Psych - Psychosomaticdelasalle
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+ Psychosomati c Medicine
Michelle Marie M. Marinas, M.D. Department of Psychiatry DLSHSI – College of Medicine
+ Psychological Factors Affecting Medical Condition Two
Basic Assumptions of Psychosomatic Medicine: 1. There is unity of mind and body (mind-body medicine) 2. Psychological factors must be taken into account when considering all disease states
In
DSM-IV-TR Psychological Factors Affecting Medical Conditions
+ Psychological Factors affecting Medical Condition
Physical disorders caused by emotional or psychological factors
Mental or emotional disorders caused of aggravated by physical illness
Exclusions: 1.
Classic mental d/o’s that have physical symptoms as part of the disorder (eg., Conversion Disorder)
2.
Somatization disorder
3.
Hypochondriasis
4.
Physical complaints associated with mental d/o’s
+ DSM-IV-TR Diagnostic Criteria A GMC (coded on Axis III) is present B. Psychological Factors adversely affect the GMC: 1. Factors have influenced the course of the GMC as shown by temporal association between psychological factors and development or exacerbation of, or delayed recovery from, the GMC 2. Factors interfere with treatment of GMC 3. Factors constitute additional health risks for the individual 4. Stress-related physiological responses precipitate or exacerbate symptoms of A.
+ If more than one factor is present, choose the most prominent… Mental Disorder affecting GMC
Psychological Personality
symptoms affecting GMC
traits or coping style affecting
GMC Maladaptive
health behaviors affecting GMC
Stress-related
GMC
physiological response affecting
+ STRESS THEORY
A circumstance that disturbs, or is likely to disturb, the normal physiological or psychological functioning of a person.
Walter Cannon: first systematic study on the relation of stress to disease
Harold Wolff: physiology of GI tract correlate with emotional states
Hans Selye: General adaptation syndrome (3 phases) Alarm reaction Stage of resistance Stage of exhaustion
+ Stress
Neurotransmitter Responses to Stress Activate noradrenergic systems in the brain (locus ceruleus) release catecholamines from ANS Activate serotonergic systems increased serotonin turnover
Endocrine Responses to Stress Corticotropin Releasing Factor (CRF) Acts at anterior pituitary Release of ACTH Synthesis and release of glucocorticoids (fight or flight)
+ Stress
Immune Response to Stress Inhibition of immune functioning by glucocorticoids Also, immune activation by other pathways Also, profound immune activation by release of cytokines, which increase glucocorticoid effects
Life Events Life situation or event, favorable or unfavorable, often occurring by chance, generates challenges to which the person must adequately respond Holmes and Rahe Social Readjustment Scale: 200 or more life-change units increases risk
+ Stress
Specific vs. Nonspecific Stress Factors Specific personalities and conflicts – certain psychosomatic diseases Meyer Friedman and Ray Rosenman – personality types Type A – coronary personality Type B Franz Alexander- unconscious conflicts and specific diseases Peptic ulcer – dependency needs Essential HPN – hostile impulses from which they feel guilty Asthma – separation anxiety
+ SPECIFIC ORGAN SYSTEMS Gastrointestinal System
Functional GI Disorders Anxiety can produce disturbances in GI function through central control mechanism or humoral effects (release of catecholamines) Vagus modulated by limbic system (emotions-gut pathway) Functional dysphagia, IBS, functional diarrhea
Peptic Ulcer Disease Increased gastric acid secretion associated with psychological stress Higher vulnerability to H. pylori
Ulcerative Colitis No generalizations about psychological mechanisms
+ Cardiovascular System
Associated with depression Severe depression after CABG – increased risk of death
Type A behavior pattern, anger, hostility Physiologic processes: reduced parasympathetic modulation of HR, increased circulation of catecholamines, increased coronary calcification, increased lipid levels
Stress Management
Cardiac arrhythmias and sudden cardiac death Acute emotions can stimulate arrythmias
+
Heart
Transplantation Stages of adaptation elicit anxiety, depression, etc. Mood disorders
Hypertension
Vasovagal
syncope Specific psychological triggers still unidentified
+ Respiratory System
Asthma Dependency needs Greater use of corticosteroids, longer hospitalizations Personality traits: intense fear, emotional lability, sensitivity to rejection, lack of persistence in difficult situations
Hyperventilation syndrome
Chronic Obstructive Pulmonary Disease (COPD) Panic and anxiety disorders are co-morbidities
+ Endocrine System
Hyperthyroidism Nervousness, insomnia, lability of mood, dysphoria Pressured speech Short attention span, impaired recent memory, exaggerated startle response Visual hallucinations, paranoid ideation, delirium
Hypothyroidism Depressed mood, apathy, impaired memory Auditory hallucinations and paranoia (myxedema madness)
Diabetes mellitus Dietary control - depression
+ Adrenal Disorders
Cushing’s Syndrome Adrenocortical hyperfunction from excessive secretion of ACTH or adrenal pathology (tumor) Severe depression to elation Clinical features of Cushing’s
Hypercortisolism Fatigue, depressed mood Emotional lability, irritability, decreased libido, anxiety Social withdrawal
Hyperprolactinemia Traumatic childhood experiences predispose to hyperprolactinemia Sexual dysfunctions: erectile disorder and
+ Skin Disorders
Atopic dermatitis (atopic eczema or neurodermatitis) Anxiety, depression Exacerbate atopic dermatitis by scratching behavior Depressive symptoms amplified itching behavior
Psoriasis Lead to stress, which triggers psoriasis Cosmetic disfigurement and social stigma
Psychogenic excoriation (psychogenic pruritus) Lesions caused by scratching or picking in response to an itch Resembles OCD: impulsive, ritualistic, repetitive, tension reducing
+
Localized pruritus Pruritus ani Pruritus vulvae
Hyperhidrosis States of fear, rage and tension Increased sweat secretion on the palms, soles and axillae Anxiety phenomenon mediated by the ANS
Urticaria Stressful life events and urticaria Stress – secretion of neuropeptides - vasodilation
+ Musculoskeletal system
Co-morbid psychiatric symptoms may be result of patient’s psychological response to the loss and discomfort imposed by the disease effect of disease process on CNS
Rheumatoid Arthritis – chronic musculoskeletal pain from inflammation of the joints depression
Systemic Lupus Erythematosus Recurrent episodes of destructive inflammation of several organs Highly unpredictable, incapacitating, potentially disfiguring
+
Low back pain
Excruciating pain, restricted movement, paresthesias, weakness or numbness
Accompanied by fear, panic and anxiety
Oftentimes debilitating
Fibromyalgia
Pain and stiffness of the soft tissues such as muscles, ligaments and tendons
“trigger points”: local areas of tenderness
Cervical and thoracic areas most commonly affected
Fatigue, anxiety, insomnia
Present in chronic fatigue syndrome and depressive d/o
+ Headaches
Psychological stress exacerbates headache, whether primary cause is physical or psychological
Migraine (Vascular) and Cluster Headaches Functional disturbance in cranial circulation Stress is al precipitant at times Overly controlled perfectionists, unable to suppress anger
Tension (Muscle Contraction) Headaches Emotional stress prolonged contraction of head and neck muscles constrict blood vessels Dull, aching pain, tightening band
+ Treatment
Good MD-patient relationship
Aaron Lazare’s Negotiating Strategies: 1. Direct education 2. Third party intervention 3. Exploration of options 4. Provision of sample treatment 5. Control sharing 6. Concession making 7. Empathic confrontation –”what would you do if you were in my place?” 8. Standard setting
+ Stress management and relaxation therapy
Stress management training 1. Self-observation • Daily diary format • How they respond to stress/ challenges each day • Stressful events that precipitate signs/ symptoms 2. Cognitive restructuring • awareness of maladaptive thoughts, beliefs and expectations 3. Relaxation training – hypnosis, biofeedback 4. Time management 5. Problem-solving • Applying solutions to problem situations
+ Consultation-Liaison Psychiatry
Study, practice and teaching of the relation between medical and psychiatric disorders
Psychiatrists serve as consultants to colleagues or other mental health professionals
CL psychiatrists are part of the medical team
Knowledge of psychiatric diagnosis + awareness of medical illnesses with psychiatric symptoms
Purpose of the diagnosis:
Identify mental disorders and psychological responses to physical illness
Patient’s personality features
Patient’s coping techniques
+ Common CL problems
Suicide attempt or threat
Depression
Agitation
Hallucinations
Sleep Disorder
Confusion
Noncompliance or Refusal to Consent to Procedure
No organic basis for symptoms
+ CL Psychiatry in special situations
Intensive Care Units
Hemodialysis Units
Surgical Units
Transplantation Issues
PSYCHO-ONCOLOGY
+ Medical Conditions that present with psychiatric symptoms
Hyperthyroidism – irritability, pressured speech, psychosis
Hypothyroidism - depression
Hypoglycemia – anxiety, confusion, agitation
Hyperglycemia – anxiety, agitation, delirium
Brain neoplasms – personality changes
Frontal lobe tumor – mood changes, impaired judgment
Occipital lobe tumor – aura, visual hallucinations
+
Temporal lobe tumor – olfactory hallucinations
AIDS – progressive dementia, depression, psychosis
Hyponatremia – confusion, lethargy, personality changes
Pancreatic Ca – depression, lethargy, anhedonia
Multiple sclerosis – anxiety, euphoria, mania
Hepatic encephalopathy – euphoria, disinhibition, psychosis, depression
Pheochromocytoma – anxiety
Wilson’s disease – mood disturbances, delusions, hallucinations
+ Mental Disorders due to a GMC
Delirium
Dementia
Short-term confusion and changes in cognition Four sub-categories: GMC, substance-induced, multiple causes, NOS
Impairment in memory, judgment, orientation and cognition
Amnestic Disorder
Memory impairment or forgetfulness 3 sub-categories: caused by medical condition (hypoxia) Caused by toxin or medication NOS
+ Delirium
Acute onset of fluctuating cognitive impairment and a disturbance of consciousness
Syndrome, not a disease, many causes
Hallmark symptom: impairment of consciousness, in association with global impairments of cognitive functioning
Sudden onset, brief and fluctuating course, rapid improvement when causative factor is identified
10-30% of medically ill exhibit delirium
Poor prognostic sign – high mortality rate for patients who exhibit delirium while in the hospital
+ DSM-IV-TR diagnostic criteria
Delirium due to a GMC
Substance Intoxication Delirium
Substance Withdrawal Delirium
Delirium NOS
+ Core features of Delirium
Altered consciousness – decreased level
Altered attention – diminished ability to focus, sustain or shift attention
Impairment in cognitive function – disorientation and decreased memory
Relatively rapid onset – hours to days
Brief duration – days to weeks
Marked, unpredictable fluctuations in severity
+ Course and Prognosis
Recede over 3-7 days after removal of causative factor
Some symptoms may take up to two weeks
Recall of the patient is characteristically spotty (“bad dream”)
Associated with high mortality rate due to the serious nature of associated medical conditions
+ Dementia
Progressive impairment of cognitive functions occurring in clear consciousness
Global impairment of intellect
Other mental functions can be affected: mood, personality, judgment, social behavior
Decline in functioning
5% prevalence in general population
+ Dementia
Dementia of the Alzheimer’s type Diagnosed when other causes have been excluded Hallmark: amyloid deposits Classic pathognomonic microscopic findings: neurofibrillary tangles, senile plaques, neuronal loss, synaptic loss Hypoactivity of acetylcholine and norepinephrine Parietal-temporal distribution
Vascular Dementia Multi-infarct dementia Pre-existing hypertension or cardiovascular risk factors
+ Dementia
Pick’s Disease
Fronto-temporal atrophy
Pick’s bodies in post-mortem specimens
Behavioral and personality changes early on
Otherwise, similar to Alzheimer’s
Lewy Body Disease
Similar to Alzheimer’s, with hallucinations, parkinsonian features and EPS
Huntington’s Disease
Parkinson’s Disease
HIV-related Dementia
Head trauma related dementia – punch-drunk syndrome (in boxers)
+ Psychiatric and Neurological Changes
Personality
Hallucinations and Delusions
Mood
Cognitive Change
Catastrophic reaction
Sundowner syndrome – drowsiness, confusion, ataxia, accidental falls
+ Mental Disorders Due to a GMC
Mood Disorder due to GMC
Secondary mood disorders
Prominent mood alteration due to direct physiological effect of a specific medical illness or agent
Affect both sexes equally
Psychological symptoms and somatic symptoms
Specifiers: with depressive features, with major depressivelike episode, with manic features, with mixed features
Eg., Depression secondary to hypothyroidism
Treatment: treat underlying medical disorder; antidepressant/ mood stabilizers may help
+ Mental Disorder due to GMC
Psychotic Disorder due to a GMC
any cerebral or systemic disease
Two subtypes: with delusions; with hallucinations
Differentiate from primary psychosis, mood disorder with psychotic features and delirium
Treatment: removal of causative factor and antipsychotics
Anxiety Disorder due to a GMC
Product of medication, intoxication or withdrawal
Most common: withdrawal from sedative-hypnotics, alcohol
Usually fluctuates in direct relation to the course of the provoking factor
Treatment: Benzodiazepines
+ Mental Disorder due to a GMC
Sleep Disorder due to a GMC
Hypersomnia
Insomnia
Parasomnia
Circadian rhythm sleep disorders – BPO’s
Sexual dysfunction due to a GMC
Etiology: medications, substances of abuse, local disease processes that affect primary or secondary sex organs, systemic disease processes
Mental D/O due to a GMC NOS
Catatonia due to a GMC: mutism, negativism, echolalia
Personality changes due to a GMC: labile type, aggressive type, apathetic type, paranoid type, other, combined, unspecified
Treatment: mood stabilizer, psychostimulant,
+ Mental Disorder due to a GMC SPECIFIC DISORDERS
Epilepsy Main psychiatric problem is personality change Temporal lobe seizures Religosity, heightened experience of emotions, changes in sexual behavior Viscosity in personality: noticeable in conversation – slow, replete with details, circumstantial Hypergraphia, pathognomonic for complex partial seizures
Brain Tumors Colloid cyst: not tumor, but can exert pressure on sturctures within diencephalon
+ Mental Disorder due to a GMC
Head Trauma Major symptoms: cognitive impairment and behavioral sequelae Post-traumatic amnesia: 6 to 12-month period of recovery, afterwhich residuals Decreased speed in information processing, decreased attention, increased distractibility, deficits in problem-solving, some language disabilities Treatment: low-dose psychotropics due to susceptibility to side effects
Demyelinating Disorders Multiple Sclerosis – cognitive impairments and behavioral Amyotrophic Lateral Sclerosis
+ Mental Disorder due to a GMC Infectious
Diseases Herpes simplex encephalitis – frontal and temporal lobes: anosmia, olfactory hallucinations, personality changes Rabies encephalitis - hydrophobia Neurosyphylis – general paresis: development of poor judgment, personality changes, decreased care of self, irritability penicillin Chronic meningitis – memory impairment, confusion
+ Mental Disorder due to a GMC Subacute
Sclerosing Panencephalitis – usu. follows measles Lyme Disease – bull’s eye rash, impaired cognitive functioning and mood changes Prion Disease Creutzfeld-Jakob Disease – cognitive impairment, aphasia, apraxia Kuru Gertsmann-Straussler-Scheinker – neurodegenerative syndrome of ataxia, chorea and cognitive decline Fatal Familial Insomnia – insomnia and ANS dysfunction, death within a year
+ Mental Disorder due to a GMC
Immune Disorders
AIDS
SLE
50% show neuropsychiatric symptoms
Depression, insomnia, labile mood, nervousness, confusion
Endocrine Disorders
Thyroid disorders
Hyperthyroidism – confusion, anxiety, agitated syndrome
Hypothyroidism – myxedema madness
Parathyroid disorders – hyper and hypocalcemia: delirium
Adrenal disorders – Addison’s (adrenocortical insufficiency), Cushing’s
Pituitary disorders – psychiatric symptoms (Sheehan’s syndrome)
+ Mental Disorder due to a GMC
Metabolic Disorders
Hepatic encephalopathy – alterations in consciousness, changes in memory, personality
Uremic encephalopathy – alterations in memory, consciousness and orientation
Hypoglycemic encephalopathy – feelings of hunger, apprehension, restlessness; then, confusion, disorientation and hallucinations
Diabetic ketoacidosis – chronic dementia
Acute Intermittent Porphyria
Disorders in heme synthesis
Result in excessive accumulation of porphyrins
Triad of symptoms: 1.
acute, colicky abdominal pain
2.
Motor polyneuropathy
3.
psychosis
+ Mental Disorder due to a GMC
Nutritional Disorders (Deficiency) Niacin – pellagra (alcohol abuse, vegetarian diet, starvation) 5 D’s: dermatitis, diarrhea, delirium, dementia, death Thiamine beri-beri, Wernicke-Korsakoff syndrome Apathy, depression, irritability, nervousness, poor concentration Cobalamin Failure of gastric mucosal cells to secrete intrinsic factor in secretion of B12 in the ileum Pernicious anemia – depression Megaloblastic madness – with paranoid features
+ Mental Disorder due to a GMC
Toxins
Mercury – mad hatter syndrome: depression, irritability, psychosis
Manganese – manganese madness
Emotional lability, pathological laughter, nightmares, hallucinations, compulsive and impulsive acts
Lead
200mg/ L – severe lead encephalopathy
Dizziness, clumsiness, ataxia, irritability, restlessness, insomnia
IV disodium edetate for 5 days
Arsenic
Prolonged exposure to Arsenic from herbicides or drinking water
Skin pigmentation, GI symptoms, characteristic garlic odor of breath, generalized sensory/ motor loss
+ Neuropsychiatric Aspects of HIV Infection and AIDS
Michelle Marie M. Marinas, M.D.
+ Specific Psychiatric Conditions AIDS
dementia
AIDS
mania
Increased
rates of MDD
Psychiatric
injuries
consequences of CNS
+
HIV is a retrovirus related to human l T-cell leukemia viruses
HIV-1: causative agent for most HIV infections
Transmission after single exposure is relatively low, but depends on viral load of contact person Anal sex Vaginal sex Needles In utero
Can develop into AIDS in 8-11 years
+ Virus
primarily targets T4 (CD4) helper lymphocytes
to which virus binds
injects RNA into lymphocyte Reverse transcriptase
RNA DNA
Incorporated into host genome Translated, transcribed
+ Diagnosis
Serum testing
Conventional: blood test – 3 to 10 days
Rapid test: oral swab – 20 minutes
Positive
Negative – not exposed, not infected, or exposed but not yet developed antibodies (less than a year)
Counseling – pre and post testing
Confidentiality – exception is to notify partners or at risk individuals, laws vary in different states
CLINICAL FEATURES
Non-neurologic factors – flu-like symptoms
Neurologic Factors – HIV mild neurocognitive disorder, HIVassociated dementia
+ Psychiatric Syndromes
HIV-associated Dementia – direct pathophysiologic consequence of HIV
Mild Neurocognitive disorder – aka HIV encephalopathy; impaired cognitive functioning, mild form
Delirium
Anxiety disorder – GAD, PTSD, OCD
Adustment disorder – 5 to 20% of patients
Depressive disorder – 4 to 40% of patients
+ Psychiatric Syndromes
Mania – most commonly in late-stage disease
Substance Abuse – IV users
Suicide – risk factors:
Friends who died from AIDS
Recent notification of HIV seropositivity
Relapses
Difficult social issues (homosexuality)
Inadequate social and financial support
Dementia or delirium
Psychotic Disorder – late stage
Worried well – seronegative but anxious
+ Treatment Prevention
is primary approach Treatment/ prevention complicated by complex societal values Complete sexual history, sexual orientation
Pharmacotherapy Reverse
transcriptase inhibitors Protease inhibitors Fusion inhibitors
+ Treatment Psychotherapy Approaches
– help deal with feelings of guilt Therapist-Related Issues – countertransference issues and burnout Involvement of Significant Others – deal with partner’s feelings of anger or guilt Partner Notification – recommendations for voluntary and involuntary interventions
+Thank you and Good luck on your quiz.
+ 1 to 4: Name 3 disorders affected or exacerbated by psychological factors 5 to 7: Name 3 mental disorders due to a general medical condition 8. Is the study, practice and teaching of the relation between medical and psychiatric disorders 9. Name one medical disorder with psychiatric symptoms 10. Identify one CL issue BONUS: Identify a CL unit
Michelle Marie M. Marinas, M.D. Department of Psychiatry DLSHSI – College of Medicine
+ Psychological Factors Affecting Medical Condition Two
Basic Assumptions of Psychosomatic Medicine: 1. There is unity of mind and body (mind-body medicine) 2. Psychological factors must be taken into account when considering all disease states
In
DSM-IV-TR Psychological Factors Affecting Medical Conditions
+ Psychological Factors affecting Medical Condition
Physical disorders caused by emotional or psychological factors
Mental or emotional disorders caused of aggravated by physical illness
Exclusions: 1.
Classic mental d/o’s that have physical symptoms as part of the disorder (eg., Conversion Disorder)
2.
Somatization disorder
3.
Hypochondriasis
4.
Physical complaints associated with mental d/o’s
+ DSM-IV-TR Diagnostic Criteria A GMC (coded on Axis III) is present B. Psychological Factors adversely affect the GMC: 1. Factors have influenced the course of the GMC as shown by temporal association between psychological factors and development or exacerbation of, or delayed recovery from, the GMC 2. Factors interfere with treatment of GMC 3. Factors constitute additional health risks for the individual 4. Stress-related physiological responses precipitate or exacerbate symptoms of A.
+ If more than one factor is present, choose the most prominent… Mental Disorder affecting GMC
Psychological Personality
symptoms affecting GMC
traits or coping style affecting
GMC Maladaptive
health behaviors affecting GMC
Stress-related
GMC
physiological response affecting
+ STRESS THEORY
A circumstance that disturbs, or is likely to disturb, the normal physiological or psychological functioning of a person.
Walter Cannon: first systematic study on the relation of stress to disease
Harold Wolff: physiology of GI tract correlate with emotional states
Hans Selye: General adaptation syndrome (3 phases) Alarm reaction Stage of resistance Stage of exhaustion
+ Stress
Neurotransmitter Responses to Stress Activate noradrenergic systems in the brain (locus ceruleus) release catecholamines from ANS Activate serotonergic systems increased serotonin turnover
Endocrine Responses to Stress Corticotropin Releasing Factor (CRF) Acts at anterior pituitary Release of ACTH Synthesis and release of glucocorticoids (fight or flight)
+ Stress
Immune Response to Stress Inhibition of immune functioning by glucocorticoids Also, immune activation by other pathways Also, profound immune activation by release of cytokines, which increase glucocorticoid effects
Life Events Life situation or event, favorable or unfavorable, often occurring by chance, generates challenges to which the person must adequately respond Holmes and Rahe Social Readjustment Scale: 200 or more life-change units increases risk
+ Stress
Specific vs. Nonspecific Stress Factors Specific personalities and conflicts – certain psychosomatic diseases Meyer Friedman and Ray Rosenman – personality types Type A – coronary personality Type B Franz Alexander- unconscious conflicts and specific diseases Peptic ulcer – dependency needs Essential HPN – hostile impulses from which they feel guilty Asthma – separation anxiety
+ SPECIFIC ORGAN SYSTEMS Gastrointestinal System
Functional GI Disorders Anxiety can produce disturbances in GI function through central control mechanism or humoral effects (release of catecholamines) Vagus modulated by limbic system (emotions-gut pathway) Functional dysphagia, IBS, functional diarrhea
Peptic Ulcer Disease Increased gastric acid secretion associated with psychological stress Higher vulnerability to H. pylori
Ulcerative Colitis No generalizations about psychological mechanisms
+ Cardiovascular System
Associated with depression Severe depression after CABG – increased risk of death
Type A behavior pattern, anger, hostility Physiologic processes: reduced parasympathetic modulation of HR, increased circulation of catecholamines, increased coronary calcification, increased lipid levels
Stress Management
Cardiac arrhythmias and sudden cardiac death Acute emotions can stimulate arrythmias
+
Heart
Transplantation Stages of adaptation elicit anxiety, depression, etc. Mood disorders
Hypertension
Vasovagal
syncope Specific psychological triggers still unidentified
+ Respiratory System
Asthma Dependency needs Greater use of corticosteroids, longer hospitalizations Personality traits: intense fear, emotional lability, sensitivity to rejection, lack of persistence in difficult situations
Hyperventilation syndrome
Chronic Obstructive Pulmonary Disease (COPD) Panic and anxiety disorders are co-morbidities
+ Endocrine System
Hyperthyroidism Nervousness, insomnia, lability of mood, dysphoria Pressured speech Short attention span, impaired recent memory, exaggerated startle response Visual hallucinations, paranoid ideation, delirium
Hypothyroidism Depressed mood, apathy, impaired memory Auditory hallucinations and paranoia (myxedema madness)
Diabetes mellitus Dietary control - depression
+ Adrenal Disorders
Cushing’s Syndrome Adrenocortical hyperfunction from excessive secretion of ACTH or adrenal pathology (tumor) Severe depression to elation Clinical features of Cushing’s
Hypercortisolism Fatigue, depressed mood Emotional lability, irritability, decreased libido, anxiety Social withdrawal
Hyperprolactinemia Traumatic childhood experiences predispose to hyperprolactinemia Sexual dysfunctions: erectile disorder and
+ Skin Disorders
Atopic dermatitis (atopic eczema or neurodermatitis) Anxiety, depression Exacerbate atopic dermatitis by scratching behavior Depressive symptoms amplified itching behavior
Psoriasis Lead to stress, which triggers psoriasis Cosmetic disfigurement and social stigma
Psychogenic excoriation (psychogenic pruritus) Lesions caused by scratching or picking in response to an itch Resembles OCD: impulsive, ritualistic, repetitive, tension reducing
+
Localized pruritus Pruritus ani Pruritus vulvae
Hyperhidrosis States of fear, rage and tension Increased sweat secretion on the palms, soles and axillae Anxiety phenomenon mediated by the ANS
Urticaria Stressful life events and urticaria Stress – secretion of neuropeptides - vasodilation
+ Musculoskeletal system
Co-morbid psychiatric symptoms may be result of patient’s psychological response to the loss and discomfort imposed by the disease effect of disease process on CNS
Rheumatoid Arthritis – chronic musculoskeletal pain from inflammation of the joints depression
Systemic Lupus Erythematosus Recurrent episodes of destructive inflammation of several organs Highly unpredictable, incapacitating, potentially disfiguring
+
Low back pain
Excruciating pain, restricted movement, paresthesias, weakness or numbness
Accompanied by fear, panic and anxiety
Oftentimes debilitating
Fibromyalgia
Pain and stiffness of the soft tissues such as muscles, ligaments and tendons
“trigger points”: local areas of tenderness
Cervical and thoracic areas most commonly affected
Fatigue, anxiety, insomnia
Present in chronic fatigue syndrome and depressive d/o
+ Headaches
Psychological stress exacerbates headache, whether primary cause is physical or psychological
Migraine (Vascular) and Cluster Headaches Functional disturbance in cranial circulation Stress is al precipitant at times Overly controlled perfectionists, unable to suppress anger
Tension (Muscle Contraction) Headaches Emotional stress prolonged contraction of head and neck muscles constrict blood vessels Dull, aching pain, tightening band
+ Treatment
Good MD-patient relationship
Aaron Lazare’s Negotiating Strategies: 1. Direct education 2. Third party intervention 3. Exploration of options 4. Provision of sample treatment 5. Control sharing 6. Concession making 7. Empathic confrontation –”what would you do if you were in my place?” 8. Standard setting
+ Stress management and relaxation therapy
Stress management training 1. Self-observation • Daily diary format • How they respond to stress/ challenges each day • Stressful events that precipitate signs/ symptoms 2. Cognitive restructuring • awareness of maladaptive thoughts, beliefs and expectations 3. Relaxation training – hypnosis, biofeedback 4. Time management 5. Problem-solving • Applying solutions to problem situations
+ Consultation-Liaison Psychiatry
Study, practice and teaching of the relation between medical and psychiatric disorders
Psychiatrists serve as consultants to colleagues or other mental health professionals
CL psychiatrists are part of the medical team
Knowledge of psychiatric diagnosis + awareness of medical illnesses with psychiatric symptoms
Purpose of the diagnosis:
Identify mental disorders and psychological responses to physical illness
Patient’s personality features
Patient’s coping techniques
+ Common CL problems
Suicide attempt or threat
Depression
Agitation
Hallucinations
Sleep Disorder
Confusion
Noncompliance or Refusal to Consent to Procedure
No organic basis for symptoms
+ CL Psychiatry in special situations
Intensive Care Units
Hemodialysis Units
Surgical Units
Transplantation Issues
PSYCHO-ONCOLOGY
+ Medical Conditions that present with psychiatric symptoms
Hyperthyroidism – irritability, pressured speech, psychosis
Hypothyroidism - depression
Hypoglycemia – anxiety, confusion, agitation
Hyperglycemia – anxiety, agitation, delirium
Brain neoplasms – personality changes
Frontal lobe tumor – mood changes, impaired judgment
Occipital lobe tumor – aura, visual hallucinations
+
Temporal lobe tumor – olfactory hallucinations
AIDS – progressive dementia, depression, psychosis
Hyponatremia – confusion, lethargy, personality changes
Pancreatic Ca – depression, lethargy, anhedonia
Multiple sclerosis – anxiety, euphoria, mania
Hepatic encephalopathy – euphoria, disinhibition, psychosis, depression
Pheochromocytoma – anxiety
Wilson’s disease – mood disturbances, delusions, hallucinations
+ Mental Disorders due to a GMC
Delirium
Dementia
Short-term confusion and changes in cognition Four sub-categories: GMC, substance-induced, multiple causes, NOS
Impairment in memory, judgment, orientation and cognition
Amnestic Disorder
Memory impairment or forgetfulness 3 sub-categories: caused by medical condition (hypoxia) Caused by toxin or medication NOS
+ Delirium
Acute onset of fluctuating cognitive impairment and a disturbance of consciousness
Syndrome, not a disease, many causes
Hallmark symptom: impairment of consciousness, in association with global impairments of cognitive functioning
Sudden onset, brief and fluctuating course, rapid improvement when causative factor is identified
10-30% of medically ill exhibit delirium
Poor prognostic sign – high mortality rate for patients who exhibit delirium while in the hospital
+ DSM-IV-TR diagnostic criteria
Delirium due to a GMC
Substance Intoxication Delirium
Substance Withdrawal Delirium
Delirium NOS
+ Core features of Delirium
Altered consciousness – decreased level
Altered attention – diminished ability to focus, sustain or shift attention
Impairment in cognitive function – disorientation and decreased memory
Relatively rapid onset – hours to days
Brief duration – days to weeks
Marked, unpredictable fluctuations in severity
+ Course and Prognosis
Recede over 3-7 days after removal of causative factor
Some symptoms may take up to two weeks
Recall of the patient is characteristically spotty (“bad dream”)
Associated with high mortality rate due to the serious nature of associated medical conditions
+ Dementia
Progressive impairment of cognitive functions occurring in clear consciousness
Global impairment of intellect
Other mental functions can be affected: mood, personality, judgment, social behavior
Decline in functioning
5% prevalence in general population
+ Dementia
Dementia of the Alzheimer’s type Diagnosed when other causes have been excluded Hallmark: amyloid deposits Classic pathognomonic microscopic findings: neurofibrillary tangles, senile plaques, neuronal loss, synaptic loss Hypoactivity of acetylcholine and norepinephrine Parietal-temporal distribution
Vascular Dementia Multi-infarct dementia Pre-existing hypertension or cardiovascular risk factors
+ Dementia
Pick’s Disease
Fronto-temporal atrophy
Pick’s bodies in post-mortem specimens
Behavioral and personality changes early on
Otherwise, similar to Alzheimer’s
Lewy Body Disease
Similar to Alzheimer’s, with hallucinations, parkinsonian features and EPS
Huntington’s Disease
Parkinson’s Disease
HIV-related Dementia
Head trauma related dementia – punch-drunk syndrome (in boxers)
+ Psychiatric and Neurological Changes
Personality
Hallucinations and Delusions
Mood
Cognitive Change
Catastrophic reaction
Sundowner syndrome – drowsiness, confusion, ataxia, accidental falls
+ Mental Disorders Due to a GMC
Mood Disorder due to GMC
Secondary mood disorders
Prominent mood alteration due to direct physiological effect of a specific medical illness or agent
Affect both sexes equally
Psychological symptoms and somatic symptoms
Specifiers: with depressive features, with major depressivelike episode, with manic features, with mixed features
Eg., Depression secondary to hypothyroidism
Treatment: treat underlying medical disorder; antidepressant/ mood stabilizers may help
+ Mental Disorder due to GMC
Psychotic Disorder due to a GMC
any cerebral or systemic disease
Two subtypes: with delusions; with hallucinations
Differentiate from primary psychosis, mood disorder with psychotic features and delirium
Treatment: removal of causative factor and antipsychotics
Anxiety Disorder due to a GMC
Product of medication, intoxication or withdrawal
Most common: withdrawal from sedative-hypnotics, alcohol
Usually fluctuates in direct relation to the course of the provoking factor
Treatment: Benzodiazepines
+ Mental Disorder due to a GMC
Sleep Disorder due to a GMC
Hypersomnia
Insomnia
Parasomnia
Circadian rhythm sleep disorders – BPO’s
Sexual dysfunction due to a GMC
Etiology: medications, substances of abuse, local disease processes that affect primary or secondary sex organs, systemic disease processes
Mental D/O due to a GMC NOS
Catatonia due to a GMC: mutism, negativism, echolalia
Personality changes due to a GMC: labile type, aggressive type, apathetic type, paranoid type, other, combined, unspecified
Treatment: mood stabilizer, psychostimulant,
+ Mental Disorder due to a GMC SPECIFIC DISORDERS
Epilepsy Main psychiatric problem is personality change Temporal lobe seizures Religosity, heightened experience of emotions, changes in sexual behavior Viscosity in personality: noticeable in conversation – slow, replete with details, circumstantial Hypergraphia, pathognomonic for complex partial seizures
Brain Tumors Colloid cyst: not tumor, but can exert pressure on sturctures within diencephalon
+ Mental Disorder due to a GMC
Head Trauma Major symptoms: cognitive impairment and behavioral sequelae Post-traumatic amnesia: 6 to 12-month period of recovery, afterwhich residuals Decreased speed in information processing, decreased attention, increased distractibility, deficits in problem-solving, some language disabilities Treatment: low-dose psychotropics due to susceptibility to side effects
Demyelinating Disorders Multiple Sclerosis – cognitive impairments and behavioral Amyotrophic Lateral Sclerosis
+ Mental Disorder due to a GMC Infectious
Diseases Herpes simplex encephalitis – frontal and temporal lobes: anosmia, olfactory hallucinations, personality changes Rabies encephalitis - hydrophobia Neurosyphylis – general paresis: development of poor judgment, personality changes, decreased care of self, irritability penicillin Chronic meningitis – memory impairment, confusion
+ Mental Disorder due to a GMC Subacute
Sclerosing Panencephalitis – usu. follows measles Lyme Disease – bull’s eye rash, impaired cognitive functioning and mood changes Prion Disease Creutzfeld-Jakob Disease – cognitive impairment, aphasia, apraxia Kuru Gertsmann-Straussler-Scheinker – neurodegenerative syndrome of ataxia, chorea and cognitive decline Fatal Familial Insomnia – insomnia and ANS dysfunction, death within a year
+ Mental Disorder due to a GMC
Immune Disorders
AIDS
SLE
50% show neuropsychiatric symptoms
Depression, insomnia, labile mood, nervousness, confusion
Endocrine Disorders
Thyroid disorders
Hyperthyroidism – confusion, anxiety, agitated syndrome
Hypothyroidism – myxedema madness
Parathyroid disorders – hyper and hypocalcemia: delirium
Adrenal disorders – Addison’s (adrenocortical insufficiency), Cushing’s
Pituitary disorders – psychiatric symptoms (Sheehan’s syndrome)
+ Mental Disorder due to a GMC
Metabolic Disorders
Hepatic encephalopathy – alterations in consciousness, changes in memory, personality
Uremic encephalopathy – alterations in memory, consciousness and orientation
Hypoglycemic encephalopathy – feelings of hunger, apprehension, restlessness; then, confusion, disorientation and hallucinations
Diabetic ketoacidosis – chronic dementia
Acute Intermittent Porphyria
Disorders in heme synthesis
Result in excessive accumulation of porphyrins
Triad of symptoms: 1.
acute, colicky abdominal pain
2.
Motor polyneuropathy
3.
psychosis
+ Mental Disorder due to a GMC
Nutritional Disorders (Deficiency) Niacin – pellagra (alcohol abuse, vegetarian diet, starvation) 5 D’s: dermatitis, diarrhea, delirium, dementia, death Thiamine beri-beri, Wernicke-Korsakoff syndrome Apathy, depression, irritability, nervousness, poor concentration Cobalamin Failure of gastric mucosal cells to secrete intrinsic factor in secretion of B12 in the ileum Pernicious anemia – depression Megaloblastic madness – with paranoid features
+ Mental Disorder due to a GMC
Toxins
Mercury – mad hatter syndrome: depression, irritability, psychosis
Manganese – manganese madness
Emotional lability, pathological laughter, nightmares, hallucinations, compulsive and impulsive acts
Lead
200mg/ L – severe lead encephalopathy
Dizziness, clumsiness, ataxia, irritability, restlessness, insomnia
IV disodium edetate for 5 days
Arsenic
Prolonged exposure to Arsenic from herbicides or drinking water
Skin pigmentation, GI symptoms, characteristic garlic odor of breath, generalized sensory/ motor loss
+ Neuropsychiatric Aspects of HIV Infection and AIDS
Michelle Marie M. Marinas, M.D.
+ Specific Psychiatric Conditions AIDS
dementia
AIDS
mania
Increased
rates of MDD
Psychiatric
injuries
consequences of CNS
+
HIV is a retrovirus related to human l T-cell leukemia viruses
HIV-1: causative agent for most HIV infections
Transmission after single exposure is relatively low, but depends on viral load of contact person Anal sex Vaginal sex Needles In utero
Can develop into AIDS in 8-11 years
+ Virus
primarily targets T4 (CD4) helper lymphocytes
to which virus binds
injects RNA into lymphocyte Reverse transcriptase
RNA DNA
Incorporated into host genome Translated, transcribed
+ Diagnosis
Serum testing
Conventional: blood test – 3 to 10 days
Rapid test: oral swab – 20 minutes
Positive
Negative – not exposed, not infected, or exposed but not yet developed antibodies (less than a year)
Counseling – pre and post testing
Confidentiality – exception is to notify partners or at risk individuals, laws vary in different states
CLINICAL FEATURES
Non-neurologic factors – flu-like symptoms
Neurologic Factors – HIV mild neurocognitive disorder, HIVassociated dementia
+ Psychiatric Syndromes
HIV-associated Dementia – direct pathophysiologic consequence of HIV
Mild Neurocognitive disorder – aka HIV encephalopathy; impaired cognitive functioning, mild form
Delirium
Anxiety disorder – GAD, PTSD, OCD
Adustment disorder – 5 to 20% of patients
Depressive disorder – 4 to 40% of patients
+ Psychiatric Syndromes
Mania – most commonly in late-stage disease
Substance Abuse – IV users
Suicide – risk factors:
Friends who died from AIDS
Recent notification of HIV seropositivity
Relapses
Difficult social issues (homosexuality)
Inadequate social and financial support
Dementia or delirium
Psychotic Disorder – late stage
Worried well – seronegative but anxious
+ Treatment Prevention
is primary approach Treatment/ prevention complicated by complex societal values Complete sexual history, sexual orientation
Pharmacotherapy Reverse
transcriptase inhibitors Protease inhibitors Fusion inhibitors
+ Treatment Psychotherapy Approaches
– help deal with feelings of guilt Therapist-Related Issues – countertransference issues and burnout Involvement of Significant Others – deal with partner’s feelings of anger or guilt Partner Notification – recommendations for voluntary and involuntary interventions
+Thank you and Good luck on your quiz.
+ 1 to 4: Name 3 disorders affected or exacerbated by psychological factors 5 to 7: Name 3 mental disorders due to a general medical condition 8. Is the study, practice and teaching of the relation between medical and psychiatric disorders 9. Name one medical disorder with psychiatric symptoms 10. Identify one CL issue BONUS: Identify a CL unit
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