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Psychiatry 

Psychiatry
Chapter:
Psychiatry
Author(s):

Tim Raine

, George Collins

, Catriona Hall

, Nina Hjelde

, James Dawson

, Stephan Sanders

, and Simon Eccles

DOI:
10.1093/med/9780198813538.003.0012
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► Aggressive behaviour emergency

Aggression often stems from fear. Agitated patients are usually frightened, so try to remember this when approaching the situation. Regardless, the safety of yourself and others is paramount at all times.

►► Call for senior help/security early if the situation is deteriorating.

  • Assess the safety—is anyone at acute risk?

  • Attempt to defuse the situation, maintain your own safety at all times

  • Try to establish the precipitant from staff/relatives (Box 12.1)

  • Ask a member of staff who knows the patient to accompany you

  • Invite the patient to sit down with you and discuss the problem

  • Listen until they feel they have explained the problem

  • Assess the patient for signs of psychosis or acute confusion—are they physiologically unwell, psychologically disturbed, or angry? Why?

  • Apologize and/or offer sympathy as appropriate

  • Address any concerns raised by the patient

  • Ask specifically about pain or worry

  • Consider offering oral sedation or analgesia

  • Emergency sedation if they are a risk to themselves or others1:

    • lorazepam 1–2mg (1mg elderly/renal failure) PO/IM/IV STAT

    • haloperidol 5–10mg (2mg elderly) PO/IM/IV STAT

    • can be used together or separately.

Mental Health Act (MHA)

In England and Wales, this Act allows the hospitalization of individuals who are believed to be affected by a mental disorder (alcohol and drug addiction alone are insufficient) that:

  • requires assessment (under section 2) or treatment (under section 2 or 3) and

  • is sufficiently serious to pose a threat to self or others and

  • requires hospitalization to which they are unable/unwilling to consent.

If you feel this applies to your patient, speak to your seniors and the psychiatrist on call urgently. They may recommend an urgent MHA assessment to consider detention under section 2 (if further assessment required) or 3 (if patient well known and symptoms typical). See Table 12.1.

Table 12.1 Key sections of the Mental Health Act, 2007

Section 2

A period of assessment and treatment which lasts for up to 28d. Not renewable. An approved mental health professional (AMHP) makes the application on the recommendation of two doctors. An AMHP may be a social worker, nurse, occupational therapist, or psychologist

Section 3

Admission for treatment up to 6mth. Is renewable for a further 6mth and annually thereafter. AMPH makes the application on the recommendation of two doctors

Section 4

Emergency admission for assessment. Lasts 72h. Requires one medical practitioner and AMHP to enact. Can be used if admission under section 2 would cause an undesirable delay

Section 5(2)

Issued by a doctor. Allows detention of an informal patient for up to 72h. Designed as an emergency order in order for a mental health act assessment to take place

Section 5(4)

Issued by a mental health nurse. Allows detention of an informal patient for up to 6h until doctor assessment

Section 17a

Supervised community treatment order

Section 136

Allows police to arrest a person in a public place and who is believed to be suffering from a mental disorder. Lasts up to 72h. The person is taken to a place of safety (eg ED)

► These powers cannot be used to detain for treatment of physical illness, unless the direct consequence of the mental disorder (eg self-harm, weight loss in anorexia nervosa). Patients under the MHA may still have capacity to decide on treatment for physical health unrelated to their mental illness. In this case, treatment decisions should be based upon an assessment of mental capacity which is decision specific (Psychiatry p. [link]).

Alcoholism

Alcoholism

Many patients will drink over the recommended limits (14 units per week ♂ and ♀), but not all of these will be ‘alcoholics’.2 Defining alcoholism is hard; if drinking, or its affects, repeatedly harms work or social life it is clearly a problem. Answering ‘yes’ to three out of four of the CAGE questions suggests alcoholism: Ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Ever felt Guilty about your drinking? Ever had an Eye-opener in the morning?

Excessive drinking can be a psychiatric issue in its own right but can also complicate many psychiatric diseases. Modifying drinking behaviour is difficult and patients must want to change.

Abuse

Excessive drinking despite mental or physical harm.

Dependence

Alcohol tolerance, withdrawal when not drinking.

Alcoholism management

Have a low threshold for commencing benzodiazepine therapy to avoid withdrawal (Table 5.12 or your local protocol). Start vitamin B1 supplementation with either IV preparations or oral thiamine and multi-vitamins .

Untreated, thiamine deficiency can lead to Wernicke’s encephalopathy (Psychiatry p. [link]). Characterized by a triad of nystagmus, ophthalmoplegia, and ataxia, but can also present with confusion, altered consciousness, vomiting, and headache. Untreated it can progress to Korsakoff’s syndrome characterized by an irreversible inability to acquire new memories associated with a tendency to confabulate. Both are treated with Pabrinex® or oral thiamine, but the memory loss in Korsakoff’s is usually permanent.

Other management

Alcohol diaries, reduced intake/abstinence plans, counselling, eg Alcoholics Anonymous, medication, eg disulfiram, address underlying social and psychiatric problems.

Alcohol withdrawal

(OHAM4Psychiatry p. 414).

Symptoms

12–36h post-alcohol: anxiety, shaking, sweating, vomiting, tonic-clonic seizures; 3–4d post-alcohol delirium tremens may develop: coarse tremor, confusion, delusions, hallucinations (untreated mortality 15%).

Signs

HTN, ↑ HR, sweaty, tremor, ↓glucose; delirium tremens: pyrexia.

Investigations

blds

May have ↓ Mg2+, ↓ PO43−, ↓ Ca2+, ↓K+ and ↓urea. Check LFTs and consider investigation for chronic liver disease.

Treatment

Prescribe reducing dose of chlordiazepoxide (Table 5.12); correct electrolyte abnormalities; give vitamin replacements PO (thiamine 25mg/24h and vitamin B (compound strong) one tablet/24h) or IV (Pabrinex® 2 pairs/8h IV for 5d). Monitor BP and blood glucose. Withdrawal seizures are usually self-limiting, treat as Psychiatry p. [link] if required.

Complications

Seizures, coma, encephalopathy, hypoglycaemia.

Aggression and violence

The majority of patients have respect for NHS staff; however under certain circumstances anyone can become aggressive:

  • Pain (Psychiatry pp. [link][link])

  • Reversible confusion or delirium, eg hypoglycaemia (Psychiatry pp. [link][link])

  • Dementia (Psychiatry pp. [link][link])

  • Inadequate communication/fear/frustration (Psychiatry p. [link][link])

  • Intoxication (medications, alcohol, recreational drugs)

  • Mental illness or personality disorder (Psychiatry pp. [link][link]

The aggressive patient

Ask a nurse to accompany you when assessing aggressive patients. Position yourselves between the exit and the patient and ensure that other staff know where you are. The majority of patients can be calmed simply by talking; try to elicit why they are angry and ask specifically about pain and worry. Be calm but firm and do not shout or make threats. If this does not help you may have to call hospital security or the police in a GP setting. It may be appropriate to offer an oral sedative or give emergency IM/IV sedation (Psychiatry p. [link]). Mental health nurses are trained in how to give both IM and IV sedation. In a GP setting, add an alert to the patient’s records to detail the incident and inform the practice manager.

The aggressive relative

Relatives may be aggressive through fear, frustration, and/or intoxication. They usually respond to talking, though make sure you obtain consent from the patient before discussing their medical details. Consider offering to arrange a meeting with a senior doctor. If the relative continues to be aggressive, remember that your duty of care to patients does not extend to their relatives; you do not have to tell them anything or listen to threats/abuse. In extreme cases you can ask security or police to remove the relative from the hospital.

Violence

Assault (the attempt or threat of causing harm) and battery (physical contact without consent) by a patient or relative is a criminal offence. If you witness an assault or are assaulted yourself, inform your seniors and fill in an incident form including the name and contact details of any witnesses. If no action is taken on your behalf inform the police yourself.

Abuse

Abuse is a violation of an individual’s human and civil rights and may consist of a single act or repeated actions. It may be physical, sexual, financial, psychological or through neglect. Patients of any age can be abused. Do not be afraid of asking patients how they sustained injuries or asking directly if someone caused them. Inform a senior if you suspect a patient has been abused (Psychiatry Box 2.11 p. [link]). Have a low threshold for involving adult/child safeguarding teams where you have concerns.

Acute confusion

Psychiatry Delirium or acute confusional state is a common but easily missed diagnosis associated with increased morbidity and mortality. Delirium can affect any patient but is especially common in the hospitalized elderly, where it may be misdiagnosed or herald dementia (or it may coexist in up to 50%). Unlike dementia, delirium is often fluctuating, worse at certain times of day and may persist for months.3,4There are two subtypes: hypoactive (higher mortality) and hyperactive.Beware the quietest and loudest patients on the ward.

Think about

► Emergencies

↓ O2, ↑ CO2, MI, CVA, intracranial bleed, meningitis, encephalitis, anticholinergic medications;

Common

Sepsis, metabolic (↓glucose, ↓Na+), drug toxicity (opioids, benzodiazepines, lithium, serotonin syndrome, neuroleptic malignant syndrome, post-GA), heart failure, head injury, alcohol withdrawal or intoxication, post-ictal, urinary retention, constipation, pain.

Ask about

Use direct questions to assess eg for pain; further history from the ward staff, relatives, notes or residential/nursing home: speed of onset, chest pain, cough, sputum, dysuria, frequency, incontinence, head injury, headache, photophobia, vomiting, dizziness;

PMH

dm, heart, lung, liver or kidney problems, epilepsy, dementia, psychiatric illness;

DH

Benzodiazepines, antidepressants, opioids, steroids, nsaids, antiparkinsonian drugs; anticholinergics, antispasmodics, anti epileptics, antipsychotics.

SH

Alcohol, recreational drugs, baseline mobility and state.

Obs

GCS (Table 11.2), temp, HR, BP, RR, O2 sats.

Look for

Respiration

Rate, depth, added sounds, cyanosis;

Pulse

Rate and rhythm;

Abdomen

Rigidity, palpable bladder;

PR

Faecal impaction;

Neuro

Signs of head injury, pupil responses, neck stiffness, photophobia, focal neurology, plantar responses;

AMT score

(See Table 12.2);

Table 12.2 Abbreviated Mental Test (AMT) score (≥8 is normal for an elderly patient)

Age

1

Recognise two people (eg Dr, nurse)

1

Date of birth

1

Year World War Two ended (1945)

1

Current year

1

Who is on the throne (Elizabeth II)

1

Time (nearest hour)

1

Recall address: ‘42 West Street’

1

Name of hospital

1

Count backwards from 20 to 1

1

Reproduced from Hodgkinson HM, ‘Evaluation of a mental test score for assessment of mental impairment in the elderly’, Age and Ageing, 1972, 1(4):233–8, by permission of Oxford University Press and the British Geriatric Society.

Drug Chart.

Investigations

Urine

Dipstick, M,c+s;

blds

FBC, U+E, lft, crp, glucose, Ca2+, consider cardiac markers, blood cultures, amylase, tft, B12, folate;

ABG

↓O2 ±↓↑CO2;

ECG

Arrhythmias;

CXR

Infection or aspiration;

CT

If focal neurology, head injury or non-resolving confusion;

LP

If ct normal.

Management

  • Nurse in a quiet, appropriately lit environment with close, supportive observation (relatives, ‘special’ nurse); avoid restraints.

  • Investigate and reverse the underlying cause. Think PInCH ME: Pain, Infection, Constipation, Hydration, Medication, Environment.

  • Sedate only if patient or staff safety threatened; use oral route where possible (eg haloperidol 0.5–1mg PO/1–2mg IM every 1–2h, max 5mg/24h; if PMH Lewy body dementia, alcohol excess or Parkinson’s, lorazepam 0.5–1mg PO/IM every 1–2h, max 2-4mg/24h).

Dementia

Psychiatry Progressive global cognitive impairment with normal consciousness.6

Think about

Common

Alzheimer’s, Lewy body disease, frontotemporal dementia (Pick’s), vascular dementia, Parkinson’s (late), normal pressure hydrocephalus, depression (pseudodementia), chronic subdural haematoma, Korsakoff’s syndrome; medications.

Rare

hiv, CJD, syphilis, space-occupying lesions, hypothyroid, B12 deficiency, malnutrition.

Ask about

Age of onset, progression, memory (short and long term), personality, thinking, planning, judgement, language, visuospatial skills, concentration, social behaviour, confusion, wandering, falls, head injury, tremor, mood, sleep quality, delusions, hallucinations, hearing, sight;

PMH

Seizures, cva/tia;

DH

Regular medications, sleeping tablets, anticholinergics; opioids, sedatives

FH

Dementia, neurological problems;

SH

Effect on work, relationships and social abilities; independence with activities of daily living (adls—food, cleaning, washing, dressing, toilet); ability to manage finances; alcohol intake; try to build a picture of the domestic environment: Who is at home and what local support is available (Box 12.3)?

Obs

gcs, hr, bp, glucose.

Investigations

► Consider capacity. If lacking, Mental Capacity Act principle should apply—’best interests’ and ‘least restrictive’ options. Psychiatry p. [link];

blds

fbc, esr, U+E, lft, Ca2+, tft, vitamin B12, folate, consider hiv, vdrl/tpHa; Mini-Mental State Examination (Box 12.6; Psychiatry p. [link]), Abbreviated Mental Test score (Psychiatry p. [link]); CLOX test (asking the patient to draw a clock); full systems exam with careful neurological exam including general appearance, tremor, gait, dysphasia, cog-wheeling.

Imaging

To rule out reversible causes and to identify dementia subtype (Boxes 12.4 and 12.5): cxr, ct/mri brain;

ECG;

SPECT (if DLB suspected),

LP; EEG

(rarely done).

Management

Refer to a neurologist/psychogeriatrician for specialist diagnosis and management; use an MDT approach to ensure the patient has appropriate accommodation and support with ADLs. Medical management may be initiated by the specialist.

Mood disturbance/psychosis

Think about

► Emergency

Acutely suicidal;

Psychosis

Schizophrenia, depression, bipolar disorder, postpartum, substance abuse, alcoholism or withdrawal;

Low mood

Depression, bipolar disorder, anxiety disorder, personality disorder, eating disorder, seasonal affective disorder, postpartum, grief, alcoholism or withdrawal, substance abuse;

High mood

Bipolar disorder, cyclothymia, substance abuse;

Organic

Endocrine (hypo/hyperthyroid, Cushing’s, Addison’s), neurological (cva, dementia, ms, Parkinson’s, head injury, brain tumour), infections (hiv, Lyme disease, EBV syphilis), inflammatory disease (eg rheumatoid, sle), autoimmune encephalitis, electrolyte imbalance (eg Na+, Ca2+), metabolic problems (eg porphyria, Wilson’s), malnutrition, anaemia, paraneoplastic, recreational drugs, medications (Psychiatry p. [link]). See Table 12.3.

Table 12.3 Common causes of mood disturbance and psychosis

History

Examination

Investigations

Depression

Low mood, tearful, loss of interests, sleep disturbance

Poor eye contact, neglect, low mood and affect, ±psychosis

Usually normal

Bipolar disorder

Mixture of low and high mood events

Signs of high or low mood, ±psychosis

Usually normal

Schizophrenia

Delusions, auditory hallucinations, apathy

Neglect, poverty of speech/thought

Usually normal

Anxiety

Worry, sweating, dizziness, palpitations

Fearful, tense or normal

Usually normal

Personality disorder

Longstanding difficulties

Evidence of self-harm, otherwise usually normal

Usually normal

Dementia

Problems with memory, concentration, cognition

Neglect, poor cognition with normal consciousness

May have abnormal ct/ mri brain

Organic cause

Weight loss, seizures, rapid onset, visual hallucinations

Neurological signs, rashes, wasting

Usually abnormal

Ask about

(See psychiatric history Psychiatry pp. [link][link].)

Medical

Bowel habit, weight change, appetite, cold/heat intolerance, tremor, previous head trauma, changes in vision, headaches, unusual sensations, weakness, seizures, sleeping problems, sexually transmitted illnesses and risk, rashes, joint pain;

Psychiatric

Early morning waking, concentration, energy levels, lack of pleasure, appetite, recent stresses, mood, change in personality, suicidal ideation;

Personal

Childhood, education, employment, relationships;

Forensic

Previous criminal convictions, custodial sentences;

PMH

Previous psychiatric problems or care, mania, suicide attempts, chronic illness;

DH

Regular medications, alternative medicines;

FH

Psychiatric problems, thyroid, liver or brain problems, occupations;

SH

Who do they live with, family, friends, alcohol intake, smoking, illicit substance abuse.

Obs

gcs, temp, hr, bp, rr, glucose.

Look for

(see mental state examination Psychiatry pp. [link][link])

Medical

Full systems exam and careful neurological exam including tremor, eye reflexes, papilloedema, tendon reflexes;

Psychiatric

General appearance, signs of neglect or flamboyancy, unusual posture or movements, aggression, affect, speech (form and content), thought (form and content including delusions), perception including hallucinations, cognition (concentration, memory, orientation), risk (to self or others), insight.

Investigations

It is important to consider organic causes of mental disturbance.

blds

Consider: FBC, U+E, lft, Ca2+, tft, esr, ana, B12, folate, cortisol, hIV (Psychiatry p. [link]), ebv and Lyme disease serology, vdrl/thpa; Psychiatrists may consider tests for autoantibodies in atypical presentations.

Urine

Toxicology screen;

LP, EEG, CT/MRI

Brain.

Management

  • Is the patient manic, psychotic (delusions or hallucinations Psychiatry p. [link]) or acutely suicidal? If so they need urgent psychiatric referral

  • Could there be an organic cause for their symptoms?

  • Is the patient already known to local community mental health team, contact the GP for information?

Bipolar disorder

Psychiatry Recurrent episodes of high mood, usually interspersed with episodes of low mood.

High mood may be mania (impairs job or social life and may have psychotic features) or hypomania (no impairment to job or social life). DSM-510 classifies bipolar disorder as occurring after even a single episode of mania; ICD-1010 classifies this as a manic episode, and reserves ‘bipolar disorder’ to describe recurrent episodes of mania, or mania with depressive episodes. Recurrent swings between mild depression and hypomania are called ‘cyclothymia’.

Mania signs

DIGFASTDistractable, Indiscrete (flamboyant, disinhibited), Grandiose, Flights of idea, ↑ Activity, ↓ Sleep, Talkative).

Investigations

Review medications (steroids), infection screen. If first manic episode:

CT

head; urine toxicology.

Treatment

Consider admission based on severity of episode and risk to self (self-harm, suicide), job, assets, relationships. Mania is treated acutely with antipsychotics (particularly olanzapine) and benzodiazepines. Antidepressants are used for depressive episodes but may precipitate mania. Preventive treatment is with lithium, carbamazepine, valproate, or lamotrigine.

Complications

Financial errors, criminal activity, unemployment, relationship breakdown, suicide.

Depression

Psychiatry Depression is low mood that is not usual and persists for over 2 weeks.11

It can be a symptom of other psychiatric disorders (eg bipolar disorder, personality disorders) or a disease in its own right.12

Symptoms

Low mood, low energy, feeling worthless or guilty, poor concentration, low self-esteem, tearfulness, loss of interests, anhedonia, recurrent thoughts of suicide or death;

Somatic symptoms

Weight/appetite loss, sleep problems (early morning wakening, insomnia or excess sleeping), loss of libido, psychomotor agitation or retardation, change in mood with time of day;

Psychotic symptoms

Delusions, hallucinations.

Signs

Neglect, agitation, slowed speech or movement, poor eye contact.

Bereavement

Avoid diagnosing within 2mth of bereavement; be aware of cultural variation in grief reactions; features pointing to depression include prolonged, severe functional impairment or psychomotor retardation.

Investigations

Often none; consider an organic cause and investigate if suspected, otherwise initiate treatment and review if not working. It is paramount to document a risk assessment at each clinical contact.

Treatment

  • Psychotherapy usually cognitive behavioural therapy (cbt) (mild–moderate depression) but many other effective therapies are available (eg psychodynamic, cognitive analytic, interpersonal, eye movement desensitization reprocessing).

  • Antidepressants (Box 12.7):

    • first line: selective serotonin re-uptake inhibitors (ssris), eg sertraline, citalopram, fluoxetine

    • if a patient does not respond to ssris, consider a second-line antidepressants, eg venlafaxine, mirtazapine. Psychiatrists may use other medications for augmentation (eg antipsychotic)

  • Electroconvulsive therapy (ect) is considered if the patient is at high risk (eg not eating or drinking) and/or treatment failure.

Prognosis

Outcome is generally good with the following: young, somatic symptoms, reactive depression (due to a life-event), and acute onset.

Complications

Deliberate self-harm, unemployment, relationship breakdown, recurrence, suicide.

Schizophrenia

Psychiatry A chronic illness characterized by psychotic symptoms lasting >1mth.13

Acute presentations are often characterized by positive symptoms; negative symptoms can persist despite treatment.

Positive symptoms

Delusions, hallucinations (often auditory): see Box 12.8.

Negative symptoms

Blunted affect, apathy, loss of drive, social withdrawal, social inappropriateness, poverty of thought/speech, cognitive impairment.

Signs

Neglect, disorganized behaviour, paranoia.

Investigations

blds

fbc, U+E, LFT, Ca2+, glucose, consider TFT, vdrl, cortisol;

Urine

Toxicology;

EEG; CT/MRI.

Psychiatrists may consider tests for autoantibodies in atypical presentations.

Treatment

All people with a first presentation should be urgently referred to a mental health team either in the community (eg crisis or Early Intervention Service) or secondary care depending on the severity (risk to self: suicide, job, assets, relationships, and others).

Antipsychotic medications (neuroleptics) are the mainstay of treatment:

  • Atypical antipsychotics Have fewer extrapyramidal side effects and a better effect on negative symptoms, eg amisulpride, olanzapine, risperidone, quetiapine, clozapine; these are the preferred treatment in newly diagnosed schizophrenia, and for those experiencing side effects or relapse on conventional antipsychotics

  • Conventional antipsychotics eg chlorpromazine, haloperidol, trifluoperazine, flupentixol.

  • ► Clozapine This is a 3rd-line antipsychotic, used in treatment-resistant schizophrenia. It can cause potentially fatal agranulocytosis; monitor FBC weekly for the 1st 18wk of treatment, 2wkly for the next 34wk, and 4wkly thereafter.

Side effects

Side effects of antipsychotics include sedation, anticholinergic effects (eg dry mouth, blurred vision, constipation), extrapyramidal side effects (eg Parkinsonism) and tardive dyskinesia (late onset oral grimacing and upper limb writhing). Procyclidine may be used to reduce Parkinsonism.

Complications

Deliberate self-harm, unemployment, relationship breakdown, stigma, social isolation, drug side effects, suicide.

Anxiety disorders/neuroses

It is normal to have a degree of worry or fear. However, if this causes distress or interferes with life then it is considered abnormal. There are several types of anxiety- and stress-related disorders:15

Specific phobic

Fear of a specific situation or object, eg flying, spiders.

Social phobia

Fear in social situations, eg public speaking.

Panic attack

Excessive fear without any obvious trigger; associated with symptoms of autonomic arousal, eg sweating, dizziness, nausea, palpitations, breathlessness; usually lasts <30min.

Panic disorder

Recurrent panic attacks with fear of having another.

Generalized anxiety disorder

(gad) Excessive worry in everyday life.

Obsessive–compulsive disorder

(ocd) Obsessive thoughts, eg ‘my hands are dirty’ leading to compulsions, eg repetitive hand washing.

Symptoms

Worry, irritability, fear, avoidance of feared situations, checking, seeking reassurance, tight chest, shortness of breath, palpitations, ‘butterflies’, tremor, tingling of fingers, aches, pain.

Signs

Tremor, ↑ HR, ↑ RR; be careful to exclude any organic causes of symptoms such as breathlessness, chest pain or palpitations.

Investigations

Consider fbc, U+E, LFT, Ca2+, cardiac markers, TFT, glucose; urinary VMA; ECG to exclude organic causes of symptoms.

Treatment

Careful explanation of the cause of their problems; relaxation techniques (Box 12.9), psychological therapies, eg CBT; medications, eg SSRIs; benzodiazepine use should be avoided in panic disorder and used only for <4wks in GAD, as these have poor long-term benefits and carry a risk of dependence.

Personality disorders

Ingrained patterns of behaviour manifesting as abnormal and inflexible responses to a broad range of personal and social situations; the diagnosis is to be avoided in adolescents when the personality is still developing.

Classification

DSM-5 divides personality disorders into 3 clusters: type A (odd, eccentric; includes paranoid); type B (dramatic, emotional; includes antisocial and borderline); type C (anxious, fearful; includes dependent).

Investigations

Usually none, but they require careful assessment over multiple occasions and the exclusion of other psychiatric diagnoses.

Treatment

Personality disorders are challenging to treat. Psychotherapies may be useful, including dialectical behaviour therapy, cognitive analytical therapy, CBT, and psychodynamic psychotherapy. Antidepressants, mood stabilizers, and antipsychotics may also be used though the evidence of benefit is limited.

Complications

Suicide, self-harm, social isolation.

Insomnia

Insomnia can be classified into primary (no comorbidity) and secondary (occurs as a symptom or association with another medical or psychiatric illness, substance misuse, sleep disorder). Short-term insomnia lasts <4 weeks and long term insomnia >4 weeks.16

Management: short term

  • First line options16: ear plugs and eye masks should be offered. Advice about good sleep hygiene (lack of electronics, caffeine, alcohol, evening exercise, bedtime routine, optimize sleeping environment).

  • If daytime impairment is severe, hypnotics are an appropriate choice for short-term insomnia only. Use lowest dose possible and ideally not for longer than 2 weeks.

  • Short acting benzodiazepines—temazepam, loprazolam, lormetazepam. Use lower dose in elderly

  • ‘Z drugs’—zopiclone, zolpidem, and zaleplon. Zopiclone: good for sleep initiation and maintenance but longer half-life may cause hangover effect, 3.75–7.5mg usual dose. Zolpidem: good for sleep induction and short half-life reduces hangover effect. Modified release version (if available) may be helpful for sleep maintenance (5–10mg usual dose).

Management: long-term

Refer for psychological therapy (CBT), sleep specialist clinic.16 Hypnotics are generally not recommended. There may be a role for modified-release melatonin in people >55 years old and those with sleep dysregulation disorders. However, the uncertain long-term safety profile of melatonin limits widespread use.

See Box 12.10 for advice on managing anxiety in yourself and other people.

Notes:

1 If a patient poses a risk to themselves or others any doctor can give emergency sedation, without the patient’s consent and with restraint, under the Mental Capacity Act (2005).

2 NICE guidelines available at Psychiatryguidance.nice.org.uk/CG115

3 NICE guidelines available at Psychiatryguidance.nice.org.uk/CG103

4 Typically ‘out-of-hours’, when you may be asked to review while on-call.

5 Inouye SK, et al. Ann Intern Med. 1990;113:941 (requires subscription).

6 NICE guidelines available at Psychiatryguidance.nice.org.uk/CG42

8 Holsinger T, et al. JAMA 2007;297:2391 (available free online at Psychiatryjama.ama-assn.org/cgi/content/full/297/21/2391).

9 Cullen B, et al. J Neurol Neurosurg Psychiatry 2007;78:790 (available free online at Psychiatryhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC2117747).

10 See Psychiatry Box 3.10 (p. [link]) for details of the DSM-5 and ICD-10 classification systems.

11 NICE guidelines available at Psychiatryguidance.nice.org.uk/CG90

12 A depressive episode is classified by DSM-5 as minor or major and may be associated with somatic symptoms or psychotic symptoms; major depressive disorder is the recurrence of major depressive episodes without mania; ICD-10 use the terms mild, moderate, and severe, adding recurrent if more than one episode without mania. See Psychiatry Box 3.10 (p. [link]) for details of the DSM-5 and ICD-10 classification systems.

13 NICE guidelines available at Psychiatryguidance.nice.org.uk/CG178

15 NICE guidelines available at Psychiatryguidance.nice.org.uk/CG113

16 NICE CKS insomnia guidelines available at Psychiatryhttps://cks.nice.org.uk/insomnia