Semester 3 Handbook - NW School of Psychiatry · 2019-06-07 · Seminars in Child and Adolescent...

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Semester 3 Handbook

MRCPsych Course

2018 – 2020

A Psychiatry Medical Education Collaborative between Mental Health Trusts and Health Education North West.

Course director – Dr Latha Hackett, Consultant in Child and Adolescent Psychiatry

Deputy course Director – Dr Dushyanthan Mahadevan, Consultant in Child and Adolescent

Psychiatry

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Contents

Brief guidelines for case conference presentation ............................................................. 18

Brief guidelines for journal club presentation ..................................................................................... 19

Syllabus Links ........................................................................................................................................ 20

Curriculum Mapping ............................................................................................................................. 21

Links to Critical Appraisal Checklists .................................................................................................... 22

Session 13: Psychosis-3 ......................................................................................................................... 23

Learning Objectives .............................................................................................................................. 23

Expert Led Session ................................................................................................................................ 23

Case Presentation ................................................................................................................................. 23

Journal Club Presentation (Select 1 paper) ......................................................................................... 23

‘555’ Topics (Select 1 topic; 5 slides with no more than 5 bullet points) ........................................... 23

Session 14: Depression-3 ...................................................................................................................... 25






MCQs ..................................................................................................................................................... 26

Session 15: Bipolar Disorder-3 ............................................................................................................. 28






MCQs ................................................................................................................................................... 29

Session 16: Anxiety disorders-2 (GAD, panic disorder, phobic anxiety disorders) .................. 31

Learning Objectives ............................................................................................................................ 31

Expert Led Session ............................................................................................................................ 31

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Case Presentation .............................................................................................................................. 31

Journal Club Presentation (Select 1 paper) ................................................................................... 31

‘555’ Topics (Select 1 topic; 5 slides with no more than 5 bullet points) .................................... 31

MCQs ..................................................................................................................................................... 32

Session 17: Suicide/self-harm-2 ........................................................................................................... 34






MCQs ..................................................................................................................................................... 35

Session 18: Perinatal psychiatry ...................................................................................................... 37

Learning Objectives ............................................................................................................................ 37

Expert Led Session ............................................................................................................................ 37

Case Presentation .............................................................................................................................. 37

Journal Club Presentation (Select 1 paper) ................................................................................... 37

Ennis, Z. and Damkier, P. (2015). Pregnancy Exposure to Olanzapine, Quetiapine, Risperidone,

Aripiprazole and Risk of Congenital Malformations. A Systematic Review. Basic & Clinical

Pharmacology & Toxicology, 116(4), pp.315-320. ................................................................................ 37

Boden, R., Lundgren, M., Brandt, L., Reutfors, J., Andersen, M. and Kieler, H. (2012). Risks of

adverse pregnancy and birth outcomes in women treated or not treated with mood stabilisers for

bipolar disorder: population based cohort study. BMJ, 345(nov07 6), pp.e7085. ............................... 37

Uguz, F. (2016). Second-Generation Antipsychotics During the Lactation Period: A Comparative

Systematic Review on Infant Safety. Journal of Clinical Psychopharmacology, 36(3), pp.244-252. ..... 37

‘555’ Topics (Select 1 topic; 5 slides with no more than 5 bullet points) .................................... 37

MCQs ................................................................................................................................................... 38

Further Reading .................................................................................................................................... 39

Other resources .................................................................................................................................... 43

Session 1: Cognition ............................................................................................................... 44

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Learning Objectives ............................................................................................................................... 44

Curriculum Links .................................................................................................................................... 44

Expert Led Session ................................................................................................................................. 44

Case Presentation .................................................................................................................................. 44

Journal Club Presentation ..................................................................................................................... 44

‘555’ Topic (5 slides with no more than 5 bullet points per slide) ........................................................ 45

MCQs ..................................................................................................................................................... 45

Additional Resources / Reading Material .............................................................................................. 46

Session 2: Alzheimer’s Disease .............................................................................................. 48







MCQs ..................................................................................................................................................... 49

Additional Resources / Reading Materials ............................................................................................ 50

Session 3: Other Neuro Degenerative Disorders ..................................................................... 52







MCQs ..................................................................................................................................................... 53


Session 4: Delirium ................................................................................................................. 56


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MCQs ..................................................................................................................................................... 58


Session 5: Mood Disorders in the Older Person ...................................................................... 60







MCQs ..................................................................................................................................................... 62


Session 6: Psychosis in the Older Person ............................................................................... 65







MCQs ..................................................................................................................................................... 66


Session 7: Anxiety Disorders in the Older Person ................................................................... 69



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MCQs ..................................................................................................................................................... 70


Session 8: Medico Legal Issues in Old Age Psychiatry ........................................................... 73







MCQs ..................................................................................................................................................... 74


Curriculum Mapping ................................................................................................................ 77

Session 1: Assessment in Child and Adolescent Psychiatry .................................................................. 78






‘555’ Topics (1 slide on each topic with no more than 5 bullet points) ................................................ 79

MCQs ..................................................................................................................................................... 79


Child and Adolescent Psychiatry. Robert Goodman and Stephen Scott. Third Edition, Wiley-

Blackwell .................................................................................................................................. 81

Child and Adolescent Psychiatry: A Developmental Approach. 4th ed. Jeremy Turk, Philip Graham,

Frank C Verhulst 2007. Oxford University Press ............................................................................. 81

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Session 2: Attention Deficit Hyperactivity Disorder (ADHD) ................................................................. 83







MCQs ..................................................................................................................................................... 84



Blackwell .................................................................................................................................. 87

Session 3: Autism Spectrum Disorder (ASD) ......................................................................................... 88







MCQs ..................................................................................................................................................... 89


Session 4: Anxiety and Depression ........................................................................................................ 93







MCQs ..................................................................................................................................................... 94

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Session 5: Attachment Disorder ............................................................................................................ 99






‘555’ Topics (1 slide on each topic with no more than 5 bullet points) .............................................. 100

MCQs ................................................................................................................................................... 100

Additional Resources / Reading Materials .......................................................................................... 102

Session 6: Assessment of Mental Health Problems in Child & Adolescents with Intellectual Disability

(ID) ....................................................................................................................................................... 104

Learning Objectives ............................................................................................................................. 104

Curriculum Links .................................................................................................................................. 104

Expert Led Session ............................................................................................................................... 104

Case Presentation ................................................................................................................................ 104

Journal Club Presentation ................................................................................................................... 104


MCQs ................................................................................................................................................... 105


Rutter's Child and Adolescent Psychiatry, Fifth Edition. ......................................................... 107

Child and Adolescent Psychiatry. ........................................................................................ 107

Robert Goodman and Stephen Scott. Third Edition, Wiley-Blackwell ............................................. 107

Session 7: Eating Disorders ................................................................................................................. 108





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MCQs ................................................................................................................................................... 109


Seminars in Child and Adolescent Psychiatry (second edition) Edited by Simon Gowers, Royal

college of Psychiatrists UK, Seminar Series ................................................................................. 111

Wiley: Handbook of Eating Disorders, 2d Edition Janet Treasure (Editor), Ulrike

Schmidt (Editor), Eric van Furth (Editor) February 2003 ISBN: 978-0-471-49768-4 ........................... 111

Psychological treatments for children and adolescents with eating disorders: In this

podcast, Professor Simon Gowers gives an overview of the different psychological therapies

available for children and adolescents with eating disorders, discussing in some detail family

therapy, interpersonal therapy and cognitive behavioural therapy ...................................... 112

http://www.psychiatrycpd.org/default.aspx?page=8284 .................................... 112

Cr189. MARSIPAN: management of really sick patients with anorexia nervosa (2nd edn) ........ 112

www.Rcpsych.ac.uk ............................................................................................................................. 112

Session 8: Legal Aspects of Child & Adolescent Psychiatry ................................................................. 112







MCQs ................................................................................................................................................... 113


Rutter's Child and Adolescent Psychiatry, Fifth Edition. ......................................................... 116

Child and Adolescent Psychiatry. ........................................................................................ 116

Robert Goodman and Stephen Scott. Third Edition, Wiley-Blackwell ............................................. 116

Session 1: Psychiatry and the Criminal Justice System ....................................................................... 118

Learning Objectives ....................................................................................................... 118

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Curriculum Links ............................................................................................................ 118

Expert Led Session ........................................................................................................ 118

Case Presentation ......................................................................................................... 118

Journal Club Presentation .............................................................................................. 119

‘555’ Topic (5 slides with no more than 5 bullet points) .................................................. 119

MCQs ............................................................................................................................ 119

Additional Resources / Reading Materials ...................................................................... 123

Session 2: The Link between Crime and Mental Disorder .................................................................. 124






‘555’ Topic (5 slides with no more than 5 bullet points) .................................................. 125

MCQs ............................................................................................................................ 126


Session 3: Too mad to murder? .......................................................................................................... 131






‘555’ Topic (5 slides with no more than 5 bullet points per slide) .................................... 133

MCQs ............................................................................................................................ 133


Session 4: Introduction to risk assessment and risk management ................................................... 138




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‘555’ Topic (5 slides with no more than 5 bullet points per slide) .................................... 139

MCQs ............................................................................................................................ 139


Session 1: Diagnosis and Treatment for People with Alcohol Problems ............................................ 141






‘555’ Topics (5 slides on each topic with no more than 5 bullet points) ............................................ 142

MCQs ................................................................................................................................................... 142


Session 2: Diagnosis and Treatment of People with Drug Misuse ...................................................... 147







MCQs ................................................................................................................................................... 149


Session 3: Diagnosis and management of people with co-occurring mental health and alcohol/drug

use conditions ..................................................................................................................................... 154






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MCQs ................................................................................................................................................... 156


Session 4: Recovery Concepts, Psycho-social Treatments and Service Development ........................ 160







MCQs ................................................................................................................................................... 161


Session 1: Referring to Psychotherapy Services .................................................................................. 181







MCQs ................................................................................................................................................... 182

4. How do you define transference? .......................................................................................... 182

A. The empathy shown by the therapist to the patient. ............................................................ 182

B. Defence mechanism where attention is shifted to a less threatening / more benign target. ...... 182

C. Therapist’s response to the patient drawn from therapist’s previous life experiences. ............. 182

D. Patient’s response to the therapist based upon their earlier relationships .............................. 182

E. All of the above ................................................................................................................ 182

5. What would suggest a patient has good psychological mindedness? .......................................... 182

A. Becoming very upset when talking about the past ................................................................ 183

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B. Finding it hard to step back and observe the situation objectively .......................................... 183

C. Needing to be talked through assessment with lots of prompts ............................................. 183

D. Reasonable sense of self esteem ........................................................................................ 183

E. None of the above ............................................................................................................ 183


Session 2: Psychological approaches to EUPD .................................................................................... 184






McMain et al (2009) “A Randomized Trial of Dialectical Behavior Therapy Versus General Psychiatric

Management for Borderline Personality Disorder” Am J Psychiatry 166:1365–1374 ........................ 185

Batement & Fonagy (2009) “Randomized Controlled Trial of Outpatient Mentalization-Based Treatment

Versus Structured Clinical Management for Borderline Personality Disorder” Am J Psychiatry 166:1355–

1364 ...................................................................................................................................... 185


MCQs ................................................................................................................................................... 186


Session 3: Psychological approaches to Depression ........................................................................... 187



1.1, 1.2, 1.3, 1.3.4, 2.3, 2.4, 2.6, 2.8, 6.1, 7.1.1, 9, 14 ......................................................................... 187





MCQs ................................................................................................................................................... 189

1. NICE guidance (CG90): ...................................................................................................... 189

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B. Recommends Computerised CBT for mild-moderate depression ............................................ 189

C. Recommends Psychotherapy for severe depression ............................................................. 189

D. Advises not combining medication with psychological therapies ............................................ 189

E. Recommends Cognitive therapy for relapse prevention ........................................................ 189

F. Defines Short-term Psychodynamic Psychotherapy as 10-15 sessions over 3-4 months ............ 189

2. Cognitive Therapy: ............................................................................................................ 189

A. Is originally based on the work of Judith Beck ...................................................................... 189

B. Identifies Cognitive Errors that lead to or maintain depressive thoughts ................................. 189

C. Focuses on non-conscious thought content ......................................................................... 189

D. Is enhanced by concurrent antidepressant treatment ........................................................... 189

E. Should not be used in older patients ................................................................................... 189

3. Psychodynamic Therapies: ................................................................................................. 189

A. Have no evidence base for effectiveness ............................................................................. 189

B. Are based on the model of the mind put forward by Freud ................................................... 189

C. Seek to eradicate a patient’s defences ................................................................................ 189

D. Were among the first to link depression to loss .................................................................... 189

E. Focus on the past ............................................................................................................. 189

4. Psychological factors in the aetiology of depression include .................................................. 189

A. Parental indifference ........................................................................................................ 189

B. Social circumstance .......................................................................................................... 189

C. Maternal Depression ........................................................................................................ 189

D. Cognitive biases or distortions ........................................................................................... 189

E. Bereavement ................................................................................................................... 189

5. Evidence of effectiveness in the treatment of depression exists for: ....................................... 189

A. Psychoanalytic therapy ..................................................................................................... 189

B. Interpersonal Therapy ....................................................................................................... 189

C. ‘Low intensity’ therapy in IAPT ........................................................................................... 189

D. Mentalization based CBT ................................................................................................... 189

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E. EMDR ........................................................................................................................................... 189


Session 4: Psychological approaches to Trauma ................................................................................. 190







MCQs ................................................................................................................................................... 192


Session 1: Psychosis Across the Ages .................................................................................................. 193



Expert Led Session (incorporating case discussion) ............................................................................ 194



MCQs ................................................................................................................................................... 195


Session 2: Depression Across The Ages ............................................................................................... 197






MCQs ................................................................................................................................................... 199


Session 3: Liaison Psychiatry Across The Ages .................................................................................... 200

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MCQs ................................................................................................................................................... 202


Session 4: Impact of Mental Illness on Carers and Families ............................................................... 205







MCQs ................................................................................................................................................... 207


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List of Contributors

Course Director

Dr Latha Hackett, Consultant in Child and Adolescent Psychiatry

[email protected]

Deputy Course Director

Dr Gareth Thomas, Consultant in Old Age Psychiatry

[email protected]

Module Leads

Across the Ages Dr Karl Coldman [email protected]

CAMHS Dr Neelo Aslam [email protected]

Forensic Dr Victoria Sullivan [email protected]

General Adult Dr Sally Wheeler [email protected]

Intellectual Disability Dr Sol Mustafa [email protected]

Old Age Dr Anthony Peter [email protected]

Psychotherapy Dr Adam Dierckx [email protected]

Substance Misuse Dr Patrick Horgan [email protected]

Trust Leads

CWP Dr Matthew Cahill [email protected]

GMMH (NMGH site) Dr Adam Dierckx [email protected]

GMMH (Prestwich site) Dr Catrin Evans [email protected]

GMMH (Prestwich site) Dr Asif Mir [email protected]

Lancashire care (Central Lancs) Dr Yousaf Iqbal [email protected]

Lancashire care (North Lancs) Dr Brijesh Desai [email protected]

Lancashire care (North Lancs) Dr Adam Joiner [email protected]

Mersey Care Dr Yenal Dundar [email protected]

NWBH Dr Naghma Malik [email protected]

Pennine Care Dr Ema Etuk [email protected]

mailto:[email protected]




















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Brief guidelines for case conference presentation

The objectives of case conference are:

1. To provide a forum to discuss complex/interesting cases in a learning atmosphere.

2. To develop your ability to present cases in a concise and logical manner.

3. To develop your presentation skills.

Guidelines for presenters:

1. Please use PowerPoint for the presentation (or if you are using other tools make sure that they are

compatible with your local IT facilities).

2. You have to present a case that is relevant to the theme of the day on which you are presenting.

3. Please meet with your educational/clinical supervisor at least 4-6 weeks prior to the presentation to

identify an appropriate case to present. If there is no suitable case in the team that you work in,

you may have to approach other teams/consultants to identify a case.

4. Cases can be chosen for their atypical presentation, diagnosis, complexity or for exploring

management options.

5. It would be helpful if you can identify specific clinical questions that would you would like to be

discussed/answered at the end of the presentation.

6. We would recommend the following structure for the presentation:

Introduction (include reasons for choosing the case)

Circumstances leading to admission (if appropriate)

History of presenting complaint

Past Psychiatric history

Medical History/ current medication

Personal/family History

Alcohol/Illicit drugs history

Forensic history

Premorbid personality

Social circumstances

Mental state examination

Investigations

Progress since admission (if appropriate)

A slide with questions that you would you like to be discussed

Discussion on differential diagnosis including reasons for and against them.

Management / treatment

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7. The structure of the presentation can vary as long it is logical and concise. Please build into the

presentation some natural points to stop and discuss the case.

8. 8. Important: Please ask a senior member of your team who knows the case to attend on the day

you are presenting.

Brief guidelines for journal club presentation

The objectives of journal club presentation are:

1) To learn to perform a structured critical appraisal of a study.

2) To learn to make appropriate use of evidence in making decisions about the care of your

patients.

3) To prepare for the MRCPsych exams.

4) To develop your presentation skills.

Guidelines for presenters:

1. Please use PowerPoint for the presentation (or if you are using other tools make sure that they

are compatible with your local IT facilities).

2. Please select one of the 3 papers listed for the week from the School of Psychiatry handbook to

present.

3. Email the paper to your local co-ordinator at least a week before the presentation so that it can

be circulated in time.

4. As the presenter you are expected to both present the paper and critically review it.

5. We would recommend the following structure for the presentation: Background to study,

methods, analysis, results, conclusions, critical appraisal of the study and implications for clinical

practice

6. The most important part of the presentation is the critical appraisal. This should include aspects

such as:

Purpose of the study

Type of study

Subject selection and any bias

Power calculation (could the study ever answer the question posed)

Appropriateness of statistical tests used

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Use of relevant outcomes

Implications of findings

Applications of findings/conclusions in your area

Directions for further research

7. Use standardized critical appraisal tools.

8. Please discuss the paper and the presentation with your educational/clinical supervisor prior to

the presentation.

Syllabus Links

MRCPsych Paper A - The Scientific and theoretical basis of Psychiatry

MRCPsych Paper B - Critical review and the clinical topics in Psychiatry

MRCPsych CASC

http://www.rcpsych.ac.uk/traininpsychiatry/examinations/about/mrcpsychpapera.aspx

http://www.rcpsych.ac.uk/traininpsychiatry/examinations/about/mrcpsychpaperb.aspx

http://www.rcpsych.ac.uk/traininpsychiatry/examinations/about/mrcpsychcasc.aspx

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GENERAL ADULT SEMESTER 3:

Curriculum Mapping

Section Topic Covered by

LEP AP LR

7.1 Disorders in adulthood

7.1.1 Unipolar depression

7.1.2 Bipolar depression

7.1.3 Schizophrenia

7.1.4 Anxiety disorders

7.1.5 OCD

7.1.6 Hypochondriasis

7.1.7 Somatization disorder

7.1.8 Dissociative disorders

7.1.9 Personality disorders

7.1.10 Organic psychoses

7.1.11 Other psychiatric disorders

7.2 Perinatal Psychiatry

7.3 General Hospital Psychiatry

7.4 Emergency Psychiatry*

7.5 Eating Disorders

7.5.1 Anorexia nervosa

7.5.2 Bulimia nervosa

7.6 Psycho-sexual disorders

7.6.1 Non-organic sexual dysfunction, etc.

7.6.2 Gender Identity Disorders

- Mental Health Act 1983

Key- LEP – Local Education Programme;

AP- Academic Programme

LR – Learning Resources

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Links to Critical Appraisal Checklists

Study Checklists

Randomized Controlled Trial

1. CONSORT Checklist

2. SIGN Checklist

3. CASP Checklist

Case-control Study 1. SIGN Checklist

2. CASP Checklist

Cohort Study 1. SIGN Checklist

2. CASP Checklist

Meta-analysis & Systematic Review

1. PRISMA statement

2. SIGN Checklist

3. CASP Checklist

Qualitative study 1. CASP Checklist

Economic study 1. SIGN Checklist

2. CASP Checklist

Diagnostic study 1. SIGN Checklist

2. CASP Checklist

http://www.consort-statement.org/

http://www.sign.ac.uk/methodology/checklists.html

http://media.wix.com/ugd/dded87_c7984187fdc74d25a3fba6c707383b15.pdf


http://media.wix.com/ugd/dded87_19dd1d558a9977c0e0b30cedf86a9da7.pdf


http://media.wix.com/ugd/dded87_36c5c76519f7bf14731ed1985e8e9798.pdf

http://www.prisma-statement.org/2.1.2%20-%20PRISMA%202009%20Checklist.pdf


http://media.wix.com/ugd/dded87_37491d0241aa448a8f3d4ae17c869472.pdf

http://media.wix.com/ugd/dded87_951541699e9edc71ce66c9bac4734c69.pdf


http://media.wix.com/ugd/dded87_ff37ab65474ac19e19ec31d5f2e4887d.pdf


http://media.wix.com/ugd/dded87_ff37ab65474ac19e19ec31d5f2e4887d.pdf

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Session 13: Psychosis-3

Journal theme: Meta-analysis / Systematic Review on Psychosis

Learning Objectives

To develop an understanding of the biopsychosocial management of schizophrenia

To develop an understanding of evidence based treatment

To develop an understanding of the use of antipsychotics in special cases e.g. liver and renal impairment

To develop an understanding of Meta-analysis / Systematic Review and develop skills for

critically appraising them.

Expert Led Session

Schizophrenia: Biopsychosocial management and evidence based treatment.

Case Presentation

A case of Schizophrenia (any subtype) /Schizoaffective disorder / Delusional disorder / Acute

and transient psychotic disorder / First-episode psychosis

Journal Club Presentation (Select 1 paper)

Zhanga J, Gallego JA, Robinson DG, Malhotra AK, Kane JM, et al. (2013). Efficacy and

safety of individual second-generation vs. first-generation antipsychotics in first-episode

psychosis: a systematic review and meta-analysis. The International Journal of

Neuropsychopharmacology; 16 (6), 1205-1218. DOI:

http://dx.doi.org/10.1017/S1461145712001277

Souza JS, Kayo M, Tassell I, Martins CB, & Elkisa H. (2013). Efficacy of olanzapine in

comparison with clozapine for treatment-resistant schizophrenia: evidence from a systematic

review and meta-analyses. CNS Spectrums; 18 (2), 82- 89. DOI:

http://dx.doi.org/10.1017/S1092852912000806

Leucht S, Cipriani A, Spineli L, Mavridis D, Örey D. (2013). Comparative efficacy and

tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis.

The Lancet; 382 (9896), 951–962. DOI: http://dx.doi.org/10.1016/S0140-6736(13)60733-3

‘555’ Topics (Select 1 topic; 5 slides with no more than 5 bullet points)

Recommendations for antipsychotics in liver disease

Recommendations for antipsychotics in renal impairment

Antipsychotics and sexual side effects

Statistics ‘555’ topic

http://dx.doi.org/10.1017/S1461145712001277

http://dx.doi.org/10.1017/S1092852912000806

http://dx.doi.org/10.1016/S0140-6736(13)60733-3

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Parametric and non-parametric tests

MCQs

1. Which one of the following led a trial that proved Clozapine's effectiveness in treating resistant schizophrenia?

A. Kretschmer

B. Cade

C. Kraepelin

D. Kane

E. Bleurer

2. Choose the correct match from the following pairs:

A. Risperidone: dibenzoxapine

B. Droperidol: butyrophenones

C. Aripiprazole: benzisothiazole

D. Thioridazine: diphenyl butyl piperidine

E. Flupentixol: dihydroindole

3. Which of the following atypical agents have the shortest half-life?

A. Quetiapine

B. Aripiprazole

C. Olanzapine

D. Clozapine

E. Risperidone

4. The patients who are prescribed clozapine or olanzapine should have their serum lipids measured

every:

A. 6 days whilst on treatment

B. One year whilst on treatment

C. 3 months for the first year of treatment

D. 6 weeks for the first year of treatment

E. 6 months for the first year of treatment

5. What percentage of patients develop Tardive Dyskinesia with every year of typical antipsychotic

exposure?

A. More than 50%

B. 2-5%

C. 5-10%

D. 20-25%

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E. 10-20%

Session 14: Depression-3

Journal theme: Qualitative study on depression

Learning Objectives

To develop an understanding of the biopsychosocial management of Depression.

To develop an understanding of evidence based treatment.

To develop an understanding of the use of antidepressant in special cases e.g. liver and renal

impairment.

To develop an understanding of Qualitative study and develop skills for critically appraising

them.

Expert Led Session

Depression- Biopsychosocial management and evidence-based treatment

Case Presentation

A case of major depressive disorder / severe depression with psychotic symptoms / dysthymia

/ recurrent depressive disorder


Mamisachvili L, Ardiles P, Mancewicz G, Thompson S, Rabin K, et al. (2013). Culture and

Postpartum Mood Problems; Similarities and Differences in the Experiences of First- and

Second- Generation Canadian Women. J Transcult Nurs; DOI: 10.1177/1043659612472197

Gensichen J, Guethlin C, Sarmand N, Sivakumaran D, Jäger C, et al. (2012). Patients’

perspectives on depression case management in general practice – A qualitative study.

Patient Education and Counselling; 86 (1), 114–119. DOI:

http://dx.doi.org/10.1016/j.pec.2011.02.020

Coupe N, Anderson E, Gask L, Sykes P, Richards DA, et al. (2014). Facilitating professional

liaison in collaborative care for depression in UK primary care; a qualitative study utilising

normalisation process theory. BMC Family Practice; 15:78. DOI: 10.1186/1471-2296-15-78

http://dx.doi.org/10.1016/j.pec.2011.02.020

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ECT – indications and contraindications

Depression – important rating scales

Treatment of refractory depression- first choice (evidence-based)


Coding and thematic analysis

MCQs

1. Which of the following neurotransmitters does Duloxetine act on?

A. Serotonin only

B. Noradrenaline and Serotonin

C. Dopamine

D. Noradrenaline, Serotonin and Dopamine

E. GABA

2. Which of the following statements about Trazodone is FALSE?

A. It is relatively safe in overdose

B. It does not have strong antihistamine properties

C. It is not a MAO-A and MAO- B inhibitor

D. It does not block 5-HT reuptake

E. It is a 5HT2 agonist

3. Which of the following are not common side effects of Mirtazapine?

A. Sedation

B. Nausea, vomiting, abdominal pain

C. Sexual dysfunction

D. Agitation, anxiety

E. Insomnia

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4. Laura is a depressed 61-year-old woman who has not responded to an SSRI and has urinary

incontinence. Which one of the following antidepressants is the best choice in this situation?

1. Phenelzine

2. Mirtazapine

3. Vortioxetine

4. Trazodone

5. Duloxetine

5. Hypertension is a common side effect of which of the following antidepressants?

A. Venlafaxine

B. Paroxetine

C. Escitalopram

D. Trazodone

E. Mirtazapine

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Session 15: Bipolar Disorder-3

Journal theme: RCT on bipolar disorder

Learning Objectives

To develop an understanding of the biopsychosocial management of Bipolar disorder.

To develop an understanding of evidence based treatment.

To develop an understanding of the use of mood-stabilizers in special cases e.g. liver and renal

impairment.

To develop an understanding of Randomized Controlled trials and develop skills for critically

appraising them.

Expert Led Session

Bipolar disorder- Biopsychosocial management and evidence-based treatment.

Case Presentation

A case of type I bipolar disorder / type II bipolar disorder / cyclothymia / bipolar disorder with

psychotic symptoms / rapid cycling bipolar disorder/ unipolar mania.


Kemp D, Gao K, Fein E, Chan P, Conroy C, Obral S, Ganocy S, Calabrese R (2012)

Lamotrigine as add-on treatment to lithium and divalproex: lessons learned from a double-blind,

placebo-controlled trial in rapid-cycling bipolar disorder. Bipolar Disord., 14(7):780-789.

Schoeyen HK, Kessler U, Andreassen OA, Auestad BH, Bergsholm P, et al. (2014).

Treatment-Resistant Bipolar Depression: A Randomized Controlled Trial of Electroconvulsive

Therapy Versus Algorithm-Based Pharmacological Treatment. The American Journal of

Psychiatry; 172 (1), 41-51. DOI: http://dx.doi.org/10.1176/appi.ajp.2014.13111517

Jones SH, Smith G, Mulligan LD, Lobban F, Law H, et al. (2010). Recovery-focused

cognitive–behavioural therapy for recent-onset bipolar disorder: randomised controlled pilot

trial. The British Journal of Psychiatry; 206 (1) 58-66. DOI: 10.1192/bjp.bp.113.141259

http://www.ncbi.nlm.nih.gov/pubmed/?term=Lamotrigine+as+add-on+treatment+to+lithium+and+divalproex%3A+lessons+learned+from+a+double-blind%2C+placebo-controlled+trial+in+rapid-cycling+bipolar+disorder

http://www.ncbi.nlm.nih.gov/pubmed/?term=Lamotrigine+as+add-on+treatment+to+lithium+and+divalproex%3A+lessons+learned+from+a+double-blind%2C+placebo-controlled+trial+in+rapid-cycling+bipolar+disorder

http://dx.doi.org/10.1176/appi.ajp.2014.13111517

29


Monitoring requirements for mood stabilizers

Treatment of acute mania

Evidence-based treatment of bipolar depression


Intention-to-treat analysis & Last Observation Carried Forward (LOCF)

MCQs

1. Sodium valproate:

A. Is mostly renally metabolised

B. Commonly causes hypertrichosis

C. Reduces lamotrigine levels

D. Is licensed for prophylaxis of BPAD

E. Is a first line choice in acute mania

2. Which of the following drugs has a high therapeutic index:

A. Lithium

B. Carbamazepine

C. Phenytoin

D. Warfarin

E. Gabapentin

3. The risk of Ebstein’s anomaly in babies born to woman taking lithium is:

A. 1:10

B. 1:100

C. 1:500

D. 1:1000

E. 1:10000

4. Which of the following commonly causes hypercalcaemia:

A. Lithium

B. Valproate

C. Risperidone

D. Quetiapine

E. Clozapine

30

5. Lithium levels in once daily nocte dosing should be taken:

A. 4 hours post dose

B. 12 hours post dose

C. 6 hours post dose

D. Immediately before the next dose

E. 8 hours post dose

31

Session 16: Anxiety disorders-2 (GAD, panic disorder, phobic anxiety disorders)

Journal theme: case –control studies on the topic

Learning Objectives

To develop an understanding of GAD, panic disorder, phobic anxiety disorders

(aetiology, epidemiology, natural history, neurobiology, genetics, diagnostic criteria,

classification, psychopathology, clinical presentation, assessment, risks) and their

management (pharmacological, psychological, social).

To develop an understanding of Case-control studies and develop skills for critically

appraising them.

Expert Led Session

Biopsychosocial management of GAD, panic disorder and phobic anxiety disorders.

GAD, panic disorder, phobic anxiety disorders

Case Presentation

A case where either GAD, panic disorder or phobic disorder is the main diagnosis or a

differential diagnosis.


Lipka J, Miltner WH, Straube T (2011) Vigilance for threat interacts with amygdala responses

to subliminal threat cues in specific phobia. Biol Psychiatry, 70(5):472-8.

Santos MA, Ceretta LB, Réus GZ, Abelaira HM, Jornada LK, Schwalm MT, Neotti

MV, Tomazzi CD, Gulbis KG, Ceretta RA, Quevedo J (2014) Anxiety disorders are associated

with quality of life impairment in patients with insulin-dependent type 2 diabetes: a case-

control study. Rev Bras Psiquiatr., 36 (4):298-304.

Kiropoulos L, Klien B, Austin D, Gilson K, Pier C, Mitchell J and Ciechomski L (2008) Is

internet-based CBT for panic disorder and agoraphobia as effective as face-to-face CBT?

Journal of anxiety disorders 22(8), 1273-1284.


CBT for agoraphobia- principles

http://www.ncbi.nlm.nih.gov/pubmed/?term=Lipka%20J%5BAuthor%5D&cauthor=true&cauthor_uid=21601831

http://www.ncbi.nlm.nih.gov/pubmed/?term=Miltner%20WH%5BAuthor%5D&cauthor=true&cauthor_uid=21601831

http://www.ncbi.nlm.nih.gov/pubmed/?term=Straube%20T%5BAuthor%5D&cauthor=true&cauthor_uid=21601831

http://www.ncbi.nlm.nih.gov/pubmed/?term=Vigilance+for+threat+interacts+with+amygdala+responses+to+subliminal+threat+cues+in+specific+phobia

http://www.ncbi.nlm.nih.gov/pubmed/?term=Vigilance+for+threat+interacts+with+amygdala+responses+to+subliminal+threat+cues+in+specific+phobia

http://www.ncbi.nlm.nih.gov/pubmed/21601831

http://www.ncbi.nlm.nih.gov/pubmed/?term=Santos%20MA%5BAuthor%5D&cauthor=true&cauthor_uid=25003555

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ceretta%20LB%5BAuthor%5D&cauthor=true&cauthor_uid=25003555

http://www.ncbi.nlm.nih.gov/pubmed/?term=R%C3%A9us%20GZ%5BAuthor%5D&cauthor=true&cauthor_uid=25003555

http://www.ncbi.nlm.nih.gov/pubmed/?term=Abelaira%20HM%5BAuthor%5D&cauthor=true&cauthor_uid=25003555

http://www.ncbi.nlm.nih.gov/pubmed/?term=Jornada%20LK%5BAuthor%5D&cauthor=true&cauthor_uid=25003555

http://www.ncbi.nlm.nih.gov/pubmed/?term=Schwalm%20MT%5BAuthor%5D&cauthor=true&cauthor_uid=25003555

http://www.ncbi.nlm.nih.gov/pubmed/?term=Neotti%20MV%5BAuthor%5D&cauthor=true&cauthor_uid=25003555

http://www.ncbi.nlm.nih.gov/pubmed/?term=Neotti%20MV%5BAuthor%5D&cauthor=true&cauthor_uid=25003555

http://www.ncbi.nlm.nih.gov/pubmed/?term=Tomazzi%20CD%5BAuthor%5D&cauthor=true&cauthor_uid=25003555

http://www.ncbi.nlm.nih.gov/pubmed/?term=Gulbis%20KG%5BAuthor%5D&cauthor=true&cauthor_uid=25003555

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ceretta%20RA%5BAuthor%5D&cauthor=true&cauthor_uid=25003555

http://www.ncbi.nlm.nih.gov/pubmed/?term=Quevedo%20J%5BAuthor%5D&cauthor=true&cauthor_uid=25003555




http://www.ncbi.nlm.nih.gov/pubmed

http://www.sciencedirect.com/science/article/pii/S0887618508000170

http://www.sciencedirect.com/science/article/pii/S0887618508000170

32

Principles of use of benzodiazepines for anxiety disorders

NICE recommendations for treatment of GAD- overview


Null hypothesis, Type-1 error and type-2 error

MCQs

1. Venlafaxine is not licenced for which of the following indications?

A. Social anxiety

B. PTSD

C. Panic disorder

D. Depression +/- Anxiety

E. GAD

2. The following are TRUE of the pharmacokinetics of benzodiazepines:

A. When long-acting they have long elimination half-life.

B. When short-acting they have a small distribution volume.

C. When long-acting they have no active metabolites

D. When short-acting they have high accumulation

E. Benzodiazepines with a half-life of 12 hours tend to be used as anxiolytics.

3. Which of the following statements is FALSE about the effects of hypnotics on sleep?

A. Benzodiazepines supress stage IV sleep.

B. With chronic Benzodiazepines use suppression of REM sleep in the early part of the night

occurs

C. On withdrawal of Benzodiazepines a rebound increase above the ‘normal’ amount of REM

sleep occurs.

D. It may take up to 6 weeks to see a return to a normal sleep pattern on Benzodiazepine

withdrawal.

E. Barbiturates are more likely to suppress REM sleep than are Benzodiazepines.

4. With regards to the NICE guidelines for GAD, which of the following is FALSE?

A. SSRIs (particularly Sertraline) are the first line medications.

33

B. SNRIs are second line.

C. If the patient cannot tolerate SSRI or SNRI, offer Pregabalin.

D. Antipsychotics should be offered for the treatment of GAD in primary care.

E. Do not offer a benzodiazepine for the treatment of GAD in primary or secondary care except

as a short-term measure during crises

5. With respect to the NICE guidelines on psychological intervention for GAD, which of the following is

FALSE?

A. CBT for people with GAD should be based on the treatment manuals used in the clinical trials

of CBT for GAD.

B. CBT for GAD usually consist of 12–15 weekly sessions (fewer if the person recovers sooner;

more if clinically required), each lasting 1 hour.

C. Practitioners providing high-intensity psychological interventions for GAD need not have regular

supervision to monitor fidelity to the treatment model.

D. If a person with GAD chooses a high-intensity psychological intervention, offer either CBT or

applied relaxation.

E. Consider providing all interventions in the preferred language of the person with GAD if

possible.

34

Session 17: Suicide/self-harm-2

Journal theme: Any study method on the topic

Learning Objectives

To develop an understanding of various facets of self-harm and suicide (aetiology,

epidemiology, neurobiology, genetics, clinical presentation, risk assessment) and their

management (pharmacological, psychological, social).

Expert Led Session

Suicide & self-harm- comprehensive risk assessment

Case Presentation

Cases related to any type of clinical presentations where suicide and/ or self-harm is the

central theme


Quinlivan L, Cooper J, Steeg S, Davies L, Hawton K, Gunnell D, Kapur N (2014) Scales for

predicting risk following self-harm: an observational study in 32 hospitals in England. BMJ

Open, doi: 10.1136/bmjopen-2013-004732.

Kapur N, Gunnell D, Hawton K, Nadeem S, Khalil S, Longson D, Jordan R, Donaldson I,

Emsley R, Cooper J (2013) Messages from Manchester: pilot randomised controlled trial

following self-harm. BJPsych 203: 73-74.

Hawtona K, Bergena H, Cooperb J, Turnbullb P, Watersc K, et al. (2015). Suicide following

self-harm: Findings from the Multicentre Study of self-harm in England, 2000–2012. Journal

of Affective Disorders; 175, 147–151. DOI: 10.1016/j.jad.2014.12.062


National Confidential Inquiry into suicide by people with mental illness – Key findings of the

latest annual report

Purpose of a Coroner’s Inquest

Suicide in prisons


http://bmjopen.bmj.com/content/4/5/e004732.abstract

http://bmjopen.bmj.com/content/4/5/e004732.abstract



35

Standard error and confidence intervals

MCQs

1. Which of the following are the signs and symptoms of Tricyclic antidepressant overdose?

A. Sedation, tachycardia, arrhythmia, hypotension, seizures, coma

B. Vomiting, tremor, drowsiness, tachycardia

C. Sweating, tachycardia, blood pressure changes

D. Tremor, weakness, confusion, hypertension

E. Lethargy, sedation, GI disturbance

2. Which of the following medications has high toxicity in overdose?

A. Lofepramine

B. SSRIs

C. Trazodone

D. Phenelzine

E. Ariprazole

3. There is meta-analysis evidence concluding that lithium reduced the risk of both attempted and

completed suicide in patients with bipolar illness by:

A. 10 %

B. 30%

C. 80%

D. 25%

E. There is no such evidence

4. Suicidal ideation is a known side effect of all of the following medications EXCEPT?

A. Chloroquine

B. Reserpine

C. Interferons

D. Amisulpride

E. Mefloquine

36

5. True or false: Increased rates have been reported with:

A. Renal dialysis

B. SLE

C. Epilepsy

D. Patients with high cholesterol

E. Peptic ulcer

37

Session 18: Perinatal psychiatry

Journal theme: Study with any method

Learning Objectives

To understand the impact / risks of major mental disorders on pregnancy and post-

partum period. To understand the general principles of prescribing; and the risks &

benefits of prescribing psychotropic medications in pregnancy, post-partum period and

breast feeding.

Expert Led Session

Evidence-based recommendations for psychotropic medications in pregnancy

[antipsychotics, antidepressants, mood stabilizers and anxiolytics].

Case Presentation

A case of any mental disorder in pregnancy or post-partum period.


Ennis, Z. and Damkier, P. (2015). Pregnancy Exposure to Olanzapine, Quetiapine,

Risperidone, Aripiprazole and Risk of Congenital Malformations. A Systematic Review. Basic

& Clinical Pharmacology & Toxicology, 116(4), pp.315-320.

Boden, R., Lundgren, M., Brandt, L., Reutfors, J., Andersen, M. and Kieler, H. (2012). Risks

of adverse pregnancy and birth outcomes in women treated or not treated with mood

stabilisers for bipolar disorder: population based cohort study. BMJ, 345(nov07 6), pp.e7085.

Uguz, F. (2016). Second-Generation Antipsychotics During the Lactation Period: A

Comparative Systematic Review on Infant Safety. Journal of Clinical Psychopharmacology,

36(3), pp.244-252.


Post-partum risks of relapse in schizophrenia, bipolar disorder and depression

Congenital malformations associated with Lithium, Valproate, Carbamazepine, Lamotrigine

and Paroxetine- salient points

Use of SSRIs in pregnancy – salient points

38


Number Needed to Treat (NNT)

MCQs

1. During pregnancy the following physiological changes occur

A. Plasma volume markedly increases and eGFR increases

B. Plasma volume markedly decreases and eGFR increases

C. Plasma volume markedly increases and eGFR decreases

D. Plasma volume markedly decreases and eGFR decreases

E. There is no change in either plasma volume or eGFR

2. Which of the following is NOT associated with exposure to SSRIs in the Perinatal period?

A. Perinatal Death

B. Persistent Pulmonary Hypertension of the Newborn

C. Postpartum haemorrhage

D. Poor neonatal adaptation syndrome

E. Preterm birth

3. Which of the following statements is TRUE regarding NICE guidelines?

A. Benzodiazepines can be offered in pregnancy for medium term treatment of anxiety

B. Consideration of medication dose changes do not have to be made during pregnancy

C. If this is a first pregnancy a women’s previous response to medication should not influence

the choice of antidepressant (being pregnant dictates the choice)

D. Lithium can be continued if the women is at high risk of relapse and an antipsychotic is

unlikely to be effective

E. Measure prolactin levels in women planning pregnancy who are taking a prolactin raising

antipsychotic as raised prolactin increases the chances of conception

4. Which of the following statements is TRUE?

A. Valproate is associated with reduced fertility in women and men

B. Taking Folic acid 5mg with Valproate will reduce teratogenicity

39

C. Valproate monotherapy is not associated with an increased risk of Attention Deficit

Hyperactivity Disorder

D. Valproate monotherapy only affects the child in the 1st and 3rd trimester

E. Valproate passes in higher concentrations than Lamotrigine in breastmilk

5. Which of the following is TRUE regarding breastfeeding?

A. Patients with postpartum mental health disorders who require pharmacotherapy should

generally be discouraged from breastfeeding

B. All psychotropic medications are transferred to breast milk in varying amounts

C. Psychotropics should be chosen with regard to longer half life and less protein binding

D. Mothers should change their pregnancy medication for breastfeeding

E. Methadone and Nicotine Replacement Therapy are incompatible with breastfeeding

Further Reading

PSYCHOSIS

Guidelines

NICE Guidance Pathway: Psychosis and Schizophrenia Pathway - :

http://pathways.nice.org.uk/pathways/psychosis-and-schizophrenia

Nice guidelines: CG178- Psychosis and schizophrenia in adults:

http://guidance.nice.org.uk/CG178

BAP guidelines: Evidence-based guidelines for the pharmacological treatment of

schizophrenia: recommendations from the British Association for Psychopharmacology-

https://www.bap.org.uk/pdfs/BAP_Guidelines-Schizophrenia.pdf

E-Learning

RCPsych CPD Online

First episode psychosis: Part 1 -assessment, diagnosis and rationale

First episode psychosis: Part 2 -treatment approaches and service delivery

Journal Articles

Feedman, R (2003) Schizophrenia. N Engl J Med 349:1738-1749

http://pathways.nice.org.uk/pathways/psychosis-and-schizophrenia

http://guidance.nice.org.uk/CG178

http://www.psychiatrycpd.org/learningmodules/first-episodepsychosispart.aspx

http://www.psychiatrycpd.org/learningmodules/first-episodepsychosispar-1.aspx

40

Woolley, J & McGuire P (2005) Neuroimaging in schizophrenia: what does it tell the clinician?

APT 11: 195-202.

Cardno A (2014) Genetics and psychosis. APT 20: 69-70

Torrey EF (1987) Prevalence studies in schizophrenia. BJPsych 150:598-608.

Macleod J (2007) Cannabis use and psychosis: the origins and implications of an

association. APT 13:400-411.

Martindale B (2007) Psychodynamic contributions to early intervention in psychosis. APT

13:34-42.

Connolly M & Kelly C (2005) Lifestyle and physical health in schizophrenia. APT 11:125-132.

Mullen P (2006) Schizophrenia and violence: from correlations to preventive strategies. APT

12:239-248

Schleifer JJ (2011) Management of acute agitation in psychosis: an evidence-based

approach in the USA. APT 17:91-100.

DEPRESSION

Guidelines

NICE Guidance Pathway: Depression Pathway-

http://pathways.nice.org.uk/pathways/depression

Nice guidelines: CG90- Depression in adults: Recognition and management

https://www.nice.org.uk/guidance/CG90

BAP guidelines: Evidence-based guidelines for treating depressive disorders with

antidepressants: A revision of the 2008 British Association for Psychopharmacology

guidelines- https://www.bap.org.uk/pdfs/BAP_Guidelines-Antidepressants.pdf

E-Learning

RCPsych CPD Online

The pharmacological treatment of resistant depression- an overview

Dual diagnosis: the diagnosis and treatment of depression with co-existing

substance misuse

Managing depression in physically ill patients

Prescription of ECT

Antidepressants and psychosexual dysfunction: Part 1 – diagnosis

Antidepressants and psychosexual dysfunction: Part 2 – treatment

Journal Articles

http://pathways.nice.org.uk/pathways/depression

http://www.psychiatrycpd.org/learningmodules/pharmacologicaltreatmentofr.aspx

http://www.psychiatrycpd.org/learningmodules/dualdiagnosisthediagnosis.aspx

http://www.psychiatrycpd.org/learningmodules/dualdiagnosisthediagnosis.aspx

http://www.psychiatrycpd.org/learningmodules/managingdepressioninphysica.aspx

http://www.psychiatrycpd.org/learningmodules/theprescriptionofelectrocon.aspx

http://www.psychiatrycpd.org/learningmodules/antidepressantsandpsychosexu.aspx

http://www.psychiatrycpd.org/learningmodules/antidepressantsandpsychose-1.aspx

41

Belmaker, RH & Agam G (2008). Major depressive disorder, N Engl J Med, 358: 55-68.

Jacob KS (2009) Major depression: revisiting the concept and diagnosis. APT 15:279-285.

Taylor D (2008) Psychoanalytic and psychodynamic therapies for depression: the evidence

base. APT 14:401-413.

Branney P & White A (2008) Big boys don’t cry: depression and men. APT 14:256-262.

Cowen P (2005) New drugs, old problems: Revisiting Pharmacological management of

treatment-resistant depression. APT 11:19-27.

Oakley C, Hynes F, Clark T (2009). Mood disorders and violence: a new focus, APT, 15:263-

270.

BIPOLAR DISORDER

Guidelines

Nice guidelines: CG185- Bipolar disorder: assessment and management

https://www.nice.org.uk/guidance/cg185

BAP guidelines: Evidence-based guidelines for treating bipolar disorder: revised third edition

https://www.bap.org.uk/pdfs/BAP_Guidelines-Bipolar.pdf

E-Learning

RCPsych CPD Online

The pharmacological management of mania

Safe Lithium Prescribing: initiation and monitoring

Journal Articles

Elanjithara T, Frangou S, McGuire P (2011) Treatment of the early stages of bipolar disorder.

APT 17:283-291.

Bouch J (2010) Bipolar disorder. APT 16:317.

Saunders KEA & Goodwin GM (2010) The course of bipolar disorder. APT 16:318-328.

ANXIETY DISORDERS

Guidelines

http://www.psychiatrycpd.org/learningmodules/pharmacologicalmanagemento-1.aspx

http://www.psychiatrycpd.org/learningmodules/safelithiumprescribinginit.aspx

42

NICE Guidance Pathway for GAD and panic disorder (with or without agoraphobia):

http://pathways.nice.org.uk/pathways/generalised-anxiety-disorder

NICE guidelines on GAD and panic disorder: CG113-

https://www.nice.org.uk/Guidance/CG113

BAP guidelines: Evidence-based pharmacological treatment of anxiety disorders, post-

traumatic stress disorder and obsessive-compulsive disorder: A revision of the 2005

guidelines from the British Association for Psychopharmacology

https://www.bap.org.uk/pdfs/BAP_Guidelines-Anxiety.pdf

E-Learning

RCPsych CPD Online

The pharmacological management of anxiety disorders

Journal Articles

Kessler RC, Chiu WT, Jim R, Ruscio AM, Shear C, Walters E. (2006). The epidemiology of

panic attacks, panic disorder and agoraphobia in the national co-morbidity survey replication.

Archives of General Psychiatry (now JAMA Psychiatry), 63(4), 415-424.

Shader RJ, Greenblatt DJ. (1993). Use of benzodiazepines in anxiety disorders. N Eng J of

Med, 328, 1398-1405.

Hamilton, M. (1959) The assessment of anxiety states by rating scale. British Journal of

Medical Psychology, 32(1), 50-55.

Linden, .M. Zubraegel .D. Baer .T. et al. (2005) Efficacy of cognitive behaviour therapy in

generalised anxiety disorders. Psychotherapy and Psychosomatics 74, 36-42.

SELF-HARM & SUICIDE

E-Learning

RCPsych CPD Online

The psychosocial management of self-harm: Part 1

The psychosocial management of self-harm: Part 2

BMJ Learning Module on suicidal behaviour and self-harm

http://learning.bmj.com/learning/module-intro/cmt-self-

harm.html?moduleId=10054668&page=1&locale=en_GB

Journal Articles

http://pathways.nice.org.uk/pathways/generalised-anxiety-disorder

http://www.psychiatrycpd.org/learningmodules/pharmacologicalmanagementof.aspx

http://www.psychiatrycpd.co.uk/learningmodules/psychosocialmanagementofsel1.aspx

http://www.psychiatrycpd.co.uk/learningmodules/psychosocialmanagementofs-11.aspx

http://learning.bmj.com/learning/module-intro/cmt-self-harm.html?moduleId=10054668&page=1&locale=en_GB

http://learning.bmj.com/learning/module-intro/cmt-self-harm.html?moduleId=10054668&page=1&locale=en_GB

43

Bouch J, Marshall JJ (2005) Suicide risk: structured professional judgement. Advances in

Psychiatric Treatment 11: 84-91.

Heeringen K, Mann JJ (2014) The neurobiology of suicide. Lancet Psychiatry 1:63-72.

O’Connor RC, Nock MK (2014) The psychology of suicidal behaviour. Lancet Psychiatry

1:73-85.

Other resources

Royal College of Psychiatrists leaflets

http://www.rcpsych.ac.uk/healthadvice/problemsdisorders.aspx

Links to the ICD10 online:

http://apps.who.int/classifications/icd10/browse/2016/en#/V

http://www.who.int/classifications/icd/en/bluebook.pdf (Bluebook)

http://www.who.int/classifications/icd/en/GRNBOOK.pdf (for research criteria)

TrOn: www.tron.rcpsych.ac.uk

http://www.rcpsych.ac.uk/healthadvice/problemsdisorders.aspx

http://apps.who.int/classifications/icd10/browse/2016/en#/V

http://www.who.int/classifications/icd/en/bluebook.pdf

http://www.who.int/classifications/icd/en/GRNBOOK.pdf

http://www.tron.rcpsych.ac.uk/

44

OLD AGE SEMESTER 3:

Session 1: Cognition

Learning Objectives

The overall aim is for the trainee to gain an overview of cognition.

By the end of the session trainees should:

o Understand the link between the cognitive domains and brain regions

o Appreciate the theory of a bedside cognitive assessment

o Have an awareness of common cognitive syndromes

o Be able to reflect on the limitations of cognitive assessment tools

Curriculum Links

Old Age Section of the MRCPsych Curriculum: 8.3

Expert Led Session

A Consultant led session based on the learning objectives listed above

Case Presentation

A case to be presented which highlights the importance of a robust assessment, including some

interesting findings in the cognitive assessment process in the older person

Journal Club Presentation

45

Cecato, J.F., Martinelli, J.E., Izbicki, R., Yassuda, M.S. and Aprahamian, I., 2017. A subtest

analysis of The Montreal Cognitive Assessment (MoCA): which subtests can best discriminate

between healthy controls, mild cognitive impairment and Alzheimer's disease?. International

psychogeriatrics, 29(4), pp.701-701.

Krishnan, K., Rossetti, H., Hynan, L.S., Carter, K., Falkowski, J., Lacritz, L., Cullum, C.M. and

Weiner, M., 2017. Changes in Montreal cognitive assessment scores over time. Assessment,

24(6), pp.772-777.

Roalf, D.R., Moore, T.M., Mechanic-Hamilton, D., Wolk, D.A., Arnold, S.E., Weintraub, D.A. and

Moberg, P.J., 2017. Bridging cognitive screening tests in neurologic disorders: A crosswalk

between the short Montreal Cognitive Assessment and Mini-Mental State Examination.

Alzheimer's & dementia: the journal of the Alzheimer's Association, 13(8), pp.947-952.

‘555’ Topic (5 slides with no more than 5 bullet points per slide)

Bedside Testing of the Frontal Lobe or the Parietal Lobe

Normal age-related changes in cognitive function

MCQs

1. Which of the following is not a bedside frontal lobe test?

A. Abstract thinking

B. Go-No-Go

C. Cognitive estimates

D. Verbal fluency

E. Clock drawing

2. Which of the following is an objective rating scale for cognition?

A. MOCA

B. GDS

C. DASS21

D. Cornell

E. MUST

46

3. All are features of Gerstmann Syndrome except:

A. Right-left disorientation

B. Anosognosia

C. Finger agnosia

D. Dyscalculia

E. Dysgraphia

4. Which of the following is seen in Wernicke’s aphasia?

A. Effortful speech

B. Telegraphic speech

C. Intact repetition

D. Impaired comprehension

E. Nystagmus

5. The following brain region is associated with semantic memory:

A. Thalamus

B. Hippocampus & entorhinal cortex

C. Anterior temporal lobe

D. Dorsolateral prefrontal cortex

E. Cerebellum

6. Which of the following is not a test of executive function?

A. Luria Task

B. Wisconsin Card Sorting Test

C. Stroop Test

D. Graded naming test

E. Verbal fluency

Additional Resources / Reading Material

Websites:

Montreal Cognitive Assessment (MOCA) available at: www.mocatest.org

http://www.mocatest.org/

47

RCPsych CPD Online Modules: Bedside Assessment of Cognition.

Journal Papers:

Tang, M. and Reitz, C., 2017. Genetics of Alzheimer's disease: an update. Future Neurology, 12(4),

pp.237-247.

Kipps, CM., & Hodges, JR., 2005. Cognitive assessment for clinicians. Journal of Neurology,

Neurosurgery & Psychiatry, 76 (suppl 1), i22-i30.

Giri, M., Zhang, M., & Lü, Y. (2016). Genes associated with Alzheimer’s disease: an overview

and current status. Clinical Interventions in Aging, 11, 665–681.

http://doi.org/10.2147/CIA.S105769

Shaik, S. S., & Varma, A. R., 2012. Differentiating the dementias: a neurological approach.

Progress in Neurology and Psychiatry, 16(1), 11-18.

Takas, A., Koncz, R., Mohan, A. and Sachdev, P., 2017. Forgetfulness, stress or mild dementia?

Cognitive assessment of older patients. https://medicinetoday.com.au/2017/may/feature-

article/forgetfulness-stress-or-mild-dementia-cognitive-assessment-older-patients/

Young, J., Meagher, D., & MacLullich, A., 2011. Cognitive assessment of older people. BMJ, 343,

d5042.

Guidelines:

NICE CG42 – Dementia https://www.nice.org.uk/guidance/Cg42

Other resources:

Hodges, J.R., 2017. Cognitive assessment for clinicians. Oxford University Press.

Jacoby R, Oppenheimer C, Dening T. (eds.), 2008. The Oxford Textbook of Old Age Psychiatry.

Oxford University Press: Oxford. Chapters on psychometric assessment, biological aspect of ageing

and clinical cognitive assessment..

Larner, A.J. ed., 2017. Cognitive screening instruments. Springer.

Volkman, N., Cohen, N. and Vroman, G., 2018. Misinterpreting Cognitive Decline in the Elderly:

Blaming the Patient. In Human Error in Medicine (pp. 93-122). CRC Press.

https://medicinetoday.com.au/2017/may/feature-article/forgetfulness-stress-or-mild-dementia-cognitive-assessment-older-patients/

https://medicinetoday.com.au/2017/may/feature-article/forgetfulness-stress-or-mild-dementia-cognitive-assessment-older-patients/

https://www.nice.org.uk/guidance/Cg42

48

Session 2: Alzheimer’s Disease

Learning Objectives

The overall aim is for the trainee to gain an overview of Alzheimer’s disease.


o Understand the epidemiology of Alzheimer’s disease.

o Understand the risk factors, genetics, neuropathology, neurotransmitters and

neuroimaging associated with Alzheimer’s Disease.

o Understand the clinical features of Alzheimer’s disease, the assessment process and the

principles of management.

o Understand the impact on carers associated with disorders like Alzheimer’s Disease.

Curriculum Links

Old Age Section of the MRCPsych Curriculum: 8.1, 8.2, 8.3, 8.4, 8.5

Expert Led Session

A Consultant led session based on the learning objectives listed above

Case Presentation

A case to be presented which highlights the diagnostic process and/or Alzheimer’s Disease and/or

BPSD (behaviour that challenges). Please consider the learning objectives above.


Gitlin, L.N., Arthur, P., Piersol, C., Hessels, V., Wu, S.S., Dai, Y. and Mann, W.C., 2018. Targeting

Behavioral Symptoms and Functional Decline in Dementia: A Randomized Clinical Trial. Journal

of the American Geriatrics Society, 66(2), pp.339-345

Sabia, S., Dugravot, A., Dartigues, J.F., Abell, J., Elbaz, A., Kivimäki, M. and Singh-Manoux, A., 2017.

Physical activity, cognitive decline, and risk of dementia: 28 year follow-up of Whitehall II cohort

study. Bmj, 357, p.j2709.

Sommerlad, A., Ruegger, J., Singh-Manoux, A., Lewis, G. and Livingston, G., 2017. Marriage and

risk of dementia: systematic review and meta-analysis of observational studies. J Neurol

Neurosurg Psychiatry, pp.jnnp-2017.

Tricco, A.C., Ashoor, H.M., Soobiah, C., Rios, P., Veroniki, A.A., Hamid, J.S., Ivory, J.D., Khan, P.A.,

Yazdi, F., Ghassemi, M. and Blondal, E., 2018. Comparative effectiveness and safety of cognitive

49

enhancers for treating Alzheimer's disease: systematic review and network meta-analysis.

Journal of the American Geriatrics Society, 66(1), pp.170-178.

Tampi R, Hassell C, Joshi P, Tampi D. 2018. Analgesics in the Management of Behavioral and

Psychological Symptoms of Dementia: A Systematic Review. The American Journal of Geriatric

Psychiatry. 31;26(3):S143-4.

White, N., Leurent, B., Lord, K., Scott, S., Jones, L. and Sampson, E.L., 2017. The management of

behavioural and psychological symptoms of dementia in the acute general medical hospital: a

longitudinal cohort study. International journal of geriatric psychiatry, 32(3), pp.297-305.


The use of antipsychotic medication and the risks associated in patients with dementia

The NINCDS-ADRDA or NIA-AA criteria

MCQs

1. The prevalence of dementia in the general UK population older than 65 is approximately:

A. 1-2%

B. 2-4%

C. 7%

D. 10%

E. 15-20%

2. In Alzheimer’s Disease, the gene for Amyloid Precursor Protein (APP) is found on the long arm of

chromosome:

A. 1

B. 12

C. 21

D. 19

E. None of the above

3. Which of the following statements regarding biomarkers in Alzheimer’s disease is true:

A. The first biomarker change in Alzheimer’s disease is reflected by a decrease in CSF tau levels

B. β amyloidosis can only be detected in venous plasma samples

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C. Amyloid-β accumulation is not sufficient to cause disease progression

D. PET imaging is estimated to be able to predict changes 25 years prior to symptoms

E. All individuals that have positive biomarker results progress at the same rate.

4. The ‘anti-dementia’ drug that blocks NMDA receptors is:

A. Rivastigmine

B. Galantamine

C. Memantine

D. Donepezil

E. All of the above

5. Which of the following combination of APOE alleles confers the highest risk of developing

Alzheimer's disease?

A. 2:2

B. 2:3

C. 3:3

D. 3:4

E. 4:4

Additional Resources / Reading Materials

Websites:

https://www.rcpsych.ac.uk/ CPD Online

capacity, empowerment and conflicts of interest

inappropriate sexual behaviour in dementia

Guidelines


Journal papers:

Banerjee S., 2009. The Use of Antipsychotic Medication for People with Dementia: Time for

Action. DOH.

https://www.rcpsych.ac.uk/


51

Cooper, S., & Greene, JDW., 2005. The clinical assessment of the patient with early dementia.

Journal of Neurology, Neurosurgery & Psychiatry, 76 (5), v15-v24.

Etters, L., Goodall, D., & Harrison, B. E., 2008. Caregiver burden among dementia patient

caregivers: a review of the literature. Journal of the American Academy of Nurse Practitioners,

20(8), 423-428.

Loy, C. T., Schofield, P. R., Turner, A. M., & Kwok, J. B., 2013. Genetics of dementia. The Lancet.

Jack, C.R., Bennett, D.A., Blennow, K., Carrillo, M.C., Dunn, B., Haeberlein, S.B., Holtzman, D.M.,

Jagust, W., Jessen, F., Karlawish, J. and Liu, E., 2018. NIA-AA Research Framework: Toward a

biological definition of Alzheimer's disease. Alzheimer's & Dementia, 14(4), pp.535-562.

Mortimer, A. M., Likeman, M., & Lewis, T. T., 2013. Neuroimaging in dementia: a practical guide.

Practical neurology, 13(2), 92-103.

Tang, M. and Reitz, C., 2017. Genetics of Alzheimer's disease: an update. Future Neurology,

12(4), pp.237-247.

Treloar, A., Crugel, M., Prasanna, A., Solomons, L., Fox, C., Paton, C., & Katona, C., 2010. Ethical

dilemmas: should antipsychotics ever be prescribed for people with dementia? The British

Journal of Psychiatry, 197(2), 88-90.

Watkin, A., Sikdar, S., Majumdar, B., & Richman, A. V., 2013. New diagnostic concepts in

Alzheimer’s disease. Advances in psychiatric treatment, 19(4), 242-249.

Other resources

Dementia UK update (2nd edition), 2007. Alzheimer’s Society.

https://www.alzheimers.org.uk/sites/default/files/migrate/downloads/dementia_uk_update.pdf

Jacoby R, Oppenheimer C, Dening T., 2008. The Oxford Textbook of Old Age Psychiatry. Oxford

University Press: Oxford. Chapters on Alzheimer’s disease, pharmacological treatment of

dementia.

Taylor, D., Barnes, T., Young, A., 2018. The Maudsley Prescribing Guidelines in Psychiatry, 13th

edition. Blackwell-Wiley.

World Health Organisation, 1992. ICD-10 : The ICD-10 Classification of Mental and Behavioural

Disorders : Clinical Descriptions and Diagnostic Guidelines. WHO.

https://www.alzheimers.org.uk/sites/default/files/migrate/downloads/dementia_uk_update.pdf

52

Session 3: Other Neuro Degenerative Disorders

Learning Objectives

To overall aim is to gain a basic overview of common neuro-degenerative disorders including Lewy

Body Dementia, Fronto-Temporal Dementia (FTD), Creutzfeldt-Jakob disease (CJD), and Dementia

in Parkinson’s disease; vascular dementia is also incorporated into this session.

For each of the disorders listed above, by the end of the session, the trainee should understand

the basic epidemiology, aetiology, clinical presentation and basic management principles

Curriculum Links

Old Age Section of the MRCPsych Curriculum: 8.1, 8.3, 8.4, 8.5, 8.11

Expert Led Session

A Consultant led session based on the learning objectives listed above.

Case Presentation

A case to be presented which highlights one of the neurodegenerative disorders named above.

Please consider the learning objectives above.


Rongve, A., Soennesyn, H., Skogseth, R., Oesterhus, R., Hortobágyi, T., Ballard, C., .& Aarsland, D.

(2016). Cognitive decline in dementia with Lewy bodies: a 5-year prospective cohort study. BMJ

open, 6(2), e010357.

Schrag, A., Siddiqui, U.F., Anastasiou, Z., Weintraub, D. and Schott, J.M., 2017. Clinical variables

and biomarkers in prediction of cognitive impairment in patients with newly diagnosed

Parkinson's disease: a cohort study. The Lancet Neurology, 16(1), pp.66-75.

Connors, M.H., Quinto, L., McKeith, I., Brodaty, H., Allan, L., Bamford, C., Thomas, A., Taylor, J.P.

and O'Brien, J.T., 2017. Non-pharmacological interventions for Lewy body dementia: a

systematic review. Psychological medicine, pp.1-10.

Coleman, K.K., Coleman, B.L., MacKinley, J.D., Pasternak, S.H. and Finger, E.C., 2017. Association

between Montreal Cognitive Assessment sub-item scores and corresponding cognitive test

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performance in patients with frontotemporal dementia and related disorders. Dementia and

geriatric cognitive disorders, 43(3-4), pp.170-179.

Sevilla, R.R., Naranjo, I.C., Cuenca, J.C.P., Rodriguez, J.M.F. and Espuela, F.L., 2018. Vascular risk

factors and white matter hyperintensities as predictors of progression to dementia in patients

with mild cognitive impairment. Current Alzheimer research


Dementia in Huntington’s Disease

The presentation of FTD

Management of psychosis in Parkinson’s disease

MCQs

1. Which of the following feature is seen more in cortical than subcortical dementia:

A. Calculation preserved

B. Aphasia occurs early

C. Apathy

D. Slowed motor speed and control

E. Adventitious movement

2. In Progressive Supranuclear Palsy (PSP), which of the following is true?

A. A tendency to fall forwards is seen

B. Onset is in the 4th decade of life

C. Dystonia is seen

D. Cortical type of dementia is noted

E. Pupils become dilated and fixed

3. A man with Parkinson’s Disease develops psychotic symptoms. What is the first line antipsychotic

treatment?

A. Quetiapine

B. Amisulpride

C. Haloperidol

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D. Risperidone

E. Clozapine

4. Which of the following MRI finding is seen in Huntington’s Disease?

A. Caudate atrophy

B. Cerebellar atrophy

C. Multiple white matter intensities

D. Pulvinar infarct

E. Lacunar infarct

5. A 70 year old man has a diagnosis of Lewy Body Dementia. Which of the following drugs has the

best evidence for improving delusions and hallucinations associated with LBD?

A. Donepezil

B. Mirtazapine

C. Risperidone

D. Clozapine

E. Rivastigmine


Websites:

Trainees Online (TrON): Neuropathology: Part 1 – dementia

RCPsych, CPD Online – useful modules on:

o Neuroimaging in dementia

o Early onset dementias

o Neuropsychiatric problems in Parkinson’s disease

o Hungtington’s disease

Journal Papers:

Braak, H., Ghebremedhin, E., Rüb, U., Bratzke, H., & Del Tredici, K., 2004. Stages in the

development of Parkinson’s disease-related pathology. Cell and tissue research, 318(1),

121-134.

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Brooks, DJ., 2002. Diagnosis and management of atypical parkinsonian syndromes. Journal

of Neurology, Neurosurgery & Psychiatry, 72(suppl 1), i10-i16.

Craufurd, D, MacLeod, R, Frontali, M, Quarrell, O, Bijlsma, EK, Davis, M, Hjermind, LE, Lahiri,

N, Mandich, P, Martinez, A and Tibben, A., 2015. Diagnostic genetic testing for Huntington's

disease. Practical neurology, 15(1), pp.80-84.

Gore, RL., Vardy, ER., & T O'Brien, J. , 2014. Delirium and dementia with Lewy bodies:

distinct diagnoses or part of the same spectrum? Journal of Neurology, Neurosurgery &

Psychiatry, 2013.

Gupta, S., Fiertag, O., & Warner, J., 2009. Rare and unusual dementias. Advances in

psychiatric treatment, 15(5), 364-371.

Ian G. McKeith, Bradley F. Boeve, Dennis W. Dickson, et al., 2017. Diagnosis and

management of dementia with Lewy bodies: Fourth consensus report of the DLB

Consortium. Neurology published online. DOI 10.1212/WNL.0000000000004058

http://n.neurology.org/content/neurology/early/2017/06/07/WNL.0000000000004058.full.

pdf

Jauhar, S. and Ritchie, S., 2010. Psychiatric and behavioural manifestations of Huntington’s

disease. Advances in psychiatric treatment, 16(3), pp.168-175.

Latoo, J., Mistry, M., & Dunne, F. J., 2012. Diagnosis and management of psychosis in

Parkinson's disease. Progress in Neurology and Psychiatry, 16(5), 7-10.

O’Brien, J.T. and Thomas, A., 2017. Vascular Dementia. Focus, 15(1), pp.101-109.

Smith, E.E., 2017. Clinical presentations and epidemiology of vascular dementia. Clinical

Science, 131(11), pp.1059-1068.

Sullivan, V, Majumdar, B, Richman, A, & Vinjamuri, S., 2012. To scan or not to scan:

neuroimaging in mild cognitive impairment and dementia. Advances in Psychiatric

Treatment, 18(6), 457-466.

Warren, JD, Rohrer, JD, & Rossor, MN., 2013. Frontotemporal dementia. BMJ;347:f4827 doi:

10.1136/bmj.f4827

http://n.neurology.org/content/neurology/early/2017/06/07/WNL.0000000000004058.full.pdf

http://n.neurology.org/content/neurology/early/2017/06/07/WNL.0000000000004058.full.pdf

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Other resources:

Jacoby R, Oppenheimer C, Dening T. (eds.), 2008. The Oxford Textbook of Old Age

Psychiatry. Oxford University Press: Oxford. Chapters on clinical aspects of dementia and on

the different forms of dementia.

Munoz, D.G. and Weishaupt, N., 2017. Vascular Dementia. In The Cerebral Cortex in

Neurodegenerative and Neuropsychiatric Disorders (pp. 119-139).

Taylor, D., Barnes, T., Young, A., 2018. The Maudsley Prescribing Guidelines in Psychiatry, 13th edition. Blackwell-Wiley.

World Health Organisation, 1992. ICD-10 : The ICD-10 Classification of Mental and

Behavioural Disorders : Clinical Descriptions and Diagnostic Guidelines. WHO.

Session 4: Delirium

Learning Objectives

The overall aim of the session is for the trainee to gain an overview of delirium

By the end of the sessions the trainee should:

o Understand the epidemiology, the risk factors associated and the basic physiological and

psychological changes associated with delirium

o Have an understanding of the clinical features of delirium, and have a framework for the

basic assessment process, principles of management, and prognosis.

Curriculum Links

Old Age Section of the MRCPsych Curriculum: 8.3, 8.4, 8.5.

Expert Led Session


Case Presentation

A case to be presented which highlights a patient presenting with possible or definite delirium.



57

Journal papers:

Balogun, S. A., & Philbrick, J. T. 2014. Delirium, a Symptom of UTI in the Elderly: Fact or

Fable? A Systematic Review. Canadian Geriatrics Journal, 17(1), 22–26.

http://doi.org/10.5770/cgj.17.90

Bush, S.H., Marchington, K.L., Agar, M., Davis, D.H., Sikora, L. and Tsang, T.W., 2017. Quality

of clinical practice guidelines in delirium: a systematic appraisal. BMJ open, 7(3),

p.e013809.

Davis, D.H., Muniz-Terrera, G., Keage, H.A., Stephan, B.C., Fleming, J., Ince, P.G., Matthews,

F.E., Cunningham, C., Ely, E.W., MacLullich, A.M. and Brayne, C., 2017. Association of

delirium with cognitive decline in late life: a neuropathologic study of 3 population-based

cohort studies. JAMA psychiatry, 74(3), pp.244-251.

Devore, E.E., Fong, T.G., Marcantonio, E.R., Schmitt, E.M., Travison, T.G., Jones, R.N. and

Inouye, S.K., 2017. Prediction of long-term cognitive decline following postoperative

delirium in older adults. Journals of Gerontology Series A: Biomedical Sciences and Medical

Sciences, 72(12), pp.1697-1702.

Neufeld, K. J., Yue, J., Robinson, T. N., Inouye, S. K., & Needham, D. M. 2016. Antipsychotic

Medication for Prevention and Treatment of Delirium in Hospitalised Adults: A Systematic

Review and Meta‐Analysis. Journal of the American Geriatrics Society, 64(4), 705-714.

van Velthuijsen, E.L., Zwakhalen, S.M., Pijpers, E., van de Ven, L.I., Ambergen, T., Mulder,

W.J., Verhey, F.R. and Kempen, G.I., 2018. Effects of a Medication Review on Delirium in

Older Hospitalised Patients: A Comparative Retrospective Cohort Study. Drugs & aging,

35(2), pp.153-161.

Yang, Y., Zhao, X., Dong, T., Yang, Z., Zhang, Q. and Zhang, Y., 2017. Risk factors for

postoperative delirium following hip fracture repair in elderly patients: a systematic

review and meta-analysis. Aging clinical and experimental research, 29(2), pp.115-126.


Delirium versus dementia

Delirium tremens

Detection of delirium

http://doi.org/10.5770/cgj.17.90

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MCQs

1. Which of the following is most common in delirium?

A. Hallucinations

B. Sleep-wake cycle disturbed

C. Labile mood

D. Increased motor activity

E. Delusions

2. What % of patients with delirium go onto develop dementia:

A. 5%

B. 10-25%

C. 25-45%

D. 1%

E. 90%

3. Which of the following is not a risk factor for delirium:

A. Recent surgery

B. Poor sight

C. Terminal illness

D. Pre-existing memory problems

E. Intellectual disability

4. Which is a clinical feature common to both dementia and delirium:

A. Rapid onset

B. Global cognitive impairment

C. Clouding of consciousness

D. Clear consciousness

E. Gradual onset over 6 months

5. Which assessment rating tool does NICE recommend using to assess for delirium:

A. MOCA

B. CAM

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C. MMSE

D. ACEIII

E. DAS21

6. Which drug is not associated with an increased risk of delirium:

A. Calcium channel blocker

B. Antihistamines

C. Benzodiazepines e.g. lorazepam

D. Antipsychotics

E. Antipsychotics


Websites:

CPD Online: Delirium in older people: assessment and management

http://www.europeandeliriumassociation.com/

http://www.scottishdeliriumassociation.com/

Guidelines

Delirium: prevention, diagnosis and management, NICE guidelines [CG103].

Journal Papers:

Clegg, A., & Young, J. B. 2010. Which medications to avoid in people at risk of delirium: a

systematic review. Age and ageing, afq140.

Fiedler, S.M. and Houghton, D.J., 2018. An In-depth Look into the Management and Treatment

of Delirium. In Clinical Approaches to Hospital Medicine (pp. 89-107). Springer, Cham.

MacLullich, A. M., Beaglehole, A., Hall, R. J., & Meagher, D. J. 2009. Delirium and long-term

cognitive impairment. International Review of Psychiatry, 21(1), 30-42.

Miller, C., Teale, E. and Banerjee, J., 2018. Cognitive Impairment in Older People Presenting to

ED. In Geriatric Emergency Medicine (pp. 199-207). Springer, Cham.

http://www.europeandeliriumassociation.com/

http://www.scottishdeliriumassociation.com/

60

O’Connell, H., Kennelly, S. P., Cullen, W., & Meagher, D. J. 2014. Managing delirium in everyday

practice: towards cognitive-friendly hospitals. Advances in psychiatric treatment, 20(6), 380-

389.

Raju, K., & Coombe‐Jones, M. 2015. An overview of delirium for the community and hospital

clinician. Progress in Neurology and Psychiatry, 19(6), 23-27.

Young, J., & Inouye, S. K. 2007. Delirium in older people. BMJ, 842-846.

Books:

Jacoby R, Oppenheimer C, Dening T. (eds.) 2008. The Oxford Textbook of Old Age Psychiatry.

Oxford University Press: Oxford. Chapter on delirium.


edition. Blackwell-Wiley. (section on delirium and delirium tremens)


Disorders : Clinical Descriptions and Diagnostic Guidelines. WHO.

Session 5: Mood Disorders in the Older Person

Learning Objectives

The overall aim of the sessions is for the trainees to gain an overview of mood disorders in later

life.


o Understand the epidemiology, aetiology and the classification of mood disorders in the

elderly.

o Understand how mood disorders present in the elderly (including psychotic features), the

assessment process including neuroimaging and the use of rating scales and the principles

of treatment including treatment resistance.

o Understand more about the risk of suicide in the elderly.

Curriculum Links

Old Age Section of the MRCPsych Curriculum: 8.3, 8.4, 8.5, 8.6, 8.7, 8.8, 8.9, 8.10.

Expert Led Session


61

Case Presentation

A case to be presented which highlights an older person presenting with a mood disorder. Please

consider the learning objectives above.


Andreas, S., Schulz, H., Volkert, J., Dehoust, M., Sehner, S., Suling, A., Ausín, B., Canuto, A.,

Crawford, M., Da Ronch, C. and Grassi, L., 2017. Prevalence of mental disorders in elderly

people: the European MentDis_ICF65+ study. The British Journal of Psychiatry, 210(2),

pp.125-131.

Hedna, K., Sundell, K.A., Hamidi, A., Skoog, I., Gustavsson, S. and Waern, M., 2018.

Antidepressants and suicidal behaviour in late life: A prospective population-based study

of use patterns in new users aged 75 and above. European journal of clinical pharmacology,

74(2), pp.201-208.

Orgeta, V., Brede, J. and Livingston, G., 2017. Behavioural activation for depression in older

people: systematic review and meta-analysis. The British Journal of Psychiatry, pp.bjp-bp.

Qiu, W. Q., Himali, J. J., Wolf, P. A., DeCarli, D. C., Beiser, A., and Au, R., 2017. Effects of

white matter integrity and brain volumes on late life depression in the Framingham Heart

Study. Int J Geriatr Psychiatry, 32: 214–221. doi: 10.1002/gps.4469.

Schaakxs, R., Comijs, H.C., Lamers, F., Beekman, A.T.F. and Penninx, B.W.J.H., 2017. Age-

related variability in the presentation of symptoms of major depressive disorder.

Psychological medicine, 47(3), pp.543-552.


Abnormal Grief Reaction

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Suicide in the elderly

MCQs

1. The features suggestive of pseudo-dementia would include all except:

A. There is a long history of memory impairment and difficult with ADLs

B. The patient complains of poor memory

C. Assessment of cognitive function often results in 'don't know answers'

D. The onset is fast

E. There is often a history of depression or an identifiable precipitant

2. An 84 year old lady presents with severe depression. She had a myocardial infarction 3 months

ago and her QTc is 490ms. Which antidepressant is the best choice?

A.Sertraline

B.Mirtazapine

C.Paroxetine

D.Citalopram

E.Duloxetine

3. An 87 year old man has lost his wife recently. Which of the following clinical features would most

suggest that this was an abnormal grief reaction?

A. Loss of sleep

B. Loss of appetite

C. Laying the dining table for the deceased at meal times

D. Anxiety

E. Suicidal ideation

4. Which is not a feature of serotonin syndrome?

A. Blurred vision

B. Confusion

C. Akathisia

D. Elevated white cells

E. Hypomimia

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5. Which rating scale is most helpful in detecting depression in people with dementia?

A. Cornell

B. MMSE

C. GDS

D. AMTS

E. Hamilton Rating Scale

6. You have a patient on lithium with a consistently elevated blood pressure. What is your most

appropriate action?

A. Start amiloride

B. Lithium must be stopped

C. Start furosemide

D. Start lisonopril

E. Start candesartan


Websites:

CPD Online Modules: Quick bite: Suicide in the elderly, treating depression in later life,

bereavement

Journal Papers:

Cattell, H. 2000. Suicide in the elderly. Advances in Psychiatric Treatment, 6(2), 102-108.

Draper, B. M. 2014. Suicidal behaviour and suicide prevention in later life. Maturitas, 79(2),

179-183.

McDonald, W.M., Hermida, A., Petrides, G. and Kellner, C., 2017. Update on New Research

and the Clinical Practice of ECT in the Elderly. The American Journal of Geriatric Psychiatry,

25(3), p.S25.

Richards, F., & Curtice, M. 2011. Mania in late life. Advances in Psychiatric Treatment, 17(5),

357-364.

Rodda, J., Walker, Z., & Carter, J. 2011. Depression in older adults. BMJ, 343.

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Books:

Jacoby R, Oppenheimer C, Dening T. (eds.) 2008. The Oxford Textbook of Old Age Psychiatry.

Oxford University Press: Oxford. Chapters on depression, suicide and manic syndromes.

Stahl, SM, 2014. Prescriber's Guide: Stahl's Essential Psychopharmacology, 6th edition

Cambridge Medicine.

Taylor, D., Barnes, T., Young, A., 2018. The Maudsley Prescribing Guidelines in Psychiatry,

13th edition. Blackwell-Wiley.(sections on mood disorders including prescribing in older

adults)



65

Session 6: Psychosis in the Older Person

Learning Objectives

The overall aim of the sessions is for the trainees to gain an overview of psychosis in later life.


o Understand the epidemiology of psychosis and psychotic disorders in the older person.

o Understand the aetiology of psychosis in the older person.

o Understand how psychosis presents in the older person, the classification of disorders,

the basic assessment process and the principles of treatment of psychosis and psychotic

disorders

Curriculum Links

Old Age Section of the MRCPsych Curriculum: 8.3, 8.4, 8.5, 8.6, 8.7, 8.8, 8.9

Expert Led Session


Case Presentation

A case to be presented which highlights an older person presenting with possible or probable

psychosis. Please consider the learning objectives above.


Almeida, O.P., Ford, A.H., Hankey, G.J., Yeap, B.B., Golledge, J. and Flicker, L., 2018. Risk of

dementia associated with psychotic disorders in later life: the health in men study

(HIMS). Psychological medicine, pp.1-11.

Howard, R., Cort, E., Bradley, R., Kelly, L., Bentham, P., Ritchie, C., Reeves, S., Fawzi, W.,

Livingston, G., Sommerlad, A. and Oomman, S., 2018. Antipsychotic treatment of very

late-onset schizophrenia-like psychosis: a randomised controlled double-blind trial. The

Lancet Psychiatry.

Louhija, U.M., Saarela, T., Juva, K. and Appelberg, B., 2017. Brain atrophy is a frequent

finding in elderly patients with first episode psychosis. International psychogeriatrics,

29(11), pp.1925-1929.

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Stafford, J., Howard, R. and Kirkbride, J.B., 2017. The incidence of very late-onset

psychotic disorders: a systematic review and meta-analysis, 1960–2016. Psychological

medicine, pp.1-12.


Factors Affecting the Choice of Antipsychotic in the Elderly

Comparison of the presentation of schizophrenia in adults vs older adults

MCQs

1. A 76 year old lady is diagnosed with ‘late paraphrenia’. Which of the following delusions is the

GP most likely to find?

A. Hypochondriachal

B. Delusions of misidentification

C. Religious delusions

D. Delusions of reference

E. Persecutory delusions

2. Very late onset schizophrenia is characterised by onset after:

A. 40 years

B. 60 years

C. 65 years

D. 70 years

E. 80 years

3. Which antipsychotic is most likely to cause postural hypotension:

A. Aripiprazole

B. Risperidone

C. Haloperidol

D. Quetiapine

E. Sulpiride

67

4. Which of the following drugs should not be used in renal failure?

A. Amisulpride

B. Aripiprazole

C. Chlorpromazine

D. Olanzapine

E. Quetiapine

5. ‘Sensitivity to antipsychotics’ is linked to which disorder?

A. Alzheimer’s Disease

B. Dementia with Lewy Bodies

C. Late onset Schizophrenia

D. Organic mood disorder

E. Huntington’s Disease


Websites:

RCPsych. The management of hyperprolactinemia in psychiatric practice, psychotropic

medication and the heart

Journal Papers:

Bartels, S.J., Fortuna, K.L. and Naslund, J.A., 2018. Serious Mental Disorders in Older

Adults: Schizophrenia and Other Late‐Life Psychoses. Aging and Mental Health, pp.241-

280.

Howard, R., Rabins, P. V., Seeman, M. V., & Jeste, D. V. 2000. Late-onset schizophrenia

and very-late-onset schizophrenia-like psychosis: an international consensus. American

Journal of Psychiatry.

Karim, S., & Byrne, E. J. 2005. Treatment of psychosis in elderly people. Advances in

Psychiatric Treatment, 11(4), 286-296.

Kyomen, H. H., & Whitfield, T. H. 2000. Psychosis in the elderly. American Journal of

Psychiatry.

68

Van Assche, L., Morrens, M., Luyten, P., Van de Ven, L. and Vandenbulcke, M., 2017. The

neuropsychology and neurobiology of late-onset schizophrenia and very-late-onset

schizophrenia-like psychosis: A critical review. Neuroscience & Biobehavioral Reviews.

Zharkova, T. and Kyomen, H.H., 2018. Treatment Dilemmas: Managing Antipsychotic

Medication Risks in Elderly with Major Neurocognitive Disorder, Stroke and Psychosis.

The American Journal of Geriatric Psychiatry, 26(3), pp.S100-S101.

Guidelines:

Psychosis and schizophrenia in adults: prevention and management. NICE guidelines

[CG178]

Books:

Jacoby R, Oppenheimer C, Dening T. (eds.) 2008. The Oxford Textbook of Old Age

Psychiatry. Oxford University Press: Oxford. Chapter on late onset schizophrenia.


Cambridge Medicine.

Taylor, D., Barnes, T., Young, A., 2018. The Maudsley Prescribing Guidelines in Psychiatry,

13th edition. Blackwell-Wiley.



69

Session 7: Anxiety Disorders in the Older Person

Learning Objectives

The overall aim of the sessions is for the trainees to gain an overview of anxiety in later life.


o Understand the epidemiology of anxiety and anxiety disorders in the older person.

o Understand the aetiology of anxiety and anxiety disorders.

o Understand how anxiety disorders present in the older person, their classification, the

basic assessment process and the principles of treatment of anxiety and anxiety

disorders.

Curriculum Links

Old Age Section of the MRCPsych Curriculum: 8.3, 8.4, 8.5, 8.7, 8.8, 8.9, 8.10

Expert Led Session


Case Presentation

A case to be presented which highlights an older person presenting with anxiety. Please

consider the learning objectives above.


Burroughs, H., Bartlam, B., Ray, M., Kingstone, T., Shepherd, T., Ogollah, R., Proctor, J.,

Waheed, W., Bower, P., Bullock, P. and Lovell, K., 2018. A feasibility study for Non-

Traditional providers to support the management of Elderly People with Anxiety and

Depression: The NOTEPAD study Protocol. Trials, 19(1), p.172.

Contrera, K.J., Betz, J., Deal, J., Choi, J.S., Ayonayon, H.N., Harris, T., Helzner, E., Martin, K.R.,

Mehta, K., Pratt, S. and Rubin, S.M., 2017. Association of hearing impairment and anxiety

in older adults. Journal of aging and health, 29(1), pp.172-184.

Crocco, E.A., Jaramillo, S., Cruz-Ortiz, C. and Camfield, K., 2017. Pharmacological

Management of Anxiety Disorders in the Elderly. Current treatment options in psychiatry,

4(1), pp.33-46.

70

Bulbena‐Cabré, A., Rojo, C., Pailhez, G., Buron Maso, E., Martín‐Lopez, L.M. and Bulbena,

A., 2018. Joint hypermobility is also associated with anxiety disorders in the elderly

population. International journal of geriatric psychiatry, 33(1), pp.e113-e119.


The Use of Lithium in the Elderly

Reversible Medical Causes of Anxiety in the Elderly

MCQs

1. Regarding the diagnosis of anxiety:

A. MMSE is a useful tool

B. The ‘Worry Scale’ is a carer’s report tool in depression

C. HADS is a useful tool

D. Cornell is the most useful scale in the over 75s

E. None of the above are true

2. A diagnosis of Generalised Anxiety Disorder can only be made after how long?

A. 6 months

B. 3 months

C. 6 weeks

D. 3 weeks

E. 1 year

3. In the elderly, anxiety is most closely linked to which condition?

A. Schizophrenia

B. Depression

C. Alzheimer’s Disease

D. Diogenes Syndrome

E. Delusional Disorders

4. A 78 year old lady has recently been started on a new medication for anxiety but has developed

hyponatraemia. Which of the following has most likely caused this?

A. Lamotrigine

71

B. Risperidone

C. Lithium

D. Citalopram

E. Quetiapine

5. Approximately how many adults aged 65 and older experience a diagnosable anxiety disorder

A. 4%

B. 11%

C. 15%

D. 21%

E. 30%


Website:

RCPsych CPD online: Pharmacological management of anxiety disorders

Journal Papers:

Badrakalimuthu, V. R., & Tarbuck, A. F. 2012. Anxiety: a hidden element in dementia.

Advances in psychiatric treatment, 18(2), 119-128.

Bleakley, S., & Davies, S. J. 2014. The pharmacological management of anxiety disorders.

Progress in Neurology and Psychiatry, 18(6), 27-32.

Hoge, E. A., Ivkovic, A., & Fricchione, G. L. 2012. Generalized anxiety disorder: diagnosis

and treatment. BMJ: British Medical Journal, 345(7885).

Morderkar, A., and Spence, S. (2008). Personality disorder in older people: how common

is it and what can be done? Advances in Psychiatric Treatment, 14: 71-77.

Guidelines:

Baldwin, D. S., Anderson, I. M., Nutt, D. J., Allgulander, C., Bandelow, B., den Boer, J. A., ...

& Malizia, A. 2014. Evidence-based pharmacological treatment of anxiety disorders, post-

traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005

guidelines from the British Association for Psychopharmacology. Journal of

Psychopharmacology, 28(5), 403-439.

72

NICE: Generalised anxiety disorder and panic disorder in adults: management. NICE

guidelines [CG113].

Books:

Jacoby R, Oppenheimer C, Dening T. (eds.), 2008. The Oxford Textbook of Old Age Psychiatry.

Oxford University Press: Oxford. Chapter on anxiety disorders in older people.


Cambridge Medicine.


edition. Blackwell-Wiley, section on depression & anxiety).


Disorders : Clinical Descriptions and Diagnostic Guidelines. WHO

73

Session 8: Medico Legal Issues in Old Age Psychiatry

Learning Objectives

The overall aim of the session is for students to gain an overview of key legislation relating to

the care of older adults.

By the end of the sessions trainees should:

o Understand the interface between the MCA and MHA.

o Understand the principles to apply when assessing capacity, including the 2-stage test.

o Understand the principles behind Deprivation of Liberty Safeguards (DoLS).

o Understand the applicability of Guardianship.

o Gain an understanding of a Lasting Power of Attorney (LPA).

o Understand the principles of testamentary capacity.

Curriculum Links

Old Age Section of the MRCPsych Curriculum: 8.1, 8.2, 8.3, 8.5

Expert Led Session


Case Presentation

A case to be presented which highlights an interesting medico legal issue in a patient seen.



Brenkel, M., Shulman, K., Hazan, E., Herrmann, N. and Owen, A.M., 2017. Assessing

Capacity in the Elderly: Comparing the MoCA with a Novel Computerized Battery of

Executive Function. Dementia and geriatric cognitive disorders extra, 7(2), pp.249-256.

Cole, J., Kiriaev, O., Malpas, P. and Cheung, G., 2017. ‘Trust me, I’m a doctor’: a

qualitative study of the role of paternalism and older people in decision-making when

they have lost their capacity. Australasian Psychiatry, 25(6), pp.549-553.

74

De Simone, V., Kaplan, L., Patronas, N., Wassermann, E. M., & Grafman, J. 2017. Driving

abilities in frontotemporal dementia patients. Dementia and geriatric cognitive

disorders, 23(1), 1-7.

Hinsliff‐Smith, K., Feakes, R., Whitworth, G., Seymour, J., Moghaddam, N., Dening, T. and

Cox, K., 2017. What do we know about the application of the Mental Capacity Act (2005)

in healthcare practice regarding decision‐making for frail and older people? A

systematic literature review. Health & social care in the community, 25(2), pp.295-308.


Legal aspects of covert medication

Lasting power of attorney - details of the application process.

MCQs

1. Which is of the following is not a core principle of MCA 2005

A. Everyone is assumed to have capacity

B. All Practical steps needs to be taken to help the person to make the decision

C. Any decision made on behalf of a person lacking capacity should be in their best interests

D. Person cannot make a unwise decision

E. Decision made on behalf of a person lacking capacity should be least restrictive

2. A person should be able to do the following to be able to make a decision:

A. Understanding the information relevant to the decision

B. Retain the information

C. Weighing up the pros and cons of the decision

D. Communicate the decision

E. All of the above

3. Lasting Power of Attorney (LPA) can potentially cover the following area:

A. Property

B. Finances

75

C. Health care decisions

D. Personal welfare decisions such as where a person lives

E. All of the above

4.Which of the following is false regarding the legal rights of an attorney with a LPA for healthcare

decisions:

A. Cannot consent to or refuse treatment if the donor has capacity to make the particular healthcare decision

B. Cannot make a decision relating to life-sustaining treatment if it is not explicitly specified in LPA

C. Cannot demand medical treatment that healthcare staff do not believe is necessary or appropriate

D. Cannot consent or refuse treatment if donor is detained under the Mental Health Act

E. Need not always make decisions in the donor’s best interests.

5. The following are true about Deprivation of Liberty Safeguards(DOLS) except:

A. The safeguards apply to only people who lack capacity

B. A DOLS authorisation in itself authorises specific treatment

C. A person can only be deprived of their liberty if it’s in their best interests to protect them from harm

D. DOLS can only be authorised if it is a proportionate response to the likelihood and seriousness of the harm

E. Applies only to people aged 18 and over


Websites

RCPsych CPD modules

Competence, capacity and decision-making ability in mental disorder, mental Capacity Act

2005: Part 1, mental Capacity Act 2005: Part 2

Other resources:

39 Essex Street http://www.39essex.com/practice-area/court-of-protection-barristers/

GMC – Capacity & consent tool. http://www.gmc-uk.org/news/29321.asp

Lucy Series https://thesmallplaces.wordpress.com/author/lucyseries/ (interesting discussion and commentary on all things related to legal capacity and human rights)

http://www.39essex.com/practice-area/court-of-protection-barristers/

http://www.gmc-uk.org/news/29321.asp

https://thesmallplaces.wordpress.com/author/lucyseries/

76

Mental Capacity Act Code of Practice (https://www.gov.uk/government/publications/mental-capacity-act-code-of-practice).

Journal Articles:

Abdool, R., 2017. Covert medication: legal, professional, and ethical considerations. The Journal of Law, Medicine & Ethics, 45(2), pp.168-169.

Braye, S., Orr, D. and Preston-Shoot, M., 2017. Autonomy and protection in self-neglect work: the ethical complexity of decision-making. Ethics and Social Welfare, pp.1-16.

Jacoby, R., & Steer, P., 2007. How to assess capacity to make a will. British Medical Journal, 7611, 155

O'Shea, T., 2018. A civic republican analysis of mental capacity law. Legal Studies, 38(1), pp.147-163. http://eprints.whiterose.ac.uk/116359/

Royal College of Psychiatrists, 2004. College statement on Covert Administration of Medicines. Psychiatric Bulletin. 28(10), pp385-386

Wilson, S., & Pinner, G. 2013. Driving and dementia: a clinician's guide. Advances in psychiatric treatment, 19(2), 89-96.

Books and other resources:

Dalley, G., Gilhooly, M., Gilhooly, K., Harries, P. and Levi, M., 2017. Financial Abuse of People Lacking Mental Capacity: A Report to the Dawes Trust. https://bura.brunel.ac.uk/bitstream/2438/15255/1/Fulltext.pdf

Jacoby R, Oppenheimer C, Dening T. (eds.) 2000. The Oxford Textbook of Old Age

Psychiatry. Oxford University Press: Oxford. Chapters 41-44 cover capacity, legal

frameworks and driving in later life.

The Law Society. 2015. Deprivation of liberty: a practical guide. The Law Society. https://www.lawsociety.org.uk/support-services/advice/articles/deprivation-of-liberty/

https://www.gov.uk/government/publications/mental-capacity-act-code-of-practice

http://eprints.whiterose.ac.uk/116359/

https://bura.brunel.ac.uk/bitstream/2438/15255/1/Fulltext.pdf

https://www.lawsociety.org.uk/support-services/advice/articles/deprivation-of-liberty/

77

Curriculum Mapping

Section Topic Covered by

LAP RAP LR

8.1 Demographic population changes in the UK and

Worldwide

8.2 District Service Provision

8.3 Specialist aspects of assessment of mental health in

older people

8.4 Psychological aspects of Physical Disease

8.5

Prevalence/ incidence, clinical features, differential

diagnosis, aetiology, management and prognosis of

the common disorders occurring in later life

8.6 Suicide and attempted suicide in old age

8.7 Psychiatric aspects of personality in old age

8.8 Psychotherapy with older adults

8.9 Bereavement and adjustment disorders

8.10 Sleep disorder in later life

8.11 Psychosexual disorders in old age

KEY: LAP = Local Educational Programme

RAP = Regional Academic Programme

LR = Learning Resources

78

CAMHS SEMESTER 3:

Session 1: Assessment in Child and Adolescent Psychiatry

Learning Objectives

Undertake assessments of children and young people; to communicate effectively with

children and young people across the age range; to take a developmental history; to

formulate and prepare a plan and identify appropriate interventions.

Describe how the emphasis of assessments in CAMHS may be different to that in Adult Mental

Health.

Curriculum Links

Child Psychiatry:

10.1 10.2 10.3 10.4 10.5 10.6

Expert Led Session

This should include consideration of room setting e.g. with appropriate toys and other

developmentally appropriate materials/approaches, the differences and similarities between

adult and child psychiatry, pointers on taking a developmental history, ICD 10, bio-

psychosocial formulation and risk assessment

Case Presentation

To highlight multi-disciplinary/multiagency nature of work (should include discussion of

school observation/assessment)

To highlight bio-psychosocial formulation

To highlight Multi-axial formulation in Child and Adolescent Psychiatry

Those trainees who are not currently in a CAMHS post should contact their local CAMHS team

for the suitable case for presentation.


Practitioner Review: Self-harm in adolescents, Ougrin D, Tranah T, Leigh E, Taylor L, Asarnow

JR. Journal of Child Psychology and Psychiatry, 2012, 53:4,337– 350, April 2012.

79

The Clinical Application of the Biopsychosocial Model in Mental Health: A Research Critique:

Álvarez, AS; Pagani, M; Meucci, P (2012) American Journal of Physical Medicine &

Rehabilitation, 2012, 91:13, S173–S180

‘555’ Topics (1 slide on each topic with no more than 5 bullet points)

Risk assessment domains and formulation

Local Safeguarding process and organisational structure

Conduct Disorder – Diagnostic Criteria /Management

MCQs

1. Patient should routinely have a neurological examination if they present with all except:

A. History of an episode of fainting

B. History of seizures

C. Developmental delay

D. Dysmorphic features

E. Abnormal gait

2. A physical risk assessment for patients with Anorexia Nervosa should include all except:

A. Assessment of BMI and weight

B. Assessment of heart rate

C. Assessment of temperature

D. Assessment of hydration status

E. Assessment of EEG abnormalities

3. During an assessment of a 14 year old patient with depression in primary care, which of the

following would prompt you to refer to tier 2 or 3 CAMHS:

A. Mild depression in those who have not responded to interventions in tier 1 after 2-3 months

B. Active suicidal plans

C. Referral requested by the young person

D. Moderate to severe depression

E. All of the above

4. Assessment of ADHD commonly include all except:

A. ADOS

80

B. School observations

C. History from parents/carers

D. Connors assessment

E. History from patient

5. Mental state examination of a 15 year old patient should include all the following except:

A. Assessment of appearance and behaviour

B. Family history

C. Assessment of speech

D. Assessment of insight

E. Assessment of cognition

6. The multi axial diagnostic formulation scheme of ICD 10 include:

A. Axis III: psychiatric disorder

B. Axis II: medical conditions

C. Axis IV: adaptive functioning

D. Axis I: psychiatric disorder

E. Axis VI: medical conditions

7. An assessment of a 3 year old with suspected Autistic Spectrum Disorder must include:

A. A home visit

B. A detailed mental state examination

C. Observation of the child interacting with others

D. All of the above A-C

E. None of the above A-C

8. CAMHS assessments in patients with speech delay should routinely include all except:

A. Family tree

B. Family history of ASD / Aspergers

C. Developmental history

D. Details of whether the patient had the combined MMR vaccine

E. Medical history

9. The presence of a disorder can be explained in terms of all except:

A. Predisposing factors

B. Precipitating factors

81

C. Perpetuating factors

D. Petulant factors

E. Protective factors

10. In regards to initial CAMHS assessment of children under 5 with speech delay:

A. You should not see them without the presence of their parent/carer in the room

B. You should aim to get the child sat down in a chair for the majority of the assessment

C. You should observe them playing and play too if appropriate

D. You should avoid difficult topics

E. You should use more directed questioning


Reading Resources

1. Managing Self Harm in Young People

http://www.rcpsych.ac.uk/files/pdfversion/CR192.pdf

2. Practice Parameters for the Psychiatric Assessment of Children and Adolescents. J. Am. Acad.

Child Ado/esc. Psychiatry. 1995,31:1386-1402. J. Am. Acad. Child Ado/esc. Psychiatry. 1997.36(10

Supplement):45-20S.

3. Practice Parameter for the Assessment of the Family. J. Am. Acad. Child

Adolesc. Psychiatry, 2007;46(7):922Y937

4. Wolpert, M., Ford, T., Trustam, E., Law, D.,Deighton, J., Flannery, H., and Fugard R. J. B. (2012)

Patient-reported outcomes in child and adolescent mental health services (CAMHS): Use of

idiographic and standardized measures, Journal of Mental Health, 21:2, 165-173

Books


Blackwell

Child and Adolescent Psychiatry: A Developmental Approach. 4th ed. Jeremy Turk, Philip

Graham, Frank C Verhulst 2007. Oxford University Press

NICE clinical guideline 133 Self-harm: longer-term management Clinical case scenarios for

health and social care professionals

http://www.rcpsych.ac.uk/files/pdfversion/CR192.pdf

http://www.amazon.co.uk/s/ref=ntt_athr_dp_sr_1?_encoding=UTF8&field-author=Robert%20Goodman&search-alias=books-uk

http://www.amazon.co.uk/s/ref=ntt_athr_dp_sr_2?_encoding=UTF8&field-author=Stephen%20Scott&search-alias=books-uk

82

E-Learning

RCPsych TRon Module

1. Overview of child and adolescent psychiatry

Assessment and treatment of children and adolescents; disorders usually first diagnosed in

infancy, childhood and adolescence; developmental disabilities; effects of adult mental illness

on children and young people, including effects of maternal mental health; effect of

depression on parental functioning and interactions and impact on child development and

functioning; cultural variations in aetiology and management; short- and long-term effects of

negative life events on development and functioning e.g. maternal loss, child abuse, chronic

or life-threatening illness; interaction between psychiatric disorder and physical illness in

children and adolescents; physical presentation of psychiatric disorder and psychiatric

presentation of physical disorder.

(Syllabus: 10 – introduction, 10.1, 10.2, 10.5)

1. The neurological examination

The neurological examination is often approached with trepidation by psychiatrists but can be

done quickly and reliably with practice. The best approach is to keep doing them as often as

possible, but in order for them to be useful, and conducted without fear, it's advantageous to

have an understanding of what you are trying to achieve. In this podcast Professor Adam

Zeman, Professor of Cognitive and Behavioural Neurology at the University of Exeter Medical

School, explains to Dr Raj Persaud how to conduct a neurological examination.

http://www.psychiatrycpd.org/default.aspx?page=20900

Journal Articles

The Child and Adolescent Psychiatric Assessment (CAPA).

Angold A, Prendergast M, Cox A, Harrington R, Simonoff E, Rutter M.

Psychol Med. 1995 Jul;25(4):739-53.


83

Session 2: Attention Deficit Hyperactivity Disorder (ADHD)

Learning Objectives

Describe signs, symptoms and differential diagnosis of Attention Deficit Hyperactivity

Disorder, and treatment options.

Curriculum Links

ADHD:

10.1 10.2 10.3 10.6 10.7 10.8.3.1 10.8.3.2 10.8.3.3 10.8.3.4 10.8.3.5

Expert Led Session

This should consider aspects of assessment, formulation, evidence base, NICE guidelines of

assessment and intervention, differential diagnosis, co-morbidities, consequences of non-

treatment and impact on substance misuse.

Case Presentation

To highlight points in assessment, use of questionnaires, use of Quantified behavioural (Qb)

test, multisource information gathering, differential diagnoses and formulation.


Treatment of Children With Attention-Deficit/Hyperactivity Disorder (ADHD) and Irritability:

Results From the Multimodal Treatment Study of Children With ADHD (MTA) Lorena

Fernandez de la Cruz, PhD, Emily Simonoff, MD, James J. McGough, MD, Jeffrey M. Halperin,

PhD, L. Eugene Arnold, MD, MEd, Argyris Stringaris, MD, PhD, MRCPsych J Am Acad Child

Adolesc Psychiatry 2015;54(1):62–70.

Long-Term Outcomes of ADHD: Academic Achievement and Performance L. Eugene Arnold1,

Paul Hodgkins2,3, Jennifer Kahle4, Manisha Madhoo5, and Geoff Kewley6. Journal of

Attention Disorders 1–13 © 2015 SAGE Publications

Study of user experience of an objective test (QbTest) to aid ADHD assessment and medication

management: a multi-methods approach

Charlotte L. Hall, Althea Z. Valentine, Gemma M. Walker, Harriet M. Ball, Heather Cogger,

David Daley, Madeleine J. Groom, Kapil Sayal and Chris Hollis

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BMC PsychiatryBMC series – open, inclusive and trusted201717:66

https://doi.org/10.1186/s12888-017-1222-5© The Author(s). 2017


Medical treatment in ADHD, types of medication, pharmacokinetics, pharmacodynamics, side

effect profile.

Formal assessment tools in ADHD assessment; pros and cons.

NICE Guidelines for ADHD .

MCQs

1. A four year old boy is brought to clinic with his parents. They report that he is inattentive at

school, will not sit and play with his siblings at home and on one occasion let go of his mother’s hand

whilst shopping and ran out into the road. Following assessment and diagnosis, what would your

initial management step be?

A. Refer patient for individualised CBT

B. Refer family for Family Therapy

C. Refer family to parent training and education sessions

D. Commence 5mg methylphenidate daily, titrating up weekly until improvement is seen


3. The parents of a 5 year old girl recently diagnosed with ADHD have cancelled their second group

parent training and education session. They tell you this is because their 11 year old son has learning

disabilities and is wheelchair bound. They have no extended family or close friends to help with child

care arrangements on the days required. What would you advise?

A. Offer to commence medication for the patient as they will not be able to attend the parent

training and education sessions

B. Offer to hold individualised parent training and education sessions on a day that would better suit

them

C. Discharge the family from your case load as they have missed two consecutive appointments

D. Ask them to contact children and family services to arrange child care whilst they attend the

training sessions


85

4. You have assessed a 7 year old boy with suspected ADHD in clinic. You would like to get further

information about his behaviour in school from his teachers. Which of the following regarding

consent to discuss the case with school is correct?

A. You will need to document that you have obtained consent from the patient’s parents or carers

before you contact the school for information

B. You will need to document that you have obtained consent from the patient before you contact

school for information

C. You don’t need consent to request information with school

D. You don’t need consent to request information from school as long as you don’t discuss

treatment with them

E. You will need verbal consent from the patient’s parents or carers before you contact the school

for information

5. Following assessment of an 8 year old boy, you diagnose severe ADHD with severe impairment of

functioning in both social and academic domains. What would be your initial step in management?

A. Refer family to Family Therapy

B. Refer patient for CBT

C. Refer family to parent training and education

D. Commence the patient on medication


6. You wish to complete a pre-drug treatment assessment on a 7 year old girl with diagnosed severe

ADHD. Which of the following is NOT routinely required?

A. Record of height and weight plotted on centile chart

B. ECG

C. Heart rate and blood pressure plotted on a centile chart

D. Mental health and social assessment

E. Assessment of cardiovascular symptoms

7. You have been seeing a 12 year old boy with ADHD. Parent training/education sessions proved

ineffective. With the parents’ consent you commenced the patient on low dose methylphenidate,

5mg daily. At the following review the methylphenidate is not working and the patient’s behaviour

continues to be impairing his social and academic functioning. You are happy that your diagnosis

remains correct. He does not describe any side effects on questioning. What would your next step in

treatment be?

86

A. Consider commencing low dose bupropion as an adjunct to methylphenidate

B. Consider stopping methylphenidate and commencing Atomoxetine

C. Stop medication and review diagnosis again

D. Consider stopping methylphenidate and commencing low dose dexamfetamine

E. Consider increasing the dose of methylphenidate

8. NICE guidance suggests that modified release preparations of methylphenidate should be

considered for all the following reasons, except:

A. Convenience

B. To increase adherence

C. To help in facilitating schools who cannot safely store medication

D. Patients with co-morbid tic disorder

E. Reducing stigma

9. ICD 10 diagnosis of hyperkinetic disorder includes all the following criteria, except:

A. Inattention, hyperactivity and/or impulsivity persistent for at least 3 months

B. Symptoms are pervasive across situations

C. Symptoms are not caused by other disorders such as autism or affective disorders

D. Symptoms cause impairment in social, academic or occupational functioning.

E. All of the above

10. Adverse effects of Methylphenidate can include all, except:

A. Raised blood pressure

B. Anorexia

C. Insomnia

D. Growth acceleration

E. Exaggeration of tic disorders


Books

Rutter's Child and Adolescent Psychiatry, Fifth Edition.

Sir Michael Rutter , Dorothy Bishop, Daniel Pine, Steven Scott , Jim S. Stevenson, Eric A.

Taylor, Anita Thapar

http://www.amazon.co.uk/s/ref=ntt_athr_dp_sr_1?_encoding=UTF8&field-author=Sir%20Michael%20Rutter&search-alias=books-uk

http://www.amazon.co.uk/s/ref=ntt_athr_dp_sr_2?_encoding=UTF8&field-author=Dorothy%20Bishop&search-alias=books-uk

http://www.amazon.co.uk/s/ref=ntt_athr_dp_sr_5?_encoding=UTF8&field-author=Jim%20S.%20Stevenson&search-alias=books-uk

http://www.amazon.co.uk/s/ref=ntt_athr_dp_sr_6?_encoding=UTF8&field-author=Eric%20A.%20Taylor&search-alias=books-uk


http://www.amazon.co.uk/s/ref=ntt_athr_dp_sr_7?_encoding=UTF8&field-author=Anita%20Thapar&search-alias=books-uk

87


Blackwell

Attention Deficit Hyperactivity Disorder” by Professor Russell Barkley.

E-Learning

Attention deficit hyperactivity disorder in children and adolescents. In this podcast Professor

Heidi Feldman, from the Stanford University School of Medicine, talks with Dr Raj Persaud on

attention deficit–hyperactivity disorder (ADHD) in children and adolescents; referring to her

recent clinical review of the disorder published in the New England Journal of Medicine.


Neurobiology of ADHD, by Dr Katia Rubia

http://www.psychiatrycpd.org/podcasts/neurobiologyofadhd.aspx

Guidelines

Attention deficit hyperactivity disorder (ADHD) (CG72)

http://www.nice.org.uk/guidance/index.jsp?action=byTopic&o=7281

Further Reading Resources

Evidence-based guidelines for the pharmacological management of attention deficit hyperactivity

disorder: Update on recommendations from the British Association for Psychopharmacology Blanca

Bolea-Alamañac1, David J Nutt2, Marios Adamou3, Phillip Asherson4, Stephen Bazire5, David

Coghill6, David Heal7, Ulrich Müller8, John Nash9, Paramalah Santosh10, Kapil Sayal11, Edmund

SonugaBarke12 and Susan J Young2 for the Consensus Group

Journal of Psychopharmacology 1–25, 2014

Downloaded from jop.sagepub.com at University of Bristol Library on February 15, 2014




http://www.psychiatrycpd.org/podcasts/neurobiologyofadhd.aspx


88

Session 3: Autism Spectrum Disorder (ASD)

Learning Objectives

Signs and Symptoms of Autism spectrum disorder including the triad of impairments

Diagnostic criteria for diagnosis of ASD including the DSM 5 and ICD 10

Causes of ASD and psychological theories of ASD including Theory of mind, Central

coherence deficit and executive function.

Interventions in ASD

Curriculum Links

Autism Spectrum Disorders:

10.8.8.1 10.8.8.2 10.8.8.3 10.8.8.4 10.8.8.5

Expert Led Session

To cover Aetiological theories of ASD, NICE guidelines in ASD, Interventions in ASD

Case Presentation

This should include detailed assessment which includes developmental history, information

from multiple sites and multiaxial formulation (ICD 10 or DSM 5 criteria used), cover signs and

symptoms, triad of impairment and interventions offered


Huerta, M., Bishop, S. L., Duncan, A., Hus, V., & Lord, C. (2012). Application of DSM-5 criteria

for autism spectrum disorder to three samples of children with DSM-IV diagnoses of

pervasive developmental disorders. American Journal of Psychiatry, 169(10), 1056-1064.

McPartland, J. C., Reichow, B., & Volkmar, F. R. (2012).

Risi, Lord, Gotham, Corsello, Chrysler et al. (Sept. 2006) Zwaigenbaum, L., Bryson, S., Lord,

C., Rogers, S., Carter, A., Carver, L., & Yirmiya, N. (2006). Combining Information from

Multiple Sources in the Diagnosis of Autism Spectrum Disorders. Journal of Am Academy of

Child & Adolescent Psychiatry, 45(9) 1094-1103

89

Berihun Assefa Dachew (a1), Abdullah Mamun (a2), Joemer Calderon Maravilla (a3) and

Rosa Alati Pre-eclampsia and the risk of autism-spectrum disorder in offspring: meta-analysis

(a3) Br J Psychiatry. 2018 Mar;212(3):142-147. doi: 10.1192/bjp.2017.27. Epub 2018 Jan 24.

Jonathan Green,a,d,* Tony Charman,e Helen McConachie,f Catherine Aldred,a,g Vicky

Slonims,h Pat Howlin,i Ann Le Couteur,f Kathy Leadbitter,a Kristelle Hudry,e Sarah Byford,j

Barbara Barrett,j Kathryn Temple,f Wendy Macdonald,c Andrew Pickles,b and the PACT

Consortium, Parent-mediated communication-focused treatment in children with autism

(PACT): a randomised controlled trial, Lancet. 2010 Jun 19; 375(9732): 2152–2160. doi:

10.1016/S0140-6736(10)60587-9


Interventions used in ASD and their evidence base to cover - One slide each for the following:

Behavioural intervention e.g. riding the rapids,

Speech and language interventions such as Early communication workshops, more than

words, talkability groups

Sleep disorders in ASD and interventions

Social Stories in ASD

MCQs

1. The M:F ratio of Childhood Autism is:

A. 1:1

B. 2:1

C. 3:1

D. 4:1

2. The prevalence of Autism Spectrum Conditions in a school based study in UK was:

A. 99 per 10,000

B. 70 per 10,000

C. 9 per 10,000

D. 1 per 10,000

3. The clinical features of Childhood Autism as described by Kanner include all the following except:

A. Autistic aloneness

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B. Delayed or abnormal speech

C. An obsessive desire for sameness

D. Onset in the first one year of life

4. The following are true about the aetiology of Autism except:

A. Higher concordance among MZ twins.

B. Increased rate of perinatal complications.

C. Decreased brain serotonin levels

D. Condition is 50 times more frequent in the siblings of affected persons

5. Which of the following is false for Rett’s syndrome:

A. Occurs only in boys

B. Onset between the ages of 7 and 24 months

C. Often develop autistic features and stereotypies

D. X linked dominant disorder

6. The following is false for Seizures in Autism:

A. Can affect quarter of autistic individuals with generalised learning disability

B. Affects 5% of autistic individuals with normal IQ

C. In autistic individuals with normal IQ the seizure onset is usually in early childhood.

D. In autistic individuals with generalised learning disability the seizure onset is usually in early

childhood

7. The following is true about the epidemiology of Autism:

A. Prevalence is decreasing in recent years

B. Associated with high socio-economic status

C. More common in boys

D. No hereditary risk

8. All the following are first line support for a child with childhood autism except:

A. Communication skills workshop

B. Behavioural support

C. Counselling and advice to parents

D. Anti-psychotic medication.

91

9. The following can be used in the diagnosis of a child with Autism except:

A. Autism diagnostic Inventory (ADI)

B. Autism Diagnostic Observation Schedule (ADOS)

C. Social Responsiveness Scale (SRS)

D. Check list for Autism in Toddlers (CHAT)

10. Which of the following drugs can be used in short term treatment of severe aggression in Autism

under specialist supervision:

A. Risperidone

B. Diazepam

C. Lorazepam

D. Promethazine


Books


Sir Michael Rutter , Dorothy Bishop, Daniel Pine, Steven Scott , Jim S. Stevenson, Eric

A. Taylor, Anita Thapar

Child and Adolescent Psychiatry. Robert Goodman and Stephen Scott. Third Edition,

Wiley-Blackwell

E-Learning

Autism, ethnicity and maternal immigration

Autism has been the subject of intense public and professional attention in recent years.

One of the biggest questions is what causes it. Like the discoveries made about

schizophrenia in the late 20th century, we are learning that autism too has genetic and

environmental determinants. Here Dr Daphne Keen discusses her paper (Keen et al, 2010)

which attempts to answer the question of whether maternal immigration and ethnicity,

together or in tandem, are implicated as being risk factors in young children who develop

autism.


Guidelines










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Autism in children and young people (CG128)


Useful handbook

www.nas.org.uk


http://www.nas.org.uk/

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Session 4: Anxiety and Depression

Learning Objectives

Describe how anxiety and depression may present and it’s management in childhood and

adolescence and the relevance of somatisation as a communication between children and

their carers.

Curriculum Links

Anxiety disorders including OCD:

10.8.4.1 10.8.4.2 10.8.4.3 10.8.4.4 10.8.4.5

Affective Disorders:

10.8.5.1 10.8.5.2 10.8.5.3 10.8.5.4 10.8.5.5

Expert Led Session

Variable presentations (with reference to developmental age) and differential diagnosis of

anxiety and depression, treatment options, evidence base for treatment, NICE guidelines for

depression.

Case Presentation

Key diagnostic features (anxiety/depression/mixed disorder) and highlight aspects of

management (including risk assessment) with reference to NICE guidance


Outcomes of Childhood and Adolescent Depression Richard Harrington, Hazel Fudge,

Michael Rutter, Andrew Pickles, Jonathan Hill, Arch Gen Psychiatry. 1990;47(5):465-473.

Fluoxetine, Cognitive-Behavioral Therapy, and Their Combination for Adolescents With

Depression Treatment for Adolescents With Depression Study (TADS) Randomized Controlled

trial; Treatment for Adolescents With Depression Study (TADS) Team -

JAMA. 2004;292(7):807-820.

Walkup, J.T., Albano, A.M., Piacentini, J., Birmaher, B., Compton, S.N., Sherrill, J.T., Ginsburg,

G.S., Rynn, M.A., McCracken, J., Waslick, B. and Iyengar, S., 2008. Cognitive behavioral

94

therapy, sertraline, or a combination in childhood anxiety. New England Journal of Medicine,

359(26), pp.2753-2766.

Emslie GJ1, Mayes T, Porta G, Vitiello B, Clarke G, Wagner KD, Asarnow JR, Spirito A, Birmaher

B, Ryan N, Kennard B, DeBar L, McCracken J, Strober M, Onorato M, Zelazny J, Keller M, Iyengar

S, Brent D. Am J Psychiatry. 2010 Jul;167(7):782-91. Treatment of Resistant Depression in

Adolescents (TORDIA): week 24 outcomes.


Evidence based psychological interventions in the treatment of anxiety disorders and

depression in children and adolescents.

Medication treatment in Anxiety and Depression and cautions

Nice Guidance Anxiety Disorders/Depression

MCQs

Anxiety

1. Treatment of social anxiety disorder in children and young people include all except which?

A. Group CBT

B. Individualised CBT

C. Psychoeducation

D. Skills training for parents

E. Mindfulness based therapy

2. What percentage of children and adolescents in the UK have clinically significant anxiety

disorders?

A. 2-4%

B. 4-8%

C. 8-12%

D. 12-15%

E. 15-20%

3. The following regarding specific phobias are true, except:

A. Fear of animals peaks at 2-4 years of age

B. Fear of the dark peaks at 4-6 years of age

C. Fear of war is most common in adolescents

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D. Fear of death peaks at 5-10 years of age

4. According to ICD10, separation anxiety can include all except:

A. Repeated nightmares involving separation

B. Preference to sleep away from home

C. School refusal

D. Getting up frequently at night to check on parents/carers

E. Persistent and unrealistic worry that harm will come to their parents/carers

5. The diagnosis of Generalised anxiety disorder in childhood includes all except:

A. Onset before 18 years of age

B. Multiple anxieties occurring across at least 2 situations

C. Feeling worn out and irritable

D. The anxiety must not be due to another condition or substance abuse

E. Occurring for over 12 months

Depression

1. The prevalence of depression in 11 – 15 year olds in the UK is:

A. 0.1% - 1%

B. 2% - 8%

C. 11% - 15%

D. 16% - 20%

E. 21 – 30%

2. A 12 year old girl is referred to the CAMHs team with symptoms of moderate – severe depression.

What is your first-line treatment?

A. Commence citalopram

B. Commence fluoxetine

C. Offer a specific psychological therapy

D. Admit to an inpatient unit

E. Refer back to GP for management of symptoms

3. The below are all risk factors for completed suicide except:

A. Previous suicide attempt

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B. Presence of substance/alcohol abuse

C. Presence of psychiatric disorder

D. Strong religious beliefs

E. Lack of social support

4. The use of medication in adolescents who self-harm:

A. SSRIs is recommended for reducing self-harming behaviour

B. Flupentixol is recommended for reducing self-harming behaviour

C. Is always indicated when it occurs in the context of mental illness

D. There is no evidence that medication reduces self-harming behaviour

E. Risperidone is indicated in the presence of self-harming behaviour

5. Select the correct statement from the below regarding self-harming behaviour amongst

adolescents:

A. Is common under 10 years of age

B. In community surveys, it is described by 80% of the adolescent population

C. Is more common in girls than boys

D. The majority of adolescents who self-harm wish to kill themselves

E. Only around 75% of adolescents who self-harm seek help

6. Among adolescents who self-harm, risk factors for later suicide include all except:

A. Depression

B. Unclear reason for act of deliberate self-harm

C. Psychosis

D. Female gender

E. Male gender

7. Depression in children and adolescents can present in different ways. Please match the incorrect

statement:

A. Adults – change of appetite with associated weight loss or weight gain. Children – similar to adults

B. Adults – loss of confidence, self esteem. Children – similar to adults

C. Adults – somatic syndrome may or may not be present. Children – somatic complaints are

frequent in children

D. Adults – depressive mood for most of the day. Children – mood irritable or depressed

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E. Adults – disproportionate self blame and feelings of excessive guilt or inadequacy. Children –

excessive or inappropriate guilt not usually present.

8. Please select the correct statement regarding suicide amongst children and adolescents in the UK:

A. Suicide is common under the age of 12 and gets progressively rarer after

B. There are roughly five suicides per million children aged 5 – 14 per year

C. Since the mid 1990’s suicide rates have increased by around 20% in both males and females

D. More female children than male children commit suicide

E. Most adolescent suicide are carefully planned in advance

9. You assess a 14 year old male who has self-harmed in the A&E department. All of the following

suggest serious suicidal intent except:

A. Extensive premeditation

B. Other people informed beforehand of his intention

C. Suicide note left

D. Carried out in isolation

E. He informed someone of his actions soon after the event

10. An 8 year old girl is referred to you. For the past month she has been performing poorly in

school, complains of being bored for most of the time, has run away from home on 3 occasions, and

has been taken to the GP by her mother due to generalised abdominal pain, for which no cause can

be found. She has a younger sibling who is 3 years old. Suggest the most likely diagnosis:

A. Factitious disorder

B. ADHD

C. Depression

D. Sibling rivalry disorder

E. Atypical autism


Books




Child and Adolescent Psychiatry.

Robert Goodman and Stephen Scott. Third Edition, Wiley-Blackwell









98

E-Learning

Anxiety disorders in children

Approximately one in ten children suffer from anxiety disorders, and in this podcast

Professor Ronald Rapee gives a broad overview of the different kinds of anxiety disorders

common in children. He also discusses how anxiety disorders in children compare with those

in adults, and highlights the nature of findings from epidemiological studies. He talks about

some of the steps in diagnosis, and the aetiology behind anxiety disorders, including genetic

and behavioural factors. Treatment is also touched on as well as some of the pitfalls to

beware of when diagnosing and treating anxiety in children.


Guidelines

Depression in children and young people (CG28)

Self-harm (CG16)

Post-traumatic stress disorder (PTSD) (CG26)

Obsessive compulsive disorder (OCD) and body dysmorphic disorder (BDD) (CG31)

Social anxiety disorder: recognition, assessment and treatment01 [CG159]




99

Session 5: Attachment Disorder

Learning Objectives

Describe the concept of attachment and its relevance for the mental health of children and

young people.

To understand the relevance of attachment theory to emotional development, affect

regulation and relationships across the lifespan.

To understand the different classifications of attachment, the conditions that promote

healthy attachment or otherwise and the clinical relevance of failure to develop selective

attachments.

Curriculum Links

Attachment disorders:

10.8.1.1 10.8.1.2 10.8.1.3 10.8.1.4 10.8.1.5

Expert Led Session

Should cover assessment, diagnostic challenges and MDT approach in managing attachment

disorder. Can also discuss the role of specialist LAC services.

Case Presentation

To discuss key features in history and presentation and discuss overlap with intrinsic disorders,

such as ASD/ADHD.


Quasi-autistic patterns following severe early global privation. English and Romanian

Adoptees (ERA) Study Team. Rutter M1, Andersen-Wood L, Beckett C, Bredenkamp D, Castle

J, Groothues C, Kreppner J, Keaveney L, Lord C, O'Connor TG. J Child Psychol Psychiatry. 1999

May; 40(4): 537-49.

Specificity and heterogeneity in children's responses to profound institutional privation.

Rutter ML1, Kreppner JM, O'Connor TG; English and Romanian Adoptees (ERA) study team. Br

J Psychiatry. 2001 Aug; 179:97-103.

Genetic, environmental and gender influences on attachment disorder behaviours.Minnis H1,

Reekie J, Young D, O'Connor T, Ronald A, Gray A, Plomin R. Br J Psychiatry. 2007 Jun; 190:490-

5.

Annotation: Attachment disorganisation and psychopathology: new findings in attachment

research and their potential implications for developmental psychopathology in childhood

100

Green and Goldwyn Journal of Child Psychology and Psychiatry Volume 43, Issue 7, pages

835–846, October 2002


Evidence based interventions in attachment disorder

Risk factors for attachment disorder

Comorbid diagnosis in attachment disorder

MCQs

1. The biological basis of attachment behaviour is:

A. The child developing relationships with other children

B. The mother wanting to protect her child from any harm

C. The child seeking proximity to the attachment figure

D. The mother’s instinct to rear children

E. All of the above

2. Attachment theory has been developed by:

A. Freud

B. Bowlby

C. Skinner

D. Piaget

E. Klein

3. Fearfulness and “frozen watchfulness” are part of which ICD 10 diagnosis:

A. Generalised anxiety disorder

B. Phobic anxiety disorder

C. PTSD

D. Reactive attachment disorder

E. Paranoid personality disorder

4. Select a feature that does NOT form part of Reactive Attachment Disorder (ICD 10) but points

towards Pervasive Developmental Disorders:

A. Abnormal pattern of social responsiveness that improves if child is placed in normal rearing

environment

http://onlinelibrary.wiley.com/doi/10.1111/jcpp.2002.43.issue-7/issuetoc

101

B. Aggressive responses towards their own or other’s distress

C. Restricted, repetitive interests and behaviours

D. Strongly contradictory social responses


5. Reactive Attachment Disorder of early infancy and childhood (DSM V) and Reactive Attachment

Disorder of Childhood (ICD 10) share common diagnostic criteria. Which of the following is NOT a

diagnostic feature in ICD 10:

A. Developed before age of 5 years

B. Abnormal pattern of social responsiveness

C. Other emotional disturbances such as fearfulness, sadness

D. Pathogenic care


6. Which of the following features is NOT part of Disinhibited Attachment Disorder of Childhood (ICD

10):

A. At age of 2 years it is usually manifest by clinging and diffuse, non-selectively focused attachment

behaviour

B. Early onset of diffuse attachments, continuing poor social interactions and lack of situation

specificity

C. Attention seeking behaviour often persists into middle and late childhood

D. Usually there is difficulty in forming close, confiding relationships with peers

E. Abnormal speech development including echolalia

7. Which of the following cognitive age ranges must a child reach to develop an attachment

relationship:

A. 2-5 months

B. 7-9 months

C. 2 years

D. 5 years

E. 7 years

8. What is the procedure called that assesses a child’s attachment behaviour:

A. Novel Situation Test

B. Attachment Assessment Procedure

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C. Strange Situation Procedure

D. Mother - Infant Attachment Battery


9. Symptoms of Reactive Attachment Disorder have to be present before which age:

A. 3 years

B. 9 months

C. 18 months

D. 8 years

E. 5 years

10. The current hypothesis is that Attachment Disorders develop as a result of:

A. Children having been brought up by a single parent

B. Children having had limited opportunities to form selected attachments

C. Children having received a vegetarian diet

D. Children having intrinsic difficulties in forming secure attachments

E. Children having a specific gene mutation


Books






E-Learning

Attachment and how it relates to psychiatry

Dr Helen Minnis discusses the issue of attachment in psychiatry and the importance of

attunement in the caregiving relationship, taking a look at the current controversies over

child care and giving guidance for psychiatrists on how to work with attachment difficulties.


Growing an Emotional brain: www.youtube.com/watch?v=fzn9OuBqKYs










http://www.youtube.com/watch?v=fzn9OuBqKYs

103

Journal Articles

A review of interventions in the parent-child relationship informed by attachment theory.

Broberg AG. Acta Paediatr Suppl. 2000 Sep;89(434):37-42.

‘Making and Breaking of Affectional Bonds Bowlby BJPsych 1977 130: 201-10 and 421-431 –

classic paper.

Attachment theory and Psychiatric Disorder: in John Bowlby and Attachment theory: Jeremy

Holmes

Why Love Matters – Sue Gerhardt

http://www.ncbi.nlm.nih.gov/pubmed?term=Broberg%20AG%5BAuthor%5D&cauthor=true&cauthor_uid=11055316


104

Session 6: Assessment of Mental Health Problems in Child & Adolescents with Intellectual Disability (ID)

Learning Objectives

To understand the influence of developmental factors on the presentation and treatment of

psychiatric disorders.

To understand the principles and practice of assessment, diagnosis and treatment, including

therapeutic modalities, psychoactive medication and environmental manipulations of

patients presenting with intellectual disability

Curriculum Links

Intellectual Disability:

13.1 13.2.1 13.2.2 13.3

Expert Led Session

Should cover assessment and the role of other professionals (OT, LD nurses, LD psychologist)

and specialist schools. Evidence based management strategies.

Case Presentation

To cover presentation and assessment of mental health problems of a child or young person

with ID; including how these differ from the non ID population and management strategies

(environmental, psychological and medical).

Those trainees who are not currently in a CAMHS post should contact their local CAMHS team

for the suitable case for presentation. Specifically you should identify which Consultants see

Children with Learning Disabilities, so an appropriate case can be identified well in advance


Einfeld SL, Ellis LA, Emerson E (2011) Comorbidity of intellectual disability and mental

disorder in children and adolescents: A systematic review. Journal of Intellectual and

Developmental Disability 36 (2) pp137-143.

Chadwick et al, (2008). Factors associated with the risk of behaviour problems in adolescents

with severe intellectual disabilities. Journal of Intellectual Disability research 52, (10),864-

876.

105


Cognitive assessment tools in ID (child)

Child Development assessment tools in paediatrics

Approaches to assessment in children and young people with limited communication

MCQs

1. People with intellectual disability have previously been classified as:

A. Mentally retarded

B. Learning disabled

C. Sub-normals

D. Imbeciles

E. All of the above

2. Intellectual disabilities are defined by which 3 core criteria?

A. Lower intellectual ability

B. Onset during childhood

C. Onset before the age of 8

D. Significant impairment of social or adaptive functioning

E. IQ scores are not fixed throughout life

3. Which of the following are generally accepted ranges (ICD-10, DSM-IV) for severity of ID (choose

4)?

A. Mild (IQ 50-70)

B. Mild (IQ 70-90)

C. Moderate (IQ 50-70)

D. Moderate (IQ 35-50)

E. Severe (IQ 20-35)

F. Severe (IQ 25-50)

G. Profound (IQ below 25)

H. Profound (IQ below 20)

4. Which of the following 2 statements are true?

A. Mild ID accounts for approximately 80% of children with ID.

B. Approximately 50% of children with ID have moderate severity.

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C. Severe ID accounts for approximately 7% of the ID group.

D. Profound ID affects 10% of children with ID.

5. The prevalence and incidence of ID varies according to gender, age, ethnicity and socioeconomic

circumstances. Which statement is false?

A. Studies generally report a female predominance in LD

B. Increased maternal age is likely to lead to an increase in incidence of LD

C. Ethnicity influences prevalence and incidence levels in ID due to the associated links with poverty,

access to healthcare, and communications barriers amongst other factors

D. Lower socioeconomic position is associated with higher prevalence of mild and moderate LD, but

not severe LD.

6. Psychiatric illnesses frequently exist comorbidly with ID. Which of the following statements is

false?

A. Prevalence of psychiatric co-morbidity ranges from 30-70%

B. There is often over diagnosis of co-morbid psychiatric conditions

C. Practically all categories of mental illness are represented in the ID population

D. Co-morbid psychiatric problems can vary and change with age

7. Match the following co-morbid problems with the age group they are most likely to present in:

1. Eating and sleep disorders A. Adolescents

2. Self-injury B. Very young children

3. ADHD C. School age children

8. Which one of the following psychiatric conditions is not generally associated with LD?

A. Attention deficit hyperactivity disorder

B. Mood disorders

C. Anxiety disorders

D. Psychotic illness

E. Obsessive compulsive disorder

F. Anorexia nervosa

G. Autistic spectrum disorder

9. Behavioural analysis involves which ABC?

A. Antecedents

107

B. Awareness

C. Boundaries

D. Behaviour

E. Consequences

F. Circumstances

10. Which statement about management of ID is inaccurate?

A. Medications are commonly under-prescribed when managing challenging behaviour associated

with ID.

B. Behavioural techniques are useful in managing ID

C. Families provide the majority of support for most people with ID

D. Social services provide the majority of support for people with ID outside of families


Books


Sir Michael Rutter , Dorothy Bishop, Daniel Pine, Steven Scott , Jim S. Stevenson, Eric A. Taylor,

Anita Thapar



Cerebra resources

http://w3.cerebra.org.uk/research/research-papers/self-injurious-behaviour-in-children-with-

intellectual-disability/

Journal Articles

Developing mental health services for Children and Adolescents with Learning Disability: A

toolkit for clinicians

http://www.rcpsych.ac.uk/pdf/devmhservcaldbk.pdf

Mental health of children with learning disabilities. Pru AllingtonSmith, Advances in

Psychiatric Treatment, 2006, vol. 12, 130–140.

Nice Guidelines

http://w3.cerebra.org.uk/research/research-papers/self-injurious-behaviour-in-children-with-intellectual-disability/

http://w3.cerebra.org.uk/research/research-papers/self-injurious-behaviour-in-children-with-intellectual-disability/

http://www.rcpsych.ac.uk/pdf/devmhservcaldbk.pdf

108

Challenging behaviour and learning disabilities: prevention and interventions for people with learning

disabilities whose behaviour challenges

https://www.nice.org.uk/guidance/ng11

Session 7: Eating Disorders

Learning Objectives

To understand the principles and practice of assessment (including psychiatric comorbidity),

diagnosis (including classification) and treatment, (therapeutic modalities, use of psychoactive

medication) in patients presenting with Eating disorders in childhood and adolescence

To understand the physical sequelae of Eating Disorders, medical management and paediatric

liaison

To understand the role of other key professional (e.g. dietician, therapists)

To understand how services are configured for the management of Eating disorders

Curriculum Links

Eating disorders:

10.8.7.1 10.8.7.2 10.8.7.3 10.8.7.4 10.8.7.5

Expert Led Session

To discuss assessment, including physical examination and management with reference to

NICE and Junior MARSIPAN Guidance and MDT management.

Case Presentation

To cover the key diagnostic features, with reference to ICD10/DSMV – including physical

examination – calculation of BMI, %weight/height ratio and plotting on centile charts.

https://www.nice.org.uk/guidance/ng11

109


Gowers SG1, Clark A, Roberts C, Griffiths A, Edwards V, Bryan C, Smethurst N, Byford S,

Barrett B.

Clinical effectiveness of treatments for anorexia nervosa in adolescents: randomised

controlled trial. Br J Psychiatry. 2007 Nov;191:427-35.

Loeb, Katharine L, and Daniel le Grange Family-Based Treatment for Adolescent Eating

Disorders: Current Status, New Applications and Future Directions. International journal of

child and adolescent health 2.2 (2009): 243–254.


Signs, symptoms and prevention of re-feeding syndrome.

Therapeutic interventions for eating disorders in children and young people

MARSIPAN Guidelines physical risk assessment in eating disorders

MCQs

1. When a child with anorexia nervosa refuses treatment that is deemed essential what do the

National Institute of Clinical Excellence recommend?

A. The Mental Health Act should not be used where parents give their consent

B. Parental consent should be relied upon in cases of persistent refusal

C. A second opinion from an eating disorders specialist should be considered only as a last resort

D. If parents also refuse the treatment, the Mental Health Act should be applied

E. The Children’s Act should be considered under circumstances where parents also refuse

treatment

2. What is the approximate ratio of girls to boys with a diagnosis of any Eating Disorder in the UK?

A. 5:1

B.10:1

C.15:1

D.20:1

E. 25:1

3. Which of the following is true?

A. In children, BMI is a stable measure of severity of Anorexia Nervosa

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B. Children with Anorexia Nervosa can present with healthy weight

C. NICE recommend low dose fluoxetine for the treatment of BN

D. During treatment patients with Anorexia nervosa should be aiming for weight gain of more than 2

kg per week

E. Oestrogen administration should not be used to treat bone density problems in children

4. What medication do NICE recommend for Bulimia Nervosa?

A. Fluoxetine

B. Olanzapine

C. Venlafaxine

D. Methylphenidate

E. Mirtazepine

5. Which of the following is not a criterion for diagnosis of Anorexia Nervosa according to ICD10?

A. Endocrine dysfunction

B. Fear of fatness

C. Over-exercise

D. Food restriction

E. Weight more than 15% below expected weight for age and height

6. All of the following are often present in both Bulimia Nervosa and Anorexia Nervosa except:

A. Food restriction

B. Self induced vomiting

C. Low weight

D. Purging

E. Episodes of overeating

7. Which of the following is a necessary early treatment for life threatening low weight in a young

person with an eating disorder?

A. Feeding high calorie meals

B. Thiamine replacement

C. NG tube feeding

D. CBT

E. Psychotropic medication

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8. Which of the following are features of anorexia nervosa (1 or more)?

A. Low FSH, LH an Oestradiol

B. Shortened QT

C. Delayed gastric emptying

D. Reduced Growth Hormone

E. Low T3, normal TSH

F. Normocytic, normochromic anaemia

9. Which of the following are true about the long term complications of Anorexia Nervosa?

A. Pubertal delay is common

B. Osteopenia and osteoporosis are less frequent in children and adolescents than in adults

C. Catch up growth can occur with nutritional restoration

D. Hormone replacement is recommended for teenagers with Anorexia

E. Weight gain and the establishment of healthy eating habits usually results in restoration of

menstruation

10. Which of the following are true regarding the prognosis of Eating Disorders:

A. Bulimia has a worse prognosis than anorexia nervosa

B. Vomiting in Anorexia Nervosa is a predictor if poor prognosis

C. The 30 year mortality rate in women with Eating Disorders has been found to be 20%

D. The mortality rate for Eating Disorders is greater than for psychiatric in patients

E. Some bone loss experienced in Anorexia Nervosa is irreversible


Books

Clinical topics in Child and Adolescent Psychiatry, Sarah Huline-Dickens RCPsych 2014

Seminars in Child and Adolescent Psychiatry (second edition) Edited by Simon Gowers, Royal

college of Psychiatrists UK, Seminar Series

Wiley: Handbook of Eating Disorders, 2d Edition Janet Treasure (Editor), Ulrike

Schmidt (Editor), Eric van Furth (Editor) February 2003 ISBN: 978-0-471-49768-4

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E-Learning

Psychological treatments for children and adolescents with eating disorders: In this

podcast, Professor Simon Gowers gives an overview of the different psychological

therapies available for children and adolescents with eating disorders, discussing in some

detail family therapy, interpersonal therapy and cognitive behavioural therapy


Additional resources

Cr189. MARSIPAN: management of really sick patients with anorexia nervosa (2nd edn)

www.Rcpsych.ac.uk

Eating disorders (CG9)


Session 8: Legal Aspects of Child & Adolescent Psychiatry

Learning Objectives

Have an understanding of broad legal frameworks and more specific aspects of the Mental Health Act,

Mental Capacity Act, Children Act with respect to children and how the law interacts with children

including issues relating to confidentiality, consent, care and treatment and safeguarding

Curriculum Links

This session overlaps with aspects of the following Individual Learning Objectives as outlined

in the competency based Curriculum for Core Training (2013):

ILO 1b, 3c, 4b,4c,4d,6a,17a,17b,17c,18a

Expert Led Session

To cover: informed consent; assessment of competence; Mental Health Act; Mental Capacity

Act; Children and Families Act.


http://www.rcpsych.ac.uk/


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Case Presentation

To cover: parental responsibility; consent; assessment of competence; and consideration of

legal frameworks in Child and Adolescent Psychiatry

Examples:

15 year old presents following overdose and refuses investigation and/or treatment

Use of The Mental Health Act in Anorexia Nervosa

“Zone of parental control” – treatment of young person under 16, with parental

agreement.

Challenges in treatment of young person over 16, at risk of deliberate self-harm,

refusing any disclosure to carers (parents)

Safeguarding aspects of a clinical case: actions taken in response to

disclosures/raising concerns.


Competence and consent to treatment in children and adolescents. Mike Shaw, Advances in

Psychiatric Treatment. 2001, vol. 7, pp. 150–159

Seeking clarity in the twilight zone: Commentary on Adolescent decision-Making and the zone

of parental control. Aaron K. Vallance Advances in Psychiatric Treatment, 2014 20:151-152

Decision-making about children’s mental health care: ethical challenges. Moli Paul, Advances

in Psychiatric Treatment, 2004, vol 10, 301-311


Parental responsibility and Children Act relevant to Looked After Children

Mental Capacity Act – Key Principles and relevance to care of Young people (under 18)

Capacity Assessment and Gillick Competence – Key principles.

Safeguarding: How to raise concerns

Safeguarding: Organisational Structures (National/Local);(Trust Procedures/Regional

Procedures)

What are Serious Case Reviews: What are these?

MCQs

1. The Mental Health Act (1983, amended 2007) applies to which of the following age groups:

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A. 16 and over

B. 18 and over

C. 16 – 65

D. 18 – 65

E. All age groups

2. A 15 year old boy, with a full understanding of the risks/benefits of treatment, consents to

treatment for ADHD. This can be offered under the framework of:

A. The Mental Health Act

B. The Children’ Act

C. Gillick competence

D. The Mental Capacity Act

E. The Family Reform Act

3. What is the definition of a child in UK child protection guidance?

A. Anyone under the age of 18

B. Anyone under the age of 16

C. Anyone under the age of 14

D. Anyone under the age of 18 in full-time education

E. Anyone under the age of 16 in full-time education

4. Which of these groups of people would not automatically qualify for Parental Responsibility (PR)

under The Children Act (1989)?

A. Mothers

B. Fathers

C. Adoptive parents

D. People with special guardianship

E. An individual with an order from a Family Court

5. A 14 year old girl has delirium secondary to a urinary tract infection, and has refused IV antibiotics

although has allowed nurses to site a cannula. She does not have capacity to make decisions

regarding this treatment, with her delirium interfering with her ability to understand information.

What would be the most likely legal framework used to treat her in this situation?

A. The Mental Capacity Act

B. The Mental Health Act

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C. Gillick competence

D. The Family Reform Act

E. Consent from an individual with Parental Responsibility

6. Which of the following difficulties experienced by young people does NOT count as a mental

disorder under the terms of the Mental Health Act?

A. Anorexia Nervosa

B. Learning Disability

C. Autism Spectrum Disorder

D. Alcohol dependence

E. Personality Disorder

7. What age group can be treated under the Mental Capacity Act:

A. Any age group

B. Any age group if the person with Parental Responsibility is unavailable

C. 14 and over

D. 16 and over

E. 18 and over

8. Which of the following is NOT relevant when considering the compulsory treatment of 16-18 year

olds?

A. Deprivation of liberty

B. The zone of parental control

C. Consent of the person with parental responsibility

D. Gillick competence

E. The Mental Health Act

9. Which of the following would NOT be used when considering IV rehydration for a 14 year old with

Anorexia Nervosa?

A. The Mental Health Act

B. Treatment with consent from the person with Parental Responsibility

C. Consent from a child with Gillick competence

D. The Mental Capacity Act

E. Emergency treatment under common law

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10. There are circumstances in which the confidentiality young people can expect may have to be

breached, to the extent of informing those with parental responsibility.

Which of the following is NOT an important factor in making this decision?

A. The young person’s age and developmental level

B. The severity of any mental disorder

C. The closeness of the relationship with the parents

D. The presence of an Autism Spectrum Disorder

E. The degree of care and protection required


Books


Sir Michael Rutter , Dorothy Bishop, Daniel Pine, Steven Scott , Jim S. Stevenson, Eric A. Taylor,

Anita Thapar



Clinical topics in Child and Adolescent Psychiatry, Sarah Huline-Dickens RCPsych 2011

E-Learning

Seclusion

In this telephone interview, Dr Stephen Elsom talks from Australia on the topical issue of

seclusion as an intervention for containing uncontrolled, disturbed behaviour of psychiatric

patients. He discusses the research evidence regarding the use of seclusion and current

thinking surrounding this practice. He also talks about methods that can be helpful to reduce

the rate of seclusion used as an intervention.


Guidelines

Mental Health Law Online

http://www.mentalhealthlaw.co.uk/Children_and_mental_health_law

Antisocial behaviour and conduct disorders in children and young people (QS59)


http://www.mentalhealthlaw.co.uk/Children_and_mental_health_law

117


A Positive and Proactive Workforce: Guidance on reducing restrictive practice in clinical and

other settings. DOH

http://www.skillsforcare.org.uk/Documents/Topics/Restrictive-practices/A-positive-

and-proactive-workforce.pdf

RCPsych CPD online

http://www.psychiatrycpd.co.uk/learningmodules/ethicalandlegalchallenges-1.aspx


http://www.skillsforcare.org.uk/Documents/Topics/Restrictive-practices/A-positive-and-proactive-workforce.pdf

http://www.skillsforcare.org.uk/Documents/Topics/Restrictive-practices/A-positive-and-proactive-workforce.pdf

http://www.psychiatrycpd.co.uk/learningmodules/ethicalandlegalchallenges-1.aspx

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FORENSIC SEMESTER 3:

Session 1: Psychiatry and the Criminal Justice System

Learning Objectives

To develop an understanding of the structure and organisation of the criminal justice

system

To develop an understanding of the mental health of prisoners and understand the

complexities of their treatment

To develop an understanding of the structure and organisation of secure psychiatric

services and the different levels of security

To develop an understanding of the framework around the management of mentally-

disordered offenders

Curriculum Links

12.2 Psychiatry and the criminal Justice System

12.2.1 The role of the psychiatrist in the assessment of mentally disordered offenders:

during arrest, prior to conviction; prior to sentencing

12.3 Practising psychiatry in a secure setting

12.3.1 The role of security in a therapeutic environment

12.3.2 The essential components of a forensic service

12.3.3 Knowledge of the prevalence of psychiatric disorder in prison populations,

suicide in prisoners and psychiatric treatment in prison settings

12.3.4 Risk management planning in forensic psychiatric practice

12.3.5 Managing mentally disordered offenders discharged into the community

Expert Led Session

An introduction to the criminal justice system. To include:

Police detention and diversion

Prison structure and organisation and prison categories

Mental health care in prison

Pathways into secure settings

MAPPA

Case Presentation

Case presentation on ‘progression through the criminal justice system to hospital’.

119

If trainee has a suitable case of a mentally-disordered offender then they may present

this.

The trainee can come to the Edenfield Centre where a suitable case can be found for

them – to access case notes and / or meet patient (if appropriate)


Please select one of the following papers:

Fazel S, Fiminska Z, Cocks C & Coid J, Patient outcomes following discharge from

secure psychiatric hospitals: a systematic review and meta-analysis, BJPsych 2016,

208: 17 – 25


Fazel S & Baillargeon J, The health of prisoners, Lancet 2011 377: 956 – 65


Shaw J, Baker D, Hunt IM et al, Suicide by prisoners: national clinical survey, BJPsych

2004, 184: 263 – 7 http://www.ncbi.nlm.nih.gov/pubmed/14990526

Bhui K, Ullrich S, Kallis C & Coid J, Criminal justice pathways to psychiatric care for

psychosis, BJPsych 2015, 1 – 7

http://bjp.rcpsych.org/content/early/2015/11/09/bjp.bp.114.153882

‘555’ Topic (5 slides with no more than 5 bullet points)

Please select one topic:

Relational security

Procedural security

Structural security

Levels of security – high / medium / low

Mental health in reach teams

MCQs

1. What is the relative risk of psychosis in prisons compared to the general population?

A. 5

B. 10




http://bjp.rcpsych.org/content/early/2015/11/09/bjp.bp.114.153882

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C. 20

D. 100

E. 2

2. How many homicide offenders have active psychiatric symptoms at the time of

committing the homicide?

A. 1 in 10

B. 1 in 5

C. 1 in 3

D. 1 in 2

E. 1 in 4

3. The rate of suicide is highest in:

A. Service users in the community

B. Sentenced prisoners

C. Service users in general psychiatric wards

D. Older prisoners facing long sentences

E. Remand prisoners

4. Which is the most common psychiatric condition in prisoners?

A. Depression

B. Personality disorder

C. Psychopathy

D. Psychosis

E. Neurosis

5. What is the prevalence of major depression in male prisoners?

A. 10%

B. 12%

C. 25%

D. 3.7%

E. 50%

EMI Questions

Mental Health Act:

121

A. Section 35

B. Section 36

C. Section 37

D. Section 38

E. Section 45A

F. Section 47 / 49

G. Section 48 / 49

H. Section 41

Match the description to the correct section under part III Mental Health Act 1983:

1. Interim Hospital Order

2. Removal to hospital of a sentenced prisoner

3. Remand to hospital for a report

4. Hospital direction and limitation direction

5. Removal to hospital of an un-sentenced prisoner

6. Hospital order

7. Restriction Order

8. Remand to hospital for treatment

Mental Health Act:

A. Section 35

B. Section 36

C. Section 37 +/- 41

D. Section 38

E. Section 45A

F. Section 47 / 49

G. Section 48 / 49

For each of the following scenarios, which section of the Mental Health Act 1983

would be most appropriate to admit the patient under?

1. Bob is 2 years into a 17 year sentence for armed robbery. Whilst in prison he becomes

unwell – he worries that the prison officers are poisoning his food, believes there are

122

cameras in his cell and has become aggressive and violent. He refuses to accept

treatment because he believes it is part of the conspiracy to poison him.

2. Sharon has been found guilty of burglary and is in HMP anywhere. She reports

experiencing distressing command hallucinations to harm herself and others. She is being

cared for on the hospital wing and has attempted to hang herself. Treatment is ineffective.

3. Peter kills his next door neighbour because he believes that he is the devil and was

planning to harm his children. He experienced command hallucinations from God

instructing him to do so. He goes to Court, where it is accepted that Peter suffers from

paranoid schizophrenia and psychiatrists recommend admission to hospital. However he

is found guilty of murder.

4. Annabelle has a known history of bipolar affective disorder. She stopped taking her

medication and during a manic episode set fire to her flat. This is her fourth fire-setting

episode when she has been manic. She frequently disengages from her CMHT and stops

taking her medication. You are of the opinion that she requires admission to hospital to

stabilise her mental state and complete some work around her fire-setting and

compliance. Which section would you recommend to the Court?

5. Simon is a member of the Jelly Baby Street gang. He has an extensive criminal record

with offences for violence, theft, carrying weapons and possession of illicit substances. He

is not known to mental health services. He has been convicted of a section 18 wounding

with intent (GBH) after he stabbed a rival gang member in the face for giving him a funny

look. Whilst on remand he develops an acute psychotic illness during which he becomes

aggressive as he believes that the dentist has planted a monitoring device in his teeth. He

has removed several teeth looking for this. You believe he should be admitted to hospital

and are asked to prepare a court report for sentencing. Which section would you

recommend?

6. Sandeep has appeared in court charged with assault, for which she is on bail. She has

a known history of schizoaffective disorder and is showing signs of relapse. She does not

engage with the community team when unwell and will not accept treatment voluntarily.

She won’t engage in assessments as to whether her offence was related to her mental

disorder. You are of the opinion that she requires admission to hospital urgently.

123


Books

Chapters 3, 5 & 24 in ‘Forensic Psychiatry: Clinical and ethical issues’ Gunn J & Taylor P,

(2013) CRC Press

Chapters 1, 2, 3, 17 & 18 in ‘Practical Forensic Psychiatry,’ Clark T & Rooprai DS (2011) Hodder

Arnold

Chapters 8 & 17 in ‘Oxford Specialist Handbook: Forensic Psychiatry,’ Eastman N, Adshead G,

Fox S et al (2012) Oxford Medical Publishing

E-Learning

RCPsych CPD online: ‘Suicides in prison’

Journal Articles

Birmingham L (2001) Diversion from custody. Advances in Psychiatric Treatment 7: 198 – 207

Birmingham L, Gray J, Mason D et al (2000) Mental illness at reception into prison. Criminal

Behaviour and Mental Health 10(2); 77 - 87

Coid JW (1998) Socio-economic deprivation and admission rates to secure forensic services.

Psychiatric Bulletin 22: 294 – 297

Coid JW, Hickey N, Kahtan N et al (2007) Patients discharged from medium secure forensic

psychiatry services: reconvictions and risk factors. British Journal of Psychiatry 190: 223 - 229

Department of Health (2009) The Bradley Report: Lord Bradley’s review of people with mental

health problems or learning disabilities in the Criminal Justice System. London: Department of

Health

Hassan L, Birmingham L, Harty M et al (2011) Prospective cohort study of mental health

during imprisonment. British Journal of Psychiatry 198: 37 – 42

Liebling A (1995) Vulnerability and prison suicide. British Journal of Criminology 35: 173 – 187

Lyall M & Bartlett A (2010) Decision making in medium security: can he have leave? Journal of

Forensic Psychiatry and Psychology 21 (6): 887 – 901

Royal College of Psychiatrists (2004) Psychiatrists & Multi-Agency Public Protection

Arrangements: Guidelines on representation, participation, confidentiality & information

exchange. London: Royal college of Psychiatrists

Shaw J, Hunt IM, Flynn S et al (2006) Rates of mental disorder in people convicted of

homicide. National clinical survey. British Journal of Psychiatry 188: 143 – 147

124

Session 2: The Link between Crime and Mental Disorder

Learning Objectives

To develop an understanding of the types of offences committed by mentally

disordered offenders

To develop an understanding of the aetiology of certain crimes including violent

offences, sex offences, criminal damage and fire-setting

To develop an understanding of the ranges of offences committed by offenders with

schizophrenia, affective disorder and personality disorder.

To develop an understanding of genetic and gender-specific factors in offending

Curriculum Links

12.1 Relationship between crime and mental disorder

12.1.1 Knowledge of the range of offences committed by mentally disordered

offenders. Specific crimes and their psychiatric relevance particularly:

homicide; other crimes of violence (including infanticide); sex offences; arson;

and criminal damage.

12.1.2 The relationship between specific mental disorders and crime: substance

misuse; epilepsy; schizophrenia; bipolar affective disorder; neuro-

developmental disorders; personality disorders

12.1.4 Mental disorders and offending in special groups: young offenders; female

offenders; offenders from ethnic minorities; offenders who are deaf or have

other physical disabilities

Expert Led Session

‘Offences committed by mentally-disordered offenders’ To cover topics including:

Sexual offending

Fire-setting

Violence

Offences against the property

125

Case Presentation

Case presentation on ‘A mentally-disordered offender’ Options for case presentation:

If trainee has a suitable case of a mentally-disordered offender then they may present

this.



To use ‘The report of the inquiry into the care and treatment of Christopher Clunis’ as the

basis of the case presentation.


Key points to be summarised from the following three papers:

Keers R, Ullrich S, DeStavola B & Coid J. (2014) Association of violence with emergence

of persecutory delusions in untreated schizophrenia. Am J Psychiatry 171:3: 332 – 339

Sarkar J & Di Lustro M (2011) Evolution of secure services for women in England.

Advances in Psychiatric Treatment 17, 323 – 31

http://apt.rcpsych.org/content/17/5/323.abstract

Chang Z, Larsson H, Lichtenstein P & Fazel S, Psychiatric disorders and violent

reoffending: a national cohort study of convicted prisoners in Sweden, Lancet Psychiatry

2015, 2: 891 – 908


‘555’ Topic (5 slides with no more than 5 bullet points)

The biology of crime including:

Genetics

Gender

Young offenders

Special group – either deaf patients / ethnic minorities / older adults / physical disabilities


126

MCQs

1. Which is the most prevalent personality disorder in prisoners?

A. Borderline

B. Anankastic

C. Narcissistic

D. Paranoid

E. Antisocial

2. Which of the following is true for female offenders?

A. Less likely to have a psychiatric disposal

B. Higher rate of reoffending than men

C. Less likely to self-harm than men

D. Violent offences are more common than crimes of passion

E. More likely to offend against family

3. Which is the most common mental disorder found in arsonists?

A. Learning disability

B. Personality disorder

C. Psychosis

D. Alcohol misuse

E. Depressive disorder

4. What percentage of violence is attributable to psychosis

A. 1%

B. 5%

C. 10%

D. 25%

E. 50%

5. Which of these genes is not linked to violence?

A. Dopamine transporter gene

B. Serotonin transporter gene

C. Monoamine-oxidase A (MAO-A) gene

D. Monoamine-oxidase B (MAO-B) gene

E. Catechol-O-methyltransferase (COMT) gene

127

EMI Questions

Stalking:

A. Rejected

B. Public-Figure

C. Intimacy-Seeking

D. Incompetent-Suitor

E. Psychotic

F. Resentful

G. Predatory

H. Psychopathic

I. Private Stranger

J. Acquaintance

Which of the above subtypes of stalking, is demonstrated in the following scenarios?

1. James is a 22 year old man who has recently started working stacking shelves in the

local supermarket. One Sunday he saw Jenny, who was doing her regular weekly shopping

and she smiled at him warmly. Over the following weeks he changes his shift patterns to that

he always works on Sundays. He follows her home to ensure that she gets there safely and

starts to leave her flowers and presents by her car in the car-park. He takes pictures of her

without her knowing and puts them on Facebook as his new girlfriend.

2. Steven lives in a block of flats and notices a new tenant (Sally) has moved into the

flat beneath him. He starts to take her post from the communal mailbox so that he can find

out more information about her such as her phone number. He starts to make anonymous

phone calls during which he makes sexual and violent comments. He follows her to work so

that he can best determine when she is alone.

3. David is a 32 year old stock-broker who lives in a penthouse apartment. He was in a

9-month relationship with Jasmine, who broke up with him 12 months ago as she was

frustrated that she rarely saw him. David was angry that had the gall to break up with him

and since then has rung her several times each day; sometimes he asks her to re-consider

but often he leaves abusive messages or silence on her answerphone. He has gone around

128

to her flat in the middle of the night with flowers, although he broke her window on one

occasion. He was angry that she didn’t come to his brother’s wedding as his guest 2 months

ago. He has posted private pictures of her on the internet.

4. Sandra is a 40 year old single woman. 3 years ago she met Olly Murs backstage at a

concert. Since then she has become “his biggest fan.” She buys any magazines or

newspapers that he is in, has several copies of all his CDs and DVDs and goes to as many

concerts as she can. She lost her job because she took so much time off pursuing this

interest. She recently found out where he lives and spends all of her time at his house so

that she can see him when he leaves and follow him. She looks through his rubbish, where

she found some lipstick and she saw a female leave his house. She has sent threats to this

woman that Olly is ‘hers’ and to leave him alone.

5. Aimee is an aspiring model. 6 months ago at a casting she met Sarah and leant her

some makeup. Sarah was given the job and signed up to an agency. Aimee believes that

Sarah must have got the job for reasons other than merit. She is angry that Sarah stole the

job from her. Since then she has anonymously posted death threats on Twitter and

Facebook. She waited outside Sarah’s house for her to come out and threw a tin of paint on

her. She phoned Sarah’s model agency pretending to be Sarah and cancelled jobs. She

hacked into her email and sent abusive messages to the boss of the model agency.

Sex Offender Treatment:

A. Selective Serotonin Reuptake Inhibitor (SSRI)

B. Anti-androgen

C. Luteinising Hormone Releasing Hormone (LHRH) agonist / Long-acting

Gonadotropin Releasing Hormone (GnRH) agonist

D. Oestrogens

Match the anti-libidinal medication used in the treatment of sex offenders to the

mechanism of action:

1. Medroxyprogesterone acetate

2. Fluvoxamine

3. Cyproterone Acetate

4. Goserelin

5. Leuprolide

6. Premarin

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Books

Chapters 8, 9, 10, 11, 12, 19, 20 & 21 in ‘Forensic Psychiatry: Clinical and ethical issues’ Gunn J &

Taylor P, (2013) CRC Press

Chapters 10, 11, 12 & 13 in ‘Practical Forensic Psychiatry,’ Clark T & Rooprai DS (2011) Hodder

Arnold

Chapter 15 in ‘Oxford Specialist Handbook: Forensic Psychiatry,’ Eastman N, Adshead G, Fox S et

al (2012) Oxford Medical Publishing

E-Learning

RCPsych CPD online: ‘Genetics for psychiatrists’

RCPsych CPD online: ‘Neurodevelopmental model of schizophrenia’

RCPsych CPD online: ‘Psychiatric aspects of homicide’

Journal Articles

Bennett D, Ogloff J, Mullen P et al (2012) A study of psychotic disorders among female homicide

offenders Psychology, Crime and Law 18(3), 231 – 243

Chitsabesan P, Kroll L, Bailey S et al (2006) Mental health needs of young offenders in custody

and in the community. British Journal of Psychiatry 188: 534 – 540

Dein K, Woodbury-Smith M (2010) Asperger syndrome and criminal behaviour. Advances in

Psychiatric Treatment 16: 37 – 43

Devapriam J, Raju LB, Singh N et al (2007) Arson: characteristics and predisposing factors in

offenders with intellectual disabilities. British Journal of Forensic Practice 9(4): 23 – 27

Eronen M (1995) Mental disorders and homicidal behavior in female subjects. American Journal

of Psychiatry 152: 1216 – 1218

Fazel S & Benning R (2009) Suicides in female prisoners in England and Wales. British Journal of

Psychiatry 194: 183 – 184

Fazel S, Sjostedt, Langstrom N et al (2007) Severe mental illness and risk of sexual offending in

men: a case-control study based on Swedish national registers. Journal of clinical psychiatry

68(4), 588 – 596

130

Ferguson CJ & Beaver KM (2009) Natural born killers: the genetic origins of extreme violence.

Aggression and Violent Behaviour 14, 286 – 94

Gannon TA (2010 Female arsonists: key features, psychopathologies and treatment needs.

Psychiatry 73(2): 173 – 189

Gordon H & Grubin D (2004) Psychiatric aspects of the assessment and treatment of sex

offenders. Advances in psychiatric treatment 10: 73 – 80

Gudjonsson GH & Henry L (2003) Child and adult witnesses with intellectual disability: the

importance of suggestibility. Legal and Criminological Psychology 8(2): 241 – 252

Holland T, Clare CH & Mukhopadhyay (2002) Prevalence of criminal offending by men and

women with intellectual disability and the characteristics of offenders: implications for research

and service development. Journal of Intellectual Disability Research 46(S1): 6 – 20

Kolko DJ & Kazdin AE (1991) Motives of childhood firesetters: firesetting characteristics and

psychological correlates. Journal of child psychology and psychiatry 32: 535 – 550

Long C, Hall L, Craig L et al (2010) Women referred for medium secure inpatient care: a

population study over a six-year period. Journal of Psychiatric Intensive Care 7(1): 17 – 26

Mohandie K, Meloy J R, McGowan MG et al (2006) The RECON typology of stalking: reliability and

validity based upon a large sample of North American Stalkers Journal of Forensic Science 51(1),

147 – 155

Monahan J, Steadman HJ, Silver E et al (2001) Rethinking risk assessment: The MacArthur study

of risk assessment and violence. Oxford: Oxford University Press.

Mullen P, Pathe M & Purcell P (2001) The management of stalkers. Advances in psychiatric

treatment 7: 335 – 342

Talbot J (2008) No One Knows: Experiences of the criminal justice system by prisoners with

learning disabilities and difficulties. London: Prison reform trust

131

Session 3: Too mad to murder?

Learning Objectives

To develop an understanding of the role of mental disorder in offending

To develop an understanding of the frequency of and types of offences committed by

those with serious mental illness

To understand the role of special syndromes in offences

To develop an understanding of vulnerability and suggestibility in mentally disordered

offenders

Curriculum Links

12.1 Relationship between crime and mental disorder

12.1.2 The relationship between specific mental disorders and crime: substance misuse;

epilepsy; schizophrenia; bipolar affective disorder; neuro-developmental

disorders; personality disorders

12.1.3 Special syndromes: morbid jealousy, erotomania, Munchausen and Munchausen by

proxy

12.1.5 Effect of victimisation and vulnerability: anxiety states including post-traumatic stress

disorder; suggestibility; anger and aggressive behaviour. Effect of compensation on

presentation

Expert Led Session

‘Too mad to murder?’ to include:

Substance Misuse

Epilepsy

Schizophrenia

132

Bipolar affective disorder

Neuro-developmental disorders

Personality disorders

Case Presentation

Case presentation on ‘a special syndrome in relation to forensic psychiatry’. To include either

morbid jealousy, erotomania, Munchausen or Munchausen by proxy.

Options for case presentation:

If trainee has a suitable case of a special syndrome then they may present this.



To use ‘The Allitt inquiry’ as the basis of the case presentation. (Munchausen by proxy)


Key points to be summarised from the following three papers:

Rose J, Cutler C, Tresize K et al (2008) Individuals with an intellectual disability who

offend, British Journal of Developmental Disabilities 106, 19 – 30

http://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&cad=rja&

uact=8&sqi=2&ved=0CCUQFjAA&url=http%3A%2F%2Fwww.researchgate.net%2Fpublic

ation%2F228505583_Individuals_with_an_intellectual_disability_who_offend%2Flinks%2

F0deec51817f57baef7000000&ei=3YngU_PiI-

nb7Aazh4DABg&usg=AFQjCNEg9xYeimpgqJchT70fngkh2vkPTA&sig2=KXDBJ1CC_DT

2OPQG6mr2KA

Fazel S, Wolf A, Chang Z et al (2015). Depression and violence: a Swedish population

study. Lancet Psychiatry 2: 224 – 32

http://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&cad=rja&uact=8&sqi=2&ved=0CCUQFjAA&url=http%3A%2F%2Fwww.researchgate.net%2Fpublication%2F228505583_Individuals_with_an_intellectual_disability_who_offend%2Flinks%2F0deec51817f57baef7000000&ei=3YngU_PiI-nb7Aazh4DABg&usg=AFQjCNEg9xYeimpgqJchT70fngkh2vkPTA&sig2=KXDBJ1CC_DT2OPQG6mr2KA






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Elbogen EB & Johnson SC (2009) The intricate link between violence and mental

disorder: results from the national epidemiological survey on alcohol and related

conditions. Archives of General Psychiatry 66(2): 152 – 161



Human rights legislation – articles 5 / 6 / 8

Ethics

MCQs

1. Which is the biggest risk factor for violence in psychosis?

A. Non-compliance with medication

B. Co-morbid personality disorder

C. Homelessness

D. Unemployment

E. Co-morbid substance misuse

2. With respect to Munchausen’s by Proxy, which of the following is incorrect?

A. More common in mothers

B. The annual incidence of fabricated or induced illness in children under 16 is 0.5 per

100,000

C. There is no clear relationship with any specific mental disorder

D. 50% perpetrators had a personality disorder

E. 21% have a history of alcohol and / or drug misuse

3. Which of the following regarding mood disorder and violence is incorrect?

A. The prevalence of depression in male prisoners is 10%


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B. The prevalence of depression in female prisoners is 25%

C. Manic patients are likely to show aggression and violence associated with admission to

hospital

D. 7% homicide perpetrators have a lifetime diagnosis of mood disorder

E. Most perpetrators of homicide-suicide are male

4. Which is the correct statement relating to substance use and the MacArthur Violence

Study?

A. Substance use increases the rate of violence among both those with and without mental

illness

B. The rate of violence for those with a mental disorder and no substance use is 25%

C. The rate of violence for those with a mental disorder and substance use is 50%

D. Substance use is a protective factor for violence

E. The highest rate of violence was for those with mood disorder and substance use

5. Which is the incorrect statement about epilepsy and offending?

A. Ictal violence is more likely in complex partial seizures

B. Most offending occurs in post-ictal or inter-ictal period

C. Violence in epilepsy is usually a feature of the disease

D. The prevalence of epilepsy in prisoners is 1 – 2%

E. The prevalence of epilepsy in the general population is 0.5 – 1%

EMI Questions

Fire Setting:

A. Crime concealment

B. Financial compensation

C. Suicidal

D. Extremism

E. Vandalism

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F. Psychosis

H. Pyromania

Match the most-likely motivation for fire-setting with the clinical scenario below.

1. Wayne is a 14 year old who whilst truanting from school with a gang of boys sets fire to an

abandoned warehouse. He waits around for the fire service to arrive and watches from a

safe distance as they put the fire out.

2. Vincent is a 48 year old man with Asperger’s Disorder. He has a history of setting fires

when he is angry. He enjoys looking at how things burn. He is upset by another resident

shouting at him and so set a fire. He feels an inner tension that is relieved when he has set

the fire. He calls the fire brigade and becomes excited when they arrive.

3. Stephanie sets fire to a university research laboratory, where she believes the researchers

are carrying out experiments on elephants. Two weeks ago she suddenly realised that the

University were dissecting elephant trunks in order to test the effects of snorting cocaine so

that the Government could develop a synthetic drug to distribute in the community.

4. Alison is a 50 year old woman who has recently separated from her husband after he left

her for another woman. Divorce proceedings have begun and she is concerned that she may

have to leave the family home because she can’t afford to pay the mortgage. She is

depressed with low mood, poor sleep, anhedonia and poor concentration. She feels that if

she loses her home she won’t have anything to live for. She sets fire to her house using

petrol in 3 seats in the living room, hallway and upstairs bedroom. She calls the fire brigade

from her mobile phone in the garden.

Human Rights:

A. Article 2

B. Article 3

C. Article 5

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D. Article 6

E. Article 8

F. Article 9

G. Article 12

These Articles of the European Convention of Human Rights (ECHR) are important in the

detention of mentally-disordered offenders. Match the correct Article with the freedom or right

it describes.

1. Right to respect for private and family life

2. Prohibition of torture

3. Right to marry

4. Right to life

5. Right to liberty and security

6. Freedom of thought, conscience and religion

7. Right to a fair trial


Books

Chapters 14, 16, 17, 18, & 26 in ‘Forensic Psychiatry: Clinical and ethical issues’ Gunn J

& Taylor P, (2013) CRC Press

Chapters 7, 8 & 9 in ‘Practical Forensic Psychiatry,’ Clark T & Rooprai DS (2011) Hodder

Arnold

Chapter 3 in ‘Oxford Specialist Handbook: Forensic Psychiatry,’ Eastman N, Adshead G,

Fox S et al (2012) Oxford Medical Publishing

E-Learning

RCPsych CPD online: ‘FREDA – a human rights-based approach to clinical practice’

RCPsych CPD online: ‘Morbid jealousy’

RCPsych CPD online: ‘Understanding and safely managing paranoid personality

disorder’

137

Journal Articles

Arsenault L, Moffit T, Caspi A et al (2000) Mental disorders and violence: results from the

Dunedin study. Archives of General Psychiatry 57: 979 – 986

Barrowcliff AL & Haddock G (2006) The relationship between command hallucinations

and factors of compliance: a critical review of the literature. Journal of forensic psychiatry

and psychology 17(2): 266 – 298

Booles CN, Neale BA, Meadow SR (1994) Munchausen syndrome by proxy: a study of

psychopathology. Child abuse and neglect G 18: 773 – 788

Fazel S, Langstrom N, Hjern A et al (2009) Schizophrenia, substance abuse, and violent

crime. Journal of the American Medical Association 301(19): 2016 – 2023

Gudjonsson GH & Henry L. (2003) Child and adult witnesses with intellectual disability:

the importance of suggestibility Legal and Criminological Psychology 8(2), 241 – 252

Large M, Smith G, Swinson N et al (2008) Homicide due to mental disorder in England

and Wales over 50 years. British Journal of Psychiatry 193: 130 – 133

Newhill CE, Eack SM & Mulvey EP (2009) Violent behavior in borderline personality

disorder. Journal of Personality Disorders 23: 541 – 554

Nielson O & Large M (2010) Rates of homicide during the first episode of psychosis and

after treatment: a systematic review and meta-analysis Schizophrenia Bulletin 36(4): 702

– 712

Roberts ADL & Coid JW (2010) Personality disorder and offending behaviour: findings

from the national survey of male prisoners in England and Wales. Journal of forensic

psychiatry and psychology 21: 221 – 237

Shaw J, Amos T, Hunt IM et al (2004) Mental illness in people who kill strangers:

longitudinal study and national clinical survey. British Medical Journal 328: 734 – 737

Shaw J, Amos T, Hunt IM et al (2006) Rates of mental disorder in people convicted of

homicide. British Journal of Psychiatry 188: 143 - 147

Swanson JW, Holzer CE, Ganju VK, Jono R (1990) Violence and psychiatric disorder in

the community: evidence from the epidemiological catchment area survey Hospital and

Community Psychiatry 41, 761 – 70

138

Tihonen J, Isohanni M, Rasanen P et al (1997) Specific major mental disorders and

criminality: a 26 year prospective study of the 1966 northern Finland birth cohort.

American Journal of Psychiatry 154: 840 – 845

Session 4: Introduction to risk assessment and risk management

Learning Objectives

To develop an understanding of what clinical risk is

To understand different risk assessment tools

To develop skills in planning how to undertake a risk assessment

To develop skills in risk formulation

To develop an understanding of risk management

Expert Led Session

• An introduction to risk

• Risk assessment tools

• Forensic clinical interview

• Risk assessment

• Risk formulation

• Risk management

Case Presentation

Case presentation to include a risk assessment.


139

Bonta J, Blais J & Wilson H (2014). A theoretically informed meta-analysis of the risk for general and violent recidivism for mentally disordered offenders. Aggression and violent behaviour 19(3): 278- 287 https://www.sciencedirect.com/science/article/pii/S1359178914000408

Klepfisz G, Daffern M & Day A. (2016) Understanding dynamic risk factors for violence. Journal of psychology, crime and law. 22 (1), 124 – 137

https://www.tandfonline.com/doi/abs/10.1080/1068316X.2015.1109091

Brown B & Rakow T. (2015) Understanding clinicians’ cues when assessing the future risk of violence: a clinical judgement analysis in the psychiatric setting. Clinical psychology & psychotherapy 23(2): 125 – 141


Arson risk assessment

Suicide risk assessment

MAPPA

DVLA, driving and mental health

MCQs

MCQ Questions

1. Which of the following is not an actuarial risk assessment tool?

A. VRAG

B. SAVRY

C. Static 99

D. SORAG

E. PCL-R

2. Which is not a static risk factor?

A. Previous violence

B. Parental criminality

C. Age

D. Substance misuse

E. Sex

https://www.sciencedirect.com/science/article/pii/S1359178914000408

https://www.tandfonline.com/doi/abs/10.1080/1068316X.2015.1109091

140

3. Which of the following are principles of risk management?

A. Victim-safety planning

B. Supervision

C. Scenario-planning

D. Treatment

E. All of the above

4. Which is not a feature of a truthful narrative?

A. Able to give basic details only

B. Able to give context

C. Able to reproduce conversations

D. Able to make comments about another’s mental state

E. Able to manage unexpected complications

5. Which is incorrect with regards to the HCR 20?

A. Most commonly used risk assessment tool in the UK

B. 10 Historical items

C. 10 Clinical items

D. It is a form of SPJ risk assessment tool

E. It includes risk formulation


Royal College of Psychiatrists -

https://www.rcpsych.ac.uk/pdf/Camden%20risk%20assessment%20and%20managemen

t.pdf

British Psychological Society -

https://www1.bps.org.uk/system/files/Public%20files/DCP/cat-381.pdf

RCPsych CPD online – Risk assessment and management of violence in general adult

psychiatry

Undrill G. (2007) The risks of risk assessment. Advances psychiatric treatment 13(4): 291

- 297

https://www.rcpsych.ac.uk/pdf/Camden%20risk%20assessment%20and%20management.pdf

https://www.rcpsych.ac.uk/pdf/Camden%20risk%20assessment%20and%20management.pdf

https://www1.bps.org.uk/system/files/Public%20files/DCP/cat-381.pdf

141

SUBSTANCE MISUSE SEMESTER 3:

Session 1: Diagnosis and Treatment for People with Alcohol Problems

Learning Objectives

Assessment, diagnosis and treatment of people with alcohol problems

To develop awareness of complications associated with alcohol use

To understand some of the practical aspects of managing people with alcohol problems

To gain awareness of local provisions and guidelines

Curriculum Links

11.1 Basic pharmacology and epidemiology

11.3 Problem drinking; alcohol dependence; alcohol-related disabilities. In-patient

and out-patient detoxification

11.4 Biological, psychological and socio-cultural explanations of drug and alcohol

dependence

11.7 The assessment and management of alcohol misusers

11.8 Culturally appropriate strategies for the prevention of drug and alcohol abuse

Expert Led Session

Concepts of harmful use/dependence

Management of alcohol withdrawals with reference to local guidelines

Case Presentation

Exploration of alternatives to admission for person with alcohol withdrawals – why

admission would be needed

Highlight assessment and management of comorbid physical symptoms in person with

alcohol problems

Liaison with local alcohol services for follow up

142


Van den Brink, W., Aubin H.J., Bladström A., Torup L., Gual A., Mann K. (2013) Efficacy of as-

needed nalmefene in alcohol-dependent patients with at least a high drinking risk level:

results from a subgroup analysis of two randomized controlled 6-month studies. Alcohol and

alcoholism, 48(5), 570-8.

Schwarzinger, M., Pollock, B., Hasan, O., Dufouil, C., Rehm, J., Baillot, S. Luchini, S. (2018).

Contribution of alcohol use disorders to the burden of dementia in France 2008–13: a

nationwide retrospective cohort study. The Lancet Public Health, 3(3):e124-e132.

Wood, A., Kaptoge, S., Butterworth, A., Willeit, P., Warnakula, S., Bolton, T., Danesh, J.

(2018). Risk thresholds for alcohol consumption: combined analysis of individual-participant

data for 599 912 current drinkers in 83 prospective studies. The Lancet, 391(10129), 1513-

1523.

‘555’ Topics (5 slides on each topic with no more than 5 bullet points)

Alcohol Related Brain Damage

Screening for alcohol use

Foetal alcohol syndrome

Long term physical complications from alcohol use

MCQs

1. Which of the following statements about Disulfiram is false:

A. Previous history of CVA is a contraindication

B. Disulfiram use will result in an decrease in accumulation of acetaldehyde in the blood stream

C. A loading dose can be used for initiation

D. Disulfiram may have a role in the treatment of cocaine dependence

E. Hepatic cell damage is a recognised adverse effect of Disulfiram

2. The following are true of Wernicke Encephalopathy except:

A. Classic triad is ocular motor abnormalities, cerebellar dysfunction, and altered mental state

B. Only 20% of patients present with the full triad

C. Altered mental state occurs in 40%

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D. Altered mental state symptoms include: mental sluggishness, apathy, impaired awareness of an

immediate situation, an inability to concentrate, confusion or agitation

E. Ocular motor abnormalities occur in 30%

3. Which of the following is not a reason to consider inpatient setting for alcohol detoxification based

on NICE guidelines:

A. Previous detoxification was inpatient setting

B. Have a score of more than 30 on the Severity of Alcohol Dependence Questionnaire

C. Have a history of epilepsy, or experience of withdrawal-related seizures or delirium tremens during

previous assisted withdrawal programmes

D. Need concurrent withdrawal from alcohol and benzodiazepines

E. Consider a lower threshold for inpatient or residential assisted withdrawal in vulnerable groups, for

example, homeless and older people

4. Features required for a diagnosis of dependence within ICD 10 include the following except:

A. A strong desire or sense of compulsion to take the substance

B. Difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of

use

C. A physiological withdrawal state when substance use has ceased or have been reduced, as

evidenced by: the characteristic withdrawal syndrome for the substance; or use of the same (or closely

related) substance with the intention of relieving or avoiding withdrawal symptoms;

D. Evidence of tolerance, such that increased doses of the psychoactive substance are required in order

to achieve effects originally produced by lower doses

E. Returning to substance use after a period of abstinence leads to more rapid reappearance of

features of dependence than with non-dependent individuals

5. The following are correct calculation of units of alcohol (percentages are in vol/vol) corrected to

nearest whole number:

A. 750 mls of 11% wine is 8 units

B. 6 Litres of 4.5% cider is 18 units

C. 5 cans of 330 mls of 4.8% lager is 8 units

D. 3 cans of 440 mls of 7.5% strong lager is 10 units

E. 2 bottles of 700 mls of 17% fortified wine is 24 units

144

EMI Questions

Drugs used in Alcohol Dependence:

A. Disulfiram

B. Acamprosate

C. Naltrexone

D. Nalmefene

E. Diazepam

F. Oxazepam

G. Lorazepam

H. Vitamin B compound strong

I. Thiamine

J. Baclofen

1a. Which medication should not be given if serum creatinine >120 micromol/L)

1b. Which medication used for detoxification should be avoided in patients with impaired liver

function

1c. Which medication acts as a partial agonist on Kappa opioid receptors

Investigations for people with alcohol use:

A. Gamma-glutamyl transferase (GGT)

B. Mean corpuscular volume

C. Carbohydrate-deficient transferrin (CDT)

D. Total bilirubin

E. Albumin

F. INR

G. Magnesium

H. Globulin

I. Alkaline phosphatase

J. Platelet Count

2a. This marker has Sensitivity of 50 to 70% in the detection of high levels of alcohol consumption in

the last 1 to 2 months but false positive with hepatitis, cirrhosis, cholestatic jaundice, metastatic

carcinoma, treatment with simvastatin and obesity.

2b. This is used in the calculation of the Maddrey's Discriminant Function for Alcoholic Hepatitis.

145

2c. A reduction in this can lead to increased risk of seizures and can be related to use of proton pump

inhibitors.


Books

Chapter 17 in Cowen, P., Harrison, P. J., Burns, T., & Gelder, M. G. (2012). Shorter Oxford

textbook of psychiatry (6th ed.). Oxford: Oxford University Press

Edwards, G. Alcohol: The World's Favorite Drug. Institute of Psychiatry London

McGrath, P. Back from the Brink: The Autobiography

Sigman, A. Alcohol Nation: How to protect our children from today's drinking culture

E-Learning

Blue Light Project: A manual for 'Working with Change Resistant Drinkers

https://www.alcoholconcern.org.uk/Handlers/Download.ashx?IDMF=8ec66a11-104f-4f02-

aed8-892e23522c14

E-learning for Healthcare (e-LfH)

http://portal.e-lfh.org.uk/Registration

o Alcohol Identification and Brief Advice

Epidemiological data on Drug and Alcohol Treatment in England

https://www.ndtms.net/default.aspx

Epidemiological Public Health Data England (Alcohol given as example)

https://fingertips.phe.org.uk/profile/local-alcohol-

profiles/data#page/1/gid/1938132984/pat/6/par/E12000002/ati/101/are/E08000003

GP learning resource centre

http://www.smmgp.org.uk/

http://www.smmgp.org.uk/html/featured-videos.php

Royal College of General Practitioners learning resource

http://elearning.rcgp.org.uk/course/index.php

Alcohol: Identification and Brief Advice

Alcohol: Management in Primary Care

Royal College of Psychiatrists CPD Online

Alcohol and the brain

Alcohol-related brain damage

Driving and mental disorders

Royal College of Psychiatrists Faculty of Addictions Psychiatry

https://www.alcoholconcern.org.uk/Handlers/Download.ashx?IDMF=8ec66a11-104f-4f02-aed8-892e23522c14

https://www.alcoholconcern.org.uk/Handlers/Download.ashx?IDMF=8ec66a11-104f-4f02-aed8-892e23522c14



https://fingertips.phe.org.uk/profile/local-alcohol-profiles/data#page/1/gid/1938132984/pat/6/par/E12000002/ati/101/are/E08000003

https://fingertips.phe.org.uk/profile/local-alcohol-profiles/data#page/1/gid/1938132984/pat/6/par/E12000002/ati/101/are/E08000003




146

http://www.rcpsych.ac.uk/workinpsychiatry/faculties/addictions.aspx

Journal Articles

Anton, R. F., O'Malley, S. S., Ciraulo, D. A., Cisler, R. A., Couper, D., Donovan, D. M., et al.

(2006). Combined pharmacotherapies and behavioral interventions for alcohol

dependence: the COMBINE study: a randomized controlled trial. JAMA, 295(17), 2003-

2017.

Group, P. (1998). Matching alcoholism treatments to client heterogeneity: treatment

main effects and matching effects on drinking during treatment. Project MATCH

Research Group. Journal of Studies on Alcohol, 58(1), 7- 29.

Home Office. Great Britain. (2012). The Government's alcohol strategy. Norwich: TSO.

Ijaz, S., Jackson, J., Thorley, H., Porter, K., Fleming, C., Richards, A., Savović, J. (2017).

Nutritional deficiencies in homeless persons with problematic drinking: A systematic

review. International Journal for Equity in Health, 16(1), 71.

Lifestyle Statistics Health and Social Care Information Centre. (2008). Statistics on alcohol

: England, 2013. London: Department of Health.

Mann, K., Lemenager, T., Hoffmann, S., Reinhard, I., Hermann, D., Batra, A., et al. (2013).

Results of a double-blind, placebo-controlled pharmacotherapy trial in alcoholism

conducted in Germany and comparison with the US COMBINE study. Addiction Biology,

18(6), 937-946.

Miller, W., & Wilbourne, P. (2002). Mesa Grande: A methodological analysis of clinical

trials of treatments for alcohol use disorders. Addiction, 93(3), 265-277.

National Institute for Health and Care Excellence. (2010). Alcohol use disorders:

diagnosis and clinical management of alcohol related physical complications CG 100.

London: National Institute for Health and Care Excellence.


diagnosis, assessment and management of harmful drinking and alcohol dependence CG

115. London: National Institute for Health and Care Excellence.


preventing harmful drinking PH24. London.

Office of National Statistics. (2017). Alcohol-specific deaths in the UK: registered in 2016.

In Office of National Statistics.

https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesof

death/bulletins/alcoholrelateddeathsintheunitedkingdom/registeredin2016

http://www.rcpsych.ac.uk/workinpsychiatry/faculties/addictions.aspx

https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeath/bulletins/alcoholrelateddeathsintheunitedkingdom/registeredin2016

https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeath/bulletins/alcoholrelateddeathsintheunitedkingdom/registeredin2016

147

Office of National Statistics. (2017) Statistics on Alcohol England, 2017.

https://www.gov.uk/government/statistics/statistics-on-alcohol-england-2017

Palmer, R. H., McGeary, J. E., Francazio, S., Raphael, B. J., Lander, A. D., Heath, A. C., et al.

(2012). The genetics of alcohol dependence: advancing towards systems-based

approaches. Drug and alcohol dependence, 125(3), 179-191.

Riley, E. P., Infante, M. A., & Warren, K. R. (2011). Fetal Alcohol Spectrum Disorders: An

Overview. Neuropsychology Review, 21(2), 73-80.

Palpacuer, C., Duprez, R., Huneau, A., Locher, C., Boussageon, R., Laviolle, B., & Naudet,

F. (2018). Pharmacologically controlled drinking in the treatment of alcohol dependence

or alcohol use disorders: a systematic review with direct and network meta-analyses on

nalmefene, naltrexone, acamprosate, baclofen and topiramate. Addiction. 113(2), 220-

237.

Pryce, R., Buykx, P., Gray, L., Stone, T., Drummond, C., & Brennan, A. (2017). Estimates of

Alcohol Dependence in England based on APMS 2014, including Estimates of Children

Living in a Household with an Adult with Alcohol Dependence Prevalence, Trends, and

Amenability to Treatment.

https://www.sheffield.ac.uk/polopoly_fs/1.693546!/file/Estimates_of_Alcohol_Depende

nce_in_England_based_on_APMS_2014.pdf

Session 2: Diagnosis and Treatment of People with Drug Misuse

Learning Objectives

Assessment, diagnosis and treatment of people with Drug Misuse

To develop working knowledge of principles of opioid substitution treatment

To increase awareness of other substances commonly misused

To develop awareness of complications associated with Drug Misuse

Curriculum Links


11.2 Considerations for prescribing and treatment modalities; Legal restrictions on

prescribing

https://www.gov.uk/government/statistics/statistics-on-alcohol-england-2017

https://www.sheffield.ac.uk/polopoly_fs/1.693546!/file/Estimates_of_Alcohol_Dependence_in_England_based_on_APMS_2014.pdf

https://www.sheffield.ac.uk/polopoly_fs/1.693546!/file/Estimates_of_Alcohol_Dependence_in_England_based_on_APMS_2014.pdf

148

11.4 Biological, psychological and socio-cultural explanations of drug and alcohol

dependence ; Cultural factors in the use and abuse of drugs

11.5 Impact of drug and alcohol use on Public Health

11.6 The assessment and management of drug misusers

11.8 Culturally appropriate strategies for the prevention of drug and alcohol abuse

Expert Led Session

Diagnosis and treatment of people with problems with opioid dependence

Rationale for using opioid substitution

Changing patterns of opioid use in recent years

Principle of initiation with methadone and buprenorphine

Case Presentation

A case of someone with polysubstance misuse

Highlight physical complications of injecting substances


Mattick RP, Breen C, Kimber J, Davoli M (2014) Cochrane Database Syst Rev. Buprenorphine

maintenance versus placebo or methadone maintenance for opioid dependence.

2:CD002207.

Abrahamsson, T., Berge, J., Öjehagen, A., & Håkansson, A. (2017). Benzodiazepine, z-drug

and pregabalin prescriptions and mortality among patients in opioid maintenance

treatment—A nation-wide register-based open cohort study. Drug and Alcohol Dependence,

174, 58- 64.

Ledberg, A. (2017). Mortality related to methadone maintenance treatment in Stockholm,

Sweden, during 2006–2013. Journal of Substance Abuse Treatment, 75, 35-41.


Novel psychoactive substances

Pain management in people with opioid dependence

149

Substance misuse problems in young people

Ethics of opiate substitution treatment

MCQs

1. Common term for illicit diazepam:

A. Plant food

B. Blues

C. Spice

D. Horse

E. Whizz

2. The following are true of Novel psychoactive substances except for:

A. GHB (gammahydroxybutrate) and GBL (gammabutyrolactone) act similarly to hallucinogens such

as LSD

B. Mephedrone is part of the cathinone family of drugs

C. Piperazines substances have stimulant effects

D. Paramethoxyamphetamine (PMA) is an methylenedioxymetamphetamine (MDMA) like substance

but associated with higher risks of death than MDMA

E. Ketamine use can results in haemorrhagic cystitis

3. The following are true of methadone except for:

A. Cases of QT interval prolongation and torsade de pointes have been reported during treatment with

methadone, particularly at high doses (>100mg).

B. Typical starting doses are in the range of 10 to 30 mgs

C. Methadone tablets are the preferred formulation for commencing treatment in opioid dependence

D. Use of Cimetidine may lead to potentiation of opioid activity due to displacement of methadone

from protein binding sites

E. Peak plasma levels occur 1-5 hours after a single dose of Methadone Mixture 1mg/1ml

4. The following are true about opioid substitution treatment except for:

A. Reduces the risk of death among heroin users

B. Suppresses illicit use of heroin

C. Reduces involvement in crime among heroin users participating in treatment

D. Reduces the risk of Blood Bourne Virus transmission, including in prisons

E. Promotes abstinence from all drugs

150

5. For long term treatment of pain using opioids, the following dose of oral morphine or equivalent

should not be exceeded:

A. 10 mg

B. 40 mg

C. 80 mg

D. 120 mg

E. 240 mg

EMI Questions

Medication used in treatment of opioid dependence:

A. Hyoscine butylbromide

B. Naloxone

C. Codeine phosphate

D. Clonidine

E. Lofexidine

F. Suboxone

G. Loperamide

H. Oxycodeine

I. Fentanyl

J. MXL morphine capsules

1a. This medication is a selective adrenergic alpha-2-receptor agonist

1b. This medication can be used to reduce risk of injecting behaviour

1c. This medication is frequently used for symptomatic relief of abdominal cramps during opioid

detoxification

Analgesics of misuse:

A. Fentanyl

B. Diacetlymorphine

C. Dihydrocodeine

D. MXL

E. Diconal

151

F. Buprenorphine

G. MST Continus

H. Tramadol

I. Methadone

J. MXL morphine capsules

2a. This compound is a combination of an antiemetic and a opioid

2b. This compound has effects on serotonin reuptake as well as effects on opioid receptors

2c. This compound is approximately 80 times more potent than morphine and is available as lozenges

and transdermal formulation


Books

Burroughs, W. Naked Lunch.

Chapter 17 in Cowen, P., Harrison, P. J., Burns, T., & Gelder, M. G. (2012). Shorter Oxford

textbook of psychiatry (6th ed.). Oxford: Oxford University Press.

Nestler, E. J., Hyman, S. E., & Malenka, R. C. (2009). Molecular neuropharmacology : a

foundation for clinical neuroscience (2nd ed. ed.). New York ; London: McGraw-Hill Medical.

Welsh, I. Trainspotting.

E-Learning

Drug Alerts

https://findings.org.uk/

http://michaellinnell.org.uk/drugwatch.html

https://wearetheloop.org/drug-alerts/

E-learning for Healthcare (e-LfH)


o Sexual Health & HIV

o Pain

European reports on substance misuse

https://findings.org.uk/

http://michaellinnell.org.uk/drugwatch.html

https://wearetheloop.org/drug-alerts/


152

http://www.emcdda.europa.eu/

Epidemiological data on Drug and Alcohol Treatment in England


Government information - Guidance for healthcare professionals on drug driving

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_

data/file/325275/healthcare-profs-drug-driving.pdf

GP learning resource centre



Neptune ( Novel Psychoactive Treatment: UK Network) E-learning modules

http://neptune-clinical-guidance.co.uk/e-learning/

Pain resources

Action on Addiction

o https://idhdp.com/mediaimport/38281/130607_pain_management_report__final_e

mbargoed_13_june.pdf

Opioid Aware:

o https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware

Living well with pain:

o http://livewellwithpain.co.uk/

Public Health England Information

https://www.gov.uk/government/organisations/public-health-england

Resource for drug advice

http://www.talktofrank.com/

Royal College of General Practitioners learning resource


o Drugs: Identification and Harm Reduction

o Drugs: Management of Drug Misuse (Level 1)

o Hepatitis B & C


Buprenorphine in opiate dependence

GHB: what psychiatrists need to know

Helping the addicted doctor

Hepatitis C and mental illness

Safe and effective opiate replacement therapy

http://www.emcdda.europa.eu/


https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/325275/healthcare-profs-drug-driving.pdf

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/325275/healthcare-profs-drug-driving.pdf



http://neptune-clinical-guidance.co.uk/e-learning/

https://idhdp.com/mediaimport/38281/130607_pain_management_report__final_embargoed_13_june.pdf

https://idhdp.com/mediaimport/38281/130607_pain_management_report__final_embargoed_13_june.pdf

https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware

http://livewellwithpain.co.uk/

https://www.gov.uk/government/organisations/public-health-england

http://www.talktofrank.com/


153

Stimulants: epidemiology and impact on mental health

Stimulants: treatment approaches and organising services

Substance misuse in older people

Royal College of Psychiatrists information

Drugs and alcohol: information for young people

o https://www.rcpsych.ac.uk/healthadvice/parentsandyouthinfo/youngpeople/drugsa

ndalcohol.aspx

Substance misuse in older people: an information guide

o https://www.rcpsych.ac.uk/usefulresources/publications/collegereports/cr/cr211.as

px

Society for the Study of Addiction

http://www.addiction-ssa.org/

US National institute on Drug Misuse

https://www.drugabuse.gov/drugs-abuse

Journal Articles

Action on Addiction. (2013). The Management Of Pain In People With A Past Or Current

History Of Addiction.

Baldwin, D. S., Aitchison, K., Bateson, A., Curran, H. V., Davies, S., Leonard, B., et al. (2013).

Benzodiazepines: risks and benefits. A reconsideration. Journal of Psychopharmacology,

27(11), 967-971.

Clinical Guidelines on Drug Misuse and Dependence Update 2017 Independent Expert

Working Group (2017). Drug misuse and dependence: UK guidelines on clinical management.

London: Department of Health.

DTB. (2016). QT interval and drug therapy. BMJ, 353, i2732.

EMCDDA. (2013). Drug prevention interventions targeting minority ethnic populations: issues

raised by 33 case studies: Publications Office of the European Union, Luxembourg.

EMCDDA. (2018). European Drug Report: Trends and Developments: Publications Office of

the European Union, Luxembourg http://www.emcdda.europa.eu/publications/edr/trends-

developments/2018.

Gossop, M., Marsden, J., Stewart, D., & Kidd, T. (2003). The National Treatment Outcome

Research Study (NTORS), 4-5 year follow-up results. Addiction, 98(3), 291-303.

Mujtaba, S., Romero, J., & Taub, C. C. (2013). Methadone, QTc prolongation and torsades de

pointes: Current concepts, management and a hidden twist in the tale Journal of

cardiovascular disease research, 4(4), 229-235.

https://www.rcpsych.ac.uk/healthadvice/parentsandyouthinfo/youngpeople/drugsandalcohol.aspx

https://www.rcpsych.ac.uk/healthadvice/parentsandyouthinfo/youngpeople/drugsandalcohol.aspx

https://www.rcpsych.ac.uk/usefulresources/publications/collegereports/cr/cr211.aspx

https://www.rcpsych.ac.uk/usefulresources/publications/collegereports/cr/cr211.aspx

http://www.addiction-ssa.org/

https://www.drugabuse.gov/drugs-abuse

http://www.emcdda.europa.eu/publications/edr/trends-developments/2018

http://www.emcdda.europa.eu/publications/edr/trends-developments/2018

154

National Institute for Health and Care Excellence. (2007). Drug misuse – opioid detoxification

CG52. London: National Institute for Health and Care Excellence.

National Institute for Health and Care Excellence. (2012). Opioids in palliative care: safe and

effective prescribing of strong opioids for pain in palliative care of adults CG140. London:

National Institute for Health and Care Excellence.

Office of National Statistics. (2017). Deaths Related to Drug Poisoning in England and Wales,

2016 Registrations.

https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/death

s/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2016registrations

Office of National Statistics. (2014). Number of deaths related to drug poisoning where

buprenorphine and/or methadone was mentioned on the death certificate by underlying

cause, England and Wales, deaths registered between 2007-2012.

The Royal College of Psychiatrists. (2018). Our Invisible Addicts, 2nd edition. College Report

CR211.

Royal College of Psychiatrists (2012). Practice standards for young people with substance

misuse problems.

Strang, J., Metrebian, N., Lintzeris, N., Potts, L., Carnwath, T., Mayet, S., et al. (2010).

Supervised injectable heroin or injectable methadone versus optimised oral methadone as

treatment for chronic heroin addicts in England after persistent failure in orthodox

treatment (RIOTT), a randomised trial. Lancet, 375(9729), 1885-1895.

Trescot, A. M., Datta, S., Lee, M., & Hansen, H. (2008). Opioid pharmacology. Pain Physician,

11(2 Suppl), S133-153.

United Kingdom Focal Point at Public Health England. (2013). United Kingdom Drug Situation

2013 Edition.

Session 3: Diagnosis and management of people with co-occurring mental health and alcohol/drug use conditions

Learning Objectives

To develop understanding of key aspects in the diagnosis and treatment of patients with co-

occurring mental health and alcohol/drug use conditions

To increase awareness of complications with pharmacological treatment in patients with co-

occurring mental health and alcohol/drug use conditions

https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2016registrations

https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2016registrations

155

To develop knowledge of risk issues in people with co-occurring mental health and

alcohol/drug use conditions

To understand how local services are implemented to manage people with co-occurring

mental health and alcohol/drug use conditions

Curriculum Links


11.5 Effect of drug and alcohol use on psychiatric illness

Expert Led Session

Diagnosis and treatment of people with psychosis and substance misuse

ICD 10/ICD 11 concepts relating to people with co-occurring mental health and alcohol/drug

use conditions)

Biological explanations of substances affecting psychosis

Case Presentation

Examine risk aspects of people with co-occurring mental health and alcohol/drug use

conditions

Relationship of the substance use to development of the symptoms


Asher CJ, Gask L. (2010) Reasons for illicit drug use in people with schizophrenia: Qualitative

study. BMC Psychiatry, 10:94

Chitty, K., Dobbins, T., Dawson, A., Isbister, G., & Buckley, N. (2017). Relationship

between prescribed psychotropic medications and co-ingested alcohol in intentional

self-poisonings. British Journal of Psychiatry, 210: 203-208 .

Newton-Howes, G., Foulds, J., Guy, N., Boden, J., & Mulder, R. (2017). Personality

disorder and alcohol treatment outcome: systematic review and meta-analysis. The

British Journal of Psychiatry, 211:22-30.


156

Personality disorder and substance misuse

Depression and alcohol

Psychotropic drug interactions with opioid substitution medications

Public health concerns of Chemsex

MCQs

1. Comparing antidepressants to placebo in people with alcohol and depression, improvements in the

following measures have recently been identified in a Cochrane Systematic Review except :

A. Reduced interview based depression score

B. Response to antidepressive medication

C. Full remission of depression

D. Increased number of abstinent patients

E. Fewer drinks per drinking day

2. Approximate percentage of people with psychosis who misuse substances at some point in their

lifetime:

A. 5

B. 20

C. 40

D. 60

E. 80

3. Using NICE guidance for people with alcohol-use disorders the following abstinence length is

suggested before treating the anxiety or depression condition:

A. 1-2 weeks

B. 3-4 weeks

C. 6-8 weeks

D. 10 -12 weeks

E. No time period specified – length of time based on clinical judgement.

4. Percentage of patients attending Community Mental Health Teams reporting past-year problem

drug use and/or harmful alcohol use has been found to be approximately:

A. 25

B. 35

C. 45

157

D. 55

E. 65

5. The following are true statements about Cannabis and psychosis except:

A. The onset of psychosis is about 3 years younger in cannabis users than in non-users

B. The relative risk of developing schizophrenia after any cannabis exposure is about 2.5

C. The specificity of the association between cannabis and psychotic disorders is low.

D. Certain genes such as COMT gene have been shown to moderate the risk of psychotic disorder with

adolescent cannabis exposure

E. Synthetic forms of cannabis such as spice do not contain cannabidiol

EMI Questions

Drugs that may induce psychiatric symptoms:

A. Gamma-Hydroxybutyric acid (GHB)

B. Lysergic acid diethylamide (LSD)

C. Ketamine

D. Phencyclidine (PCP)

E. Diazepam

F. Amphetamine

G. Cocaine

H. Alcohol

I. Cannabis

J. Butane

1a. This psychoactive component of this drug acts through the type 1 form of the receptors which

are found in high concentrations throughout the cerebellum, hippocampus, basal ganglia, cortex,

brainstem, thalamus and hypothalamus

1b. This compound acts as an agonist at 5HT2A receptor

1c. One of the main mechanisms of action of this drug is by reverse transfer of the neurotransmitter

dopamine

Psychotropic medications used in people with co-occurring mental health and alcohol/drug use

conditions:

A. Diazepam

158

B. Quetiapine

C. Risperidone

D. Citalopram

E. Amisulpride

F. Sertraline

G. Baclofen

H. Olanzapine

I. Aripipazole

J. Fluoxetine

2a. Disulfiram can inhibit the metabolism of this compound

2b. This antipsychotic should be considered in patients with impaired liver function

2c. This agent may have a role in promoting maintenance of alcohol abstinence and can be safely used

in patients with impaired liver function


E-Learning


Dual diagnosis: the diagnosis and treatment of depression with co-existing substance

misuse.

Journal Articles

Agabio, R., Trogu, E., & Pani, P. (2018, 4). Antidepressants for the treatment of people with

co-occurring depression and alcohol dependence. The Cochrane database of systematic

reviews, 4, CD008581.

Bebbington, P., & McManus, S. (2009). Adult psychiatric morbidity in England, 2007: results

of a household survey. London: National Centre for Social Research

Caton, C., Hasin, D., Shrout, P., Drake, R., Dominguez, B., Samet, S., & Schanzer,

B. (2006). Predictors of psychosis remission in psychotic disorders that co-occur with

substance use. Schizophrenia Bulletin, 32(4), 618-25.

Colizzi, M., & Murray, R. (2018, 4 20). Cannabis and psychosis: what do we know and what

should we do? The British Journal of Psychiatry, 212(04), 195-196.

Conner, K. R., Pinquart, M., & Duberstein, P. R. (2008). Meta-analysis of depression and

substance use and impairment among intravenous drug users (IDUs). Addiction, 103(4), 524-

534

159

Conner, K. R., Pinquart, M., & Gamble, S. A. (2009). Meta-analysis of depression and

substance use among individuals with alcohol use disorders. Journal of Substance Abuse

Treatment, 37(2), 127-137

Conner, K. R., Pinquart, M., & Holbrook, A. P. (2008). Meta-analysis of depression and

substance use and impairment among cocaine users. Drug and Alcohol Dependence, 98(1-2),

13-23

Davis, L. L., Pilkinton, P., Wisniewski, S. R., Trivedi, M. H., Gaynes, B. N., Howland, R. H., et al.

(2012). Effect of concurrent substance use disorder on the effectiveness of single and

combination antidepressant medications for the treatment of major depression: an

exploratory analysis of a single-blind randomized trial. Depression and anxiety, 29(2), 111-

122.

Delgadillo, J. G., C. Gilbody, S. Payne, S. (2013). Depression, anxiety and comorbid substance

use: association patterns in outpatient addictions treatment. Mental Health and Substance

Use, 6(1), 59-75

Foulds, J., Adamson, S., Boden, J., Williman, J., & Mulder, R. (2015). Depression in patients

with alcohol use disorders: Systematic review and meta-analysis of outcomes for

independent and substance-induced disorders. Journal of Affective Disorders, 185:47-59.

Healthcare Quality Improvement Partnership. (2018). National Confidential Inquiry into

Suicide and Homicide: Report 2018.

Iovieno, N., Tedeschini, E., Bentley, K., Evins, a., & Papakostas, G. (2011). Antidepressants for

major depressive disorder and dysthymic disorder in patients with comorbid alcohol use

disorders: a meta-analysis of placebo-controlled randomized trials. The Journal of clinical

psychiatry, 72 (8), 1144-51.

Maremmani, A. G., Rovai, L., Rugani, F., Bacciardi, S., Dell'osso, L., & Maremmani, I. (2014).

Substance abuse and psychosis. The strange case of opioids. Eur Rev Med Pharmacol Sci,

18(3), 287-302

National Institute for Health and Care Excellence. (2011). Psychosis with coexisting

substance misuse CG120. London: National Institute for Health and Care Excellence

Niemi-Pynttäri, J., Sund, R., Putkonen, H., Vorma, H., Wahlbeck, K., & Pirkola, S.

(2013). Substance-induced psychoses converting into schizophrenia: A register-

based study of 18,478 finnish inpatient cases. Journal of Clinical Psychiatry, 74(1),

e94-9.

Nunes E V, Levin F R. (2004) Treatment of depression in patients with alcohol or other drug

dependence: a meta-analysis. JAMA, 291(15), 1887-1896

160

Pettinati, H., O'Brien, C., & Dundon, W. (2013). Current status of co-occurring mood and

substance use disorders: A new therapeutic target. American Journal of Psychiatry, 170(1),

23–30

PHE. (2017). Better care for people with co-occurring mental health, and alcohol and drug

use conditions.

Radhakrishnan, R., Wilkinson, S. T., & D'Souza, D. C. (2014). Gone to Pot - A Review of the

Association between Cannabis and Psychosis. Front Psychiatry, 5, 54

Riper, H., Andersson, G., Hunter, S., de Wit, J., Berking, M., & Cuijpers, P. (2014). Treatment

of comorbid alcohol use disorders and depression with cognitive-behavioural therapy and

motivational interviewing: A meta-analysis. Addiction, 109(3), 394-406

Starzer, M., Nordentoft, M., & Hjorthøj, C. (2018). Rates and predictors of conversion to

schizophrenia or bipolar disorder following substance-induced psychosis. American Journal

of Psychiatry, 175(4), 343-350.

Weaver, T., Madden, P., Charles, V., Stimson, G., Renton, A., Tyrer, P., et al. (2003).

Comorbidity of substance misuse and mental illness in community mental health and

substance misuse services. The British Journal of Psychiatry, 183, 304-313

Session 4: Recovery Concepts, Psycho-social Treatments and Service Development

Learning Objectives

To understand principle of recovery and how this is implemented with drug and alcohol

services

To gain knowledge of some of the basic concepts of motivation interviewing

To gain knowledge about how services for drug and alcohol are developed

To understand what ancillary services are frequently used with alcohol and drug services

Curriculum Links

11.5 Impact of drug and alcohol use on Public Health

11.10 Motivational Interviewing

Expert Led Session

161

Psychosocial treatments for people with substance misuse problems

Overview of various interventions that are offered in substance misuse: brief interventions,

mapping techniques (e.g. ITEP), motivational interviewing overview

Useful to use youtube clips below for teaching session

Case Presentation

Presentation of a person who had significant substance misuse problem +/- comorbid

mental illness who has recovered and resources employed to effect and maintain this

recovery


Heather, N. (2017). Q: Is Addiction a Brain Disease or a Moral Failing? A: Neither.

Neuroethics, 10(1), 115-124.

Hibbert, L., & Best, D. (2011). Assessing recovery and functioning in former problem drinkers

at different stages of their recovery journeys. Drug and Alcohol Review, 30( 1), 12-20

Humphreys K, Blodgett JC, Wagner TH.(2014) Estimating the efficacy of Alcoholics

Anonymous without self-selection bias: An instrumental variables re-analysis of randomized

clinical trials. Alcoholism: Clinical and Experimental Research, 38(11), 2688-94

.


Overview of non-statutory services ( e.g. AA, NA, SMART)

Risks associated with substance misuse in prisoners

Harm minimisation approaches in substance misuse services

Gambling disorder – diagnosis and treatment

MCQs

1. Which of the following is not an example of change talk:

A. Desire: I would like to stop using alcohol

B. Ability: I could stop alcohol use

C. Reason: Alcohol worsens my psoriasis

D. Accomplishment: I finally stopped alcohol

162

E. Need: I have got to stop alcohol

2. Prochaska and DiClemente’s stages of change include the following except:

A. Contemplation

B. Preparation

C. Maintenance

D. Relapse

E. Persistence

3. Who of the following is most closely linked with Motivational Interviewing:

A. Carl Jung

B. Carl Rogers

C. David Winnicott

D. Aaron Beck

E. Melanie Klein

4. All of the following are key principles of Motivational Interviewing except:

A. Roll with resistance

B. Express empathy

C. Develop discrepancy

D. Support self efficacy

E. Strengthen safety behaviour

5. Which of the following is true of needle exchange programmes in the UK

A. Pharmacies are unable to provide this service

B. It is only available to people prescribed opioid substitute medications

C. It is only available in urban centres with populations greater than 50000

D. Only qualified nursing staff can dispense equipment

E. It reduces injection risk behaviours among people who inject drugs, in particular self- reported

sharing of needles and syringes, and frequency of injection

EMI Questions

Potential mechanisms to manage resistance:

163

A. Simple reflection

B. Amplified reflection

C. Double sided reflection

D. Shifting focus

E. Reframing

F. Agreement with a twist

G. Emphasising personal control

H. Coming alongside

I. Reaction

J. Summarizing

1a. This approach enables the validity of the client’s raw observation to be regarded but tries to

interpret the observation in a new way.

1b. This may be considered when someone says “I am my own man, I do not need you to tell me what

to do”

1c. The following exchange highlights this approach:

Client: “I have been able to use more heroin than other people in my town”

Therapist: “Perhaps you are simply immune to the effects of heroin”.

Mutual aid groups:

A. Alcoholics Anonymous (AA)

B. SMART Recovery

C. GamCare

D. TalkToFrank

E. Teen Challenge UK

F. British Doctors’ and Dentists' Group

G. Narcotics Anonymous (NA)

H. Breaking free

I. Kaleidoscope

J. Discover

2a. This is a global, community-based organization with a multi-lingual and multicultural membership.

It was founded in 1953.

2b. This is a science-based programme to help people manage their recovery from any type of

addictive behaviour. It began in 1994.

164

2c. This is a free drug advice service that is aimed at parents and children in particular. It is available

24 hours a day and online and by text message.


Books

Miller, W. R., & Rollnick, S. (2012). Motivational interviewing : helping people change (3rd

ed.). New York, NY: Guilford Press. (any edition reasonable)

Rodgers, N. Le Freak: An Upside Down Story of Family, Disco, and Destiny

E-Learning

Drink and Drug News- local update on substance misuse with recovery focus

https://drinkanddrugsnews.com/

Harm minimisation

http://www.prenoxadinjection.com/

https://www.harmreduction.co.uk/resources

Motivation interviewing

http://www.youtube.com/watch?v=80XyNE89eCs

http://www.youtube.com/watch?v=URiKA7CKtfc

http://www.youtube.com/watch?v=s3MCJZ7OGRk

http://www.youtube.com/watch?v=_KNIPGV7Xyg

Journal Articles

Best, D., Albertson, K., Irving, J., Lightowlers, C., Mama-Rudd, A., & Chaggar, A. (2015). The

UK Life in Recovery Survey 2015 : the first national UK survey of addiction recovery

experiences. Project Report. Sheffield. Helena Kennedy Centre for International Justice.

Sheffield Hallam University.

Faculty of Addictions Psychiatry, R. C. o. P. (2014). Gambling: the hidden addiction. Faculty

report FR/AP/01. Future trends in addictions – discussion paper 1.

Degenhardt, L., Larney, S., Kimber, J., Gisev, N., Farrell, M., Dobbins, T., et al. The impact of

opioid substitution therapy on mortality post-release from prison: retrospective data linkage

study. Addiction. 109(8), 1306-1317.

Gossop, M., Trakada, K., Stewart, D., & Witton, J. (2005). Reductions in criminal convictions

after addiction treatment: 5-year follow-up. Drug and alcohol dependence, 79(3), 295-302.

https://drinkanddrugsnews.com/

http://www.youtube.com/watch?v=80XyNE89eCs

http://www.youtube.com/watch?v=URiKA7CKtfc

http://www.youtube.com/watch?v=s3MCJZ7OGRk

http://www.youtube.com/watch?v=_KNIPGV7Xyg

165

Hall, W., Carter, A., & Forlini, C. (2015). The brain disease model of addiction: Is it supported

by the evidence and has it delivered on its promises? The Lancet Psychiatry, 2, 105–110.

Heather, N., Best, D., Kawalek, A., Field, M., Lewis, M., Rotgers, F., Heim, D. (2017).

Challenging the brain disease model of addiction: European launch of the addiction theory

network. Addiction Research and Theory, 26(4), 249-255.

Larney, S., Gisev, N., Farrell, M., Dobbins, T., Burns, L., Gibson, A., et al. Opioid substitution

therapy as a strategy to reduce deaths in prison: retrospective cohort study. BMJ Open, 4(4),

e004666.

National Institute for Health and Care Excellence. (2014). Needle and syringe programmes

PH52. London: National Institute for Health and Care Excellence.

Strang, J. (2012). Medications in recovery re-orientating drug dependence treatment:

National Treatment Agency.

Volkow, N., & Koob, G. (2015). Brain disease model of addiction: Why is it so controversial?

The Lancet Psychiatry, 2(8), 677-679.

INTELLECTUAL DISABILITIES SEMESTER 3:

Session 1: History Taking and Communication in Patients with an

Intellectual Disability

Learning Objectives

Awareness of the difficulties encountered in assessing patients with an intellectual disability

Use of other forms of communication rather than just verbal

The importance and role of the developmental history

To develop an understanding of how patients with an intellectual disability can present

with conditions such as a mental disorder

Curriculum Links

166

13.3 Clinical

13.3.1 Assessment and communication with people with intellectual disability.

13.3.2 The presentation and diagnosis of psychiatric illness and behavioral disorder in people

with intellectual disability, including the concept of diagnostic overshadowing

13.2.2 Aetiology. The influence of psychological and social factors on intellectual and

emotional development in people with intellectual disability, including the concept of

secondary handicap.

Expert Led Session

Assessment, interviewing & gathering information in adults with Intellectual disability

Case Presentation

Case presentation of local patient with intellectual disability, identified by tutor or

specialist in post. (This does not have to be an inpatient and discussion with the local ID

team may be appropriate in advance to identify such a case). Brief discussion on aetiology

as applicable to the case in a formulation type summary


Assessment of mental health problems in people with autism Xenitidis K., Paliokosta E.,

Maltezos S. and Pappas V. (2007). Advances in Mental Health and Learning Disabilities 1, 4,

15-22.

A guide to intellectual disability psychiatry assessments in the community. Advances in

psychiatry Treatment November 1, 2013 19:429-436

Learning disability in the accident and emergency department. Advances in Psychiatric

Treatment January 2005 11:45-57

167


Please select one of the following:

Assessment of the agitated patient in the emergency room setting (focus on

environment, style of communication, getting informant history etc)

How to assess for a mental illness in a patient with a Intellectual disability (Focus on

depressed mood or psychosis depending on confidence of chair- possible mute patient,

signs and how they differ, role of biological symptoms and effect on routine)

How to perform a full Developmental History (Focus on all aspects of development and issues

of schooling, statement of educational needs, support and current functional ability etc)

MCQs

1. With regard to people with intellectual disabilities, which of the following is false:

A. Diagnosis of intellectual disability is dependent on significantly sub-average IQ and associated

deficits in adaptive behaviour with onset occurring before 18 years of age

B. The prevalence of intellectual disability in the general population is 3%

C. Mental health problems are more common than in the general population

D. Mental health problems always present as challenging behaviour

E. The philosophy of normalisation supports people with intellectual disabilities accessing generic

health services.

2. According to ICD-10, the following is not a degree of mental retardation:

A. Borderline

B. Moderate

C. Profound

D. Severe

E. Mild

3. Disruptive and dissocial behaviour occurs more commonly in which of the following category?

A. Mild intellectual disability

B. Moderate intellectual disability

C. Severe intellectual disability

D. Profound intellectual disability

E. Equally common across all categories

4. The prevalence of epilepsy in the intellectual disability population is approximately:

A. 1-2%

B. 5-10%

C. 10-15%

D. 20-25%

168

E. 50%

5. The communication style that does not interfere with assessment in the intellectual disability

population is:

A. Denial

B. Fabrication

C. Engagement

D. Digression

E. Suggestibility


Books

Intellectual Disability Psychiatry: A Practical Handbook. Edited by Angela

Hassiotis, Diana Andrea Barron and Ian Hall.(2010) Wiley Publications.

The Psychiatry of Intellectual Disability. Edited by Meera Roy, Ashok Roy &

David Clark. 2006 Radcliffe Publishing Ltd.

Royal College of Psychiatrists. DC-LD: Diagnostic Criteria for Psychiatric Disorders

for Use with Adults with Learning Disabilities/mental Retardation (Occasional paper)

http://www.rcpsych.ac.uk/publications/collegereports/op/op48.aspx

E-Learning

http://www.gmc-uk.org/learningdisabilities/

Journal Articles

Cooper, A., Simpson, N. (2006). Assessment and classification of psychiatric

disorders in adults with learning disabilities. Psychiatry, 5: 306-11.

Cooper, S.-A., van der Speck, R. (2009) Epidemiology of mental ill health in adults

with intellectual disabilities. Current Opinion in Psychiatry. 22: 431-436.

http://www.rcpsych.ac.uk/publications/collegereports/op/op48.aspx

http://www.gmc-uk.org/learningdisabilities/

169

Session 2: Mental Disorders in Intellectual Disability

Learning Objectives

Recognising and identifying how the presentation of mental disorders differs in ID population

Importance of collateral information from various sources

Role of medication/ doses/side effects

Curriculum Links

13.1 Services

13.1.2 The provision of specialist psychiatric services for people with intellectual disability

13.2.1 The factors which might account for the observed high rates of psychiatric behavioral

disorders in this group.

13.3.2 The presentation and diagnosis of psychiatric illness and behavioral disorder in people


13.3.4 The application of psychiatric methods of treatment in intellectual disability including

drug treatments. The application of a multidisciplinary approach to the management of

mental health problems in people with intellectual disability

Expert Led Session

Dr Patel’s presentation - Mental disorders

Case Presentation

Case presentation of a local patient with intellectual disability, identified by tutor or

specialist in post. If there is neither a specialist consultant nor tutor in post discussion with

the local ID team may be appropriate in advance to identify such a case. Brief discussion

on aetiology as applicable to the case in a formulation type summary



Cooper S.A., Smiley E., Morrison J., Williamson A. and Allan L. (2007) Mental ill-health

in adults with intellectual disabilities: prevalence and associated factors. British Journal

of Psychiatry 190, 1, 27-35.

170

Hurley A.D. (2006) Mood disorders in intellectual disability. Current Opinion in Psychiatry

19, 5, 465-469.

Cooper S.A. Melville C.A. and Enfield S.L. (2003) Psychiatric diagnosis, intellectual

disabilities and Diagnostic Criteria for Psychiatric Disorders for Use with Adults with

Learning Disabilities/Mental Retardation (DC-LD). Journal of Intellectual Disability Research

47, supplement one, 3-15.



Assessment of the Psychotic patient in the community setting (focus on environment, style

of communication, getting informant history etc.)

Perform a risk assessment in a patient with a moderate Learning disability who is

presenting with self-injurious behaviour (Focus on nature of behaviours, communication

ability of the patient, issues of any change.)

What are the roles of a community ID nurse, speech and Language therapist and an

Occupational therapist in the ID team?(You can discuss this with your local ID team to

guide with the task)

MCQs

1. In individuals with severe learning disability, self-injurious behaviour has a peak

occurrence between the ages of:

A. 10-15 yrs

B. 15-20

C. 20-25

D. 25-30

E. 35-40

2. Self-injurious behaviour is common in which of the following:

A. Cri du chat syndrome

B. Angelman syndrome

C. Downs Syndrome

D. Cornelia de Lange syndrome

E. Lesch Nyhan syndrome

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3. Prevalence of depression in ID is around:

A. 1%

B. 2-4%

C. 5-15%

D. 16-25%

E. 26 -35%

4. Which of the following apply to the PAS-ADD:

A. Was developed from the SCID

B. Focuses exclusively to Axis II Disorders

C. Designed for completion by carers with knowledge of psychopathology

D. Each item is rated on a 6 point scale

E. It comprises a life events and a problems section

5. In patients with ID and schizophrenia compared with patients with ID alone, the following

were noted:

A. Impaired mobility

B. High birth weight

C. Gestation beyond 38 weeks

D. Impaired hearing

E. Low rates of obstetric complications


Books

Seminars in the psychiatry of learning disabilities – second edition (2003), The Royal college of Psychiatrists, Gaskell

Psychiatric and behavioural disorders in developmental disabilities and mental retardation (2001), Edited by Nick Bouras, Cambridge University Press, 1999. Reprinted 2001.

Practice guidelines for the assessment and diagnosis of mental health problems in adults with intellectual disability (2001) Deb, S., Matthews, T., Holt, G., & Bouras, N. published by Pavillion for the European Association for mental Health in Mental Retardation.

Sturmey, P. (1995) DSM-III-R and persons with dual diagnoses: conceptual issues and strategies for future research, Journal of intellectual Disability Research, 39, 357-364

Corbett, J. A. (1979) Psychiatric morbidity and mental retardation. In: F. E. James and R. P. Snaith (Eds.) Psychiatric illness and Mental Handicap, London: Gaskell.

Lund, J. (1985) The prevalence of psychiatric morbidity in mentally retarded adults, Acta Psychiatrica Scandinavica, 72, 563-570

172

Reiss, S. (1988) The Reiss Screen for Maladaptive Behaviour. Ohio: IDS Publishing Corporation.

Matson JL and Bamburg J (1998) Reliability of the assessment of dual diagnosis (ADD), research in Developmental Disabilities 20, 89-95

Moss S (2002) The mini PAS-ADD interview pack, Brighton: Pavilion Publishing

Roy A, Matthew H, Martin D and fowler V (2002) HoNOS-LD: Health of the Nation Outcome scale for people with Learning Disabilities, Kidderminster: British Institute of Learning Disabilities

Journal Articles

Bouras, N. and Drummond, C. (1992) Behaviour and psychiatric disorders of people with mental handicaps living in the community. Journal of Intellectual Disability Research, 36, 349-357.

Patel, P., Goldberg, D., and Moss, S. (1993) Psychiatric Morbidity in older people with moderate and severe learning disability: The Prevalence Study, British Journal of Psychiatry, 163, 481-491.

Diagnostic Criteria for Psychiatric Disorders for adults with learning disabilities (DC-LD) (2003) Journal of Intellectual Disability Research, 47, supplement 1.

173

Session 3: Behavioural Issues in Intellectual Disability

Learning Objectives

Understanding challenging behaviour and awareness of methods of recording/ assessing

Aetiology of challenging behaviours

Management options

Curriculum Links

13.1 Services

13.1.2 The provision of specialist psychiatric services for people with intellectual disability

13.2.1 The factors which might account to the observed high rates of psychiatric behavioural disorders in this group

13.3.2 The presentation and diagnosis of psychiatric illness and behavioural disorder in people with intellectual disability, including the concept of diagnostic overshadowing

Expert Led Session

Challenging Behaviour Talk

Case Presentation

Case presentation of local patient with intellectual disability presenting with behavioural

problems, identified by tutor or specialist in post (this does not have to be an inpatient

and discussion with the local ID team may be appropriate in advance to identify such a

case). Brief discussion on aetiology as applicable to the case in a formulation type

summary



Unwin G.L. and Deb S. (2008) A multi-centre audit of the use of medication for the

management of behavioural problems in adults with intellectual disabilities. British Journal

of Learning Disabilities, 36, 2, 140-143

Cooper S.A. Melville C.A. and Enfield S.L. (2003) Psychiatric diagnosis, intellectual

disabilities and Diagnostic Criteria for Psychiatric Disorders for Use with Adults with

Learning Disabilities/Mental Retardation (DC-LD). Journal of Intellectual Disability Research

47, supplement one, 3-15.

174

Group-based cognitive-behavioural anger management for people with mild to moderate

intellectual disabilities: cluster randomised controlled trial BJP October 2013 203:288-296;



Review of Frith Guidelines on management of Patients with ID that present with Aggressive

or Self Injurious behaviours. (Read the Guidelines in particular the flow charts)

Describe challenging behaviour and the various phases of the cycle of challenging behaviour

(Focus on nature of behaviours, communication ability of the patient, issues of any change.)

Formal Assessment of a behavioural problem with a view to intervention. (You can discuss

this with your local ID team to guide with the task). Steps involved, would include ABC

charts or functional assessments and basic behavioural interventions

MCQs

1. Causes of challenging behaviour in a person with learning disability:

A. Pain

B. Overstimulation

C. Under stimulation

D. Wanting attention

E. All of the above

2. The following statements are true of factors increasing challenging behaviours in a person

with learning disability except which option?

A. Undetected physical illness

B. Communication problems

C. Underlying mental illness

D. Environmental issues

E. Problem solving ability

3. Inappropriate behaviours may be maintained by re-enforcement from others. Which of

the following is a process that helps to identify factors maintaining that behaviour?

A. Functional analysis

B. Statistical analysis

C. Procedural analysis

D. Behavioural analysis

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EMI Questions

Match each of the following psychological strategies to their possible effects:

A. Proactive Strategies

B. Positive Programming

C. Focused Support

D. Reactive Strategies

1. Systematic instructions given for greater skills and competence development which improves

social integration

2. To produce rapid results and reduce reactive strategies

3. Designed to manage the behaviours at the time they occur

4. To produce change over time


E-Learning

www.LD-Medication.bham.ac.uk

British Psychological Society and Royal College of Psychiatrists (BPS & RCPsych, 2006). Challenging behaviour: a unified approach. Available:

http://www.rcpsych.ac.uk/pdf/23%2009%202011%20LD%20PSYCH%20READING%20LIST.pdf

http://www.ld-medication.bham.ac.uk/

http://www.rcpsych.ac.uk/pdf/23%252009%25202011%2520LD%2520PSYCH%2520READING%2520LIST.pdf

176

Session 4: Offenders in Intellectual Disability

Learning Objectives

Awareness of differences in offending behaviours in ID population

Outcome following Offence

Treatment options for offenders with ID

Curriculum Links

13.1 Services

13.1.2 The provision of specialist psychiatric services for people with intellectual disability *Forensic ID

13.2.1 The factors which might account to the observed high rates of psychiatric behavioural

disorders in this group.

13.2.2 The influence of psychological and social factors on intellectual and emotional development

in people with intellectual disability, including the

13.3.2 The presentation and diagnosis of psychiatric illness and behavioural disorder in people


13.2.1 The factors which might account to the observed high rates of psychiatric behavioural

disorders in this group

13.3.7 The assessment, management and treatment of offenders with intellectual disability

Expert Led Session

Dr. Razzaque Lecture (and Dr Burke and Dr Gupta) + optional case vignettes

Case Presentation

Case presentation of local patient with intellectual disability presenting with offending behaviour

problems. , identified by tutor or specialist in post (this does not have to be an inpatient and discussion

with the local ID team may be appropriate in advance to identify such a case). Brief discussion on

aetiology as applicable to the case in a formulation type chair to pose question if patient has an IQ of

55 how will this alter i.e. pathway/management.

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Mentally disordered detainees in the police station: the role of the psychiatrist APT March 2010 16:115-123; doi:10.1192/apt.bp.107.004507

Ian Hall Young offenders with a learning disability APT July 2000 6:278-

285; doi:10.1192/apt.6.4.278

S. Halstead Forensic Psychiatry for People with Learning Disability APT March 1996 2:76-85;

doi:10.1192/apt.2.2.76

Arrest patterns among mentally disordered offenders. BJP September 1988 153:313-6 ‘555’ Topics (5 slides on each topic with no more than 5 bullet points)


Describe the pathway of a person with intellectual disability following a recent fire

setting incident

Describe Disability Discrimination Act and its impact on patients and clinicians. (Focus

on nature of behaviours, communication ability of the patient, issues of any change.)

Safe Guarding Formal Assessment of a behavioural problem with a view to intervention.

(You can discuss this with your local ID team to guide with the task)

MCQs

1. Offenders with ID compared to other offenders:

A. Start offending at a later age

B. Frequently are convicted of single offences

C. Arson offences are over represented

D. More in severe and profound disability

E. Less likely to be convicted

2. Mentally ill offenders with ID were found to be:

A. Younger at first conviction

B. Had less admissions to psychiatric hospitals

C. Showed a high frequency of violence

D. Tended to be females

E. Committed more serious offences during the follow-up period

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3. In patients with ID referred for evaluation for a report, the percentage felt not competent to stand

trial is (approximately):

A. Up to 10%

B. 11 - 20%

C. 21 - 30%

D. 31 - 40%

E. 41 - 50%

4. In offenders with ID the following is the most commonly used form of psychological input/ therapy:

A. Psychodynamic Psychotherapy

B. Gestalt Therapy

C. Cognitive Behavioural Therapy

D. Response and stimulus prevention

E. Dialectical Behavioural Therapy

5. Regarding the PCL-R;

A. Low scores are related to recidivism

B. Relate to Cluster A personality disorders

C. Those in medium security have higher scores than those in high security

D. Scoring patterns in ID population are significantly different compared to the general population

E. High scores relate to aggression


**William Fraser & Michael Kerr (eds) Seminars in the psychiatry of learning disability Gaskell

Press 2003 ISBN 1-901242-93-5

Chapter 16: Forensic psychiatry and learning disability by Susan Johnston

Wm Lindsay et al (Eds) Offenders with developmental disabilities 2004. Willey ISBN: 0-471-

48635-3

Ian Hall Young offenders with a learning disability APT July 2000 6:278-

285; doi:10.1192/apt.6.4.278

S. Halstead Forensic Psychiatry for People with Learning Disability APT March 1996 2:76-85;

doi:10.1192/apt.2.2.76

Mentally disordered detainees in the police station: the role of the psychiatrist APT March

2010 16:115-123; doi:10.1192/apt.bp.107.004507

Kalpana Dein and Marc Woodbury-Smith Asperger syndrome and criminal behaviour APT

January 2010 16:37-43; doi:10.1192/apt.bp.107.005082

David Murphy Understanding offenders with autism-spectrum disorders: what can forensic

services do?: commentary on... asperger syndrome and criminal behaviour APT January 2010

180

16:44-46; doi:10.1192/apt.bp.109.006775

Michael A. Ventress, Keith J. B. Rix, and John H. Kent: Keeping PACE: fitness to be

interviewed by the police APT September 2008 14:369-381; doi:10.1192/apt.bp.107.004093

Legal aspects in Psychiatry of Learning Disability:

This module does not currently include a specific lecture on legal aspects. You should be familiar

with the Mental Health Act 1983 and Mental Capacity Act 2005 from other modules on this course.

Some supplementary reading is included here:

Asit B. Biswas and Avinash Hiremath: Mental capacity assessment and ‘best interests’

decision-making in clinical practice: a case illustration APT November 2010 16:440-447;

doi:10.1192/apt.bp.108.006494

PSYCHOTHERAPY SEMESTER 3:

Session 1: Referring to Psychotherapy Services

Learning Objectives

Identify relevance to psychotherapy of particular aspects of the psychiatric history. Account for psychiatric presentation in psychological terms. Know when to refer patients appropriately to specialist services Understand that psychotherapies have an empirical evidence base underpinning referral for treatment

Curriculum Links

6 – Organization & Delivery of Psychiatric Services 7.1.x.4 – Psychological aspects of treatment 9.0 – Psychotherapy 9.1.1 – Dynamic Psychotherapy or 9.3 CBT or 9.4 other modalities * *Depending on case material and therapy described.

Expert Led Session

What happens in a specialist psychotherapy assessment and why? What therapies are indicated for which common conditions? – To include reference to the current evidence base. NICE Guidance and its limits / omissions.

Case Presentation

Case presentation of a local patient referred for psychotherapy. Case to be identified by tutor/chair/specialist in post. To highlight aspects of psychiatric history that indicate referral to psychotherapy. To highlight aspects of history that would be relevant for specialist psychotherapy assessment. To highlight factors that suggest good or bad prognostic signs for therapy outcome.


The paper should preferably be selected in discussion with the chair / presenter of the expert led session

• Schöttke H. et al (2017) “Predicting psychotherapy outcome based on therapist interpersonal skills: A five-year longitudinal study of a therapist assessment protocol” Psychotherapy Research 27(6): 642–652

• Clarke et al (2013) “Cognitive analytic therapy for personality disorder: randomised controlled trial” BJP 202:129-134 (with accompanying Editorial) Mulder & Chanen (2013) “Effectiveness of cognitive analytic therapy for personality disorders” BJP 202:89-90

• Lorentzen et al (2013) “Comparison of short- and long-term dynamic group psychotherapy: randomised clinical trial” BJP 203:280-287

182

• Leichsenring & Rabung (2008) “Effectiveness of Long-Term Psychodynamic Psychotherapy: A Meta-Analysis” JAMA 300(13): 1551-1565


Select one of the following:

• Important aspects of psychiatric history to include in referral

• Positive predictors of engagement with therapy

• Relative contraindications to therapy

• Potential adverse effects of therapy

MCQs

1. The following theorists are correctly matched with the concepts that they introduced: A. Sigmund Freud The Subconscious B. Melanie Klein The Paranoid-Schizoid Position C. David Malan The Two Triangle technique D. Herbert Rosenfeld Containment E. Anna Freud The Ego 2. Defences: A. Are always pathological. B. Reduce anxiety. C. Enhance conscious insight. D. Are universal. E. Develop later in childhood. 3. A psychotherapy formulation: A. Leads to a diagnosis. B. Ignores the past. C. Is only applicable in psychotherapy. D. Is theory neutral. E. Makes predictions.

4. How do you define transference?

A. The empathy shown by the therapist to the patient.

B. Defence mechanism where attention is shifted to a less threatening / more benign target.

C. Therapist’s response to the patient drawn from therapist’s previous life experiences.

D. Patient’s response to the therapist based upon their earlier relationships

E. All of the above

5. What would suggest a patient has good psychological mindedness?

183

A. Becoming very upset when talking about the past

B. Finding it hard to step back and observe the situation objectively

C. Needing to be talked through assessment with lots of prompts

D. Reasonable sense of self esteem



Jessica Yakeley (2014)“Psychodynamic psychotherapy: developing the evidence base” APT 20:269-279 Chess Denman (2011) “The place of psychotherapy in modern psychiatric practice” APT 17:243-249

184

Session 2: Psychological approaches to EUPD

Learning Objectives

The overall aim of the session is to understand emotionally unstable personality disorder from a psychological /psychotherapy perspective.

By the end of the session the trainee should have an understanding of the psychological aspects of this diagnosis.

By the end of the session the trainee should have a more detailed understanding of at least one of the newer therapy approaches to EUPD.

Curriculum Links

2.x – Human Development 6 – Organization & Delivery of Psychiatric Services 7.1.9.1-5 – Psychological aspects of treatment 9.0 – Psychotherapy 9.1.1 – Dynamic Psychotherapy or 9.3 CBT or 9.4 other modalities * *Depending on case material and therapy described.

Expert Led Session

Developments in the psychological understanding of EUPD: aetiology and presentation What therapies are indicated for EUPD? – To include reference to the current evidence base. NICE Guidance and its limits / omissions. Learning points for general mental health work

Case Presentation

Case Presentation of patient with Emotionally Unstable Personality Disorder

Preferably a patient who has had / is having psychological therapy for this.

Good level of detail about background history essential

185


Please select one of the following papers: Clarke et al (2013) “Cognitive analytic therapy for personality disorder: randomised controlled trial” BJPsych 202:129-134

(with accompanying Editorial) Mulder & Chanen (2013) “Effectiveness of cognitive analytic therapy for personality disorders” BJPsych 202:89-90

McMain et al (2009) “A Randomized Trial of Dialectical Behavior Therapy Versus General Psychiatric Management for Borderline Personality Disorder” Am J Psychiatry 166:1365–1374 Batement & Fonagy (2009) “Randomized Controlled Trial of Outpatient Mentalization-Based Treatment Versus Structured Clinical Management for Borderline Personality Disorder” Am J Psychiatry 166:1355–1364 Doering et al (2010) “Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised controlled trial” BJPsych 196:389-395 Bamelis et al (2014) Results of a Multicenter Randomized Controlled Trial of the Clinical Effectiveness of Schema Therapy for Personality Disorders Am J Psychiatry 171: 305 – 322



• Signs & Symptoms of Emotionally Unstable Personality Disorder

• Biological aetiology of EUPD

• Drug treatments in EUPD

186

MCQs

1. The following are symptoms of Emotionally Unstable Personality Disorder (EUPD): a. Unstable or unclear self-image b. Callous unconcern for others c. Increased impulsivity d. Intense anger and aggression e. Unstable and intense relationships

2. EUPD is group in ‘Cluster B’ of DSM-IV along with:

a. Antisocial PD b. Schizotypal PD c. Narcissistic PD d. Dependent PD e. Histrionic PD

3. The following have been recommended by NICE in the treatment of EUPD:

a. Brief Dynamic Psychotherapy b. Mentalization Based Treatment c. Mindfulness Based Therapy d. Olanzepine e. Dialectical Behaviour Therapy

4. The following statements about EUPD are true:

a. EUPD is more commonly diagnosed in women b. EUPD is a lifelong condition if untreated c. Psychoanalysis is an effective treatment for EUPD d. EUPD is easily distinguished from mood disorder e. Almost all patients with EUPD have a history of abuse f. Patients with EUPD have a lower risk of death by suicide compared to those with mood

disorder g. Admissions to hospital lasting more than six months adversely affect prognosis. h. Prescribing antidepressants for unstable mood symptoms can be helpful i. EUPD can be co-morbid with mood disorder j. Severity of symptoms can be rated with the Zanarini scale


NICE on Borderline Personality Disorder – Clinical Guideline 78 & Quality Standards

Borderline Personality Disorder: An evidence based guide for generalist mental health professionals

by Anthony Bateman & Roy Krawitz Oxford (2013)

Choi-Kane et al “What works in the treatment of Borderline Personality Disorder" Curr Behav

Neurosci Rep (2017) 4:21–30

187

Session 3: Psychological approaches to Depression

Learning Objectives

To increase awareness of the psychological aspects of Depressive Disorder.

To have an introductory knowledge of the main psychological models for depression.

To have an overview of psychological treatments for Depression

Curriculum Links

1.1, 1.2, 1.3, 1.3.4, 2.3, 2.4, 2.6, 2.8, 6.1, 7.1.1, 9, 14

Expert Led Session

An overview of psychological therapies for Depressive Disorder

Case Presentation

This should be of a patient with depression, not necessarily one who is in / has had therapy. There

should be sufficient background history to generate a discussion about the psycho-social factors in

aetiology


The paper should preferably be selected in discussion with the chair / presenter of the expert led

session

Driessen et al (2015) The efficacy of short-term psychodynamic psychotherapy for

depression: A meta-analysis update Clinical Psychology Review 42: 1-15

Gottems Bastos et al (2015) The efficacy of long-term psychodynamic psychotherapy,

fluoxetine and their combination in the outpatient treatment of depression Psychotherapy

Research 25(5): 612-624

(Other paper suggested by expert if applicable)

188



Psychological factors in the aetiology of depression

Psychological symptoms of depression

Current psychological treatments for depression recommended by NICE

189

MCQs

1. NICE guidance (CG90):

B. Recommends Computerised CBT for mild-moderate depression

C. Recommends Psychotherapy for severe depression

D. Advises not combining medication with psychological therapies

E. Recommends Cognitive therapy for relapse prevention

F. Defines Short-term Psychodynamic Psychotherapy as 10-15 sessions over 3-4 months

2. Cognitive Therapy:

A. Is originally based on the work of Judith Beck

B. Identifies Cognitive Errors that lead to or maintain depressive thoughts

C. Focuses on non-conscious thought content

D. Is enhanced by concurrent antidepressant treatment

E. Should not be used in older patients

3. Psychodynamic Therapies:

A. Have no evidence base for effectiveness

B. Are based on the model of the mind put forward by Freud

C. Seek to eradicate a patient’s defences

D. Were among the first to link depression to loss

E. Focus on the past

4. Psychological factors in the aetiology of depression include

A. Parental indifference

B. Social circumstance

C. Maternal Depression

D. Cognitive biases or distortions

E. Bereavement

5. Evidence of effectiveness in the treatment of depression exists for:

A. Psychoanalytic therapy

B. Interpersonal Therapy

C. ‘Low intensity’ therapy in IAPT

D. Mentalization based CBT

E. EMDR

190


Sigmund Freud “Mourning and Melancholia” (1917 [1915]) Standard Edition 14: 237-258

Aaron Beck “Cognitive Therapy and the Emotional Disorders” 1976

Session 4: Psychological approaches to Trauma

Learning Objectives

Recognised clinical presentation of PTSD and Complex Trauma

Increase awareness of psychological treatments for PTSD and Complex Trauma

Curriculum Links

6 – Organization & Delivery of Psychiatric Services

7.1 – Psychological aspects of treatment

9.0 – Psychotherapy

9.1.1 – Dynamic Psychotherapy

or 9.3 CBT or 9.4 other modalities *

*Depending on case material and therapy described.

Expert Led Session

Background review of PTSD presentation

Psychological treatments for PTSD including NICE Guidance

Introduction to Complex Trauma

Case Presentation

Case presentation of a patient with PTSD or Complex Trauma.

To highlight aspects of psychiatric history that indicate diagnosis.

To highlight aspects of history that would be relevant for specialist psychotherapy

assessment.

To highlight factors that suggest good or bad prognostic signs for therapy outcome.

191


The paper should preferably be selected in discussion with the chair / presenter of the expert led session

• Bradley R. et al (2005) ‘A Multidimensional Meta-Analysis of Psychotherapy for PTSD’ Am J Psychiatry 162:214–227

• Santiago PN, Ursano RJ, Gray CL, Pynoos RS, Spiegel D, et al. (2013) ‘A Systematic Review of PTSD Prevalence and Trajectories in DSM-5 Defined Trauma Exposed Populations: Intentional and Non-Intentional Traumatic Events’. PLoS ONE 8(4): e59236. doi:10.1371/journal.pone.0059236

• Shalev A. Y. et al (2012) ’Prevention of Posttraumatic Stress Disorder by Early Treatment’ Arch Gen Psychiatry. 69(2):166-176



• Important aspects of psychiatric history to include in referral

• Evidence for and against ‘post-event debriefing’ or single interview

• Aetiology of PTSD

192

MCQs

1. The following treatments are indicated in PTSD:

A. EMDR B. Debriefing C. Psychoanalysis D. Schema Focused CBT E. Psychodynamic Psychotherapy

2. The following are risk factors for an increased likelihood of PTSD:

A. Male gender. B. Introverted character. C. Family history of Narcissistic Personality Disorder. D. Bereavement. E. Low educational attainment.

3. The following are part of the six diagnostic criteria for PTSD in ICD-10:

A. Exposure to any sort of trauma. B. Occasional memories of the traumatic event. C. Avoidance of situations that remind the person of the trauma. D. Normal social functioning. E. Symptoms of at least one week duration.

4. The following have been used in military circles as terms for what we now would call PTSD:

A. Shell Shock B. Lack of Moral Fibre C. Vietnam War Syndrome D. Old Soldier’s Syndrome E. Battle Paralysis

5. The following statements are true of PTSD:

A. Comorbidity is unusual B. There are detectable effects on the hypothalamo-pituitary axis C. “flashbacks’ or intrusive memories of the trauma are characteristic D. Endogenous opioids function is affected in PTSD E. Soldiers are at less risk of PTSD than rape victims


PTSD NICE Guidance CG26 (2005): to be reviewed 2018

Understanding Trauma: A Psychoanalytic Approach by Caroline Garland (1998) Karnac Books

193

ACROSS THE AGES SEMESTER 3:

Session 1: Psychosis Across the Ages

Learning Objectives

The overall aim is for the trainee to gain an overview into the similarities and differences

of psychosis across the different age ranges.

By the end of the session, trainees should understand the commonality and differences

in presentation of psychosis in different age groups.

By the end of the session, trainees should understand the aetiology of psychosis in different

age groups.

By the end of the session, trainees should understand the assessment and treatment process

for psychosis in the different age groups.

Curriculum Links

1b: Recognise how the stage of cognitive and emotional development may influence the aetiology, presentation and management of mental health problems

2a: Be familiar with contemporary ICD or DSM diagnostic systems with the ability to discuss the advantages and limitations of each

2a: State the typical signs and symptoms of psychiatric disorders as they manifest across the age range, including affective disorder; anxiety disorders; disorders of cognitive impairment; psychotic disorders; personality disorders; substance misuse disorders; organic disorders; developmental disorders; and common disorders in childhood

2a: Use the diagnostic system accurately in identifying specific signs and symptoms that comprise syndromes and disorders across the age range

2b: Describe the various biological, psychological and social factors involved in the predisposition to, the onset of and the maintenance of psychiatric disorders across the age range, including trauma

3a: Develop an individualised assessment and treatment plan for each patient and in collaboration with each patient

3a: Be able to explain to patients, families, carers and colleagues the process and outcome of assessment, investigation and treatment or therapeutic plan

3c: Accurately assess the individual patient’s needs and whenever possible in agreement with the patient, formulate a realistic treatment plan for each patient for adult patients with common presenting problems.

3c: Be able to do the above with psychiatric problems as they present across the age range

3c: Consider the impact of the mental illness in an adult patient directly and indirectly on children and young people in the adult’s care or who are likely to come into contact with the adult.

7a: Define the clinical presentations and natural history of patients with severe and enduring mental illness

194

Expert Led Session (incorporating case discussion)

A Consultant led session based on the learning objectives above focussing on Psychosis

across the ages

Session coordinated by LEP Lead, with panel of 3 Expert Consultant Colleagues, representing

child, old age and general/liaison psychiatry


Choose 1 only:

Child and Adolescent:

Adult Outcomes of Child- and Adolescent-Onset Schizophrenia: Diagnostic Stability and

Predictive Validity Chris Hollis, Ph.D., MRCPsych. (Am J Psychiatry 2000; 157:1652–1659)

Double-blind comparison of first- and second-generation antipsychotics in early-onset

schizophrenia and schizo-affective disorder: findings from the treatment of early-onset

schizophrenia spectrum disorders (TEOSS) study. Sikich L1, Frazier JA, McClellan J, Findling

RL, Vitiello B, Ritz L, Ambler D, Puglia M, Maloney AE, Michael E, De Jong S, Slifka K, Noyes N,

Hlastala S, Pierson L, McNamara NK, Delporto-Bedoya D, Anderson R, Hamer RM, Lieberman

JA. Am J Psychiatry. 2008 Nov;165(11):1420-31. doi: 10.1176/appi.ajp.2008.08050756. Epub

2008 Sep 15.

General Adult:

The Myth of Schizophrenia as a Progressive Brain Disease, Robert B. Zipursky, Thomas

J. Reilly, Robin Murray. Schizophrenia Bulletin vol. 39 no. 6 pp. 1363–1372, 2013,

doi:10.1093/schbul/sbs135. Advance Access publication November 20, 2012

Köhler, S., van Os, J., de Graaf, R., Vollebergh, W., Verhey, F., & Krabbendam, L. (2007).

Psychosis risk as a function of age at onset. Social psychiatry and psychiatric epidemiology,

42(4), 288-294.

Older Adult:

Brunelle, S., Cole, M. G., & Elie, M. (2012). Risk factors for the late‐onset psychoses: a

systematic review of cohort studies. International journal of geriatric psychiatry, 27(3), 240-

252.


Choose one:

Choice of antipsychotic treatment in the three age groups

195

Differences in Psychological interventions for psychosis in the three age groups

Differences of Social interventions for psychosis in the three age groups

MCQs

1) If you are working with a 15 year old boy who is presenting with auditory hallucinations and a belief that they are being followed, which 4 question areas are most relevant?

A. Family history of psychosis

B. Recent drug use, including cannabis

C. Recent decline in motivation, academic performance and self-care

D. Recent change in affect

E. Recent change in concentration and energy levels

2) You learn that your patient has a strong family history of psychosis, is hearing voices in external space, and believes that thoughts are being put into his head from the television. Which of the following areas form part of your ongoing assessment?

A. Thyroid function test

B. Test of Prolactin Levels

C. Test of visual fields

D. Detailed early developmental history

E. Urine drugs screen

3) People with Schizophrenia have an increased rate of:

A. Premature death

B. Diabetes

C. Heart disease

D. Smoking

E. All of the above

2.

3. 4) Which of the following statements is FALSE with regards to cognitive impairment in schizophrenia:

A. It is consistent with the neurodevelopmental theory of schizophrenia

B. It is present in drug-naïve patients

C. It is present in the majority of patients with schizophrenia

D. It is not clearly related to specific symptoms

E. It is only found in chronic elderly patients

5) Schizophrenia in older adults is most accurately described by the term:

A. Late-onset schizophrenia

B. Very-late onset schizophrenia

C. Paraphrenia

196

D. Dementia praecox

E. Delusional disorder

6) All but the following are described as risk factors for late-onset psychosis:

A. Sensory impairment

B. Social isolation

C. Polypharmacy

D. Male gender

E. Age-related deterioration of frontal and temporal lobes



TrOn module: overview of child and adolescent psychiatry

https://www.aacap.org/App_Themes/AACAP/docs/resources_for_primary_care/cap_resources_for_medical_student_educators/Pediatric%20Psychosis.ppt

Emerging psychiatric syndromes associated with antivoltage-gated potassium channel complex antibodies Prüss H, Lennox BR. J Neurol Neurosurg Psychiatry 2016;0:1–6. doi:10.1136/jnnp-2015-313000

Old age

Karim, S., & Byrne, E. J. (2005). Treatment of psychosis in elderly people. Advances in Psychiatric

Treatment, 11(4), 286-296.)

Schizophrenia Michael J Owen, Akira Sawa, Preben B Mortensen. The lancet Vol 388 July 2, 2016



197

Session 2: Depression Across The Ages

Learning Objectives

The overall aim is for the trainee to gain an overview into the similarities and

differences of depression across the different age ranges.


in presentation of depression in different age groups.

By the end of the session, trainees should understand the aetiology of depression in

different age groups.

By the end of the session, trainees should understand the assessment and treatment

process for depression in the different age groups.

Curriculum Links





2b: Describe the various biological, psychological and social factors involved in the predisposition to, the onset of and the maintenance of psychiatric disorders across the age range, including trauma (as described, ILO 1, 1a) history








198

A Consultant led session based on the learning objectives listed, which examines the

similarities and differences in depression across the ages

Session coordinated by LEP Lead, with panel of 3 Expert Consultant Colleagues,

representing child, old age and general/liaison psychiatry


Choose 1:


Clinical Messages: From the Treatment for Adolescents With Depression Study (TADS), John

S. March, M.D., M.P.H. Benedetto Vitiello, M.D. (Am J Psychiatry 2009; 166:1118–1123)

Recovery and Recurrence Following Treatment for Adolescent Major Depression. Curry J,

Silva S, Rohde P, et al. Arch Gen Psychiatry. 2011;68(3):263-

269.doi:10.1001/archgenpsychiatry.2010.150.

Psychological therapies versus antidepressant medication, alone and in combination for

depression in children and adolescents. Cox GR1, Callahan P, Churchill R, Hunot V, Merry SN,

Parker AG, Hetrick SE. Cochrane Database Syst Rev. 2012 Nov 14;11:CD008324. doi:

10.1002/14651858.CD008324.pub2.

General Adult:

Age and gender in the phenomenology of depression. Am J Geriatr Psychiatry. Brodaty H,

Cullen B, Thompson C, et al. Jul 2005;13(7):589-596

Older Adult:

Cuijpers, P., van Straten, A., Smit, F., & Andersson, G. (2009). Is psychotherapy for

depression equally effective in younger and older adults? A meta-regression analysis.

International Psychogeriatrics, 21(01), 16-24.

Prognosis of Depression in Old Age Compared to Middle Age: A Systematic Review of

Comparative Studies. Alex J. Mitchell, MRCPsych. Hari Subramaniam, MRCPsych. (Am J

Psychiatry 2005; 162:1588–1601)

Hegeman, J. M., Kok, R. M., Van der Mast, R. C., & Giltay, E. J. (2012). Phenomenology of

depression in older compared with younger adults: meta-analysis. The British Journal of

Psychiatry, 200(4), 275-281.

Cole, M. G., & Dendukuri, N. (2003). Risk factors for depression among elderly community

subjects: a systematic review and meta-analysis. American Journal of Psychiatry, 160(6),

1147-1156.Choose MW 2012 paper phenomenology

199


Choose 1:

SSRI use in CAMHS- risks and benefits

Prescribing of antidepressants and age-related considerations

Prognosis of depressive disorders

MCQs

1) Which of the following is TRUE:

A. Early-onset depression always has a better outcome than late-onset depression

B. Oxidative stress leads to neuronal cell death

C. ECT is not associated with irreversible memory problems

D. It is not possible to clinically monitor cognitive effects of ECT

E. Late-onset depression is not associated with vascular dementia

2) In dementia, it is TRUE that:

A. Depression may mimic its symptoms and signs

B. Late-onset depression is not associated with APOE e4

C. Depression is not a risk factor

D. Late-onset depression is always a prodrome of Alzheimer’s disease

E. Late-onset depression is a prodrome of vascular dementia

3). In terms of aetiology, early-onset depression can be more associated than late-onset depression

with:

A. Family history

B. Vascular disease

C. Reduced hippocampal volume

D. Smaller prefrontal lobe volume

E. Smaller caudate nuclear volume

4) All of the following are more prevalent in depression in later life, except:

A. Increased somatic complaints

B. Greater risk of psychotic symptoms

C. Hypochondriasis

D. Hypersomnia

E. Psychomotor disturbance

5) In what proportion of older people is depression comorbid with dementia?

A) 10%

200

B) 20%

C) 30%

D) 40%

E) 50%

6) Which of the 2 following blood tests can be most helpful in the assessment of a depressed child?

A. Thyroid Function Test

B. Full Blood Count

C. Urea and Electrolytes

D. Urine Drugs Screen

E. Inflammatory markers

7) Which of the 3 following interventions does NICE recommend in the treatment of depression in a

14 year old child?

A. Cognitive Behavioural Therapy

B. Interpersonal Therapy

C. Sertraline with Concurrent CBT

D. Fluoxetine with Concurrent Family Therapy

E. EMDR



Treatment of Resistant Depression in Adolescents (TORDIA): Week 24 Outcomes. Emslie, G. J.,

Mayes, T., Porta, G., Vitiello, B., Clarke, G., Wagner, K. D., … Brent, D. (2010). The American Journal

of Psychiatry, 167(7), 782–791. http://doi.org/10.1176/appi.ajp.2010.09040552

Old age

Allan, C. L., & Ebmeier, K. P. (2013). Review of treatment for late-life depression. Advances in

psychiatric treatment, 19(4), 302-309.

Rodda, J., Walker, Z., & Carter, J. (2011). Depression in older adults. BMJ,343.

Session 3: Liaison Psychiatry Across The Ages

Learning Objectives

The overall aim is for the trainee to gain an overview into the similarities and

differences of liaison across the different age ranges.

201


in presentation of common conditions in liaison psychiatry in the different age groups.

By the end of the session, trainees should understand the assessment and treatment

process of common conditions in liaison psychiatry in the different age groups.

Curriculum Links





2b: Describe the various biological, psychological and social factors involved in the predisposition to, the onset of and the maintenance of psychiatric disorders across the age range, including trauma







7a: Define the role of rehabilitation and recovery services. Define the concept of recovery

7a: Define the concept of quality of life and how it can be measured

7a : Demonstrate an appreciation of the effect of chronic disease states on patients and their families

7a: Demonstrate an appreciation of the importance of co-operation and collaboration with primary healthcare services, social care services, and non-statutory services


A Consultant led session based on the learning objectives listed.

Session coordinated by LEP Lead, with panel of 3 Expert Consultant Colleagues, representing child, old age and general adult liaison psychiatry

202


Choose 1:


Psychological therapies for the management of chronic and recurrent pain in children and

adolescents. Eccleston, C., Palermo, T. M., Williams, A. C. D. C., Lewandowski, A., & Morley,

S. (2009). The Cochrane Library.

Adult Outcomes of Pediatric Recurrent Abdominal Pain: Do They Just Grow Out of It?

John V. Campo, Carlo Di Lorenzo, Laurel Chiappetta, Jeff Bridge, D. Kathleen Colborn, J.

Carlton Gartner, Paul Gaffney, Samuel Kocoshis, David Brent

Pediatrics Jul 2001, 108 (1) e1; DOI: 10.1542/peds.108.1.e1

General Adult:

Fava GA et al (2010) The spectrum of anxiety disorders in the medically ill. J Clin Psychiatry.

2010 Jul;71(7):910-4. doi: 10.4088/JCP.10m06000blu. Epub 2010 Jun 1.

Older Adult:

Esiwe, C., Baillon, S., Rajkonwar, A., Lindesay, J., Lo, N., & Dennis, M. (2015). Screening for

depression in older adults on an acute medical ward: the validity of NICE guidance in using

two questions. Age and ageing, afv018.

Jackson, T. A., Naqvi, S. H., & Sheehan, B. (2013). Screening for dementia in general hospital

inpatients: a systematic review and meta-analysis of available instruments. Age and ageing,

aft145.

Sheehan, B., Lall, R., Gage, H., Holland, C., Katz, J., & Mitchell, K. (2013). A 12-month follow-

up study of people with dementia referred to general hospital liaison psychiatry services.

Age and ageing, 42(6), 786-790.


Choose one:

Common psychiatric conditions, in (medical/surgical) hospital patients

Classification of somatoform disorders

Medically unexplained symptoms

MCQs

1) You have joined your consultant in a paediatric diabetes clinic, and you are asked to assess a

16year old boy who is doing well at school, but has not been able to attain control of their diabetes.

Which 3 areas must you consider?

A. Mood and concentration

203

B. Weight and body image

C. Paranoid and hallucinations

D. Post-traumatic symptoms

E. Alcohol and smoking

2) You are contacted about 14 year old girl who has been treated for a paracetamol overdose in

A&E. Her father has arrived and offered to take her home and bring her to see you tomorrow. He

does not want her admitted into the paediatric bed that has been identified. What 3 things do you

do?

A. Meet with the father and child and obtain consent to interview the child alone

B. Contact social services as this sounds suspicious

C. Meet with the father and child and ask why he wants to take her home

D. Admit the child to the ward under the Mental Health Act

E. Speak to the nurses in A&E to learn more about the child's presentation before the father

arrived, and what their interaction has been like

3) Factitious disorder:

A Is more common in Males

B Is less common in Healthcare workers

C Comprise 20% of referrals from General Medicine to Psychiatry

D Rarely involves presentations of chest pain

E Is commonly associated with depression

4) Which of the following is not true :

A Pancreatic cancer confers high risk of developing depression

B Paraneoplastic syndromes are commonly associated with small cell lung cancer

C Autoimmune Limbic encephalitis is always associated with neoplasms

D Body image disturbance is present in 50% of women with breast cancer

E Treatment with steroids can result in development of psychotic symptoms

5) Which is true with regards to differences in pharmacokinetics in older vs younger adults?

A) Older adults have reduced body fat

B) Older adults have increased body water

C) Creatinine and GFR are not effected by age

D) Volume of distribution of lipophilic drugs increases in older adults

E) The T½ of psychotropic drugs is constant across the adult age range

6) Regarding mental disorder in acute hospital patients, which statement is false:

A) >30% of inpatients have a mental disorder

B) 30-60% of outpatients have medically unexplained symptoms

204

C) Dementia and depression are the most frequent disorders in older adult inpatients

D) Depression is frequently unrecognised in older adult inpatients

E) The presence of mental disorder does not affect mortality


Child Psychiatry:

Paediatric liaison work by child and adolescent mental health services. Woodgate, M.,

Garralda, M. Child Adolesc Ment Health. 2006;11:19–24.

Medically unexplained symptoms in young people: The doctor’s dilemma. Geist, R., Weinstein,

M., Walker, L., & Campo, J. V. (2008). Paediatrics & Child Health, 13(6), 487–491.

Metaphors and medically unexplained symptoms: Schwartz, Eben S, The Lancet , Volume

386 , Issue 9995 , 734 – 735

General Adult:

Halford, J., & Brown, T. (2009). Cognitive–behavioural therapy as an adjunctive treatment in

chronic physical illness. Advances in psychiatric treatment, 15(4), 306-317.

Segal, T., & Ranjith, G. (2016). Psychiatric assessments on medical wards: a guide for general

psychiatrists. BJPsych Advances, 22(1), 8-15.

Older adult

Review of treatment for late-life depression Charlotte L. Allan & Klaus P. Ebmeier. Advances

in psychiatric treatment (2013), vol. 19, 302–309 doi: 10.1192/apt.bp.112.010835

205

Session 4: Impact of Mental Illness on Carers and Families

Learning Objectives

The overall aim is for the trainee to gain an overview into the impact of mental illness

on the families and carers of patients across the different age ranges.

By the end of the session, trainees should understand the impact of longstanding mental

illness on families/Carers.

By the end of the session, trainees should how to include families/Carers in the treatment

plan.

By the end of the session, trainees should understand challenges that families face and

impact of this on the therapeutic relationship between doctor/patient/family/carer.

Curriculum Links





2b: Describe the various biological, psychological and social factors involved in the predisposition to, the onset of and the maintenance of psychiatric disorders across the age range, including trauma (as described, ILO 1, 1a) history







7a: Define the role of rehabilitation and recovery services Define the concept of recovery

7a: Define the concept of quality of life and how it can be measured

7a: Awareness of disability/housing benefits that patients may be entitled to claim

206

7a : Demonstrate an appreciation of the effect of chronic disease states on patients and their families

7a: Demonstrate an appreciation of the impact of severe and enduring mental illness on patients, their families and carers

7a: Demonstrate an appreciation of the importance of co-operation and collaboration with primary healthcare services, social care services, and non-statutory services

Expert Led Session

Carer/family perspective of MH in the child, adult and older adult

Case Presentation

2x 30 minute cases highlighting the clinical presentations focusing on family/ carer perspective, for

any mental disorder, in two different age groups:

Child and Adolescent

Adult

Older People


Choose 1:


Postpartum depression predicts offspring mental health problems in adolescence

independently of parental lifetime psychopathology. Tjitte Verbeek , Claudi L.H. Bockting ,

Mariëlle G. van Pampus , Johan Ormel , Judith L. Meijer , Catharina A. Hartman , Huibert

Burger. Journal of Affective Disorders 136 (2012) 948–954

General Adult:

Ohaeri, JU (2003) The burden of caregiving in families with a mental illness: a review of 2002.

Current Opinion in Psychiatry, 16 (4), 457–465

Older Adult:

Lee DR, McKeith I, Mosimann U, Ghosh‐Nodyal A, Thomas AJ. Examining carer stress in

dementia: the role of subtype diagnosis and neuropsychiatric symptoms. International

journal of geriatric psychiatry. 2013 Feb 1;28(2):135-41.


What is meant by a Carers assessment?

What is meant by parenting assessment?

Nearest relative versus next of kin

http://journals.lww.com/co-psychiatry/toc/2003/07000

207

Lasting Powers of Attorney

Burden of Care – Social impact

MCQs

1) You are working in an ADHD clinic with an ADHD nurse, a mother and son arrive after a period of

missed appointments, and both mother and son now want to recommence ADHD medication. The

mother is very angry and negative about her son, and then starts crying. What 3 things do you say to

her?

A. This is emotional cruelty and you will need to report her to social services

B. Untreated ADHD is a very difficult condition to live with, once he is on medication she will not

have any problems

C. Living with a child with a developmental disorder is very difficult, you recommend that she

speaks to her GP and requests a referral to a counsellor

D. Even when children are taking medication, there are often ongoing difficulties with

behaviour, you recommend that she joins the local ADHD support group

E. You acknowledge that children with developmental disorders may not be maturing and

becoming independent at the same rate as their peers and acknowledge the extra pressure

this places on her

2) You are asked to see 13 year old Hannah the younger sibling of 19 year old James who has been

diagnosed with schizophrenia. Hannah has been withdrawn and quiet and told her grandmother she

is hearing voices. What do you do?

A. Urgently start antipsychotics, psychosis is genetic

B. Meet with Hannah alone to learn more about the impact of mental illness on the whole

family

C. Tell the parents this is contagion and to ignore it

D. Assess Hannah for depression and anxiety

E. Recommend parents try to structure activities alone with Hannah

3) The following is true regarding carers of older adults:

A) They have better mental health if they have fewer than 8 people in their social network

B) They are less likely to be depressed if they are women

C) They are more likely to have osteoarthritis than non-carers

D) They consult their GP more often after the care role has ended

E) They have a lower risk of hypertension than non-carers

4) Regarding carers which statement is false:

A) There are over 6.5 million carers in the UK

B) Most carers are male

C) 3 in 5 people will be carers at some point in their lives

208

D) Carers provide around £120 billion worth of unpaid care annually

E) The number of carers over the age of 65 is increasing faster than any other age group



http://www.nhs.uk/conditions/social-care-and-support-guide/pages/young-carers-

rights.aspx

http://www.youngminds.org.uk/for_parents/worried_about_your_child/young_carers

The effect of ADHD on the life of an individual, their family, and community from preschool

to adult life: V A Harpin, Arch Dis Child 2005;90:suppl 1 i2-i7 doi:10.1136/adc.2004.059006

Kuhn, E. S., & Laird, R. D. (2014). Family support programs and adolescent mental health:

review of evidence. Adolescent Health, Medicine and Therapeutics, 5, 127–142.

http://doi.org/10.2147/AHMT.S48057

General Adult:

Meeting the mental and physical healthcare needs of carers Irene Cormac & Peter Tihanyi.

Advances in Psychiatric Treatment (2006), vol. 12, 162–172

Old age

Carers UK. (2015). Facts about carers. [online] Available at: https://www.carersuk.org/for-

professionals/policy/policy-library/facts-about-carers-2015 [Accessed 01/08/16])

http://www.nhs.uk/conditions/social-care-and-support-guide/pages/young-carers-rights.aspx

http://www.nhs.uk/conditions/social-care-and-support-guide/pages/young-carers-rights.aspx

http://www.youngminds.org.uk/for_parents/worried_about_your_child/young_carers

https://www.carersuk.org/for-professionals/policy/policy-library/facts-about-carers-2015

https://www.carersuk.org/for-professionals/policy/policy-library/facts-about-carers-2015

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