Psychiatry and medicine

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Psychiatryandmedicine
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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 (
  Nun-asu ) , 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 ).

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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.
• ??? ?????? ?? ???? ?????? ????? ???????.

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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.

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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 ).

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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.

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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.

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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 ).

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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 ).

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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 ).

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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 ( Parkinsons
  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 ).

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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.

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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
  problem-solving counselling, but more severe
  requires antidepressant medication.

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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.

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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.

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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.
• Cushings 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.

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Psychological problems associated with movement
disorders

• Parkinsons 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.
• Writers and occupational cramps these
  conditions are thought to be psychogenic.

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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.

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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.

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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.

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Treatment of chronic pain.

• Acknowledge the reality of the symptoms.
• Explain the origin of the pain discuss the
  patients 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.

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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 ).

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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 patients 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.

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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.

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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.

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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).

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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
  doctors must know by his talent what they are
  suffering from.

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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 own language.

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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.
• ????? ????????? ????? ???????.
• 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 gini causing mental illnesses are
  decreasing leading most people to attend
  psychiatric clinics.