Psychological medicine

Chapter 23 Psychological medicine




Introduction


Psychiatry is concerned with the study and management of disorders of mental function: primarily thoughts, perceptions, emotions and purposeful behaviours. Psychological medicine, or liaison psychiatry, is the discipline within psychiatry that is concerned with psychiatric and psychological disorders in patients who have physical complaints or conditions. This chapter will primarily concern itself with this particular branch of psychiatry.


The long-held belief that diseases are either physical or psychological has been replaced by the accumulated evidence that the brain is functionally or anatomically abnormal in most if not all psychiatric disorders. Physical, psychological and social factors, and their interactions must be looked into, in order to understand psychiatric conditions. This philosophical change of approach rejects the Cartesian dualistic approach of the mind/body biomedical model and replaces it with the more integrated biopsychosocial model.









The psychiatric history


As in any medical specialty, the history is essential in making a diagnosis. It is similar to that used in all specialties but tailored to help to make a psychiatric diagnosis, determine possible aetiology, and estimate prognosis. Data may be taken from several sources, including interviewing the patient, a friend or relative (usually with the patient’s permission), or the patient’s general practitioner. The patient interview also enables a doctor to establish a therapeutic relationship with the patient. Box 23.2 gives essential guidance on how to safely conduct such an interview, although it is unlikely that a patient will physically harm a healthcare professional. When interviewing a patient for the first time, follow the guidance outlined in Chapter 1 (see pp. 10–12).



Components of the history are summarized in Table 23.1.


Table 23.1 Summary of the components of the psychiatric history












































Component Description

Reason for referral


Why and how the patient came to the attention of the doctor


Present illness


How the illness progressed from the earliest time at which a change was noted until the patient came to the attention of the doctor


Past psychiatric history


Prior episodes of illness, where were they treated and how? Prior self-harm


Past medical history


Include emotional reactions to illness and procedures


Family history


History of psychiatric illnesses and relationships within the family


Personal (biographical) history


Childhood: Pregnancy and birth (complications, nature of delivery), early development and attainment of developmental milestones (e.g. learning to crawl, walk, talk). School history: age started and finished; truancy, bullying, reprimands; qualifications


Adulthood: Employment (age of first, total number, reasons for leaving, problems at work), relationships (sexual orientation, age of first, total number, reasons for endings of relationships), children and dependants


Reproductive history


In women: include menstrual problems, pregnancies, terminations, miscarriages, contraception and the menopause


Social history


Current employment, benefits, housing, current stressors


Personality


This may help to determine prognosis. How do they normally cope with stress? Do they trust others and make friends easily? Irritable? Moody? A loner? This list is not exhaustive


Drug history


Prescribed and over-the-counter medication, units and type of alcohol/week, tobacco, caffeine and illicit drugs


Forensic history


Explain that you need to ask about this, since ill-health can sometimes lead to problems with the law. Note any violent or sexual offences. This is part of a risk assessment. Worst harm they have ever inflicted on someone else? Under what circumstances? Would they do the same again were the situation to recur?


Systematic review


Psychiatric illness is not exclusive of physical illness! The two may not only co-exist but may also have a common aetiology



The mental state examination (MSE)


The history will already have assessed several aspects of the MSE, but the interviewer will need to expand several areas as well as test specific areas, such as cognition. The MSE is typically followed by a physical examination and is concluded with an assessment of insight, risk and a formulation that takes into account a differential diagnosis and aetiology. Each domain of the MSE is given below; abnormalities that might be detected and the disorders in which they are found are summarized in Table 23.2. The major subheadings are listed below.








Thoughts


In addition to those abnormalities looked at under ‘speech’ (see above), abnormalities of thought content and thought possession are discussed here. Delusions (Table 23.2) can be further categorized as primary or secondary. Depending on whether they arise de novo or in the context of other abnormalities in mental state.




Cognitive state


Examination of the cognitive state is necessary to diagnose organic brain disorders, such as delirium and dementia. Poor concentration, confusion and memory problems are the most common subjective complaints. Clinical testing involves the screening of cognitive functions, which may suggest the need for more formal psychometry. A premorbid estimate of intelligence, necessary to judge changes in cognitive abilities, can be made from asking the patient the final year level of education and the highest qualifications or skills achieved.


Testing can be divided into tests of diffuse and focal brain functions.








Severe behavioural disturbance


Patients who are aggressive or violent cause understandable apprehension in all staff, and are most commonly seen in the accident and emergency department. Information from anyone accompanying the patient, including police or carers, can help considerably. Box 23.3 gives the main causes of disturbed behaviour.





Management of the severely disturbed patient


The primary aims of management are control of dangerous behaviour and establishment of a provisional diagnosis. Three specific strategies may be necessary when dealing with the violent patient:



Remember that the behaviour exhibited is a reflection of an underlying disorder and as such portrays suffering and often fear. The approach to the agitated or even the violent patient therefore must take this into account and the steps used are with the intention of alleviating this suffering whilst maintaining the safety of the individual, the other patients and staff. Technically speaking, this management begins at the point of an initial assessment that takes into account prior episodes of disturbed behaviour and its precipitants. Armed with this knowledge it may be possible to prevent a recurrence.


‘Verbal de-escalation’. If a patient’s behaviour causes concern, the first step is to try and defuse the situation. Put more simply, this means talking to the patient. It may be something that is relatively simple to correct that has led to the disturbed behaviour such as staff explaining their intentions in approaching the patient.


Medication may be used but an effort should always be made to offer this on an oral basis. The protocol in the UK is to offer a short-acting benzodiazepine in the first instance, such as lorazepam (0.5–1 mg). Patients suffering from a psychotic disorder and who are already taking antipsychotics may be more appropriately treated with an antipsychotic but do not assume that this is the case and be wary of the ‘neuroleptic-naive’ patient. In the delirious or elderly patient, benzodiazepines should be avoided, as they may worsen any underlying confusion and can cause paradoxical agitation. In this instance, low-dose haloperidol is appropriate (2.5–5 mg). More recently, antihistamines have been added to this protocol, such as promethazine. Medications should be given sequentially, rather than all at once, where possible and allowing between 30 min and 1 h for them to take effect.


Physical restraint. In the instance that the above measures do not resolve the situation, physical restraint may be necessary in order to maintain safety and to administer medications on an intramuscular basis (note that for haloperidol this will alter the maximum dose it is safe to use in a 24-hour period). This should not be the first step taken nor should it be performed by staff unless they have been adequately trained in approved methods of control and restraint. This will typically mean nursing staff on a psychiatric ward or security staff on a general medical or surgical ward. Although this may vary between countries, in the UK it is the case that doctors will never be involved in the restraint of the patient. Restraint is a potentially dangerous intervention, even more so when mixed with psychotropic medication, and deaths have occurred as a direct consequence.


Monitoring. If medications (oral or otherwise) are employed, with or without restraint, regular monitoring of physical parameters such as blood pressure, pulse, respiratory rate and oxygen saturation should be performed at a frequency dictated by the level of ongoing agitation and consciousness.







Classification of psychiatric disorders


The classification of psychiatric disorders into categories is mainly based on symptoms and behaviours, since there are currently few diagnostic tests for psychiatric disorders. There currently exists an unhelpful dualistic division of psychiatric disorders from neurological diseases, since the pathologies of at least the majority of each group of conditions are located in the brain, e.g. Alzheimer’s disease causing dementia and a pseudobulbar palsy causing emotional lability.


Psychiatric classifications have traditionally divided up disorders into neuroses and psychoses.



There are several problems with a neurotic-psychotic dichotomy. First, neuroses may be as severe in their effects as psychoses. Second, neuroses may cause symptoms that fulfil the definition of psychotic symptoms. For instance, someone with anorexia nervosa may be convinced that they are fat when they are thin, and this belief would meet all the criteria for a delusional belief. Yet we would traditionally classify the illness as a neurosis.


The ICD-10 Classification of Mental and Behavioural Disorders published by the World Health Organization has largely abandoned the traditional division between neurosis and psychosis, although the terms are still used. The disorders are now arranged in groups according to major common themes (e.g. mood disorders and delusional disorders). A classification of psychiatric disorders derived from ICD-10 is shown in Table 23.5, and this is the classification mainly used in this chapter (ICD-11 will be available in 2014).


Table 23.5 International classification of psychiatric disorders (ICD-10)







The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV-TR) is an alternative classification system (DSM-V in 2013).





Psychiatric aspects of physical disease


People with non-psychiatric, ‘physical’ diseases are more likely to suffer from psychiatric disorders than those who are well. The most common psychiatric disorders in physically unwell patients are mood or adjustment disorders and acute organic brain disorders (delirium). The relationship between psychological and physical symptoms may be understood in one of four ways:



Table 23.6 Psychiatric conditions sometimes caused by physical diseases

















































Psychiatric disorders/symptom Physical disease

Depressive illness


Hypothyroidism


Cushing’s syndrome


Steroid treatment


Brain tumour


Anxiety disorder


Thyrotoxicosis


Hypoglycaemia (transient)


Phaeochromocytoma


Complex partial seizures (transient)


Alcohol withdrawal


Irritability


Post-concussion syndrome


Frontal lobe syndrome


Hypoglycaemia (transient)


Memory problem


Brain tumour


Hypothyroidism


Altered behaviour


Acute drug intoxication


Postictal state


Acute delirium


Dementia


Brain tumour


Factors that increase the risk of a psychiatric disorder in someone with a physical disease are shown in Table 23.7.


Table 23.7 Factors increasing the risk of psychiatric disorders in the general hospital




















Patient factors



Setting



Physical conditions



Treatment







Functional or psychosomatic disorders


So-called functional (in contrast to ‘organic’) disorders are illnesses in which there is no obvious pathology or anatomical change in an organ and there is a presumed dysfunction of an organ or system. Examples are given in Table 23.8. The psychiatric classification of these disorders would be somatoform disorders, but they do not fit easily within either medical or psychiatric classification systems, since they occupy the borderland between them. This classification also implies a dualistic ‘mind or body’ dichotomy, which is not supported by neuroscience. Since current classifications still support this outmoded understanding, this chapter will address these conditions in this way.


Table 23.8 ‘Functional’ somatic syndromes







The word psychosomatic has had several meanings, including psychogenic, ‘all in the mind’, imaginary and malingering. The modern meaning is that psychosomatic disorders are syndromes in which both physical and psychological factors are likely to be causative. So-called medically unexplained symptoms and syndromes are very common in both primary care and the general hospital (over half the outpatients in gastroenterology and neurology clinics have these syndromes). Because orthodox medicine has not been particularly effective in treating or understanding these disorders, many patients perceive their doctors as unsympathetic and seek out complementary or even alternative treatments of uncertain efficacy.


Because epidemiological studies suggest that having one of these syndromes significantly increases the risk of having another, some doctors believe that these syndromes represent different manifestations of a single ‘functional syndrome’, indicating a global somatization process. Functional disorders also have a significant association with depressive and anxiety disorders. Against this view is the evidence that the majority of primary care people with most of these disorders do not have either a mood or other functional disorder. It also seems that it requires a major stress or the development of a co-morbid psychiatric disorder in order for such sufferers to see their doctor, which might explain why doctors are so impressed with the associations with both stress and psychiatric disorders. Doctors have historically tended to diagnose ‘stress’ or ‘psychosomatic disorders’ in people with symptoms that they cannot explain. History is full of such disorders being reclassified as research clarifies the pathology. An example is writer’s cramp (p. 1122) which most neurologists now agree is a dystonia rather than a neurosis.


The likelihood is that these functional disorders will be reclassified as their causes and pathophysiology are revealed. Functional brain scans suggest enhancement of brain activity during interoception in more than one syndrome. Interoception is the perception of internal (visceral) phenomena, such as a rapid heartbeat.




Chronic fatigue syndrome (CFS)


There has probably been more controversy over the existence and cause of CFS than any other ‘functional’ syndrome in recent decades. This is reflected in its uncertain classification as neurasthenia in the psychiatric classification and myalgic encephalomyelitis (ME) under neurological diseases. There is now good evidence for the independent existence of this syndrome, although the diagnosis is made clinically and by exclusion of other fatiguing disorders. Its prevalence is 0.5–2.5% worldwide, mainly depending on how it is defined. It occurs most commonly in women between the ages of 20 and 50 years.




Aetiology


Functional disorders often have some aetiological factors in common with each other (Table 23.9), as well as more specific aetiologies. For instance, CFS can be triggered by certain infections, such as infectious mononucleosis and viral hepatitis. About 10% of patients who have infectious mononucleosis have CFS 6 months after the onset of infection, yet there is no evidence of persistent infection in these patients. Those fatigue states which clearly do follow on a viral infection can also be classified as post-viral fatigue syndromes.


Table 23.9 Aetiological factors commonly seen in ‘functional’ disorders
















Predisposing



Precipitating (triggering)



Perpetuating (maintaining)



Other aetiological factors are uncertain. Immune and endocrine abnormalities noted in CFS may be secondary to the inactivity or sleep disturbance commonly seen. The role of stress is uncertain, with some indication that the influence of stress is mediated through consequent psychiatric disorders exacerbating fatigue, rather than any direct effect.


Mar 31, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Psychological medicine
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