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Consult-Liaison Psychiatry Introduction to CL Psychiatry 1 Working in the General Hospital 2 Evaluation of Clinical Decision Making 3-4 Evaluation of Medically Ill Patients 5-8 Assessment prior to solid organ or bone marrow transplantation 9-10 Medically Unexplained Symptoms 11-12 Differential Diagnosis of Medically Unexplained Symptoms 13- 14 Somatization Disorder 15-16 Conversion Disorder 17-18 Factitious disorder (Munchausen‘s Syndrome) 19-20 Pain Disorder 21 (22 blank) Mental Disorders due to General Medical Conditions 23-34 Acute Confusional States (Delirium) 25-26 Psychiatric Issues in the Chronically Ill 27-28 End-of-Life Care 29-30 Introduction Consult/liaison (CL) Pychiatry is concerned with the diagnosis and management of psychiatric and psychological illness in general medical populations. It is unique among the psychiatric sub-specialties in that it concerns itself not with a particular subset of disorders, or treatment of patients of a particular age range, but patients within a particular clinical setting. The development of a distinct sub-specialty of CL psychiatry is in some ways a result of the separation of psychiatric specialists from their medical and surgical colleagues and practices. The sub-speciality is a relatively recent innovation and dates in its current form since the 1960s. Motivations to its development were the low rate of outside referral in proportion to prevalence of the disorders in the population under review and increasing medical specialization leading to lack of confidence and competence with psychiatric/psychological problems. The role that these problems play in the course and outcome of physical illness is well documented and increasingly appreciated across medical practice. Treatment research that has better defined successful interventions, as well as the decrease in stigma associated with emotional disorders has generated more activity in this field. The role of the CL psychiatrist will be defined, more than the other sub- specialties, by custom and practice in the hospital concerned. The consultation aspect of the job covers episodic referrals made for advice on diagnosis, prognosis, need for further investigations, or management. It may include patients where the request is to consider taking over care. The liaison aspect refers to a closer relationship with a unit, with involvement in unit planning, staff support, policy development, and training as well as involvement in individual clinical cases. The balance between the liaison and consultation aspects of the job will depend on the specialty concerned, and the hospital type. In many hospitals, specialists in this field are often identified under a broader division of Behavioral Health, and the model is one of both general CL work across medical specialties and behavioral health personnel imbedded within specialties. CL psychiatrists often further focus on medical subspecialties such as hematology/oncology, obstetrics and gynecology, transplantation, or neurological illnesses. The main workload will in general include: Diagnosis of new psychiatric illness in general patients. Management of pre-existing psychiatric illness in general patients. Somatic presentation of psychiatric illness. Psychiatric and emotional complications of physical illness. Management of medically unexplained illnesses. Management of behavioral disturbance. Assessment and management of altered mental status Assessment following attempted suicide and deliberate self-harm. Assessment of alcohol and drug abuse. Problems related to childbirth and the puerperium. Issues related to capacity and legal powers. Working in the general hospital CL psychiatry is unusual in that you will work as a psychiatrist based in a general hospital. This can bring its own difficulties and challenges as well as rewards. General hospital physicians in the various specialties will have their own ideas about psychiatry, as well as about the indicated treatment in any given case (which may differ from your own). Nonetheless it is well to remember that you have a range of skills and knowledge that will be useful and are not often known by your medical colleagues. You should rely on these and your own judgment, backed up by senior colleagues, in difficult situations. And always remember that you are a physician first and foremost. Don‘t assume that the primary medical team has done all that is indicated or necessary to assure medical stability or clarity in a given patient. When you come to work in a general hospital you may feel initially overwhelmed. There are many new disorders, altered presentations of familiar disorders, a new tempo of working, and patients suffering from complicated medical conditions (e.g. ICU patients) which may go beyond your medical training. CL psychiatry takes a variety of types of referrals and they will vary by the type of hospital, the population served, and the specialty mix within the hospital. The person receiving the referral should take details of the patient, his/her inpatient primary treatment team and contact persons, and the nature of the problem, including its urgency. It is important to clarify what questions the treatment team want addressed. It is also important to clarify that the patient and parents (with pediatric patients) understand that a psychiatric referral has been made and all agree to this. Where the situation is not an emergency, it can be useful to review any psychiatric or departmental records for previous contacts, prior to assessing the patient. On arrival to the unit, review the medical record of this and previous admissions and speak to a senior member of the treatment team. Clarify the patient‘s diagnosis and any investigations or treatments planned. Discuss the patient with the nursing staff—they often have useful information regarding the patient‘s symptoms around the clock and their mood day to day. Arrange a private room for the interview if at all possible. Introduce yourself to the patient as a psychiatrist or behavioral health specialist. Explain your role, which may be misunderstood by the patient, who may feel you are there to ―see if I‘m crazy‖. Addressing up front the patient‘s anxieties or misconceptions about the involvement of psychiatry in their care will contribute to a more productive and valid assessment overall. Stating that the medical team is concerned about some of the patient‘s symptoms and they want a specialist in these symptoms to give them some advice is often an acceptable phrasing for patients. A written document should be placed in the medical chart as soon as possible after the completion of the consult. If this is not possible, a brief ―holding‖ note can address any critical issues, pending completion of the full consult. It is important to discuss your findings with the medical team face to face. If a definitive psychiatric diagnosis is possible, write this clearly in the notes, along with a provisional management plan and any treatment recommendations. Clarify if further psychiatric review is planned, and note which symptoms should result in more urgent concern. Thoroughly sign out all patients to the covering evening/ weekend psychiatrist. Evaluation of Decision-Making Capacity One of the more difficult and complex psychiatric consultations occurs when the medical team inquires whether a patient is ―competent‖ to make medical decisions. Although competency is a broad legal issue which can only be decided in the United States by the court system, CL psychiatrists can help guide the team in determining whether the patient has the capacity to make individual decisions. A psychiatric capacity evaluation usually involves several steps: 1) determining the specific decision being asked of the patient; 2) examining whether the patient has the ability to give informed consent; 3) evaluating whether any psychiatric condition is interfering with the patient‘s judgment or ability to appreciate the medical decision; and 4) working within a multidisciplinary team to determine the final decision. Step 1 – Identify the Question Although medical teams have a legitimate interest in knowing whether a patient is competent to make decisions or requires a surrogate decision- maker, a blanket recommendation is frequently impossible because of the differing capacity requirements for simple versus complex decisions. For example, if a diabetic patient is asked to provide blood to check their glucose level, the extremely low risk to benefit ratio would require only limited understanding and ability to manipulate information. It is probably sufficient that they know that they have diabetes and understand that if they don‘t monitor and control their glucose, it could hurt them. In contrast, for a terminal cancer patient to participate a Phase I chemotherapy trial with very limited benefit and considerable side effects, they would need to demonstrate a thorough appreciation of the issues involved. Step 2 – Examine the Patients Ability to Give Informed Consent Once a particular question has been identified (e.g., whether a patient can refuse an amputation in the setting of osteomyelitis and early gangrene), it is necessary to explore whether the patient has the ability to understand and provide informed consent. This evaluation can be done by any medical professional, and in many cases is most appropriately evaluated by the physicians who best understand the risks and benefits of what they are offering. As part of our evaluation, we need to confirm that they have an appreciation of: a) the nature of their illness or condition b) the procedure, medication, or other treatment being offered to them c) the most important risks and potential benefits associated with that treatment d) any alternative treatment options, as well as the consequence of avoiding any action Many times the patient conveys a limited understanding of these issues. This may reflect underlying cognitive deficits or medical problems; however, it is also possible that many of these areas have not yet been discussed with the patient. In that case, it is often prudent to ask the medical team to discuss these issues in your presence, while you examine the patient‘s ability to process and retain this information. Step 3 – Evaluate the Presence of Psychiatric Illness and Determine Whether it is Influencing the Patient’s Decision Even if the patient‘s decision reflects a fair grasp of the elements of consent, it is necessary to determine whether their judgment is being influenced by mental illness. For example, if the patient with gangrene understands the nature of their infection and the risks of surgery versus delaying treatment, we would not support their making a decision to avoid surgery if the decision was based on auditory hallucinations telling them that they don‘t deserve to live. Therefore a comprehensive psychiatric assessment, including an evaluation of how they have made their decision, is essential. The psychiatric evaluation for a capacity assessment needs to be comprehensive, particularly focusing on cognitive functions, reasoning and judgment; however, it is otherwise similar to any thorough psychiatric examination. The primary difference lies in the additional examination of how the patient has made similar choices in the past and what role psychiatric symptoms are playing in their current decision. Although it is common for psychiatric symptoms to be present, one of the biggest challenges in a capacity assessment is determining whether these symptoms alter the patient‘s judgment to the extent that they are unable to determine their treatment. For example: 1) Depression is frequently seen in people with chronic illnesses. Does this mean that a terminal patient can never refuse treatment because their decision might be influenced by depression? 2) Psychosis may alter the patient‘s reality testing; however, most psychotic individuals retain their ability to make medical decisions if their psychosis does not alter their reasoning in that area. 3) Cognitive impairment is frequently variable, based on diagnosis, time of day, when medications were given and other factors. Is a patient able to make decisions if they can only describe them adequately at certain times? Step 4 – Gather Additional Information. Frequently patients decision-making capacity may not be clear-cut and we are left with the task of developing a consensus. Other individuals who may guide your recommendation include: 1) the patient’s family, particularly the likely surrogate decision-maker. If they agree with the patient, then the issue of the patient‘s capacity is less critical to the outcome. 2) a medical ethics/legal consultant. These individuals (often part of the hospital system) can help the team understand whether the patient is making a decision that is consistent with their prior decisions and expressed wishes, as well as whether forcing treatment would be ethically/legally reasonable. 3) social worker, physical and occupational therapists. They can be of great assistance in identifying the patient‘s surrogate decision maker and examining whether the patient is able to function independently. Final Consultation Report Once all of these steps are completed, we can advise the medical team on the patient‘s capacity to make the identified decision. Although these psychiatric consultations can be difficult and time-consuming, they can also be highly rewarding, as the outcome almost always has an immediate and profound impact on the patient‘s life and health. Evaluation of Medically Ill Patients Assessing medical patients for psychiatric disease can be a difficult task since the symptoms of psychiatric disorders may overlap with those of many medical conditions. Also, it can be difficult to determine whether patients have a treatable psychiatric syndrome, versus typical emotional reaction in the context of their medical burden, and/or a mood disorder secondary to drugs, alcohol, medical conditions, or medications. Yet, it is often the job of the Consult-Liaison (CL) psychiatry team to discriminate the subtle distinctions among the potential etiologies. There are clinical pearls which may be helpful when evaluating patients for depression, anxiety, and psychosis. Lastly, there are also characteristic psychiatric syndromes produced in the context of medical burden that will be discussed at the later in the chapter. Detailed information on diagnosis and treatment of individual conditions is discussed throughout other chapters in this handbook. Depression When assessing patients‘ depressive symptoms it may be hard to tease apart whether disturbances in energy, sleep, appetite, and concentration are related to the medical condition itself or whether they are symptoms of depression. Since several of these symptoms may be caused by medical illness, the presenting symptoms may mimic Major Depressive Disorder (MDD). On the other hand, if you exclude all overlapping symptoms and attribute them to the medical condition, it may be difficult to reach the diagnosis of MDD even when it is present. In cases such as these which are many in the consult-liaison world, there are a clinical pearls of depression which may be most useful to ask about. Clinical Pearls: Is it Depression or a Medical Cause? All of these factors weighed together can give you a better picture of the etiology of the depressed mood as well as the severity. 1. Hopelessness: It can be helpful to know how patients view their situation. Do they have plans for the future? What do they think the future looks like for them? Do they think things will ever improve? Depressed people will tend to have a pessimistic view of the future. 2. Anhedonia: Is the patient still doing things they enjoy doing (if they are physically able to)? If not, do they still wish they could do those things or have they lost interest for these things? 3. Tearfulness: Are they crying a lot? Are they tearful most of the day? This is more consistent with depression. 4. Consistency of the Feelings: Are they depressed most of the day or are there periods of the day when their mood lifts? Depressed individuals usually have consistent episodes of decreased mood that last for weeks. 5. Lack of Reactivity: Are they flat in affect? Emotionless? These are more indicative of a clinical depression. 6. Social Isolation: Do they look forward to visitors/family? Are they uninterested in having visitors? One caveat to watch out for is for patients who want visitors but are afraid to look weak or in the "sick role." i.e.: Depressed individuals may have decreased interest in spending time with family, and may not be happy even after visitors arrive. 7. Collateral Information: Obtaining information from close family or friends can be crucial in the assessment of medical patients as they often add insight into the severity, duration, and temporal relationship of the symptom course. The clinical picture taken together with DSM-IV-TR criteria will paint the picture of whether patients have clinical depression versus another etiology. If they are severely disabled, unable to participate in care, hopeless or suicidal it may be prudent to treat symptoms of major depression regardless of actual etiology. On the other hand, if the clinical picture looks less severe it may be reasonable according to one's clinical judgment to watch the depression for a few weeks to see if it improves on its own with correction of the underlying medical condition. If the medical condition is not expected to resolve in the near future, it may be helpful to treat the depression to improve mood and functioning level (see the depression chapter for more details). Psychosis Psychotic symptoms can be characteristic of many disorders, namely withdrawal syndromes, delirium, dementia, and primary psychotic disorders. There are some helpful hints to consider when assessing psychosis and its underlying cause so as to differentiate primary psychotic disorders (i.e. due to psychiatric illness) from other syndromes with a secondary psychosis (i.e. due to a medical condition or substance use diagnosis). Clinical Pearls: Is it Psychotic Disorder or a Medical cause? 1. Visual hallucinations: Visual hallucinations are more likely to be related to delirium, where as auditory hallucinations are more characteristic of a primary psychotic disorder. 2. Daily Fluctuations: A waxing and waning picture with alterations in attention and alertness are more likely something suggesting delirium as opposed to a primary psychotic disorder. 3. Timeline: How long has the psychosis been occurring? Is this new? Was there a gradual decline? A primary psychotic disorder typically has an obvious prodrome and/or emotional stressor and typically occurs in younger patients with a family history of psychosis. Some forms of dementia can also present with psychotic features, and typically occur in older patients or patients with family history of dementia. When assessing for dementia, it is helpful to gain information from collateral sources as to any cognitive or executive decline from baseline and how long the decline has been occurring over. See page ### for more details on dementia. 4. Vital Signs: Withdrawal syndromes also can present with psychotic symptoms. It is helpful to look for any autonomic instability, vital sign changes, sweating, and tremor which may suggest an underlying withdrawal from alcohol or other sedatives. Such changes would be less likely in a primary psychotic disorder. Evaluation of Medically Ill Patients (continued) Anxiety Anxiety is a common phenomenon in medically ill patients, yet the diagnosis and treatment may be difficult for a few reasons. First, many times medical patients don't meet full criteria for a DSM-IV-TR diagnosis of an anxiety disorder. However, despite not meeting criteria for a DSM-IV-TR diagnosis, medical patients often have realistic worries over health, finances, work and family all related to their medical illness and the losses it produces. It is important to assess the worry and anxiety and make a decision based on symptom severity and impairment whether treatment would help the anxiety. Another reason why diagnosis of anxiety may be difficult in medical patients is because it is difficult to assess whether symptoms of anxiety like shortness of breath, heart palpitations, dizziness, insomnia, diaphoresis, and restlessness are part of a medical illness or related to an anxiety disorder. In these situations there are some important aspects to consider in your assessment of anxiety. Clinical Pearls: Is it Anxiety or Medical Cause? 1. Medical Work-Up: Assess for medical causes for symptoms first. Has the patient had a complete medical evaluation for the physical complaints? If the medical tests have come back normal (e.g. EKG, lab work, TSH, chest x-ray, PFTs), then diagnosis of anxiety disorder should be a diagnosis of exclusion. 2. Substance Abuse/Ingestion: Patients should have a urine drug screen/ urine toxicology to rule out substance intoxication or withdrawal as a cause for the physical complaints, agitation, subjective feelings of restlessness, and anxiety. If clinically indicated, some institutions also have a more comprehensive serum drug screen to rule out other drugs of abuse. If an overdose is suspected, levels of acetaminophen, aspirin, tricyclic antidepressants, and an ethanol level should also be checked. If clinically indicated, some institutions also have a more comprehensive serum drug screen to rule out other drugs of abuse. Find out what your institution screens for and always think about those substances that may not show up on your institution‘s drug screen (i.e. they may not pick up all metabolites of benzodiazepines or opiates, or may include drugs known to have local emphasis). Monitor for any possible withdrawal from drugs, especially alcohol or benzodiazepines which many be contributing to the subjective feelings of anxiety. Refer to the substance use chapter for details on the treatment of substance withdrawal. 3. Past Psychiatric History: Does the patient have an underlying anxiety disorder that is being made worse by a new medical stressor? 4. Characteristic Symptoms Associated with specific Medical Illnesses Patients with pulmonary disease, COPD, Asthma, lung transplant patients and airway assisted patients on weaning trials can all have anxiety surrounding feelings of shortness of breath. Sometimes these findings can be mistaken for anxiety or panic disorder, and vice versa. Do the subjective match the objective findings? Assess mental processes surrounding these feelings. Does the patient feel like or fear they are going to die? Have a sense of doom? Fear they are going crazy? It is helpful to know exactly what the patient is experiencing when they have the sensation of feeling short of breath. If they are having an anxiety/panic type reaction to the experience it may be an anxiety syndrome. However, there often times is an overlap between true respiratory symptoms and anxiety, and treating both problems may be necessary. Assessment prior to solid organ or bone marrow transplantation For patients with a disease of a solid organ (heart, lung, kidney, liver, bowel, pancreas) or a leukemia, a transplantation offers the prospect of significant improvement in their mortality and quality of life. Unfortunately, the supply of donor organs is less than the number of potential recipients. Because of this, patients requiring a variety of transplantations will suffer declining health while awaiting transplantation and 10–20% of listed patients will die while awaiting transplant. This places a responsibility on the assessing team to consider carefully each potential candidate for listing for transplantation in order to ensure the best use of the donor organs. Psychiatric assessment of patients prior to listing for transplantation may be anticipatory and routine, or may be requested in the following situations: Fulminant organ failure following intentional ingestion (e.g., acetaminophen or paracetamol in livers) Liver disease secondary to alcoholic liver disease (ALD) Patients/families with history of mental illness Patients with previous or current drug misuse. Patients/families with history of non-adherence Patients/families with significant psychosocial disruption Living related donor The involvement of the psychiatrist in the assessment prior to listing for transplantation should in no sense be a moral judgement as to the patient‘s or family‘s suitability. The issues are whether or not there are psychiatric (Biopsychosocial) factors which would jeopardize the survival of the donor organ. The psychiatric opinion may have the most profound implications for the patient or family and so assessment should be as thorough as time allows. In addition to taking psychiatric, psychosocial and developmental history and MSE, family members, PCP (if available), and hospital case records should be consulted. Fulminant organ failure following ingestion The issue is whether there is: ongoing intent to die or refusal of transplant (which would normally preclude transplantation); or whether there is a history of repeated overdoses in the past, significant psychiatric disorder, or ongoing drug or alcohol misuse (which would be relative contraindications). Liver disease secondary to Alcoholic Liver Disease (ALD) Suitably selected patients transplanted for ALD have similar outcomes in terms of survival and quality of life to patients transplanted for other indications. Units will have individual policies regarding these patients which should be consulted if available. The issue is whether the patient, who has already damaged one liver, will damage a second. There is a wider issue of maintaining the public confidence in the appropriate use of donated organs. For liver disease secondary to ALD, consider: How long have they been abstinent (is there independent verification of this)? Do they accept alcohol as the cause of liver failure? Do they undertake to remain abstinent post-transplant? Do they have a history of dependence or harmful use? What is their history of involvement in alcohol treatment services and in the past, how have they responded to relapse? When were they told that their drinking was causing liver damage, and what was their response? Given the above findings and your routine psychiatric assessment, the transplant team will seek your opinion as to: The patient‘s psychiatric diagnosis. Their risk of relapse. Their risk of re-establishing harmful/dependant drinking. The potential for successful intervention should this occur. History of mental illness/drug misuse Generally speaking a diagnosis of mental disorder (other than progressive dementia) does not preclude transplant. The important issues are whether the mental disorder will affect compliance or longer-term mortality in its own right. Close liaison with the patient‘s normal psychiatrist is clearly crucial here. Ongoing substance dependence is generally a contraindication to transplantation and should be addressed before listing. History of non-adherence to treatment/psychosocial disruption Non-adherence with treatment may be the reason for a patient‘s need for transplant, or places the patient at risk for future morbidity or mortality and the loss of a donated organ if not recognized early in assessment. Past medical records and discussions with past treatment teams will provide information regarding this area of risk for a given patient or family. In addition, pre-transplant evaluation by multiple team members, including behavioral health, should identify psychosocial factors that place a patient or family at risk for non-adherence, and provide the team an opportunity to be pro-active to increase the likelihood of future adherence and transplant success. Living-related donors This type of transplant uses organs or tissues from a matched and usually biologically related donor. Examples include bone marrow, kidney or sections of liver or lung. In this case, the donor is an additional focus of evaluation, with the goal of determining informed consent and the absence of coercion. Medically Unexplained Symptoms A substantial proportion of patients presenting to primary care offices and medical hospitals have symptoms which do not fit any known medical diagnosis. When the symptoms are vague, transient, and do not affect the person‘s functioning, often no treatment is necessary. However, these symptoms can be severe and disabling, resulting in numerous medical hospitalizations and substantial morbidity. Consultation-Liaison psychiatrists‘ help is most often requested when the symptoms do not conform to any known medical disorder, when the pattern of symptoms or behavior make it unlikely to be medically driven (e.g., bilateral tonic-clonic ―seizures‖ in a conscious individual), or when the intensity of pain or other symptoms appears grossly out of proportion to physical findings, particularly in pain syndromes). The CL psychiatrist role in these cases is to assess for psychiatric disorders and guide both the medical team and patient toward treatment options in a non-judgmental and constructive fashion. This section will focus on the diagnosis and management of symptoms which are relatively discrete in presentation and not consciously produced. Common Presentations and Referrals Patients can present to any specialty with unexplained symptoms, but the most common sources of psychiatric referrals in medical hospitals include: • Cardiology referrals for atypical chest pain • GI Medicine consultations for diarrhea, constipation, and/or abdominal pain of unknown etiology • Gynecology referrals for chronic pelvic pain • Medicine/Pulmonary referrals for unexplained shortness of breath, including inability to wean from a ventilator • Neurology referrals for tension headaches, pseudoseizures, and unexplained weakness or loss of sensation Assessment The initial assessment includes a thorough review of medical records and a discussion with the primary team as to the chronology of the patient‘s symptoms, tests performed, and the reasons they believe the symptoms are ―psychosomatic‖ in origin. In addition to a comprehensive evaluation of psychiatric symptoms, the consultative interview should also focus on the patient‘s understanding of their illness and any connection they have observed between emotions, events in their lives, and the intensity of their symptoms. This discussion should be conducted in an exploratory fashion, without suggesting that the symptoms are ―all in their head.‖ Explaining the CL psychiatric exam to the medical patient Patients are usually willing to discuss the psychological distress associated with being ill. However, they may feel angry and insulted by the notion that they are ―faking‖ their illness. As such, it is prudent for the primary team to explain the consult and its purpose prior to the CL psychiatric exam visit. Thoughtfully word your initial contact with patients to avoid alienating them. Collateral information from friends, family, and their primary care physician will help establish whether the patient is obtaining primary or secondary gain from being ill, as well as the chronology of the patient‘s symptoms and associated stressors. Management Principles of Medically Unexplained symptoms The primary approach to treating patients with medically unexplained symptoms involves: Avoid confrontation. Remember that these disorders are likely unconscious (i.e., the patients are not actively aware they are somehow creating/exacerbating the symptoms- it is below their level of conscious awareness). Most attempts to force the patient to recognize that they are producing symptoms will result in loss of their trust and alliance. Working with the medical team to avoid countertransference and limit polypharmacy. Patients with unexplained illnesses are often difficult, time- consuming, and frustrating to the medical staff. Educate staff as to the unconscious nature of these illnesses and the important role they can play in recovery. Recognize that multiple ineffective medications may have been added early in the course of their illness and may now be withdrawn. Treat underlying psychiatric disorders. In addition to treating conditions that meet DSM-IV-TR criteria, look to treat the atypical anxiety and depression described in the following sections, and consider empiric use of antidepressants if symptoms persist. Alternative treatments such as physiotherapy, increased activity/exercise, massage therapy, acupuncture, and hypnosis should be considered. Arrange regular non-contingent medical follow-up. As the patient‘s unexplained medical symptoms may persist due to secondary gain from medical attention, arrange frequent medical appointments (about every 6 weeks) which are not contingent on the patient‘s experience of symptoms Encouraging psychiatric follow-up. This allows the patient to explore the underlying psychiatric issues which may be expressed with somatic symptoms, and it transfers some of the dependency needs of the patient from the medical system to their therapist or psychiatrist. C/L Tips for Unexplained Symptoms Differential Avoid confrontation Diagnosis Work closely with the medical team Avoid/Monitor countertransference of Limit polypharmacy Medically Treat underlying psychiatric disorders Arrange regular non-contingent medical follow-up Unexplaine Encourage psychiatric follow-up d Symptoms The differential diagnosis for relatively acute, isolated, medically unexplained symptoms includes: Uncommon medical syndromes which have not yet been diagnosed Symptoms directly related to psychiatric disorders such as depression, panic attacks, and psychosis Conversion Disorder Pain disorders Somatization Disorder Factitious Disorder Malingering As stated earlier, it is important not to fall into the dichotomy of assigning medical versus psychiatric causes to somatic symptoms, as these syndromes often involve a component of learned behavior. Patients are likely to have had pain, seizures, or other symptoms of a medical illness prior to, or concurrent with, their current presentation. Medical practice has shifted to encourage psychiatric involvement in these cases prior to exhausting all medical testing. This minimizes the perception that psychiatric consultation is a reaction to the team ―giving up,‖ and creates a more collaborative environment. Probably the most frequent cause of medically unexplained symptoms is atypical presentations of depression and anxiety. Depression, particularly in the elderly, can present with a predominance of medical symptoms, particularly pain, GI complaints, weakness, loss of appetite and insomnia. Similarly, many unexplained cases of chest pain and shortness of breath can be attributed to anxiety such as atypical panic attacks. The primary difference between these anxiety symptoms and Panic Disorder is that many of these cases have a less discrete onset and offset, have limited symptoms, and/or may have clear environmental triggers (e.g., whenever a ventilator patient starts a weaning trial they become more short of breath). Psychotic disorders can present with somatic symptoms as part of the schizophrenia spectrum, although the psychiatric diagnosis of these individuals has often been established at an earlier point. The greater difficulty for patients presenting with psychotic symptoms lies in identifying delusional disorders of the somatic type, which frequently presents with few symptoms other than physical complaints. Conversion disorders are in some ways prototypical of this group of illnesses, and have been well described for decades. The primary feature of Conversion Disorder is the unconscious production of neurological symptoms affecting motor or sensory systems. This may include classical ‗hysterical paralysis‘, sensory loss (often in non-physiological patterns), or the development of atypical seizures (either by pattern or lack of concurrent EEG findings). The course of conversion disorders is quite variable, often with abrupt onset, variable duration, and high probability of recurrence. Individuals with Pain disorders may have pain that is solely attributed to their medical conditions, but frequently develop pain related to both medical and psychological factors. Finally, a patient with medically unexplained symptoms may have a lifelong history of medical concerns as part of Somatization Disorder, or may be consciously producing symptoms in order to achieve primary or secondary gains (as part of a Factitious Disorder or Malingering). Given the differences in treatment for these patients, these syndromes are covered elsewhere in this chapter. Somatization disorder Somatization Disorder is a disorder of multiple medically unexplained symptoms, affecting multiple organ systems, presenting before the age of 40. It is usually chronic in adults. In children, it usually involves one or a few organ systems, often for shorter periods of time (undifferentiated somatoform d/o or somatoform d/o nos). In all ages, it is associated with significant psychological distress, functional impairment, and repeated presentations to medical services. Full blown somatization disorder or ‗Briquet’s syndrome‘ probably represents the severe end of a continuum of abnormal illness behavior. Clinical features Patients will have long, complex medical histories (‗fat/large-file‘ patients), although at interview may minimize all but the most recent symptomatology. Symptoms may occur in any system and are to some extent suggestible. The most frequent symptoms are non-specific and atypical. There may be discrepancy between the subjective and objective findings (e.g. reports of intractable pain in a patient observed by nursing staff to be joking with relatives). Symptoms are usually concentrated in one system at a time but may move to another system after exhausting diagnostic possibilities in the previous. Life of the patient revolves around the illness as does family life. Diagnosis is usually only suspected after negative findings begin to emerge as normal medical practice is to take complaints at face value. There is excessive use of medical service and alternative therapies. Chronic cases will have had large numbers of diagnostic procedures and surgical or medical treatments. There is a high risk of iatrogenic harm and iatrogenic substance dependence. Hostility and frustration can be felt on both sides of the doctor- patient relationship. There may be ‗doctor-shopping‘ and ‗splitting‘ of the attitudes of staff caring for them. Psychological approaches to treatment are hampered by on-going investigations of ever rarer diagnostic possibilities and by the attribution of symptoms to fictitious but ‗named‘ medical entities. Two-thirds of patients will meet criteria for another psychiatric disorder, most commonly major depressive or anxiety disorders. There is also association with personality disorder and substance abuse. They characteristically deny emotional symptoms or attribute them directly to physical handicaps—‗the only reason I‘m depressed is this constant pain‘. Etiology Observable clinical association with childhood illnesses in the patient or the family, and a history of parental anxiety towards illness. Increased frequency of somatization disorder in first degree relatives. Possible neuropsychiatric basis to the disorder with faulty assessment of normal somatic sensory input. Association with childhood physical and sexual abuse. Epidemiology Lifetime prevalence of ~0.2%. Markedly higher rate in particular populations. Female:Male ratio 5:1. Age of onset varies from childhood to early 30s. Differential diagnosis Undiagnosed physical illness, particularly those with variable, multi-system presentations (e.g. SLE, AIDS, porphyria, tuberculosis, multiple sclerosis). Onset of multiple symptoms for the first time in patients over 40 should be presumed to be due to unexposed physical disease. Psychiatric disorder: major affective and psychotic illnesses may initially present with predominately somatic complaints. Diagnosis is by examination of other psychopathology. However, many of somatization disorder patients exhibit psychiatric and medical comorbidity. Other somatoform disorders: distinguish from hypochondriasis (presence of firm belief in particular disorder), pain disorder (pain rather than other symptoms is prominent), conversion disorder (functional neurological loss without multi-system complaints), factitious disorder (intentional production or feigning of physical symptoms to assume sick role) and malingering (intentional production of false or grossly exaggerated physical symptoms with external incentives). In practice the main distinction is between the full and severe somatization disorder and somatization as a symptom of other disorders. Assessment (see earlier in this chapter). Establish reasons for referral, experience of illness, attitudes to symptoms, personal and psychiatric history, family perspective. Initial management (see earlier in this chapter) Make, document, and communicate the diagnosis. Acknowledge symptom severity and experience of distress as real but emphasize negative investigations and lack of structural abnormality. Reassure patient of continuing care. Attempt to reframe symptoms as emotional. Assess for and treat psychiatric comorbidity as appropriate. Reduce and stop unnecessary drugs. Consider case conference involving PCP and treating physicians. Educate parents/family. On-going management Regular review and management by single, named doctor preferably the PCP. Reviews should be at planned and agreed upon frequency, avoiding emergency consultations. Symptoms should be examined and explored with a view to their emotional ‗meaning‘. Avoid tests ‗to rule out disease‘; investigate objective signs only. All secondary referrals made through one individual. Disseminate management plan. These patients can exhaust a doctor‘s resources—plan to share the burden over time. Some evidence for the effectiveness of patient education in symptom re- attribution, brief contact psychotherapy, group therapy, or CBT if the patient can be engaged in this. Prognosis Poor in the full disorder; tendency is for chronic morbidity with periods of relative remission. Treatment of psychiatric comorbidity and reduction of iatrogenic harm will reduce overall morbidity. Key for recovery in children and adolescents is rehabilitation and return to usual activities as soon as possible. Conversion disorder The loss or disturbance of normal motor or sensory function which initially appears to have a neurological or other physical cause but is attributed to a psychological cause. This disorder was initially explained by psychodynamic mechanisms—repression of unacceptable conscious impulses and their ‗conversion‘ to physical symptoms, sometimes with symbolic meaning. In ICD and DSM, the presumed psychodynamic mechanisms are not part of the diagnosis. The initiation or worsening of the symptom or deficit is preceded by conflicts or stressors. Symptoms are not produced intentionally and the presence of ‗secondary gain‘ is not part of the diagnosis. Per DSM-IV-TR, symptoms cannot be fully explained by a medical condition or the direct effects of a substance or as a culturally sanctioned behavior or experience. Conversion disorders are classified with the somatoform disorders in DSM-IV- TR. Clinical features Vary depending on the area affected but the following are commonly seen: Paralysis One or more limbs or one side of the face or body may be affected. Flaccid paralysis is common initially but severe, established cases may develop contractures. Often active movement of the limb is impossible during examination but synergistic movement is observed (e.g. Hoover’s test: the patient is unable to raise the affected limb from the couch but is able to raise the unaffected limb against resistance with demonstrable pressing down of the heel on the ‗affected‘ side). Loss of speech (aphonia) There may be complete loss of speech, or loss of all but whispered speech. There is no defect in comprehension and writing is unimpaired (and becomes the main method of communication). Laryngeal examination is normal and the patient‘s vocal cords can be fully opposed while coughing. Sensory loss The area of loss will cover the patient‘s beliefs about anatomical structure rather than reality (e.g. ‗glove‘ distribution, marked ‗midline splitting‘). Pseudoseizures Non-epileptic seizures are found most commonly in those with genuine epilepsy. Pseudoseizures generally occur only in the presence of an audience, no injury is sustained on falling to the ground, tongue biting and incontinence are rare, the ‗seizure‘ consists of generalized shaking, rather than regular clonic contractions, and there is no post-ictal confusion or prolactin rise. This is the most common presentation of conversion disorder in children and adolescents. Etiology Not known, but hypotheses include: Psychological – an expression of an underlying or unconscious conflict. Biological – precipitated by excessive cortical arousal. Family systems – modeling behavior; presence of enmeshment, overprotection, rigidity and a lack of conflict resolution. Learning theory – learning the benefits of the ‗sick role‘. At high risk may be an abused child who cannot disclose. Sociocultural – more accepted way to ask for help. Diagnosis The diagnosis will usually be suspected when physical or neurological findings do not conform to known anatomical pathways and physiological mechanisms. It is established by 1) excluding underlying disease, or demonstrating minor disorder insufficient to account for the symptoms; 2) finding of ‗positive signs‘ (e.g., demonstration of function thought to be absent or capturing a pseudoseizure on a video EEG); 3) a convincing psychological explanation for the deficit. Additionally helpful though nonspecific is a prior history of conversion symptoms or recurrent somatic complaints or disorder, family or individual stress and psychopathology (recent stress, grief, sexual abuse) or the presence of a symptom model. Differential diagnosis Includes: multiple medical diagnoses (e.g., migraines, temporal lobe epilepsy, CNS tumors, MS, myopathies, SLE). Dual diagnosis present in up to 1/3rd of conversion disorders. Anxiety, depression. Diagnosis not made if symptom is better accounted for by another diagnosis. Somatoform disorders Dissociative disorders Malingering and factitious disorder Treatment Education and formulation presented in a conference with the primary treatment team. Be supportive and non-judgmental, using positive statements (‗we have good news for you‘) rather than negative (‗we couldn‘t find anything; it‘s all in your head‖). No controlled treatment studies. CBT, IPT, supportive psychotherapy, family therapy, biofeedback all potentially helpful. Treat psychiatric comorbidity. Prognosis For acute conversion symptoms, especially those with a clear precipitant, the prognosis is good, with expectation of complete resolution of symptoms (70–90% resolution at follow-up). In children and adolescents, conversion disorder usually occurs suddenly and temporarily. Outcomes are poorer for longer-lasting and well-established symptoms in the presence of chronic stressors. Factitious disorder (Munchausen’s Syndrome) In factitious disorder, patients intentionally falsify their symptoms and past history and fabricate signs of physical or mental disorder with the primary aim of assuming the sick role and obtaining medical attention and treatment. The diagnostic features are the intentional and conscious production of signs, falsification, or exaggeration of the history and the lack of gain beyond medical attention and treatment. Three distinct sub-groups are seen. Wandering: mostly males who move from hospital to hospital, job to job, place to place, producing dramatic and fantastic stories. There may be aggression or antisocial PD and comorbid alcohol or drug problems. Non-wandering: mostly females; more stable lifestyles and less - dramatic presentations. Often in paramedical professions; overlap with chronic somatization disorder. Association with borderline PD. By proxy: mostly female. Mothers, caregivers, or paramedical and nursing staff who simulate or prolong illness in their dependants—here the clinical focus must be on the prevention of further harm to the dependant. Most victims are infants or young children. In children, this is a form of child abuse, and must be treated as such. Additional qualifiers attached to diagnosis include predominantly physical features, predominantly psychological features or both. The behaviors can mimic any physical or psychiatric illness. Behaviors include: self-induced infections, simulated illnesses, interference with existing lesions, self-medication, altering records, reporting false physical or psychiatric symptomatology. Early diagnosis reduces iatrogenic morbidity and is facilitated by: awareness of the possibility; a neutral interviewing style using open rather than closed questions; alertness to inconsistencies and abnormalities in presentation; use of other available information sources; and careful medical record keeping. Videotaping in the hospital has been used successfully to establish a diagnosis with certainty, especially in factitious disorder by proxy. Differential diagnosis Any genuine medical or psychiatric disorder. Somatization disorder (no conscious production of symptoms and no fabrication of history), malingering (secondary gain for the patient e.g. compensation, avoiding army service, avoiding detention), substance misuse (also gain, e.g. the prescription of the abused drug), hypochondriasis, psychotic and depressive illness (associated features of the primary mental illness). Etiology Unknown. There may be a background of childhood sexual abuse or childhood emotional neglect, a disrupted family or marriage. Probably more common in women and those with a nursing or paramedical background. Association with personality disorder, often borderline. Management There are no validated treatments. Patients are often reluctant to consider psychiatric assessment and may leave once their story is questioned. Management in these cases is directed towards reducing iatrogenic harm caused by inappropriate treatments and medications. In the case of factitious d/o by proxy, when suspicions are high, child protective services should be contacted, and appropriate steps to protect the child should be taken. Direct challenge: Easier if there is direct evidence of feigned illness; the patient is informed that staff are aware of the intent to feign illness and the evidence is produced. This should be in a non-punitive manner with offer of ongoing support. Indirect challenge: Here the aim is to allow the patient a face- saving ‗way out‘, while preventing further inappropriate investigation and intervention. One example is the ‗double bind‘ ‗if this doesn‘t work then the illness is factitious‘. Systemic change: Here the understanding is that there is no possibility of change in the individual and the focus is on changing the approach of the health care system to assessing them in order to minimize harm. These strategies can include dissemination of the patient‘s usual presentation and distinguishing marks to regional hospitals, ‗black-listing‘, ‗Munchausen‘s registers‘, etc. As these strategies potentially break confidentiality and can decrease the risk of detecting genuine illness, they should be drawn up in a multidisciplinary fashion involving senior staff, with legal input. Pain disorder In pain disorder, associated with psychological factors with or without general medical condition, there is a complaint of persistent severe and distressing pain which is not explained or not adequately explained by a general medical condition. The causation of the symptom is attributed to psychological factors. This disorder is diagnosed where the disorder is not better explained by somatization disorder, another psychiatric diagnosis, or psychological factors affecting general medical condition. All pain is a subjective sensation and its severity and quality as experienced in an individual is dependant on a complex mix of factors including the situation, the degree of arousal, the affective state, the beliefs about the source, and meaning of the pain. The experience of pain is modified by its chronicity and associations. There is a ‗two-way‘ relationship with affective state, with pain predisposing to anxiety and depressive illness, while anxiety and depressive illness tend to worsen the subjective experience of pain. Comorbidity In common with the other somatoform disorders there is substantial overlap with major depression (~40% in pain clinic patients) and anxiety disorders. Substance abuse (including iatrogenic opiate dependency) and personality disorder patients are over-represented. Epidemiology No population data are available. The prevalence of patients with medically unexplained pain varies by clinical setting; higher in inpatient settings, particularly surgery, and highest in pain clinic patients. Differential diagnosis Factitious disorder, malingering, psychological factors affecting medical condition, substance abuse, and a host of medical diagnoses in which pain may be a central feature, such as sickle cell anemia. Assessment History from patient and informants, length of history (may be minimized), relationship to life events, general somatization, experience of illness, family attitude to illness, periods of employment, associated morbidity, treatments, beliefs about cause, comorbid psychiatric symptoms. Management (see the beginning of this chapter for more details). It is important to recognize and treat occult comorbid depression. It is often helpful to adopt an a theoretical approach: ‗let‘s see what works‘, and to resist pressure for ‗all or nothing‘ cure or a move to investigation by another specialty. Opiates are not generally effective in chronic pain of this type and add the risk of dependence. Psychological treatments: these are directed towards enabling the patient to manage and ‗live with‘ the pain, rather than aspiring to eliminate it completely; can include relaxation training, biofeedback, hypnosis, group work, CBT. Pain clinics: these are generally anaesthetist-led with variable psychiatric provision. They offer a range of physical treatments such as: antidepressants, TENS, anti-convulsants, and local or regional nerve- blocks. Mental Disorders due to General Medical Conditions All psychiatric illnesses are by their nature organic—that is, they involve abnormalities of normal brain structure or function. The term ‗organic illness‘ in modern psychiatric classification, however, refers to those conditions with demonstrable effects in CNS function, either due to primary CNS pathology (e.g. temporal lobe seizures; CVA; TBI; MS) or the indirect effects of systemic illness over CNS physiology (e.g. electrolyte disturbances; inflammatory cytokines; steroid induced psychosis; pain). Substance misuse related organic disorders are discussed in the substance misuse chapter. Specific Diagnostic criteria for Mental Disorder due to a general medical condition can be found in the DSM IV-TR. The reader is encouraged to review these criteria. This section briefly discusses common traumatic, inflammatory, degenerative, infective, and metabolic conditions that may manifest as mental disorders. Many psychiatric symptoms and disorders can have an organic etiology. For this reason, every patient who presents with psychiatric symptomatology requires a thorough history, review of systems and physical examination, including neurological examination. Laboratory investigations should follow as guided by findings in physical and neurological examination and clinical history. Mental health patients have been identified as an at-risk population and general physical health status can have significant effects over the course and presentation of primary psychiatric disorders. Acute exacerbation of otherwise stable or treatment refractory psychiatric patients should also prompt the clinician for examination of possible systemic illness. Clinicians, particularly the psychiatric consultant, should strive for thorough BioPsychoSocial diagnostic and treatment formulations. Below are listed common organic causes of psychiatric syndromes (delirium, dementia, and amnestic disorders are discussed later): Organic causes of depression Neurological (CVA; epilepsy; Parkinson‘s disease; brain tumor; dementia; MS; Huntington‘s disease; head injury) Infectious (HIV and related opportunistic infections; EBV/CMV infectious mononucleosis; Lyme) Endocrine and metabolic (hypothyroidism; hyperprolactenemia; Cushing‘s; Addison‘s disease; parathyroid disease; vitamin deficiencies) Cardiac disease (MI; cardiac bypass surgery; CHF) Systemic Lupus Erythematosus, Rheumatoid arthritis, Cancer Medications (analgesics; antihypertensives; L-dopa; anticonvulsants; benzodiazepines antibiotics; steroids; OCP; cytotoxics; cimetidine;) Drugs of abuse (alcohol; benzodiazepines; cannabis; cocaine; opioids)/ Toxins Organic causes of mania Neurological (CVA; epilepsy; brain tumor; head injury; MS) Endocrine (hyperthyroidism; ;steroid producing tumors;) Medications (steroids; antidepressants; INH; cytotoxics) Drugs of abuse (cannabis; cocaine; amphetamines)/ Toxins Organic causes of anxiety Neurological (epilepsy; dementia; head injury; CVA; brain tumor; MS; Parkinson‘s disease) Pulmonary (COPD) Cardiac (arrhythmias; CHF; angina; mitral valve prolapse) Hyperthyroidism; Hypoglycemia; Metabolic acidosis/alkalosis; pheochromocytoma Medications (antidepressants; antihypertensives; antiarrythmics (e.g. adenosine), flumazenil) Drugs of abuse (alcohol; benzodiazepines; caffeine; cannabis; cocaine; LSD; ecstasy; amphetamines) Organic causes of psychosis Neurological (epilepsy; head injury; brain tumor; dementia; encephalitis e.g. HSV, HIV; neurosyphilis; brain abscess; CVA) Endocrine (hyper/hypothyroidism; Cushing‘s; hyperparathyroidism; Addison‘s disease) Metabolic (uremia; electrolyte disturbance; porphyria) SLE (‗lupus psychosis‘) Medications (steroids; L-dopa; INH; anticholinergics; antihypertensives; anticonvulsants; stimulants) Drugs of abuse (cocaine; LSD; cannabis; PCP; amphetamines; opioids) Toxins (i.e. organophosphates; heavy metals) Organic Causes of Catatonia - Neurological (neoplasm, CVA, encephalitis, dementia, Parkinson‘s) - Metabolic (hypokalemia; hypercalcemia; homocystinuria; hepatic encephalopathy) - Medications (e.g. neuropleptics; depolarizing agents) Organic Causes of Personality Change - Neurological (Frontal Lobe or Right hemispheric lesions; Huntington‘s; epilepsy; encephalitis; prion disease; dementia) - Metabolic (Thyroid disease; hypoglycemia; adrenal disease) - Systemic Lupus Erythematosus - Medications (steroids; antidepressants; mood stabilizers; neuroleptics and atypical antipsychotics; stimulants) - Drugs of abuse Acute Confusional States (Delirium) Key Features A stereotyped response of the brain to a variety of insults, very commonly seen in hospital inpatients. It is a clinical syndrome of fluctuating global cognitive impairment associated with behavioral abnormalities. Like other acute organ failures it is more common in those with chronic impairment of that organ. Epidemiology Extremely common in medical and surgical inpatients (10–20%). Risk Factors include: extremes of age; pre-existing dementia; sensory impairment; stroke; mental illness; metabolic abnormalities burn victims and multiple trauma; serious physical illness; perioperative period (especially cardiac); emergency procedures and prolonged operations; polypharmacy; alcohol and benzodiazepine dependence. Carries significant morbidity and mortality and others and is associated with prolonged lengths of stay. Clinical features Impaired level of consciousness with reduced ability to direct, sustain, and shift attention. Global impairment of cognition with disorientation, and impairment of recent memory and abstract thinking. Disturbance in sleep/wake cycle; excessive dreaming with persistence of experience during wakefulness. Psychomotor disturbances including agitation or hypoactivity. Emotional lability. Perceptual distortions, illusions, and hallucinations—characteristically visual. Speech may be rambling, incoherent, and thought disordered. There may be poorly developed paranoid delusions. Most commonly: Onset of clinical features is rapid with fluctuations in severity over minutes and hours (even back to apparent normality). Differential diagnosis Mood disorder; psychotic illness (new major mental disorder very much less likely than delirium in a hospitalized patient, particularly if elderly); post-ictal; dementia (characteristically has insidious onset with stable course and clear consciousness—clarify functional level prior to admission). Pick‘s Disease (acute onset rapidly deteriorating dementia); acute intoxication. Etiology is typically multi-factorial and the most likely cause varies with the clinical setting in which the patient presents. Theorized that multiple etiologies lead to final common neuronal pathway affecting cholinergic and dopaminergic systems in the prefrontal, non-dominant parietal and fusiform cortex and anterior thalami. Common Etiologies of Delirium: Intracranial: CVA (especially RMC a. territory); traumatic head injury; encephalitis; primary or metastatic tumor; raised ICP. Metabolic: Hypoxia; dehydration; anemia; electrolyte disturbance; hepatic encephalopathy; uremia; cardiac failure; hypothermia. Endocrine: Pituitary, thyroid, parathyroid or adrenal diseases; hypoglycemia; diabetes mellitus; vitamin deficiencies (thiamine, B12, folate, nicotinic acid). Infectious: UTI; chest infection; abscess; cellulitis; bacteremia. Substance intoxication or withdrawal Alcohol; benzodiazepines; anticholinergics; psychotropics; lithium; antihypertensives; diuretics; anticonvulsants; digoxin; steroids; NSAIDs. Pain; Others: Fecal impaction; restrains or immobility Course and prognosis: Delirium usually has a sudden onset, usually lasts less than 1 week, and resolves quickly once the medical etiology is resolved. There is often patchy amnesia for the period of delirium but patients can be aware of the experience. Associated with medical treatment challenge and high mortality (estimated to be up to 50% at 1 yr). Causes significant disruption of therapeutic milieu in hospital units. Assessment: Delirium is a Medical Emergency - Attend promptly. Review time-course of condition with nursing and medical staff and review notes including medication administration records and available laboratory data. Assess medical history and history of present illness for pre-morbid functional level and concomitant risk factors. EEG may be useful if diagnosis is in doubt. Diffuse slowing of background activity common to most causes of delirium Low voltage fast activity seen in alcohol and benzodiazepine withdrawal Other patterns may be indicative of other process (non convulsive status, acute confusional migraine). Management Identify and treat precipitating cause. Prevent complications and support functional needs. In most cases symptomatic management with pharmacological (e.g. neuroleptics) and environmental measures (e.g. stimulus modification, reassurance) should not be delayed by investigations of main etiology. Asses for adequacy of pain control. Provide education and support to staff. Avoid sedation unless severely agitated or necessary to minimize risk to patient or to facilitate investigation/treatment. Consider use of benzodiazepines early in the course of suspected alcohol or benzodiazepine withdrawal syndrome. Regular clinical review and follow-up (MMSE useful in daily monitoring cognitive improvement at follow-up). Psychiatric Issues in the Chronically Ill According to the Centers for Disease Control ―Chronic diseases‖—such as heart disease, cancer, and diabetes—are the leading causes of death and disability in the United States. These diseases account for 7 of every 10 deaths and affect the quality of life of 90 million Americans.‖ Advances in medical sciences and overall improvements in nutrition, public health and social services have increased life expectancy in the general population as well as survivability in patients with chronic ―organic‖ disease. This has in turn challenged health service organizations and individual clinicians to adequately assess and intervene in the myriad of biological, psychological and social needs of the chronically ill population. Psychiatric Comorbidity In-patient based studies have found no significant increased prevalence of psychiatric comorbidities in chronically vs. acutely ill patients, with the presence of life threatening illness being the major factor affecting the prevalence of concomitant psychiatric disease. In contrast, population and Family Medicine practice based studies have found higher rates of depression, anxiety and other psychiatric comorbidities in chronically ill patients when compared to the general population. The presence of mood and other mental disorders in medically ill patients is well recognized as a significant factor leading to increased health care resource utilization and is associated with lower scores in multiple quality of life measurements. Pediatric Population The clinician working with pediatric populations faces additional challenges in assessing and intervening in a child with chronic illness and the impact that it may have on the patient and her caretakers. Biological factors in children include, but are not limited to, increased sensitivity to medication side effects/polypharmacy and limited information on drug metabolism of most psychotropics. Illness specific risk factors to be assessed in the process of psychosocial diagnostic and therapeutic formulation include: Formulation of Risk Factors for Chronic Illness Onset: specific vulnerabilities based on developmental stage (e.g. 6 mo – 5yrs; early adolescence) Etiology: environmental exposure or inherited genes – provide specific stressors on family (i.e. rational responsibility vs. guilt) Diagnosis: uncertainty of diagnosis or misdiagnosis negatively affects the family/ medical provider relationship. Deformity: (including chronic pain), negatively affects development Disability: of self image, social and financial supports and achievement of socio-cognitive developmental tasks. MR population carries higher risk of abuse and neglect. Prognosis: negative prognosis carries greater risk to adaptive emotional development. MH provider may assist patient, families and other medical providers in copping with realistic expectations Multiple or frequent hospitalizations can also increase the risk of a negative impact on a child and his family. Other dynamic factors to be considered during clinical assessment and intervention strategies include: sociocultural context of hospitalizations and significance of illness, parents/family adaptive abilities and support systems, and the child‘s developmental capabilities to cope with illness. Specific Illnesses The reader is referred to published texts on child and adolescent psychiatry for a more comprehensive discussion, including specific issues in target populations such as Cystic Fibrosis, Insulin Dependent Diabetes, Epilepsy/CNS disorder, and Oncology. The reader is also referred to this book‘s section on psychiatry in the terminally ill/ end of life care, and on the practice of psychiatry in a hospital setting for other useful information. End-of-Life Care Psychiatry has an important role to play in assuring excellent care of terminally ill patients. Rates of anxiety and depression are high both in terminal patients and their families. In addition to treating these symptoms, psychiatrists may be called on to help balance potential delirium resulting from pain meds and other palliative treatments. This section covers issues faced by CL psychiatrists in examining and treating dying patients, including personal, diagnostic, and therapeutic challenges. Personal Issues for the CL Psychiatrist As psychiatrists, we are privileged to share intimate moments with our patients, including helping them to cope with the powerful emotions experienced during the last phases of life. CL psychiatrists can use their interview skills to help the patient express their understanding of their illness, their preference regarding whether to pursue aggressive medical treatment, and their fears and concerns about death. We can also help patients and their families to conduct ―life-reviews‖ to help understand what the patients have valued in their life, and to help the patient determine their goals and wishes at this stage. This process not only elicits powerful emotions from patients, but from ourselves and other members of the health-care team. Many of us have a strong instinct to ―fix the problem‖, and are uncomfortable with accepting the inevitability of death. Pay attention to your own emotions and beliefs, and don‘t hesitate to talk with other mental health professionals and staff who routinely work in palliative care in order to stave off feelings of failure or despair. Being with patients through this intense time will often feel rewarding, particularly if you help the patient to feel they have been heard and suffering has been kept to a minimum. Diagnostic Issues and Barriers to Care Despite the high rate of psychiatric symptoms in hospitalized patients, particularly in terminal patients, psychiatrists remain under-utilized as part of palliative care. This likely stems from a number of issues, including a sense that the patient‘s emotional symptoms are ―understandable‖ and therefore, not treatable; the desire not to ―stigmatize‖ an otherwise psychiatrically healthy patient; and the difficulty in distinguishing somatic symptoms of depression and anxiety from physical symptoms of advanced disease. Diagnosis and Treatment? As discussed earlier in this chapter, one of the challenges in CL psychiatry is to determine whether to diagnose and treat depression and anxiety when some or all of the symptoms can be confounded by their medical condition. These include but are not limited to symptoms such as fatigue, sleep and appetite disturbance, and poor concentration. The primary diagnostic approaches are to use either an inclusive approach (counting symptoms even if they overlap with medical symptoms), an exclusive approach (using only symptoms which are relatively specific for depression), or a substitutive approach (adding relatively specific symptoms such as tearfulness, hopelessness, and social isolation to help determine whether the patient requires treatment). In general, we have advocated for a substitutive approach; however, even these symptoms can be difficult to assess in dying patients. Feelings of hopelessness Terminal patients may feel ―hopeless.‖ They may choose not to interact with certain family or friends because it is fatiguing or they don‘t wish to be remembered as ill or weak. Activities that previously gave the patient pleasure may be impossible or feel frivolous. We would therefore suggest that a symptom-based, relatively inclusive approach be utilized in terminal patients, with an emphasis on relieving suffering. Particular attention needs to be given to the issue of suicide, as a desire for death may be one of the strongest indicators of depression and unrelieved suffering. Rates of suicide are high in terminal patients. It is important, however, not to interpret all thoughts of death and dying as ―suicidal.‖ Most terminal patients have thoughts that they might be better off dead if they get to a point where they are in unremitting pain or they have no ―quality of life.‖ Treatment Strategies Treatment goals for psychiatric disorders in terminally ill patients are relatively focused on relieving distress, with less emphasis on achieving remission. As in other psychiatric populations, choice of antidepressant medication is frequently guided by side-effect profiles and potential drug interaction. For example, patients with cachexia and sleep disturbance may receive mirtazapine because of its efficacy in improving those symptoms. In addition, given the relative time pressure of treating terminal patients, antidepressants may be combined with psychostimulants in patients with anergia, amotivation, or anhedonia. Anxiety symptoms are frequently treated with antidepressants and benzodiazepines; however, narcotics and neuroleptics may play a greater role in reducing anxiety in patients with dyspnea or severe pain. In all cases, attention needs to be paid to balancing the need to reduce distress and/or pain against potential cognitive deterioration or suppression of respiratory drive that may be caused by the treatment itself. Delirium Delirium is also frequently seen in terminally ill patients. Whereas the primary approach for most delirious patients is to identify and treat the underlying cause, this may not be a reasonable goal in severely ill patients where the disease causes direct CNS effects, or pain relief will require some loss of cognitive clarity. Both pharmacologic and behavioral interventions may be useful to minimize the distress caused by their confusion. Medication strategies are similar to those with other cases of delirium (see earlier section in this chapter), with a greater emphasis on prophylactic treatment with neuroleptics/antipsychotics to decrease agitation and possibly confusion. Behavioral measures may include: decreasing stimulation such as excessive noise and lights which may confuse patients and increase paranoia; asking family members to be present when possible to provide reassurance and comfort; decreasing the emphasis on frequent reorientation and cognitive testing; and informing patients of blood draws and other care before it occurs. Summary It may be human nature avoid talking about death and dying, and we may find difficulty in caring for terminal patients. It reminds us of our own mortality, and we may feel uncomfortable treating someone when there appears to be nothing to ―fix.‖ Although challenging personally, diagnostically, and therapeutically, psychiatric care of terminal patients can be extremely rewarding for the treatment team, patients and families.
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