) is described below.
or restricted interests and social abilities should be intact Conduct disorder and reactive attachment disorder are
(e.g. able to make normal eye contact). In generalized anx- described in Chapter 30. They can be distinguished from
iety disorder, anxiety covers many areas, not just social ADHD in that in conduct disorder the child breaks rules
situations. deliberately rather than impulsively and resists complet-
Personality disorders can be distinguished from autism ing tasks because they do not wish to conform, rather than
by the associated features (see Chapter 17), for example, being unable to sustain attention. In reactive attachment
finding little pleasure in anything in schizoid personality disorder, a child may appear socially disinhibited, as with
disorder, magical thinking in schizotypal personality dis- ADHD, but will struggle to form any sustained relation-
order, a desire for perfection in anankastic personal- ships, which is not the case for ADHD.
ity disorder, feelings of emptiness and frequent self-harm in
emotionally unstable personality disorder and the ability to
read social situations, but to disregard social obligations, in
dissocial personality disorder. HINTS AND TIPS
Clinical features of autism spectrum disorders in adults
vs. children are shown in Table 18.2. In adults presenting Sensory processing abnormalities such as
for the first time with a possible diagnosis of autism, intel- hypersensitivity to sound or touch are common
lectual disability is rare, and impairments tend to be milder in autism spectrum disorders and attention
than in those diagnosed in childhood. Because difficul- deficit hyperactivity disorder. The presence of
ties are likely to be at the milder end of the spectrum, it is such abnormalities increases the likelihood of a
very important to clarify the severity of the person’s diffi- neurodevelopmental diagnosis but is not required
culties and the degree to which they impact their life (e.g. for a diagnosis.
problems in initiating or sustaining employment, education
and/or relationships). Your own mental state examination
Table 18.2 Clinical features of autism spectrum disorder presenting at different ages

Examples
Presenting in childhood Presenting in adulthood
Domain
Impaired social Not interested in peers. Not able to make small talk.
interaction Little eye contact. Doesn’t pick up social cues.
Impaired communication Delayed speech. Pedantic, overly formal use of language.
Restricted, stereotyped Intense interest in physical aspects of Intense interest in objects or numbers,
interests and behaviours objects or numbers (e.g. lining up milk bottle often enjoyment gained from categorizing
tops). or collecting (e.g. listing train timetables).
Inflexible adherence to routine. Inflexible adherence to routine.
Repetitive movements (e.g. clapping, rocking). Repetitive movements less common.
157
Adults
In adults presenting with attentional difficulties, the
ATTENTION DIFFICULTIES IN CHILDREN
main differentials are shown in Box 18.4. As with so-
Normal for age cial impairment, it is paramount to take a history of the
Secondary to sensory impairment (e.g. myopia) time course of difficulties with a collateral developmen-
Secondary to mental or physical health problem tal history from someone who knew the patient well
as a child or contemporaneous documentation such as
(e.g. anxiety, restlessness due to pain)
school reports.
Secondary to psychosocial adversity (e.g. hunger)
If impairments in attention have had onset or signifi-
Intellectual disability cantly worsened in adulthood, then it is important to
Attention deficit hyperactivity disorder exclude other conditions that could have caused this, for ex-
Conduct disorder ample, a traumatic brain injury, dementia, a depressive epi-
Reactive attachment disorder sode or anxiety. Bipolar affective disorder can present with
Tourette syndrome or dyskinesia mood instability similar (but more severe) than that seen in
Specific learning difficulty ADHD. The use of substances, particularly amphetamines,
must be excluded.
Emotionally unstable personality disorder overlaps
with ADHD in terms of impulsivity and rapid emotional
Attention deficit hyperactivity disorder variation. However, ADHD is not associated with feelings
Problems in the three domains below should be present, of emptiness or self-harm. Dissocial personality disorder
causing significant functional impairment in at least two overlaps with ADHD in that both are associated with law
settings (e.g. school and home) for at least 6 months: breaking and often found in prison populations. However,
1. Impaired attention: Rather than failing to pay attention in ADHD the offences tend to be committed impulsively
children pay more attention to more cues and are whereas in dissocial personality disorder there is more
unable to eliminate unnecessary cues. This may likely to be premeditation.
manifest as difficulty completing work or play tasks;
not listening when being spoken to; being highly
distractible – moving from one activity to another;
reluctance to engage in activities that require a
sustained mental effort (e.g. schoolwork) unless very HINTS AND TIPS
interested in the task (e.g. video games); being forgetful
The symptoms of neurodevelopmental
or regularly losing things.
2. Impulsivity: Children with ADHD are unable to disorders overlap with the symptoms of many
suppress impulses and therefore respond to all other psychiatric disorders and it is important
impulses. This may manifest as difficulty awaiting to be aware of the possibility of a missed
turn, interrupting others’ conversations or games or neurodevelopmental diagnosis. This applies
prematurely blurting out answers to questions. particularly to patients with atypical patterns of
3. Hyperactivity: Children with ADHD fail to pause and symptoms or response (e.g. rapid cycling bipolar,
to consider options and consequences prior to acting. treatment-resistant depression) and to patients
This may manifest as restlessness, incessant fidgeting, with several diagnoses, none of which quite
running and jumping around in inappropriate
seem to fit.
situations, excessive talkativeness or noisiness or
difficulty engaging in quiet activities.
HINTS AND TIPS Clinical features of ADHD in adults vs. children are
shown in Table 18.3. In adults presenting for the first time
When assessing a person’s ability to concentrate, with a possible diagnosis of ADHD, impairments tend to be
remember to take their developmental stage into milder than in those diagnosed in childhood. Because diffi-
account. A rule of thumb is that a preschool child culties are likely to be at the milder end of the spectrum, it is
would be expected to be able to concentrate for at very important to clarify the severity of the person’s difficul-
least 3 minutes, a child at primary school for at least ties and the degree to which they impact their life. Your own
10 minutes and an adolescent for at least 30 minutes. mental state examination (see Table 18.4) and a collateral
history are crucial. Not everyone who gets bored easily has
ADHD or any other psychiatric diagnosis.
158
Table 18.4 Mental state abnormalities in people with

ATTENTION DIFFICULTIES IN ADULTS neurodevelopmental disorders
Typical findings on mental
Within normal range Disorder state examination
Secondary to substance abuse Intellectual disability Very dependent on severity of
Intellectual disability disability.
Attention deficit hyperactivity disorder Struggles to understand your
Personality disorder questions. Gives short answers
with limited vocabulary.
• Emotionally unstable Dysarthric.
• Dissocial
Autism spectrum Reduced eye contact. Does
Secondary to other psychiatric disorder disorder (ASD) not pick up on social cues
• Bipolar affective disorder (e.g. when it is the end of the
• Generalized anxiety disorder appointment). Speech may
have limited intonation, be
• Depression
oddly accented or be unusually
Brain injury (e.g. traumatic, cerebrovascular formal or pedantic. Talks
accident, infection, inflammation) excessively about topics of
Neurodegeneration (e.g. dementia) particular interest to them, does
not take turns as in a normal
conversation. Affect unreactive
or odd, not able to use facial
expression to communicate
naturally.
Attention deficit Adults may be fidgety. Children
hyperactivity disorder may get up from chair, play
(ADHD) noisily with toys, run around
waiting room, shout. Person
Table 18.3 Clinical features of attention deficit may talk at length in a tangential
hyperactivity disorder presenting at different ages fashion. They may speak over
you or finish your sentences.
Examples
Information may need to be
Presenting in Presenting in repeated. Easily distracted by
childhood adulthood external noises (e.g. traffic or a
distant telephone).
Domain
Tourette syndrome Tics. Features of comorbid
Inattention Poor self- Frequently loses
attention deficit hyperactivity
organization (e.g. important items
disorder.
loses school jumper). (e.g. keys, wallet,
Needs instructions phone).
repeated. Struggles
Careless mistakes to complete Problems with controlling
in schoolwork. administrative movements
tasks.
Impulsivity Shouts out answers Makes reckless Abnormal movements can result from a diverse range of
to questions. decisions. problems, for example, orthopaedic, rheumatological, neu-
Difficulty waiting Completes others’ rological or nutritional problems. Those covered here are
turn. sentences. those that are thought to be due to a problem with cortical
Easily led. Avoids queuing. processing of the coordination of movement (see Table 18.5),
Risk taker. rather than a problem with the mechanics of a movement.
Hyperactivity Moves around Movement less
inappropriately. of a problem in Developmental motor coordination disorder/
Excessively adulthood. specific developmental disorder of motor
talkative, goes off May avoid function
on tangents. situations where
This disorder is characterized by significantly impaired
sitting still is
expected (e.g. gross and fine motor skills in the absence of intellectual dis-
cinema, theatre). ability, sufficient to cause marked functional impairment.
Over-talkative For example, very slow or inaccurate when catching a ball,
with tangential walking or riding a bike (gross), or using scissors, cutlery
conversation. zippers or pens (fine). This generally improves with age.
159
Table 18.5 Types of motor abnormality

Abnormality Description Examples
Tic Quick, sudden, movement arising unpredictably, generally Eye-blinking, mouth twitching, grunting
occurring for a brief time. (simple) or shouting out words, squatting,
Often stereotyped (i.e. the same movement) and recurrent, twirling while walking, making obscene
but not rhythmic. Suppressible and suggestible. Usually gestures (complex).
occurs at age 5–7 years.
Stereotypy Identical, nonfunctional movement repeated many times. Hand flapping, twisting, rocking, head
Arises in a fixed, predictable manner. Person can be banging, grimacing, humming, grunting.
distracted from movement but cannot voluntarily suppress.
Usually occurs by age 2 years.
Mannerism Goal-directed movement that individual performs frequently Twirling hair, rolling eyes, clearing throat
in a way unique to them. Under voluntary control. May be (common, part of personality).
bizarre if in response to delusional idea. Jerking head, twiddling finger movements
(rarer, bizarre).
Tourette syndrome Learning difficulty (see Box 18.5 for communication tips)

Tics are sudden, repetitive, nonrhythmic motor movements • Do you have problems looking after yourself?
or vocalizations (see Table 18.5). They are usually preceded • Do you have problems with reading? Or writing?
by a premonitory feeling of discomfort. They are involun- Or maths?
tary; however, they can be voluntarily suppressed (although • Is it difficult to understand what people are saying?
this can be very difficult, like trying to suppress the urge Autism spectrum disorder
to sneeze). They are also often suggestible (i.e. can be pro- • What is a friend?
voked by discussing them or by observing others’ tics) and • What are your hobbies?
become more prominent during times of stress. Tics are di- • How would you know if someone was sad?
vided into: • What would you do if someone was sad?
• Simple motor tics (e.g. eye-blinking, neck-jerking, • Can you make small talk?
facial grimacing) ADHD
• Simple vocal tics (e.g. grunting, coughing, barking, • When did you last lose your bank card/phone/keys?
sniffing) • Do you often make careless mistakes?
• Complex motor tics (e.g. jumping, touching self, • Have you been told you don’t listen?
copropraxia (use of obscene gestures)) • Are you distracted easily by background noises?
• Complex vocal tics (senseless repetition of words, • Are you fidgety?
coprolalia (use of obscene words or phrases)) • What’s it like inside your head?
(people with ADHD will often answer that it is busy and
Tourette syndrome is characterized by the presence of
chaotic)
both multiple motor tics and one or more vocal tics for
Tourette syndrome
more than 1 year. The motor tics usually present by age
• Do you find yourself making pointless movements
7 years, although tics can present as early as 2 years of age.
or sounds?
Obsessive compulsive disorder and ADHD are common
• Do you get an urge beforehand?
comorbidities.
• Can you suppress the urge? (Like with a sneeze or
an itch?)
• What happens if you suppress it?
(People with Tourette syndrome report discomfort)
ASSESSMENT
See Figure 18.2 for an overall approach to assessing neuro- Examination
developmental conditions.
• Assess for physical signs suggestive of a syndromic
intellectual disability, for example, large ears in
History Fragile X.
The following questions may be helpful in screening for the • Assess for physical disorders that could cause the
disorders below: presenting complaint.
160
Assessment 18
Patient may have problems with learning, social interaction,

communication, attention or movement control
Consider screening tool

in adults (e.g. AQ-10)
History from patient
Consider diagnostic
interview guide (e.g. DIVA)
Observation of patient Consider standardized

in clinical setting assessment (e.g. ADOS)
Consider structured
questionnaire
Collateral history (e.g. Conners’ scale
covering development (ADHD)),
and current difficulties Social responsiveness
scale (ASD)
In children, speak to carers at home and carers at school (e.g. teachers).
In adults, speak to parent, former teachers or get school reports.

Also ask to speak to partner/someone who knows patient well now.
Observation of patient
in educational setting
(children only)
Exclude:
Difficulties within range of normality
Difficulties without associated functional impairment
Difficulties present in only one setting
Difficulties with onset in adulthood
Difficulties due to other causes:
Sensory impairment
Other psychiatric disordera
Physical health problemsa
Psychosocial adversity
Consider making diagnosis of

neurodevelopmental disorder
a
ADHD, Attention deficit hyperactivity disorder; Note, Comorbid conditions are very common in
ADOS, Autism Diagnostic Observation Schedule; ASD, neurodevelopmental disorders so do not preclude
autism spectrum disorder; AQ-10, autism-spectrum the diagnosis – but do not diagnose a
quotient - 10 items; DIVA, diagnostic interview guide neurodevelopmental disorder if difficulties are
for ADHD in adults. better explained by an alternative disorder.
Fig. 18.2 Approach to neurodevelopmental disorder assessment.
• Complete a mental state examination focusing on testing is increasingly used in identifying the cause of
behaviours suggestive of the neurodevelopmental intellectual disability, but it is not required for the di-
disorder you are assessing for (see Table 18.4). agnosis. Some investigations may be useful in excluding
differentials or in identifying suspected comorbidities,
Investigations for example, an EEG in someone with repetitive move-
ments to exclude epilepsy, thyroid function in someone
No specific investigations are required to make a di- who has become restless and lost weight to exclude
agnosis of a neurodevelopmental disorder. Genetic hyperthyroidism.
161
BOX 18.5 COMMUNICATION DISCUSSION OF CASE STUDY

CONSIDERATIONS IN INTELLECTUAL
DISABILITY John is likely to meet criteria for ADHD, although a school
observation needs to be arranged. He has problems main-
Allow extra time taining attention (e.g. completing schoolwork, remembering
Speak first to the person with the intellectual homework, on the football pitch), impulse control (e.g. talking
disability, not their carer over friends, jumping out of trees) and hyperactivity (e.g. not
Assess their understanding early and involve them able to sit through a class or a film) that are more severe than
as much as possible those seen in his peers. He may also have sensory hypersensi-
Ask short, simple questions tivity to noise. His difficulties occur in multiple settings. These
Use literal, direct language, not abstract or medical problems are causing him functional impairment in educa-
terms (e.g. ‘Does it hurt when you pee?’ rather tional attainment, socializing and risks to his person. There
is no evidence of intellectual disability, sensory impairment,
than ‘How are your waterworks?’ or ‘Do you
psychosocial adversity or physical or mental health problems.
experience dysuria?’)
Now read Chapter 29 about neurodevelopmental disor-
ders and their management.
Chapter Summary
• Neurodevelopmental disorders are disorders where abnormal development of the central

nervous system leads to impairments in brain function.
• To be classed as a disorder, an impairment in brain function should also cause an
impairment in social, occupational or adaptive function.
• Intellectual disability results in an IQ <70 with impairments in adaptive functioning.
• Autism spectrum disorders cause a triad of impairments in social interaction,
communication and restricted or repetitive behaviours.
• Attention deficit hyperactivity disorder causes a triad of impairments in attention,
impulsivity and hyperactivity.
• Tourette syndrome causes a combination of motor and vocal tics.
162
Cause and
Management
Chapter 19
Dementia and delirium�� 165

Chapter 20
Alcohol and substance-related disorders �� 173

Chapter 21
The psychotic disorders: schizophrenia�� 183

Chapter 22
The mood (affective) disorders �� 191

Chapter 23
The anxiety and somatoform disorders �� 199

Chapter 24
Eating disorders�� 205

Chapter 25
The sleep–wake disorders�� 209

Chapter 26
The psychosexual disorders�� 215

Chapter 27
Disorders relating to the menstrual cycle,

pregnancy and the puerperium �� 221
Chapter 28
The personality disorders �� 227

Chapter 29
The neurodevelopmental disorders �� 231

Chapter 30
Child and adolescent psychiatry�� 237

Chapter 31
Older adult psychiatry�� 245

Chapter 32
Forensic psychiatry �� 251
Dementia and delirium
19
This chapter discusses the most common disorders associ- • Dementia with Lewy bodies (DLB), 4%
ated with the complaints described in Chapter 7, which you • Frontotemporal dementia, approximately 2% (20% of
might find helpful to read first. early onset dementia)
• Parkinson dementia 2%
• Other causes of dementia 3%
DEMENTIA Aetiopathology
Each type of dementia will be discussed separately.
Epidemiology
The overall prevalence of dementia is approximately 1% of Alzheimer dementia
the total UK population, rising sharply with increasing age. Alzheimer dementia (AD) is classified as:
Fig. 19.1 illustrates the increasing prevalence of dementia
• Early onset (onset before age 65 years, usually familial,
with age. The prevalence in persons aged 65 years or over
with relatives also affected before age 65 years)
is approximately 7%, in those over 80 years about 20%
• Late onset/sporadic (onset after age 65 years, either no
and in those over 90 years of age around 30%. Dementia
family history or relatives affected after age 65 years)
that manifests before the age of 65 years is referred to as
early-onset. This arbitrary age cut-off is sometimes import- At present, the cause of most cases of AD is unknown. It
ant when determining which service will treat a patient appears to be a combination of multifactorial genetic risk
(see Chapter 31). Alzheimer dementia is more common in factors, vascular risk factors and other uncertain environ-
women and vascular dementia more common in men. mental factors. The characteristic pathological changes are:
Dementia is a syndrome due to various diseases, most 1. Beta-amyloid plaques between neurones
commonly neurodegeneration or vascular damage as below: 2. Neurofibrillary tangles of hyperphosphorylated tau
• Alzheimer dementia, 62% of cases inside neurones
• Vascular dementia, approximately 17% It is unclear whether either of these changes are a cause or a
• Combined Alzheimer and vascular (‘mixed’) dementia, consequence of neuronal damage and death. The abnormal-
approximately 10% ities generally begin in the medial temporal lobe (where key
structures relating to memory are located) before becoming
more diffuse, resulting in generalized cortical atrophy and
compensatory ventricular enlargement. Degeneration of
cholinergic neurons in the nucleus basalis of Meynert leads
40 to a deficiency of acetylcholine, which can be partially re-
versed by some anti-dementia medications (cholinesterase
inhibitors). These drugs can temporarily slow the loss of
cognitive function but not reverse or ultimately prevent it.
30
Genetic factors
% Prevalence
Late-onset AD. First-degree relatives of people with AD have

20 a threefold increased risk for developing AD themselves.
The most important gene associated with late-onset AD is
the gene that codes a protein involved in cholesterol metab-
olism called apolipoprotein E (ApoE), which is encoded by
10 three different common alleles (ε2, ε3 and ε4). Individuals
who inherit one copy of the ApoE ε4 allele are at a roughly
threefold increased risk for developing AD and those with
0 two copies are at a roughly 10-fold increased risk. However,
50 60 70 80 90 other environmental and genetic factors must be involved
Age (years) because having two ApoE ε4 alleles does not guarantee the
Fig. 19.1 Graph showing increasing prevalence of dementia development of AD and many patients with AD have no
with age. copies of the allele. Genome-wide association studies have
165
identified approximately 20 genes in which polymorphisms

contribute a small increase in risk for AD. These genes are BOX 19.1 NONGENETIC RISK FACTORS FOR
ALZHEIMER AND VASCULAR DEMENTIA
involved in amyloid processing, lipid transport and metab-
olism, endocytosis and immune response. Vascular Both Alzheimer
Early-onset AD. Some forms of early-onset familial AD
are inherited in an autosomal dominant fashion. Three Previous Smoking Head injury
genes have been isolated so far: stroke Hypertension Low
• Amyloid precursor protein – chromosome 21 Atrial Diabetes educational
• Presenilin-1 – chromosome 14 fibrillation Hypercholesterolaemia attainment
• Presenilin-2 – chromosome 1 Previous myocardial infarct
These genes are all involved in metabolism of the amyloid Obesity
protein. These autosomal dominant dementias present be-
Late onset depression
tween the ages of 30 and 60 years, sometimes as early as
28 years of age when there is a mutation at presenilin 1.
Adults with trisomy 21 (Down syndrome) invariably
develop neuropathological changes similar to AD by mid-
dle age and many will develop dementia. This has been at-
tributed to triplication and over-expression of the gene for
amyloid precursor protein (APP). HINTS AND TIPS
The National Institute for Health and Care

HINTS AND TIPS Excellence (2015) recommends that individuals
You should be aware of four genes in Alzheimer reduce their risk for dementia in later life by quitting
dementia (AD) – one in late-onset AD, and three in smoking, being more active, reducing alcohol,
early-onset autosomal dominant AD: eating healthily and maintaining a healthy weight.
• In late-onset AD, the ApoE ε4 allele increases an
individual’s susceptibility to develop AD.
• In early-onset AD, the possession of a mutated
Vascular dementia
version of one of three genes, amyloid precursor
The cause of vascular dementia is presumed to be multiple
protein, presenilin-1 and presenilin-2, is strongly
cortical infarctions or many small subcortical infarctions
associated with development of AD. in white matter (Binswanger disease) resulting from wide-
Late-onset sporadic AD accounts for the spread cerebrovascular disease. On occasions, vascular de-
overwhelming majority of all AD cases. mentia can arise from a single infarct in a strategic area. As
with both Alzheimer dementia and cerebrovascular disease,
vascular dementia is closely associated with increasing age.
In rare cases, the disease is linked to NOTCH3, a gene on
Nongenetic factors
chromosome 19 involved in vascular smooth muscle cells
The main environmental risk factors for AD are vascular
response to injury (cerebral autosomal dominant arteriop-
(see Box 19.1). It is unclear whether vascular insufficiency
athy with subcortical infarcts and leukoencephalopathy;
in part causes the plaques and tangles seen in AD or whether
CADASIL). The risk factors for developing vascular demen-
vascular damage reduces the brain’s reserve, making a given
tia are the same as for cerebrovascular disease in general
amount of neurodegeneration more likely to manifest clin-
(Box 19.1).
ically. Head injury and low educational attainment are also
risk factors.
Lewy body dementias
Dementia with Lewy bodies and Parkinson disease de-
HINTS AND TIPS mentia are now viewed as part of a continuum with the
umbrella term Lewy body dementias (LBD). They have
Neurodegeneration seems to be associated with the same pathogenesis and as both diseases progress they
misplaced proteins: Alzheimer disease, dementia become increasingly similar. Both are associated with the
with Lewy bodies and frontotemporal dementia all deposition of Lewy bodies: neuronal inclusions composed
involve the accumulation of degradation-resistant of abnormally phosphorylated neurofilament proteins
protein aggregates (see Table 19.1 for more detail).
aggregated with ubiquitin and α-synuclein. The initial
distribution of Lewy bodies probably determines which
symptoms occur first and hence which diagnosis is given
166
Dementia 19
Table 19.1 Neuropathology of dementia

Abnormal
Dementia type protein(s) Macroscopic findings Microscopic findings
Alzheimer dementia Beta amyloid Generalized cerebral atrophy, Extracellular amyloid plaques
Tau beginning in medial temporal Intracellular neurofibrillary
lobes tangles containing
hyperphosphorylated tau and
ubiquitin
Frontotemporal dementia Tau Atrophy of frontal and Intracellular aggregates of
(a heterogeneous collection TDP temporal lobes, particularly tau, TDP or FUS.
of dementias including Pick FUS anteriorly
disease and progressive
supranuclear palsy)
Dementia with Lewy bodies α-synuclein Mild atrophy frontal, parietal, Lewy bodies (intracellular
occipital lobes aggregates of α-synuclein
and ubiquitin) in cortex
Parkinson disease (dementia α-synuclein Atrophy of substantia nigra Lewy bodies in brainstem
point prevalence of 25%, and locus coeruleus nuclei
increasing with duration)
Huntington disease Huntingtin Marked atrophy of basal Intracellular aggregates of
ganglia and often frontal huntingtin and ubiquitin
lobes
Creutzfeldt–Jakob disease Prion protein Spongiform changes Extracellular prion protein
throughout cortex and plaques, particularly in
subcortical nuclei cerebellum
Vascular dementia None identified Infarction – multiple small Infarcted grey and or white
(in most cases) infarcts, or single large or matter
strategic infarct
FUS, Fused-in-sarcoma protein; TDP, TAR DNA-binding protein with molecular weight 43 kDa.
initially. Early deposition in the brain stem is thought to

underlie the rapid eye movement (REM) sleep behaviour HINTS AND TIPS
disorder that often precedes the onset of LBD by several
If dementia occurs at the same time or within a year
years (see Chapter 25). Deposition in the substantia nigra,
of onset of parkinsonism, dementia with Lewy bodies
with associated neuronal death, results in parkinsonism.
is diagnosed. If dementia occurs more than a year
Deposition in the cortex results in cognitive impairment
and hallucinations. after well-established Parkinson disease, Parkinson
Familial cases of dementia with Lewy bodies are rare disease with dementia is diagnosed. The umbrella
but can be caused by mutations in the genes coding for term Lewy body dementia describes both disorders.
α-synuclein (SNCA), an intracellular signalling protein
(LRRK2) and lysosomal processing. Fifteen percent of
people with Parkinson disease have a family history of the
disorder, associated with mutations in the same genes as RED FLAG
dementia with Lewy body and with mutations in genes
coding for proteins involved in the ubiquitin-proteasome It is important to recognize Lewy body dementias
system (e.g. parkin). as they require a specific management approach.
The syndrome of parkinsonism (as opposed to the spe- Key features supporting Lewy body dementia
cific disorder of idiopathic Parkinson disease) can be due rather than Alzheimer dementia are visual
to any injury to the basal ganglia: cerebrovascular disease, hallucinations and parkinsonism early in dementia,
head injury, carbon monoxide poisoning, dopamine antag- and a history of rapid eye movement sleep
onists (including antipsychotic medication) or other neu- behaviour disorder.
rodegenerative disorders (e.g. Parkinson-plus syndromes
such as progressive supranuclear palsy).
167
Frontotemporal dementia Most cases of Creutzfeldt–Jakob disease (CJD) appear

Frontotemporal dementias are a heterogeneous group of to be sporadic, affecting people aged in their 50s, although
neurodegenerative disorders associated with degeneration it can be transmitted iatrogenically (e.g. via infected cor-
of the anterior part of the brain. Their pathology and pre- neal transplants and surgical instruments). It presents with
sentation overlap with motor neurone disease. There are a rapidly progressing dementia with cerebellar ataxia and
three main variants: behavioural and primary progressive myoclonic jerks over 6–8 months. The electroencepha-
aphasia, which is subdivided into nonfluent and semantic logram (EEG) characteristically shows stereotyped sharp
variants (see Table 7.4). Macroscopically, they are associated wave complexes.
with bilateral atrophy of the frontal and anterior temporal New variant CJD (nvCJD) is thought to be secondary
lobes (atrophied paper-thin gyri known as ‘knife-blade at- to the ingestion of BSE-infected beef products. It typically
rophy’) and degeneration of the striatum. Microscopically, presents in young adults with mild psychiatric symptoms
three main types of intracellular inclusion body have been such as depression and anxiety preceding the develop-
identified, containing mainly tau (e.g. Pick bodies; 30%– ment of ataxia, dementia and finally death over a period
50% cases) the TAR DNA-binding protein (50% of cases) of 18 months. There are no characteristic EEG changes, al-
or the fused-in-sarcoma protein (10% of cases). Mutations though nvCJD may have a characteristic MRI picture: a bi-
in genes encoding three proteins account for around 60% laterally evident high signal in the pulvinar (post-thalamic)
of familial frontotemporal dementia: tau (microtubule sta- region. As a result of public health measures, the incidence
bilization), C9orf72 (endosomal trafficking) and progran- of this rare disorder has declined further, only affecting one
ulin (a protein involved in neuronal repair and lysosomal or two people per year in the UK since 2012.
degradation).
HIV-related dementia
Infection with the human immunodeficiency virus (HIV) is
COMMUNICATION
thought to cause direct damage to the brain in addition to
Pick disease is strictly a neuropathological the complications of HIV infection, such as opportunistic
diagnosis requiring the presence of Pick bodies at infections (cerebral cytomegalovirus infection, cryptococ-
post-mortem, but previously it was used to mean cosis, toxoplasmosis, tuberculosis, syphilis) and cerebral
lymphoma. HIV encephalopathy presents clinically as a
the clinical diagnosis of any type of frontotemporal
subcortical dementia and neuropathological examination
dementia.
shows diffuse multifocal destruction of the white matter
and subcortical structures.
Huntington disease Assessment, clinical features,

Huntington disease has autosomal dominant inheritance investigations and differential
with complete penetrance. It is caused by an excessive num-
ber of trinucleotide (CAG) repeat sequences, usually more diagnosis
than 40, in the gene encoding the protein ‘huntingtin’. The Discussed in Chapter 7.
length of the abnormal trinucleotide repeat sequence is in-
versely correlated to the age of onset of the disease. This
abnormal protein is associated with neuronal death, par- Management
ticularly in the basal ganglia, giving rise to the distressing There is no cure for any of the neurodegenerative forms of de-
motor signs of the disease. mentia. Although the prognosis is invariably continued deteri-
oration, considerable improvements in the quality of patients’
Creutzfeldt–Jakob disease and other lives are possible through a variety of psychosocial and phar-
prion-related diseases maceutical approaches. The principles of management are:
A prion is an infectious protein. All the prion-related de- • Treating the underlying cause if possible (e.g.
mentias result in a spongiform degeneration of the brain in hypothyroidism, modifying vascular risk factors)
the absence of an inflammatory immune response, associ- • Slowing down the rate of cognitive decline using anti-
ated with the deposition of the prion protein (PrP) in the dementia drugs if indicated
form of beta pleated sheets. • Managing associated disorders or complications (e.g.
A number of prion diseases exist: kuru (prion trans- aggression, depression, psychotic symptoms)
mitted by cannibalism of neural tissue, described in the • Addressing resulting functional problems (e.g. kitchen
highland tribes of New Guinea), Gerstmann–Sträussler skills, financial management, social isolation)
syndrome (autosomal dominant condition caused by muta- • Providing advice and support for carers
tion of PrP gene on chromosome 20), scrapie in sheep and • Advising on legal measures to prepare for loss of
BSE (bovine spongiform encephalopathy) in cattle. capacity (e.g. Power of Attorney, Advance Statements)
168
Dementia 19
Specific management strategies its relatively benign side-effect profile. Benzodiazepines

should be avoided if at all possible because they worsen
Maintaining cognitive functioning cognition, predispose to delirium, increase fall risk
Alzheimer dementia: and may paradoxically disinhibit (and make more
• The cholinesterase inhibitors, donepezil, rivastigmine aggressive) those with dementia.
and galantamine, are recommended by National • Psychotic symptoms do not require treatment if they
Institute for Health and Care Excellence (NICE; are not distressing to the patient nor causing risk to
2011) for patients with mild-moderate Alzheimer others. If there is felt to be significant distress, a trial
dementia. Up to half the patients given these drugs will of an antipsychotic can be considered. Consider and
show a slower rate of cognitive decline and possible document the increased risk for cerebrovascular events.
improvement in behavioural and psychological Discontinue if there is no benefit within 12 weeks.
symptoms. • Depression in dementia is managed similarly to
• Memantine, is recommended by NICE (2006) for those depression in older adults but with even more care
with moderate to severe Alzheimer dementia or for taken to avoid anticholinergic drugs, which can worsen
those who cannot tolerate cholinesterase inhibitors. It is cognition.
an N-methyl-d-aspartate (NMDA) receptor antagonist,
thought to reduce excitotoxic damage by blocking HINTS AND TIPS
NMDA receptors and preventing the influx of calcium.
Most medications should be prescribed at lower
Vascular dementia: Cholinesterase inhibitors are not
doses in older adults. In general, prescribe
recommended (NICE 2006). The cornerstone of treatment
is preventing further strokes by ensuring vascular risk fac- according to the rule ‘start low and go slow’. This
tors are optimally managed. In mixed Alzheimer/vascular is particularly true when prescribing psychotropic
dementia, cholinesterase inhibitors can be prescribed. medications for those with vulnerable brains (e.g.
Lewy body dementias: Cholinesterase inhibitors are rec- dementia) where doses a tenth of what would be
ommended. Rivastigmine has the most evidence of benefit used in a younger adult can be sufficient.
in both Lewy body dementia and dementia associated with
Parkinson disease.
Frontotemporal dementias: Cholinesterase inhibitors
can worsen behavioural abnormalities and are not usually
recommended. Legal issues
Structured group cognitive stimulation programmes can • People with dementia are likely in due course to lose
be of benefit in mild to moderate dementia of all types. the capacity to be able to make decisions about their
welfare and financial affairs. It is advisable to arrange
Reducing behavioural and psychological Power of Attorney as early as possible, before the
symptoms of dementia person loses capacity to authorize this. They may also
• Behavioural and psychological symptoms of dementia wish to consider an Advance Statement.
(BPSD) are the noncognitive symptoms of dementia, • People with dementia may lose the ability to drive
including anxiety, agitation, delusions, hallucinations, safely and they and their carers should be advised
aggression, wandering and sexual disinhibition (see to notify the Driver and Vehicle Licensing Agency
Chapter 7). (DVLA) and their insurer of their diagnosis.
• If a patient develops BPSD, carefully assess for a change
in their physical health, including pain. People with
dementia may find it very difficult to communicate RED FLAG
discomfort. Consider medication side-effects including
constipation. Assess for depression. Consider also a • Benzodiazepines should be avoided if at all
change in the person’s environment – are they troubled possible in most patients with dementia, as
by noise, extremes of temperature, other people’s they are particularly vulnerable to their adverse
behaviour? effects such as sedation, falls and delirium.
• NICE (2006) recommends aromatherapy, massage, • Remember that 50% of patients with
animal-assisted therapy, multisensory stimulation or dementia with Lewy bodies will have a
therapeutic use of music or dancing for agitation. catastrophic reaction to antipsychotics (even
• Pharmacological treatment can be considered for atypicals), precipitating potentially irreversible
disturbed behaviour such as aggression or agitation parkinsonism, impaired consciousness, severe
that does not respond to nonpharmacological strategies
autonomic symptoms and a two- to threefold
and is causing significant distress or risk. Anxiolytic
medication such as trazodone can be useful because of
169
g lucocorticoids), disrupted blood–brain barrier (allowing

increase in mortality. Benzodiazepines and entry of toxins and cytokines to the brain) and impaired
cholinesterase inhibitors are safer in this group cholinergic neurotransmission.
of patients. This exemplifies the need to exercise
caution when prescribing antipsychotics and the
importance of differentiating the various types of HINTS AND TIPS
dementia. The cause of delirium is almost always
multifactorial. This means prevention and
management should address multiple factors too.
Course and prognosis

The course of dementia is invariably progressive. Around
a third of people with dementia live in residential care.
Assessment, clinical features,
Dementia is a life-shortening illness directly and indirectly, investigations and differential
because it reduces the ability to communicate and tolerate diagnosis
management of physical problems. A diagnosis of demen-
tia roughly halves a person’s remaining life expectancy. The Discussed in Chapter 7.
average duration of survival from the time of diagnosis of a
late-onset dementia is 4 years, although there is a wide range. Management
Delirium can be highly distressing for patients and
anxiety-provoking for medical ward staff who are not ex-
perienced in dealing with agitated patients. It can also be
DELIRIUM very distressing for the families and friends of the patient.
Fortunately, it is treatable if managed appropriately and
Epidemiology urgently. See Fig. 19.2 for a management algorithm incor-
porating recommendations by NICE (2010). General prin-
Most research into the epidemiology of delirium concen-
ciples of management are as follows:
trates on older adults, who, along with infants and young
children, are more vulnerable to this disorder. The preva- • Hospitalization is essential: delirium is a medical
lence in hospitalized, medically ill patients ranges from 10% emergency (unless prior ceiling of care discussions
to 30%. Between 10% and 35% of patients over the age of have concluded that this is not appropriate).
65 years are delirious on admission and a further 10%–40% • Vigorously investigate and treat any underlying medical
develop a delirium during hospitalization, with incidence condition.
increasing up to 87% in those admitted to intensive care. • Always assess medication use, including over-the-
Patients with dementia are at an increased risk for develop- counter treatments: this is a high yield intervention.
ing a delirium; up to two-thirds of cases of delirium occur • To limit confusion and foster trust, try to ensure that
in patients with dementia. the patient is nursed by the same staff consistently.
• Merely the physical presence of a reassuring person is
often enough to calm a distressed patient.
Aetiology • Maximize visual acuity (e.g. glasses, appropriately lit
Delirium is a final common pathway of disrupted homeo- environment) and hearing ability (e.g. hearing aid,
stasis. It is nearly always multifactorial. In healthy individ- quiet environment) to avoid misinterpretation of
uals, multiple severe insults are required to cause it (e.g. stimuli.
head injury followed by sedative medication followed by • Encourage a friend or family member to remain with
surgery). In those with vulnerable brains (e.g. dementia), the patient to help comfort and orientate them.
a minor insult is sufficient (e.g. constipation or a urinary • Clocks, calendars and familiar objects may be helpful
tract infection). The commonest causes are medication with orientation.
(most commonly anticholinergics, opiates or benzodiaze- • Avoid medication unless the patient’s agitation is
pines) or systemic illness, particularly infection. See Box 7.1 causing them extreme distress, a significant risk to
for a fuller list. Sometimes no cause is found – this does not themselves or others or preventing them from receiving
preclude the diagnosis. Around a third of cases are viewed essential medical investigations or treatment.
as preventable. • Antipsychotics, especially low-dose haloperidol, are
The pathophysiological mechanism remains unclear generally effective in treating delirious symptoms, in
and may vary with cause. Suggested mechanisms include: part due to their sedative qualities, but perhaps also due
aberrant stress response (neurotoxic effects of excess to their effects on the dopamine–acetylcholine balance.
170
Delirium 19
Delirium
Find and Relieve Review

treat cause symptoms legal status
History (patient, notes, Environment Delirious patients lack

ward staff, relatives, GP) • Clear communication of who you capacity
As many as can be accessed are and who and where they are • Accepting treatment?
• Calm, consistent, reassuring • Attempting to leave?
Examination (including nursing staff Use of legislation may be
observations, neurological • Encourage presence of required.
and standardize cognitive friend/family member
test.) As much as the patient • Quiet, peaceful room (but avoid
can tolerate change of room or ward)
• Optimize sensory acuity (e.g.
glasses, well-lit room, hearing aid)
Kardex
• Orientation aids (e.g. clock,
• New drug started?
familiar objects)
• Old drug stopped?
Investigations
• Review of recent lx
Medication
• Consider further lx
Only if severely distressed, at high
risk or unable to tolerate essential
Routine lx investigations or treatment
• FBC, U&E, LFT, Ca, • Consider haloperidol 0.5 mg
Glucose, CRP regularly + PRNa (Aim to use for
less than a week with review at
• CXR
least daily and specify stop date.)
• ECG
• Avoid benzodiazepines (unless
• Urinalysis
substance withdrawal)
If indicated by history/
• Avoid high doses of antipsychotic.
examination
If ineffective, use small doses more
• ABG
often rather than increase dose.
• TFT
• Offer orally first. Consider i.m.
• Blood cultures
if refuses. i.m. may need to be
• Other cultures (e.g. urine)
given under common law or
• Head CT
mental health act.
• Lumbar puncture
• Check kardex for drugs that
• EEG
may perpetuate delirium (e.g.
anticholinergics)
Interventions for all

Ensure hydrated
(oral > s.c. > i.v.)
Ensure adequate nutrition
Check for and treat
constipation
Check for and treat pain
Encourage mobility/activity
as far as possible (allow to
wander where safe)
Fig. 19.2 Management of delirium. aUse antipsychotics cautiously in patients with dementia with Lewy bodies or
parkinson disease (see earlier) or with a prolonged QTc. Use benzodiazepines instead. ABG, arterial blood gas; Ca,
calcium; CRP, C-reactive protein; CT, computed tomography; CXR, chest X-ray; ECG, electrocardiogram; EEG,
electroencephalogram; FBC, full blood count; GP, general practitioner; i.m., intramuscular; i.v., intravenously; LFT, liver
function test; PRN, when necessary; s.c., subcutaneous; TFT, thyroid function test; U&E, urea and electrolytes.
171
• Olanzapine can be given if haloperidol is ineffective Course and prognosis

or contraindicated (e.g. history of dystonia, long QTc).
Low doses should be given initially (e.g. 2.5 mg). The average duration of a delirium is 7 days, but delirium can
• Avoid benzodiazepines unless the patient is at high risk be prolonged for weeks or months, even after the initial insult
and has not responded to haloperidol, as they tend to is treated. Inpatients who develop delirium have an increased
prolong delirium. The exception is alcohol- or substance- mortality, with around a third dying during that admission.
related delirium, in which they are highly effective. This is unsurprising given that delirium is often a sign of se-
vere systemic illness. Those who survive have an increased
The specific management of delirium tremens is outlined
duration of admission, are at increased risk for complica-
in Chapter 20.
tions such as pressure sores and falls and are more likely to
be discharged to institutional care. An episode of delirium in-
RED FLAG creases the risk for developing dementia sixfold and, in those
Remember that delirium indicates the presence of with preexisting dementia, delirium can accelerate cognitive
a medical condition that should be managed on a decline.
medical, not a psychiatric, ward. Remember this
when making referrals.
Chapter Summary
• Dementia is very common, affecting around 7% of those aged over 65 years and
increasing with age.
• The four commonest types of dementia in older adults are: Alzheimer > vascular > Lewy
body > frontotemporal.
• Neurodegenerative dementia arises due to abnormally folded proteins, vascular
dementia due to one or many infarcts.
• Dementia cannot be cured but the commonest forms can be slowed using cholinesterase
inhibitors.
• Behavioural and psychological symptoms of dementia should be managed
nonpharmacologically wherever possible.
• Delirium is very common in hospitalized older adults, particularly those with preexisting
cognitive impairment, sensory impairment, polypharmacy or who are severely unwell.
Think delirium!
• Delirium is a medical emergency that requires prompt assessment and treatment of
causes.
• Management of the symptoms of delirium requires environmental approaches for all and
medication for a minority.
172
Alcohol and substance-related
disorders 20
This chapter discusses the disorders associated with the Table 20.1 Epidemiology of alcohol usea
complaints described in Chapter 8, which you might find
Prevalence
helpful to read first. Alcohol-related disorders will be pre-
within adults
sented first, followed by other psychoactive substances. in England in
2014, 2015 or Association with
2016 gender and age
ALCOHOL DISORDERS Alcohol use 57% drank any

alcohol within
63% men, 51%
women
the last week Age 16–24 years
Epidemiology (this proportion least likely to drink
is gradually
Alcohol use is declining in the UK but is still associated with reducing)
high morbidity and mortality and overall is the most harm- Hazardous use 15% binge Male to female
ful psychoactive substance in common use (see Fig. 20.1). of alcohol drank within ratio 1:1
Middle-aged people are the most likely to drink dependently (>8 (male) or 6 previous week Age 16–24 years
and to die of complications from alcohol abuse. Men are (female) units/ most likely to
more likely to drink excessively than women. See Table 20.1. alcohol in binge
1 day)
Alcohol 1.4% Male to female
80 dependence ratio 3:1
Highest
72
dependency rates
70
in 25–64-year-olds
60 Hospital 7% of all Male to female
55 54 admissions hospital ratio 2:1
Total harm score
50 related to admissions (1.1 Most admissions

alcohol million) in 55–74-year-olds
40 Deaths related 1.4% of all Male to female
33 to alcohol deaths (7000) ratio 2:1
30 27 Highest death rate
23 in 55–64-year-olds
20
20 a
These are self-report values; alcohol sales figures show actual
consumption is higher.
10 9
0 Aetiology
co n
et e
(p ine
Ca ne
Ec s
)
y
H l
i
ph der
in
ho
as
ab
ac ero
The causes of alcohol dependence are multifactorial and are

i
ca
am
am
st
co
nn
Am ow
et
Al
determined by biological, psychological and sociocultural

Co ph
k
e
m
in
Cr
factors.
ha
ca
et
M
Harm to others (e.g. crime, RTA, violence, child

neglect, economic cost) Genetic and biochemical factors
Harm to user (e.g. mental health problem, physical Strong evidence shows a genetic component to alcohol
health problem, death, loss of income, loss of relationships) dependence. Family studies show an increased risk for de-
pendence among relatives of dependent individuals. Twin
Fig. 20.1 Relative harmfulness of commonly used
studies indicate that monozygotic twins have a higher con-
psychoactive substances. Alcohol causes the most harm
to others with heroin and crack cocaine causing the most
cordance rate than dizygotic twins and adoption studies in-
harm to users. When scores are combined, alcohol is the dicate a heritable component. The nature of this influence
most harmful substance. RTA, Road traffic accidents. is unclear. It may operate at the level of heritable personal-
(Modified from Nutt, DJ et al., (2010), Drug harms in the ity characteristics or it might relate to the body’s inherited
UK: a multicriteria decision analysis. Lancet, 376 (9752); biochemical susceptibility to alcohol and its consequences.
1558–1565.) For example, 50% of East Asians have a deficiency in
173
Alcohol and substance-related disorders
mitochondrial aldehyde dehydrogenase, leading to flushing although differentiating cause and effect can be difficult
and palpitations after small quantities of alcohol; this may (see Chapter 8). There is also evidence linking alcohol de-
explain reduced rates of consumption and dependence in pendence with antisocial and borderline personality traits.
these cultures. Possible explanations for this could include any of the fol-
From a biochemical perspective, chronic alcohol con- lowing: attempts to self-medicate to relieve symptoms, the
sumption influences a range of receptors and intracellular use of alcohol as a (maladaptive) coping mechanism, the
signalling proteins to cause long-term changes in plasticity lack of a supportive environment, impulsivity, or the lack
in reward pathways, and to cause epigenetic changes. Some of insight into the risks associated with excessive alcohol.
of the systems implicated are decreasing activity (down-
regulation) of γ-aminobutyric acid (GABA) systems and Social and environmental factors
increasing activity (up-regulation) of glutamate (mainly N- The cultural attitude towards alcohol affects the prevalence
methyl-d-aspartate, or NMDA) systems. of alcohol-related problems (e.g. lower rates in Jewish so-
cieties as opposed to Mediterranean countries). Enormous
Psychological factors cross-cultural variation in the way that people behave when
Behavioural models explain dependence in terms of oper- drinking alcohol has been noted (e.g. alcohol consumption
ant conditioning where: in the UK, US and Australia is associated with antisocial be-
• Positive reinforcement occurs when the pleasant haviour and violence, while in Mediterranean countries it is
effects of alcohol consumption reinforce drinking generally more peaceful), suggesting that the effect that alco-
behaviour (despite adverse social and medical hol has on behaviour is linked to social and cultural factors
consequences). rather than solely to the chemical effects of ethanol. Alcohol
• Negative reinforcement occurs when continued consumption is greatly affected by price; strong evidence ex-
drinking behaviour is reinforced by the desire to ists to suggest that the more affordable alcohol is, the more is
avoid the negative effects of alcohol withdrawal consumed and the more harm results (see Fig. 20.2).
symptoms. There is an association between certain occupations and
deaths from alcoholic liver disease. The highest risk profes-
An alternative behavioural explanation is the observational
sions are members of leisure and catering trades (publicans
learning theory (modelling), which suggests that patterns
especially), doctors, journalists and those involved with
of drinking are modelled on the drinking behaviour of rela-
shipping and travel. Furthermore, higher rates of depen-
tives or peers. Family studies support the idea that drinking
dence are noted in unskilled workers and the unemployed
habits follow those of older relatives.
compared with those with higher incomes. This may be
The presence of psychiatric (anxiety, bipolar affective
partly explained by the ‘social drift’ caused by alcohol de-
disorder, depression, schizophrenia) or physical illness ap-
pendence (see Box 8.2).
pears to increase the risk for alcohol abuse and dependence,
180 900
160 800
140 700
Alcohol-related conditions
Hospital discharge rates
120 600
Affordability
100 500
80 400
60 300
40 200
Affordability
20 Discharges 100
0 0
02
82
92
00
10
90
08
84
88
98
94
04
96
06
86
20
19
19
20
20
19
20
19
19
19
19
20
19
20
19
Year
Fig. 20.2 Increasing alcohol affordability is associated with increasing alcohol-related harm. Alcohol has become around
45% more affordable in the UK since 1980, and alcohol-related hospital admissions have quadrupled. As the affordability
of alcohol has increased, so has the number of hospital discharges for alcohol-related conditions (rates shown here are
per 100,000 people in the population of Scotland). This is the rationale for minimum unit pricing. Modified from Scottish
Government (2012). Framework for Action: Changing Scotland’s Relationship with Alcohol. Available at: https://www.gov.
scot/Publications/2009/03/04144703/14.)
174
Alcohol disorders 20
The frequency of significant life events increases the risk

for harmful drinking. Although the anxiolytic properties of avoiding high-risk situations, attending mutual
alcohol are often used as a means of coping with stress, the aid groups). Encourage the patient to select one
social and physical complications of heavy drinking often or two to begin with.
lead to further stress. E - Empathy - be warm, reflective and
understanding
Assessment, clinical features, S - Self-efficacy – help the patient to feel confident
they can make the proposed changes.
investigations and differential Encourage the patient to describe their ability
diagnosis to make the change in their own words, for
Discussed in Chapter 8. example: ‘Do you think this is a change you’ll be
able to make?’.
Management
The management of alcohol-related problems varies
markedly depending on the pattern of use. Advice about
reducing intake may be sufficient for hazardous drinkers
Treatment of alcohol withdrawal
All clinicians need to be able to recognize alcohol with-
and can be delivered by general practitioners (GPs) or any
drawal because of its high mortality and morbidity. The
health care professional. See the box below for guidance on
treatment of the alcohol withdrawal syndrome is commonly
how to deliver a brief alcohol intervention. Up to a third
termed ‘detoxification’. The following points are important:
of people with alcohol problems manage to abstain from
alcohol without any formal treatment or self-help pro- • For the majority of patients, an outpatient or
gramme. Dependent drinkers may require a more inten- community-based detoxification will be safe and
sive intervention, delivered by a specialist alcohol advisory effective.
service. Management of the latter group can be consid- • Contraindications to detoxification in the community
ered as having two overlapping objectives: the treatment include severe dependence, a history of withdrawal
of alcohol withdrawal and the longer-term maintenance of seizures or delirium tremens, an unsupportive home
abstinence. environment, significant physical or psychiatric
comorbidity, advanced age, pregnancy, or a previous
failed community detoxification. In these cases,
HINTS AND TIPS inpatient detoxification is advised.
• Unplanned, short notice detoxification should only
Components of a brief alcohol be undertaken if absolutely necessary (e.g. if a patient
intervention (FRAMES) has to be an inpatient for another reason). In general,
Research has shown that the features below detoxification works best when it is planned in advance
contribute to the effectiveness of a brief alcohol to allow the perpetuating factors for dependence to be
addressed alongside detoxification.
intervention. Remember the acronym FRAMES:
• In order to relieve severe symptoms and reduce the risk
F - Feedback – after taking a history or using for developing seizures or delirium tremens, a drug with
a screening tool, point out the patient’s similar neurochemical effects to alcohol is prescribed,
alcohol problem and/or how alcohol usually a benzodiazepine (such as chlordiazepoxide,
may have contributed to their presenting diazepam or lorazepam). Initially, high doses are given,
complaint. which are gradually reduced over 5–7 days.
R - Responsibility – the decision whether or • Medication may not be necessary if the patient has
not to change is the patient’s responsibility. been drinking less than 15 units/day (men) or 10
Emphasizing this is less likely to trigger units/day (women) and has no current or previous
withdrawal symptoms.
resistance.
• Alcohol withdrawal is a high-risk time for precipitating
A - Advice – clearly state that cutting down or
Wernicke encephalopathy (brain damage due to
stopping alcohol will reduce the patient’s risk for thiamine deficiency). Thiamine is therefore given
future health problems. prophylactically to those undergoing alcohol
M - Menu – provide a range of options the patient withdrawal. If a patient is well nourished and otherwise
can use for change (e.g. a substance diary, physically well, oral supplements are recommended.
alternative activities to drinking, identifying and However, parenteral thiamine (Pabrinex) is needed
if there is any suspicion of the onset of Wernicke, if
someone is acutely physically unwell for any reason, if
175
they are admitted to hospital, if they are malnourished

or if they have decompensated liver disease. Monitoring of temperature, fluid,
• Every time the brain withdraws from alcohol it electrolytes and glucose:
is at risk for delirium with persistent cognitive • Risk for hyperthermia, dehydration,
impairment. However, continuing alcohol also places hypoglycaemia, hypokalaemia, hypomagnesaemia
the individual at risk for brain damage. If a person
relapses after detox, it is usually recommended to General principles for managing delirium
wait for at least 6 months before initiating a further (see Chapter 19)
detox, to balance the risk for brain damage due to
withdrawal vs, ongoing use.
• Acamprosate is given in some centres because of
its potential neuroprotective effect during alcohol COMMUNICATION
withdrawal.
Some patients think that ‘detoxification’ refers to
The box below summarizes the management of delirium
the treatment of alcohol dependence. However,
tremens and Wernicke encephalopathy.
it only refers to the management of physical and
psychiatric symptoms of withdrawal. Treating
alcohol dependence involves addressing biological,
MANAGEMENT OF DELIRIUM TREMENS psychological and social factors that may have
precipitated and perpetuated its development.
Emergency hospitalization essential
Physical examination and investigations:
Thorough search for alternative cause of delirium
associated with alcohol use, for example RED FLAG
• Infection Delirium tremens is a medical emergency that is
• Head injury common on medical and surgical wards. Despite
• Liver failure appropriate care and treatment, it is associated
• Gastrointestinal haemorrhage with a mortality of 5%–15% (estimated to be
Assess for signs of: as high as 35% if untreated), emphasizing the
• Wernicke encephalopathy need for prompt recognition and appropriate
Medication: treatment. Make sure that you know the symptoms
(Chapter 8) and management well.
Control withdrawal symptoms and reduce risk for
seizures
• Large doses of a drug with similar
neurochemical actions to alcohol (e.g. Maintenance after detoxification
benzodiazepines. Intravenous therapy seldom Remaining abstinent from alcohol is not as simple as a suc-
needed). Also prevents and controls seizures. cessful detoxification. Often the period post-detoxification
• Follow local guidelines regarding dosage and highlights psychosocial issues to the patient that intoxica-
choice of benzodiazepine: in general, dosage is tion had previously allowed them to ignore. This may in-
symptom driven (e.g. using CIWA) or follows a clude the reasons they started to drink to excess in the first
place and the damage they have done to themselves and
reducing regime.
others subsequent to becoming dependent. For this reason,
• Only use antipsychotics (e.g. haloperidol) for psychosocial interventions are crucial in allowing the pa-
severe psychotic symptoms (risk for lowering tient to process emotional distress and to develop a new net-
seizure threshold). work of friends with similar experiences who are now sober.
Prophylaxis against or treatment of Wernicke Recovery can be a transformational process, with changes
Encephalopathy far wider reaching than simply achieving abstinence.
• Large dosages of parenteral (intramuscular or Psychosocial interventions
slow intravenous) thiamine – two Pabrinex Not all interventions are suited to all patients, but the huge
ampoules twice daily for 5 days. Oral thiamine is range available means there will be something that meets
not adequate in delirium tremens. the needs of everyone. Many interventions include assessing
where a patient’s motivation for change is using Prochaska
and DiClemente’s stages of change model (Fig. 20.3). The
176
Alcohol disorders 20
Transtheoretical model of Behavioural change
Precontemplation Contemplation
(not thinking about change) (thinking about change)
Relapse Preparation
(return to previous (decision to make
behaviour) change)
Maintenance
Action
(trying to prevent
relapse) (making change)
Fig. 20.3 Prochaska and DiClemente stages of change. (Adapted with permission from Prochaska JO, et al. In search of
how people change; applications to addictive behaviours. Am Psychol. 1992;47:1102–14)
various forms of psychosocial intervention that have been • Residential rehabilitation communities: these can
shown to be effective in managing alcohol problems include: provide intensive periods of structured holistic
• Motivational interviewing (see Chapter 3) support (e.g. 12 weeks or longer) in the difficult period
• Cognitive behavioural therapy (CBT): focusing on immediately following detoxification.
cue exposure, relapse prevention work, behavioural • Peer support
contracting, dealing with trauma symptoms
• Mutual aid organizations
Pharmacological therapy
• 12-step fellowship organizations (e.g. Alcoholics
Various pharmacological strategies have been shown to be
Anonymous): based around a 12-step programme
useful in the maintenance of abstinence from alcohol. They
of spiritual and personal development
should be offered as an adjunct to appropriate psychosocial
• SMART recovery uses CBT to facilitate group
measures:
self-help
• Social support: social workers, probation officers • Disulfiram (Antabuse): blocks the aldehyde
and citizens’ advice agencies may be able to help with dehydrogenase enzyme, causing an accumulation
homelessness, criminal charges and debt of acetaldehyde if alcohol is consumed. This causes
unpleasant symptoms of anxiety, flushing, palpitations,
headache and nausea very soon after alcohol
HINTS AND TIPS consumption. It is contraindicated in patients with
heart failure, stroke or coronary heart disease and
For every person who drinks to excess, multiple caution is advised in people with hypertension, severe
others are adversely affected. The families of liver disease, cognitive impairment, psychosis and
people who misuse alcohol or other substances personality disorder.
can also benefit from mutual aid through • Acamprosate (Campral): enhances GABA transmission
organizations such as Al-Anon. Support for families and inhibits glutamate transmission via NMDA
can also indirectly help the user. receptors and appears to reduce the likelihood of
relapse after detoxification by reducing craving. It is
safe to use while drinking.
177
• Naltrexone (Nalorex) and nalmefene (Selincro): block and motivation. People with any alcohol use disorder have an
opioid receptors, and appear to both reduce cravings increased risk for death compared to age-matched controls
for alcohol, and – when taken in conjunction with (threefold in men, fivefold in women). Alcohol dependence
normal drinking – reduce the pleasant effect of alcohol, is associated with a 12-fold increase in the risk for completed
therefore decreasing the desire to drink and the amount suicide, with deaths through accidents, cancer and cardio-
consumed. vascular disease also common.
• The use of antidepressants and benzodiazepines is
not recommended as pharmacological means for the
maintenance treatment of abstinence from alcohol.
OTHER PSYCHOACTIVE
Course and prognosis SUBSTANCES
Alcohol dependence has a variable course and is often associ-
ated with numerous relapses. However, the prognosis is not as
Epidemiology
poor as is often thought, with around 50%–60% of people with In 2014, 29% of adults in England and Wales had tried a recre-
alcohol dependence showing abstinence or significant func- ational substance (35% of men and 23% of women). In 2016,
tional improvement 1 year after treatment. Good prognostic 1 in 12 young or middle-aged adults (aged 16–59 years) in
indicators include being in a stable relationship, employ- England and Wales had used a recreational substance within
ment, having stable living conditions with good social sup- the last year. Cannabis, cocaine and ecstasy are the most
ports, lack of cognitive impairment and having good insight commonly used recreational drugs in the UK. Use is most
Table 20.2 Epidemiology of substance use

Prevalence within adults in
England in 2014, 2015 or 2016 Association with gender and age
Within the last year, in 18–59-year-olds:
Recreational drug use 8% Male to female 2:1
(this proportion is gradually (12% vs 5%)
reducing) Younger people more likely to have used
(18% aged 16–24 years)
Cannabis use 6.5% (this proportion is gradually Male to female 2:1
reducing) (9% vs 4%)
37% of users are frequent users
(more than once a month)
Cannabis dependence 2.3% of general adult population Male to female 2:1
show signs of dependence (3.7% vs 1.6%)
Cocaine use (powder)a 2.2% Male to female 3:1
(majority once or twice a year) (3.3% vs 1.2%)
Ecstasy (MDMA) use 1.5% Male to female 3:1
(majority once or twice a year) (2.2% vs 0.8%)
New psychoactive substance use 0.7% Male to female 3:1 (1.1% vs 0.4%)
Younger people more likely to have used
(2.6% aged 16–24 years)
Opioid dependence 0.3% Male to female 4:1
(0.4% vs 0.1%)
Commonest in 25–44-year-olds
Hospital admissions related to Approximately 0.7% of all hospital Male to female 3:1
recreational drugs (mental and admissions Over half of admissions in
behavioural problems, poisoning) (100,000) 25–44-year-olds
Deaths related to recreational 0.5% of all deaths (2500) (drug- Male to female 3:1
drugs related deaths are increasing) Over half of deaths occurred in
30–49-year-olds
80% died via unintentional overdoses
a
Crack cocaine is smoked. Powder cocaine is snorted or injected. Crack cocaine’s effects have faster onset and it is more likely to be
associated with addiction. In the UK crack cocaine is much less commonly used than powder cocaine.
178
Other psychoactive substances 20
c ommon among men and among young people. Fewer than Assessment, clinical features, drug
1 in 100 people have used a novel psychoactive substance
within the last year. Opioid use is rare by comparison with
classification and differential
other drug use but has the highest morbidity and mortality. diagnosis
See Fig. 20.1 and Table 20.2. Discussed in Chapter 8.
Aetiology Management
Management of recreational drug dependence involves
Occasional or experimental use of recreational substances
is not the same as drug dependence. However, ongoing use • Harm-reduction of continued use
of recreational substances over a period of time can lead to • Physical detoxification (if a withdrawal syndrome exists)
development of a dependence syndrome, particularly drugs • Maintenance of abstinence if patient wishes to stop using
with a strong potential for the development of dependence A detailed description of management strategies regarding
(namely opioids and benzodiazepines). Using opioids for the use of all recreational substances is beyond the scope of
as little as 7 consecutive days can result in dependence. this book. Patients should be directed to local substance use
Dependence on any drug is associated with stimulation of services (run by National Health Service or third sector staff)
the brain‘s ‘reward system’ (by increasing dopamine release who will be able to direct patients towards appropriate re-
in the mesolimbic pathway). Aetiological factors for recre- sources. There is a great deal of information on harm reduc-
ational drug dependence are not well understood, although tion techniques online (e.g. Know the Score, CREW). Patients
they appear to be related to a mixture of biopsychosocial who are dependent on opioids tend to be seen by National
factors. The operant conditioning model described in the Health Service resources because prescriptions are often in-
alcohol section also applies to other psychoactive sub- volved in management. However, for many drugs there is
stances. Similarly, price, availability and cultural attitudes no medication-based treatment (cannabis, cocaine, amphet-
appear to be key factors influencing the use of recreational amines, novel psychoactive substances). People who wish to
substances. In addition, social deprivation, childhood ad- receive help in reducing use of such substances are likely to be
versity, a family environment of substance abuse, conduct able to find suitable support via third sector organizations and
disorder in childhood, antisocial personality disorder and mutual aid (e.g. fellowship organizations such as Narcotics
severe mental illness all increase the likelihood of substance Anonymous or Cocaine Anonymous). Key points on the
misuse problems. treatment of opioids and benzodiazepines are described later.
Table 20.3 Opioid substitute prescribing: comparison of methadone and buprenorphine

Methadone Buprenorphine
Mechanism Long acting mu opioid receptor agonist Long acting mu opioid receptor partial agonist
Side-effects As all opioids: constipation, sedation, Less sedating, less euphoric than methadone
euphoria, nausea.
At doses above 100 mg/day,
electrocardiogram to check for QTc
prolongation recommended.
Overdose risk Prolonged action increases risk for Lower risk as partial agonist
overdose if other depressants used on top
Withdrawal symptoms A few days to weeks A few days
Precipitated Does not occur Can occur if taken by a person with opioid
withdrawal dependency and circulating opioids
Methods to prevent Supervised consumption Supervised consumption or combination with
diversion naloxone (opioid antagonist which is inactive
if taken orally but blocks receptors if injected
(Suboxone))
Ceiling effects None Cannot satisfy very strong cravings as partial
agonist (less suitable for people using large
amounts of heroin)
Starting daily dose 10–40 mg 4–8 mg
Maintenance daily Typically 60–120 mL Typically 12–16 mg
dose
179
Opioids tion therapy, removing the patient’s need to purchase illicit

Opioid use is associated with high rates of drug-related opioids to manage cravings and withdrawal. Table 20.3
death, and other health complications such as blood-borne compares the two forms of opioid substitution therapy rec-
viruses, infective endocarditis and abscesses. It is also asso- ommended by NICE: methadone and buprenorphine. If they
ciated with a high cost to society through unemployment, are felt equally suitable, methadone should be prescribed.
crime and child neglect. One of the primary aims when However, management of opioid dependence is more than
someone is opioid-dependent is to minimize the harms as- just a prescription (see Table 20.4 for the key areas to ad-
sociated with chaotic drug use. This can be achieved through dress). Establishing a therapeutic reliance with the patient
a period of stabilization with long-acting opioid substitu- where they feel in control of their management is important.
Table 20.4 Biopsychosocial management of different stages of opioid dependence

Domain Key actions
Harm reduction Psychoeducation
Offer substitute prescribing
Consider child protection and give advice on minimizing harm to children from drug use
Offer
• take-home naloxone kit
• needle exchange
• contraception advice/condoms
• blood-borne virus screening (Hepatitis B and C, HIV)
Psychosocial Encourage attendance at mutual aid groups (fellowships or SMART Recovery)
intervention Signpost to extra support if needed with housing, benefits, food, debts
Signpost to training and vocational opportunities
Consider:
• Motivational interviewing
• Trauma-specific psychoeducation or CBT
• Behavioural couples therapy
• Family interventions
• Contingency management
• Residential rehabilitation
Substitute Before initiation, confirm dependent use via toxicology screens and attendance in withdrawal
prescribing (see Table 8.1)
Consider methadone or buprenorphine (see Table 20.3)
Initiate under supervised consumption
Regular review for dose titration to be sufficient to remove cravings but not to cause
intoxication
Long-term aim can be stability on maintenance prescription or abstinence
Detoxification Minimize withdrawal symptoms by providing gradual reduction in opioid substitution therapy
(e.g. 5 mg methadone/fortnight).
Opioid withdrawal is uncomfortable and distressing, although it is not life-threatening. If
required, offer symptomatic relief:
• A range of symptoms: lofexidine (alpha2-adrenoreceptor agonist)
• Diarrhoea: loperamide
• Nausea: metoclopramide or prochlorperazine
• Stomach cramps: mebeverine or hyoscine butylbromide
• Pain: paracetamol or ibuprofen
• Anxiety/agitation/insomnia: propranolol or diazepam (short-term only))
Abstinence Encourage ongoing attendance at mutual aid meetings.
Encourage participation in recovery community activities (e.g. cafes, sports groups).
Naltrexone (an opioid antagonist) can be used to block the euphoriant effects of future opioid
use. It induces withdrawal if the patient has circulating opioids.
Develop a crisis plan.
Ensure patient is aware how to regain rapid access to services should relapse occur.
CBT, Cognitive-behavioural therapy.
180
Other psychoactive substances 20
Caution must be exercised when attempting withdrawal

RED FLAG from benzodiazepines as it can very rarely be fatal. The
Drug-related deaths via unintentional overdose benzodiazepine withdrawal syndrome may include halluci-
are increasing in the UK, with opioids, alcohol, nations, convulsions and delirium. Symptoms can emerge
benzodiazepines, antidepressants, antipsychotics
within hours to days, depending on the half-life of the ben-
zodiazepine. Management of benzodiazepine withdrawal
and gabapentinoids frequently implicated. Always
involves initially converting drugs with a shorter half-life
provide a take-home naloxone kit to someone who
(e.g. lorazepam) to drugs with a longer half-life (usually di-
uses opioids and offer training on how to use it to azepam). Doses are then reduced very slowly by around an
the patient and those who are in close contact with eighth every fortnight, depending on patient response. If
them. withdrawal symptoms emerge, the rate of reduction can be
slowed, but increasing the dose should be avoided if at all
possible.
RED FLAG
HINTS AND TIPS
When a patient is admitted to hospital, always
Sudden discontinuation of a patient’s long-
confirm methadone and benzodiazepine doses
term sleeping tablet when they are admitted to
with the dispensing pharmacy as soon as possible.
hospital can lead to a withdrawal syndrome: only
Patients can provide inaccurate information.
consider this if the patient’s condition means
Prescribing a dose of methadone higher than
benzodiazepines must be avoided and ideally
the patient has actually been taking can result in
reduce the dose gradually.
death.
Benzodiazepines
Benzodiazepine-dependence often arises iatrogenically Mortality in heroin users is 12-fold that of the general pop-
when patients are prescribed benzodiazepines every day ulation. A longitudinal study in the USA found that after
for longer than 2–4 weeks. It can also arise when patients two decades 28% of male heroin users had died, 18% were
purchase benzodiazepines illicitly. If someone is depen- in prison, 23% were still using and 29% were abstinent. The
dent on illicit benzodiazepines, they can be offered a de- median duration of opioid use is 10 years. As with alcohol,
toxification prescription if they are truly committed to relapse rates following detoxification are high and are most
abstinence, but they should not be offered a maintenance likely to succeed with psychosocial support in place. A
prescription (unlike with opioids, there is no evidence that quarter to a third of people entering treatment achieve and
this reduces harm). maintain long-term abstinence.
Chapter Summary
• Alcohol is the most harmful psychoactive substance in common use.

• Alcohol and substance problems are more common in men.
• Alcohol withdrawal is a potentially fatal condition that requires treatment with
benzodiazepines and thiamine.
• Management of all alcohol and substance use disorders requires psychosocial
interventions.
• Mutual aid is a key component of maintaining abstinence for many people dependent on
substances.
• Harm from opioids is reduced by opioid substitute therapy.
181
The psychotic disorders:
schizophrenia 21
The main types of psychotic disorder are schizophrenia, 100
schizoaffective disorder, delusional disorder and acute 90
and transient psychoses. This chapter will concentrate on 80
schizophrenia, the most prevalent and widely researched 70
disorder in this group. 60
% risk
50% 50%
50
40
30
SCHIZOPHRENIA
20
13%
10%
10
History 0
1%
in
a
s
tic nd
Ideas about the disorder we now term ‘schizophrenia’
nt
in
ni
nt
tw
re
tw
go s a
re
re
hi es
pa
ph
ic
zy g
pa
sc tiv
crystallized towards the end of the 19th century. The
di lin
ot
zo
ne
ith la
th
yg
b
O
w o re
Si
Bo
oz
concept of this disorder has evolved during the 20th cen-
on
N
M
tury. Important landmarks in the definition of this dis- Lifetime risk
order are: Fig. 21.1 Lifetime risk for developing schizophrenia if
• 1893: Emil Kraepelin separated affective psychoses (e.g. relatives have schizophrenia.
mania) from nonaffective psychoses; he gave the term
‘dementia praecox’ to clinical conditions resembling the
main forms of schizophrenia. • Men have a higher incidence than women (ratio of
• 1911: Eugen Bleuler coined the term ‘schizophrenia’ 1.4:1) but equal prevalence (possibly due to a higher
(splitting of the mind); his description placed more rate of mortality among male sufferers).
emphasis on thought disorder and negative symptoms • There is an increased prevalence in lower
than on positive symptoms. socioeconomic classes (classes IV and V). This is
• 1959: Kurt Schneider defined first-rank symptoms, more likely to be due to social drift (impairment of
which are now the basis of criteria (a)–(d) of the functioning caused by schizophrenia results in a ‘drift’
International Statistical Classification of Diseases and down the social scale) rather than social causation
Related Health Problems 10 (ICD-10) classification (poor socioeconomic conditions contribute to the
(see Boxes 9.2 and 9.3). development of schizophrenia).
• 1970 to the present: The main international • There is an increased incidence in urban (inner city)
classification systems, ICD-10 and the Diagnostic compared with rural areas.
and Statistical Manual for Mental Disorders 5 (DSM- • The incidence and prevalence are higher in migrants,
5), have further clarified the diagnostic criteria. The with a relative risk of 4.6.
main distinction between ICD-10 and DSM-5 is that
the latter specifies a 6-month duration of symptoms Aetiology
and places a large emphasis on social or occupational
dysfunction. The aetiology of schizophrenia involves a complex interac-
tion of biological and environmental factors.
Epidemiology Genetic
• The incidence is approximately 15/100,000 individuals There is a strong tendency for schizophrenia to run in fam-
per year. ilies. Fig. 21.1 shows the lifetime risk for developing schizo-
• The prevalence varies geographically but is phrenia if relatives have schizophrenia. Twin studies show
approximately 1% in most settings. a higher concordance rate for monozygotic twins (50%)
• The lifetime risk is approximately 1% (see also than for dizygotic twins (10%), although this also shows
Fig. 21.1). that environmental factors are important, as monozygotic
• The age of onset is typically between late teens and concordance is not 100%. Adoption studies provide further
mid-30s. Women have a later age of onset. Men: evidence for a genetic factor: babies adopted away from
18–25 years; women: 25–35 years. parents with schizophrenia to parents without retain their
183
The psychotic disorders: schizophrenia
increased risk, whereas the risk is not increased when ba- Neurotransmitter abnormalities
bies are adopted to parents with schizophrenia from biolog- Abnormalities in a range of neurotransmitter systems have
ical parents without. Over 100 genetic variations associated been found in schizophrenia, predominantly glutamate and
with a small increase in risk have been identified, mainly in dopamine. It is not yet known how such abnormalities in-
genes implicated in neurodevelopment, immune function, teract to lead to disorder, and if some abnormalities are a
glutamatergic and dopaminergic neurotransmission and consequence rather than a cause of the disorder. The gluta-
calcium signalling. Rare high penetrance genetic variations mate hypothesis of schizophrenia suggests that N-methyl-
also exist, for example, deletion of a region of chromosome d-aspartic acid (NMDA) receptor hypofunction contributes
22 is associated with a 30% risk for schizophrenia. The over- to the pathogenesis of schizophrenia. The main evidence for
all risk is likely to result from a complex interaction of a this hypothesis is that genetic variants in NMDA receptor
large number of genes, and their interaction with environ- and related genes are associated with schizophrenia, and
mental factors. that giving NMDA receptor blockers to healthy control sub-
jects causes psychotic symptoms.
The dopamine hypothesis suggests that schizophrenia
COMMUNICATION is secondary to overactivity of the mesolimbic dopamine
pathway in the brain. The key evidence for this pathway is
Schizophrenia is not purely genetic in aetiology – that the dopamine D2 receptor has been genetically linked
environment is also important. You may want to to schizophrenia, antipsychotics block dopamine D2 re-
bear this in mind when discussing the diagnosis ceptors, and drugs that potentiate this pathway (e.g. am-
with patients and their families: parents may find phetamines, antiparkinsonian drugs) are known to cause
a genetic description accusational, while for the psychotic symptoms.
patient it will have ramifications about having
children themselves.
Adverse life events
Exposure to childhood trauma (e.g. sexual abuse, death of
a parent, neglect) increases the risk for schizophrenia in
adulthood around threefold. Stressful life events in adult-
Developmental factors hood occur more frequently in the months before a first
Schizophrenia is associated with complications during psychotic episode or relapse and may, therefore, precipitate
pregnancy and birth. In addition, the observation that the illness. However, it may be that the early stages of the
more people with schizophrenia are born in late win- illness itself cause the stressful events.
ter or spring has led to the theory that schizophrenia is
linked to second-trimester influenza infection. Prenatal
malnutrition may also increase risk: maternal starvation COMMUNICATION
early in gestation doubles the risk for schizophrenia in
offspring. Between the 1940s and 1970s, the concept of
the ‘schizophrenogenic mother’ was common
Brain abnormalities and suggested that schizophrenia was caused by
Structural and functional brain abnormalities are associ- early life difficulties in the relationship between
ated with schizophrenia, even in those with first-episode the patient and their family. Although it is true that
psychosis who have never received treatment. Structural childhood adversity including emotional abuse
imaging is not yet diagnostic, but frequently identified ab- and neglect is associated with schizophrenia in
normalities include: adulthood, it is no longer thought that relationship
• Ventricular enlargement (appears to be associated with difficulties alone can cause schizophrenia, and
negative symptoms) families can be reassured on this point.
• Reduced brain size (frontal and temporal lobes,
hippocampus, amygdala, parahippocampal gyrus)
• Reduced connectivity between brain regions
(particularly frontal and temporal lobes) Cannabis
Furthermore, people with schizophrenia demonstrate a Chronic cannabis use is associated with an increased risk
wide range of cognitive abnormalities, particularly on tasks for schizophrenia (use on more than 10 occasions associ-
testing social cognition and memory. They also experi- ated with a twofold increase in risk). Although there may
ence abnormalities of sensory integration leading to ‘soft’ be a degree of ‘self-medication’ in that people who are be-
neurological signs (e.g. abnormalities of stereognosis or coming unwell try recreational substances in an attempt
proprioception). to normalize their mental state, there is also evidence that
184
Schizophrenia 21
cannabis use contributes to the causation of schizophre- have little or no benefit on negative symptoms (e.g. apathy
nia: psychotic symptoms can occur during acute intoxi- and social withdrawal).
cation, an association even when use is several years prior
to first presentation, and a dose–response effect. Although First- or second-line antipsychotic
cannabis use increases the risk for psychotic disorders, Differences in efficacy between antipsychotics are small,
the fact remains that the majority of people who use it do with the exception of clozapine, which is the most ef-
not become mentally unwell. This suggests that it may be fective antipsychotic known, but is not used first line
particularly detrimental to those who are already predis- because of its side-effects. Therefore the main fac-
posed to schizophrenia in some way, for example, through tor influencing choice of antipsychotic is tolerability.
genetic risk. Antipsychotics commonly cause side-effects, and as
they are generally long-term medications, it is import-
ant to find one whose side-effects the patient feels they
can tolerate for the foreseeable future. National Institute
HINTS AND TIPS for Health and Care Excellence (NICE; 2009) does not
recommend a particular antipsychotic as first line, but
NICE (2014) recommends screening for rather suggests that patients should be involved as much
posttraumatic stress disorder in anyone with a as possible in the decision. See Table 21.1 for a compar-
first presentation of psychosis, because of the ison of some common antipsychotic side-effects and see
link between adverse life events and psychotic Chapter 2 for more information on antipsychotic side-
symptoms. effects and classification.
Treatment-resistant schizophrenia
Around two-thirds of people respond to the first anti-
psychotic trialled. Treatment-resistant schizophrenia is
defined as a lack of satisfactory clinical improvement de-
investigations and differential spite the sequential use of at least two antipsychotics for
diagnosis 6–8 weeks, one of which should be a second-generation
antipsychotic. If a patient appears treatment resistant, re-
Discussed in Chapter 9.
assess the diagnosis, check concordance, check whether
psychological therapies have been offered, and assess for
Management comorbid substance use. If treatment resistance is con-
firmed, offer clozapine at the earliest opportunity, as-
As with many chronic medical conditions, schizophrenia
suming there are no contraindications and the patient is
cannot be cured. However, appropriate management can
in agreement with taking oral medication and attending
greatly reduce symptoms and relapse. Long-term medica-
for regular blood tests. Clozapine is not used as a first-
tion is the mainstay of treatment, although psychosocial
line medication due to its significant side-effects includ-
treatment is also very important.
ing life-threatening agranulocytosis in just less than 1%
of patients. Thus regular haematological monitoring is
Treatment setting obligatory (initially weekly, then monthly) and patients
The initial treatment setting depends on the presentation are required to be registered with a monitoring service.
and severity of illness. Home treatment is preferable, but Clozapine will benefit over 60% of treatment-resistant
hospitalization is often necessary in cases of first-episode patients.
psychosis and when there is a significant risk that psychotic Concordance with medication is poor in schizophrenia,
symptoms may lead to harm to self or others, or self-neglect. with around 75% of patients stopping antipsychotics within
Detention under mental health legislation may be necessary 2 years. This frequently leads to relapse. Concordance can
in patients with reduced insight and impaired judgement. be increased using depot intramuscular medication (ad-
Long-term community management is provided by ministered 1–12 weekly), increased social support and pa-
community mental health teams or assertive outreach teams tient education.
with the help of a care coordinator and regular follow-up in The length of treatment requires careful consider-
a psychiatric outpatient clinic. Patients with schizophrenia ation as single episodes cannot be predicted and most
who have symptoms that are stable and well controlled can patients with schizophrenia relapse. After a first episode,
be managed in primary care. prophylactic treatment is recommended for 1–2 years
but relapse rates are high upon discontinuation (80%–
Pharmacological treatment 98%). Relapse is less likely if withdrawal of treatment is
Antipsychotics are of benefit in reducing positive symp- gradual, over a few weeks. For most patients, antipsy-
toms (e.g. delusions and hallucinations). However, they chotics are a long-term, lifelong, treatment.
185
Table. 21.1 Side-effects of commonly used antipsychotics

Weight gain/
Extrapyramidal metabolic Drug-specific
Antipsychotic Sedation side-effects syndrome Hyperprolactinaemia important side-effects
First generation
Chlorpromazine Very Common Common Common Photosensitivity
common
Haloperidola Common Very common Common Common QTc prolongation
on average >20 ms
(baseline ECG
recommended)
Flupentixol Common Common Common Common
(Depixol)a
Zuclopenthixol Common Common Common Common
(Clopixol)a
Second generation
Olanzapinea Very Common Very Rare
common common
Quetiapine Very Common Very Rare
common common
Risperidonea Common Very common Common Very common
Aripiprazolea Common Common Rare Rare
Clozapine Very Common Very Rare Agranulocytosis
common (tardive common Hypersalivation
dyskinesia very
rare)
a
Can be given in long-acting intramuscular injection (depot) form.
ECG, Electrocardiogram.
HINTS AND TIPS HINTS AND TIPS
Acute dystonias are a particularly distressing Early institution of medication may improve
side-effect of antipsychotics. They can be caused prognosis. Early detection is therefore critical.
by any dopamine antagonist (e.g. the antiemetic If uncertain, take a collateral history – a family
metoclopramide), so they may be encountered in member may well have noticed changes
other specialities too. They should be promptly earlier and this may prove invaluable. You will
treated with an anticholinergic such as procyclidine, particularly want to bear this in mind with young
parenterally if required (see Table 2.7*). male patients who often have an earlier onset,
a worse outcome and prominent negative
symptoms that may have been mistaken for
depressive symptoms.
Other pharmacological treatments
Benzodiazepines can be of enormous benefit in short-term re-
lief of behavioural disturbance, insomnia, aggression and ag-
itation, but they do not have any specific antipsychotic effect.
Antidepressants and lithium are sometimes used to aug- Physical health monitoring
ment antipsychotics in treatment-resistant cases, especially Patients with schizophrenia are at increased risk for car-
when there are significant affective symptoms, as is the diovascular disease. This risk is increased further by using
case in schizoaffective disorders, or in postschizophrenia antipsychotics. Therefore NICE (2014) recommends that a
depression. health screen should be carried out prior to commencing
Electroconvulsive therapy is now rarely used in schizo- treatment, then at least annually, focusing on cardiovascu-
phrenia. The usual indication is the rare case with severe lar risk factors and including enquiry as to diet and activ-
catatonic symptoms. ity levels. An electrocardiogram (ECG) is needed prior to
186
Schizophrenia 21
c ommencing an antipsychotic if the patient is in hospital, Acute behavioural disturbance

has a history of cardiovascular disease, a family history of
sudden cardiac death or has evidence of cardiovascular Severe psychomotor agitation or aggressive behaviours
disease on examination (e.g. hypertension). Pretreatment frequently occur in acutely ill psychotic patients. It is vi-
ECGs are also recommended for some antipsychotics at tal that the correct diagnosis is established, especially in
high risk for prolonging the QTc interval (e.g. haloperidol). patients who are not well known. Many other conditions,
During treatment initiation, NICE (2014) recommends for example, mania, delirium, dementia and alcohol and
weekly weights for the first 6 weeks, then again at 12 weeks substance intoxication or withdrawal, can present with
alongside assessment of serum lipids, glucose, pulse and acute aggression and agitation, all of which require spe-
blood pressure. cial consideration. The algorithm in Fig. 21.2 describes the
principles of acute management. Many regions also have
local protocols.
Psychological treatments
Historically, psychotic disorders were thought to be un-
responsive to psychological interventions, but increasing HINTS AND TIPS
evidence points towards their value in augmenting drug
treatments: Lorazepam is the only benzodiazepine that has a
• Schizophrenia can be a devastating condition and is reliable rate of absorption from muscle tissue and
associated with significant social morbidity. Therefore therefore should always be used, if at all possible,
the importance of support, advice, reassurance and when benzodiazepines are given intramuscularly.
education to both patients and carers cannot be Other advantages include its relatively short half-
overemphasized. life (10–20 hours) and its lack of active metabolites
• Cognitive-behavioural therapy has been shown to be during elimination (no accumulation).
effective in reducing some symptoms in schizophrenia.
It is also useful for helping patients with poor insight
come to terms with their illness, thereby increasing
concordance with medication. It can also help the
patient become aware of early warning signs of relapse. Course and prognosis
It is recommended by NICE (2014) for all patients with The course of schizophrenia is highly variable and difficult
schizophrenia. to predict for individual patients. In general, the disorder is
• Family psychological interventions focus on alliance chronic, showing a relapsing and remitting pattern. About
building, reduction of expressions of hostility and 15% have a single lifetime episode with no further relapses.
criticism (expressed emotion), setting of appropriate However, the majority of patients have a poor outcome
expectations and limits and effecting change in characterized by repeated psychotic episodes with hospital-
relatives’ behaviour and belief systems. Family izations, depression and suicide attempts.
intervention has been shown to reduce relapse and About 10% of patients with schizophrenia will die by sui-
admission rates. It is recommended by NICE (2014) for cide. Those most at risk are young men who have attained
all patients with schizophrenia who live with or are in a high level of education and who have some insight into
close contact with their family. their illness. The periods soon after the onset of illness and
in the months following discharge from hospital are partic-
Social inputs ularly high risk, although all patients with schizophrenia are
Issues beyond pharmacological and psychological treatment at lifelong increased risk for suicide.
should be addressed to optimize community functioning; The lifespan for patients with schizophrenia is on av-
these include financial benefits, occupation, accommoda- erage 15 years shorter than for the general population.
tion, daytime activities, social supports and support for car- Causal factors include suicide, smoking, socioeconomic
ers. A variety of agencies can provide these services, notably deprivation, cardiovascular disease, respiratory disease and
health services, social services, local authorities, local support accidents.
groups and national support groups (e.g. SANE, MIND). The overall prognosis for schizophrenia appears to
All patients with schizophrenia should be assessed for be better in low-income as opposed to middle- and high-
the care programme approach to achieve optimum coordi- income countries; the reasons are unclear but may reflect
nation in the delivery of services. Community psychiatric better extended-family social support or greater social ac-
nurses, consultant psychiatrists, occupational therapists, ceptance once recovered. The factors associated with a good
psychologists or social workers are appointed as care coor- prognosis are:
dinators. Their primary role is to coordinate the multifac- • Female sex
eted aspects of patients’ care and to monitor mental state • Married
and concordance with medication. • Older age of onset
187
All interventions should occur simultaneously and early
Environmental Behavioural Medical interventions (rapid tranquilization)

interventions interventions consider another cause of the agitation (e.g. alcohol withdrawal)
• Create a calm • Talk slowly
environment and softly
–Turn off • Never turn
TV/radio your back to
–Remove other the patient
patients to • Place yourself Accepting oral Refusing oral medication.
another room between the medication Significant risk to self or others
• Remove objects exit and the
that can be used patient
as weapons (e.g. • Be aware – eye
chairs, ashtrays contact may
etc.) help establish
• Get help from a rapport, or
trained staff may seem
threatening oral lorazepam 1-2 mg i.m. lorazepam 1-2 mg
• Innocuous (0.5 mg in older adults) (0.5 mg in older adults)
questions about
sleeping and
eating may
prove a useful If psychotic context or ineffective If psychotic context or ineffective
distraction consider in addition oral consider in addition i.m.
• Convey a antipsychotic but aim to avoid antipsychotic
genuine sense combining antipsychotics •Haloperidol 5 mg and/or
of concern promethazine 50 mg
• Allow patient
to verbalize
feelings but
cut short if
anger is
escalating
• Restraint may Repeat as required every 45-60 minutes
be necessary Consider i.v. tranquilization in exceptional circumstances only
with removal Review legal status: if intramuscular medication given under common law
to a safer patient requires assessment for detention
secluded area Review by senior doctor at least daily
Precautions for rapid tranquilization

•If parenteral benzodiazepines are given, flumazenil must be available
•If haloperidol is given, procyclidine must be available (dystonias)
•After parenteral rapid tranquilization, frequently observe temperature,
respiratory rate, hydration and level of consciousness until patient ambulatory
Fig. 21.2 Acute management of the agitated or aggressive patient (NICE, 2015).
• Abrupt onset of illness (as opposed to insidious onset) • Absence of negative symptoms
• Onset precipitated by life stress • Illness characterized by prominent mood symptoms or
• Short duration of illness prior to treatment family history of mood disorders
• Good response to medication • Good premorbid functioning
• Paranoid subtype, as opposed to hebephrenic
subtype (see Chapter 9)
188
Schizophrenia 21
Chapter Summary
• Schizophrenia occurs in around 1% of people worldwide.

• It arises from a combination of genetic and environmental factors
influencing neurodevelopment and neurotransmission.
• Schizophrenia is treated with a combination of pharmacological (antipsychotics) and
psychological therapy.
• Clozapine is an antipsychotic used for treatment-resistant schizophrenia.
• Acute behavioural disturbance should initially be managed with de-escalation techniques
(behavioural and environmental) with medication (oral or parenteral) if required.
• Schizophrenia is associated with significantly reduced life expectancy: screening for and
treating physical health problems are important.
• The majority of people with schizophrenia experience a relapsing and remitting course.
189
The mood (affective) disorders
22
This chapter discusses the disorders associated with the Genes Early life experience
presenting complaints in Chapters 6, 10 and 11, which you
might find helpful to read first:
• Suicide and self-harm (Chapter 6) Stress
• Depressive disorders (Chapter 10)
• Bipolar affective disorder (Chapter 11)
• Cyclothymia and dysthymia (Chapters 10 and 11)
Mood disorder
Fig. 22.1 Simplified model of aetiology of mood disorder.
DEPRESSIVE DISORDERS
variants that increase the risk for depression also increase
Epidemiology the risk for other major mental disorders. The particular
genes involved are only beginning to be identified, but so far
Table 22.1 summarizes the epidemiology of the mood
include genes involved in calcium signalling, mitochondrial
disorders.
enzymes and regulation of growth of new neurons. To com-
plicate matters further, some genetic influence may only
Aetiology manifest in particular circumstances (gene–environment
Depression is a multifactorial disorder, with interacting risk interactions).
factors from many aspects of a patient’s make-up. Genetics,
early upbringing and personality can increase vulnerability Early life experience
to depression, with episodes arising depending on the level Parental separation (e.g. divorce) during childhood in-
of acute and chronic stress experienced (see Fig. 22.1). creases the risk for depression in adult life. This may partly
relate to the loss of a parent, and partly to the disruption of
Genetics care to the child. Other types of childhood adversity (e.g.
Twin studies show the heritability of depression as 40%– neglect, physical and sexual abuse) increase the risk for de-
50%. The genetic risk is likely to be contributed to by mul- pression and other psychiatric disorders. Postnatal depres-
tiple genes of individual small effect. Interestingly, recent sion in mothers can be associated with an indifferent early
genome-wide association studies have found that genetic upbringing, leading to poor self-esteem and increased risk
for depression in the child.
Table 22.1 Epidemiology of the mood disorders Personality

Average
Genetics and early upbringing combine to shape person-
Lifetime age of Sex ratio ality, so it is unsurprising that some personality features
risk onset (female:male) are associated with increased risk for mood disorder. The
personality trait ‘neuroticism’ (anxious, moody, shy, easily
Recurrent 10%–25% Late 20s 2:1
depressive (women) stressed) has consistently been found to increase the risk
disorder 5%–12% for unipolar depression. Certain personality disorders (e.g.
(men) borderline personality disorder, obsessive-compulsive per-
Bipolar 1% 20 years Equal sonality disorder) also increase the risk for depression.
affective incidence
disorder Acute stress
Cyclothymia 0.5%–1% Adolescence, Equal Adverse life events are common around the start of a depres-
early incidence sive episode, particularly loss or humiliation events such as
adulthood bereavement, relationship breakup or redundancy. The life
Dysthymia 3%–6% Childhood, 2–3:1 event may not necessarily be causal, as being depressed—or
adolescence, at risk for depression—may also increase the risk for expe-
early riencing adverse life events. In recurrent depression, later
adulthood
episodes are less likely to be triggered by life events.
191
Chronic stress Management

The psychological and physiological effects of chronic stress
may make someone vulnerable to depression and also re- A biopsychosocial approach is considered for the manage-
duce their ability to cope with more acute stressful life ment of depression, which means that consideration should
events. Chronic stressors such as poor social support (e.g. be given to treating biological, psychological and social as-
lack of someone to confide in), not having employment pects of the illness. See Fig. 22.2.
outside the home and raising young children are associ-
ated with depression. Chronic pain and any other chronic Treatment setting
illness, particularly heart disease and stroke, are also associ- Most patients with depression can be treated successfully
ated with depression. in primary care, or in a psychiatric outpatient clinic. Day-
hospital attendance may be helpful in patients with chronic
Neurobiology or recurrent illness, especially if poor motivation or low
The final common pathway of the multiple aetiologi- self-esteem has led to a reluctance to go outside the home
cal routes to mood disorder is abnormal brain structure and make contact with others. Intensive support at home
and function. It is likely that mood disorders are due to from crisis teams or inpatient admission may be advisable
malfunctioning communication between multiple brain for assessment of patients with:
regions involved in emotion regulation, rather than just • Highly distressing hallucinations, delusions or other
one key abnormal area. Recurrent early onset depression psychotic phenomena
is associated with reduced volume of the hippocampus, • Active suicidal ideation or planning, especially if
amygdala and some regions of frontal cortex. Depression suicide has previously been attempted or many risk
with onset in later life is associated with white matter factors for suicide are present (see Chapter 6)
hyperintensities on neuroimaging, thought to represent • Lack of motivation leading to extreme self-neglect (e.g.
small silent infarctions. dehydration or starvation)
Neurochemically, multiple interacting neurotransmitter Detention under mental health legislation may be necessary
pathways are likely to be important. The two main abnormalities for patients who need admission but are unwilling to accept
identified in depression are overactivity of the h
ypothalamic– inpatient treatment and lack capacity to make decisions re-
pituitary–adrenal axis and deficiency of monoamines garding their treatment (see Chapter 4).
(noradrenaline (norepinephrine), serotonin, dopamine).
Lifestyle advice
Assessment, clinical features, All patients with low mood should be advised to avoid alco-
investigations and differential hol and substance use, eat a healthy diet, exercise regularly
and practice good sleep hygiene (e.g. avoid caffeine and
diagnosis smoking in the evenings, do not sleep during the day, set
Discussed in Chapters 6, 10 and 11. regular sleep and wake times, do not use the bedroom for
All patients with low mood: advice on sleep hygiene and regular physical activity
Mild depression Psychosocial intervention

or (low intensity)
Persistent sub-threshold symptoms •Self-help CBT
•Structured group physical activity
Minimal functional impairment
Psychosocial intervention
(high intensity)
•Individual CBT
Moderate depression •Individual IPT
or
Severe depression
AND
Mild to marked functional impairment
Antidepressant medication
Fig. 22.2 Summary of first-line treatment for depression (NICE Guidelines 2009).
192
Depressive disorders 22
studying/watching TV). Patients can be referred to exercise Table 22.2 Factors influencing choice of antidepressant
groups; discounts may be available for those suffering from
Factor Considerations
depression.
Side-effects SSRIs, in general, are the best
tolerated antidepressants.
Psychological treatment Side-effects should be matched
The National Institute for Health and Care Excellence to a patient’s symptoms, lifestyle
(NICE; 2009) recommends that psychological treatments and preferences (e.g. the weight
are used first line for mild depression, and in combination gain caused by mirtazapine may be
with drug treatments for moderate–severe depression. The preferable to the sexual dysfunction
severity of depression is determined in part by the number caused by the SSRIs); some
patients benefit from the sedation
of symptoms (see Chapter 11) but mainly by the degree of
caused by some antidepressants
functional impairment (i.e. whether the patient is still able (e.g. amitriptyline, trazodone,
to fulfil their normal social and occupational roles). Chapter mirtazapine (see Chapter 2)).
3 covers psychological treatments in detail. Modalities often
Previous good Prescribe previous drug.
used in depression are: response
• Cognitive behavioural therapy (CBT) Risk for overdose SSRIs are safer in overdose than
• Interpersonal therapy venlafaxine, which is safer than
• Psychodynamic therapy TCAs.
• Family and marital interventions Severity of For severe depression requiring
• Mindfulness-based cognitive therapy depression hospitalization, antidepressants
that affect both noradrenaline
(norepinephrine) and serotonin may
be preferable, that is, TCAs and
COMMUNICATION high-dose venlafaxine (SSRIs may
be slightly less effective in treating
Patients reluctant to take medication may prefer depression of severity sufficient to
the idea of ‘talking therapies’. It is worth noting that cause hospitalization).
cognitive-behavioural therapy can be as effective Atypical Atypical depression (i.e.
as antidepressants in treating moderate depressive depression hypersomnia, overeating and
episodes and that when used after medication it anxiety) may respond preferably to
can reduce the rate of relapse up to 4 years later. MAOIs.
You may want to discuss both options with the Comorbid physical SSRIs can cause or worsen
health problems hyponatraemia.
patient, encouraging the use of both but allowing
SSRIs should not normally be
the patient to make the final decision – this often prescribed to people taking an
aids concordance. nonsteroidal antiinflammatory
drug, warfarin or heparin (as
SSRIs increase risk for bleeding).
SSRIs should be avoided in
those taking ‘triptan’ drugs for
migraine.
Pharmacological treatment TCAs are contraindicated in
NICE (2009) recommends antidepressants only for pa- patients with a recent myocardial
tients with moderate–severe depression or for patients with infarction, or arrhythmias.
persistent sub-threshold depressive symptoms or mild to See NICE (2009) Depression in
moderate depression who have not benefited from a low- Adults with a Chronic Physical
Health Problem for further
intensity psychosocial intervention. SSRIs (e.g. sertraline,
details.
paroxetine, citalopram, fluoxetine) are recommended by
NICE (2009) as first-line antidepressants because they have Comorbid mental Patients with obsessions or
health problems compulsions may respond
the fewest side-effects. All antidepressants are similarly
preferably to high-dose SSRIs or
effective if prescribed at the correct dose and taken for an clomipramine.
adequate length of time. Clinicians therefore tend to choose A depressive episode with
an antidepressant based not on efficacy, but on its side-effect psychotic features usually requires
profile (taking into account patient preference and comor- the adjunctive use of antipsychotic
bidity), and on which symptoms of depression are most trou- medication.
blesome. Table 22.2 summarizes some of the factors guiding MAOI, Monoamine oxidase inhibitor; NICE, National Institute for
the choice of an antidepressant. See Chapter 2 for more Health and Care Excellence; SSRI, selective serotonin reuptake
inhibitor; TCA, tricyclic antidepressant.
information on antidepressant mechanisms and side-effects.
193
Antidepressants are most effective in moderate–severe

depression, where around 50% of patients will respond (com- COMMON PITFALLS
pared with 30% on placebo), when prescribed at an adequate • Patients may tell you that they have already
dose for a sufficiently long period (usually 4–6 weeks, lon-
taken antidepressants and that they do not
ger in older adults), with appropriate patient education and
work. People often respond to antidepressants
encouragement. When an antidepressant has brought remis-
sion of symptoms, it should be continued at full dose (i.e. at from some classes but not others, so it can still
the dose that induced the remission) for at least 6 months to be worth trialling a different antidepressant –
reduce the relapse rate. Patients with a history of recurrent you may want to explain this before prescribing.
depressive disorder may benefit from taking antidepressants • Remember that patients are often prescribed
for a longer period, perhaps even lifelong in severe cases. The inadequate doses for inadequate lengths of
prophylactic effect of antidepressants in reducing relapse has time before the medication is changed – this
been demonstrated for at least 5 years (with imipramine). does not represent treatment failure, for which a
Treatment often fails due to inadequate dose of drug, dura- treatment dose needs to have been prescribed
tion of treatment or poor concordance; therefore these factors for 6–8 weeks without a response. You may find
should always be ruled out. Box 22.1 describes the strategies
it useful to document dose and treatment period
in your drug history.
BOX 22.1 OPTIONS IF AN ANTIDEPRESSANT

DOES NOT WORK
that can be used when a patient has not responded to an an-
When an antidepressant does not work, management tidepressant at the correct dose for the correct length of time.
options include:
• Confirm concordance. Electroconvulsive therapy
• Confirm duration of treatment and dose (at least See Chapter 2 for information on the administration and
4 weeks at minimum therapeutic dose, longer side-effects of electroconvulsive therapy (ECT). Indications
periods may be required in older adults). for ECT in depression include:
• Reassess the diagnosis: Is depression the cause • Poor response to adequate trials of antidepressants
of their low mood? Are they using alcohol or • Intolerance of antidepressants due to side-effects
substances? Do they have a different psychiatric • Depression with severe suicidal ideation
• Depression with psychotic features, severe
disorder? Is there an ongoing psychosocial
psychomotor retardation or stupor
stressor?
• Depression with severe self-neglect (poor fluid and
• Consider psychological therapy, if this is not food intake)
already in place. • Previous good response to ECT
• Increase the dose of the current antidepressant
(e.g. increasing fluoxetine from 20 mg to 40 mg).
• Change to another selective serotonin reuptake
inhibitor (SSRI; e.g. from fluoxetine to sertraline). Depression is self-limiting, and without treatment a first
• If trialled two SSRIs, or not appropriate to do depressive episode will generally remit within 6 months to
1 year. However, the course of depression is often chronic
so: change to another antidepressant from a
and relapsing and around 80% of patients have a further de-
different class (e.g. from sertraline (SSRI) to
pressive episode, with the risk for future episodes increasing
venlafaxine (selective serotonin-norepinephrine
with each relapse.
reuptake inhibitor) or mirtazapine). Depression is one of the most important risk factors for sui-
• If adequately trialled at least two antidepressants, cide; rates of suicide are over 20 times greater in patients with
consider augmenting the current antidepressant depression compared with those in the general population.
with lithium or another antidepressant, for
example, mirtazapine (usually done by a
psychiatrist). Antipsychotics can also be used BIPOLAR AFFECTIVE DISORDER
as augmenting agents in treatment-resistant
depression. There are many other options. Epidemiology
• Consider electroconvulsive therapy if criteria met.
Table 22.1 summarizes the epidemiology of the mood
disorders.
194
Bipolar affective disorder 22
Aetiology • Excessive psychomotor agitation with risk for self-

injury, dehydration and exhaustion
Similar to depression, bipolar disorder is thought to arise • Thoughts of harming self or others
from an interaction between genes and environmental
Detention under mental health legislation is often necessary
stress, with genes being particularly important. Twin stud-
in those lacking capacity to make decisions regarding treat-
ies estimate heritability at 65%–80%. First-degree relatives
ment. Patients with bipolar disorder may also require hos-
of a patient with bipolar disorder have a roughly seven-
pital admission for depressive episodes for reasons outlined
fold increased risk for bipolar disorder (10%), a twofold to
in the section on depression above.
threefold increased risk for unipolar depression (20%–30%)
and a higher risk for schizophrenia/schizoaffective disor-
der. Thus genetic susceptibility for severe mental disorder Pharmacological treatment
is not disorder specific: patients with a family history of any The mainstays of acute and maintenance treatment of bi-
of bipolar, schizophrenia or schizoaffective disorder are at polar illness are mood stabilizers (lithium and some antie-
increased risk for bipolar disorder. Risk for most patients is pileptics (sodium valproate/valproic acid, lamotrigine and
likely contributed to by multiple alleles of small individual carbamazepine)) and antipsychotics (which stabilize mood
effect, although some rare high-penetrance alleles proba- as well as reduce psychotic symptoms).
bly also exist. Many of the mutations identified so far that
slightly increase the risk for bipolar disorder also increase
Treatment of acute mania or hypomania or
the risk for schizophrenia, including genes related to neuro-
nal development, neurotransmitter metabolism (dopamine mixed affective state
and serotonin) and ion channels. Antidepressants should be discontinued (this may need
The most important environmental risk factor is child- to be gradual if half-life is short, to avoid discontinua-
birth. There is a 50% risk for mania postpartum in those tion symptoms). Short-term, benzodiazepines are often
with untreated bipolar affective disorder. helpful in reducing severe behavioural disturbance. An
Neurobiologically, structural and functional abnor- antimanic agent should be started. NICE (2014) recom-
malities in brain regions linked to emotion and reward mends an antipsychotic (haloperidol, olanzapine, que-
(particularly hippocampus, amygdala, anterior cingulate tiapine or risperidone), in part because of their benefits
and corpus callosum) have been identified. Multiple neu- in reducing behavioural disturbance. If a different mood
rotransmitter pathways have been implicated, with stron- stabilizer is already being taken it can be continued, with
gest evidence for dopaminergic pathway hyperactivity in consideration given to increasing the dose. If there is no
mania and some evidence for dopaminergic hypoactivity improvement, augmentation is recommended with an an-
in depression. tipsychotic. Because lithium can be harmful if taken for
less than 2 years (discontinuation of lithium can precipi-
tate mania), it is not advisable to start lithium in a manic
Assessment, clinical features, patient who is unlikely to be concordant with long-term
investigations and differential treatment.
diagnosis
Discussed in Chapters 10 and 11. Treatment of acute depression in context
of bipolar disorder
Antidepressants need to be coprescribed with an antimanic
Management agent, to avoid precipitating a hypomanic or manic episode.
The main management scenarios are: They should not be prescribed for mild depressive symp-
• Treatment of acute mania or hypomania toms, only moderate–severe. Doses should start low and
• Treatment of acute depression increase only gradually. Often, choice will be influenced by
• Maintenance treatment (prevention of relapse) what medication someone is already taking. The first-line
options are either quetiapine or a combination of fluoxe-
tine and olanzapine (quetiapine and olanzapine have anti-
Treatment setting
depressant properties in addition to antipsychotic effects).
The initial treatment setting depends on the presentation
If these medications are not of benefit, lamotrigine alone
and severity of illness. A manic episode needs referral to
can be given. If someone is already taking lithium or val-
secondary care. It may be managed by a crisis team, but may
proate, ensure the dose is providing a level at the upper
necessitate a period of hospitalization in cases of:
end of the therapeutic window/is at maximum, and con-
• Impaired judgement endangering the patient or others sider augmenting in turn with the three options as above.
around them (e.g. sexual indiscretion, overspending, Long-term antidepressants should be avoided, with gradual
aggression) discontinuation once depression has been in remission for
• Significant psychotic symptoms 3–6 months.
195
Maintenance treatment Psychological treatment

Not everyone who has suffered from a manic or hypo- A structured psychological intervention is recommended
manic episode needs long-term prophylactic treatment. for all people with bipolar affective disorder to improve
Maintenance treatment is recommended in those who insight and awareness of early warning signs and identify
have had a manic episode associated with serious adverse strategies the patients can use themselves to stabilize their
risk or consequences, a manic episode and another disor- mood. If they are in close contact with family members, a
dered mood episode or repeated hypomanic or depressive family intervention is also recommended. In bipolar depres-
episodes with significant functional impairment or risk. sion, a high-intensity psychological intervention is advised
Treatment for at least 2 years is recommended but in prac- (cognitive behavioural therapy, interpersonal therapy or
tice is often required lifelong. behavioural couples therapy). Psychological therapy is not
If maintenance treatment is indicated, NICE (2014) recommended in hypomania or mania, when patients are
recommends lithium as first line. Lithium requires regular generally unable to engage. Psychological therapies can harm
blood tests (usually three monthly) to monitor plasma level as well as help, and therapists need to have training specifi-
(see Chapter 3). Discontinuation of lithium can precipitate cally to work with people with bipolar affective disorder.
relapse, meaning net benefit is likely to be gained only af-
ter at least 2 years of treatment. Second line is to augment Electroconvulsive therapy
lithium with valproate. If someone is not able to take lith- Although ECT may precipitate a manic episode in bipolar
ium (e.g. cannot tolerate, cannot attend for routine blood patients, it can be an effective antimanic agent, especially
monitoring), alternatives are valproate (not in a woman in severe mania and mixed states. It can also be used in a
of childbearing age as it is associated with a high risk for severe depressive episode within bipolar affective disorder.
neural tube defects), olanzapine or quetiapine. Third-line
options are lamotrigine (protects poorly against the manic
pole) or carbamazepine (high risk for drug interactions due Course and prognosis
to induction of liver enzymes). More than 90% of patients who have a single manic episode
go on to have future episodes. The frequency of episodes
varies considerably, but on average equates to four mood
HINTS AND TIPS episodes in 10 years. Between 5% and 15% of patients have
four or more mood episodes (depressive, manic or mixed)
Do not forget to take a comprehensive family within 1 year, which is termed rapid cycling and is associated
history – including of treatment of psychiatric with a poor prognosis. Completed suicide occurs around 6
diagnoses. There is evidence to suggest that the times more often in people with bipolar affective disorder
level of response to lithium runs in families. than in the general population.
RED FLAG DYSTHYMIA AND CYCLOTHYMIA

Different preparations of lithium and valproate
(which can mean sodium valproate, valproic
Aetiology
acid or semisodium valproate) have different The extent to which the aetiologies of dysthymia and cy-
bioavailabilities so it is important to specify the clothymia resemble those of depression and bipolar affec-
preparation when prescribing. tive disorder is unclear. There are biological similarities
between dysthymia and depression; for example, rapid eye
movement latency is decreased in both conditions. Genetic
studies link cyclothymia and bipolar affective disorder, as
up to one-third of patients with the former have a positive
Physical health monitoring family history of the latter.
People with bipolar affective disorder are at increased risk
for cardiovascular disease, regardless of whether they are
taking medication with metabolic side effects or not. NICE
Epidemiology and course
(2014) recommends an annual physical health check in- Fig. 22.1 summarizes the epidemiology of the mood disor-
cluding weight, pulse, fasting blood glucose, glycosylated ders. Both dysthymia and cyclothymia have an insidious onset
haemoglobin, lipids and liver function. Any abnormalities and a chronic course, often beginning in childhood or adoles-
should be proactively treated. Extra monitoring is required cence. A significant number of patients with c yclothymia will
for those taking lithium (renal function, thyroid function go on to suffer more severe affective disorders, most notably
and calcium). bipolar affective disorder. Dysthymia may coexist with de-
196
Dysthymia and cyclothymia 22
pressive episodes (double depression), anxiety disorders and namely, a low-intensity psychological therapy initially, with
emotionally unstable personality disorder. consideration given to high-intensity psychological interven-
tion or medication if this is ineffective. There are no specific
Assessment, clinical features, guidelines for treating cyclothymia, but again the emphasis
is on psychological intervention, supporting the individ-
investigations and differential ual to develop self-management strategies. If medication is
diagnosis felt worthwhile in cyclothymia, the options are a long-term
Discussed in Chapters 10 and 11. mood stabilizer (most likely lithium) or the short-term use
of low doses of mood stabilizing antipsychotics (e.g. olan-
zapine, quetiapine) during times of high stress when mood
Management is felt to be least stable. Antidepressants should be used with
Dysthymia should be treated according to the NICE guide- caution in cyclothymia owing to their occasional tendency
lines on ‘persistent subthreshold depressive symptoms’, to turn mild depressive symptoms into hypomania.
Chapter Summary
• Mood disorders are common and disabling disorders with onset in early adulthood.
• Risk factors for mood disorders are genetic vulnerability, exposure to childhood adversity
and stress.
• Most episodes of depression can be managed in the community, but life-threatening
symptoms require hospital admission.
• Most episodes of mania require hospital admission. Hypomania may be manageable in
the community.
• Treatment for depression depends on severity. Milder forms benefit from psychological
intervention, more severe episodes require both psychological and pharmacological
treatment.
• First-line pharmacological treatments for mood disorders are:
• Depressive episode (unipolar depression): selective serotonin reuptake inhibitor
• Depressive episode (bipolar depression): olanzapine and fluoxetine, or quetiapine
• Manic episode: haloperidol or olanzapine or risperidone or quetiapine
• Maintenance: lithium
197
The anxiety and somatoform
disorders 23
This chapter discusses the most important disorders associ-
ated with the presenting complaints in Chapters 12, 13, 14 HINTS AND TIPS
and 15, which you might find helpful to read first. In clinical settings, over 95% of patients who
present with agoraphobia also have a current
diagnosis or a past history of panic disorder. You
may want to bear this in mind while screening for
ANXIETY DISORDERS
symptoms.
Epidemiology
The anxiety disorders are the most common of all the psy-
chiatric disorders with a combined 1-year prevalence rate HINTS AND TIPS
of 12%–17%. Epidemiological data collected from different
countries have shown varying prevalence rates for the indi- Anxiety disorders tend to be more common
vidual anxiety disorders, likely reflecting varying thresholds in women than men, apart from social phobia
for diagnosis (see Table 23.1 for the epidemiology of the and obsessive-compulsive disorder where the
anxiety disorders). It is important to remember that anxi- prevalence is about equal.
ety disorders are usually underdiagnosed in primary care
settings, or only recognized years after onset. A large UK
survey found that only a third of people with clinically sig-
nificant anxiety disorders were receiving treatment of any
Aetiology
kind (psychological or pharmacological). Genetic and biological factors
Genetic factors contribute moderately to risk for develop-
ment of most anxiety disorders, with a heritability of 30%–
COMMUNICATION 50%. There is likely to be considerable genetic overlap with
depression. It is possible that different environmental expe-
The anxiety disorders are frequent and closely riences in people with similar genetic vulnerabilities lead to
related in aetiology, symptoms and management. either depression or anxiety, or both.
For this reason, they are often grouped together Panic disorder and obsessive-compulsive disorder
along with depression under the heading ‘common (OCD) appear to be the most heritable anxiety disorders,
mental disorders’. with more than a third of those affected having a first-
degree relative with the same diagnosis. OCD shares genetic
risk with Tourette syndrome (see Chapter 29).
Table 23.1 Epidemiology of the anxiety disorders

One-year
Anxiety disorder prevalencea Usual age of onset Sex ratio (female:male)
Generalized anxiety disorder 3% Variable: childhood to late 2–3:1
adulthood
Panic disorder (with or without 4% Late adolescence to mid-30s 2–3:1
agoraphobia)
Social phobia 4% Mid-teens About equal
Specific phobia 4% Childhood to adolescence 2:1
Posttraumatic stress disorder 4% Any age – after trauma 2:1
Obsessive-compulsive disorder 2% Adolescence to early adulthood Equal
a
One-year prevalence rates from Narrow et al 2002. Revised prevalence estimates of mental disorders in the United States. Archives of
General Psychiatry 59:115–23.
199
The anxiety and somatoform disorders
The three main neurotransmitter systems implicated be exposed to the neutral stimulus (e.g. not getting into
in anxiety disorders are γ-aminobutyric acid (GABA), se- a car at all, not going to the zoo at all).
rotonin and noradrenaline (norepinephrine). Evidence for These theories explain why techniques such as exposure re-
their role is that these are the neurotransmitters predom- sponse prevention (see Chapter 3) are effective.
inantly affected by benzodiazepines, selective serotonin
reuptake inhibitors (SSRIs) and tricyclic antidepressants
(TCAs). Calcium-dependent neural signalling has been Assessment, clinical features,
linked to anxiety by genome-wide association. investigations and differential
Obsessive-compulsive symptoms are often reported diagnosis
following damage to the caudate nucleus in the basal gan-
glia (e.g. Sydenham chorea). Amygdala hyperactivation is Discussed in Chapters 12, 13, 14 and 15.
found in a number of anxiety disorders, including posttrau-
matic stress disorder (PTSD) and social phobia, in response Management
to the relevant anxiety-inducing stimuli. However, anxiety
disorders likely reflect abnormalities in networks of brain
regions, rather than individual regions alone. HINTS AND TIPS
Although patients may have genes and life

Social and psychological factors experiences that predispose them to anxiety
Anxiety disorders have been linked to stressful life events.
disorders, often maladaptive patterns of
In PTSD a significant traumatic event is essential to the di-
agnosis, although only around 10%–30% of people who ex- thinking and behaviour exacerbate and maintain
perience such an event go on to develop PTSD. Psychosocial symptoms. This means that psychoeducation and
stressors may also precede the onset of symptoms in other psychological therapies can be very effective.
anxiety disorders.
Cognitive-behavioural theories suggest that symp-
toms are a consequence of inappropriate thought pro-
cesses and over-estimation of dangers, as in the case of
panic attacks:
COMMUNICATION
• A cognitive model of the panic attack suggests that an
attack may be initiated when a susceptible individual When describing psychological therapies to
misinterprets a normal body stimulus. For example, a patients, you may wish to remind them that
patient may become aware of their heart beating. Instead avoidance perpetuates anxiety. To overcome
of dismissing this as normal, they may assume that it is anxiety, it is necessary to feel anxious.
under excessive pressure and that something could be Psychological therapies guide patients to do this in
physically wrong. This fear activates the sympathetic a structured and gradual manner.
nervous system (the ‘fight or flight’ response), producing
a real increase in the rate and strength of the heartbeat.
A vicious cycle ensues in which the perception of
increasing cardiac effort convinces the sufferer that they
Psychological therapies are recommended as first-line
are on the point of collapse or a myocardial infarction.
treatment for anxiety disorders, particularly milder
The resulting crescendo of symptoms may proceed to
forms. Pharmacological treatments are also of benefit, but
a full-blown panic attack involving several of the panic
longer-term treatment is generally required so the risk for
symptoms listed in Box 12.1.
side-effects and complications is high. Pharmacological
Cognitive-behavioural models for phobias suggest a two- treatment can be offered first line for moderate to severe
step process: anxiety disorders if a patient wishes this, or if psychological
• A neutral stimulus is paired with an aversive stimulus treatment has been insufficient. In severe cases, combining
(classical conditioning, e.g. driving and an accident) or the two is required. Fig. 23.1 summarizes the most import-
anxiety is felt about an intrinsically aversive stimulus ant concepts in treating anxiety disorders, based on the
(e.g. a snake). National Institute for Health and Care Excellence (NICE)
• The neutral stimulus is then associated with anxiety, guidelines for common mental health disorders (2011), gen-
and avoiding it reduces anxiety (e.g. not driving after eralized anxiety disorder and panic disorder (2011), PTSD
an accident, not going into the reptile house in the zoo). (2005) and OCD (2005). It is important that you familiarize
The association thus becomes self-reinforcing (operant yourself with this diagram, as anxiety disorders are com-
conditioning) and it becomes increasingly difficult to mon in primary care settings and 90% are managed there.
200
Anxiety disorders 23
Anxiety or low mood
If harmful or dependent alcohol or other substance use: treat use first Treat alcohol use
(often leads to large improvement in anxiety or depressive symptoms) (Chapter 20)
If anxiety symptoms secondary to depression: treat depression first

Treat depression
If depressive symptoms secondary to anxiety disorder: treat anxiety first
(Figure 22.2)
If unclear, ask patient their preference
Identify diagnosis and severity, select appropriate treatment in consultation with patient
Mild-moderate (minimal Moderate-severe (mild-marked functional impairment)

functional impairment) or persistent sub-threshold symptoms
Disorder Psychological Therapy Psychological Therapy Pharmacological Therapy
GAD Self-help CBT SSRI

Applied relaxation 2nd line: Alternative SSRI,
Venlafaxine, Pregabalin
Panic Disorder Self-help CBT SSRI
(with or without 2nd line: Imipramine, clomipramine
agoraphobia)
Social Phobia Self-help CBT SSRI
Consider PRN propranolol
nd
2 line: MAOI
short term benzodiazepines only
OCD Self-help Individual CBT (with ERP) SSRI
individual or group CBT (with 2nd line: Alternative SSRI,
ERP) Clomipramine
PTSD Watchful waiting (if within 4 Trauma-focused CBT or Paroxetine

weeks of trauma) EMDR Mirtazapine
Trauma-focused CBT or 2nd line: Amitriptyline, Phenelzine
EMDR (if greater than 4 Sleep disturbance: Z drug or
weeks since trauma) Benzodiazepine
Specific Phobia Self-help CBT (desensitisation, flooding PRN benzodiazepine can be
or modelling) considered for rarely occurring
situations (e.g. flying)
Consider referral to secondary care if: risk for self-harm or suicide, marked self neglect, nonresponse to at
least two treatments, significant co-morbidity (e.g. substance use, physical health problems)
Fig. 23.1 Management of anxiety disorders. CBT, Cognitive-behavioural therapy; EMDR, eye movement desensitization
and reprocessing therapy; ERP, exposure response prevention; MAOI, monoamine oxidase inhibitor; SSRI, selective
serotonin reuptake inhibitor.
Psychological treatment a ‘vicious cycle’ of spiralling fear and sympathetic

• There is strong evidence for the use of cognitive- activation. When the patient understands this model,
behavioural therapy (CBT) in most anxiety disorders. the therapist may encourage the patient to break the
• CBT is the first-line treatment for specific phobias, cycle by challenging the assumption that the original
mainly in the form of behaviour therapy, which stimulus (e.g. palpitations) is indicative of an
may involve systematic desensitization, flooding or impending physical dysfunction (e.g. heart attack).
modelling (see Chapter 3). • Effective treatments in PTSD include trauma-focused
• In panic disorder, CBT may help the sufferer to CBT (CBT addressing thoughts and behaviours
understand that panic attacks can start from a related to memories of the trauma) or eye movement
misinterpretation of a normal stimulus, leading to desensitization and reprocessing therapy (where the
201
patient is asked to think about the trauma while also severe side-effects and interactions with other drugs or
attending to another sensory stimulus (e.g. lights food components (cheese reaction, see Chapter 2).
or beeps; see Table 3.4). Psychological debriefing • A β-blocker such as propranolol can also be used as
immediately after trauma is not advised. required to reduce autonomic arousal to anxiety-
• Applied relaxation is used in generalized anxiety inducing stimuli, but it is more effective to treat the
disorder. This focuses on being able to relax muscularly anxiety directly if possible.
during situations in which the patient is or may be
anxious. HINTS AND TIPS
• Other therapies commonly used in anxiety disorders
include supportive, psychodynamic and family Inhibition of serotonin uptake seems to be the
therapies, although there is less evidence for their essential component of effective drug therapy for
efficacy (see Chapter 3). obsessive-compulsive disorder as evidenced by
• Counselling may be helpful for patients who the efficacy of the selective serotonin reuptake
are experiencing stressful life events, illnesses or
inhibitors and clomipramine. Clomipramine,
bereavements (see Chapter 3).
which predominantly inhibits serotonin reuptake,
is more effective than the other tricyclic
Pharmacological treatment
antidepressants, which predominantly inhibit
• In general, drugs need to be titrated up to higher doses
noradrenaline (norepinephrine) reuptake inhibition
and take longer to work in anxiety disorders than in
depression (e.g. up to 12 weeks at the British National (e.g. desipramine, nortriptyline).
Formulary maximum dose for a trial of an SSRI in
OCD).
• SSRIs are first-line treatments for most anxiety
disorders due to their proven efficacy and tolerable Course and prognosis
side-effect profile. Venlafaxine has a similar side-effect
profile and also has proven efficacy in generalized The prognoses of the anxiety disorders vary greatly between
anxiety disorder. individuals:
• Restlessness, jitteriness and an initial increase in • Generalized anxiety: Is likely to be chronic,
anxiety symptoms may occur in the first few days of but fluctuating, often worsening during
treatment with either the SSRIs or the TCAs, which times of stress.
may reduce concordance in already anxious patients. • Panic disorder: Depending on treatment, up to one-
This can be managed by titrating the dose up half of patients with panic disorder may be symptom
slowly or by using benzodiazepines in combination free after 3 years, but one-third of the remainder have
with antidepressants during the first few days of chronic symptoms that are sufficiently distressing to
treatment. significantly reduce quality of life. Panic attacks are
• Benzodiazepines are highly effective in reducing central to the development of agoraphobia, which
anxiety. However, the rapid development of tolerance usually develops within 1 year after the onset of
and dependence means they are not recommended recurrent panic attacks.
for the majority of anxiety disorders. They can be • Social phobia: Usually has a chronic course, although
prescribed as a short-term hypnotic in PTSD, or for adults may have long periods of remission. Life
infrequent ‘as required’ use in social phobia (e.g. to stressors (e.g. a new job) may exacerbate symptoms.
allow a speech to be given) or specific phobias (e.g. to • Specific phobias: Have an uncertain long-term
allow blood to be taken). They are not recommended prognosis, but it is thought that simple phobias
for generalized anxiety disorder, panic disorder or that persist from childhood are less likely to remit
OCD unless used short-term in a crisis. than those that begin in response to distress in
• Pregabalin is licensed for treatment of generalized adulthood.
anxiety disorder (often used after an SSRI trial), • PTSD: Approximately half of patients will recover fully
epilepsy and neuropathic pain. within 3 months. However, a third of patients are left
• TCAs are generally considered only after other treatments with moderate to severe symptoms in the long-term.
have been tried owing to their increased frequency The severity, duration and proximity of a patient’s
of adverse effects (e.g. dry mouth, sedation, postural exposure to the original trauma are the most important
hypotension, tachycardia). Clomipramine, the most prognostic indicators.
serotonergic of the TCAs, has proven efficacy in OCD. • OCD: The majority have a chronic fluctuating course,
• The monoamine oxidase inhibitors, despite being with worsening of symptoms during times of stress.
effective in some conditions, are not considered first- About 15% of patients show a progressive deterioration
line treatment for anxiety owing to the possibility of in functioning.
202
Dissociative and somatoform disorders 23
Table 23.2 Epidemiology of somatization disorder and hypochondriacal disorder

Anxiety disorder Lifetime prevalence Usual age of onset Sex ratio
Somatization disorder 0.2%–2% Before 25 years of age, Far more common in women
often in adolescence (about 10:1)
Hypochondriacal disorder 1%–5% Early adulthood Equal
Body dysmorphic disorder 2% Adolescence (declines Slight female excess
with age)
Functional/dissociative Varies between specific disorders
disorders
DISSOCIATIVE AND Assessment, clinical features,

SOMATOFORM DISORDERS investigations and differential
diagnosis
The dissociative disorders were described in Chapter 14. The
common somatoform disorders (somatization disorder, hy- Discussed in Chapters 14 and 15.
pochondriacal disorder, body dysmorphic disorder), facti-
tious disorder and malingering were discussed in Chapter 15. Course and prognosis
Somatoform disorders tend to have a chronic epi-
Epidemiology sodic course, with waxing and waning symptoms of-
Table 23.2 presents the epidemiological data for somatoform ten exacerbated by stress. Good prognostic features in
disorders. Functional or dissociative disorders are even more hypochondriacal disorder include acute onset, brief du-
common – around a third of patients seen in hospital medi ration, mild hypochondriacal symptoms, the presence
cal outpatient clinics. Functional seizures are found in around of physical comorbidity and the absence of a comorbid
one in seven people attending a first fit clinic; functional pa- psychiatric disorder. Functional/dissociative disorders
resis is as common as multiple sclerosis (affecting around 4 in vary widely in outcome. Some patients experience one
100 000 people per year), and up to half of presentations with acute episode, then make a full recovery; others become
‘status epilepticus’ are in fact prolonged functional seizures. very disabled.
Aetiology Management
The aetiology of dissociative and somatoform disorders is NICE (2005) recommends CBT (including exposure with
poorly understood. Childhood sexual abuse increases the response prevention) for body dysmorphic disorder with
risk for somatoform and dissociative disorders, although any degree of functional impairment. SSRIs are recom-
the majority of patients with the disorders have not been mended in addition for those with moderate to severe body
abused. Growing up in environments where physical dis- dysmorphic disorder. Little research is available regarding
tress is more readily acknowledged than psychological the treatment of somatization and hypochondriacal disor-
distress may have a role. Symptoms often (but not always) ders. Pharmacotherapy will only alleviate symptoms when
have onset or worsen after a stressor and this may be be- the patient has a comorbid drug-responsive condition such
cause emotional states influence the way pain and other as an anxiety disorder or depression. Both individual and
bodily sensations are perceived. Symptoms also often fol- group psychotherapy (mainly CBT) may be useful in re-
low an actual, minor, physical insult, for example, functional ducing symptoms by helping patients to cope with their
leg weakness following a sprained ankle or irritable bowel symptoms and develop alternative strategies for managing
syndrome following a viral infection. Similarly, functional their emotions. Box 23.1 summarizes the role of the gen-
seizures occur most often in people who also experience ep- eral practitioner in managing patients with somatoform
ileptic seizures. There is no convergent pathophysiological disorders. A supportive relationship with an empathic
explanation, but current theories include: doctor able to work with the patient to guide understand-
1. Abnormally intense self-directed attention interferes with ing of their condition is likely to be the most important
normal ‘automatic’ cognitive processing, causing errors intervention.
(much like thinking too long about how to spell a word) In functional/dissociative disorders, a clear and empath-
2. Abnormal sense of agency or disrupted sensory ically delivered explanation that emphasizes reversibility
prediction prevents patients from differentiating self- can often be helpful (see Table 23.3). Treat comorbid psy-
generated versus involuntary movements, or normal chiatric disorders, consider CBT, and consider physiother-
from abnormal sensory input apy for those who are deconditioned
203
BOX 23.1 ROLE OF THE GENERAL COMMUNICATION

PRACTITIONER IN MANAGING PATIENTS WITH
SOMATOFORM DISORDERS A diagnosis of functional symptoms can be hard to
explain. Phrases such as ‘you are experiencing a
• Arrange to see patients at regular fixed intervals,
functional, not a structural problem’ or ‘a software
rather than reacting to the patient’s frequent
not a hardware problem’ may help to reassure
requests to be seen.
patients that you believe they are experiencing
• Increase support during times of stress for the
symptoms, but these are not driven by a disorder
patient.
which requires specific treatment.
• Take symptoms seriously, but also encourage
patients to talk about emotional problems,
rather than just focusing on physical complaints.
• Limit the use of unnecessary medication, Table 23.3 Explanation and advice in dissociative/
especially those that may be abused (e.g. functional disorders
benzodiazepines, opiates). State what is wrong ‘You have functional seizures’.
• Treat coexisting mental disorders (e.g. anxiety, ‘You have irritable bowel
depression). syndrome’.
• Limit investigations to those absolutely State what is not ‘You do not have epilepsy, coeliac
necessary, based on objective signs. wrong disease, bowel cancer etc.’.
• Have a high threshold for referral to specialists. Describe the ‘Your body is not damaged but it
• Communicate the diagnosis clearly and mechanism is not working properly’.
empathically. Try metaphor ‘It’s a software not a hardware
• If possible, arrange that patients are only seen problem’.
by one or two doctors in the practice to help Explain how the Demonstrate tremor entrainment,
with containment and to limit iatrogenic harm. diagnosis was Hoover sign, etc. Share normal
made investigation results. Point
• Help patients to think in terms of coping with out other symptoms such as
their problem, rather than curing it. derealisation/depersonalization.
• Involve other family members and carers in the State you believe ‘I do not think you are making
management plan. them these symptoms up’.
• Consider referral to a psychiatrist or Emphasize the ‘Many people have similar
psychologist. problem is common symptoms’.
Emphasize the ‘There is no damage, so there is
problem gets better potential to make a full recovery’.
Emphasize ‘It’s not your fault, but there are
self-help things you can do to make it
better’.
Chapter Summary
• Anxiety disorders are common, often chronic conditions, arising more frequently in
women than men.
• Self-help is the first-line therapy for the majority of mild anxiety disorders.
• Psychological therapies are first line for moderate to severe anxiety disorders.
• Medication, usually selective serotonin reuptake inhibitors, can also be offered for
moderate to severe anxiety disorders.
• Principles of treatment in somatoform and dissociative disorders are to take a holistic
approach, give a clear explanation of diagnosis and minimize iatrogenic harm.
204
Eating disorders
24
This chapter discusses the disorders associated with the in these domains are seen in unaffected relatives of those
presenting complaints in Chapter 16, which you might find with anorexia, and in those who have recovered and have a
helpful to read first. normal body mass index (suggesting that these findings do
not simply reflect the substantial cognitive changes associ-
ated with starvation).
ANOREXIA AND BULIMIA Cultural influences

NERVOSA In Western culture, the widely portrayed notion of the
‘ideal body’ influences perception of body image, meaning
Epidemiology that unusual thinness is often valued more than natural
curves. The increase in eating disorders seen in low- and
See Table 24.1. middle-income countries supports the concept that ideal-
ized thinness may influence risk for eating disorder, but it
Aetiology is very hard to prove.
As with the majority of mental disorders, both biological
and psychosocial factors have been implicated. Neurobiology
The key neurobiological pathways underlying eating disor-
der remain to be clarified, but increased volume of the or-
Genetics bitofrontal cortex (involved in reward processing) has been
Estimates from twin studies suggest that around two-thirds
found in anorexia and bulimia, both during and after an ep-
of the variance in the liability to eating disorders is due to
isode of illness (suggesting that the findings are not merely
genetic factors. Genome-wide association studies in an-
a consequence of starvation).
orexia so far have not identified any common risk variants,
but have been underpowered.
Early life experience investigations, complications and
Premature birth and some perinatal complications increase differential diagnosis
the risk for a later eating disorder, potentially implicating
epigenetic changes. Childhood adversity (physical, sexual Discussed in Chapter 16.
or neglect) also increases the risk for an eating disorder.
Relationship difficulties are often (but not always) found
within families of patients with anorexia nervosa, including
HINTS AND TIPS
overprotectiveness, enmeshment (overinvolvement, with
lack of differentiation between parent and child), conflict Although depression and obsessive-compulsive
avoidance, lack of conflict resolution and rigidity (resis- disorder may coexist with anorexia nervosa,
tance to change). these symptoms can also result from the effects
of starvation. It is helpful to ask, ‘what happened
Personality first?’, and aim to restore weight before treating
It is possible that the inherited liability might be mediated any remaining mood or anxiety symptoms.
by certain personality traits, including perfectionism (high
attention to detail) and rigidity/obsessionality. High scores
Table 24.1 Epidemiology of anorexia and bulimia nervosa

Disorder Prevalence Sex ratio Age of onset
Anorexia nervosa 0.9% of women 3:1 Typically mid-adolescence
0.3% of men (10:1 in some studies)
Bulimia nervosa 1.5% of women 3:1 Typically late adolescence or early adulthood
0.5% of men
205
Eating disorders
Management have common principles: they are long-term (20–40

sessions), they encourage regaining a healthy weight,
Anorexia nervosa they involve carers wherever possible and they seek to
Ambivalence towards treatment coupled with the psycho- develop a positive therapeutic relationship. See Chapter 3
logical consequences of starvation (poor concentration, for more information about psychological therapies.
depression, lethargy) means that anorexia nervosa is often The only medication recommended by NICE (2017) in
difficult to treat. Treatment should be collaborative, with anorexia is a multivitamin. Previously, fluoxetine was often
an early aim of establishing a therapeutic alliance. Fig. 24.1 trialled, but this is now felt to be ineffective. A selective sero-
gives an overview of management recommendations tonin reuptake inhibitor may be of benefit in comorbid anx-
(National Institute for Health and Care Excellence (NICE) iety or depressive illnesses, but a return to a normal weight
2017). Suspected cases should be referred to a specialist eat- should be attempted first, as this is likely to improve mood
ing disorder service for assessment. and anxiety. When prescribing for anyone who is significantly
Psychotherapy, preferably with familial involve- malnourished, be aware of the additional risks of medications
ment, is the treatment modality of choice for patients in this group, particularly QTc prolongation. Dose reductions
with anorexia nervosa. Table 24.2 lists the psychologi- and cautious titration are likely to be required.
cal interventions recommended by NICE (2017). The Weight should be monitored, and physical complica-
interventions for anorexia nervosa differ in detail but tions (see Chapter 17) actively sought.
Suspected eating disorder
Refer
Multidisciplinary specialist eating disorder team
Assess
Treatment Setting
Assess for eating disorder and comorbidity

Low-moderate risk Manage in community
Risk assessment:
Physical health Severe physical risk (e.g. sepsis) Admit to medical ward
(specialist eating disorder unit if available)
Mental health
Severe psychiatric risk (e.g. suicidal) Admit to psychiatric ward
Treat
• Psychoeducation about nutrition and weight

• Psychological therapy (see Table 24.2)
• Medication: multivitamin if low BMI
• High physical risk requires safe refeeding with
specialist advice
Fig. 24.1 Overview of management of eating disorders. BMI, Body mass index.
Table 24.2 Psychological interventions recommended in eating disorders (NICE 2017)

Anorexia nervosa Bulimia nervosa
First line Second line First line Second line
Adult One of: • Different first-line therapy Guided self-help CBT-ED
• CBT-ED • Focal psychodynamic therapy (CBT informed)
• MANTRA
• SSCM
Young person Family therapy One of: Family therapy CBT-ED
(anorexia focused) • CBT-ED (bulimia focused)
• Psychotherapy (adolescent
anorexia focused)
CBT-ED, Individual eating-disorder-focused cognitive-behavioural therapy; MANTRA, Maudsley Anorexia Nervosa Treatment for Adults;
NICE, National Institute for Health and Care Excellence; SSCM, specialist supportive clinical management.
206
Anorexia and bulimia nervosa 24
Hospitalization is necessary in certain medical cir- with frequent electrolyte monitoring for the highest risk pe-
cumstances (e.g. body mass index less than 13.5 kg/m2, riod (first week of feeding) and with thiamine replacement.
rapid weight loss, severe electrolyte abnormalities, syn-
cope) and psychiatric circumstances (risk for suicide, so-
cial crisis). RED FLAG
In severe cases, patients can lose insight into the sever- Refeeding syndrome can arise in anyone who is
ity of their illness, by virtue of both the psychopathology malnourished, for example; alcohol dependence,
of the illness and the neuropsychological effects of star-
postoperatively, malabsorption syndromes.
vation. Where a patient lacks capacity to make decisions
regarding his/her care and treatment, it may be necessary
to use mental health legislation (see Chapter 4) to effect
compulsory admission to hospital, and to initiate life-
saving treatment. HINTS AND TIPS
While mental health legislation in all UK countries only
makes provision for the compulsory treatment of mental Hypophosphataemia is the hallmark of refeeding
illness (not physical illness), food is considered to be treat- syndrome. If you only remember one thing about it,
ment for mental illness because it leads to improvement in remember to check for that. If it is significantly low,
the psychological symptoms (impaired decision making) replace it, either orally or intravenously, depending
caused by starvation. Therefore, as a final resort, in certain on how low it is (check local guidelines).
cases patients may be force-fed under mental health legis-
lation. In extreme cases, nasogastric or intravenous feeding
may be necessary.
Bulimia nervosa
Patients with bulimia nervosa tend to be more motivated to
RED FLAG address their eating difficulties and are usually of a normal
weight. Treatment is predominantly psychological, rang-
A person with anorexia who is dangerously ing from psychoeducation, self-help manuals and self-help
underweight and refusing to eat should be groups in mild cases to individual cognitive-behavioural
assessed for compulsory treatment (feeding) under therapy in more serious cases (Table 24.2). Management
mental health legislation. by specialist eating disorder services may be necessary in
severe cases. Inpatient treatment is not usually required;
however, it may be necessary for the treatment of electro-
lyte disturbances resulting from purging (which can be fa-
Refeeding syndrome tal), or for management of the risk for suicide or self-harm.
When a patient starts eating after a prolonged (more than Antidepressants are no longer recommended to treat un-
5 days) period of starvation, care must be taken to avoid complicated bulimia. However, comorbid substance abuse
refeeding syndrome. This arises because of a rapid switch and depression are common and should be managed as
from gluconeogenesis (catabolic state) to insulin release standard. Unlike with anorexia, mood and anxiety symp-
stimulating glycogen, fat and protein synthesis (anabolic toms are unlikely to be due to malnutrition.
state), resulting in rapid intracellular uptake of the cofactors
needed for this, such as potassium, phosphate and magne- Prognosis
sium (Table 24.3). The associated electrolyte disturbances
can be potentially fatal. Management hinges on replacement Anorexia
of fluid and electrolytes, which may need to be intravenous. Although weight and menstrual functioning usually im-
To avoid it, refeeding is generally commenced cautiously, prove, eating habits and attitudes to body shape and weight
often remain abnormal. Recovery is slow; time to complete
remission in anorexia nervosa is typically 5 years. Around a
fifth of patients make a full recovery, a quarter develop buli-
Table 24.3 Clinical features of refeeding syndrome mia nervosa and a fifth remain severely unwell. The remain-
Electrolyte abnormalities Clinical manifestations der tend to follow a relapsing-remitting course. Risk for death
Hypophosphataemia Muscle weakness
in those with anorexia is increased sixfold relative to an age-
Hypokalaemia Seizures matched population. Premature death is predominantly due
Hypomagnesaemia Peripheral oedema to the complications of starvation (e.g. arrhythmia, sepsis),
Hyponatraemia Cardiac arrhythmias and around a fifth of deaths are due to suicide. Factors asso-
Metabolic acidosis Hypotension ciated with a poorer prognosis are described in Box 24.1 and
Thiamine deficiency Delirium indicate that poorer outcomes are seen in more severe illness.
207
Eating disorders
Bulimia
BOX 24.1 POOR PROGNOSTIC FACTORS
The course of bulimia is also variable, although generally bet-
IN ANOREXIA NERVOSA
ter than anorexia, with 50%–70% of patients achieving either
• Long duration of illness full or partial recovery after 5 years. Risk for death in those
• Age of onset prepuberty or greater than with bulimia nervosa is doubled compared with age-matched
17 years old controls. Poor prognostic factors include severe bingeing and
purging behaviour, low weight and comorbid depression.
• Male sex
• Very low weight
• Binge–purge symptoms
• Personality difficulties
• Difficult family relationships
Chapter Summary
• Eating disorders arise due to a mixture of genetic and environmental risk factors.
• The mainstay of treatment for both anorexia and bulimia is structured psychological
intervention.
• Anorexia nervosa is associated with a high mortality, mainly due to physical
complications of starvation.
• Admission to hospital may be required to safely manage high-risk patients with eating
disorders, potentially using mental health legislation.
• Recovery is typically slow, and many patients have a relapsing/remitting course.
208
The sleep–wake disorders
25
Sleeping is intimately related to mental health. Not only can Insomnia
psychiatric illnesses such as depression and schizophrenia
disturb the quantity and quality of sleep, but certain psy- Insomnia describes sleep of insufficient quantity or poor
chiatric drugs can also have the same effect. Furthermore, quality due to:
persistent primary sleep disturbances, which are common, • Difficulty falling asleep
can result in significant psychological consequences in an • Frequent awakening during the course of sleep
otherwise mentally healthy individual. • Early morning awakening with subsequent difficulty
getting back to sleep
• Sleep that is not refreshing despite being adequate in
length.
DEFINITIONS AND In addition to daytime tiredness, persistent insomnia can

have significant effects on mood, behaviour and perfor-
CLASSIFICATION mance. It has been shown that insomnia can also lead to an
impairment of health-related quality of life similar to heart
Sleep is divided into five distinct stages as measured by failure or depression.
polysomnography (see discussion later): four stages of non-
rapid eye movement (non-REM; stages 1, 2, 3 and 4) and an
REM stage. Fig. 25.1 summarizes the key characteristics of HINTS AND TIPS
the stages of sleep. When considering sleep disturbance in mental
Sleep can be disrupted due to:
illnesses you may find it useful to think in terms of
1. Primary sleep disorders ‘altered sleep patterns’ rather than of insomnia.
2. Sleep disorders secondary to another mental illness While common in depression, it is only early
3. Sleep disorders secondary to another medical
morning wakening that is part of the somatic
condition
syndrome (see Chapter 11) and 20% of people
4. Sleep disorders secondary to the use of a substance
with depression will have atypical symptoms (e.g.
This chapter will focus principally on primary sleep disor-
weight gain, increased appetite and hypersomnia.)
ders, which are not caused by another medical condition
(e.g. arthritis) or mental illness (e.g. depression), and do
not occur secondary to the use of a substance (e.g. alcohol).
These disorders are presumed to arise from some defect of Primary insomnia is diagnosed when present for at least
an individual’s endogenous sleeping mechanism (the retic- 3 months, and not attributable to medical or psychiatric
ular activating system) coupled with unhelpful learned be- illness, substance misuse or other dyssomnia or parasom-
haviours (e.g. worrying about not sleeping). The primary nia. The numerous causes of insomnia as summarized in
sleep disorders, in turn, are divided into the dyssomnias and Box 25.1 include primary sleep disorders, medical and psy-
the parasomnias: chiatric illness and substance use.
1. The dyssomnias are characterized by abnormalities in
the amount, quality or timing of sleep. Assessment of insomnia
They include: Assessment involves excluding a medical, psychiatric or
a. Primary insomnia substance-related cause of insomnia. Many cases of primary
b. Primary hypersomnolence insomnia are related to poor sleep hygiene (see Box 25.2 for
c. Narcolepsy advice to offer patients). Therefore it is essential to enquire
d. Circadian rhythm sleep disorders about sleeping times and patterns, and caffeine consump-
e. Sleep-related breathing disorders tion. It is also useful to obtain collateral information from
f. Sleep-related movement disorders (restless leg the patient’s sleeping partner regarding sleeping patterns,
syndrome) snoring and movements during the night.
2. The parasomnias are characterized by abnormal The following questions might be helpful in eliciting the
episodes that occur during sleep or sleep–wake key symptoms of insomnia:
transitions. They include non-REM sleep arousal • Do you fall asleep quickly or do you find yourself
disorders (night terrors and sleepwalking), nightmares tossing and turning for some time before
and REM sleep behaviour disorder. dropping off?
209
Stage of sleep Duration spent in this Characteristics and electroencephalogram (EEG) findings
phase during night
Stage 1 5% • Transition from wakefulness to sleep
EEG: theta waves
Theta waves: low amplitude, spike-like waves, 4–7 Hz
Stage 2 45% EEG: sleep spindles and K-complexes
Sleep spindles: short rhythmic K-complex: sharp negative

waveform clusters of 12–14 Hz wave followed by a slower
positive component
Stage 3 and 4 25% • Deep sleep

(Slow wave • Unusual arousal characteristics: disorientation, sleep terrors, sleepwalking
sleep) • Occur in first third to half of night
EEG: delta waves

Stage 3 – delta waves <50%
Stage 4 – delta waves >50%
Delta waves: high amplitude, low frequency (<4 Hz)
REM 25% • Occurs cyclically through the night, every 90 minutes alternating with
non-REM sleep
• Each episode increases in duration – most episodes occur in last third of
night
• Features penile erection, skeletal muscle paralysis, and surreal dreaming
(including nightmares)
EEG: low amplitude, high frequency, with sawtooth waves
Saw-tooth pattern
Fig. 25.1 Stages of sleep. REM, Rapid eye movement.
• Do you wake up repeatedly in the night or can you If, after a full history, the cause of insomnia remains unclear,
sleep through once you have managed to the National Institute for Health and Care Excellence (NICE;
get to sleep? 2015) recommends a sleep diary. Refer the patient to a sleep
• Do you sometimes awaken too early in the morning specialist for further investigation if there is diagnostic un-
and then find that you are unable to get back to sleep? certainty, or a suspicion of sleep apnoea, circadian rhythm
• Is your sleep refreshing or do you still feel tired in the disorders, parasomnias or narcolepsy. Further investigation
morning? is likely to include polysomnography: the simultaneous
210
Definitions and classification 25
BOX 25.1 COMMON CAUSES OF INSOMNIA BOX 25.2 GOOD SLEEP HYGIENE
Primary sleep disorders • Avoid sleeping during the day.

• Dyssomnias • Exercise during the day (but not within 4 hours
a. Primary insomnia of bedtime) and maintain a healthy diet.
b. Circadian rhythm sleep disorders (jet lag, shift • Eliminate the use of stimulants (e.g. caffeine,
work) nicotine, alcohol) within 6 hours of bedtime.
c. Sleep-related breathing disorders (sleep • Condition the brain by only using the bed for
apnoea syndromes) sleeping and sex – not for reading,
d. Sleep-related movement disorders (restless watching TV, etc.
legs syndrome) • Go to bed and awaken at the same time each day.
• Parasomnias (all) • Avoid stimulating activities before bedtime (e.g.
television, games). Instead, engage in relaxation
Psychiatric disorders
techniques or reading.
• Anxiety • Try having a hot bath or drinking a cup of warm
• Depression milk near bedtime.
• Mania • Avoid large meals near bedtime.
• Schizophrenia • Ensure that the bed is comfortable and that the
Physical disorders bedroom is quiet.
• Painful conditions (malignancies, arthritis, reflux • Do not lie in bed awake for longer than 15
disease) minutes (but do not watch the clock!). Get up
• Cardiorespiratory discomfort (dyspnoea, and do another relaxing activity and try sleeping
coughing, palpitations) later.
• Nocturia (prostatic hypertrophy, urinary tract
infections)
• Metabolic or endocrine conditions (thyroid
disease, renal or liver failure)
Management of primary insomnia
• Central nervous system lesion (especially
The most important aspect of management is providing ed-
brainstem and hypothalamus) ucation about correct sleep hygiene (see Box 25.3).
Substances There is a limited role for medication in the treatment of
• Caffeine and other stimulants primary insomnia. Hypnotics may help in the short-term,
• Alcohol
but the development of tolerance to their effects (usually
within 2 weeks), possible dependence and their propensity
• Prescribed drugs (e.g. selective serotonin
to cause rebound insomnia limit their use. Therefore they
reuptake inhibitors, some antipsychotics)
should only be prescribed on a time-limited basis, ideally
• Substance withdrawal syndrome for use on alternate or occasional nights rather than every
night. Drugs with a long half-life should be avoided, to
prevent leaving patients feeling drowsy the next day (the
rocess of monitoring various physical parameters during
p ‘chemical hangover’) and to avoid accumulation with re-
sleep, including electroencephalogram, electrocardiogram, peated doses. Commonly used agents include the ‘Z-drugs’
electromyogram, electrooculogram (eye movement), blood (zopiclone, zolpidem, zaleplon) and benzodiazepines with
oxygen saturation, chest and abdominal excursion, mouth a short half-life (such as temazepam). NICE (2015) advises
and nose air entry rates and the loudness of snoring. that if there is no response to one hypnotic, an alternative
should not be prescribed.
COMMUNICATION
Primary hypersomnolence
When considering insomnia, ask what the normal
amount of sleep is for the patient in order for them Hypersomnia describes excessive sleepiness that manifests
to feel refreshed in the morning and what time they as either a prolonged period of sleep or sleep episodes that
occur during normal waking hours.
normally wake up. There is significant individual
Primary hypersomnolence is diagnosed when patients
variation.
present with hypersomnia for at least a month not attribut-
able to a medical or psychiatric condition, substance use or
211
other dyssomnia (especially narcolepsy and sleep apnoea) 3. Hypnagogic or hypnopompic hallucinations (see
or parasomnia. The numerous causes of hypersomnia as Chapter 9)
summarized in Box 25.3 include primary sleep disorders, 4. Sleep paralysis at the beginning or end of sleep episodes
medical and psychiatric illness, substance use and sleep The symptoms arise from elements of REM sleep intrud-
deprivation. The treatment of primary hypersomnia is usu- ing into wakefulness. Diagnosis is confirmed by observing
ally with stimulants such as dexamphetamine, methylphe- rapid onset of REM on polysomnography during sleep la-
nidate and modafinil. tency studies.
In type 1 narcolepsy, cataplexy always occurs. It is due
Narcolepsy to a deficiency of hypocretin, a neuropeptide that regulates
the initiation of REM sleep. Levels are low in cerebrospinal
Narcolepsy typically presents in young people aged 10– fluid obtained via lumbar puncture. It is thought to arise
20 years who report an abrupt onset of pervasive daytime following autoimmune-mediated damage to hypocretin-
sleepiness. It affects around 1 in 2000 people. Symptoms of producing cells in the hypothalamus, triggered following an
narcolepsy are the tetrad of: infection. Over 98% of people with type 1 narcolepsy have
1. Irresistible attacks of refreshing sleep that may occur at a particular human leukocyte antigen haplotype. In type 2
inappropriate times (e.g. driving) narcolepsy (which is even rarer) cataplexy either does not
2. Cataplexy (sudden, bilateral loss of muscle tone usually occur or is atypical. Its aetiology overlaps with type 1 narco-
precipitated by intense emotion leading to collapse and lepsy but in general is less well understood.
lasting for seconds to minutes) The treatment of narcolepsy includes taking naps at reg-
ular times and ensuring sufficient duration of night-time
sleep. Typically, stimulants are needed to reduce daytime
BOX 25.3 COMMON CAUSES sleepiness (modafinil is first line). Cataplexy, sleep paraly-
OF HYPERSOMNOLENCE sis and hallucinations at the sleep–wake boundary can be
improved by low-dose antidepressants (usually venlafaxine
Primary sleep disorders or clomipramine). Noradrenaline and serotonin suppress
Dyssomnias REM sleep, and so do antidepressants.
a. Primary hypersomnolence
b. Narcolepsy Circadian rhythm sleep disorders
c. Sleep-related breathing disorders (sleep Circadian rhythm sleep disorder (sleep–wake schedule
apnoea syndromes) disorder) is characterized by a lack of synchrony between
d. Sleep-related movement disorders (restless an individual’s endogenous circadian rhythm for sleep and
legs syndrome) that demanded by their environment, resulting in the in-
e. Circadian rhythm sleep disorders (jet lag, shift dividual being tired when they should be awake (hyper-
work) somnia) and being awake when they should be sleeping
Parasomnias (all) (insomnia). This disorder results from either a malfunction
of the internal ‘biological clock’ that regulates sleep or from
Psychiatric disorders an unnatural environmental change (e.g. jet lag, night-
Depression with atypical features shift work). Treatment comprises sleep hygiene, enhancing
Physical disorders environmental cues regarding time of day (e.g. having a
dark bedroom) and bright light therapy.
• Encephalitis and meningitis
• Stroke, head injury, brain tumour
• Degenerative neurological conditions Sleep-related breathing disorders
• Toxic, metabolic or endocrine abnormalities Abnormalities of ventilation during sleep can cause re-
• Kleine–Levin syndrome peated disruptions to sleep. This results in unrefreshing
Substances sleep and excessive sleepiness during the day. Obstructive
sleep apnoea syndrome, the most common breathing-
• Alcohol related sleep disorder, is characterized by obstruction of the
• Prescribed drugs (e.g. antipsychotics, upper airways during sleep, despite an adequate respiratory
benzodiazepines, tricyclic antidepressants) effort. Typically, an individual will have noisy breathing
• Substance withdrawal syndrome during sleep with loud snoring interspersed with apnoeic
Secondary to insomnia or sleep episodes lasting from 20 to 90 seconds, sometimes asso-
ciated with cyanosis. It is an increasingly common condi-
deprivation
tion, affecting around 10% of men, 5% of women and 1%
of children. The prevalence is much higher in obese, elderly
212
Definitions and classification 25
or hypertensive individuals and is also prominent in some Nonpharmacological management includes sleep hygiene,
patients with intellectual disabilities. The repeated stress of exercise and avoidance of agents which may worsen symp-
sudden arousals has significant cardiovascular and neuro- toms (e.g. alcohol, caffeine, medication). Pharmacological
psychiatric morbidity and should be actively excluded when management is reserved for severe cases for short p eriods
an at-risk patient presents with hypersomnia, impairment (e.g. 6 months) and includes dopamine agonists (e.g. prami-
of concentration and memory or other psychiatric symp- pexole, ropinirole) or antiepileptics which bind v oltage-gated
toms. Collateral history from a bed partner, who is often calcium channels (gabapentin, pregabalin).
aware of the sleeping difficulties, is extremely useful.
The diagnosis is confirmed by polysomnography with
concurrent monitoring of electroencephalogram and res- Non-REM sleep arousal disorders
piration. Treatment comprises lifestyle advice (weight loss, Non-REM sleep arousal disorders are recurrent incomplete
avoidance of alcohol, sleep on one’s side, not back) and pro- awakenings from sleep during sleep stages outwith REM,
vision of nasal continuous positive airway pressure. generally slow wave sleep and generally during the first
third of the night. The duration of the incomplete awak-
RED FLAG ening is generally 1–10 minutes but can be up to an hour.
The two main subtypes are night terrors and sleep walk-
Obstructive sleep apnoea increases the risk for ing. They are thought to share a common pathophysiology.
road traffic accidents around sevenfold, and also Management is to exclude other diagnoses, offer reassur-
increases the risk for systemic hypertension. It ance and advise good sleep hygiene. It is not necessary to at-
is a useful diagnosis to make as the majority of tempt to terminate episodes, but it may be useful to remove
patients respond well to treatment with continuous potentially harmful objects or routes from around someone
positive airway pressure. However, most cases go who sleepwalks frequently.
undiagnosed.
Sleep terrors (night terrors)
Sleep terrors are episodes that feature an individual (usually
a child) abruptly waking from sleep, usually with a scream,
HINTS AND TIPS appearing to be in a state of extreme fear. These episodes are
associated with:
Medication and substances increase the risk for • Autonomic arousal, for example, tachycardia, dilated
obstructive sleep apnoea, particularly opiates, pupils, sweating and rapid breathing
benzodiazepines and alcohol. Always take a • A relative unresponsiveness to the efforts of others
substance history in someone presenting with to comfort the person, who appears confused and
symptoms of sleep apnoea. disorientated
Upon full awakening, there is amnesia for the episode and no
recall of any dream or nightmare. Sleep terrors are seen in up to
6% of children aged 4–12 years and usually resolve by adoles-
Sleep-related movement disorder cence. Sleep terrors should be distinguished from nightmares,
Restless legs syndrome is the commonest sleep-related panic attacks and epileptic seizures. Panic attacks tend not to
movement disorder. Patients report uncomfortable sen- be associated with confusion, and amnesia is uncommon.
sations in their legs when at rest (typically crawling, burn-
ing, tingling or itching), which are relieved by movement. Sleepwalking (somnambulism)
Because inactivity is required for sleep, restless leg syndrome Sleepwalking is characterized by an unusual state of con-
can delay sleep onset and precipitate awakenings. The dis- sciousness in which complex motor behaviour occurs
order arises most frequently in young adults and generally during sleep. While sleepwalking, the individual has a blank
worsens slowly over time, affecting around 1 in 50 people. staring face, is relatively unresponsive to communication
It runs in families, is twice as common in women, and often from others and is difficult to waken. When sleepwalk-
occurs transiently during pregnancy. Medication can cause ers do wake up, either during an episode or the following
it, particularly lithium, antidepressants, antihistamines morning, they have no recollection of the event ever having
and dopamine antagonists (e.g. metoclopramide, antipsy- occurred. Sleepwalking is not associated with impairment
chotics). Key differentials are peripheral neuropathy (not of cognition or behaviour, although there may be an initial
worse at night), vascular disease (worsened by movement, brief period of disorientation subsequent to waking up from
not relieved) and akathisia (movement driven by an inner a sleepwalking episode. The peak prevalence of sleepwalk-
restlessness, not a specific need to move legs). Ferritin levels ing occurs at the age of 12 years, with an onset between the
should be checked, as restless legs are a rare presentation of age of 4 and 8 years. About 2%–3% of children and about
iron deficiency, which impacts on dopamine metabolism. 0.5% of adults have regular episodes. Sleepwalking runs in
213
families, with 80% of sleepwalkers having a positive family REM sleep behaviour disorder
history for sleepwalking or sleep terrors.
Unlike the other parasomnias, REM sleep behaviour disorder
is more common in older adults, typically presenting in men
Nightmares in their 50s. There is a failure of muscle atonia during REM,
Between 10% and 50% of children, aged 3–5 years, expe- allowing dreams to be acted out. The dream content is often
rience repeated nightmares, and they also occur occasion- of a negative and violent nature, so sufferers may jerk, punch,
ally in up to 50% of adults. Nightmares are characterized shout, get out of bed or attack their partner. This occurs regard-
by an individual waking from sleep due to an intensely less of whether the sufferer has a history of violence and aggres-
frightening dream involving threats to survival, security or sion. When awakened, patients often report very vivid, intense,
self-esteem. Nightmares are distinguished from sleep ter- threatening dreams. Often, patients present because of injuries
rors by the observation that not only is the individual alert to themselves or their partner. The behaviours are more frequent
and orientated immediately after awakening but is able to in the last third of the sleep period and can occur cyclically (as
recall the bad dream in vivid detail. Furthermore, night- REM sleep occurs approximately every 90 minutes).
mares tend to occur during the second half of the night There is a strong association between REM sleep be-
because they arise almost exclusively during REM sleep, haviour disorder and neurodegenerative conditions involv-
which tends to be longer and have more intense, surreal ing abnormal deposition of synuclein protein (Parkinson
dreaming during the latter part of the night. Nightmares disease, Lewy body dementia, multisystem atrophy). Over
can be precipitated by withdrawal from REM-suppressing half of patients will go on to be diagnosed with Parkinson
agents (such as antidepressants or alcohol) or by com- disease, potentially up to 10 years later. The sleep disorder
mencing β-blockers or dopamine agonists. Management is can improve as the neurodegeneration progresses.
to reassure, avoid medications that may precipitate night- Management includes environmental modification to
mares and advise avoidance of stress. reduce injury (e.g. cushions around the bed, removal of po-
tentially dangerous objects from the bedroom). Clonazepam
is highly effective in reducing the behaviours (up to 90% of
cases). Interestingly, tolerance does not seem to arise, so it
can be continued long-term.
HINTS AND TIPS

RED FLAG
Upon awakening from a rapid eye movement Rapid eye movement sleep behaviour disorders
(REM) parasomnia, the patient is alert and recalls often arise in the early stages of neurodegenerative
a dream. Patients who are woken from a non-REM conditions such as Parkinson disease and
parasomnia are disorientated and confused, with Lewy body dementia. Careful assessment and
no recollection of a dream or their behaviour. monitoring of neurological status are needed.
Chapter Summary
• Sleep can be disrupted due to a primary sleep disorder, a psychiatric condition, a medical
condition or substance use (prescribed medications or recreational).
• Dyssomnias are characterized by abnormalities in the amount, quality or timing of sleep.
• Parasomnias are characterized by abnormal episodes that occur during sleep or sleep–
wake transitions.
• Good sleep hygiene, ensuring sufficient duration of sleep and avoiding recreational
substances are recommended for all patients with sleep problems.
• Hypnotics can be helpful for short-term use in insomnia but lose effectiveness if
continued long-term.
FURTHER READING
Sleep diary sample Epworth sleepiness scale
http://yoursleep.aasmnet.org/pdf/sleepdiary.pdf http://epworthsleepinessscale.com/about-the-ess/
214
The psychosexual disorders
26
Healthy sexual functioning requires a healthy body and, consists of both psychological and biological processes
perhaps more importantly, a healthy mind and relationship. and it is rarely possible to identify cases of sexual dysfunc-
Physical or psychological problems (or a combination of the tion with a purely physiological or purely psychological
two) can cause a wide variety of sexual problems. Mental aetiology. Nevertheless, both the International Statistical
health workers may be consulted about sexual problems Classification of Diseases and Related Health Problems,
that are largely due to psychological difficulties (not pre- 10th revision (ICD-10) and the Diagnostic and Statistical
dominantly due to a biological problem) – that is, psycho- Manual of Mental Disorders, 5th Edition (DSM-5) stipulate
sexual problems. that a sexual dysfunction disorder should only be diagnosed
The psychosexual disorders can be classified into three when the problem is not better explained by medication use,
groups: substance use or a physical medical condition. Table 26.1
• Sexual dysfunction summarizes the sexual dysfunction disorders.
• Disorders of sexual preference (paraphilias)
• Gender identity disorders
HINTS AND TIPS
Women have a large interindividual variability in

the type and duration of stimulation that results
SEXUAL DYSFUNCTION
in orgasm. The diagnosis of female orgasmic
disorder should only be made if the ability to
Clinical features achieve orgasm is less than would be reasonably
Sexual stimulation is summarized in a four-phase sexual expected for a woman’s age, sexual experience
response cycle (Fig. 26.1). Sexual dysfunction describes and quality of sexual activity – and then only if the
pain associated with intercourse or abnormalities of the orgasmic dysfunction results in marked distress or
sexual response cycle that lead to difficulties in participat- relationship difficulties.
ing in sexual activities. Although this chapter is focused
on psychological dysfunction, the sexual response cycle
Phase 1: Desire
Consists of sexual fantasies and the desire to have sexual activity
Phase 2: Excitement
Consists of the subjective sense of sexual pleasure and the accompanying physiological changes (e.g. erection in the
man; vaginal lubrication in the woman)
Phase 3: Orgasm
Consists of the peaking of sexual pleasure, release of sexual tension and rhythmic contraction of the perineal
muscles and pelvic reproductive organs (men: sensation of ejaculation inevitably followed by ejaculation;
women: contractions of outer third of vagina)
Phase 4: Resolution
Consists of a sense of muscular relaxation and general well-being. Men are refractory to further erection and orgasm
for a period of time. Women may be able to have multiple orgasms.
Fig. 26.1 The four-phase sexual response cycle.
215
Table 26.1 Sexual dysfunction disorders

Phase of cycle Dysfunctiona Description
Desire Lack or loss of sexual desire (male hypoactive Loss of desire to have, or to fantasize about sex –
sexual desire disorder; female sexual interest/ not due to other sexual dysfunction (e.g. erectile
arousal disorder) dysfunction, dyspareunia)
Sexual aversion and lack of sexual enjoyment Avoidance of sex due to negative feelings (fear,
anxiety, repulsion) or lack of enjoyment
Excitement Failure of genital response (male erectile Inability to attain or maintain sexual intercourse
disorder; female sexual arousal disorder) due to an inadequate erection in men, or poor
lubrication–swelling response in women
Orgasm Orgasmic dysfunction (female orgasmic disorder; Recurrent absence, or delay, of orgasm or
delayed ejaculation) ejaculation despite adequate sexual stimulation
Premature ejaculation (premature ejaculation) Recurrent ejaculation with minimal sexual
stimulation before the man wishes
Sexual pain Nonorganic dyspareunia (genito-pelvic pain/ Genital pain during sex in men or women – not
penetration disorder) due to other sexual dysfunction (e.g. poor
Vaginismus lubrication–swelling response, vaginismus) or
medical condition (e.g. atrophic vaginitis)
Recurrent, involuntary spasm of the muscles that
surround the outer third of the vagina, causing
occlusion of the vaginal opening
a
The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) terms are in square brackets; the International Statistical
Classification of Diseases and Related Health Problems, 10th revision (ICD-10) terms are not. In general, DSM-5 has simplified the
classification of symptoms into fewer sexual dysfunction disorders. The current draft of ICD-11 (not yet published) is similar to DSM-5.
Epidemiology Table 26.2 Reported frequency of sexual dysfunction

in Britons aged 16–74 years
Sexual dysfunction is very common. A recent large UK sur-
vey found that 42% of men and 51% of women reported (%)a
one or more problems with sexual response lasting at least Men Premature ejaculation 15
3 months, but only around 10% of people were distressed Lack of sexual interest 15
about their sexual function. The self-report cross-sectional Erectile difficulties 13
prevalence (not clinical diagnoses) of specific sexual dys- Unable to achieve orgasm 9
functions is shown in Table 26.2. The evidence suggests that: Women Lack of sexual interest 34
• The prevalence of sexual problems in women tends Unable to achieve orgasm 16
to decrease with increasing age, except for those who Trouble lubricating 13
report trouble lubricating. Dyspareunia 8
• Men, by contrast, have an increased prevalence of a
Problem present for 3 or more months in those who have
erectile problems with increasing age. had sex within previous year (data from Sexual function in
Britain: findings from the third National Survey of Sexual
• Sexual dysfunction is more likely among people with
Attitudes and Lifestyles (Natsal-3). Mitchell KR et al.,
poor physical and emotional health (particularly Lancet. 2013 Nov 30;382(9907):1817–29. Doi: 10.1016/
depression). S0140-6736(13)62366-1.)
• Sexual dysfunction is highly associated with negative
experiences in sexual relationships.
• Sexual dysfunction is associated with relationship • Fears of consequences of sex (e.g. pregnancy, sexually
difficulties: being unhappy in a relationship, not being transmitted diseases)
in a steady relationship and difficulties communicating • A poor or deteriorating relationship (e.g. feeling
with a partner about sex. undesirable, finding the partner undesirable, lack of
trust, feelings of resentment or hostility, lack of respect,
fear of rejection)
Aetiology • Anxiety about sexual performance or physical
There are many, often interrelated, psychosocial factors that attractiveness
may result in psychogenic sexual dysfunction: • Fatigue, stress or difficult psychosocial
• Ambivalent attitude about sex or intimacy (e.g. anxiety, circumstances
fear, guilt, shame) Frequently, there is more than one psychosocial problem
• History of rape or childhood sexual abuse that can affect more than one of the phases of the sexual
216
Sexual dysfunction 26
response cycle. For example, the belief that sex is inherently

sinful in the context of an abusive relationship may lead to RED FLAG
a lack of desire, a poor lubrication–swelling response and Erectile dysfunction is a strong predictor of
difficulty in reaching orgasm.
coronary artery disease and is a common
presenting symptom of diabetes mellitus. Assess
Differential diagnosis cardiovascular risk and glucose in all men
Other causes of sexual dysfunction should be excluded presenting with erectile dysfunction.
when assessing a patient with sexual dysfunction. These
include:
• Medical conditions (e.g. diabetes mellitus, vascular
disease, vaginitis, endometriosis, spinal cord injuries, HINTS AND TIPS
pelvic fractures, prostatectomy, multiple sclerosis,
thyroid disease, hyperprolactinaemia) The clear presence of a biological cause of sexual
• Prescribed or recreational drugs (see Box 26.1) dysfunction does not rule out a psychogenic sexual
• Psychiatric illness: mental disorders such as depression, dysfunction, as the two are often interrelated. For
anxiety and alcohol dependence are frequently example, a 55-year-old man with diabetes and
associated with sexual dysfunction. In addition, advanced atherosclerosis notices a weakened
psychiatric medication often results in sexual
erection; he subsequently becomes anxious during
dysfunction as a side-effect. However, sexual functioning
sex, fearing that he is losing his virility. This leads to
frequently improves as the patient’s mental illness (e.g.
depression) improves, even though the medication (e.g. a complete loss of his erectile potency.
antidepressants) may have adverse sexual effects.
Assessment considerations
BOX 26.1 PRESCRIBED AND RECREATIONAL
DRUGS ASSOCIATED WITH SEXUAL • The wide differential diagnosis requires a comprehensive
DYSFUNCTION history including medical, psychiatric, sexual and
relationship histories as well as current medication and
Psychiatric drugs recreational substance use. Questions regarding sexual
• Antidepressants (tricyclics, SSRIs and MAOIs)a activities outside the problematic context (e.g. morning
• Antipsychotics (especially first-generation erections, masturbation, sexual fantasy) can be very helpful.
• A thorough physical examination, including genitalia,
antipsychotics)
should be conducted. In addition, gynaecological
• Benzodiazepines
examination may be needed for cases of dyspareunia or
• Lithium vaginismus in women.
Recreational drugs • Blood tests should be performed to assess for
• Alcohol medical causes of sexual dysfunction, particularly
• Amphetamines hyperprolactinaemia, hypotestosteronaemia and, in
• Cannabis erectile dysfunction, glucose and lipids. Rarely, further
investigations may be necessary to exclude medical
• Cocaine
causes of erectile dysfunction (e.g. monitoring of
• Opiates
nocturnal penile tumescence (excludes physiological
Medical drugs causes of impotence if able to have erection during
• Antiandrogens rapid eye movement sleep) and monitoring penile
• Anticonvulsants blood flow with Doppler ultrasonography).
• Antihistamines
• Antihypertensives (including β-blockers)
• Digoxin COMMUNICATION
• Diuretics Taking a sexual history can be embarrassing
a The antidepressant least likely to be associated with sexual for both patients and doctors, and basic
dysfunction is mirtazapine.
MAOI, Monoamine oxidase inhibitor; SSRI, selective serotonin
communication skills are very important. Privacy
reuptake inhibitor. should be ensured, and nonverbal aspects of
217
Table 26.3 Specific exercises useful in sexual

communication utilized (e.g. body language, use
dysfunction
of silence). Straightforward terminology should
be used (e.g. ‘vagina’, rather than ‘down below’; Sexual dysfunction Exercise
‘condom’, rather than ‘protection’). Reassurance Female orgasmic Exercises in sexual fantasy and
and acknowledgement of discomfort (e.g. ‘I can disorder masturbation, sometimes with a
vibrator or dildo
see how difficult this is for you to talk about’) can
be very helpful. Premature ejaculation Squeeze technique: partner or
individual squeezes the glans of
penis for a few seconds when
he feels that he is about to
ejaculate
Start–stop method: stimulation
Management considerations is halted and arousal is allowed
to subside when the man feels
• Many patients need no more than reassurance, advice
that ejaculation is imminent. The
and sexual education. Patients who have significant process is then repeated
relationship difficulties may benefit from relationship Quiet vagina: man keeps
counselling before attempting specific treatment for penis motionless in vagina
sexual dysfunction. for increasing periods before
• Some couples with minor problems benefit from ejaculating
self-help materials, particularly those with no major Vaginismus Desensitization, first by finger
relationship difficulties. insertion followed by dilators of
• Urology clinics deal mainly with physiological sexual increasing size
dysfunction, particularly erectile problems.
• Sexual dysfunction clinics have multidisciplinary teams
that focus on both psychological and physical aspects
of sexual dysfunction and are best equipped to deal
with cases that do not respond to nonspecific
measures. BOX 26.2 MANAGEMENT OF MEN WITH
• Some couples benefit from sex therapy, in which ERECTILE DYSFUNCTION
partners are treated together and are taught to
• Check testosterone level.
communicate openly about sex, in addition to receiving
• Calculate 10-year cardiovascular risk and
education about sexual anatomy and the physiology
of the sexual response cycle. They also take part in manage appropriately.
graded assignments, beginning with caressing of their • Lifestyle advice:
partner’s body, without genital contact, for their own and • Weight loss, stop smoking, reduce alcohol,
then their partner’s pleasure. These behavioural tasks increase exercise.
progress through a number of stages with increasing • If a man cycles more than 3 hours a week:
sexual intimacy, with the focus remaining on pleasurable advise a trial without cycling.
physical contact as opposed to the monitoring of sexual • Medication:
arousal or the preoccupation with achieving orgasm. • Consider substituting potentially contributory
Couples suitable for sex therapy include those with a medication (see Box 26.1).
significant psychological component to their problem,
• Consider a phosphodiesterase inhibitor
those with reasonable motivation and those with a
(sildenafil, tadalafil or vardenafil), regardless
reasonably harmonious relationship.
• Table 26.3 summarizes some of the specific exercises of the cause.
often used in the context of sex therapy that may be
helpful with particular problems.
• Biological treatments may be very effective, especially
for erectile problems (e.g. oral sildenafil (Viagra),
intracavernosal injections, vacuum devices, prosthetic
implants and surgery for venous leakage). See Box 26.2.
Prognosis
Testosterone may increase sexual drive in patients Vaginismus has an excellent prognosis. Premature ejacu-
with low levels of the hormone. For difficulties with lation and psychogenic erectile dysfunction also respond
premature ejaculation, selective serotonin reuptake fairly well to treatment. Problems associated with low
inhibitors may delay ejaculation, but this is rarely a sexual desire, especially in men, seem more resistant to
long-term solution. treatment.
218
Gender identity 26
or early adulthood. Paedophilia and exhibitionism are fre-

DISORDERS OF SEXUAL quently seen in a forensic setting and account for the ma-
PREFERENCE (PARAPHILIAS) jority of sexual offenders referred for a psychiatric opinion
(see Chapter 32). Prevalence of paraphilias in the general
The essential features of a paraphilia are recurrent sexually population has not been reliably assessed. The aetiology is
arousing fantasies, sexual urges or behaviours involving: (1) unknown, but there is often an impaired capacity for affec-
nonhuman objects; (2) the suffering or humiliation of one- tionate sexual activity, and patients with paraphilia often
self or one’s partner; or (3) children or other nonconsenting have comorbid personality disorders.
individuals. However, normal sexuality need not necessar-
ily be focused on genitals with the aim of reproduction. To
be a disorder, the paraphilia needs to be causing significant RED FLAG
harm, or high risk for harm, to the individual or others. It is
useful to divide the paraphilias into two groups: Paraphilias can emerge due to medical or
1. Abnormalities of the object of sexual interest (e.g. psychiatric conditions: mania, frontal lobe
paedophilia, fetishism, transvestic fetishism). injury, neurodegenerative conditions or as a rare
2. Abnormalities of the sexual act (e.g. exhibitionism, side-effect of high doses of dopaminomimetic
voyeurism, sexual sadism, sexual masochism). medication. Always ask about the duration of an
Table 26.4 summarizes the specific paraphilias. The para- unusual sexual preference.
philias are mainly confined to men (with the exception of
sexual masochism) and usually begin in late adolescence
Management options include behaviour therapy (co-

Table 26.4 The paraphilias vert sensitization, where patients attempt to pair paraphilic
Abnormalities of the object of sexual interest thoughts with humiliating consequences) and aversion
therapy (pairing paraphilic thoughts with a noxious stim-
Paedophilia Sexual fantasies, urges or behaviours
involving children ulus such as an unpleasant odour or taste). Individual
psychodynamic and group therapies are also used.
Fetishism Sexual fantasies, urges or behaviours
Cognitive-behavioural therapy programmes and antiandro-
involving inanimate objects or parts of
the body that are not directly erogenous gens (e.g. cyproterone acetate) have shown some efficacy
in the treatment of some paedophiles and exhibitionists;
Transvestic Sexual fantasies, urges or behaviours
however, there is little evidence that any treatment is con-
fetishism involving cross-dressing (wearing of
clothes of the opposite sex). Rare in sistently effective in either of these conditions. It should be
women. noted that, dependent on risk for offending, management
within a forensic setting may be required (see Chapter 32).
Other Many other abnormal objects of sexual
interest are found more rarely (e.g. Paraphilias associated with a young age of onset, a high
animals (zoophilia or bestiality), corpses frequency of acts, no remorse about acts and a lack of moti-
(necrophilia), faeces (coprophilia), urine vation for change have a particularly poor prognosis.
(urophilia))
Abnormalities of the sexual act
Exhibitionism Sexual fantasies, urges or behaviours
involving the exposure of genitals to GENDER IDENTITY
unsuspecting strangers
Voyeurism Sexual fantasies, urges or behaviours Gender identity describes an individual’s inner sense of
involving the act of observing being male or female. This usually corresponds to the per-
unsuspecting people engaging in sexual son’s sexual identity which comprises all their biological and
activity or undressing anatomical sexual characteristics (i.e. external and inter-
Frotteurism Sexual fantasies, urges or behaviours nal genitalia, chromosomes, sex hormones and secondary
involving touching or rubbing against a sex characteristics). Gender identity is thought to be fully
nonconsenting person formed by the age of 3 years.
Sexual sadism Sexual fantasies, urges or behaviours There has been considerable debate over the years as
involving the infliction of acts of physical to whether gender identity disorder (termed transsexual-
or psychological suffering or humiliation ism in ICD-10) is a mental disorder. Many do not regard
on others
cross-gender feelings and behaviours as a ‘disorder’, and
Sexual Sexual fantasies, urges or behaviours instead question what constitutes a normal gender iden-
masochism involving the infliction of acts of tity or gender role. DSM-5 has replaced the term with the
humiliation or suffering on oneself
(less stigmatizing) term ‘gender dysphoria’ and the current
219
draft of ICD-11 (not yet published) uses the term ‘gender

incongruence’. HINTS AND TIPS
Many areas provide multidisciplinary clinics for people Transgenderism, transsexualism and transvestism
whose biological gender is inconsistent with their gender
are not the same.
identity. The role of the psychiatrist is to exclude the pres-
ence of mental disorder as a cause of gender dysphoria (e.g. • Transgenderism describes identifying with a
a delusional belief in schizophrenia), and to assess and treat gender different to the gender assigned at birth.
comorbid mental disorders which may be present. • Transsexualism describes a refusal to live as the
Patients who are committed to gender change can be gender assigned at birth.
helped with hormones and surgery, usually after they have • Transvestism describes dressing in clothes
completed a ‘real life test’, which involves living as the oppo- intended for members of the opposite sex.
site sex for at least a year.
Questions you may find useful are ‘Do you wish
to be accepted as the opposite sex?’ ‘Are you
content with your gender?’ ‘Does cross-dressing
cause sexual arousal?’ The latter would suggest
transvestic fetishism.
Chapter Summary
• Sexual dysfunction is common, particularly in those with poor physical or emotional

health.
• It often arises due to a combination of physical and psychological factors.
• It is important to exclude potentially serious causes, particularly cardiovascular disease
and diabetes in erectile dysfunction.
• Management of any psychological component hinges on reassurance, psychoeducation
and graded intimate contact.
• Paraphilias are unusual sexual interests that are viewed as disorders when associated
with significant harm, or risk for harm, to the individual or others.
• Gender dysphoria/incongruence is a mismatch between a person’s initial gender
assignment and experienced gender. Rarely, this arises due to mental disorder.
220
Disorders relating to the
menstrual cycle, pregnancy and
the puerperium 27
do not differ in levels of reproductive hormones, there is
PREMENSTRUAL SYNDROME some evidence that those with PMS are more sensitive to a
given level of progesterone. The responsiveness to proges-
Clinical features terone is probably influenced by serotonin (which normally
The premenstrual syndrome (PMS) has been defined as the dampens the behavioural consequences of progesterone)
recurrence of symptoms during the premenstruum, with and possibly also influenced by γ-aminobutyric acid.
their absence in the postmenstruum. Symptoms tend to
occur in the 10 days prior to menstruation, peaking 2 days Management
before menses begin and remit in the 2 weeks following.
Management is informed by aetiology, with the principles
Mental health symptoms include low mood, labile mood,
being stress reduction, ovulation suppression (which pre-
irritability, concentration difficulties, anxiety and fatigue.
vents the luteal rise in progesterone) and central nervous
Physical symptoms such as headache, abdominal bloating
system serotonin enhancement.
and breast tenderness are also fairly common. The timing
In mild PMS, NICE (2014) recommends advice on
of a given symptom relative to menstruation rather than its
healthy eating, stress reduction, regular sleep and regular
exact nature is what is diagnostically important.
exercise. In moderate PMS, NICE (2014) recommends a
The Diagnostic and Statistical Manual of Mental
new-generation combined oral contraceptive (first-line
Disorders, 5th Edition (DSM-5) and the current draft
treatments are those containing the progestogen drospire-
of International Statistical Classification of Diseases and
none). If pain is a prominent symptom, paracetamol or a
Related Health Problems, 11th edition (ICD-11; not
nonsteroidal antiinflammatory drug is recommended. If
yet published) describe premenstrual dysphoric disorder
the patient is interested in psychological intervention, refer
(PMDD), which in essence are the mental health symptoms
for cognitive-behavioural therapy (CBT). In severe PMS
of PMS combined with significant distress or functional im-
(which would include anyone with a diagnosis of PMDD),
pairment. Prospective evaluation of symptoms over at least
the strategies for moderate PMS should be trialled first,
two cycles is recommended prior to making the diagnosis,
and a selective serotonin reuptake inhibitor (SSRI) tried if
as retrospective recall is unreliable.
these are ineffective. This can be given either continuously
The National Institute for Health and Care Excellence
or during the luteal phase only (days 15–28, stopping on
(NICE; 2014) classifies PMS as mild, moderate or severe
first day of menses). Standard doses of common SSRIs are
depending on its impact on personal, social or professional
recommended (e.g. fluoxetine 20 mg). If these treatment
life. Mild PMS does not interfere with normal functioning
options do not work, further treatments can be initiated
in these domains, moderate PMS causes interference, and
under specialist supervision including gonadotropin-
severe PMS causes withdrawal from these domains.
releasing hormone analogues with add-back hormone re-
placement therapy (HRT) or even surgical treatment with
Epidemiology/aetiology add-back HRT.
Up to 40% of women report experiencing some symptoms
of PMS, however, only around a fifth seek medical help and
only about 5% of women experience symptoms of a sever-
ity sufficient to interfere with their work or lifestyle. The MENOPAUSE
prevalence is higher in women who experience significant
degrees of psychosocial stress, have a history of trauma, are There is little evidence that the menopause itself leads to an
obese, have a family history of PMS or who have a history of increased incidence of mental illness. Psychological symp-
depression or anxiety. In those who have a history of mental toms may understandably accompany the changes that oc-
health problems it is important to confirm that the luteal cur with the menopause; however, it should be remembered
phase symptoms are not merely an exacerbation of difficul- that this is a time associated with other psychosocial stress-
ties that are present continuously. If this is the case, manage- ors, such as children leaving home and a growing awareness
ment should focus on the primary mental health problem. of ageing. There is no clear psychiatric indication for HRT
The principal theory of causation is that the rise in and its use for psychological symptoms remains controver-
progesterone during the luteal phase is responsible for
sial. HRT should never substitute treatment with recognized
symptoms of PMS. Although women with and without PMS antidepressants for the treatment of a depressive illness.
221
Disorders relating to the menstrual cycle, pregnancy and the puerperium
PSYCHIATRIC CONSIDERATIONS BOX 27.1 INDICATIONS FOR REFERRAL TO

IN PREGNANCY PERINATAL MENTAL HEALTH SERVICES
Preconceptual counselling (e.g. for women with

• The development of new psychiatric illnesses during
pregnancy is no more common than in the general bipolar disorder).
population. However, both psychosocial stressors and Pregnant women who are severely psychiatrically
changing or stopping maintenance medications in unwell.
women with a history of major mental illnesses carry a Pregnant women who are at high risk for significant
degree of risk, and the puerperium is a high-risk period puerperal illness.
for relapse in major mental illness, particularly bipolar Women who are psychiatrically unwell and are the
affective disorder. Domestic violence is more common main carers of babies under 6 months of age.
during pregnancy, and this can impair mental health Pregnant women with harmful or dependent use of
and resilience. substances including alcohol should be referred
• Women with a major mental illness (bipolar affective
to a specialist substance misuse team.
disorder, schizophrenia, severe depression) or a history
of puerperal psychosis who are pregnant or planning
pregnancy should be referred to perinatal psychiatry
services, even if they have been stable for some years. be made prior to conception (if possible). Up-to-
Box 27.1 summarizes the indications for referral to a date information on the use of medications during
specialist perinatal mental health team. pregnancy should always be sought.
• For patients prescribed psychotropic medication • There is an increased incidence of adverse life
during pregnancy, a judgement needs to be made – events in the weeks prior to a spontaneous abortion
in conjunction with the patient – regarding the risk (miscarriage).
for relapse against the risk for medication-induced • Following miscarriage and termination of pregnancy,
teratogenic or adverse effects for the mother or child. there is an increased risk for adjustment and
Risks associated with various psychotropic medications bereavement reactions (see Chapter 14). In addition,
are summarized in Table 27.1. Decisions should the risk for puerperal psychosis remains.
Table 27.1 Psychiatric medication during pregnancy and breastfeedinga

Drug group Pregnancy Breastfeeding
Selective serotonin Can be associated with withdrawal symptoms Paroxetine and sertraline: very small amounts
reuptake inhibitors in neonates, which are generally mild and excreted in breast milk; short half-life fluoxetine
self-limiting. Rarely associated with persistent and citalopram are excreted in relatively larger
pulmonary hypertension when given after first (but still small) amounts. Fluoxetine has a long
trimester. half-life and thus may accumulate.
Tricyclic Have been used during pregnancy for many Tricyclics are excreted in small amounts only
antidepressants years. Commonly result in mild and self-limiting but avoid doxepin (accumulation of metabolite).
withdrawal reactions in neonates.
Mood stabilizers All are associated with teratogenicity. Valproate Risk for neonatal lithium toxicity as breast
and carbamazepine increase the risk for milk contains 40% of maternal lithium
neural tube defects and should be avoided in concentration. Avoid if possible. Consider the
pregnancy. Valproate also increases the risk for use of valproate or carbamazepine if necessary,
developmental disorders (30%–40% of babies). but bear in mind risk for infant hepatotoxicity.
Lithium increases the risk for cardiac defects but
may be taken during pregnancy.
Antipsychotics Most antipsychotics have no established Only small amounts excreted but possible
teratogenic effects but may cause self-limiting effects on developing nervous system. Avoid
extrapyramidal side-effects in neonates. high doses due to risk for lethargy in infant.
Olanzapine increases risk for gestational
diabetes.
Benzodiazepines Associated with floppy infant syndrome May cause lethargy in infant. Choose drugs
and other hypnotics (hypotonia, breathing and feeding difficulties) with short half-lives (e.g. lorazepam) if
and neonatal withdrawal syndrome. necessary.
a
Information on the risks of medication during pregnancy and breastfeeding is constantly evolving. Seek up-to-date advice (see box
below).
222
Puerperal disorders 27
HINTS AND TIPS PUERPERAL DISORDERS

It is easy to be put off by the potential Any mental disorder can arise during or be exacerbated by
consequences of medication on a developing pregnancy, delivery or new motherhood. These experiences
foetus but remember that a psychiatrically unwell are anxiety provoking, stressful and potentially life-threatening.
mother is harmful for a baby’s gestation and They can be difficult for anyone to deal with, even without pre-
infancy also: risks of stopping medication often vious mental health problems, and can worsen symptoms or
outweigh risks of continuing. This decision needs maladaptive behaviours in those with existing mental health
problems. This chapter covers the most common and impor
to be made in conjunction with the patient, and any
tant perinatal psychiatric disorders, but all the other mental
partners or family the patient wishes to involve.
disorders can and do occur in the perinatal period.
In general, the symptoms of a mental disorder are the
same within and without the perinatal period, but manage-
HINTS AND TIPS ment can be different as treatment decisions involving med-
ication during pregnancy or breastfeeding require a careful
General principles of prescribing in pregnancy are: risk–benefit analysis.
• use the drug with the lowest known risk to
mother and foetus
HINTS AND TIPS
• use the lowest effective dose
• use a single drug rather than multiple drugs, if The incidence of psychiatric illness in the
possible and be aware that doses may need puerperium is exceptionally high. In primiparous
adjusted due to physiological consequences of women, there is up to a 35-fold increased risk for
pregnancy. developing a psychotic illness and needing hospital
admission in the first month following childbirth.
Women with bipolar affective disorder have a 40%
HINTS AND TIPS chance of relapse during the postpartum period,
with 20% experiencing a severe relapse. This
Pseudocyesis is the rare condition when a emphasizes the importance of close vigilance in
nonpregnant woman has the signs and symptoms the postpartum period, especially in women with a
of pregnancy (e.g. abdominal distension, breast personal or family history of mental illness.
enlargement, cessation of menses, enlargement
of the uterus). Couvade syndrome describes the
condition in which men develop typical pregnancy-
related symptoms during their partner’s pregnancy Postnatal ‘blues’
(e.g. morning sickness, vague abdominal pains, Also known as ‘maternity blues’ and ‘baby blues’, this
labour pains). Both of these conditions are occurs in up to 50% of postpartum women. It presents within
psychosomatic and should be distinguished from the first 10 days postdelivery, symptoms peak between days
delusion of pregnancy. Pseudocyesis and delusion of 3 and 5 and it resolves within 2 weeks. It is characterized
pregnancy may occur together. by episodes of tearfulness, mild depression or emotional la-
bility, anxiety and irritability. There appears to be no links
with life events, demographic factors or obstetric events,
which is suggestive of an underlying biological cause (e.g.
HINTS AND TIPS a sudden fall in progesterone postdelivery). Postnatal blues
is self-limiting, resolves spontaneously and usually only
Useful sources of up-to-date information regarding requires reassurance. However, an apparent bad case of
medication during pregnancy and breastfeeding are postnatal blues may mark the onset of postnatal depression.
• UK teratology information service Symptoms lasting longer than 2 weeks should raise suspi-
(UKTIS; http://www.uktis.org/) cion of a depressive episode.
• Best use of medicines in pregnancy (BUMPS;
http://www.medicinesinpregnancy.org/) Postnatal depression
• Drugs and Lactation Database (LACTMED;
https://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm) Clinical features
Postnatal depression usually develops within 3 months of
delivery (and can start during pregnancy), with peak time of
223
onset at 3–4 weeks. A depressive episode arising more than long-term harm to a baby, but there are significant risks
6 months after delivery is not generally viewed as postna- for the baby’s cognitive and emotional development if
tal depression. The symptoms are similar to a nonpuerperal the mother has untreated depression. Table 27.1 pro-
depressive episode: low mood, loss of interest or pleasure, vides information on the use of psychotropic medication
fatigability and suicidal ideation (although suicide is rare). in breastfeeding mothers. Mothers with severe postnatal
Note that sleeping difficulties, weight loss and decreased li- depression with suicidal/infanticidal ideation may re-
bido can be normal for the first few months following deliv- quire hospital admission, with admission with the baby
ery. Additional features of postnatal depression may include: to a mother-and-baby unit usually being preferable.
• Anxious preoccupation with the baby’s health, often Electroconvulsive therapy may be indicated and usually
associated with feelings of guilt and inadequacy results in a rapid improvement, which is important to al-
• Reduced affection for the baby with possible impaired low the woman to resume contact with the baby as soon
bonding as possible. Remember that the assessment of the infant’s
• Obsessional phenomena, typically involving recurrent well-being is an additional part of the comprehensive psy-
and intrusive thoughts of harming the baby (it is chosocial and risk assessment.
crucial to ascertain whether these are regarded as
distressing (ego-dystonic), as obsessions usually are, or
whether they pose a potential risk).
• Infanticidal thoughts (thoughts of killing the baby) HINTS AND TIPS
require urgent psychiatric assessment. True infanticidal
If a woman has been on an antidepressant
thoughts are different from obsessions in that they
during pregnancy, do not change after delivery
are not experienced as distressing (ego-syntonic as
opposed to ego-dystonic), and (worryingly) may to a different antidepressant that is ‘better for
involve active planning. breastfeeding’. Doing this means the child is
exposed to two medications, instead of one.
Epidemiology and aetiology The foetus is exposed to far greater levels of
In high-income countries, postnatal depression is the most antidepressant in utero than levels transmitted
common complication of childbirth, with rates of around in breast milk, so if they are healthy at delivery
12%. Evidence suggests that biological factors are not as they are unlikely to be harmed by further, lower,
important as they are in postnatal blues and postpartum exposure.
psychosis. Psychosocial factors are strongly linked to the
development of postnatal depression, with the lack of a
close confiding relationship, intimate partner violence, low
income and young maternal age all implicated. A previous
history of depression is an important risk factor. In women Prognosis
with a history of depression, obstetric complications during Most women respond to standard treatment and episodes
delivery are associated with an increased rate of postnatal resolve within 3–6 months; however, some patients have a
depression. protracted illness and may require long-term treatment and
follow-up. Woman who develop postnatal depression have
Management around a 40% increased risk for developing a similar illness
The diagnosis and management of postnatal depression following childbirth in the future. Postnatal depression is
are often undertaken within primary care. Psychological associated with disturbances in the mother–infant relation-
and social measures, such as mother-and-baby groups, ship, and this can lead to problems with the child’s cognitive
relationship counselling and problem solving, are often and emotional development.
helpful. Midwives and health visitors can be very helpful.
In mild cases, NICE (2014) recommends facilitated self-
help. For more severe illness, NICE (2014) recommends RED FLAG
a high-intensity psychological intervention (e.g. CBT) or
antidepressant medication (a tricyclic, SSRI or serotonin– Suicide is a leading cause of maternal death,
norepinephrine reuptake inhibitor). Antidepressants even though it is fortunately rare (1 in 100,000
may be transmitted in small quantities to the baby via pregnancies). About 60% of cases were
breast milk, and a judgement needs to be made, in con- experiencing a severe affective or psychotic illness
junction with the patient, of the risks versus benefits of at the time of death. Always ask about thoughts of
medication. It should be noted that (with the exception suicide in a new mother who is mentally unwell.
of doxepin) there has never been evidence to suggest that
antidepressants transmitted via breast milk have caused
224
Puerperal disorders 27
Perinatal anxiety disorders (e.g. postnatal depression). The woman may seek help,
or difficulties may be identified by a health visitor.
Clinical features Management is to involve an early years service who can
Anxiety disorders in the perinatal period present very provide guidance to the mother regarding positive infant
similarly to anxiety disorders outside the perinatal period interactions.
and can include generalized anxiety disorder, obsessive-
compulsive disorder, phobias and posttraumatic stress dis- Postpartum (puerperal) psychosis
order, which may have onset following a highly distressing
delivery. Tokophobia is a specific phobia of childbirth and Clinical features
can be primary (nulliparous) or secondary (often following The postpartum period is an extremely high-risk period for
a difficult first delivery). Anxiety disorders can occur on the development of a psychotic episode. Postpartum (puer-
their own or comorbidly with depression. peral) psychotic episodes characteristically have an abrupt
onset with rapid deterioration. About 50% of symptoms
Epidemiology and aetiology begin on postnatal days 1–3 and the vast majority within
Anxiety disorders occur in around 13% of women who 2 weeks of delivery. Episodes typically begin with insomnia,
are pregnant or postpartum. Many of these disorders arise restlessness and perplexity, later progressing to suspicious-
prior to pregnancy rather than being triggered by it, how- ness and marked psychotic symptoms (often with content
ever, there is some evidence that the risk for new-onset related to the baby). The symptoms can be polymorphic,
obsessive-compulsive disorder is increased postpartum and frequently fluctuate dramatically in their nature and

(approximately doubled). Risk factors for perinatal anxiety intensity over a short space of time. Mood symptoms are
disorders are unclear but are probably similar to those for prominent, and can comprise elation, depression or both
anxiety disorders outside the perinatal period (see Chapter (mixed affective state). Patients often retain a degree of in-
23), combined with the natural increase in anxiety that re- sight, and may not disclose certain bizarre delusions or sui-
sponsibility for a vulnerable new infant brings. cidal/homicidal thoughts.
Management
The diagnosis and management of perinatal anxiety are RED FLAG
often done within primary care. As with postnatal de-
Postpartum psychosis is a psychiatric emergency.
pression, midwives and health visitors can be very helpful
in identifying psychosocial supports such as community The rapidly fluctuating nature of symptoms means
groups and classes. The first-line intervention in all cases that a very cautious approach to management
is a psychological therapy (NICE 2014). The nature of the needs to be taken – a person who seems
therapy depends on the type of anxiety disorder and its reasonably well at interview could deteriorate
severity, following the general NICE guidance for adults rapidly. Admission is required in all cases.
(see Chapter 23). Medication may also be required, par-
ticularly if a woman is already taking this or has required
it in the past.
Epidemiology and aetiology
Prognosis Postpartum psychosis develops in about 1 in 500 child-
With the exception of posttraumatic stress disorder, anxi- births. It occurs more frequently in primiparous women,
ety disorders tend to be chronic, relapsing/remitting con- and those who have a personal or family history of bipolar
ditions. Anxiety disorders during pregnancy are a risk affective disorder or postpartum psychosis. If a close fam-
factor for postnatal depression. Prenatal maternal anxiety ily member has bipolar affective disorder, the risk can be as
is associated with altered stress-induced cortisol responses high as 15 in 500 childbirths. Psychosocial factors seem less
in 7-month-old infants and subsequently in adolescence, important, unlike in postnatal depression. Occasionally, a
potentially influencing the child’s own risk for anxiety and postpartum psychosis may be precipitated by an obstetric
depression. complication (e.g. preeclampsia, puerperal infection) or
medication. Delirium secondary to such complications is an
important differential. Box 27.2 summarizes the risk factors
Failure to bond for postpartum psychosis.
Some women struggle to form a loving bond with their
baby. Mothers at particular risk include those whose own Management
mother–infant attachment was insecure (see Table 30.1), Postpartum psychosis is a psychiatric emergency. The as-
women who experienced childhood neglect or sexual sessment of the risk for infanticide and suicide is crucial.
abuse and women with perinatal psychiatric difficulties Concerning symptoms include:
225
BOX 27.2 RISK FACTORS FOR POSTPARTUM HINTS AND TIPS

PSYCHOSIS
The prevalence of postnatal blues, postnatal
Previous postpartum psychosis depression and puerperal psychosis is inversely
History of mood disorder (particularly bipolar related to their severity:
affective disorder) • Postnatal blues develops after 1 in 2 childbirths.
Family history of postpartum psychosis or bipolar • Postnatal depression develops after 1 in 10
affective disorder childbirths.
Primiparous mother • Puerperal psychosis develops after 1 in 500
Delivery associated with caesarean section or childbirths.
perinatal death
Electroconvulsive therapy can be particularly effective in

• Thoughts of self-harm or harming the baby severe or treatment-resistant cases. Psychosocial interven-
• Severe depressive delusions (e.g. belief that the baby is, tions are similar to those for other psychotic episodes, but
or should be, dead) also include providing support for the father.
• Command hallucinations instructing the mother to
harm herself or her baby Prognosis
Hospitalization is invariably necessary, with joint admis- Most cases of puerperal psychosis will have recovered by
sions to a mother-and-baby unit being preferable when 3 months (75% within 6 weeks). Around one in six women
the mother is able to look after her infant under supervi- who have a first episode of mood disorder following deliv-
sion. Detention under mental health legislation may be ery will go on to develop bipolar disorder. There is about
necessary. Depending on presentation, antipsychotics, an- a 50% chance of experiencing a recurrence of postpartum
tidepressants and mood-stabilizing medications are indi- psychosis after future childbirths, which can be reduced by
cated. Benzodiazepines may be needed in cases of severe prophylactic therapy. Women who have had both puerperal
behavioural disturbance. All psychotropic drugs should be and nonpuerperal depressive or manic episodes (i.e. have
used with caution in breastfeeding mothers (see Table 27.1), an established mood disorder) have up to an 85% chance of
but many women are too unwell to breastfeed in any case. future puerperal psychotic episodes.
Chapter Summary
• Premenstrual dysphoric syndrome describes mood and anxiety symptoms during the
luteal phase only, which are severe enough to cause functional impairment.
• Treatment of premenstrual dysphoric disorder includes lifestyle advice, preventing
ovulation via oral contraception, cognitive-behavioural therapy and selective serotonin
reuptake inhibitors.
• Postnatal blues is a common and self-limiting episode of mood and anxiety symptoms,
which resolve within 2 weeks of delivery.
• Postnatal depression is a common and potentially serious episode of depression arising
within 6 months of delivery.
• Management of postnatal depression is very similar to standard management of
depression, but in severe cases admission to a mother-and-baby unit may be required
and electroconvulsive therapy is recommended at an early stage.
• Postpartum psychosis is a rare but very serious illness generally arising within 2 weeks of
delivery.
• In all cases of postpartum psychosis admission to a mother-and-baby unit is required for
risk management.
226
The personality disorders
28
This chapter discusses the disorders associated with the Genetics
presenting complaints in Chapter 17, which you might find • Monozygotic twins show a higher concordance for
helpful to read first. personality disorders than dizygotic twins, suggesting a
heritability of 30%–60%.
• Cluster A personality disorders (see Table 17.1;
especially schizotypal) are more common in the
THE PERSONALITY DISORDERS relatives of patients with schizophrenia.
• Some authors have suggested that schizoid
Epidemiology and schizotypal personality disorders may be a
neurodevelopmental disorder, possibly within the
There is a lack of consensus about the definition of per- autistic spectrum.
sonality disorders. Although the Diagnostic and Statistical • Depressive disorders are more common in the relatives
Manual of Mental Disorders, 5th Edition (DSM-5) and of patients with emotionally unstable (borderline)
International Statistical Classification of Diseases and personality disorder.
Related Health Problems, 10th revision (ICD-10) classifi-
cation systems have produced definitions, it is rare for a pa-
tient with a personality disorder to neatly match with only
Early life experience
• Early adverse social circumstances (such as parental
one discrete category. It is also unclear whether there is any
alcoholism, physical or emotional neglect, violence,
correlation between diagnostic criteria and the subjective
sexual abuse) are associated with the development of
experiences of people identified as having disordered per-
cluster B personality disorders (see Table 17.1).
sonality. While a number of structured interview schedules
• There is a strong association between borderline
and diagnostic instruments have been validated, the level of
personality disorder and childhood sexual abuse,
correlation between these is generally poor. Mental health
although this is not universal.
professionals also remain divided as to how personality
• Various psychoanalytical theories suggest that disordered
disorders should be conceptualized, with some clinicians
attachment between infants and their caregivers lead to
questioning whether the diagnosis is of any clinical benefit.
difficulties in relationships throughout the rest of life,
Patients with personality disorders have a significantly
which may manifest as personality disorders.
increased mortality, as well as physical and psychiatric mor-
bidity. Relationships with relatives and friends are adversely
affected, and there is a strong association between some Assessment, clinical features,
types of personality disorder and involvement with health classification and differential
care and criminal justice services.
diagnosis
Community studies have shown the prevalence of any
personality disorder to be 4%–13%, with an increased prev- Discussed in Chapter 17.
alence in younger age groups (particularly 25–44 years), and
an equal distribution between the sexes. This varies accord- Management
ing to the population group sampled. It is higher in patients
frequently consulting general practitioners (GPs; 10%–30%), In the past, there has been considerable debate concern-
even higher in psychiatric outpatient clinics (30%–40%) ing how (and by whom) patients with personality disorders
and higher still in psychiatric inpatients (40%–50%), self- should be managed. Previously, personality disorders were
harming patients (40%–80%) and prisoners (50%–80%). generally considered to be untreatable. However, advances
Table 28.1 describes the prevalence of the individual in diagnosis, psychotherapy and psychopharmacology have
disorders and their relevant epidemiology. Note the broad equipped clinicians with a variety of treatment options that
ranges of prevalence from different studies, highlighting the can be useful in maximizing engagement with services, reduc-
lack of correlation in the current literature. ing distress, managing comorbid mental illness and substance
misuse, improving relationships and optimizing quality of life.
Patients with emotionally unstable (borderline) person-
Aetiology ality disorder are frequently encountered in clinical prac-
Different environmental and biological/genetic factors are tice, and the most is known about what treatments do, and
implicated in the aetiology of different personality disor- do not, help people with this diagnosis. This will therefore
ders, supporting their heterogenicity. be the focus of this section.
227
Table 28.1 Epidemiology of personality disorders

Prevalence in general
Personality disorder population (%) Comments
Paranoid 0.7–4.4 More common in males and lower socioeconomic classes
More common in relatives of patients with schizophrenia
Schizoid 0.7–4.9 More common in males and offender populations
May be more common in relatives of patients with
schizophrenia
Schizotypal 1.6–3.9 More common in relatives of patients with schizophrenia
May be slightly more common in males
Emotionally unstable 1.2–5.9 More prevalent in younger age groups and females
(borderline) Aetiological link with childhood sexual abuse
Most contact with services in mid-20s
40-fold increase in suicide rate
Associated with poor work history and single marital status
Often comorbid with depression, substance abuse, bulimia
and anxiety
Antisocial (dissocial) 0.6–4.5 Much more common in men
Highest prevalence in 25–44 year olds
Associated with school dropout, conduct disorder and urban
settings
Very high prevalence in prisons and forensic settings
Highly comorbidity with substance abuse
Histrionic 0.4–2.9 Recent research shows equal gender ratio (previously thought
to be more common in women)
Narcissistic 0.1–6.2 More common in males and forensic settings
Dependent 0.3–0.6 Often comorbid with borderline personality disorder
Avoidant (anxious) 1–5.2 Equal gender ratio
Comorbid with social phobia
Obsessive compulsive 1.2–7.9 More common in white, male, highly educated, married and
(anankastic) employed individuals
Principles of managing patients with PRINCIPLES OF CARE IN MANAGING

emotionally unstable personality disorder EMOTIONALLY UNSTABLE PERSONALITY
DISORDER
Patients with emotionally unstable personality disorder
should not be excluded from health or social care services • Be positive, kind and nonjudgemental (many are
because of their diagnosis or because they have self-harmed. victims of abuse).
A consistent and tolerant approach should be taken.
• Be accessible, consistent and reliable (do what
Autonomy and choice should be encouraged, with the pa-
you say you will do).
tient being actively involved in deciding treatment options
and in finding solutions to their problems. An optimistic, • Encourage autonomy; facilitate the patient to
trusting and nonjudgemental relationship should be devel- find his/her own solutions to problems.
oped. Endings and transitions may evoke strong emotions • What is the problem right now?
and reactions in patients with emotionally unstable per- • What has worked in the past?
sonality disorder, and as such should be carefully planned • What would you like to do?
and structured to minimize distress. A multidisciplinary • What is an achievable change?
approach to care should be considered, as psychological, • Manage transitions and changes carefully, in a
social and biological treatment modalities all have an im- planned way.
portant role. A comprehensive assessment should be made • Monitor for comorbid mental illness (e.g.
of sources of distress to self and others (thoughts, emotions,
depression or substance use)
behaviour and relationships), other comorbid mental illness
and specific impairments of functioning at work or home.
228
The personality disorders 28
Crisis management biological, psychological and social management strategies

It can be useful to develop a crisis management plan in con- can be employed in the shorter term, with the aim of facili-
junction with the patient, detailing self-management strat- tating trust, building a positive relationship with health and
egies, sources of support (family, friends, telephone-based social care services and identifying and alleviating sources
services) and details on how to access emergency care. This of distress.
should be shared with the patient and other relevant profes-
sionals (GPs, assessment and crisis teams). Psychopharmacology
There are no medications that are currently recommended
EXAMPLE CRISIS PLAN IN EMOTIONALLY specifically for the treatment of emotionally unstable per-
UNSTABLE PERSONALITY DISORDER sonality disorder (National Institute for Health and Care
Excellence (NICE) 2009). However, drugs can be useful
Triggers that might lead to a crisis to treat comorbid mental illness, or to manage cases of be-
e.g. Losing job, drinking too much alcohol, havioural disturbance and suicidal behaviour during the
argument with partner more severe phases. In addition, there is some evidence that
Things I can do to help myself some drugs may be efficacious in targeting specific symp-
e.g. Talk to my friend, go to a movie, exercise, get toms. For instance, antipsychotics may be of some use in
enough sleep, avoid drugs and alcohol treating the pseudo-psychotic symptoms that are some-
When I should seek help times experienced, in reducing agitation and in stabilizing
e.g. If I injure myself badly, if I am having very mood. Antidepressants may be useful in treating depressive
symptoms. Selective serotonin reuptake inhibitors may help
strong thoughts of suicide, if I feel so sad that I
with obsessive-compulsive symptoms as well as impulsiv-
can’t go to work, if my friend advises me to
ity and self-harming behaviour. Mood stabilizers such as
Who I should contact and how lithium, sodium valproate and lamotrigine may be useful
e.g. Samaritans, general practitioner, community in treating aggression, impulsivity and mood instability.
psychiatric nurse, crisis team, NHS24, best Benzodiazepines should be used with caution due to the
friend, mother potential for abuse, dependence and diversion.
Psychosocial
Short-term drug treatments can be useful to alleviate Supportive psychotherapy provides patients with an author-
distress during a crisis. If possible, this should be agreed in ity figure during times of crisis. Regular contact with a health
advance with the care team and the patient. Drugs with ac- care professional can also provide the patient with a sense
ceptable side-effects and low dependence profiles are pref- of containment. Members of the multidisciplinary team can
erable, and should be dispensed in small quantities if there provide psychoeducation, as well as facilitating development
is a risk for overdose. Drugs should not be used in place of of coping strategies, relaxation and distraction techniques,
other more appropriate interventions. improving disturbed relationships and development of skills
Before admission to acute in-patient psychiatric care, and hobbies. In cooperation with social services, issues such
crisis resolution or home treatment teams should be con- as housing, finances and employment can be addressed.
sidered. Admission may be necessary if the management
of the crisis involves significant risk to self or others that
cannot be managed within other services. If possible, ac- COMMUNICATION
tively involve the patient in the decision, and ensure that it
is based on an explicit, joint understanding of the potential People with emotionally unstable personality
benefits (and likely harm) that may result from admission. disorder by definition have difficulties forming
Agree the length and purpose of the admission in advance. and maintaining relationships, and that includes
If the patient is detained under mental health legislation, doctor–patient relationships! Misunderstandings and
ensure that this is regularly reviewed and that management frustration are common on both sides. Remember
on a voluntary basis is resumed at the earliest opportunity. to be calm, clear and consistent and try to take
After a crisis has resolved, ensure that the care plan is the long view; do not let one difficult encounter
updated. If drug treatment was started, review this and dis-
dominate your relationship with the patient.
continue if possible. If this is not possible, ensure that it is
regularly reviewed to monitor effectiveness, side-effects,
misuse and dependency.
Longer-term management
Short-term management The long-term management of patients with emotion-
While treatment of emotionally unstable personality disor- ally unstable personality disorder involves addressing and
der should be considered to be a long-term process, various modifying maladaptive traits of personality. This generally
229
involves psychological therapy. Because traits and be- safe environment. These placements tend to be reserved for
haviours tend to be deeply engrained, this process can take those with severe functional impairment or very high ser-
many years. Around 40% of people with emotionally unsta- vice usage, because of their high cost.
ble personality disorder disengage with psychotherapy, and
so it is important to build a trusting relationship and to be
prepared for therapeutic change taking a long time. HINTS AND TIPS
There is evidence suggesting the efficacy of various mo-
dalities of psychotherapy in the treatment of emotionally Remember that personality disorders involve
unstable personality disorder. It may be that the consistency long-standing personality traits. While they are
of therapy, the maintenance of boundaries and the empathic ‘treatable’, pharmacotherapy is not the mainstay,
and nonjudgemental stance of the therapist allows for the but is used to alleviate specific symptoms (e.g.
successful development of a therapeutic relationship, which comorbid depression, anxiety or impulsivity).
may in itself be more important than the specific type of Medications are unlikely to affect maladaptive
therapy. For more information on psychotherapy, see personality traits. With appropriate psychosocial
Chapter 3. The following psychological treatments can be interventions, these may significantly improve
helpful in emotionally unstable personality disorder:
with time. You may want to consider this when
• Dialectical behaviour therapy uses a combination of discussing management with patients.
cognitive and behavioural therapies, with relaxation
techniques and mindfulness. It involves both individual
and group therapy, and can be helpful in reducing
self-harming and improving functioning. It is
recommended by NICE (2009). Course and prognosis
• Mentalization-based therapy focuses on allowing The course of personality disorders, and the prognosis of
patients to better understand what is going on in both sufferers, is not as dire as was once thought. Some 78%–99%
their minds and in the minds of others. It can utilize of patients with emotionally unstable personality disorder
both individual and group components. will show signs of sustained symptomatic remission at 16-
• Cognitive behavioural therapy has been adapted for use year follow-up. Patients with antisocial personality may also
as ‘schema-focused therapy’. improve with time, especially if they have formed a relation-
• Cognitive analytical therapy. ship with a therapist. Schizotypal and obsessive-compulsive
• Psychodynamic psychotherapy, as both individual and personality disorders tend to be stable over time, although
group therapy, which focuses on the relationship with schizotypal patients may go on to develop schizophrenia.
the therapist. Patients with personality disorder have a greater inci-
Therapeutic communities are a residential form of therapy, dence of other mental illnesses such as depression, bipolar
where the patient may stay for weeks or months. The com- affective disorder, anxiety and schizophrenia. Furthermore,
munity tends to run as a ‘democracy’, with patients often these tend to be more severe and have a worse prognosis
having as much say as the staff. Most of the therapeutic than if the personality disorder was not present. Patients
work is done in groups, and patients learn from getting on with personality disorder (especially cluster B) also have far
(or not getting on) with others. It differs from ‘real life’ in higher rates of suicide and accidental death than the general
that any disagreements or upsets happen in a controlled and population.
Chapter Summary
• Personality disorders are common, particularly in users of health services.

• Comorbid mental illnesses are more frequent and difficult to treat in those with
personality disorder.
• When managing emotionally unstable personality disorder:
• Take a consistent, nonjudgemental approach.
• Help the patient to make a crisis plan and share it with everyone involved in the
patient’s care.
• Symptoms can be improved by long-term psychological treatments such as dialectical
behavioural therapy.
• Medication is only recommended in crises and for comorbid mental illnesses.
• Personality disorders generally gradually improve over decades.
230
The neurodevelopmental
disorders 29
Neurodevelopmental disorders are a large and diverse Table 29.2 Causes of intellectual disability
group. This chapter covers those that most commonly pres-
Genetic Trisomies or large structural variants
ent to psychiatry: intellectual disability, autism spectrum
(e.g. Down syndrome, fragile X
disorders (ASDs), attention deficit hyperactivity disorder syndrome, Prader–Willi syndrome)
(ADHD) and Tourette syndrome. Inherited point mutations (e.g.
phenylketonuria, neurofibromatosis,
tuberous sclerosis, Lesch–Nyhan
syndrome, Tay–Sachs disease, other
enzyme-deficiency diseases)
INTELLECTUAL DISABILITY De novo (sporadic) point mutations
have been identified in over 700 genes,
potentially all with the capacity to
Epidemiology and aetiology contribute to intellectual disability
Key epidemiology is shown in Table 29.1. Some common Prenatal Congenital infections (e.g. TORCH
causes of intellectual disability are shown in Table 29.2. No infections (toxoplasmosis, rubella,
clear aetiology can be determined in at least a third of pa- cytomegalovirus, herpes simplex and
zoster (chicken pox)), also syphilis and
tients with mild intellectual disability, suggesting they may
human immunodeficiency virus (HIV))
represent the lower end of the normal distribution curve Substance use during pregnancy (e.g.
for intellectual functioning. Specific causes are more likely foetal alcohol syndrome, prescribed
to be found in people with severe or profound intellectual drugs with teratogenic effects)
disabilities. Complications of pregnancy (e.g.
preeclampsia, intrauterine growth
retardation, antepartum haemorrhage)
Assessment, clinical features, Perinatal Birth trauma (e.g. intracranial
haemorrhage, hypoxia)
investigations and differential Prematurity (e.g. intraventricular
diagnosis haemorrhage, hyperbilirubinaemia
(kernicterus), infections)
See Chapter 18.
Environmental Neglect, malnutrition (e.g. iodine
deficiency in developing countries), poor
linguistic and social stimulation
Medical Infections (e.g. meningitis, encephalitis)
conditions in Head injury
childhood Toxins (e.g. lead, other heavy metals)
Table 29.1 Epidemiology of neurodevelopmental
disorders
Population Sex ratio Management and prognosis
Disorder prevalencea (female:male)
Intellectual disability 1% 1:1.5
Prevention and detection
Primary prevention includes genetic screening and
Autism spectrum 1% 1:3 counselling for higher risk groups, prenatal testing

disorders
(e.g. amniocentesis, rhesus incompatibility), improved
Attention deficit 5% in children 1:2 perinatal and neonatal care and early detection of meta-
hyperactivity disorder 2.5% in adults bolic abnormalities that may contribute to intellectual im-
Tourette syndrome 0.3% 1:3 pairment (e.g. phenylketonuria, neonatal hypothyroidism).
a
These estimates are approximate but taken from meta-analysis Milder intellectual disabilities may be less obvious, and
where possible. Different diagnostic systems give different early detection requires the ability of teachers and family
prevalence estimates doctors to be able to identify difficulties as soon as possible.
231
The neurodevelopmental disorders
Secondary prevention aims to prevent the p rogression of

disability, by providing compensatory education and early HINTS AND TIPS
attempts to reduce behavioural problems. If you suspect a Epilepsy is a common comorbidity in individuals
child has an intellectual disability, this should be discussed
with intellectual disabilities and can often
with either a paediatrician or a child and adolescent mental
complicate assessment and management.
health specialist, who will be able to provide guidance on
local services. If you suspect an adult has an undiagnosed Remember that a number of different psychotropic
mild intellectual disability, this should be discussed with medications can lower seizure threshold, and that
the local intellectual disabilities team, who may suggest an ‘mood stabilizers’ (with the exception of lithium) are
initial referral for neuropsychological assessment. antiepileptic medications.
Help for families

Families require information, advice and both psycholog-
ical and practical support from the time that the diagno- COMMUNICATION
sis is first made. Adequate time should be devoted to this,
and should aim to involve the parents in helping their child Collateral histories are invaluable when assessing
achieve their full potential. Support should be ongoing, someone with an intellectual disability. When a
and should focus on education, practical matters and psy- change in behaviour occurs, it is useful to ask
chological support. This may need to be increased at the about what else has changed in the patient’s life or
more challenging times, such as puberty, starting or leaving their daily routine. However, the prevalence of other
school, times of stress (e.g. bereavement or illness) and the
psychiatric disorders is three to four times higher
transition to adult services.
and so these must be excluded.
Education, training and occupation

If the needs of a child with intellectual disability can be
met by mainstream education, this should be encouraged
due to the benefits of societal inclusion and mutual un-
Psychiatric care
Given the higher prevalence of comorbid mental illness in
derstanding. However, many children with intellectual
this group, people with intellectual disabilities should have
disabilities have complex needs that are better addressed
access to specialist care (usually on an outpatient, commu-
in specialist schools. Later, vocational guidance should be
nity or day-patient basis) as and when required. Because
offered: most people with mild intellectual disabilities are
the assessment and management of psychiatric illness and
able to take mainstream or supported employment (e.g.
behavioural disturbances in individuals with intellectual
Remploy).
disability can be difficult, most areas have multidisciplinary
specialist teams. These teams can address not only major
Housing and social support mental illnesses (e.g. schizophrenia, bipolar affective dis-
Most people with mild intellectual disabilities are able to order, depression), but can also help manage autism and
live independently, with varying degrees of social and famil- challenging behaviours. Psychotropic medication may be
ial support. Assessment of tasks of daily living will be nec- indicated; however, given the common difficulties with
essary to ensure that people are appropriately placed. For unusual presentations, polypharmacy, comorbidities and
people with more severe difficulties, residential care may be sensitivity to medication, there should be a low threshold
necessary. In such cases, development of social skills should for seeking advice from, or referral to, a specialist doctor.
be encouraged as far as is practical. Behavioural therapy may be useful in the management of
maladaptive or otherwise difficult behaviours (e.g. self-
Medical care injury, aggression, destructiveness).
People with intellectual disabilities should have the same
access to medical services as everyone else, although com-
munication difficulties and false attribution of symptoms
to the intellectual disability (diagnostic overshadowing) AUTISM SPECTRUM DISORDERS
mean care is often suboptimal. Extra medical care is often
required due to comorbidities such as physical disability
or epilepsy. Many general hospitals have specialist nurses
who are experienced in the management of individuals Key epidemiology is shown in Table 29.1. Autism is a highly
with intellectual disabilities admitted for medical treat- heritable condition (heritability of around 80%). A substantial
ment or surgery. proportion of this genetic risk is not inherited but arises from
232
Attention deficit hyperactivity disorders 29
sporadic mutations – de novo (sporadic) variants occur four

times as often in people with autism as their unaffected sib- BOX 29.1 PSYCHOSOCIAL INTERVENTIONS
IN ADULTS WITH AUTISM (NICE 2012)
lings. Rare variants in over 800 genes have been linked to au-
tism in this manner and are thought to be the cause in around Everyone:
one in five cases. Common genetic variants of small effect are
• Self-help or support groups – for individuals,
also thought to exist, but these have not yet been conclusively
and for their families, partners or carers.
identified. Analyses of common biological processes influ-
enced by the numerous implicated genes have highlighted a • Social learning program (group or individual).
range of core cellular functions underlying synaptic formation Should include modelling of useful social
and signalling: cell adhesion, chromatin r emodelling and reg- behaviour, explicit statement of social rules and
ulation of transcription and translation. It seems likely that strategies for difficult social situations.
what is currently referred to as ‘autism spectrum disorder’ is If appropriate to individual:
made up of many different sorts of disorder influencing dis- • Supported employment programme
tinct but related basic neuronal functions.
• Structured leisure activity, with a facilitator
Although genetics may seem far removed from clinical
• Anger management
practice at present, it can provide clinically relevant infor-
mation. For example, if parents have one child with autism, • Antivictimization intervention
the overall risk for having a second child with autism is • Crisis plan
10%–15%. However, if genetic testing identifies a causative
genetic variant as de novo or inherited, this risk can be much
more accurately estimated at 1% or 50%, respectively (if the
variant is 100% penetrant). children, a social–communication intervention that is play
based and designed to maximize joint attention and recip-
HINTS AND TIPS
rocal communication between the child and their parents,
carers or teachers is recommended (NICE 2013). Comorbid
Many of the genes linked to autism have also been mental health problems (e.g. anxiety or depression) should
associated with intellectual disability, epilepsy, be treated as normal, except that psychological interven-
schizophrenia and attention deficit hyperactivity tions should focus more on changing behaviour rather than
cognitions and avoid the use of metaphor and hypothetical
disorder: the same genetic variants can influence
situations.
risk for many neurodevelopmental disorders.
ASDs are lifelong conditions for which there is no cure.
The functional impact of symptoms fluctuates in response
to stressors such as change (school, relationships, employ-
ment) and physical illness. The prognosis is extremely vari-
COMMUNICATION able, reflecting the great variability between those with a
diagnosis. An intelligence quotient (IQ) above 70, commu-
There is no evidence to support the claim that the nicative language by age 5 years and absence of epilepsy are
measles, mumps, rubella (MMR) vaccine results in predictors of better long-term outcome. Some people can
autism. The small study that did suggest there was learn to develop strategies to work around their difficulties
a link has since been conclusively discredited. and make use of their strengths; however, many continue
to have difficulty in finding employment or friendship and
require family support into adulthood. Those with a comor-
bid intellectual disability are unlikely to be able to live inde-
Assessment, clinical features, pendently in adulthood.
investigations and differential
diagnosis
See Chapter 18.
ATTENTION DEFICIT
HYPERACTIVITY DISORDERS
Management and prognosis
No pharmacological treatments are recommended for the
core symptoms of autism (National Institute for Health and Key epidemiology is shown in Table 29.1. Twin stud-
Care Excellence (NICE) 2012, 2013). Instead, the emphasis ies have shown that ADHD has one of the highest her-
is on psychosocial interventions (see Box 29.1, adults). In itabilities of all psychiatric illnesses, at around 80%.
233
The neurodevelopmental disorders
A f irst-degree relative of someone with ADHD has a 20%

chance of also having ADHD. Replicated candidate gene COMMUNICATION
studies and genome-wide association studies of copy
Parents’ concerns need to be addressed as well
number variants implicate variants in genes encoding
as the patient’s. Treatment of attention deficit
dopaminergic, serotonergic and glutamatergic pathways
hyperactivity disorder has received much media
as influencing risk.
Prenatal, perinatal and postnatal environmental factors interest, especially potential side-effects – be
also modestly increase risk: maternal smoking, alcohol con- aware of this. Methylphenidate is associated with
sumption and heroin use during pregnancy; very low birth growth suppression with prolonged use. It is only
weight; foetal hypoxia; perinatal brain injury and prolonged prescribed in specialist settings with regular weight
emotional deprivation during infancy. and height monitoring. Drug holidays can be used
to allow children to make-up growth gains. Rarely,
Assessment, clinical features, atomoxetine is associated with liver dysfunction
investigations and differential and suicidality.
diagnosis
See Chapter 18.
RED FLAG
Management and prognosis Before starting attention deficit hyperactivity
disorder drug treatment, assess height, weight,
Children
blood pressure and heart rate and personal or
Psychosocial interventions are recommended in all cases
and are used first line in children and young people with family history of cardiovascular disease. Then
mild to moderate ADHD, and in all preschool children monitor these parameters during treatment.
(NICE 2008). The choice of treatment naturally depends Stimulants are sympathomimetic and can suppress
on the developmental stage of the child or adolescent. appetite.
Useful strategies include parental education or training,
cognitive-behavioural therapy (CBT) and social skills
training.
Pharmacological management is the first-line treatment COMMUNICATION
in school-age children with severe ADHD and is second
line for those with moderate ADHD in whom psychoso- One way to sum up management of severe
cial interventions have been of insufficient benefit (NICE childhood attention deficit hyperactivity disorder
2008). The central nervous system stimulant methylpheni- (ADHD), or adult ADHD, is to tell patients they
date (Ritalin, Concerta, Equasym) is normally tried in the need both ‘pills and skills’. ‘Pills’ can provide a
first instance. Atomoxetine (Strattera) and dexamfetamine
window of opportunity to allow people to develop
are also licensed in the UK for the management of ADHD:
organizational ‘skills’ they struggled to achieve
these tend to be used in cases where methylphenidate is in-
effective or poorly tolerated. In treatment-resistant cases, before.
the (unlicensed) use of bupropion, clonidine, modafinil and
guanfacine, as well as some antidepressant drugs, may be
considered; however, this should only be done following re-
ferral to a tertiary centre. Adults
Improvement usually occurs during adolescence, par- Pharmacological management is first line for adults with
ticularly in hyperactivity. Unstable family dynamics and moderate or severe ADHD. Psychological interventions
coexisting conduct disorder are associated with a worse such as CBT may have benefit, but little research is available
prognosis. Around two-thirds of patients have symptoms yet. Methylphenidate is recommended first, with dexamfet-
persisting into later life, although most do not require amine and atomoxetine second line.
ongoing management from adult mental health services. Diversion of stimulant medication is a risk in young
Children with ADHD are at increased risk for substance people and adults. If someone is actively using recreational
use and imprisonment in adult life. However, many people substances, advise them that they should stop doing so be-
with ADHD go on to have successful and enjoyable lives, fore a trial of ADHD medication. If fears remain regarding
with professional athletes, doctors, journalists and actors diversion, try atomoxetine or lisdexamfetamine (Elvanse).
publicly stating they have ADHD. Lisdexamfetamine is a prodrug that is metabolized to
234
Tourette syndrome 29
dexamfetamine by an enzyme in red blood cells. This limits

the rate at which dexamfetamine is generated, reducing its
TOURETTE SYNDROME
potential for abuse.
Key epidemiology is shown in Table 29.1. Aetiology is un-
RED FLAG clear but abnormalities in dopaminergic neurotransmission
have been found.
Stimulant medications are often diverted. If a
child needs stimulant medication prescribed
and there is a past or current history of parental Assessment, clinical features,
substance misuse, the school can be asked to investigations and differential
dispense medication, or an alternative used. diagnosis
If a young person or adult is actively using
recreational substances, they need to stop before See Chapter 18.
any stimulants can be prescribed. If this is not
possible, or if diversion is suspected at any point, a Management and prognosis
nonstimulant alternative can be tried.
Often tics do not require treatment, particularly if they
are not interfering with daily life. Tourette syndrome is
very commonly comorbid with other conditions (anxi-
ety, obsessive-compulsive disorder, ADHD), and these
Little research has been done on the persistence of should be treated first, according to standard guide-
ADHD symptoms across the lifespan. It seems reasonable lines. If tics remain problematic after other disorders are
that symptoms might become more tolerable as people treated, psychological treatments should be tried first
learn additional coping strategies (e.g. diaries, remind- (psychoeducation, habit reversal and exposure and re-
ers), or modify their environment to minimize functional sponse prevention). If tics persist, clonidine (an agonist)
impairment (e.g. get a job that requires brief bursts of sus- is recommended first. Antipsychotics can also help (hal-
tained attention only). ‘Drug holidays’ every couple of years operidol, pimozide, risperidone or aripiprazole). Risk for
to assess whether medication is still of benefit are probably side-effects should always be balanced against benefits on
worth trying. an individual basis.
ADHD is often comorbid with other psychiatric disor- Around two-thirds of children and young people with
ders (bipolar disorder, depression, anxiety disorders, sub- Tourette syndrome go on to have no or very mild tics in
stance use), so ensure these are assessed and treated also. adulthood.
Chapter Summary
• Neurodevelopmental disorders are common, particularly attention deficit hyperactivity

disorder (ADHD).
• Neurodevelopmental disorders are often comorbid with other mental disorders and
epilepsy. It is important to treat comorbid conditions.
• Intellectual disability and autism spectrum disorders are managed primarily with
psychosocial interventions.
• ADHD is managed with a combination of psychosocial and pharmacological
interventions.
235
Child and adolescent
psychiatry 30
This chapter covers the assessment and management of sets the tone for that child’s expectations for the rest of
problems with mood, anxiety or conduct in children and their life: how others are likely to behave towards them
young people. Neurodevelopmental disorders, including and how they should behave in return. Put simply, if a
intellectual disability, can cause similar symptoms or be co- child is shown kindness and understanding, they are
morbid with these disorders, but are covered separately in likely to become a kind and empathic adult. If a child is
Chapters 18 and 29. Mental illnesses that commonly affect ignored and neglected, they are less likely to be social or
adults such as eating disorders, bipolar affective disorder caring towards others. If a child is treated inconsistently,
and schizophrenia can also present in adolescence; these sometimes with love, sometimes with disdain, they will
are predominantly covered in their own chapters but also expect the world to be unpredictable and chaotic, people
briefly here. Finally, this chapter briefly covers child abuse. in authority to be untrustworthy and themselves as un-
Mental disorders in children can both be caused by child able to be in control. Disrupted attachment during early
abuse and increase the risk of experiencing abuse, and it is childhood can often lead to behavioural difficulties in
important to always be alert to this possibility. children and potentially personality disorders in adult-
hood (see Table 30.1).
Importantly, not everyone who has a difficult upbring-
ing will have a difficult adulthood; many individuals are re-
CHILD AND ADOLESCENT silient, and behaviour and thinking patterns can be changed
MENTAL HEALTH SERVICES (sometimes with the help of psychological therapy). It is
also important to note that primary caregivers do not al-
Child and Adolescent Mental Health Services (CAMHS) ways provide an optimal early environment for a range of
provide emotional and mental health support, diagnosis reasons, some within and some outwith their control (e.g.,
and treatment to individuals up to the age of 18 years. postnatal depression, substance use, poverty, bereavement,
Children often find it difficult to explicitly verbalize war). Nonetheless, encouraging parents and care providers
psychological distress. Instead, the presenting problem is to provide a loving and responsive environment for in-
most commonly a nonspecific concern about a child’s ab- fants and young children has become a key governmental
normal behaviour or performance (e.g., ‘being disruptive priority.
in the classroom’), often raised by someone other than the
young person (e.g., parent, schoolteacher, paediatrician).
This means the ability to take a good history and synthesize HINTS AND TIPS
information from multiple sources is particularly important
in CAMHS. As you meet children, young people and adults
Family and wider community are important in assess- who seem to be behaving in harmful ways, it
ing and maintaining a young person’s well-being and this can often be helpful to try to understand how
is reflected in the broad composition of multidisciplinary their early experiences have shaped them. Often
teams in CAMHS, which are likely to include psychiatrists, thoughts or behaviours that are helpful during
psychologists, occupational therapists, community men-
times of adversity (e.g., not trusting others when
tal health workers, social workers, community psychiatric
experiencing abuse) can become unhelpful in other
nurses, family therapists and creative therapists. Fig. 30.1
shows an overview of the tiered approach to CAMHS ser- times and contexts (e.g., difficulty forming close
vices common in the UK. relationships).
ATTACHMENT
EPIDEMIOLOGY
Attachment refers to the bond between an infant and
their primary caregiver. How the primary caregiver re- Mental health problems affect around 1 in 10 children. See
sponds to a young child’s needs during their early years Table 30.2 for individual disorders.
237
Child and adolescent psychiatry
Tier Services
Highly specialist CAMHS

Provide intensive support to the most severely affected
4 young people (e.g., inpatient unit, day programmes,
sexual trauma team, paediatric liaison team)
Specialist CAMHS
MDT providing assessment and treatments in community.
3 Manage young people with more complex and severe
disorders.
Mental Health Practitioners

2 CAMHS trained. Manage young people with milder
disorders. Provide training to universal services.
Universal Services
1 GPs, social workers, health visitors, school nurses,
teachers, youth justice workers, voluntary agencies
Fig. 30.1 Tiered structure of CAMHS. CAMHS, Child and Adolescent Mental Health Services; GP, general practitioner;
MDT, multidisciplinary team.
Table 30.1 Attachment styles

Child attachment
style Caregiver behaviour Child behaviour Adult attachment style Adult behaviour
Secure (two-thirds) Responsive, Happy, curious ‘Autonomous’ Able to self-soothe,
understanding, but also able to
consistent maintain relationships.
Insecure (a third)
‘Avoidant’ Aloof, unresponsive, Emotionally distant, ‘Dismissive’ Desire to be
(21%) ridiculing withdrawn independent.
Avoidance of intimacy.
‘Ambivalent/resistant’ At times sensitive, at Anxious, uncertain, ‘Preoccupied’ Hypersensitive
(16%) times ignores angry to rejection,
care-seeking.
‘Disorganized’ Abusive, scary, scared Sad, angry, fearful ‘Disorganized’ Fearful, abusive,
(rare) dissociative.
238
Mental illness in children and adolescents 30
Table 30.2 Epidemiology of mental disorders in e xperience inappropriate and excessive anxiety about sep-
childhood and adolescence aration from attachment figures. This disorder is only
diagnosed when the anxiety is of such a severity that it is
Prevalence in under
Typical age of 18-year-olds (post-
markedly different from other children of a similar age or
Disorder presentation typical age of onset) when it persists beyond the usual age period (e.g., a 6-year-
old girl becoming incredibly distressed when her mother
Intellectual Infancy or 3%
drops her off at school).
disability preschool
Autism spectrum Preschool or 1%
disorder primary Phobic anxiety disorder
Minor phobic symptoms are common in childhood, and
Attention deficit Preschool or 5%
the object of the phobia varies with developmental stage
hyperactivity primary
disorder (e.g., fear of animals or monsters in preschool children).
Phobic anxiety disorder is diagnosed when the phobic
Anxiety Primary or 5% (up to 20% have a
object is age inappropriate (e.g., a 9-year-old boy who
disorders older phobia)
is afraid of monsters under the bed), or where levels
Conduct Primary or 8% males, 4% of anxiety are clinically abnormal. Nondevelopmental
disorder older females
phobias (e.g., agoraphobia) do not fall under this cate-
Oppositional Primary or 4% gory, but under the adult phobia category (see Chapters
defiant disorder older 12 and 23).
Eating disorders Adolescence 1%
Depression Adolescence 4% Obsessive-compulsive disorder
Bipolar affective Late Rare Median age of onset is 10 years, but can be from age
disorder adolescence 5 years. About two-thirds of young children have various
Schizophrenia Late Rare
rituals/habits (e.g., lining up toys, specific stories before
adolescence bed) that parents may be concerned is OCD. What is im-
portant to bear in mind is the developmental stage of the
Personality Late Characteristic traits
disorder adolescence common, but not
child. Rituals/habits help children to make sense of the
usually diagnosed in world around them as they grow and develop. OCD is
adolescence suggested if the ritual/habit is very intense or frequent,
impairs the child’s ability to function or causes them dis-
tress. Another key difference between diagnosis in adults
and children is that children are not required to recog-
nize their thoughts as abnormal. Treatment is largely
MENTAL ILLNESS IN CHILDREN psychological.
AND ADOLESCENTS
Social anxiety disorder
Normal stranger anxiety occurs in well-adjusted children
Anxiety disorders from 8 months to 1 year of age. Social anxiety disorder is
The anxiety disorders in childhood are often thought to be a persistent and recurrent fear and/or avoidance of strang-
exaggerations of normal developmental trends rather than ers. This disorder is only diagnosed when the anxiety is
discrete illnesses in themselves. They rarely persist into of such a severity that it is markedly different from other
adulthood and tend to have a good prognosis. The treat- children of a similar age or when it persists beyond the
ment of these disorders is focused on behavioural and fam- usual age period.
ily therapy. In late adolescence common anxiety disorders
of adulthood (generalized anxiety disorder, panic disorder
and obsessive-compulsive disorder (OCD)) emerge; diag-
HINTS AND TIPS
nosis and management are very similar to adulthood (see
Chapters 12, 13 and 23) but with an even stronger emphasis Social anxiety is common in children with
on psychological therapy. neurodevelopmental disorders. Remember to
screen for autism and attention deficit hyperactivity
disorder (see Chapter 18) in a child presenting with
Separation anxiety disorder anxiety.
Normal separation anxiety usually occurs in children
from 6 months to 2 years of age. However, some children
239
HINTS AND TIPS HINTS AND TIPS
School refusal is the refusal to go to school It helps to remember that family histories should relate
because of anxiety. It may be caused by to both genetic lineage and factors that influence
separation anxiety (younger children), another psychological development: the risk of developing
mental illness (e.g., depression, social phobia) conduct disorder is increased if a first-degree relative
or negative psychosocial factors (e.g., bullying, suffers from it, but also if there is a history of antisocial
teasing). Truancy, by contrast, is an absence personality disorder in a close family member,
from school by choice and is associated with regardless of whether they are a biological relative.
conduct disorder, poor academic performance,
family history of antisocial behaviour and large
family size.
Reactive attachment disorder
Occurs in children under 5 years of age who have been se-
verely neglected and unable to form a secure attachment to
a primary caregiver. Manifests with abnormal social rela-
Disorders of social behaviour tionships, for example, fearfulness and hypervigilance, with-
drawal, listlessness, aggression, not seeking or responding
Conduct disorder to comfort, no interest in play. Paradoxically, some children
Conduct disorder is one of the commonest reasons for may be indiscriminately warm and disinhibited towards
referral to CAMHS. The disorder is characterized by a re- strangers, showing no preference for their primary caregiver.
petitive and persistent pattern of aggression to people and
animals, destruction of property (including fire-setting),
deceitfulness or theft and major violations of age-appropriate Elective mutism (selective mutism)
societal expectations or rules (e.g., truancy, staying out at Elective mutism is a selectivity in vocal communication
night, running away from home). Rates among populations depending on the social circumstances. The child speaks
in young offender institutions have been estimated to be as normally in some situations (e.g., at home), but is mute in
high as 87%. The male-to-female ratio is approximately 2:1. others (e.g., at school). These children have adequately de-
Aetiological factors include genetics, parental psychopa- veloped language comprehension and ability (although a
thology (mental illness, substance abuse, antisocial person- minority may have slight speech delay or articulation prob-
ality traits), child abuse and neglect, poor socioeconomic lems). It usually presents before the age of 5 years, is slightly
status and poor educational attainment. Many adolescents more common in girls and is associated with psychological
improve by adulthood; however, a substantial propor- stress, social anxiety and oppositional behaviour.
tion go on to develop antisocial personality disorder and
substance-related problems, especially those with an early Disorders of elimination
age of onset. Management is predominantly psychosocial.
The National Institute for Health and Care Excellence Nonorganic enuresis
(NICE; 2013) recommends parental skills training pro- This condition is characterized by the involuntary voiding
grammes for parents/carers, cognitive-behavioural of urine in children who, according to their developmen-
problem-solving programmes for young people and mul- tal stage, should have established consistent bladder con-
timodal interventions (e.g., multisystemic therapy) aim- trol (therefore ordinarily not diagnosed before the age of
ing to influence how the young person interacts with their 5 years). It may occur during the day or night and is not
family, school, community and criminal justice system. directly caused by any medical condition (e.g., seizures,
Input from social work is often required as the young per- diabetes, urinary tract infection, constipation, structural
son can be outwith parental control. abnormalities of the urinary tract) or use of a substance
(e.g., diuretic). Two types of enuresis have been described:
primary enuresis means that urinary continence has never
Oppositional defiant disorder been established; and secondary enuresis means that conti-
A persistent pattern of negative, defiant, hostile and disrup- nence has been achieved in the past. Nonorganic enuresis
tive behaviour in the absence of behaviour that violates the occurs in around 7% of 5 year olds; 4% of 10 year olds and
law or the basic rights of others as occurs in conduct disor- around 1% of adolescents over 15 years. Gender distribu-
der (e.g., theft, cruelty, bullying, assault). Children with this tion is equal in younger patients; however, cases that persist
disorder deliberately defy requests or rules, are angry and into adolescence tend to be males. Aetiological factors in-
resentful and annoy others on purpose. Management is very clude genetics, developmental delays, psychosocial stressors
similar to conduct disorder. (moving house, birth of a sibling, start or change of school,
240
Mental illness in children and adolescents 30
divorce, bereavement) and inadequate toilet training. About ment (cognitive-behavioural therapy, interpersonal ther-
75% of children with nonorganic enuresis have a first- apy, family therapy or psychodynamic psychotherapy) for
degree biological relative who has had the same problem. moderate-to-severe depression. This can be combined with
Management (NICE 2010) involves exclusion of physical fluoxetine from the start, or fluoxetine trialled if no im-
cause, parental education about toilet training (especially in provement is seen with psychological therapy. Second-line
primary enuresis), behavioural therapy (pad and buzzer ap- antidepressants are sertraline and citalopram.
paratus, star chart, bladder training) and—as a last resort—
pharmacotherapy (imipramine, nasal desmopressin). Most
cases of nonorganic enuresis resolve by adolescence.
RED FLAG
Nonorganic encopresis Selective serotonin reuptake inhibitors should be

This condition is characterized by the deposition of normal started at lower doses in adolescents than adults.
faeces (i.e., not diarrhoea) in inappropriate places, in children Young people should be monitored closely for
who—according to their developmental stage—should have thoughts of self-harm or suicide weekly for the first
established consistent bowel control (therefore ordinarily not month of commencing treatment or after a dose
diagnosed before the age of 4 years). It may be due to un- increase.
successful toilet training where bowel control has never been
achieved (primary encopresis) or may occur after a period
of normal bowel control (secondary encopresis). Encopresis
may result from a developmental delay; coercive or punitive Bipolar affective disorder and
potty training; emotional, physical or sexual abuse; a dis-
turbed parent–child relationship; parental marital conflict or
schizophrenia
Severe and enduring mental illnesses such as bipolar affec-
can feature as a symptom of a neurodevelopmental disorder
tive disorder and schizophrenia often begin to manifest in
(e.g., autism or intellectual disability). About 1% of 5 year
adolescence (60% of bipolar disorder has onset before age 20)
olds have the condition and it is more common in males.
but are uncommonly fully symptomatic or diagnosed until
Management includes ruling out an organic cause (constipa-
late adolescence. Suspected cases are generally managed in
tion with overflow incontinence, anal fissure, gastrointestinal
early intervention for psychosis teams. Classification is the
infection), assessing and treating disturbed family dynamics
same as in adulthood. Treatment follows the same principles
(ruling out child abuse), parental guidance regarding toilet
as in adults but focusses on psychological treatments and
training and behaviour therapy (e.g., star chart). Stool soften-
family interventions rather than pharmacological treatments,
ers may be used for constipation. The prognosis is good with
with a smaller range of medications used in young people.
90% of cases improving within a year.
Management of acute mania remains pharmacological.
Disorders arising in adolescence Personality disorder

and adulthood The concept of diagnosing personality disorder in CAMHS
is somewhat controversial. By definition, personality dis-
Eating disorders orders are stable and enduring patterns of maladaptive be-
Eating disorders (see Chapter 16 and 24) often commence haviour (see Chapter 17). Young people are still developing
in adolescence. Symptomatology and diagnosis are the their ways of responding to the world, and have had lim-
same as in adulthood. The management is very similar to ited life experience, making it hard to predict whether any
that recommended for adults except the first-line treatment maladaptive behaviours will persist or not. However, core
is always psychological therapy (family-based therapy is the aspects of personality are evident from infancy onwards,
gold standard in young people), not medication. When as- and it is to be expected that someone who will later have a
sessing physical risk from eating disorder in adolescents it is personality disorder will show evidence of these traits from
important to refer to age-specific guidelines (e.g., the Junior childhood onwards. Certainly, adolescents exhibit charac-
Management of Really Sick Patients with Anorexia Nervosa teristic behaviours and symptoms identical to those seen in
(MARSIPAN) guidelines). adults with personality disorders.
It can be harmful to label a young person with a personal-
Depression ity disorder diagnosis which turns out to be incorrect, but it
Depression also arises frequently in adolescence. The can also be harmful to misattribute problems due to personal-
treatment is similar to adults, but psychological therapies ity traits to a different mental disorder, or to minimize them.
are first line and a far smaller range of antidepressants are Pragmatically, if a diagnosis is helpful (e.g., in young person or
recommended. NICE (2005) suggests watchful waiting carer understanding, to access appropriate treatment, to avoid
for mild depression and an individual psychological treat- inappropriate treatment, to access other supports), it is useful
241
to make. Treatment of personality disorder in CAMHS is very

similar to that in adulthood (see Chapter 28). Psychological RED FLAG
therapies in CAMHS offer a particularly powerful opportu- Children have the same right to confidentiality
nity to allow the young person to adjust their trajectory. as adults. However, if you believe or suspect
a child is being abused, you have a duty to
break confidentiality and report this promptly
CHILD ABUSE to authorities as per local guidelines (generally
a social worker or a paediatrician). If there is
Child abuse includes the overlapping concepts of physical,
sexual and emotional mistreatment, as well as neglect or imminent risk, you should contact the police.
deprivation of the child. Child abuse is very common: around
1 in 4 adults report severe abuse of some kind as a child, with 1
in 20 children in the UK experiencing sexual abuse. Table 30.3
lists the risk factors associated with child abuse. In addition to
the physical manifestations, victims of abuse may present with
failure to thrive and symptoms of depression, anxiety, aggres- RED FLAG
sion, age-inappropriate sexual behaviour and self-harm. They
are also at an increased risk for the development of a substan- What to do if a child discloses
tial range of psychiatric problems in later life. abuse to you
All National Health Service Trusts in the UK have spe- Listen carefully – do not interrupt or express
cific child protection guidelines which should be easily surprise or your own views
accessible and consulted before they are needed. Box 30.7
Say
provides some general principles. All healthcare staff (not
just child psychiatrists and paediatricians) have a duty to • ‘You’ve done the right thing to tell me’
protect children from harm, and the safety of a child should • ‘It’s not your fault’
always take priority. If a child discloses abuse (of any sort), • ‘I believe you’
or if you suspect that they are being abused or neglected, Share
confidentiality cannot be maintained, and this should (if
appropriate) be explained to the child. Comprehensive • Tell a senior doctor
notes should be kept, and care taken to allow the child to • Share the information with authorities
make the disclosure in their own words without suggestion • Consider if the child is safe to go home
from others (either family or healthcare staff). Concerns • Tell the child what you plan to do, if age
should be reported as soon as practically possible. While appropriate
local procedures vary slightly, the police, social workers and • Document carefully using child’s own words
the duty paediatrician should be able to offer guidance. In • Do not challenge the alleged abuser
some cases, the child may be in imminent danger (e.g., be-
ing taken home by the alleged perpetrator). It may be nec-
essary to involve the police to prevent further harm and to
remove the child to a place of safety.
ASSESSMENT CONSIDERATIONS
Table 30.3 Risk factors for child abuse
IN YOUNG PEOPLE
Parent/environmental factors Child factors
Parents who were abused Low birth weight or • Problems need to be considered in the context of
prematurity a child’s developmental stage; for example, ‘temper
Parental substance abuse Early maternal separation tantrums’ are normal for a 2-year-old child but should
have subsided by age 5 years.
Parental mental illness Unwanted child
(intellectual disability, Intellectual or physical • Parents or carers usually accompany children and
depression, schizophrenia, disability young adolescents. It is often useful to first interview
personality disorders) Challenging behaviour them—with or without the child present—to obtain
Step-parent Hyperactivity a full description of the current concerns, as well as a
Young, immature parents Excessive crying complete history (psychiatric, neurodevelopmental,
educational and medical). An indirect evaluation of the
Parental criminality
parents’ personalities, marital relationship and style of
Poor socioeconomic status and parenting often creates another perspective from which
overcrowding
to understand the context of the presenting complaint.
242
Further reading 30
• An interview with the young person usually follows. • Further information can be obtained from structured
The ability of youngsters to provide a candid account and semistructured interviews [e.g., Kiddie Schedule
of their difficulties varies dramatically. The assessment for Affective Disorders and Schizophrenia (K-SADS-P),
style should be tailored to the individual abilities of the Diagnostic Interview Schedule for Children (NIMH-
young person rather than to their age. In children who DISC-IV)], objective assessment instruments [Autism
are unable to articulate their inner experiences (usually Diagnostic Observation Schedule (ADOS)] and parent/
younger children), it is often necessary to observe them teacher/self-rating scales [strengths and difficulties
in play situations. questionnaire (SDQ), attention deficit hyperactivity
• The child’s own understanding of their difficulties disorder rating Scale IV].
should (if possible) be taken into consideration, as this
can affect their management (in terms of motivation
to engage with psychosocial interventions, and
concordance with medication).
• It may be useful to change the order of the assessment
to build rapport. For example, start with open and
FURTHER READING
general questions about school and home rather than
Junior MARSIPAN guidelines for management of eating disorders
the presenting complaint.
in under 18-year-olds http://www.rcpsych.ac.uk/usefulresources/
• The importance of obtaining collateral information publications/collegereports/cr/cr168.aspx
cannot be overstated. This is extremely important Summary of multisystemic therapy
in fully understanding the development of the http://mstservices.com/files/overview_a.pdf.
presenting problem, and the young person’s premorbid Website with useful resources for carers of young people with men-
functioning. It includes obtaining academic, tal health problems
educational or psychological reports as well as https://www.minded.org.uk/.
discussions with teachers and any other agencies Website with information about psychotropic medication for
involved. Remember to obtain consent from the young people
Headmeds.org.uk.
parent/carer (and the child, if they are able).
Chapter Summary
• Mental health problems are common in children and adolescents.

• Collateral histories and multidisciplinary working are particularly important in Child and
Adolescent Mental Health Services.
• Anxiety disorders in childhood often resolve by adulthood.
• First-line treatment of mental health problems in young people is generally psychological,
not pharmacological.
• Child abuse is common. Communicating concerns is key.
243
Older adult psychiatry
31
The most common psychiatric disorders in older adults are
dementia and delirium (see Chapter 19). This chapter con- 20% in people over 80 y
siders other psychiatric disorders in older adults.
Ageing is associated with an increased prevalence of
both mental and physical health problems. Older adults
% prevalence
may also face new social challenges such as coming to terms
10%–15%
with retirement; income reduction; living alone or being
separated from family; death of spouse, siblings and peers
3%–15%
and coping with deteriorating physical health and mobility.
Patients used to arbitrarily come under the care of older
adult psychiatrists at the age of 65 years. However, concerns
7%
were raised that an automatic transfer to older adult services 1% 1%
at a given age resulted in age-based discrimination. Instead,
a ‘needs-based’ approach is now being taken in the majority
a
tia
e
n
rd y
ni
iv
io
so iet
s
en
ct
er
re
ss
x
of areas, whereby patients with problems that older adult
ffe
ph
em
re
An
ep
ra
zo
D
di
services are expert in are transferred, with everyone else re-
D
hi
la
er
Sc
po
rd
Bi
maining under the care of general adult services, whatever
so
Disorder
di
their age. This also has the advantage of maintaining conti- Fig. 31.1 Prevalence of mental illness in people over the
nuity of care. Examples of patients that older adult services age of 65 years.
are best placed to manage are:
• People with dementia of any age.
• People with a mental disorder and significant physical
Depression
problems or frailty which cause or complicate the • Depression in older adults presents similarly to that
management of their mental illness (e.g., delirium, in younger people, but a slightly different symptom
or someone with both schizophrenia and chronic set needs to be focused on. Symptoms such as fatigue,
obstructive pulmonary disease requiring nursing home insomnia and anorexia are more likely to arise in older
care). adults for reasons other than depression and so are
• People with mental health problems closely related to less specific in supporting the diagnosis. Similarly,
the ageing process (e.g., a grief reaction or depression poor concentration and memory are very common in
triggered by social isolation). older adult depression but could also reflect a cognitive
Regardless of which services care for them, the number of disorder (see Chapter 7). Instead, negative cognitions
people aged over 65 years is set to increase substantially such as guilt, hopelessness and suicidality are given
over coming decades. Currently, one in five of the UK pop- more diagnostic weight. There are also certain features
ulation is over 65 years of age but by 2040 one in four people of depression that are more common in older adults:
are projected to be aged over 65 years. The number of ‘very • Severe psychomotor agitation or retardation.
old’ (aged over 85 years) is also continuing to increase. • Cognitive impairment (sometimes called ‘depressive
pseudodementia’).
• Poor concentration.
• Generalized anxiety.
MENTAL ILLNESS IN OLDER • Excessive concerns about physical health
(hypochondriasis).
ADULTS
• When psychotic, older adults are particularly likely to
have hypochondriacal delusions, delusions of poverty
Epidemiology and nihilistic delusions (see Table 9.1).
The prevalence of all mental illness tends to increase with Depression is often underdiagnosed in older adults, so
age and tends to be higher in residential homes. Fig. 31.1 a high index of suspicion is needed. Older adults are also
summarizes the prevalence of the individual psychiatric less likely to be referred to mental health services regarding
disorders in older adults. depression. This may reflect a perception that low mood is
245
part of normal ageing: it is not. Effective management of

depression is important not least because older adults are at HINTS AND TIPS
high risk for completed suicide, even though the prevalence Some selective serotonin reuptake inhibitors
of self-harm in this group is lower than in younger adults.
side-effects are more likely to occur in older
adults than younger adults: hyponatraemia
(consider monitoring sodium), gastrointestinal
RED FLAG
bleeding (consider proton pump inhibitor) and
Always think about depression in an older adult drug interactions (least likely with citalopram and
presenting with abnormal illness behaviour: sertraline).
hypochondriasis is a common presenting
symptom.
Electroconvulsive therapy (ECT) is a very effective treat-

ment for severe depression in older adults and should be
considered for severe symptoms of psychosis, suicidality or
life-threatening food and fluid refusal. Dementia is not a
RED FLAG contraindication.
Self-harm in an older adult should be considered Poor prognostic factors include comorbid physical ill-
to be with suicidal intent until proven otherwise. ness, severity of illness and poor concordance with antide-
pressant medication. The median duration of an episode is
18 months, longer than in younger adults. Having depres-
sion reduces life expectancy in older adults by on average
3 years, even when physical illness is taken into account. It
The principles of treatment are the same as for younger also doubles the person’s risk of developing dementia.
adults, taking a stepwise approach guided by severity of ill-
ness. In addition, it is particularly important to check for
physical problems or medication that can cause low mood HINTS AND TIPS
as the likelihood of these is higher in older adults (see Tables
11.1 and 11.2). Cotard syndrome describes the presence of
Mild depression and subthreshold symptoms may re- nihilistic and hypochondriacal delusions as part
spond well to psychosocial interventions alone (e.g., be- of a depressive psychosis and is typically seen in
friending, assistance in accessing community supports such older adults
as lunch clubs, structured exercise programmes).
Psychological therapies for depression (mainly
cognitive-behavioural therapy) are just as effective in

older adults as in younger adults and are recommended in HINTS AND TIPS
those with moderate-to-severe depression. Psychological
therapies are particularly useful for patients whose co- A common triad in older adults is depressive
morbidities place them at high risk of side-effects from symptoms, cognitive impairment and functional
medications. impairment. It is often difficult to tease out whether
The National Institute for Health and Care Excellence someone is experiencing depression manifesting
(NICE) also recommends antidepressant medication for with cognitive impairment or an early dementia
those with moderate-to-severe depression, although med- leading to comorbid depression. Ideally, depression
ication should be introduced cautiously as older adults
is treated first, then cognition reassessed once
have an increased risk of developing adverse side-effects
mood is euthymic.
and generally need lower doses. Selective serotonin re-
uptake inhibitors are first line. Tricyclic antidepressants
should be avoided if possible as postural hypotension and
cognitive impairment are very common side-effects in
older adults. Response to antidepressants is often slower
Anxiety disorders
in older adults, with benefits taking 6–8 weeks to emerge. Studies that have assessed prevalence of anxiety disorders in
Lithium augmentation may be used in treatment-resistant older adults alongside younger adults have found that anxi-
cases, although the dose is generally lower than that used ety disorders reduce with age. Generalized anxiety disorder
in younger adults. is the commonest specific anxiety disorder in those aged
246
Assessment considerations in older adults 31
over 65 years (affecting 2%–7%), specific phobias affect The treatment is with antipsychotics, but some work is
around 3% and social phobia, obsessive-compulsive disor- needed in building up a therapeutic relationship as these
der and panic disorder are all uncommon, each occurring patients are often difficult to engage and poor concor-
in less than 1%. It is rare for anxiety disorders to arise for dance is associated with a poor treatment response. Note
the first time in older adults. Importantly, anxiety (partic- that although late-onset schizophrenia does seem to be
ularly health related) is a common presenting symptom of a distinct entity, it is not a term used by the International
depression in older adults, so anyone presenting for the first Classification of Diseases, 10th edition (ICD-10) or the
time with anxiety in later life should be carefully assessed Diagnostic and Statistical Manual of Mental Disorders, 5th
for depression. edition (DSM-5); here, these patients would be classified as
Treatment of anxiety disorders in older adults is broadly having schizophrenia or delusional disorder.
similar to that in younger adults, with evidence supporting
benefits from both medication and psychological thera-
pies (although psychological therapies appear to be not as HINTS AND TIPS
beneficial as in younger adults). Benzodiazepines should be
avoided where at all possible because of the risks of cogni- ‘Diogenes syndrome’ is the term used to describe
tive impairment and falls in older adults. a self-isolated person who lives in a state of
significant self-neglect, which may include
Mania hoarding and lead to squalid living conditions.
This is purely a descriptive term and may occur
Unlike depression, the incidence of bipolar affective disor-
in individuals who misuse alcohol or have frontal
der does not increase with age, although late-onset cases
lobe dysfunction, personality disorder and
seem to be less influenced by genetic factors (fewer of these
patients have positive family histories for mood disorders). chronic psychotic illness. It may also occur at a
In a fifth of cases, mania is precipitated by an acute medical younger age.
condition (e.g., stroke or myocardial infarction), making it
particularly important to screen for physical or medication
causes (see Box 10.2). Hyperactive delirium is an important
differential. The presentation and treatment are similar to
those of younger adults. ASSESSMENT CONSIDERATIONS
IN OLDER ADULTS
Late-onset schizophrenia (late
• Home assessments are a very important part of older
paraphrenia) adult psychiatry. Patients can be assessed in their
Older adult psychiatrists in the UK use the term late-onset normal environment and collateral information can
schizophrenia or late paraphrenia to denote a group of pa- be obtained from family members. It is important to
tients who develop their first psychotic symptoms late in life, ascertain whether the patient can be managed at home
usually over the age of 60 years. Late-onset schizophrenia is (i.e., risk of harm to self and others; ability to carry
characterized predominantly by delusional thinking, usually out activities of daily living, drive, manage financial
of a persecutory or grandiose nature. These delusions tend affairs), or whether additional community support or
not to be as bizarre as they sometimes are in earlier-onset hospitalization is needed.
schizophrenia (e.g., rather than believing that secret agents • Collateral information from the patient’s general
are monitoring them by satellite, a patient with paraphrenia practitioner (GP), family and carers is an important
may assert that the neighbours have been poisoning their part of history taking.
water supply). Hallucinations may occur, but disorganized • Ensure the patient has any aids they require to optimize
thinking, inappropriate affect and catatonic features are rarer their communication (e.g., glasses, hearing aids,
than in younger adults. The key differentials are dementia, dentures).
delirium or medication-induced psychotic symptoms. • Mental state examination follows the same format as
The aetiology of late-onset schizophrenia seems differ- for all adults, although extra consideration should be
ent to early onset schizophrenia in that affected patients given to the assessment of cognitive functioning and
are less likely to have a family history of schizophrenia. In it is advisable to always do a standardized test (see
addition, late-onset schizophrenia is far more common in Table 7.6 for examples).
women than men – unlike early onset schizophrenia, which • A thorough physical assessment is very important –
is slightly more likely to arise in men. Sensory deprivation, this may be best done by the patient’s GP. Do not forget
particularly hearing loss, and social isolation are also impli- to consider hearing and vision as well as tremors and
cated in its aetiology. involuntary movements.
247
• Routine investigations in newly diagnosed or the risk of adverse reactions, drug interactions and poor
hospitalized older adults include: full blood concordance. Therefore, prescribing psychotropic drugs
count, urea and electrolytes, liver function tests, for common, self-terminating symptoms such as insom-
thyroid function tests, calcium, glucose, urinalysis nia and headache should be avoided wherever possible.
(with midstream urine microscopy and culture When psychotropic drugs are recommended, follow-up
if indicated), chest X-ray, electrocardiogram and arrangements should include a timely assessment of re-
consideration of serum magnesium, phosphate, sponse and discontinuation of any ineffective treatments.
vitamin B12 and folate and a computed tomography Medication should not be a substitute for adequate social
or magnetic resonance imaging of the head. care, the lack of which often underlies many nonspecific
Remember that the chances of a physical illness symptoms.
causing or aggravating a mental disorder are
significant in older adults. Concordance
Concordance is often a problem in older adults, especially
with those who are visually impaired, cognitively impaired,
take numerous drugs and live alone. This may be improved
TREATMENT CONSIDERATIONS by simplifying medication regimens, taking time to explain
IN OLDER ADULTS dosing schedules, using large font prescription labels or
concordance aids such as dosette boxes. Organizing super-
vision of medication by a relative, friend or support worker
Physiological changes with ageing
may be necessary.
There are a number of physiological changes that occur
with ageing, which may affect the way the body handles Psychosocial interventions
certain drugs. Table 31.1 describes the most important Psychological treatments, such as cognitive-behavioural
changes and their effects. The net result of these changes therapy, can be used with success in older adults as with
is that the tissue concentration of a drug may be increased younger adults. Reality orientation and reminiscence ther-
by over 50%, especially in malnourished, dehydrated and apies have been used to reduce disorientation and stimu-
debilitated patients. Therefore, the adage, ‘start low and go late remote memories in patients with dementia. Practical
slow’ applies especially to the use of psychotropic drugs in psychosocial interventions such as memory aids (e.g., note-
the older adult. books, calendars) and assistance with mobility and daily ac-
tivities by a support worker should not be underestimated.
Polypharmacy Occupational therapy assessment of activities of daily liv-
In 2012–2013, around 80% of those aged over 65 years ing, which assess skills such as washing, dressing, eating,
in the UK were taking at least one prescribed medica- shopping, give carers an indication of patients’ strengths
tion, with around two-thirds taking three or more and and weaknesses and enable a care package to be tailored
a quarter taking six or more. Polypharmacy increases that caters specifically for these.
Table 31.1 Age-related changes in drug handling and effects

Physiological changes Effects
Reduction in renal clearance Drugs excreted by filtration (e.g., lithium) need lower doses.
(glomerular filtration rate and Drug concentrations may rise rapidly with dehydration, heart failure, etc.
tubular function)
Decreased lean body mass and Volume of distribution increases for lipid-soluble drugs (most psychotropic drugs),
total body water and increased and reduces for water-soluble drugs (e.g., lithium). Half-life of lipid-soluble drugs
body fat prolonged.
Decreased plasma albumin Reduced drug binding resulting in increased physiologically active unbound
fraction.
Reduced hepatic metabolism and May increase the bioavailability and elimination of some drugs.
first-pass metabolism
Increased sensitivity to central Sedating drugs may result in drowsiness, confusion, falls and delirium. Tricyclics
nervous system drugs are more likely to be associated with anticholinergic and postural hypotensive
effects. Antipsychotics are more likely to be associated with parkinsonism and
increased risk of cerebrovascular accident.
Decreased total body mass Lower doses of drugs needed (think in terms of milligram/kilogram as opposed to
standard dose for all).
248
Treatment considerations in older adults 31
Chapter Summary
• Mental illness in older adults is overall similar in presentation and management to

younger adults.
• Depressive episodes in older adults often have prominent features of cognitive
impairment, agitation and health-related anxiety.
• Self-harm in an older adult should be considered to be with suicidal intent until proven
otherwise.
• New-onset mood, anxiety and psychotic illnesses are rare but do occur.
• Be cautious with psychotropic medication use in older adults.
• Psychological interventions are effective in older adults.
249
Forensic psychiatry
32
Forensic psychiatry is concerned with assessment and treat- patients with mental disorders are four times more likely
ment of mentally disordered offenders as well as the assess- to fall victim to violence than members of the general
ment of the dangerousness of individuals who may not yet population. However, there is a significantly higher prev-
have committed an offence. In practice, forensic psychiatric alence of mental disorders among prisoners than in the
services tend to assess and manage those who pose a high general population for all mental disorders investigated
risk to the safety of others (typically, those who have com- (Table 32.1). Longitudinal studies suggest that most men-
mitted murder, attempted murder, severe sexual assault or tal disorders manifest prior to imprisonment, not as a
arson). Some patients may be managed in the community; consequence of it. Substance use is extremely common in
however, others may require treatment and rehabilitation in prisoners, with around a quarter of patients misusing alco-
a secure environment. Levels of security can vary from a hol and a third to a half misusing substances. Around one
locked ward in a psychiatric hospital to a high-security ‘spe- in six prisoners has a major depressive or psychotic illness.
cial hospital’ (Broadmoor, Rampton/Ashworth Hospitals or Female inmates are more likely to have a mental disorder
The State Hospital in Scotland). than male inmates.
Identifying mental disorder in prisoners is important
not least because the suicide rate in custody is around nine
times that of the general population and could potentially
MENTAL DISORDER AND CRIME be reduced by care plans to support inmates at high risk.
Patients who are very unwell can be transferred from prison
The vast majority of patients suffering from a mental ill- to a secure psychiatric hospital. This is essential when com-
ness have never committed an offence, and most offences pulsory treatment under mental health legislation is re-
are not committed as a result of a mental illness. Indeed, quired, as this cannot be given in prison.
Table 32.1 Mental disorders associated with crime

Mental disorder % of Prison population Associations with crime
Personality disorder 10–65 Associated with violent crime, especially antisocial personality
disorder. Antisocial and emotionally unstable personality
disorders are frequently diagnosed in forensic settings, often in
association with comorbid substance abuse.
Alcohol and 10–60 Substance misuse Substance misuse is a key factor that significantly increases
substance use 10–30 Alcohol misuse the risk of violence in those with or without an existing mental
disorder. Alcohol intoxication may also lead to driving offences
and breaches of the peace, and offences may be committed to
fund drug habits.
Neurodevelopmental ADHD 11–25 Impulsivity and mood instability in ADHD is associated with both
disorders Intellectual disability violent and nonviolent crimes.
0.5–1.5 There is an association between intellectual disabilities and
sexual offences (especially indecent exposure), as well as arson.
The prevalence of autism spectrum disorders in offenders is
uncertain.
Psychotic disorders 5 Schizophrenia increases the risk of violent acts by a factor of
four. Many offences committed by people with schizophrenia
are minor and are manifestations of impaired social skills. More
people with schizophrenia are victims of crime than perpetrators
Mood disorders Depression 10 Depression is rarely associated with homicide. These cases are
Bipolar affective disorder usually due to mood-congruent delusions (e.g., everyone would
2–7 be better off dead) and are often followed by suicide. Postnatal
depression is sometimes a cause of maternal filicide.
Offences by manic patients usually reflect financial irresponsibility
or acts of aggression, which are usually not serious.
ADHD, Attention deficit hyperactivity disorder.
251
Forensic psychiatry
Although those who commit crimes are more likely to

have a mental disorder than the general population, it is HINTS AND TIPS
important to note that the mental disorder alone is rarely The term ‘psychopath’ is frequently misused. It is
sufficient to result in offending behaviour.
not a diagnosis in the Diagnostic and Statistical
More commonly, risk factors which predispose to
Manual of Mental Disorders, 5th Edition, the
mental disorder also predispose to offending, for exam-
ple, childhood abuse and chronic stress. Prison inreach International Statistical Classification of Diseases
mental health services therefore offer a good opportu- and Related Health Problems, 10th edition (ICD-10)
nity to alleviate suffering in those with mental health or the current draft of ICD-11. It is defined using
problems but will not necessarily reduce the risk of the Hare Psychopathy Checklist – Revised, and
reoffending. in essence is a diminished ability to feel empathy
How best to manage offenders with personality dis- coupled with antisocial behaviour. Only around 1 in
orders is particularly controversial. Personality disorder 10 people with antisocial personality disorder meet
is more common in offenders, but it is unclear whether criteria for psychopathy.
treating personality disorder reduces offending. This is
at least in part because personality disorder is hard to
treat, requiring long-term psychological therapy and
motivation on the part of the patient (see Chapter 28).
Government initiatives focused on those with ‘dangerous
and severe personality disorders’ (now termed ‘offend-
ASSESSING AND MANAGING RISK
ing personality disorders’) aimed to reduce offending OF VIOLENCE
rates by focusing resources on offenders with personal-
ity disorders (predominantly antisocial and emotionally The key principle in assessing the risk of violence that a
unstable), and providing specialist units in which such patient with a mental disorder poses to others presents an
individuals can be detained while they receive the treat- ethical conflict between protecting the community from
ment. The problem with this approach is that it may have a potentially violent offender and respecting the human
led to those with personality disorder being detained rights of the individual in question (see Chapter 4). This is
for longer than those without personality disorders who often a very difficult balance to achieve. Forensic multidis-
had committed similar offences, potentially indefinitely, ciplinary teams in the UK have moved from simply trying
in the hope that treatment would reduce risk of offend- to predict the risk of future violence (generally unsuccess-
ing, but without evidence that this was a likely outcome. ful) to looking at the evidence-based risk factors present in
Attempting to improve assessment and access to treat- an individual patient. This enables a formulation of scenar-
ment for those with personality disorder in prisons ios in which future violence would be more likely to occur,
seems sensible, but indefinite detainment while waiting facilitating the creation of management plans which will
for treatments to work does not. decrease the risk in a proactive fashion. Approaches to as-
sessment include:
• Unaided clinical risk assessment: This involves
HINTS AND TIPS drawing on the experience of the clinician involved.
This has been demonstrated to be associated with a
Mental disorders associated with violent crime less effective and less accurate risk assessment than
(alcohol and substance dependence, attention evidence-based methods.
deficit hyperactivity disorder, personality disorders • Actuarial methods: Assessment using predetermined
and paranoid psychotic disorders) have a static actuarial or statistical variables (e.g., demographic
factors). These methods do not take into account the
multiplicative effect for the risk of future violence
specific factors of the case, and—used in isolation—can
when they occur in combination.
be misleading.
• Structured clinical judgement: Assessment utilizing
both empirical actuarial knowledge and clinical
expertise. The Historical/Clinical/Risk Management
20-item (HCR-20) scale is by far the predominant
HINTS AND TIPS mode of risk assessment used in the UK, and is
particularly useful in assisting with risk management.
Delusional jealousy (Othello syndrome) is often
Some newer tools have been developed that take
associated with alcohol abuse and linked to violent
protective factors significantly into account.
crime such as assault and homicide.
Box 32.1 summarizes some of the factors that have been
associated with the risk of violence.
252
Considerations in court proceedings 32
BOX 32.1 SOME FACTORS ASSOCIATED WITH CONSIDERATIONS IN COURT

RISK OF VIOLENCEa PROCEEDINGS
Historical (History of problems with…)
Where there are grounds to believe that the accused may
H1. Violence have been suffering (or is currently suffering) from a men-
H2. Other antisocial behaviour tal disorder, a psychiatric defence may be used. This means
H3. Relationships that the presence of mental disorder may have been a mit-
H4. Employment igating factor in the offence or may interfere with court
H5. Substance use proceedings. Throughout the UK, this is mainly based on
H6. Major mental disorder case law rather than legislation. The role of the forensic psy-
H7. Personality disorder chiatrist is to act as an expert witness to the court. While
H8. Traumatic experience the psychiatrist can make recommendations, the ultimate
H9. Violent attitudes decision comes from the court.
H10. Treatment or supervision response
Clinical (Recent problems with…) Fitness to plead
C1. Insight Individuals with mental disorder are not exempt from tak-
C2. Violent ideation or intent ing responsibility for their actions. However, defendants
C3. Symptoms of major mental disorder should be competent to stand trial and mount a defence
C4. Instability against their charges. The term ‘fitness to plead’ is used in
C5. Treatment or supervision response English law to describe this capacity. Using psychiatric and/
Risk Management (Future problems with…) or psychological evidence, the court determines this by as-
R1. Professional services and plans sessing whether the accused can:
R2. Living situation • Understand the nature of the charge.
R3. Personal support • Understand the difference between a plea of guilty and
R4. Treatment or supervision response not guilty.
R5. Stress or coping • Instruct counsel (legal representation).
a • Follow the evidence brought before the court.
HCR-20 v3 items, from HCR-20 2013 by the Mental Health,
Law, and Policy Institute, Simon Fraser University. Reprinted • Challenge a juror.
with permission from the copyright owner.
Criminal responsibility
Before a defendant can be convicted, criminal responsi-
A clinician confronted with an individual who poses a
bility needs to be determined. It should be determined
serious risk of violent behaviour will need to discuss the
whether, at the time of the offence, the person was able
case with colleagues, including social workers and forensic
to control their own behaviour and choose whether to
mental health specialists. Compulsory hospitalization may
commit an unlawful act or not. Integral to this process is
be required in some cases.
the concept of mens rea (‘guilty intent’ or ‘guilty mind’),
which means that the individual realized the nature of,
ETHICS and intended to commit, the unlawful act. Varying levels
Clinicians have a duty to breach confidentiality to
of mens rea are recognized, known as ‘modes of culpabil-
ity’. Actus reus (‘guilty act’ or ‘crime’) means the person
warn potential victims of serious threats that have
is guilty of committing the act, whatever their intent. A
been made (in consultation with the police), as per
defendant may be deemed to have decreased criminal cul-
the Tarasoff ruling. pability due to:
• Age: In England and Wales, children are only deemed
legally responsible for their actions after the age
COMMUNICATION
of 14 years. Children under the age of 10 years are
deemed incapable of criminal intent (doli incapax).
A history of violent behaviour is the best predictor of Children aged 10–14 years are not considered
future violent behaviour. It is important to both ask criminally responsible unless the prosecution can
the patient about this and seek verification from other prove mens rea.
• Reason of insanity: In English law, legal insanity (not a
sources (police, social workers, medical records).
psychiatric term) is defined in terms of the M’Naghten
Rules, which state that ‘at the time of committing the
253
Forensic psychiatry
act, the party accused was labouring under such a

defect of reason, from disease of the mind, as to not HINTS AND TIPS
know the nature and quality of the act he was doing, Self-induced (voluntary) intoxication with alcohol
or, if he did know it, that he did not know what he was
or other drugs cannot be used as a defence on the
doing was wrong.’ It is a defence that is rarely successful
grounds of insanity or diminished responsibility.
due to the high threshold of the legal definition of
insanity.
• Diminished responsibility: In English law, a defence
of diminished responsibility is only available in
relation to charges for murder. If successful, this
will lead to the accused being found guilty of HINTS AND TIPS
manslaughter rather than murder, which allows for
It is the responsibility of the Court (taking into
flexible sentencing (murder carries a mandatory
life sentence). It depends upon the presence of consideration advice from expert witnesses) to
‘an abnormality of mind (whether arising from a decide upon sentencing or ‘disposal’ (i.e., what
condition of arrested or retarded development of happens to the individual after trial). In cases
mind or any inherent causes or induced by disease or where psychiatric defences are successfully used,
injury)’. An ‘abnormality of mind’ is not a psychiatric the Court may utilize mental health legislation to
term and is open to wide interpretation, leading to transfer the individual to a secure hospital. In other
successful defences such as ‘emotional immaturity’ cases, the Court may decide to impose a custodial
and ‘premenstrual tension’. sentence, or to place conditions upon the individual
• Automatism: An act committed without presence of (e.g., to adhere to a drug treatment programme).
mind (e.g., during sleepwalking or epileptic seizure)
may warrant this rare defence.
Chapter Summary
• Forensic psychiatrists assess and treat mental disorders in people who have committed
serious offences.
• Mental disorders are more common in offenders, but usually do not directly cause
offending.
• Misuse of drugs and alcohol is a major risk factor for offending.
• Assessment of risk of future violence is imprecise, but is aided by a structured approach.
• Forensic psychiatrists act as expert witnesses regarding the impact of mental disorder on
criminal responsibility.
254
SELF-ASSESSMENT
Single best answer (SBA) questions�� 257
Extended-matching questions (EMQs) �� 275
SBA answers �� 297
EMQ answers�� 311

Single best answer (SBA)
questions
5. A 37-year-old woman who takes lithium for bipolar
Chapter 2 Pharmacological therapy and affective disorder has recently completed a course of
electroconvulsive therapy ibuprofen for a knee injury. She now feels very tired
1. Nurses ask for urgent review of a 24-year-old man and weak. She is unsteady on her feet and has a
who is a psychiatric inpatient and is hypertensive, coarse tremor. A random lithium level is assessed.
tachycardic and pyrexial. He is very drowsy and has What is the lowest result that would strongly suggest
rigid limbs. What action will most help distinguish her symptoms are due to lithium toxicity?
between neuroleptic malignant syndrome and A. 0.2 mmol/L
serotonin syndrome? B. 0.4 mmol/L
A. Checking serum creatinine kinase C. 0.8 mmol/L
levels. D. 1.0 mmol/L
B. Looking at his prescription. E. 1.8 mmol/L
C. Checking his past medical history.
D. Formally assessing his cognition. Chapter 3 Psychological therapy
E. Monitoring his condition over time. 1. A 49-year-old man has been struggling to move on with
his life after his son died in a car accident 6 months ago.
2. Nurses ask for urgent review of a 24-year-old man Which of the following would be the most appropriate
who is a psychiatric inpatient and is hypertensive, psychological therapy in the first instance?
tachycardic and pyrexial. He is very drowsy and has A. Psychodynamic therapy
rigid limbs. He was admitted a week ago with a first B. Cognitive-behavioural therapy
episode psychosis and has received large doses of C. Person-centred counselling
haloperidol since. What is the most appropriate first D. Exposure and response prevention
management step? E. Mindfulness-based cognitive therapy
A. Discontinue all antipsychotics.
B. Work up for electroconvulsive 2. A 35-year-old man is undergoing psychodynamic
therapy. psychotherapy, and a letter from his therapist
C. Give dantrolene. describes his ‘transference.’ Which of the following is
D. Give bromocriptine. the most accurate description of transference?
E. Assess ABC. A. The level of trust in the patient-therapist
relationship.
3. A 37-year-old woman with treatment-resistant B. Good eye contact throughout sessions.
schizophrenia is considering commencing clozapine. C. Patient response towards the therapist based on
What should she be advised regarding the monitoring previous relationships.
that is initially required? D. The level of empathy in the patient-therapist
A. Weekly blood pressure checks. relationship.
B. Weekly liver function tests. E. Therapist attitude towards the patient based on
C. Weekly full blood counts. previous relationships.
D. Weekly lipid profiles.
E. Weekly fasting glucose assays. 3. A 25-year-old male student has a history of
depression and has been referred for cognitive-
4. A 45-year-old woman has recently started behavioural therapy. He reports that ‘my life is over
phenelzine. She is out for lunch with her friend who because I failed my final exams.’ Which of the
is a doctor. She asks her friend what she can eat following most accurately describes this cognitive
from the menu. distortion?
A. Broccoli and stilton soup. A. Emotional reasoning
B. Pickled herring on a bed of salad. B. Fortune telling
C. Marmite and sesame toast. C. Personalization
D. Smoked mackerel pâté. D. Labelling
E. Egg mayonnaise toastie. E. Magnification
257
Single best answer (SBA) questions
4. A 57-year-old teacher attends her general practitioner 4. A 34-year-old woman is experiencing a manic
requesting a referral for interpersonal therapy after episode with psychotic features. She broke her leg
reading about it in a magazine. In which of the jumping off a bus shelter but denies the need for
following conditions has interpersonal therapy proven surgery as she thinks she can heal her leg herself.
to be of benefit? The decision is whether she needs surgery or not.
A. Alzheimer disease What is the best description of her capacity to make
B. Moderate depression this decision?
C. Generalized anxiety disorder A. Capacity should be assumed to be present.
D. Paranoid schizophrenia B. Capacity is absent because of impaired
E. Panic disorder communication.
C. Capacity is absent because of impaired
Chapter 4 Mental health and the law understanding.
D. Capacity is absent because of impaired retention
1. A 72-year-old woman has recently been diagnosed
of information.
with dementia. She continues to drive and gets
E. Capacity is absent because of impaired ability to
shopping for her and her partner every week. He says
balance and weigh up information.
there are no problems with her driving. What should
she be advised?
5. A 55-year-old man has schizophrenia with chronic
A. She should stop driving immediately.
auditory hallucinations and negative symptoms. The
B. She should stop driving once she feels her driving
decision is whether he should take a statin or not.
is not as good as it used to be.
What is the best description of his capacity to make
C. She should stop driving once her partner feels her
this decision?
driving is not as good as it used to be.
A. Capacity should be assumed to be present.
D. She should notify the Driver and Vehicle Licencing
B. Capacity is absent because of impaired
Agency (DVLA).
communication.
E. Her general practitioner will notify the DVLA.
understanding.
2. A 23-year-old man has suffered a head injury in a road
D. Capacity is absent because of impaired retention
traffic accident and has a Glasgow Coma Scale (GCS)
of information.
score of 8. A decision needs to be made as whether
E. Capacity is absent because of impaired ability to
he should be ventilated or not. What is the best
balance and weigh up information.
description of his capacity to make this decision?
A. Capacity should be assumed to be present.
B. Capacity is absent because of impaired Chapter 5 Mental health service provision
communication. 1. Which patient is LEAST likely to need secondary
C. Capacity is absent because of impaired mental health services?
understanding. A. A 34-year-old woman with a first episode
D. Capacity is absent because of impaired retention of depression, responding well to cognitive
of information. behavioural therapy
E. Capacity is absent because of impaired ability to B. A 34-year-old woman with a first episode of
balance and weigh up information. depression, who has not responded to cognitive
behavioural therapy or two antidepressants
3. A 59-year-old man has suffered Wernicke's C. A 34-year-old woman with a first episode of
encephalopathy and now cannot remember any new hypomania and previous episode of depression
information. A decision needs to be made regarding D. A 34-year-old woman with a first episode
which accommodation option he should choose. What is of depression who recently took a planned
the best description of his capacity to make this decision? overdose
A. Capacity should be assumed to be present. E. A 34-year-old woman who says she has been
B. Capacity is absent because of impaired depressed for years but objectively seems
communication. euthymic
understanding. 2. A 21-year-old man with no past history is experiencing
D. Capacity is absent because of impaired retention odd beliefs that he has some special power and that
of information. things around him are of special significance. He
E. Capacity is absent because of impaired ability to struggles to explain these beliefs further and says they
balance and weigh up information. cannot be true. He has stopped going out with his
258
friends and his personal hygiene has deteriorated. He A. Late onset schizophrenia
has no thoughts of harm to himself or others. Which B. Lewy body dementia
team should he be referred to? C. Alzheimer dementia
A. Community mental health team D. Delirium
B. Early intervention in psychosis team E. Charles Bonnet syndrome
C. Assertive outreach team
D. Home treatment team 2. A woman brings her 62-year-old father to register at
E. Inpatient unit a new GP practice as he has recently moved to the
area to be closer to her. He tells the GP about an
exciting and varied past personal and medical history
Chapter 6 The patient with thoughts of but his daughter says none of this is true, and that for
suicide or self-harm some years now he has had a very poor memory for
1. A 23-year-old woman presents at the accident and both old and new information. He can spell ‘WORLD’
emergency department stating that she is feeling backwards and draw a clock face without difficulty.
suicidal and has taken an overdose of paracetamol He used to be a heavy drinker. What is the most likely
several hours ago. What is the most appropriate initial diagnosis?
management step? A. Amnesic syndrome
A. History of circumstances leading to overdose B. Dementia
B. Mental state examination C. Alcohol excess
C. Measurement of serum paracetamol levels D. Malingering
D. Determination of suicidal intent E. Fugue state
E. Evaluation of current social supports
3. A 75-year-old retired fisherman presents to his
2. A 45-year-old policeman with a history of self-harm, general practitioner with a 12-month history of
depression and alcohol dependence discloses that gradual onset, gradually worsening memory
he has been thinking about ways of killing himself impairment confirmed by his wife. He is no longer
since his wife left him a month ago. Which ONE of the able to cook or help mend nets like he used to.
following preparatory measures would suggest strong ACE-III is 76/100. He has a past medical history
suicidal intent? of hypertension and is an ex-smoker. Physical
A. Internet research examination is normal. He has had normal full blood
B. Contacting the Samaritans count, U&Es, calcium, glucose, vitamin B12, folate
C. Telling his ex-wife of his plans and thyroid function tests in the last month. What
D. Making a will and paying bills further investigations should this man receive?
E. Telling his general practitioner of his plans A. Computed tomography (CT) of the head
B. C-reactive protein and erythrocyte sedimentation rate
3. A 29-year-old builder with a diagnosis of depression C. Syphilis and HIV serology
states that he is considering various methods of D. Electroencephalogram (EEG)
suicide. Which ONE of the following plans places him E. Cerebrospinal fluid examination
at highest risk of suicide?
A. Jumping from a height 4. A 77-year-old woman is an inpatient on a general
B. Paracetamol overdose medical ward. She was admitted 2 weeks ago
C. Suspension hanging with a severe urinary tract infection (UTI) requiring
D. Firearm wound intravenous antibiotics. In A&E her abbreviated
E. Carbon monoxide poisoning mental test (AMT) was 2/10. Since admission she has
been disorientated and hallucinating. Her antibiotics
finished a week ago and her inflammatory markers
Chapter 7 The patient with impairment of
returned to normal. Four days ago she was almost
consciousness, memory or cognition discharged, but became very confused and agitated
1. An 82-year-old woman is brought to A&E by her the night before going. Repeat AMT was 4/10. Prior
family. They are concerned that over the last couple to admission she functioned well and was cognitively
of days she has been very suspicious of them, has normal. What is the most likely diagnosis?
mentioned seeing wolves in her kitchen and has been A. Delirium
pacing her sitting room all night. She scores 4/10 on B. Late onset schizophrenia
the Abbreviated Mental Test. She normally functions C. Lewy body dementia
well, living alone with no carers. What is the most D. Alzheimer dementia
likely diagnosis? E. Charles Bonnet syndrome
259
5. A 74-year-old man is admitted to hospital because he A. Benzodiazepines

has acute cognitive impairment and is hypervigilant B. Parenteral thiamine
and agitated. Past medical history is of insomnia C. Full physical exam
and ischaemic heart disease. His medications are D. Neck of femur repair
amitriptyline 50 mg nocte, aspirin 75 mg mane, E. Consistent nursing care
lisinopril 5 mg, omeprazole 20 mg mane, simvastatin
20 mg nocte. His daughter thinks he has recently 4. A 27-year-old man comes to your outpatient clinic
started a new medication. Physical examination, and tells you that he has been injecting heroin on
blood tests, electrocardiogram, chest X-ray and head a daily basis for several months and wants you to
computed tomography are normal. What is the most restart his methadone to help him stop. What is the
likely cause of his presentation? most appropriate initial step in patient care?
A. Amitriptyline A. Prescribe his previous dose of methadone
B. Aspirin B. Give him some dihydrocodeine to use first
C. Lisinopril C. Obtain a urine sample for drug testing
D. Omeprazole D. Refer him to the drug counselling service
E. Simvastatin E. Give him advice on harm minimization
Chapter 8 The patient with alcohol or 5. A 35-year-old woman asks you about ‘safe’ limits for
drinking alcohol. You know the answer is 14 units per
substance use problems week; however, she asks you to explain this in terms
1. A 54-year-old man reports consuming a litre of vodka of how many drinks she can safely take. What would
per day. Which of the following symptoms is not you tell her?
consistent with alcohol dependence? A. Six pints (568 mL) of continental lager (5.3%
A. He feels compelled to drink alcohol by volume (ABV)) per week
B. After having a drink he feels shaky and sweaty B. A ‘half bottle’ (350 mL) of premium gin (40% ABV)
C. He started off by drinking a quarter litre of vodka per per week
day but now needs a litre to have the same effect C. Two bottles (2 × 750 mL) of red wine (12.5% ABV)
D. He has noticed his mood has been low since he per week
started drinking every day and thinks this might be D. A large (3 L) bottle of strong white cider (8.4%
due to alcohol ABV) per week
E. He has stopped going to visit his family because E. Six bottles (6 × 330 mL) of ‘alcopops’ (4.9% ABV)
they don’t like him to drink per week
2. A 57-year-old woman described auditory 6. A 24-year-old accountant confides in you that he has
hallucinations telling her that she was evil. These tried cocaine on a work night out. He experienced
started a week ago, after several months of heavy some strange feelings and wants to know whether
alcohol use. She is socially isolated. Her mood, these were likely to be due to cocaine, or whether
concentration and memory were normal. Other he was sold something else. Which of the following
than slightly abnormal liver function tests, physical symptoms is not suggestive of cocaine intoxication?
examination and investigations were normal, and A. Chest pain
breath alcohol was undetected. What is the most B. Fast heart rate
likely diagnosis? C. Fever
A. Delirium tremens D. Hallucinations
B. Late-onset schizophrenia E. Drowsiness
C. Hepatic encephalopathy
D. Alcoholic hallucinosis
Chapter 9 The patient with psychotic
E. Wernicke–Korsakoff syndrome
symptoms
3. A 62-year-old salesman is admitted to an orthopaedic 1. A 78-year-old widow with macular degeneration is
ward following a fractured neck of femur. Two days later brought to her general practitioner by her daughter
(before surgery to repair his hip), he appears shaky, who is concerned that her mother has been asking
confused, and disorientated and tells you that he can her to move nonexistent dogs and cats off her couch.
see a small horse on the table. His wife discloses that Her mother is otherwise alert, orientated and in good
he had been drinking a bottle of whisky per day in the health. What is the most likely diagnosis?
3 months prior to admission. Which of the following A. Brain tumour
aspects of his management should be delayed? B. Charles Bonnet syndrome
260
C. Delirium follow on from each other. Sometimes he laughs or

D. Dementia grimaces for no discernible reason. What subtype of
E. Schizophrenia schizophrenia does he have?
A. Catatonic
2. A 62-year-old man with schizophrenia attends B. Hebephrenic
his general practitioner. He is dishevelled and C. Paranoid
smells strongly of tobacco. He reports feeling that D. Simple
someone is pressing on his chest, particularly when E. Undifferentiated
he approaches the church at the top of the hill. He
wonders if it is the devil. What is the most probable Chapter 10 The patient with elated or
cause of the sensation in his chest?
A. Delusion of control irritable mood
B. Ischaemic heart disease 1. Reception staff ask the general practitioner to
C. Persecutory delusion see a 29-year-old man with a history of bipolar
D. Tactile hallucination affective disorder who has arrived 2 hours late for
E. Thought disorder his appointment. He is speaking very quickly and
the words don’t make sense. What is the most likely
3. A 43-year-old man tells his general practitioner, ‘I cause for his presentation?
think my wife is having an affair’. She has frequently A. Manic episode
been coming home late from work and 2 weeks ago B. Hypomanic episode
he thought he saw her kissing another man. He is C. Depressive episode
very upset by this and determined to get conclusive D. Cyclothymia
evidence to confront her with. He has quit his job E. Schizophrenia
to follow her and taken out a personal loan to
purchase cameras to place in her car, workplace 2. A 55-year-old man has had several admissions to
and handbag. What is the psychopathology hospital with elated episodes when he believes he is
described here? Jesus Christ but has never been depressed. What is
A. Delusion the diagnosis?
B. Erotomania A. Recurrent hypomania
C. Hallucination B. Bipolar affective disorder
D. Obsession C. Schizoaffective disorder
E. Over-valued idea D. Cyclothymia
E. Recurrent mania
4. A 19-year-old man is brought to accident and
emergency by his flatmates because for the 3. A 25-year-old farmer is brought to accident and
last fortnight, he has been complaining the emergency by the police after he tried to steal a
neighbours are talking about him and tonight tractor. He is agitated, but shows no remorse,
stated ‘enough was enough’ and picked up his stating loudly that it rightfully belongs to him as he
cricket bat to go and confront them. His friends is the King of Tractors. He has no past psychiatric
cannot hear the neighbours. The man has smoked history, past medical history or previous criminal
cannabis every day for the last 6 months and has offences. Which investigation will be most important
recently been experimenting with some ‘stimulant diagnostically?
medication’ he bought online. What is the most likely A. Computed tomography (CT) scan
diagnosis? B. Electroencephalogram (EEG)
A. Delusional disorder C. Full blood count
B. Depressive episode, severe, with psychotic D. Urine drug screen
features E. Thyroid function
C. Psychosis secondary to psychoactive
substance use 4. A 24-year-old unemployed woman presents to her
D. Schizophrenia general practitioner asking to be treated for bipolar
E. Schizophrenia-like psychotic disorder disorder. She has looked it up on the internet and
thinks it may explain why she is always losing her
5. A 16-year-old boy is referred to psychiatry because he temper with people. Her mood swings frequently,
has not been able to attend school for 3 months and sometimes several times in a day. She often does
has lost contact with his friends. He is very difficult things she later regrets and has never managed to
to understand because his words do not seem to maintain a long-term relationship or job. She has had
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these mood swings from when she was a little girl. She says she feels really depressed. What is the most
What is the most likely diagnosis? appropriate initial step in patient care?
A. Bipolar affective disorder A. Start an antidepressant
B. Dysthymia B. Refer to psychiatry
C. Cyclothymia C. Ask her to complete a mood diary
D. Personality disorder D. Watchful waiting
E. Substance use E. Check full blood count, urea and electrolytes, liver
function test and thyroid function test
Chapter 11 The patient with low mood
1. A 40-year-old woman who was started on a new Chapter 12 The patient with anxiety, fear or
medication a month ago presents with a 4-week avoidance
history of depression. Which of the following might 1. A 21-year-old student calls an ambulance for the fourth
account for her presentation? time in a month because of chest pain, shortness of
A. Paracetamol breath and a feeling she is about to die. This settles
B. Omeprazole by the time she reaches the accident and emergency
C. Salbutamol department. On all occasions, her examination,
D. Verapamil electrocardiogram and cardiac enzymes are normal.
E. Prednisolone She has her final exams in a fortnight and admits she is
very worried. What is the most likely diagnosis?
2. A 35-year-old woman presents with mild depression. A. Acute coronary syndrome
On examination you notice a midline neck swelling. B. Thyrotoxicosis
What is the most appropriate initial step in patient C. Hypoglycaemia
care? D. Panic attack
A. Refer to psychiatry E. Asthma
B. Check thyroid function
C. Start an antidepressant 2. A 57-year-old obese man keeps cancelling appointments
D. Request a neck ultrasound with the practice nurse to have bloods taken for
E. Advise her to return if the symptoms persist cholesterol and glucose. Although he is normally very
cheerful and relaxed, he becomes pale, sweaty and
3. A 55-year-old man with no previous psychiatric history tremulous when you offer to take his bloods during the
presents with low mood, anhedonia and fatigue. consultation. What is the most likely diagnosis?
He has come for help as he believes his organs are A. Myocardial infarction
rotting away. What is the most likely diagnosis? B. Hyperglycaemia
A. Bipolar disorder C. Blood-injection-injury phobia
B. Schizoaffective disorder D. Panic disorder
C. Schizophrenia E. Hypochondriasis
D. Depressive episode with psychotic features
E. Dementia 3. A 63-year-old woman with a history of depression
presents to the accident and emergency department
4. A 25-year-old student turns up late for her and tells you she has a dry mouth, a choking
appointment. She gives a 1-month history of low sensation, butterflies in her stomach, palpitations and
mood, anhedonia and fatigue. What is the most shortness of breath. She tells you she had some bad
important area to cover in what remains of the news recently. What is the most appropriate first step
appointment time? in management?
A. Presence of biological symptoms of depression A. Electrocardiogram (ECG)
B. Drug history B. Airway, breathing, circulation (ABC)
C. Family history of mood disorder C. Psychiatry referral
D. Suicidal ideation D. Bloods: full blood count, urea and electrolytes,
E. Past medical history liver function tests and troponin
E. Arterial blood gas (ABG)
5. A 19-year-old shop assistant presents in tears
because her boyfriend broke up with her the day 4. A 24-year-old man who was recently diagnosed with
before. She did not sleep well last night and did not type 1 diabetes attends his general practitioner (GP).
feel like having breakfast. She feels hopeless about Over the last month he has experienced recurrent
the future and thinks she will never meet anyone else. attacks of anxiety associated with sweating and
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tachycardia. The episodes do not seem to have any his house is unlocked and has developed a routine of
triggers, last for about 20 minutes, and resolve when checking every door and window nine times before
he sits down with his girlfriend and has a cup of tea leaving the premises. This means he has to get up
and a biscuit. What should the GP advise the patient half an hour early and sometimes come home from
to do next time it happens? work early to recheck. This has caused friction with a
A. Deep breathing exercises new manager at work and over the last month he has
B. Note it in a diary noticed his mood is lower. He no longer enjoys playing
C. Take diazepam football, is very tired all the time, and is struggling to
D. See a counsellor concentrate at work. What is the most likely diagnosis?
E. Check blood sugar A. Depressive episode
B. Obsessive-compulsive disorder (OCD)
5. A 44-year-old businessman presents to his general C. Generalized anxiety disorder
practitioner (GP) because for the last month he has D. OCD with comorbid depressive episode
felt anxious, sweaty and shaky in the mornings. He E. Obsessive-compulsive (anankastic) personality
feels better when he has lunch and generally his mood disorder
is good. He admits to drinking a bottle of red wine
every night, and usually having champagne during 4. A 33-year-old graphic designer is driven to
business lunches. What is the most likely diagnosis? produce perfect images. She has always been very
A. Depressive episode conscientious, even at primary school. The thought
B. Diabetes of a mistake in one of her designs makes her feel so
C. Panic disorder anxious she often stays late at work checking them
D. Alcohol withdrawal through. She is proud of the quality of work, and feels
E. Work phobia her colleagues are sloppy and should work harder.
She had to leave her last company because she told
Chapter 13 The patient with obsessions and the manager this. What is the most likely diagnosis?
A. Obsessive-compulsive disorder
compulsions B. Obsessive-compulsive (anankastic) personality
1. A 29-year-old woman mentions she is obsessed with disorder
a TV talent show. She watches each episode multiple C. No mental illness
times and has pictures of all the contestants on her D. Autistic spectrum disorder
bedroom wall. She called in sick the day of the final as E. Obsessive-compulsive disorder with
her shift clashed with the showing. She enjoys watching subsyndromal depressive symptoms
and thinking about the show and thinks she might
audition next year. What is the most likely diagnosis? 5. A 23-year-old woman reports a voice inside her head
A. No mental illness telling her to harm herself. She is not sure where it
B. Social phobia comes from as no one is around when she hears it.
C. Obsessive-compulsive (anankastic) personality What is the psychopathology she displays?
disorder A. Obsession
D. Obsessive-compulsive disorder B. Pseudohallucination
E. Delusional disorder C. Rumination
D. Thought insertion
2. A 36-year-old man keeps thinking about his own E. Hallucination
death. He sees repetitive images of his body in a
coffin. He tries to distract himself, but it does not
Chapter 14 The patient with a reaction to a
work. The images started about 3 months ago,
around the time he started to feel low in mood stressful event
associated with fatigue, less pleasure in life, insomnia 1. A 23-year-old man with a history of schizophrenia
and anorexia. What is the most likely diagnosis? appears confused and withdrawn the morning after he
A. Obsessive-compulsive disorder was severely assaulted by a group of youths in the local
B. Generalized anxiety disorder park. He has no recollection of the event. Which of the
C. Depressive episode following diagnoses should be initially considered?
D. Hypochondriacal disorder A. Acute stress reaction
E. Nihilistic delusion B. Adjustment disorder
C. Relapse of schizophrenia
3. A 44-year-old man has had intrusive thoughts for D. Intracranial haemorrhage
several years regarding security. He keeps thinking E. Posttraumatic stress disorder
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2. A 57-year-old woman has been referred urgently

by her general practitioner for symptoms of low
Chapter 15 The patient with medically
mood, weight loss and insomnia. These have been unexplained physical symptoms
troublesome for the past 10 weeks, since she 1. A 26-year-old male teacher attends his general
watched her husband drown while on a yachting practitioner (GP) requesting tests to confirm that he
holiday. Which of the following would be suggestive is suffering from multiple sclerosis. He thinks that he
of a diagnosis of depression rather than a normal has this because he had some stabbing pain in his
bereavement reaction? upper arm last week. The pain has now resolved
A. Thinking that she would be better off dead and examination is unremarkable. Which ONE of the
B. Difficulty concentrating on watching the following should the GP do?
television A. Watchful waiting
C. Inability to tend to her self-care or get out B. Refer for urgent neurology appointment
of bed C. Organize magnetic resonance imaging scan and
D. Extreme guilt for not making her late husband lumbar puncture
wear a lifejacket D. Tell the patient that he is worrying too much
E. Hearing the voice of her late husband while lying E. Organize another appointment in 3 days
alone in bed
2. A 25-year-old woman insists that she wants plastic
3. A 28-year-old woman was signed off her job in a surgery on her nose, as she feels it is crooked and
call centre 2 weeks ago with ‘work-related stress’, deformed. She has stopped leaving the house for fear
a month after she was promoted to a supervisory of other people noticing. She cannot stop thinking
position in a new department. She has no psychiatric about how ugly it is, and this often keeps her awake
history and denies substance misuse. At interview, at night. On examination, her nose is entirely normal,
she tells you she feels ‘unable to cope’ with the and she does appear slightly reassured when told this.
demands of her new role. She is sleeping well, and Which of the following is the most likely diagnosis?
continues to enjoy jogging on a daily basis. Which A. Somatic delusional disorder
of the following would be the most appropriate B. Factitious disorder
diagnosis? C. Malingering
A. Depressive disorder D. Body dysmorphic disorder
B. Adjustment disorder E. Hypochondriacal disorder
C. Conversion disorder
D. Acute stress disorder 3. A 32-year-old former nurse complains of pelvic
E. No mental illness pain. Despite the apparent severity of the pain
and the presence of multiple abdominal surgical
4. 19-year-old female asylum seeker is brought to scars, her physical appearance, examination and
hospital by a social worker regarding concerns basic investigations are entirely normal. She tells
with her memory. She recalls her entire life until you in detail about her previous diagnoses and
3 months ago when she received news that invasive investigations, and requests pethidine and a
government militia were coming towards her diagnostic laparoscopy. She is visiting from a distant
former hometown in Sierra Leone. She has town. Which of the following should be the next step
memory of the last 4 weeks of her life in the UK in her management?
and is able to tell you about her current address, A. Urgent diagnostic laparoscopy
social circle and circumstances. You see from B. Prescribe pethidine
her medical notes that she had a termination C. Tell her that she is lying
of pregnancy 6 weeks ago; however, she has D. Contact previous centres of care
no recollection of either the conception or the E. Refer to psychiatry
procedure. Physical examination and investigations
reveal no abnormalities, and she seems indifferent 4. A 72-year-old man is referred to psychiatry because
to her difficulties. Which ONE of the following is of dyspnoea and stabbing pain in his chest. He
the most likely diagnosis? has not seen a general practitioner for years, and
A. Dissociative amnesia examination and routine blood tests are normal. The
B. Anterograde amnesia following head medical doctor feels that he has panic attacks. Which
trauma ONE of the following should be the next step in his
C. Transient global amnesia management?
D. Posttraumatic stress disorder A. Cognitive-behavioural therapy
E. Wernicke–Korsakoff’s syndrome B. Further physical investigations
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C. Explanation of functional illness anxious and gets palpitations. She is sometimes sick,
D. Antidepressant medication not always after meals. Physical examination and
E. Watchful waiting investigations reveal no abnormalities. What is the
most likely diagnosis?
5. A 41-year-old woman is a frequent visitor to her A. Bulimia nervosa
general practitioner (GP). She has had numerous B. Depressive episode, severe
investigations over several years for a multitude C. Panic disorder
of physical symptoms, including abdominal pain, D. Anorexia nervosa
dysmenorrhoea, dysuria and difficulty swallowing. E. Alcohol dependence
She refuses to accept her GP’s explanation that there
is no physical cause for her symptoms. She is now 4. A 25-year-old female lawyer has a diagnosis of
requesting a referral to a neurologist because she has anorexia nervosa, with a body mass index of 14.5
a persistent tingling sensation in her legs. Which of the kg/m2. Which of the following investigation results
following is the most likely diagnosis? requires urgent treatment?
A. Multiple sclerosis A. Glucose 3.7 mmol/L
B. Factitious disorder B. Haemoglobin 95 g/L
C. Somatisation disorder C. Total cholesterol 7 mmol/L
D. Hypochondriacal disorder D. Phosphate 0.7 mmol/L
E. Generalised anxiety disorder E. Potassium 2.1 mmol/L
Chapter 16 The patient with eating or weight 5. A 19-year-old female accountant describes a dread
of fatness, and feels that she is overweight despite
problems having a body mass index of 13.6 kg/m2. She
1. A 22-year-old female medical student is brought describes a 1-year history of severely restricting her
to your clinic by her mother, who discovered she dietary intake. She reports amenorrhoea (secondary)
was making herself vomit after meals. Which of the and has lanugo hair. Which of the following is the
following is suggestive of a diagnosis of anorexia most likely diagnosis?
nervosa rather than bulimia nervosa? A. Depressive episode, severe
A. Body weight at least 15% below expected for B. Bulimia nervosa
height C. Paranoid schizophrenia
B. A dread of fatness and a distorted image of being D. Anorexia nervosa
too fat E. Obsessive-compulsive disorder
C. Use of herbal dieting medications
D. A tendency to exercise excessively 6. A 17-year-old boy has anorexia nervosa and is receiving
E. A preoccupation with being thin weekly weights and physical examination. Which of the
findings below places him at high physical risk?
2. The weight of a 13-year-old boy is 25% lower A. Blood pressure 95/65 mm Hg supine, 88/60 mm
than expected, having previously been on the 50th Hg erect
percentile for both height and weight. He has not B. Capillary refill time <2 seconds
started puberty. He reports that he eats well and C. Heart rate 58 bpm, regular
denies any concerns regarding body image. What is D. Temperature 36.5°C
the most appropriate next management step? E. Unable to rise from squatting without assistance
A. Refer for psychiatric assessment
B. Refer for cognitive-behavioural therapy
Chapter 17 The patient with personality
C. Investigate for physical causes of growth
restriction problems
D. Try to establish rapport to facilitate assessment 1. A 20-year-old woman attends her general practitioner
E. Ask him to keep a food diary frequently reporting low mood. Which of the following
symptoms would support a diagnosis of emotionally
3. A 32-year-old barmaid is worried that she has lost a unstable personality disorder?
great deal of weight recently (body mass index 17). A. Chronic feelings of emptiness
She describes feeling tired all the time and having B. Callous unconcern for the feelings of others
no appetite. Her mood has been low for the last C. Perfectionism that interferes with task completion
3 months, and she is anhedonic. She drinks six D. Seeking others to make most of one’s important
vodkas and cokes when she is working, and three life decisions
on her days off. If she doesn’t have a drink she feels E. Takes pleasure in few, if any, activities
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2. A 45-year-old male, single and living alone, seems during the interview. What is the most appropriate
indifferent to praise or criticism, appears aloof and initial step in management?
prefers his own company. He is not depressed and A. Check thyroid function
there has been little change in his situation since B. Collateral history from teacher
he left school. Which of the following personality C. Ensure he has an up-to-date eye test
disorders is most likely? D. Genetic testing to exclude ADHD
A. Narcissistic personality disorder E. Refer for ADHD assessment
B. Antisocial personality disorder
C. Avoidant personality disorder 2. A 1-year-old girl has stopped crawling. She
D. Schizoid personality disorder used to cry a lot but is now calm and placid.
E. Paranoid personality disorder She had developed a social smile but has not
done this for a few weeks. She also makes
3. A 25-year-old male prisoner injured a fellow inmate by less eye contact than she used to. What is the
throwing him down the stairs. He states that he feels most likely diagnosis?
no guilt as the man ‘was asking for it’ after looking A. Autism spectrum disorder
at him strangely. Which of the following personality B. Heller syndrome
disorders is most likely? C. Intellectual disability
A. Borderline personality disorder D. Muscular dystrophy
B. Schizoid personality disorder E. Rett syndrome
C. Antisocial personality disorder
D. Paranoid personality disorder 3. A 23-year-old man reports he is very anxious in
E. Anankastic personality disorder social situations. He recently lost his job because
he talked too much in the office. Now he is worried
4. A 19-year-old man has carved the name of his ex- about talking to others at all. He says he ‘doesn’t
partner on his chest. He reported feeling incredibly get the rules’ and he thought his workmates were
depressed since she separated from him and kicked him enjoying what he was telling them about the history of
out of the house the day before. He is crying and tells photocopiers. What is the most likely diagnosis?
you that he wants to die. He is intoxicated with alcohol. A. Anankastic (obsessive-compulsive) personality
Which of the following is the most likely diagnosis? disorder
A. Acute severe depression B. Autism spectrum disorder
B. Borderline personality disorder C. Depressive episode
C. Adjustment reaction D. Generalized anxiety disorder
D. No mental illness or personality disorder E. Social phobia
E. Unable to say
Chapter 19 Dementia and delirium
5. A 22-year-old man has a long history of self-harm,
1. A 91-year-old nursing home resident with severe
explosive outbursts of anger, impulsive, reckless
Alzheimer dementia frequently shouts unintelligible
behaviour, feelings of emptiness and quickly forming
words. Physical examination and investigations are
intense and volatile ‘love–hate’ relationships. He reports
normal, and she does not seem low in mood. Staff
hearing the voice of his uncle, who sexually abused him
can detect no pattern or triggers to her shouting. She
as a child, inside his head when he is feeling stressed.
appears mildly distressed by it. What option should be
He has no history of mental illness. Which of the
tried first to reduce her shouting?
following would be the most appropriate diagnosis?
A. Aromatherapy
A. Borderline personality disorder
B. Antipsychotic
B. Schizoid personality disorder
C. Antidepressant
C. Dependent personality disorder
D. Cholinesterase inhibitor
D. Paranoid personality disorder
E. Referral to speech and language therapy
E. Antisocial personality disorder
2. A 75-year-old man has Lewy body dementia. His
carers are worried that he is not eating well. He tells
Chapter 18 The patient with
his general practitioner that he is certain his carers
neurodevelopmental problems are trying to poison him. What management strategy
1. A 7-year-old boy keeps getting up at school and should be avoided if possible?
walking to the front of the classroom. His mother is A. Antipsychotics
worried he has attention deficit hyperactivity disorder B. Nutritional supplements
(ADHD). He is not restless at home and sits calmly C. Cholinesterase inhibitors
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D. Antibiotics 3. A 45-year-old man is being treated by the alcohol

E. Antidepressants problems team. He has successfully been ‘detoxified’
using chlordiazepoxide. Which of the following is true
3. A 77-year-old man was admitted 3 days ago with regarding his future pharmacological treatment?
abdominal pain of uncertain aetiology. Initially he was A. Trazodone can be prescribed to treat his alcohol
alert and orientated but nurses are concerned that dependence
he is now acutely disorientated and agitated. Which B. Long-term, low-dose chlordiazepoxide is the
medication is most likely to explain his behaviour? treatment of choice
A. Paracetamol C. Naltrexone can be helpful even if he relapses to
B. Metoclopramide drinking
C. Co-codamol D. Acamprosate causes an unpleasant reaction
D. Omeprazole when taken with alcohol
E. Cyclizine E. Disulfiram should control his cravings for alcohol
4. A general practitioner (GP) is asked to visit a 71-year- 4. A 26-year-old woman asks you for help with her
old woman in her home. She is disorientated in time, heroin dependence. She does not want to receive
does not recognize the GP (whom she has known methadone, as she feels this is more addictive than
for years) and is very drowsy. She is plucking at heroin. Which of the following drugs might she prefer
her bed clothes and refuses to let the GP examine to try as substitution therapy?
her because she thinks he wants to hurt her. Her A. Lofexidine
husband states she was fine until 2 days ago, but B. Diazepam
now he cannot cope with her. Where should the C. Buprenorphine
GP manage this lady with acute onset psychotic D. Clonidine
symptoms? E. Naltrexone
A. Her own home
B. Day hospital
C. Emergency respite via social work
Chapter 21 The psychotic disorders:
D. Acute medical ward schizophrenia
E. Acute psychiatric ward 1. A pregnant woman with schizophrenia asks how likely
her child is to develop schizophrenia? Her partner
does not have a mental illness.
Chapter 20 Alcohol and substance-related
A. 1%
disorders B. 12.5%
1. A 29-year-old man with alcohol dependence C. 2.5%
syndrome tells you that he wants to give up drinking, D. 37.5%
but he is worried that he will lose all his friends E. 50%
from the pub. At which stage of the Prochaska and
DiClemente Transtheoretical Model of Change would 2. A pregnant woman with schizophrenia asks how likely
you consider him to be? her child is to develop schizophrenia? Her partner also
A. Precontemplation of change has schizophrenia.
B. Contemplation of change A. 1%
C. Preparation for change B. 12.5%
D. Action for change C. 25%
E. Maintenance of change D. 37.5%
E. 50%
2. A 21-year-old homeless woman tells you that she
uses £20 of heroin per day via intravenous injection. 3. A 22-year-old man was started on olanzapine
She is keen to be prescribed methadone. Which of 4 months ago for a first episode of schizophrenia. He
the following measures would be essential prior to is now symptom free, but troubled by weight gain.
starting methadone? He asks how long in total he needs to stay on an
A. History from a friend to corroborate her usage antipsychotic?
B. Viral serology for HIV and hepatitis B and C A. 6 months
C. Thorough physical examination with focus on B. 9 months
injection sites C. 1–2 years
D. Admission to psychiatric hospital D. 3–5 years
E. Urine drug test to confirm presence of opioids E. Lifelong
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4. A 27-year-old woman has developed schizophrenia. jump off some scaffolding to prove he is invincible. He
She is interested in talking therapies. What type of does not believe he is unwell and says there is no way
psychological therapy does NICE (2014) recommend he is coming into hospital. What is the best initial step
to her? in management?
A. Psychodynamic psychotherapy A. Appointment with general practitioner later
B. Interpersonal therapy that day
C. Dialectical behaviour therapy B. Informal admission
D. Cognitive-behavioural therapy C. Admission under mental health legislation
E. Cognitive analytic therapy D. Urgent outpatient psychiatric review
E. Police custody after arrest for breach of
5. A 35-year-old woman experiencing a manic episode the peace
with psychotic features had been attempting to make
the voices go away by repeatedly banging her head 3. A 45-year-old man is admitted to hospital with a
against her sink. De-escalation techniques had not 6-week history of low mood. He plans to kill himself at
worked, and she had refused oral medication, so the first opportunity because he believes the world is
in view of the significant risk to herself she received going to end soon and wants to die quickly. He is not
intramuscular rapid tranquillization. She has no past currently on any medication. What would be the best
medical history. It is now 30 minutes postadministration management option?
and she is sitting dozing peacefully in the quiet room. A. Citalopram
What monitoring does she now require? B. Amitriptyline
A. No monitoring is required C. Quetiapine
B. General observations D. Citalopram and quetiapine
C. Temperature, pulse, blood pressure, respiratory E. Amitriptyline and quetiapine
rate, hydration status and consciousness level
every hour 4. A 29-year-old postgraduate student with a diagnosis
D. Temperature, pulse, blood pressure, respiratory of bipolar affective disorder is admitted with a
rate, hydration status and consciousness level manic episode after stopping medication. She is
every 15 minutes very agitated on the ward, pacing, being verbally
E. Continuous monitoring of pulse, blood pressure aggressive to staff and fellow patients, and punching
and respiratory rate with regular temperatures her wardrobe. What is the best medication to
commence?
6. A 35-year-old woman has received intramuscular A. Lithium
rapid tranquillization. Which of the following B. Olanzapine
complications is least important to monitor for? C. Citalopram
A. Respiratory depression D. Valproate
B. Inability to protect her own airway E. Lamotrigine
C. Hyperglycaemia
D. Acute arrhythmia 5. A 36-year-old lecturer with moderate to severe
E. Life-threatening hypotension depression wants to try a psychological therapy for
depression. Which of the following should be offered?
Chapter 22 The mood (affective) disorders A. Self-help cognitive-behavioural therapy (CBT)
1. Which of the following patients with depression would be B. Structured group physical activity
the highest priority for electroconvulsive therapy (ECT)? C. Individual CBT
A. Someone who is not eating or drinking D. Dialectical behaviour therapy
B. Someone who believes they are already dead, so E. Graded exposure therapy
there is no point taking medication
C. Someone who has experienced no benefit from Chapter 23 The anxiety and somatoform
two antidepressants
D. Someone who has benefited from ECT in the past disorders
E. Someone who has experienced no benefit from 1. A 35-year-old woman has been recently diagnosed
several antidepressants but does not want ECT with somatization disorder. How should this diagnosis
change her management by her general practitioner?
2. A 24-year-old man is brought to accident and A. She should not be allowed access to urgent
emergency by the police. He has a 1-week history of appointment slots
irritable mood, insomnia and grandiose delusions that B. She should be seen on a planned, regular
he has super powers. The police found him about to schedule
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C. She should not be investigated for physical 3. A 29-year-old female actuary is diagnosed with
complaints anorexia nervosa. Which of the following factors is
D. She should never be prescribed benzodiazepines associated with a poor prognosis?
E. She should be reassured that her symptoms do A. Early age of onset
not really exist B. Rapid weight loss
C. Binge–purge symptoms
2. A 17-year-old school pupil has a phobia of bodily D. Family history of anorexia
fluids but aspires to be a nurse. What treatment can E. Slow to engage with psychotherapy
she be offered?
A. None – she should change her career plans 4. A 17-year-old woman has been diagnosed with anorexia
B. Cognitive-behavioural therapy (CBT) with nervosa. Which medication should she be advised to
desensitization take until she regains a healthy nutritional intake?
C. CBT focused on trauma A. Citalopram
D. Diazepam when necessary (PRN) – to be taken B. Fluoxetine
before any possible contact with bodily fluids C. Multivitamin
E. Selective serotonin reuptake inhibitor (SSRI) D. Paroxetine
E. Sertraline
3. A 29-year-old chemist has obsessive-compulsive
disorder (OCD) regarding orderliness. She has been 5. A 21-year-old woman with severe anorexia nervosa
tidying up her colleagues’ laboratory benches and was found collapsed in the street secondary to heart
spoilt some experiments. She has been threatened failure due to malnutrition. She has subsequently been
with dismissal. She does not want to try any talking admitted to a specialist eating disorder unit to receive
therapies. What treatment can she be offered? nasogastric feeding under mental health legislation.
A. Clomipramine Which of the following blood test results raises
B. Mirtazapine concern that she is experiencing refeeding syndrome?
C. Selective serotonin reuptake inhibitor (SSRI) A. Calcium 2.4 mmol/L
D. Pregabalin B. Magnesium 1.7 mEq/L
E. Self-help C. Phosphate 0.3 mmol/L
D. Potassium 3.7 mmol/L
Chapter 24 Eating disorders E. Sodium 141 mmol/L
1. A 17-year-old boy has a body mass index of
16 kg/m2, wears baggy clothes, and states that he is Chapter 25 The sleep–wake disorders
worried about being overweight. He is diagnosed with 1. A 33-year-old woman describes creeping, burning
anorexia nervosa, although he does not feel that he sensations in her legs which keep her awake at night.
has a problem. However, he is agreeable to meeting She finds getting up and walking around eases them.
a therapist, mainly to please his mother. Which of Her mother had the same problem. She has tried
the following modalities of psychotherapy would be nonpharmacological management and would like to
recommended in the first instance? try medication. Which medication is recommended
A. Maudsley model of anorexia treatment for adults first line?
B. Family therapy A. Fluoxetine
C. Focal psychodynamic psychotherapy B. Haloperidol
D. Cognitive-behavioural therapy C. Lithium
E. Specialist supportive clinical management D. Metoclopramide
E. Pramipexole
2. A 20-year-old man has a body mass index of
16 kg/m2, wears baggy clothes, and states that he is 2. A 33-year-old woman describes creeping, burning
worried about being overweight. He was diagnosed sensations in her legs which keep her awake at
with anorexia nervosa as a 17-year old. After a period of night. The pain also affects her throughout the day.
treatment and remission his symptoms have returned. She finds getting up and walking around makes
Which of the following modalities of psychotherapy little difference. She has poorly controlled type one
would be recommended in the first instance? diabetes. What is the most likely diagnosis?
A. Exposure-response prevention therapy A. Akathisia
B. Family therapy B. Intermittent claudication
C. Focal psychodynamic psychotherapy C. Iron deficiency
D. Interpersonal therapy D. Neuropathy
E. Specialist supportive clinical management E. Restless legs syndrome
269
3. A 33-year-old woman describes trouble sleeping at 4. A 22-year-old man tells his general practitioner that
night, with early morning wakening. She has recently he enjoys dressing as a woman during sex with his
been diagnosed with depression and started on partner. What is he describing?
fluoxetine (20 mg) 2 weeks ago. Her mood is slightly A. Gender dysphoria
better, but she is worried that her sleep is not. What is B. Transgenderism
the next best management step? C. Transsexualism
A. Increase fluoxetine dose D. Transvestic fetishism
B. Keep a sleep diary E. Transvestism
C. Refer for polysomnography
D. Sleep hygiene advice Chapter 27 Disorders relating to the
E. Short course of temazepam
menstrual cycle, pregnancy and the puerperium
1. A 27-year-old schoolteacher reports increased
Chapter 26 The psychosexual
irritability in the week prior to menstruation. This
disorders quickly resolves within a day of starting her period.
1. A 24-year-old woman presents to her general Most of the time the irritability does not cause her
practitioner concerned that she achieves orgasm any problems apart from when recently she had
infrequently during penetrative sex with her partner. an argument with her boyfriend. What is the best
What should she be advised? management option?
A. Caressing without genital contact can A. Encourage exercise
improve sex B. Prescribe combined oral contraceptive pill
B. Sexual dysfunction is rare in young people C. Prescribe ibuprofen
C. She is likely to have a physical problem preventing D. Prescribe selective serotonin reuptake
orgasm inhibitor (SSRI)
D. She should stop any medication which could be E. Refer for cognitive-behavioural therapy (CBT)
contributing
E. Talking about sexual problems with her partner is 2. A 53-year-old company director reports low mood,
likely to increase anxiety in the bedroom increased fatigability and early morning wakening
for the past 2 months, accompanied by increased
2. A 57-year-old man tells his general practitioner he is suicidal thoughts. She has had to take some time
unable to have an erection, even when masturbating. off work. She attributes her symptoms to her
He occasionally found it hard to achieve an erection menopause. What is the best management option?
as a younger man but it has got much worse A. Hormone replacement therapy
recently. He was previously obese but has lost B. Dietary and lifestyle advice
weight recently. What is the most important next C. Omega-3 fish oils
management step? D. Counselling
A. Advise to lose more weight and return if problem E. Psychological therapy
persists
B. Check blood glucose 3. A 25-year-old artist has a history of bipolar affective
C. Direct to self-help resources regarding sexual disorder. She has been taking lithium and has been
dysfunction well for the past 3 years. She wants to start a family
D. Prescribe sildenafil with her partner and has heard that lithium can cause
E. Refer to urology problems with fetal malformations. What is the most
appropriate management?
3. A 63-year-old man with Parkinson disease has A. Switch to semisodium valproate
recently started making obscene phone calls. He B. Switch to carbamazepine
becomes sexually aroused during this. He has been C. Discontinue lithium and continue without treatment
working his way through his wife’s address book D. Switch to olanzapine
and several of her friends have been very distressed. E. Refer to perinatal mental health team
Which of the medications below is least likely to have
caused this behaviour? 4. A 33-year-old woman previously experienced a
A. Levodopa protracted episode of postnatal depression following
B. Olanzapine the birth of her first child, which necessitated
C. Pergolide admission to a mother-and-baby unit. The episode
D. Pramipexole responded well to antidepressant medication. She has
E. Selegiline recently become pregnant and is incredibly anxious
270
that she will become unwell again postnatally. What is university (which is unusual for her). Normally, she is
the most appropriate management? easily angered, but relatively cheerful. At assessment
A. Reassure that becoming unwell again would be she reports increased thoughts of suicide, but no
unlikely immediate plans. What is the most appropriate next
B. Restart antidepressant treatment immediately step in management?
C. Referral to psychologist to identify relapse signature A. Refer for dialectical behaviour therapy
D. Watchful waiting B. Request a urine drug screen
E. Referral to perinatal mental health team C. Prescribe diazepam
D. Admit to an acute psychiatric ward
5. A 22-year-old lady is found by the police. She was E. Suggest ‘weekly dispensing’ of medication
knee-deep in a river with her 2-week-old baby boy.
She reported that the infant was possessed by the 4. A 29-year-old man has a diagnosis of antisocial
devil, and that she needed to drown him to save personality disorder. He coldly tells his psychiatrist of
humanity. At interview, she appears perplexed and his intention to kill his landlord following an argument
is openly responding to auditory hallucinations. She about rent arrears, before describing a detailed plan
does not want to be admitted to hospital as she does on how he would stab him in the throat. What is the
not think she is unwell. She has a very supportive most appropriate next management step?
family who are keen to look after her at home. What is A. Ask him to return for review in 1 week
the most appropriate management option? B. Prescribe diazepam
A. Detention in hospital under mental health act C. Warn the police and the intended victim
B. Treatment at home under care of crisis team D. Admit to psychiatric hospital under detention
C. Transfer to police cells and charge with attempted E. Refer for anger management
murder
D. Urgent referral for outpatient follow-up by perinatal Chapter 29 The neurodevelopmental
mental health team
E. Urgent referral to social work disorders
1. A 23-year-old man is diagnosed with an autism
spectrum disorder. Which medication can be prescribed
Chapter 28 The personality disorders to reduce the core symptoms of his disorder?
1. A 19-year-old hairdresser has a diagnosis of A. Fluoxetine
emotionally unstable personality disorder, and B. Methylphenidate
requests information on drug treatment that may be C. None
beneficial. What should she be advised? D. Risperidone
A. Sodium valproate is effective for reducing E. Sodium valproate
interpersonal problems
B. Omega-3 fatty acids are effective in reducing 2. A 7-year-old boy has recently been diagnosed with
impulsivity attention deficit hyperactivity disorder (ADHD). It
C. Risperidone is effective for reducing anger is having a substantial impact on his behaviour at
D. Amitriptyline reduces chronic feelings of emptiness school, and he is at risk of expulsion. What is the first-
E. Drug treatment is not the main intervention line treatment?
A. Atomoxetine
2. A 34-year-old man has a diagnosis of emotionally B. Cognitive-behavioural therapy
unstable personality disorder, and requests information C. Dexamfetamine
on different types of psychotherapy that may be D. Methylphenidate
beneficial. Which of the following psychological E. Parent-training/education programme
treatments does NICE (2009) recommend?
A. Dialectical behaviour therapy 3. A 12-year-old boy has multiple motor tics and
B. Mentalization-based therapy repeatedly shouts ‘Batman!’ when he is stressed or
C. Psychodynamic excited. He had to leave the cinema once because of
D. Cognitive-analytical therapy this but is otherwise not troubled by his symptoms.
E. Therapeutic communities What is the first-line treatment for this disorder?
A. Clonidine
3. A 27-year-old female postgraduate student has a B. No treatment
diagnosis of emotionally unstable personality disorder. C. Pimozide
She reported low mood and insomnia for the past D. Psychoeducation
month and has subsequently been absent from E. Risperidone
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Chapter 30 Child and adolescent psychiatry Chapter 31 Older adult psychiatry

1. For the past 6 months, a 12-year-old boy has 1. A 74-year-old woman gives a 6-month history of
repeatedly been in trouble with the police. Recently, low mood, anhedonia and fatigue associated with
he has been violent towards his sister and has killed difficulty concentrating and remembering. Neighbours
her pet hamster. His mother sought help after he have noticed she is forgetting to put her bins out and
deliberately set the garden shed on fire. What is the no longer cooks meals for herself. Her score on the
most likely diagnosis? Addenbrooke’s Cognitive Examination (ACE-III) is
A. Antisocial personality disorder 72/100. What is the best management option?
B. Conduct disorder A. Antidepressant
C. Oppositional defiant disorder B. Cholinesterase inhibitor
D. Reactive attachment disorder C. Memantine
E. Substance misuse D. Refer for aromatherapy and massage
E. Refer for counselling
2. An 8-year-old girl presents with encopresis. During
examination by the junior doctor, genital warts and 2. A 72-year-old widow has presented to her general
vaginal trauma are noted. What is the next most practitioner 20 times in the last month with minor
appropriate step in management? physical concerns. Previously she attended
A. The child should be sent home and seen in infrequently. During consultations she is restless,
outpatients wrings her hands and seems to struggle to remember
B. The parents should be confronted by the advice given to her. Her friends are struggling to cope
nurses as she telephones them throughout the night to check
C. The child should be directly asked what they are alright. Her score on the Abbreviated Mental
happened Test (AMT) is 10/10. What is the most likely diagnosis?
D. Police should be contacted to question the girl A. Mild cognitive impairment
E. The duty social worker and on-call paediatrician B. Generalized anxiety disorder
should be alerted C. Depressive episode
D. Late onset schizophrenia
3. A 16-year-old girl presents with a 2-month history of E. Hypochondriacal disorder
low mood and fatigue. She no longer enjoys playing
netball and feels her friends do not like her any more. 3. A 71-year-old widower has a 3-month history of
She is still attending school but is no longer doing well low mood, fatigue and anhedonia associated with
academically. What treatment should she be offered anorexia. He was transferred from a general hospital
first line? to a psychiatric hospital 4 weeks ago after an episode
A. Citalopram of acute kidney injury precipitated by poor oral intake.
B. Cognitive-behavioural therapy He has been commenced on an antidepressant but is
C. Fluoxetine poorly concordant and his presentation has changed
D. Sertraline little. His kidney function has not returned to baseline
E. Watchful waiting as he continues to drink little fluid. What is the best
management option?
4. A 16-year-old girl presents with low mood. She has A. Electroconvulsive therapy (ECT)
had episodes of low mood for most of her life, often B. Continue current oral antidepressant
varying from good to bad and back again within a C. Commence depot medication with antidepressant
day. She has never had any close friends because properties
she feels her peers have always rejected her. She has D. Change to an alternative oral antidepressant
self-harmed by cutting since the age of 13 years, and E. Change to lithium
often makes herself sick after meals. She says she
feels angry and empty at the same time. After her 4. An out-of-hours general practitioner calls for advice
father took an overdose she started hearing his voice about a patient who has been ‘behaving oddly’. The
inside her head telling her to do it too. Her body mass computer system is down, so their past psychiatric
index is 22 kg/m2. What is the most likely diagnosis? history is unknown. Which of the patients below is
A. Bipolar affective disorder most likely to have late-onset schizophrenia?
B. Bulimia nervosa A. A diabetic man who reports that the police are
C. Depressive episode stealing his thoughts
D. Emotionally unstable personality disorder B. A deaf woman who lives alone and reports that
E. Schizophrenia the police are trying to rob her
272
C. An obese woman who lives alone and is thought 8. An 82-year-old widow with no past psychiatric
disordered history presents to her general practitioner (GP)
D. A blind woman who lives alone and reports seeing requesting a repeat prescription of trazodone. Her
policemen in her living room every night supply should not have run out yet, and she admits
E. A man with ischaemic heart disease who can hear she took six extra tablets at the weekend in the hope
talking on the police radio in all the rooms in his of ‘going to sleep and not waking up’. In the event
house she just overslept, and no harm was done. She feels
foolish now and would just like to go home and stop
5. A 76-year-old woman who started mirtazapine for a wasting the GP’s time. What is the best management
depressive episode 4 weeks ago attends her general option?
practitioner. Her son also has depression and noticed A. Ask her to attend accident and emergency (A&E)
improvement after 2 weeks of an antidepressant. B. Review by GP in a week
She has not noticed any benefit or side-effects from C. Refer to the local lunch club
mirtazapine and is wondering if she should change D. Refer to psychiatric outpatients
treatment. What would be the best management option? E. Refer for urgent, same day, psychiatric review
A. Change to the antidepressant that worked for
her son Chapter 32 Forensic psychiatry
B. Augment mirtazapine with the antidepressant that
1. A 32-year-old man with substance misuse problems
worked for her son
reports he is thinking of taking up mugging to fund
C. Change to a tricyclic antidepressant
his habit. Which of the following factors in his history
D. Continue mirtazapine for at least 8 weeks
places him at highest risk of future violence?
E. Discontinue mirtazapine and observe without
A. Having a mental disorder
antidepressant
B. Using substances
6. A 77-year-old lady with a history of bipolar affective C. Previous violence
disorder no longer requiring medication is brought D. Experiencing command hallucinations
to the accident and emergency department by her E. Childhood abuse
family. In the past 24 hours she has started behaving
very oddly – getting dressed in the middle of the night, 2. A 19-year-old gentleman has been charged with a
dropping to the ground and shaking her leg about serious assault. He appears incredibly distracted
and shouting irritably at people when she is asked and distressed and is openly responding to auditory
questions about her orientation. Her Abbreviated hallucinations. The forensic psychiatrist has been
Mental Test score is 2/10. What is the most likely asked to assess his fitness to plead. What finding
diagnosis? on mental state exam would suggest he was fit to
A. Lithium toxicity plead?
B. Manic episode A. He is unable to say why he is in custody
C. Hypomanic episode B. He asks for most questions to be repeated as he
D. Somatization disorder is distracted by hallucinations
E. Delirium C. He is thought disordered, with loosening of
associations such that his answers are very hard
7. A general practitioner (GP) pays a home visit to a to follow
74-year-old man with a long history of schizophrenia. D. He believes he has been abducted by aliens and
The man mentions that he is more bothered by his answers will determine the fate of the universe
auditory hallucinations than normal. The GP notices E. He is able to give a coherent account of events
little piles of olanzapine tablets on saucers in the leading up to the offence but denies memory of
kitchen and living room. The man admits that he is the offence itself
struggling to keep track of whether he has taken his
medication or not. What would be the best way to 3. A 36-year-old man with schizophrenia has committed
improve concordance? a crime. He asks his lawyer if he can be considered
A. Start a depot antipsychotic to have had diminished responsibility. What is the only
B. Dispense medication weekly in a labelled charge diminished responsibility applies to?
dosette box A. Arson
C. Refer for a support worker to prompt medication B. Rape
D. Arrange daily dispensing at the local pharmacy C. Theft
E. Change the time of olanzapine so he can take it in D. Grievous bodily harm
the morning with his other medication E. Murder
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4. A 21-year-old man has been charged with assaulting controlling his bursts of anger. What diagnosis should
a police officer. He has a lengthy history of police he be further assessed for?
contacts from adolescence onwards, mainly for A. Antisocial personality disorder
impulsive acts of aggression. He dropped out of B. Attention deficit hyperactivity disorder (ADHD)
school at 14 years of age because he struggled to C. Autism spectrum disorder
concentrate. He is angry with himself for getting into D. Bipolar affective disorder
trouble with the police again and is asking for help in E. Emotionally unstable personality disorder
274
Extended-matching questions
(EMQs)
Each answer can be used once, more than once or not H. Pramipexole
at all. I. Reboxetine
Chapter 2 Pharmacological therapy and Select the antidepressant whose mechanism is best
described by the descriptions below:
electroconvulsive therapy
1. 5-HT 2C receptor antagonist and melatonin receptor
Management of antipsychotic-induced
agonist.
extrapyramidal side-effects
2. Inhibits serotonin and noradrenaline reuptake pumps;
A. Intramuscular procyclidine does not affect acetylcholine receptors.
B. Oral procyclidine 3. Inhibits serotonin and noradrenaline reuptake pumps;
C. Propranolol also blocks acetylcholine receptors.
D. Stop anticholinergics 4. Reversible inhibition of monoamine oxidase A.
E. Oral olanzapine 5. Inhibits dopamine and noradrenaline reuptake pumps.
F. Intramuscular haloperidol
G. Resuscitation
H. Baclofen Chapter 3 Psychological therapy
I. Dantrolene
Modalities of individual psychotherapy
J. Quinine
A. Psychoanalysis
For each of the following patients, select the ONE best B. Cognitive-behavioural therapy
management option from the list above. C. Mentalization-based therapy
D. Psychodynamic psychotherapy
1. A 22-year-old woman recently commenced on an E. Dialectical behaviour therapy
antipsychotic who is pacing her bedroom and says F. Exposure and response prevention
she feels very restless. G. Eye movement desensitization and reprocessing
2. A 22-year-old woman recently commenced on H. Cognitive analytic therapy
an antipsychotic who is staring at the ceiling and I. Systematic desensitization
clenching her jaw tightly. J. Mindfulness-based cognitive therapy
3. A 22-year-old woman recently commenced on K. Interpersonal therapy
an antipsychotic who is collapsed in her bedroom
with a fast pulse, low blood pressure, reduced For the examples below, select the ONE most appropriate
consciousness level and stiff limbs. modality of psychological therapy from the list above.
4. A 26-year-old man who commenced antipsychotics
a month ago. His face shows little expression, and he 1. A 28-year-old man has a diagnosis of emotionally
does not swing his arms when he walks. He does not unstable personality disorder. He reports that he
have a tremor, and his gait is not shuffling. often finds it difficult to know what others are thinking
5. A 34-year-old man who has been on antipsychotics about him and tends to expect the worst and act
and regular procyclidine for over a decade. He makes accordingly. He sometimes has difficulty knowing
frequent darting movements with his tongue but what he is thinking and feeling.
seems unaware of this. 2. A 57-year-old lady has a depressive disorder of
moderate severity. She attributes her symptoms to the
fact that her father has been taken into a nursing home,
Mechanism of action of antidepressants her daughter has left home to attend university and she
A. Agomelatine was recently made redundant from her job in the bank.
B. Amitriptyline 3. A 35-year-old woman has a diagnosis of agoraphobia.
C. Bupropion She wants to start a practical sort of therapy in which
D. Citalopram she does not need to talk about her difficult past.
E. Duloxetine 4. A 24-year-old ex-soldier has a diagnosis of
F. Moclobemide posttraumatic stress disorder. He requests a talking
G. Phenelzine therapy. In the past, he tried treatment with a therapist
275
Extended-matching questions (EMQs)
who ‘made me look at moving lights while I talked with his mother who does not feel he is safe to go
about what happened,’ and found this unhelpful. home. He is refusing admission because he thinks the
5. A 42-year-old gentleman has a diagnosis of doctors want to torture him.
obsessive-compulsive disorder and is mainly troubled 2. A 26-year-old man with schizophrenia. He has been
by having to check switches and locks in his home. charged with attempted murder after he attacked his
He feels that a therapy that is ‘more practical than mother, who he believed to be trying to torture him
talking’ would be helpful. by whispering derogatory comments to him all night,
even while he was staying at a friend’s house.
3. A 26-year-old man with schizophrenia. He has
Psychodynamic psychotherapy
been charged with a breach of the peace after he
A. Acting out repeatedly shouted in the street at 2 a.m. He told the
B. Projective identification police he was telling the voices to go away. Because it
C. Hypnosis did not work, he is now considering suicide.
D. Catharsis 4. A 26-year-old man with schizophrenia. He has been
E. Parapraxis brought into the accident and emergency department
F. Transference by ambulance after an attempted hanging. He is
G. Rationalization unable to speak and has stridor and low oxygen
H. Counter-transference saturations.
I. Dream interpretation 5. A 26-year-old man with schizophrenia. He suffered a
J. Working through hypoxic brain injury after attempting to hang himself
and now has very poor short-term memory. He
For each of the following, select the ONE most needs treatment with antibiotics for a urinary tract
appropriate descriptor from the list above. infection, but he does not realize he has one. The
need for antibiotics has been explained to him on
1. A 32-year-old woman, who has previously been very three different occasions, but he does not recall the
punctual, has arrived late and slightly inebriated for information by the time he is due to receive treatment.
the past six sessions since the therapist was on leave.
2. The therapist of a 59-year-old woman realizes that he
has been talking to her as if she were a mother figure. Chapter 5 Mental health service provision
3. A 43-year-old man feels better after his first psychotherapy
Choice of service provision for mental disorder
session, because he has ‘got it off his chest.’
4. A 21-year-old says ‘I’m glad we’re almost finished.’ A. Acute general adult inpatient unit
She intended to say ‘I’m sad we’re almost finished.’ B. Assertive outreach team
5. A 29-year-old man has been avoiding his C. Community mental health team
psychotherapist for the past few weeks, following D. Day hospital
what he considered to be a ‘clash of personalities.’ E. Early intervention in psychosis team
He decided to return and is keen to uncover his F. Home treatment team
unconscious reasons behind this. G. Liaison psychiatry review
H. Outpatient clinic
I. Primary care
Chapter 4 Mental health and the law J. Rehabilitation unit
Legislation For each case below, select which service they should be
A. Mental health legislation referred to:
B. Mental capacity legislation
C. Forensic mental health legislation 1. A 24-year-old man with a first episode of moderate
D. Criminal legislation depression.
E. No legislation required 2. A 24-year-old man who is an inpatient on a
F. Common law gastroenterology ward with inflammatory bowel
disease. He is low in mood and fatigued.
Which type of legislation could help in the management of 3. A 34-year-old man with schizophrenia. Today he
the following cases? attempted to hang himself because he is terrified the
secret services are planning to torture him.
1. A 26-year-old man with schizophrenia and comorbid 4. A 34-year-old man with schizophrenia who is currently
depression. He is currently severely depressed with an inpatient on a general adult ward. He has been
an active plan to commit suicide by hanging. He lives taking a therapeutic dose of clozapine for 12 weeks
276
but has ongoing auditory hallucinations. He has not 4. A 62-year-old woman reports that she took a ‘handful’
been in employment since the onset of his illness. of her antidepressant tablets then told her husband
5. A 34-year-old man with schizophrenia who is what she had done. She is unsure whether she
homeless and injects heroin. He frequently attends wanted to die. She has been in intermittent contact
A&E reporting auditory hallucinations but has not with the community mental health team several times
attended numerous appointments with his CPN and during her adult life with periods of poor motivation
psychiatrist. and alterations in her sleep pattern; however, she has
also had long periods of being well and managing
Chapter 6 The patient with thoughts of to work in the local supermarket. She reports strong
feelings of guilt and recent social withdrawal. At
suicide or self-harm interview, you feel that her affect is flat and she is
tearful. She does not drink alcohol or use drugs.
Mental disorder and self-harm
5. A 15-year-old girl was found having tried to hang
A. Obsessive-compulsive disorder herself in the family bathroom. She left a suicide
B. Anorexia nervosa note and was discovered by chance by the family
C. Alcohol-dependence syndrome cleaner. You notice that she looks thin. Her parents
D. Lesch–Nyhan syndrome report that she has been ‘picky’ with food over the
E. Mania with psychotic symptoms past few months, but they have not noticed anything
F. Emotionally unstable personality disorder else because of their busy jobs as lawyers. On
G. Depressive episode, moderate severity examination, you note that she is wearing very baggy
H. Schizophrenia clothes and has fine hairs over visible skin areas.
I. Generalized anxiety disorder She has actively resisted physical examination. She
J. Depressive episode, severe with psychotic features tells you that nothing is wrong at all, and that she
K. Dissocial personality disorder just wants to get home to study for her forthcoming
exams.
For each of the following patients, select the ONE most
likely mental disorder from the list above.
Immediate psychiatric management of the
1. A 19-year-old woman states that she is going to kill patient who has inflicted harm upon themselves
herself because ‘the voices in my head are telling me A. Admission to psychiatric intensive care unit (PICU/IPCU)
to’. These started troubling her this morning after an B. Admission to inpatient psychiatric ward
argument with her mother. Yesterday, she felt fine C. Admission to medical assessment/short stay ward
with no voices. She has no symptoms of depression. D. Discharge with immediate outreach team involvement
She insists that ‘it will be all your fault when I commit E. Discharge with community mental health team later in
suicide’ and demands admission to a psychiatric the week
ward. She has a history of self-harm by cutting and F. Discharge with outpatient psychiatry clinic
is well known to mental health services from previous appointment next month
emergency presentations. G. Discharge with appointment with alcohol addictions
2. A 50-year-old male bank manager who tried to gas services
himself in his car is found in a remote forest clearing H. Discharge to police custody
at 4:30 a.m. by a dog walker. Typed letters to his wife I. Discharge with information on non-NHS support
and children (currently on holiday) were found on the services
passenger seat. He has no psychiatric history. He J. Discharge with prescription for antidepressant
appeared intoxicated; however, he states he is not medication
a big drinker. He described recent weight loss and K. Discharge to the care of general practitioner
wakening early in the morning. He is convinced that a
recent financial crisis is all his fault. For each of the following cases, select the ONE most
3. A 22-year-old man presents with his mother. She is appropriate management option from the list above.
concerned that he has burned his chest with cigarettes
multiple times and appears to have created the image 1. A 57-year-old, unemployed, divorced man who
of a crucifix. He insists that he is the second coming lives alone took an overdose of a benzodiazepine.
of Jesus Christ and has special powers of healing that A scribbled suicide note was left, and he called
command respect. You note that he is dishevelled, emergency services before falling unconscious.
topless, talking very fast about loosely related ideas, He saw his keyworker from the alcohol addictions
and is very distractible. There is no history of substance team earlier that day who provided him with
misuse. He has never been to church. benzodiazepines for a community detoxification.
277
She felt that he was in ‘good humour’ when she and she tells you that she is not suicidal. She reports
saw him. He has presented numerous times in the that her self-harm was previously improving, but has
past with minor overdoses. At interview, he appears recently become more frequent due to academic
very drowsy and smells strongly of alcohol. He is pressures. She is keen to go home, and refuses to
inconsolably tearful, stating that he is ‘ruined’ and have any involvement in the future with mental health
wants to die. services.
2. A 20-year-old, unemployed, single woman took an
overdose of dihydrocodeine. She was found collapsed Chapter 7 The patient with impairment of
in the street and required naloxone. Her urine drug consciousness, memory or cognition
test is positive for cannabis and cocaine. Upon
wakening, she threatens to kill the nurse who has Differential diagnosis of cognitive impairment
taken her cigarettes. She continues to be physically, A. Delirium
verbally and racially aggressive to A&E staff. She has B. Dementia
had one short admission to a psychiatric ward 2 years C. Mild cognitive impairment
ago, and was discharged after assaulting a member D. Subjective cognitive impairment
of staff. On discharge, the consultant concluded ‘no E. Depression (‘pseudodementia’)
signs of mental illness’. At interview, she screams F. Psychotic disorders
at you to supply her with more dihydrocodeine, and G. Mood disorders
threatens to kill herself if you do not comply. H. Intellectual disability
3. A 33-year-old, married taxi driver (male) was found I. Dissociative disorders
by his wife in the loft, holding a nail gun to his head. J. Factitious disorder and malingering
He was slightly intoxicated and broke down in tears K. Amnesic syndrome
while agreeing to attend hospital. He has no history
with psychiatric services, and—despite having taken For each of the following patients, select the most likely
a drink tonight—does not usually drink alcohol. He diagnosis from the list above.
described feeling like he ‘can‘t be bothered’ since he
had his pay severely cut about 2 months ago, and 1. A 62-year-old teacher presents to her general
has since been burdened by creditors calling him. At practitioner (GP) because she feels she is not
interview, he described poor sleep, weight loss, lack remembering the names of the children in her class as
of energy, and guilt about his loss of libido. While he well as she used to. She is worried she has dementia
described ongoing suicidal feelings, he described like her mother. She has no difficulties in activities
his daughter and wife as strong protective factors, is of daily living and her mood is normal. She scores
regretful that ‘things have come to this’, and glad that 100/100 on ACE-III.
his wife found him before he did ‘something stupid’. 2. A 62-year-old teacher presents to her GP because
He seems a bit more optimistic after assessment. she feels she is not remembering the names of the
4. A 67-year-old, retired widow with no psychiatric children in her class as well as she used to. She is
history, took an overdose of four of her blood worried she has dementia like her mother. She has no
pressure tablets. She waited until after her daughter difficulties in activities of daily living and her mood is
went on holiday, and was only discovered when her normal. She scores 80/100 on ACE-III.
neighbour visited unexpectedly and saw a suicide 3. A 62-year-old teacher presents to her GP because she
note addressed to her daughter on the coffee table, feels she is not remembering the names of the children
stating that she could not go on without her recently in her class as well as she used to. She is worried she
deceased husband. She later told the psychiatrist that has dementia like her mother. She has noticed herself
she was ‘just a silly old lady’ and denied any suicidal getting lost in the school corridors sometimes and her
intent. She just wanted to go home to look at her husband now does all the shopping because she kept
wedding photographs. getting disorientated in the supermarket. Her mood is
5. A 26-year-old, single, mature student, who lives with normal. She scores 80/100 on ACE-III.
flat-mates, presents at the accident and emergency 4. A 62-year-old teacher presents to her GP because
department requesting sutures for a self-inflicted she feels she is not remembering the names of the
laceration on her inner thigh. She has previously children in her class as well as she used to. She is
been involved with mental health services due to worried she has dementia like her mother. She has
self-harming, but disengaged with them 2 years no difficulties in activities of daily living and scores
previously because she did not agree with their 90/100 on ACE-III, losing marks only in the domain
diagnosis of emotionally unstable personality disorder. of memory. She admits she has been low in mood
She is on no medication. She is reluctant to talk to recently, is not enjoying work any more, is fatigued,
a psychiatrist; however, you manage to engage her has lost weight and is not sleeping well.
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5. A 62-year-old teacher presents to her GP because is normal apart from dizziness when she gets off the
she feels she is not remembering the names of the examination couch.
children in her class as well as she used to. She is 4. A 43-year-old traffic warden presents to her GP with
worried she has dementia like her mother. She has weight gain and amenorrhoea. She is surprised to
no difficulties in activities of daily living and scores be going through the menopause so soon as her
90/100 on ACE-III, losing marks only in the domain of mother’s occurred in her late 50s. She is finding
memory. She admits she has drunk alcohol to excess herself forgetful at work, checking cars on the same
for several years, as did her mother. During a recent streets repeatedly. She has got into trouble for
admission with pancreatitis she was noted to show this and feels very low in mood. ACE-III is 80/100.
signs of alcohol withdrawal. Physical examination shows hypertension, a plethoric
complexion and central obesity.
Potentially reversible causes of dementia 5. A 76-year-old woman attends her GP with a
12-month history of gradually worsening memory
A. Subdural haematoma
problems and low mood. Past medical history
B. Brain tumour
includes renal calculi and abdominal pain for which no
C. Normal pressure hydrocephalus
cause has been identified. ACE-III is 76/100. Physical
D. Hyperthyroidism
examination is normal.
E. Hypothyroidism
F. Hyperparathyroidism
Subtypes of dementia
G. Hypoparathyroidism
H. Cushing syndrome A. Alzheimer dementia
I. Addison disease B. Vascular dementia
J. Vitamin B12 deficiency C. Mixed dementia
K. Folate deficiency D. Frontotemporal dementia
E. Lewy body dementia
For each of the following patients, select the most likely F. Parkinson disease with dementia
diagnosis from the list above. G. Progressive supranuclear palsy
H. Huntington disease
1. A 74-year-old woman presents to her general I. Creutzfeldt–Jakob disease
practitioner (GP) with her husband who is concerned J. Neurosyphilis
that over the last 8 weeks she has become K. HIV-related dementia
increasingly forgetful and disorientated. She has
burnt a couple of pans after leaving them unattended. For each of the following patients, select the most likely
Some days she takes afternoon naps, which is cause from the options above.
new for her. When pressed he recalls she was hit 1. A 77-year-old woman has a 9-month history of gradual
on the head by a football around 3 months ago onset, gradually worsening cognitive impairment. She
while watching her grandson's team but seemed forgets recent events and people’s names. She can no
fine afterwards. Past medical history includes longer manage her finances. Past medical history is of
atrial fibrillation and asthma. ACE-III is 70/100 and psoriasis and asthma. Head computed tomography
neurological exam shows normal conscious level and (CT) showed generalized atrophy, particularly marked
a subtle right hemiparesis. in the medial temporal lobes.
2. A 76-year-old widower attends his GP because of 2. A 74-year-old man has a 10-month history of
urinary incontinence. As he walks into the room he progressive cognitive impairment. His family notice he
has a broad based, stiff-legged gait. He is very slow seems to worsen suddenly and then plateau before
to answer questions and seems not to be paying abruptly worsening again. He has marked word-
close attention to what is asked. He says he cannot finding difficulties and an abnormal gait. Past medical
remember when his incontinence started or how history is of ischaemic heart disease, hypertension and
often it occurs. Past medical history is of a duodenal diabetes. He is a current smoker. CT of the head shows
ulcer only. ACE-III is 74/100 and neurological exam is generalized atrophy, small vessel disease and an old
normal apart from his gait. lacunar infarct.
3. A 52-year-old woman presents to her GP with 3. A 67-year-old retired chef has a 12-month history of
memory and concentration problems. She reports gradual personality change. He was previously polite and
feeling tired and sluggish for the last 6 months. considerate but has become very rude and tactless. He
She feels low in motivation and mood and has quit is having an affair with a waitress from his old restaurant.
her running club because she can't be bothered His wife of 40 years is thinking of leaving him but he says
to keep up any more. Past medical history is he does not care. Head CT shows generalized atrophy,
unremarkable. ACE-III is 98/100. Physical examination particularly marked in the frontal lobes.
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4. An 81-year-old man has an 18-month history of D. Amphetamine

fluctuating cognitive impairment on a background E. Diazepam
of a gradual cognitive deterioration. He has been F. Cocaine
investigated for delirium but no cause found. G. Ketamine
Sometimes he is very drowsy during the day. He is H. Mephedrone
increasingly stiff and finds it hard to roll over in bed. I. Buprenorphine
He also finds it hard to keep his balance and has J. Lysergic acid diethylamide
had a lot of falls recently. Sometimes he experiences
visual hallucinations of cats and mice. Head CT shows For each of the following statements, select the most
generalized cerebral atrophy. appropriate answer from the options above.
5. A 71-year-old man was diagnosed with Parkinson
disease 5 years ago. He has a 1-year history of 1. Deviated nasal septum
cognitive impairment causing him to forget people’s 2. Depersonalisation
names and where he has left his clothes. Sometimes 3. Bacterial endocarditis
he has hallucinations of former work colleagues 4. Memory impairment, particularly if taken
walking around the room. CT of the head shows long-term
generalized cerebral atrophy. 5. Precipitated opioid withdrawal
Clinical features in cognitive impairment Chapter 9 The patient with psychotic

A. Apraxia symptoms
B. Agnosia
C. Aphasia Differential diagnosis of psychosis
D. Amnesia A. Delusional disorder
E. Perseveration B. Dementia/delirium
F. Disinhibition C. Depressive episode, severe, with psychotic
G. Dyscalculia features
H. Dyslexia D. Manic episode with psychotic features
I. Apathy E. Neurodevelopmental disorder
F. Personality disorder
For each of the following patients, select the clinical G. Psychosis secondary to a general medical
feature described from the options above. condition
1. When shown a pair of scissors a woman states they H. Psychosis secondary to psychoactive
are scissors but cannot work out how to cut with substance use
them. She can mimic the correct action when shown. I. Schizoaffective disorder
2. When shown a pair of scissors a woman states they J. Schizophrenia
are ‘those things used for cutting paper’ but cannot K. Schizophrenia-like psychotic disorders
name them.
3. A woman uses scissors to cut a piece of paper into For each of the following patients, select the ONE most
squares as asked. When asked to then cut triangles, likely diagnosis from the list of options above.
she keeps cutting squares.
4. When shown a pair of scissors a woman is unable to 1. The mother of a 22-year-old man asks for a home
name them or describe their function. When she is visit from their general practitioner (GP). For the last
allowed to touch them she quickly identifies what they 6 weeks her son has barely left his room and seems
are. She has normal visual acuity. to be collecting tinfoil. She is adamant that he has
5. When given a pair of scissors inside a covered box, a never used drugs. He is in second year at university,
woman turns them around in her hands but is unable having passed first year with a distinction, but
to name them. When she is allowed to look at them 6 months ago he lost interest and stopped going to
she quickly identifies them. She has normal sensation lectures. He tells the GP that a terrorist organization is
in her hands. trying to brainwash him into becoming a terrorist and
he needs the tinfoil to make it more difficult for them
to beam thoughts into him.
Chapter 8 The patient with alcohol or 2. A 45-year-old man has recurrent episodes of
substance use problems low mood associated with third person auditory
A. MDMA hallucinations in the form of an abusive running
B. Cannabis commentary. These symptoms do not occur
C. Heroin separately.
280
3. A 52-year-old man has recurrent episodes of low naval service. He has become very extravagant,
mood associated with second person auditory wanting to sell their home and give half the proceeds
hallucinations in the form of abusive comments. to charity. He forgot their wedding anniversary. On
He has noticed his mood starts to dip first, and the examination he has unusually brisk reflexes.
hallucinations emerge as his mood worsens. 2. A 57-year-old accountant is brought to accident
4. A 47-year-old teacher presents to his GP for the 25th and emergency by the police after going to the
time in 6 months convinced he has bowel cancer, supermarket in swimming trunks and flippers. He
despite having had a normal colonoscopy and does not see what the problem is. He states he wore
abdomen/pelvis computed tomography. He tells his the flippers because he has a constant headache
GP he knows logically he cannot have bowel cancer which worsens when he bends down to tie his
but at the same time he is certain he does. His mood shoelaces. He has no psychiatric history or previous
is normal and he is still working. encounters with the police.
5. A 37-year-old man who is brought to accident and 3. A 46-year-old vegan goes to her GP because for the
emergency by the police for assessment after he last 6 months she has found herself unusually clumsy,
called them to say his neighbour is persecuting him tripping over rugs and stairs in a way she never did
by refusing to move her wheelie-bin. The police before. She feels like everyone is watching her when
note multiple previous calls over the last decade she stumbles in the street and is sure she heard a
about previous neighbours. The man agrees it is group of strangers commenting on how they planned
possible the neighbour has some other reason for to rob her.
not wanting to move the wheelie-bin, but thinks it 4. A 42-year-old man is admitted for emergency
is most likely because she wants to spite him. He surgery following a road traffic accident. Two days
is angry with the police for bringing him to see a after admission he becomes agitated and asks the
doctor, stating he plans to contact his lawyer about charge nurse why there are so many insects in the
their behaviour. ward (there are none). He keeps rubbing his skin and
6. A woman requests a GP home visit for her 78-year- saying, ‘get away, get away’. He has a stumbling gait
old father who has no previous psychiatric history. and his eyes make rapid small movements to the side
She is concerned that he has told her he can hear his and back again.
mother and sister, who are both dead, talking. She is
also concerned that he seems very forgetful and does
not seem to be looking after himself properly. He is Mental state examination in psychosis
quite cheerful and enjoys speaking with his relatives. (perceptual disturbance)
A. Audible thoughts
B. Extracampine hallucination
Psychosis secondary to a general medical C. Gustatory hallucination
condition or psychoactive substance use D. Hypnagogic hallucination
A. Amphetamine E. Hypnopompic hallucination
B. Cerebral tumour F. Kinaesthetic hallucination
C. Cocaine G. Olfactory hallucination
D. Corticosteroids H. Pseudohallucination
E. Cushing syndrome I. Second person auditory hallucination
F. L-dopa J. Tactile hallucination
G. Neurosyphilis K. Third person auditory hallucination
H. Huntington disease L. Visceral hallucination
I. Hyperthyroidism
J. Hypothyroidism For each of the following patients, select ONE clinical
K. Thiamine deficiency feature described from the list of options above.
L. Vitamin B12 deficiency
1. I hear a man saying ‘you idiot’ in the corner of the
For each of the following patients, select the ONE most room but no one’s there.
likely cause from the options above. 2. I hear a man saying ‘you idiot’ inside my head.
3. I hear a man in Newcastle talking to me even though I
1. A 62-year-old retired navy officer is brought to his live in Edinburgh.
general practitioner (GP) by his wife. She is concerned 4. My spleen is moving around inside me.
that his personality has changed over the last few 5. As I’m drifting off to sleep I catch a glimpse of a ginger
months. He has been unusually cheerful and keeps cat beside the bed, but I have no cat.
mentioning that he expects to be knighted for his 6. I taste rotting meat all the time.
281
Mental state examination in psychosis (thought but so far no one has commented. Fortunately, he
disturbance) is able to stay up late catching up on work without
A. Delusion of control feeling tired the next day. He denies any drug or
B. Delusion of infidelity alcohol use.
C. Delusion of misidentification 2. A 22-year-old trainee electrician is brought to Accident
D. Delusion of reference and emergency by the police after he was found
E. Erotomania breaking into an electronics shop. He states he
F. Grandiose delusion needed the parts for a new jetpack he is designing—
G. Loosening of association he plans to start a new business with it which will
H. Nihilistic delusion ‘revolutionize transatlantic flight’. He has resigned
I. Persecutory delusion from his apprenticeship in order to spend more time
J. Somatic delusion on this venture. He is irritable with the male police
officer but flirtatious towards the female police officer.
For each of the following patients, select ONE clinical He denies drug or alcohol use.
feature described from the list above. 3. A 37-year-old man with a history of bipolar disorder
was admitted to a psychiatric ward one day ago.
1. ‘I’m sure I’m being spied on by the government, I can The nurses tell you he has been very elated and
tell because of the amount of junk mail I get’. disinhibited so far today. When you interview him he
2. ‘My boss definitely loves me, even though he denies it seems low and tearful, but as the interview progresses
every time I remind him.’ he gets very irritable and starts to speak too quickly
3. ‘I can’t understand why that woman has dressed up for you to ask him any more questions.
as my wife and keeps referring to me as her husband’. 4. A 36-year-old secretary attends her GP because she
4. ‘The newsreader on the radio keeps reading out my is feeling unusually irritable at work. Sometimes she
name for some reason’. loves her job and sometimes she hates it, but forces
5. ‘I don’t need to eat because I’m already dead’. herself to attend. Right now she is also feeling irritable
6. ‘Someone else’s thoughts are inside my head.’ with her family and neighbour. She has noticed her
7. ‘Why should the cat indeed bend that carrot tomatoes mood has seemed to cycle since her late teens, but it
are red.’ has never stopped her doing anything.
5. A 28-year-old doctor suffers from recurrent depressive
disorder. He has recently started a stressful new job
Chapter 10 The patient with elated or
and his flatmates are worried because he doesn’t seem
irritable mood to be eating or sleeping well, despite seeming quite
cheerful. He paces the flat at night talking about new
Differential diagnosis of elevated or irritable mood
operative techniques he is designing. His consultant
A. Hypomanic episode sent him home from work because he refused to scrub
B. Manic episode without psychotic features for theatre, stating ‘I’m pristine already’.
C. Manic episode with psychotic features
D. Mixed affective episode
E. Bipolar affective disorder Elevated or irritable mood secondary to a
F. Cyclothymia general medical condition or psychoactive
G. Schizophrenia substance use
H. Schizoaffective disorder A. Huntington disease
I. Elevated or irritable mood secondary to a general B. Multiple sclerosis
medical condition C. Parkinson disease
J. Elevated or irritable mood secondary to psychoactive D. Cerebral tumour
substance use E. Cushing disease
K. Delirium/dementia F. Hypothyroidism
G. Hyperthyroidism
For each of the following patients, select the ONE most H. Anabolic steroids
likely diagnosis from the list above. I. Corticosteroids
J. L-dopa
1. A 40-year-old lawyer attends his general practitioner K. Cocaine
(GP) asking for a medication to reduce his sex drive L. Amphetamine
because his wife is complaining. He is smartly dressed
in a new suit and says he feels ‘on top of the world’. For each of the following patients, select the ONE most
He has been finding it hard to stay focused at work likely cause from the options above.
282
1. A 66-year-old man with a shuffling gait and reduced 4. The patient speaks rapidly and initially starts to answer
facial expression has recently had a medication a question but very rapidly diverts onto lots of other
increase. Now he is elated, spends all his time playing topics. It is very confusing to listen to but in retrospect
online poker and asked his wife where all the monkeys there are links between the topics. Some of the links
in the kitchen had come from. were rhyming words.
2. A 22-year-old student is brought to accident and 5. The patient is trying to complete serial 7s but keeps
emergency (A&E) by his friends from a party because being distracted by the noise of hoovering.
he tried to fly off the roof. He is adamant he is 6. The patient comments there is a beautiful blue bird
Superman. He admits to having swallowed a pill in the corner of the room, but no one else can see
earlier. On examination he is restless with dilated anything there.
pupils.
3. A 28-year-old bodybuilder has recently become
convinced he will win the next world championship. Chapter 11 The patient with low mood
He is irritable with his girlfriend whenever she queries
this. He is also hypersexual and forgetful and has Differential diagnosis of low mood
been reprimanded at work. A. Mild depressive episode
4. A 62-year-old woman is an inpatient on an acute B. Moderate depressive episode
medical ward following a severe asthma exacerbation. C. Severe depressive episode without psychotic features
The nurses notice she seems irritable and suspicious D. Severe depressive episode with psychotic features
and keeps asking for a single room ‘as befits E. Recurrent depressive episode
someone of my status’. Her daughter says this is a F. Dysthymia
complete change from normal. G. Bipolar affective disorder
5. A 45-year-old woman presents to A&E with H. Schizoaffective disorder
palpitations. When not seen immediately she I. Low mood secondary to a general medical condition
becomes extremely irritated and starts pacing in J. Low mood secondary to psychoactive substance use
the waiting room. On examination she has a tremor,
pupils are normal and electrocardiogram (ECG) shows For each of the following patients, select the ONE most
sinus tachycardia. She shouts at the ECG technician likely diagnosis from the list above.
for not being gentle enough when she removes the
electrodes. 1. A 40-year-old man feels he has been depressed for
20 years. He cannot recall a lengthy period of normal
mood since his early adulthood. Despite this, he is
Mental state examination in elevated or irritable
able to work as a supermarket manager, has a loving
mood
relationship with his wife and reports that he quite
A. Pressured speech enjoyed his last holiday in Tenerife.
B. Flight of ideas 2. A 24-year-old waitress has had low mood and
C. Tangential thinking lethargy for 3 weeks. She finds it harder than normal
D. Poor concentration to remember her customer’s orders. She thinks this
E. Psychomotor retardation is because she has never been an intelligent person.
F. Psychomotor agitation She is eating normally, sleeping well and enjoyed
G. Hyperacusis going out to the movies last night.
H. Visual hyperaesthesia 3. A 71-year-old widowed woman who lives alone
I. Auditory hallucination is brought to the surgery by her neighbour. The
J. Visual hallucination neighbour is shocked because the patient put a rude
note through his door telling him to get his drains
Lead in: For each of the following patients, select ONE unblocked in order to get rid of the stench in the
clinical feature described from the list of options above. street. No one else has noticed a bad smell. Before
her husband died the patient used to be very social
1. There are no natural breaks in the conversation and it and visited her neighbours frequently. On examination,
is impossible to interrupt the patient without speaking she is unkempt and walks very slowly. When you ask
over them. her questions, she makes poor eye contact and does
2. The patient comments she has never seen a blue as not answer for a long time.
blue as the nurse’s uniform before. 4. A 35-year-old cashier presents to his general
3. The patient speaks normally and initially starts to practitioner asking for a sick line. He feels he cannot
answer a question but quickly diverts onto related but continue at work because for the last month he has
unimportant topics. been low in mood and finds himself becoming easily
283
tired during his shifts. He is not enjoying talking with previous years. You see she attended 3 months ago
his colleagues as much as he used to. He finds himself with a sore eye and blurred vision which resolved
wakening at 5 a.m. (he normally rises at 8 a.m.) and spontaneously.
lies in bed worrying about the day ahead. His mood is
a bit better in the evenings. He has been eating poorly Mental state examination in low mood
and lost a stone in weight over the last month.
A. Poor self-care
5. A 42-year-old construction worker reports intermittent
B. Malingering
low mood. Sometimes he is so low he is unable to go
C. Reduced range of reactivity
to work. On closer questioning it seems it is mainly
D. Incongruous affect
Mondays he misses, and the weekends he feels low.
E. Low mood
The problem has come on over the last year, when
F. Psychomotor retardation
he has been binge-drinking at the weekends after his
G. Psychomotor agitation
wife left him. On weekends when he looks after his
H. Marche à petits pas
daughter he does not drink and feels fine.
I. Negative cognition
J. Hopelessness
Low mood secondary to a general medical K. Complete anhedonia
condition L. Partial anhedonia
A. Huntington disease
B. Parkinson disease For each of the following patients, select ONE clinical
C. Multiple sclerosis feature described from the list of options above.
D. Cerebral tumour
E. Cushing syndrome 1. A 76-year-old widowed retired headmistress is
F. Addison disease brought to accident and emergency by her family who
G. Conn syndrome are concerned she has not been eating. She paces
H. Thrombocytopenia the cubicle, keeps buttoning and unbuttoning her coat
I. Hypothyroidism and does not sit down when offered a chair.
J. Hyperthyroidism 2. A 44-year-old architect being treated for depression
K. Systemic lupus erythematosus is upset because he has lost a contract after the
company went bust. He says this means he will lose
For each of the following patients, select the ONE key all his other contracts and never be asked to design
diagnosis to exclude from the list above. another building.
3. A 22-year-old woman tells her general practitioner
1. A 52-year-old care assistant presents to her general (GP) she has passed a recent exam but does not
practitioner (GP) with a 6-month history of low mood smile or appear pleased. Later she mentions she has
and fatigue. She complains she has put on a lot of broken up with her partner but does not look sad or
weight recently despite no changes in her diet or relieved. She describes both things in a similar tone of
exercise. On examination she is obese, hypertensive speech.
and the blood pressure cuff leaves a bruise. 4. A 36-year-old sales assistant attends his GP straight
2. A 35-year-old traffic warden presents to his GP after from work for a prescription of citalopram. He has
he tripped over the curb and banged his knee. He greasy hair and stains on his shirt and is slightly
also mentions a 3-month history of low mood. He malodorous.
is not sure why he tripped but has been stumbling 5. A 55-year-old lorry driver tells his GP he has lost
more often than he used to and has given up football. interest in everything he used to enjoy. He no longer
He does not drink. He thinks he may have a family plays darts or watches football as he does not care
history of depression because his father went into a who wins now. However, he did enjoy spending time
psychiatric hospital in his early 40s and died there with his grandson at the weekend.
10 years later.
3. A 46-year-old florist presents because for the last
2 months she has felt tired all the time and low in
Chapter 12 The patient with anxiety, fear or
mood. She feels ugly, her hair never seems to be avoidance
glossy anymore and she thinks her skin is dry and
flaky. On examination, her pulse is 52 regular. Differential diagnosis of anxiety, fear or
4. A 26-year-old veterinary student presents with avoidance
tingling in her left arm. She becomes tearful during A. Agoraphobia with panic disorder
the consultation, admitting she is finding the fourth B. Agoraphobia without panic disorder
year of her studies much more difficult than the C. Social phobia
284
D. Generalized anxiety disorder most of the time and has had two panic attacks.
E. Panic disorder These symptoms had onset after he witnessed an
F. Depressive episode armed robbery but he denies flashbacks and still buys
G. Acute stress reaction milk in the shop where he witnessed the robbery.
H. Posttraumatic stress disorder
I. Adjustment disorder Anxiety secondary to a general medical condition
J. Personality disorder or psychoactive substance use
K. Anxiety secondary to a general medical condition A. Cushing syndrome
L. Anxiety secondary to psychoactive substance use B. Hypoglycaemia
C. Hyperthyroidism
For each of the following patients, select the ONE most D. Pheochromocytoma
likely diagnosis from the list above. E. Caffeine
F. Alcohol
1. A 25-year-old librarian avoids being with others G. Cannabis
whenever possible. He does all his shopping online H. Amphetamine
and always volunteers to reshelve books rather than I. Fluoxetine
deal with enquiries. When he is forced to interact with J. Mirtazapine
people he can feel himself blushing and sweating. He K. Trazodone
feels they are scrutinizing and judging him critically,
even though he knows he is not really a bad person. For each of the following patients, select the ONE most
2. A 43-year-old woman feels she has been on edge likely cause from the options above.
for 2 years. She spends most of each day worrying
about many trivial topics and sometimes she feels 1. A 63-year-old shopkeeper with hypertension has
something bad is going to happen for no reason. She periodic episodes of anxiety, tachycardia, sweating
lies awake at night thinking about these things. She and pallor. She can identify no triggers but recalls her
often has a dry mouth, epigastric discomfort and a mother having a similar problem. Her random glucose
bilateral frontal headache. is elevated.
3. A 28-year-old secretary presents to her general 2. A 48-year-old scientist with a past medical history
practitioner with weight loss. Six months ago in a of vitiligo presents with a 3-month history of anxiety,
supermarket she suddenly felt like she was going to die. increased appetite and heat intolerance. Her hands
She had pain in her chest, was short of breath and her are shaky, and she has knocked over a lot of test
arms and lips tingled. She rushed outside and the feeling tubes recently.
subsided, but now she does not like to go into any large 3. A 25-year-old joiner has recently been diagnosed
shops and is eating less well. She is still going to work with depression and commenced an antidepressant
but now walks 5 miles each way as she does not want 4 days ago. Since then he has been very restless
to be on a bus and have another attack. As long as she and agitated and frequently called his friends for
is in her house or with her friends she is relaxed. reassurance. His sleep has worsened further.
4. Over the last 3 months, a 35-year-old builder has 4. A 23-year-old man has started a new job as a welder.
experienced several episodes of sudden onset He has noticed that he gets very irritable and anxious
shortness of breath, palpitations, sweatiness, nausea, by the end of the day and has had to go home early
feeling that the world is unreal and feeling he is about a couple of times. He sweats a lot while working so is
to die. These feelings resolve spontaneously over 20 drinking a lot of his favourite soft drink, ‘Go-Man’.
minutes. He cannot identify any triggers. In particular, 5. A 19-year-old man is brought to accident and
they are not brought on by exercise and he can emergency by his friends. He is pacing the cubicle, is
continue to do his active job. His electrocardiogram tachycardic, hyperventilating, sweating and has dilated
(ECG) is normal. pupils. He jumps when his name is called. His friends
5. A 37-year-old professional violinist finds himself unable saw him swallow a white tablet earlier in the evening.
to play concerts. He can play well when alone but
starts to sweat and shake such that he cannot play
properly when in the presence of others. He has had
Chapter 13 The patient with obsessions and
to cancel a tour. These symptoms came on after he compulsions
received a series of negative reviews. In general, he is
a relaxed person who enjoys socializing. Differential diagnosis of obsessions and
6. A 42-year-old policeman has experienced low mood, compulsions
anhedonia, fatigue, early morning wakening and A. No mental illness
anorexia for the last month. He has free-floating anxiety B. Obsessive-compulsive disorder
285
C. Depressive episode C. Rumination

D. Phobia D. Pseudohallucination
E. Agoraphobia with panic disorder E. Hallucination
F. Agoraphobia without panic disorder F. Over-valued idea
G. Social phobia G. Delusion
H. Panic disorder H. Thought insertion
I. Eating disorder I. Flashback
J. Personality disorder
K. Hypochondriacal disorder For each of the following descriptions, select the ONE
most likely psychopathology from the options above.
For each of the following patients, select the ONE most
likely diagnosis from the list above. 1. ‘I keep seeing images of germs crawling on my skin.
I try to stop my mind showing them to me, but I
1. For the last year, a 27-year-old woman has can't’.
experienced repetitive images of soiled hands that she 2. ‘After I got viral gastroenteritis, I became much more
acknowledges are from her own mind. Washing her careful about hygiene. I’m worried I'll get it again. Now
hands reduces her fear that her hands are dirty, but I autoclave every utensil and piece of crockery I use. I
now she spends around 2 hours a day washing and is had to give up my job at the hospital, it wasn't worth
developing contact dermatitis. She has tried to wash the risk’.
less but this makes her very anxious. 3. ‘I lie awake at night thinking about all the ways I could
2. For the last year, a 27-year-old nurse has been have avoided getting sick. I think about it from all the
influenced by a National Health Service advertising different angles but never reach a conclusion’.
campaign featuring soiled hands spreading infection. 4. ‘I keep hearing a voice inside my head saying,
Washing her hands reduces her fear that they are “you’re dirty”. I don’t know who it is but I think they're
dirty. Now she washes her hands before and after probably right’.
every patient contact, up to 100 times a day, and is 5. ‘I keep hearing a voice outside my head saying,
developing contact dermatitis. “you’re dirty”. I don’t know who it is, but I think they're
3. For the last 4 months, a 27-year-old woman has probably right’.
experienced repetitive images of herself having 6. ‘Someone puts ideas in my head. like thoughts of
sexual encounters with children. This makes her feel germs, and of being ill. I don't know how they get in
extremely guilty and unclean. Showering reduces her there, but they're not my thoughts’.
fear that she will engage in such behaviour, but she 7. ‘When I saw a picture on TV of germs crawling on
now has to spend several hours a day in the shower. someone’s skin, I knew that I was fatally ill. The
She describes herself as worthless and hopeless and doctor told me I was fine, but I know my days are
admits that 6 months ago she started to feel low in numbered’.
mood, anhedonic and fatigued.
4. After a bad experience as a child, a 27-year-old woman
has been terrified of illness. Most of the time she has Chapter 14 The patient with a reaction to a
no problems, but if she meets anyone who is unwell stressful event
she avoids them and washes her hands thoroughly to
reduce her risk of contracting their illness. If she cannot Dissociative disorders
get away from the person, she feels overwhelmingly A. Stupor
anxious and may have a panic attack. B. Dissociative anaesthesia
5. For the last 4 months, a 27-year-old woman has C. Depersonalization disorder
experienced recurrent thoughts of herself as being fat D. Functional seizures
and ugly. She feels these thoughts are her own, and E. Functional paralysis
are appropriate, as she believes she is fat and ugly. F. Psychogenic amnesia
She has been avoiding food and exercising lots. Her G. Fugue state
periods have stopped and her body mass index is 17. H. Hysterical blindness
She still views herself as overweight. I. Dissociation secondary to psychoactive
substance use
J. Dissociative identity disorder
Differentiating types of repetitive or intrusive
thoughts Assuming physical causes have been excluded, which
A. No mental illness of the above would be the most likely diagnosis for the
B. Obsession following?
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1. A 29-year-old mother of two, with a history of collision with a lorry. He feels lucky to be alive, and
depression and a family history of epilepsy, has you are unable to elicit any other psychopathology.
recently started having seizures, which last for less 3. A 52-year-old deep sea diver has felt constantly ‘on
than a minute, and do not cause tongue-biting, edge’ for the last 3 months since he was involved in
incontinence or post-ictal confusion. She denies an incident involving loss of oxygen flow while deep
alcohol or drug use and seems indifferent to her under the sea. He was convinced that he was going
predicament. Her husband tells you that this started to die. He reports vivid nightmares and has been
when he told his wife of his new job on an oil rig. He unable to return to work.
now feels he cannot leave home for fear that she will 4. A 27-year-old woman is referred from the
be seriously harmed by the seizures. neurosurgical unit 4 months after a fall from a first-
2. A 46-year-old businessman from a distant city is floor balcony. She reports episodes of derealization,
brought to hospital by the police, after apparently followed by visual hallucinations, loss of memory and
trying to withdraw money from a building society and extreme tiredness.
being unable to remember his name. At interview,
he seems unable to recall any personal details about
himself and has no idea where he is. He is carrying
Chapter 15 The patient with medically
a bundle of business cards for a company that was unexplained physical symptoms
recently reported to have gone bankrupt.
3. A 21-year-old male prisoner complains of lack of Diagnosis of medically unexplained physical
sensation in his right arm, anterior abdomen and left symptoms
leg. Neurological examination is otherwise normal. A. Munchausen syndrome by proxy
The prison guard tells you that he has been moved to B. Body dysmorphic disorder
protective custody because a senior gang member C. Factitious disorder
has threatened to kill him. D. Somatic delusional disorder
4. An 18-year-old tells you that she feels like she is ‘in a E. Schizophrenia
bubble’ and feels that everything around her appears F. Hypochondriacal disorder
to be unreal and distant from her life. She has no G. Somatization disorder
psychiatric history and was fine until yesterday. Her H. Malingering
parents tell you that she returned home from a ‘rave’ I. Severe depression with psychotic features
party only a couple of hours ago. J. Dissociative disorder
For each of the following scenarios, select the most

Diagnosis following stressful events appropriate diagnosis from the list above.
A. Acute stress reaction
B. Posttraumatic stress disorder (PTSD) 1. A 23-year-old quit her job as a dancer 2 years ago
C. Moderate depression because she is preoccupied with the idea her breasts
D. Adjustment disorder are misshapen. Now she barely leaves the house,
E. Bereavement response wears baggy clothes and is requesting surgical
F. Acute/transient psychotic disorder augmentation. The cosmetic surgeon noted no
G. Alcoholic hallucinosis abnormalities.
H. Panic disorder 2. An 8-year-old girl is drowsy. Her mother tells you
I. Conversion disorder that it is sudden onset. On examination, you find
J. Temporal lobe epilepsy subcutaneous needle marks between her toes. One
K. Musculoskeletal injury of the nurses finds an insulin syringe on the bedside
while her mother is at the bathroom.
3. A 21-year-old man is preoccupied by a small scar behind
From the options above, which of the diagnoses would be
his ear, which he believes is where the government have
the most appropriate for the scenarios below?
implanted a microchip to insert thoughts.
4. A 65-year-old man in a surgical ward with abdominal
1. The wife of a 35-year-old Royal Air Force pilot has pain believes that he is dead and rotting from the
been hearing the voice of her husband, who was inside.
recently killed on duty in Syria. She has been feeling 5. A 45-year-old man complains of whiplash following a
very low in mood since his death. road traffic accident and asks you to complete a medical
2. An 18-year-old man complains of pains in his neck report. He tells you he has been disabled permanently
and right shoulder that seem to have developed and alway wears a neck brace. You saw him getting off
shortly after he was driving a car that had a head-on the bus earlier that morning wearing no neck brace.
287
Physical consequences of eating disorders

Chapter 16 The patient with eating or weight
A. Lanugo
problems
B. Caries
Psychiatric causes of low weight C. Xerosis
D. Russell’s sign
A. Schizophrenia E. Onychorrhexis
B. Specific phobia F. Alopecia areata
C. Depression, severe without psychotic symptoms G. Cheilitis
D. Bulimia nervosa H. Acrocyanosis
E. Alcohol dependence I. Striae distensae
F. Alzheimer dementia
G. Acute psychotic episode For the statements below, select the most appropriate
H. Anorexia nervosa descriptive term from the list above.
I. Obsessive-compulsive disorder
1. The fine, downy hair often seen on the body of
For the case vignettes below, pick the most likely sufferers of anorexia nervosa.
psychiatric cause from the list above. 2. Erosion of dental enamel caused by repeated vomiting.
3. Dry nails, often associated with anorexia nervosa.
1. A 42-year-old man with schizophrenia has a body 4. Stretch marks on the abdomen, associated with rapid
mass index (BMI) of 17, with evidence of rapid weight changes in body weight.
loss. He denies any problems with body image. He 5. A callus on the knuckle that may develop as a result
says he is a little lonely as his mother died recently, of self-induced vomiting.
and they used to live together. However, his mood is
not pervasively low and there are no acute psychotic
symptoms.
2. A 19-year-old male student was admitted to a problems
general medical ward after collapsing in the street.
He denies any problems and tells you it was Diagnosis of personality disorder
‘probably just a funny turn’. His BMI is 22, serum A. Paranoid personality disorder
potassium is 2.1 mmol/L, there are U waves on his B. Schizoid personality disorder
electrocardiogram (EKG) and you notice that his C. Schizotypal personality disorder
parotid glands appear swollen. D. Borderline personality disorder
3. A 16-year-old girl has lost 15 kg in the last 3 months, E. Antisocial personality disorder
giving her a BMI of 16. She denies any body image F. Narcissistic personality disorder
concerns but tells you that she is only able to eat food G. Histrionic personality disorder
prepared in a specific, time-consuming manner. She H. Dependent personality disorder
knows this is irrational; however, if she doesn’t do I. Avoidant (anxious) personality disorder
this the prospect of contamination with food-borne J. Anankastic personality disorder
pathogens causes her to have unpleasant panic
attacks. For the following, select the most appropriate personality
4. A 62-year-old ex-model has recently begun to lose disorder from the list above. Assume absence of mental
weight, and her BMI is 18. She has a past history of illness and that a diagnosis of a personality disorder is
anorexia nervosa. She reported that she could not appropriate.
bring herself to eat because of intense worry that
she would vomit. Any time that she has tried to eat, 1. A 24-year-old accountant wears inappropriate
she has suffered a panic attack and has ended up clothes to work. Her colleagues feel that she is
vomiting. She suffered from a severe case of norovirus always flirtatious and always seeks to be the centre of
about 6 weeks ago. attention. When this does not happen, she tends to
5. A 21-year-old plumber with no past psychiatric history become very upset and dramatically displays emotion.
has recently lost 12 kilograms, causing his BMI to fall 2. A 47-year-old housewife refuses to leave her abusive
to 15. He appears incredibly frightened and tells you partner, despite having recently been hospitalized
that the owners of all the food shops in his locality are after he assaulted her. She feels that she could never
poisoning his food on behalf of government agents, manage without him.
who want him dead because of his involvement in 3. A 26-year-old unemployed man is constantly
recent terrorist attacks. preoccupied by the mischief of local youths and is
288
concerned that he is a ‘marked man’. He cannot hold 1. A 24-year-old woman lives alone and works in a
down a job as he always becomes concerned that bakery. She cannot serve customers as she finds it
colleagues are talking about him behind his back. His very difficult to use the cash register or give the correct
last girlfriend left him 3 years ago after he accused her change. She needed extra help at school with reading
of cheating on him. and writing and did not achieve any qualifications.
4. A 49-year-old successful entrepreneur feels that others 2. A 19-year-old man lives alone, does not see his family
have trouble getting on with him. His fourth marriage and is unemployed. He has no support at home and
has recently ended because of his affairs. He has spends much of his time writing programmes on
always been incredibly confident and able to succeed. his computer and reading about the mathematics
5. A 35-year-old website designer has difficulty making of quantum mechanics. He has always found social
friends because of his fear of others criticizing, rejecting interactions to be difficult and strongly dislikes
or disliking him. Instead, he socializes mainly using socializing with others. There were no problems with
social networking sites and will not physically meet language development.
others until he is sure they will like and accept him. 3. A 14-year-old boy is wheelchair-bound and
incontinent. He lives with his mother, who is his main
carer. He is unable to undertake any activities of daily
Traits of personality disorder living and his mother has to feed him.
A. Callous unconcern for the feelings of others 4. A 35-year-old woman lives in sheltered accommodation
B. Excessive sensitivity to setbacks and rebuffs and requires support to cook meals, to keep her flat
C. Consistent preference for solitary activities tidy and to do laundry. She has a job at a local toy
D. Perfectionism that interferes with task completion factory, where she works on a production line and is
E. Over-concern with physical attractiveness closely supervised by a trained support worker.
F. Frantic efforts to avoid real or imagined 5. A 22-year-old man lives with his family, who are his
abandonment main carers. He requires some assistance getting
G. Allowing others to make most of one’s important life dressed and tending to his personal hygiene;
decisions however, he can do this by himself on good days.
H. Excessive preoccupation with being rejected in social He can feed himself and spends his days watching
situations children’s television programmes and playing with
Lego.
For the personality disorders listed below, pick a common
trait from the above examples. Differential diagnosis in adults presenting for
attention deficit hyperactivity disorder (ADHD)
1. Histrionic personality disorder. assessment
2. Schizoid personality disorder. A. ADHD
3. Obsessive-compulsive personality disorder. B. Bipolar affective disorder
4. Paranoid personality disorder. C. Depressive episode
5. Dependent personality disorder. D. Dissocial personality disorder
E. Emotionally unstable personality disorder
Chapter 18 The patient with F. Generalized anxiety disorder
G. Intellectual disability
neurodevelopmental problems
H. No mental disorder
Functional estimation of IQ in intellectual I. Traumatic brain injury
disability J. Substance abuse, harmful
A. >100 (above average intelligence) Select the most likely diagnosis for the situations below.
B. 86–100 (below average intelligence)
C. 71–85 (borderline intellectual disability) 1. A 24-year-old woman reports her thoughts are
D. 50–69 (mild intellectual disability) racing and she is unable to sit still for more than a
E. 35–49 (moderate intellectual disability) few minutes. She has felt this way for the past week.
F. 20–34 (severe intellectual disability) She denies any substance abuse. She had a similar,
G. <20 (profound intellectual disability) milder, episode a few months ago.
2. A 31-year-old man has had five jobs in the last 2 years.
For each of the scenarios below, select the ONE most He keeps getting fired for making careless mistakes.
appropriate estimation of IQ and level of disability from the He says he has always been this way. He is fidgety in
list above. the interview. He uses cocaine most weekends.
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3. A 42-year-old man cannot concentrate and feels F. Naltrexone

extremely irritable. He is pacing his house and having G. Loperamide
thoughts of suicide. These feelings began after his H. Methadone
wife left him a month ago. I. Paracetamol
4. A 26-year-old man has just been released from J. Diazepam
prison for assaulting a police officer while on a
night out. He was expelled from school for bad For the following questions, select the most appropriate
behaviour (talking too much, disturbing other drug from the list above.
pupils, not doing homework). He regrets the
assault and would like to go to college but keeps
1. A 37-year-old man is admitted to A&E via emergency
losing the application form.
ambulance. He is Glasgow Coma Scale (GCS) 5/15, with
5. A 39-year-old man struggles to concentrate on tasks such
pinpoint pupils and a respiratory rate of six per minute.
as paying his bills. He has started gambling. At interview
He has syringes and hypodermic needles in his pocket.
his speech is hard to interrupt and his thought form
2. A 22-year-old man wants to abstain entirely from
tangential. He has had to give up his job as an accountant
opioids. He is not interested in substitution therapy.
following involvement in a road traffic accident.
However, he asks if he can be prescribed something
to ‘take the edge off’ the withdrawal state.
Chapter 19 Dementia and delirium 3. A 30-year-old woman is motivated to stop injecting
heroin. However, she feels that she needs to be
Management of dementia
prescribed a substitute for the long-term. She was
A. Donepezil previously spending £100 per day on heroin.
B. Rivastigmine 4. A 27-year-old man is undergoing detoxification from
C. Galantamine dihydrocodeine, but he is troubled by profuse diarrhoea.
D. Memantine 5. A 38-year-old lady who intermittently abuses
E. Citalopram opioids asks to be prescribed a drug to reduce the
F. Methylphenidate associated ‘high’, as she feels this will discourage
G. Quetiapine her from using.
H. Trazodone
I. No treatment recommended by current guidelines
Prochaska and DiClemente Transtheoretical
For each of the following patients, select the best treatment Model of Change
for maintaining cognition from the options above.
A. Precontemplative
1. A woman with a recent diagnosis of Alzheimer B. Relapse
dementia who continues to live at home with support C. Preparation
workers visiting daily. D. Action
2. A woman with a diagnosis of Alzheimer dementia who E. Contemplative
lives in a nursing home and is aphasic. F. Maintenance
3. A woman with a diagnosis of Alzheimer dementia who G. Termination
continues to live at home with support workers visiting H. Recycling
daily. Her past medical history includes sick sinus
syndrome, chronic obstructive pulmonary disease For the following questions, select the most appropriate
(COPD) and an active peptic ulcer. term from the list above.
4. Parkinson disease with dementia.
5. Frontotemporal dementia. 1. A 31-year-old nurse has set a ‘quit date’ to stop
smoking.
2. A 62-year-old salesman has been abstinent from
Chapter 20 Alcohol and substance-related alcohol for 30 years, and is no longer even tempted
disorders by the thought of drinking.
3. A 22-year-old female student does not consider her
Pharmacological management of opioid heavy cannabis use to be a problem.
dependence 4. A 29-year-old banker is considering stopping his
A. Naloxone cocaine use; however, he is worried about what his
B. Dihydrocodeine friends will say.
C. Levacetylmethadol 5. A 33-year-old unemployed man has been using heroin
D. Buprenorphine on a daily basis for the last 2 weeks since his partner
E. Lofexidine left him. He had previously been clean for 3 years.
290
Treatment of alcohol dependence 2. A 28-year-old model experiencing a first episode of

A. Alcoholics anonymous psychosis. She is very keen to avoid weight gain.
B. Lorazepam 3. A 33-year-old man experiencing his second episode
C. Psychoeducational group of psychosis. He recalls very unpleasant tremor and
D. Disulfiram rigidity with the antipsychotic he used previously and
E. Thiamine would like to avoid these symptoms.
F. Chlordiazepoxide 4. A 36-year-old man with schizophrenia who has
G. Naltrexone had multiple relapses after forgetting to take oral
H. Cognitive-behavioural therapy (CBT) medication.
I. Acamprosate 5. A 26-year-old woman who has tried 3 months of
J. Motivational interviewing olanzapine and 3 months of risperidone at optimum
K. Diazepam doses but remains troubled by distressing psychotic
experiences associated with functional impairment.
For the questions below, select the most appropriate
treatment option from the list above. Presentation of antipsychotic side-effects
A. Photosensitivity
1. A 55-year-old man, currently drinking 70 units of alcohol
B. Postural hypotension
per day, requires a benzodiazepine during an inpatient
C. Hypersalivation
detoxification. He suffers from severe chronic liver failure.
D. Dry mouth
2. A 45-year-old woman with alcohol dependence is
E. Agranulocytosis
uncharacteristically confused, walking with an ataxic
F. Parkinsonism
gait and has nystagmus. She does not smell of alcohol.
G. Akathisia
3. A 57-year-old woman with a history of alcohol
H. Dystonia
dependence is currently abstinent. However, she wants
I. Somnolence
help to ‘avoid temptation’. She does not want drugs
J. Hyperprolactinaemia
and is frightened by the prospect of group therapy.
4. A 36-year-old man is currently abstinent from alcohol
Select the ONE term used to describe the following side-
but has experienced a couple of ‘slips’ that he
effects from the list of options above.
attributed to powerful cravings. He is also prescribed
tramadol for knee pain.
1. A 27-year-old man wakes up each morning drooling
5. A 44-year-old man has recently stopped drinking and
onto a wet pillow.
wants to remain abstinent for life. He considers alcohol
2. A 57-year-old woman describes feeling dizzy. On
to be a ‘disease’ and does not really want to be involved
examination, she has a supine blood pressure of
with health services. He is socially isolated and feels that
140 mmHg systolic and an erect blood pressure of
he would benefit from meeting like-minded individuals.
100 mmHg systolic.
3. A 22-year-old woman has noticed milk coming
Chapter 21 The psychotic disorders: from her nipples bilaterally, but is not pregnant or
breast-feeding.
schizophrenia
4. A 43-year-old man collapses with a severe
Antipsychotic choice in schizophrenia pneumonia. He has an undetectable neutrophil
count.
A. Chlorpromazine
5. A 30-year-old woman keeps crossing and uncrossing
B. Haloperidol
her legs during an interview. She also keeps
C. Flupentixol depot
smoothing her hair and handbag. She says she feels
D. Clozapine
like she is ‘crawling out of my own skin’.
E. Quetiapine
F. Aripiprazole
G. Risperidone Chapter 22 The mood (affective) disorders
H. No antipsychotic indicated
Treatment setting for depression
For each of the following patients, select the ONE best A. Admit to psychiatric hospital
management option from the options above. B. Admit to general medical hospital
C. Manage in primary care
1. A 47-year-old woman with schizophrenia. She D. Refer to psychiatric outpatients routinely
remembers a good response to haloperidol in her 20s E. Refer to psychiatric outpatients urgently
and would like to try it again. F. Refer to crisis team
291
For each of the following patients, select the ONE best E. Applied relaxation
management option from the list above. F. Selective serotonin reuptake inhibitor (SSRI)
G. Tricyclic antidepressant (TCA)
1. A 55-year-old man with a severe depressive episode H. Benzodiazepine
who has sent goodbye emails to his family. A dog I. Venlafaxine
walker alerted the police after he found him in isolated J. Pregabalin
woodland tying a noose to a tree.
2. A 55-year-old man with a moderate depressive For each of the following patients, select the ONE best
episode which has not responded to adequate trials first-line management option from the list above.
of two antidepressants. He denies suicidal ideas and
maintains an oral intake. 1. A 23-year-old woman has symptoms of posttraumatic
3. A 55-year-old man with a severe depressive episode stress disorder (PTSD) following being raped 2 weeks
who reports derogatory second person auditory ago. She is no longer attending classes at university
hallucinations. He denies suicidal ideas and maintains as she avoids leaving her house.
an oral intake. 2. A 23-year-old woman has symptoms of PTSD
4. A 55-year-old man with a severe depressive episode following being raped 2 weeks ago. She is still able to
who has lost 3 stone in weight over 3 months and has attend classes at university.
refused food and fluids for the last 2 days. 3. A 23-year-old woman has symptoms of PTSD
5. A 55-year-old man with a mild depressive episode following being raped 2 months ago. She is still able
who has not benefited from self-help CBT. to attend classes at university.
4. A 47-year-old former soldier has tried trauma-focused
First-line antidepressants CBT for PTSD but continues to have symptoms which
A. Selective serotonin reuptake inhibitor (SSRI) markedly affect his functioning.
B. Venlafaxine 5. A 35-year-old survivor of an airplane crash has tried
C. Duloxetine talking therapies and two first-line drug therapies
D. Mirtazapine for severe PTSD symptoms. She would like to try a
E. Amitriptyline further medication.
F. Lofepramine
G. Phenelzine
H. Moclobemide Management of generalized anxiety disorder and
I. Lithium panic disorder
A. Self-help
For each of the following patients with moderate to severe B. Watchful waiting
depression, select the ONE best first-line antidepressant C. Cognitive-behavioural therapy (CBT)
from the options above. D. Eye movement desensitization and reprocessing
therapy
1. A 49-year-old stunt man on long-term ibuprofen for E. Applied relaxation
back pain. F. Selective serotonin reuptake inhibitor (SSRI)
2. A 23-year-old shop assistant with no past medical G. Monoamine oxidase inhibitor
history. H. Benzodiazepine
3. A 32-year-old teacher whose chief complaint is I. Pregabalin
insomnia.
4. A 45-year-old butcher who says he will stop any For each of the following patients, select the ONE best
antidepressant that affects his sexual function. first-line management option from the list above.
5. A 64-year-old librarian with stress incontinence.
1. A 27-year-old female grocer has panic disorder. She
has had to leave her shop on several occasions in the
Chapter 23 The anxiety and somatoform last month because of panic attacks.
disorders 2. A 27-year-old female grocer has panic disorder but
does not feel it stops her from doing anything.
Management of posttraumatic stress disorder 3. A 44-year-old zookeeper has generalized anxiety
A. Self-help disorder and is unable to work. He has tried CBT in the
B. Watchful waiting past and would now like to try a different talking therapy.
C. Cognitive-behavioural therapy (CBT) with exposure 4. A 44-year-old zookeeper has generalized anxiety
response prevention disorder and is unable to work. He has tried CBT in
D. Eye movement desensitization and reprocessing therapy the past and would now like to try a medication.
292
5. A 44-year-old zookeeper has generalized anxiety the death of her mother, starting work in her current
disorder and is unable to work. He has tried CBT firm, and not being able to stand up to dominant male
and an SSRI in the past and would now like to try a partners, have played a role in the development of her
different class of medication. illness. She is keen to explore these.
5. A 14-year-old schoolboy was recently diagnosed
Chapter 24 Eating disorders with anorexia nervosa. It is noted that his parents
consistently correct him when he is trying to tell
Treatment strategies for patients with eating his story. Mum is a consultant surgeon, and dad is
disorders a barrister, and both spend a lot of time at work.
A. Nutritional advice from general practitioner They have persistently told him that they want him
B. High-dose fluoxetine to be a doctor when he grows up and have set high
C. Voluntary sector referral standards for him. However, when interviewed alone,
D. Motivational interviewing he stated that he aspired to attend art college and
E. Cognitive-behavioural therapy (eating disorder hoped for a career in photojournalism.
focused)
F. Interpersonal therapy
G. Family therapy Chapter 25 Sleep–wake disorders
H. Community mental health team involvement
Diagnosis of sleep–wake disorders
I. Intensive home treatment by specialist eating disorder
service A. Circadian rhythm sleep disorders
J. Informal admission to general psychiatric ward B. Primary insomnia
K. Forced, involuntary nasogastric feeding under mental C. Insomnia secondary to psychiatric disorder
health legislation D. Insomnia secondary to general medical condition
E. Insomnia secondary to substances
For the scenarios below, select the most appropriate F. Narcolepsy
management strategy from the list above. G. Non-rapid eye movement (non-REM) sleep arousal
disorder
1. A 23-year-old pole-dancer has a diagnosis of H. Primary hypersomnolence
anorexia nervosa. Her weight has recently stabilized I. REM sleep behaviour disorder
and is slowly increasing. She has previously appeared J. Sleep-related breathing disorder
fairly bubbly and cheerful. However, she reports a K. Sleep-related movement disorder
3-week history of tearfulness, loss of interest in all
hobbies, early morning wakening and strong suicidal What is the most likely diagnosis?
thoughts. When questioned directly, she tearfully
discloses that she bought a rope and posted final 1. A 52-year-old man fractures his wrist after punching
letters earlier today and intends to hang herself this his wardrobe while asleep. His wife reports that he
evening when her flatmate goes out to work. She was repeatedly shouting ‘Leave me alone!’ When
says she is amenable to whatever management is woken he recalls a vivid dream about being chased by
suggested. terrorists. He has no past psychiatric history, uses no
2. A 19-year-old male medical student has a diagnosis substances and is otherwise well.
of bulimia nervosa. 2. A 14-year-old girl fractures her wrist after walking into
3. A 16-year-old schoolgirl has a diagnosis of anorexia her wardrobe while asleep. When woken she seems
nervosa. She has been under the care of the disorientated. In the morning she recalls nothing of the
specialist intensive team but has continued to lose night’s events. Her father experienced sleep terrors
weight. Her body mass index is currently 11.7 kg/ during childhood.
m2. On examination, it is noted that she has 3. A 52-year-old man fractures his wrist after being in a
incredible difficulty concentrating. She is hypotensive road traffic accident caused by him falling asleep at
and bradycardic. Blood tests show profound the wheel. He reports excessive daytime sleepiness
hypoglycaemia and hypokalaemia. There are U waves for the past 5 years. His wife reports that he snores.
on electrocardiogram. She vehemently refuses to His body mass index is 37 kg/m2 and his blood
eat, refutes that she has a problem and categorically pressure is 180/100 mmHg.
declines hospital admission. She just wants to be left 4. A 27-year-old man fractures his wrist after leaping off
alone to study for her A levels. a bus shelter to prove he can fly. He has not slept for
4. A 28-year-old lawyer has a diagnosis of anorexia the last 3 nights. He denies any use of substances
nervosa. She is motivated to engage with treatment. and his urine drug screen is clear. He was depressed
She feels that a number of her past difficulties, including for 3 months the previous year.
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5. A 23-year-old woman fractures her wrist after falling psychomotor retardation. Her husband reports that
suddenly to the floor when her uncle makes a joke. she has not been eating or drinking for the past week.
She sleeps well at night, but also often falls asleep 5. A 29-year-old mother of a 2-month-old girl is tearful
during the day without warning. and reports feeling low in mood. She is finding
breastfeeding difficult. She has early morning
wakening and has stopped running the mother-and-
Chapter 26 The psychosexual disorders baby group she set up while pregnant.
Medication associated with psychosexual
disorders Psychotropic medication in pregnancy
A. Clozapine A. Haloperidol
B. Fluoxetine B. Olanzapine
C. Mirtazapine C. Diazepam
D. Paracetamol D. Aripiprazole
E. Propranolol E. Imipramine
F. Pregabalin F. Lithium carbonate
G. Ropinirole G. Carbamazepine
H. Salbutamol H. Fluoxetine
I. Trazodone I. Chlorpromazine
Select the medication most likely to cause the problem: From the list above, select the medication described by
each of the statements below.
1. Difficulty in achieving orgasm.
1. Should not be prescribed to women of childbearing
2. Difficulty in achieving an erection.
age, due to the high risk of neural tube defects.
3. Exhibitionism.
2. Associated with increased risk of gestational diabetes.
4. Prolonged, painful erection.
3. May be continued in pregnancy if risks of
discontinuation are high, but should be balanced
Chapter 27 Disorders relating to the against the increased risk of fetal heart defects.
menstrual cycle, pregnancy and the puerperium 4. May be continued in pregnancy if benefits outweigh
risks, but associated with an increased risk of
Management of mental illness in the puerperium pulmonary hypertension in the neonate.
A. Lithium 5. Likely to need dose adjustment during pregnancy.
B. Sertraline
C. Maternal skills teaching Chapter 28 The personality disorders
D. Doxepin
E. Reassurance and check-up in 1 week Management of patients with personality
F. Olanzapine disorders
G. Sodium valproate A. Weekly dispensing of medication
H. Electroconvulsive therapy B. Detention under mental health legislation
I. Mirtazapine C. Informal, time-limited admission to psychiatric ward
D. Removal to police custody
For the situations below, select the most appropriate E. Referral for mentalization-based therapy
management strategy from the list above. F. Encouragement to engage with existing care plan
G. Referral to social work
1. A 17-year-old mother of a 3-month-old baby reports H. Trial of antipsychotic medication
that she is finding motherhood to be a burden and is I. Advice regarding lifestyle choices
worried that she is not ‘doing it properly’. J. Day-hospital referral
2. A 26-year-old lady appears weepy and reports feeling K. Urgent multiagency meeting
‘down’ 3 days after the birth of her son.
3. A 24-year-old lady with a history of bipolar affective Choose the most appropriate intervention for the cases
disorder is 1 week postpartum and presents with below.
auditory hallucinations and ideas that the father of the
child is Jesus Christ. 1. A 36-year-old lady with dependent personality
4. A 33-year-old lady with a history of depression disorder arrives at accident and emergency
is 4 weeks postpartum. She has marked demanding admission to the hospital because she
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feels that she is not coping at home. She has missed 4. A 27-year-old man with ASD
her last two appointments with the occupational 5. A 10-year-old girl with Tourette syndrome
therapist.
2. A 22-year-old lady with emotionally unstable
personality disorder was brought to hospital by police Chapter 30 Child and adolescent psychiatry
after being restrained to prevent her from jumping
from a railway viaduct. She is covered in bruises and Diagnosis of psychiatric disorders with onset in
reports that her partner assaulted her and threw her childhood or adolescence
out of the house. She is inconsolably upset, extremely A. Academic setting inappropriate to ability
pessimistic and voicing ongoing suicidal intent and B. Age-appropriate behaviour
plans. C. Attention deficit hyperactivity disorder (ADHD)
3. A 43-year-old man has paranoid personality disorder. D. Child abuse
He is socially isolated and has longstanding worries E. Conduct disorder
that he will be targeted by local youth gangs. He F. Elective mutism
does not trust doctors; however, he has recently G. Oppositional defiant disorder
acknowledged that his concerns are perhaps H. Reactive attachment disorder
unfounded. I. Separation anxiety disorder
4. A 19-year-old lady has a diagnosis of emotionally J. Social anxiety
unstable personality disorder, and an extensive K. Specific phobia
history of self-harm. She has recently developed
a comorbid depressive illness that her general For each scenario below, choose the most likely
practitioner (GP) feels would benefit from treatment corresponding option from the list given above.
with an antidepressant. However, the GP is reluctant
to prescribe because of previous overdoses. 1. A 6-year-old boy is referred by an educational
5. A 39-year-old man with a diagnosis of anxious psychologist, due to his behaviour at school. He
personality disorder reports recent initial insomnia. He seems to be unable to concentrate on his schoolwork
attributed this to worries about his future. Since he and has been running around the classroom
was made homeless, he has been spending his days distracting fellow pupils from completing their work,
drinking complimentary coffee in the support centre. often by jumping on tables and throwing chairs
When he cannot sleep at night, he lies in bed and around. On one occasion, he flooded the play area
smokes cigarettes. when he broke a water pipe. His parents are very
surprised, because he is entirely normal at home.
2. A 12-year-old boy has been incredibly disobedient,
Chapter 29 The neurodevelopmental both at school and within the home. He has been
disorders dancing in front of the TV when his father has been
watching the football. He has also been using swear
Psychosocial interventions in words in the house, and—on two occasions in the last
neurodevelopmental disorders week—has run away from home after being confined
A. Anger management to his room. His parents are surprised that he has not
B. Antivictimization intervention been bullying others, or in trouble with the police.
C. Cognitive-behavioural therapy 3. A 4-year-old girl watches other children playing at
D. Habit control nursery but does not attempt to join in. When she falls
E. Nil recommended over in the playground she cowers away when an adult
F. Parent-training/education programme offers first-aid. She has a sad demeanour but otherwise
G. Play-based social–communication intervention shows little emotion. She has been taken into care after
H. Social learning program experiencing physical abuse from both parents.
I. Structured leisure activity 4. A 10-year-old girl has always been shy. Recently,
J. Supported employment programme her father worked away for a month. Now she is
experiencing nausea and abdominal pain every
Select the psychosocial intervention which is recommended morning, except at the weekends. She can be
as first-line treatment for each of the cases below. persuaded to go to school but only if her father walks
with her to the school gates.
1. A 7-year-old boy with attention deficit hyperactivity 5. A 4-year-old boy has recently been adopted by his
disorder (ADHD) aunt and uncle after his parents died in a road traffic
2. A 27-year-old woman with ADHD accident. He had normal language development and
3. A 7-year-old girl with autism spectrum disorder (ASD) initially he seemed to settle in well to his new home.
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However, he gradually stopped speaking at home. C. Antisocial personality disorder

Nursery staff report he speaks normally there. During D. Mania with psychotic symptoms
the consultation he initially does not speak but does E. Severe depression with psychotic symptoms
so when his adoptive parents leave the room. His F. Emotionally unstable personality disorder
adoptive parents appear caring but anxious and G. De Clérambault syndrome
unsure what to do. They have been arguing recently. H. Delirium tremens
I. Obsessive-compulsive disorder
J. Mild intellectual disability
Chapter 31 Older adult psychiatry K. Drug-induced psychosis
Adverse drug reactions in older adults receiving
For each of the following scenarios, select the most
psychotropic medication
appropriate diagnosis from the list above.
A. Lithium
B. Sodium valproate 1. A 35-year-old man was arrested after he assaulted
C. Diazepam a bus driver. He believed that the driver was trying to
D. Lorazepam procure the services of his wife, who he is convinced
E. Trazodone is working as a prostitute. He has dismissed extensive
F. Mirtazapine reassurances from his wife and his own siblings. He
G. Amitriptyline reports that he has a sword in the back of his car and
H. Fluoxetine intended to ‘get the truth out of her’. He has a history
I. Olanzapine of alcohol abuse.
J. Haloperidol 2. A 50-year-old man with no psychiatric history was
arrested after committing a public order offence on a
For each of the following patients, select the medication train home from a music festival. He assaulted three
most likely to be implicated in their presentation from the police officers and required restraint. At interview,
options above. he appears distressed and is clearly responding
to auditory hallucinations. He is convinced that
1. A 67-year-old woman complains of insomnia, anxiety the police are Nazis who plan to use his brain for
and anorexia. She has tinnitus and keeps mistaking experimentation.
her oxygen tubing for a snake. She was admitted 3. A 21-year-old woman has been charged with fraud.
10 days ago with a myocardial infarction and her She has applied for several credit cards and bank
sleeping tablet was stopped. loans in the last fortnight and has used a number
2. A 72-year-old man receiving treatment for depression of different names to do so. She says that she is a
presents with general malaise. His serum sodium is pop star and needs money to fund a world tour. She
126 mmol/L. was recently discharged from hospital following a
3. A 69-year-old man receiving treatment for bipolar depressive episode.
affective disorder presents with vomiting and 4. A 44-year-old man is arrested and charged with
diarrhoea. His serum sodium is 151 mmol/L. murdering a sandwich shop clerk, who was on his
4. A 74-year-old man collapses. His electrocardiogram way home from work. He has an extensive forensic
shows torsade de pointes. He was admitted history and is a well-known member of an organized
5 days ago with delirium requiring pharmacological criminal gang. He denies any psychiatric history
management. and admits killing the man because he got his order
5. An 81-year-old woman has delirium. She has recently wrong. He appears cold and emotionless.
been started on analgesia for trigeminal neuralgia. 5. A 30-year-old man is arrested and charged with
setting his neighbour’s caravan on fire. He appears
Chapter 32 Forensic psychiatry to be from a distant town; however, he reports that
he used to have contact with psychiatric services as
Diagnosis of mental disorder in offenders a youngster. He thought his actions would please
A. Othello syndrome people in his neighbourhood because the flames were
B. Paranoid schizophrenia ‘pretty’.
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SBA answers
therapy have little evidence to support their use in

Chapter 2 Pharmacological therapy and this instance. Exposure and response prevention
electroconvulsive therapy is a behavioural therapy used in the treatment of
1. B. Looking at his prescription. Although the two obsessive-compulsive disorder.
syndromes have features in common, they can nearly 2. C. Transference is the theoretical process by
always be easily distinguished by medication history which the patient transfers feelings or attitudes
(see Table 2.8). Clonus is another useful distinguishing experienced in an earlier significant relationship
factor, as it is present in serotonin syndrome but onto the therapist. Counter-transference refers to
absent in neuroleptic malignant syndrome (where the feelings that are evoked in the therapist during
lead-pipe rigidity is common). the course of therapy. The therapist pays attention
2. E. Assess ABC. This man is likely to be experiencing to these feelings, as they may be representative
neuroleptic malignant syndrome. After ABC has of what the patient is feeling, and so helps the
been addressed, all antipsychotics should also be therapist to empathize with the patient. Often, the
discontinued. The other answers are all possible therapist has undergone therapy themselves as part
treatment options, but none are first-line. Before they of their training: this helps the therapist to separate
are considered, he needs initial resuscitation, and out what feelings belong to them, and what feelings
then is likely to need transfer to a general hospital for belong to the patient.
investigation and monitoring. See Table 2.8. 3. E. This cognitive distortion is an example of
3. C. Weekly full blood counts (FBCs). Without magnification (also known as ‘catastrophization’),
monitoring, just under 3% of patients treated with where things get ‘blown out of proportion.’ An
clozapine develop neutropenia (low neutrophil count), example of emotional reasoning in this context would
and just under 1% develop agranulocytosis (negligible be ‘I feel so miserable, so I must have failed my
neutrophil count). This is most likely to occur early in exam.’ An example of fortune telling would be ‘I failed
treatment. Therefore, weekly FBCs are advised initially. my exam, so in the future no one will employ me.’ An
As for all antipsychotics, she will also require regular example of personalization would be ‘It is all my fault:
checks of blood pressure, liver function, lipid profile I failed my exams.’ An example of labelling would be ‘I
and glucose. These parameters should be checked am stupid.’ Note that more than one type of cognitive
every 1–3 months initially, then annually. distortion can exist in the same patient in the same
4. E. Egg mayonnaise toastie is the only safe option, circumstances. See Table 3.3.
given the dietary restrictions required for irreversible 4. B There is a strong evidence base to support the use
monoamine oxidase inhibitors such as phenelzine. of interpersonal therapy in the treatment of mild to
See Box 2.2. She should also avoid drinking Chianti moderate depression. See Table 3.5 for modalities of
wine with lunch. benefit in the other conditions listed.
5. E. 1.8 mmol/L. Her symptoms are consistent with
lithium toxicity in the 1.5–2.0 mmol/L range. However, Chapter 4 Mental health and the law
symptoms of toxicity can manifest at lower levels,
1. D. She needs to notify the DVLA of her diagnosis.
particularly in older adults. Toxicity is likely to have
They will then ask for a doctor's report and potentially
been precipitated by the recent course of nonsteroidal
a driving assessment and are likely to arrange more
antiinflammatory drugs. See Table 2.3.
frequent reviews of the licence than otherwise (e.g.,
annually). It is the DVLA’s decision as to whether she
Chapter 3 Psychological therapy is fit to drive or not. Many patients with mild dementia
1. C. This man is suffering from a prolonged grief are found fit to continue to drive. Patient and partner
reaction. In the first instance, it would be helpful reports of driving can be unreliable as patients can
to refer him to bereavement counselling, which have poor insight and partners may not want to act
most commonly takes the form of person-centred in a way they perceive as harming the patient, or
counselling. In the United Kingdom, Cruse is a themselves. It is the patient’s responsibility to notify
large voluntary sector service offering bereavement the DVLA although doctors may need to do so if
counselling. Psychodynamic therapy, cognitive- patients ignore this advice and present a significant
behavioural therapy and mindfulness-based cognitive risk to others through driving.
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SBA answers
2. B. The patient lacks capacity as his low GCS means finances, writing suicide notes) are the most worrying
he will not be able to communicate his decision. He is signs and suggest strong suicidal intent. Contacting
also unlikely to be able to understand, to retain and to voluntary support agencies (such as the Samaritans)
weigh up information, but this cannot be assessed in suggests emotional distress, but also a degree of
the absence of communication. ambivalence. Telling his wife of his plans may be a
3. D. He is likely to lack capacity for any decisions way of communicating his feelings to her but is not
requiring more consideration than is available in necessarily a final act. Disclosing plans to a health
working memory as he will not be able to retain care professional does not reduce his risk.
information for long enough to weigh it up. As a 3. C. Suspension hanging is the most common method of
guide, someone should be able to retain information completed suicide in England, Wales and many other
for as long as necessary to make a decision. A quick countries. Means are widely available and lethality is
decision, e.g., meal choice, does not require a long high. Self-inflicted firearm wounds are most common
time to make. A big decision, e.g., where to live, in the United States. Paracetamol is the most common
would normally be something that a person would drug of overdose in the UK; however, advances in
consider and mull over for a few days at least. medical treatment and public health measures have
4. C. She lacks capacity for the decision about surgery, reduced mortality associated with this. Jumping from
as she does not believe the information because of a height is a fairly ‘public’ method of suicide, thus is
delusion. However, she is likely to have the capacity often reported in the news (although media coverage
to make decisions about which she does not have of all suicides has reduced in recent years due to
delusions. campaigns to reduce ‘advertising’ of suitable locations).
5. A. He should be assumed to have the capacity to Carbon monoxide poisoning used to be fairly common;
make a decision about a statin, unless his psychotic however, catalytic converters on modern motor
symptoms relate to cholesterol (which is unusual) or vehicles has reduced fatality of this method.
he is very thought disordered.
Chapter 7 The patient with impairment of

Chapter 5 Mental health service provision
consciousness, memory or cognition
1. A. The other options demonstrate treatment resistance
1. D. Delirium. This is suggested by her acute onset
(B), bipolar disorder (C), significant risk to self (D) and
objective cognitive impairment associated with
diagnostic uncertainty (E), all of which means referral to
sleep–wake cycle disturbance. Suspicion and visual
secondary care should be considered.
hallucinations are common in delirium. Although
2. B. Early intervention in psychosis team. This man may
Lewy body dementia is commonly associated with
be experiencing prodromal psychosis. He does not
visual hallucinations it is excluded by the acute onset.
currently appear to be at high enough risk to require
Similarly, Alzheimer dementia is excluded by the acute
home treatment or admission. As he does not have
onset. Late onset schizophrenia remains a possibility
an established diagnosis of mental illness, an assertive
but is far less likely than delirium. Charles Bonnet
outreach team is not appropriate. A community mental
syndrome would not account for all the features here,
health team could manage him, but early intervention
e.g., persecutory beliefs, sleep–wake cycle
teams are expert at identifying early psychosis and are
disturbance, cognitive impairment.
therefore best placed to monitor him.
2. A. Amnesic syndrome. This man has an isolated
long-term anterograde and retrograde memory
impairment with intact working memory and other
Chapter 6 The patient with thoughts of cognitive function. He is confabulating. A history of
suicide or self-harm alcohol excess raises the possibility of Korsakoff
1. C. Measuring serum paracetamol levels (plus INR, syndrome as the cause. He does not have dementia
liver function, other baseline bloods) to determine the because the impairment is not global or progressive.
requirement for potentially life-saving treatment is the 3. A. This gentleman has a likely diagnosis of dementia.
priority in this case. This can be measured from 4 NICE (2006) recommends the blood tests this man
hours postingestion although levels become harder has already received plus structural neuroimaging
to interpret after 15 hours. The other options are all as a minimum assessment for reversible causes
important aspects of psychiatric evaluation and risk of dementia. However, there is some clinical
assessment but are not urgent. judgement involved. Practice varies locally and
some centres would not request a CT head unless
2. D. While researching methods is also worrying, there are neurological signs. There is no reason to
acts of closure (such as making a will, organizing think this man needs syphilis and HIV serology but
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SBA answers
for other patients it may be appropriate. EEG and in his delirium, unless it is felt that the fracture itself is
lumbar puncture are not recommended routinely a significant contributor to his presentation. The other
in assessment of dementia but may be indicated options are all interventions which should be offered in
in particular circumstances (e.g., if frontotemporal delirium tremens. Benzodiazepines are used for alcohol
dementia or Creutzfeld-Jakob disease is suspected). withdrawal but not for other sorts of delirium. He should
See Table 7.7. be empirically treated with parenteral thiamine as it is
4. A. Delirium. This woman has recently been extremely very difficult to exclude Wernicke–Korsakoff syndrome
unwell. Even though her UTI has been successfully in delirious patients, and the consequences of missing
treated, the brain can often lag behind the rest of it can be severe A full physical exam may highlight
the body when recovering from a serious illness. The evidence of Wernicke−Korsakoff (ophthalmoplegia,
fluctuation in her mental state may reflect a resolving ataxia) or highlight other contributors to the delirium
or a new delirium. It would be wise to reassess for (e.g., chest infection). Consistent nursing care will help
other causes that may have been missed initially or to calm and orientate him.
occurred since admission, e.g., a hospital acquired 4. E. Providing harm reduction advice is always important
pneumonia. It may be that she will not regain her and can be effective immediately (e.g., directing him
premorbid cognitive functioning and in due course to a needle exchange service, offering screening
will be diagnosed with dementia, but it is too early to for blood-borne viruses, offering a home naloxone
make this diagnosis. injection kit). Prior to any substitute prescribing, it is
5. A. Amitriptyline. This man has a delirium. vital to establish that the drug being substituted is
Anticholinergic medication is a common cause of actually being used, making urine drug testing the next
delirium, as are opiates. Amitriptyline is sometimes essential step. Prescribing methadone to someone
used to reduce insomnia, although this is extremely who is not opioid-tolerant can be fatal. Similarly,
inadvisable in an older adult, so this may be the prescribing his previous dose of methadone could be
precipitant. Starting or stopping any medication can fatal as he may be less opioid-tolerant now than he
potentially cause delirium but this does not occur was previously. It is necessary for methadone doses
commonly with the other medications listed. to be initiated at a low level and gradually increased
if required (titrated against withdrawal symptoms).
Chapter 8 The patient with alcohol or Referring him to a drug counselling service may well be
appropriate if he wishes to engage. See Chapter 20.
substance use problems 5. B. To calculate alcohol units, take the % ABV and
1. B. Alcohol withdrawal would be suggested by multiply by volume (in litres): e.g., 40 × 0.350 = 14
symptoms of shakiness and sweatiness after a period units; 350 mL of a 40% ABV spirit contains 14 units.
of not drinking, not after having a drink. Onset of such Six pints (3.408 L) of continental lager (5.3% ABV)
symptoms after drinking is suggestive of a comorbid contains 18 units; two bottles (1.5 L) of red wine
anxiety disorder or physical health problem (e.g., (12.5% ABV) contains 18.75 units; 3 L of strong white
angina) which may be related to alcohol consumption cider (8.4% ABV) contains 25.2 units; and six bottles
(e.g., atrial fibrillation). The other options are all (1.980 L) of alcopops (4.9% ABV) contains 9.7 units.
features of alcohol dependence (compulsion to drink, She should also be told that there is no ‘safe‘ level
tolerance, persistence despite harm, neglect of other at which to drink alcohol, merely lower to higher risk
activities). The symptoms of dependence not listed levels. If she plans to drink the full 14 units, it should
are difficulties in controlling alcohol consumption and be recommended that she spreads her alcohol
withdrawal symptoms. See Box 8.1. consumption over around 3 days per week.
2. D. This is classic alcoholic hallucinosis. Note the 6. E. Drowsiness. Hyperalertness, tachycardia,
absence of memory or attentional problems, excluding hyperthermia, hypertension and psychotic symptoms
delirium tremens or Wernicke−Korsakoff syndrome. arise commonly during cocaine use. Chest pain is a
Late-onset schizophrenia should be in the differential very concerning symptom suggesting arrhythmia or
diagnosis, but is unlikely in this case. Social isolation cardiac ischaemia due to coronary artery spasm. He
is often a cause or consequence of alcohol misuse. should be advised to seek emergency medical care if
Hepatic encephalopathy is excluded by her otherwise this occurs after consumption.
normal physical examination.
3. D. This man is delirious, and the history of heavy
alcohol use suggests this is likely to be an alcohol Chapter 9 The patient with psychotic
withdrawal delirium. Note the visual ‘Lilliputian symptoms
hallucinations’ of small figures (in his case, a horse), 1. B. Charles Bonnet syndrome. Based on the
which are typical of alcohol withdrawal. Any surgical information given here, Charles Bonnet syndrome
intervention should be delayed pending improvement is the most likely diagnosis. However, it is crucial to
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SBA answers
exclude delirium with a physical examination and not screen for novel psychoactive substances).
cognitive assessment. The main differentials in a healthy young man
2. B. Ischaemic heart disease. This man has risk factors are a manic episode or mania secondary to
for ischaemic heart disease (age, male, smoker) and psychoactive substance use. Full blood count
gives a description of exercise-induced chest pain with should be performed to check for evidence of
a classic ‘weight on chest’ description typical of cardiac infection, but is likely to be normal. Thyroid function
ischaemia. People with schizophrenia are at increased test should be checked to exclude hyperthyroidism
risk of cardiovascular disease. Although this symptom but is also likely to be normal. EEG and CT head
could also be a tactile hallucination, it is important to should only be requested if there are neurological
exclude a physical origin before making this attribution. abnormalities.
3. E. Over-valued idea. Delusional jealousy is the key 4. D. Personality disorder. This woman describes
differential here, but the belief his wife is having a persistent pattern of maladaptive behaviour
an affair appears to be based on logical grounds, present since childhood associated with social and
so he cannot be said to be delusional. The belief occupational dysfunction. This is most likely to be
is not described as recurrent or intrusive so is not a personality disorder, with prominent impulsivity. It
an obsession. However, the impact of the belief would be important to get a collateral history before
on this man’s life is substantial as he has become making a definite diagnosis. The mood swings are
preoccupied with it to an unreasonable extent. This is faster than would occur within bipolar affective
an over-valued idea. disorder and she has never had a period of euthymia,
4. B. Psychosis secondary to psychoactive substance required for a diagnosis of a mood disorder. The
use (a drug-induced psychosis). This is the most symptoms cause marked functional impairment,
likely diagnosis; however, a definite diagnosis requires excluding cyclothymia. Dysthymia is prolonged low
a longitudinal assessment. The diagnosis would mood, not mood swings. Although substance use can
be confirmed if he stops using substances and his cause and worsen emotional lability it should not have
symptoms resolve. However, chronic cannabis use onset in childhood.
is a risk factor for schizophrenia and if his symptoms
persist despite abstaining from substances this may Chapter 11 The patient with low mood
emerge as the diagnosis. At present he has not 1. E. Prednisolone is the only medication listed commonly
had the symptoms long enough to meet criteria for associated with depression. The others are not.
schizophrenia in any case. 2. B. The midline neck swelling may represent a goitre.
5. B. Hebephrenic. This boy shows prominent thought Given the patient’s symptoms are mild, there is time
disorder, incongruous affect and negative symptoms. to check her thyroid function before commencing
Hebephrenic schizophrenia has an early onset and a treatment. If she is hypothyroid this should be treated
poor prognosis. first, which may normalize her mood without need
for an antidepressant. Mild depression does not
Chapter 10 The patient with elated or need referral to psychiatry. A neck ultrasound is likely
to be needed also, but thyroid function should be
irritable mood
checked first. She should not be sent away without
1. A. Manic episode, with accelerated speech investigation as the cause of the midline neck swelling
and probable thought disorder. Hypomania and needs determined.
cyclothymia are excluded by the significant functional 3. D. The patient reports symptoms of depression
impairment his symptoms have caused him. An alongside a mood-congruent nihilistic delusion.
agitated depression could be associated with an Therefore, the most likely diagnosis is a severe
increased rate of speech, but the content should be depressive episode with psychotic features. His lack
understandable. Schizophrenia can be associated of past psychiatric history makes schizoaffective
with thought disorder, but very rarely with accelerated disorder, schizophrenia and bipolar disorder unlikely,
rate of speech. as onset at his age is rare. Early-onset dementia
2. B. Bipolar affective disorder. An episode of with behavioural and psychological symptoms is an
depression is not necessary to meet criteria for unlikely possibility, but to check for this, his cognition,
bipolar affective disorder. Recurrent mania and family history and ability to care for himself should be
hypomania are not diagnoses. No first-rank carefully assessed.
symptoms are mentioned, making schizoaffective 4. D. Suicidal ideation should be checked in everyone
disorder unlikely. Cyclothymia is excluded by the with a potential depressive episode. The other areas
presence of psychotic symptoms. are all important but can be explored at a later review.
3. D. Urine drug screen. This will demonstrate recent 5. D. This patient is in a situational crisis. It is likely
use of common recreational drugs (although it will that her symptoms will resolve spontaneously. She
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SBA answers
needs reassurance and to be offered a follow-up 5. D. Alcohol withdrawal. This man is drinking at least
appointment to check on her progress. She cannot 60 units/week. He is experiencing physiological
be diagnosed with depression as her symptoms are withdrawal symptoms after a few hours without
present for less than 2 weeks, and she is unlikely to alcohol, and the symptoms are relieved by further
benefit from an antidepressant. However, she may alcohol. Although anxiety in the morning may be
still be at risk of self-harm and should be screened part of diurnal variation in a depressive disorder, this
for this. She does not need investigations or a mood man’s mood is generally good, excluding depression.
diary unless her symptoms persist. Her symptoms are A phobia of something related to work is unlikely as
not severe enough to need referral to psychiatry at the symptoms have only had onset recently (although
present. enquiring regarding recent changes at work could
be helpful). Hypoglycaemia secondary to diabetes
is unlikely to present only in the mornings. Panic
Chapter 12 The patient with anxiety, fear or
disorder is excluded by the clear relationship with
avoidance alcohol.
1. D. Panic attack. This is the most likely diagnosis
based on the history. However, it is important to
Chapter 13 The patient with obsessions and
take a full medical history (e.g., asthma, congenital
heart disease) and family history (e.g., sudden death compulsions
in young relatives) and to exclude other causes such 1. A. No mental illness. Lay people often use ‘obsession’
as hyperthyroidism and hypoglycaemia, particularly loosely. Her thoughts of the show are not obsessional
given her repeat attendances. It would also be as they are ego-syntonic, pleasurable and not
useful to know whether the attacks appear to have resisted. She describes no compulsions. She is not
triggers (e.g., substance use/withdrawal, going to delusional in that there is no evidence of irrational
the library). thinking. She is not socially phobic in that she has
2. C. Blood-injection-injury phobia. This is suggested by not reported anxiety in social situations. There is no
his situational paroxysmal anxiety and avoidance. evidence of a persistent pattern of perfectionism and
A myocardial infarction is unlikely to occur every time rigid thinking, as would be expected in anankastic
he is due to see the practice nurse. Hypoglycaemia, personality disorder. Calling in sick represents
not hyperglycaemia, could cause these symptoms but unethical behaviour rather than a mental illness.
is unlikely without a history of diabetes. Panic disorder 2. C. Depressive episode. This man reports obsessions,
does not have a specific trigger. Hypochondriasis is but they are concurrent with the change in his mood,
fear of having an illness, not fear of being investigated meeting the criteria for a depressive episode of
for one. moderate severity (five depressive symptoms). The
3. B. Airway, Breathing, Circulation. The first step in obsessions are mood-congruent. Depression rather
management is ABC. She is speaking to you, so her than obsessive-compulsive disorder is the primary
airway is maintained independently. The next step diagnosis. Generalised anxiety disorder is unlikely as
is to ascertain her breathing and circulation status. he does not report free-floating anxiety about many
Although the differential includes a panic attack, she topics. Hypochondriacal disorder is unlikely as he is
could also be experiencing a wide range of acute not worried about a particular condition, but being
medical problems requiring urgent management. An dead. A nihilistic delusion is not suggested as he
ECG, ABG, blood tests and psychiatry referral may all tries to distract himself, suggesting he is resisting the
be appropriate in due course. image rather than accepting it as reality.
4. E. Check blood sugar. Someone with type 1 diabetes 3. D. OCD with comorbid depressive episode. This
will be receiving insulin. The description sounds man describes obsessions and compulsions
very much like hypoglycaemia. If hypoglycaemia associated with functional impairment of greater than
is confirmed it is important to treat the episode 2 weeks duration, giving him a diagnosis of OCD.
by consuming carbohydrate, and then examine Superimposed on this he has developed a depressive
his insulin/food/activity regime to reduce further episode of mild severity. Generalised anxiety disorder
episodes. If his blood sugars are normal, he may be is unlikely as he does not report free-floating anxiety
experiencing panic attacks as part of panic disorder. about many topics. There is no evidence of a
Keeping a diary and deep breathing exercises may persistent pattern of perfectionism and rigid thinking,
help with these (See Chapter 23 for management). as would be expected in anankastic personality
Seeing a counsellor may help if he is experiencing a disorder.
stressful life event, illness or bereavements. Diazepam 4. B. Obsessive-compulsive (anankastic) personality
is only recommended in social or specific phobia, for disorder. This is suggested by her lifelong history of
infrequent as required use. unusual conscientiousness and perfectionism which
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SBA answers
has caused some functional impairment (reduction of make her way to the UK and apply for asylum, which
leisure time and being made redundant). Her thoughts would suggest that cognitive impairment has not been
of perfection are ego-syntonic and not resisted, global (excluding transient global amnesia), and she
meaning they are not true obsessions. Staying late to has been able to function at a reasonable level. She
check is not a compulsion as it is not an unreasonable has no symptoms suggestive of posttraumatic stress
way to achieve her goal (assuming she does not disorder at this time, and the memory loss is more
check an excessive number of times). There is no prolonged than would be expected in this disorder.
evidence of low mood, excluding subsyndromal In terms of stressful events, while she is unable to
depressive symptoms. There is no evidence of social recall anything, she is seeking asylum from an area
difficulties, making an autism spectrum disorder in which human rights violations are widely reported.
unlikely. The fact that she was pregnant with no recollection of
5. B. Pseudohallucination. She reports a perception in conception or termination may suggest that she has
the absence of a stimulus from within internal space. been the victim of rape (which would be a traumatic
A hallucination would occur in external space. An stressor).
obsession would be attributed to herself. Thought
insertion would be attributed to an external agency.
A rumination is not experienced as a voice, but as a Chapter 15 The patient with medically
thought (see Table 13.1).
unexplained physical symptoms
1. A. These situations are commonly encountered by
Chapter 14 The patient with a reaction to a GPs. The patient may well be developing multiple
stressful event sclerosis; however, his symptoms are minimal and
1. D. It is vital to robustly exclude physical aetiology prior insufficient to make any diagnosis. Overzealous
to attributing symptoms to psychological causes. attempts to take his problems seriously by a
In this case, excluding intracranial haemorrhage well-intentioned doctor (such as referral to neurology,
secondary to head injury should take priority. This advanced investigations or arranging urgent follow-up)
should include a history of the mechanism of assault may reinforce his belief that something is wrong.
(with corroboration from a witness if possible), However, dismissal by telling him it is ‘all in his head’
full neurological examination and appropriate (or—at this stage—even empathic suggestion of
investigations (which may include a computed psychiatric illness) is likely to cause him to seek a
tomography brain scan). second opinion, and in any case is irresponsible
2. C. This describes symptoms of fairly marked given the inconclusive evidence. In the first instance,
psychomotor retardation, which would be suggestive empathic acknowledgement and explanation, and
that a depressive illness has developed from the inviting the patient to reattend if further symptoms
bereavement reaction. The other symptoms (wanting arise (watchful waiting) is the most balanced option of
to be dead, poor concentration, intense guilt, the above.
hallucinations involving the deceased) are typical of 2. D. This woman describes classic symptoms of body
normal bereavement. dysmorphic disorder. She is concerned with her
3. B. This woman is suffering from an adjustment appearance as opposed to an underlying disease
disorder, characterized by difficulty coping with a (hypochondriacal disorder). If she did hold the
significant change in circumstances. Feelings of over-valued idea with delusional intensity, somatic
inability to cope are fairly typical of difficult adjustment. delusional disorder should be considered. Note
Note the duration of onset of symptoms (longer than that some patients may exaggerate (or even feign)
for an acute stress reaction), and the fact that she psychological sequelae of imagined or minor flaws in
has been signed off work, suggesting disruption their appearance to receive medical care (factitious
to occupational functioning (which suggests that a disorder) or cosmetic surgery paid for by the state,
diagnosis is appropriate, as opposed to ‘no mental which would be malingering.
illness’). She does not appear to be suffering from 3. D. This history is highly suggestive of factitious
other symptoms that would suggest depression or a disorder (female, healthcare professional, symptoms
conversion disorder. without signs, broad knowledge, specific demands,
4. A. This case is fairly typical of dissociative amnesia. far from home). It is imperative to contact previous
She has no memory of a circumscribed period of her hospitals to get more information; however, asking
life, with intact memory for her past and the more the patient for such contact details may yield vague
recent present. While head trauma and Wernicke- answers (in some cases, requesting such details will
Korsakoff syndrome (due to inadequate nutrition) is result in the patient discharging themselves). Details
naturally a concern, she appears to have been able to of such patients are often shared between local
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SBA answers
accident and emergency departments. It is not safe is worried she has lost weight. Her vomiting sounds
to prescribe pethidine or arrange a laparoscopy. It is more likely to relate to gastritis secondary to alcohol
not ethical to tell her she is lying without any definite excess, not purging.
evidence of this. It is too early to refer to psychiatry, 4. E. potassium 2.1 mmol/L. She requires an
although this may help in due course if she is willing to electrocardiogram and cautious intravenous
engage. replacement of potassium. Hypoglycaemia, anaemia,
4. B. Onset of such symptoms in older people with no hypercholesterolaemia and hypophosphatemia are
significant medical or psychiatric history is more likely all common in anorexia nervosa but the values given
to be indicative of insidious organic disease. Prior here are not dangerously low.
to attribution of symptoms to a psychological origin, 5. D. This woman has anorexia nervosa. She is
physical disease needs to be thoroughly excluded. dangerously underweight. While all of the listed mental
In this case, physical investigations have been illnesses can cause weight loss, they are differentiated
inappropriate to exclude likely physical illnesses. from specific eating disorders by the presence of dread
At minimum he requires an electrocardiogram. of fatness, distortion of body image and subsequent
5. C. This presentation is classic somatization disorder. restriction of her dietary intake. The diagnosis of bulimia
Note the multiple and changing symptoms, refusal to is excluded given her low body mass index.
accept the absence of physical cause and duration 6. E. Unable to rise from squatting without assistance. His
of more than 2 years. Multiple sclerosis is possible, blood pressure and heart rate place him at moderate
but more weight than normal should be placed on risk but his capillary refill time and temperature are
objective evidence before this is investigated. There within the normal range. See The Royal College of
is no evidence she is lying about her experiences, Psychiatrists ‘Management of Really Sick Patients with
making factitious disorder unlikely. She is concerned Anorexia Nervosa’ (child and adult versions) for more
about her symptoms rather than an underlying details on physical risk assessment in anorexia nervosa.
disorder, excluding hypochondriacal disorder.
Generalised anxiety disorder is possible if she also
reports anxiety about things other than physical
symptoms. problems
1. A. Chronic feelings of emptiness is the only criterion
Chapter 16 The patient with eating or weight listed here for borderline (emotionally unstable)
personality disorder. According to DSM-5, a diagnosis
problems of borderline personality disorder requires a pervasive
1. A. A body weight of at least 15% below expected pattern of instability of interpersonal relationships,
for height is suggestive of anorexia nervosa. Patients self-image and affect, as well as marked impulsivity,
with bulimia nervosa are often of normal or increased beginning by early adulthood and present in a variety
weight. Preoccupation with being thin, as well as a of contexts.
dread of fatness and a distorted perception of being 2. D. This man is likely to have schizoid personality
too fat are associated with both anorexia and bulimia disorder, as suggested by his stable and pervasive
nervosa. Again, use of medication and exercise traits of social isolation and indifference to the
as means of controlling weight can occur in both opinions of others, with no evidence of an alternative
disorders. mental disorder. It is important to exclude an autism
2. C. While patients with eating disorders often deny their spectrum disorder. See Table 17.1 for descriptions of
symptoms, it is very important to exclude insidious the other personality disorders listed here.
physical illness as a cause of weight loss before 3. C. This man is likely to have antisocial personality
attributing it to a psychiatric disorder. Physical causes disorder. Antisocial personality disorder is very
can include malignancy, inflammatory disorders, prevalent within prisons. However, a fuller psychiatric
infection and endocrine abnormalities. It would also history would be needed prior to making this
be important to take a collateral history from his main diagnosis.
caregiver, including psychosocial stressors. 4. E. In this case, there is too little information to
3. E. Alcohol dependence. Self-neglect due to alcohol make or exclude any diagnosis. The man is in a
or substance use is a common cause of weight state of emotional distress following a significant
loss. Dependence is suggested by her withdrawal life event (breakdown of a relationship, potential
symptoms when she does not have access to alcohol homelessness), which is compounded with acute
(which are not panic attacks). Low mood is commonly intoxication. Initial management should focus on
associated with alcohol excess as alcohol is a physical care, alleviating distress, ensuring his (and
depressant: the treatment is to stop alcohol. Anorexia her) safety and achieving sobriety. Further psychiatric
and bulimia nervosa are excluded by the fact that she assessment (including collateral history) at a later
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SBA answers
time is needed to establish a diagnosis or absence of 2. A. Antipsychotics. Antipsychotics can cause

mental illness. irreversible severe parkinsonian reactions in patients
5. A. It is likely that this man has borderline personality with Lewy body dementia. They are not absolutely
disorder. Note the link between childhood sexual contraindicated but should be used with even
abuse and borderline personality disorder. more caution than in other types of dementia and
ideally under specialist advice. The other options
may all potentially be of benefit – if his delusion is
Chapter 18 The patient with
due to concurrent infection (antibiotics), depression
neurodevelopmental problems (antidepressants) or worsening dementia –
1. C. Ensure he has an eye test. This boy may not cholinesterase inhibitors can improve behavioural
be able to see the blackboard. Children can be and psychological symptoms of dementia. Nutritional
embarrassed to admit this. ADHD and thyroid supplements may be of benefit whatever the cause if
dysfunction are unlikely given that the symptoms are he is losing weight.
only present in one setting. Genetic testing is not yet 3. C. Co-codamol. This contains both codeine and
indicated in ADHD and certainly cannot be used to paracetamol. Opiates are very common causes of
exclude it. A collateral history from the teacher would delirium in older adults, both in their own right and due
be helpful if his eye test comes back normal. to their side-effect of constipation. Opiates are often
2. E. Rett syndrome. The fact that she initially started during acute admissions for pain or surgery.
developed normally, then regressed, excludes Any medication can potentially precipitate delirium,
autism and intellectual disability. Heller syndrome but opiates, benzodiazepines and anticholinergics are
(childhood disintegrative disorder) is possible but the commonest.
unlikely as it is more common in males and usually 4. D. Acute medical ward. This lady is delirious. This is a
has onset after the age of 2 years. Muscular medical emergency. She needs to be fully physically
dystrophy is also possible, but the child would investigated. Her acute-onset psychotic symptoms
be more likely to present with generalized muscle are almost certainly due to her delirium, not a primary
weakness, rather than only a reduced use of those psychotic disorder.
muscles important for social interaction. It also
mainly affects boys.
3. B. Autism spectrum disorder. This is suggested by
Chapter 20 Alcohol and substance-related
his poor understanding of social cues and the hint disorders
that he has an unusually intense interest. To make 1. B. This man is currently contemplating changing
this diagnosis definitive, a much fuller history would his behaviour. He recognizes the need for change
be required. Social phobia is unlikely as the problem (he wants to give up), but he is ambivalent about
is his poor social understanding, not him feeling that it (worrying he will lose all his friends). Motivational
others are critical of him. Social anxiety is nonetheless interviewing may be helpful to allow him to
common as a consequence of autism. Anankastic progress to the next stage of preparation for
personality disorder is unlikely as this does not impair change.
the ability to interact socially. A depressive episode 2. E. Prior to prescribing methadone, it is essential to
might follow his redundancy but it is not the primary confirm the use of opioids. A urine drug test can be
problem. Generalized anxiety is unlikely as he has used to do this. Admission to psychiatric hospital
not mentioned worrying about anything except social is not necessary, although dose titration should
situations. be undertaken in a controlled clinical environment
with facilities to measure physiological response to
opioids, and with emergency treatment for opioid
Chapter 19 Dementia and delirium toxicity (i.e., naloxone) close to hand. Viral serology
1. A. Aromatherapy. This woman has a behavioural testing and physical examination is important
and psychological symptom of dementia. screening for health complications from intravenous
Nonpharmacological options are recommended as a drug use, but it is not necessary for a methadone
first line by NICE (2006), unless there is immediate risk prescription. Forcing a patient to identify a confidant
of harm or severe distress. In the event of these risks, for the purposes of corroboration can lead to
antipsychotics would be first line (after consideration problems, either placing false security in a possibly
of risk of stroke) and cholinesterase inhibitors second inaccurate historian or causing disengagement with
line. Antidepressants are only indicated if there is services.
evidence of depression. Referral to speech and 3. C. Naltrexone is an opioid receptor antagonist. This
language therapy is unlikely to be of benefit given her may control cravings and reduces the pleasurable
severe dementia. effects of drinking alcohol, reducing ‘reward’ and – by
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SBA answers
operant conditioning – can ‘extinguish’ the desire If none of the above have occurred, observations
to drink (the ‘Sinclair method’). Disulfiram causes should be hourly until the patient is able to walk
an unpleasant reaction when taken with alcohol. and interact normally. If the patient refuses or
Acamprosate may be helpful in controlling cravings. remains too behaviourally disturbed to allow
Long-term antidepressants or benzodiazepines are observations, they should be regularly observed for
not recommended for the sole purpose of maintaining respiratory effort, airway and consciousness level.
abstinence. However, antidepressants may be helpful See Fig. 21.2.
for treating comorbid depression. 6. C. Transient hyperglycaemia secondary to stress
4. C. Buprenorphine (Subutex) is a partial opioid may arise but is unlikely to be clinically important.
agonist and can be used for substitution therapy. All the other options are potentially life-threatening:
The other drugs can be used in treating various benzodiazepines can cause respiratory depression,
stages of opioid dependence; however, none are oversedation by any means can cause loss of airway,
true ‘substitutes’. antipsychotics and hyperarousal increase the risk of
arrhythmia, and benzodiazepines and antipsychotics
Chapter 21 The psychotic disorders: can both cause hypotension. Additional
life-threatening complications of antipsychotic
schizophrenia use include seizures and dystonias. All these
1. B. If one parent has schizophrenia, the probability complications can occur with oral formulations also,
of their offspring having schizophrenia is 13%. The but are more likely when large doses are given via a
population lifetime risk is 1%. See Fig. 21.1. fast-acting method.
2. E. If both parents have schizophrenia, the probability
of their offspring having schizophrenia is 50%. The
population lifetime risk is 1%. See Fig. 21.1. Chapter 22 The mood (affective) disorders
3. C. This is a difficult question as there is little solid 1. A. Someone who is not eating or drinking. ECT
evidence about the optimum period of treatment for is indicated in options A–D, but not E. Treatment-
a first episode of psychosis. Without prophylactic resistant depression is an indication for ECT but if the
antipsychotics following a first episode of schizophrenia, patient has capacity and does not wish it, it is not
over half of patients will relapse within a year. The given. No information is given to suggest s/he lacks
current recommendation is to continue antipsychotics capacity, which is presumed to be present in adults
for 1–2 years after a first episode. However, many unless proven otherwise. Life-threatening reduction in
patients wish to stop sooner. In this case, a gradual oral intake, psychotic depression and previous good
reduction over a few weeks reduces the risk of relapse. response to ECT are all other indications for ECT.
Alternatively, this man may prefer to switch to an If a prioritization has to be made, a life-threatening
antipsychotic less associated with weight gain. reduction in oral intake presents the highest risk and
4. D. Cognitive-behavioural therapy. The other modalities so should be treated first.
are not recommended in schizophrenia. Interpersonal 2. C. Admission under mental health legislation. This
therapy and cognitive-behavioural therapy are man is experiencing a manic episode with psychotic
indicated in depression. Dialectical behavioural features. His psychotic beliefs place him at high
therapy is indicated in emotionally unstable personality risk of injury or death and are impairing his ability
disorder. Cognitive analytic therapy is indicated in to make decisions regarding management of his
eating disorders. Family therapy is also recommended mental health. It is not safe to let him go home and
if the patient lives with or is in close contact with their police custody is not appropriate given his behaviour
family. is driven by illness. He may be persuadable to be
5. D. Temperature, pulse, blood pressure, respiratory admitted informally but if not, he would meet criteria
rate, hydration status and consciousness level should for detention under mental health legislation (see
be checked every 15 minutes following parenteral Chapter 4).
administration of rapid tranquillization (until there are 3. D. Citalopram and quetiapine. This man has a
no further concerns about the patient’s physical health severe depressive episode with psychotic features.
status) where any of the following apply (NICE 2015): A combination of an antidepressant and an
Patient appears to be asleep or sedated antipsychotic is indicated. Citalopram is normally tried
Patient has recently taken recreational drugs or alcohol before amitriptyline as it has fewer side-effects. In
BNF maximum doses for medication have been addition, amitriptyline is more toxic than citalopram
exceeded in overdose. Given his suicidal ideation it is best to
Patient has a pre-existing physical health problem choose the less toxic medication. Quetiapine or any
Patient experienced any harm as a result of the other second-generation antipsychotic would be
intervention. reasonable to treat his psychosis.
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SBA answers
4. B. Olanzapine. Olanzapine, risperidone, quetiapine

or haloperidol are the first-line antimanic agents
Chapter 24 Eating disorders
recommended by NICE (2014). Lithium should not 1. B. Family therapy is the first-line psychological
be started in the acute situation in someone with therapy for adolescents recommended by NICE
a history of nonconcordance. Valproate should be (2017). The other therapies are all used in adults with
avoided where possible in a woman of childbearing anorexia.
age. Lamotrigine is not recommended during 2. E. Specialist supportive clinical management. This
acute mania as it is ineffective. Citalopram, or any is one of the three psychotherapeutic modalities
other antidepressant, should be discontinued in a recommended first line by NICE (2017) for anorexia
manic patient. This woman is likely also to need in adults. It is simply high-quality weekly outpatient
rapid tranquillization with a benzodiazepine (see treatment including psychoeducation about nutrition
Fig. 21.2). and weight, a positive therapeutic relationship and
5. C. Individual CBT. Self-help CBT and structured group physical monitoring. Family therapy is first line for
physical activity are recommended by NICE for mild treating anorexia and bulimia in young people. Focal
depression (2011). Dialectical behaviour therapy is psychodynamic psychotherapy is a second-line
a psychological therapy for borderline personality treatment in anorexia. Interpersonal therapy is used to
disorder. Graded exposure therapy is used to treat treat depression and exposure-response prevention
obsessive-compulsive disease and phobias. is used to treat obsessive-compulsive disorder.
3. C. The presence of binge–purge symptoms is
associated with a poorer prognosis in sufferers of
Chapter 23 The anxiety and somatoform anorexia nervosa, as is late age of onset, very low
disorders weight (not rapid weight loss), long duration of illness,
1. B. Seeing patients with anxiety about their physical personality difficulties and difficult family relationships.
health on a regular basis can help contain their The presence of a family history of anorexia is not
anxieties and reduce the total number and number necessarily indicative of poor prognosis, neither is the
of urgent appointments they need. However, this rate of engagement with psychotherapy.
does not mean they should not be allowed access 4. C. NICE (2017) recommends that people with
to urgent appointment slots – they will experience anorexia nervosa should be encouraged to take
physical health problems along with somatization. a multivitamin and multimineral supplement.
Similarly, investigations should be carefully considered Selective serotonin reuptake inhibitors are no
and avoided if possible, but some are likely to longer recommended in the management of eating
still be required to safely exclude other disorders. disorders unless there is comorbid depression or
Benzodiazepines are not indicated for somatization anxiety, and these disorders are most likely to resolve
disorder but may be indicated for some other reason. with weight gain alone.
The nature of somatization disorder should be 5. C. Phosphate 0.3 mmol/L. All the other
explained to patients, but it should not be done in a blood results are in the normal range.
confrontational manner. Phrases such as ‘all in the Hypophosphataemia is the hallmark of refeeding
mind’ should be avoided as patients are genuinely syndrome and a low level indicates that
experiencing symptoms (see Box 23.1). replacement is required, along with frequent
2. B. CBT with desensitization is recommended for monitoring of phosphate, magnesium, sodium and
phobias with mild to severe functional impairment. potassium levels. Calcium levels are not generally
Trauma-focused CBT is for posttraumatic stress affected in refeeding syndrome.
disorder. PRN diazepam would not be advisable given
she is likely to come into contact with bodily fluids on
a daily basis. SSRIs are not recommended for specific Chapter 25 The sleep–wake disorders
phobias. 1. E. Pramipexole. Dopamine agonists such as pramipexole
3. C. An SSRI is the first-line drug therapy for obsessive- and ropinirole are recommended as first-line treatment for
compulsive disorder. Clomipramine is a second- restless legs syndrome. The other medications listed are
line drug therapy. Mirtazapine and pregabalin are all potential causes of the syndrome.
not recommended by current guidelines. Self- 2. D. Neuropathy. A peripheral neuropathy is suggested
help is recommended for mild symptoms but this by her history of diabetes. Restless legs syndrome
woman’s symptoms are associated with marked is unlikely as the pain is not brought on by inactivity.
functional impairment. Talking therapies are first line Iron deficiency is an uncommon cause of restless
for moderate to severe OCD and she should be legs syndrome. Intermittent claudication is unlikely as
encouraged to reconsider a talking therapy if a SSRI is exercise would worsen symptoms. Akathisia would
ineffective. not be limited to her legs.
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SBA answers
3. D. Sleep hygiene advice. Everyone who is struggling CBT are all options in managing moderately severe
with sleep should be given sleep hygiene advice, PMS. SSRIs are reserved for severe PMS.
particularly those with depression. Her insomnia is 2. E. Psychological therapy. While the woman in
likely secondary to depression and should improve the case description attributes her symptoms to
over time as her mood improves. It is too early to the menopause, the duration of the symptoms
increase the dose of fluoxetine. Hypnotics should be accompanied by the presence of suicidal thoughts
avoided where possible as patients can suffer from are more suggestive of a depressive illness. The
daytime drowsiness and develop tolerance. A sleep functional impact and suicidal thoughts suggest an
diary or referral is not indicated. episode of at least moderate severity. The National
Institute for Health and Care Excellence (NICE; 2009)
recommends a combination of an antidepressant and
Chapter 26 The psychosexual disorders psychological therapy (cognitive-behavioural therapy
1. A. Caressing without genital contact can improve or interpersonal therapy) as first line for treating
sex. This is the kind of advice which may be given moderate-to-severe depression. Counselling may also
during sex therapy or in self-help materials related be useful if she has issues relating to relationships or
to sexual dysfunction. All the other pieces of advice bereavements she would like to reflect on, but it is not
are the opposite of what should be given: sexual usually a treatment for depression. Dietary and lifestyle
dysfunction is common at all ages, physical problems advice (avoiding alcohol, tobacco, eating a balanced
are a rare cause of anorgasmia, medication may diet, exercising) should be offered to everyone with
cause sexual dysfunction but should not be stopped mood symptoms but are unlikely to be sufficient in
immediately (a substitution may be required) and good this case. Around the menopausal years, there can
communication with a partner about sex is associated be an increase in psychosocial stressors (children
with fewer sexual difficulties. leaving home, ‘facing up’ to growing older, changes
2. B. Check blood glucose. Erectile dysfunction is a in personal relationships, etc.), which may increase
common presenting symptom in diabetes, as is the risk of developing depression independently of the
weight loss. Excluding diabetes is the priority here. hormonal changes that arise during the menopause.
All of the other options can also be appropriate Hormone replacement therapy can be useful in certain
management options in erectile dysfunction circumstances; however, it does not suit everyone,
depending on the context (see Box 26.2). and should not be used as a substitute for recognized
3. B. Olanzapine. All the other agents are treatments in the management of major depression.
dopaminomimetic agents: levodopa is metabolized to Omega-3 fish oils may reduce menopausal vasomotor
dopamine, pergolide and pramipexole are dopamine symptoms (hot flushes) but are not recommended as
receptor agonists and selegiline is a monoamine a treatment for depression.
oxidase B inhibitor, reducing the breakdown of 3. E. Refer to perinatal psychiatry. This is a complex
dopamine. High doses of dopaminomimetic agents risk–benefit scenario that needs to be carefully
have rarely been associated with new paraphilias in discussed with the patient and which draws
Parkinson disease, typically younger men with a long on the latest available evidence. Her history of
duration of illness. Olanzapine is a dopamine receptor bipolar disorder places this woman at high risk
antagonist which has been used to treat paraphilias in of postpartum psychosis, even with prophylactic
Parkinson disease. treatment. Discontinuing treatment increases her
4. D. Transvestic fetishism. This is the experience of sexual risk of relapse at any time. A mentally unwell mother
arousal due to dressing in clothing normally worn by is harmful for the child in utero and once born.
members of the opposite sex. It is not a problem unless However, all the mood stabilizers are associated
it is causing harm to the individual or others. with teratogenic effects to various degrees (valproate
> carbamazepine > lithium; see Table 27.1). The
Chapter 27 Disorders relating to the absolute risk of congenital abnormalities remains low
with lithium but is unacceptably high with valproate or
menstrual cycle, pregnancy and the puerperium
carbamazepine, so switching to them would not be
1. A. Encourage exercise. This woman has mild helpful. Discontinuing lithium and remaining without
premenstrual syndrome (PMS). One argument prophylaxis may be an option depending on the
with her boyfriend is not evidence of significant severity of her previous mood episodes. Switching to
functional impairment. For mild PMS, the National olanzapine is also a reasonable option as it is thought
Institute for Health and Care Excellence (NICE; 2014) to be safe in pregnancy but would depend on her
recommends healthy eating, stress reduction, regular past experience with this drug.
sleep and regular exercise, particularly during the 4. E. Refer to perinatal mental health team. Reassurance
luteal phase. The oral contraceptive pill, ibuprofen and that she will not become unwell cannot be given.
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SBA answers
This lady has a history of severe postnatal depression account for a month of low mood. Benzodiazepines
and is at greatly increased risk of suffering a further should be avoided where possible given the risks
episode. She should be referred to the perinatal of dependence, particularly high in someone with
mental health team. Given this history, and her good persistent symptoms. Dialectical behaviour therapy is
response to medications in the past, commencing recommended for treatment of emotionally unstable
antidepressant treatment later in pregnancy or early personality disorder in the long term but will not help
postpartum may be beneficial. The perinatal mental depression in the short–medium term.
health team would explore the risks versus benefits of 4. C. Given the significant risk to another person,
this option. When choosing an agent, consideration confidentiality needs to be broken in this case. The
should be given to previously effective drugs, and the psychiatrist has a duty to immediately warn the
mother’s choice to breastfeed. police. In addition, the specific and detailed content
5. A. Detention in hospital under mental health act. This of the threat necessitates that the intended victim be
woman is experiencing a postpartum psychosis and warned (see the Tarasoff case for further details). The
is at very high risk of infanticide given the severity of responsibility for this falls on the doctor; however, in
her illness, the content of her delusion and the active practice the police will usually be happy to facilitate
steps she has taken towards killing her son. This this. Detention under mental health legislation
risk is too high to be managed at home, however would not be appropriate, as the threat should be
supportive her family. She lacks capacity to make addressed by law enforcement agencies in the first
decisions about her treatment due to her absent instance. Meticulous notes would need to be kept. It
insight, therefore requiring admission under detention is likely that he would be held criminally responsible
rather than informally. This should be to a mother- for his actions. Review in 1 week is too late. Anger
and-baby unit if available. Transfer to police cells is management may be appropriate in due course but
not appropriate as she requires intensive psychiatric does not deal with the acute risk. Diazepam should be
care which cannot be provided there. Outpatient avoided given risks of dependence and absence of an
follow-up is not sufficient to manage her acute risk. indication.
A referral to social workers is likely to be helpful in
due course as they may be able to identify additional Chapter 29 The neurodevelopmental
supports for the patient, but the priority at the
disorders
moment is to maintain her and her child’s safety in
hospital. 1. C. There is no pharmacological treatment for the core
symptoms of autism spectrum disorder. The
first-line treatment is social skills training. The
Chapter 28 The personality disorders medications listed may be indicated to manage
1. E. Drug treatment is not the main intervention. NICE common comorbidities of autism spectrum disorder,
(2009) does not recommend drug treatment for the anxiety or depression (fluoxetine), attention deficit
core symptoms of emotionally unstable personality hyperactivity disorder (methylphenidate), psychosis
disorder. However, some medications can be helpful (risperidone) or epilepsy (sodium valproate).
in reducing agitation during crises and in treating 2. D. Methylphenidate. NICE (2008) recommends this as
comorbid mental illness. The main intervention is first-line drug treatment for severe ADHD in school-
psychological therapy. age children. Dexamfetamine and atomoxetine are
2. A. All of the options have evidence supporting their second line. Parent-training/education programmes
use in emotionally unstable personality disorder, but are recommended as first line for school-age children
dialectical behaviour therapy is the ‘gold standard’ with mild to moderate impairment. However, severe
and recommended by NICE (2009). impairment is suggested by the fact this boy is at
3. E. Ensure weekly dispensing of medication. This risk of losing his school place. Cognitive-behavioural
woman is probably suffering from a comorbid therapy is recommended for older adolescents with
depressive episode. Management of this should mild to moderate ADHD.
be discussed with the patient – she may opt for 3. D. This boy has Tourette syndrome.
‘watchful waiting’ or it may be appropriate to start an Psychoeducation is first-line treatment for this:
antidepressant. As her risk of suicide has increased, speaking to him, his family and his teachers to
it is sensible to reduce her access to means of explain the diagnosis and that the majority of cases
suicide by suggesting weekly dispensing. Her risk is improve by adulthood. The other options are all drug
not so high that she needs admission. A urine drug treatments that can reduce tics. However, as the
screen may be helpful in excluding a substance- tics are causing little interference with day-to-day
induced acute change in mood, but substance activities, he may find the side-effects outweigh the
use (with the exception of alcohol) is unlikely to benefits.
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SBA answers
hours. However, EUPD is a risk factor for comorbid

Chapter 30 Child and adolescent psychiatry depression. Disordered eating is common in EUPD.
1. B. Conduct disorder. This is suggested by his major Bulimia is unlikely given the rest of the history,
violations of societal norms (arson and severe but it would be useful to check what her weight-
aggression). Oppositional defiant disorder is often related cognitions are to definitely exclude this (see
considered to be a ‘milder’ variant of conduct Chapter 16). Schizophrenia is unlikely as she is not
disorder, where defiant behaviour is characteristic, reporting any psychotic symptoms (she reports
but this tends not to involve criminality or violating the pseudohallucinations, not hallucinations).
rights of others. Conduct disorder is associated with
the development of antisocial personality disorder,
criminality and substance misuse in later life. He is too Chapter 31 Older adult psychiatry
young to diagnose a personality disorder. Substance 1. A. Antidepressant. The key issue here is the
misuse is a possibility which should be explored but diagnosis. She presents with a common triad in older
is unlikely to present with oppositional behaviour adults: depressive symptoms, cognitive impairment
in isolation. Reactive attachment disorder presents and functional impairment. It is often difficult to tease
under the age of 5 years with disordered social out whether someone is experiencing depression
interaction. manifesting with cognitive impairment or an early
2. E. Vaginal trauma and genital warts are not normal in dementia leading to comorbid depression. Ideally,
an 8-year-old girl, and the findings should immediately depression is treated first, then cognition reassessed
raise suspicions of sexual abuse. The safety of the child once mood is euthymic. An antidepressant would
is paramount, and steps should be taken to maintain be first line in view of her cognitive impairment, but
this. While protocols vary slightly between areas, child counselling or psychological therapy could still be
protection procedures usually advise contacting the considered in someone with this level of cognitive
duty social worker and/or the local paediatrician on-call impairment.
for child protection. If in any doubt about a possible 2. C. Depressive episode. It is common for depression
child protection concern, either of these parties will to manifest with prominent features of anxiety,
usually be more than happy to offer guidance. The child psychomotor agitation and hypochondriacal ideas
should not be directly asked about what happened in older adults. Mild cognitive impairment is the next
at this stage: a formal interview needs to be arranged most likely differential – although her AMT score of
involving the police, social workers and paediatric 10/10 is reassuring, a more sensitive test such as the
staff. Police will not question the girl just now. Parents Addenbrooke’s Cognitive Examination (ACE-III) may
should never be ‘confronted’ by medical staff; however, still show an objective impairment. Generalized anxiety
it is obviously courteous (if possible) to let them know disorder or hypochondriacal disorder is unlikely
what is going on and what will happen next. The child to have onset so late in life, and diagnosis would
should not be allowed home until all relevant agencies require a longer duration of symptoms. There are no
are involved and safety at home can be ensured. This psychotic features to suggest schizophrenia.
may not be possible, and an alternative place of safety 3. A. ECT. All of the suggested management strategies
may have to be sought. Should the parent remove the are reasonable, but ECT is preferable because
child from safety, it would be appropriate to contact the of this man’s potentially life-threatening poor fluid
police given the magnitude of the concerns. intake and poor medication concordance. Depot
3. B. Cognitive-behavioural therapy. This girl has a medication would get around the concordance
probable diagnosis of depression, of moderate problem but there are no depot medications licensed
severity (based on her functional impairment). NICE as antidepressants. ECT is the quickest and most
(2005) recommends individual psychological therapy effective treatment for depression known and seems
first line. Fluoxetine is the first-line antidepressant, to work particularly well in older adults.
sertraline and citalopram are second line. Watchful 4. B. All of these patients could potentially have late-
waiting is recommended only in mild cases. onset schizophrenia. However, symptoms of late-
4. D. Emotionally unstable personality disorder (EUPD). onset schizophrenia are predominantly delusional,
This is suggested by her long-term rapidly fluctuating rather than bizarre or negative symptoms (as in
mood, difficulties in relationships, self-harm, patients A and C). Patient D is more likely to have
pseudohallucinations (the voice inside her head) Charles Bonnet syndrome. Late-onset schizophrenia
and disturbed self-image (feeling empty). Childhood is far more common in women than in men, and
adversity is a risk factor for EUPD and suggested social deprivation and hearing impairment are also risk
by a parental overdose. Bipolar affective disorder factors.
or a depressive episode would be associated with 5. D. Continue mirtazapine for at least 8 weeks.
episodes of altered mood which lasted for days, not Older adults can take longer to show response to
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SBA answers
antidepressants, so an adequate trial is at least are fatal in minor overdose. Her ongoing intent is
8 weeks. Augmentation is not necessary at this stage unclear from the vignette. She may require admission
and increases the risk of drug interactions. Tricyclics or urgent community support from mental health
are not recommended as first line in older adults due services.
to their side-effect profile.
6. E. Delirium. This lady has acute-onset cognitive
impairment: delirium until proven otherwise. The Chapter 32 Forensic psychiatry
history is concerningly suggestive of a focal seizure. 1. C. The best predictor of future violence is past
She needs to be admitted to a medical ward for violence. The other options also increase his risk of
investigation. A manic or hypomanic episode would future violence, particularly substance use.
be highly unlikely to have such a rapid onset. Were 2. E. An individual being considered unfit to plead
she on lithium, it would be crucial to check a random through mental illness is relatively uncommon. The
lithium level as her presentation could also be due to mental state findings given in A–D are all fairly extreme
lithium toxicity. abnormalities suggesting that he would struggle to
7. B. This is the simplest and easiest of the options. If understand the difference between a plea of guilty
concordance remains poor despite this, prompting and not guilty (D), understand the nature of the charge
by a carer could be considered. A depot could be (D), instruct counsel (A and C), follow the evidence
useful if the patient wishes it, or his insight reduces brought before the court (C) or challenge a juror (B
and he requires compulsory treatment. Daily and C). Amnesia (real or reported) for the offence itself
dispensing is normally reserved for methadone or for does not necessarily impact on fitness to plead.
those at high risk of overdose. In general, simplifying 3. E. Murder is the only charge for which diminished
medication regimes to once daily is a good idea, but responsibility may apply. If the accused is found
unfortunately olanzapine is likely to be too sedating to have diminished responsibility, the conviction is
to allow use in the mornings. Potentially, his other reduced to manslaughter (or culpable homicide in
once daily medication could be changed to the Scotland). This was particularly important historically
evening. when murder carried the death penalty.
8. A. Ask her to attend A&E. It is unclear what dose of 4. B. ADHD. This is a typical history for someone
trazodone she has taken, or whether she has taken with ADHD symptoms of impulsivity and emotional
any other tablets. She needs examination, blood instability leading to offending behaviour. It may be that
samples tested and an electrocardiogram. The next treatment for ADHD helps this young man (see Chapter
step would be for her to receive an urgent psychiatric 29). However, it would be crucial to gain collateral
review. This lady has recently attempted suicide. history from someone who knew him well during his
Older adults are at high risk of completed suicide. development before making this diagnosis. The other
She may perceive taking extra trazodone as far more options are also consistent with the majority of the
harmful than it actually is, as she may have memories vignette and important to consider. The final diagnosis
of barbiturates – highly toxic sleeping tablets, which that is imperative to explore is his use of substances.
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EMQ answers
5. C. Bupropion. Pramipexole is a dopamine receptor

Chapter 2 Pharmacological therapy and agonist.
electroconvulsive therapy General feedback: See Table 2.1.
Management of antipsychotic-induced
extrapyramidal side-effects Chapter 3 Psychological therapy
1. C. Propranolol. This woman is probably Modalities of individual psychotherapy
experiencing akathisia. This is hard to treat, but
1. C. Mentalization is the process by which we
propranolol or benzodiazepines can help. See
implicitly and explicitly interpret our and others’
Table 2.7. Ideally, the dose of antipsychotic is
actions as meaningful on the basis of intentional
reduced. Quinine can be used for restless leg
mental states. Mentalization-based therapy is
syndrome when in bed. The differential includes
a treatment intended to improve the capacity
agitation secondary to psychosis.
to mentalize, which is often a specific difficulty
2. F. Intramuscular procyclidine. This woman is
in those with borderline personality disorder.
experiencing a dystonia with an oculogyric
This is thought to improve emotional regulation
crisis and trismus. Her clenched jaw means
and interpersonal relationships. He may also
administering oral procyclidine is not possible.
find useful dialectical behaviour therapy, which
Baclofen and dantrolene should be used for
incorporates mentalization training.
chronic spasticity.
2. K. Interpersonal therapy is based on the
3. G. Resuscitation. This woman is acutely unwell.
assumptions that problems with interpersonal
She needs ABC and probably a periarrest
relationships and social functioning contribute
call/999 ambulance. She may have neuroleptic
significantly to mental illness. Main areas of
malignant syndrome or a range of other
focus include role disputes, role transitions,
differentials (e.g., meningitis, substance
interpersonal deficits and grief. She may also
intoxication). Dantrolene is not an emergency
find cognitive-behavioural therapy of benefit,
treatment and is not indicated until the
for example, if interpersonal therapy is not
diagnosis is clearer.
available.
4. B. Oral procyclidine. This man has drug-induced
3. I. Systematic desensitization is a type of
parkinsonism. In the early stages, the features
behavioural therapy that can be useful in the
are different to idiopathic parkinsonism.
treatment of phobias. It involves compilation of
Anticholinergics can help, but ideally the dose
a hierarchy of phobic stimuli (e.g., standing at
of antipsychotic would be reduced or an
the front door, going into the garden, going to
alternative antipsychotic trialled.
the end of the street, going to the supermarket)
5. D. Stop anticholinergics. This man has tardive and. with support from the therapist and the
dyskinesia. This is hard to treat but stopping use of appropriate relaxation techniques.
anticholinergics (in this case procyclidine) and working through the hierarchy in order to face
reducing or withdrawing antipsychotics, if increasingly anxiety-provoking scenarios.
possible, can help.
4. B. Trauma-focussed cognitive-behavioural therapy
Mechanism of action of antidepressants can be useful in the treatment of posttraumatic
1. A. Agomelatine. stress disorder, where the emphasis is
on identifying and changing thoughts,
2. E. Duloxetine. Venlafaxine also works this way.
feelings, sensations and behaviour related
Tricyclic antidepressants are SNRIs, which
to the traumatic event. The ‘dual attention
also influence muscarinic, histaminergic and
stimulus’ type of therapy that the gentleman
α-adrenergic receptors.
in the scenario describes is eye movement
3. B. Amitriptyline. Tricyclic antidepressants are
desensitization and reprocessing, which can
SNRIs, which also influence muscarinic,
also be helpful for some.
histaminergic and α-adrenergic receptors.
5. F. Exposure and response prevention is a type
4. F. Moclobemide. Phenelzine is an irreversible
of behavioural therapy in which the patient is
inhibitor of monoamine oxidase A and B.
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EMQ answers
encouraged not to respond to the obsessional legislation as in case 1. Although he has been
thought with a compulsive act. Relaxation charged by the police, his offence is not severe
techniques are used instead to overcome the enough to require management under forensic
anxiety associated with not carrying out the legislation.
compulsion. 4. F. Common law. It is in this man’s best interests
to receive aggressive airway management
Psychodynamic psychotherapy and oxygen. He currently lacks the capacity
1. A. This is an example of acting out: behaving in to consent as he is unable to communicate.
a certain way in order to express thoughts Treatment under common law is indicated
or feelings that the person feels otherwise to sustain life and to prevent serious
incapable of expressing. deterioration.
2. H. Counter-transference is the process whereby 5. B. Mental capacity legislation. As this man
the therapist unconsciously interacts with the needs treatment for a physical problem,
patient as if they were a significant figure from mental health legislation is not appropriate.
the patient’s past. He lacks capacity as he is unable to
retain information for long enough. It is
3. D. Catharsis is a Greek word meaning ‘cleansing’
not an emergency, so common law is not
or ‘purging.’ It is often used to describe a
appropriate.
feeling of relief after an outpouring of emotive
material.
4. E. Parapraxis is a term used to describe an
error of memory, speech, writing, reading or Chapter 5 Mental health service provision
action that may be due to the interference of Choice of service provision for mental disorder
repressed thoughts and unconscious features 1. I. Primary Care. Most episodes of depression are
of the individual’s personality. It is commonly managed in primary care. Referral to secondary
referred to as a ‘slip of the tongue’ or a care should be considered in cases that are
‘Freudian slip.’ resistant to treatment or high risk or that present
5. J. Working through describes the concept of diagnostic uncertainty.
working over one’s emotional difficulties from 2. G. Liaison psychiatry review. Liaison psychiatrists
the past. In psychotherapy, it usually follows provide psychiatric care to people admitted
an ‘impasse’, which can be thought of as a to general hospitals. This man may be
therapeutic stalemate. experiencing a depressive episode, symptoms
of physical illness, side effects from medication,
or an adjustment reaction.
Chapter 4 Mental health and the law 3. A. Acute general adult inpatient unit. This
Legislation man is high risk and therefore requires
1. A. Mental health legislation. This man has evidence hospital admission. He cannot safely be
of mental disorder (depressive episode with managed at home. As he has an established
psychotic symptoms) significantly affecting his diagnosis of schizophrenia, the early
ability to make decisions about his treatment intervention in psychosis team is unlikely to
(delusional belief that he will be tortured). be needed.
He is at high risk (active plan of suicide by 4. J. Rehabilitation unit. This man has treatment-
violent means, mental disorder, young male) resistant schizophrenia with ongoing symptoms
and hospital is the least restrictive option despite appropriate treatment. He also has
(risk cannot be managed safely at home). He functional impairment. A rehabilitation unit will
therefore meets the criteria for detention under be able to optimize his ability to live well despite
the mental health act. ongoing symptoms.
2. C. Forensic mental health legislation. This man 5. B. Assertive outreach team. This man
has evidence of mental disorder (psychotic has schizophrenia with complex needs
symptoms) and has been charged with a (homelessness, comorbid substance use), poor
serious offence. The severity of his charge engagement, frequent use of crisis services
means he needs assessment and treatment and a need for intensive support (ongoing
under forensic, not civil, legislation. symptoms). A community mental health team is
3. A. Mental health legislation. This man meets unlikely to be able to support him as well as an
criteria for detention under mental health assertive outreach team.
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EMQ answers
withdrawal. Discharging a patient in this state

Chapter 6 The patient with thoughts of is unacceptable, as he is at risk of not only
suicide or self-harm committing further acts of self-harm, but of
Mental disorder and self-harm medical complications. He is also possibly
1. F. Emotionally unstable personality disorder. She is unable to look after himself and could be
a young woman with a long history of self-harm, vulnerable from exploitation or accidents.
difficulties with interpersonal relationships and 2. H. This person should be discharged to police
auditory pseudohallucinations at times of stress. custody. Her overdose does not appear to
Of note, she has no symptoms suggestive of a have been with strong suicidal intent (she
depressive illness. was found in the street), and she is exhibiting
2. J. Depressive episode, severe with psychotic drug-seeking and manipulative behaviour. While
features. This man has made a serious many patients like this do not require police
suicide attempt. Note that he went to some involvement, she has committed physical,
effort to prevent discovery (remote location, verbal and racial assaults on healthcare
unsocial hour) and made acts of closure workers, and needs to face consequences for
(typed letters imply that some thought had these actions. Admission to a psychiatric ward
gone into these). He has biological and is unlikely to be beneficial, and may even prove
psychotic symptoms of depression. He detrimental by reinforcing the suggestion that
may have intoxicated himself to reduce behaviour of this nature is driven by mental
his inhibitions prior to the act and is not illness.
necessarily alcohol dependent. 3. E. This gentleman should be referred for urgent
3. E. Mania with psychosis. This young man’s self- (later in the week) input from the community
inflicted injuries are in keeping with his grandiose mental health team. He is likely to be suffering
beliefs (of a religious nature), of which he is from a depressive illness, probably precipitated
entirely convinced. He is disinhibited and feels by financial and employment difficulties. While he
that he has special powers. He also exhibits flight is clearly remorseful about his suicidal behaviour,
of ideas on mental state examination. Important he appears to be struggling with his current
differential diagnoses in this case would be a situation, has some biological symptoms of
drug-induced state or an organic illness. depression, and could well benefit from input
by the community mental health team. He has
4. G. Depressive episode of moderate severity would
a concerned and supportive wife and a stable
be the most fitting of the listed diagnoses.
domestic situation, which is why immediate
Note the pattern of previous periods of illness,
outreach team involvement is not necessary at
punctuated by periods of relatively good
present.
functioning. There is no mention of psychotic
symptoms, and drugs or alcohol are not 4. B. This lady most likely requires admission to
implicated. a psychiatric ward for further assessment
and management of her mental state and
5. B. Anorexia nervosa. Although a full history and
risk. Should she refuse, use of mental health
physical examination would be required to
legislation may need to be considered. Despite
definitively establish this diagnosis, the patient’s
the overdose being relatively small, this is likely
history and presentation is suggestive of a
due to lack of knowledge and there appears
serious eating disorder. Note the baggy clothes
to have been very clear suicidal intent. First
and the lanugo hair.
presentations of self-harm in older adults
should be considered to be with suicidal intent
Immediate psychiatric management of the unless there is clear evidence to the contrary.
patient who has inflicted harm upon themselves Intensive outreach support in this case would
1. C. An admission to a medical assessment/short be inappropriate given the very high risk of
stay ward is necessary, with a psychiatric imminent further acts, despite her pleas that
evaluation when he sobers up. He is she will be fine.
currently too intoxicated (with drugs and 5. I. Discharge with information on non-NHS support
alcohol) to undertake an adequate mental services. Despite her history and diagnosis, this
state examination and risk assessment, woman appears to be functioning at a relatively
and admission to a psychiatric ward would high level (studying, not self-harming until recent
not be appropriate due to potential medical stressors). She has made it clear that she is not
complications of alcohol intoxication/ wishing mental health service input; however,
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EMQ answers
it could be that she would benefit from non- There should therefore be a low threshold for
NHS resources. Information on local student suspecting an intracranial bleed after minor
support agencies or voluntary support services or no injury. A chronic subdural haematoma
for people who self-harm should be offered. as opposed to neurodegenerative cause of
Most of these agencies accept self-referrals and dementia is suggested by her relatively quick
distribute leaflets to local mental health bases. cognitive deterioration, possible fluctuating
conscious level (uncharacteristic afternoon
naps), neurological signs and history of head
Chapter 7 The patient with impairment of injury. It is not uncommon for there to be a
consciousness, memory or cognition latent period of days to weeks between injury
and symptoms. The next step should be brain
Differential diagnosis of cognitive impairment
imaging.
1. D. Subjective cognitive impairment. This woman
2. C. Normal pressure hydrocephalus. This is
presents with concerns about her memory
suggested by this man’s incontinence, ataxia
but has a normal score on standardized
and cognitive impairment, the classic triad
cognitive assessment. This may reflect her
of ‘wet, wobbly, wacky’. Often this disorder
high educational level. It would be important to
is idiopathic. The next step should be brain
clarify how old her mother was when she was
imaging.
diagnosed with dementia, to guide frequency
3. I. Addison disease. This often presents insidiously
of follow-up (above 65 years of age suggests
with fatigue, loss of stamina, weight loss, apathy
the teacher has a 3-fold increased risk, under
and memory problems. Postural hypotension is
65 years suggests the possibility of a stronger
common and is suggested by her dizziness on
genetic risk).
rising. Hyperpigmentation of the palmar creases
2. C. Mild cognitive impairment. This woman has a
and buccal mucosa is often present but easy to
below normal score on standardized cognitive
miss. Addison disease is rare, so this woman
assessment but no impairment in activities of
is most likely to be suffering from depression,
daily living. This low score is quite concerning
but it would be important to check urea and
in view of her young age and high educational
electrolytes (hyponatraemia, hyperkalaemia) and
attainment and she should be referred to a
glucose (hypoglycaemia) and consider a short
young onset memory clinic for comprehensive
synacthen test (diagnostic test).
investigation.
4. H. Cushing syndrome. This is suggested by the
3. B. Dementia (early onset). This woman has a
central obesity, amenorrhoea, hypertension,
below normal score on standardized cognitive
plethoric face and characteristic psychiatric
assessment and impairment in activities of daily
symptoms of low mood and forgetfulness.
living. She should be referred to a young onset
Glucose is likely to be elevated. The next
memory clinic for comprehensive investigation.
step would be to refer for a dexamethasone
In view of her family history, genetic testing and
suppression test to confirm the diagnosis.
counselling of any children may be considered.
5. F. Hyperparathyroidism. Hyperparathyroidism
4. E. Depression. This woman has symptoms of a
causes hypercalcaemia. Mild hypercalcaemia
depressive episode of moderate severity. This
(<3.0 mmol/L) is common in older women and
is likely to account for her cognitive symptoms
often asymptomatic. Symptoms when present
and loss of marks on cognitive testing.
include low mood, abdominal pain, bone pain
5. K. Amnesic syndrome. This woman has a specific and renal calculi. Mild memory problems often
memory impairment on standardized cognitive occur, progressing to a delirium if calcium levels
assessment. She recently experienced alcohol are very high (>3.8 mmol/L). The next step should
withdrawal which may have been complicated be to check serum calcium and phosphate.
by unrecognized Wernicke encephalopathy,
leaving her now with Korsakoff syndrome.
She should be prescribed thiamine, undergo Subtypes of dementia
structural brain imaging and options for 1. A. Alzheimer dementia. Medial temporal atrophy is
managing her alcohol use discussed with her. an early change in Alzheimer.
See Chapter 20. 2. B. Vascular dementia. Note this man’s multiple
vascular risk factors and evidence of
Potentially reversible causes of dementia cerebrovascular disease on imaging.
1. A. Subdural haematoma. This woman has atrial 3. D. Frontotemporal dementia. This is particularly
fibrillation and so is likely to be on warfarin. common in younger adults.
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EMQ answers
4. E. Lewy body dementia. than 1 month. The diagnosis is supported

5. F. Parkinson disease with dementia. Parkinson by his age and functional decline prior to the
disease is associated with an increased risk of onset of symptoms. Although his mother
dementia. does not think he misuses substances, it
General feedback: see Table 7.4. would be important to exclude this by asking
the man himself and performing a urine drug
Clinical features in cognitive impairment screen.
2. I. Schizoaffective disorder. This man has
1. A. Apraxia (intact motor ability shown by her ability
concurrent mood symptoms and first rank
to mimic).
symptoms of schizophrenia. His mood and
2. C. Aphasia (expressive nominal aphasia).
psychotic symptoms are equally prominent,
3. E. Perseveration (receptive aphasia is less likely as making a recurrent psychotic depression
she understood the initial instructions). unlikely.
4. B. Agnosia (visual). 3. C. Depressive episode, severe, with psychotic
5. B. Agnosia (tactile, also called astereognosia). features. This man has mood symptoms and
General feedback: See Table 7.1. psychotic symptoms which are not typical
of schizophrenia (because they are second
Chapter 8 The patient with alcohol or rather than third person). The mood symptoms
appear to be more prominent than the
substance use problems psychotic symptoms, making schizoaffective
1. F. Chronic insufflation (‘snorting’) of cocaine can disorder unlikely.
cause damage to the nasal septum. 4. A. Delusional disorder. This man has a
2. G. Ketamine is a potent glutamatergic (NMDA longstanding unshakeable belief arrived at
receptor) channel blocker, and is a potent through faulty reasoning: a delusion. He has
short-acting dissociative anaesthetic. It is insight into this. Schizophrenia is unlikely
legitimately used in veterinary surgery as an because the delusion is nonbizarre and
anaesthetic agent. It can also be used as functioning is intact.
an anaesthetic analgesic agent in human 5. F. Personality disorder. This man is not delusional
medicine. as his belief is not fixed. He is suspicious and
3. C. Heroin. Intravenous drug use is a major risk litigious. The history from the police of multiple
factor for bacterial endocarditis, blood-borne previous calls suggests his difficulties are
virus infection, deep vein thrombosis and longstanding. This would be consistent with a
injection site cellulitis or abscesses. Other paranoid personality disorder. However, a fuller
substances on the list can be injected, but background history would be required to make a
heroin is the commonest injected recreational definite diagnosis.
drug. 6. B. Dementia/delirium. This man has cognitive
4. E. Diazepam. Like alcohol, benzodiazepine impairment, functional decline and auditory
intoxication and long-term use is associated hallucinations. It is crucial to exclude delirium by
with memory impairment. clarifying the onset of these symptoms (acute or
5. I. Buprenorphine is a partial opioid agonist. When chronic), by assessing his consciousness level
taken by an opioid naïve person, it can cause and by completing a full physical examination
euphoria, sedation, and other symptoms of and basic investigations. Dementia can also be
opioid intoxication. However, when taken by associated with hallucinations. A mood disorder
someone who is opioid-dependent and already is made less likely by the description of him
has a lot of circulating opioid receptor agonists as ‘cheerful’; however, a severe depressive
present (e.g., heroin), it can displace these episode could also account for his symptoms.
agonists from opioid receptors and cause Schizophrenia is unlikely to have such late
withdrawal symptoms. onset.
Psychosis secondary to a general medical

Chapter 9 The patient with psychotic
condition or psychoactive substance use
symptoms
1. G. Neurosyphilis. This is now a rare diagnosis in
Differential diagnosis of psychosis the UK but should always be considered in
1. J. Schizophrenia. This man describes the those with work or travel histories that may
symptom of thought insertion for greater have placed them at risk of contracting syphilis.
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EMQ answers
Neurosyphilis is a type of tertiary syphilis that

emerges several years after initial infection.
Chapter 10 The patient with elated or
Clinical features are diverse but can include irritable mood
personality change, grandiose behaviour and Differential diagnosis of elevated or irritable
dementia, along with upper motor neurone mood
abnormalities such as brisk reflexes and 1. A. Hypomanic episode. This man describes
extensor plantars. elated mood with a decreased need for
2. B. Cerebral tumour. This man is socially disinhibited sleep, poor concentration, increased energy,
with a headache suggestive of raised increased recent expenditure and increased
intracranial pressure. The presence of focal libido. It is interfering with his social and
neurological signs would further support the occupational functioning, but these activities
diagnosis. are not completely disrupted. We are not given
3. L. Vitamin B12 deficiency. As a vegan, this information on past mood abnormalities, so
woman is at risk of vitamin B12 deficiency the diagnosis of bipolar affective disorder is not
(which is present only in meat and dairy appropriate.
products). She describes ataxia and paranoia, 2. C. Manic episode with psychotic features. This
both of which can be features of vitamin B12 man has irritable mood, sexual disinhibition
deficiency. and grandiose delusions which have led him
4. K. Thiamine deficiency. This man is likely to commit an offence and quit his career.
experiencing Wernicke encephalopathy. Schizophrenia is made less likely by the
He is experiencing visual hallucinations and presence of mood symptoms and disinhibition. It
possibly tactile hallucinations of insects would be important to check a urine drug screen
beneath the skin (formication). He is ataxic to exclude mania secondary to psychoactive
and has nystagmus. Thus, he has the classic substance use. We are not given information on
triad for Wernicke: confusion, ataxia and past mood abnormalities, so the diagnosis of
ophthalmoplegia. Although this man’s alcohol bipolar affective disorder is not appropriate.
history is unknown, the time course of these 3. D. Mixed affective episode. This man shows rapid
symptoms is consistent with the onset of changes between an elated, low and irritable
alcohol withdrawal and alcohol use may have mood within 24 hours.
predisposed him to being in a road traffic 4. F. Cyclothymia. This woman describes
accident. alternating periods of mild elation and mild
depression since early adulthood which do not
Mental state examination in psychosis impact on her functioning.
(perceptual disturbance) 5. E. Bipolar affective disorder. Current episode
1. I. Second-person auditory hallucination. mania with psychotic features. This man has a
2. H. Pseudohallucination. history of depression and now presents with
3. B. Extracampine hallucination. reduced sleep, reduced appetite, psychomotor
4. L. Visceral hallucination. agitation and a grandiose delusion which
has resulted in marked disruption to his
5. D. Hypnagogic hallucination.
occupational function.
6. C. Gustatory hallucination.
Mental state examination in psychosis (thought Elevated or irritable mood secondary to a

disturbance) general medical condition or psychoactive
1. I. Persecutory delusion. substance use
2. E. Erotomania. 1. J. L-dopa. This man probably has Parkinson
3. C. Delusion of misidentification (Capgras disease and is likely to be treated with
syndrome). dopaminergic agents such as L-dopa, a
precursor to dopamine. Excess dopamine
4. D. Delusion of reference.
is associated with euphoria, psychosis
5. H. Nihilistic delusion.
and a reduction in impulse control. Note
6. A. Delusion of control. it is the treatment rather than Parkinson’s
7. G. Loosening of associations. disease itself which is associated with these
See Table 9.1 for explanation. symptoms.
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EMQ answers
2. L. Amphetamine. Amphetamine intoxication can 4. B. Moderate depression. This man has the three
be associated with an acute psychosis. It is core symptoms of depression and two further
a sympathomimetic and so associated with symptoms (disturbed sleep and appetite). He
dilated pupils. Cocaine can have similar effects is having great difficulty continuing his normal
but is normally smoked or snorted. activities, meeting criteria for moderate depression.
3. H. Anabolic steroids. These are commonly used by 5. J. Low mood secondary to psychoactive substance
bodybuilders to increase muscle bulk but can use. This would normally be diagnosed as harmful
be associated with changes in mood, arousal use of alcohol (see Chapter 20). This man gives
and cognition. a clear history of low mood following alcohol
4. I. Corticosteroids. High dose corticosteroids excess. This is impacting upon his mental health
are often prescribed for severe acute asthma. and occupational functioning. He is easily able to
Mood changes and psychosis are common abstain from drink, indicating he is not dependent.
psychiatric complications of steroid use.
Low mood secondary to a general medical
5. G. Hyperthyroidism. This is suggested by tremor,
condition
tachycardia and irritability. Substance use is an
important differential although her normal pupils 1. E. Cushing syndrome is an excess of cortisol.
make use of a stimulant less likely. It can present with depression or psychosis.
Clinical features include obesity, hypertension
Mental state examination in elevated or irritable and easy bruising.
mood 2. A. Huntington disease is an autosomal dominant
1. A. Pressured speech. neurodegenerative disorder beginning in the
basal ganglia. Depression is often an early
2. H. Visual hyperaesthesia. This is an increased
symptom. Increased clumsiness and poor
intensity of perception.
coordination can be subtle early features of
3. C. Tangential thinking.
the movement disorder which progresses to
4. B. Flight of ideas. marked ataxia with choreiform movements.
5. D. Poor concentration (or distractibility). Huntington disease is not always talked
6. J. Visual hallucination. A perception in the absence about in families and the description of the
of a stimulus. patient’s father is more typical of the course of
Huntington than of depression.
Chapter 11 The patient with low mood 3. I. Hypothyroidism is suggested by this woman’s
fatigue, low mood, dry, thin hair, dry skin and
Differential diagnosis of low mood
bradycardia.
1. F. Dysthymia. This man describes subsyndromal
4. C. Multiple sclerosis would be an important
symptoms of depression which emerged in
differential. This is suggested by her two
adulthood and do not significantly interfere with
neurological symptoms separated in time and
his functioning. The lack of discrete episodes
place. Depression is common in multiple
excludes recurrent depressive disorder.
sclerosis.
2. A. Mild depressive episode. This woman has two out
of three of the core symptoms of depression, poor
Mental state examination in low mood
concentration and poor self-esteem. There are no
biological symptoms mentioned. She is able to 1. G. Psychomotor agitation. This is a common
continue her normal activities, meeting criteria for feature of depression in older adults.
mild depression. 2. I. Negative cognition. When considering the loss
3. D. Severe depression with psychotic features. of the contract this man has demonstrated
This woman has a clear change in functioning Beck’s cognitive triad: negative views of himself,
from her baseline, psychomotor retardation the world and the future.
and what may be olfactory hallucinations of 3. C. Reduced range of reactivity (blunted affect).
foul smells leading to the secondary delusional This woman’s affect does not vary as would be
belief that her neighbour’s drains are clogged. expected when discussing content of different
Although her mood is not reported, she is at types.
risk of depression following a bereavement 4. A. Poor self-care. This is particularly concerning
and these hallucinations are typical of severe as personal appearance is important to this
depression. man’s job.
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EMQ answers
5. L. Partial anhedonia. This man reports a markedly Anxiety secondary to a general medical condition
reduced interest in all activities with loss of the or psychoactive substance use
ability to derive pleasure from most, but not all, 1. D. Pheochromocytoma. Although, because of
activities he previously enjoyed. its rarity, this remains an unlikely diagnosis
for the scenario, it is the most likely from the
options given. The features suggestive of
Chapter 12 The patient with anxiety, fear or pheochromocytoma are the family history (not
avoidance always present), hypertension, hyperglycaemia
Differential diagnosis of anxiety, fear or and intermittent episodes of increased
avoidance catecholamine release. The history alone is not
diagnostic: urinary or serum catecholamine
1. C. Social phobia. This man has a generalized
assays and imaging of the adrenals would be
social phobia shown by his avoidance of social
required.
situations and marked anxiety and distress
when in them. 2. C. Hyperthyroidism. This lady already suffers
from one autoimmune disorder (vitiligo)
2. D. Generalized anxiety disorder. This lady
which increases her risk of another (Graves
has experienced continuous anxiety and
disease). Tremor, heat intolerance, anxiety and
apprehension about minor matters associated
increased appetite are classic symptoms of
with autonomic overactivity and muscle tension
hyperthyroidism.
for over 6 months.
3. I. Fluoxetine. Selective serotonin reuptake
3. A. Agoraphobia with panic disorder. This lady had
inhibitors can initially be alerting and agitating,
a panic attack in a supermarket and has now
particularly in young people. This can increase
become increasingly avoidant of crowding and
the risk of suicide in the severely depressed.
confinement. Her symptoms are restricted to
Use of an alternative antidepressant should be
these situations. The weight loss may well be
considered.
explained by her reduced dietary intake and
increased exercise, but other disorders should 4. E. Caffeine. Caffeine has anxiogenic effects.
be screened for, i.e., hyperthyroidism. Many soft drinks contain large amounts of
caffeine.
4. E. Panic disorder. This man reports repeated
nonsituational panic attacks including a 5. H. Amphetamine. This drug increases
sensation of derealization. His symptoms could concentrations of dopamine and noradrenaline
be due to cardiac problems but his young age, (norepinephrine), leading to increased
lack of exercise-induced symptoms and normal sympathetic nervous system activation.
ECG are reassuring. Cocaine intoxication would give a similar
presentation.
5. C. Social phobia (specific to playing a musical
instrument in concert). This man has a
social phobia as shown by his situation- Chapter 13 The patient with obsessions and
specific anxiety and avoidance. This is not compulsions
a generalized social phobia but is limited to
Differential diagnosis of obsessions and
one specific situation. The Diagnostic and
compulsions
Statistical Manual of Mental Disorders, 5th
Edition codes for generalized or performance 1. B. Obsessive-compulsive disorder. This woman
only social phobias whereas ICD-10 does not has a greater than 2-week history of both
differentiate. obsessions and compulsions associated with
6. F. Depressive episode. This man has the three functional impairment.
core symptoms of depression and two further 2. A. No mental illness. This woman is not
biological symptoms. His anxiety symptoms experiencing obsessions or compulsions. She
are concurrent with his depression so the is responding to external influences and her
primary diagnosis is of a depressive disorder handwashing may realistically reduce the feared
rather than an anxiety disorder. Although his outcome of infection transmission.
symptoms had onset following a traumatic 3. C. Depressive episode. This woman has the three
event, they are too prolonged to be an acute core symptoms of depression and two further
stress reaction, too severe to be an adjustment symptoms. Her obsessions and compulsions
disorder, and he denies two of the three key are concurrent with her depression so the
symptoms of posttraumatic stress disorder primary diagnosis is of a depressive disorder
(flashbacks, avoidance and hyperarousal). rather than obsessive-compulsive disorder.
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EMQ answers
4. D. Phobia. This woman has situation-specific anxiety stressor, the nondermatomal distribution of signs
with avoidance and panic attacks. She does not and the otherwise normal neurological exam.
have obsessional thoughts, rather her anxiety 4. I. Dissociation secondary to psychoactive
is brought on by external stimuli. Although she substance use. Given the history of onset, and
washes her hands to reduce her anxiety, it is not the fact that she was at a party the previous
a purposeless or excessive action, meaning it is evening, initial consideration should be given
not a compulsion. She is not hypochondriacal as to substance-induced dissociation. Common
she does not believe she is ill. substances associated with this include
5. I. Eating disorder. This woman’s low body weight, ketamine and tranquillizers; however, it can
self-induced weight loss, body image disturbance also occur following ingestion of less common
and amenorrhoea mean she meets criteria substances such as mescaline or peyote.
for anorexia nervosa. She is not experiencing
obsessions as she describes ego-syntonic Diagnosis following stressful events
thoughts which she does not resist. Rather they 1. E. Bereavement response. Note the chronological
are over-valued ideas as they are plausible beliefs proximity to his death, and that the psychotic
which have come to dominate her life. content features her husband.
2. K. Musculoskeletal injury. Note the distribution
Differentiating types of repetitive or intrusive of injuries and given the fact he was a driver
thoughts (in the UK, the driver’s seatbelt crosses the
1. B. Obsession. The patient knows the images right shoulder) this is likely to be a whiplash/
originate from their mind and is trying to resist seatbelt-related injury. There is no suggestion of
(see Table 13.1). psychogenic origin in this case.
2. F. Over-valued idea. The fear of infection is logical 3. B. PTSD is the likely diagnosis in this case. Note the
but held with undue importance. It is not an hyperarousal, avoidance and nightmares. Also
obsession as it is not viewed as abnormal or note the persistent duration of the symptoms.
resisted (see Table 13.1). 4. J. These symptoms are fairly typical of temporal
3. C. Rumination (see Table 13.1). lobe epilepsy. Note the history of likely head
4. D. Pseudohallucination (see Table 13.1). injury (implied by the fact she was referred from
5. E. Hallucination (see Table 13.1). the neurosurgical unit). She should be referred
6. H. Thought insertion (see Table 13.1). for electroencephalogram.
7. G. Delusion (strictly, a delusional perception). This
belief is fixed, was arrived at illogically, and is not Chapter 15 The patient with medically
amenable to reason. The patient experienced a unexplained physical symptoms
normal perception but interpreted it with delusional
Diagnosis of medically unexplained physical
meaning, termed a ‘delusional perception’. This is
symptoms
a first rank symptom of schizophrenia.
1. B. Body dysmorphic disorder.
2. A. This is highly suggestive of Munchausen
Chapter 14 The patient with a reaction to a
syndrome by proxy. The safety of the child
stressful event should be the immediate concern.
Dissociative disorders 3. E. This is a first rank symptom of schizophrenia.
1. D. This woman appears to be suffering from functional 4. I. Psychotic depression (Cotard syndrome).
seizures. This is suggested by the chronological 5. H. Malingering. While more information would
association with a significant stressor (being told ideally be required, this scenario is suggestive of
that she will be left alone when her husband starts malingering.
work). These are often more common in those with
a family or personal history of epilepsy.
Chapter 16 The patient with eating or weight
2. G. This is a classic presentation of a dissociative
problems
fugue, or ‘fugue state’. The man is unable to
recount any personal details and appears to Psychiatric causes of low weight
have travelled from a distant city. Note the 1. A. This man with schizophrenia may not be able
possible severe stressor of being involved with a to look after himself due to negative symptoms
company that has recently been bankrupted. of schizophrenia impairing his motivation and
3. B. Dissociative anaesthesia. This is suggested by executive function. His mother may have
the chronological association with a significant been providing substantial support with meal
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EMQ answers
preparation. He needs a functional assessment 3. A. Paranoid personality disorder.

by an occupational therapist. It is also important 4. F. Narcissistic personality disorder.
to exclude depression, alcohol or substance 5. I. Avoidant (anxious) personality disorder.
misuse, or psychotic symptoms as an
General feedback: see Table 17.1
alternative cause for his weight loss.
2. D. Even though he has told you that he is fine, it is Traits of personality disorder
likely that he is suffering from bulimia nervosa.
1. E. Over-concern with physical attractiveness.
Both hypokalaemia and swollen parotid glands
2. C. Consistent preference for solitary activities.
can be caused by excessive vomiting. The
This differs from avoidant (anxious) personality
hypokalaemia is probably responsible for the U
disorder in that the latter tend to avoid social
waves on the ECG.
activities for fear of rejection or criticism, while
3. I. This girl describes classic obsessive-
the former appear to lack any real desire for
compulsive symptoms: obsession (fear of
social activities.
infection); compulsion (having to prepare food
3. D. Perfectionism that interferes with task
in a specific manner), with awareness that it is
completion.
irrational, but severe anxiety if the compulsion
is not used to ‘cancel out’ the obsession. 4. B. Excessive sensitivity to setbacks and rebuffs.
4. B. Despite this woman’s history of anorexia 5. G. Allowing others to make the most of one’s
nervosa, her current presentation is not important life decisions. Note that ‘Frantic
suggestive of relapse. She appears to have efforts to avoid real or imagined abandonment’
developed a specific phobia (with panic attacks) is a trait of borderline personality disorder. A
of vomiting, which has probably resulted from trait of dependent personality disorder is the
her recent physical illness (norovirus, the ‘winter preoccupation with being abandoned rather than
vomiting bug’). The link between the two could the frantic attempts to avoid it. Be aware that the
be understood as an example of psychological disorders commonly overlap or exist together.
‘conditioning’. General feedback: see Table 17.1
5. G. The cause of weight loss in this case does not
suggest any concern with body shape. Instead, Chapter 18 The patient with
this man appears not to be eating food because
neurodevelopmental problems
of a delusional belief that the food would be
poisoned. He is suffering from an acute psychotic Functional estimation of IQ in intellectual
episode. More information is needed to make disability
a diagnosis of schizophrenia or psychotic 1. D. This lady has a mild intellectual disability and
depression. Assessing for substance use is crucial. will have an estimated IQ of 50–69. Individuals
in this group represent the majority (85%) of all
Physical consequences of eating disorders people with intellectual disabilities.
1. A. Lanugo 2. A. From the information given, this gentleman
2. B. Caries manages to live alone without support. His
3. E. Onychorrhexis symptoms suggest that he may suffer from an
autism spectrum disorder. His interests would
4. J. Striae distensae
suggest that he has above-average intelligence
5. D. Russell’s sign (IQ > 100).
General feedback: xerosis is dry skin, alopecia areata 3. G. This boy has a profound intellectual disability (IQ
is spot baldness and acrocyanosis is blueness of the < 20). He is unable to care for himself and fully
extremities. All of these signs can occur in anorexia dependent on the support of others.
nervosa. Cheilitis is inflammation of the lips, which 4. E. This woman has a moderate intellectual
can occur in bulimia or anorexia when associated with disability (IQ 35–49). She is able to live on her
vomiting own, albeit in a supported housing complex
with a great deal of support.
Chapter 17 The patient with personality 5. F. This gentleman has a severe intellectual
disability (IQ 20–34). He lives with his family,
problems
who are his main carers and is able to perform
Diagnosis of personality disorder simple tasks under supervision. His self-care
1. G. Histrionic personality disorder. skills are limited, but sometimes he seems able
2. H. Dependent personality disorder. to contribute to these.
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EMQ answers
Differential diagnosis in adults presenting for 4. B. Rivastigmine. This is the cholinesterase inhibitor
attention deficit hyperactivity disorder (ADHD) with the best evidence for maintaining cognition
assessment in Parkinson disease with dementia and Lewy
1 B. Bipolar affective disorder. Her symptoms body dementia, although other cholinesterase
may represent hypomanic episodes. ADHD inhibitors are also of benefit.
is excluded by the episodic nature of the 5. I. No treatment recommended by current
symptoms. A urine drug screen would be helpful guidelines. Unfortunately, no medications have
to support her report of no substance abuse. yet been found to slow the progression of
2 J. Substance abuse, harmful. His behaviour while frontotemporal dementia.
not under the influence of substances for a period
of at least six months needs to be assessed Chapter 20 Alcohol and substance-related
before a diagnosis of ADHD can be considered. disorders
Cocaine use may well lead to making careless
mistakes at work. His history of possibly having Pharmacological management of opioid
ADHD symptoms from childhood is not relevant dependence
unless he has on-going symptoms now. 1. A. It is likely that this man has overdosed on
3 C. Depressive episode. The acute onset of these intravenous opioids, leading to respiratory
symptoms excludes ADHD. Irritability and depression and a reduced consciousness level.
psychomotor agitation are common in depression. Naloxone is an opioid antagonist and needs to
4 A. ADHD. A fuller history would be needed to be given to reverse toxicity. Naltrexone is also
make this diagnosis definitive. However, ADHD an opioid antagonist, but it needs to be given
is suggested by his problems with impulsivity orally so is not suitable for someone with a low
and inattention present during childhood and GCS (risk of aspiration).
adulthood. Dissocial personality disorder is 2. E. Lofexidine can be helpful in reducing the
unlikely as the assault sounds impulsive and he unpleasant symptoms of opioid withdrawal.
is now regretful of this. It would not be advisable to prescribe
5 I. Traumatic brain injury. This would need to be benzodiazepines to someone who already has
confirmed by checking the details of his injuries substance dependence.
in the road traffic accident. ADHD is excluded 3. H. While methadone, buprenorphine and
by the lack of significant difficulties prior to the dihydrocodeine are used as substitution therapy,
accident. He may be suffering neuropsychological this lady’s heavy use of heroin means that she
sequelae post damage to his frontal lobes. is likely to have severe withdrawal symptoms.
As a partial opioid agonist, buprenorphine is
likely to precipitate a withdrawal state given the
Chapter 19 Dementia and delirium magnitude of her usage. There is some evidence
Management of dementia to suggest that dihydrocodeine can be as
1. A. Donepezil. This woman has mild to moderate effective as methadone. However, because it is
dementia for which cholinesterase inhibitors are in tablet form, it is easier to divert and its use is
recommended. Donepezil is first line. therefore not widespread. Levacetylmethadol is a
2. D. Memantine. This woman has severe dementia synthetic opioid similar to methadone, which is no
for which memantine is recommended. longer prescribed due to dangerous arrhythmias.
3. D. Memantine. This woman has mild to moderate 4. G. This man could benefit from loperamide, which
dementia for which cholinesterase inhibitors are is a mu-opioid receptor agonist that acts only
recommended. However, she has a number in the large intestine to reduce gut motility (and
of relative contraindications to cholinesterase hence diarrhoea).
inhibitor use. Their cholinergic effects can 5. F. Naltrexone is an opioid receptor antagonist that
induce bradycardia, which may be particularly can be used to reduce the euphoric effects of
problematic in those with conduction defects. opioids. Naloxone would also have this effect,
Similarly, cholinergic drugs can cause but it needs to be given parenteral and is short-
bronchoconstriction, which may be problematic acting, and therefore naltrexone is preferred.
in COPD and asthma. Cholinergic drugs can
Prochaska and DiClemente Transtheoretical
also increase gastric acid secretions, which
Model of Change
could worsen peptic ulceration. Overall, it would
probably be better to try memantine first for this 1. C. Preparation.
woman. 2. G. Termination.
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EMQ answers
3. A. Precontemplative. 3. E. Quetiapine. From the options given, haloperidol,

4. E. Contemplative. risperidone and chlorpromazine are most likely
5. B. Relapse. to be associated with extrapyramidal side-
effects. Aripiprazole is less associated with
General feedback: see Fig. 20.3
extrapyramidal side-effects, but quetiapine has
an even lower likelihood. Flupentixol is a depot
Treatment of alcohol dependence medication and the majority of patients prefer
1. B. Lorazepam. Given that benzodiazepines are oral. Clozapine is not indicated as the patient is
metabolized in the liver and that impaired liver not treatment resistant.
function can delay metabolism and excretion, 4. C. Flupentixol depot formulation. Long-acting
drugs with a long half-life can accumulate and intramuscular injections (depot formulations)
increase the risk of toxicity. From the three administered 1–12 weekly are a good option for
benzodiazepines listed, lorazepam has the patients with poor concordance.
shortest half-life and is therefore safest to use
5. D. Clozapine. This woman has treatment-resistant
for detoxification in this case. Oxazepam is
schizophrenia as she has had two trials of
often used for the same reason.
antipsychotic at adequate doses for adequate
2. E. Thiamine. From the history given, this lady is not durations, including at least one second-
intoxicated. She appears to be suffering from generation drug.
the triad of symptoms associated with Wernicke
encephalopathy and needs urgent treatment with Presentation of antipsychotic side-effects
parenteral thiamine.
1. C. Hypersalivation. This is most commonly seen
3. H. CBT, focusing on identifying cues and with clozapine. Most antipsychotics cause a dry
preventing relapse, could be very helpful for mouth.
this lady. Motivational interviewing, with a focus
2. B. Postural hypotension. This is a side-effect of
on ‘promoting change’, may not be so useful
most antipsychotics, secondary to adrenergic
as she is already abstinent. Psychoeducation
receptor blockade.
tends to happen in groups and because she
3. J. Hyperprolactinaemia, causing galactorrhoea.
is not keen on this, there is a risk of early
This is a side-effect of most but not all
disengagement.
antipsychotics, secondary to D2 receptor
4. I. Acamprosate may be helpful in reducing
blockade in the tuberoinfundibular pathway.
cravings. Naltrexone is also thought to reduce
4. E. Agranulocytosis. Without monitoring, this
cravings, but it is likely to reduce the efficacy of
is seen in just under 1% of patients taking
the tramadol.
clozapine.
5. A. Alcoholics Anonymous is a 12-step mutual
5. G. Akathisia. This is frequent purposeless movement
programme that could be useful for this man.
associated with a subjective inner restlessness.
It is not run by health services, and consists
It is very unpleasant for patients, and a risk
of self-funded groups. Their ethos is one of
factor for suicide. It is a side-effect of most
complete abstinence and their system of peer
antipsychotics and some other psychotropics
support (or ‘sponsorship’) can be very beneficial
also. High doses are a risk factor.
for some.
Chapter 22 The mood (affective) disorders

Chapter 21 The psychotic disorders:
Treatment setting for depression
schizophrenia
1. A. Admission to psychiatric hospital. This man is
Antipsychotic choice in schizophrenia at high risk of suicide because of his age, sex,
1. B. Haloperidol. Although haloperidol is not first violent method of planned suicide, final acts
line for schizophrenia, patient preference is and mental disorder. The extremely high suicidal
important in the choice of antipsychotic. She intent indicated by the circumstances of his
should have an electrocardiogram before presentation means hospital admission is the
recommencing as haloperidol can prolong the only safe management option.
QTc. 2. D. Refer to psychiatric outpatients routinely.
2. F. Aripiprazole. This is the antipsychotic least A psychiatric referral is advisable given his
likely to be associated with weight gain and treatment-resistant depression. There is no
the metabolic syndrome. First-generation suggestion of acute risk to necessitate an
antipsychotics would be the next best choice. urgent referral.
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EMQ answers
3. F. Refer to crisis team. Even without evidence 3. D. Eye movement desensitization and reprocessing
of risk to self or others, psychotic features are therapy. This or trauma-focused CBT is
suggestive of a very severe depression that recommended for all severities of PTSD where
could worsen rapidly. the trauma occurred more than 4 weeks ago.
4. A. Admit to psychiatric hospital. This man has 4. F. SSRI. Mirtazapine or paroxetine are
depression with poor oral intake. This is not recommended as first-line medications for PTSD.
manageable in the community. He needs an 5. G. TCA. Amitriptyline (a tricyclic antidepressant)
urgent physical examination and blood samples and phenelzine (monoamine oxidase inhibitor)
evaluation. If his renal function is acutely impaired, are second-line drug therapies for PTSD.
he may need transfer to a general hospital for
intravenous fluids. If this man is in a general Management of generalized anxiety disorder and
hospital at the time of mental health assessment, panic disorder
he should be physically assessed prior to transfer. 1. C. CBT. First-line therapy for moderate to severe
5. C. Manage in primary care. The next step for panic disorder is CBT.
this man is to consider a higher intensity 2. A. Self-help. First-line therapy for mild panic
psychological intervention or an antidepressant. disorder is self-help materials.
First-line antidepressants 3. E. Applied relaxation. This and CBT are the two
psychological therapies recommended for
1. D. Mirtazapine. SSRIs increase risk of bleeding
moderate to severe generalized anxiety disorder.
when coprescribed with nonsteroidals and
anticoagulants. Mirtazapine is suggested as 4. F. SSRI. First-line drug therapy for moderate to
an alternative first-line antidepressant by NICE severe generalized anxiety disorder is an SSRI.
(2009). 5. I. Pregabalin. This is a second-line drug therapy
2. A. SSRI. NICE (2009) recommends SSRIs as first- for moderate to severe generalized anxiety
line antidepressants if there are no cautions. disorder.
3. A. SSRI. NICE (2009) recommends SSRIs as first-
line antidepressants. Sleep disturbance often Chapter 24 Eating disorders
resolves as depression improves. A more sedating Treatment strategies for patients with eating
antidepressant such as mirtazapine would be a disorders
good second-line option. 1. J. Informal admission to general psychiatric ward.
4. D. Mirtazapine. Although first line, SSRIs often It would appear that this lady has developed a
cause sexual dysfunction. If avoidance of comorbid depressive illness. Her eating appears
this side-effect is very important to patients, to have been improving. Therapeutic priority
an alternative such as mirtazapine can be should be given to managing her depressive
considered. symptoms and her high risk of completing
5. C. Duloxetine. Duloxetine is licensed for both stress suicide. From the options listed, the most
incontinence and depression. It is a joint serotonin appropriate would be an informal admission to
and noradrenaline (norepinephrine) reuptake a general psychiatric ward. Outpatient or home
inhibitor. This action in the spinal cord leads to treatment may be considered; however, given
increased tone in the urethral sphincter. It would the levels of risk involved, admission to hospital
be reasonable to try to avoid polypharmacy by would probably be more appropriate.
using one drug to treat both problems. 2. E. NICE recommends cognitive-behavioural therapy
as the first-line intervention for bulimia nervosa.
Chapter 23 The anxiety and somatoform Initially, this should be delivered via guided self-
help but if this is ineffective or inappropriate, then
disorders
therapist-guided individual cognitive-behavioural
Management of posttraumatic stress disorder therapy is recommended.
1. D. Eye movement desensitization and 3. K. This girl is incredibly unwell, and her current
reprocessing therapy. This or trauma-focused physical condition poses a threat to her life.
CBT is recommended for moderate to severe By virtue of her mental illness, and probably
PTSD even if the trauma occurred less than also her state of malnutrition, she clearly lacks
4 weeks ago. capacity to make decisions regarding her
2. B. Watchful waiting. This is recommended for healthcare. Immediate hospital treatment is
symptoms of mild PTSD within 4 weeks of the required, and she should be transferred urgently
trauma. under mental health legislation. In addition,
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EMQ answers
given her persistent refusal to eat, and her least likely to be associated with sexual
lack of capacity and insight, it is likely that side-effects.
involuntary nasogastric feeding will be required 2. E. Propranolol. Antihypertensives including β-
to save her life. This is both a clinically and blockers can result in erectile dysfunction.
medicolegally difficult situation and should be 3. G. Ropinirole is a dopamine agonist. Paraphilia is a
managed by a specialist. rare side-effect of dopamine agonists.
4. E. Cognitive-behavioural therapy (eating 4. I. Trazodone. Priapism is a very rare side-
disorder focused). This is one of the first-line effect of any drug which blocks α-adrenergic
psychological therapies recommended by receptors.
NICE (2017) for managing anorexia. Although
this women’s difficulties with relationships
may suggest interpersonal therapy, this is not Chapter 27 Disorders relating to the
currently recommended for management of
menstrual cycle, pregnancy and the
eating disorders.
5. G. Family therapy; This boy lives in a family in puerperium
which both parents are high-achievers, and Management of mental illness in the puerperium
subsequently feels pressured to live up to their 1. C. This woman may benefit from maternal skills
expectations. Family therapy is likely to be teaching. The health visitor can be an invaluable
useful in this case and is the first-line treatment resource for providing this.
recommended by NICE (2017) for anorexia in 2. E. This woman appears to be suffering from the
adolescents. ‘baby blues’. Simple reassurance should be
given. This will likely pass after 10 days or so,
Chapter 25 The sleep–wake disorders but follow-up is important to ensure that she is
not developing postnatal depression.
Diagnosis of sleep–wake disorders
3. F. This woman appears to be developing a
1. I. REM sleep behaviour disorder. This commonly
puerperal psychosis. Given her symptoms,
presents in middle-aged men. Details of the
the use of an antipsychotic medication is
dream are recalled. It is closely linked with
indicated. Olanzapine is widely used for
synucleinopathies.
puerperal psychosis. Electroconvulsive therapy
2. G. Non-REM sleep arousal disorder. Sleepwalking may be required if she does not respond to
and sleep terrors are both subtypes of nonpharmacological treatment. These interventions
REM sleep arousal disorders. Sufferers are would need to be delivered on an inpatient
disorientated on waking. The two subtypes are basis, preferably in a mother-and-baby
closely linked and run in families. psychiatric unit.
3. J. Sleep-related breathing disorder. This increases 4. H. This woman is likely to have a severe postnatal
the risk of road traffic accidents several fold. depressive illness. Given her presentation
Obesity increases risk for it, and hypertension and her poor oral intake, her illness should be
can arise as a consequence. His wife’s considered to be potentially life-threatening.
account of snoring is suggestive of upper Electroconvulsive therapy should be
airway obstruction, but he would need further considered.
investigation to confirm the diagnosis.
5. B. This woman is likely to be suffering a depressive
4. C. Insomnia secondary to psychiatric disorder. This episode with some functional impairment
history is suggestive of mania, likely secondary suggesting it is of moderate severity. The
to bipolar disorder. National Institute for Health and Care Excellence
5. F. Narcolepsy. This history is suggestive of (NICE; 2014) recommends she should be
cataplexy. Intrusive daytime sleepiness is the offered antidepressant medication or a high-
other core symptom of narcolepsy. intensity psychological intervention (e.g.,
cognitive-behavioural therapy). Should she wish
to start an antidepressant, sertraline is a good
Chapter 26 The psychosexual disorders
choice as very little is excreted in breast milk.
Medication associated with psychosexual Doxepin should be avoided in breastfeeding
disorders mothers but in general tricyclics are probably
1. B. Fluoxetine. Selective serotonin reuptake safe in breastfeeding. She may also benefit
inhibitors are commonly associated with from referral to the health visitor for support with
anorgasmia. Mirtazapine is the antidepressant breastfeeding.
324
EMQ answers
Psychotropic medication in pregnancy 2. C. Informal, time-limited admission to psychiatric

1. I. Both carbamazepine and sodium valproate are ward. She is clearly distressed and—in the
associated with the development of neural tube short term—at incredibly high risk of completing
defects. It is not recommended to prescribe suicide or otherwise harming herself. It would
carbamazepine or sodium valproate to women of also appear that there is no safe place to
childbearing age, and less teratogenic alternatives which she could be discharged. A short ‘crisis’
should be considered. If it is considered admission to a psychiatric ward, of agreed
absolutely necessary (e.g., treatment-resistant duration and with clear goals and boundaries,
mania), reliable contraception is essential. would allow for her distress and short-term
risk to be managed, and longer-term support
2. B. Olanzapine is associated with an increased
organized. Discharging her to police custody is
risk of gestational diabetes. It should be
not appropriate.
prescribed with caution in all pregnant women,
and alternatives should be used in women 3. H. It may be worth offering this gentleman
who are already at increased risk of gestational a trial of antipsychotic medication. While
diabetes (e.g., obesity, gestational diabetes psychotherapeutic measures would be more
during previous pregnancy, strong family history likely to be effective in the long term, he
of diabetes). In any case, blood and/or urinary appears to be untrusting of services, and it
glucose should be regularly monitored. would be unlikely that he would engage with
this. A small dose of an antipsychotic may be
3. F. The use of lithium during pregnancy has been
enough to reduce his paranoia to the extent
associated with an increased risk of fetal heart
that he may engage with a psychotherapist and
defects, including but not limited to Ebstein
may also provide a reason for ongoing contact
anomaly (displacement of the opening of the
with doctors such that trust and rapport can be
tricuspid valve). Cardiac abnormalities occur in
established.
around 1 in 100 live births, increasing twofold
to 2 in 100 live births in children exposed to 4. A. Weekly dispensing. Depression arising in
lithium. There is a dose–response effect, with patients with personality disorders can be
higher doses associated with greater risk. This amenable to drug treatment; however, the
risk needs to be balanced against the risk of benefits of this need to be balanced with the
relapse of illness associated with discontinuation risk of overdosing on potentially harmful drugs.
of lithium, as untreated affective/psychotic illness Antidepressants dispensed on a weekly/twice-
can place the fetus at greatly increased risk. weekly/three times weekly/daily basis can, to
some degree, modify this risk.
4. H. A class effect of selective serotonin reuptake
inhibitors taken in the third trimester is an 5. I. This gentleman could benefit from lifestyle
increased risk of persistent neonatal pulmonary advice. His situation has recently changed,
hypertension (absolute risk increased from 1 in which may explain his increased anxiety.
1000 to 3 in 1000 live births). This needs to be However, it is likely that his caffeine
balanced against the risk of untreated anxiety or consumption is contributing to his insomnia,
depression on the developing fetus. and that smoking cigarettes all night is
perpetuating the problem. Advice regarding
5. F. Lithium. Lithium levels should be checked
caffeine, nicotine, diet and exercise should be
every 4 weeks during pregnancy. Physiological
given in the first instance.
changes during pregnancy mean doses have to
be increased on average by 50% during the third
trimester to remain within the therapeutic range. Chapter 29 The neurodevelopmental
disorders
Chapter 28 The personality disorders Psychosocial interventions in
Management of patients with personality neurodevelopmental disorders
disorders 1. F. Parent-training/education programme is first line
1. F. Encourage to engage with existing care plan. for children of school age.
Patients with dependent personality disorder 2. E. Nil recommended. Although cognitive-
can quickly become institutionalized, and behavioural therapy may be helpful in adults
alternatives to admission should be preferred. with ADHD, particularly in those with residual
In this case, the lady should be empathically symptoms after medication, there is insufficient
reassured, and encouraged to engage with her evidence for NICE to currently recommend its
occupational therapist. standalone use as first line.
325
EMQ answers
3. G. Play-based social–communication intervention. of stopping a short-acting benzodiazepine

First-line intervention for children of school age (e.g., lorazepam) or up to 3 weeks for a longer
with ASD. acting drug (e.g., diazepam). Symptoms include
4. H. Social learning program. First-line intervention insomnia, anxiety, anorexia, tremor, perspiration,
for adults with ASD. tinnitus and perceptual disturbances. such as
5. D. Habit control. Psychoeducation, habit control this woman’s visual illusion.
or exposure and response prevention are 2. H. Fluoxetine. All antidepressants, but particularly
recommended first line for Tourette syndrome. selective serotonin reuptake inhibitors, can be
associated with the syndrome of inappropriate
secretion of antidiuretic hormone, leading to
Chapter 30 Child and adolescent psychiatry hyponatraemia. This is particularly likely in older
Diagnosis of psychiatric disorders with onset in adults.
childhood or adolescence 3. A. Lithium. Lithium can induce nephrogenic
1. A. Academic setting inappropriate to ability. While diabetes insipidus, leading to hypernatraemia if
many of the behaviours are suggestive of fluid intake cannot be maintained, e.g., due to
the core symptoms of ADHD, note that they diarrhoea and vomiting. Dehydration increases
appear to be limited to the academic setting (he the risk of lithium toxicity (which is renally
appears fine at home). ADHD is pervasive rather excreted) so a random lithium level should also
than situational, and this case is suggestive be urgently checked for this man.
that the boy may be having difficulties with 4. J. Haloperidol. This man is likely to have received
schoolwork (either because it is too difficult or haloperidol to manage his delirium. Haloperidol
too easy). can cause prolongation of the QT interval. In
2. G. Oppositional defiant disorder is similar extreme cases this can lead to torsade de
to conduct disorder in that behaviour is pointes. Olanzapine is less likely to have this
negativistic, rebellious, defiant and disruptive. side-effect.
However, unlike conduct disorder, the behaviour 5. G. Amitriptyline. Anticholinergic medication is a
associated with oppositional defiant disorder big risk factor for delirium. Amitriptyline is often
does not violate the rights of others and prescribed for neuropathic pain.
troubles with the law are less common.
3. H. Reactive attachment disorder. This is
suggested by the child’s history of abuse,
Chapter 32 Forensic psychiatry
marked fearfulness and social withdrawal. The Diagnosis of mental disorder in offenders
diagnosis is not child abuse alone, as not all 1. A. This man has delusional jealousy. He is
children who are abused respond in this way or convinced that his partner is being unfaithful,
go on to experience mental disorder. despite extensive reassurances and evidence
4. I. Separation anxiety disorder. This is suggested to the contrary. The name ‘Othello syndrome’
by the child’s fear of removal from a major is derived from the play Othello by William
attachment figure, triggered by a time apart. Shakespeare, in which the protagonist murders
She is more anxious about this than would be his wife (Desdemona. which means ‘the
expected of a 10-year-old. She is experiencing unfortunate’ in Greek). Othello syndrome is
somatic symptoms of anxiety. associated with alcohol misuse and violence.
5. F. Elective mutism. This is suggested by the child’s Treatment includes antipsychotic medication
normal language development and ability to and psychotherapy; however, given the very
speak in some situations. Elective mutism often poor prognosis, it is often said that the most
follows emotional trauma (such as separation effective treatment is ‘geographical’ (i.e.,
from parents, war, severe illness) and situations relocation of the spouse to a distant area).
where there is conflict at home. 2. K. The symptoms present in this man (delusions
and hallucinations) are suggestive of a paranoid
psychotic state. Given his age, the implied rapid
Chapter 31 Older adult psychiatry onset of symptoms and the fact that he has no
Adverse drug reactions in older adults receiving psychiatric history, this is unlikely to be a first
psychotropic medication presentation of paranoid schizophrenia. The fact
1. C. Diazepam. Abruptly discontinuing that he has been at a music festival should be
benzodiazepines can result in withdrawal a pointer that substances may be implicated in
symptoms. These can have onset within a day his presentation. His symptoms are not typical
326
EMQ answers
of an alcohol-withdrawal delirium; however, this a crime of such magnitude is strongly suggestive

is an important differential. of dissocial/antisocial personality disorder. It
3. D. This lady is likely to be suffering from a manic could be that the man also scores highly on the
illness. She has grandiose delusions (that she Hare Psychopathy Checklist Revised (the ‘gold
is a pop star). Note that she has recently been standard’ for assessing psychopathy). Further
hospitalized with a depressive illness: her mania assessment would be required to confirm this
may be associated with drug treatment or may diagnosis.
signify the presence of a bipolar illness. Crimes 5. J. There is an association between fire-setting
related to mania include financial offences and and mild intellectual disability. This should be
occasionally aggression. differentiated from arson (deliberate fire-raising
4. C. The nature of this crime (killing a man in retribution for secondary gain, e.g., insurance money),
for a mistake in making a sandwich) is alarming. pyromania (compulsion to set fires, followed
The fact this man has an extensive forensic by a ‘release of tension’), wilful destruction of
history, is actively involved with organized crime property (e.g., in antisocial personality disorder)
and appears cold and emotionless in the face of or fire-setting driven by other mental disorders.
327
Glossary
Affect Affect refers to the transient ebb and flow of Derealization Derealization is feeling that external reality
emotion in response to particular stimuli, for example, is strange or unreal.
smiling at a joke or crying at a sad memory. It is assessed Depression A depressed mood is when a patient describes
by observing the patient’s posture, facial expression, feeling depressed, sad, dejected, despondent or low. A
emotional reactivity and speech. The two components that depressive disorder is a specific psychiatric condition
should be assessed are the appropriateness of the affect and diagnosed if the mood change is sufficiently severe and
its range. See Chapter 1. chronic and occurs with other symptoms.
Anxiety Anxiety is a mood state. It is a response to an Dissociation Dissociation is an altered state of
unknown, internal or vague threat. This is distinct from consciousness in which normally integrated experiences
fear, which is defined later. The experience of anxiety or processes are disrupted. For example, walking to work
consists of both apprehensive or nervous thoughts and the on ‘autopilot’ and not noticing a new shop front – the
awareness of a physical reaction to anxiety. See Chapter 12. sensory information has not been integrated with the
Attempted suicide An episode of deliberate self-harm, conscious experience. Depersonalization and derealization
which did not end in death but was driven by suicidal are dissociative symptoms (see definitions above). Extreme
intent. This is in contrast to episodes of nonfatal deliberate dissociative states can be associated with disorders
self-harm driven by other motivations. See Chapter 6. including non-epileptic seizures and fugue. See Chapter 14.
Capacity Capacity is the ability of an individual to make Dysphasia Dysphasia is an impairment of language
their own decisions. See Chapter 4. abilities despite intact sensory and motor function. See
Circumstantiality Circumstantiality describes over- Chapter 7.
inclusive speech that is delayed in reaching its final goal. Dyspraxia Dyspraxia is an impairment of the ability to
This is because of excessive detail and diversion. However, carry out skilled motor movements despite intact motor
the final goal will be reached, which distinguishes it from function. See Chapter 7.
flight of ideas. Circumstantiality can be found in the Dysgnosia Dysgnosia is an impairment in the ability to
normal population but is increased in anxiety disorders interpret sensory information despite intact sensory organ
and hypomania. See Chapter 9. function. See Chapter 7.
Compulsions Compulsions can be defined as repetitive Echolalia Echolalia is when a patient senselessly repeats
mental operations (such as counting) or physical acts (such words or phrases that have been spoken near them. It
as checking) that a patient feels compelled to perform can be viewed either as a form of disorganized thinking
in response to their own obsessions. The motivation for or as an abnormality of speech. It occurs in a range of
compulsions is the reduction of anxiety generated by an psychiatric conditions such as schizophrenic catatonia,
obsession. The compulsion may be either unrelated to the autism and dementia.
preceding obsession (e.g., counting) or an unnecessarily Fear Fear, similar to anxiety, is an alerting signal in
excessive response to the obsession (e.g., handwashing). response to a potential threat. It differs from anxiety in
See Chapter 13. that it is a response to a known, external or definite object.
Delusion A delusion is the most severe form of an Anxiety and fear are discussed on Chapter 12.
abnormal idea. It is a fixed belief arrived at illogically and First-rank symptoms First-rank symptoms were
is not amenable to reason. It is not accepted in the patient’s described by Schneider who suggested that the presence of
cultural background. The presence of a delusion signifies a one or more first-rank symptoms, in the absence of organic
psychotic disorder. See Chapter 9. disease, was sufficient to diagnose schizophrenia. These
Delusional perception Experiencing a normal perception symptoms still feature strongly in modern diagnostic
but interpreting it with delusional meaning. For example, criteria for schizophrenia. See Chapter 9.
‘I heard the clock chime and I knew that meant the aliens Flight of ideas Flight of ideas can be described as either
were planning to kill me’. This is a first-rank symptom of a disorder of thought form or an abnormality of speech.
schizophrenia. See Chapter 9. It describes thinking that is markedly accelerated and
Depersonalization Depersonalization is feeling yourself results in a stream of loosely connected concepts. The link
to be strange or unreal. between concepts can be normal, tenuous or through puns
329
Glossary
and clanging. It differs from circumstantiality in that the symptoms, which may lead patients to believe that they are
links between concepts are more tenuous and the final goal dying, having a heart attack or going mad. See Chapter 12.
is less likely to be reached. In its extreme form, speech can Paranoia Paranoia has a range of meanings. Strictly it
become unintelligible or approach the incoherent thought means that someone is falsely relating things to themselves
disorder of schizophrenia. See Chapter 9. [e.g., fears that someone wishes to harm them (persecutory
Functional symptoms Functional symptoms are delusions, feelings that the TV/radio/Internet is specifically
physical symptoms without identifiable physiological designed to communicate with them (delusions of
or structural cause. They may arise due to dysfunction reference)]. It is used by lay people to mean that someone
of high-level cortical processing of motor and feels persecuted or at risk ‘I’ve felt awfully paranoid
sensory information. They are genuinely experienced, recently, I don’t feel safe outside’. Paranoid schizophrenia is
involuntary and not necessarily related to past or current a subtype of schizophrenia.
trauma. See Chapter 14. Perseveration Perseveration is when a patient
Hallucination Hallucinations are perceptions that occur inappropriately repeats an initially correct action. For
in the absence of external stimuli and are indistinguishable example, unnecessarily repeating a word or phrase, or
from normal sensation. See Chapter 9. applying the rules of one task to a second task.
Illusion Illusions are misperceptions of real external Pseudohallucinations Pseudohallucinations are
stimuli. For example, spots on the carpet are perceived as perceptions that occur in the absence of external stimuli
insects. Illusions can occur in healthy people particularly but are experienced in the internal world rather than the
when tired, not concentrating, experiencing strong external world. For example, hearing a voice ‘inside my
emotions or intoxicated with substances. head’. See Chapter 9.
Insight Insight describes a patient’s understanding of Psychosis Psychosis is the presence of hallucinations,
the nature and degree of his or her mental illness and the delusions or thought disorder.
recognition of the need for treatment. An assessment of Psychotherapy Psychotherapy is an umbrella term
insight is an integral part of the mental state examination. for psychological or talking therapy. There are a large
See Chapter 1. number of psychological therapies; the most common
Mood Mood is sustained emotion over a period. This ones include supportive therapy, cognitive-behavioural
differs from a ‘feeling’, which is a short-lived experience, and therapy, psychodynamic psychotherapy, family therapy
‘affect’, which is the external expression of transient emotion. and group therapy. It is sometimes used to refer to a
Neologism Neologism is an example of disorganized subtype of psychological therapies only: psychodynamic
thinking. It is a new word created by the patient, often psychotherapy and psychoanalysis.
combining syllables. It is classically associated with Psychotropic medication Psychotropic medication
schizophrenia and can also occur in organic brain disorder. influences cognition, mood or behaviour. All medications
They also arise in popular culture, for example, ‘webinar’ used to treat psychiatric disorders are psychotropic.
(a seminar on the Web) or ‘staycation’ (staying at home for Rumination Repeatedly thinking about the causes and
a vacation). experience of previous distress and difficulties. Voluntary
Obsession An obsession is an involuntary thought, image thinking which is not resisted.
or impulse, which is recurrent, intrusive, unpleasant and Self-harm Self-harm is a blanket term used to mean
enters the mind against conscious resistance. Patients any intentional act done in the knowledge that it was
recognize that the thoughts are a product of their own potentially harmful. It can take the form of self-poisoning
mind even though they are involuntary and repugnant. (overdosing) or self-injury (cutting, slashing, burning,
See Chapter 13. etc.). See Chapter 6.
Over-valued idea An over-valued idea is an incorrect Suicide Suicide is the act of intentionally ending one’s
belief that is not impossible (in contrast to some own life.
schizophrenic delusions), is held with marked emotional Thought disorder Thought disorder is speech so
investment but not with unshakable conviction. See disorganized that it becomes difficult to understand what
Chapter 9. is meant. The coherency of patients with disorganized
Panic attack Panic attacks are discrete episodes of short- thinking varies from being mostly understandable in
lived (usually less than 1 hour), intense anxiety. They patients exhibiting circumstantial thinking to being
have an abrupt onset and rapidly build up to a peak level completely incomprehensible in patients with a word salad
of anxiety. They are accompanied by strong autonomic phenomenon. See Chapter 9.
330
Index
Note: Page numbers followed by f alcohol abuse (Continued) antidepressant (Continued)

indicate figures, t indicate tables and investigations, 84 schizophrenia, 186
b indicate boxes. management, 175–178 side-effects and contraindications,
pharmacological therapy, 177–178 17–19 (see also individual drugs)
psychosocial interventions, 176–177 antipsychotics, 19
A (see also substance abuse) commonly used, 21t
alcohol dependence, 76–77 history and classification, 21
Abbreviated Mental Test, 69t
alcoholic hallucinosis, 79 indications, 24
abnormal beliefs, 89–90, 101
alcohol-related anxiety disorder, 79–80 mechanism of action and side-effects,
acamprosate (Campral), 177
alcohol related brain damage 22–24, 23t
accelerated thinking, 100
(ARBD), 79b personality disorder, 229
accommodation, 49
alcohol-related cognitive disorders, in pregnancy, 222t
activities of daily living (ADL), 63
78–80 schizophrenia, 185–186
acute stress reaction, 130
alcohol-related disorders, 75–78 side-effects, 186t, 282–283 (see also
AD. See Alzheimer’s dementia
alcohol-related mood disorder, 79 individual drugs)
Addenbrooke’s Cognitive Examination–
alcohol-related psychotic disorder, 79 antisocial personality disorder, 148–149,
III, 69t
Alcohol Use Disorders Identification Test 148t, 228t
ADHD. See attention deficit hyperactivity
(AUDIT), 83 anxiety disorders, 110, 199–202
disorder
alcohol withdrawal, 77–78, 78b, 175–176 aetiology, 199–200
adjustment disorder, 110–111, 130
all-or-nothing thinking, 33t genetic and biological factors, 199–200
adolescents. See child/adolescent psychiatry
Alzheimer’s dementia (AD), 165–166 social and psychological factors, 200
Adults with Incapacity (Scotland) Act
classification, 165 assessment, 120
(2000), 42
cognitive functioning, 169 case study, 115b, 120–121
Advance Decisions, 42
environmental factors, 165–166 child/adolescent psychiatry, 239–240, 239t
adverse drug reactions, 296. See also
genetic factors, 165–166 definitions and clinical features, 115–116
specific drugs
neuropathology, 167t diagnostic algorithm for, 118f
adverse life events, 54
nongenetic factors, 166, 166b (see also differential diagnosis, 116–120, 117b
aetiology, 10, 11t
dementia) epidemiology, 199, 199t
affect, 8, 107
amenorrhoea, 141, 145–146 examination, 120
ageing. See older adults, mental illness in
amitriptyline, 299 generalized, 115–118
age-related physiological changes, 248,
amnesia, 61 history, 120
248t
amnesic syndrome, 68–69, 68b investigations, 120
agitation, 108
anorexia nervosa, 141, 265 management, 200–202, 201f
agoraphobia, 117
aetiology, 205 course and prognosis, 202
airway, breathing, circulation (ABC), 301
epidemiology, 205t drugs, 202
akathisia, 24t
ICD-10 criteria, 142b pharmacological treatment, 202
alcohol abuse, 6, 173–178
management, 206–207, 206f psychological treatment, 201–202
aetiology, 173–175
prognosis, 207, 208b medical conditions and substance abuse,
genetic and biochemical factors,
symptoms, 142 (see also eating 119–120, 120t
173–174
disorders) nonsituational, 117–119
psychological factors, 174
antidepressant older adults, 246–247
social and environmental factors,
bipolar affective disorder, 195 paroxysmal, 115–116
174–175
classification, 15, 17t in perinatal period, 225
assessment, 83–84
depression, 193–194, 193t physical signs, 116b
case study, 73b, 84–85
discontinuation syndrome, 19 psychiatric problems associated with,
complications, 77b
history, 15 119, 119t
course and prognosis, 178
indications, 15 reaction to stress, 119 (see also specific
and crime, 251t
mechanism of action, 15, 16f disorders)
epidemiology, 173, 173f, 173t
older adults, 246, 309–310 anxiolytics/hypnotics
examination, 83–84
personality disorder, 229 benzodiazepines, 26–27
harmful use of, 76
pharmacodynamics, 17t classification, 25, 26t
health risks, 74f
postnatal depression, 224 history, 25
history, 83
331
Index
anxiolytics/hypnotics (Continued) Autism Diagnostic Observation Schedule bizarre delusions, 90

mechanism of action, 26 (ADOS), 243 blackouts, 78–79
in pregnancy, 222t autism spectrum disorder, 159t, 232–233, 266 blood-injection-injury phobia, 301
Z drugs, 26–27 (see also individual aetiology, 232–233 bodily distress disorder, 136
drugs; individual drugs) child/adolescent psychiatry, 239t body dysmorphic disorder, 136–137, 264
apathy, 60t, 63 clinical features, 157, 157t cognitive-behavioural therapy, 203
aphasia, 60t differential diagnosis, 155–157, 156b epidemiology, 203t
apolipoprotein E (ApoE), 165–166 epidemiology, 231t, 232–233 body mass index (BMI), 141, 141b
appearance, 7 history, 160 borderline personality disorder, 148t, 149b,
appetite, loss of, 108 management, 233, 233b 228t, 266, 272
Appropriate Medical Treatment test, 37 psychosocial interventions, 233b management, 227–230, 228–229b
Approved Clinician (AC), 38t automatic thoughts, 32 brain-derived neurotrophic factor
Approved Mental Health Practitioner automatism, 254 (BDNF), 15
(AMHP), 37, 38t avoidant (anxious) personality disorder, breastfeeding, drugs and, 222t
apraxia, 60t 148–149, 148t, 228t breathing-related sleep disorders,
aripiprazole, side-effects, 186t 212–213
aromatherapy, 266
Asperger syndrome, 156
B bulimia nervosa, 142
aetiology, 205
assertive outreach teams, 48 baby blues. See postnatal blues epidemiology, 205t
assessment behaviour, 7–8 ICD-10 criteria, 142b
alcohol abuse, 83–84 behavioural and psychological symptoms management, 206f, 207
anxiety disorders, 120 of dementia (BPSD), 169 prognosis, 208
classification, 12 behavioural experiments, 32 symptoms, 142 (see also eating
cognitive impairment, 69–70 behaviour therapy, 32, 33t disorders)
delusions, 96 beliefs, abnormal. See abnormal beliefs buprenorphine (Subutex), 179t, 180, 267
depression, 111–112 benzodiazepines buspirone, 27
eating disorders, 142–145 abuse, 181
anxiety disorders, 202
examination, 112
fear, 120 behavioural and psychological
C
formulation, 10–12 symptoms of dementia, 169 CADASIL, 166
hallucinations, 96 classification, 25, 26t CAGE questionnaire, 6, 83
history, 4–7 history, 25 CAMHS. See Child and Adolescent Mental
insomnia, 209–211 indications, 26 Health Services
interview technique, 3–4 insomnia, 211 cannabinoids, 80–81t
investigations, 112 mechanism of action, 26 capacity, 41–43
mania/hypomania, 103 personality disorder, 229 carbamazepine, 19–21, 21t, 196
mental state examination, 7–9 in pregnancy, 222t care coordinator, 48
neurodevelopmental disorders, schizophrenia, 186 care programme approach (CPA), 47–48
160–161, 161f side-effects, 26–27 Care Quality Commission, 38t
personality disorder, 149–150 bereavement, 133 cataplexy, 212
physical examination, 10 depression vs., 134t catatonia, 92–93
procedure, 3f Parkes’s stages, 133f catatonic schizophrenia, 94
psychosis, 96–97 beta-amyloid plaques, 165 Categorical classification system, 12
risk, 9–10 binge eating disorder, 145. See also eating CBT. See cognitive behavioural therapy
substance abuse, 83–84. (see also specific disorders cerebral autosomal dominant arteriopathy
conditions) Binswanger disease, 166 with subcortical infarcts and
atomoxetine (Strattera), 234–235 biological/somatic symptoms, 108 leukoencephalopathy (CADASIL),
attachment, 237, 238t bipolar affective disorder, 101–102, 110, 166
attempted suicide, 53, 56 300 Charles Bonnet syndrome, 89, 299–300
attention deficit hyperactivity disorder aetiology, 191f, 195 check blood sugar, 301
(ADHD), 159t, 233–235 child/adolescent psychiatry, 239t, 241 cheese reaction, 18
aetiology, 233–234 course and prognosis, 196 child abuse, 242
case study, 153b, 162 epidemiology, 191t, 194 risk factors, 242t
child/adolescent psychiatry, 239t management, 195–196 child/adolescent psychiatry, 237, 239–243
clinical features of, 159t acute mania/hypomania, 195 anxiety disorders, 239–240
differential diagnosis, 157–158, drugs, 195 assessment, 242–243
158–159b, 289–290 electroconvulsive therapy, 196 attachment, 237, 238t
epidemiology, 231t, 233–234 maintenance treatment, 196 developmental disorders, 239–242
history, 160 pharmacological treatment, 195 elimination disorders, 240–241
management, 234–235 physical health monitoring, 196 epidemiology, 237, 239t
attention, impaired, 63 psychological treatment, 196 social behaviour disorders, 240 (see also
auditory hallucinations, 79, 88–89 treatment setting, 195 specific disorders)
332
Index
Child and Adolescent Mental Health Services community mental health nurses (CPNs), 47 delusions, 9, 89–90, 124t
(CAMHS), 237, 238f, 240–242 community mental health teams, 47 assessment, 96
childhood disintegrative disorder, 156 Community Treatment Order (TCO), bizarre, 90
chlordiazepoxide, 26t 37–38 classification, 90, 91t
chlorpromazine, 21t, 186t complex posttraumatic stress disorder, of control, 91t
cholinesterase inhibitors, 169 130. See also posttraumatic stress grandiose, 91t
circadian rhythm sleep disorders, 212 disorder of infestation, 91t
circumstantiality, 100 compulsions. See obsessive-compulsive of infidelity, 91t
circumstantial thinking, 91 disorder (OCD) of love, 91t
citalopram, 268 compulsory admission, 39t misidentification, 91t
CJD. See Creutzfeldt–Jakob disease compulsory treatment order (CTO), 41 mood-congruent, 90
clomipramine, 202 concentration, reduced, 108–109 nihilistic, 91t
clonidine, 235 concordance, 248 persecutory, 91t
closed questions, 4 conduct disorder, 239t, 240, 272 primary, 90
clozapine, 21, 24b, 186t consciousness, 59, 60f of reference, 91t
co-codamol, 267 impaired, 63 religious, 91t
cognition, 9, 59 consent to treatment, 39 secondary, 90
cognitive analytic therapy, 35t capacity, 41–43 somatic, 91t
cognitive-behavioural formulation, 34f conversion, 137–138 dementia, 63–66, 111
cognitive behavioural therapy (CBT), 32, conversion disorder. See dissociation aetiopathology, 165–168
177, 230, 268 coprophilia, 219t alcohol abuse, 79
anxiety disorders, 200–202 Cotard syndrome, 91t, 246b behavioural and psychological
attention deficit hyperactivity disorder, counselling, 29–30 symptoms, 63–64
234 counter-transference, 30, 32b clinical features, 65t
body dysmorphic disorder, 203 court proceedings, 253–254 cognitive symptoms, 63
child/adolescent psychiatry, 272 criminal responsibility, 253–254 computed tomography, 298–299
depression, 246 fitness to plead, 253 cortical and subcortical, 66t
phobias, 200–201, 269 Couvade syndrome, 223b course and prognosis, 170
premenstrual syndrome, 221 Creutzfeldt–Jakob disease (CJD), 168 CT appearances, 70t
schizophrenia, 187, 268 neuropathology, 167t delirium vs., 64t
therapies derived from, 35t new variant, 168 differential diagnosis, 66–67
cognitive disorders criminal responsibility, 253–254 diseases causing, 65b
delirium, 61–63 current medication, 5 epidemiology, 165
dementia, 63–66 (see also specific cyclothymia, 110, 196–197 functional impairment, 63
conditions) aetiology, 196 hallucinations, 95
cognitive distortion, 32, 33t epidemiology, 191t, 196–197 legal issues, 169–170
cognitive impairment, 59, 60t, 63 management, 197 management, 168–170
advantages and disadvantages, 69t cyclothymic disorder, 102 behavioural and psychological
amnesic syndrome, 68–69, 68b symptoms of dementia, 169
assessment, 69–70
case study, 70–71
D maintenance of cognitive
function, 169
chronic, 66 dangerous and severe personality mania/hypomania, 103
clinical features, 280 disorders, 252 memory impairment, 63
cognitive examination, 69–70 day hospitals, 48 neurological symptoms, 64
depression, 68 declarative memory, 59–61, 61b neuropathology, 167t
differential diagnosis, 66–69, 67b, 67f defence mechanisms, 30, 31t potentially reversible causes, 314
dissociative disorders, 68 delirium, 61–63, 111, 298–299 praecox, 183
factitious disorder, 68 aetiology, 170 prevalence, 165f
history, 69 causes, 62b subtypes, 314–315
intellectual disability, 68 course and prognosis, 172 type, 64–66 (see also specific dementia)
investigations, 70 vs. dementia, 64t denial, 31t
malingering, 68 diagnostic features, 62b dependent personality disorder, 148–149,
mild, 67–68 differential diagnosis, 66–69 148t, 228t
physical examination, 70 epidemiology, 170 depersonalization, 131b
psychosis, 68 hallucinations, 95 depression, 102
stable, 68 management, 170–172, 171f aetiology, 191–192, 191f
subjective, 68 mania/hypomania, 103 acute stress, 191
cognitive symptoms medication, 63b (see also dementia) chronic stress, 192
dementia, 63 delirium tremens, 176b. See also alcohol early life experience, 191
depression, 108–109 withdrawal genetic risk, 191
mania/hypomania, 100 delusional disorder, 95 neurobiology, 192
common law, 43 delusional jealousy, 252b personality, 191
333
Index
depression (Continued) dissociative anaesthetics, 80–81t Ekbom syndrome, 91t

antidepressants, 193–194, 193t dissociative disorder, 131, 137, 203 elective mutism, 240
assessment, 111–112 aetiology, 203 electroconvulsive therapy (ECT)
vs. bereavement, 134t cognitive impairment, 68 administration and mechanism of
biological/somatic symptoms, 108 course and prognosis, 203 action, 27
bipolar (See bipolar affective disorder) differential diagnosis, 138 bipolar affective disorder, 196
case study, 107b, 112 epidemiology, 203, 203t contraindications, 28
child/adolescent psychiatry, 239t, 241 management, 203, 204t depression, 194
clinical features, 107–109 disulfiram (Antabuse), 177 history, 27
cognitive impairment, 68 doctrine of necessity, 43 indications, 27
cognitive symptoms, 108–109 domestic violence, 222 older adult, 246, 272
core symptoms, 107–108 donepezil, 169 schizophrenia, 186
definitions, 107–109 dopaminergic pathways, 22f side-effects, 27
differential diagnosis, 109–111, 109b, 317 Down syndrome, 166 elimination disorders, 240–241
diurnal variation, 108 Driver and Vehicle Licensing Authority emergency detention order (EDO), 39–40
epidemiology, 191, 191t (DVLA), 44–45, 44t, 169, 297 emotionally unstable personality disorder
examination, 112 driving, fitness for, 44–45 (EUPD). See borderline personality
general medical conditions associated dementia, 169 disorder
with, 111t, 284 drugs wheel, 82f emotional reasoning, 33t
history, 111–112 DSM-5, 12 encopresis, nonorganic, 241
ICD-10 classification, 108, 110, 110b adjustment disorder, 130 energy, increased, 99–100
investigations, 112 bereavement, 133 enuresis, nonorganic, 240–241
management, 192–194, 192f dissociative disorders, 131 epilepsy, 232b, 233
biopsychosocial approach, 192 medically unexplained symptoms, episodic memory, 61
course and prognosis, 194 136–137 EPSEs. See ex-trapyramidal side-effects
electroconvulsive therapy, 194 personality disorder, 148–149, 148t, 227 erectile dysfunction, 218b
lifestyle advice, 192–193 dyscalculia, 155 erotomania, 91t
pharmacological treatment, 193–194 dysexecutive syndrome, 60t euphoria, 63
psychological treatment, 193 dysfunctional assumptions, 32 European Convention on Human Rights
treatment setting, 192 dysgnosia, 60t (ECHR), 43
mood/affective disorders, 110 dyslexia, 155 exhibitionism, 219t
older adults, 245–246, 272 dysmorphophobia. See body dysmorphic explicit memory, 59–61, 61b
postnatal, 223–225 disorder exposure therapy, 33t
prescribed drugs causing, 111t dysphasia, 60t extracampine hallucinations, 89
psychotic symptoms, 109 dyspraxia, 60t ex-trapyramidal side-effects (EPSEs), 21,
recurrent, 110 dyssomnias, 209. See also sleep disorders 22–23b, 24t
secondary, 111 dysthymia, 110, 196–197 eye movement desensitization and
suicide risk, 109 aetiology, 196 reprocessing, 35t
depressive episode, 110, 301 epidemiology, 191t, 196–197
depressive pseudodementia, 245
deprivation of liberty safeguards, 42
management, 197
dystonia, 24t
F
derealization, 131 factitious disorder. See Munchausen
syndrome
detoxification, 175–176, 180t
maintenance after, 176–178
E family history, 5–6
developmental disorders, 159–160 early morning wakening, 108 family therapy, 34–35, 269
dexamfetamine, 234 early-onset Alzheimer dementia, 165–166 fantasy, 31t
Diagnostic and Statistical Manual of Mental eating disorders, 111, 205–208 fat folder syndrome, 135
Disorders, 5th Edition (DSM-5), 215 assessment, 142–145 fear
Diagnostic Interview Schedule for case study, 141b, 145–146 assessment, 120
Children (NIMH-DISC-IV), 243 child/adolescent psychiatry, 239t, 241 case study, 115b, 120–121
dialectical behaviour therapy (DBT), 33, definitions and clinical features, 141–142 definitions and clinical features,
230, 271 differential diagnosis, 144f, 145, 145b 115–116
differential diagnosis, 10, 11t. see also ICD-10 classification, 142b diagnostic algorithm for, 118f
specific conditions management, 206f, 323–324 differential diagnosis, 116–120, 117b
dimensional classification system, 12 medical complications, 142–143, 143b medical conditions and substance abuse,
diminished responsibility, 254 physical consequences, 320 119–120, 120t
Diogenes syndrome, 247b psychological interventions, 206t. (see psychiatric problems associated with,
diphenhydramine (Nytol), 27 also specific disorders) 119, 119t
disinhibition, 60t echolalia, 92 reaction to stress, 119 (see also anxiety
disordered thought form, 100 echopraxia, 93t disorders; phobia)
dissociation, 131–132 eclectic therapy, 29b female orgasmic disorder, 215, 218t
dissociative amnesia, 264 ECT. See electroconvulsive therapy fetishism, 219t
334
Index
first-rank symptoms, 88, 93, 94b H I

fitness to plead, 253
flashback, 124t hallucinations, 9, 87, 124t, 247 ICD-10, 12
flight of ideas, 91, 100–101 assessment, 96 anorexia nervosa, 142b
flupentixol (Depixol), 21t, 186t auditory, 88–89, 109 Asperger syndrome, 156
fluvoxamine, 17t classification, 88f bulimia nervosa, 142b
folie à deux, 95 extracampine, 89 depression, 108, 110, 110b
forensic history, 6 functional, 89 dissociative disorder, 131, 137
forensic psychiatry, 251–254 gustatory, 89 eating disorders, 142b
court proceedings, 253–254 hypnagogic, 89 obsessive-compulsive disorder, 125b
mental disorder and crime, 251–252, hypnopompic, 89 personality disorder, 147–148, 227
251t kinaesthetic, 89 schizophrenia, 94b
risk of violence, 252, 253b olfactory, 89, 109 sexual dysfunction disorder, 215
forensic sections, 39, 40t reflex, 89 somatization disorder, diagnosis, 136
formulation, 10–12 somatic, 89 substance dependence, 75b
aetiology, 10, 11t special forms of, 89 identifying information, 4
description of patient, 10 superficial, 89 illusions, 88
differential diagnosis, 10, 11t visceral, 89 imipramine, 16f
management, 10–12, 11t visual, 89 (see also specific impaired attention, 63, 158, 159t
prognosis, 11t, 12 hallucinations) impaired cognitive function, 63
fortune telling, 33t hallucinogens, 80–81t impaired consciousness, 63
free-floating anxiety. See generalized haloperidol, 21t, 186t implicit memory, 59–61, 61b
anxiety disorder Hare Psychopathy Checklist–Revised, 252 impulsivity, 158, 159t
Freud, Sigmund, 30, 30f hebephrenic schizophrenia, 94 Independent Mental Health Advocates
frontotemporal dementia, 168 Heller syndrome, 156 (IMHA), 38t
cognitive functioning, 169 hierarchical diagnostic system, 12 infancy and early childhood, 6
neuropathology, 167t high functioning autism, 156 infestation, delusions of, 91t
frotteurism, 219t Historical/Clinical/Risk Management, 20- inhalants, 80–81t
full blood count (FBC), 24 item (HCR-20), 252 in-patient units, 49
functional disorder, 135–137, 136t, 203, history insight, 9
203t family, 5–6 insomnia, 209–211, 324
functional hallucinations, 89 past medical, 5 assessment, 209–211
functional impairment, 63 past psychiatric, 5 causes of, 211b
functional neurological disorders, 131, personal, 6 management, 211
132t presenting complaint, 4–5 intellectual disability, 159t, 231–232
functional neurological symptom disorder, psychiatric, 4–7 aetiology, 231
137 histrionic personality disorder, 148–149, causes of, 231t
functional symptoms, 131, 135–136 148t, 228t child/adolescent psychiatry, 239t
HIV-related dementia, 168 classification, 154, 155t
home treatment teams, 48 clinical features, 154–160
G hopelessness, 109 cognitive impairment, 68
galantamine, 169 hormone replacement therapy (HRT), 221 communication considerations, 162b
ᵞ-aminobutyric acid, 221 Human Rights Act (1998), 42–43 and crime, 251t
gender dysphoria. See gender identity human rights legislation, 43 differential diagnosis, 154–160
disorder humour, 31t epidemiology, 231, 231t
gender identity disorder, 219–220 Huntington disease, 167t, 168 history, 160
generalized anxiety disorder, 115–118, hyperactivity, 158, 159t management, 231–232
116f hyperglycaemia, 268 education, training and occupation,
course and prognosis, 202 hypersomnia, 211–213 232
differential diagnosis, 138 hypersomnolence, 211–212, 212b help for families, 232
epidemiology, 199t hypnagogic hallucinations, 89 housing and social support, 232
management, 292–293 hypnopompic hallucinations, 89 medical care, 232
pregabalin, 202 hypnotics. See anxiolytics/hypnotics prevention and detection, 231–232
general practitioners (GPs), 47 hypochondriacal disorder, 136–137 psychiatric care, 232
Gerstmann–Sträussler epidemiology, 203t intellectualization, 31t
syndrome, 168 features in, 203 intelligence quotient (IQ), 154, 233, 289
grandiose delusions, 91t, 101 management, 203 interpersonal therapy (IPT), 32–33
grandiosity, 100 hypokalaemia, 145b interview, 3–4
group-based peer support, 29b hypomania. See mania/hypomania closed questions, 4
group therapy, 34 hypophosphataemia, 207b current medication, 5
guilt, 109 hypothalamic–pituitary–gonadal axis, 141 history (See history)
gustatory hallucinations, 89 hysteria, 131 open questions, 4
335
Index
interview (Continued) loosening of association, 91–92 memory, 59–61, 61t

premorbid personality, 7 lorazepam, 26t impairment, 63
presenting complaint, 4 low mood. See depression loss (See amnesia)
intracranial haemorrhage, 263 reduced, 108–109
investigations, 10–12 menopause, 221
IQ. See intelligence quotient
irrelevant answers, 92
M Mental Capacity Act (2005), 41–42
mental disorder, 37
ischaemic heart disease, 300 magnification, 33t, 297 Mental Health Act (1983) (amended,
isocarboxazid, 17t maintenance therapy, 196 2007), 37–39
malingering, 137 civil sections, 37–39
management consent to treatment, 39
J formulation, 10–12, 11t definitions, 37
plan, 12 forensic sections, 39
jealousy, delusional, 252b
mania/hypomania officials, 38t
judgement, impaired, 100
algorithm for diagnosis, 104, 104f Mental Health (Care & Treatment)
assessment, 103 (Scotland) Act (2003), 39–41
K biological symptoms, 100 Mental Health Act Manager, 37, 38t
case study, 99b, 104 Mental Health (Northern Ireland) Order
Kiddie Schedule for Affective Disorders and cognitive symptoms, 100 (1986), 41
Schizophrenia (K-SADS-P), 243 core symptoms, 99–100 Mental Health Review Tribunal, 37
kinaesthetic hallucinations, 89 differential diagnosis, 101–103, 101b, mental health service provision
knight’s move thinking, 91–92 316 history, 47
Korsakoff syndrome. See Wernicke– distinction between, 103t primary care, 47
Korsakoff syndrome examination, 103 secondary care, 47–49
kuru, 168 general medical condition, 102–103, Mental Health Tribunal (MHT), 38t
315–316 mentalization-based therapy, 31, 35t, 230
history, 103
L investigations, 103
mental retardation. See intellectual disability
mental state examination (MSE), 7–9,
labelling, 33t medical and substance causes, 102b 55–56
lamotrigine, 19–21, 21b, 21t, 196 mental state examination, 317 methadone, 179t, 180
lanugo hair, 143 mood/affective disorders, methylphenidate, 234, 271
late-onset Alzheimer dementia, 165–166 101–102, 110 mild cognitive impairment, 67–68
late-onset schizophrenia, 247 older adults, 247 milieu therapy, 35
LBD. See Lewy body dementia psychotic symptoms, 100–101 mindfulness-based cognitive therapy, 35t
learning disability. See intellectual treatment, 195 mind reading, 33t
disability manic episode, 300 Minnesota Multiphasic Personality
legal issues manic stupor, 99 Inventory (MMPI), 148
capacity, 41–43 mannerism, 160t mirtazapine, 15, 18
common law, 43 MAOIs, 15, 18–19, 19b Misuse of Drugs Act (1971), 82f
dementia, 169–170 maternity blues. See postnatal blues mixed affective episode, 99, 101
fitness to drive, 44–45 measles, mumps, rubella (MMR) vaccine, mixed affective state, 195
human rights legislation, 43 233 M’Naghten Rules, 253–254
Mental Health Act (1983) (amended, medical conditions moclobemide, 16f, 17t
2007), 37–39 anxiety disorders, 120t modafinil, 211–212
Mental Health (Care & Treatment) depression, 111t, 317 moderate depression, 297
(Scotland) Act (2003), 39–41 mania/hypomania, 102–103, 315–316 monoamine oxidase inhibitor (MAOI), 15
Mental Health (Northern Ireland) Order psychosis, 95, 280–281 Montreal Cognitive Test, 69t
(1986), 41 medical history, 5 mood, 8, 99
proxy decision making, 42–43 medically unexplained physical symptoms, elevated (See mania/hypomania)
Lewy body dementia (LBD), 166–168 131, 135 low (See depression)
cognitive functioning, 169 assessment, 139 mood-congruent delusions, 90, 101
neuropathology, 167t case study, 135b, 139 mood (affective) disorders, 95, 110, 191–197
Liaison psychiatry, 48 definitions and clinical features, aetiology, 191f
libido, loss of, 108 135–137 and crime, 251t, 313
Lilliputian hallucinations, 89 differential diagnosis, 137–139, 138b, epidemiology, 191t
lisdexamfetamine (Elvanse), 234–235 287 mania/hypomania, 101–102. (see also
lithium, 20, 20t flow chart for, 138f specific disorders)
bipolar affective disorder, 196 medication, 19 mood disturbance, 63
older adults, 246 current, 5 mood stabilizers, 229, 232
schizophrenia, 186 delirium, 63b history, 19
lofepramine, 16f medullary pyramids, 22b indications, 20
lofexidine, 27 memantine, 169 mechanism of action, 19
336
Index
mood stabilizers (Continued) new variant CJD (nvCJD), 168 organic personality disorder, 147, 150
in pregnancy, 222t nightmares, 214 Othello syndrome, 252b
side-effects and contraindications, night terrors. See sleep terrors outpatient clinics, 48
20–21 (see also individual drugs) nihilistic delusions. See Cotard syndrome overgeneralization, 33t
motivational interviewing (MI), 33–34 N-methyl-D-aspartate (NMDA) receptor, overvalued ideas, 9, 90, 124t, 298
motor abnormality, 159, 160t 169
multivitamin, 269
Munchausen syndrome, 137
schizophrenia, 184
nonorganic encopresis, 241
P
mutism, elective, 240 nonorganic enuresis, 240–241 paediatric psychiatry. See child/adolescent
non-REM sleep arousal disorders, 213–214 psychiatry
N NOTCH3, 166 paedophilia, 219t
palilalia, 92
nalmefene (Selincro), 178
naltrexone (Nalorex), 178
O panic attack, 301
panic disorder, 118–119, 199, 199t
narcissistic personality disorder, 148–149, obsession, 9, 124t cognitive-behavioural therapy, 201
148t, 228t obsessive-compulsive disorder (OCD), course and prognosis, 202
narcolepsy, 212, 324 119, 199 differential diagnosis, 138
National Health Service Trusts, 242 algorithm for diagnosis, 126f epidemiology, 199t
National Health System, 31 case study, 123b, 127 management, 292–293
National Institute for Health and Care child/adolescent psychiatry, 239 paranoid personality disorder, 148–149,
Excellence (NICE) clinical features, 123–124 148t, 228t
Alzheimer dementia, 169 course and prognosis, 202 paranoid schizophrenia, 94
anxiety disorders, 200 definitions, 123–124 paraphilias, 219, 219t
behavioural and psychological differential diagnosis, 124–125, parasomnias, 209. See also sleep disorders
symptoms of dementia, 169 125–126t, 145 Parkinson disease
body dysmorphic disorder, 203 epidemiology, 199t with dementia, 166–167
delirium, 170 ICD-10 classification, 125b neuropathology, 167t
depression, 193, 241 serotonin reuptake inhibitors, 269 parkinsonism, 24t, 166–167
dialectical behaviour therapy, 230 obsessive-compulsive personality disorder, paroxetine, 16f, 17t
eating disorders, 206t 148–149, 148t, 228t paroxysmal anxiety, 115–116, 116f
erectile dysfunction, 218b obsessive-compulsive symptoms, 5 past medical history, 5
insomnia, 210–211 obstructive sleep apnoea syndrome, 212–213 past psychiatric history, 5
mood disorders, 193, 195–197 occupational record, 6 patient, description of, 10
perinatal anxiety disorders, 225 OCD. See obsessive-compulsive disorder perception, 9, 87
postnatal depression, 224 offending personality disorders, 252 perceptual disturbance, 63, 87–89, 101
posttraumatic stress disorder, 185b olanzapine, 172, 268, 270 perinatal anxiety disorders, 225
premenstrual syndrome, 221 side-effects, 186t persecutory delusions, 91t, 101
schizophrenia, 186–187 older adults, mental illness in, 245–248 perseveration, 92
Nearest Relative (NR), 38t age-related physiological changes, 248, persistent somatoform pain disorder, 136
necrophilia, 219t 248t personal alarms, 3
negative symptoms, 92 anxiety disorders, 246–247 personal history, 6
neologisms, 92 assessment, 247–248 alcohol and substance abuse, 6
neurodevelopmental disorders, 96, 103, concordance, 248 forensic history, 6
111, 153–161, 159t, 231–235 depression, 245–246 infancy/early childhood, 6
assessment, 160–161, 161f epidemiology, 245, 245f late childhood/adolescence, 6
attention deficit hyperactivity disorders, late-onset schizophrenia, 247 occupational record, 6
233–235 mania, 247 relationships, marital and sexual
autism spectrum disorders, 232–233 polypharmacy, 248 history, 6
case study, 153b, 162 psychosocial interventions, 248 social circumstances, 6
clinical features, 154–160 treatment, 248 (see also delirium; personality disorder, 95–96, 103, 111, 147,
and crime, 251t dementia) 157, 227–230, 300
definition, 153 olfactory hallucinations, 89 aetiology, 227
diagnosis, 154f open questions, 4 assessment, 149–150
differential diagnosis, 154–160 operant conditioning model, 174, 179 case study, 147b, 151
epidemiology, 231t operational definitions, 12 child/adolescent psychiatry, 239t,
intellectual disability, 231–232 opiates, 63, 213 241–242
symptoms, 158b opioid dependence, 180–181 classification, 147–149, 148t
Tourette syndrome, 235. (see also specific epidemiology, 178t clinical features, 147
disorders) pharmacological management, 267 course and prognosis, 230
neurofibrillary tangles, 165 stages of, 180t and crime, 251–252, 251t
neuroleptic malignant syndrome, 25t opioids, 80–81t definitions, 147
neuroleptics, 21–24 oppositional defiant disorder, 239t, 240 differential diagnosis, 150–151, 150t
337
Index
personality disorder (Continued) primary care, 47 psychotherapy (Continued)

dimensional and categorical approach, 148 prion protein (PrP), 168 counselling, 29–30
epidemiology, 227, 228t problem-solving counselling, 29–30 dialectical behavioural therapy, 33
management, 227–230, 228b, 294–295 procedural memory, 59–61, 61b family therapy, 34–35
crisis management, 229 Prochaska and DiClemente group therapy, 34
long-term, 229–230 transtheoretical model of change, indications
psychopharmacology, 229 176–177, 177f alcohol disorders, 176–177
psychotherapy, 229–230 prognosis, formulation, 11t, 12 anorexia nervosa, 206t
short-term, 229 projection, 31t anxiety disorders, 201–202
mixed, 148 (see also specific personality propranolol, 202 autism spectrum disorders, 233b
disorders) proxy decision making, 42–43 bipolar affective disorder, 196
personality traits, 147–149, 151 pseudocyesis, 223b depression, 193, 241
personalization, 33t pseudohallucination, 88, 124t menopause, 221
person-centred counselling, 29–30, 297 psychiatric assessment neurodevelopmental disorders, 295
pharmacological therapy classification, 12 older adults, mental illness in, 248
alcohol disorders, 177–178 formulation, 10–12 perinatal anxiety disorders, 225
anxiety disorders, 202 history, 4–7 schizophrenia, 187
bipolar affective disorder, 195 interview technique, 3–4 indications for, 35, 36t
depression, 193–194 mental state examination, 7–9 individual, 275
schizophrenia, 185–186 physical examination, 10 interpersonal therapy, 32–33
phenelzine, 16f, 17t procedure, 3f motivational interviewing, 33–34
phobia, 117, 200–201, 239, 269. See also risk, 9–10. (see also specific conditions) personality disorders, 229–230
anxiety disorders; social phobia psychiatry psychodynamic, 30–32
physical illness, 54 classification in, 12 supportive, 29–30
Pick disease, 168 history, 4–7 therapeutic community, 35. (see also
PMS. See premenstrual syndrome illness, 54 specific modalities)
polypharmacy, 248 psychoactive substances, 111 psychotic disorder, 183–188, 251t. See also
polysomnography, 209–213 psychoanalysis, 31 schizophrenia
poor concentration, 100 psychodynamic psychotherapy, 30–32, 230 psychotic symptoms, 109, 169, 184–185
postnatal blues, 223 psychodynamic therapy, 35t psychotropic drugs. See specific drugs
postnatal depression, 223–225 psychomotor excitation, 99 psychotropic medications
clinical features, 223–224 psychomotor function, 7–8, 92–93 antidepressants, 15–19
epidemiology and aetiology, 224 psychomotor retardation, 108 antipsychotics, 21–24
management, 224 psychopathy, 252 anxiolytics, 25–27
prognosis, 224–225 psychopharmacology, 229 hypnotics, 25–27
postpartum psychosis, 225–226, 226b, 294 psychosexual disorders, 215–220 mood stabilizers, 19–21
posttraumatic stress disorder (PTSD), classification, 215 PTSD. See posttraumatic stress disorder
130–131, 200 gender identity, 219–220 puerperal disorders, 223–226
cognitive-behavioural therapy, 201–202 paraphilias, 219, 219t failure to bond, 225
course and prognosis, 202 sexual dysfunction, 215–218, 215f, 216t, postnatal blues, 223
epidemiology, 199t 218t postnatal depression, 223–225
management, 292 psychosis psychosis, 225–226, 226b
symptoms, 130 algorithm for diagnosis, 96, 96f
Power of Attorney, 42 assessment, 96–97
pramipexole, 269 case study, 87b, 97
Q
prednisolone, 300 clinical features, 87–93 quetiapine, 186t, 268
pregabalin, 27 cognitive impairment, 68
anxiety disorders, 202 definitions, 87–93
generalized anxiety disorders, 202 differential diagnosis, 93–96, 145
R
pregnancy, 221–223 early intervention in, 48 rapid eye movement (REM) sleep
perinatal psychiatry services, 222 examination, 97 behaviour disorder, 166–167, 214
pseudocyesis, 223b investigations, 97 rapport, 3, 4b
psychiatric considerations, 222–223, medical conditions and substance abuse, reaction-formation, 31t
222t, 325 95, 95b reactive attachment disorder, 240
puerperal disorders, 223–226 mental state examination, 281 reboxetine, 16f, 17t
premature ejaculation, 218, 218t postpartum (puerperal), 225–226, 226b. recreational drugs, 80–81t
premenstrual dysphoric disorder (PMDD), (see also specific disorders) recurrent depressive disorder, 110
221 psychosocial stress, 129. See also stress refeeding syndrome, 269
premenstrual syndrome (PMS), 221, 270 psychotherapy clinical features, 207t
premorbid personality, 7 approaches, 29–35 management, 207
presenting complaint, 4–5 behaviour therapy, 32 referral to perinatal mental health team,
pressure of speech, 100 cognitive-behavioural therapy, 32 222b, 270–271
338
Index
reflex hallucinations, 89 secondary care (Continued) sexual preference disorders, 219, 219t
rehabilitation units, 49 care programme approach, 47–48 sexual sadism, 219t
relationship, 6 community mental health teams, 47 short-term detention certificate, 40–41
religious delusions, 91t day hospitals, 48 sleep disorders, 209–214
repression, 31t early intervention in psychosis, 48 breathing-related, 212–213
residual schizophrenia, 94 home treatment teams, 48 circadian rhythm, 212
Responsible Clinician (RC), 37, 38t in-patient units, 49 decreased need for sleep, 100
restless legs syndrome, 213 Liaison psychiatry, 48 definitions and classification, 209–214
Rett syndrome, 156 outpatient clinics, 48 diagnosis, 293–294
RIMAs, 18–19 rehabilitation units, 49 early wakening, 108
risk assessment, 9–10 Second Opinion Approved Doctor hypersomnolence, 211–212, 212b
risk factors for suicide, 54, 54b (SOAD), 38t, 39 insomnia, 209–211
risperidone, 186t sectioning. See compulsory admission nightmares, 214
rivastigmine, 169 sedating antihistamines, 27 stages of sleep, 209, 210f
rumination, 124t sedatives, 80–81t sleep hygiene, 211b, 270
Russell’s sign, 143 selective serotonin reuptake inhibitor, 15, sleep-related movement disorder, 213
17, 18b sleep terrors, 213
S selective serotonin reuptake inhibitor
(SSRI)
sleep–wake cycle disturbance, 63
sleepwalking, 213–214
schizoaffective disorder, 94–95, 103, 110 anxiety disorders, 202 SNRIs. See serotonin-noradrenaline
schizoid personality disorder, 148–149, depression, 193 reuptake inhibitors
148t, 228t, 266 obsessive-compulsive disorder, 269 social anxiety disorder, 239–240
schizophrenia, 93, 103, 183–188 personality disorder, 229 social behaviour disorders, 240
acute behavioural disturbance, 187 in pregnancy, 222t social circumstances, 6
aetiology, 183–185 premenstrual syndrome, 221 (see also social phobia, 117
adverse life events, 184 individual drugs) cognitive-behavioural
brain abnormalities, 184 self-esteem therapy, 200, 269
cannabis, 184–185 elevated sense of, 100 course and prognosis, 202
developmental factors, 184 poor, 109 epidemiology, 199t
genetic factor, 183–184 self-harm sodium valproate. See valproate
neurotransmitter abnormalities, 184 assessment, 53–56 somatic delusions, 91t
catatonic, 94 case study, 53b somatic hallucinations, 89
child/adolescent psychiatry, 239t, 241 definition, 53 somatization disorder, 136–137, 203
course and prognosis, 187–188 depression, 109 aetiology, 203
and crime, 251t management, 56 course and prognosis, 203
differential diagnosis, 138 risk assessment, 56. (see also specific epidemiology, 203, 203t
epidemiology, 183 conditions) management, 203, 204t
history, 183 self-help, 29b somatoform autonomic dysfunction, 136
ICD-10 diagnostic guidelines, 94b semantic memory, 61 somatoform disorders, 136–137
late-onset, 247 separation anxiety disorder, 239 somnambulism. See sleepwalking
lifetime risk of developing, 183–184, 183f serotonin-noradrenaline reuptake specific phobia, 117, 225
management, 185–187, 188f inhibitors, 17 cognitive-behavioural therapy, 200–201
drugs, 185–186, 186t serotonin reuptake inhibitors. See selective course and prognosis, 202
pharmacological treatment, 185–186 serotonin reuptake inhibitor epidemiology, 199t
physical health monitoring, 186–187 serotonin syndrome, 19, 25t speech, 8, 100
psychological treatments, 187 sertraline, 16f, 17t SSRI. See selective serotonin reuptake
social inputs, 187 Severity of Alcohol Dependence inhibitor
treatment setting, 185 Questionnaire (SADQ), 83 stereotypy, 160t
motor symptoms, 93t sexual dysfunction, 215–218, 215f stimulants, 80–81t
paranoid, 94 aetiology, 216–217 strengths and difficulties questionnaire
residual, 94 assessment, 217–218 (SDQ), 243
Schneider’s first-rank symptoms, 94b clinical features, 215–216 stress, 129–133
subtypes, 94 (see also psychosis) differential diagnosis, 217 acute stress reaction, 130
schizophrenia-like psychotic disorders, 94 drugs, 217b bereavement, 133
schizophreniform disorders, 103 epidemiology, 216, 216t case study, 129b, 134
schizotypal personality disorder, 148–149, exercises in, 218t definitions and clinical features,
148t, 228t frequency, 216t 129–133
school refusal, 240b management, 218, 218t differential diagnosis, 131b,
scrapie, 168 phase of cycle, 216t 133–134, 319
secondary care, 47–49 prognosis, 218 nature of patient’s reaction, 130–132
accommodation, 49 sexual history, 6 precipitation/exacerbation, 132–133
assertive outreach teams, 48 sexual masochism, 219t psychosocial, 129
339
Index
stress (Continued) T V
PTSD (See posttraumatic stress disorder)
traumatic, 129–130 tangentiality, 100 vaginismus, 218, 218t
stupor, dissociative, 130 tangential thinking, 91 valproate, 19–21, 20–21b, 21t
subjective cognitive impairment, 68 tardive dyskinesia, 24t vascular dementia, 166
sublimation, 31t TCAs. See tricyclic antidepressants cognitive functioning, 169
substance abuse, 6, 19, 178–181 temazepam, 211 neuropathology, 167t
aetiology, 179 therapeutic communities, 35, 230 nongenetic factors, 166b
assessment, 83–84 therapy venlafaxine, 16f, 17, 17t
case study, 73b, 84–85 current, 5 violence
course and prognosis, 181 ECT (See electroconvulsive therapy). domestic, 222
and crime, 251t (see also specific modalities) risk of, 252, 253b
diagnostic algorithm, 74f thought blocking, 92 visceral hallucinations, 89
differential diagnosis, 80–83 thought disorder, 90–92, 92f visual hallucinations, 79, 89
epidemiology, 173f, 178–179, 178t thought disturbance, 63 voyeurism, 219t
examination, 83–84 thought insertion, 124t
harmful use of, 73–75 thoughts, 8–9
hazardous use of, 73b tics, 160, 160t W
history, 83 tokophobia, 225 watchful waiting, 264
investigations, 84 Tourette syndrome, 159t, 199, Wechsler Intelligence Scale, 154
management, 179–181 (see also alcohol 235, 271 weight loss, 108, 145
abuse) differential diagnosis, 160 differential diagnosis, 145
substance dependence, 75, 75b epidemiology, 231t physical causes, 145
substance intoxication, 73 history, 160 Wernicke encephalopathy, 175–176
substance withdrawal, 75 transference, 30, 32b, 297 Wernicke–Korsakoff syndrome, 78–79
suicidal ideation, 300 transgenderism, 220b word salad, 90–92
suicide transsexualism, 219–220, 220b
adverse life events, 54 transvestic fetishism, 219t, 270
attempted, 53 transvestism, 220b Y
management, 56 tranylcypromine, 16f, 17t
traumatic stress, 129–130 Yerkes–Dodson law, 115, 115f
case study, 53b
definition, 53 trazodone, 18, 169
depression, 109 tricyclic antidepressants (TCAs)
intent, 54–55 obsessive-compulsive disorder, 202
Z
mental state examination, 55–56 pharmacological therapy, 15, 18, 18t, zaleplon, 211
physical illness, 54 22b Z drugs
planned, 54 in pregnancy, 222t classification, 25, 26t
psychiatric illness, 54 side-effects, 246 (see also individual history, 25
risk factors, 54, 54b drugs) indications, 26
sulpiride, 21t tyramine-rich foods, 19 mechanism of action, 26
superficial hallucinations, 89 side-effects, 26–27
supported accommodation, 49 zolpidem, 211
supportive psychotherapy, 29–30, 229
U zoophilia, 219t
suppression, 31t urine drug screen, 300 zopiclone, 211
suspension hanging, 298 urophilia, 219t zuclopenthixol (Clopixol), 21t, 186t
340

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What are the different editions of the book and their authors?

What are the different editions of the book and their authors?

What are the roles and names of the series editors and faculty advisor mentioned in the text?

What are the roles and names of the series editors and faculty advisor mentioned in the text?

Psychiatry

First and second edition authors:

Third edition authors:

Fourth edition authors:

© 2019, Elsevier Limited. All rights reserved.

First edition 1999

We wish you all the best for your future careers!

Shreelata Datta and Philip Xiu

I am deeply thankful to my husband, Jonathan Shutt, and to my family, for

Shreelata Datta and Philip Xiu

Series Editors’ foreword . . . . . . . . . . . . . . . . . . . . . . . . v Patient management following self-harm

Differential diagnosis..................................................124 24 Eating disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 205

19 Dementia and delirium. . . . . . . . . . . . . . . . . . . . . . 165 31 Older adult psychiatry . . . . . . . . . . . . . . . . . . . . . . 245

Psychiatric assessment and diagnosis�������������������������������������������������������� 3

Pharmacological therapy and electroconvulsive therapy �������������������������� 15

Mental health and the law �������������������������������������������������������������������������� 37

Mental health service provision ����������������������������������������������������������������� 47

Mental state examination

Fig. 1.1 Outline of the psychiatric assessment procedure.

Rapport building is vital when working in History of presenting complaint

Table 1.1 Typical questions used to elicit specific

specialties; for example, enquiring about nausea,

implicated in the aetiology of many psychiatric

Later childhood and adolescence Alcohol and substance use

MENTAL STATE EXAMINATION Appearance

The MSE, like a physical examination, is a snap-

• Relevant background details (e.g. past psychiatric

HINTS AND TIPS

When presenting your differential diagnosis,

Table 1.2 Example of a case formulation (differential diagnosis, aetiology, management)

Organization). The eleventh revision, ICD-11, is close

HINTS AND TIPS

Noradrenaline Noradrenaline (norepinephrine)

Tricyclic antidepressants (TCA)

Table 2.1 Classification and pharmacodynamics of the antidepressants

Anticholinergic: muscarinic Dry mouth An early warning sign of a hypertensive crisis is

BOX 2.2 DRUGS AND FOODS THAT MAY HINTS AND TIPS

These include lithium and the anticonvulsants valproate,

Indications Table 2.3 Side-effects and signs of toxicity of lithiuma

Valproate is available in formulations as sodium RED FLAG

It follows that the following investigations are needed prior

Table 2.4 Side-effects of valproate, carbamazepine and lamotrigine

and haematological functions prior to and soon after start-

Table 2.5 Commonly used antipsychotics

Mechanism of action and cardiovascular mortality, so it is important to monitor and

Fig. 2.2 Dopaminergic pathways.

Table 2.6 The clinical effects and side-effects of conventional antipsychotics

HINTS AND TIPS

Table 2.7 Antipsychotic-induced extrapyramidal side-effects and treatment

Table 2.8 Distinguishing neuroleptic malignant syndrome from serotonin syndrome

Table 2.9 Classification of the benzodiazepines and Z drugs

Mechanism of action • Patients should be warned about the potential dangers

Indications of Z drugs Alcohol, opiates, barbiturates, tricyclic

Other hypnotic and anxiolytic Indications

The single factor most commonly associated with

Ego (’the actual’):

Psychiatric assessment and diagnosis�� 3

Pharmacological therapy and electroconvulsive therapy �� 15

Mental health and the law �� 37

Mental health service provision �� 47

atients to evaluate their social interactions and improve

arents and siblings or may also include extended family.

ngoing hospital admission). Conditions such as attending ap-

The patient with low mood�� 107

The patient with obsessions and compulsions �� 123

The patient with a reaction to a stressful event �� 129

The patient with eating or weight problems �� 141

The patient with personality problems�� 147

The patient with neurodevelopmental problems �� 153