Antisocial behaviour in adults

Probability diagnosis

Functional: no medical or mental component

Drugs: alcohol, illicit (see list) or prescribed

Alcohol: acute or chronic

Antisocial personality disorder esp. cluster B

Affective (mood) disorders

Drug withdrawal incl. alcohol, hypnotics

Mental impairment

Serious disorders not to be missed

Vascular:

• Cerebrovascular disease including SAH

• Acute coronary syndromes

Infection:

• Encephalitis/meningitis

• HIV/AIDS

• Septicaemia

Tumours:

• Cerebral tumours

Other:

• Post ictal (epilepsy)

• Delirium

• Subdural haematoma

• Psychosis: schizophrenia, bipolar, paraphrenia

• Schizotypal personality disorder

Pitfalls (often missed)

Head injury

Fluid and electrolyte imbalance

Dementia esp. early

Rarities:

• Neurosyphilis

• Prion disease e.g. CJD

• Premenstrual dysphoria syndrome

Masquerades checklist

Depression—major

Diabetes: hypoglycaemia

Drugs: iatrogenic/social–illicit

Thyroid/other endocrine: hyper/hypothyroid

Is the patient trying to tell me something?

Consider conversion disorder (hysterical fugue)

Malingering/fabrication

Severe anxiety/panic

Key history

• Nature of behaviour and precipitants, associations

• Psychiatric history: anxiety, OCD, depression, hypomania, personality traits, fugue features

• Past, family and psychosocial history, developmental history, epilepsy, Parkinson disease, family history

• Drug history: prescribed (see list), OTC, alcohol, social/illicit drugs (see list)

Key examination

This is limited.

• General features: appearance and behaviour of patient, vital signs

• General respiratory, neurological and cardiovascular examination

• Pulse oximetry

• Mental state examination

Key investigations

First line:

• urinalysis

• blood glucose

• FBE

• U&E

Consider:

• LFTs (γGT)

• ECG

• TFTs

• KFTs

• cerebral imaging

Diagnostic tips

Pay close attention to drug use esp. alcohol, caffeine, narcotics and amphetamines e.g. ‘ice’

Prescribed drugs: major and minor tranquilisers, anti-Parkinson, cardiogenic, corticosteroids.

Non-prescribed drugs: marijuana, LSD, opioids, amphetamines, ecstasy, cocaine, gamma hydroxybutyrate (‘fantasy’), solvents e.g. petrol sniffing.

Cluster B antisocial personality disorders incl. histrionic, narcissistic and borderline.