18_Semple_Chap18.indd 766 12/7/2012 3:52:15 PM behavioral DISORDERS AND \200\230CHALLENGING \200\231 behavior 767 relationships, speci \201 c environmental stressors, consistency of care, and lack of stim ulation. Comorbidity Psychiatric disorders may complicate the presentation of behavioral pr oblems, e.g. ADHD (see b p. 726); conduct disorder/ oppositional de \201 ant disorder (see b p. 625); tic disorders (see b p. 632); anxiety disorders (see b p. 639) \200\224fears/ph obias, separation anxiety (see b p. 640), PTSD (see b p. 646), OCD (see b p. 648); depressi ve disorder (see b p. 652); bipolar disorder (see b p. 656); pervasive developmental disord ers (see b p. 630). Identi \201 cation and appropriate treatment may signi \201 cantly im prove behavioral problems. Behavioral phenotypes Many genetic causes of LD are associated with characteristic patterns of behavior. Recognizing these \200\230behavioral repertoires \200\231 may help in diag- nosis and management, and forms the basis for ongoing research into the genetic basis of so me behavioral problems. Examples include: Down \200\231s syndrome (oppositional, conduct, a nd ADHD); fragile X syndrome (autism, ADHD, stereotypies, e.g. hand \202 apping); Lesch \200\223Nyhan syndrome (self- mutilation); Prader \200\223Willi syndrome (OCD, multiple imp ulsive behavior disorder, e.g. hyperphagia, aggression, skin picking); Smith \200\223Mageni s syn- drome (severe ADHD, stereotypies \200\224 \200\230self-hugging \200\231, severe self -injurious behaviors, insomnia); Williams syndrome ( \200\230pseudomature \200\231 language ability in some; initially affectionate and engaging; later anxious, hyperactive, and unco operative). Box 18.4 Criteria for clinically signi \201 cant challenging behavior \200 At some time the behavior has caused more than minor injuries to themselves or others, or d estroyed their immediate living or working environment. At least weekly behaviors requiring intervention by staff; placed them in physical danger; caused damage that could not be rec ti \201 ed; caused at least 1hr of disruption. Behavior has caused over a few minutes \200 \231 disruption at least daily. Qureshi H (1994) The size of the problem. In Emerson E, McGill P, and Mansell J (eds), Seve re mental retardation and challenging behaviors: designing high quality services. London: C hapman and Hall 1 Einfeld SL and Aman M (1995) Issues in the taxonomy of psychopathology in mental retardat ion. J Autism Dev Disord 25: 143 \200\22367. 18_Semple_Chap18.indd 767 12/7/2012 3:52:15 PM CHAPTER 18 Learning disability 768 Management of behavioral disorders At all stages in assessment and management, it is essent ial to involve par- ents, carers, and other allied professionals (e.g. teachers) both as so urces of information and in implementing any proposed interventions. Assessment \200 \200 \200 \200 Exclusion of psychiatric disorder. Exclusion of physical disorder and assessment of general health. Assessment of physical impairments (vision, hearing, etc.). Assessment of communic ation dif \201 culties (including formal speech and language assessment). Assessment of sp eci \201 c cognitive impairments (including formal psychological testing). Identi \201 ca tion of environmental and social factors. Use of behavioral diaries (by carers/staff): ABCs \200\224antecedents, behaviors, consequences. \200 Management Following assessment, speci \201 c factors should be addressed \200\224psychiat ric/ physical causes, reduction of stimuli/reinforcers, modi \201 cation of environ- menta l factors. Approaches may involve: Educational interventions understanding) and for patients (to ensur e educational needs are being appropriately met in a suitable setting). Social intervention s carers, or widen access to other services or facilities (to provide opportunities for soc ial interaction and improve support networks). Facilitating communication of needs Addressi ng impairments of hearing, vision, and language (including use of pictures, sign language, electronic speech devices). Behavioral interventions operant conditioning (e.g. removal of aversive stimuli, rewarding \200\230good \200\231 behavior, use of appropriate attention \200\224 \200\230neutral \200\231 response to attention-seeking behaviors), secondary reinf orcers, modeling, \200\230positive programming \200\231. Cognitive approaches cognitive im pairment and language abilities \200\224may range from counseling on speci \201 c issues t o simple imitation of relaxation/ breathing techniques. Pharmacotherapy (e.g. ADHD \200\224 stimulants; OCD \200\224SSRIs; antidepressant treatment; tic disorders \200\224antipsychoti cs; epilepsy \200\224anticonvulsants). Sometimes a trial of antipsychotic treatment may be useful for serious aggression, hyperactivity, or stereotypies (often depot; caution in epil epsy; increased risk of EPSEs). Other options for aggression, agitation, or self-injurious behaviors (mainly empirical evidence): anticonvulsants, lithium, -blockers, buspirone. Fo r self-injurious behaviors alone there is some evidence for opiate antagonists (e.g. naltre xone). Both for families/carers (to improve To address unmet needs at home, with family/ Modi \201 cation of behavior using At an appropriate level for degree of Treatment for speci \201 c comorbid conditions 18_Semple_Chap18.indd 768 12/7/2012 3:52:15 PM MANAGEMENT OF behavioral DISORDERS 769 Physical interventions (i.e. restraint): from splints and headgear to isolation (to protect individual and others from injury/damage to property). Any intervention should be closely monitored to ensure compliance, acceptability, and thera peutic response. In the case of medication, side- effects should be minimized and if treatm ent is deemed ineffective drugs should be carefully withdrawn (to avoid secondary problems) . 18_Semple_Chap18.indd 769 12/7/2012 3:52:15 PM CHAPTER 18 Learning disability 770 Transition periods Adolescence This may be a dif \201 cult transitional period; issues tha t may require atten- tion include: \200 Engaging with adult services provided by supported mainstream or special schools may lead t o problems if there is not a smooth transition to adult services. Where appropriate (or ava ilable) this may include moving to social educational/ day centers. Some countries have spe ci \201 c legislation to ensure that needs are identi \201 ed early (e.g. \200\230transi tional planning \200\231 from the age of 14 under the UK Education Act 1993). Social/econom ic independence \200 Loss of the additional support Employment sheltered employment, workshops, or supported open employment. Despite changing attitudes, there are considerable barriers to \201 nding work in the open job market, alt hough for some this may be worth pursuing. Living arrangements increase the burden of care shouldered by the family. For some, the wish for independence or the lack of family support may be best met with small group homes where support may be tailored to individual needs. Sexual relationships the fact that people with LD have normal sexual desires, which can be more of a problem for families/carers than the individuals themselves. Nonetheless, issues raised by appropriate sexual relationships will include consideration of contraception, und erstanding of the responsibilities of parenthood, issues of commitment and marriage. Many p eople, particularly with mild LD, are capable of being successful parents and provide a sta ble environment for children with appropriate support. Policy and practice guidelines will often exist on this contentious topic, for example the \200\230Making choices, keeping saf e \200\231 policy in Lothian. Depending on the level of disability, this may be in Loss of additional social supports may actually Societal views may \201 nd it dif \201 cult to accept Later adulthood \200 Changing health needs unrecognized and there may be failure to access services. Patients wi th LD may lack capacity to consent to necessary medical treatment but this should not be al lowed to prevent appropriate treatment. Changing mental health needs These may relate to ch anging symptomatology over time, altered tolerance of medication, and additional speci \201 c age-related cognitive impairment (e.g. due to chronic intractable epilepsy or early- onset Alzheimer \200\231s disease in Down \200\231s syndrome). Ageing carers level of care for their children ought to be considered before a crisis is reached. This requires an ongo ing assessment of the patient \200\231s needs and the carer \200\231s abilities. Increasing reliance on carers may lead to social With increasing age, health needs may go The ability of carers to continue to provide the same 18_Semple_Chap18.indd 770 12/7/2012 3:52:15 PM TRANSITION PERIODS 771 isolation for the patient, and it is prudent to raise the issue of planning for the future at an early stage. Death of carers may produce multiple simultanous dif \201 culties when a patient with LD must cope with bereavement, loss of a familiar home setting, and adjustme nt to new carers and living with other individuals in a group setting. 18_Semple_Chap18.indd 771 12/7/2012 3:52:15 PM CHAPTER 18 Learning disability 772 Family issues Having a child with LD is a major and often unexpected blow to any fam- ily. Individual responses vary, but the majority of parents adapt well to the situation and show remarkable resilience and resourcefulness. Depression is quite common in parents and shoul d not be overlooked. Important positive factors include having a good relationship with the ir partner and the support of relatives and friends. Needs and priorities will vary over ti me and should be identi \201 ed early and addressed collaboratively with the involvement o f parents and other carers in any key decisions (see Needs and priorities b p. 773). Early impact Prenatal diagnostic screening can place parents in the unexpected position of having to make dif \201 cult choices even before the birth of their child. Advice and coun seling are a necessary and important part of the screen- ing process, and should not be ign ored even when testing is regarded as \200\230routine \200\231. The mistaken assumption th at screening \200\230guarantees \200\231 a healthy child may lead to even greater feelings of disappointment and anger, mag- ni \201 ed further by anxious times after the birth, wi th a baby in a special care unit. Although some conditions can be diagnosed at birth, often parents only realize there is a problem when their child fails to reach developmen- tal mi lestones, or develops seizures after an apparently \200\230normal \200\231 infancy. Often the response is one of bereavement (see b p. 388) or guilt, and parents may need support to \200\230work through \200\231 their feelings. The importance of diagnosis Clear diagnosis is essential and may greatly relieve the anxiet ies of many parents who may blame themselves for their child \200\231s problems. It may all ow access to speci \201 c supports including parent groups and support organiza- tions. Th ese can provide valuable support and education and help answer the many questions which par ents have (e.g. usual course, associated problems, prognosis). For inherited conditions, th e issue of further genetic counseling/testing of family members needs to be addressed. Prov ision of clear information allows individuals to make informed decisions about being tested and to weigh the risks of having other affected children. The effect on other family members Although it was previously thought that having a child w ith LD impacted adversely on other unaffected siblings (often leading to the removal of the child from the family), there is little evidence that this is the case and worries about l ong-term damage appear unfounded. In fact, brothers and sisters of individuals with LD ofte n appear to be drawn to the caring pro- fessions and many end up working as doctors, nurses , teachers, or provid- ing support for children with special needs. Grandparents may be a u seful supportive resource for parents, but may also need to come to terms with their own fe elings of having a disabled grandchild. 18_Semple_Chap18.indd 772 12/7/2012 3:52:15 PM FAMILY ISSUES 773 The \200\230burden of care \200\231 For carers, informal support may actually be more valu able than formal (professional) support. Frequent appointments or regular home visits may b e more disruptive than helpful. Developmental delay brings with it asso- ciated problems (e .g. longer time until the child can walk, achieve con- tinence, acquire language/communicat ion skills, establish a normal sleep pattern). The social, \201 nancial, and psychologica l impact on carers should be acknowledged and appropriate help and support provided. For in fants and children, schooling may be both a bene \201 t (in terms of learning social skill s, support/respite for parents, and close contact with teachers/other parents) and a burden (particularly if necessary specialist schooling is not locally available). Transitional pe riods (e.g. adolescence/early adulthood) are accompanied by parental anxieties as well as c hanges in how needs are met (see Transition periods b p. 770). Advance planning will go som e way to alleviate increased carer stress. Carers may also be concerned about what will hap pen to their child when they are no longer able to care for them and the open discussion of these issues, with provisional planning, may help avert crises. Needs and priorities \200 \200 \200 \200 Early, accurate diagnosis. Informative genetic advice to parents and other family members. Access to high-quality primary (and secondary) health care. Advice and access to appropriat e help and support (practical help, \201 nancial assistance, social and educational needs ). Help and advice with any communication problems (communication aids, learning of sign la nguage). Consideration of the needs of carers (education, support groups, respite care). Pr ovision of specialist and domiciliary help with speci \201 c behavioral problems. \200 \230Safety net \200\231 of open access to increased support when necessary. Acknowledgement that needs will change over time (and planning for this \200\224see b p. 770). \200 18_Semple_Chap18.indd 773 12/7/2012 3:52:16 PM This page intentionally left blank 775 Chapter 19 Liaison psychiatry Introduction 776 Working in the general hospital 778 Assessment of depressive and anxiety s ymptoms 780 Assessment of psychotic symptoms and confusion 782 Parasuicide assessment 784 M anagement after parasuicide 786 Depression in physical illness 788 Acute confusional state (delirium) 790 Capacity and consent 794 Medically unexplained symptoms 1: introduction 796 Medically unexplained symptoms 2: clinical presentations 798 Medically unexplained symptoms 3: management principles 800 Somatization disorder 802 Somatoform pain disorder 804 Conver sion (dissociative) disorders 806 Hypochondriasis 808 Body dysmorphic disorder 810 Chronic fatigue syndrome 812 Factitious disorder (Munchausen \200\231s syndrome) 814 Assessment pri or to organ transplantation 816 19_Semple_Chap19.indd 775 12/7/2012 4:30:26 PM CHAPTER 19 Liaison psychiatry 776 Introduction Liaison psychiatry1 is concerned with the assessment and management of psychia tric and psychological illnesses in general medical populations. The subspecialty is a rela tively recent innovation and has expanded consider- ably in both role and practitioner numb ers over the last 25yrs. It offers an opportunity for interesting and varied clinical pract ice and research at the interface between psychiatry and medicine. History The development of a distinct subspecialty of liaison psychiatry arose in large part due to the physical se paration of psychiatric special- ists from their medical and surgical colleagues with the e stablishment of asylums separate from the general hospitals in the nineteenth century. Foll owing this separation, a number of practitioners remained within the general hospitals with a special interest in \200\230nervous disorders \200\231, working at the boundary between neurology and psychiatry. At that time the distinc- tion between the two specialties was n ot as clear as it later became. As neurological practice became more scienti \201 c, the role of psycho- logical factors b ecame less an object of clinical attention for neurologists. At the same time, psychoanalyt ic theories were pre-eminent within psy- chiatry, and interest in, and involvement with, or ganic illnesses declined. However, by the early twentieth century there was increasing atte ntion to psychosomatic factors in the etiology and maintenance of disease and their role in recovery. With the onset of \200\230biological psychiatry \200\231 in the mid-twentieth c entury, a number of pioneering individuals began psychi- atric practice within the general hospitals. They advocated the need for recognition and treatment of psychological factors i n physical illness and began the process of establishing links with medical colleagues, ide ntifying appropriate cases for intervention and gaining funding for service develop- ment a nd research. The development of the subspecialty was motivated by the low rate of outside referral in pr oportion to prevalence of the disorders in the medical population and increasing medical sp ecialization leading to lack of con \201 dence and competence with psychiatric/psychologic al problems in physicians and surgeons. By the 1970s a distinct subspeciality was recog- ni zed in both the UK and the US. It was staffed mainly by sole practition- ers who were gener ally con \201 ned to the larger hospitals. They developed services and established models and ways of working and in particular developed links with individual departments with part icular needs. In the last fourth-century there has been growth in both role and practitione r numbers. This growth has often been service-led, with demand and hence funding from indiv idual clinical services who see the need for regular psy- chiatric input. Roles and respons ibilities The role of the liaison psychiatrist and the types of referral seen will vary by the hospital type, the population served, and the specialty mix within the hospital. \200 Direct consultation on the general wards diagnosis, prognosis, and management of psychiatr ic disorder. Direct liaison with specialist units A closer relationship with a specialist u nit, with involvement in unit planning, staff support, policy Requests for advice on 19_Semple_Chap19.indd 776 12/7/2012 4:30:26 PM INTRODUCTION 777 development, and training as well as involvement in individual clinical cases. Emergency de partment symptoms suggestive of mental disorder, following deliberate self- harm, and of pa tients brought in by the police to a \200\230place of safety \200\231. Outpatient referral s Outpatients referred from general medical, surgical, or obstetric clinics. Some services also take GP referrals, particularly of cases with somatization or medically unexplained sy mptoms. Teaching and training Formal teaching of undergraduate and postgraduate medical tra inees and training of paramedical and nursing staff. Research and audit psychiatric effects of medical illness and into deliberate self-harm. Assessment of patients presenting with Particularly research into the psychological and Presentations The range of psychiatric presentations and disorders seen in the general hosp ital is very wide and liaison psychiatrists can expect to see conditions described in all o f the chapters of this handbook. In our clinical practice we have found the following 12 re ferral types to be the most common. \200 Patients presenting after deliberate self-harm or with suicidal thoughts or plans (b p. 784 ). Assessment of mood or anxiety symptoms ( Issues of consent, capacity, or detainability ( Assessment of confusion or cognitive impairment ( Assessment of psychotic symptoms ( Reque st for advice in a patient with pre-existing psychiatric problems. b p. 470). Patients refe rred during pregnancy or in the puerperium ( Medically unexplained symptoms ( Alcohol or dr ug problems ( Assessment prior to listing for organ transplantation ( Psychiatric symptoms secondary to organic illness (Chapter 5). Eating disorders (Chapter 10). \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 b p. 780). b p. 794). b p. 790). b p. 782). b p. 796). b p. 552, p. 592). b p. 816). 1 The subspecialty is generally known as \200\230liaison psychiatry \200\231 within the UK , but is also referred to as \200\230psychosomatic medicine \200\231, \200\230consultatio n \200\223liaison psychiatry \200\231, and \200\230psychological medicine \200\231. 19_Semple_Chap19.indd 777 12/7/2012 4:30:26 PM CHAPTER 19 Liaison psychiatry 778 Working in the general hospital While working as a psychiatrist in a medical setting you ar e in a sense act- ing as an ambassador for psychiatry1 in general. You may well be the only psychiatrist whom colleagues in other specialties will regularly meet. You should therefor e aim to be available, approachable, considerate, practical, and strive to be a \200\230pr oblem-solver \200\231. In this role as \200\230ambassador for psychia- try \200\231 you wi ll have the opportunity to meet and encourage medical students and doctors in training, som e of whom may not have previously thought of psychiatry as a career. You will also have the opportunity to teach staff in multiple professions and grades, both on a case by case basi s, and during formal teaching sessions. When you \201 rst come to work in the general hospital you may feel overwhelmed. There ar e 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. Additionall y, general hospital doctors in the various specialties will have their own ideas about psyc hiatry, 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 wil l be useful and are not shared by other members of staff. You should rely on these and your own judge- ment, backed up by senior colleagues, in dif \201 cult situations. Taking referrals The person receiving the referral should take details of the patient, thei r GP, their treating team, and the nature of the problem, including its urgency. It is impo rtant to clarify what questions the treating team wants addressed. It is vital to clarify t hat the patient understands that psychiatric referral has been made and agrees to this. Gathering information Where the situation is not an emergency, it is useful to review any d epartmental or other psychiatric records for previous contacts, prior to assessing the pati ent. A discussion with the GP may also be helpful. On arrival on the ward, review the medic al record of this and previous admissions and speak to a senior member of the treating team . Clarify the patient \200\231s diagnosis and any investigations or treatments planned. Dis cuss the patient with the nursing staff \200\224they may have useful information regarding the patient \200\231s symptoms around the clock and their mood day to day. Approach to the patient Arrange a private room for the interview if at all possible. Introd uce yourself to the patient as a psychiatrist or a psychological medicine specialist. Expla in your role, which may be misunderstood by the patient, who may feel you are there to \200\230see if I \200\231m crazy \200\231. Stating that the medical team is concerned about some of the patient \200\231s symptoms and they want a specialist in these symptoms to giv e them some advice is often an acceptable phrasing for patients. 19_Semple_Chap19.indd 778 12/7/2012 4:30:26 PM WORKING IN THE GENERAL HOSPITAL 779 Assessing psychiatric symptoms on the general wards The assessment of psychiatric symptoms in the general hospital is broadly similar to their assessment in psychiatric settings. The re are, however, a number of important differences: \200 The patient \200\231s medical condition, the clinical urgency of the situation or the setti ng (e.g. A&E, ITU) may make full or normal assessment impossible. The patient \200\231s med ical symptoms may confuse the issue: symptoms of psychiatric disorders overlap with those o f many medical conditions. The differential diagnosis and relative likelihood of various ps ychiatric diagnoses is different between the general medical and psychiatric populations. The assessment of depressive, anxiety, and psychotic symptoms and of confusion on the gener al wards is described on b pp. 780 \200\22391, as well as the differential diagnosis for th ese symptoms in the general setting. Management of psychiatric illness on the general wards The pharmacology and psychology of p articular psychiatric disorders is broadly similar in the psychiatric and the general hospi tal setting. The differences relate to factors imposed by the patient \200\231s medical con dition and the environment. When considering medication, consult b pp. 968 \200\22379 which describe the prescribing of psychotropics in speci \201 c medical conditions. Documenting your \201 ndings When documenting your \201 ndings in the medical notes rem ember that the written record has a dual purpose \200\224it acts both to document the clini cal contact and to communicate information about your \201 ndings and opinion. In general , the medical team will be more interested in the opinion and any associated management adv ice than in detailed history or psychiatric formulation. You should avoid any jargon or acr onyms which are speci \201 c to psychiatry. Stating your opinion Aim to speci \201 cally answer any questions you have been asked. If a de \201 nitive 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 \201 ndings with the medical te am face to face. Remember that general hospital doctors will have less experience than you in psychiatric issues and it will be necessary to \200\230spell out \200\231 some things \200\224e.g. what is the implication of detention? What side-effects should they look out f or after antipsychotic prescription? 1 Masterton G (2003) Liaison psychiatry and general hospital management. Br J Psychiat 183: 366. 19_Semple_Chap19.indd 779 12/7/2012 4:30:26 PM CHAPTER 19 Liaison psychiatry 780 Assessment of depressive and anxiety symptoms Depressive symptoms One of the most common re ferrals in liaison psychiatry is of patients with low mood. Apparent low mood is a common p resentation of hypoactive delirium (b p. 790) and so assessment of orientation and basic co gnitive testing is an important part of the assessment of mood symptoms in the general sett ing. If delirium is ruled out, the next step is to assess the nature and severity of the mo od disorder and, if depressive illness is present, to make suggestions as to appropriate ma nagement. Differential diagnosis Depressive illness (b p. 788 and p. 248), hypoactive delirium (b p. 790), normal emotional response to illness or loss, adjustment reactions (b p. 386), drug o r alcohol misuse, depression secondary to organic cause. Organic causes of depressive sympt oms \200 Neurological (CVA, epilepsy, Parkinson \200\231s disease, brain tumor, dementia, multiple s clerosis, Huntington \200\231s disease, head injury) Infectious (HIV and related opportunis tic infections, EBV/CMV, infectious mononucleosis, Lyme disease) Endocrine and metabolic (h ypothyroidism, hyperprolactinaemia, Cushing \200\231s disease, Addison \200\231s disease, p arathyroid disease) Cardiac disease (MI, cardiac bypass surgery, heart failure) Systemic di sease (systemic lupus erythematosus [SLE], rheumatoid arthritis, cancer) Medications (analg esics, antihypertensives, levodopa (L-dopa), anticonvulsants, benzodiazepines, antibiotics, steroids, combined oral contraceptive, cytotoxics, cimetidine) Substance misuse (alcohol, BDZs, cannabis, cocaine, opioids). \200 Key points in assessment \200 ? Examine for orientation and perform a Is there evidence of confusion basic test of cognit ive function (e.g. abbreviated mental test [AMT], MMSE). Acute onset of confusion (or acute deterioration of existing impairment) together with an apathetic, \200\230depressed \200 \231 presentation, is seen in patients with hypoactive delirium (b p. 790). How does the pa tient describe their mood understanding of the patient \200\231s subjective mood. Often ref errals are made without this information because patients \200\230look depressed \200\231. Explore cognitive depressive symptoms may be less useful as diagnostic features in physica lly ill patients \200\224 impairment of sleep, appetite, energy levels, concentration, and libido may be due to depression or may be due to the medical condition itself. For this rea son cognitive symptoms are more important diagnostically: \200 ? It is vital to gain an Biological depressive features Do they describe hopelessness What do they think the future holds for them? Do they think t hings will ever improve? Patients with depressive illnesses tend to maintain ? How do they view their situation? 19_Semple_Chap19.indd 780 12/7/2012 4:30:26 PM ASSESSMENT OF DEPRESSIVE AND ANXIETY SYMPTOMS 781 a gloomy and pessimistic view of the future, while non-depressed patients will often remain optimistic about improvements in their condition and look forward to rehab or discharge. A nhedonia physically able to)? If not, do they still wish they could do those things or have they lost interest altogether? Do they seem to retain pleasure in family visits? Lack of r eactivity indicative of a clinical depression. Are they still doing things they enjoy doing (if they are Are they \202 at in affect? Emotionless? These are more Collateral information who know the patient well. This can add insight into the severity, d uration, and temporal relationship of the symptom course. Obtain information from close family or others Anxiety symptoms Anxiety is a common phenomenon in medically ill patients and may often be viewed as appropriate to their current situation. Where it is severe, prolonged, out of kee ping with the current situation, or is interfering with appropriate medical management it m ay become a focus of clinical atten- tion. Often medical patients don \200\231t meet full d iagnostic criteria for diagnosis of an anxiety disorder \200\224it is important to make an individual assessment and make a decision based on symptom severity and impairment whether treatment would help the anxiety. Differential diagnosis Realistic worry over medical condition, primary medical condition, a lcohol withdrawal, prescribed or illicit drug withdrawal (esp. benzodiazepine or opiate), d rug intoxication (esp. stimulants), generalized anxiety disorder or panic disorder (new or exacerbation of pre-existing disorder), anxiety as part of a depressive illness, speci \201 c phobia (esp. needle phobia). Organic causes of anxiety symptoms \200 Neurological (epilepsy, dementia, head injury, CVA, brain tumor, MS, Parkinson \200\231s di sease). Pulmonary (COPD, asthma, airway-assisted patients on weaning trials). Cardiac (arrh ythmias, heart failure [CHF], angina, mitral valve prolapse). Hyperthyroidism, hypoglycaemi a, metabolic acidosis/alkalosis, phaeochromocytoma. Medications (antidepressants, antihyper tensives, antiarrhythmics). Drugs of abuse (alcohol, BDZs, caffeine, cannabis, cocaine, LSD , ecstasy, amfetamines). \200 \200 Key points in assessment \200 Assess for medical causes for symptoms \201 rst. Has the Medical work-up patient had a co mplete medical evaluation for the physical complaints? Consider substance abuse/ingestion A lways take a drug/alcohol history, and selected patients should have urine drug screen. Pas t psychiatric history disorder that is being made worse by a new medical stressor? ? Do the subjective match the Are there psychological anxiety symptoms objective \201 ndings? Doe s the patient feel like or fear they are going to die? Have a sense of doom? Fear they are going crazy? Does the patient have an underlying anxiety 19_Semple_Chap19.indd 781 12/7/2012 4:30:26 PM CHAPTER 19 Liaison psychiatry 782 Assessment of psychotic symptoms and confusion Psychotic symptoms While referrals for asses sment of apparent psychotic symptoms are com- mon in the general setting, presentations wit h functional psychoses are rare in comparison with psychiatric hospitals. They are seen in the emer- gency department, in patients brought in by police to a \200\230place of safety \200\231 and after self-harm (especially in those using violent or bizarre methods). Howeve r, in the majority of cases in the general hospital psychotic fea- tures represent organic illnesses \200\224commonly delirium, or are part of a withdrawal syndrome. Differential diagnosis Delirium (b p. 790), drug intoxication or withdrawal, alcohol withdr awal, epileptic phenomena (b p. 156), dementia (b p. 132), schizophrenia (b p. 178), acute/ transient psychotic disorders (b p. 226). Organic causes of psychosis \200 Neurological (epilepsy, head injury, brain tumor, dementia, encephalitis, e.g. HSV, HIV, ne urosyphilis, brain abscess, CVA). Endocrine (hyper/hypothyroidism, Cushing \200\231s, hyper parathyroidism, Addison \200\231s disease). Metabolic (uraemia, electrolyte disturbance, po rphyria). SLE ( \200\230lupus psychosis \200\231). Medications (steroids, levodopa (L-dopa) , interferon, anticholinergics, antihypertensives, anticonvulsants, stimulants). Drugs of a buse (cocaine, LSD, cannabis, PCP, amfetamines, opioids). \200 \200 Key points in assessment \200 The nature of any hallucinations characteristic of functional psychoses, while visual hallu cinations (and visual illusions and misperceptions) are seen in organic conditions. Presenc e of \202 uctuations Note whether symptoms are \202 uctuating in nature or associated w ith confusion and/or behavioral disturbance. A waxing and waning picture with alterations i n attention and alertness suggest delirium as opposed to a primary psychotic disorder. Prev ious history previous or current history of drug or alcohol use. Time course of illness pre sent? Was there a gradual or sudden onset? Have previous similar episodes occurred before? Vital signs symptoms. It is helpful to look for any autonomic instability, vital sign chang es, sweating, and tremor which may suggest an underlying withdrawal from alcohol or other s edatives. Such changes would be less likely in a primary psychotic disorder. Auditory hallucinations are Note any previous history of psychotic illness or How long have psychotic symptoms been Withdrawal syndromes can present with psychotic 19_Semple_Chap19.indd 782 12/7/2012 4:30:26 PM ASSESSMENT OF PSYCHOTIC SYMPTOMS AND CONFUSION 783 Confusion A common referral is the request to assess for the severity and possible cause of confusion. A wide range of disorders and insults to the brain produce three common clinica l presentations: (1) acute confusional state or delirium, (2) dementia (progressive or non- progressive), and (3) acute or chronic confusion. A common question is the extent to which a confu- sion re \202 ects acute or chronic de \201 cit \200\224often linked to requests for opin- ion about capacity/consent and placement issues. Another key question is whether there is a reversible component to the condition. Differential diagnosis Delirium (b p. 790), dementia (b p. 132), alcohol withdrawal, drug i ntoxication or withdrawal, Wernicke \200\223Korsakoff syndrome, epileptic phe- nomena, func tional psychoses. Key points in assessment \200 Bedside cognitive testing orientation in time, place, and p erson, and make an objective measurement of confusion (e.g. AMT, MMSE, ACE \200\224 b p. 70 ). Previous history For an accurate account of the previous history in a confused patient i t is vital to have corroboration of the patient \200\231s account \200\224this should ideal ly be by a live-in or close relative or friend, but in their absence a neighbor or GP may p rovide useful information. Note any previous history of cognitive impairment or functional decline; any history of alcohol of drug use; and any history of previous similar episodes. Previous functional level cognitive de \201 cit now, and the level of cognitive function o ver the lifespan, re \202 ected in the educational achievement of the patient and their wo rk status, and their recent cognitive function as re \202 ected in their self-care, etc. M edical status records and nursing notes/observations. Note recent investigation \201 ndin gs, noting particularly any abnormal results or recent changes. Examine drug kardex for any medications associated with confusion \200\224 have any medications recently been started or stopped? Consideration of specialist testing neurocognitive assessment may be helpful. C onsideration of imaging colleagues, consider whether cerebral imaging (e.g. CT, MRI) is ind icated. Assess conscious level (via GCS \200\224 b p. 69), It is important to consider the degree of Note current medical condition as recorded in the case In selected cases specialist In consultation with medical and radiology 19_Semple_Chap19.indd 783 12/7/2012 4:30:27 PM CHAPTER 19 Liaison psychiatry 784 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 men- tal health professionals in t he assessment of patients following parasuicide relates to the following observations: \200 In this population of patients, roughly 1% will die by completed suicide in the 24mths afte r the initial parasuicidal act, with the risk highest in the weeks following the original a ct. This represents a mortality by suicide 50 \200\223100 times that of the general populat ion. The rates of completed suicide are signi \201 cantly raised in all mental disorders e xcepting mental handicap and dementia. Studies examining completed suicides in patients wit h mental illness show inadequate doses of therapeutic drug treatment, increased dropout rat e from follow-up and increased presence of untreated comorbidity. Clear risk factors exist for completed suicide (see Box 19.1) and the closer the parasuicidal patient approximates t o 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 th e mental state.