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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. Medicine and Psychiatry. Lecture outline . Buffalo Psychiatric Center Medical disease causes psychiatric syndromes

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Medicine and Psychiatry

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  1. Michael Merrill, MD, MS, MJ Internal Medicine & Preventive Medicine Hospitalist South Buffalo Mercy Hospital January 24, 2007 Lecture notes: www.drmikemerrill.com Medicine and Psychiatry

  2. Lecture outline • Buffalo Psychiatric Center • Medical disease causes psychiatric syndromes • Psychiatric illness affects medical disease and treatment

  3. 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.

  4. Open Ward, Richardson building, circa 1890

  5. Workshop, late 1940’s.

  6. 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

  7. 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]

  8. 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.

  9. 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

  10. 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 • Chronic pain • Primary dementia  hallucinations, paranoia • Medication effect • Etc. etc. etc.

  11. 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

  12. 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)

  13. 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

  14. 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.

  15. 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

  16. 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

  17. Case 4 • 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)

  18. Case 4, continued • 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.

  19. 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)

  20. Practical med-psych, cont'd • Probably you should: • History: • Medication history • Brain injury • Family history • Labs: chemistries, CBC, urinalysis

  21. 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

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