Liaison Psychiatry - BB

Question 1

Dissociative disorder- normal

Answer 1

• Normal to dissociate - disconnection from whats going around you eg when forget drive to work
• Can normally snap out of it when necessary

Question 2

What is dissociative disorder?

Answer 2

• Feeling of disconnection becomes intense and often
• Stops functioning in daily life
• Group of disorders - impaired awareness of someones actions, thoughts, physical sensations and identify
• Stem from trauma - abuse/neglect, way of adapting

Question 3

Groups of DD

Answer 3

• Depersonalisation/derealization disorder - least severe
• Dissociative amnesia
• Dissociative identity disorder - most severe

Question 4

Depersonalisation/derealisation disorder

Answer 4

• Detachement from oneself - depersonalisation
• Feeling that world around you isn’t real
• Feel as though watching selves from outside
• Emotionally numb/weak sense self
• Little emotion, problems forming relationships
• Severe - trouble recognising places, people or objects
• Can also have altered sense of time, brain fog, prone anxiety

Question 5

Dissociative amnesia

Answer 5

• Blocks out important personal information - eg what mother likes like
• Localised (most, eg trauma event), generalised (can’t remember any past, can be stress induced), systematised (catergory of information eg person/location) or continious (each new event after happens, only knows present moment, not always related to trauma)
• Generalised can cause dissociative fugue - disorientated wandering, confused about who they are, forget deeply ingrained skills

Question 6

Dissociative identity disorder

Answer 6

• AKA multiple personality disorder
• Two types - covert (most common) vs overt
• Covert - sudden and dramatic shifts in way person perceives, thinks or feels, new characterstics, may think person is speaking to them
• Aware unusual, feel powerless
• Overt - outright assume 2 or more distinct identities. Act differently, not aware this is happening always, can forget portions of day.
• Overt can danger person, prevalence suicide

Question 7

Diagnosis differentials DD

Answer 7

• Substance intoxication eg hallucinogens (LSD), ketamine
• Seizures
• Brain trauma
• Dementia
• Anxiety disorder
• Bipolar - mood swings last longer than DD
• Schizophrenia - mood swings but last longer than DD

Question 8

Treatment for DD

Answer 8

• Psychotherapy - process trauma.
• Facilitate fusion of identities in DID

Question 9

What is somatic symptom disorder? (somatisation)

Answer 9

• Physical symptoms not explained by physical or mental disorder
• Symptoms are real
• Made worse by fact can’t be physically explained

Question 10

Diagnois requirements SSD

Answer 10

• Unexplained somatic symptoms for more than 6 months
• Can be incredibly varied symptoms - location, seveirty and changes vary over time
• Pain usually persists over time

Question 11

Cognitive symptoms of SSD

Answer 11

• Peristent thoughts about symptoms
• Worry
• Anxiety
• Thoughts about death

Rate severity using this - mild if one cognitive, moderate if 2, severe if 2 or more and multiple physical symptoms or one severe symptom

Question 12

Cause SSD

Answer 12

• Too much psychological stress - lead to boildy symptoms
• Or extreme sensitivity to bodily changes - common experiences amplified

Question 13

Treatment of SSD

Answer 13

• Improve cognitive symptoms - CBT

Question 14

What may be more suggestive of pseudoseizures on history and exam rather than seizures?

Answer 14

• Asynchoronous limb movements
• Resisting attempts to open eyes
• Protective/avoidance behaviour - patient doesn’t sustain injuries
• No post-itcal period
• Patient able to recall what happened
• Tongue biting and incontinence very rare
• Prolonged seizure - more than 3 mins

Question 15

What blood test may strengthen belief that is pseudoseizure?

Answer 15

• Prolactin - not diagnostic of seizure but often released during seizure
• Higher levels are detected in first 2 hrs post seizure

Question 16

Approach in managing someone post pseudoseizure

Answer 16

• Non-judgementally - important she does not feel dismissed/judged
• Significant emotional stress may have caused event - explore this
• If unsure if seizure - consider first fit clinic

Question 17

Factitious symptoms vs malingering

Answer 17

• In factitious disorder - feign symptoms intentionally but with no clear secondary gain (other than to achieve sick tole and therefore care)
• Malingering - intentionally reporting/producing symptoms for clear secondary gain (often monetary)

Question 18

Puerperal psychosis risk factors

Answer 18

• PMH post-partum psychosis
• Past history of bipolar affective disorder or schizoaffective disorder

Question 19

Who to refer for re puerperal psychosis?

Answer 19

• Daytime hours - perinatal psychiatry team
• OOH - psychiatry SHO/SPR

Question 20

Differentials for 60 year old female with grandiose delusions and hallucinations

Answer 20

Delirium
Mania - ?bipolar

Question 21

Management of steroid induced psychosis/mania

Answer 21

• Antipsychotic first time
• Liase with oncology team, patient and family re risk/benefit for continuing steroid and whether to gradually reduce
• May or may not need MHA inc inpatient psychiatric care
• Long term f/u in outpatients, gradual reduce antipsychotic
• Psychoeducation re relapse