Internet Mental Health

DELIRIUM






Internet Mental Health Quality of Life Scale (Client Version)

Internet Mental Health Quality of Life Scale (Therapist Version)

  • Confused, poor attention, disoriented to time and place.

  • Onset is abrupt and duration is short (hours to weeks).

  • Fluctuating course (more at night).

  • Due to rapid changes in brain function that occur with physical or mental illness.

Prediction

    Usually lasts less than 1 week, but the duration is variable and the degree of severity ranges from mild to very severe. Full recovery is common if underlying physical cause is corrected; complications depend on underlying physical cause.

Problems

    Occupational-Economic Problems:

    • Causes significant impairment in occupational and social functioning.

    • Confusion ranges from mild to severe and potentially life-threatening.

    Antagonistic (Antagonism):

    • May become violent

    Disinhibited (Disinhibition):

    • Too confused to safely do usual daily activities (e.g., driving, money management, parenting).

    Confused (Impaired Intellect):

    • Disturbance in attention and awareness: e.g., reduced ability to direct, focus, sustain, and shift attention; reduced orientation to the environment.

    • Develops over a short period of time: (usually hours to a few days), represents a change from baseline attention and awareness.

    • Fluctuating course: usually worsens at night when there is less stimulation to orient the individual.

    • Has other disturbances in cognition: e.g., memory deficit, disorientation, language, visuospatial ability, or perception.

    • Not due to a preexisting neurocognitive disorder: Not better explained by another preexisting, established, or evolving neurocognitive disorder and does not occur in the context of a severely reduced level of arousal, such as coma.

    • Due to medical or substance use disorder: is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e., due to a drug of abuse or to a medication), or exposure to a toxin.

    Anormally Inhibited or Disinhibited (Low or High Extraversion):

    • Social withdrawal (due to confusion)

    • May be hyperactive, hypoactive, or a mixture of both

    Negative Emotions (Negative Emotion):

    • Mood may be anxious, depressed or highly changable.

    Medical:

    • Causes: New-onset stroke or transient ischemic attack, subdural hematoma, epilepsy, meningitis, encephalitis, brain abscess, and neurosyphilis can cause delirium. Delirium is often the only symptom of myocardial infarction, urinary tract infection and pneumonia in older people. Other causes of delirium are: hypoxia, pulmonary embolism, alcoholic ketoacidosis, hip fracture, metabolic abnormalities, hypoglycemia or hyperglycemia, drug toxicity, drug withdrawal (benzodiazepine, alcohol), acute psychosis, advanced cancer, endocrine abnormalities (hypothyroidism, adrenal crisis), and urinary obstruction.



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Delirium, Not Induced By Alcohol And Other Psychoactive Substances F05 - ICD10 Description, World Health Organization
An etiologically nonspecific organic cerebral syndrome characterized by concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behavior, emotion, and the sleep-wake schedule. The duration is variable and the degree of severity ranges from mild to very severe.
Delirium - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with delirium needs to meet all of the following criteria:

  • A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).

  • The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate during the course of the day.

  • An additional disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial ability, or perception).

  • These cognitive disturbances are not better explained by another preexisting, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma.

  • There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e., due to a drug of abuse or to a medicatioin), or exposure to a toxin, or is due to multiple etiologies.


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Diagnostic Features

Delirium is a potentially life-threatening disorder characterized by an acute, fluctuating change in mental status, with inattention, disorganized thinking, and altered levels of consciousness. The individual with Delirium may be hyperactive, hypoactive, or a mixture of both. Treatment should immediately attempt to treat the physical cause of the Delirium. New-onset stroke or transient ischemic attack, subdural hematoma, epilepsy, meningitis, encephalitis, brain abscess, and neurosyphilis can cause delirium. Delirium is often the only symptom of myocardial infarction, urinary tract infection and pneumonia in older people. Other causes of Delirium are: hypoxia, pulmonary embolism, alcoholic ketoacidosis, hip fracture, metabolic abnormalities, hypoglycemia or hyperglycemia, drug toxicity, drug withdrawal (benzodiazepine, alcohol), acute psychosis, advanced cancer, endocrine abnormalities (hypothyroidism, adrenal crisis), and urinary obstruction.

Effective Therapies

Outcome depends on the physical cause of the Delirium. Antipsychotic medication [1], high-dose lorazepam, or electroconvulsive therapy (ECT) is effective for the Delirium caused by Bipolar I Disorder [2] [3]. Neuroleptic malignant syndrome (caused by antipsychotic medication) and serotonin syndrome (caused by SSRI antidepressant medication) can both cause Delirium. Many other medications and medical disorders can cause Delirium.

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Stories

Rating Scales


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Treatment Guidelines



World Health Organization Delirium and Dementia Treatment Guidelines

Download Printable Version

Treatment


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    "In physical science a first essential step in the direction of learning any subject is to find principles of numerical reckoning and practicable methods for measuring some quality connected with it. I often say that when you can measure what you are speaking about and express it in numbers you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind: it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science, whatever the matter may be."

    Lord Kelvin (1824 – 1907)


  • The best summary on bad research is given by Laura Arnold in this TEDx lecture. If you read nothing else about research, you owe it to yourself to watch this short video - it is excellent!

  • Canadian researchers who commit scientific fraud are protected by privacy laws: There are criminals in every community - even in the scientific research community (especially if a lot of money is at stake). Criminal researchers can hide their fraud behind outdated privacy laws.

  • The power of asking "what if?"

  • The active placebo effect: 2300 years ago, the Greek Stoic philosophers taught that it is not the objective event, but our subjective judgment about the event, that determines our behavior. The active placebo effect bears witness to this ancient wisdom.

  • Criteria For High Quality Research Studies

  • It is troubling that a recent study found that two-thirds of important psychological research studies couldn't be replicated. High quality research must meet the following criteria:

    • Randomized Controlled Trial:
      Ask: Was the trial randomized? Was the randomization procedure described and was it appropriate? The best research design is to have research subjects randomly assigned to an experimental or control group. It is essential that confounding factors be controlled for by having a control group or comparator condition (no intervention, placebo, care as usual etc.).

    • Representative Sample:
      Ask: Do the research subjects represent a normal cross-section of the population being studied? Many psychological research studies using university students are flawed because their subjects are not representative of the normal population since they are all W.E.I.R.D. (White, Educated, Intelligent, Rich, and living in a Democracy).

    • Single Blind Trial:
      Ask: Was the treatment allocation concealed? It is essential that the research subjects are kept "blind" as to whether they are in the experimental or control group (in order to control for any placebo effects).

    • Double Blind Trial (Better Than Single Blind Trial):
      Ask: Were blind outcome assessments conducted? In a double blind study, neither the research subjects nor the outcome assessors know if the research subject is in the experimental or control group. This controls for both the placebo effect and assessor bias.

    • Baseline Comparability:
      Ask: Were groups similar at baseline on prognostic indicators? The experimental and control groups must be shown to be comparable at the beginning of the study.

    • Confounding Factors:
      Ask: Were there factors, that weren't controlled for, that could have seriously distorted the study's results? For example, research studies on the effectiveness of mindfulness cognitive therapy in preventing depressive relapse forgot to control for whether the research subjects were also simultaneously receiving antidepressant medication or other psychological treatments for depression.

    • Intervention Integrity:
      Ask: Was the research study protocal strictly followed? The research subjects must be shown to be compliant (e.g., taking their pills, attending therapy) and the therapists must be shown to be reliably delivering the intervention (e.g., staying on the research protocol).

    • Statistical analysis:
      Ask: Was a statistical power calculation described? The study should discuss its statistical power analysis; that is whether the study size is large enough to statistically detect a difference between the experimental and control group (should it occur) and usually this requires at least 50 research subjects in the study.

      Ask: Are the results both statistically significant and clinically significant? The results should be both statistically significant (with a p-value <0.05) and clinically significant using some measure of Effect Size such as Standardized Mean Difference (e.g., Cohen's d >= 0.33). The summary statistics should report what percentage of the total variance of the dependent variable (e.g., outcome) can be explained by the independent variable (e.g., intervention). In clinical studies, the study should report the number needed to treat for an additional beneficial outcome (NNTB), and the number needed to treat for an additional harmful outcome (NNTH).

        Number Needed To Benefit (NNTB): This is defined as the number of patients that need to be treated for one of them to benefit compared with a control in a clinical trial. (It is defined as the inverse of the absolute risk reduction.) Note: Statistically, the NNTB depends on which control group is used for comparison - e.g., active treatment vs. placebo treatment, or active treatment vs. no treatment.

        Number Needed To Harm (NNTH): This is defined as the number of patients that need to be treated for one of them to be harmed compared with a control in a clinical trial. (It is defined as the inverse of the absolute increase in risk of harm.)

        Tomlinson found “an NNTB of 5 or less was probably associated with a meaningful health benefit,” while “an NNTB of 15 or more was quite certain to be associated with at most a small net health benefit.”

      Ask: Does the researcher accept full responsibility for the study's statistical analysis? The researcher should not just hand over the study's raw data to a corporation (that may have $1,000 million invested in the study) to do the statistical analysis.

    • Completeness of follow-up data:
      Ask: Was the number of withdrawals or dropouts in each group mentioned, and were reasons given for these withdrawals or dropouts? Less than 20% of the research subjects should drop out of the study. The intervention effect should persist over an adequate length of time.

    • Handling of missing data:
      Ask: Was the statistical analysis conducted on the intention-to-treat sample? There must be use of intention-to-treat analysis (as opposed to a completers-only analysis). In this way, all of the research subjects that started the study are included in the final statistical analysis. A completers-only analysis would disregard those research subjects that dropped out.

    • Replication of Findings:
      Ask: Can other researchers replicate this study's results? The research study's methodology should be clearly described so that the study can be easily replicated. The researcher's raw data should be available to other researchers to review (in order to detect errors or fraud).

    • Fraud:
      Ask: Is there a suspicion of fraud? In a research study, examine the independent and dependent variables that are always measured as a positive whole number (e.g., a variable measured on a 5-point Likert-type scale ranging from "1 = definitely false to 5 = definitely true" etc.). For each of these variables, look at their sample size (n), mean (M) and standard deviation (SD) before they undergo statistical analysis. There is a high suspicion of fraud in a study's statistics:

      • If the M is mathematically impossible (online calculator): This is one of the easiest ways to mathematically detect fraud. The mean (M) is defined as "the sum (Sum) of the values of each observation divided by the total number (n) of observations". So: M = Sum/n. Thus: (Sum) = (M) multiplied by (n). We know that, if a variable is always measured as a positive whole number, the sum of these observations always has to be a whole number. For these variables to test for fraud: calculate (M) multiplied by (n). This calculates the Sum which MUST be a positive whole number. If the calculated Sum isn't a positive whole number; the reported mean (M) is mathematically impossible - thus the researcher either cooked the data or made a mistake. A recent study of 260 research papers published in highly reputable psychological journals found that 1 in 2 of these research papers reported at least one impossible value, and 1 in 5 of these research papers reported multiple impossible values. When the authors of the 21 worst offending research papers were asked for their raw data (so that its reliability could be checked) - 57% angrily refused. Yet such release of raw data to other researchers is required by most scientific journals. (Here is an example of a research paper filled with mathematically impossible means.)

      • If the SD is mathematically impossible (online calculator): When researchers fraudulently "cook" their data, they may accidently give their data a mean and standard deviation that is mathematically impossible for a (normally distributed) strictly positive variable (because the "cooked" M and SD would mathematically require the strictly positive variable's range of data to include negative numbers). For a normally distributed sample of size of 25-70, this occurs when the SD is greater than one-half of the M; for a sample size of 70+, this occurs when the SD is greater than one-third of the M [using these formulas].

      • If the SD/M is very small (i.e., the variable's standard deviation is very small compared to the mean suggesting data smoothing).

      • If the SD's are almost identical (i.e., the variables have different means but almost identical standard deviations).

      • If the 4th digit of the values of the variables aren't uniformly distributed - since each should occur 10% of the time (Benford's Law).

      • If the researcher is legally prevented from publishing negative findings about a drug or therapy because that would violate the "nondisclosure of trade secrets" clause in the research contract (i.e., it is a "trade secret" that the drug or therapy is ineffective - hence this can not be "disclosed"). Approximately half of all registered clinical trials fail to publish their results.

      • If the researcher refuses to release his raw data to fellow researchers (so that they can check its validity). In order to be published in most scientific journals, a researcher must promise to share his raw data with fellow researchers. Thus a researcher's refusal to do so is almost a sure indicator of fraud.

      • If the research study's data contradicts the study's own conclusions - surprisingly, this often occurs.

  • Calling Bullshit In The Age of Big Data - "Bullshit is language, statistical figures, data graphics, and other forms of presentation intended to persuade by impressing and overwhelming a reader or listener, with a blatant disregard for truth and logical coherence." Reading the syllabus of this university course should be required reading for every student of mental health. This syllabus is absolutely fantastic!

  • Statistical Methods in Psychology Journals: Guidelines and Explanations - American Psychologist 1999

  • Not All Scientific Studies Are Created Equal - video

  • The efficacy of psychological, educational, and behavioral treatment

  • Estimating the reproducibility of psychological science

  • Psychologists grapple with validity of research

  • Industry sponsorship and research outcome (Review) - Cochrane Library

  • 'We've been deceived': Many clinical trial results are never published - (text and video)

  • Junk science misleading doctors and researchers

  • Junk science under spotlight after controversial firm buys Canadian journals

  • Medicine with a side of mysticism: Top hospitals promote unproven therapies - Are some doctors becoming modern witchdoctors?

  • When Evidence Says No, But Doctors Say Yes


  • Cochrane Reviews (the best evidence-based, standardized reviews available)

Research Topics


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