WCS42 Psychiatric Conditions In Medical Settings Flashcards
Approach to Co-existing physical and psychiatric symptoms
***30% of patients are estimated to have significant psychiatric morbidity that warrants attention (primarily depressive and anxiety disorders)
- Co-morbid medical and psychiatric conditions (by chance)
Predominant physical symptoms
1. Psychiatric presentations of Medical conditions
2. Psychological / Psychiatric symptoms in reactions to Medical conditions of treatment
3. Psychiatric complications of Medical treatment
Predominant psychiatric symptoms
1. Medical presentations of Psychiatric conditions
2. Medical complications of Psychiatric conditions (e.g. deliberate self-harm, overdose leading to medical complications, anorexia nervosa)
3. Medical complications of Psychiatric treatment
Difficulties in Dx of depression in patients with chronic medical condition
- Many symptoms of medical illness could resemble those of depression
- fatigue, anorexia, weight loss, insomnia, weakness, diminished concentration
- hypoactive delirium
- medical / treatment adverse effects - Desire for death vs Adaptive death acceptance in terminal-ill patients
- active suicidal idea always an alarming sign - Difficulty in determination of “hopelessness”, “worthlessness” and “guilt feeling” as depressive symptoms
- Any distorted cognitions? E.g. maximising and catastrophic thoughts, over-generalisation etc. - Physical suffering and disability may diminish the capacity to experience pleasures in formally enjoyable activities
- depressed mood / withdrawal ***disproportionate to disability could be an hint - Depressive symptoms may manifest in ***atypical / masked forms e.g. amplification of somatic symptoms, non-compliance / refusal of medical treatment
***Medical presentations of Psychiatric conditions
- Somatic symptoms as part of secondary symptoms of other psychiatric disorders
- mood disorders, anxiety disorder, eating disorders etc.
- e.g. Pain symptoms with Depression - Psychiatric disorders with somatoform symptoms as the main presentations
- psychosomatic, hysteria, neurasthenia etc.
Models of relation between psychiatric disorders and somatisation symptoms
1st postulation: Somatisation as a **Masked presentation of psychiatric illness
Psychiatric disorder
∵ —> **Psychiatric defences —X—> Psychiatric symptoms
∴ —> Unexplained physical symptoms —> Health care utilisation
2nd postulation: Somatisation as an **Amplifying Personal Perceptual Style
Psychiatric disorder (將雞毛蒜皮的事情放大)
—> **Amplifying perceptual style
—> Unexplained physical symptoms + Psychiatric symptoms
3rd postulation: Somatisation as a **Tendency to seek care for common symptoms
Common physical symptoms —> **Psychological distress —> Health care utilisation
4th postulation: Somatisation as a **Response to the incentives of health care system
Psychological distress —> **Health care system —> Unexplained physical symptoms
Psychiatric disorder with somatoform symptoms as the main presentations
ICD-10: Somatoform disorders
- **Somatisation disorder
- **Persistent somatoform pain disorder
- ***Hypochrondriacal disorder
- Factitious disorder
- Malingering (詐病)
DSM-5: Somatic symptoms and related disorders
- **Somatic symptom disorder
- **Illness anxiety disorder
- Factitious disorder
- Malingering (詐病)
Somatisation disorder (ICD-10)
- ***>=2 years of multiple and variable physical symptoms with no adequate physical explanation found
- ***Preoccupation with the symptoms causes persistent distress and leads to repeated consultations / sets of investigations
- Persistent refusal to accept medical reassurance
- Some degree of impairment of social and family functioning
- Characterised by a combination of GI, CVS, Genitourinary, Skin and Pain symptoms
Persistent somatoform pain disorder (ICD-10)
- Predominant complaint: Persistent, Severe + Distressing pain
- cannot be explained fully by a physiological process / physical disorder
- in association with emotional conflict / psychological problems
- Chronic: >=6 months + continuously on most days
Somatic symptom disorder SSD (DSM-5)
Criteria for Somatic symptom disorder:
- ***>=1 somatic symptoms that are distressing / result in significant disruption of daily life
- ***Excessive thoughts, feeling, behaviours related to the somatic symptoms / associated health concerns as manifested by >=1 following:
—> disproportionate and persistent thoughts about seriousness of one’s symptoms
—> persistently high level of anxiety about health / symptoms
—> excessive time and energy devoted to these symptoms / health concerns - Although any one somatic symptom may not be continuously present, state of being symptomatic is persistent (>=6 months)
Main focus: ***Somatic symptoms
- More common in women
- Chronic but fluctuating course that rarely remit completely
- Propensity of Doctor shopping
- Risk of iatrogenic complications from numerous tests, procedures and medications
- Potential of drug misuse (narcotic analgesic, benzo)
- Common to have co-morbid Axis 1 diagnosis (e.g. depression) + Axis 2 diagnosis (e.g. underlying personality difficulties)
Illness anxiety disorder / Hypochondriacal disorder (ICD-10)
Main focus: **Worry
- **Preoccupation with having / acquiring a serious illness, clearly excessive / disproportionate
- ***Somatic symptoms relatively mild
- High level of anxiety about health, easily alarmed about personal health status
- Perform excessive health-related behaviours / exhibits maladaptive avoidance
- >=6 months
- Equally common in men / women
- High medical use and high potential of iatrogenic damage from repeated investigations
- distorted belief that good health is relatively symptom-free state, and symptoms mean disease
Belief is ***NOT of delusional intensity
Trigger (News, information, event, illness)
—> perceived threat
—> apprehension
—> ***Increased focus on body, Physiological arousal, Checking behaviour and reassurance seeking
—> preoccupation with perceived alteration / abnormality of bodily sensations, state
—> interpretation of body sensation / signs as indicating severe illness
—> perceived threat
Somatoform disorder (體化症) vs Factitious disorder (人為障礙症) vs Malingering (詐病)
Somatoform (體化症):
- unconscious
- feels ill, unconscious process
- purpose: assume sick role
Factitious disorder (人為障礙症):
deceives others by appearing sick, by purposely getting sick or by self-injury
- unconscious
- feels ill, consciousness process (intentional)
- purpose: assume sick role
Malingering (詐病):
- conscious
- does not feel ill
- purpose: secondary gain e.g. retreat from responsibility
Psychological mechanisms underlying somatic presentations
- Physiological mechanisms
- autonomic arousal
- muscle tension
- hyperventilation
- physiological effects of inactivity
- sleep disturbance - Psychological mechanisms
- perceptual factors
- beliefs
- mood
- personality factors - Interpersonal mechanisms
- reinforcing actions of relatives and friends
- health care system
- disability system
Anxiety-Pain relationship
Pain
—> Fear
Physiological mechanism
1. —> Avoidance of activity —> Inactivity —> Deconditioning —> Weakness —> Pain
Psychological mechanism
2. —> Somatic focus —> Impaired cognitive functioning —> Misattribution and magnification —> Pain
***Approach to patients
- ***Explain that the symptoms are real and familiar to doctor
- Provide a positive explanation, including how behavioural, psychological and emotional factors may exacerbate physiologically based somatic symptoms
- ***Offer opportunity for discussion of their worries
- ***Arrange for regular follow-ups and review
- ***Identify and treat mood / anxiety disorder
- Protect patients from iatrogenic problems
- ***Minimise polypharmacy
- Provide specific treatment when indicated
- Discuss and agree a treatment plan
- Change social dynamics
- Reduce your expectation of cure and instead aim for containment and damage limitation
- Encourage return to normal activity and work (coping and not curing)
- Recognise and control negative reactions, beware of counter-transference
Psychiatric presentations of Medical conditions: Delirium
Disturbance is due to:
—> **Medical condition
—> **Concomitant medications
—> Substances intoxication / withdrawal
- Disturbance of consciousness and reduced ability to focus, sustain, shift attention
- Change in cognition (e.g. memory, orientations, language / perceptual disturbance) not better explained by a pre-existing / evolving dementia
- Disturbance develops over a short period of time (hours to days) + tends to fluctuate over the course of day
2 distinct types:
- Hyperactive delirium: increased motor activities, agitation, hallucinations, inappropriate behaviour (DDx from psychosis)
- Hypoactive delirium: reduced motor activities, lethargy, poorer prognosis (DDx from depression)
Risk factors of delirium
- Prior cognitive impairment
- Older age
- Severity of illness
- Psychoactive drug use
- Polypharmacy
- Infection with HIV
- UTI
- Surgery, particularly prolonged cardiopulmonary bypass surgery
***Single-etiology delirium is the exception
