Master Psychiatry
for MRCP Part 1

Core Concepts

Psychiatry is the medical specialty focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders. The **biopsychosocial model** is central.

• **Mental State Examination (MSE):** Systematic assessment of a patient's current mental state (e.g., appearance, mood, thought, perception, cognition, insight).
• **Capacity Assessment:** Ability to understand information, retain it, weigh it, and communicate a decision. Essential for consent and MHA applications.
• **Mental Health Act (MHA) 1983/2007 (England & Wales):** Legal framework for involuntary detention and treatment. Key sections:
  • **Section 2:** Admission for assessment (up to 28 days), non-renewable.
  • **Section 3:** Admission for treatment (up to 6 months initially), renewable.
  • **Section 5(2):** Emergency detention by a doctor (up to 72 hours) for inpatients.
• **Neurotransmitters:**
  • **Dopamine:** Reward, motivation; excess in mesolimbic pathway linked to positive psychotic symptoms.
  • **Serotonin:** Mood, sleep, appetite; implicated in depression and anxiety.
  • **Noradrenaline:** Alertness, arousal, mood; implicated in depression and anxiety.
  • **GABA:** Inhibitory; low levels linked to anxiety.
  • **Acetylcholine:** Memory, learning; deficit in Alzheimer's disease.

Clinical Presentation

• **Psychosis (e.g., Schizophrenia, Bipolar Mania/Psychotic Depression):**
  • **Positive Symptoms:** Hallucinations (auditory 2nd/3rd person common), delusions (persecutory, reference, control), thought disorganization.
  • **Negative Symptoms:** Alogia (poverty of speech), avolition (lack of motivation), anhedonia (loss of pleasure), affective flattening, social withdrawal.
• **Depression (Major Depressive Disorder):** Persistent low mood, anhedonia, fatigue, sleep disturbance, appetite changes, poor concentration, worthlessness/guilt, suicidal ideation.
• **Mania/Hypomania (Bipolar Disorder):** Elevated/irritable mood; increased energy; decreased need for sleep; pressured speech; flight of ideas; grandiosity; impulsivity; distractibility. Hypomania is milder, without marked functional impairment or psychotic features.
• **Anxiety Disorders:**
  • **Generalized Anxiety Disorder (GAD):** Chronic, excessive worry.
  • **Panic Disorder:** Recurrent, unexpected panic attacks (intense fear, autonomic symptoms).
  • **Obsessive-Compulsive Disorder (OCD):** Obsessions (intrusive thoughts) leading to compulsions (repetitive behaviors/mental acts).
  • **Post-Traumatic Stress Disorder (PTSD):** Re-experiencing, avoidance, negative cognitions/mood, hyperarousal after trauma.
• **Delirium:** Acute onset, fluctuating course, disturbed consciousness and attention, disorientation, often visual hallucinations. *Always consider organic cause.*
• **Dementia:** Gradual onset, progressive cognitive decline (memory, executive function, language), clear consciousness, affects daily functioning.
• **Personality Disorders:** Enduring, pervasive, inflexible patterns of inner experience and behavior deviating from cultural norms, causing distress/impairment.

Diagnosis (Gold Standard)

Clinical diagnosis based on detailed history (patient and collateral), thorough Mental State Examination (MSE), and adherence to diagnostic criteria (ICD-10/11 or DSM-5). Crucially, this involves ruling out organic causes.

• **Investigations to rule out organic causes:**
  • **Blood tests:** FBC, U&Es, LFTs, TFTs, B12, Folate, Calcium, Glucose, CRP, ESR, Syphilis serology, HIV, Urine drug screen.
  • **Neuroimaging (CT/MRI brain):** Indicated for first-episode psychosis, atypical presentations, new-onset cognitive impairment, focal neurological signs.

Management (First Line)

• **General Principles:** Multidisciplinary team (MDT) approach, comprehensive risk assessment, psychoeducation, social support.
• **Psychosis (e.g., Schizophrenia):**
  • **Acute:** Oral or IM antipsychotics (e.g., Olanzapine, Haloperidol).
  • **Maintenance:** Atypical antipsychotics (e.g., Risperidone, Quetiapine). Clozapine for treatment-resistant schizophrenia.
  • **Psychological:** CBT for psychosis, family therapy.
• **Depression:**
  • **Mild:** Watchful waiting, guided self-help, CBT.
  • **Moderate-Severe:** SSRIs (e.g., Sertraline, Escitalopram) first-line. CBT. Electroconvulsive Therapy (ECT) for severe/resistant/psychotic depression.
• **Bipolar Disorder:**
  • **Acute Mania:** Antipsychotics (e.g., Olanzapine, Quetiapine), mood stabilisers (Lithium, Valproate).
  • **Acute Depression:** Quetiapine, Olanzapine + Fluoxetine, Lamotrigine. Avoid antidepressants alone (risk of mood switching).
  • **Maintenance:** Lithium (first-line), Valproate, Lamotrigine, Atypical antipsychotics.
• **Anxiety Disorders (GAD, Panic, Social Phobia):**
  • SSRIs (e.g., Sertraline, Escitalopram), CBT.
  • Short-term benzodiazepines (e.g., Lorazepam) for acute severe anxiety (risk of dependence).
• **Obsessive-Compulsive Disorder (OCD):** High-dose SSRIs, CBT (Exposure and Response Prevention).
• **Post-Traumatic Stress Disorder (PTSD):** Trauma-focused CBT, EMDR, SSRIs.
• **Delirium:** Treat underlying medical cause. Supportive care. Low-dose antipsychotics (e.g., Haloperidol) for severe agitation/psychosis if non-pharmacological methods fail.

Exam Red Flags