PSYCHIATRY REVISION

KEY POINTS

Differential Diagnosis Pyramid: OPMAPS

Delirium, Dementia, GMC
Schizophrenia, Schizophreniform, Organic Drugs/Toxins
Schizoaffective, Deulsional, Brief Amnestic disorder
Psychotic, Shared psychotic, Psychotic
Psychosis due to GMC/Drugs Depression, Dystyhmic,
Mood Bipolar I/II, Cyclothymic
Panic ± Agoraphobia Mood due to GMC/Drugs
Specific/Social phobia Anxiety
OCD, PTSD, Acute stress, GAD
Cluster A: mad
Personality Cluster B: bad
?Adjustment disorder with Cluster C: sad
depressed mood, Somatoform Social/Environment

Mental Health Act

 PATIENT MUST FULFIL ALL 5 CRITERIA:

1. The person appears to have a mental illness (a medical condition

characterized by a disturbance in thought, mood, perception and memory)
2. The person requires immediate treatment which can be obtained by
involuntary admission
3. The person requires urgent treatment for the health and safety of themselves
and others (or to prevent deterioration)
4. The person is unable to or refuses to give consent, due to their illness
5. The patient cannot be treated in a manner that is less restrictive

Cognitive Assessment

Orientation Date, Day, Year, Season, Location, Country

Memory Register, Recall, Long Term (impression), Confabulation
Concentration Days of the week backwards, Spell WORLD Backwards
Intelligence General impression from interview

Frontal Lobe Word Lists (10 fruits)

Abstract thoughts (differences/ similarities, proverbs)
Parietal Lobe Dyspraxia (3 step command, intersecting pentagons)
Agnosia (naming fingers, writing on skin)
Language Dysphasias – fluent, non-fluent

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PSYCHOTIC DISORDERS

Schizophrenia

Definition:
- A psychiatric disorder characterized by disturbances in speech, emotion,
cognition, perception and volition. (delusions, hallucinations, or disorganized
speech and thought)
Epidemiology:
- 1/1000 Australia
- Male:Female, 1:1
- Onset late teens, early twenties
- Males more severely affected than females (earlier onset)
Aetiology:
- Subtle disruptions in brain development and maturation in utero
- Combination of genetic and environmental/non-genetic influences
- Physical condition brought out by a life stressor (eg. Starting college, new job)
Risk factors:
- Family Hx
- Prenatal Virus
- Birth complications/trauma
- Cannabis use < 18yrs
Symptoms:

Positive Negative Cognitive

Hallucinations Lack of motivation Impaired planning
Delusions Poor self-care Impaired insight
Disorganised speech Blunted affect Impaired memory
Disorganised behaviour Reduced speech output Reduced mental flexibility

DSM IV:
- A disturbance lasting ≥ 6 months, with at least 1 month of Active symptoms
(positive or negative) with resultant social/occupational dysfunction.
- Excludes schizoaffective, mood disorder, substance abuse, general med
condition (GMC)
- NB: Schizophreniform is typically used as a preliminary diagnosis for
schizophrenia. Due to the complexities of schizophrenia, an initial diagnosis
is very often tentative and schizophreniform is therefore used.

dDx for Psychosis:

1. Psychosis due to psychoactive drug (intoxication or withdrawal)
2. Primary Schizophreniform psychosis
3. Borderline/Schizotypal disorder with decompensation

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Assessment:
1) Engage Patient for History and Examination
- Thorough physical, mental history and examination is ideal
- May not be realistic depending on patient state
- May need corroborative history from family/carers
- Use open ended questions initially
? Has anything happened lately that has upset you
? What is the most important thing you would like help with
? Have you noticed anything suspicious going on around you
? Have you felt like people are talking about you, or watching you in an unusual
manner
?Has anything on the TV or radio, or in the newspapers, seemed to refer to you
personally
?Have you heard people talking to you or about you when there was nobody
around
2) Assess Risk
- Past risk of self harm
- Current risk of self harm
- Risk of harm to others (includes: depressed mood, agitation, aggression)
- Need for hospital admission/involuntary treatment
3) Evaluate triggers
- Substance abuse
- Medication non-compliance
- Stressful life event
4) Assess current treatment
- Medication compliance
- Adverse effects (extrapyramidal)
- Attitudes towards medication/treatment
- Insight
5) Past History – Relevant Issues
- Level of formal education
- Most recent time of highest level of psychosocial functioning
- First onset of psychotic symptoms
- Degree of recovery between episodes
- Attitudes towards family and significant others
- Family history
6) Physical Examination
- Vital signs
- Hydration and Oxygen satursation status
- Blood Glucose
- Urinanalysis + Toxicology (amphetamines)
- Rule out organic factor – infection, metabolic
7) Further investigations
- EEG Baseline measurements if starting Rx:
- CT/MRI -Weight, ECG, Bloods, TFTs, LFTs,
- Thyroid Glucose, lipids
- FBE - Repeat 6/12 if treatment continues
- Serology: HIV
- Vit B12/Folate

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Management
1) Psychoeducation
a. Patient Education (early warning signs, strategies for early
intervention: eg. increase antipsychotics, add benzo, abstain from
drugs, stress management, help seeking)
b. Family Education
2) Psychosocial Intervention
a. Multidisciplinary approach: GP, Psychiatrist, Social workers
b. Involve family in treatment (family therapy: problem solving, stress
management, listening skils)
c. Cognitive Behavioural Therapy
d. Social Skills Training: learning to behave in situations, eg. Eye
contact, speech volume, length of response etc.
e. Engage services to assist with: HOPELESS (housing, occupation,
primary support, education, legal, economic, service access, social
environment)
f. Address co-morbid substance abuse (Motivational interviewing)
3) Medication
a. Benzodiazepines (Short-term use): for immediate symptoms and
insomnia, anxiety, agitation, aggression.
b. Typical Antipsychotics/Atypical Antipsychotics
c. Depot Antipsychotics (only if oral + psychosocial support fails)
d. Clozapine (for treatment resistant cases: agranulocytosis, myocarditis)
e. ± ECT
f. ± Antidepressants
g. ± Mood stabilisers
4) Maintenance
a. First episode patients with excellence response may have medication
free trial after 1-2 years (but continue psychosocial interventions)
b. Repeated episodes or Dx of schizophrenia requires medication for at
least 5 years
c. Consider Depot for persistent relapse which does not respond to
psychosocial intervention (medication compliance enhancement)
d. Consider CTO for patients who fail to co-operate with community
based care (maintain for at least 6 months)
e. GP care for physical health: metabolic S/E, poor self care

Prognosis
- Relapses (80%)and continuing disability are common
- Progressive deterioration is not inevitable
- Disabiltiy diminishes with time, may even remit
- 1/10 patients with chronic psychosis return to full time work

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Antipsychotics:

Typical Atypical Depot

Chlorpromazine Amisulpride (Solian®) Risperidone
Pericyazine Sedation +++ Aripiprazole (Abilify®) (Risperdal
Thioridazine Extrapyramidal + Clozapine (Clopine®) Consta®)
Olanzapine (Zyprexa®)
Droperidol Quetiapine (Seroquel®)
Flupenthixol Risperidone (Risperdal®)
Fluphenazine Sedation + Ziprasidone (Zeldox®)
Haloperidol Extrapyramidal +++
Pimozide
Trifluoperazine
Zuclopenthixol

Mode of Action:
- varying affinity for D2 receptors
- blockade
Response:
- onset 2-3 weeks
- atypicals tend to have less Extrapyramidal side effects (EPS)
Side Effects: SHE WAS ME
Sedation
Hypotension: postural
Extrapyramidal: dystonia, akathesia, parkinsonism, tardive dyskinesia

Weight
Anticholinergic: dry mouth, blurred vision, constipation
Sexual Dysfunction

Metabolic: glucose tolerance, serum lipids

Endocrine: hyperprolactinaemia (gynaecomastia, galactorrhea, amenorrhea,
libido)

Clozapine:
Side effects:
- Agranulocytosis (1%) in first 20 weeks
- Myocarditis in first 6 weeks
- Seizures
- Cardiomegaly
- Disruption of cardiac excitability
- “SHE WAS ME”
Monitoring:
- Baseline haematological and cardiac (ECG, ECHO, Serum troponin)
- Weekly WCC for first 18 weeks, then monthly for duration of treatment,
then for 1 month after stopping
- Fasting blood glucose and lipids every 6 months

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Substance Abuse

Syndromes:
Substance Abuse
- A maladaptive pattern of substance use, which causes clinically significant
impairment or distress
Criteria: ≥3 sx in a 12 month period
1. failure to fulfill roles
2. use in physically hazardous situations (eg. Driving, heavy machinery)
3. recurrent legal problems
4. recurrent interpersonal/social problems due to the substance

Substance Dependence:
- A maladaptive pattern of substance use, which causes clinically significant
impairment or distress
Criteria: ≥3 sx in a 12 month period
1. Tolerance: need ↑ amount to achieve desired effect
2. Withdrawal (sx usually the opposite of the drugs effect +
anxiety/depression/sleep disturbance)
3. Preoccupation: salience, craving, ↓control, continuation
 priority of drinking (Salience)
 compulsion to use (Craving)
 impaired control over alcohol use (Control)
 continued use despite harmful effects (Continuation)

Aetiology:
1. The nature of drug
a. Pleasurable psychological effects
b. Rapid action
2. The individual
a. Genetic predisposition (esp. alcohol)
b. Personal characteristics (poor impulse control, limited problem solving
skills, negative mood)
c. Upbringing (modeling by parents, coping skills)
d. Psychiatric illness (depression, anxiety, schizophrenia, OCD)
3. Socio-Cultural factors
a. Cultural acceptance
b. Availability
c. Price

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Physical Consequences:
Substance and Effect Mechanism of Harm
Alcohol Widespread tissue damage
 Acute
Disinhibition, increased amounts leads - Gastritis, Acute pancreatitis, Trauma
to sedation.  Chronic Disease
Peripheral vasodilation (warm flush, - Cirrhosis, Pancreatitis, Cardiomyopathy
reducing core body temp)
Diuretic Withdrawal State
- Acute
- Severe: Delerium Tremens
Trauma while under the influence
Reduced Immune Function
Nutritional Deficiency: vit b12, thiamine
Sedatives-Hypnotics Deliberate OD
Mix with Alcohol or other CNS depress.
Anxiolytic, Sedative, Hyponotic action (Benzos relative safe in OD)
Withdrawal syndrome – resembles anxiety
Cannabis Cognitive impairment (dose response)
Psychosis (paranoid, aud/vis hallucin)
Produces a ‘high’  intensification of
normal senses, euphoria, laughter,
talkative, floating on air.
Tachycardia, postural hypo (light
headed), Hunger
Impaired memory, concentrartion

Heroin and other Opiates Sharing Needles (HIV, Hep B/C)

Disinhibition/High risk behaviour (STD)
IV heroin use results in a “rush”  OD (resp depression, pupil constrict)
euphoria, warmth, ‘kick’ resembling Withdrawal
orgasm in lower abdomen. Followed by - initial: craving, restless, flu-like
several hours of floating/euphoria. - late: ↑anxiety/craving, piloerect, pupil
Drowsiness, labiliy, mental clouding dilation, N/V/D

PsychoStimulants: Withdrawal syndrome – lethargy,

- Cocaine inanition, depression
Smoking crack  Short acting high (5- Psychosis (acute or chronic use) – by
10mins), followed by intense depression definition must persist >48hours
and craving
- Amphetamines (Ecstacy ICE)
Euphoria, excitement, talkativiess
Increased sex drive, reduced sleep
Dilated pupils, tachycardia, nausua
Hallucinogens (LSD)
Increased sensory awareness (vivid
smell, colour), altered perception and
ability to differentiate self & env.

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Other…
Chronic Alcohol Use:
 Wernicke-Korsakoffs: amnestic disorders caused by thiamine deficiency
- Wernicke(acute, reversible): Ocular palsy, ataxia, vestibular, delirium
- Korsakoffs (chronic): marked short term memory loss, cant learn new info,
anterograde amnesia, confabulation

Dual Diagnosis
- co-occurrence of psychiatric conditions and substance use is higher than
expected in population
- 30% with mental disorder are diagnosed with substance use disorder (2-3
higher than population)
- Substance use can exacerbate psych disorder (vice versa): risk of symptom
exacerbation, relapse, compromised medication efficacy, poor compliance.

Psychosocial Consequences:
Psychological Social
Withdrawal Features Domestic and allied
Neuroses (anxiety, social phobia) Occupation
Other phobias Financial
Psychoses Legal
Suicidal attempt/ideation

Assessment:
1. Common presentations;
a. Acute intoxication/withdrawal:
i. Delirium
ii. Psychosis
iii. Sleep disturbance
iv. Anxiety
v. Depression
vi. Agitation
b. Chronic use
i. Depression
ii. Dementia
iii. Phobias
iv. Psychosis
2. History
a. Alcohol:
i. use a ‘top down’ approach by suggesting high amounts and
allowing them to correct downwards.
ii. Avoid term ‘alcoholic’
b. Drugs: elicit the name of every drug used –
i. Quantity
ii. Frequency
iii. Duration
iv. Route of use
v. Last use
vi. Cost
vii. Source: ?doctor shopping, prostitution, crime

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viii. Assess Substance related problems

ix. Assess Substance dependence
1. Craving
2. Impaired control
3. Prioritisation
4. Withdrawal
5. Tolerance
6. Continued use despite harm
c. Past Use
d. Drug of Choice
e. Most problematic Drug
f. Purpose and meaning of drug to client
i. Reasons for substance use
ii. Precipitants
iii. Effects
iv. Consequences
g. Family History
h. Treatment History
i. Risk-Taking Behaviour
j. Assess Motivation for Change
i. How interested are you in changing you substance use?
ii. Do you feel than you need to change your substance
use?
iii. Do you really want to stop using?
iv. What could you do to get on top of you use?
v. How confident are you that you can achieve this?

3. Examination
a. Evidence of substance use: smell, track marks
b. Decline in global functioning
i. Poor general appearance
ii. Hygiene
iii. Overall health
iv. Nutrition
4. Investigation
a. Urine
b. Serum
c. Breathtests
5. Management
a. Motivational Interviewing
i. FLAGS = Feedback, Listening, Adivice, Goals, Strategies
b. Asses Stage of Change
i. Pre-contemplation: do not wish to change
ii. Contemplation: ambivalence
iii. Action: decision to change and implemented strategies
iv. Maintenance
v. ± Relapse

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Alcohol
1. Harmful/Hazardous use
1. 5% of males
2. 2% of females
3. > 40g (4 standard drinks) for males
4. >20g (2 standard drinks) for females
5. 1 can beer = 1.5 SD
6. 1 bottle wine = 8 SD
7. 1 bottle spirits = 25 SD
2. Dependence
1. Salience
2. Craving
3. Control
4. Continued use despite harm
5. Withdrawal
6. Tolerance
3. Alcohol Withdrawal
1. Can last from 24 hours – 2 weeks
2. Characterised by CNS hyperactivity
3. Can range from Mild Delerium Tremens (DTs)
4. Mild = nausea, tremor, sweats, anxiety, seizures
5. Complex = Confusion, distractibility, hallucination, paranoia
6. DTs = extreme hyperactivity, seizure, delirium  life threatening
4. Management
1. Motivational interviewing
2. Diazepam
5. Alcohol Withdrawal Scale
“People Think All Alcoholics Travel Hung Over”
1. Perspiration (0-4)
2. Tremor (0-3) Score:
3. Anxiety (0-4) 1-4 = mild withdrawal
4. Agitation (0-4) 5-9 = moderate
5. Temperature (0-4) 10-14 = severe
6. Hallucinations (0-4) ≥15 = very severe
7. Orientation (0-4)
(med review if >10)
Total: /27

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ANXIETY DISORDERS

Post-Traumatic Stress Disorder

Definition:
- The re-experiencing of an extremely traumatic event accompanied by
symptoms of increased arousal and avoidance of stimuli associated with the
trauma.
Epidemiology:
- Male:Female = 1:2
Aetiology:
- Unclear as to the interrelationship between Stressor and Personal vulnerability
- Traumatic event causes marked psychological distress and feelings of
horror/fear/hopelessness
- There is a failure to integrate traumatic event and there is disruption in the way
the memories and processed and laid down
- Memories can then be triggered by means of primitive conditioning which
sustains heightened arousal
- Avoidance/Numbing is the homeostatic attempt to modulate this feeling of
constant unease.
Risk Factors:
- Female
- Natural Disaster
- War
- Rape
- Assault
- Motor Vehicle Accident
- Predatory Violence
Symptoms:
Intrusive Phenomena Hyperarousal Avoidance/Numbing
Recollection Difficulty sleeping Thoughts/Feeling/Conversations
Nightmares Exaggerated startle Activities/People/Places
Flashback Hypervigilance Inability to recall aspects
Irritability/Anger Diminished interest in activities
(Associated with Difficulty concentrating Feelings of estrangement
intense psychological Restricted affect
distress) Bleak outlook of future

DSM IV:
1) Traumatic Event: person experienced/witnessed/was confronted by:
a. Actual/Threatened death or serious injury to self
b. Threat to physical integrity of self or others
c. Results in feelings of intense fear, helplessness, horror
2) Re-experiencing
3) Hyperarousal
4) Avoidance/Numbing
5) Duration >1 month

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Assessment:
1) Evaluate trauma
a. Event
b. Response: feelings, thoughts, behaviours
c. Sequelae: avoidance, hyperarousal
2) Characterize course
a. Acute (<3/12)
b. Chronic (>3/12)
c. Delayed onset (>6/12 after stressor. May be reactivated by other stress)
d. NB: Acute Stress Disorder lasts >1/12 after stressor
3) Assess Social Functioning
a. Work habit
b. Relationships
c. Dissociation
d. Vulnerability to subsequent stressors (change in how life’s stressors
are perceived)
e. Any legal ramifications/compensation claims
4) Assess other Psychiatric Sequelae
a. Substance Abuse
b. Social/Specific Phobias
c. Depression
d. “Thrill seeking”
Management:
Aims:
1) Dampen down arousal
2) Evaluate meaning of trauma
3) Systematic desensitization
4) Promote Coping skills
Methods:
1) Psychoeducation
2) Psychotherapy
a. Eg. CBT
3) Medication
a. SSRI (Fluoxetine, Sertraline, Paroxetine) = short term to facilitate
therapy
b. ± Short term Anti psychotics for severe cases
Prognosis:
- Resolves in 60% of obvious cases
- May have long term residual symptoms

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Panic Disorder
Definition:
- Recurrent, unexpected panic attacks about which there is intense, persistent,
concern.
Epidemiology:
- Begins in teens, early 20s
- Later onset (ie. 40s) suggests organic cause
Aetiology: often unclear ?
Risk Factors: ?
Symptoms:
1. Panic Attack:
- Discrete period of intense fear/discomfort, reaching peak within 10
minutes.
- 4/13 symptoms:
Somatic Symptoms Cognitive Symptoms
Palpitations Sense of Choking Depersonalisation
Chest Pain Nausea/Abdo discomfort Fear of dying
Sweating Dizzy Fear of losing control
Trembling/Shaking Numb/Tingling
Shortness of breath Chills or hot flush

2. Agoraphobia:
- Avoidance or anxiety in places or situations in which – escape might
be difficulty/embarrassing, help may not be available.
- Occurs in 90% of cases
- Usually towards a wide range of situations, eg. Shopping, trains
3. Other Symptoms
- Depression is coming 2/3
- Alcohol/Benzo abuse
- Social/Occupational impairment
- Interpersonal difficulties
- Suicide Attempts
DSM IV:
- ≥ 1 month of persistent concern
- Worry about implications of an attack
- Significant change in behaviour related to the attacks

Assessment:
Before diagnosis:
1. Is this a normal anxiety response to a life stress?
2. Is the anxiety a response to a life stress but in excess of the expected
levels? (Adjustment disorder)
3. Is the person a habitual worrier? Is this therefore trait anxiety (anxious
personality?)
4. If there is an anxiety disorder, is it 1o or 2o.
a. Substance intoxication/withdrawal
b. OTC drugs: caffeine, nasal decongestants, bronchodilators
c. General medical condition (DINES)

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SYSTEM EXAMPLE
Deficiency state Vitamin B12, pellagra
Inflammatory RA, SLE
Neurological Neoplasm, infection, MS, Huntingtons, Wilsons
Endocrine Adrenal (Phaeo), Thyroids, Pituitary
Systemic Hypoxia, Hypoglycaemia
5. Is there a cardiac/serious problem?
a. Arrhythmias can mimic panic
b. Recurrent PE’s can mimic panic
 After Diagnosis:
6. If panic disorder, are they ‘spontaneous’ or ‘cued’ ?
7. Identify triggers/exacerbating factors
a. Physical conditions
b. Psychosocial stress
c. Lifestyle factors: caffeine, inadequate sleep, excessive work
8. Is there associated Agoraphobia?
9. Determine severity and degree of functional impairment
a. Psychosocial
b. Occupational
10. Is there associated substance abuse?
11. Is there associated depression?
12. Assess suicide risk/safety

Management:
1. Psychoeducation
a. Self help books, written information
2. Psychotherapy for panic
a. CBT: Hyperventilation, Stress management
b. Cognitive therapy: breaking link between bodil sensations and
their incorrect interpretation
c. Behavioural Therapy:, Relaxation Techniques
3. Biological
a. Used for severe cases who do not respond to psychotherapy
b. Antidepressants:
i. SSRIs may exacerbate condition before anti-panic effect
takes over
ii. TCAs are dangerous in OD, so avoid in suicidal patients
c. Benzodiazepines
i. Good for short term relief
ii. Risk of misuse
iii. Risk of tolerance and withdrawal
4. Psychotherapy for Agoraphobia
a. CBT: hierarchy of fearful situations established and graded
exposure is used. Can be individual or group.
5. Address co-morbidities
a. Always address alcohol abuse first (before anxiety)  detox
b. Co-morbid Depression indicates greater relapse and recurrence and
chronicity. Priority given to treating depression.

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MOOD DISORDERS

Depression
Definition:
Major Depressive Disorder:
- One or more episodes of major depression which causes significant
psychosocial/occupation impairment.
 Others:
1) Dysthymic Disorder
2) Adjustment Disorder with Depressed Mood
3) Depressive disorder NOS
Epidemiology:
- More common in females (16%) than males (8%)
- Mean age of onset is late 20s
Aetiology:
Genetic Twin studies show higher
concordance.
Suggests polygenetic
inheritance of vulnerability to
mood disorder.

Biogenic Amines Monamines for depression

Biological
Neuroendocrine Abnormalities Altered HPA axis, overactivity
in 50% of depressed patients.
Substance Induced Steroids
OCP

L-DOPA
Antihypertensives
Antibiotics
Analgaesics
Anticonvulsants

Benzodiazepine
EtOH
Illicit Drugs

Personality traits Dependent

Psychological Obsessional
Histrionic
Stress Loss
Loss of:
- relationship
Social Stress - job
- status
- loved one
- health

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Risk Factors:
- Family history
- Stressful life event
- Concurrent physical illness
Symptoms:
“Depressed People Will Seem Flat. People Can Get Suicidal”
1. Depressed/Lowered Mood ** (may have diurnal variation, worse in morning)
2. Loss of Pleasure (anhedonia) **
3. Weight Loss
4. Sleep Disturbance (early morning wakening suggests melancholia)
5. Fatigue/Loss of Energy
6. Psychomotor agitation/retardation
7. Concentration difficulties/Indecisiveness
8. Guilt/Worthlessness
9. Suicidal ideation/Preoccupation
** Criteria 1 or 2 is mandatory

NB: Lowering of self-esteem/self-worth is prominent (cf. anxiety, grief – where self-

esteem remains intact)
NB: “Neurovegetative Symptoms”: Sleep, Energy, Concentration, Appetite, Libido

DSM IV:
1. 5/9 symptoms for >2 weeks
2. symptoms cause significant psychosocial/occupational distress or impairment
3. Do not include symptoms clearly due to general medical condition

Risk Assessment

Current Attempt Current Risks

1. Ideation 1. Current Problems
2. Intent 2. Anger/hostility/impulsivity
3. Plan 3. Depression/ Anxiety/ Hopelessness
4. Means 4. Disorientation/Disorganisation
5. Final Acts 5. Substance Abuse
6. Precautions 6. Psychosis
7. Lethality 7. Medical Status
8. Help Seeking 8. Social Withdrawal
9. Precipitants 9. Lack of desire for help
10. Prior attempts 10. Poor psychiatric past experiences
11. Poor coping strategies (eg. DSH)
12. Lack of social connectedness

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Assessment:
1. Conduct MSE
General Appearance Stooped posture
Reduced self-care
Loss of weight
Patient looks downcast, drawn, sullen appearance
May be tearful
Rapport Poor eye contact
Behaviour Slowed activity, lack of spontaneous movement and speech
OR
Agitated with hand-wringing, restlessness, pacing
Mood/Affect Mood may be reactive (mild) or unreactive (severe)
Affect may be blunted (moderate) )or flattened (severe)
Speech and Language Lack of spontaneous speech
Thought Negative, pessimistic themes
- Stream May have psychotic delusions of guilt, worthlessness,
- Form persecution, death, nihilism, poverty.
- Content
Perception May have auditory hallucinations located in the head,
referred to as ‘voices of conscious’.
Cognition May have loss of concentration, poor motivation
Insight and Judgement Perceived benefit of interview (mild) or no benefit (severe)
May have limited insight (severe)

Suicide/Risk Ideation and thoughts of dying

Intent, Plan, Means, Past Attempts, Current Risk

2. Classify type of depression

- Psychotic
o Delusions and Hallucinations
o Mood congruent or incongruent
- Melancholic
o Criterion A: consummatory anhedonia OR non-reactive mood
o Criterion B (≥3): distinct quality to depressed mood, worse in morning,
early morning wakening, marked psychomotor retardation/agitation,
major LOA or LOW, notable guilt.
- Atypical
o Mood reactivity
o Leaden paralysis (limbs feel heavy like lead)
o Hypersomnia
o Increased Appetite/ Weight gain
o Marked Indecisiveness
o Sensitivity to interpersonal rejection
- Post-partum
o Onset within 4 weeks postpartum
- Catatonic
o Motoric immobility, excessive motor activity, extreme negativism
mutism peculiarities of voluntary movement, echolalia, echopraxia

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3. Further history
- Past history, treatments and responses
- Psychosocial triggers
- Premorbid personality and coping style
- Family history
4. Past medical hx:
- Any physical illness related to depression: Parkinsons, MS, Hungtingtons,
Hypothyroid, Cushings, SLE, RA, malignancy, HIV
- Any current medications: steroids, L-DOPA, isotretinoin, interferon
5. Further Investigation
- TFTs
- FBE
- CT/MRI
6. Consider dDx:
- Secondary Depression: Anorexia, Schizophrenia, Anxiety disorders, OCD,
Substance abuse (needs concurrent management)
- Schizophrenia: social withdrawal, deterioration of personal habits, loss of
interest. MSE would show thought disorder
- Early Dementia: irritability, disturbed mood
6. Appraise Severity/Suicide Risk
- ? Reactive or Unreactive mood
- ? Understandable reaction to circumstances
- ? Psychomotor changes
- ? Neurovegetative symptoms

Management:
1. Psychoeducation (patient and family)
a. Current acute/chronic stressors
b. Nature of depression: course, treatment
c. Signs of relapse and action plan
d. Reassurance
2. Psychosocial Intervention
a. CBT
b. MBCT (mindfulness-based cognitive therapy, awareness of oneself in
the ‘here and now’)
c. DBT (dialectical behaviour therapy: exploring alternate solutions)
d. IPT (interpersonal therapy: focus on current relationships)
3. Physical Treatments
a. Antidepressants (2 weeks before improvement)
b. ECT
- Consider inpatient treatment for:
o Psychotic depression
o Significant suicide risk
o Significant homicide risk
o Unable to cope at home
o Seriously physically unwell
Prognosis:
- 50-80% have recurrent type, with episodes lasting ≈6 months (2wks – 1 yr)
- Symptoms free time in between may contract with age
- Some patients suffer 1 episode and make complete recovery

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Antidepressants
1. TCAs (Amitriptyline =Endep®)
- Only used in treatment resistant cases due to side effect profile
- Muscurinic S/E: dry mouth, blurred vision, constipation
- Histaminic S/E: drowsiness, weight gain
- Adrenergic S/E: tachycardia, postural hypotension
- Can cause “Serotonin Syndrome” (if combined with other drugs
affecting serotonin)
i. Agitation/Restlessness
ii. Sweating
iii. Diarrhea
iv. Hyperreflexia
v. Lock of coordination
vi. Shivering/Tremor
- TCAs are cardiotoxic in overdose
2. MAOIs (Phenelzine = Nardil ®)
- Irreversible inhibitors of MAO A & B
- Usually reserved for treatment resistant cases
- Best for Atypical Depression
- Can cause Hypertensive Crisis (“Cheese Reaction”)
i. Severe headache
ii. Chest pain
iii. Palpitations
iv. Stiff neck
v. Intracranial haemorrhage
- Patients must adhere to strict diet (no matured cheese, wines)
3. SSRIs (Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline)
- First line drugs for uncomplicated depression
- Never given in combination with TCAs or MAOIs (serotonin
syndrome)
- S/E include:
Gastrointestinal Central Nervous System Sexual
Anorexia Headache Anorgasmia
Nausea Anxiety Decreased libido
Diarrhoea Agitation Ejaculatory failure
Constipation Akithisia Impotence

*This category usually

persists

4. Other
a. Moclobemide= Aurix ®
i. Reverisble Inhibitor of Monoamine Oxidase A (RIMA)
ii. Safe, well tolerated
iii. No dietary requirements
iv. Rarely causes sexual dysfunction
b. Venlefaxine= Efexor ®
i. Serotonin & Noradrenaline Reuptake Inhibitor (SNRI)
ii. Broader action
iii. Particularly useful for Melancholic Depression

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c. Mirtazapine= Avanza®
i. Noradrenaline & Specific Serotonin Antagonist (NaSSA)
ii. Fewer sexual problems
iii. Good if sleep disturbance is marked
d. Reboxetine = Edronax®
i. Noradrenaline Reuptake Inhibitors (NARI)
ii. Fewer sexual problems
iii. Good if apathy and anergia are prominent

Electroconvulsive Therapy (ECT)

- Safe and effective treatment
- Administered under anaestheisa with a trained psychiatrist
- Administered 2-3 x week, for 6-12 treatments
- Mortality risk very low
- S/E:
i. Headache
ii. Confusion
iii. Memory impairment
- Indications = Severe depression:
i. Starvation
ii. Dehydration
iii. High suicide risk
iv. Psychotic symptoms
v. Treatment resistant

Treatment Algorithm
1. SSRI
2. Mixed Action: Venlefaxine, Mertazapine, Raboxetine
3. TCA (or MAOI)
4. ECT

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Bipolar Disorder

Definition:
1. Bipolar I: A mood disorder characterized by abnormally and persistently
elevated, expansile or irritable mood, sufficient to cause marked
psychosocial/occupation impairment or hospitalization.
2. Bipolar II: A mood disorder characterized by one or more major depressive
episodes and at least one hypomanic episode.

Epidemiology:
1. Male:Female = 1:1
2. Onset late 20s (rare over age of 50)
Aetiology:
3. Polygenetic predisposition to mood disorders
4. Dopamine hypothesis of psychosis
Risk Factors:
5. Can be triggered by antidepressants
6. Poor Compliance is biggest cause of recurrence (poor insight, lifelong illness)

Symptoms: Manic Episode

“Get Some Sleep. Forget Delusional Answers Please.”
1. Grandiosity/ Inflated sense of self
2. Sleep – need is decreased
3. Speech – pressured, loud
4. Flight of ideas/Formal thought disorder
5. Distractibility
6. Agitation/Activity – psychomotor agitation, goal directed
7. Pleasure-seeking activities – excessive, negative consequence

DSM IV:
Mania
1. Expansive/Elevated/Irritable mood for ≥ 1 week (or any duration if
hospitalized) + At Least 3 symptoms
2. Irritable mood alone for ≥ 1 week (or any duration if hospitalized) + At Least
4 symptoms
Hypomania
7. Symptomatic criteria met for mania EXCEPT
1. Shorter duration (of at least 4 days)
2. Not severe enough to cause marked function impairment/ hospitalization
3. Absence of psychotic features

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Assessment:
General Appearance May seem eccentric, odd.

Rapport Energetic, but irritable and frustrated under surface.

Behaviour Hyperactive
Psychomotor agitation/ Increased Drive/Goal directed
Decreased need for sleep

Mood/Affect Elevated, Expansive, Euphoric mood

Irritable Mood

Speech and Language Rapid, Loud, Pressured

Thought Formal Thought Disorder:

- Stream Flight of Ideas/Loosening of Associations
- Form Jokes, Puns, Plays on Words
- Content Delusions of: grandiosity, erotmania, special powers

Perception Hallucinations in severe states (God instructing them)

Cognition Impaired concentration/Distractibility

Insight and Judgement Often severely impaired  may have devastating social
consequences (business, sexual, driving, spending)

Suicide/Risk May be quite impulsive, reckless

Acute Management
1. Rule out organic conditions/drug induced states
2. May require involuntary admission if severe
3. Use Valproate ± atypical antipsychotic initially (Lithium is too slow onset)
4. ± Benzodiazepine to lessen hyperactivity
 If mild, can be treated as outpatient with Valproate/Lithium, but need family
member to monitor compliance due to poor insight.

Long Term Management:

1. Evaluate long term mood stabilizing options for patient
- Warrented for 2 episodes in 2 years, may begin after just single episode
2. Psychoeducation for both patient and family
- About illness, nature, course, treatment, signs of relapse
3. Psychosocial intervention
- CBT, IPT, Family therapy
- Can help improve compliance and prevent recurrence. Individualise.
4. Biological Treatment
1. Lithium, Valproate, Carbemazapine
2. Monitor S/E
3. Prevent both elation and depression in 80% of patients

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Mood Stabilisers
1. Lithium
a. First line or Bipolar 1
b. Narrow therapeutic window  requires monitoring
c. Blood tests to check levels
d. Significant role in maintenance and reducing suicide risk
(antidepressants can trigger mania or rapid cycling, avoid if poss)

Lithium Profile
Side Effects Short Term Long term
Polydipsia Weight gain
Usually settle over time Polyuria Renal changes
N/V/D Dry Skin
Metallic Taste Hypothyroidism (often
Difficulty concentrating need thyroxine)
Fatigue
Tremor/Weakness
Worsening acne/psoriasis
Toxicity (Others might think you Avoid dehydration
look drunk) Do not change salt intake
Can occur due to : Slurred speech
4. Overdose Balance disturbance Stop drug immediately
5. Drug interaction Visual disturbance
(NSAIDS, Severe N/V/D Nb/ Teratogenic 1st trim.
diuretics, ACEI) Severe tremor/twitch
6. Dehydration Severe drowsiness
7. Salt deprivation

2. Sodium Valproate
a. First line for Bipolar II, Rapid Cycling, Schizoaffective Disorder
b. Better tolerated than lithium

Valproate Profile
Side Effects Nausea/Indigestion
Weight Gain Discuss with doctor
Usually settle over time Sedation
Transient Hair Loss Teratogenic in 1st trim.

Toxicity Liver Failure

Haematological Alterations Stop drug immediately
(blood dyscrasias)

3. Carbemazapine
a. Used in mania and preventing bipolar recurrence
4. Lamotragine
a. Can be used for depressive symptoms in bipolar I

Prognosis:
- Generally requires indefinite treatment and psychosocial support

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EATING DISORDERS

Anorexia Nervosa
Definition:
- The relentless pursuit of thinness characterized by marked self-induced weight
loss and a refusal to maintain normal body weight.
Epidemiology:
- Adolescent and young women
- Onset ~ 15-19 (now younger)
- Lifetime prevalence 0.5%
- Male:female ~ 1:10
- Developed world
Aetiology:
- Genetic contribution
- Environment exposure
- Often develops as child tries to keep control of their world
Risk Factors:
- Stressful social environment – parental conflict, family dysfunction
- Perfectionism
- Low Self-esteem
- Weight concerned environment
- Underweight/thin family
Symptoms:
Cognitive Behavioural Neurovegetative
Obsession with Thinness Restricting Depressed mood
Preoccupation with food Laxatives Decreased libido
Food Rituals/Ruminations Excessive exercise Decreased concentration
Increased interest in food Diuretics Lethargy/Fatigue
Denial of hunger/dieting Induced Vomiting Disrupted sleep

DSM IV:
1. Failure to maintain normal body weight (weight < 85% of that expected, or
>15% below normal, or BMI <17.5 for those over 18. Underage, use charts)
2. Intense fear of gaining weight/becoming fat (though underweight)
3. Distorted perception of body shape/Undue influence of body weight/shape on
self-evaluation, or denial of seriousness of current low body weight.
4. Amenorrhea if post-menarchal (absence of at least 3 consecutive periods)

Classify Type:
a. Restricting: Not regularly engaged in bingeing/purging
b. Bingeing/Purging: Regularly engaged in bingeing/purging

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Assessment:
1. History:
- When were you last well?
- Document all eating disorder symptoms
- Effects of illness on her life
- Symptoms of starvation
- Co-morbid depressions, OCD, social phobias, past psych hx?
- Motivation for change
- Previous help sought
- Reactions of family and friends
- Collateral history
- Relevant family problems

2. Physical Exam (consequences of starvation)

“Not Eating Has Many Intense Effects. Girls Rarely Stay Confident.”

Neurovegetative Depressed mood, attention, libido, sleep, appetite

Electrolyte Low K+, PO43-- , Mg, Ca
Haematological Anaemia of chronic disease (normocytic/chromic)
Metabolic Hypothermia, Hypoglycaemia, Hypercholesterol
Immunological Bacterial infection
Endocrine Amenorrhea
Gastrointestinal Mallory weiss, swollen salivary glands, dental caries, ↓motility
Renal Ketones, acute/chronic renal failure
Skin/Bone Dry skin, lanugo hair, facial purpura, Osteopenia
Cardiac Arryhthmia, Bradycardia

3. MSE
General Appearance May have Low BMI
Look for layering of clothes
Rapport -
Behaviour -
Mood/Affect Dysphoriac affect
Irritibility
Speech and Language -
Thought Preoccupation with weight/shape
- Stream Feelings of inadequacy
- Form
- Content
Perception -
Cognition Poor concentration
Cognitive function reduced
Insight and Judgement May be limited
Suicide/Risk -

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Investigations:
1. Screen for underling organic illness (ESR, TFT, Coeliac screen)
2. Screen for acute medical complications
a. FBE – anaemia
b. ESR – severe sepsis
c. U+E as well as K, Mg, Ca, Phospate (need to ask specifically)
d. LFTs, albumin, total protein – malnourishment
e. Random Glucose – hypoglycaemia or diabetes
f. ECG – bradycardia, arryhtmia, hypokalaemia (long QT)
g. CXR – TB or staph
h. DEXA or Bone Densitometry (if >12 months amenorrhea)
3. Annual Bone Density
4. Monitor phosphate during refeeding: hypophosphataemia can present as
delirium, cardiac failure – can be precipitated by IV dextrose)
dDX:
- Normal weight loss (anorexia has pervasive concern and uncompromising
attitudes)
- Major depressive disorder
- OCD
- Physical Disorder: thyrotoxicosis, Ulcerative colitis, malignancy, infection
- Schizophrenia

General Management:
1. Psychoeducation – multidisciplinary appraoch
a. Patient and Carers
b. Acknowledge ambivalence
c. Provide information and access to support groups
d. Restore nutrition
e. Involve Dietician
2. Psychotherapy (often long term)
a. Family therapy (effective for adolescents): non-blaming technique
b. Behavioural techniques – reward weight gain
c. Cognitive therapy – challenge anorexic attitudes, identify role of AN
3. Biological
a. SSRI for co-morbid depression
Admission to Hospital/Psych Referral  Specialist Eating Disorder Unit
- BMI < 16
- Rapid weight loss (4-5kg/week or 1kg/week over many weeks)
- Abnormal investigation results: ECG, LFTs, FBEs
- Severe dehydration and BP <90
- Severe bradycardia and faintness
- Suicidal risk
- Extreme Diuretic/Laxative use
- Failed to improve as outpatient
- Extreme social isolation/family situation
- Marked co-morbiditiy
NB/ Refer to paedatrician if prepubescent

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Prognosis:
- Usualy duration of illness ≈ 7 years
- Those treated early may recover
o 40% make good 5 yr recover
o 40% have residual minor sx
o 20% have major ongoing illness
- Residual morbidity is common
o Stunted growth, infertility
o Osteoporosis
o Dental erosion
o Memory and learning deficits
o Proximal myopathy
s
1. Good prognostic factors:
a. Absence of severe emaciation (BIM>17.5)
b. Absence of medical complications
c. Desire to change
d. Supportive family/friends
2. Poor Prognostic factors
a. Longer duration of illness
b. Older age of onset
c. Disturbed family relationships
d. Co-morbid psychiatric conditions

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Bulimia Nervosa
Definition:
Epidemiology:
- 1-3% of women < 45
- Young women
- Onset late teens-early adult
- More common in western world
Aetiology:
1. Cognitive Behavioural View
a. Low self-esteem 
b. Over-concern about shape and weight 
c. Extreme Dieting 
d. Binge Eating 
e. Compensatory purging/over-exercising/fasting
Risk Factors:
- History of Obesity
- History of parental problems
- Restricting dietary intake
- Perfectionism
- Mood disorder
- Sexual/physical abuse
- Early menarche
- Parental abuse
Symptoms:
Cognitive Behavioural
- Depressed mood after binge - Consumption of High calorie/easily
- Self-depricating thoughts after binge consumed foods during binges.
- Realisation that eating pattern abnormal - Inconspicuous eating (concealed from
- Sense of shame/lack of control family)
- Self-induced vomiting/abdo pain /
social interruption/sleep following binge
- Repeated attempts to lose weight
(restricted diets, vomiting, laxatives,
exercise)

DSM IV:
1. Recurrent episodes of binge eating
a. Eating an amount of food significantly larger than what other people
would eat in a similar time in similar circumstances.
b. A sense of loss of control/shame about bingeing
2. Inappropriate or excessive compensatory behaviours to prevent weight gain
3. Binging and compensatory behaviours occurs 2x week for 3 months
4. Self evaluation is unduly influenced by body shape/weight

Classify Type:
a. Purging: Has regularly engaged in self-induced vomiting or misuse of
laxatives, diuretics or enemas
b. Non-Purging: Has used other compensatory behaviours (ie. fasting or
excessive exercise) but has Not regularly engaged in self-induced
vomiting or misuse of laxatives, diuretics or enemas

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Assessment:
1. Physical
- Hair loss, acne, dry skin
- Dental erosion, decay
- Mouth ulcers, swollen parotids
- Bloodshot eyes
Management:
1. Psychoeducation
2. Psychotherapy
a. **CBT – monitoring of weight/shape concerns
b. Dietary counseling
c. Interpersonal psychotherapy
3. Biological
a. SSRI for comorbid depression
4. Admission to hospital if:
a. Well designed Outpatient treatment has failed
b. Suicidal
c. Antidepressants are needed but cannot have safe monitoring without
admission
Prognosis:
- 52% make good recover (10 years)
- 9% have ongoing bulimia

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PERSONALITY DISORDERS

Borderline Personality Disorder

Definition:
8. A pervasive pattern of instability of affect, self-image and interpersonal
relationships which leads to marked occupational and psychosocial
impairment.
Epidemiology:
9. 10% of adult population have a personality disorder of some kind
10. Rises to 30% of inpatients presenting with depression ,anxiety, substance
abuse.
11. Equal male:female
12. Borderline patients found in 1% of population
13. Rises to 10% amongst psychiatric outpatients and 1/5 inpatients
Aetiology:
14. Combination of genetics and environment
Risk Factors:
15. Profound developmental trauma
16. Childhood sexual abuse
17. Childhood neglect
18. Parenting alternating between extremely intrusive and extremely neglectful
Symptoms: “PRAISED”
1. Paranoid ideas
2. Relationship instability
3. Affect instability, Aggression, Attachment issues
4. Impulsivity, Identity disturbance
5. Suicidal ideation/Self harm
6. Emptiness
7. Dissociative phenomena – depersonalisation

DSM IV:
Assessment:
19. Transference: patients thoughts/feelings and fantasise (positive and negative)
towards the therapist reflects unconscious relationships with past significant
others.
20. Counter-transference is the therapist response to transference
Management:
1. Acute management:
- Medical management of self injury/overdose
- Treatment of drug/alcohol intoxication and withdrawal
- ? Psychotropic for acute psychiatric states
- Assess suicide risk/ risk to others
2. Long term
- Long Term, Individual Psychotherapy
a. Supportive
b. Psychodynamic
c. Interpersonal
d. Cognitive Behavioural Therapy
e. Integrated: Cognitive Analytic Therapy
- ± Marital, family and group therapies if indicated

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3. Biological
- Benzodiazepine: short term to curb anxiety
- Antipsychotics: low doses may be used initially to curb aggression
- Mood Stabilisers: may be indicated long term to help curb impulsivity and
suicidality (if the patient can co-operate)
-
Prognosis:
- Some will improve by middle age, but have often aliented
spouses/family/friends by this stage
- High risk of suicide, especially borderline patients (10%)
- Psychotherapies and medications can improve prognosis.

Obsessive-Compulsive Disorder

Definition:
Epidemiology:
Aetiology:
Risk Factors:
Symptoms:
DSM IV:
Assessment:
Management:
Prognosis:

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ORGANIC BRAIN DISORDERS

Dementia
Definition:
21. Development of multiple cognitive deficits manifested as changes in Memory,
Intellectual functioning, Behaviour and Personality.
Epidemiology:
22. 1% of population
23. More common after age 60 (prevalence doubles every 5 years of age)
Aetiology:
1) Alzheimer’s disease………………… 50-60%
2) Cerebrovascular disease…………….. 10-15%
3) Dementia with Lewy Bodies………... 10-15%
4) Mixed Alzheimer’s and CVD………. 10-15%
5) Other………………………………… 5-10%
a. Fronto-temporal dementia
b. Alcohol related brain damage
Mnemonic: “DEMENTIA”
- Degenerative
o Alzheimers (most common)
o Parkinsons
o Huntingtons
o Picks disease
o Lewey Body Disease
- Emotional
- Metabolic (hypoglyc,TSH,electrolyte)/Nutritional (vit b12,folate,niacin)
- Ear/Eye impairment
- Normal Pressure Hydrocephalus (gait apraxiaincontinencedementia)
- Tumour (1o/2o)/Trauma (SDH)/Toxic (EtOH)
- Infection (HIV/TB/CJD/Syphillis)
- Atherosclerotic/Vascular (Stepwise dementia)
Risk Factors:
24. Alzheimer’s: family HX
25. Vascular: stroke, HTN, smoking, DM, AF
26. Other: alcohol abuse

Symptoms: Signs
Behavioural and Psychological Symptoms of 37. Poor hygiene
Dementia (BPSD) 38. Poor diet
27. Mood change 39. Unsafe use of appliances
28. Delusions 40. Failure to pay bills
29. Misidentification of familiar place/people 41. Tendency to get lost
30. Hallucinations 42. Repetitive questioning
31. Personality change
32. Excessive motor behaviour
33. Noisiness
34. Resistance to care
35. Aggression
36. Sexual disinhibition

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DSM IV:
1) Memory impairment + ≥1:
a. Aphasia Language disturbance
b. Apraxia Impaired ability to carry out motor activities despite
intact motor function
c. Agnosia Impaired ability to recognize/identify objects despite
intact sensory function
d. Executive Function Impaired functions of planning, organizing,
sequencing, abstract thinking
2) Gradual decline and continuous decline
3) Significant impairment in social or occupational functioning
4) Significant decline from a previous level of functioning

Assessment:
1. History
a. Ascertain nature/extent of cognitive deficit
b. Determine impact on function
c. Corroborative history is important: duration, onset, progression, help,
mood, psychotic sx, challenging behaviours.
d. Determine time course and Establish cause
e. Diagnose comorbid conditions such as delirium and depression
f. Check adequacy of familial and social support
2. MSE
General Appearance Person living alone may look neglected, malnourished
Person living with carers may look groomed/nourished
Rapport Person may be able to conceal cognitive impairment for
some time, as GP meeting are often predictable after many
years.
Demands that exceed patient’s capacity may lead to
extreme emotional/physical disturbance = catastrophic
reaction.
Behaviour Mild-mod dementia: alert, attending.
If complicated by delirium, gauge arousal and attention:
(hyperaroused or drowsy, easily distracted)
Mood/Affect 20% have comorbid depression: look for social
withdrawal, teary, agitated, noisy, insomnia, anorexia.
May often look anxious/weary when asked about feelings
Agitation worse in late afternoon (‘sundowning’)
Speech and Language Word finding ability profound aphasia
Thought Simple in content, rambling and repetitive
- Stream/Form May be accompanied by delusions – spouse in imposter,
- Content people stealing from you when something is misplaced…
Perception May have hallucinations – visual most commonly, of
children and animals.
More bizarre, florid delusions may indicate delirium
Cognition Disorientation to time is common.
People often blame lack of knowledge of day, week, time on
retirement, poor vision, social isolation etc. But time
should remain intact in cognitively capable people.
Important to do MMSE

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Insight and Judgement Often lost early so patient believes they are coping well.
Limitations of MMSE:
- Screening test
- Provides baseline for reference, not diagnostic without additional info
- Need to be interpreted in the light of other material obtained
- Low scores may be due to: poor vision/hearing, depression, lack of co-
operation, English fluency, limited education.
- Test does not assess frontal lobe function: insensitive for persons of above
average intelligence with early dementia.

3. Ddx
- Subdural haematoma
- Cerebral tumour
- Normal pressure hydrocephalus
4. Investigations
 Exclude complicating factors
i. Anaemia
ii. Diabetes
iii. Hypothyroid
iv. Vit B12 deficiency
v. Drug toxicity
a. FBE
b. ESR
c. Glucose
d. U+E
e. TFTs
f. Urine microscopy + culture
g. Other: LFTs, folate, syphilis, HIV
h. Imaging: CT (high yield)

Management:
1. Acute:
i. Establish diagnosis
ii. Exclude treatable causes
iii. Excluding Depression/Delirum as contributing to confusion
2. Long term
i. Ensure optimal physical health
ii. Continual assessment of ADLs
iii. Education and support for carers
iv. Involvement in decisicons regarding care – wills, advanced
directives
3. Biological
i. Cholinesterase inhibitors (donepezil) – short term improvement, 6-
12 months delay in decline.
ii. Antidepressants – SSRI for comorbid depression
Less used:
iii. Benzos – short/medium term to relieve daytime anxiety (risk
falls)
iv. Antipsychotics – limited role, reduced anxiety, agitation,
psychotic sx. (S/E parkinsonism, falls, tardive dyskinesia)

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v. Mood stabilizers – reduce agitation/aggression

Nb/ All psychotropic drugs can induce delirium. Also, digoxin, GCS,anticonvulsants
4. Social
i. Home help
ii. Meals on wheels
iii. Day care
iv. Respite
v. Dosette boxes
vi. Nursing help –bathing etc
vii. Carer support – distress, isolation, anxiety, ill health, financial
viii. Admission to residential facilities
Prognosis:
- No cure as yet
Duration ≈ 10 years Alzheimers, 6years DLB

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Delerium

Definition:
43. Transient global cognitive impairment of presumed organic aetiology.
44. A disturbance in consciousness and a change in cognition that develop over a
short time.
Epidemiology:
45. 1% prevalence in general population
46. Higher in hospitals: 5-15%
47. Common in children or elderly
Aetiology:

Risk Factors:
48. Coexisting dementia (40% demented patients are delirious on admission)
49. Depression
50. Acute psychological stress
51. Sleep/sensory deprivation
52. Bereavement
53. Brain damage
54. Substance abuse
55. Drug/alcohol dependence
56. Hearing/visual impairement
Symptoms:
1. Clouding of Consciousness: ↓ Alertness, Awareness, Attention, Arousal
a. Sleep-wake cycle reversal: somnolent during day, agitated at night.
b. Psychomotor activity: range from apathy  restless. Picking at bed
clothes.
2. Cognition
a.
DSM IV:
1. A disturbance in consciousness – Reduced clarity in awareness of environment
impaired ability to focus, shift or
sustain attention

2. A change in cognition or disturbance Memory deficit, disorientation, language

in perception not better accounted disturbance
for by evolving/existing dementia

3. Occurs over a short period and tends Hours – three Days

to fluctuate through the day

4. Evidence (history/phys/Ix) than General Medical Condition

disturbance is caused by direct Symptoms during substance intoxication
physiological consequence of GMC Develop only after withdrawal
More than one aetiology
Assessment:Management:Prognosis:

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