Medicine (Abingdon, England : UK ed.)最新文献

Substances of abuse dysregulate key brain systems involved in motivation, reward, decision-making and memory. As drug use evolves into a compulsive addiction, there are adaptations in these systems, mediated by a number of different neurotransmitters. The mesolimbic dopaminergic pathway plays a central role in the reinforcing effects of drugs and the development of addiction. As addiction develops, there is a shift away from positive reinforcement to compulsive, habitual drug-seeking behaviours driven, for example, by craving or aversive withdrawal symptoms. Although the potential for addiction is common to many drugs, the underlying mechanisms, neurotransmission systems and adaptations vary between drugs. This review focuses on the neurobiology of addiction and tolerance for substances including alcohol, benzodiazepines, opioids and stimulants.

Delirium is a common neuropsychiatric syndrome. However, it is often misdiagnosed and management can be inconsistent and distressing for patients and their families. It has a diverse multifactorial aetiology and results in cerebral dysfunction. The criteria of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, and the International Classification of Diseases, 11th revision, are increasingly unified in describing the core symptoms and profile. The new profiles are characterized by an acute disturbance of attention with a fluctuating pattern and impaired cognition. These profiles then incorporate non-cognitive symptoms, including disordered thinking and hallucinations. Non-pharmacological interventions prioritize staff training, early intervention including physiotherapy, a review of medications and environmental adaptations. Potential pharmacological approaches include the careful use of sedation and low-dose antipsychotics.

Psychological therapies have been significantly developing in terms of theory and evidence over the past 30 years. They can be categorized into four broad families, defined by distinct theories of the person, psychopathology and change: cognitive behavioural, psychodynamic, person-centred and family/couples therapies. The underpinning theory and therapeutic approach of each form of therapy are briefly described, together with current outcome evidence with key references. Appropriate electronic resources are cited for each of the approaches described, and the wider literature on psychological approaches and current UK NHS planning is briefly covered.

Functional disorders (FDs) are characterized by physical symptoms that trigger the individual to seek healthcare but remain unexplained after appropriate medical assessment. They are common and cause significant distress and disability. What doctors say and do, and the design of the healthcare system, play key roles in their aetiology. When patients present with physical symptoms, it is important to rule out serious physical pathology. However, an early ‘positive’ diagnosis of FDs can lead to better outcomes than diagnosis by exclusion. Commonly associated psychiatric conditions include depression, anxiety and alcohol/substance abuse. If reassurance and simple reattribution techniques do not lead to symptom resolution, consider cognitive behavioural therapy or the use of antidepressants as neuromodulating agents (rather than as antidepressants per se).

Depression is an under-recognized, undertreated, common relapsing disorder that causes significant distress and impairment in social and occupational functioning. It is associated with an increased risk of death, not only through suicide, but also from physical illnesses such as cardiovascular disease. High-risk groups such as those suffering from chronic physical health problems should be screened for depression. Its aetiology is multifactorial, and co-morbidity with other psychiatric disorders is common. The assessment of depression requires determining the duration, symptom severity, suicide risk and functional impairment of the current episode, co-morbid diagnoses, past mood and treatment history, as well as obtaining a developmental, social and family history. Treatment is guided by illness severity, presentation and previous history, and includes psychosocial interventions, with antidepressant medication reserved for persistent and moderate to severe depression. Prevention of relapse is a priority, and risk factors for this should be assessed and used to guide prophylactic drug and psychological treatment.

Psychiatric assessment in elderly individuals requires a particular focus on cognition and co-morbid physical illness. There can be differences in psychiatric manifestation between younger and older adults. A structured approach to history-taking with a good understanding of the diagnostic hierarchy of psychiatric disorders allows for a clear biopsychosocial formulation. For organic conditions, particularly with cognitive and neurobehavioural deficits, management must be informed by the real-world impact of these problems.

Anxiety symptoms and disorders are common in community settings and primary and secondary care. Symptoms can be mild and transient, but many people are troubled by severe symptoms causing great personal distress and impairing social and occupational function. The societal burden from anxiety disorders is considerable, but many who might benefit from treatment are not recognized or treated. Recognition relies on a keen awareness of the psychological and physical symptoms of all anxiety disorders, and accurate diagnosis on identifying the specific features of particular disorders. All anxiety disorders have a range of contributory causes. The need for treatment is determined by the severity and persistence of symptoms, level of associated disability, impact on everyday life, presence of coexisting depressive symptoms and other features such as good response to or poor tolerability of previous treatments. The choice of treatment is influenced by patient characteristics and patient and doctor preferences. There is much overlap between different anxiety disorders in evidence-based and effective therapies (e.g. prescription of a selective serotonin reuptake inhibitor, course of cognitive behavioural therapy), but there are important differences. It thus helps to become familiar with the characteristic features and evidence base for each disorder.

Impulsive and compulsive disorders are common in young people, present in many medical settings, but frequently overlooked and left untreated. This article provides a primer on impulsivity and compulsivity, focusing on attention-deficit hyperactivity disorder (the archetypal impulsive disorder), obsessive–compulsive disorder (the archetypal compulsive disorder) and gambling disorder (a condition involving both features). We focus on their presentations, epidemiology, pathogenesis and usual course, how to recognize them clinically (including brief screening tools) and management approaches. Finally, we highlight other types of impulsive and compulsive symptom that are common but require more research to establish optimal assessment and treatment approaches.