General Hospital Psychiatry and Somatisation

Question 1

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

Answer 1

More

physical

physical

inquired

normal

management

ill-equipped

Question 2

what is the Importance of recognising psychiatric disorders in general hospital patients?

Answer 2

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

Question 3

what is Liaison Psychiatry?

Answer 3

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

Question 4

what are Common mental health problems
in the general hospital?

Answer 4

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

Question 5

what are some less Common mental health problems
in the general hospital?

Answer 5

—Schizophrenia

Bipolar affective disorder

Melancholia (Severe depression)

Question 6

what are the Reasons for increased prevalence?

Answer 6

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

Question 7

whats the epidemiology of self harm?

Answer 7

—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

Question 8

—All patients admitted with self-harm should routinely receive a what?

Answer 8

psychosocial (psychiatric) assessment

Question 9

self harm is often related to what?

Answer 9

Often related to social problems or substance misuse

Question 10

what is done in a Self-harm assessment?

Answer 10

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

Question 11

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 _______

Answer 11

assessment

medically fit

practical

Question 12

what is Delirium
(acute organic confusional state)?

Answer 12

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

Question 13

what is seen in delerium?

Answer 13

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)

Question 14

what is Delirium Tremens?

Answer 14

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)

Question 15

management of acute confusion:

what Environmental and supportive measures?

Answer 15

Education of relatives, medical and nursing staff

Make environment safe

Optimise stimulation (ensure they have glasses, hearing aid, clock on wall, batteries)

Orientation

Question 16

management of acute confusion:

Correct factors contributing to delirium - such as what?

(Likely to be a combination of causes)

Answer 16

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

Question 17

who is depression common in?

Answer 17

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

Question 18

Substance misuse/dependence:

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

what may it present as?

Answer 18

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)

Question 19

what are Functional Disorders?

Answer 19

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

Question 20

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

Answer 20

inappropriate

disability

Question 21

what is seen in people with functional disorders?

Answer 21

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

Question 22

how do we treat functional disorders?

Answer 22

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

Question 23

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

—

Answer 23

hospital

recognised

physical

ill-equipped