In qualitative research, data saturation refers to the point where additional data collection becomes unnecessary as the responses obtained are repetitive and do not provide any new insights. This is when the researcher has heard the same information repeatedly and there is no need to continue recruiting participants. Understanding data saturation is crucial in qualitative research.

The likelihood of developing PTSD is greater for females. Additionally, experiencing significant distress and dissociation during the initial traumatic event are also linked to the development of PTSD.

Stress disorders, such as Post Traumatic Stress Disorder (PTSD), are emotional reactions to traumatic events. The diagnosis of PTSD requires exposure to an extremely threatening of horrific event, followed by the development of a characteristic syndrome lasting for at least several weeks, consisting of re-experiencing the traumatic event, deliberate avoidance of reminders likely to produce re-experiencing, and persistent perceptions of heightened current threat. Additional clinical features may include general dysphoria, dissociative symptoms, somatic complaints, suicidal ideation and behaviour, social withdrawal, excessive alcohol of drug use, anxiety symptoms, and obsessions of compulsions. The emotional experience of individuals with PTSD commonly includes anger, shame, sadness, humiliation, of guilt. The onset of PTSD symptoms can occur at any time during the lifespan following exposure to a traumatic event, and the symptoms and course of PTSD can vary significantly over time and individuals. Key differentials include acute stress reaction, adjustment disorder, and complex PTSD. Management of PTSD includes trauma-focused cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and supported trauma-focused computerized CBT interventions. Drug treatments, including benzodiazepines, are not recommended for the prevention of treatment of PTSD in adults, but venlafaxine of a selective serotonin reuptake inhibitor (SSRI) may be considered for adults with a diagnosis of PTSD if the person has a preference for drug treatment. Antipsychotics such as risperidone may be considered in addition if disabling symptoms and behaviors are present and have not responded to other treatments. Psychological debriefing is not recommended for the prevention of treatment of PTSD. For children and young people, individual trauma-focused CBT interventions of EMDR may be considered, but drug treatments are not recommended.

An 18 C temperature reading is below the typical range for urine, indicating that the sample may not be fresh and could potentially be a replacement sample.

Drug Screening

Drug testing can be conducted through various methods, but urinalysis is the most common. Urine drug tests can be either screening of confirmatory. Screening tests use enzymatic immunoassays to detect drug metabolites of classes of drug metabolites in the urine. However, these tests have limitations, such as false positives due to cross-reactivity. Therefore, any positive test should be confirmed through gas chromatography of mass spectrometry.

People may try to manipulate drug testing procedures by adulterating the sample. Normal urine parameters, such as temperature, specific gravity, and pH, can assist in detecting adulterated samples. Adulterants include household items like vinegar, detergent, and ammonia, as well as commercially available products. Diluted urine may also yield false negatives.

Detection times vary from person to person, and the approximate drug detection time in urine can be found in a table provided by Nelson (2016). False positives can occur due to cross-reactivity, as illustrated by Moeller (2017). Clinicians should be aware of the limitations of urine drug tests and the potential for manipulation.

Familial Risk of Alzheimer’s Disease

The risk of developing Alzheimer’s disease is increased for first-degree relatives of patients who develop the disorder before the age of 85. This risk is three to four times higher than the risk for individuals without a family history of the disease. It is important for healthcare professionals to advise relatives of patients with Alzheimer’s disease about their increased genetic risk and provide appropriate support and resources.

Drug Misuse (Law and Scheduling)

The Misuse of Drugs Act (1971) regulates the possession and supply of drugs, classifying them into three categories: A, B, and C. The maximum penalty for possession varies depending on the class of drug, with Class A drugs carrying a maximum sentence of 7 years.

The Misuse of Drugs Regulations 2001 further categorizes controlled drugs into five schedules. Schedule 1 drugs are considered to have no therapeutic value and cannot be lawfully possessed of prescribed, while Schedule 2 drugs are available for medical use but require a controlled drug prescription. Schedule 3, 4, and 5 drugs have varying levels of restrictions and requirements.

It is important to note that a single drug can have multiple scheduling statuses, depending on factors such as strength and route of administration. For example, morphine and codeine can be either Schedule 2 of Schedule 5.

Overall, the Misuse of Drugs Act and Regulations aim to regulate and control the use of drugs in the UK, with the goal of reducing drug misuse and related harm.

Cholinesterase inhibitors are approved for treating Alzheimer’s dementia and Parkinson’s disease dementia (rivastigmine). However, their use in frontotemporal dementia can worsen behavior. According to NICE guidelines, these drugs can be used for non-cognitive symptoms in dementia with Lewy bodies if non-pharmacological methods are ineffective of unsuitable, and if antipsychotic drugs are not appropriate of have not been effective. They may also be used in mixed dementia with a primary Alzheimer’s pathology.

The SCOFF Questionnaire for Screening Eating Disorders

The SCOFF questionnaire is a tool used to screen for eating disorders. It consists of five questions that aim to identify symptoms of anorexia nervosa or bulimia. The questions include whether the individual makes themselves sick because they feel uncomfortably full, worries about losing control over how much they eat, has recently lost more than one stone in a three-month period, believes themselves to be fat when others say they are too thin, and whether food dominates their life.

A score of two or more positive responses indicates a likely case of anorexia nervosa or bulimia. The questionnaire has a sensitivity of 84.6% and specificity of 98.6% when two or more questions are answered positively. This means that if a patient responds positively to two of more questions, there is a high likelihood that they have an eating disorder. The negative predictive value of the questionnaire is 99.3%, which means that if a patient responds negatively to the questions, there is a high probability that they do not have an eating disorder.

Overall, the SCOFF questionnaire is a useful tool for healthcare professionals to quickly screen for eating disorders and identify individuals who may require further assessment and treatment.

The typical location for the implanted pulse generator (IPG) in DBS treatment is subcutaneously below the clavicle, which is similar to where cardiac pacemakers are placed. While IPGs are sometimes placed abdominally, it is less common. Peripherally inserted central catheter (PICC) lines are usually located in the antecubital fossa, and external microphones for cochlear implants are implanted in the temporal bone. Cardiac pacemakers may be placed in the axilla.

Diagnostic Shadowing: The Danger of Assuming One Condition Explains All

Diagnostic shadowing refers to the risk of assuming that a single condition can account for all of a patient’s behavior of symptoms. This can lead to misdiagnosis and inappropriate treatment. For instance, a patient with a learning disability may be assumed to be aggressive solely due to their disability, when in fact they may have an underlying condition such as schizophrenia that has not been identified. Failing to recognize this underlying condition can result in ineffective treatment and a failure to address the root cause of the patient’s behavior. It is important for healthcare professionals to be aware of the potential for diagnostic shadowing and to consider all possible explanations for a patient’s symptoms. By doing so, they can provide more accurate diagnoses and better care for their patients.

Hanson & Bussiere (1998) conducted a thorough analysis on this topic and found that the most significant indicators of sexual offense recidivism are factors associated with sexual deviance, including deviant sexual preferences, previous sexual offenses, early onset of sexual offending, and the variety of sexual crimes committed. The most powerful predictor was determined to be sexual attraction to children, as measured by phallometric assessment.

Methods of Risk Assessment

Methods of risk assessment are important in determining the potential harm that an individual may pose to others. There are three main methods for assessing risk to others: unstructured clinical approach, actuarial risk assessment, and structured professional judgment. The unstructured clinical approach is based solely on professional experience and does not involve any specific framework. Actuarial risk assessment uses tools that are based on statistical models of weighted factors supported by research as being predictive for future risk. Structured professional judgment combines professional judgment with a consideration of static and dynamic risk factors. Following this, the risk is formulated, and a plan is devised. There are various tools available for each method, such as the Historical-Clinical-Risk Management-20 (HCR-20) for violence, the Risk of Sexual Violence Protocol (RSVP) for sexual risk, and the Hare Psychopathy Checklist (PCL-R) for violence. It is important to use a multidisciplinary approach and consider all relevant risk factors in the formulation.

NICE recommends a combination of oral antipsychotic medication and psychological interventions, specifically family intervention with individual cognitive-behavioral therapy, for children and young people experiencing their first episode of psychosis.

Schizophrenia in children and young people is treated similarly to adults, according to the NICE Guidelines. The Maudsley Guidelines suggest avoiding first generation antipsychotics and using olanzapine, aripiprazole, and risperidone, which have been proven effective in randomized controlled trials. In cases where treatment resistance is present, clozapine should be considered.

Measures of dispersion are used to indicate the variation of spread of a data set, often in conjunction with a measure of central tendency such as the mean of median. The range, which is the difference between the largest and smallest value, is the simplest measure of dispersion. The interquartile range, which is the difference between the 3rd and 1st quartiles, is another useful measure. Quartiles divide a data set into quarters, and the interquartile range can provide additional information about the spread of the data. However, to get a more representative idea of spread, measures such as the variance and standard deviation are needed. The variance gives an indication of how much the items in the data set vary from the mean, while the standard deviation reflects the distribution of individual scores around their mean. The standard deviation is expressed in the same units as the data set and can be used to indicate how confident we are that data points lie within a particular range. The standard error of the mean is an inferential statistic used to estimate the population mean and is a measure of the spread expected for the mean of the observations. Confidence intervals are often presented alongside sample results such as the mean value, indicating a range that is likely to contain the true value.

If an individual experiences symptoms that meet the criteria for Post-Traumatic Stress Disorder but the event of situation is not considered serious, they should be diagnosed with adjustment disorder instead. Additionally, it is common for individuals who have experienced a highly traumatic event to develop adjustment disorder rather than Post-Traumatic Stress Disorder. The diagnosis should be based on meeting the full diagnostic criteria for either disorder, rather than solely on the type of stressor experienced.

Stress disorders, such as Post Traumatic Stress Disorder (PTSD), are emotional reactions to traumatic events. The diagnosis of PTSD requires exposure to an extremely threatening of horrific event, followed by the development of a characteristic syndrome lasting for at least several weeks, consisting of re-experiencing the traumatic event, deliberate avoidance of reminders likely to produce re-experiencing, and persistent perceptions of heightened current threat. Additional clinical features may include general dysphoria, dissociative symptoms, somatic complaints, suicidal ideation and behaviour, social withdrawal, excessive alcohol of drug use, anxiety symptoms, and obsessions of compulsions. The emotional experience of individuals with PTSD commonly includes anger, shame, sadness, humiliation, of guilt. The onset of PTSD symptoms can occur at any time during the lifespan following exposure to a traumatic event, and the symptoms and course of PTSD can vary significantly over time and individuals. Key differentials include acute stress reaction, adjustment disorder, and complex PTSD. Management of PTSD includes trauma-focused cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and supported trauma-focused computerized CBT interventions. Drug treatments, including benzodiazepines, are not recommended for the prevention of treatment of PTSD in adults, but venlafaxine of a selective serotonin reuptake inhibitor (SSRI) may be considered for adults with a diagnosis of PTSD if the person has a preference for drug treatment. Antipsychotics such as risperidone may be considered in addition if disabling symptoms and behaviors are present and have not responded to other treatments. Psychological debriefing is not recommended for the prevention of treatment of PTSD. For children and young people, individual trauma-focused CBT interventions of EMDR may be considered, but drug treatments are not recommended.

Measures of dispersion are used to indicate the variation of spread of a data set, often in conjunction with a measure of central tendency such as the mean of median. The range, which is the difference between the largest and smallest value, is the simplest measure of dispersion. The interquartile range, which is the difference between the 3rd and 1st quartiles, is another useful measure. Quartiles divide a data set into quarters, and the interquartile range can provide additional information about the spread of the data. However, to get a more representative idea of spread, measures such as the variance and standard deviation are needed. The variance gives an indication of how much the items in the data set vary from the mean, while the standard deviation reflects the distribution of individual scores around their mean. The standard deviation is expressed in the same units as the data set and can be used to indicate how confident we are that data points lie within a particular range. The standard error of the mean is an inferential statistic used to estimate the population mean and is a measure of the spread expected for the mean of the observations. Confidence intervals are often presented alongside sample results such as the mean value, indicating a range that is likely to contain the true value.

The use of SSRIs and tricyclics is not recommended for individuals under the age of 18 who engage in deliberate self-harm. Instead, family therapy and counseling are preferred options. The Committee on Safety of Medicines has advised against the use of citalopram, escitalopram, paroxetine, and sertraline due to an unfavorable balance of risks and benefits for treating depressive illness in this age group. While fluoxetine has shown some benefit, there are concerns about an increased risk of self-harm and suicidal thoughts.

DBT is a specialized version of CBT designed specifically for individuals with borderline personality disorder.

Dialectical Behavioural Therapy (DBT) is a form of psychotherapy that is tailored for patients with borderline personality disorder. It combines behavioural therapy with aspects of Zen Buddhism and dialectical thinking to help patients develop important interpersonal and emotional regulation skills. DBT has five functions, including enhancing behavioural capabilities, improving motivation to change, assuring new capabilities generalise to the natural environment, structuring the environment so that appropriate behaviours are reinforced, and enhancing motivation of the therapist.

DBT uses a hierarchy of treatment targets to help the therapist determine the order in which problems should be addressed. The treatment targets in order of priority are life-threatening behaviours, therapy-interfering behaviours, quality of life behaviours, and skills acquisition. DBT skills include mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation. Overall, DBT is an effective form of therapy for patients with multiple problems, and it helps them develop the skills they need to achieve their goals and improve their quality of life.

The relative risk (RR) of the event of interest in the exposed group compared to the unexposed group is 2.5.

RR = EER / CER
EER = 10 / 200 = 0.05
CER = 10 / 500 = 0.02
RR = EER / CER
= 0.05 / 0.02 = 2.5

This means that the exposed group has a 2.5 times higher risk of experiencing the event compared to the unexposed group.

Measures of Effect in Clinical Studies

When conducting clinical studies, we often want to know the effect of treatments of exposures on health outcomes. Measures of effect are used in randomized controlled trials (RCTs) and include the odds ratio (of), risk ratio (RR), risk difference (RD), and number needed to treat (NNT). Dichotomous (binary) outcome data are common in clinical trials, where the outcome for each participant is one of two possibilities, such as dead of alive, of clinical improvement of no improvement.

To understand the difference between of and RR, it’s important to know the difference between risks and odds. Risk is a proportion that describes the probability of a health outcome occurring, while odds is a ratio that compares the probability of an event occurring to the probability of it not occurring. Absolute risk is the basic risk, while risk difference is the difference between the absolute risk of an event in the intervention group and the absolute risk in the control group. Relative risk is the ratio of risk in the intervention group to the risk in the control group.

The number needed to treat (NNT) is the number of patients who need to be treated for one to benefit. Odds are calculated by dividing the number of times an event happens by the number of times it does not happen. The odds ratio is the odds of an outcome given a particular exposure versus the odds of an outcome in the absence of the exposure. It is commonly used in case-control studies and can also be used in cross-sectional and cohort study designs. An odds ratio of 1 indicates no difference in risk between the two groups, while an odds ratio >1 indicates an increased risk and an odds ratio <1 indicates a reduced risk.

Promethazine is approved for temporary use in managing sedation, allergies, hives, and symptoms of nausea and vomiting. However, it is not approved for treating insomnia.

Insomnia is a sleep disorder characterized by difficulty falling asleep, staying asleep, waking up too early, of feeling unrefreshed after sleep. The management of insomnia depends on whether it is short-term (lasting less than 3 months) of long-term (lasting more than 3 months). For short-term insomnia, sleep hygiene and a sleep diary are recommended first. If severe daytime impairment is present, a short course of a non-benzodiazepine hypnotic medication may be considered for up to 2 weeks. For long-term insomnia, cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment.

Pharmacological therapy should be avoided, but a short-term hypnotic medication may be appropriate for some individuals with severe symptoms of an acute exacerbation. Referral to a sleep clinic of neurology may be necessary if another sleep disorder is suspected of if long-term insomnia has not responded to primary care management. Good sleep hygiene practices include establishing fixed sleep and wake times, relaxing before bedtime, maintaining a comfortable sleeping environment, avoiding napping during the day, avoiding caffeine, nicotine, and alcohol before bedtime, avoiding exercise before bedtime, avoiding heavy meals late at night, and using the bedroom only for sleep and sexual activity.

Antipsychotics: Minimum Effective Doses

The Maudsley Guidelines provide a table of minimum effective oral doses for antipsychotics in schizophrenia. The following doses are recommended for first episode and relapse (multi-episode) cases:

– Chlorpromazine: 200mg (first episode) and 300mg (relapse)
– Haloperidol: 2mg (first episode) and 4mg (relapse)
– Sulpiride: 400mg (first episode) and 800mg (relapse)
– Trifluoperazine: 10mg (first episode) and 15mg (relapse)
– Amisulpride: 300mg (first episode) and 400mg (relapse)
– Aripiprazole: 10mg (first episode and relapse)
– Olanzapine: 5mg (first episode) and 7.5mg (relapse)
– Quetiapine: 150mg (first episode) and 300mg (relapse)
– Risperidone: 2mg (first episode) and 4mg (relapse)

The minimum effective doses may vary depending on individual patient factors and response to treatment. It is important to consult with a healthcare professional before making any changes to medication dosages.

The DSM-5 states that symptoms of ASD must be present in the early developmental period, although they may not be fully apparent until social demands exceed limited capacities of are masked by learned strategies later in life. Typically, symptoms are recognized between 12-24 months of age, but may be observed earlier if developmental delays are severe of later if symptoms are more subtle. While individuals with ASD may have formal language skills such as vocabulary and grammar, their ability to use language for reciprocal social communication must be impaired in order to meet diagnostic criteria.

Autism Spectrum Disorder (ASD) is a lifelong disorder characterized by deficits in communication and social understanding, as well as restrictive and repetitive behaviors. The distinction between autism and Asperger’s has been abandoned, and they are now grouped together under the ASD category. Intellectual ability is difficult to assess in people with ASD, with an estimated 33% having an intellectual disability. ASD was first described in Europe and the United States using different terms, with Leo Kanner and Hans Asperger being the pioneers. Diagnosis is based on persistent deficits in social communication and social interaction, as well as restricted, repetitive patterns of behavior. The worldwide population prevalence is about 1%, with comorbidity being common. Heritability is estimated at around 90%, and both genetic and environmental factors seem to cause ASD. Currently, there are no validated pharmacological treatments that alleviate core ASD symptoms, but second-generation antipsychotics are the first-line pharmacological treatment for children and adolescents with ASD and associated irritability.

Opiate withdrawal is more likely to result in diarrhoea than opiate use.

Illicit drugs, also known as illegal drugs, are substances that are prohibited by law and can have harmful effects on the body and mind. Some of the most commonly used illicit drugs in the UK include opioids, amphetamines, cocaine, MDMA (ecstasy), cannabis, and hallucinogens.

Opioids, such as heroin, are highly addictive and can cause euphoria, drowsiness, constipation, and respiratory depression. Withdrawal symptoms may include piloerection, insomnia, restlessness, dilated pupils, yawning, sweating, and abdominal cramps.

Amphetamines and cocaine are stimulants that can increase energy, cause insomnia, hyperactivity, euphoria, and paranoia. Withdrawal symptoms may include hypersomnia, hyperphagia, depression, irritability, agitation, vivid dreams, and increased appetite.

MDMA, also known as ecstasy, can cause increased energy, sweating, jaw clenching, euphoria, enhanced sociability, and increased response to touch. Withdrawal symptoms may include depression, insomnia, depersonalisation, and derealisation.

Cannabis, also known as marijuana of weed, can cause relaxation, intensified sensory experience, paranoia, anxiety, and injected conjunctiva. Withdrawal symptoms may include insomnia, reduced appetite, and irritability.

Hallucinogens, such as LSD, can cause perceptual changes, pupillary dilation, tachycardia, sweating, palpitations, tremors, and incoordination. There is no recognised withdrawal syndrome for hallucinogens.

Ketamine, also known as Vitamin K, Super K, Special K, of donkey dust, can cause euphoria, dissociation, ataxia, and hallucinations. There is no recognised withdrawal syndrome for ketamine.

The Significance of Containment in Therapeutic Relationships

Containment is a term coined by Bion to describe the process of emotional containment, which is best exemplified by the relationship between a mother and her infant. Infants often project their unbearable feelings onto their mothers, who receive and accommodate them for a while, making them tolerable and acceptable again to the child.

In therapeutic relationships, containment plays a crucial role. It occurs when one person receives and comprehends the emotional communication of another without being overwhelmed by it. The receiver then processes the information and communicates understanding and recognition back to the other person. This process can help restore the other person’s capacity to think.

Overall, containment is an essential aspect of therapeutic relationships, as it allows individuals to express their emotions without fear of being judged of rejected. It creates a safe space for individuals to explore their feelings and thoughts, leading to greater self-awareness and personal growth.

Snowball sampling is a unique technique utilized in qualitative research when the desired sample trait is uncommon. In such cases, it can be challenging of expensive to locate suitable respondents. Snowball sampling involves existing subjects recruiting future subjects, which can help overcome these difficulties. For more information on this method, please refer to the additional resources provided.

The question is specifically inquiring about the physical symptom, which is also known as the somatic symptom. The term ‘somatic’ pertains to bodily sensations of experiences, rather than mental of emotional ones.

Generalised Anxiety Disorder: Symptoms and Diagnosis

Generalised anxiety disorder is a condition characterized by persistent symptoms of anxiety that last for several months and occur on most days. The symptoms can be either general apprehension of excessive worry about multiple everyday events, such as family, health, finances, and work of school. In addition to these symptoms, individuals with generalised anxiety disorder may experience muscular tension, motor restlessness, sympathetic autonomic overactivity, nervousness, difficulty concentrating, irritability, of sleep disturbance.

To diagnose generalised anxiety disorder, healthcare professionals look for specific essential features. These include marked symptoms of anxiety that are not restricted to any particular environmental circumstance, and are accompanied by additional characteristic symptoms such as muscle tension, autonomic overactivity, nervousness, difficulty concentrating, irritability, and sleep disturbances. The symptoms must persist for at least several months, for more days than not, and cannot be better accounted for by another mental disorder of medical condition. The symptoms must also result in significant distress of impairment in personal, family, social, educational, occupational, of other important areas of functioning.

In the UK, sertraline and fluvoxamine are approved for treating obsessive compulsive disorder in young individuals, while other SSRIs such as fluoxetine, paroxetine, and citalopram have demonstrated safety and efficacy and may be used off-label.

OCD and BDD are two mental health disorders that can affect children. OCD is characterized by obsessions and compulsions, while BDD is characterized by a preoccupation with an imagined defect in one’s appearance. Both disorders can cause significant distress and impairment in daily functioning.

For mild cases of OCD, guided self-help may be considered along with support and information for the family of caregivers. For moderate to severe cases of OCD, cognitive-behavioral therapy (CBT) that involves the family of caregivers and is adapted to suit the child’s developmental age is recommended. For all children and young people with BDD, CBT (including exposure and response prevention) is recommended.

If a child declines psychological treatment, a selective serotonin reuptake inhibitor (SSRI) may be prescribed. However, a licensed medication (sertraline of fluvoxamine) should be used for children and young people with OCD, while fluoxetine should be used for those with BDD. If an SSRI is ineffective of not tolerated, another SSRI of clomipramine may be tried. Tricyclic antidepressants other than clomipramine should not be used to treat OCD of BDD in children and young people. Other antidepressants (MAOIs, SNRIs) and antipsychotics should not be used alone in the routine treatment of OCD of BDD in children of young people, but may be considered as an augmentation strategy.

Teratogens and Their Associated Defects

Valproic acid is a teratogen that has been linked to various birth defects, including neural tube defects, hypospadias, cleft lip/palate, cardiovascular abnormalities, developmental delay, endocrinological disorders, limb defects, and autism (Alsdorf, 2005). Lithium has been associated with cardiac anomalies, specifically Ebstein’s anomaly. Alcohol consumption during pregnancy can lead to cleft lip/palate and fetal alcohol syndrome. Phenytoin has been linked to fingernail hypoplasia, craniofacial defects, limb defects, cerebrovascular defects, and mental retardation. Similarly, carbamazepine has been associated with fingernail hypoplasia and craniofacial defects. Diazepam has been linked to craniofacial defects, specifically cleft lip/palate (Palmieri, 2008). The evidence for steroids causing craniofacial defects is not convincing, according to the British National Formulary (BNF). Selective serotonin reuptake inhibitors (SSRIs) have been associated with congenital heart defects and persistent pulmonary hypertension (BNF). It is important for pregnant women to avoid exposure to these teratogens to reduce the risk of birth defects in their babies.

There are several licensed options for treating ADHD in adults, including lisdexamfetamine, atomoxetine, dexamphetamine, and methylphenidate.

ADHD Diagnosis and Management in Adults

ADHD is a behavioural syndrome characterised by symptoms of inattention, hyperactivity, and impulsivity. The DSM-5 and ICD-11 provide diagnostic criteria for ADHD, with the DSM-5 recognising three subtypes of the condition: predominantly inattentive, predominantly hyperactive-impulsive, and combined.

Treatment for ADHD in adults includes medication and non-pharmacological interventions. NICE recommends offering medication to adults with ADHD if their symptoms are still causing significant impairment after environmental modifications have been implemented and reviewed. Methylphenidate of lisdexamfetamine are first-line medications, with atomoxetine offered for those who cannot tolerate the former two. Additional medication options may be considered with advice from a tertiary ADHD service.

NICE advises against elimination diets, dietary fatty acid supplementation, and the use of the ‘few foods diet’ for ADHD. Prior to initiating medication, referral to cardiology is recommended if there is a suggestion of cardiac pathology. If a person with ADHD develops mania of psychosis, ADHD treatment should be stopped until the episode has resolved. If a person taking stimulants develops tics, medication options may be adjusted.

– Schizophrenia and other primary psychotic disorders are characterized by impairments in reality testing and alterations in behavior.
– Schizophrenia is a chronic mental health disorder with symptoms including delusions, hallucinations, disorganized speech of behavior, and impaired cognitive ability.
– The essential features of schizophrenia include persistent delusions, persistent hallucinations, disorganized thinking, experiences of influence, passivity of control, negative symptoms, grossly disorganized behavior, and psychomotor disturbances.
– Schizoaffective disorder is diagnosed when all diagnostic requirements for schizophrenia are met concurrently with mood symptoms that meet the diagnostic requirements of a moderate or severe depressive episode, a manic episode, of a mixed episode.
– Schizotypal disorder is an enduring pattern of unusual speech, perceptions, beliefs, and behaviors that are not of sufficient intensity of duration to meet the diagnostic requirements of schizophrenia, schizoaffective disorder, of delusional disorder.
– Acute and transient psychotic disorder is characterized by an acute onset of psychotic symptoms, which can include delusions, hallucinations, disorganized thinking, of experiences of influence, passivity of control, that emerge without a prodrome, progressing from a non-psychotic state to a clearly psychotic state within 2 weeks.
– Delusional disorder is diagnosed when there is a presence of a delusion of set of related delusions, typically persisting for at least 3 months and often much longer, in the absence of a depressive, manic, of mixed episode.

Psychotic Depression

Psychotic depression is a type of depression that is characterized by the presence of delusions and/of hallucinations in addition to depressive symptoms. This condition is often accompanied by severe anhedonia, loss of interest, and psychomotor retardation. People with psychotic depression are tormented by hallucinations and delusions with typical themes of worthlessness, guilt, disease, of impending disaster. This condition affects approximately 14.7-18.5% of depressed patients and is estimated to affect around 0.4% of community adult samples, with a higher prevalence in the elderly community at around 1.4-3.0%. People with psychotic depression are at a higher risk of attempting and completing suicide than those with non-psychotic depression.

Diagnosis

Psychotic depression is currently classified as a subtype of depression in both the ICD-11 and the DSM-5. The main difference between the two is that in the ICD-11, the depressive episode must be moderate of severe to qualify for a diagnosis of depressive episode with psychotic symptoms, whereas in the DSM-5, the diagnosis can be applied to any severity of depressive illness.

Treatment

The recommended treatment for psychotic depression is tricyclics as first-line treatment, with antipsychotic augmentation. Second-line treatment includes SSRI/SNRI. Augmentation of antidepressant with olanzapine or quetiapine is recommended. The optimum dose and duration of antipsychotic augmentation are unknown. If one treatment is to be stopped during the maintenance phase, then this should be the antipsychotic. ECT should be considered where a rapid response is required of where other treatments have failed. According to NICE (ng222), combination treatment with antidepressant medication and antipsychotic medication (such as olanzapine or quetiapine) should be considered for people with depression with psychotic symptoms. If a person with depression with psychotic symptoms does not wish to take antipsychotic medication in addition to an antidepressant, then treat with an antidepressant alone.

Eating Disorders: NICE Guidelines

Anorexia:
For adults with anorexia nervosa, consider individual eating-disorder-focused cognitive behavioural therapy (CBT-ED), Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), of specialist supportive clinical management (SSCM). If these are not acceptable, contraindicated, of ineffective, consider eating-disorder-focused focal psychodynamic therapy (FPT). For children and young people, consider anorexia-nervosa-focused family therapy (FT-AN) of individual CBT-ED. Do not offer medication as the sole treatment.

Bulimia:
For adults, the first step is an evidence-based self-help programme. If this is not effective, consider individual CBT-ED. For children and young people, offer bulimia-nervosa-focused family therapy (FT-BN) of individual CBT-ED. Do not offer medication as the sole treatment.

Binge Eating Disorder:
The first step is a guided self-help programme. If this is not effective, offer group of individual CBT-ED. For children and young people, offer the same treatments recommended for adults. Do not offer medication as the sole treatment.

Advice for those with eating disorders:
Encourage people with an eating disorder who are vomiting to avoid brushing teeth immediately after vomiting, rinse with non-acid mouthwash, and avoid highly acidic foods and drinks. Advise against misusing laxatives of diuretics and excessive exercise.

Additional points:
Do not offer physical therapy as part of treatment. Consider bone mineral density scans after 1 year of underweight in children and young people, of 2 years in adults. Do not routinely offer oral of transdermal oestrogen therapy to treat low bone mineral density in children of young people with anorexia nervosa. Consider transdermal 17-β-estradiol of bisphosphonates for women with anorexia nervosa.

Note: These guidelines are taken from NICE guidelines 2017.