Intro to Psych - Psychiatric Disorders and Physical Health

Question 1

What is the MoCA?

Answer 1

Montreal Cognitive Assessment - normally scored out of 30

Looks to assess brain function

Question 2

What is the difference between an illusion and hallucination?

Answer 2

E.g. seeing something during the night, a shadow that looks like a person, etc.

Hallucination = seeing something when there is no stimulus

Question 3

What is Psychosis?

Answer 3

Delusions and hallucinations - loss of touch with reality

Question 4

What is the ICD?

Answer 4

International Classification of Diseases - published by WHO

Question 5

Case Study: Richard
Had stroke - cannot move his right arm or leg
Scored 22/25 on MoCA
Used to be active, now angry at stroke, misses his wife, misses his old life
Emotional lability - mood swings
Has hallucinations and delusions about care home manager, kids, etc.

What would Richard be diagnosed as according to the ICD?

Answer 5

2 diagnoses:

1. Adjustment disorder - mood swings, anger, sadness at loss of old life = adjusting to stressful life event (stroke)
2. Organic delusional disorder - persistent and recurrent delusions dominate clinical presentation, may be accompanied by bizarre hallucinations

Organic = physical cause = symptoms started after the stroke

Question 6

What is Post-stroke psychosis?

What is the prevalence?

What are some common delusional themes?

Answer 6

Psychosis (loss of touch with reality) after a stroke

4.67% = delusions; 5.05% = hallucinations
More common in right hemisphere strokes (5:1)

Delusions of: persecutory, jealousy, environment

Question 7

What is the interaction between physical illness and mental health?
What percentage of the population have physical illnesses, mental illnesses, and both?

Answer 7

30% of UK population = long term condition
20% of UK population = mental health condition
Interaction = 30% of long term conditions have a mental health problem, 50% of mental health conditions have a physical problem

Question 8

How many times more likely are you to develop ____ if you have ____:

__x the risk to develop depression and anxiety if you have CVD
__x the risk to develop depression if you have diabetes
__x the risk of panic disorder if you have COPD
__x the risk of depression if you have musculoskeletal disorders

Answer 8

3x the risk to develop depression and anxiety if you have CVD
2x the risk to develop depression if you have diabetes
10x the risk of panic disorder if you have COPD
2x the risk of depression if you have musculoskeletal disorders

Question 9

What discrete mental illnesses develop from the causes below?

Thyrotoxicosis -
Thyroid deficiency -
Cushings disease - 
Infections - 
Cancer - 
Parkinson's disease -

Answer 9

Discrete = you either have it or you don’t

Thyrotoxicosis - anxiety, mania
Thyroid deficiency - depression, dementia
Cushings disease - depression
Infections - psychosis
Cancer - depression
Parkinson’s disease - depression, anxiety, dementia

Question 10

How do chronic mental illness affect physical illnesses and life expectancy?

Answer 10

People with chronic illnesses = greater risk for physical illnesses esp. due to diet, exercise, smoking, alcohol, drugs, medications (side effects)

People with chronic mental illnesses die 20 years younger than the general population

Question 11

What factors may affect timely diagnosis of physical disorders in people with (chronic) mental illness?

Answer 11

1. Chronic mental health issue = more tolerant of symptoms
2. Diagnostic overshadowing = e.g. patient presenting with physical problem and mental health problem, physical problem signed off under mental health illness
3. Stigma
   4, Lack of resources for diagnosis and treatment - mental health cause 1/3 of the morbidity in the UK but only gets 11% of the funding

Question 12

What is an early sign of dementia?

Answer 12

Sticking to a very strict routine and not coping if routine gets derailed
e.g. if they buy groceries from a corner shop, they don’t know what to do if that shop is closed

Question 13

What is the MoCA?

Where do the 30 points come from?

Answer 13

Montreal Cognitive Assessment

Visuo-spatial skills assessed by asking them to draw certain things
Recognise animals
Remember some words
Do some repeating of numbers
Can you tap every time you’re told the letter ‘A’?
Simple subtractions
Repeating some sentences
Test of abstraction
Delayed recall - recall the words learnt previously
Orientation - how many words can you say in 1 minute

Question 14

What is delirium?

Answer 14

Acute confusional state

Question 15

Case Study - Fred
Initially, scored 20/30 on the MoCA

What was he diagnosed with?

Admitted many months later with fall, fracture on wrist - confusion, visual hallucinations, disoriented, sometimes aggressive, delusions, score of 10/30 on MoCA

What was he diagnosed with?

Answer 15

Initially = Alzheimer’s

After fracture = Delirium (ICD definition) = organic cerebral syndrome characterised by disturbance of consciousness and attention, perception, thinking, memory, psychomotor behaviour, emotion. Ranges from mild to severe

Organic = physical cause

Question 16

What is the prevalence of delirium?

How does delirium affect physical illnesses?

Answer 16

Most common mental disorder in hospital
Present in 20% acute hospital patient’s >65 on admission
20% more develop delirium after admission
Overall = 30% on wards, 80% in intensive care
50% undetected / hypoactive

Delays discharge
Increases mortality

Question 17

What are the causes of delirium?

Answer 17

Always physical cause - usually multiple

Infection (Urine, pneumonia, cellulitis, wound etc)
Change in environment (ITU, HDU, ward)
Medication (opiates, anticholinergics, steroids)
Alcohol withdrawal
Surgery
Pain 
Liver / renal impairment
Hypoxia
Hyponatraemia
Stroke
Encephalitis
Constipation 
Urine Retention 
Dehydration

Question 18

What are predisposing factors for delirium?

Answer 18

Advanced age
Dementia (often undetected)
Impaired activities of daily living
Immobility
Sensory impairment
Urinary catheterisation
Malnutrition
Alcohol
Depression

Question 19

How is Delirium managed?

Answer 19

Anticipate 
Modify risk factors if possible
Early diagnosis
Treat the causes
Good nursing - single room, well lit, familiar staff / family
Medication
Wait

Question 20

What happened to Fred 3 months later?

Answer 20

Still in hospital
Stormy course
Hospital acquired pneumonia
Interview with police; security guards complained with allegation of assault!
Detained under Section 3 of Mental Health Act
Settled but never back to cognitive baseline
Needed residential care
Homes reluctant to take him due to section

Eventually found a care home for army veterans

Question 21

What are some examples of stigma in Fred’s case?

Answer 21

Delay diagnosing pneumonia = not seen on every ward round
Interview by Police = meaningless and punitive
Detained under Mental Health Act = unnecessary. Mental Capacity Act appropriate
Reluctance of nursing homes to take Fred
Liaison team harangued by acute hospital staff

Question 22

What is stigma (in regards to mental illness)

How does stigma lead to discrimination?

How prevalent is stigma?

Answer 22

Stigma = challenges faced by people with mental illness related to knowledge, attitudes, and behaviour of people they meet. Often due to:
Poor understanding of mental health
Negative attitude
Social exclusion

Stigma leads to discrimination = increases the disability caused by mental illness, creates disadvantage with personal relationships, education, and work

Pervasive and widespread
75% people with mental illness experience stigma

Question 23

What is intrapersonal stigma?

What is interpersonal stigma?

What is structural stigma?

Answer 23

Intrapersonal stigma:
Direct effect on the individual
Internalised discrimination
Compounded by direct effects of illness

Interpersonal stigma:
Family
Friends
Colleagues

Structural stigma:
Poor resources and funding
Access to physical health care