Understanding Psychiatric Symptoms: Obsessions, Compulsions, Delusions, Hallucinations, and Thought Interference

Psychiatric symptoms can be complex and difficult to understand. Here are some explanations of common symptoms:

Obsessions are intrusive thoughts, images, or impulses that repetitively and stereotypically enter a person’s mind. They are often distressing and patients try unsuccessfully to resist them. Common themes include aggression, dirt and contamination, fear of causing harm, religion, and sex.

Compulsions are repetitive and stereotyped acts or rituals that are often carried out as an attempt to neutralize distressing obsessional thoughts. Patients typically recognize these behaviors as pointless and ineffective, and try to resist them, often unsuccessfully.

Delusions are false, fixed, and firmly held beliefs that are not in keeping with a person’s social, cultural, and religious background. Patients typically do not recognize them as false or irrational and do not try to resist them, even if they find them distressing.

Hallucinations are sensory experiences that occur without an external stimulus that could produce such perception. They can be perceptions in any sensory modality, such as hearing a voice in the absence of anyone actually talking.

Thought interference consists of a patient’s firm belief that an external entity is interfering with their thoughts, usually by introducing thoughts in their mind, stealing thoughts from them, or being able to access their thoughts. Patients usually lack insight into these pathological experiences.

Understanding these symptoms can help individuals and their loved ones seek appropriate treatment and support.

In the management of alcohol withdrawal, decreasing doses of long-acting benzodiazepines are commonly used. This is because long-term alcohol use can cause an imbalance in the brain’s excitatory and inhibitory neurotransmitters, leading to symptoms of an overactive sympathetic nervous system when alcohol is suddenly stopped. These symptoms can include restlessness, sweating, tremors, and agitation, and can even progress to seizures and delirium tremens. Long-acting benzodiazepines, such as chlordiazepoxide or diazepam, potentiate the action of the inhibitory neurotransmitter GABA and can help mitigate the risk of seizures and other withdrawal symptoms. Carbamazepine, an anticonvulsant, may also be used as a second-line medication if benzodiazepines are not appropriate. Haloperidol, a typical antipsychotic, is not typically used in alcohol withdrawal as it does not reduce the risk of seizures. Lorazepam, a short-acting benzodiazepine, is also not typically used in this context as long-acting benzodiazepines are preferred for their longer half-life.

Alcohol withdrawal occurs when an individual who has been consuming alcohol chronically suddenly stops or reduces their intake. Chronic alcohol consumption enhances the inhibitory effects of GABA in the central nervous system, similar to benzodiazepines, and inhibits NMDA-type glutamate receptors. However, alcohol withdrawal leads to the opposite effect, resulting in decreased inhibitory GABA and increased NMDA glutamate transmission. Symptoms of alcohol withdrawal typically start at 6-12 hours and include tremors, sweating, tachycardia, and anxiety. Seizures are most likely to occur at 36 hours, while delirium tremens, which includes coarse tremors, confusion, delusions, auditory and visual hallucinations, fever, and tachycardia, peak at 48-72 hours.

Patients with a history of complex withdrawals from alcohol, such as delirium tremens, seizures, or blackouts, should be admitted to the hospital for monitoring until their withdrawals stabilize. The first-line treatment for alcohol withdrawal is long-acting benzodiazepines, such as chlordiazepoxide or diazepam, which are typically given as part of a reducing dose protocol. Lorazepam may be preferable in patients with hepatic failure. Carbamazepine is also effective in treating alcohol withdrawal, while phenytoin is said to be less effective in treating alcohol withdrawal seizures.

If a patient is under section 2 or 3, treatment can be administered even if they refuse it. Patients who are detained under section 3 can be treated against their will, regardless of their capacity. However, after three months, if the patient still refuses treatment, an impartial psychiatrist must review the proposed medication and agree with the treating team’s plan. The Mental Health Act takes precedence over the Mental Capacity Act, so a best interests meeting is not necessary. The treating team must consider the patient’s best interests, and in this case, they believe that medication is necessary for Rosie’s mental health. While benzodiazepines can alleviate agitation and distress, they are unlikely to improve her psychotic symptoms, so they are not a suitable option. If Rosie continues to refuse treatment after three months under section 3, a second opinion will be required.

Sectioning under the Mental Health Act is a legal process used for individuals who refuse voluntary admission. This process excludes patients who are under the influence of drugs or alcohol. There are several sections under the Mental Health Act that allow for different types of admission and treatment.

Section 2 allows for admission for assessment for up to 28 days, which is not renewable. An Approved Mental Health Professional (AMHP) or the nearest relative (NR) can make the application on the recommendation of two doctors, one of whom should be an approved consultant psychiatrist. Treatment can be given against the patient’s wishes.

Section 3 allows for admission for treatment for up to 6 months, which can be renewed. An AMHP and two doctors, both of whom must have seen the patient within the past 24 hours, can make the application. Treatment can also be given against the patient’s wishes.

Section 4 is used as an emergency 72-hour assessment order when a section 2 would involve an unacceptable delay. A GP and an AMHP or NR can make the application, which is often changed to a section 2 upon arrival at the hospital.

Section 5(2) allows a doctor to legally detain a voluntary patient in hospital for 72 hours, while section 5(4) allows a nurse to detain a voluntary patient for 6 hours.

Section 17a allows for Supervised Community Treatment (Community Treatment Order) and can be used to recall a patient to the hospital for treatment if they do not comply with the conditions of the order in the community, such as taking medication.

Section 135 allows for a court order to be obtained to allow the police to break into a property to remove a person to a Place of Safety. Section 136 allows for someone found in a public place who appears to have a mental disorder to be taken by the police to a Place of Safety. This section can only be used for up to 24 hours while a Mental Health Act assessment is arranged.

Understanding Phobias and Dissociative Disorders

Phobias and dissociative disorders are two types of mental health conditions that can significantly impact a person’s daily life. Phobias are intense and irrational fears of specific objects or situations, while dissociative disorders involve a disconnection from reality as a coping mechanism.

Agoraphobia is a common and severe phobia that affects mostly women and involves a fear of open spaces and crowded places. Social phobia, on the other hand, is a fear of being scrutinized in public and tends to start in adolescence. Acrophobia is a specific phobia that involves a fear of heights.

Treatment for phobias often involves psychological interventions such as cognitive-behavioral therapy. Dissociative disorders, on the other hand, typically require more intensive therapy to address the underlying trauma that led to the dissociation.

It’s important to seek professional help if you or someone you know is struggling with a phobia or dissociative disorder. With the right treatment and support, it is possible to manage these conditions and improve overall quality of life.

Hoover’s sign is a useful clinical tool that can quickly differentiate between organic and non-organic leg paresis. In cases of non-organic paresis, pressure is felt under the affected leg when the unaffected leg is lifted against pressure. This is due to involuntary contralateral hip extension.

Based on this scenario, the likely diagnosis is a conversion disorder, which is characterized by the loss of motor function in the leg without any organic cause. The positive result of Hoover’s sign supports this diagnosis.

Babinski’s sign is a reflex that involves dorsiflexion of the big toe upon plantar stimulation. It is indicative of an upper motor neuron lesion of the corticospinal tract.

Brudziński’s sign is a reflex that involves the flexion of the hips with forced flexion of the neck. It is typically associated with meningitis but can also be present in patients with subarachnoid hemorrhage and encephalitis.

The glabellar tap sign, also known as Myerson’s sign, involves tapping the area above the nose and between the eyebrows (glabella) repeatedly. Healthy patients usually blink in response to the first 2-3 taps, but if a patient is unable to resist blinking beyond this, it can be indicative of early Parkinson’s disease.

The straight leg raise test, also known as Lasègue’s sign, involves raising the straight leg to reproduce radiating leg pain. A positive result indicates a likely lumbar disc herniation.

Psychiatric Terms for Unexplained Symptoms

There are various psychiatric terms used to describe patients who exhibit symptoms for which no organic cause can be found. One such disorder is somatisation disorder, which involves the presence of multiple physical symptoms for at least two years, and the patient’s refusal to accept reassurance or negative test results. Another disorder is illness anxiety disorder, which is characterized by a persistent belief in the presence of an underlying serious disease, such as cancer, despite negative test results.

Conversion disorder is another condition that involves the loss of motor or sensory function, and the patient does not consciously feign the symptoms or seek material gain. Patients with this disorder may be indifferent to their apparent disorder, a phenomenon known as la belle indifference. Dissociative disorder, on the other hand, involves the process of ‘separating off’ certain memories from normal consciousness, and may manifest as amnesia, fugue, or stupor. Dissociative identity disorder (DID) is the most severe form of dissociative disorder and was previously known as multiple personality disorder.

Factitious disorder, also known as Munchausen’s syndrome, involves the intentional production of physical or psychological symptoms. Finally, malingering is the fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain. Understanding these psychiatric terms can help healthcare professionals better diagnose and treat patients with unexplained symptoms.

Based on the man’s PHQ-9 score and varied symptoms, it appears that he is suffering from severe depression. According to NICE guidelines, a combination of an antidepressant and psychological intervention is recommended for this level of depression, with an SSRI being the first choice antidepressant. Therefore, citalopram with CBT would be the appropriate treatment in this case. Referral to psychiatry is not necessary at this time. Venlafaxine would be considered as a later option if other antidepressants were ineffective. While fluoxetine is a good first-line antidepressant, it should be combined with a psychological intervention for severe depression. CBT alone is suitable for mild to moderate depression, but for severe depression, an antidepressant in combination with psychological intervention is recommended.

In 2022, NICE updated its guidelines on managing depression and now classifies it as either less severe or more severe based on a patient’s PHQ-9 score. For less severe depression, NICE recommends discussing treatment options with patients and considering the least intrusive and resource-intensive treatment first. Antidepressant medication should not be routinely offered as first-line treatment unless it is the patient’s preference. Treatment options for less severe depression include guided self-help, group cognitive behavioral therapy, group behavioral activation, individual CBT or BA, group exercise, group mindfulness and meditation, interpersonal psychotherapy, SSRIs, counseling, and short-term psychodynamic psychotherapy. For more severe depression, NICE recommends a shared decision-making approach and suggests a combination of individual CBT and an antidepressant as the preferred treatment option. Other treatment options for more severe depression include individual CBT or BA, antidepressant medication, individual problem-solving, counseling, short-term psychodynamic psychotherapy, interpersonal psychotherapy, guided self-help, and group exercise.

Fluoxetine is the preferred SSRI for children and adolescents.

Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.

The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.

When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.

When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.

Anorexia is characterized by low levels of various substances, including growth hormone, glucose, salivary glands, cortisol, cholesterol, and carotene.

Characteristics of Anorexia Nervosa

Anorexia nervosa is a disorder that is characterized by a number of clinical signs and physiological abnormalities. The most notable feature of this disorder is a reduced body mass index, which is often accompanied by bradycardia and hypotension. In addition, individuals with anorexia nervosa may experience enlarged salivary glands, which can cause discomfort and difficulty swallowing.

Physiological abnormalities associated with anorexia nervosa include hypokalaemia, which is a deficiency of potassium in the blood, as well as low levels of FSH, LH, oestrogens, and testosterone. Individuals with anorexia nervosa may also have raised levels of cortisol and growth hormone, impaired glucose tolerance, hypercholesterolaemia, hypercarotinaemia, and low T3.

Overall, anorexia nervosa is a complex disorder that can have a significant impact on an individual’s physical and emotional well-being. It is important for individuals who are struggling with this disorder to seek professional help in order to receive the support and treatment they need to recover.

The young man in question is likely suffering from borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD). This condition is characterized by unstable relationships, alternating between idealization and devaluation of others, recurrent self-harm, unstable self-image and self-esteem, suicidal behavior, difficulty controlling anger, and efforts to avoid abandonment. All of these traits are present in this patient, making BPD the most likely diagnosis.

Narcissistic personality disorder is not a likely diagnosis for this patient, as it is characterized by a grandiose sense of self-importance, lack of empathy, and a sense of entitlement. These traits are not present in this patient, and his periods of devaluing her partner are temporary and not pervasive.

Dependent personality disorder is also an unlikely diagnosis, as this condition is characterized by a pervasive need for others to make decisions for the patient and constant reassurance. While the patient has felt that he cannot live without his partner in the past, his labile mood and alternating view of his partner make this diagnosis less likely.

Paranoid personality disorder is also an unlikely diagnosis, as patients with this condition tend to be reluctant to confide in others and have an unforgiving attitude when insulted or questioned. The patient in question does not exhibit these traits, and his difficulty with trusting friends is likely due to his belief that he is undeserving of them.

Personality disorders are a set of personality traits that are maladaptive and interfere with normal functioning in life. It is estimated that around 1 in 20 people have a personality disorder, which are typically categorized into three clusters: Cluster A, which includes Odd or Eccentric disorders such as Paranoid, Schizoid, and Schizotypal; Cluster B, which includes Dramatic, Emotional, or Erratic disorders such as Antisocial, Borderline (Emotionally Unstable), Histrionic, and Narcissistic; and Cluster C, which includes Anxious and Fearful disorders such as Obsessive-Compulsive, Avoidant, and Dependent.

Paranoid individuals exhibit hypersensitivity and an unforgiving attitude when insulted, a reluctance to confide in others, and a preoccupation with conspirational beliefs and hidden meanings. Schizoid individuals show indifference to praise and criticism, a preference for solitary activities, and emotional coldness. Schizotypal individuals exhibit odd beliefs and magical thinking, unusual perceptual disturbances, and inappropriate affect. Antisocial individuals fail to conform to social norms, deceive others, and exhibit impulsiveness, irritability, and aggressiveness. Borderline individuals exhibit unstable interpersonal relationships, impulsivity, and affective instability. Histrionic individuals exhibit inappropriate sexual seductiveness, a need to be the center of attention, and self-dramatization. Narcissistic individuals exhibit a grandiose sense of self-importance, lack of empathy, and excessive need for admiration. Obsessive-compulsive individuals are occupied with details, rules, and organization to the point of hampering completion of tasks. Avoidant individuals avoid interpersonal contact due to fears of criticism or rejection, while dependent individuals have difficulty making decisions without excessive reassurance from others.

Personality disorders are difficult to treat, but a number of approaches have been shown to help patients, including psychological therapies such as dialectical behavior therapy and treatment of any coexisting psychiatric conditions.

The most significant risk factor for psychotic disorders is a person’s family history.

Understanding the Epidemiology of Schizophrenia

Schizophrenia is a psychotic disorder that affects a significant portion of the population. The strongest risk factor for developing this condition is having a family history of the disorder. Individuals with a parent who has schizophrenia have a relative risk of 7.5. Additionally, monozygotic twins have a 50% chance of developing schizophrenia, while siblings have a 10% chance. In contrast, individuals with no relatives with schizophrenia have a 1% chance of developing the disorder.

Aside from family history, other factors can increase the risk of developing schizophrenia. Black Caribbean ethnicity has a relative risk of 5.4, while migration and living in an urban environment have relative risks of 2.9 and 2.4, respectively. Cannabis use also increases the risk of developing schizophrenia, with a relative risk of 1.4.

Understanding the epidemiology of schizophrenia is crucial in identifying individuals who may be at risk of developing the disorder. By recognizing these risk factors, healthcare professionals can provide early interventions and support to prevent or manage the onset of schizophrenia.

Sectioning under the Mental Health Act is a legal process used for individuals who refuse voluntary admission. This process excludes patients who are under the influence of drugs or alcohol. There are several sections under the Mental Health Act that allow for different types of admission and treatment.

Section 2 allows for admission for assessment for up to 28 days, which is not renewable. An Approved Mental Health Professional (AMHP) or the nearest relative (NR) can make the application on the recommendation of two doctors, one of whom should be an approved consultant psychiatrist. Treatment can be given against the patient’s wishes.

Section 3 allows for admission for treatment for up to 6 months, which can be renewed. An AMHP and two doctors, both of whom must have seen the patient within the past 24 hours, can make the application. Treatment can also be given against the patient’s wishes.

Section 4 is used as an emergency 72-hour assessment order when a section 2 would involve an unacceptable delay. A GP and an AMHP or NR can make the application, which is often changed to a section 2 upon arrival at the hospital.

Section 5(2) allows a doctor to legally detain a voluntary patient in hospital for 72 hours, while section 5(4) allows a nurse to detain a voluntary patient for 6 hours.

Section 17a allows for Supervised Community Treatment (Community Treatment Order) and can be used to recall a patient to the hospital for treatment if they do not comply with the conditions of the order in the community, such as taking medication.

Section 135 allows for a court order to be obtained to allow the police to break into a property to remove a person to a Place of Safety. Section 136 allows for someone found in a public place who appears to have a mental disorder to be taken by the police to a Place of Safety. This section can only be used for up to 24 hours while a Mental Health Act assessment is arranged.

The most likely diagnosis for the patient in this vignette is schizophrenia. Early symptoms of schizophrenia can include social withdrawal and behavioral changes, which may go unnoticed before the onset of delusions and hallucinations. The patient’s belief that his mother is trying to poison him needs to be explored to confirm whether it is an actual delusion. While illicit drug use can cause psychotic symptoms similar to schizophrenia, the gradual onset and progression of symptoms in this case suggest a diagnosis of schizophrenia rather than amphetamine misuse. Depression can also cause delusions, but depressive delusions are usually congruent with the mood and tend to have themes of guilt or hopelessness. The combination of symptoms presented in this vignette cannot be safely explained by normal teenage behavior. While schizotypal disorder can resemble schizophrenia, it does not have the characteristic symptoms seen in this vignette.

Schizophrenia is a mental disorder that can have varying prognoses depending on certain factors. Some indicators associated with a poor prognosis include a strong family history of the disorder, a gradual onset of symptoms, a low IQ, a prodromal phase of social withdrawal, and a lack of an obvious precipitant. These factors can contribute to a more severe and chronic course of the illness, making it more difficult to manage and treat. It is important for individuals with schizophrenia and their loved ones to be aware of these indicators and seek appropriate treatment and support.

Features and Diagnostic Criteria of Anorexia Nervosa

Anorexia Nervosa (AN) is a serious eating disorder characterized by a distorted body image and an intense fear of gaining weight. Here are some features and diagnostic criteria of AN:

Increased excessive physical activity: Patients with AN tend to exercise excessively to lose weight.

Low plasma cortisol levels: AN patients have low levels of cortisol, a hormone that helps regulate metabolism and stress response.

Buccal pigmentation: This is not a typical feature of AN.

Raised gonadotrophin levels: Gonadotrophin levels are usually reduced in AN, leading to amenorrhoea in women and loss of sexual interest in men.

Hyperkalaemia: AN patients may have high levels of potassium in their blood.

Diagnostic criteria: According to the ICD-10, a definite diagnosis of AN requires body weight maintained at least 15% below the expected, self-induced weight loss, body image distortion, endocrine disorder involving the hypothalamic–pituitary–gonadal axis, and delayed or arrested pubertal events if onset is prepubertal.

Understanding Anorexia Nervosa: Features and Diagnostic Criteria

After a myocardial infarction, Sertraline is the preferred SSRI due to its extensive research in this patient population compared to other SSRIs. It is important to note that the patient may also be taking antiplatelets and should be cautioned about the potential for dyspepsia and gastrointestinal bleeding. Co-prescribing a proton pump inhibitor should be considered.

Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.

The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.

When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.

When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.

The Mental Health Act (MHA) has several sections that allow for compulsory admission and treatment of individuals with mental disorders. Section 5(2) can only be used for inpatients and is implemented by the Responsible Clinician or their designated deputy. It lasts for 72 hours and should be followed by a formal Mental Health Act assessment for consideration of detention under Section 2 or 3. Section 2 allows for compulsory admission and assessment of individuals who cannot be safely assessed in the community and refuse voluntary admission. It requires an application from the patient’s nearest relative or an Approved Mental Health Professional (AMHP) and two medical recommendations. It lasts up to 28 days and can be appealed within 14 days of admission. Section 136 allows the police to remove individuals from public places and take them to a place of safety, such as a Mental Health Unit or Accident and Emergency. Section 3 allows for compulsory admission and treatment of individuals who pose risks to self or others and refuse voluntary admission. It requires an application from the patient’s nearest relative or an AMHP and two medical recommendations. It lasts up to 6 months and can be appealed within the first 6 months and then once a year. Section 4 is an emergency section that allows for detention in hospital for up to 72 hours and requires an application from an AMHP or the patient’s nearest relative and one medical recommendation. It can be converted to Section 2 if a second medical recommendation is obtained within 72 hours and should only be used in urgent cases.

Considering the patient’s increasing symptoms of psychosis, it is possible that non-compliance with their risperidone medication is an issue. In such cases, it is recommended to consider once monthly IM antipsychotic depot injections for patients with poor oral compliance. However, the patient’s risperidone dose would need to be re-titrated to their previous level.

Clozapine is typically used for treatment-resistant psychosis after trying two other antipsychotics. However, there is no evidence of the patient having tried multiple antipsychotics, and it appears that risperidone was effectively controlling their symptoms. If risperidone is not effective, quetiapine could be tried before considering Clozapine, provided there are no contraindications.

While cognitive behavioural therapy (CBT) can be helpful in reducing symptoms of psychosis, it is less likely to be effective than monthly depot injections.

Based on the patient’s history, there is no indication that they pose a risk to themselves or others that would warrant admission. Therefore, efforts should be made to manage the patient in the community.

Atypical antipsychotics are now recommended as the first-line treatment for patients with schizophrenia, as per the 2005 NICE guidelines. These medications have the advantage of significantly reducing extrapyramidal side-effects. However, they can also cause adverse effects such as weight gain, hyperprolactinaemia, and in the case of clozapine, agranulocytosis. The Medicines and Healthcare products Regulatory Agency has issued warnings about the increased risk of stroke and venous thromboembolism when antipsychotics are used in elderly patients. Examples of atypical antipsychotics include clozapine, olanzapine, risperidone, quetiapine, amisulpride, and aripiprazole.

Clozapine, one of the first atypical antipsychotics, carries a significant risk of agranulocytosis and requires full blood count monitoring during treatment. Therefore, it should only be used in patients who are resistant to other antipsychotic medication. The BNF recommends introducing clozapine if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs, one of which should be a second-generation antipsychotic drug, each for at least 6-8 weeks. Adverse effects of clozapine include agranulocytosis, neutropaenia, reduced seizure threshold, constipation, myocarditis, and hypersalivation. Dose adjustment of clozapine may be necessary if smoking is started or stopped during treatment.

Understanding Eating Disorders: Bulimia Nervosa

Bulimia nervosa is an eating disorder that is characterized by binge eating followed by purging behaviors such as vomiting, laxative abuse, excessive exercise, and drug use. Individuals with bulimia often experience feelings of loss of control and intense guilt during binge episodes. Pitting of tooth enamel caused by stomach acid is a common sign of regular vomiting. Unlike anorexia nervosa, bulimia is not usually associated with severe weight loss. The condition is ten times more common in women. It is important to recognize the symptoms of bulimia and seek professional help for proper diagnosis and treatment.

When it comes to quickly calming down patients who are exhibiting disruptive behavior, oral lorazepam is typically the first choice. According to NICE guidelines, either intramuscular lorazepam or a combination of intramuscular haloperidol and intramuscular promethazine should be used for rapid tranquilization in patients with acute behavioral disturbances. However, lorazepam is recommended for patients who have not previously taken antipsychotic medication and for those whose heart health is uncertain.

Understanding Psychosis

Psychosis is a term used to describe a person’s experience of perceiving things differently from those around them. This can manifest in various ways, including hallucinations, delusions, thought disorganization, alogia, tangentiality, clanging, and word salad. Associated features may include agitation/aggression, neurocognitive impairment, depression, and thoughts of self-harm. Psychotic symptoms can occur in a range of conditions, such as schizophrenia, depression, bipolar disorder, puerperal psychosis, brief psychotic disorder, neurological conditions, and drug use. The peak age of first-episode psychosis is around 15-30 years.

Lithium is known to cause tremors, particularly a fine non-distractible rest tremor. This side effect is more common at higher doses and in cases of toxicity, but can still occur at treatment levels. Diazepam, a medication commonly used to manage acute anxiety and tremors, is unlikely to produce any motor effects from typical use. Mirtazapine, an antidepressant, can cause tremors but it is much less common than in other antidepressants. Olanzapine, an antipsychotic medication, can also cause tremors but they are usually coarse and affect the mouth and face. Based on the description of the tremor, it is more likely that lithium is the cause.

Lithium is a medication used to stabilize mood in individuals with bipolar disorder and as an adjunct in treatment-resistant depression. It has a narrow therapeutic range of 0.4-1.0 mmol/L and is primarily excreted by the kidneys. The mechanism of action is not fully understood, but it is believed to interfere with inositol triphosphate and cAMP formation. Adverse effects may include nausea, vomiting, diarrhea, fine tremors, nephrotoxicity, thyroid enlargement, ECG changes, weight gain, idiopathic intracranial hypertension, leucocytosis, hyperparathyroidism, and hypercalcemia.

Monitoring of patients taking lithium is crucial to prevent adverse effects and ensure therapeutic levels. It is recommended to check lithium levels 12 hours after the last dose and weekly after starting or changing the dose until levels are stable. Once established, lithium levels should be checked every three months. Thyroid and renal function should be monitored every six months. Patients should be provided with an information booklet, alert card, and record book to ensure proper management of their medication. Inadequate monitoring of patients taking lithium is common, and guidelines have been issued to address this issue.

Monitoring is crucial for detecting the life-threatening side effect of clozapine, which is agranulocytosis/neutropenia.

Atypical antipsychotics are now recommended as the first-line treatment for patients with schizophrenia, as per the 2005 NICE guidelines. These medications have the advantage of significantly reducing extrapyramidal side-effects. However, they can also cause adverse effects such as weight gain, hyperprolactinaemia, and in the case of clozapine, agranulocytosis. The Medicines and Healthcare products Regulatory Agency has issued warnings about the increased risk of stroke and venous thromboembolism when antipsychotics are used in elderly patients. Examples of atypical antipsychotics include clozapine, olanzapine, risperidone, quetiapine, amisulpride, and aripiprazole.

Clozapine, one of the first atypical antipsychotics, carries a significant risk of agranulocytosis and requires full blood count monitoring during treatment. Therefore, it should only be used in patients who are resistant to other antipsychotic medication. The BNF recommends introducing clozapine if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs, one of which should be a second-generation antipsychotic drug, each for at least 6-8 weeks. Adverse effects of clozapine include agranulocytosis, neutropaenia, reduced seizure threshold, constipation, myocarditis, and hypersalivation. Dose adjustment of clozapine may be necessary if smoking is started or stopped during treatment.

Tangentiality is when someone goes off on a tangent and does not return to the original topic. It is a type of formal thought disorder that is often seen in people with schizophrenia. The person may provide excessive and unnecessary details that are somewhat relevant to the question but never answer the central point. Circumstantiality is similar, but the person ultimately provides an answer. Clang associations involve using words that sound similar but have no logical connection, while perseveration is when someone continues to respond to a previous question even after a new one has been asked.

Thought disorders can manifest in various ways, including circumstantiality, tangentiality, neologisms, clang associations, word salad, Knight’s move thinking, flight of ideas, perseveration, and echolalia. Circumstantiality involves providing excessive and unnecessary detail when answering a question, but eventually returning to the original point. Tangentiality, on the other hand, refers to wandering from a topic without returning to it. Neologisms are newly formed words, often created by combining two existing words. Clang associations occur when ideas are related only by their similar sounds or rhymes. Word salad is a type of speech that is completely incoherent, with real words strung together into nonsensical sentences. Knight’s move thinking is a severe form of loosening of associations, characterized by unexpected and illogical leaps from one idea to another. Flight of ideas is a thought disorder that involves jumping from one topic to another, but with discernible links between them. Perseveration is the repetition of ideas or words despite attempts to change the topic. Finally, echolalia is the repetition of someone else’s speech, including the question that was asked.

The risk of relapse is significantly decreased, and patients should be comforted by the fact that antidepressants are non-addictive.

Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.

The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.

When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.

When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.

Compared to other selective serotonin reuptake inhibitors, paroxetine has a greater likelihood of causing discontinuation symptoms.

Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.

The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.

When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.

When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.

Tricyclic antidepressants are not commonly used for depression anymore due to their high risk of causing dangerous overdose. Therefore, when selecting an antidepressant for a patient who is at high risk of overdose, it is important to choose a class of antidepressants that are less toxic if taken in excess. TCAs have a narrow therapeutic index, which means that even moderate doses can lead to severe cardiovascular and CNS toxicity. Complications of TCA overdose include prolonged hypotension, cardiac arrhythmias, and seizures, which can ultimately result in death due to cardiovascular collapse.

Diagnosis of TCA overdose is typically made based on clinical presentation, and classic ECG changes may be observed, such as sinus tachycardia progressing to wide complex tachycardia and ventricular arrhythmias as the severity of intoxication increases. Treatment involves correcting acidosis, hypoxia, and electrolyte imbalances, as well as administering hypertonic sodium bicarbonate to improve conduction abnormalities and hypotension. Anti-arrhythmic drugs should generally be avoided, and benzodiazepines are the preferred treatment for seizures.

Tricyclic Antidepressants for Neuropathic Pain

Tricyclic antidepressants (TCAs) were once commonly used for depression, but their side-effects and toxicity in overdose have led to a decrease in their use. However, they are still widely used in the treatment of neuropathic pain, where smaller doses are typically required. TCAs such as low-dose amitriptyline are commonly used for the management of neuropathic pain and the prophylaxis of headache, while lofepramine has a lower incidence of toxicity in overdose. It is important to note that some TCAs, such as amitriptyline and dosulepin, are considered more dangerous in overdose than others.

Common side-effects of TCAs include drowsiness, dry mouth, blurred vision, constipation, urinary retention, and lengthening of the QT interval. When choosing a TCA for neuropathic pain, the level of sedation may also be a consideration. Amitriptyline, clomipramine, dosulepin, and trazodone are more sedative, while imipramine, lofepramine, and nortriptyline are less sedative. It is important to work with a healthcare provider to determine the appropriate TCA and dosage for the individual’s specific needs.

Weight gain is a common side effect of atypical antipsychotics.

Atypical antipsychotics are now recommended as the first-line treatment for patients with schizophrenia, as per the 2005 NICE guidelines. These medications have the advantage of significantly reducing extrapyramidal side-effects. However, they can also cause adverse effects such as weight gain, hyperprolactinaemia, and in the case of clozapine, agranulocytosis. The Medicines and Healthcare products Regulatory Agency has issued warnings about the increased risk of stroke and venous thromboembolism when antipsychotics are used in elderly patients. Examples of atypical antipsychotics include clozapine, olanzapine, risperidone, quetiapine, amisulpride, and aripiprazole.

Clozapine, one of the first atypical antipsychotics, carries a significant risk of agranulocytosis and requires full blood count monitoring during treatment. Therefore, it should only be used in patients who are resistant to other antipsychotic medication. The BNF recommends introducing clozapine if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs, one of which should be a second-generation antipsychotic drug, each for at least 6-8 weeks. Adverse effects of clozapine include agranulocytosis, neutropaenia, reduced seizure threshold, constipation, myocarditis, and hypersalivation. Dose adjustment of clozapine may be necessary if smoking is started or stopped during treatment.

Severe restlessness may be caused by antipsychotics, known as akathisia.

Antipsychotics are a group of drugs used to treat schizophrenia, psychosis, mania, and agitation. They are divided into two categories: typical and atypical antipsychotics. The latter were developed to address the extrapyramidal side-effects associated with the first generation of typical antipsychotics. Typical antipsychotics work by blocking dopaminergic transmission in the mesolimbic pathways through dopamine D2 receptor antagonism. They are associated with extrapyramidal side-effects and hyperprolactinaemia, which are less common with atypical antipsychotics.

Extrapyramidal side-effects (EPSEs) are common with typical antipsychotics and include Parkinsonism, acute dystonia, sustained muscle contraction, akathisia, and tardive dyskinesia. The latter is a late onset of choreoathetoid movements that may be irreversible and occur in 40% of patients. The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients, including an increased risk of stroke and venous thromboembolism. Other side-effects include antimuscarinic effects, sedation, weight gain, raised prolactin, impaired glucose tolerance, neuroleptic malignant syndrome, reduced seizure threshold, and prolonged QT interval.

Duration of Antidepressant Treatment for Depression

It is recommended that a single episode of depression should be treated for at least six months after recovery to prevent relapse. Recurrent episodes warrant at least 12 months of treatment after recovery. Stopping antidepressant treatment immediately on recovery puts patients at a high risk of relapse, with 50% of patients experiencing a relapse of their depressive symptoms. During the recovery phase, adults should receive the same dose used for the treatment of the acute phase. The medication should then be tapered off over a few weeks, according to the type of antidepressant used.

Stopping medication prematurely, such as after one month or six weeks, would put the patient at a high risk of relapse. If the patient has been using antidepressants over a very short term and has found it maximally effective, they may be able to come off medication sooner than six months. However, this should be managed with caution and only recommended if there are other extenuating factors which would cause them to want to stop, such as side-effects or poor compliance. In this case, the patient has been using sertraline for four months already, has not indicated poor compliance, and there is no indication of issues with side-effects.

Common Psychiatric Medications and Their Side-Effects

Haloperidol: A typical antipsychotic drug that can cause extrapyramidal side-effects (EPSEs), including acute dystonic reactions. Treatment is with anticholinergic drugs or benzodiazepines.

Clozapine: An atypical antipsychotic mainly used in treatment-resistant schizophrenia. Common side-effects include sedation, constipation, hypersalivation, weight gain, and metabolic syndrome. Rare but important side-effects include agranulocytosis, arrhythmias, and myocarditis. EPSEs are possible but rare.

Diazepam: A benzodiazepine used in anxiety, insomnia, seizures, and muscle spasms. Side-effects include sedation, muscle weakness, drowsiness, and confusion. EPSEs are not a recognised side-effect and may improve with the use of benzodiazepines.

Lithium: A mood stabiliser used in the treatment of mania, depression, and bipolar disorder. Side-effects include gastrointestinal disturbances, tremor, polydipsia, polyuria, and electrolyte disturbances. Lithium-induced hypothyroidism is common. EPSEs are not a side-effect of lithium.

Olanzapine: An atypical antipsychotic used in the treatment of schizophrenia and acute mania. Common side-effects include sedation, weight gain, and metabolic symptoms. EPSEs can occur but are not a typical side-effect of olanzapine.

Differentiating between Schizophrenia and other Mental Disorders

Schizophrenia is a mental disorder that is characterized by delusions, hallucinations, abnormal behavior, social withdrawal, blunted emotions, and breaks in thought processes. These symptoms are often accompanied by an irritable or depressed mood. When presented with a patient exhibiting these symptoms, schizophrenia is the most likely diagnosis.

Dissociative identity disorder, on the other hand, is a complex psychological disorder where the individual appears to have two or more distinct personalities that alternate and dictate their behavior. This disorder is associated with severe childhood trauma, which is not present in the case of the patient in question.

Bipolar disorder is characterized by extreme mood swings, ranging from mania to depression. While the patient exhibits some symptoms of depression, they are not displaying symptoms of mania, making bipolar disorder an unlikely diagnosis.

Delirium is a serious disturbance in mental abilities that results in confused thinking and reduced awareness of the environment. While an underlying physical cause should be excluded, the patient’s symptoms are more consistent with a psychotic illness than delirium.

Depression is characterized by continuous low mood, hopelessness, low self-esteem, tearfulness, and irritability. While patients with severe depression may suffer from psychotic episodes, the patient in question is exhibiting symptoms more consistent with schizophrenia, such as knights move thinking and responding to auditory hallucinations.

In conclusion, differentiating between schizophrenia and other mental disorders requires a thorough understanding of the symptoms and their presentation. While some disorders may share similar symptoms, a careful evaluation of the patient’s history and behavior can help determine the correct diagnosis.