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

Eating disorders are common, affecting 5–10% of young people, with >50% of these having an illness that persists for >5 years. The main eating disorders are anorexia nervosa, bulimia nervosa and binge-eating disorder. Eating disorders with binge eating now dominate. New diagnostic categories have been introduced (avoidant/restrictive food intake disorder, pica, rumination disorder). Genetic factors interacting with environmental stress (some shared with other psychiatric disorders, others relating to metabolism and eating) increase the risk. Self-management strategies, including a focus on social emotional functioning and behavioural change skills to manage fears and habits, are moderately effective. Olanzapine shows some evidence in anorexia nervosa but cannot be generally recommended, fluoxetine is approved in bulimia nervosa, and lisdexamfetamine has been approved for binge-eating disorder in some countries, although not the UK. Inpatient care and family involvement are important in the management of anorexia nervosa.

Schizophrenia is a severe mental illness affecting several domains of cognition and behaviour. The illness commonly manifests in late adolescence to early adulthood and often follows a prolonged course. It is associated with a high degree of morbidity and mortality, and is a leading contributor to disease burden and health and social care costs throughout the world. Antipsychotic medication are the mainstay of treatment but are limited by significant adverse effects, and around one-quarter of patients do not respond to standard antipsychotic treatment. Schizophrenia is associated with a range of adverse physical health outcomes, which can be compounded by lifestyle factors, barriers to health and social care, and the adverse effects of treatment. Psychological and social interventions are a crucial element of care, particularly in alleviating negative psychotic symptoms. Current theories view schizophrenia as a disorder of early brain development, with interacting genetic and environmental risk factors.

Migration and asylum occur for a range of personal and geopolitical reasons. In an increasingly globalized world, migrants, refugees and asylum seekers show higher than expected rates of mental illness. Cultures and cultural identities strongly influence presentation, help-seeking and therapeutic alliance. Minority ethnic groups have higher than expected rates of psychiatric disorders, and their idioms of distress and pathways to care often vary compared with the majority population: thus, they need particular consideration in terms of their mental healthcare. Clinicians dealing with minority ethnic groups must use a culturally sensitive and appropriate approach. This paper highlights some of the factors that clinicians need to be aware of and take into account while planning therapeutic interventions. The authors make recommendations regarding assessment and management. Assessment must incorporate factors including primary language, religion, cultural identity and, where applicable, migration history. ‘Cultural competence’ must be a priority in developing and delivering services.

Attention-deficit hyperactivity disorder (ADHD) is a common condition with neurodevelopmental origins that typically starts in early childhood and follows a persistent trait-like course. It is characterized by inattention, impulsivity and hyperactivity that persist over time and lead to clinical and psychosocial impairments. Emotional instability is a common feature and sometimes the main presenting complaint. Neurodevelopmental and psychiatric co-morbidities are common. ADHD can be diagnosed and treated at all ages, and persists into adulthood in around two-thirds of individuals. Many adults with ADHD were not diagnosed as children. Psycho-education and environmental adaptations are recommended in all cases. If significant impairment remains in at least one domain after implementation and a review of environmental modifications, pharmacological treatments are recommended. Drug treatments are similar at all ages. Methylphenidate is the recommended first-line drug in children and adolescents. If ineffective or not tolerated, lisdexamfetamine is recommended as second-line treatment, followed by atomoxetine and guanfacine. In adults, lisdexamfetamine or methylphenidate is recommended as first-line treatment, followed by atomoxetine. Atomoxetine can be used as first line when there are concerns with potential drug abuse or diversion, or high levels of co-morbid anxiety. ADHD-focused groups should be offered if significant impairment remains after drug treatment.

The aim of this article is to draw attention to how the process of assessment, diagnosis, and formulation of children with suspected psychiatric disorder differs from that of adults. Development and the importance of context are two key concepts. These influence each stage of assessment: the gathering of clinical information, identification of symptoms, making of a diagnosis and development of a formulation.

Dementia is an umbrella term for a number of organic brain diseases that together affect approximately 940,000 people in the UK. Most diseases leading to dementia are characterized by processes that result in the abnormal build-up of proteins in the brain. The most common cause of dementia is Alzheimer's disease, but other important causes include vascular dementia, dementia with Lewy bodies and fronto-temporal dementia. The management of dementia largely focuses on helping patients and families to manage increasing care needs as the condition progresses, including the treatment of troublesome neuropsychiatric symptoms. Current pharmacological treatments are based on the neurochemical changes that are found in these diseases. Cholinesterase inhibitors and N-methyl-d-aspartate receptor antagonists offer a modest effect in ameliorating cognitive and neuropsychiatric symptoms in Alzheimer's disease. However, the treatment of neuropsychiatric symptoms in dementia is still largely empirical and is hampered by either limited efficacy of medication or troublesome adverse effects. Key potential future developments in dementia include anti-amyloid treatments for Alzheimer's disease and blood biomarkers to aid diagnosis.

All doctors should expect to have some patients with intellectual disability. People with intellectual disability have high rates of physical and mental ill-health problems, and co-morbidity is typical. Frequently associated conditions such as epilepsy, aspiration and choking can cause avoidable death, and problems such as gastro-oesophageal reflux disorder, sensory impairments and injuries can cause recurrent symptoms, persistent disability and distressed behaviour. Other developmental conditions, psychosis and behavioural problems are common. Be aware of readily treatable associated physical conditions such as hypothyroidism in Down syndrome. Problem behaviour can be a sign of distress, which can be the result of physical ill-health, mental ill-health, environmental factors or a combination of these. Medical assessment requires well-developed communication skills and access to multiple sources of information, which must involve relatives and paid carers as well as the person with intellectual disability, so sufficient time should be allocated. Use a biopsychosocial–developmental framework. Avoid attributing symptoms of medical conditions to the person's developmental disabilities (‘diagnostic overshadowing’), which results in illness going untreated. People with intellectual disability face many barriers in accessing healthcare, and proactive approaches are required. Specialist intellectual disability teams, where available, are excellent resources for specialist multidisciplinary assessment and advice.

Bipolar disorder (BD) is characterized by the episodic disturbance of mood into depression or elation. Bipolar I disorder (BD-I) is defined by mania, bipolar II disorder (BD-II) by major depression and hypomania. BD is heritable; many gene variants of small effect contribute to risk. Anxiety co-morbidity is common. The management of BD usually requires long-term medical treatment, and psycho-education is also key to management. Severe manic episodes, with or without mixed features, should be treated by an oral dopamine receptor antagonist/partial agonist. The treatment of bipolar depression is currently controversial. For an early treatment effect, quetiapine, lurasidone or olanzapine can be useful. Lamotrigine is underused. An antidepressant is not recommended as monotherapy for patients with BD but can be given with additional treatment to protect them from manic relapse. Relative or even marked treatment resistance can occur in depressed bipolar patients. The burden and pattern of illness should dictate the treatment choice and combination. If it is predominantly mania, the most antimanic agents (e.g. lithium, valproate, a dopamine receptor antagonist/partial agonist) are combined; for predominantly depressive BD, lamotrigine, quetiapine, lurasidone or olanzapine can be more appropriate. Long-term use of antidepressants can be justified if patients relapse on their discontinuation.

Assessment of patients with mental health problems is often seen as different from assessment in other areas of medicine. However, it has much in common with any area of medicine in which taking a good history is vital. It should be conducted in a systematic way using good interview techniques. A clear knowledge and understanding of the signs of mental illness is essential for accurate assessment, which should allow the clinician to reach a differential diagnosis, and to estimate how much confidence can be placed in the primary diagnosis. Although there are few diagnostic tests in psychiatry, the appropriate investigation of patients includes an assessment of their physical health (and whether this might relate to their psychiatric presentation), formal and detailed assessment of their cognitive function (which can help characterize or localize possible brain pathology), objective ratings of the severity of symptoms and neuro-imaging if indicated.