General Hospital Psychiatry and Somatisation Flashcards
Psychiatric problems in the General Hospital - Key Points:
(mental health problems) ____ common than in the general population
Not always recognised:
- may disguise themselves as _______ disorder
- focus on ______ disorder, mental symptoms not _______ about (therefore often missed)
- reaction considered to be _______
Can affect ____________ of physical condition
General hospital staff may feel ___________ to deal with such problems
More
physical
physical
inquired
normal
management
ill-equipped
what is the Importance of recognising psychiatric disorders in general hospital patients?
Provide appropriate mental health treatment
Shorten length of treatment in hospital
Avoidance of unnecessary investigations and inappropriate treatment (therefore reducing risk of iatrogenic harm)
Enhance recovery and rehabilitation process
Improve quality of life
what is Liaison Psychiatry?
Subspecialty of psychiatry that works with patients in general hospitals
Work with medical and surgical colleagues in the management of mental health problems in their patients
Provides specialist care to patients with a range of problems including self harm, adjustment to illness, and physical and psychological co-morbidities
Provide education for general hospital clinicians in the basics of management of mental health problems in the general hospital
what are 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 with substance misuse
Eating disorders
Functional disorders
what are some less Common mental health problems
in the general hospital?
Schizophrenia
Bipolar affective disorder
Melancholia (Severe depression)
what are the Reasons for increased prevalence?
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 patients with mental health problems (e.g. self harm)
Functional (somatoform, dissociative…) disorders
whats the epidemiology of self harm?
Self-harm commonest reason for admission in females < age 65
More common in females but over recent years increase in self-harm rates in young males
Admission rates at ARI (2019) ~ 833 SH referrals
15-20% of patients will repeat within one year
Approximately 1% of patients will go on to complete suicide within one year
Paracetamol commonest drug taken in overdose (Tablet overdose is the most common type of non-fatal self harm)
May be associated with significant mental illness and/or personality disorder (but often is not)
Substance misuse common (alcohol, drugs)
Often associated with multiple social problems
All patients admitted with self-harm should routinely receive a what?
psychosocial (psychiatric) assessment
self harm is often related to what?
Often related to social problems or substance misuse
what is done in a Self-harm assessment?
Create an environment where a patient feels listened to, can experience relief and may begin to identify solutions
Identify risk factors for further self-harm, completed suicide
Identify mental disorder and need for further psychiatric treatment (often isn’t one)
Identify psychosocial stressors and patient’s way of coping
Identify appropriate help, even in absence of mental disorder
Patients should routinely receive an __________ after self harm
Patients do not need to be “___________” to be assessed
Do not need to wait until morning for assessment following self-harm – but that may be appropriate depending on individual circumstances
See patient as soon as it is _______
assessment
medically fit
practical
what is Delirium
(acute organic confusional state)?
Very common in general hospital patients (up to 20%)
Usually acute or sub-acute onset
Characterised by global cognitive impairment
Disorientation in time and place
Fluctuating levels of arousal
Impaired attention/concentration
Disordered sleep wake cycle
what is seen in delerium?
Increased/decreased motor activity (hyperactive/hypoactive delirium)
Disorganised thinking, as indicated by rambling, irrelevant or incoherent speech
Perceptual distortions leading to misidentification, illusions or hallucinations
Changes in mood, such as anxiety, depression and lability of mood
May be mistaken for schizophrenia (Psychotic symptoms in delirium are often transient and fluctuating rather than fixed and stable)
what is Delirium Tremens?
Most serious manifestation of alcohol withdrawal
Mortality 5%
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 – fast activity (normally slowing in standard delirium)
management of acute confusion:
what Environmental and supportive measures?
Education of relatives, medical and nursing staff
Make environment safe
Optimise stimulation (ensure they have glasses, hearing aid, clock on wall, batteries)
Orientation
management of acute confusion:
Correct factors contributing to delirium - such as what?
(Likely to be a combination of causes)
This is main treatment - Often not one cause found, often several small insults contributing:
Disorientation
Dehydration
Constipation
Hypoxia
Immobility/limited mobility
Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
who is depression common in?
Twice as common in general hospital patients than general population
More common in chronic illness, e.g. chronic renal failure, diabetes, rheumatoid arthritis
Particularly common in certain neurological diseases, e.g. MS, Parkinson’s disease, stroke
May be more difficult to detect due to overlap in symptomatology with physical disorder(s) (Reduced appetite and concentration common across many diseases)
More common in patients with previous history of depression
Substance misuse/dependence:
Approximately 20% of admissions directly related to the ill effects of alcohol use
what may it present as?
physical complications
intoxication
Withdrawal (including delirium)
ARBD
trauma/accident
drug-induced psychosis (e.g. novel psychoactive substances)
feigned illness in order to obtain drugs (rare and far down differential diagnosis list)
what are Functional Disorders?
Real physical symptoms that are not caused by a structural lesion or abnormality but a functioning of bodily systems
A functional disorder is a medical condition that impairs normal functioning of bodily processes that remains largely undetected under examination, dissection or even under a microscope. At the exterior, there is no appearance of abnormality.
a medical condition in which there is a problem with the functioning of the nervous system and how the brain and body sends and/or receives signals, rather than a structural disease process such as multiple sclerosis or stroke
Functional disorders:
one third of new neurology outpatients
present to all specialities
may be subject to multiple investigations and __________ treatment
often have significant _______
may have other underlying or co-morbid psychiatric disorder
List of presentations to various medical specialities
Symptoms usually perpetuated by psychological and social factors rather than purely biological ones
inappropriate
disability
what is seen in people with functional disorders?
Psychological symptoms more common in FND
Approximately 2/3 patients with FND have past history of mental health problems.
History of adverse childhood experiences/trauma may predispose to FND
BUT:
30-60% of patients with FND have no history of childhood adversity
Such events in general population are not rare
Approximately 1/3 of patients with other neurological disorders have psychiatric symptoms/history of mental illness
Psychiatric symptoms may be secondary to FND
These are relevant factors, but not that useful in diagnosis
how do we treat functional disorders?
Explanation of FND (May not believe the diagnosis)
Medications for co-morbid mental health problems
Psychological therapies - CBT, Others including IPT and psychodynamic therapies
Other therapies for co-morbid disorders i.e. OT for agoraphobia
Summary:
Mental disorders are more common in the ______ than in the general population
Not always _________
Can affect management of _______ condition
General hospital staff may feel __________ to deal with such problems
hospital
recognised
physical
ill-equipped
