Stringer et al: Psychiatry PRN: Principles, Reality, Next Steps
How many risk factors or clinical signs have you spotted?
Drawing by Darcy Muenchrath
Low mood – the patient looks miserable.
From Psychiatry PRN: “As well as feeling pervasively low, people may describe irritability, anxiety, or tearfulness. Diurnal variation of mood may occur, where one part of the day feels worse (classically the mornings).”
Anergia – he is lying down; his house is untidy because he doesn’t have the energy to finish domestic tasks.
From Psychiatry PRN: “Anergia is low energy, described by patients as feeling ‘tired all the time’; they may not finish tasks because they quickly feel worn out, and this can hugely affect their ability to function. Movements may be obviously slowed down (psychomotor retardation).”
Anhedonia - the ‘phone is off the hook, and his appearance is unkempt, signifying withdrawal from daily life.
From Psychiatry PRN: “Anhedonia is the loss of enjoyment and interest in activities they previously enjoyed”.
Altered sleep patterns – he is awake at 4.06am.
From Psychiatry PRN: “An altered sleep pattern is common, typically as initial insomnia (difficulty falling asleep) or early morning wakening (waking at least 2 hours earlier than normal).”
Drawing by Darcy Muenchrath
Forgetfulness – gas hob left on; dog has not been fed; fridge door is open; handbag is in the fridge; the sink is overflowing and the house is unclean. The fact that the calendar is out of date by years suggests that the problems are chronic, and thus more likely to be dementia than delirium or depression.
From Psychiatry PRN: “Dementia often begins with forgetfulness, principally for recent events. There may be mild
mistakes in day-to-day activities (e.g. muddling up appointments, mislaying items). Initial problems are often attributed to normal ageing or absent-mindedness. Anxiety or depression may occur early, especially when insight is intact. Forgetfulness worsens over time and new information becomes harder to retain. Disorientation sets in—for time, then place, and finally person. People with dementia may confuse day and night, become lost easily, or fail to recognize family and friends. Increasingly, people become less independent, needing more help with ADLs. Thinking and language become impoverished; mood and personality are also affected.”
Drawing by Ayesha Lodhia
From Psychiatry PRN: “ There is good evidence for a genetic basis to schizophrenia. The lifetime risk increases from 1% to 10% for first-degree relatives of people with schizophrenia; and 48% for a child whose parents are both affected (Tsuang et al. 2001). Monozygotic twin concordance is 40–50%, whereas for dizygotes it is 10–20% (Cardno et al. 1999). Adoption studies show that children of people with schizophrenia, raised in families without schizophrenia, remain at high risk of the disorder. Numerous genetic loci are currently under investigation, though it is unlikely that a single ‘schizophrenia gene’ exists (van Haren et al. 2008). Instead, multiple susceptibility genes probably interact, each making someone slightly more likely to develop schizophrenia.”
From Psychiatry PRN: “Smoking cannabis more than 50 times as a teenager makes you six times more likely to develop schizophrenia (Andreason et al. 1988). Adolescents are very vulnerable since their brains are still developing.”
Urban life and birth
From Psychiatry PRN: “The incidence of schizophrenia is twice as high in urban than rural areas. This may be due to drift or to stress specific to the urban environment.”
From Psychiatry PRN: “Maternal prenatal malnutrition or viral infections increase the risk of schizophrenia, as do pre-eclampsia, low birth weight, and emergency Caesarean section. These may reflect underlying genetic abnormalities, or hypoxic brain damage.”
Ethnic minority status
From Psychiatry PRN: “These rates seem to vary with ethnicity, with Black Caribbean and Black African populations showing the highest rates (a 4 to 6-fold increase compared to the White British population) (Fearon et al. 2006). This is neither fully understood, nor explained by preferential migration, diagnostic bias, higher rates of schizophrenia in the country of origin, or lower social class.”
From Psychiatry PRN: “First- and second-generation immigrants have an average threefold increase in the risk of schizophrenia compared with indigenous populations (Cantor-Graae and Selten 2005).”
Drawing by Ayesha Lodhia
From Psychiatry PRN: “Suicide is often preceded by life events, especially bereavement and other losses. Childhood adversity such as abuse or neglectful parenting may predispose individuals to suicide many years later.
Physical health problems
From Psychiatry PRN: “Chronic, painful and terminal illnesses increase the risk of suicide.”
From Psychiatry PRN: “People who die by suicide are more likely to be isolated, divorced, widowed, single, unemployed, or living alone. Social cohesion is a protective factor. The suicide rate decreases during wars (Stengel 1964), presumably because the suicidal impulse is subsumed by a sense of being connected to other people in resisting a common enemy.”
Mental health causes
From Psychiatry PRN: “Nine out of ten individuals who die by suicide have a major mental illness at the time of death”.
From Psychiatry PRN: “The elderly (over 65s) and younger (15–30 years) age groups are at highest risk of suicide. It is second only to road accidents as a cause of death in men aged 15–24 years, and overall men are three to four times more likely than women to die by suicide in the UK. This is partly due to the method chosen: men use more violent methods, e.g. hanging, shooting.”
From Psychiatry PRN: “The risk of suicide is increased by having a family history of mental illness or suicide. These factors are independent of each other.”