Antisocial behaviour in adults

Question 1

Probability diagnosis

Answer 1

Functional: no medical or mental component

Drugs: alcohol, illicit (see list) or prescribed

Alcohol: acute or chronic

Antisocial personality disorder esp. cluster B

Affective (mood) disorders

Drug withdrawal incl. alcohol, hypnotics

Mental impairment

Question 2

Serious disorders not to be missed

Answer 2

Vascular:

• Cerebrovascular disease including SAH
• Acute coronary syndromes

Infection:

• Encephalitis/meningitis
• HIV/AIDS
• Septicaemia

Tumours:

• Cerebral tumours

Other:

• Post ictal (epilepsy)
• Delirium
• Subdural haematoma
• Psychosis: schizophrenia, bipolar, paraphrenia
• Schizotypal personality disorder

Question 3

Pitfalls (often missed)

Answer 3

Head injury

Fluid and electrolyte imbalance

Dementia esp. early

Rarities:

Neurosyphilis

Prion disease e.g. CJD

Premenstrual dysphoria syndrome

Question 4

Masquerades checklist

Answer 4

Depression—major

Diabetes: hypoglycaemia

Drugs: iatrogenic/social–illicit

Thyroid/other endocrine: hyper/hypothyroid

Question 5

Is the patient trying to tell me something?

Answer 5

Consider conversion disorder (hysterical fugue)

Malingering/fabrication

Severe anxiety/panic

Question 6

Key history

Answer 6

Nature of behaviour and precipitants, associations

Psychiatric history: anxiety, OCD, depression, hypomania, personality traits, fugue features

Past, family and psychosocial history, developmental history, epilepsy, Parkinson disease, family history

Drug history: prescribed (see list), OTC, alcohol, social/illicit drugs (see list)

Question 7

Key examination

Answer 7

This is limited.

General features: appearance and behaviour of patient, vital signs

General respiratory, neurological and cardiovascular examination

Pulse oximetry

Mental state examination

Question 8

Key investigations

Answer 8

First line:

• urinalysis
• blood glucose
• FBE
• U&E

Consider:

• LFTs (γGT)
• ECG
• TFTs
• KFTs
• cerebral imaging