CASC Knowledge Essentials16 · Sleep, gender health and inpatient emergencies
16 · Sleep, gender health and inpatient emergencies
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Written by Resident Doctor Committee · Published
16.1 Meningioma and new psychiatric symptoms
A meningioma arises from the meninges. Many are slow-growing and non-malignant, but pressure, oedema and location can still cause serious problems. A frontal lesion may present with disinhibition, apathy, personality change or poor judgement. Seizures, focal signs, progressive cognitive decline and headache strengthen the structural differential.
“Benign” does not mean harmless. MRI defines the lesion; definitive grading usually needs tissue. Surveillance, surgery and radiotherapy have different roles depending on symptoms, growth, location and histology. The scan label alone cannot predict the individual outcome.
Steroids reduce oedema, not the tumour itself. Chemotherapy is not routine first-line meningioma treatment. Psychiatric symptoms may improve after treatment, but recovery is not guaranteed.
16.2 Confidentiality and candour
You can listen to a relative without breaching confidentiality. The issue is what you disclose. General illness information can often be shared without revealing personal details. Personal information usually needs consent or another valid basis: best interests where appropriate, a legal duty, or proportionate disclosure to prevent serious harm.
“Next of kin” gives no automatic right to information or to consent for an adult.
Candour: when something goes wrong that causes, or could cause, harm or distress, be open, explain what is known, apologise and offer support. An adverse reaction does not automatically prove negligence. The clinician's professional duty and the organisation's statutory notification duty are related but distinct.
Capacity and MHA criteria answer different questions. A capacitous adult can ordinarily refuse physical treatment, even unwisely, yet may meet MHA criteria for detention/treatment of mental disorder. A risky choice alone does not establish incapacity. Inpatient holding powers do not apply simply because someone is in A&E.
16.3 Physical deterioration during seclusion
Seclusion means supervised confinement, with the person prevented from leaving, to contain severely disturbed behaviour likely to harm others. It does not treat dehydration, delirium or psychosis. A quieter patient may be physically worse through sedation, infection, immobility or poor intake.
Food/fluid refusal may reflect persecutory beliefs, depression, catatonia, delirium, pain or medication effects. Catatonia: mutism, immobility, posturing, negativism, echophenomena or abnormal excitement in a characteristic cluster. Complications include dehydration, thrombosis and pressure injury. Simply increasing antipsychotics is not its treatment pathway.
Dehydration: tachycardia, hypotension, oliguria and renal impairment; sodium may be high, normal or low. Raised CK: can follow agitation/restraint and does not alone establish NMS. Fever, rigidity, mental-state change and autonomic instability after dopamine blockade need urgent assessment.
Rapid tranquillisation: calm enough to be safe
NICE adult options are IM lorazepam alone or IM haloperidol + IM promethazine. Selection depends on physical health, previous response and interactions. Prefer lorazepam if information is insufficient or no ECG is available; haloperidol is problematic with relevant cardiac/QT risk. Benzodiazepines still risk respiratory depression, especially with alcohol, opioids or respiratory disease.
After rapid tranquillisation | Frequency |
|---|---|
Consciousness, respiratory rate, pulse/BP, temperature, hydration | At least hourly until concerns resolve |
Sedated/intoxicated, physical-health problems, harmed during restraint, or BNF maximum exceeded | Every 15 minutes |
Adult seclusion needs the appropriate MHA basis. Emergency seclusion of an informal patient requires immediate MHA assessment.
Unrousable is not the target. Respiratory depression needs urgent airway/medical care. Flumazenil is not a routine antidote for every sedated patient: it can precipitate seizures, including in benzodiazepine dependence and some mixed overdoses.
16.4 Gender incongruence and gender dysphoria
Identity, expression and sexual orientation are different. Gender incongruence is a persistent mismatch between experienced gender and assigned sex. ICD-11 places it under sexual health, not mental disorders. Clothing/interests alone do not establish the diagnosis. Gender dysphoria emphasises associated distress; being transgender is not itself a psychiatric illness.
Depression, anxiety, autism or psychosis may coexist without automatically invalidating identity. A single unusual belief, stereotyped childhood preference or sexual-arousal test cannot establish the whole history.
Adult care and hormone effects
Goals differ. Adults may seek social changes, voice therapy, hormones, surgery, psychological support or combinations. Discuss fertility preservation before interventions that affect reproductive function. Adult pathways cannot simply be applied to children.
Treatment | Effects | Point to retain |
|---|---|---|
Oestradiol-based treatment | Breast development; fat distribution, skin and sexual-function changes | Does not reliably raise a voice deepened by testosterone; assess thromboembolic/cardiovascular risk |
Testosterone-based treatment | Deeper voice, facial/body hair, more muscle, often amenorrhoea | Some changes persist; erythrocytosis requires haemoglobin/haematocrit monitoring |
Surgery | Permanent procedure-specific changes | Sexual-function and fertility effects vary by procedure |
Regimen, route and individual risk determine monitoring.
Testosterone is not contraception. Pregnancy can occur without periods; testosterone is not recommended during pregnancy. Neither guaranteed sterility nor guaranteed reversibility is an accurate promise.
16.5 Insomnia and its important alternatives
Insomnia = difficulty sleeping despite adequate opportunity, with daytime consequences. It may involve onset, maintenance or returning to sleep after waking. Chronic insomnia lasts at least three months, several nights weekly. Too little opportunity to sleep is a different problem.
Pattern | Distinguishing clue |
|---|---|
Depression | Full depressive syndrome; early waking alone is insufficient |
Mania/hypomania | Reduced need for sleep without expected fatigue, with increased energy/activity |
Obstructive sleep apnoea | Snoring, witnessed pauses, choking/gasping, unrefreshing sleep, daytime sleepiness |
Restless legs | Unpleasant urge to move, worse at rest/evening, relieved by movement |
Circadian disorder | Sleep is relatively normal on the preferred schedule, but mistimed for daily demands |
Narcolepsy | Sleep attacks/excessive sleepiness; may include cataplexy, sleep paralysis and sleep-related hallucinations |
Drugs/substances | Caffeine, stimulants, alcohol, withdrawal and timing of medicines |
Alcohol may help sleep onset but fragment later sleep. Consider pain, nocturia, respiratory disease and menopausal symptoms. Treating depression does not always resolve a separately maintained insomnia disorder.
Sleep apnoea and narcolepsy
OSA: repeated upper-airway obstruction causes sleep disruption and intermittent desaturation, with cardiovascular and accident risks. Weight management and CPAP address the mechanism; adding sedation does not.
Cataplexy: brief loss of muscle tone, often emotion-triggered, with awareness preserved. Distinguish it from syncope or a generalised seizure. Hypnagogic/hypnopompic hallucinations occur at sleep onset/waking and need not mean psychosis. Not every person with narcolepsy has the whole cluster.
Why CBT-I helps
Worry about sleep → prolonged wakefulness in bed → irregular timing/naps → further insomnia. CBT-I addresses this with stimulus control, sleep scheduling/restriction and cognitive work. Sleep hygiene supports it but is often insufficient alone.
Benzodiazepines/Z-drugs risk dependence, rebound insomnia, impaired daytime performance and falls; their role is usually short term. Daridorexant blocks orexin receptors. NICE permits it for adults with insomnia ≥3 nights/week for ≥3 months, substantial daytime impairment, and CBT-I ineffective, unavailable or unsuitable. Review within three months; stop if ineffective.