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Chapter 69: The disturbed patient

INTRODUCTION

There is not a sight in nature so mortifying as that of a Distracted Person, when his imagination is troubled, and his whole soul is disordered and confused.

JOSEPH ADDISON (1672–1719)

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 69.1).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.

Table 69.1A general classification of psychiatric disorders1
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Table 69.1 A general classification of psychiatric disorders1

Organic mental disorders:

  • acute organic brain syndrome (delirium)

  • chronic organic brain syndrome (dementia)

Psychoactive and substance use disorders:

  • toxic states

  • drug dependency

  • withdrawal states

Schizophrenic disorders

Mood disorders:

  • major depression

  • bipolar (manic depressive) disorder

  • adjustment disorders with depressed mood

  • dysthymia

Anxiety disorders:

  • generalised anxiety disorder

  • panic disorder

  • obsessive–compulsive disorder

  • phobic disorders

  • post-traumatic stress disorder

Disorders specific to children

Other disorders:

  • postpartum psychiatric illness

  • eating disorders

  • personality disorders

  • body dysmorphic disorder

Key facts and checkpoints

  • Depression affects 15% of people over 65 and can mimic or complicate any other illness, including delirium and dementia.1

  • Elderly patients with depression are at a high risk of suicide.

  • Always search vigorously for the cause or causes of delirium.

  • Seeing patients in their home is the best way to evaluate their problem and support systems. It allows opportunities for a history from close contacts and for checking medication, alcohol intake and other factors.

  • The diagnosis of dementia can be overlooked: a Scottish study showed that 80% of demented patients were not diagnosed by their GP.2

  • Patients with a chronic brain syndrome (dementia) are at special risk of an acute brain syndrome (delirium) in the presence of infections and many prescribed drugs.1

  • Consider prescribed and illicit substances, including the severe anticholinergic delirium syndrome.

  • The key feature of dementia is impaired memory.

  • The two key features of delirium are disorganised thought and attention.

  • Hallucination guidelines:

    • – auditory: psychoses, e.g. schizophrenia

    • – visual: almost always organic disorder

    • – olfactory: temporal lobe epilepsy

    • – tactile: cocaine abuse, alcohol withdrawal

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 DIAGNOSTIC APPROACH

A summary of the diagnostic strategy model for the disturbed or confused patient is presented in TABLE 69.2.

Table 69.2The disturbed mind: diagnostic strategy model
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