Psychiatry: Psychiatry of Demographic Groups

Child Psychiatry I

Classification

  • Figure 19.1 shows how ICD-10 classifies childhood psychiatric disorders. DSM-5 categorises ADHD, autistic spectrum and communication disorders, intellectual disability, specific learning and motor disorders including Tourette’s disorder as neurodevelopmental disorders. Emotional and conduct disorders are categorised with adult disorders of emotion (depression/anxiety) and conduct/personality.

Psychiatric assessment of children

Interview the child, parental figures and teachers. Ask about:

  • current behavioural or emotional difficulties (including mood, sleep, appetite, elimination, relationships and antisocial behaviours);
  • school behaviour and academic performance;
  • daily routine (including hobbies);
  • family structure and interactions and past or current separations.
    Look for signs of abuse or neglect (Figure 19.2), interaction with parental figures and parenting style. Physical, including neurological, examination is an important part of the assessment.

Epidemiology

  • About 10% of boys and 6% of girls aged 5–10 years have an emotional or behavioural disorder, with the excess in boys due to higher rates of hyperkinetic ADHD and conduct disorders.
  • Figure 19.3 shows the main childhood disorders and their relationship to gender and age.

Hyperkinetic disorders (ICD-10); Attention-Deficit Hyperactivity Disorder (ADHD) (DSM-5)

  • Core symptoms are the presence for at least six months of:
    • short attention span
    • distractibility
    • overactivity
    • impulsivity.
  • Symptoms are almost always present by the age of 7, and occur in at least two settings (e.g. home and school).
  • It is less commonly recognised in the UK (using ICD-10 criteria) (<1%) than in the USA (7%) (using DSM-5 criteria), probably reflecting the UK’s narrower concept of ADHD.
  • ADHD frequently coexists with:
    • conduct disorder
    • anxiety and/or depression
    • language delay
    • specific reading retardation
    • antisocial behaviour
    • clumsiness.
  • Comorbidity predicts a poorer prognosis. Children with comorbid ADHD and conduct disorder are at particular risk of substance misuse disorders in adolescence.
  • Aetiological factors include:
    • genetic loading
    • social adversity
    • parental alcohol abuse
    • dietary constituents (lead, tartrazine)
    • exposure to tranquillisers.
      Severe forms are often associated with low intelligence, particularly in the context of brain damage (cerebral palsy, epilepsy).
  • Treatment approaches include:
    • parent training/education programmes;
    • classroom behavioural interventions by trained teachers;
    • methylphenidate in school-age children;
    • sometimes atomoxetine, a noradrenaline reuptake inhibitor.
  • In the majority of patients, the ADHD continues into adulthood, but diagnosis is frequently not made, they are not treated, and there are numerous adverse consequences including an excess of adult antisocial behaviour. Hyperactivity usually lessens by adolescence but learning difficulties may persist.

Conduct disorders

  • These are characterised by persistent disruptive, deceptive and aggressive behaviours, including:
  • The prevalence (4%) is higher in lower social classes.
  • Conduct disorders are associated with:
  • low self-esteem (poor peer relationships in 20%)
  • hyperkinetic disorders ADHD
  • learning or developmental disorders.
  • They are categorised as:
    • socialised conduct disorder – where behaviours are viewed as normal within the peer group or family;
    • unsocialised conduct disorder – where behaviours are solitary, with peer and parental rejection.
  • Aetiological factors include:
    • family disharmony;
    • harsh, violent, inconsistent parenting;
    • parents with alcohol dependence, antisocial personality disorder or depression.
  • Management involves sessions (typically 8–12) of group or individual parent-training/education programmes. These aim to:
    • help parents understand their own and their child’s emotions and behaviour;
    • improve parents’ communication with their child;
    • use behavioural management principles to help parents improve their child’s problem behaviours, e.g. through
      role-play, and homework to use rehearsed behaviours at home.
  • Cognitive–behavioural and social skills therapies may target the child’s aggressive behaviour or poor social interactions.
  • Antisocial behaviours persist into adult life in two-thirds of children with conduct disorder. Adults with antisocial personality disorder, substance, affective, anxiety and eating disorders, schizophrenia and mania, are more likely to have had conduct disorder.
  • Oppositional defiant disorder is:
    • usually seen in children under the age of 10 years;
    • characterised by persistent, angry and defiant behaviours;
    • similar to conduct disorder without severe aggressive or dissocial acts, and has a better prognosis.

Emotional disorders

  • As well as anxiety and depressive disorders, which occur in all ages, ICD-10 includes diagnoses describing unusually severe or persistent emotional responses to normal developmental phases (e.g. separation anxiety disorder and sibling rivalry disorder). Treatment involves behavioural and family therapy.
  • Generalised anxiety, the most common emotional disorder in childhood, has autonomic (palpitations, dry mouth) and psychological (fear) components. Somatic symptoms, particularly abdominal pain, are common. Predisposing factors include the child’s temperament and parental overprotection.
  • Phobias, particularly of the dark or of strangers, are common in small children and usually not clinically significant. When persistent and intense (often in response to parental or social reinforcement) the avoidance may become pathological.
  • Depression presents similarly to the adult disorder. Treatment involves psychological therapies. Current UK guidelines do not recommend the routine use of antidepressants; selective serotonin reuptake inhibitors (SSRIs) have been linked to suicidal or aggressive behaviour (fluoxetine is an exception, although careful monitoring is still advised).
  • Completed suicide is rare in children, and equally prevalent in boys and girls. Attempted suicide is more common in girls (3× boys) and lower social classes.
  • Bereavement reactions are common, with similar symptoms and stages of grief to adults. They may last for several months.
    Enuresis and temper tantrums in younger children, and sleep disturbance, poor school performance, acting-out behaviours and depressive illness in older children, may ensue. Where a parent has died, the surviving parent’s coping mechanisms are crucial.
  • Obsessive–compulsive disorder (OCD). Isolated obsessions and compulsions (e.g. not walking on paving-stone lines) are common in childhood. The prevalence of OCD is estimated to be around 0.3–1%. OCD presents much as in adults and usually responds to cognitive behavioural therapy (usually requiring family cooperation). Fluoxetine may be prescribed cautiously.
  • School refusal is not a diagnosis in itself. Child anxiety, bullying and difficult family dynamics are common causes. It accounts for 1% of school absences, with no gender or social class differences. It may present with somatic symptoms (headache, abdominal pain). Three peak ages are recognised: aged 5–6 years (separation anxiety); aged 10–11 years (school transition); and adolescents (12+ years) (low self-esteem and depression). Parents (often overprotective with no excess of marital discord) are aware and often collude. Treatment is graded or abrupt resumption of school attendance. Outcome is good in 60% of cases, although one-third have social difficulties and agoraphobia in adulthood.

Child Psychiatry II

Social functioning disorders

Elective (Selective) mutism

(can be diagnosed at any age and is not included under most of ‘child psychiatry’, i.e. neurodevelopmental disorders)

  • The child speaks fluently in familiar situations, such as home, but there is a lack of speech in less familiar settings, such as school, where there is an expectation of speaking.
  • The disturbance interferes with educational or occupational achievement or with social communication.
  • The duration is at least one month (not linked to the first month of school)
  • The failure to speak is not attributable to lack of knowledge
  • Affected children are usually very shy, withdrawn, with marked separation anxiety and a fear of social embarrassment.
    Two-thirds have language developmental delay.
  • Prevalence is approximately 1/1000.
  • Onset is typically in early childhood.
  • Aetiology is genetic (increased family history of elective mutism and adult social phobia) and environmental (typically geographical or social isolation and anxious and overprotective parents).
  • Long-term studies suggest that communication difficulties may extend into adulthood. The condition may be a precursor of adult social phobia.

Reactive attachment disorder

  • This is characterised by persistent abnormalities in a child’s pattern of relationships with parental figures and in other social situations; it usually develops before the age of 5. There are usually poor peer relations, fearfulness and hypervigilance that do not respond to reassurance, aggression towards self and others, misery, withdrawal and, in some cases, failure to thrive.
  • Reactive attachment disorder arises from severe disturbance in the formation of early attachment relationships, often due to severe parental neglect, abuse or mishandling.
  • Treatment seeks to achieve responsive, consistent parenting. This may require removing the child from the family.
  • If unresolved, it may progress to conduct disorder or adult antisocial personality disorder.

Other disorders

Enuresis

  • This is non-organic, involuntary bladder emptying after the age of 5 years. It can occur by day, by night or both, and is defined as secondary if there has been a period of urinary continence and primary if not.
  • Prevalence is 10% at age 5, 5% at age 10 and 1% at age 18. It is twice as common in boys.
  • Aetiological factors include positive family history, unsettling family events, developmental delay and other behavioural problems in the child.
  • Management involves:
    • exclusion of physical pathology (especially urinary tract infection);
    • addressing excessive or insufficient fluid intake or abnormal toileting patterns;
    • reward systems (e.g. star charts) used to reinforce success, but the emphasis should be on adherence to the programme rather than to dryness;
    • enuresis alarms: these devices are activated by moisture; alarms achieve dryness over time by training the child to recognise the need to pass urine and to wake to go to the toilet or hold on;
    • medication: desmopressin (synthetic antidiuretic hormone) or imipramine (a tricyclic antidepressant) are sometimes prescribed.
  • Ninety per cent of cases resolve by adolescence.

Encopresis

  • The deposition of stool in inappropriate places in the presence of normal bowel control.
  • Most children are faecally continent by 4 years. Prevalence of encopresis is about 2% in boys and 1% in girls at age 8 years.
  • Encopresis may reflect anger (with deposits positioned to cause maximum distress to parents/carers) or regression in children unable to cope with the increasing independence expected of them. Voluntary faecal retention with subsequent overflow is present in some cases.
  • Physical causes for constipation (e.g. Hirschsprung’s disease) or pain on defecation must be ruled out.
  • Encopresis is associated with emotional disturbance; intelligence is usually average or below average. There may be underlying parental marital conflicts, punitive potty training and/or sexual abuse.
  • Treatment aims both to restore normal bowel habits and to improve parent/child relationships. Parents should be encouraged to ignore the soiling and in particular not to punish the child. More specific treatments include behaviour modification (e.g. star chart) and family therapy. Drug treatments are of very little use, except the use of laxatives if constipation is present.
  • Ninety per cent of cases improve within one year and almost all resolve by adolescence. Associated conduct disorder may, however, persist.

Developmental/Neurodevelopmental disorders

Pervasive developmental disorders (PDD): is contained in ICD-10, but not DSM-5.

  • These are among the most frequent childhood neurodevelopmental disorders, present in 60–70/10 000. They include:
    • autism
    • asperger’s syndrome
    • childhood disintegrative disorder

Autistic Spectrum Disorder

  • DSM-5 uses the term ‘autism spectrum disorder’ (ASD) to refer to all these disorders (ICD 10 lists them separately).
  • This is present in about 20/10 000 children; it is more common in boys (3× more than in girls) and in social classes 1 and 2.
  • The onset is before the age of 3 years and can even occur in the first few months. Three features are regarded as essential to the diagnosis:
    • a pervasive failure to make social relationships (aloofness, lack of eye contact, poor empathy, etc.), i.e. social–emotional reciprocity;
    • major difficulties/deficits with verbal and non-verbal communication/language development;
    • deficits in developing, maintaining, and understanding relationships;
    • resistance to change with associated ritualistic and/or manneristic behaviours.
  • These may all reflect an inability to process emotional cues.
  • Affected children often exhibit:
    • inappropriate attachments to unusual objects,
    • insistence on sameness,
    • a restricted range of interests and activities,
    • stereotyped behaviours (rocking, twirling, etc.),
    • hyper/hyporeactivity to sensory input,
    • unpredictable outbursts of screaming or laughter,
    • DSM-5 requires specification of severity.
  • Ninety-five per cent have an IQ <95, but some have isolated skills (rote memory, computation).
  • Learning disability, deafness and childhood schizophrenia must be considered in the differential diagnosis.
  • Aetiological factors include:
    • genetic loading: associated genetic disorders include tuberous sclerosis and Fragile X syndrome;
    • perinatal complications.
  • Treatment is with specialist, intensive (>25 hours a week) behavioural treatments. These typically:
    • break down skills (such as communication and cognitive skills) into small tasks, then teach those tasks in a highly structured way;
    • reward and reinforce positive behaviour;
    • discourage and redirect inappropriate behaviour.
      Family support and counselling are crucial.
  • Fifteen per cent achieve fully independent functioning as adults.
  • Outcome is considerably better in those with a non-verbal IQ >70 and/or those in whom speech has developed by the age of 6 years.

Asperger’s syndrome (included in ICD-10 not DSM-5)

  • This is a less severe form of PDD with later onset, normal intelligence and language development and schizoid personality. Pedantic speech and a preoccupation with obscure facts often occur.

Childhood disintegrative disorder (disintegrative psychosis) (included in ICD 10, not included in DSM-5)

  • This is very rare; prevalence is around 2/100 000.
  • It is characterised by normal initial development (to age 4 years) and the subsequent onset of a dementia with social, language and motor regression with prominent stereotypes.
  • The aetiology includes infections (especially subacute sclerosing panencephalitis) and neurometabolic disorders.

Specific developmental disorders

Specific reading (learning) retardation
  • Reading difficulties that interfere with academic progress and are not accounted for by low intelligence, poor schooling or visual or auditory difficulties.
  • Prevalence is between 5% and 10%, with a marked male and working-class preponderance.
  • Neuropsychological testing often reveals perceptual and/or language deficits and there may be coexistent attention-deficit hyperactivity disorder (ADHD).
  • Dyslexia is an alternative name

Psychotic disorders

  • Psychoses of childhood are rare.
  • Childhood schizophrenia may be acute in onset (carrying a better prognosis) or have a prodrome of apparent developmental delay.
  • As in adolescence and adulthood, there is a genetic predisposition and the presentation is with hallucinations, delusions and thought disorder, but with a greater preponderance of motor disturbance, particularly catatonia.
  • Antipsychotics are the mainstay of treatment, but the risk of weight gain and metabolic syndrome is particularly high in young people and vigilance to such side effects is crucial.
  • Mania was thought not to occur before adolescence but is now increasingly recognised in the post-pubertal years.

Sleep problems

  • These are common in normal children with night-time wakefulness in 20% and sleep-talking in 10%.
  • DSM-5 refers to ‘Sleep–wake disorders’ including insomnia, hypersomnolence, narcolepsy, restless legs syndrome (not to be confused with akathisia), substance use disorders and those included below. In addition one must remember that sleep difficulties can be symptoms of ADHD and Tourette Syndrome.
  • Night terrors, in which children sit up terrified and screaming but cannot be woken sufficiently to be reassured, have a peak incidence (3%) at age 4–7 years and frequently a positive family history. They arise from deep (stage 4) sleep and are accompanied by tachycardia and tachypnoea. The incidences are aggravated by daytime stress and usually resolve spontaneously.
  • Nightmares (peak incidence age 5–6 years) that occur during REM sleep may be equally frightening and are also often stress related, but the child can be easily woken and reassured.

Links between child and adult mental health

There are strong links between childhood and adult mental health:

The Psychiatry of Adolescence

Adolescence

  • Adolescence starts with the onset of puberty and lasts until the attainment of full physical maturity.
  • About 13% of boys and 10% of girls aged 10–15 years have a psychiatric disorder.
  • Conduct and hyperkinetic disorders ADHD are more common in boys and emotional disorders (mostly anxiety and depression) in girls.
  • No psychiatric diagnoses are specific to adolescence; most adult and child psychiatric disorders are seen, often modified by the child’s developmental stage.

Psychiatric assessment in adolescence

  • Common presentations of psychiatric disorders in adolescence include emotional upset, identity issues, conflict with parents, delinquent behaviour and poor school performance.
  • Comorbidity (between mental disorders and with substance misuse and self-harm) is even more common than in adults:
  • Level of functioning and apparent ‘disorders’ must be distinguished from developmental norms.
  • Young people often do not acknowledge their own problems and parental and school involvement may cause conflict and distress.
    Trust and rapport must often be built up slowly in the face of resentment, suspicion and fear of being thought of as ‘mad’.
  • It is important to talk to the family to understand their perspective, as well as the family dynamics, which may be crucial in both aetiology and management.
  • Developmental history is important because many adolescent disorders have clear childhood antecedents.
  • The diagnostic process is the same as in adults, and DSM-IVTR or ICD-10 classifications are used.

Conduct disorder

  • Conduct disorder may emerge or worsen in adolescence.
  • About one-third of adolescents with conduct disorder develop adult antisocial personality disorder.
  • Psychosocial intervention should be the first line of treatment, along with treating comorbid disorders.
  • If problems are severe, medication may be used cautiously.
    • Atypical antipsychotics (in particular risperidone, which is licensed for conduct disorder) may reduce aggressive behaviours, especially if there are coexisting neurodevelopmental disorders, such as autistic spectrum disorder.
    • Selective serotonin reuptake inhibitors (SSRIs) may reduce impulsivity, irritability and lability of mood.

Eating disorders

  • Anorexia nervosa and bulimia nervosa are each found in about 1% of adolescents.
  • Anorexia has its peak prevalence in adolescence and, if mild, may be difficult to distinguish from age-appropriate preoccupation with dieting.
  • Adolescent-onset bulimia is increasingly common.

Mood disorders

  • Mild episodes of depression (characterised by loneliness and low self-esteem) occur in 25% of adolescents, and moderate or severe depression in about 8%.
  • Depression is about four times more common in adolescent girls.
  • Clinical features are essentially the same as in adults, but poor appetite, weight loss and feelings of hopelessness may be more prominent than overt sadness; sleep is more often prolonged than disrupted.
  • Interventions may include:
    • family therapy;
    • individual psychotherapy (particularly cognitive behavioural therapy);
    • antidepressants may be indicated where biological features are prominent. Because of concerns that SSRIs may increase the risk of suicidal thoughts and self-harm, only fluoxetine is generally recommended for depression under the age of 18.
  • Mania has a prevalence of up to 1% in adolescence; the presentation and management principles are similar to those for adults. Substance abuse and schizophrenia are the main differential diagnoses.

Anxiety, stress-related disorders

  • Anxiety most frequently presents as overwhelming, non-specific worrying and repeated need and/or demand for reassurance.
  • School refusal (as opposed to truancy) may arise from specific school-related phobias, anxiety or depression.
  • Social phobias, characterised by avoiding contact with strangers, are also seen. Reassurance and advice (to adolescent, parents and school) on coping strategies and, in more serious cases, behavioural therapy, usually help.
  • Anxiety may also arise in response to stress; presentations and management of acute stress reaction and post-traumatic stress disorder (PTSD) are similar to adults.

Obsessive–compulsive disorder (OCD)

  • Mild obsessionality is common in adolescence; true OCD may show prominent obsessional slowness and behaviour sufficiently bizarre to resemble schizophrenia. Resistance to the thoughts and behaviours may be absent.
  • Treatment usually involves cognitive behavioural therapy.
  • Where psychological treatment alone is not sufficient, SSRIs are recommended, with careful monitoring for side effects.
  • OCD usually continues into adulthood.

Schizophrenia

  • The peak age of onset of schizophrenia is in late adolescence.
  • Presentation is usually with deteriorating school performance; clinical features are otherwise as in adult life.
  • In younger adolescents, initial presentation is often with:
    • bizarre behaviour
    • social withdrawal and anxiety
    • only fleeting first-rank symptoms.
  • The differential diagnosis includes organic states, mood disorder, drug-induced psychosis, adolescent crises and schizoid personality.
  • Atypical antipsychotics and rehabilitation are the mainstays of management. Given the limited safety data on antipsychotic use in youth, clinicians should be vigilant for side effects.

Self-harm

  • Deliberate self-harm (DSH) is widespread in adolescents.
    It is more than twice as common among females as males.
    About 10% of girls aged 15–16 reported harming themselves in the previous year in a recent European survey. About half the young people decided to harm themselves in the hour before doing so, and many did not attend hospital or tell anyone else.
  • It is often related to problems in relationships (family or friends) or problems with school or study.
  • In the UK, over 90% of self-harm attempts involve overdoses, most often of paracetamol.
  • Contagion (self-harming behaviour linked to peer-group influences) may be an important factor in DSH by adolescents, especially in girls who cut themselves.
  • All children and young people who have harmed themselves should be admitted to a paediatric ward under the overall care of a paediatrician and assessed fully the following day.
  • Actual suicide (particularly in boys and where there is coexistent substance abuse) has become more frequent in recent years, and the risk must be considered.

Substance abuse

  • This is common in adolescence. Aetiology can include:
    • family and social adversity (or relative opulence)
    • vulnerable personality
    • peer pressure
    • associated conduct disorder or depression.
  • The hallmarks of problematic abuse are:
    • abrupt deterioration in school performance (absenteeism, low grades, poor discipline);
    • lawbreaking, fights;
    • apparent personality change;
    • lethargy, lack of motivation, lack of concentration;
    • unexplained deterioration in physical health;
    • slurred speech, drowsiness.
  • The patient usually denies any problems, and information from school or friends may therefore be vital.
  • Depression and self-harm are frequent; the rise in adolescent suicide is largely accounted for by substance misuse.

Capacity and confidentiality

  • The Mental Capacity Act (2005) in England and Wales and the Adults with Incapacity (Scotland) Act 2000 apply to people aged 16 and over. For those younger than 16, there is established case law governing consent to medical treatment.
  • The Mental Health Acts may apply to a person of any age, but in practice children are usually treated informally with their consent or that of a parent.
  • Health professionals are bound by duties of confidentiality to their patients and this includes young people.
  • There are some exceptions to this, in particular if the patient or another person is at risk of harm (e.g. from an abuser).
  • Respecting confidentiality does not mean that information should not be shared. Dialogue with parents and other carers and professionals is critical to care. It means professionals should seek consent to disclose information.

Learning Disability (Mental Retardation)

Definition and epidemiology

  • Learning disability (LD) comprises:
    • low intellectual performance,
    • onset at birth or in early childhood,
    • reduced life skills.
  • About 1.5% of the population has an LD. This has not fallen despite recent reductions in the incidence of severe LD because of concurrent improvements in prevention (see below) and survival.

Aetiology

  • Mild LD is not usually associated with specific causes and represents
    the lower end of the IQ normal distribution curve. IQ
    in general is strongly genetically determined, although the close
    correlation between parental and child IQ is also partly explained
    by shared social and educational deprivation.
  • More severe LD is usually related to specific brain damage.
  • Causes may be:
    • genetic:
      – chromosomal (e.g. Down, Klinefelter or Turner’s syndrome);
      – X-linked: Fragile X, Lesch–Nyhan syndrome;
      – autosomal dominant: tuberose sclerosis, neurofibromatosis;
      – autosomal recessive: usually metabolic disorders (e.g. phenylketonuria).
      Autism is usually associated with LD.
  • antenatal:
    • infective (e.g. toxoplasma, rubella and cytomegalovirus);
    • hypoxic, toxic or related to maternal disease.
  • perinatal: prematurity, hypoxia, intracerebral bleed
  • postnatal: infection, injury, malnutrition, hormonal, metabolic, toxic, epileptic.

Classification and clinical features

LD is classified as mild, moderate, severe and profound.

Psychiatric illness

  • The prevalence of psychiatric disorders is increased in people with LD (although most people with LD do not have a psychiatric disorder). Reasons for this include the following factors:
    • genetic
    • organic (particularly epilepsy)
    • psychological (frustration)
    • social (such as stigma).
  • Making specific psychiatric diagnoses can be difficult (particularly in people with moderate or severe LD) because of:
    • coexisting language deficits,
    • symptoms being attributed to the person’s LD.
  • Psychological reactions to adverse life events (such as bereavement) are often not recognised by carers.
  • Disorders with increased prevalence in LD include:
    • behavioural disturbance: more common with increasing severity of LD; occurs in <40% of children and 20% of adults with severe LD (e.g. purposeless or self-injurious behaviour, aggression or inappropriate sexual behaviour such as masturbation in public);
    • depression: diagnosis rests more on motor and behavioural changes (reduced sleep, retardation, tearfulness, etc.) than verbal expressions of distress;
    • anxiety: disorders (including obsessive–compulsive disorder and phobias);
    • dissociative symptoms: amnesia, episodes of unconsciousness, etc.;
    • schizophrenia: prevalence is 3% in LD and usually presents with simple and repetitive hallucinations and unelaborated, usually persecutory, delusions;
    • mania: usually presents as overactive/irritable behaviour.

Antenatal detection and prevention

  • Antenatal genetic counselling and testing gives parents the option of termination of pregnancy (e.g. for Down syndrome).
  • Improved perinatal care reduces the risk of brain injury.
  • Early detection of hormonal or metabolic problems (myxoedema, phenylketonuria) may allow treatment before LD occurs.

Management

  • Most people with LD now live in domestic homes, usually with their families.
  • Support is provided by primary care, educational and social services. Specialist multidisciplinary community teams coordinate local services; assess and manage any concurrent mental illness, social skills and problem-solving training; and provide support with finances and accommodation.
  • Children with mild LD usually receive educational support within mainstream schools; as adults, they may need support to access employment. Fewer people with LD than adults of normal intelligence with mental illness are in paid occupations.
  • Treatment of mental illness is similar to that for patients without LD. Challenging behaviour is usually managed with behavioural therapy and changes to the individual’s living situation and daily activities.
  • People with LD need written information to be accessible (in a format they can understand). Those with more severe LD sometimes use Makaton, a communication system of signs and gestures.
  • People with LD should be supported to make their own decisions if they can; if they cannot, decisions need to be made in their best interests, and capacity legislation applies.
  • It is important to be alert to potential reasons for psychological distress in people with LD. Common themes include:
    • realising that they may not achieve full independence,
    • realising that their parents are likely to die before they do,
    • issues around their sexuality.
  • Sensitive, frank communication at a level the person with LD can understand is important.
  • People with LD are at increased risk of physical, emotional and sexual abuse.

Cross-cultural Psychiatry

  • Culture is the way that different groups of people perceive the world and interact with their environment. It incorporates patterns of social and family relationships and religious beliefs.
  • Cross-cultural psychiatry examines concepts of mental health and illness and how symptomatology is culturally determined.

How culture can influence mental illness presentation and treatment

  • Figure 23.1 shows how culture may affect the presentation, diagnosis and outcome of mental illness.
  • It is important to consult someone knowledgeable in the relevant culture where there is doubt, to prevent misdiagnosing (or missing a diagnosis of) mental disorder.

Culture and standardised diagnosis

  • The World Health Organization’s International Pilot Study on Schizophrenia, carried out in the 1960s and 1970s, showed the following:
    • The prevalence of schizophrenia was remarkably stable across cultures.
    • Prognosis was better in non-Western societies. This may reflect greater availability of home support without high expressed emotion and the absence of a stigmatising label of chronic schizophrenia.
    • People with schizophrenia in Western developed countries showed a higher frequency of depressive symptoms, primary delusions, thought insertion and thought broadcasting, while in non-Western developing countries visual hallucinations were more frequent.
    • Psychotic disorders (including psychotic depression and schizophrenia) were diagnosed reliably (using very similar criteria) in different cultures, but neurotic (anxiety/depression) and dissociative diagnoses were much less secure.

Mental illness and minority ethnic groups living in Western countries

  • In the UK, the prevalence of schizophrenia is higher in African Caribbean people, especially those who are second generation, while the prevalence of schizophrenia in Caribbean countries is not raised.
  • Irish people have particularly high rates of psychiatric hospital admissions.
  • Putative explanations for these higher prevalences of mental illness in immigrant groups include:
    • higher rates of socioeconomic disadvantage;
    • racism;
    • the stress of migration (especially for refugees and asylum-seekers;
    • higher propensity for mental illness among those who move to another country;
    • misdiagnosis of affective disorders or cultural expressions of distress as schizophrenia;
    • differential responses by police, social and treatment services to some minority ethnic groups.
  • South Asian women have a higher rate of overdoses than White British women. This might reflect ‘culture conflict’ in this group.
  • Older African Caribbean people in the UK appear to be at greater risk of vascular dementia because of their higher prevalence of hypertension and other cardiovascular risk factors.

Racial differences in pharmacological response

Racial differences in distribution of enzyme polymorphisms explain:

  • increased sensitivity to alcohol (and decreased prevalence of alcohol dependence) in Asian people;
  • greater susceptibility to drug-induced dyskinesias in Asian people;
  • higher plasma levels for given doses of tricyclic antidepressants and lithium in Black than White Americans, with resultant increased sensitivity to both therapeutic and adverse effects.

Culture-bound syndromes

  • These denote patterns of symptoms or abnormal behaviour that are only recognised as illnesses in specific cultures.
  • DSM-5 places the emphasis on ‘cultural concepts of distress’.
    In ICD-10, they are coded according to the symptoms experienced (e.g. under dissociative or somatoform disorders).
  • Many have been described, mostly representing somatic and/or dissociative responses to stress. They include the
    following.
    • Amok, described in Africa, Asia and New Guinea, is a response to humiliation involving initial brooding, followed by a period of altered consciousness with uncontrollable (usually homicidal and sometimes suicidal) rage, for which the subject has no subsequent memory. Traditionally, surviving sufferers were immune from legal redress, much as the French crime passionnel.
    • Ataque de nervios occurs in Hispanic American groups, and consists of a grief reaction characterised by fluctuating conscious level (often with subsequent amnesia), crying, shouting, trembling and difficulty in moving limbs. Hyperventilation may be important in precipitating symptoms.
    • Latah, which occurs in Asia and North Africa, is a response to intense stress characterised by altered consciousness, hypersuggestibility and mimicry (including echolalia and echopraxia).
    • Koro, found mainly in Asia, involves intense anxiety centred on the belief that the genitalia are retracting and that their disappearance will result in death. The traditional management is to tie a string around the penis and pull. Koro is associated with local tradition that ghosts have no genitals and is thus not delusional.
    • Brain fag is found mainly in African students and is characterised by concentration difficulties, vague somatic complaints and depressed mood.
    • Some ‘Western’ syndromes, including multiple personality disorder, overdosing, anorexia nervosa, bulimia nervosa and chronic fatigue syndrome, may also be considered culture bound.

Psychiatry and Social Exclusion

  • Socially excluded people face barriers accessing essential services or participating in everyday life. Exclusion usually results from multiple disadvantages and perhaps an inability to negotiate meeting complex needs arising from those disadvantages.
  • People at risk of social exclusion include those who are homeless, prisoners, immigrants and people with disabilities or mental illness. Mental illness may be the cause or result of social exclusion.
  • Those who are socially excluded can become trapped in a cycle of unemployment, poverty, crime, poor-quality accommodation or homelessness.
  • In this chapter we look at the mental health of groups who are often socially excluded and discuss how mental health services have tried to reduce barriers to them accessing help for psychiatric disorders.
  • In all these groups, people’s socioeconomic status and experiences vary as much as in the general population. For example, asylum seekers are defined legally rather than on their plight, experience of asylum or status or income in their home country.
  • The likelihood of experiencing a severe mental illness varies with gender (being more common in women) and degree of economic disadvantage in these groups as in the general population.

Homeless people (Figure 24.1)

  • A minority of homeless people are rough sleepers; many more sleep in squats, night shelters, temporary accommodation or ‘sofa-surf ’ on friends’ floors.
  • In many areas, dedicated teams provide psychiatric and medical care for homeless people, in hostels, day centres, outpatient centres and, where necessary, the street. This targeted, flexible outreach service can reach a far higher number of homeless people than conventional services and provide care that they find acceptable. It is, however, more expensive.

Refugees

  • Nearly 1% of the world’s population are refugees or displaced people. Asylum seekers are those waiting for the government to decide if they will be granted refugee status.
  • Refugees have increased rates of anxiety, depression and posttraumatic stress disorder (PTSD) (<10% of refugees). High rates of suicide have been reported among asylum seekers held in detention or whose applications have been refused.
  • Figure 24.2 shows the stresses that may increase the vulnerability of asylum seekers to mental illness. They may be held in detention centres; access to welfare and housing is restricted and they cannot legally work. Forced unemployment among asylum seekers can lead to disability from which they cannot recover because employment permits income and a positive role in a society where they may be seen as competitors for resources.
  • Asylum seekers and refugees may face difficulties in accessing primary and (particularly) secondary health care, including psychiatric treatment because of language barriers or uncertainty over how to access help. Using interpreters where needed and providing information about how to access local services can help overcome these barriers.
  • Most applications for asylum in the UK are rejected, and those who remain after their application has been refused may be particularly vulnerable because they lose access to all benefits, accommodation, health and social care (except emergency care) and face deportation to the country from which they have fled.

Prisoners

  • Figure 24.3 shows the high rates of mental illness in prison and the reasons for it. Despite serious attempts by the prison service to keep illicit substances out of prisons, over a third report using drugs during their prison term. Drug use is particularly high among people charged with burglary, robbery and theft, suggesting that the high costs of illicit drugs may be a factor in their criminality.
  • People who have more social support, fewer recent stressful life events and who were working and married before entering prison are more likely to remain mentally healthy while in prison, but the proportion of such people in the prison system is low.
  • In the past most psychiatric care in UK prisons was provided by prison doctors, who referred to local psychiatric services when required. In response to concerns that prisoners were receiving a lower standard of care than the general population, Community Mental Health In-Reach Teams have been set up in many prisons.
    People who have committed serious offences (murder, rape or serious violent offences) usually receive any psychiatric care required from regional forensic services.
  • Prisoners who are seriously mentally ill cannot be compulsorily treated within the prison system in the UK, since the Mental Health Acts do not recognise prison hospital wings as hospitals.
    These prisoners must be transferred to psychiatric (usually secure) units with agreement of the courts. High secure UK psychiatric facilities such as Broadmoor, Rampton and Ashworth are classified as hospitals, although they work in partnership with the prison system.

Psychiatry and Female Reproduction

Mental illness during pregnancy

  • Around 10% of pregnant women have significant depression or anxiety. It is more common in those with:
    • a past psychiatric history,
    • conflicting feelings about the pregnancy,
    • a history of sexual abuse as a child,
    • ultrasound scans showing fetal anomalies.
  • The risk of psychosis is only increased if prophylactic medication is stopped, usually because of possible teratogenic effects.
  • Alcohol and drug misuse often reduces in pregnancy.
  • Alcohol, LSD and possibly cocaine are teratogenic.
  • Opiates and alcohol can cause intrauterine growth retardation and withdrawal in the newborn.
  • Suicide attempts may be reduced in pregnancy; those that occur are often associated with substance misuse.

Postpartum disorders

  • Figure 25.1 shows the postpartum disorders, when they usually happen and how common they are.
  • Risk of postpartum disorders appears similar after perinatal death (and less after abortion) to that after normal pregnancy and childbirth. Adequate opportunity to grieve should be provided, and bereavement counselling may be required. Formal psychiatric illness following termination of pregnancy is rare, but guilt feelings are common, need ventilating and may re-emerge in subsequent pregnancies.
  • Women who have a history of serious mood disorder (affective disorder or affective psychosis), postpartum or otherwise, have a risk of recurrence after childbirth of between 1 in 2 and 1 in 3. Ask about psychiatric history prenatally to plan management.

Postpartum blues

  • Postpartum blues are common and normal.
  • The symptoms are emotional lability, crying, irritability and worries about coping with the baby.
  • The cause is unclear; women with a history of premenstrual syndrome are at higher risk; elevated antepartum progesterone levels and precipitate postpartum falls in oestrogen, progesterone and sodium have been implicated.
  • There is no clear relationship with obstetric or social variables.
  • The blues are self-limiting, usually ending within a few days, but severe blues increase the risk of postpartum depression.
    No specific intervention is required (apart from reassurance), although, if symptoms do not resolve within two weeks, assess for depression.
  • Appropriate antenatal education to warn expectant mothers and their partners about the blues is helpful.

Postpartum depression

  • Clinical features are as for other depressive illness but may also include:
    • guilt and anxiety concerning the baby,
    • feelings of inadequate mothering,
    • unreasonable fears for the baby’s health,
    • a reluctance to hold or feed the baby,
    • (more rarely) thoughts of harming the baby.
  • It persists for a year or more in 25% of cases. Many cases are undetected.

Management involves full psychosocial assessment (including possible risk to mother and the baby).

  • First line of treatment for mild to moderate perinatal depression is psychological therapy and not antidepressants because of the potential for adverse effects in the foetus or breastfeeding baby (see Table 25.1).
  • Deliberate self-harm and suicide are less common in pregnancy and the postpartum year than at other times, but suicide is still one of the leading causes of maternal death in the UK and may be associated with infanticide.
  • Interruption to the development of the mother–baby bond may occur; this is not specific to depression and may also occur in the context of ambivalence about the pregnancy or adverse life events. Prolonged maternal depression may also affect later social and cognitive development of the child, even after resolution of the maternal illness.
  • About 10% of fathers also experience prenatal and postpartum depression. This is most common in the six months after the birth and is associated with maternal depression and relationship dissatisfaction.

Postpartum psychoses

  • Risk appears highest:
    • in those with a previous episode of psychosis (postpartum or otherwise – see Figure 25.1),
    • in first-time mothers,
    • after instrumental delivery,
    • in those with a family history of affective disorder.
  • Symptoms:
    • usually affective, most depressive but up to one-third manic (postpartum onset of schizophrenia is relatively unusual);
    • affective psychoses are often associated with Schneiderian first rank symptoms;
    • emotional lability and subjective confusion are common.
  • Assessment of suicide risk and of risk to the baby (who may suffer from neglect, inappropriate care, deliberate harm or even infanticide) is essential.
  • Treatment usually requires hospitalisation, sometimes compulsorily, and, unless there are specific reasons not to do so, this should be with the baby to a specialist mother-and-baby unit.
  • Treatment is usually with antipsychotics. Electroconvulsive therapy (ECT) has been reported to be particularly effective, irrespective of diagnostic group.
  • Short-term prognosis is excellent.

Prescribing in pregnancy and during breastfeeding

  • Antidepressants and antipsychotics are prescribed to many pregnant and breastfeeding women. We need to balance the risks of prescribing and not prescribing (Table 25.1).
  • Breastfeeding women prescribed psychotropic drugs should be advised how to time feeds to avoid peak drug levels in milk and how to recognise adverse drug reactions in their babies.
  • The evidence base is rapidly changing and specialist pharmacists or perinatal psychiatrists should be consulted where possible for updates on the current evidence.
  • When prescribing antidepressants, consider that:
    • Tricyclic antidepressants, such as amitriptyline, imipramine and nortriptyline, have lower known risks during pregnancy than other antidepressants, but most tricyclic antidepressants have a higher fatal toxicity index than selective serotonin reuptake inhibitors (SSRIs).
    • Sertraline is the SSRI with the lowest known risk during pregnancy. Paroxetine should be avoided as it has been associated with fetal heart defects and neonatal pulmonary hypertension (as have other SSRIs to a lesser extent); SSRIs are associated with a neonatal behavioural syndrome.
    • All antidepressants carry the risk of withdrawal or toxicity in neonates; in most cases effects are mild.
    • Imipramine, nortriptyline and sertraline are present in breast milk at relatively low levels; citalopram and fluoxetine
      are present at relatively high levels.
  • Mood stabilisers should be avoided where possible because:
    • Sodium valproate increases the risk of neural tube defects (from around 6 to 100–200 in 10 000) and can affect a child’s intellectual development.
    • Carbamazepine increases the risk of neural tube defects (to around 20 to 50 in 10 000) and other major fetal malformations including gastrointestinal tract problems and cardiac abnormalities.
    • Lithium raises the risk of cardiac malformations from 0.8% to an estimated 6%.
    • They can have adverse effects in breast-fed infants.
  • Antipsychotics are preferred to mood stabilisers for bipolar disorder. Low-dose typical antipsychotics such as haloperidol, chlorpromazine or trifluoperazine have the lowest known risks.
    Antipsychotics can induce an extrapyramidal syndrome in the baby. Olanzapine has been associated with gestational diabetes.
  • Benzodiazepines can cause cleft palate and other fetal malformations, and ‘floppy baby syndrome’ in the neonate.

Premenstrual Dysphoric Disorder (PDD)

  • Symptoms include low or labile mood, insomnia, poor concentration, irritability, poor impulse control, food craving and physical complaints (headache, breast tenderness and bloating).
  • Onset is after ovulation, with improvement within a few days of the onset of menstrual flow.
  • DSM-5 categorises it as PDD; ICD-10 lists it as a physical disorder.
  • Up to 95% of women of reproductive age have some symptoms, but only 3–8% meet the criteria for PDD.
  • Possible aetiological factors include a decrease in serotonin levels after ovulation, probably owing to interactions between oestrogen and serotonergic systems. Oestrogen may affect transcription of genes coding for synthesis of neurotransmitters and their receptors.

Functional Psychiatric Disorders in Old Age

  • Older people may suffer from the same functional psychiatric disorders as younger adults (mood, anxiety and psychotic disorders), and the presentation and management of these are essentially the same as earlier in life.
  • Older people continue to manifest personality disorders.
    • The degree of distress and disability caused by impulsive and antisocial traits often decreases with age.
    • Other traits may cause particular difficulty in negotiating the challenges of old age (e.g. people with schizoid traits may be less willing to accept home care, and people with anxious traits may have particular difficulty coping with chronic illness).

Depression in old age

Epidemiology and clinical features

  • Increased age is not linked with higher rates of depression, which affects around 13% of older people. Depression is more common in those with physical illnesses and/or dementia.
  • Older people with depression are less likely to receive treatment with antidepressants or talking therapy, even though they frequently consult their GP. This is partly because of the unjustified idea that depression is an inevitable consequence of ageing and also because of important differences in clinical presentation.
  • Older people with depression are less likely than younger people to report low mood; they may present needing help but with presenting complaints other than low mood.
  • They are also less likely to express suicidal ideation despite being at substantially higher risk of completed suicide.
  • Compared with younger adults, depression in older adults is more likely to present with:
    • disturbed sleep (but decreased sleep duration occurs in normal ageing);
    • multiple physical problems for which no cause can be found;
    • motor disturbance (retardation and/or agitation);
    • dependency having previously been independent.

Aetiology

  • Genetic factors are significant, although family history is less often positive than in younger depressed patients.
  • People who become depressed for the first time in late life are more likely to have brain-imaging abnormalities and poor treatment response. This suggests that late first-onset depression may, in some cases, reflect the onset of neurodegenerative changes.
  • Dementia is a risk factor for developing depression.
  • There is a well-documented association between vascular risk factors and depression in later life; about 20% of people with coronary artery disease develop depression.
  • Loss(es), such as bereavement, deteriorating physical health or financial insecurity may lead to depression. A third of older people live alone; many are socially isolated and lack confiding relationships.
  • Being in residential or nursing care doubles the risk of depression in old age.
  • Depression is increased in carers of people with dementia.

Management

  • Both physical and psychological treatments are effective, but they are underused in older people.
  • Reducing social and sensory isolation may be important (through, for example, hearing aids and glasses, and day centre referral).
  • Cognitive behavioural therapy may need to be modified to the needs of an older group but is effective in group as well as individual settings. In dementia, the focus may be on behavioural management and working with carers.
  • Antidepressants with a relative lack of contraindications and favourable side-effect profiles, including selective serotonin reuptake inhibitors (SSRIs), venlafaxine and mirtazapine, have been critical for the effective treatment of depression in older people, though randomised placebo-controlled trial evidence for efficacy is limited.
  • Tricyclic antidepressants are effective but usually avoided because of the higher risk of clinically important side effects, particularly postural hypotension and resultant falls.
  • Lithium augmentation is effective in some older patients with refractory depression.
  • Adherence to antidepressant treatment may be difficult to achieve in older people, particularly since they may take longer (up to eight weeks) to take effect. However, if there is little or no response to an adequate antidepressant at four weeks, a switch to an antidepressant from a different class should be considered.
  • There is new evidence that antidepressants are not effective in dementia (so consider other treatment first unless severe depression/risk of suicide).
  • Electroconvulsive therapy (ECT) is very effective in more severe depression, particularly in patients with delusions or psychomotor retardation and those refusing food or fluid, in whom the risk of irreversible physical deterioration is high.

Prognosis

  • Depression doubles the mortality rate in older people. Factors explaining this include:
    • medical morbidity – related to hypercortisolaemia in chronic depression, decreased exercise, non-adherence to medication, and self-neglect;
    • increased risk of suicide, especially in older depressed men.
  • The prognosis is improved by early intervention, because longer duration of depressive episode predicts poor outcome.
    There is a high risk of chronicity (about 50% if untreated) and of relapse. Secondary prevention (continuing antidepressant therapy to prevent relapse) is highly effective.

Anxiety disorders

  • General anxiety is often coexistent with (and responsive to the same treatment approaches as) depression.
  • New episodes of phobic disorder, particularly agoraphobia, are often precipitated by traumatic events (e.g. a fall).

Mania in old age

  • Mania accounts for about 20% of all psychiatric admissions for affective disorders in older people. Most have a past history of depression.
  • In about 20% of cases, new onset mania in older age is precipitated by acute physical illness such as stroke.
  • A tenth of new onset cases of mania occur over the age of 60.
  • Overt elation is less often present than in mania in earlier life, although the patient generally has grandiose ideation. The clinical picture more usually consists of irritability, lability of mood and perplexity, much like that of delirium but distinguishable by clear consciousness.
  • Antipsychotics are effective in acute treatment, and some (e.g. olanzapine) are affective at preventing relapse, but atypical antipsychotics must be used with particular caution in people with dementia or vascular risk factors because of increased risks of stroke.
  • Lithium may be used both acutely and in prophylaxis, although as many as 25% of older people (particularly those with Parkinson’s disease or dementia) develop neurotoxicity. Both therapeutic and toxic effects of lithium may occur at lower blood levels in old age, so close monitoring is needed.
  • The prognosis with treatment is good, although recurrence occurs in up to 50% by ten years.

Psychotic disorders

  • Older people with psychosis may have illnesses that have continued from earlier in life or be presenting with a first episode.
  • Symptoms are as for younger adults.
  • There is a second peak in the incidence of schizophrenia over the age of 60.
  • ICD-10 and DSM-5 do not distinguish between illnesses with onset in early and later life, but according to consensus:
    • late onset schizophrenia = onset age 40 to 60;
    • very late onset schizophrenia = onset age 60+.
  • Aetiological factors include:
    • a genetic component (with excess family history of psychiatric illness and particularly schizophrenia);
    • sensory deprivation (particularly deafness);
    • social isolation – people who have had few relationships often become isolated with retirement or immobility or occasionally loss of a partner in older age;
    • brain imaging abnormalities in schizophrenia as in younger people;
    • organic brain disease and underlying physical illness.
      Figure 26.3 describes the aetiology of late onset psychosis.
  • Treatment is often difficult because of lack of insight, but response to antipsychotics, combined if possible with social reintegration, is usually good. As older people are at particular risk of tardive dyskinesia, atypical antipsychotics are recommended.
  • Relapse is frequent if antipsychotics are withdrawn.