Medical Psychology

Clinical Medicine Year 2 • Mental Health Disorders Anxiety Disorders: Clinical Features, Assessment and Evidence-Based Management Anxiety is a normal alarm response that becomes a disorder when fear, worry or avoidance is excessive, persistent, difficult to control and associated with clinically significant distress or impairment. Anxiety symptoms can also signal cardiac, respiratory, endocrine, neurological, toxicological or medication-related illness. A safe clinician treats both the mind and the body. Emergency warning: New chest pain, syncope, severe breathlessness, neurological deficit, hypoxia, delirium, intoxication/withdrawal, suicidal intent or inability to function requires urgent medical assessment. Do not label a first panic-like episode without considering acute physical disease. Learning objectives Differentiate generalised anxiety, panic disorder, agoraphobia, social anxiety, specific phobia and trauma-related anxiety. Assess symptoms, avoidance, comorbidity, substances, medical causes and risk. Use brief tools such as GAD-7 without replacing clinical judgement. Apply psychoeducation, CBT, exposure, stress management and safe pharmacotherapy. Recognise why long-term benzodiazepines are unsafe and when emergency referral is required. 1. Anxiety symptom domains Domain Examples Cognitive Excessive worry, catastrophic predictions, fear of losing control, poor concentration and hypervigilance. Emotional Fear, dread, irritability, apprehension and panic. Physical/autonomic Palpitations, sweating, tremor, dyspnoea, chest tightness, dizziness, nausea, paraesthesia and muscle tension. Behavioural Avoidance, reassurance seeking, checking, escape, substance use and reduced activity. 2. Common anxiety disorders Generalised anxiety disorder (GAD) Excessive worry about several everyday domains on most days, difficult to control and accompanied by restlessness, fatigue, tension, irritability, poor concentration or sleep disturbance. Assess duration, functional effect, depression, trauma, substances and medical illness. Panic disorder Recurrent unexpected panic attacks with sudden intense fear and autonomic symptoms, followed by persistent concern or avoidance. Panic attacks can occur in other disorders; panic disorder requires the characteristic recurrent and anticipatory pattern. Agoraphobia Fear/avoidance of situations where escape or help may be difficult, such as crowds, public transport, open spaces or being outside alone. Clarify whether avoidance is driven by panic, trauma or social evaluation. Social anxiety disorder Marked fear of scrutiny, embarrassment or negative evaluation, causing avoidance or endurance with intense distress. Distinguish shyness, autism, psychosis and culturally appropriate modesty. Specific phobia Marked fear of a particular object or situation, such as animals, heights, injections or blood. Graded exposure is usually the key treatment. 3. Assessment Clarify the episode: trigger, onset, duration, peak, symptoms, thoughts, behaviour, avoidance and recovery. Measure impact: work/school, relationships, sleep, self-care, travel, finances and substance use. Assess mood and risk: depression, bipolarity, self-harm, suicide, psychosis, trauma and domestic violence. Review medical causes: thyroid disease, arrhythmia, asthma, anaemia, hypoglycaemia, seizures, menopause, pregnancy and medication effects. Ask about substances: caffeine, stimulants, cannabis, alcohol withdrawal, decongestants, steroids and herbal products. Use collateral and a culturally appropriate interpreter when needed. 4. Screening and investigations GAD-7, PHQ-4, panic questionnaires and symptom diaries can quantify burden and response. A score is not a diagnosis and should not rule out serious disease. For a new or atypical presentation consider vitals, glucose, ECG, pregnancy test, FBC, thyroid function, electrolytes, oxygenation and targeted tests guided by symptoms. Chest pain, syncope, wheeze, focal neurology, fever or reduced consciousness needs a medical pathway. 5. Psychological treatment CBT: identify catastrophic thoughts, safety behaviours and avoidance; test predictions and build graded exposure. Applied relaxation and breathing: teach slow, comfortable breathing without encouraging hyperventilation or excessive monitoring. Exposure: gradual, planned and repeated practice in feared situations; never forced and not used until medical stability is established. Stress management: sleep routine, exercise, mindfulness/relaxation, problem-solving and reduction of caffeine/stimulants. Guided self-help and group/online formats: useful where specialist access is limited, with safety and follow-up. 6. Medication treatment SSRIs are often first-line when anxiety is persistent, moderate/severe or psychotherapy is unavailable/insufficient. Start low because initial activation can occur, explain delayed benefit and review early. Medicine Typical adult educational range Cautions Sertraline Start 25–50 mg daily; usual 50–200 mg/day GI effects, activation, sexual dysfunction, hyponatraemia, bleeding and serotonin syndrome. Escitalopram Start 5–10 mg daily; usual 10–20 mg/day QT risk and dose reduction in older/hepatic patients. Fluoxetine Start 10–20 mg daily; usual 20–60 mg/day Activating, long half-life and enzyme interactions. Venlafaxine Start 37.5–75 mg/day; common range 75–225 mg/day Monitor BP, activation, withdrawal and overdose risk. Buspirone Start 5–10 mg two/three times daily; common total 20–30 mg/day Delayed benefit; dizziness and interactions; not an acute panic medicine. Benzodiazepines WHO advises against benzodiazepines for routine GAD or panic treatment. For acute, severe anxiety they may be considered only briefly, generally no more than 3–7 days, with a clear stop plan. Risks include dependence, withdrawal seizures, falls, cognitive impairment, disinhibition and respiratory depression, especially with opioids, alcohol or other sedatives. 7. Panic attacks in the emergency setting Assess ABCDE, glucose, oxygenation, pulse, BP, temperature and ECG when indicated. Exclude acute coronary syndrome, arrhythmia, asthma, pulmonary embolism, hypoglycaemia, thyroid disease, seizure, stimulant toxicity and withdrawal according to presentation. Use calm explanation, reduce stimulation, sit with the patient and coach comfortable slow breathing. Avoid repeated reassurance tests that reinforce health anxiety; arrange appropriate follow-up and CBT. Assess suicide risk, depression, substance use and domestic violence before discharge. 8. Comorbidity Depression and anxiety commonly coexist; treat both and monitor suicide risk. Substance use may be an attempt to self-medicate but can worsen panic and withdrawal. PTSD requires trauma-informed assessment and may need a separate therapy pathway. OCD, psychosis, bipolar disorder, ADHD, autism and personality-related difficulties can change treatment choice. 9. Special populations Pregnancy/breastfeeding: balance untreated illness and medicine exposure; use specialist guidance and discuss therapy/support first where appropriate. Older adults: check falls, cognition, polypharmacy, hyponatraemia and anticholinergic burden. Young people: assess safeguarding, school, family, self-harm and developmental factors; use age-appropriate pathways. Medical disease: do not assume anxiety is psychological when symptoms are new, exertional or atypical. 10. Relapse prevention Identify triggers, early warning signs, avoidance cycles and coping skills. Agree a graded activity/exposure plan, sleep routine and exercise target. Plan medicine adherence, tapering and what to do if activation or suicidal thoughts emerge. Give emergency contacts and define when chest pain, syncope, severe breathlessness or suicidality needs urgent care. 11. Worked cases First panic-like episode A

Clinical Medicine Year 2 • Mental Health Disorders • Reproductive Health Postnatal Depression and Postpartum Psychosis: Recognition, Assessment and Management Pregnancy, childbirth and the first year after birth are opportunities to identify and treat mental illness within maternal and child health services. Postnatal depression is a depressive episode during pregnancy or after birth; postpartum psychosis is a rare, rapidly evolving psychiatric emergency often linked to bipolar-spectrum illness. Care must protect the mother, infant and family while respecting dignity, breastfeeding goals, culture and reproductive choices. Emergency: New confusion, severe insomnia, rapidly changing mood, grandiose or bizarre beliefs, hallucinations, thoughts of harming self or baby, inability to care for the infant, severe agitation or catatonia may indicate postpartum psychosis. Do not leave the mother alone with the baby while urgent psychiatric and medical assessment is arranged. Learning objectives Differentiate baby blues, postnatal depression, anxiety, bipolar episodes and postpartum psychosis. Screen and assess maternal mood, suicide/infanticide risk, psychosis, functioning, infant safety and social support. Plan psychological, social, pharmacological and emergency care while considering pregnancy and lactation. Recognise obstetric, medical, substance-related and medication causes of mental symptoms. 1. Common perinatal presentations Presentation Typical features Action Baby blues Transient tearfulness, irritability, anxiety and emotional lability beginning in first days; functioning and bonding largely preserved Reassure, practical support, sleep and review if persistent, severe or worsening. Postnatal depression Persistent low mood/loss of interest, guilt, hopelessness, sleep/appetite change, anxiety, poor concentration, suicidal thoughts or impaired bonding Full assessment, safety plan, psychological/medical treatment and infant/family support. Postpartum psychosis Rapid onset of confusion, insomnia, mood elevation/depression, delusions, hallucinations, disorganisation or dangerous behaviour Emergency psychiatric and medical assessment; usually inpatient care. Bipolar episode Reduced need for sleep, high energy, pressured speech, grandiosity, impulsivity or depression; may be triggered by sleep loss Specialist assessment; avoid antidepressant monotherapy if bipolarity suspected. Trauma/anxiety/OCD Intrusive thoughts, panic, hypervigilance, avoidance or unwanted infant-harm images without intent Assess intent and control; offer psychological care and urgent escalation if psychosis or intent is present. 2. Risk factors Previous depression, bipolar disorder, psychosis, postpartum psychosis or severe premenstrual symptoms. Suicide/self-harm history, family history of bipolar or postpartum psychosis, abrupt sleep loss and stopping maintenance medicine. Unplanned pregnancy, obstetric complications, neonatal illness, pain, anaemia, thyroid disease or difficult birth. Domestic violence, poverty, isolation, stigma, conflict, migration, bereavement, infertility treatment and lack of practical support. Alcohol/drug use, HIV/TB, chronic illness, medication interactions and breastfeeding difficulties. 3. Assessment in maternity and primary care Privacy and consent: speak with the mother alone when safe; explain confidentiality and its limits. Symptoms/course: mood, pleasure, anxiety, sleep, energy, appetite, guilt, bonding, intrusive thoughts, psychosis and duration. Bipolar screen: past elevated/irritable periods, reduced need for sleep, grandiosity, impulsive spending/sex, psychosis and family history. Risk: suicidal thoughts/plan, thoughts of harming infant, command voices, access to medicines/pesticides/weapons, domestic violence and ability to supervise baby. Medical review: vitals, bleeding, pain, infection, anaemia, thyroid symptoms, seizures, pre-eclampsia/postpartum hypertension, delirium and substance exposure. Collateral: partner/family observations of sleep, behaviour, confusion, spending, speech and infant care. Function: feeding, hygiene, breastfeeding, sleep opportunities, bonding, support and safe accommodation. 4. Screening tools The Edinburgh Postnatal Depression Scale (EPDS), PHQ-9 or locally validated tool can identify symptoms and monitor change. A positive screen is not a diagnosis and must be followed by clinical assessment. Ask directly about self-harm even if the EPDS score is low. Screen at antenatal, postnatal and child-health contacts according to local service capacity and referral pathways. 5. Differential diagnosis and investigations Baby blues, major depression, bipolar disorder, postpartum psychosis, PTSD, OCD, panic and adjustment disorder. Delirium, eclampsia/postpartum hypertension, thyroid disease, anaemia, infection/sepsis, hypoglycaemia, epilepsy, head injury and medication effects. Alcohol or drug intoxication/withdrawal, HIV/TB, severe sleep deprivation and adverse effects of steroids or other medicines. Targeted tests: glucose, FBC, electrolytes/renal/liver function, thyroid tests, urine/protein and blood pressure for pre-eclampsia, infection tests, toxicology, ECG and pregnancy status where relevant. 6. Management of postnatal depression Mild symptoms: psychoeducation, practical support, sleep protection, problem-solving, behavioural activation and low-intensity psychological interventions. Moderate/severe symptoms: structured CBT/IPT or other therapy, antidepressant when indicated, family support and close follow-up. Psychotic depression, severe self-neglect or suicide risk: urgent specialist care, safety containment, medication and possible ECT. Include the infant: support feeding, bonding, safe caregiving, immunisation/clinic attendance and caregiver relief. Do not blame the mother for difficulty bonding. 7. Medicines, pregnancy and breastfeeding Choose medicines through shared decision-making: untreated severe illness also harms mother and infant. Review previous response, gestation/postpartum stage, breastfeeding, comorbidity, dose, interactions and infant monitoring. Use current Uganda formulary, product information and specialist perinatal advice. Medicine/class Educational points Key cautions Sertraline Common starting 25–50 mg daily; usual 50–200 mg/day Monitor activation, GI effects, sexual effects, hyponatraemia, bleeding and infant sedation/feeding where breastfeeding. Fluoxetine Common start 10–20 mg daily; usual 20–60 mg/day Long half-life and more infant accumulation than some SSRIs; assess risk/benefit and prior response. Antipsychotics May be necessary for severe depression with psychosis or bipolar/postpartum psychosis Monitor sedation, metabolic effects, EPS, prolactin, QT and infant exposure; specialist choice. Lithium Highly effective for bipolar relapse prevention and postpartum psychosis risk in selected patients Requires levels, renal/thyroid monitoring, hydration and specialist breastfeeding/pregnancy planning. Valproate Generally avoid in people who may become pregnant unless strict current safeguards apply Major fetal malformation and neurodevelopmental risk; hepatotoxicity, pancreatitis and thrombocytopenia. 8. Postpartum psychosis Postpartum psychosis often begins within the first two weeks, but any rapid postpartum change is concerning. Symptoms may include extreme insomnia, confusion, fluctuating attention, elation or despair, bizarre beliefs about the infant, voices, visual experiences, disorganisation, aggression or catatonia. Insight may be absent. Ensure immediate safety of mother and baby; do not leave them alone if risk is present. Call urgent psychiatric, obstetric and medical support; assess ABCDE, glucose, blood pressure, temperature, seizures, infection, thyroid and substances. Arrange emergency specialist admission, preferably a mother-and-baby unit where safe and available; do not delay life-saving transfer when unavailable. Treat mania, psychosis, depression, catatonia or delirium according to specialist protocol; ECT may be needed for life-threatening or treatment-resistant illness. Support the family and plan infant care, breastfeeding, sleep and safeguarding.

Clinical Medicine Year 2 • Mental Health Disorders Personality Disorders: Assessment, Diagnosis, Treatment and Crisis Management Personality disorders are enduring patterns of inner experience and behaviour that differ markedly from cultural expectations, begin by adolescence or early adulthood, are inflexible across situations and cause distress, impairment or risk. They are not character defects, deliberate “badness” or a reason to deny care. Modern practice emphasises severity, trait domains, developmental history, trauma, culture, strengths and current risks. Emergency rule: A personality-disorder diagnosis never explains away active suicide risk, overdose, severe self-harm, psychosis, intoxication/withdrawal, delirium, violence or medical instability. Stabilise first, assess risk directly and use a clear crisis plan. Learning objectives Define personality disorder and explain the dimensional direction of ICD-11. Recognise common borderline, antisocial, avoidant, dependent, narcissistic, schizoid, paranoid and obsessive-compulsive traits. Differentiate personality disorder from mood, psychotic, trauma, neurodevelopmental and substance-use disorders. Plan structured assessment, psychological treatment, safe prescribing and crisis care. Communicate without stigma and maintain therapeutic boundaries. 1. Classification DSM-5-TR retains categorical personality-disorder diagnoses and also describes an alternative dimensional model. ICD-11 uses a general personality-disorder diagnosis graded by severity, with trait qualifiers such as negative affectivity, detachment, dissociality, disinhibition and anankastia; borderline pattern qualification may be used where relevant. Older ICD-10/DSM cluster language remains common in teaching, but clinicians should record the classification system and code actually used. Historical teaching group Common patterns Cluster A Paranoid, schizoid and schizotypal traits: suspiciousness, detachment, unusual beliefs or social discomfort. Cluster B Borderline, antisocial, narcissistic and histrionic traits: emotional instability, impulsivity, disregard of others, grandiosity or attention-seeking. Cluster C Avoidant, dependent and obsessive-compulsive traits: fear of rejection, submissiveness, need for care, perfectionism and control. 2. General features Longstanding pattern across relationships, work, family and community rather than a single episode. Early developmental onset, often influenced by temperament, attachment, trauma, neglect, instability and social adversity. Difficulty regulating emotion, interpreting others, tolerating rejection or delaying impulses. Recurrent interpersonal conflict, self-harm, substance use, unsafe sex, aggression, dissociation or occupational instability. Coexisting depression, bipolar disorder, PTSD, ADHD, autism, psychosis, eating disorder and substance use are common. 3. Important patterns Borderline pattern Instability of relationships, self-image and affect; intense fear of abandonment; impulsivity; recurrent self-harm or suicidal behaviour; chronic emptiness; anger; transient stress-related paranoia or dissociation. Assess current intent and means every time; self-harm is not “attention seeking” and requires compassionate care. Antisocial pattern Persistent disregard for rights and safety of others, deceitfulness, impulsivity, aggression, irresponsibility and lack of remorse. Assess violence, victim safety, substance use, childhood conduct problems, trauma, cognitive impairment and legal context without stereotyping or assuming inevitable violence. Narcissistic pattern Grandiosity, need for admiration, entitlement, sensitivity to criticism and impaired empathy. Shame, depression, rage or suicidality may follow perceived humiliation. Maintain respectful boundaries and assess comorbidity. Avoidant and dependent patterns Avoidant traits involve social inhibition, inadequacy and fear of criticism; dependent traits involve submissiveness, difficulty making decisions and intense fear of separation. Assess social anxiety, abuse, coercion and practical support. Paranoid, schizoid and schizotypal patterns Persistent mistrust, social detachment, restricted affect or unusual beliefs may resemble psychosis. Establish reality testing, cultural context, developmental course, substances and whether hallucinations or fixed delusions are present. Obsessive-compulsive personality pattern Preoccupation with order, perfectionism, control and rules can impair flexibility and relationships. Distinguish from OCD, where intrusive obsessions and compulsions are usually experienced as unwanted. 4. Assessment Build trust: explain that the goal is to understand patterns and support recovery, not to label or blame. Timeline: developmental history, relationships, schooling/work, trauma, losses, episodes, self-harm and substance use. Current state: mood, psychosis, anxiety, dissociation, sleep, cognition, intoxication/withdrawal and medical symptoms. Function: housing, finances, employment, parenting, legal problems, support and safety. Collateral: obtain consent where possible; use carefully limited information where serious risk requires disclosure. Formulation: vulnerabilities, triggers, maintaining cycles, protective factors and patient goals. 5. Risk assessment Risk Questions Suicide/self-harm What happened, intent, planning, access, lethality, previous episodes, triggers, substances, reasons for living and ability to stay safe? Violence Threats, target, plan, means, intoxication, impulsivity, past violence, protective factors and victim safety. Vulnerability Abuse, exploitation, homelessness, coercive relationships, financial harm and risk to children. Medical risk Overdose, wounds, pregnancy, eating disorder, withdrawal, infection, head injury and medication toxicity. Do not use a low-risk label to replace formulation. Risk changes with rejection, intoxication, relationship loss, discharge, anniversaries and treatment transitions. 6. Psychological treatment Borderline personality disorder Structured, coherent psychological therapy is first-line; examples include dialectical behaviour therapy (DBT), mentalisation-based treatment, schema-focused and transference-focused approaches. DBT skills include mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness; use a written crisis plan and chain analysis of self-harm. Do not use brief crisis admissions repeatedly as the only treatment; agree admission criteria, length and goals in advance. Address trauma, substance use, eating symptoms, sleep, relationships and vocational function. Antisocial personality disorder Use structured psychological programmes targeting impulsivity, problem-solving, anger, substance use and offending behaviour; maintain clear boundaries, consistency, safety planning and multidisciplinary communication. Treat depression, anxiety, ADHD or substance use when present. Other patterns CBT, schema work, interpersonal therapy, social-skills training, trauma-informed care and family work can target the dominant difficulties. Treatment should be collaborative, culturally responsive and long enough to consolidate skills. 7. Medicines No medicine reliably cures a personality disorder. Avoid routine polypharmacy and prescribing primarily to control relationships or staff distress. Target a comorbid disorder or a specific short-term symptom with a documented rationale, review date and overdose plan. Antidepressants may treat a comorbid depressive or anxiety disorder but do not replace psychotherapy or risk care. Antipsychotics may be considered short-term for severe transient psychosis or aggression after assessment; monitor metabolic, movement and cardiac effects. Mood stabilisers are not routine treatment for borderline personality disorder; use only for a clear comorbid indication or specialist plan. Benzodiazepines can worsen disinhibition, dependence, overdose and trauma-related dissociation; avoid routine use. 8. Crisis management Assess ABCDE, injuries, intoxication/withdrawal, pregnancy and overdose; treat medical emergencies. Move to a calm, private setting and use one consistent team where possible. Ask directly about suicidal/violent intent and access to means; involve safeguarding and senior staff.

Clinical Medicine Year 2 • Mental Health Disorders Mood Disorders: Depression, Bipolar Disorder, Assessment and Management Mood disorders are conditions in which persistent or episodic changes in mood, energy, activity, cognition and behaviour cause distress or functional impairment. The major clinical groups are depressive disorders and bipolar disorders. Accurate assessment matters because treating bipolar depression as unipolar depression alone may precipitate mania, while severe depression with suicide risk or psychosis may require urgent specialist treatment. Emergency warning: Urgently assess active suicidal intent, severe self-neglect, psychotic depression, mania with dangerous behaviour, delirium, catatonia, severe agitation, intoxication/withdrawal, postpartum psychosis and medical instability. Do not leave a high-risk patient alone while arranging care. Learning objectives Describe depressive, manic and hypomanic episodes and their functional effects. Differentiate unipolar depression, bipolar disorder, psychotic mood disorders, adjustment reactions, grief and medical/substance causes. Perform a structured history, mental-state examination, risk assessment and targeted investigation plan. Compare psychosocial, antidepressant, mood-stabilising, antipsychotic and ECT treatment approaches. Plan monitoring, relapse prevention, pregnancy safety, family support and follow-up. 1. Mood-episode syndromes Syndrome Core features Clinical importance Depressive episode Low mood or loss of interest plus cognitive, emotional, physical and behavioural symptoms Assess duration, severity, suicide, psychosis, bipolarity and function. Mania Elevated/irritable mood with increased energy/activity, reduced need for sleep and impaired judgement Often requires urgent specialist care; psychosis or danger may require admission. Hypomania Similar change but less severe, without marked impairment, psychosis or need for admission May be missed unless collateral history is obtained; suggests bipolar spectrum illness. Mixed features Depressive and manic symptoms occur together or change rapidly High risk of impulsivity, substance use and suicide; specialist review is important. 2. Depressive disorders Ask about persistent sadness, loss of interest or pleasure, guilt/worthlessness, hopelessness, low energy, sleep/appetite change, psychomotor change, poor concentration, suicidal thoughts and physical symptoms. Document duration, pervasiveness, functional effect and whether symptoms are better explained by bipolar disorder, substances, grief or medical illness. Severity Mild: distress and some impairment, but basic functioning remains possible. Moderate: multiple symptoms with clear functional impairment. Severe: pervasive symptoms, marked impairment, psychosis, self-neglect or serious suicide risk. PHQ-9 or another validated tool can measure symptoms and change, but it does not diagnose bipolarity, psychosis or safety. Item-level suicide assessment is always required. 3. Bipolar disorders Bipolar I disorder includes at least one manic episode; depressive episodes are common but not required for the diagnosis. Bipolar II involves hypomania and major depression without a history of mania. Other specified or cyclothymic patterns require longitudinal specialist assessment. Mania assessment Elevated, expansive or irritable mood; increased energy/activity. Reduced need for sleep, pressured speech, racing thoughts, distractibility and grandiosity. Risky spending, sexual behaviour, driving, aggression, substance use or unrealistic projects. Psychosis, poor insight, impaired capacity, neglect of food/fluids and risk to others. Ask about previous episodes, family history, antidepressant or steroid exposure, substances, thyroid symptoms, sleep deprivation and collateral observations. Use a timeline: mood symptoms, psychosis, sleep, substances, medicines and function. 4. Differential diagnosis Presentation Alternatives to consider Clues Low mood Bipolar depression, grief, adjustment, thyroid disease, anaemia, HIV, substances, medication effects Past elevated episodes, atypical physical findings, exposure timeline and collateral. High energy/irritability Stimulants, corticosteroids, hyperthyroidism, delirium, seizures, sleep deprivation New drug/substance, fluctuating consciousness, fever or neurological signs. Psychotic mood symptoms Schizophrenia-spectrum illness, delirium, substance-induced psychosis Relationship of psychosis to mood episodes and attention/medical signs. Bereavement Normal grief, prolonged grief disorder, major depression Trajectory, pervasive impairment, hopelessness, suicidality and loss of pleasure. 5. Comprehensive assessment History: presenting symptoms, duration, episodic course, sleep, energy, appetite, cognition, trauma, substances and function. Past history: episodes, admissions, suicide attempts, psychosis, response/adverse effects and adherence. Family history: bipolar disorder, suicide, psychosis, substance use and medical illness. Physical/neurological exam: observations, glucose, thyroid signs, movement, pregnancy, nutrition and neurological red flags. Risk: suicide, self-neglect, violence, impulsivity, access to means, dependants, exploitation and protective factors. Collateral: sleep, spending, speech, behaviour, baseline and changes noticed by family. 6. Investigations Full blood count, electrolytes/renal function, glucose/HbA1c, liver function and thyroid tests when clinically indicated. Pregnancy testing where relevant before valproate, lithium, radiation or teratogenic treatment. HIV/syphilis, malaria/TB or other infection tests according to symptoms, risk and local epidemiology. ECG before QT-risk medicines, overdose, syncope, cardiac disease or significant electrolyte disturbance. Drug levels for lithium/selected anticonvulsants; toxicology when it changes management. Neuroimaging/EEG/CSF only when atypical, neurological, rapidly progressive or medically concerning features justify them. 7. Management principles Share a formulation and treatment plan; combine psychosocial, biological and social interventions. Address sleep, nutrition, activity, alcohol/drugs, physical health, trauma, housing and family support. Use the least restrictive safe care; admission may be required for high risk, psychosis, severe self-neglect, mania or inability to engage safely. Agree measurable targets: sleep, mood, activity, suicidal thinking, function, mania symptoms and adverse effects. 8. Psychological and social treatment CBT, behavioural activation, interpersonal therapy and problem-solving for depression. Psychoeducation, family-focused therapy, routine/sleep stabilisation and relapse planning for bipolar disorder. Exercise, meaningful activity, social connection, supported education/employment and substance-use care. Collaborative safety plan: warning signs, coping strategies, trusted contacts, professional contacts and means safety. 9. Antidepressants SSRIs are commonly first-line for unipolar depression and anxiety. Screen for past mania/hypomania, psychosis, suicide risk, substances and interactions before prescribing. Medicine Typical adult educational dose Important cautions Sertraline Start 25–50 mg daily; usual 50–200 mg/day GI effects, sexual dysfunction, activation, hyponatraemia, bleeding and serotonin syndrome. Fluoxetine Start 10–20 mg daily; usual 20–60 mg/day Activating, long half-life and enzyme interactions; discontinuation is less common. Escitalopram Start 5–10 mg daily; usual 10–20 mg/day QT and dose cautions in older age, hepatic disease or cardiac risk. Mirtazapine Start 15 mg at night; usual 15–45 mg/day Sedation, appetite/weight gain and metabolic effects; may help insomnia/poor appetite. Venlafaxine Start 37.5–75 mg/day; common range 75–225 mg/day Blood-pressure monitoring, withdrawal, activation, serotonin syndrome and overdose toxicity. Review early after initiation or dose change, especially when suicide risk or activation is present. Continue after remission for the recommended period and taper gradually to reduce withdrawal. Avoid antidepressant monotherapy when bipolar disorder is suspected. 10. Bipolar disorder medicines Lithium Uses: acute mania and long-term

Clinical Medicine Year 2 • Mental Health Disorders Schizophrenia: Clinical Features, Diagnosis, Treatment and Long-Term Care Schizophrenia is a serious, treatable mental disorder involving a characteristic combination of psychotic symptoms, negative symptoms, cognitive difficulties, altered mood and functional impairment. It is not “split personality,” a moral failure or a life sentence without recovery. Early, respectful, continuous care can reduce relapse, disability, suicide risk and physical-health inequality. Emergency warning: Assess urgently for suicide, violence, command hallucinations, severe self-neglect, catatonia, delirium, intoxication/withdrawal, neuroleptic malignant syndrome and inability to care for basic needs. First-episode or atypical psychosis requires medical and substance-related assessment. Learning objectives Describe positive, negative, cognitive, affective and psychomotor features of schizophrenia. Differentiate schizophrenia from mood, substance-induced, delirium and medical/neurological psychoses. Complete a comprehensive first-episode and relapse assessment. Plan pharmacological, psychological, family, social and physical-health care. Monitor treatment, manage adverse effects and build relapse prevention. 1. Clinical domains Domain Examples Clinical impact Positive symptoms Delusions, hallucinations, disorganised speech and behaviour Distress, risk, impaired judgement and social disruption Negative symptoms Avolition, anhedonia, alogia, blunted affect and social withdrawal Loss of function, employment, relationships and self-care Cognition Attention, working memory, processing speed and executive dysfunction Learning, planning, adherence and independent living difficulties Affective symptoms Depression, anxiety, irritability, hopelessness and emotional dysregulation Suicide risk, substance use and relapse vulnerability Psychomotor/catatonia Agitation, retardation, posturing, mutism, stupor or stereotypies Medical complications and emergency risk 2. Course and phases Prodrome: social withdrawal, sleep change, reduced function, suspiciousness, declining self-care or unusual experiences. First episode: clear psychosis with marked distress or functional decline; early treatment can improve outcome. Acute phase: positive symptoms and risk require active treatment, sometimes admission. Recovery/stabilisation: symptoms reduce; titrate treatment, restore function and address adverse effects. Maintenance: prevent relapse, maintain physical health, social roles and recovery goals. 3. Diagnostic assessment Establish symptoms, onset, duration, mood relationship, function, trauma, substances, medicines and previous episodes. Obtain collateral history to define baseline, timeline, adherence, sleep, risk and functioning. Perform physical and neurological examination, vitals, glucose, movement examination and pregnancy assessment where relevant. Investigate medical/substance mimics, especially at first episode or with red flags. Document a longitudinal formulation and provisional diagnosis when duration or exclusion remains uncertain. 4. Differential diagnosis Condition Clues Schizoaffective disorder Prominent mood episodes plus a period of psychosis outside mood episodes. Bipolar mania with psychosis Elevated/irritable mood, reduced need for sleep, high energy, grandiosity and episodic course. Psychotic depression Severe depressive syndrome and psychosis during the mood episode. Substance/medication-induced psychosis Symptoms closely linked to intoxication, withdrawal or a medicine; reassess when sober/stable. Delirium/medical psychosis Fluctuating attention, altered consciousness, abnormal vitals, seizures, focal signs or atypical onset. Delusional disorder Persistent delusion with relatively preserved functioning and little pervasive disorganisation. 5. Risk assessment Suicide: hopelessness, depression, command voices, substance use, previous attempts, recent discharge and access to means. Violence: threats, persecutory beliefs, command hallucinations, intoxication, weapons, impulsivity and past violence. Self-neglect: food/fluid refusal, homelessness, untreated medical illness, inability to obtain medicines or severe disorganisation. Vulnerability: abuse, exploitation, coercive relationships, financial harm and risk to children or dependants. Use a collaborative, least-restrictive safety plan. Admission or urgent specialist care may be needed when risk cannot be safely managed in the community. 6. Physical-health assessment Baseline weight/BMI, waist, pulse, blood pressure, glucose/HbA1c, lipids, smoking, alcohol/substances and movement examination. ECG when cardiac history, syncope, QT-risk medicine, overdose, electrolyte abnormality or antipsychotic indication warrants it. FBC, electrolytes/renal/liver function, thyroid, pregnancy test and HIV/syphilis or other infection tests guided by presentation and local policy. Assess cardiovascular risk, diabetes, respiratory disease, oral health, sexual/reproductive health, HIV/TB care and access to exercise/nutritious food. 7. Antipsychotic treatment Offer one antipsychotic after shared discussion of benefits, adverse effects, previous response, route, cost, pregnancy, metabolic and cardiac risks. Start low and titrate gradually. Avoid routine polypharmacy and document the target symptoms and review date. Medicine Common adult educational range High-yield cautions Risperidone Start 0.5–1 mg/day; usual 2–6 mg/day EPS, akathisia, prolactin, orthostasis and renal dosing. Olanzapine Start 5–10 mg/day; usual 10–20 mg/day Weight gain, diabetes, dyslipidaemia and sedation; smoking alters levels. Quetiapine Titrate gradually; common range 150–800 mg/day Sedation, orthostasis, metabolic effects and QT risk. Aripiprazole Usually 10–15 mg/day; common range 10–30 mg/day Akathisia, insomnia and impulse-control problems; lower metabolic burden. Haloperidol Often 0.5–5 mg/day initially; higher specialist doses may be used EPS, dystonia, QT prolongation and NMS. Clozapine Start 12.5 mg once/twice daily and titrate slowly; many need 200–450 mg/day Treatment resistance or persistent suicidality under specialist FBC/ANC and medical monitoring. 8. Monitoring and adverse effects Review response, adherence, sedation, orthostasis, akathisia, dystonia, parkinsonism, tardive movements and suicidality. Monitor weight/BMI, waist, BP, glucose/HbA1c, lipids, smoking and physical activity. Ask about prolactin symptoms: amenorrhoea, galactorrhoea, sexual dysfunction and infertility. Teach warning signs of NMS, severe rash, myocarditis, agranulocytosis and clozapine constipation/ileus. Do not mistake akathisia for worsening psychosis or increase the dose reflexively. 9. Treatment resistance and clozapine Confirm diagnosis, adherence, dose, duration, substance use, interactions and adequate trials before labelling treatment resistance. Clozapine is considered after persistent symptoms despite adequate trials of two antipsychotics or in selected persistent suicidality. It requires a specialist programme, blood-count monitoring, constipation prevention and education about fever, sore throat, infection, chest pain, breathlessness, seizures and smoking changes. 10. Long-acting injectable antipsychotics Long-acting injections can reduce missed doses and provide predictable exposure when the patient prefers them or adherence has been difficult. Confirm oral tolerability, explain injection-site effects, product-specific loading/oral overlap, missed-dose plans, pregnancy considerations and the difficulty of rapidly reversing adverse effects. Consent and shared decision-making are essential. 11. Psychosocial and recovery interventions Family psychoeducation, communication training and an early-warning plan. CBT for psychosis to reduce distress and improve coping. Supported employment/education, occupational therapy, social skills and rehabilitation. Substance-use treatment, sleep/routine stabilisation, exercise and smoking cessation. Peer support, housing, social protection, legal/safeguarding referrals and culturally responsive care. 12. Relapse prevention Identify the patient’s early warning signs: reduced sleep, social withdrawal, suspiciousness, voices, disorganised speech, substance escalation, missed doses or unusual spending. Write a plan naming trusted contacts, crisis services, medicine support, means safety and thresholds for urgent review. Review

Clinical Medicine Year 2 • Mental Health Disorders Functional Psychosis: Assessment, Differential Diagnosis and Management Functional psychosis describes psychotic symptoms arising primarily from a psychiatric disorder rather than an identified structural, metabolic, infectious, toxicological or neurological cause. It is a clinical description, not permission to skip a medical assessment. Hallucinations, delusions and disorganised thinking can occur in schizophrenia-spectrum illness, mood disorders, substance-related conditions, delirium and brain disease. Emergency warning: First-episode or rapidly changing psychosis with fever, fluctuating attention, reduced consciousness, seizures, severe headache, focal neurological signs, catatonia, head injury, immunosuppression, pregnancy/postpartum state or recent drug exposure requires urgent medical/neurological assessment. Learning objectives Define psychosis and distinguish functional psychosis from delirium, substance-induced and medical causes. Differentiate schizophrenia-spectrum, mood-related, brief/acute psychosis and delusional disorders. Complete a first-episode psychosis assessment including risk, collateral history, physical examination and investigations. Plan acute treatment, maintenance, psychosocial support, relapse prevention and follow-up. 1. Psychosis as a syndrome Domain Examples Delusions Fixed false beliefs not shared by the cultural group, such as persecution, reference, grandiosity, guilt, jealousy or somatic beliefs. Hallucinations Perceptions without an external stimulus; auditory voices are common, but visual, tactile, olfactory and gustatory experiences need careful medical assessment. Disorganised thought/speech Derailment, tangentiality, incoherence, neologisms, poverty of speech or thought blocking. Disorganised behaviour Markedly odd behaviour, agitation, neglect, unpredictable actions or catatonic signs. Negative symptoms Avolition, anhedonia, alogia, blunted affect and social withdrawal; distinguish from depression, sedation and social deprivation. Cognitive change Attention, working memory, executive and processing-speed difficulties that affect function. 2. Functional psychosis categories Schizophrenia A persistent or recurrent psychotic illness with positive symptoms, negative symptoms, cognitive change and functional decline. Duration and exclusion criteria differ by classification. Document course, remission, severity and treatment response rather than relying only on the label. Schizoaffective disorder Prominent mood episodes occur with schizophrenia-spectrum symptoms, with a period of psychosis also occurring outside a major mood episode. Establish the longitudinal timeline from collateral history; a single visit cannot reliably distinguish it from bipolar or depressive psychosis. Brief or acute and transient psychotic disorder Psychosis begins abruptly and lasts a limited period with eventual return toward baseline. Stress, sleep loss, substances and medical causes still need assessment. Relapse and later schizophrenia or mood disorder remain possible, so follow-up is essential. Delusional disorder One or more persistent delusions occur with relatively preserved functioning and without the pervasive disorganisation typical of schizophrenia. Assess risk, stalking/violence, mood, substance use, neurological causes and the cultural context of the belief. Mood disorder with psychotic features Psychotic symptoms occur during severe depression or mania. Determine whether psychosis is confined to mood episodes. Mania may include reduced need for sleep, increased energy, pressured speech, grandiosity and risky behaviour; psychotic depression may include guilt, nihilism or somatic beliefs. 3. Red flags for non-functional psychosis Acute or fluctuating onset, impaired attention or altered arousal. Fever, autonomic instability, severe headache, meningism, seizures or focal neurological signs. Visual/olfactory hallucinations, abnormal movements, marked cognitive decline or atypical age of onset. Recent stimulant, cannabis, hallucinogen, steroid, anticholinergic or other medicine exposure. Head injury, cancer, HIV/TB, autoimmune disease, pregnancy/postpartum state or endocrine illness. 4. First-episode psychosis assessment Safety: suicide, violence, command hallucinations, access to weapons/pesticides, vulnerability, self-neglect, exploitation and ability to care for dependants. History: onset, symptoms, mood, sleep, function, trauma, substances, medicines, medical/neurological symptoms and previous episodes. Collateral: baseline personality and function, timeline, behaviour, adherence, substance exposure, sleep and family history. Examination: observations, glucose, neurological examination, hydration, infection, movement disorder, head injury and pregnancy possibility. Investigations: targeted blood tests, toxicology, ECG and metabolic baseline; CT/MRI/EEG/CSF for red flags. 5. Psychosis and risk Ask directly about suicidal thoughts, command voices, plans, intent, means, previous attempts and reasons for living. Assess violence risk: threats, persecutory beliefs, command hallucinations, weapons, intoxication, impulsivity, past violence and access to the alleged target. Assess vulnerability: homelessness, exploitation, unsafe relationships, neglect, inability to obtain food/medicines and risk to children. Use the least restrictive safe plan: collaborative de-escalation, safe room, observation, family support and urgent admission where necessary. 6. Immediate management Reduce noise and stimulation; introduce yourself, use short sentences, maintain safe distance and offer choices. Treat medical or substance-related causes; psychosis with delirium is not managed as routine schizophrenia. If severe agitation threatens safety, follow local emergency sedation protocol with airway, breathing, circulation, glucose, ECG and sedation monitoring. Assess capacity for treatment decisions; a diagnosis does not automatically remove capacity. 7. Antipsychotic treatment Choose one antipsychotic after discussing previous response, metabolic risk, movement effects, prolactin, QT risk, sedation, pregnancy, cost and availability. Start low, titrate gradually, use an adequate trial and measure symptoms/function. Avoid routine polypharmacy. Example Typical adult educational range Important cautions Risperidone Start 0.5–1 mg/day; common range 2–6 mg/day EPS, akathisia, prolactin, orthostasis and renal-dose considerations. Olanzapine Start 5–10 mg/day; common range 10–20 mg/day Weight gain, diabetes, dyslipidaemia and sedation; smoking changes metabolism. Quetiapine Start low and titrate; common range 150–800 mg/day by indication Sedation, orthostasis, metabolic and QT effects. Aripiprazole Usually 10–15 mg/day; common range 10–30 mg/day Akathisia, insomnia and impulse-control problems; relatively lower metabolic burden. Haloperidol Often 0.5–5 mg/day initially; higher specialist doses may be used EPS, dystonia, QT prolongation and NMS; caution in Parkinson/Lewy-body disease. Before treatment record weight/BMI, waist, blood pressure, pulse, glucose/HbA1c, lipids, movement examination, cardiac history and ECG when indicated. Monitor symptoms, adherence, sedation, akathisia, EPS, metabolic effects, prolactin symptoms and suicidality. 8. Clozapine and treatment resistance Consider clozapine under specialist services when persistent symptoms continue despite adequate trials of two antipsychotics, or for persistent suicidality in appropriate patients. It requires full blood-count monitoring and education about fever, sore throat, infection, severe constipation, abdominal pain, chest pain, breathlessness and seizures. Smoking changes can rapidly alter levels. Never begin, stop or adjust it outside the local specialist system. 9. Psychosocial treatment Family psychoeducation and communication training. CBT for psychosis to reduce distress and improve coping, alongside medicine. Supported education/employment, occupational therapy, social-skills support and rehabilitation. Substance-use treatment, sleep/routine stabilisation and relapse-prevention planning. Trauma-informed care, housing, legal/safeguarding support and peer services. 10. Duration, adherence and relapse prevention Explain expected time to benefit

Clinical Medicine Year 2 • Mental Health Disorders Dementia and Major Neurocognitive Disorders: Assessment, Types and Management Dementia is an acquired decline in memory and/or other cognitive abilities that interferes with independence, relationships and everyday activities. It is not a normal part of ageing. Modern classifications also use major neurocognitive disorder; mild neurocognitive disorder describes measurable decline with preserved independence. Dementia is a clinical syndrome with many causes, and mixed pathology is common. Do not miss delirium: A sudden or fluctuating change in attention, consciousness or cognition is delirium until proven otherwise. Delirium may be superimposed on dementia and requires urgent assessment for infection, hypoxia, glucose/electrolyte disturbance, medication toxicity, withdrawal, seizure, stroke or head injury. Learning objectives Define dementia/major neurocognitive disorder and distinguish it from normal ageing, delirium, depression and mild cognitive impairment. Recognise Alzheimer, vascular, Lewy-body, frontotemporal, Parkinson-related, HIV-associated and mixed patterns. Take a collateral history, assess cognition and function, investigate reversible contributors and formulate a differential. Manage cognition, behavioural symptoms, safety, capacity, safeguarding and caregiver strain. Explain indications, contraindications, adverse effects and monitoring of cognitive medicines. 1. Clinical significance of cognitive change Concept Clinical meaning Normal ageing Occasional forgetfulness without progressive loss of independence; learning with cues remains possible. Mild neurocognitive disorder/MCI Objective decline greater than expected, but independence is largely preserved with reminders or extra effort. Major neurocognitive disorder/dementia Decline interferes with finances, medicines, cooking, transport, hygiene, continence or safety. Delirium Acute, fluctuating disturbance in attention and awareness caused by medical, toxicological or medication-related illness. Depressive cognitive symptoms Subjective memory difficulty and slowed processing may improve with mood treatment; depression may coexist with dementia. 2. Common causes and patterns Alzheimer disease Usually begins with gradually progressive episodic-memory difficulty, followed by language, visuospatial, executive and functional decline. Later stages involve dependence, behavioural symptoms, dysphagia and communication difficulty. Vascular cognitive impairment May follow strokes or small-vessel disease. Stepwise or gradual progression, executive dysfunction, slowed processing, gait change, focal signs and vascular risk factors are clues. Mixed Alzheimer–vascular disease is common. Dementia with Lewy bodies and Parkinson disease dementia Fluctuating cognition, well-formed visual hallucinations, REM sleep behaviour disorder, parkinsonism, falls and autonomic symptoms suggest Lewy-body disease. Cognitive decline after established Parkinson disease suggests Parkinson disease dementia. Neuroleptic sensitivity is important. Frontotemporal dementia Often presents earlier with disinhibition, apathy, loss of empathy, compulsions, dietary change or progressive language impairment while memory may be relatively preserved early. It may be mistaken for depression, mania or personality disorder. HIV-associated and other infectious disorders Consider HIV-associated neurocognitive disorder, neurosyphilis, TB, cerebral malaria, cryptococcal disease and other infections according to symptoms, immune status and local epidemiology. Assess adherence, opportunistic disease and interactions. Reversible or contributing causes Delirium, depression, sleep apnoea, pain and sensory impairment. Anticholinergic, sedative, opioid or polypharmacy effects. Thyroid disease, B12/folate deficiency, anaemia, renal/hepatic disease and electrolyte abnormalities. Alcohol/drugs, head injury, seizures, normal-pressure hydrocephalus, tumour and autoimmune disease. 3. History and collateral assessment Onset/course: first sign, rate of progression, stepwise change, fluctuation and recent deterioration. Domains: memory, attention, language, visuospatial ability, planning, judgement, social cognition and orientation. Function: finances, cooking, shopping, transport, telephone, work, medicines, hygiene, continence, feeding and mobility. Behaviour/mood: apathy, depression, anxiety, agitation, aggression, hallucinations, delusions, wandering, sleep and appetite. Medical and exposure history: strokes, seizures, Parkinsonism, head injury, HIV/TB, vascular risk, alcohol, medicines, herbal products and family history. Social context: housing, food, finances, caregiver capacity, abuse, neglect, isolation, spiritual beliefs and access to follow-up. 4. Examination and cognitive assessment Record vitals, weight, nutrition, hydration, hearing, vision, gait, falls, neurological signs and parkinsonism. Perform a full mental state examination and assess attention, registration, delayed recall, recognition, executive function, language, abstraction and visuospatial skills. MoCA, MMSE or a validated local tool can establish a baseline; document language, education, sensory impairment, interpreter use and fatigue. A score does not diagnose dementia or determine capacity alone. 5. Investigations Full blood count, electrolytes/urea/creatinine, calcium, glucose, liver function and urinalysis. Thyroid function, B12/folate, HIV/syphilis testing when indicated by symptoms and consent, and malaria/TB or other infection tests according to local epidemiology. Medication/substance review, oxygenation and ECG where cardiac or medicine risk exists. CT/MRI for rapid or young onset, focal signs, seizures, gait disorder, head injury, atypical progression or diagnostic uncertainty. EEG for episodic altered awareness or unexplained fluctuations; lumbar puncture, autoimmune or genetic tests only when the clinical phenotype justifies specialist assessment. 6. Management goals Treat reversible contributors. Preserve independence, dignity, communication and meaningful activity. Reduce distress without unnecessary sedation or restraint. Prevent falls, delirium, medication harm, malnutrition, pressure injury and caregiver breakdown. Support the person and family through diagnosis, progression and end-of-life planning. 7. Non-drug management Predictable routine, orientation board, good lighting, clocks and familiar objects. Glasses, hearing aids, dentures, preferred language and one-step communication. Exercise, meaningful activity, music, reminiscence, social contact and occupational therapy. Manage pain, constipation, urinary symptoms, sleep, nutrition, hydration, dental and visual problems. Use calm reassurance and redirection rather than arguing; identify triggers for wandering or agitation. Offer caregiver education, respite, support groups, home-based services and community resources. 8. Cognitive medicines Cholinesterase inhibitors and memantine provide symptomatic benefit for selected patients; they do not cure dementia. Confirm indication, discuss realistic goals and review benefit and harm. Medicine Uses and typical adult titration Important cautions Donepezil Alzheimer and selected specialist use in Lewy-body/Parkinson dementia. Start 5 mg nightly; increase to 10 mg after about 4–6 weeks if tolerated. Nausea, diarrhoea, weight loss, insomnia, bradycardia, syncope and QT risk; caution in conduction disease, ulcers, asthma and interactions. Rivastigmine Alzheimer/Parkinson dementia. Oral start 1.5 mg twice daily and titrate; patch commonly 4.6 mg/24 h then 9.5 mg/24 h. GI effects, weight loss, tremor, bradycardia and patch reactions. Apply one patch only and remove the old one. Galantamine Alzheimer disease. Start 4 mg twice daily or modified-release 8 mg/day; increase gradually to 16–24 mg/day. GI effects, dizziness, weight loss, bradycardia and interactions; adjust in renal/hepatic impairment. Memantine Moderate-to-severe Alzheimer disease or intolerance/contraindication to cholinesterase inhibitors. Start 5 mg/day, increase by 5 mg weekly to 20 mg/day. Dizziness, headache, constipation, confusion, hypertension and hallucinations; reduce

Clinical Medicine Year 2 • Mental Health Disorders • Emergency Focus Delirium: Recognition, Assessment, Causes and Emergency Management Delirium is an acute neuropsychiatric syndrome characterised by a disturbance in attention and awareness that develops over a short period, fluctuates during the day and is caused by an underlying medical, toxicological or medication-related problem. It is common, dangerous and frequently missed, especially when the patient is quiet or sleepy. Delirium is not simply “confusion,” dementia, psychosis or bad behaviour. Emergency principle: Delirium is a medical emergency until the precipitating cause is found and treated. Stabilise airway, breathing and circulation; check glucose and oxygenation; assess sepsis, stroke, seizure, overdose, withdrawal, hypoxia, electrolyte disturbance, head injury and medication toxicity. Learning objectives Define delirium and recognise hyperactive, hypoactive and mixed presentations. Use bedside attention and arousal assessment and a structured tool such as the 4AT or CAM. Identify common precipitants and red flags for infection, neurological disease, toxicology and metabolic emergencies. Plan immediate investigations, non-drug management, medication review and prevention. Communicate with family, document fluctuation and arrange follow-up after recovery. 1. Core diagnostic features Feature What to look for Acute onset New change over hours to days, or clear worsening from a recent baseline Fluctuating course Better and worse periods, often worse at night; document when the patient is most alert Inattention Cannot sustain or shift focus; easily distracted; loses the thread of conversation Altered awareness Hyperalert, lethargic, stuporous or variably responsive Cognitive/perceptual change Disorientation, memory impairment, disorganised thinking, illusions or hallucinations Medical cause Evidence of infection, metabolic illness, medication, intoxication/withdrawal, neurological or other physiological disturbance 2. Types of delirium Hyperactive: agitation, restlessness, shouting, aggression, hallucinations, pulling lines or attempting to leave. Hypoactive: drowsiness, slowed responses, reduced movement, withdrawal, quiet confusion and poor intake. It is easily mistaken for depression or fatigue. Mixed: alternates between agitation and reduced arousal. Type does not determine severity. Hypoactive delirium may carry a high risk because deterioration is less visible and the cause can be missed. 3. Who is at risk? Older age, dementia, previous delirium, frailty or severe cognitive impairment. Severe infection, surgery, trauma, burns, pain, dehydration, hypoxia or immobility. Renal/hepatic failure, electrolyte or glucose disturbance, anaemia and malnutrition. Polypharmacy, anticholinergic medicines, sedatives, opioids, corticosteroids and abrupt withdrawal. Alcohol or benzodiazepine withdrawal, stimulant or other drug intoxication. Visual/hearing impairment, unfamiliar environment, sleep disruption, urinary retention and constipation. Critical illness, mechanical ventilation, neurological disease and severe systemic inflammation. 4. Delirium versus other presentations Condition Distinguishing features Delirium Acute/fluctuating course, impaired attention and altered arousal; medical cause likely Dementia Insidious progressive decline; attention relatively preserved early; delirium may be superimposed Depression Low mood, reduced motivation and slowed thinking but attention usually more consistent; can coexist with delirium Psychosis Delusions/hallucinations with relatively clear attention and arousal in primary psychosis; visual hallucinations and fluctuation suggest delirium Catatonia Marked psychomotor syndrome; may coexist with delirium or be caused by medical illness; rigidity, mutism and posturing need specialist assessment Non-convulsive seizure Episodes of altered awareness or automatisms; EEG may be required 5. Immediate assessment: ABCDE plus attention Airway and breathing: patency, respiratory rate, oxygen saturation, aspiration risk, carbon dioxide retention and respiratory depression. Circulation: pulse, blood pressure, perfusion, temperature, ECG, sepsis screen and intravenous access when needed. Disability: capillary glucose, AVPU/GCS, pupils, seizure activity, focal deficits, pain and signs of intoxication or withdrawal. Exposure: fever, rash, trauma, pressure injury, dehydration, urinary retention, constipation, medication patches and evidence of poisoning. Attention: ask the person to follow a simple conversation, recite months backwards, digit span or sustain eye contact; compare with baseline. Collateral: ask family or caregivers exactly when the change began, what is different and what the person’s baseline function was. 6. Structured tools 6.1 The 4AT The 4AT is a rapid delirium screen with four domains: Alertness: normal, clearly abnormal hyperalert or drowsy. AMT4: age, date of birth, place and current year. Attention: months of the year backwards or another validated attention task. Acute change or fluctuating course: from informant, notes or observation. A positive score supports further clinical assessment; it does not identify the cause or replace examination. Consider sensory impairment, language, education, aphasia and baseline cognition. 6.2 Confusion Assessment Method (CAM) CAM requires acute onset and fluctuating course plus inattention, and either disorganised thinking or altered level of consciousness. Use only with training and clinical judgement. Record the actual findings rather than writing “CAM positive” alone. 7. Investigating the cause 7.1 Bedside and immediate tests Capillary glucose, oxygen saturation, temperature, pulse, blood pressure and respiratory rate. ECG for arrhythmia, overdose, electrolyte disturbance or QT-risk medicines. Bladder scan where urinary retention is possible; assess bowel function and pain. Pregnancy test where relevant before radiation or teratogenic treatment. 7.2 Laboratory and infection assessment Full blood count, electrolytes, urea/creatinine, calcium/magnesium, glucose, liver function and urinalysis. Blood cultures, urine culture, malaria testing, HIV/TB or other infection tests according to symptoms, immune status and local epidemiology. Blood gas, lactate, ketones, toxicology or drug levels when respiratory failure, shock, diabetic ketoacidosis, poisoning or medicine toxicity is possible. Medication reconciliation including anticholinergics, opioids, sedatives, steroids, antihistamines, withdrawal of alcohol/benzodiazepines and recently changed medicines. 7.3 Neurodiagnostics Urgent CT for head injury, focal deficit, severe sudden headache, anticoagulation, seizure or concern about bleeding/mass effect. MRI for subacute unexplained cognitive change, atypical presentations or suspected encephalitis/structural disease when stable and available. EEG for suspected non-convulsive status, unusual spells, post-ictal confusion or persistent unexplained fluctuating consciousness. Lumbar puncture for suspected meningitis/encephalitis after contraindication assessment and urgent senior advice; never delay emergency antibiotics when meningitis is suspected. 8. Treating delirium: find and correct the cause Infection: cultures and prompt antimicrobial treatment according to local protocol when indicated. Hypoxia or respiratory failure: oxygen and ventilatory support; investigate pneumonia, pulmonary disease or opioid/sedative effect. Metabolic disturbance: correct glucose, electrolytes, renal/hepatic failure, dehydration and acid-base disorders safely. Medication or toxin: stop non-essential contributors; use an antidote only with appropriate toxicology guidance. Withdrawal: use a validated local alcohol/benzodiazepine withdrawal pathway; monitor seizures and autonomic instability. Pain, urinary retention and constipation: assess actively and treat while avoiding

Clinical Medicine Year 2 • Mental Health Disorders Organic Mental Disorders: Medical and Neurological Causes, Assessment and Management Organic mental disorder is an older teaching term for mental or behavioural symptoms caused by a demonstrable disease, injury, intoxication, withdrawal or physiological disturbance affecting the brain or body. Modern classifications use more specific terms such as delirium, major or mild neurocognitive disorder, substance/medication-induced disorder and mental disorder due to another medical condition. The important clinical message is unchanged: a new psychiatric presentation may be a medical emergency until reversible causes have been considered. Emergency warning: Acute confusion, fluctuating attention, reduced consciousness, seizure, fever, meningism, severe headache, focal neurological signs, hypoxia, hypoglycaemia, head trauma, overdose, severe withdrawal, catatonia or autonomic instability requires urgent medical assessment. Do not assume “organic” means mild, chronic or untreatable. Learning objectives Define organic mental disorders and explain their relationship to current ICD and DSM terminology. Recognise medical, neurological, infectious, toxicological, endocrine and nutritional causes of psychiatric symptoms. Distinguish delirium, dementia/neurocognitive disorder, substance-induced syndromes and functional psychiatric illness. Plan a targeted assessment, investigation, treatment and prevention strategy. Communicate with family and document a safe formulation when the cause is not yet certain. 1. How medical disease produces psychiatric symptoms Mechanism Examples Clinical pattern Diffuse brain dysfunction Sepsis, hypoxia, hypoglycaemia, hepatic or renal failure Inattention, fluctuating arousal, confusion, agitation or drowsiness Focal or structural disease Stroke, tumour, subdural haematoma, traumatic brain injury Personality change, focal deficits, seizures, language or executive dysfunction Neurodegeneration Alzheimer disease, Lewy-body disease, frontotemporal degeneration Progressive cognitive, behavioural, visuospatial or movement changes Endocrine/metabolic disease Thyroid disease, calcium disorder, adrenal disease, B12 deficiency Mood, anxiety, psychosis, weakness, neuropathy or cognitive change Infection/inflammation HIV, neurosyphilis, malaria, TB, meningitis, encephalitis, autoimmune disease Acute or subacute confusion, seizures, psychosis, personality change or fever Substance/medication Alcohol, stimulants, sedatives, steroids, anticholinergics, dopamine blockers Intoxication, withdrawal, mood/psychotic symptoms, delirium or toxicity 2. Red flags for an organic cause Sudden onset, rapid progression or a waxing-and-waning course. Impaired attention, altered level of consciousness or disorientation that is disproportionate to the psychiatric symptoms. New onset at an atypical age, especially later life or childhood without developmental explanation. Fever, weight loss, night sweats, severe headache, meningism, rash, hypoxia or abnormal vital signs. Focal neurological findings, seizures, gait change, abnormal pupils, new incontinence or movement disorder. Visual hallucinations, olfactory hallucinations, fluctuating cognition or prominent cognitive decline. Recent head injury, pregnancy/postpartum state, immunosuppression, cancer, endocrine disease or new medicine. Exposure to alcohol, recreational drugs, pesticides, traditional medicines or occupational toxins. 3. Common causes to remember 3.1 Neurological Stroke, subdural haematoma, brain tumour, hydrocephalus and traumatic brain injury. Epilepsy, post-ictal states, non-convulsive status epilepticus and encephalitis. Alzheimer disease, Lewy-body disease, frontotemporal dementia, Parkinson disease dementia and vascular cognitive impairment. Multiple sclerosis, demyelination, autoimmune encephalitis and neurodegenerative disorders. 3.2 Infectious and inflammatory Sepsis, meningitis, encephalitis, HIV-associated disease, neurosyphilis, cerebral malaria and tuberculosis. Autoimmune encephalitis, vasculitis, systemic lupus and other inflammatory disease. Always combine exposure, immune status, fever, neurological findings and local epidemiology; no single negative test excludes every infection. 3.3 Endocrine, metabolic and nutritional Hypo- or hyperthyroidism, hypoglycaemia, diabetes emergencies, adrenal disease and severe electrolyte/calcium abnormalities. Renal or hepatic failure, hypoxia/hypercapnia, dehydration, malnutrition and B12/folate deficiency. Porphyria, Wilson disease and other rare metabolic conditions when the phenotype and age are suggestive. 3.4 Toxicological and medication-related Alcohol intoxication or withdrawal, opioids, sedatives, stimulants, cannabis, hallucinogens, inhalants and pesticides. Anticholinergics, corticosteroids, dopaminergic medicines, antimalarials, antiepileptics, sedatives, polypharmacy and abrupt withdrawal. Review herbal and traditional preparations without ridicule; composition and contamination may be uncertain. 4. Clinical assessment Stabilise: ABCDE, observations, capillary glucose, oxygenation, temperature, hydration and level of consciousness. Define onset: establish exact time course and compare with documented baseline. Seek collateral: family, caregiver, school/work records, ambulance staff and previous notes. Examine: general, cardiovascular, respiratory, abdominal and detailed neurological examinations, including gait and movements. Review exposures: all medicines, recent changes, alcohol/drugs, toxins, infection risks, head injury and withdrawal. Investigate the question: glucose, electrolytes/renal/liver tests, FBC, infection tests, thyroid/B12 and other targeted tests; ECG, CT/MRI, EEG or lumbar puncture when indicated. Reassess: organic syndromes evolve. Repeat attention, arousal, observations and examination after treatment or time. 5. Delirium versus dementia versus functional illness Feature Delirium Dementia/neurocognitive disorder Functional psychiatric illness Onset Hours to days Usually months to years Variable; may be episodic or gradual Course Fluctuating, often worse at night Progressive or stepwise; attention relatively preserved early Depends on disorder; attention often less globally impaired Attention Impaired and easily distractible May be preserved early Usually preserved unless severe illness or substances Consciousness Hyperactive, hypoactive or mixed; altered arousal common Usually clear until late stages Usually clear, except catatonia, severe depression or intoxication Priority Medical emergency; find and treat cause Assess cause, function, safety and support Psychiatric formulation after medical/substance assessment 6. Investigations 6.1 Core tests when clinically indicated Capillary glucose, oxygen saturation, temperature and ECG when acute or unstable. Full blood count, electrolytes/urea/creatinine, calcium/magnesium, glucose, liver function and urinalysis. Thyroid function, B12/folate, HIV/syphilis, malaria, TB or other infection tests based on signs, risk and local protocol. Pregnancy test where relevant before radiation, teratogenic medicines or procedures. Toxicology and alcohol levels only when results will change care; interpret detection windows and false results. 6.2 Specialist investigations CT/MRI: focal deficit, head trauma, severe headache, seizure, new atypical psychosis, rapidly progressive cognition, cancer or immunosuppression. EEG: episodic altered awareness, seizures, post-ictal states, fluctuating unexplained symptoms or suspected encephalitis. Lumbar puncture: suspected meningitis/encephalitis, inflammatory disease or selected autoimmune presentations after contraindication assessment. Autoimmune/metabolic tests: guided by phenotype and specialist advice, not indiscriminate screening. 7. Management principles Treat the cause: oxygen, glucose, antibiotics/antimalarials, fluids, electrolyte correction, antidotes, seizure treatment, withdrawal management or surgery as indicated. Provide a safe environment: orientation cues, glasses/hearing aids, sleep protection, hydration, pain control, mobilisation and family presence where safe. Review and stop non-essential medicines that worsen cognition, sedation, anticholinergic burden or delirium. Use de-escalation and least-restrictive care. Medication for severe agitation is a last resort with airway, ECG and sedation monitoring. Rehabilitate cognition and function; plan caregiver support, follow-up, capacity and safeguarding. 8. Prevention

Clinical Medicine Year 2 • Mental Health Disorders Classification and Management of Mental Disorders: DSM-5-TR and ICD-11 Classification gives clinicians a shared language for describing patterns of symptoms, course, severity, causes and functional impact. It supports communication, treatment planning, research, health records and service organisation. A classification is not the patient, and a code is not a complete formulation. Diagnosis must remain a careful clinical process that includes safety, physical health, culture, development, substance use, trauma, strengths and the patient’s own goals. Terminology note Teaching materials sometimes write “DSM V” and “ICD IV.” The current DSM terminology is DSM-5-TR (the fifth edition, text revision). The WHO classification is ICD-11; ICD-10 remains important in many records and examinations. There is no current psychiatric “ICD-IV” system. Always follow the classification required by the school, hospital and national reporting system, and document the source of the code. Emergency rule: Never wait for a diagnostic label before treating hypoglycaemia, hypoxia, sepsis, overdose, delirium, severe withdrawal, status epilepticus, catatonia, violent agitation or imminent suicide risk. Learning objectives Explain why mental-disorder classifications are useful but cannot replace clinical formulation. Outline the major DSM-5-TR and ICD-11 families of mental, behavioural and neurodevelopmental disorders. Distinguish primary psychiatric illness from disorder due to a medical condition, substance/medication or delirium. Apply a biopsychosocial, culturally responsive and risk-informed management framework. Document a provisional or confirmed diagnosis, differential, severity, psychosocial formulation and management plan. 1. What makes a mental disorder? A mental disorder is generally a clinically significant disturbance in cognition, emotion regulation or behaviour associated with distress, impairment, risk or loss of functioning. Distress alone is not always a disorder; cultural practices, normal grief, understandable reactions to danger and differences that do not cause clinically significant harm should not be pathologised. Conversely, a person may have a serious disorder even when they minimise symptoms or appear calm. Core diagnostic dimensions Dimension Questions for the clinician Symptoms What experiences, behaviours, thoughts, emotions, bodily symptoms or developmental changes are present? Time course When did they begin? Sudden or gradual? Episodic, persistent, fluctuating or progressive? Severity How intense, frequent and dangerous are they? Is there psychosis, suicidality, aggression or inability to eat/sleep? Function What has changed in self-care, relationships, school, work, parenting and community life? Exclusions and causes Could this be delirium, a medical/neurological condition, a substance, a medicine, a developmental difference or a culturally accepted experience? Context What are the person’s culture, trauma, social determinants, strengths, supports and goals? 2. DSM-5-TR and ICD-11: how they differ Feature DSM-5-TR ICD-11 Publisher and purpose American Psychiatric Association; detailed clinical diagnostic manual World Health Organization; global disease classification for clinical, public-health and reporting use Current edition DSM-5-TR, published 2022 ICD-11 in effect as a basis for health reporting from 2022; WHO’s mental-health CDDR published 2024 Use of codes Uses ICD-10-CM codes in the DSM-5-TR text for many settings Uses ICD-11 categories and codes, with clinical descriptions and diagnostic requirements Approach Operational criteria, severity and specifiers; categorical diagnoses with dimensional elements Global clinical descriptions, essential features, boundaries and dimensional approaches in selected conditions Best practice Use criteria plus clinical judgement, collateral information and cultural formulation Use CDDR/ICD guidance plus local policy, clinical judgement and context DSM and ICD categories overlap but are not always identical. Do not convert a code by memory when a precise code matters; use the current electronic browser or institutional coding manual. If the picture is incomplete, document a provisional, other-specified or unspecified diagnosis rather than inventing certainty. 3. Major families of mental and behavioural disorders 3.1 Neurodevelopmental disorders These begin during the developmental period and affect intellectual, motor, language, communication, attention, learning or social functions. Examples include intellectual developmental disorder, autism spectrum disorder, attention-deficit/hyperactivity disorder, communication disorders, specific learning disorders, motor disorders and tic disorders. Assess developmental history, school/work function, adaptive skills, language, sensory impairment and collateral information. Rule out hearing/vision problems, epilepsy, sleep disorders, trauma, substance exposure and intellectual or neurological conditions. Management is developmental and environmental: education adjustments, behavioural support, family training, occupational/speech therapy, social protection and selected medication. 3.2 Schizophrenia spectrum and other primary psychotic disorders Psychosis is a syndrome, not a diagnosis. It may involve delusions, hallucinations, disorganised thought or behaviour, negative symptoms and cognitive change. The differential includes schizophrenia, schizoaffective disorder, brief or acute psychosis, mood disorder with psychotic features, substance-induced psychosis, psychosis due to a medical condition and delirium. Establish duration, mood relationship, functional decline, substance exposure, physical/neurological signs and collateral history. Management may include antipsychotic medicine, psychological and family interventions, physical-health monitoring, substance-use treatment, supported education/employment and crisis planning. Treat red flags such as altered attention, fever, seizures, catatonia, head injury, immunosuppression or abrupt atypical onset as possible medical illness. 3.3 Catatonia Catatonia is a psychomotor syndrome that may occur in mood disorders, psychosis, neurological disease, infection, autoimmune illness or medication withdrawal. Signs include stupor, mutism, negativism, posturing, waxy flexibility, echophenomena, agitation and refusal of food or fluid. Malignant catatonia with fever and autonomic instability is an emergency. Assess hydration, renal function, CK, infection, seizures, medication and medical causes, and seek specialist treatment urgently. 3.4 Bipolar and related disorders Bipolar disorders involve episodes of mania or hypomania, often with depressive episodes. Mania includes elevated, expansive or irritable mood with increased energy and associated reduced need for sleep, pressured speech, grandiosity, racing thoughts, distractibility and risky behaviour. Assess psychosis, substance use, thyroid disease, medicines and safety. Acute mania may require a low-stimulation environment, antipsychotic treatment, mood stabiliser and sometimes admission. Long-term care includes relapse prevention, sleep/routine stabilisation, medicine monitoring, family work, psychoeducation and treatment of substance use. Antidepressant monotherapy can worsen mania or rapid cycling in susceptible patients; reassess the diagnosis before prescribing. 3.5 Depressive disorders Depressive disorders involve persistent low mood or loss of interest plus cognitive, emotional, physical and behavioural symptoms. Assess duration, severity, psychosis, bipolarity, suicide risk, substances, grief, medical illness, pregnancy/postpartum state and social stress. Management may combine psychoeducation, behavioural activation, CBT/IPT, social support, antidepressant medicine and ECT for selected severe or life-threatening presentations. Do not equate a questionnaire score with