PSYCHIATRY REVISION

KEY POINTS

Differential Diagnosis Pyramid: OPMAPS

Mental Health Act

PATIENT MUST FULFIL ALL 5 CRITERIA:

1. The person appears to have a mental illness (a medical condition characterized by a disturbance in thought, mood, perception and memory)

2. The person requires immediate treatment which can be obtained by involuntary admission

3. The person requires urgent treatment for the health and safety of themselves and others (or to prevent deterioration)

4. The person is unable to or refuses to give consent, due to their illness5. The patient cannot be treated in a manner that is less restrictive

Cognitive Assessment

Orientation Date, Day, Year, Season, Location, CountryMemory Register, Recall, Long Term (impression), ConfabulationConcentration Days of the week backwards, Spell WORLD BackwardsIntelligence General impression from interview

Frontal Lobe Word Lists (10 fruits)Abstract thoughts (differences/ similarities, proverbs)

Parietal Lobe Dyspraxia (3 step command, intersecting pentagons)Agnosia (naming fingers, writing on skin)

Language Dysphasias – fluent, non-fluent

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Cluster A: madCluster B: badCluster C: sad

Delirium, Dementia, GMCDrugs/ToxinsAmnestic disorder

Schizophrenia, Schizophreniform, Schizoaffective, Deulsional, Brief Psychotic, Shared psychotic, Psychosis due to GMC/Drugs Depression, Dystyhmic,

Bipolar I/II, CyclothymicMood due to GMC/DrugsPanic ± Agoraphobia

Specific/Social phobiaOCD, PTSD, Acute stress, GAD

?Adjustment disorder with depressed mood, Somatoform

Personality

Organic

Psychotic

Mood

Anxiety

Social/Environment

PSYCHIATRY REVISION

PSYCHOTIC DISORDERS

Schizophrenia

Definition:- A psychiatric disorder characterized by disturbances in speech, emotion,

cognition, perception and volition. (delusions, hallucinations, or disorganized speech and thought)

Epidemiology:- 1/1000 Australia- Male:Female, 1:1- Onset late teens, early twenties- Males more severely affected than females (earlier onset)

Aetiology:- Subtle disruptions in brain development and maturation in utero- Combination of genetic and environmental/non-genetic influences- Physical condition brought out by a life stressor (eg. Starting college, new job)

Risk factors:- Family Hx- Prenatal Virus- Birth complications/trauma- Cannabis use < 18yrs

Symptoms:

Positive Negative CognitiveHallucinationsDelusionsDisorganised speechDisorganised behaviour

Lack of motivationPoor self-careBlunted affectReduced speech output

Impaired planningImpaired insightImpaired memoryReduced mental flexibility

DSM IV:- A disturbance lasting ≥ 6 months, with at least 1 month of Active symptoms

(positive or negative) with resultant social/occupational dysfunction.- Excludes schizoaffective, mood disorder, substance abuse, general med

condition (GMC)- NB: Schizophreniform is typically used as a preliminary diagnosis for

schizophrenia. Due to the complexities of schizophrenia, an initial diagnosis is very often tentative and schizophreniform is therefore used.

dDx for Psychosis:1. Psychosis due to psychoactive drug (intoxication or withdrawal)2. Primary Schizophreniform psychosis3. Borderline/Schizotypal disorder with decompensation

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Assessment:1) Engage Patient for History and Examination

- Thorough physical, mental history and examination is ideal- May not be realistic depending on patient state- May need corroborative history from family/carers- Use open ended questions initially? Has anything happened lately that has upset you? What is the most important thing you would like help with? Have you noticed anything suspicious going on around you? Have you felt like people are talking about you, or watching you in an unusual manner?Has anything on the TV or radio, or in the newspapers, seemed to refer to you personally?Have you heard people talking to you or about you when there was nobody around

2) Assess Risk- Past risk of self harm- Current risk of self harm- Risk of harm to others (includes: depressed mood, agitation, aggression)- Need for hospital admission/involuntary treatment

3) Evaluate triggers- Substance abuse- Medication non-compliance- Stressful life event

4) Assess current treatment- Medication compliance- Adverse effects (extrapyramidal)- Attitudes towards medication/treatment- Insight

5) Past History – Relevant Issues- Level of formal education- Most recent time of highest level of psychosocial functioning- First onset of psychotic symptoms- Degree of recovery between episodes- Attitudes towards family and significant others- Family history

6) Physical Examination- Vital signs- Hydration and Oxygen satursation status- Blood Glucose- Urinanalysis + Toxicology (amphetamines)- Rule out organic factor – infection, metabolic

7) Further investigations- EEG- CT/MRI- Thyroid- FBE- Serology: HIV- Vit B12/Folate

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Baseline measurements if starting Rx:-Weight, ECG, Bloods, TFTs, LFTs, Glucose, lipids - Repeat 6/12 if treatment continues

PSYCHIATRY REVISION

Management1) Psychoeducation

a. Patient Education (early warning signs, strategies for early intervention: eg. increase antipsychotics, add benzo, abstain from drugs, stress management, help seeking)

b. Family Education2) Psychosocial Intervention

a. Multidisciplinary approach: GP, Psychiatrist, Social workersb. Involve family in treatment (family therapy: problem solving, stress

management, listening skils)c. Cognitive Behavioural Therapyd. Social Skills Training: learning to behave in situations, eg. Eye

contact, speech volume, length of response etc.e. Engage services to assist with: HOPELESS (housing, occupation,

primary support, education, legal, economic, service access, social environment)

f. Address co-morbid substance abuse (Motivational interviewing)3) Medication

a. Benzodiazepines (Short-term use): for immediate symptoms and insomnia, anxiety, agitation, aggression.

b. Typical Antipsychotics/Atypical Antipsychoticsc. Depot Antipsychotics (only if oral + psychosocial support fails)d. Clozapine (for treatment resistant cases: agranulocytosis, myocarditis)e. ± ECTf. ± Antidepressantsg. ± Mood stabilisers

4) Maintenancea. First episode patients with excellence response may have medication

free trial after 1-2 years (but continue psychosocial interventions)b. Repeated episodes or Dx of schizophrenia requires medication for at

least 5 yearsc. Consider Depot for persistent relapse which does not respond to

psychosocial intervention (medication compliance enhancement)d. Consider CTO for patients who fail to co-operate with community

based care (maintain for at least 6 months)e. GP care for physical health: metabolic S/E, poor self care

Prognosis- Relapses (80%)and continuing disability are common- Progressive deterioration is not inevitable- Disabiltiy diminishes with time, may even remit- 1/10 patients with chronic psychosis return to full time work

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Antipsychotics:

Typical Atypical DepotChlorpromazinePericyazineThioridazine

Sedation +++Extrapyramidal +

Amisulpride (Solian®)Aripiprazole (Abilify®)Clozapine (Clopine®)Olanzapine (Zyprexa®)Quetiapine (Seroquel®)Risperidone (Risperdal®)Ziprasidone (Zeldox®)

Risperidone(Risperdal Consta®)

DroperidolFlupenthixolFluphenazineHaloperidolPimozideTrifluoperazineZuclopenthixol

Sedation +Extrapyramidal +++

Mode of Action:- varying affinity for D2 receptors- blockade

Response:- onset 2-3 weeks- atypicals tend to have less Extrapyramidal side effects (EPS)

Side Effects: SHE WAS MESedationHypotension: posturalExtrapyramidal: dystonia, akathesia, parkinsonism, tardive dyskinesia

WeightAnticholinergic: dry mouth, blurred vision, constipationSexual Dysfunction

Metabolic: glucose tolerance, serum lipidsEndocrine: hyperprolactinaemia (gynaecomastia, galactorrhea, amenorrhea, libido)

Clozapine:Side effects:

- Agranulocytosis (1%) in first 20 weeks- Myocarditis in first 6 weeks- Seizures- Cardiomegaly- Disruption of cardiac excitability- “SHE WAS ME”

Monitoring:- Baseline haematological and cardiac (ECG, ECHO, Serum troponin)- Weekly WCC for first 18 weeks, then monthly for duration of treatment,

then for 1 month after stopping- Fasting blood glucose and lipids every 6 months

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Substance Abuse

Syndromes:Substance Abuse

- A maladaptive pattern of substance use, which causes clinically significant impairment or distress

Criteria: ≥3 sx in a 12 month period1. failure to fulfill roles2. use in physically hazardous situations (eg. Driving, heavy machinery)3. recurrent legal problems4. recurrent interpersonal/social problems due to the substance

Substance Dependence:- A maladaptive pattern of substance use, which causes clinically significant

impairment or distressCriteria: ≥3 sx in a 12 month period

1. Tolerance: need ↑ amount to achieve desired effect2. Withdrawal (sx usually the opposite of the drugs effect +

anxiety/depression/sleep disturbance)3. Preoccupation: salience, craving, ↓control, continuation

priority of drinking (Salience) compulsion to use (Craving) impaired control over alcohol use (Control) continued use despite harmful effects (Continuation)

Aetiology:1. The nature of drug

a. Pleasurable psychological effectsb. Rapid action

2. The individuala. Genetic predisposition (esp. alcohol)b. Personal characteristics (poor impulse control, limited problem solving

skills, negative mood)c. Upbringing (modeling by parents, coping skills)d. Psychiatric illness (depression, anxiety, schizophrenia, OCD)

3. Socio-Cultural factorsa. Cultural acceptanceb. Availabilityc. Price

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Physical Consequences:Substance and Effect Mechanism of Harm

Alcohol

Disinhibition, increased amounts leads to sedation.Peripheral vasodilation (warm flush, reducing core body temp)Diuretic

Widespread tissue damage Acute- Gastritis, Acute pancreatitis, Trauma Chronic Disease- Cirrhosis, Pancreatitis, Cardiomyopathy

Withdrawal State- Acute- Severe: Delerium Tremens

Trauma while under the influenceReduced Immune Function Nutritional Deficiency: vit b12, thiamine

Sedatives-Hypnotics

Anxiolytic, Sedative, Hyponotic action

Deliberate ODMix with Alcohol or other CNS depress.(Benzos relative safe in OD)Withdrawal syndrome – resembles anxiety

Cannabis

Produces a ‘high’ intensification of normal senses, euphoria, laughter, talkative, floating on air. Tachycardia, postural hypo (light headed), HungerImpaired memory, concentrartion

Cognitive impairment (dose response)Psychosis (paranoid, aud/vis hallucin)

Heroin and other Opiates

IV heroin use results in a “rush” euphoria, warmth, ‘kick’ resembling orgasm in lower abdomen. Followed by several hours of floating/euphoria.Drowsiness, labiliy, mental clouding

Sharing Needles (HIV, Hep B/C)Disinhibition/High risk behaviour (STD)OD (resp depression, pupil constrict)Withdrawal- initial: craving, restless, flu-like- late: ↑anxiety/craving, piloerect, pupil dilation, N/V/D

PsychoStimulants:- Cocaine

Smoking crack Short acting high (5-10mins), followed by intense depression and craving

- Amphetamines (Ecstacy ICE)Euphoria, excitement, talkativiessIncreased sex drive, reduced sleepDilated pupils, tachycardia, nausua

Withdrawal syndrome – lethargy, inanition, depressionPsychosis (acute or chronic use) – by definition must persist >48hours

Hallucinogens (LSD)Increased sensory awareness (vivid smell, colour), altered perception and ability to differentiate self & env.

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Other…Chronic Alcohol Use: Wernicke-Korsakoffs: amnestic disorders caused by thiamine deficiency

- Wernicke(acute, reversible): Ocular palsy, ataxia, vestibular, delirium - Korsakoffs (chronic): marked short term memory loss, cant learn new info,

anterograde amnesia, confabulation

Dual Diagnosis- co-occurrence of psychiatric conditions and substance use is higher than

expected in population- 30% with mental disorder are diagnosed with substance use disorder (2-3

higher than population)- Substance use can exacerbate psych disorder (vice versa): risk of symptom

exacerbation, relapse, compromised medication efficacy, poor compliance.

Psychosocial Consequences:Psychological Social

Withdrawal FeaturesNeuroses (anxiety, social phobia)Other phobiasPsychosesSuicidal attempt/ideation

Domestic and alliedOccupationFinancialLegal

Assessment:1. Common presentations;

a. Acute intoxication/withdrawal:i. Deliriumii. Psychosisiii. Sleep disturbanceiv. Anxietyv. Depressionvi. Agitation

b. Chronic usei. Depressionii. Dementiaiii. Phobiasiv. Psychosis

2. Historya. Alcohol:

i. use a ‘top down’ approach by suggesting high amounts and allowing them to correct downwards.

ii. Avoid term ‘alcoholic’b. Drugs: elicit the name of every drug used –

i. Quantityii. Frequencyiii. Durationiv. Route of usev. Last usevi. Costvii. Source: ?doctor shopping, prostitution, crime

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viii. Assess Substance related problemsix. Assess Substance dependence

1. Craving2. Impaired control3. Prioritisation4. Withdrawal5. Tolerance6. Continued use despite harm

c. Past Used. Drug of Choicee. Most problematic Drugf. Purpose and meaning of drug to client

i. Reasons for substance useii. Precipitantsiii. Effectsiv. Consequences

g. Family Historyh. Treatment Historyi. Risk-Taking Behaviourj. Assess Motivation for Change

i. How interested are you in changing you substance use?ii. Do you feel than you need to change your substance

use?iii. Do you really want to stop using?iv. What could you do to get on top of you use?v. How confident are you that you can achieve this?

3. Examinationa. Evidence of substance use: smell, track marksb. Decline in global functioning

i. Poor general appearanceii. Hygieneiii. Overall healthiv. Nutrition

4. Investigationa. Urineb. Serumc. Breathtests

5. Managementa. Motivational Interviewing

i. FLAGS = Feedback, Listening, Adivice, Goals, Strategiesb. Asses Stage of Change

i. Pre-contemplation: do not wish to changeii. Contemplation: ambivalenceiii. Action: decision to change and implemented strategies iv. Maintenancev. ± Relapse

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Alcohol1. Harmful/Hazardous use

1. 5% of males2. 2% of females3. > 40g (4 standard drinks) for males4. >20g (2 standard drinks) for females5. 1 can beer = 1.5 SD6. 1 bottle wine = 8 SD7. 1 bottle spirits = 25 SD

2. Dependence1. Salience2. Craving3. Control4. Continued use despite harm5. Withdrawal6. Tolerance

3. Alcohol Withdrawal1. Can last from 24 hours – 2 weeks2. Characterised by CNS hyperactivity3. Can range from Mild Delerium Tremens (DTs)4. Mild = nausea, tremor, sweats, anxiety, seizures5. Complex = Confusion, distractibility, hallucination, paranoia6. DTs = extreme hyperactivity, seizure, delirium life threatening

4. Management1. Motivational interviewing2. Diazepam

5. Alcohol Withdrawal Scale“People Think All Alcoholics Travel Hung Over”

1. Perspiration2. Tremor3. Anxiety4. Agitation5. Temperature6. Hallucinations7. Orientation

(0-4)(0-3)(0-4)(0-4)(0-4)(0-4)(0-4)

Total: /27

Score:1-4 = mild withdrawal5-9 = moderate10-14 = severe≥15 = very severe

(med review if >10)

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ANXIETY DISORDERS

Post-Traumatic Stress Disorder

Definition:- The re-experiencing of an extremely traumatic event accompanied by

symptoms of increased arousal and avoidance of stimuli associated with the trauma.

Epidemiology:- Male:Female = 1:2

Aetiology:- Unclear as to the interrelationship between Stressor and Personal vulnerability- Traumatic event causes marked psychological distress and feelings of

horror/fear/hopelessness- There is a failure to integrate traumatic event and there is disruption in the way

the memories and processed and laid down- Memories can then be triggered by means of primitive conditioning which

sustains heightened arousal- Avoidance/Numbing is the homeostatic attempt to modulate this feeling of

constant unease.Risk Factors:

- Female- Natural Disaster- War- Rape- Assault- Motor Vehicle Accident- Predatory Violence

Symptoms:Intrusive Phenomena Hyperarousal Avoidance/Numbing

RecollectionNightmaresFlashback

(Associated with intense psychological distress)

Difficulty sleepingExaggerated startleHypervigilanceIrritability/AngerDifficulty concentrating

Thoughts/Feeling/ConversationsActivities/People/PlacesInability to recall aspectsDiminished interest in activitiesFeelings of estrangementRestricted affectBleak outlook of future

DSM IV:1) Traumatic Event: person experienced/witnessed/was confronted by:

a. Actual/Threatened death or serious injury to selfb. Threat to physical integrity of self or othersc. Results in feelings of intense fear, helplessness, horror

2) Re-experiencing3) Hyperarousal4) Avoidance/Numbing5) Duration >1 month

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Assessment:1) Evaluate trauma

a. Eventb. Response: feelings, thoughts, behavioursc. Sequelae: avoidance, hyperarousal

2) Characterize coursea. Acute (<3/12)b. Chronic (>3/12)c. Delayed onset (>6/12 after stressor. May be reactivated by other stress)d. NB: Acute Stress Disorder lasts >1/12 after stressor

3) Assess Social Functioninga. Work habitb. Relationshipsc. Dissociationd. Vulnerability to subsequent stressors (change in how life’s stressors

are perceived)e. Any legal ramifications/compensation claims

4) Assess other Psychiatric Sequelaea. Substance Abuseb. Social/Specific Phobiasc. Depressiond. “Thrill seeking”

Management:Aims:

1) Dampen down arousal2) Evaluate meaning of trauma3) Systematic desensitization4) Promote Coping skills

Methods:1) Psychoeducation2) Psychotherapy

a. Eg. CBT3) Medication

a. SSRI (Fluoxetine, Sertraline, Paroxetine) = short term to facilitate therapy

b. ± Short term Anti psychotics for severe casesPrognosis:

- Resolves in 60% of obvious cases- May have long term residual symptoms

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Panic DisorderDefinition:- Recurrent, unexpected panic attacks about which there is intense, persistent,

concern.Epidemiology:

- Begins in teens, early 20s- Later onset (ie. 40s) suggests organic cause

Aetiology: often unclear ?Risk Factors: ?Symptoms:

1. Panic Attack: - Discrete period of intense fear/discomfort, reaching peak within 10

minutes. - 4/13 symptoms:

Somatic Symptoms Cognitive SymptomsPalpitationsChest PainSweatingTrembling/ShakingShortness of breath

Sense of ChokingNausea/Abdo discomfortDizzyNumb/TinglingChills or hot flush

DepersonalisationFear of dyingFear of losing control

2. Agoraphobia:- Avoidance or anxiety in places or situations in which – escape might

be difficulty/embarrassing, help may not be available.- Occurs in 90% of cases- Usually towards a wide range of situations, eg. Shopping, trains

3. Other Symptoms- Depression is coming 2/3- Alcohol/Benzo abuse- Social/Occupational impairment- Interpersonal difficulties- Suicide Attempts

DSM IV:- ≥ 1 month of persistent concern- Worry about implications of an attack- Significant change in behaviour related to the attacks

Assessment:Before diagnosis:

1. Is this a normal anxiety response to a life stress?2. Is the anxiety a response to a life stress but in excess of the expected

levels? (Adjustment disorder)3. Is the person a habitual worrier? Is this therefore trait anxiety (anxious

personality?)4. If there is an anxiety disorder, is it 1o or 2o.

a. Substance intoxication/withdrawalb. OTC drugs: caffeine, nasal decongestants, bronchodilatorsc. General medical condition (DINES)

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SYSTEM EXAMPLEDeficiency state Vitamin B12, pellagraInflammatory RA, SLENeurological Neoplasm, infection, MS, Huntingtons, WilsonsEndocrine Adrenal (Phaeo), Thyroids, PituitarySystemic Hypoxia, Hypoglycaemia

5. Is there a cardiac/serious problem?a. Arrhythmias can mimic panicb. Recurrent PE’s can mimic panic

After Diagnosis:6. If panic disorder, are they ‘spontaneous’ or ‘cued’ ?7. Identify triggers/exacerbating factors

a. Physical conditionsb. Psychosocial stressc. Lifestyle factors: caffeine, inadequate sleep, excessive work

8. Is there associated Agoraphobia? 9. Determine severity and degree of functional impairment

a. Psychosocialb. Occupational

10. Is there associated substance abuse?11. Is there associated depression?12. Assess suicide risk/safety

Management:1. Psychoeducation

a. Self help books, written information2. Psychotherapy for panic

a. CBT: Hyperventilation, Stress managementb. Cognitive therapy: breaking link between bodil sensations and

their incorrect interpretationc. Behavioural Therapy:, Relaxation Techniques

3. Biologicala. Used for severe cases who do not respond to psychotherapyb. Antidepressants:

i. SSRIs may exacerbate condition before anti-panic effect takes over

ii. TCAs are dangerous in OD, so avoid in suicidal patientsc. Benzodiazepines

i. Good for short term reliefii. Risk of misuseiii. Risk of tolerance and withdrawal

4. Psychotherapy for Agoraphobiaa. CBT: hierarchy of fearful situations established and graded

exposure is used. Can be individual or group.5. Address co-morbidities

a. Always address alcohol abuse first (before anxiety) detoxb. Co-morbid Depression indicates greater relapse and recurrence and

chronicity. Priority given to treating depression.

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MOOD DISORDERS

DepressionDefinition:Major Depressive Disorder:

- One or more episodes of major depression which causes significant psychosocial/occupation impairment.

Others:1) Dysthymic Disorder2) Adjustment Disorder with Depressed Mood3) Depressive disorder NOS

Epidemiology:- More common in females (16%) than males (8%)- Mean age of onset is late 20s

Aetiology:

Biological

Genetic Twin studies show higher concordance. Suggests polygenetic inheritance of vulnerability to mood disorder.

Biogenic Amines Monamines for depression

Neuroendocrine Abnormalities Altered HPA axis, overactivity in 50% of depressed patients.

Substance Induced SteroidsOCP

L-DOPAAntihypertensivesAntibioticsAnalgaesicsAnticonvulsants

BenzodiazepineEtOHIllicit Drugs

PsychologicalPersonality traits Dependent

ObsessionalHistrionic

Stress Loss

Social Stress

Loss of:- relationship- job- status- loved one- health

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Risk Factors:- Family history- Stressful life event- Concurrent physical illness

Symptoms: “ D epressed P eople W ill S eem F lat. P eople C an G et S uicidal” 1. Depressed/Lowered Mood ** (may have diurnal variation, worse in morning)2. Loss of Pleasure (anhedonia) **3. Weight Loss4. Sleep Disturbance (early morning wakening suggests melancholia)5. Fatigue/Loss of Energy6. Psychomotor agitation/retardation7. Concentration difficulties/Indecisiveness8. Guilt/Worthlessness9. Suicidal ideation/Preoccupation

** Criteria 1 or 2 is mandatory

NB: Lowering of self-esteem/self-worth is prominent (cf. anxiety, grief – where self-esteem remains intact) NB: “Neurovegetative Symptoms”: Sleep, Energy, Concentration, Appetite, Libido

DSM IV:1. 5/9 symptoms for >2 weeks2. symptoms cause significant psychosocial/occupational distress or impairment3. Do not include symptoms clearly due to general medical condition

Risk Assessment

Current Attempt Current Risks1. Ideation2. Intent3. Plan4. Means5. Final Acts6. Precautions7. Lethality8. Help Seeking9. Precipitants10. Prior attempts

1. Current Problems2. Anger/hostility/impulsivity3. Depression/ Anxiety/ Hopelessness4. Disorientation/Disorganisation5. Substance Abuse6. Psychosis7. Medical Status8. Social Withdrawal9. Lack of desire for help10. Poor psychiatric past experiences11. Poor coping strategies (eg. DSH)12. Lack of social connectedness

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Assessment:1. Conduct MSEGeneral Appearance Stooped posture

Reduced self-careLoss of weightPatient looks downcast, drawn, sullen appearanceMay be tearful

Rapport Poor eye contactBehaviour Slowed activity, lack of spontaneous movement and speech

ORAgitated with hand-wringing, restlessness, pacing

Mood/Affect Mood may be reactive (mild) or unreactive (severe)Affect may be blunted (moderate) )or flattened (severe)

Speech and Language Lack of spontaneous speechThought

- Stream- Form- Content

Negative, pessimistic themesMay have psychotic delusions of guilt, worthlessness, persecution, death, nihilism, poverty.

Perception May have auditory hallucinations located in the head, referred to as ‘voices of conscious’.

Cognition May have loss of concentration, poor motivationInsight and Judgement Perceived benefit of interview (mild) or no benefit (severe)

May have limited insight (severe)

Suicide/Risk Ideation and thoughts of dyingIntent, Plan, Means, Past Attempts, Current Risk

2. Classify type of depression- Psychotic

o Delusions and Hallucinationso Mood congruent or incongruent

- Melancholico Criterion A: consummatory anhedonia OR non-reactive moodo Criterion B (≥3): distinct quality to depressed mood, worse in morning,

early morning wakening, marked psychomotor retardation/agitation, major LOA or LOW, notable guilt.

- Atypicalo Mood reactivityo Leaden paralysis (limbs feel heavy like lead)o Hypersomniao Increased Appetite/ Weight gaino Marked Indecisiveness o Sensitivity to interpersonal rejection

- Post-partumo Onset within 4 weeks postpartum

- Catatonico Motoric immobility, excessive motor activity, extreme negativism

mutism peculiarities of voluntary movement, echolalia, echopraxia

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3. Further history- Past history, treatments and responses- Psychosocial triggers- Premorbid personality and coping style- Family history

4. Past medical hx:- Any physical illness related to depression: Parkinsons, MS, Hungtingtons,

Hypothyroid, Cushings, SLE, RA, malignancy, HIV- Any current medications: steroids, L-DOPA, isotretinoin, interferon

5. Further Investigation- TFTs- FBE- CT/MRI

6. Consider dDx:- Secondary Depression : Anorexia, Schizophrenia, Anxiety disorders, OCD,

Substance abuse (needs concurrent management)- Schizophrenia : social withdrawal, deterioration of personal habits, loss of

interest. MSE would show thought disorder- Early Dementia : irritability, disturbed mood

6. Appraise Severity/Suicide Risk- ? Reactive or Unreactive mood- ? Understandable reaction to circumstances- ? Psychomotor changes- ? Neurovegetative symptoms

Management:1. Psychoeducation (patient and family)

a. Current acute/chronic stressorsb. Nature of depression: course, treatmentc. Signs of relapse and action pland. Reassurance

2. Psychosocial Interventiona. CBTb. MBCT (mindfulness-based cognitive therapy, awareness of oneself in

the ‘here and now’)c. DBT (dialectical behaviour therapy: exploring alternate solutions)d. IPT (interpersonal therapy: focus on current relationships)

3. Physical Treatmentsa. Antidepressants (2 weeks before improvement)b. ECT

- Consider inpatient treatment for:o Psychotic depressiono Significant suicide risko Significant homicide risko Unable to cope at homeo Seriously physically unwell

Prognosis:- 50-80% have recurrent type, with episodes lasting ≈6 months (2wks – 1 yr)- Symptoms free time in between may contract with age- Some patients suffer 1 episode and make complete recovery

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Antidepressants1. TCAs (Amitriptyline =Endep®)

- Only used in treatment resistant cases due to side effect profile- Muscurinic S/E: dry mouth, blurred vision, constipation- Histaminic S/E: drowsiness, weight gain- Adrenergic S/E: tachycardia, postural hypotension- Can cause “Serotonin Syndrome” (if combined with other drugs

affecting serotonin)i. Agitation/Restlessnessii. Sweatingiii. Diarrheaiv. Hyperreflexiav. Lock of coordinationvi. Shivering/Tremor

- TCAs are cardiotoxic in overdose2. MAOIs (Phenelzine = Nardil ®)

- Irreversible inhibitors of MAO A & B- Usually reserved for treatment resistant cases- Best for Atypical Depression- Can cause Hypertensive Crisis (“Cheese Reaction”)

i. Severe headacheii. Chest painiii. Palpitationsiv. Stiff neckv. Intracranial haemorrhage

- Patients must adhere to strict diet (no matured cheese, wines)3. SSRIs (Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline)

- First line drugs for uncomplicated depression- Never given in combination with TCAs or MAOIs (serotonin

syndrome)- S/E include:

Gastrointestinal Central Nervous System SexualAnorexiaNauseaDiarrhoeaConstipation

HeadacheAnxietyAgitationAkithisia

AnorgasmiaDecreased libidoEjaculatory failureImpotence

*This category usually persists

4. Othera. Moclobemide= Aurix ®

i. Reverisble Inhibitor of Monoamine Oxidase A (RIMA)ii. Safe, well toleratediii. No dietary requirementsiv. Rarely causes sexual dysfunction

b. Venlefaxine= Efexor ®i. Serotonin & Noradrenaline Reuptake Inhibitor (SNRI)ii. Broader actioniii. Particularly useful for Melancholic Depression

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c. Mirtazapine= Avanza®i. Noradrenaline & Specific Serotonin Antagonist (NaSSA)ii. Fewer sexual problemsiii. Good if sleep disturbance is marked

d. Reboxetine = Edronax®i. Noradrenaline Reuptake Inhibitors (NARI)ii. Fewer sexual problemsiii. Good if apathy and anergia are prominent

Electroconvulsive Therapy (ECT)- Safe and effective treatment- Administered under anaestheisa with a trained psychiatrist- Administered 2-3 x week, for 6-12 treatments- Mortality risk very low- S/E:

i. Headacheii. Confusioniii. Memory impairment

- Indications = Severe depression:i. Starvationii. Dehydrationiii. High suicide riskiv. Psychotic symptomsv. Treatment resistant

Treatment Algorithm1. SSRI2. Mixed Action: Venlefaxine, Mertazapine, Raboxetine3. TCA (or MAOI)4. ECT

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Bipolar Disorder

Definition:1. Bipolar I: A mood disorder characterized by abnormally and persistently

elevated, expansile or irritable mood, sufficient to cause marked psychosocial/occupation impairment or hospitalization.

2. Bipolar II: A mood disorder characterized by one or more major depressive episodes and at least one hypomanic episode.

Epidemiology:1. Male:Female = 1:12. Onset late 20s (rare over age of 50)

Aetiology:3. Polygenetic predisposition to mood disorders4. Dopamine hypothesis of psychosis

Risk Factors:5. Can be triggered by antidepressants6. Poor Compliance is biggest cause of recurrence (poor insight, lifelong illness)

Symptoms: Manic Episode“G et S ome S leep. F orget D elusional A nswers P lease.”

1. Grandiosity/ Inflated sense of self2. Sleep – need is decreased3. Speech – pressured, loud4. Flight of ideas/Formal thought disorder5. Distractibility6. Agitation/Activity – psychomotor agitation, goal directed7. Pleasure-seeking activities – excessive, negative consequence

DSM IV:Mania

1. Expansive/Elevated/Irritable mood for ≥ 1 week (or any duration if hospitalized) + At Least 3 symptoms

2. Irritable mood alone for ≥ 1 week (or any duration if hospitalized) + At Least 4 symptoms

Hypomania7. Symptomatic criteria met for mania EXCEPT

1. Shorter duration (of at least 4 days)2. Not severe enough to cause marked function impairment/ hospitalization3. Absence of psychotic features

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Assessment:General Appearance May seem eccentric, odd.

Rapport Energetic, but irritable and frustrated under surface.

Behaviour HyperactivePsychomotor agitation/ Increased Drive/Goal directedDecreased need for sleep

Mood/Affect Elevated, Expansive, Euphoric moodIrritable Mood

Speech and Language Rapid, Loud, Pressured

Thought- Stream- Form- Content

Formal Thought Disorder: Flight of Ideas/Loosening of AssociationsJokes, Puns, Plays on WordsDelusions of: grandiosity, erotmania, special powers

Perception Hallucinations in severe states (God instructing them)

Cognition Impaired concentration/Distractibility

Insight and Judgement Often severely impaired may have devastating social consequences (business, sexual, driving, spending)

Suicide/Risk May be quite impulsive, reckless

Acute Management1. Rule out organic conditions/drug induced states2. May require involuntary admission if severe 3. Use Valproate ± atypical antipsychotic initially (Lithium is too slow onset)4. ± Benzodiazepine to lessen hyperactivity

If mild, can be treated as outpatient with Valproate/Lithium, but need family member to monitor compliance due to poor insight.

Long Term Management:1. Evaluate long term mood stabilizing options for patient

- Warrented for 2 episodes in 2 years, may begin after just single episode2. Psychoeducation for both patient and family

- About illness, nature, course, treatment, signs of relapse3. Psychosocial intervention

- CBT, IPT, Family therapy- Can help improve compliance and prevent recurrence. Individualise.

4. Biological Treatment1. Lithium, Valproate, Carbemazapine2. Monitor S/E3. Prevent both elation and depression in 80% of patients

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Mood Stabilisers1. Lithium

a. First line or Bipolar 1b. Narrow therapeutic window requires monitoringc. Blood tests to check levelsd. Significant role in maintenance and reducing suicide risk

(antidepressants can trigger mania or rapid cycling, avoid if poss)

Lithium ProfileSide Effects

Usually settle over time

Short TermPolydipsiaPolyuriaN/V/DMetallic TasteDifficulty concentratingFatigueTremor/WeaknessWorsening acne/psoriasis

Long termWeight gainRenal changesDry SkinHypothyroidism (often need thyroxine)

Toxicity

Can occur due to :4. Overdose5. Drug interaction

(NSAIDS, diuretics, ACEI)

6. Dehydration7. Salt deprivation

(Others might think you look drunk)Slurred speechBalance disturbanceVisual disturbanceSevere N/V/DSevere tremor/twitchSevere drowsiness

Avoid dehydrationDo not change salt intake

Stop drug immediately

Nb/ Teratogenic 1st trim.

2. Sodium Valproatea. First line for Bipolar II, Rapid Cycling, Schizoaffective Disorderb. Better tolerated than lithium

Valproate ProfileSide Effects

Usually settle over time

Nausea/IndigestionWeight GainSedationTransient Hair Loss

Discuss with doctor

Teratogenic in 1st trim.

Toxicity Liver FailureHaematological Alterations (blood dyscrasias)

Stop drug immediately

3. Carbemazapinea. Used in mania and preventing bipolar recurrence

4. Lamotraginea. Can be used for depressive symptoms in bipolar I

Prognosis:- Generally requires indefinite treatment and psychosocial support

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EATING DISORDERS

Anorexia NervosaDefinition:

- The relentless pursuit of thinness characterized by marked self-induced weight loss and a refusal to maintain normal body weight.

Epidemiology:- Adolescent and young women- Onset ~ 15-19 (now younger)- Lifetime prevalence 0.5%- Male:female ~ 1:10- Developed world

Aetiology:- Genetic contribution- Environment exposure- Often develops as child tries to keep control of their world

Risk Factors:- Stressful social environment – parental conflict, family dysfunction - Perfectionism- Low Self-esteem- Weight concerned environment- Underweight/thin family

Symptoms:Cognitive Behavioural Neurovegetative

Obsession with ThinnessPreoccupation with foodFood Rituals/RuminationsIncreased interest in foodDenial of hunger/dieting

RestrictingLaxativesExcessive exerciseDiureticsInduced Vomiting

Depressed moodDecreased libidoDecreased concentrationLethargy/FatigueDisrupted sleep

DSM IV:1. Failure to maintain normal body weight (weight < 85% of that expected, or

>15% below normal, or BMI <17.5 for those over 18. Underage, use charts)2. Intense fear of gaining weight/becoming fat (though underweight)3. Distorted perception of body shape/Undue influence of body weight/shape on

self-evaluation, or denial of seriousness of current low body weight.4. Amenorrhea if post-menarchal (absence of at least 3 consecutive periods)

Classify Type:a. Restricting : Not regularly engaged in bingeing/purgingb. Bingeing/Purging : Regularly engaged in bingeing/purging

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PSYCHIATRY REVISION

Assessment:1. History:

- When were you last well?- Document all eating disorder symptoms- Effects of illness on her life- Symptoms of starvation- Co-morbid depressions, OCD, social phobias, past psych hx?- Motivation for change- Previous help sought- Reactions of family and friends- Collateral history- Relevant family problems

2. Physical Exam (consequences of starvation)“Not Eating Has Many Intense Effects. Girls Rarely Stay Confident.”

Neurovegetative Depressed mood, attention, libido, sleep, appetiteElectrolyte Low K+, PO43-- , Mg, CaHaematological Anaemia of chronic disease (normocytic/chromic)Metabolic Hypothermia, Hypoglycaemia, HypercholesterolImmunological Bacterial infectionEndocrine AmenorrheaGastrointestinal Mallory weiss, swollen salivary glands, dental caries, ↓motilityRenal Ketones, acute/chronic renal failureSkin/Bone Dry skin, lanugo hair, facial purpura, OsteopeniaCardiac Arryhthmia, Bradycardia

3. MSEGeneral Appearance May have Low BMI

Look for layering of clothesRapport -Behaviour -Mood/Affect Dysphoriac affect

IrritibilitySpeech and Language -Thought

- Stream- Form- Content

Preoccupation with weight/shapeFeelings of inadequacy

Perception -Cognition Poor concentration

Cognitive function reducedInsight and Judgement May be limitedSuicide/Risk -

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Investigations:1. Screen for underling organic illness (ESR, TFT, Coeliac screen)2. Screen for acute medical complications

a. FBE – anaemiab. ESR – severe sepsisc. U+E as well as K, Mg, Ca, Phospate (need to ask specifically)d. LFTs, albumin, total protein – malnourishmente. Random Glucose – hypoglycaemia or diabetesf. ECG – bradycardia, arryhtmia, hypokalaemia (long QT)g. CXR – TB or staphh. DEXA or Bone Densitometry (if >12 months amenorrhea)

3. Annual Bone Density4. Monitor phosphate during refeeding: hypophosphataemia can present as

delirium, cardiac failure – can be precipitated by IV dextrose)dDX:

- Normal weight loss (anorexia has pervasive concern and uncompromising attitudes)

- Major depressive disorder- OCD- Physical Disorder: thyrotoxicosis, Ulcerative colitis, malignancy, infection- Schizophrenia

General Management:1. Psychoeducation – multidisciplinary appraoch

a. Patient and Carersb. Acknowledge ambivalencec. Provide information and access to support groupsd. Restore nutritione. Involve Dietician

2. Psychotherapy (often long term)a. Family therapy (effective for adolescents): non-blaming techniqueb. Behavioural techniques – reward weight gainc. Cognitive therapy – challenge anorexic attitudes, identify role of AN

3. Biologicala. SSRI for co-morbid depression

Admission to Hospital/Psych Referral Specialist Eating Disorder Unit- BMI < 16- Rapid weight loss (4-5kg/week or 1kg/week over many weeks)- Abnormal investigation results: ECG, LFTs, FBEs- Severe dehydration and BP <90- Severe bradycardia and faintness- Suicidal risk- Extreme Diuretic/Laxative use- Failed to improve as outpatient- Extreme social isolation/family situation- Marked co-morbiditiy

NB/ Refer to paedatrician if prepubescent

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Prognosis:- Usualy duration of illness ≈ 7 years- Those treated early may recover

o 40% make good 5 yr recovero 40% have residual minor sxo 20% have major ongoing illness

- Residual morbidity is commono Stunted growth, infertilityo Osteoporosiso Dental erosiono Memory and learning deficitso Proximal myopathys

1. Good prognostic factors:a. Absence of severe emaciation (BIM>17.5)b. Absence of medical complicationsc. Desire to changed. Supportive family/friends

2. Poor Prognostic factorsa. Longer duration of illnessb. Older age of onsetc. Disturbed family relationshipsd. Co-morbid psychiatric conditions

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PSYCHIATRY REVISION

Bulimia NervosaDefinition:Epidemiology:

- 1-3% of women < 45- Young women- Onset late teens-early adult- More common in western world

Aetiology:1. Cognitive Behavioural View

a. Low self-esteem .b Over-concern about shape and weight .c Extreme Dieting .d Binge Eating

e. Compensatory purging/over-exercising/fastingRisk Factors:

- History of Obesity- History of parental problems- Restricting dietary intake- Perfectionism- Mood disorder- Sexual/physical abuse- Early menarche- Parental abuse

Symptoms:Cognitive Behavioural- Depressed mood after binge- Self-depricating thoughts after binge- Realisation that eating pattern abnormal- Sense of shame/lack of control

- Consumption of High calorie/easily consumed foods during binges.- Inconspicuous eating (concealed from family)- Self-induced vomiting/abdo pain / social interruption/sleep following binge- Repeated attempts to lose weight (restricted diets, vomiting, laxatives, exercise)

DSM IV:1. Recurrent episodes of binge eating

a. Eating an amount of food significantly larger than what other people would eat in a similar time in similar circumstances.

b. A sense of loss of control/shame about bingeing 2. Inappropriate or excessive compensatory behaviours to prevent weight gain3. Binging and compensatory behaviours occurs 2x week for 3 months4. Self evaluation is unduly influenced by body shape/weight

Classify Type:a. Purging : Has regularly engaged in self-induced vomiting or misuse of

laxatives, diuretics or enemasb. Non-Purging : Has used other compensatory behaviours (ie. fasting or

excessive exercise) but has Not regularly engaged in self-induced vomiting or misuse of laxatives, diuretics or enemas

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PSYCHIATRY REVISION

Assessment:1. Physical

- Hair loss, acne, dry skin- Dental erosion, decay- Mouth ulcers, swollen parotids- Bloodshot eyes

Management:1. Psychoeducation2. Psychotherapy

a. **CBT – monitoring of weight/shape concernsb. Dietary counselingc. Interpersonal psychotherapy

3. Biologicala. SSRI for comorbid depression

4. Admission to hospital if:a. Well designed Outpatient treatment has failedb. Suicidalc. Antidepressants are needed but cannot have safe monitoring without

admissionPrognosis:- 52% make good recover (10 years)- 9% have ongoing bulimia

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PERSONALITY DISORDERS

Borderline Personality DisorderDefinition:

8. A pervasive pattern of instability of affect, self-image and interpersonal relationships which leads to marked occupational and psychosocial impairment.

Epidemiology:9. 10% of adult population have a personality disorder of some kind10. Rises to 30% of inpatients presenting with depression ,anxiety, substance

abuse.11. Equal male:female12. Borderline patients found in 1% of population13. Rises to 10% amongst psychiatric outpatients and 1/5 inpatients

Aetiology:14. Combination of genetics and environment

Risk Factors:15. Profound developmental trauma16. Childhood sexual abuse17. Childhood neglect18. Parenting alternating between extremely intrusive and extremely neglectful

Symptoms: “PRAISED”1. Paranoid ideas2. Relationship instability3. Affect instability, Aggression, Attachment issues4. Impulsivity, Identity disturbance5. Suicidal ideation/Self harm6. Emptiness7. Dissociative phenomena – depersonalisation

DSM IV:Assessment:

19. Transference: patients thoughts/feelings and fantasise (positive and negative) towards the therapist reflects unconscious relationships with past significant others.

20. Counter-transference is the therapist response to transferenceManagement:

1. Acute management:- Medical management of self injury/overdose- Treatment of drug/alcohol intoxication and withdrawal- ? Psychotropic for acute psychiatric states- Assess suicide risk/ risk to others

2. Long term- Long Term, Individual Psychotherapy

a. Supportiveb. Psychodynamicc. Interpersonald. Cognitive Behavioural Therapye. Integrated: Cognitive Analytic Therapy

- ± Marital, family and group therapies if indicated

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3. Biological- Benzodiazepine: short term to curb anxiety- Antipsychotics: low doses may be used initially to curb aggression - Mood Stabilisers: may be indicated long term to help curb impulsivity and

suicidality (if the patient can co-operate) -

Prognosis:- Some will improve by middle age, but have often aliented

spouses/family/friends by this stage- High risk of suicide, especially borderline patients (10%)- Psychotherapies and medications can improve prognosis.

Obsessive-Compulsive Disorder

Definition:Epidemiology:Aetiology:Risk Factors:Symptoms:DSM IV:Assessment:Management:Prognosis:

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ORGANIC BRAIN DISORDERS

DementiaDefinition:

21. Development of multiple cognitive deficits manifested as changes in Memory, Intellectual functioning, Behaviour and Personality.

Epidemiology:22. 1% of population23. More common after age 60 (prevalence doubles every 5 years of age)

Aetiology:1) Alzheimer’s disease………………… 50-60%2) Cerebrovascular disease…………….. 10-15%3) Dementia with Lewy Bodies………... 10-15%4) Mixed Alzheimer’s and CVD………. 10-15%5) Other…………………………………

a. Fronto-temporal dementiab. Alcohol related brain damage

5-10%

Mnemonic: “DEMENTIA”- Degenerative

o Alzheimers (most common)o Parkinsonso Huntingtonso Picks diseaseo Lewey Body Disease

- Emotional- Metabolic (hypoglyc,TSH,electrolyte)/Nutritional (vit b12,folate,niacin)- Ear/Eye impairment- Normal Pressure Hydrocephalus (gait apraxiaincontinencedementia)- Tumour (1o/2o)/Trauma (SDH)/Toxic (EtOH)- Infection (HIV/TB/CJD/Syphillis)- Atherosclerotic/Vascular (Stepwise dementia)

Risk Factors:24. Alzheimer’s: family HX25. Vascular: stroke, HTN, smoking, DM, AF26. Other: alcohol abuse

Symptoms:Behavioural and Psychological Symptoms of Dementia (BPSD)

27. Mood change28. Delusions29. Misidentification of familiar place/people30. Hallucinations31. Personality change32. Excessive motor behaviour33. Noisiness34. Resistance to care35. Aggression36. Sexual disinhibition

Signs37. Poor hygiene38. Poor diet39. Unsafe use of appliances40. Failure to pay bills41. Tendency to get lost42. Repetitive questioning

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PSYCHIATRY REVISION

DSM IV:1) Memory impairment + ≥1:

a. Aphasia Language disturbanceb. Apraxia Impaired ability to carry out motor activities despite

intact motor functionc. Agnosia Impaired ability to recognize/identify objects despite

intact sensory functiond. Executive Function Impaired functions of planning, organizing,

sequencing, abstract thinking2) Gradual decline and continuous decline3) Significant impairment in social or occupational functioning4) Significant decline from a previous level of functioning

Assessment:1. History

a. Ascertain nature/extent of cognitive deficitb. Determine impact on functionc. Corroborative history is important: duration, onset, progression, help,

mood, psychotic sx, challenging behaviours.d. Determine time course and Establish causee. Diagnose comorbid conditions such as delirium and depressionf. Check adequacy of familial and social support

2. MSEGeneral Appearance Person living alone may look neglected, malnourished

Person living with carers may look groomed/nourishedRapport Person may be able to conceal cognitive impairment for

some time, as GP meeting are often predictable after many years.Demands that exceed patient’s capacity may lead to extreme emotional/physical disturbance = catastrophic reaction.

Behaviour Mild-mod dementia: alert, attending.If complicated by delirium, gauge arousal and attention: (hyperaroused or drowsy, easily distracted)

Mood/Affect 20% have comorbid depression: look for social withdrawal, teary, agitated, noisy, insomnia, anorexia.May often look anxious/weary when asked about feelingsAgitation worse in late afternoon (‘sundowning’)

Speech and Language Word finding ability profound aphasiaThought

- Stream/Form- Content

Simple in content, rambling and repetitiveMay be accompanied by delusions – spouse in imposter, people stealing from you when something is misplaced…

Perception May have hallucinations – visual most commonly, of children and animals.More bizarre, florid delusions may indicate delirium

Cognition Disorientation to time is common.People often blame lack of knowledge of day, week, time on retirement, poor vision, social isolation etc. But time should remain intact in cognitively capable people.Important to do MMSE

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Insight and Judgement Often lost early so patient believes they are coping well.Limitations of MMSE:

- Screening test- Provides baseline for reference, not diagnostic without additional info- Need to be interpreted in the light of other material obtained- Low scores may be due to: poor vision/hearing, depression, lack of co-

operation, English fluency, limited education.- Test does not assess frontal lobe function: insensitive for persons of above

average intelligence with early dementia.

3. Ddx- Subdural haematoma- Cerebral tumour- Normal pressure hydrocephalus

4. Investigations Exclude complicating factors

i. Anaemiaii. Diabetesiii. Hypothyroidiv. Vit B12 deficiencyv. Drug toxicity

a. FBEb. ESRc. Glucosed. U+Ee. TFTsf. Urine microscopy + cultureg. Other: LFTs, folate, syphilis, HIVh. Imaging: CT (high yield)

Management:1. Acute:

i. Establish diagnosisii. Exclude treatable causesiii. Excluding Depression/Delirum as contributing to confusion

2. Long termi. Ensure optimal physical healthii. Continual assessment of ADLsiii. Education and support for carersiv. Involvement in decisicons regarding care – wills, advanced

directives 3. Biological

i. Cholinesterase inhibitors (donepezil) – short term improvement, 6-12 months delay in decline.

ii. Antidepressants – SSRI for comorbid depressionLess used:

iii. Benzos – short/medium term to relieve daytime anxiety (risk falls)

iv. Antipsychotics – limited role, reduced anxiety, agitation, psychotic sx. (S/E parkinsonism, falls, tardive dyskinesia)

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v. Mood stabilizers – reduce agitation/aggressionNb/ All psychotropic drugs can induce delirium. Also, digoxin, GCS,anticonvulsants

4. Sociali. Home helpii. Meals on wheelsiii. Day careiv. Respitev. Dosette boxesvi. Nursing help –bathing etcvii. Carer support – distress, isolation, anxiety, ill health, financialviii. Admission to residential facilities

Prognosis:- No cure as yet

Duration ≈ 10 years Alzheimers, 6years DLB

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Delerium

Definition:43. Transient global cognitive impairment of presumed organic aetiology.44. A disturbance in consciousness and a change in cognition that develop over a

short time.Epidemiology:

45. 1% prevalence in general population46. Higher in hospitals: 5-15%47. Common in children or elderly

Aetiology:

Risk Factors:48. Coexisting dementia (40% demented patients are delirious on admission)49. Depression50. Acute psychological stress51. Sleep/sensory deprivation52. Bereavement53. Brain damage54. Substance abuse55. Drug/alcohol dependence56. Hearing/visual impairement

Symptoms:1. Clouding of Consciousness: ↓ Alertness, Awareness, Attention, Arousal

a. Sleep-wake cycle reversal: somnolent during day, agitated at night.b. Psychomotor activity: range from apathy restless. Picking at bed

clothes.2. Cognition

a.DSM IV:

1. A disturbance in consciousness – impaired ability to focus, shift or sustain attention

Reduced clarity in awareness of environment

2. A change in cognition or disturbance in perception not better accounted for by evolving/existing dementia

Memory deficit, disorientation, language disturbance

3. Occurs over a short period and tends to fluctuate through the day

Hours – three Days

4. Evidence (history/phys/Ix) than disturbance is caused by direct physiological consequence of GMC

General Medical ConditionSymptoms during substance intoxicationDevelop only after withdrawalMore than one aetiology

Assessment:Management:Prognosis:

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