Topic: Psychiatry and Medicine

Lecturer: Dr. Jimenez

In the general population

Physical illness and physical symptoms are associated
with an increase of psychiatric disorder (Wells et al,
1988; Koenkeand Price, 1993
Strong association between somatic symptoms and
psychiatric morbidity in primary care (WHO)

Psychological problems more frequent in ER as well as

gynecological and medical out-patients.
Primary care physicians often fail to recognize
psychiatric disorder in patients with physical illness
(Goldberg, and Huxley, 1980)
Psychiatric and Physical disorders occurring together by
chance
Psychiatric and Physical disorders often
independently of one another and then interact.

Introduction

Affective and adjustment disorders more

common in the elderly
Drinking problems more common in younger
men

Moderate and severe physical disorder was

associated with psychiatric disorder
The more medically unexplained symptoms, the
higher the association with psychiatric disorder
Medically unexplained symptoms were more
common than those with a physical explanation
Medically and non-medically explained
symptoms often occurred together (Kisely and
Goldberg 1996; Simon et al; Kisely et al 1997;
Simon 2000.)

arise

Psych do may affect the patients response to

physical symptoms and increase the problems of
medical management

Eating disorder and diabetes

Depression and MI

Physical illness may lead to deterioration of

psychiatric do

DM or hypertension and depression

Psychological factors affecting the onset and course of

physical illness

GALANG.E.GARCIA.J.SANTOS.VENTENILLA

1. Psychiatric and psychological

disorders
occurring together by chance
2. Psychological factors affecting the onset and
course of physical illness
3. Psychological factors contributing to medically
unexplained symptoms
4. Psychological and psychiatric consequences of
physical illness
5. Psychiatric
problems
with
physical
complications

Outline:

In general hospital in-patients, outpatients and

emergency rooms more than 25% of patients in
medical wards have a psychiatric disorder

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Main message:
Psychiatric disorders and some
psychological symptoms that are not severe enough to
satisfy the diagnostic criteria for a psychiatric disorder
are frequently encountered by primary care physicians.
Therefore, problems should not be missed.

Medically unexplained symptoms are extremely

frequent in the general population (Mayou et al 1995;
Simon 2000)

Minor transient symptoms

Persistent symptoms and syndromes, often
associated with psychiatric disorder
Factitious disorder
Factitious disorder by proxy
Malingering

Epidemiology

Common
More frequent in women than in men
Can cause absenteeism, frequent doctor
consults; taking meds and distress (Koenke and
price 1993); von Korff et al 1998)

Etiology: interaction of physiological, pathological and

psychological variables
1. Starts with bodily sensations awareness of
abnormal heart rate
2. Mental state (concern and anxiety result in
focusing on the subjective symptoms and make
the perception of the symptom worse-anxiety
leads to panic

Major pathology
Minor pathology

Childhood illness
Family illness and consultation in childhood
Childhood consultation and school absence
Physical illness in adult life
Experience and satisfaction with medical
consultation
Illness in family and friends
Publicity in television, newspapers, internet
Knowledge of illness and its treatment

Association with psychiatric disorder

Majority are not associated with psychiatric disorder
Persistent are likely to be associated with psychiatric
disorder

Usually anxiety and depression

Assessment

Some causes of bodily sensations

Illness experience which may affect interpretation of

bodily sensations and concern

Consider psychological factors from onset

Appropriate physical investigation to exclude
physical cause
Clarify psychological and physical complaints
Clarify previous personality and concerns about
physical illness
Understand patients beliefs and expectation
Identify depression or other psychiatric disorder
Identify psychosocial problems

General principles of
unexplained symptoms

treatment

of

medically

Sinus tachycardia and benign minor arrhythmias

Effects of fatigue
Hangover
Effects of overeating
Effects of prolonged inactivity
Autonomic effects of anxiety
Lack of sleep

Emphasize that symptoms are real and familiar

and that medical care is appropriate
Provide physical treatment for any associated
established disease and co-ordinate physical
and other care
Offer explanation and discuss
Allow patients and families to ask questions
Discuss the role of psychological factors in all
medical care

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Physiological processes

Treatments suitable for non-specialist care

Discussion and explanation of etiology

Treatment of any minor underlying physical
problem
Anxiety management
Advice on diary monitoring and graded return
to full activities
Specific self-help programmes
Involvement of relatives and explanation of the
treatment

Chronic Fatigue
Also post-viral fatigue syndrome; neurasthenia;
myalgic encephalomyelitis

Psychotic, melancholic, or bipolar depression

Psychotic disorders
Dementia
Anorexia or bulimia nervosa
Alcohol or other substance abuse
Severe obesity

Possible causal factors in chronic fatigue syndrome

Biological

Precipitating Perpetuating

Genetic
Previous
depression

Virus

Stresses

Clinically evaluated, medically unexplained

fatigue of at least 6 months duration that is:

Of new onset
Not result of ongoing exertion
Not substantially alleviated by rest
A substantial reduction in previous level of
activities

The occurrence of 4 or more of the following

symptoms:

Subjective memory impairment

Sore throat
Tender lymph nodes
Muscle pain
Joint pain
Headache
Unrefreshing sleep
Post-exertional malaise lasting for more than 24
hours

Does not have

HPA
axis
disturbance
Inactivity

Psychological Personality
Response to Disease
(perfectionism) stress
attribution
Avoidant
coping style
Social

Case definition of chronic fatigue syndrome

Predisposing

Life conflicts
Iatrogenic
factors

Assessment

Exclude any treatable organic or psychiatric

cause of chronic fatigue
Detailed description of course of symptoms and
their consequences for the patient
Inquire about depression
Acknowledge the reality of the patients
symptoms and the disability associated with
them
Provide appropriate information to patient and
family
Encourage return to normal functioning
Provide help with occupational and practical
problems

Irritable Bowel abdominal pain or discomfort, with or

without an alteration of bowel habits, persisting for
longer than 3 months in the absence of any
demonstrable organic disease

Active, unresolved or suspected disease

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Treat any primary psychiatric disorder

Agree on a treatment plan

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Fibromyalgia- syndrome of generalized muscle aching,

tenderness, stiffness, and fatigue, often accompanied
by poor sleep
Factitious disorder- intentional production of feigning
of physical or psychological symptoms which can be
attributed to a need to assume the sick role
Malingering fraudulent simulation or exaggeration of
symptoms that is motivated by external incentives
Psychological and psychiatric consequences of physical
illness

Adjustment disorder
Major depression
Anxiety disorder
Somatoform disorder
Substance misuse
Eating disorder
Sleep disorder
Factitious disorder
Sexual disorders

Psychological vulnerability
Social circumstances
Other life stresses

Reactions of others

Family
Employers
Doctors

Some organic causes of common psychiatric symptoms

Depression

Anxiety

Fatigue

Wekness
Determinants of the occurrence of psychiatric disorder
among physically ill patients

Episodes of epilepsy

The physical disease as a cause of:

Headache
Symptomatic psychiatric disorder
Threat to normal life
Disability
Pain

Nature of the treatment

Side effects
Mutilation
Demands for self-care

Loss of weight

Carcinoma,
infections,
neurological
disorders
including dementias, diabetes,
thyroid disorder, Addisons
disases,
Systemic
lupus
erythematosus
Hyperthyroidism,
hyperventilation,
phaeochromocytoma,
hypoglycemia,
neurological
disorders, drug withdrawal
Anemia, sleep disorders,
chronic infection, diabetes,
hypothyroidism,
Addisons
disease, carcinoma, Cushings
syndrome, radiotherapy
Myasthenia gravis, peripheral
neuropathy
Hypoglycemia,
phaeochromocytoma, early
dementia, toxic states
Migraine, giant cell arteritis,
space-occupying lesions
Carcinoma,
diabetes,
tuberculosis, hyperthyroidism,
malabsorption

Some drugs with psychological side effects

Drug
Antiparkisonian agents
Anticholinergic drugs
L-dopa

Side effect
Disorientation, agitation,
confusion,
visual
hallucinations
Acute organic syndrome,

GALANG.E.GARCIA.J.SANTOS.VENTENILLA

Most common response resilience

Unsual emotional response anxiety, then
depression
Psychiatric disorder in up to 30%

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Factors in the patient

Antihypertensives
Methyldopa
Calcium-channel blockers
Clonidine
Sympathetic blockers

depression,
symptoms

psychotic

Tiredness,
depression;

weakness,

Impotence,
depression
Disorientation,
confusion,
disturbance
Weakness,
depression

Digitalis

Diuretics
Analgesics
Salicylamide
Phenacetin

mild

mood
apathy,

Confusion,
agitation,
amnesia
Dementia with chronic
abuse

Antituberculous therapy
Isoniazid
Cycloserine
steroids

Acute organic syndrome

and mania
Confusion,
schizophrenia-like
syndrome

* FIN *
*Yo! Please dont rely solely on this trans, this is just the
more readable copy of the handout that was given to us.
However, we just made it more highlighter friendly and
printer friendly.
If you guys dont have the Kaplan book or ebook (that we
think is pretty vital to this course) heres a link where you can
download it fo sho: www.4shared.com/file/CqtDmSp/Kaplan_and_Sadocks_Synopsis_of.html
Its a chm file. If this link doesnt work, just read the trans and
keep calm.
~Psych trans team OUT~

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THAT IN ALL THINGS GOD MAY BE GLORIFIED.

GALANG.E.GARCIA.J.SANTOS.VENTENILLA