Acute confusional state delirium by mikesanye

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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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