Transcript Diabetes Mellitus

CONSULTATION
AND LIASION
PSYCHIATRY
Prof. M L Adelekan
Consultant Psychiatrist
Royal Blackburn Hospital
Blackburn-UK
Introduction
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Consultation work – Psychiatrist is available to give
opinions on patients referred by physicians and
surgeons.
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Liaison work – Psychiatrist is part of medical or surgical
team, and offers advice about any patient to whose care
he feels able to contribute.
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Consultation approach implicitly assumes that the team referring
possess the skills of assessment and management of psychiatric
patients.
Liaison approach aims to increase the skills of staff in
assessment and management of psychiatric problems.
In practice, most Consultation Liaison psychiatrists (CL
Psychiatrists) combine elements of both the approaches.
The C - L Psychiatrist
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Can play many roles in medical wards:
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A skillful and brief interviewer.
A good psychiatrist and psychotherapist.
A teacher.
A knowledgeable physician who understands the medical
aspects of case.
Tools are interview and serial clinical observations.
Purpose of diagnosis:
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Identify mental disorders and psychological responses to
physical illnesses.
To identify patient’s personality features.
Assess patient’s characteristic coping techniques.
Recommend therapeutic intervention most appropriate to
patient’s needs.
The Psychiatric consultation
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The consultation has two parts:
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Assessment of the patient.
Communication with the referrer.
Assessment:
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Not essentially different from that of any other patient referred for
psychiatric opinion.
Should take into account the patient’s physical health state and
willingness to see a psychiatrist.
Information from medical notes and discussion with staff on the
ward are necessary.
Psychiatrist should familiarise with the medical treatment plan
and side effect profile of the drugs the patient is receiving.
The assessment interview
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Make clear to the patient the purpose of the interview.
Discuss the patient’s anxieties about seeing a
psychiatrist.
Appropriate detailed history and mental state
examination.
Extend the examination of nervous system if necessary.
Collect collateral history with regards to patient’s social
background and past psychiatric disorders from:
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Ward staff or key worker.
Relatives.
Family doctor.
Discussion with referrer
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Discuss proposed plan with referrer.
Make sure recommendations are feasible and
acceptable.
Make sure to answer relevant questions about the
patient.
Management
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Care should be taken when prescribing psychotropic
medication keeping in view about patient’s metabolism,
excretion etc.
Realistic assessment about further supervision of the
patient on the ward should be made.
Make arrangements for follow up.
A few C – L Psychiatric situations
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Post overdose or self harm/suicide attempt
Diabetes Mellitus
Aggressive, Volatile and Confused patients
Accidents
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Cardiac Disorders.
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Angina, Acute MI, Non cardiac chest pain.
Post Operative problems
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Head trauma, delirium etc.
Delirium, limb amputation, organ transplantation etc.
Cancer
Pseudo epilepsy
Infections
Sensory Disorders
Consent to treatment.
Diabetes Mellitus
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Requires prolonged medical supervision and informed
self care.
Many physicians emphasize on psychosocial aspect.
Stressful situations lead to endocrine changes.
Many diabetics show poor compliance during stress
resulting in ‘Brittle Diabetes’.
Compliance with blood testing, diet and insulin use is
frequently poor.
Psychiatric problems include depression and anxiety.
Comorbid Eating Disorders complicate management of
Diabetes.
Misuse of insulin can occur in such individuals to lose
weight.
Pregnancy is difficult time for diabetic women.
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Increased risk of miscarriage and foetal malformations.
Diabetes Mellitus
 Impotence can occur in men.
 Psychogenic impotence found in chronic debilitating disease.
 Due to Pelvic Autonomic Neuropathy or Endocrine problems.
 Organic psychiatric syndromes may present as
 Disturbed behaviour, headaches, nausea, rapid pulse,
hypotension and dehydration.
 Management includes
 Treatment of co morbid conditions like depression.
 Blood glucose awareness training to improve the understanding
of symptoms.
 Behavioural methods to improve self care, psychological and
pharmacological methods of sexual dysfunction etc.
 Tricyclic antidepressants may be helpful in treating the pain in
Neuropathy.
HIV Infection
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Emotional distress common due to
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Psychiatric problems include Adjustment disorder,
Depressive disorder, Anxiety disorder and suicide.
Most common at the time of diagnosis.
Suicide risk is greater in advanced stages.
HIV Encephalopathy and Sub acute Encephalitis occur
late in about 1/3rd of patients.
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The brain is affected at the early stage of infection.
Relentless progressive course.
Reactions of other people.
Neuropsychiatric disorders can occur simultaneously e.g drug
abusers.
May proceed to Dementia.
Delirium may occur in opportunistic infection or cerebral
malignancy.
HIV Infection
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Social consequences are considerable due to public
fears and stigma.
Cultural differences in acceptance, rejection, availability
of family and other support are major determinants of
quality of life.
Problems in relation to illicit drug use are very common.
Treatment
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Psychiatrists should be involved in planning treatment for
AIDS patients.
May provide counselling, treat NeuroPsychiatric
conditions and other co morbid Psychiatric conditions.
Extent of care needs in dementia in AIDS is still under
research.
Cancer
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Some patients delay seeking help as they deny
symptoms.
Diagnosis of cancer may cause Anxiety or Depression.
The diagnosis of cancer may cause shock, anger and
disbelief, as well as anxiety and depression. Most
common associated disorder is Adjustment disorder.
Longer – term consequences: Major depression occurs
throughout the course of cancer affecting 10-20 % of pxs
and appears to be more frequent in those suffering pain.
Progression and recurrence of cancer lead to increased
psychiatric disturbance resulting from worsening of
physical symptoms, fear of dying or the development of
organic brain syndrome.
Cancer (contd)
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Delirium and dementia may arise from brain metastases, which
originate most often from Ca of the Lung, but also from tumours of
the breast and alimentary tract and from melanomas.
Neuropsychiatric problems (paraneoplastic syndromes) are
sometimes induced by some types of cancer in the absence of
metastases, notably Ca of the Lung, ovary, breast, stomach and
Hodgkin’s Lymphoma. Aeitology thought to be autoimmune
response to the tumour
Treatment for Ca may cause psychological disorders as follows:
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Emotional distress may follow mastectomy and other mutilating surgery
 Radiotherapy causes nausea, fatigue and emotional distress
 Chemotherapy often causes malaise and nausea and anxiety about the
treatment may cause anticipatory nausea before it is started
Cancer (contd)
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Family and other close relatives of cancer patients may
experience psychological problems, although may adjust
fairly well.
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Management Principles
Skilled communication in conveying the diagnosis to pxs
and how it would affect their lives
Depression and Anxiety should be treated at the earliest.
Counselling, social support groups and Cognitivebehavioural treatments are shown to improve survival
rate along with good effects on immunity.
Pxs most likely to need psychological treatment include
those with previous psych. disorder, poor adjustment to
other problems and lacking a supportive family
Some practical emergency problems
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Anxious patient
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Physical symptoms of panic is the reason for presentation.
Hyperventilation responds to rebreathing into a paper bag.
Anxiety can become worse by response of uncomprehending
staff.
Distress relief can be obtained by understanding manner and
occasional use of a benzodiazepine.
Angry patient
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Helpful to comment on patient’s anger and ask directly about the
reason.
Be honest and give straightforward information.
It may be appropriate for the doctor to admit to feeling upset by
any accusations made.
It is never sensible to show anger or unduly submissive.
Some practical emergency problems
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Aggressive patient
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Arrange for adequate but unobtrusive help.
If needing restraint then it should be with minimal force and
adequate number of people.
Physical contact should be avoided unless the purpose is clearly
understood by the team and the patient.
Diazepam(5-10mg), Haloperidol(2-5mg) or Lorazepam (1-2mg)
can be given to calm the patient.
Consent to treatment
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Patients may be unwilling to accept treatment for many reasons.
Occasionally it is mental illness that interferes with patient’s
ability to make informed decision.
If the patient has mental disorder that is impairing his decision
then use of legal powers of compulsory assessment and
treatment are indicated.
Questions/Comments
Thank
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