| 🧠 Acute Psychosis |
- Hallucinations, delusions, paranoia or thought disorder.
- Disorganised behaviour, agitation, distress or social withdrawal.
- May be due to schizophrenia, bipolar disorder, psychotic depression, substances, delirium, neurological disease or endocrine/metabolic illness.
- First episode psychosis needs careful medical and substance assessment.
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- Mental state examination and risk assessment.
- Collateral history and time course.
- Screen for organic causes: delirium, infection, hypoglycaemia, thyroid disease, seizures, head injury, drugs.
- Bloods/ECG/toxicology as clinically indicated before antipsychotics where possible.
- Neuroimaging if focal neurology, seizure, head injury, atypical features or acute confusion.
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- Reduce stimulation and use verbal de-escalation.
- Offer oral medication where possible.
- Antipsychotic treatment under local/psychiatric guidance, considering previous response and side effects.
- Benzodiazepine may be used short-term for severe anxiety/agitation depending on cause.
- Urgent mental health liaison/crisis assessment; consider admission if high risk, severe impairment or unable to care for self.
- Use Mental Health Act assessment if necessary and legal criteria met.
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| 🔪 Suicidal Ideation / Self-Harm / Suicide Attempt |
- Thoughts of death, suicidal intent, plan, preparation or access to means.
- Recent self-harm, overdose, ligature, cutting or high-risk behaviour.
- May present with hopelessness, shame, agitation, intoxication, depression, psychosis, trauma or relationship crisis.
- Risk increases with prior attempts, male sex, isolation, substance misuse, severe mental illness, chronic pain, recent discharge or major loss.
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- Immediate physical assessment and treatment of injuries/overdose.
- Psychosocial assessment: intent, planning, triggers, supports, protective factors, ongoing risk and needs.
- Medication/toxicology tests if overdose suspected, including paracetamol level where relevant.
- Assess safeguarding, domestic abuse, intoxication and capacity.
- Do not use risk scales alone to decide discharge or treatment.
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- Ensure immediate safety: observation, remove means where proportionate, treat medical harm.
- Compassionate, non-judgemental assessment.
- Urgent mental health assessment before discharge if ongoing risk or significant self-harm.
- Create a safety plan and crisis contacts.
- Involve family/carers where appropriate and consent allows, or where serious risk justifies information sharing.
- Admit to medical or psychiatric setting if medically unwell, unsafe, intoxicated with ongoing risk, lacks capacity, or needs containment/assessment.
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| ⚡ Acute Mania |
- Elevated, expansive or irritable mood.
- Increased energy, reduced need for sleep, pressured speech, racing thoughts.
- Grandiosity, disinhibition, impulsive spending/sex/driving or aggression.
- Psychotic symptoms may occur.
- Consider substances, antidepressants, steroids, thyrotoxicosis or neurological disease.
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- Mental state examination and risk assessment.
- Collateral history is essential because insight is often poor.
- Bloods: U&E, LFT, TFT, glucose, FBC; pregnancy test where relevant.
- Drug/alcohol screen if indicated.
- Medication review: antidepressants, steroids, stimulants.
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- Reduce stimulation and address sleep deprivation.
- Stop antidepressants/stimulants where clinically appropriate and under supervision.
- Antipsychotic is commonly used acutely; mood stabiliser may be initiated by specialists.
- Short-term benzodiazepine may help agitation/insomnia.
- Admission is often needed if risk, psychosis, severe disinhibition, exhaustion or inability to care for self.
- Consider Mental Health Act assessment if necessary.
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| 🔥 Neuroleptic Malignant Syndrome |
- Fever, “lead-pipe” rigidity, altered mental state and autonomic instability.
- Usually follows antipsychotic initiation, dose increase, depot antipsychotic or dopamine withdrawal.
- Tachycardia, labile BP, sweating and confusion.
- Complications: rhabdomyolysis, AKI, arrhythmia, respiratory failure.
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- Clinical diagnosis.
- CK often markedly raised.
- FBC, U&E, LFT, clotting, CRP, blood cultures if infection differential.
- Urinalysis for myoglobinuria.
- ECG and temperature monitoring.
- Differentiate from serotonin syndrome, malignant hyperthermia, sepsis, catatonia and heatstroke.
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- Stop antipsychotic/dopamine-blocking drug immediately.
- Urgent medical/ICU assessment if severe.
- IV fluids, cooling, electrolyte correction and renal protection.
- Benzodiazepines may help agitation/rigidity.
- Dantrolene, bromocriptine or amantadine may be used in severe cases under specialist advice.
- Do not restart antipsychotics until fully recovered and specialist plan made.
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| 🌡 Serotonin Syndrome |
- Triad: mental state change, autonomic instability and neuromuscular hyperactivity.
- Agitation, confusion, sweating, diarrhoea, fever, tachycardia and hypertension.
- Hyperreflexia, clonus, tremor and myoclonus - often more prominent in lower limbs.
- Triggered by SSRI/SNRI/MAOI, tramadol, linezolid, lithium, MDMA, triptans or overdose/interaction.
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- Clinical diagnosis; Hunter criteria may be used.
- Medication and recreational drug history.
- CK, U&E, LFT, clotting, VBG/ABG if severe.
- ECG if overdose or QT-risk medication.
- Differentiate from NMS: serotonin syndrome is usually faster onset with clonus/hyperreflexia.
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- Stop serotonergic drugs immediately.
- Supportive care, IV fluids and active cooling for hyperthermia.
- Benzodiazepines for agitation, tremor and muscle activity.
- Cyproheptadine may be considered in moderate/severe cases under specialist/toxicology advice.
- Severe hyperthermia/rigidity may need ICU, sedation and paralysis.
- Discuss overdose/complex cases with TOXBASE/NPIS.
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| 🍷 Alcohol Withdrawal Delirium / Delirium Tremens |
- Occurs usually 48–72 hours after last drink, but timing varies.
- Agitation, confusion, tremor, sweating, tachycardia, hypertension and fever.
- Visual hallucinations and severe insomnia.
- Seizures may occur earlier in withdrawal.
- High risk with previous DTs/seizures, heavy dependence, acute illness or poor nutrition.
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- Clinical diagnosis and alcohol history.
- CIWA-Ar or local withdrawal scoring if appropriate.
- Bloods: U&E, Mg, phosphate, glucose, LFT, FBC, clotting.
- Consider infection, head injury, Wernicke’s encephalopathy, hepatic encephalopathy or intoxication as differentials.
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- Benzodiazepine-based withdrawal treatment according to local protocol.
- Give thiamine before glucose where possible if malnourished/alcohol-dependent.
- Parenteral thiamine if Wernicke’s risk or suspected Wernicke’s encephalopathy.
- Correct magnesium, potassium and phosphate.
- IV fluids only if dehydrated; avoid overhydration.
- HDU/ICU if severe agitation, seizures, hyperthermia, arrhythmia or high benzodiazepine requirements.
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| ⚠️ Violent / Aggressive Behaviour |
- Threats, shouting, intimidation, physical aggression or escalating agitation.
- May be due to psychosis, mania, intoxication, withdrawal, delirium, pain, hypoxia, hypoglycaemia, head injury or fear.
- Risk factors: weapons, substance use, paranoia, command hallucinations, prior violence, acute stressors.
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- Dynamic risk assessment: immediate danger, weapons, exit route, staff safety.
- Check medical causes when safe: glucose, oxygen, observations, head injury, intoxication.
- Collateral from police/ambulance/carers if available.
- Assess capacity and legal framework if treatment/refusal issues arise.
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- Prioritise safety: call security/police if needed, remove other patients, keep exit clear.
- Use de-escalation first: calm voice, space, choices, reduce stimuli.
- Offer oral medication before IM where possible.
- Rapid tranquillisation only if there is immediate risk and de-escalation fails.
- Follow local/NICE rapid tranquillisation policy, including physical observations afterwards.
- Use restraint only as last resort, for shortest time, with trained staff and monitoring.
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| 🧊 Catatonia / Malignant Catatonia |
- Stupor, mutism, posturing, negativism, waxy flexibility or refusal to eat/drink.
- May alternate with agitation.
- Malignant catatonia: fever, autonomic instability, rigidity and delirium.
- Associated with mood disorders, psychosis, autism, neurological disease or medical illness.
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- Clinical diagnosis; Bush-Francis Catatonia Rating Scale may help.
- Exclude NMS, serotonin syndrome, encephalitis, seizures, metabolic causes and infection.
- Bloods, CK, U&E, LFT, CRP, ECG; consider EEG/LP/imaging if indicated.
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- Urgent psychiatry and medical review.
- Lorazepam challenge may be diagnostic and therapeutic under specialist guidance.
- Maintain hydration, nutrition, pressure care and VTE prevention.
- ECT is highly effective for severe, malignant or refractory catatonia.
- Avoid antipsychotics until diagnosis clarified, as they may worsen catatonia/NMS risk.
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| 🤰 Postpartum Psychosis |
- Usually within days to weeks after birth.
- Rapid mood swings, insomnia, agitation, confusion, delusions or hallucinations.
- May include thoughts of harm to self or baby, or bizarre beliefs about the infant.
- Risk increased with bipolar disorder or previous postpartum psychosis.
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- Urgent mental state and risk assessment.
- Assess risk to mother, baby and others.
- Exclude delirium, infection, thyroid disease, pre-eclampsia/eclampsia, substance use.
- Collateral from partner/family/midwife/health visitor.
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- Same-day emergency psychiatric assessment.
- Do not leave mother alone with baby if risk is unclear/high.
- Mother and baby unit admission where available and appropriate.
- Antipsychotic/mood stabiliser treatment under perinatal psychiatry guidance.
- Involve obstetrics, GP, midwife/health visitor and safeguarding where needed.
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| 🍽 Severe Eating Disorder Medical Risk |
- Very low weight, rapid weight loss, syncope, weakness or cold intolerance.
- Bradycardia, hypotension, hypothermia or dehydration.
- Electrolyte disturbance, especially hypokalaemia or hypophosphataemia.
- Purging, laxative misuse or excessive exercise.
- Risk of refeeding syndrome when nutrition is restarted.
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- Weight/BMI and recent weight-loss trajectory.
- Observations including lying/standing BP, pulse and temperature.
- ECG for bradycardia/QT prolongation.
- Bloods: U&E, Mg, phosphate, glucose, LFT, FBC.
- Assess suicide/self-harm risk and safeguarding.
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- Urgent medical admission if medically unstable or high refeeding risk.
- Correct electrolytes and monitor ECG if severe.
- Specialist eating disorder/psychiatry and dietetic input.
- Careful nutritional rehabilitation with refeeding monitoring.
- Use legal frameworks only when necessary and proportionate to preserve life.
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| 🧠 Delirium / Organic Behavioural Disturbance |
- Acute fluctuating confusion, inattention, altered consciousness or new hallucinations.
- May appear as agitation, aggression, withdrawal or paranoia.
- Common causes: infection, hypoxia, pain, constipation, urinary retention, drugs, dehydration, metabolic disturbance.
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- 4AT/CAM, collateral baseline cognition.
- Glucose, oxygen saturation, observations, pain assessment.
- FBC, U&E, CRP, calcium, LFT; urine/CXR/cultures only as clinically indicated.
- Bladder scan and bowel history.
- Medication review.
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- Treat cause: infection, hypoxia, pain, retention, constipation, dehydration, drugs.
- Reorientation, glasses/hearing aids, sleep hygiene, mobilisation and hydration.
- Avoid unnecessary sedatives and anticholinergics.
- Short-term antipsychotic only if severe distress/risk and after reversible causes addressed.
- Medical admission rather than psychiatric admission if primary delirium/organic cause.
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