Acute Stress Disorder

Acute stress disorder is a short-lived but severe disorder caused by an overwhelming, psychologically traumatic experience. The symptoms develop rapidly, but tend to resolve within a matter of days. These include psychological symptoms, such as feeling numb and detached, dazed and disorientated, and physical symptoms, such as sweating, shakiness, palpitations and insomnia. Some patients will go on to develop post-traumatic stress disorder.

If there is persistent denial that the event has occurred, the patient should be cautiously prompted to recall the facts. A short course of a benzodiazepine tranquilliser and/or hypnotic may help severe agitation or insomnia.

Delirium

A sudden change in the mental state or sudden onset of behaviour that is out of character in an older person is most likely to be due to an acute confusional state (delirium). Even if a patient is confused it is paramount to take a history, which may give clues to the cause of the delirium. It also gives you the opportunity to assess the severity of confusion. The patient will benefit from reassurance. Of course, don’t dismiss the possibility that the patient is not confused and her jewellery is indeed missing! A physical review and review of investigations must be done as soon as is possible as delirium is a serious condition with a high morbidity and mortality. Sedation should only be used as a last resort and preferably only once the cause of the delirium has been established.

DSM-IV criteria for alcohol dependence

The six DSM-IV criteria for alcohol dependence are:
1. inability to cut down
2. repeated efforts to control drinking
3. amnesic periods
4. drinking increasing amounts
5. ongoing drinking despite detrimental consequences
6. withdrawal symptoms.

Macular oedema

Visual impairment more marked for reading than distance is very suggestive of macular disease, and the likely cause of symptoms in this case is diabetic maculopathy, when the central fovea becomes affected by retinal oedema or frank hard exudate. Age-related macular degeneration would be unlikely in a man of this age (48y)

Korsakoff's psychosis

This woman is clearly at high risk of alcohol-related disease as she has a high-risk profession and abnormal blood tests.

The fact that she seems to be confabulating makes Korsakoff's the best diagnosis. She has no evidence of nystagmus or ataxia suggestive of Wernicke's encephalopathy. Subdural haematoma is usually easily diagnosed by CT scan. Alcohol withdrawal usually occurs 48-72 hours after the last alcoholic drink (and we do not have any timings here).

Do not forget to exclude hypoglycaemia, hyponatraemia and hypomagnesaemia as causes of fits in alcoholics.

Dissociative disorders

In dissociative disorders there is a temporary but drastic modification of a person’s character or sense of personal indentity.

Conditions that can present with dissociative symptoms include schizophrenia, TLE, depression, head injury, delirium, dementia, drugs and acute stress disorder.

Other features of TLE can include epigastric discomfort, jamais vu, and intense anxiety or depression.

LSD can cause hallucinations in any modality.

Hyperventilation and disproportionate worrying suggest acute stress disorder.

Side Effects of Antipsychotics

The side effects of antipsychotics include :

• Extrapyramidal symptoms 
• Stiffness
• Tremor
• Hypersalivation
• Acute dystonia
• Akathisia
• Tardive dyskinesia 
• Anticholinergic symptoms 
• Blurred vision
• Constipation
• Urinary retention
• Dry mouth
• Confusion
• Agitation
• Seizures
• Antihistaminergic symptoms 
• Sedation
• Alpha-blocking effects
• Orthostatic hypotension
• Leucopenia 
• Increased prolactin secretion 
• Amenorrhoea
• Galactorrhoea
• Sexual dysfunction
• Weight gain
• Obstructive jaundice 
• Retinitis pigmentosa (with thioridazine >600 mg/d), 
• Allergic dermatitis / photosensitivity
• Neuroleptic malignant syndrome

Fig 1: Tardive dyskinesia

Akathisia

Acute Dystonia

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Serotonin syndrome

Serotonin syndrome is a rapidly progressive condition that is characterised by confusion, agitation, myocolonus, rigidity, tremor, hyperreflexia, hyperthermia, gastrointestinal upset, tachycardia, and hypo or hypertension.
It is due to excessive serotonin caused by a number of mechanisms including increased release of stored serotonin or reuptake inhibition. This is a potentially fatal condition. Treatment includes stopping the offending drug and supportive measures to reduce the risk of rhabdomyolysis.

Wernicke’s encephalopathy

Wernicke’s encephalopathy typically presents with ophthalmoplegia (horizontal and vertical nystagmus, weakness / paralysis of the lateral rectus muscles, weakness / paralysis of conjugate gaze), ataxia (predominantly affecting stance or gait, and often without clear-cut intention tremor) and confusion.

Horizontal nystagmus

Vertical nystagmus

Lateral rectus muscle

Conjugate gaze