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Ovid: Oxford Handbook of Psychiatry

Editors: Semple, David; Smyth, Roger; Burns, Jonathan; Darjee, Rajan; McIntosh, Andrew Title: Oxford Handbook of Psychiatry, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Chapter 17 – Liaison psychiatry Chapter 17 Liaison psychiatry P.726
Introduction Liaison psychiatry is concerned with the diagnosis and management of psychiatric and psychological illness in general medical populations. It is unique among the psychiatric sub-specialties in that it concerns itself not with a particular subset of disorders, or treatment of patients of a particular age range, but patients within a particular clinical setting. The development of a distinct sub-specialty of liaison psychiatry is in some ways a result of the separation of psychiatric specialists from their medical and surgical colleagues and practices. There are after all no liaison surgeons; general surgeons merely attend general medical wards as required and give advice to the treating team or take over the patient’s care. The sub-speciality is a relatively recent innovation and dates in its current form since the 1960s. Motivations to its development were the low rate of outside referral in proportion to prevalence of the disorders in the population under review and increasing medical specialisation leading to lack of confidence and competence with psychiatric/psychological problems. The role of the liaison psychiatrist will be defined, more than the other sub-specialties, by custom and practice in the hospital concerned. The main workload will in general include:

  • Diagnosis of new psychiatric illness in general patients.
  • Management of pre-existing psychiatric illness in general patients.
  • Somatic presentation of psychiatric illness.
  • Psychiatric and emotional complications of physical illness.
  • Management of medically unexplained or functional illnesses.
  • Management of behavioural disturbance.
  • Assessment following attempted suicide and deliberate self-harm.
  • Assessment of alcohol and drug abuse.
  • Problems related to childbirth and the puerperium.
  • Issues related to capacity and legal powers.

The sub-specialty referred to as liaison psychiatry in the UK is, in most of the rest of the world, referred to as ‘consultation-liaison psychiatry’. This longer name better describes the two related approaches of practitioners in this field. The consultation aspect of the job covers episodic referrals made for advice on diagnosis, prognosis, need for further investigations, or management. It may include patients where the request is to consider taking over care. The liaison aspect refers to a closer relationship with a unit, with involvement in unit planning, staff support, policy development, and training as well as involvement in individual clinical cases. The balance between the liaison and consultation aspects of the job will depend on the specialty concerned, and the hospital type. P.727
Presentations of psychiatric illness on the general wards While working in liaison psychiatry you can expect to see a wide variety of disorders and presentations. Many of these will not be unique to the general setting, and their management is described in other sections of this book. Some common referrals are:

  • Adjustment disorder p. 364
  • Depressive illness pp. 246, 247, 248, 249, 250, 251
  • Patients presenting after parasuicide pp. 730, 731, 732, 733
  • Alcohol problems pp. 504, 505, 506, 507, 508, 509, 510, 511, 512, 513, 514, 515, 516, 517, 518, 519, 520, 521, 522, 523, 524, 526, 527, 528, 529, 530, 531, 532, 533
  • Drug problems pp. 534, 535, 536, 537, 538, 539, 540, 541, 542, 543, 544, 545, 546, 547, 548, 549, 550, 551, 552, 553, 554, 555, 556, 557, 558, 559, 560
  • Acute confusional state p. 734
  • Psychiatric aspects of organic conditions pp. 130, 131
  • Medically unexplained symptoms pp. 736, 737, 738, 739
  • Behavioural disturbance pp. 896, 897
  • Assessment of dementia pp. 132, 133
  • Post-partum illnesses p. 756
  • Illnesses specific to women pp. 434, 435, 436, 437
  • Questions regarding capacity p. 822
  • Issues of consent to/refusal of treatment pp. 820, 821, 822, 823

P.728
Working in the general hospital Liaison psychiatry is unusual in that you will work as a psychiatrist based in a general hospital. This can bring its own difficulties and challenges as well as rewards. Firstly you will be operating ‘on enemy territory’ to some extent. General hospital doctors in the various specialties will have their own ideas about psychiatry, as well as about the indicated treatment in each case (which may differ from yours). Nonetheless it is well to remember that you have a range of skills and knowledge that will be useful and are not shared by other members of staff. You should rely on these and your own judgement, backed up by senior colleagues, in difficult situations. When you come to working in a general hospital you may feel initially overwhelmed. There are many new disorders, altered presentations of familiar disorders, a new tempo of working, and patients suffering medical conditions about which you may know very little. Liaison psychiatry takes a variety of types of referral and they will vary by the type of hospital, the population served, and the specialty mix within the hospital. The person receiving the referral should take details of the patient, their GP, their treating team, and the nature of the problem, including its urgency. It is helpful to clarify what questions the treating team want addressed. It is also important to clarify that the patient understands that psychiatric referral has been made and agrees to this. Where the situation is not an emergency, it can be useful to review any psychiatric or departmental records for previous contacts, prior to assessing the patient. A discussion with the GP may also be helpful. On arrival on the ward, review the medical record of this and previous admissions and speak to a senior member of the treating team. Clarify the patient’s diagnosis and any investigations or treatments planned. Discuss the patient with the nursing staff—they may have useful information regarding the patients symptoms around the clock and their mood day to day. Arrange a private room for the interview if at all possible. Introduce yourself to the patient as a psychiatrist or psychological medicine specialist. Explain your role, which may be misunderstood by the patient, who my feel you are there to ‘see if I’m crazy’. Stating that the medical team are concerned about some of the patient’s symptoms and they want a specialist in these symptoms to give them some advice is often an acceptable phrasing for patients. If a definitive psychiatric diagnosis is possible, write this clearly in the notes, along with a provisional management plan and any treatment recommendations. Clarify in the notes if further psychiatric review is planned and when, and which symptoms should cause them to seek an earlier review. If at all possible, discuss your findings with the medical team face to face. P.729
P.730
Parasuicide assessment Parasuicide is a deliberately undertaken act which mimics the act of suicide but does not result in death. Psychiatric assessment of such patients is mandatory once their medical condition allows. The involvement of mental health professionals in the assessment of patients following parasuicide relates to the following observations:

  • In this population of patients, roughly 1% will die by completed suicide in the 24 months after the initial parasuicidal act, with the risk highest in the weeks following the original act. This represents a mortality by suicide 50–100 times that of the general population.
  • The rates of completed suicide are significantly raised in all mental disorders excepting mental handicap and dementia. Studies examining completed suicides in patients with mental illness show inadequate doses of therapeutic drug treatment, increased drop-out rate from follow-up, and increased presence of untreated comorbidity.
  • Clear risk factors exist for completed suicide (see below) and the closer the parasuicidal patient approximates to these demographics, the greater the relative risk. However, the absolute risk is low and estimate of the risk in a particular case relies on assessment of the individual act and the mental state.

Assessment The initial management of the patient following overdose or other deliberate self harm will be by specialist toxicologists or general medical/surgical specialists. Early psychiatric assessment may be required for advice regarding detainablity, behavioural disturbance, drug/alcohol withdrawal, or delirium, but assessment of the parasuicide itself should be deferred until conscious level is full. The history should focus on the act itself, the patient’s mental state and recent life events, and past medical/ psychiatric history. It may be easier to assess these in reverse order moving from the factual history towards the emotive descriptions of the parasuicidal act itself after building rapport. Features of act

  • Method -90% of parasuicides are by self-poisoning with self-cutting making up most of the remainder. Use of method likely to be fatal (e.g. jumping, hanging) is indicative of clear intent to die.
  • Patient’s belief in the lethality of the method Did the patient believe that that combination of tablets was likely to be fatal? Serious suicidal intent is associated with medically trivial overdoses—and vice versa.
  • Length of planning Was the act impulsive—‘on the spur of the moment’, or planned in advance—and for how long?
  • Triggers Was there a clear precipitant (e.g. row with partner)? Were they intoxicated at the time? Was there any direct ‘gain’ (e.g. patient in custody at the time of act)?
  • Final acts Was there a suicide note? Did they make any other ‘acts of closure’ (e.g. setting affairs in order, arranging for the care of children)?
  • Precautions to avoid discovery Where did the act take place? Would they have anticipated being found? Did they signal or tell their intentions to another? Was anyone else actually present at the time?
  • Previous similar acts Is this act a repeat of a previous non-fatal act? Are there any different features?
  • P.731

  • Actions after act What did they do after the act? How did they end up coming to hospital?

Mental state

  • Attitude now to survival Are they relieved or disappointed to be alive? Do they have ongoing wish to die? How do they feel about the future and what plans (if any) do they have?
  • Affective symptoms Current affective symptoms. Recent symptoms of low mood, anhedonia, and hopelessness. Biological depressive features.
  • Substance misuse problems Evidence for current drug or alcohol misuse or dependence.
  • Other mental disorder Enquire directly about other symptoms of mental disorder as directed by the history.
  • Risk to others Is there any evidence of intent to harm anyone else? Did the parasuicidal act put anyone else at risk?

Personal and past medical/psychiatric history

  • Recent life events Describe recent loss or change of events (e.g. bereavements, job loss, relationship break-up).
  • Current life situation State of current significant relationships. Type and security of job and accommodation. Presence of legal/criminal problems.
  • Previous or current psychiatric diagnoses Clarify with hospital records if further details required or if significant history.
  • Physical health problems Again clarify with records or GP if required.

Risk factors for completed suicide

  • Socio-demographic factors
    • Male sex
    • Elderly
    • Single, divorced, or widowed
    • Living alone, poor social support
    • Unemployed or low socio-economic class
  • Personal/mental health factors
    • Previous parasuicide or DSH
    • Any mental disorder (greatest risk in major depression and anorexia nervosa, then functional psychosis, then neurotic and personality disorders)
    • Dependence on alcohol or drugs
    • Recent inpatient psychiatric treatment
    • Concurrent physical disorder
    • Recent bereavement

P.732
Management after parasuicide Reasons for act Only a minority of patients presenting after parasuicide have evidence of clear intent to die. Assessment will reveal a mixture of the following types of case:

  • Those whose intent was unequivocally to die but were prevented by discovery, chance, or overestimation of the lethality of the method.
  • Those who were ambivalent whether they lived or died, ‘letting the chips fall as they may’.
  • Those whose act was impulsive and ‘in the heat of the moment’ in response to an immediate stressor.
  • Those whose actions were designed to communicate distress—the classical ‘cry for help’.
  • Those whose actions were manipulative in nature and designed to provoke changed behaviour from others.
  • Those attempting to escape from intolerable symptoms or an intolerable situation.
  • Those whose intent is later unclear even to themselves.

There may initially be diagnostic confusion with the following groups: 1) deliberate overdoses of drugs taken for intoxicating effect; 2) deliberate self-harm (e.g. wrist cutting) which is a repetitive, ritualistic action whose intent is to relieve tension, not to kill or seriously injure; 3) accidental overdoses of prescribed or OTC medication. 1 and 2 may merit psychiatric evaluation in their own right and 3 should be examined carefully for evidence of post hoc rationalisation of a parasuicide. Assessment aims By the end of assessment you should aim to answer the following questions:

  • Is there ongoing suicidal intent Evidenced by: continuing stated wish to die; ambivalence about survival; sense of hopelessness towards future; clear intent to die at time of act.
  • Is there evidence of mental illness Diagnosed in the normal way. Most common diagnoses are depressive illness and alcohol misuse. Be alert to comorbid substance misuse and to the combination of an acute stressor on the background of a chronic condition.
  • Are there non-mental health issues which can be addressed Many patients will reveal stressors such as: family or relationship difficulties; emotional problems (particularly relating to previous abuse; school or employment problems; debt; legal problems; problems related to immigration). They can be usefully directed to appropriate local services.

Management

  • Ongoing suicidal intent In many cases this will be managed by admission to a psychiatric ward, on a compulsory basis if necessary.
  • Mental illness
    • Patients already known to mental health services Here close liaison with the usual team is required to agree a joint management plan.
    • New diagnoses Here the focus should be on integrating with an appropriate service for follow-up, rather than necessarily starting new treatments. The type of appropriate follow-up depends on the P.733
      type of disorder (e.g. GP review for moderate depressive illness, referral to alcohol services for alcohol abuse). Short-term community outreach from liaison psychiatry can ‘bridge’ the patient to the general services. Try to ensure follow-up is as soon as possible, even if non-urgent, as otherwise non-attendance is very high.
    • Admission required For both new and established mental illnesses, admission will sometimes be indicated after parasuicide even where there is no ongoing suicidal intent. This may be due to seriousness of condition (e.g. new psychotic illness) or to allow for a period of inpatient assessment of mental state. It should not simply be in order to defer or devolve the decision about discharge—ask yourself what will have changed to mean discharge in a few days will be safer than now.
  • Other issues With the patient’s permission discuss the case with an appropriate agency (e.g. abuse counselling service, school counsellor). Clarify the appropriateness of the referral and referral method and feed these back to the patient.
  • In all cases Discuss and agree management plan with patient. In most cases discuss with GP (mandatory if GP input is required). Consider provision of emergency crisis card giving details of emergency psychiatric service and telephone contact for emergency counselling/support services.

Frequent attenders A small minority of patients attend emergency services repeatedly with parasuicidal acts or deliberate self harm without suicidal intent. A management plan for such patients should be agreed on a case-by-case basis. The aim should be to avoid ‘rewarding’ maladaptive behaviours, (e.g. by repeated admissions providing ‘time-out’ from stressful situations), while providing appropriate support and treatment. P.734
Acute confusional state (delirium) Essence A stereotyped response of the brain to a variety of insults, very commonly seen in hospital inpatients. It is a clinical syndrome of fluctuating global cognitive impairment associated with behavioural abnormalities. Like other acute organ failures it is more common in those with chronic impairment of that organ. Epidemiology Extremely common in medical and surgical inpatients (10–20%). Particularly vulnerable include: elderly; pre-existing dementia; blind or deaf; very young; post-operative (especially cardiac); burn victims; alcoholic and benzodiazepine dependent, serious illness particularly multiple. Carries significant mortality as well as morbidity to patient and others and is a cause of delayed discharge. Clinical features

  • Impaired level of consciousness with reduced ability to direct, sustain, and shift attention.
  • Global impairment of cognition with disorientation, and impairment of recent memory and abstract thinking.
  • Disturbance in sleep/wake cycle with nocturnal worsening of symptoms.
  • Psychomotor agitation and emotional lability.
  • Perceptual distortions, illusions, and hallucinations—characteristically visual.
  • Speech may be rambling, incoherent, and thought disordered.
  • There may be poorly developed paranoid delusions.
  • Onset of clinical features is rapid with fluctuations in severity over minutes and hours (even back to apparent normality).

Differential diagnosis Mood disorder; psychotic illness (new major mental disorder very much less likely than delirium in a hospitalised patient, particularly if elderly); post-ictal; dementia (characteristically has insidious onset with stable course and clear consciousness—clarify functional level prior to admission). Aetiology The cause is frequently multi-factorial and the most likely cause varies with the clinical setting in which the patient presents.

  • Intracranial CVA; head injury; encephalitis; primary or metastatic tumour; raised ICP.
  • Metabolic Anaemia; electrolyte disturbance; hepatic encephalopathy; uraemia; cardiac failure; hypothermia.
  • Endocrine Pituitary, thyroid, parathyroid or adrenal diseases; hypoglycaemia; diabetes mellitus; vitamin deficiencies (thiamine, B12, folate, nicotinic acid).
  • Infective UTI; chest infection; wound abscess; cellulitis; SBE.
  • Substance intoxication or withdrawal Alcohol; benzodiazepines; anticholinergics; psychotropics; lithium; antihypertensives; diuretics; anticonvulsants; digoxin; steroids; NSAIDs.
  • Hypoxia Secondary to any cause.

Course and prognosis Delirium usually has a sudden onset, usually lasts less than 1 wk, and resolves quickly. There is often patchy amnesia for P.735
the period of delirium. Mortality is high (estimated to be up to 50% at 1 yr). May be a marker for the subsequent development of dementia. Assessment

  • Attend promptly (situation only tends to deteriorate and behaviorally disturbed patients cause considerable anxiety on medical wards).
  • Review time-course of condition with nursing and medical staff and review notes—particularly medicine kardex and blood results.
  • Establish pre-morbid functional level (e.g. from relatives or GP).

Management 4 main principles of management:

  • Identify and treat precipitating cause.
  • Provide environmental and supportive measures (below).
  • Avoid sedation unless severely agitated or necessary to minimise risk to patient or to facilitate investigation/treatment.
  • Regular clinical review and follow-up (MMSE useful in monitoring cognitive improvement at follow-up).

Environmental and supportive measures in delirium

  • Education of all who interact with the patient (doctors, nurses, family, etc.).
  • Reality orientation techniques. Firm clear communication—preferably by same staff member. Use of clocks and calendars.
  • Create an environment that optimises stimulation (e.g. adequate lighting) reduce unnecessary noise; mobilise patient whenever possible.
  • Correct sensory impairments (e.g. hearing aids; glasses).
  • Optimise patient’s condition—attention to hydration, nutrition, elimination, pain control.
  • Make environment safe (remove objects with which patient could harm self or others).

Footnote Brown TM and Boyle MF (2002) Delirium. BMJ 325, 644–7. Sedation in delirium

  • Use single medication.
  • Start at low dose and titrate to effects.
  • Give dose and reassess in 2–4 hours before prescribing regularly.
  • Avoid PRN medication if possible.
  • Review dose regularly and taper and stop ASAP.
  • Consider:
    • Haloperidol 0.g–1mg up to max of 4mg daily
    • Lorazepam 0.5mg–1mg up to max of 4mg daily
    • Risperidone 1mg–4mg up to max of 6mg daily

P.736
Medically unexplained symptoms (1)—introduction It is increasingly recognized that a substantial proportion of patients presenting to primary care, or to any hospital specialty will have symptoms for which, after adequate investigation, no cause can be found. Non-specific symptoms without underlying organic pathology are very common and usually transient. Where they become prolonged enough to merit medical attention they may present to any speciality, with presentations such as pain, loss/disturbance of function, and altered sensation. Symptom ‘meaning’ The ‘problem’ of Medically Unexplained Symptoms (MUS) arises, in part, from the different meanings symptoms hold for patient and doctor. Patients present to doctors with illness (symptoms and behaviours); doctors diagnose and treat disease (pathology and other recognised syndromes). The patient wants explanation and treatment for their symptoms and the route to this is a generally through being given a diagnosis. If there is no recognised diagnosis available the doctor may respond with ‘there’s nothing wrong’, expecting to be met with pleasure. The patient however is baffled—there is ‘something wrong’ and the symptoms are still there. The doctor may then undertake a number of courses of action: continue to investigate in the hope of finding something; treat the patient anyway as a therapeutic trial; refer to another specialty; or dismiss the patient. Psychiatric role The role of psychiatry in the assessment and management of these patients has changed substantially over recent years (hopefully for the better). Formerly patients were referred ‘at the end of the line’, often after prolonged, inconclusive tests and unsuccessful interventions. Patients often misinterpreted (and resented) the referral as suggesting that symptoms were ‘all in your mind’, or were feigned. Psychiatrists sometimes took an overly narrow view of their role and responsibility, unhelpfully dismissing patients as having ‘no psychotic or depressive illness’, or colluding with patient’s desire for a ‘clean bill of mental health’ in order to return to treatment seeking behaviour. We are currently at an early stage of our understanding of medically unexplained illnesses. While no specialty has ‘all the answers’ in the management of this patient group, psychiatry can offer: experience of the presentation of MUS across the hospital specialties; ability to assess and treat the frequently comorbid depressive/anxiety symptoms; and a tolerance for diagnostic uncertainty and ability to take a long-term view of improvements. Misdiagnosis A frequently expressed concern doctors hold about this group of patients is the risk of ‘getting it wrong’, (often associated with poorly formed worries about litigation). A long-held belief was that, despite repeated negative findings, all such patients (or a majority), would eventually be found to suffer from an organic disease which would, in retrospect, account for their symptoms. This concern was largely based on older, poorly conducted studies with significant methodological flaws. Recent follow-up studies suggest that the misdiagnosis rate for functional illness is 5–10%, (e.g. comparable to other medical and psychiatric P.737
diagnoses such as idiopathic epilepsy and schizophrenia). This improvement has followed both the development of modern imaging and investigatory techniques, and the use of operational diagnostic criteria for psychiatric diagnosis. Iatrogenic harm A problem common to all members of this group of disorders is the potential for iatrogenic harm. These patients often accrue considerable morbidity and even mortality due to excess negative investigations, irradiation, operative procedures, etc. Those disorders associated with chronic pain carry the risk of iatrogenic opiate dependency. Often at the later stages of the patient’s illness this secondary morbidity is more problematic than the original symptoms. A major positive intervention in these patients is therefore the avoidance of iatrogenic harm. P.738
Medically unexplained symptoms (2)—clinical presentations Classification Patients presenting with somatic symptoms for which no adequate physical cause can be found make up a large and heterogeneous group in all clinical settings, from primary to tertiary care. Our lack of full understanding of this group of disorders is reflected in the confusing and disputed classification system adopted. Our modern concepts arose from the concept of ‘hysteria’—of repressed emotions being expressed as physical symptoms. There are differences between ICD-10 and DSM-IV in the classification of this group of disorders and each classification contains a number of disputed and unsatisfactory categories. One difficulty has been the residual old labels still in use; another has been the confusion of names indicating symptom and disorder; a third has been the substantial overlap between the syndromes described. Somatisation This is the experience of psychological distress as physical symptoms. Its distinction from other symptoms seen in functional illness is shown opposite. Somatisation is a symptom of various disorders commonly seen in liaison psychiatry and may occur: 1) as a normal accompaniment of physical illnesses; 2) as a common presentation of depressive illness; 3) as a core component of illness (‘somatic syndromes’); 4) as part of a longstanding pattern of behaviour (‘somatisation disorder’). 1) As a normal accompaniment of physical illness Complaint of symptoms and help-seeking behaviour is adaptive. All illnesses have emotional components which deserve attention. Both doctor and patient may be more comfortable dealing with specialty-appropriate symptoms (e.g. a patient presenting with pain post-radiotherapy may be articulating a desire for reassurance that the tumour has not reoccurred). While some doctors may be reluctant to deal with the emotional context of illness, patients may have worries and express these as somatic complaints. These should often be understood as part of the emotional reaction to illness, not dismissed as ‘functional overlay’. Their appropriate treatment is via consultation with the responsible clinician. Psychological factors may (positively or negatively) influence outcome in treatment of physical illnesses by their effects on advice seeking, treatment compliance, and perceived quality of life. 2) As a common presentation of depressive illness Somatic complaints are common presentations of affective illnesses, with this prevalence increased in certain sub-groups (e.g. elderly, children, certain immigrant populations). Conversely, anxiety and depressive symptoms are a common finding in both the physically ill and those with somatisation. 3) As a core component of the illness (the ‘somatic syndromes’) These conditions are usually reported as individual clinical syndromes; however, several factors are common to them all. There is presentation P.739
by the patient with symptoms which are suggestive of an underlying organic illness; these symptoms cause distress; there is no identifiable organic illness which is sufficient to explain the symptoms; and the causation is attributed to psychological factors which may be more or less apparent. A variety of presentations are seen across the medical and surgical specialties: GI medicine—irritable bowel syndrome Gynaecology—chronic pelvic pain Rheumatology—fibromyalgia Cardiology—atypical chest pain ENT—globus hystericus Neurology—tension headache, pseudo-seizures 4) Part of a longstanding pattern of behaviour Somatisation disorder (pp. 742, 743). Causative mechanisms Currently unclear, but the following may play a part: patient psychological factors; patient’s health beliefs; affective state; underlying personality; degree of autonomic arousal; increased muscle tension; effects of hyperventilation; effects of disturbed sleep; effects of prolonged inactivity; impaired ability to filter afferent stimuli. Functional symptoms

  • Somatisation: the experience of bodily symptoms with no, or no sufficient psychical cause, with presumed psychological causation.
  • Hypochondriasis: the belief that one has a particular illness despite evidence to the contrary—an overvalued idea.
  • Conversion: the process by which thoughts or memories unacceptable to the conscious mind are repressed from conscious expression and ‘converted’ into physical symptoms, sometimes with symbolic meaning to the patient.
  • Dissociation: the separation of unpleasant emotions and memories from consciousness with subsequent disruption to the normal integrated function of consciousness.
  • Dysmorphophobia: the belief that one has a significant deformity—an overvalued idea.
  • Pain: an unpleasant sensory or emotional experience associated with actual or potential tissue damage.
  • ‘Functional overlay’: symptoms ‘over and above’ those thought to be appropriate given the extent of the (undoubted) organic illness.

P.740
Medically unexplained symptoms (3)—management principles Accepting cases for assessment Psychiatrists should be reluctant to accept patients for assessment of MUS where significant doubt still exists in the treating doctor’s mind as to the diagnosis (e.g. where significant further investigations are planned). They should also be reluctant to be put in the position of ‘last hurdle’ before an otherwise planned intervention (e.g. ‘I’ll perform your operation if the psychiatrist gives the go-ahead’). Management principles Definitive treatments validated by RCT evidence are not currently available for MUS. In addition, these patients present a heterogenous group, in terms of presentation, ‘psychological mindedness’, and severity. Nonetheless the following principles may be helpful. Management should include: 1) thorough assessment; 2) confident diagnosis; 3) clear explanation; 4) minimisation of iatrogenic harm; 5) empirical use of potentially beneficial treatments; and 6) consideration of involvement in treatment trials. Assessment

  • Prior to the consultation, obtain the full hospital case records for all specialties. Discuss the case with the GP and obtain copies of GP records if available. Clarify whether the patient is seen in other hospitals or health care services and aim to obtain these records. Establish whether there are any pending investigations and what the patient has been told about their presumed diagnosis.
  • At the interview: establish full details of current symptoms; circumstances of symptom onset; and ‘life context’ of symptom development.
  • Explore their illness beliefs: specific worries about cause and possible prognosis; ask the patient to describe their understanding of their symptoms and what they feel they may represent.
  • Full details of past medical history (may be reticent—‘no problems before current symptoms’ or overly dramatic); what were they told at the time by the doctors treating them?
  • Remember to explore possible psychiatric differential diagnoses—full mental state as normal, even if no symptoms spontaneously mentioned.
  • Observe patient in waiting room/onward/entering and leaving room—be alert to inconsistencies in symptoms.

Diagnosis

  • A positive and confident diagnosis is crucial.
  • Be willing to make organic and non-organic diagnosis (e.g. where there is undoubted organic disease but also significant MUS morbidity).
  • Acknowledge the patient’s distress and disability; a diagnosis of MUS should not mean to the patient that you believe that there is ‘nothing wrong with them’.

Explanation

  • Terminology in this field is variable, imprecise, and potentially offensive (e.g. supratentorial, hysterical). The terms ‘functional illness’ or ‘medically unexplained illness’ are generally acceptable to patients.
  • P.741

  • Begin with a clear explanation summing up what is (and what is not) wrong: ‘You are suffering from a functional, not structural, problem of your nervous system. This is a common problem which we have seen in many other patients.’ Various analogies may be used as appropriate (e.g. computer hardware vs. software problem; piano working but out of tune).
  • Emphasise what can and cannot be done: ‘We can help train the body to function normally again’, ‘We might not be able to pinpoint the exact cause’.
  • Allow the patient to query what you have said (you should have allowed sufficient time at the end of the interview). Allow carers/ relatives to become involved in this exploration of your explanation.
  • Copy your clinic letter to the GP and the hospital professionals caring for patient. Consider, in certain situations, copying the letter to patient.

Minimise iatrogenic harm

  • In all MUS patients, be aware of the risk of iatrogenic harm and justify any risks taken by benefit to the patient, over and above the gratification of seeming to give the patient ‘what they want’.
  • Accept that there may be a chronic illness which can be managed but not ‘cured’.
  • Appropriately investigate genuinely new symptoms.
  • In planning further investigations in patients with MUS, proportionately greater weight should be placed on objective rather than subjective change.
  • Clear verbal, written (and in some cases, face to face) communication between all involved professionals is especially crucial in this group of patients: everyone should ‘know what’s going on’.
  • Accept that there will be a proportion of severe cases who are unable to leave sick role and who must be managed by changing how the system responds to them.

Empirical use of potentially beneficial treatments

  • Often there is improvement in patient perception of symptoms following confident diagnosis and explanation.
  • All patients with prominent depressive/anxiety symptoms should have these treated in the normal way.
  • Consider empirical trial of antidepressant medication even where affective features are not prominent.
  • Consider use of physiotherapy to aid regaining of functional loss.
  • Consider referral for assessment for formal psychotherapy.
  • Consider referral to other resource (e.g. pain management).

Involvement in treatment trials

  • Little is known about the course of these disorders over time and less about appropriate treatments: consider patients for involvement in research.

P.742
Somatisation disorder A chronic disorder of multiple medically unexplained symptoms, affecting multiple organ systems presenting before the age of 40. It is associated with significant psychological distress, functional impairment, and repeated presentations to medical services. Full blown somatisation disorder or ‘Briquet’s syndrome’ probably represents the severe end of a continuum of abnormal illness behaviour (pp. 6, 7). Clinical features Patients will have long, complex medical histories (‘fat-file’ patients), although at interview may minimise all but the most recent symptomatology. Symptoms may occur in any system and are to some extent suggestible. The most frequent symptoms are non-specific and atypical. There may be discrepancy between the subjective and objective findings (e.g. reports of intractable pain in a patient observed by nursing staff to be joking with relatives). Symptoms are usually concentrated in one system at a time but may move to another system after exhausting diagnostic possibilities in the previous. Life revolves around the illness as does family life. Diagnosis is usually only suspected after negative findings begin to emerge as normal medical practice is to take complaints at face value. Key diagnostic feature is multiple, atypical, and inconsistent medically unexplained symptoms in a patient under the age of 40. There is excessive use of medical service and alternative therapies. Chronic cases will have had large numbers of diagnostic procedures and surgical or medical treatments. High risk of iatrogenic harm and iatrogenic substance dependence. Hostility and frustration can be felt on both sides of the doctor-patient relationship. There may be ‘doctor-shopping’ and ‘splitting’ of the attitudes of staff caring for them. Psychological approaches to treatment are hampered by on-going investigations of ever rarer diagnostic possibilities and by the attribution of symptoms to fictitious but ‘named’ medical entities. Two-thirds of patients will meet criteria for another psychiatric disorder, most commonly major depressive or anxiety disorders. There is also association with personality disorder and substance abuse. They characteristically deny emotional symptoms or attribute them directly to physical handicaps—‘the only reason I’m depressed is this constant pain’. Aetiology Observable clinical association with childhood illnesses in the patient and a history of parental anxiety towards illness. Increased frequency of somatisation disorder in first degree relatives. Possible neuropsychiatric basis to the disorder with faulty assessment of normal somatic sensory input. Association with childhood sexual abuse. Epidemiology Lifetime prevalence of -0.2%. Markedly higher rate in particular populations. ♀:♂ ratio 5:1. Age of onset is childhood to early 30s. Differential diagnosis Undiagnosed physical disorder: particularly those with variable, multi-system presentations (e.g. SLE, AIDS, porphyria, tuberculosis, multiple sclerosis). Onset of multiple symptoms for the first time in patients over 40 should be presumed to be due to unexposed physical disease. Psychiatric disorder: major affective and psychotic illnesses may P.743
initially present with predominately somatic complaints. Diagnosis is by examination of other psychopathology, however over half of somatisation disorder patients exhibit psychiatric comorbidity. Other somatoform disorders: distinguish from: hypochondriasis (presence of firm belief in particular disorder), somatoform pain disorder (pain rather than other symptoms is prominent), conversion disorder (functional neurological loss without multi-system complaints). In practice the main distinction is between the full and severe somatisation disorder and somatisation as a symptom of other disorders. Assessment (see p. 740). Establish reasons for referral, experience of illness, attitudes to symptoms, personal and psychiatric history, family perspective. Initial management (see general principles, pp. 740, 741) Make, document, and communicate the diagnosis. Acknowledge symptom severity and experience of distress as real but emphasise negative investigations and lack of structural abnormality. Reassure patient of continuing care. Attempt to reframe symptoms as emotional. Assess for and treat psychiatric comorbidity as appropriate. Reduce and stop unnecessary drugs. Consider case conference involving GP and treating physicians. On-going management

  • Regular review by single, named doctor.
  • Reviews should be at planned and agreed frequency, avoiding emergency consultations.
  • Symptoms should be examined and explored with a view to their emotional ‘meaning’.
  • Avoid tests ‘to rule out disease’, investigate objective signs only.
  • All secondary referrals made through one individual.
  • Disseminate management plan.
  • These patients can exhaust a doctor’s resources—plan to share the burden over time.

Some evidence for the effectiveness of patient education in symptom re-attribution, brief contact psychotherapy, group therapy, or CBT if the patient can be engaged in this. Prognosis Poor in the full disorder; tendency is for chronic morbidity with periods of relative remission. Treatment of psychiatric comorbidity and reduction of iatrogenic harm will reduce overall morbidity. P.744
Somatoform pain disorder In somatoform pain disorder (pain disorder in DSM-IV) there is a complaint of persistent severe and distressing pain which is not explained or not adequately explained by organic pathology. The causation of the symptom is attributed to psychological factors. This disorder is diagnosed where the disorder is not better explained by somatisation disorder, another psychiatric diagnosis, or ‘functional overlay’ of organic disease. All pain is a subjective sensation and its severity and quality as experienced in an individual is dependant on a complex mix of factors including the situation, the degree of arousal, the affective state, the beliefs about the source, and meaning of the pain. The experience of pain is modified by its chronicity and associations and there is a ‘two-way’ relationship with affective state, with chronic pain predisposing to depressive illness, while depressive illness tends to worsen the subjective experience of pain. Comorbidity In common with the other somatoform disorders there is substantial overlap with major depression (-40% in pain clinic patients) and anxiety disorders. Substance abuse (including iatrogenic opiate dependency) and personality disorder patients are over-represented. Epidemiology No population data are available. The prevalence of patients with medically unexplained pain varies by clinical setting; higher in inpatient settings, particularly surgery, and highest in pain clinic patients. Differential diagnosis Elaboration of organic pain, malingering, substance abuse, sickle cell crisis, angina. Assessment History from patient and informants, length of history (may be minimised), relationship to life events, general somatisation, experience of illness, family attitude to illness, periods of employment, treatments, beliefs about cause, comorbid psychiatric symptoms. CSA. Management (see general principles, pp. 740, 741). It is important to recognise and treat occult comorbid depression. It is often helpful to adopt an atheoretical approach: ‘let’s see what works’, and to resist pressure for ‘all or nothing’ cure or a move to investigation by another speciality. Opiates not generally effective in chronic pain of this type and add the risk of dependence. Psychological treatments: these are directed towards enabling the patient to manage and ‘live with’ the pain, rather than aspiring to eliminate it completely; can include relaxation training, biofeedback, hypnosis, group work, CBT. Pain clinics: these are generally anaesthetist-led with variable psychiatric provision. They offer a range of physical treatments such as: antidepressants, TENS, anti-convulsants, and local or regional nerve-blocks. P.745
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Conversion (dissociative) disorders A loss or disturbance of normal function which initially appears to have a physical cause but is attributed to a psychological cause. The disturbance conforms to the patient’s conception of pathological processes. These disorders were initially explained by psychodynamic mechanisms—repression of unacceptable conscious impulses and their ‘conversion’ to physical symptoms, sometimes with symbolic meaning. In ICD and DSM the presumed psychodynamic mechanisms are not part of the diagnosis. Symptoms are not produced intentionally and the presence of ‘secondary gain’ is not part of the diagnosis. Classification ICD-10 and DSM-IV classify these disorders differently. In ICD-10 dissociation and conversion are used synonymously, with dissociation preferred as it does not imply a definite psychological explanation. All expressions of such disorders are classified together under the heading ‘F44, dissociative (conversion) disorders’. In DSM-IV ‘conversion’ refers to motor or sensory deficit, while ‘dissociation’ refers to disturbance in function of consciousness. Conversion disorders are classified with the somatoform disorders, while dissociative disorders are classified separately (see pp. 932, 933). Clinical features These vary depending on the area affected but the following are commonly seen:

  • Paralysis One or more limbs or one side of the face or body may be affected. Flaccid paralysis is common initially but severe, established cases may develop contractures. Often active movement of the limb is impossible during examination but synergistic movement is observed (e.g. Hoover’s test: the patient is unable to raise the affected limb from the couch but is able to raise the unaffected limb against resistance with demonstrable pressing down of the heel on the ‘affected’ side).
  • Loss of speech (aphonia) There may be complete loss of speech, or loss of all but whispered speech. There is no defect in comprehension and writing is unimpaired (and becomes the main method of communication). Laryngeal examination is normal and the patient’s vocal cords can be fully opposed while coughing.
  • Sensory loss The area of loss will cover the patient’s beliefs about anatomical structure rather than reality (e.g. ‘glove’ distribution, marked ‘midline splitting’).
  • Seizures Non-epileptic seizures are found most commonly in those with genuine epilepsy. The non-epileptic attacks generally occur only in the presence of an audience, no injury is sustained on falling to the ground, tongue biting and incontinence are rare, the ‘seizure’ consists of generalised shaking, rather than regular clonic contractions, and there is no post-ictal confusion or prolactin rise.

Diagnosis The diagnosis will usually be suspected due to the non-anatomical or clinically inconsistent nature of the signs. It is established by 1) excluding underlying organic disease, or demonstrating minor disorder insufficient to account for the symptoms; 2) finding of ‘positive signs’ (i.e. demonstration of function thought to be absent); 3) a convincing psychological explanation for the deficit. P.747
Treatment Supportive psychotherapy, explanation that symptoms were initially organic but now problems are due to maladaptive response, perhaps with physiotherapy involvement. Treatment of psychiatric comorbidity. Prognosis For acute conversion symptoms, especially those with a clear precipitant, the prognosis is good, with expectation of complete resolution of symptoms (70–90% resolution at follow-up). Poorer outcomes for longer-lasting and well-established symptoms. P.748
Hypochondriasis Hypochondriasis is the preoccupation with the fear of having a serious disease which persists despite negative investigations and causes distress and impaired function. Clinical features The central and diagnostic clinical feature is the preoccupation with the idea of having a serious medical condition, usually one which will lead to death or serious disability. The patient may repeatedly ruminate on this possibility and minor insignificant bodily abnormalities, normal variants, normal functions, and minor ailments will be interpreted as signs of serious disease. The patient will consequently seek medical advice and investigation but is unable to be reassured in a sustained fashion by negative investigations. The form of the belief is that of an over-valued idea; the patient may be able to accept that his worries are groundless but nonetheless be unable to stop dwelling and acting on them. Where the belief in illness is of delusional intensity, the patient should be treated as for delusional disorder (p. 234). Aetiology As in somatisation disorder there may be a history of childhood illness, parental illness, or excess medical attention-seeking in the parents. CSA and other emotional abuse or neglect are associated. In one aetiological model, individuals with combination of anxiety symptoms and predisposition to misattribute psychical symptoms, seek medical advice. The resulting medical reassurance provides temporary relief of anxiety which acts as a ‘reward’ and makes further medical attention seeking more likely. Epidemiology Equal sex incidence. Very variable prevalence depending on group studied, (0.8%–10.3%), higher in secondary care. Differential diagnosis The main differentiation is from the feared physical disease. In most cases this is straightforward, but the possibility of an early, insidious disease with vague physical signs and normal baseline investigations should be considered. Comorbidity High (>50%) incidence of generalised anxiety disorder. Hypochondriasis may also coexist with major depressive illness, OCD, and panic disorder. Examination of the time course of symptom development and most prominent clinical features helps to distinguish primary hypochondriasis from a secondary clinical feature of these disorders. Management Initial Allow patient time to ventilate their illness anxieties. Clarify that symptoms with no structural basis are real and severe. Aim to plan continuing relationship and review, not contingent upon new symptoms. Explain negative tests and resist the temptation to be drawn into further exploration. Patients will in the early stages often change or expand symptomatology. Emphasise aim to improve function. Break cycle of reassurance and repeat presentation—family education may help in this. Pharmacological Uncontrolled trials demonstrate antidepressant benefit, even in the absence of depressive symptoms. Try fluoxetine 20mg, increasing to 60mg, or imipramine up to 150mg. Psychotherapy Behavioural P.749
therapy (response prevention and exposure to illness cues); CBT (identify and challenge misinterpretations, substitution of realistic interpretation, graded exposure to illness-related situations, and modification of core illness-beliefs), 75% symptom reduction in one controlled trail1. References 1 Warwick HM, Clark DM, Cobb AM, Salkovskis PM (1996) A controlled trial of cognitive-behavioural treatment of hypochondriasis. BJP 169, 189–95. P.750
Dysmorphic disorder The core clinical feature of dysmorphic disorder is preoccupation with the belief that some aspect of physical appearance is markedly abnormal, unattractive or pathological. This preoccupation causes distress and has the characteristics of an over-valued idea, it is not amenable to reassurance. The bodily part is found to be normal, or if abnormal is only trivially so compared with the degree of distress. It is an unusual condition which has only relatively recently come prominently to clinical attention. It rarely presents directly, but such individuals may present requesting plastic surgery or mutilating surgical procedures, and hence come to psychiatric attention. There are many similarities to OCD in terms of clinical features and treatment response. Clinical features There is preoccupation with the idea that some specified aspect of their appearance is grossly abnormal, markedly unattractive, or diseased. Any part of the body may be affected, most usually the face, head, and secondary sexual characteristics. Patients believe that the supposed deficit is noticeable to others and attempt to hide or minimise it. These beliefs may develop delusional intensity. There is associated functional impairment, agoraphobia, and risk of suicide. Comorbid behaviours such as skin picking, rubbing, topical applications may cause worse secondary problems. Clinically significant disorder causes severe functional impairment, restriction of relationships and employment opportunities, and the risk of iatrogenic morbidity by unwarranted surgical procedures. Aetiology Begins in late childhood or early adolescence, overlap with normal worries at this age. Epidemiology Equal sex incidence. Less than 1% prevalence but markedly over-represented in some groups (e.g. plastic surgery (10%) and dermatology). 10% incidence in first-degree family members. Comorbidity 60% risk of major depression. Differential diagnosis There is a significant overlap in terms of symptom profile with social phobia, hypochondriasis, OCD, somatic delusions in schizophrenia, and anorexia nervosa. Where the concerns are persistently delusional, ICD-10 reclassifies as delusional disorder, while DSM-IV allows diagnosis of a delusional form. Treatment

  • Operative Plastic surgery to the affected part is generally not indicated, even successful surgery risks being followed by a new preoccupation or a focus on surgical scarring.
  • Pharmacological Evidence for clinical effectiveness of SSRI, try fluoxetine 20mg increasing to 60mg. If ineffective try clomipramine up to 300mg. If delusional features, add antipsychotic.
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  • Psychological Evidence for CBT, treatment focused on response prevention, challenging cognitive errors, and behavioural tasks.

Prognosis Chronic course with fluctuating symptom severity. Partial rather than full remission. P.752
Factitious disorder (Munchausen’s Syndrome) In factitious disorder patients intentionally falsify their symptoms and past history and fabricate signs of physical or mental disorder with the primary aim of obtaining medical attention and treatment. The diagnostic features are the intentional and conscious production of signs, falsification, or exaggeration of the history and the lack of gain beyond medical attention and treatment. Three distinct sub-groups are seen.

  • Wandering mostly males who move from hospital to hospital, job to job, place to place, producing dramatic and fantastic stories. There may be aggressive personality or dissocial PD and comorbid alcohol or drug problems.
  • Non-wandering mostly females; more stable lifestyles and less dramatic presentations. Often in paramedical professions; overlap with chronic somatisation disorder. Association with borderline PD.
  • By proxy mostly female. Mothers, carers, or paramedical and nursing staff who simulate or prolong illness in their dependants—here the clinical focus must be on the prevention of further harm to the dependant.

The behaviours can mimic any psychical and psychiatric illness. Behaviours include: self-induced infections, simulated illnesses, interference with existing lesions, self-medication, altering records, reporting false physical or psychiatric symptomatology. Early diagnosis reduces iatrogenic morbidity and is facilitated by: awareness of the possibility; a neutral interviewing style using open rather than closed questions; alertness to insistencies and abnormalities in presentation; use of other available information sources; and careful medical record keeping. Differential diagnosis Any genuine medical or psychiatric disorder. Somatisation disorder (no conscious production of symptoms and no fabrication of history), malingering (secondary gain for the patient e.g. compensation, avoiding army service), substance misuse (also gain i.e. the prescription of the drug), hypochondriasis, psychotic and depressive illness (associated features of the primary mental illness). Aetiology Unknown, there may be a background of childhood sexual abuse or childhood emotional neglect. Probably more common in men and those with a nursing or paramedical background. Association with personality disorder. Production of psychiatric symptoms associated with borderline PD, CSA or emotional abuse. Management There are no validated treatments. Patients are often reluctant to consider psychiatric assessment and may leave once their story is questioned. Management in these cases is directed towards reducing iatrogenic harm caused by inappropriate treatments and medications.

  • Direct challenge Easier if there is direct evidence of feigned illness; the patient is informed that staff are aware of the intent to feign illness and the evidence is produced. This should be in a non-punitive manner with offer of ongoing support.
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  • Indirect challenge Here the aim is to allow the patient a face-saving ‘way out’, while preventing further inappropriate investigation and intervention. One example is the ‘double bind’ ‘if this doesn’t work then the illness is factitious’.
  • Systemic change Here the understanding is that there is no possibility of change in the individual and the focus is on changing the approach of the health care system to assessing them in order to minimise harm. These strategies can include dissemination of the patient’s usual presentation and distinguishing marks to regional hospitals, ‘black-listing’, ‘Munchausen’s registers’, etc. As these strategies potentially break confidentiality and can decrease the risk of detecting genuine illness, they should be drawn up in a multidisciplinary fashion involving senior staff.

P.754
Chronic fatigue syndrome Chronic fatigue syndrome (CFS) is the current preferred name for a clinical syndrome whose central feature is severe fatigue, unrelated to exertion and unrelieved by rest. Fatigue is a symptom characterised by a subjective feeling of lethargy, lack of energy, exhaustion, and a feeling of ‘increased effort to do anything’. Patients also complain of aching muscles, poor unrefreshing sleep, aching joints, and headaches. They may date the symptoms very precisely to an episode of viral infection with sore throat, fever, and tender lymph nodes. CFS is currently preferred to the names myalgic encephalomyelitis (ME) and post-viral fatigue syndrome as it doesn’t imply knowledge of underlying pathology or aetiology. It should be understood that CFS is not a disorder in the conventionally accepted sense, but a characteristic clinical syndrome. The syndrome shows diagnostic overlap with major depression, somatisation disorder, and hypochondrias but cannot be subsumed into these diagnoses because of substantial areas of lack of fit. Any criteria for CFS will be contentious and will include many people with chronic organic illnesses. Patients with this syndrome will often have passionately held beliefs about the cause of their symptoms and the appropriate management. A practical, pragmatic approach is advised from the doctor. A separate diagnosis of CFS does not appear in DSM-IV; patients not meeting criteria for somatisation disorder would be categorised as ‘undifferentiated somatoform disorder’. Aetiology Unknown; a minority of cases have confirmed onset with viral illness but ongoing viral replication or chronic infection is not the cause. At the moment is understood in terms of an acute reaction to stress or minor illness in vulnerable individual with a persisting clinical syndrome caused by deconditioning and other secondary phenomena. Vulnerable individuals are those with abnormal symptom attribution, increased awareness of normal bodily processes, cognitive errors, and perfectionist personality types. Comorbidity Many patients with CFS will meet the criteria for another psychiatric diagnosis, most commonly major depression. Arguments exist for calling CFS a form of atypical depression; however this is untenable in a significant minority of cases. Not only do patients resist a ‘psychiatric’ diagnosis, but many do not have anhedonia or pervasively low mood, and attribute any mood disturbance to the restriction on their activities caused by their illness. Nonetheless, treatment of comorbid depressive or anxiety symptoms can produce clinical improvement. Investigation findings Non-specific subjective cognitive impairment similar to that found in depression. Normal muscle function with poor performance on tolerance testing related to deconditioning. No characteristic blood abnormalities or immune system abnormalities. Possible cortisol depression? There are no definite and replicable abnormal findings. Do minimum indicated tests. Assessment Establish the diagnosis and identify comorbid psychiatric disorders. Avoid confrontation with the patient and attempt to agree a P.755
common understanding of the disorder. Acknowledge the severity of the symptoms and the consequent disability. Aim to take the focus of the interview towards potentially beneficial interventions and away from unwarranted investigations. Management

  • Medication Give antidepressant treatment trial even where no clear-cut evidence of affective symptoms. Try SSRI first (e.g. paroxetine 20mg) as this patient group is intolerant of side-effects.
  • Graded exercise Establish via diary record the patient’s daily activity level, establish with them their maximal tolerable level even on their worst day, and encourage them to perform this level of activity every day, no more and no less, with gradual negotiated increase over time. The aim is to break the cycle of inactivity, brief excess activity, and consequent exhaustion.
  • Psychotherapy Some evidence for the effectiveness of CBT.

Prognosis Poor for established cases with continuing ill-health of fluctuating nature. P.756
Illnesses related to childbirth Always ask about thoughts of self-harm or harming the baby. Despite the significant life event that pregnancy is, psychiatric admission and completed suicide are less common in pregnancy than at other times. There may be sub-clinical mild anxiety or mood disturbance, worse in the third and first trimesters. 10% risk of clinical depression in the first trimester associated with past history of depression, previous abortion, previous intra-uterine loss, unwanted pregnancy. Third trimester depression may persist as postpartum depression. Avoid drug treatment in the first trimester. ‘Baby blues’ Up to 3/4 of new mothers will experience a short-lived period of tearfulness and emotional lability starting two or three days after birth and lasting one to two days. This is common enough to be easily recognisable by midwifery staff and requires only reassurance and observation towards resolution. There is weak evidence that it may be related to post-partum reductions in levels of oestrogen, progesterone, and prolactin (which do occur around 72 hrs after the birth). Postnatal depression (PND) A significant depressive episode, temporally related to childbirth, occurring in 10–15% of women within 6 months post-partum (peak 3–4 weeks). The clinical features are similar to other depressive episodes, although thought content may include worries about the baby’s health or her ability to cope adequately with the baby. There may be a significant anxiety component. 90% of cases last less than 1 month; 4% greater than one year. Risk factors Personal or family history of depression, older age, single mother, poor relationship with own mother, ambivalence towards or unwanted pregnancy, poor social support, significant other psycho-social stressors, severe ‘baby blues’, previous post-partum psychosis, (no evidence for association with obstetric complications). Management Early identification and close monitoring of those ‘at risk’ (use of Edinburgh Postnatal Depression Scale in primary care setting—see opposite); prevention by education, support, and appropriate pharmacological intervention; depressive episode treated in usual way with antidepressants and/or brief CBT, if severe or associated with thoughts of self-harm or harm to baby, may require hospital admission. Postpartum psychosis An acute psychotic episode, occurring following 1.5/1000 live births, peak occurrence at 2 wks postpartum. Aetiology is unknown, but may relate to reduction of oestrogen (leading to DA super-sensitivity), cortisol levels, or postpartum thyroiditis. Symptoms 3 common clinical presentations: prominent affective symptoms (80%)—mania or depression with psychotic symptoms; schizophreniform disorder (15%); acute organic psychosis (5%). Common features include: lability of symptoms; insomnia; perplexity, bewilderment, and disorientation; thoughts of suicide or infanticide. Risk factors Personal or family history of major psychiatric disorder; lack of P.757
social support; single parenthood; previous postpartum psychosis (30% risk of psychosis; 38% risk of PND). Management Prevention identification, education, support, and treatment of ‘at risk’ individuals; Treatment admission to hospital (specialist mother-baby unit if possible); for major affective disorder there is good evidence for ECT, mood stabilisers (esp. carbamazepine), and early use of antidepressants; psychotic symptoms should be treated with usual protocol (see pp. 198, 199, 200, 201). Edinburgh Postnatal Depression Scale (EPDS)1 As you have recently had a baby, we would like to know how you are feeling. Please UNDERLINE the answer which comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today. I have been able to laugh and see the funny side of things As much as I always could/Not quite so much now/Definitely not so much now/Not at all I have looked forward with enjoyment to things. As much as I ever did/Rather less than I used to/Definitely less than I used to/ Hardly at all * I have blamed myself unnecessarily when things went wrong. Yes, most of the time/Yes, some of the time/Not very often/No, never I have been anxious or worried for no good reason. No, not at all/Hardly ever/Yes, sometimes/Yes, very often * I have felt scared or panicky for not very good reason. Yes, quite a lot/Yes, sometimes/No, not much/No, not at all * Things have been getting on top of me. Yes, most of the time I haven’t been able to cope at all/ Yes, sometimes I haven’t been coping as well as usual/ No, most of the time I have coped quite well/ No, I have been coping as well as ever * I have been so unhappy that I have had difficulty sleeping. Yes, most of the time/Yes, sometimes/Not very often/No, not at all * I have felt sad or miserable. Yes, most of the time/Yes, quite often/Not very often/No, not at all * I have been so unhappy that I have been crying. Yes, most of the time/Yes, quite often/Only occasionally/No, never * The thought of harming myself has occurred to me. Yes, quite often/Sometimes/Hardly ever/Never Response categories are scored 0, 1, 2, and 3 according to increased severity of the symptoms. Items marked with an asterisk are reverse scored (i.e. 3, 2, 1, and 0). A total score of 12+ is regarded as significant. References 1 Cox JL, Holden JM, Sagovsky R (1987) Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. BJP 150, 782–6. P.758
Transsexualism Transsexualism is characterised by the feeling of one’s gender being different from one’s biological sex. The characteristic statement made by male to female transsexuals is ‘I feel like a woman trapped in a man’s body’. This describes the core clinical feature of these patients which is an enduring belief that they are ‘really’ of the opposite sex. This is associated with marked unhappiness and discomfort in the birth sex and a persistent desire to live and be treated as a member of the opposite sex. Transsexuals usually come to psychiatric attention, not because they wish to change these feelings, but in order to gain the psychiatrist’s support for undertaking sex reassignment surgery (SRS). SRS is a contentious treatment whose early reported successes have been disputed. In addition it is expensive and irreversible and so if it is to be considered, extreme care in the selection process is required. Assessment should be by a specialist in gender identity disorders, working in close liaison with the surgical team. The aim is to make the diagnosis, to offer alternative treatments, to provide supportive psychotherapy, and to supervise the real-life test. Aetiology Unknown primary cause. Most transsexuals report that their beliefs about their gender were present from early childhood. Karyotype and phenotypic development is normal. Epidemiology Prevalence of 1 in 30 000 for male to female (MTF) transsexuals and 1 in 100 000 for female to male (FTM) transsexuals. MTF to FTM ratio is 3–4:1 in most samples. Differential diagnosis Transvestism (the wearing of clothes of the opposite sex for sexual or other purposes, not associated with the core belief of incorrect gender found in the transsexual); intersexed condition (ruled out by normal karyotyping and normal primary and sexual characteristics for the birth sex); schizophrenia (occasionally associated with a delusion that the patient is the wrong sex or is changing sex). Comorbidity Deliberate self-harm and suicidal gestures are common and may be directed at underscoring the need for surgery. Genital mutilation is rare. Some MTF transsexuals work in the sex industry and have consequent increased risk of STDs and HIV infection. Assessment Many such patients will arrive with their diagnosis (‘I am a transsexual’) and preferred treatment option (hormones and sex reassignment surgery) already fixed in their minds. The aim of assessment is to establish the diagnosis with certainty. Contraindications to treatment are psychotic illness, major depression, substance misuse, and personality disorder. Treatment

  • Psychological treatments Aimed at altering the core beliefs. Ineffective in the majority of cases and are generally not welcomed by the patient. If the diagnosis of transsexualism is made then the psychiatrist’s role is supervision of the transition, with liaison with the primary care and surgical teams and psychological support during the inevitable difficulties.
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  • Real-life test Most centres require a successful ‘real-life test’ of at least one year prior to consideration for surgery. During this time the patient undertakes to live full time and attempt to find employment in the new sex. Patients will change their name and ‘come out’ to friends and family.
  • Hormones Oestrogen treatment in MTF transsexuals produces diminished libido and erectile function, some breast and hip development, and skin softening; there is no effect on voice pitch and speech therapy may be required to produce an acceptable female vocal pattern. Androgen treatment in FTM transsexuals produces muscle development, some lowering of vocal pitch, male pattern of bodily hair development, and amenorrhoea.
  • Surgery For MTF patients surgery involves orchidectomy and penectomy with vaginoplasty using penile skin. The cosmetic results can be good, although candidates vary in their ability to be orgasmic post-surgery. For FTM patients surgery involves bilateral mastectomy, hysterectomy, and bilateral salpingo-oopherectomy. Phalloplasty is undertaken in less then half of patients as current techniques are neither cosmetically acceptable or functional for penetration.

Prognosis No RCT are available comparing SRS with other treatment. Cohort follow-up studies report >90% of patients reporting improvement following SRS on measures of psychological adjustment, absence of regret, and vocational adjustment. P.760
Assessment prior to liver transplantation For patients with end-stage liver disease, a liver transplantation offers the prospect of significant improvement in their mortality and quality of life. There is no equivalent in liver failure to kidney dialysis and the supply of donor livers is less than the number of potential recipients. Because of this, patients requiring liver transplantation will suffer declining health while awaiting transplantation and 10–20% of listed patients will die while awaiting transplant. This places a responsibility on the assessing team to consider carefully each potential candidate for listing for transplantation in order to ensure the best use of the donor livers. Psychiatric assessment of patients prior to listing for liver transplantation may be requested in the following situations:

  • Fulminant liver failure following overdose (usually paracetamol)
  • Liver disease secondary to alcoholic liver disease (ALD)
  • Patients with history of mental illness
  • Patients with previous or current drug misuse.

The involvement of the psychiatrist in the assessment prior to listing for transplantation should in no sense be a moral judgement as to the patient’s suitability. The issues are whether there are psychiatric factors which would jeopardise the survival of the donor liver. The psychiatric opinion may have the most profound implications for the patient and so assessment should be as thorough as time allows. In addition to taking psychiatric history and MSE, family members, GP, and hospital case records should be consulted. Fulminant liver failure This will often follow on from a late presenting paracetamol overdose. At the point patients are seen it is often unclear whether they are going to recover or to deteriorate to the point of requiring transplant. They should be seen as soon as possible after presentation as encephalopathy may develop as their condition worsens. The issue is whether there is: ongoing intent to die or refusal of transplant (which would normally preclude transplantation); or whether there is a history of repeated overdoses in the past, significant psychiatric disorder, or ongoing drug or alcohol misuse (which would be relative contraindications). Liver disease secondary to ALD Suitably selected patients transplanted for ALD have similar outcomes in terms of survival and quality of life to patients transplanted for other indications. Units will have individual policies regarding these patients which should be consulted if available. The issue is whether the patient, who has already damaged one liver, will damage a second. There is a wider issue of maintaining the public confidence in the appropriate use of donated organs. Consider:

  • How long have they been abstinent (is there independent verification of this)?
  • Do they accept alcohol as the cause of liver failure?
  • Do they undertake to remain abstinent post-transplant?
  • Do they have a history of dependence or harmful use?
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  • What is their history of involvement in alcohol treatment services and in the past, how have they responded to relapse?
  • When were they told that their drinking was causing liver damage, and what was their response?

Given the above findings and your routine psychiatric assessment, the transplant team will seek your opinion as to:

  • The patient’s psychiatric diagnosis.
  • Their risk of relapse.
  • Their risk of re-establishing harmful/dependant drinking.
  • The potential for successful intervention should this occur.

History of mental illness/drug misuse Generally speaking a diagnosis of mental disorder (other than progressive dementia) will not preclude transplant. The important issues are whether the mental disorder will affect compliance or longer-term mortality in its own right. Close liaison with the patient’s normal psychiatrist is clearly crucial here. Ongoing substance dependence is generally a contraindication to transplantation and should be addressed before listing.

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