Transcript Psychiatry

Psychiatry
Dr N Fernando
2nd May 2006
Content
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Psychiatric history
Mental state examination
Assess suicide risk
Multi-Disciplinary Team (MDT)
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Community Psychiatric Nurse (CPN)
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Psychiatric Social Workers
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Occupational Therapists (OT)
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Impact of mental illness on relatives
Schizophrenia
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Affective disorders )
Anxiety
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Clinical features
Dementia
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Delerium
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their management
Eating Disorders )
Alcohol Misuse
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Understand
their roles
Psychiatric History
• A story……Chronological……detailed
• From before birth
– Family history
• ….through birth & early adulthood
– Personal, Educational, Psychosexual, Work history
• ….through life difficulties
– Substance misuse, forensic
• ….status before the current episode
– PMH, PSH, PPH, pre-morbid personality
– Medications, allergies, social circumstances
• ….to the current presentation
– PC & HPC
Psychiatric History
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PC/HPC
PMH/PSH/PPH
MEDS/ALLERGIES
Personal History
– Early
– Schooling & Academic achievements
– Sexual history & preferences/ Work history
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Substance use incl. alcohol, caffeine, nicotine
Forensic history
Family History
Current social circumstances
Pre-morbid personality
Mental State Examination
• Appearance & Behaviour
• Speech
• Mood (s) & (o)
• Thoughts
– Disorders of form, content, flow
– Deliberate self harm/suicidality
• Perceptions
• Cognition
– Conscious level
Memory - STM,LTM
• Insight
Orientation
Abstract thinking
A&C
Model for Aetiology
Biological
Predisposing
Precipitating
Perpetuating
Psychological
Social
Model for Aetiology
Biological
Predisposing
Precipitating
Perpetuating
Psychological
Social
Genetic Loading
Gender
Brain Injury/LD
Physical Illness
Substance Misuse
Previous Psychiatric Hx
Personality factors
Parental modelling
Cognitive factors – low
IQ, Beck’s triad,
cognitive distortions,
locus of control
High EE
Parental discord
Poor socio-economic
factors
Isolation
Debts
Non-compliance
Substance misuse
Physical illness/trauma
Iatrogenic – drugs
Hormonal – Menopause
Psychiatric illness
Poor insight
Assault/conflict
Loss of loved object
Single word/comment
Significant life events
Isolation
Lack of support
Increasing stressors
Change of environment
Brain Injury
Non-compliance
Substance misuse
Physical illness
Genetic loading
Personality factors
Cognitive factors
Poor insight
Anxiety
Reduced motivation
Isolation
Poor socio-economic
factors
High EE
Family discord
Model for managing treatment
Risk Assessment
Investigations
Immediate
& Short
term
Will inform initial management
Physical examination / Bloods / Radiology / EEG
Urine toxicology, analysis, microscopy, c & s
Collateral information
Disposal +/- MHA
Home / community team f/up / OPC / IP with risk assessment & observation
level +/- MHA use
Initiate treatment
Social
Remove from environment
Daily protocol
Limit setting
Obs., assess behaviour
R/v Diagnosis
Psychological
Reassurance
Therapeutic alliance
Psycho-education
Physical
Drugs & ECT
Surgery
OT
Physio/Speech Ther.
With additional investigations if required
R/v Risk
With reference to MHA status
Medium
term
Optimise
treatment
Social
Reduce stressors
- Relationship (RELATE)
- Financial (debt counselling,
benefits)
- Housing (future placement)
Long term
Follow-up
Regular review of treatment within CPA (Care Programme Approach)
Psychological
Therapeutic alliance
Psycho-education incl.
relapse prevention
(relapse work)
Counselling
CBT/Psychotherapy
Family/IP/Group th’py
Physical
Increase/change drug
Augment
ECT
Rating scales
OT/Physio/Speech
therapy
Model for managing treatment
Summary
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Talk, negotiate, dialog (therapeutic alliance, psychoeducation)
Informal  formal (?MHA use)
Period of observation (best before initiating treatment)
Medication – if required
– Least toxic, least dose, shortest length (as possible)
• Talking therapies
– Counselling, CBT, psychotherapy, IP therapy, Group
• Follow up
– Review, optimise therapy
– Aftercare - CPA (Care Programme Approach)
– maintain therapeutic alliance, psychoeducation
Prognostic factors
Good
Immediate
Longer term
Poor
•Acute Onset
•Family support
•Rapid de-escalation of
symptoms/signs
•Older age group generally
•Poor insight
•Physical illness
•Poor response to past/present tx
•Substance misuse
•Good response to treatment
•Good insight & engagement
with services
•Effective psycho-education
•Younger age group generally
•Poor insight
•Ongoing substance use
•Disengagement with services
•Chronic psychiatric illnesses
•Physical illness
Multi-Disciplinary Team work (MDT)
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Basis of psychiatric diagnosis, treatment and management
Consensual decisions (most times)
Good communication skills
Important to include patient & carer in decisions
All professional have stake in patient care
– Doctors, ward staff, OT, psychologists, pharmacists,
community staff, any other therapists working with patient
– Their concerns and views to be considered & documented
• Final decision – ALL to be in agreement (if possible) thereby
sharing risk and responsibility
• Care plan – jointly appraised, agreed and maintained
• Medical staff have overall responsibility (RMO status)
– This is currently under review by DHS
Community Psychiatric Nurses (CPN)
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Work within community teams
‘Key-worker’ to coordinate care & liaise with RMO/wards,etc
Have experience of dealing with mental illness
Have good communication & organisation skills
Ideally have psycho-social skills
Work with challenging patients & their families including
psychoeducation
Have a good understanding of relapse signatures, particular
stressors and behaviour patterns of their clients
Understanding of other services that may benefit patient &
refer appropriately
Have confidence in managing & advising reg. medications
Give depot medications
Psychiatric Social Workers
• Experience in social work
• Emphasis on mental health issues & impact on social
services
• Appropriate use of services & benefits
• Social history of patient
• ASW work – Approved Social Worker (Section 12 approved)
– Coordinating mental health act assessments
– Makes application for detention under MHA 1983
– Aware of social circumstances that may impact on presentation
in community at time of MH assessment
– Be aware of next of kin & their views
– At MHA no other disposal apart from hospital admission
– Be aware of changes in mental health law
– Furnish reports to tribunals – patients under MHA 1983
Occupational Therapists (OT)
• Work within hospital or community
• Have a wide range of OT background skills
• Good communication & psycho-social skills to work with
highly challenging group of patients
• Understanding of mental health & impact on daily
functioning
• Understand medications and its similar impact
• Assess patient’s level of activity and living skills
– ADL assessment – Activities of Daily Living
– Compare with patients needs/desires and abilities
• Set up graduated activities to improve patient’s level of
functioning in a manageable and sustainable programme
• Advocate for patient if required (reg. their functioning)
Impact of mental health on relatives
• Can be significant & prolonged
• Stressful;
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Concerns that they or their children may be affected
Dealing with someone not in touch with reality – constantly
Dealing with someone constantly breaching limits
Dealing with someone becoming ill & feeling unable to help
Dealing with disorganisation & aggression
Dealing with services not able to respond fast enough
Dealing with poor insight from affected relative & meds need
• Concern for relative
– Can be excessive  High expressed emotion (EE)
• Increase risk of physical illness & mental illness
– Stress related & depression (Carer assessment useful)
Delusions – Definition
• Belief which is firmly held despite evidence to
the contrary which is out with their religious,
social and cultural experience
• Different from ‘overvalued idea’
• Many themes
– Paranoid, Persecutory, Grandiose, Delusions of
reference, Guilt or worthlessness, Hypochondriachal,
Religious, Sexual, etc…
Hallucinations - Definition
• Perception in the absence of stimuli
• Can be normal experience –
hypnogogic/hymnopompic
• Based on different senses
– Auditory (2nd, 3rd person, running commentary, thought
echo)
– Visual (commonly underlying organic condition)
– Gustatory
– Olfactory
– Somatic (tactile & deep)
Schizophrenia
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Fundamental & characteristic distortions of thinking & perception
Inappropriate or blunted affect
Delusions (secondary) & Perplexity common
Onset Acute or gradual
M=F - Later onset in women
Genetic component
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1 parent affected
Both parents
1 sibling affected
MZ twins
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13%
46%
10%
48%
risk in kids
risk in kids
in other siblings
concordance
• Life events & expressed emotions associated with relapses
• CT changes – predate illness
– Smaller temporal lobes by 15-20% & Enlarged ventricles
– PET scans  functional disturbances in frontal & temporal structures
• Cognitive changes – late feature generally
Schizophrenia
First rank symptoms
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3rd person auditory hallucinations
Running commentary
Thought echo
Made feelings
Made impulses
Made actions
Thought insertion
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Thought withdrawal
) Thought
Thought broadcasting ) Alienation
Somatic passivity
Delusional perception
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Passivity
Phenomena
Schizophrenia
Definition: ICD 10 criteria
– At least 1 month duration of symptoms
– 1 clear CORE symptom or >= 2 if less clear
or >=2 from Secondary group
CORE group -
Thought echo, alienation
Delusions of passivity, Delusional perception
3rd person, running commentary
persistent delusions
Secondary group - Persistent hallucinations – any modality
Thought block/neologisms
Catatonic behaviour/ Negative symptoms
Significant & Consistent change in overall quality
Schizophrenia - Types
• Paranoid
– Commonest, hallucinations +/- delusions prominent
• Hebephrenic
– starts bet 15-25yrs, poor prog.
– Affective changes, irresponsible, inappropriate behaviour
• Catatonic
– Prominent psychomotor disturbance, rarely seen in west
• Post Schizophrenic depression
– Negative symptoms prominent usually, ^risk of suicide
• Residual Schizophrenia
– At least one previous psychotic episode
– Period of 1 year, where +ve  -ve symptoms
• Simple Schizophrenia
– Uncommon, insiduous and progressive
– No previous psychotic episode, vagrancy may occur
Schizophrenia
Negative symptoms
6 A’s
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Attention reduced
Avolition
Anhedonia
Affective blunting
Apathy
Alogia
Schizophrenia - management
Risk Assessment
Investigations
Immediate
& Short
term
Long term
Physical examination / Bloods
Urine toxicology
Collateral information
Disposal +/- MHA
Home / community team f/up / OPC / IP with risk assessment & observation
level +/- MHA use
Initiate treatment
Social
Remove from environment
Daily protocol
Limit setting
Obs., assess behaviour
R/v Diagnosis
Medium
term
Risk to themselves, others, or risk of further deterioration of mental health
Physical
Antipsychotic
medications
Anxiolytics
Sleeping tablets
With additional investigations if required
R/v Risk
With reference to MHA status
Optimise
treatment
Social
Reduce stressors
- Relationship (RELATE)
- Financial (debt counselling,
benefits)
- Housing (future placement)
Follow-up
Psychological
Reassurance
Therapeutic alliance
Psycho-education
Psychological
Therapeutic alliance
Psycho-education incl.
relapse prevention
(relapse work)
Counselling
CBT
Refer CMHT if approp.
Physical
Increase/change drug
Augment
OT
Regular review of treatment within CPA (Care Programme Approach)
Schizophrenia - Management
Summary
Therapeutic alliance
MHA use if appropriate
MDT decisions
Reduce stressors
Support – psychological, psychoeducation, reduce EE
Drugs:
Antipsychotics
Anxiolytics
Antidepressants
Hypnotics (to aid sleep)
Schizophrenia - Antipsychotics
Summary
Therapeutic alliance
Most appropriate choice – clinical basis
Atypicals 1st line in new cases (NICE)
- Start low and increase as tolerated
- Raise dose to therapeutic level
- If no response in 4-6 weeks, consider change, seek help
- Watch for side-effects
Side-effects;
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Drowsiness, wt gain
reduced blood pressure
EPSE
Sexual dysfunction
Non-compliance
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Reduce dose, another
drug to counter effects,
change to another
- Consider depot medication
Treatment resistant (inadequate response to two a/p)
- Clozaril (regular FBC, co-ordinated via CPMS – Clozaril Patient Monitoring
Service)
Affective Disorders
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Depression
Bipolar Affective Disorder (BPAD)
Hypomania
Mania
Persistent Mood Disorders
– Cyclothymia
– Dysthymia
Depression
• Definition: ICD – 10 requirements
– 2/52 duration of symptoms
– 3 Core symptoms – Mood, Anhedonia, Anergia
– 7 additional Sx.
• A&C
• DSH acts
worthlessness
hopelessness
appetite
sleep
self esteem
• Mild (at least 2 core + 2 other)
– Distressed but able to function with ordinary work
• Moderate (at least 2 core + 3 other)
– Will have considerable difficulty c/t with work
• Severe (All 3 core + 4 other or more)
– Suicide a distinct risk & unlikely to continue with work
– Need to look for psychotic symptoms
Depression - Management
Risk Assessment
Investigations
Immediate
& Short
term
Risk to themselves, others, or risk of further deterioration of mental health
Physical examination / Bloods +/- Radiology
Urine toxicology, C&S
Collateral information
Disposal +/- MHA
Home / community team f/up / OPC / IP with risk assessment & observation
level +/- MHA use
Initiate treatment
Social
Remove from environment
Daily protocol
Observe Mental state
R/v Diagnosis
Psychological
Reassurance
Therapeutic alliance
Psycho-education
Physical
Antidepressant
Anxiolytic
Night sedation
With additional investigations if required
R/v Risk
With reference to MHA status
Medium
term
Optimise
treatment
Social
Reduce stressors
- Relationship (RELATE)
- Financial (debt counselling,
benefits)
- Housing (future placement)
Long term
Follow-up
Regular review of treatment within CPA (Care Programme Approach)
Psychological
Therapeutic alliance
Psycho-education incl.
relapse prevention
(relapse work)
Counselling
CBT/psychotherapy
Refer CMHT if required
Physical
Increase/change drug
Augment
ECT
Occupational therapist
Depression – Use of Antidepressants
• Discuss choice of drug with the patient
– Therapeutic effects, adverse effects, discontinuation effects
• Start ANTIDEPRESSANTS
– Titrate to recognised therapeutic dose
– Assess efficacy over 4-6 weeks
– Continue for 4-6 months at full treatment dose
• Consider long-term treatment in recurrent depression
• If no effect
– Increase dose (to maximum dose if tolerated) & assess over 2/52
– Try another antidepressant from another class
• Titrate as above
– Little improvement  Treatments for refractory depression
Bipolar Affective Disorder (BPAD)
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>=2 episodes of mood/activity changes
Recovery complete between episodes
M=F
Usually abrupt onset of mania
Manic episode – last median of 4 months
Depressive episode – last median of 6 months
Often follow stressful life events
First episode  occur at any age (Most freq bet 20-29 years)
Increasing age  Increased frequency & length of episodes
1-2% of population at some point in their lives
Genetic predisposition
– BPAD  11% risk of Depression (UP) in 1st degree relatives
– BPAD  8% risk of BPAD in 1st degree relatives
• Morbidity & mortality is HIGH  suicide/accidental
deaths/concurrent illnesses
Bipolar Affective Disorder (BPAD)
Features
Elated mood
Grandiose ideas & inflated self esteem
Increased energy & activity
Flight of ideas
Pressure of speech
Increased libido
impaired judgement & impulsive behaviour
Reduced need for sleep
Increased creativity
Impaired attention & concentration
Psychotic symptoms
Bipolar Affective Disorder (BPAD)
Diagnosis
>=2 episodes
At least one should be mania
Manic episode >= 1/52
Depression
>= 2/52
Rapid cycling = 4 or more episodes / year
Severity
Hypomania  Mania  Mania with psychotic features
Bipolar Affective Disorder (BPAD)
Hypomania
- Increased mood & activity for at least a few days
- interfere with work/social activity
Mania
- Increased mood & activity for at least a week
- Disrupt work/social activity
Mania with psychotic features
- As above with psychotic features
- most severe form
Bipolar Affective Disorder (BPAD)
MANAGEMENT
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Same as for depression & table
Important to gain therapeutic alliance
Consider admission +/- use of MHA
Assess RISKS carefully and address to reduce impact
Commence drug treatment if appropriate
- Sedation/mood stabilisation (Lithium)/Antipsychotic
- Antidepressant (watch for rebound mania)
- ECT
Talking therapy
- CBT based
- Psychoeducation including Relapse signature work
Social work involvement
- reduce stressors – finances/housing, etc
Follow-up review (CMHT & key-worker allocation)
Optimise social skills
- employment, self esteem, ADLs, etc..
Persistent Mood Disorders
Cyclothymia
Persistent instability of mood
Onset in early life (teens)
Chronic course
Not severe to fulfill BPAD (Episodes <1/52 mania, <2/52 depres.)
Dysthymia
Chronic lowness of mood, prolonged periods of time
usually able to cope with ADLs & demands
Begins in early adulthood
Last for several years
Can be associated with bereavement
Anxiety Disorders
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Agoraphobia
Social phobia
Specific phobia
Panic Disorder
GAD
OCD
PTSD
Agoraphobia
Features
- Most incapacitating of phobic disorders
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F:M = 3:1
Onset early in adult life (15-35 yrs)
Autonomic/psychological symptoms  secondary to anxiety
terrified of collapse/left helpless in public
Anxiety generally restricted to; crowds/public places/travelling
alone/travelling away from home.
- Avoidance of phobic situation is prominent, can become housebound
- presence of other disorders  depression, obsessional symptoms, panic
Management
- Ongoing assessment
- Psychoeducation
- CBT – Work with cognitions (homework), Graded exposure with relaxation
- Graded activity
- Drugs: SSRIs
Social Phobia
Features
- 8% of all phobias
- Centred around FEAR OF SCRUTINY by others
- Lead to avoidance of social situation
- Fear of vomiting in public
-M=F
- Associated with low self-esteem & fear of criticism
- May present with blushing/hand tremor/nausea/urgency
- Diagnosis:
- Anxiety  cause of symptoms & restricted to certain situations
- Avoidance of phobic situation
Management
- Ongoing assessment
- Psychoeducation
- CBT – Work with cognitions (homework), Graded exposure with
relaxation
- Drugs: SSRIs
Specific phobias
Features
- restricted to highly specific situations
- persistent irrational fear of object
- contact with this  immediate anxiety response
- Avoidance of object
- Fear/avoidance/distress  interfere with individual’s life
- Fear is recognised as being irrational/excessive
- start in childhood/early adulthood
Management
- Ongoing assessment
- Psychoeducation
- CBT – Graded exposure with relaxation
- Drugs: SSRIs
Panic Disorder
Features
- Recurrent anxiety attacks, can be severe (panic)
- Unpredictable & sudden onset
- Almost always due to fear of dying/losing control/going mad
- Attacks last for minutes only
- 20% adults  at least once in life;
2% in 1 yr  freq to get P.D. diagnosis
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- Onset mid 20’s, 1 panic attack in late teens
- Panic attack: Increase fear  autonomic symptoms  hurried exit
If this occurs in a situation  avoid situation
- Diagnosis:
- Panic attacks not in background of another disorder
- Several severe autonomic attacks in last 1/12
- No objective danger, not only in specific circumstances, relatively
free from anxiety between attacks
Management
- Ongoing assessment
- Psychoeducation
- CBT – Recognise early warning signs, Relaxation, challenge avoidance
- Hyperventillation  can induce panic in vitro (useful in training)
- (SSRIs)
Generalised Anxiety Disorder (GAD)
Features
- Essential feature is anxiety, which is generalised, persistent and not
restricted to any situation (‘free floating’)
- +/- somatic symptoms
- F > M, Variable course
- Often related to chronic environmental stress
- Diagnosis:
- Primary symptom of anxiety (most days, for weeks/months)
- To include apprehension, motor tension, autonomic overactivity
Management
- Ongoing assessment
- Psychoeducation (Avoid caffeine)
- CBT: Relaxation, Graded activity, assertiveness training
- Drugs: Amitriptyline, Venlafaxine, Buspirone, Clonidine
Benzodiazepines – NOT advocated, can be used for short course
- Yoga
Obsessive Compulsive Disorder (OCD)
Features
- Essential features  Obsessive thoughts +/- Compulsive acts
- Close relationship with depressive features
-F=M
- Prominent Anankastic features in personality
- Onset childhood/early adulthood
- Family history of OCD/Tourette Syndrome
- Underlying the act is FEAR (of dirt, etc…)  Ritual is way of reducing fear
- Diagnosis:
Obsessional thoughts +/- Compulsive acts  most days 2/52
Be distressing/interfere with activities
Obsessional symptoms – recognised as own, resisted unsuccessfully, NOT
pleasurable, repetitive (impulses & thoughts)
Compulsive acts – stereotyped behaviour, repeated, not enjoyable, no useful
task completed, attempts to resist, recognised as pointless, seen as preventing
an unlikely event (‘magical undoing’)
Management
- Ongoing assessment
- Psychoeducation, distraction techniques (thought stopping)
- CBT: Work with cognitions (homework), Exposure & response prevention
- Drugs: SSRIs (at higher dose)
Clomipramine (past, can still use)
BEST effects when combined with CBT
Post Traumatic Stress Disorder (PTSD)
Features
- Delayed/protracted response to stressful situations
- Excessive use of alcohol +/- drugs in majority
- Recovery expected in majority; Small number  chronic  personality change
- Diagnosis:
- Within 6/12 (usually)
Other Sx
- Traumatic, exceptional event
- Repetitive intrusive recollections, flashbacks OR
Re-enactment of events in memory/imagery/dreams (nightmares)
- Emotional numbing
- Autonomic symptoms – hyperarousal, hypervigilence (startle reaction),
insomnia
- Anxiety & depression – suicidal ideation
- ‘Cues’  Increase arousal  Avoidance of such cues
Management
- Ongoing assessment
- Psychoeducation
- CBT: Aim of tx.  Remove fear of situation/position
Vitro: Graded exposure (in imagery) & relaxation
Vivo: Systematic desensitisation with relaxation
- Drugs: SSRIs (at higher dose)
Dementia
Features
- SYNDROME due to disease of brain
- Chronic/progressive
- Disturbance of multiple higher cortical function
- Consciousness NOT clouded
- Impaired cognition
- Deterioration of emotional control/social behaviour/motivation
- Memory
- Affects registration, storage, retrieval of new information
- Previously learned material may not be affected
- Thinking
- Processing of information is affected, difficult to attend
more than one stimulus at a time
- Reduced reasoning capacity
- Reduced flow of ideas
- Diagnosis:
- Primary  Evidence of decline in both MEMORY and THINKING which
is enough to affect ADLs
- Clear consciousness
- For at least 6/12 (for confident diagnosis)
Dementia
Types
Alzheimer's
Vascular
Lewy Body
HIV
Parkinson’s
Pick’s
Huntington’s
Creutzfeldt-Jakob
Normal Pressure Hydrocephalus
Dementia – Alzheimer’s Disease
Features
- Primary degenerative brain disease
- Usually in later life, but can occur earlier
- Early onset  +ve FH, rapid course, prominent features of temporal and
parietal lobe dysfunction
- Down’s Syndrome  increased risk of AD
- May be associated with vascular dementia
- Memory problem is main feature
- 1% at 65y, 10% at 80y, 40% at 90y (Rule: doubling every 5 years)
- Pathology:
Marked reduction in population of neurones
Neurofibrillary tangles
Neuritic plaques
Granullovacuolar bodies
Marked reduction in enzyme choline acetyl-transferase
- Diagnosis:
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Presence of dementia (see previous slide for guide)
Insidious onset & slow deterioration
Absence of features of systemic & other brain disease
Absence of sudden onset
Dementia
Reversible causes of dementia
These need to be excluded
Hypothyroidism
Hypercalcaemia
Vitamin B12 deficiency
Niacin Deficiency (Folate)
Normal pressure hydrocephalus
Subdural haematoma
Syphilitic
Dementia - Management
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Refer Memory Clinic
Differentiate from delerium/depression/paranoid disorders
Look for treatable causes (previous slide)
Physical investigations
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Mini Mental State Examination MMSE (Memory Clinic)
Treatment;
Treatable causes
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Vascular Dementia – Reduce risk
Manage BP
Low dose aspirin (note bleeding potential)
Surgical treatment of carotid stenosis
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FBC/U&E/LFT/TFT/Gluc/VitB12&Folate/Syphilis serology/Ca&Phos/ESR
Urine analysis & culture
ECG & CXR
CT Brain
Behavioural changes – non-pharmacological
Drugs:
Antidepressants
Anxiolytics
Antipsychotics
Anti-cholinesterase Inhibitors (Memory Clinic)
Dementia - MMSE
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Yr, month, DoW, date, season
Place, Floor, city, county, country
3 Objects to remember
WORLD backwards, serial 7’s
Recall 3 objects
Pen, watch – identify
Repeat phrase ‘No ifs ands or buts’
3 stage command
Read & follow instruction
Write sentence (verb & noun)
Interlocking pentagons
Total
5
5
3
5
3
2
1
3
1
1
1
30
26-30 normal, 20-25 mild, 13-20 moderate, <12 severe
(These figures are guidelines only, correlate with clinical picture)
Acute Confusional State (Delerium)
Features
- Rapid onset
- Can be diurnally fluctuating
- Any age, most common > 60y
- Transient, fluctuating intensity
- most recover within 4/52
- BUT can last for 6/12 esp. with chronic liver disease, Carcinoma, SBE
- Diagnosis: Impairment of consciousness & attention
Global disturbance of cognition
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Impairment of recent memory & recall
Disorientation in time, severely of place & person
Perceptual distortions; illusions, hallucinations esp. visual
+/- transient delusions
Psychomotor disturbances – hypo or hyperactivity,
enhanced startle reaction
Disturbance of sleep-wake cycle
Emotional disturbance
Acute Confusional State (Delerium)
Management
Dialogue with family, carers, ward staff
Safety – consider admission
Nurse separately if possible, well lit, approach away from blind spots
Full Examination – in detail
Investigations
Common causes – infections, constipation, overmedication, TIAs
Look actively for physical basis
Bloods, ECG, Radiology if appropriate
Treat as found
Anorexia Nervosa
Features
- Deliberate weight loss – induced and sustained by patient
- Adolescent girls/young women (peak age 13-16yrs)
F >> M
- An independent syndrome (Inter-observer reliability, chronic form similar)
- Aetiology unclear – increasing evidence of socio-cultural, biological and vulnerable
personality. Less evidence of specific psychological
mechanisms
- Associated with under-nutrition  Secondary biological features
- Incidence 5:100,000 pa; Prevalence approx 1% of young females
- Diagnosis:
- Body wt maintained <=15% below expected or BMI <=17.5
- Wt loss is self induced – avoid fat, vomiting, purging, exercise,
appetite suppressants +/- diuretics
- Body image distortion
- Widespread endocrine disorder of H-P-Gonadal axis
- Amenorrhoea, Reduced sexual interest, Increased levels of GH &
cortisol, changes in peripheral metabolism of thyroid hormones,
abnormalities of insulin secretion
- Onset before puberty
- Pubertal changes can be delayed/arrested
-
Prognosis:
1/3rd
better in 3y, 1/3rd better in 3-6y, 1/3rd better in 6-12y
4% chronic
Mortality = 15%
Anorexia Nervosa
Management
Cornerstone of therapy is talking therapy
<18y  Family Therapy – to reduce EE, loosening of bonds (help with
failure of individuation)
>18y  Interpersonal Therapy
Self help and CBT does not work well
- BUT behavioural structure similar for managing Bulimia Nervosa
can be helpful if AN has improves
Treat any comorbid condition – i.e. depression
Bulimia Nervosa
Features
- Preoccupation with control of body weight  extreme measure to reduce
fattening effects of food
- Age and sex distribution similar to Anorexia Nervosa
- May be sequel to persistent AN
- Vomiting  electrolyte imbalance & physical problems (Tetany, etc..)
- Incidence 2-15/100,000; Prevalence of approx 1%
- Diagnosis: - Persistent preoccupation with eating and irresistable craving for
food – with strict dieting for ‘control’  Succumb to bingeing
- Counteract fattening effects – self induced vomiting, purgative
abuse, alternative periods of starving, drug use (suppressants,
thyroid prep., diuretics)
- Psychopathology – morbid dread of fatness
- Pt sets sharply defined wt threshold
- +/- earlier episode of AN
-Prognosis: - 50% improve
- 50% relapsing
Bulimia Nervosa
Management
Cornerstone is CBT
- ‘All or nothing thinking’
- Work to change this and other harmful cognitions  use of diary keeping
and homework setting (Survey of friends, Are fat people
unhappy/unsuccessful?, Are fat perople lonely?)
- Behaviour modification
- Food dairy
- Tight shopping list (Only what’s on it)
- Limiting food (in home)
- Set meal to set plan
- Leave a little at end of meal  throw to signify end of meal
- Self help books ‘Getting better bite by bite’
- Group therapy – for support
- Interpersonal therapy
-
50% improve
Self Harm - ‘DSH’
Definition:
- ‘a non-fatal act in which an individual deliberately causes self- injury or
ingests a substance in excess of any prescribed or generally recognised
dose’
Kreitman (1977)
Associations
-
FOUR times as many stressful events in last 6/12
Early parental loss, history of parental neglect/abuse, Childhood sexual abuse
Personality factors (poor i/p problem solving skills)
Hopelessness & impulsiveness
Long term probs in marriage, kids, work, health
Unemployment (esp. in men but also women now)
Poor physical health (esp. epilepsy)
- Psychiatric illness
- Depression (high rates: up to 90+ percent)
- Psychotic (between 5-15%)
- Alcohol & drug misuse
- About 50% had contact with NHS in the preceding week
Self Harm - ‘DSH’
After DSH episode; outcomes
1. Repeat DSH (15-25% in first 12 months)
Lots of Associated factors; Previous attempt, personality
disorder, alcohol and drug misuse, previous psychiatric tx, etc….
2. Risk of suicide (1-2% risk )
This is x 100 higher than in general population
10,000% increased risk than general population
At 8 years f/up
 3% have committed suicide
 This is TWICE the expected no. from natural
causes (unclear why)
IMPORTANT to assess at time of presentation to prevent repetition and
increased morbidity and mortality
Self Harm - ‘DSH’
-
Increasing since 1960s
Current rate of 3 per 1000 per year
180,000 cases per year (60m pop)
Higher rates in UK than other Western European countries
Most common in young people
Male:Female = 1:1 (Peak age for men is older)
High rates in
-
Divorced (men & women)
teenage wives
lower social classes
high unemployment
overcrowding
many children in care, etc…
Self Harm - Treatments
Studies have demonstrated that some treatments
may be of benefit
- Problem-solving therapy
- Emergency contact card (controversial)
- Behavioural therapy
Also delivery of well organized care has benefits of
- Recognition & treatment of major mental illness
- Recognition & help for personal & social difficulties
Risk assessment
Inform / predict / safety / legal / best practice
Mandatory & done by all (not recognised)
If done following incident
Look at factors - Before incident
- Incident
- After incident
If predicting  Can use rating scale (TAG Score)
Risk assessment - method
(Guidelines only….)
Before incident
•
•
•
•
•
•
•
Depressed? Suicidal thoughts? If so when, freq, last
What steps taken towards these plans? When? Where?
Did you act on it before? If so what was done and where?
(If not, what stopped you?)
Any pre-planning? Left any notes behind?
Use of any substances such as alcohol?
Harm to others? Elaborate…
Incident
• How were you found and by whom? How did you get to A&E?
• What did you do and how?
• What did you expect to happen?
After incident
•
•
•
•
What are your thoughts about the attempt?
How does talking about this make you feel?
Future plans, thoughts of further self harm? If so, intent?
What help would make it easier?
Alcohol History - Guidelines
•
•
How long – From what age? Years?
Daily consumption?
•
•
Other daily activities?
Presence of withdrawal symptoms?
•
•
•
Alcohol use – out of control?
Tolerance – need to drink more to have the same effect?
Medical complications? (esp. related to alcohol)
•
•
•
Past history of alcohol detox’s and contact with services
Patient’s attitude towards drinking
(Depressive symptoms & DSH/suicidality)
–
–
–
–
–
–
What time is first drink of day?
What do you drink and where?
How much do you drink and rate?
What time is last in day?
Any days without alcohol?
When did you start to drink daily?
– In morning or after abstinence?
– Craving for alcohol?
– What helps?
– Aware that alcohol is causing physical harm
Substance Misuse - Alcohol
Is this a problem?
- Alcohol misuse  drinking that causes mental,
physical or social harm to the individual
- CAGE questionnaire
- if >=2 positive then important to consider for
DEPENDENT and HARMFUL use of alcohol
and consider referral to ALCOHOL/DRUG
services
Substance Misuse - Alcohol
Dependent use (>= 3 in last year)
•
•
•
•
•
•
Craving
Uncontrolled drinking – difficulty controlling consumption
Physiological withdrawal state
Tolerance
Salience of drinking – loss of other interests
C/t drinking despite evidence of harmful consequences
Substance Misuse - Alcohol
Harmful use – criteria
• Clear evidence alcohol is causing harm
– Physical, psychological, Dysfunctional behaviour
• Nature of harm clearly identified
• Persistent use of alcohol
– At least 1 month or repeatedly over 1 year
Substance Misuse - Alcohol
Management
- Raise awareness of problem
- Increase motivation to change
- Withdraw alcohol (or controlled drinking)
- Support and advice
- CBT – social skills, relapse prevention
- Marital therapy
- Medication – disulfiram, acamprosate (reduce craving)
- Community Alcohol Team (CAT)
- Community detox – Community Teams
- Inpatient detox – Springfield, Wentworth
- Community follow-up
- Support services – Alcoholic Anonymous, CAT