MRCPsych Leicester 2008
Alex Mitchell, Consultant in LiaisonPsychiatry
Alex Mitchell, Consultant in LiaisonPsychiatry
MRCPsych -Update on Liaison Psychiatry
MRCPsych -Update on Liaison Psychiatry
Five Questions for AudienceFive Questions for Audience
• List any medical disorder with a high rate of
(A) Depression (B) Psychosis (C) Cognitive Impairment (d) Anxiety
• List a psychiatric condition with an organic basis
• List 1 neurological & 1 psychiatric disorder that has a
diagnosis test available
• What causes most disability worldwide?
What is Liaison Psychiatry?
Simple Definition: Psychiatric care in medical settings
UK Definition: Psychiatric Complications of Medical illness
organic conditions=>
How are Psychiatric Disorders Classified?How are Psychiatric Disorders Classified?
MoodPsychosis
Cognition
Unipolar Depression
Bipolar Affective Disorder
Adjustment Disorder
Anxiety Disorders
Post-Partum Affective Disorders
Organic Affective Disorders
Brief Reactive Psychosis
Schizophrenia
Persistent Delusional Disorder
Organic Psychosis
Delirium
Dementia
Organic Amnesic Syndrome
Authors Comments – Psychiatric disorders may be reduced to these three presenting clusters
How do Psychiatric Disorders Present?How do Psychiatric Disorders Present?
TransientRelapsing
Chronic
Acute Stress Reaction
Normal Grief
Adjustment disorder
Brief Reactive Psychosis
Mild Depression
Delirium
Major Depression
Bipolar Affective Disorder
Obsessive-Compulsive Disorder
Schizophrenia
Dementia
Anorexia Nervosa
Personality Disorders
Authors Comments – The presentation of psychiatric disorders can be conceptualized in the following time periods
MoodPsychosis
Cognition
Unipolar Depression
Bipolar Affective Disorder
Adjustment Disorder
Anxiety Disorders
Post-Partum Affective Disorders
Organic Affective Disorders
Brief Reactive Psychosis
Schizophrenia
Persistent Delusional Disorder
Organic Psychosis
Delirium
Dementia
Organic Amnesic Syndrome
Neurological Disease
Parkinson’sEpilepsyMultiple Sclerosis
Alzheimer’s Disease
Head Injury
Stroke
NUS
CNS Tumours
HIV/AIDs
Huntington’s
Tourette’s
CJD
Toxins
MND
Alcohol
Systemic
What Causes Most Disability?What Causes Most Disability?
• Acute lower respiratory infections• Cancer• Cerebrovascular disease• Childhood diseases• Chronic obstructive pulmonary disease• Depression• Diarrhoeal diseases• Falls • Ischaemic heart disease• HIV/AIDS • Malaria• Road traffic accidents• Tuberculosis
Burden of Neuropsychiatric Disease - DALYsBurden of Neuropsychiatric Disease - DALYs
The Impact of Mental HealthThe Impact of Mental Health
Worldwide Causes of Disability
Disease % of All DisabilityAcute lower respiratory infections 7%
HIV/AIDS 6%
Diarrhoeal diseases 5%
Depression 4%
Ischaemic heart disease 4%
Childhood diseases 3.8%
Cerebrovascular disease 3.5%
Malaria 3.1%
Road traffic accidents 2.8%
Chronic obstructive pulmonary disease 2.6%
Tuberculosis 2.3%
Falls 2.1%
Murray CJL, Lopez AD (1997) Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet 349 (9063): 1436-1442.
Western Causes of Disability
Disease % of All DisabilityIschaemic Heart Disease 12%
Smoking 10%
Physical Inactivity 7%
High Blood Pressure 6%
Obesity 5%
Dementia 4%
Depression 4%
Lung Cancer 4%
Poor Diet 3%
High Cholesterol 2%
Illicit Drugs 2%
Murray CJL, Lopez AD (1997) Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet 349 (9063): 1436-1442.
Comments – Psychiatric illness are among the most important causes of disability in young people, and their prevalence is increasing
What Psych Conditions Have A Diagnostic Test?What Psych Conditions Have A Diagnostic Test?
Functional Psychiatric Disorders?Organic Psychiatric Disorders?Neurological Disorders?
Neurosyphilis
Hydrocephalus
SuicidalityMisc. Poisoning Syndromes
Factitious DisorderCarbon Monoxide Poisoning
MalingeringDegenerative DementiasWilson’s Disease
Bulimia NervosaPost-partum psychosisKluver Bucy Syndrome
Somatization DisorderPost-natal depressionNon-degenerative dementia
HypochondriasisMaternity BluesDelirium (often)
Adjustment DisorderAlcohol DependencySleep Apnoea
Acute Stress ReactionAlcohol WithdrawalNarcolepsy
Personality DisordersDrug WithdrawalHuntington’s Chorea
Generalised Anxiety DisorderGilles de la TouretteAlcohol Intoxication or Harmful Use
Mild Depression??Melancholic DepressionIllicit Drug Intoxication
Separation AnxietyPanic AttacksSydenham’s chorea
School RefusalAnorexia NervosaLesch-Nyhan Syndrome
ADHDAutismFragile X
Conditions that have little chance of a diagnostic test
Conditions that NEARLY have a diagnostic test
Conditions with a Diagnostic Test
Examples of Psychiatric Complications
Audience Examples?
CNS Disorder Depression (all types)
Cognitive Deficits
Dementia Psychosis
Alcohol 15% 80% 15% 5%
Epilepsy 20% Unknown rare 5%
Alzheimer’s disease 30% 100% 100% 30%
Head Injury 35% 3% Unknown 3%
HIV dementia 25% 40% 25% 6%
Huntington’s Disease 25% 40% Unknown 8%
Multiple Sclerosis 50% 50% 5% 10%
Parkinson’s Disease 50% 80% 30% 20%
Stroke 50% 50% 20% 5%
Subarachnoid Haemorrhage 20% 30% Unknown Unknown
Normal Control 10% 5% 2% 1%
Examples of Causation
Aetiology of stroke?
Risk FactorsHypertensionSmokingHyperlipidaemiaExerciseGenetic FactorsMedical Illness
Risk FactorsHIV ExposureUnsafe SexBlood transfusionImmunosuppression
Primary PathologyAtheromaEmboli
Primary PathologyHIV in CNS
DiseaseCerebrovascular Accident
PathogenesisMetabolic dysregulation
PathogenesisHypoxia
SyndromeDelirium
ComplicationsAgitationHallucinationsHigh mortality ratePoor Compliance
ComplicationsFallsIncontinenceHigh mortality rateMemory Loss
Aetiology of Ischemic Stroke
Aetiology of Depression in Parkinson’s disease
Risk FactorsParkinson’s diseaseStressful life-eventsGenetic FactorsDisability & handicapMedication
Primary Pathology? Basal ganglia disease
Pathogenesis? Stress hormone dysregulation? Psychological mechanisms
DisorderDepression
ComplicationsParasuicidePoor ComplianceSelf-neglectSocial isolation
Aetiology of HIV Related Delirium
Risk FactorsAlcohol ConsumptionNutritional CompromiseLiver DiseaseMedical Illness
Primary PathologyNeuronal LossSynaptic Degeneration
DiseaseDementia
PathogenesisDirect neurotoxicity
ComplicationsLoss of functionSelf-neglectSocial isolationUnemploymentDisintegration of personality
Aetiology of Alcohol Induced Dementia
Aetiology is ComplexAetiology is ComplexAuthors Comments – Understanding the cause of psychiatric disorders is difficult because they are multifactoral
Classification
Some Important Neuropsychiatric Conditions
Alzheimer’s diseaseAlzheimer’s disease
Fronto-temporal DementiaFronto-temporal Dementia
Huntington’s ChoreaHuntington’s Chorea
Multiple SclerosisMultiple Sclerosis
Vascular Dementia - SPECTVascular Dementia - SPECT
Head InjuryHead Injury
Parkinson’s DementiaParkinson’s Dementia
Cerebral Tumour - MetastasesCerebral Tumour - Metastases
Alcohol – Wernicke KorsakoffsAlcohol – Wernicke Korsakoffs
Questions?
Easily Overlooked SyndromesEasily Overlooked Syndromes
Alcohol Problems
Illicit Drug Problems
Anxiety Disorders
Anger & Irritability
Delirium
Early Dementia
Eating Disorders
Not volunteered?
Not diagnosed?
Not referred?
Not treated?
Symptoms
OccurHelp
SeekingSymptoms
Recognized
Referral
Occurs
Symptoms
Validated
Treatment
Occurs
Authors Comments – Many syndromes are easily overlooked by health professionals leading to unnecessary delays in treatment
Lag time Lag time Lag time Lag time Lag time
years months weeks weeks days
Illness
BeginsIllness
Resolves
Recognition of Depression x 256Recognition of Depression x 256
• Depressed Patients Do Not Seek Help1 in 4 patients seek help
• Depressed Patients Are Not Diagnosed1 in 4 depressed patients are diagnosed
• Depressed Patients Are Not Treated1 in 4 depressed patients are offered treatment
• Depressed Patients Are Not Adequately Treated1 in 2 depressed patients are given appropriate dose
• Depressed Patients May Not Respond1 in 3 only pick up one prescription1 in 3 do not respond to their first antidepressant
Authors Comments – Depression (and other disorders) may or may not be recognized in the community for various reasons