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Summary Psychiatry overview for medical finals
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An overview of all psychiatric conditions needed for medical finals, as well as MSE and psychiatric history taking.
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Psychiatry - key conditions for medical finals
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PsychiatryPsychoses ............................................................................................................................................... 2
Psychosis.......................................................................................................................................................... 2
Schizophrenia ................................................................................................................................................... 5
Mood (Affective) disorders...................................................................................................................... 8
Depression ....................................................................................................................................................... 8
Bipolar affective disorder ............................................................................................................................... 11
Anxiety and stress-related disorders ..................................................................................................... 13
Phobic anxiety disorders................................................................................................................................. 14
Social Phobia/anxiety disorder ................................................................................................................................................. 14
Agoraphobic ............................................................................................................................................................................. 14
Specific Phobias ........................................................................................................................................................................ 15
Panic disorder (+/- agoraphobia)..................................................................................................................... 15
Generalised anxiety disorder .......................................................................................................................... 16
Obsessive compulsive disorder .............................................................................................................. 16
Reaction to severe stress and adjustment disorders .............................................................................. 18
Acute stress reaction ...................................................................................................................................... 18
Adjustment disorder....................................................................................................................................... 18
Post-traumatic stress disorder ........................................................................................................................ 18
Medically unexplained Sx ..................................................................................................................... 19
Somatoform disorders .................................................................................................................................... 19
Dissociative (conversion) disorders ................................................................................................................. 20
Personality disorders ............................................................................................................................ 21
Substance misuse ................................................................................................................................. 25
Alcohol abuse ................................................................................................................................................. 29
Old person’s psychiatry ......................................................................................................................... 31
Delirium ......................................................................................................................................................... 31
Dementia ....................................................................................................................................................... 33
Eating disorders.................................................................................................................................... 39
Anorexia nervosa ........................................................................................................................................... 39
Bulimia nervosa.............................................................................................................................................. 41
Other types of EDs .......................................................................................................................................... 43
Self-harm ............................................................................................................................................. 43
Suicide.................................................................................................................................................. 44
Perinatal psychiatric disorders .............................................................................................................. 45
Liaison psychiatry ................................................................................................................................. 46
Child Mental Health .............................................................................................................................. 46
Common psychiatric disorders - children and adolescents...................................................................... 47
, Anxiety disorders ........................................................................................................................................... 47
Depression ..................................................................................................................................................... 48
Conduct and emotional disorders (behavioural problems) ............................................................................... 48
Personality disorder ....................................................................................................................................... 49
(Gilles de la) Tourette’s syndrome ................................................................................................................... 49
Eating Disorders ............................................................................................................................................. 49
Psychotic illness ............................................................................................................................................. 49
Autism spectrum disorders ............................................................................................................................. 50
Attention Deficit Hyperactivity disorder (Hyperkinetic disorder) ...................................................................... 53
Psychiatric history ................................................................................................................................ 55
Mental state examination .................................................................................................................... 56
Suicide Risk Assessment ........................................................................................................................ 59
Bio-psycho-social model ....................................................................................................................... 59
Medications and treatments ................................................................................................................. 59
Antidepressants: ............................................................................................................................................ 60
Antipsychotics ................................................................................................................................................ 62
Antianxiolytics ............................................................................................................................................... 65
Hypnotics ....................................................................................................................................................... 67
Mood stabilisers ............................................................................................................................................. 67
Psychotherapy ...................................................................................................................................... 68
Electroconvulsive therapy ..................................................................................................................... 70
Psychiatry – Legal aspects..................................................................................................................... 70
Levels of observation on the wards ....................................................................................................... 72
Grief reaction ....................................................................................................................................... 72
Insomnia .............................................................................................................................................. 72
Hallucinations:
Psychoses Auditory – 1st person (audible thoughts),
2nd person (hear voices talking to them),
3rd person (hear voices speaking about
them)
Psychosis Somatic – tactile (skin being touched),
Psychosis = mental state in which reality is greatly disordered. 3 main Sx are Hygric (feeling of fluid), visceral (false
hallucinations, delusions, thought disorder. Psychotic episodes can begin perception of internal organs),
suddenly/gradually, and last days/weeks/months – individual usually doesn’t realise Kinaesthetic (false perception of
they are psychotic. There is extreme impairment of ability to think clearly, respond joints/muscles e.g. feel limbs vibrating)
Extracampine – delusions that occur
with appropriate emotion, communicative effectively, understand reality and behave outside limits of a person’s sensory field
appropriately. It describes Sx, not a diagnosis. Prevalence 31.7/100,000. Pt typically e.g. hear voices from 100 miles away
brought to doctor/ED by 3rd party. Functional – normal sensory stimulus
• Hallucinations = perception w/o a stimulus, can be in any sensory modality. needed to cause hallucination e.g.
‘Normal’ hallucinations in general population can hypnogogic (on falling doorbell ringing → hearing voices
asleep) and hypnopompic (on waking up).
o Auditory are most common. Visual hallucinations more common in delirium.
o Olfactory hallucination – frontal lobe e.g. medial meningioma pathology can compresses olfactory nerve
(need to rule out organic cause)
o Pseudohallucination = involuntary sensory experience which is vivid enough to be regarded as a
hallucination, but considered by the person as subjective and unreal (occurs in inner subjective space e.g.
, voices heard inside one’s head, not in the outside world). Hypnagogic and hypnopompic hallucinations
are examples. Pseudohallucinations can occur in normal grief reaction. True hallucinations will be
perceived in the outside world.
• Delusions = fixed, firmly held abnormal belief outside social and cultural norms, that cannot be reasoned away,
that is held despite evidence to the contrary. Examples = delusions of grandeur, control (believe others are
controlling them), reference (ordinary events/objects/behaviours have a particular meaning just for them),
eratomanic (believe everyone is in love with you), persecutory (believe others are out to harm them), nihilistic
(belief of being dead, having lost one’s own internal organs or not existing at all as a human being), Othello
syndrome (delusional jealousy – believe that their partner is unfaithful)
o Can be primary (do not occur in response to previous psychopathological state), secondary (consequence
of pre-existing psychopathological states e.g. mood disorders), mood congruent/incongruent, bizarre
(completely impossible) or non-bizarre.
**Encapsulated delusion - An isolated mistaken, but unshakeable belief in something for which there is neither evidence
nor common acceptance occurring in the absence of other signs or symptoms of psychiatric illness.
• Thought disorder = impairment of ability to form thoughts from logically connected ideas so thoughts = confused
and disturbed.
o Flight of ideas, loosening of association (knight’s move thinking), alogia (poverty of speech – little info
conveyed by speech and may only talk if prompted) thought blocking (interrupt themselves mid-
sentence), circumstantiality (excessive irrelevant details), distractible speech (trouble maintaining a
topic), echolalia (repeat words spoken around them), perseveration (initially correct response is
inappropriately repeated)
• Disorders of self = individual can no longer distinguish between themselves and the world.
Psychosis may be preceded by a prodromal period which can last from a few days → around 18 months. This period
involves emotional and behavioural changes → in personal functioning and social withdrawal. Period often followed by
acute psychotic episode.
RFs = BAME, FHx (strongest RF for psychotic disorders), recreational drug use, Hx of traumatic life events, complications of
pregnancy/birth, neurodevelopmental delay, urban living, high-dose corticosteroids, Toxoplasma gondii exposure,
migration
ICD-10 criteria – psychotic disorders:
• Schizophrenia
• Schizotypal Disorder – latent schizophrenia. Have eccentric behaviour, suspiciousness, unusual speech,
deviations of thinking and affect, but no hallucinations/delusions
• Persistent Delusional Disorder
o Delusional disorder - development of single/set of delusions for at least 3mths
▪ Paraphrenia – organised system of paranoid delusions +/- hallucinations, and without
deterioration of intellect or personality (no -ve Sx).
o Other persistent delusional disorders e.g. delusional dysmorphophobia
• Acute and Transient Psychotic Disorder – psychotic episode similar to schizophrenia (with no organic
causation) but lasting <1mth. Usually no prodromal period, often precipitated by life stress
• Induced Delusional Disorder – shared paranoid disorder. Characterised by presence of similar delusions in two
or more individuals with close emotional links
• Schizoaffective Disorder – both symptoms of schizophrenia and a mood disorder (mania or depression) in
same episode of illness
• Other Non-organic Psychotic Disorders – delusional or hallucinatory disorders that don’t meet other criteria
• Unspecified Non-organic Psychosis
In schizoaffective disorder, the psychotic symptoms may or may not be present during the times when a person is
experiencing depression or mania. In mood disorder with psychotic features, delusions/hallucinations are NOT present
without mood disorder.
, Causes of +ve Sx (differentials):
• Non-organic causes (functional psychosis)
o Schizophrenia and other psychotic disorders – delusions are bizarre, persecutory and auditory ones are in
the 3rd person.
o Primary mood (affective) disorders - psychosis that is congruent with mood. Depressed patients may
have delusions of guilt, nihilism or unpleasant auditory hallucinations, and auditory ones are in 2nd
person. Manic patients may hear the voice of God talking to them, have grandiose delusions and auditory
ones are in 2nd person.
o Personality disorders – never achieve normal baseline
o Postpartum psychosis - severe and needs to be recognised quickly. More common in patients with history
or family history of bipolar disorder or psychotic illness. Onset is days to wks of delivery. Develops over
hrs to days.
o Drug-induced
• Organic causes
o Neurological conditions - Parkinson’s, dementia, Huntington’s, autoimmune encephalitis, epilepsy
(especially temporal lobe), brain tumour, stroke, trauma
o Delirium – hypoxia, medication interaction/withdrawal, sepsis, sleep deprivation, metabolic/electrolyte
derangements
o Metabolic derangements - hyperthyroidism, hypercalcaemia, hypoglycaemia
o Autoimmune – SLE, MS
o Cushing’s
o Vitamin B deficiency
o Malignancy - ovarian teratoma, small cell lung cancer
o Infections – syphilis, malaria, HIV and AIDS
o Substance abuse/drug induced - onset of psychotic Sx
during/within 2 weeks of taking drug, persistence of Sx for
>48 hours, duration of Sx not >6 months.
▪ Medication – steroids, dopamine agonists
▪ Recreational drugs - methamphetamine (crystal
meth), cannabis, LSD, ecstasy, ketamine, cocaine
Investigations: (look for underlying organic cause and rule out
differentials)
• MSE, full neuro exam
• Bloods
o FBC and LFTs – if abnormal (+macrocytosis) → alcohol
abuse. WCC and inflamm markers in infection.
o Electrolyte levels – rule out derangements
o Serological tests – syphilis
o Blood borne virus screen
o Autoimmune screen
o TFTs
• Bedside test
o BM
o Urine dipstick +/- MSU
o ECG – look for long QT if considering antipsychotics
• Urine screen – drug abuse (can also do blood or hair screens)
• Imaging
o CT/MRI – suggested neurological abnormality/ persistent cognitive impairment. Look for atrophy of
lateral ventricles.
o Consider EEG if suspect epilepsy
Management of psychosis:
• Early intervention in psychosis team to coordinate care if 1st episode
• Assess risk – high risk need same-day mental health assessment by early intervention in psychosis service
• Prompt admission to psychiatric unit. May need to be enforced under mental health act.
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