Psychiatric disorder in elderly & consultation-liaison psychiatry

Name: Nur Aisyah Binti Idris082012100068

Contents

• Schizophrenia• Mood disorder• Consultation-liaison psychiatry

Schizophrenia

Epidemiology• 2001, 24 million people worldwide suffer from

schizophrenia• Prevalence is about 0.5-1%• Incidence is about 0.5/1000• Occur later in women

Schizophrenia

• Characterized by disturbances in thought & verbal behavior, perception, affect, motor behavior & relationship to the external world

• Diagnosis based on clinical feature

Clinical features• Thought & speech

disorders– Autistic thinking– Loosening of association– Thought blocking– Neologisms– Mutism, poverty of

speech, poverty of ideation, echolalia, preservation, verbigeration

– delusion

• Disorder of perception– Visual hallucination– Auditory hallucinations

• Elementary auditory hallucination

• Thought echo• Third person hallucination• voices commenting on

ones action

• Disorder of affect– Apathy, emotional blunting,

emotional shallowness, anhedonia, inappropriate emotional response

• Disorder of motor behavior– Decrease– Increase– Mannerism, grimacing,

decreased self care, poor grooming

– Catatonic features ( catatonic type)

• Negative symptoms– Lack of initiative ass with

psychomotor slowing– Asociality, anhedonia, alogia

• Other features• Decreased functioning in

work, social, self care• Loss of ego boundaries• Multiple somatic symptoms• Insight is absent & social

judgment poor

Suicide in schizophrenia

• Presence of co-morbid depressive symptoms• Command hallucinations• Impulsive behavior• Presence of anhedonia

Clinical types

• Classified into several subtypes:– Paranoid schizophrenia– Hebephrenic schizophrenia– Catatonic schizophrenia– Residual schizophrenia– Undifferentiated schizophrenia– Simple schizophrenia– Post-schizophrenic depression– Others

Nuclear schizophrenia

Paranoid sc.

• Delusion of persecution, reference, grandeur, control• Hallucination-have a persecutory/grandiose contents• No prominent disturbances of affect, volition speech & motor behavior• Insidious, later in life, progressive& complete recovery does not occur• Functional capability is slightly impaired• Dd(x): delusional disorder, paranoid personality disorder

Hebephrenic sc.

• Marked thought disorder, incoherence, severe loosening of associations• Delusion & hallucination fragmentary & changeable• Emotional disturbance, mannerism, mirror gazing• Poor self care, impaired social and occupation functioning, social withdrawal• Insidious, early 2nd decade, progressive & downhill, recovery is poor

Catatonic Sc.

• Marked disturbances of motor behavior, in addition to the general guideline of Sc• 3 form of clinical : excited catatonic, stuporous catatonic, alternating catatonic,• Onset in late 2nd & early 3rd decade, course is episodic, recovery from episode usually

complete

Residual & latent Sc

• Residual Sc. Similar to latent & symptoms are similar to prodromal symptoms of sc. Diff : diagnose after at least one episode has occurred.

• Prominent negative symptoms with absence of florid psychotic symptoms.

Undifferentiated SC.

• Features of no subtypes are fully present• Features of more than 1 subtypes are exhibited

Simple Sc.

• Most difficult to diagnose• Early onset (2nd decade), very insidious, progressive course, ‘negative symptoms’, vague hypochodriacal, drift down the

social ladder & living shabbily & wandering aimlessly.• Delusion & hallucination absent& if present short lasting & poorly systematized• Prognosis is poor

Post Sc. depression

• Develop depressive features within 12months of an acute episode of sc.• Develop in presence of residual or active features of sc• increased risk of suicide• Important to distinguish the depressive features from –ve symptoms of sc & extrapyramidal ramidal side effect of

antipsychotic medication.

Other subtypes

Pseudoneurotic sc

Schizophreniform disorder

Oneiroid sc

Von gogh syndrome

Late paraphrenia

Pfropf sc.

Pseudoneurotic Schizophrenia

• Ist describe by Hoch & Polatin

• Initial phase-predominant neurotic symptoms last for years & show poor response to treatment

• 3 classical features: pan anxiety, pan-neurosis, pansexuality

Schizophreniform disorder

• features of sc as diagnostic criteria

• Duration is less than 6 months

• Prognosis is better• Introduce by Langfeldt

(1961)-to designate good prognosis cases

• ICD-10 called acute schizophrenia –like psychosis

Oneiroid schizophrenia

• By Mayer –Gross• Acute onset, clouding of

consciousness, disorientation, dream like states & perceptual disturbances with rapid shifting

• Episode is usually brief

Van Gogh syndrome• Dramatic self-mutilation

occur schizophrenia• After the name of famous

painter Vincent Van Gogh

Late paraphrenia

• By Sir Martin Roth • Occurs late in life (6th decade)• MC in women,

unmarried/widowed• Delusion of persecution with

bizarre & fantastic content• Hallucination of all kind can

be present• At present –under paranoid

sc late onset type

Pfropf schizoprenia

• Syndrome of sc occurring in presence of mental retardation

• There is often a poverty of ideation & delusion not usually very well-systematised

• Behavioral disturbances much more prominent than delusion & hallucinations

Type 1 & type 2 schizophrenia• Tj Crow divided SC. Into 2 subtypes• Type 1-positive symptoms• Acute presentation, good response

to medication, good outcome• Type 2-negative symptoms• Chronic in course, have poor

response to medication & outcome

• Dilated ventricles on CT scan of brain.

Positive symptoms

Negative symptoms

Disorganised symptoms

Delusionhallucination

Affective flatteningAlogiaAnhedoniaAvolitionAttentional impairment

Inappropriate affectDisorganised behaviorThought disorderLoosening of associations

How to diagnose?

• 1st step-exclude psychoses with known organic cause.

• 2nd step-rule out possibility of mood disorder• 3rd step-exclude possibility of other nonorganic

psychoses• 4th step-look also for co-morbid medical &

psychiatric disorder

Prognosis Good prognostic factor Poor prognostic factor

Acute /abrupt in onsetOnset > 35 years of agePresent of precipitating stressorGood premorbid adjustmentCatatonic subtype Short duration (<6months)Presence of depressionPredominance of positive symptomsFamily history of mood disorderFirst episodePyknic physiqueFemale sexGood social supportPresence of confusion, perplexity, disorientation in acute phaseProper treatment, good treatment concordance, good response to treatmentOutpatient treatmentNormal cranial CT scan

Insidious onsetOnset <20 years of ageAbsence of stressorPoor premorbid adjustmentDisorganized, simple, undifferentiated, chronic Catatonic subtype Chronic course (>2years)Absence of depressionPredominance of negative symptomsFamily history of schizophreniaPast history of schizophreniaAsthenic physiqueMale sexPoor social support, unmarriedFlat or blunted affectAbsence of proper treatment, poor response to treatmentinstitutionalisationEvidence of ventricular enlargement on cranial CT scan

Aetiology

• Biological theories– Genetic hypothesis– Biochemical theories– Brain imaging

• Psychological theories– Stress– Information processing

hypothesis – Psychoanalytical theories

• Sociocultural theories

Management

• Somatic treatment– Pharmacological treatment– Electroconvulsive therapy– Miscellaneous treatment

• Psychosocial treatment & rehabilitation

Mood disorder

• Psychological disorder characterized by the elevation or lowering of a person’s mood.

• Emotion can be describe as 2 main types:– Affect: short-lived emotional response to an idea

or an event– Mood: a sustained and pervasive emotional

response which colors the whole psychic life

Classification

ICD-10 classified :• Manic episode • Depressive episode• Bipolar mood (affective) disorder• Recurrent depressive disorder• Persistent mood disorder• Other mood disorder

Clinical features & diagnosisManic episode• Lifetime risk 0.8-1%• Occur in episodes lasting usually

3-4 months, complete clinical recovery

• Future episodes can be manic, depressive / mixed

• Characterized by :– Elevated, expansive/ irritable mood– Psychomotor activity– Speech & thought– Goal-directed activity– Other features– Absence of underlying organic

cause

• cause disruption in occupational & social activities

Depressive episode• Life-time risk of depression in

males 8-12%, female 20-26%• Last for at least 2 week • Features:

– Depressed mood– Depressive ideation/cognition– Psychomotor activity– Physical symptoms– Biological functions– Psychotic features– suicide

Bipolar mood disorder• MDP• Recurrent episode of mania &

depression in the same patient at different times

• These episodes can occur in any sequence

• Further classified into bipolar 1 & bipolar 2

• Current episode in bipolar mood disorder is specified:– Hypomanic– Manic without psychotic symptoms– Manic with psychotic symptoms– Mild or moderate depression– Severe depression, without psychotic

symptoms– Severe depression, with psychotic

symptoms– Mixed – remission

Recurrent depressive disorder• Disorder characterized by

recurrent depressive episodes (at least 2 episode & unipolar)

• Current episode is specified as one of:– Mild– Moderate– Severe without psychotic

symptoms– Severe with psychotic

symptoms– In remission

Persistent mood disorder• Disorder last for >2years • But not severe enough to

labelled as even hypomania or mild depressive episode

• Persistent mild depression dysthymia

• Persistent instability of mood between mild depression & mild elationcyclothymia

Other Mood disorder• Includes the diagnosis of

mixed affective episode• Full clinical picture of

depression & mania present at the same time intermixed or alternate rapidly with each other

Prognosis• Prognosis is better than schizophreniaGood prognostic factors Poor prognostic factors

Acute or abrupt onsetTypical clinical featuresSevere depressionWell-adjusted premorbid personalityGood response to treatment

Co-morbid medical disorder, personality disorder or alcohol dependenceDouble depressionCatastrophic stress or chronic ongoing stressUnfavorable early environmentMarked hypochondriacal featuresPoor drugs compliances

Aetiology

Biological theories– Genetic hypothesis– Biochemical theories– Neuroendocrine

theories

Psychosocial theories– Stress– Cognitive & behavioral

theories

How to diagnose?

• 1st step: exclude a disorder with known organic cause

• 2nd step: rule out possibility of acute & transient psychotic disorder, schizo-affective disorder

• 3rd step: exclude possibility of other non-organic psychoses

• 4th step: exclude possibility of adjustment disorder

Management

Somatic treatment Antidepressant –starting dose 75-150mg imipramine• Asses after 2 weeks, non

improve increase 300mg of imipramine

• SSRI, SNRI newer antidepressant, less anticholinergic side effect, safer drugs to use in elderly

• Uncomplicated depressive episode– Full therapeutic dose of

chosen antidepressant for 6-9 month, after achieving full remission

– Taper antidepressant medication when treatment is to be stopped after the continuation phase

• Refractory to antidepressant medication– A change of

antidepressant – Combination of 2 types

of antidepressant– Augmentation with

lithium– Augmentation with T3 or

T4– Augmentation with

antipsychotic– ECT

Lithium • Treatment of manic episode

& for prevention of further episode in BPD.

• Acute manic episode- antipsychotic + lithium

• Usual therapeutic dose range 900-1500mg lithium carbonate per day.

• Needs to be closely monitored by repeated blood level

• Blood lithium level > 2.0mEq/L toxicity

• >2.5-3.0mEq/L lethal

• Antipsychotic– Risperidone, olanzapine,

quetiapine, haloperidol, aripiprazole

• Mood stabilizers– Sodium valproate,

carbamazepine & oxcarbazepine

• Other treatment• Psychosurgery rarely

used method• Resorted to only

exceptional situation

• Procedure performed:– Stereotactic subcaudate

tractotomy– Stereotactic limbic

leucotomy• Psychosocial treatment– Cognitive behavior

therapy– Interpersonal therapy– Behavior therapy– Group therapy

Other syndrome of depression & mania

Involutional melancholia• By kraepelin• Severe depression

occur in the involutional period of life (40-65)

• Marked agitation, presence of psychotic features, multiple somatic symptoms

Mixed anxiety depressive disorder• Presence of depressive &

anxiety symptoms which result in significant distress/ disability

• Important to consider diagnosis of either mood disorder or anxiety disorder.

Masked depression • Depressive mood is not

easily apparent & usually hidden by somatic symptoms

• Common in elderly• A more detail

examination will bring out the tell-tale symptomatology of depression

Depressive equivalents• Not apart of the

depressive syndrome but still comparable to depression (affective spectrum of disorders)

• Show clinical response to antidepressant

• Disorder include agoraphobia, chronic pain, paresthesia, panic attack, alcoholism, drug abuse, hysteria, OCD

Double depression• Major depressive episode,

superimposed on an underlying dysthymia or neurotic depression

Agitated depression• Severe depression +marked motor

restlessness or agitation• Seen alone or along with

involutional melancholia• Treat: antidepressant +

antipsychotic/benzodiazepine

Secondary depression & secondary mania• Occur secondarily to certain

physical disease & drugs

Seasonal mood disorder• Either bipolar/ recurrent

depressive episode

• More commonly in women• Tends to occur in same

season on each occasion

• Depressionwinter• Maniasummer• Due to changes in length of

the day & effect on hypothalamus

Neurotic depression• Characterized:

– Presence of mild to moderate depression– Depressive symptoms occur in response to stress but quite

disproportionate– Other neurotic symptoms often present– Preoccupation with stressful condition

• Course is chronic with fluctuation• Other common features

– Reactivity of mood is preserved– May be insomnia /hypersomnia– Mood may be worse in the evening – Suicidal threats & gestures are more common than complete suicide

consultation-liaison psychiatry

• consultation-liaison psychiatry a.k.a consultative psychiatry or Liaison psychiatry

• the branch of psychiatry that specializes in the interface between general medicine and psychiatry

• taking place in a hospital or medical setting.

• Liaison psychiatry has areas of overlap with other disciplines including psychosomatic medicine, health psychology and neuropsychiatry

• The role of the consultation-liaison psychiatrist is to see patients with comorbid medical conditions at the request of the treating medical or surgical consultant or team.

• Referrals are made when the treating medical team has questions about a patient's mental health.

Typical issues• Patients with medical conditions that result in psychiatric or

behavioral symptoms• Supporting the management of patients with mental disorder

who have been admitted for the treatment of medical problems.

• Assisting with assessment of the capacity of a patient to consent to treatment.

• patients with medically unexplained physical symptoms.

• Patients who have attempted suicide or self-harm.• Assisting with the diagnosis, treatment and functional

assessment of people with dementia, including advice on discharge planning or the need for long-term care.

References

• A short textbook of psychiatry, Niraj Ahuja, 20th edition

• https://en.wikipedia.org/wiki/Liaison_psychiatry

Thank you