Liaison Psychiatry and Organic Illness

Liaison psychiatry is a subspecialty of psychiatry which involves the diag­nosis, treatment, and management of psychiatric illness in patients who have physical illnesses or present with physical symptoms. There is considerable overlap between psychiatric and medical condi­tions which requires close working relationships with medical colleagues. Liaison psychiatry is a fascinating area where the range of psychiatric presentations is wide, every case is different, and there is opportunity to keep up to date with medicine as it evolves. Within the UK there are different models practiced in different areas, ranging from assessment and signposting services to services with provi­sion for long-term outpatient follow-up. There is increasing interest in the provision of liaison services in primary care because of the challenges faced by GPs in treating patients with medically unexplained symptoms. Another driver is the hugely increased morbidity and mortality rates seen in patients with co-morbid physical and mental illnesses who receive the majority of their treatment in secondary care.

Psychological Treatment and Psychotherapy

Psychological therapies are often the first-line treatments for psychi­atric disorders, depending on their nature and severity. In many cases they work best in conjunction with medication. The UK government is encouraging improved and timely access to psychological treatments in both primary and secondary care services. Psychological treatments can be carried out in community mental health services, specialist psycho­therapy services, and the private sector. Psychological therapies have a rich history. Today a number of evidence-based, innovative treatments are available. There is advanced research in psychotherapy, which comes with its own challenges. Psychotherapies can be delivered to individuals, families, couples, or groups. They can be as short as a few sessions or can last for more than a year, depending on the modality. The focus may be varied, such as anxiety symptoms, specific phobias, relationship problems, mood distur­bances, or difficult life events. Psychodynamic psychotherapy gives people a fixed time to think—and talk—about the feelings we all have about ourselves and other peo­ple such as family or close ones. CBT focuses on how we think about the things going on in our life—thoughts, images, beliefs, and attitudes (cognitive processes)—and how this impacts the way we behave and deal with emotional problems. Family therapy looks at the family as a system and works on each individual’s relationship with others and involvement with the problem.

Psychopharmacology

Psychotropic drugs are the main form of physical treatment in psychiatry and they exert their action by mainly acting on dopamine, noradrenaline, serotonin, and muscarinic receptors. Antipsychotics, which are the mainline treatment for psychotic ill­nesses, usually act by blocking dopamine receptors in the dopamine pathways of the brain, usually the mesolimbic system. The D2 receptors are the usual target of the antipsychotics, although clozapine, which is considered the gold standard antipsychotic, has a strong affinity for the D4 receptors. The underlying principle of antipsychotic treatment builds on the dopamine theory of schizophrenia, whereby an excess of dopa­mine is linked to the development of psychotic symptoms. Overactive dopamine receptors are thought to be involved in this, and thus block­age of the dopamine receptors through antipsychotics can provide relief from psychotic symptoms. Antipsychotics are divided into typical and atypical, and the defining feature of typicals is their propensity to cause EPSEs. This is thought to be due to the fact that typical antipsychotics are not specific for dopa­mine receptors in the mesolimbic pathways, but can also block those in mesocortical, tuberoinfundibular, and nigrostriatal pathways. Atypical antipsychotics can impact on a variety of receptor types, such as serotonin, and thus they are usually subclassified according to their pharmacological properties. Their heterogeneous pharmacodynamics in part explains their variable side-effect profile. One common side-effect of atypical antipsychotics is their tendency to trigger metabolic syndrome, which is a cluster of cardiovascular risk factors including dyslipidaemia, hypertension, central obesity, and impaired glucose tolerance. They also cause endocrine-related side-effects, such as hyperprolactinaemia. An important adverse effect seen with any antipsychotic is neuroleptic malignant syndrome (NMS), which is an idiosyncratic reaction to antipsy­chotics taken even at therapeutic doses. Patients can present with hyper­thermia, rigidity, autonomic disturbances, and altered mental state over 24–48 hours. It can be potentially life threatening, and thus, if suspected, urgent referral to a general hospital is required. Antidepressants also vary greatly with regards to their pharmacologi­cal properties, but the majority increase the concentration of neuro­transmitters in the synaptic cleft to alleviate depressive symptoms.

Learning Disability

Intellectual disability is defined by the World Health Organization (WHO) as: ‘a significantly reduced ability to understand new or complex infor­mation and to learn and apply new skills (impaired intelligence) resulting in a reduced ability to cope independently (impaired social functioning)’, and begins before adulthood, with a lasting effect on development. People with an intellectual disability can develop any of the mental ill­nesses common to the general population; however, they are up to three times more likely to develop a mental illness. This predisposition to psy­chiatric illness can occur due to a variety of reasons, including associated genetic syndromes, brain injury, and sensory impairments. People with an intellectual disability are also more likely to have negative psychoso­cial experiences, such as deprivation, abuse, separation/loss events, low self-esteem, and financial disadvantage, and consequently the ensuing effects of these can affect their mental health. The psychiatric assessment of a person with an intellectual disability broadly covers the same as that of the general population; however, a different approach at times is needed to adapt to the individual’s com­munication skills. It may be necessary to complete history taking from a family member or carer, and an MSE may even have to be completed solely on observable behaviours. It is also more pertinent to focus on any co-existing medical conditions, such as epilepsy which is present in 25–30% of people with an intellectual disability. The WHO states that the true prevalence of intellectual disability is close to 3%. The vast majority of these people (85%) have mild intel­lectual disability defined as an IQ of 50–69 points. Many of these peo­ple can and do access mainstream services (with or without additional support). In whichever service you work, doctors and medical students will encounter people with intellectual disabilities, and an awareness of their needs is essential.

Psychiatry of Old Age

This chapter of practice exam questions aims to put you, albeit briefly, in the seat of an old age psychiatrist dealing with important aspects of psychiatric disease in older adults. Our population is ageing and this, in addition to wider public understanding and earlier diagnoses of dementia, is leading to an increasing burden of disease. Furthermore it is acknowledged that the incidence of affective and psychotic disorders unexpectedly peaks again as we reach old age and can be devastating if not recognized and managed effectively. The unique challenge of psychiatry of old age is the need for a sound grasp of general medicine and neurology to tackle unusual presentations of illness and possible multiple co-morbidities, in addition to a ground­ing in psychiatric theory. There remains a great need for lateral think­ing, particularly in liaison work on the medical and surgical wards where delirium is rife and can masquerade as everything psychiatric. Within the specialty, true collaboration exists as allied health professionals and psy­chiatrists work together at problem solving to improve patients’ quality of life beyond simply offering medication. An understanding of the pathology, epidemiology, diagnosis, and treat­ment of mental illness and dementia in older adults is an essential skill for any doctor at the coalface. Working with older adults is incredibly rewarding and never stops being educational to the clinician. These patients and their carers will continue to challenge and impress you throughout your career. As you manage to feel more confident with the facts, the practicalities and benefits of talking to and helping older adults become clearer. There is nothing that surpasses learning on the job, with many opportunities through attachments in psychiatry, GPs, ED, and geriatric wards. There are excellent resources available with regard to dementia, including NICE guidelines and the Alzheimer’s Society website. The aim of the following questions is to touch on a range of areas throughout the subject, taking us from first principles to practical applica­tion, through effective management, and support of older adults’ mental health and wellbeing.

Emergency Department Psychiatry

All doctors working in the ED will regularly meet patients with acute mental health problems. Five percent of total ED attendees are attrib­utable to mental disorder. With nationwide ED attendances averaging 400 000 per week during November to April 2013, the trend shows a growing pressure on emergency services. However, these figures repre­sent just the tip of the true burden of acute mental illness in our com­munities. Stigma, the healthcare funnel, and marginalization often mean that it is the sickest who finally present to the ED. It is also important to recognize the co-morbidity of mental illness and addictions in those seeking help for what initially appear to be physical complaints, as so often the mind and body are closely intertwined. Most common psychiatric presentations to the ED include DSH, alco­hol and substance misuse, delirium, acute psychosis, factitious disorders, medically unexplained symptoms (MUS), and acute stress reactions (such as to trauma). DSH is common but under-recognized. A quarter of people who die by suicide attended the ED in the preceding year. All patients in the ED presenting with self-harm should have a detailed psychosocial assessment. Alcohol is responsible for 0% of all ED attendances. It is also an independent variable, raising the risk of DSH. Substance users are also frequent attendees, with high levels of medical morbidity and mortality. Patients with a dual diagnosis of substance use plus mental illness fre­quently present with multiple psychosocial problems. Acute psychosis may be caused by a functional disorder, such as schizophrenia, but organic conditions must also be considered. Where a patient is extremely disturbed in the ED, restraint and sedation may be necessary to enable safe and adequate assessment. Security presence may also be required to minimize the risk of violence, where this has been identified. Implications for working in the ED are that all doctors should famil­iarize themselves with the management of common acute psychiatric presentations. Know how to access local Trust rapid tranquillization guidelines. Read NICE guidelines for management of self-harm. Seize opportunities to screen for mental illness and social problems.

Assessment And Interviewing Skills

Psychiatry is unique as a specialty. In the past century, medical technology has advanced at breakneck speed supporting diagnostic refinement, yet this has had limited impact in the area of mental health. It is not possible to diagnose mental illness with a blood test, a radiological investigation, or other such investigative tools. It requires a doctor to hone their ‘end of the bed’ observation skills and develop a sophisticated understand­ing of psychopathology. This familiarity of descriptive psychopathology then needs to be applied in everyday practice to recognize the symp­toms being presented, allowing interpretation of illness states. Similar symptoms can present in different illnesses and their relevance needs to be understood in the context of the history of the person. Psychiatric assessments with well-developed interview skills are the cornerstone of psychiatric practice. This can feel a daunting task to medical students and junior doctors who are well used to the protection of many investigation options at their fingertips. Psychiatric patients are often the most challenging to interview. They can present in ways that confront even the most experienced doctor— highly distressed, aggressive, withdrawn, disconnected from reality, or uncooperative, to describe just a few situations. They may not have cho­sen to see a doctor and may have come willingly or unwillingly due to someone else’s worry about them. These factors often create a difficult starting point from which to engage patients and establish a trusting doc­tor–patient relationship. The reasons for a person’s presentation, especially in the acute set­ting, are often highly anxiety provoking—attempted suicide, threatened suicide, or highly disturbed behaviour. This challenges doctors to remain calm in order to maintain the capacity to manage the assessment without relying on the armoury of procedures other specialties often can. A firm grasp of the MSE and the core aspects of a psychiatric history helps to negotiate numerous potential challenges during the interview. Interviewing and interpretative skills can be developed, akin to a cardi­ologist learning the sounds of different heart murmurs.

Substance Misuse Psychiatry

Clinicians in all areas of medicine are likely to encounter people with substance misuse issues, so an understanding of the key issues is essen­tial. Human beings have used intoxicating substances, such as alcohol, nicotine, cannabis, and heroin, for millennia. Motivations might include experimentation, pleasure, social enhancement, or for physical or psy­chological pain management. Some people who use these legal and illegal substances experience problems related to their use, including loss of control, adverse consequences, withdrawals or cravings, damaged end organs, risky behaviour, and premature death. Substance misuse impacts not only on individual physical and mental health but also upon families and wider society by increased healthcare, criminal justice, social ser­vices, and unemployment costs. Drug and alcohol problems affect between 10% and 25% of the popu­lation each year, and up to 35% of people have ever used illicit drugs. Alcohol, an intoxicating sedative, is the most commonly used drug, with 25% of the UK population drinking above ‘low-risk’ limits. In England in 2010 there were an estimated 300 000 opiate, crack-cocaine, and inject­ing drug users, and only half were in treatment. Substance misuse is commonly associated with physical and mental health co-morbidity. The prevalence of co-existing mental health and substance use problems (termed ‘dual diagnosis’) may affect between 30% and 70% of those presenting to healthcare and social care settings. In general, four interrelationships in dual diagnosis are recognized: • substance use leading to social problems and psychological symptoms not amounting to a diagnosis • substance use leading to social dysfunction and secondary psychiatric and physical illness • substance use exacerbating an existing mental or physical health prob­lem and associated social functioning • primary psychiatric illness precipitating substance misuse which may also be associated with physical illness and affect social ability. Given the array of substance misuse problems, an individual treat­ment approach is essential and may involve psychological, pharmaco­logical, and social intervention. An empathic, non-judgemental clinical approach is essential to engage people with substance misuse problems. Motivational interviewing is an evidence-based talking therapy to help people in denial about their problems make changes for themselves and avoids imposing change prematurely.

Child and Adolescent Psychiatry

Child and adolescent psychiatry is the medical specialty that works with children, young people, and families with emotional and behavioural problems. As children and young people are still developing and grow­ing, their emotional wellbeing and functioning needs to be thought about in this context, making it different from adult psychiatry. Communication with people of all ages is vital within the specialty and information from a wide variety of sources, including parents or carers, school, and peers, is used to inform the clinical picture, in addition to history-taking and direct observations of the child’s behaviour. Play is often used to understand younger children’s thoughts and feelings. In theory, the specialty covers children and young people from birth up to the teenage years, although different services cover slightly different age ranges. The spectrum of difficulties covered within the specialty include psy­chiatric disorders also seen in adults (such as psychosis); problems spe­cific to the age group (such as separation anxiety); lifelong conditions which start in childhood (such as ADHD); and conditions that may pre­sent in different ways in childhood or adolescence (such as phobias). Approaches to treatment include psychopharmacological interven­tions, and numerous therapeutic modalities including family therapy and CBT, which can be modified for different age groups. Most work is community based, although there are specialist inpatient units which offer on-going educational opportunities to young people who need the intensive support and risk reduction of a hospital admission. Work tends to be done within MDTs using a range of knowledge and expertise to offer the most appropriate care.

Community psychiatry

An inpatient admission to a psychiatry ward has a high cost both eco­nomically and psychologically. While it is necessary at times to treat someone in hospital, the majority of the work in maintaining good men­tal health is done while the patient is living their usual life with its highs, lows, and challenges. Community psychiatry aims to manage people with mental illness in their own environment. There are many benefits to this, including promoting a sense of normality, allowing for continued support from family and friends, and helping to bridge the change between ill­ness and recovery. Because of this, community psychiatry covers almost everything in psychiatry and is as much a speciality of exclusion as a spe­cific group: no under 18s (child and adolescent), over 65s (psychiatry of old age), addictions (substance misuse), or the law (forensic psychiatry). But a community psychiatrist can’t be too exclusive because local differ­ences, based on what other dedicated services are available, and sub­threshold presentations mean that a good working knowledge of most conditions is essential. In many ways, community psychiatrists are the GPs of the speciality. The only way to manage such a large and varied workload is to make good use of the multidisciplinary team (MDT): community psychiatric nurses (CPNs), occupational therapists (OTs), speech and language therapists (SALTs)—the list of acronyms is endless but essential. A good community psychiatrist has a team they can rely on to help keep a watch­ful eye over their clinical population; managing their day-to-day care and anticipating problems before a relapse develops. The balance between giving space for recovery and monitoring to ensure efficient treatment is hard to achieve but gratifying when it occurs. Part of the skill set of a good community psychiatrist is an understand­ing of the research statistics: prevalence of disorders, treatment rates, and prognosis. These allow for faster diagnosis and evidence-based treatments to speed up recuperation. The minutiae of these facts aren’t needed, but a broad understanding helps shape assessment and management.