Sutarta, I. Putu Candra S.
Ardani, I. Gusti Ayu I.
Aryani, Luh Nyoman A.
Windiani, I. Gusti Ayu T.
Adnyana, I. Gusti Ngurah S.
Psychological and Behavioral Factors Associated with Cyclic Vomiting Syndrome: Case Report.
Open Access Macedonian Journal of Medical Sciences,
Psychosomatic medicine or consultation-liaison psychiatry is the branch of psychiatry that focuses on the mental health issues which accompany, or develop as a result of, other medical disorders. This subdiscipline forms an important part of training in psychiatry. This book provides an ideal first exposure to the inseparable nature of physical and psychological health and illness, and a comprehensive introduction to the broad range of disorders seen on the psychiatric consult service. Organized into a series of bitesized chapters, each focusing on a typical consult question, this handbook provides a practical and portable reference which should set both strategy and tactics for the next generation of consulting psychiatrists. Essential reading for medical students, psychiatry residents and psychosomatic fellows, this manual will provide immediate, in-the-field guidance on the evaluation and management of common consultation requests.
'… an excellent entry-level text for students, postgraduate trainees and many other professionals.'
Source: The British Journal of Psychiatry
'… accomplishes the goal of presenting and explaining noteworthy topics in caring for medically and psychiatrically ill patients. … would benefit clinicians in all specialities.'
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Consultation psychiatrists are skilled clinicians and expert liaisons in the general hospital setting. Clear communication improves the process of the consultation as well as the result, by ensuring accurate, timely, and helpful interventions. The first steps in the consultation process include the institutional and personal organization, consulting individual, patient, consult question and acuteness of the consult. Medications can be the cause and cure formyriad psychiatric issues. Identifying unnecessary and/or psychiatrically offensive medications is a significant part of consultation psychiatry. Anticholinergic medications, benzodiazepines, and narcotics are particularly deliriogenic in the medically ill or debilitated. Interventions other than medications can be helpful as well, including reorienting and reassuring the patient as needed, providing necessary assistive devices (including hearing aids and eyeglasses), using interpretive services when needed, explaining procedures and communicating clearly with the patient, and having family meetings.
Physicians make at least an informal decision on a continual basis regarding the patient's ability to give informed consent. The difference between competency and capacity is a common misconception, and the terms, competency and capacity, are often used interchangeably in consult requests. Capacity is often considered an all-or-none phenomenon, and this may be the most common fallacy. The most common diagnoses which prompt request for capacity evaluation include dementia and delirium. Other diagnoses include substance abuse, affective disorders, personality factors, and psychotic disorders. Some states have laws which limit the ability to give consent to medical treatment for certain groups of patients. For instance, patients who are involuntarily committed for mental illness in Louisiana may not give consent for major surgery without a court order. Denial, a defense mechanism utilized to avoid unpleasant effects by denying aspects of reality, can be helpful for patients in some cases.
It is important to remember that medical illness and hospitalization can be very stressful, even for the most well adjusted individuals. Under stressful situations, individuals may regress and display personality styles inconsistent with their typical behavior, or may display extremes of typical behavior. Classically, coping has been defined as how an individual manages and attempts to alter a stressful situation. Whereas coping styles are primarily consciously applied behavioral actions, defense mechanisms are largely unconscious, psychological processes used by patients to deal with reality and to maintain self-image. Classically, countertransference was explained as reactions to a patient that represent the past life experiences of the clinician. Although it is not obvious, passive aggression and idealization are very common in dependent clingers. Despite limited evidence for the use of psychotropic medications in personality disorders, they still can have some benefit.
Most psychotropics are highly protein bound and are influenced by fluctuations in protein levels. Specific drug-binding proteins include albumin and globulin, which generally bind to acidic (e.g. valproic acid) and basic (e.g. tricyclic antidepressant) psychotropic drugs, respectively. Although anticonvulsants are used in psychiatry for stabilization of bipolar disorder, alcohol withdrawal, and aggression, medically ill patients may also receive these drugs during treatment for epilepsy, neuropathic pain, and migraines. Lithium has multiple systemic effects and can precipitate or exacerbate underlying medical illness. Antidepressant use within the psychiatric setting has greatly expanded to include treatment of eating disorders, premenstrual dysphoric disorder, chronic aggression and impulsivity, and impulse control disorders. The serotonin antagonist reuptake inhibitor (SARI) trazodone is commonly used for sleep because of sedating properties. Antipsychotics are also used at times as antinauseants and for the treatment of refractory hiccups. Psychostimulants improve depression and fatigue in the medically ill.
The components of a suicide risk assessment should be easy to remember, be based on empirically demonstrable essential features, be readily transferable from emergency room or intensive care unit to consulting room, foster a therapeutic alliance, facilitate the gathering of valid information, and guide treatment decisions. Often after a serious suicide attempt, the patient suffers from medical complications while at the same time needing intensive psychiatric evaluation and treatment. Medical-psychiatry units (MPUs) can fill this gap in care for those with combined, complex medical and psychiatric illness. It is very important to restrain other physicians from automatically prescribing antidepressants for every medically ill patient who expresses a wish to die, which tends to pathologize normal grieving and leads to the overuse of psychotropic drugs. No empirical evidence has been found to support no-suicide or no-harm contracts; these contracts do not prevent suicides, nor do they protect one against malpractice lawsuits.
To manage the agitated patient, it's critical to understand the origin of the behavior. This doesn't mean theorizing about the neurobiological underpinnings. Offering to inject the patient with an antipsychotic would not usually be welcomed as a first intervention. No specific medication is approved by the FDA for control of agitation and combative behavior. Droperidol is another very effective agent, although recent FDA black box warnings about the risk for cardiac arrhythmias and case reports of sudden death reported with its use have led to greater caution. Antipsychotics often provide non-specific but effective control of violent behavior regardless of its cause. Haloperidol is the most studied agent. Agitation of delirium is generally responsive to monotherapy with antipsychotics, and haloperidol is the agent with which physicians have the most experience and for which efficacy is best supported by the medical literature.
The timing of events often provides the best clues to the cause of the delirium. Alteration in consciousness is the sine qua non of delirium and is best measured by testing attention. The Glasgow Coma Scale, as modified for the Acute Physiology and Chronic Health Evaluation (APACHE) III study, formally rates consciousness. The Folstein Mini-Mental State Examination (MMSE) is a helpful tool that tests orientation, attention, memory, language, comprehension, and construction. The primary, definitive treatment of delirium is reversal of its underlying cause(s), while dopamine blockade is adjunctive. As a disturbance of consciousness with cognitive, affective, and behavioral manifestations, delirium, put simply, is acute brain failure. Use of dopamine antagonists is adjunctive; haloperidol remains the treatment of choice for fulminant delirium with agitation. Resolution of the delirious state often lags behind reversal of the causative medical or surgical problem.
Some familial preponderance with somatization disorder has been found in 10% to 20% of first-degree female relatives. An increased incidence of alcohol abuse, antisocial personality disorder, and depression has been reported in first-degree male relatives. The differential diagnosis includes anxiety disorders, factitious disorder, malingering, mood disorders, multi-system medical disorders, schizophrenia with somatic delusions, and other somatoform disorders. Cognitive-behavioral therapy (CBT) reduces disability, physical symptoms, and psychological distress for both somatoform disorders and medically unexplained physical symptoms. Caution is prudent in making this diagnosis as many organic disorders may present in a similar fashion to conversion disorders. Hypochondriasis (HC) is the misinterpretation of benign symptoms resulting in preoccupation with having a serious disease. Patients with body dysmorphic disorder (BDD) are thought to be fearful of negative appraisals from others, because of a bias for misinterpreting facial expressions as negative.
The cause of factitious disorder is a matter of speculation. Risk factors are thought to include histories of child abuse, childhood hospitalizations that may have been attempts to escape abusive and chaotic families and households, and parental rejection or over-reaction to illness. Patients with factitious disorder can self-induce illness in ways that result in severe disfigurement or death, often from unnecessary medical interventions. Presentations of factitious disorder and its most severe variant, often called Munchausen's syndrome, can range from completely fabricating a medical (or psychiatric) illness, to aggravating or exaggerating symptoms, to simulating an illness, such as by mimicking a generalized seizure episode or by inducing one. Most authors do not discuss treatment for malingering because it is not considered a mental illness. However, some authors emphasize the importance of letting the malingerer save face while giving up the sick role. Recovery, not confession, is often the most realistic goal.
This chapter discusses cortical dementias that include Alzheimer's disease, fronto-temporal dementia and dementia with Lewy bodies, subcortical dementias that include Parkinson's disease and Huntington's disease, and mixed dementias that include vascular dementia. Deficits characteristic of both cortical and subcortical dementias, depending on the location and extent of cerebrovascular lesions, may occur. Numerous neuropsychiatric sequelae are associated with traumatic brain injury (TBI), making it difficult to identify a well-defined syndrome. Thorough psychiatric and medical histories are critical in diagnosing patients who present with agitation and cognitive changes. Laboratory and neuroimaging studies are of variable utility in evaluating for reversible causes of altered mental status. A number of medications have been studied for their effects on dementia-related agitation. The most common categories include antipsychotics, antiepileptic medications, antidepressants, and cognitive enhancers. Controlled studies on pharmacologic treatment for agitation in Huntington's disease are rare.
The American Heart Association and others have recommended screening for depression among those with cardiovascular disease (CVD). It has been further suggested that this screening should occur at least quarterly. In addition to an appropriate and targeted work-up for CVD, patients should be screened for conditions related to depression and heart disease, such as sleep apnea. Once the diagnosis of depression has been made, a variety of treatment options are available. These include antidepressants, psychotherapy, and exercise. Relaxation and stress management approaches also may be of benefit. Beta-blockers do not cause depression and should not be avoided in patients with depression and CVD. Although case reports have documented a number of psychiatric adverse effects of hydroxymethylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors or statins, such effects have not been reported in systematic studies. Use of statins does not appear to increase risk of suicide.
Practice guidelines for the care of post-stroke patients clearly state that all patients must be assessed for the presence of depression. However, several factors can complicate the diagnosis of depression following stroke: first, language disorders due to decreased level of consciousness or fluent (Wernicke's) aphasia with comprehension deficit. Although the pathogenesis of post-stroke depression (PSD) remains unknown, a biopsychosocial approach to treatment is probably the most appropriate. The physical treatments include antidepressants and electroconvulsive therapy. Most studies have failed to find a difference in recovery when comparing patients given antidepressants versus those given placebo. Six studies have found that patients with post-stroke depression have increased mortality compared with non-depressed stroke patients. As PSD has been associated with impaired recovery and increased mortality, consideration of a preventive intervention among non-depressed patients should be discussed with the patient, the family, and the treating physician.
The first step in treating a patient with Parkinson's disease (PD) and psychiatric symptoms is ensuring that the patient actually has PD. No disease-modifying treatments or neuroprotective drugs exist for PD. Treatments include levodopa; dopamine agonists such as pramipexole, ropinirole, and apomorphine; monoamine oxidase inhibitors such as seligiline and rasagaline; and glutamatergic antagonists such as amantadine. Psychiatric symptoms are highly prevalent in PD, but are often unrecognized and undertreated, and are easily missed if not specifically investigated. Psychotherapy is evidence based treatment for many idiopathic psychiatric disorders, and does not cause side effects or worsen motor symptoms. The specific psychiatric disorders in Parkinson's disease are: mood disorders, anxiety disorders, psychotic disorders and cognitive disorders. The other psychiatric symptoms in Parkinson's disease are: delirium, sleep disorders, and sexual disorders.
The most common causes of traumatic brain injury (TBI) are motor vehicle accidents, falls, violence, and sports and recreational activities. Severity of head injury can be determined on the basis of any combination of the following: initial Glasgow Coma Scale (GCS), the duration of loss of consciousness (LOC), and the duration of post traumatic amnesia (PTA). The underlying etio-pathogenesis of post-TBI depression is most likely multi-factorial and most likely involves biopsychosocial factors. This chapter lists out the risk factors for post-TBI depression. Several psychiatric syndromes have been reported in individuals with TBI. These include disturbances of mood, cognition, personality, and behavior. Accurate diagnosis of post-TBI major depression is arduous because a number of symptoms of major depression, particularly the neuropsychiatric symptoms, are directly related to the brain injury itself. The approach to management may follow a biopsychosocial model involving pharmacotherapy, psychotherapy, education, and support for caregivers or family members.
A seizure may be an acute symptomatic or unprovoked event. Acute symptomatic seizures have a cause such as brain trauma, infection, or drug withdrawal. The disorders in people with epilepsy (PWE) are: psychiatric disorders, depressive disorders, bipolar disorders, anxiety disorders, and cognitive disorders. Psychiatric disorders in PWE are best managed by avoiding the ictus altogether. Although antiepileptic drug (AED) decision-making should be guided by a neurologist, it is important to understand basic treatment strategies along with the potential for rash and fetal malformations. Experts agree that monotherapy is the treatment of first choice for partial and generalized epilepsies. If the first AED fails, neurologists prescribe monotherapy with a second AED. Valproic acid use increases the risk of major malformations and should be avoided during the first trimester. The indications for psychotropic use in someone with epilepsy are the same as in the general population.