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Forpsychologicalinterventions,progressshouldbereviewedat4–8weekintervals For pharmacological interventionsreview within 2 weeks, then at4, 6, and 12 weeks. If at12 weeksitisdecidedtocontinue,reviewat8–12weekintervals.Continueforatleast6monthsafter theoptimumdoseisreachedifeffective.
Specialconsiderations
Refertospecialistservicesifsignificantsymptomsremainaftertriallingtwotreatments.
Furtherreading
1.BaldwinA(ed)(2020).Psychiatry.In:OxfordHandbookofClinicalSpecialities,11thed(pp.682–
773). Oxford: Oxford University Press. Available at:
https://doi.org/10.1093/med/9780198827191.003.0012
2.SimonC,EverittH,vonDorpF,etal.(2020).OxfordHandbookofGeneralPractice,5thed(pp.963–
96). Oxford: Oxford University Press. Available at:
https://doi.org/10.1093/med/9780198808183.003.0027
1AmericanPsychiatric Association.(2013).Diagnosticandstatistical manual ofmentaldisorders(5th
ed.).https://doi.org/10.1176/appi.books.9780890425596
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Chapter42
Post-traumaticstressdisorder
Guideline: NICE NG116 (Post-traumatic stress disorder):
https://www.nice.org.uk/guidance/ng116
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Post-traumatic stress disorder (PTSD) is an anxiety disorder which can develop after experiencing or witnessing a traumatic event. The condition is thought to result from inadequatememoryprocessingandresultsinsymptomsthatcanbedisabling.
Diagnosis
History
Assess for possible triggers of PTSD, i.e. discuss whether the patient has ever experiencedorwitnessedanysingle,repeated,ormultipletraumaticevents,suchas:
Seriousaccidents Physical,sexual,ordomesticassaultorabuse War,conflict,ortorture Seriousphysicalhealthproblemsortraumaticchildbirthexperiences.
Askaboutthefollowing:
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Flashbacks—intrusivememoriesormentalimagery,recurrentnightmares Avoidanceoftriggers,i.e.anystimulusthatprovokesrecollectionofthetrauma Hyperarousal,includinghypervigilance,anger,andirritability Negativechangestomoodandthinking Numbingofemotions Dissociation(feelingdisconnectedfromyourself,yourthoughts,feelings,ormemories) Difficultyinregulatingemotions Problemsmaintainingrelationships Negativeperceptionofoneself,includingfeelingworthlessordefeated.
Askaboutanyassociatedfunctionalimpairment.
Conductariskassessmentandconsidersuiciderisk.
Management
Patienteducation
Provide patients and families/carers with verbal and written information regarding symptoms, treatmentoptions,and supportgroups. Goodsourcesof writteninformation are http://www.mind.org.uk/information-support, http://www.nhs.uk/conditions or
http://www.rcpsych.ac.uk/mental-health.
ReassurepatientsthatPTSDistreatable.
ImprovingAccesstoPsychologicalTherapies(IAPT)programme
In England, IAPT services offer psychological therapies for depression and anxiety disorders, including trauma-focused therapies for PTSD. Patients can generally self­refer or be referred by a professional. IAPT services will be appropriate for most patients with PTSD, although referral to secondary care may be necessary for ↑ complexity, severity, or risk. More information on IAPT services can be found at:
https://www.england.nhs.uk/mental-health/adults/iapt/
Psychologicalinterventions
Optionsinclude:
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Trauma-focusedCBT Trauma-focusedcomputerizedCBT Eyemovementdesensitizationandreprocessing(EMDR)
Inthecaseofpersistentsymptomsaftertrauma-focusedtherapy,considerCBTtargetedat specificsymptoms(e.g.sleepdisturbance).Thiscanalsobeconsideredforpatientswho areunableorunwillingtoengageintrauma-focusedtherapy.
Pharmacologicalmanagement
OnlyofferdrugtreatmenttopatientswithadiagnosisofPTSD(i.e.donotuseforprevention) Onlyconsiderifthepatientprefersdrugtreatmenttopsychologicalinterventions Consider a SSRI, such as sertraline 25mg OD. Venlafaxine may also be considered as an alternative(off-labeluse) Considerantipsychoticssuchasrisperidone,inadditiontopsychologicaltherapiesif:
Thepatienthasdisablingsymptomsandbehaviours,(e.g.psychoticsymptoms)AND
Theirsymptomshavenotrespondedtootherdrugorpsychologicaltreatments Antipsychotictreatmentshouldonlybeinitiatedbyaspecialist.
Psychosocialconsiderations
Take thesefactors into account and help the patientto manage them (this may involve referringtootherservices/agenciesforsupport).
Examplesinclude:
Safeguardingconcerns Homelessness Socialisolation Substanceabuse Financialhardship Interpersonaldifficulties.
Complications
Drugoralcoholmisuse:additionalsupportmayberequiredfromspecialistaddictionservices Depression: treating PTSD first will often lead to an improvement in depressive symptoms.
However,ifthedepressionissevereenoughtomakePTSDtreatmentproblematic,orifthereisa significantriskofharm,itispreferabletotreatthedepressionfirst.
Monitoringandfollow-up
Alldrugtreatmentsshouldbereviewedregularlybyaspecialist.
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Furtherreading
1. Ehlers A (2012). Post-traumatic stressdisorder. In:Geddes JR, AndreasenNC, Lopez-IborJ,etal. (eds) New Oxford Textbook of Psychiatry, 2nd ed (chapter 93). Oxford: Oxford University Press. Availableathttps://academic.oup.com/book/24770/chapter/188331538
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Chapter43
Psychosisandschizophrenia
Guideline:NICECG178(Psychosisandschizophreniainadults:prevention
andmanagement):https://www.nice.org.uk/guidance/cg178
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
This chapter covers the prevention and management of schizophrenia, schizoaffective disorder, schizophreniform disorder, and delusional disorder (this excludes psychosis secondary to bipolar affective disorder or depressive disorder). These disorders are characterizedbypsychoticsymptoms.
Assessment
Psychoticsymptoms
Psychosismaymanifestsubtlywith achangein mood orwithdepressive symptoms. More overt psychotic symptoms can broadly be divided into hallucinations and delusions.Hallucinationsaretheexperienceofasensoryperceptionintheabsenceof an external stimulus. Delusions are falsebeliefs whichthepatientholdsdespiteclear evidencetothecontrary.Commonsymptomsinclude:
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Auditoryhallucinations:
Hearingvoicesarguingorarunningcommentaryontheiractions
Delusions:
Persecutorydelusions,e.g.fearofbeinghurtorkilled,fearsofbeingstalkedorconspired against Delusions of grandeur, e.g. believing themselves to have a special talent or to be a millionaire Delusionaljealousy,e.g.beliefthatapartnerisbeingunfaithful Nihilisticdelusions,e.g.believingthattheydonotexistoraredead,theirlovedonesare dead,theworldnolongerexists,orthattheiractionsmaydestroytheworld
Disordersofthought:
Thoughtecho:patienthearstheirthoughtsspokenaloudshortlyafterthinkingthem Thoughtinsertion:thepatientbelievesthatsomeoneisputtingthoughtsintotheirbrain Thought withdrawal: the patient believes that someone is removing thoughts from their brain Thought broadcasting: the patient believes that their thoughts are being broadcasted so otherscanhearthem.
History
Coverthefollowing:
Psychiatrichistoryandriskassessment Prescribedmedicationandrecreationaldrughistory Medicalhistoryandfullphysicalexamination(toidentifyphysicalillness,includingorganicbrain disorders,andprescribeddrugtreatmentsthatmayresultinpsychosis) Lifestyle(includingweight,smoking,alcohol,nutrition,physicalactivity,andsexualhealth) Psychosocialincludingsocialnetworks,relationships,andtrauma(assessforPTSD;seeChapter
42)
Developmentalhistory Socialhistory,includingculturalissues,leisureactivities,andcaringresponsibilities Occupationalandeducationalhistory,andfinancialstatus.
Preventingpsychosis
A first episodeofpsychosisistypicallyprecededbyaprodromal period, lastingfrom a fewdaysto18months.Apersonshouldbeconsideredatriskofdevelopingpsychosisif theymeetthecriteriainTable43.1.
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Table43.1Prodromalcriteriaforpatientsatriskofdevelopingpsychosis
Distressed + Declineinsocialfunctioning + Atleastoneofthefollowing:
Transientorattenuatedpsychoticsymptoms Otherexperiencesorbehavioursuggestiveofpossiblepsychosis Afirst-degreerelativewithpsychosisorschizophrenia
Ifpatientsfitthesecriteria,theyshouldbereferredforurgentassessmentbyaconsultant psychiatrist.
Patientswithprodromalsymptomsshouldbeoffered:
CBT±familyintervention Treatmentforanycomorbidpsychiatricdisorder,includingsubstancemisuse.
Theyshouldnotbegivenantipsychoticmedicationinitially.
Ifthepatientisnotformallydiagnosedwithpsychosisbutsymptomspersist,continue
monitoringforsignsofemergingpsychosisforupto3years.
Management
Patienteducation
Make patients and their carers aware of appropriate peer support and self-management programmes Ensuretheyhavereceivedappropriateinstructionofwhattodo/whotocallinacrisis.
Lifestyleandsimpleinterventions
Facilitateeducation/occupationalactivities Supportpatientstostopsmoking.Usemedicationssuchasbupropionandvareniclinecautiouslyas theymayworsenpsychiatricsymptoms.
Psychologicalinterventions
OfferCBTandfamilytherapy Considerofferingarttherapy(particularlyfornegativesymptoms) Ifpatientschoosetotrypsychologicalinterventionwithoutmedication,advisethemthatthisisless effectivethancombinedtherapy Monitorregularlyandreviewtreatmentwithinamonth.
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Pharmacologicalmanagement
Offer antipsychotic medication (combined with psychological interventions—see
‘Psychological interventions’) to all patients with psychosis, guided by a consultant
psychiatrist.Discussthefollowingwiththepatientandtheircarer:
Responsetopreviousantipsychoticmedication Expectedbenefits Potentialsideeffects(Table43.2).
Table43.2Potentialsideeffectsofantipsychotics
Typeofsideeffect Example Antipsychoticslikelytocausethesesideeffects
Metabolic Weightgain,diabetes Clozapine,olanzapine,quetiapine
Extrapyramidal Akathisia,dyskinesia,dystonia Typicalantipsychotics(e.g.haloperidol)
Cardiovascular ProlongedQTinterval Haloperidol,pimozide
Hormonal Hyperprolactinaemia Amisulpride,risperidone,paliperidone
Baselinetests
Baselineinvestigationsbeforestartinganantipsychotic:
Weight Waistcircumference Pulseandbloodpressure Fastingbloodglucose HbA1c Lipidprofile Prolactinlevels Assessmentofanymovementdisorders Assessmentofnutritionalstatus,diet,andlevelofphysicalactivity.
PerformabaselineECGif:
Usinghaloperidol,clozapine,orchlorpromazine(manufacturerrequirement) A physical examinationindicatescardiovascular risk(e.g.hypertension)or thereis a history of cardiovasculardisease.
Antipsychoticprescribing
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Startatthelowerendofthetherapeuticrangeandtitrateupwardsasneeded Monitorforsideeffectsandadverseeffects Iftolerated,trialthemedicationattheoptimumdosefor4–6weeks Donotcombineantipsychotics(apartfromshort-termwhenswitching) Thereisnospecific orderinwhichantipsychotics shouldbetried.Itwilldependonpatientand doctorpreference.Allpatientswillrespondtoandtoleratemedicationsdifferently,thereforethere isnofirst-linemedicationwhichwillbesuitableforallpatients.However,clozapineshouldnot beusedinitially Examplesofantipsychoticswhichcouldbetriedinitiallyinclude:
First-generation(typical)antipsychotics:chlorpromazine,flupentixol,haloperidol Second-generation(atypical)antipsychotics:olanzapine,risperidone,quetiapine.
Treatmentresistance
Forpatientswhodonotrespondtotreatment:
Checkadherence Checkthatthedoseanddurationwereadequate Checkthatpsychologicaltherapieshavebeenofferedandengagedwith Consideriftherecouldbeconcurrentsubstanceabuse,interactingmedications,orphysicalillness Reviewthediagnosis.
Clozapineshouldbeofferedtopeoplewithschizophreniawhohavefailedtorespondto separatetrials(atadequatedurationanddose)ofatleasttwodifferentantipsychotics,one ofwhichmustbeanon-clozapineatypicalantipsychotic.
Ifsymptomsdonotrespondadequatelytoclozapine,checkplasmaclozapinelevels. Ifnecessary,consideraddinganotherantipsychotic.
Depot/long-actinginjectableantipsychoticmedication
Considerusingdepotmedicationsif:
Thisisthepatient’spreference Thereisariskofnon-adherencetomedication.
Monitoringandstoppingantipsychotics
Informpatientsthatiftheystopmedicationwithin1–2yearstheirriskofrelapseishigh Reviewmedicationannuallyasaminimum Stopmedicationgraduallyandmonitorcloselyforsignsofrelapseforatleast2years.
Patients taking antipsychotic medication should continue to have their physical health monitoredinsecondarycare(inaccordancewithTable43.3)for atleast1year,oruntil theirconditionhasstabilized.
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