Management of acute behaviour disturbances

• Acute behaviour disturbances are commonly encountered in neurological practice. Psychiatric disorders may accompany neurological disease or may present with somatic symptoms that suggest neurological lesions but for which no organic pathology can be detected.

• Evidence of intellectual impairment, particularly reduced level of consciousness, disorientation, and memory deficits, enables conditions such as delirium, which are due to overt physical disease, to be distinguished from affective, anxiety, and acute psychotic disorders. The psychotic disorders are not usually associated with overt physical disease although in a few patients they may be the presenting manifestations of an occult lesion in the central nervous system or elsewhere. The likelihood of this increases with advancing age and if there is no previous personal or family history of psychiatric illness or no apparent psychosocial precipitating factor.

• Successful management requires close collaboration between neurologists and psychiatrists. It is essential to be familiar with the psychotropic drugs that are most appropriately used for patients with neurological disorders. Tricyclic antidepressants and selective serotonin re-uptake inhibitors are both used for treating depression, but the latter group of drugs may prove more acceptable because of their lower incidence of side effects.

• Acute psychotic disorders require treatment with neuroleptic drugs, the main groups being the phenothiazines and butyrophenones. Rapid control of acute psychosis is essential when it is associated with aggressive behaviour and it is important that clinicians are familiar with regimens of parenteral neuroleptic administration and indications for compulsory treatment.

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