Unexplained symptoms

There are a wide variety of psychiatric terms for patients who have symptoms for which
no organic cause can be found:
Somatisation disorder:
 multiple physical SYMPTOMS present for at least 2 years
 patient refuses to accept reassurance or negative test results

Hypochondrial disorder:
 persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
 patient again refuses to accept reassurance or negative test results

Conversion disorder:
 typically involves loss of motor or sensory function
 the patient doesn't consciously feign the symptoms (factitious disorder) or seek
material gain (malingering)
 patients may be indifferent to their apparent disorder - la belle indifference -
although this has not been backed up by some studies
Aphonia:
Aphonia describes the inability to speak. Causes include:
 recurrent laryngeal nerve palsy (e.g. Post-thyroidectomy)
 psychogenic Aphonia is considered part of conversion disorder

Dissociative disorder:
 dissociation is a process of 'separating off' certain memories from normal
consciousness
 in contrast to conversion disorder involves psychiatric symptoms e.g.
Amnesia, fugue, stupor
 dissociative identity disorder (DID) is the new term for multiple personality
disorder as is the most severe form of dissociative disorder
Munchausen's syndrome:
 also known as factitious disorder
 the intentional production of physical or psychological symptoms
Malingering:

fraudulent simulation or exaggeration of symptoms with the intention of
financial or other gain
Globus hystericus: is part of the anxiety disorders and thought to be due to somatisation.
This sensation is fluctuating and there is no mechanical problem. It is a diagnosis of exclusion.

1
 Sleep paralysis
 Sleep paralysis is a common condition characterized by transient paralysis of skeletal
muscles which occurs when awakening from sleep or less often while falling asleep.
 It is thought to be related to the paralysis that occurs as a natural part of REM (rapid
eye movement) sleep.
 Sleep paralysis is recognised in a wide variety of cultures

Features:
1) paralysis - this occurs after waking up or shortly before falling asleep
2) hallucinations - images or speaking that appear during the paralysis

Management:
 if troublesome clonazepam may be used

2
Mood (affective) disorders
Depressive disorders
Mania, hypomania and bipolar disorder

Depression
Screening
The following two questions can be used to screen for depression
1. 'During the last month, have you often been bothered by feeling down, depressed or
hopeless?'
2. 'During the last month, have you often been bothered by having little interest or
pleasure in doing things?'

A 'yes' answer to either of the above should prompt a more in depth assessment.

Assessment:
There are many tools to assess the degree of depression including:
 The Hospital Anxiety and Depression (HAD) scale and
 The Patient Health Questionnaire (PHQ-9).

1) Hospital Anxiety and Depression (HAD) scale

 consists of 14 questions, 7 for anxiety and 7 for depression
 each item is scored from 0-3
 produces a score out of 21 for both anxiety and depression
 severity:
 0-7 normal,
 8-10 borderline,
 11+ case
 patients should be encouraged to answer the questions quickly

2) Patient Health Questionnaire (PHQ-9)

 Asks patients 'over the last 2 weeks, how often have you been bothered by any of
the following problems?'
 9 items which can then be scored 0-3
 includes items asking about thoughts of self-harm
 depression severity:
 0-4 none,
 5-9 mild,
 10-14 moderate,
 15-19 moderately severe,
 20-27 severe

3
NICE use the DSM-IV criteria to grade depression:
1) Depressed mood most of the day, nearly every day
2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day,
nearly every day
3) Significant weight loss or weight gain when not dieting or decrease or increase in
appetite nearly every day
4) Insomnia ‫ األرق‬or hypersomnia ‫ فرط النوم‬nearly every day
5) Psychomotor agitation or retardation nearly every day
6) Fatigue or loss of energy nearly every day
7) Feelings of worthlessness or excessive or inappropriate guilt nearly every day
8) Diminished ability to think or concentrate or indecisiveness nearly every day
9) Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a
suicide attempt or a specific plan for committing suicide
Early morning walking is a classic somatic symptom of depression and develops
earlier than general insomnia
Subthreshold
depressive symptoms Fewer than 5 symptoms

Mild depression  Few, if any,

 symptoms in excess of the 5 required to make the
diagnosis, and symptoms result in only minor functional
impairment

Moderate depression Symptoms or functional impairment are between 'mild' and

'severe'

Severe depression  Most symptoms and

 The symptoms markedly interfere with functioning.
 Can occur with or without psychotic symptoms

4
Management Of Depressive Disorders
Physical
 Stop depressing drugs (alcohol, steroids)
 Regular exercise (good for mild to moderate depression)
 Antidepressants (choice determined by side-effects, co-morbid illnesses and interactions)
 Adjunctive drugs (e.g. lithium; if no response to two different antidepressants)
 Electroconvulsive therapy (ECT) (if life-threatening or non-responsive)
Psychological
 Education and regular follow-up by same professional
 Cognitive behaviour therapy (CBT)
 Other indicated psychotherapies (couple, family, interpersonal)
Social
 Financial: eligible benefits, debt counselling
 Employment: acquire or change job or career
 Housing: adequate, secure tenancy, safe, social neighbours
 Young children: child-care support
Treatments combined
 The most effective treatment is a mixture of CBT and an antidepressant

5
 Tricyclic Antidepressants
 TCAs are used less commonly now for depression due to side-effects& toxicity in
overdose.
 They are however used widely in the treatment of neuropathic pain, where smaller
doses are typically required.

Common side-effects:
Due to antimuscarinic side effects more common with imipramine
1) Drowsiness, tachycardia
2) dry mouth
3) blurred vision, Mydriasis (dilated pupils)
4) constipation
5) urinary retention

Choice of tricyclic:
1) low-dose amitriptyline is commonly used in:
 the management of neuropathic pain and
 the prophylaxis of headache (both tension and migraine)
2) lofepramine has a lower incidence of toxicity in overdose
3) amitriptyline and dosulepin (dothiepin) are considered the most dangerous in
overdose
More sedative Less sedative

Amitriptyline Imipramine
Dosulepin Lofepramine
Clomipramine Nortriptyline
Trazodone*
*trazodone is technically a 'tricyclic-related antidepressant'

6
 Tricyclic overdose
 Overdose of TCAs is a common presentation to emergency departments
 Amitriptyline and dosulepin (dothiepin) are particularly dangerous in overdose.

Early features relate to anticholinergic properties:

1) Agitation, dry mouth,
2) dilated pupils, blurred vision
3) sinus tachycardia,
4) constipation, urinary retention

Features of severe poisoning include:

1) arrhythmias
2) seizures
3) metabolic acidosis
4) coma

ECG changes include:

1) sinus tachycardia
2) widening of QRS
3) prolongation of QT interval
 Widening of QRS > 100ms is associated with an increased risk of seizures,
 whilst QRS > 160ms is associated with ventricular arrhythmias

Management:
1) IV bicarbonate may reduce the risk of seizures and arrhythmias in severe toxicity
2) Arrhythmias:
 Response to lignocaine (1b) is variable and it should be emphasized that
correction of acidosis is the first line in management of tricyclic induced
arrhythmias
 Class 1a (e.g. Quinidine) and class Ic antiarrhythmics (e.g. Flecainide) are
contraindicated as they prolong depolarisation.
 Class III drugs such as amiodarone should also be avoided as they prolong the
QT interval.
3) Intravenous lipid emulsion (intralipid) is increasingly used to bind free drug and
reduce toxicity
4) Dialysis is ineffective in removing tricyclics (however can be used for acidosis
refractory to NaHCO3)

TCAs can cause SIADH

If BZD + TCA toxicity do not give flumazenil as it reduces its
seizure threshold

7
 St John's Wort
 shown to be as effective as tricyclic antidepressants in the treatment of mild-
moderate depression

Mechanism:
 thought to be similar to SSRIs (although noradrenaline uptake inhibition has also
been demonstrated)
 NICE advise 'may be of benefit in mild or moderate depression, but its use should not
be prescribed or advised because of uncertainty about appropriate doses, variation
in the nature of preparations, and potential serious interactions with other drugs'

Adverse effects:
1) profile in trials similar to placebo
2) can cause serotonin syndrome
3) Inducer of P450 system, therefore:
 Decreased levels of drugs such as warfarin, ciclosporin.
 The effectiveness of the COC may also be reduced

8
 Selective serotonin reuptake inhibitors
SSRIs are considered first-line treatment for the majority of patients with depression.
1) Citalopram (although re: QT interval) and fluoxetine are currently the preferred SSRIs
2) Sertraline is useful post myocardial infarction as there is more evidence for its safe
use in this situation than other antidepressants
3) SSRIs should be used with caution in children and adolescents. Fluoxetine is the drug
of choice when an antidepressant is indicated

Adverse effects:
1) gastrointestinal symptoms:
 the most common side-effect
 There is an increased risk of GIT bleeding.
 A proton pump inhibitor should be prescribed if a patient is also taking a NSAID
2) Patients should be counselled to be vigilant for increased anxiety and agitation after
starting a SSRI
3) Fluoxetine and paroxetine have a higher propensity for drug interactions

Citalopram and the QT interval

 The Medicines and Healthcare products Regulatory Agency (MHRA) released a
warning on the use of citalopram in 2011
 It advised that citalopram and escitalopram are associated with dose-dependent QT
interval prolongation
 Should not be used in those with:
1) congenital long QT syndrome;
2) known pre-existing QT interval prolongation;
3) or in combination with other medicines that prolong the QT interval
 The maximum daily dose is now:
 40 mg for adults;
 20 mg for patients older than 65 years;
 20 mg for those with hepatic impairment

9
Interactions:
1) NSAIDs: NICE guidelines advise 'do not normally offer SSRIs', but if given co-prescribe
a proton pump inhibitor
2) Warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering
mirtazapine (sertraline and citalopram appear to be the safest antidepressants to
prescribe with warfarin).
3) Aspirin: see above
4) Triptans: avoid SSRIs

 Following the initiation of antidepressant therapy patients should normally be

reviewed by a doctor after 2 weeks.
 For patients under the age of 30 years or at increased risk of suicide they should be
reviewed after 1 week.
 If a patient makes a good response to antidepressant therapy they should continue on
treatment for at least 6 months after remission as this reduces the risk of relapse.
 When stopping a SSRI the dose should be gradually reduced over a 4 week period
(this is not necessary with fluoxetine).
 Paroxetine has a higher incidence of discontinuation symptoms.

Discontinuation symptoms:
1) increased mood change
2) restlessness
3) unsteadiness
4) paraesthesia
5) difficulty sleeping
6) sweating
7) GIT symptoms: pain, cramping, diarrhoea, vomiting

10
Citalopram 1) the preferred SSRIs
2) prolong the QT interval
Fluoxetine 1) the preferred SSRIs
2) the drug of choice in children and adolescents
3) Can be stopped abruptly
4) fluoxetine and paroxetine have a higher propensity for drug
interactions
5) Postnatal depression: fluoxetine is best avoided due to a long half-life
Sertraline 1) useful post myocardial infarction
2) Postnatal depression may be used if symptoms are severe
whilst they are secreted in breast milk it is not thought to be harmful
to the infant
Paroxetine 1) Postnatal depression may be used if symptoms are severe
whilst they are secreted in breast milk it is not thought to be harmful
to the infant
2) treatments for PTSD
3) fluoxetine and paroxetine have a higher propensity for drug
interactions
4) Paroxetine has a higher incidence of discontinuation symptoms

Mirtazapine 1) NICE guidelines recommend avoiding SSRIs and considering

mirtazapine if the pt is taking warfarin or heparin
2) treatments for PTSD

sertraline and citalopram appear to be the safest antidepressants to prescribe with warfarin

Mirtazapine: ‫للعلم فقط‬

 Tetracyclic structure different from SSRIs, TCAs and MAOIs;
 through its central presynaptic alpha2-adrenergic antagonist effects, stimulates
norepinephrine and serotonin release;
 potent antagonist of 5-HT2 and 5-HT3 serotonin and histamine receptors; is a
moderate alpha1 adrenergic and muscarinic antagonist

11
 Electroconvulsive therapy
 Electroconvulsive therapy is a useful treatment option for patients with severe
depression refractory to medication or those with psychotic symptoms.
 The only absolute contraindication is raised intracranial pressure.

Short-term side-effects:
1) Headache
2) Nausea
3) Short term memory impairment
4) Memory loss of events prior to ECT
5) Cardiac arrhythmia

Long-term side-effects:
 some patients report impaired memory

Cognitive behavioural therapy

Main points
 Useful in the management of depression and anxiety disorders
 Usually consists of one to two hour sessions once per week
 Should be completed within 6 months
 Patients usually get around 16-20 hours in total

12
 Seasonal affective disorder
 Seasonal affective disorder (SAD) describes depression which occurs predominately
around the winter months.
 Bright light therapy has been shown to be more effective than placebo for patients
with SAD

Post-concussion syndrome
Post-concussion syndrome is seen after even minor head trauma

Typical features include:

1) Headache
2) Fatigue
3) Dizziness
4) Anxiety/depression

13
 Post-partum mental health problems
Post-partum mental health problems range from the 'baby-blues' to puerperal psychosis.

The Edinburgh Postnatal Depression Scale may be used to screen for depression:
 10-item questionnaire, with a maximum score of 30
 Indicates how the mother has felt over the previous week
 Score > 13 indicates a 'depressive illness of varying severity'
 Sensitivity and specificity > 90%
 Includes a question about self-harm

Baby-blues Postnatal depression Puerperal psychosis

 Seen in around 60-  Affects around 10% of  Affects approximately 0.2%

70% of women women of women
 Typically seen 3-7  Most cases start within a  Onset usually within the first
days following birth month and typically 2-3 weeks following birth
and is more peaks at 3 months
common in primips
 Mothers are  Features are similar to  Features include:
characteristically depression seen in other 1) severe swings in mood
anxious, tearful and circumstances (similar to bipolar
irritable disorder) and
2) disordered perception (e.g.
auditory hallucinations)

 Reassurance and  As with the baby blues  Admission to hospital is

support, reassurance and usually required
 the health visitor support are important
 There is around a 20% risk of
has a key role
 Cognitive behavioural recurrence following future
therapy may be pregnancies
beneficial.
 Certain SSRIs such as
sertraline and
paroxetine* may be used
if symptoms are
severe** - whilst they are
secreted in breast milk it
is not thought to be
harmful to the infant

*paroxetine is recommended by SIGN because of the low milk/plasma ratio

**fluoxetine is best avoided due to a long half-life
14
 Hypomania vs. mania
The presence of psychotic symptoms differentiates mania from hypomania

Psychotic symptoms:
1) delusions of grandeur
2) auditory hallucinations

The following symptoms are common to both hypomania and mania:

1) Mood:
 predominately elevated
 irritable

2) Speech and thought:

 pressured
 flight of ideas
 poor attention

3) Behaviour:
 insomnia
 loss of inhibitions: sexual promiscuity, overspending, risk-taking
 increased appetite

15
 Suicide
Factors associated with risk of suicide following an episode of deliberate self harm:
1) Efforts to avoid discovery
2) Planning
3) Leaving a written note
4) Final acts such as sorting out finances
5) Violent method

These are in addition to standard risk factors for suicide

1) Male sex
2) Advancing age
3) Unemployment or social isolation
4) Divorced or widowed
5) History of mental illness (depression, schizophrenia)
6) History of deliberate self harm
7) Alcohol or drug misuse

16
Anxiety disorders

General anxiety disorder

 This occurs in 4–6% of the population and is more common in women.
 Symptoms are persistent and often chronic.

Grief reaction
 It is normal for people to feel sadness and grief following the death of a loved one and
this does not necessarily need to be medicalised.
 However, having some understanding of the potential stages a person may go through
whilst grieving can help determine whether a patient is having a 'normal' grief reaction
or is developing a more significant problem.

One of the most popular models of grief divides it into 5 stages:

1) Denial:
 This may include a feeling of numbness and also pseudohallucinations of the
deceased, both auditory and visual.
 Occasionally people may focus on physical objects that remind them of their
loved one or even prepare meals for them

2) Anger: This is commonly directed against other family members and medical
professionals
3) Bargaining
4) Depression
5) Acceptance

 It should be noted that many patients will not go through all 5 stages.
 Abnormal, or atypical, grief reactions are more likely to occur in women and if the
death is sudden and unexpected. Other risk factors include a problematic relationship
before death or if the patient has not much social support.

Features of atypical grief reactions include:

1) Delayed grief: sometimes said to occur when more than 2 weeks passes before
grieving begins.
2) Prolonged grief: difficult to define. Normal grief reactions may take up to and beyond
12 months

17
 Post-traumatic stress disorder
 Post-traumatic stress disorder (PTSD) can develop in people of any age following a
traumatic event, for example a major disaster or childhood sexual abuse.
 It encompasses what became known as 'shell shock' following the First World War.
 One of the DSM-IV diagnostic criteria is that symptoms have been present for more
than one month

Features:
1) Re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive
images
2) Avoidance: avoiding people, situations or circumstances resembling or associated
with the event
3) Hyperarousal: hypervigilance for threat, exaggerated startle response, sleep
problems, irritability and difficulty concentrating
4) Emotional numbing - lack of ability to experience feelings, feeling detached from
other people
5) Depression
6) Drug or alcohol misuse
7) Anger
8) Unexplained physical symptoms

Management:
1) Following a traumatic event single-session interventions (often referred to as
debriefing) are not recommended
2) Watchful waiting may be used for mild symptoms lasting less than 4 weeks
3) Military personnel have access to treatment provided by the armed forces
4) Trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation
and reprocessing (EMDR) therapy may be used in more severe cases
5) Drug treatments for PTSD should not be used as a routine first-line treatment for
adults. If drug treatment is used then paroxetine or mirtazapine are recommended

18
 Obsessive compulsive disorder
(OCD)
Pathophysiology:
 some research suggest childhood group A beta-haemolytic streptococcal infection
may have a role

Associations:
1) Depression (30%)
2) Schizophrenia (3%)
3) Sydenham's chorea
4) Tourette's syndrome
5) Anorexia nervosa

19
 Alcohol withdrawal
Mechanism:
 Chronic alcohol consumption:
1) Enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and
2) Inhibits NMDA-type glutamate receptors

 Alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA

and increased NMDA glutamate transmission)

Features:
 symptoms start at 6-12 hours
 peak incidence of seizures at 36 hours
 Peak incidence of delirium tremens is at 72 hours:
 Visual hallucinations,
 autonomic instability (tachycardia, hypertension, and pyrexia),
 obtundation ‫ تبلد اإلحساس‬and confusion.
 Sweating, tremors and
 Agitation
(Autonomic instability and hallucinations are not features of opiate withdrawal).

Management:
1) Benzodiazepines
2) carbamazepine also effective in treatment of alcohol withdrawal
3) phenytoin is said not to be as effective in the treatment of alcohol withdrawal
seizures

Alcohol problem drinking management

Nutritional support:
 SIGN recommends alcoholic patients should receive oral thiamine if their 'diet may be
deficient'
Drugs used:
1) Benzodiazepines for acute withdrawal
2) Disulfram:
 Promotes abstinence
 alcohol intake causes severe reaction due to inhibition of acetaldehyde
dehydrogenase
 Patients should be aware that even small amounts of alcohol (e.g. in perfumes,
foods, mouthwashes) can produce severe symptoms.
 Contraindications include IHD and psychosis

3) Acamprosate:
 reduces craving,
 known to be a weak antagonist of NMDA receptors,
 improves abstinence in placebo controlled trials

20
Drug misuse and dependence
Benzodiazepines
 Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-
aminobutyric acid (GABA) by increasing the frequency of chloride channels.
 They therefore are used for a variety of purposes:
1) sedation
2) hypnotic
3) anxiolytic
4) anticonvulsant
5) muscle relaxant

 Patients commonly develop a tolerance and dependence to benzodiazepines and care

should therefore be exercised on prescribing these drugs.
 The Committee on Safety of Medicines advises that benzodiazepines are only
prescribed for a short period of time (2-4 weeks).
 The BNF gives advice on how to withdraw a benzodiazepine.
 The dose should be withdrawn in steps of about 1/8 (range 1/10 to 1/4) of the daily
dose every fortnight‫ كل أسبوعين‬.
 A suggested protocol for patients experiencing difficulty is given:
1) switch patients to the equivalent dose of diazepam
2) reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg
3) time needed for withdrawal can vary from 4 weeks to a year or more

Benzodiazepine withdrawal syndrome

 a condition very similar to alcohol withdrawal syndrome:
 Occurs If patients withdraw too quickly from benzodiazepines
 This may occur up to 3 weeks after stopping a long-acting drug.

Features include:
1) Insomnia
2) Irritability
3) Anxiety
4) Tremor
5) Loss of appetite
6) Tinnitus
7) Perspiration ‫عرق‬
8) Perceptual disturbances ‫اضطرابات إدراكية‬
9) Seizures

21
 Schizophrenia
Risk of developing schizophrenia:
 Monozygotic twin has schizophrenia = 50%
 Parent has schizophrenia = 10-15%
 Sibling has schizophrenia = 10%
 No relatives with schizophrenia = 1%

Schizophrenia features:
Schneider's first rank symptoms may be divided into auditory hallucinations, thought
disorders, passivity phenomena and delusional perceptions:
A) Auditory hallucinations of a specific type:
1) two or more voices discussing the patient in the third person
2) thought echo
3) voices commenting on the patient's behaviour
B) Thought disorder:
1) Occasionally referred to as thought alienation
2) thought insertion
3) thought withdrawal
4) thought broadcasting
C) Passivity phenomena:
1) bodily sensations being controlled by external influence
2) actions/impulses/feelings - experiences which are imposed on the individual or
influenced by others
D) Delusional perceptions:
A two stage process where first a normal object is perceived then secondly there is a
sudden intense delusional insight into the objects meaning for the patient e.g. 'the
traffic light is green therefore I am the King'.
E) Other features of schizophrenia include
1) impaired insight
2) incongruity/blunting of affect (inappropriate emotion for circumstances)
3) decreased speech
4) neologisms: made-up words
5) catatonia
6) negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive
pleasure), alogia (poverty of speech), avolition (poor motivation)

Factors associated with poor prognosis:

 strong family history
 gradual onset
 low IQ
 premorbid history of social withdrawal
 lack of obvious precipitant
22
23
 Antipsychotics
 Antipsychotics act as dopamine D2 receptor antagonists,
blocking dopaminergic transmission in the mesolimbic pathways
 Conventional antipsychotics are associated with problematic extrapyramidal side-
effects which has led to the development of atypical antipsychotics such as clozapine
 (Chlorpromazine , haloperidol, Phenothiazines)

Extrapyramidal side-effects:
1) Parkinsonism
2) Acute dystonia (e.g. torticollis, oculogyric crisis)
 Diphenhydramine is used in the treatment of acute dystonia.
 Benztropine or diazepam can also be used.
3) Akathisia (severe restlessness)
4) Tardive dyskinesia
(Late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of
patients, may be irreversible, most common is chewing and pouting of jaw)

The Medicines and Healthcare products Regulatory Agency has issued specific warnings
when antipsychotics are used in elderly patients:
1) increased risk of stroke
2) increased risk of venous thromboembolism
Other side-effects
1) antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
2) sedation, weight gain
3) raised prolactin: galactorrhoea,
4) SIADH,
5) impaired glucose tolerance,
6) neuroleptic malignant syndrome: pyrexia, muscle stiffness
7) reduced seizure threshold (greater with atypicals)
8) prolonged QT interval (particularly haloperidol)

Phenothiazines have antiemetic and antipsychotic properties, making them the medication of
choice for acute porphyria episodes. Can be used in migraine

24
 Atypical Antipsychotics
 Should be used first-line in patients with schizophrenia, according to 2005 NICE
guidelines.
 The main advantage of the atypical agents is a significant reduction in extra-pyramidal
side-effects.

Adverse effects of atypical antipsychotics:

1) Weight gain
2) Clozapine is associated with agranulocytosis (see below)

The Medicines and Healthcare products Regulatory Agency has issued specific warnings
when antipsychotics are used in elderly patients:

1) increased risk of stroke (especially olanzapine and risperidone)

2) increased risk of venous thromboembolism

Examples of atypical antipsychotics

 Clozapine
 Olanzapine
 Risperidone
 Quetiapine
 Amisulpride

Clozapine:
 One of the first atypical agents to be developed
 Carries a significant risk of agranulocytosis and full blood count monitoring is
therefore essential during treatment.
 For this reason clozapine should only be used in patients resistant to other
antipsychotic medication

Adverse effects of clozapine:

1) Agranulocytosis (1%), neutropaenia (3%)
2) reduced seizure threshold
Can induce seizures in up to 3% of patients
3) Atypical antipsychotics such as olanzapine/risperidone/clozapine have been
associated with hyperglycaemia and insulin resistance.
The mechanism remains obscure, but withdrawal of the medication may produce
resolution of the diabetes.

25
 Neuroleptic Malignant Syndrome
 Neuroleptic malignant syndrome is a rare but dangerous condition seen in patients
taking antipsychotic medication.
 Caused by a sudden reduction in dopamine activity, either from blockade of dopamine
receptors or withdrawal of dopaminergic agents.
 It carries a mortality of up to 10% and can also occur with atypical antipsychotics.
 It may also occur with dopaminergic drugs (such as levodopa) for Parkinson's
disease, usually when the drug is suddenly stopped or the dose reduced.

Features:
1) more common in young male patients
2) Onset usually in first 10 days of treatment or after increasing dose but it can occur
at any time during the treatment with antipsychotic medications.
3) Concomitant treatment with lithium or anticholinergics may increase the risk of
NMS.
4) Pyrexia
5) rigidity
6) Altered mental status
7) Autonomic dysfunction
8) tachycardia
9) A raised creatine kinase is present in most cases.
−1
10) The creatine phosphokinase concentration is always elevated (>1000 IU/L ),
reflecting myonecrosis secondary to intense muscle contracture.
11) A leukocytosis may also be seen

Management:
1) stop antipsychotic
2) IV fluids to prevent renal failure
3) reduction of body temperature with antipyretics.
4) dantrolene* may be useful in selected cases
5) bromocriptine, dopamine agonist, may also be used

*thought to work by decreasing excitation-contraction coupling in skeletal muscle by

binding to the ryanodine receptor, and decreasing the release of calcium from the
sarcoplasmic reticulum

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 Charles Bonnet syndrome
 Charles Bonnet syndrome (CBS) is characterised by persistent or recurrent complex
hallucinations (usually visual or auditory), occurring in clear consciousness.
 This is generally against a background of visual impairment (although visual
impairment is not mandatory for a diagnosis).
 Insight is usually preserved.
 This must occur in the absence of any other significant neuropsychiatric disturbance.

Risk factors include:

1) Advanced age
2) Peripheral visual impairment
3) Social isolation
4) Sensory deprivation
5) Early cognitive impairment

 Charles Bonnet syndrome (CBS) is equally distributed between sexes and does not
show any familial predisposition.

 The most common ophthalmological conditions associated with this syndrome are
age-related macular degeneration, followed by glaucoma and cataract.

 Well-formed complex visual hallucinations are thought to occur in 10-30 percent of

individuals with severe visual impairment.

 Prevalence of Charles Bonnet syndrome (CBS) in visually impaired people is thought

to be between 11 and 15 percent.

 Around a third find the hallucinations themselves an unpleasant or disturbing

experience.

 In a large study published in the British Journal of Ophthalmology, 88% had Charles
Bonnet syndrome (CBS) for 2 years or more, resolving in only 25% at 9 years (thus it is
not generally a transient experience).

Cox (2014) Negative outcome Charles Bonnet Syndrome. Br J Ophthalmol.

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Eating disorders
Anorexia Nervosa
Anorexia nervosa is the most common cause of admissions to child and adolescent
psychiatric wards.
Epidemiology:
 90% of patients are female
 predominately affects teenage and young-adult females
 prevalence of between 1:100 and 1:200

Diagnosis: (based on the DSM-IV criteria)

1) person chooses not to eat - BMI < 17.5 kg/m^2, or < 85% of that expected
2) intense fear of being obese
3) disturbance of weight perception
4) amenorrhoea = 3 consecutive cycles

The prognosis of patients with anorexia nervosa remains poor.

Up to 10% of patients will eventually die because of the disorder.

Features:
Anorexia nervosa is associated with a number of characteristic clinical signs and
physiological abnormalities which are summarised below

1) Reduced BMI
2) Bradycardia
3) Hypotension
4) Enlarged salivary glands

Physiological abnormalities:
1) hypokalaemia
2) low FSH, LH, oestrogens and testosterone
3) low T3
4) raised cortisol and growth hormone
5) impaired glucose tolerance
6) hypercholesterolaemia
7) hypercarotinaemia

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 Bulimia Nervosa
Bulimia nervosa is a type of eating disorder characterised by episodes of binge eating
followed by intentional vomiting

Management:
1) referral for specialist care is appropriate in all cases
2) cognitive behaviour therapy (CBT) is currently consider first-line treatment
3) interpersonal psychotherapy is also used but takes much longer than CBT
4) pharmacological treatments have a limited role - a trial of high-dose fluoxetine is
currently licensed for bulimia but long-term data is lacking

Body dysmorphic disorder

 Body dysmorphic disorder sometimes referred to as dysmorphophobia.
 It is a mental disorder where patients have a significantly distorted body image

Diagnostic and Statistical Manual (DSM) IV criteria:

 Preoccupation with an imagine defect in appearance. If a slight physical anomaly is
present, the person's concern is markedly excessive
 The preoccupation causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning
 The preoccupation is not better accounted for by another mental disorder (e.g.,
dissatisfaction with body shape and size in Anorexia Nervosa)

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Involuntary detention or commitment 1191

30
 Mental Capacity Act
The Mental Capacity Act 2005 uses a functional test of capacity.
In the case of the MCA, the specific tests applied are that the individual must show an
ability to Understand and retain the relevant information Weigh their options (and see the
consequences of any choice) Communicate their choice.
Although the Mental Capacity Act is specific to England and Wales, the functional test of
capacity is used internationally and forms the basis for legislation in Scotland, USA and
most English-speaking nations.
Whilst previously expressed wishes should be taken into account, these usually form part
of a 'best interests' assessment, which occurs after capacity has been evaluated. The
issue of previously expressed wishes would not be a determinant under functional tests
of capacity, and mentally capacitated individuals have a right to contradict previously
expressed wishes.
Using widely accepted criteria for the functional test of capacity, the answer is inability to
understand the relevant information.
Irrational decision making is called the 'rational outcome' approach - it is not a functional
test of capacity and is not used, for example, in the Mental Capacity Act as it is too
subjective.
Although 'communicating choice' is a criterion in the MCA, loss of a hearing aid would
not be considered a sufficiently good reason to judge lack of capacity. The onus is on the
doctor to alleviate any remediable communication problem prior to assessing capacity.
Many functional tests of capacity have a 'diagnostic hurdle', that is, the presence of
mental illness might be a reason to trigger a mental capacity assessment, but mental
illness itself is no reason automatically to assume lack of capacity - this would be a
'status' test of capacity.

Tourette syndrome
 Presents before 18 years of age and many children grow out of it.
 The criteria for diagnosis require multiple motor and one or more vocal tics, showing
themselves over a year, with not more than three consecutive months tic free.
 The motor tics often have a build up that the patient is aware of, like an itch.
Commonly they involve blinking, throat clearing or shoulder shrugging.
 Although his father has epilepsy this is unlikely to be epilepsy as the shouting of
swear words is a typical vocal tic of Tourette's.

Huntington's disease
 It is a neurodegenerative genetic disorder that is autosomal dominant.
 The features are of choreiform movements, problems with coordination and walking,
behavioural and psychiatric problems.
 The disease leads eventually to dementia and premature death.

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 Rett syndrome
 Predominantly affects females and is a neurodevelopment disorder of the grey matter.
 The sufferers have small hands and feet with deceleration of head growth.
 Many patients are epileptic, display repetitive hand movements, rarely develop speech
and also have GI problems, such as constipation.

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33
 Serotonin syndrome
Causes:
 Monoamine oxidase inhibitors MAOI
 SSRIs ( ‫ سؤال االمتحان‬plus sumatriptan)
 Ecstasy
 Amphetamines

Features:
 neuromuscular excitation e.g. hyperreflexia, tremor, myoclonus, incoordination,
seizures,
 autonomic excitation (e.g. hyperthermia, tachycardia, HTN, salivation)
 altered mental state e.g. confusion, anxiety, hypomania, agitation, coma

Treatment: cyproheptadine

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