Psychiatry - Liaison psychiatry Flashcards
How can psychiatric disorders present with physical symptoms?
Psychiatric disorders often present with physical symptoms (e.g. anxiety with palpitation and sweating). When physical symptoms are an expression of psychological problems, the relationship is known as a somatisation or more helpfully, medically unexplained symptoms.
Common psychiatric disorders that present with physical symptoms include anxiety, depression and adjustment disorder.
What are somatoform conditions?
These are a group of psychiatric conditions that are manifest with physical symptoms. Specifically, somatoform conditions are those in which there is a persistent preoccupation with physical health and physical symptoms but NOT by psychological symptoms. This has several subtypes:
- somatisation/ somatoform disorder
- hypochondriacal disorder
- body dysmorphic disorder
What is somatoform disorder? How common is it?
This is characterised by repeated presentations of physical symptoms with persistent request for medical investigations, in spite of repeated negative findings or reassurance. If any physical disorders are present, they are insufficient to explain the severity of symptoms or patient distress.
It affects about 10% of medical outpatients, with females more affected than males (1:20). The underlying aetiology may involve familial components in 10-20% of first degree relatives.
How should somatoform disorder be managed?
Confirming the diagnosis is the first step in management. It is important to engage the patient as they frequently change doctors. The aim of treatment is not to cure, but to limit the possibility of additional harm through inappropriate investigations/ treatment. Psychological treatment such as supportive psychotherapy is reported to be useful. Pharmacotherapy is indicated when there is secondary depression or anxiety.
What is the definition of hypochondriacal disorder?
The essential feature is a persistent precoccupation with the possibility of having one or more serious illnesses and progressive physical disorders. Patients have persistent somatic complaints or a persistent preoccupation with their physical appearance.
Marked depression and anxiety are often present, and may justify additional diagnoses. It may be primary or secondary to other disorders and is more common in males.
The aetiology is unknown.
How is hypochondriacal disorder treated?
It is important to first rule out a physical basis. If it is primarily psychological, cognitive behavioural therapy is useful. If it is secondary, then treatment of the primary disorder is important.
What is body dysmorphic disorder?
This is characterised by a persistent preoccupation with the body - e.g. shape and size of certain features. Patients remain distressed about it, and some may demand surgery. Treatment of this disorder is difficult. Surgery can sometimes be helpful to reduce stress, however, selection of patients who are likely to benefit is difficult. Surgery should be avoided in those with unrealistic expectations of surgery and are dissatisfied with previous cosmetic procedures. Their distress may be reduced by supportive therapy.
What is factitious disorder?
This refers to feigning of physical or psychological symptoms, with the aim of being diagnosed as ill. The patient does not have any external gain such as avoiding work or financial gains. They can present with a wide range of psychological and physical symptoms. Common ones encountered are skin lesions, diarrhoea of unknown origin, pyrexia of unknown origin, and brittle diabetes. Diagnosis and treatment is difficult. It is vital to carefully observe for discrepancies among clinical findings before making the diagnosis. Once the diagnosis is confirmed the implications of this should be explained to the patient. Some patients admit their behaviour and others deny it.
What factors determine how patients with physical illness respond psychologically?
There is growing evidence that people may react to physical illness emotionally. The pattern of respond may be of several types - it could be in the form of anxiety, depression, paranoid reaction, adjustment disorder, and preoccupation with illness or post traumatic stress disorder.
Determinants of response include:
- individual factors: type of premorbid personality
- disease: significance and meaning of the illness
- social environment: financial threat or concurrent social problems
- coping styles
In contrast, psychological factors appear to have no direct causal link, but may contribute to the aetiology of physical illness by affecting compliance, preventing patients from seeking medical attention and maintaining unhealthy habits (e.g. smoking).
List some common medical conditions that present with psychiatric symptoms
Hyperthyroidism: excitability, insomnia, impaired cognition
Hypothyroidism: depressed affect, lethargy, paranoia
Hyperglycaemia: anxiety, agitation, delirium
Frontal lobe tumour: mood changes, irritability, facetiousness, impaired judgement
SLE: depression, mood disturbance, psychosis, delusions
AIDS: progressive dementia, personality change, depression, loss of libido, impaired memory, decreased concentration
MS: mood changes, anxiety, euphoria, and mania
What is the likely diagnosis in the following case?:
“A 19-year-old woman presents to the accident and emergency department saying that she has taken an unknown number of sleeping tablets. In addition, she has a number of lacerations to her left forearm which appear to have been self-inflicted and which are bleeding profusely. She is accompanied by her boyfriend, who says that she took the pills and cut herself with a razor after they had had an argument. He immediately brought her to hospital. The general medical team has assessed her, dressed her wounds, and consider that she is physically t to be discharged. The team tells you that she has presented in this way many times before and ask you to sanction her discharge.”
The preferred diagnosis in this case is personality disorder, probably emotionally unstable.
Other differentials to consider are:
- depression
- no mental disorder
What information in the history supports the diagnosis in the following case, and what other information would help confirm it?
“A 19-year-old woman presents to the accident and emergency department saying that she has taken an unknown number of sleeping tablets. In addition, she has a number of lacerations to her left forearm which appear to have been self-in icted and which are bleeding profusely. She is accompanied by her boyfriend, who says that she took the pills and cut herself with a razor after they had had an argument. He immediately brought her to hospital. The general medical team has assessed her, dressed her wounds, and consider that she is physically t to be discharged. The team tells you that she has presented in this way many times before and ask you to sanction her discharge.”
The history of repeated self harm, which sounds impulsive as it occurred after an argument, is suggestive of a personality disorder rather than acute mental illness. Impulsivity which may lead to repeated self harm, drug and alcohol abuse, criminal conviction and sexual promiscuity for example is especially characteristic of emotionally unstable personality disorder (remember there are 2 types of emotional personality disorder in cluster B).
Such people also have instability of mood and disturbed self image (resulting in unclear goals and direction of life, perhaps ambivalence over sexual orientation). Patients may also complain of chronic feelings of emptiness and fear of abandonment. This type of personality disorder is strongly associated with a history of child abuse.
