Psychiatry Clinical Reference and Management Notes
Posted on May 28, 2026 in Medicine
Obsessive-Compulsive Disorder (OCD)
Core Concepts
| Term | Definition |
|---|
| Obsession | Intrusive, unwanted thought |
| Compulsion | Repetitive act to reduce anxiety |
- Diagnosis: Symptoms persist >2 weeks
- Usually has preserved insight
- SSRIs: Higher doses needed; response may take ≥12 weeks
Management
| Severity | First-Line |
|---|
| Mild impairment | CBT + ERP |
| Severe / poor CBT response | Add SSRI |
| Severe functional impairment | Refer secondary mental health |
Exposure and Response Prevention (ERP)
- Expose patient to anxiety trigger
- Prevent compulsive behaviour
Pharmacology
| Drug | Key Point |
|---|
| Clomipramine | Alternative first-line |
| Clomipramine SEs | Dry mouth + weight gain |
Depression
Management
| Severity | Treatment |
|---|
| Less severe | Guided self-help |
| More severe | CBT + antidepressant |
- SSRIs are first-line antidepressants
- Continue antidepressants: ≥6 months after remission
Pseudodementia vs. Dementia
| Depression | Dementia |
|---|
| Rapid onset | Gradual onset |
| Global memory loss | Short-term memory loss |
| Sleep disturbance common | Less prominent |
Electroconvulsive Therapy (ECT)
Indications
- Treatment-resistant depression
- Catatonia
- Severe/life-threatening depression
Side Effects
- Memory impairment
- Arrhythmias
Mirtazapine
| Useful Effects | Clinical Use |
|---|
| Sedation | Insomnia |
| Increased appetite | Poor appetite/weight loss |
Cotard Syndrome
- Delusion that the patient is dead or non-existent
SSRIs and Antidepressants
Important Associations
| Fact | Association |
|---|
| Hyponatraemia | SSRIs |
| QT prolongation | Citalopram |
| Child SSRI | Fluoxetine |
| Post-MI SSRI | Sertraline |
| Long half-life | Fluoxetine |
Dangerous Combinations
| Combination | Risk |
|---|
| SSRI + MAOI | Serotonin syndrome |
| SSRI + NSAID | GI bleed (give PPI) |
| SSRI + triptan | Serotonin syndrome |
Switching SSRIs
| Situation | Action |
|---|
| Fluoxetine → another SSRI | Stop + wait 4–7 days |
| Citalopram/sertraline/paroxetine → another SSRI | Direct switch |
Discontinuation Syndrome
- Symptoms: Dizziness, electric shock sensations, anxiety, GI upset/diarrhoea
- Management: Reduce gradually over 4 weeks
Pregnancy Risks
| Drug/Timing | Risk |
|---|
| SSRI 1st trimester | Congenital heart defects |
| SSRI 3rd trimester | Persistent pulmonary HTN newborn |
| Paroxetine | Congenital malformations |
Anxiety Disorders
Generalized Anxiety Disorder (GAD)
- Rule out thyroid disease
- Risk factor: Being divorced/separated
- Management: First-line is SSRI (sertraline); if ineffective, try another SSRI or SNRI
Panic Disorder
- SSRIs are the most common treatment
PTSD and Acute Stress Disorder
Acute Stress Disorder
- Timing: Within 4 weeks of trauma
- Treatment: Trauma-focused CBT
Post-Traumatic Stress Disorder (PTSD)
Core Features
- Re-experiencing (flashbacks/nightmares)
- Avoidance (avoiding reminders)
- Hyperarousal (hypervigilance/sleep problems)
- Symptoms persist >1 month
Management
- First-line: Trauma-focused CBT or EMDR
- If ineffective: SSRI or venlafaxine
Alcohol Withdrawal
Timeline
| Time | Feature |
|---|
| 6–12 hrs | Withdrawal symptoms |
| 36 hrs | Seizures |
| 72 hrs | Delirium tremens |
Delirium Tremens
- Hallucinations, confusion, delusions, autonomic instability
Management
- Standard: Chlordiazepoxide or diazepam
- Liver cirrhosis: Lorazepam
- Assessment: CIWA scale
Korsakoff Syndrome
- Anterograde amnesia, retrograde amnesia, confabulation
Alcohol Units
Units = [Volume (ml) x ABV] / 1000
Eating Disorders
Anorexia Nervosa
- Features: Lanugo hair, bradycardia, cold intolerance, hypercarotenaemia, amenorrhoea
- Metabolic pattern: Most things low; Growth hormone, glucose, salivary glands, cortisol, cholesterol, and carotinaemia are high
- Management: Family therapy for children/adolescents
Bulimia Nervosa
- Features: Binge eating and purging (vomiting, laxatives, diuretics, excessive exercise)
Bipolar Disorder and Mania
Clinical Features
| Type | Feature |
|---|
| Bipolar I | Mania |
| Bipolar II | Hypomania |
- Hypomania: Elevated mood, pressured speech, flight of ideas, no psychosis, >4 days
- Mania: Persistently elevated mood, psychotic symptoms possible, >1 week
Management
- Mania while on antidepressant: Stop antidepressant
- Acute mania: Antipsychotic (e.g., olanzapine)
- Referral: Mania (Urgent CMHT), Hypomania (Routine CMHT)
Schizophrenia and Psychosis
Symptoms
- First-rank: Thought insertion, withdrawal, broadcasting
- Negative: Alogia, avolition, anhedonia, blunted affect
Prognostic Factors
- Poor: Gradual onset, low IQ, prodromal social withdrawal
Speech Disorders
- Tangentiality, circumstantiality, knight’s move, flight of ideas, clang associations, echolalia, word salad
Other Features
- Catatonia, circadian rhythm disturbance, steroid-induced psychosis
Antipsychotics
Side Effects
- Weight gain, dyslipidaemia, diabetes (associated with atypicals)
Clozapine
- Agranulocytosis (monitor FBC), constipation, seizures, smoking cessation raises levels
- If missed >48 hrs: Restart titration
Aripiprazole
- Least prolactin elevation; best tolerated atypical
Extrapyramidal Side Effects
| Condition | Features | Treatment |
|---|
| Acute dystonia | Oculogyric crisis/torticollis | Procyclidine |
| Akathisia | Inner restlessness | Reduce/change drug |
| Tardive dyskinesia | Late involuntary movements | Tetrabenazine |
Lithium
- Monitoring: Level 12 hrs post-dose; check after 1 week of dose change
- Side effects: Hypothyroidism, hyperparathyroidism, hypercalcaemia, benign leucocytosis
Personality Disorders
- Borderline: Self-harm, unstable relationships (Treatment: DBT)
- Schizoid: Social withdrawal, cold, low libido
- Schizotypal: Odd beliefs, eccentric
- Avoidant: Fear of criticism/rejection
- Obsessive-Compulsive: Perfectionistic, rigid
- Paranoid: Suspicious, unforgiving
Somatic and Functional Disorders
| Disorder | Key Feature |
|---|
| Illness anxiety | Fear of serious illness |
| Somatisation | Multiple unexplained symptoms |
| Functional neurological | Neurological symptoms without organic disease |
| Munchausen | Intentional symptoms |
| Malingering | Symptoms for external gain |
- Hoover’s sign: Suggests non-organic leg weakness
Delusional Syndromes
- Parasitosis: Bugs infestation
- Erotomania: Famous person loves them
- Othello syndrome: Delusional jealousy
