Health Questions and Answers

Care of the Psychiatric Patient

Define somatization disorder.
According to the DSM-IV, it is a psychiatric condition characterized by multiple, recurrent physical complaints for which no organic basis can be found. The disorder begins before age 30 and is more common in females. Common physical complaints include vomiting, pain in the extremities, shortness of breath, amnesia, pain in the sexual organs or rectum, and dysmenorrhea. The patient makes frequent visits to physicians because of the physical symptoms, and internists often see and evaluate these patients.

How should the internist approach the patient with somatization disorder?
Because the cycle in somatization disorder (or any somatoform disorder) often is physical complaint → unrevealing work-up → empiric therapy → unsatisfying outcome → return to doctor, the danger of iatrogenic disease is quite real. The physician who can establish a long-lasting relationship with the patient is occasionally able to break the cycle with good history-taking and examination skills and diagnostic and therapeutic restraint. Even more important is that the patient trusts the physician-often patients develop substantial mistrust of health care providers after repeated encounters are fruitless and they are labeled “crocks.” A dedicated primary care physician may be able to identify underlying emotional or mental health issues (e.g., sexual abuse) that may be amenable to psychiatric consultation and treatment. The treating physician should express empathy for the patient, acknowledging the patient’s difficulties and challenges, and a commitment to helping the patient cope with his or her symptoms.

What is a personality disorder?
A personality disorder is an enduring pattern of maladaptive behavior that interferes with a person’s ability to achieve success and satisfaction in interpersonal and work relationships. Patients with personality disorders meeting DSM-IV criteria more frequently sustain injuries, attempt suicide, abuse substances, and have poorer outcomes for depression treatment than the general population.

Define the three groups of personality disorders.
The DSM-IV divides 10 personality disorders into three groups:
• Cluster A: “odd or eccentric” (paranoid, schizoid, schizotypal)
• Cluster B: “dramatic” (histrionic, narcissistic, borderline, antisocial)
• Cluster C: “anxious” (avoidant, dependent, obsessive-compulsive)

When should a clinician suspect that a patient has a personality disorder?
Such patients often pose severe challenges to a physician’s professionalism and empathy. They often do not see a connection between their behavior and its outcomes, and pointing out such relationships can lead to considerable anger. It may be impossible to establish a mutually satisfying patient-physician relationship; the patient alternates between glowing approval and open distrust of the physician. A physician’s own discomfort within a particular patient-physician relationship may signal the presence of a personality disorder. Patients with severe behavioral difficulties should be referred to mental health professionals for treatment. In addition, patients presenting with depression or anxiety disorders who also have symptoms suggestive of a coexistent personality disorder should be referred to mental health professionals, because the personality disorder frequently complicates the treatment of the mood disorder.

What is a panic attack?
A panic attack is a sudden feeling of extreme fear or terror. The DSM-IV criteria stipulate that the panic attack and the associated physical symptoms start abruptly and reach a peak within 10 minutes. Furthermore, sufferers should manifest at least four of the following symptoms:
• Cardiopulmonary: chest pain/discomfort, shortness of breath, palpitations
• Neurologic: trembling/shaking, paresthesias, dizziness, lightheadedness
• Autonomic: sweating, chills, hot flashes
• Gastrointestinal: nausea, abdominal pain, feeling of choking
• Psychiatric: feelings of unreality or of being detached from oneself, fear of losing control, fear of dying

When is panic disorder diagnosed?
Panic disorder is diagnosed when a person has recurrent panic attacks and, after at least one of the attacks, one month or more of worry about the attack or a change in behavior related to the attack (e.g., avoidance of the place of occurrence).

List the differential diagnoses for panic attack.
• Alcohol withdrawal
• Amphetamine abuse
• Asthma
• Caffeinism
• Cardiac dysrhythmias
• Cardiomyopathies
• Cocaine abuse
• Complex partial seizures
• Cushing’s syndrome
• Drug withdrawal
• Electrolyte abnormalities
• Hyperparathyroidism
• Hyperthyroidism
• Hypoglycemia
• Hypothyroidism
• Marijuana-induced palpitations
• Menopausal symptoms
• Mitral valve prolapse
• Pheochromocytoma
• Pulmonary embolism
• Vertigo

How do you differentiate between delirium and dementia?
Both are associated with impairment of the three main aspects of cognition: thinking, perception, and memory. In dementia, however, the cognitive impairment develops insidiously and is enduring, whereas in delirium the impairment has an abrupt onset and is short-lived. Moreover, delirious patients are frequently not completely alert, whereas patients with dementia maintain alertness until the disease is quite advanced

What is “steroid psychosis”?
Corticosteroid use is frequently associated with changes in mood (euphoria, dysphoria, or emotional lability), sleep pattern (insomnia, weird dreams, nightmares), and appetite (usually increased). Corticosteroids also can have important effects on behavior and thought processes, inducing frank psychosis in persons without a history of psychiatric disturbance or decompensation in known psychotics.

How should the diagnosis and treatment of hypertension be handled in patients with a major psychiatric disorder?
In patients with major depression, schizophrenia, or bipolar disorder, elevated blood pressure should be evaluated in the same way as for patients without these disorders. Diuretics must be used with caution in patients treated with lithium because they may cause volume depletion, lithium toxicity, coma, and even death. Beta blockers and central alpha agonists may not be advisable for patients with depression, and reserpine is contraindicated in depressed patients.

List reasonable medications for treatment of hypertension in patients with a major psychiatric disorder.
• Thiazide diuretics (for patients not on lithium therapy)
• Beta blockers
• Long-acting calcium channel blockers (e.g., verapamil, felodipine)
• Angiotensin-converting enzyme (ACE) inhibitors (monitor serum creatinine in patients taking lithium)

Beta blockers and central alpha agonists are best avoided if compliance is a problem, because sudden cessation of these medications is associated with rebound hypertension.

What renal lesions may be caused by chronic lithium treatment?
Up to 20% of patients on chronic lithium therapy develop resistance to antidiuretic hormone (ADH), resulting in polyuria and polydipsia. Lithium accumulates in the collecting tubule cells and interferes with the ability of ADH to increase water permeability. Nocturia not accompanied by fluid ingestion before sleep suggests a urinary concentrating defect. However, polyuria in a patient on lithium therapy cannot be automatically ascribed to the lithium. Psychiatric patients also may have primary polydipsia or central diabetes insipidus. Other renal complications of chronic lithium treatment are type I (distal) renal tubular acidosis and nephrotic syndrome due to minimal change disease or glomerulosclerosis.

What conditions and drugs can cause lithium retention and hence toxicity?
• Any condition that causes or predisposes a patient to volume depletion or renal ischemia can cause decreased lithium excretion and hence toxicity: Gl losses, CHF, and cirrhosis.
• Certain types of drugs, if not monitored carefully, can disturb lithium excretion: diuretics, NSAIDs, and ACE inhibitors.

What are the symptoms of lithium toxicity?
Symptoms include coarse tremors, muscle weakness, ataxia, delirium, nausea, vomiting, diarrhea, leukocytosis, sinus bradycardia, hypotension, seizures, and, in the most severe cases, coma.

How is severity of lithium toxicity graded?
• Mild: lithium level of 1.5-2.5 mEq/L
• Moderate: lithium level of 2.5-3.5 mEq/L
• Severe: lithium level > 3.5 mEq

How is lithium toxicity treated?
• Volume repletion if the patient is hypovolemic
• Oral charcoal in cases of acute overdose (to adsorb other ingested drugs)
• Hemodialysis (treatment of choice in severe cases)

When should hemodialysis be initiated to treat lithium toxicity?
Hemodilaysis should be initiated if the serum lithium level is > 4 mEq/L, regardless of symptoms. With lower lithium levels, hemodialysis should be initiated if patients have severe symptoms or concomitant conditions (e.g., CHF, cirrhosis) that limit urinary excretion. Effective dialysis is likely to require several sessions or a long session of 8-12 hours, because the movement of lithium from within to outside cells is slow. In addition, there may be a rebound in the serum lithium level after cessation of a short hemodialysis session.

Define serotonin syndrome. What are the symptoms?
Serotonin syndrome can result when a patient takes two or more serotonergic agents with different mechanisms of action, either concurrently or in close succession. Symptoms include altered mental status, altered muscle tone (hyperreflexia, myoclonus, tremor, ataxia), autonomic instability with wide fluctuations in vital signs, hyperthermia, and diarrhea.

Which drugs may cause serotonin syndrome?
Any two agents from the list below may cause the syndrome. Of note, because some agents have very long half-lives, great caution must be used in starting a second agent in patients who have just stopped another serotonergic agent.
• Serotonin precursor: tryptophan.
• Serotonin release at the synapse: some amphetamines, selective serotonin-reuptake inhibitors (SSRIs: citalopram, fluoxetine, paroxetine, sertraline) and other newer antidepressants (e.g., venlaxafine), tricyclic antidepressants, trazodone, dextromethorphan, meperidine, tramadol.
• Decreased serotonin metabolism: monoamine oxidase (MAO) inhibitors; St. John’s wort (has MAO inhibitor activity in vitro).
• Other serotonergic activity: buspirone, lithium, sumatriptan, dihydroergotamine

What combination has caused most cases of serotonin syndrome?
To date, most reported cases appear to have resulted from the combination of SSRIs and MAO inhibitors. If a patient is to begin therapy with an MAO inhibitor after treatment with an SSRI, at least 2 weeks should be allowed for washout of the SSRIs. The exception is fluoxetine, which may require up to 5 weeks.

How is serotonin syndrome treated?
Treatment of serotonin syndrome chiefly involves withdrawal of the inciting drug(s). There are some reports of rapid resolution of symptoms with cyproheptadine.

Define neuroleptic malignant syndrome (NMS).
NMS is a clinical state of high fever, muscle rigidity, altered mental status, and dysautonomias that is thought to arise from depletion of dopamine in the central nervous system. The chief causative agents are the major tranquilizers (e.g., haloperidol), which are antidopaminergic in nature. Some patients develop the syndrome suddenly, after years of treatment with major tranquilizers; it also has been reported after sudden cessation of treatment with dopaminergic agents. Although NMS seems to resemble the serotonin syndrome in some of its features, experts currently believe that they are two distinct entities.

How is NMS treated?
Treatment of NMS consists of cooling, bromocriptine for mild or dantrolene for severe cases, and, most importantly, withdrawal of the offending agent.

Describe the diagnosis of anorexia nervosa.
Anorexia nervosa is a psychiatric disorder that predominantly affects young women. Because of disordered body image, patients labor to stay extremely thin by eating little; purging with induced vomiting, laxatives, or enemas; and sometimes exercising excessively. In addition to abnormal body image, the DSM-IV requires the following three findings for a diagnosis of anorexia nervosa: (1) refusal to maintain a body weight within 15% of the ideal for age and sex, (2) amenorrhea, and (3) fear of weight gain.

What medical complications may result from anorexia nervosa?
Anorectic patients develop numerous laboratory abnormalities and medical complications. Low electrolyte levels may lead to sinus bradycardia or arrhythmias. Amenorrhea is common and may persist after the weight gain that is a sign of successful treatment. Relative hypothyroidism may occur, with low serum T3 but normal serum T4 levels. Dry skin and hair and cold intolerance may be seen. The left ventricle may become thin, and anorectic patients may develop CHF with aggressive refeeding. Thus increased oral intake must be monitored carefully. Anorectics are prone to the development of osteoporosis because of estrogen deficiency and poor intake of calcium and vitamin D.


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