• Psychiatry

Topics In This Section

Primary Psychiatry Disorders

Anorexia Nervosa
Attention Deficit Hyperactivity Disorder
Autism
Bipolar Disorder
Borderline Personality Disorder
Conversion Disorder
Depression
Generalised Anxiety Disorder
Obsessive Compulsive Disorder
Post-Traumatic Stress Disorder
Schizophrenia
 

 

Emergency Psychiatry

Acute Agitation
Risk Assessment

Drug-Related Problems

Alcohol Withdrawal
Delirium Tremens
Lithium Toxicity
Neuroleptic Malignant Syndrome
Opioid Overdose
Opioid Withdrawal
Paracetamol Overdose
Serotonin Syndrome
Tricyclic Antidepressant Overdose
Wernicke's Encephalopathy


Emergency psychiatry

Acute agitation

●      Verbal (and non-verbal) de-escalation techniques
●      If: Unsuccessful. Then: Offer antipsychotic or benzodiazepine oral
●      If: Unsuccessful Then: after appropriate inpatient treatment orders (ITO), physical restraint and IM chemical restraint

 

Risk assessment

  • Risk of self-harm/suicide:
    • Static: Previous self-harm, previous suicide attempts, family history of suicide, age/gender.
    • Dynamic: suicidal ideation, substance intoxication, psychosocial stressors, psychosis, access to weapon.
  • Risk to others:
    • Static: Previous harm to others, antisocial personality traits.
    • Dynamic: substance intoxication, psychosis, psychosocial stressors, psychosis, access to weapon.
  • Vulnerability
    • Example: Homelessness, lack of self care, sexual disinhibition
  • Risk to reputation/mental instability
    •  Example: Reckless driving, reckless spending, impulsivity (such as causing drug use)
  • Risk of absconding
    • Example: Accepting of treatment, previous absconding

 

Drug-related problems

Alcohol withdrawal

Clinical features:

  • Uncomplicated
    • Sweating
    • Tremor.
    • Nausea/vomiting.
    • Anxiety.
    • Headache.
  • Complicated:
    • Alcoholic hallucinosis (occurs 12-24 hours since decreased drinking).
    •  Seizures (occurs 1-2 days since decreased drinking).
    • Delirium tremens (occurs 2-3 days since decreased drinking - see delirium tremens summary)

Investigation:

  • Diagnostic: Clinical diagnosis. Alcohol withdrawal scale

Treatment:

  •  Best: Diazepam (PRN as per alcohol withdrawal scale every 2 hours until symptoms subside) and thiamine.

 

Delirium tremens

Clinical features:

  • Confusion. Agitation. Tremors
  • May be associated with seizures, hallucinations and delusions.
  • Systemic symptoms - tachycardia, hypertension, tachypnoea, fever.

Investigation:

  • Diagnostic: Clinical diagnosis.

Treatment:

  •  Initial: Consider ICU admission to stabilise patient
  • Best:
    • Diazepam (PO) and thiamine
    • May require antipsychotic. If: Extrapyramidal side effects then emerge, then: give benztropine

 

Lithium toxicity

Clinical features:

  • “Like drunk” + tremor
  •  Associated with slurred speech, ataxia, nausea and vomiting, confusion.

Investigation:

  •  Diagnostic: serum lithium levels
  • Key investigation: ECG

Treatment:

  • Best:
    • (1) Stop lithium. Consider gastric decontamination in overdose (must be <6 hours since ingestion).
    • (2) Supportive care (especially hydration)
    • (3) Monitor ECG (most commonly see T wave flattening).
    • Consider dialysis.

 

Neuroleptic malignant syndrome

Clinical features:

  • Variable, though generally develops over 1-3 days (compared to serotonin syndrome, which develops over hours)
  • FARM
    • Fever
    • Autonomic instability
    • Rigidity
    • Mental state altered

Investigation:

  • Diagnostic: Clinical features + raised CK

Treatment:

  • Best:
    • All: Cease anti-dopaminergic drug and admit to ICU for supportive care
    • All: antidotal therapy: bromocriptine (or dantrolene)
    • If: hyperthermia. Then: cool (e.g. with icepacks)
    • Consider diazepam for sedation

Note: Similar syndrome may occur with abrupt cessation of anti-Parkinson’s medications (termed parkinsonism hyperpyrexia syndrome)

 

Opioid overdose

Clinical features:

  • Decreased GCS.
  • Decreased respiratory rate.
  • Bilateral myosis (“pinpoint pupils”).

Investigation:

  • Diagnostic: Can generally be a clinical diagnosis (otherwise urine levels)

Treatment:

  • 1st line: Naloxone
  • Due to half-life of naloxone (compared with certain opiates) patients may re-develop respiratory depression in the 2 hours following naloxone administration. It is important to monitor for respiratory depression and consider further naloxone or naloxone infusion.
  • If: withdrawal symptoms emerge (see opioid withdrawal section), then: do not treat with further opioids.

 

Opioid withdrawal

Clinical features:

  • Classical: piloerection, rhinorrhoea and yawning.
  • Also features opposite of opioid use: anxiety, diarrhoea + N/V, dilated pupils.

Investigation:

  • Diagnostic: Clinical diagnosis

Treatment:

  • Best:
    • Buprenorphine
    • 2nd line: Clonidine

 Note: Methadone is used for long-term maintenance therapy and not for acute management of opioid withdrawal.

 

Paracetamol overdose

Clinical features:

  • 4 stages:
    • Day 0-1: Asymptomatic or isolated nausea and vomiting
    • Day 1-3: RUQ pain. LFT derangement.
    • Day 3-4: Features of liver failure (jaundice, coagulopathy, hepatic encephalopathy) and renal failure
    • Day 4-weeks: Recovery

Investigation:

  • Diagnostic: Measure serum paracetamol levels 4 hours after ingestion
  • Also: LFTs, EUC, BGL

Treatment:

  • Initial:
    • If: <1 hour since ingestion. Then: activated charcoal
  • Best:
    • N-acetylcysteine (NAC)
    • If: 1-4 hours since ingestion. Then: wait until 4-hour serum paracetamol can be measured then proceed as below.
    • If: 4-8 hours since ingestion. Then: NAC as per nonogram (calculated using time since ingestion and serum level of paracetamol)
    • If: >8 hours since ingestion. Then: NAC empirically.
    • If: Unknown time. Then: NAC empirically

 

Serotonin syndrome

Clinical features:

  • Onset usually over hours (compared to NMS, which occurs over days/weeks)
  • Similar to NMS
    • Autonomic instability. Hyperthermia. Flushed skin
    • Confusion.
    • Rigidity
  • Distinguishing features: Myoclonus. Hyperreflexia. Tremor. Dilated pupils.

Investigation:

  • Diagnostic: Clinical diagnosis (and normal CK)

Treatment:

  • Best:
    • Stop serotonergic drugs and give benzodiazepines for agitation
    • If: no improvement. Then: cyproheptadine (antidote)
    • If: Severe. Then: Sedate, intubate, paralyse and cool

 

Tricyclic antidepressant overdose

Clinical features:

  • Sedation
  • Anticholinergic effects: Dry eyes, dry mouth, flushing, dilated pupils

Investigation:

  • Key investigation: ECG showing QRS widening. ECG changes can be used to predict progression.

Treatment:

  • Initial: ABCs and ICU admission (especially continuous cardiac monitoring)
  • If: Evidence of CNS depression. Then: intubation
  • If: Hypotension. Then: IVT
  • Sodium bicarbonate and hyperventilation aiming for pH 7.45-7.55

 

Wernicke’s encephalopathy

Clinical features:

  • Generally associated with alcohol consumption.
  • Triad:
    • Delirium
    • Ophthalmoplegia - Commonly bilateral 6th cranial nerve palsies
    • Truncal ataxia

Investigation:

  • Diagnostic: Clinical diagnosis

Treatment:

  • Best:
    • IM or IV thiamine (not oral), followed by glucose.

Note: classically instructed to give thiamine before glucose to malnourished alcoholics to avoid Wernicke’s encephalopathy

 

Primary psychiatric disorders

Anorexia nervosa

Clinical features:

  • Underweight (BMI < 18.5) and Disturbed body image with fear of gaining weight
  • Differs from bulimia nervosa, where weight is normal.
  • May have binging and purging behaviour.
  • Amenorrhoea. Lanugo hair. Russell's sign.
  • Comorbid psychiatric conditions (depression/anxiety)

Investigation:

  • Initial: Check for organic complications (e.g. vitals, ECG, hypovolaemia, hypokalaemia, hypomagnesemia, hypophosphatemia)
  • Diagnostic: BMI and clinical

Treatment:

  • Initial: treat any life threatening complications (namely hypokalaemia and dehydration). May require medical hospital admission.
  • Best:
    • (1) Restore normal weight (watch out for refeeding syndrome)
    • (2) Psychotherapy (esp. family therapy)

 

Attention deficit hyperactivity disorder (ADHD)

Clinical features:

  • Children < 12 years-old
  • Attention deficit - forgets things, easily distracted
  • Hyperactivity - running and climbing
  • Impulsivity - interrupts, can’t wait in line

Investigation:

  • Clinical diagnosis. Rule out hearing and visual impairment. Determine sleep and eating patterns prior to commencing pharmacotherapy.

Treatment:

  • Non-pharmacological: Psychoeducation. Liaise with schools
  • Pharmacological: dexamphetamine or methylphenidate (make sure no possibility of drug diversion)

 

Autism

Clinical features:

  • Difficulty with communication (verbal, non-verbal and, accordingly, difficulty with relationships)
  • Repetitive behaviours (repeated movements, routines, narrow interests)

Investigation:

  • Diagnostic: Clinical diagnosis (assessment by paediatrician, psychologist and speech pathologist)
  • Workup: Hearing testing (rule out impairment), Chromosomal analysis (to exclude genetic causes)

Treatment:

  •  Best:
    • Aim is to maximise functioning
    • Family education and support. Multi-D approach. Speech therapy. Social therapy. Special schooling.
    • Pharmacological treatment may include antipsychotics (for management of aggression, tics) and SSRIs (for management depression, anxiety).

 

Bipolar disorder

Clinical features:

  • DIGFAST
    • Distractibility
    • Impulsivity
    • Grandiosity
    • Flight of ideas
    • Agitation - psychomotor
    • Sleep decreased
    • Talks fast (pressure speech)
    • Mania: Psychotic features or severe symptoms enough to warrant hospitalisation. Duration ≥1 week. Otherwise: Hypomania.

Investigation:

  • Initial: Rule out organic and substance causes
  • Diagnostic: Clinical diagnosis

Treatment:

  • Initial: Risk assessment +/- admission +/- detention
    • If: acute mania. Then: olanzapine or risperidone
    • If: depression. Then: antidepressant and a drug for prophylaxis of bipolar disorder
    • All: Prophylaxis of bipolar disorder:
  • 1st line: lithium (must be monitored). Measure lithium levels first few days after commencing lithium or change in dose. Then every 3 months.
  • 2nd line: sodium valproate
  • Psychotherapy: CBT and/or psycho-education.

 

Borderline Personality Disorder

Clinical features:

  • Unstable self image
  • Unstable relationships
  • Unstable regarding impulses (sexually, spending, driving, binge eating)
  • Unstable anger (difficulty controlling anger)
  • Unstable affect
  • Self harm/suicide

Investigation:

  • Clinical Diagnosis, though Initial investigations should be conducted to rule out organic and substance causes

Treatment:

  • Initial: Risk assessment +/- admission +/- detention
  • Best: Primarily psychotherapeutic
  • Dialectical behaviour therapy - DIME
    • Distress tolerance
    • Interpersonal skills
    • Mindfulness-based therapy
    • Emotional regulation training

 

Conversion disorder

Clinical features

  • Examples of manifestations of conversion disorder include:
    • Non-epileptic seizures - conscious during generalised “seizure”, gradual onset, side to side head shaking, closed eyes with resistance to eye opening
    • Functional weakness - assess with arm-drop test or Hoover’s sign
    • Functional tremor - voluntary movement with other limb and observe for entrainment
    • Functional vision loss - tubular visual field deficit

Investigations:

  • Must exclude biological disease. Avoid protracted investigations.

Treatment:

  • Explain diagnosis (psychoeducation)
  • Acknowledge that symptoms are real, not feigned. Likely due to physical manifestation of psychological distress
  • Psychotherapy (e.g. CBT)

 

Depression (MDD single/recurrent or dysthymia)

Clinical features:

  • DIGSPACES
    • Depression
    • Interest loss (Anhedonia)
    • Guilt
    • Sleep decreased
    • Psychomotor retardation
    • Appetite change
    • Concentration decrease
    • Energy decrease
    • Suicidal ideation

Investigation:

  • Initial: rule out medical causes (e.g. TFTs) and drug use
  • Diagnostic: Clinical diagnosis (Based on DSM-V)

Treatment:

  • Initial: Risk assessment +/- admission +/- detention
  • Best:
    • Mild depression:
      • 1st line: Psychological therapies (CBT) - more effective than antidepressants.
      • 2nd line: SSRI
    • Moderate-Severe depression
      • 1st line: Antidepressants (more effective) +/- psychological therapies
    • Melancholic depression
      • Antidepressants and/or ECT
    • If: severe self-neglect (e.g. nil oral intake), then: ECT
    • Psychotic depression
      • 1st line: ECT
      • Or SSRI + antipsychotic
    • If: insomnia + poor appetite. Then: Mirtazapine

Note: If SSRI being used in conjunction with NSAID. Then: Start PPI

 

Generalised anxiety disorder

Clinical features

  • ≥6 months
  • Excessive/prolonged anxiety and worry.
  • DERMIS
    • Difficulty concentrating
    • Easily fatigued
    • Restless
    • Muscle tension
    • Irritability
    • Sleep disturbance

Investigation:

  • Initial: Rule out organic (e.g. TFTs) and substance causes (stimulants)
  • Diagnostic: Clinical diagnosis

Treatment:

  • Initial: Risk assessment +/- admission +/- detention
  • Best:
    • 1st line: Psychological therapies such as relaxation techniques/coping strategies/CBT
    • 2nd line: SSRI
    • If: circumstances involve short-term crisis. Then: benzodiazepines may be used.

Note: A similar approach can be used for panic disorder and specific phobic disorders (except with systematic desensitisation) and agoraphobia and generalised social anxiety disorder

 

Obsessive compulsive disorder

Clinical features:

  • Obsessions: recurrent, intrusive *unwanted* thoughts/urges/images (ego dystonic). This is in contrast to obsessive compulsive personality disorder, which is egosyntonic
    • Examples include: thoughts/urges/images regarding contamination, violence (either committing or suffering), sexual behaviour (e.g. thoughts of committing rape) and symmetry
  • Compulsions: behaviour or action which relieves anxiety caused by obsession
    • Examples include: skin picking, hand washing, object counting
  • Frequently comorbid anxiety and mood disorders

Investigations: Clinical diagnosis

Treatment:

  • Non-pharmacological: Behavioural therapy (exposure and response prevention therapy), psychotherapy
  • Pharmacological: SSRI

 

Post-traumatic stress disorder (PTSD)

Clinical features:

  • Follows an event in which the individual experienced, observed or was threatened by trauma.
  • Trauma may take many forms including personal violence, sexual assault, motor vehicle accidents and natural disasters.
    • ≥1 month duration of symptoms (compared with acute stress disorder)
    • Flashbacks/memories/dreams of event
    • Avoidance of reminders/thoughts of event
    • Hyperarousal symptoms (exaggerated startle response, hypervigilance, angry outbursts, difficulty sleeping)
    • Mood/cognitive disturbance related to event (e.g. can’t remember or blames self)
    • Mood/cognitive disturbance related to self/world (e.g. depressed, feelings of worthlessness, detached, inability to experience positive emotions)

Treatment:

  • 1st line: Psychotherapy (trauma-focussed CBT and/or exposure therapy and/or Eye movement desensitisation and reprocessing)
  • 2nd line: SSRI or SNRI

 

Schizophrenia

Clinical features

  • ≥6 months disturbance. Including ≥1 month positive symptoms
  • Positive symptoms
    • Delusions
    • Hallucinations (typically auditory)
    • Thought disorder
    • Catatonia
  • Negative symptoms - 5A’s: Anhedonia, affect blunting, avolition, alogia, apathy

Investigation:

  • Diagnostic: Clinical diagnosis
  • Rule out drug-induced or medical causes

Treatment:

  • Initial: Risk assessment +/- admission +/- detention
  • Best:
    • 1st line (better side effect profile): Particularly if: extrapyramidal side effects or negative symptoms are biggest concern. Then: atypical antipsychotics (e.g. olanzapine)
    • If: metabolic side effects or positive symptoms are biggest concern. Then: typical antipsychotic (e.g. haloperidol)
    • If: lack of compliance. Then: consider depot (e.g. haloperidol)
    • If: Failed 2 antipsychotics. Then: clozapine
    • Psychosocial support