PSYCHOSIS
SCHIZOPHRENIA
Positive:
 Delusions
 Hallucinations
 Disorganised
speech
 Disorganised
behaviour
Negative:
 Affective blunting
 Aolgia: speech
 Avolition:
motivation
 Asocial
ORGANIC
MEDICAL
 Hthyroid
 TBI
 Delirium
 Tumour
 Dementia
PSYCHOTIC
1-6/12 =
Schizophrenifor
m
Drugs:
 Amphetamines
 Pred
 Alcohol –
Korsakoff
Mood =
Schizoaffective
mood
>1/12 each >6/12
Overall NEVER FORGET
<1/12 = brief
psychotic
Delusional = less
impact + no
other symptoms
OTHER
MOOD
 Depression
with psychosis
= delusions of
nilism
(rotting),
poverty
(negative)
 Bipolar =
grandiose
delusions
 Post partum
psychosis
Anxiety
Shared psychotic
disorder = one
dominant
CLUES:
2+ voices
Running commentary
Bizarre delusions
PD





Schizotypal
Schizoid
Paranoid
Borderline
OCPD
Factitious = have
conversations
Malingering
ACUTE PSYCHOSIS
Hx/Ex = Substance abuse, Thyroid, IVDU
Bloods = FBE, UEC, BGL, LFT, TASH, B12
UDS, ECG
Comorbid = D&A, Anxiety, Mania
Social = occupation, financial, residential, relationship
CHRONIC
Hx/Ex = Compliance, SE, Substance abuse
Ix= FBE, UEC, BGL, LFT, TSH, Vit D
ECG
Confirm Dx = reassess symptoms/risk/current MX
Comorbid = Depression
Social = carer burnout, home help
Septic screen
AFFECTIVE
DSM
DDX
DEPRESSION
>2/52
MANIA
>1/52 or hospital
SAD A FACES
ORGANIC
 Metabolic = hThyroid
 Chronic condition
 Dementia
 Drugs = illicit, pred,
alcohol
GRANDIOSE
ORGANIC
 Metabolic = HThyroid
 Drugs = illicit,
prednisolone, dex,
alcohol
 Delirium
PSYCHOSIS = Schizoaffective
(previous psychosis w/o mood)
MOOD
 Depression with
psychosis = guilt
delusions
 Bipolar in depression
phase = previous high
 Postpartum
 Premenstrual
dysphoric disorder
ANXIETY
 Comorbid
 Constant worrying
 Obsessions,
compulsions
 Panic attacks
 Agoraphobia
ADJUSTMENT = precipitating
BEREAVEMENT
PERSONALITY = just
differential

PSYCHOSIS
Schizophrenia,
schizophreniform,
brief psychotic
disorder

Schizoaffective =
previous w/o mood

Shared psychotic
MOOD
 Mixed = mania with
depressive content
 Hypomanic = >4d but
less social effect
 Post partum
PERSONALITY
Schiotypal
Borderline
Narcisstic
Histrionic
ADHD
BIPOLAR DEPRESSION
ACUTE MANIA = emergency – risk to reputation, relationship, finances – involuntary admission
Identify organic cause
Hx/Ex = compliance, substance use, thyroid
Ix = FBE, UEC, LFT, ESR, Glucose, Urinalysis
DDX = TFT, UDS, Serum Li/Valproate
Assess = MSE, Risk, Alcohol/Drugs
Acute Mania
First-line: Olanzapine: 5mg PO → 10mg, max 30mg
Risperidone: 0.5-1mg PO → 2mg, max 6mg
Second-line: Haloperidol 1.5mg PO, max 10mg
Other 2nd generation antipsychotics
Lithium 750-1000mg PO
Sodium valproate 200-400mg PO bd
Carbamazepine 100-200mg PO bd
Psychoeducation = Mania, Compliance, Substance abuse, Underlying medical condition
CBT, Social rhythms therapy, Compliance therapy
Social = Psychologist, Social work, D&A rehab
Prophylaxis = 2+ episodes of mania or depression/ First episode severe
Lifestyle= sleep, routine, food
First-line prominent mania: Lithium 125-500mg PO bd for 2/52 then adjust based on serum Li
First-line prominent depression: Lamotrigine 25mg PO nocte for 2/52 → 50g 2/52 → 100mg 1/52 →
200mg (half if combine with sodium valproate)
First-line mania and depression: Olanzapine (5-30mg)
Quetiapine (50-400mg bd)
Second-line: Carbamazepine 200-400mg to 400-800mg
Sodium valproate 400-500mg to 1.5-3g daily
Monitor compliance: serum Li, valproate
Monitor SE: kidneys, thyroid, Ca2+
Psychoeducation = mania, compliance, substance use, underlying medical condition
CBT
Social rhythms therapy
Compliance therapy
Social = Psychologist, Social work, D&A rehab
DEPRESSION MANAGEMENT
Identify organic causes
Physical assessment:
● Comorbid medical conditions, e.g. HIV
● Cerebrovascular disease
● Thyroid
Bloods:
● FBE, U&Es, LFTs, Cr, ESR, glucose, urinalysis
DDx: TFTs, coeliac screen
Assess:
● Premorbid personality
● Coping skills
● Risk: suicidality, homicidal, psychotic
Comorbid:
● Alcohol and drugs: treat first
● Anxiety: treat with depression
● PD: treat parallel or w/ depression
● Insomnia
MILD- MOD = GP managed – refer if inadequate response by 12wk/psychotic/suicidal/homicidal
Treat and educate = Substance abuse
● Underlying medical condition
Lifestyle =Good sleep, routine, food
Medications = First-line (50% respond):
● SSRI, SNRI, mirtazapine
Psychotherapy:
● CBT + ACT
● IPT
● Challenge negative thoughts
Treat comorbid:
● OCD: desensitisation
● PTSD: eye movement desensitization
● Anxiety: CBT
SEVERE = admit for high risk
Same +/- ECT and bigger whammier drugs (diazepam, etc.) where they can be monitored
Psychotic: trial of TCA + antipsychotic
Right unilateral ECT with continuing or reinstating effective antidepressant
May require lithium augmentation
Experimental: DBS and TMS
COGNITION
DSM
Onset
Duration
History
LOC
Attention
Orientation
Behaviour
Psychomotor
Sleep-Wake
Mood/Affect
Cognition
Memory
Language
Delusions
Hallucinations
DEMENTIA
Memory impairment
Gradual
Months to years
Progressive,
irreversible
Normal
Not initially affected
Intact initially
Disinhibited
ImapiredADL
Personality change
Normal
Fragmented
Labile
Decreased executive
Paucity of thought
Recent loss
Agnosia, aphasia,
decreased
comprehension,
repetition, speech
echolalia
Compensatory
Variable
Bland
DELIRIUM
Conscinsousness/Cognition
change
Acute
Days to weeks
Fluctuates, reversible
PSEUDODEPRESSION
Fluctuate
Decreased
Intact
Difficulty
concentrating
Intact
Self harm/sucidide
Impaired, fluctuates
Severe
agitation/retardation
Subacute
Variable
Recurrent, reversible
Extremes/fluctuates
Reversed
Anxious, irritable,
fluctuates
Fluctuates
Slowing
EMW
Depressed, stable
Marked recent
Dysnomia, dysgraphia,
speech rambling,
irrelevant, incoherent,
subject change
Recent
Not affected
Nightmarish
Visual common
Bizarre
Nihilistic, somatic
Less common
Fluctuates
ASSESS = identify organic cause
Hx/Ex = underlying medical condition, chronic alcohol use
Delirium bloods = FBE, UEC, CMP, Glucose, ESR, LFT, BUN, TSH, Vit B 12, Folate, Albumin, Urine MCS
ECG, CXR, CT head, Tox screen, VDRL, HIV, LP, EEG, Blood cultures
Dementia = FBE, UEC, LFT, TSH, Glucose, Lipids, VIt B12/D, VDRL, HIV, Hearing/vision
CT = <60, rapid onset, recent head trauma, unexplained neuro sx
DEMENTIA MX = Treat underlying medical cause
Cholinesterase inhibitor = Donepezil
 Anorexia, NV, diarrhea, insomnia, cramp, dizzy, depression, lethargy, fatigue, tremor,
incontinence, sweating
Orientation cues + Education/Support
Comorbid = depression, anxiety, psychosis
Alzheimer’s Australia Vic Roads
DELIRIUM = ABx
Risperidone 0.5-2mg
Assess 3-6/12
Carer help
Olanzapien 2.5-10mg
Low dose benzo = Lorazepam 0.5-1mg
Withdrawal from alcohol = Diazepam
Orientate = quiet, well lit, famililar face, room near nurse station
CBT
ANXIETY
PANIC = recurrent unexpected panic attacks – reach peak within 1m
 Bio = autonomic (palpitations, sweating, trembling, shaking, SOB, dizzy), choking, chest pain,
nausea, paraesthesia
 Psychological = impending doom, depersonalisation, derealisation, fear of losing control,
fear of dying
 > 1/12 of = worry about attack/implication/behaviour change
 Agoraphobia = anxiety about being in places/situation where escape is difficult – avoid or
endure panic
ACUTE EPISODE ANXIETY RANDOMLY
DISORDER WHEN WORRY ABOUT REPEAT
AGORAPHOBIA = STAY INDOORS
Psychosocial = supportive psychotherapy, relaxation techniques, CBT
Biological = SSRI/SNRI start low, go slow
GAD
Blank mind
Easy fatigue
Sleep disturbance
Keyed up
Irritablility
Muscle tension
>3, more days than not 6/12 (1 in children)
LONG TERM ANXIETY AND WORRY ABOUT VARIOUS THINGS
DIFFICULT TO CONTROL
BESKIM
Lifestyle = caffeine and etOH avoidance, sleep hygiene
Psychological = psychotherapy, relaxation, mindfulness, CBT
Biological = BEnzo, SSRI/SNRI, TCA, Beta block
Phobic Disorder = exposure to stimulus invariably provokes immediate anxiety response
 Recognises fear as excessive, unreasonable
 Situation avoided or endured
 Interfere with life
Social phobia = fear of social or performance situation
ACUTE EPISODIC ANXIETY ABOUT ONE THING
RECOGNISES AS EXCESSIVE AND UNREASONABLE
STAYS HOME TO AVOID SOCIAL
Psychological = exposure therapy, desensitisation, insight orientation
Bio = Beta block/Benzo in acute
SSRI/MAOI/Clomipramie
OCD
Obsession= recurrent, excessive, intrusive, unwanted
Compulsion = driven to perform, unrealistic, to neutralise, time consuming, not connected in
realistic way
>1 hour
Interfere with life
Psychological = CBT, desensitiation, flooding, thought stopping, implosion therapy
Bio= SSRI higher and longer treatment, Risperidone/Haloperidol
PTSD = exposed to traumatic event
RE EXPERIENCE = dreams, flashbacks, feels realistic/reliving
AVOIDING/NUMBING = avoid thoughts/feelings/conversations/activites/places - detached
INCREASED AROUSAL = difficult falling/staying asleep, irritable, concentration, hypervigilance, startle
>1/12
Psychological = CBT, systematic desensitisiation, relaxation, thought stopping
Biological = SSRI, quetiapine/olanzapine, risperidone
ASD = same as PTSD but 2d – 4w duration
 Initial state of daze = narrowing of attention, disorientation, in ability to comprehend
 PTSD but more acute
ADJUSTMENT = emotional/behavioural sx in response to stressor within 3/12 of onset
OUT OF PROPORTION
DOES NOT PERSIST WHEN STRESSOR IS GONE - not >6/12 post stressor Rule out BPD
ORGANIC ANXIETY
CVS = Post MI, ARrhthmia, CHF, PE, MV prolapse
Resp = Asthma, COPD, Pnemonia, Hyperventilation
Endocrine = Hthyroid, Phaeo, hypoglycaemia, Hyperadrenalism, HParathyroid
Metabolic = V B12, Porphyria
Neuro – Neoplasm, vestibular dysfunction, encephalitis
Intoxication = caffine, amphetamines, cocaine, thyroid drugs, decongestants
Withdrawal = benzo, alcohol
RULE OUT ORGANIC
NEVER FORGET DRUG
OTHER PSYCH CAUSES
Psychotic = delusions causing anxiety
Mood = comorbid depression – irritable mania
Personality disorder = Avoidant, Dependent
Somatoform disorder
Factitious
Malingering = want BENZO
PERSONALITY = enduring pattern of inner experience and behaviour that deviates markedly from
expectations of individual’s culture
Two or more of:
 Cognition
 Affect
 Interpersonal functioning
 Impulse control
Inflexible and pervasive across range of situations
Distress or marked functioning for those around them
Pattern is stable
A – MAD = odd, eccentric, withdrawn
Familial a/w psychotic disorder
Defence = intellectualisation, projection, magical thinking
Paranoid (0.5-3%) = distrustful
Schizotypal (3-5%) = eccentric
Schizoid = loner
B – BAD = dramatic, emotional, inconsistent
Familial a/w mood disorder
Defence = denial, acting out, regression, splitting, projective identification, idealisation
Borderline (2-4%) = ambivalent
Narcissistic (2%) = grandiose
Histrionic (1-3%) = dramatic
Antisocia (3%) = remorseless
C – SAD = anxious, fearful
Familial a/w anxiety disorder
Defence = isolation, avoidance, hypochondriasis
Avoidant (0.5-1.5%) = ashamed
Dependent (1.6-6.7%) = clingy
Obsessive-Compulsive (3-10%) = perfectionist
EATING DISORDER = 5 year duration
Mortality = 20% after 20 years
Natural = cardiac/infection 4 times
Suicide = 32 times
First degree female relative = 10 times
5 times general population
ANOREXIA = refusal to maintain body weight
 Fear of gaining weight
 Disturbed body image
 Amenorrhoea
1%
Restricting vs. Binge/Purge
Patients near to death often look well:
● BMI: <13 high risk
● Weight loss: >1kg/w for a month
Physical assessment:
● Height, weight, BMI
● Centile charts for <18y
● HR and BP
● Core temperature
● Peripheries (circulation, oedema)
● CVS including postural BP
● Muscle power (sit up, squat, stand)
Investigate complications of:
● Starvation (AN)
● Purging behaviour (dental)
● Associated physical complications (DM, pregnancy)
● Excessive exercise
● Stunted/incomplete development (MSK, reproductive)
● Dietary imbalance (high fibre, low fat)
Bloods:
● FBE, U&Es, LFTs, Cr, ESR, glucose, urinalysis
● Ca, Mg, PO4, serum proteins, CK
● DDx: TFTs, coeliac screen, FSH, LH, prolactin
● Nutrition: B12, folate, vitamin D, Zn, Fe
● Beware: K+ (<3 mmol), low P+, hypoglycaemia (<3 mmol), Na+ (<125 mmol)
Imaging:
● ECG
● CXR (DDx for weight loss/TB)
DEXA (12mth of amenorrhoea)
BULIMIA = recurrent episode of binge – inappropriate compensatory behaviour
2-4%
Purge vs. Non purge
Admit to hospital for high risk where resuscitation required
Outpatient:
● Psychological and physical assessment at least every 6mth
● If deteriorate or no significant improvement, up intensity (individual → individual + family → inpatient)
Inpatient:
● Resuscitation
● Nutritional support
● Beware refeeding syndrome
● Structured symptom-focussed treatment regime expecting weight gain - explain and agree on target inhospital weight and promise not to go over
Weight:
● 0.5-1kg/w inpatient
● 0.5kg/w outpatient
● 3500-7000 extra calories/w
● May multivitamins/mineral
● Total parenteral nutrition is no unless significant GIT dysfunction
● Feeding against will - last resort
Medication:
● None - comorbid depression/OCD may resolve with weight gain
● Beware drugs that prolong QT:
○ Antipsychotics
○ TCAs
○ Macrolide abx ‘-mycin’
○ Some antihistamines
● Beware drugs that compromise cardiac
○ ECG if needed
● Put alert in file for med SE
● No oestrogen in kids (premature fusion of epiphyses)
General:
● No physical activity - # risk
● Paeds referral in <18 for growth
Psychotherapy = Reduce risk
● Encourage weight gain, healthy eating
● Facilitate psychological/physical recovery
Outpatient:
● At least every 6 months if not more
● For at least 1 year post-discharge
Inpatient:
● Psychological treatment
Psychotherapies
● Focus on eating behaviour and attitudes
● FAMILY THERAPY:
○ Include siblings
○ Share information
○ Advice on behavioural management/set boundaries
○ Facilitate communication
● CBT:
○ CBT-BN 16-20 sessions 4-5mth
● Psychoeducation, etc.
● Evidence for: supportive psychotherapy, interpersonal therapy
Long term supportive therapy
ADOLESCENTS = HEEADSSS
Home = whats home like?
Who? Where? Stable?
Education/Employment? = performance? Behaviour? Financially secure?
Eating = diet? Perception? Weight change?
Activities = How do you spend time? Dangerous behaviour? Peers?
Drugs = Energy drink? Smoke? Alcohol? Drugs?
Sex = Active? Contraception? Partners? STIs? Sexuality?
Suicidality = Mood? Thoughts? Attempts? Risk?
Safety = drink driving