1b// Psychiatry and Physical Health Flashcards
What do you look at in a mental state examination? (8)
A+B (general what they look like)
speech
mood
perceptions
thought content
thought form
insight
cognition
When is post-stroke psychosis most commonly seen?
right sided middle cerebral artery (MCA) lesions affecting the frontal and temporal regions
What is the most commonly reported psychotic symptom of post-stroke psychosis?
delusions
- most delusions of a persecutory or jealous type - N.B. fixed, false belief not understandable within the person’s sociocultural setting
What is a delusion called of a persecutory or jealous type?
Othello’s syndrome
What is the most common perceptual abnormality of post-stroke psychosis?
auditory hallucinations followed by visual
What is the management of post-stroke psychosis?
o No controlled studies looking at treatment. Some response to antipsychotic medication
o N.B – Increased risk of stroke with antipsychotics use in those with dementia
How common are neuropsychiatric symptoms following a stroke?
occurs in at least 30% and are a major predictor of poor outcome
What does it mean the interplay between physical and mental health?
many long term medical conditions are risk factors for the development of mental disorders
What is the interplay between CVD and mental health?
associated with 3x increased risk of depression and anxiety
What is the interplay between MSK disorders and mental health?
associated with 2x increased risk of depression
What is the interplay between diabetes and mental health?
associated with 2x increased risk of depression
What is the interplay between COPD and mental health?
associated with 10x increased risk of panic disorder
What are more examples of physical illness causing mental illness?
What is the mental adverse affect of dopamine agonists?
psychosis
What is the mental adverse affect of L-dopa?
psychosis, delirium, anxiety, depression
What is the mental adverse affect of steroids (prednisolone)?
depression, mania, psychosis, anxiety
What is the mental adverse affect of dopamine agonists isoniazid (TB antibiotics)?
mania, psychosis
What is the mental adverse affect of anticholinergics?
delirium, anxiety, psychosis
What is the mental adverse affect of isoretinoin (roaccutane)?
depression
What is the mental adverse affect of digoxin?
depression, psychosis
What is the mental adverse affect of interferon alpha?
depression, mania, psychosis
What is the mortality gap?
People with chronic mental illness are at greater risk of all cause mortality; the so called “mortality gap”
What are the multifactorial causes of physical health in those with mental health?
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
How do you manage the multifactorial causes of physical health with mental health?
- Choose medication that minimises impact on physical health
o 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
Can mental illness present with physical symptoms?
Yes
What does the MRI brain scan look like in patients with alzheimer’s?
ventricles look larger (aka atrophy of brain matter)
temporo-parietal cortical atrophy
mesial temporal lobe atrophy
mild small vessel disease
What is delirium?
An acute confusional state and a neuropsychiatric manifestation of physical illness/injury/interventions o Can be considered as “acute brain failure” compared to “chronic brain failure” (dementia)
“Delirium is characterized by a disturbance of attention, orientation, and awareness that develops within a short period of time, typically presenting as significant confusion or global neurocognitive impairment, with transient symptoms that may fluctuate depending on the underlying causal condition or etiology. Delirium often includes disturbance of behaviour and emotion, and may include impairment in multiple cognitive domains. A disturbance of the sleep-wake cycle, including reduced arousal of acute onset or total sleep loss with reversal of the sleep- wake cycle, may also be present. Delirium may be caused by the direct physiological effects of a medical condition not classified under mental, behavioural or neurodevelopmental disorders, by the direct physiological effects of a substance or medication, including withdrawal, or by multiple or unknown etiological factors”
How is delirium broadly classified?
o Hyperactive – Agitation, hallucinations, inappropriate behaviour
o Hypoactive – Lethargy, reduced concentration, reduced alertness, reduced oral intake
o Mixed – A combination of the above
What is the epidemiology of delirium?
o Affects 50% of those in hospital aged >65
o Complicates 80% of ITU admissions
o May affect 14% of those >85 in the community
o Leads to increased mortality and delays in discharge
What are the risk factors of delirium? (not exhaustive) (5)
o Advancing age
o Cognitive impairment (e.g. dementia), sensory impairment
o Poor nutrition
o Polypharmacy/alcohol misuse
o Frailty
What are common causes/ precipitating factors of delirium?
Common causes/ precipitating factors - Physical illness or injury (e.g. infection, constipation, urinary retention, electrolyte disturbance, pain, acute vascular events, dehydration)
o i.e. pretty much anything can cause delirium in those sufficiently at risk!
What is the pathophysiology of delirium?
Pathophysiology - Is poorly understood and likely multi-factorial
A critical illness leads to increased cortisol levels and cerebral hypoxia (older adults predisposed) which leads to ↓acetylcholine synthesis and dysfunctions of hippocampal and neocortical areas (↑500 times dopamine and ↑adrenergic output) (Maldonado, 2008)
likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity (Wilson et al, 2020)
What is the management for delirium? (5)
Anticipate and address any modifiable risk factors (e.g. reducing polypharmacy, visual and hearing aids)
Optimise treatment of underlying co-morbidities
Treat any underlying cause (e.g. UTI, constipation, physical injury, electrolyte disturbance, dehydration)
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 you manage the challenging behaviours of delirium?
o Address underlying unmet needs (thirst, need for toilet, discomfort/pain)
o Safe and low stimulation environments
o Verbal and non-verbal de-escalation techniques
o In extremis – Short term pharmacological interventions (e.g. low dose Haloperidol [0.5mg] for <7 days)
What are the stigmas in mental health?
3 in 4 people with mental illness experience stigma
o Rates are higher in those from Black, Asian and ethnic minority groups
o Cultural variation in the perception of mental illness
In 1998 RCPsych started a 5 year campaign to reduce stigma called “Changing Minds”
Stigma is a barrier to accessing all aspects of care
Stigma can also be a risk factor for people experiencing abuse, rejection and isolation
Stigma contributes to difficulties in employment
What factors affect the diagnosis of physical disorders in people with mental illness? (3)
o Illness behaviour (e.g. poor insight, mistrust of others, chaotic lifestyle)
o Diagnostic overshadowing (misattribution of physical symptoms to psychiatric symptoms)
o Lack of resources/lack of access to services (low socio-economic status is a risk factor for the development of mental
disorders)
A 78 year old male is admitted to hospital with a community acquired pneumonia (CAP). During the night he reports seeing insects on his bed. This is most likely to be caused by?
delirium
Describe adjustment reaction?
State of SUBJECTIVE DISTRESS and EMOTIONAL DISTURBANCE, usually interfering with social functioning and performance, arising in the period of adaptation to a significant life change or a stressful life event… the manifestations vary and include depressed mood, anxiety or worry (or mixture of these), a feeling of inability to cope, plan ahead, or continue in the present situation, as well as some degree of disability in the performance of daily routine.
describe organic delusional disorder?
a disorder in which persistent or recurrent delusions dominate the clinical picture. the delusions may be accompanied by hallucinations. Some features suggestive of schizophrenia, such as bizarre hallucinations or thought disorder, may be present.
Describe some features of post-stroke psychosis.
What is emotional lability?
inability to control emotions due to right hemisphere brain damage
- common complication of stroke
Describe how having a chronic mental illness affects life expectancy and risk of physical illness.
people with chronic mental illness are at greater risk of physical illness
- diet and exercise
- smoking, alcohol and drugs
- medication
people with chronic mental illness die 20 years younger than the general populatoin
What factors may affect timely diagnosis of physical disorders in people with mental illness? (4)
illness behaviour
diagnostic overshadowing
stigma
lack of resources
What is diagnostic overshadowing?
Diagnostic overshadowing, which is ajudgment bias where health care professionals mistakenly attribute clinical manifestations of physical illness(eg, pain, tachycardia, hypertension) to manifestations associated with a pre-existing mental illness.
Describe organic cerebral syndrome.
organic cerebral syndrome characterized by concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behaviour, emotion, and the sleep-wake schedule. The duration is variable and the degree of severity ranges from mild to severe.
What is delirium and how does it affect patients?
delirium is a psychiatric manifestation of a physical illness
- can be hypoactive or hyperactive
delays discharge and increases mortality
What is delirium also known as?
also known as acute confusional state
What causes delirium? (14)
Infection (urine, pneumonia, cellulitis, wound etc.)
Change in environment (ITU, HDU, ward)
Medication (opiates, anticholinergics, steroids)
Alcohol withdrawal
Surgery
Pain
Liver/ renal impairment
Hyponatraemia
Hypoxia
Stroke
Encephalitis
Constipation
Urine retention
Dehydration
What are some delirium-predisposing factors?
advanced age
dementia (often undetected)
impaired activities of daily living
immobility
sensory impairment
urinary catheterization
malnutrition
alcohol
depression
How to manage delirium?
Anticipate
Modify risk factors if possible
Early diagnosis
Treat the causes
Good nursing
- single room, well lit, familiar staff/ family
Medication
Wait!
What is stigma?
Stigma is a barrier to accessing care
Stigma leads to abuse, rejection and isolation
What are the different types of stigma?
Do you understand this Intro to Psych Diagram?
