Depressed mood

Depressive disorder is common, with a prevalence of approximately 5% in the general population. Depression is at least twice as common in the medically ill. It is important to note that depression has physical as well as mental symptoms (Box 10.7). The diagnosis of depression in the medically ill, who may have physical symptoms of disease, relies on detection of the core psychological symptoms of low mood and anhedonia.

Elated mood

Elation, or euphoria, is the converse of depression and is characteristic of mania. It may manifest as infectious joviality, over-activity, lack of sleep and appetite, undue optimism, over-talkativeness, irritability, and recklessness in spending and sexual behaviour. When elated mood is severe, psychotic symptoms are often evident, such as delusions of grandeur (e.g. believing erroneously that one is royalty). Elevated mood is much less common than depressed mood, and in medical settings is often secondary to drug or alcohol misuse, an organic disorder or medical treatment. Where none of these applies, the patient may have a bipolar disorder (p. 244).

Medically unexplained somatic symptoms

Patients commonly present to doctors with physical symptoms. Whilst these symptoms may be an expression of a medical condition, they often are not. They may then be referred to as ‘medically unexplained symptoms’ (MUS). MUS are very common in patients attending general medical outpatient clinics. Almost any symptom can be medically unexplained, e.g.:

Patients with MUS may receive a medical diagnosis of a so-called functional somatic syndrome, such as irritable bowel syndrome (Box 10.10), and may also merit a psychiatric diagnosis on the basis of the same symptoms. The most frequent psychiatric diagnoses associated with MUS are anxiety or depressive disorders. When these are absent, a diagnosis of somatoform disorder may be appropriate (Box 10.11).

Differential diagnosis

The main medical differential diagnosis for MUS is from symptoms of a medical disease. Diagnostic difficulties are most likely with unusual presentations of common diseases and with rare diseases. MUS are commonly an expression of depression and anxiety. A medical and psychiatric assessment should be completed in all cases (Fig. 10.1).

Delusions and hallucinations

Disturbed and aggressive behaviour

Disturbed and aggressive behaviour is common in general hospitals, especially in emergency departments. Most behavioural disturbance arises not from medical or psychiatric illness, but from alcohol intoxication, reaction to the situation and personality characteristics. The key principles of management are, first, to establish control of the situation rapidly and thereby ensure the safety of the patient and others, and, second, to assess the cause of the disturbance in order to remedy it. Establishing control requires the presence of an adequate number of trained staff, an appropriate physical environment and sometimes sedation (Fig. 10.2). Hospital security staff and sometimes the assistance of the police may be required. In all cases, the staff approach is important; a calm, non-threatening manner expressing understanding of the patient’s concerns is often all that is required to defuse potential aggression (Box 10.12).

If sedating drugs are required, antipsychotic drugs, such as haloperidol, and benzodiazepines, such as diazepam, are commonly used. The choice of drug, dose, route and rate of administration will depend on the patient’s age, sex and physical health, as well as the likely cause of the disturbed behaviour. The benefits of sedation must be balanced against the associated risks, however. Haloperidol can cause acute dystonias, including oculogyric crises, while the benzodiazepines can precipitate respiratory depression in patients with lung disease, and encephalopathy in those with liver disease. Thus, for a frail elderly woman with emphysema and delirium, sedation may be achieved with a low dose (0.5 mg) of oral haloperidol, while for a strong young man with an acute psychotic episode, at least 10 mg of intravenous diazepam and a similar dose of haloperidol may be needed. A parenterally administered anticholinergic agent, such as procyclidine, should be available to treat extrapyramidal effects arising from haloperidol, and flumazenil (p. 217) to reverse respiratory depression if large doses of benzodiazepines are used.

Confusion

This is a vague term used to describe a range of primarily cognitive problems, including disturbances in perception, belief and behaviour. ‘Confusion’ usually presents as a problem when it becomes clear that the patient cannot comply with medical care; they may repeatedly wander off the ward, pull out essential cannulae and catheters, and hit nurses. The methods of assessment of cognitive function range from simple screening questions to detailed psychometric testing. All doctors should be able to undertake a brief cognitive assessment, as outlined above (p. 233).

Self-harm

Self-harm (SH) is a common reason for presentation to medical services. The term ‘attempted suicide’ is potentially misleading, as most such patients are not unequivocally trying to kill themselves. Most cases of SH involve overdose, of either prescribed or non-prescribed drugs (Ch. 9). Less common methods include asphyxiation, drowning, hanging, jumping from a height or in front of a moving vehicle, and the use of firearms. Methods that carry a high chance of being fatal are more likely to be associated with serious psychiatric disorder. Self-cutting is common and often repetitive, but rarely leads to contact with medical services.

The incidence of SH varies over time and between countries. In the UK, the lifetime prevalence of suicidal ideation is 15% and that of acts of SH is 4%. SH is more common in women than men, and in young adults than the elderly. (In contrast, completed suicide is more common in men and the elderly (see Box 10.9).) There is a higher incidence of self-harm among lower socioeconomic groups, particularly those living in crowded, socially deprived urban areas. There is also an association with alcohol misuse, child abuse, unemployment and recently broken relationships.

Differential diagnosis

The main differential diagnosis is from accidental poisoning and so-called ‘recreational’ overdose in drug users. It must be remembered that SH is not a diagnosis but a presentation, and may be associated with any psychiatric diagnosis, the most common being adjustment disorder, substance and alcohol misuse, depressive disorder and personality disorder. In many cases, however, no psychiatric diagnosis can be made.

Initial management

A thorough psychiatric and social assessment should be attempted in all cases (Fig. 10.3), although some patients will discharge themselves before this can take place. The need for psychiatric assessment should not, however, delay urgent medical or surgical treatment, and may need to be deferred until the patient is well enough for interview. The purpose of the psychiatric assessment is to:

• establish the short-term risk of suicide

• identify potentially treatable problems, whether medical, psychiatric or social.

Topics to be covered when assessing a patient are listed in Box 10.14. The history should include events occurring immediately before and after the act, and especially any evidence of planning. The nature and severity of any current psychiatric symptoms must be assessed, along with the personal and social supports available to the patient outside hospital.

 10.14   Assessment of patients after self-harm

Current attempt

• Patient’s account

• Degree of intent at the time: preparations, plans, precautions against discovery, note

• Method used, particularly whether violent

• Degree of intent now

• Symptoms of psychiatric illness

Background

• Previous attempts and their outcome

• Family and personal history

• Social support

• Previous response to stress

• Extent of drug and alcohol misuse

Most SH patients have depressive and anxiety symptoms on a background of chronic social and personal difficulties and alcohol misuse but no psychiatric disorder. They do not usually require psychotropic medication or specialised psychiatric treatment but may benefit from personal support and practical advice from a GP, social worker or community psychiatric nurse. Admission to a psychiatric ward is necessary only for persons who:

• have an acute psychiatric disorder

• are at high risk of suicide

• need temporary respite from intolerable circumstances

• require further assessment of their mental state.

Approximately 20% of SH patients make a repeat attempt during the following year and 1–2% kill themselves. Factors associated with suicide after an episode of SH are listed in Box 10.9.

Alcohol misuse

Misuse of alcohol is a major problem worldwide. It presents in a multitude of ways, which are discussed further on page 252 and in Box 10.35 (p. 253). In many cases, the link to alcohol will be all too obvious; in others, it may not be. Denial and concealment of alcohol intake are common. In the assessment of alcohol intake, the patient should be asked to describe a typical week’s drinking, quantified in terms of units of alcohol (1 unit contains approximately 8 g alcohol and is the equivalent of half a pint of beer, a single measure of spirits or a small glass of wine). Drinking becomes hazardous at levels above 21 units weekly for men and 14 units weekly for women. The history from the patient may need corroboration by the GP, earlier medical records and family members. The mean cell volume (MCV) and γ-glutamyl transferase (GGT) may be raised, but are abnormal in only half of problem drinkers; consequently, normal results on these tests do not exclude an alcohol problem. When abnormal, these measures may be helpful in challenging denial and monitoring treatment response. The prevention and management of alcohol-related problems are discussed on page 253.