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Mental Health — Disease Index & Clinical Criteria

Written by Betra Youhanna, a medical student and not a doctor — check every detail against your own teaching.

Deck-derived finals-triage sheet · 14 disease entries + 13 criteria across 3 lectures · ICC-3 · Dementia · Neuropsychology (VM 086) · DM/Renal Psychiatry (VM 156)

C/P — Clinical Presentation
Inves — Investigations
Mng — Management
Special — Pathognomonic / disease-unique

Dementia Syndromes

6 entries
1

Alzheimer's Disease (AD)

Clinical Presentation
  • Insidious onset, usually memory impairment first → subsequently global cognitive deficits
  • Neurological examination normal early in disease
  • Case 1 — gradual memory decline over ~4 y; forgets conversations; misplaces items → believes others took them; forgets appointments; got lost driving a familiar route; poor insight; long-term memory fuzzy (mixes up vacation details); repeats same question
  • Late — cannot learn new information; forgets who wife/children are; slurred speech; sees people not in the room; needs help with ADLs; falls → wheelchair
  • Younger patients — prominent visuospatial deficits → posterior cortical atrophy (entry 5); language variant = logopenic aphasia
Investigations
  • Blood tests — exclude reversible causes
  • Neuropsychology — formal domain assessment, measure change
  • Brain imaging — hippocampal atrophy early → global cerebral atrophy later; serial coronal MRI shows progressive hippocampal loss over 18–36 months
  • EEG — excludes seizures; may help diagnosis
Management
  • Cholinesterase inhibitors e.g. donepezil — NICE (2007): treat only if MMSE 10–20
  • Treat co-existing depression; avoid sedatives; review the drug chart
Special — Pathology
  • Amyloid plaques + (tau-positive) neurofibrillary tangles
  • Biochemical deficiency of acetylcholine
2

Dementia with Lewy Bodies (DLB)

Clinical Presentation
  • Insidious onset — often executive function + posterior cortical functions
  • Memory less affected than AD
  • Fluctuating cognition · visual hallucinations · parkinsonism
  • Case 2 — restless in sleep from ~age 60; inattention + problem-solving difficulty; tremor + falls → diagnosed PD; visual hallucinations (small animals, children not present); losing track of time; insists on non-existent appointments; MMSE 25/30, executive dysfunction, posterior cortical deficits, memory relatively good, day-to-day fluctuation
Investigations
  • Standard dementia work-up — bloods, neuropsychology, imaging, EEG
Management
  • Cholinesterase inhibitors (AD and DLB)
  • Caution — sensitivity to neuroleptic drugs
Special
  • Neuroleptic sensitivity — disease-defining caution
  • Memory relatively spared vs AD; posterior-cortical + executive early
3

Frontotemporal Dementia (FTD)

Clinical Presentation — Behavioural Syndrome
  • Personality change · inappropriate social behaviour / disinhibition
  • Apathy, reduced speech · loss of empathy · loss of insight · abnormal eating behaviour
  • Executive dysfunction but memory relatively preserved
  • Case 3 — mid-50s; problem-solving trouble at work → paperwork only; initially treated as depression (bereavement) without improvement; impulsive; inappropriate comments; no concern for others' distress; less affectionate; MMSE 29/30, executive dysfunction, other domains intact
Investigations
  • Dementia work-up; consider space-occupying lesion in differential
Management
  • May need SSRI or neuroleptic later for behavioural symptoms — be cautious
Special — Pathology & Variants
  • Previously Pick's disease; frontal + temporal lobe atrophy
  • Semantic dementia — loss of knowledge of concepts → naming/comprehension difficulty; empty speech with circumlocutions
  • Progressive non-fluent aphasia — difficulty with speech production, comprehension intact
4

Vascular Dementia (VaD)

Clinical Presentation
  • Insidious onset in most — often 'slowing up' of cognition
  • Focal neurological signs / symptoms
  • Many have 'mixed' AD and VaD
Management
  • Aspirin or other antiplatelet agent
  • Treat vascular risk factors — hypertension, raised cholesterol
Special
  • Focal neurology + mixed AD/VaD pattern distinguish it from pure AD
5

Posterior Cortical Atrophy (Visual Variant AD)

Clinical Presentation
  • Marked, progressive visuospatial impairment with sparing of verbal functions (verbal memory + verbal reasoning)
  • Visual disorientation; language problems (logopenic aphasia); often younger patients
Investigations
  • MRI + PET — atrophy + decreased metabolism in parieto-occipital cortex (often right worse than left)
Special — Benson et al. 1988 features
  • Visuospatial impairments
  • Visual agnosia — apperceptive
  • Topographical disorientation
  • Dressing apraxia
  • Hemichromatopsia
6

Reversible Causes & Differentials of Cognitive Decline

Differentials to Exclude
  • Metabolic — hypothyroidism, B12 deficiency, folate deficiency
  • Depression (pseudodementia) — the Depression? Apathy? Dementia? triad to disentangle
  • Space-occupying lesion (SOL)
  • Seizures — excluded on EEG
Why It Matters
  • Bloods, imaging (SOL) and EEG (seizures) are done to catch reversible causes before labelling a degenerative dementia

Dementia Assessment

2 entries
7

History, 'Walk Round the Brain' & Behavioural Observation

History — from Patient AND Informant
  • Cognitive/neuropsychiatric/neurological symptoms: FIRST symptoms · TEMPO · memory · language · other cognitive areas · behaviour · neurological symptoms
  • Medical symptoms · PMH · drugs · detailed family history · social history
'Walk Round the Brain' — Localisation
  • Subcortical / primary sensory — alert & oriented? can they see and hear?
  • Left ('dominant') hemisphere — peri-Sylvian language; medial temporal → verbal memory
  • Right temporal — visual memory / face recognition
  • Right parietal — visuospatial / perceptual skills
  • Left parietal — literacy, calculation, limb praxis, forward digit span
  • Frontal — executive function
Observing the Patient — Behaviour
  • Impulsive · disinhibited/inappropriate · irritable · utilization behaviour · apathetic/impassive (looking to partner to respond) · eye contact · echolalia
8

Dementia — Investigations & Management

Investigations
  • Blood tests — exclude reversible causes
  • Neuropsychology — formal domain assessment, measure change
  • Brain imaging — excludes reversible cause (e.g. SOL); may aid diagnosis
  • EEG — excludes reversible cause (e.g. seizures); may aid diagnosis (alpha rhythm)
Management — 1) Drugs (by type)
  • VaD — aspirin/antiplatelet + treat vascular risk factors (hypertension, raised cholesterol)
  • AD & DLB — cholinesterase inhibitors e.g. donepezil (NICE 2007: MMSE 10–20)
  • FTD — SSRI or neuroleptic later for behavioural symptoms (cautious)
  • All dementias — treat co-existing depression; avoid sedatives; review drug chart
Management — 2) Non-pharmacological
  • Environmental modifications & activities; establishing routines
  • Safety, mobility, special senses, diet, continence
  • Social — needs assessments & services (GP vital), carers/families, day centres, finances/Power of Attorney, driving, occupational (esp. younger patients)

Diabetes & Renal Disease

3 entries
9

Type 1 Diabetes Mellitus

Clinical Presentation
  • Often younger age of onset; due to insulin deficiency
  • Polydipsia, polyuria, weight loss, fatigue, lethargy, infection, ketoacidosis
Investigations
  • Blood — raised glucose; urine — ketones; ABG — sometimes acidosis
Management
  • Insulin — keep glucose in normal range, adjust for diet & exercise
  • Regimen e.g. long-acting recombinant human insulin at night + shorter-acting during the day
  • Insulin pumps not commonly used in the UK (popular elsewhere)
  • Advice on diet, smoking, foot care
Special — Complications & Monitoring
  • Microvascular — retinopathy, neuropathy, nephropathy · Macrovascular — cardiovascular, cerebrovascular, peripheral vascular disease
  • Monitor — BP, HbA1c, fundi, lipids · Meds — renal-protective, lipid-lowering, aspirin, antihypertensives
10

Type 2 Diabetes Mellitus

Clinical Presentation
  • Often later age at onset; an 'epidemic' (171 M in 2000 → ~366 M by 2030; ~3 M UK, 90% type 2)
  • Often obesity ('diabesity') + reduced exercise → reduced insulin secretion + insulin resistance
  • May be preceded by impaired glucose tolerance / impaired fasting glycaemia
  • Presentation less acute than type 1 — thirst, polyuria, weight loss, infections
Management
  • Often oral hypoglycaemics e.g. metformin, gliclazide; may progress to insulin
  • General DM management — education + lifestyle (diet, smoking, exercise, alcohol); modify risks (BP, lipids, glycaemic control); screen & monitor complications (eyes, kidneys, feet/legs, heart, brain)
Special — Macrovascular Sequelae (deck)
  • MI · coronary atherosclerosis · cerebral infarct · cerebral bleed · peripheral vascular disease · necrotic leg wound
11

Chronic Kidney Disease / Renal Failure

Clinical Presentation
  • Variable — from weakness & fatigue
  • Late — arrhythmias, encephalopathy, seizures, coma
  • Spectrum — acute · chronic · end-stage renal disease · dialysis · transplantation; others (UTIs, renal stones, glomerulonephritis)
Investigations
  • Blood & urine tests, renal ultrasound, sometimes renal biopsy
Management
  • Treat causes + modify risk factors (hypertension, hyperlipidaemia)
  • ESRD → dialysis (haemodialysis / peritoneal) and/or transplantation
Special
  • Main causes of ESRD in the UK — hypertension, diabetes, glomerulonephritis
  • 5-stage classification by eGFR (see Criteria); opportunistic screening — value not yet known

Psychiatric Aspects of Physical Illness

3 entries
12

Depression in Physical Illness

Relationship to Physical Illness — 3 Routes
  • Physical condition causes depression directly (HPA — hypothalamic-pituitary-adrenal axis)
  • Medications cause depression — e.g. steroids, beta-blockers
  • Physical condition → psychological response → depression. Risk factors: CNS-affecting conditions, serious/life-threatening illness, past history of depression, lack of social support
Assessment (Biopsychosocial)
  • Harder to diagnose — biological features (appetite, sleep, weight loss, lethargy) may be due to the physical illness
  • More reliable markers — depressed mood, morning depression, hopelessness
  • May present as abnormal illness behaviours / non-adherence; DDx — adjustment disorder, substance misuse
Management — NICE CG91
  • Antidepressants for mild depression complicating physical health
  • Choose with the physical disorder in mind — SSRI-induced hyponatraemia in older people; drug interactions
  • Group CBT / behavioural couples therapy (moderate); collaborative care (moderate–severe non-responders)
13

Psychiatric Comorbidity in Diabetes & Renal Disease

Comorbid Psychiatric Disorders (both)
  • Depression · anxiety & panic disorder · PTSD · delirium · psychosis · adjustment disorder · non-adherence · abnormal illness behaviours
Diabetes
  • Commonest comorbidity = anxiety + depressive disorders; also confusional states
  • Diabetics at twice the risk of depression; depression increases mortality; adherence problems common
Renal Disease
  • Acute & chronic renal failure → delirium + neuropsychiatric problems
  • Comorbid disorders common → more hospitalisation (mainly depression or dementia); increased suicide in end-stage renal failure
  • Transplantation → better physical & psychological outcomes than dialysis; dialysis → neuropsychiatric problems if fluid/diet adherence poor
Special — ESRD Adjustment
  • Adapt to chronic illness + cope with dialysis; can resemble a grief reaction; denial common (may be adaptive)
  • Cognitive adaptation — managing uncertainty, searching for meaning, loss of control, openness, emotional + medical support; cognitive distortions + negative automatic thoughts common
14

Clinical Cases — DM & Renal (teaching points)

Case Vignettes
  • Case 1 — 24F, DM from age 12, insulin (lantus + novorapid), poor control (HbA1c up to 12%), recurrent abscesses, misses clinic → non-adherence & poor motivation
  • Case 2 — 55M, DM since 20, below-knee amputation + visual loss, failing renal transplant, TIAs + angina → depressed mood in multi-complication diabetes
  • Case 3 — 18M, DKA, refusing fluids + insulin → Mental Capacity Act in the acute setting
  • Case 4 — 50M, alcohol dependence, memory problems, DM on insulin, repeated admissions after insulin overdose when intoxicated → risk management
  • Case 5 — 78F, routine eGFR 50 → letter to attend → extreme anxiety at CKD stage 3 → health anxiety & implications of screening
  • Case 6 — 52M, renal failure from multiple myeloma, haemodialysis 3×/week, not transplant-eligible → chronic dysthymia

Diagnostic Criteria

2 entries
1

DSM-IV-TR — Psychological Factors Affecting General Medical Condition

Criterion A

  • A general medical condition is present

Criterion B — psychological factors adversely affect it via one of:

  • (1) Influenced the course — close temporal association with development, exacerbation, or delayed recovery
  • (2) Interfere with treatment
  • (3) Constitute additional health risks
  • (4) Stress-related physiological responses precipitate or exacerbate symptoms

Named subtypes (examples)

  • Mental disorder affecting… — e.g. major depressive disorder delaying recovery from MI
  • Psychological symptoms affecting… — e.g. depression delaying recovery from surgery; anxiety exacerbating asthma
  • Personality traits / coping style affecting… — e.g. pathological denial of need for surgery; hostile pressured behaviour → CVD
  • Maladaptive health behaviours — overeating, lack of exercise, unsafe sex
  • Stress-related physiological responses — ulcer, hypertension, arrhythmia, tension headache
  • Other / unspecified factors — interpersonal, cultural, religious
2

ICD-10 F54 — Psychological & Behavioural Factors with Disorders Classified Elsewhere

  • Records psychological or behavioural influences thought to have played a major part in the aetiology of physical disorders classified in other chapters
  • Resulting mental disturbances usually mild and often prolonged (worry, emotional conflict, apprehension) — do not themselves justify a category in this chapter
  • Example conditions — asthma, dermatitis, gastric ulcer, mucous colitis, ulcerative colitis, urticaria

Cognitive Assessment Tools

1 entry
3

MMSE — Mini-Mental State Examination (/30)

PointsTask
5Orientation to time — year, season, date, day, month
5Orientation to place — country, city, area, hospital, floor
3Registration — repeat 3 objects (bus, door, rose)
5Attention — serial 7s backwards, or "WORLD" backwards
3Recall — the 3 objects
2Naming — pencil, watch
1Repetition — "No ifs, ands, or buts"
33-stage command
1Read & obey — "Close your eyes"
1Write a sentence
1Copy 2 intersecting pentagons

Total 30. Many limitations — most useful for assessing change over time.

Neuropsychological Assessment (VM 086)

3 entries
4

Neuropsychological Assessment — Purpose & Principles

Premise

  • Specific brain regions underpin specific cognitive processes

Why refer

  • (1) Aid diagnosis · (2) determine nature & extent of impairment · (3) assess change in functioning · (4) direct intervention / rehabilitation

How it works — examines dissociations (differences) between:

  • Pre-morbid (optimal) vs current intellectual functioning — has overall level changed?
  • Different cognitive domains — any specific impairment?
  • Different aspects of one domain — which aspect is impaired?
  • Material-specific domains — is the impairment lateralised?
5

Neuropsychological Test Battery by Domain

#DomainTests
1Premorbid estimateNational Adult Reading Test (NART); educational + occupational history; reading-test performance
2Current IQWechsler Adult Intelligence Scale-III — Verbal (Vocabulary, Similarities, Arithmetic, Digit Span) & Performance (Picture Completion, Picture Arrangement, Block Design)
3MemoryRecognition & Recall, each verbal + non-verbal — Recognition Memory Test (Words, Faces); AMIPB story + figure recall
4LanguageGraded Naming Test
5Visual processingIncomplete Letters
6Attention & executiveStroop Test · Verbal fluency · Weigl Sorting Test · Trail Making Test B · Hayling Sentence Completion Test
7Speed of information processingSymbol Digit Modalities Test
6

Case Pattern → Posterior Cortical Atrophy

Test Results

  • Premorbid NART FSIQ 98 (Average); Verbal IQ 102 (Average) vs Performance IQ 55 (Impaired)
  • Memory — RMT Words 25th %ile vs RMT Pictorial <1st %ile; Language (Graded Naming) 25–50th %ile
  • Visual processing — Incomplete Letters <5th %ile; Executive — Verbal fluency 82nd %ile, Hayling Average

Preserved vs Impaired

  • Preserved — single-word reading/comprehension, writing, verbal reasoning, naming by description, calculation, executive function, verbal memory
  • Impaired — non-verbal reasoning, picture naming, non-verbal memory, construction, visual-perceptual + visual-spatial function

Interpretation

  • Marked, progressive visuospatial impairment with sparing of verbal functions → Posterior Cortical Atrophy syndrome (visual variant AD)

Behaviour-Change & Psychotherapy Frameworks

4 entries
7

NICE CG91 — Depression with a Chronic Physical Health Problem

  • Antidepressants — consider for mild depression complicating the physical illness; account for physical disorder, side effects (esp. SSRI hyponatraemia in older people) & drug interactions
  • Group CBT or behavioural couples therapy (if relevant) — for moderate depression
  • Collaborative care — for moderate–severe depression not responding to CBT, interpersonal therapy, an antidepressant, or a combination
8

Cognitive Behavioural Therapy (CBT)

  • Model — physical symptoms, thoughts, emotions and behaviours are interrelated
  • Useful when patients struggle to adjust to illness, adhere to treatment, or show abnormal illness behaviours
  • Assessment — functional analysis of events + identifying cognitive distortions → formulation
  • Treatment — education, cognitive restructuring, behavioural interventions
9

Motivational Interviewing (Rollnick & Miller)

  • Patient-centred counselling to facilitate change in health-related behaviours
  • Principles — express empathy · develop the discrepancy (deeply held values vs current behaviour) · work with resistance to change · increase self-confidence to make change possible
10

Transtheoretical Model of Change (Prochaska & DiClemente)

  • Provides the theoretical background for motivational interviewing
  • Stages of change: Precontemplation → Contemplation → Preparation → Action → Maintenance

Prescribing

2 entries
11

Psychotropic Medication in Diabetes

  • Most antipsychotics increase diabetes risk — highest with clozapine & olanzapine
  • Least diabetogenic — aripiprazole, amisulpride, ziprasidone
  • SSRI (e.g. fluoxetine) — suggested first-line antidepressant
  • Duloxetine — used in diabetic neuropathy
  • TCAs & MAOIs — increase weight and affect glucose control
12

Psychotropic Medication in Renal Disease

  • Impaired renal function → altered pharmacokinetics + reduced drug excretion
  • Lithium is nephrotoxic — avoid in moderate–severe renal failure
  • 'Start low and go slow'
  • Antipsychotics — avoid those excreted by the kidney (e.g. sulpiride) and those with anticholinergic effects; haloperidol & olanzapine considered reasonable

Classifications

1 entry
13

Chronic Kidney Disease — Staging by eGFR

StageeGFR (ml/min)Severity
1>90—
260–89Mild failure
330–59Moderate failure
415–29Severe failure
5<15End-stage failure