general hospital psychiatry and somatisation

Question 1

common mental health problems in the general hospital

Answer 1

self harm
affective and adjustment disorders - depression, anxiety
organic brain syndromes - delirium, dementia, amnesic syndromes
personality disorders
psychiatric disorders associated w/ substance abuse
eating disorders
functional disorders

Question 2

less common mental health problems in the general hospital

Answer 2

sz
BPAD
melancholia - severe depression

• can present w/ co-morbid physical conditions

Question 3

why are mental health problems more prevalent in the general hospital than in the public

Answer 3

challenges of physical illness - psychological (incl treatment), effect of physical illness on brain functioning, treatment of physical illness (e.g. medication)

increased physical morbidity in pts w/ mental health problems e.g. self harm

functional (somatoform, dissociative) disorders

Question 4

how common is self-harm

Answer 4

commonest reason for admission in F <65y/o

more common in F but recently increased rates in young M

admission rates ARI ~833 in 2019

substance misuse is common - alcohol, drugs

Question 5

what should happen for all patients admitted with self-harm

Answer 5

should routinely receive a psychosocial (psychiatric assessment) after self harm

patients don’t need to be medically fit to be assessed

don’t need to wait until morning for assessment following self-harm - but this may be appropriate depending on individual circumstances

Question 6

self-harm and suicide

Answer 6

not always with suicidal intent but often is

15-20% of pts who self-harm will repeat within 1yr
~1% will die by suicide within a year

Question 7

what is the most common drug taken in overdose

Answer 7

paracetamol

tablet overdoses are the most common form of non-fatal self-harm

Question 8

link between self-harm and mental illness

Answer 8

may be associated w/ significant mental illness and/or personality disorder

(but often isn’t)

Question 9

self-harm assessment

Answer 9

environment - patient feels listened to, can experience relief, may begin to identify solutions

identify risk factors - for further self harm and completed suicide

identify mental disorder - diagnosis and need for further psychiatric treatment

identify psychosocial stressors and patient’s way of coping

identify appropriate help - even in the absence of mental disorder

Question 10

psychiatric features of delirium

Answer 10

increased/decreased motor activity - hyper/hypoactive delirium

disorganised thinking - as indicated by rambling/irrelevant/incoherent speech

perceptual distortions leading to misidentification, illusions or hallucinations

changes in mood e.g. anxiety, depression, lability

may be mistaken for sz

Question 11

how severe is delirium tremens

Answer 11

most serious manifestation of alcohol withdrawal

mortality 5%

Question 12

physical features of delirium and onset

Answer 12

usually acute/sub-acute onset

characterised by global cognitive impairment

disorientation in time and place

fluctuating levels of arousal

impaired attention/concentration

disordered sleep-wake cycle

Question 13

how common is delirium

Answer 13

very common in general hospital pts

up to 20%

Question 14

features of delirium tremens

Answer 14

often presents dramatically but may be a prodrome of insomnia, fearfulness, panic, nightmares

vivid hallucinations 
delusions 
confusion
tremor
agitation
sleeplessness
autonomic overactivity 
impaired consciousness

Question 15

EEG changes in DT

Answer 15

fast activity

Question 16

how long does DT last

Answer 16

usually <72hrs

recurrent phases may rarely occur over a longer period of time

Question 17

complications of DT

Answer 17

on resolution of a prolonged attack, amnesic syndrome may remain
- likely due to unnoticed wernicke’s encephalopathy

mortality due to: 
CV collapse
infection 
hyperthermia 
self-injury

Question 18

management of acute confusion - overview

Answer 18

Question 19

management of acute confusino

Answer 19

environmental and supportive measures - education of relatives and healthcare staff, safe environment, optimise stimulation, orientation

correct contributary factors

Question 20

contributing factors to correct when managing delirium/acute confusion

Answer 20

disorientation

dehydration, constipation, poor nutrition

hypoxia, infection, polypharmacy, pain

immobility/limited, sensory impairment, sleep disturbance

Question 21

medications to avoid in delirium

Answer 21

avoid sedation

unless severely agitated or required to facilitate investigation or treatment

Question 22

principles of medication management of delirum

Answer 22

use single medication

start slow, assess response

lower doses in frail elderly

Question 23

antipsychotics for delirum

Answer 23

risperidone 0.5-1mg

quetiapine 12.5-25mg

if iM required - consider aripiprazole, olanzapine

Question 24

benzodiazepines for delirium

Answer 24

can prolong delrium so avoid as much as possible

lorazepam 0.5-1mg

use in withdrawal states - diazepam, chlordiazepoxide - caution in liver failure

Question 25

promethazine for delirium

Answer 25

sedative anti-histamine

oral/IM - 10-25mg

off licence use

can worsen delirium

caution in elderly - anticholinergic effects, prolongs QTc, lowers seizure threshold

Question 26

antipsychotic use in withdrawal states

Answer 26

avoid antipsychotics in alcohol/drug withdrawal unless well covered w/ benzodiazepines due to lowering of seizure threshold

Question 27

prevalence of depression in the hospital

Answer 27

2x as common in general hospital pts than general pop

more common in chronic illness e.g. chronic renal failure, DM, rheumatoid arthritis

particularly common in certain neurological diseases e.g. MS, parkinsons, stroke

may be more difficult to detect - overlap in symptomatology w/ physical illness

more common in pts/ w/ PH of depression

Question 28

how commmon is substance misuse/dependence

Answer 28

~20% of admissions directly related to the ill effects of alcohol use

Question 29

how can substance misuse/dependence present

Answer 29

physical complications

intoxication

withdrawal incl delirium

ARBD

trauma/accident

drug induced psychosis

feigned illness in order to obtain drugs

Question 30

what would a comprehensive joint assessment and care from the medical and psychiatric teams involve

Answer 30

acute management of initial presentation and treatment required

maintenance of safety

assessment of longer term mental health problems

referral onwards for appropriate care

Question 31

what are functional disorders

Answer 31

umbrella term for real physical symptoms that aren’t caused by a structural lesion or abnormality but rather the functioning of bodily systems

psychiatrically classed as dissociative disorders or somatoform disorders

separate from factitious disorders

Question 32

what are factitious disorders

Answer 32

where a patient will consciously feign/elaborate symptoms for unconscious reasons

aka Munchausen syndrome

Question 33

classification of functional disorders

Answer 33

classed in ICD-10 as mental disorders (incl. dissociative, somatoform and other neurotic disorders0

ICD-11 will contain section on functional (dissociative) neurological disorders

Question 34

how common are functional neurological disorders

where do they present

impact on health

Answer 34

1/3 of new neurology outpatients

present to all specialties

may be subject to multiple investigations and inappropriate treatment

often have significant disability
may have other underlying/co-morbid psychiatric disorder

Question 35

examples of functional disorders

Answer 35

neurology - functional neurological disorder, non-epileptic attack disorder, persistent postural-perceptual dizziness

gastroenterology - IBS, cyclical vomiting syndrome, functional dyspepsia

rheumatology - fibromyalgia, benign hypermobility syndrome

general/infectious disease - chronic fatigue syndrome

ENT/dentistry - TMJ dysfunction, atypical facial pain

gynae - loin pain haematuria syndrome, chronic pelvic pain

cardio - atypical chest pain

resp - chronic hyperventilation

Question 36

mental health and functional disorders

Answer 36

psychological symptoms more common in FND

~2/3 pts w/ FND have PMH of mental health problems

hx of adverse childhood experiences/trauma may predispose to FND

BUT:

• 30-60% of pts have no hx of childhood adversity
• such events in general pop aren’t rare
• ~1/3 of pts w/ other neurological disorders have psychiatric sx/hx of mental illness
• psych symptoms may be 2y to FND

THESE ARE RELEVANT FACTORS BUT NOT THAT USEFUL IN DIAGNOSIS

Question 37

management of FND

Answer 37

explanation of FND

medications for co-morbid mental health problems

psychological therapies - CBT, IPT, psychodynamic

other therapies for co-morbid disorders - e.g. OT for agoraphobia

physio and occupational therapy can be useful depending on the symptom

MDT approach