Chapter 45: The disturbed patient

The disturbed and confused patient is a complex management problem in general practice. The cause may be a single one or a combination of several abnormal mental states (see TABLE 45.1).¹ The cause may be an organic mental disorder, which may be a long-term insidious problem such as dementia, or an acute disorder (delirium), often dramatic in onset. On the other hand, the cause of the disturbance may be a psychiatric disorder such as panic disorder, mania, major depression or schizophrenia.

The manifestations of the disturbance are many and include perceptual changes and hallucinations, disorientation, changes in consciousness, changes in mood from abnormally elevated to gross depression, agitation and disturbed thinking, including delusions.

A summary of the diagnostic strategy model for the disturbed or confused patient is presented in TABLE 45.2.

Probability diagnosis

The diagnosis depends on the age and presentation of the patient. In a teenager the probable causes of acute confusion or irrational behaviour include drug toxicity or withdrawal, schizophrenia, severe depression or a behavioural disorder.

It is the elderly who commonly present with confusion. The questions that must be asked are:

• Is the problem one of the 4 Ds—dementia, delirium, depression, drugs or something else?

• If delirium is the problem, what is the cause?

Depression affects 15% of people over 65 and can mimic other causes of confusion and behavioural disturbance.

Significant prescribed drugs include hypnotics, sedatives, oral hypoglycaemics, antihypertensives, digoxin, antihistamines, anticholinergic drugs and antipsychotics.

Serious disorders not to be missed

There are many serious underlying disorders that must be considered, especially with delirium (see TABLE 45.3). Cerebral organic lesions, including space-occupying lesions (e.g. cerebral tumour, subdural haematoma), severe infection (systemic or intracerebral) and cancer at any site, especially lung, breast, bowel, or lymphoma, must be ruled out.

The sudden onset of delirium may suggest angina, myocardial infarction or a cerebrovascular accident. Twenty per cent of patients with delirium also have underlying heart failure.³

Pitfalls

There are many pitfalls, especially with drug toxicity or withdrawal from the so-called illicit drugs. In the elderly in particular, fluid and electrolyte disturbances, such as dehydration, hypokalaemia, hyponatraemia and hypocalcaemia, can cause delirium. Bowel disturbances such as faecal impaction or constipation can cause delirium and incontinence of both faeces and urine.

Seven masquerades checklist

All the following disorders can cause disturbed or confused behaviour, particularly in the elderly:

• depression: a very important cause of ‘pseudodementia’

• drugs: toxicity or withdrawal (see TABLE 45.4)

• diabetes: especially hypoglycaemia, which can occur with type 2

• anaemia: often from self-neglect or chronic blood loss

• thyroid disorders: both hyperthyroidism and hypothyroidism can present with disturbed behaviour; ‘myxoedemic madness’ may be precipitated by atropine compounds

• urinary tract infection: causes or contributes to 20% of cases of hallucinations or illusions²

• spinal dysfunction: with its many severe pain syndromes, such as sciatica, can be a significant factor

Psychogenic factors

Apart from the primary psychiatric disorders of anxiety, depression, mania and schizophrenia, relatively simple and subtle social problems, such as loneliness, boredom, a domestic upset, financial problem or similar issues, can trigger a confusional state.

History

Developing rapport with the disturbed or confused patient is essential and can be helped by a warm handshake or a reassuring pat on the shoulder. The basis of the history is a careful account from relatives or witnesses about the patient’s behaviour.

When communicating with the patient, speak slowly and simply (avoid shouting), face the patient and maintain eye contact. Important features are the past history and recent psychosocial history, including recent bereavement, family upsets and changes in environment. Search for evidence of depression and note any organic symptoms such as cough, constipation and so on.

Mental status examination

The most practical bedside screening test of mental function is the Mental Status Questionnaire of Kahn and colleagues,⁴ which includes 10 simple questions.

1. What is the name of this place?

2. What city are you in now?

3. What year is it?

4. What month is it?

5. What is the date today?

6. What year were you born?

7. When is your birthday?

8. How old are you?

9. Who is the prime minister/president?

10. Who was the prime minister/president before him?

(Interpretation: normal 9–10; mildly impaired 8–9; confused/demented 7 or less.)

Other MMSEs are presented in CHAPTER 8.

Examination

The patient’s general demeanour, dress and physical characteristics should be noted at all times. Assess the patient’s ability to hear, see, speak, reason, obey commands, stand and walk. Any problems related to the special senses can cause confusion.

Look for features of alcohol abuse, Parkinson disease and hypothyroidism.

Examine the neurological system and keep in mind the possibility of a subdural haematoma, which may have followed a forgotten fall.

Don’t omit the rectal examination to exclude faecal impaction, melaena, cancer and prostatomegaly (in males), and also check the bladder for evidence of chronic retention.

Investigations

Investigations to consider for delirious or demented patients (unknown cause):

• urinalysis and microscopy

• cultures of blood and urine

• total and differential blood count; ESR

• blood glucose

• urea and creatinine and electrolytes

• calcium and phosphate

• vitamin D

• thyroid function tests

• liver function tests

• serum vitamin B12 and folate levels

• ECG/troponin (? acute coronary syndrome)

• chest X-ray

• cerebral CT scan, especially non-contrast CT

• syphilis serology

• HIV

• arterial blood gases

Delirious or psychotic patients can be paranoid and respond defensively to the world around them. This behaviour can include aggressive and violent behaviour resulting in danger to themselves, their friends and family and to their medical attendants.

Dangerousness should be assessed from features such as the patient’s past history (especially previous dangerous behaviour), age and sex, recent stress, victim behaviour, muscle bulk, presence of weapons, degree of overactivity and the manner of handling of the present distress by others. The patient may be in a state of acute panic and trying to flee a situation or in an agitated psychotic state prepared to confront the situation. It should be emphasised that most violent individuals are not mentally ill.

Most cases require an injection (the ideal intravenous administration can be extremely difficult and hazardous), which is often interpreted as a physical attack. It may not be possible to diagnose the cause of the problem before giving the injection.

Approach to management

• Assess the environment and don’t move into the patient’s space until in a position of control.

• React calmly. Communicate calmly and simply.

• State your task firmly and simply.

• Try to control the disturbed patient gently.

• Ensure the safety of all staff and make certain that heroics are not attempted in dangerous circumstances.

• An adequate number of staff to accompany the doctor is essential—six is ideal (one for immobilisation of each limb, one for the head and one to assist with drugs).¹

• Patients should be placed on the floor in the prone position.

Principles of sedative administration¹

• Use the safest possible route of administration whenever possible (i.e. oral in preference to parenteral but often impractical). Intravenous administration has the lowest margin of safety.

• Parenteral administration should be restricted to severely disturbed patients.

• Closely monitor vital signs during and after sedative administration.

• Avoid intramuscular diazepam because of poor absorption.

• Be cautious of intravenous midazolam (Hypnovel) in such patients because of the risk of respiratory depression.

• Avoid benzodiazepines in patients with respiratory insufficiency. Haloperidol is an alternative.

• Patients have died from cardiopulmonary arrest after repeated sedative administration (especially benzodiazepines), so intensive monitoring is essential.

Monitor the following adverse effects:

• respiratory depression

• hypotension

• dystonic reactions, including choking

• neuroleptic malignant syndrome

Treatment options¹

The treatment in acute medical and psychiatric settings depends on the appropriate mode of administration. Benzodiazepines are generally the drugs of first choice over antipsychotics in tranquillisation.⁵ However, the IV route allows titration to the desired degree of sedation and has a more immediate effect.

Intravenous medication

• diazepam or midazolam 5 mg IV initially

• then

• 2.5–5 mg increments IV, repeated every 3–4 minutes until required level of sedation (rousable drowsiness) is reached—up to a maximum of 20–30 mg, when specialist advice is needed especially if further boluses are necessary

• and/or droperidol 5–10 mg IV

Intramuscular medication

If this route considered appropriate:

• midazolam 5–10 mg IM

• or (if history of benzodiazepine tolerance)

• droperidol 5–10 mg IM

• or

• olanzapine 5–10 mg repeated every 2–4 hours

• or

• combination midazolam/droperidol

(These first two injections can be repeated in 20 minutes if required. Droperidol is similar to haloperidol but more sedating. Keep in mind the rare but potentially fatal laryngeal dystonia with high doses—cover with benztropine 2 mg IM.)

Oral medication (if considered appropriate)

• diazepam 5–20 mg (o), repeated every 2–6 hours (max: 120 mg/24 hours)

• or

• lorazepam 1–2 mg (o), repeated every 2–6 hours (max: 10 mg/24 hours)

If sedation is not achieved, add an antipsychotic medications e.g. olanzapine 5–10 mg initially or risperidone 0.5–1 mg initially.

Postdisturbance evaluation

Determine the likely cause, such as:

• acute organic brain syndrome: toxic causes, infection

• alcohol or drugs (illicit or prescribed): intoxication, withdrawal

• manic illness

• severe depression

• schizophrenic syndrome

• severe panic

Acute organic brain syndrome (delirium)

The many labels of acute organic brain syndrome include:

• delirium

• acute confusional state

• toxic confusional state

• confusional episode

• acute brain syndrome

Main clinical features

• Clouding of conscious state

• Disorientation

• Impaired attention

• Impaired memory

• Global cognitive defect—onset over days/hours

Refer to the box.

• The patients are usually elderly.

• Anxiety and agitation can be severe but in hypoactive deliria (usually due to metabolic disturbance) the conscious state can vary from drowsiness to coma.

• Odd behaviour with mood swings can occur.

• Psychotic symptoms can occur.

• Delusions are usually fleeting.

• The disturbance is usually worse at night and may be aggravated by sedation.

• Visual hallucinations are a feature of alcohol withdrawal.

• Attacks on bystanders may result (uncommon).

Always seek a cause.¹ A list of causes is presented in TABLE 45.3. The most important causes are:

• infections (usually in urinary tract, lungs or ear, or systemic in young or elderly)

• prescribed drugs

Consider this cause (from drugs with anticholinergic properties or illicit substances). Features include hyperactivity, marked thought disorder, vivid visual hallucinations and very disturbed behaviour.

In the earlier stages it may mimic the various psychiatric disorders, including anxiety, depression, various hallucinatory states, particularly agitated schizophrenia (rarely), extreme manic states, complex partial seizures, dementia. Consider deafness. Delirium is common in the hospital setting.

Investigations

Investigations are those listed under ‘The clinical approach’ earlier in the chapter.

Treatment

Principles:

• Acute delirium is a medical emergency.

• Establish normal hydration, electrolyte balance and nutrition.

• Consider alcohol withdrawal and give a trial of thiamine when the cause of delirium is unknown.

• Attend to helpful environmental factors (e.g. calm atmosphere, a night-light, orientation clues, presence of friends and relatives).

• Give oxygen if hypoxic, e.g. respiratory distress

Medication¹ may not be needed, but it will be if there are symptoms of anxiety, aggression or psychosis (doses for a fit adult).

For anxiety and depression:

• midazolam 1.25–5 mg IM

For psychotic behaviour:

• haloperidol 0.5 mg (o) as a single dose

• or

• olanzapine 2.5–10 mg (o) daily in 1 or 2 doses

If oral administration is not possible or when parenteral medication is required (cover with benztropine 2 mg (o) or IM):

• haloperidol 0.5 mg IM as single dose

• or

• olanzapine 2.5 mg IM as single dose

For anticholinergic delirium:

• tacrine hydrochloride 15–30 mg with caution by slow IV injection (an antidote)

Note:

• For hypoxia, give oxygen.

• Avoid benzodiazepines, especially in children and in patients with respiratory insufficiency.

• Consider necessity for pain relief.

• Use lower doses of parenteral medications in the very old and frail.

Dementia (chronic organic brain syndrome)

Dementia or neurocognitive disorder is an important diagnosis to consider in the elderly patient. The DSM criteria for dementia are presented in CHAPTER 8.

The main feature of dementia is impairment of memory, especially recent memory, when the person cannot remember what has happened a few hours (or even moments) earlier but may clearly remember the events of the past.

The more serious behavioural changes encountered with dementia tend to occur in the advanced stages. However, these disturbances may be precipitated by illness such as infections, emotional upset and drugs. These serious disturbances include:

• uninhibited behaviour

• hallucinations (generally uncommon)

• paranoid delusions

If a stable patient becomes acutely disturbed, delirium should be suspected.

Presenile dementia—Alzheimer type

The main features are:

• onset in late 50s and early 60s

• insidious onset

• early loss of short-term memory

• progressive decline in intellect

• death in 5–10 years

• more common in Down syndrome

Differential diagnosis of dementia

There are two approaches to the differential diagnosis, including consideration of the classic causes of disturbed behaviour as summarised in the mnemonic in TABLE 45.5.⁶

However, the foremost differential diagnosis should be ‘pseudodementia’ caused by severe depression.

A simple comparison between schizophrenia and dementia is shown in TABLE 45.6.

A vigorous search for a possible cause of dementia is warranted since there are a significant number of reversible causes. In particular, it is important to exclude the psychiatric conditions that may mimic dementia.

Treatment¹

• To control psychotic symptoms or disturbed behaviour:

  • risperidone 0.5–2 mg (o) daily

  • or

  • olanzapine 2.5–10 mg (o) daily in 1 or 2 doses

• To control symptoms of anxiety and agitation: oxazepam 15 mg (o) 1 to 4 times daily. Avoid benzodiazepines for more than 2 weeks

• For depression—administer antidepressants

Acute psychosis is the presence of the mental state where appreciation of reality is impaired as evidenced by the presence of typical psychotic symptoms such as delusions, hallucinations, mood disturbance and bizarre behaviour.⁷ Refer to the diagnostic strategy for hallucinations in TABLE 45.7.

The differential diagnoses of patients presenting with psychoses is presented in TABLE 45.8.

Early diagnosis

Early recognition of a psychosis, particularly schizophrenia, is extremely important, as early intervention leads to improved outcomes. Early or prodromal symptoms include the following:

• social withdrawal

• reduced attention and concentration

• reduced drive and motivation

• depressed mood

• anxiety

• irritability/agitation

• suspiciousness

• sleep disturbance

• deterioration in role functioning

It is appropriate to ask the correct questions in order to elicit psychotic symptoms. These are presented in TABLE 45.9.

Schizophrenia and associated disorders

The term ‘schizophrenia’ (Bleuler 1911) refers to a group of severe psychiatric illnesses characterised by severe disturbances of emotion, language, perception, thought processes, volition and motor activity. The causes of schizophrenia disorders are unknown, but genetic factors and drug abuse are implicated.

Signs and symptoms of schizophrenia

• Positive

  • — delusions

  • — hallucinations

  • — thought disorder

  • — disorganised speech and behaviour

• Negative

  • — flat affect

  • — poverty of thought

  • — lack of motivation

  • — social withdrawal

  • — reduced speech output

• Cognitive

  • — distractibility

  • — impaired working memory

  • — impaired executive function (e.g. planning)

  • — impaired insight

• Mood

  • — mania (elevation)

  • — depression

Other features include:

• bizarre behaviour

• subject to tension, anxiety or depression

• deterioration in work and study performance

• peak incidence 15–25 years⁸—smaller peak at 40 years

• lifetime prevalence 1 in 100

• equal sex incidence

• high risk of suicide

Differential diagnosis

Organic factors need to be excluded, especially drugs:

• amphetamines

• hallucinogens (e.g. LSD)

• marijuana

Also consider complex partial seizures and a personality disorder. Other psychoses are presented in TABLE 45.8.

A comparison of delirium, dementia and functional psychosis is presented in TABLE 45.10.

Management

Drug treatment is only a part of total management. Explanation and appropriate reassurance to the family with patient and family supportive care is obviously essential. Supportive psychotherapy is important in all phases. A team approach is necessary to cope with the disorder, which usually has a devastating effect on the family. Referral for specialist care is appropriate.

• Hospitalisation usually necessary

• Drug treatment for the psychosis¹

Drug treatment may include the first-generation (typical or conventional) antipsychotics such as haloperidol and chlorpromazine, which are effective for managing the ‘positive’ symptoms, or the second generation (atypical) antipsychotics such as risperidone, olanzapine, quetiapine, clozapine, amisulpride and aripiprazole, which in addition are more effective at treating the ‘negative’ and other symptoms of schizophrenia.⁹

The usual practice rule is to start with a second-generation antipsychotic at a low dose and titrate upwards at a rate and to a level that is optimal for the patient. Patients with a first psychotic episode may respond to lower than usual doses.⁵

1. When oral medication is possible, first-line treatment (for the first episode) is one of (with starting doses):^1,10,11

   • amisulpride 100 mg nocte

   • asenapine 5 mg sublingual bd

   • aripiprazole 10 mg once daily

   • lurasidone 40 mg once daily

   • olanzapine 5 mg nocte

   • paliperidone 3 mg nocte

   • quetiapine 50 mg bd → 200 mg bd (by day 5)

   • risperidone 0.5–1 mg nocte → 2 mg nocte

   • ziprasidone 40 mg bd → 80 mg bd (risk of ↑ QT)

   • zuclopenthixol 20 mg nocte Practice tips

     Typical initial oral therapy:

     • olanzapine 5 mg

     • or

     • risperidone 0.5 mg

   If response is inadequate in 3 weeks increase the dose according to prescribing guidelines.

   If no response after 4–6 weeks consider a change to:¹²

   • an alternative second-generation agent (above)

     or

   • a first-generation antipsychotic such as:

     • chlorpromazine 200 mg once daily → 500 mg

     • haloperidol 1.5 mg once daily → 7.5 mg

     • trifluoperazine 2 mg bd

2. Parenteral medication should be avoided if possible in acute care, but if required:^1,11

   • haloperidol 2.5–10 mg IM, initially, up to 20 mg in 24 hours, depending on the response

   • or

   • olanzapine 5–10 mg IM initially (do not use with benzodiapines concurrently)

   • add

   • benztropine 1–2 mg (o) bd (to avoid dystonic reaction)

   • or

   • zuclopenthixol acetate 50–150 mg IM as a single dose

   If dystonic reaction:

   • benztropine 1–2 mg IV or IM

   If very agitated use:

   • diazepam 5–10 mg (o) up to 40 mg/day or 5–10 mg IV

Long-term antipsychotic medication is recommended to prevent relapse.¹

• Examples of oral medication regimens:^11,12

  • olanzapine 5–10 mg (o) nocte

  • or

  • risperidone 0.5–1 mg (o) bd up to 2–4 mg

  • or

  • quetiapine 150 mg (o) bd

• Aim for lowest possible dose to maintain control.

• Chlorpromazine is not recommended for long-term use because of photosensitivity reactions.

• Use depot preparations if compliance is a problem (usually test dose first):^1,10

  • fluphenazine decanoate 12.5 mg IM, initially then 12.5–50 mg every 2–4 weeks

  • or

  • haloperidol decanoate 50 mg IM, initially then 50–200 mg every 4 weeks

  • or

  • flupenthixol decanoate 10 mg IM, initially then 20–40 mg every 2–4 weeks

  • or

  • risperidone 25–25 mg IM initially then every 2 weeks, titrated to clinical response

  • or

  • zuclopenthixol 100 mg IM, initially then titrated to 200–400 mg every 2–4 weeks

Tips with depot preparations:

• Start with IM test doses and then titrate to recommended controlling levels (half or full starting dose).

• May take 2–4 months to produce a stable response, so oral supplements may be necessary.

• Not as effective as oral therapy.

• Give as deep IM injection with 21 gauge needle in buttock.

• Use lowest possible dose to avoid tardive dyskinesia.

• Reassess at least every 3 months.

• Closely monitor patient for movement disorders.

Consider other causes (e.g. substances abuse). ECT may help the agitated patient, especially if catatonic. Consider a trial of clozapine (12.5 mg (o) bd initially increasing to 200–600 mg daily), with strict monitoring for blood dyscrasias and cardiotoxicity, or olanzapine (5–20 mg daily). A trial of adjunctive ECT should be considered in patients who fail to respond to clozapine.

Movement disorders from antipsychotic medication¹

• Usually bizarre muscle spasms affect face, neck, tongue and trunk

• Oculogyric crises, opisthotonos and laryngeal spasm

  Treatment:

  • benztropine 1–2 mg IV or IM

• Subjective or objective motor restlessness of feet and legs

• Generally later onset in course of treatment

Treatment:

• reduce dosage until akathisia less troublesome or substitute thioridazine

• can use oral propranolol, diazepam or benztropine as a short-term measure

• Seen relatively early in treatment

• The akinesia can be confused with drug-induced depression

Treatment:

• use lower dose or substitute a phenothiazine in low dosage

• alternatively, use benztropine or benzhexol

Tardive dyskinesia is a syndrome of abnormal involuntary movements of the face, mouth, tongue, trunk and limbs. This is a major problem with the use of long-term antipsychotic drugs and may occur months or years (usually) after starting treatment and with drug withdrawal. Avoid prolonged use of metoclopramide.

Differential diagnosis:

• spontaneous orofacial dyskinesia

• senile dyskinesia

• ill-fitting dentures

• neurological disorders causing tremor and chorea

If drug withdrawal is ineffective, use tetrabenazine 12.5 mg (o) daily, increasing as necessary.¹² The risks and benefits of continuing therapy have to be weighed.

Note: Because of the difficulty with managing tardive dyskinesia, prevention in the form of using the lowest possible dosage of antipsychotic medication is essential. This involves regular review and adjustment if necessary.

This is a potentially fatal adverse effect that can develop at any time. It develops in hours to days.

Syndrome: high temperature, muscle rigidity, altered consciousness. Milder variants can occur (refer to CHAPTER 53).

Treatment:

• discontinue medication

• ensure adequate hydration with IV fluids

• if life-threatening:

  • bromocriptine 2.5 mg (o) bd, gradually increasing to 5 mg (o) tds

  • and

  • dantrolene 50 mg IV every 12 hours for up to 7 doses

• consultant referral

Various psychotrophic agents, particularly the phenothiazines, are prone to cause the adverse effect of prolongation of the QT interval with potential severe outcomes.

Bipolar disorder

The mood disorders are divided into depressive disorders and bipolar disorders. Bipolar is a broad term to describe a recurrent illness with episodes of either mania or depression with return to normal function in between. The swing in moods in bipolar disorders (manic depressive disorders) is illustrated in FIGURE 45.1. It affects 1%–2% of the population.

Bipolar I disorder has one fully fledged manic or mixed episode and usually depressive episodes.

Bipolar II disorder is defined as a major depressive episode with at least one hypomanic episode lasting a minimum of 4 days but no classic manic episodes.

The symptoms of mania may appear abruptly, usually in the teens or young adulthood.

Typical inherent features, in addition to the above, include:

• reckless behaviour, overspending

• hasty decisions (e.g. job resignation, hasty marriages)

• impaired judgment

• increased sexual drive, energy and activity

• poor insight into the problem

• variable psychotic symptoms—paranoia, delusions, auditory hallucinations

Note: The peak onset is in early adult life. The exact cause is unknown, but there is a strong hereditary basis. Episodes may be precipitated by stress.

‘Hypomania’ is the term used to describe the symptoms of mania that are similar to but less severe (without criterion C) and of shorter duration.

The subsequent major depressive phase is associated with a high risk of suicide.

Good questions to ask the patient with suspected ‘bipolar’ disorder:

• How have you been feeling in yourself?

• Have you felt especially good about yourself?

• Do you feel that you are special or have special powers?

• Have you been spending more than usual?

• Have you been needing less sleep than usual?

Management of acute mania^1,15

This is a medical emergency requiring hospitalisation for protection of both family and patient. Involuntary admission is usually necessary. It may be a first episode or a relapse due to poor treatment compliance or substance abuse. A recent meta-analysis indicates that antipsychotics are the most efficacious drugs.

Treatment

First line:¹

• olanzapine 5 mg (o) nocte initially then increasing to 10 mg

• or

• risperidone 1 mg (o) nocte initially then increasing to 2 mg

Second line:

• haloperidol or a second-generation antipsychotic e.g. aripiprazole¹⁶

• or

• lithium carbonate 750–1000 mg (o) daily in 2 or 3 divided doses increasing according to serum levels

• or (a mood stabilising agent)

• sodium valproate 200–400 mg (o) bd initially

• or

• carbamazepine 100–200 mg (o) bd initially

If a parenteral antipsychotic drug is required:

• haloperidol 5–10 mg IM or IV

• Repeat in 15–30 minutes if necessary (risk of tardive dyskinesia)

• Change to oral medication as soon as possible

Failure to respond to treatment:^17,18,19

• ensure maximum concentration of first drug

• switch to a different drug e.g. olanzapine to lithium

• combine drugs, e.g. second-degree antipsychotic + lithium

• ECT is of proven benefit for recalcitrant problems

Remember to provide supportive psychotherapy with appropriate psychosocial interventions.

(Over 90% will have a recurrence at some time: consider medication if two or more episodes of either mania or depression in the previous 4 years.)

• lithium carbonate125–500 mg (o) bd then adjusted

• or

• second-generation antipsychotic agent

• or (if depression prominent)

• lamotrigine or carbamazine or sodium valproate

Use long-term lithium (e.g. 3–5 years). Target plasma level for maintenance is usually 0.6–0.8 mmol/L. A US study recommended lithium as the prime mood stabiliser.¹⁶

• If poor response, use another agent.

• Unwanted side effects of lithium include:

  • — a fine tremor

  • — muscle weakness

  • — weight gain

  • — gastrointestinal symptoms

  • — hypothyroidism

  • — nephrotoxicity

• With anti-epileptics, adjust dosage according to clinical response and toxicity.

This is a difficult component to treat and antidepressants should not be used alone.¹¹ Many mood-stabilising agents appear to have a bimodal (antidepressant and antimania) effect and can be useful in the absence of classical antidepressants.¹⁵

A recommended regimen is:

• an antidepressant (e.g. SSRI, SNRI or MAOI)

• plus

• lithium, valproate, carbamazepine, quetiapine, lamotrigine or olanzapine (one of these used for prophylaxis)

Antidepressants are usually withdrawn within 1–2 months because of a propensity to precipitate mania.

ECT is an effective treatment for bipolar depression while psychological therapies such as CBT and psychoeducation have proven efficacy.

Bipolar I patients usually recover but proceed to have further episodes of depression or mania.¹¹

Promote a caring support and pyschoeducation program for patient and family. Educate about the patient’s ‘relapse signature’ for a manic or depressive episode.

Body dysmorphic disorder⁵

Body dysmorphic disorder is characterised by a preoccupation with the belief that some aspect of physical appearance is abnormal, unattractive or diseased. The person’s concern and distress is out of proportion to any imagined or actual defect and usually not amenable to reassurance. This preoccupation causes significant functional impairment. The condition rarely presents directly and may be over-represented in the area of dermatology or plastic surgery. It begins in late childhood or early adolescence. The person’s focus is on the face, head or secondary sexual characteristics.

Patients may be helped by counselling and psychotherapy including CBT. There is clinical evidence that SSRIs help if the symptoms suggest an obsessive–compulsive disorder. An antipsychotic agent may help where beliefs are delusional or in the context of a psychotic disorder.

Depression

Depression is very common and presents in a great range of severity. In the context of ‘the disturbed patient’ depression can be confused with dementia or a psychosis, particularly if the following are present:

• psychomotor agitation

• psychomotor retardation

• delusions

• hallucinations

Assessment¹

The following questions need to be addressed:

• Is the depression primary (i.e. not secondary to another psychiatric condition such as schizophrenia or anxiety disorder)?

• Is it part of a bipolar disorder? Has there been a previous manic or hypomanic episode? If so, a different approach to treatment is required.

• Is the depression caused by another illness or physical factor (e.g. hypothyroidism, cerebrovascular disease or medication)?

• Is the patient psychotic?

• Is the patient a suicide risk?

The treatment of depression is presented in CHAPTER 19.

It is important for the GP to be aware of the effects of self-administration of psychoactive substances, especially their toxic or withdrawal effects. They form a significant consideration for the differential diagnosis of disturbed patient behaviour. The following substances can cause these effects.

Alcohol

Toxic and withdrawal effects, including delirium tremens, are outlined in CHAPTER 21. Abrupt withdrawal can cause symptoms ranging from tremors, agitation and dysphoria (feeling thoroughly miserable) to fully developed delirium tremens. Epileptic seizures may also occur.

Barbiturate dependence

Tolerance and symptoms on withdrawal are the main features. Barbiturate withdrawal is a very serious, life-threatening problem and may be encountered in elderly people undergoing longstanding hypnotic withdrawal. Symptoms include anxiety, tremor, extreme irritability, twitching, seizures and delirium.

Management¹

Undertake withdrawal with medical supervision as an inpatient.

• Transfer the patient to phenobarbitone or diazepam. phenobarbitone 120 mg (o) hourly until sedation

• or

• phenobarbitone 30 mg for each 100 mg of shorter-acting barbiturate

• reduce the dose gradually over 10–14 days

• or

• diazepam 20–40 mg orally, daily

• reduce the dose gradually over 10–14 days

Benzodiazepine dependence

Withdrawal symptoms in the dependent patient include anxiety, restlessness, irritability, palpitation and muscle aches and pains, but delirium and seizures are uncommon except with very high doses. The shorter the half-life, the greater the dependence.

Withdrawal is best achieved by supervising a gradual reduction in dosage aided by relaxation techniques and behavioural strategies to help patients cope with insomnia and anxiety.

Refer to CHAPTER 21 for the effects of opioid dependence, stimulant substance abuse, hallucinogen abuse and cannabis use and dependence.

The following disturbance problems do occur and must be taken seriously, especially the potential for suicide in the second decade. Many of these disorders are presented in more detail in CHAPTER 94.

Attention deficit hyperactivity disorder

Clinical features:

• short attention span

• distractibility

• overactivity

• impulsiveness

• antisocial behaviour

Depression

Major depression follows the same criteria as for adults. Suicidal ideation has to be considered and taken very seriously if present. Imipramine is probably the drug of choice.

Bipolar disorders

Mania is seldom diagnosed before puberty. Adolescents may present (uncommonly) with symptoms of mania or hypomania.

Schizophrenia and related disorders

Schizophrenia is rare before puberty. The criteria for diagnosis are similar to adults:

• delusion

• thought disorder

• hallucinations

• 6 months or more of deterioration in functioning

Autism

Aggression and irritability can be a feature, especially during adolescence.

Tourette syndrome

Behavioural problems can be part of this syndrome, which requires the attention of an experienced consultant.

Obsessive–compulsive disorders

In about one-third of cases the onset is between 5 and 15 years of age.

Dangerousness has been defined as a ‘propensity to cause serious physical injury or lasting psychological harm to others’ and, in the context of people with mental illness, ‘the relative probability of their committing a violent crime’.²⁰

Dangerousness is not related only to mental illness and, interestingly, most offenders have no psychiatric diagnosis. It is not an inherited, immutable characteristic of an individual but tends to surface on impulse in a particular context given a whole range of situational factors. Prediction of the risk of violence is not straightforward.

Various groups have been identified as contributing risk factors for violent conduct.²⁰

• Schizophrenic psychoses, including: older male paranoid schizophrenics; younger males prone to act violently and impulsively, presumably due to hallucinatory commands

• Morbid jealousy: associated with delusions of infidelity

• Antisocial personality disorder

• Mood disorder: violence, usually associated with depression (rarely mania); parents with severe depression; history of suicide attempts in depression

• Episodic discontrol syndrome (similar to intermittent explosive disorder)

• Intellectual disability combined with personality disorder and behavioural disturbances

• Alcohol abuse or dependency

• Amphetamine or benzodiazepine abuse or dependency

From a management viewpoint, homicidal threats must be taken very seriously.

The diagnostic strategy model for antisocial behaviour in adults is presented in TABLE 45.11.

The haunting issue of suicide and parasuicide is presented in CHAPTER 19. The disturbed patient is always a suicide risk rather than a homicide risk. The importance of recognising depression with an associated suicide risk in the elderly patient has been emphasised heavily in this chapter.

Facts and figures²¹

• More than 90% of suicides occur without underlying chronic conditions but most people are significantly depressed at the time.

• In Australia, suicide is the second most common cause of death between the ages of 11 and 25 years. Children as young as 5 years of age have committed suicide.

• Those who talk about suicide may attempt it later.

• About half of those committing suicide have seen a doctor within their last month of life.

• Around 80–90% of suicides have given clear or subtle warnings to family, friends or doctors.

• There is no evidence that asking patients about suicidal ideation provokes suicidal acts.

• Doctors in Australia and other Western countries have a high suicide rate.

Suicide risk

Blumenthal’s²² overlapping model lists five groups of risk factors (see FIG. 45.2):

1. Psychiatric disorders:

   • affective disorder and alcohol abuse in adults

   • schizophrenia

   • depression and conduct disorder in young people

   • anorexia nervosa

2. Personality traits:

   • impulsiveness and aggression

3. Environmental and psychosocial factors:

   • poor social supports

   • chronic medical illness (e.g. AIDS)

   • significant loss

4. Family history and genetics (both nature and nurture):

   • emulation of relatives

   • specific ethnic groups in custody

5. Biological factors:

   • possible serotonin deficiency

Parasuicide

Parasuicide is attempted suicide; in many cases, patients are drawing attention to themselves as a ‘plea for help’. It is important for the GP to take an active role in the support of the patient and family after discharge from hospital, but preferably in conjunction with a psychiatric or counselling service. Arrange frequent consultations at first and ensure adequate follow-up, especially for missed appointments.

People with personality disorders may become very distressed and acutely disturbed under stress or provocation, and this may involve dramatic scenes, including public suicide threats. It is important to recognise personality disorders because they usually cause considerable distress to the patients, their family, society and GPs. The prevalence is estimated as 11–12%.¹

In practice, the personality disorders of most concern are those that present with hostility, either verbal or physical, particularly if a suicide or homicide threat is involved. It is a mistake to assume that those patients who manifest violent or psychopathic behaviour have a personality disorder or, conversely, that the meek and mild are free from personality disorder.

The diagnosis of personality disorder can be difficult. As practitioners we tend to have a ‘gut feeling’ about the diagnosis but often find it difficult to classify the personality of the patient and then to manage it appropriately.

The main characteristics of a personality disorder are:¹

• lack of confidence and low self-esteem

• long history from childhood

• difficulties with interpersonal relationships and society

• recurrent maladaptive behaviour

• relatively fixed, inflexible and stylised reaction to stress

• minimal insight

• perception of difficulties as external to themselves

The medical/psychiatric significance:

• maladaptive relationships with GPs and society

• problem of sexually dysfunctional lives

• risk of substance abuse and self-destructive behaviour

• prone to depression and anxiety (usually low grade)

• susceptible to ‘breakdown’ under stress

Personality is the result of a genetic template and the continuing interaction of the person with outside influences (peer pressures, family interactions, influential events) and personal drives in seeking an identity. The outcome is a unique behaviour pattern manifesting as a personality trait or character reflective of the individual’s self-image and fundamental to his or her sense of personal identity.²⁴

Although personality is unique, it is possible to make a hypothesis that one is normal or abnormal. If abnormal, it is possible to stereotype it according to the predominant symptoms or behaviours.

Using the International Classification of Disease (ICD-10) and the DSM-5 classification, various subtypes are readily identifiable (see TABLE 45.12),⁵ which can be considered in three main groups. There is a considerable overlap between the subtypes within a group²⁵ and it is more important to understand the specific features of a person’s personality than to categorise them.²⁶

The antisocial personality disorders (ASPD) group (1–2% of population) tend to come to the attention of GPs more frequently, with some individuals representing ‘heart-sink’ patients because of demanding, angry or aggressive behaviour. They are more common among people in prison. The withdrawn group are typically withdrawn, suspicious and socially isolated but fall short of a true psychotic syndrome. GPs have problems communicating with them because they are often suspicious, which can make proper physical examination and management difficult.

In the dependent and inhibited groups, which may overlap with an anxiety state, the main features are nervousness, timidity, emotional dependence and fear of criticism and rejection. They are frequent attenders (the ‘fat file’ syndrome) and are often accompanied by friends and relatives because of their insecurity.

Management

The best treatment is a supportive, ‘therapeutic’ community and an understanding and supportive GP. Psychotherapies are the key to long-term treatment. It is vital to understand that people with personality disorders perceive the world from a fundamentally different perspective. Problematic patients, if agreeable, may respond well to psychological intervention and behavioural techniques, especially operant conditioning (reinforcing acceptable behaviour) and averse conditioning (correcting inappropriate behaviour).^1,24 CBT has the most to offer.

The borderline and narcissistic disorders in particular respond well to specific types of psychotherapeutic intervention. Patients’ self-esteem needs careful support while maladaptive modes of behaviour are confronted. Hospitalisation is rarely required except for those at risk of suicide (e.g. antisocial patients).

Medication has limitations but may be useful to treat those individuals who temporarily decompensate into a psychosis, an anxiety state or depression. One study has shown that antipsychotic medication in low dosage (e.g. haloperidol 5 mg daily) is effective in treating the problematic behaviours in paranoid and some antisocial personality disorders.²⁷

There are dangers to the therapist and it is important not to ‘buy into’ a particular psychopathy, especially with seductive, manipulative or paranoid patients.²²

Indications for referral to a psychiatrist:

• severe depression

• high suicide risk

• actual suicide attempt: recent or in the past

• suspected psychiatric disorders in the elderly: ?depression or schizophrenia; ?depression or dementia

• failure to improve with treatment

• poor family and social supports

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Bipolar disorder

• Personality disorders

• Schizophrenia

NICE Pathways: Personality disorders. National Institute for Health and Care Excellence (NICE) <https://pathways.nice.org.uk/pathways/personality-disorders>