Transcript med_psych_for_medical_students

Medicine and Psychiatry
Michael Merrill, MD, MS, MJ
Internal Medicine & Preventive Medicine
Hospitalist
South Buffalo Mercy Hospital
January 24, 2007
Lecture notes:
www.drmikemerrill.com
Lecture outline
• Buffalo Psychiatric Center
• Medical disease causes psychiatric
syndromes
• Psychiatric illness affects medical disease
and treatment
Buffalo Psychiatric Center
• Opened1880 as Buffalo State Asylum for the
Insane
• As recently as 40 years ago, 3,000 patients
• Buffalo State College built on old farmland
• Now, 240 inpatients
• Average LOS is 4 years; some stay for decades
• Mostly schizophrenia and other chronic
psychoses
• Also personality disorders, especially borderline
and antisocial.
Open Ward, Richardson building, circa 1890
Workshop, late 1940’s.
Schizophrenia
• (Not multiple personalities, as in colloquial use)
• “splitting apart of consciousness”
• Therefore, brain has trouble talking to itself;
information bounces around as “voices”.
• Think about it as:
– Inability to differentiate dreams from reality
• A rule-out diagnosis
Schizophrenia: DSM-IV criteria
(abbreviated)
• A Characteristic symptoms: Two or more of the following,
each present for a significant portion of time during a
one-month period: delusions, hallucinations,
disorganised speech, grossly disorganised or catatonic
behaviour, negative symptoms (ie, affective flattening,
alogia, or avolition). …
• B Social/occupational dysfunction: [impairment of] work,
interpersonal relations, or self-care …
• C Duration: [at least six months]
• D [not schizoaffective disorder or mood disorder]
• E … the disturbance is not due to the direct
physiological effects of a substance (eg, a drug of
abuse, a medication) or a general medical condition.
• F [not a developmental disorder]
Case 1
• Female with progressive dementia, psychosis,
movement disorder.
• Repeated BPC admissions.
• History of college education.
• Gradual decline in cognition over the decades.
• Movement disorder attributed to tardive
dyskinesia.
• Dementia attributed to normal progress of
severe schizophrenia.
Medical  Psych
• Infection: confusion (expected in hospital
admissions of elderly)
• Hypothyroidism – depression, psychosis
• B12 deficiency – varied neuropsych
manifestations
• Syphilis & ? Lyme disease - psychosis
• Celiac disease/malabsorption - psychosis
• Magnesium deficiency - anxiety
• Vitamin D deficiency - depression
• Substance abuse – psychosis
• Hypoglycemia: stupor
Med  Psych - 2
• Temporal lobe epilepsy: psychosis
• Other Neurological disorders
– Brain tumor  seizure activity  psychosis, agitation
– Traumatic Brain Injury
• Congenital syndromes
– Velocardiofacial syndrome
– Turner’s syndrome
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Chronic pain
Primary dementia  hallucinations, paranoia
Medication effect
Etc. etc. etc.
Case 2
• 58-year-old female with schizophrenia, seizures.
• PTA, worsening psychosis and agitation,
worsened control of seizures. Developed
inability to walk.
• At BPC: ataxia, delayed DTR’s.
• TSH = 1.25 (0.3 – 5.0)
• Free T4 = 0.46L (0.71 – 1.85)
• Replacement with LT4 suppressed TSH slightly,
eliminated ataxia, allowed patient to walk.
• Diagnosis: central hypothyroidism
Psych  Medical
• History may be impossible
– Hallucinations
– Paranoia
– Lying
– Somatization
– Occasionally, reality-based honesty
– (“snakes in chest”)
• Smoking: self-medication
• Self-mutilation: borderlines
• Assaults and fights (including staff)
Psych  Medical - 2
• Treatment refusals: “I’m a doctor. I don’t have
diabetes.”
– Treatment over objection
• Inherent qualities of schizophrenia
– Increased death rate: average age at death OMH: 45
for outpatients, 55 for inpatients
– QTc: sudden cardiac death – interactions with other
meds
– Decreased pain perception: walking around on a
broken leg
– Polydipsia and hyponatremia  seizures
Case 3
• 22 year old female with borderline personality
disorder
• Spent most of childhood at Children’s
Psychiatric Center
• History of physical and sexual abuse.
• Bites own arms, inserts foreign bodies into
vagina and anus, swallows batteries and pins,
hits head against wall, defecates on floor, runs
around naked. Recently inserting pens into
granulating wound at chest tube site.
• ECT performed with some positive benefit.
Psych drug side effects
• Clozapine = “mother of all side effects”
• Constipation
– Some patients on four or five drugs to make them
defecate regularly; still get impacted.
• Sialorrhea/drooling
– Scopolamine patches
• QTc interval.
• Orthostatic hypotension: fludrocortisone
• Parkinsonism
Drug side effects - 2
• Essential tremor
• Akathisia: can look like anxiety
• Obesity and diabetes mellitus (atypical
antipsychotics)
• Dystonic reaction
• Tardive dyskinesia
• Neuroleptic malignant syndrome
• Dysphagia
• Choking
Case 4
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57 year old female, psych hx since age 19
admitted to BPC with uncontrolled mania
History of many years therapy with lithium
PMH: severe MVA with multiple fractures,
idiopathic pulmonary hypertension, SBOs x 3.
• Social: 1.5 PPD smoker. No significant
employment history. Many interpersonal conflicts
with family around money (inheritance)
Case 4, continued
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Family: brother died in Vietnam war.
ROS: no polydipsia, no polyuria.
Exam: Normotensive. Disheveled. Rapid speech. S4.
Labs: presented with creatinine of 1.5. Had
hyperkalemia requiring daily kayexalate. Urine specific
gravity never rose above 1.020 despite dehydration.
• Diagnosis: nephrogenic diabetes insipidus secondary to
lithium.
• No specific therapy at this time apart from needing to
maintain hydration.
Practical med/psych workup
(my opinion)
• Mandatory:
– Bloods:
• B12 level, methylmalonic acid
• TSH, free T4
• 25-hydroxy vitamin D level
– CT head (looking for hydrocephalus, stroke)
Practical med-psych, cont'd
• Probably you should:
– History:
• Medication history
• Brain injury
• Family history
– Labs: chemistries, CBC, urinalysis
Practical med-psych, cont'd
• Optional:
– Hemochromatosis workup (Fe saturation, if > 60%
liver biopsy)
– Syphilis screen (rare around here these days)
– Wilson's disease workup (e.g. Ceruloplasmin,
ophthalmologist exam for KF rings)
– Tox screen
– Celiac disease screen (antibodies)
– EEG
– MRI
– Neuropsychology evaluation
– Genetics consultation