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How to Use These Notes

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PSYCHIATRY - Study Notes (Topics 39-48)

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39. Specific Personality Disorders: Anankastic, Anxious, Dependent

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Anankastic (Obsessive-Compulsive) Personality Disorder

1. Feelings of excessive doubt and caution
2. Preoccupation with details, rules, lists, order, organization, schedules
3. Perfectionism that interferes with task completion
4. Excessive conscientiousness, scrupulousness, undue preoccupation with productivity to the exclusion of pleasure and interpersonal relationships
5. Excessive pedantry and adherence to social conventions
6. Rigidity and stubbornness
7. Unreasonable insistence that others submit to one's own way of doing things, or reluctance to allow others to do things
8. Intrusion of insistent and unwelcome thoughts or impulses

1. Preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost
2. Perfectionism that interferes with task completion (cannot finish project because own standards are not met)
3. Excessively devoted to work and productivity to the exclusion of leisure and friendships
4. Overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)
5. Unable to discard worn-out or worthless objects even when they have no sentimental value
6. Reluctant to delegate tasks or to work with others unless they submit to exactly their way of doing things
7. Adopts a miserly spending style toward self and others; money is viewed as something to be hoarded for future catastrophes
8. Shows rigidity and stubbornness

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Anxious (Avoidant) Personality Disorder

1. Persistent and pervasive feelings of tension and apprehension
2. Belief that one is socially inept, personally unappealing, or inferior to others
3. Excessive preoccupation with being criticized or rejected in social situations
4. Unwillingness to become involved with people unless certain of being liked
5. Restrictions in lifestyle because of need to have physical security
6. Avoidance of social or occupational activities that involve significant interpersonal contact, because of fear of criticism, disapproval, or rejection

1. Avoids occupational activities involving significant interpersonal contact (fears criticism, disapproval, or rejection)
2. Unwilling to get involved with people unless certain of being liked
3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed
4. Preoccupied with being criticized or rejected in social situations
5. Inhibited in new interpersonal situations because of feelings of inadequacy
6. Views self as socially inept, personally unappealing, or inferior to others
7. Unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

• CBT targeting core beliefs of inadequacy and anticipated rejection
• Graduated social exposure
• SSRIs/SNRIs (especially if comorbid social anxiety)
• Group therapy (allows safe social practice)
• Long-term therapy needed; prognosis better than Cluster A/B

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Dependent Personality Disorder

1. Encouraging or allowing others to make most of one's important life decisions
2. Subordination of one's own needs to those of others on whom one is dependent, and undue compliance with their wishes
3. Unwillingness to make even reasonable demands on the people one depends on
4. Feeling uncomfortable or helpless when alone, because of exaggerated fears of inability to care for oneself
5. Preoccupation with fears of being abandoned by a person one has a close relationship with, and of being left to care for oneself
6. Limited capacity to make everyday decisions without an excessive amount of advice and reassurance from others

1. Difficulty making everyday decisions without excessive advice/reassurance
2. Needs others to assume responsibility for most major areas of their life
3. Difficulty expressing disagreement with others (fear of loss of support or approval)
4. Difficulty initiating projects or doing things on their own (lack of self-confidence, not lack of motivation/energy)
5. Goes to excessive lengths to obtain nurturance and support, to the point of volunteering to do things that are unpleasant
6. Feels uncomfortable or helpless when alone (because of exaggerated fears of being unable to care for themselves)
7. Urgently seeks another relationship as a source of care and support when a close relationship ends
8. Unrealistically preoccupied with fears of being left to take care of themselves

• Psychotherapy: CBT (building autonomy, assertiveness training), psychodynamic
• Avoid reinforcing dependency in the therapeutic relationship itself
• SSRIs for comorbid depression/anxiety
• Risk: vulnerability to abusive relationships; may remain in harmful situations rather than risk separation

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40. Neurodevelopmental Disorders: Mental Retardation (Intellectual Disability)

Definition

1. Significant limitations in intellectual functioning (reasoning, learning, problem-solving) - typically IQ ≤70 (approximately 2 standard deviations below mean)
2. Significant limitations in adaptive behavior (conceptual, social, and practical skills needed for daily life)
3. Onset during the developmental period (before age 18)

ICD-10 Classification by Severity

Prevalence and Epidemiology

• Prevalence: ~1-3% of the general population
• M:F = approximately 1.5:1
• Most common cause overall: Down syndrome (trisomy 21) in moderate-severe range; Fragile X syndrome is the leading inherited cause

Etiology

• Chromosomal: Down syndrome (T21), Edward syndrome (T18), Patau (T13), Turner, Klinefelter, Fragile X (FMR1 gene mutation)
• Teratogenic: alcohol (Fetal Alcohol Spectrum Disorder - most preventable), infections (TORCH), radiation
• Metabolic: PKU (phenylketonuria - treatable by diet), hypothyroidism, galactosaemia
• Structural CNS malformations

• Birth asphyxia, prematurity, intraventricular hemorrhage, neonatal hypoglycemia

• CNS infections (meningitis, encephalitis)
• Severe TBI, near-drowning
• Toxins (lead, mercury)

Psychiatric Comorbidities ("Dual Diagnosis")

• ADHD (~15-25% in mild ID)
• Stereotyped movement disorders
• Autism Spectrum Disorder (~30% in moderate-severe ID)
• Mood disorders, anxiety
• Psychosis (schizophrenia prevalence ~3x general population)
• Behavioral phenotypes specific to genetic syndromes: Prader-Willi (hyperphagia, OCD traits), Angelman (happy affect, minimal speech), Lesch-Nyhan (self-injurious behavior)

Assessment

• Standardized IQ tests: WAIS (adults), WISC (children), Leiter (non-verbal)
• Adaptive behavior scales: Vineland Adaptive Behavior Scales, AAMR Adaptive Behavior Scale
• Full medical/genetic workup, chromosomal analysis, metabolic screening

Management

• No cure for most forms; management is habilitative (developing skills) rather than rehabilitative
• Early intervention: speech/language therapy, occupational therapy, physiotherapy, special education
• Supported employment and community living programs
• Pharmacotherapy: for psychiatric comorbidities (same agents as general population but with increased sensitivity; start low, go slow); treat pain/epilepsy
• Genetic counseling for families
• Legal advocacy: guardianship, rights protection, education rights

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41. Attention Deficit Hyperactivity Disorder (ADHD)

Definition and Epidemiology

• Most common childhood behavioral disorder: prevalence ~5-7% in children worldwide; ~2.5% in adults
• M:F = 2-3:1 in children (male predominance in hyperactive/combined; more equal in inattentive)
• Persists into adulthood in ~60-70% of cases

DSM-5 Diagnostic Criteria

1. Fails to give close attention to details/makes careless mistakes
2. Difficulty sustaining attention in tasks or play
3. Does not seem to listen when spoken to directly
4. Does not follow through on instructions; fails to finish tasks
5. Difficulty organizing tasks and activities
6. Avoids/dislikes tasks requiring sustained mental effort
7. Loses things necessary for tasks
8. Easily distracted by extraneous stimuli
9. Forgetful in daily activities

1. Fidgets with or taps hands/feet; squirms in seat
2. Leaves seat when remaining seated expected
3. Runs about or climbs in situations where it is inappropriate (in adults: subjective feeling of restlessness)
4. Unable to play or engage in leisure activities quietly
5. "On the go" / acts as if "driven by a motor"
6. Talks excessively
7. Blurts out answers before question is completed
8. Difficulty waiting their turn
9. Interrupts or intrudes on others

• Combined (ADHD-C): both inattention and hyperactivity-impulsivity criteria met
• Predominantly Inattentive (ADHD-PI): "daydreamer"; often missed, especially in girls
• Predominantly Hyperactive-Impulsive (ADHD-HI): more visible; rare in isolation

ICD-10: Hyperkinetic Disorder (F90)

Neurobiology

• Dopaminergic and noradrenergic dysregulation in prefrontal cortex
• Structural MRI: reduced volume in prefrontal cortex, caudate nucleus, cerebellum
• Genetic: highly heritable (~76%); DAT1, DRD4, DRD5 gene variants implicated

Comorbidities

• Oppositional defiant disorder (~40-50%)
• Conduct disorder (~25%)
• Learning disabilities (~25-30%)
• Anxiety disorders (~25%)
• Mood disorders, especially in adults
• Substance use disorders (untreated ADHD increases risk 2-3x)
• Sleep disorders
• ASD (can now be co-diagnosed in DSM-5)

Treatment

• Parent training in behavior management (especially in young children)
• Classroom accommodations (extra time, preferential seating, structured environment)
• CBT (for older adolescents and adults)
• Psychoeducation for child, family, teachers

• Methylphenidate (Ritalin, Concerta - extended release): dopamine/norepinephrine reuptake inhibitor; onset within 30 min; immediate or extended release; most widely used and studied; response rate ~70-80%
• Amphetamine salts (Adderall, Dexamfetamine): dopamine/norepinephrine releasing agent + reuptake inhibitor; equally effective; also first-line
• Side effects (stimulants): decreased appetite, weight loss, insomnia, headaches, abdominal pain, elevated BP/HR, rebound effect, tics (controversial); potential for misuse/diversion; Schedule II substances

• Atomoxetine (Strattera): selective norepinephrine reuptake inhibitor (SNRI); first non-stimulant approved; once/twice daily; no abuse potential; onset 4-6 weeks; good when tics or substance abuse concern; SE: GI upset, initial sedation, black-box warning for suicidality in children
• Guanfacine ER / Clonidine ER: alpha-2 agonists; useful for ADHD + tics or aggression; also second-line
• Bupropion: NDRI; evidence in adults; not first-line

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42. Autistic Spectrum Disorders (ASD)

Definition

1. Persistent deficits in social communication and social interaction across multiple contexts
2. Restricted, repetitive patterns of behavior, interests, or activities

• Symptoms present in the early developmental period (though may not fully manifest until social demands exceed capacity)
• Symptoms cause clinically significant impairment

DSM-5 Diagnostic Criteria

1. Deficits in social-emotional reciprocity (abnormal social approach, failure of back-and-forth conversation, reduced sharing of interests/emotions/affect, failure to initiate/respond to social interactions)
2. Deficits in nonverbal communicative behaviors used for social interaction (poor eye contact, abnormal body language, deficits in understanding/using gestures, absent facial expressions)
3. Deficits in developing, maintaining, and understanding relationships (difficulties adjusting behavior to social contexts, difficulty making friends, absence of interest in peers)

1. Stereotyped or repetitive motor movements, use of objects, or speech (simple motor stereotypies, lining up toys, echolalia, idiosyncratic phrases)
2. Insistence on sameness, inflexible adherence to routines, ritualized patterns (extreme distress at small changes, rigid thinking, greeting rituals, same route)
3. Highly restricted, fixated interests that are abnormal in intensity or focus
4. Hyper- or hyporeactivity to sensory input (apparent indifference to pain/temperature, adverse response to specific sounds/textures, excessive smelling/touching of objects, visual fascination with lights/movement)

• Level 1: Requiring support
• Level 2: Requiring substantial support
• Level 3: Requiring very substantial support

ICD-10 Classification (more fragmented, replaced by ASD in ICD-11)

• F84.0 Childhood autism (Kanner's autism): classic; onset before 3 years; language delay + social/behavioral features
• F84.1 Atypical autism
• F84.2 Rett syndrome (now recognized as genetic - MECP2 mutation; predominantly girls)
• F84.5 Asperger's syndrome: normal language/cognitive development; social deficits + restricted interests; NO intellectual disability; merged into ASD spectrum in DSM-5

Epidemiology

• Prevalence: ~1 in 36 children (CDC 2023); rates have risen substantially (increased awareness + diagnostic criteria changes)
• M:F = ~4:1 (females often underdiagnosed; present differently - "camouflaging")
• Highly heritable: ~80% concordance in monozygotic twins

Neurobiology

• Multiple genetic factors; de novo mutations (CHD8, SHANK3, NRXN1); copy number variants
• Synaptic protein abnormalities, altered connectivity between brain regions
• Brain overgrowth in early childhood then relative plateau
• NOT caused by vaccines (Wakefield 1998 paper retracted, fraudulent)

Assessment

• Gold standard diagnostic tools: ADOS-2 (Autism Diagnostic Observation Schedule) + ADI-R (Autism Diagnostic Interview - Revised)
• Developmental history from parents/caregivers; cognitive/language assessment
• Medical workup: EEG (~30% of ASD have epilepsy), genetic testing (chromosomal microarray, Fragile X), audiological assessment

Comorbidities

• Intellectual disability (~30-40%)
• Epilepsy (~30%)
• ADHD (~50-70%)
• Anxiety disorders (~40-50%)
• Depression (especially in higher-functioning adults)
• Sleep disorders (insomnia, ~50-80%)
• GI problems (constipation, GI pain)
• Sensory processing differences

Treatment

• Applied Behavior Analysis (ABA): most evidence for improving communication, social, and adaptive skills; intensive early intervention (20-40 hrs/week) in young children
• Speech and language therapy: communication skills, augmentative/alternative communication (AAC) for non-verbal children
• Occupational therapy: sensory integration, daily living skills
• Social skills groups
• Special education: individualized education plans
• Pharmacotherapy (for comorbidities only, not core ASD features):
  • Risperidone / Aripiprazole: FDA-approved for irritability/aggression/self-injurious behavior in ASD
  • SSRIs: for anxiety or repetitive behaviors (modest evidence)
  • Methylphenidate/Atomoxetine: for comorbid ADHD
  • Melatonin: for sleep disorders
• Family support and psychoeducation: essential

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43. Anorexia Nervosa

Definition

DSM-5 Diagnostic Criteria

• Restricting type: weight loss achieved by dieting, fasting, and/or excessive exercise; no binge/purge episodes
• Binge-eating/purging type: recurring binge eating or purging behavior (self-induced vomiting, laxatives, diuretics) in the context of low weight

• Mild: BMI ≥17
• Moderate: 16-16.99
• Severe: 15-15.99
• Extreme: <15

ICD-10: F50.0 Anorexia Nervosa

• Body weight ≥15% below expected (or BMI ≤17.5)
• Self-induced weight loss (avoidance of fattening foods + one of: self-induced vomiting/purging, excessive exercise, use of appetite suppressants/diuretics)
• Body image distortion (dread of fatness as intrusive, overvalued idea)
• Endocrine disorder: amenorrhea in females (or loss of libido in males)

Epidemiology

• Lifetime prevalence: ~1% women; ~0.1-0.3% men
• Peak onset: adolescence (15-19 years); bimodal peak at 14 and 18
• Highest mortality of any psychiatric disorder (~5-10% per decade); causes: starvation, electrolyte imbalance, cardiac arrhythmia, and suicide

Medical Complications

Treatment

• Criteria for hospitalization: BMI <15, rapid weight loss (>1 kg/week), electrolyte disturbance, cardiac instability, syncope, suicide risk, failure of outpatient treatment
• Nasogastric feeding if oral intake insufficient; in extremis: parenteral nutrition

• Structured meal plan; gradual caloric increase (starting ~1200-1500 kcal/day, increasing slowly)
• Monitor phosphate, potassium, magnesium, glucose (refeeding risk)

• In adolescents: Family-Based Treatment (FBT / Maudsley Approach): most evidence; parents take control of eating; best outcomes in adolescent AN
• In adults: CBT-E (Enhanced CBT for eating disorders); Adolescent-focused psychotherapy; SSCM (specialist supportive clinical management); psychodynamic therapy
• Anorexia-specific CBT: addresses core beliefs about weight/shape, perfectionism, and emotional avoidance

• No drug approved specifically for AN
• Olanzapine: modest evidence for weight gain and reducing anxiety around eating (low-dose, 2.5-5 mg/day)
• SSRIs: not effective during starvation state (serotonin synthesis requires adequate tryptophan/nutrition); may help once weight restored for comorbid depression/OCD
• Treat osteoporosis: calcium + vitamin D; consider bisphosphonates if severe

• ~50% full recovery, ~30% partial recovery, ~20% chronic/fatal course
• Worse prognosis: older age at onset, longer duration, binge-purge subtype, medical severity, comorbid personality disorder

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44. Psychomotor Excitation in Mental Disorders: Causes and Emergency Interventions

Definition

Causes (Differential Diagnosis)

• Acute psychosis (schizophrenia, brief psychotic episode) - most common
• Manic episode (acute mania/mixed state)
• Severe agitated depression
• Borderline/antisocial personality disorder (impulsive aggression)
• Delirium (hyperactive type - see below)
• Dissociative episodes
• Catatonic excitement

• Delirium from any cause (infection, metabolic, drug intoxication/withdrawal)
• Substance intoxication: alcohol, stimulants (cocaine, amphetamine), PCP, bath salts (synthetic cathinones)
• Substance withdrawal: alcohol (DTs), benzodiazepine withdrawal
• Neurological: post-ictal state, encephalitis (anti-NMDA receptor), TBI, stroke
• Metabolic: hypoglycemia, thyrotoxicosis, hyponatremia, hypoxia
• Pain (especially in non-verbal patients with dementia)
• Akathisia (antipsychotic-induced inner restlessness - must distinguish from agitation requiring more antipsychotic)

Risk Assessment

• STAMP/OAS (Overt Agitation Severity Scale) or PANSS Excited Component
• Assess for: immediate danger, weapons, triggers, history of violence, intoxication
• Key risk factors for violence: male sex, youth, substance misuse, history of violence, command hallucinations, persecutory delusions, antisocial PD, akathisia

Emergency Interventions (Stepped/De-escalation Approach)

• Calm, non-threatening tone; maintain safe distance
• Reduce stimulation (quiet environment, remove bystanders)
• Empathic listening; validate emotions ("I can see you're frightened")
• Offer choice, negotiate; avoid confrontation or commands
• Offer oral medication voluntarily

• Lorazepam 1-2 mg PO/sublingual
• Olanzapine 10 mg PO/wafer (Zydis)
• Haloperidol 5 mg PO
• Promethazine 25-50 mg PO (antihistamine/antipsychotic combination; useful when etiology unclear)

• Lorazepam 1-2 mg IM (first-line for most causes, including unknown etiology)
• Haloperidol 5 mg IM (for psychotic agitation; avoid in DTs and Lewy body dementia)
• Olanzapine 10 mg IM (avoid combining IM olanzapine with IM benzodiazepine - respiratory depression risk)
• Promethazine 50 mg IM (can be combined with haloperidol; reduces EPS)
• Droperidol IM/IV: rapid onset; effective; QTc monitoring required
• For alcohol/benzo withdrawal agitation: high-dose IV diazepam or lorazepam; NOT haloperidol alone (does not prevent seizures)

• Last resort only; legal and ethical requirements (documentation, appropriate staffing, monitoring)
• Prone restraint (face-down) is particularly dangerous - positional asphyxia risk
• Continuous monitoring of airway, breathing, circulation, oxygen saturation, ECG
• Remove restraint as soon as safely possible

• Vital signs every 5-15 minutes
• Pulse oximetry
• Resuscitation equipment available (flumazenil for benzodiazepine reversal, naloxone for opioids)

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45. Suicidal Behaviour in Mental Disorders: Causes and Emergency Interventions

Definitions

• Suicidal ideation: thoughts about suicide (passive = wish to be dead; active = plan to kill oneself)
• Suicidal attempt: non-fatal self-injurious behavior with some intent to die
• Deliberate self-harm (DSH): self-injurious behavior that may or may not have suicidal intent (includes self-cutting, burning, overdose)
• Suicide: completed self-killing

Epidemiology

• ~800,000 suicides per year worldwide (WHO)
• Suicide is the leading cause of death in 15-29 year-olds in many countries
• For every completed suicide: ~20 attempts
• M:F = 3-4:1 for completed suicide (men use more lethal methods); F>M for attempts

Causes and Risk Factors

• Depression (50-60% of suicides): highest absolute number; most important risk
• Bipolar disorder (risk 20-30x general population; mixed states and depressive phases particularly high risk)
• Schizophrenia (lifetime risk ~5-10%; often during periods of insight, post-discharge)
• Borderline personality disorder (lifetime risk ~8-10%)
• Alcohol/substance use disorders (10-15% of alcoholics die by suicide; disinhibition, impulsivity, hopelessness)
• Anorexia nervosa (highest suicide risk of eating disorders)
• PTSD, panic disorder

• Previous suicide attempt (strongest single predictor; risk 30-40x higher)
• Male sex
• Older age (men), young adult (women)
• Access to lethal means (firearms, medications)
• Social isolation, recent loss (bereavement, divorce, unemployment)
• Chronic physical illness (pain, terminal diagnosis)
• Family history of suicide
• Recent discharge from psychiatric hospital (peak risk in first 2 weeks)
• Impulsivity, hopelessness (the most potent psychological predictor), worthlessness

• Strong social/family support
• Religious belief (inhibits suicidal behavior in some cultures)
• Children at home (especially for women)
• Help-seeking behavior, good therapeutic alliance
• Restricted access to means
• Reason for living

Risk Assessment Tools

• SAD PERSONS scale (historical but still used in teaching)
• Columbia Suicide Severity Rating Scale (C-SSRS): gold standard; rates ideation and behavior
• Beck Scale for Suicide Ideation (BSS)
• PHQ-9 item 9 (screening in primary care)

• Specific plan (method, time, place)
• Access to lethal means
• Strong intent; hopelessness
• Previous serious attempt
• Psychotic command hallucinations ordering suicide
• Recent discharge from hospital

Emergency Interventions

• Establish safety; do not leave alone
• Ask directly about suicidal ideation (asking does NOT increase risk - evidence shows it may reduce it)
• Assess severity: ideation frequency, plan, intent, means, deterrents
• Assess mental state (psychosis, intoxication, severe depression)

• Safety planning (collaborative; list coping strategies, contacts, crisis line numbers, reasons for living)
• Remove/restrict access to means (medications locked away, firearms removed from home)
• Increase outpatient follow-up frequency
• Involve family/carer with patient consent
• Crisis card / crisis team contact

• Admit to psychiatric inpatient unit (voluntary if possible)
• If patient refuses, consider involuntary admission under Mental Health Act if criteria met
• One-to-one nursing observation (constant or intermittent)
• Treat underlying psychiatric disorder aggressively (antidepressant, antipsychotic, mood stabilizer)
• Lithium: only psychotropic with robust evidence for anti-suicidal effect (reduces completed suicide ~80% in mood disorders)
• Clozapine: reduces suicidal behavior in schizophrenia (only antipsychotic FDA-approved for this)
• ECT: for severe suicidal depression, especially with psychosis or refusal to eat

• Medical treatment (GCS, vital signs, antidote: N-acetylcysteine for paracetamol overdose; naloxone for opioids; flumazenil for benzodiazepines; activated charcoal if within 1 hour and airway protected)
• Psychiatric assessment before discharge
• Safety planning
• Brief contact interventions (postcards, follow-up calls) shown to reduce re-attempt

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46. Food Refusal in Mental Disorders: Causes and Emergency Interventions

Definition

Causes by Diagnosis

• Anorexia nervosa: most classic cause; motivated by fear of weight gain and body image distortion
• ARFID (Avoidant/Restrictive Food Intake Disorder): limited food intake based on sensory characteristics, fear of choking/vomiting, or lack of interest in eating; NOT motivated by weight/shape concerns; often in autism and anxiety disorders
• Orthorexia (not a formal diagnosis): obsessive restriction of "unhealthy" foods

• Persecutory delusions about food being poisoned
• Olfactory/gustatory hallucinations (food tastes bad/contaminated)
• Command hallucinations ordering not to eat
• Nihilistic delusions (belief that stomach/bowel does not exist)

• Severe depression: loss of appetite, anhedonia, inability to initiate eating, psychomotor retardation
• Depressive stupor: complete withdrawal from food and fluids
• Manic episode: too distractible/excited to eat

• Confusion, altered consciousness; unable to recognize/initiate eating; paranoid misidentification of food

• Dysphagia, apraxia of eating, loss of recognition of food, behavioral agitation at mealtimes, loss of satiety regulation (frontotemporal dementia may cause hyperphagia instead)

• Complete immobility and mutism; refuses or cannot eat

• Contamination obsessions about food; ritual-bound eating that makes adequate nutrition impossible

• Dysphagia (neurological, structural), severe nausea/vomiting, mucositis, oral pain

Assessment

• Medical: weight, BMI, vital signs, electrolytes (K+, Na+, Mg²+, PO₄), LFTs, FBC, glucose, BUN/Creatinine
• Swallowing assessment (SLT) if dysphagia suspected
• Psychiatric assessment: identify driving psychopathology

Emergency Interventions

• Treat psychotic food refusal with antipsychotics (rapid tranquilization if needed)
• Treat severe depressive stupor or catatonic food refusal with lorazepam +/- ECT
• Treat anorexia with multidisciplinary eating disorder team (see Topic 43)

• Oral supplementation: high-calorie oral nutritional supplements (Fortisip, Ensure); encourage +/- assist with eating
• Nasogastric (NG) tube feeding:
  • Indicated if oral intake inadequate and patient refuses voluntary feeding
  • May be given under mental health legislation/incapacity law if patient lacks capacity
  • For anorexia: used in life-threatening situations; can be voluntary or compulsory
  • For psychotic food refusal: may be bypassed once antipsychotic takes effect
• Parenteral nutrition (TPN): only if GI tract non-functional or NG tube cannot be placed

• In most jurisdictions, a patient who lacks capacity due to a mental disorder can be fed against their will under mental health or mental capacity legislation
• In anorexia, the mental illness (cognitive distortion about weight) impairs capacity, and compulsory nasogastric feeding may be lawful
• Always document decision-making capacity assessment, best-interest decision, multi-disciplinary involvement, and patient/family discussion

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47. Legal Regulation of Ordinary Psychiatric Practice

Core Legal Principles in Psychiatry

• The default for all psychiatric treatment is voluntary consent
• Patient must give informed consent: capacity to understand information, weigh it, and communicate a decision; must be given information about diagnosis, treatment, benefits, risks, alternatives
• Capacity is decision-specific and fluctuating (not all-or-nothing)

• Assume capacity unless proven otherwise
• Incapacity must be caused by an impairment or disturbance of mind
• Four-part capacity test: can the patient (1) understand the information, (2) retain it long enough to decide, (3) weigh/use it, (4) communicate their decision?
• If lacking capacity: best interest decision; least restrictive option; involve family/proxy

• All clinical information is confidential; cannot be shared without patient consent
• Exceptions to confidentiality (duty to breach):
  • Risk of serious harm to the patient (if not competent to decide)
  • Risk of serious harm to an identifiable third party (Tarasoff duty to warn/protect - US; similar in many jurisdictions)
  • Public health notifications (notifiable diseases)
  • Court orders
  • Child protection concerns (mandatory reporting)
• Document rationale for any breach

• Contemporaneous, accurate, factual records
• Patient has right of access (subject to some exceptions)
• Risk assessments, capacity assessments, and treatment decisions must be documented

• Only permissible to prevent harm; least restrictive principle applies
• Must follow local policy/law; documented, time-limited, regularly reviewed
• Not to be used as punishment

• Requires informed consent from a capable patient
• If patient lacks capacity: second opinion required (in many jurisdictions, independent psychiatrist approval mandatory - e.g., SOAD in UK)

• Psychotropics can only be prescribed in accordance with licensed indications, or off-label with appropriate documentation
• Clozapine: requires registration in national monitoring systems (CPMS/REMS), mandatory FBC monitoring
• Controlled drugs (stimulants, benzodiazepines): require special prescription and dispensing rules

• Psychiatrists owe a duty of care to patients; must meet the standard of a reasonable psychiatrist (Bolam test)
• Breaches: failure to assess suicide risk properly; failure to act on it; wrongful detention

• Right to appeal detention (Tribunal/Hospital Managers)
• Right to an independent mental health advocate (IMHA)
• Right to a named nurse/responsible clinician
• Right to aftercare on discharge (Section 117 aftercare in England & Wales)

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48. Forensic Psychiatry: Non-Responsibility (Non Compos Mentis), Compulsory Treatment

Definition of Forensic Psychiatry

• Psychiatric assessment of individuals involved with the criminal or civil justice system
• Fitness to stand trial / fitness to plead
• Criminal responsibility
• Risk assessment for violence/recidivism
• Treatment of mentally disordered offenders
• Expert witness testimony

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Criminal Responsibility and Mental Disorder

• Actus reus: the guilty act
• Mens rea: the guilty mind (intention, knowledge, recklessness)

Legal Tests for Non-Responsibility

1. The nature and quality of the act being done, OR
2. That what they were doing was wrong (legally or morally)

1. To appreciate the criminality (wrongfulness) of his conduct, or
2. To conform his conduct to the requirements of law."

• Personality disorders (especially antisocial PD) do NOT qualify as grounds for non-responsibility
• Substance intoxication voluntarily induced does NOT generally qualify
• Psychopathy is NOT a recognized defense

Diminished Responsibility

• Abnormality of mental functioning from a recognized medical condition that substantially impaired ability to understand the nature of conduct, form a rational judgment, or exercise self-control
• Reduces murder to manslaughter (does not result in acquittal)

Fitness to Plead (Competency to Stand Trial)

1. Understand the charges against them
2. Understand the nature and purpose of the proceedings
3. Understand the possible consequences (conviction)
4. Instruct a solicitor/counsel
5. Follow the evidence and court proceedings
6. Give evidence in their own defense

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Compulsory (Involuntary) Treatment

Criteria for Involuntary Admission (Mental Health Act - principles common across most jurisdictions)

1. Mental disorder of a nature or degree warranting detention
2. Necessity: the treatment cannot be given unless the patient is detained (patient refuses or lacks capacity)
3. Risk: detention necessary for the health or safety of the patient, OR for the protection of others

Mental Health Act (England & Wales 1983, amended 2007) Key Sections

Treatment Under the Mental Health Act

• Once detained on Section 3: consent to treatment provisions apply
  • First 3 months: RC can treat without consent
  • After 3 months: either patient consents or a Second Opinion Appointed Doctor (SOAD) must certify treatment appropriate
• ECT: always requires either valid consent or SOAD approval, even in first 3 months
• Medication for physical disorders is governed by capacity law (Mental Capacity Act), NOT the Mental Health Act

Community Treatment Orders (CTOs)

• Allow treatment of detained patients (previously on Section 3) in the community
• Conditions may include: residence at specified address; accepting medication (community); attending appointments
• If conditions breached: patient can be recalled to hospital
• Controversial: evidence of effectiveness mixed; risks of coercion

Compulsory Treatment Controversy

• Ethical tension: patient autonomy vs. duty to protect (patient and public)
• International human rights: UN CRPD (Convention on Rights of Persons with Disabilities) argues against compulsory treatment on grounds of disability alone
• Debate about least restrictive alternative; importance of advance directives

Disposal Options for Mentally Disordered Offenders

Risk Assessment in Forensic Psychiatry

• HCR-20 V3: Historical-Clinical-Risk Management scale (20 items; most widely used for violence risk)
• PCL-R (Hare Psychopathy Checklist Revised): measures psychopathic traits; predictor of recidivism
• OASys (UK prison/probation)
• VRAG (Violence Risk Appraisal Guide): actuarial tool
• Static-99: sexual offending recidivism

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Quick Revision Summary for Topics 39-48