14 - Liaison Psychiatry Flashcards
What is Liaison psychiatry?
Liaison psychiatrists provide psychiatric care to medical patients (taking physical and mental health together)
They attend emergency departments, general hospital in and out patients, and primary care medical service
What are some conditions that liaison psychiatrists might look at?
What psychiatric disorders can steroid treatment precipitate?
When the dose of steroids is high
- STEROID INDUCED MANIA
- Psychosis
- Affective disorders e.g depression, bipolar
What may be more suggestive of pseudoseizures (or dissociative seizures) on both history and examination than seizures?
- Asynchronous limb movements – often bizarre
- Resisting attempts to open eyes
- Protective/avoidance behaviour – i.e. patient doesn’t sustain injuries
- Emotional trigger for event e.g. happens during argument.
- No post-ictal period (generalised seizure often lengthy recovery)
- Patient able to recall what happened during the actual seizure
- Tongue biting and incontinence very rare
- Prolonged seizure >3 mins
What test can you do to distinguish a pseudo seizure from a seizure?
- Prolactin – this is not diagnostic of a seizure, however prolactin is often released during a seizure and therefore higher levels are detected in the first 2 hours post-seizure. This would not be the case in pseudoseizures.
What are factitious symptoms? (Munchausen’s)
A patient will feign symptoms but with no clear secondary gain other than to achieve the sick role and therefore care.
Post Partum Psychosis but need to rule out delirium
What is important to note in the history of a woman who may be experiencing postpartum psychosis?
- Past history of postpartum psychosis
- Past history of Bipolar affective disorder or Schizoaffective disorder
How is steroid induced mania treated?
- Treat as for any other mania – usually antipsychotic first-line
- Liaise with oncology team risk/benefit of continuing steroid and whether to gradually reduce
- Long term psychiatric follow up in outpatients, gradual reduction of antipsychotic
- Psychoeducation re. relapse indicators of future mood episodes for both patient and family
What is the definition of the following:
- Somatoform disorders
- Dissociative (conversion) disorders
Somatoform disorders
Symptoms are suggestive of a physical disorder but in the absence of a physiological illness leading to the presumption that they are caused by psychological factors. Sufferers repeatedly seek medical attention
Dissociative (conversion) disorders
Symptoms which cannot be explained by a medical disorder and where there are convincing associations in time between symptoms and stressful events. Unpleasant stressful events are ‘converted’ into symptoms
What is the prevalence of somatoform disorders and what are some risk factors for this?
0.1 to 2%
What are some different types of somatoform disorders?
What is the ICD10 criteria for somatisation disorder?
Multiple recurrent frequently changing physical symptoms not explained by a physical illness
Often dependent on analgesics with some form of functional impairment
What is hypochondriacal disorder?
Patient misinterprets normal bodily sensations which leads them to develop non-delusional preoccupations that they have a serious physical disease e.g cancer
They refuse to accept reassurance from doctors
How are Somatoform disorders diagnosed?
Diagnosis of exclusion
Multiple vague symptoms occurring in different organ systems
What is Malingering?
Patients intentionally fake or induce illness for secondary gain; e.g. drug seeking, disability benefits, avoiding work or prison time
How are somatoform and dissociative disorders managed?
Biological: SSRIs for any underlying mood disorders
Psychological: CBT, Coping strategies
Social: Involve family members who reinforce the sick role
What are the common causes of acute confusional state?
(important card to go over)
- Delirium
- Psychosis
What is the difference between conversion disorder and somatosisation disorder?
Conversion is usually neurological (motor or sensory symptoms)
Somatosisation is usually physical/physiological
What is baby blues and how many women does it affect?
Affect more than 50% of women in the first week or so after birth
- Mood swings
- Low mood
- Anxiety
- Irritability
- Tearfulness
Symptoms are usually mild, only last a few days and resolve within two weeks of delivery. No treatment is required.
What is post natal depression and what is the prevalence of this?
1 in 10 women, peak incidence at 3 months post birth
Two weeks symptoms of:
- Low mood
- Anhedonia (lack of pleasure in activities)
- Low energy
What are some risk factors for postpartum depression?
- History of postpartum depression (50%)
- Unipolar/ bipolar depression (25%)
- Unplanned pregnancy
- Lack of support
- Marital problems
- Social circumstances
How is post partum depression treated?
Need to treat as can affect infants cognitive and social skills
- Mild: additional support, self-help and follow up with their GP
- Moderate: antidepressants and CBT
- Severe: may need input from specialist psychiatry services
What antidepressant should you not use for post partum depression?
Fluoxetine as high doses in breast milk
Can use other SSRIs and TCAs
What tool can be useful to measure post natal depression?
- Edinburgh Postnatal Depression Scale
- PHQ9
What is the epidemiology of post partum psychosis?
1 in 1000 women (0.1-0.2%)
Peak onset at 2-3 weeks post birth
What are some of the presenting features of post partum psychosis?
- Delusions that are mood-congruent
- Hallucinations
- Depression
- Mania
- Confusion
- Thought disorder
What are some of the risk factors for puerperal psychosis?
- Previous postpartum psychosis has 30% recurrence risk
- Previous postpartum depression
- Single parenthood
- Reduced social support
- Previous mental illness
Prevent by having individualised care plan for high-risk individuals
How is postpartum psychosis treated?
EMERGENCY ASSESSMENT
- Admission to the mother and baby unit
- CBT
- Medications (antidepressants, antipsychotics or mood stabilisers)
- Electroconvulsive therapy (ECT)
- Social support
