Psychosocial Issues Experienced in a Coronary Care Unit (CCU)

Relating to the patient

1. The suffering of others in the CCU
2. Paraphernalia of tubes, machines, wires, etc
3. Death of others.
4. Possibility of having to witness a CPR etc.

Relating to the Attendants

1. Unsure of the progress
2. Unaware of patients' perceptions and mental state.
3. Watching a medley of news coming from inside for other attendants.
4. Crying or wailing of other attendants.

Doctors

Dressed in white coats and scrubs walking about looking serious and pacing hurriedly creating a sense of emergency and danger.

Assessment and Management of Opioid Use Disorder, Withdrawal, and Intoxication Syndromes

Neurobiology of Opioid Dependence and withdrawal

Opioids act at specific opioid receptors in the central nervous system. Stimulation of these receptors suppresses the firing rate of noradrenergic neurons in the midbrain, thus causing CNS depression and reduction of anxiety. Euphoria is also because of the release of dopamine at nucleus coeruleus in the forebrain by dopaminergic neurons that originate in the ventral tegmental area in the midbrain. Opioid use causes reinforcement of the drug-taking behaviours because of these euphoric effects and the relief from anxiety. Repeated usage also causes neuroadaptive changes in these neurons, such that progressively less dopamine release in the nucleus coeruleus and less suppression of midbrain noradrenergic cells lead to reduced effects or increased doses being taken by the person (tolerance). When the person stops taking the drug, overexcited noradrenergic neurons in the midbrain give rise to the characteristic withdrawal symptoms of opioids.

Interventions for Opioid use Disorders 

Brief interventions

2. Group-based psychoeducational interventions
3. Information and advice
4. Opportunistic brief interventions

Formal psychosocial interventions

2. Contingency management
3. Cognitive-behavioural therapy and psychodynamic therapy
4. Interventions to improve concordance with naltrexone

Methadone for heroin dependence and withdrawal treatment

Methadone is a long-acting opiate agonist; its withdrawal begins after 36 hours; by this time heroin withdrawal has already peaked. Because of this, the symptoms of methadone withdrawal are milder. Long half-life also makes it less likely to make a user depend on it (remember withdrawal or the use of the drug to prevent withdrawal symptoms are part of the dependence syndrome).  

 

Depressive Pseudodementia

Introduction:

Depressive pseudodementia is a condition that has been described as having cognitive impairment, memory loss, and other symptoms that mimic those of dementia, but are caused by depression instead of a degenerative brain disease. In this article, we will explore the current understanding of depressive pseudodementia, including its diagnosis, symptoms, and treatment.

Diagnosis:

Depressive pseudodementia is not a recognized diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is the standard diagnostic manual for mental health conditions. However, some experts believe that it is a useful concept for understanding the relationship between depression and cognitive impairment (1). To be diagnosed with depressive pseudodementia, a patient must have symptoms that resemble those of dementia, but the symptoms must be caused by depression rather than a degenerative brain disease (2).

Symptoms:

The symptoms of depressive pseudodementia can include forgetfulness, confusion, difficulty concentrating, and problems with language and decision-making. These symptoms may be severe enough to interfere with daily activities and work, and may lead to a misdiagnosis of dementia. However, unlike dementia, which is a progressive and irreversible condition, the cognitive symptoms of depressive pseudodementia can be improved with appropriate treatment of the underlying depression (2).

Treatment:

Treatment for depressive pseudodementia typically involves psychotherapy and/or antidepressant medication. With proper treatment, the cognitive symptoms of the condition can be reversed, and patients can regain their cognitive functioning (3). However, early diagnosis is important, as delay in treatment can lead to a worsening of symptoms and decreased effectiveness of treatment (2).

Conclusion:

In conclusion, depressive pseudodementia is a condition that is characterized by cognitive impairment that is caused by depression. While it is not a recognized diagnosis in the DSM-5, it is considered a useful concept by some experts. The condition can be effectively treated with psychotherapy and/or medication, and early diagnosis is important for a good prognosis.

References:

1. Aalten, P., van Valen, E., de Vugt, M. E., Lousberg, R., Jolles, J., Verhey, F. R., & Rozendaal, N. (2003). Awareness and behavioral problems in dementia patients: A prospective study. International psychogeriatrics, 15(4), 365-375.
2. Steffens, D. C., Otey, E., Alexopoulos, G. S., Butters, M. A., Cuthbert, B., Ganguli, M., ... & Taylor, W. D. (2006). Perspectives on depression, mild cognitive impairment, and cognitive decline. Archives of general psychiatry, 63(2), 130-138.
3. Sheline, Y. I. (2003). Depression and the hippocampus: cause or effect?. Biological psychiatry, 54(3), 201-202.

Mental Health ACT of 2001 Explanation

 Mental Health ACT of 2001 Explanation

The following is a plain-language summary of the Mental Health Act (Ordinance) (2001). We made it to help make learning easy. 

If a patient is suffering from a mental disorder for which he needs inpatient assessment to prevent harm to the patient himself or others, but he is not willing to get admitted, section 10 can be used to admit(detain) him against his will (i.e. involuntarily). First, an application must be written (context from section 17, general provisions) by the nearest relative of the patient. A psychiatrist or medical officer can also write the application but, they must inform the nearest relative as soon as possible when they write the application. Anyone who writes the application must also specify the reasons for his eligibility to write the application. This application (Section 10à) must be based on the recommendations of two practitioners (one must be a1 psychiatrist, one medical officer). These two practitioners will write down their opinions and must specify the reasons why detention in the hospital is required (i.e., there is a risk, he is suffering, cannot be managed in the community, he is not consenting). The application must be signed and verified by the applicant.

With this application in hand, (Section-16à) the applicant (or someone authorized by him) can now take/convey the 2patient to the psychiatric 3facility for detention within two weeks after he was last examined by the psychiatrist or the medical officer who recommended detention. The (Section 15à) husband or wife of the patient will present the application (section 17) to the 4hospital management. If the spouse cannot present it, then the nearest relative of the patient must present it. He/she also must specify his connection/relationship with the patient (e.g. I am his brother) and the reason why the patient’s spouse can not present the application (e.g., she is dead, he is abroad, etc.). He must sign and verify the application before presenting it (in the psychiatric facility where they want to detain him). It is also mandatory that the presenter of the application must be an adult and must have personally seen the patient in the last two weeks.

The application (Section-16) authorizes the hospital management to detain him, within two weeks after he was last examined by the psychiatrist or the medical officer who recommended detention. They can do this without the need to verify that the signatures are real, and the practitioners who recommended detention are qualified

The psychiatrist (section 23à) can discharge a patient after assessment if he finds him capable of taking care of himself and not dangerous to himself and others. He must inform the relatives of the patient and notify the authority who referred him for detention about his discharge.

If you think that a patient needs a treatment which can save his life, or prevent harm to himself or others, including suffering or worsening of his condition violence, deliberate self-harm, suicide, etc., you should obtain consent as in other cases, according to section 51. But, if that is not possible, then you can give the treatment without consent, but only in the conditions enlisted.

The court will fix an amount of payment for the guardian of the patient so that he can spend on the care and maintenance of the patient and his dependents (e.g., children, wife, etc.). The manager of the property of the patient will keep paying this amount to the guardian.

The manager of the property will handle the care and the cost of treatment and maintenance of the patient and his dependents (e.g., children, wife, etc.). 

If a patient is not able to take care of himself, the court may name a guardian for him, who can look after him in a psychiatric facility.

 

 

 

 Schizotypal Personality Disorder

 Scenario

During an informal gathering, a teacher at a medical school discusses with you a first-year student who has just moved away from his parents to a hostel. The teacher states that he behaves strangely and tries to avoid socialisation. He does not have any friends but passes his time with video games. He sometimes enjoys spiritual activities and shows interest in magic. When a colleague tried to make fun of him, he resented a lot and lodged a written complaint with the principal. The parents state he is like this since his former life and has always been "different" but a "good" child. His academic record varies from average to above average.

1. What is the most likely diagnosis?
2. What psychodynamic factors may have contributed?
3. What are the risk factors for developing this disorder?

Diagnosis 

Schizotypal disorder/schizotypal personality disorder

Risk factors

This is more frequent among biological relatives of individuals with schizophrenia than among adopted relatives or controls (Kendler et al., 1981). 

A review of 17 structural imaging studies of people with this personality disorder found brain abnormalities that were similar in most ways to those in people with schizophrenia (Dickey et al., 2002). 

Similarly, there is sound evidence for a genetic contribution, with heritability scores of 0.35–0.81 in twin studies (Ji et al., 2006; Kendler et al., 2006, 2007). 

These findings suggest that this personality disorder may be a milder form of schizophrenia, or that the 2 are related in some other way.

Diagnostic criteria

To diagnose a schizotypal personality disorder, the patient must exhibit five or more of:

1. Ideas of reference, which must be non-delusional.
2. Odd beliefs or magical thinking, for example in clairvoyance, a sixth sense. 
3. Unusual ideas and perception and bodily illusions. 
4. Odd thinking and speech.
5. Suspicion or paranoid ideation.  
6. Inappropriate or constricted affect- 
7. Odd, eccentric or peculiar appearance and behaviour.
8. Lack of friends and confidants other than family.
9. Social anxiety that doesn't get better with familiarity because of paranoid fears

Mnemonic: ME PECULIAR

• M: Magical thinking or odd beliefs
• E: Experiences unusual perceptions
• P: Paranoid ideation
• E: Eccentric behaviour or appearance
• C: Constricted (or inappropriate) affect
• U: Unusual (odd) thinking and speech
• L: Lacks close friends
• I: Ideas of reference
• A: Anxiety in social situations
• R: Rule out psychotic disorders and pervasive developmental disorder

Summary of NICE Guidance for First-Episode Schizophrenia

> A complete assessment is mandatory before starting treatment

For people with first-episode psychosis offer:

●       oral antipsychotic medication with

●       psychological interventions (family intervention and individual CBT.)

Advise people who want to try psychological interventions alone that these therapies are more effective when delivered with antipsychotic medication.

If the person still wants to try psychological interventions alone:

1. offer family intervention and CBT
2. agree a time (1 month or less) to review treatment options, including introducing antipsychotic medication 
3.  continue to monitor symptoms, distress, impairment, and level of functioning (including education, training, and employment) regularly.

It is also mandatory to assess and monitor the physical health of the patients before commencing antipsychotics and during treatment.

Especially

1. Weight, BMI
2. Blood pressure and pulse
3. Serum lipids
4. Motor system and EPSEs
5. Blood glucose testing

And other baseline investigations

 

 

Human Resources, Psychometric and Treatment Facilities you need to make the Forensic Evaluations

Scenario

The local authorities have requested you to provide forensic psychiatry support for prison services in your area. What are the various human resources, psychometric, and treatment facilities that you would require to make the forensic evaluations?

Human Resources

1. Forensic psychiatrist
2. Forensic psychologist
3. Occupational therapist
4. Social worker
5. Trained nurses

Psychometric Tools

1. Historical clinical risk management-20 
2. Violence risk appraisal guide
3. Psychopathy checklist Revised
4. Sexual violence risk 20
5. Stalking assessment and management
6. Spousal assault risk assessment guide

General Scales

1. PANNS
2. HAMD
3. IPDE
4. HADS
5. CAGE/AUDIT
6. COWS
7. Coloured progressive matrices 

Treatment Facilities

1. Seclusion rooms
2. Electroconvulsive therapy rooms

Establishing a Geriatric (old-age) Clinic; Medications and their Principles, Psychometric Tools, and Intake Performa

Scenario:

In view of increasing needs for elderly population requiring psychiatric help, your medical superintendent asked you to develop a senior citizens' clinic in your hospital. 

1. Enlist and classify all medicines that you will need. 
2. State the principles on which you base your choices.
3. Enlist 8 psychometric tests/scales you will need?
4. Which information do you think you will consider while developing an intake proforma?

Principles Of Prescribing Medications in the Elderly

1. Avoid drugs with long-half-lives (increased already in this population because of reduced renal and liver function, increased volume of distribution and relatively higher body fat content)
2. Avoid drugs that worsen cognitive function, keeping in mind the rates of dementia in this population.
3. Keep in mind the risk of fall and over sedation with central depressants and the propensity to side effects.
4. Avoid drugs with an alpha-receptor blocking property (hypotension, prostate hypertrophy)

Suitable Choice of Medications in the Elderly 

Acetylcholine Esterase Inhibitors

1. Donepezil
2. Rivastigmine
3. Galantamine

NMDA Antagonists 

• Memantine

Antipsychotics

• Risperidone
• Quetiapine
• Haloperidol

Antidepressants

• Sertraline
• Citalopram
• Escitalopram
• Mirtazapine 
• Trazodone (for agitation and as a hypnotic)

Hypnotics

1. Lorazepam
2. Temazepam
3. Lormetazepam

Mood Stabilizers

• Valproate
• Carbamazepine
• Lithium Carbonate

Psychometric Tools and Rating Scales

Cognitions

1. MMSE
2. MoCA
3. Six-item cognitive scale
4. 7-Minute Screen

Behavioural

1. Mouse PAD
2. Behave AD

Delirium

• CAM

Depression

1. Geriatric depression rating scale
2. Cornel scale

Activities 

1. Bristol Scale
2. Disability scale for dementia

Global Function

• Clinical dementia rating

Other 

1. Frontal Assessment Battery
2. Hachinski scale

Intake Performa for Old-Age Units

The following are the useful components of the Intake Performa you would need. 

1. Identification data including a picture for later identification and demographics
2. Indication for admission 
3. Full history from the patient and carers
4. Complete physical and neurological and mental state examination
5. Functional assessment including cognitive status, motor functioning and mobility, activities of daily living especially self-care, global function, capacity, sensory impairments
6. Social assessment
7. Accommodation needs, 
8. Need for a carer 
9. Needs of carers
10. financial and legal issues
11. Power of attorney
12. Social activities
13. Risks: especially Risk of fall, risk of abuse
14. Pension/social support
15. Next of kin

Postnatal Causes of Learning Disability (Intellectual Disability)

Postnatal causes of learning or intellectual disability include head injury, infections, neurodegeneration, and toxicities. A study on the causes of developmental disability found bacterial meningitis, child battering, vehicle-related injuries, and otitis media as the most common causes. However, a developmental disability is a broader term that can include motor developmental disabilities too. The results still give us an idea as this overlap heavily with causes of pure intellectual disability. See Table 1.

Table 1: Most Common Causes of Developmental Disability
Bacterial meningitis	31%
Child battering	15%
Motor-vehicle- related injuries	11%
Otitis media	11%
Postnatal causes of developmental disabilities in children aged 3-10 years -- Atlanta, Georgia, 1991. MMWR Morb Mortal Wkly Rep 1996 Feb 16 45 130134

Head injury

1. Traumatic (accidental) brain injury; one of the most preventable causes of intellectual disabilities.
2. The shaken baby syndrome is the most common cause of non-accidental head injury that affects developing brains. 
3. They classify postnatal hypoxia as a perinatal cause if this occurs immediately following birth. However, if it occurs later, we may classify it as another postnatal cause of intellectual disability. 

Infections

1. Meningitis, especially bacterial meningitis, is one of the most common causes of intellectual disability. 
2. Encephalitis, that might be viral can also cause intellectual disability. At a later age, the international classification of disease categories the sequelae of encephalitis under organic mental conditions as a postencephalitic syndrome. 

Degenerative or demyelinating disorders 

Rett syndrome 

Signs of intellectual (learning) disability appear in girls with Rett syndrome at around 18 months to four years of age. Rett syndrome is a genetic disorder that occurs to due MeCP2 gene mutation; it is prenatal, but the appearance of intellectual disability is postnatal. 

Epilepsy

Children with frequent recurrent epileptic fits, for example, those with infantile spasms may develop intellectual disability because of brain injury. Children who experience more frequent fits and those who have more severe seizures are more likely to develop seizures than others. 

Toxic-Metabolic Disorders

Lead poisoning 

Lead poising could occur in areas where they still use lead in gas and other chemicals. Lead poising is a highly preventable cause of intellectual disabilities. 

Malnutrition

Malnutrition is a relevant cause of intellectual disability in countries with chronic malnutrition, it is a rare cause of intellectual disabilities overall, especially in developed countries. 

Environmental Deprivation

Non-stimulating environments impact intellectual development, for example, long-term institutional care. Severe long-term institutional deprivation could more likely cause intellectual disability than less severe brief institutionalisation. 

References

Postnatal Causes of Developmental Disabilities in Children (CDC)

Intellectual Disability: Causes (asha.org)

POSTNATAL CAUSES OF DEVELOPMENTAL DISABILITY. (jwatch.org)