Psychiatry and Medicine

Dr Jon Laugharne University of Western Australia

Organic causes of Psychiatric Symptoms

Depression carcinoma, infections,

diabetes, thyroid disorder, SLE, beta blockers Anxiety hyperthyroidism, hypoglycaemia, drug withdrawal, phaeochromocytoma Fatigue anaemia, chronic infection, diabetes, carcinoma, Addisons disease

Diabetes
Depression and anxiety
Hyperglycaemia can cause delirium Early dementia

Hyperthyroidism
Anxiety
Emotional lability Hyperactivity

Fatigue

Hypothyroidism
Depression
Can cycle into mania (myxoedema

madness)
Cognitive impairment

Steroids
Depression
Mania Paranoia

Maternity Blues
2-3 days post-partum
Labile mood 50-60% mothers (partic primigravida)

Often some anxiety/depression in final

trimester Resolves spontaneously

Postnatal Depression
Onset in early weeks postpartum
10% women Tiredness, irritability, anxiety are

prominent symptoms Chronic if untreated Risk factors previous depression, obstetric complications, social difficulties

Postnatal depression Rx
Supportive psychotherapy
Problem solving Relaxation advice

Practical supports
Anti-depressants

amitriptyline/imipramine

Postpartum Psychosis
1-2 weeks post partum
Delirium (sepsis)

Affective
Schizophreniform

Postpartum psychosis
Attitude to baby? Risks to baby or self?
Treat the clinical syndrome

Antidepressants
Antipsychotics Valium

ECT

Psychiatric drugs & breastfeeding

Avoid if possible
Antidepressants OK Antipsychotics OK

Carbamazepine OK
Monitor baby Can mother use formula alternative?

Pregnancy & psychiatric drugs

Avoid if possible in 1st trimester
Avoid carbamazepine Haloperidol rather than chlorpromazine

Antidepressants OK
Clinical decision risks vs benefits

Delirium
Disorientation
Fluctuating level of consciousness Confused thinking

Labile mood
Anxiety/panic Hallucinations/delusions

Causes of delirium (brain)

Infections - meningitis, encephalitis,

malaria.
SOLs tumour, haemorrhage
Injury/trauma Epilepsy postictal, status

Causes of delirium (non-brain)

Metabolic uraemia, hypoxia, liver failure
Drugs anticholinergics, L-dopa,

anticonvulsants, digitalis Alcohol DTs Illicit drugs Endocrine hypo/hyperglycaemia Infection typhoid fever Nutrition thiamine deficiency, B12 Postoperative confusion

Treating delirium
FIND and TREAT CAUSE
Sedate chlorpromazine 100mg 8hrly or

diazepam 2-5mg 6hrly Nurse in unstimulating environment darkened room

Unexplained medical symptoms

Interpretation of physical sensations
Personality Mental state

Knowledge
Beliefs/cultural factors Symptoms/behavioural change/disability

Somatoform Disorders
Somatization disorder
Hypochondriasis Pain disorder

Conversion disorder
Body dysmorphic disorder

Management principles
Investigations to exclude physical cause
Clarify nature of complaint ?previous personality

?concerns about physical illness

?beliefs and expectations ?depression/anxiety /other psych

disorder ?psychosocial problems

Principles of management
Do not overinvestigate
Explain and discuss your diagnosis Explain symptoms are real and taken

seriously Treat any associated psychiatric or physical disorder Involve relatives/supports if possible

Principles of management
Problem solving (to reduce stressors)
Relaxation Gradual increase in activities

Cognitive therapy
Antidepressants amitriptyline 75-

250mg/day Anxiolytics diazepam up to 2-5mg tds (beware dependence)