liason psych day 4 Flashcards
how common are medically unexplained symptoms.
Accounts for up to 20% of GP consultations
MUS is associated with 20-50% more outpatient costs6 & 30% more hospitalisation7,8
• Investigation causes significant iatrogenic harm9,
what actually helps manage medically unexplained symptoms? what should you do?
Just being there:
MUS is about the doctor having a number
of hypotheses. Many patients with unexplained symptoms just need reassurance. Most people with MUS
who see their GPs will improve without any specific treatment, particularly when their GP gives an explanation for symptoms
that makes sense, removes any blame
from the patient, and generates ideas
about how to manage their symptoms.28, 29
Treat the Treatable:
Advocate specific treatments that will help acute or chronic conditions – use pain ladders, control dyspnoea in COPD and angina in IHD. Remember to maximise treatment and symptom control of long-term conditions and pain, whilst balancing treatment with potential adverse effects.
- Consider altering medication – ask if it might be medication causing or aggravating the symptoms.
- 30-60% of people in chronic pain have depression.30 Depression is four times more common in patients with low back pain (in primary care).31 Treating depression helps with pain, including arthritis.32
- Screen for depression and treat appropriately.
- CBT helps with MUS33 and with chronic pain.34 It also reduces fatigue in Chronic Fatigue Syndrome.35
- Physiotherapy and exercise therapies help and should be encouraged.36, 37, 38, 39
- Communicate with other clinicians involved – consider a shared plan agreed with the patient and professionals.
how do you hand over responsibility of medically unexplained symptoms to the patient
- Share the action plan – around goals and functional improvement; suggest that the patient may monitor his or her symptoms to observe fluctuation.
- Agree that the goal is to restore function, as well as minimising symptoms.
- Develop an individual personal health plan (similar to ones for other long term conditions); but not a pre-defined one.
- Reassure about long-term improvement and reversibility of symptoms, the ability of the body to recover
- Introduce the idea that emotions can aggravate physical symptoms, being careful not to imply you disbelieve them.
• Believe in patients and their ability to manage this; encourage them; build
on their strengths.
Safety Net
• Understand positive risk management and discuss that with the patient; share the uncertainty.
- Reassure the patient that they will always be taken seriously and any working hypothesis will be reassessed.
- Safety net in agreement with the patient.
- Inform and document about “Red Flag” symptoms and signs. Agree actions if the situation changes and in what timescale and encourage continuity of care.
- To address uncertainty in general practice on how to manage these symptoms, pathways of care should support alternatives to hospital referral
explanation and reassurance in medically unexplained symptoms
Explanation and reassurance should not involve telling
the patient that there is nothing wrong, as clearly this is not the case. A qualitative study of general practitioners’
explanations found that patients were most
satisfied if their doctors gave an explanation for
symptoms that made sense, removed any blame from
them, and generated ideas about how they could
manage their symptoms
Overinvestigation and overtreatment can cause iatrogenic
damage. In addition, although giving a disease a
label may lead to relief because the symptoms are seen as “legitimate,” it may lead to increased “illness
behaviour.” In a longitudinal survey of primary care
patients with chronic fatigue, those who were diagnosed
with myalgic encephalomyelitis had a worse
prognosis than those diagnosed with chronic fatigue
syndrome.1
use of antidepressants in medically unexplained symptoms
Antidepressants can help—a systematic review of 94
randomised controlled trials (6595 people) of antidepressants
prescribed for medically unexplained
symptoms found that they significantly improved
symptoms (number needed to treat four).18 No one
type of antidepressant was better than the others.
Because their effectiveness was independent of their
antidepressive action, low doses may be helpful.
association between self harm and psychiatric disorders
More than 90% those who present with self-harm have (at least one) psychiatric disorder:
–Depression (2/3)
–Substance misuse
–Anxiety disorders
•Personality disorder is also common (½):
–Borderline / emotionally unstable
–Histrionic
•People with schizophrenia are most at risk of self-harm.
6 possible motives for self harm
1 - to die 2 - communicate distress 3 - escape distress 4 - self punishment 5 - a means of control 6 - to cause guilt in others
most common methods of self harm
self poisining is about 90%, self injury only 10%
if a patient has poisoned themselves where should you get info on how to treat
- TOXBASE is a clinical toxicology database for UK national poisons information service – advice on managing patients presenting with overdoses.
- National Poisons Information Service – 24 hour telephone service.
how much paracetamol can cause liver injury
10-15g = about 20-30 tablets. but even as low as 5g can be sufficient in those at high risk.
how does paracetamol cause liver injury
NAPQI - toxic metabolite. depletes glutathione. treatment is activated charcoal if presents in under 2 hours and give Nacetylcysteine which is a precursor to glutathione.
if someone comes in with a paracetamol overdose what do you do
medical treatment, assess risk of repeat, refer to mental health liaison team
assessment of suicide risk
•Clear description of circumstances
–When / where / what?
–Who was around?
–Precautions not to be found or interrupted?
–Preparations for death – affairs in order? Writing a note?
–Did they disclose the act?
–How did they access care?
•Determine intent –Why did they take the overdose? –What did they want to happen? –What did they think would happen? Physical severity of self-harm not a good indicator of intent. –Planning? –Attitude to act – remorseful, guilty –Future-oriented thinking –Previous self-harm
Obtain a collateral (family, GP)
–Patient may be vague or say what they think you want to hear
–May be guarded
•Use of scales is not recommended but be aware of actuarial risk factors
Risk factors for suicide after self-harm
- Older age
- Male sex
- Psychiatric disorder
- Social isolation
- Avoiding discovery of self-harm
- Medically severe self-harm
- Strong suicidal intent
- Physical illness
- Hopelessness
- Substance misuse
- Violent method of self-harm
•Self-harm alone is a risk factor for future suicide – highest risk being within 6 months of the episode.
suicide attempt Low level risk - clinical picture and management
•Clinical picture: –Suicidal ideation but no intent –Passive death wish –Supportive environment and close relationships –One-off event, impulsive –Medically little harm –Physically healthy –No psychiatric history •Possible management: –Discharge back to GP –Possible referral to secondary mental health services
