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Psychiatry and medicine

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Title: Psychiatry and medicine


1
Psychiatryandmedicine
2
Introduction.
  • Thousands years ago, people of Mesopotamia ( the
    land of two rivers ) used to treat their patients
    with magic, chemicals extracted from herbs, if no
    help by prayers begging for cure from Gods.
  • They used to have many Gods God of medicine (
    Nun-asu ) , God of knowledge ( Nun-Keseda who
    was represented by as a stick snake.
  • They use to differentiate between the magician (
    Aspu ) the doctor ( Asu ).
  • Many prescriptions were found in the ruins of the
    Iraqi civilization,written on bars of clay in old
    Iraqi script ( cuneiform writing of Sumer ).

3
Introduction ( cont.)
  • Abn-sina, during Abbasian times, was the first to
    describe the effect of psyche on the body ( what
    is known as psychosomatic now a day ) in the case
    of young man who was emaciated because he
    couldn't marry the girl he loved, by monitoring
    his pulse while mentioning special places in the
    town, the pulse, he noticed, increased while
    approaching the house of his love due to the
    emotion it stirred.
  • Al-razi said that doctors must always persuade
    patients that they would be cured from their
    sufferings.
  • ??? ?????? ?? ???? ?????? ????? ???????.

4
Psychiatry and Medicine
  • Physical psychiatric symptoms occur commonly
    together in patients who consult doctors.
  • Psychiatric disorder often presents with physical
    complaints.
  • Psychological symptoms are a frequent consequence
    of acute chronic organic illness.
  • At least a quarter of patients with physical
    complaints can be diagnosed as suffering from
    psychiatric disorder.

5
Associations between physical and psychiatric
disorder.
  • Chance association physical psychiatric
    disorders are both common.
  • Psychological factors as a cause of physical
    disorder.
  • Psychiatric complications of physical illness
    its treatment ( e.g. heart disease, delirium
    dementia ).
  • Some psychiatric disorders can cause physical
    symptoms ( e.g. palpitation in an anxiety
    disorder ).
  • Physical complications of psychiatric disorder (
    e.g. deliberate self- harm, eating disorders ).

6
Epidemiology
  • Unexplained physical symptoms are among the
    commonest reasons for seeking treatment are
    often due to psychiatric disorder.
  • Psychological problems are especially frequent in
    accident emergency ,gynaecological medical
    out-patient clinics, medical geriatric wards.
  • Affective disorders are common in younger women,
    organic mental disorders in the elderly
    drinking problems in young men.
  • About a quarter of patients in medical wards have
    a psychiatric disorder of some kind..
  • 15 of o.p. with definite medical diagnosis have
    an associated psychiatric disorder.
  • 40 of those with no medical diagnosis have a
    psychiatric disorder.

7
Psychological complications of physical illness.
  • Most people are resilient when ill and carry on
    without undue distress.
  • About a quarter of cases may have substantial
    psychological impact.
  • Disturbances of mental state, which may be severe
    enough to be classified as psychiatric disorder.
  • Impaired quality of life.
  • Unnecessarily poor physical outcome.
  • Adverse effects on family and others.
  • Inappropriate or excessive consultation.
  • Poor compliance with treatment.

8
Common psychiatric disorders in the physically ill
  • More common ( adjustment, depressive, anxiety
    disorders delirium).
  • Less common ( somatoform disorders, dementia,
    panic phobic disorder, p.t.s.d.,mania,
    schizophrenia delusional disorders.
  • The usual reaction to acute illness ( anxiety,
    depression, delirium complete or partial denial
    of the diagnosis ).
  • In disabling chronic illness ( adjustment,
    anxiety depressive disorders ).
  • Major medical surgical treatments are also
    important causes of psychological symptoms.
  • Drug treatment ( depression, delirium, psychotic
    symptoms elation).
  • Chemotherapy of cancer ( cause very great
    distress ).
  • Radiotherapy ( anxiety depression ).
  • Surgical treatment ( anxiety before after
    operation ).

9
Medications reported to cause depression.
  • Cardiovascular drugs ( Alpha-methyldopa,
    Reserpin, Propranolol, Guanithidine, Clonidine,
    Thiazide diuretics, Digitalis).
  • Hormones ( Oral contraceptives, A.C.T.H.,
    Anabolic steroids ).
  • Psychotropics ( Benzodiazepines, Neurotropics ).
  • Anticancer drugs ( Cyclserine ).
  • Anti-inflammatory ( NSAIDs ).
  • Anti-infective agents ( Ethambutol, Sulfonamides
    ).
  • Others ( Cocaine withdrawal, Amphetamines,
    L-dopa, Cimetidine, Rantidine, Disulfiram,
    Metoclopramide ).

10
Medication reported to cause other psychiatric
symptoms.
  • Delirium ( CNS depressants, Digoxin, Cimetidine
    Anti-cholinergic drugs ).
  • Psychotic symptoms Hallucinogenic drugs,
    Appetite suppressants, Sympathomimetic drugs
    Corticosteroids ).
  • Elation ( Anti-depressants, Corticosteroids,
    Izoniazide Anti- cholinergic drugs ).

11
Determinants of the psychological impact of
physical illness.
  • Most anxiety depression following physical
    illness is part of a psychological reaction.
  • Several medical disorders also cause anxiety
    depressive symptoms directly ( Parkinsons
    disease, stroke, infections, endocrine disorders
    malignancy).
  • Illness factors ( pain, threat to life, course,
    duration disability).
  • Treatment factors ( side effects, uncertainty of
    outcome self-care demands ).
  • Patients factors ( psychological vulnerability,
    social circumstances, other stresses reactions
    of others ).
  • Factors associated with high risk of psychiatric
    problems include ( severity of illness,
    unpleasant treatment vulnerable patients ).

12
Psychiatric assessment of a physically ill
patient.
  • Psychiatric assessment is similar to that of
    psychiatric patient except that it requires
    knowledge of the nature and prognosis of the
    physical illness.
  • Screening questions for psychiatric symptoms (
    e.g. have you been very worried about your
    health? How have you been sleeping? Etc.).
  • Screening questions about the psychiatric
    history.
  • Screening question about social factors.
  • Observation of the patient ( mood behaviour
    during the interview ).
  • If emotional disorder is suspected , take a full
    psychiatric history.

13
Management
  • Some emotional distress is an almost inevitable
    accompaniment of the stress of physical illness
    its treatment, it can be often reduced by
    appropriate treatment. Advice, explanation
    discussion.
  • Treatment of any specific psychiatric disorder is
    similar to that of physically healthy person,
    particular attention should be paid to the side
    effect of the psychotropic drugs.
  • Adjustment disorder needs further opportunity for
    problem solving follow-up.
  • Anxiety disorder, brief treatment with a
    benzodiazepine can be helpful.
  • Depressive disorder can be helped by support or
    problem-solving counselling, but more severe
    requires antidepressant medication.

14
Psychological problem associated with cancer
  • The doctor needs to set aside adequate time to
    explain the prognosis and what treatment can be
    offered
  • Emotional reaction on diagnosis or recurrence is
    manifested by severe distress in the form of an
    adjustment disorder or, in over a third of
    patients, a psychiatric disorder ( anxiety
    depression ).
  • Emotional reactions to surgery, radiotherapy, or
    chemotherapy.
  • Anticipatory nausea with chemotherapy.
  • Organic mental disorder due to metastasis,
    metabolic changes, or chemotherapy.
  • Neuropsychiatric syndrome.
  • Depressive other reactions to terminal illness.

15
Psychological problem associated with accidents
trauma.
  • Psychological factors are important contributory
    causes of accidents ( e.g. overactivity conduct
    disorder in children, alcohol drug abuse in
    young adults, and organic mental disorders in the
    elderly.
  • Following accidents, anxiety depressive
    symptoms are common especially when there is
    injury to the head.
  • Some road accident victims develop phobic travel
    anxiety or, less frequently PTSD.
  • Compensation neurosis ( or accident neurosis )
    has been used for physical or mental symptoms
    caused psychologically and occurring when there
    is an unsettled claim for compensation.
  • Prolonging the disability.

16
Psychological problems associated with myocardial
infarction
  • The sudden onset of severe chest pain frequently
    causes anxiety.
  • In severe infarcts, delirium is frequent.
  • A sizable minority of patients show denial with
    little distress, if denial persist it may lead to
    non-compliant with treatment.
  • In the weeks after an infarct patients
    frequently describe depressive symptoms.
  • A few patients develop a depressive illness and
    this is associated with increased mortality in
    the ensuing month.
  • Cardiac aftercare and rehabilitation concentrates
    on physical fitness should take into account
    anxiety about physical activity, sexual problems
    as well as any depressive disorder.

17
Psychological problems associated with endocrine
disorders
  • Diabetes psychiatric disorders especially eating
    disorder.In advanced cases, cerebrovascular
    diseases, poor glycaemia control may lead to
    cognitive impairment.
  • Hyperthyroidism restlessness, irritability, and
    distractibility may resemble an anxiety disorder.
    Medical treatment usually results in improvement
    in the psychological symptoms.
  • Hypothyroidism in infancy leads to retardation.
    In adult leads to mental slowness, apathy, poor
    memory and occasionally organic mental disorder
    or severe depression. Paranoid symptoms are
    common. Early treatment usually reverse the
    psychiatric symptoms.
  • Cushings syndrom depressive symptoms are
    frequent
  • Corticosteroids treatment depression but a manic
    disorder is more common.
  • Phaeochromocytoma episodic attacks of anxiety
    with blushing, sweating, palpitation, headache,
    and raised blood pressure.

18
Psychological problems associated with movement
disorders
  • Parkinsons disease there is increase incidence
    of dementia depression.Anticholinergics may
    cause excitement, delusions and hallucinations.
    Levodopa may cause delirium.
  • Spasmodic torticollis psychological factors can
    increase the symptoms, however, it is more likely
    to have organic cause.
  • Tics they are more common in childhood than in
    adults.more common in boys than girls. worsened
    by anxiety.
  • Writers and occupational cramps these
    conditions are thought to be psychogenic.

19
Some specific symptoms and syndromes.
  • Chronic fatigue syndrome.
  • Chronic pain.
  • Multiple chronic symptoms ( somatization disorder
    ).
  • Headache atypical facial pain.
  • Non-cardiac chest pain benign palpitations.
  • Irritable bowel syndrome abdominal pain.
  • Dissociative conversion disorders. Hysteria
  • Self-inflicted simulated illness.Factitious
    disorder. Malingering.

20
Management of unexplained physical symptoms
  • Presenting for the first time Appropriate
    physical investigations. Possible psychological
    causes.
  • Treatment Acknowledge reality of the
    symptoms.treat any psychiatric disorder.
  • Persistent symptoms review the need for further
    investigations. Take full psychiatric history.
    discuss with relatives. Cognitive therapy.
  • Failure to improve physical reassessment.
    consider referral to a psychiatrist or clinical
    psychologist.

21
Management of multiple somatic symptoms.
  • Take full history interview relatives.
  • Review medical notes discuss with doctors
    currently involved.Attempt to simplify the
    medical care.perform only essential
    investigations. Minimize the use of psychotropic
    drugs.
  • Arrange brief regular appointments.
  • Avoid repeating reassurance about the symptoms
  • Focus on coping with disability psychosocial
    problems.
  • Encourage gradual return to normal activities.

22
Treatment of chronic pain.
  • Acknowledge the reality of the symptoms.
  • Explain the origin of the pain discuss the
    patients concern.
  • Treat any cause if possible.
  • Agree a regime of analgesics with the patient.
  • Discuss how the patient might cope better with
    the pain.
  • Involve the family in the management plan.
  • Consider antidepressant medication.

23
Psychiatric services in general hospital
  • In large hospital psychiatric advice is needed
    from a special consultation liaison service.
  • Emergency service for patients admitted after
    deliberate self-harm.
  • Emergency consultation for other accident and
    emergency department attenders.
  • Consultation service for in-patients.
  • Out-patient care for patients referred with
    psychiatric complications of physical illness or
    functional somatic symptoms.
  • Regular liaison visits to selected medical,
    surgical and gynaecological units in which
    psychiatric problems are especially common ( e.g.
    neurology, renal dialysis, terminal care ).

24
Psychiatric emergencies in general hospital
practice.
  • Thorough clinical assessment, like any other
    medical emergency.
  • Establish a good relationship with the patient,
    to take a brief history, observe behaviour, and
    assess the mental state.
  • When the patients behaviour is very disturbed,
    the history may be taken from other people such
    as relatives or nurses.
  • Mistakes will be avoided and time saved if the
    assessment is as complete as the circumstances
    permit.

25
Acute disturbed behaviour and violence.
  • Delirium, schizophrenia, mania, agitated
    depression and alcohol drug-related problems
    are the most common.
  • The first task is to assess the risk of violence.
  • Arrange for adequate help to be available.
  • The doctor should appear calm and helpful, avoid
    confrontation, and try to persuade the patient to
    talk about the reason for his anger.
  • If the patient responds so aggressively, restrain
    should be accomplished quickly by an adequate
    number of people.
  • Help of the police may be required for patient
    thought to possess any of offensive weapon.

26
Drug treatment of disturbed or violent patients.
  • If a patient is very frightened, and reassurance
    fails, oral or parental diazepam (5-10 mg ) is
    useful.
  • If the patient is more disturbed, rapid calming
    can usually be achieved with 2-10 mg of
    haloperidol injected I.v or I.m.
  • Chlpopromazine (75-150 mg. I.m. ) is more
    sedating, but more likely to cause hypotension.
  • Extrapyramidal side effects may require treatment
    with an antiparkinsonian drug.

27
Psychiatric aspect of obestetrics and
gynaecology.
  • Pregnancy ( unwanted pregnancy, hyperemesis
    gravidarum, pseudocyesis couvade syndrome ).
  • Loss of a fetus stillbirth.
  • Post-partum mental disorders ( maternity
    blues, puerpural depression psychosis).
  • Menstrual disorders ( premenstrual syndrome, the
    menopause hysterectomy).

28
The impact of culture on physical illness.
  • Consultation- with the increasing health
    services available, people of the Emirates like
    other Arab countries, started to attend hospital
    other health facilities seeking medical
    treatment. Islam believers know that illnesses
    are both God creation God who will cure. The
    doctors are intermediate, try to ease people
    sufferings until cure or death.
  • Interview- Emirates like other developing
    countries are keen on expressing their suffering,
    but few found it difficult may even think that
    doctors must know by his talent what they are
    suffering from.

29
The impact of culture on physical illness (
cont.).
  • Examination- Some found it difficult to be
    exposed for examination especially so the
    genitalia taboo . Orthodox Moslems found it
    most difficult to let women be examined by male
    doctor especially so in obstetric gynecology.
  • Investigations treatment- As far as faith in
    the doctors ability to help, most will be
    copmliant with the investigation procedure
    treatment.
  • Follow up- Prefer to attend some doctors, who
    appears to be empathic understanding
    preferably of high qualifications speaking
    their own language.

30
The impact of culture on mental illness.
  • Consultation- Still some patients are forced to
    attend faith healers. Faith healers especially
    those who practice reading Quraan have a very
    strong effect on believers, who believe in the
    miracle of reciting verses from The holly Quraan.
    Prophet Mohammed said honey Quraan are the cure
    for body soul.
  • ????? ????????? ????? ???????.
  • Interview- Face some difficulties because of
    poor verbal expression poor mental health
    education. Arabic speaking doctors will help to
    overcome these difficulties explain the nature
    of the mental illness to the patient or his
    family.
  • Management- The believes that witchcraft, evil
    eye gini causing mental illnesses are
    decreasing leading most people to attend
    psychiatric clinics.
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