4.2 - Mental disorders and physical health

Question 1

What is an adjustment reaction?

Answer 1

A state of mental distress, interfering with social functioning, that arises from a significant life change or stressful life event

Question 2

What do the manifestations of an adjustment reaction include? (5)

Answer 2

• depressed mood
• anxiety
• worry
• feeling of inability to cope, plan ahead or continue in the present situation
• degree of disability in the performance of daily routine

Question 3

What is post-stroke psychosis?

Answer 3

Neuropsychotic symptoms following stroke occur in at least 30% and are a major predictor of poor outcome

Question 4

Post-stroke psychosis is most commonly seen following what lesions?

Answer 4

Most commonly seen in right-sided middle cerebral artery lesions affecting the frontal and temporal regions

Question 5

What are the most commonly reported psychotic symptom of post-stroke psychosis?

Answer 5

• delusions - most delusions of a persecutory or jealous type (Othello’s syndrome)
• fixed, false belief not understandable within the person’s sociocultural setting

Question 6

What are the most common perceptual abnormalities of post-stroke psychosis?

Answer 6

Auditory hallucinations followed by visual

Question 7

How is post-stroke psychosis managed?

Answer 7

• no controlled studies looking at treatment
• some respond to antipsychotic medication
• increased risk of stroke with antipsychotics in those with dementia

Question 8

Why do a lot of people with long term physical conditions also have mental health issues (30%)? (2)

Answer 8

• long term conditions cause disability, inability to work or socialise
• some medications like high-dose steroids can cause mental health problems

Question 9

Why do a lot of people with mental health issues also have long term health conditions (46%)? (4)

Answer 9

• chronic stress –> excess cortisol
• antipsychotics can have long term negative effects on CV system that can increase risk of heart disease and stroke
• people tend to have bad lifestyle choices e.g. alcohol, smoking
• some reluctant to access care - pessimism

Question 10

What are some examples of long term medical conditions that are associated with increased risk of mental illness? (4)

Answer 10

• cardiovascular disease - 3x risk of depression/anxiety
• MSK disorders - 2x risk of depression
• diabetes - 2x risk of depression
• COPD - 10x risk of panic disorder

Question 11

What is the first job of a psychiatrist?

Answer 11

Exclude an organic cause (physical illness) for the patient’s presentation

Question 12

What mental illnesses can Addison’s disease lead to?

Answer 12

Depression, poor concentration, irritability

Question 13

What mental illnesses can hypercalcaemia lead to?

Answer 13

Depression, anxiety

Question 14

What mental illnesses can hyperthyroidism lead to?

Answer 14

Anxiety, mania

Question 15

What mental illnesses can hypothyroidism lead to?

Answer 15

Depression, cognitive impairment

Question 16

What mental illnesses can Cushing’s syndrome lead to?

Answer 16

Depression

Question 17

What mental illnesses can infections (HPV, syphilis) lead to?

Answer 17

Psychosis, dementia

Question 18

What mental illnesses can SLE lead to?

Answer 18

Depression

Question 19

What mental illnesses can cancer lead to?

Answer 19

Depression

Question 20

What mental illnesses can Parkinson’s disease lead to?

Answer 20

Depression, anxiety, dementia, psychosis

Question 21

What mental illnesses can phaeochromocytoma lead to?

Answer 21

Anxiety

Question 22

What mental illnesses can dementia lead to?

Answer 22

Psychosis, aggression/violence, depression, anxiety

Question 23

What mental illnesses can Huntington’s disease lead to?

Answer 23

Psychosis, aggression/violence, cognitive impairment, depression, anxiety

Question 24

What psychological adverse effects can dopamine agonists cause?

Answer 24

Psychosis

Question 25

What psychological adverse effects can L-dopa cause?

Answer 25

Psychosis, delirium, anxiety, depression

Question 26

What psychological adverse effects can steroids (prednisolone) cause?

Answer 26

Depression, mania, psychosis, anxiety

Question 27

What psychological adverse effects can isoniazid (TB antibiotic) cause?

Answer 27

Mania, psychosis

Question 28

What psychological adverse effects can isoretinoin (roaccutane) cause?

Answer 28

Depression

Question 29

What psychological adverse effects can digoxin cause?

Answer 29

Depression, psychosis

Question 30

What psychological adverse effects can interferon alpha cause?

Answer 30

Depression, mania, psychosis

Question 31

What are people with chronic mental illness at greater risk of?

Answer 31

All cause mortality ('mortality gap') - patients suffering from severe mental disorders have a reduced life expectancy compared to the general population of up to 10-25 years

Question 32

What multifactorial causes result in the mortality gap in those with chronic mental illnesses? (4)

Answer 32

- 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

Question 33

How can the multifactorial causes of the mortality gap be managed? (5)

Answer 33

- choose medication that minimises impact on physical health e.g. weight gain sparing antidepressants and antipsychotics in those with already increased BMI - monitoring of cardiometabolic factors (BMI, HbA1c, lipid profile, blood pressure) - smoking cessation - dietary advice - drug and alcohol support services

Question 34

What is delirium?

Answer 34

An acute confusional state and a neuropsychiatric manifestation of physical illness/injury/interventions - can be considered 'acute brain failure' (vs 'chronic brain failure' in dementia)

Question 35

What can delirium be broadly classified as? (3)

Answer 35

- hyperactive - agitation, hallucinations, inappropriate behaviour - hypoactive - lethargy, reduced concentration, reduced alertness, reduced oral intake - mixed - combination of above

Question 36

What is the epidemiology of delirium?

Answer 36

- affects 50% of those in hospital aged >65 - complicates 80% of ITU admissions - may affect 14% of those >85 in community - leads to increased mortality and delays in discharge

Question 37

What are some risk factors for delirium? (5)

Answer 37

- advancing age - cognitive impairment (e.g. dementia), sensory impairment - poor nutrition - polypharmacy/alcohol misuse - frailty

Question 38

What are some common causes/precipitating factors of delirium?

Answer 38

- physical illness/injury: - infection - constipation - urinary retention - electrolyte disturbance - pain - acute vascular events - dehydration - pretty much anything can cause delirium in those sufficiently at risk

Question 39

What is a mnemonic for the causes of delirium?

Answer 39

- P - pain - I - infection - N - nutrition - C - constipation - H - hydration - M - medication - E - environment / electrolyte disturbance

Question 40

What is the pathophysiology of delirium?

Answer 40

Poorly understood and likely multifactorial - (a critical illness leads to increased cortisol levels and cerebral hypoxia (older adults predisposed) which leads to reduced ACh synthesis and dysfunctions of hippocampal and neocortical areas - increase dopamine 500x and adrenergic output) - (likely several neurobiological processes that contribute to delirium pathogenesis including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity)

Question 41

How is delirium managed? (6)

Answer 41

- anticipate and address any modifiable risk factors (e.g. reduce polypharmacy, visual and hearing aids) - optimise treatments of underlying co-morbidities - treat any underlying cause (e.g. UTI, constipation, physical injury, electrolyte disturbance, dehydration) - re-orientation strategies (familiar environments, clocks, remind of name and location) - normalise sleep-wake cycle (encourage uninterrupted sleep, use appropriate lighting, discourage daytime napping) - maintain safe mobility to avoid falls

Question 42

How is challenging behaviour in delirium managed? (4)

Answer 42

- 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)

Question 43

How prevalent is stigma around mental health?

Answer 43

- 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

Question 44

What does stigma lead to? (3)

Answer 44

- barrier to accessing all aspects of care - can be a risk factor for people experiencing abuse, rejection and isolation - contributes to difficulties in employment

Question 45

What factors affect the diagnosis of physical disorders in people with mental illness? (3)

Answer 45

- illness behaviour (e.g. poor insight, mistrust of others, chaotic lifestyle) - diagnostic overshadowing (misattribution of physical symptoms to psychiatric symptoms) - lack of resources/access to services (low socioeconomic status is a risk factor for the development of mental disorders)