general hospital psychiatry and somatisation Flashcards
common mental health problems in the general hospital
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
less common mental health problems in the general hospital
sz
BPAD
melancholia - severe depression
- can present w/ co-morbid physical conditions
why are mental health problems more prevalent in the general hospital than in the public
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
how common is self-harm
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
what should happen for all patients admitted with self-harm
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
self-harm and suicide
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
what is the most common drug taken in overdose
paracetamol
tablet overdoses are the most common form of non-fatal self-harm
link between self-harm and mental illness
may be associated w/ significant mental illness and/or personality disorder
(but often isn’t)
self-harm assessment
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
psychiatric features of delirium
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
how severe is delirium tremens
most serious manifestation of alcohol withdrawal
mortality 5%
physical features of delirium and onset
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
how common is delirium
very common in general hospital pts
up to 20%
features of delirium tremens
often presents dramatically but may be a prodrome of insomnia, fearfulness, panic, nightmares
vivid hallucinations delusions confusion tremor agitation sleeplessness autonomic overactivity impaired consciousness
EEG changes in DT
fast activity
how long does DT last
usually <72hrs
recurrent phases may rarely occur over a longer period of time
complications of DT
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
management of acute confusion - overview
management of acute confusino
environmental and supportive measures - education of relatives and healthcare staff, safe environment, optimise stimulation, orientation
correct contributary factors
contributing factors to correct when managing delirium/acute confusion
disorientation
dehydration, constipation, poor nutrition
hypoxia, infection, polypharmacy, pain
immobility/limited, sensory impairment, sleep disturbance
medications to avoid in delirium
avoid sedation
unless severely agitated or required to facilitate investigation or treatment
principles of medication management of delirum
use single medication
start slow, assess response
lower doses in frail elderly
antipsychotics for delirum
risperidone 0.5-1mg
quetiapine 12.5-25mg
if iM required - consider aripiprazole, olanzapine
benzodiazepines for delirium
can prolong delrium so avoid as much as possible
lorazepam 0.5-1mg
use in withdrawal states - diazepam, chlordiazepoxide - caution in liver failure
promethazine for delirium
sedative anti-histamine
oral/IM - 10-25mg
off licence use
can worsen delirium
caution in elderly - anticholinergic effects, prolongs QTc, lowers seizure threshold
antipsychotic use in withdrawal states
avoid antipsychotics in alcohol/drug withdrawal unless well covered w/ benzodiazepines due to lowering of seizure threshold
prevalence of depression in the hospital
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
how commmon is substance misuse/dependence
~20% of admissions directly related to the ill effects of alcohol use
how can substance misuse/dependence present
physical complications
intoxication
withdrawal incl delirium
ARBD
trauma/accident
drug induced psychosis
feigned illness in order to obtain drugs
what would a comprehensive joint assessment and care from the medical and psychiatric teams involve
acute management of initial presentation and treatment required
maintenance of safety
assessment of longer term mental health problems
referral onwards for appropriate care
what are functional disorders
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
what are factitious disorders
where a patient will consciously feign/elaborate symptoms for unconscious reasons
aka Munchausen syndrome
classification of functional disorders
classed in ICD-10 as mental disorders (incl. dissociative, somatoform and other neurotic disorders0
ICD-11 will contain section on functional (dissociative) neurological disorders
how common are functional neurological disorders
where do they present
impact on health
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
examples of functional disorders
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
mental health and functional disorders
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
management of FND
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
