Cognitive behaviour, perinatal and childhood psychiatry

Behavioural and Psychological Symptoms of Dementia (BPSD)

• BPSD includes wandering, agitation, physical aggression, verbal outbursts, delusions, hallucinations, and sleep disturbances.
• Clinical Approach:
  • Step 1: Identify and treat underlying physical causes (pain, urinary retention, infection, constipation, medication changes).
  • Step 2: Implement non-pharmacological interventions first: person-centred care, sensory stimulation, validation therapy, music therapy, gentle redirection, and structured daily routines.
• BPSD prescribing consent: Seek the patient’s informed consent when they have capacity; otherwise use the legally authorised substitute decision maker and local framework. Discuss increased stroke/mortality risks, document the target symptom and review/deprescribe promptly when possible.

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Perinatal Psychiatry: Postpartum Spectrum & Pharmacotherapy

Childbirth involves profound physiological, hormonal, and psychological transitions. Psychiatric disorders in the perinatal period require prompt diagnosis to preserve maternal well-being, infant safety, and mother-infant attachment.

1. Postpartum Blues ("Baby Blues")

• Affects up to $80\%$ of mothers, driven by precipitous postpartum declines in oestrogen and progesterone.
• Presents on days 2-3 with emotional lability, transient weeping, irritability, and anxiety. Resolves spontaneously within 10 to 14 days without clinical impairment. Management involves validation, reassurance, practical family support, and sleep optimization.

2. Postnatal Depression (PND)

• Affects $10-15\%$ of mothers, typically developing within 4 to 12 weeks postpartum (and up to 12 months).
• Characterized by pervasive low mood, loss of pleasure, intense fatigue, excessive anxiety regarding infant health, maternal guilt, feelings of incompetence, detachment from the infant, and suicidal ideation.
• EPDS: A screening result prompts clinical assessment rather than proving depression. Question 10 asks about self-harm; explore intent, safety and supports directly. Symptoms during pregnancy and throughout the postpartum year deserve assessment.
• Pharmacotherapy in Breastfeeding: When psychological therapies (CBT) are insufficient, SSRIs are indicated. Sertraline is the preferred first-line antidepressant in breastfeeding due to its extremely low excretion into breast milk (producing undetectable or negligible infant serum concentrations) and robust safety profile. Paroxetine also has low milk excretion, whereas fluoxetine has a long half-life and higher milk concentration.

3. Postpartum Psychosis

• Rare ($1-2\text{ per } 1,000$ deliveries) but catastrophic psychiatric emergency.
• Major Risk Factor: Personal or family history of Bipolar Affective Disorder (recurrence risk exceeds $25-50\%$) or prior postpartum psychosis.
• Clinical Presentation: Abrupt onset within days to weeks postpartum, presenting with delirium-like perplexity, cognitive disorganization, rapid affective switching (euphoria, agitation, deep despair), severe insomnia without fatigue, auditory hallucinations, and bizarre delusions frequently involving the infant (e.g., delusions of demonic possession, defective baby, or sacrificial salvation).
• Infanticide & Suicide Risk: Altruistic infanticide or maternal suicide can occur with terrifying rapidity.
• Postpartum psychosis: Immediate supervised psychiatric care and infant safeguarding are required. A mother–baby unit is preferred when appropriate and available, but emergency admission must not be delayed while awaiting a specific bed. Exclude medical causes and select treatment with specialist perinatal advice.

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Paediatric Psychiatry: ADHD, ODD & Conduct Disorder

1. Attention-Deficit/Hyperactivity Disorder (ADHD)

• A neurodevelopmental disorder characterized by persistent, developmentally inappropriate levels of inattention, hyperactivity, and impulsivity.
• DSM-5 Diagnostic Criteria:
  • At least 6 symptoms of inattention and/or at least 6 symptoms of hyperactivity-impulsivity (at least 5 symptoms for adolescents/adults $\ge 17$ years) persisting for at least 6 months.
  • Several symptoms must have been present prior to age 12 years.
• ADHD assessment: Establish developmental appropriateness, duration, impairment and symptoms in at least two settings, with several symptoms before age 12. Rating scales and collateral help but no named scale is mandatory or sufficient by itself. Assess sleep, hearing, learning, anxiety and trauma.
  • Symptoms must cause clear functional impairment in academic, social, or occupational activities.
• Multimodal Management:
  • Psychoeducation, classroom accommodations, and Behavioural Parent Training (BPT) are foundational.
  • First-Line Pharmacotherapy: Psychostimulants—methylphenidate (Ritalin, Concerta) and dexamfetamine / lisdexamfetamine (Vyvanse). Mechanism: inhibition of dopamine and noradrenaline reuptake transporters (DAT and NET), boosting catecholaminergic transmission in the prefrontal cortex.
  • Pre-Treatment Cardiovascular Screening: Detailed personal and family cardiovascular history (screening for congenital cardiac anomalies, syncope, chest pain, and unexplained sudden premature death in relatives $< 40$ years). Baseline pulse, blood pressure, and accurate plotting of height and weight on growth centile charts.
  • Adverse Effects & Monitoring: Anorexia, weight loss, growth velocity slowing (monitor growth charts regularly), sleep-onset insomnia (administer stimulants early in the day), headaches, and motor tics. Second-line non-stimulant agents include atomoxetine (selective noradrenaline reuptake inhibitor), clonidine, and guanfacine (alpha-2 adrenergic agonists).

2. Disruptive Behaviour Disorders: ODD vs Conduct Disorder

• Oppositional Defiant Disorder (ODD): Defiance and hostility directed toward parents and teachers. Children argue with adults, refuse to obey rules, deliberately annoy others, and blame others for their mistakes. Crucially, they do not violate basic societal laws or inflict intentional physical cruelty.
• Conduct Disorder (CD): Severe, persistent antisocial behavior violating the rights of others. Features include initiating fights, physical cruelty to people or animals, using dangerous weapons, deliberate firesetting, breaking into houses or cars, mugging, and chronic truancy from school beginning before age 13. Childhood-onset type ($< 10\text{ years}$) carries a poor prognosis, frequently progressing to adult Antisocial Personality Disorder (ASPD) (which cannot be formally diagnosed before age 18, and requires documented antecedent conduct disorder before age 15).

Dementia assessment beyond a subtype label

Obtain a history from the person and, with consent, someone who knows their baseline. Assess function, mood, medicines, hearing/vision and reversible contributors, then use a culturally and linguistically appropriate cognitive test and targeted investigations. A low score alone does not diagnose dementia. Fluctuation and hallucinations can occur early in Lewy body disease, so the simple delirium-versus-dementia table has exceptions. Delirium can persist despite treatment and signals vulnerability.

Offer practical supports, driving assessment, medication supervision when needed, advance care discussions and carer support. Cholinesterase inhibitors and memantine offer symptomatic benefit in appropriate phenotypes; they do not guarantee prevention of neurodegeneration. New disease-modifying Alzheimer therapies require specialist eligibility and safety assessment rather than being routine for all dementia. Behaviour change should first prompt a search for pain, illness, unmet needs and environmental distress.

Primary references (checked 7 October 2026): RCH ADHD guidance.