• Typical (first generation):
o Example: haloperidol, chlorpromazine.
o Side effects:
Extrapyramidal symptoms (EPS): dystonia, parkinsonism, akathisia, tardive dyskinesia.
Neuroleptic malignant syndrome (NMS): fever, rigidity, autonomic instability, raised CK, renal failure.
Hyperprolactinaemia (especially with high-potency agents).
• Atypical (second generation):
o Examples:
Olanzapine: metabolic syndrome (weight gain, hyperlipidaemia, diabetes).
Risperidone: dose-dependent hyperprolactinaemia.
Clozapine: agranulocytosis (weekly FBC monitoring initially), myocarditis, seizures, hypersalivation.
Quetiapine: more sedating; useful in bipolar depression.
• Indications:
o Schizophrenia spectrum, acute mania, severe agitation.
• SSRIs (e.g., sertraline, citalopram):
o First-line for depression and anxiety.
o Side effects: GI upset, sexual dysfunction, hyponatraemia (esp. elderly).
• SNRIs (e.g., venlafaxine, duloxetine):
o Useful if SSRIs ineffective.
o Caution: venlafaxine can ↑ BP at higher doses.
• Tricyclics (TCAs) (e.g., amitriptyline, nortriptyline):
o Effective but limited by anticholinergic effects (dry mouth, constipation, urinary retention), orthostatic hypotension.
o Toxic in overdose: arrhythmias (Na⁺ channel blockade).
• MAOIs (e.g., phenelzine, tranylcypromine):
o Dietary tyramine → hypertensive crisis ("cheese reaction").
o Avoid with SSRIs (serotonin syndrome risk).
• Uses:
o Short-term severe anxiety, acute agitation, alcohol withdrawal (chlordiazepoxide).
• Risks:
o Dependence and tolerance.
o Withdrawal: insomnia, agitation, tremor, seizures.
• Avoid long-term use (max 2–4 weeks generally).
• Lithium:
o Narrow therapeutic index (target 0.6–1.0 mmol/L maintenance).
o Toxicity signs: tremor, ataxia, vomiting, diarrhoea, confusion → can progress to seizures and coma.
o Monitoring: TFTs, U&Es, calcium, lithium levels every 3 months once stable.
o Renal and thyroid dysfunction, hyperparathyroidism.
• Valproate:
o Useful in acute mania and maintenance.
o Risks: hepatotoxicity, pancreatitis, teratogenicity (neural tube defects → avoid in women of
childbearing potential unless no alternative).
• Carbamazepine:
o Alternative for bipolar; also used in trigeminal neuralgia.
o Risks: agranulocytosis, hyponatraemia (SIADH).
• Indications:
o Severe or psychotic depression, catatonia, severe mania.
• Effectiveness: rapid symptomatic relief.
• Side effects:
o Headache, transient retrograde/anterograde amnesia.
• Contraindications: relative (raised ICP, recent MI).
• CBT (Cognitive Behavioural Therapy):
o Evidence-based for depression, anxiety, PTSD, OCD.
o Targets negative thought patterns and behaviours.
• Psychodynamic psychotherapy:
o Focus on unconscious processes and early relationships.
o Suited for personality disorders, long-standing interpersonal issues.
• DBT (Dialectical Behaviour Therapy):
o Specifically designed for borderline personality disorder.
o Focus: emotion regulation, distress tolerance, interpersonal effectiveness.
• IPT (Interpersonal Therapy):
o Targets relationship problems, grief, role transitions.
o Evidence-based for depression.
• Motivational interviewing:
o Especially for substance use disorders; non-confrontational, elicits change motivation.
• Serotonin syndrome: triad of autonomic instability, neuromuscular abnormalities, altered mental state; risk with SSRIs + MAOIs.
• Akathisia (inner restlessness) → can mimic worsening anxiety; managed with beta-blockers or dose adjustment.
• Clozapine is the only drug with proven efficacy in treatment-resistant schizophrenia.
• Lithium toxicity precipitated by dehydration, NSAIDs, ACE inhibitors, diuretics.
• CBT-i is most effective for chronic insomnia (better than hypnotics).
• TCAs avoid in elderly → fall risk, cognitive impairment.
• High-dose SSRIs used in OCD; require longer duration to assess efficacy (~12 weeks).
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Author & Educational Disclaimer
Author:
Dr Phillip Cockrell BM FRCP DipClinEd
Dr Phillip Cockrell is a UK Consultant Physician in Internal Medicine, currently working at Queen Alexandra Hospital, Portsmouth University Hospitals NHS Trust. He has previously worked as a registrar across Intensive Care Medicine, Gastroenterology, Cardiology, Stroke Medicine, Acute Medicine, and Respiratory Medicine.
He has held senior leadership roles including Associate Clinical Director of the Acute Medical Unit, Clinical Director of Internal Medicine, and Chief of Medicine. Dr Cockrell has over 15 years’ experience in postgraduate medical education, having lectured extensively across the MRCP syllabus and contributed to MRCP revision teaching and course development.
Dr Cockrell holds a Bachelor of Medicine (BM), Fellowship of the Royal College of Physicians (FRCP), and a Diploma in Clinical Education (DipClinEd). His teaching approach is based on structured consolidation of complex medical topics to support efficient and effective revision for postgraduate examinations.
Purpose of this content:
The material on this page is intended solely for educational purposes to support revision for the MRCP (UK) Part 1 examination. It reflects examination-relevant principles of internal medicine and is designed to aid learning and pattern recognition.
Medical disclaimer:
This content is designed for postgraduate medical examination revision and does not constitute medical advice, diagnosis, or treatment guidance and must not be used as a substitute for professional clinical judgement, local guidelines, or specialist consultation. Clinical decisions should always be made in the context of individual patient circumstances and current national guidance.
