General Hospital Psychiatry and Somatisation

Question 1

How would you go about planning management for a patient who has presented to hospital due to self harm?

Answer 1

Need to identify the cause, although the picture may not always be clear

• Is there any mental disorder present in the patient?

Self harm may not always be reflective of mental disorder but rather of societal pressures:

• Identify risk factors: young, employment status, relationships (abusive?), etc

Question 2

What is delirium characterized by?

Answer 2

Acute confusional state

Characterized by global cognitive impairment

Disorientated in time and place

May include: Changes in motor activity / disorganized thinking / perceptual distortions / changes in mood

Question 3

What are some of the most important first steps in the management of acutely confused patients?

Answer 3

Education of relevant staff and family, make environment safe

Optimize stimulation (make sure patient has glasses / hearing aids etc)

Correct the factor causing the delirium***

Question 4

Are sedatives used in the management of acute delirium?

Answer 4

Usually avoid the use of sedatives

Except in the treatment of alcohol and benzodiazepine withdrawal states where benzodiazepines are given to reduce the excitation in the brain in order to prevent seizures

Question 5

Which medications may be used in the treatment of acute delirium?

Answer 5

Antipsychotics
- Oral dose first, make sure it isn’t a withdrawal state first because can lower seizure threshold

Benzodiazepines
- Withdrawal states, can prolong delirium if used inappropriately

Promethazine
- Sedative antihistamine, has an anticholinergic effect though so can prolong delirium. Also prolongs QT interval and lowers seizure threshold

Question 6

What are functional disorders?

Answer 6

Real physical symptoms that are not caused by structurtal lesions or abnormalities

Can present to any speciality and may be the cause of mental stressors or post infection syndromes

eg: IBS / functional neurological disorder / chronic fatigue syndrome / atypical facial pain / chronic hyperventilation

Question 7

Is there a strong correlation between functional neurological disorder and psychiatric issues?

Answer 7

Approximately 2/3 of patients with functional neurological disorder have a history of mental disease

Still a large portion of patients with FND that do not have any mental disorder though

Extremely rare for psychotic disorders to accompany FND, usually affective / anxiety

Question 8

What is functional neurological disorder?

Answer 8

Neurological disorders that can manifest in many ways such as motor abnormalities, change in consciousness levels, sensory dysfunction etc.

• Not caused by structural abnormalities in the nervous system and tests such as MRI / EEG are usually normal

Question 9

How is functional neurological disorder usually treated?

Answer 9

Cognitive behavioural therapy / Interpersonal therapies

• Also treat co-morbid conditions (eg. agoraphobia)