Download Psychiatry and Medicine

Psychiatry
and
medicine
Introduction.
• Thousands years ago, people of Mesopotamia ( the land of
two rivers ) used to treat their patients with magic,
chemicals extracted from herbs, if no help by prayers &
begging for cure from “ Gods”.
• They used to have many Gods ; God of medicine ( Nunasu ) , God of knowledge ( Nun-Keseda who was
represented by as a stick & snake.
• They use to differentiate between the magician ( Aspu ) &
the doctor ( Asu ).
• Many prescriptions were found in the ruins of the Iraqi
civilization,written on bars of clay in old Iraqi script (
cuneiform writing of Sumer ).
Introduction ( cont.)
• Abn-sina, during Abbasian times, was the first to describe
the effect of psyche on the body ( what is known as
psychosomatic now a day ) in the case of young man who
was emaciated because he couldn't marry the girl he loved,
by monitoring his pulse while mentioning special places in
the town, the pulse, he noticed, increased while
approaching the house of his love due to the emotion it
stirred.
• Al-razi said that doctors must always persuade patients that
they would be cured from their sufferings.
.‫• على الطبيب أن يوهم المريض دائما بالشفاء‬
Psychiatry and Medicine
• Physical & psychiatric symptoms occur
commonly together in patients who consult
doctors.
• Psychiatric disorder often presents with
physical complaints.
• Psychological symptoms are a frequent
consequence of acute & chronic organic illness.
• At least a quarter of patients with physical
complaints can be diagnosed as suffering from
psychiatric disorder.
Associations between physical
and psychiatric disorder.
• Chance association: physical & psychiatric disorders are
both common.
• Psychological factors as a cause of physical disorder.
• Psychiatric complications of physical illness & its
treatment ( e.g. heart disease, delirium & dementia ).
• Some psychiatric disorders can cause physical symptoms (
e.g. palpitation in an anxiety disorder ).
• Physical complications of psychiatric disorder ( e.g.
deliberate self- harm, eating disorders ).
Epidemiology
• Unexplained physical symptoms are among the commonest reasons
for seeking treatment & are often due to psychiatric disorder.
• Psychological problems are especially frequent in accident &
emergency ,gynaecological & medical out-patient clinics, medical &
geriatric wards.
• Affective disorders are common in younger women, organic mental
disorders in the elderly & drinking problems in young men.
• About a quarter of patients in medical wards have a psychiatric
disorder of some kind..
• 15% of o.p. with definite medical diagnosis have an associated
psychiatric disorder.
• 40% of those with no medical diagnosis have a psychiatric disorder.
Psychological complications of
physical illness.
• Most people are resilient when ill and carry on without
undue distress.
• About a quarter of cases may have substantial
psychological impact.
• Disturbances of mental state, which may be severe enough
to be classified as psychiatric disorder.
• Impaired quality of life.
• Unnecessarily poor physical outcome.
• Adverse effects on family and others.
• Inappropriate or excessive consultation.
• Poor compliance with treatment.
•Common psychiatric disorders in the physically ill
• More common ( adjustment, depressive, anxiety disorders & delirium).
• Less common ( somatoform disorders, dementia, panic & phobic
disorder, p.t.s.d.,mania, schizophrenia & delusional disorders.
• The usual reaction to acute illness ( anxiety, depression, delirium &
complete or partial denial of the diagnosis ).
• In disabling chronic illness ( adjustment, anxiety & depressive
disorders ).
• Major medical & surgical treatments are also important causes of
psychological symptoms.
• Drug treatment ( depression, delirium, psychotic symptoms & elation).
• Chemotherapy of cancer ( cause very great distress ).
• Radiotherapy ( anxiety & depression ).
• Surgical treatment ( anxiety before & after operation ).
Medications reported to cause depression.
• Cardiovascular drugs ( Alpha-methyldopa, Reserpin,
Propranolol, Guanithidine, Clonidine, Thiazide diuretics,
Digitalis).
• Hormones ( Oral contraceptives, A.C.T.H., Anabolic
steroids ).
• Psychotropics ( Benzodiazepines, Neurotropics ).
• Anticancer drugs ( Cyclserine ).
• Anti-inflammatory ( NSAIDs ).
• Anti-infective agents ( Ethambutol, Sulfonamides ).
• Others ( Cocaine withdrawal, Amphetamines, L-dopa,
Cimetidine, Rantidine, Disulfiram, Metoclopramide ).
Medication reported to cause
other psychiatric symptoms.
• Delirium ( CNS depressants, Digoxin,
Cimetidine & Anti-cholinergic drugs ).
• Psychotic symptoms Hallucinogenic drugs,
Appetite suppressants, Sympathomimetic
drugs & Corticosteroids ).
• Elation ( Anti-depressants, Corticosteroids,
Izoniazide & Anti- cholinergic drugs ).
Determinants of the psychological impact
of physical illness.
• Most anxiety & depression following physical illness is part of a
psychological reaction.
• Several medical disorders also cause anxiety & depressive symptoms
directly ( Parkinson’s disease, stroke, infections, endocrine disorders &
malignancy).
• Illness factors ( pain, threat to life, course, duration & disability).
• Treatment factors ( side effects, uncertainty of outcome & self-care
demands ).
• Patients factors ( psychological vulnerability, social circumstances,
other stresses & reactions of others ).
• Factors associated with high risk of psychiatric problems include
( severity of illness, unpleasant treatment & vulnerable patients ).
Psychiatric assessment of a physically ill patient.
• Psychiatric assessment is similar to that of psychiatric
patient except that it requires knowledge of the nature and
prognosis of the physical illness.
• Screening questions for psychiatric symptoms ( e.g. have
you been very worried about your health? How have you
been sleeping? Etc.).
• Screening questions about the psychiatric history.
• Screening question about social factors.
• Observation of the patient ( mood & behaviour during the
interview ).
• If emotional disorder is suspected , take a full psychiatric
history.
Management
• Some emotional distress is an almost inevitable
accompaniment of the stress of physical illness & its
treatment, it can be often reduced by appropriate treatment.
Advice, explanation & discussion.
• Treatment of any specific psychiatric disorder is similar to
that of physically healthy person, particular attention
should be paid to the side effect of the psychotropic drugs.
• Adjustment disorder needs further opportunity for problem
solving & follow-up.
• Anxiety disorder, brief treatment with a benzodiazepine
can be helpful.
• Depressive disorder can be helped by support or problemsolving counselling, but more severe requires
antidepressant medication.
Psychological problem associated with
cancer
• The doctor needs to set aside adequate time to explain the
prognosis and what treatment can be offered
• Emotional reaction on diagnosis or recurrence is
manifested by severe distress in the form of an adjustment
disorder or, in over a third of patients, a psychiatric
disorder ( anxiety & depression ).
• Emotional reactions to surgery, radiotherapy, or
chemotherapy.
• Anticipatory nausea with chemotherapy.
• Organic mental disorder due to metastasis, metabolic
changes, or chemotherapy.
• Neuropsychiatric syndrome.
• Depressive & other reactions to terminal illness.
Psychological problem associated with
accidents & trauma.
• Psychological factors are important contributory causes of
accidents ( e.g. overactivity & conduct disorder in children,
alcohol & drug abuse in young adults, and organic mental
disorders in the elderly.
• Following accidents, anxiety & depressive symptoms are
common especially when there is injury to the head.
• Some road accident victims develop phobic travel anxiety
or, less frequently PTSD.
• Compensation neurosis ( or accident neurosis ) has been
used for physical or mental symptoms caused
psychologically and occurring when there is an unsettled
claim for compensation.
• Prolonging the disability.
Psychological problems associated with
myocardial infarction
• The sudden onset of severe chest pain frequently causes anxiety.
• In severe infarcts, delirium is frequent.
• A sizable minority of patients show denial with little distress, if denial
persist it may lead to non-compliant with treatment.
• In the weeks after an infarct patients frequently describe depressive
symptoms.
• A few patients develop a depressive illness and this is associated with
increased mortality in the ensuing month.
• Cardiac aftercare and rehabilitation concentrates on physical fitness
should take into account anxiety about physical activity, sexual
problems as well as any depressive disorder.
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Psychological problems associated
with
endocrine
disorders
Diabetes: psychiatric disorders especially eating disorder.In advanced
cases, cerebrovascular diseases, poor glycaemia control may lead to
cognitive impairment.
Hyperthyroidism: restlessness, irritability, and distractibility may
resemble an anxiety disorder. Medical treatment usually results in
improvement in the psychological symptoms.
Hypothyroidism: in infancy leads to retardation. In adult leads to
mental slowness, apathy, poor memory and occasionally organic
mental disorder or severe depression. Paranoid symptoms are common.
Early treatment usually reverse the psychiatric symptoms.
Cushing’s syndrom: depressive symptoms are frequent
Corticosteroids treatment: depression but a manic disorder is more
common.
Phaeochromocytoma: episodic attacks of anxiety with blushing,
sweating, palpitation, headache, and raised blood pressure.
Psychological problems associated
with movement disorders
• Parkinson’s disease: there is increase incidence of
dementia & depression.Anticholinergics may cause
excitement, delusions and hallucinations. Levodopa may
cause delirium.
• Spasmodic torticollis: psychological factors can increase
the symptoms, however, it is more likely to have organic
cause.
• Tics: they are more common in childhood than in
adults.more common in boys than girls. worsened by
anxiety.
• Writer’s and occupational cramps: these conditions are
thought to be psychogenic.
Some specific symptoms and
syndromes.
• Chronic fatigue syndrome.
• Chronic pain.
• Multiple chronic symptoms ( somatization
disorder ).
• Headache & atypical facial pain.
• Non-cardiac chest pain & benign palpitations.
• Irritable bowel syndrome & abdominal pain.
• Dissociative & conversion disorders. Hysteria
• Self-inflicted & simulated illness.Factitious
disorder. Malingering.
Management of unexplained
physical symptoms
• Presenting for the first time: Appropriate physical
investigations. Possible psychological causes.
• Treatment: Acknowledge reality of the
symptoms.treat any psychiatric disorder.
• Persistent symptoms: review the need for further
investigations. Take full psychiatric history.
discuss with relatives. Cognitive therapy.
• Failure to improve: physical reassessment.
consider referral to a psychiatrist or clinical
psychologist.
Management of multiple somatic
symptoms.
• Take full history & interview relatives.
• Review medical notes; discuss with doctors
currently involved.Attempt to simplify the medical
care.perform only essential investigations.
Minimize the use of psychotropic drugs.
• Arrange brief regular appointments.
• Avoid repeating reassurance about the symptoms
• Focus on coping with disability & psychosocial
problems.
• Encourage gradual return to normal activities.
Treatment of chronic pain.
• Acknowledge the reality of the symptoms.
• Explain the origin of the pain & discuss the
patient’s concern.
• Treat any cause if possible.
• Agree a regime of analgesics with the patient.
• Discuss how the patient might cope better with the
pain.
• Involve the family in the management plan.
• Consider antidepressant medication.
Psychiatric services in general hospital
• In large hospital psychiatric advice is needed from a
special consultation liaison service.
• Emergency service for patients admitted after deliberate
self-harm.
• Emergency consultation for other accident and emergency
department attenders.
• Consultation service for in-patients.
• Out-patient care for patients referred with psychiatric
complications of physical illness or functional somatic
symptoms.
• Regular liaison visits to selected medical, surgical and
gynaecological units in which psychiatric problems are
especially common ( e.g. neurology, renal dialysis,
terminal care ).
Psychiatric emergencies in general
hospital practice.
• Thorough clinical assessment, like any other
medical emergency.
• Establish a good relationship with the patient, to
take a brief history, observe behaviour, and assess
the mental state.
• When the patient’s behaviour is very disturbed, the
history may be taken from other people such as
relatives or nurses.
• Mistakes will be avoided and time saved if the
assessment is as complete as the circumstances
permit.
Acute disturbed behaviour and
violence.
• Delirium, schizophrenia, mania, agitated depression and
alcohol & drug-related problems are the most common.
• The first task is to assess the risk of violence.
• Arrange for adequate help to be available.
• The doctor should appear calm and helpful, avoid
confrontation, and try to persuade the patient to talk about
the reason for his anger.
• If the patient responds so aggressively, restrain should be
accomplished quickly by an adequate number of people.
• Help of the police may be required for patient thought to
possess any of offensive weapon.
Drug treatment of disturbed or
violent patients.
• If a patient is very frightened, and reassurance
fails, oral or parental diazepam (5-10 mg ) is
useful.
• If the patient is more disturbed, rapid calming can
usually be achieved with 2-10 mg of haloperidol
injected I.v or I.m.
• Chlpopromazine (75-150 mg. I.m. ) is more
sedating, but more likely to cause hypotension.
• Extrapyramidal side effects may require treatment
with an antiparkinsonian drug.
Psychiatric aspect of obestetrics
and gynaecology.
• Pregnancy ( unwanted pregnancy,
hyperemesis gravidarum, pseudocyesis &
couvade syndrome ).
• Loss of a fetus & stillbirth.
• Post-partum mental disorders ( maternity ‘
blues’, puerpural depression & psychosis).
• Menstrual disorders ( premenstrual
syndrome, the menopause & hysterectomy).
The impact of culture on physical
illness.
• Consultation:- with the increasing health services
available, people of the Emirates like other Arab
countries, started to attend hospital & other health
facilities seeking medical treatment. Islam
believers know that illnesses are both God
creation & God who will cure. The doctors are
intermediate, try to ease people sufferings until
cure or death.
• Interview:- Emirates like other developing
countries are keen on expressing their suffering,
but few found it difficult & may even think that
The impact of culture on physical
illness ( cont.).
• Examination:- Some found it difficult to be
exposed for examination especially so the
genitalia ‘ taboo’ . Orthodox Moslems found it
most difficult to let women be examined by male
doctor especially so in obstetric & gynecology.
• Investigations & treatment:- As far as faith in the
doctors’ ability to help, most will be copmliant
with the investigation procedure & treatment.
• Follow up:- Prefer to attend some doctors, who
appears to be empathic & understanding &
preferably of high qualifications & speaking their
The impact of culture on mental
illness.
• Consultation:- Still some patients are forced to attend faith
healers. Faith healers especially those who practice reading
Quraan have a very strong effect on believers, who believe
in the miracle of reciting verses from The holly Quraan.
Prophet Mohammed said honey & Quraan are the cure for
body & soul.
.‫• عليكم بالشفائين العسل والقران‬
• Interview:- Face some difficulties because of poor verbal
expression & poor mental health education. Arabic
speaking doctors will help to overcome these difficulties &
explain the nature of the mental illness to the patient & or
his family.
• Management:- The believes that witchcraft, evil eye &