33 Flashcards
Mental Health
4 types of anxiety disorders
- Phobia
- Obsessive Compulsive Disorder
- Panic disorder
- Generalised anxiety disorder
Somatic symptoms of anxiety
Main:
- Sweating
- Palpitations
- Dry mouth
- Tremor
Other:
- Dizziness
- Chest pain
- Breathlessness
- Globus hystericus
Psychological symptoms of anxiety
- Worry
- Apprehension
- Fear of impending disaster
- Catastrophizing
- Poor concentration
- Irritability
Generalised anxiety disorder definition
6 months + of excessive worry about everyday issues disproportionate to any inherent risk causing distress or impairment.
ICD-10
More than 6 months with 4 symptoms - one must be palpitations, tremour, sweating or dry mouth.
Risk factors for generalised anxiety disorder
Family history (4x increased if 1st degree family member)
Aged 33-54
Female
Being divorced, separated, living alone or lone parent
Childhood adversity
Stressors
Social isolation
Somatisation disorder
- Multiple physical SYMPTOMS present for at least 2 years
- Patient refuses to accept reassurance or negative test results
Hypochondrial disorder
- Persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
- Patient again refuses to accept reassurance or negative test results
Malingering
- Fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
Munchausen’s syndrome
- Also known as factitious disorder
- The intentional production of physical or psychological symptoms
Dissociative disorder
- Dissociation is a process of ‘separating off’ certain memories from normal consciousness
- In contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
- Dissociative identity disorder (DID) is the most severe form of dissociative disorder
Conversion disorder
- Typically involves loss of motor or sensory function
- The patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
- Patients may be indifferent to their apparent disorder (la belle indifference)
What investigations should be done if anxiety is suspected?
TFTs Urine drug screen 24 hour urine Pulmonary function tests ECG
What screening tool can be used for generalised anxiety disorder?
GAD2 or GAD7
Management of generalised anxiety
- Identification, assessment and education. Treat any alcohol or substance abuse
- Low intensity psychological interventions
- CBT OR drug treatment
- sertraline
- alternative SSRI or venlafaxine
- pregabalin
- benzodiazepine (short term only) - Specialist care
Comprehensive care and drug combinations
Consider propranolol for symptomatic control
Define phobia
Intense fears of specific objects or situations that are triggered upon actual or anticipated exposure to phobic stimuli
Incidence of phobias
- 8% of population
- Average of onset 7-10 years
- 2-3 times more common in women
- Increased in Caucasian
Risk factors for phobia
Female
Anxiety or mood disorders
Substance misuse disorders
Stress and negative life events
Treatment for phobia
- Recognition and diagnosis
2. Graded exposure
Describe graded exposure
Systematic desensitisation - deliberate confrontation of fear until anxiety reduces
Needs to be
- Repeated frequently
- Graded in steps
- Wait in situation until the anxiety reduced (otherwise reinforces)
- Clearly specified and planned
- Prolonged
- No artificial anxiolytic
Define panic disorder
ICD10
Recurrent panic attacks not consistently associated with a specific situation or object. Occur spontaneously.
Moderate = 4 or more attacks in 4 weeks
Severe = 4 or more attacks in 1 week for 4 weeks
Define panic attack
Discrete episode of intense fear or discomfort.
Starts abruptly.
Reaches a crescendo after a few minutes.
4 or more of the following symptoms;
- Palpitations, difficulty breathing, dizzy, hot flushes, sweating, derealisation, cold chills, trembling, chest pain, fear of losing control, numbness, dry mouth, tingling
Risk factors for panic disorder
Female 20-30 First degree relative Caucasian Smoking Major life disorders Asthma Caffeine
Treatment for panic disorder
- Recognition and diagnosis
- CBT or medication
- SSRI (citalopram or paroxetine) - Specialist care
Define obsessions
Unwanted intrusive thoughts, doubts, images or urges that repeatedly enter the mind
Define compulsions
Repetitive behaviours or mental acts that a person feels compelled to perform in response to an obsession. Involuntary.
Define rumination
Mental acts repeated endlessly in response to intrusive ideas and doubts
Incidence of OCD
1.6% of the population
Equal in gender
Age in men = late adolescent
Age in women = early 20s
Definition of OCD
Obsessional symptoms and compulsive acts
Most days for at least 2 weeks
Source of distress or interferes with activities
Treatment for OCD
Mild - low intensity psychological therapy or CBT. If no response SSRI
Moderate - choice between CBT and ERP (exposure and response prevention) OR SSRI
Severe - CBT and ERP and SSRI
Then can trial clomipramine alone
Then can add clomipramine to SSRI
Symptoms of depression
Depressed mood Energy Loss Pleasure loss (anhedonia) Retardation/Agitation Eating changes Sleep disturbance Suicidal thoughts I'm a failure (loss of self-esteem/confidence) Only me to blame (guilt) No concentration
Screening for depression
PHQ9 Patient health questionnaire
HAD - hospital anxiety and depression scale
Epidemiology of depression
25% women, 10% men Female PMHx of depression Significant physical illness causing disability or pain Other mental health problems African-Caribbean, Asian Refugees, asylum seekers Family history
Definition of depression
1 core symptom: low mood or anhedonia plus some of other symptoms
Mild - 4 symptoms
Moderate - 5 to 6 symptoms
Severe - 7+ symptoms or any psychotic symptoms
Causes of depression
Drugs = steroids, contraceptive pill, digoxin, beta blockers Hypothyroid Heart disease Stroke Cancer MS Dementia Alcohol abuse Illicit drug use Child birth (post-natal depression) Life events - unemployment, divorce, bereavement
Investigations in depression
U+Es LFTs TFTs Calcium FBC glucose inflammatory markers Magnesium Syphilis Drug screen
Treatment for depression
MILD
- low intensity psychological therapies
MODERATE
Antidepressant or CBT
SEVERE
Antidepressant and CBT
Antidepressant choice
- SSRIs- fluoxetine, sertraline, citalopram
- SNRI - venlafaxine
- TCAs (high risk in OD)
Note - increased risk of suicide in first 2 weeks
Define Bipolar disorder
Chronic illness associated with episodes of mania and depression
At least 2 episodes in which a persons mood are significantly disturbed (1 of which MUST be mania or hypomania)
What are the 2 types of bipolar disorder
Type 1 - manic episodes. they are severe and result in impaired functioning and frequent hospital admission
Type 2 - not full mania - hypomanic episodes. No psychotic symptoms
Define mania
At least 3 of the following symptoms:
- Grandiosity
- Decreased need for sleep
- Pressured speech
- Flight of ideas
- Distractibility
- Psychomotor agitation
- Excess pleasurable activity with no thought for consequences
Epidemiology of bipolar disorder
2%
Type 1 higher in males, type 2 in females
Onset between 13 and 30
Strong family history relation
Drug or alcohol use Major life changes Abuse in childhood Early onset depression Periods of high stress
Symptoms of mania
Grandiose ideas Pressure of speech Excessive energy Racing thoughts Flight of ideas Over activity Less sleep Easily distracted Unkempt Increased appetite Sexual disinhibition Recklessness financially
SEVERE
Auditory hallucinations
Delusions of persecution
Lack of insight
What is rapid cycling
4+ cycles of depression and mania in 1 year with no asymptomatic episodes
Associated with longer course of illness, earlier age of onset, increase suicide, increased drug and alcohol abuse
TEST THYROID FUNCTION
Management of acute manic episode
Increase antipsychotic dose to maximum if already taking
- Haloperidol, olanzapine,quetiapine, risperidone
- If one is not effective swap to another
- If the second doesn’t work - add lithium
STOP all antidepressants
Management of depressive episodes in bipolar disorder
Use antidepressants carefully as can tip into mania - only used with anti-mania medication
Don’t treat if mild
Moderate to severe
- Fluoxetine and olanzapine or quetiapine alone
- Lamotrigine alone
Management of rapid cycling
Stop all antidepressnats
Anti-mania therapy maximises
Lithium + valproate
Long term treatment of bipolar disorder
- Lithium
- Add valproate
Continue for 2 years but may need for 5 years.
ECT can provide rapid improvement in severe mania but is short lived
Prognosis of bipolar
Average 10 episodes in a lifetime
High risk of recurrence
Symptom free episodes get shorter with increased time
25-55% have at least 1 suicide attempt
Highest rate of suicides
Define psychosis
- Seeing or hearing things others do not
- Having unusual thoughts or beliefs
- Feeling confused or suspicious
Stages of psychosis
- Prodromal phase
Unclear, drop in functioning, sleep or mood disturbance - Psychosis and threshold
Frank symptoms of psychosis - can occur at any age but most likely to occur in late teens, women tend to be older - Remission
- Relapse
What is the early intervention rationale for psychosis?
Reduce the impact of psychosis by offering interventions at the earliest stage of condition as the longer the duration of the untreated psychosis = worse prognosis
Early intervention work with 14-35 year olds for first occurrence for up to 3 years
Reduce the impact
What risks should be assessed under mental health
Suicide Self-harm Aggressive behaviour Neglect Exploitation by others Self-neglect
Risk factors for suicide
Male Older age or teen Previous attempt Mental illness in 90% Divorced, single or widowed Bereavement Social isolation Physical ill health Unemployed
What are the 3 categories of suicide/self-harm
Failed suicide attempt - high risk of re-attempting. Likely to have mental health problems.
Impulsive self-harm with ambivalence to death = overdose taken after a stressful event. No real suicidal intent. Tend to be young and female.
Repeated self-harm without suicidal intent.
If a person presents with suicide - what questions need to be asked?
Events preceding the event
Details of the act themselves
Intentions
Current thoughts about suicide
Was it planned?
What happened after?
Any previous attempts?
What are the 5 stages of grief (Kubler-Ross)
Denial (and isolation) Anger Bargaining Depression Acceptance
What is complicated grief?
Pathological reaction to loss associated with long term physical and psychological dysfunction
Longer than 6 months and stuck in maladaptive state!
Significant deviation from cultural norm or increase intensity of impairment
Risk factors for complicated grief
Parental abuse Parental death controlling parents Close relationship with deceased Insecure attachment styles Emotional dependency Sudden death Death in hospital
Define adjustment disorder
Transient states of distress and emotional disturbance which arises in the course of adapting to a significant life change, serious physical illness or possibility of serious illness.
Stressor is not of unusual or catastrophic type.
- Must start within 3 months of stressful life event (usually within 1 month)
- Course does not exceed 6 months
- Depressive or anxiety symptoms that cause functional impairments
Aetiology of adjustment disorders
Relationship break up Unemployment Occupational dispute Bereavement Illness
Presentation of adjustment disorder
- Depressed mood
- Anxiety
- Worrying
- Feeling or irritability to cope, plan ahead or continue
- Difficulty in daily living
- Liable to dramatic behaviour or violence
- Palpitations, rapid breathing, diarrhoea, tremor
- Aggression, deliberate self-harm, alcohol abuse, drug misuse, social difficulties
ICD10 subtypes of adjustment disorders
Brief depressive reaction
Prolonged depressive reaction
Mixed anxiety and depressive reaction
Adjustment disorder - emotion/conduct/mixed
Prognosis of adjustment disorders
Usually resolve within a few months
Definition of schizophrenia
At least one must be present most of the time for 1 month:
- Thought echo, insertion, withdrawal or broadcast
- Delusions of control referred to body parts, actions or sensations
- Delusional perception
- Hallucinatory voices giving running commentary, discussing the patient or coming from a part of the patient’s body
- Persistent bizarre or culturally inappropriate delusions
OR 2 of the following for most of the time for 1 month:
- Persistent daily hallucinations accompanied by delusions
- Incoherent or irrelevant speech
- Catatonic behaviours - stooping and posturing
- Negative symptoms such as marked apathy, blunted or incongruous mood
Epidemiology of schizophrenia
15 per 100,000 incidence
7 per 1000 prevalence
Starts in adolescence and early 20s
Peak age of onset is later in women
More common in men
More common in Blacks and ethnic minorities
FHx association
Subtypes of schizophrenia
Paranoid - delusions or hallucinations prominent
Hebephrenic - sustained, flattened or incongruous affect, lack of goal directed behaviour, prominent thought disorder
Catatonic - sustained evidence over at least 2 weeks of catatonic behaviour including: stupor, excitement, posturing, rigidity.
Simple - considerable loss of personal drive, progressive deepening of negative symptoms
Management of schizophrenia
“Factors associated with poor prognosis
- Strong family history
- Gradual onset
- Low IQ
- Premorbid history of social withdrawal
- Lack of obvious precipitant
- Early intervention services
- MDT
- Health promotion
- Increased compliance with medication
Medical: usually risperidone or olanzapine
- Agree choice of antipsychotic
- Titrate as necessary to minimum effective dose
- Assess over 6-8 weeks
- If not suitable, change drug and repeat steps 1-3
- If not suitable use clozapine”
First rank symptoms of schizophrenia
First rank symptoms:
- Lack of insight
- Auditory hallucinations: thought echo, 3rd person commentary
- Thought disorder (insertion, withdrawal, interruption, broadcasting)
- Delusional perceptions (abnormal significance for normal event)
- External control of emotions
- Somatic passivity: thoughts, sensations and actions are under external control
Negative symptoms of schizophrenia
Negative symptoms:
- Underactivity
- Low motivation
- Social withdrawal
- Emotional flattening
- Self-neglect
Schizophrenia aetiology
Multifactorial: genetic, environmental and social
- Greatest risk factor is FHx (40% in monozygotic twins)
- NRG1 has some part
- Dopamine in mesolimbic system plays a key role
- Excessive dopamine adds salience to mundane and insignificant thoughts or perceptions
- Amphetamine misuse increases synaptic dopamine and can cause delusions and hallucinations
Signs of schizophrenia
“Appearance
Behaviours: withdrawal, suspicion, repetitive purposeless movements
Speech: interruptions to the flow of thought (thought blocking), loosing of associations, knight’s move thinking
Mood/affect: flattening, incongruous or odd
Thoughts: word salad, derailment, knights move thinking, thought insertion, thought withdrawal, thought broadcast
Beliefs: delusion perceptions, delusions regarding thought control or broadcasting, passivity of experiences
Hallucinations
Cognition: attention, concentration, orientation and memory should be assessed and is often impaired”
Risk factors for schizophrenia
“Risk factors:
- FHx
- Premature birth or low birth weight
- Perinatal hypoxia
- Intrauterine infection (influenza in 2nd trimester)
- Abnormal early cognitive neuromuscular development
- Social isolation
- Urban lifestyle
- Illicit drug use
- Migrants
- Abnormal family interactions
- Black and ethnic minority”
Investigations in schizophrenia
"FBC and LFTs Check for alcohol abuse Urine screening for drug misuse Serological tests for syphilis Check for intoxication or drug overdose
Rule out: Organic causes: - Drug induced psychosis: amphetamine, LSD, cannabis - Temporal lobe epilepsy - Encephalitis - Alcoholic hallucinosis - Dementia - Delirium - Cerebral syphilis
Psychiatric causes:
- Mania
- Psychotic depression
- Personality disorder
- Panic disorders
- Dissociative identity disorder”
Management of schizophrenia
“Factors associated with poor prognosis
- Strong family history
- Gradual onset
- Low IQ
- Premorbid history of social withdrawal
- Lack of obvious precipitant
- Early intervention services
- MDT
- Health promotion
- Increased compliance with medication
Medical: usually risperidone or olanzapine
- Agree choice of antipsychotic
- Titrate as necessary to minimum effective dose
- Assess over 6-8 weeks
- If not suitable, change drug and repeat steps 1-3
- If not suitable use clozapine”
Prognosis for schizophrenia
More than 80% of patients with their first episode will recover
20% will never have another episode
Worse prognosis with: poor premorbid adjustment, slow insidious onset, long duration of untreated psychosis, prominent negative symptoms
Differentials for schizophrenia
Organic
- Drug Induced Psychosis - Amphetamine, LDS, Cannabis
- Temporal Lobe Epilepsy
- Encephalitis
- Alcoholic Hallucinosis
- Dementia
- Delirium
- Cerebral Syphilis
Psychiatric
- Mania
- Psychotic Depression
- Personality Disorder
- Panic Disorders
- Dissociative Identity Disorder
Define psychosis
Severe mental disorder in which there is extreme impairment of ability to think clearly, respond with appropriate motion, communicate effectively, understand reality and behave appropriately.
Define delusions
False, fixed strange or irrational belief with is firmly held
Define hallucinations
Sensory perception without an appropriate stimulus
Delusional themes
Delusion of control - someone else controlling feelings, behaviours and thoughts
Delusional jealousy
Delusion of guilt
Thought insertion
Delusion of reference
Erotomania - belief that someone is in love with them
Grandiose
Grandiose religious - person is god or chosen to act as god
Persecutory - followed/harassed/cheated or conspired against
Cotard delusion
Thought or belief that they don’t exist or that they have died
Delusion of reference
Insignificant remarks or events have personal significance to patient
Types of hallucinations
Hallucinations:
- Visual: more common in organic illness e.g. TLE, epilepsy, Parkinson’s.
- Auditory: more common in functional psychiatric illness.
- Tactile: cocaine bugs, simple partial seizures, somatic passivity experiences.
- Olfactory: epileptic aura, tumours, schizophrenia.
- Gustatory: epileptic aura and attack, functional illness.
Lilliputian Hallucinations
Seen in TLE (temporal lobe epilepsy)
Size distortion
Alice in Wonderland syndrome
Also seen in migraines, brain tumours and EBV
Types of disordered thoughts
Paucity of thought
Thought block
Rapid uncontrollable thoughts
Formal thought disorders
- Derailment
- Loosening of association
- Knight’s move thinking
- Word salad
Organic causes of psychosis
Delirium - infections, electrolyte disturbance
Epilepsy
Medications - steroids, antibiotics, antivirals, dopamine agonists, stimulants
Cancer
MS
SLE
Neurodegenerative disorders e.g. Parkinson’s
Drug or alcohol withdrawal
Psychaitric causes of psychosis
Schizophrenia Schizoaffective disorder Bipolar disorder Major depression Acute psychosis Dementia Personality disorders
Risks in schizophrenia
Suicide rate is 10-15%
High in early stages of disease
Self-neglect
Risk to others - mild increased in minor aggressive acts.
Extrapyramidal side effects of antipsychotics
Dystonia
Pseudoparkinsonism
Akathisia
Tardive dyskinesia
Sedation
Hyperprolactinaemia
Decreased seizure threshold
Postural hypotension
Tardive dyskinesia
Late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw.
Akathisia
SEVERE RESTLESSNESS
Akathisia is a movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion, as well as by actions such as rocking while standing or sitting, lifting the feet as if marching on the spot, and crossing and uncrossing the legs while sitting.
Dystonia
Dystonia is a movement disorder in which a person’s muscles contract uncontrollably.
The contraction causes the affected body part to twist involuntarily, resulting in repetitive movements or abnormal postures
E.g. torticollis, oculogyric crisis)
Dissociation (conversion) define
Psychological distress manifests as physical and mental signs
e.g. paralysis and amnesia
Relationship between physical and psychiatric illness
- Psychiatric symptoms can be a consequence of physical illness e.g. organic
- Physical symptoms are manifestations of psychiatric disorder e.g. MUS and somatisation
- Psychiatric symptoms that are manifestations of underlying physical illness
e. g. hypothyroid - Psychiatric symptoms precipitating physical illness
Anxiety, depression can precipitated seizures, MS relapses, pain
Define medically unexplained symptoms
Physical symptoms not explained by organic disease and there is positive evidence or assumption that the symptoms are linked to psychological factors
- Not a diagnosis of exclusion
- requires positive psychological factors
- Most are transient and not deliberately produced
Define illness denial
Behaviours to avoid the stigma
Inability to accept the physical or mental illness
Define illness affirmation
Behaviours that inappropriately affirm the illness
Disproportionate disability in relation to signs and symptoms
Define somatisation
Manifestation of psychological stress as physical complaints with medical consultation.
Can be acute or chronic
often associated with psychiatric diagnosis
Not a conscious process
ICD10 definition of medically unexplained symptoms
2 years of multiple and various physical symptoms
Persistent refusal to accept advice and reassurance that there is no physical aetiology
Some degree of impaired functioning
Temporal relationship to stresses
Features of chronic somatisation
Many unexplained symptoms (often pain)
Multiple investigations
Frequent consultations
Excessively disabled
Polypharmacy
Thick case notes
Dissatisfied with care
odd beliefs
Unrealistic expectations of care
Denial or minimise life problems
Define dissociative disorder
acute and dramatic onset
Psychological distress manifests as physical mental signs
Mental symptoms
e.g. amnesia, fatigue states
Caused by stressful life events, child hood neglect or abuse.
Define conversion disorders
acute and dramatic onset
Psychological distress manifests as physical signs
PHYSICAL symptoms
e.g. paralysis, blindness
Caused by stressful life events, childhood neglect or abuse.
Prevalence and outcome of medically unexplained symptoms
20% of general population
10-33% of GP presenting complaints
Secondary care 30-50%
50% recede in 12 months
2.5% persist and lead to repeated consultation
Conversion and dissociation disorders recover quickly
Clinical identification of MUS
- Symptoms do not fit with existing disease models
- Patient is unable to give clear and precise description of symptoms
- Symptom or disability seems excessive in comparison to pathology
- Temporal relationship to stressful life events
- Patient attends frequently with different symptoms
- Patient over anxious about the meaning of symptoms
- Patient complains of pain in various sites
Management of MUS
- Acknowledge that symptoms are genuine
- Provide clear explanation of investigations, results and conditions excluded
- Avoid extra investigations of referrals unless clinically indicated
- Address the patients concerns
- Set up brief regular meetings every 6-8 weeks (they need to feel they are being taken seriously)
- Symptom management e.g. analgesics, laxatives, antispasmodics, weight loss and exercise
- Treat any anxiety or depression if present +/- IAPT
- Counsellor if required
Aim for patient coping and decreased impact on life rather than symptom cure.
Ways of parents managing child stress
- Provide safe, secure, familiar, consistent environment
- Encourage the child to ask questions
- Listen to child without being critical
- Use encouragement and affection
- Use positive encouragement not punishment
- Allow child to make choices and have some control
- Recognise signs of unresolved stress
Methods of screening for dementia
Mini mental state exam (MMSE) MOCHA ACE-III DEMTECT AMTS
Diagnostic criteria for dementia:
- Affects ability to function in normal activities
- Represents a decline from a previous level of function
- Cannot be explained by delirium or other psychiatric disorder
- Has been established from history and cognitive assessment
- Involve impairment of at least 2 cognitive domains”
Describe MMSE
Out of 30
Cut off 24
- Most commonly used for complaints of problems of memory
- Used for diagnosis and assesses progression and severity
- Tests memory, attention and language
- Not good for mild impairment
X doesn’t test frontal function
X not designed to measure change
Describe MOCHA
Out of 30
Cut off 26
- Aimed at detection of mild cognitive impairment
- Relatively comprehensive but brief
- Not biased towards a particular cognitive domain
- Not suitable for patients in advanced stages
Describe ACE-III
Out of 100
Cut off 82-88
- Robust validation in various neurodegenerative conditions
- Appropriate for longitudinal studies
- Sensitive to subtle impairments
- Not sensitive to behavioural impairments
Describe AMTS
Out of 10 Cut off 6-8 - Widely used in hospital settings - 10 questions - Easy to use - Insufficient for more detailed assessment of cognition
Define dementia
Syndrome that is chronic and progressive in nature where there is a deterioration of cognitive function beyond what might be expected in normal aging.
Affects: memory, thinking, orientation, comprehension, calculation, learning capacity.
Impairment in cognitive function is commonly accompanied and occasionally preceded by deterioration in emotional, social control or motivation
Treatment of dementia
”- Ensure no treatable cause has been missed
- FBC, ESR or CRP, U+Es, LFTs, glucose, calcium, TFTs, B12 and folate
- MSU
- VDRL/TPHA (syphilis)
- Consider blood cultures, CXR, MRI and psychometric testing
- Specialised assessment required to determine subtype
- Can use HMPAO-SPECT to distinguish Alzheimer’s from other types
- CSF if ?CJD
- Imaging: MRI preferred”
Dementia aetiology
“1.5% of 65-69
22% of over 85s
- Increases with age
- Similar prevalence in males and females
- Alzheimer’s more common in women.
- Vascular and mixed more common in men
- More common in Caucasians”
Differtials for dementia
Potentially treatable disease:
- Substance abuse
- Hypothyroidism
- Space occupying lesions
- Normal pressure hydrocephalus
- Syphilis
- Vitamin B12 deficiency”
Diagnostic criteria for dementia
“Diagnostic criteria for dementia:
- Affects ability to function in normal activities
- Represents a decline from a previous level of function
- Cannot be explained by delirium or other psychiatric disorder
- Has been established from history and cognitive assessment
- Involve impairment of at least 2 cognitive domains”
Epidemiology of dementia
1.5% of 65-69
22% of over 85s
Increases with age Similar prevalence in males and females Alzheimer's more common in women. Vascular and mixed more common in men More common in Caucasians
Aetiology of dementia
Alzheimer's (50%) Vascular dementia (25%) Dementia with Lewy bodies (15%) Frontotemporal dementia (5%) Mixed dementia Parkinson's disease
Potentially treatable disease:
- Substance abuse
- Hypothyroidism
- Space occupying lesions
- Normal pressure hydrocephalus
- Syphilis
- Vitamin B12 deficiency
Aetiology of dementia
Alzheimer's (50%) Vascular dementia (25%) Dementia with Lewy bodies (15%) Frontotemporal dementia (5%) Mixed dementia Parkinson's disease
Potentially treatable disease:
- Substance abuse
- Hypothyroidism
- Space occupying lesions
- Normal pressure hydrocephalus
- Syphilis
- Vitamin B12 deficiency
Management of dementia (general)
- Person centred care
- Discuss options
- Valid consent where possible
- Cognitive stimulation programmes
- Music/Art/Dance therapy
- Structured exercise program
Pathophysiology of Alzheimer’s disease
”- Formation of senile plaques and neurofibrillary triangles
- Excess amyloid beta peptides due to over production or decreased clearance
- Formation of dense amyloid plaques
- Plaques cause inflammatory process - cytokines, complement cascade
- Synaptic and neuronal injury and cell death
- Decreased brain weight
- Cortical atrophy: temporal, frontal and parietal areas
- Beta amyloid plaques
- Neurofibrillary triangles
- Neurotransmitter deficiencies”
Risk factors for Alzheimer’s disease
“Risk factors:
- Increase in women
- Increases with age
- FHx (x3.5 if 1st degree family member)
- Apolipoprotein E4
- Head injury
- Hypercholesterolaemia
- Hypertension
- Diabetes
- Down’s syndrome”
Presentation of Alzheimer’s
“Early stages:
- Memory lapses
- Nominal dysphasia
- Difficulty finding the right words
- Inability to remember recent events
- Forgetting appointments
Progresses to:
- Language difficulties
- Apraxia
- Difficulty planning
- Confusion
Late Stage:
- Wandering, disorientation
- Apathy
- Psychiatric depression, hallucination delusions
- Incontinence
- Altered eating habits
- Behavioural changes - disinhibition, aggression, agitation
Diagnostic criteria for Alzheimer’s
- Dementia established by examination and testing
- Deficits in 2 areas of cognition
- Insidious onset (months-years)
- Progressive worsening
- No change in consciousness
- Onset between 40 and 90 with no other cause
Management of Alzheimer’s
“1. Acetylcholinesterase (AChE) inhibitors
- Donepezil, galantamine, rivastigmine
- For mild-moderate disease as long as benefit
- NDMA antagonist
- Memantine
- For moderate disease intolerant to AChE and severe disease
No cure.”
Define vascular dementia
Group of syndromes of cognitive impairment caused by ischaemia or haemorrhage secondary to cerebrovascular disease
Aetiology of vascular dementia
”- Stroke related: single infarct or multi-infarct
- Subcortical: small vessel disease or Binswanger’s disease
- Mixed: Alzheimer’s and vascular
- Leukoaraiosis: subcortical leukoencephalopathy
- Haemorrhage
- SPORADIC: most are sporadic, some familial traits
- CADASIL: most common inherited”
Presentation of vascular dementia
”- Focal neurological abnormalities: visual disturbances, sensory or motor symptoms
- Extrapyramidal symptoms
- Difficulty with attention and concentration
- Seizures
- Depression and/or anxiety
- Early presence of disturbance in gait, unsteadiness, increased falls
- Bladder symptoms without urological dysfunction
- Emotional liability, psychomotor retardation, depression”
Pathophysiology of vascular dementia
“Group of syndromes of cognitive impairment caused by ischaemia or haemorrhage secondary to cerebrovascular disease
- Once infarct or bleed reaches a certain volume, it will exhaust brains compensation
- Small infarcts are due to arteriosclerosis secondary to hypertension”
Risk factors for vascular dementia
Hx of stroke or TIA AF Hypertension Diabetes Hyperlipidaemia Smoking Obesity CHD Fhx of stroke or CHD
Diagnostic criteria for vascular dementia
- Diagnosed dementia
- Deficits interfere with ADLs
- Cerebrovascular disease - signs or imaging
- A relationship between disorders
- Onset of dementia within 3 months of stroke
- Abrupt deterioration in cognitive functions
- Fluctuating stepwise progression of cognitive defects
Presenting features of vascular dementia
Focal neurological abnormalities - visual disturbances, sensory or motor symptoms
EPS - extrapyramidal symptoms
Difficulty with attention and concentration
Seizures
Depression and/or anxiety
Early presence of disturbance in gait, unsteadiness, increased falls
Bladder symptoms without urological dysfunction
Emotional liability, psychomotor retardation, depression
Treatment for vascular dementia
No specific pharmacological treatment
Modify vascular risk factors
Complications of vascular dementia
Behavioural problems - wandering, delusions, hallucinations, poor judgement Depression Falls and gait abnormalities Decubitus ulcers Aspiration pneumonia
Prognosis worse than Alzheimer’s - 3-5 years
Lewy body dementia diagnostic criteria
Diagnostic criteria of Lewy body dementia:
- Presence of dementia
- At least two core features:
- Fluctuating attention and concentration
- Recurrent well formed visual hallucinations
- Spontaneous parkinsonism
Lewy Body dementia pathophysiology
“Characterised by eosinophilic intracytoplasmic neuronal inclusion bodies (LEWY BODIES) in brainstem and neocortex.
- Pathology mimics Parkinson’s
- Lewy body inclusions are composed of a protein called alpha-synuclein”
Symptoms of lewy body dementia
”- Dementia: memory loss, decline in problem solving and spatial awareness
- Fluctuating levels of awareness and attention
- Visual hallucinations
- Sleep disorders”
Signs of lewy body dementia
” Signs of mild Parkinsonism:
- Tremor
- Rigidity
- Poverty of facial expression
- Festinating gait”
Treatment of Lewy body dementia
Avoid neuroleptic drugs
Cholinesterase inhibitors (Rivastigmine) can help treat cognitive decline
Average survival 5-8 years
Define fronto-temporal dementia
Also known as Picks disease
Affects frontal and/or temporal lobes
It is one of the more common causes of dementia before the age of 65
Epidemiology of FT dementia
More common in men
Mean presentation 53-58 years
No difference in ethnicity
15 per 100,000
Pathophysiology of FT dementia
”- Affects frontal and/or temporal lobes
- Is one of the more common causes of dementia before the age of 65
- Patients sometimes lose inhibitions
- Atrophy of frontal and temporal lobes
- Focused
- No increased plaques
- Protein inclusions in neurons and glial cells (TAU, TDP, FUS)”
Presentation of FT dementia
3 main clinical syndromes defined by predominant symptom at presentation
Behavioural variant FT dementia (50%):
- Loss of inhibition
- Inappropriate social behaviour
- Decrease motivation
- Loss of empathy and sympathy
- Change in preferences
- Repetitive compulsive behaviour
- Decreased memory
- Echolalia
- Mutism
Progressive non-fluent aphasia:
- Slow, hesitant
- Difficult speech
- Grammatical errors in speech
- Loss of literary skills
- Impaired understanding of complex sentences
- Impairment of swallowing and coughing on demand
Semantic dementia:
- Loss of vocab with fluency or maintained speech
- Difficulty finding right word
- Loss of recognition
- Preserved memory and visuospatial skills
- Asking meaning of familiar words
Treatment of FT dementia
”- Stop cholinergics or CNS drugs
- SSRIs may help with behavioural symptoms
- Can use atypical antipsychotics if psychosis and agitation
- Levodopa/carbidopa if Parkinson’s symptoms”
Define delirium
“Aetiologically non-specific organic cerebral syndrome characterised by concurrent disturbances of consciousness and attention, perception, memory, behaviour, emotion and sleep wake cycle
Duration is variable, as is severity
Types of delirium
Types of delirium:
- Prevalent: condition present on admission
- Incident: occurs during admission
- Hypoactive: apathy and quiet confusion. Can be confused with depression
- Hyperactive: agitation, delusions, disorientation”
Epidemiology of delirium
- 0.4% of population
- Increases with age
- More common in males
- 30% of ED patients
- Only 20-50% detected by medical professionals
- Most common complication of hospital stay in elderly
Prognosis:
- Short term has no effect on mortality
- Long term has 2-3x mortality
- Some do not return to baseline
Risk factors od delirium
Risk factors
- Elderly
- Malignancy
- HIV/AIDS
- Pre-existing cognitive issue
- Past delirious episode
- Burns
- Emergency surgery
- Orthopaedic surgery (hip)
- Drug/substance abuse
- Social isolation
- Poor mobility
- Terminally ill
- Change of environment
Aetiology of delirium
”- Acute infections: e.g. Malaria, septicaemia
- Medications: benzos, analgesia, anticholinergics, anticonvulsants, steroids, digoxin
- Toxic substances: alcohol, CO, barbiturates, drug or alcohol withdrawal
- Vascular: stroke, cardiac failure, ischaemia, subdural, subarachnoid, vasculitis, migraine
- Metabolic: hypoxia, electrolyte disturbance, hypo/hyperglycaemia, hepatic failure, CKD
- Vitamin deficiencies: B12, thiamine, nicotinic acid
- Endocrine: hypo/hyperthyroid, hypopituitarism, Cushing’s syndrome
- Intracranial: epilepsy, tumour, trauma, subarachnoid haemorrhage
- Post-operative state
- Drug/alcohol withdrawal”
Symptoms of delirium
”- Clouded consciousness (absent in other causes of psychosis)
- Impaired cognition/ disorientation
- Poor concentration
- Memory deficits
- Abnormalities in sleep wake cycle
- Abnormalities of perception (hallucinations and illusions)
- Agitation
- Emotional lability
- Psychotic ideas
- Neurological signs (tremor and unsteady gait)”
Investigations for delirium
“Confusion assessment (must have 3/4):
- Acute onset and fluctuating course
- Inattention
- Disorganised thinking OR Changed level of consciousness
Full examination FBC U+Es Glucose LFTs TFTs Troponin Vitamin B12 Syphilis PSA Urine dipstick and microscopy Blood cultures and serology ECG Pulse ox (and ABG if indicated) CXR and AXR
Other - head CT, LP, EEG”
Management of delirium
“Treat underlying cause
If cannot provide consent then treat in best interests
- Supportive management: clear communication, reminder of day/time/place, clocks, familiar staff and objects from home
- Environmental measures: single room control noise, lights and temperature, maintain abilities, attention to incontinence
- Medical management: antipsychotics if aggressive and not responding to de-escalation (haloperidol and olanzapine)
Chlordiazepoxide used in delirium tremens (result of alcohol withdrawal following dependency)”
Prognosis of delirium
Short term has no effect on mortality
Long term - 2-3x mortality
Some do not return to baseline
Complications - hospital acquired infections, pressure sores, fractures, residual impairment, stupor, coma, death
Indications for ECT
- Severe depression where fluid intake is so poor that it is life threatening
- Depressive stupor
- Psychomotor retardation
- Psychotic depression
- Depression with strong suicidal features
- Treatment resistant
Contraindications to ECT
Recent MI Arrhythmias Heart failure Stroke Respiratory problems GORD
Side effects for ECT
Mortality 1 in 10,000 Prolonged seizures Headache, nausea, muscular aches Post ictal - confusion, impaired attention Some memory issues
Social and emotional development milestones 0-3 months
Interest in people Start to learn and recognise their primary caregivers Can be comforted by familiar adults Respond positively to touch Smiles
Social and emotional development milestones
3-6 months
Plays peek a boo
Pays attention to own name
Smiles spontaneously
Laughs out loud
Social and emotional development milestones
6-9 months
Wider emotional range, strong preferences for familiar people
Expresses several emotions
Distinguishes friends from strangers
Shows displeasure at loss of toys
Social and emotional development milestones
9-12 months
Able to feed themselves with fingers
Can hold a cup with 2 hands and drink with assistance
Hold out arms and legs when dressed
Anxious when separated from primary caregiver
Social and emotional development milestones
1-2 years
Intense feelings for parents Play by themselves, initiate own play Express negative feelings Begins to be helpful e.g. put things away Assertive
Social and emotional development milestones
2-3 years
Assertive about preferences
Awareness of emotions and feelings or others
Rapid mood shifts
Displays aggression
Enjoys parallel play, solitary actions near other children
Begins to play house
Defends positions
Social and emotional development milestones 3-4 years
Becomes more independent Completes simple tasks Wash hands unassisted More interested in other children More likely to share
Define autism
Range of conditions with varying degrees of severity.
Includes Asperger’s and Rhett’s
It is a developmental disorder which affects 4 domains and starts before the age of 3. Domains:
- Repetitive behaviours
- Imagination
- Language/communication
- Social
6 abnormalities, 2 from B1
Symptoms of autism
Symptoms of autism (categories): B1 - SOCIAL - Eye contact, gesture, body language - Failure to develop peer relationships - Empathy and social responses - Lack of seeking to share interest and pleasure
B2 - COMMUNICATION
- delay in language development (without gesture compensation)
- conversational reciprocity
- repetitive or unusual language
- imagination
B3 - BEHAVIOUR
- preoccupation with abnormal intensity/content
- Compulsions, rituals, sameness
- Mannerisms or stereotypes
- Sensory preoccupations or fears”
Asperger’s
Same as autism BUT
- No delay in language
- No significant delay in cognitive development
- Other associations:
- Motor clumsiness
- Some have isolated special skills
Epidemiology of autism
”- Prevalence 6 in 1000
- Under 3
- More common in males
- No racial associations
- Positive family history
Increasing prevalence over the last few years due to increasing diagnosis”
Signs and symptoms of autism
”- Language delay or regression
- Verbal and non-verbal communication impairment
- Social impairment
- Repetitive, rigid or stereotyped interests, behaviours and activities
- Placid or irritable as baby
- Unusual posturing
- Motor stereotypies
- Sensory interests”
Aetiology of autism
Genetic factors Maternal rubella Meningitis/encephalitis Fragile X syndrome Tuberous sclerosis Down's syndrome
NOT parental or environmental
Pathophysiology of autism
UNKNOWN
3 Neurocognitive theories of autism
- THEORY OF MIND
Difficulties in considering how others may think and react in certain situations. Cannot put themselves into the minds of others - WEAK CENTRAL COHERENCE
Failure to integrate information into meaningful whole. Can’t make meaning of things, can’t get the gist - EXECUTIVE FUNCTION
Difficulties with problem solving and forward planning in order to achieve a goal
Management of autism
“MDT approach
- Multiple assessments: play based, school observations
- Exclude other causes: deafness, abuse, attachment disorder, OCD, LD etc.
- Develop social communication and learning and problem solving
- Teach idiom and metaphor
- Support routines of learning
- Provide support and respite care and sibling support”
Investigations of autism
”- Childhood autism rating scale
- Diagnostic questionnaires
- Observational assessment (multiple)
- Fragile X and chromosome microarray testing
- EEG/MRI”
Differentials for autism
ADHD
Social communication disorder
Schizoid personality disorder
Define ADHD
“Attention Deficit Hyperactivity Disorder
- Begins in childhood with functional impairment, most often in home and school
- ? dysfunction of NA and dopamine
- 85% respond to stimulants
- ? dysfunction in frontal subcortical circuits due to executive dysfunction
- Decreased activation in basal ganglia and anterior frontal lobe
Types of ADHD:
- Hyperactive impulse type (15%)
- Inattentive type 20-30%
- Combined type (50-75%)”
RF of ADHD
“Risk factors:
- Family history
- Low birth weight
- Maternal smoking in pregnancy
- Poverty
- Lead exposure
- Iron deficiency”
Investigations in ADHD
“ADHD rating scale or attention deficits disorders evaluation scale
Consider neuropsychological testing”
Types of ADHD
Hyperactive impulse type (15%) Inattentive type 20-30% Combined type (50-75%)
Hyperactive impulse type ADHD (15%)
“Hyperactive impulse type ADHD (15%):
- Fidgets with hands or feet/squirms in seat
- Leaves classroom when remaining seated is expected
- Runs or climbs excessively when inappropriate
- Difficulty playing or engaging in activities quietly
- On the go
- Talks excessively
- Blurts out answers before questions fished
- Difficulty waiting turn
- Interrupts or intrudes on others”
Inattentive type ADHD (20-30%)
“Inattentive type ADHD (20-30%):
- Fails to given attention to detail/careless mistakes
- Difficulty sustaining attention in tasks or play
- Doesn’t listen when spoken to directly
- Doesn’t follow through on instruction e.g. homework
- Difficulty organising tasks and activities
- Avoids/dislikes tasks requiring sustained mental effort
- Loses things necessary for tasks
- Easily distracted
- Forgetful in daily activities”
Management of ADHD
“Pre-school: no drug treatment
School with moderate impairment:
- Group based parent education programmes
- CBT and social skills training
School with severe impairment:
- Methylphenidate + psychoeducation + adjunct behavioural therapy
- Atomoxetine
- Guanfacine or clonidine
- Antidepressant
Parent training in communication, positive feedback, effective time outs and co-ordination of school behavioural plan”
Epidemiology of depression in children
1% in children
3% post-puberty
Twice as common in girls
Prevalence increasing
Presentation of depression in children
- Running away from home
- Separation anxiety
- School refusal
- Complaints of boredom
- Poor school performance
- Antisocial behaviour
- Insomnia or hypersomnia
- Somatic complaints
- Irritability
- Social withdrawal
Management of depression in children
Midl psychological therapy used 1st line
Moderate - refer to CAMHS
Medication only alongside psychological therapies
FLUOXETINE is the only drug where benefits>risks
ECT only if very severe with life threatening symptoms (aged over 12)
Risk factors of depression in children
Risk factors:
- Family discord
- Bullying
- History of parental depression
- Physical, sexual or emotional abuse
- Homelessness
- Ethnic and cultural factors
- Refugee
- Living in institutional setting
Prognosis of childhood depression
Prognosis:
- 10% recover spontaneously in 3 months
- 50% depressed at 12 months
- 30% will have recurrence within 5 years
- Worse prognosis with females, previous episodes of depression
- 1-3% attempt suicide with 5- 15% recurrence
Conduct disorder
Psychological disorder diagnosed during childhood or adolescence that presents itself through a repetitive and persistent pattern of behaviour in which age appropriate norms are violated.
Aggressive behaviour/deceitfulness/destruction of property/violation of rules
Types of conduct disorders
- Socialised conduct disorder
- Unsocialised conduct disorder
Conduct disorders confined to family context
Oppositional defiant disorder
Epidemiology of conduct disorders
More common in males
8% of boys, 5% girls
Appears in early to middle childhood
Oppositional defiant disorder is more common in the under 10s
RFs
- Second hand smoking
- Male
- Non contact or mobile family
- Coercive/ineffective parenting
- Hyperactivity/ inattention
- Smoking in pregnancy
- Low birth weight
Symptoms and criteria for conduct disorder
Must be under 18
At least 3 out of 15 criteria in past 12 months, at least 1 in last 6 months
Aggression to people/animals
- bullies, threatens, intimidates
- initiates physical fights
- use of a weapon
- physically cruel to people or animals
- stolen something while confronting victim
- forced someone into sexual activity
Destruction of property
- deliberately fire setting, aiming to cause damage
- Deliberately destroyed property
Deceitfulness or left
- Broken into house or car
- Often lies to obtains goods, favours or void obligations
- Stolen items without confronting victim
Serious violation of rules
- stays out at night desperate parental prohibitions
- run away from home overnight (2+)
- truant from school aged under 13
Oppositional defiant disorder
Usually frequent or severe tantrums
Often argues with adults
Actively refuses adult request or defied rules
Deliberately does things to annoy others
Blames others for their mistakes
Touchy or easily annoyed by others
Angry or resentful
Spiteful
Management of oppositional defiant disorder
Multi-axial approach
Deal with psychological illness, cognitive functioning, development, physical illness and psychosocial issues
- May have developmental delay
- Discrepancy between age and development
- May have physical problems - Hunter’s
Comprehensive assessment
Parent training programs
Child group social and cognitive problem solving programmes
If oppositional defiant disorder 0 given methyphenidate or atomoxetine
- Clear rules or commands
- Promoting play and positive relationships
Classification of learning disabilities
Mild IQ 50-70
Language fair. little sensory or motor deficits. reasonable level of independence
Moderate IQ 35-49
Better receptive than expressive language
Severe IQ 20-34
Increasing sensory and motor deficits. 50% will have epilepsy.
Profound IQ<20
Increase need. Vulnerable. Developmental level at about 12 months
Epidemiology of LD
- More common in males
- Prevalence 2%
- Decrease life expectancy
Define learning disability
- IQ < 70
- Loss of adaptive social functioning
- Onset before age 18
Aetiology of learning disability
Genetics: Down’s, Fragile X, Turner’s, Klinefelter’s
Metabolic: phenylketonuria, galactosaemia, Tay-Sachs disease, Hurler’s syndrome
Structural disorders: tuberous sclerosis, hydrocephalus, neurofibromatosis
Intrauterine: iodine deficiency, infection (CMV, rubella, toxoplasmosis)
Drugs - phenytoin, alcohol
Cerebral malformations
Pre-eclampsia, premature labour, APH
Prologned labour, trauma, asphyxia
Neonatal - hypoglycaemia, severe neonatal jaundice, meningitis, encephalitis anoxia, hypothyroid, malnutrition
Presentation of learning disability
Physical:
- Motor and mobility problems
- Abnormalities in movement
- Speech, vision and hearing problems
- Epilepsy
- Urinary and faecal incontinence
- Increase risk of obesity, fractures, GORD, constipation
Psychological (all increased in LD):
- Schizophrenia
- Anxiety and depression
- Personality disorder
- Early onset dementia
- ADHD
- Autism
Behavioural:
- Threatening own and others safety
- Violent but harmless behaviour
- Temper tantrums
Sleep disorders
Communication difficulties
Investigations for LD
No lab investigations
Diagnosis made by history, observations and assessment
- If developmental delay then chromosome and fragile X testing
- TFTs
- If severe delay, head MRI and CK
Management of LD
MDT support:
- Social worker
- Psychologist
- SALT
- Physiotherapist
- Nurses
- Occupational therapist
- Annual check with GP
- Direct support and coaching
- Psychotropic drugs rarely used
- Behaviour support plan (identify reactive and preventative strategies)
- Anger management programmes
Symptoms of depression in a patient with LD
- Agitation
- Weight changes
- Appetite changes
- Poor sleep
- Psychomotor retardation
- Tearfulness
Biological problems more relevant when expression of feelings is difficult
Ways of assessing for drug and alcohol dependence
CAGE questionnaire
AUDIT
SADQ
Ways of assessing for drug and alcohol dependence
CAGE questionnaire
AUDIT
SADQ
Cage Questionnaire
Cut Down?
Annoyed by people criticising your drinking?
Guilty about drinking?
Eye-opener
2 or more points suggests a problem, but it is not very specific
AUDIT for alcohol
Alcohol Use Disorders Identification Test
10 items, 4 levels of risk
0-7 - alcohol education
8-15 = simple advice on cutting down
16-19 = simple advice + brief counselling and continued monitoring
20-40 = referral to specialist for diagnostic evaluation and treatment
SADQ for alcohol
Assesses severity and degree of dependence once a problem is identified
Covers
- physical withdrawal symptoms
- affective withdrawal symptoms
- relief drinking
- frequency of alcohol consumption
- speed of onset
<16 = mild dependence
16-30 = moderate
>30 severe dependence
ICD10 definition of dependence syndrome
Physiological and behavioural and cognitive phenomena in which use of a substance takes a higher priority than other behaviours.
3 or more in past year:
- A strong desire to take a substance
- Difficulties in controlling substance taking behaviour
- Physiological withdrawal
- Evidence of tolerance
- Neglect of other interests
- Persisting with substance use despite clear evidence its harmful
- Narrowing of drinking repertoire (alcohol only)
Symptoms of alcohol withdrawals
Clear evidence or recent cessation or reduction plus 3 of:
- tremor
- sweating
- nausea, retching, vomiting
- tachycardia
- hypertension
- headache
- psychomotor agitation
- malaise, weakness
- insomnia
- transient hallucinations or illusions
- Grand mal convulsions
Epidemiology of alcohol dependence
9% men and 4% women show signs
More common in males
RFs
- higher income
- older people
Epidemiology of drug dependence
- More likely in younger population 16-19
- More common in men
- Increased in urban living
- Increased in those visiting night clubs
- Increased in homosexuals
- Increased in mixed ethnic backgrounds
Most commonly cannabis, then opiates then cocaine
Long term physical complications of alcohol misuse
GI - oesophagitis, varices, peptic ulcers, pancreatitis, hepatitis, cirrhosis, cancer (stomach, liver, oesophagus)
CV - HTN, arrhythmia, cardiomyopathy, IHD, stroke
Neuro - amnesia, seizures, peripheral neuropathy, cerebellar degeneration, optic atrophy, central pontine myelinosis
Other - episodic hypoglycaemia, vitamin deficiencies, anaemia, accidents, aspiration pneumonia, increased infection risk, impotence
Alcohol/drug misuse aetiology
- Behavioural and learning theories: drug acts as positive reinforce
- Psychodynamic theory: needs more satisfied by drug. reliable outcome. Influence of child abuse
- Social: increased if FHx. Peer pressure from friends
- Occupation: stressful job
- Life events: separation, bereavement
Complications of alcohol misuse
Social complications of alcohol misuse
- Family and marital difficulties
- Employment difficulties
- Accidents
- Financial problems
- Vagrancy
- Homelessness
- Crime
Psychiatric complications of alcohol misuse
- Mood and anxiety disorders
- Suicide
- Deliberate self-harm
- Alcoholic hallucinosis
- Othello syndrome (pathological jealousy)
- Cognitive impairment
Delirium Tremens
Medical emergency
Clouding of consciousness Disorientation in time and space Impaired short term memory Fear, agitation, restlessness Vivid visual hallucinations Paranoid delusions Insomnia Autonomic disturbances Coarse tremor nausea and vomiting Seizures Dehydration and electrolyte imbalance
Wernicke-Korsakoff syndrome
Wernicke-Korsakoff syndrome (WKS) is a type of brain disorder caused by a lack of vitamin B1 (thiamine). The syndrome is actually two separate conditions that can occur at the same time, Wernicke’s disease (WD) and Korsakoff syndrome. Usually, people get the symptoms of WD first. WD is also known as Wernicke’s encephalopathy.
** Confusion + ataxia + ocular palsy **
- Impaired consciousness and confusion
- Nystagmus
- Abducens and conjugate palsies
- Pupillary abnormalities
- Peripheral neuropathy
Results from thiamine B1 deficiency secondary to alcohol dependence!
Prognosis:
- 20% recover
- 10% diet
- 70% Korsakoff’s
Korsakoff’s syndrome
Korsakoff syndrome is a chronic memory disorder caused by severe deficiency of thiamine (vitamin B-1). Korsakoff syndrome is most commonly caused by alcohol misuse, but certain other conditions also can cause the syndrome.
Irreversible syndrome of prominent impairment of recent memory resulting from neuronal loss, gliosis and haemorrhage in mammillary bodies and damage to dorsomedial nucleus of thalamus
Wernicke’s encephalopathy (WE),
Wernicke encephalopathy (WE) is the presence of neurological symptoms caused by biochemical lesions of the central nervous system after exhaustion of B-vitamin reserves, in particular thiamine (vitamin B1).
Opiates and their effects
Heroin, morphine, codeine, buprenorphine, tramadol, fentanyl
- Dreamy/detached/euphoria
- Respiratory depression
- Sedation
- Anorexia
- Constipation
- Loss of libido
- Pruritus
Stimulants and their effects
Cocaine, crack cocaine, amphetamines, ice, coaince, methyphenidate, MDMA
- Euphoria
- Decrease need for sleep and food
- increased energy and activity
MOA of cocaine
- Blocks reuptake of serotonin and catecholamines
- Especially dopamine
- Euphoria
- Increased confidence and energy
- High disease can cause visual and auditory hallucinations
Depressants and their effects
Benzodiazepines, alcohol, barbiturates
Impair consciousness Impair coordination Disinhibition Analgesia Amnesia
Hallucinogens and their effects
LSD, cannabis, MDMA
- Visual hallucinations
- Time distortion
- Euphoria
- Emotional lability
MOA of LSD
Partial agonism of 5HT receptors
Define plasticity
Extent to which drug effects are shaped by internal and external cues
High = LSD, cannabis, solvents
Low = heroin, amphetamines
Define tolerance
Decrease effect for the same drug dose on repeated exposure
Risk factors for illicit drug use
Younger age
Living in council or inner city area
Male
Living in London
Single, divorced or cohabiting
Unemployed
Earning over £30,000 per year
Renting accommodation
Visiting night clubs
Psychological management of substance misuse
Motivational interviewing
- Follows cycles of change
- Based on cognitive dissonance theory
- Decisional balance, non-confrontational
CBT
Contingency management
- incentives to encourage staying off drugs
- rewards
12 step AA
Social support: occupation, finance, groups, housing, education
Medications involved in managing alcohol misuse
Chlordiazepoxide - prevents DTs, fits and rescue drinking
Pabrinex - B vitamins used to treat Wernicke-Korsakoff syndrome
Acamprosate -used in abstinence and prevention of relapse. Blocks GABA and NDMA receptors to decrease cravings
Naltrexone - competitive antagonist of opioid receptor. Decreases pleasure from drinking alcohol
Disulfram - inhibits acetyl dehydrogenase, causes build up of acetaldehyde causing unpleasant effects
Drugs used in managing opiate misuse
Methadone/Buprenorphine
- Removes hazards of illicit drug use
- removes criminal activity to fund habit
- removes risk of injecting street drugs (VTE, sepsis)
- Can be used as maintenance and detox with gradual drop in dose
Can withdraw cold turkey
- Lofexidine (alpha 2 antagonist) can decrease sweats and cramps
Drug used in managing benzodiazepine withdrawal
Flumazenil - benzodiazepine (selective GABAA antagonist) receptor antagonist
Management of smoking cessation
- Advice, self-help materials, referral
- individual behavioural counselling
- Group therapy
- Self-help materials
- nicotine replacement therapy
- Medications: varencicline, buproprion
- Referral to NHS stop smoking services
Advice for those trying to stop smoking
Prepare mentally to stop - set a date, expect it to be hard, list reasons why to stop Involve family and friends Avoid situations associated with smoking Replace smoking with another activity Set targets and rewards for completion Try again if relapse Use medication!
Risk factors for NON FATAL deliberate self harm
Young Female Financial/housing/employment/education Personality disorder Alcohol/substance misuse Social isolated Single
Common methods for non-fatal deliberate self harm
Medication OD
Self-cutting
Risk factors for suicide
Male 25-44 Single/widowed/divorced/separated Unemployed/retired Elderly Immigrants and refugees Prisoners Bereaved Vets, pharmacists, doctors, farmers Recent life crisis Victim of abuse Access to means Hx of self-harm Mental illness Physical illness - cancer/aids/epilepsy/MS/stroke
Assessing risk after self-harm or suicide
- Precipitant
- Planned
- Method
- Alone
- Any alcohol
- Any precautions against discovery
- Help seeking
- How did they feel when they were found
- RFs for suicide
- Examine mental state
- Outlook for the future
- Current suicidal intent
- Homicidal intent
- Any protective factors
Physical complications for eating disorders
Hypokalaemia Peripheral oedema Hypotension Sudden death Arrhythmia Anaemia and thrombocytopaenia Hypoglycaemia Osteoporosis Constipation Infections Lack of growth or secondary sexual characteristics Infertility AKI or CKD Renal calculi Anxiety and mood disorders Alcoholism Social difficulties
Psychological complications of eating disorders
Mood swings Low self-esteem Suicide Clinical depression Guilt and shame Anxiety Fear of discovery Hypervigilance Obsessional thoughts and pre-occupation Withdrawal from relationships in favour of social isolation Loneliness
Define anorexia nervosa
Eating disorder characterised by low body weight, intense fear of gaining weight and body image disturbance
- Weight loss, BMI <17.5
- Weight loss is self-induced by avoidance of fattening food
- Self-perception of being fat with intrusive dread of fatness which leads to low self-imposed weight threshold
- Endocrine disorder involving hypothalamic-pituitary-gonadal axis
Epidemiology of anorexia nervosa
Increase in female
Increased in 15-19 years
Caucasians
0.3% prevalence
25% get concomitant OCD
50-70% develop dysthymia
RF of anorexia nervosa
- Obsessive and perfectionist traits
- exposure to western media
- middle and upper socioeconomic class
- family dysfunction
Aetiology and pathophysiology of anorexia nervosa
- Genetic links
- Other psychiatric illness, perfectionism, low self-esteem
- A susceptible person will diet
- weight loss gives positive reinforcement to continue behaviours
- low weight and starvation leads to nutritional imbalances and physiological change
- Obsessive behaviours facilitate maintenance of anorexic cycle
- Fear of food
- Corticotrophin-releasing hormone released during starvation promotes appetite suppression
Signs and symptoms of anorexia nervosa
Weight loss Amenorrhoea Orthostatic hypotension Fear of gaining weight Decreased subcut fat Bradycardia Disturbed body image Fatigue Dehydration Calorie restriction Poor concentration Arrhythmia Fainting Hair loss Constipation
Investigations in anorexia nervosa
FBC - normocytic normochromic anaemia
mild leukopenia, thrombocytopenia
U+Es - low K, Na, Mg, phosphate, Ca, glucose. Raised urea
TFTs - low T3
LFTs - raised AST and ALT, low ALP
Dipstick - ketonuria
ECG
Bone densitometry = osteoporosis or osteopenia
Management of anorexia nervosa
Psychological interventions (at least 6 months)
- CBT
- Interpersonal therapy
- Family interventions
- Medication is not the sole or primary treatment
- Inpatient care if high risk
- Measure weight gain - aim for 0.5-1kg per week
- May require multi-vitamin supplementation
Feeding against will is the last resort and only under Mental Health Act or Children’s Act
Prognosis of anorexia
Highest mortality of all psychiatric conditions 50% full recovery 33% improve 20% chronic Mortality rate 4%
CD10 definition for bulimia nervosa
Eating disorder characterised by recurrent episodes of binge eating, followed by behaviours aimed at compensating for the binge
- Recurrent episodes of over eating (2x/week over a 3 month period)
- Persistent preoccupation with eating and irresistible food craving
- Patients attempt to counteract fattening effects of food by: self-induced vomiting, purging, alternating periods of starvation or use of drugs: diuretics, laxatives, appetite suppressants, thyroid preparations
Epidemiology of bulimia nervosa
0.5-1% More common in females (x10) Caucasian 20-35 years High heritability
RFs of bulimia nervosa
Severe life stresses Personality disorder Physical/sexual abuse Substance misuse Fhx of depression Early menarche Parental/childhood obesity Family dieting Fhx of eating disorder Premorbid psychiatric disorder Disruptive events in childhood = parental death, alcoholism Perceived pressure to be thin
History features of bulimia nervosa
Regular binge eating Attempts to counteract binges Preoccupation with weight/imaging Preoccupation with food/diet Mood disturbance/anxiety Low self esteem Self-harm Irregular periods GI symptoms Hx of dieting
Examination findings in bulimia nervosa
Usually normal if no complications Weight, height, BP Swollen parotid gland Russell's sign - callus on back of hand from teeth and vomiting Dental erosions Oedema if laxative or diuretic misuse
Management of bulimia nervosa
CBT adapted for bulimia
Nutritional and meal support
Medication - fluoxetine
Manage physical aspects
Neuroleptic malignant syndrome
MEDICAL EMERGENCY
Life threatening neurological disorder most often caused by adverse reaction to neuroleptic or antipsychotics.
Thought to be due to decreased levels of dopamine activity due to dopamine receptor blockage
- Muscle cramps
- Tremor
- Fever
- Unstable BP
- Diaphoresis
- Rigidity
- Sudden changes in mental status - agitation, delirium, coma
Cause:
- Haloperidol
- Promethazine
- Chlorpromazine
- Levodopa
To a lesser extent: clozapine, olanzapine, risperidone, quetiapine
Stop antipsychotics
Aggressive treatment of hyperthermia
Supportive intensive care
Which classes drugs are associated with hyponatremia?
SSRIs
Chlorpropamide Carbamazepine Tricyclic antidepressants, Lithium, MDMA/ecstasy, Tramadol, Haloperidol, Vincristine, Desmopressin, Fluphenazine
Citalopram contraindication
- Congenital long QT syndrome
- Known pre-existing QT interval -prolongation
- In combination with other medicines that prolong QT interval
Avoid all SSRIs with triptans
What must you rule out prior to diagnosing anxiety?
Thyroid disease (hyperthyroidism)
Other differentials:
- Pheochromocytoma
- Wilson’s disease
- Depression
SSRI use during third trimester increases risk of what?
Fluoxetine - persistent pulmonary hypertension of the newborn
Paroxetine - congenital malformations, particularly in the first trimester
SE of amitriptyline?
Anticholinergic effects
Tachycardia,
Dry mouth,
Mydriasis
Urinary retention.
Benzodiazepine withdrawal symptoms
If patients withdraw too quickly from benzodiazepines they may experience benzodiazepine withdrawal syndrome, a condition very similar to alcohol withdrawal syndrome.
This may occur up to 3 weeks after stopping a long-acting drug.
Features include: insomnia irritability anxiety tremor loss of appetite tinnitus perspiration perceptual disturbances seizures
GABAa drugs
Benzodiazepines increase the frequency of chloride channels
Barbiturates increase the duration of chloride channel opening
ECT side effects
Short-term side-effects
- Headache
- Nausea
- Short term memory impairment
- Memory loss of events prior to ECT
- Cardiac arrhythmia
Long-term side-effects
- Some patients report impaired memory
“Conventional antipsychotics
(first-generation)”
"Haloperidol Chlorpromazine Flupentixol Sulpiride Loxapine"
“Atypical antipsychotics
(second-generation)”
"Risperidone Paliperidone Clozapine Olanzapine Quetiapine Aripiprazole Amisulpride"
What can cause a rise in clozapine blood levels?
Smoking cessation can cause a significant rise in clozapine levels, and so it should be discussed with a psychiatrist before stopping smoking.
Starting smoking, or smoking more, can reduce clozapine levels.
Stopping drinking can also reduce levels, as alcohol binges can increase the level.
Omitting doses will cause a reduction in clozapine levels, and stress and weight gain won’t have major effects on the level
Adverse effects of clozapine
Agranulocytosis (1%), neutropaenia (3%)
Reduced seizure threshold - can induce seizures in up to 3% of patients
Anorexia features (biochemical findings)
Most things low!
- Hypokalaemia
- Low FSH, LH, oestrogens and testosterone
- Low T3
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
Benzodiazepine SE
Anterograde amnesia.
Falls risk.
Lots of withdrawal symptoms after LT use.
Benzodiazepine indication
Sedation Hypnotic Anxiolytic Anticonvulsant Muscle relaxant
Sudden onset psychosis causes?
Steroid-induced psychosis
Which scoring system could be used to assess alcohol withdrawal severity?
Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale
Are typical or atypical antipsychotics associated with reduced seizure threshold?
Atypical
Examples of atypical antipsychotics:
- Clozapine
- Olanzapine
- Risperidone
- Quetiapine
- Amisulpride
- Aripiprazole
What class is mirtazapine?
Mirtazapine is a noradrenergic and specific serotonergic antidepressant which increases release of neurotransmitters by blocking alpha-2-adrenoreceptors
Used in severe depression.
First line management in a patient with delirium tremens?
Lorazepam
Haloperidol for those who do not respond to oral lorazepam.
Flashbacks
Perseveration
Anergia
Flight of ideas
Circumstantiality
Flashbacks are an immersive experience, so would not be an accurate description of this scenario.
Perseveration is a sign which may be associated with Parkinson’s Disease. It refers to a patient needlessly repeating a word or phrase which they had previously expressed.
Anergia is not a speech abnormality. It describes a lack of energy- or increased fatigability with minimal exertion. This may be a symptom of unipolar depression.
Flight of Ideas is a phenomenon which may be seen during a manic phase. It is a rapid shifting of ideas with only superficial associations between them, such that the speech is difficult to follow.
Circumstantiality is the correct answer. This refers to overinclusive speech that is delayed in reaching its final goal. It can be a sign of anxiety or hypomania. It is still possible to follow the speech, and it does eventually reach its goal.
Brief psychotic disorder is a sudden, short-term display of psychotic behaviour. It may include hallucinations or delusions, and can occur following a stressful event.
Having a personality disorder is a predisposing factor for brief psychotic disorder.
It does often result in a return to baseline functioning.
This condition most often affects people in their 20s, 30s, and 40s.
The duration of an episode is at least one day but less than one month.
Patients are not always aware of the change in their behaviour.
Brief psychotic disorder is a sudden, short-term display of psychotic behaviour. It may include hallucinations or delusions, and can occur following a stressful event.
Having a personality disorder is a predisposing factor for brief psychotic disorder.
It does often result in a return to baseline functioning.
This condition most often affects people in their 20s, 30s, and 40s.
The duration of an episode is at least one day but less than one month.
Patients are not always aware of the change in their behaviour.
MoA of antidepressants:
- Mirtazapine
- Fluoxetine
- Amitriptyline
- Bupropion
- Milnacipran
- Mirtazapine is an antidepressant preferred in patients with anorexia nervosa as it also elevates the appetite and produces weight gain.
- Fluoxetine is a selective serotonin reuptake inhibitor and it is not contraindicated in anorexia nervosa. It can produce gastrointestinal distress or sexual dysfunction as side-effects, and young patients can therefore not be compliant with the medication.
- Amitriptyline is a tricyclic antidepressant and is used mostly for major depression. It has a worse side-effect profile than selective serotonin reuptake inhibitors.
- Bupropion is an atypical antidepressant which is commonly used for smoking cessation. It is however contraindicated in anorexia nervosa or bulimia nervosa as it lowers the seizure threshold and predisposed these patients to seizures.
- Milnacipran is a serotonin-norepinephrine reuptake inhibitor and it is not contraindicated in anorexia nervosa. It has stimulant properties and the most common side effect is an increase in blood pressure.
Alpha-fetoprotein
This test is a marker of hepatocellular carcinoma and certain non-seminoma testicular cancers
Interferon-gamma release assay
Reactivation of TB in an important complication of biologic therapy and an IGRA is a test for TB latency.
