Psychopathology 411

Antisocial personality disorder (ASPD)

Definition
Antisocial personality disorder (ASPD) is a condition characterized by a lack of
empathy and regard for other people.
Symptoms

There are a number of defining symptoms of antisocial personality disorder.

People with ASPD:

 May begin displaying symptoms during childhood; such behaviour’s

may include fire setting, cruelty to animals, and difficulty with authority
 Often have legal problems resulting from failures to conform to social
norms and a lack of concern for the rights of others
 Often act out impulsively and fail to consider the consequences of their
actions
 Display aggressiveness and irritability that often lead to physical
assaults
 Have difficulty feeling empathy for others
 Display a lack of remorse for damaging behaviour
 Often have poor or abusive relationships with others and are more likely
to abuse or neglect their children
 Frequently lie and deceive others for personal gain

These characteristics often lead to major difficulties in many life areas. At its
core, the inability to consider the thoughts, feelings, and motivations of other
people can lead to harmful disregard for others.

As adults, the disorder can be destructive to both the person living with it and
those who come into contact with them. People with antisocial personality
disorder are more likely to engage in risk-taking behaviour’s, dangerous
activities, and criminal acts. Those with the disorder are often described as
having no conscience and feel no regret or remorse for their harmful actions.

Diagnosis of ASPD

Symptoms of antisocial personality disorder often begin during childhood,

although the condition is often not diagnosed until later in life. As children, it
is common for those who develop this disorder to experience violent bursts of
anger and show cruelty towards animals. They are also often described as
bullies by their peers.
While the condition may begin in childhood, it cannot be officially diagnosed
before the age of 18. Kids who display these symptoms are diagnosed
with conduct disorder.

In order to be diagnosed with ASPD, a person must display a disregard and

violation of the rights of others before the age of 15. This disregard is indicated
by displaying at least one of seven symptoms:

 Disregard for the safety of the self and others

 Failure to obey laws
 Impulsive behaviour
 Irritability and aggression
 Lack of remorse for actions
 Lying or manipulating others for profit or amusement
 Pattern of irresponsibility

Causes of antisocial personality disorder

The exact causes of antisocial personality disorder are not known. Personality
is shaped by a variety of forces including nature and nurture.

 were abused as a child

 grew up with parents who had ASPD
 grew up with alcoholic parents

1. Genetics
ASPD is more common among the first-degree biological relatives of
those with the disorder than in the general population. Research
suggests that ASPD is likely strongly linked to inheritance and that
environmental influences probably exacerbate its development.
2. Upbrings
Upbringing can also have an important influence. Childhood abuse,
neglect, and trauma have also been linked to the onset of ASPD. If a
child's parents are abusive and dysfunctional, children may learn such
behavioural patterns and later display them with their own kids. Kids
who grow up in disorganized and neglectful homes also lack the
opportunities to develop a strong sense of discipline, self-control, and
empathy for others.
3. Brain differences
A number of factors have been found to increase the risk of the disorder,
including smoking during pregnancy and abnormal brain function.
Research suggests that people with ASPD have differences in the frontal
 lobe, the area of the brain that plays a role in planning and judgment.
People with the disorder also tend to require greater stimulation and
may seek out dangerous or illegal activities to raise their arousal to an
optimal level.

Treatment for ASPD

Antisocial personality disorder is difficult to treat for a number of reasons.

People with the disorder rarely seek out treatment on their own. Those who do
generally receive treatment only after some type of altercation with the legal
system.

While people with ASPD often come into contact with the criminal justice
system, research suggests that incarceration and other punitive measures are
largely ineffective since people with the condition are usually unresponsive to
punishment.

- Psychotherapy
Cognitive behavioural therapy (CBT) can be useful in helping
individuals gain insight into their behaviour’s and to change
maladaptive thought patterns. Effective results usually occur only after
long-term treatment. Group and family therapy as well as
mentalization-based therapy, which targets the ability to recognize and
understand the mental state of oneself and others, have also been
studied for ASPD and show promise.
- Medication: Medications may be used to treat some of the symptoms
that a person with ASPD may experience. Some of the medications that
may be prescribed include:

 Anti-anxiety medications
 Antidepressants
 Antipsychotics
 Mood stabilizers

Psychopathy
Definition

A constellation of traits that comprises affective features, interpersonal

features, as well as impulsive and antisocial behaviours. The affective
features include lack of guilt, empathy, and deep emotional attachments to
others; the interpersonal features include narcissism and superficial
charm; and the impulsive and antisocial behaviour’s include dishonesty,
manipulativeness, and reckless risk-taking. Although psychopathy is a risk
factor for physical aggression, it is by no means synonymous with it. In
contrast to individuals with psychotic disorders, most psychopaths are in
touch with reality and seemingly rational. Psychopathic individuals are
found at elevated rates in prisons and jails, but can be found in community
settings as well.

Causes

No one knows exactly what causes psychopathy but it is likely a

combination of genetics, environmental and interpersonal factors. For
example, children of psychopaths are more likely to be psychopaths
themselves, suggesting genetic influence.

Additionally, some early life experiences have been shown to increase the
risks of becoming a psychopath. Poor parenting, parenting that focuses on
punishment (rather than rewards) and inconsistent parenting appear to
help cause psychopathy. Additional risk factors for psychopathy include:

 Substance abuse by the parents

 Separation from a parent or lack of parental involvement
 Child physical abuse or neglect

Signs and symptoms of psychopathy

 Superficial charm and glibness

 Inflated sense of self-worth
 Constant need for stimulation
 Lying pathologically
 Conning others; being manipulative
 Lack of remorse or guilt
 Shallow emotions
 Callousness; lack of empathy
 Using others (a parasitic lifestyle)
 Poor control over behaviour
 Promiscuous sexual behaviour
 Behavioural problems early in life
 Lack of realistic, long-term goals
 Being impulsive
 Being irresponsible
 Blaming others and refusing to accept responsibility
 Having several marital relationships
 Delinquency when young
 Revocation of conditional release
 Criminal acts in several realms (criminal versatility)
 Paraphilia
Definition

An emotional disorder characterized by sexually arousing fantasies, urges, or

behaviours that are recurrent, intense, occur for at least 6 months, and cause
significant distress or interfere with the sufferer’s work, and social function, or
other important areas of functioning.

Types of paraphilia

1. Voyeurism: watching an unsuspecting/non-consenting individual who

is either nude, disrobing, or engaging in sexual activity
2. Exhibitionism: exposing one’s genitals to an unsuspecting person
3. Frotteurism: touching or rubbing against a non-consenting person
4. Sexual masochism: being humiliated, beaten, bound, or otherwise
suffering
5. Sexual sadism: the physical or emotional suffering of another person
6. Pedophilia: sexual activity with a prepubescent child (usually 13 years
old or younger)
7. Fetishism: a sexual fascination with nonliving objects or highly specific
body parts (partialism). Examples of specific fetishisms include
somnophilia (sexual arousal by an unconscious person) and urophilia
(deriving sexual pleasure from seeing or thinking about urine or
urinating)
8. Transvestism: cross-dressing that is sexually arousing and interferes
with functioning
9. Autogynephilia is a subtype of transvestism that refers specifically to
men who become aroused by thinking or visualizing themselves as a
woman.
10. Another specified paraphilia: some paraphilias do not meet full
diagnostic criteria for a paraphilic disorder but may have uncontrolled
sexual impulses that cause enough distress for the sufferer that they are
recognized. Examples of such specific paraphilias include necrophilia
(corpses), scatology (obscene phone calls), coprophilia (feces and
defecation), and zoophilia (animals).

Any two types of paraphilia in details

a. Sexual sadism disorder

- Definition
Sexual sadism is infliction of physical or psychological suffering (eg:
humiliation, terror) on another person to stimulate sexual excitement
and orgasm. It is sexual sadism that causes significant functional
impairment or is acted on with a non-consenting person.
- Symptoms
Sexual sadism DSM-5 criteria – which lays out the symptoms that one
must display in order to be diagnosed with the disorder – is short and to
the point, listed earlier in the definition. The two criteria must be
present for at least 6 months and cause the individual severe distress or
dysfunction. Again, these symptoms are:

 Recurrent and intense sexual arousal from the physical or

psychological suffering of another person, as manifested by
fantasies, urges, or behaviour’s.
 The individual has acted on these sexual urges with a nonconsenting
person, or the sexual urges or fantasies cause clinically significant
distress or impairment in social, occupational, or other important
areas of functioning.
When a mental health professional is assessing and/or diagnosing
sexual sadism disorder, they must specify if.
  In a controlled environment: Whereas the individual is living in an
institutional setting or another setting that restricts opportunities to
engage in sadistic sexual behaviours.
 In full remission: Whereas the individual has not acted on his or her
paraphilic interests and urges with a nonconsenting person, and
hasn’t felt distressed or impaired in important areas of life, within
the last 5 years (or longer) while in an uncontrolled environment.
In order to meet the diagnostic criteria for sexual sadism disorder, the
sexually sadistic focus must have:
Been present for at least 6 months.
Involved recurrent and intense sexual arousal from the physical
or psychological suffering of another person, as manifested by
fantasies, urges, or behaviour’s
Included the individual acting on these urges with a non-
consenting person.
AND/OR: The sexual urges or fantasies have caused clinically
significant distress or impairment in social, occupational, or
other important areas of functioning.
Sexual sadistic disorder may be specified as:
In a controlled environment, when an individual lives in an
institution or other setting where opportunities to engage in
sadistic sexual behaviour’s are restricted.
In full remission, when the individual has not acted on urges
with a non-consenting person, and there has been no distress or
impairment in social, occupational or other areas of functioning
for at least 5 years while in an uncontrolled environment.
- Causes and triggers of sexual sadism disorder
As with most mental health disorders, there is not one specific known
cause of sexual sadism disorder. However, there are several theories,
such as escapism: the individual uses sexual sadism to distract
themselves from or escape unpleasant realities.
 Sexual sadism disorder typically develops in young adulthood. The
average age of onset in one study of sadistic males was 19.4
years. Advancing age is likely to have the same reducing effect on this
disorder as it has on other paraphilic disorders.

Some studies show that temporal lobe abnormalities may be implicated

in sexual sadism, but more information is needed before any strong
conclusions can be made. There is no conclusive evidence regarding
what causes or triggers sexual sadism disorder. While other psychiatric
disorders may be diagnosed along with sexual sadism disorder, this does
not demonstrate causation.

- Treatment of sadism sexual disorder

Sexually sadistic interests do not require treatment unless causing

significant impairment or distress, or harm to self or another has
occurred. For individuals who do experience distress or impairment as a
result of their sexual fantasies, urges or behaviour, psychotherapy is the
most common treatment approach.

Some medications have been shown to be effective in reducing the

compulsive behaviour associated with sexual sadism disorder when
utilized in conjunction with therapy.

1. Sex therapy

Counselling with a certified sex therapist who specializes in

paraphilias will ensure a knowledgeable and non-judgmental
approach to psychotherapy. A sex therapist will take a detailed
sexual and psychosocial history to assess for factors that
contribute to the sadistic interest and its expression through
urges, fantasies and behaviours.

The therapist will explore the onset and context of the symptoms
being experienced, especially any changes in the situations or cues
that have escalated sadistic thoughts or urges. The therapist may
teach skills for navigating urges as they arise and/or employ
Cognitive-Behavioural Therapy (CBT) techniques (see below.) Co-
occurring psychological conditions, such as mood disorders
or hypersexuality, will also be assessed and treated.

2. Cognitive behavioural therapy

Sex therapists with CBT training will employ cognitive

restructuring techniques to identify and change thoughts and
behaviors. They may utilize aversion therapy or guided imagery to
reduce interest in sadistic fantasies and change masturbatory
 habits. Studies have shown CBT to be an effective treatment for
sexual sadism disorder, particularly when utilized in conjunction
with drug therapy.

 Antidepressants

Selective Serotonin Reuptake inhibitors (SSRIs) such as

Prozac/fluoxetine can help with co-occurring mood disorders,
such as depression or anxiety, while simultaneously lowering
sex drive. A lowered sex drive can help with the impulsivity
associated with sadistic thoughts and behaviors, however does
not directly address the sadistic urges without therapy.

 Antiandrogens

Medroxyprogesterone acetate and cyproterone acetate are

members of a class of drugs which can be used to lower
testosterone levels temporarily in order to reduce sex drive and
allow for more effective therapy. These drugs help reduce the
levels of circulating testosterone and prime the recipient for
cognitive restructuring therapy techniques.

b. Transvestic disorder

- Definition

Transvestic disorder is experiencing recurrent and intense sexual

arousal, urges, and behaviour from wearing clothes traditionally worn
by a different gender.

It is not a mental disorder. Instead, transvestic disorder falls under the

umbrella term of paraphilia, any atypical sexual thoughts or erotic
behaviour.

- Signs and symptoms

Transvestic disorder is a complicated condition. Still, there are signs

and symptoms that medical professionals look for to make an official
diagnosis. These signs may even begin as early as childhood.

According to the DSM-5, someone with symptoms of transvestic

disorder will feel repeated sexual arousal from cross-dressing for at least
6 months. This arousal may manifest as urges or fantasies for physical
behaviours.
1. Arousal

If you experience repeated arousal from looking at or feeling

clothing, fabrics, or undergarments typically worn by someone of
a different sex, you may have symptoms of transvestic disorder.
This repeated arousal is a key component of diagnosis.

Following arousal, you may seek sexual gratification from contact

with these clothing items.

2. Social distress

The second key symptom of transvestic disorder is that your urges

or actions cause distress or social impairment.

This could be when at work, with family, or in other social

settings. Unlike some paraphilic disorders, this impairment can
be personal and does not necessarily have to affect others for a
diagnosis.

3. Frequency

The DSM-5 guidelines state that a person must feel urges to cross-
dress or experience arousal for more than 6 months for a
diagnosis. This is the third key symptom.

Many people will exhibit signs of transvestic disorder at least

once in their life. However, those with the disorder will
experience these feelings repeatedly.

4. Feeling of guilt

Other studies have found that those with symptoms of transvestic

disorder may feel periods of guilt following the act of cross-
 dressing. This may be a sign of the social distress the condition
can cause.

However, this is not a definitive symptom of transvestism.

- Treatment od transvestism

Social and support groups

Sometimes psychotherapy

Transvestism is considered a disorder and thus requires treatment only

if it causes distress, interferes with functioning, or leads to behaviour
likely to result in injury, loss of a job, or imprisonment.

Only a few people with transvestism seek medical care. Those who do
may be motivated by an unhappy spouse or by worry about how the
cross-dressing is affecting their social life and work. Or they may be
referred by courts for treatment. Some seek medical care for other
problems, such as a substance use disorder or depression.

Social and support groups for men who cross-dress are often very
helpful.

Psychotherapy, when needed, is focused on helping people accept

themselves and control behaviour’s that could cause problems.

No drugs are reliably effective.

Schizophrenia
Definition

Schizophrenia is a chronic, severe mental disorder that affects the way a person
thinks, acts, expresses emotions, perceives reality, and relates to others. Though
schizophrenia isn’t as common as other major mental illnesses, it can be the most
chronic and disabling.

- Causes

The cause of schizophrenia is uncertain — the so-called nature-versus-

nurture concept is heavily debated. The most established theory is the
“stress-vulnerability” model. This model proposes that schizophrenia is
caused by a combination of three types of factors, specifically:
 Biological — for example family history (a genetic cause is suggested,
but no single gene has been found to be responsible and it is more likely
that there are small changes in several genes) or brain injury (caused by
birth trauma or fetal exposure to infection)

Social — such as low socioeconomic status, poor housing, social

isolation, loss of cultural identity and discrimination

Psychological — including early living environment and stressful life

events
- Symptoms

Schizophrenia symptoms are classified into two groups: positive and

negative. Positive symptoms are those which cause an excess or
distortion of normal function, including:

 Delusions — delusions can be somatic (involving false beliefs about

physical illnesses), grandiose (containing beliefs of self-importance and
having special powers or abilities) or paranoid (where there are beliefs
of persecution)
 Hallucinations — hallucinations can be auditory, tactile, visual,
olfactory or gustatory, characterised by experiences when there are no
external stimuli
 Disorganised speech and behaviour
 Thought disorders — thought disorder is characterised by
disorganised speech, which is believed to be due to abnormal thoughts;
thoughts can be blocked (where little or no thoughts occur), or can
appear to have been inserted into, or withdrawn from, the mind by
others
 Ideas of reference — ideas of reference occur when a person believes
that certain external phenomena such as TV, radio or newspaper articles
are reporting about them or talking directly to them (ideas of reference
can also be considered delusions if there are beliefs that external
happenings relate directly to the individual)

Negative symptoms are those that lead to a decrease or loss of normal

function, including lack of emotion, apathy, poor or non-existent social
functioning, lack of motivation, reduced speech, lack of initiative, slow
movements and poor self-care.

It is common for people with schizophrenia to lack insight to such an

extent that they do not believe they are ill.

Schizophrenia usually happens in stages, with different symptoms and

behaviors depending on the stage.
  Onset (prodrome). This is an early phase that happens before a
person develops more severe symptoms. It can include social
withdrawal, anxiety, lack of motivation and neglect of personal hygiene.
 Active. This is when psychotic symptoms take full effect. Another term
for this is “psychotic break,” where a person shows a disconnection from
reality. That includes showing at least two of the five main symptoms
listed immediately below.
 Residual. People in this stage still have some schizophrenia signs and
symptoms, but they’re not as severe. Odd beliefs, lack of motivation,
decreased feelings of enjoyment or pleasure, limited speaking and
reduced emotional expression tend to be the most noticeable effects.
Many people often improve to the point where they seem mostly or fully
recovered. However, this is usually temporary, and symptoms of
schizophrenia will return as a person goes back into the active stage of
the condition.

- Diagnosis
Schizophrenia is diagnosed using the International Classification of
Diseases Version 10 (ICD-10) criteria.
For a diagnosis to be made there must be clear evidence of either:

 One of the following — hallucinations, delusions or thought disorder

 Two of the following — catatonia, negative symptoms or a consistent
change in personal behaviour
These symptoms must be present for the majority of a one-month period.

Generally, a diagnosis of schizophrenia will not be made based on a single

episode of psychosis. This is because psychosis can occur as part of a number
of different mental health conditions or be due to another cause

The onset of the first episode of psychosis of schizophrenia is usually preceded

by a prodromal phase. This phase includes symptoms that can cause a
deterioration in functioning, such as reduced concentration and attention,
reduced drive and motivation, sleep disturbance and anxiety.

Young people often fail to complete further education and become isolative
and socially withdrawn. Delay in diagnosing and treating first episode
psychosis increases the risk of more severe long-term positive and negative
symptoms. The ICD-10 criteria are also used to classify a patient with
schizophrenia based on his or her prominent symptoms at presentation. For
example, paranoid schizophrenia has prominent symptoms of paranoid
delusions accompanied by auditory hallucinations.
Presentation Key feature
Paranoid schizophrenia Paranoid delusion, auditory
hallucination and perceptual
disturbances.
Hebephrenic schizophrenia Prominent affective changes, thought
disorder, fleeting and fragmented
delusion and hallucination,
irresponsible and unpredictable
behaviour, mannerism, incoherent
speech and social isolation.
catatonic schizophrenia Fluctuating psychomotor
disturbance (including hyperkinesis
[overactive restlessness] and stupor),
long period of posturing (voluntary
inappropriate or bizarre posture),
vivid scenic hallucination may be
present.
Undifferentiated schizophrenia Used when symptoms are not within
the above three categories or when
symptoms fall into more than one of
these sub-types
Post schizophrenic depression A depressive episode following an
episode of acute illness. Some
positive or negative symptoms of
schizophrenia must be still present
but they are no longer dominating
the clinical picture.
Residual schizophrenia Long standing negative symptoms
Simple schizophrenia Progressively strange behaviour,
poor social functioning, deteriorating
daily functioning, negative
symptoms, overt psychotic
symptoms are generally not present.
Other schizophrenia For example: cenesthopathic
schizophrenia (somatic hallucination
causing abnormal bodily sensation)
Schizophrenia, unspecified Any disorder where symptoms have
not been fully assessed and classified
as above.
- Risk factors

While there aren’t any confirmed causes of schizophrenia, there are

several factors and circumstances that researchers have connected to
the condition.

 Genetics. People with a family history of schizophrenia — especially a

parent or sibling with it — have a much higher risk of developing this
condition.
 Environment. Many factors in the world around you can increase your
risk of developing schizophrenia. Being born during the winter increases
your risk slightly. Certain illnesses that affect your brain, including
infections and autoimmune diseases (where your immune system
attacks part of your body), can also increase your risk.
Extreme stress for long periods can also play a role in developing it.
 Development and birth circumstances. How you developed before
you were born plays a role in schizophrenia. The risk of having
schizophrenia goes up if your mother had gestational
diabetes, preeclampsia, malnutrition or a vitamin D deficiency while she
was pregnant with you. The risk also increases if you were underweight
at birth or if there were complications during your birth (such as your
mother needing to undergo an emergency caesarean section).
 Recreational drug use. Researchers have linked schizophrenia with
certain recreational drugs, especially in larger amounts and earlier in
life. The connection between heavy marijuana (cannabis) use as a
teenager is one of the best-studied of these links. However, there’s
disagreement on whether or not marijuana use is a direct cause of
schizophrenia or if it’s just a contributing factor.

Delirium
Definition

Delirium is a type of confusion that happens when the combined strain of

illnesses, environmental circumstances or other risk factors disrupts your
brain function. It’s more common in adults over 65. This condition is
serious and can cause long-term or permanent problems, especially with
delays in treatment. However, it’s also often preventable.

Delirium is a sudden change in your alertness and thinking. People with

delirium typically become confused and have trouble paying attention.
 - Types of delirium

Delirium is categorized by its cause and characteristics.

1. Hypoactive delirium

People with hypoactive delirium may be:

 unusually drowsy or sleepy

 unable to focus or pay attention
 quiet and withdrawn
 slower than usual when moving their body
2. Hyperactive delirium

People with hyperactive delirium may:

 appear agitated or anxious

 speak fast or loudly
 become restless, or unable to sit still
 respond negatively or aggressively to caregivers
 seem watchful or paranoid

3. Mixed delirium

Mixed delirium is a combination of both hyperactive and

hypoactive delirium. People with mixed delirium have hyperactive
delirium symptoms at some times, and hypoactive delirium
symptoms at other times.

 Typical activity level: You’re still confused and not fully

aware of your surroundings, but your activity level is
similar to what’s usual for you.
 Shifting activity level: You shift back and forth between
the hyperactive and hypoactive delirium types. Sometimes
you may show hyperactive symptoms but then change to
hypoactive symptoms. This can also involve hypoactive
 symptoms and sleeping during the day, and hyperactive
symptoms like agitation or aggression at night.

4. Alcohol withdrawal delirium

Alcohol withdrawal delirium, or delirium tremens, is a form of the

condition that can happen to people who drink large amounts of
alcohol for many years. If someone who regularly drinks a lot
suddenly tries to stop drinking, severe withdrawal including
delirium is possible.

Delirium tremens is a medical emergency that requires immediate

treatment to prevent severe complications. If it’s left untreated, it
can be fatal in up to 37% of cases. Fortunately, early treatment
greatly improves the outcomes.

- Causes

Delirium happens when stressors like inflammation or infection interfere with

your brain function. There are many possible causes.

The condition is very common among older adults who need hospital care.
Around one-third of hospital patients over age 70 experience delirium at some
point during their hospital stay. It’s possible for younger people to experience
delirium too, although it’s less common.

Any condition or factor that significantly changes your brain function can
cause severe mental confusion. These include:

 certain medications, such as sedatives, blood pressure medications,

sleeping pills, and pain relievers
 acute illness
 infections
 worsening symptoms of a long-term (chronic) illness
 lack of oxygen — for example, breathing difficulties from asthma
 blocked arteries (ischemia) — for example, in the brain or heart
 severe pain
 dehydration
  sleep deprivation
 metabolic issues, such as low blood sugar or an electrolyte imbalance
 alcohol withdrawal in people with long-term, heavy alcohol use
 surgery or general anaesthesia

Medication side effects are a major cause of delirium. Up to 39% of the time,
delirium is caused by medications.

- Factors of delirium

The possible factors that can contribute to developing delirium in a medical

setting include:

 Conditions you have. People with dementia have a higher risk of

developing delirium. Many conditions, such as cancer, infections
(including HIV, pneumonia or COVID-19), sepsis or stroke can make it
more likely to happen. People with a recent bone fracture are also at
higher risk for developing delirium.
 Procedures you undergo or treatments you receive. People who
undergo major surgery, especially unplanned urgent or emergency
surgery, have a much higher risk of developing
delirium. Intubation or mechanical ventilation can also make it much
more likely to happen.
 Mobility. Not moving for extended periods, especially lying down, can
affect brain function. People who move and participate in physical
therapy have a lower risk of developing delirium, and delirium is shorter
if they do still develop it.
 Tethers. This term refers to anything attached to or inserted into your
body that limits how you move. This includes intravenous (IV, into your
vein) lines or Foley catheters (inserted devices that drain pee directly
from your bladder), oxygen tubes or physical restraints. Even minor
devices like a heart monitoring sensor patch can be a tether.
 Medications you take. Some medications can increase your risk of
developing delirium, even when used as prescribed. Because of this,
healthcare providers often avoid prescribing certain medications to
people 65 and older or those with a history of certain conditions.
Polypharmacy, taking more than five medications at a time, also
increases your risk.
 Nonmedical drug or medication use. Nonmedical use of drugs,
including using prescription medications in a way other than
prescribed, can cause drug-induced delirium.
 Your environment. Natural lighting helps your body maintain its
sense of night and day, and losing that sense can greatly increase your
 risk of developing delirium. Sound is another sense that can affect your
sleep/wake cycle. Lack of sleep is a significant contributor to delirium.
 Lack of pain management. Poorly managed or unmanaged pain can
contribute to your risk of having delirium.
 Stimulation (or lack of it). Your body needs sensory input, and if
you aren’t getting it, this can negatively affect your brain (especially as
you get older). People who need hearing aids or eyeglasses have a higher
risk of developing delirium, especially if they aren’t using these assistive
items.
 End-of-life factors. Delirium is possible during the end stages of life,
especially for people receiving palliative care or hospice care.
 Social isolation. Separation or isolation from family, friends and
loved ones can worsen delirium. Family members are valued members
of the treatment team and can assist in keeping you aware of your
surroundings. People who have family members visiting have a lower
likelihood of developing delirium and/or have fewer days where they
experience delirium.

- Risk factors

Several risk factors can make it easier to develop delirium. They include:

 Age (especially 65 and older). Many changes that happen naturally

as you age also increase your risk of developing delirium.
 Dementia (or other degenerative brain diseases). Delirium can
happen more easily in people who have an existing condition that affects
brain functions. All degenerative and age-related brain diseases can
contribute to delirium or make it more likely to happen.
 Other chronic physical conditions. Diseases and conditions like
heart disease and COPD put a strain on your body. That strain can make
it easier for delirium to happen. The more chronic conditions like these
that you have, the greater the strain and the higher the risk.
 Mood disorders. A history of mood disorders, particularly depression,
increases your risk of developing delirium.
 Vision and hearing loss later in life. Your senses, especially vision
and hearing, help you know what’s happening around you. Loss of those
senses reduces your brain’s ability to use cues from the outside world,
making it easier for delirium to develop.
 Misuse of alcohol and nonmedical drug use. Nonmedical opioid
and benzodiazepine drug use strongly increases the risk of developing
delirium.
 Previous history of delirium. People with a history of delirium are
at higher risk of developing it in the future.
 Frailty. This medical term describes how vulnerable you are to illness
or injury. Frailty naturally increases as you get older. That’s why a fall
for a young adult may not cause any injury, but a similar fall for
 someone over 65 can be more dangerous. Likewise, physical frailty
makes it easier to develop delirium, especially later in life.

- Diagnosis

A healthcare provider diagnoses delirium based on a combination of methods.

These include:

 A physical exam.
 A neurological exam.
 Observing your behaviour and any symptoms you show.
 Talking to you and asking questions.
 A review of your medical history.
 Lab testing.

Many health professionals use the Confusion Assessment Method

(CAM) to diagnose or rule out delirium. This is a screening test that
helps them observe whether or not:

 your behaviour and mental state is fluctuating over time

 you have a hard time paying attention or following others as they speak
 you have trouble keeping your thoughts organized
 you’re experiencing an altered state of alertness

There aren’t any lab or diagnostic tests that can diagnose delirium directly.
However, a variety of tests can play a role in searching for possible causes.
These include electrolyte imbalances (such as low sodium), checking
glucose (“blood sugar”) levels, or looking for signs of infection. If testing
finds any causes, that can also help guide treatment.

- Symptoms

Delirium affects your mind, emotions, movements, and sleep patterns.

You might have a hard time concentrating or feel confused about what’s
happening around you. You may also move more slowly or quickly than usual,
and experience mood swings.

Other symptoms may include:

  not thinking clearly
 having trouble speaking clearly or participating in a conversation
 being easily distracted
 losing track of what time it is and where you are (disorientation)
 sleeping poorly or feeling drowsy
 sudden changes in your ability to carry out everyday activities, like
eating or walking
 difficulty remembering recent events
 becoming agitated or paranoid

If alcohol withdrawal progresses to delirium, symptoms may include:

 confusion
 hallucinations
 rapid heart rate
 high blood pressure
 excessive sweating
 dangerously high body temperature
 agitation

- Treatment of delirium

Depending on the cause of the delirium, treatment may include taking

or stopping certain medications.

In older adults, an accurate diagnosis is important for treatment, as

delirium symptoms are similar to dementia, but the treatments are very
different.

Medications
 Your doctor may prescribe medications to treat the underlying cause of
your delirium. For example, if your delirium is caused by a severe
asthma attack, you might need an inhaler to restore your breathing.

If a bacterial infection is causing the delirium symptoms, antibiotics

may be prescribed. In some cases, your doctor may recommend that you
stop taking certain medications if they are causing delirium.

If you are experiencing substance withdrawal, you may be prescribed

medication to manage your symptoms.

Delirium itself is not usually treated with medication. Rather, it is the

underlying cause that is being treated. But if you have severe symptoms
of hyperactive delirium that do not improve, antipsychotic medications
may be considered.

Supportive care

Reducing stress and creating a calm environment can help you recover
from delirium. You may find it helpful to:

 set a clear daily routine

 eat and drink water on a regular schedule
 keep clocks and calendars visible to orient yourself
 maintain good sleep habits
 be physically active in ways that are safe for you
 put on your glasses and hearing aids daily, if you use these devices

If you are caring for someone with delirium, do your best to:

 speak calmly and use short sentences

 reassure them
 avoid moving your loved one to an unfamiliar room or place during
recovery, if it’s not necessary
 share familiar objects, like photos
 Counselling

If you’re feeling disoriented, counselling may help to anchor your

thoughts.

Counselling is also used as a treatment for people whose delirium was

brought on by substance use. In these cases, the treatment can help you
abstain from using the substances that brought on the delirium.

In all cases, counselling is intended to make you feel comfortable and

give you a safe place to discuss your thoughts and feelings.

- Case study
81 years old man with diagnosis of benign prostate hypertrophy and
hypertension, came in with history:
a. 3 days prior to admission, low-grade fever and nocturia. Poor
sleep. Daughter gave him diphenhydramine for sleep.
b. Day of admission, become confused, had hight grade fever.
c. No loss of consciousness, vomiting
d. Past medical history: hypertension
e. Personal/social history: smoke tobacco
f. In hospital diagnosed to have UTI and have acute urinary
retention
g. 6 hours after admission, became combative, agitated, confused.
Pulled out IV and insisted on going home.

Objective

a. To define the syndrome of delirium.

b. To identify the symptoms of delirium
c. To differentiate delirium from other psychiatric, neurological and
medical conditions
d. To describe patient prognosis
e. To discuss base medical management
 Attention deficit hyperactivity disorder
(ADHD)
Definition
Attention-deficit/hyperactivity disorder (ADHD) is one of the most common
and most studied neurodevelopmental disorders in children. “Neuro” means
nerves. Scientists have discovered there are differences in
the brains, nerve networks and neurotransmitters of people with ADHD.

ADHD is a long-term (chronic) brain condition that causes executive

dysfunction, which means it disrupts a person’s ability to manage their own
emotions, thoughts and actions. ADHD makes it difficult for people to:

 Manage their behaviour.

 Pay attention.
 Control overactivity.
 Regulate their mood.
 Stay organized.
 Concentrate.
 Follow directions.
 Sit still.

Kids usually receive a diagnosis during childhood and the condition often lasts
into adulthood. However, effective treatment is available. Left untreated,
ADHD can cause serious, lifelong complications.

Types of ADHD

Symptoms are grouped into three types:

Inattentive. A child with ADHD:

 Is easily distracted
 Doesn't follow directions or finish tasks
 Doesn't seem to be listening
 Doesn't pay attention and makes careless mistakes
 Forgets about daily activities
 Has problems organizing daily tasks
 Doesn’t like to do things that require sitting still
 Often loses things
 Tends to daydream
Hyperactive-impulsive. A child with ADHD:

 Often squirms, fidgets, or bounces when sitting

 Doesn't stay seated
 Has trouble playing quietly
 Is always moving, such as running or climbing on things. (In teens and
adults, this is more often described as restlessness.)
 Talks excessively
 Is always “on the go,” as if “driven by a motor”
 Has trouble waiting for their turn
 Blurts out answers
 Interrupts others

Combined presentation

Children with this presentation show at least six symptoms from both of the
other types. Symptoms of inattentiveness and hyperactivity-impulsivity
present equally. This type is what people most commonly associate with
ADHD. About 70% of cases fall under this type

Unspecified presentation

In these cases, symptoms may be so severe that children clearly demonstrate

dysfunction but don’t meet official symptom criteria for a diagnosis of ADHD
inattentive, hyperactive/impulsive or combined type. In such cases, providers
assign “unspecified ADHD” as the diagnosis.
ADHD Symptoms in Adults
Symptoms of ADHD may change as a person gets older. They include:

 Often being late or forgetting things

 Anxiety
 Low self-esteem
 Problems at work
 Trouble controlling anger
 Impulsiveness
 Substance misuse or addiction
 Trouble staying organized
 Procrastination
 Easily frustrated
 Often bored
 Trouble concentrating when reading
 Mood swings
 Depression
 Relationship problems

Symptoms
Providers use the signs of ADHD to diagnose and determine the type of
condition: inattentive, hyperactive/impulsive, combined or unspecified. The
American Psychiatric Association’s Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition Text Revision (DSM-5-TR™) provides
guidelines providers use to make diagnoses.

Predominantly inattentive presentation

ADHD symptoms in kids with inattentive presentation include difficulty

focusing, organizing and staying on task. According to the DSM-5-TR, a child
with this type must display at least six of the following nine behaviours. (The
behaviours must pose a problem in daily activity, at school and at home — not
just from time to time, as most children engage in these behaviours.)

 Trouble paying attention to details or making careless mistakes.

 Issues remaining focused on tasks and activities.
 Difficulty listening well, daydreaming or seeming distracted.
 Trouble with following instructions and/or finishing tasks.
 Difficulty with organizing tasks and activities.
 Avoiding or disliking tasks that require continuous mental effort.
 Losing things frequently.
 Easily distracted by outside stimuli.
 Forgetful in daily activities

Predominantly hyperactive/impulsive presentation

People with hyperactive/impulsive type display the following ADHD
symptoms. According to the DSM-5-TR, a child must display at least six of the
following nine behaviours. These must pose problems in daily activity.

 Fidgeting with or tapping hands or feet or squirming frequently.

 Leaving their seat when remaining seated is expected.
 Running or climbing when it’s not appropriate.
 Trouble playing or engaging in leisure activities quietly.
 Always seeming “on the go” or “driven by a motor.”
 Talking too much.
 Blurting out answers before questions are completed.
 Frequent trouble waiting for their turn.
 Often interrupting or intruding on others’ conversations or games.

Combined presentation

People with combined type display behaviours from both the inattentive and
hyperactive/impulsive categories. According to the DSM-5, children must
display at least 12 of the total behaviours (at least six inattentive behaviours
and six hyperactive/impulsive behaviours).

Causes
Scientists have identified differences in the brain structure and activity of
people with ADHD. The frontal lobe is the front part of your brain, the part
behind your forehead. The frontal lobe is responsible for planning, paying
attention, making decisions and using language to moderate behaviour.
Researchers call this kind of activity directed attention. The brains of people
with ADHD tend to reach their full maturity at a later time than those of
neurotypical people.

People use directed attention to suspend automatic attention, a second kind of

attention, which is very strong in people with ADHD. Directed attention,
however, takes a lot of effort and is difficult to use. In a person with ADHD,
directed attention skills tend to be weaker. Automatic attention is the kind of
attention you use when you’re doing something that’s interesting or engaging.
Directed attention is the kind of attention you use when you must do
something that’s tiring or of low interest. (For example, in childhood, boring,
repetitive tasks.)

In addition, nerve cells called neurons transmit signals in your brain. These
signals travel through your brain in groups of neurons called networks.
Scientists call the automatic attention network in your brain the default mode.
They call the directed attention network in your brain the task-positive mode,
or your brain’s executive network. Researchers have found major networks
that work differently in people with ADHD. Neurotransmitters — chemicals
that help transmit signals from one nerve cell to another — also play a role in
ADHD.

Although researchers have discovered these brain differences, they don’t

completely understand why they occur and lead to symptoms of ADHD. But
current research shows that genetics plays a vital role. ADHD often runs in
families — a child with ADHD has a 1 in 4 chance of having a parent with the
condition.

Other possible causes and risk factors of ADHD may include:

 Lead exposure.
 Brain anatomy.
 Substance uses during pregnancy.
 Premature birth.
 Low birth weight.

The following aren’t causes of ADHD:

 Allergies.
 Immunizations.
 Eating too much sugar.
 Too much time staring at screens.
 Poor parenting.
 Social and environmental factors such as poverty.

Treatment
The goal of ADHD treatment is to improve your child’s symptoms so they can
function more effectively at home and school. For younger children (ages 4
and 5), providers recommend intervention for parents as the first line of
treatment before medication is tried.

In most cases, the best ADHD treatment for older children, adolescents and
adults includes a combination of behavioural therapy and ADHD medication.

Behavioural therapy

For children younger than age 13, providers recommend parent training in
behaviour management. For adolescents, they recommend other types of
behavioural therapy and training such as social skills training or executive
function training. The goal of behavioural therapy is to learn or strengthen
positive behaviours while eliminating unwanted or concerning behaviours.
The goal of executive function training is to improve organizational skills and
self-monitoring.

Medication
Medication can help people with ADHD manage their symptoms and the
behaviours that cause issues with their friends, family and other contacts. The
U.S. Food and Drug Administration has approved several different types of
medications to treat ADHD in children as young as 6 years old.

 Stimulants: Stimulants are the most widely used ADHD medications.

Between 70% and 80% of children with ADHD show fewer ADHD
symptoms when taking these medications.
 Nonstimulants: Nonstimulants don’t work as fast as stimulants and
generally don’t have as big of an impact, but their effect can last up to 24
hours. Your child’s provider may recommend the addition of a
nonstimulant if stimulants aren’t working.
 Antidepressants: The FDA hasn’t approved antidepressants as a
treatment for ADHD. But healthcare providers sometimes prescribe
them alone or in combination with another ADHD medication.

Your child may need to try different medications and different doses before
they find the right balance between the benefits and side effects.