1B psychiatry and physical health Flashcards
What is an adjustment disorder?
- Recent psychosocial stressors (illness and move into care)
- Mood lability and preoccupation on stressors
- Psychotic symptoms typically not seen
How long do adjustment disorders last for?
Typically resolve after 6 months
Why do a lot of people with long term conditions also have mental health issues?
- Long term conditions cause disability, inability to work or socialise
- Some medications like high dose steroids can cause mental health problems
What are common delusional themes?
- Persecutory- when you think someone is putting you in danger
- Jealousy
- Delusions about the environment
Most common perceptual abnormalities are auditory hallucinations followed by visual
What about the treatment for delusions/hallucinations?
No controlled studies looking at treatment. Some response to antipsychotic medication
N.B – Increased risk of stroke with antipsychotics use in those with dementia
Describe the interaction between physical and mental illness
- pink is people with long term conditions
- purple is people with mental health problems
Which long term medical conditions are associated with increased risk of mental illness?
- CVD → 3x risk of depression and anxiety
- Diabetes → 2x risk of depression
- COPD → 10x risk of panic disorder
- MSK disorder → 2x risk of depression
What discrete mental illness can Addison’s disease cause?
Depression, poor concentration, irritability
What discrete mental illness can hypercalcaemia cause?
Depression, anxiety
What discrete mental illness can hyperthyroidism cause?
Anxiety, mania
What discrete mental illness can hypothyroidism cause?
Depression, cognitive impairment (dementia)
What discrete mental illness can Cushing’s syndrome cause?
Depression
What discrete mental illness can infections (syphilis, HIV) cause?
Psychosis, dementia
What discrete mental illness can cancer cause?
Depression
What discrete mental illness can Parkinson’s disease cause?
Depression, anxiety, dementia, psychosis
What discrete mental illness can phaeochromocytoma cause?
Anxiety
What discrete mental illness can dementia cause?
Psychosis, aggression/violence, depression, anxiety
What discrete mental illness can Huntington’s disease cause?
Psychosis, aggression/violence, cognitive impairment, depression, anxiety
What mental illness can be as a result of a dopamine agonist adverse effect?
Psychosis
What mental illness can be as a result of a L-dopa adverse effect?
Psychosis, delirium, anxiety, depression
What mental illness can be as a result of a steroids (prednisolone) adverse effect?
Depression, mania, psychosis, anxiety
What mental illness can be as a result of an isoniazid (TB antibiotic) adverse effect?
Mania, psychosis
What mental illness can be as a result of a anticholinergics adverse effect?
Delirium, anxiety, psychosis
What mental illness can be as a result of a isotretinoin (roaccutane) adverse effect?
Depression
What mental illness can be as a result of a Digoxin adverse effect?
Depression, psychosis
What mental illness can be as a result of an interferon alpha adverse effect?
Depression, mania, psychosis
What is the mortality gap?
People with chronic mental illness are at greater risk of all cause mortality.
What are causes of the ‘mortality gap’?
Multifactorial Cause:
- Medication adverse effects (e.g. weight gain, dyslipidaemia, insulin insensitivity, hypertension, sedation)
- Increased rates of smoking, illicit substance use and alcohol intake
- Poor diet and exercise
- Chaotic lifestyles and low socioeconomic status
Describe the management to reduce the ‘mortality gap’.
- Choose medication that minimises impact on physical health
- e.g. weight gain sparing antidepressants and antipsychotics in those already with increased BMI
- Monitoring of cardiometabolic factors (BMI, HbA1C, lipid profile, blood pressure)
- Smoking cessation
- Dietary advice
- Drug and alcohol support services
Define delirium
ICD 11 (6D70)
An acute confusional state and a neuropsychiatric manifestation of physical illness/injury/interventions.
Can be considered as ‘acute brain failure’ compared to ‘chronic brain failure’ (dementia)
How is delirium classified?
- Hyperactive
- Hypoactive
- Mixed
What is hyperactive delirium?
Agitation, hallucinations, inappropriate behaviour
What is hypoactive delirium?
Lethargy, reduced concentration, reduced alertness, reduced oral intake
What is mixed delirium?
Mix of hyper/hypoactive delirium
What are some risk factors of delirium?
- Advancing age
- Cognitive impairment (e.g. dementia), sensory impairment
- Poor nutrition
- Polypharmacy/alcohol misuse
- Frailty
What are some common causes/precipitating factors of delirium?
Physical illness or injury (e.g. liver/renal impairment, hyponatraemia, constipation, alcohol withdrawal, infection, urinary retention, electrolyte disturbance, pain, acute vascular events, dehydration)
Describe the pathophysiology of delirium
Poorly understand and likely multi-factorial.
A critical illness leads to increased cortisol levels and cerebral hypoxia (older adults predisposed) which leads to decreased acetylcholine synthesis and dysfunctions of hippocampal and neocortical areas (x500 fold increase in dopamine, increased adrenergic output).
How is delirium managed?
- Anticipate
- Modify risk factors if possible (e.g. reducing polypharmacy, visual and hearing aids)
- Early diagnosis
- Treat any underlying cause (e.g. UTI, constipation, etc)
- Re-orientation strategies (familiar environments, use of clocks, reminding of name and current location)
- Normalise sleep-wake cycle (encourage uninterrupted sleep, use of appropriate lighting, discourage daytime napping)
- Maintain safe mobility to avoid falls
How do we deal with challenging behaviour in delirium?
- Address underlying unmet needs (thirst, need for toilet, discomfort/pain)
- Safe and low stimulation environments
- Verbal and non-verbal de-escalation techniques
- In extremis: short term pharmacological interventions (e.g. low dose Haloperidol [0.5mg] for <7 days)
Why is delirium in hospitals bad?
- Affects 50% of those in hospital aged >65
- Complicates 80% of ITU admissions
- May affect 14% of those >85 in the community
- Leads to increased mortality and delays in discharge
What is stigma?
Challenges faced by people with mental illness related to knowledge, attitudes and behaviour of people they meet
How many people with mental illness experience stigma?
3 in 4 people with mental illness experience stigma.
- Rates are higher in those from BAME groups
- Cultural variation in the perception of mental illness
What factors affect the diagnosis of physical disorders in people with mental illness?
- Illness behaviour (e.g. poor insight, mistrust of others, chaotic lifestyle)
- Diagnostic overshadowing (misattribution of physical symptoms to psychiatric symptoms)
- Lack of resources/lack of access to services (low socio-economic status is a risk factor for the development of mental illness)
What causes psychotic depression?
- Recent psychosocial stressors
- Older age and chronic medical conditions are risk factors
How does psychotic depression present?
- Core features of depression
- Paranoid psychosis rare. Typically a mood congruent psychosis is seen (delusions of nihlism, guilt, Cotard’s syndrome)
- Visual hallucinations uncommon
What can cause behavioural and psychological symptoms of dementia?
- Known history of recent vascular insult to the brain
- Delusions and hallucinations can be seen in BPSD
- Ongoing vascular risk factors and advancing age (main risk factor for dementia)
- Cognitive concerns raised by carers
- BPSD typically a feature of more advanced disease
