What study materials people use preparing for paper B MRCPSych

• Cambridge stats course. It runs online over a weekend and is excellent.
• SPMM
• MRCPSych Mentor

Biopsychosocial Model of Healthcare and doctor-patient relationship

The biopsychosocial model of healthcare emphasizes the following paradigms of doctor-patient relationship

• Psychosocial assessment,
  
• Use of communication skills,
  
• Informational care,
  
• Counseling,
  
• Crises intervention, and
  
• Extension of care to the family.
  

  
   

 

"The biopsychosocial model is an interdisciplinary model that looks at the interconnection between biology, psychology, and socio-environmental factors. The model specifically examines how these aspects play a role in topics ranging from health and disease models to human development. George L. Engel developed this model in 1977 and is the first of its kind to employ this type of multifaceted thinking. The biopsychosocial model has received criticism about its limitations but continues to carry influence in the fields of psychology, health, medicine, and human development."

Source: Biopsychosocial model - https://en.wikipedia.org

Mental Health Professionals As ‘Silent Frontline Healthcare Workers’: Perspectives from Three South Asian Countries

Sheikh Shoib¹, Anoop Krishna Guppta², Waleed Ahmad³, Shijo John Joseph⁴, Samrat Singh Bhandari⁴

Abstract

Mental health professionals across the globe foresaw the mental health impact of the coronavirus disease 2019 (COVID-19) pandemic. They have faced a scarcity of trained professionals, rising morbidities, lack of protective gear, shortage of psychotropic drugs, and poor rapport building because of masking and social distancing. Amidst all, they have responded with approaches that focus on continuing mental health services to the patients already in care, educating the vulnerable people to help them cope with these stressors, and providing counselling services to patients and families affected by the pandemic.

LEAD-IN

The unprecedented impact of the coronavirus disease 2019 (COVID-19) pandemic has caused a jolt to various realms of life and various groups of people globally. There is a plethora of mental health and psychosocial issues associated with COVID-19. The psychological repercussions of the pandemic in the general population and amongst health professionals may last a long time compared to the acute medical crisis. The enduring outcomes of this pandemic are not yet fully estimated. Early screening of mental health and timely action can go a long way in improving the quality of people affected.[1,2] Mental health professionals across the globe foresaw the mental health impact of such an extraordinary crisis and have responded with approaches that focus on continuing mental health services to the patients already in care, educating the vulnerable people to help them cope with these stressors, and providing counselling services to patients and families affected by the pandemic.

Examples from all over the globe have proven that mental healthcare workers have been on the frontline but, peculiarly, deal with the crisis times. Among other regions in Italy, in Lombardi, Mental health workers provided mental health services to the citizens most severely struck by the pandemic on priority, and providers ensured continuous provision. [3] The psychiatry service in Spain formulated a contingency plan reorganising human resources, closing some units and shifting to telepsychiatry practice, alongside two programmes specifically focusing on the homeless.[4] Comparable changes have been described and suggested in the United States[5] and France[6] to strengthen mental healthcare delivery during challenging times. The United Kingdom Academy of Medical Sciences and Mental Health Charity took the initiative in the early weeks. They suggested the acute need for quality research to discover the vulnerable groups and the effects of COVID-19 on the brain’s functioning.[7] China provided telemental health services, including supervision, training, and psychological services (counselling and psychoeducation) to the people highly susceptible to the infection.[8] In Australia, officials increased the funded services and appointed consultants and specialists, whereas they did not focus on facilitating the people in mental health services.[9] In Malaysia, online counselling services and psychological first-aid were provided to the people throughout the pandemic by utilising reactive support systems.[10]

The authors have, with this, thrown some light on their perspectives on the contributions of mental health professionals as frontline healthcare workers in India, Pakistan, and Nepal.

THE REPUBLIC OF INDIA

A report from the World Health Organization (WHO) mentions the Government’s total expenditure on mental health in India as 1.30 % of the overall government health expenditure. The country has only 0.29 psychiatrists per 100,000 people.[11] There is undeniably a shortfall in the quantity and quality of mental health services and their distribution in the country. Another publication estimates the number of psychiatrists in India currently as about 9000 and the number of psychiatry graduates per year as about 700. Based on these estimates, India has 0.75 psychiatrists per 100,000 population, against the preferable number of at least three psychiatrists per 100,000. With 3 psychiatrists per 100,000 population as the preferable number, the study mentions that the number of psychiatrists required to reach the desired ratio in India is 36,000. The country is currently short of 27,000 psychiatrists based on the current population.[12] According to a survey conducted by the Indian Psychiatric Society (IPS), there has been an increase in cases of mental health disorders in India by 20% within a week of the commencement of the nationwide lockdown. The country can anticipate a major mental health crisis resulting from unemployment/loss of jobs, alcohol use issues, financial adversity, intimate partner violence, and monetary liabilities in the subsequent months. The at-risk population comprises around 150 million persons with existing psychological issues, survivors of COVID-19, frontline healthcare workers, youngsters, differently-abled persons, female adults, those working in unorganised sectors/immigrant workers, and older adults. The current need is to construct a community-based capacity to manage local issues long after the acute stage of the pandemic.[13]

Considering the potential of relapse of illness, if psychotropic medications are not made available to patients due to a lack of new prescriptions, society has asked to relax the norms so that patients can get their refills with old prescriptions or through online prescriptions till the crisis is over.[14] The various state branches under the aegis of IPS have made available a list of over 650 psychiatrists who have volunteered to meet the need of the affected population. This voluntary telepsychiatry service will provide psychological support to patients with pre-existing psychiatric conditions and healthcare workers involved in the care of COVID-19 patients.[15]

To assist, educate, and advise psychiatrists towards providing telepsychiatry services as a routine in their clinical practice, IPS and the National Institute of Mental Health and Neuro Sciences (NIMHANS) have brought out an operational guide aimed at practising psychiatrists in India as well as low and middle-income countries (LAMIC). This guide covers legal, technology, electronic case documentation, consultation, online prescription, teletherapy aspects, basic minimum standards for documentation, and proformas for ready reference and use by the patients/their relatives/nominated representatives, and the psychiatrists.[16] With practice guidelines and standard operating procedures available, telepsychiatry seems well set for gaining wider acceptance and adoption in India.

THE ISLAMIC REPUBLIC OF PAKISTAN

In Pakistan, mental health service providers have responded similarly and have faced special challenges. There is a shortage of mental health professionals, with only a few hundred fully trained psychiatrists and almost non-existent psychotherapeutic services. The current pandemic has worsened the situation even further. Psychiatrists and other mental health professionals have responded with various programmes to mitigate the impact of COVID-19 on the mental health of the citizens and the mental health services. Almost all hospitals across Pakistan provide free telepsychiatry services to patients in their respective areas. Similarly, the Pakistan Psychiatric Society has been active in supporting the nation’s mental health, carrying out social media awareness campaigns and making suggestions to the Government of Pakistan to take steps in this direction.[17] The Aga Khan University Hospital, Karachi, launched a mental health programme for children and adolescents to help and train parents to do therapies at home and enable them to deliver rehabilitation to their children in such needs.[18] Likewise, an Online Mental Health Rapid Response Team started providing counselling to patients from remote areas of Pakistan.[19]

Because of the lack of reliable internet connectivity across the country, especially in rural areas, and low education rates, providing internet-based services has not been without its own problem. The consensus among psychiatrists is that patients have not been seeking telepsychiatry services as expected. Similarly, the response of the Government of Pakistan has been lukewarm.

THE FEDERAL DEMOCRATIC REPUBLIC OF NEPAL

The Nepalese society believes that a doctor should always work selflessly despite the pain. Health professionals in Nepal have already been facing anxiety and depression.[20] Lack of personal protective gear, inadequate hospital infrastructure, stigma towards healthcare workers, and lack of governmental preparedness have worsened the already prevalent burnout in a resource-deprived health system.[21-24]

Mental healthcare workers (MHW) face additional hindrances. Uses of masks and social distancing in psychiatry have only blunted the interview and therapeutic effects due to poor rapport and slowed communication.[25] MHWs have been working in a situation where a psychiatric pandemic is looming over. They are known and expected to spend more time than other professionals due to extensive history, psychotherapy, and counselling. They are expected to listen patiently and lend tissue to weeping patients daily during a pandemic or later. Thus, limited contact or exposure is impractical.

Most of the psychiatrists in Nepal are known to serve through satellite clinics. They have not been able to continue that since the Government implemented the country-wide lockdown on March 24, 2020.[26] In the absence of consultation, old cases have worsened, and an increased suicide rate during the pandemic.[21] The unavailability of medicines in rural areas has added to the misery. Local pharmacists tend not to provide psychotropic drugs without a prescription. Nepal has only 0.36 psychiatrists per 100,000 population.[27] Amidst this, they have been working without complaining. Additionally, they have used online social platforms and telepsychiatry to serve the needy. Most of the service they offer is for free. The Psychiatrists’ Association of Nepal has provided free helpline numbers. Local psychiatrists have volunteered, and each has received up to 30 calls per day! Some have been posting educational videos, while others are attending webinars and discussions on social media intending to alleviate anxiety and combat depression in the general population. Several pages and blogs have been created over the last few months, and the only reward expected is someone being benefited. This has been useful in LAMIC before.[28]

In conclusion, the silently working Nepalese psychiatrists are likely to have increased work after the lockdown is lifted shortly. We suggest task shifting as a handy tool to serve Nepalese remotely located on the rugged landscape. We need to train local community workers and paramedics to assist the overworked MHWs.

LEAD-OUT

Hopefully, perspectives from these three South Asian countries will take the readers through a roller coaster ride of the role of mental health professionals on the frontline. It highlights the lack of mental health professionals to face the impending psychiatric pandemic. The common hindrances faced by India, Pakistan, and Nepal are poor social connectivity, possible scarcity of psychotropic drugs, and failed outreach clinics. The complex landscapes, especially in the northern part of these three countries, have added to the misery. However, the silver lining that appears to be is telepsychiatry that can make it possible to reach the socially and geographically distanced population (Table 1).

It is also imperative to focus on survivors and healthcare professionals following the pandemic in alleviating the burden of distress in humans. Peer support can alleviate this anguish, encouraging social connections and improving physical safety. Social distancing need not be emotional distancing. Also, there cannot be a better time than now to promote Mental Health Gap Action Plan (mhGAP). Thus, psychiatrists can train local practitioners and primary care physicians to treat and counsel local patients under supervision. This is likely to alleviate mounting stress for mental healthcare workers. Last but not least, the health of MHWs needs to be prioritised by the respective governments to sustain the health system during the psychiatric pandemic that is likely to follow.

About the Authors

¹Jawahar Lal Nehru Memorial Hospital, Srinagar, Jammu and Kashmir, India, ²National Medical College, Birgunj, Nepal, ³Department of Psychiatry and Behavioural Sciences, Peshawar Medical College, Mercy Teaching Hospital, Peshawar, Pakistan, ⁴Department of Psychiatry, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India

NICE Guidance on Electroconvulsive Therapy

NICE recommends to use electroconvulsive therapy (ECT) only to attain quick and short-term improvement of severe symptoms if an adequate trial of other options has not been effective and/or when the condition is considered to be potentially life-threatening, in individuals with:

• catatonia
  
• a prolonged or severe manic episode.
  

Indication to an individual must be based a documented assessment of the risks and potential benefits to the individual.

Exercise caution when considering electroconvulsive therapy during pregnancy, in older people, and in children and young people.

Valid consent should be obtained in all cases where the individual can grant or refuse consent. The decision to use electroconvulsive therapy should be made jointly by the individual and the clinician(s) responsible for treatment, based on an informed discussion after full information about the risks and potential benefits, without pressure or coercion, the involvement of patient advocates and/or carers is strongly encouraged.

If informed consent is not possible advance directives should be taken fully into account.

Clinical status should be assessed following each electroconvulsive therapy session and treatment should be stopped when a response has been achieved, or sooner if there is evidence of adverse effects.

Cognitive function should be monitored on an ongoing basis, and at a minimum at the end of each course of treatment.

Repeat Course

Consider a repeat course under the circumstances indicated for patients who previously responded. In patients who have not previously responded, a repeat trial should be undertaken only after all options have been considered and following discussion with individual/carer/advocate.

Schizophrenia

Do not recommend to patients with schizophrenia.

Depression

For patients with depression, see use electroconvulsive therapy as recommended in the NICE guidance on the treatment of depression.

What are the components of the Positive behavior support (PBS)

Components of the Positive behavior support (PBS)

1. System change
   
2. Environmental alterations
   
3. Skill intrusion—teaching the student alternative behaviors
   
4. Behavioral consequences

What is functional communicative training?

Functional communicative training:

Teaching children to ask for what he/she wants through language instead of problem behavior.

What is the approximate salary package in the psychiatric department for a junior doctor?

Is it different from the ED salary packge for a junior SHO level?
My current packge is 42,969 plus 50% banding = 64,453 per annum in emergency duty, junior level non-trainee post.
Will it decrease if I move to a non-trainee SHO (speciality house officer) post in the same trust in psychiatry?

£64,000 is a good salary for a junior doctor.
The salary packages depend on level of responsibility and frequency of oncalls.
All jobs advertised will have a range & given your previous experience you can ask them to give you higher side of the range

It will definitely go down but you will have more time and more work life balance,—more valuable than money.

I assume your salary is so high as there is so much unsocialable hours. I imagine base salary will be the same but total less as just some twilights, night and weekends- normal day will be 9-5. It should say pay in the job description

Can you apply for the MTI UK Scheme before passing MRCPsych?

You do not need to pass MRCPsych paper-A or Paper B before you apply for the MTI. You can apply to the program before passing any part of the MRCPsych exams. The following are your requirements to enter the MTI scheme. 

1. GMC-recognized primary medical qualification from an internationally accepted medical institution. 
2. An acceptable internship (or equivalent) of 12 months. 
3. Three years of experience working in Psychiatry in the last five years. 
4. Working in psychiatry for the last year. 
5. A score of 7.5 in IELTS academic or grade b on OET taken in the last 18 months.  
6. You have received or will work towards a postgraduate qualification in psychiatry.

What is the discrete trial format?

The discrete trial format:

It is one to one, Short and clear instructions, Planned, uses prompting and prompt fading, reinforcement.

What was the 1970s psychoanalytic approach to children with autism?

The 1970s psychoanalytic approach:

Applied Behavior Analysis (ABA), based on operant-conditioning, target behaviors (excess of unwanted and or deficits of wanted) are modified with reinforcement approximations (shaping).

Applied behavior analysis, also called behavioral engineering,
applying empirical approaches based upon the principles of respondent and operant conditioning to change behavior of social significance. It is the applied form of behavior analysis; the other two forms are radical behaviorism and the experimental analysis of behavior. (Wikipedia)

1960s Psychoanalytic Approach to Children with Autism

The 1960s psychoanalytic approach to children with autism:

Base on Lovaas- socialization study

Building social behavior in children with autism by use of electric shock. Method- use of identical twins: Tell them to come here and shock them until they move toward the experimenter. They based applied behavior analysis on it, supported by decades of research behind the Lovaas approach and more if you include the research into Skinner's theories, on which they base it.

Predictors of response

1. Early: better the outcome in younger children. 
2. Intensive more sessions per week. 
3. Duration: longer duration of therapy. 
4. With Parents: Children accompanied by parents in therapy do better.

What are the psychoanalytic approaches to the treatment of patients with autism?

Holding therapy (Tinbergen 1983):
A failure to bond Parent holds child to cause the autistic defense to crumble.

Humanistic play therapy (Axline 1965): Encouraged the expression of feelings through play and unconditional positive regard.

OPTIONS (Kaufman 1976) Parents spent every waking hour with child follow child lead

Factors that Obstruct Effective Communication

The following factors can interfere with effective communication during clinical assessment. 

• Lack of exclusivity, for example, assessment on the bedside inside a unit of 20 patients. 
• Anxiety by a doctor, because of which divides their attention and concentrating, not the assessment is difficult. 
• Awkward seating that makes it difficult to relax while assessing a patient. 
• Lack of attention to the nonverbal cues
• Offensive remarks.
• Frequent interruptions. 
• Selective listening.
• Daydreaming. 

What are the techniques of active reading and learning?

1. Read the summary to get an idea
2. Study the table of contents
3. Read all the bold faced excerpts and boxed summary
4. Leaf through the entire chapter
5. Identify the most important and unfamiliar words
6. Highlight the key points
7. Develop deeper understanding
8. Compare to your previous concepts

What are the characteristics of a physician according to the holistic medicine?

Belief in potential of healing act
Capacity to listen and empathies
Respect and dignity of humans
Tolerance to difference of opinion
Gentle spirit
Ability to mix creative thinking
Never give up.

What are the different types of doctor patient relationship?

Vertical model
Teacher student model
Mutual participation model
Informational care model

Capacity and Consent for MRCPsych Exams

Capacity and Consent

What is the definition of consent?

Consent is permission for something to happen or agreement to do something consent is to give permission for something to happen

What do you need for valid consent?

Given freely without duress or coercion legally capable of consenting cover the intervention/procedure it must be informed it has to endure the time needed for treatment. 

If a patient consents to treatment can they then change their mind?

Yes, either before treatment or at any point during treatment. 

What information do you have to portray to the patient when trying to get consent?

What the treatment consists of the main beneficial effects, risks, and unwanted side effects of treatment.

What sort of additional aids could you use in trying to obtain consent?

Written/ visual aids translators’ friends/relatives time to reflect- especially if a large treatment

What is capacity?

Capacity is the ability to make a decision

What is the capacity to consent like in delirium?

As delirium is a fluctuating illness at some points during the day, they will have the capacity and at other points, they will not.

Once someone has the capacity is it definite that the individual has full capacity?

False- you can have the capacity to make a decision about one thing but not have the capacity for another decision capacity can also fluctuate over time

If consent is needed for a treatment who should take the consent?

The person conducting the treatment/procedure

What 3 things must you be able to do to have capacity?

1. Understand and retain relevant information
2. Use and weigh that information to make a decision
3. Communicate that decision

When can you use the Adults with Incapacity Act?

If the person is incapable of acting or making decisions communicating decisions, understanding decisions, or retaining the memory of decisions

What is the general overall reason for using adults with incapacity act?

In relation to any matter by reason of mental disorder or of inability to communicate because of physical disability

What can cause the disability that would require the use of the adults with incapacity act?

Mental disorder or physical disorder

What sort of things can a patient not be able to do for you to use the adults with incapacity act?

They aren't able to understand 

1. The purpose of the intervention, its nature, and purpose and why it is being proposed
2. The main benefits/ risks and alternatives
3. Consequences of not receiving an intervention

Should we assume capacity?

We should assume capacity until proven otherwise.

What is the age for most people being thought of as having capacity?

Age 16 and onwards

You always must have the legal documentation and paperwork in order before you use the mental health act or Adults with Incapacity Act--true or false?

This is not true. In an emergency deal with the situation first and then deal with the paperwork

What are the principles of the adults with incapacity act?

1. Intervention must benefit the adult
2. Such a benefit cannot reasonably be achieved without the intervention
3. Take account of past and present wishes
4. Consult with other relevant persons
5. Encourage the adult to use residual capacity

Should you move to use the Adults with Incapacity Act quickly?

No, you should try and get capacity, and then if you can’t then use the Adults with Incapacity Act.

What are the main things you need to know about the Adults with Incapacity Act?

Section 47 certificate of incapacity power of attorney guardianship

What is the role of the Adults with Incapacity Act section 47 certificate?

Authorize practitioner to provide reasonable interventions related to the treatment authorized

Does section 47 certificate of the Adults with Incapacity Act allow you to use force?

No, it does not authorize you to use force unless its immediately necessary and only for as long as necessary

Does the AWI section 47 certificate allow you to transport an individual?

No, you can’t move the patient to the place of treatment

If you have an adult that needs to be transported to a place of care under the AWI section 47 certificate how can you move them to a place of treatment?

Emergency order from the mental health act or get a warrant to move them

The bottom line when would you use AWI section 47?

Use to authorize the treatment of a physical disorder in someone without the capacity to consent to that treatment

Who fills out the section 47 AWI form?

The most senior treating clinician

When will someone appoint a power of attorney?

Whilst they still have the capacity.

What roles do the power of attorneys have?

They can act in decisions relating to their financial or health welfare

What is the point in a power of attorney?

It is a person that the patient trusts to help make decisions for them in case they lose capacity at some point. 

Can you only have one power of attorney?

No, you can have more than one. 

Who applies for guardianship?

One or more individual or local authority. 

Who grants guardianship?

The sheriff. 

What does the guardianship there for?

To watch out for your welfare or financial status

What is the overall reason for guardianship?

When the person required someone to make specific decisions on their behalf over the long term, but they have now lost capacity so cannot appoint a power of attorney. 

What powers does a welfare guardian have?

They can have a role in voicing the treatment that the patient will get but they cannot place the adult in hospital for treatment of a mental disorder against their will.

What happens if the patient does not comply with the wishes of the welfare guardian?

The sheriff can issue a compliance order. 

If you have a patient with a mental illness that needs to be placed in the hospital what should you use to do this

Use the Mental Health Act. 

Is this true that a welfare guardian can make decisions on a patient’s behalf but cannot enforce them?

TRUE

What is the role of the mental health act?

It allows for the treatment of mental disorders or the physical consequence of a mental disorder in someone without the capacity to consent to treatment

What are the 3 different sections of the mental health act

Emergency detention certificate short term detention certificate compulsory treatment order

What are the criteria that you have to meet for emergency detention under the mental health act?

1. Likely to have a mental disorder
2. Significantly impaired decision-making ability regarding treatment due to mental disorder 
3. Detention in hospital is necessary as a matter of urgency to determine what treatment is needed
4. The risk to health, safety, or welfare of the person or the safety of others
5. Making arrangements for s44 would involve undesirable delay

What are your criteria for short term detention under the mental health act?

1. Likely to have a mental disorder.
2. Dignificantly impaired decision-making ability regarding treatment, due to mental disorder
3. Detention in hospital is necessary for assessment of treatment 
4. Risk to health, safety or welfare of the person, or risk of safety of others
5. Cannot be treated voluntarily

What controls whether a young person is able to consent to treatment?

Are they able to make decisions through understanding them and weighing the options?

At what age in Scotland are you presumed to have capacity?

16

Can you give your own consent under the age of 16?

Yes, if deemed to have capacity using Gillick competence

What does a young person have to be able to do to be deemed as having capacity?

Understand the nature, purpose, and consequences of investigation or treatment understand the consequences of not having treatment understand, retain, use and weigh this information and communicate their decision

Do you want the parents involved in capacity and consent with children?

Yes, as far as possible.

What do you do if you have a child under the age of 18 that doesn't have capacity?

You can ask one parent for consent - do not need both if both parents disagree then seek legal advice

Is there a lower age limit for the mental health act?

No

If you have to force treatment on a child is it better to use the mental health act or parental consent?

Mental health act - you are more protected and the relationship between carer and patient is still intact

When in particular in children would you want to use the mental health act as backing over parental consent?

If you must use force if you have to use IM medication nasogastric feeding and electroconvulsive therapy

Open Ended Questions

An open-ended question is one that puts the least restrictions over the answer to a select option-list. For example, an open-ended question to assess the thoughts would be:

What do you think about most often?

You can already notice, it is impossible to ask an absolute-open ended question. 

For the purpose of the Research Workshop, the College of Physicians and Surgeons states: 

Open-ended questions elicit detailed responses and provide no preselected options. These types of questions are the hallmark of qualitative research.  

Also, learn the advantages of open-ended questions. 

The new Maudsley Practice Guidelines for Physical Health Conditions in Psychiatry

New: The Maudsley Practice Guidelines for Physical Health Conditions in Psychiatry 

Authors: David M. Taylor, Fiona Gaughran, Toby Pillinger

The Maudsley Practice Guidelines for Physical Health Conditions in Psychiatry provide an evidence-based and practical approach for psychiatric and general practitioners to screen, investigate, and manage common physical health conditions observed in persons with severe mental illness. The book bridges the gap between psychiatric and physical health care for the seriously mentally ill and is written by an extraordinary team of acknowledged professionals in medicine, surgery, pharmacy, dietetics, physiotherapy, and psychiatry.

The Maudsley Practice Guidelines for Physical Health Conditions in Psychiatry cover the following: 

• Assessment and care guidelines for well over a hundred various medical and surgical presentations encountered often in persons with major mental illness.
• Physical health emergencies in the psychiatric context.
• Evidence-based methods for the treatment of psychiatric drugs' physical adverse effects
• Advice on how to help persons with major mental illness live a healthier lifestyle, such as quitting smoking and making dietary and physical activity modifications.

The Maudsley Practice Guidelines for Physical Health Conditions in Psychiatry is ideal for both psychiatrists and general practitioners who want to enhance the quality of care they deliver to persons with significant mental illness.

The 753-page Book comprises 88 Chapters grouped under 15 parts—each based on a speciality such as cardiology, endocrinology, gastroenterology and emergency medicine. 

About the Authors

David M. Taylor 

BSc, MSc, PhD, FCMHP, FFRPS, FRPharmS, FRCP (Edin)

Director of Pharmacy and Pathology, Maudsley Hospital; and Professor of Psychopharmacology, King’s College, London, UK

Fiona Gaughran

MD, FRCP(I), FRCP (Lon), FRCP (Edin), FRCPsych, FHEA

Lead Consultant Psychiatrist, National Psychosis Service (Bethlem Royal Hospital); 

Director of Research and Development, South London and Maudsley NHS Foundation Trust; 

Reader in Psychopharmacology and Physical Health, King’s College, London, UK

Toby Pillinger 

MA (Oxon), BM BCh, MRCP, PhD

Academic Clinical Fellow, South London and Maudsley NHS Foundation Trust 

and the Institute of Psychiatry, Psychology and Neuroscience, Kings College, London, UK.

Age Disorientation in Schizophrenia

1. Age-disoriented patients are cognitively more impaired than their age-oriented counterparts.
2. Whether the cognitive impairment is present to a greater degree premorbid among these patients, studies have not yet established this, but some data support this.
3. Others have reported that rated school performance and grade-level do not distinguish age-disoriented from age-oriented subjects.
4. Some have suggested that marked cognitive decline occurs following the first break. 
5. Harvey et al. reported that age-related decline in mini-mental state examination scores is dramatically greater among age-disoriented schizophrenia patients than age-oriented subjects, consistent with more rapid deterioration.
6. Examination of the specific PANSS items revealed that the age-disoriented group was consistently more delusional and more conceptually disorganized and showed increased stereotyped thinking, motor retardation, unusual thought content, disorientation, and poor attention.
7. There was no relationship between the proximity of assessment month to birth month and the severity of age disorientation.
8. There was no relationship between total mini-mental state examination score and either rote memory on the Miller-Selfridge recall task context memory on the same recall task or the type/token ratio generated from the speech sample.
9. Age-disoriented patients have certain more severe psychiatric symptoms, more voluntary motor disturbances, more orofacial involuntary movements, and more severe non-localizing sensory signs.
10. Most of the assessed cognitive abilities of the age disoriented (i.e., mini-mental state examination performance, context memory, speech repetitiveness) are more disrupted than those of matched age-oriented schizophrenic control subjects.
11. Within the age-disoriented group, there was no relationship between mini-mental state examination total scores and other cognitive features, suggesting that age disorientation is not merely an issue of increased severity.
12. More severe motor abnormalities predict poor outcome. 
13. Studies have associated the emergence of involuntary orofacial movements with more severe cognitive decline among schizophrenic samples, irrespective of age disorientation.

Advantages of Open-Ended Questions

What are the advantages of open-ended questions?

During the clinical assessment, open-ended questions are always preferred to close-ended questions. there are several advantages to the open-ended questions. 

If you still don't know What are Open-Ended Questions?

1. Open-ended questions allow patients to start talking about themselves and puts them at ease as they have the floor. 
2. Allows you time to think and plan areas of questioning as you assess their style and content of the response.
3. Allows a period of non-verbal response from interviewer; listening and facilitating. 
   
   >> Just slight info: To Have the floor means to have the right or opportunity to speak in a group, especially at a formal event or gathering. 

Please, Dr. Dunstaple, your colleague has the floor. You'll have the opportunity to reply when he has finished speaking. 

Clinical Vignette: Management of a Patient with Treatment-Refractory Depression

Mr X is a known case of depressive illness for the last 1 year. He has stopped responding after two different groups of antidepressants were tried and has been labelled as a patient of treatment-resistant depression. 

1. How will you assess the cause of this resistance?
2. Write the treatment algorithm that you will follow for his management?
3. If you had to start lithium in this case, what protocol would you follow to start it and how will you monitor it?

Treatment Options for Refractory Depression

Vignette: Assessment of Depression

A 33-year-old man who is a driver-by-profession presented to you with decreased appetite, loss of sleep, and irritability for the last three months. There is no past or family history of psychiatric conditions. He is the only earning member of his family and must go to work every day to make a living. On physical examination, his pulse is 90 beats per minute with an irregular rhythm.

a) Outline your assessment and management plans.
b) What precautions you will take while prescribing psychotropic medications in this case?
c) Enumerate all possible differential diagnoses in this case.

Assessment of Treatment Resistance in Depression

 Assessment of Treatment Resistance  

1. Reconsider the diagnosis, especially considering bipolar depression and hypothyroidism.  
2. Identify comorbidities.  
3. Ensure that adequate dosages for adequate durations have been given 
4. Confirm adherence to treatment  
5. Evaluate for maintaining factors and repeated experiences of stressful circumstances.

Delusions in Psychotic Depression

(Mnemonic: GINPH)

● Delusions of Guilt

● Delusions of Impoverishment (can also be considered as a type of nihilistic delusion.

● Nihilistic delusions, including Cotard syndrome

● Persecutory delusions*

● Hypochondriacal delusions

Patients with Psychotic depression  consider these thoughts well-deserved unlike in schizophrenia where patients feel remorse towards them and mania where patients consider them a response to the great position they have earned. 

When these delusions occur against a background of depressed mood, they are mood-congruent and favor the diagnosis of psychotic depression. When patients with depression have delusions of grandeur or even neutral delusions e.g. delusions of reference, they are mood-incongruent delusions" and favor the diagnosis of schizophrenia (ICD-10).

Psychosis Versus Neurosis

What is psychosis?
A psychiatric disorder in which the thoughts, affective-response, ability to recognize reality, and ability to communicate and relate to others shows impairment sufficient to interfere grossly with the capacity to deal with reality. The classic characteristics of psychosis are.


Impaired reality testing
Hallucinations
Delusions
Disorganization.

Psychosis

1. Insight is absent in patients with psychosis. 
2. In patients with psychosis, there is an impairment in judgment and reasoning. 
3. They lose contact with reality. For example, they believe in the voices they hear. 
4. Delusions are often present. Delusions are psychotic features and are never normal (if a belief meets any criteria of normality, it's not a delusion). 
5. True hallucinations are present, even though hallucinations, especially hypnagogic and hypnopompic hallucinations, also occur in normal people.  
6. Patients with psychosis may exhibit changes in personality, especially patients with schizophrenia with a chronic course. 

Neurosis

1. In patients with neurosis, insight is present to a greater extent.  
2. there is no impairment in judgment and reasoning in patients with neurosis. 
3. These patients do not lose contact with reality, so, for example, even if they experience hallucinations, they acknowledge them as being abnormal. 
4. Delusions do not occur in patients with neurosis. 
5. True hallucinations are usually absent, except for hypnopompic and hypnagogic hallucinations. 
6. Change in personality is unusual. Patients with repeated traumatic experiences may still exhibit personality changes.