► Box 12.1 Common causes
Aggression often stems from fear. Agitated patients are usually frightened, so try to remember this when approaching the situation. Regardless, the safety of yourself and others is paramount at all times.
►► Call for senior help/security early if the situation is deteriorating.
• Assess the safety—is anyone at acute risk?
• Attempt to defuse the situation, maintain your own safety at all times
• Try to establish the precipitant from staff/relatives (Box 12.1)
• Ask a member of staff who knows the patient to accompany you
• Invite the patient to sit down with you and discuss the problem
• Listen until they feel they have explained the problem
• Assess the patient for signs of psychosis or acute confusion—are they physiologically unwell, psychologically disturbed, or angry? Why?
• Apologize and/or offer sympathy as appropriate
• Address any concerns raised by the patient
• Ask specifically about pain or worry
• Consider offering oral sedation or analgesia
• Emergency sedation if they are a risk to themselves or others1:
In England and Wales, this Act allows the hospitalization of individuals who are believed to be affected by a mental disorder (alcohol and drug addiction alone are insufficient) that:
• requires assessment (under section 2) or treatment (under section 2 or 3) and
• is sufficiently serious to pose a threat to self or others and
• requires hospitalization to which they are unable/unwilling to consent.
If you feel this applies to your patient, speak to your seniors and the psychiatrist on call urgently. They may recommend an urgent MHA assessment to consider detention under section 2 (if further assessment required) or 3 (if patient well known and symptoms typical). See Table 12.1.
► These powers cannot be used to detain for treatment of physical illness, unless the direct consequence of the mental disorder (eg self-harm, weight loss in anorexia nervosa). Patients under the MHA may still have capacity to decide on treatment for physical health unrelated to their mental illness. In this case, treatment decisions should be based upon an assessment of mental capacity which is decision specific (
p. 30).
Table 12.1 Key sections of the Mental Health Act, 2007
| Section 2 | A period of assessment and treatment which lasts for up to 28d. Not renewable. An approved mental health professional (AMHP) makes the application on the recommendation of two doctors. An AMHP may be a social worker, nurse, occupational therapist, or psychologist |
| Section 3 | Admission for treatment up to 6mth. Is renewable for a further 6mth and annually thereafter. AMPH makes the application on the recommendation of two doctors |
| Section 4 | Emergency admission for assessment. Lasts 72h. Requires one medical practitioner and AMHP to enact. Can be used if admission under section 2 would cause an undesirable delay |
| Section 5(2) | Issued by a doctor. Allows detention of an informal patient for up to 72h. Designed as an emergency order in order for a mental health act assessment to take place |
| Section 5(4) | Issued by a mental health nurse. Allows detention of an informal patient for up to 6h until doctor assessment |
| Section 17a | Supervised community treatment order |
| Section 136 | Allows police to arrest a person in a public place and who is believed to be suffering from a mental disorder. Lasts up to 72h. The person is taken to a place of safety (eg ED) |
Many patients will drink over the recommended limits (14 units per week ♂ and ♀), but not all of these will be ‘alcoholics’.2 Defining alcoholism is hard; if drinking, or its affects, repeatedly harms work or social life it is clearly a problem. Answering ‘yes’ to three out of four of the CAGE questions suggests alcoholism: Ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Ever felt Guilty about your drinking? Ever had an Eye-opener in the morning?
Excessive drinking can be a psychiatric issue in its own right but can also complicate many psychiatric diseases. Modifying drinking behaviour is difficult and patients must want to change.
Abuse Excessive drinking despite mental or physical harm.
Dependence Alcohol tolerance, withdrawal when not drinking.
Alcoholism management Have a low threshold for commencing benzodiazepine therapy to avoid withdrawal (Table 5.12 or your local protocol). Start vitamin B1 supplementation with either IV preparations or oral thiamine and multi-vitamins .
Untreated, thiamine deficiency can lead to Wernicke’s encephalopathy ( p. 368). Characterized by a triad of nystagmus, ophthalmoplegia, and ataxia, but can also present with confusion, altered consciousness, vomiting, and headache. Untreated it can progress to Korsakoff’s syndrome characterized by an irreversible inability to acquire new memories associated with a tendency to confabulate. Both are treated with Pabrinex® or oral thiamine, but the memory loss in Korsakoff’s is usually permanent.
Other management Alcohol diaries, reduced intake/abstinence plans, counselling, eg Alcoholics Anonymous, medication, eg disulfiram, address underlying social and psychiatric problems.
Alcohol withdrawal (OHAM4 p. 414).
Symptoms 12–36h post-alcohol: anxiety, shaking, sweating, vomiting, tonic-clonic seizures; 3–4d post-alcohol delirium tremens may develop: coarse tremor, confusion, delusions, hallucinations (untreated mortality 15%).
Signs HTN, ↑ HR, sweaty, tremor, ↓glucose; delirium tremens: pyrexia.
Investigations blds May have ↓ Mg2+, ↓ PO43−, ↓ Ca2+, ↓K+ and ↓urea. Check LFTs and consider investigation for chronic liver disease.
Treatment Prescribe reducing dose of chlordiazepoxide (Table 5.12); correct electrolyte abnormalities; give vitamin replacements PO (thiamine 25mg/24h and vitamin B (compound strong) one tablet/24h) or IV (Pabrinex® 2 pairs/8h IV for 5d). Monitor BP and blood glucose. Withdrawal seizures are usually self-limiting, treat as p. 348 if required.
Complications Seizures, coma, encephalopathy, hypoglycaemia.
The majority of patients have respect for NHS staff; however under certain circumstances anyone can become aggressive:
• Reversible confusion or delirium, eg hypoglycaemia ( pp. 374–375)
• Inadequate communication/fear/frustration ( p. 22–23)
The aggressive patient Ask a nurse to accompany you when assessing aggressive patients. Position yourselves between the exit and the patient and ensure that other staff know where you are. The majority of patients can be calmed simply by talking; try to elicit why they are angry and ask specifically about pain and worry. Be calm but firm and do not shout or make threats. If this does not help you may have to call hospital security or the police in a GP setting. It may be appropriate to offer an oral sedative or give emergency IM/IV sedation ( p. 370). Mental health nurses are trained in how to give both IM and IV sedation. In a GP setting, add an alert to the patient’s records to detail the incident and inform the practice manager.
The aggressive relative Relatives may be aggressive through fear, frustration, and/or intoxication. They usually respond to talking, though make sure you obtain consent from the patient before discussing their medical details. Consider offering to arrange a meeting with a senior doctor. If the relative continues to be aggressive, remember that your duty of care to patients does not extend to their relatives; you do not have to tell them anything or listen to threats/abuse. In extreme cases you can ask security or police to remove the relative from the hospital.
Violence Assault (the attempt or threat of causing harm) and battery (physical contact without consent) by a patient or relative is a criminal offence. If you witness an assault or are assaulted yourself, inform your seniors and fill in an incident form including the name and contact details of any witnesses. If no action is taken on your behalf inform the police yourself.
Abuse Abuse is a violation of an individual’s human and civil rights and may consist of a single act or repeated actions. It may be physical, sexual, financial, psychological or through neglect. Patients of any age can be abused. Do not be afraid of asking patients how they sustained injuries or asking directly if someone caused them. Inform a senior if you suspect a patient has been abused ( Box 2.11 p. 107). Have a low threshold for involving adult/child safeguarding teams where you have concerns.
Delirium or acute confusional state is a common but easily missed diagnosis associated with increased morbidity and mortality. Delirium can affect any patient but is especially common in the hospitalized elderly, where it may be misdiagnosed or herald dementia (or it may coexist in up to 50%). Unlike dementia, delirium is often fluctuating, worse at certain times of day and may persist for months.3,4There are two subtypes: hypoactive (higher mortality) and hyperactive. ► Beware the quietest and loudest patients on the ward.
Box 12.2 CAM: Confusion assessment method
This validated aid to the recognition of delirium requires the presence of both:5
Both of the above must be present, plus either:
Source: data from Wei LA. J Am Geriatr Soc 2008;56:823–30.
Think about ► Emergencies ↓ O2, ↑ CO2, MI, CVA, intracranial bleed, meningitis, encephalitis, anticholinergic medications; Common Sepsis, metabolic (↓glucose, ↓Na+), drug toxicity (opioids, benzodiazepines, lithium, serotonin syndrome, neuroleptic malignant syndrome, post-GA), heart failure, head injury, alcohol withdrawal or intoxication, post-ictal, urinary retention, constipation, pain.
Ask about Use direct questions to assess eg for pain; further history from the ward staff, relatives, notes or residential/nursing home: speed of onset, chest pain, cough, sputum, dysuria, frequency, incontinence, head injury, headache, photophobia, vomiting, dizziness; PMH dm, heart, lung, liver or kidney problems, epilepsy, dementia, psychiatric illness; DH Benzodiazepines, antidepressants, opioids, steroids, nsaids, antiparkinsonian drugs; anticholinergics, antispasmodics, anti epileptics, antipsychotics. SH Alcohol, recreational drugs, baseline mobility and state.
Obs GCS (Table 11.2), temp, HR, BP, RR, O2 sats.
Look for Respiration Rate, depth, added sounds, cyanosis; Pulse Rate and rhythm; Abdomen Rigidity, palpable bladder; PR Faecal impaction; Neuro Signs of head injury, pupil responses, neck stiffness, photophobia, focal neurology, plantar responses; AMT score (See Table 12.2); Drug Chart.
Investigations Urine Dipstick, M,c+s; blds FBC, U+E, lft, crp, glucose, Ca2+, consider cardiac markers, blood cultures, amylase, tft, B12, folate; ABG ↓O2 ±↓↑CO2; ECG Arrhythmias; CXR Infection or aspiration; CT If focal neurology, head injury or non-resolving confusion; LP If ct normal.
• Nurse in a quiet, appropriately lit environment with close, supportive observation (relatives, ‘special’ nurse); avoid restraints.
• Investigate and reverse the underlying cause. Think PInCH ME: Pain, Infection, Constipation, Hydration, Medication, Environment.
• Sedate only if patient or staff safety threatened; use oral route where possible (eg haloperidol 0.5–1mg PO/1–2mg IM every 1–2h, max 5mg/24h; if PMH Lewy body dementia, alcohol excess or Parkinson’s, lorazepam 0.5–1mg PO/IM every 1–2h, max 2-4mg/24h).
Table 12.2 Abbreviated Mental Test (AMT) score (≥8 is normal for an elderly patient)
| Age | 1 | Recognise two people (eg Dr, nurse) | 1 |
| Date of birth | 1 | Year World War Two ended (1945) | 1 |
| Current year | 1 | Who is on the throne (Elizabeth II) | 1 |
| Time (nearest hour) | 1 | Recall address: ‘42 West Street’ | 1 |
| Name of hospital | 1 | Count backwards from 20 to 1 | 1 |
Reproduced from Hodgkinson HM, ‘Evaluation of a mental test score for assessment of mental impairment in the elderly’, Age and Ageing, 1972, 1(4):233–8, by permission of Oxford University Press and the British Geriatric Society.
Progressive global cognitive impairment with normal consciousness.6
► Worrying features Rapid progression, <65yr.
Think about Common Alzheimer’s, Lewy body disease, frontotemporal dementia (Pick’s), vascular dementia, Parkinson’s (late), normal pressure hydrocephalus, depression (pseudodementia), chronic subdural haematoma, Korsakoff’s syndrome; medications. Rare hiv, CJD, syphilis, space-occupying lesions, hypothyroid, B12 deficiency, malnutrition.
Ask about Age of onset, progression, memory (short and long term), personality, thinking, planning, judgement, language, visuospatial skills, concentration, social behaviour, confusion, wandering, falls, head injury, tremor, mood, sleep quality, delusions, hallucinations, hearing, sight; PMH Seizures, cva/tia; DH Regular medications, sleeping tablets, anticholinergics; opioids, sedatives FH Dementia, neurological problems; SH Effect on work, relationships and social abilities; independence with activities of daily living (adls—food, cleaning, washing, dressing, toilet); ability to manage finances; alcohol intake; try to build a picture of the domestic environment: Who is at home and what local support is available (Box 12.3)?
Obs gcs, hr, bp, glucose.
Investigations ► Consider capacity. If lacking, Mental Capacity Act principle should apply—’best interests’ and ‘least restrictive’ options. p. 30; blds fbc, esr, U+E, lft, Ca2+, tft, vitamin B12, folate, consider hiv, vdrl/tpHa; Mini-Mental State Examination (Box 12.6; p. 377), Abbreviated Mental Test score ( p. 375); CLOX test (asking the patient to draw a clock); full systems exam with careful neurological exam including general appearance, tremor, gait, dysphasia, cog-wheeling. Imaging To rule out reversible causes and to identify dementia subtype (Boxes 12.4 and 12.5): cxr, ct/mri brain; ECG; SPECT (if DLB suspected), LP; EEG (rarely done).
Management Refer to a neurologist/psychogeriatrician for specialist diagnosis and management; use an MDT approach to ensure the patient has appropriate accommodation and support with ADLs. Medical management may be initiated by the specialist.
Box 12.3 Support organizations
• Dementia UK (0845 257 6678 
www.dementiauk.org)
• Alzheimer’s Society (0300 222 1122 www.alzheimers.org.uk) [for England, Wales and Northern Ireland] or Alzheimer’s Scotland (0808 808 3000 www.alzscot.org)
• Carers Direct (0300 123 1053 www.nhs.uk/carersdirect) for telephone and online support and advice for carers
• Age UK (0800 169 6565 www.ageuk.org.uk) for a wide range of advice and services in support of ageing people
Box 12.4 Common types of dementia
Alzheimer’s Slowly progressive loss of memory, with later loss of language, executive or visuospatial functions; anticholinesterases (eg donepezil) may benefit in moderate disease, memantine in severe disease.
Vascular Impairment of memory and at least one other cognitive domain in the presence of vascular risk factors ±neuroimaging evidence of ischaemia; often co-exists with Alzheimer’s.
Lewy body Core symptoms make diagnosis probable: (1) Fluctuating attention/concentration, (2) Parkinsonian motor signs, (3) Recurrent visual hallucinations, (4) REM sleep problems (acting out dreams). Neuroleptic sensitivity and SPECT scan support diagnosis (with 1 core feature).
Frontotemporal Prominent and early language loss ±loss of social functioning/disinhibition; may present in younger age group.
Box 12.5 Some potentially reversible causes of dementia
Sub-dural haematoma Dementia ±focal neurology (eg limb weakness); more common in elderly, atrophic brains; often history of trauma; characteristic CT appearances; evacuate.
Normal pressure hydrocephalus Dementia, magnetic gait and subtle personality changes are early signs and urinary incontinence with hydrocephalus on CT and normal CSF opening pressure; idiopathic (50%) or may occur after meningitis, trauma or subarachnoid haemorrhage; ventriculo-peritoneal shunt may improve symptoms.
Korsakoff ’s syndrome Amnesia and confabulation seen in thiamine deficiency (eg alcoholism); may show very slow and limited improvement with thiamine replacement.
B12/Folate deficiency/ hypothyroidism/hypocalcaemia Can all be corrected and may result in improvement. Replace B12 before folate.
Box 12.6 Mini-Mental State Examination (MMSE)7
Despite copyright problems, the MMSE7 remains widely available in most hospitals and is a helpful screening test. The test consists of 30 questions which together test various components of a patient’s mental state:
• orientation (in time, place and person)
• registration (ability to listen and recite, to obey commands)
• attention and arithmetic (counting backwards)
• recall (reciting a list of objects)
The maximum score in the MMSE is 30, though ≥28 is regarded as ‘normal’. Scores of 24–27 are borderline and <24 suggests dementia. Results are unreliable if the patient is delirious, has a sensory impairment, affective disorder or has not been taught to read and write in English. An abbreviated (10-point) version is often used ( p. 375) and correlates well with MMSE for those with very high or low scores; in the intermediate range and for tracking changes, MMSE is a more reliable test. There are also numerous other, less widely used tests of cognitive function.8 In general these have been less well validated (if at all).9).
► Worrying features Delusions, hallucinations, suicidal intent.
Think about ► Emergency Acutely suicidal; Psychosis Schizophrenia, depression, bipolar disorder, postpartum, substance abuse, alcoholism or withdrawal; Low mood Depression, bipolar disorder, anxiety disorder, personality disorder, eating disorder, seasonal affective disorder, postpartum, grief, alcoholism or withdrawal, substance abuse; High mood Bipolar disorder, cyclothymia, substance abuse; Organic Endocrine (hypo/hyperthyroid, Cushing’s, Addison’s), neurological (cva, dementia, ms, Parkinson’s, head injury, brain tumour), infections (hiv, Lyme disease, EBV syphilis), inflammatory disease (eg rheumatoid, sle), autoimmune encephalitis, electrolyte imbalance (eg Na+, Ca2+), metabolic problems (eg porphyria, Wilson’s), malnutrition, anaemia, paraneoplastic, recreational drugs, medications ( p. 379). See Table 12.3.
Ask about (See psychiatric history pp. 162–164.) Medical Bowel habit, weight change, appetite, cold/heat intolerance, tremor, previous head trauma, changes in vision, headaches, unusual sensations, weakness, seizures, sleeping problems, sexually transmitted illnesses and risk, rashes, joint pain; Psychiatric Early morning waking, concentration, energy levels, lack of pleasure, appetite, recent stresses, mood, change in personality, suicidal ideation; Personal Childhood, education, employment, relationships; Forensic Previous criminal convictions, custodial sentences; PMH Previous psychiatric problems or care, mania, suicide attempts, chronic illness; DH Regular medications, alternative medicines; FH Psychiatric problems, thyroid, liver or brain problems, occupations; SH Who do they live with, family, friends, alcohol intake, smoking, illicit substance abuse.
Obs gcs, temp, hr, bp, rr, glucose.
Look for (see mental state examination pp. 162–164) Medical Full systems exam and careful neurological exam including tremor, eye reflexes, papilloedema, tendon reflexes; Psychiatric General appearance, signs of neglect or flamboyancy, unusual posture or movements, aggression, affect, speech (form and content), thought (form and content including delusions), perception including hallucinations, cognition (concentration, memory, orientation), risk (to self or others), insight.
Investigations It is important to consider organic causes of mental disturbance. blds Consider: FBC, U+E, lft, Ca2+, tft, esr, ana, B12, folate, cortisol, hIV ( p. 504), ebv and Lyme disease serology, vdrl/thpa; Psychiatrists may consider tests for autoantibodies in atypical presentations. Urine Toxicology screen; LP, EEG, CT/MRI Brain.
• Is the patient manic, psychotic (delusions or hallucinations p. 164) or acutely suicidal? If so they need urgent psychiatric referral
• Could there be an organic cause for their symptoms?
• Is the patient already known to local community mental health team, contact the GP for information?
Table 12.3 Common causes of mood disturbance and psychosis
| History | Examination | Investigations | |
| Depression | Low mood, tearful, loss of interests, sleep disturbance | Poor eye contact, neglect, low mood and affect, ±psychosis | Usually normal |
| Bipolar disorder | Mixture of low and high mood events | Signs of high or low mood, ±psychosis | Usually normal |
| Schizophrenia | Delusions, auditory hallucinations, apathy | Neglect, poverty of speech/thought | Usually normal |
| Anxiety | Worry, sweating, dizziness, palpitations | Fearful, tense or normal | Usually normal |
| Personality disorder | Longstanding difficulties | Evidence of self-harm, otherwise usually normal | Usually normal |
| Dementia | Problems with memory, concentration, cognition | Neglect, poor cognition with normal consciousness | May have abnormal ct/ mri brain |
| Organic cause | Weight loss, seizures, rapid onset, visual hallucinations | Neurological signs, rashes, wasting | Usually abnormal |
Recurrent episodes of high mood, usually interspersed with episodes of low mood.
High mood may be mania (impairs job or social life and may have psychotic features) or hypomania (no impairment to job or social life). DSM-510 classifies bipolar disorder as occurring after even a single episode of mania; ICD-1010 classifies this as a manic episode, and reserves ‘bipolar disorder’ to describe recurrent episodes of mania, or mania with depressive episodes. Recurrent swings between mild depression and hypomania are called ‘cyclothymia’.
Mania signs DIGFAST—Distractable, Indiscrete (flamboyant, disinhibited), Grandiose, Flights of idea, ↑ Activity, ↓ Sleep, Talkative).
Investigations Review medications (steroids), infection screen. If first manic episode: CT head; urine toxicology.
Treatment Consider admission based on severity of episode and risk to self (self-harm, suicide), job, assets, relationships. Mania is treated acutely with antipsychotics (particularly olanzapine) and benzodiazepines. Antidepressants are used for depressive episodes but may precipitate mania. Preventive treatment is with lithium, carbamazepine, valproate, or lamotrigine.
Complications Financial errors, criminal activity, unemployment, relationship breakdown, suicide.
Examples of medications with psychiatric side effects
Depression is low mood that is not usual and persists for over 2 weeks.11
It can be a symptom of other psychiatric disorders (eg bipolar disorder, personality disorders) or a disease in its own right.12
Symptoms Low mood, low energy, feeling worthless or guilty, poor concentration, low self-esteem, tearfulness, loss of interests, anhedonia, recurrent thoughts of suicide or death; Somatic symptoms Weight/appetite loss, sleep problems (early morning wakening, insomnia or excess sleeping), loss of libido, psychomotor agitation or retardation, change in mood with time of day; Psychotic symptoms Delusions, hallucinations.
Signs Neglect, agitation, slowed speech or movement, poor eye contact.
Bereavement Avoid diagnosing within 2mth of bereavement; be aware of cultural variation in grief reactions; features pointing to depression include prolonged, severe functional impairment or psychomotor retardation.
Investigations Often none; consider an organic cause and investigate if suspected, otherwise initiate treatment and review if not working. It is paramount to document a risk assessment at each clinical contact.
• Psychotherapy usually cognitive behavioural therapy (cbt) (mild–moderate depression) but many other effective therapies are available (eg psychodynamic, cognitive analytic, interpersonal, eye movement desensitization reprocessing).
• Antidepressants (Box 12.7):
• first line: selective serotonin re-uptake inhibitors (ssris), eg sertraline, citalopram, fluoxetine
• if a patient does not respond to ssris, consider a second-line antidepressants, eg venlafaxine, mirtazapine. Psychiatrists may use other medications for augmentation (eg antipsychotic)
• Electroconvulsive therapy (ect) is considered if the patient is at high risk (eg not eating or drinking) and/or treatment failure.
Prognosis Outcome is generally good with the following: young, somatic symptoms, reactive depression (due to a life-event), and acute onset.
Complications Deliberate self-harm, unemployment, relationship breakdown, recurrence, suicide.
Box 12.7 Starting an antidepressant medication
• Antidepressants generally start to work by 2–3wk but can take 6wk
• ► Suicide risk may increase over the first few weeks (review early)
• Antidepressants are generally well tolerated; side effects are usually mild
• Treatment should continue for at least 6mth after the symptoms have resolved (or longer if recurrent depressive episode) and to reduce physical withdrawal symptoms (especially SSRIs)
• Antidepressants should be gradually weaned rather than stopped abruptly.
A chronic illness characterized by psychotic symptoms lasting >1mth.13
Acute presentations are often characterized by positive symptoms; negative symptoms can persist despite treatment.
Positive symptoms Delusions, hallucinations (often auditory): see Box 12.8.
Negative symptoms Blunted affect, apathy, loss of drive, social withdrawal, social inappropriateness, poverty of thought/speech, cognitive impairment.
Signs Neglect, disorganized behaviour, paranoia.
Investigations blds fbc, U+E, LFT, Ca2+, glucose, consider TFT, vdrl, cortisol; Urine Toxicology; EEG; CT/MRI. Psychiatrists may consider tests for autoantibodies in atypical presentations.
Treatment All people with a first presentation should be urgently referred to a mental health team either in the community (eg crisis or Early Intervention Service) or secondary care depending on the severity (risk to self: suicide, job, assets, relationships, and others).
Antipsychotic medications (neuroleptics) are the mainstay of treatment:
• Atypical antipsychotics Have fewer extrapyramidal side effects and a better effect on negative symptoms, eg amisulpride, olanzapine, risperidone, quetiapine, clozapine; these are the preferred treatment in newly diagnosed schizophrenia, and for those experiencing side effects or relapse on conventional antipsychotics
• Conventional antipsychotics eg chlorpromazine, haloperidol, trifluoperazine, flupentixol.
► Clozapine This is a 3rd-line antipsychotic, used in treatment-resistant schizophrenia. It can cause potentially fatal agranulocytosis; monitor FBC weekly for the 1st 18wk of treatment, 2wkly for the next 34wk, and 4wkly thereafter.
Side effects Side effects of antipsychotics include sedation, anticholinergic effects (eg dry mouth, blurred vision, constipation), extrapyramidal side effects (eg Parkinsonism) and tardive dyskinesia (late onset oral grimacing and upper limb writhing). Procyclidine may be used to reduce Parkinsonism.
Complications Deliberate self-harm, unemployment, relationship breakdown, stigma, social isolation, drug side effects, suicide.
Box 12.8 First-rank symptoms14
| Delusions | Passivity |
| Delusional perception | Passivity of thought, feelings, or actions |
| Hallucinations | Thought flow and possession |
| Thought echo (audible thoughts) | Thought withdrawal |
| Third-person auditory hallucinations | Thought insertion |
| Running commentary | Thought broadcasting |
| In the absence of organic pathology, the presence of these features is suggestive, but not diagnostic of, schizophrenia. | |
It is normal to have a degree of worry or fear. However, if this causes distress or interferes with life then it is considered abnormal. There are several types of anxiety- and stress-related disorders:15
Specific phobic Fear of a specific situation or object, eg flying, spiders.
Social phobia Fear in social situations, eg public speaking.
Panic attack Excessive fear without any obvious trigger; associated with symptoms of autonomic arousal, eg sweating, dizziness, nausea, palpitations, breathlessness; usually lasts <30min.
Panic disorder Recurrent panic attacks with fear of having another.
Generalized anxiety disorder (gad) Excessive worry in everyday life.
Obsessive–compulsive disorder (ocd) Obsessive thoughts, eg ‘my hands are dirty’ leading to compulsions, eg repetitive hand washing.
Symptoms Worry, irritability, fear, avoidance of feared situations, checking, seeking reassurance, tight chest, shortness of breath, palpitations, ‘butterflies’, tremor, tingling of fingers, aches, pain.
Signs Tremor, ↑ HR, ↑ RR; be careful to exclude any organic causes of symptoms such as breathlessness, chest pain or palpitations.
Investigations Consider fbc, U+E, LFT, Ca2+, cardiac markers, TFT, glucose; urinary VMA; ECG to exclude organic causes of symptoms.
Treatment Careful explanation of the cause of their problems; relaxation techniques (Box 12.9), psychological therapies, eg CBT; medications, eg SSRIs; benzodiazepine use should be avoided in panic disorder and used only for <4wks in GAD, as these have poor long-term benefits and carry a risk of dependence.
Ingrained patterns of behaviour manifesting as abnormal and inflexible responses to a broad range of personal and social situations; the diagnosis is to be avoided in adolescents when the personality is still developing.
Classification DSM-5 divides personality disorders into 3 clusters: type A (odd, eccentric; includes paranoid); type B (dramatic, emotional; includes antisocial and borderline); type C (anxious, fearful; includes dependent).
Investigations Usually none, but they require careful assessment over multiple occasions and the exclusion of other psychiatric diagnoses.
Treatment Personality disorders are challenging to treat. Psychotherapies may be useful, including dialectical behaviour therapy, cognitive analytical therapy, CBT, and psychodynamic psychotherapy. Antidepressants, mood stabilizers, and antipsychotics may also be used though the evidence of benefit is limited.
Complications Suicide, self-harm, social isolation.
Insomnia can be classified into primary (no comorbidity) and secondary (occurs as a symptom or association with another medical or psychiatric illness, substance misuse, sleep disorder). Short-term insomnia lasts <4 weeks and long term insomnia >4 weeks.16
• First line options16: ear plugs and eye masks should be offered. Advice about good sleep hygiene (lack of electronics, caffeine, alcohol, evening exercise, bedtime routine, optimize sleeping environment).
• If daytime impairment is severe, hypnotics are an appropriate choice for short-term insomnia only. Use lowest dose possible and ideally not for longer than 2 weeks.
• Short acting benzodiazepines—temazepam, loprazolam, lormetazepam. Use lower dose in elderly
• ‘Z drugs’—zopiclone, zolpidem, and zaleplon. Zopiclone: good for sleep initiation and maintenance but longer half-life may cause hangover effect, 3.75–7.5mg usual dose. Zolpidem: good for sleep induction and short half-life reduces hangover effect. Modified release version (if available) may be helpful for sleep maintenance (5–10mg usual dose).
Refer for psychological therapy (CBT), sleep specialist clinic.16 Hypnotics are generally not recommended. There may be a role for modified-release melatonin in people >55 years old and those with sleep dysregulation disorders. However, the uncertain long-term safety profile of melatonin limits widespread use.
See Box 12.10 for advice on managing anxiety in yourself and other people.
Box 12.10 Managing anxiety in yourself and others
One of your fundamental roles as a doctor is to be a container for the anxiety of others: patients, relatives, nurses, other doctors. This is known as countertransference and can be particularly challenging when on call. Hospitals and sick people cause anxiety in us all and the mind is adept at finding ways to rid us of this. Projecting it onto an unwitting junior doctor is an easy release. Recognizing that this is happening (and that it is natural and ‘unconscious’) can be helpful in not taking things personally. Recognizing that you may also be doing it can be even more helpful. We can all feel victimized or angry at others but neither of these ‘defences’ tend to help us. Try and be polite, helpful, and a good team-player. Acknowledging your own and others’ stress can be therapeutic in itself and if in doubt, share uncertainty and anxiety with your team or trusted colleague. Remember, no matter how you feel, you are not alone.
1 If a patient poses a risk to themselves or others any doctor can give emergency sedation, without the patient’s consent and with restraint, under the Mental Capacity Act (2005).
2 NICE guidelines available at guidance.nice.org.uk/CG115
5 Inouye SK, et al. Ann Intern Med. 1990;113:941 (requires subscription).
3 NICE guidelines available at guidance.nice.org.uk/CG103
4 Typically ‘out-of-hours’, when you may be asked to review while on-call.
6 NICE guidelines available at guidance.nice.org.uk/CG42
7 Folstein MF, et al. J Psychiatr Res 1975;12:189 (requires subscription).
8 Holsinger T, et al. JAMA 2007;297:2391 (available free online at jama.ama-assn.org/cgi/content/full/297/21/2391).
9 Cullen B, et al. J Neurol Neurosurg Psychiatry 2007;78:790 (available free online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2117747
10 See Box 3.10 (p. 163) for details of the DSM-5 and ICD-10 classification systems.
11 NICE guidelines available at guidance.nice.org.uk/CG90
12 A depressive episode is classified by DSM-5 as minor or major and may be associated with somatic symptoms or psychotic symptoms; major depressive disorder is the recurrence of major depressive episodes without mania; ICD-10 use the terms mild, moderate, and severe, adding recurrent if more than one episode without mania. See Box 3.10 (p. 163) for details of the DSM-5 and ICD-10 classification systems.
13 NICE guidelines available at guidance.nice.org.uk/CG178
14 Originally described by Kurt Schneider, a leading German psychiatrist, in 1959.
15 NICE guidelines available at guidance.nice.org.uk/CG113
16 NICE CKS insomnia guidelines available at https://cks.nice.org.uk/insomnia