Common presentations of mental distress in physical health conditions - PowerPoint Presentation

1. Common presentations of mental distress in physical health conditionsPeter Byrneconsultant liaison psychiatristRoyal London Hospitalpeter.byrne@nhs.nhs.net

2. 49 y.o. separated woman2/12 of deteriorating mood, energy; currently no interest in life. Suicidal thoughts (e.g. “I want to just get to sleep … and never wake up”); these upset her most days but no intent with no history of self harm.She is already on an antidepressantWhat is your management plan?

3. Additional details1. She has Crohn’s disease, and has stopped leaving the houseStaying in bed 4/weekRecent steroids 2. Three years ago, she discovered husband’s infidelityHe left; she tested HIV +: she told no one3. Following 6 years of sustained physical and sexual abuse by father, that she disclosed at 14: family angry, father left. He died last year – she did not go to funeral. Never had psychological intervention 4. She started Sertraline but when her symptoms (pain, diarrhoea) returned, she stopped this. Lost benefits, now in debt. Additional weight loss.

4. Did you forget to ask about alcohol?

5. What does these cases tell us?Understand that Crohn’s disease (pain, loss of weight AND social functioning) and functional GI Pain are both strong drivers of depression and anxietyReal life outside her / our controlBenefits of history taking: patient is not a bowel support system; she has a past, a present, and a psychological style…Depression is treatable, often missed

6. Medically Unexplained Symptoms, MUS…PPSPatients defined by what they do NOT have… patients have symptoms (pain, dysfunction in a system) where (extensive) investigations can not find any pathology. (MUS? Patients say more tests needed). Stone says NNO: # needed to offendDavid Goldberg defined, then disowned MUSBodily distress disorder, Persistent Physical Symptoms Cost: Dementia (5.6%), mental disorders (5%), MUS (4.8%), cancer & stroke (3.2% each)

7. Stigmatising termsFrequent fliers (intensive service user group)Heartsinkers – (hint: feeling may be mutual)Time wastersDoctor shoppersFat filers (pre-computer notes)AcopicHypochondriacs

8. Functional somatic syndromes, FSSSomatoform disordersMUSConversion disordersOrganic pathology

9. FSS: defined by syndromes (symptoms) rather than objective evidence of disease processOverlap & cause considerable disabilitySymptom cluster decides which clinic(s)…But the three most effective treatments for FSS are (in descending order): CBT, antidepressants and psychosocial treatments, including graded exercise therapy and social prescribing Functional somatic syndromes

10.

11.

12. Aetiology of FSS…MUSEarly experience → Predisposing factors→ Thinking styles → Health anxietyGenetic links for minority of FSS e.g. CFSVariation (X1-X 6) in reporting of child sexual abuseCommon story of precipitant: stress, infection As clinicians move from biomedical to psychosocial explanations of FSS, persuading patients on a similar journey puts the C in CBTByrne (2011): FSS in Hospital Medicine November 2011: 604.

13. Positive diagnosis; stepped care approachRed flags: PR bleeding, weight loss, age > 60 and family history of bowel or ovarian cancerSelf-help (info) + lifestyle changes especially gentle exercise Dietary advice (low FODMAP): MDT approachSymptom-targeted meds (GP or GI clinic)Psychological evaluation… BGS recommends CBT, psychodynamic and SSRIs for general SxIrritable bowel syndrome

14. Stepped careSelf management: quality information sourcesPeer groups: informal, formal… communityPrimary care: GP, nurse, others, outreachLocal community services: district nurse, social careIAPT: improved access to psychological therapySecondary care psychiatry: liaison clinicsSecondary care psychiatry: comm mental healthTertiary care: highly specialist services, ACT

15. Red Flags: adult patients know too Back pain CardiovascularAge over 50.Bladder dysfunction.History of cancer.Immunosuppression.Night pain.History of trauma.Saddle anaesthesia.Lower extremity neurological deficit.Chest Pain on exertionShortness of BreathSymptoms of stroke or TIAAbdominal and Gastrointestinal SymptomsLoss of consciousness or signific lightheadedness Severe headacheVisual Changes.

16. LOW

17. Referral of 33 woman with constipationStarted at high school: “offered a colostomy”Three normal (unassisted) bowel motions / yearAbdomen feels full – three different types of painChart diagnosis of endometriosis; probable migraineSaw Psychology at UCH: no self harm, no psych HxTaught music in Europe – back to mother in mid 20sOE: distressed, not depressed; histrionic traits

18. Topiramate (oral)Tapentadol IR (oral)Zopiclone (oral)Temazepam (oral)Sodium docusate (oral)Cyclizine (oral)Levothyroxine (oral)Folic acid (oral)Hydrocortisone (oral)Norethisterone (oral)Morphine (oramorph) 10mg/5ml PO… On 8 January, 8 separate doses of Oramorph 20 mg.Movicol POMedications on DC

19. Health anxiety+ emeshed rel with her motherAdamant that CBT made her problems worseDeclines SSRIs to treat anxiety and improve sleepBreakdown of relationship with surgical teamAccepted GP letter, recommending psychotherapyACT: acceptance and commitment therapy… to reduce “life draining activities” and reframe symptomsTHAT was Jan 2019; represented to ED on Feb 12.Formulation & Plan

20. Aims of treatmentBiomedicalSymptomsInvestigationsMedicationOperationsDisabilityCuringPsychosocialEngaging with distressBroaden the agendaProblem solvingInvolve relativesRehabilitationCoping

21.

22. ↓Sleep, alcohol, meds