Psychiatry Revision Guide✅

🧠 Psychiatry is about symptoms, risk, function, context and formulation. A safe psychiatric assessment does not just name a diagnosis; it asks what the patient is experiencing, how long it has been happening, how it affects life, what risks are present, and what biological, psychological and social factors are maintaining the problem. For exams and clinical practice, always assess risk to self, risk to others, self-neglect, safeguarding, capacity, substance use, and physical causes of psychiatric symptoms.

✅ 1. Psychiatric Assessment Structure

🗣️ 1.1 History of Presenting Problem

• Clarify the main problem in the patient’s own words.
• Ask about onset, duration, triggers, progression and current severity.
• Explore mood, anxiety, sleep, appetite, energy, concentration, motivation and enjoyment.
• Ask about psychotic symptoms: hallucinations, delusions, paranoia, thought interference and passivity experiences.
• Ask about mania symptoms: reduced need for sleep, increased energy, pressured speech, grandiosity, impulsivity and risk-taking.
• Ask about trauma symptoms: re-experiencing, nightmares, avoidance, hyperarousal and emotional numbing.
• Assess functional impact: work, study, relationships, self-care, finances, parenting and social withdrawal.

🧬 1.2 Background History

• Past psychiatric history: diagnoses, admissions, crisis team input, therapy, medications, response and side effects.
• Previous self-harm or suicide attempts: method, intent, planning, rescue, regret and recurrence.
• Past medical history: thyroid disease, epilepsy, head injury, dementia, chronic pain, endocrine disease, neurological disease.
• Medication history: antidepressants, antipsychotics, mood stabilisers, steroids, dopamine agonists, isotretinoin, stimulants.
• Substance history: alcohol, cannabis, cocaine, amphetamines, opioids, benzodiazepines, novel psychoactive substances.
• Family history: mood disorder, psychosis, suicide, addiction, neurodevelopmental conditions.
• Personal history: childhood adversity, education, work, relationships, housing, finances, forensic history, trauma.

🌍 1.3 Social and Protective Factors

• Who does the patient live with?
• Are there dependants, children, vulnerable adults or caring responsibilities?
• Are there supports: family, friends, GP, community mental health team, faith/community groups?
• Are there current stressors: bereavement, debt, work, bullying, relationship breakdown, homelessness, immigration issues?
• Protective factors: children, pets, beliefs, future plans, therapeutic relationships, reasons for living.
• Risk factors: isolation, unemployment, domestic abuse, substance misuse, access to means, recent discharge from hospital.

🧠 Exam pearl: A psychiatric diagnosis without a risk assessment is incomplete. In OSCEs, explicitly state risk to self, risk to others, self-neglect, safeguarding and capacity.

🧠 2. Mental State Examination

⚠️ 2.1 MSE Red Flags

• Command hallucinations telling the patient to harm self or others.
• Severe thought disorder preventing coherent communication.
• Delusions involving persecutory threat, guilt, nihilism or passivity.
• Marked psychomotor retardation with poor intake or stupor.
• Agitation with escalating risk, intoxication or possible delirium.
• Fluctuating consciousness, disorientation or inattention — think delirium.

🚨 3. Risk Assessment

🩸 3.1 Suicide and Self-Harm Risk

• Ask directly: “Have you had thoughts of ending your life?”
• Clarify ideation: passive death wish vs active suicidal thoughts.
• Ask about plan: method, timing, location, preparation and access to means.
• Ask about intent: how likely they feel they are to act, deterrents, ambivalence, reasons for living.
• Ask about previous attempts: method, medical seriousness, planning, rescue, regret and repetition.
• Ask about recent triggers: loss, shame, relationship breakdown, debt, diagnosis, disciplinary action.
• Assess protective factors and whether they are currently accessible and meaningful.

🛡️ 3.2 Risk to Others and Safeguarding

• Ask about thoughts of harming others, threats, violence, weapons and specific targets.
• Explore paranoia, command hallucinations, jealousy delusions and substance intoxication.
• Consider safeguarding children if a parent/carer is severely depressed, psychotic, intoxicated, suicidal or violent.
• Consider domestic abuse, coercive control, exploitation, elder abuse and neglect.
• Document and escalate concerns through local safeguarding pathways.

🧍 3.3 Self-Neglect and Vulnerability

• Assess food, fluids, hygiene, heating, housing, medication adherence and ability to seek help.
• Look for dehydration, malnutrition, pressure sores, untreated wounds or unsafe living conditions.
• Self-neglect may occur with depression, psychosis, dementia, substance misuse, learning disability or trauma.

🚨 Safety pearl: Risk is dynamic. A patient can move from “low” to “high” risk after intoxication, relationship conflict, discharge, bad news or access to means. Always document current risk and what could increase it.

🌧️ 4. Depression

Depression is a syndrome of persistent low mood and/or anhedonia with cognitive, biological and functional symptoms. It is not simply sadness; it affects sleep, appetite, concentration, energy, psychomotor activity, guilt, hope and risk.

🔍 4.1 Clinical Features

• Core symptoms: low mood, loss of interest/pleasure, reduced energy.
• Cognitive symptoms: poor concentration, low self-esteem, guilt, hopelessness, suicidal thoughts.
• Biological symptoms: sleep disturbance, appetite/weight change, reduced libido, diurnal variation.
• Psychomotor symptoms: agitation or retardation.
• Severe depression may include psychotic features: nihilistic, guilt or poverty delusions; mood-congruent hallucinations.
• Assess severity by symptom burden, duration, function, risk and psychotic symptoms.

🧪 4.2 Differentials and Physical Causes

• Hypothyroidism, anaemia, B12 deficiency, chronic infection, malignancy, chronic pain.
• Medication effects: steroids, beta-blockers in some patients, isotretinoin, interferon, some anticonvulsants.
• Substance misuse: alcohol, cannabis, stimulants, sedatives.
• Bipolar depression: past hypomania/mania may be missed unless specifically asked.
• Grief and adjustment disorder may overlap but differ in duration, pervasiveness and functional impairment.

💊 4.3 Management

• Assess risk first; urgent crisis response if active suicidal intent, psychosis, severe self-neglect or inability to maintain safety.
• Mild depression: active monitoring, guided self-help, exercise, sleep, social prescribing, psychological therapy.
• Moderate-severe depression: psychological therapy, antidepressants, or combination depending on preference and severity.
• SSRIs are commonly first-line; warn about delayed onset, early side effects and initial anxiety.
• Review early after starting antidepressants in younger/high-risk patients.
• Severe psychotic depression may require urgent specialist care, antipsychotic plus antidepressant, or ECT in life-threatening cases.

🧠 Exam pearl: Always ask about past mania before starting antidepressants. Antidepressant monotherapy can destabilise bipolar disorder.

🌪️ 5. Bipolar Disorder and Mania

⚡ 5.1 Mania and Hypomania

• Elevated, expansive or irritable mood with increased energy/activity.
• Reduced need for sleep without fatigue.
• Pressured speech, racing thoughts, distractibility.
• Grandiosity, overconfidence and increased goal-directed activity.
• Risk-taking: spending, sexual behaviour, driving, substances, business decisions.
• Psychosis may occur in mania, often grandiose or persecutory.
• Hypomania is less severe and does not cause marked impairment or psychosis.

🚨 5.2 Acute Mania Risks

• Financial, sexual, occupational and legal harm.
• Disinhibition and vulnerability to exploitation.
• Aggression or risk-taking when frustrated or paranoid.
• Exhaustion, dehydration and poor intake.
• Safeguarding risk if caring for children or vulnerable adults.

💊 5.3 Management Principles

• Assess need for urgent psychiatric admission if severe, psychotic, risky or lacking insight.
• Stop antidepressants if contributing to mania, with specialist advice.
• Acute treatment often involves antipsychotics and/or mood stabilisers.
• Long-term prophylaxis may include lithium, valproate, lamotrigine or antipsychotic options depending on pattern and patient factors.
• Valproate has major pregnancy-prevention restrictions and teratogenic risk.
• Lithium requires renal, thyroid and level monitoring; toxicity risk rises with dehydration, NSAIDs, ACE inhibitors and diuretics.

🌀 6. Psychosis and Schizophrenia

Psychosis means impaired reality testing, commonly with hallucinations, delusions or thought disorder. Schizophrenia is one cause, but psychosis can also occur in mood disorders, delirium, dementia, substances, epilepsy and autoimmune disease.

🔍 6.1 Positive, Negative and Cognitive Symptoms

• Positive symptoms: hallucinations, delusions, thought disorder, passivity experiences.
• Negative symptoms: apathy, anhedonia, social withdrawal, reduced speech, flattened affect.
• Cognitive symptoms: impaired attention, memory, planning and social cognition.
• Functional decline, self-neglect and social withdrawal often precede obvious psychosis.

👂 6.2 Hallucinations and Delusions

• Auditory hallucinations are common in schizophrenia, especially voices commenting or discussing the patient.
• Visual hallucinations should raise concern for delirium, dementia, substances, neurological disease or Charles Bonnet syndrome.
• Delusions are fixed false beliefs not explained by culture/subculture.
• Passivity phenomena include thought insertion, thought withdrawal, thought broadcasting and made actions/feelings.

🧪 6.3 First-Episode Psychosis Work-up

• Drug screen if relevant, alcohol/substance history.
• Physical examination and neurological screen.
• Bloods: FBC, U&E, LFT, TFT, glucose/HbA1c, lipids, B12/folate, inflammatory/infective tests if indicated.
• Consider autoimmune encephalitis, epilepsy, HIV/syphilis, Wilson disease or tumour if atypical features.
• Baseline ECG, weight, BP and metabolic profile before antipsychotics where possible.

💊 6.4 Management

• Early intervention in psychosis improves engagement and outcomes.
• Antipsychotics reduce positive symptoms but require shared decision-making and side-effect monitoring.
• Psychological interventions include CBT for psychosis and family intervention.
• Relapse prevention includes medication adherence, early warning signs, sleep, substance reduction and crisis planning.
• Clozapine is used for treatment-resistant schizophrenia but requires blood monitoring due to agranulocytosis risk.

⚠️ Clinical pearl: Visual hallucinations, fluctuating consciousness and poor attention are delirium red flags, not classic schizophrenia.

😰 7. Anxiety, Panic, OCD and PTSD

🌊 7.1 Generalised Anxiety Disorder

• Excessive worry across multiple domains, difficult to control.
• Symptoms: restlessness, fatigue, poor concentration, irritability, muscle tension, sleep disturbance.
• Assess caffeine, stimulants, alcohol withdrawal, hyperthyroidism and arrhythmias.
• Management: psychoeducation, CBT, relaxation, sleep, exercise, SSRIs/SNRIs where appropriate.

💥 7.2 Panic Disorder

• Recurrent unexpected panic attacks with fear of further attacks or behavioural change.
• Symptoms: palpitations, chest tightness, breathlessness, trembling, sweating, dizziness, derealisation, fear of dying.
• Exclude acute medical causes when presentation is new or atypical: ACS, PE, arrhythmia, asthma, thyrotoxicosis.
• CBT and SSRIs are common treatments; benzodiazepines are generally avoided long-term.

🔁 7.3 Obsessive-Compulsive Disorder

• Obsessions are intrusive unwanted thoughts/images/urges causing anxiety.
• Compulsions are repetitive behaviours or mental acts performed to reduce distress or prevent feared harm.
• Common themes: contamination, checking, symmetry, harm, sexual/religious intrusive thoughts.
• Insight varies; shame often delays disclosure.
• Management: CBT with exposure and response prevention, SSRIs at adequate dose/duration.

🧨 7.4 PTSD

• Occurs after exposure to actual/threatened death, serious injury or sexual violence.
• Symptoms: re-experiencing, nightmares, avoidance, hyperarousal, negative mood/cognitions.
• Assess comorbid depression, substance misuse, dissociation and self-harm.
• Management: trauma-focused CBT or EMDR; medication may help comorbid symptoms.

🍽️ 8. Eating Disorders

⚖️ 8.1 Anorexia Nervosa

• Restriction of energy intake leading to significantly low weight.
• Intense fear of weight gain or persistent behaviour interfering with weight restoration.
• Disturbance in body image or lack of recognition of seriousness.
• Physical signs: bradycardia, hypotension, hypothermia, lanugo hair, amenorrhoea, osteoporosis, muscle wasting.
• Psychological signs: rigidity, perfectionism, fear around meals, compulsive exercise, social withdrawal.

🔁 8.2 Bulimia Nervosa and Binge Eating Disorder

• Bulimia: recurrent binge eating with compensatory behaviours such as vomiting, laxatives, fasting or excessive exercise.
• Binge eating disorder: recurrent binge eating without regular compensatory behaviours.
• Complications of vomiting: hypokalaemia, metabolic alkalosis, dental erosion, parotid enlargement, oesophagitis.
• Assess shame, secrecy, body image distress and risk of self-harm.

🚨 8.3 Medical Risk in Eating Disorders

🚨 Exam pearl: A normal BMI does not exclude medical danger in an eating disorder. Rapid weight loss and electrolyte disturbance can be high risk.

🧓 9. Delirium, Dementia and Old Age Psychiatry

⚡ 9.1 Delirium

• Acute fluctuating disturbance in attention and cognition.
• Common triggers: infection, pain, constipation, urinary retention, dehydration, hypoxia, drugs, electrolyte disturbance.
• Hypoactive delirium is quiet, withdrawn and often missed.
• Management: treat cause, reorient, hydrate, mobilise, optimise sleep, ensure glasses/hearing aids, avoid unnecessary sedatives.
• Antipsychotics are only for severe distress/risk and after non-drug approaches, with caution.

🧠 9.2 Dementia

• Progressive cognitive decline affecting daily function.
• Alzheimer’s: early episodic memory problems.
• Vascular dementia: stepwise decline, vascular risk factors, focal signs.
• Lewy body dementia: visual hallucinations, fluctuations, parkinsonism, REM sleep behaviour disorder.
• Frontotemporal dementia: behavioural/personality change or language variant, often younger onset.
• Always exclude delirium, depression, B12 deficiency, hypothyroidism, medications and alcohol.

🌧️ 9.3 Depression in Older Adults

• May present with apathy, somatic complaints, cognitive symptoms, weight loss or functional decline.
• Differentiate depression from dementia, but they can coexist.
• Assess suicide risk carefully; older men have high suicide risk.
• Medication choices need attention to falls, hyponatraemia, QTc, bleeding and interactions.

💊 10. Psychiatric Medication

🌧️ 10.1 Antidepressants

🌀 10.2 Antipsychotics

• Typical antipsychotics: haloperidol, chlorpromazine; higher extrapyramidal side-effect risk.
• Atypical antipsychotics: olanzapine, risperidone, quetiapine, aripiprazole, clozapine.
• Side effects: sedation, weight gain, diabetes, dyslipidaemia, QT prolongation, prolactin rise, extrapyramidal symptoms.
• Neuroleptic malignant syndrome: fever, rigidity, autonomic instability, confusion, raised CK — emergency.
• Clozapine: agranulocytosis, myocarditis, seizures, constipation/ileus, metabolic syndrome; requires monitoring.

⚖️ 10.3 Mood Stabilisers

• Lithium: effective for bipolar relapse prevention and suicide reduction; monitor levels, renal and thyroid function.
• Valproate: effective for mania but highly teratogenic and restricted in people who could conceive.
• Lamotrigine: useful in bipolar depression prevention; titrate slowly due to rash risk.
• Carbamazepine: interactions, hyponatraemia, blood dyscrasias; specialist use.

🚨 10.4 Serotonin Syndrome vs NMS

🍷 11. Substance Use and Alcohol

🍺 11.1 Alcohol Dependence

• Features: craving, tolerance, withdrawal, loss of control, continued use despite harm, neglect of other activities.
• Withdrawal: tremor, sweating, anxiety, insomnia, nausea, tachycardia, hypertension.
• Severe withdrawal: seizures, hallucinations, delirium tremens.
• Wernicke’s encephalopathy: confusion, ataxia, ophthalmoplegia; give thiamine urgently if suspected.
• Management: motivational interviewing, detox planning, relapse prevention, thiamine, psychosocial support.

💉 11.2 Drug Use

• Cannabis can worsen anxiety, psychosis and motivation in vulnerable individuals.
• Stimulants can cause paranoia, agitation, insomnia, hypertension and arrhythmias.
• Opioid dependence risks overdose, respiratory depression, infection and social harm.
• Benzodiazepine dependence causes dangerous withdrawal if stopped abruptly.
• Harm reduction includes naloxone, needle exchange, BBV testing, substitution therapy and psychosocial support.

⚖️ 12. Capacity, Consent and Mental Health Law

🧠 12.1 Capacity

• Capacity is decision-specific and time-specific.
• A person has capacity if they can understand, retain, use/weigh relevant information and communicate a decision.
• An unwise decision does not prove lack of capacity.
• Support decision-making before concluding incapacity.
• If capacity is lacking, act in best interests using the least restrictive option.

🔒 12.2 Confidentiality and Risk

• Confidentiality is not absolute.
• Information may be shared with consent, legal requirement, safeguarding need or overriding public interest.
• Use the minimum necessary information and document reasoning.
• Do not promise secrecy if there is serious risk to the patient or others.

🏥 12.3 Mental Health Act Principles

• The Mental Health Act allows compulsory assessment/treatment for mental disorder when legal criteria are met.
• Detention requires risk and necessity, not merely diagnosis.
• Informal admission should be used where safe and appropriate.
• Patients detained under the MHA still require physical healthcare, dignity and rights information.

⚖️ OSCE pearl: Capacity is not “does the patient agree with me?” It is whether they can understand, retain, use/weigh and communicate about this specific decision.

🚨 13. Psychiatric Emergencies

📚 14. OSCE / Exam Pearls

• Always ask about suicide directly and calmly.
• Always ask about past mania before diagnosing unipolar depression.
• Visual hallucinations and fluctuating attention suggest delirium before schizophrenia.
• Psychiatric symptoms can be caused by endocrine, neurological, infectious, drug and metabolic disease.
• Capacity is decision-specific and time-specific.
• Command hallucinations, access to means and recent attempts increase immediate risk.
• Postpartum psychosis is an emergency.
• Eating disorder risk is not determined by BMI alone.
• Alcohol withdrawal can kill; give thiamine when Wernicke’s is possible.
• Do not label patients as “attention-seeking”; describe behaviour, distress, risk and needs.

📌 15. Quick Differentials Table

📚 References

• NICE. Depression in adults: treatment and management. NG222.
• NICE. Self-harm: assessment, management and preventing recurrence. NG225.
• NICE. Psychosis and schizophrenia in adults: prevention and management. CG178.
• NICE. Bipolar disorder: assessment and management. CG185.
• NICE. Eating disorders: recognition and treatment. NG69.
• NICE. Post-traumatic stress disorder. NG116.
• GMC guidance on consent, confidentiality and decision-making should be checked for UK medicolegal context.
• Local crisis team, liaison psychiatry, perinatal mental health, safeguarding and Mental Health Act pathways should always be followed.

⚠️ Disclaimer

This article is for medical education and exam revision. Clinical decisions should follow current local mental health pathways, crisis policies, safeguarding procedures, Mental Capacity Act and Mental Health Act processes, formularies, senior advice and national guidance. Psychiatric emergencies such as high suicide risk, severe agitation, delirium, postpartum psychosis, neuroleptic malignant syndrome, serotonin syndrome, catatonia and severe eating disorder medical instability require urgent senior input.