4.2 - Mental disorders and physical health Flashcards
What is an adjustment reaction?
A state of mental distress, interfering with social functioning, that arises from a significant life change or stressful life event
What do the manifestations of an adjustment reaction include? (5)
- 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
What is post-stroke psychosis?
Neuropsychotic symptoms following stroke occur in at least 30% and are a major predictor of poor outcome
Post-stroke psychosis is most commonly seen following what lesions?
Most commonly seen in right-sided middle cerebral artery lesions affecting the frontal and temporal regions
What are the most commonly reported psychotic symptom of post-stroke psychosis?
- delusions - most delusions of a persecutory or jealous type (Othello’s syndrome)
- fixed, false belief not understandable within the person’s sociocultural setting
What are the most common perceptual abnormalities of post-stroke psychosis?
Auditory hallucinations followed by visual
How is post-stroke psychosis managed?
- no controlled studies looking at treatment
- some respond to antipsychotic medication
- increased risk of stroke with antipsychotics in those with dementia
Why do a lot of people with long term physical conditions also have mental health issues (30%)? (2)
- long term conditions cause disability, inability to work or socialise
- some medications like high-dose steroids can cause mental health problems
Why do a lot of people with mental health issues also have long term health conditions (46%)? (4)
- 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
What are some examples of long term medical conditions that are associated with increased risk of mental illness? (4)
- cardiovascular disease - 3x risk of depression/anxiety
- MSK disorders - 2x risk of depression
- diabetes - 2x risk of depression
- COPD - 10x risk of panic disorder
What is the first job of a psychiatrist?
Exclude an organic cause (physical illness) for the patient’s presentation
What mental illnesses can Addison’s disease lead to?
Depression, poor concentration, irritability
What mental illnesses can hypercalcaemia lead to?
Depression, anxiety
What mental illnesses can hyperthyroidism lead to?
Anxiety, mania
What mental illnesses can hypothyroidism lead to?
Depression, cognitive impairment
What mental illnesses can Cushing’s syndrome lead to?
Depression
What mental illnesses can infections (HPV, syphilis) lead to?
Psychosis, dementia
What mental illnesses can SLE lead to?
Depression
What mental illnesses can cancer lead to?
Depression
What mental illnesses can Parkinson’s disease lead to?
Depression, anxiety, dementia, psychosis
What mental illnesses can phaeochromocytoma lead to?
Anxiety
What mental illnesses can dementia lead to?
Psychosis, aggression/violence, depression, anxiety
What mental illnesses can Huntington’s disease lead to?
Psychosis, aggression/violence, cognitive impairment, depression, anxiety
What psychological adverse effects can dopamine agonists cause?
Psychosis
What psychological adverse effects can L-dopa cause?
Psychosis, delirium, anxiety, depression
What psychological adverse effects can steroids (prednisolone) cause?
Depression, mania, psychosis, anxiety
What psychological adverse effects can isoniazid (TB antibiotic) cause?
Mania, psychosis
What psychological adverse effects can isoretinoin (roaccutane) cause?
Depression
What psychological adverse effects can digoxin cause?
Depression, psychosis
What psychological adverse effects can interferon alpha cause?
Depression, mania, psychosis
What are people with chronic mental illness at greater risk of?
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
What multifactorial causes result in the mortality gap in those with chronic mental illnesses? (4)
- 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 can the multifactorial causes of the mortality gap be managed? (5)
- 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
What is delirium?
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)
What can delirium be broadly classified as? (3)
- hyperactive - agitation, hallucinations, inappropriate behaviour
- hypoactive - lethargy, reduced concentration, reduced alertness, reduced oral intake
- mixed - combination of above
What is the epidemiology of delirium?
- 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
What are some risk factors for delirium? (5)
- 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/injury:
- infection
- constipation
- urinary retention
- electrolyte disturbance
- pain
- acute vascular events
- dehydration
- pretty much anything can cause delirium in those sufficiently at risk
What is a mnemonic for the causes of delirium?
- P - pain
- I - infection
- N - nutrition
- C - constipation
- H - hydration
- M - medication
- E - environment / electrolyte disturbance
What is the pathophysiology of delirium?
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)
How is delirium managed? (6)
- 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
How is challenging behaviour in delirium managed? (4)
- 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)
How prevalent is stigma around mental health?
- 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 does stigma lead to? (3)
- barrier to accessing all aspects of care
- can be a risk factor for people experiencing abuse, rejection and isolation
- contributes to difficulties in employment
What factors affect the diagnosis of physical disorders in people with mental illness? (3)
- 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)
