SPMM

SPMM Course
Success in Psychiatric Membership Masterclass
MRCPsych CASC Course
1
INDEX- CASC STUDY MATERIALS
No Topic Page
number
1 Elicit symptoms of Depression 7
2 Elicit hallucinations 10
3 Elicit first rank symptoms of Schizophrenia 13
4 Elicit delusions 16
5 Elicit symptoms of hypomania and mania 20
6 Elicit symptoms of anxiety disorders 23
7 Social phobia 25
8 Elicit symptoms of Obsessive compulsive disorder 27
9 Mental state examination & simple CASC 29
10 Insight assessment 33
11 Pre-morbid personality 34
12 Suicide risk assessment- History 36

13 Suicide risk assessment- Management 39
Cognitive examination
14 Cognitive examination 43
15 Extended cognitive examination 45
16 Frontal lobe function tests 48
Physical examination
17 Extra pyramidal symptoms- Examination 51

18 Cranial nerves examination 53
19 Thyroid examination 56
20 Upper limbs- sensory & motor examination 58
21 Lower limbs- sensory & motor examination 59
22 Alcohol misuse- physical examination 62
23 Cerebellar signs & symptoms 64
24 Cardiovascular examination 67
25 Fundoscopy 69
2
Management
26 Neuroleptic malignant syndrome- Discussion 70

27 Bipolar disorder & use of lithium during pregnancy 73
28 Treatment resistant Schizophrenia 78
29 Chronic Schizophrenia & assertive outreach- 80
Discussion
30 Treatment resistant depression 82
31 Obsessive compulsive disorder- Management 84
32 Post traumatic stress disorder- assessment 87
Old Age Psychiatry
33 Dementia- Obtaining Collateral history 92

34 Dementia- General management & services available 98
35 Alzheimers disease (counselling) 100
36 Antidementia drugs- Discussion 102
37 Vascular dementia- History & Discussion 106
38 Lewy body dementia- Discussion 111
39 Parkinsons disease psychosis- Management 117
40 Fronto-temporal dementia 119
41 Depressive pseudodementia 120
42 Wandering behaviour- assessment 121
43 Behavioural & Psychological symptoms of dementia 122
44 Dementia- Non pharmacological management 123
45 Non cognitive symptoms of dementia- Drug 124
management
46 Acute confusional state (Delirium) 127
47 Old Age Mania 130
48 Old Age Psychosis 132
49 Elderly abuse 136
50 Testamentary capacity 139
51 Driving & dementia 139
Child & Adolescent Psychiatry
52 ADHD- History taking 144

53 ADHD Treatments (Methylphenidate) 148
54 ADHD- General management 151
3
55 Conduct disorder- History taking 153
56 Autistic child- assessment 157
57 School refusal- assessment & management 159
58 Childhood sexual abuse- Management 161
59 Bullying- Assessment & Management 164
60 Tic disorders 167
61 Enurectic child 168
62 Mute child 170
63 Deliberate self-harm in children & adolescents 172
Learning disability
64 Challenging behaviour in LD patient 176

65 Depression in LD patient- assessment 179
66 Epilepsy 185
67 Temporal lobe epilepsy 186
68 Learning disabled patient- wanting to become parent 189
themselves
69 Abuse in Learning disabled patient- assessment 191
70 Downs syndrome & Dementia- Discussion 196
Forensic psychiatry & Risk assessments
71 Staff Assault 199

72 Patient found hanging 203
73 Violence risk assessment 205
74 Morbid jealousy- Assessment & Management 208
75 Erotomania- Assess dangerousness & Discussion 212
76 Psychosis & stalking- Assessment & Discussion 217
77 Sexual offence (Paedophilia)- Assessment 222
78 Fitness to plead 224
Eating disorders
79 Bulimia- History taking 228

80 Anorexia & Bulimia- Counselling 232
81 Anorexia- Etiology, management & discussion 237
82 Anorexia- Forced feeding & use of mental health act 239
83 Re-feeding syndrome 240
4
Perinatal Psychiatry
84 Puerperal disorders- history taking & risk assessment 243

85 Post natal depression- counselling 245
86 Post natal illness (Depression & Psychosis- 247
Management)
Substance misuse
87 Alcohol misuse- history taking 252

88 Complications of alcoholism 255
89 Alcohol dependence- Management 256
90 Opioid dependence- history taking 261
91 Opioid dependence- Management 264
92 Substance misuse in pregnancy- discussion of risks and 266
management
Psychotherapy
93 Cognitive behavioural therapy 271

94 Assess cognitive errors 273
95 Psychodynamic psychotherapy 278
96 Agoraphobia- Systematic desensitisation 279
97 OCD- Exposure & response prevention 281
98 Panic disorder & hyperventilation syndrome 283
99 Interpersonal therapy- assess suitability 285
100 Psychotherapy- sudden termination due to transference 287
reactions
Sleep & sexual disorders
101 Impotence- assessment & management 289

102 Antidepressant induced sexual dysfunction 291
103 Insomnia- assessment & management 293
Liaison Psychiatry & Miscellaneous topics
104 Delirium tremens- Management 297
5
105 Conversion disorder- assessment & discussion 298
106 Hypochondriasis- History & discussion 301
107 Grief reaction- assessment 305
108 Borderline personality disorder 307
109 Body dysmorphic disorder 308
110 Post concussion syndrome 311
111 Somatoform pain disorder 312
112 Frontal lobe injury- assessment & examination 313
113 Breaking bad news 315
114 Post MI depression- history taking & management 316
115 Capacity assessment (Refuse treatment) 321
116 Capacity assessment of care needs 324
117 Mental capacity act & mental health act 326
118 Mental health act- Discussion 327
119 Supervised community treatments 330
120 List of Psychotropic medications & side effects 331
Counselling topics
120 Clozapine 333

121 Lithium Augmentation 336
122 ECT 340
123 ECT administration 343
124 Schizophrenia 344
125 Bipolar disorder 349
126 Depression 352
Others
127 Home treatment teams & outreach teams 353
128 Early onset psychosis- assessment & management 356
129 Royal college model feedback forms 359
6
ELICIT PSYCHOPATHOLOGY
ELICIT SYMPTOMS OF DEPRESSION
Areas to be covered;
Core Symptoms of depression (low mood, anhedonia, fatigueability)

Biological symptoms
Cognitive and emotional symptoms
Ideas of guilt and unworthiness
Depressive cognition (negative thoughts) and suicidal ideation
Rule out co-morbidity
Eliciting core Symptoms of Depression
Low mood;
How are you feeling in yourself?
How has your mood been lately?
How bad has it been? Have you cried at all?
If I were to ask you to rate your mood, on a scale of 1 to 10 where ten is normal and one
is as depressed as you have ever felt, how would you rate your mood now?
Anhedonia
Can you still enjoy the things you used to enjoy? (Or)
Have you lost enjoyment in things you used to enjoy?
Is the level of enjoyment same as before?
What are the things that you find enjoyable/interesting??
Reduced energy level and decreased activity
How have you been in your energy levels these days?
Have you been feeling drained of energy lately?
How do you spend your day?
Have you wanted to stay away from other people?
Other symptoms of depression
Eliciting biological symptoms

How has your sleep been recently?
Do you need less sleep than usual?
Have you had any trouble getting off to sleep?
Do you wake early in the morning?
Does you mood vary over the course of the day?
Is your depression/mood worse at any particular time of day?
What is the best time/worst time of the day for you?
7
What has your appetite been like recently?
Have you lost any weight lately?
Has there been any change in your interest in sex?
Cognitive symptoms
How has your concentration been lately?
What is your memory like at the moment?
Emotional Symptoms
How confident do you feel in yourself?
How do you describe your self-esteem to be?
Ideas of guilt
Do you feel that youve done something wrong?
Do you feel guilty about anything at the moment?
Do you tend to blame yourself at all?
Do you tend to blame anyone else for you problems?
Do you have any regrets?
Do you feel that youve committed a crime, (or) sinned greatly (or) deserve punishment?
Eliciting suicidal intent and negative thoughts

Do you have any worries on your mind at the moment?
Have you ever felt that life wasnt worth living?
How do you see the future?
Do you feel inferior to others (or) even worthless?
Do you feel hopeless about yourself? (Or) Has life seemed quite hopeless?
Do you feel helpless?
Do you feel that life is a burden?
Do you wish yourself dead? Why do you feel this way?
Have you had thoughts of ending your life?
Have you thought about how would you do it?
Did you actually try?
Would you do anything to harm yourself or to hurt yourself?
Have you got any plans to end your life? What plans?
Duration, course, effects, coping

How long have you been feeling this way?
What do you think might have caused this?
How is it affecting your life?
How do you manage to cope?
8
Do you get any help?
1. Anxiety, obsessions
2. Psychosis/Hypomania or mania
3. Coping strategies like alcohol and illicit drug use.
TASK: DEPRESSION- ELICIT SYMPTOMS
You are seeing this middle-aged gentleman in your clinic following referral by GP
who was concerned about his low mood. Elicit his symptoms to arrive at a diagnosis.
Expanded construct: The candidate is expected to assess symptoms of depression,

assess nature & severity, rule out co-morbidity and perform appropriate risk assessment.
Assess circumstances leading to current presentation
Assess core symptoms of depression (low mood, anhedonia, lack of energy)
Other Symptoms of depression (disturbance in biological functions, poor

concentration & memory, depressed negative cognitions, low self-esteem etc)
Risk assessment- self harm (suicidal thoughts, plans etc), Self neglect
Co-morbidity (alcohol abuse, anxiety etc)
Significant history (Personal and family history)
9
ELICIT HALLUCINATIONS
Areas to cover
Explore the hallucinatory experience (auditory hallucinations)

To clarify whether these are elementary/complex hallucinations
To identify if they are true/pseudo hallucinations
To clarify whether they are Second or third person hallucinations
Explore hallucinations in other modalities
Duration, effects and coping
Auditory hallucinations
I understand that recently you have been hearing voices when there is no one around you and
nothing else to explain it. Can you tell me more about it?
(OR)
I should like to ask you a routine question, which we ask of everybody.
Do you ever seem to hear voices (or) noises when there is no one about and nothing else to
explain it?
If the patient agrees, then this experience should be further clarified.
Elementary hallucinations
Do you hear noises like tapping or music?
What is it like?
Does it sound like muttering or whispering?
Can you make out the words?
Second person auditory hallucinations

Do you hear voices?
Can you please give me some examples of the sort of things the voice said?
Who is it you are talking to? Can you recognize those voices?
If you recognize them, then whose voices are they?
How many voices do you hear?
Do the voices belong to men, women or children?
Do they speak directly to you?
Do you hear your name being called?
Do they tell you what to do? Can you please give me an example?
Do they give orders? Do you obey?
Can you carry on two-way conversion with the voices?
Third person hallucinations

Do you hear several voices talking about you? (or)
10
Do they refer to you as he or she like a 3rd person?
What do they say?
Do you hear voices like a running commentary instructing you to do things?
Do they seem to comment on what you are thinking, reading or doing?
Confirm whether they are true hallucinations

Where do these voices appear to come from?
Do you hear them in your mind or in you ears?
Do the voices come from inside (or) outside your head?
Do you hear them as clearly as you hear me?
Can you start or stop them?
Do you feel that they are real or do you feel that they are just voices?
Hypnagogic / hypnapompic hallucination

When did this occur? Were you fully awake when you heard these voices?
Do these voices disturb your sleep?
Do you hear them more at any particular time like when you go to bed or when you wake up?
Visual hallucination
Have you seen things that other people cant see?
What did you see? Can you please give me an example?
When do you see them and how often?
Was the vision seen with your eyes (or) in your mind?
How do you explain it?
Were you half asleep at that time?
Has it occurred when you are fully awake?
Did you realize that you are fully awake?
Olfactory hallucination
Is there anything unusual about the way things feel or taste or smell? (Open question)
Do you ever notice strange smells that other people arent bothered by?
What did you smell? Can you please give me an example?
Gustatory hallucination
Have you noticed that food or drink seems to have an unusual taste recently?
What did you taste? Can you please give me an example?
Tactile hallucination
11
Have you had any strange or unusual feelings in your body?
Do you ever feel that someone is touching you, but when you look there is nobody there?
Some people have funny sensations on the body, for example, insects crawling or
electricity passing or muscles being stretched or squeezed. Have you had any such
experiences?
Duration, Course, Effects, Coping

How long have you had these experiences for?
How often do you have them?
Why do you think they are happening to you?
1. Contributing factors to illness and stressors

2. Anxiety
3. Depression
4. Mania/Hypomania
12
ELICIT FIRST RANK SYMPTOMS OF SCHIZOPHRENIA
Areas to be explored:
Auditory Hallucinations- Third person auditory hallucinations, Running commentary

hallucinations
Thought-Alienation Phenomena- Thought withdrawal, Thought insertion and Thought
broadcasting
Passivity phenomena-Made feelings, made impulses and made volition or acts,
somatic passivity
Delusional perception
Clarification, Effects and coping
Open question: I gather that you had been through a lot of stress and strain recently.
When under stress sometimes people have certain unusual experiences.
By unusual experience, I mean for example, hearing noises or voices when there was no one
about to explain it?
Have you had any such experiences?
If the patient agrees, then this experience should be further clarified.

Can you tell me more about the voices?
Can you please give me some examples of the sort of things the voice said?
Third person auditory hallucinations

Do the voices discuss you between themselves?
Do you hear several voices talking about you?
Do they refer to you as he (or) she as a 3rd person?
What do they say?
Running commentary hallucinations

Do you hear voices commenting on what you are doing?
Do the voices seem to comment on what you are thinking, reading or doing etc?
Do you hear voices like a running commentary instructing you to do things?
Hearing thoughts spoken aloud

Are the voices repeating your own thoughts back to you?
Can you hear what you are thinking?
Do you ever seem to hear your own thoughts echoed or repeated?
What is it like?
Where does it come from?
13
Thought alienation phenomenon (open question)
Are you able to think clearly? (OR)
Have you experienced any difficulties in your thinking?
Do you ever get the feeling that someone is interfering with your thoughts? If so, in what
way? Could you please explain it?
Thought broadcasting
Do you feel that your thoughts are private (or) are they accessible to others in any way?
Can other people read your mind?
Are your thoughts broadcast, so that other people know what you are thinking?
How do you know?
Thought insertion
Are thoughts put into your head which you know are not your own?
How do you know they are not your own?
Where do they come from?
Thought withdrawal
Do your thoughts ever seem to be taken from you head, as though some external person (or)
forces were removing them? (Or)
Do your thoughts disappear (or) seem to be taken out of your head?
Could someone take your thoughts out of your head? Would that leave your mind empty or
blank?
Can you give an example?
Passivity of affect, impulses and volitions

Are you always in control of what you feel and do? (Open question)
Is there something or someone trying to control you? What is it?
Do you feel in control of your thoughts, actions and will? (Or)
Do you ever get the feeling that you are being controlled? That someone else is forcing your
thoughts, moods or actions on you?
Do you feel under the control of some force or power other than yourself as though you are a
robot or a zombie without a will of your own?
Does this force make your movements for you without you willing it?
Does this force or power force its feelings on to you against you will?
Does this force have any other influence on your body?
Somatic passivity
Does any force possess you?
14
What does that feel like?
Do you feel that someone or some force plays on your body and produces strange bodily
sensations like special waves affecting your body?
Does this force have any other influence on your body?
Can you please give me an example and can you also describe it for me?
Delusion perception:
Did you at any time realize that things happening around you have a special meaning for
you? Can you give me an example?
Can you explain that? What happened exactly?
Has a sudden explanation occurred out of the blue to you?

What do you think is causing these experiences?
How long have you had these experiences?
Who do you think is causing them?
Why do they do so? And how do they do that?
How would you explain them? Could it be your imagination?
How do they affect you? How do they make you feel?
How would you cope with them? What do you intent to do about them?
TASK: ELICIT FIRST RANK SYMPTOMS
Mr. Andrew Hill is a 28-year-old gentleman admitted informally to the psychiatric ward
with a history of bizarre behaviour and auditory hallucinations. He has a long-standing
diagnosis of paranoid schizophrenia for more than 10 years and is on 8mg of
Risperidone. Assess his mental state to look for first rank symptoms of schizophrenia and
perform risk assessment. Do not take history.
Expanded construct: The candidate is expected to explore psychopathology in

detail, identify presence of psychotic symptoms characteristic of schizophrenia and
perform appropriate risk assessment
Hallucination- Auditory (Third person, Running commentary)
Hallucinations- source, type, timing, reality with which they are experienced
Thought alienation phenomenon (Thought Broadcasting, insertion, withdrawal)
Passivity phenomenon (Passivity of affect, impulse/thoughts, actions/volition)
Paranoia, persecutory delusions, other psychotic symptoms
Clarification and seek explanation for psychotic symptoms
15
Assess degree of conviction, Effects and coping
Risk assessment: (Self-harm, violence, non-compliance

Aggression, absconsion, substance misuse etc)
ELICIT DELUSIONS
Areas to be covered:
Address the patients main concerns and the reasons for the presentation.
Elicit the main abnormal belief and the content of the delusional idea.
Elaboration and seeking explanation of delusional beliefs
Assess their onset (primary/secondary) and their fixity (partial / complete).
Assess the degree of conviction
Effects and coping.
Screening the patient for the presence of other kinds of delusional beliefs than the one
described above.
Risk assessment especially risk of harm to self or others secondary to the current
delusional ideas.
Listen to the patient. Pick up clues from what the patient says to you.
Open Question
Have you experienced anything strange, bizarre or unusual? Or perhaps something that
has puzzled you?
Do you have any particular worries preying on your mind at the moment? (OR)
Do you have any upsetting thoughts or distressing thoughts on your mind at the moment?
Delusions of persecution
How well have you been getting on with people?
Do you ever feel uncomfortable as if people are watching you? (Or) talking about you behind
your back? (Or) paying attention to what you are doing?
Do you ever feel that people are trying to harm you in any way?
Is anyone trying to interfere with you or make your life miserable?
Is anyone deliberately trying to poison you (or) to kill you?
Is there any organisation like the Mafia behind it?
Delusions of reference
Do people seem to drop hints about you or say things with a special meaning?
When you watch television, hear radio or read newspapers, do you ever feel that the stories
refer to you directly? (Or)
16
Do you see any messages for yourself/reference to yourself on TV or radio or in the
newspapers?
When you watch television, hear radio or read newspapers, do you ever feel that the stories
refer to things that you have been doing?
Delusions of control or passivity

Is there anyone trying to control you?
Do you feel that you are under the control of a person or force other than yourself?
Do you feel as if youre a robot or zombie with no will of your own?
Do they force you to think, say or do things?
Do they change the way you feel in yourself?
Delusions of grandiosity
How do you see yourself compared to others?
Is there something out of the ordinary about you?
Do you have any special power or abilities?
Are you specially chosen in any way?
Is there a special mission to your life?
Are you a prominent person (or) related to someone prominent like royalty?
Are you very rich (or) famous?
What about special plans?
Delusions of guilt
Do you feel that you are to blame for anything and that you are responsible for anything
going wrong?
Do you have guilt feelings as if you have committed a crime or a sin?
Do you feel you deserve punishment?
Nihilistic delusions
Do you feel something terrible has happened or will happen to you?
So do you feel that you have died?
Has part of your body died or been removed? Inquire about being doomed, being a
pauper, intestines being blocked etc.
Religious delusions
Are you especially close to God or Christ?
Can God communicate with you?
17
Hypochondriacal delusions
How is your health?
Do you worry that there is anything wrong with your body?
Are you concerned that you might have a serious illness?
Delusions of jealousy
Can you tell me about your relationship?
Do you feel that your partner reciprocates your loyalty?
Note:
If the patient says yes to any of the delusions, then pick up the clues from what the
patient says to you.
Invite the patient to elaborate further on a positive response. Always probe for further
elaboration of the beliefs and seek examples
Always try to assess the degree of conviction, explanation, effects and coping.
Also try to assess their onset (primary/secondary) and their fixity (partial / complete).
Conviction, explanation, effects, coping

What do you think is causing these experiences?
Who do you think is causing them?
Why do they do so? And how do they do that?
How would you explain them?
Ask how he/she copes with these thoughts, what he/she has done and what he/she intends to
do about them.
Always check whether the delusion is:

Primary or secondary
How did it come into your mind that this was the explanation?
Did it happen suddenly or out of the blue? How did it begin?
Degree of conviction:
Even when you seemed to be most convinced, do you really feel in the back of your mind that it
might well not be true, that it might be your imagination? (Or)
Do you ever worry that all of this may be due to your mind playing tricks?
The patient may have one or more delusional beliefs. It is important to ask about other
delusional beliefs. For example, if a patient presents with persecutory delusions, it is
important to ask about other delusional types such as delusions of reference, delusions of
grandiosity, delusions of guilt etc, by using appropriate mix of open and closed questions
and picking up clues appropriately.
18
Risk assessment:
1. Risk of harm to self
2. Risk of harm to others secondary to the current delusional ideas
3. Risk of Aggression and violence
4. Risk of non-compliance, Absconsion
5. Risk of alcohol and substance misuse
Also try and rule out other psychotic symptoms (like hallucinations, thought alienation symptoms
etc), as part of your assessment.
Delusional disorders- types
Erotomania (de Clerambault syndrome); It occurs most often in women and

there is an erotic conviction that a person with higher status is secretly in love
with the patient. The patients make efforts to contact this person and some cases
are associated with dangerous or assaultive behaviour. Clinical samples are often
female and forensic samples contain a preponderance of males. Patients may
make efforts to contact this person, may result in stalking behaviour and the risk
of violence is high.
Grandiose Patients believe they fill some special role, have some special
relationship, or possess some special abilities. They may be involved with social
or religious organisations.
Jealous (Othello syndrome); Characterised by a delusion of infidelity. Patients
possess the fixed belief that their spouse or partner has been unfaithful. Often
patients try to collect evidence and/or attempt to restrict their partner's activities.
Dangerousness is significantly high as morbid jealousy contributes to both wife
battering and homicide and often associated with forensic cases involving murder.
Persecutory; this is the most common presentation of delusional disorder.
Patients are convinced that others are attempting to do them harm. Often they
attempt to obtain legal recourse, and they sometimes may resort to violence.
Somatic Varying presentation, from those who have repeat contact with
physicians requesting various forms of medical or surgical treatment to patients
who are delusionally concerned with bodily infestation, deformity
(dysmorphophobia) or odour.
19
ELICIT SYMPTOMS OF HYPOMANIA AND MANIA
Core Symptoms of Hypomania/mania
Biological and Cognitive symptoms
Overoptimistic ideation and grandiosity
Exploring grandiose delusions and clarification
Risk assessment-Tendency to engage in behaviour that could have serious consequences
Clinical features of Mania

Elevated mood/irritable mood
Increased energy, which may manifest as over activity, excitement, reduced need for
sleep, pressured speech, racing thoughts and flight of ideas
Increased self-esteem, evident as overoptimistic ideation, over familiarity and grandiosity
Reduced attention and increased distractibility
Tendency to engage in behaviour that could have serious consequences such as spending
recklessly, sexual disinhibition leading to possible exploitation and reckless driving etc
Marked disruption to family life, social activities and occupation.
Core features of Hypomania / Mania

Have you sometimes felt unusually/particularly cheerful and on top of the world, without any
reason?
If I were to ask you to rate your mood, on a scale of 1 to 10, how would you rate your
mood now?
Have you felt so irritable recently that you shouted at people or started fights or arguments?
How is your energy level?
Do you find yourself extremely active but not getting tired?
Have you felt particularly full of energy lately (or) full of exciting ideas?
Have you felt that you were much more active or did many more things than usual?
Biological symptoms
How are you sleeping?
Do you need less sleep than usual and found you did not really miss it?
How has your appetite been like recently?
20
Have you lost /gained any weight?
How is the sexual side of your relationship?
Have you been more interested in sex recently than usual?
Cognitive symptoms
How has your concentration been like recently?
What is your thinking like at the moment?
Are you able to think clearly?
Do your thoughts drift off so that you do not take things in?
Do you find that many thoughts race through your mind and you could not slow your mind
down?
Eliciting overoptimistic ideation and grandiose ideas

Do you feel much more self-confident than usual?
How do you see yourself compared to others?
Are you specially chosen in any way?
Do you have any special powers or abilities quite out of the ordinary? Do you have any
special gifts or talents? If so, what is it?
Is there a special mission to your life?
Are you a prominent person (or) related to someone prominent like the royalty?
Are you very rich (or) famous?
Have you felt especially healthy?
Have you developed new interests lately?
Have you been buying interesting things recently?
Tell me about your plans for the future? Do you have any special plans?

If the patient harbors grandiose delusions, then pick up the clues from what the patient
says to you.
Invite the patient to elaborate further on a positive response. Always probe for further
elaboration of the beliefs and seek examples
Always try to assess the degree of conviction, explanation, effects and coping.
Tendency to engage in behaviour that could have serious consequences

Has there ever been a period of time when you were not your usual self and you did things
that were unusual for you like spending too much money that ot you into trouble?
Has there ever been a period of time when you were not your usual self and that other people
might have thought were excessive, foolish or risky?
21
Explore in detail about the symptom history, mode of onset, duration, progress, precipitating
factor and associated problems.

Rule out co-morbidity such as:

Depression
Psychotic symptoms
Coping mechanisms i.e. Drug and alcohol misuse.
TASK: MANIA WITH PSYCHOTIC SYMPTOMS
Perform mental state examination on this lady Miss Tracy Burrows, who had been to a
rock concert and was shouting very loudly and dancing around. The police brought her to
the A&E department. When she arrived at the hospital 45 minutes earlier, a casualty
doctor saw her briefly and gave her diazepam injection to calm her after she had refused
tablets. She is now a little calmer and willing to talk. Examine her mental state and
establish whether any abnormal psychopathology is present.
Expanded construct: The candidate is expected to assess the circumstances that led to
current presentation and assess her mental state, looking for features of mania with
psychotic symptoms. They should also perform risk assessment
Assess Circumstances leading to current presentation
Symptoms of mania; Mood- Elated mood (usually out of keeping with

circumstances), Increased energy (over activity, Pressured speech, racing thoughts,
Reduced need for sleep)
Thoughts- Increased self-esteem (Over-optimistic ideation, grandiosity),

Delusions of grandiosity and paranoia (content)- Explore and clarify
Grandiose delusions- Evaluation of falseness of beliefs And degree of conviction
Perceptual disturbances, (Hallucinations of different modalities),

Insight assessment
Risk assessment
22
1. Preoccupation with extravagant Schemes/vulnerability
2. Thoughts of self-harm
3. Agitation/aggression/violence
ELICIT SYMPTOMS OF ANXIETY DISORDERS

Symptoms of Generalised Anxiety
Psychological arousal-fearful anticipation, worrying thoughts, restlessness, poor

concentration, irritability, sleep disturbances
Autonomic arousal-dry mouth, difficulty in swallowing, constriction in the chest,
difficulty in breathing, palpitations, chest pain, tremor, headaches, muscle tension,
sweating and tingling in the extremities
Sleep disturbance-insomnia, night terror
Avoidance of places, situations and people as part of coping strategy
Areas to cover
Psychological symptoms of anxiety including sleep disturbance

Physical symptoms of anxiety
Avoidance mechanism
Enquire about panic attacks
Rule pout agoraphobias and other phobias
Rule out co morbidity
Eliciting anxiety symptoms
Have there been times when you have been very anxious (or) frightened? What was this like?
Have you had the feeling that something terrible might happen?
Have you had the feeling that you are always on the edge?
Do you worry a lot about simple things?
Tell me what made you feel so anxious? And tell me about your anxiety symptoms?
How long youve been feeling so anxious?
How does it interfere with your life and activities?
Tell me about your sleep please. (Explore for sleep disturbance)
23
Are you sometimes afraid to go to sleep because you know that you will get unpleasant
dreams?
How has your concentration been recently?
Do you loose your temper more often that you used to? (Irritability)
Eliciting panic attacks
Have you noticed any changes in your body when you feel anxious?
Have you had times when you felt shaky, your heart pounded, you felt sweaty, dizzy and you
simply had to do something about it?
Were you getting butterflies in stomach, jelly legs, and trembling of hands?
Have you ever had a panic attack? What was it like?
What was happening at the time? Could you please describe it for me?
How often do you get these attacks?
How does it interfere with your life and activities?
Agoraphobia
Do you tend to get anxious in certain situations such as traveling away from home (or) being
alone?
What about meeting people like in a crowded room?
What about situations like being in a lift or tube?
Do you tend to avoid any of these situations because you know that youll get anxious?
How much does it affect your life?
Social Phobias
Do any particular situations make you more anxious than others?
Do you tend to get anxious when meeting people e.g. going into a crowded room and
making conversation?
What about speaking to audience? What about eating or drinking in front of other people?
Special phobias
Do you have any special fears like some people are scared of cats or spiders or birds?
Avoidance
Do you tend to avoid any of these situations because you know that youll get anxious?
Do you make any effort to avoid activities, places or people because you know that you
will feel more anxious and embarrassed?
What would you do? How does that make you feel?
Duration, Effects and coping

24
Rule out co-morbidity:

a. Depression
b. Obsessional symptoms
c. Anxious personality- would you say you were an anxious person?
TASK: ANXIETY AND AGORAPHOBIA- HISTORY TAKING
TASK: Mrs. Catherine wood is a 40-year-old married housewife. She has been referred
by her GP to the outpatients clinic due to her anxieties about going out of her house.
Take a history to establish the nature and extent of her problems.
Expanded construct: The candidate is expected to obtain detailed history to establish

the nature and extent of her problems.
They should assess the following areas;
Elicitation of anxiety symptoms

(Psychological Symptoms-feeling anxious all the time, inability to relax, poor
concentration, irritability, poor sleep- initial insomnia)
Elicitation of physical symptoms

(GIT, Cardiovascular, CNS, Musculoskeletal, respiratory etc)
Agoraphobia- description, precipitants

Three themes of home, crowding and confinement (supermarkets, buses, trains,
shops and in situations they cannot leave easily)
Panic attacks-description, onset, duration, frequency,

Intensity, any precipitants
Avoidance and anticipatory anxiety

Impact on life-house bound and dependency,
Rule out Co-morbidity (Mood Symptoms, substance misuse etc)
25
TASK: SOCIAL PHOBIA
You are seeing Mr. Cockfield in your outpatients clinic. He is due to be married soon but
extremely worried about the occasion.
Obtain history to arrive at a diagnosis and identify possible aetiology.
Expanded construct: The candidate is expected to obtain history and explore

psychopathology to make a diagnosis of social phobia. They should also identify the
possible etiological factors for the current problems.
They should elicit
Symptoms of incapacitating anxiety restricted to particular social situations, leading

to a desire for escape or avoidance
Somatic symptoms- blushing, dry mouth, trembling, perspiration when exposed to

feared situations
Elicit consequences of social phobia-

(Avoidance, social withdrawal, lack of confidence, difficulty in maintaining social
relationships, vocational problems- work in less demanding jobs, well below their
abilities etc)
Rule out co-morbidity- anxiety spells, panic attacks and agoraphobia.

Alcohol and substance misuse
Etiology- Family history

(Genetic factors- predisposition towards overly interpreting situation as dangerous)
Etiology- Environmental factors- Individual interpretations of social cues

(The particular trigger for the conditioned fear response depends on the social
situation in which first episode of anxiety experienced)
26
ELICIT SYMPTOMS OF OBSESSIVE-COMPULSIVE DISORDER
Areas to cover;
Obsessional thoughts-ideas, images or impulses

Compulsive acts/rituals-washing, cleaning, checking, counting
Resistance and avoidance
Duration, effects and coping
Rule out co-morbidity-depression, anxiety
Obsessional thoughts
Do any unpleasant thoughts / ideas keep coming back to your mind, even though you try hard
not to have them? (Or)
Do you have any recurring thoughts, ideas, or images that you cannot get rid of your mind?
How often do you have these thoughts?
Are these thoughts your own or are they put into your mind by some external force?
Where do they come from?
What is it like? How do you explain it?
What do you do when you get these thoughts?
Are they distressing and if so in what way?
Is there anything you try to do to stop these thoughts?
What happens when you try to stop them?
Compulsive acts
Do you ever find yourself spending a lot of time doing the same thing over and over again
even though you have already done it well enough? For example
Do you spend a lot of time on personal cleanliness, like washing over and over even though
you know that youre clean?
Does contamination with germs worry you?
27
Do you find that you have to keep on checking things that you know that you have already
done? Like gas taps, doors, and switches?
What happens when you try to stop them?
Do you have to touch (or) count things many times?

Do you have any other rituals?
Do you find it difficult to make decisions even for simple trivial things? (Obsessional
ruminations)
Do you have any impulses to do unwise things?
What kind and do you ever give in to these impulses?
Explore in detail about the symptom history, mode of onset, duration, precipitating factors and
associated problems.
Duration, Effects and coping

Co-morbidity: Ask about associated symptoms, such as:
Depression, Generalized anxiety, Phobias
Anankastic personality traits Do you tend to do things / keep things in an organized way?
Ref: Adapted from Get through MRCPsych; Preparation for CASC (Dr. Sree Murthy)
TASK: OBSESSIVE COMPULSIVE DISORDER- ASSESS SYMPTOMS
Mrs. Jacqueline Smith is a 37-year-old woman referred by her GP after suffering

from stress at work. Assess her symptoms to arrive at a diagnosis
Expanded construct: The candidate is expected to obtain detailed history to arrive at a

diagnosis of obsessive-compulsive disorder and rule out co-morbidity.
History- obsessional symptoms (mode of onset, duration and progression)

And the anxiety Symptoms associated.
Nature and quality of obsessions

(Thoughts, ideas, images, ruminations, doubts)
Phenomenology of obsessions-own thought,

Unpleasurable, repetitive, resistance & response
28
Elicitation of compulsive behaviours and associated rituals
Other behaviours-washing, checking, Counting etc
Impact on quality of life

(Social, occupational and family)
Co-morbidity
(Mood Symptoms, anxiety symptoms, alcohol abuse etc)
MENTAL STATE EXAMINATION
The Mental State Examination is designed to obtain information about specific aspects of the
individuals mental experiences at the time of the interview.
Remember the following order

Appearance and behaviour
Speech
Mood
Thought
Perception
Cognition
Insight
Note:
There is no need to comment about behaviour and speech in this station unless the examiner
specifically asks you. Most candidates generally tend to forget to assess cognitive state and
insight, which are also important components of mental state examination, and it carries equal
credit in marks as that of mood, thoughts and perception.
TASK: ASSESS MENTAL SATE EXAMINATION
The following five tasks are repeatedly asked in the examination.

In all these type of tasks, it is important to explore psychopathology in depth as they
present with some form of delusions and hallucinations.
It is vital to pick up clues, probe it and explore further.
Risk assessment should be done as part of the mental state examination.
Listen to what the patient says as they have scripted instructions AND TRY TO
PICK UP THE CLUES. E.g. Delusional ideas- elicit and explore- Clarify, probe
it -Onset, nature, type & content, and assess the degree of conviction with which
abnormal beliefs are held
29
Always ask these questions- WHAT, WHO, WHY, HOW
Ask for explanation, effects and coping
Abnormal experiences: Source, content, timing, reality with which they are
experienced-
Assess mode of onset, duration and progression, impact of current functioning
Range and depth of psychopathology explored, depth of enquiry into symptoms is very
important and these 2 are often identified as a areas of concern by examiners.
TASK 1: LEAVE PLAN- MSE & RISK ASSESSMENT
Mr. Andrew Turner is a 32-year-old gentleman with a history of paranoid schizophrenia

and was recently admitted to the hospital under detention of the mental health act. He is
due to go out today with his sister for a brief visit to town but the ward manager is
worried about his mental state and has asked you to assess the risk. Perform Risk
assessment and assess his mental state to establish whether any abnormal
psychopathology is present.
Expanded construct: The candidate is expected to Perform Risk assessment and

assesses his mental state to establish whether any abnormal psychopathology is present
MSE findings- paranoia, delusions of reference
MSE findings- bizarre delusional ideas, abnormal thought content,

Rule out other psychotic phenomenon
Look for perceptual abnormalities- Auditory hallucinations (nature, type,

source, timing, content, reality with which it is experienced),
Hallucinations in other modalities
Assess current mood

Assess current level of insight
Perform Risk Assessment- h/o absconding, self-harm, previous suicide attempts,

current suicidal thoughts, violence
30
TASK 2: PSYCHOSIS-EXAMINATION
TASK: Mr. Paul Brown is a 45-year-old gentleman brought by the police to the A&E
department. He went to the police station earlier today and said that he is giving up
a. Assess his thoughts and establish what abnormal belief he holds

b. Establish whether any other psychopathology is present.
Expanded construct: The candidate is expected to assess his thoughts and establish what
abnormal belief he holds and establish whether any other psychopathology is present.
They should be able to elicit;
Paranoia, Persecutory delusions- Elicitation, Exploration and clarification
Delusions of guilt- Exploration and clarification
Evaluation of falseness of beliefs and degree of conviction,

Effects and coping
Third person auditory hallucinations- content, source, timing and reality with which
they are experienced
Delusional perception- Elicitation, Exploration and clarification, seek explanation
Look for other psychotic symptoms (Any other abnormal beliefs, other
hallucinatory
Experiences, thought alienation etc)
TASK 3: PSYCHOTIC DEPRESSION- ELICIT PSYCHOPATHOLOGY
Miss. Rosie Green is a 33-year-old lady who was detained under the mental health act
and admitted last night, as she thinks she is dead and tried to burn her body on a fire.
Examine the patient to establish what abnormal belief she holds.
Expanded construct: The candidate is expected to examine the patient to establish what
abnormal belief she holds and look for features of psychotic depression. Also perform
relevant risk assessment.
Eliciting Nihilistic delusions- exploration and clarification,
Eliciting Delusions of guilt- explore, clarify delusions
Evaluate the falseness of beliefs and Assess degree of conviction
31
Assess symptoms of depression and psychosis
Risk assessment
(Self-harm, self neglect etc)
TASK 4: POLICE CUSTODY- MSE
The police have asked you to assess Mr. John Fox who is under their custody. The police
following a telephone call from his neighbour arrested him due to his erratic behaviour.
Identify reasons for his presentation and assess him for the presence of psychotic
symptoms.
Expanded construct: The candidate is expected to assess circumstances leading to his

arrest, assess him for the presence of psychotic symptoms and explore psychopathology
They should;
Assess Circumstances leading to his custodial arrest (precipitants and triggers)
Elicit paranoia and delusions of persecution

(Explore and clarify nature, type and content)
Assess the degree of conviction,

Effects and coping
Other symptoms (bizarre delusions, auditory hallucinations, other modalities of

hallucinations)
Look for other psychotic symptoms (thought alienation phenomenon- broadcasting,

insertion and withdrawal)
Risk assessment (suicide, violence etc)
TASK 5: SCHIZOPHRENIA- FAILED OUTPATIENT- MSE
You have been asked to assess Mr. Simon Grayson who lives in a residential hostel for
the mentally ill. He has failed to attend outpatient clinic appointments and CPN is
concerned about him. Assess him for abnormal. Assess his mental state and explore
psychopathology .
Expanded construct: The candidate is expected to assess his thoughts and establish
what abnormal belief he holds. And establish whether any other psychopathology is
present.
32
Paranoia, Persecutory delusions- Elicitation, Exploration and clarification
Bizarre delusional ideas- Exploration and clarification
Evaluation of falseness of beliefs and degree of conviction, Effects and coping
Third person auditory hallucinations- content, source, timing and reality with which
they are experienced
Delusional perception- Elicitation, Exploration and clarification, seek explanation
Look for other psychotic symptoms (Any other abnormal beliefs, other
hallucinatory Experiences, thought alienation etc)
Mood Symptoms
Risk assessment (self harm, violence, non compliance etc)
ASSESS INSIGHT
Insight is most usefully inquired about and reported as a series of health beliefs: There are three
1. Believing that their abnormal experiences are symptoms and the symptoms are attributable to
psychiatric illness
Does the patient believe that their abnormal experiences are symptoms?
Does the patient believe their symptoms are attributable to illness?
Do they believe that the illness is psychiatric?
2. Belief that assistance of some kind is needed to help with the problems.
3. Assess attitude to treatment and psychiatric services
Do they believe that psychiatric treatment might benefit them?

Would they be willing to accept advice from a doctor regarding their treatment?
Insight assessment
Questions
I understand that recently you have been hearing voices when there is no one around you
and nothing else to explain it. Could it be that your experiences are part of an illness
affecting your mind? (0R)
You described several symptoms namely and what is your explanation of these
experiences? Do you think that the symptoms were part of you nervous condition?
Do you consider that you are ill in any way? (OR)
Do you think there is anything the matter with you?
What do you think it is? Do you have a physical or mental illness?
Could it be a nervous condition? What is it?
33
Do you feel that you need help to deal with this problem?
What kind of help do you think would be useful?
Do you need treatment for mental problem now?
Why do you think that you have come into the hospital?
What do you feel about being in hospital?
Do you think that it has helped you to be here? If so, in what way?
Has the medication been helpful?
Do you think that medication helps you to remain well?
Will you take the recommended medication for the future?
Have any other treatment been helpful
ELICIT PREMORBID PERSONALITY
Predominant mood
Interpersonal relationships
Coping strategies
Hobbies, interest and beliefs
Screening for Paranoid, Schizoid, Schizotypal personality traits
Screening for Antisocial, Borderline and Histrionic personality traits
Screening for Anxious, Dependent and Anankastic personality traits
Enquire about:
1. Predominant mood
Optimistic / Pessimistic
Stable / prone to anxiety
Cheerful / Despondent
2. Interpersonal relationships
Current friendships and relationships
Previous relationship ability to establish and maintain
Sociability Family, Friends, Work mates and Superiors
3. Coping strategies
How does the patient cope with problems?
When you find yourself in difficult situations, what do you do to cope??
4. Personal interests-Hobbies, Leisure time
34
What sort of things do you like to do to relax?
5. Beliefs religious beliefs- Are you religious?
6. Habits food fads, alcohol, current/ previous use of drugs (etc.)
Now proceed to explore for individual personality traits (cluster A,B or C)
Questions
Start with open questions:
How would you describe yourself as a person before you were ill?
How do you think other people would describe you as a person?
Then ask closed questions about individual personality traits:
Cluster A (Paranoid, Schizoid, Schizotypal)
How do you get on with people? (Paranoid)
Do you trust other people? (Paranoid)
Would you describe yourself as a loner? (Schizoid)
Were you able to make friends?
Do you have any close friends? (Schizoid)
Do you indulge in fantasies? Sexual and non-sexual fantasies, daydreaming?
Do you like to be around other people or do you prefer your own company??
Cluster B (Antisocial, Borderline and Histrionic)

Whats your temper like? (Antisocial, emotionally unstable)
How do you deal with criticisms?
Are you an impulsive person? (Impulsive)
Do you take responsibility for your actions? (Antisocial, impulsive)
Are you over-emotional (histrionic)?
How do you cope with life? (Borderline)
How do you react to stress?? (Borderline)
Do you maintain long-term relationships with people? (Antisocial, borderline)
Do you often feel that you are empty inside?
Cluster C (Anxious, Dependent and Anankastic)

Are you anxious (or) shy? (Anxious / avoidant)
Are you a worrier? (Anxious, dependent)
How much do you depend on others? (Dependent)
Would you describe yourself as a perfectionist? (Anankastic)
Do you tend to keep things in an orderly way? (Anankastic)
Do you have unusually high standards at work / home (Anankastic)
Ref: Adapted from Get through MRCPsych; Preparation for CASC (Dr. Sree Murthy)
35
RISK ASSESSMENT
SUICIDE RISK ASSESSMENT AND MANAGEMENT
Suicide risk assessment has usually been asked as a paired/complex station, whereby in the first
station you will be asked to obtain history, perform a risk assessment, and in the next station you
would be expected to discuss with the consultant, over the phone, about the assessment done and
your further management plan.
Suicide risk assessment: Areas to be concentrated upon
Obtain more information about the overdose

Evaluate the degree of suicidal intent and seriousness of the attempt
Investigate symptoms of depression/psychosis or other forms of mental illness
Assess current mental state including suicidal thoughts
Past history and background information
Assess coping methods and ability to seek help.
Step 1: Obtain the following information about the overdose
1. How many tablets were taken?

2. What type of tablets was taken?
3. When was the overdose taken?
4. How was the medication obtained?
5. Where was the patient when she took the overdose?
6. How and by who was she discovered?
36
7. What did he/she do after the overdose?
8. How did he/she end up coming to hospital?
9. Did he/she take anything else with the tablets, for example, alcohol?
10. Why did she take the overdose? (Or)
What was the event leading up to the suicidal act? (Or)
What made her think of harming herself? (Or)
What sorts of things have been worrying her?
If the patient is not forthcoming with all the details, use more closed questions and also examples
like;
Conflict in a close relationship
A major loss or separation
Family disharmony
Difficulties at work
Financial worries/housing
Health problems
Redundancy or legal problems.
Was there any direct gain (E.g. patient in custody at the time of the act)
Step 2: Assessment of the degree of suicidal intent and seriousness of the attempt
A detailed assessment should include evaluation of the characteristics of the attempt:
Remember 4 Ps:
P Planning/impulsivity
P Performance in isolation or in front of others
P Preparations made prior to the act
P Precautions to avoid discovery of others
A. The degree of suicidal intent
Did the person plan the attempt carefully or was it impulsive?

Did she take any steps towards doing this? (E.g. getting pills)
Was anyone else actually present at the time?
Did she convey her suicidal intent to others?
Where did the act take place?
Would she have anticipated being found?
Did she take measures to avoid discovery?
Did she make any preparations like arranging for the care of children etc?
Did she leave any suicide note?
B. The seriousness of the attempt
What method was used?

Did the person understand the consequences of the method she used?
37
a. For example, was the person taking an overdose aware of the actions of the drug and did
she believe that the dose taken would be fatal?
b. Did she take all the tablets or did she leave behind a few?
c. What are the problems experienced by the patient currently?
(Please see point 10 in step 1)
Step 3: Explore depressive symptoms (see chapter on assessing depression) and or psychotic
symptoms with duration and their impact on current functioning
Step 4: Assess current mental state: mood and depressed negative cognitions such as
hopelessness, worthlessness etc
How do you feel in yourself?

Do you still feel that life is not worth living?
Suicidal thoughts and plans
Do you still have thoughts of harming yourself in any way?

What do you think you might do?
Have you made any plans?
When are you intending to do it?
What prevents you from doing it?
Step 5: Past history and background information
Does she have a past history of suicidal behaviour?

Does she suffer from a mental illness, for example depression, psychosis, anxiety disorder,
borderline personality disorder?
Is there a history of non-compliance with treatment?
Does she abuse alcohol or drugs?
Is there a family history of mental illness, alcohol or substance abuse, violence or suicidal
behaviour?
Step 6: Coping methods and ability to seek help
What were her reactions to previous stresses, failures and losses?

What does she usually do when there is a problem?
How does she usually cope?
With whom does she share her worries?
How supportive are family and friends?
Does she get any help?
In the past, did anyone offer her any help? How did she find it?
Risk factors for completed suicide
38
Male sex
Elderly
Single, divorced or widowed
Living alone with poor social support
Previous Para suicide or DSH
Presence of mental illness/ recent history of inpatient psychiatric treatment
Concurrent physical illness
Social/life events- Recent bereavement, unemployment
History of Alcohol and or drug dependence
Serious attempt
Violent method chosen
Evidence of careful planning
Active psychological symptoms
Active suicidal ideation, communication and intent
Feelings of guilt, hopelessness, worthlessness and depressive features
SUICIDE RISK ASSESSMENT- MANAGEMENT AND DISCUSSION

Decision making and developing a management plan
By the end of the assessment, we should be able to answer the following questions, which might
help in decision making and formulating a safe management plan;
a. Is there evidence of mental illness?

b. Is there ongoing suicidal intent?
c. Are there non-mental health issues, which can be addressed?
d. Ascertain the level of social support available
Decision-making
Following the assessment:
1. If she does appear to have a mental illness, which is of the nature and degree that requires
hospital treatment or if she is likely to be at risk to herself should she leave hospital at this
time, then try to encourage a voluntary admission. This may help to assess the seriousness of
the underlying mental health condition or to allow for a period of inpatient assessment of
mental state.
2. If that does not work, it would be appropriate to detain her under Section 5 (2) of the Mental
Health Act and you should also let the RMO know that the patient is on Section 5 (2), so that a
Mental Health Act assessment can be arranged as soon as possible and detention for
assessment or for treatment can be considered if necessary.
Developing a management plan
39
The management plan should be tailored according to the needs of individual patients and it is
important to develop a clear plan to help the individual get safely through this period of distress.
The general suggestions for this management plan are outlined below.
Ensure appropriate supervision/hospitalisation for the individual: Immediately after the

suicidal attempt, do not leave the individual alone for any length of time. Remove all means of
committing suicide.
If the patient is to be discharged from the hospital, involve family members in caring for the
individual. Family and friends may be able to provide suitable supervision. Encourage a
supportive network away from the clinician (e.g. family, friends, and agencies).
Ensure the individual has immediate 24-hour access and support and consider provision of
emergency crisis card giving details of emergency psychiatry service (e.g. crisis team, general
practitioner, hospital, telephone support) and telephone contact for emergency counselling or
support services.
If the individual requires medication, ensure she only has access to a very small amount.
Neutralise the precipitating problem by encouraging the view that all problems can be
solved. Help the individual to resolve any immediate conflicts with others.
Discuss and agree the management plan with the patient. If the patient is already known to
the mental health services, then close liaison with the usual team to agree a joint management
plan is very helpful.
Give a follow-up outpatient appointment with your team in a weeks time and make
arrangements for one of the members of the community mental health team or the crisis
assessment and treatment team/ home treatment team to contact the patient, within the next 24
hours.
Engage in Ongoing consultation with superiors or colleagues.
If the risks remains high and there are no community interventions available, then the patient
should be considered for admission.
If there are clear signs of depression or other forms of mental illness, consider admission for
the safe treatment of the mental health condition in a protected environment like a hospital.
If the patient is to be admitted to the hospital, communicate the observation requirements to
the nursing staff. Ensure that the patient is adequately supervised and record the level of
nursing observation after a consensus is agreed with the nursing team.
Management plan- (Short-term and Long-term). Adopt a Bio psychosocial approach and
involve the multi-disciplinary team.
Treat mental health problems with medication,
Provide psychological input and counselling
Address psychosocial stressors like help with financial problems, arrangements for
accommodation etc
Discuss long term monitoring in the community and support
Additional interesting clinical scenarios (Adapted from Oxford handbook of psychiatry-pg910)

1. 52-yr-old gentleman, admitted with chest pain, who ought to remain in the hospital for overnight
telemetry, cardiac enzymes, and repeat ECG (in the morning), but does not wish to do so. He is
not incapable and not suffering from a mental disorder. The decision rests with him (he has a right
to refuse even if you think he is acting foolishly).
2. 22-yr-old gentleman, who admits to ingesting 56 aspirin, brought to GP by a concerned friend,
now refusing to get in an ambulance to go to hospital. Most people would agree that she is
40
possibly suffering from a mental disorder (suggested by her recent OD), hence there are grounds
for use of MHA, with emergency treatment under common law.
3. 18-yr-old lady admitted after a paracetamol overdose who needs further treatment but wishes to
leave. She has some depressive features and may possibly be under the influence of alcohol. There
is sufficient suspicion of mental disorder to detain under the MHA (perhaps more than in the
previous scenario); treatment would be under common law.
4. 34-yr-old lady with long history of anorexia nervosa, current weight under 6st, with clear physical
complications of starvation (and biochemical abnormalities), refusing admission for medical
management. Clear mental disorder, as well as a risk to themselves, detain under the MHA;
emergency treatment under common law.
5. 53-yr-old Previously seen in A&E following a fall whilst intoxicated, brought back up to A&E 6
days later by spouse with fluctuating level of consciousness (also has been drinking heavily)
suspected extradural, but angrily refusing CT head. Capacity impaired both by alcohol and
potentially serious underlying treatable physical disorder. Necessary urgent investigation
warranted as in patient's best interests with use of sedation (if necessary) under common law.
6. 67-yr-old gentleman with post-operative URTI who presents as confused, wishing to leave the
ward because he is late for his brother's wedding. There is a clear mental disorder and he ought to
be detained under the MHA; treat under common law (sedate if necessary).
7. 23-yr-old gentleman admitted with psychotic illness, who wants to go home to confront the
neighbours whom he believes have conspired with the police to get him banged up in a nut hut.
Clear mental disorder, detain under MHA; emergency treatment if required under common law.
The consultant over the phone could discuss the following areas;
1. Obtain more information about the overdose (false information-strictly to be avoided)

2. Evaluation of the degree of suicidal intent and the seriousness of the attempt
3. To ascertain the presence of Depression or other forms of mental illness
5. Assessing current mental state including Suicidality and ongoing plans
6. Past history, family history, social support and coping strategies.
7. Risk assessment (Mild/moderate/serious). What is the degree of risk in this case?
8. Outcome of the assessment (Admission/discharge/consider detention under the MHA).
How will you proceed with the assessment? Would you consider using mental health act
in this case?
9. Discuss the management plans (short-term and long-term plan for this patient)
10. Also discuss about role of anti-depressants, efficacy and side effects.
11. Discuss psychological interventions such as CBT, counselling etc.
12. Please discuss the role of crisis assessment and treatment team (CAT team)/ home
treatment team in such cases.
13. What do you think are the important risk factors for suicide? (Both static and dynamic
risk factors)
PAIRED STATION
TASK: SUICIDE RISK ASSESSMENT
41
TASK: (PART-A) Assess the current risk of suicide in Ms. Becky Morris a 20-year-old
young woman admitted to the A& E following an overdose.
a. Evaluate the degree of suicidal intent and the seriousness of the attempt
b. Obtain further history to help you to devise a management plan.
In the next station you will be asked to speak to the consultant.
Expanded construct: Core task - The candidate is expected to cover the

following areas in history
Obtain more information about the overdose and explore the reasons for overdose
Evaluate the degree of suicidal intent and the seriousness of the attempt
(Planning, performance in isolation, Precautions to avoid discovery,
Suicidal note etc)
Investigate for symptoms of Depression and or other forms of mental illness
Assess current mental state including suicidal thoughts

(Clear suicidal plans, fixed or Fleeting suicidal thoughts)
Past h/o overdoses, DSH,

Past h/o Mental illness etc
Current Social Circumstances

Coping strategies
RELATED TASK IN THE SECOND STATION (PART-B)
In this station you are asked to discuss to the consultant over the phone about the patient
you have just assessed. You should provide details about the overdose itself; discuss risk
assessment and management plan for this case.
Expanded construct: The candidate is expected to discuss the following areas with the
consultant during discussion;
Providing information about the overdose and reasons behind it
Evaluation of the degree of suicidal intent and the seriousness of the attempt
For ascertaining the presence of Depression/and or other forms of mental

illness
42
Assessing current mental state
Past history and social support
Range and depth of Risk explored.

(Risk assessment- Mild/moderate/serious)
Outcome of the assessment

(Admission/discharge/ To consider for detention-when)
Management plan- (Short-term and Long-term)

Bio psychosocial approach, Role of medications,
Psychological input, involving specialized teams etc
COGNITIVE EXAMINATION
MINI-MENTAL STATE EXAMINATION
Score
Orientation
5 () -What is the (year), (season), (month), (date), (day).
5 () -Where are we: (country, county, city/town, building name, floor of the
building)
Registration
3 () -Ask if you can test the individuals memory. Name 3 objects (e.g. apple, table,
penny) taking one second to say each one. Then ask the individual to repeat the names of all three
objects. Give one point for each correct answer. After this, repeat the object names until all three
are learned up to 6 trials).
Score
Attention and calculation
5 () -Spell world backwards. Give 1 point for each letter that is in the right order
DLROW = 5, DLORW = 3).
-Alternatively, do serial 7s. Ask the individual to count backwards from 100 in
blocks of 7 (93, 86, 79, 72, 65). Now I would like you to take 7 away from 100. Now take away
43
from the number you get. Now keep subtracting until I tell you to stop. Stop after 5 subtractions.
Give one point for each correct answer. If one answer is incorrect (e.g. 92) but the following
answer is 7 less than the previous answer (i.e. 85), count the second answer as being correct.
Recall
3 () -Ask for the 3 objects repeated above. What were the 3 objects I asked you to
repeat a little while ago? Give 1 point for each correct object. (Recall should be tested five
minutes after presenting the words).
Language
2 () -Point to a pencil and ask the individual to name this object (l point).
Do the same with a wrist-watch (1 point).
1 () -Ask the individual to repeat the following: No ifs, ands or buts (l point).
You may repeat the phrase if the individual has difficulty hearing or understanding you, up to a
maximum of five times, but the score should be based only on the first attempt to repeat the
phrase.
3 () -Give the individual a piece of blank white paper and ask him or her to follow a
3-stage command. Take the paper in your right hand, fold it in half with both hands and put the
paper down on your lap (1 point for each part correctly followed). Give only one trial.
1 () -Show the individual the CLOSE YOUR EYES message. Ask him or her to
read the message and do what it says (give 1 point if the individual actually closes his or her
eyes).
1 () -Ask the individual to write a sentence on a blank piece of paper. The sentence
must contain a subject (real or implied) and a verb, and must be sensible. Punctuation and
grammar are not important (1 point).
1 () -Show the individual the intersecting pentagons and ask him or her to copy the
design exactly as it is (1 point). Each pentagon should have 5 sides and 5 clear corners and the
two shapes must intersect to score 1 point. Tremor and rotation are ignored.
TASK: COGNITIVE EXAMINATION
Perform cognitive examination on Mr. Smith a confused elderly gentleman, who was
found wandering in the streets and brought to the A&E department by the police.
Expanded construct: The candidate is expected to perform thorough cognitive

assessment and should be able to cover different areas of cognitive domains.
They should able to test the following domains
Orientation to time (Year, season, month, date &day),

Orientation to place (Country, county, town, building, floor),
Orientation to person (name, age etc)
44
Registration (three-item test)
Retention and recall
Attention and calculation (93,86, 79, 72, 65) Or

WORLD backwards(D-L-R-O-W), Or
Months of the year backwards
Language & Comprehension:

Naming, repeating and 3 Stage command,
Reading, writing
Visuo-spatial: copying / draw a clock face
Working memory- Digit span

Semantic memory
EXTENDED COGNITIVE EXAMINATION
Detailed Cognitive assessment involves checking for;

Orientation to time, place and person
Attention
Calculation
Memory
Language
Visuospatial and visuoconstructive functions
Executive functions
Assessment of praxis
Orientation to time
What is the year?
What is the season?
What is the month?
What is the day of the week?
45
What is the date?
Orientation to place
What is the country?
What is the county/state/province?
What city are we in?
What is the name of the hospital or building?
What floor are we on?
Also check for orientation to person (Full name, age and occupation)
Attention and concentration

Serial reversal tasks-spelling W-O-R-L-D backwards, Serial 7s from 100
The other tests include reciting months of the year backwards, weeks of the day backwards
Calculations: Ask the patient to perform mental arithmetic such as additions, Subtraction,
Multiplication or divisions. For example ask the patient to write down four or five numbers and
add them up.
Memory
Working memory:
Forward digit span: Here a series of numbers is read to the subject who then repeats the
numbers forwards. The numbers should be read evenly at one per second and start from three
digits. The normal range is 7+/- 2.
Backward digit span: Here the subject is asked to repeat the string of numbers backwards (Eg
the examiner reads 396 and the patient reads 693). The normal range is 5+/- 2.
Anterograde memory (new learning)

Registration and recall of three items;
Ask if you can test the individuals memory. Name 3 objects (e.g. apple, table, penny) taking one
second to say each one. Then ask the individual to repeat the names of all three objects.
Ask for the 3 objects repeated above. What were the 3 objects I asked you to repeat a little while
ago? Give 1 point for each correct object. (Recall should be tested five minutes after presenting
the words).
Registration and recall of a seven-item name and address

I am going to read you a name and address that I would like you to repeat after me. We will be
doing it three times so that you have a chance to learn it and I will be asking you about it later.
Then read out the following address;
46
John Brown,
42, West street, Luton
Bedfordshire
This can be recorded as a score out of 7 on the first learning trial E.g. 4/7. Repeat the entire name
and address in completion before the subject again tries to complete. Recall can be tested at 5-10
minutes. A score of 5 or less may give cause for concern if all seven items were learnt.
Retrograde memory (Memory for Personal events)

Where did you grow up and go to school?
When did you finish school?
When did you get married?
Semantic memory (General events)

Who is the current prime minister of the UK?
Who is the previous prime minister of the UK?
Who is the current president of USA?
Who is the previous president of USA?
What are the years of 2nd world war?
Has anything important happened in the world recently (description of any recent news
events like political, sports events, accidents, catastrophes
Language
1. Comprehension
Simple commands- E.g. Close your eyes, touch your nose
2. Repetition: Sentences that are used for testing
Repeat No Ifs and or buts
The orchestra played and the audience applauded.
3. Naming-Point to two or three objects and ask patient to name. Ask the patient to name high
frequency global names such as (E.g. Watch, Jacket) and also more specific/less frequency items
such as (Eg Label or winder) that are generally more difficult.
4. Word Fluency-Ask patients to generate a list of as many animals as possible in one minute
(normal 15 in a category in one minute). Typical categories used to test include animals, fruits,
vehicles etc.
5. Reading: Show the individual the CLOSE YOUR EYES message. Ask him or her to read the
message.
6. Writing: Ask the individual to write a sentence on a blank piece of paper. The sentence must
contain a subject (real or implied) and a verb, and must be sensible.
Visuospatial and visuoconstructive functions

Asking the subject to copy drawings or shapes, which are three dimensional in nature, tests this.
47
Clock Drawing test: Draw a circle and ask the subject to fill in numbers and hands to current
time and tell the subject to set the time at 10 to 5. This task will assess visuo-spatial abilities and
executive functions. In this task look for signs of neglect or of disorganization in the approach.
This can indicate perceptual and perceptuomotor deficits, constructional apraxia and unilateral
neglect.
Executive function: This involves frontal lobe functions that includes verbal fluency, cognitive
estimation, abstract thinking and reasoning, response inhibition, motor sequencing and
programming (please read chapter-frontal lobe function testing)
Praxis: Ideomotor praxis

Show me how you brush your teeth?
Show me how you comb your hair?
Show me how you cut paper with scissors?
Ideational praxis: The subject should be asked to perform a complex task with multiple steps for
example, placing a letter in an envelope, sealing it, addressing it, stamping it and then posting it.
Orobuccal praxis: Here the subject is asked to carry out specific movements on command like
stick out your tongue, lick your lips etc.
FRONTAL LOBE FUNCTION TESTING

Assessment of verbal fluency/Category fluency
The Patient is asked to name as many words as possible beginning with either the letters F, A or
S in one minute. (Ideally all three ought to be tested). Normal subjects should produce at least 15
words for each letter. Less than 10 items is definitely abnormal.
Alternatively you can use a category (name as many animals as possible in one minute). Typical
categories used to test include animals, fruits, vehicles etc.
Assessment of abstraction
Proverb interpretation
Ask the patient the meaning of two common proverbs:
Example 1: Too many cooks spoil the broth
Example 2: A stitch in time saves nine.
Similarities
The patient is asked to explain the similarities between things (use things that are routinely used).
Example:
a. Table and chair
b. Apple and orange.
c. Glass and ice
48
Cognitive Estimation: Ask the patient to make estimates such as
What is the height of an average English man?
How many camels are there in England?
Co-ordinated movements (tests response inhibition and set shifting)
Alternate sequence: An alternative sequence of squares and triangles are shown to the patient
and they are asked to copy it.
Go-no-go test: Ask the patient to place a hand on the table and to raise one finger in response to a
single tap, while holding still in response to two taps. You tap on the under surface of the table to
avoid giving visual cues.
Luria three-step task: A sequence of hand positions is demonstrated which would be placing a
fist, then edge of the palm and then a flat palm onto the palm of the opposite hand and repeating
the sequence (fist-edge-palm)
It can be demonstrated up to five times.
Frontal lobe release signs:

Glabellar tap: Tap between the patients eyebrows, which causes repeated blinking even after
five or more taps, if it is positive.
Primitive reflex: This would include Grasp reflex in which you stroke the patients palm while
distracting the patient, watch for involuntary grasping and pouting reflex in which you tap on a
spatula on patients lips, resulting in spouting and both reflexes can be subtle.
FRONTAL LOBE FUNCTION TESTING

Subtest Comments
Similarities Compare two objects look for categorisation and not description of common
parts. Conceptualisation of the whole objects is more important for abstract
ability.
Lexical Can use supermarket list generation or FAS test. Tests not only the speed and
fluency accuracy but also the ability to shift from a narrow set to the next. E.g.
supermarket list must include not only fruits, but also bakery items, households
etc.
Luria motor Fist palm edge must not be verbally facilitated. Test for motor planning,
test execution and error correction.
Go/on go test Tests response inhibition, absence of perseveration and resistance to
interference.
Cognitive e.g. How tall is an average English woman? Use questions that need abstract
estimate not mere factual thinking.
testing
Trail making Consists of two parts. In part A simple number sequence is used to join the dots.
test: Test B uses alternating numbers and letters and is thought to be more sensitive
for frontal lobe dysfunction. Not specific for frontal lobe; tests visuomotor
tracing, attention, conceptualisation and set shifting.
Other tests Include alternate pyramids and squares drawing, proverb interpretation, and to
49
some extent frontal release signs and digit span (normal: 72 forwards, 51
backwards) reflect frontal functions.
Semple et al (Ed). The Oxford Handbook of Psychiatry 1 st edition. Oxford University Press 2005.
PARIETAL LOBE FUNCTION TESTING

Subtest Comments
Alexia & Agraphia Dominant, part of Gerstmann syndrome. Intact speech but cannot read or
write meaningful language
Anosognosia Patient does not recognise functional deficits of their body. Non dominant
lobe.
Calculation ability Dominant, part of Gerstmann syndrome. Involves mathematical functions.
Mere recognition and use of numbers is called arithmetic ability.
Constructional Inability to draw shapes or construct geometrical patterns. Mostly
apraxia nondominant.
Finger agnosia Dominant, part of Gerstmann syndrome.
Graphesthesia Ability to recognise what number or alphabet is scratched on ones skin
without seeing.
R-L orientation Dominant, part of Gerstmann syndrome.
Stereognosis Ability to recognise objects by palpation, and without visual inspection.
Two point Cortical sensation; Somatosensory cortical function
discrimination
Visual field Inferior quadrantanopia is seen on opposite side of lesion. (note: both
defects inferior and superior quadrantanopia are more common in occipital optic
radiation lesions)
Semple et al (Ed). The Oxford Handbook of Psychiatry 1 st edition. Oxford University Press 2005.
TASK: FRONTAL LOBE FUNCTION TESTING
TASK: Mr. Brown is a 65-year-old gentleman who was picked up by the police as he
was found wandering in the streets and exposed himself to a female in the public.
Perform Cognitive assessment specifically looking for features of frontal lobe
dysfunction. Do not take history.
Expanded construct: The candidate is expected to Perform Cognitive assessment

specifically looking for features of frontal lobe dysfunction. They should be able to
complete most of these tests given below;
Assessment of verbal fluency (Word-F, word-A, Word-S)

Category fluency (animals, birds etc)
Assessment of abstraction-
Proverb interpretation
Similarities test
Cognitive estimate testing (2 tests)
50
Co-ordinated movements- Luria three step task
Coordinated movements (response inhibition and set shifting)-

Go-no-go test
Perseveration (alternate sequences test)
Examination of Primitive reflexes

(Glabellar tap, grasp and pouting reflex)
Others
PHYSICAL EXAMINATION
EXTRAPYRAMIDAL SIDE EFFECTS-EXAMINATION

EPSEs would include;
1. Akathisia (Motor restlessness)
2. Dystonia (uncontrolled muscular contraction)
3. Pseudoparkinsonsim-Tremor, Rigidity, Bradykinesia, mask-like facies and festinant
gait
4. Tardive dyskinesia (abnormal movements)
Suggested approach
Greet the patient and introduce yourself
Address the patients concerns first
Ask the patient briefly about any abnormal movements like slowness, stiffness, shakiness,
feeling of inner restlessness and any other body movements which bother the patient
Explain briefly what you are going to do and ask for consent (Obtain permission before you
proceed)
51
Ensure that the patient knows that during this examination you will be testing his hands,
legs, and mouth and that you will make him walk to observe his gait
Observe the patient at rest for a few seconds.
Ask the patient whether there is anything in his or her mouth and, if so, to remove it.
Ask if he or she wears dentures. Ask whether teeth or dentures bother the patient now.
Ask whether the patient notices any movements in his or her mouth, face, hands, or feet. If
yes, ask the patient to describe them and to indicate to what extent they bother the patient.
Ask the patient to open his or her mouth. (Observe the tongue at rest within the mouth.) Do
this twice.
Ask the patient to protrude his or her tongue. (Observe abnormalities of tongue movement.)
Do this twice.
Have the patient sit in chair with hands on knees, legs slightly apart and feet flat on floor.
(Look at the entire body for movements while the patient is in this position. Observe for 15
seconds.)
Ask the patient to sit with hands hanging unsupported if male, between his legs, if female
and wearing a dress, hanging over her knees. (Observe hands and other body areas for at
least 15 seconds.)
Ask the patient to tap his or her thumb with each finger as rapidly as possible for 10 to 15
seconds, first with right hand, then with left hand. (Observe facial, hand and leg
movements.)
Flex and extend the patients left and right arms, one at a time.
Ask the patient to stand up. (Observe the patient (15 seconds). Observe all body areas
again, hip included.)
Ask the patient to extend both arms out in front, palms down. (Observe trunk, legs, and
mouth.)
Have the patient walk a few paces, turn, and walk back to the chair. (Observe hands and
gait.) Do this twice
TASK: PHYSICAL EXAMINATION- EPSEs
You are a junior doctor in accident and emergency department. The nurses have asked
you to see this young gentleman Mr. Paul Brown who is restless, angry and agitated.
The A&E doctor mentions that he went to his GP three days ago who gave him some new
tablets. He thinks his problems started after taking those tablets.
1. Explore the reasons why GP prescribed the medication.
2. Assess his symptoms and perform appropriate physical examination
Expanded construct: The candidate is expected to explore the reasons for the
medication to be prescribed, assess his symptoms and perform appropriate physical
examination
Ask for symptoms of EPSEs- Inner restlessness, stiffness, shakiness,

abnormal body movements etc
Examination-facial and oral movements

Lips, Perioral areas, jaw, Tongue, Dental status
52
Examination of upper limbs; Tremor-outstretched hands
Rigidity-Wrist, elbow and shoulder joint
Examination-Leg movements, Resting posture, Seated on chair with Hands

on knees (Observe for 15 seconds)
Examination: legs slightly apart, Seated with hands hanging unsupported etc
Observation on Standing posture, Observation with both arms extended and

palms down (Observe for 15 sec), Examination of gait
Explaining the possible diagnosis to the patient (Akathisia, which is

medication induced) and allay anxiety
CRANIAL NERVES EXAMINATION

1st Cranial nerve (Usually questioning is all that is required unless equipment is provided to
check formally)
Do you have difficulty with your sense of smell?
Has he smelled his coffee this morning?
2nd Cranial nerve
To check for visual acuity

Do you have any difficulty with your vision?
Sit in front of the patient. (If he has glasses for long sight he should put them on).
a. Check one eye at a time by asking to close other eye. Do the test by finger counting method.
Or
b. A near vision chart is provided. Ask the patient to read sections of print from a distance of
30 cm. The smallest size that can be read is recorded (e.g. N6)
To check for field of vision

Mapping visual fields
53
Be at the same eye level with the patient. Ask the patient to cover their right eye with their right
hand, and cover your left eye with your left hand, and then ask the patient to look in your eye
without moving their head. Move your finger to check peripheral fields.
Colour vision: Not essential.
Pupils
Direct and consensual reflexes: A bright light is shone into one eye and the reaction of both
pupils (direct and consensual reflexes) is noted. Before you flash the light make sure you tell
the patient that you will be shining a bright light in his eyes, which may cause a bit of
discomfort.
Accommodation reflex: The patient is asked to look into the distance and then at a finger
positioned 10 cm directly in front of his/her nose. The pupils are examined as the patient
attempts to focus on the finger and the reaction of the pupils to accommodation are noted.
Tell the examiner that ideally you would like to perform fundoscopy to examine the optic disc.
3rd, 4th and 6th Nerve

Ask patient to look into your eyes and to follow your moving finger without moving his head.
Describe the letter H with your finger, beginning at the centre of the horizontal line, go to left
then up and down, bring the finger back to opposite side and do the same. The patient is asked to
report any double vision. Watch for nystagmus.
5th Cranial nerve
Sensory part
Check superficial sensation on various parts of the face with a cotton swab in all three
dermatomes alternating both sides. Ask the patient to close his eyes before you proceed and to
answer YES when he feels the swab.
Motor part
Check the muscles of mastication.
Ask to clench the teeth. Then feel for masseters and temporalis.
The patient is asked to open the mouth against resistance from your hand, which should be
placed firmly under the patients chin.
You have been asked to ignore the jaw jerk and corneal reflexes.
7th Cranial nerve
Sensory part
Did you taste your breakfast this morning?
Motor part
Can you show me your teeth please?
Ask him to shut his eyes tightly while you try to open them gently-screw your eyes up tight.
Other tests: Ask the patient to raise his eyebrows, blow out his cheeks, and purse his lips
tightly.
8th Cranial nerve (Vestibulocochlear)
54
Check whether there is any problem with the hearing in either ear?
Test hearing sensitivity to a whispered sound or a ticking wristwatch.
Alternatively rub finger and thumb together in front of each ear in turn and ask whether the
patient can hear that.
If there is no problem in hearing inform the patient that youd like to conduct detailed hearing
tests, once youve tested the other nerves.
9th and 10th Cranial nerve

Request him to open his mouth and ask him to say AAAHHH loudly; comment on soft
palate and uvulary movement.
You have been asked to ignore the gag reflex.
11th Cranial nerve

Ask the patient to shrug shoulders against resistance.
Shrug your shoulders and keep them shrugged- push down on the shoulders
Ask the patient to turn his head in both directions against resistance.
Turn your head to the left side, now to the right-feel for the sternomastoid muscle on the side
opposite to the turned head.
12th Cranial nerve

Ask him to open his mouth and show his tongue and look for any deviation, wasting or
tremors.
Inspect the tongue as it lies on the floor of the mouth, noting any wasting, fasciculation and
involuntary movement.
The patient is then asked to stick out the tongue and waggle it from side to side.
Cranial nerves examination:

No. Name Main clinical action
I Olfactory Smell each side separately
II Optic test visual acuity using Snellens charts (near and distance), colour
using Ishihara charts, field by confrontation/perimetry and pupillary
reflexes.
III Oculomotor Eyelid elevation, eye elevation, ADduction, depression in ABduction,
efferent (pupil)
IV Trochlear Eye intorsion, depression in ADduction
V Trigeminal Facial and corneal sensation, muscles of mastication
VI Abducens Eye ABduction
55
VII Facial Facial movement, taste fibres
VIII Vestibular Balance Romberg / Caloric test
Cochlear Hearing Rinne, Weber tests.
IX Glossopharyngeal Sensation - soft palate, taste fibres
X Vagus Cough, palatal and vocal cord movements
XI Accessory Head turning, shoulder shrugging
XII Hypoglossal Tongue movement
Adapted from Kumar & Clark Textbook of clinical medicine 6 th edition Pg 1179
EXAMINATION OF THYROID GLAND

General examination
Nails look for pallor/clubbing/cyanosis

Hands sweating/warmth/acropachy/acrocyanosis
Tremors: Ask the patient to stretch out his hands for full extension of the wrist and elbow. If
the tremor is not obvious, place your palm against the patients outstretched fingers to feel for
it. Alternatively, you can place a piece of paper on the dorsum of the patients outstretched
hands and it will oscillate if a fine tremor is present.
Pulse rate and rhythm
Tongue pallor/cyanosis
Legs Pretibial myxoedema.
Local examination: Check the exposure from jaw to the nipple line.
Inspection
56
Pizzillos method: The patients hands are placed behind the head and the head is pushed
backwards against the clasped hands. Look for any obvious swelling on swallowing and on
protrusion of tongue: the thyroid swelling usually moves upwards on swallowing
Look for scars, sinuses and erythema
Any dilated or engorged veins in the neck and on the chest
Visible pulsations if any.
Palpation
From front
Confirm findings of inspection
Feel for the trachea and its displacement if present
Carotid pulsations: feel one at a time.
The thyroid gland should ideally be palpated with the patients neck slightly flexed. The gland
may be palpated from behind and from the front with the four fingers of each hand placed on
each lobe.
Lower limit of thyroid is checked while the patient is swallowing
Check for cervical lymphadenopathy.
Percussion
Only if lower limit of the gland is not palpable (direct percussion on the sternum).
Auscultation
Check for thyroid and carotid bruit.
Eye signs
Exophthalmos (from behind): Relative protrusion of the eyes can be observed by standing
behind a seated patient and looking downward toward the chin from the forehead to assess the
displacement of one globe as compared to the contra lateral side. Also look at the patient from
the side.
Check for lid lag. Hold the patient's head still with one hand and ask her to follow the index
finger of the other hand. Move it up and then down. With lid lag, as the finger moves down,
some white cornea is seen above the iris.
Reflexes
Ankle jerk: The slow relaxing ankle jerk is usually best demonstrated with the patient kneeling
on a chair or bed with the feet hanging over the edge, and the examiner standing behind the
patient.
Clinical features of Hypothyroidism
Symptoms: Tiredness, Lethargy, myalgia, Weight gain, Constipation, Dislike of cold,

Menorrhagia, Hoarse voice, Depression, Dementia
Signs: Bradycardia, Dry skin and hair, Toad-like face, Goitre, Slowly relaxing reflexes,
Congestive cardiac failure, Non-pitting oedema, Pericardial effusion and Peripheral neuropathy
TASK: THYROID EXAMINATION
57
INSTRUCTIONS TO THE CANDIDATE: Mr. Ronald suffers from bipolar affective
disorder and is currently on lithium carbonate 1000 mg. Over the last six months he has
been feeling increasingly tired and lethargic. His blood tests reveal low T3, T4 and raised
TSH Levels. Elicit possible symptoms and signs of thyroid dysfunction. Perform
appropriate clinical examination. Do not take history of bipolar disorder
Expanded construct: The candidate is expected to elicit symptoms of hypothyroidism

and perform detailed thyroid examination
Elicit symptoms of hypothyroidism

(Weight gain, constipation, lethargy, poor appetite, cold intolerance etc)
General Examination
Hands, Nails, Pulse rate and tremors
Examination of Eyes (Lid Lag. Lid Retraction, Exophthalmos)
Inspection- Swelling on swallowing

Scars, sinuses, engorged veins, pulsations
Palpation (Confirm inspection findings)

Feel for trachea, cervical lymph nodes
Carotid pulsations, Laheys method of examination
Percussion and auscultation

Thyroid bruit and carotid bruit
Reflexes for ankle jerk and

Pretibial myxoedema
SENSORY AND MOTOR EXAMINATION OF UPPER LIMBS

General examination
Nails pallor, cyanosis, capillary filling and tropic changes
Hair loss on the limb
Any obvious joint pathology
Pulse.
Inspection
Posture of limb
Look for any obvious deformity
Wasting of limb and fasciculation
Scars, sinuses, erythema or swelling.
Palpation
Ask permission before you proceed
58
Temperature compare both the sides
Limb girth measurement above and below the joint.
Sensory examination
For this exam purpose you check for:
Dorsal column
Superficial sensation (Touch)

Test using a cotton swab. The patient should have his eyes closed. The patient should feel the
cotton swab on his face or sternum before you proceed.
Vibration sense
Use 128 Hz frequency tuning fork. Tell patient that this is a tuning fork and when you place it on
his bony prominences it will feel like a buzz. Usually it is tested on the first metacarpo-phalangial
joint for upper limb. Here again make the patient feel the tuning fork on his sternum before you
proceed and ensure his eyes are closed.
Positional sense
Tested by checking movement of the distal interphalangial joint of the thumb with eyes closed. If
the patient cannot feel the position then check the proximal joints till he feels it. (If he cannot feel
moving first distal interphalangial joint, then move the wrist, if still negative move the elbow
joint.)
Lateral column
Pain sensation
Tested here with redheaded pins on the dermatomes. They do not usually allow pain sensation to
be tested, but you must mention that ideally you would like to test it.
Temperature
Mention that ideally you would like to test the temperature also.
Motor examination
Check for the muscle bulk on both the sides in the upper arms, lower arms and hands
Check for tone: Ensure that he does not have any joint pain in that limb. Test the tone in the
arms by passively bending the arm to and fro and in the hands by flexing and extending all the
joints, including the wrist.
Check power
Put your arms out to the side with arms at 90 degrees to your body with elbows flexed, (best to
demonstrate this to the patient yourself)
Deltoid (C-5) Stop me pushing them down
Biceps- (C-5,6) Bend your elbow, stop me straightening it
Triceps: (C-7) Push you arm out straight and resist elbow extension
Offer two fingers and ask the patient to squeeze your fingers (C-8, T-1)
Spread your fingers apart and stop me pushing them together (Dorsal interossei-ulnar nerve)
Hold this piece of paper between your fingers; stop me pulling it out (palmar interossei-ulnar
nerve)
59
Reflexes
Check for biceps C5, C6
Check for Triceps C7
Check for Supinator C5, C6
Cerebellar signs
Upper limb: fingernose test (one test is enough)-Touch my finger, touch your nose;
backwards and forwards quickly and neatly
Check for involuntary movements-tremor. Fasciculation.
Conclusion : For upper limbs mention examination of cervical spine
SENSORY AND MOTOR EXAMINATION OF LOWER LIMBS

General examination
Nails pallor, cyanosis, capillary filling and trophic changes
Hair loss on the limb
Any obvious joint pathology
Pulse.
Inspection
Posture of limb
Look for any obvious deformity
Wasting of limb and fasciculation
Scars, sinuses, erythema or swelling.
Palpation
Ask permission before you proceed
Temperature compare both the sides
Limb girth measurement above and below the joint.
Sensory examination
For this exam purpose you check for:
Dorsal column
Superficial sensation
Test using a cotton swab. The patient should have his eyes closed. The patient should feel the
cotton swab on his face or sternum before you proceed.
Vibration sense
Use 128 Hz frequency tuning fork. Tell patient that this is a tuning fork and when you place it on
his bony prominences it will feel like a buzz. Usually it is tested on the first metatarso-phalangial
joint or on the medial malleoli for the lower limbs. Here again make the patient feel the tuning
fork on his sternum before you proceed and ensure his eyes are closed.
Positional sense
Tested by checking movement of the distal interphalangial joint of the big toe with eyes closed. If
the patient cannot feel the position then check the proximal joints till he feels it. (If he cannot feel
60
moving first distal interphalangial joint, then move the ankle, if still negative move the knee
joint.)
Lateral column
Pain sensation
Tested here with red-headed pins on the dermatomes. They do not usually allow pain sensation to
be tested, but you must mention that ideally you would like to test it.
Temperature
Mention that ideally you would like to test the temperature also.
Motor examination
Check for muscle bulk above and below the knee joint
Check for tone: Ensure that he does not have any joint pain in that limb. Examine the muscle
tone in each leg by passively moving it at the hip and knee joints-roll the leg sideways, backwards
and forwards on the bed, lift the knee and let it drop or bend the knee
Check power
Tell the patient to lift the leg up and ask the patient to stop you pushing it down (L 1,2)
Bend your knee and dont let me straighten it (L5, S1,2)
With knee still bent, push out straight against my hand (L-3,4)
Bend your foot down and push my hand away (S-1)
Cock up your foot, point your toes at the ceiling and stop me pushing your foot down (L4,5)
Reflexes
Check for knee reflexes (L 3,4)
Check for ankle jerks (S1,2) and check for ankle clonus at the same time
Check the plantar reflex
Cerebellar signs
Kneeheel test: Tell the patient to put your heel just below your knee then run it smoothly
down your shin, now up your shin, now down etc
Rombergs test: This should be tested with the patients feet together and the arms
outstretched. Make sure that you are ready to catch the patient if there is any possibility of
ataxia.
Check for gait, and involuntary movements.
Conclusion
Ideally mention that you will also examine the dorsolumbar spine
TASK: NEUROLOGICAL EXAMINATION
Mr. Lawrence was admitted informally to the ward this morning with a diagnosis of
depression and somatisation disorder. He complains of numbness and tingling sensations
in his right upper limb for the last 4 weeks. Perform both sensory and motor examination
in his upper limb and rule out any neurological deficits. Do not take history.
61
Expanded construct: The candidate is expected to perform detailed neurological
examination
General Examination
(Nails, hair, joint pathology, pulse)
Inspection and palpation

(Posture, deformity, wasting, scars, swelling
Temperature, Limb girth measurement)
Sensory examination
(Lateral column-Pain, Temperature)
Sensory examination
(Dorsal Column-Touch, Vibration, positional sense)
Motor examination
(Tone and Power-flexors at elbow, wrist Flexors, deltoid,
biceps, triceps, Thumb extensors and opposition)
Motor examination
(Reflexes-Biceps, Triceps and supinator)
Motor examination- (Tremors, Co-ordination

Finger-nose test)
ALCOHOL MISUSE PHYSICAL EXAMINATION

Examine the patient from the end of the bed
Look for classical stigmata, such as:
Jaundice
Abdominal distension
Spider naevi mainly on trunk, face and arms
Caput medusae (dilated veins on the abdominal wall)
Gynaecomastia.
General examination
Examine skin
Abrasions, bruises, scars suggestive of falls or violence.
Examine hair
62
Decreased body hair.
Examine face
Facial redness
Bilateral parotid enlargement.
Examine eyes
Icterus
Pallor
Check for nystagmus
Examine hands
Leuconychia
Clubbing
Palmar erythema
Dupuytrens contracture
Ask patient to bend both hands back, looking for asterixis (flapping tremor).
Systemic examination
Cardiovascular examination
Check Pulse for tachycardia
Check the blood pressure for evidence of hypertension (raised in heavy alcohol misuse)
Precordial examination and auscultation
Peripheral oedema (heart failure seen with heavy alcohol misuse).
Respiratory examination
Respiratory rate orthopnoea.
Abdominal examination
Check for asymmetry
Check for ascites
Check for palpable liver (Hepatomegaly) and look for tenderness in the Epigastric and right
hypochondriac regions.
Testicular atrophy (males).
Neurological examination
Motor examination
Bulk and tone: Look for muscle wasting
Power: Loss of power with heavy drinking; quadriplegia
Reflexes: Increased deep tendon reflexes
Abnormal movements: Tremor seen in acute alcohol withdrawal (delirium tremens) and and
also check for Myoclonus
Co-ordination and gait: Ataxia (cerebellar damage, Wernickes syndrome).
Sensory examination
Sensation: Altered sensations and or loss of pain sensation in the limbs and trunk
Other cortical functions

Speech dysarthria
Vision loss of visual acuity (optic atrophy)
Orientation confusion seen in a variety of alcohol-induced states.
63
CEREBELLAR SIGNS AND SYMPTOMS
(Adapted from Neurology for psychiatrists)
Cerebellar signs
Ataxia
Hypotonia
Intention tremor an oscillating tremor that accelerates in pace on
approaching the target
Dyssynergia Results in loss of smoothness of execution of a
(incoordination) motor activity.
Dysmetria (past pointing) overshooting or undershooting of a target while
attempting to reach an object
Dysdiadochokinesis inability to perform rapid alternating
movements Tested by asking the patient to
64
tap 1 hand on the other repeatedly while
simultaneously pronating and supinating the
hand
Dysrhythmia inability to tap and keep a rhythm
Dysarthria staccato or scanning speech with poor
modulation of the volume and pitch of the
speech.
Finger-nose test and heel-shin test:
These two tests are helpful to detect intention tremor and dysmetria.
An intention tremor is absent at rest but develops as the patient moves wilfully. Dysmetria is the
inability to perform accurate targeted movements. Instead, the movements are jerky and the target
is overshoot (past-pointing)
In the finger-nose test, the patient is asked to touch the examiners index finger, held at an arms
length from the patient, with the tip of his or her own finger and then to touch the end of his or
her nose. This is repeated several times without stopping. The tests can me made more sensitive
by moving the target finger.
The heel-shin test is a similar test to the finger-nose but using the legs. The patient is asked to
place the heel of one foot on the knee of the other leg and slide the heel down along the shin and
then to lift it clear and repeat this action.
Repetitive movements:
The patient is asked to slap the palm and then the back of the palm alternatively on his or her
knee. This is then repeated as rapidly as possible. A patient with dysdiadochokinesia is unable to
perform such rapid alternating movements and instead moves irregularly and loses the pattern.
Truncal ataxia: When asked to sit up from a lying position without the use of the hands, the
patient falls to one side.
Ataxic gait: It is broad-based, uncoordinated and unsteady, with the patient veering towards the
side of the lesion. The patient walks with the feet spaced widely apart. In mild cases, the ataxic
gait may only be present on walking heel-to-toe in a straight line.
Rombergs Test: Here, the patient is initially asked to stand with the feet together and the eyes
open. The eyes are then closed. Observe whether the patient remains steady. Be prepared to
intervene and support the patient in case of a fall. If the patient is steady with the eyes open but
begins to fall when the eyes are closed, this is termed as Rombergs test positive and indicates a
loss of proprioreception. Swaying backwards and forwards upon eye closure suggests a cerebellar
syndrome. Severe unsteadiness with eyes open and feet together is indicative of cerebellar or
vestibular syndromes.
Ataxic dysarthria; The speech is slow, slurred and scanning. Words are broken down into their
component syllables and uttered with varying force. Ask the patient to repeat some difficult
phrases such as The British constitution orEast Register Street is opposite West Register Street
65
Eye signs: Pursuit movements are slow and feature catch-up saccadic movements that attempt
to maintain target fixation. Test pursuit eye movements by holding a finger about an arms length
from the patient, in order to avoid strain on convergence and asking for it to be followed solely
with the eyes (i.e without any head movements). Slowly move the finger horizontally and
vertically in the centre of the visual field and at the extremes of the lateral gaze while keenly
observing the patients eye movements.
Eye movements also exhibit hypometric saccades or hypermetric saccades, in which the eyes
undershoot or overshoot the target when fixating. Cerebellar lesions also produce horizontal
nystagmus in which the fast phase points towards the side of the lesion.
Hypotonia: A minor feature of cerebellar dysfunction
Pendular tendon reflexes: Pendular reflexes are not brisk but involve less damping of the limb
movements than is usually observed when a deep tendon reflex like a knee reflex is elicited. It is
best observed when the patients lower legs are allowed to hang and swing freely off the end of
an examining table. A normal or brisk knee jerk would have little more than one swing forward
and one back. Patients with cerebellar injury may have a knee jerk that swings forwards and
backwards several times. Insults to the cerebellum may lead to pendular reflexes.
TASK: CEREBELLAR SIGNS
Mr. John Murphy is a 43-year-old divorced gentleman with a history of severe alcohol
dependence. He has not been drinking for 2 months but feels a little unsteady in walking
and clumsy when using his hands. A recently performed CT brain scan showed evidence
of cerebellar atrophy. Perform physical examination looking for features of cerebellar
dysfunction.
Expanded construct: The candidate is expected to perform physical examination

looking for features of cerebellar dysfunction.
Cerebellar signs
Eye signs (nystagmus) and Hands (intention tremors)
Cerebellar signs
(Alternating movements-Dysdiadochokinesia
And dysarthria-staccato speech)
Co-ordination: Finger-Nose test,

Heel-shin test
66
Gait-examination
(Ataxic gait-with eyes open and closed)
Motor examination
(Tone, Power and reflexes)
CARDIOVASCULAR EXAMINATION
In the examination, you will be asked to perform cardiovascular examination and look for
signs of vascular dementia (specifically)
Suggested approach
Introduce yourself to the patient
Confirm the identity of the patient
Obtain verbal consent from the patient
Ensure privacy and achieve adequate exposure
In case of females do not forget to ask for chaperone
General examination; Observe whether the patient is breathless, cyanosed, and pale or whether
he/she has a malar flush (face) and Xanthelesmas (hypercholesterolemia)
67
Eyes Jaundice and pallor
Tongue Pallor and cyanosis
Nails Pallor/clubbing/cyanosis/splinter haemorrhage
Palm Palmar erythema
Pulse Rate and rhythm with radial pulse. Volume and character in brachial pulses on both
sides. Look for signs of atrial fibrillation
Blood pressure- look for raised blood pressure (Systolic or diastolic)
Carotids Check one at a time. Look for carotid bruit.
JVP Ask the patient to recline at 45 on the couch. Turn his head to the left side and look for
any rise of JVP.
Oedema Ankles. But mention that you would like to look for sacral oedema.
Systemic examination
Inspection
Apex beat: Localize the apex beat with respect to the mid-clavicular line and rib spaces, firstly
by inspection for visible pulsation.
Deformity
Redness, scars and sinuses
Engorged veins.
Palpation: Remember to ask for permission before touching the patient

Locate the apex beat and mention its character: If the apex beat is rigorous, then you
should be able to stand out the index finger on it, to localise the point of maximum impulse
and assess the extent of its thrust. It can be graded as just palpable, lifting, thrusting (stronger
than lifting) or heaving
Feel for any thrills: Palpation with your hand on different areas will detect a tapping impulse
especially over the mitral and pulmonary area.
Parasternal heave: Place the flat of your right palm parasternally over the right ventricular
area and apply sustained and gentle pressure. If right ventricular hypertrophy is present, you
will feel the heel of your hand lifted by its force.
Percussion is not necessary here.

Auscultation
1. Mitral: Ask patient to turn to left side. Auscultate first with diaphragm then with bell.
2. Tricuspid: Use diaphragm.
3. Pulmonary: Use diaphragm. Listen for any splitting of sounds on deep inspiration.
4. Aortic: Use diaphragm. Ask patient to lean forward and hold breath in deep expiration.
5. Auscultation of the base of lungs for crepitations.
Mention that you would like to complete the examination and check for hepatomegaly
Also look for signs of peripheral vascular disease:
1. Check peripheral pulses; Loss of pulses (best discriminator is an abnormality of the

posterior tibial pulse)
2. Possibly bruits
3. Coolness to touch
4. Slow capillary refill (over 2 seconds)
5. Shiny hairless skin with atrophic nails
6. Look for poor wound healing, ulcers and possibly gangrene.
68
Ask the patient to dress up.
Thank the patient and thank the examiner.
TASK: CARDIOVASCULAR EXAMINATION
Mr. Brown is a 57-year old gentleman admitted to the psychiatric ward with history of
cognitive difficulties. He is a known type 2 diabetic for five years and has had a number
of falls recently. Perform cardio vascular examination looking in particular for signs of
vascular dementia Explain to the examiners what you are looking for?
Expanded construct: The candidate is expected to perform cardio vascular examination

looking in particular for signs of vascular dementia
General examination
(Eyes, Xanthelesmas, tongue, nails, Carotids, Raised JVP)
Pulse (Rate, regularity, volume and character)

Look for features of atrial fibrillation
Blood pressure-to be mentioned,

Peripheral oedema, peripheral pulses
Inspection (Precordial examination, Apex beat, Deformity,

redness, scars and engorged veins)
Palpation- locate apex beat & mention its character,

Feel for any thrills, Parasternal heave
Auscultation (mitral, tricuspid, aortic, pulmonary areas)

Basal crepitations
FUNDOSCOPY
Suggested approach
Greet the patient and introduce yourself
Confirm if you have to address the examiner or the patient
Purpose of visit should be explained
Obtain permission before you proceed.
Explain that:
You have to look into the back of the patients eyes using this light.
You have to do it with the light in the room switched off.
The light can be uncomfortable.
69
You will have to come so close to the patient that your face may touch his. Get the patients
permission.
Ensure that the ophthalmoscope is working. Turn it on. Check the light.
Ask the patient to remove his glasses and look at an object at a distance and at eye level,
and to blink and breathe normally.
Either keep your own glasses/lenses or remove your glasses/lenses and dial up the
appropriate lens for your refractive error; lenses for myopia and + lenses for
hypermetropia.
Stand or sit on the side to be examined at 1 metre from the patient and with eyes level with
the patients. Ask the patient to stare at a fixed point in the distance.
With the right hand holding the ophthalmoscope, approach the patients right side at an
angle of about 15, nasally and inwards and at a distance of 30 cm. Ensure that you use
your right eye to examine the patients right eye and your left eye to examine the patients
left eye.
Consider your eye and the ophthalmoscope functioning as a single unit. Bring your eye
slowly towards the patients eye until you are as close as possible without touching the
eyelashes.
The back of the patients eye should be in focus.
Look systematically, start with the lens, then vitreous, followed by the disc, vessels in the
centre, in each quadrant and then the macula.
When the retina is in focus, follow a blood vessel to the optic disc. The optic disc is slightly
pink with sharp borders and a central cup. Look at the four arteries and the accompanying
veins, especially where they cross each other. Look for pallor, swelling, new vessel
formation, exudates and haemorrhages.
Locate any abnormality as though the fundus is a clock with the disc at the centre. The
diameter of the disc (1.5 mm) is used as the unit of measurement. For example, hard
exudates at 4, 6 and 9 oclock, 23 disc diameters from the disc.
Look at the macula by asking the patient to look directly at the light and using a narrow
beam.
Examine both eyes. The findings should be given in the same order as the examination. Even if
the diagnosis is obvious, first inform the findings first, and then give the diagnosis.
Thank the patient and thank the examiner.
The common slides that are usually kept in the examinations are:
1. Normal Fundus
2. Papilloedema
3. Diabetic retinopathy
4. Hypertensive retinopathy.
MANAGEMENT - DISCUSSION
NEUROLEPTIC MALIGNANT SYNDROME
A rare, life-threatening, idiosyncratic reaction to antipsychotic medication
Signs and symptoms

Symptoms: Fever, diaphoresis, rigidity, confusion, fluctuating consciousness, fluctuating
blood pressure, tachycardia
Signs: Elevated creatinine kinase, leucocytosis, and altered liver function tests.
70
Course; May last 7-10 days after stopping oral antipsychotics and up to 21 days after depot
antipsychotics (e.g. fluphenazine).
Risk factors
High potency typical antipsychotic drugs
Recent or rapid dose increase of antipsychotics
Rapid dose reduction
Abrupt withdrawal of anticholinergic drugs
Psychosis, organic brain disease, alcoholism, Parkinsons disease
Hyperthyroidism
Agitation
Dehydration.
Morbidity: Rhabdomyolysis, renal failure, aspiration pneumonia, , seizures, respiratory failure,

arrhythmias, DIC, worsening of primary psychiatric disorder (due to withdrawal of
antipsychotics).
Investigations
Blood tests include: FBC, Blood cultures, LFTs, U&Es, calcium and phosphate levels,
serum CK, ABGs, coagulation studies
a. Creatinine phosphokinase (CK) elevated

b. Arterial blood gases (looking for metabolic acidosis)
c. Coagulation screen
d. Serum iron (has been reported to be low)
EEG: Non-focal generalised slowing on electroencephalography, consistent with

encephalopathy, has been reported in over half of NMS cases
CT scan
Lumbar puncture.
Cerebrospinal fluid examinations, sepsis evaluation, brain-imaging studies are negative in NMS,
and allow for the exclusion of other causes of fever and neurological deterioration.
Management
N.B. If diagnosed in a psychiatric setting, transfer patient to acute medical services where
intensive monitoring and treatment are available
In the psychiatric unit:

a. Withdraw antipsychotics (offending drug)
b. Monitor temperature, pulse, BP.
c. Possible transfer to the medical unit if patient shows evidence of further deterioration in
his/her physical health status.
In the medical unit:

Rehydration.
Supportive measures-Oxygen, correct volume depletion and hypotension with IV fluids,
reduce the temperature using cooling blankets, antipyretics
71
Sedation with benzodiazepines which are useful in reversing catatonia, are easy to administer,
and can be tried initially in most cases.
1st line pharmacotherapy to reduce rigidity: Dantrolene sodium appears to be beneficial in
cases of NMS involving significant rigidity and hyperthermia. It has been beneficial in rapidly
reducing extreme temperature elevations in many cases.
2nd line pharmacotherapy to reduce rigidity: Trials of bromocriptine, amantadine, or
other dopamine agonists may be tried in patients with moderate symptoms of NMS. L-dopa
and carbamazepine have also been used.
3rd line-ECT, Consider ECT for treatment after other interventions have failed.
Rhabdomyolysis: vigorous hydration and alkalisation of the urine suing IV sodium
bicarbonate to prevent renal failure.
Artificial ventilation if required.
Restarting
Antipsychotic treatment will be required in most instances and antipsychotics rechallenge
is associated with acceptable risk.
Stop antipsychotics for at least 5-7 days, preferably longer.
Allow time for symptoms and signs to resolve completely.
Begin with very small dose and increase very slowly with close monitoring of temperature,
pulse and blood pressure.
CK monitoring may be useful.
Consider using an antipsychotic structurally unrelated to that associated with NMS or a drug
with low dopamine affinity (quetiapine or clozapine).
Avoid depots and high potency conventional antipsychotics for the future.
ECT may be preferred

a. If NMS symptoms are refractory to other measures
b. In patients with prominent catatonic features
c. In patients who develop a residual catatonic state or remain psychotic after NMS has resolved.
Mortality: 5-20% and death is usually due to respiratory failure, cardiovascular failure, renal
failure, myoglobinuria, arrthymias and disseminated intravascular coagulation. However with
good supportive care, prognosis is good.
Differential diagnosis:
Malignant hyperthermia
Lethal catatonia
Meningitis/encephalitis
Serotonergic syndrome
Toxicity due to other drugs (amphetamines, cocaine etc)
Septic shock
TASK: NEUROLEPTIC MALIGNANT SYNDROME- DISCUSSION
Mr. Brian White was admitted to the acute Psychiatric ward two days ago
following a first episode of acute psychosis. Brian was very agitated and required
rapid tranquillisation with IM Haloperidol. Unfortunately he has developed
Neuroleptic malignant syndrome and was subsequently transferred to medical unit for
72
treatment. His father who is angry & upset has come to the ward and demanded to see a
doctor to find out what has happened.
a. Address his concerns and allay his anxiety

b. Explain the nature of his sons condition and the prognosis.
c. Do not take history
Expanded construct: The candidate is expected to address relatives concerns and allay
his anxiety. They should be able to explain the nature of his sons condition and the
.
prognosis They should be able to;
Explain rationale for treating with Haloperidol Injection
Explain Nature and causation of NMS
Explain clinical features of NMS
Discuss Investigations & possible treatments
Discuss Implications for future management and antipsychotic rechallenge
Listening & responding appropriately to interviewee

1. Is he going to die?
2. Prognosis
Helping with Hospital Complaints procedure
TREATMENT BIPOLAR AFFECTIVE DISORDER & USE OF

LITHIUM DURING PREGNANCY
Treatment of bipolar affective disorder in pregnancy: (general useful points)
Most of the patients who become pregnant while on medication and patient with severe
illness & with high risk of relapse should be maintained on medication
Maintenance strategies should involve dosage reduction and regular review of side
effects( Kohen, 2004)
73
Discontinuation of mood stabilisers in pregnancy should take place only when
absolutely necessary and be followed by frequent monitoring( Kohen, 2004)
For women who have had a long period without relapse, the possibilities of withdrawing
treatment before conception and for at least the first trimester should be considered.
(Maudsley.2007)
Avoid valproate and combination of mood stabilizers
If Valproate or carbamazepine is prescribed; Prophylactic folic acid (5 mg daily, from at
least a month before conception) should be used.
Prophylactic Vitamin K should be given mother & neonate after delivery when Valproate
or carbamazepine is used.
Lithium:
1. 1 in 10 chance of having a malformation if lithium is continued through first trimester.

2. The UK National Teratology Information Service have concluded that lithium increases
the risk of all types of malformation of approximately three-fold and with a weighting
towards cardiac malformations of around eight-fold (Williams & Oke, 2000)
3. Ebsteins anomaly-Relative risk compared to general population-10-20times higher, but
the absolute risk is low at 1:1000. (Absolute spontaneous risk of Ebsteins is 1 in 20,000.
Cohen et al., JAMA 1994;271:146-150)
4. Maximum risk is at 2-6 weeks after conception when many pregnancies are still
undiscovered.
5. Foetal toxicity-Hypotonia, lethargy, poor reflexes, respiratory difficulties & Cardiac
arrhythmias. ( Note- these are reversible and do not cause later complication)
6. Important- Risk to mother and child of lithium withdrawal might have been
underestimated and risk to foetus of lithium exposure might have been overestimated.
7. Risk of relapse-up to 70% within 6 months, faster the discontinuation- higher the risk of
relapse.
8. The risk of relapse on discontinuation during pregnancy is same for pregnant and non-
pregnant women. But among women with bipolar disorder who elect to discontinue
lithium therapy in the puerperium, the estimated risk of relapse is threefold higher than for
nonpregnant, nonpuerperal women.
Lithium during breast feeding
1. Lithium is contraindicated during breast-feeding ( Kohen ,2005) .However, the use of

lithium during breast feeding varies between absolute contraindication to mother's
informed choice (Maudsley Guidelines, 2007).Lithium serum concentration and CBC
should be monitored for infants exposed to lithium.
2. 40- 50% of maternal serum level is excreted in breast milk.
3. Infant serum level can rise up to 200% of maternal serum concentration (range 5%-
200%)
4. Serum level in lithium can be raised due to diminished renal clearance in neonates
5. Toxicity has been reported -cyanosis, lethargy, Hypotonia, heart murmur ( these
symptoms resolved after stopping the breast feeding)
Risk to the mother:
Risk of non compliance as she might stop it if she wants to get pregnant
Risk of possible relapse during pregnancy if the treatment is stopped.
74
Risk of puerperal psychosis / post natal mental illness following childbirth. The risk of
relapse following delivery is significantly more especially in the first month postpartum
Risk of harm to self (poor self care, self neglect, self harming behaviour and lack of
obstetric care)
Stress involved during pregnancy, labour and upbringing that could precipitate relapse.
Risks to the new born: -
Risks involved during pregnancy due to the effects of medication (i.e.) abortion,
congenital abnormalities, teratogenic effects like Ebsteins anomaly.
Risk of harm to baby following childbirth ranging from child neglect to infanticide if
mother relapses.
Risks of child inheriting the disorder from the mother (The chances of getting the illness
to first degree relatives is 10%)
The mental health of the mother may influence foetal well being, obstetric outcome and
child development (may affect the Cognitive and emotional development of the infant)
It is important to explain the risks involved to the patient and her partner having
obtained consent from the patient. It is also important to get patients informed consent
before any further steps are actually taken.
It is generally favourable to withdraw lithium treatment during pregnancy and consider

alternative treatments if necessary. Help and support patient during decision making
process but allow the patient to make the ultimate decision
What are the alternate options if the mother wants to get pregnant but would like to
continue lithium?
Management Plan: -Explain to the patient that No mood stabilizer is clearly safe
during pregnancy and breast-feeding.
For women who have had a long period without relapse, the possibility of with drawing
treatment pre conception and for at least the first trimester should be considered
Slow discontinuation of lithium before conception is the preferred course of action.
Lithium should be stopped by gradual reduction of the dosage, with close monitoring of
the mental state, review her periodically in the outpatient clinic and involve the CPN to
monitor for signs of relapse and offer her more support in the community.
First trimester no medication as a golden rule due to risk of teratogenicity which is
high during this period. Period of maximum risk is 2-6 weeks post conception
Involve the partner and family in her care and try to minimize the psychosocial stressors
and monitor for early signs of relapse.
If necessary, treat her with conventional typical antipsychotics such as
Haloperidol/chlorpromazine (Literature studies suggests lower risk) for a short
period of time.
Women prescribed lithium should undergo level 2 ultrasound of the fetus and foetal
echocardiography should be performed at 6 and 18 weeks gestation to screen for
Ebsteins anomaly
During the second or third trimester, if discontinuation is unsuccessful-restart and
continue lithium treatment. Consider reintroducing lithium at a lower dose-by second
trimester (organogenesis would have already taken place and therefore the risk is low)
75
In the 3rd trimester, the use of lithium may be problematic because of changing
pharmacokinetics; an increasing dose of lithium is required to maintain the lithium level
during pregnancy (especially in the third trimester) as total body water increased, but the
requirements return abruptly to pre pregnancy levels immediately after delivery.
Monitor serum lithium levels on a weekly basis and use smaller divided doses in the last
month. Proximal to the date of confinement either discontinue lithium 2-3 days before
delivery or decrease the dose by one half or one quarter. This would help against
potential toxicity to the mother as she may get dehydrated during labour and also
safeguards against neonatal withdrawal effects.
After Delivery
Discuss with the obstetrician, midwives about her management plan and work in close
liaison..
Nursing staff to monitor her behaviour, biological functions, and mood and general
mental state. Provide nursing support from the psychiatric team if necessary.
Avoid breast-feeding and change to bottle-feeding (more rest for the mother and less
stressful). I would advise not to breast feed because of the risk of lithium toxicity in
the infant with immature kidneys, which may not be able to excrete the lithium.
Provide support, reassurance to the mother, partner & family.
If admission is necessary, then transfer her to mother & baby unit.
Lithium treatment programme (Adapted from Kohen,2004)
1. In women on maintenance treatment, serum lithium level should be monitored every 4

weeks through out the pregnancy
2. Lithium dosage should be adjusted to match the lower end of the therapeutic range
3. Lithium should not be discontinued abruptly; prior to delivery the dosage should be
gradually tapered to 60-70% of the original maintenance level
4. Lower doses and frequent blood monitoring should be norm in pregnant women starting
lithium in the first trimester of pregnancy
5. Lithium commenced in second and third trimester of pregnancy or perinatal period can
help reduce the risk of puerperal psychosis
6. No decision is risk free
7. guidelines should vary with the severity of the illness
8. Should undergo level 2 ultrasound and echocardiography of the foetus at 6 & 18 weeks
gestation to screen Ebstein's anomaly.(Maudsley.2007)
9. Increased dose of lithium is required during 3rd trimester as total body water increases,
but the requirement returns abruptly to pre-pregnancy level immediately after delivery .
What are the alternate options if the mother would like to get pregnant but doesnt want
to take lithium?
Again explain to the patient that No mood stabilizer is clearly safe during pregnancy
and breast-feeding.
For women who have had a long period without relapse, the possibility of with drawing
treatment pre conception should be considered
Slow discontinuation of lithium is the preferred course of action. Lithium should be
stopped by gradual reduction of the dosage, with close monitoring of the mental state,
76
review her periodically in the outpatient clinic and involve the CPN to monitor for signs
of relapse and offer her more support in the community.
Involve the partner and family in her care and try to minimize the psychosocial stressors
and monitor for early signs of relapse.
First trimester no medication as a golden rule due to risk of teratogenicity which is
high during this period. Period of maximum risk is 2-6 weeks post conception
Where continued use is deemed essential (e.g.) serious suicidal risk (or) manic episode)
then low dose monotherapy is strongly recommended as the teratogenic effects are
probably dose related.
Use either carbamazepine or sodium valproate, preferably carbamazepine (0.5-1%) as
the risk of neural tube defect is higher for valproate (2-3%)
All patients should take folic acid (5mg/daily) for at least a month before conception,
this may reduce the risk of neonatal neural tube defects, craniofacial defects and use of
carbamazepine in the 3rd trimester may necessitate the need for maternal vitamin K.
Ensure & liaise with GP, health visitor, and obstetrician and keep them informed of the
progress and your further management plan.
Review the patient periodically to assess her mental state, medication and psychosocial
functioning.
After Delivery
Work in close liaison with obstetrician, paediatrician, and midwives and discuss her
management after delivery.
Nursing staff to monitor her behaviour, biological functions, and mood and general
mental state. Provide nursing support from the psychiatric team if necessary.
Continue the current medication used before labour (Carbamazepine/valproate).
Preferably avoid breast feeding and change to bottle feeding as carbamazepine is

excreted in breast milk and may induce seizure like activity, drowsiness, irritability,
high pitched crying, poor feeding and hyper excitability in few infants. However, if
mother prefers to breastfeed, it should not be discouraged.
Provide support, reassurance to the mother, partner & family.
If patient shows any signs of relapse and admission becomes necessary, then transfer her
to mother & baby unit.
TASK: USE OF LITHIUM DURING PREGNANCY- DISCUSSION (PAIRED STATION)
Mrs. Brown suffered from another episode of mania and was treated on Lithium
carbonate 600 mg. Mrs. Maria Brown is attending your clinic every 3 months for
management of her bipolar illness. She is in stable remission for last 1 year on Lithium
carbonate 600 mg.
77
She is married for last 5 years and wants to start a family. She is currently taking oral
contraceptive and wants advice regarding her plans to get pregnant. Address her concerns
Do not take history.
Expanded construct: The candidate is expected to discuss pros and cons of taking or
stopping lithium during pregnancy and following childbirth. They should also discuss the
best way of managing the situation. They should discuss the following points;
Risk to mother- pregnancy

1. Risk of relapse during pregnancy if Lithium stopped (high)
2. Stress involved during pregnancy & Labour- precipitate relapse
Risk to mother- after childbirth

3. Risk of relapse after childbirth
4. Poor self-care, lack of obstetric care
Risk to baby
5. Congenital anomalies, abortions, Ebsteins anomaly
6. Child neglect to infanticide, if mother relapses
Risk to baby
7. Risk of child inheriting the disorder
8. Maternal mental health to influence Cognitive and emotional well being of baby
Breast-feeding not indicated

(Could add more stressadvice bottle feeds)
Discuss further management options

(Taper and stop lithium before stopping Contraception, close monitoring essential,
Remain lithium free during pregnancy but should be on conventional
antipsychotics
Restart as soon as she could take oral medication after delivery to avoid relapse,
advice bottle feeding, increased support for mother)
TREATMENT RESISTANT SCHIZOPHRENIA

The possible causes of treatment resistance includes
Misdiagnosis
Non compliance
Co morbid substance misuse
Co-morbid Affective illness
78
On going psychosocial stressors
Possible Secondary gain from being in the hospital
High Expressed emotion (EE) in the family
To rule out any organic causes e.g. temporal lobe epilepsy
The aim of assessment would be to explore (or) investigate either of the causes that are
mentioned above, confirm the diagnosis, confirm resistance and to treat it as treatment
resistance.
Review his/her history; do a mental state examination and a physical examination.
Id obtain more information from the GP, family members/carers, and nursing team, refer
to old discharge summaries & psychiatric reports, and obtain more information from
all other professionals involved in his care.
In the history, Id specifically look for recent stressful live events, past history of mental
illness, treatment effects, family history of mental illness/ epilepsy, medical illnesses,
current medications, drug or alcohol abuse, social difficulties, lack of social support, look
out for evidence of high EE and also for the possibility of any secondary gain from being
in hospital
Id discuss with the nursing staff that monitor his behaviour, biological functions and
compliance with medications. (for inpatients)
Id repeat his investigation including LFTs & TFTs and if there are positive findings that
suggest possible organic cause, then I would do CT Scan/ EEG (temporal lobe epilepsy,
head injury, drug induced psychosis) and urine drug screen should be considered.
Check the patients medication card, and check whether the antipsychotic medication
has been tried on adequate dosage (maximum BNF limits) for adequate duration (6-8
weeks).
When I check the medications, I will check for the dose and check whether the patient is
really taking the drug, duration of treatment with the drug.
If poor compliance related to poor tolerability, discuss with the patient and change the
drug to some other acceptable drug.
If poor compliance is related to other factors e.g. Lack of insight
Then Consider A. Depot medication B. Compliance therapy C. Compliance aids (e.g.)
medidose system.
Medical treatment: If the patients tolerate the medications and full adherences to medication
confirmed then switch to Clozapineas other treatments are ineffective.
Clozapine treatment:
Perform baseline blood tests including WCC and differential count, baseline ECG before
starting clozapine.
Register with the relevant monitoring service
Further blood testing continues weekly for the first 18 weeks and then every 2 weeks for
the remainder of the year (52 weeks) and after that blood monitoring is done monthly.
Additional monitoring requirements: weight, lipid profile, HbA1-c and LFTs once in six
months.
Start at low dose of 12.5 mg/day
Average dose in UK is around 450 mg/day
Response usually seen in the range of 150-900 mg/day
79
Most studies indicate that threshold for response is in the range of 350-420 microgms/L
Possible common side effects: Sedation, hyper salivation, constipation, tachycardia,
fever, weight gain, fluctuations in blood pressure
Serious side effects: Seizures, neutropenia/Agranulocytosis, myocarditis especially in the
first 18 weeks
It is important to bear in mind that it may take 3-6 months or even 1 year before
maximum benefit could be achieved.
Optimising clozapine treatment where 3-6months of clozapine has provided
unsatisfactory benefit-Augmentation strategies.
Augmentation strategies would include;
1. Add Risperidone (2mgs/day)- Increases Clozapine plasma levels. May also have additive
antipsychotic effects
2. Add Sulpiride (400 mg/day)- May be useful in partial or non responders.
3. Add Amisulpiride (400-800 mg/day)
4. Add Haloperidol (2mg/day)
5. Add Lamotrigine (25-300 mg/day)- May be useful in partial or non responders.
6. Add Omega-3-triglycerides (2-3g EPA daily)
Psychosocial interventions-
A) Psycho education to the patient and the family
B) Compliance therapy
(C) Family Therapy It focuses on basic education about the illness and its management,
strategies to decrease tension and stress within the family, and maintain reasonable expectations.
It is also helpful to address issues such as high expressed emotions within the family and prevent
further relapse and hospitalisation.
(D) Cognitive Behavioural Therapy for treatment resistant delusions and hallucinations. It
involves Modifying dysfunctional schemas, modifying beliefs about delusions, reality testing
and presentation of plausible alternate explanations. It involves modifying beliefs about
hallucinations by testing out feared consequences and improving coping strategies using
behavioral techniques (eg) activity scheduling.
CBT decreases the severity of positive symptoms and relapse/ readmission.(London- East Anglia
Trial)
Also worth mentioning MDT involvement, medical and CPN input
Social
OT assessment to determine the level of functioning and can help us for his
rehabilitation work and aim for independent living
Assessment of the current social situation, Provide more support to the patient and the
family E.g. Housing and aim for rehabilitation gently to the community.
Support groups and voluntary organizations such as MIND, National Schizophrenia
Fellowship may also be helpful.
80
Note:
For patients to be commenced on Clozapine, it would be ideal to admit them to the
hospital rather than doing it in the community.
They should be encouraged to get admitted as an informal patient.
If patient refuses informal admission, they should be detained in the hospital for further
treatment, as the risks of not treating psychotic illness is high.
For co-morbid drug and alcohol misuse, it should be treated first. Alcohol can interact
with medications and influences the effect of psychotropic drugs.
The treating clinical multidisciplinary team led by a consultant psychiatrist is responsible
for the care of the patient
CHRONIC SCHIZOPHRENIA-DISCUSSION & MANAGEMENT
Task: (PART-A) You are the psychiatrist working for the Assertive Outreach Team. You
have to talk to a nurse in your team about Mr. Mark Potter, who is a 29 year old
gentleman diagnosed with Schizophrenia and has been currently treated in the
community. You are going to talk to his father in the next station. He is waiting to speak
to you regarding his son, as he is very concerned about a telephone call from his son at
the weekend.
Expanded construct: The candidate is expected to;
Obtain history, circumstances leading to current presentation,

Patients mental state and current symptamatology, insight
Psychiatric history- details of treatments received including hospitalisations,

detentions etc
Details of Medications (past and present)
Community support and monitoring
Risk assessment
(Self-harm, violence, self-neglect, non-compliance, drug and alcohol misuse)
Exploring reasons for treatment resistance

(Co-morbidity, drug & alcohol misuse, ongoing psychosocial stressors, non
compliance, high EE etc)
LINKED STATION: (PART-B)

Discuss the management of this patient with his father who is dissatisfied with the care
provided and address his concerns.
81
Expanded construct: The candidate is expected to discuss the management of this
patient with his father who is dissatisfied with the care provided and address his
concerns. They should be able to cover the following areas during discussion;
Address concerns;
1. Injection- why not working & why discharged prematurely last time
2. Clozapine- why not tried before
Addressing concerns;
1. Where and how to treat- management
2. Management of alcohol misuse
3. Interaction of Alcohol with Clozapine regimen
Explain possible diagnosis Treatment resistant psychosis and possible factors
Discussion about use of mental health act and community treatment order
(when, how and why if it would become necessary)
TREATMENT RESISTANT DEPRESSION

Management
82
Try to obtain a detailed comprehensive history, perform mental state examination,
physical examination, arrange for relevant laboratory investigation to rule out any
medical health problems such as hypothyroidism, multiple sclerosis etc.
In the history, it is important to identify any ongoing psychosocial stressors, co morbid

psychiatric conditions such as anxiety, grief reaction, PTSD, Psychosis, drug & alcohol
abuse, possibly could be due to her prescribed medications, (Cardiac drugs or
corticosteroids), lack of social support, premorbid personality.
I would follow the Treatment algorithm for depression as outlined below. As there is
poor response with the current drug, I would discuss with the patient and start her on a
new antidepressant
Titrate the new antidepressant to recognized therapeutic dose and assess the efficacy
over 4-6 weeks. Increase dose and assess over a further 2 weeks.
If no desired response achieved, give an antidepressant from a different class. Titrate to
the therapeutic dose assess over 4-6 weeks. Increase dose as necessary.
If no effect, consider treatment of refractory depression. Augmentation of
antidepressants with Lithium, Tri-iodothyronine, high dose venlafaxine, L-Tryptophan,
Combination of SSRI with mirtazapine.
Also Try psychosocial interventions like CBT, family therapy, individual / group
psychotherapy.
If no response, obtain a second opinion and ECT treatment (8-10 treatments) should be
tried, if all other measures fail (after obtaining informed consent)
Consider combination of multiple drugs and review diagnosis.
TASK: TREATMENT RESISTANT DEPRESSION
You have been asked to see Mr. Jeremy Smith, who gives a history of 3 episodes of
depression in the past, which remitted with Fluoxetine 20 mg. About six months ago, he
started to experience symptoms of a relapse consisting of low mood and energy,
anhedonia, poor concentration and appetite. He is constipated and has gained weight. He
complains of sleeping more and has negative self-perceptions.
The GP saw him and fluoxetine 20mg was reinstated. However after 6 weeks, the
symptoms had not improved and the dose was increased to 40 mg. After 6 weeks on this
dose there was no response and the patient was switched to venlafaxine 150 mg.
Although there has been some improvement in mood, other symptoms remain. The
diagnosis is confirmed.
a. Given the patients circumstances, explain the management options.
b. Discuss other relevant investigations you many need in order to make a final choice
83
The core task at this station is to discuss the management options of refractory depression
including further investigations, drug treatment and psychological treatments. They
should;
Cover standard treatment approaches to refractory depression-

2 antidepressants (different classes) for adequate dose and duration
Emphasise that the best approach is to combine Pharmacological

And Psychological therapies
Discuss specific treatment strategies with confidence

1. Alternative treatments
2. Combined drug therapies
Discussing the most appropriate treatment strategy for the patient

And not deliver a list of every possible treatment strategy
ECT- should not be the highest priority and should be tried only when all other
measures fail
Check on physical health, past and family medical history- particularly

hypothyroidism, hypertension, epilepsy and coronary heart disease
H/o substance misuse
Consider further investigations like thyroid function tests, ECG etc

Emphasise need for more physical examination- BP, Pulse etc
OBSESSIVE COMPULSIVE DISORDER
84
Treatment of OCD in adults ( adapted from NICE 2006)
Treat any co. morbidity such as depression (50-70%) and anxiety.

Medication: - SSRIS Fluoxetine, Paroxetine, Sertraline and Fluvoxamine are ffective
in reducing obsessional symptoms on higher dosages (Nearly 50-60% response rate)
Fluoxetine (20 60 mg); this mainly targets the obsessional symptoms. Paroxetine (20-
60 mg); Anxiolytic profile and anti Obsessional effect
50% of the treated patients improve substantially and attempts have been made to
increase the response rate by adding a second drug to the SSRI (augmentation)
Relapse is common and high in the few weeks after an SSRI has been stopped
Anxiolytic drug: - Benzodiazepines and Anxiolytic drugs can give short term
symptomatic relief and should not prescribed for more than 3 weeks but for longer
treatment.
Augmentation with small doses of an antipsychotic may be tried
85
Other drugs of use may include Clomipramine, Buspirone and Clonazepam.
Non-Drug treatments
Counselling and psycho education of the patient and the family - This involves explanation of
the symptoms and providing reassurance that these symptoms are not an early sign of insanity.
Also counsel relatives and spouse as often they may involve other family members in their rituals,
and encourage them to adopt a firm but sympathetic attitude to the patient. Involve the family and
educate about the illness, provide emotional support and encouragement
CBT- Cognitive behavioural Therapy: -

The Cognitive component of CBT involves identify and modify maladaptive cognitions and
seeks to reduce to suppress and avoid Obsessional thoughts.
The Behavioural component involves Behavioural techniques such as exposure and response
prevention which would be exposing the individual to those situations that triggers anxiety (or)
discomfort and refrain the individual voluntarily from performing his (or) her ritual.
The therapist works with the patient and helps the individual plan a graded programme of
exposure tasks. These anxiety provoking situations are then arranged in order according to those
that generate the most anxiety (or) discomfort (hierarchy of tasks) the patient is also provided
training for relaxation and taught one step to the next until the person can mange the last step with
minimal anxiety without getting anxious.
The situation can be real (or) imagined (a real life situation will be more effective), usually done
in graded steps and can be practiced regularly with self-exposure tasks.
Combined drug and psychological treatments may be the most effective option.
1. TASK: OBSESSIVE COMPULSIVE DISORDER ASSESS SYMPTOMS
Miss. Michelle Wright is a 30-year-old woman who has been referred by her GP
for excessive hand washing. Take appropriate history to arrive at a diagnosis.

diagnosis of obsessive-compulsive disorder and rule out co-morbidity. They should elicit
the following;
History- obsessional symptoms (mode of onset, duration and progression)

And the anxiety Symptoms associated.
Nature and quality of obsessions

(Thoughts, ideas, images, ruminations, doubts)
Phenomenology of obsessions-own thought,

Unpleasurable, repetitive, resistance & response
Elicitation of compulsive behaviours and associated rituals

Other behaviours-washing, checking, Counting etc
86
Impact on quality of life

(Social, occupational and family)
Co-morbidity
(Mood Symptoms, anxiety symptoms, alcohol abuse etc)
2. TASK: OBSESSIVE COMPULSIVE DISORDER FAILED PSYCHOLOGY
Mrs. Sally Hutchinson has been diagnosed with Obsessive Compulsive Disorder. She has
attended a day hospital and has had a 12-week programme of psychological treatment.
Her symptoms have not improved and now drug treatment with Fluoxetine (Prozac) is
being proposed. She wants more information about the drug treatment for her symptoms.
You are now seeing her in the day hospital for a review. Speak to her to address her
concerns.
Expanded construct: The candidate is expected to discuss about the role of

antidepressants in OCD treatments and address his concerns
Mechanism of action of SSRIs
Side effects (CNS, GIT and sexual side effects)
Efficacy (60%)
Duration of treatments (Long term treatment indicated)
Address concerns- Addictive potential
Concerns- Aggression/suicidal thoughts
Risk of relapse on stopping medication- high
Alternative medication (if drug doesnt work)
Inpatient treatment- ? Not needed

Staying at work
POST TRAUMATIC STRESS DISORDER
ELICITING PTSD HISTORY
87
Explore the following:
1. Details of the traumatic incident itself

2. Look for core features of post-traumatic stress disorder (PTSD) that includes hyperarousal,
intrusions and avoidance
3. Assess the mode of onset, duration, progression of current symptoms and impairment in
different areas of functioning (Social and occupational functioning)
4. Rule out co-morbidity.
PTSD- It may begin very soon after the stressful event or after an interval usually of days but
occasionally of months, though rarely more than 6 months.
Principal symptoms
Hyperarousal
1. Persistent anxiety and Irritability or outbursts of anger

2. Insomnia
3. Poor concentration and exaggerated startle response
Intrusions
1. Intensive intrusive imagery (flashbacks)

2. Vivid memories
3. Recurrent distressing dreams and nightmares
Avoidance
1. Actual or preferred avoidance of circumstances resembling or associated with the stressor

2. Emotional detachment and inability to feel emotions
3. Diminished interest in activities.
Others
Inability to recall either partially or completely, some important aspects associated with the
stressful event.
A. Traumatic incident
Explore the details of the accident, in particular the perceived severity and establish the level of
distress and fear at the time of the event.
Could you describe the accident please? (Here approach the patient empathetically as it is
difficult to talk about traumatic incidents, and acknowledge the patients distress.)
Find out about when it happened, how (terrifying) it was?
Ask about any injuries in particular head injury, loss of consciousness, whether any other
person was injured etc.
Inquire about any blame, litigation, court cases and their outcome.
88
B. Core features of PTSD
Intrusions
How often do you think about the accident?
Do you sometimes feel as if the accident is happening again?
Do you get flashbacks?
Have you revisited the scene?
Do you get any distressing dreams/nightmares of the event?
What would happen if you hear about an accident?
Do you have any difficulties remembering parts of the accident?
Hyper arousal
Have you had the feeling that you are always on the edge?
Do you tend to worry a lot about things going wrong? (Feeling anxious)
Do you startle easily? (Enhanced startle response)
Tell me about your sleep please. (Explore for sleep disturbance)
Are you sometimes afraid to go to sleep?
How has your concentration been recently?
How has your memory been lately?
Do you loose your temper more often that you used to? (Irritability)
Avoidance
How hard is it for you to talk about the accident?
Do you deliberately try to avoid thinking about accidents?
Have you been to the place where the accident happened?
Do you make any effort to avoid the thoughts or conversations associated with the trauma?
How would you do that?
Do you make any effort to avoid activities, places or people that arouse recollection of the
trauma?
Emotional detachment and numbness

How do you feel in yourself generally?
Have there been any changes in your feelings generally? (Emotional detachment).
C. Assess the duration, progress, severity, frequency of current symptom and impairment of
normal functioning
I would like to know how your problems have been affecting you, your family and social life
(Open question)
How do you feel in yourself generally?
How has all this been affecting you?
How do you spend your time these days?
Enquire about effect on family, social life and work
4. Rule out Co-morbidity

a. Mood symptoms, especially depression
b. Other anxiety symptoms
c. Current coping mechanisms including drugs and alcohol
89
Explore premorbid personality, past history
Before all this happened, what sort of a person were you?

How did you cope with stress?
Have you had any mental health problems before the accident?
TASK: POST TRAUMATIC STRESS DISORDER- HISTORY TAKING
You are seeing Miss. Jane Howard, a 31-year-old woman who has returned from
Afghanistan, where he was working with British Army very closely. He was arrested last
night after he was agitated and hiding behind Land Rover. He was drunk at that time. He
was crying continuously in the police cell throughout the night. Take a history & assess
mental state to arrive a diagnosis. Also rule out co-morbidity.
Expanded construct: The candidate is expected to
Obtain details of the traumatic accident- nature and extent of the problem,
severity of symptoms and impairment on current functioning
Hyper arousal Symptoms (Persistent Anxiety, irritability,

Poor concentration, insomnia, enhanced startled response etc)
Intrusions (flashbacks, nightmares, Recurrent distressing Day dreams)
Avoidance of reminders of the events

(Place, person and activities), emotional detachment, numbness
Rule out co-morbidity, coping strategies

(Depression, anxiety, substance misuse etc)
MANAGEMENT OF PTSD
Trauma-focused CBT (psychological treatment) should be offered to those with severe
posttraumatic symptoms lasting 1 month or longer after a traumatic event. It can prevent the
emergence of chronic PTSD in individuals with post-traumatic symptoms, and it should be
provided on an individual outpatient basis. The treatment should be regular and continuous,
usually at least once a week, and the same person should deliver it. The duration of trauma-
focused CBT should normally be 8 to 12 sessions but if initiated earlier within the first month,
fewer sessions may be sufficient (NICE, 2005)
90
Pharmacological treatment
Drug treatment should not be considered as a routine first line treatment.

Selective serotonin reuptake inhibitorsparoxetine hydrochloride, sertraline hydrochloride,
fluoxetine hydrochloride
Tricyclic antidepressentsamitriptyline, imipramine
Venlafaxine mirtazapine
Phenelzine sulphate, lamotrigine
Higher doses of SSRIs are generally not recommended but individual patients may benefit from
higher doses. In the acute phase of PTSD for the management of sleep disturbance
use a hypnotic medication for short-term use but, if longer-term drug treatment is required,
consideration should be given to the use of suitable antidepressants.
Treatment periods of up to 12 weeks are needed to assess efficacy.
Psychological treatment
Trauma-focused individual cognitive behavioural therapy

The therapist aims to explain the traumatic event from the patients perspective providing
information about the normal response to severe stress.
This involves:
Recall of images of the traumatic events and exposure to situations that are being avoided
Self-monitoring of symptoms
Cognitive restructuring through the discussion of evidence for and against the patients belief
systems
Interpretation of the event and attributions following the event
Anger management for those who feel angry about the traumatic events and their causes
Anxiety management and relaxation training.
Other psychological interventions

Eye movement and desensitization reprocessing (EMDR)
Supportive therapy/non-directive therapy
Hypnotherapy
Psychodynamic therapy.
Eye movement desensitization and reprocessing:

This is one of the new interventions used for the treatment of PTSD.
The therapist waves his or her fingers back and forth in front of the patients eyes, and the patient
is asked to track theses movements while focusing on a traumatic event. The act of tracking while
concentrating seems to allow a different level of processing to occur. The patient is able to review
the event more calmly or more completely than before.
It also involves a cognitive behavioural component, where the negative belief about themselves
that resulted from the trauma is explored and the patient rates their level of emotions and the
extent to which they believe this new belief.
Longer-term treatment
Continue drug treatment for a further 12 months in patients who are responding at 12 weeks
91
Monitor the efficacy and tolerability regularly during long-term treatmentthe best evidence
is for SSRIs.
Treatment of PTSD:
NICE guidelines for PTSD - summary
Encourages primary care diagnosis and screening it is probably

underdiagnosed.
Up to 30% of people exposed to trauma may develop PTSD.
PTSD can also develop in children.
Watchful waiting if symptoms are mild and present for less than 4 weeks after
trauma.
Trauma-focussed CBT - individual basis as outpatients to be offered to all with
severe symptoms present for less than 3 months
If present for more than 3 months (chronic) offer trauma focussed CBT or
EMDR.
If no improvement consider pharmacological treatment.
Paroxetine, mirtazapine for general use; amitriptyline or phenelzine for
specialist use.
92
OLD AGE PSYCHIATRY
DEMENTIA OBTAINING COLLATERAL HISTORY
In the exam, you may be asked to take collateral history about dementia in general or about
specific types such as vascular dementia, Lewy body dementia and Fronto temporal dementia.
However, the format would remain almost the same and the areas to be covered are outlined
below;
The important areas to be covered are:

Mode of onset, duration and progression of the symptoms
Ask in detail about cognitive, behavioural, psychological, physical and biological
symptoms
Risk assessment
Past medical history
Past psychiatric history
Relevant personal history
Relevant family history.
Remember 5As
Amnesia-Impaired ability to learn new information and to recall previously
learned information
Aphasia-Problems with language (receptive and expressive)
Agnosia-Failure of recognition, especially people
Apraxia-Inability to carry out purposeful movements even though there is no
sensory or motor impairment
Associated disturbance-behavioural changes, delusions, hallucinations
Introduce yourself to the patients relative and address the main concerns
a. Please describe for me the problems your husband has been having? (Open question)
b. Can you give me examples of his forgetfulness?
c. Anything else you are concerned about?
Onset and progression
a. When did the symptoms start?
b. What symptoms were noticed first?
c. Did it start gradually or suddenly?
d. Has it progressed gradually or suddenly?
e. Are there any fluctuations?
Cognitive symptoms
Inquire about symptoms in all cognitive domains such as memory, orientation, attention&
concentration, language, visuospatial abilities, naming, recognition, reading, writing, ability to
perform daily activities, problem solving and judgement etc.
Memory (Make sure that you enquire about both short term and long term loss, if present)
93
Short-term memory:
Can he remember things that happened in the last few minutes or in the day?
Can you give me some examples?
Like Forgetting peoples names,
Like Forgetting appointments or important dates
Like Forgetting conversations they have had with people
Like Forgetting where they have put things (misplacement of personal and household
items)
Repeating oneself, asking the same question more than once
Forgetting to take medication or taking it twice etc
Long-term memory
Can he remember events that happened a few years ago?

Can you please give me some examples?
Does prompting or recognition help?
Is it consistent or patchy?
Attention & concentration: Ask about difficulties with attention and concentration
Temporal and Spatial disorientation

Does he know the time of the day, the day of the week, date of the month etc?
How often does he lose his way at home or in the neighbourhood?
What about getting lost on what are familiar routes?
Visuospatial difficulties, Agnosia

Does he have difficulty recognising things, places or people?
Does he have difficulty in recognising familiar faces?
Nominal dysphasia: Ask about difficulties with remembering names of people etc.
Language difficulties
How about the way he speaks?
Does he have any word-finding problems?
Can he understand when someone speaks to him?
Dyslexia, dysgraphia
What about reading and writing?
Dyspraxia
The memory problems that you describe, do they affect his ability to look after himself, or to
do the things he used to?
Does he have difficulty doing things for himself like maintaining personal hygiene, washing,
cooking, laundry etc? (Activities of daily living)
Has he got difficulty in cooking a meal or organising bills to be paid? (Activities of daily
living)
94
Is he able to handle money?
Can he do his own shopping?
Judgement, decision making

What about planning, making decisions etc?
Has he got difficulty in solving everyday problems that he used to solve?
2. Behavioural symptoms
Has there been any change in his behaviour like being more irritable than usual?
Have you noticed any change in personality that seems to have occurred recently?
Ask about becoming aggressive frequently, episodes of violent and anger outbursts
Also enquire about behaving inappropriately, socially withdrawn, wandering at nighttime,
disinhibited behaviour, repetitive behaviours etc.
3. Psychological symptoms
Inquire about symptoms of depression (low mood, crying spells) and anxiety
Also enquire about paranoia, auditory and visual hallucinations and other psychotic symptoms.
4. Physical symptoms
Ask briefly about:
Sensory impairment
Weakness of limbs
Gait disturbance
Parkinsons disease any abnormal movements
Incontinence.
5. Biological symptoms
Inquire about:
Sleep disturbance and symptoms getting worse at night
Appetite disturbance
Loss of weight.
Risk assessment
Self neglect
Self harm
Inappropriate use of medication
Falls
Wandering
Fire risk safety in the home, can use cooker safely, smoking etc.
Management of finances
Risk of driving.
Other relevant factors in the patients history

Current medication
Past medical history
a. High blood pressure
b. Diabetes
c. Thyroid disorders
d. Infections
95
e. Stroke
Past psychiatric history: particularly depression
Family history of dementia
Risk factors for dementia
a. Alcohol
b. Head injury
Personal history
a. Education
b. Occupation
c. Living situation
Note: The diagnostic criteria for all the common dementias are given below;
Dementia in Alzheimers disease (diagnostic criteria)

Global deterioration in intellectual capacity and disturbance in higher cortical
functions like memory, thinking, orientation, comprehension, calculation, language,
learning abilities and judgement, an appreciable decline in intellectual functioning
and some interference with personal activities of daily living.
Insidious onset with slow deterioration
Absence of clinical evidence or findings from special investigations suggestive of
organic brain disease or other systemic abnormalities.
Absence of sudden onset or physical/neurological signs
TASK: DEMENTIA OBTAINING COLLATERAL HISTORY
Obtain Collateral history from Mr. White whose 81-year-old wife was referred to you by
her GP as she has problems with her memory for the last 2 years.
Obtain history to identify her cognitive difficulties
Also look for evidence of functional impairment.
Expanded construct: The candidate is expected to Obtain history to identify her

cognitive difficulties and also look for evidence of functional impairment. They should
assess the following areas on history taking;
Presenting problems: Onset, duration, severity and progression
Cognitive Symptoms: Memory & confusion- Short term and long term
memory impairment with examples
Cognitive Symptoms- Orientation to time, place,

attention & concentration, Visuospatial dysfunction
Cognitive Symptoms; Language/communication difficulties, Recognition,

naming difficulties, Reading, writing etc
Functional abilities- Personal ADLs

Domestic ADLs & Community ADLs
96
Risk assessment- self-neglect, wandering, aggression, accidental self harm
etc
RISK ASSESSMENTS IN DEMENTIA

Risks are common in all types of dementia and systematic evaluation of risk may therefore be
extremely valuable.
In dementia risks will change with the progression of the disease and it should be reviewed
regularly. Relevant questions will include the following:
1. Is there a risk of harm?

2. If so what sort of harm, to whom?
3. How immediate is the risk?
4. What is the likely severity?
5. How likely is it to happen?
6. How long will it last?
7. What factors contribute to the risk?
Having determined the nature and magnitude of a risk consider the following:
1. Can the risk be reduced?

2. Should it be reduced?
3. How can these factors be modified or managed?
4. Consider the patients attitude to risk and the view or carers.
There are risks of harm occurring both to the patient and to others
Common risks include:
1. Risk of self-neglect, this may manifest as poor diet or hygiene etc. Inability or
willingness to accept help when needed for nutrition and other basic daily needs can
result in poor physical health and wellbeing.
2. Risk of falls; These are significantly more common in dementia and this occurs
particularly to people who have relatively preserved functional capability,. They are
associated with wandering, use of medication, current acute confusional state and may
necessitate the need for a greater level of supervision.
3. Risk of wandering; this is usually more distressing to carers than risk presenting to the
patient. In dementia, getting lost in unsafe areas is quite common.
4. Risk of self-harm; this is a risk which is related to psychiatric disorder such as
depression, psychosis and it needs to be considered.
5. Risk of non-compliance to medications, treatment and care plan.
6. Fire risk; this could be due to inappropriate use of electrical appliances and smoking
habits. This may be easily modifiable through removal or modification of kitchen
appliances, gas fire etc.
97
7. Risk of financial abuse; this could happen in the form of theft or fraud, modification of
wills, misuse of a patients money.
8. Risk of aggression towards the patient by carers or family. This is usually under reported
by the patient through fear or due to cognitive problems and are less easy to identify. This
should be considered if there are unexplained falls or unusual patterns of bruising.
9. Risk to others; this may be caused by agitation and aggressive behaviour, particularly in
the context of personal care. Verbal aggression is the commonest form and the longest
lasting in the course of dementia. Physical aggression is most prevalent among people
with more severe dementia.
10. Risk of driving; road traffic accident and injury risk increase with the severity of
dementia. In most countries it is mandatory for the driver to report the important health
factors to the licensing authority who will then request further information from the
patients medical team. Patients and carers should be reminded of this responsibility at
diagnosis.
11. Risk of carers strain; the dependence needs associated with dementias and the
consequent potential for emotional stress on care givers can make the person with
dementia more vulnerable to physical, emotional, financial or sexual abuse and
exploitation from those on whom he or she depends (ABA, 1997)
12. Other risks; public health risks from failure to handle refuse and household hygiene.
98
GENERAL MANAGEMENT OF DEMENTIA
Dementia screen investigations
Perform a detailed mental state examination, baseline cognitive assessment including

MMSE (Mini Mental State Examination) but if score is below 24/30, which suggests a
Dementing illness, then I shall arrange for further investigations.
Geriatric depression scale to rule out possible depressive illness.
Arrange for blood investigations including FBC, ESR, LFTs, Renal function tests, TFTs,
blood sugar, B12 & folate, urine C &S, ECG and chest X-ray
CT/MRI brain scan to be arranged if there is any significant history (or) positive finding
on physical examination and investigations, (or) if you suspect infarcts, white matter
disease (or) space occupying lesion.
Psychometric testing may be useful in comparing current functioning with the premorbid
state, useful to assess various cognitive domains like memory, language and executive
functions and assists in.
a) Clarification of diagnosis.
b) Prediction of outcome c) Identifying the need of support and intervention
d) Monitoring change
Hospital treatment either formally or informally will only be considered if there are any ongoing
imminent risks and I would prefer treating the patient in the community with the help of the
multidisciplinary team members and through setting up an appropriate care package.
Treatments:
Our aim is to offer a range of Biopsychosocial interventions involving different members of the
multidisciplinary team. A multidisciplinary team approach should be adopted. The aim should be
to maintain the elderly person at home as long as possible, provide continuing care and support to
relatives and others who care for the elderly person at home.
Anti dementia drugs (Acetyl cholinesterase inhibitors) to be considered assessment involves

administering the MMSE (Score between 10 and 20), the dose should be optimised by reviewing
in the memory clinic at 6-weekly, 3 monthly and then 1 year review. Those remaining on drug
treatment should be the after be assessed at 6 monthly intervals.
Inpatient management
Nursing levels of observation monitor his behaviour, biological functions, and
compliance with medications and provide him with more support.(If only admitted)
Also treat other co-morbid conditions such as anxiety, and depression with
antidepressants, paranoia and hallucinations with antipsychotics, behavioural symptoms
with antipsychotics, SSRIS & mood stabilizers, insomnia with hypnotics
Note: For Behavioural disturbances, first consider non-pharmacological strategies of
management before using drugs.
99
Treat any treatable physical disorders that can precipitate acute confusional state e.g.
UTI, Constipation.
Psychosocial management:
Psycho education to the patient and the family regarding the nature of the illness, course
of the illness, prognosis, treatment options and the support that could be offered by the
services.
Involve other members of the multidisciplinary team such as Clinical psychologist,
occupational therapist, community psychiatry nurse and social worker.
Psychologist to help for practical aspects of memory impairment and memory
enhancement techniques. Behavioural methods can be used to reduce problems in social
skills, eating behaviour and for continence. Memory aids such as notebook and alarm
clocks have been used to assist patient with memory disorder.
Day hospitals can offer both short term and continuing care for patients together with
support for relatives, provide them with structure and stimulation during the day time and
also includes psychological intervention such as anxiety management, reminiscence
therapy and reality orientation.
CPN to monitor mental state & cognitive functions in the community, monitor for
therapeutic effects and side-effect profile of anti dementia medications.
OT assessment can determine activities of living skills (ADL assessment) and assess
risk and safety at home. OT assessment may be helpful in advising on aids or
environmental (or) other modification that would promote independence and minimize
risks.
Social services To perform community care assessment or NEEDS assessment and
CARERS assessment. Care Package to be organized in the form of home help, meal
on wheels, day care provisions include day centers, social clubs, emergency call systems
and care-line (pendants), self help groups, voluntary organizations, (Alzheimers
society, Age concern, FISH) regular respite care to give a break to the carer and social
worker to look into her finances and advises on making a formal application for enduring
power of Attorney.
Long term placement-warden controlled flats, residential homes, nursing homes
depends on his level of functioning, psychosocial needs and nursing assessment
Support to Carers
1. Social services to perform carers assessment to increase his existing care package that
would address all needs
2. Day centre attendance
3. Regular respite to ease off the carers strain.
4. Support from CPN or community support worker
5. Attend relatives support groups
Carer Assessment
100
This involves assessment of the social circumstances that includes reviewing the care givers
ability to provide the type of care needed, current use of formal care services, quality and the
adequacy of the care givers own social and family support system. It is also important to assess
the presence of any physical or mental illness in carers, change in carers state of health and
personal resources, and other stressors in their lives.
ALZHEIMERS DEMENTIA (COUNSELLING)

In patients with dementia, there is a progressive, irreversible destruction of brain cells
that leads to memory loss, confusion, personality and behaviour changes.
Alzheimers disease is one among them and it is the commonest type of the dementias.
Everyone loses brain cells, as they get older. In people with Alzheimers disease, this
process is more severe and rapid than in normal ageing. The parts of the brain that deal
with memory are usually affected first. The onset of this illness tends to be gradual.
Loss of short-term memory is usually the first noticeable sign. Patients become
increasingly forgetful and slowly other parts of the brain are affected. In the later stages
people may develop problems with their speech or undertaking practical tasks.
It affects 5% of people over the age of 65. Both males and females are affected. Although
it mostly affects people over 65, it can also occur in young people.
Making a definite diagnosis of Alzheimers disease while the person is still alive is
difficult. Only at post-mortem can a diagnosis be confirmed. So a thorough medical and
psychiatric assessment is always essential.
In the early stages a person with dementia often appears confused and forgetful about
things that have just happened. Long-term memory tends to stay intact and for this reason
people with dementia often dwell in the past. Also, in the early stages, concentration
and decision-making become difficult and Mood changes are also frequent.
In the later stages, people with dementia need a great deal of help . Often they are unable
to recognise even close family and friends. Communication is frequently a problem:
Personal safety is also very much at risk, especially for those who smoke or cook. Even
simple things like dressing become difficult. The stress upon carers is enormous, as it
becomes difficult to leave someone alone for even a few minutes.
Unfortunately, it is a progressive condition. The illness cannot be halted or reversed
Most studies have shown people to live for 510 years after being diagnosed. However it
really is impossible to make firm predictions in individual patients.
101
Help and support can be offered in various different ways: Memory clinics are specialist
outpatient clinics set up specifically to diagnose and often treat people complaining of
memory problems. They have the ability to investigate, diagnose and treat people
suffering from memory problems with antidementia drugs and also monitor their
response to treatment periodically.
Different members of the multidisciplinary team will be involved such as Community
psychiatric nurse, social worker, occupational therapist and physiotherapist
Social services; Allocation of a care manager or social worker who will perform NEEDS
assessment for patient, CARERS Assessment for carers and organise care package. This
includes home help, meals on wheels, possible attendance to a day centre, sitting
services, respite care and residential care in the longer term.
Occupational therapist; He/ she will perform functional assessment to assess safety at
home and offer aids and adaptations. Eg to supply bath equipment, banister rails, a
wheelchair, stair lifts and special seating etc.
As dementia progresses, people become increasingly unable to manage their own affairs.
In the early stages of the disease the person with dementia may be competent enough to
appoint somebody with Power of Attorney for managing his or her affairs. A solicitor can
arrange this. However, if the persons mental capacity is too limited for a valid Power of
Attorney, it may be necessary to put his or her affairs under the jurisdiction of the Court
of Protection.
Driving: Not everyone with dementia is banned from driving but if a person has severe
degree of cognitive impairment it is dangerous for him or her to do so and it is strictly not
advisable as the rights of the individual to drive are outweighed by the risk to others.
Worth mentioning The Alzheimers disease Society, local self-help group and relatives
support groups.
102
ANTI-DEMENTIA DRUGS
Summary of NICE guidance on acetylcholinesterase inhibitors.
Acetyl cholinesterase inhibitors such as Donepezil, Rivastigmine and

Galantamine may be prescribed for those with Alzheimers disease with a
MMSE score between 10 and 20 points.
Diagnosis must be made in specialist clinic and only specialists should initiate
treatment.
Assessment of cognitive functioning and activities of daily living should be made
before starting drug treatment.
Only those likely to comply with drug treatment should be considered.
If MMSE scores indicated no deterioration or improvement and there is
evidence of global or functional improvement then treatment should continue.
Those remaining on drug treatment should be assessed at 6 monthly intervals.
.
Anti-dementia drugs starting dose Treatment dose
1. Donepezil 5 mg daily 10 mg daily
2. Rivastigmine 1.5 mg BD 6 mg BD
3. Galantamine 4 mg BD 12 mg BD
4. Memantine 5 mg daily 10 mg daily
Common side effects reported: When adverse effects occur, they are largely predictable; excess
cholinergic stimulation leads to nausea, vomiting, dizziness, insomnia and diarrhoea.
Use with caution: Acetyl cholinesterase inhibitors should be used with caution in patients with
sick sinus syndrome, or other supraventricular conduction abnormalities, those who are
susceptible to peptic ulcer disease and in asthma and chronic obstructive pulmonary disease.
Memantine
It acts as an antagonist at N-methyl-D- asparate (NMDA) receptors, an action that, in theory, may
be neuroprotective and thus disease modifying drug.
Lecture notes on anti-dementia drugs

Donepezil (Aricept), rivastigmine (Exelon), Galantamine (Reminyl) are cholinesterase inhibitors
used to treat mild to moderate cognitive impairment in Alzheimer's disease. These drugs can be
used in patients with MMSE score between 10 and 20.
They reduce the inactivation of the neurotransmitter Acetylcholine and, thus, potentiate the
cholinergic neurotransmitter, which in turn produces a modest improvement in memory and goal-
directed thought.
Donepezil is well tolerated and widely used. Rivastigmine and Galantamine appear more likely to
cause gastrointestinal (GI) and neuropsychiatric adverse effects than does Donepezil. None of
these medications prevents the progressive neuronal degeneration of the disorder.
103
Rivastigmine has been evaluated in the symptomatic treatment of patients with mild-to-moderate
dementia associated with idiopathic Parkinson's disease. Although the evidence is preliminary, it
is the best available evidence among the other options for Parkinsons related dementia.
Rivastigmine appears to improve both cognition and activities of daily living in patients with
PDD, resulting in a clinically meaningful benefit in a large number of cases.
Emre M, Aarsland D, Albanese A et al. Rivastigmine for dementia associated with Parkinson's disease. N
Engl J Med 2004;351:2509-2518.
ANTIDEMENTIA DRUGS EXPLAIN TO A CARER
Recently some new drugs have been made available for the treatment of Alzheimers
disease. These drugs are collectively called antidementia drugs. There are no major
differences between these drugs. Some of the examples include Donepezil (Aricept),
rivastigmine and Galantamine. More drugs are on the way.
It will not cure the illness completely, but it may help to stabilise the illness or improve it
for a while. It may help his memory. He can also have general benefits including
improving alertness and motivation. More often carers see general improvements in
behaviour or mood.
Efficacy: Research studies have shown that 4050% of people who have taken these
drugs have shown some improvement or stabilisation of their condition over a period of
six months.
Mechanism of action: In Alzheimers disease, one of the chemicals in the brain called
acetylcholine, which is important for learning and memory, is in short supply. So if you
have less acetylcholine activity, then you may have less memory ability and reduced
learning. The drugs act by increasing the brain levels of acetylcholine and help to
stabilise or improve memory, learning and functioning.
Initiation: First of all, the specialist will see the patient in the memory clinic. People
are often given a screening memory test called the mini mental state examination also
called as MMSE. The total score is 30, and we suggest starting these drugs when the
MMSE score lies between 10 and 20. But before that, we have to find out if the drug suits
the patient. We will take a history, including a detailed medical history to rule out severe
heart, kidney or liver problems or breathing problems and do relevant investigations
necessary to rule out any treatable causes for his memory problems. Then we will also do
a formal assessment of his daily living skills and if all goes well then we may start him on
these drugs
104
The patients are initially started on a low dose of these medications. These drugs take at
least 4 weeks to show their full effect at the starting dose. After 4 weeks, we may
increase his dose.
Initially we usually prescribe these drugs for a trial period of 3 months to see, if at the
end of 3 months, your father has shown any benefits from this drug. If not we may take
him off the drug
If he/she does show improvement, he will be on it for a long period of time, as long as it
is benefitting him. Then we will need to review him approximately every 6 months to see
if it is worthwhile continuing the treatment.
The mini mental state examination also called as MMSE is repeated once every six
months and we suggest stopping these drugs when the MMSE score goes below 10 out of
30
However, in some patients, if we stop the drug they may deteriorate rapidly and we may
have to consider reintroducing it.
Adverse effects: All medicines have side-effects, yet some patients may experience none
of them. The most common problem is feeling nauseous or a bit sick in the beginning.
But it tends to disappear gradually as the body gets used to the treatment and generally
will not last more than a few days. Other common side effects are loss of appetite,
headache, dizziness, tiredness, muscle cramps and sometimes-poor sleep. The uncommon
and rare side effects are urinary retention and seizures.
Donepezil, Rivastigmine and Galantamine-Common side effects would include Nausea,
vomiting, insomnia, and diarrhea
Drowsiness is not a main side effect of these drugs but if you do feel drowsy, then you
should not drive or operate dangerous machinery. You should take extra care as they may
affect your reaction times.
The combination of Donepezil and alcohol may cause drowsiness. However, patients on
Donepezil can have an occasional drink, if they wish.
You should have no problems if you take other medications and does not affect the liver
These drugs are not addictive. There is no evidence of withdrawal symptoms.
These drugs are now available on the NHS and is free of cost
Cardiac effects: May cause bradycardia and dizziness. It should be used with caution in
patients with history of heart block. Do an ECG and seek cardiac opinion, if you are in
doubt
105
Note: It is worth mentioning at the end about information leaflets, fact sheets and other
information available in books and on the Internet.
TASK: ANTIDEMENTIA DRUGS
Mr. Paul Smith was assessed in the memory clinic and has been diagnosed with
Alzheimers disease. You are seeing him in the memory clinic and decided to start him
on Rivastigmine (Exelon). His brother Mr. Tony Smith wants to discuss more about the
drug. Talk to him about effects and side- effects of this drug. Address his concerns. Do
not take history.
Expanded construct: The candidate is expected to discuss about antidementia drugs-

mechanism of action, efficacy, side effects and monitoring. They should be able to
address the carers concerns
Explain the rationale for starting this drug

Mechanisms of action
Explain Duration and efficacy of treatment (40- 50%)
Describe side effects

(GI upsets, nausea, vomiting, headache, dizziness etc)
Monitoring and follow-up

(Memory clinic, MMSE, CPN support)
Address Concerns-
1. Hepatic impairment- no evidence, titrate slowly
2. Expensive
3. Addictive potential
Sources of information- Leaflets, web sites
106
VASCULAR DEMENTIA
Presence of a dementia syndrome, defined by cognitive decline from a previously higher
level of functioning and manifested by impairment of memory and of two or more
cognitive domains (orientation, attention, language, Visuospatial functions, executive
functions, motor control and praxis) and deficits should be severe enough to interfere
with activities of daily living not due to physical effects of stroke alone.
Onset may usually follow a cerebrovascular event and is more acute
Course is usually stepwise, with periods of intervening stability.
Focal neurological signs & symptoms or neurological evidence of cerebrovascular
disease (CVD) judged etiologically related to the disturbance. CVD defined by the
presence of focal signs on neurological examination, such as hemiparesis, lower facial
weakness, Babinski sign, sensory deficit, hemianopia and dysarthria and evidence of
relevant CVD by brain imaging (CT or MRI)
Emotional and personality changes are typically early, followed by cognitive deficits that
are often fluctuating in severity.
Symptoms not occurring during the course of the delirium
Its presentation is variable and three syndromes are commonly recognised
Cognitive deficits following a single stroke: Not all strokes result in cognitive
impairment, but when they do the deficits depend upon the site of the infarct. Cognitive
deficits tend to be particularly severe with certain midbrain and thalamic strokes.
Cognitive deficits may remain fixed or recover, either partially or completely.
Multi-infarct dementia: Multiple strokes lead to stepwise deterioration in cognitive
function. Between strokes there are periods of relative stability. There are often risk
factors for cardiovascular disease.
Progressive small-vessel disease (Binswanger disease): Multiple microvascular infarcts
of perforating vessels leads to progressive lacunae formation and white matter
leukoariosis on MRI. This is a subcortical dementia with a clinical course characterised
by gradual intellectual decline, generalised slowing, and motor problems (e.g. gait
disturbance and dysarthria). Depression and pseudobulbar palsy are not uncommon.
Adapted from Oxford handbook of psychiatry- 1st edition; pg144
Clinical features:
Suggested by vascular risk factors like diabetes, hypertension, smoking etc, with other
supporting evidence on history, examination or tests.
Emotional and personality changes are typically early, followed by cognitive deficits
(including memory deficits) that are often fluctuating in severity.
Cognitive impairment may be patchy compared to the more uniform impairments seen in
Alzheimers disease.
107
Depression and anxiety with episodes of affective lability and confusion are common,
especially at night.
Urinary incontinence and falls without other explanation are often early features.
Physical signs include features of arteriovascular disease together with neurological
impairments (e.g.) are common. Other evidence of vascular pathology eg atrial
fibrillation, peripheral vascular disease is often present.
Management
Establish causative factors.

Treat vascular risk factors aggressively. Daily aspirin, lipid lowering drugs such as
statins, ACE inhibitors and other antihypertensive may delay course of disease, although
is not well evidenced.
General health interventions and risk factor modifications include changing diet, stopping
smoking, and managing hypertension, optimising diabetic control, and increasing
exercise is recommended.
VASCULAR DEMENTIA- EXPLANATION
Vascular Dementia is one of the most common forms of dementia.

Vascular dementia is generally common in patients over the age of 70.
Vascular dementia is more common in men than women and is seen in 1% - 2% of
individuals over the age of 70.
Although the risk factors for vascular dementia do run in families, the vast majority of cases
are not the result of genetic disease and therefore the risk of passing them onto children is
small.
Definition: Vascular dementia is the general name that is due primarily to disease of blood
vessels supplying the brain. The disease may primarily involve one of the large arteries, causing
multiple infarcts or smaller perforating arteries causing small vessel disease.
There are different forms of vascular dementia and multi infarct is one amongst them. In
patients with multi infarct dementia he or she is known to have vascular disease and then,
over a period of years has several clinical strokes (both minor and major) resulting in
increasing physical and cognitive status deterioration.
It is certainly possible for patients to have severe cognitive difficulties following a single
stroke or multiple strokes leading to stepwise deterioration.
Etiology: Smoking is a major risk factor for vascular dementia causing both large vessel and
small vessel disease. The other risk factors for vascular disease include hypertension,
108
hypercholesterolemia or raised blood cholesterol, diabetes, valvular heart disease and irregular
heart beat (atria fibrillation), old age, male sex and family history of vascular disease
Diagnosis: The clinical history and examination is crucial in the diagnosis of vascular dementia.
It is extremely vital to obtain a clear history from the patient and carers and also perform a full
physical examination looking for signs such as hemiplegia (weakness of one side of the body)
and dysphasia (impairment of speech), poor mobility, bowel or bladder dysfunction. The
important investigation is structural imaging with CT or MRI brain scan.
Treatment:
Anti-dementia drugs (acetylcholinesterase inhibitors) are not currently licensed for use in
vascular dementia, although some studies suggest a possible benefit.
The treatments for vascular dementia includes risk factor modification strategies such as
lowering the blood pressure using anti hypertensive medication, drugs like Statins to reduce
raised cholesterol which reduces the risk of further stroke even in patients who start with low
cholesterol levels. There is also good evidence that Aspirin reduces the risk of a stroke by
about 20% in individuals with vascular disease.
Other medical conditions predisposing to stroke such as diabetes and valvular heart disease
will need specific treatment.
The prognosis of vascular dementia is similar to that of Alzheimers the disease tends to be
progressive with death on average 5-7 years after diagnosis.
Although there is little direct evidence that lifestyle changes can help in the management of
vascular dementia these lifestyle changes can help prevent further deterioration in vascular
dementia. The following are advisable :
1. Good exercise with a daily walk for 20-30 minutes
2. Eating a healthy diet which is low in cholesterol and saturated fat
3. To maintain ideal body weight
4. Give up smoking and avoid excess alcohol
5. Ensure adequate stimulation for the brain
6. Keep your mind active with reading and solving crosswords etc
7. Have your blood pressure and blood glucose checked regularly and control carefully
if it is raised
8. Talk to your GP about taking Aspirin
109
PAIRED STATION:
TASK: VASCULAR DEMENTIA- HISTORY & DISCUSSION
Obtain Collateral history from Mr. Brown whose 79-year-old father was referred to
you by GP as he has problems with his memory for the last two years. Obtain
history from his son to arrive at a diagnosis. Perform appropriate risk assessment.
In the next station, you will discuss about his illness with his son.
Expanded construct: The candidate is expected to obtain detailed history from relative
of a patient with cognitive impairment to arrive at a diagnosis. They should also perform
appropriate risk assessment.
They should assess the following areas;
Mode of onset, duration and progression of symptoms

Further exploration of presenting symptoms
Cognitive symptoms (Short term; long term memory, Orientation, Intermittent

confusion)- Seek examples
Other areas of cognitive domains- Language difficulties, Visuospatial

difficulties, recognition, reading, writing etc
Assess Functional abilities- ADL skills
Mood and Psychological Symptoms (Depression, anxiety, paranoia, delusions,

hallucinations)
Physical Symptoms-
(Incontinence, gait disturbance, sensory & Motor deficits, aphasia,
Parkinsonian movements)
Medical History (Diabetes, Hypertension, Heart disease, high cholesterol etc)

& Medications (Aspirin, statins, Warfarin etc)
Personal and family history
Risk assessment (Falls, aggression, wandering, Non-compliance, carer stress)
110
RELATED TASK IN THE SECOND STATION
Mr. Brown was already assessed and following this, his dementia screening bloods is
now completed and the diagnosis of vascular dementia was made, as CT brain scan
showed severe ischemic changes involving both small and large vessels in the brain
Explain the diagnosis and prognosis to his son.

Discuss modification of risk factors and general health interventions.
Expanded construct: The candidate is expected to explain the diagnosis and prognosis
of vascular dementia to his son. They should discuss general health interventions and also
address concerns specifically raised by the relatives.
They should discuss the following points;
Explain the diagnosis of vascular dementia- Nature of the illness
Explain course and outcome of illness (progressive illness)
Role of antidementia drugs- no strong evidence
Discussion about life style modification and

a. Dietary modifications, rest and sleep hygiene
b. Exercise, keep them physically & mentally active
c. Cut down/ stop- smoking, alcoholism
Treatment of vascular risk factors aggressively

a. Inform GP about continuing Aspirin, warfarin
b. Optimisation of diabetic control
c. Blood pressure control through antihypertensives (ACE-Inhibitors)
d. Monitoring cholesterol and prescribing statins etc
Address concerns;
a. Aggression and agitation- Is it common
b. Forgetting medications- home carers, Dossette box
111
DEMENTIA WITH LEWY BODIES (DLB)
Dementia with Lewy bodies (DLB) is the third commonest dementia in the UK after
Alzheimers disease (AD) and vascular dementia (VaD) and accounts for approximately
10-20% of all dementia cases.
Clinical features to aid the diagnosis of DLB include detailed and recurrent visual
hallucinations, fluctuating cognitive impairment, and symptoms of parkinsonism. These
three clinical symptoms are termed core features. The presence of two of these three
core features has traditionally constituted a diagnosis of probable DLB whereas the
presence of only one feature is termed possible DLB.
Revised criteria for the diagnosis of dementia with Lewy bodies
Core features (Two features required for a diagnosis of probable DLB in a cognitively
impaired patient, one for possible DLB)
Fluctuating cognition with pronounced variations in attention and alertness
Recurrent visual hallucinations that are typically well formed and detailed
Spontaneous features of parkinsonism
Suggestive features: (One core feature plus one or more suggestive features sufficient in
a cognitively impaired patient to make a diagnosis of probable DLB)
Low dopamine transporter uptake in the basal ganglia demonstrated by SPECT or PET
imaging
Severe neuroleptic sensitivity
REM sleep behavioural disorder
The pathophysiology of DLB and idiopathic Parkinsons disease (IPD) are the presence
of cerebral Lewy bodies.
It is arguable that DLB, IPD and Parkinsons disease dementia represent different
manifestations of a continuous disease spectrum.
Lewy bodies are the basic pathology of both idiopathic PD and dementia with Lewy
bodies (DLB). In the former, the Lewy bodies are predominantly located in the brain
stem (and thereby disrupt the nigrostriatal fibres), and in the latter the Lewy bodies are
predominantly found in the limbic and and neocortical association areas. It is estimated
that 75% of DLB patients will develop parkinsonian features during the course of their
illness.
Conversely, 40% of IPD patients will develop a clinical dementia and many others will
have cognitive problems of a lesser severity. Consequently, IPD and DLB may represent
two ends of a disease spectrum of underlying Lewy body pathology.
112
The SPECT ligands 123I-FP-CIT (N-fluropropyl-2-carbomethoxy-3-4-[123I] iodophenyl
tropane), 123I--CIT, and the PET ligand 18F-dopa ([I18F] flurodopa) can be used to image
the presynaptic dopaminergic terminals in the corpus striatum.
The 123I-FP-CIT agent is also known commercially as the DaTSCAN.
Following the intravenous administration of 123 I-FP-CIT, 123 I--CIT, or 18 F-dopa to the
individuals, the uptake in the corpus striatum will appear as two mirror image commas
The importance of an accurate diagnosis
It can be extremely important to the psychiatrist/neurologist to be aware as to whether the

cognitively impaired patient has DLB or a non-DLB form of dementia. Most importantly
there has to be a judicious use of antipsychotics (neuroleptics) in patients with cerebral
Lewy bodies.
In a patient with Lewy body dementia, the presynaptic dopaminergic terminals will be
markedly reduced and therefore there will be less dopamine produced into the synaptic
cleft. The effects of antipsychotics are to blockade the D2 receptors. This will therefore
exacerbate the situation within the synapse in that the relatively little dopamine being
produced is not able to interact with the blockaded post-synaptic D2 receptors. This can
provoke a parkinsonian crisis in up to 80% of patients with DLB who are administered
antipsychotics, which can be fatal in approximately 50% of these cases.
Consequently, the first line of treatment for psychotic symptoms in DLB patients are
acetylcholinesterase inhibitors and when anti-psychotics are used as the second line
treatment they have to be introduced with extreme caution at a low dosage.
Cholinergic therapy for the cognitive impairment is effective, and indeed maybe more
effective in DLB patients than in AD patients which is most probably as a consequence
of the greater cerebral cholinergic deficit in the former. Hence, cholinergic therapy in
DLB is the initial treatment of choice, both for the cognitive and psychiatric
manifestations.
Awareness of the presence of cortical Lewy bodies by the clinician can increase their
confidence in the management of these complex DLB patients. As the disease progresses
there has to be a fine balance between preserving movement or cognition, as the
introduction of anti-psychotics as second line treatment for psychosis will exacerbate the
parkinsonian symptoms.
Summary of recommendations by NICE for neuro-imaging in patients with

suspected dementia if the diagnosis is in doubt
MRI/CT To detect structural abnormalities and subcortical vascular changes

HMPAO SPECT To help differentiate Alzheimers disease, vascular dementia and
frontotemporal dementia
FDG PET To help differentiate Alzheimers disease, vascular dementia and
frontotemporal if HMPAO SPECT is not available
123
I-FP-CIT To establish the diagnosis of DLB
Adapted from: Imaging in dementia with Lewy bodies; A review (Paul Kemp and Clive holmes)
Imaging the dopaminergic system in suspected Parkinsonism, drug induced movement disorders,
and Lewy body dementia (Paul Kemp)
113
Lewy body dementia: If both motor symptoms and cognitive symptoms develop within 12
months, then it is conventional to give a diagnosis of Lewy body dementia. In this condition,
cognitive and behavioural impairments precede motor phenomena and are more severe.
Note that several features are common to DLB and Delirium such as fluctuations, effects of
drugs, perceptual and psychotic phenomenon etc. But the following is true of DLB
Onset is insidious
Progression is gradual
No precipitating illness is found (eg infections)
Hallucinations are complex and not the result of misperception of stimuli
Delusions are well formed and may be persistent
Parkinsons disease dementia:

If the Parkinsonian symptoms have existed for more than 12 months before dementia
develops then a diagnosis of Parkinsons disease dementia is given.
This applies even if the dementia syndrome is otherwise typical of LBD.
Here the motor impairments precede conginitive impairments and are more severe.
Many patients with Parkinsons disease may have subtle impairments of cognition, too
mild to justify a diagnosis of dementia. Slowed thinking, deficits in visuospatial, attention
and executive function are commonly seen
LEWY BODY DEMENTIA- EXPLANATION
Dementia with Lewy Body is lately considered to be the second most common form of
dementia after Alzheimers disease.
It is the most common dementia syndrome associated with Parkinsonism, which mainly
affects the elderly population.
DLB accounts for 15-25% of dementia cases in the elderly. Men may be at a higher risk of
developing Lewy Body Dementia than women.
Etiology: The cause of dementia with Lewy Body is still unknown. It is considered to be a neuro-
degenerative disorder associated with abnormal structures, which are called Lewy Bodies, found
in certain areas of the brain. These are spherical tiny protein deposits and the presence of these
structures in the brain disturbs the brains normal functioning, can interrupt the action of some
important chemical messengers in the brain. It is still not yet fully understood how they cause
damage in the brain.
114
Clinical presentation: DLB can be difficult to diagnose and this is usually done by a specialist.
In addition to memory problems patients with DLB experience, hallucinations, motor impairment
due to Parkinsons disease and fluctuating alertness.
People with Dementia of Lewy Body will have the following:-

1. Motor symptoms such as tremor and rigidity with decreased muscle activity resulting in
muscle stiffness, which may fluctuate greatly, making some days more difficult than
others.
2. Frequent visual hallucinations which are well formed and detailed
3. Fluctuations in alertness and consciousness
4. Increased sensitivity to some drugs which act on the brain, especially antipsychotic
medication
The progression of this disorder occurs in a similar fashion to Alzheimers disease and the
patients will experience a steady decline in their cognitive ability.
Investigation: There is no specific investigation to diagnose Lewy Body Dementia. The

diagnosis of Dementia with Lewy Body remains a clinical one. Blood tests and brain scans are
performed in these patients and they are aimed at excluding other causes for the symptoms rather
than confirm the diagnosis.
Treatment: At present there is no cure for Dementia with Lewy Body. Patients with Lewy Body
Dementia may require different types of medication:-
a. Anti Parkinsonian medication which are used to treat the motor symptoms of Parkinsons
Disease
b. Although the cholinesterase inhibitor drugs are not licensed for treating Dementia with
Lewy Body recent research suggests that drugs like Rivastigmine may be useful in
treating Dementia with Lewy Body. Recent guidelines from the National Institute of
Clinical Excellence do suggest that these drugs should be considered, especially for
people who have non cognitive symptoms like apathy and hallucinations, causing
significant distress or leading to behaviour that challenges.
c. Anti psychotic medication should be used with extreme caution as these patients are often
very sensitive and it should be used carefully to avoid the increase in severity of
115
symptoms. It it should be prescribed with utmost care under constant supervision and
should be monitored regularly.
d. A lot of these patients may also tend to develop depression and anti depressants may be
used to treat symptoms of depression.
The likely prognosis is generally poor as there is no specific treatment to reverse the progression
of the disease.
(Ref: www.alzheimers.org.uk, Dementia-Questions answered- Brown and Hillam)
PAIRED STATION
LEWY BODY DEMENTIA
TASK: Mr. Kenneth Taylor is an 81-year-old gentleman who was diagnosed with
Parkinsons disease 9 months ago. He has developed cognitive problems and visual
hallucinations during this period. Recent DAT scan is consistent with findings of Lewy
Body dementia. Discuss his diagnosis and treatment options for this condition with his
daughter in law.
Expanded construct: The candidate is expected to discuss diagnosis, clinical

presentations, and treatments for Lewy body dementia. Also address relatives concerns.
Clarification and clear explanation of diagnosis
Lewy body dementia nature and causation (neurodegenerative disorder and

Lewy bodies)
Lewy body dementia clinical presentations

(Motor symptoms of Parkinsons disease, fluctuating levels of consciousness and
cognitive decline, visual hallucinations etc)
Differentiating it from Parkinsons dementia
Address concerns
1. Role of L-dopa
2. DAT scan and its role in diagnosis
Treatments
1. Role of antidementia drugs
2. Psycho education, reassurance and support
3. Liaison with neurologist
Management of falls (physiotherapy and OT assessment, environmental

adaptations etc)
116
RELATED TASK IN THE NEXT STATION (PART-B)
You have seen this patient with Lewy body dementia with daughter in law in the station
before at the onset of problems a year ago. You are now asked to see his son of this
patient who has a well-established diagnosis of Lewy body dementia. His grandfather
who is on Rivastigmine 1.5mg BD is cognitively better but has deteriorated with regards
to visual hallucinations & confusion. Address his concerns about further management of
this condition.
Expanded construct: The candidate is expected to discuss management options for

neuropsychiatric manifestations of Lewy body dementia and address concerns expressed
by carer. The discussion should involve following areas;
Acknowledge carers distress and offer support (CPN support, care package,
carer assessments)
Discuss reasons for psychotic presentation

1. Explain- could be behavioural and psychological symptoms of dementia
2. Could be a Side effect of antiparkinsonian medications
3. Could be a non motor symptom of Parkinsons disease
4. Rule out physical causes like infections
Treatment approaches
1. Increasing dose of anti-dementia drugs (Rivastigmine)
2. Reducing medications for Parkinsons disease- liaise with neurologist
(Aim to achieve a balance between treating motor and non-motor
symptoms)
Treatment options
1. Benzodiazepines (not indicated) Risk of falls, dependence
2. Aromatherapy, re-orientation etc- complementary treatments
Discussion about role of antipsychotics-

a. Better to avoid if not distressing
b. Educate- neuroleptic sensitivity
Should be used with extreme caution if it is severely distressing (Quetiapine- low
dose)
117
PARKINSONS DISEASE & DRUG INDUCED PSYCHOSIS-
MANAGEMENT
The patients with Parkinsons disease could often present with psychotic symptoms characterised
by paranoia, visual and auditory hallucinations etc.
There could be many plausible explanations that could be offered.
a. It could be drug related (side effect of antiparkinsonian medication)

b. It could be a non motor feature of Parkinsons disease
c. A possible manifestation seen in Lewy body type of dementias
d. Rule out very late onset psychotic illness or a relapse of psychotic illness
e. To rule out acute confusional state
Useful points in management if patients present with psychotic symptoms
In the early stage, patients may have retained insight and require no specific therapy other
than the reassurance and supportive psychotherapy.
Psycho Education to the patient and the family about the nature of the illness,
treatment options and the possible side effects of antiparkinsonian medication that can
cause psychosis and hallucinations
If the patient has insight and hallucinations are infrequent and not troubling, do not treat.
Consideration of the motion-emotion balance is paramount when prescribing medications
in Parkinsons disease dementia. It is important to acknowledge that medicines that treat
symptoms in one domain (motor symptoms) may worsen symptoms in other domains
(non motor symptoms) and therefore adopting a balanced approach is very important
Gradual withdrawal of non-essential drugs such as anticholinergics, selegeline,
amantadine and dopamine agonists. Monitor for signs of motor deterioration.
If necessary, core reduction in levodopa therapy. Readjust dose of L-Dopa, Alter the
timing of meds and doses, preferably giving L-dopa after food. This might slow down the
rate of absorption and minimize the side effects.
Wait and watch policy is often adopted.
Add an atypical antipsychotic in the hope of attenuating future psychosis.
Consider oral atypical antipsychotic medication, preferably quetiapine (12.5 mg-75 mg
but higher doses may be required) associated with lower incidence of EPSEs and also it
dose not require blood count surveillance. In refractory cases use clozapine in small
doses is preferred as it is the most effective and only licensed antipsychotic in PD but
regular blood tests and close monitoring for neutropenia and agranulocytosis is essential.
Consider ACHEIs inhibitors such as Rivastigmine, particularly if the patient has
dementia and it may be also useful in treating hallucinosis and psychosis and can help
with other neurobehavioral features such as apathy and anxiety.
118
Consider ECT- Psychotic symptoms, depression and motor symptoms usually respond
well but the risk of inducing delirium is high, particularly in patients with pre-existing
cognitive impairment.
Others
Offer CPN support to monitor his mental and cognitive state
Work in close liaison with the neurologist, GP, Parkinsons disease nurse, family and
communication between different teams is of paramount importance.
The psychiatric team should review the patient periodically and the treatment programme
should incorporate assessments of both motor and non-motor symptoms.
It is important to acknowledge that most patients with benign hallucinosis will
ultimately develop more neuropsychiatric problems in their disease course. More severe
psychotic symptoms are a significant risk factor for placement in a residential EMI or
nursing EMI home setting.
The probable diagnosis for this case would be Parkinsons disease dementia which is a
pathological entity slightly different from Lewy body dementia
Implications of untreated psychotic symptoms

1. Impairs quality of life
2. Exacerbate caregivers distress
3. Increases the likelihood of residential care
4. Increased mortality
119
FRONTO-TEMPORAL DEMENTIA
A form of dementia, characterised by preferential atrophy of fronto-temporal regions,
with usually early onset.
Early symptoms include personality change and social disinhibition, preceding memory,
or other cognitive impairment.
It accounts for 20% of cases of presenile dementias
Family history is positive in 50% of cases.
Men are more affected than women.
The average duration of illness is 8 years
Onset is often early (35-75) and either behavioural or language difficulties dominate
the picture. Forgetfulness is mild in the early stage.
Behavioural problems are most common
Language dysfunction may include word finding difficulty, problems naming or
understanding words, lack of spontaneous speech and circumlocution.
In contrast to Alzheimers disease, memory is affected later and less severely. Spatial
orientation is well preserved.
Insight is characteristically lost early.
As the illness progresses, symptoms of frontal lobe dysfunction may become apparent,
which includes behavioural rigidity, loss of social skills, disinhibition, impulsivity,
emotional lability, fatuousness, executive dysfunction, reduced verbal fluency, motor and
verbal perseveration, Hyperorality and repetitive behaviours.
Later impairments becomes more broad similar to severe Alzheimers disease
Behavioural features of FTD specified in diagnostic criteria
Core features (Adapted from Oxford handbook of psychiatry)
Insidious onset and gradual progression.

Early decline in social interpersonal conduct.
Early impairment in regulation of personal conduct.
Early emotional blunting.
Early loss of insight.
Supportive features
Behavioural disorder
o Decline in personal hygiene and grooming.
o Mental rigidity and inflexibility.
o Distractibility and impersistence.
o Hyperorality and dietary changes.
o Perseverative and stereotyped behaviour.
120
o Utilisation behaviour.
Speech and language
o Altered speech output (aspontaneity and economy of speech/ pressured speech).
o Stereotypy of speech.
o Echolalia.
o Perseveration.
o Mutism.
Physical signs
o Primitive reflexes.
o Incontinence
DEPRESSIVE PSEUDODEMENTIA
Checklist
o History of symptoms- Dating back the onset of symptoms, progression of Sx,
Recognition of cognitive difficulties, depressive symptoms preceding cognitive
difficulties, Nocturnal accentuation of symptoms etc
o Explore for depressive Sx (cognitive Sx, Biological, emotional and behavioural
Sx including Risk Assessment)
o Basic assessment of cognition
o Assessment of insight- Acknowledges presence of low mood, and emphasises
difficulties
o Previous psychiatric history
Major Clinical Features Differentiating Pseudo dementia from Dementia

(Adapted from Kaplan & sadock-Synposis of psychiatry-10th edition)
Pseudodementia Dementia
1. Onset can be dated with some precision Onset can be dated only within broad limits
2. Symptoms of short duration before medical Symptoms usually of long duration before
help is sought medical help is sought
3. Rapid progression of symptoms after onset Slow progression of symptoms throughout

course
4. History of previous psychiatric dysfunction
common History of previous psychiatric dysfunction
5. Patients usually complain much of cognitive unusual
loss Patients usually complain little of cognitive loss
6. Patients emphasize disability and Patients conceal disability and often appear
communicates strong sense of desire unconcerned.
7.Nocturnal accentuation of dysfunction
uncommon Nocturnal accentuation of dysfunction common
8. Attention and concentration often well Attention and concentration usually faulty
preserved
Near-miss answers frequent
9.Don't know answers typical
Memory loss for recent events usually more
121
10.Memory loss for recent and remote events severe than for remote events
Usually severe
WANDERING BEHAVIOUR IN DEMENTIA
Explore the reason for wandering

Boredom
Continuing a habit-lifelong walkers
Energy-need for more exercise
Loss of memory- short term memory loss
Confusion about the time
Feeling lost or uncertain in a new environment
Pain and discomfort-arthritic pain or rheumatic pain
Side effect of medication
Response to anxiety-very agitated and anxious
Searching for the past-to search for someone or something related to their past or a task to
performtask which they have done in the past related to former occupation
Enquire about Cognitive Sx, other Behavioural Sx, Biological Sx, and psychological Sx and
ADL skills.
Enquire about the medications, disturbed sleep pattern, daytime activity (day time chores and
stimulation)
122
Ask about the carers support (both informal and formal), place where they live like residential
home
Ask whether the person carries some form of identification- safe return ID bracelet
Ask whether local police notified of wandering risk, inform local shopkeepers and neighbours.
Risk assessment
Road sense (risk of RTAs),
Risk of robbery and financial exploitation (should not wear expensive jewellery and
should not carry a large sum of money)
Risk of accidents at home like cooking
Risk of falls
Driving
ASSESSMENT OF BEHAVIOURAL AND PSYCHOLOGICAL

SYMPTOMS OF DEMENTIA
Behavioural and psychological symptoms of dementia is an umbrella term that embraces a
heterogenous group of non cognitive symptoms and behaviours that occur in people with
dementia.
Behavioural problems are common in dementia including Alzheimers type and may occur in any
stage of the disease. 2/3rds of people with dementia experience some BPSD at any one time point
and for 1/3rd of community dwelling people with dementia the level of BPSD will be in the
clinically significant range (Lyketsos et al 2000). Often it is behavioural problems that lead to
institutionalisation and managing them successfully may enable a patient to remain in their own
home.
Behavioural manifestations: The behavioural problems could present in different ways in the
form of
a. Anger outbursts, irritability, psychomotor agitation, and aggression (verbal and
physical)
b. Socially inappropriate behaviour in the form of sexual disinhibition,
inappropriate urination and attention seeking.
c. Others would include wandering, hoarding behaviour.
123
Psychological Symptoms: This would include depression, apathy, anxiety, paranoia, delusions
and hallucinations.
The assessment process involves identifying any concurrent physical health

problems such as urinary tract infection, chest infection and sources of physical
discomfort like pain, constipation, urinary retention etc or due to the effects of
drug treatments, example use of anticholinergics should be considered.
It is also important to consider possible concurrent psychological contributory
factors such as depression, fear, anxiety or paranoia.
The availability and quality of relationships with others (care-givers) as well as
the current ability to cope with the needs of the person with dementia will shape
behavioural patterns.
The characteristics of the environment should also be considered for example
physical space, comfort and adaptation to promote independence. The
environment should be homelike, familiar and interesting. Using artefacts,
painting, which are designed to create a natural or homelike setting may be tried
to reduce agitation, aggression and wandering into others rooms.
Activities may reduce boredom, wandering and aggression. Activity programmes
with trained volunteers may reduce aggressive incidents in patients whose
wandering occurs in the context of boredom and inactivity.
Effective therapies like music, bathing, exercise, pets, aromatherapy is helpful.
Simple interventions including distraction, reassurance may help with delusion
and hallucinations. Anxiety may respond to relaxation techniques
Interventions for specific behavioural problems can replace the structure of the
ABC analysis of behaviour (Stokes 1990). Analysis is made to identify
antecedents, problem behaviour and consequences of each problem behaviour
and clear management plan is tailored according to the needs of the patient.
Above all, boosting care giver support, increasing time for self and providing
carer education and training in the management of BPSD can be effective in
decreasing burden and mollifying its impact on the carer (Ostwald et al 1999)
DEMENTIA- NON PHARMACOLOGICAL MANAGEMENT

1. Create a safe, caring environment usually in the patients own home and a predictable
routine is extremely helpful.
2. Suggest simple memory enhancement techniques and interventions to improve coping
(example calendars, lists, alarms). Involve psychologist wherever needed.
3. Encourage both physical and mental activity including social activities like attending
social clubs and day centres.
4. Occupational therapy home assessment should be performed routinely to identify
hazards, minimise risks and maximise safety of the patient.
5. Simplify medication and provide dossett box or similar to aid compliance.
6. Organise carers to assist with activities of daily living and prompt medication etc.
7. Educate patient and families about the disease and how to cope with the manifestations at
different stages of the illness.
8. Offer support to care givers and consider counselling and support care givers by
encouraging them to attend the support groups organised by voluntary agencies like.
Offer support in the form of respite care, sitting services etc
124
9. Try to identify and modify reversible factors such as sepsis in the form of UTI, chest
infection, cellulitis, constipation or drug side effects. Periodical Review by GPs would be
extremely helpful. It is important to treat any co-morbid medical or psychiatric illness.
10. In addition, vascular risk factors should be addressed.
If psychosocial or behavioural interventions have limited success then the use of medication may
be appropriate. Medications may be needed for delusions, hallucinations, and serious distress or
danger from behaviour disturbance or symptoms of depression.
Most patients also have co-morbid depression and this should be treated with anti-depressant
medication, SSRIs are much preferred to tricyclic antidepressants.
There are a few disadvantages of using medication

This includes:
1. Side effects profiles of each classes of medication. (Postural hypotension, excessive

sedation, Anticholinergic side effects of traditional antipsychotics and older
antidepressants)
2. Potential to worsen confusion.
3. Increase in the risk of falls.
4. Reduce mobility.
NON-COGNITIVE SYMPTOMS OF DEMENTIA-

PHARMACOLOGICAL MANAGEMENT
The best drug is that which for that patient with that problem has worked previously.
A clinical decision to use antipsychotics should therefore take into account the
risk to the patient and carers symptoms, the level of distress and potentially adverse
medication effects.
The NICE guidance on dementia suggests that antipsychotic drugs should be

used in the first instance only if an individual is severely distressed or if there is an
immediate risk of harm to others. The choice of antipsychotic should be made after an
individual risk-benefit analysis. The dose should be low initially and then titrated
upwards.
Antipsychotic medications have often been prescribed to treat the non cognitive
symptoms of dementia (Eg delusions, hallucinations, anxiety, agitation and aggression
etc). For problematic symptoms such as delusions, hallucinations and paranoia atypical
antipsychotics should be used at the lowest dose that is effective. Conventional anti-
psychotics may worsen cognitive decline in dementia.
125
However, Risperidone and Olanzapine are associated with risks of serious
adverse cerebrovascular events which may outweigh the benefits especially when used in
the longer term (Schneider 2005). An increased risk cannot be excluded for other
antipsychotics (both atypical and typical) or other patient populations and so all
antipsychotics should be used with caution with risk factors for stroke
Since the restrictions were imposed on the use of Olanzapine and Risperidone,
Quetiapine has become widely used at the dose of 50-100mg daily. However, evidence to
support Quetiapines efficacy is much weaker than that for Risperidone or Olanzapine.
The increased risk of sedation, postural hypotension, extra pyramidal movement

side effects (with the potential to increase the risk of falls in the elderly) that
antipsychotics may cause must be considered in the choice of medicine and monitored
closely once treatment has started.
Others:
1. If depression is prominent try SSRI such as Citalopram. SSRIs are safe and effective
2. For agitation, anxiety and irritability consider Trazadone which is sedative
antidepressant, initially 50mg nocte, increase as needed, maximum 300mg daily. For
agitation Trazadone may be considered especially when accompanied by depressive
symptoms (Suld El 2001).
3. Anxiolytics such as Benzodiazepines may be used for brief anxiety including
situations.
4. Anticholinesterase inhibitors may improve behaviour as well as cognition. They may
be given first line especially if symptoms are moderate and not acute in onset.
5. Non neuroleptic treatments such as carbamazepine have demonstrated efficacy over
placebo in the treatment of agitation (Tariot et al 1990)
Finally, review drug use regularly. Behavioural problems are often periodic so consider trials of
treatment, especially in those whose behavioural disturbance was not severe and have responded
to treatment.
In summary, whichever drug is chosen the 3-T approach should be followed.

1. Target symptoms requiring treatment.
2. Titrate the drug dose from a low starting dose.
3. Time limit prescriptions so that ineffective treatment is not unnecessarily continued.
(Ref: Maudlsey prescribing guidelines, Oxford Textbook of old age psychiatry,
Oxford Handbook of Geriatric medicine, Oxford Handbook of Psychiatry)
PAIRED STATION
TASK: AGGRESSION AND DIFFICULT BEHAVIOUR- DEMENTIA
An elderly man with Alzheimers dementia in a nursing home tried to hit another
resident and has presented with behavioural problems. Obtain detailed history from the
support worker and identify the reasons for his presentation
126
Expanded construct: The candidate is expected to obtain detailed collateral
information to arrive at a diagnosis. It is important to explore and establish the possible
causative factors for his difficult behaviour. They should assess the following areas;
Identify specific behavioural problems-

Psychiatric symptoms that could be causing these problems

Depression/psychosis, dementia.
Physical problems- constipation, UTI, pain, infection
Other factors- Loss of mobility + loss of gardening activity, lack of routines
Change in social environment new resident & wife not visiting
Structured activities at home to overcome boredom

(Music, art, activity nurse, pet animals, bingo, games etc)
RELATED TASK IN THE LINKED STATION
You have started this man on Olanzapine for his behavioural symptoms. Now speak to
the son who is upset and angry about the treatment plan.
Expanded construct: The candidate is expected to explain the possible reasons

for his challenging behaviour and should be able to address concerns raised by angry
carer
Address concerns- Use of antipsychotics-
(Demand rationale behind prescribing it and allay anxieties of carer)
Discussion (Non pharmacological interventions)
Aromatherapy, pet therapy, Music therapy, multisensory stimulation, bingo etc
Discuss about engaging in some form of meaningful activities
(Avoid boredom, structured day time routines with optimal level of stimulation,
encourage more time in garden)
127
Encourage him to visit his wife- (could be one reason)
Discuss alternatives and or Other options
(Staff education, Moving him to another home with bigger space etc)
ACUTE CONFUSIONAL STATE (DELIRIUM)- MANAGEMENT

Obtain history and more detailed information from nursing staff and medical colleagues
Check investigation Routine bloods including FBC, ESR, CRP, Vitamin B12, & folate
assay, LFTs, U&E, TFTs, Random blood glucose, (to rule out electrolyte and metabolic
abnormalities) Blood culture, urine for culture and sensitivity to rule out sources of
infection.
Arrange for further investigation like Chest X-Ray, ECG, CT scan and other
investigations if there are positive findings that warrant it.
Physical examination including Neurological examination.
Treatment:
Identify and treat the underlying cause. (Infection with appropriate
antibiotics, Rehydration for possible dehydration, reducing meds for
medication toxicity)
Ensure fluid and electrolyte balance.
General measures frequent explanation, reorientation and reassurance.
Relatives and friends to visit the patient frequently.
Providing adequate nursing support, frequent staff changing to be avoided.
Optimise the environment to maximize the orientation and therefore the patient
should be nursed in a quiet single room with good lighting and a friendly familiar
128
environment. (appropriate clothes, quality lighting, at an appropriate level for the
time of day, a clock or outside view to aid orientation, optimise visual and
auditory acuity by providing spectacles and hearing aids that work)
Medication to control distress, prevent exhaustion and to promote adequate
sleep. Haloperidol is suitable, generally between 3 and 15mg/ day and if
necessary can be given intramuscularly. In elderly patients, the total daily oral
dose is 0.5-4mg
New generation atypical agents such as Quetiapine (50-100 mg) can also be used.
Avoid using benzodiazepines unless it is really necessary as it can exacerbate
confusion, worsen the cognitive status, precipitate falls and can cause
disinhibition in the elderly.
Review Periodically. Possible transfer to a psychiatric ward if not manageable
on a medical ward but usually not necessary.
Competency: Patients with delirium are not usually competent to direct treatment.
Common law allows assessment and treatment in their best interests. It may include
d. Temporary physical restraint to administer drugs
e. Holding within a ward or hospital, if patient tries to leave
f. Covert administration of essential drugs etc
In such situations, it is important to offer clear explanations to staff and family members of the
need for such interventions and their ethical and legal justifications and it should be documented
clearly in the medical notes.
Mental Health act: In that case. One could use the common law in an emergency situation. The
use of the mental health legislation is appropriate for delirium, which is an organic confusional
state, and it is a form of mental illness within the meaning of the act. The mental health act can
certainly be used to admit in cases of delirium with severe behavioural disturbance to psychiatric,
medical or geriatric wards.
Physical Restraint is terrifying and has adverse mental and physical sequelae. It is only rarely
needed. In cases of severe aggression, brief mobilization of the patient using minimum force
necessary may be on balance in the patients interests.
Where to treat: In many cases the patient should be admitted to an acute general hospital where
there are advanced diagnostic facilities such as CT brain scan and staff trained to manage acute
illness. The admission is usually for a brief period. With appropriate support and monitoring,
discharge home or transfer to a less acute environment can often be achieved early.
Delirium vs dementia
Feature Dementia Delirium

Onset Slow Rapid
Duration Months to years Hours to weeks
Attention Preserved Fluctuates
Memory Impaired remote memoryImpaired recent and immediate memory
Speech Word-finding difficulty Incoherent (slow or rapid)
Sleep-wake cycleFragmented sleep Frequent disruption (e.g., day and night reversal)
Thoughts Impoverished Disorganized
Awareness Unchanged Reduced
Alertness Usually normal Hypervigilant or reduced vigilance
(Adapted from Lipowski ZJ. Delirium: Acute Confusional States. Oxford: Oxford University Press; 1990)
129
TASK: ACUTE ON CHRONIC CONFUSIONAL STATE- PAIRED STATION
Mrs. Dorothy Payne is an 81-year-old lady admitted to a medical ward with history of
fever and confusion. She is off the ward to get a chest X-Ray done. Speak to her daughter
to obtain collateral information with a view to come to a conclusion of her diagnosis.
Expanded construct: The candidate is expected to obtain detailed collateral information

to arrive at a diagnosis. It is also important to establish whether there is any evidence of
dementia in this patient. They should assess the following areas;
Memory loss and confusion- Examples

Assess other areas of cognitive domains

Rule out common causes of delirium (infection, constipation, pain etc)
Perceptual abnormalities (visual and auditory hallucinations)-

Source, type, content, reality with which it is experienced
Paranoia and delusional ideas- Clarify and seek explanation
Mood Symptoms- fluctuations, lability

Disruption in sleep wake pattern
Risk assessment- wandering, falls, non-compliance,

Aggression & agitation etc
Obtain further history to rule out the presence of dementia
You are the psychiatric doctor who has obtained collateral information from Mrs.
Dorothy Paynes daughter. You have not yet assessed the patient as she is off the ward to
get chest X-Ray done. Speak to the student nurse Michelle Parker, who is looking after
Mrs. Dorothy Payne, to discuss diagnosis and management.
Expanded construct: The candidate is expected to speak to discuss your findings on

history, diagnosis, investigations, treatments and management. They should;
Discuss findings on history (cognitive decline, paranoia, hallucinations,

mood lability, disrupted sleep wake pattern etc)
Discuss possible differential diagnosis
130
(delirium, acute on chronic confusional state etc)
Discuss aetiology (infection, constipation etc)
Discuss necessary Investigations

(contact GP, Collateral information from family members, medical history,
Medication, bloods, urine- confusion screen, CT scan etc)
Treatment - (medical/psychiatric ward, Identify and treat precipitating cause,

provide environmental & supportive measures- optimisation of environment,
consistent nursing- reassurance and reorientation etc)
Use of medications to manage challenging behaviour,

(Avoid sedation unless severely agitated, frequent review & follow up)
Delirium- prognosis & recurrence
? Possibility of dementia, discussion with family,

Emphasise need for further testing and monitoring
OLD AGE MANIA

Mania accounts for 5-10% of mood disorders in the elderly.
The 1-year prevalence of BD among adults aged 65 and older is 0.4%,
significantly lower than in younger adults (1.4%).
Average age at onset is 55 years and female to male ratio is 2:1
Mania presents a similar clinical picture as in younger patients. But it is more
often followed by a depressive episode in older patients and mixed affective
presentation seems more common.
First episode mania in late-life is uncommon; but these patients have lesser
familial loading than younger bipolar patients and have more secondary mania
than bipolar disorder. (Often precipitated by drugs like corticosteroids, L-Dopa
etc)
Patients with first-episode mania in late life are twice as likely to have a comorbid
neurological disorder. This may or may not explain the affective presentation.
Lithium is used as first line prophylaxis but usually lower dosages are indicated.
A lower therapeutic range around 0.4 to 0.6mmol/L is suggested for prophylaxis
(Shulman, 2002)
Age appropriate doses of neuroleptics may be used
Management is similar to that described in adult patients.
131
OLD AGE MANIA- PAIRED STATION
Task: Mr. John Read is a retired farmer brought to the accident and emergency
department by his wife, who has been worried about his behaviour. For the last 2 weeks
he has been aggressive, agitated and behaving out of character. Medics have done LFT,
U&Es, FBC and urinalysis that are normal. Talk to him to find any reasons for his wifes
concerns and assess his mental state. Do not perform cognitive assessment.
Expanded construct: The candidate is expected to assess the circumstances that led
to current presentation and assess his mental state. They should also perform risk
assessment
Assess Circumstances leading to current presentation
Symptoms of mania; Mood- Elated mood (usually out of keeping with

circumstances), Increased energy (over activity, Pressured speech, racing thoughts,
Reduced need for sleep)
Thoughts- Increased self-esteem (Over-optimistic ideation, grandiosity),

Delusions of grandiosity and paranoia (content)- Explore and clarify
Grandiose delusions- Evaluation of falseness of beliefs And degree of conviction
Perceptual disturbances, (Hallucinations of different modalities),

Insight assessment
Risk assessment
1. Preoccupation with extravagant Schemes/vulnerability
2. Thoughts of self-harm
3. Agitation/aggression/violence
RELATED TASK IN THE LINKED STATION (PART-B)
You have seen this retired farmer Mr. Read with recent change in his behaviour.
Talk to his wife Mrs. Cilla Read and discuss possible reasons for his presentation.
Discuss your management plan for this patient with his wife. Do not take collateral
history
Expanded construct: The candidate is expected to discuss possible causes for his
current presentation and address concerns expressed by the carer.
Discussion about possible causes for presentation

(Mania with psychosis, Relapse of bipolar disorder, acute confusional state, and
Organic mania- drug induced, dementia, cerebral causes etc)
132
Address concerns- Seek clarification and justify diagnosis of mania
Emphasis need for further assessment (Collateral history, medications, contacting

GP, past psychiatric history.
Address concerns-
Why not acute confusional state or why not dementia?
(Emphasise need for further cognitive assessment, CT scan etc)
Offer informal admission. (Aim- Risk minimization, mental state monitoring, further
assessment & Treatment, MDT involvement)
Detention under the mental health act, if needed-Best interests.
Address Concerns:
Relatives cannot give proxy consent, seeking second opinion.
Relatives-kept informed throughout care planning and decision making process

(Inclusion)
OLD AGE PSYCHOSIS

Psychotic symptoms of acute onset are usually seen in delirium secondary to a medical condition,
drug misuse and drug-induced psychosis.
Chronic and persistent psychotic symptoms may be due to a primary psychotic disorder such as:
Chronic schizophrenia
Late-onset schizophrenia
Delusional disorders
Affective disorders
Psychosis owing to neurodegenerative disorders, such as Alzheimers disease, vascular
dementia, dementia with Lewy bodies or Parkinsons disease
Chronic medical conditions.
Clinical features:
Persecutory delusions are the most common symptoms of late paraphrenia; they are
found in around 90% of patients (Almeida et al, 1995a)
Auditory hallucinations occurs in approximately 75% of cases
Visual hallucinations are observed in up to 60% of patients
133
First rank symptoms are less common while negative symptoms and thought disorder are
extremely uncommon
Few patients may present with delusions only (10-20%). Partition delusions (attack
through the wall, neighbours spying via any partition) are common.
According to ICD patients must either be diagnosed as having delusional disorder or
schizophrenia no separate diagnosis exists for paraphrenia
Late onset schizophrenia is characterised by (Palmer et al 2001)

Fewer negative symptoms
Better response to antipsychotics
Better neuropsychological performance Greater likelihood of visual hallucinations
A lesser likelihood of formal thought disorder
A lesser likelihood of affective blunting
A greater risk of developing Tardive dyskinesia ( The risk of developing Tardive
dyskinesia with older antipsychotics is increased in older people by 5-6 times (Kane
1999))
Similarities between early onset and late onset schizophrenia

Presence and severity of positive symptoms
Early psychosocial maladjustments
Subtle brain abnormalities revealed by imaging
Risk factors for late onset psychosis:

The contributory factors for increased risk of psychosis in elderly people would include;
Neurochemical changes associated with ageing

Age related deterioration of frontal and temporal cortices
Cognitive decline
Social isolation
Sensory deprivation (hearing loss and visual impairment)- Social isolation and
sensory deprivation are significantly associated in many studies of late onset
psychosis.
Polypharmacy
Paranoid and schizoid personality traits
Life events
Female sex
Family history, albeit weaker than younger onset schizophrenia.
Management:
No strong evidence base a Cochrane review failed to identify any eligible studies for the
treatment of late onset schizophrenia. Antipsychotics are used at a low dose with good response.
One must exclude Lewy body dementia before any such exercise and also must be aware of
vascular risks associated with second-generation antipsychotics.
Treatment
The atypical antipsychotics, which have a better side-effect profile, are considered to be more
suitable for elderly people
134
More recently there have been concerns raised regarding the safety of atypical antipsychotics
in psychosis due to dementia. The committee on the safety of medicine concluded that
olanzapine and risperidone were associated with a two-fold increase in the risk of stroke (a
small but significant risk of cerebrovascular events) in elderly patients especially in people
over 80 years, and this restriction has been extended to other atypical antipsychotics
In elderly people, age-related bodily changes affect the pharmacokinetics and
pharmacodynamics of antipsychotic drugs, which have numerous side effects that can be more
persistent and disabling in older people
Follow the principle START LOW AND GO SLOW
Research literature on the use of conventional antipsychotics suggests significant
improvement in psychotic symptoms with the use of haloperidol and trifluoperazine
hydrochloride
The usefulness of clozapine for treatment-resistant early-onset schizophrenia is well-
established but concerns about the toxicity and the need for monitoring white cell counts due
to more frequent occurrence of agranulocytosis has led to limited use in older patients and
should probably be used in treatment resistance and severe tardive dyskinesia.
The recommended doses of atypical antipsychotics for elderly people are given in the table below
but this should be taken as a guideline and the dosing regimen should be tailored according to the
needs of individual patients.
Recommended doses of atypical antipsychotics for elderly people

Starting dose (mg/day) Maximum dose (mg/day)
Olanzapine 1-5 5-15
Risperidone 0.25-0.5 2-3
Quetiapine fumarate 12.5-25 100-200
Clozapine 6.25 50-100
Ziprasidone 15-20 80-160
Psychological treatment:
Psychological treatment involves a novel approach for older people that integrates cognitive
behavioural techniques and social skills training. It aims to reduce their cognitive
vulnerabilities and improve their ability to cope with stress and to adhere to other forms of
treatment
With psychosocial interventions, such as a combination of interpersonal and independent
skills training together with standard occupational therapy was associated with improved
social functioning and independent living.
OLD AGE PSYCHOSIS- PAIRED STATION
TASK: Mr. Roger smith is a 75-year-old gentleman who was admitted against his will to
the psychiatric ward yesterday. The neighbours were concerned about him and the
consultant saw him at his home. He was not cooperative to take information yesterday.
You are asked to see him for 10 minutes before the ward rounds. Examine his mental
state and assess his thoughts and perceptions. Do not take history.
Do not perform cognitive assessment. You are seeing his brother in the next station
135
Expanded construct: The candidate is expected to examine his mental state and assess
his thoughts and perceptions.
Elicit, explore and clarify - delusions

Paranoia and persecutory delusions, partition delusions
Elicit, explore and clarify - partition delusions, ideas of reference
Evaluate the nature of beliefs and degree of conviction

Effects and coping
Hallucinations- type, content, source and reality with which they are
experienced (Auditory hallucinations-2nd and 3rd person, gustatory
hallucinations)
Rule out other psychotic symptoms, mood symptoms, cognitive symptoms
Assess contributory factors- social isolation, sensory deprivation, physical health

like infection, dementia etc
Risk assessment- self harm, self-neglect, violence, non-compliance
Mr. Roger Smith had physical examination done and blood investigations were all
normal. He was started on Olanzapine 10mgs.You are seeing his brother Mr. Brian Smith
now. Explain the diagnosis and management of his brothers condition. Address his
concerns
Expanded construct: The candidate is expected to explain the diagnosis and

management of patients condition to his brother. Address his concerns. They should
discuss the following areas
Explain- diagnosis of old age psychosis and reasons for giving this diagnosis
Explain nature and causation of psychosis in old age
Discuss treatment options (admission for further assessment & treatment, perform
investigations, risk management, role of medications)
Antipsychotics- dose, duration, efficacy and side effects
Long term management- Encourage to live in community, MDT involvement, CPN

support, psychiatric review, identify needs, provision of care package (day centres,
luncheon clubs etc)
136
Address specific concerns by relative-
1. Alternative accommodation- warden controlled sheltered housing
2. Is it the same as schizophrenia
ELDERLY ABUSE
A GP has requested you to assess this 73-year-old lady who lives with her husband, her
main carer and she is incontinent. Her incontinence nurse is concerned about her bruises,
black eye and unexplained injuries and when asked she refused to discuss about it and the
husband also refused to disclose any information.
How would you manage this situation?
1. What would be the aim of your assessment?

2. How would you approach the husband?
3. You suspect physical and emotional abuse in this patient. How would you manage the
situation?
4. If the lady is depressed and husband cannot cope with her needs, what would you do?
5. What treatments would you offer to the patient? What support would you offer to the carer?
6. What are the signs of physical, emotional and sexual abuse?
7.What are the potential risk factors for abuse in the elderly?
Given the information above, I think that the lady could be abused by her partner due to
stress involved in care giving, possibly secondary to mental illness and lack of
adequate social support
137
Arrange for a domiciliary visit to assess the lady and her husband, with a member of the
team preferably social worker (Joint assessment)
I would try to contact the district nurse to obtain more information, what she has noticed
that generates her concerns, nature and duration of the suspected abuse and enquire more
about objective evidence of abuse noticed.
Obtain information from GP (if he/she has any concerns, any history of recurrent
presentation to the surgery with unexplained physical problems like bruises, cuts or
injuries) and obtained information about past psychiatric history if any (either partner),
medical history, current list of medication and social circumstances
Make arrangement for a joint assessment and with an informant (relative/carer) who
knows the couple well, and to act as an intermediary.
The aim of my assessment would be to decide whether there is any clear evidence of abuse to the
patient, whether there is serious risk of harm to the patient or her husband and whether there is
any immediate need for immediate hospitalization or removal from the situation of abuse.
If access granted to see the patient, interview the couple individually first and then
together and then with other members of the family if any.
But in case if access denied, then we have to involve the police (or) the court, if there is
convincing evidence of continuing (or) increased severity of abuse towards his wife.
Ask in detail about the nature, onset and history of the bruises and injuries, frequency
and intensity of the maltreatment if any and try to get an accurate account of events
from the patients perspective.
I would be very careful in framing my questions to ensure that I did not suggest answers
or discourage her from disclosure.
Explore in details about the couples relationship, history of serious and chronic
relationship difficulties, drug and alcohol history, social difficulties, the degree of
social support.
After obtaining history, assess her current mental state and look for any evidence of
mental illness (depression, psychosis), subjective and objective mood assessment,
suicidal thoughts and her insight.
Also assess the cognitive state including the MMSE to rule out possible cognitive
impairment and insight.
Physical examination, neurological examination, assessment of the injuries sustained in
detail to be done.
Interviewing the couple:

Then the couple would be interviewed together which could help us to observe the quality of their
interaction, level of communication, whether they appear to care about each other, hostility,
anger, disagreements, irritability and failure to resolve conflicts could be assessed.
Assess the husband:
I would talk to the husband to get a better picture of the problem, try to make a
nonjudgmental approach, be empathetic and demonstrate understanding of the
burdens shouldered as caregivers.
I would also try to establish whether he suffers from any functional or organic illness or
possible cognitive impairment that might affect his judgement
Full assessment of the Burden of Care borne by the patients husband should be
carried out. Assess for existing care package and evaluation of the service such as home
138
help, home carers, meals on wheels, respite care and benefits they are entitled to should
be assessed in detail.
The safety of the abused person should be given prime importance.
If there were any evidence of abuse then I would report the identified abuse to the local
social services department, contact the duty social worker and follow the local protocol
for abuse of the elderly and vulnerable adults. (safeguarding vulnerable adults policy)
Inform police if a crime has been committed.
Remove the abused person from the situation of abuse and offer hospital admission to
bring the maltreatment to end immediately, to perform a full comprehensive
assessment, risk assessment and assessment of her needs.
The treatment would involve multidisciplinary approach with a wide range of
Biopsychosocial interventions and it would be focused on both the patient and her
husband
Assess whether the abused person/perpetrator is suffering from a physical or mental
health illness, drug and alcohol misuse and offer help to the abuser himself and review
the existing care package to offer more help and support.
Treat any physical illness in this case possible chronic UTI causing incontinence
An underlying depressive illness in either partner may require antidepressants
medication.
For severe marital problems, marital (or) couple therapy or family therapy may
be useful. (Counselling).
If the patient suffers from a Dementing illness, medical treatment includes
cognitive enhancers
I would also involve other members of the team

OT Assessment at home to suggest adaptations with a view of
minimizing risks, to promote independent living and improve the
environmental situation
Social services in the form of home help, meal on wheels, respite care
would be arranged to have a break for both the carer, and address
financial issues.
Psychologist to be involve for family therapy or marital therapy to deal
with marital and family problems
CPN support to monitor with compliance and to provide additional
support.
Day hospital or day centre attendance for structure and stimulation
during the day time
Carers assessment- and referral to the local carers support association.
Arrange a case conference or network strategy meeting involving
different professionals in her care and plan discharge with
comprehensive care plan, risk management plan and crisis management
plan in place.
Important features indicating abuse in an elderly person.
Report from concerned person
139
Sudden change in behaviour
Caregivers refusal to allow visitors to see an elderly patient alone
SIGNS
Physical abuse: Bruises, black eyes, rope marks, bone fractures, broken bones, skull fractures,
open wounds, cuts, punctures, untreated injuries in various stages of healing, sprains,
dislocations and internal injury (or) bleeding.
Sexual abuse: Bruises around breast, genitalia, unexplained vaginal, and bleeding torn, sustained
(or) bloody underclothing.
Emotional abuse: Emotionally upset, withdrawn, non-communicative, non-responsive and

agitated behaviour.
Signs of neglect: dehydration, malnutrition, poor personal hygiene, untreated bedsores,

unattended health problems, unsafe living conditions (wiring, heat, water) and unsanitary and
unclean living conditions.
Risk factors for abuse in the elderly
Increased physical and emotional dependency on the abuser.

Presence of worsening cognitive impairment or dementia in the victim
Presence of learning difficulties
Poor social support and ongoing psychosocial stressors
Presence of mental illness, drug and alcohol misuse in the abuser.
Marital difficulties and past history of violence
TESTAMENTARY CAPACITY
It refers to the capacity to make a valid will.
The will may be legally valid if the testator is of Sound disposing mind at the time of making
it.
This depends on four legal criteria.

Whether the testator understands what a will is and what the consequences are (Is ware of
what a will constitutes)
Basic understanding of the nature and extent of the property. (Knows the general extent
of their assets)
He/she must be aware of the people who might reasonably expect to benefit from the
assets (should know the name of close relatives and can assess their claims to the
property)
He/She should be free from an abnormal state of mind and must be free of delusional
beliefs that might affect the distribution of assets and must not be under the influence of
any drugs that tend to distort the patients mental capacity as far as making a will is
concerned.
DRIVING AND DEMENTIA
140
It is extremely difficult to assess driving ability in those with dementia. The variable
presentations and rates of progression are acknowledged.
All new patients diagnosed with dementia should notify DVLA and insurance providers. Based
on medical reports, a decision regarding fitness to drive is usually made.
Group 1 drivers: In early dementia when sufficient skills are retained and progression is slow, a
licence may be issued subject to annual review. A formal driving assessment may be
necessary.
Group 2 drivers: Refuse or revoke licence. Those who have poor short-term memory,
disorientation, lack of insight and judgement are almost certainly not fit to drive
CHILD AND ADOLESCENT PSYCHIATRY

The lecture notes are prepared by Dr. Sree Murthy and Dr. Sunanda Ghosh (SPR in child
psychiatry, Hertfordshire and some notes are Adapted from Get through work-place based
assessments in psychiatry by Sree Murthy
IMPORTANT GENERAL CONCEPTS
Interviewing the family: It is advisable to see the child or adolescent with all members of the
family.
Enquire about the presenting problem and try to obtain a full description of the problem
behaviour from parents, teachers, child etc. It should include
The mode of onset or evolution of the presenting problem
The nature and severity of the presenting problem
Frequency
The setting in which the problem behavior manifests like home environment or at school
The effect of it on siblings, family members, friends, school, attitude of others to the
childs behaviour and the way that the parents deal or react with the problem behaviour.
Also enquire about other current problems or complaints.
141
Then try to obtain more history and in any child psychiatry case, remember to obtain the
following information in history. Developmental history and parental relationship issues may be
best obtained from parents.
Birth History prenatal, perinatal & postnatal History
Developmental History-milestones (cognitive, languages, motor and social skills)
History of Serious childhood illness/ hospitalisations.
Childhood neurotic traits (temper tantrums, enuresis, thumb sucking, nail biting).
Losses/ separation
Problems at home: Abuse physical emotional and sexual, other difficult situation at
home including parental disharmony and sibling rivalry, quality of parental and parent
child relationship.
Problems at school: Teasing, Bullying, poor academic performances, change of school,
extra help, learning support (etc).
Problems with peers being bullied / exposed to antisocial behaviour, drugs etc.
Recent Stressful events
Rule out the possibility of Secondary gain for the problem behaviour.
Interviewing the child

Young children should be invited to play using age appropriate toys, which would help to
establish rapport and gain the childs confidence.
It would be more appropriate to begin the interview well away from the presenting problems by
enquiring about friends, siblings, school, interests and hobbies etc.
Then it would be useful to enquire about the following;

The childs view of the problem,
Mood, any particular worries and or fears
Sleep and appetite
Relationships with siblings and family members
Relationship with friends or peers at school
Enquire about difficulties at school like bullying etc
Fantasy life
Abnormal experiences
Suicidality
MSE:
Observation of a childs Appearance, behaviour, nutritional state.
Activity level, fidgetiness, involuntary movements,
Look for evidence of neglect, bruising etc
Habits and mannerisms,
Rapport, eye contact and spontaneous talk.
Mood observe for signs of sadness, misery, tension, and anxiety.
Look for presence of delusion, hallucination, thought disorder.
Level of awareness and evidence of absence seizures or minor epilepsy.
Also look for childs relationship with parents, interactions, resentment and ease of
separation. If siblings can be present, then their behaviour and interaction can also be
evaluated.
It is also important to observe the pattern of interaction and emotional atmosphere of
family and also observe the ease of communication between family members.
142
Physical Examination-usually have a parent present.
Psychological assessment-measures of intelligence and educational achievements are often
valuable.
Common Psychological intervention used in Child psychiatry
Behavioural therapy: Behavioural methods are used to encourage new behaviour by positive
reinforcement (e.g. Praise, rewards), modelling and efforts are made to remove any factors in the
childs environment that are reinforcing unwanted behaviour through negative reinforcement (e.g.
By removing the childs privilege.)
It has four stages

1. Define and record the behaviour
2. Identify the stimuli and reinforcement
3. Change the reinforcement
4. Monitor progress.
Functional behaviour analysis is performed to analyse the (ABC) antecedents, behaviour and
consequences with the help of parents. Parents are taught how the childs unacceptable behaviour
may be reinforced unintentionally by paying attention to it and they are also taught how to
reinforce normal behaviour by praise (or) rewards and measures to eliminate unwanted behaviour
by removing the childs privileges.
Cognitive therapy: It is useful mainly for older and school age children who have the
capabilities to describe their problems and who can learn to control their ways of thinking that
give rise to symptoms and problem behaviour and the methods generally resemble those used
with adults. The most common targets of CBT and social skills therapies for children are
aggressive behaviour, emotional dysregulation, social interactions and self evaluation.
Family therapy: Symptoms of the child are often considered as an expression of

malfunctioning of the family, which is the primary focus of treatment. Therefore both parents are
involved often together with the child and may be joined by other children and members of the
extended family.
The family therapists have the following goals that would include
Improved communication within the family,
Improved autonomy for each member
Improved agreement about roles and reduced conflict.
Parent management training improve the skills of parents with deficient

Parenting skills and is mainly used to assist parents of children with behavioural problems that
require special parenting skills for example the parents of children with conduct disorder or hyper
activity.
These programme use Behavioural principal as explained above. The parents are provided with
written information and videotapes showing other parents applying these behavioural principals.
It also involves teaching Good parenting skill that include
Promoting a positive relationship with the child
Using praise and rewards to increase desirable sociable behaviour
Setting of clear rules and directions
Using consistent and calmly executed consequences for unwanted behaviour.
Reorganising the childs play to prevent problems.
143
Teachers training and interventions in school
Teachers are taught technique for use with children in their class and focus on
interventions to promote positive behaviour.
The important targets of classroom techniques would be
Promoting positive behaviour and following established class rules and procedures
Preventing problem behaviour and preventing the escalation f angry behaviour and acting
out
Teaching social and emotional skills such as problem solving and conflict resolution
Multi-systemic therapy
The intervention model with the most empirical support for treating children and
adolescents with Conduct Disorder is Multisystemic Therapy (MST).
Problem behaviours are conceptualised as being linked with individual characteristics
and with various aspects of the multiple systems in which the child is embedded,
including the family, peers, schools, and neighbourhood.
On a highly individualized basis, treatment goals are developed in collaboration with the
family, and systemic strengths E.g. an aptitude for sports or music are used as levers for
therapeutic change.
Specific interventions used in MST are based on the best of the empirically validated
treatment approaches such as cognitive behaviour therapy and the pragmatic family
therapies. Specific interventions are designed to promote responsible behaviour and
reduce irresponsible behaviour.
Intervention requires daily or weekly effort by parents and they are designed to promote
and empower parents and families to address their childrens needs across multiple
contexts and resolve future difficulties.
The therapy is given for 3 months and then stopped.
The progress is monitored on a weekly basis, which enables barriers to improvement to
be addressed immediately. The parents and teenagers fill in weekly questionnaires on
whether they have been receiving therapy as planned.
The primary goals of MST are to reduce rates of antisocial behaviour in the adolescent
and reduce out-of- home placements.
Social interventions - Remember 5S

Special education and teaching to remedy backwardness in reading, writing and
arithmetic skills
Social worker family assessment, individual counselling for the child and members of
the family, arrangements for special care, finances and accommodation.
Support increased support to parents and teachers.
Social activities more indoor and outdoors activities at school and joining social clubs.
Substitute care respite care, residential care, fostering, day patient and in patient
care.
144
ATTENTION DEFICIT HYPERACTIVITY DISORDER
Clinical features of ADHD
Useful points:
Clinical features:
Hyperactivity-impulsivity symptoms include: fidgeting, moving, getting up and running

about, climbing on desks, etc.; talking excessively; unable to play quietly; blurting out
answers; jumping the queue; continually interrupting.
Inattention symptoms include: cannot sustain attention; easily distracted; poor task
completion; dislikes, can't organize, and makes mistakes with tasks that require attention;
doesn't listen, is forgetful, and loses things for tasks.
Very young children are often sensitive, have poor sleep, cry a lot, and are constantly
active. (Adapted from Oxford handbook of psychiatry)
Diagnostic criteria:
145
According to DSM-IV criteria, to meet the diagnosis of ADHD, some symptoms must be
present before the age of 7 years, although ADHD is not diagnosed in many children until
they are older than 7 years when their behaviours cause problems in school and other
places.
To confirm a diagnosis of ADHD, impairment from inattention and/or hyperactivity-
impulsivity must be observable in at least 2 settings and interfere with developmentally
appropriate functioning socially, academically, or in extracurricular activities and should
persist for at least six months.
ADHD is not diagnosed when symptoms occur in a child, adolescent, or adult with a
pervasive developmental disorder, schizophrenia, or other psychotic disorder.
Prevalence:
In the USA, incidence is estimated at 3-5%. DSM-4 gives prevalence estimates for
ADHD of 3-5% in school age children but different studies performed in different centres
and countries give rates that vary from 1.7% to 16.1 % (Jadad et al 1999)
In Great Britain a lower incidence was reported than in the United States. 2-5% school
children and adolescents would meet the DSM-IV criteria of ADHD, only 1% would
meet the criteria for hyperkinetic disorder.
ADHD is more prevalent in boys than in girls. Male-female ratios range from 9:1 to 6:1
in clinical samples but are about 4:1 in community-based population studies.
TASK: ADHD- HISTORY TAKING
Mrs. Young is a 32-year-old lady attending the CAMHS Clinic with her 6-year-old son
Abraham. The GP referred her son to the clinic for psychiatric evaluation.
a. Obtain history from his mother looking for features of attention deficit hyperactivity
disorder.
b. Rule out co-morbidity.
Expanded construct: The candidate is expected to Obtain history from the childs
mother looking for features of attention deficit hyperactivity disorder and Rule out co-
morbidity. They should be able to obtain;
Brief history of symptoms: Onset, duration, Nature and severity of presenting

problems, frequency, provoking and ameliorating factors, Criteria met both
at home and at school
146
Hyperactivity-extreme and persistent restlessness
Sustained and prolonged motor activity (fidgeting, moving, getting up and
running, continually interrupting, unable to play quietly)
Impulsiveness and difficulty in withholding responses- talking excessively,

blurting out answers, jumping the queue etc
Inattention symptoms; difficulty in maintaining attention, Lack of persistence

with tasks, easily distracted, is forgetful and loses things for tasks.
Rule out co morbidity (conduct disorder, antisocial behaviour, Tic disorders,

Autistic spectrum disorders, Learning disability, depression etc)
INTERVIEW
Elicit History of behaviour, initially with open ended questions:
What are your concerns for Abraham? Or Abraham, has your mother explained why we
had to come for this appointment today
Do you feel you have any problems at school?
Why do you think your teacher/mother/GP is concerned for you?
Can you give me some examples of such behaviour?
How do you find him in comparison to his siblings/other children of his age group.
[Behaviour should be out of ordinary in the context of developmental age/ environment]
Is his behaviour any different when he is at home/at school. Or, when/where is this
behaviour commonly seen/ most noticeable. [Is behaviour persistently noted in more than
one area school, home, shopping mall etc]
When were these concerns first noted/Who first pointed out these concerns and
when.[Symptoms should have been noticeable before 7 years of age. Also sometimes the
behaviour may be age appropriate, but deemed not acceptable by parent or responsible
adult. Look out for recent changes in behaviour indicating a possibility of recent psycho-
social changes including abuse, bullying, parental separation etc Also helps explore
comorbidity ]
Identify Core symptoms:
Tip:Based on time remaining and the answers to your open ended questions, you may chose to
focus on those symptoms which have not been elicited. You may also ask the parent to elaborate
on examples already given while focussing on specific symptoms.
Inattention:
What does he like/not like about school? [dislike of activities that take mental effort,
dislike of teachers or subjects that require attention]
Is he often distracted? If yes ask for examples and details eg: What can you see him
doing when he is sitting in front of the television? Is he able to tell you what happened in
the program? Is he constantly fidgeting while watching the television? While playing
147
games does he keep changing games? or Left on his own, how long can he play the
same game for.
Do you find that you need to give him instructions in a particular way? [Possible h/o not
listening when spoken to directly] or Does he seem to forget instructions? What happens
when you give him instructions?
Is he an organised child?
Would you say that Abraham is a forgetful child. What kind of things would he forget
How often does this happen? or Does he tend to lose his belongings at school?
Hyperactivity
Do you feel able to take Abraham to the Cinema/ go shopping with Abraham. What
would happen if you took him to a shopping Mall? [Some questions may elicit symptoms
across various domains]
What was Abraham actually doing when the teacher felt he was being hyper
Would you say that he was always on the go/driven by a motor?
Is he able to remain on his seat when he is expected to do so? What does he do while
he remains seated?[eg: fidgeting, tapping etc]. How often does he/do you feel restless or
fidgety? How often did you feel so restless that you could not sit still?
Does he climb on furniture
How is he during play time/ Can he play on his own without disturbing other children
Impulsivity:
Do you have any specific concerns regarding Abrahams safety at home or on the roads?
How does Abraham explain his behaviour?
What does Abraham do when he has to wait for his turn at a queue?
What happens/ Are you able to have a conversation with your friends when Abraham is
around? Or When Abraham is at home, are you able to talk to friends on the phone? [&
why]
Has Abraham had any serious injuries in the past? [H/o multiple visits to A&E, H/o
fractures during play due to carelessness or impulsivity]
Co morbidity:
In general, would you describe Abraham as a happy child?
Does Abraham tend to worry about anything in particular?
Has school made any specific complaints against Abraham [?conduct/oppositional
behaviour]
Ask re: Suicidality/self harm
Have school reported any specific learning disability?
Development:
How was Abraham as a young child/before all these problems started
Do you remember any specific events that may have affected your or Abrahams health
during child birth
148
ADHD- COUNSELLING & METHYLPHENIDATE TREATMENT
The term attention deficit hyperactivity disorder is used mainly in the USA. In UK, the
official term is hyperkinetic disorder.
These children usually under 5-s are overactive, restless and excitable. They have
difficulty concentrating and have problems with attention control. They are easily
distracted and do not finish things. They are impulsive, suddenly doing things without
thinking first.
Although this type of behaviour is not uncommon in children, it becomes a problem
when these characteristics are exaggerated, when compared to other children of the same
age.
We do not know the exact cause of this disorder. It tends to run in families and genetic
factors seem to play a part. Boys are generally affected more than girls.
There is no specific blood test or other investigations for ADHD.
149
The assessment is usually done by a child psychiatrist or specialist paediatrician and a
full diagnosis can be made.
There is some evidence about the effect of diet on children as some children may be
sensitive to certain foods and can become hyperactive on them. If parents notice such
changes with specific foods, it is best to avoid them.
Some medications such as methylphenidate may reduce hyperactivity and improve
concentration as well. It possibly could help children to think more clearly, to understand
things better and feel more in control of themselves.
The exact mechanism of action of stimulant medications is not clearly known and it
possibly seem to affect parts of the brain involved with paying attention and organising
our behaviour
The effect begins within 30-60 minutes of taking them. Longer acting preparations are
also available. However, the exact amount of dose will be adjusted by the specialist
Common side effects would include reduced appetite and staying awake later than usual.
Less common side effects would include tics or twitches, drowsiness or dizziness,
headache, tummy aches and or feeling sick.
For most children, medications may need to be continued for several years and some may
need medication as adults
Treatment will be monitored regularly by specialist. Your GP should perform regular

health checkups and repeat prescriptions.
However medications are used as one part of the treatment for ADHD.
Effective treatment will include advice and support for the parents
Practical ways of helping child to improve behaviour include praising good behaviour,
rewards for good behaviour, praising for efforts and achievements and brief periods of
time away from other when presenting with challenging behaviour.
It is also important that the child has adequate help with learning in the classroom from
teachers and with controlling difficult behaviour
Management
1. Advice on managing difficult behaviour
2. Education and explanation of the condition to parents
3. Medication-drugs like methylphenidate and dexamphetamine. These are stimulant
medications that affect the action of certain chemicals in the brain. They can possibly
reduce hyperactivity and increase attention in children and are used as one part of the
treatment for ADHD.
4. Special support and teaching. Advice to teachers on structured activities and reward
systems for positive behaviour.
NICE GUIDELINES
NICE guidance on the use of methylphenidate (Ritalin) for attention deficit/hyperactivity disorder
(ADHD) in childhood
150
Methylphenidate is recommended for use as part of a comprehensive treatment
programme for children with a diagnosis of severe attention deficit/hyperactivity disorder
(ADHD).
Methylphenidate is not currently licensed for children under the age of six or for children
with marked anxiety, agitation, or tension; symptoms or family history of tics or
Tourette's syndrome; hyperthyroidism; severe angina or cardiac arrhythmia; glaucoma; or
thyrotoxicosis. Caution is required in the prescribing of methylphenidate for children and
young people with epilepsy, psychotic disorders, or a history of drug or alcohol
dependence.
Diagnosis should be based on a timely, comprehensive assessment conducted by a
child/adolescent psychiatrist or a paediatrician with expertise in ADHD. It should also
involve children, parents and carers, and the child's school, and take into account cultural
factors in the child's environment. Multidisciplinary assessment, which may include
educational or clinical psychologists and social workers, is advisable for children who
present with indications of significant comorbidity.
Treatment with methylphenidate should only be initiated by C&A psychiatrists or
paediatricians with expertise in ADHD, but continued prescribing and monitoring may be
performed by GPs, under shared care arrangements with specialists.
Careful titration is required to determine the optimal dose level and timing. The drug
should be discontinued if improvement of symptoms is not observed after appropriate
dose adjustment.
A comprehensive treatment programme should involve advice and support to parents and
teachers, and could, but does not need to, include specific psychological treatment (such
as behavioural therapy). While this wider service is desirable, any shortfall in its
provision should not be used as a reason for delaying the appropriate use of medication.
Children on methylphenidate therapy should receive regular monitoring. When
improvement has occurred and the child's condition is stable, treatment can be
discontinued at intervals, under careful specialist supervision, in order to assess both the
child's progress and the need for continuation of therapy
TASK: ADHD COUNSELLING & TREATMENT
Mr. Abraham is a 6-year-old boy attending the CAMHS Clinic. He has been assessed and
diagnosed with ADHD. Mrs. Young is curious to know about the diagnosis and drugs
available for the treatment of her sons condition. She is worried about other siblings.
Address her concerns and allay her anxiety.
Expanded construct: The candidate is expected to discuss the diagnosis and drugs
available for the treatment of ADHD. Also Address moms other concerns and allay her
anxiety.
Explain diagnosis of ADHD in simple terms
151
Explain nature of the condition and aetiology
Methylphenidate- Mode of action and efficacy, duration of treatment,

Side effects (Short-term and long-term)
Concerns
1. Blood tests to confirm diagnosis
2. Growth suppression
Concerns
1. Stimulant and its effect on sleep
2. Need for special diet
Other Concerns
1. Effect on other child
2. ? Affect unborn child
ADHD- NOTES ON MANAGEMENT
Investigation: -
a) Connors rating scale parents and teachers (before diagnosis)

b) Educational psychology assessment
c) Psychometric assessment (IQ) WISC
d) Family Assessment
f) School visit- to observe his/her behaviour at school, Liaise with the teachers and to the
educational psychologist.
g) CT/EEG - if clinically indicated.
Treatment:
152
According to NICE guidance, Methylphenidate is recommended for use as part of
comprehensive treatment programme for children with a diagnosis of ADHD. The
diagnosis should be based on a timely comprehensive assessment conducted by a child
and Adolescent psychiatrist or paediatrician with expertise in ADHD.
Drug treatment should only be part of the treatment plan and appropriate psychological,
psychosocial and behavioural interventions should be put in place.
Methylphenidate should be used as first line treatment: Start with 5-10 mg in the
morning, can add 5-10 mg at mid-day, late dose should be avoided as it can cause
insomnia. The dosage can be titrated up to a maximum of 60 mg/day in divided doses
using weekly increments of 5-10 mg
Side effects: loss of appetite and weight loss, nausea, vomiting, insomnia, anxiety,
dysphoria, headaches, raised blood pressure and rarely tics.
Growth retardation may be a long-term side effect of high doses over longer periods.
Recommended monitoring- BP, Pulse, height & weight, monitor for insomnia, mood and
appetite changes and the development of tics regularly
Monitor response using Connors rating scale
Discontinue if no benefits seen in 1 month
Methylphenidate sustained release tablets: Start initially on 18 mg in the morning, titrated
up to a maximum of 54 mg.
However methylphenidate is not currently licensed for children under the age of six.
Other drugs that could be used would include Dexamphetamine and Atomoxetine.
Atomoxetine should be started on 40 mg, which should be increased to 80 mg after a
weeks time. The once daily dosing is convenient for use in school children.
Monitoring of LFTs is advisable for children on Atomoxetine.
Psychological:
a. Behavioural modification programme: Methods of behavioural modification may help to

reduce the inadvertent reinforcement of over activity by parents and teachers.
Involve the family and school and educational psychologist.
b. Parent management training improve the skills of parents with deficient parenting skill.
Good parenting skill training include
1. Promoting a positive relationship with the child
2. Praise and rewards for sociable behaviour
3. Setting of clear rules and commands, consistent and calm consequences for unwanted
behaviour.
c. Teachers Training teachers need advice about management, which may include remedial
teaching.
d. Social skills training
Social: Support to parents and teachers.

Social worker family assessment and special care.
Note: - Also need to consider co morbidity especially anxiety, conduct disorder, developmental
disorder, OCD and tic disorders.
153
If left untreated, ADHD can lead to
1. Increased rate of substance misuse
2. Increased rate of juvenile delinquency in the long run
3. Increased rated of psychiatric disorders such as depression and anxiety
4. Academic failure and increased rate of subsequent antisocial behaviour.
CONDUCT DISORDER
Conduct disorder is an enduring set of antisocial and aggressive behaviours that evolves over
time, usually characterized by aggression and violation of the rights of others. Oppositional
Disorder have similar negative attributes, but in a limited fashion.
According to ICD10, oppositional disorder is a subtype of conduct disorder. DSM-IV excludes

oppositional disorder if a conduct disorder is present.
Diagnostic criteria:
Children with conduct disorder are likely to demonstrate behaviours in the following four
categories
154
Physical aggression or threats of harm to people, cruelty to people and animals
Destruction of their own property or that of others
Theft or acts of deceit
Frequent and serious violation of age-appropriate rules. (Like truanting or running away)
Other features would include early sexual behaviour, lack of empathy, low self-esteem, and gang
involvement.
Usually should be present for substantial duration of minimum six months.

According to DSM-4 criteria, these behaviours should begin before the age of 13.
[Childhood onset type symptoms present before age 10, Adolescent onset type
symptoms develop after age10]
CD is the cause of great suffering in both the individual and in society; it is one of the major risk
factor for adult antisocial behaviour posing a major burden on public resources. Conduct disorder
occurs with greater frequency in the children of parents with antisocial personality disorder and
alcohol dependence than in the general population. In the Isle of White study, CD was found to
be the most common psychiatric disorder amongst 10-11 yearr olds.
Epidemiology:
Estimated rates of conduct disorder among the general population range from 1 to 10
percent, with a general population rate of approximately 5 percent.
The disorder is more common among boys than girls, and the male: female ratio is 4:1.
Risk factors for CD
Ontario Child Health Survey[1987] : Three most significant risk factors:

Family dysfunction
Parental mental illness
Low income
Rutter [1978] :
Low socioeconomic status, [Low family income]
Criminality of father,
Overcrowding,
Maternal neurosis,
Institutional care
Chronic marital discord
Assessment-checklist
Clarify the purpose of the assessment

Obtain a full history with collateral from Parents, school and community
Identify causal risk and protective factors.
Assess for co morbidity and make a diagnosis
Formulate the problem and establish management plan
TASK: CONDUCT DISORDER- HISTORY TAKING
155
You have been asked to assess John, 12-year-old boy in the CAMHS clinic. He was
referred for outpatient evaluation by his GP, after being picked up by police for running
away from home. Obtain history from his mother Ms. Kate to arrive at a diagnosis. Also
obtain relevant background information.
Expanded Construct:
History of presenting problems, duration and reasons for presentation-

Explore mums concerns in detail.
Physical aggression or threats of harm to people, cruelty to people and animals,

bullying and intimidation of others, starting physical fights, using weapons in fights.
Destruction of their own property or that of others, vandalism

Theft or acts of deceit, shoplifting, setting fires to cause damage
Frequent and serious violation of Age-appropriate rules

(Like truanting or running away, lying, cheating etc)
Risk factors; (Family history of antisocial behaviour,

Parental criminality, domestic violence
Poor School achievement etc

(Depression, ADHD, substance misuse etc)
Interview
Introduction:
I understand that I have been asked to see John after he was picked up by police for running away
from home. I feel there might be a lot going on for you and John at present. I was hoping to find
out more about it in the time given to me before I met John.
Presenting Problems:
- What happened on the day when John ran away from home?
- Did something make him upset. Is this the first time he has wanted to run away/ behaved
in this way?
- Has he been doing anything unusual lately? Has his behaviour been different lately?
H/o conduct disorder:

- Can you give me examples of being disobedient? Does he also behave in this manner
outside home? Has he ever been excluded from school?
- How does he react to being told no?
- Does he get involved in physical fights? Has he ever hurt any animal or pet?
- Have you known John to steal or lie? Has he ever broken the law? Has he ever damaged
property?
- How does John respond when hes found stealing or lying?
156
- Does he often stay out of house for late / or at night even when hes been told to come
back?
- What concerns have you heard from school? What can you tell me about his attendance
at school?
- Do you feel that John could be a bully at school?
- Is this the only time police had to be concerned about Johns behaviour?
- Would you say that these problems are significant to a point that they affect his normal
life?
- How long has this been a problem for? For how long has he been behaving badly?
- If John were here, would he agree with what you have said/ agree that he has a difficult
behaviour [People with conduct disorder minimise their difficulties]
Personal history + Risk Factors for Conduct Disorder:

- Who else is there in the family? Does anyone in the family have a story/behaviour similar
to Johns?
- Does any member of your family have a problem with alcohol or uses drugs like cannabis
etc. Do you know if John uses alcohol, tobacco or illicit substance abuse?
- Can you tell me more about Johns father?
- Is there any history of violence in the family? Can you tell me if the police ever arrested
or charged a member of your family?
- Has John ever hurt himself?
- Has John felt that life is not worth living?
- Do you know if John ever carries a knife or any other weapon?
Treatment:
Psychological: -
Behavioural programme: Functional behaviour analysis to analyze the (ABC)

antecedents, behaviour and consequences with the help of parents. Parents are taught how
the childs antisocial behaviour may be reinforced unintentionally by paying attention to
it and they are also taught how to reinforce normal behaviour by praise (or) rewards and
measures to eliminate unwanted behaviour by removing the childs privileges. These
programmes should focus on issues such as damage to property, non-compliance with
house or school rules, physical and verbal abuse.
Parent management training programme: - These programme use Behavioural

principal as explained above. The parents are provided with written information and
videotapes showing other parents applying these Behavioural principals. It also involves
teaching Good parenting skill that include promoting a positive relationship with the
child, Praise and rewards for sociable behaviour, setting of clear rules and commands,
consistent and calm consequences for unwanted behaviour.
Teachers remedial teaching if there are any associated reading difficulties.
Anger management: helpful for habitually aggressive children and these programme
teaches how to inhibit sudden inappropriate response to angry feeling for (e.g.) stop &
think what I should I do?) and also to reappraise the intention of other people and use
more socially acceptable forms of self esteem.
157
Family Therapy
Multi-systemic therapy: (Therapy with the best available evidence)
The intervention model with the most empirical support for treating children and adolescents with
Conduct Disorder is Multisystemic Therapy (MST).
Problem behaviours are conceptualised as being linked with individual characteristics and with
various aspects of the multiple systems in which the adolescent is embedded, including the
family, peers, schools, and neighbourhood. On a highly individualized basis, treatment goals are
developed in collaboration with the family, and family strengths are used as levers for
therapeutic change.
Specific interventions used in MST are based on the best of the empirically validated treatment
approaches such as cognitive behaviour therapy and the pragmatic family therapies. The primary
goals of MST are to reduce rates of antisocial behaviour in the adolescent, reduce out-of- home
placements, and empower families to resolve future difficulties.
Physical:
Medication Not first line treatment.
Consider treatment with stimulants for co-morbid ADHD if psychosocial treatments fail.
Treatment with antidepressants there is evidence of co-morbid depression.
There is growing evidence supporting the use for risperidone in aggressive behaviour but
should be used with caution due to EPSEs
Social:
Social services family assessment, increased support to parents (for the sake of mother
and other siblings in this case) and family respite care.
Residential placement in a foster home, group home (or) special home needed
occasionally. This should be done only for compelling reasons.
Referral to youth clubs, youth offending teams
Prognosis:
CD usually runs a prolonged course in childhood. (Rutter et al)
According to research evidence, almost half of people who had attended a child guidance
clinic for conduct disorder showed some form of antisocial behaviour in adult life
(Robins 1966)
Follow up studies indicate that about 40-50% of CD children had antisocial PD diagnoses
in their early adulthood and many of the rest had persistent and widespread social
difficulties below the threshold for diagnosis of a personality disorder.
AUTISTIC CHILD
Autism is a pervasive developmental disorder involving deficits in language and non-verbal
communication, marked impairment in reciprocal social and interpersonal interaction and
abnormal behavioural characteristics such as repetitive or stereotypical behaviour. All of these
should be present before the age of 36 months. It is characterised by a triad of symptoms:
Abnormal social relatedness

A qualitative abnormality in communication or play
Restricted, repetitive, and/or stereotyped behaviour, interests, and activities
158
In addition, 70% have mild to moderate LD. The remaining 30% with normal IQ are classified as
either high-functioning autism (with language difficulties) or Asperger's syndrome (with normal
language).
Aspergers syndrome represents mild case of autism without any significant delay in language or
cognitive development including intelligence
AUTISM AND ASPERGERS SYNDROME
Simple Explanation: These are developmental disorders that are caused due to abnormalities in
the way the brain develops and works. The children may have difficulties in three areas
1. Socialising
2. Behaviour-unusual behaviour
3. Communication
It usually shows itself in the first three years of life. Little is known about the causes of this
condition and they appear to be genetic conditions.
Investigation:
1. Psychologist to be involved to perform psychometric assessment to determine IQ assessment
and rule out Learning disability
2. Educational psychologist assessment
3. ADI with trained assessor, ADI R (autism diagnostic interview revised)
4. ADOS assessment (trained assessor), (ADOS-G Autism diagnostic observation schedule
generic)
5. Speech and language assessment
Treatment:
Educate the parents about diagnosis, treatment options and prognosis.
Behavioural management-functional analysis of target behaviour and the formulated
plan should focus on promoting desired behaviour and reduce unwanted ones. If the child
is behaving inappropriately view this as needing to be clearer about the rules and state the
rules of expected behaviour very clearly.
Adequate effort should be taken to educate the child in a mainstream school setting
with more intensive support.
If his functioning is very low, Special schooling of appropriate educational placement
should be considered having obtained report from educational psychologist, SENCO
(school educational needs coordinator), obtaining medical report and involvement from
social worker
Social services to be involved comprehensive assessment of social care needs for the
child and the family, Attend special day schools and encourage living at home.
SS to arrange Special care, childcare assistance and residential schooling.
Vocational training older adolescents.
Increased support to the family
Join a voluntary organization and autistic society meet other parents of autistic
children and discuss common problems.
Medical management:
Medication very little role may be helpful in addressing specific problems.
159
Antidepressants such as SSRIs may be effective in ameliorating repetitive and
aggressive behaviors.
Psychostimulant medication for co-morbid ADHD.
Antipsychotics such as risperidone are probably effective in the treatment of
hyperactivity, aggression, and repetitive behaviour and possibly effective in the treatment
of depression and irritability.
TASK: AUTISM- HISTORY TAKING
Mrs. Young is a 32-year-old lady attending the CAMHS Clinic with her 5-year-old son
Paul. The community paediatrician referred him, because he wanted a psychiatric opinion
as his speech is delayed and he is reported to be not normal. Obtain developmental
history from his mother looking for features of autism
Expanded construct: The candidate is expected to Obtain history from the childs
mother looking for features of autistic spectrum disorder. They should be able to obtain;
Birth history
Developmental History -milestones
(Motor, language, cognitive and social skills)
Gross impairment in reciprocal social interaction

(Poor Eye contact, failure to develop peer relationships, Reduced interest in shared
Enjoyment, lack of social reciprocity & empathy etc)
Qualitative impairments in communication or play

(Delay or lack of spoken language, difficulty
In initiating or sustaining conversation, lack of developmentally appropriate
symbolic or social play)
Restricted, repetitive and stereotyped interests or activities

(Resistance to change, obsessive preoccupations with routine, timetable, objects;
stereotyped body movements like hand flapping, Body rocking)
Rule out co morbidity

(Learning disability, seizures, ADHD etc)
SCHOOL REFUSAL
Refusal to go to school or stay in school, even when under pressure from parents and
school authorities.
School refusal is considered as a problem rather than a diagnosis, it is a condition that
often co-occurs with anxiety disorders.
School refusal is characterized by significant difficulty attending school, resulting in
prolonged absence and/or severe emotional upset in children
160
These children often display excessive fearfulness, temper outbursts, or complaints of
feeling ill when faced with the prospect of going to school. The complaint is more of
physical symptoms such as headaches, abdominal pain, nausea, palpitations etc.
The nature of the anxiety associated with school refusal behaviour is likely to change
with age, as is the nature of the precipitating events. For example, fear of separation is
more common in younger school refusers, while in older children social-evaluative fears,
such as fears of teachers or peers, are more commonly reported.
Sex distribution-equal
Three main incidence peaks by age:
Age 5: School entry. Essentially a manifestation of separation anxiety

Age 11: commonest age of presentation. May be triggered by transfer to
secondary school.
Age 14-16: First presentation of depression or phobic anxiety
School Refusers Truants

1. Presence of emotional symptoms Presence of antisocial symptoms
2. Family history of neurosis Family history of antisocial behaviour
3. Over-protective parenting Inconsistent discipline
4. Satisfactory academic achievement Poor academic achievement
5. Small family or the youngest member Large family size
Treatment: The treatment should involve different members of the multidisciplinary team
working with the child, family and school and it should be tailored to the needs of the child.
1) Anxiety management and Relaxation training for anxious children
2) Family therapy to explore issues like over protective parents at home. It may change the
family dynamics and may empower the parents to aid the childs return to school.
The first step is to carry out a functional analysis of the school refusal behaviour, to organize a
meeting with school and parents and should consider Best Return to-School Package that
should involve the parents, teachers and child in the programme.
If the onset is acute, then a rapid introduction to school should be aimed for. Arrangements
should be made for an early return to school.
It is at times more satisfactory for someone other than the mother to accompany the child to
school at first
If chronic, then a graded programme of exposure to school life may be needed.

Support the family and child, and aim for graded start back to school.
Steps: Graded Behavioural Plan
Establishing a good therapeutic relationship with the child and the family.
Identification of triggering factors/situation which gives rise to anxiety at home/ (or)
school.
Selection of appropriate method of desensitizing the boy to the feared situation.
Challenge & confront the feared situation.
161
Review of progress at appropriate intervals and identifying high-risk situation for relapse.
Biological:
Treat any co morbid illness such as anxiety or depression. Antidepressants rarely necessary but
are helpful
Social:
1. Increase socialization by joining clubs.
What about Home Tuition?

1. May worsen the problem.
2. Increase time away from school
3. Social relationship may be affected.
4. Education may be affected longer term.
School refusal
1. It is egodystonic as the child can be upset about not going to school

2. Usually there is associated anxiety or somatic symptoms
3. The parents are usually aware of the non attendance
Truancy
1. It is ego-syntonic as the child is usually not usually distressed about the non attendance
2. Usually associated with antisocial behaviour
3. The parents are not usually aware of the childs non attendance
Impact of unchanged situation
1. Worsening of current situation

2. Social relationships may be affected and possibility of impairment of adequate social skills
3. Deterioration in self-confidence, mood and self-esteem
4. Long term education may be affected.
CHILDHOOD SEXUAL ABUSE

Task: You are assessing a 14-year-old girl in the A& E department who has taken
an overdose of paracetamol tablets. Whilst assessing her, she showed a paper on her
hand reading RAPE and during discussion, she discloses that her stepfather has
been sexually abusing her. Her stepfather was seated in the waiting room.
162
How would you proceed? Discuss how you would manage this situation with the
consultant.
Expanded construct:
Acknowledge-serious issue, Take as much history as possible,

Also not to contaminate evidence
Inform child-about necessity to break confidentiality

And share information with colleagues
Short term: Medical Treatment for overdose,

Referral to social worker, child protection officer, police if needed,
To inform-parental responsibility
Child to be accompanied & supported
Assess mental state of the child

Risk: Ongoing suicidal thought, plans
Risk of other siblings at home
Offer admission to hospital- Paediatric ward or child psychiatric unit for

further assessment and monitoring
In the intermediate and long term: Social services to conduct a full

investigation (SW- Emergency protection order, care order if there are
imminent risks involved), Network meetings,
Press charges against the perpetrator if needed
Further management for child; Counselling, Psychotherapy and support

Also seek senior colleague support and discuss with lead consultant for child
abuse issues
Possible questions from the consultant:
How would you proceed?

Who else should be involved in this case?
Who else should be considered in your risk management?
If there were imminent ongoing risks what would you do?
What support can be offered to the child on a long-term basis?
What are the short term and log term implications of prolonged abuse?
Suggested approach:
I will take it seriously and I will try to take as much history as possible to make a social
service referral but not too much in order not to contaminate the evidence i.e when it
occurred, is it occurring now who else is involved.
I will not go into the details of actual abuse, I will tell the child this is one of the instances
where I would have to break confidentiality and share information with my colleagues
163
I will make sure that one of my colleagues sits with the child while I make the referral to
the duty social worker in local social service team
I will follow it up by a written referral, I will inform whoever has the parental
responsibility and make sure the child is safe I will keep the child until the social services
come and make a decision for the placement of the child.
I will also do a mental state examination, as this may be required when they make a
decision about the childs placement.
In the intermediate and long term, I will be involved in network meetings and
recommendations and she and family may require psychotherapy in long run.
I am aware in the short term it is the social service responsibility to conduct a full
investigation
Important points:
When sexual abuse is disclosed then the assessing professional should stop the interview after
gathering the minimum information to suggest that this is what has happened and inform the
social services and senior colleague. The reason why the interview needs to be stopped is for
fear of contaminating the evidence given by the child.
The parents need to be informed that social services were contacted and depending on the
concerns and the structure of the family the child might be placed in an alternative
accommodation.
The child will be interviewed by the trained professional and examined by specially trained
community paediatrician. This way the childs testimony might be thought to be affected by the
questions asked by the untrained professional and might be invalidated.
The issue of paramount importance is.

Safety of the child (according to the children act 1989, the welfare of the child is
paramount) -? Confidentiality.
Contact social service the social worker has to be involved.

Also seek senior colleague support and discuss with lead consultant who deals with child
abuse issues
The social service dept (SW) would decide whether the child should stay with parents
(or) care placement is necessary. SW- Emergency protection order, police protection
order if there are imminent risks involved.
In some cases, the risk of returning the child to the parents is too great and separation is
required. If the parents do not agree, to separation then care order can be sought by
the social services.
When abuse is Severe prolonged (or) permanent, Separation may be necessary and
parents may face criminal charges.
Further management of the child;

Counselling help them to deal with the emotional impact of the abuse, to come
to terms with it and to improve her low self esteem.
Psychotherapy and support.
Note: If intercourse may have taken place within 72 hours, collection of specimen from
genitals & other region should be done. Usually a paediatrician or police surgeon should
carry out this physical examination with special experience in the problem.
164
Outcomes:
Short term, abuse can result

1. Change in a childs behaviour and emotional state
2. Can feel socially isolated, anxious and depressed
3. Sexualized behaviour may develop
Long term
1. Low self-esteem and depression in adults.
2. Inability to form satisfactory adult relationships
3. Impact on parenting abilities
4. Linked with the development of self-injurious behaviour and eating disorders.
Principles of assessment and management of child abuse

(Adapted from Oxford handbook of psychiatry)
Early detection in children at high-risk or presenting with alerting signs

A multi-disciplinary approach is essential with early consultation across disciplines
Maintain confidentiality where necessary and possible
Assessment should be measured, sympathetic, and above all child-centred
Attempt to engage and involve parents/carers at all stages and keep them informed in all
but the most exceptional circumstances
Evaluate the child's physical, emotional, cognitive, and sexual development, as well as
the child's position in the family
Evaluate the family in terms of: degree of social isolation and support; levels of stress;
emotional maturity of the parents; parental relationship; role of non-abusing parent; and
family dynamics
Consider extra-familial factors such as: deficiencies in support services; failure of inter-
professional communication; socio-political environment
Important to clarify the family's perception of the problem and to gain their cooperation
with changes/interventions required
Remove/hospitalise child if there is an immediate risk of, or ongoing, abuse
Consider whether siblings are at risk
Involve social services early
Consider whether police involvement is required immediately or whether there is time for
a measured multidisciplinary response
Balance the benefits/costs of non-intervention versus that of intervention
Above all, put the needs of the child first
BULLYING- ASSESSMENT AND MANAGEMENT
Bullying- Notes
Definition: Repeated and deliberate use of physical or psychological means to hurt to

another child, without adequate provocation and in the knowledge that the victim is
165
unlikely to retaliate effectively. (Goodman and Scott 1997). It is considered to be one of
the stressful events that children may encounter at school.
Prevalence of this problem: 2-8% of children once or more a week. (Goodman and
Scott 1997)The bullies are most often boys than girls and are more likely to be physically
aggressive. Girls are more likely to campaign against them or exclude them.
The three main types of bullying are:
physical (hitting, kicking etc)

verbal (name calling, racist remarks)
Indirect (spreading rumours, excluding someone from social groups).
Effect on people who are being bullied
Becoming shy and nervous

Lacking concentration
Clinging to adults
Feigning illness,
Taking unusual absences
Low self confidence and self-esteem
Interventions;
School level
class level
Individual level
national level - anti bullying campaigns
1. School level:
Attention to school ethos and staff morale to help deal with the problem [hence our role
(psychiatrists) in school consultations]
Building design modification etc - bullying happens in unsupervised areas.
Staff intervention should be immediate
Staff should have good supervision
Well structured curriculum and early identification of the vulnerable child's needs
Special nominated staff to address bullying
2. Class level
Define what is bullying - class awareness
Increase student empathy for victims
Whistle blowing
Understand that bullies themselves may have several emotional problems , social
difficulties etc
166
3. Individual level: School to deal with the bullies including praising them when they
get better
4. National level: Anti bullying campaigns with speakers at school, clubs etc
Evidence
For the victim:
7-11 year old - evidence in descending order - playgroup therapy > nurture work >
parent counselling - school consultation
11 above : group therapy and behaviour modification more effective than parent
counselling and teacher consultation
Task: BULLYING & OVERDOSE (ASSESSMENT & MANAGEMENT)
Miss. Amy Morris is a 14-year-old girl who was brought into the A&E Department by
her mother after taking an overdose. Assess this young girl to identify the reasons for
taking it and seriousness of the overdose.
Expanded construct: The candidate is expected to assess this young girl to identify the
reasons for taking an overdose and assess seriousness of the overdose. They should be
able to;
Obtain more information about the overdose

Explore the reasons for overdose
Evaluate the degree of suicidal intent and the seriousness of the attempt
(Planning, performance in isolation, Precautions to avoid discovery,
Suicidal note etc)
Obtain history of Bullying- physical & Emotional bullying with details

and examples
Risk assessment (Clear suicidal plans, fixed or Fleeting suicidal thoughts,

future plans etc)
History & Assessment;

Establish the nature- Could be physical or psychological
The intensity and severity may vary from a horseplay to serious assault
Duration- Could be occasional/short-lived or regular and long standing
Intentionality-could vary from thoughtless or accidental to premeditated and
calculated
167
Enquire about environment e.g. in school, outside school etc
Number of People involved-(one child or gang) bullying specific to an individual or does
the bully trouble others or to a group, systemic bullying etc.
Threats made if any
Motivation- In boys, the chief motive is personalized power but in girls, it is more to do
with affiliation, as the victim is excluded and scapegoated
Action taken so far - if school based bullying - was school aware, if so who, what
happened.
Establish awareness of school policy (anti-bullying policy)
If outside school / sexual bullying, damage to property etc then, were police involved?
Management
1. Inform school
2. Increase teacher supervision and vigilance
3. Raise awareness of bullying (may be happening to other kids)
4. Anti-bullying campaign- speakers at school, clubs etc
5. Support for bullying and bullied
6. Involve school liaison child psych practitioner
7. Involve parents at all points if possible
Immediate management
If bullying is suspected or reported, the incident will be dealt with immediately by the
member of staff who has been approached.
A clear account of the incident will be recorded and given to the head teacher
If anything more - social services and police may be involved.
Parents/carers should be kept informed at all points if possible.
Long term management
Making school environment safe with immediate staff intervention, good supervision and
special nominated staff to address bullying
Psychological support to victim - may that be advise, counselling or 1:1 age appropriate
therapy from play / art therapy, self help books etc
Behaviour modification strategy: A child can do things differently to avoid being
vulnerable, and to stop bullying. Research evidence suggests that behaviour modification
strategies will show success in one setting [e.g. clinic] but it does not necessarily extend
to another environment [e.g. school grounds]. Hence main intervention should be at
school via school resources.
Pupils who have bullied will be helped by discussing what happened, discovering why
they became involved , establishing the wrong doing and need to change and most
importantly informing parents or guardians to help change the attitude of the person.
168
TIC DISORDER
behaviour from parents, teachers, child etc.
The mode of onset or evolution of the problem
The nature, severity, frequency and duration of the presenting problem
Type of tics (Motor, vocal or both)
The setting in which the problem behavior manifests like home environment or at school
The effect of it on siblings, family members, friends, school,
Also enquire about other current problems or complaints
Look for any co-morbid conditions such as ADHD, OCD, conduct disorders and others
like anxiety and depression,
Look for family h/o tics, obsessive and compulsive symptoms, anxiety disorders,
depression, other neurological and neurodevelopmental problems.
I would explore the childs medical history including any history of infective illness.
Treatment: -
Psychological: -
1. Advice for parents to ignore tics as commenting on them makes no difference and may
affect the childs self-esteem
2. Education about the condition. Liaise with the schools, Tic Breaks at school
3. Groups with affected young persons
4. Reduction of external stressors.
Parental support: Families may require support and education to understand the condition.
Medical management:
Mild forms may not require specific treatment.

First line: The first choice drug is Clonidine. It is the medication with the most
favourable side effect profile-BP needs monitoring-dose needs to go up slowly by 25-50
mcg per week usually up to 200 mcg daily. Beware abrupt withdrawal.
For more severe cases low dose risperidone or Sulpiride can be tried.
Treat the co morbid condition like OCD and ADHD accordingly.
Treatment of Co-morbid psychiatric disorder such as OCD and ADHD may be clinically
more important than treatment of the core features of the syndrome
Associated possible co-morbid conditions

1. ADHD-Hyperactivity and behavioural problems (25-50%)
2. OCD (30-60%)
3. Behavioural problems
4. Emotional disorders such as anxiety and depression
Prognosis: Many tics occurring in childhood last only a few weeks. Others last longer but 80-
90% of cases improve within 5 years. A few cases become chronic and may be life-long.
Tourettes disorder: Characterized by multiple motor tics and one or more vocal tics. The onset
is often during childhood. Typically symptoms wax and wane, frequently becoming less
prominent after adolescence.
169
Risperidone and Sulpiride have been shown to be effective and well tolerated.
Other drugs that could be used are Clonidine, Haloperidol and Pimozide
ENURECTIC CHILD
behaviour from parents, teachers, child etc.
The mode of onset or evolution of the problem
The nature, severity, frequency and duration of the presenting problem
Whether it is nocturnal or diurnal or both?
Course: Distinguish between primary (never dry) and secondary (previously dry) enuresis
The effect of it on siblings, family members, friends, school,
Also enquire about other current problems or complaints
Look for any co-morbid conditions such as anxiety, depression (child may experience
shame, embarrassment, moodiness, social withdrawal symptoms) and conduct disorders.
Enquire about family history of enuresis, generalised developmental delay; poor potty
training;
Also enquire about psychosocial stressors (e.g. birth of a sibling, early hospitalisation,
starting school, domestic conflict, parental divorce)
Medical history: UTI; obstructive uropathy; diabetes, seizures, drug side-effects.
Management
Behavioural modification is the mainstay and includes:
Restrict fluids at night and Night lifting

A simple Star chart with a reward system for dry nights and/or days can be effective.
Bell and pad: This involves putting a pad underneath the childs sheet, which is
connected to an electrical buzzer. The buzzer goes off as soon as the child starts to wet
the bed. The child then gets up and will use the toilet. The child will gradually learn to
wake and use the toilet by itself. The child should be praised and rewarded for their dry
nights. It takes many weeks for this training to become effective.
Mattress alarm, Night alarm-This is based on the principles of classical conditioning
model. Night alarms are devices with a sensor to detect a few drops of urine. They serve
as unconditioned stimulus and are generally placed in the childs underwear at nighttime.
It works like a pager with either sound or vibration to awaken the child. In this phase of
unconditioned stimulus, the child wakes, holds the rest of the urine volume until getting
to the toilet and then completes voiding. After several weeks of practice, the conditioned
response to the alarm develops and the physiologic sensations associated with the
initiation of voiding cause the child to awaken before actual voiding begins. The main
drawback is that it takes many weeks for this training to become effective and it is also
not helpful for diurnal cases.
Imipramine- anticholinergic effect of increasing sphincter tone. 80% have some
improvements but tolerance may develop after 6 weeks.
Important points:
170
Primary enuresis describes the child who has never attained significant continence.
Secondary enuresis describes the child who at one point had been dry for 6 months to
1 year but is now wetting again.
Diurnal enuresis occurs both during awake and sleep periods whereas nocturnal
enuresis occurs only when the child is sleeping.
Children with enuresis are 2-6 times more likely to have a psychiatric disorder than
the general population.
Nocturnal enuresis has a strong genetic component-68% concordance rate in
monozygotic twins and 36% concordance in dizygotic twins.
Interview
Introduction:
Your GP has asked for an assessment for Laura, as her school work has been worsening. I would
like to use this session to listen to your worries, and think about what might be happening.
H/o Presenting Complaint:

- What are your worries for Laura?
- Other than school work, is there anything else that you are worried about?
- Could you tell me a bit more about it?
- When did you first notice these problems?
- Has anything happened in Lauras life which could be related to how she is now?
H/o Enuresis
- Has there been a time when she has been dry?
- Is this an ongoing problem, or has it started recently?
- Are there times when the problem seems to be solved on its own? [Or if the problems
become worse]
- Does the problem exist only at night, or does it also occur in daytime?
- Does she have any problems opening her bowels?
Family H/o including parental attitudes towards the problem:
- Are you aware of any other member in the family who had similar problems?
- Do these problems occur more frequently around particular members of the family? If so,
with whom and why?
- Have there been any recent changes in the family that could have lead to this problem?
[Especially for sudden onset/secondary enuresis]
- What do you do when you find out Laura has been incontinent/wet? How do you react in
such situations?
- How does Laura feel/what does she say when you find out that she has been wet?
Collateral H/o:
- For primary enuresis brief developmental history.
- For Secondary enuresis Consider changes in family, problems at school, other medical
illness, overall mood.
- If there is one thing that Laura would like to change in her life, what do you think would
that be?
171
- Has Laura ever seen a counselor or a psychiatrist before?
MUTE CHILD
Qn. The G.P. in your catchment area refers a 7 years old girl who refuses to speak at
school, but she is fine at home.
How would you assess her?

What are the diagnostic possibilities?
How would you investigate this case?
What type of treatments could possibly help her?
Given the information above, Id think of the following possibilities.

1. Elective mutism
2. Emotional disorder of childhood
3. Natural shyness, but more at school
4. Deafness
5. Autistic spectrum disorder
6. Childhood psychosis (extremely rare)
Arrange for an outpatient appointment to see the child with the parents (or) those who
have the Parental responsibility
Collect more information from GP, school teachers, school reports, educational
psychologist report (after obtaining consent from parents)
In the O.P. appointment assess the child with the parents and then the child on its own
(separately).
I would obtain a detailed comprehensive history, mental state examination, and physical
examination including neurological examination.
In the history, Id be particularly interested in the onset and progression of her current
problem, whether its confined to one situation like school and also look for any
precipitants.
Id obtain more information and Hx including Birth Hx prenatal, perinatal & postnatal
Hx, Developmental Hx, milestones (cognitive, language, motor and social skills), Serious
childhood illness/ hospitalizations, Childhood neurotic traits (temper tantrums, enuresis,
thumb sucking, nail biting), losses/ separation, quality of parental and parent child
relationship.
At school: I would be more interested to specifically look for Problems at school such as
Bullying, poor academic performance, change of school, teacher (or) friends, extra help,
learning support (etc). Problems with peers being bullied / exposed to antisocial
behavioural drugs, Stressful events and Secondary gain
At Home: Also look for issue like over protection at home, ways of communication at
school (nodding, shaking head etc), ability to form any social relationship.
In questioning the parents it is important to ask whether speech and comprehension are
normal at home.
Id explore for family h/o mental illness, parental criminality, drug and alcohol issues in
the family, parenting style (inconsistent and harsh discipline) any relevant medical
problems, epilepsy, any history of speech abnormality and medication.
172
Interview: Observe Interaction between child and parents, observe for any absence seizures.
Physical Examination: Detailed physical & neurological examination.
Investigation:
a. Psychometric testing may be necessary

b. Educational psychologist assessment.
c. Speech and language therapy assessment
d. CT/EEG if it is clinically indicated.
e. Doing a School Visit may be more helpful.
Treatment: The treatment should focus on treating the underlying cause of her mutism and to get
her settled at school.
Speech and language therapy

If there was a speech abnormality leading to embarrassment and avoidance and leading to
school avoidance as a consequence, organize speech therapy for any impediment.
Speech therapy assessment and intervention may help particularly where articulation
problems are present.
Psychological:
Behavioural modification graded re introduction to school and rewarding for positive
behaviour such as talking would be the best option. Behavioural work usually in the
school aims to decrease social anxiety.
Family therapy- Addressing Family issues like over protective parents.
If there any precipitant like trauma, counseling may be of help.
Social:
Encourage more activities at school indoor & outdoor.
Joining local clubs to improve her sociability.
Parental support
Prognosis:
Mutism usually resolves, but the prognosis is worse if no improvement occurs in 6-12 months
ADOLESCENT ATTEMPTED SUICIDE

Qn. You have been asked to assess a 14 years old girl at the A&E dept who has recently
taken an overdose of 15 tablets of paracetamol. How would you assess her?
If the girl is depressed, how would you manage?
173
What medication would you prefer for childhood depression?
Overdose at 14 has to be considered as a Serious Issue.

According to NICE guidelines, the girl needs to be admitted overnight in a paediatric
ward. Her parents need to be contacted.
A social worker needs to be involved. It is usually the duty of the paediatric team
treating the child to inform the SW.
Before seeing the child, I would obtain more information from the GP, the paediatric
team. The ward nursing staff and any other mental health professionals involved in this
case. (If case is open to CAMHS)
Assess the child with the parents and then the child separately.
In the interview I would like to obtain a detailed comprehensive history, perform risk
assessment and Ill do a mental state examination.
Id like to obtain more information about the Overdose itself and circumstances at the
time of overdose, look for any factors that could have motivated the childs overdose. I
will consider drug and alcohol abuse.
I would assess the degree and seriousness of the suicidal attempt- planned / impulsive,
performance in isolation (or) in front of others, preparations done precaution taken and?
Possible suicidal note any left
Id look for family h/o mental illness, depression, DSH, suicide, substance misuse and
past history of suicidal behaviour
Id be particularly interested to know whether the child has been experiencing any
difficult situation at home, school (or) other situation such as physical, emotional, sexual
abuse, neglect by parent, harsh and excessive discipline at home, bullying, poor
achievement and poor relationship at school.
Id explore the childs thoughts about death knowledge and concepts and the feelings that
he/she has towards his/her own death.
I also assess the childs coping strategies, social support, reaction to previous stresses,
failures and losses and the ways of getting help, past h/o impulsive and aggressive
behaviour.
MSE: In the mental state, Id look for any previous (or) current evidence of mental illness
particularly depression, anxiety (or) psychosis, features of Self neglect, eye contact and
rapport, psychomotor retardation, speech content, depressed mood, depressed negative
cognition, suicidal thoughts, any active plans, violent, thoughts, guilt feeling, delusion,
hallucinations and also assess his insight.
Risk assessment: Lastly this involve appraisal of the risk of repetition both short and long term.
If the risk of repetition is such that admission to a mental health unit is not required then the girl
will be discharged with appropriate care plan including review within a week of the discharge.
She will need to be referred to a CAMHS.
If she is depressed, we need to consider the following interventions
Psychological interventions such as Cognitive Behavioural Therapy are found to be

effective in mild or moderate degree of depression and should be usually tried first
unless depression is severe.
174
CBT is particularly useful for older children who can describe and learn to control
the ways thinking that give rise to symptoms and problem behaviours. Older children
and adolescents can be treated with methods devised for adults.
If these are inappropriate, have failed or simply not available then fluoxetine is the
treatment of choice. The patient and their parents should be well informed about the
potential problems associated with SSRI treatment and know how to seek help in an
emergency.(medication education is essential)
Also involve other members of the MDT team like other cases and adopt a Bio
psychosocial approach relevantly.
If the depression is severe and if there is high risk of repetition, the inpatient treatment need to be
considered.
Note: Up to a third of young people with an episode of depression will have a diagnosis of
bipolar affective disorder within 5 years. The younger the child, the greater the risk
Key points:
Depression:
Psychological treatments should always be considered as first line treatment for children
with depressive illness.
If pharmacological treatment is necessary, then Fluoxetine is the treatment of choice.
(Fluoxetine 10-20 mg/day)
If there is no adequate response to Fluoxetine and drug treatment is still considered to be
necessary, then alternative SSRIs such as citalopram or Sertraline should be tried
cautiously.
Paroxetine is specifically contraindicated due to increased risk of suicide
Severe depression that is unresponsive to other treatments or if it life threatening, may
respond to ECT. It should not be used in children under the age of 12.
Early treatment with mood stabilizers should be considered, as up to a third of patients
who suffered an episode of depression will have a diagnosis of bipolar disorder within 5
years.
Establish therapeutic alliance and provide education to child and family. A

multidisciplinary approach should be adopted.
Mild depression: 2 weeks of watchful waiting. After 4 weeks supportive therapy, self
help or group CBT. With self help consider, advice on exercise, sleep hygiene and
anxiety management to the young person.
Psychotherapy is considered as a reasonable initial treatment in mild to moderate
depression and this may be individual, group, or family therapy. CBT is one of the most
researched techniques, but IPT, behaviour therapy, psychodynamic therapy, and
supportive therapy are used.
Moderate to severe depression CAMHS review, +/- 3 months of individual CBT, IPT,
or shorter term family therapy. Consider an alternate psychotherapy if first mode doesnt
help. CBT can reduce the duration of illness as compared to the other psychological
treatments.
Several studies have demonstrated efficacy with selective serotonin reuptake inhibitors
(SSRI) antidepressants, especially using fluoxetine. Fluoxetine is the best-studied
antidepressant with the strongest efficacy data, and consequently is the only
antidepressant to receive FDA and MHRA approval and has been allowed by CSM for
use for the treatment of depression in children and adolescents. Monitor for emergence of
175
agitation , irritability, unusual changes in behaviour and emergence of suicidality at
initiation and when dosages are changed. Paroxetine evidence shows that Paroxetine
has little impact to treatment, symptom levels, functional status or clinical improvement.
Paroxetive is also more likely to bring serious adverse effects [and discontinuation] and
increased suicidal behaviour.
SSRIs are regarded as 1st line pharmacotherapy. TCAs are not supported by trials and
have been associated with cardiac toxicity. .
Combination treatment should be considered in all cases (i.e. psychotherapy +
medication).
The final CBT efficacy trial in a diagnosed sample is the Treatment of Adolescents with
Depression Study (TADS) . TADS is the only published study to compare CBT,
fluoxetine, their combination, and placebo. In this large[n=439], well-powered
investigation, CBT (43% significantly improved) was not superior to placebo (35%),
whereas both combination (71%) including fluoxetine, and fluoxetine alone (61%), were
markedly superior to both CBT and to placebo. The combination treatment (CBT +
fluoxetine) showed a faster recovery than any of the other treatments, although fluoxetine
alone had as favourable outcomes with respect to the Clinical Global Impression
Improvement (CGI-I) and baseline-adjusted endpoints and in more severely depressed
patients. Combined treatment was superior to fluoxetine alone with regard to remission
(37 vs. 20%).
ECT not recommended for 5-11 year olds. In older persons, only in severe depression,
life threatening symptoms, or severe intractable symptoms not responding to other
treatment
Anxiety disorders
Psychological treatments such as CBT should always be considered as first line treatment
for children with anxiety disorders
If pharmacological treatment is necessary, then SSRIs are first line agents.
IMPORTANT CONCEPTS IN CHILD PSYCHIATRY

PARENTAL RESPONSIBILITY
Clarify who has parental responsibility for the child?
Inform and involve them in your plan of action.
176
Remember, In general the Interests of the child takes precedence over those
of the parent.
For conflicts of interest, such problems can usually be resolved by discussion
with the Parents and between the professionals caring for the child and for
the parent.
In case in which the parents refusal appears not to be in the interest of the child
(both refusing treatment) then there are provision for a decision by a court of
law.
Parental responsibility is given to:
Mother
Father - if he is married to mother at time of birth or they marry subsequently
- or if mother signs a form
Anyone holding a Residence Order
Social Services, if the child is under a Care Order
Gillick Competency
Some children are able to consent to treatment at a younger age than 16, if it is
considered that the particular child has the capacity to make that decision.
A Gillick competent child can consent to treatment and override their parents But
cannot refuse treatment.
According to Gillick case, the minor could consent without the need to obtain the consent
of the parent.
It is probable however that with certain more invasive and risky treatments, the consent
of a parent could be legally necessary as well as clinically desirable.
If a minor under the age of 16 years refuses treatment, this can be over ruled by the
parents if refusal is likely to harm.
Consent
This can be obtained from a Gillick competent child or someone with parental capacity.
If the child refuses but those with parental consent agree, then the procedure can be done
If parents refuse, it is possible to ask for a Specific Issue Order under The Children Act,
or for the social services to take proceedings in order to obtain parental responsibility
Enforced admission: If a child needing admission under the MHA refuses but his parents
consent he or she can be detained under the mental health act. If parents also refuse-This can be
done under the Mental Health Act, which does not have a lower age limit
LEARNING DISABILITY
177
Acknowledgement: The lecture notes are prepared by Dr. Sree Murthy and Dr. Edward De
Costa (Consultant in Learning Disability in North Essex and some notes are Adapted from Get
through work-place based assessments in psychiatry by Sree Murthy)
CHALLENGING BEHAVIOUR
Assessment and management

The assessment relies on information from the individual, family members, carers, teachers and
other professionals involved in his/her care. In those individuals with limited or no verbal skills,
behavioural observations and recent changes that have been experienced should be taken into
consideration and in such cases, collateral information from regular carers plays a major role in
the assessment and management of such individuals.
The assessment should focus on identifying the possible common causes of challenging
behaviour, which includes the following;
Common causes of challenging behaviour in LD population.

Presence of Psychiatric disorder-depression, psychosis, ADHD etc
Presence of Physical disorder pain and discomfort, infections, constipation, epilepsy,
cerebral palsy etc.
Side effects of medication especially psychotropic medications
Environmental factors-Change in environment / carers.
Difficulties in communication (frustration)
Sensory deficits such as vision or hearing impairment
Desire to escape unpleasant situations.
Psychosocial factors such as bereavement/disrupted family, recent stressful events,
adverse experiences such as social rejection, neglect, physical, emotional or sexual abuse.
Poor temperament particularly high emotionality, poor sociability and high activity.
The assessment process involves the following;

Identification of the problem behaviour
Identifying the possible precipitants and exacerbating factors
When was it first identified
Duration of the problem behaviour
What situation it occurs and what form it takes
How problem is managed
What are the alleviating factors
Explore the possibility of recent environmental changes
Explore the possibility of recent physical changes
Management:
Following the assessment, the management plan should be tailored according to the needs of the
individual patient and specific factors should be addressed for example, presence of
physical/psychiatric causes, modification of environmental factors if any and reduction of
stimuli/reinforcers of challenging behaviour.
Immediate management
178
If the disturbed behaviour results from a psychiatric disorder, the treatment is similar in
most ways to that for a patient of normal intelligence with the same disorder and in
addition will also require a behavioural regime
If the patient has evidence of mental illness and the risks are high then Consider
admission to Learning Disability unit, possibility under the mental health Act (? Secure
unit if there are serious risks involved).
For agitated behaviour try rapid tranquillisation (first try oral medications and then
parental injections)
Discuss with the nursing team/ manager and decide on level of nursing observation.
If due to physical cause, liaise with other specialties, GP and treat it accordingly.
Other Approaches:
Education: Both for families/carers to improve understanding.

Addressing impairments of vision, hearing and language using sign language, use of
pictures etc.
Social interventions: Addressing the unmet needs at home with family/carers and widen
access to other services to improve support network.
Physical intervention: This varies from use of splints, headgear, and physical restraint to
isolation in order to protect individual and others from injury or damage to property.
Behavioural Therapy (please see below)
Behavioural Therapy:
Functional behavioural assessment: ABC chart. This is based on accounts by family and carers
and asks the parents (or) care staffs to keep records of behaviour such as eating, sleeping and
general activity, so that problems can be identified and quantified.
Record keeping is an effective way of defining the problem, identifying relevant antecedents
and consequences and informing management. A diary is a useful way of recording the
information, identifying the problem, identifying the possible causes and establishing a baseline.
Institute the ABC analysis (Antecedents, Behaviour and Consequences):

Can antecedents (triggers) be identified?
If so, can they be modified in order to prevent the challenging behaviour?
Can Consequences that reinforce the behaviour be identified? If so, can they be modified?
Consent to treatment:
Many of the severely learning disabled people are unable to give informed
consent and the clinical team must proceed in the Patients best interests after
an assessment of their capacity to give consent to medical treatment.
If the patient is intellectually impaired so as not to understand the choice (he) or
she faces and if there is a medical emergency, it may be appropriate to proceed
with treatment under Common Law, Principles of best interest
But if there is time, it may be necessary to refer the case for review in court (for
example difficult situations like medical termination of pregnancy etc)
TASK: CHALLENGING BEHAVIOUR IN LEARNING DISABLED- HISTORY
179
You are in the learning disability outpatient clinic. Mr. Daniel Benjamin, who is the
manager of the Seven seas care home, attends your clinic with Ms. Pauline Baker who
suffers from severe Learning disability and has poor communication skills. Mr. Benjamin
mentioned that the care staffs at home are finding it increasing difficult to cope with his
challenging behaviour. Elicit more history, to identify possible cause of challenging
behaviour and explain it to him briefly
Expanded construct: The candidate is expected to elicit more history, to identify

possible cause of challenging behaviour and explain it to the carer briefly. They should
assess the following areas
Brief history of symptoms & exploration of presenting complaints-

Mode of onset, duration, frequency, severity, possible triggers.
Exclusion of psychiatric disorder

(Symptoms of Depression, psychosis)
Exclusion of physical disorder and drug-induced (Infection, pain,

constipation, medication induced etc)
Assessment of physical Impairment (vision, hearing, mobility)

Communication difficulties/Cognitive impairment
Identification of environmental and social factors

(Changes in carers/homes, history of major loss etc)
Explain reasons to carer (Multifactorial-change in carers, Infection,

Medication-induced, Communication Difficulties etc)
DEPRESSION IN LEARNING DISABILITY
180
Depressive symptoms in people with learning disabilities vary according to their degree of their
disability. The higher the intellectual ability the closer the symptoms of depression are to those of
the general population.
The distinct symptoms based on the degree of disability include:

For mild learning disability; tearfulness, loss of energy, loss of interest, low
Self esteem and diurnal variation of mood.
For moderate learning disability; social isolation, self injurious behaviour and
Weight loss.
In people with severe degree of learning disability, depression seems to be presented with
atypical symptoms or behavioural equivalents. It presents in the form of behavioural
disturbances such as aggression, irritability and self injurious behaviour.
Suicide:
It is likely that both suicide and suicidal intent in relation to deliberate self harm have
been underestimated in populations with learning disability.
It is certainly difficult to judge intent when self injurious behaviour is a common
presentation in individuals with severe and profound learning disability but it is also
possible that such behaviour is sometimes related to suicidal intent in the presence of a
depressive illness.
(Sovner et Al- Journal of Intellectual Disability research 37, 301-311).
Community studies done by Benson and Laman concluded that the suicidal group were
younger, more likely to be of borderline mental handicap, and have chronic health
problems or physical disability.
Sternlicht et al studied a cohort of subjects in institutional care and reported that
attempted suicide rate of 0.9% compared with 1% for the general population at the time.
However, in the general population group women were more likely to attempt suicide
than men, whereas the reverse was true for the learning disability group.
The majority of the learning disability group who attempted suicide were the mild and
borderline range of IQ but unfortunately no attempt was made to formulate a psychiatric
diagnosis for those who attempted suicide in this study.
SELF-INJURIOUS BEHAVIOUR IN LEARNING DISABILITY
It can take the form of head banging, banging other body parts, scratching, biting,
pinching and hair pulling etc
It is often multifactorial in origin i.e combination of physical, psychiatric and
environmental factors
It is important to rule out physical illness and neurological conditions such as epilepsy
The common psychiatric conditions would include depression, anxiety and psychosis
The other contributory factors would include communication difficulties, those with
impairments in vision, hearing and mobility. The lower the IQ, the greater the incidence.
Environmental factors would include lack of stimulation, self stimulation, over
stimulation, lack of attention, too much attention, rejection, material reward, social
escape through being removed from communal areas and adverse life events etc.
The rare genetic syndrome associated with SIB includes Lesch-Nyhan syndrome and
Smith-Magenis syndrome.
181
It is important to understand why the patient with LD self-harms and therefore
psychological/behavioural strategies for dealing with it can then be put in place
ELICITING SYMPTOMS OF DEPRESSION IN LD PATIENTS

Core Symptoms of depression
Biological symptoms
Cognitive and emotional symptoms
Ideas of guilt and unworthiness
Depressive cognition (negative thoughts) and suicidal ideation
The interview questions that have to be elicited from patients in this context have been
described in two sections. The first section will have questions relating to the individual
symptoms or symptom groups that are appropriate for people with borderline to very mild
learning disabilities. However for many other patients as the level of learning disability
increases it will be necessary to use more simple language relevant to the individual
symptoms or symptom groups and this has been described under the section mild to moderate
learning disability
A. Eliciting core Symptoms of Depression
Low mood;
Borderline to Mild (higher I.Q within this range) Learning Disability
How has your mood been lately?
How bad has it been? Have you cried at all?
If I were to ask you to rate your mood, on a scale of 1 to 10 where ten is normal and one
is as depressed as you have ever felt, how would you rate your mood now?
Mild (lower I.Q within this range) to Moderate Learning Disability

o Are you happy or sad?
o Are you sad sometimes / most of the time/ all the time?
o Have you been crying?
o Can you snap out of it?
Anhedonia
Can you still enjoy the things you used to enjoy? (Or)
Have you lost enjoyment in things you used to enjoy?
Is the level of enjoyment same as before?
What are the things that you find enjoyable/interesting??
182
o Are they activities / things that you have stopped doing?
o Are they activities / things that you do less than before?
o Why have you stopped doing these activities/things?
o Have you lost interest in these activities?
o Do you enjoy life?
Reduced energy level and decreased activity

How have you been in your energy levels these days?
Have you been feeling drained of energy lately?
How do you spend your day?
Have you wanted to stay away from other people?
o Do you feel lively?
o Do you feel everything is too much trouble?
o Do you feel that you cant be bothered to do things?
o Can you force yourself to do things?
Eliciting biological symptoms

Do you need less sleep than usual?
Do you wake early in the morning?
Does you mood vary over the course of the day?
Is your depression/mood worse at any particular time of day?
What is the best time/worst time of the day for you?
What has your appetite been like recently?
Have you lost any weight lately?
Has there been any change in your interest in sex?
o How much sleep are you getting right now?
o Are you sleeping less in the last few days/ last few weeks?
o Do you lie awake?
o What keeps you awake, Is you mind very active?
o Do you get up very early?
o Have you been eating less/ less than usual?
o Do you eat enough?
o Do you have to force/make yourself to eat?
o Do you feel sad in the morning/ sad at the end of the day/ sad later on in the day?
183
Cognitive symptoms
How has your concentration been lately?
What is your memory like at the moment?
o Can you keep your mind on any activity?
o Can you pay attention to the things you want to?
o Can you watch a T.V program right through?
o Can you remember where you have put the things that you like?
o Can you remember where you have put things like your wallet, keys, CDS?
o Can you remember where you had been /the places you had been to earlier on today/
yesterday?
Emotional Symptoms
o Do you think that you are as good as other people?
o Do you think that you are worse than other people?
o Do you worry what people say about you?
o Do you worry that people say bad things about you?
o How does this affect you?
Ideas of guilt
Do you feel that youve done something wrong?
Do you feel guilty about anything at the moment?
Do you tend to blame yourself at all?
Do you tend to blame anyone else for you problems?
Do you feel that youve committed a crime, (or) sinned greatly (or) deserve punishment?
o Do you think that you have done something bad/wrong?
o Do you think that you should be blamed for anything?
o What bad thing /wrong thing have you done?
o For what bad/wrong thing are you to be blamed?
Eliciting suicidal intent and negative thoughts

184
Do you have any worries on your mind at the moment?
Have you ever felt that life wasnt worth living?
Do you feel inferior to others (or) even worthless?
Do you feel hopeless about yourself? (Or) Has life seemed quite hopeless?
Do you feel helpless?
Do you feel that life is a burden?
Do you wish yourself dead? Why do you feel this way?
Have you had thoughts of ending your life?
Have you thought about how would you do it?
Did you actually try?
Would you do anything to harm yourself or to hurt yourself?
Have you got any plans to end your life? What plans?

o Do you think that life is not worth living?
o Do you think that you would be better of dead?
o Have you thought of doing anything to kill yourself?
o What have you thought of doing to kill yourself / end your life?
o Have you tried to kill yourself /end your life?
o What did you do to kill yourself/end your life?

1. Anxiety, obsessions
2. Psychosis/Hypomania or mania
185
DEPRESSION IN LEARNING DISABLED PATIENT
TASK: Mr. Alan Smith is a 25-year-old gentleman with Downs syndrome and has a
mild degree of mental retardation. He was referred to your clinic by his CPN, who was
concerned about his deteriorating mood. Elicit features of depression and perform risk
assessment for suicidality.
Expanded construct: The candidate is expected to elicit features of depression and

perform risk assessment for suicidality in a patient with Downs syndrome using simple
language. They should be able to ascertain the following areas during history taking and
examination
Exploration of Presenting Problems- mode of onset, duration and severity
Core features of depression

(Low mood, anhedonia, Low energy levels)
Biological features of depression (Sleep, appetite, weight)
Emotional and behavioural features of depression

(Social withdrawal, irritability, lack of motivation, low self confidence and
self-esteem, Worthlessness, helplessness and guilt feelings)
Risk: Suicidal thoughts and plans, self-neglect,

Agitation/aggression
186
EPILEPSY IN LEARNING DISABILITY
Epilepsy is more common and more difficult to diagnose and to treat in people with
mental retardation than in those with normal intellect.
Epilepsy is the most common neurological condition and the prevalence figures have
varied considerably across studies. The usual prevalence figures in the general population
without epilepsy are about 5-10/1000 persons excluding febrile convulsions, single
seizures and inactive cases. There is overrepresentation of epilepsy in subjects with
intellectual disability. Community studies have indicated prevalence rates of epilepsy
ranging from 6% among people with mild intellectual disability to 24% in severe
intellectual disability 7 and 50% in profound disability
Epilepsy may begin at any age and its presentation may change with time, and be of
multiple forms in the same person.
Epilepsy may be misdiagnosed in patients with LD, particularly when there is a history of
sudden unexplained aggression, self-mutilation, and other bizarre behaviours, including
abnormal or stereotyped movements, fixed staring, rapid eye blinking, exaggerated startle
reflex, attention deficits, or unexplained intermittent lethargy.
Epilepsy is commonly associated with numerous causes of LD e.g. Down's syndrome (5-
10%), fragile X (25%), Angelman syndrome (90%), Rett syndrome (90%).
Behavioural problems may be associated with antiepileptic drugs, and may be more
common in patients with brain injury or LD (e.g. phenobarbitone, Primidone,
benzodiazepines, Vigabatrin).
There is wide variation in outcome; however up to 70% of patients with LD can achieve
good control of their epilepsy without major side effects.
History taking in the evaluation of seizures
a. Detailed description of episode obtained from patient-

b. Detailed description of episode obtained from witness- about nature, duration and type of
seizures, loss of consciousness etc
c. Past Medical history:
1. Birth history
2. History of febrile convulsions during childhood
3. Intracranial infections
4. Tumour
d. Family history: Epilepsy or neurological disease
e. Drug History: Prescribed medications, alcohol and recreational drugs
187
TEMPORAL LOBE EPILEPSY
It is a complex partial seizure which may begin with impairment of consciousness or may
be preceded by the features of a simple partial seizure
Complex partial seizures arise from the temporal lobe in about 60% of cases and the
frontal lobe in about 30% of cases
Complex partial seizures in their complete form have three components, aura, altered
consciousness and automatisms (3-As)
Auras: Auras are equivalent to simple partial seizures. The clinical form depends on the part of
the cortex involved in the seizure. These therefore include
1)motor manifestations
2) Somatosensory or special sensory manifestations (simple hallucinations): Altered
perceptual experiences include both distortions of real perceptions and spontaneous
hallucinations. Auditory hallucinations-buzz ling sound, a voice or voices or muffling
sounds .Visual hallucinations may consist of the simple elements and complex formed
hallucinations of scenes, faces or visions of past experiences. Gustatory or olfactory
hallucinations. Paranoid delusions and hallucinations may figure prominently during the
course of attacks. Distorted shape, size and distance of objects. Things may appear
shrunken (Micropsia) or larger (Macropsia) than usual and Tilting of structures.
3) Autonomic manifestations; Effects include epigastric rising sensation or nausea,
tachycardia, piloerection sweating, pallor and salivation
4)Psychic manifestations Feelings of Dj vu or Jamais vu, a sense of familiarity or
unfamiliarity. Experience of depersonalization or Derealization Strong affective
experiences such as fear and intense anxiety. Presence of confusion and disorientation
5)Dysphasic symptoms, dysmnestic symptoms, cognitive symptoms, affective symptoms
Temporal lobe seizures produces the most varied and complex auras of all. A variety of
autonomic effects and visceral sensations occur prominently in temporal lobe auras and
the Epigastric aura is perhaps the most common of all.
Altered Consciousness. This may follow the aura or evolve simultaneously. The altered
consciousness takes the form of an absence and motor arrest, during which the patient is
motionless and inaccessible (the motionless stare). The patient stares blankly, becomes wide
eyed, motionless stare, dilated pupils with behavioral arrest and becomes unresponsive to
questions or commands.
Automatisms are defined as involuntary motor actions which occur during or in the aftermath of
epileptic seizures in a state of altered consciousness. There is total amnesia for the events of an
automatism. Automatisms can be of various types such as lip smacking, chewing and swallowing
movements, salivation, picking at the clothes, facial grimacing and hand gestures with continuous
movements of the hands. Certain complex acts such as walking may continue. Some people may
become violent and aggressive
Auras, altered consciousness and automatisms vary considerably in duration. They

generally last for very short periods (1-2 minutes to a few minutes) although longer
seizures sometimes lasting hours are occasionally encountered.
188
When the epileptic foci spread from temporal lobe to other areas of the brain, it evolves
to a secondary generalized seizure
This is followed by a Post ictal period of confusion
Post ictally, the patient is amnesic for the period of the seizure and may feel sleepy and
confused.
Elicit history
Infections, Trauma, Tumors
Medical history and medications
Family history of seizures, Febrile seizures, Past history of seizures
Psychiatric disorder- panic disorder, psychogenic seizures
Note: Absence epilepsy- no auras, lasts less than 30 seconds and no post ictal phase
Isolated auras with prominent psychological content such as hallucinations, depersonalization or
other subjective experiences are sometimes referred to as psychic seizures
Symptom elicitations; (Depersonalization and Derealization)

Have you yourself felt unreal that you were not a person, not in the living world or that you were
outside yourself, looking at yourself from outside? (Depersonalization)
Have you had the feeling that things around you were unreal? (Derealization)
What was it like? How do you explain it?
HISTORY TAKING- TEMPORAL LOBE EPILEPSY
TASK: Mr. Martin Brown is a 30-year-old gentleman with borderline IQ and has
reasonably good communication skills. You have been asked to assess him at A&E
department because he has been behaving strangely whilst out drinking with his girl
friend. His girl friend Rosy has mentioned to him that he has had a few weird turns in
the last couple of months. He also takes Dothiepin 150 mg. Take appropriate history to
arrive at a diagnosis
Expanded construct: The candidate is expected to take relevant history to arrive at a

diagnosis of temporal lobe epilepsy.
Description of episodes (Nature, type, frequency, duration),

H/o absence seizures
Pre-epileptic phase- History of Aura,

Absences (stare blankly and become unresponsive to commands)
Automatisms
(lip smacking, chewing, swallowing movements, facial grimacing, hand
gestures etc)
Abnormal experiences
189
(Illusions, hallucinations, Dejavu experiences, depersonalisation, Others)
Ictal phase: Secondary generalization and loss of consciousness,

Generalised tonic-clonic activity
Post ictal phase (confused, sleepy, headache, amnesia, incontinence etc)
Significant history: Past history (including febrile seizures), head injury etc
Medical conditions, Medications, recreational drugs, alcohol etc
Family history of seizures
190
PEOPLE WITH LEARNING DISABILITY WHO BECOME PARENT
THEMSELVES
Learning disability or intellectual limitation in itself is not an absolute bar to
parenthood.
The fertility rate of learning disabled people appears to be generally low.
Sexuality and pregnancy is a common fear of many parents of learning disabled
adolescents.
People with LD have normal sexual desires which can be more of a problem for
families/carers than the individuals themselves. The argument against allowing people
with learning disabilities to have sexual partners often involve judgements about whether
someone is deemed fit to be a parent.
Long term sexual relationships and parenting children are considered to be an integral
part of being an adult, including learning disabled people. Unfortunately people with
learning disabilities are seldom encouraged to develop sexual relationships.
One of the personal rights authorised in article 8 of the European Convention of Human
Rights is one of which guarantees respect for private life. An individual with learning
disabilities is entitled to be treated as normally as possible by the law, consistent with the
protection against harm or abuse.
In the U.K, research has demonstrated that some people with learning disabilities can
become successful parents provided they are given appropriate and effective support.
(Booth, TT. www.intellectualdisability.info). Many people, particularly with mild LD,
are capable of being successful parents and provide a stable environment for children
with appropriate support.
Problems usually arise with planning ahead and constant protection from danger that
young babies require. However, there are now techniques to help teach these skills.
Undermining the learning disabled mother or father should not be encouraged and the
secret of success in such teaching is a positive attitude of enhancing skills.
If a learning disabled woman has a partner who is both stable and more able many
women cope extremely well
It becomes difficult only when a young woman with learning difficulties finds a partner
with even more problems and has, for example, high risk of being hurt by a violent man
and of failing to protect children from similar abuse. It is problems such as these rather
than the learning disability itself that makes the safety of the children questionable
When the child grows older the problems increase as the balance between protection and
encouraging new skills becomes more difficult.
Therefore, specialist mental health teams for people with learning disabilities should
include organising services around patients wishes and needs that includes sexual needs
as well.
LEARNING DISABILITY- ANXIOUS RELATIVES
TASK : You are seeing Mr. Robert Lawrence, a 26-year-old gentleman with mild
learning disability in your clinic. He lives with his girl friend in a residential home who
also has mild learning disability. She is now 6 months pregnant. They are anxious that
their newborn baby will be taken away after birth by social services. Elicit his concerns.
His mother Mrs. Dorothy Lawrence has accompanied him to the clinic today. Also elicit
her fears and allay her anxiety
191
Expanded construct: The candidate is expected to address concerns and allay fears of a
learning disabled patient and relatives. They should be able to discuss the following
areas;
Address concerns by the son-

Role of social services in child upbringing if both parents have LD
Address concerns by the son-

Rights of parents and rights of visiting the child
Elicit mothers fears and allay her concerns

Why they were not sterilized?
Worries about burden of raising her grandson
Anxious about whether the grandchild would also be mentally retarded
192
ABUSE IN LEARNING DISABILITY
(Prepared by Dr. Edward da costa)
What is Abuse?
Abuse is a violation of an individuals human and civil rights by any other person or persons.
Abuse may consist of a single act or repeated acts. It may be physical, verbal or psychological, it
may be an act of neglect or an omission to act or it may occur when a vulnerable person is
persuaded to enter into a financial or sexual transaction to which he or she has not consented, or
cannot consent. Abuse can occur in any relationship and may result in significant harm to, or
exploitation of, the person subjected to it. (No Secrets, Department of Health 2000)
People with learning disability have an increased vulnerability to abuse (Brown & Craft, 1992)
because of dependence on other people for personal care; an imbalance of power between the
carer and the person being cared for; difficulties in communicating; lack of sexual knowledge and
assertiveness; and guilt and shame at being disabled (Sinason, 1993a,b)
Legislation has been passed and there is a legal framework to ensure that all vulnerable adults
have safeguards to protect them from abuse. Legislation gives the local authority a range of
powers, including the ability to enter and inspect premises where a vulnerable person is believed
to be at risk, and to remove such a person for assessment or protection. Every local authority
(County Council) must ensure that they have the requisite policies and operational procedures for
adult safeguarding which needs to be multi-agency in nature with the lead role resting with Social
Services. All professionals within health and social care services should be adequately trained so
that they know how to act when they encounter abuse.
A study by Cooke found that the average prevalence of definite experience of abuse was found to
be 4 5 % of individuals with learning disability.
Presentation of abuse: The presentation of abuse depends on the kind of abuse perpetrated, and
the psychological impact, which it had. Physical and sexual abuse and neglect may be diagnosed
from physical signs and symptoms in the same way as would happen with children, but if there
are not present, diagnosis can be much more difficult where the victims are non-verbal. It is
therefore necessary to be aware of possible psychological manifestations of abuse, such as a
change in personality or behaviour.
The person may demonstrate
1. An increase in sexual preoccupation

2. Sexually inappropriate behaviour, and/or avoidant behaviour.
3. They may be aggressive towards themselves or others
4. Can become withdrawn
5. Suffer sleep disturbances
6. Lose previous skills and have a reduced level of functioning.
Abuse must therefore always be considered as a possible differential diagnosis in someone with
learning disability who presents with psychiatric symptoms.
193
Individual and group psychoanalytic psychotherapy within the National Health Service for
children and adults with learning disabilities who were emotionally disturbed or hurt by abuse
and other trauma was pioneered by the Yorkshire Association for Psychodynamic Psychologists,
by St Georges Hospital Medical School Psychiatry of Disability Department and by the Tavistock
Clinic in London in the 1980s. As such treatment depends on emotional rather than cognitive
intelligence (Stokes & Sinason, 1992), the severely and profoundly learning disabled are also
able to benefit and show a reduction in symptoms (Sinason, 1993a).
Indeed there is no level of disability which makes someone ineligible for psychoanalytic
treatment (Hollins et al, 1994). The only difference is the technique used with people with little
or no verbal or sign language (Makaton signs). In there circumstances adults are provided with
drawing equipment, anatomical dolls and other items so that concerns can be communicated by
non-verbal means. Sinason (1993a) found large home-shopping catalogues particularly useful.
More recent additions to a psychotherapy kit for adults with limited language abilities are the
adult picture books of male and female abuse (Hollins et al, 1993a,b) produced by St Georges
Hospital Medical School in the Books Beyond Words series.
The stages and themes that have to be explored and worked through with learning disabled
abuse victims share similarities with other victims.
There is often a sense of betrayal of trust, shame, self-disgust, fear of telling a secret, guilt at
sexual excitement or involuntary responses. Where the abuse was not perpetrated by a stranger
but by a trusted worker, family member or friend, there are the issues of poor family attachment,
low self-esteem and little or poor sex education (Brown & Craft, 1992) prior to the abuse.
It may be necessary and desirable to use several different therapeutic approaches simultaneously,
e.g. an antidepressant + art therapy + self assertiveness training.
Defects in cognitive functioning and limited maturation may make it impossible to process the
memories and emotions induced by the abuse, leading to chronic psychological dysfunction.
What is expected of me?
Ignoring abuse is not an option if at anytime you think that a vulnerable person is being
abused or is at risk of abuse you must report your concerns so that they can be looked
into.
If you come across a situation where you think a vulnerable person is at risk of abuse you
must not ignore the information. Do not assume that others know what you know. You
must tell so that others can help.
Remember that vulnerable adults have human rights. You have a duty of care to ensure
the rights and needs of the vulnerable person is your main consideration.
If at any time you feel the person needs urgent medical assistance call for an ambulance
or arrange for the appropriate medical professional/service to see the person at the earliest
opportunity.
194
If at the time you have reason to believe the vulnerable person is in immediate and
serious risk of harm or that a crime has been committed call the police.
If you see something that concerns you or you are given information that causes you to be
concerned about a vulnerable person then:
o Keep calm; this will help the vulnerable person
o Make sure that the person is safe
o Listen carefully to what is said
o Observe what you see around you, if possible
o Reassure and take care of the person
o Get help as soon as possible.
Remember you will need to record everything that you saw, heard and did. Record the
facts of what happened.
Remember it is expected that you pass on any concerns immediately to the Adult
Safeguarding Service or contact your consultant psychiatrist supervisor in this context.
Signs of possible physical abuse
Unexplained injuries, bruises or burns, especially if recurrent

Improbable excuses given for injuries
Refusal to discuss injuries
Untreated injuries or delay in reporting them
Excessive physical punishment
Signs of possible physical neglect
Constant hunger
Poor personal hygiene
Constant tiredness
Poor state of clothing
Frequent lateness or non-attendance at school
Untreated medical problems
Signs of possible emotional abuse
Low self-esteem, continual self-deprecation

Sudden speech disorder
Rocking, head-banging, or other neurotic behaviour
Self-mutilation
Signs of possible sexual abuse
Behavioural
Lack of trust in adults or over-familiarity with adults

Fear of a particular individual
Social isolation, withdrawal, and introversion
195
Sleep disturbances (nightmares, irrational fears, bed wetting, fear of sleeping alone,
needing a nightlight)
Running away from home
Girls taking over the mothering role
Unusual interest in genitals of adults, children, or animals
Expressing affection in inappropriate ways
Developmental regression
Over-sexualised behaviour
Physical/medical
Bruises, scratches, or other marks to the thighs or genital area

Itch, soreness, discharge, unexplained bleeding from the rectum, vagina, or penis
Pain on passing urine or recurrent urinary tract infection
Recurrent vaginal infection
Venereal disease
Stained underwear
Discomfort/difficulty walking or sittin (Adapted from; Oxford Handbook of
Psychiatry, 1st Edition)
References:
SETSAF: Southend, Essex and Thurrock Adult Safeguarding Policy.
Abuse of people with learning disabilities and other vulnerable adults, Advances in Psychiatric
Treatment (1998), vol. 4, pp, 119-125, L.B.Cooke & V.Sinason.
TASK: LEARNING DISABILITY AND ABUSE
You have been asked to speak to the key worker of Mr. Ram Sahey, a 26-year-old man
with moderate to severe degree of learning disability who attends the day centre. The key
worker is concerned that Paul has been withdrawn and tearful. Obtain more history from
the key worker to identify causes for his presentation and arrive at a diagnosis.
Expanded construct: The candidate is expected to obtain clear history to identify the
possibility of ongoing abuse in learning disabled population. They should be able to
ascertain the following areas during history taking.
Areas to be targeted in history taking
1. Exploration of Presenting Problems- mode of onset, duration and severity
2. Exploration of patients social circumstances residence, support from family

and carers, educational, community, occupational and recreational activities
3. Elicit features of physical injuries and physical symptoms which could be

suggestive of physical abuse and neglect (such as bruising of any part of the
body, cigarette burns, finger-mark bruising, linear whip marks, dehydration,
196
dishevelled appearance etc)
4. Elicit psychiatric symptoms and features of psychiatric disorder that could

be manifestations of physical or sexual abuse (recent onset of social
withdrawal, irritability, aggressive or other disturbed behaviour, sexualised
behaviour, anxiety and autonomic arousal, etc)
5. Explore whether key- worker has information about patients level of

communication, intellectual functioning and skills, and social interaction in
different settings e.g., college, day hospital, community facilities, when in the
presence of family members,
6. Explore other causes for patients presenting symptoms such as epilepsy,

ataxia, mobility problems, vision and hearing problems, and adverse effects
from medication resulting in falls, bumping into things. Whether involved in
any violent incidents due to conflicts or incompatibility with other patients,
chronic history of self injurious behaviour
7. Ascertain whether manager has made attempts to contact family to obtain

their account of reason for patients presenting symptoms, whether there is
evidence of inconsistencies in their explanation and observed presenting
symptoms.
197
DOWNS SYNDROME AND DEMENTIA
Qn. A 45 year old patient with Downs syndrome living with his elderly parents who
reported episodes of aggression, wandering, gradual deterioration in self-care, and reduced
ability to engage in everyday activities. They also noticed him to have poor memory. His
long-term live in carer has recently moved to another country.
What are the diagnostic possibilities?

What are the risks involved?
What treatments can you offer?
How would you support his elderly parents?
What are the possible causes of challenging behaviour in LD population?
Given the information, I shall think of the following possibilities.

Early Stages of Dementia/Alzheimers (possibly the patient has started developing
cognitive and behavioural symptoms of dementia)
Depression/pseudo dementia
Bereavement (loss of his long term live in carer)
Change in physical status
? Psychotic illness
Rule out organic causes such as Hypothyroidism, infections and epilepsy
The risks identified include
Risk of harm to self, self-neglect

Risk to others-violence and aggression
Risk of non-compliance
Risk of excessive carers strain.
Liaise with GP and obtain more information from other professionals involved.
Make arrangements to see the patient in the community by arranging a domiciliary visit
with one of the members of the team
Obtain more information from the parents about his general functional abilities, sleep and
appetite pattern, and specific management problems in detail if any and also ascertain the
degree of social support.
My assessment would involve history taking, physical examination, mental state
examination, detailed cognitive examination and comprehensive risk assessment.
I would be more interested to look for features of depression such as low mood,
anhedonia, fatigueability and biological symptoms such as disturbances in sleep and
appetite.
I would try to elicit more information with a view to differentiate and elicit signs and
symptoms of dementia and associated changes in behaviour and mood, changing level of
support, associated physical changes and premorbid functioning.
I would also clarify whether his current difficulties that he experiences predate the loss of
his long term live in carer and whether these symptoms were worsened or triggered by
theses life events.
198
Physical examination including neurological examination and rule out sensory deficits
such as hearing impediment or poor eye sight which is not uncommon in downs
syndrome.
Investigations:
Detailed cognitive assessment with the help of the psychologist to rule out any Dementing
illness-I would use the DMR scale (Dementia scale for mentally retarded persons) to measure
the level of cognitive deficits
Detailed Neuropsychological assessment may be required to build up an accurate picture

of his current Needs, general level of intelligence and functioning, specific
development strengths and weaknesses.
Routine blood investigations to rule out organic causes of this presentation such as UTI,
Chest infection, constipation, hypothyroidism etc.
Dementia screen work up-FBC, B12 and folate levels, LFT, U&Es, TFTs, blood glucose
CT/MRI scan
Medical management:
Treat any medical illness accordingly.eg UTI

Treat any co morbid psychiatric illness such as depression/psychosis with antipsychotics
or antidepressants
If the disturbed behaviour results from a psychiatric disorder, the treatment is similar in
most ways to that for a patient of normal intelligence with the same disorder and in
addition will also require a behavioural regime.
For most serious and persistent disorders, he/she may require hospital admission for
more, intensive behavioural management, which may be combined with
pharmacotherapy.
Antipsychotics and benzodiazepines drugs are often useful in the short term but need to
try psychological intervention.
Patients on medications needs review by a psychiatrist regularly for organizing effective
on going monitoring, regular physical examination as patients may suffer from over
sedation, delirium and EPSE, and also for frequent monitoring of its effects and
adjustment for dosage.
Antidementia drugs for possible cognitive impairment/Dementing illness. Consider
Acetyl cholinesterase inhibitors treatment for Alzheimers dementia with specialist
advice which may help with cognitive and behavioural symptoms and possible
improvement in ADL skills
For most serious and persistent disorders, it may require hospital admission for more
intensive behavioural management, which may be combined with pharmacotherapy,
depending on risk factors and mental state.
Psychological treatments:
a) Psychologist to be involved in assessing behaviour and analyze it. They will be able to offer
counselling to cope with his recent loss and to help him with practical aspects of memory
impairment.
199
b) Behavioural modification: Often, carers are involved in behavioural assessment and treatment
methods. Ask the parents (or) carers to keep records of behaviour such as eating, sleeping and
general activity, so that problems can be identified and quantified and it is important to support
them adequately. Worth mentioning -ABC chart
b) Family work: Parents should be involved in the planning and provision of care.
The parents need continuing psychological support, which may be provided as a programme for
the whole family. Explanation to parents on many occasion and provide continuing Support.
Social management
Social worker to be involved for Needs assessment and carers assessment and to
arrange for Practical support in the form of home carers, day care, respite care.
Involve different members of the multidisciplinary team also psychologist, community
psychiatric nurses, occupational therapist.
Occupational therapists-Consider reassessment of ADL skills and vocational guidance.
Long term options for LD patients.

Remain at home with increased support and respite for the parents
Independent living with / without support.
Admission to a nursing home (or) group home.
Hospital admission (only necessary if there is acute mental illness)
200
FORENSIC PSYCHIATRY
STAFF ASSAULT
The nurse in charge of your ward urgently bleeps you and informs that one of your patients
has assaulted a member of the staff and is still holding a weapon.
Acknowledge that this is a Serious Issue
My immediate concerns would be safety of the nurse assaulted, patient involved, and
other patients in the ward, other staff and myself
My main aims would be;
To ensure the safety of everyone in the ward

Disarm and isolate the patient
To debrief the member of staff
To reassure the staff and other patients.
Rush to the site of assault immediately
Remove all other patients from the site who do not need to be there.
If the staff is badly assaulted and if it warrants treatments call the ambulance and transfer
the staff to A&E accompanied by another staff to provided more support and reassurance.
Call the police for help.
Gather adequate trained nurses (trained in control & Restrain techniques).
First step would be disarm the patient and any weapon taken away from the patients
would have to be disposed of in such a way as to prevent its retrieval and re-use by the
patient.
Transfer the patient to the Seclusion Room and consider a low stimulus, secure
environment and give some time-out for the patient.
Approach the patient with sufficient staff.

Allow him plenty of room.
Try Deescalating measures talk-down (Use calm non challenging voice, avoid
confronting and use appropriate body language).
201
Try to explore the cause for this behaviour, what provoked this behaviour and assess if
this violence may be secondary to his mental illness.
Try to obtain a thorough history and examination looking for features of drug and alcohol
intoxication or withdrawal, features of psychosis and organic causes of confusional state.
Consider the risk to self, get more information if possible, do a MSE and if possible
physical examination.
The patient is psychotic and need further treatment
Persuade him to take medications.
Try oral meds and if patients refuse he may need parenteral medications (Use local trust
guidelines of Rapid tranquillization) and also monitor his vital signs.
Reassess him later and review the case with other nursing staff.
Discuss the situation with the consultant and the on call manager.
The nurses & doctors should take further management decision jointly.
Ensure clear documentation of medical and nursing notes.
Staff Debriefing It helps to ventilate their feelings, reduce the distress and to assess the
need for further Psychological support and time off to recover.
Staff meeting to discuss in detail to prevent future incidents, to improve security in the
ward, to review the existing policies and procedures and to institute preventative
measures.
Documentation in the incidents form for possible auditing.
Community group meeting reassuring other patients in the ward.
Consider forensic assessment later.
Ensure that you do not hesitate to call on police assistance to disarm an unarmed patient.
Staff wishes to press charges, then the police to be involved to press charges and to get
proper record of witness statements.
If patient is not mentally unwell, establish with police their response.

Seek senior advice in an acute psychiatric emergency.
Mention about SUI (Serious untoward incident) review. It is a process which analyses,
what could have been done differently to have a good outcome and learning lessons.
202
SIGNIFICANT ASSAULT ON A PSYCHIATRIC WARD- PAIRED STATION
TASK: (PART-A) You are the on call doctor. You have been asked to assess Mr. Coleman who
is currently in psychiatric ward and has assaulted one of the nursing staff this morning. Assess
circumstances leading to assaultative behaviour. Perform mental state examination and risk
assessment. You will be asked to discuss his case with ward manager
Expanded construct: The candidate is expected to assess circumstances leading to

assaultative behaviour. Perform mental state examination and risk assessment
They should explore the following areas;
Assess circumstances that led to assaulting nursing staff- clarify
Mental state examination- Look for signs of mental illness that could have
precipitated aggressive behaviour
(Delusions, hallucinations, lack of insight, agitated mood, irritability, depression etc)
Risk assessment- Thoughts of self harm,

Violent thoughts- staffs/other patients, Previous history of violent behaviour etc
Past psychiatric history- Treatments, current medications
Assessing patients view on the assault,

? Taking responsibility for his actions etc
You have been asked to discuss mental state findings with Mr. Sean Gold, Ward Manager
of the psychiatric ward where this assault has occurred. You are also expected to
formulate a joint management plan to deal with aggression from this patient in
association with the ward manager.
Expanded construct: The candidate is expected to discuss mental state findings with
Ward Manager of the psychiatric ward where this assault has occurred. They are also
expected to formulate a joint management plan to deal with aggression from this patient.
Discuss Current Mental state and Risk assessment

Patients views on assault.
Discussion- Role of medication and Rapid tranquillization
203
The joint plan would be that the patient though has mental illness,
1. Has responsibility for his actions
2. Fit to be interviewed by the police
3. Let the nurse press charges to let the patient become aware that such
aggression would not be tolerated.
Closer monitoring,
Improve staff awareness of the risk
More one to one time, time-out
Behavioural approach (ABC analysis) in dealing with his aggression
Avoiding frustration of the patient,

Provide more opportunities for leisure/diversion, games, occupational therapy etc
Further discussion points- Involvement of specialists for their assessment

(Forensic services).
No place for increasing or adding medication.
204
PATIENT FOUND HANGING
You receive a telephone call from the ward whilst you are in the out patient clinic, and you
were informed that one of your patients has been found hanging in her room.

Assume that the patient dies, then how would you proceed?
What more could be done to avoid later complaints, litigation and victimization?

Ill acknowledge that this is an Emergency situation.
Inform nursing staff to release the patient from the ligature, call an ambulance and emergency
team (Dial 999).
Commence CPR by trained staff and keep other patients away from the scene. Inform that you
will be in the ward as soon as possible.
Speak to receptionist, explain the situation, and ask for patients in the clinic to be rebooked. Rush
to the ward immediately.
Get quick, brief history from the nursing staff.
Make sure that CPR has been instigated; make arrangements to transfer the patients by ambulance
to A & E.
Speak to the A & E colleague and give a clear handover to the team at A & E.
Assume that the patient dies, then how would you proceed?
Acknowledge this is a very difficult situation for all those involved.
My aim would be to
1. Support the nursing staffs, other members of the team, other patients on the ward, and
bereaved family
2. To avoid victimization and make it a good learning experience.
Inform RMO as soon as possible.

Inform the on call manager as soon as possible (Trust)
Inform relatives.
Arrange for Ward Staff meeting to debrief, take particular care to avoid victimization and
make a supportive approach.
Time off to recover Staff involved directly.
Arrange for a Community meeting and inform other patients, Provide them with more support
and beware of copycat suicides & vulnerable patients to be reassured
Arrange for a Family Meeting discuss with the family members, explain (events) what has
actually happened
Help them to manage the crisis situation, consider the need for bereavement, answer their
queries and concerns, This can help to avoid later complaints and litigation.
205
I would also discuss with patients GP and other professional involved in his care (e.g.) key
worker in the community.
Ensure clear documentation of medical and nursing notes and make sure that they are kept in a
safe, locked environment and incidents form to be filled in for auditing.
Inform the coroner, Coroners court .
Inform national confidential inquiry (NCI) in to suicide of people with mental illness.
Learning from our mistakes and efforts to prevent such events happening in the future.
Departmental case conference to get peer support
206
VIOLENCE-RISK ASSESSMENT
Areas to be concentrated upon
1. Previous history of violence, the severity of the violence and the context in which the
violence occurred
2. Current violent impulses and fixed thoughts to harm anybody
3. Explore the current possibility of being acutely unwell mentally and being non compliant
with medication
4. Enquire about current alcohol and drug use.
Previous history of violence

Can you describe the incident that happened recently when you lost your control
and became violent?
What caused the incident in the first instance? What are the triggers for the
violent outburst?
Is it associated with acts of violence to people, property or both?
Was it just verbal aggression or did you physically hit somebody?
Does the incident result in injury to others?
Did you use any weapon during this incident?
What were you feeling at the time of the violence?
Is there remorse following the outburst?
Explore whether the patient has history of violence like hurting others, fights, trouble with the
police etc and also enquire about family history of violence.
Are you the sort of person who has trouble controlling your anger?
Have you found yourself hitting people when you are angry?
Have you found yourself damaging property when you are angry?
What is the most violent thing that you have ever done?
Present violent impulses

Is there anything about the present situation that makes you feel like damaging things or
hitting people now?
Do you feel that you might damage things now?
Do you feel that you might hit people now?
Are you angry at anyone?
Who are you angry at?
Are you thinking about hurting the person mentioned?
When do you think you might hurt?
Where will you do this?
How long have you been thinking this way?
How do you intend to harm and how serious it can be?
Do you feel strongly to do so?
Do you have access to weapons etc?
Are you able to control these thoughts about hurting?
207
Do you think that you would be able to stop yourself from hurting the person if you
wanted to?
Look for psychotic Symptoms and compliance to treatment plan:

2. Is there something or someone trying to control you?
3. Do you feel under the control of some force or power other than yourself as though you are a
robot or a zombie without a will of your own?
4. Do you feel that forces beyond your control dominate your mind?
5. Are thoughts put in your head that are not your own?
6. Do you think that there might be people who intend to do you harm?
7. Who are they? What do you intend to do about it?
8. Enquire about command hallucinations and hallucinations of a derogatory or threatening
content. (Please check the chapter on eliciting hallucinations)
9. Explore delusions of persecution and reference (Please check the chapter on eliciting
delusional ideas)
10. Have you been taking your medication regularly?
11. Do you think that you might be unwell at the moment?
12. In what way do you think you are unwell?
13. What are your thoughts about inpatient treatment in the hospital?
Substance use: Enquire about current alcohol and drug use

Have you used any alcohol over the past few days?
Have you used other drugs over the past few days?
Were you using drugs or alcohol in the past when you were violent?
Have you taken anything now?
Note: If the clinician believes that there is real likelihood of violence, then it is important to
discuss with the patient, your duty to inform the concerned people.
The clinician should consider immediate action which would be contacting and warning the
individual about the potential risk of violence to him/her.
If the person cannot be contacted immediately, then we should inform the police and once
informed they too have a duty to warn that person of the risk of violence.
If in doubt, then seek consultation with a senior colleague.
Potential risk factors for violence

Being male
Low intelligence
Living or growing up in a violent subculture
Past history of violence
History of violence in the family
History of poor impulse control
Easy access to weapons and victims
Abuse of drugs or alcohol
Factors associated with dangerousness
Gender: Male Gender
208
History; One or more previous episodes of violence, repeated impulsive behaviour,
evidence of difficulty in coping with stress, antisocial traits
Circumstances; provocation or precipitant likely to occur, alcohol or drug abuse
The offence; bizarre violence, lack of provocation,
Mental state: paranoid beliefs, morbid jealousy, lack of self control, threats to repeat
violence, deceptiveness, continuing denial, lack of regret
TASK: VIOLENCE- RISK ASSESSMENT
Mr. John Abraham is a 28-year-old gentleman with a long-standing history of paranoid

schizophrenia. He has been admitted to a low secure forensic unit and is now been
charged with serious assault. You have been asked by the court to assess him.
a. Assess circumstances leading to index offence.

b. Ask him relevant questions to identify risk of future violent offending.
Expanded construct: The candidate is expected to Assess circumstances leading to

index offence and ask him relevant questions to identify risk of future violent offending.
Assess Circumstances leading to Index offence- (location, people, timing, triggers,

drug or alcohol involved, Severity of violence)
Assess Patients view about the offence; Anger, Denial, lack of remorse, lack of guilt
Ongoing thoughts of violence etc
Obtain Significant Personal history (Traumatic childhood, violent father, Victim of

domestic violence etc)
Obtain Psychiatric history- (Low IQ, Conduct disorder, Psychotic illness, non-
compliance)
Obtain Previous Forensic history (Past violent offences, arrests, Convictions,

sentences etc)
Look for Other Risk factors- (Single, unemployed, homelessness, Drug & alcohol
Misuse, lack of stable Relationships)
Personality traits- (Repeated impulsive behaviour, Difficulty in coping with stress,

Antisocial personality traits)
209
MORBID JEALOUSY- ASSESSMENT
Check list:
History of alleged assault and Circumstances leading to the act.
Assessment of evidence for the Belief of Wifes infidelity & intense seeking Behaviour
(Searching in diaries, Handbags, Smells of perfumes, Aftershaves etc)
Assessment of strength of beliefs, degree of conviction and other abnormal beliefs (The
partner plotting against the patient, Trying to poison him etc)
Risk assessment- Risk to self, wife and third party, Risk to children, Hx of violent
behaviour or aggression, Recent/active threat, Stalking, harassing, carrying a weapon
Screening other psychotic Sx-other delusions &Hallucinations, mood symptoms
Co-morbidity: Alcohol & substance misuse, Sexual problems, marital problems and
paranoid personality traits
(Adapted from www. Trickcyclists.co.uk)
History:
Take a full psychiatric history including;
Threatened and perpetrated violence-enquiries about arguments, confrontations, threats

and actual violence perpetrated by the jealous individual should be made)
The quality of the relationships-marital relationship, sexual and domestic violence history
should be elicited.
Family constitution
Evidence of associated mental illness such as affective disorders, psychotic disorders and
substance misuse should be elicited.
It is also important to obtain collateral history from spouse. Both partners should be interviewed
separately and then together.
Mental state examination:
The form of morbid jealousy ( May take the form of a delusion, an obsession, or an
overvalued idea or combinations of these)
Associated psychopathology
Risk assessment:
1. Suicide
2. History of domestic violence
3. Risk to children-The risk to children in the household should be considered and
protecting them is a paramount concern.
4. History of interpersonal violence, including any third party
210
MANAGEMENT- MORBID JEALOUSY
Principles of management involve treating the mental disorder (psychosis, depression etc) and
risk management.
Admission to hospital
1. For further assessment of mental state
2. To carry out a comprehensive risk assessment
3. Instigate clear management plan, both short term and long term
4. Arrange adequate follow up and support on discharge.
Adequate treatment of any associated disorder such as schizophrenia, delusional disorder (or)
mood disorder with antipsychotic, antidepressants and mood stabilizers.
1. Admission to hospital (compulsory detention if necessary)-When it gives rise to

appreciable distress, a significant risk of harm or if it is not managed satisfactorily by
outpatient treatment, admission to hospital may be necessary.
2. If there appears to be a risk of violence, the concerned doctor should warn the partner.
Geographical separation of the partners may be all is effective if morbid jealousy is refractory to
treatment (Shepherd 1961). In such cases, the Geographical separation of the partner is
recommended to ensure safety.
Consider Gradual reintroduction into the community
3. Consider close monitoring, multidisciplinary team involvement, and periodic risk

assessments by more than one person
4. Treatment with antipsychotic medication or with antidepressants
5. Treatment of co-morbid condition such as substance misuse and alcoholism
6. Psychological therapies-Couple therapy, CBT ( If obsessions are prominent) and dynamic
psychotherapy (in whom personality disorders with borderline and paranoid traits are
present)
7. Child protection proceedings should be instituted if necessary-children in the household
may witness arguments between their parents, suffer from emotional and physical abuse
or even be injured accidentally during assaults.
Prognosis:
It depends on various factors such as underlying phenomenology, the existence of co-

morbid mental disorders and response to treatment.
Those with a psychotic illness generally have a poorer prognosis but a third of patients
may show significant improvement (Langfeldt 1961 and Mooney 1965).
211
The possibility that morbid jealousy will recur is significant and therefore careful
monitoring is warranted indefinitely
Note: - Bear in mind that it is not uncommon for feelings of pathological jealousy to wane once a
relationship has ended. Sometimes, the problem re-emerges if the patient enters a new
relationship.
Prognosis:- Depends on a number of factors, that includes premorbid personality and underlying
psychiatric disorder. Research evidence suggests that over half of them still had persistent (or)
recurrent jealousy. The prognosis is often poor.
Risk of suicide accused partner deciding to end the relationship.

Risk of homicide
Risk of Physical injury inflicted by jealous patients.
Specific threats made to partner (or) to others Disclose to the concerned person/ police
(duty of care- Issues of confidentiality/ Tarasoff case.
MORBID JEALOUSY- RISK ASSESSMENT
TASK: (PART-A): Mr. Harris Brown is a 48-year-old gentleman brought to the Place of
safety (Section 136 Suite) by the police because he was screaming obscenities and threats
at his wife as she left to spend a few days with her mother and came back home. Take
history from the patient and perform risk assessment, which would help you to decide
further management with his wife in the next station.
Expanded construct: The candidate is expected to obtain detailed history from the
patient and perform appropriate risk assessment. They should assess the following areas;
Circumstances leading to presentation (onset, duration and severity),
Assessment of evidence for the Belief of wifes infidelity & intense seeking
Behaviour (Searching in diaries, Handbags, Smells of perfumes, Aftershaves,
Credit cards, Underwear etc)
Assessment of strength of beliefs and Degree of conviction

Screening for psychotic Symptoms -other types of delusions & Hallucinations,
Mood symptomatology
Risk assessment- Suicide risk, history of domestic violence, risk to third party
(E.g suspected rival), past history of violent behaviour, risk to Children,
Recent/active threat, Stalking, harassing, carrying a weapon etc
Past psychiatric History, Forensic history
Co-morbidity: Alcohol & substance misuse, Sexual problems, marital problems,

Paranoid personality traits
212
Mr. Harris brown has now been assessed. Explain his diagnosis and further management
plan to his wife. Address her concerns
Expanded construct: The candidate is expected to explain the diagnosis, should

also explain their management plan both short term and long term to his wife, and explain
risks involved. The areas to be covered include;
Explain the diagnosis-Morbid Jealousy (Delusions of infidelity)
Emphasise risk involved to wife
Management
(Admission to hospital compulsory detention if necessary,
Geographical separation of partners, risk assessment and evaluation)
Treatment with antipsychotics, Treat co-morbidity,
Gradual re-introduction into community,

Offer support to wife,
Multidisciplinary Team approach
Persistence in the candidate in saying- this was a high risk situation given
his history and his deterioration in mental state recently and that he would
need to come into hospital for further admission
213
EROTOMANIC DELUSIONS- ASSESS DANGEROUSNESS
Part A: Erotomania Assess (Compiled by Dr. Mark Tarn & Dr. Sree Murthy)
A young man has come to the hospital reception and demanded to speak to a staff nurse,
that he is in love with. The receptionist has asked you to see him. Obtain a history to
assess his thoughts and beliefs. Establish the level of dangerousness.
In a real life you would begin by deciding the appropriateness of the receptionists
request.
Background information would be needed, who is this man?

Is he a current or ex-patient of the unit?
Is the nurse in question aware of his visit?
Does she understand why he has turned up unannounced?
In the real situation you are likely to be involving the police from the start and they will
probably be in the best position to interview this man with the teams advice.
The CASC station does instruct you to interview him, how should you proceed?
Firstly, normally you would not interview him alone and you would be cautious
regarding him carrying any weapons (there may be a search facility). An appropriate
interview room would be selected, with the patient furthest from the door and you having
access to an alarm.
Explain to him the limits of confidentiality.
How to approach this situation;
When assessing dangerousness, it is extremely important to consider about static

and dynamic risk factors.
When talking to the patient, the examiner would expect candidates to be empathic
and offer support/ validation for his distress.
They should approach him in a non-confrontational and non-judgmental manner.

They should ask very open questions initially and try to build rapport.
214
Areas to be targeted in the history
1. Beginning by asking neutral questions to establish rapport and keep control of the
interview, terminating it if necessary.
Where is the patient from?

Who does he live with? Is he employed and as what?
2. Ask him to tell you about the nurse.
How did they meet?

Was it through his mental health needs?
What does he believe is the quality of their relationship?
How does he know that? (ask for evidence)
How much does he know about the nurse?
Is this the first time he has sort her out?
Does he know he know her mobile/email address?
Does he know where she lives?
Has he been there?
Has he been observing her?
Does he know if she has a partner already?
What will he do about that?
Check the conviction of his beliefs could he have misinterpreted her actions/words?
Was she not just doing her job?
3. Enquire about his mental health history

Is he a patient of mental health services?
What is his diagnosis?
What medication is he on?
Does he have symptoms of mental illness now? Paranoia?
Is he taking his meds?
How does he usually cope with stress?
Has he taken it as prescribed?
Self harm in past? Current MSE.
4. Drug & Alcohol history, forensic history, personality- static factors
Ask about drugs and alcohol- Does he use alcohol or drugs?

His forensic history and history of violence? When did he first get into trouble
with the police?
Ask about previous offending and any custodial sentences?
Have similar episodes happened but theyve not been brought to the attention of
the criminal justice system? Any offences against the person?
215
What is his personality like? Is he impulsive or short tempered? Does he have
antisocial/ procriminal attitudes?
5. Previous similar presentation and psychosexual history
Has this happened with anyone else (unfrequented love)?

What were the circumstances?
Ask about psychosexual history (particularly fantasises and other partners).
6. Current thoughts and plans:
What will he do with the nurse if they meet?

What are his thoughts if his feelings are not reciprocated?
Would he hurt the nurse? Would he become suicidal?
Does he have current thoughts of violence- or suicide?
Does he have access to weapons?
Lastly, what will he do now if he cant see her and she has informed staff that she
never wants to see him?
Reasons for failing in this station:
1. If the candidate could not take control of the situation/ be empathic to his distress.
2. If the candidates did not perform a brief MSE looking at psychotic and mood
symptoms.
3. If the candidate did not ask about several static and dynamic risk factors-
especially about thoughts of violence/ homicide/ weapons/ substance misuse/
forensic history.
Part B: Erotomania Explain

You assessed this man earlier. Later staff told him that he cant see her. He became
aggressive and waved a knife. He was overpowered, arrested, taken to the police station,
but was released by mistake. He is now loose in the community. Discuss this situation
with the nurse and answer her questions. Explain your Risk assessment and Risk
management plan.
Firstly, any planning (including the reduction of risk) can only be carried out with close
liaison with the police. The candidate is the best informed regarding the patient and
he/she will have already relayed that information to the police. The nurse should be
encouraged to seek the polices advice at the end of the interview with appropriate
support. The consultant is on his/her way in.
216
The risk to the nurse has primacy over the confidentiality owed to the patient, because of
the immediacy of action required. This does not mean that the candidate has to provide
all information provided by the patient but it should be proportional and relevant to the
risk.
The patient may know where the nurse lives, her mobile number and her normal routines.
You should explore with the nurse if it is feasible for her to stay with friends/relatives and
ensure advice is taken from the police.
Does she need to return to her accommodation to pick up items?

Will the police escort her?
Is there a member of staff that can escort her to her car/bus stop?
Who can she call for support?
How will her work commitments be affected?
The nurse may well ask as what will be the likely outcome of his inappropriate contact.
An honest answer should be given and avoid over reassurance if groundless.
EROTOMANIA- ASSESSMENT OF RISK AND MANAGEMENT
TASK
A young man has come to the hospital reception and demanded to speak to a staff nurse,
that he is in love with. The receptionist has asked you to see him.
Obtain a history to assess his thoughts and beliefs. Establish the level of dangerousness .
Expanded construct: The candidate is expected to assess patients abnormal beliefs
(nature and content) and establish the level of dangerousness.
They should;
Begin by asking neutral questions to establish rapport and keep control of the
interview, terminating it if necessary.
Explore the level of information known about the other person (whom he is in love
with)
Familiarity, closure, previous meetings, email, mobile address, living address,
observations, Does he know if she has a partner already? Etc
Delusions of love- elicit, explore and clarify, effects and coping
Assess fixity and degree of conviction

Seek explanation for content of delusional beliefs
Risk assessment- Aggression, violence, stalking, threatening acts,

Self harm, thoughts of harming the concerned person)
217
Past history, psychiatric history, drug and alcohol history
Forensic history, Psychosexual history- sexual fantasies and deviant sexual practices
Be able to take control of the interview and demonstrate positive ability to deal with
angry patient
You assessed this man earlier. Later staff told him that he cant see her. He became
aggressive and waved a knife. He was overpowered, arrested, taken to the police
station, but was released by mistake. He is now loose in the community.
Discuss this situation with the nurse and answer her questions.
Explain your Risk assessment and Risk management plan.
Expanded construct: The candidate is expected to discuss this situation of Erotomania

(delusional disorder) with the nurse and Explain Risk assessment and Risk management
plan. They should;
Provide a summary of the discussion and explain presence of

abnormal beliefs with severe degree of conviction.
Explain diagnosis of delusional disorder (delusions of love)- nature

of the disorder. Address concerns- ? Schizophrenia/ personality
disorder etc
Provide all information pertinent to the risk to the nurse and

explain the level of dangerousness (aggression, violence, stalking
etc)
Address concerns by the nusrse - sexual fantasies, sexual deviance,

aggression etc.
Encourage close liaison with the police and a pragmatic plan.
Avoid false reassurance.
Encourage the nurse to seek out appropriate support and

alternative accommodation as directed by the police.
218
Give an honest opinion regarding how the case may proceed.
PSYCHOSIS & STALKING BEHAVIOUR
(Written by Dr. Fatema Ibrahimi and edited by Dr. Sree Murthy)
TASK: The police arrested Mr. Steve Bridge, a 37-year-old gentleman as he

broke in to Mrs. Emily Parkers home whom he knows from his college about 20
years ago. You were transferred from police station to a local psychiatric unit for
psychiatric evaluation. He has made contact with her about 6 months ago and
has been pestering her. She has brought an injunction order against him but
today broke in to her home. Perform mental state examination and assess any
risk.
Expanded construct: The candidate is expected to Perform mental state examination

looking for evidence of mental illness and do appropriate risk assessment. They should
explore the following areas;
Circumstances of the index offence: was it planned/unplanned, what were his intentions,
use of substances/alcohol at the time
Explore Persecutory (suspicious/paranoid) beliefs- clarify, assess the degree of

conviction, seek explanation, impact on life and coping strategies
Thoughts (delusions) of parts of his life being controlled by another person

Establish if other psychotic symptoms present: perceptual disturbances, thought
alienation, passivity phenomenon
Establish if mood/affective component to presentation
Risk assessment: Self- any thoughts, plans or intentions to harm self currently or in the
past
Risk assessment: others- any thoughts, plans or intentions to harm the victim or her
friends/family (with physical/verbal aggression or threats) or plans to defend himself
219
from harm
Assess insight: into mental illness, offending, impact on his own life and the victim
Risk of non-compliance to treatment plan
Any past history of violence or aggression and previous risk behaviour

Forensic history
Patients mental health history including substance use,
Family history
Patients attitude towards recent events and the likelihood of a recurrence of dangerous
behaviour.
Related task in the linked station: In the next station you are going to discuss the
assessment with the Crisis team member Mr. Richard Evans
Expanded construct: The candidate is expected to discuss mental state findings and risk
assessment with social worker with the crisis team. Candidate should have a view on the
management of this patient ie. If admission or CRT appropriate and this should include
the risk assessment and impact on victim.
Summarise & describe the events leading to the patients arrest and transfer for assessment
Was it planned, what were his intentions (towards both the victim and her property)
Summarise the mental state focusing on the positive findings and Provide details of the key
aspects including persecutory (suspicious/paranoid) beliefs, thoughts (delusions) of parts of
his life being controlled by another person
Discuss level of insight into current mental health,

Need for follow up and treatment and association with his offending
Risk assessment- risk to self and others (including victim and her friends/family),
RISK OF REOFFENDING
Discuss main treatment options: i.e.

out-patient follow up, CRT involvement, in-patient admission (Emphasise inpatient
treatment)
High risk of re-offending if not admitted, unlikely to take up treatment in community as

poor insight,
Risk to victim physical and emotional, potential risk to her friends/family (he has there
details)
220
CRT/out-patient involvement unlikely to be able to reduce these risks immediately, wiwill
require treatment and likely delay in onset of action
More appropriate for CRT ooonce delusions and insight improved?
Reading material
Part A- Mental state examination and risk assessment
It is important to try to establish the patients views around circumstances of his

arrest.
1. What were his intentions in breaking into the property and whose property was
it?
2. Had he planned the break in for long was it impulsive?
3. Did he hope to find this woman there and confront her or was he looking for
something?
4. Was he aware that by breaking into her property he would be breaking the
injunction? Try to establish his views on the injunction.
It is essential to try to establish his beliefs about this woman and his paranoia as
being of a delusional degree/nature. Therefore once he has spoken of his paranoia
and this womans involvement (which he will if you establish circumstances of
the arrest) you must demonstrate to the examiner that these are delusional beliefs.
Establishing a belief as being delusional must be done sensitively and

considerately, but this needs to be balanced with not colluding with the beliefs.
Asking general questions first such as if there could be any other explanations for
the things that he believes have been happening to him? How certain is he that
this woman is involved/behind it all? Why would she take an injunction out
against him/ why would the courts agree to the injunction?
Does he feel that any of his experiences recently could be related to his mental
health? Has he ever seen or been in contact with psychiatric services in the past?
221
His main psychopathology are the fixed delusional beliefs- however you must
cover the main components of the MSE. Confirm his mood/affect. Also establish
there are no perceptual disturbances, thought alienation or passivity phenomenon-
if you are asking screening questions try to explain that you have a few routine
questions to ask and not just jump in with Do you hear voices?
A brief question about drugs and alcohol (and if intoxicated during the offence)
might be useful but not essential if running short on time.
With regards to the risk assessment- try to leave adequate time to cover the
essential components- this aspect should not be left until the bell when you are
short on time. A candidate is not going to pass if part of a station is relating to risk
and this is not adequately covered.
Risk to self- Has he currently any thoughts, plans or intentions to harm himself?
He is feeling in danger, sometimes when people feel in danger they think that the
only way out is to end their life- has he ever experienced this? Does he perceive
the things he is doing as dangerous or harmful to himself eg trouble with the
police?
Risk to others- Any specific thoughts, plans or intentions to threaten or harm the
victim? Does he believe/understand that the break in might be quite frightening
for the victim? Has he thought of using physical violence towards her? Has he any
plans relating to others (he got hold of the contact details of her friends/family)
who he believes may be involved or linked with her?
Has he been violent or aggressive in the past? Forensic history/trouble with the
police in the past?
Reasons for failing: Failure to explore psychopathology and risks
Part B
Discuss your assessment with the Crisis Team
It is important to be able to concisely summarise your assessment. This will

require a summary of the circumstances of his presentation ie circumstances
leading up to arrest.
It is important to discuss the link between the offence and the delusional beliefs.
The ongoing beliefs and limited insight into his mental health is an essential
component to planning follow up and treatment options. It is also essential to
highlight the high risk of reoffending and possible violence unless his mental
health is treated.
222
Options would involve out-patient follow up- however poor insight and previous
disengagement would not make this ideal currently. Would also be essential to try
to reduce further offending and to think about risks to the victim and trying to
keep her safe.
CRT (Crisis resolution team) working with the patient could offer the option to
monitor regularly and even commencing medication- however they could not
confidently prevent him reoffending or keep the victim safe.
Admission would be an option in the short term that could allow the risks to be
contained and for treatment to be commenced. The aim of commencing treatment
would be to treat the delusions and hopefully reduce the offending behaviour and
risk to victim as these are linked. It may be necessary to mention using the mental
health act as a last option if he was not willing to have an admission.
Even if your view is the patient clearly needs admission- it is also good practice to
mention the other options and why they are not suitable in your opinion at this
stage. Safety of the patient and others will obviously be an essential factor in
considering your mangement options.
Your remit here is to clearly explain your assessment and your views with this
colleague. They do not necessariy need to agree with everything you say, but you
should have a valid reason behind your opinions.
223
SEXUAL OFFENCE
ASSESSMENT:
Full psychiatric history and MSE emphasis on the nature of the incident(s), psychosexual history,
and previous offences, utilising sources of information other than the accused
We need to explore the details of the offence, patients account of the offence, was the
offence related to drug (or) alcohol misuse, low IQ etc
Whether the patients index offence was linked to his mental illness, his level of insight,
look for any evidence of subsequent (or) recent dangerous sexual behaviour, his attitude
to the offence and any evidence for change
History:
Developmental milestones, history of sexual abuse
Psychosexual history (Paraphilia and sexually deviant behaviour)
Drug and alcohol history in relation to offences
Detailed forensic history- previous offences (sexual and non-sexual); previous
supervision failure; frequency, types, and escalation in sexual offending; physical harm to
victims and use of weapons
Current social circumstances, social difficulties (Employment problems and relationship
difficulties), lack of social support
Premorbid personality traits (look for paranoid traits and impulsive behaviour)
MSE: - Lack of guilt, fantasies, lack of remorse, lack of empathy, lack of insight,
Suicidal/ violent thoughts, denial/ minimisation and cognitive distortions; future plans and
attitudes towards intervention.
Risk: - Risk to self, others, children, sexual behaviour, Recidivism
Management of sex offenders:
Some mentally disordered offenders require treatment in hospital (esp. those with mental
illness or marked LD). Treatment is directed towards any associated psychiatric disorder.
In psychotic sex offenders it is usually important to address factors common to other sex
offenders.
Those with personality disorders, Paraphilias, and substance misuse are normally dealt
with by the criminal justice system. Most sex offenders are dealt with solely through the
224
criminal justice system. The Role of a psychiatrist is to establish the presence (or)
absence of a major mental illness and to arrange for appropriate disposal under the
mental health Act. If there is no mental illness, then the law should take its course of
action and are usually best dealt with by the criminal justice system
Within the criminal justice system, both in prison and the community, group CBT
programmes have been developed. Sex offender treatment program (SOTP) is run by
prison services, introduced in UK in 1992. It is based on CBT principles.
A small number of sex offenders receive psychodynamic treatment at specialist clinics.
Medications such as anti-androgens, antigonadotrophins, and SSRIs may be used in a few
offenders. Use Of Sex Hormones (Or) Drugs to Reduce Sexual Drive can be tried to
Augment With Psychologically Based Therapies (E.g.) Cyproterone Acetate
Sex education
Behavioural treatment has been directed towards encouraging desirable sexual
behaviour
RISK ASSESSMENT (SEXUAL OFFENCE)

Predictors of Recidivism for sexual offence
Male Gender
Low IQ
Lower Age
Previous criminal record/Previous history of sexual offence
History of child hood sexual abuse, and other abuse
Juvenile sex offences
Deviant sexual practices like excessive masturbation, self reported deviant sexual
fantasias and urges.
Involved in Paraphilia (Exhibitionism, Voyeurism)
Previous history of poor engagement with services
Personality disorder (esp. antisocial PD)
Access to victims, Attitudes towards victim - low victim empathy, justification of sexual
crimes, and that theyre entitled to express their high sexual drive
Intoxication with drugs/ alcohol
TASK: SEXUAL OFFENCE- PAEDOPHILIA
Take a history from Mr. Kenneth Roberts, a 40-year-old man who has been arrested by
police for allegation of sexual molestation to a 7-year old child who is a neighbour next
door. Please take a history in relation to a possible diagnosis of paedophile. Do not
conduct a mental state examination
Expanded construct: The candidate is expected to assess circumstances of the offence,

take a history in relation to a possible diagnosis of paedophile and look for specific
factors for paedophilic activity.
Assess circumstances of the act/offence, Intent of the act, Grooming activity
Obtain Patients view about the offence and arrest; Denial, minimisation,
justification, lack of remorse, lack of guilt, low victim empathy, feelings of
entitlement
225
Obtain relevant Personal history (traumatic childhood, history of childhood abuse),
Past psychiatric history, Drug and alcohol history
Obtain relevant Psycho-sexual history (deviant sexual practices, excessive

masturbation and urges, sexual fantasies, Paraphilia, h/o paedophile activity, sexual
preference - attracted to children, explore sexual activity & relationship with adults
Previous Forensic history (sexual and non-sexual offences), juvenile sexual offences,
history of cautioning, conviction, sentencing, previous history of similar offences)
Assess Current social circumstances- friends and support system

(Unemployment, homelessness, lack of stable Relationships, abnormal personality
traits- impulsivity, lack of empathy)
FITNESS TO PLEAD-PRITCHARD CRITERIA

It relates to the mental state of the defendant AT THE TIME OF THE TRIAL.
Criteria:
Ability to understand charge and effect of plea-guilty/not guilty
Ability to instruct counsel
Ability to challenge juror
Ability to follow evidence and court proceedings
If a defendant is found unfit to plead, another jury is sworn in and a trial proceeds on factual
information. The disposal is usually a hospital order if the defendant is found guilty.
Clinical assessment of fitness to plead

The assessment of fitness to plead is concerned with the current mental state and ability of an
accused. This involves:
Making a diagnosis of mental disorder

Determining the impact of this disorder on the abilities covered in the legal criteria.
Clinicians should be aware that the mental state of an individual may change and therefore if
some time has elapsed between a clinical examination and the accused's appearance in court then
a brief re-examination may be necessary
COURT REPORT
General format for a COURT REPORT
Clarify the following information

1. Who requests the court report?
Defense solicitor
226
Prosecution solicitor
Court
2. Why and what issues?
Fitness to plead
MSE at time of offence, current mental state and risk of reoffending
Psychiatric defenses
Disposal issues (prison sentence, hospital order (or) probation order requiring treatment
in the community)
3. Stage - 1) Pre- trial
2) Pre - Conviction
3) Post - Conviction
4) Post - Sentence
4. Need to gather information from a range of medical and legal sources prior to completing the
assessment.
Sources of information
Previous psychiatric / forensic reports
Indictment sheet
Custody record
List of Previous convictions
Book of evidence
Accusation and charge sheet
Medical/ psychiatric, general practice notes (patients consent)
The court report should include history, diagnosis, and alleged persons mental state
now and at the time of the index offence, conclusions, opinions and
recommendations to the court. The clinical issues will involve those that psychiatrists
usually assess: diagnosis, treatment needs, prognosis, etc
A thorough review should be made of the history of previous violence, the nature of the
current offence, the circumstances of the current offence and the mental state, and
especially his intention.
The recommendations must comment on whether the person is fit to plead, treatability,
prognosis and the risks involved (esp. risk of re offending)
Recommendations:-
Prior to trial: - Remand in custody for psychiatric report, remand to a psychiatric hospital for
treatment.
During the trial: - Pt found guilty and has a treatable mental disorder, then the possibilities are
Voluntary treatment
Probationary order
Compulsory treatment under various legislations of the mental health Act.
The legal issues: The request for psychiatric assessment should indicate the legal issues towards
which the psychiatrist should direct the assessment.
The main issues to consider are usually:
227
Fitness to plead
Responsibility
The presence of mental disorder and whether assessment and/or treatment under
compulsion (or otherwise) is required
The risk the person poses (may be relevant in whether a restriction order is imposed, in
determining if disposal should be to a secure unit or special hospital, or perhaps in
determining the nature of the sentence imposed
MEDICAL LEGISLATION: CAN ADVICE ON TREATMENT OF MENTAL ILLNESS

BUT CANNOT ADVICE ON JUDGEMENT ISSUE
PRISON VISIT-what to do?

Psychiatrists may be asked to assess prisoners for the following reasons:
To provide court reports

To provide assessment and treatment at the request of a prison medical officer
For statutory purposes (e.g. preparing reports for the parole board)
Before you go to prison, contact the prison health care wing, arrange an interview and take your
ID BATCH. When arranging to see a prisoner, a psychiatrist should make an appointment, which
will fit, in with the prison routine.
The psychiatrist will have to wait to be escorted by prison staff. Prisoners should be seen on their
own unless prison staff or other sources indicate this would be unwise.
In prison ensure your safety first.

Introduce yourself and clarify the purpose of the interview.
Explain to the patient that the purpose of the interview is to prepare a
report and the report will be delivered to the authority who has requested
it (confidentiality can only be maintained that far
Ask the prisoner for a relative's telephone number and permission to
speak to them.
The prison medical file may not contain all the necessary information, and in some cases other
prison records should be examined.
Gather information from the following:
Prison medical officer
Prison staffs-wing staffs and health staffs
Inmate medical record (IMR)
Health care wing
Court liaison CPN
Prison based CPN
228
History taking, MSE, and information gathering should proceed as with any other psychiatric
assessment.
IMPORTANT CONCEPTS IN FORENSIC PSYCHIATRY

Insanity defense: Mc Naughten Rule
To establish a defense on the ground of insanity, it must be clearly proved that at the time of
committing the act the accused party was laboring under such a defect of reason, from a disease
of the mind, as not to know the nature and quality of the act he was doing or if he did know it,
that he did not know he was doing what was wrong
Fitness to stand trial: Ability to conduct oneself appropriately in court

Diminished responsibility-applies only to murder
Conviction for murder carries a mandatory and indeterminate life sentence
Diminished responsibility changes murder to manslaughter
Being guilty of manslaughter and not murder enables disposal at the discretion of the
judge-usually a hospital order (section 37or 37/41 of Mental Health Act 1983)
Disposal Issues
This means whether the defendant should receive a
Prison sentence
Hospital order
Probation order requiring treatment in the community.
Section 37 Hospital order +/- restriction order (England and Wales)
Section 41 To protect the public from serious harm (England and Wales)
Tarasoff Case
The clinician or therapist has a duty to use reasonable care to protect third parties against
danger posed by the patient.
Confidentiality:
In the issue of confidentiality, the current trend is that if there are serious concerns about the
safety of third parties, we encourage the patient to inform authorities failing which we would
do it. Disclose information if
229
The patient gives valid consent
Consent is assumed to be implicit in their action
It is in the interest of the patient
It is in the public interest
Christopher Clunis report (Ritchie report)-

Patient with schizophrenia who was in continuous contact with health and social services since
1986-but still committed homicide in 1992.
Report stated An assessment of risk of dangerousness should be included in the discharge
summary whenever the patient has acted with violence
Note:
1. Psychiatric defenses-Mental state at the time of the offence/crime
2. Fitness to plead-current mental state and ability to understand court proceedings
3. Disposal issues-Current mental state-when patient mental state is stabilized, the patient
should be sent back to prison to serve the sentence.
EATING DISORDERS
ELICITING EATING DISORDER HISTORY

1. Psychological issues
2. Eating issues
3. Physical issues
4. Psychosocial stressors
5. Rule out co-morbidity.
ANOREXIA NERVOSA- salient features
Weight loss > 15% and below expected BMI (Body mass index) of 17.5 or less
Body image distortion-Fear of fatness held as an intrusive overvalued idea
Avoidance of fattening foods, with behaviours aimed at losing weight like vomiting,
purging, over exercise, use of appetite suppressants and/or diuretics.
Amenorrhoea in women, a loss of sexual interest and potency in men
Pubertal delay if onset is early
BULIMIA NERVOSA- salient features
Persistent preoccupation with food & eating and an irresistible craving for food
Binges-episodes of overeating
Attempts to counteract the fattening effects of foods by one or more of the following
like self-induced vomiting, alternating periods of starvation, purgative abuse, over
exercise and use of appetite suppressants, diuretics
Morbid fear of fatness with imposed low weight threshold
230
1. Psychological issues
Do you think you have a problem with your weight and eating?
How do you feel about your weight right now?
What is your ideal weight?
Why is the weight ideal for you?
Are you satisfied with how you look??
Do you feel fat? / Do you feel ugly?
How do you feel when you see your image in a mirror?
Do you feel that you have a distorted body image? If so, in what way?
Do you fear loss of control? What do you mean by that?
What do you feel would happen if you did not control your weight (or) eating?
2. Eating issues
What is a typical days eating?
Is there a pattern? Does it vary?
Do you avoid any particular foods? And if so, why?
Do you restrict fluids?
Binge eating
Do you ever have times where you feel that your eating is out of control or seems excessive?
Do you ever binge eat? (i.e. eat during a short space of time, quantities of food that are
definitely larger than most people would eat during a similar time and in similar
circumstances).
When did you first start binge eating?
How often do you do it and why do you do it?
Could you please describe me about a typical binge?
Obtain information about type of foods eaten, quantity of food, and duration of the binge
How do you feel just before you binge?
Can you identify any particular cause (e.g. feelings, stressors, social situations, etc.) that may
trigger the binge?
How do you feel while you are binge eating?
How do you feel after bingeing?
Attempts to counteract the fattening effects of foods

Vomiting
Have you ever had to make yourself sick? If so how?
How often do you do this?
Can you tell me why you make yourself vomit?
231
Laxatives, diuretics, emetics, appetite suppressants, Exercise
Often many people with these problems use other methods to control their weight like (give
examples and ask specifically) taking Laxatives, water pills, emetics, and appetite
suppressants?
For what reason do you use it?
Do you fast for a day or more?
Do you exercise?
How often do you exercise?
Is this to burn off calories?
Do you use exercise as a means of controlling your weight?
3. Physical symptoms
a. Menstrual changes
When was your last period? Are you menstruating regularly?
b. Changes in libido
c. Symptoms of anemia: weakness, lethargy, constipation
Do you feel the cold badly?
Have you noticed any weakness in your muscles?
Have you fainted or had dizzy spells?
4. Explore the possibility of any recent psychosocial stressors

a. Any difficult situation at home or at work
b. Current relationships and any difficulties with it.
c. Social activities and life in general.
d. Any other Recent Stressors/stressful life events
5. Rule out co-morbidity: Do not forget to rule out depression and other neurotic symptoms
You can use the same questions given in the chapter on depression and anxiety.
ASSESS RISK FACTORS: (adapted from Fairburn & Harrison, 2003)

Female sex
Adolescence and early adulthood
Western cultural adaptation
Family history of ED, depression
Family history of substance misuse, especially alcoholism (bulimia nervosa)
Family history of obesity (bulimia nervosa)
Adverse parenting (especially low contact, high expectations, parental discord)
Childhood sexual abuse
Critical comments about eating, shape, or weight from family and others
Occupational and recreational pressure to be slim
Low self-esteem
Perfectionism (anorexia nervosa more than bulimia nervosa)
Past history of being obese (bulimia nervosa)
Early menarche (bulimia nervosa)
232
ASSESS PROGNOSTIC FACTORS:
In the last few exams, the candidates were also asked to look for prognostic factors, which are
given below
Anorexia: Poor prognostic factors include:
o Male sex
o late age of onset
o Chronic illness
o bulimic features (vomiting/purging)
o excessive weight loss
o poor childhood social adjustment
o poor parental relationships
Bulimia: The prognosis is generally good, unless there are significant issues of low self-esteem
or evidence of severe personality disorder.
TASK: BULIMIA NERVOSA -HISTORY TAKING
Instruction to candidate: You are asked to see Ms. Rose, a 24-year-old lady who has
insulin dependent diabetes mellitus. The GP was concerned about her poor diabetic
control and the patient admits to omitting insulin in order to lose weight. Take a history
to assess for the presence of eating disorder and assess prognostic factors
Expanded construct: The candidate is expected to obtain a good history for eating
disorders, specifically for bulimia nervosa and should be able to assess prognostic factors
They should cover the following areas
Psychological Symptoms (Body image disturbance, Morbid fear of fatness)
Physical symptoms (Fatigueability, Constipation, Dizziness, weakness)

Amenorrhoea- to rule out anorexia
Persistent Preoccupation with eating, irresistible food craving, Eating

pattern and Bulimic behaviour- Binge eating episodes (feelings before
During and after binges)
Measures taken to lose weight - Avoidance of foods/fluids

Vomiting, Over exercise, laxatives, stimulants, Diuretics, others
Prognostic factors: Low self-esteem, personality & Relationship difficulties,

Lack of adequate social support etc
233
ANOREXIA AND BULIMIA- COUNSELLING
Anorexia symptoms:
1. Fear of fatness
2. Under-eating
3. Excessive loss of weight
4. Vigorous exercise to burn off calories
5. Monthly periods in girls becomes irregular or stop
Anorexia usually starts in the mid-teens. These disorders most often start in the teenage
years while the sufferer is still at home.
Women suffer from these disorders 10 times as often as men.
It affects around 1 fifteen-year-old girl in every 150, 1 fifteen-year-old boy in every 1000.
Occasionally it may start earlier, in childhood, or later, in the 30s or 40s.
Girls from high socio-economic families (eg professional families) are perhaps more
likely to develop it than girls from working-class backgrounds. In most cases, there is
often a strong family history with other members of the family often had similar
symptoms.
In normal people, when the desired weight is reached, the normal dieting stops. In
anorexia the dieting and the loss of weight continue until the sufferer is well below the
normal limit for her age and height and are more determined to keep your weight well
below normal.
Although technically, the word anorexia means loss of appetite, sufferers with anorexia
actually have a normal appetite, but drastically control their eating.
Bulimia symptoms:
1. Fear of fatness
2. Worry more and more about your weight but stay a Normal weight
3. Binge eat
234
4. Irregular menstrual periods
5. Vomiting and/or excessive use of laxatives to get rid of calories
Bulimia usually affects a slightly older age group, often women in their early to mid-
twenties who also have been overweight as children.
It will affect 4 out of every 100 women at some time in their lives, rather fewer men
Like anorexics, people with bulimia suffer from an exaggerated fear of becoming fat.
In bulimia, patients usually manage to keep their weight within normal limits.
This is possible because although the patients tries to lose weight by making themselves
sick or taking laxatives, they also binge eat, which involves eating, in a very short time,
large quantities of fattening foods that you would not normally allow yourself.
For example, you might get through numerous packets of biscuits, several boxes of
chocolates and a number of ice creams in two hours or less. At times, they may even take
someone elses food or shoplift to satisfy the urge to binge. Afterwards the patients may
make themselves feel sick, and feel very guilty and depressed.
Aetiology of eating disorders
There is no simple answer and there are several different factors, which could play an
important part in the causation;
1. Social pressure
2. Family factors
3. Recent life stressors and upsetting events
4. A feeling of achievement and taking control by dieting
5. Depression
6. Low-self esteem
7. Puberty
Social Pressure: It is common in western societies and culture, which value thinness and
consider thin is beautiful. As a result, almost everybody diets at some time or other. So due to
immense social pressure a lot of young women diet excessively and eventually tend to develop
anorexia.
Family: Eating is an important part of our life and Refusing food can have a big influence in the
family. Some children and teenagers seem to find that saying no to food is the only way they can
either express their feelings or have any influence in the family.
Upsets and emotional distress; People react in different ways to the bad things that happen to
them in life. For people with eating disorders such as anorexia or bulimia, it seems to be triggered
off by an upsetting event, such as the death or break-up of a relationship. Sometimes, an
important event in life like leaving home or marriage could trigger an episode of illness. Eating
disorders have been related to life difficulties, physical illnesses and sexual abuse etc.
235
Puberty: Anorexia can reverse some of the physical changes of becoming an adult- like
development of breast and menstrual periods in women, development of facial and pubic hair in
men. This may help to put off the demands of getting older or becoming an adult, particularly
sexual ones.
Low self-esteem: People with eating disorders compare themselves unfavourably to other people
and losing weight can be one way of trying to get a sense of self-respect and self-worth.
Control: For most people dieting can be a very satisfying activity. We get this feeling of
achievement when the scales tell us that we have lost a couple of kilograms in weight. It is good
to feel that we have managed to control ourselves in a clear, visible way. It can be especially
satisfying for girls in their teens who may often feel that weight is the only part of their lives over
which they do have any control. So it is easy to see how dieting can become an end in itself,
rather than just a way of losing weight.
Depression: Sometimes people are upset, depressed or even just bored they eat a lot for comfort.
Many sufferers with bulimia have depressive symptoms and it may be that their binges started off
as a way of coping with feeling unhappy.
Seeking Help: In anorexia, the sufferer will hardly admit that they have a problem and continue
to believe that they are over-weight. It is usually family members who realise that something is
wrong when they notice their sister or daughter is not only thin but continuing to lose weight.
Assessment: The first step involves obtaining history from patient and family members by a
psychiatrist. They will need to be weighed. They may need a physical examination and blood
tests. It is important to identify the predisposing and precipitating and perpetuating factors for the
current episode of illness. This will involve discussing many aspects of her feelings and her life.
Anorexia: If someone has become excessively thin and her periods have stopped, or if the weight
loss threatens life, admission to hospital is usually considered. In-patient treatment consists of
much the same combination of dietary control and talking, only in a more supervised and more
structured environment.
Bulimia:
Here, the priority is to get back to a regular pattern of eating. The aim is to maintain a
steady weight on three meals a day at regular times, without either starving or vomiting.
It is important to request keeping diaries of their disordered eating habits and developing
self-control.
They may benefit from dietary counselling and educations.
For those sufferers with depression in addition to their bulimia, antidepressant medication
may be necessary. High doses of antidepressants like Fluoxetine can reduce the urge to
binge eat.
Patients are encouraged to become members of the self-help group in which other people
share similar problems. These groups can provide both information and support during
the difficult times that everybody with these problems goes through.
Psychotherapy: This involves talking about things in the past or present that may have a
bearing on the eating disorder and other personal difficulties. The psychotherapy sessions
may help to rebuild your sense of self-esteem in patients with both anorexia and bulimia
Cognitive behavioural therapy:
236
CBT helps to look at your thoughts and feelings in detail- done for I hour per week. The patient
may be asked to maintain a diary of their eating habits and helps to find out the triggering factor
for binges. They can think about better ways of thinking about and dealing with these thoughts
and feelings. These sessions would also help to build their self-esteem and confidence.
Interpersonal therapy: This is usually done with an individual therapist. It mainly concentrates
on interpersonal relationships and its effects on current life. It will help to rebuild supportive
relationships with that can meet their emotional needs, which is better than eating.
Compulsory treatment: This becomes necessary if some one has become very unwell that their
body weight becomes dangerously low and put their life at risk. In some circumstances they
become so unwell that they cannot make proper decisions for themselves and in such situations
compulsory treatment becomes necessary.
Outcomes:
Anorexia
More than half of sufferers make a recovery.
The average duration of illness is between 5 or 6 years
Sometimes it may take a long time like 15-20 years for people to make complete
recovery
1 in 5 of severely ill people may also die
Bulimia:
More than half of sufferers recover and would cut their bingeing and purging by atleast
half, will help people to get back some control of their life
Recovery usually takes place slowly over a few months or in cases over many years
Both CBT and IPT work just as effectively over a year
Research evidence suggests that Combining medications and psychotherapy is found to
be more effective than either treatments on its own.
(Adapted from www.rcpsych.ac.uk)
TASK: ANOREXIA NERVOSA- HISTORY & DISCUSSION (PAIRED

STATION)
PART-A: Miss Kate Lewis is a young woman who was previously diagnosed with
anorexia nervosa in the past. Currently her weight is normal. She went to the GP and
reported that she feels loosing weight as she is stressed since 1 month. Take the family
and personal history from her and assess etiological factors for her illness. Do not take
history to establish the diagnosis of anorexia nervosa. Do not perform mental state
examination. In the next station you will discuss with a student nurse about etiology and
management of her illness.
Expanded construct: The candidate is expected to obtain family and personal history
from her and assess etiological factors for her illness.
Current eating patterns, h/o recent weight loss, amenorrhoea,
237
preoccupied with food when under stress
Significant family history- mothers sisters,

Mother- high expectations and critical, father- uninvolved.
Sister- high achiever and attractive
Significant personal history- overweight at school, h/o glandular fever

during childhood leading to weight loss and positive comments from
peers, generally lacking confidence
Past psychiatric history of anorexia, h/o losing weight during stressful

times like exams
Precipitants & current stressors- Relationship breakdown
In this station, speak to newly trained nurse Miss. Linda Taylor, to explain the etiology
and discuss the management of Miss. Kate Lewis condition.
Expanded construct: The candidate is expected to explain the etiologic and discuss the
management of this womans condition. The candidate is also expected to discuss the
predisposing, precipitating and perpetuating factors for her illness and they should also
discuss the treatment options for her condition
Nature of the illness (anorexia nervosa) and common

presentations
Discuss the common etiological factors for AN
Discuss the reasons for this patients presentation (Predisposing,

precipitating and perpetuating factors)
Discuss treatment options
238
Discuss psychological interventions (CBT, Family therapy)
Concerns:
1. Prognosis
2. Body image distortion in this patient.
Management-stepped care approach

(Gradual Weight restoration, BMI chart, Correction-fluid &
electrolyte Balance, Nutritional Counselling, input from dietician)
ANOREXIA NERVOSA- MANAGEMENT & DISCUSSION
Outpatient treatment
Most people with anorexia nervosa can and should be treated in an outpatient setting. (NICE
recommendations)
Outpatient management should involve a psychological treatment with physical monitoring
provided by a healthcare professional competent to give it and to assess the physical risk of the
illness to the patient, and the monitoring should normally continue for at least 6 months (NICE
recommendations
Inpatient treatment will be considered if:
BMI less than 13.5
Severe suicidal risk & severe depression.
Rapid weight loss with pts weight is dangerously low.
Electrolyte imbalance leading to ECG changes (low potassium <3 mmo1/L)
Crisis situation
Failed out patient care.(non compliance)
239
The goals of inpatient therapy should be fully discussed with the patient and the family:
Addressing physical and psychiatric complications
Development of a healthy meal plan
Addressing underlying conflicts, such as low self-esteem and planning new coping strategies
Enhancing communication skills (Semple et al).
General Management:
Inpatient treatment
Patients should be admitted to a setting in which skilled refeeding and careful physical
monitoring is available in combination with psychosocial interventions. The inpatients should
follow a structured symptom-focused treatment regimen with the expectation of weight gain to
achieve weight restoration
Medical:
Hospitalise for weight restoration and monitoring as part of the medical management. It
is reasonable to aim for a weight gain of between 0.5 and 1 kg each week, & weight
restoration takes between 8 and 12 weeks
Rehydration and correction of serum electrolytes.
Instigate nutritional rehabilitation and involve the dietician for nutritional counselling:
Aim for a target weight, refeeding programme- a balanced diet of 2500 3000 k
calories/day provided as three or four meals a day with supplementary snacks.
Following weight restoration, the patient should be offered outpatient psychological

treatment, and typically this outpatient treatment and physical monitoring following
inpatient weight restoration should continue for at least 12 months
Nursing:
Offer support at meal times, monitor her food intake
Eating pattern should be supervised by a nurse to provide support, reassurance and to
ensure that the patient does not induce vomiting (or) take purgatives.
Monitor for Suicidality, impulsive behaviour
Psychological Interventions
Education to the patient and the family about the disorder and its treatment is important, health
hazards of weight loss and starvation
Behaviour programme positive reinforcement and encouragement of positive behaviour.
CBT: The psychologist would attempt cognitive restructuring to identify automatic negative
thoughts and to challenge core beliefs. CBT has been particularly used with the aim of modifying
abnormal cognitions about shape, weight and eating and the behavioural component focuses on
behavioural experiments include self-monitoring of weight, goal setting, assertiveness training
and relaxation.
Additional points:
240
The inpatients should receive psychological treatment that focuses on:
Eating behaviour
Attitudes to weight and shape and
On wider psychosocial issues
No drugs have been shown to be of specific benefit in the treatment of anorexia nervosa,
therefore, the main treatment approach must be psychological in nature including:
Cognitive behavioural therapy
Interpersonal therapy
Focal psychodynamic therapy
Family interventions focused explicitly on eating disorders for children and adolescents
(NICE recommendations)
The therapist needs to be flexible and willing to attend to the physical as well as the
psychological issues presented by the patient
Therapists from the psychodynamic tradition may need to be more active than usual, but those
with a cognitive behavioural approach may need to spend more time than usual exploring the
complexities of their patients attitudes to their illness
Unfortunately, no one approach has been demonstrated to be convincingly better than the
other (Fairburn, 2005)
For adolescent patients, there is a clear consensus that it is helpful for clinicians to involve the
family in treatment (Russell et al, 1987), which leads to the recommendation of conjoint
family therapy involving the patient, family and therapist meeting together, or family
counselling in which the clinicians meets separately with the patient and her family
A combined approach is beneficial compared with an individual approach and has a more
favourable outcome.
Educationnutritional education to challenge overvalued ideas, self-help manuals

Pharmacologicalfluoxetine hydrochloride, tricyclic antidepressants
Psychologicalfamily therapy, individual psychodynamic therapy, and cognitive behavioural
therapy.
TASK: EATING DISORDER- Forced Feeding & use of Mental Health Act-
discussion
You have assessed Ms. Rose, an 18-year-old college student referred by GP and is now
diagnosed with Anorexia. Talk to the mother Mrs. Lisa Williams who is concerned that
her daughter might die of anorexia. She would like her daughter to be sectioned and
treated in the hospital. The patient has given permission for you to talk with her mother.
Expanded construct:
Professionalism including but not limited to harmful interaction; failure to respect

individuals rights; ethical behaviour etc
(Understanding of personal rights of patient, Understanding for uses of MHA for
anorexia)
241
Addressing concerns-
? Forced feeding
? Sectioning
Treatments - Psychology input - Family therapy, CBT
Others- antidepressants
Inpatient admission criteria

(Very low body mass index, Medical complications,
Low vital signs, Potential risk of suicide etc)
Management-stepped care approach

(Gradual Weight restoration, BMI chart,
Correction-fluid & electrolyte Balance, Nursing involvement-eating diary)
Nutritional Counselling, input from dietician,

Risk assessment and evaluation
RE-FEEDING SYNDROME
Refeeding syndrome is a syndrome consisting of metabolic disturbances that occur as a result of
reinstitution of nutrition to patients who are starved or severely malnourished
Renourishment is the process of avoiding refeeding syndrome.
Syndrome: Refeeding syndrome usually occurs within four days of starting to feed. Patients can
develop fluid and electrolyte disorders, especially hypophosphatemia, along with neurologic,
pulmonary, cardiac, neuromuscular, and hematologic complications. Most effects result from a
sudden shift from fat to carbohydrate metabolism and a sudden increase in insulin levels after
refeeding which leads to increased cellular uptake of phosphate.
Refeeding increases the basal metabolic rate. Intracellular movement of electrolytes occurs along
with a fall in the serum electrolytes including phosphate, potassium, magnesium, glucose, and
thiamine. Significant risks arising from refeeding syndrome include confusion, coma,
convulsions, and death.
This syndrome can occur at the beginning of treatment for anorexia nervosa when patients are
reintroduced to a healthy diet. The shifting of electrolytes and fluid balance increases cardiac
workload and heart rate. This can lead to acute heart failure. Oxygen consumption is also
increased which strains the respiratory system and can make weaning from ventilation more
difficult.
Treatment: Refeeding syndrome can be fatal if not recognized and treated properly. If
potassium, phosphate or magnesium are low then this should be corrected. Prescribing thiamine,
242
vitamin B complex (strong) and a multivitamin and mineral is recommended. Biochemistry
should be monitored regularly until it is stable.
Re-feeding syndrome (Explained in simple terms)
What is re-feeding syndrome?
It is a disorder of fluid and salt balance in the body brought on by a shift from fat and protein
metabolism to carbohydrate metabolism.
When does it occur?
It occurs when the body goes from starvation mode to having enough.
Who are more likely to be affected?
The groups most at risk of refeeding syndrome is patients with anorexia nervosa, cancer patients,
chronic alcoholics, post operative patients and following patients suffering from long term
starvation (developing countries)
Why does it happen?
Human body is generally dependent on glucose to provide the energy for all its functions.
Glucose usually comes from carbohydrates. The breakdown of carbohydrates is controlled by
insulin. As a result of long term starvation, the body runs out of carbohydrate to process and
insulin secretion is reduced. Now the body allows the alternative energy source such as proteins
and fats to break down as a direct effect of reduced insulin secretion. This provides some glucose
as well as some unwanted products and most importantly allows a shift of salts such as
phosphate and potassium from within the cells into the blood stream
However on re-feeding, there is sudden shift from fat to carbohydrate metabolism and insulin
secretion increases leading to shift of salts from the blood back into the cells. This leads to low
levels of those salts in the blood stream particularly phosphates and potassium.
This sudden salt shift can cause swelling in hands and feet (edema). Low phosphate in blood can
cause muscular problems and in extreme cases lead to seizures and coma. Low potassium levels
can cause disturbance in heart rhythm called as arrhythmias and in extreme cases can lead to even
death. It could result in respiratory failure, heart failure, an irregular heartbeat, seizures, coma
and blood cell dysfunction
How do we manage these patients?
It can hopefully be avoided by a very cautious approach to nutrition and refeeding. The calorie
intake should be built up gradually over one week (start at 5 k cal/kg/day). It is important to
normalise salt levels first, restore circulating volumes and regular monitoring of electrolytes with
prompt correction as needed is the most appropriate way to approach.
If potassium, phosphate or magnesium are low then this should be corrected. Prescribing
thiamine, vitamin B complex (strong) and a multivitamin and mineral is recommended.
Ref: www.wikipedia.org.wiki, www.bathnes.gov.uk/ Emma Bradley
243
Risks of re-feeding;
With re-feeding, cardiac decompensation may occur, especially during the first 2 wks (when the
myocardium cannot withstand the stress of an increased metabolic demand). Symptoms include
excessive bloating, oedema, and, rarely, congestive cardiac failure (CCF).
To limit these problems:
Measure U&Es and correct abnormalities before re-feeding.

Recheck U&Es every 3 days for the first 7 days and then weekly during re-feeding
period.
Attempt to increase daily caloric intake slowly by 200- 300 kcal every 3-5 days until
sustained weight gain of 1- 2 pounds per week is achieved.
Monitor patient regularly for development of tachycardia or oedema.
Adapted from Oxford handbook of Psychiatry; 383
TASK: RE-FEEDING SYNDROME- DISCUSSION
You are about to speak to a CAMHS CPN with regards to Jane (16 year old girl) who has
a diagnosis of anorexia. The CPN has been seeing Jane at home in the last few weeks to
monitor her weight and diet. Last week, Jane's mum had pushed Jane to eat a lot and as a
result she has gained 3kg in 1 week. A recent blood test was normal apart from borderline
low phosphate. The CPN has asked to speak to you as she is worried about Jane. Address
her concerns.
Expanded construct: The candidate is expected to discuss about re-feeding syndrome in

patients with eating disorder and address concerns raised by mental health professional.
Explain the diagnosis of Re-feeding syndrome and discuss nature

of this condition
Discuss the possible causation of re-feeding syndrome
Explain common Clinical presentations and mechanisms behind it
Reassurance and offer clear explanation for current presentation
Discuss Management of the condition
244
PERINATAL PSYCHIATRY
PUERPERAL DISORDER RISK ASSESSMENT AND MANAGEMENT
This station has been asked as a paired/linked station, where in the first station you will be asked
to do a risk assessment, and in the next station you may have to discuss with the consultant over
the phone about the outcome of your assessment and management plan.
Areas to be concentrated upon

1. Explore the risk factors for post natal illness
2. Bonding and assess relationship with the baby
3. Assess the mothers mental state
Look for depressive symptoms and negative thoughts such as worthlessness
Look for psychotic symptoms
Thoughts of harming herself and the baby
Assess cognitive state and insight
4. Relevant history including past psychiatric history, family history and social support.
1. Risk factors
Ask briefly about 4Ps:
P-Parity
P-Planned/unplanned pregnancy
P-Partner
245
Are you currently in a relationship?
How are things between you and your partner/husband?
Have there been any difficulties since the baby was born?
P-Problems during pregnancy and or during labour
How did you get on generally during the pregnancy?
Tell me about how the delivery went.
14. Relationship with the baby
Please tell me about your baby

How do you feel about your baby?
How are you coping with the baby?
Does he sleep well?
Does he cry too much?
Have you been losing your temper with the baby?
Does he have any problems?
3. Mental state examination
How do you feel in yourself?

How do you feel as a mother?
Do you feel useless or worthless as a mother?
Do you feel trapped as a mother?
Do you blame yourself for something you have done or thought?
Ask questions regarding her anxiety about the well being of the baby and any abnormal
ideas about the baby
Are you worried/concerned about the baby?
Do you have any particular worrying thoughts about the baby? Tell me more about it?
Do you think there is something wrong with the baby? If so what do you think is wrong with
the baby and why do you think so?
Are you worried that someone might take the baby away? Who do you think might take the
baby away and why would they do so?
Enquire about depressive symptoms and psychotic symptoms

Weepiness, Low mood, Tiredness, exhaustion
Anxiety, Irritability, Insomnia
Paranoid thoughts, hearing voices or seeing things
Risk assessment explore any thoughts of harming herself or the baby

Have you thought of doing something to yourself? If so, what would you do?
Do you have any thoughts of harming yourself?
What did you think you might do to yourself?
Do you feel that you need to do something to the baby?
Can you explain that please?
Have you heard voices that tell you to harm the baby?
4. Relevant history
246
Past psychiatric history of depression, bipolar disorder, psychosis, anxiety disorder etc
Family history of mental illness, family history of postnatal illness
Social support-support from friends and family
Recent significant life stressors
Any misfortunes like bereavement, the partners losing his job, housing, financial problems,
etc.
Also assess the cognitive functions and insight at the end of your assessment
Cognitive functions look for disorientation to time and place
Insight- what do you think is the problem?
Do you think you might be unwell?
POST NATAL DEPRESSION- COUNSELLING

Postnatal depression means becoming depressed after having a baby and it is one of the
common complications following childbirth. It is like other kinds of depression except
that it is brought on by having a baby.
It is quite common, yet often unrecognised. One out of every ten women suffers from
PND.
It usually starts within a month of the delivery but can start up to six months later. It can
go on for months, or even years, if untreated.
Symptoms include Depressed mood feeling low, unhappy and tearful, Exhaustion and
loss of energy, Sleep and appetite disturbance, Feelings of
guilt/incompetence/hopelessness, Suicidal thoughts, plans, or actions, anxiety and
exaggerated fears concerning the self, the baby or the partner.
The exact cause of PND is unknown. Probably there isnt a single cause, but a number of
different stresses may have the same consequence, or may act together.
247
The risk factors are Previous history of depression (especially PND), Lack of support
from the partner and family, Recent stressful life events, An accumulation of misfortunes
such as bereavement, the partner losing his job, housing and money problems, etc
It seems likely that huge hormone changes take place at the time of giving birth, but this
evidence is still lacking and women who do, and who do not, get PND have similar
hormone changes.
Mothers with PND often worry if they might harm their babies, but they never do.
The treatment is similar to depression. Usually, the mother may need only reassurance,
practical support and supportive counselling. If depression is associated with marital
problems, they will have to be tackled through marital counselling. One of the most
important aspects of treatment is educating new fathers. Educate the partner about
postnatal depression, the demands of being a mother and practical and emotional support
that she needed.It is also very important to address her social difficulties, her needs and
provide adequate social support.
For some, antidepressant drugs will be needed. In very severe cases, other drugs and
even ECT may be needed.
There is no need to necessarily stop breastfeeding. Antidepressants that does not get into
your mothers milk and affect baby in any way are available and could be used.
The chance of someone without a history of depression getting a PND is 1015% and
someone who already had one episode of PND getting a second one is higher which is
around 2040%.
Some of the common strategies of prevention and early intervention include:Prenatal
education, Encourage the mother to keep in touch with the GP, to attend antenatal
classes, take your partner with you and also to keep in touch with the health visitor,
Encourage the importance of regular exercise, rest, sleep, nutritious food; maintaining
good relationships with your partner and family is important. Techniques such as
relaxation training, confidence building courses and assertiveness training may be
useful for preventing the escalation of stress and help them to cope with difficult
situations.
Research evidence shows that PND adversely affects mothering, bonding motherinfant
relationship and the emotional development of the infant.
248
POST-NATAL ILLNESS- GENERAL MANAGEMENT
Your management plan should be formulated according to the nature and severity of the
postpartum illness and all the following options should be considered in your management
plan, which should be tailored according to the needs of individual patient.
Early identification of the presence of postnatal illness
Education and Explanation about the disorder to the patient and the family
Organise Extra Support and practical help for the mother either through friends, family
or professional help
Close Monitoring of those at risk
Provide or refer for specific treatments such as individual counselling, marital
counselling, and Psychotherapy especially cognitive behavioural therapy.
Depressive episode-appropriate pharmacological intervention with antidepressants
If depression is severe or associated with thoughts of self-harm or harm to the baby, may
require hospital admission (specialist mother and baby unit if possible)
Psychotic symptoms should be treated with antipsychotic medications and should follow
the treatment protocol for treatment of psychotic illness.
For major affective disorders there is also good evidence for ECT and mood stabilisers
Prevention of future episodes through pre-natal education, enhancing coping and stress
management techniques such as relaxation training and assertiveness training should be
also considered.
249
Risk factors for postnatal depression
1. Older Age
2. Single mother
3. Unplanned pregnancy
4. Personal history of depression
5. Family history of depression
6. Poor social support
7. Significant other psychosocial stressors
Risk factors for postpartum psychosis

1. Personal history of major psychiatric disorder
2. Previous postpartum psychosis (30% risk of developing psychosis in the subsequent
pregnancies)
3. Family history of major psychiatric disorder
4. Single parenthood
5. Lack of adequate social support
Postpartum psychosis
An acute psychotic episode, occurring following 1.5/1000 live births
Peak occurrence at 2 wks postpartum.
Aetiology is unknown
3 common clinical presentations: prominent affective symptoms (80%) -mania or
depression with psychotic symptoms; schizophreniform disorder (15%); acute organic
psychosis (5%). (Ref: Oxford handbook- pg no: 756)
Common features include: lability of symptoms; insomnia; perplexity, bewilderment, and
disorientation; thoughts of suicide or infanticide.
POST NATAL MENTAL ILLNESS-MANAGEMENT

Puerperal psychosis
Make sure that appropriate investigations including all blood investigations were done to rule
out any organic cause for this presentation.
CT/MRI scan to exclude any intracranial pathology
Admission to the psychiatric unit depends on:

Risk to mother and baby
Social support available
Severity of the condition.
Admission to hospital informal but if patient refuses, I may have to consider use of mental
health legislation for possible detention.
Mother and baby unit ideal place to treat postnatal illnesses to minimize any adverse effects on
maternal bounding, and all contact between mother & baby should initially be supervised by
nursing staff and reviewed according to the progress.
If the mother has serious thoughts of harming the baby, I would advise staff to separate the baby
from its mother immediately. Once when she is recovering, then the baby should be introduced to
the mother gradually.
250
Psychosocial interventions
Education, supportive counselling and Reassurance to the patient, partner and the family
Counselling or marital therapy
Behaviour therapy release mothering skills and improve confidence
Involve the CPN Input, social worker to be involved
Liaise & work in close liaison with the GP, health visitor, community psychiatric nurse
and obstetrician.
Offer health education, support to the patient, partner and the family and also Advice
adequate rest
Attending a postnatal support groups
Information and advice on planning subsequent pregnancies
Would you consider Breast-feeding: -

Most psychotropic medication are not indicated during lactation period, Therefore
discontinue and change it to bottle-feeding preferably, it gives the mother some rest
especially during the acute phase of the illness.
If the mother still decided to breastfeed, then the benefits would have to be weighed
against the risk of exposure in the infant. In which case I would use low dose lowest
optimum dose of antipsychotics preferably Sulpiride or olanzapine (recommended by
the Maudsley guidelines 2007)
I would tend to avoid drugs with long half life and the time feeds as to avoid peak plasma
drug levels in the milk
When will you consider ECT treatment: -

Disorders of moderate (or) marked severity (Depressive (or) manic disorders)
Acute onset and no definite improvement within a short period.
If there is high degree of risk involved (Suicidal risk, risk of neglect and infanticide
risk)
Good Prognostic factors
Acute onset
Affective illness
Good social support.
First episode
Well adjusted pre morbid functioning
Lack of social adversities.
Risk of psychosis during pregnancy and labour

General population-0.1-0.25%
The risk of perinatal psychosis is about 50% in women with a history of bipolar disorder
The risk of postpartum psychosis in patient with a history of postpartum psychosis is 50-
90%
If the diagnosis is POSTNATAL DEPRESSION
Most women can be treated effectively in primary care by brief, supportive (on) problem
solving treatments together with practical support.
Few of them may benefit from antidepressant medication.
Few may require referral to specialist psychiatric services.
251
Postnatal depression adversely affects the mother infant relationship and also the
cognitive and emotional development of the child.
Prognosis:
a) The recurrence rate of depressive illness in the puerperium after subsequent childbirth would
be 20 30%.
b) 50% women who have suffered a puerperal depressive illness will later suffer a depressive
illness that is not puerperal.
Recommendations during Breast-feeding

(Extracted from The Maudsley Prescribing guidelines 2005-2006)
Antipsychotics - Sulpiride, olanzapine

Antidepressants - Paroxetine/ Sertraline
Mood Stabilizers - Avoid if possible; valproate if essential
Sedative - Lorazepam for anxiety, zolpidem for sleep.
General Principles during pregnancy and lactation

Continue the same medication given during pregnancy.
Use the lowest effective dose.
Avoid poly pharmacy.
Avoid drugs with a long half-life.
Time the feeds to avoid peak drug levels in the milk.
TASK: PERI-NATAL PSYCHIATRY- HISTORY & DISCUSSION (PAIRED

STATION)
TASK: Mrs. Rachel Smith is a 35-year-old lady who was referred to the psychiatrist by
her GP because of low mood. She has a 7-month-old baby and is now 10 weeks pregnant.
Obtain history from mother and perform risk assessment. In the next station you will be
asked to discuss her presentation with he husband.
Expanded construct: The candidate is expected to obtain history from mother to find
out evidence of post-natal illness and perform appropriate risk assessment. They should
assess the following areas;
Explore History of presenting problems in detail

Elicit mode of onset and Duration
Assess possible risk factors

(Parity, planned pregnancy or not, Problems during pregnancy & Labour, partner-
relationship)
Biological, behavioural,
Cognitive and Emotional symptoms (Guilt feelings etc) of depression
252
Assess relationship with the baby and bonding
Enquire about Mental state: (Rule out psychosis)

Paranoia, hallucinations, Delusional ideas about the baby,
Depressed Negative thoughts, Cognitive functions
Risk assessment:
Suicidal thoughts, Infanticidal thoughts, self-neglect
Assessment of support network, Past psychiatric history
Related task in the second station; (PART-B)
Discuss the diagnosis and management plan with the patients husband Mr. Robert Smith.
Address his concerns and allay his fears
Expanded construct: The candidate is expected to discuss the diagnosis and

management plan of postnatal illness with the patients husband and allay his fears. The
discussion should focus on various areas;
Explain diagnosis and clinical presentation (Offer Clarification and justification)

Post partum psychosis (affective presentation)- depression with psychotic symptoms
Management-
(Admission to hospital-mother & baby unit,
Early use of antidepressants, use of antipsychotics, ECT )
Effect on her children- unborn baby & existing child

(Mother-infant relationship, emotional problems in children in later years,
Lack of obstetric care, neglect)
Addressing concerns
1. Breast feeding whilst on psycho tropics
2. ECT treatments during pregnancy- good evidence for ECT
Addressing concerns
Self harm,
Fear of harming the baby etc
253
ADDICTION PSYCHIATRY
ELICITING ALCOHOL HISTORY

Note: Eliciting alcohol history can be asked as a paired/linked station, where in the first station
you may be asked to explore the current usage, longitudinal history & to specifically look for
features of alcohol dependence.
In the second half of the linked station, you may be asked to discuss the complications suffered
following alcohol misuse and also to assess insight & motivation of the patient to stop drinking.

1. Current usage
2. Longitudinal history
3. CAGE questionnaire
4. Edwards and Gross criteria for alcohol dependence
5. Risk factors
6. Complications-physical, psychological, social and legal
7. Insight and motivation
8. Rule out mood, psychotic symptoms and or illicit drug abuse.
254
Questions
A. Current usage in a typical day/week
1. Do you drink alcohol at all?

2. What do you usually drink?
3.How often do you have a drink?
4.How many drinks do you have on a typical day of drinking?
5. Describe a typical day for me. Could you describe any pattern?
6. What sort of effect does alcohol have on you?
B. Longitudinal history
1. When did it all start?

2. What was the first drink?
3. With whom did you have the first drink?
4. Was it out of your own will (or) peer pressure?
5. How did you progress to the current level?
a. Started drinking occasionally (social drink)
b. Regular weekend drinking
6. How much would you drink at the weekend?
a. Regular evening drinking
b. Regular lunchtime drinking
c. Early morning drinking (progressive)
7. What did you used to drink in the past? And what do you drink now?
C. CAGE questions
Do you feel that you have to cut down on your drinking?
Do people annoy by criticising your drinking?
Do you feel guilty about your drinking?
Do you have to drink first thing in the morning to steady your nerves?
D. Edwards and Gross criteria for dependence syndrome
Compulsion
Do you sometimes crave for a drink? (Or)
Do you have a compulsive urge to drink?
Do you find it hard to stop drinking once you start?
Tolerance
How much can you drink without feeling drunk? Nowadays, do you need more alcohol to get
drunk than you needed before? (Or)
Does a drink have less of an effect on you than before?
Withdrawal symptoms
What happens if you miss your drink? (Or)
What would happen if you go without a drink for a day or two? (Or)
255
If you dont drink for a day (or) two, do you experience any withdrawal
symptoms such as sweating, shaking, feeling sick, headaches and pounding in
your heart?
Treatment and rapid re-instatement

Ask about details of treatment and details of any period of abstinence?
What helped you keep off drink?
Have you ever had an extended period of time when you did not drink?
What happened to make you start drinking again?
Have you ever gone to anyone for help with your drink problem?
Have you ever been in hospital because of your drinking?
Have you ever been involved in any detoxification programme? Was it
completed or not?
If not, what are the reasons for the failure?
Primacy
How important is drink compared with other activities for you?
How often do you miss family and social commitments because of drinking? (Or)
Have you been giving primary importance to alcohol and have you been neglecting other
alternative pleasures (or) interests?
Relief drinking
Do you need a drink first thing in the morning to steady your nerves?
Do you have to gulp the first few drinks of the day?
Stereotyped pattern
Do you always drink in the same pub?
Do you always drink with the same company?
E. Risk factors for alcohol abuse
Ask about:
Occupation
Psychiatric history
Family history of alcoholism
Premorbid personality
Physical health problems

What do you think are the consequences of your drinking? (Open question)
Have you ever had any health problems due to drinking?
(Now ask more specific questions)
Accidents and head injury
Memory problems
Blackouts, falls, fits
Loss of appetite, weight loss
Mental health problems
256
Have you ever had severe shaking, heard voices and seen things that were not there after heavy
drinking?
Also ask specifically about
Anxiety, depression
Suicidal ideation/ behaviour.
Social problems
Relationship difficulties with the partner, children, family members and friends
Has your drinking ever led to problems with your family, friends, work or the police?
How has it affected your family life?
Have you had any row or arguments with friends or mates?
Problems at working place
Has your drinking had an effect on your job like missing work, late, Monday absences etc
Financial problems
Have you ever had any financial problems because of your habit?
Legal problems drink driving, drunk and disorderly behaviour, fights while drunk.
Have you actually had an accident or hurt yourself?
Have you ever been convicted of drink driving?
Have you ever been arrested because of your dinking?
Insight and motivation

Do you think that the problems you experience currently is related in any way to your
drinking?
What makes you feel that way and could you please explain that?
Do you feel you have a problem with alcohol?
What would you like to do?
Have you ever thought of giving it up completely?
What do you think will happen if you give up completely?
TASK: ALCOHOL AND ITS EFFECTS ON MOOD:
Mr. Jim Thornhill was referred to your outpatient clinic by his GP as he was worried
about his excessive alcohol consumption. Routine blood tests taken at GP surgery
showed evidence of abnormal liver function tests including raised GGT. Obtain history to
establish his pattern of drinking and its effect upon his mood.
Expanded construct: The candidate is expected to establish patients pattern of drinking

and its effect upon his mood
Assess core symptoms of depression

(low mood, anhedonia, lack of energy)
257
Other Symptoms of depression (disturbance in biological functions, poor
concentration & memory, depressed negative cognitions, low self-esteem etc)
Current alcohol history and pattern of drinking
Assess features of alcohol dependence

(Tolerance, withdrawal symptoms, compulsion, primacy, reinstatement etc)
Risk assessment- self harm, self neglect,

deterioration in physical and mental health
TASK- ASSESS SOCIAL& LEGAL COMPLICATIONS OF ALCOHOLISM

You are assessing Mr. Stuart Thompson in the community addiction clinic. He is
dependent on alcohol for about ten years. Establish his current alcohol consumption and
socio-legal complications related to alcohol misuse.
Expanded construct: The candidate is expected to establish patients current level of

alcohol consumption and assess social and legal complications of alcoholism
Alcohol history- current use and pattern of drinking (describe a typical days
drinking)
Relationship difficulties with wife (agitation, physical aggression, arguments and

fights leading to relationship breakdown)
Work issues (lateness, missed days at work, drinking at work place, warnings
about poor performance)
Police issues (drink driving, drunk & disorderly behavior, arguments & fights
with public, damage to public property, outstanding charges against them)
Financial problems (financial difficulties, debts etc)
Wider social network issues (loss of friends, social contacts, banned from clubs)
ALCOHOL DEPENDENCE
258
Pharmacological management
Treatment of alcohol use disorders typically involves a combination of pharmacotherapy and
psychosocial interventions
Detoxification is a treatment designed to control both the medical and psychological
complications that may occur temporarily after a period of sustained alcohol misuse
It usually involves chlordiazepoxide at diminishing doses over 7 to 10 days with thiamine
supplementation
The doses of medication should be titrated against withdrawal symptoms.
Outpatient detoxification:
The benzodiazepines are prescribed in alcohol withdrawal in order to control withdrawal
symptoms and to reduce the risk of withdrawal seizures
Chlordiazepoxide is usually prescribed in a rapidly reducing regimen in order to reduce the
development of secondary dependence; it has a lower abuse potential compared with other
benzodiazepines
Chlordiazepoxide is the drug of choice for most uncomplicated alcohol dependent patients, but
if there are doubts about compliance or concerns about drinking at any stage during outpatient
detoxification, then the patient should be reviewed and breathalyzed before dispensing the
next days supply of the drug.
Indications for prescribing a reducing regimen:
Clinical evidence of alcohol withdrawal features
History of alcohol dependence syndrome
Consumption of alcohol is greater than 10 units per day over the last 10 days
Indication for inpatient detoxification:
Symptoms of Wernicke-Korsakoff syndrome
Past history of seizures or delirium during withdrawals
Acute confusional presentation
High risk of suicide
History of poly drug misuse
Co-morbid mental health illness, e.g., depression, psychosis
Lack of stable support in the community, e.g., homelessness
Severe malnutrition/severe physical health conditions.
Chlordiazepoxide regimen for moderate and severe dependence:

Day 1 20 mg qid
Day 2 15 mg qid
Day 3 10 mg qid
Day 4 5 mg qid
Day 5 5 mg bid
In severe dependence, even larger doses of chlordiazepoxide may be required and will often
require specialist/inpatient treatment
For inpatient detoxification, the chlordiazepoxide should be prescribed according to a flexible
regimen over the first 24 to 48 hours with the dosage titrated according to the severity of
withdrawal symptoms. This is followed by a 5-day reducing regimen (a typical regimen might
be 1020 mg qid reducing gradually over 57 days). This is usually adequate, and longer
treatment is rarely helpful or necessary.
Other medications
259
Supplementary vitaminsgenerally, a 4-week course of 100 mg thiamine tds is
recommended, but if there are symptoms suggestive of malnourishment or Wernicke-
Korsakoff syndrome then parenteral B vitamins are recommended
Anticonvulsantsbenzodiazepines in sufficient dosage are the most effective anticonvulsant
in alcohol withdrawal
Antipsychoticsit is generally not advisable to start a new psychotropic at this time as most
of the antipsychotics reduce seizure threshold. However, if there are psychotic symptoms like
delusions or hallucination it could be initially managed by increasing the dose of
benzodiazepine. The addition of an antipsychotic, such as haloperidol 510 mg orally up to 30
mg/day, should be considered if this fails, but given sufficient benzodiazepine cover you
should address the concern of a possible reduction in seizure threshold following antipsychotic
use.
Maintenance treatments
Aversive drugs:
Disulfiram:
It is an irreversible inhibitor of acetaldehyde dehydrogenase, which can act as an adjunct to
therapy and is prescribed once abstinence is achieved
Dose: give a 5-day loading dose of 800 mg/day followed by a maintenance dose of 200 mg
or 400 mg on alternate days
Common side effects: headache, halitosis
Rare reports of hepatotoxicity and psychotic reactions have been reported.
Anti-craving drugs:
Acamprosate calcium:
-aminobutyric acid (GABA) transmission in the
brain, and patients taking it report diminished alcohol craving
Dose: 666 mg tds, once abstinence is achieved
Side effects: pruritus, gastrointestinal upset, rash
Naltrexone hydrochloride:
It antagonizes the effects of endogenous endorphins released by alcohol consumption. It
appears to be effective in reducing total alcohol consumed and the number of drinking days
Dose: 50 mg/day, once abstinence is achieved
Side effects: Feeling anxious, headache, fatigue, flu-like symptoms, gastrointestinal
symptoms, sleep disturbance.
Psychological: These psychological treatments can be offered in a group setting or individually
Supportive psychotherapy: Education, advice and counseling about the physical social
and psychological complications of excessive drinking and problem solving approach to
normal day-to-day difficulties.
CBT- CBT approaches stress the role of education and the improvement of social and
interpersonal skills. It also involves relapse prevention that includes identifying
situational (or) interpersonal triggers that cause an individual to drink excessively,
suggestions to change the social milieu to get away from the drinking friends and develop
new interest and activities and then to plan, rehearse new methods of coping with these
situation and adopt simple behavioural approaches such as self monitoring, dairy
keeping.
260
Motivational interviewing: Client centred counselling style, and it is a technique in which the
patient is motivated by the therapist to identify and develop and the patients are encouraged to
believe that they can take control and conquer their habit. It involves the following;
F - Feedback of personal risk (or) impairment

R - Emphasis on personal responsibility for change
A - Clear advice to change
M - Menu of alternative change options
E - Therapeutic empathy as a counseling style
S - Enhancement of patient self efficacy (or Optimism)
AA alcoholic anonymous and related 12 step programs: self help group that works
through a 12 step process, in which drinkers make emotional confession and admit that
they are powerless over alcohol and make a moral inventory of themselves.
Use of MHA: For Emergency treatment use common law

For pure alcohol problems, mental health legislation cannot be applied
For delirium tremens, which is an organic confusional state, mental health legislation would
apply as it is an organic confusional state which is a mental illness and therefore within the
meaning of the act.
TASK: ALCOHOL DEPENDENCE- HISTORY & DISCUSSION (PAIRED

STATION)
Ms. Samantha Pinter, a 32-year-old lady was admitted to the medical ward with
abdominal pain and gastritis. Routine blood tests show raised GGT and MCV. The
physicians have requested an assessment.
a. Elicit detailed alcohol history to assess the nature and extent of her problems
b. Assess her insight and motivation.
Expanded construct: The candidate is expected to discuss the following areas in

alcohol history taking, establish features of alcohol dependence, assess complications and
rule out co-morbidity.
261
Current usage and Longitudinal history
Features of Dependence syndrome

(Compulsion, tolerance, withdrawal symptoms)

(Reinstatement, primacy, Relief drinking etc)
Complications (Physical, psychological)
Complications (social, Legal)
Insight and motivation
Rule out mood and psychotic Symptoms

Any illicit drug abuse.
You have assessed this patient on a medical ward who suffers from alcohol dependence
and was admitted with physical health complications such as gastritis.
a. She is worried about other complications of alcohol misuse and would like to discuss
more about it.
b. She wants to know more about seeking help to get over it?
Expanded construct: The candidate is expected to discuss sensible drinking, explain

complications of alcoholism, treatment options available for alcohol dependence
syndrome.
Sensible drinking- Explanation
Warning signs of excessive drinking
Explain Complications
(Physical, mental, social and legal)
Addressing specific concerns

1. ? Liver cancer
2. ? Memory problems
3. ? Admission to hospital
Discussion- Changing habit (Realising, accepting the problem
262
Getting help, keep going once you have achieved it - drinking diary)
Alcohol Detoxification programme-outpatient, Chlordiazepoxide regime
Discuss Anticraving drugs-Acamprosate etc
Psychology input-CBT, Counselling
Others-Alcohol Anonymous, support- GP, family and friends
OPIOD MISUSE- ELICIT ILLICIT DRUG HISTORY
The areas to be explored are:

1. Current usage
2. Longitudinal history
3. Look for features of drug dependence
4. Complications-physical, mental, social and legal
5. Assess Insight and motivation
6. Risk assessment-sharing needles, unsafe sex etc
7. Rule out co-morbidity
Open questions
Are there any tablets (or) medicines that you take apart from those you get from your doctor?
263
Is there anything that you buy from the chemists (or) getting from friends?
Have you ever used any recreational drugs such as cannabis, cocaine/ crack, amphetamines,
speed, ecstasy, LSD (or) acid? (Ask about individual drugs by naming them).
What about tablets to settle your nerves (or) help you sleep?
Current usage
What drugs are you using now?
What is the frequency of use?
What is the pattern of typical drug using?
What is the amount of drug taken? (In appropriate measures)
What effect is the patient seeking when using the drug?
Ask if more than one drug is used at a time.
How much money do you spend in a day/week for getting these drugs?
What is the route of use? (Oral, smoked, snorted, injected)
If injected, the following questions are useful to ask.
a. Are needles used?
b. Where are they obtained?
c. Are needles shared?
d. What sites are used for injection?
What risky behaviour does the patient engage in?
a. Injecting and sharing needles
b. Involving in Unsafe sex
c. Sex for drugs
How is he/she financing the drug use??
Longitudinal history
Ask about the patients age of first use of drugs, and when the patient started to use the drug
regularly
When did it start?
What was the first drug taken?
Was it by your own will (or) peer pressure?
How did you progress to the current level?
When did you start taking them regularly?

Compulsion
Do you sometimes crave for drugs?
Do you have a compulsive urge to take drugs?
Tolerance
Do you have to increase the amount of drugs that you take to get the same effect (or) same
amount has given you less effect than earlier?
264
Withdrawal symptoms
If you dont take drugs for a day (or) two, do you experience any withdrawal symptoms? For
example, if the patient takes heroin, ask about symptoms such as sweating, gooseflesh,
running nose, watery eyes etc.
Ask the patient to describe them in their own words?
Treatment & re-instatement: Enquire about the patients past experience of treatment for a drug
problem
Have you ever gone to anyone for help to come out of this?
Have you ever been in hospital for a drug problem?
Have there been any periods of abstinence when you were not using any drugs and if so, what
has helped the patient to achieve this?
What triggers have brought on this habit again?
Complications
Have you experienced any complication? (Ask about physical, mental and social complications?
Have you ever worried about?
Hepatitis B, C and HIV,
Complications of injecting like infections, abscesses, sepsis
Accidents, head injury, falls, fits
Anxiety, depression, hearing voices, seeing things
Financial problems
Row or arguments with friends or family members or working place
Insight
Do you feel you have a problem with drugs?
Do you think that the difficulties that you experience currently are related in any way to your
drug problems?
Motivation
What would you like to do?
Have you ever thought of giving it up completely?
What do you think will happen if you give up completely?
TASK: OPIOID DEPENDENCE- HISTORY
Mr. Tony Gordon, a 32-year-old gentleman was seen in the drug and alcohol outpatient
clinic following referral from his GP, as he has a history of multiple drug use. Take a
history of drug misuse and establish features of drug dependence syndrome.
Expanded construct: The candidate is expected to take a history of drug misuse

and establish features of drug dependence syndrome.
265
Elicit type & Quality of drug use
Duration of abuse and cost
Obtain Longitudinal history
Mode of administration & needle sharing
Withdrawal symptoms
Social impact of drug use- relationship, employment, financial and legal
Psychiatric symptoms- depression, mood change or psychosis or hallucinations
Physical problems
Patients reflection on his drug taking
OPIOD MISUSE AND DEPENDENCE

Opiate withdrawal:
The withdrawal symptoms appear 6 to 24 hours after the last dose and typically last 5 to 7
days, peaking on the second or third day
Methadone is longer acting and withdrawal symptoms are much more prolonged with
symptoms peaking on the seventh day or so and lasting up to 14 days.
Pharmacological strategies
Methadone hydrochloride
Currently, methadone is the drug of choice used in opiate detoxification regimens and
maintenance
266
Methadone is a long acting synthetic opioid with a long half-life of 24 hours and is suitable for
daily dosing
It is prescribed as a coloured liquid, available at concentration of 1mg/mL, but it is unsuitable
for parenteral use
At doses of more than 80 mg/day it produces near saturation of opiod receptors, minimizing
the reward of further consumption
Methadone should be initiated according to the severity of withdrawal symptomsstart with
1020 mg methadone depending on the level of tolerance (low: 1020 mg; moderate: 2540
mg)
Review daily over the first week with dose increments of 510 mg/day if indicated;
methadone reaches a steady state 5 days after the last dose change.
Stabilization may take up to 6 weeks to achieve and during this period the patient should be
reviewed regularly after the first week, making subsequent increases by 10 mg on each review
up to 120 mg.
In Rapid Reduction regimens reduce the dose over 14 to 21 days using symptomatic drugs
as adjuncts.
Slow reduction is to be done gradually over a period of 4 to 6 months reducing by 510 mg
each fortnight
During the process of reduction regimens, make the largest absolute cuts at the beginning and
more gradual cuts as the total dose falls
Oral methadone is effective in (Welch and Strang, 1999):
Reducing illicit drug use
Reduced injecting
Reduced criminal activity
Improved physical health
Improved social well-being
Research evidence has shown that a methadone script reduces street usage, criminality and
drug-related mortality.
Buprenorphine (Subutex):
Buprenorphine is a partial opiate agonist effective in treating opioid dependence.
It alleviates/prevents opioid withdrawal and craving. It reduces the effects of additional opioid
use because of its high receptor affinity.
It is long-acting and the duration of action is related to the dose administered, and it can be
used effectively for shorter-term in-patient detoxifications following the same principles as for
methadone.
Dose increases should be made in increments of 24 mg at a time, daily if necessary, up to a
maximum daily dose of 32 mg.
Effective maintenance doses are usually in the range of 1224 mg daily, which should be
achieved within 12 weeks of starting Buprenorphine.
Lofexidine hydrochloride
Lofexidine hydrochloride is an alpha-adrenergic agonist given as a 710 day treatment
course, followed by a gradual withdrawal over 24 days
St
divided doses
Due to risk of postural hypotension blood pressure should be monitored
Symptomatic medications are used in ameliorating opiate withdrawal symptoms:

Metoclopramide hydrochloride
267
For treatment of symptoms such as nausea, vomiting
10 mg dose up to maximum of 30 mg/day
Loperamide hydrochloride
For treatment of diarrhoea
4 mg initial dose with 2 mg after each loose stool, maximum dose 16 mg/day
Ibuprofen
For headaches, body aches and muscle pain
400 mg dose up to 1600 mg/day.
Relapse preventionNaltrexone hydrochloride is used as an aid to relapse prevention in

previously dependent opiate users who have successfully completed detoxification
It should be started at 25 mg and the dose should be increased to 50 mg/day
The total dose may be given 3 days per week, which also aids compliance
It is also used to facilitate rapid detoxification over 5 to 7 days in specialist centres.
Harm Reduction/Minimization
Harm reduction is a kind of strategy taken to reduce the morbidity and mortality for the drug
users without necessarily insisting on abstinence from drugs.
A few examples include:
Advice regarding safe sex
Advice directed at the use of safer drugs
Advice directed at safer routes of administration
Advice regarding safer injecting practice
Treatment of co-morbid mental or physical health problems
Engagement with other sources of help
Prescription of maintenance opiates or benzodiazepines.
(Ref: Get through Long case presentations in psychiatry- Dr.Sree Murthy)
SUBSTANCE MISUSE IN PREGNANCY- EXAM RELATED TOPIC

Important points about heroin and methadone in pregnancy
The candidate is expected to discuss all the risks associated with drug use in pregnancy
It is important that they explain that methadone and heroin are not teratogenic.
Continued use of heroin might provoke miscarriage or intrauterine death
268
The candidate should explain that drugs being used cross the placenta and after birth the
baby might experience neonatal abstinence syndrome
It is important to monitor baby for signs of opioid withdrawal as well as possibly that the
baby might need to be treated
Also it is worth mentioning that babies born to mothers on heroin alone were more likely
to be premature and small for dates. These effects could be reduced when the mother is
stable on methadone
Opiate withdrawal syndromes in babies include irritability, high pitched cry, jitteriness,
sneezing and colic.
Important points about cocaine/crack
Also cocaine or crack is associated with some teratogenecity of genitourinary system and
bones of the skull
Discuss risk of placental abruption with cocaine use
Use of cocaine and crack do result in abstinence syndrome after birth
There is a higher incidence of sudden infant death syndrome when using cocaine/crack
Role of social services
Social services: Some men and women worry that their baby may be taken away by
social services. Their baby may be taken into care because they misuse drugs. Opioid
misuse in itself is not a reason to involve social services or to assume that they cant be
good parents and cannot care for their baby. However, if there are significant concerns
abut the safety and welfare of the child, the involvement of social services will become
absolutely necessary. But this rule is applicable for people who dont use any drugs too.
Social services would ne involved if there are concerns about neglect or harm to children
or if the pattern of drug use would lead to risks to the children (involving children in drug
seeking activities).
PREGNANCY AND OPIOID USE
Substitute prescribing can occur at any time in pregnancy and carries a lower risk than
continuing illicit use.
The emphasis must therefore be on early engagement in treatment, and, methadone
maintenance treatment during pregnancy, in the context of a multidisciplinary team
(including obstetricians, neonatologists and addictions specialists) and detailed holistic
package of care, (including comprehensive psychosocial input); this is currently regarded
as the gold standard.
269
Stability on prescribed medication and attendance at antenatal clinics are the main goals
of treatment.
Principles of managing pregnant opioid user:

Therapeutic alliance
Aim to reduce risk-taking behaviours (sharing needles, prostitution).
Stabilize on non-injectable alternatives such as methadone.
If considering detoxification, this should be done in the middle trimester avoid
first trimester for the fear of abortion and last trimester for the fear of
premature birth.
Close liaison with obstetric, midwifery, and paediatric teams, and with social
services where appropriate.
HIV and hepatitis screening (vaccination where appropriate).
Stabilization on an oral substitute drug should always be the initial aim.

Ideally, the mother should be encouraged to become abstinent prior to deliveryoften
this may not be possible.
If detoxification is planned, it should be carried out with caution in the second trimester
of pregnancy
If pregnancy begins while a woman is taking high doses of methadone, the dosage should
be reduced slowly (e.g., 1 mg every 3 days), and foetal monitoring must be carried out
closely.
It is important to stabilize opioid misusers who are on methadone and the dose may need
to be increased in the third trimester due to increased metabolism
Maternal metabolism of methadone may increase towards the third trimester of
pregnancy. At this time, an increased methadone dose may be required or occasionally
split dosing on the medication to prevent withdrawal.
There is no clear relationship between maternal methadone dose and the intensity of
neonatal withdrawal but lower doses (15 mg) are advocated during maintenance.
The main effects on unborn baby due to opioid misuse during pregnancy are low birth
weight and pre term delivery. It is important to explain that higher the doses and duration
of substance misuse and intake, the greater is the risk to the foetus
Methadone is not a contraindication to breast feeding but local policies may vary.
Less data are available for buprenorphine maintenance but it appears similar benefits are
seen for mother and foetus as for methadone
The risks to the mother and baby are least on methadone.
Psychosocial interventions: Consider family or couples therapy (as pregnant women often
have substance misusing partners)
Social services: Some men and women worry that their baby may be taken away by
social services. Their baby may be taken into care because they misuse drugs. Opioid
misuse in itself is not a reason to involve social services or to assume that they cant be
good parents and cannot care for their baby. However, if there are significant concerns
abut the safety and welfare of the child, the involvement of social services will become
absolutely necessary. But this rule is applicable for people who dont use any drugs too.
270
Opiate withdrawal syndrome in babies;
Usually begins 24-48 hours after birth, depending on the time of last dose.
However, signs may not appear in the infant until 3-4 days after birth.
Hyperirritability, gastrointestinal dysfunction, respiratory distress, and vague autonomic

symptoms (eg, yawning, sneezing, mottling, fever). Tremors and jittery movements,
high-pitched cries, increased muscle tone, and irritability are common.
Normal reflexes may be exaggerated. Loose stools are common, leading to possible
electrolyte imbalances and diaper dermatitis.
Methadone withdrawal symptoms typically appear within 48-72 hours but may not start
until the infant is aged 3 weeks. Milder with buprenorphine withdrawal.
The majority of neonates born to methadone-maintained mothers will, however, require

treatment for neonatal abstinence syndrome (NAS).
Pregnancy and breast feeding methadone:

Major risk is via injection to the baby infection and the effects of drug itself causing
stillbirth, premature birth, antenatal complications, low birth weight, microcephaly and
neonatal withdrawal.
Although the newborn may experience a withdrawal symptom, as described, there is no
evidence of an increase in congenital defects with methadone.
Methadone is considered compatible with breast feeding, although other risk factors, such
as HIV, hepatitis C, use of benzodiazepines, cocaine and other drugs need to be
considered and may mean that breast feeding is contra-indicated.
The Clinical Guidelines recommend that breast feeding should still be encouraged, but
that with regards to methadone and breast feeding the dose is kept as low as possible
while maintaining stability, and the infant monitored to avoid sedation.
Pregnancy and breast feeding buprenorphine:

Currently there is insufficient evidence, regarding the use of buprenorphine as an opioid
substitute treatment during pregnancy or breastfeeding to be able to define its safety
profile. More evidence is available on the safety of methadone, which, for that reason,
makes it the preferred choice.
However, women well maintained on buprenorphine prior to pregnancy may remain on
buprenorphine following full informed consent and advice that safety of buprenorphine in
pregnancy has not been demonstrated.
Please note buprenorphine is not licensed for use in pregnancy and should not be initiated
in this circumstance by a non-specialist.
Ref: The 10th Maudlsey prescribing guidelines- Pg 316-317
TASK: SUBSTANCE MISUSE IN PREGNANCY (HISTORY & DISCUSSION)-

PAIRED STATION
271
Miss Janet Atkinson is a young lady under drug and alcohol services, currently on
methadone and she thinks that she might be pregnant now. She is worried about the baby
because of drug use and their effects. Take history of her drug usage including the
prescribed drugs, relevant past history and social history. Address her concerns. In the
next station you will speak to the partner of this woman.
Expanded construct: The candidate is expected to take a focused history eliciting drug
and alcohol use in history and relevant past history. They should;
Obtain a history that picks up the relevant information about illicit drug and
alcohol use (heroin, methadone and crack/cocaine)
Explore the extent of the problem (including street costs)
Explore mode and practice of administration (injection sites)

Engagement in risky behaviours (sharing needles, unprotected intercourse)
Explore withdrawal effects/ abstinence
Explore circumstances of her pregnancy and her feelings about it

Rule out mood symptoms
Obtain personal history, current social circumstances and support network
In the previous station, you interviewed a pregnant woman. You are now about to see her
partner. She has given full consent to discuss anything you feel appropriate with her
partner. Explain what the risks to the baby in utero and postpartum are. Ensure that you
address his ideas, concerns and expectations.
Expanded construct:
The candidate is expected to explain risks associated with multiple substance use in
pregnancy. They should discuss the following points;
Discuss all the risks associated with drug use in pregnancy

(Infection and the effects of drug itself causing stillbirth, premature birth, antenatal
complications, low birth weight)
272
Reassure- methadone and heroin are not teratogenic. However Continued use of
heroin might provoke miscarriage or intrauterine death
Effect on new born baby - neonatal abstinence syndrome (possible)

Monitor baby for signs of opioid withdrawal as well as possibly that the baby might
need to be treated
Ideal time for detoxification (2nd trimester). Continue methadone throughout

pregnancy. Babies born to mothers on heroin alone were more likely to be
premature and small for dates. These effects could be reduced when the mother is
stable on methadone
Breast feeding- possible, on methadone doses less than 80 ml daily. To be avoided if

patient is on high dose BDZ or if there is additional illicit drug use which is not
controlled
Discussion about Role of social services in management (take baby away from her)-
Opioid misuse in itself is not a reason to involve SS. However, if there are significant
concerns abut the safety and welfare of the child, the involvement of social services will
become absolutely necessary.
Management- stability on prescribed medication and attendance at antenatal clinics
are the most important goals of treatment
Cocaine or crack- associated with some teratogenecity of genitourinary system and

bones of the skull, Discuss risk of placental abruption with cocaine use
Use of cocaine and crack do result in abstinence syndrome after birth. Higher
incidence of sudden infant death syndrome when using cocaine/crack
PSYCHOTHERAPY
COGNITIVE BEHAVIOURAL THERAPY

CBT stands for cognitive behavioural therapy. There are two main types of treatments for
depression. One is the physical treatment such as medication or ECT, and the other is the
273
psychological or talking treatments. CBT is one of the most commonly used
psychological treatments.
Cognitive therapy is a way of helping people to cope with stress and emotional problems.
The idea behind it is quite simple the way we think about things affects how we feel
emotionallyWhen people are depressed, they often have negative thoughts about
themselves, their future and the world in general. These thoughts come automatically into
their minds. These negative thoughts or cognitions, undermine their self-confidence,
and make them feel even more depressed leading to unhelpful behaviours. The therapist
will work with you to identify the thinking and behavioural patterns that contribute to
how you feel, and help you to make changes.
CBT looks at here and now issues rather than things from the past. It helps people to
learn new methods of coping and solving problems, which they can use for the rest of
their lives.
CBT usually lasts for 8 to 12 weeks. Usually there will be one session a week, each
lasting about 50 minutes.Someone with special training and experience in CBT such as a
psychologist, a nurse therapist, a psychiatric social worker or a psychiatrist will be seeing
you.
In the first few sessions, the client and the therapist decide which problems seem to be
the most important. Clients/patients take an active part and carry out homework tasks
between sessions. They will often be asked to keep a diary of their thoughts, feelings and
behaviours in the situations that they find particularly stressful. They then discuss these in
detail in the sessions with the therapists, asking themselves whether or not their ways of
thinking are realistic. They can then learn to change these ways of thinking to use more
helpful ones.
Research has shown that it is particularly helpful for people who suffer from anxiety or
depression. It may also be used to treat panic attacks and eating disorders such as
bulimia.
Research evidence suggest that CBT and antidepressants enhance each others effects.
Patients can still continue taking your medications and will still have access to supports
like GP.
CBT helps by changing your thinking and behaviour patterns and in fact, the last few
sessions focus on relapse prevention. Hence, it is effective in reducing the chances of
relapse.
274
TASK: COUNSELLING-CBT
You have assessed Mrs. Wood a 35-year-old lady in the outpatient clinic who has a
diagnosis of recurrent depressive disorder. She has a history of partial response to two
different antidepressant drugs. You would like her to be referred to the psychology
department for CBT and the patient wants to know more about it.
Explain to the patient how CBT works and address her concerns
Do not take history
Expanded construct: The candidate is expected to discuss the nature, principles and
structure of CBT. They should;
Explain the nature of therapy

(Psychological/talking, here and now principles)
(Behaviour-mood-cognition link)
Basic principles of therapy

(Cognitive/behavioural components, negative automatic thoughts,
thoughts diary, graded task assignments)
Structure of therapy
(Number, duration, therapist-trained in CBT and supervised etc)
Expected Outcome and offer further information

(Use in depression, prevents relapse)
Addressing patients concerns

(Homework tasks, stopping meds,
Dealing with emergencies)
ASSESS COGNITIVE ERRORS

(This topics is Compiled by Rinku Alam and edited by Dr. Sree Murthy)
Tips on how to perform well on the Assess cognitive errors station.
This is not an easy station. The main reason is because generally it takes practice to be able to
spot the errors and they usually will not exactly fit the examples.
Also, this station is not only about eliciting the errors, but then being able to convey this to the
examiner. In this respect this is similar to all elicit stations (eg first rank symptoms).
275
When a patient/actor talks freely handing you the material, I would then identify the distortions
whilst going along or hold them in mind to describe all at the end.
If the patient/actor is less forthcoming, specific lines of enquiry are required. Whilst examining
this station, I have found that many candidates explore only pathology ie where things are
negative or have gone wrong for the patient. Here I think you must question the healthy part of
the patient, the premorbid state and areas of positive functioning.
It is likely that the College will change the script at some point, so I have given a general outline,
with examples mainly in two possible scenarios the footballer & depressed secretary. I would
be surprised if the scenario did not describe someone who was premorbidly well functioning.
The actor will give the current concern ensure you explore this to clarify what is going on
pointing to a diagnosis (but not to waste time at the expense of the task). Depending on what the
task is, some of these areas can be done as you go along or at the end (eg depressive symptom
screen etc).
From the start, I would keep in mind a number of the cognitive distortions and as you come
across any of them, begin to explore each one to clarify and identify to the examiner.
My technique would be at each negative remark made by the actor/patient, pose the opposing
positive possibility using the Socratic method. Each area will reveal a number of errors in
thinking that can then be identified.
Easier cognitive distortions:
Catastrophising towards the start, the actor/patient is likely to say: Im a terrible footballer, I
shouldnt play any more, if I play again the team will lose or the project failed because I could
not manage the deadline, this will happen with next weeks project, and I will lose my job
When the actor says this identify it as: you seem to think that there will be a catastrophic
outcome because of this.... or, you only see the worst case scenario all the time
As soon as the actor suggests he or she is a waste of space, a loser or a no good person etc
check that this is a term they apply to themselves globally ie in other areas, and without evidence
that may lead to alternative conclusion then say you seem to label you self in a particular way
ie identifying Labelling.
As soon as it is clear, point out the dichotomous thinking. Even from the little mentioned above
clarify there is no room for anything other than complete failure or success, or that imperfection
means failure. You could already say you seem to think in very black and white way or if
your performance is not perfect, you see yourself as a complete failure
I would then clarify the pre-morbid state, the usual activities, behaviours using tangible factual
information, if possible measurable, to identify previous achievements and abilities, (previous
goals scored, remarks from employers, projects managed well, successful interviews, exams
passed).
From here it is easy to identify previous good functioning point it out you tell me that you
scored many goals in the past/ had always worked to deadlines before / performed well / passed
exams / told that you are a good employee but you seem to minimise your achievements
276
And conversely you seem to focus only negative aspects and magnify these in your mind.
This leads onto how the patient then ignores the positive areas only picking on the negative
aspects there is no balance with respect to the evidence or information the patient could use, ie:
out of a number of possible alternatives, you select ( in an abstract way) only the negative
So if the footballer says he was a top goal scorer and now is a failure after missing a couple of
goals: out of many matches you focus on the one you did not perform well
With the footballer you could also check about others in the team who also did not score, the
coachs comments to the whole team (pt hears only the negative directed to him). With the
secretary scenario look at similar areas others who also missed deadlines or were not
performing well.
The more difficult errors:
Ask about other areas within the scenario the relationship with other players, coach, office
colleagues, bosses, friends, activity groups, family etc.
Here I would think about the material presented and think about and explore each distortion in
turn when any one is hinted at.
Again at any negative aspect ask about the alternative positive with the idea kept in your mind
that there is a distortion ie that the patient perceives there is a problem, but this is in error.
The secretary thinks everyone in the office now hate her how does she know this? is there an
alternative explanation why they behave in this way that has nothing to do with the patient? Here
she is pointing to personalisation. You may have something from the scenario thus far many
staff are losing their jobs so is it possible they are all tense and avoid eye contact with
everyone? (with the footballer it could be how the team are after the match). But this also
extends others will know about her failures the security or doorman at the office they all
now dislike her for the (catastrophic nature of her) failings. you seem to feel that everyone
thinks you are personably responsible for what has happened, but without being able to think
about any other more plausible reasons for their behaviour the boss shouts not because he is
having a bad day but because of the patients failing.
It could be that the pt feels responsible for an event that was not in their control, but as if
something they did had some effect over the situation. (the main idea is that there is no evidence
of a connection between the two) its my fault the car crashed I was playing music, if I hadnt
then the driver wouldnt have crashed.
Overgeneralisation (making an extreme statement): From what is given so far you could also
ask about the extent of the negative conclusions given. Does the feeing of being a failure extend
past the football field, or the office? They generalise from one instance: one missed goal means I
always mess up or: If because of failing to score or meet the deadline, not only are they bad at
their job, but this pattern will continue, no-one will like them and they feel they are a bad parent.
ie I would say this negative conclusion extends beyond the current situation, or you seem to
make a generalisation that extends beyond the current situation
277
Arbitrary Inference (jumping to conclusions): again, at negative conclusion look at the
evidence for this. Everyone in the office hates her - but she cannot identify any root cause other
that the missed deadline, or for the footballer he feels disliked and even when the other team
mates make positive remarks, he still feels they dont like him as a person. you seem to come to
a particular conclusion about this, in the absence of any evidence and even when the evidence
contradicts this
Some candidates also try to point out the errors to the patient/actor who will not appreciate it.
At this stage, they will not have the insight the idea is that in the therapy this could be looked at
and challenged (perhaps by behavioural experiments)
In some respects, this station could be compared to eliciting First Rank symptoms some the
patient will divulge and you have to clarify them, other will require specific questions. For both
scenarios, you need to have a definition in mind and either pick them out as the patient speaks, or
specifically draw them out. Similarly, practice makes this easy. I would suggest that with each
depressed patient you come across in your clinical work, take a moment to fish out the cognitive
errors they will be there. Alternatively look out for them in yourself in the darker moments
prior to the exam!
Heres a one statement example: I havent done enough work this Sunday afternoon, Im going
to fail the exam, Im such a failure! minimizing all the previous study (assuming there has
been previous study!); selectively abstracting this one session and maximizing its importance;
catastrophising; setting up the dichotomy; labelling self as a failure - which could be an
overgeneralisation.
Summary
keep in mind the cognitive distortions

take brief history put yourself in the scenario
at each negative pose the opposing positive using the Socratic method
look at pre-morbid functioning focusing on specifically identifiable markers of
achievements and successes
explore areas linked to scenario but also other areas: work, family, friends, social life,
hobbies looking out for the cognitive errors as you go along
with in what is said try to work out which distortion fits and explore specifics
clearly identify them as you go along or summarise at the end to let the examiner know
Cognitive distortion examples

(MOSPAD-C)
Minimisation and Minimises positive outcomes while exaggerates negative events.
magnification
Over generalizing Generalizing a small element to the whole; e.g. A depressed
schoolteacher thinks one student in the class is sleeping so the entire
class is bored of my lecture
Selective abstraction Selectively picks failures and errors and ignores positive features e.g.
A dysthymic student can talk only about his minor failures and
withdrawals from college competitions, and chooses to ignore the A
grades and accolades that he has received so far.
278
Personalization Assuming personal responsibility for all that has gone bad A woman
with PTSD says Its my fault; I shouldnt have played that music when
Ben was driving
Labelling Here the distortion leads to a global, over generalized negative view of
oneself; You label yourself as hopeless, incompetent, invalid or a victim
Arbitrary inference Predicting without sufficient evidence. E.g. I did my OSCEs on the last
day last autumn and failed, I am sure this is going to happen again.
Dichotomous black or white thinking - I will either pass the MRCPsych, get ST4 job
thinking and have a family or I will fail the exam, have no training job and remain
unmarried forever
Catastrophisation Always predicting the worst case scenario to happen. E.g. A woman
with panic attacks can sense mild palpitation after some house work, and
thinks she is going to have a massive heart attack and immediate death.
Adapted from Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical

Psychiatry, 10th Edition. Lippincott Williams & Wilkins 2007
TASK: ASSESS COGNITIVE ERRORS & DISCUSSION (PAIRED STATION)
TASK-A: Mr. Mark Wallace is a 28-year-old successful footballer who has failed to
score in an important cup match 2 months ago. He has been feeling anxious since then
and is not willing to play football now. His team manager is extremely concerned about
his mental state. Speak to him and elicit the presence of cognitive distortions. In the next
station, you will be asked to speak to the players manager.
Expanded construct: The candidate is expected to obtain history and elicit the presence
of cognitive distortions.
History of presenting problems, duration and impact on current

functioning
Cognitive distortions- Explore & elicit examples of 'maximisation'

and minimisation,
Cognitive distortions - Explore & elicit examples of selective

abstraction, personalisation and labelling
Cognitive distortions - Explore & elicit examples of dichotomous

thinking, overgeneralization
Speak to the manager Mr. Arnold Lewis about management and prognosis.
279
Expanded construct: The candidate is expected to explain the presence of cognitive
distortions, discuss the treatment options available and address concerns.
Explain current problems identified- severe anxiety spells, panic attacks,

negative thinking, lack of confidence
Treatments-
Role of medications (antidepressants)
Psychological treatments
CBT- To address cognitive distortions and to help him with positive thinking
Relaxation training and breathing exercises
CBT- Principles and structure of treatments

Relapse prevention\
Concerns
Antidepressant medications- ? Impair performance
Psychotropic medications- ? Conflict with FA rules for drugs in sport
Role of Benzodiazepines- addictive potential, tolerance and excessive sedation,

hangover effects.
PSYCHODYNAMIC PSYCHOTHERAPY
Psychodynamic psychotherapy is one form of talking treatments and is based on listening
and talking. It involves exploring past conflicts (journey of self exploration) in relation to
your current problems in order to make change possible
It aims to treat people with long histories of serious emotional difficulties. These are
linked to personal development, often over many years, and sometimes right from early
childhood. The aim in psychotherapy is to look more deeply into the emotions, conflicts
and distress behind your mental health diagnoses.
A brief course of psychotherapy would last about three months, and a course of group
therapy or long term individual therapy can last for a couple of years.
Your motivation and relationship with the therapist is extremely important. The initial
280
consultations aim to help think about this, in collaboration with a therapist. If you are
well motivated and set yourself realistic goals, psychotherapy is likely to be of benefit.
However the therapist can only offer guidance and the ultimate responsibility of changing
is with the patient.
It is effective in reducing symptoms, improving relationships and self esteem
The therapist is usually a mental health professional who may be either medical
(psychiatrists), or non-medical (nursing, psychology, occupational therapy or others).
They will normally have specialist psychotherapy training in addition to their core
professional background, or be in a training course and receiving supervision.
It is offered on a weekly basis- same day, same time and same place
Each session normally last fifty minutes and group therapy meetings are for one and a
half hours. Some specialised groups are for longer than this.
There is a small possibility that you may feel worse before you feel better, as the therapy
requires an uncovering of painful feelings and memories that be experienced as a relief
but it may also stir up uncomfortable feelings.
There are often two waits before you start regular therapy. The first is after you are
referred and before you attend an assessment appointment and the second is after the
assessment appointment while you are waiting for an available space. Due to the excess
demand on most psychotherapy services, both of these waits are often months rather than
weeks.
The patients are generally advised to stay on their routine medications whilst undergoing
psychotherapy. However, arrangements are more variable, and it is something you should
discuss with your therapist, and also the other professionals responsible for the
prescription of your medication. What do I do in an emergency or crisis?
In case of emergencies, you will need to use your normal network 'of support. However,
it may be important to bring the difficulties you experienced to the attention of your
therapist at the next session.
It is always possible to leave therapy if you feel that it is not working. The wise thing to
do is to first talk about your difficulties with your therapist before you decide to stay or
leave. Ultimately, if you want to stop, it is up to you.
Psychotherapy files are often kept separate from other hospital notes and confidentially
will be maintained, unless there is any risk to third parties. The files contain your initial
letter, summary of your assessment, notes from the process of your treatment, including
your attendance and content of the sessions, GP correspondence and discharge letter.
AGORAPHOBIA- TREATMENT OPTIONS
Agoraphobia is a common problem and it is definitely treatable.

There are a number of different treatments available including education, psychological
treatments and medication.
Education may sound simple, but patient and family need to know about the nature of the
illness, what keeps it going and how to deal with it.
281
There are two main types of medication, benzodiazepines and antidepressants.
Benzodiazepines for example (Valium) start working very quickly and can be useful in
the short term but they are addictive, and people may become dependent on them.
Antidepressants would be a better option. They treat and modify the chemical imbalance
in the brain which might be responsible for this condition. We start them at a low dose
and increase gradually. They may take up to 8 weeks to start working. Once you feel
better, you will have to continue the medication for about 6 months, if not longer. Then
we have to taper it off gradually and stop. They are not addictive.
The name of the psychological treatment offered is called as systematic
desensitisation. This treatment is also called graded exposure with relaxation. In this
therapy, first the patient will be taught relaxation exercises to help them control the
anxiety and panic. Then we make a list of hierarchy of situations that you find difficult to
face. We arrange them from the least difficult to the most difficult and you may find it
easier to face situations if you move from the least to the most difficult, Then you start
by facing the easiest situation, whilst managing to relax. When you feel comfortable with
that situation, you then go onto the next one. You will have to practice this daily. e.g. like
going out of the front door of your house, going out to your garden from your house, then
going out to a nearby shop with a family member/friend and then going out to a
supermarket with a family member/friend and so on.
Practice the steps until it no longer causes anxiety. Once you feel confident with one step,
move on to a more difficult step and repeat the practice.
If there are difficulties in getting out of the house, then we can arrange for the therapist
to come to your house to help you initially.
Your family members and or your partner have an important role in the treatment and it
will be very helpful if they can also be involved to improve confidence and support them.
TASK: AGORAPHOBIA- SYSTEMATIC DESENSITISATION
You have seen Mrs. Wood who has been diagnosed as suffering from agoraphobia. Now
speak to her husband Mr. Jonathan Wood to explain diagnosis, etiology and treatments
available for this condition. Address his concerns.
Expanded construct: The candidate is expected to explain diagnosis, aetiology and
treatments available for this condition. They should be able to explain the principles and
structure of psychological treatments. They should be able to;
Explain diagnosis in simple terms
282
Explain treatment options
1. Education about anxiety and phobic avoidance
2. Drug treatments-antidepressants
Psychological: CBT
(Systematic desensitisation, Relaxation training and breathing exercises)
Basic principles (Graded exposure to feared situations, anxiety

management, Management of the fight-flight response, avoidance
mechanism reinforcing it etc)
Structure of therapy (Weekly session, 40-50 minutes,

Therapist aided and homework tasks)
Family and social support- vital
Address concerns
1. Cant come out of the house- Therapist to do home visits.
2. Valium and Antidepressants-? Dependency
OCD- EXPOSURE AND RESPONSE PREVENTION

OCD can be treated through drug treatment, psychological or talking treatment or by a
combination of both. The antidepressant medications have been shown to be helpful in treating
OCD.
The most common side effects found with antidepressant medicines are nausea, headaches, dry
mouth, blurred vision, dizziness and feeling sleepy. However it is important to remember that
they are not addictive. They will not cause withdrawal symptoms when you stop taking them.
283
If you are given drug treatment for OCD, you may have to stay on treatment on a higher dosage
for a long time. This is to make sure theres no chance of symptoms returning.
Different forms of psychological treatments and the most commonly used treatments are
Exposure and response prevention, Cognitive behavioural therapy.
Exposure and Response prevention: The treatment strategy involves exposing the individual to
stimuli that trigger anxiety or discomfort, and then having the individual voluntarily refrain from
performing his or her ritual or compulsion.
For each ritual the individual will be required to list a range of situations that cause anxiety and
The individual would then rate each of these situations according to the amount of anxiety or
distress that would arise if he or she did not perform the particular ritual.
These are then arranged in order according to those that generate the least anxiety or discomfort
to those that generate the most anxiety or discomfort. The first task in the list would be an activity
that is mildly discomforting but not too difficult, while the last task in the list would be the most
difficult task that the individual can imagine.
Before starting theses exercises, it is important to provide training for slow breathing exercises
and relaxation. These exercises can be used prior to commencing each step of the graded
exposure hierarchy to ensure that the individual is calm and relatively relaxed at the beginning of
each graded exposure session.
It is worth mentioning the following points:
This is a simple but highly effective technique
It is usually done in graded steps
The active participation of clients is necessary
The situation can be real or imagined (a real-life situation will be more effective)
It can be practised regularly with self-exposure tasks.
It is used particularly in treatment of phobias and OCD
TASK: OCD- CBT (EXPOSURE AND RESPONSE PREVENTION)
Miss. Michelle Wright is a 30-year-old woman who has been referred by her GP for
excessive hand washing and has been recently diagnosed with obsessive-compulsive
disorder in your clinic. She is terribly worried about her condition getting worse. She is
not keen to take any medications and would like to receive some form of psychological
treatments. Speak to her about CBT for the treatment of OCD and address her concerns.
284
Expanded construct: Core task - (60-70% relative weighting)
The candidate is expected to discuss the psychological treatment options for OCD and
explain exposure and response treatment in detail.
Mention CBT as the main form of psychological treatment

Explain the nature of therapy (here and now principles, Behaviour-mood-
cognition link)
Discuss about cognitive aspects (identify thinking error, automatic thoughts,

Socratic questioning in challenging thoughts)
Behavioural aspects- Exposure and response prevention

(Clear explanation)
Exposure techniques for obsessions, and response prevention useful in
ritualistic behaviour
Relaxation and breathing exercises

Focusing On anxiety management first before behaviour therapy
Structure of Psychological sessions (Time-limited, regular sessions,

Behavioural experiments, Goal settings, Home-work assignments)
Discuss efficacy and relapse prevention
Social treatments (Support-family and friends, self-help groups)

Sources of information (leaflets)
PANIC DISORDER- HYPERVENTILATION SYNDROME

Reassurance; A person with a panic attack might think that he or she is having a heart
attack. This is because some of the symptoms of a panic attack are also experienced
during a heart attack for example, chest pain and breathlessness. It is therefore
understandable that a person who is having a panic attack may think he or she is having a
heart attack. If chest pain is recurrent or long lasting, it is wise to have a thorough
285
medical investigation to rule out the presence of heart disease. If heart disease is not
present then it is unlikely that subsequent chest pain is caused by a heart attack.
It is probably best for him or her to sit quietly and use the slow breathing exercise for
about five to ten minutes. However, if pain is still present after ten minutes of slow
breathing, the individual is advised to seek medical advice.
Definition: Panic disorder involves recurrent and sometimes unpredictable attacks of
anxiety or panic. Panic attacks are defined by a sudden onset of intense apprehension and
fear of dying The attacks start suddenly without any obvious precipitants, are extremely
distressing, and last for a few minutes, sometimes longer. These attacks are not restricted
to specific circumstances but may occur in any situation.
Flight or Fight response: When we are exposed to a physical threat, our bodies
automatically respond so that we are able to defend ourselves or escape from a
threatening situation. This response is also known as the flight-or-fight response.
When you become anxious and panicky it leads to an increase in the speed and depth of
breathing. This over-breathing, also called hyperventilation, may lead to the following
symptoms: In the brain it causes dizziness, light-headedness, confusion, breathlessness,
and feelings of unreality. In the body it causes an increase in heartbeat, numbness and
tingling in the hands and feet, cold clammy hands, stiffness in the muscles, muscle
twitching or cramps and irregular heartbeats. People who over-breathe often tend to
breathe from their chest rather than from their diaphragm. As the chest muscles are not
made for breathing, these muscles tend to become tired and tense. Thus individuals can -
experience symptoms of chest tightness or even severe chest pains.
The first step in preventing and controlling hyperventilation is to recognise how and when
hyperventilation occurs. In order to reduce the symptoms it will be necessary to increase
and steady the level of carbon dioxide in the blood which will help the individual reduce
habitual over-breathing and this is achieved through slow breathing exercise. Here the
individual is instructed to breathe in and hold his or her breath, and then instructed to
breathe slowly out, saying the word relax to themselves in a calm, soothing manner every
time they breathe out. This should be repeated in cycles until all the symptoms of over-
breathing have gone.If individuals follow this exercise as soon as they notice the first
signs of over-breathing, the symptoms should subside within a minute or two and panic
attacks will hopefully be avoided. The more frequently individuals practise this slow
breathing exercise, the better they will become at using slow breathing to prevent anxiety
from escalating.
286
TASK: PANIC DISORDER-HYPERVENTILATION (DISCUSSION)
Mr. Paul Andrew is a 40 YO gentleman who suffers from panic disorder. He has called
the ambulance, as he was worried that he might be suffering from a heart attack. He has
been investigated with normal results and cardiologists said its all in his head. He is
still feeling anxious because his father and uncle died of heart attack. His wife Mrs.
Shirley Andrews is extremely concerned about him and wanted to speak to the
psychiatrist.
a. Explain the symptoms to his wife and address her concerns.
b. Also explain what hyperventilation syndrome is and what happens as a result of
it?
Expanded construct: The candidate is expected to discuss about mechanism behind

panic attacks and explain the phenomenon of hyperventilation.
Offer clear explanation for chest pain, breathlessness and other

symptoms
Reassure relative- Medically cleared and not having a heart attack,

Cover list of investigations done so far.
Explaining diagnosis-panic disorder, nature & frequency

Explain Fight-flight response
Explaining hyperventilation Syndrome, the mechanism involved,

Possible Ways to prevent it.
Emphasise Importance of Relaxation Techniques and Breathing

exercises
Address Concerns-
? Getting back to work
? Role of Medications
INTERPERSONAL THERAPY
Interpersonal therapy (IPT) is mainly used for the treatment of depressive illness (mild-moderate)
and bulimia nervosa. It is a time-limited and disorder-focused therapy which deals with
symptoms in the here and now
Principle:
The focuses of treatment are the current interpersonal relationships and their relationship
to the development of illness.
287
Emotional problems are best understood by studying the interpersonal context in which
they arise.
It does not make any assumptions about the causation of the illness, but aims to use the
connection between the onset of depressive symptoms and the current interpersonal
problems as a focus of treatment
Resolving the interpersonal problem is seen as a route to recovery.
The four interpersonal areas related to illness development include:
a. Grief (loss of a loved object/relation)
b. Interpersonal disputes e.g. Conflict with family members, colleague or a
friend
c. Change of role (e.g. graduation, new mother, retirement, job loss, medical
ill health)
d. Interpersonal deficits.(inadequate interpersonal relationships)
Structure:
It is time-limited
Treatment lasts for 12-16 hour long weekly sessions, offered by trained therapist
The therapist starts with a diagnostic phase, in which the disorder is identified and
explained. Inventory of all close relationships is created in early part of therapy.
The therapist will now try to link the depressive symptoms with one of the four
interpersonal areas and will pursue strategies specific to one of these problem areas.
The therapist is directive and takes an active & supportive stance.
The patient is encouraged to identify and carry through change in interpersonal
relationships and to test the possibility of consequent improvement in their symptoms.
The final phase involves assessment of improvement and develops ways of identifying
and countering depressive symptoms, should they recur in the future and plan for
termination of therapy.
TASK: INTERPERSONAL THERAPY (ASSESS SUITABILITY)
You are seeing Mrs. Pauline Smith in the outpatient clinic. Take history from her, as she
is feeling low in her mood, and assess her suitability for IPT (Inter Personal Therapy).
Expanded construct: The candidate is expected to obtain important history and assess
suitability of patient for interpersonal therapy.
Assess depressive features- Core symptoms, emotional and

biological symptoms etc
Assess for Selection criteria- outpatient, Establishing mild to

moderate depressive illness. Non-psychotic depressive illness, non-
bipolar illness
Identify interpersonal problem areas- Grief (complicated

bereavement after the death of a loved one)
Identify interpersonal problem areas- Interpersonal deficits
288
(History of social impoverishment, inadequate or unsustaining
interpersonal relationships)
Identify interpersonal problem areas- Interpersonal role disputes

(conflicts with a significant other- a partner, other family member,
close friend etc)
Identify interpersonal problem Role transitions (Economic or

family change- the beginning or end of a relationship or career, a
move, a promotion, retirement, graduation, diagnosis of a medical
illness)
Assess motivation and willingness to comply

Route to recovery- Resolving interpersonal issues
PSYCHOTHERAPY- REASONS FOR TERMINATING

TREATMENT
Reasons for terminating treatment;

1. Making good progress in psychotherapy- You have come to understand your life
and its unconscious motivations to such an extent that you no longer need a
psychotherapist to guide you
2. Ambivalence and poorly motivated patient- may drop out quickly
289
3. Pragmatic reasons- Progress made in current life situations- Initially might come
to psychotherapy due to depression and unemployment. After a few sessions
might find a new job and quit psychotherapy
4. Move away- Received a job offer and decided to move.
5. Lack of time- Feeling more confident and wanting to get back to
school/university/job etc and no longer has the time for psychotherapy
6. Financial issues and lack of affordability may prevent the treatment from
continuing
7. Unfortunate reasons- psychotherapist performing his or her job incompetently
8. Patient believes that the trust has been broken despite efforts to speak about the
problem within the treatment, than may be no other option than for the client to
terminate treatment for his or her own psychological safety
9. Therapist inducing strong transference reactions on to the patient.
10. Therapist changing his job or moving to a different place
11. A therapist may have counter transference issues that can interfere with the
treatment
12. Sometimes a psychotherapist will realize that the psychotherapy has moved into
an area that requires expertise he or she does not have, and trying to continue
psychotherapy without proper training or supervision would be an ethical
violation.
Reference: A guide to psychology and its practice; Termination of psychotherapy.
Reasons for dropping out of psychotherapy
These may be patient related or therapist/service related
Patient related
1. Psychodynamic factors e.g. Transference

2. Demographic. Although studies show different results, some do show that risk factors
for drop out are younger age group (eg 25-30 year olds), and minority ethnic status. All
studies show low SE status is a risk factor for drop out.
3. Patients explanatory model for his illness and also his view of treatment
4. Patients motivation - again this may relate to psychodynamic factors (particularly
ambivalence), although lack of a social support is also a risk factor for drop out.
5. Other patient characteristics: increased drop out if patient socially isolated, passive
aggressive, hostile and has a PD diagnosis
Therapist/service related
1. Accessibility of service
2. Therapist characteristics (i.e. there may be an objective reality to the therapist being
problematic, we cannot always explain encounters through an understanding of the
transference).
References
290
Early withdrawal from mental health treatment: Implications for psychotherapy practice.
Barrett, Marna S.; Chua, Wee-Jhong; Crits-Christoph, Paul; Gibbons, Mary Beth;
Thompson, Don Psychotherapy: Theory, Research, Practice, Training, Vol 45(2), Jun
2008, 247-267
Transference : This is the process by which a patient displaces onto his therapist
feelings, ideas etc which derive from previous figures in his life. Loosely it is the
patients emotional attitude towards his therapist. In the early days of psychoanalysis
transference was regarded as a regrettable phenomenon, which interfered with the
recovery of, repressed memories and disturbed the patients objectivity. However Freud
revised this view. He came to see it as an essential part of the therapeutic process. It is
the therapists detachment and refusal to play along with the patients preconceptions,
which creates a novel situation in which it is possible to interpret to the patient that she is
behaving as though the therapist (in this case) was the father. One can then see that there
is a case in this scenario to recommend that returning to therapy will give her a good
opportunity to do some psychological work on how her internal relationship with her
father affects her fundamentally in subsequent relationships.
Reference: Rycroft C. A Critical Dictionary of Psychoanalysis. London: Penguin, 1995
SLEEP AND SEXUAL DISORDERS
IMPOTENCE
Common Triggers for sexual problems
1) Could be due to a physical cause.

Medical illness diabetes mellitus, post MI, hypothyroidism, Addisons disease.
291
Surgical cause recent child birth, surgeries involving the rectal area & perianal area (eg)
colostomy, episiotomy, operation for prolapse, amputation.
Drugs prescribed antipsychotics, SSRI antidepressants, antihypertensive (diuretics,
Beta blockers); non prescribed (alcohol, cannabis, cocaine)
2) Could be due to a Psychological cause.

Psychiatric illness depression, low self esteem, excessive self-monitoring of arousal; feelings of
guilt about sex;; Schizophrenia with negative symptoms.
Anxiety performance anxiety
3) Social causes: Marital conflicts & relationship difficulties, life stressors; performance anxiety;
previous significant negative sexual experience (esp. rape or childhood sexual abuse issues).
4) Lack of adequate sexual knowledge, fear of pregnancy or STDs etc
5) Environmental: Fear of or interruptions (e.g. from children, parents)
6) Factors related to the partner: Sexual attractiveness (gender, physical characteristics); sexual
inexperience, evidence of disinterest, poor technique, and preference for sexual activities that are
unappealing to the partner.
The patient should be interviewed with the sexual partner. The two should be seen separately and
then together
It is vital to explore the mode of onset, duration, course and progression of the problems
define the problem
Knowledge of sexual techniques and possible anxieties about sex, why have they sought
help now?
Also enquire whether erection possible in any situation
Whether difficulties are associated with a particular part of sexual activity
Enquire about early morning erection to distinguish between physical and psychiatric
cause
The following questions may also be helpful
Male:
Has there been a previous period of normal function?
Has the failure occurred with more than one partner?
Does erection occur during foreplay?
Does erection occur on waking (or) in response to masturbation?
Any evidence of drug/ alcohol abuse.
Female :
Anxiety about intercourse
Lack of sexual interest
Inadequate sexual foreplay by the partner.
Ask a detailed medical Hx, Surgical Hx, list of medication, past psychiatric history, social
difficulties such as financial difficulties, stressful life events, work related stress.
292
Explore for interpersonal difficulties, serious marital problems, insufficient sexual information,
and performance anxiety
In the assessment also explore about relationship problems such as anger, loss of affection, sexual
orientation, sexual preferences, tiredness, anxiety, and depression, past sexual experience causing
fear (or) disgust.etc
Treatment
Establish the reasons for seeking help and provide information, advice and education on
sexual problem.
Treat any primary cause found (physical, psychological, or psychiatric).
Address general relationship issues- Inter personal conflicts marital therapy (couple
therapy), Counselling
Consider specialist referral (behavioural work, graded individual and couple exercises
require experienced therapist (e.g. sensate focus techniques).
If it is drug induced
The most obvious first step is to decrease the dose (or) discontinue the offending drug
where appropriate.
Switch to a different drug that is less likely to cause the specific sexual problem
experienced.
Antidote drugs can be tried (eg) cyproheptadine for SSRI induced sexual dysfunction.
Drugs such as sildenafil (phosphodiesterase inhibitor, Viagra) or Alprostadil are only
effective in the treatment of erectile dysfunction
Sex therapy Master and Johnson
It has 4 characteristics features.
Treat the partners together

Help them to communicate better, about their sexual relationship.
Education about the anatomy and physiology of sexual intercourse.
To take part in a series of Graded tasks involving techniques such as sensate focus,
waxing and waning
Graded Tasks:
Begin with tender physical contact.
Sensate focus caress any part of other persons body except the genitalia to give
pleasure and enjoyment.
Progress from non genital-to-genital sensate focusing.
Once strong erection are produced, Stop caressing by female partner and to wait for
erecting to subside before restarting.
Waxing and waning technique.
Last stage penetration woman should take change and insert his penis.
293
TASK: ANTIDEPRESSANTS INDUCED SEXUAL DYSFUNCTION
PART-A: Mr. Patrick Murphy is a 46-year-old gentleman who was diagnosed with
depression and was started on Fluoxetine 40 mg by the GP. The patient told his CPN that
he wants to come off the medication and you are reviewing him in your clinic. Address
his concerns and find out why he wants to come off fluoxetine. Obtain further history
from the patient to identify cause for his concerns.
You will speak to his wife in the next station.
Expanded construct: The candidate is expected to obtain history to find out and find
out why he wants to come off Fluoxetine. Obtain further history from the patient to
identify cause for his concerns. They should;
Explore current problems and obtain more history

(Mode of onset, duration, progression, precipitants if any)
Acknowledge the difficulty in talking about Sexual problems,

Reassure-common and could be treated
Agree to speak to his partner
Elicit briefly Symptoms of depression

(Low mood, anhedonia, Fatigueability, disturbed sleep etc)
Obtain detailed sexual history

(Lowered libido, Arousal difficulties, Reaching orgasm too soon or Failure,
Erectile failure, inability to maintain erection etc)
Identifying possible triggers for sexual problems

(Physical, psychological- ? depression,
Environmental factors, Factors related to the partner)
Addressing concerns-
1. Longer term effect of medication on sex life
2. Risk of stopping meds- not advisable
LINKED STATION (PART-B)
Mr. Patrick Murphy, who is extremely worried, has requested you to speak to his wife
Mrs. Lorraine Murphy, who is seated in the waiting room. Talk to his wife explaining
your findings from history and discuss further management of his problems.
Expanded construct: The candidate is expected to explain findings from history

obtained from her husband and discuss further management of his problems.
294
Explain current problems and possible reasons for presentation
(Sexual problems- could be a feature of depression,
? SE of medications (possible) but history suggests possibility of depression as the
cause
Discuss possible side effects of Fluoxetine

(Sexual, CNS and GIT side effects)
Discuss alternatives
Addressing concerns
a. Review and try new medication, if problem persists
b. Risk of relapse on stopping meds
Concerns:
c. Discussion about Remedial treatments (Viagra)
d. Discussion about herbal remedies
e. Addictive potential
Discussion about counselling and psychological treatments
INSOMNIA- SLEEP DISORDER
SLEEP HISTORY
Chief complaints:
What are the main complaints/problems/difficulties? (Ask the patient to describe it in
their own words)
295
When did it start or when did it first occur?
How troublesome are these symptoms?
Do the symptoms fluctuate in severity?
How much does it affect your life?
Identifiable stressors:
Were there any identifiable stressors present at the time of onset of these difficulties?
(Relationship break-up, bereavement, financial crisis etc).
Are these stressors still present?
Daily routines
Clarify whether the patient has difficulty falling asleep or staying asleep or early
wakening in the mornings
Also tell the patient to describe the sleep itself. (estimated number and duration of
awakenings, periods of restlessness, night mares etc)
Tell me about your bed time routine.
Enquire about daily routine before getting ready for bed, time of getting into bed at night,
and feeling worried, anxious, racing thoughts, irritable or depressed at bed time.
Enquire about activities performed in bed before sleep such as reading, watching TV, sex
etc and approximate time at which the individual falls asleep.
Enquire about the time of final waking in the morning and time of getting out of bed in
the morning.
You should enquire about usual routine followed after waking, daily activities etc?
Enquire about daily naps (when, where, why and how long). Also question about the
level of alertness throughout the day and ask about decrease in performance at work and
other activities. Enquire about feeling physically or mentally tired during the day.
Try to roughly calculate the number of hours slept in 24 hours, including day time naps.
History
Past history of sleep problems and treatments received including usefulness and side
effects.
Family history of sleep problems
Past psychiatric history- depression (early morning wakening), bipolar disorder (difficult
sleeping and decreased need for sleep in the manic phase), generalised anxiety disorder(
difficulty with getting to sleep), panic disorder (frequent wakening at night with
autonomic arousal symptoms), PTSD (night mares and re-experiencing of the traumatic
events), Schizophrenia (disrupted sleep), eating disorder etc
Medical history- Chronic pain, excessive urination at night time, constipation, breathing
difficulties (to rule out COPD, Asthma, Congestive heart failure), chronic headaches,
medical disorders like Parkinsons disease, diabetes, arthritis, peptic ulcer etc.
Enquire about medications- both over-the-counter and prescribed medications. Ask for
the time of the day at which it is taken.
Drug and alcohol history- type and quantity of drugs and alcohol consumed during day
time. Ask specifically about each of these- alcohol, nicotine, caffeine, cannabis, and other
illicit drugs
Social circumstances and life events: (Relationship break-up, bereavement, moving
home, work related stress, financial crisis, unemployment, legal problems, social
isolation etc)
296
Management of insomnia
A GP has referred a 65 years old gentleman who seems to suffer from insomnia. There is no past
history of medical illness apart from osteoarthritis.
How would you proceed and manage?
What are the possible causes of insomnia?
What are the measures promoting sleep hygiene?
Given the information here, I shall think of sleep disorders causing Insomnia.
My assessment would involve ruling out different cause for insomnia.

Physical cause (breathing difficulties, Pain, headache, Urinary frequency)
Medical disorders (arthritis, peptic ulcer), respiratory disorders (COPD, cystic fibrosis,
asthma), cardiovascular disorders (chronic heart failure), diabetes, Parkinson's disease,
endocrine disorders (Addison's disease, Cushing's syndrome).
Psychiatric cause (anxiety, depression, mania, psychosis, adjustment reaction)
Substance misuse (illicit substances and alcohol related)
Medication drugs given at inappropriate times (eg.) stimulant medication in the evening.
Unrealistic expectation by the patient.
Poor sleep hygiene.
Id arrange for an outpatient appointment to assess the patient individually and with the
partner (after obtaining informed consent).
Obtain information from GP about medical history and psychiatric history if any, old
psychiatric and medical notes, and previous & current medication list.
Id like to obtain a detailed comprehensive history, perform a mental state examination,

physical examination and investigation.
Id obtain a detailed history of the sleep complaint, mode of onset, duration, progression
of symptoms, pattern of occurrence, factors making sleep pattern better (or) worse, day
time short naps, impact on normal day to day functioning.
Also Id explore for past history of mental illness, family history of mental illness,
medical illnesses, current medications, current level of social support, social difficulties
such as housing, unemployment, drug and alcohol history, premorbid personality,
forensic history and any recent stressful life events like illness, bereavement.
Mental state examination look for evidence of depression, anxiety, subjective and
objective mood assessment, any abnormal beliefs, preoccupations, phobias, suicidal/
violent thoughts, cognitive assessment to rule out dementia and also insight.
Physical examination including neurological examination.
Investigation:
297
Routing blood investigations
Collateral history from partner (or) family members.
Video recording (EEG recordings in a sleep laboratory (or) at home)
Polysomnography (rarely needed)
Treatment
If insomnia is secondary to another condition (physical (or) psychiatric disorder) then

treat the cause accordingly.
First try non-pharmacological strategies and if it doesnt help then medical

management with drugs should be considered.
Choices include: benzodiazepines, zopiclone/zolpidem, chloral hydrate, and sedating

antidepressants (e.g. trazodone). They should only be used to treat insomnia when it is
severe, disabling, or subjecting the individual to extreme distress.
Encourage sleep hygiene approaches and principles of sleep education.
a. Avoid late evening exercise; reduce caffeine (or) alcohol intake/smoking, excessive daytime
sleep and napping, large late meals and thinking about problems before going to bed.
b. Encourage bed time routines, regular exercise (not in the evening), routine of rising and retiring
at the same time each day, use anxiety management (or) relaxation techniques and sleep
environment should be quiet, familiar and comfortable.
c. Other measure like relaxation techniques, anxiety management, medication, yoga, listening to
relaxation cassettes.
Cognitive behavioural treatments have been shown to be effective, cognitive intervention

such as paradoxical intervention and thought restructuring and behavioural strategies
such as stimulus control, sleep restriction and maintaining sleep dairy.
Benzodiazepine Hypnotics:
Short acting difficulty getting off to sleep but risk of dependence and tolerance.
Long acting frequent / early morning wakening but risk of day time sedation and loss
of co-ordination.
Non-benzodiazepine hypnotics such as Zopiclone and zolpidem but again possible risk
of dependence and may impair driving.
Important principles:
Use the lowest effective dose.
Prescribe for short term (no more than 4 weeks). Ideally hypnotics should be used as
short-term adjuncts to other forms of therapy and prolonged administration should be
avoided.
Then use intermittent dosing where possible (alternate nights) and discontinue slowly.
Caution about rebound insomnia/ withdrawal symptoms. Interrupted courses (i.e. 5 nights
with medication, 2 without) for no more than 4 weeks may help avoid tolerance and
reduce the rebound insomnia that often accompanies cessation.
298
Avoid use in respiratory disease, severe hepatic impairment and in addiction prone
individuals.
Address psychosocial difficulties and help the patient and the family
LIAISON PSYCHIATRY & MISCELLANEOUS TOPICS

DELIRIUM TREMENS- TELEPHONE ADVICE ABOUT A
CONFUSED PATIENT
A. Introduce yourself to your colleague
299
B. Explore more history, which includes:
Circumstances of the injury and admission
Past psychiatric history and medications
Medical history and medications
Drug and alcohol history
Current social situation
C. Give priority to alcohol history

Current usage and longitudinal history.
Enquire for features of dependence syndrome.
Enquire about withdrawal symptoms both physical and psychological symptoms.
Ask for symptoms of delirium tremens which include clouding of consciousness,
disorientation in time and place, poor attention span, visual hallucinations and illusions, which
are often vivid and frightening. Tactile hallucinations of insects crawling over body may
occur.
Ask for any autonomic disturbance, which include fever, sweating, tachycardia, hypertension,
pupillary dilatation.
Ask about neurological signs and symptoms.
D. Ask about their current management plan and what their team feels about the patient
Ask for necessary blood investigations and other investigations to rule out acute confusional state
(FBC, ESR, blood culture, LFT, U&E, creatinine, TFT, chest X-ray, ECG, urine C&S).
E. Give further management advice that includes

Treat the underling cause if any such as infection, dehydration etc
Ensure adequate fluid and electrolyte balance, providing adequate nutrition
Optimisation of environment- well lit quiet room with adequate lighting
Nursing support-Consistent nursing support to offer reassurance, reorientation and
explanation. If possible, discuss about providing input from the psychiatric nursing team
Librium sliding scale (detoxification regime with Chlordiazepoxide (Librium) in a
reducing dose).
Using parenteral benzodiazepines to achieve quick sedation.
Instituting parenteral, high potency vitamins (thiamine supplementation or
multivitamins).
Avoiding use of phenothiazine antipsychotics (Haloperidol) due to risk of inducing
seizures.
Warn about the risk of withdrawal seizures and Wernickes encephalopathy.
Offer to see patient if necessary.
CONVERSION DISORDER
Definition: A loss or disturbance of normal function, which initially appears to have a physical
cause but is attributed to a psychological cause (Emotional cause)
300
Etiology: There is no one explanation for this disorder. However it was initially thought as
possibly caused by repression of unacceptable conscious impulses/thoughts/feelings, which are
later converted to physical bodily symptoms and are sometimes represented with symbolic
meaning.
It can manifest in several different ways;
These vary depending on the area affected but the following are commonly seen:
Paralysis One or more limbs or one side of the face or body may be affected.
Loss of speech. There may be complete loss of speech, or loss of all but whispered
speech. There is no defect in comprehension or understanding and writing is unimpaired
(It often becomes the main method of communication).
Sensory loss
Blindness
Seizures and others
It is important to acknowledge that the symptoms are not produced intentionally
Diagnosis; The diagnosis will usually be suspected due to the non-anatomical or clinically
inconsistent nature of the signs and symptoms. Firstly it is important to exclude underlying
organic disease
Secondly, it is important to identify the presence of positive signs i.e. demonstration of function
thought to be absent and lastly there should be a convincing psychological explanation for the
presentation.
Treatment
Obtain medical and psychiatric history from patient and informants
Physical causes should be ruled out by full examination and appropriate investigation
Supportive psychotherapy; Sympathetic explanation and reassurance that the patient is
suffering from a temporary condition and does not have a permanent disabling disorder.
Treatment of psychiatric co morbidity like depression etc. Offer continuing assessment
and treatment of psychiatric and social problems
Avoidance of reinforcement of disability.
Prognosis
The prognosis is generally good for those patients with a clear precipitant and if
symptoms were of sudden onset and shorter duration.
Complete resolution of symptoms is possible and has been observed in 70-90% of cases
at follow-up.
If the symptoms are longer lasting and well established, then the outcome is more likely
to be poorer.
TASK: CONVERSION DISORDER- HISTORY TAKING & DISCUSSION
Assess this lady Mrs. Mary Ellis, who is admitted under Neurologist for the last 5 days
with paralysis of one upper limb & the opposite side lower limb. Obtain history to arrive
301
at a diagnosis. You will discuss the findings and diagnosis with the husband in the next
station.

diagnosis. They should;
Detailed history of the presenting complaints:

Onset, duration, severity, progression
Assess circumstances leading to current presentation
Ongoing psychosocial stressors & identification of psychological factors

Relationship difficulties, job stress, stress of looking after mother etc
Rule out co morbidity- mood symptoms etc

Identification of secondary gain
Rule out physical causes for current presentation
You have already assessed and obtained history from Mrs. Mary Ellis. In this station,
Explain to the husband Mr. Martin Ellis, about his wifes current condition & address his
concerns.
Expanded construct: The candidate is expected to discuss diagnosis, explain the role of
psychological factors leading to current presentation and discuss prognosis and
treatments available for conversion disorder. They should;
Able to synthesize the presenting complaint and rule out possibility of organic
causes- Offer clear explanation
Inform possible diagnosis- Role of psychological factors

(? Conversion disorder- physical effects of a conflict)
Discuss possible etiological factors- Precipitants & Recent stressors

Relationship difficulties, job stress, stress of looking after mother etc
Discuss outcome- short-term and long term

(May undergo spontaneous resolution, some may need active rehabilitation)
Addressing concerns
1. Stroke or not
2. Hysteria
302
Discuss Treatments- Role of medications, psychotherapy etc)
HYPOCHONDRIASIS
Hypochondriasis is the preoccupation with the fear of having a
serious disease, usuall y one which lead to death or serious disability and
303
this constant preoccupation persists despite negati ve investigations
In this condition, minor ail ments will be int erpreted as signs of

serious disease.
As a result of this, the patient will consequently seek medical
advice and investi gati on but is unable to be reassured
There is a persistent refusal to accept the advice and reassurance
of doctors that no such physical illness exists.
It could cause si gnificant distress, i mpaired function and severe
disability.
The form of the belief is that of an over -valued idea. Here the
patient may be able to accept that his/her worries are groundless but
nonetheless be unable to stop dwelling or wo rrying and acting on t hem.
It is seen equall y in men and women, bet ween the ages of 20 and
30 years.
Co-morbidit y: It is associated with generali zed anxiet y disorder in
more than 50% of cases. It may also coexist with maj or depressi ve
illness, panic diso rder and obsessi ve compulsive disorder
Etiology:
Hypochondriasis is multifactorial in origin
Past experience of true organic disease, especially in childhood in
either oneself or a family member may predispose to the development
of this disorder. In many cases, there may be a histor y of childhood
illness, parental illness, or excess medical at tention seeking in the
parents.
Childhood motional abuse or neglect, childhood sexual abuse are
associated.
Psychological model: Indi viduals with combination of an xiet y
symptoms and predisposition to misattribute psychical symptoms,
seek medical advice. T he resulting medical r eassurance provides
temporar y relief of anxiety, which acts as a reward and makes
further medical attention seeking more li kel y.
Precipitati ng factors are usually si gnificant psychosocial
stressors. The condition is often perpetuated by persistence of such
stresses and advantages of sick role.
Management:
Allow patient ti me to ventilate their illness anxieties.
Organic disease shoul d be excl uded
Pri mar y psychiatric di sorder such as depression and anxiet y
should be treated vi gorously
Explain negati ve tests and a void further unnecessary tests.
Specific medical inter ventions should be kept to a mini mum.
It is i mportant to establish continuing re lationships and review
patients regularl y and attention should be gi ven to any social and
personal factors from which the complaints are considered to arise.
Emphasi ze aim to im prove f unction .
304
Education: Education about the role of psychological factors in the
development of sympt oms and how to cope with such symptoms is vital.
Break cycle of reassur ance and repeat presentation - famil y education and
support would be helpful in this regard
Psychological : CBT is the most i mportant specific treatment of ch oice.
The aim of CBT is to

1. Identif y and challenge misinterpretations
2. Substitution of realistic interpretation
3. Graded exposure to ill ness -related situations with response
prevention should be undertaken.
4. Modification of core illness -beliefs.
An RCT concluded that a six-session CBT intervention modestly but significantly improved a
range of hypochondriacal symptoms, beliefs, and attitudes at six and 12 months.
Medical: Antidepressants are certainly the second line treat ment of choice if
CBT fails or if there i s significant co -morbi dity. SSRI are recommended.
Antidepressants li ke fl uoxetine 20mg, increasing to 60mg, or i mipr amine up to
150mg are helpful, as most hypochondriacal symptoms in the gener al
population are secondary to depression.
Prognosis:
Prognosis of often poor, with indivuduals having chronic mild disbility for most
of their adult life.
Hypochondriasis often is refractory to treatment and improvement involved

better coping methods rather than cure.
Role functioning may improve as a functional outcome.
Reduced distress associated with beliefs rather than eradication of beliefs is the
primary outcome expected (Barsky et al 2004).
References
1 Warwick HM, Clar k DM, Cobb AM, Sal kovskis PM (1996) A cont rolled trial
of cognitive -behaviour al tre atment of hypochondriasis. BJP 169, 189- 95.
2. Oxford Handbook of psychiatry - Pg 748 -749.
TASK: HYPOCHONDRIASIS- HISTORY & DISCUSSION
305
Mr. Mark Powell presents with headaches and believes he has brain cancer.
Investigations by a neurologist including CT brain scan were normal.
Take a history of pain and associated symptoms. Obtain further history to arrive at a
diagnosis. You will be asked to speak to his girl friend in the next station.
Expanded construct: The candidate is expected to obtain clear history form the patient
to arrive at a diagnosis of hypochondriasis. They should assess the following areas;
History of presenting complaints- mode of onset, duration, progression of

symptoms, triggers
Pre-occupation and Information seeking behaviour (sources- internet, TV,

Magazines etc)
Seeking constant reassurance
Impact on current life (personal, social, occupational life)
Past medical history (anxieties about health in the past)
Personal and social history (childhood illness, parental illness, frequent medical
opinion seeking behaviour in parents)
Rule out co-morbidity (depression, anxiety, panic disorder, OCD, alcohol etc)
You have assessed Mr. Mark Powell already. Now speak to his girlfriend Miss. Jane
Moore about his diagnosis, management, and the impact on their relationship. Address
her concerns.
Expanded construct: The candidate is expected to explain the nature of illness and
discuss various treatment options available for the treatment of hypochondriasis.
They should discuss the following areas;
Explain possible diagnosis (Hypochondriasis- form of overvalued idea)
Explain nature of the problem with clinical presentation (featured by preoccupation

& rumination, constantly seeking reassurance despite negative investigation)
Address Concerns- need for further tests and investigation (not necessary)
Reason for seeking reassurance should be explained - (The resulting
306
medical reassurance provides temporary relief of anxiety, which acts
as a reward and makes further medical attention seeking more likely)
Treatment options (medical, psychological, social)- Antidepressants (Fluoxetine)

Emphasize aim to improve function.
CBT (principle and structure)- Identify and challenge misinterpretatio ns,

substitution of realistic interpretation, graded exposure to illness -
related situations, and modification of core illness -beliefs
Role of family members and education- Break cycle of reassurance and

repeat presentation (family education may help in t his)
GRIEF REACTION
307
Normal grief:
The classical symptoms experienced after bereavement which would include disbelief, shock,
numbness, and feelings of unreality; anger; feelings of guilt; sadness and tearfulness; pining or
searching, preoccupation with the deceased; disturbed sleep and appetite and, occasionally,
weight loss; seeing or hearing the voice of the deceased (Hallucinations of widowhood)
Usually these symptoms gradually reduce in intensity, with acceptance of the loss and
readjustment. A typical grief reaction lasts up to 12 months with an average duration of 6 months.
Abnormal grief:
It is also called as morbid or pathological or complicated grief. It is a grief reaction that is very
intense, prolonged, delayed (or absent), or where symptoms outside the normal range are seen:
e.g. preoccupation with feelings of worthlessness, thoughts of self-harm or suicide, excessive
guilt, marked slowing of thoughts and movements, a prolonged period of lack of ability to
function, hallucinatory experiences (other than the image or voice of the deceased).
The criterion for abnormal intensity is that the symptoms meet the criteria for a depressive
disorder. The criterion for abnormal duration is that the response lasts more than 6 months.
Areas to be explored:
Brief assessment of timing, onset of symptoms and course.
Depressive Symptoms with biological (poor sleep, lack of appetite) and cognitive sx (low
concentration, poor memory)
Behavioural Sx and emotional Sx
e. Pining or searching
f. Preoccupation with the deceased
g. Hallucinations of widowhood-visual/auditory
h. Feelings of guilt
Atypical Grief Reaction:

1. Prolonged duration and severity of symptoms- Lack of ability to function
2. Thoughts of self-harm or suicide
3. Mummification
4. Other Hallucinatory experiences apart from hallucinations of widowhood.
Likely Causes of abnormal grief:

1. Sudden and unexpected death of the deceased
2. Insecure survivor, Dependent or ambivalent relationship with the
deceased
3. Presence of dependent children and so cannot show grief easily
4. Presence of previous psychiatric disorder in the survivor
TASK: GRIEF REACTION- HISTORY TAKING
308
The GP has referred Mrs. White, 35-year-old woman whose husband died seven months
ago. She is not coping well following the death of her husband. Take an appropriate
history to assess whether this is normal bereavement reaction or determine if she has
features of abnormal grief reaction
Expanded construct: The candidate is expected to take an appropriate history to assess

whether this is normal bereavement reaction or determines if she has features of
abnormal grief reaction. They should try to obtain the following information during the
interview.
Assessment of feelings at the time of her husbands death,

Onset, duration, course of symptoms and impact
Assessment of current mood, biological,

Emotional and other Symptoms of depression
Features of normal grief reaction

a. Pining or searching,
b. Preoccupation with the deceased
Features of normal grief reaction

c. Feelings of guilt
d. Pseudo hallucinations of widowhood
Atypical grief reaction-features

a. Other hallucinatory experiences
b. Thoughts of self harm, suicide
Atypical grief reaction-features

c. Inability to function
d. Mummification
EMOTIONALLY UNSTABLE PERSONALITY DISORDER-BORDERLINE TYPE
309
Features:
Unstable mood and emotions- patient subject to episodes of depression elation only for a
shorter duration, which may mimic functional illness
Lack of self-control
Chronic feelings of emptiness
Unstable intense relationships- multiple, intense and abusive
Unstable self image (unclear aims and lack of clear goals in life ) and unstable sexual
preferences (often unclear or disturbed) leading to homosexuality and abnormal sexual
behaviour
Impulsivity including a series of suicidal threats or acts of self-harm and violence
Fear of abandonment and frantic efforts to avoid them
Quasi-psychotic or Dissociative symptoms in times of stress
TASK: BORDERLINE PERSONALITY DISORDER
Miss. Sarah Cohen is a 23-year-old woman who presented to the A&E with multiple
lacerations in both her legs. The nurses think that she has a personality disorder. Elicit
history to arrive at a diagnosis and perform risk assessment.
Expanded construct: The candidate is expected to obtain history and elicit symptoms
suggestive of borderline personality disorder and also perform appropriate risk
assessment.
Affective instability & Chronic feelings of emptiness
A pattern of unstable and intense Interpersonal relationships
Impulsivity & recurrent suicidal behaviour, gestures or threats,

(History of DSH), Inappropriate intense anger
Frantic efforts to avoid Real or imagined abandonment,
Identity disturbance; unstable Self-image or sense of self,

Lack of achievable goals, H/O abuse
Transient stress related paranoid Ideation or quasi-psychotic

experiences
Risk assessment
(Suicidal thoughts, plans etc)
310
BODY DYSMORPHIC DISORDER
Body dysmorphic disorder also called as Dysmorphophobia, is described as a subjective
description of ugliness and physical defect which the patient feels is noticeable to others
It is characterized by a preoccupation with an imagined defect in appearance, or if there is

a slight physical anomaly and the concern is out of proportion to the anomaly
It is an excessive concern (overvalued idea) about trivial or non-existent physical

abnormalities, which are perceived to be deformities. Here the patient is constantly pre-
occupied, convinced and tormented by abnormal belief that some part oh his/her body is
too large, too small or misshapen, which to other people, the appearance is normal or
there is a trivial abnormality
There is a spectrum of patients with overvalued ideas to those whose beliefs are held with
delusional conviction. Beliefs about deformity that are of delusional intensity are
classified under delusional disorders
The common complaints are about the nose, ears, eyes, eyelids, mouth, jaw, chin,
buttocks, penis, breasts, skin, hair but any part of the body may be involved. The
preoccupation is frequently focussed on several body parts simultaneously.
The assessment should involve exploring the nature of the pre-occupations with
appearance and of the ways in which this has interfered with personal, social life and
occupational or other important areas of functioning.
The affected person might think that other people notice and talk about his deformity and
therefore involve in elaborated grooming rituals to hide the perceived defect
They would get involved in time consuming behaviours such as re-examining, repeated
checking, mirror-gazing, excessive camouflage, comparison of features, skin-pricking,
reassurance seeking, avoidance of social situation. etc
BDD affects 1-2% of population. This condition usually begins in late adolescence and is
chronic with some fluctuations over time.
The prevalence is significantly higher (11.9%) among people who receive dermatological
care than those who dont.
It has a high degree of co-morbidity with mood disorders, OCD and social phobia. can
occur as part of other psychiatric disorders such as depression or schizophrenia, or may
be associated with social phobia or personality disorders
Screening questions for the diagnosis of body dysmorphic disorder
Do you currently think a lot about your appearance?

What features are you happy with?
Do you feel your features are ugly or unattractive?
How abnormal or noticeable do you think your features are?
311
On an average day, how many hours do you spend thinking about your abnormal
features?
Please add up all the time that your feature is on your mind and make the best estimate?
Does your feature currently cause you a lot of distress?
How many times a day do you usually check your features?
How often do you feel anxious about your feature in social situations?
Does it lead to you avoiding social situations?
Has your feature had an effect on dating or existing relationship?
Has your feature interfered with your ability to work or study?
(Adapted from psychiatry Journal March 06; pg 94)
Management;
The treatment of this condition is often difficult, as most patients lack insight and will not
accept psychiatric treatment or referral
Surgery is usually contraindicated and it is important to explain the lack of success of this
approach and suggest there are other effective treatments. Patients may seek plastic
surgery but the outcome is not good
Some patients will mutilate themselves in attempt to do their own surgery. Assess
patients for suicidal ideation, as the risk is high.
If there is co-morbid depression or psychosis, it should be treated in the usual way.
Good liaison with GP and cosmetic surgeons is extremely important to avoid un-
necessary and unhelpful surgery. Joint appointments may be extremely helpful to ensure
consistent advice. The help seeking behaviour of patients also need to be contained as
they may repeatedly try to consult other plastic surgeons, dermatologists and psychiatrists
etc.
Some patients are helped by reassurance and practical support
Serotonergic antidepressants may be effective in high doses and for long periods.
SSRIs are often helpful in patients with depressive symptoms. Drugs may be helpful
particularly when there are clear symptoms of depressive/ delusional beliefs
The NICE guidelines on BDD recommend Cognitive behavioural therapy (CBT) or
SSRIs as evidence based treatments.
TASK: BODY DYSMORPHIC DISORDER- HISTORY TAKING
You are seeing Miss. Sarah White, a 27-year-old lady who has seen her GP complaining
that her eyes are wide apart. Obtain history to explore the nature and extent of her
problems. Assess her to clarify her diagnosis.
Expanded construct: The candidate is expected to elicit psychopathology suggestive of

body dysmorphic disorder and cover following important points during the interview.
Nature and description of presenting problems
312
(Onset, duration, and severity), and impact on normal functioning
(Personal, social and occupation)
Assess the strength of Beliefs and degree of conviction (overvalued ideas/

delusional),
Look for any other abnormal beliefs
Avoidance Behaviour-Social situations, social withdrawal,

Lack of self confidence etc
Compulsive habits & behaviour- Mirror gazing, Repeated checking and

elaborated Grooming rituals
Risk assessment:
1. Suicidal ideation
2. Risk of actually performing surgery themselves
3. Risk of unwanted tests and investigations

Rule out co-morbidity-Depression, social phobia, schizophrenia
POST CONCUSSIONAL SYNDROME
313
Post concussional syndrome is the commonest psychiatric disorder following head injury.
It occurs following head trauma, usually sufficiently severe to result in loss of
consciousness
Since this syndrome often occurs after mild head injury, it has been suggested that it is
psychologically based. The duration and severity of symptoms are highly variable
The symptoms would include headache, fatigue, dizziness, irritability, increased
sensitivity to noise, anxiety, depression, mild cognitive impairment leading to impairment
of memory, insomnia, sleep disturbance, reduced tolerance to stress and possibly sexual
dysfunction
It is also accompanied by feelings of anxiety or depression, resulting from loss of self-
esteem and fear of permanent brain damage and Hypochondriacal symptoms are not
uncommon.
Some of them embark on a search for diagnosis and cure and may adopt a permanent
sick role
These complaints are not necessarily associated with compensation motives
It generally resolves following mild or moderate head injury but persists indefinitely in a
small proportion of patients with severe head injury
SOMATOFORM PAIN DISORDER
314
This condition is characterised by patients with chronic pain that is not caused by any
physical or specific psychiatric symptoms
Specific pain syndromes include headache, facial pain, backache and pelvic pain.
Here pain is the predominant focus of presentation. A full description of the pain and the
circumstances in which it occurs should be explored.
Psychological factors may have an important role in onset, severity and exacerbation.
Assessment should involve beliefs about the causes of pain and its implications, pain
behaviours including the presentation of symptoms, requests for medication and
responses to pain should be explored.
The pain is of sufficient severity to cause distress or impairment of social and
occupational functioning.
The consequences of chronic pain like secondary insomnia and physical inactivity should
be enquired into.
It is important to enquire any symptoms suggestive of depressive or other psychiatric
disorder and rule out possible physical causes through appropriate examination and
thorough investigation.
In common with the other somatoform disorders there is substantial overlap with major
depression (-40% in pain clinic patients) and anxiety disorders.
In summary, the assessment should involve the following; History from patient and
informants, length of history, relationship to life events, experience of illness, family
attitude to illness, periods of employment, treatments, beliefs about cause and co morbid
psychiatric symptoms.
TASK: SOMATOFORM PAIN DISORDER
Mrs. Lewis was referred by his GP to your outpatient clinic for psychiatric assessment.
She is not happy about it as she thinks that she suffers from severe chronic pain and there
is nothing wrong with her mentally. Obtain history to arrive at a diagnosis
Expanded construct: The candidate is expected to obtain history to arrive at a diagnosis

of somatoform disorder.
Full description of the pain and the circumstance in which it occurs (onset,
Duration, frequency, severity, aggravating & relieving factors)
Pain behaviour- verbal & non verbal behaviours including the presentation of
symptoms, requests for medication, responses to pain,
Beliefs about the causes of pain and its implications
Role of psychological factors in maintenance and exacerbation
Significant distress or impairment of social, occupational and family

functioning
Consequences of pain- secondary insomnia, inactivity etc
Appropriate examination and thorough investigation of, possible physical

causes.
315
Rule out co-morbidity- depressive disorder or other psychiatric disorder
TRAUMATIC BRAIN INJURY (FRONTAL LOBE INJURY)

Damage to the frontal lobe usually results in profound changes in personality which
broadly fit into categories of disturbed mood, poor judgement and impaired social
awareness and motivation
Personality changes are characterised by disinhibition with reduced social awareness and
control, loss of finer feelings and sexual indiscretions.
Depression and anxiety are common. Mood changes include periods of irritability,
elevated mood (fatuous, childishness making jokes and performing pranks) and can also
present with apathy, loss of spontaneity, drive and motivation, catastrophic response
(inability to adapt to the unexpected) leading to agitation and aggression
Errors of judgement with decreased abstracting ability, impaired attention &
concentration, difficulties in planning and problem solving is not uncommon
Other features include perseveration of speech and movements, repetition of phrase and
sentences, decreased articulation, sparse speech and decreased verbal fluency
The bedside tests that are sensitive to frontal lobe dysfunction would include verbal
fluency, inability to interpret proverbs and movements requiring co-ordinated series of
actions
TASK: ORGANIC PSYCHIATRY- TRAUMATIC BRAIN INJURY
TASK: PART-A: Mr. Benjamin Jones had suffered head injury two years ago and was
treated in the hospital for memory problems. Initially, he improved quite rapidly but this
began to plateau and his wife Mrs. Sherlie Jones feels that there has been little change
since then. She has noticed significant change in his behaviour and personality recently.
He has now presented to the A&E with his wife. Take a history of personality change
from his wife and obtain other relevant information.
Expanded construct: The candidate is expected to take a detailed history of personality

change from his wife following head injury. They should explore;
Reasons for presentation to A&E

Exploration of current problems - Onset, duration and progression, impact
on normal functioning
Personality changes-
(Disinhibition with over familiarity, childish excitement, lack of motivation,
lack of initiative, slowing of thought and behaviour, perseveration)
Behavioural changes-
(Impulsivity, Irritability, anger outbursts, withdrawn,
Agitation, aggression etc)
Cognitive symptoms- Memory dysfunction, Poor recall and recognition,
Language-Limited vocabulary, Difficulties in planning and problem solving,
316
Impairment in ADL skills
Psychological symptoms
(Apathy, flattened emotions, depression, emotionalism, lability)
Risk assessment: Self-neglect, aggression/ violence, Exploitation
LINKED STATION- PART B

Mr. Jones has reported problems with his memory, and there has been a change of his
personality since then. Perform detailed cognitive examination based on your findings.
Do not take history
Expanded construct: The candidate is expected to Perform detailed cognitive

examination based on findings in history. They should test the following areas of
cognitive domains.
Attention, concentration, calculation

(WORLD backwards, months of the year backwards, serial 7s)
Short-term memory- Registration, retention and recall

(3-item recall or 7 item name and address (for younger people)
Working memory (Forward span 7 2, backward span 52)

Episodic (autobiographical)
Semantic memory (personal events, Public events)
Naming, repetition and Comprehension (three stage commands)

Reading, writing, Copying (three dimensional figure)
Frontal executive function

(Verbal fluency-F, A and S )
Frontal executive function

(Cognitive estimates, similarities, proverbs)
Fist-Edge-Palm test, Go-no-Go test

Alternating sequences, primitive reflexes
BREAKING BAD NEWS
317
Ensure that you are up to-date on all the latest information about the disease condition
itself and the current condition of the patient before breaking the news
Suggest that family members, carers or friends come along to support and invite other
members of the multidisciplinary team who are involved in the care of the patient.
Begin with introduction and context. It is also useful to make some ice breaking
comments.
Establish what is already known. Set the scene and give a warning shot (I am afraid I
have some bad news)
Try to use simple jargon free language to describe events, giving bite-sized chunks of
information
Allow time for the news to sink in, long silences may be necessary and try not to fill them
because you are uncomfortable.
Allow time for emotional reactions and reassure in verbal and non-verbal ways that this is
an acceptable and normal response.
Do not be afraid to show your own emotions whilst maintaining professionalism and
strive for genuine empathy.
Encourage questions, clarify understanding if possible
Discuss about the different treatment options available, possible prognosis and the
involvement of multidisciplinary team members and the different types of support
available
TASK: BREAKIND BAD NEWS
Mr. Green is a 78-year-old gentleman admitted to the psychiatric unit 3 days ago with a
history of acute confusional state. He was living independently until 3 months ago when
he began experiencing episodes of confusion and cognitive problems that were rapidly
worsening.
CT brain scan was taken and it showed a large tumour mass with a central necrosis in the
left temporal region and secondaries in the right parietal region. The bloods and chest X-
ray were fine.
Discuss CT results with his daughter Mrs. Patricia Green and address her concerns
Expanded construct:
Ice breaking non-medical comments

Begin with introductions and context
Establish what is already known

Set the scene; give a warning shot
Management of interview including empathic responses,

Allowing time for the news to sink in,
Allow time for emotional reactions
318
Listening & responding appropriately to interviewee,
Reassure in verbal and non-verbal ways, body language.
Communication- Use of simple jargon free language to describe

Avoiding false information and false reassurances
Professionalism- Show your own emotions whilst maintaining professionalism
Discuss about treatment options

(Surgery, radiotherapy, chemotherapy etc) and prognosis
Involvement and support from the Medical team, palliative care team and
Multidisciplinary team, Mac Millan nurse etc
Summarize and clarify Understanding, Check that the recipient has understood the
information given
Encourage Questions
Demonstrate advanced listening skills

Ability to give balanced, factual information
Give information in a structured, focused and fluent manner
319
MYOCARDIAL INFARCTION AND DEPRESSION
It has long been recognized that psychological factors and psychiatric illness affect the
course and outcome of coronary heart disease (CHD)
In patients receiving hospital treatment for CHD, the prevalence of major depression is
13% to 23%. Evidence obtained from prospective studies suggests that major depression
may be an independent risk factor for the development of CHD after controlling for life
style factors. There is some evidence that depression is a risk factor for cardiovascular
morbidity and mortality in patients with coronary heart disease
20% of patients with coronary heart disease have co morbid depression

Patients who have persistent depression, despite treatment, may be at increased cardiac
risk.
Following an acute Myocardial infarction, major depression has been demonstrated to
be a predictor of mortality in the first 6 months with an effect equal to that of a
history of previous infarct.
A number of mechanisms have been suggested;
i. Depression may interfere with adherence to recommended management

such as cardiac rehabilitation and smoking cessation
ii. Altered serotonin function in people with depression makes them more
vulnerable to serotonin mediated platelet activation, subsequent
vasoconstriction and thrombosis
iii. Abnormalities of autonomic regulation mediated by depression may lead
to alterations of resting heart rate and heart rate variability, which
increases the risk of ventricular arrhythmias.
There is now substantial evidence for the safety of SSRIs in IHD and MI. The largest
randomized trail to date compared Sertraline with placebo in patients developing
depression within 30 days of an infarct.
Sertraline was not only found to be safe and effective but the study found a trend towards
fewer subsequent cardiac events in those treated with the antidepressant.
The Sertraline Antidepressant Heart Attack Randomized Trial (SADHART) is to date the
largest randomized trial evaluating use of an antidepressant medication for depressed
patients with heart disease.
o Sertraline vs placebo 16-week trial.
o no difference in safety (change in left ventricular ejection fraction, increase in
premature ventricular contractions, or prolongation of the QT interval) between
the treatment and placebo groups
o A nonsignificant reduction in the composite end point (MI or CHD death) in the
Sertraline group (relative risk, 0.77; 95% confidence interval, 0.51-1.16).
o SSRIs may be directly cardio protective by reducing platelet activation.
o But there was little difference in depression status between groups receiving
Sertraline and placebo after 24 weeks of treatment. However, the effect of
Sertraline was greater in the patients with severe and recurrent depression.
So far, however, only two clinical trials have been conducted to determine whether
320
treating depression reduces the risk for cardiac events following a recent acute
myocardial infarction:
o the Enhancing Recovery in Coronary Heart Disease (ENRICHD) study
o the Myocardial Infarction and Depression Intervention Trial (MIND-IT)
o In the primary analyses, both the ENRICHD and MIND-IT interventions had
only modest effects on depression and neither of them improved survival
Developing good habits and Life-style changes
Avoid stressful work and take regular breaks at work

Learn to relax This can involve learning methods of progressive relaxation, or simply
setting aside time when you are not working to relax with a long bath, a quiet stroll,
listening to music.
Avoid tobacco and recreational drugs. Caffeine and alcohol should be used only in
moderation.
Encourage Sleep Hygiene
Encourage physical activities, exercise and day time activities: regular exercise helps
reduce levels of stress. It will also keep you fit, helps prevent heart disease, and improve
quality of sleep.
Relaxation
Distraction: Finding a pursuit (sport, hobby or music) that has no deadlines and no
pressures and not work-related can allow you to forget about your usual stresses.
Support from family and friends: Utilise other sources of help and advice both informal
(friends, family, self-help books) and formal.
Organizing your own medical care
References:
Van Melle, J.P. et al (2007) Effects of antidepressant treatment on long-term depression

status and cardiac prognosis in depressed MI patients. British Journal of Psychiatry, 190,
460-466
Glassman A H, O Connor C M, Califf R M et al. Sertraline treatment of major depression

in patients with acute MI or unstable angina, JAMA 2002: 288:701-09
Psychiatry and medicine Journal; pg 90-92 (Angharad Rutley, Steven Reid)
321
TASK: POST-MI DEPRESSION (HISTORY TAKING AND DISCUSSION)
You are seeing Mr. Simon Warner, a 53-year-old gentleman who is on a cardiac
rehabilitation programme after suffering a myocardial infarction. He has been feeling low
for the past few weeks. Elicit history to establish diagnosis. Take a social history and
assess him particularly looking at his understanding and attitudes to his illness. In the
next station, you will discuss the management with the consultant.
Expanded construct: The candidate is expected to elicit history to establish diagnosis of

post-MI depression. Take a social history and assess him particularly looking at his
understanding and attitudes to his illness
Assess recent circumstances leading to hospitalisation

(MI, IHD, Cardiac rehabilitation programme)
Assess- Symptoms of depression (low mood, biological Symptoms,

Depressed negative thoughts etc)
Assess understanding and attitude to illness

(Denial, casual attitude, not serious on life style changes, poor engagement
etc)
Significant Social history (supportive wife, full time physical teacher)

And Work related stress
Life style changes (smoking, alcoholism, diet, exercise, coping stress,

Non compliance to medications etc)
PAIRED TASK IN THE LINKED STATION (PART-B)
Discuss your findings and treatment plan with consultant including medical and non-
medical management strategies for this patient.
Expanded construct; The candidate is expected to discuss their findings and treatment
plan with consultant including medical and non-medical management strategies for this
patient They should discuss the following areas;
Summary of findings from history

Able to give a case formulation,
Views about patients understanding and attitude to illness
Discussion
a. Prevalence of depression in IHD (20-25%)
b. Mortality rate-2-6 times higher mortality rate post MI.)
322
Antidepressant choices
Post MI depression- treatment with SSRI (Sertraline), SADHART Trial
Discussion about Tricyclic antidepressants and venlafaxine and explain the

rationale behind not using them now
Life style modification (Avoid alcohol, cessation of smoking, avoid stress,

relaxation, good sleep, balanced diet, regular exercise, compliance with
medications etc)
Other input (psychological treatments like CBT, counselling about life style
changes & and perhaps involving a Dietitian for advice on healthy eating)
323
ASSESS CAPACITY
CAPACITY ASSESSMENT
Assessment of competence of adult patients in order to have the capacity to give consent to
treatment, an individual must be able to understand.
Nature of the problem and proposed treatment.
Pros and cons of having the proposed treatment and the consequences of not receiving the
proposed treatment.(If not known explain the procedure, risks, benefits and common side
effects)
Whether the patient has the cognitive ability to understand the information, believe the
information, Retain the information and weight up the information and come to a
decision.
Assess other factors which may interfere with capacity (i.e) mental illness
MENTAL CAPACITY ACT
The Act defines capacity as follows;

An adult can be considered unable to make a particular decision if;
He or she has an impairment of or disturbance in the functioning of the mind or brain,
whether temporary or permanent
AND
He or she is unable to undertake any of the following steps

Understand the information relevant to the decision
Retain that information
Use or weigh that information as part of the decision making process
Communicate that decision made (by talking, sign language or other means)
When trying to assess capacity, try to explore the following;

The nature of the problem and proposed treatment
Why someone has said that he/she needs it
The treatments principle risks and benefits
Patients ability to retain this information and make a reasoned decision
The consequences of not receiving the proposed treatment.
Whether he or he has an impairment or disturbance in the functioning of the mind or brain
Patients reasons for refusing treatment.(in this scenario)
Task: ASSESS CAPACITY TO REFUSE TREATMENT
Miss. Franklin was admitted to the medical ward following acute GI bleeding and your
medical colleagues wanted to investigate it and treat her further. The medics called you
because she is refusing IV fluids, medications, sedatives and upper GI endoscopy. She is
known to have past psychiatric history and is on depot injection. The medics wanted her
to be assessed by the psychiatrist to determine whether the patient has the mental capacity
to refuse treatment.
324
Expanded construct: The candidate is expected to determine whether the patient has
the mental capacity to refuse treatment and also identify if there is any evidence of
impairment in her mind or brain
They should be able to ascertain whether the patient has;
Abnormal Mental state exam findings: Look for delusional ideas, paranoid beliefs,
other Psychotic/Mood symptoms/any evidence of Impairment of disability of mind
or brain
Ability to Understand information relevant to the decision-nature and Purpose of

treatment
Ability to retain information for a sufficient length of time to make decisions
Use or weigh the information as part of the decision making process (Benefits and
risks of the various treatment options, alternatives and identify the choices available
to the patient)
Consequences of accepting or refusing proposed treatments,

Communicate the decision and maintain choices
Inform patient that the best Possible decision not made
Make sure you explore all the areas by asking relevant questions given below;
The nature of the problem and proposed treatment

Tell me what you understand about the nature of the problem?
Tell me what is your understanding about the treatment that has been planned?
Why has someone said that he needs it?

Why do you think that you need an operation/ procedure?
Why do the surgeons think that you need an operation/ procedure?
The treatments principle risks and benefits and the consequences of not receiving the
proposed treatment/ procedure
The patients understanding of the risks of the procedure

Have you been told about the risks of having the operation/ procedure?
Do you think that it might be painful/you may die?
The patients understanding of the risks of not having the procedure

What do you think will happen if you are not having this procedure?
Do you think that you will get better if nothing is done?
Can you tell me the pros and cons of the operation/ procedure?
325
Note: If the patient does not understand the relevant information then clarify it with the patient,
address his queries, offer clear explanation and give the information in simple, clear terms and
then assess whether he had understood it.
Does the patient believe the above information?

1. Do you believe there is a problem in your tummy?
2. Do you believe that if the swelling is not operated on, it may burst and cause major problems
and that you could even die?
Ascertain the final decision

Tell me why you have decided to refuse the operation?
Rule out psychotic symptoms/mood symptoms and ask for any disturbance in thinking or
having any unusual experiences
Assess if the patient has been attentive throughout the interview, could understand and believe
the relevant information.
If the patient has the capacity to make the decision, explain to the patient what you have
decided and express your concern that the patient had not made the best possible decision (if
the patient still refuses to have the operation).
Address the patients concern about being sectioned

Explain to the patient that the Mental Health Act (1983) is to ensure the safety, protection and
treatment of people with mental illness and that we can section someone only for treatment of
mental health problems and not for physical health problems.
Following the assessment, If there is no clear evidence of mental illness, then explain to the
patient that he is not mentally ill and that he/she is not sectionable at the moment.
However,
Suggest to the patient that it is important to fix an appointment with the surgeon, anaesthetist
and the staff in the ward to discuss the issue again in the near future.
Explain that the surgical team will ask the patient to sign a discharge against medical advice
form
Explain that although the patient is free to make the decision, it is contrary to the advice of the
medical and surgical team.
Note: Candidate should offer to come back and reassess the patient at a later time/date to establish
consistency of thinking and decision making.
326
TASK: CAPACITY ASSESSMENT OF CARE NEEDS
PART-A: You have been asked to assess Mr. Donald Bateman who has a diagnosis of
dementia, have dementia, recently been admitted to hospital following a heart attack.
The family and the hospital staff have suggested that he should have more support at
home to help him cope, which he has refused. You have refused this. You have been
asked to assess his mental capacity to make such a decision.
Expanded construct: The candidate is expected to determine whether the patient

has the mental capacity to refuse care needs and also identify if there is any evidence of
impairment in her mind or brain
They should be able to ascertain whether the patient has;
Abnormal Mental state exam findings: Look for delusional ideas, paranoid beliefs,
other Psychotic/Mood symptoms/any evidence of Impairment of disability of mind
or brain
Ability to Understand information relevant to the decision-nature and Purpose of

having care package whilst at home
Ability to retain information for a sufficient length of time to make decisions
Use or weigh the information as part of the decision making process

(Benefits of having care at home and risks involved in refusing care, and explore
alternatives available to the patient)
Consequences of accepting or refusing proposed care,

Communicate the decision and maintain choices
Inform patient that the best Possible decision not made
PART-B: RELATED TASK IN THE LINKED STATION
You have now assessed his capacity. Now discuss with his son Mr. Antony Bateman,
your findings and the outcomes of your assessment. Address his concerns and queries .
327
Expanded construct: The candidate is expected to discuss the outcomes of his/her
capacity assessment of needs and discuss the importance of making decisions based on
patients best interests.
Explain the findings of capacity assessments for his care needs

(capacitous/incapacitated) and outcome
Explain how you assessed patients decision making ability (capacity) and what
conclusion they reached
Address concerns by carer (If anything can be done to help him make decisions, and
if this would be likely to work)
Emphasise - Decisions should be taken based on best interests of the patient (If
patient lacks capacity and making unsafe decisions with lack of awareness of risks
involved)
Address concerns- Is it legal to go and provide care against their wishes
Check list for determining best interests; (this includes taking into account the
persons past and present wishes (in particular, any relevant written statements
made by the person when capacity was present), the persons beliefs and values and
views of anyone involved in the care of the person and any donee of a lasting power
of attorney)
Address Concerns- Does he/she lacks capacity to make any decisions about his life
and care? (Capacity is decision- specific)
328
Mental Capacity Act 2005 - summary
(Adapted from5)
The Act will generally only affect people aged 16 or over and provides a statutory framework to
empower and protect people who may lack capacity to make some decisions for themselves, for
example, people with dementia, learning disabilities, mental health problems, stroke or head
injuries who may lack capacity to make certain decisions.
The Act deals with the assessment of a persons capacity and acts by carers of those who
lack capacity (came into effect in October 2007):
It makes it clear who can take decisions in which situations and how they should go about this. It
enables people to plan ahead for a time when they may lack capacity. The Act will cover major
decisions about someones property and affairs, healthcare treatment and where the person lives,
as well as everyday decisions about personal care (such as what someone eats), where the person
lacks capacity to make the decisions themselves.
Five key principles
A presumption of capacity every adult has the right to make his or her own decisions
and must be assumed to have capacity to do so unless it is proved otherwise;
Individuals being supported to make their own decisions a person must be given all
practicable help before anyone treats them as not being able to make their own decisions;
Unwise decisions just because an individual makes what might be seen as an unwise
decision, they should not be treated as lacking capacity to make that decision;
Best interests an act done or decision made under the Act for or on behalf of a person
who lacks capacity must be done in their best interests;
Least restrictive option anything done for or on behalf of a person who lacks capacity
should be the least restrictive of their basic rights and freedoms.
The Act deals with two situations where a designated decision-maker can act on behalf of
someone who lacks capacity:
Lasting Powers of Attorney (LPAs) The Act allows a person to appoint an attorney to act on
their behalf if they should lose capacity in the future. This is like the current Enduring Power of
Attorney (EPA) in relation to property and affairs, but the Act also allows people to empower an
attorney make health and welfare decisions.
EPA is enduring power of attorney. An EPA is a legal process in which you, the donor gives, the
legal right to one (or) more people the Attorneys to manage your financial affairs and your
property. Make sure that the donor understands the nature of power she is donating. The
lasting power of attorney remains effective, even when the donor becomes mentally incapable,
providing the necessary steps are taken.
Applying more that one attorney may reduce the risk of exploitation
329
Court appointed deputies The Act provides for a system of court appointed deputies to
replace the current system of receivership in the existing Court of Protection. Deputies will be
able to be appointed to take decisions on welfare, healthcare and financial matters as authorized
by the new Court of Protection but will not be able to refuse consent to life-sustaining treatment.
The Act creates a new public body and a new official to support the statutory framework, both
of which will be designed around the needs of those who lack capacity:
A new Court of Protection- Cop is an office of the Supreme Court with jurisdiction in
England and Wales. Its function is to protect the finances and property of people who are
mentally incapable of dealing with their own affairs.
A new Public Guardian
The Act also includes three further key provisions to protect vulnerable people:
Independent Mental Capacity Advocate (IMCA)

Advance decisions to refuse treatment
A criminal offence
Mental Health Act

The mental health act is to ensure the safety, protection and treatment of people with mental
illness.
Detention of a patient to the hospital under the MHA will be considered
A. The patient is suffering from a mental disorder of a nature or degree that warrants in
hospital for assessment or assessment followed by medical treatment.
B. He or she ought to be detained in the best interests of the patients own health or safety or
with a view to the protection of other people.
Doctors holding power: Under doctors holding power or section 5(2) of the mental health act,
you can be kept in the hospital for 72 hours. This means that the doctor who assessed you thinks
that you need to be in hospital.
You must not leave the hospital premises during this time unless a doctor tells you that you may.
If you try to leave, the nurses can stop you and if you leave, you can be brought back.
During this period of 72 hours (three days and nights), you can be seen by two doctors and an
approved social worker. If this did not happen by the end of 72 hours, you will be free to leave
but you may also decide to stay on as a voluntary patient.
What happens after that?
When you are assessed by the second doctor, he or she may say that you need to stay in the
hospital for a longer time. The doctor will tell you why and for how long it is likely to be.
If the doctor decides that you do need to stay, then the social worker will discuss with you about
what other help you should have whilst you go home.
330
Appeal: You cannot appeal against the decision to detain you in hospital under doctors holding
power or section 5 (2) of the MHA.
The doctor (we) will tell you about any treatment he thinks you need. However, you have the
right to refuse treatment if you wish to. You can be given treatment against your wish only under
exceptional circumstances.
Section 2 of MHA or Admission to hospital for assessment: You can be kept in the hospital for
28 days. This means that the doctor who assessed you thinks that you need to be in hospital and
you may be given treatment during this time.
However, when he or she becomes better, we start with increasing period of leave authorised by
the responsible medical officer.
During this period of 28 days, the doctor will decide whether you should stay for a while longer
than 28 days and if so, you will be placed under section 3 or admission to hospital for treatment.
You can ask the hospital managers to let you leave the hospital. Your nearest relative can also
write to the hospital managers. It usually takes 72 hours for them to look at the request and during
this period, they can get a report from your treating doctor.
You can also write to the mental health review tribunal for your discharge. If you wish to do so,
you must write to them within the first 14 days after your admission to hospital and the hearing
will be arranged within the following 7 days.
Discharge: By any of the following;

RMO
Hospital managers
The nearest relative who must give 72 hours notice. The RMO can prevent him or her
discharging a patient by making a report to the hospital managers
MHRT-within 14 days of detention
Section 3 of MHA or Admission to hospital for treatment: Under this section, you can be kept
in the hospital for up to six months. This means that the doctor who assessed you thinks that you
should be admitted to hospital for medical treatment of your mental health condition.
During this period of 6 months, the doctor will inform you when he thinks that you are well
enough to leave hospital. If the doctor thinks that it is necessary for you to stay longer than 6
months, it will be discussed towards the end of six months.
You can write to the mental health review tribunal for your discharge. Your nearest relative or the
person presently exercising the nearest relative functions is also entitled to apply.
331
Treatment: For the first three months, you can be given medicine or drug treatment for your
mental disorder. If you need treatment beyond this period and if you do not or cannot consent,
then an independent doctor will be requested to visit the patient. The independent doctor is also
called as second opinion approved doctor (SOAD). He or she is appointed by the mental health
act commission and is independent of your hospital.
Following assessment by the independent doctor, if he/she agrees you should have it, then the
treatment will be continued.
Discharge: By any of the following;

RMO
Hospital managers
The nearest relative who must give 72 hours notice.
MHRT- If you wish to do so, you can apply any time within the first six months while
you are kept in the hospital. You may reapply if you are kept in hospital for a second six
months and once every year you are kept in hospital after that.
Mental Health Review Tribunal (MHRT): This is an independent judicial body which reviews
the need for the continued detention of patients in the hospital. The tribunal will consist of a
lawyer, who also acts as the chairman or president, a psychiatrist and lay person. It will be held
usually in the hospital where you are detained.
Legal representation is available to anyone who has applied for a mental health review tribunal.
The hospital usually has the list of solicitors who specialise in these matters or you can contact
any other solicitor who you think would be able to assist you.
Physical illness: MHA cannot be used to treat physical illnesses. However, in conditions like
delirium (when a physical disorder gives rise to psychiatric conditions), eating disorders (
psychiatric disorder leading to physical complications) and when patients are on Clozapine
treatment, when the treatment of a mental health condition necessitates regular blood monitoring,
in all these special situation MHA could be applied.
Mental Health Act Commission (MHAC): The mental health act commission safeguards to
ensure good practice. They regularly review to see how hospitals are using the act by making
visits to interview detained patient in the hospitals. They also appoint medical practitioners to
give second opinions under the act.
332
Supervised community treatment (SCT):
SCT is specially designed to support patients with a history of non compliance and revolving-
door patients who are caught up in a cycle of relapse and readmissions.
Others may be patients who, during a period of detention in hospital, are identified by their
responsible clinician (RC) as needing the support and structure which SCT offers, to pre-empt
release in the community and avoid further lengthy admission to hospital under the CT.
Therefore SCT offers a chance for re-establishing their lives in the community with support and
monitoring of the team which works closely with them.
Criteria which must be met before a community treatment order is made (CTO)
The patients is detained under section 3 of the mental health act for treatment or an
unrestricted order
The patient is suffering from a mental disorder of a nature or degree which make it
appropriate for the patient to receive medical treatment
It is necessary for the patients health and safety, or for the safety of other persons, that the
patient should receive treatment
Subject to the patient being liable to be recalled, such treatment can be provided without
the patient continuing to be detained in a hospital
It is necessary that the responsible clinician should be able to exercise the power to recall
the patient to hospital
Appropriate medical treatments is available for the patient
(Adapted from Supervised community treatment; A guide for practitioners- Oct 2008)
333
PSYCHOTROPIC MEDICATIONS
Routine questions:
The name of the medications and the reasons for using it

When and how to take it
The most likely side effects, those unlikely but important and what to do if they occur
How to know if it is effective
How long to continue taking it?
The risk of stopping it.
Whether other medications can be taken at the same time
Whether other remedies alter the medicines effect
Whom to contact to check on any concerns about side effects
What food or drink e.g. alcohol should be avoided while taking the medication
SIDE EFFECTS OF MEDICATIONS
TYPICAL ANTIPSYCHOTICS-Sedation, hypotension, autonomic side effects like dry mouth,

constipation, blurred vision, urinary retention, impaired ejaculation, EPSEs like akathisia,
tremors, weight gain and ECG changes
ATYPICAL ANTIPSYCHOTICS
Olanzapine-drowsiness, dry mouth, constipation, hypotension, oedema, weight gain, impaired

glucose tolerance
Risperidone-insomnia, agitation, anxiety, headache, nausea, abdominal pain, weight gain,

sometimes EPSEs, increased prolactin levels causing amenorrhoea, galactorrhoea, loss of libido,
breast engorgement
Quetiapine- dizziness, drowsiness, postural hypotension, dry mouth, weight gain
Amisulpride-insomnia, agitation, nausea, constipation, increased prolactin levels causing

amenorrhoea, galactorrhoea, loss of libido, breast engorgement, osteoporosis)
Clozapine-dizziness, drowsiness, constipation, weight gain, hypersalivation, tachycardia, fever,

neutropenia/agranulocytosis, seizures
TRICYCLIC ANTIDEPRESSANTS- sedation, hypotension, autonomic side effects like dry

mouth, constipation, blurred vision, urinary retention, impaired ejaculation, weight gain, ECG
changes and arrhythmias
334
SELECTIVE SEROTONIN RE-UPTAKE INHIBITORS (Fluoxetine, paroxetine,
citalopram and sertraline) -Nausea, Vomiting, Dyspepsia, abdominal pain, headache, sweating,
anxiety, agitation, insomnia, sexual dysfunction
VENLAFAXINE-Nausea, headache, dry mouth, insomnia, dizziness, sweating, somnolence,

sexual dysfunction, elevation of blood pressure at higher doses.
MIRTAZAPINE- headache, nausea, dizziness, increased appetite, weight gain, drowsiness,

oedema.
LITHIUM-increased thirst, polyuria, polydipsia, nausea, vomiting, abdominal pain, muscular

weaknesses, tremors, weight gain, acne, hypothyroidism
CARBAMAZEPINE-drowsiness, ataxia, diplopia, nausea, hepatitis, rashes, blood dyscrasias
SODIUM VALPROATE- Headache, nausea, vomiting, sedation, hair loss, weight gain, ataxia,
blood dyscrasias.
ANTI-DEMENTIA DRUGS: Nausea, vomiting, insomnia, and diarrhea
335
CLOZAPINE
Clozapine is one of the newer antipsychotic drugs used to treat symptoms of
schizophrenia in people who have not done well on at least two other similar
drugs, e.g. who have not responded or who have had unpleasant side effects.
Dopamine is the chemical messenger mainly involved with thinking, emotions,
and behaviour. In schizophrenia, it may be overactive which helps to produce
some of the symptoms of the illness. The main effect that clozapine has is to
block some of the dopamine in the brain, reducing the effect of having high
levels, and reducing the symptoms caused by too much dopamine.
Blood tests: Clozapine can upset the blood of about two or three in every hundred
people taking it. It can reduce the number of white cells or neutrophils in the
blood. This makes it much harder for your body to fight infections. The patients
must, therefore, have regular blood tests for as long as you are taking this
medicine.
Monitoring: Regular blood testing is the main form of monitoring. You will have
a blood test every week for at least 18 weeks. After 18 weeks all your blood
results will be reviewed, and if all is well, testing may change to every second
week until the end of the first year of treatment.The risk of neutropenia
decreases after the first year of treatment. So if your blood tests have been
satisfactory, you should be able to transfer to testing every four weeks. Testing
will then continue every four weeks for as long as you are taking clozapine.
Some effects of clozapine, such as drowsiness, appear soon after taking it. The
most important action, helping to control the symptoms of your illness, may take
several weeks to months or even up to a year of regular medication to become
fully effective. In the same way, if your dose or treatment is changed, it may take
an equally long time before you notice the effects of such a change.
Duration of treatment: This is very difficult to tell, as peoples responses are
different. However, you will probably need to continue your treatment for several
years. Long-term treatment should be reviewed every three to six months or
336
sooner if there are problems. It is likely that you will benefit from clozapine by
taking it for many years.
Clozapine is not addictive.
It is unwise to stop taking clozapine suddenly, even if you feel better. Your
symptoms can return if treatment is stopped too early. This may occur some
weeks or even many months after the drug has been stopped and we call it
rebound psychosis.
Some of the common side effects are drowsiness, Constipation, hypotension,
Hyper salivation, fever and palpitations. To keep these unwanted effects to a
minimum, we will start you on a low dose and increase it slowly as well as
adjusting the dose depending on how you react. This way of tailoring medicines
to an individual is called titration.
One of the more serious side effects is that it can reduce the number of white cells
or neutrophils in the blood, resulting in a condition called neutropenia. This
makes it much harder for your body to fight infections. On higher dosage, it can
also induce a seizure or a fit.
Warning signs: If you think you have a cold, sore throat or any other infection,
tell your doctor or nurse immediately. They will arrange a blood test to check
your white cell count. If your white cell count is normal you should be able to
continue with your treatment, but your doctor will tell you if this is the case.
Some people feel the benefit of their treatment within a few days while other
people can wait from a few months to a year. Therefore, its important to be
patient and give your treatment a chance to work.
About 6 out of 10 people will benefit from taking clozapine. Some do very well
and others will be a bit better. Unfortunately, some people do not respond to the
medicine, but they will not be made any worse by trying it.
337
TASK: CLOZAPINE TREATMENT
Mr. Andrew Hill suffers from a relapse of his schizophrenic illness and is currently an
inpatient. He has been tried on several typical and atypical antipsychotics including
Haloperidol and Quetiapine.
He still remains psychotic, despite good adherence to Risperidone.
Your team has decided starting him on clozapine in the ward round.
Discuss about clozapine treatment with Mr. Hill and address his concerns and
expectations.
Expanded construct: The candidate is expected to discuss about clozapine

treatment, monitoring, side effects and address concerns expressed by the patient.
Explain the rationale for starting clozapine (treatment resistance)
Describe the process of initiation, Monitoring and duration of treatment

(Start on low dose, weekly bloods for 18 weeks, fortnightly bloods up to 52 weeks-
No Bloods, no Clozapine)
Rationale for blood tests

(Allay anxieties regarding Frequent Blood tests & needle phobia)
Describe common side effects

(Sedation, postural hypotension, constipation, hyper salivation, Weight gain etc)
Dangerous side effects- Agranulocytosis and seizures
Explain RISKS-
1.Neutropenia- if not monitored closely
2. Risk of relapse on stopping meds suddenly
Addressing other concerns

1. EPSEs
2. Weight gain
3. Drowsiness
338
LITHIUM TREATMENT
Lithium is a mood stabiliser. It is used in treating and controlling mood disorders
like depression and mania, especially when they keep coming back. It is also used
to increase the effect of antidepressant drugs when these are not working enough
on their own. Lithium tends to lead to fewer manic and depressive episodes or to
their disappearance.
Lithium is a substance, which occurs naturally in food and water. Small amounts
can therefore be found in the body.
Initiation: Before beginning lithium therapy, your doctor will need some
information that includes your medical history including heart disease, thyroid -
disease, kidney disease, psoriasis or epilepsy or any history of mental health
problems in your family, especially mania or depression. Also tell your doctor
about any medications you are taking, especially diuretic medications (water pills
used to treat high blood pressure), drugs used for asthma, painkillers, steroids and
antidepressants.
It may be necessary for you to undergo a number of tests to ensure that the
medication can be used safely, and these include Kidney function test, thyroid
function test and ECG
Blood tests: Once you have begun treatment, it will also be necessary to have
regular blood tests (sometimes called a lithium level, a serum lithium level or
a plasma lithium level). This test is important because it enables the doctor to
monitor the amount of lithium in the bloodstream, and therefore ensures that your
dosage is both effective and safe. Doses are adjusted to keep the blood level
within the range of 0.4 and 1.0 m mol per litre, which is considered to be the
appropriate therapeutic range to maximise benefits and minimise side effects.
Monitoring: Blood tests are needed more often in the early stages of treatment or
when your dosage is adjusted. In these circumstances, they may be needed at least
once a week. Once serum levels have stabilised, they will be needed only once a
month and even less frequently later. As a rough guide, blood tests should be
done at least every three months once serum levels have stabilised.
339
Caution: It is important to make sure that the body is provided with proper
amounts of salt and water is a very important part of lithium therapy. It is
important to maintain salt and water balance and also to avoid excessive loss of
both water and salt.
Side-effects: Like other drugs, lithium may cause adverse effects. Some are
relatively mild and occur during the initial adjustment period. These can happen
in the first few weeks after starting lithium treatment. Some of the early adverse
effects may include Feeling thirsty, Passing more urine than usual, Blurred vision,
Dry mouth, Bad metallic taste in the mouth, Slight muscle weakness, Occasional
loose stools and Fine trembling of the hands
Some of the long-term side effects are excessive weight gain, Changes in kidney
functioning, which may lead to damage, Reduced thyroid activity, shaky hands
and skin rash.
If the level of lithium in your blood is too high, you will experience Persistent
diarrhoea, severe nausea/vomiting, severe hand tremors, Blurred vision, Slurred
speech, Lack of co-ordination, Confusion and Frequent muscle twitching. In such
conditions, it may be necessary to stop taking lithium temporarily until your
physical health has returned to normal.
Response: This will vary from person to person. Depending on the course of your
condition lithium may prove necessary to prevent episodes of mania or depression
for the rest of your life.
It doesnt always work. Some people do not respond to lithium therapy and others
cannot tolerate it. Some may respond only partially, and may experience reduced
or less severe episodes of depression and mania. It may take six months to a year
to achieve a full effect as a preventive treatment.
Lithium Augmentation to current antidepressant- Initiation and monitoring
Detailed physical and neurological examination and arrange for appropriate

investigation: - (Pre lithium treatment work up)-FBC, U&E, TFT, ECG,
Renal function tests.
340
Discuss with the patient about the therapeutic effects, side effect profile and
discontinuation effects & also involve the family.
Monitoring
Start at 400 mg once daily, check plasma level after 5-7 days, 12 hours after dose,
then check plasma level every week until the required therapeutic level is reached
(0.4 0.6 m mol/L for recurrent depression).
Once stable, check, level once every 3-6 months, check renal function test &
thyroid function test and ECG every 6 months.
Provide the patient with lithium card, which should be, carried the entire time
and also provide patients information leaflet. (Basic information about lithium
and how to minimize the risk of toxicity).
Side effects: - Nausea, Metallic taste, diarrhoea, polyuria, polydipsia, Tremor, muscular
weakness.
Long Term side effects: Weight gain, hypothyroidism, impaired kidney function & rarely
renal failure, exacerbation of acne, ECG changes, diabetes insipidus (SIADH)
Lithium Toxicity: - Levels >1.5 m mol/L,

Vomiting, Diarrhoea, muscles weakness, drowsiness, coarse tremor, dysarthria ataxia,
restlessness, muscle twitching, seizures and death.
Prevention of lithium toxicity:

Ensure the importance of maintaining an adequate fluid balance.
Stop lithium immediately if toxicity suspected and Need to contact the GP if there is
Vomiting, Diarrhoea, Fever, and infection
Avoid over exercise, sunbathing, and salt free diet & avoid dietary changes).
Interactions Diuretics, NSAIDS, Haloperidol, ACE inhibitors, SSRIS, Carbamazepine

and alcohol.
Women of childbearing age should be advised to use reliable contraception.
Maintenance treatment 2-3 years (minimum) to be reviewed regularly,

and the risk of relapse may be reduced by decreasing the dose of lithium very gradually
(over a period of one month).
341
TASK: COUNSELLING-LITHIUM AUGMENTATION
Mr. Paul Williams is a 40-year-old gentleman who suffers from recurrent depressive
disorder. He has been tried on antidepressants with minimal success and is currently on
mirtazapine. Your team has decided to start him on Lithium for augmentation of
antidepressant effects. He would like to discuss with you to know more about this
medication. Address his concerns.
Expanded construct: The candidate is expected to discuss about lithium drug and the
purpose of augmentation. They should also emphasize the importance of monitoring,
explain side effects and address concerns of the patient. They should;
Explain the rationale behind Augmentation

Explain nature of the drug
Describe the monitoring and duration of treatment
Describe side effects- Short term & long term

Address concerns about Renal impairment
Explain Warning Signs of Lithium toxicity

When and how to stop it?
Discuss Risk
1.Risk of relapse on stopping medications
2.Ensure adequate hydration (Salt and water balance) - Holidays-avoid
sunbathing (dehydration)
Addressing concerns
3.? Addictive potential
4. Drinking alcohol to moderation
342
ECT COUNSELLING
ECT stands for electro convulsive therapy. ECT is most commonly used to treat
severe depression not responding to drug treatment. In severe cases of depression,
ECT may be the best treatment and it can be life saving.
It is not a barbaric treatment. Due to the advances in the field of anaesthesia and
with modern equipment, ECT has become more sophisticated and you may not
experience any pain or suffering.
The exact mechanism of how it works is not known. During ECT, a small
amount of electric current is passed across your brain. This current produces a
fit/seizure, which affects the entire brain including centres that control thinking,
mood, appetite and sleep. Repeated treatments alter the chemical imbalance in the
brain and bring them back to normal. This helps you begin to recover from your
illness.
An ECT treatment involves having an anaesthetic. The anaesthetist will ask you
to hold out your hands so you can be given an anaesthetic injection. It will make
you go to sleep and cause your muscles to relax completely. You will be given
some oxygen to breathe as you go off to sleep. Once you are fast asleep, a small
amount of electric current is passed across your head and this causes a mild
fit/seizure in the brain. There are little movements of your body because of the
relaxant injection that the anaesthetist gives.
Over 8 out of 10 depressed patients who receive ECT respond well, making
ECT the most effective treatment for severe depression.
A course of ECT involves 6 to 8 treatment sessions on an average and is usually
given twice a week.
Some patients may be confused and get headaches just after they awaken from the
treatment, and this generally clears up within an hour or so. Sometimes your
memory of recent events may be upset and this memory loss goes away within a
few days or weeks. But ECT does not have any long-term effects on your memory
or your intelligence.
ECT is amongst the safest medical treatments given under general anaesthesia;
the risk of death or serious injury with ECT is rare and occurs in about one in
343
50,000 treatments. This is much lower than that reported for childbirth. Very
rarely deaths do occur and these are usually because of heart problems..
ECT consent form: At some stage before the treatments, we will ask you to sign a
consent form for ECT. If you sign the form it means that you are agreeing to have
up to a certain number of treatments (usually 6). You can refuse to have ECT and
you may withdraw your consent at any time, even before the first treatment has
been given. The consent form is not a legal document and does not commit you
to have the treatment. It is a record that an explanation has been given to you and
that you understand to your satisfaction what is going to happen to you.
Withdrawal of your consent to ECT will not in any way alter your right to
continue treatment with the best alternative methods available.
ECT usually works more quickly than medication. But with regard to medication,
we could try yet another antidepressant drug. However, you may have to wait for
up to 6 to 8 weeks to know whether the new drug is effective, and there is the
possibility of new side effects. Drug therapy also has risks and complications and
drug treatment is not necessarily safer than ECT.
Concerns about memory loss; If there are serious concerns about memory
problems, instead of giving the electrical stimulus bilaterally across both temples,
we can give it unilaterally to just one side of the head.
TASK: ECT COUNSELLING
Mr. Smith has now been treated with fluoxetine 40 mg daily for 6 weeks and then
Venlafaxine 150 mg for 6 weeks, but has not improved. He did comply with these
treatments. Your team has decided that he is treated with ECT.
He has very little knowledge about ECT. You are asked to give the patient information
about ECT with a view of assisting him in deciding whether he is willing to agree to have
the procedure. Address patients beliefs, concerns and expectations about treatment.
Address his questions.
You are not required to assess his capacity to consent treatment.
Expanded construct: The candidate is expected to discuss nature and purpose of

treatments, number and duration of treatments, discuss efficacy and side effects, and
discuss alternatives.
344
Basic description of ECT/
Cover the rationale of ECT in refractory depression (Nature and purpose of
treatments)
Discuss what the procedure of ECT entails & ECT Work-up
Number and duration of treatments
Concerns
1. Barbaric treatment- not anymore
2. Risk of death and major injuries- very low
Discuss Potential benefits, efficacy (8 out of 10 get better)

Side-effects (headache, vomiting, dizziness, slight confusion,
Muscle aches, memory loss)
Consent issues
1. Not a legal form
2. Can withdraw consent-any time
Concerns
1. Memory loss-Unilateral ECT will be considered.
2. Discuss alternatives
Give them adequate time to decide

Discuss Sources of information (Leaflets, websites, talk to nurses etc)
345
ECT ADMINISTRATION
Suggested approach
Greet and introduce yourself.
Obtain permission before you proceed.
Check that it is the correct patient and confirm the identity of the patient.
Check documentation to see that the patient has consented and ECT consent form has been
duly signed, or if on a section of the Mental Health Act, appropriate forms have been filled
out.
Ask for consent again and briefly explain the procedure.
Check that the pre-ECT form has been filled in, with emphasis on nil by mouth for at least
6 hours prior to ECT
Check that the physical examination has been done prior to ECT, all necessary
investigations duly completed (FBC, U&Es, any other relevant investigation) and
anaesthetic opinion obtained.
Check the medical notes to ensure that the psychiatric team has seen her after the last
treatment to record progress and any adverse effects of ECT (if any after the last treatment)
Check the treatment card to check for current medications.
Check ECT machine is functioning properly and make sure that the appropriate dose has
been set up
Once the patient is anaesthetised the ECT electrodes should be placed accordingly and the
treatment is administered.
Apply electrodes to scalp and test for adequate contact between the electrodes and the scalp
before treatment.
Indicate the electrode placement for unilateral and bilateral ECT
During treatment, also observe the nature, type and duration of the seizures
Make sure that you have documented the current used, type and duration of seizures, any
complications that arose, in the medical notes and on the ECT form.
Make sure that the patient is taken to the recovery room accompanied by a nurse and the
vital signs are being monitored.
Comment on your findings to the examiner as well as the EEG interpretation.
Thank the examiner at the end and leave the station.
Electrode positions
Bilateral: 4 cm above the midpoint of the line between external auditory meatus and the lateral
angle of the eye.
Unilateral: First electrode is placed on the Nondominant side, 4 cm above the midpoint of the
line between external angle of the eye and the external auditory meatus. The second electrode is
placed 10 cm above the first, vertically above the meatus on the same side.
EEG interpretation
Look for the stimulus on the EEG record. The EEG usually develops patterned sequences
consisting of high voltage sharp waves and spikes, followed by rhythmic slow waves that end
abruptly in a well-defined endpoint.
346
SCHIZOPHRENIA COUNSELLING AND DICUSSION
DISCUSSION POINTS;
Schizophrenia is a common mental illness, which affects one person in a hundred.

It usually develops in the late teens or early twenties, although it can start in middle age
or even much later in life.
Symptoms may be described as positive or negative. These are divided into positive
symptoms, which are abnormal experiences like delusions and hallucination, and
negative symptoms, which indicate decrease or absence of normal behaviour.
No one as yet knows for sure what causes it.
There seem to be a number of different causes- chemical imbalance, genetic factors,
stress may act as a trigger and street drugs
It can be inherited.It means that if a close relative has it, and then your chance of getting
the illness is higher. Remember that it is not the illness itself that is inherited, but the
tendency to get the illness.
Is schizophrenia a split mind? There is a common idea that it means having more than
one personality or a split personality. This is untrue. People with schizophrenia have only
one personality although their personality may be disturbed in some way.
People who suffer from schizophrenia are rarely dangerous. They are no more
unpredictable than anyone else. Street drugs or alcohol usually sparks off any violent
behaviour. This is the same as for people who do not suffer from schizophrenia.
Research has proven that families cannot, and do not, cause schizophrenia.
There is no specific test for schizophrenia. Doctors diagnose schizophrenia when a
person displays a specific group of symptoms.
When a person becomes mentally ill, they are usually treated in the hospital for a further
assessment and diagnosis to be made. Afterwards, they can often be treated whilst living
at home, especially if they have a supportive family.
Drugs help to alleviate the most disturbing symptoms of the illness. However, they do
not provide a complete answer.
There are medications called antipsychotics that help to reduce the symptoms and the
anxiety associated with the symptoms. These are made up of chemicals that alter and
correct the chemical imbalance in the brain.
347
Medication is the mainstay of treatment for schizophrenia. We cant cure the illness
completely but we can control the symptoms.
All antipsychotic medication has a beneficial effect on the symptoms of schizophrenia,
but individual patients respond differently to different medication and may need
different doses to have the desired effect.
Some common side effects of antipsychotic medications include drowsiness, shakiness,
restlessness, muscle stiffness, increased appetite, weight gain, dry mouth and dizziness.
The good news is some of the newer medication does not have the unpleasant side effects
of restlessness, muscle stiffness, and shakes and is equally effective.
If an individual stops taking his/her medication against the advice of their doctor then the
chances of their having an attack of schizophrenia are more than doubled. For most
people, the symptoms usually come back in about six months after stopping medication.
We cant cure schizophrenia. We can only control the symptoms. Some people have only
one attack but many people will experience periods when the symptoms return these are
called relapses. A few sufferers will have symptoms all the time.
The medication controls the symptoms and promotes recovery, but it does not cure the
illness. The symptoms often tend to come back. This is much less likely to happen if the
person continues taking medication even when they feel well. For most people, the
symptoms usually come back in about six months after stopping medication. A small
number of people are able to stop medication with no ill effects. Most people, however,
need to take maintenance therapy indefinitely, to prevent relapse. For the best
outcome, everyone involved, including the person, the family, the community psychiatric
team and others need to work together from an early stage.
The illness is likely to affect studies, work and social life. However, many people with
schizophrenia live independently, and more and more people are able to work and to have
families.
Ways of helping somebody with schizophrenia-By encouraging the person to take their
medication, trying to reduce stressful events, supporting the individual by encouraging
them to regain their former skills, trying to build up their confidence and be
encouraging and positive.
Several other forms of therapy may be helpful in assisting recovery, in addition to the
conventional treatments. Some examples are:
Talking therapy
Family therapy.
348
Relaxation therapy
Exercise
TASK: SCHIZOPHRENIA EXPLANATION
Mr. Peter Hill is a 19-year-old university student, who is currently an in-patient on your
ward and was admitted few days ago with bizarre behaviour, persecutory delusions and
auditory hallucinations. He is recovering from his first episode of psychosis and is being
treated with Olanzapine. His mother is angry to know from the nurses that he has been
diagnosed with schizophrenia.
Ms. Linda Hill wants to discuss with you about Peters illness and Prognosis of his
condition
Expanded construct: The candidate is expected to explain the diagnosis of

Schizophrenia. They should also discuss aetiology and prognosis of schizophrenia. They
should be able to deal with angry relative assertively and try to calm them down. They
should;
Explain diagnosis and nature of the illness

(Rationale behind his diagnosis)
Causal explanation and alleviate guilt

(Multifactorial-family history, Chemical imbalance, Stress,
? Sparked off by illicit drugs etc)
Address concerns-
1. Violence and aggression
2. Other children to be affected.
Medication-Olanzapine- Discuss Efficacy and side effects

Duration of treatment
Explain prognosis- Worries about son getting back to normal life
Discuss Support MDT, CMHT, CPN etc

Sources of information-Information leaflets and website
349
Evidence for early intervention:
1. PRIME study used olanzapine in a low dose to prevent progression

with favourable results though it is not a powerful data to be
generalised.
2. EPPIC from Melbourne (McGorry et al) reported that a combination

of CBT and risperidone could reduce the conversion rate at 6
months; though longer follow-up suggested that a delay not
prevention effect was possible. Warner reappraised the results of
EPPIC report and found out that even one additional case of
schizophrenia would have nullified the much glorified results.
3. The Lambeth Early Onset (LEO) study compared specialised care
(low dose atypical anti-psychotics, CBT using manualised protocols,
family counselling and vocational strategies) based on a model of
assertive outreach with standard care. The remission rates were
lower with specialised care.
4. CBT may have a role in reducing progression from at risk state to
full blown schizophrenia as suggested by EDIE trial (Morrison,
2004).
5. The SoCRATES study (Study of Cognitive Reality Alignment
Therapy in Early Schizophrenia) compared CBT with supportive
counselling for a first- or second-episode of schizophrenia wherein at
18-month follow-up (Tarrier et al., 2004), the addition of both CBT
and supportive counselling showed a significant improvement.
Treating the first episode:
Summary of NICE guidelines (from Patel & David 2005):
350
The choice of antipsychotic drug should be made jointly by the patient and responsible clinician, on
the basis of an informed discussion of benefits and side-effects
Oral atypical antipsychotics are recommended as first-line treatment for patients with newly diagnosed
schizophrenia
If a patient on oral typical antipsychotics has adequate symptom control but is experiencing unacceptable
side-effects, an oral atypical should be considered
If a patient on an oral typical has good symptom control and no unacceptable side-effects, a routine switch
to an atypical preparation is not recommended
Clozapine should be used at the earliest opportunity for patients with evidence of treatment-resistant
schizophrenia
A risk assessment should be performed regarding treatment adherence, and depot preparations should be
prescribed when appropriate
Where more than one atypical drug is considered appropriate, the drug with the lowest purchase cost
(allowing for daily required dose) should be prescribed
Where full discussion between the patient and responsible clinician is not possible, oral atypicals should be
the treatment of choice because of the lower potential risk of extrapyramidal symptoms
Antipsychotic therapy should be initiated as part of a comprehensive package of care that addresses the
patients clinical, emotional and social needs
Atypical and typical antipsychotics should not be prescribed concurrently, except for short periods to cover
changeover of medication
351
BIPOLAR DISORDER
Mania is usually a short-lived illness, which, with treatment, you would expect to recover
from in a couple of months. However, people who have had a period of mania also suffer
from the other side of the illness, which is depression. So this illness also called bipolar
disorder because there are the two poles of mania and depression.
Bipolar disorder is quite a common illness. About one person in 100 will develop this
disorder at some time in their lives.
The disorder usually starts before the age of 30 but may occur at any time in the lifespan.
Women and men are equally likely to be affected.
There is no specific medical test that can be done to decide whether someone has bipolar
disorder. This disorder can only be diagnosed by observing your behaviour and by
listening to what you and your family say about your pattern of moods and behaviours.
No one knows exactly what causes this.Bipolar disorder is probably caused by a number
of factors including heredity, chemical imbalance in the brain and stress\
In an episode of mania, you may feel very happy and excited, full of energy, very active,
unable or unwilling to sleep, behaving in a bizarre way, recklessly spending your money,
less inhibited about your social and sexual behaviour, Speaking very quickly and
jumping very quickly from one idea to another, full of new and exciting ideas and
making plans that are grandiose and unrealistic, Making odd decisions on the spur of the
moment, sometimes with disastrous consequences
Bipolar disorder usually (but not always) involves episodes of depression. Most people
with bipolar disorder do, however, have periods of depression at some point in their
lives.
If you are thinking about the chances of having either an episode of mania or depression
in the future, it is about 50/50. It is impossible to make future predictions. But in the
longer run most people do have another period of depression or mania.
Prognosis: It is impossible to make future predictions. Each episode of mania, depression,
or mixed phase lasts for a while and then stops. The person usually feels completely well
again.
The length of time that a person remains well between episodes of illness varies from one
person to the next. Some people may have only two or three episodes of illness and other
352
people may have more episodes of illness. The good news, however, is that with regular
medication you can reduce or even prevent further episodes of illness.
Severity of illness differs from one person to another and even in the same person;
severity varies from one episode to the next. Some episodes may be so severe that the
person needs to spend time in hospital. Other episodes could be very mild and may not
need hospital care and with early treatment, the episode of illness is likely to be less
severe and hospital admission may be avoided.
This disturbance can be treated with medications, which are called mood stabilisers. One
of the most commonly used mood stabilisers is lithium and there are also other mood
stabilisers like sodium valpraote.
Valproate is generally used in the treatment of epilepsy to help control fits or seizures.
Valproate can also be used to help mood disorders (especially if the person is high as
an antimanic) and some other illnesses, particularly when other treatments have not been
effective.
It is not entirely clear how valproate works (either as a mood stabiliser or as an
anticonvulsant), as it causes several actions in the brain. There is a chemical messenger
(or neurotransmitter) called GABA, which calms the brain down. Valproate helps to
stop the breakdown of GABA and so leaves enough in the brain thereby controlling
overactivity/mania and acts as a mood stabiliser.
Some of the common side effects are drowsiness, feeling sick, increased appetite,
weight gain, you may have an upset stomach and you may feel tired all the time.
Some people also complain of hair loss, disturbed menstrual periods in women and on
higher doses some patients feel unsteady on their feet.
You should certainly carry on the treatment for a longer period of time and it will need to
be reviewed by psychiatrists in outpatients
How can I help myself with this illness?- Learn to cope with mood swings, learning to
recognise the onset of mania or depression, Find out as much as you can about your
illness and how you can be helped, avoid stressful situations, getting a right balance in
your life between work, leisure and relationships with your family and friends.
353
TASK: BIPOLAR AFFECTIVE DISORDER- EXPLAIN
Mrs. Maria Brown is a 30year old married teacher who is an informal patient on the
ward. Prior to admission, her mood was elated, spent thousands of pounds on buying
plastic plants to decorate her flat and felt as if she is a chosen environmentalist. She was
treated on Citalopram for depression 2 years ago.
She has now recently recovered from her first episode of mania and is at the beginning of
her hospital stay. She is currently on Valproate Semisodium (Depakote). She would like
to discuss about the nature and etiology of her illness, management and prognosis of her
condition
Expanded construct: The candidate is expected to discuss about the nature, etiology of
bipolar illness and prognosis of her condition. They should discuss about the role of
Sodium valproate in the management of her condition, discuss possible side effects and
address her concerns. They should;
Explaining the possible diagnosis

Explain clinical presentation of mania
Causal explanation (aetiology)

(Hereditary, stress, chemical imbalance etc)
Depakote-Discuss side effects (G I upset, sedation, tremor etc)
Address concerns about side effects

1. Hair loss, Weight gain, Sexual SE
2. Using oral contraceptive pills
Addressing Concerns
1. Remissions and exacerbations-possible
2. Stopping meds-possible risk of relapse
Discussion about prognosis- Returning to work
Emphasise need for Long-term treatment, monitoring and support
354
DEPRESSION
Most of us feel sad or miserable at times. We recover quite quickly from our
sadness, especially if we have other good things happening in our lives. Some people,
however, continue to feel extremely miserable for long periods of time even though there
may no longer be a good reason for feeling this way, and may find it difficult to get
through the day. Severe depression that occurs for no obvious reason, or that continues
for a long time, at least for a period of two weeks is called major depression or a
depressive disorder.
Depression is a common and treatable illness. Research evidence shows that up
to 25% of the population may suffer from this disorder at some time in their lives. Most
cases of depression are mild, but about one person in 20 will have a moderate or severe
episode.
It can affect people from any age group and females are affected more commonly
than males.
Symptoms of a depressive disorder; Feeling miserable, loss of interest or pleasure
in usual activities, which you used to enjoy, loss of appetite with excessive loss of
weight, loss of interest in sex, loss of energy, and greatly decreased levels of activity, loss
of sleep despite feeling exhausted, Bleak and pessimistic views of the future and insome
cases thoughts of killing or harming yourself.
No one knows exactly what causes depression. There is no one cause for
depression and it varies greatly from one person to another.
Possible causes- hereditary factors, chemical imbalance, stressful life events,
vulnerable personality
For moderate depression medications such as antidepressants and talking
treatments may be needed. For severe depression, antidepressants are usually necessary
before talking treatments can be of help, and it usually needs the help of a specialist, a -
psychiatrist. Only a small number of people with depression ever need admission to
hospital. They tend to have depressions that are life threatening or are just not getting
better.
Antidepressants do not relieve your depression straight away. These drugs take
some time to have an effect on your mood. It may take six to eight weeks before the
355
maximum benefits of antidepressant medication are noticed. Therefore, you should not
expect to notice the benefits from this medicine too quickly
Continue taking the medication for about six months to one year after -
recovery. The general rule is that you should carry on taking antidepressants at least for 6
months after your depression has lifted.
There are three useful forms of psychotherapy:Cognitive therapy.
Behavioural therapy and Interpersonal therapy.
CBT- Please read notes on CBT
Interpersonal therapy; This form of therapy aims to help people resolve one or
more of their interpersonal problems that may be causing or prolonging symptoms of
depression. For example, interpersonal therapy may target the adjustment to difficult life
situations and may help with the resolution of interpersonal disputes (e.g. marital
problems or disputes with family members at home (or) with colleagues at work).
356
COMMUNITY TEAMS
Crisis Resolution/ Home Treatment team

Crisis Resolution/ Home Treatment refers to a system for the rapid response and
assessment of mental health crisis in the community with the possibility of offering
comprehensive acute psychiatric care at home until the crisis is resolved, and usually
without hospital admission.
Acute care is delivered by a specialist team so as to provide an alternative to hospital

admission for individuals with serious mental illness who are experiencing acute
difficulties.
It is commonly useful in adults (16 to 65 years old) with severe mental illness (e.g.
schizophrenia, manic depressive disorders, and severe depressive disorder) with an acute
psychiatric crisis of such severity that, without the involvement of a crisis
resolution/home treatment team, hospitalization would be necessary.
Act as a 'gatekeeper' to mental health services, rapidly assessing individuals with acute
mental health problems and referring them to the most appropriate service.
Remain involved with the client until the crisis has resolved and the service user is linked
into on-going care.
If hospitalisation is necessary, be actively involved in discharge planning and provide

intensive care at home to enable early discharge.
Reduce service users' vulnerability to crisis and maximise their resilience.
The following principles of care are important:
1. A 24 hour a day, 7 day a week service.

2. Rapid response following referral. (DoH guidelines specify 1
hour)
3. Intensive intervention and support in the early stages of the
crisis. (Up to one visit per shift)
4. Active involvement of the service user, family and carers.
5. Assertive approach to engagement.
6. Time-limited intervention that has sufficient flexibility to
respond to differing service user needs.
7. Learning from the crisis a psycho-educational approaches
(Adapted from www.rethink.org.uk)
357
ASSERTIVE OUTREACH TEAM
A mental health team that offers a long term commitment to supporting people with
enduring mental health difficulties
It involves skilled and experienced multi-professional team working with people who
need ongoing support in the community
This team works in partnership with people, and with their families and carers, offers
flexible and meaningful support to meet individual needs
How does the team work?
The team will try to listen to patients experiences and find out what they would like
support with and over time the patients will get to know several members of the team
well
The support offered can be frequent and ongoing people using the service can get
support every day if needed. There are no time limits support can be for years rather
than months
The team will be there in times of crisis, but also when things are going well
Working together could include illness related matters (e.g. medication) but also may
include working on social issues (finances, housing etc) or expanding on things that
patients already do well.
What service can be expected?
Regular meetings to discuss patients experiences and views about theirs strengths and problems
To talk over specific subjects like hearing voices, distressing beliefs etc
Discussion about medication
Support in detecting early signs of illness and reducing the risk of relapse
The team will work with people close to you to help them understand their experiences better
and manage stress at home
Practical assistance with finding and maintaining a home
Help with money issues and obtaining benefits
Support to find suitable occupation, work or training
(Adapted from www.awp.nhs.uk)
358
EARLY ONSET PSYCHOSIS- ASSESSMENT AND MANAGEMENT
TASK: (PART-A) You have been asked to assess Mr. John Abraham who is a 15 year
old boy, referred by his GP as his parents felt that there is something wrong in his mental
health. Talk to him to look for evidence of psychosis. In the next station, you will have
to discuss the management plan with the consultant
Expanded construct: The candidate is expected to assess patients mental state and
explore the presence of psychopathology indicating psychosis
They should be able to elicit the following features in MSE
Paranoia and Persecutory delusions- elicitation,

Exploration and clarification
Delusional mood and bizarre delusional ideas, Ideas of reference-

Elicitation, Exploration and clarification
Evaluate the falseness of beliefs and asses degree of conviction
Auditory hallucination- 2nd and 3rd person (source, content, timing,

reality with which it is experienced),
Rule out hallucinations in other modalities.
Other significant history and symptoms- Illicit drug history, difficulties

with coping, deterioration in performance, social isolation, poor
concentration etc.
Risk assessment (self-harm, violence, non-compliance, drug and alcohol

misuse)
Related task in the second station: PART-B
Describe your findings to the examiner. Discuss the differential diagnosis and
management plan with the consultant
Expanded construct: The candidate is expected to describe their findings in history and
mental state examination to the examiner. They are also expected to discuss the
differential diagnosis and management plan with the consultant
They should discuss the following topics;
359
Summary of findings from history and mental state,
Case formulation
Differential diagnosis and the reasons for considering them
Management of first episode psychosis- Medical

(Atypical antipsychotics, dose, titration, side effects, monitoring etc)
Management- psychosocial management strategies

1. Education and support to patient and family
2. Psychological treatments- Family therapy, CBT
3. Abstain from cannabis
Discussion
a. Community treatment, involvement of early intervention team/first
episode psychosis team
b. Concerns- Depot medication/ Clozapine- not to consider at this stage
Long term Support MDT, CMHT, CPN support& monitoring
EARLY INTERVENTION TEAM FOR FIRST

EPISODE PSYCHOSIS
Indications:
People aged between 14 and 35 with a first presentation of psychotic symptoms.
Intervention Team serves young people with early Psychosis who are aged 1435 and
their families and also during the first three years of psychotic illness.
Purpose: Intervening early in the course of the disease can prevent initial problems and improve
long term outcomes. If treatment is given early in the course of the illness and services are in
place to ensure long-term concordance (co-operation with treatment), the prospect for recovery is
improved.
An early intervention service should be able to:

Reduce the stigma associated with psychosis and improve
professional and lay awareness of the symptoms of psychosis
and the need for early assessment.
360
Reduce the length of time young people remain undiagnosed
and untreated
Develop meaningful engagement, provide evidence-based
interventions and promote recovery during the early phase of
illness
provide a user centred service i.e. a seamless service available
for those from age 14 to 35 that effectively integrates child,
adolescent and adult mental health services and works in
partnership with primary care, education, social services, youth
and other services
www.schizophreniaguidelines.co.uk
Potential benefits
Disability accumulates in the Prodromal state, therefore creating an avenue for help is
warranted
Engagement and trust are more likely to be established
Rapid intervention can be offered for those who progress to psychosis
Co morbidity such as substance misuse and mood symptoms can be managed
Symptomatic cases can be treated with appropriate medication and psychosocial
interventions
Research strategies for effective intervention can be developed
361
MRCPsych Clinical examination (CASC)
Topic: ROYAL COLLEGE MODEL FEEDBACK FORM
Candidate Name: Candidate Number:
Examiner please mark one lozenge
KEY: A = Clear pass B = Pass C = Fail
D = Clear fail E = Unacceptable Fail
* Global Rating A B C D E
1 Questioning style e.g. use of appropriate mix of open & closed

questions
2 Listening and responding appropriately to interviewee/discussant.
3 Management of interview/examination including empathic
responses.
4 Lack of appropriate focus on the required task.
5 Fluency of interview/examination/discussion.
6 Professionalism including but not limited to harmful interaction;
failure to respect individuals rights; ethical behaviour etc.
7 Appropriate choice of avenues of enquiry, tests or examination
including significant omissions.
8 Range and/or depth of history explored.
9 Range and depth of psychopathology explored.
10 Prioritisation, recognition of importance and appropriateness of
information including significant omissions
11 Analysis of problems and synthesis of opinions.
362
Clinical Assessment of Skills and Competencies- Areas of Concern
(Adapted from www.rcpsych.ac.uk)
Below are listed the pool of areas of concern that we select from in listing
options for examiners at each station.
Questioning style e.g. use of appropriate mix of open & closed

questions
Listening and responding appropriately to interviewee/discussant
Management of interview/examination including empathic
responses
Lack of appropriate focus on the required task
Fluency of interview/examination/discussion
Choice of avenues of enquiry, tests or examination including
significant omissions
Range of history explored
Depth of history explored
Range of risk explored
Depth of enquiry into risk
Range of psychopathology explored
Depth of enquiry into symptoms and/or psychopathology (signs
elicited at examination)
Range of cognition tested and appropriate application of cognitive
testing
Application of cognitive testing
Extent of physical examination
Quality of physical examination
Analysis of problems & synthesis of opinion
Prioritisation, recognition of importance and appropriateness of
information delivered and/or management
Professionalism including but not limited to harmful interaction;
failure to respect individuals rights; ethical behaviour etc
(Ps: These feedback forms are created solely for course

purpose with some modifications from the Royal college
CASC feedback forms. The forms are prepared by
collating two aspect; the areas of concern to be
identified by the examiners and Expanded construct,
which includes the list of areas that is expected by
candidates to cover, while performing each task in the
CASC exams.
363
Please note that in the exam 70-80% of relative weighting will be
allocated to core task and 20-30% of relative weighting will be allocated
to candidates interview and communication skills. )
For further reading;
Get Through MRCPsych: Preparation for the CASC (second edition)-

Dr. Sree Murthy
Good Luck and Best wishes.

SPMM course team
Disclaimer:
These lecture notes are prepared by consulting various published sources including peer reviewed
journals, books and internet resources. Some chapters are adapted with permission from my own
book Get through MRCPsych; preparation for the CASC. These are acknowledged wherever
possible; due to the structure of this revision notes, acknowledgements have not been possible for
every passage/fact. We do not check the accuracy of drug related information using external
sources; no part of these notes should be used as prescribing information.
Revised and updated by Sree Prathap Mohana Murthy

May 2011
Past is a misery..
Future is a mystery.
Present is a gift.
Thats why it is called as present.
So enjoy the present and every moment of your life.

Swami Sukabodhanandha
364

SPMM

Uploaded by

Copyright:

Available Formats

SPMM

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

SPMM

Uploaded by

Copyright:

Available Formats

SPMM Course

Success in Psychiatric Membership Masterclass

MRCPsych CASC Course

12 Suicide risk assessment- History 36

17 Extra pyramidal symptoms- Examination 51

26 Neuroleptic malignant syndrome- Discussion 70

Old Age Psychiatry

33 Dementia- Obtaining Collateral history 92

Child & Adolescent Psychiatry

52 ADHD- History taking 144

64 Challenging behaviour in LD patient 176

Forensic psychiatry & Risk assessments

71 Staff Assault 199

79 Bulimia- History taking 228

84 Puerperal disorders- history taking & risk assessment 243

87 Alcohol misuse- history taking 252

93 Cognitive behavioural therapy 271

Sleep & sexual disorders

101 Impotence- assessment & management 289

Liaison Psychiatry & Miscellaneous topics

104 Delirium tremens- Management 297

120 Clozapine 333

129 Royal college model feedback forms 359

Core Symptoms of depression (low mood, anhedonia, fatigueability)

Eliciting core Symptoms of Depression

Other symptoms of depression

Eliciting biological symptoms

Eliciting suicidal intent and negative thoughts

Duration, course, effects, coping

Rule out co-morbidity

TASK: DEPRESSION- ELICIT SYMPTOMS

Expanded construct: The candidate is expected to assess symptoms of depression,

Assess circumstances leading to current presentation

Assess core symptoms of depression (low mood, anhedonia, lack of energy)

Other Symptoms of depression (disturbance in biological functions, poor

Co-morbidity (alcohol abuse, anxiety etc)

Significant history (Personal and family history)

Explore the hallucinatory experience (auditory hallucinations)

Second person auditory hallucinations

Third person hallucinations

Confirm whether they are true hallucinations

Hypnagogic / hypnapompic hallucination

Duration, Course, Effects, Coping

Rule out co-morbidity

1. Contributing factors to illness and stressors

Auditory Hallucinations- Third person auditory hallucinations, Running commentary

If the patient agrees, then this experience should be further clarified.

Third person auditory hallucinations

Running commentary hallucinations

Hearing thoughts spoken aloud

Passivity of affect, impulses and volitions

Clarification, Effects and coping

TASK: ELICIT FIRST RANK SYMPTOMS

Expanded construct: The candidate is expected to explore psychopathology in

Hallucination- Auditory (Third person, Running commentary)

Thought alienation phenomenon (Thought Broadcasting, insertion, withdrawal)

Passivity phenomenon (Passivity of affect, impulse/thoughts, actions/volition)

Paranoia, persecutory delusions, other psychotic symptoms