Mental Health Conditions MLA Flashcards
What is acute stress reaction?
Acute stress disorder is defined as an acute stress reaction that occurs in the first 4 weeks after a person has been exposed to a traumatic event (threatened death, serious injury e.g. road traffic accident, sexual assault etc). This is in contrast to post-traumatic stress disorder (PTSD) which is diagnosed after 4 weeks.
A transient disorder that develops in an individual with no other apparent mental disorder in response to exceptional physical and/or mental stress; usually subsides within hours or days. It should last no more than one month.
What are the features of acute stress reaction?
Features include:
- intrusive thoughts e.g. flashbacks, nightmares
- dissociation e.g. ‘being in a daze’, time slowing
- negative mood
- avoidance
- arousal e.g. hypervigilance, sleep disturbance
What is the management of acute stress reaction?
Management:
- trauma-focused cognitive-behavioural therapy (CBT) is usually used in first line
- benzodiazepines
- sometimes used for acute symptoms e.g. agitation, sleep disturbance
- should only be used with caution due to addictive potential and concerns that they may be detrimental to adaptation
What are differentials for acute stress reaction?
- Differentials for this condition can include adjustment disorder. The key difference between these conditions is that an acute stress reaction will typically follow a highly stressful event, whereas with adjustment disorder, the stressor need not be severe or outside the “normal” human experience. For example, the difference between seeing a fatal car accident vs being made redundant.
Explain alcoholic liver disease
Alcoholic liver disease covers a spectrum of conditions:
- alcoholic fatty liver disease
- alcoholic hepatitis
- cirrhosis
Patient symptoms and signs with alcoholic hepatitis?
Patients look like: (symptoms)
- Malaise, high TPR (temperature, pulse, respiratory rate)
- Anorexia
- D&V (diarrhoea and vomiting)
- Tender hepatomegaly +/- jaundice
- Bleeding
- Ascites
Selected investigation findings: (signs)
- gamma-GT is characteristically elevated
- the ratio of AST:ALT is normally > 2, a ratio of > 3 is strongly suggestive of acute alcoholic hepatitis
- High WCC
- Low platelets
- High INR
- High AST
- High MCV
- High urea
- Jaundice, encephalopathy or coagulopathy = SEVERE hepatitis
What is the management for alcoholic hepatitis?
Selected management notes for alcoholic hepatitis:
- glucocorticoids (e.g. prednisolone 40mg/d for 5 days) are often used during acute episodes of alcoholic hepatitis
- Maddrey’s discriminant function (DF) is often used during acute episodes to determine who would benefit from glucocorticoid therapy
- it is calculated by a formula using prothrombin time and bilirubin concentration
- pentoxyphylline is also sometimes used
- the STOPAH study (see reference) compared the two common treatments for alcoholic hepatitis, pentoxyphylline and prednisolone. It showed that prednisolone improved survival at 28 days and that pentoxyphylline did not improve outcomes
- Vitamins
- Vitamin K -> 10mg/d IV for 3 days
- Thiamine -> 100mg/d PO (high dose can be given by IV this is Pabrinex)
- Optimise nutrition 35-40kcal/kg/d (use ideal body weight for calculations)
- Don’t use low-protein diets as prevents sepsis, encephalopathy, death
- Daily: weight, LFT, U&Es, INR
What is the prognosis of alcoholic hepatitis?
Prognosis
- Mild episodes hardly affect mortality if severe mortality is roughly 50% at 30 days
- 1 year after admission for alcoholic hepatitis -> 40% are dead
What is anxiety disorder: generalised (GAD)? (& epidemiology)
Anxiety is a common disorder that can present in multiple ways. NICE define the central feature as an ‘excessive worry about a number of different events associated with heightened tension.’
Always look for a potential physical cause when considering a psychiatric diagnosis. In anxiety disorders, important alternative causes include hyperthyroidism, cardiac disease and medication-induced anxiety (NICE). Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants and caffeine.
ICD-10 Criteria
Generalized and persistent ‘free floating’ anxiety symptoms involving elements of:
- Apprehension (worries about future misfortunes, feeling on edge, difficulty in concentrating)
- Motor tension (restless fidgeting, tension headaches, trembling, inability to relax)
- Autonomic overactivity (light-headedness, sweating, tachycardia, epigastric discomfort, dizziness etc)
Epidemiology
- 1.6% suffering from GAD at any one point
- Very rarely begins after 35
What is the management of anxiety disorder: generalised (GAD)?
Management of GAD
NICE suggest a stepwise approach:
- step 1: education about GAD + active monitoring
- step 2: low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
- step 3: high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information
- step 4: highly specialist input e.g. Multi-agency teams
Drug treatment
- NICE suggest sertraline should be considered the first-line SSRI
- if sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI)
- examples of SNRIs include duloxetine and venlafaxine
- If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin
- interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month
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General Management
- Most can be treated in primary care setting
- Advice and reassurance can help early or mild problems from worsening (psycho-education)
- Counselling alone may be very effective – addresses patients worries (reassure about somatic symptoms)
- Self help materials
- CBT has good evidence
- Other therapies: anxiety management training, relaxation techniques, autogenic training (self-monitoring anxiety and applying relaxation techniques), brief focal psychotherapy, marital or familial therapy
Note on sedatives
- Benzodiazapines should not be prescribed for more than 10 days due to risk of dependency and sedation. Use only to overcome symptoms so severe they obstruct initiation of more appropriate psychological treatment
- Diazepam preferred due to longer half life (less risk of withdrawal symptoms with neurotic symptoms, neurological symptoms like ataxia, paraesthesia, hyperacusis and other major symptoms such as hallucinations, psychosis and epilepsy)
Drug Therapy
- First line drug is an SSRI or SNRI
- SSRI combined with CBT may be superior to either alone
- Also, Busipirone (5HT1A¬ agonist) is suitable for short term management
- Delayed onset of action
- Diminished efficacy in previous benzo users
- Side effects: dizziness, headache and nausea
- Minimal sedation
- B-blockers effective in patients with somatic anxiety symptoms (CI in asthma and heart block)
- Low-dose antipsychotics can also be used
- Pregabalin may also be of use
What is anxiety disorder: post-common stress disorder?
Anxiety is a common disorder that can present in multiple ways. NICE define the central feature as an ‘excessive worry about a number of different events associated with heightened tension.’
Always look for a potential physical cause when considering a psychiatric diagnosis. In anxiety disorders, important alternative causes include hyperthyroidism, cardiac disease and medication-induced anxiety (NICE). Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants and caffeine.
What is the management of anxiety disorder: post-traumatic stress disorder?
Management
Again a stepwise approach:
- step 1: recognition and diagnosis
- step 2: treatment in primary care - see below
- step 3: review and consideration of alternative treatments
- step 4: review and referral to specialist mental health services
- rstep 5: care in specialist mental health services
Treatment in primary care
- NICE recommend either cognitive behavioural therapy or drug treatment
- SSRIs are first line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
What are the clinical features of GAD?
Clinical features
- Depersonalization (altered or lost sense of personal reality or identity) and derealisation (surroundings feel unreal). Note this is also seen in depression, schizo, alcohol, drugs, epilepsy
What are the differential diagnosis’ of general anxiety disorder (GAD)?
Differential Diagnosis
- Hyperthyroidism (look for goitre, tremor, tachycardia, weight loss, arrhythmia, exophthalmos)
- Substance misuse (intoxication – amphetamines; withdrawal – benzo, alcohol)
- Excess caffeine
- Depression: anxiety common feature of depression and likewise. Which came first and which is currently more prominent are useful clues. If both, diagnose mixed anxiety and depressive disorder
- Anxious (avoidant) personality disorder: patient describes themselves as an anxious person with no recent major increase in anxiety levels. (note this disorder can predispose)
- Dementia (early)
- Schizophrenia (early)
What is the prognosis of GAD?
Prognosis
- The more chronic the condition, the worse the prognosis
- Stable premorbid personality good prognostic sign
What are the features of panic disorder (& epidemiology & ICD-10)
Features of Panic Disorder
- Breathing difficulties
- Chest discomfort
- Palpitations
- Tingling or numbness in hands, feet or around the mouth: Hyperventilation blows off CO2, raising pH, Calcium binds to albumin leads to hypocalcaemia. If extreme, carpopedal spasm (curling of fingers and toes can occur)
- Shaking, sweating, dizziness
- Depersonalization/ derealisation
- Can lead to fear of situation where panic attacks occur or agoraphobia
- Conditioned fear of fear pattern develops
ICD-10 criteria
- Recurrent attacks of severe anxiety not restricted to any particular situation or set of circumstances and therefore unpredictable
- Secondary fears of dying, losing control or going mad
- Attacks usually last for minutes; often there is a crescendo of fear and autonomic symptoms
- Comparative freedom from anxiety symptoms between attacks (but anticipatory anxiety is common)
Epidemiology of Panic Disorder
- 1-2% in general population
- 2-3x more common in females
- Bimodal: peaks at 20yo and 50yo
- Agoraphobia occurs in 30-50%
- Risk of attempted suicide is raised when comorbid depression, alcohol misuse or substance misuse
What are the differential diagnosis for panic disorder?
Differential Diagnosis for Panic Disorder
- Other anxiety disorders: GAD and agoraphobia
- Depression (if depression precedes or criteria for depression fulfilled, it takes precedence)
- Alcohol or drug withdrawal
- Organic causes: CVS or respiratory disease. Others: hypoglycaemia, hyperthyroidism. Rarely: pheochromocytoma.
What is the psychological management of panic disorder?
Psychological Management of Panic Disorder
- Reassurance
- CBT effective in 80-100%
- CBT is first line
- Initial education about nature of panic attacks and fear of fear cycles
- Cognitive restructuring; detecting flaws in logic
- Interoceptive exposure techniques such as controlled exposure to somatic symptoms(breathing in CO2 and physical exercise)
- Secondary agoraphobic avoidance: treat by situational exposure and anxiety management techniques
What is the drug management of panic disorders?
Drug management of Panic Disorder
- SSRIs are first line drug treatment (but 2nd line to CBT)
- Also, clomipramine (tricyclic with similar action on serotonin) is effective Prognosis
- 50-60% remit with medication; 80-100% with CBT
What are the features of mixed anxiety and depressive disorder?
Features of Mixed Anxiety and Depressive Disorder
- ICD-10 criteria: symptoms of anxiety and depression are both present but neither clearly predominates
- Treat with counselling, cognitive therapy or psychotherapy, especially interpersonal therapy
- Treating the depression usually relieves anxiety symptoms (SSRIs are best)
What are the features of specific/isolated phobias?
Features of Specific/isolated phobias
- ICD-10 criteria: restricted to highly specific situations such as proximity to particular animals, heights, thunder, flying, blood etc
- Often clear in early adulthood
- Result in avoidance
- Phobias of blood and bodily injury lead to bradycardia and hypotension upon exposure
- Severity depends on effect on quality of life ( pilots afraid of flying)
- Always exclude co-morbid depression
What are features of agoraphobia?
Features of Agoraphobia
- ICD-10 criteria: Fear not only open spaces but also of related aspects, such as the presence of crowds and difficulty of immediate easy escape back to a safe place, usually home (may occur with or without panic disorder)
- Commonly in 20s or mid-thirties
- May be gradual or precipitated by a sudden panic attack
- Comorbid depression is common (be wary of drugs and alcohol to overcome)
- Also higher incidence of sexual problems
- Differentials:
- Depression
- Social phobia
- Obsessive Compulsive Disorder
- Schizophrenia (may stay because of social withdrawal or as a way of avoiding perceived persecutors)
What are features of social phobia?
Features of Social Phobia
- Most common anxiety disorder
- ICD-10 criteria: Fear of scrutiny by other people in comparatively small groups (as opposed to crowds), leading to avoidance of social situations
- Comparatively small = around 5-6 people (Usually 1-2 is fine)
- May be specific (public speaking) or generalized (any social setting)
- Physical symptoms: blushing, fear of vomiting
- Symptoms include blushing (characteristic), palpitations, trembling, sweating
- Can be precipitated by stressful or humiliating experiences, death of a parent, separation, chronic stress
- Genetic vulnerability
- May abuse alcohol or drugs (perpetuating problem)
- Mental state examination: may appear relaxed as phobic object or situation not present
What are the differentials for phobias?
Differentials for Phobias
- Shyness (in social phobia, there is fear)
- Agoraphobia
- Anxious personality disorder
- Poor social skills/autistic spectrum disorders (will not show good skills when relaxed)
- Benign essential tremor (familial, worse in social situations, responds to benzo and alcohol)
What are investigations for phobias?
Investigations of Phobias
- History and Examination
- m
- Social and occupational assessments for effect on quality of life
- Collateral History
What is the management for phobias?
Management of Phobias
Behavioural therapy is treatment of choice,
Exposure techniques most widely used aiming to reach systematic desensitization (using a graded hierarchy approach for e.g.)
- Flooding (taking someone with fear of heights to a tower),
- Modelling (individual observes therapist engaging with phobic stimulus)
- Agoraphobia and panic disorders: CBT treatment of choice
- Social phobia: CBT is the treatment of choice Drug management
- SSRIs and MAOIs (phenelzine) most useful in agoraphobia and social phobia
- Tricyclic antidepressants best for those with depressive component
- Agoraphobia + panic disorder: CBT first line and SSRI 2nd line
- Benzodiazepines can be used before a phobic situation
- B-blockers are effective if somatic symptoms predominate Prognosis
- Animal phobias have the best outcome
- Agoraphobias do worse
Early diagnosis and treatment are essential (shorter à better
What is OCD?
OCD
Obsessive-compulsive disorder (OCD) is characterised by the presence of either obsessions or compulsions, but commonly both. The symptoms can cause significant functional impairment and/ or distress.
An obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person’s mind. Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one’s mind.
It is thought that 1 to 2% of the population have OCD, although some studies have estimated 2 to 3%.
What is the aetiology behind OCD?
s
What are some associations with OCD?
Associations
- depression (30%)
- schizophrenia (3%)
- Sydenham’s chorea
- Tourette’s syndrome
- anorexia nervosa
What is the management of OCD?
Management
- If functional impairment is mild
- low-intensity psychological treatments: cognitive behavioural therapy (CBT) including exposure and response prevention (ERP)
- If this is insufficient or can’t engage in psychological therapy, then offer choice of either a course of an SSRI or more intensive CBT (including ERP)
- If moderate functional impairment
- offer a choice of either a course of an SSRI (any SSRI for OCD but fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP)
- If severe functional impairment
- offer combined treatment with an SSRI and CBT (including ERP)
Notes on treatments
- ERP is a psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands). This helps them confront their anxiety and the habituation leads to the eventual extinction of the response
- if treatment with SSRI is effective then continue for at least 12 months to prevent relapse and allow time for improvement
- If SSRI ineffective or not tolerated try either another SSRI
What is anxiety?
Definition
Anxiety disorders include Generalized Anxiety disorder, phobias, panic disorder, Obsessive Compulsive Disorder and Post-traumatic Stress Disorder
What is the concept of neuroses? (anxiety)
Concept of neuroses
- Symptoms that are both understandable and with which one can empathize
- Insight is maintained
- This is as opposed to delusions which are not understandable or cannot be empathised with
- Neuroses are quantitively but not qualitatively different from normal
- Neuroses different to ‘neurotic’ individuals who often suffer from lifelong personality difficulties
What is the epidemiology behind anxiety?
Epidemiology
- Most predominantly female
- Affects up to 10% of all individuals
- Comorbidity with depression, substance misuse and personality disorder is common
- If individual presents after age 35-40 years, it is more likely due to depressive disorder or organic disease
- Associated Factors: Lower social class, unemployment, divorced, renting rather than owning, no educational qualifications, urban living Aetiology
- Genetics: family history often seen, people with high neuroticism scores more likely
- Early experiences and life events:
- Childhood adversity predispose
- Life events (WW1 trenches most extreme example)
What are some symptoms of anxiety?
Symptoms of Anxiety
- Psychological: Fears, worries, poor concentration, irritability, depersonalization, derealisation, insomnia (can’t fall asleep), night terrors
- Motor symptoms: Restlessness, fidgeting, feeling on edge
- Neuromuscular: tremor, tension headache, muscle ache, dizziness, tinnitus
- GI: Dry mouth, can’t swallow, nausea, indigestion, butterflies, flatulence, frequent or loose motions
- CVS: Chest discomfort, palpitation
- Respiratory: Difficulty inhaling, Tight/constricted chest
- GI: Urinary frequency, erectile dysfunction, Amenorrhoea
What is attention deficit hyperactivity disorder? (ADHD)
Attention deficit hyperactivity disorder
March 2018 saw NICE issue new guidance around recognising and managing attention deficit hyperactivity disorder (ADHD). This condition can inflict significant morbidity on a child’s life and thus has consequences into adulthood, making good diagnosis and treatment vital.
DSM-V defines ADHD as a condition incorporating features relating to inattention and/or hyperactivity/impulsivity that are persistent. Like many paediatric conditions, developmental delay has to be an element. Six of these features have to be present for children up to the age of 16 years; in those aged 17 or over, the threshold is five features (Table below).
QUESMED
Attention deficit hyperactivity disorder (ADHD) is a condition where children under the age of 12 years old have hyperactive behaviour and problems paying attention that have a significant impact in more than one setting (for example, home and school).
What is the management of ADHD?
Management
NICE stipulates a holistic approach to treating ADHD that isn’t entirely reliant on therapeutics. Following presentation, a ten-week ‘watch and wait’ period should follow to observe whether symptoms change or resolve. If they persist then referral to secondary care is required. This is normally to a paediatrician with a special interest in behavioural disorders, or to the local Child and Adolescent Mental Health Service (CAMHS). Here, the needs and wants of the patient, as well as how their condition affects their lives should be taken into account, to offer a tailored plan of action.
Drug therapy should be seen as a last resort and is only available to those aged 5 years or more. Patients with mild/moderate symptoms can usually benefit from their parents attending education and training programmes. For those who fail to respond, or whose symptoms are severe, pharmacotherapy can be considered:
- Methylphenidate is first line in children and should initially be given on a six-week trial basis. It is a CNS stimulant which primarily acts as a dopamine/norepinephrine reuptake inhibitor. Side-effects include abdominal pain, nausea and dyspepsia. In children, weight and height should be monitored every 6 months
- If there is inadequate response, switch to lisdexamfetamine;
- Dexamfetamine should be started in those who have benefited from lisdexamfetamine, but who can’t tolerate its side effects.
In adults:
- Methylphenidate or lisdexamfetamine are first-line options;
- Switch between these drugs if no benefit is seen after a trial of the other.
All of these drugs are potentially cardiotoxic. Perform a baseline ECG before starting treatment, and refer to a cardiologist if there is any significant past medical history or family history, or any doubt or ambiguity.
Like most psychiatric conditions, whether adult or paediatric, a thorough history and clinical examination are key, especially given the overlap of ADHD with many other psychiatric and physical conditions.
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Management
- Conservative:
- Behavioural techniques
- Extra support at school. However, ADHD does not generally affect intellectual ability.
- Medical:
- Stimulant medication such as methylphenidate. These medicines have some activity in the frontal lobe thus increasing executive function, attention, and reducing impulsivity.
What is aetiology behind ADHD?
Aetiology
- ADHD is associated with reduced activity in the frontal lobe, resulting in problems with executive function. This impairs the ability to focus on different tasks and inhibit impulsive behaviours.
What is the prognosis of ADHD?
Prognosis
- About 50% of children with ADHD continue to have significant problems with behaviour, or, more commonly, attention, into adulthood.
What is autism spectrum disorder?
Autism spectrum disorder
Autism is a neurodevelopmental condition characterized by qualitative impairment in social interaction and communication as well as repetitive stereotyped behaviour, interests, and activities. Symptoms are usually present during early childhood, but may be manifested later. Autism spectrum disorder (ASD) may occur in association with any level of general intellectual/learning ability, and manifestations range from subtle problems of understanding and impaired social function to severe disabilities. Although there is no cure for ASD, early diagnosis and intensive educational and behavioural management may improve outcomes.
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Autistic spectrum disorders (ASDs) are characterised by a spectrum of social, language and behavioural deficits. Socially, children with autism do not enjoy or seek comfort from the company of other people. They lack ‘theory of mind’; they are not able to imagine the perspective of other people.
What is the epidemiology of autism spectrum ddisorder?
Epidemiology
The prevalence of ASD has increased over time, primarily as a result of changes in definitions and increased awareness.
- Recent estimates suggest a prevalence of 1-2%.
- ASD is three to four times more common in boys than girls.
- Around 50% of children with ASD have an intellectual disability.
What are the clinical features of autism spectrum disorder?
Clinical features
Children or adults with autism may exhibit a broad range of clinical manifestations. Social communication impairments and repetitive behaviours are present during early childhood (typically evident before 2–3 years of age), or maybe manifested later. The clinical features can be classified as:
- Impaired social communication and interaction:
- Children frequently play alone and maybe relatively uninterested in being with other children.
- They may fail to regulate social interaction with nonverbal cues like eye gaze, facial expression, and gestures.
- Fail to form and maintain appropriate relationships and become socially isolated.
- Repetitive behaviours, interests, and activities:
- Stereotyped and repetitive motor mannerisms, inflexible adherence to nonfunctional routines or rituals are often seen.
- Children are noted to have particular ways of going about everyday activities.
- ASD is often associated with intellectual impairment or language impairment.
- Attention deficit hyperactivity disorder (35%) and epilepsy (18%) are also commonly seen in children with ASD.
- ASD is also associated with a higher head circumference to the brain volume ratio.
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Presentation
- As the name suggests children with autism can present with a spectrum of severities. In its most severe form:
- Children with autism are not able to understand that other people have thoughts and feelings, prefer to play alone and avoid eye contact.
- Children with autism have speech and language delay, monotonous tones of voice with limited expression and problems using pronouns (confuse ‘I’, ‘you’, ‘she’ etc.). They also interpret speech literally, and so have problems with the use of idiom (e.g. ‘it’s raining cats and dogs’).
- In terms of behaviour, children with ASD commonly have narrow interests (e.g. trains), ritualistic behaviours that rely heavily on routine, and stereotyped movements (e.g. rocking, flapping hand movements).
- Autistic spectrum disorders are commonly associated with learning difficulties.
- About 25% of children with autism may also have seizures.
What is the management of autism spectrum disorder?
Management
Autism spectrum disorder (ASD) is a chronic condition that requires a comprehensive treatment approach. Although there is no cure for ASD, early diagnosis and early intensive treatment have the potential to affect outcomes. Treatment, which should be initiated early, involves educational and behavioural management, medical therapy, and family counselling.
The goal is to increase functional independence and quality of life through
- Learning and development, improved social skills, and improved communication
- Decreased disability and comorbidity
- Aid to families
Non-Pharmacological Therapy:
- Early educational and behavioural interventions:
- Applied behavioural analysis (ABA).
- ASD preschool program.
- Treatment and Education of Autistic and Communication related handicapped CHildren (TEACCH)/Structured Teaching method.
- Early Start Denver Model (ESDM).
- Joint Attention Symbolic Play Engagement and Regulation (JASPER).
-
Pharmacologic interventions: no consistent evidence demonstrating medication-mediated improvements in social communication
- SSRIs: helpful to reduce symptoms like repetitive stereotyped behaviour, anxiety, and aggression
- Antipsychotic drugs: useful to reduce symptoms like aggression, self-injury.
- Methylphenidate: for attention deficit hyperactivity disorder (ADHD).
- Family support and counselling:
- Parental education on interaction with the child and acceptance of his/her behaviour.
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Management
- Management of autistic spectrum disorders is complex, with the need for multidisciplinary team management and extra support for the family.
- Applied behavioural analysis is one technique that can be of benefit, whereby positive behaviours are encouraged and negative behaviours are ignored.
What is the prognosis of autism spectrum disorder?
Prognosis
- Autistic spectrum disorders require a huge amount of support, as less than 10% of children with ASD will be able to live independently as adults.
What is bipolar affective disorder?
Bipolar affective disorder
Bipolar disorder is a chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression.
What is the epidemiology behind bipolar?
Epidemiology
- typically develops in the late teen years
- lifetime prevalence: 2%
What are the types of bipolar affective disorder?
Two types of bipolar disorder are recognised:
- type I disorder: mania and depression (most common)
- type II disorder: hypomania and depression
What is mania/hypomania?
What is mania/hypomania?
- both terms relate to abnormally elevated mood or irritability
- with mania, there is severe functional impairment or psychotic symptoms for 7 days or more
- hypomania describes decreased or increased function for 4 days or more
- from an exam point of view the key differentiation is psychotic symptoms (e.g.delusions of grandeur or auditory hallucinations) which suggest mania
What is the management of bipolar affective disorder?
Management
- psychological interventions specifically designed for bipolar disorder may be helpful
- lithium remains the mood stabilizer of choice. An alternative is valproate
- management of mania/hypomania
- consider stopping antidepressant if the patient takes one; antipsychotic therapy e.g. olanzapine or haloperidol
- management of depression
- talking therapies (see above); fluoxetine is the antidepressant of choice
- address co-morbidities
- there is a 2-3 times increased risk of diabetes, cardiovascular disease and COPD
Explain a primary care referral of bipolar affective disorder
Primary care referral
- if symptoms suggest hypomania then NICE recommend routine referral to the community mental health team (CMHT)
- if there are features of mania or severe depression then an urgent referral to the CMHT should be made
What is the aetiology behind bipolar affective disorder?
Aetiology
The aetiology of Bipolar Affective Disorder is not fully understood, but there is clear evidence to suggest that there is a genetic component and it can be inherited. Triggers for manic episodes can include stressful life events, physical illness or illicit substance misuse. A ‘manic switch’ can sometimes be induced by someone with Bipolar Affective Disorder taking antidepressants to treat a depressive episode.
What are the clinical features of bipolar affective disorder?
Clinical features
During periods of depression the patient may become withdrawn and tearful, with low mood, poor sleep and anhedonia. They may experience suicidal thoughts or make attempts.
Manic episodes are characterised by elevated mood or irritability. They may make impulsive and dangerous decisions with little thought for consequences. The need for sleep is often reduced. Mood congruent delusions may be present. They often have pressured speech and exhibit flight of ideas.
Explain the diagnostic criteria of bipolar affective disorder (DSM)?
Diagnostic criteria
The full DSM criteria for the diagnosis of bipolar disorder are as follows:
Bipolar disorder is diagnosed when a person has at least one episode of a manic or a hypomanic state, and one major depressive episode.
Mania
The DSM defines mania as a “distinct period of abnormally and persistently elevated, expansive, or irritable mood.” The episode must last at least a week. The mood must have at least three of the following symptoms:
- Elevated self-esteem
- Reduced need for sleep
- Increased rate of speech
- Flight of ideas
- Easily distracted
- An increased interest in goals or activities
- Psychomotor agitation (pacing, hand wringing etc.)
- Increased pursuit of activities with a high risk of danger
Hypomania
Additionally, the DSM states that in hypomania “the episode (should not be) severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalisation, and there are no psychotic features”
Depression
The DSM states that a major depressive episode must have at least four of the following symptoms. They should be new or suddenly worse, and must last for at least two weeks:
- Changes in appetite or weight, sleep, or psychomotor activity
- Decreased energy
- Feelings of worthlessness or guilt
- Trouble thinking, concentrating, or making decisions
- Thoughts of death or suicidal plans or attempts
What is the acute management of bipolar affective disorder?
Acute management of bipolar disorder
Bipolar disorder may be seen as an acute presentation of either mania or depression. The management of these are as follows:
Acute mania with agitation: patients will typically require IM therapy, either a neuroleptic or a benzodiazepine. They may need urgent admission to a secure unit.
Acute mania without agitation: oral monotherapy can be attempted with an antipsychotic. Sedation and a mood stabilizer such as lithium can be added if necessary.
Acute depression: mood stabilizer and/or atypical antipsychotic and/or antidepressant with appropriate psychosocial support.
All of these patients will require long-term follow up and maintenance therapy.
What is the chronic management of bipolar affective disorder?
Chronic management of bipolar disorder
Patients with bipolar disorder are at high risk of relapse into either depression or mania. As such, they require careful follow-up and ongoing maintenance treatment.
Lithium is the gold standard medication for bipolar disorder and acts as a mood stabiliser. Valproate is a suitable second line alternative. Anti-psychotics and anti-convulsants may also be used in treatment resistant cases.
Additionally, NICE recommends that all patients with bipolar disorder have access to psychological therapies. These should be targeted towards bipolar disorder specifically, and should be high intensity in nature. This can include CBT, interpersonal therapy or couples/family therapy.
What are the factors favouring delirium over dementia?
Factors favouring delirium over dementia
- impairment of consciousness
- fluctuation of symptoms: worse at night, periods of normality
- abnormal perception (e.g. illusions and hallucinations)
- agitation, fear
- delusions
What are some factors suggesting depression over dementia?
Factors suggesting diagnosis of depression over dementia
- short history, rapid onset
- biological symptoms e.g. weight loss, sleep disturbance
- patient worried about poor memory
- reluctant to take tests, disappointed with results
- mini-mental test score: variable
- global memory loss (dementia characteristically causes recent memory loss)
What is delirium?
Delirium or acute confusional state is a common condition affecting predominantly elderly people. It is seen in up to 30% of elderly inpatients.
What are some clinical features of delirium?
Clinical features
It can present in a number of different ways, including:
- Disorientation
- Hallucinations
- Inattention
- Memory problems
- Change in mood or personality
- Disturbed sleep
Patients may be very agitated or very sedated and hypo-active.
What is the aetiology behind delirium?
Causes (Mnemonic: DELIRIUMS)
Common causes of delirium can be remembered using the mnemonic DELIRIUMS:
- D - Drugs and Alcohol (Anti-cholinergics, opiates, anti-convulsants, recreational)
- E - Eyes, ears and emotional
- L - Low Output state (MI, ARDS, PE, CHF, COPD)
- I - Infection
- R - Retention (of urine or stool)
- I - Ictal
- U - Under-hydration/Under-nutrition
- M - Metabolic (Electrolyte imbalance, thyroid, wernickes
- (S) - Subdural, Sleep deprivation
What are the investigations for delirium?
Investigations
A full physical examination and infection screen should be carried out in these patients.
What is the management of delirium?
Management
Management of delirium is predominantly to treat the underlying cause. Maintaining an environment with good lighting and frequent reassurance is helpful. In extremely agitated patients small doses of haloperidol or olanzapine may be considered.
What is dementia?
Dementia
Dementia is thought to affect over 700,000 people in the UK and accounts for a large amount of health and social care spending. The most common cause of dementia in the UK is Alzheimer’s disease followed by vascular and Lewy body dementia. These conditions may coexist.
QUESMED
Definition
According to ICD-10, dementia is a syndrome, usually of chronic or progressive nature, which involves impairment of multiple higher cortical functions, such as memory, thinking, orientation, comprehension and language.
What are the features of dementia?
Features
- diagnosis can be difficult and is often delayed
- assessment tools recommended by NICE for the non-specialist setting include: 10-point cognitive screener (10-CS), 6-Item cognitive impairment test (6CIT)
- assessment tools not recommended by NICE for the non-specialist setting include the abbreviated mental test score (AMTS), General practitioner assessment of cognition (GPCOG) and the mini-mental state examination (MMSE) have been widely used. A MMSE score of 24 or less out of 30 suggests dementia
- Consciousness is not affected in the early stages (in comparison with delirium which will be)
- Identify a decline in memory and thinking which impairs activities of daily living
What is the management of dementia?
Management
- in primary care, a blood screen is usually sent to exclude reversible causes (e.g. Hypothyroidism). NICE recommend the following tests: FBC, U&E, LFTs, calcium, glucose, ESR/CRP, TFTs, vitamin B12 and folate levels. Patients are now commonly referred on to old-age psychiatrists (sometimes working in ‘memory clinics’).
- in secondary care, neuroimaging is performed* to exclude other reversible conditions (e.g. Subdural haematoma, normal pressure hydrocephalus) and help provide information on aetiology to guide prognosis and management
*in the 2011 NICE guidelines structural imaging was said to be essential in the investigation of dementia
What is the aetiology behind dementia?
Common causes
- Alzheimer’s disease
- cerebrovascular disease: multi-infarct dementia (c. 10-20%)
- Lewy body dementia (c. 10-20%)
Rarer causes (c. 5% of cases)
- Huntington’s
- CJD
- Pick’s disease (atrophy of frontal and temporal lobes)
- HIV (50% of AIDS patients)
What are the important differentials behind dementia?
Important differentials, potentially treatable
- hypothyroidism, Addison’s
- B12/folate/thiamine deficiency
- syphilis
- brain tumour
- normal pressure hydrocephalus
- subdural haematoma
- depression
- chronic drug use e.g. Alcohol, barbiturates
What us Alzheimer’s disease?
Alzheimer’s disease
The most common cause of dementia is Alzheimer’s disease, a chronic and progressive form of dementia, which is caused by characteristic neuropathological features such as amyloid plaques and tau proteins. Alzheimer’s disease is caused by a build up of amyloid protein deposits around brain cells and tau protein tangles within brain cells.
Definition
Alzheimer’s disease is degenerative condition of the brain that leads to memory loss and ultimately global impairment of brain function.
What are the clinical features of Alzheimer’s disease?
Clinical Features
A useful mnemonic to remember the features of Alzheimer;s is the ‘4As’:
- Amnesia (recent memories lost first)
- Aphasia (word-finding problems, speech muddled and disjointed)
- Agnosia (recognition problems)
- Apraxia (inability to carry out skilled tasks despite normal motor function)
What is diagnosis of vascular dementia mainly based on?
Diagnosis is made based on:
- A comprehensive history and physical examination
- Formal screen for cognitive impairment
- Medical review to exclude medication cause of cognitive decline
- MRI scan – may show infarcts and extensive white matter changes
National Institute for health and care excellence (NICE) recommends that diagnosis be made using the NINDS-AIREN criteria for probable vascular dementia
Presence of cognitive decline that interferes with activities of daily living, not due to secondary effects of the cerebrovascular event
- established using clinical examination and neuropsychological testing
Cerebrovascular disease
- defined by neurological signs and/or brain imaging
A relationship between the above two disorders inferred by:
- the onset of dementia within three months following a recognised stroke
- an abrupt deterioration in cognitive functions
- fluctuating, stepwise progression of cognitive deficits
Presence of cognitive decline that interferes with activities of daily living, not due to secondary effects of the cerebrovascular event
- established using clinical examination and neuropsychological testing
Cerebrovascular disease
- defined by neurological signs and/or brain imaging
A relationship between the above two disorders inferred by:
- the onset of dementia within three months following a recognised stroke
- an abrupt deterioration in cognitive functions
- fluctuating, stepwise progression of cognitive deficits
What criteria is used in practise to grade depression?
NICE use the DSM-IV criteria to grade depression:
- Depressed mood most of the day, nearly every day
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
- Significant weight loss or weight gain when not dieting or decrease or increase in appetite nearly every day
- Insomnia or hypersomnia nearly every day
- Psychomotor agitation or retardation nearly every day
- Fatigue or loss of energy nearly every day
- Feelings of worthlessness or excessive or inappropriate guilt nearly every day
- Diminished ability to think or concentrate, or indecisiveness nearly every day
- Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
Management of depression (various stages and methods)
For mild to moderate depression
Persistent subthreshold depressive symptoms or mild to moderate depression
General measures
- sleep hygiene
- active monitoring for people who do want an intervention
Drug treatment
- do not use antidepressants routinely but consider them for people with:
- a past history of moderate or severe depression or
- initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least 2 years) or
- subthreshold depressive symptoms or mild depression that persist(s) after other interventions
- if a patient has a chronic physical health problem and mild depression complicates the care of the physical health problem
The following ‘low-intensity psychosocial interventions’ may be useful:
BELOW IN THE TABLE
An alternative is group-based CBT
- be based on a model such as ‘Coping with depression’
- be delivered by two trained and competent practitioners
- consist of 10-12 meetings of 8-10 participants
- typically take place over 12-16 weeks, including follow-up
For patients with chronic physical health problems NICE also recommend considering a group-based peer support programme:
- focus on sharing experiences and feelings associated with having a chronic physical health problem
- consist typically of 1 session per week over 8-12 weeks
Management of moderate and severe depression
Depression: management of unresponsive, moderate and severe depression
NICE produced updated guidelines in 2009 on the management of depression in primary and secondary care. Patients are classified according to the severity of the depression and whether they have an underlying chronic physical health problem.
Please note that due to the length of the ‘quick’ reference guide the following is a summary and we would advise you follow the link for more detail.
Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions and moderate and severe depression
For these patients NICE recommends an antidepressant (normally a selective serotonin reuptake inhibitor, SSRI)
The following ‘high-intensity psychological interventions’ may be useful:
TABLE BELOW
For people who decline the options above, consider:
- counselling for people with persistent subthreshold depressive symptoms or mild to moderate depression; offer 6-10 sessions over 8-12 weeks
- short-term psychodynamic psychotherapy for people with mild to moderate depression; offer 16-20 sessions over 4-6 months
For patients with chronic physical health problems the following should be offered:
- group-based CBT
- individual CBT
What are the clusters of personality disorders?
What are the types of headaches
What is the relationship of Wernicke’s encephalopathy and Korsakoff syndrome?
If not treated Korsakoff’s syndrome may develop as well. This is termed Wernicke-Korsakoff syndrome and is characterised by the addition of antero- (most) and retrograde (limited) amnesia and confabulation in addition to the above symptoms.
