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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5230_Библиотеки_им_академика_М_И_Перельмана.pdf
Table3.2 Abbreviated Mental Test (AMT) score (≥8 is normal foran
elderly patient)
Age Recognise two people (eg Dr, nurse)
Date of birth Year World War Two ended (945)
Current year Who is on the throne (Charles III)
Time (nearest hour) Recall address:‘42 West Street’
Name of hospital Count backwards from 20 to
Reproduced from Hodgkinson HM, ‘Evaluation of a mental test score for assessment of
mental impairment in the elderly’, Age and Ageing, 972, (4):233– 8, by permission of
Oxford University Press and the British Geriatric Society.
K Box 3.2 CAM:Confusion assessmentmethod
This validated aid5 to the recognition of delirium requires the presence ofboth:
• Acute onset + uctuating and Inattention (world backwards)
Both of the above must be present, plus either:
• Disorganized thinking or Altered level of consciousness.
Source:data from Wei LA. J Am Geriatr Soc 2008;56:823– 30.
383ACUTE CONFUSION
384 CHAPTER3 Psychiatry
Dementia
$ Progressive global cognitive impairment with normal consciousness
and impact on ADLs.
2Worrying features Rapid progression,<65yr.
Think about Common Alzheimer’s, Lewy body disease, frontotemporal
dementia (Pick’s), vascular dementia, Parkinson’s (late), normal pressure
hydrocephalus, depression (pseudodementia), chronic subdural haematoma, Korsako ’s syndrome; medications.
hypothyroid, vitamin B
Ask aboutAge of onset, progression, memory (short and long term), per-
sonality, thinking, planning, judgement, language, visuospatial skills, concentration, social behaviour, confusion, wandering, falls, head injury, tremor, mood,
sleep quality, delusions, hallucinations, hearing,sight. The collateral history will
be vital;
PMHSeizures, CVA/ TIA; DH Regular medications, sleeping tablets,
anticholinergics; opioids, sedatives;
SH Eect on work, relationships, and social abilities; independence with ac-
tivities of daily living (ADLs— food, cleaning, washing, dressing, toilet); ability
to manage nances; alcohol intake; try to build a picture of the domestic environment:Who is at home and what local support is available (Box3.3)?
ObsGCS, HR, BP, glucose.
Investigations 2Consider capacity. If lacking, Mental Capacity Act
principles should apply— ’best interests’ and ‘least restrictive’ options. E
p. 30;
blds FBC, ESR, U+E, LFT, Ca
HIV, VDRL/ TPHA; MMSE (Box 3.6; E p. 385), AMT score (E p. 383);
CLOX test (asking the patient to draw a clock); full systems exam with
careful neurological exam including general appearance, tremor, gait,
dysphasia, cog- wheeling;
identify dementia subtype (Boxes 3.4 and 3.5): CXR, CT/ MRI brain;
ECG; SPECT (if DLB suspected); FDG-PET (if diagnosis uncertain and
Alzheimer’s suspected);
Management Refer to a neurologist/ psychogeriatrician for specialist
diagnosis and management; use an MDT approach to ensure the patient
has appropriate accommodation and support with ADLs. Medical management may be initiated by the specialist.
6
deciency, malnutrition.
2
Imaging To rule out reversible causes and to
LP; EEG(rarelydone).
Rare HIV, CJD, syphilis, SOL,
FH Dementia, neurological problems;
2+
, TFT, vitamin B2, folate, consider
T Box 3.3 Support organizations
• Dementia UK (0800 888 6678 Mwww.dementiauk.org)
• Alzheimer’s Society (0333 50 3456 Mwww.alzheimers.org.uk)
for England, Wales, and Northern Ireland or Alzheimer’s Scotland
(0808 808 3000 Mwww.alzscot.org)
• Carers Direct (0300 23 053 Mwww.nhs.uk/ carersdirect) for
telephone and online support and advice forcarers
• Age UK (0800 678 602 Mwww.ageuk.org.uk) for a wide range of
advice and services in support of ageingpeople
6
NICE guidelines available at Mguidance.nice.org.uk/ NG97
K Box 3.4 Common types ofdementia
Alzheimer’sSlowly progressive loss of memory, with later loss of language,
executive or visuospatial functions; anticholinesterases (eg donepezil) in
mild–moderate disease ± memantine in moderate–severe disease.
VascularImpairment of memory and at least one other cognitive domain in
the presence of vascular risk factors ±neuroimaging evidence of ischaemia;
often co exists with Alzheimer’s.
Lewy body Core symptoms make diagnosis probable: () uctuating
attention/ concentration, (2)parkinsonian motor signs, (3)recurrent visual
hallucinations, (4)REM sleep problems (acting out dreams). Neuroleptic
sensitivity and SPECT scan support diagnosis (with one core feature).
Frontotemporal Prominent and early language loss ±loss of social func-
tioning/ disinhibition; may present in younger agegroup.
K Box 3.5 Some potentially reversible causes ofdementia
Subdural haematomaDementia ±focal neurology (eg limb weakness); more
common in elderly, atrophic brains; often history of trauma; characteristic
CT appearances; evacuate.
Normal pressure hydrocephalus Dementia, magnetic gait, and subtle per-
sonality changes are early signs and urinary incontinence with hydrocephalus on CT and normal CSF opening pressure; idiopathic (50%) or may
occur after meningitis, trauma, or subarachnoid haemorrhage; ventriculoperitoneal shunt may improve symptoms.
Korsako ’s syndrome
Amnesia and confabulation seen in thiamine deciency (eg alco-
holism); may show very slow and limited improvement with thiamine replacement.
Vitamin B2/folate deciency/ hypothyroidism/ hypocalcaemia Can all be cor-
rected and may result in improvement. Replace vitamin B
K Box 3.6 Mini- Mental State Examination (MMSE)
before folate.
2
7
Despite copyright problems, the MMSE7 remains widely available in most
hospitals and is a helpful screening test. The test consists of 30 questions
which together test various components of a patient ’s mentalstate:
• orientation (in time, place, and person)
• registration (ability to listen and recite, to obey commands)
• attention and arithmetic (counting backwards)
• recall (reciting a list of objects)
• language (naming objects, reciting an address,etc)
• executive function (copying a drawing).
The maximum score in the MMSE is 30, though ≥28 is regarded as ‘normal’.
Scores of 24– 27 are borderline and <24 suggests dementia. Results are unreliable if the patient is delirious, has a sensory impairment, aective disorder, or
has not been taught to read and write in English. An abbreviated (0- point) version is often used (E p. 383) and correlates well with MMSE for those with very
high or low scores; in the intermediate range and for tracking changes, MMSE
is a more reliable test. There are also numerous other, less widely used tests
of cognitive function.
7
Folstein MF, etal. J Psychiatr Res 975;2:89 (requires subscription).
8
Holsinger T, etal. JAMA 2007;297:239. Mjama.ama- assn.org/ cgi/ content/ full/ 297/ 2/ 239
9
Cullen B, etal. J Neurol Neurosurg Psychiatry 2007;78:790. Mhttps:// www.ncbi.nlm.nih.gov/ pmc/
articles/ PMC27747
8
In general these have been less well validated (if atall).
385DEMENTIA
9
386 CHAPTER3 Psychiatry
Mood disturbance/ psychosis
2Worrying features Delusions, hallucinations, suicidal intent.
Think about 2Emergency Acutely suicidal; Psychosis Schizophrenia,
depression, bipolar disorder, postpartum, substance abuse, alcoholism
or withdrawal;
order, personality disorder, eating disorder, seasonal aective disorder,
postpartum, grief, alcoholism or withdrawal, substanceabuse;
Bipolar disorder, cyclothymia, substanceabuse;
hyperthyroid, Cushing’s, Addison’s), neurological (CVA, dementia, MS,
Parkinson’s, head injury, brain tumour), infections (HIV, Lyme disease,
EBV syphilis), inammatory disease (eg rheumatoid, SLE), autoimmune
encephalitis, electrolyte imbalance (eg Na
(eg porphyria, Wilson’s), malnutrition, anaemia, paraneoplastic, recreational drugs, medications (E p. 387). See Table3.3.
Ask about(See psychiatric history Epp. 58–60.) MedicalBowel habit,
weight change, appetite, cold/ heat intolerance, tremor, previous head
trauma, changes in vision, headaches, unusual sensations, weakness, seizures, sleeping problems, sexually transmitted illnesses and risk, rashes,
jointpain;
lack of pleasure, appetite, recent stresses, mood, change in personality, suicidal ideation;
Forensic Previous criminal convictions, custodial sentences; PMH Previous
psychiatric problems or care, mania, suicide attempts, chronic illness;
DH Regular medications, alternative medicines; FH Psychiatric problems,
thyroid, liver, or brain problems, occupations;
family, friends, alcohol intake, smoking, illicit substanceabuse.
ObsGCS, temp, HR, BP, RR, glucose.
Look for (See mental state examination E pp. 58–60.) Medical Full
systems exam and careful neurological exam including tremor, eye reexes, papilloedema, tendon reexes;
signs of neglect or amboyancy, unusual posture or movements, aggression, aect, speech (form and content), thought (form and content
including delusions), perception including hallucinations, cognition (concentration, memory, orientation), risk (to self or others), insight.
Investigations It is important to consider organic causes of mental
disturbance;
folate, cortisol, HIV (E p. 494), EBV and Lyme disease serology, VDRL/
THPA; psychiatrists may consider tests for autoantibodies in atypical
presentations;
Management
• Is the patient manic, psychotic (delusions or hallucinations E p. 60),
or acutely suicidal? If so they need urgent psychiatric referral
• Could there be an organic cause for their symptoms?
• Is the patient already known to local community mental health team?
Contact the GP for information.
Low mood Depression, bipolar disorder, anxiety dis-
Organic Endocrine (hypo/
+
, Ca2+), metabolic problems
Psychiatric Early morning waking, concentration, energy levels,
Personal Childhood, education, employment, relationships;
SHWho do they live with,
Psychiatric General appearance,
blds Consider: FBC, U+E, LFT, Ca
Urine Toxicology screen; LP; EEG; CT/ MRIBrain.
2+
, TFT, ESR, ANA, B2,
High mood
Table3.3 Common causes ofmood disturbance and psychosis
Depression Low mood, tearful,
Bipolar
disorder
Schizophrenia Delusions, auditory
Anxiety Worry, sweating,
Personality
disorder
Dementia Problems with
Organic
cause
History Examination Investigations
loss of interests, sleep
disturbance
Mixture of low and
high mood events
hallucinations, apathy
dizziness, palpitations
Long-standing
diculties
memory, concentration,
cognition
Weight loss, seizures,
rapid onset, visual
hallucinations
Poor eye contact,
neglect, low mood
and aect, ±psychosis
Signs of high or low
mood, ±psychosis
Neglect, poverty of
speech/ thought
Fearful, tense, or
normal,
iHR, iRR
Evidence of selfharm, otherwise
usually normal
Neglect, poor
cognition with normal
consciousness
Neurological signs,
rashes, wasting
Usually normal
Usually normal
Usually normal
Usually normal
Usually normal
May have
abnormal CT/
MRI brain
Usually abnormal
Bipolar disorder
$ Recurrent episodes of high mood, usually interspersed with episodes
of lowmood.
High mood may be mania (impairs job or social life and may have psychotic features) or hypomania (no impairment to job or social life). DSM- 5 and ICD-
classify bipolar disorder as occurring after even a single episode of mania
though recurrent episodes with periods of depression are typical. Recurrent
swings between mild depression and hypomania are called ‘cyclothymia’.
Mania signs DIGFAST— Distractable, Indiscreet (amboyant, disinhibited),
Grandiose, Flights of idea, iActivity, dSleep, Talkative.
Investigations Review medications (steroids), infection screen. If rst
manic episode:
CThead; Urine toxicology.
TreatmentConsider admission based on severity of episode and risk to self
(self- harm, suicide), job, assets, relationships. Mania is treated acutely with
antipsychotics (particularly olanzapine) and benzodiazepines. Antidepressants
are used for depressive episodes but may precipitate mania. Preventive treatment is with lithium, carbamazepine, valproate, or lamotrigine.
ComplicationsFinancial errors, criminal activity, unemployment, relation-
ship breakdown, suicide.
387MOOD DISTURBANCE/PSYCHOSIS
0
Examples ofmedications withpsychiatric side eects
• NSAIDs, antihypertensives, β- blockers, digoxin, oral
contraceptive pill, antiepileptics, corticosteroids, antibiotics,
cytotoxics, levodopa, anticholinergics, sedatives
• These may all aect mood, cognition, or exacerbate underlying
psychiatric disease.
0
See E Box 3.0 for details of the DSM- 5 and ICD- classication systems.
388 CHAPTER3 Psychiatry
Depression
$ Depression is low mood that is not usual and persists for >2wk.
It can be a symptom of other psychiatric disorders (eg bipolar disorder,
personality disorders) or a disease in its own right.
2
Symptoms Low mood, low energy, feeling worthless or guilty, poor con-
centration, low self- esteem, tearfulness, loss of interests, anhedonia,
recurrent thoughts of suicide ordeath;
Somatic symptomsWeight/ appe-
tite loss, sleep problems (early morning wakening, insomnia, or excess
sleeping), loss of libido, psychomotor agitation or retardation, change
in mood with time ofday;
Psychotic symptomsDelusions, hallucinations.
Signs Neglect, agitation, slowed speech or movement, poor eye contact.
BereavementAvoid diagnosing within 2mth of bereavement; be aware of
cultural variation in grief reactions; features pointing to depression include
prolonged, severe functional impairment or psychomotor retardation.
Investigations Often none; consider an organic cause and investigate if
suspected, otherwise initiate treatment and review if not working. It is
paramount to document a risk assessment at each clinical contact.
Treatment
• Psychotherapy usually cognitive behavioural therapy (CBT) (mild–
moderate depression) but many other eective therapies are
available (eg psychodynamic, cognitive analytic, interpersonal, eye
movement desensitization reprocessing).
• Antidepressants (moderate–severe depression) (Box3.7):
•
st line:selective serotonin re- uptake inhibitors (SSRIs), eg
sertraline, citalopram, uoxetine
•
if a patient does not respond to SSRIs, consider a 2nd line antidepressant, eg venlafaxine, mirtazapine. Psychiatrists may use
other medications for augmentation (eg antipsychotic)
• Electroconvulsive therapy (ECT) is considered if the patient is at high
risk (eg not eating or drinking) and/ or treatment failure.
PrognosisOutcome is generally good with the following:young, somatic
symptoms, reactive depression (due to a life event), and acuteonset.
Complications Deliberate self- harm, unemployment, relationship break-
down, recurrence, suicide.
T Box 3.7 Starting anantidepressant medication
• Antidepressants generally start to work by 2– 3wk but can take6wk
• 2Suicide risk may increase over the rst few weeks (reviewearly)
• Antidepressants are generally well tolerated; side eects are usuallymild
• Treatment should continue for at least 6mth after remission (or
longer if recurrent depressive episode) to reduce relapses
• Antidepressants should be gradually weaned rather than stopped abruptly
to attenuate physical withdrawal symptoms (especiallySSRIs).
NICE guidelines available at Mguidance.nice.org.uk/ CG90
2
A depressive episode is classied by DSM- 5 as minor or major and may be associated with
somatic symptoms or psychotic symptoms; major depressive disorder is the recurrence of major
depressive episodes without mania; ICD- uses the terms mild, moderate, and se vere, adding
recurrent if more than one episode without mania. See E Box 3.0 (p. 59) for details of the
DSM- 5 and ICD- 0 classication systems.
389MOOD DISTURBANCE/PSYCHOSIS
Schizophrenia
$ A chronic illness characterized by psychotic symptoms for >mth.
3
Acute presentations are often characterized by positive symptoms;
negative symptoms can persist despite treatment.
Positive symptomsDelusions, hallucinations (often auditory)(Box3.8).
Negative symptoms Blunted aect, apathy, loss of drive, social withdrawal,
social inappropriateness, poverty of thought/ speech, cognitive impairment.
Signs Neglect, disorganized behaviour, paranoia.
Investigations bldsFBC, U+E, LFT, Ca
tisol;
Urine Toxicology; EEG; CT/ MRI. Psychiatrists may consider tests for
2+
, glucose, consider TFT, VDRL, cor-
autoantibodies in atypical presentations.
Treatment On rst presentation should be urgently referred to a mental
health team either in the community or secondary care depending on severity (risk to self: suicide, job, assets, relationships, and others). MDT
approach essential to assess psychological, physical, and social factors. Antipsychotic medications and psychological interventions (CBT and family
intervention) are the mainstay of treatment.
•
Atypical antipsychotics Have fewer extrapyramidal side eects and
a better eect on negative symptoms, eg amisulpride, olanzapine,
risperidone, quetiapine, clozapine; these are the preferred treatment
in newly diagnosed schizophrenia, and for those experiencing side
eects or relapse on conventional antipsychotics
•
Conventional antipsychotics Eg chlorpromazine, haloperidol, triuoperazine,
upentixol.
2Clozapine This is a 3rd- line antipsychotic, used in treatment-
resistant schizophrenia. It can cause potentially fatal agranulocytosis;
monitor FBC weekly for the st 8wk of treatment, 2wkly for the next
34wk, and 4wkly thereafter.
Side eects Side eects of antipsychotics include sedation, anticholinergic
eects (eg dry mouth, blurred vision, constipation), extrapyramidal side
eects (eg Parkinsonism), and tardive dyskinesia (late onset oral grimacing
and upper limb writhing). Procyclidine may be used to reduce Parkinsonism.
Complications Deliberate self- harm, unemployment, relationship break-
down, stigma, social isolation, drug side eects, suicide.
K Box 3.8 First- rank symptoms
Delusions Passivity
Delusional perception Passivity of thought, feelings, or actions
Hallucinations Thought ow and possession
Thought echo (audible thoughts) Thought withdrawal
Third- person auditory hallucinations Thought insertion
Running commentary Thought broadcasting
In the absence of organic pathology, the presence of these features is suggestive,
but not diagnostic of, schizophrenia.
3
NICE guidelines available at Mguidance.nice.org.uk/ CG78
4
Originally described by Kurt Schneider, a leading German psychiatrist, in959.
4
390 CHAPTER3 Psychiatry
Anxiety disorders
It is normal to have a degree of worry or fear. However, if this causes
distress or interferes with life then it is considered abnormal. There are
several types of anxiety- and stress- related disorders
Specic phobiaFear of a specic situation or object, eg ying, spiders.
Social phobiaFear in social situations, eg public speaking.
Panic attack Excessive fear without any obvious trigger; associated with
symptoms of autonomic arousal, eg sweating, dizziness, nausea, palpitations, breathlessness; usually lasts <30min.
Panic disorder Recurrent panic attacks with fear of having another.
Generalized anxiety disorder(GAD) Excessive worry in everydaylife.
Obsessive– compulsive disorder (OCD) Obsessive thoughts, eg
‘my hands are dirty’ leading to compulsions, eg repetitive hand washing.
Symptoms Worry, irritability, fear, avoidance of feared situations, checking,
seeking reassurance, tight chest, shortness of breath, palpitations, ‘butteries’,
tremor, tingling of ngers, aches,pain.
Signs Tremor, iHR, iRR; be careful to exclude any organic causes of
symptoms such as breathlessness, chest pain, or palpitations.
InvestigationsConsider FBC, U+E, LFT, Ca
2+
, cardiac markers, TFT, glucose;
urinary VMA; ECG and CXR to exclude organic causes.
TreatmentCareful explanation of the cause of their problems; relaxation tech-
niques (Box 3.9), psychological therapies, eg CBT; medications, eg SSRIs; benzodiazepine use should be avoided in panic disorder and used only for <4wks in
GAD as these have poor long- term benets and carry a risk of dependence.
K Box 3.9 Relaxation techniques
• Breathing exercises (silently counting breaths upto0)
• Visualization techniques (imagining a place, colour, or image that is calming)
• Progressive muscle relaxation (tensing and relaxing muscle groups inturn)
• RelaxationCDs
• Yoga.
Personality disorders
Ingrained patterns of behaviour manifesting as abnormal and inexible responses to a broad range of personal and social situations; the diagnosis
is to be avoided in adolescents when the personality is still developing.
Classication DSM- 5 divides personality disorders into three clusters: type
A(odd, eccentric; includes paranoid); type B (dramatic, emotional; includes
antisocial and borderline); type C (anxious, fearful; includes dependent).
InvestigationsUsually none, but they require careful assessment over mul-
tiple occasions and the exclusion of other psychiatric diagnoses.
Treatment Personality disorders are challenging to treat. Psychotherapies may
be useful, including dialectical behaviour therapy, cognitive analytical therapy,
CBT, and psychodynamic psychotherapy. Antidepressants, mood stabilizers,
and antipsychotics may also be used though the evidence of benet is limited.
ComplicationsSuicide, self- harm, social isolation.
5
NICE guidelines available at Mguidance.nice.org.uk/ CG3
5
:
Insomnia
Insomnia can be classied into primary (no comorbidity) and secondary
(occurs as a symptom or association with another medical or psychiatric illness, substance misuse, sleep disorder). Short- term insomnia lasts
<4wk and long-term insomnia >4wk.
Management:shortterm
• st-line options6:ear plugs and eye masks should be oered. Advice
about good sleep hygiene (lack of electronics, caeine, alcohol,
evening exercise, bedtime routine, optimize sleeping environment)
• Consider CBT if sleep hygiene measures fail
• If daytime impairment is severe, hypnotics are an appropriate choice
for short- term insomnia only. Use lowest dose possible and ideally not
for longer than wk.
• ‘Z drugs’— zopiclone, zolpidem, and zaleplon. Zopiclone:good
for sleep initiation and maintenance but longer half- life may cause
hangover eect, 3.75– 7.5mg usual dose. Zolpidem:good for sleep
induction and short half- life reduces hangover eect. Modied-release
version (if available) may be helpful for sleep maintenance (5– 0mg
usualdose).
Management:long term
Refer for psychological therapy (CBT), sleep specialist clinic.6
Hypnotics are generally not recommended. There may be a role for
modied- release melatonin in people >55yr old and those with sleep
dysregulation disorders. However, the uncertain long- term safety prole
of melatonin limits widespreaduse.
See Box 3.0 for advice on managing anxiety in yourself and other people.
K Box 3.0 Managing anxiety inyourself andothers
One of your fundamental roles as a doctor is to be a container for
the anxiety of others: patients, relatives, nurses, other doctors. This
is known as countertransference and can be particularly challenging
when on call. Hospitals and sick people cause anxiety in us all and the
mind is adept at nding ways to rid us of this. Projecting it onto an
unwitting junior doctor is an easy release. Recognizing that this is happening (and that it is natural and ‘unconscious’) can be helpful in not
taking things personally. Recognizing that you may also be doing it can
be even more helpful. We can all feel victimized or angry at others but
neither of these ‘defences’ tend to help us. Try and be polite, helpful,
and a good team player. Acknowledging your own and others’ stress
can be therapeutic in itself and if in doubt, share uncertainty and anxiety with your team or trusted colleague. Remember, no matter how
you feel, you are notalone.
E pp. 36–7 for further resources on stress management.
6
391INSOMNIA
6
NICE CKS insomnia guidelines available at Mhttps:// cks.nice.org.uk/ insomnia
