Mental Disorders Scott Hall ST6 General Psychiatry firstname.lastname@example.org
Objectives • To understand the concept of mental disorder in greater depth • To be able to decide when and how to formulate a referral to psychiatry • To gain an overview of several common psychiatric syndromes presenting to general hospital settings (psychosis, major affective disorder, delirium, self harm)
“Dodgy” dichotomies • Functional/organic • Psychiatric/psychological • Reactive/endogenous • Brain/Mind • Diagnosis/formulation • “Manipulative”/”Genuine” • Illness/disease • Psychosis/neurosis • Conscious/unconscious • Mild/moderate/severe • Axis I/Axis II • State/trait
Legal definition (Mental Health Act 1983) • Any disorder or disability of mind • Functional versus organic is not a helpful dichotomy
1. Psychosis • What does it look like? • Differential • Management/When to refer?
Textbook definition Mental disorder • in which the thoughts, feelings, affective response, ability to recognise reality • and ability to communicate and relate to others are • sufficiently impaired to interfere grossly with the capacity to deal with reality; • the characteristics of psychosis are impairedreality testing, hallucinations, delusions and illusions. • Kaplan & Saddock “Comprehensive textbook of psychiatry” – 7thed, glossary p686
mental state abnormalities in psychotic illness Thought Behaviour Perception Catatonia Form Content Delusions Hallucinations Illusions Pseudohallucinations Overvalued Ideas Circumstantiality Fusion Knight´s Move Thinking Auditory Derailment Tactile Word Salad Visual Olfactory & Gustatory Thought Block
2. (major) Affective disorders • What does it look like? • Differential • Management
recurrent bipolar spectrum treatment resistance poor inter-episode recovery Bipolar Affective Disorder
Frequency and severity of specific symptoms in mania 1. Goodwin FK, Jamison KR. 1990 Manic-Depressive IllnessOxford University Press Inc., New York, NY: 227-244 2. Bowden CL. J Clin Psychiatry 2006;67:1501-1510
3. Delirium • What does it look like? • Differential • Management/When to refer?
Diagnostic criteria (ICD-10) Clouding of consciousness Disturbance of cognition Psychomotor disturbances Disturbance of sleep Symptoms have a rapid onset and show fluctuation over the course of the day *Objective evidence of an underlying cerebral or systemic disease that can be presumed to be responsible
NICE Guideline - Treatment • STEP 1 • Identify and treat underlying cause • Environmental factors • STEP 2 • Verbal and non-verbal de-escalation techniques • STEP 3 • Consider short term use of antipsychotics • Haloperidol • Olanzapine • STEP 4 • Re-evaluate for other underlying causes
4. Self harm • What does it look like? • Differential • Management/When to refer? • Further reading
Definition of self harm • Self harm is common in the general population • “intentional self-poisoning or injury, irrespective of the apparent purpose of the act” • Why?
The Mental State Examination • Why? • What does it add? • Jaspers and empathy • What about our own unconscious processes? Countertransference
Risk assessment • What are we asking? What is risk? ( Very difficult for a rare event on an individual level) • Short term vs medium vs long • Why? • The psychosocial assessment • Evidence based risk assessment • Involves identifying, ranking and integrating multiple risk and protective factors into an overall clinical judgment of risk
Risk “factors” for completed suicide • Psychiatric diagnosis • Medical and psychiatric co-morbidities • Deliberate self harm / form • Anxiety • Childhood sexual abuse • Impulsivity and aggression • Melancholia • Don’t forget protective factors
Adverse Course of Illness Characteristics Loss of Social and Medical Support Early onset More time ill Loss of Sign. Other More time depressed Lack of Confidant Single Mother Decrease Health Care Access More severe Depression * Genetic Vulnerability * Family Hx of Suicide and Drug Abuse * Suicide Attempts Lack of Insurance Less Education Axis I: Eating disorders Lower income Education, Income, Marital Status Being single Anxiety disorders Sexual Abuse Axis II Physical Abuse Cluster A, B,C Comorbidities Medical Traumatic Life Events
Risk assessment tools • Beck Inventory • Example of a structured risk assessment tool • Integrates commonly known risk factors into a “scoreable” tool • ?Clinical utility
Summary • Diagnosable mental disorder is common • Psychological dysfunction is extremely common • The above are not mutually exclusive • Risk is dynamic, complex and is more than a paper exercise • Assessment and management of mental status changes is everyone’s responsibility and sometimes requires further assessment by a psychiatrist