PSYCHIATRY II

(1st SEMESTER)| Management Of Psychiatric Disorders Due to Another Medical Condition|Dr. Alipio

Psychiatric Disorders Secondary To Another Medical Condition Agitation in the ICU

Delirium due to ... • Consider pharmacotherapy when agitation becomes a hindrance
Major and Mild Neurocognitive to proper medical treatment.
Neurocognitive Disorders
Disorders due to ... • Haloperidol (fast acting)
*Dementia, TBI, et al o 2-5 mg IM/IV initial dose (or lower in elderly emaciated)
Psychotic Disorder due to (AMC)… or more after an hour if still agitated
- With delusions o Or oral if can tolerate
- With hallucinations o Daily Dose range - 5 to 40 mg/day
Schizophrenia Spectrum • Other Options
Substance/ Medication Induced
Disorder o Olanzapine – 2.5 - 10 mg/day orodispersible tablet
Psychotic Disorder
Catatonia Associated with (AMC) * • Benzos - respi depression; associated with increased mortality in
catatonia specifier elderly
Bipolar and Related Disorder due to Stop and THINK before medicating
(AMC) ... • Do any meds needs to be stopped or lowered?
- With manic features • T – TOXIC SITUATIONS (CHF, Shock, Dehydration, Deliriogenic
- With manic or hypomanic like Meds, Organ Failure)
Bipolar and Related Disorder • H – Hypoxemia
episode
- With mixed features • I – Infection, Immobilization
Substance/ Medication Induced • N – Nonpharmacologic interventions
Bipolar and Related Disorder • K – K+ or electrolyte problems
• Wag diphenhydramine sa ICU kasi lalo nakakdisorient
NEUROCOGNITIVE DISORDERS Deliriogenic Medications
Delirium by Other Names • Anticholinergics – Diphenhydramine! Atropine, hyoscine
• ICU Psychosis • Analgesics – codeine, fentanyl, morphine, pethidine
• Acute Confusional State • Anticonvulsants – phenytoin, phenobarbital
• Acute Brain Fai lure • Antidepressants – amitriptyline, paroxetine
• Encephalitis • Antihistamines – chlorphenamine, promethazine
• Encet,alopathy • Antiemetics – prochlorperazine
• Toxic Metabolic State • Antipsychotic – chlorpromazine
• CNS Toxicity • Cardiovascualr meds – atenolol, digoxin, dopamine, lidocaine
• Paraneoplastic Limbic Encephalitis • Corticosteroids – hydrocortisone, dexamethasone, prednisolone
• Sundowning • Hypnotic agents – diazepam, thiopental
• Cerebral Insufficiency • Misc – Furoseminde, ranitidine
• Organic Brain Sydnrome • Bawasan ito para mabawasan psych ssx
• Always be vigilant with these drugs
Hyperactive Delirium - yung usual na delirium, need ng restraints, may Management of Major Neurocognitive Disorder due to ...
physical na ginagawa • General Principle is the same : Treat underlying medical condition
Hypoactive Delirium - like catatonia, di gumagalaw • Usual Manifestations warranting referral to psychiatry
o Agitation - manage with antipsychotics
Management o Psychosis - manage with antipsychotics
• Symptoms recede over 3-7 days post removal of causative factor o Aggression - manage with antipsychotics or
(up to 2 weeks) anticonvulsants
• The older the patient and the longer the patient is delirious, the • Manage Environment/Milieu - ensure safety, refer to
longer the delirium and its residual effects take to resolve occupational therapist, refer to social worker
• Post delirium derealization (feels they had a really bad dream • Psychoeducate family or manage expectations in cases when
they vaguely remember) changes are irreversible or poor prognosis
• PRIMARY GOAL - - TREAT THE UNDERLYING CAUSE • Symptomatic management is most likely applicable
• Physical support - restraints "may" be necessary - keep the patient PSYCHOSIS DUE TO AMC
safe from themselves Causes
• Epilepsy (SLPE - Schizophrenia-like psychosis in Epilepsy) - very common
• Milieu - manage surroundings, simulate daytime and nightime
o pag di well controlled, later my psychotic symptoms, usually
with light, do not understimulate or overstimulate with sounds, post ictal, pero interictal
orient them with familiar people and objects (orient them to time, o may psychosis ang tawag ay slpe - treated w/ antipsychotics
place, explain procedures) • Traumatic brain injury
• Pwede magkaron ng chronic delirium o accident, confusion ay TBI na (check the criteria)
• Meron sequence (unang disorient sa time then place) then person • Primary brain tumors or mets
• Dementia is chronic delirium • Autoimmune Disorders - SLE and the like
• Delirium in elderly - usually caused by electrolyte imbalance • Thyroid Disorders
• Huntington's
• CNS Infections
• Cerebrovascular Disease
• Multiple Sclerosis

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 PSYCHIATRY II
(1st SEMESTER)| Management Of Psychiatric Disorders Due to Another Medical Condition|Dr. Alipio
BIPOLAR DISORDER DUE TO AMC o Electrolyte Imbalance
o Hypoxia
Causes o Porphyria
• MS – control the manic symptoms o Substance overdose/Poisoning*
• Stroke • Respiratory Conditions
o Nagkaroon ng manic episode after stroke o Asthma
o usually irreversible o COPD
• TBI o Pulmonary Edema
• Cushing's Disease o Pneumothorax
• Patients are usually completely normal before tapos may manic
episodes after occurrence of the diseases above Management
• PRIORITY : Treat underlying medical condition - improving
Management medical condition will improve mental status of patient
• TREAT UNDERLYING MEDICAL CONDITION - maximize medical • Psychotherapy
management o Insight Oriented Psychotherapy
• When hypomania/mania persists, px may need maintenance o CST-informed Brief Psychotherapy
treatment with anticonvulsants/mood stabilizers, possibly o Supportive Psychotherapy
combination therapy with atypical anti psychotics • Reassurance
• Psychoeducation of px and family - Teach relative para alam nila • Psychoeducation
what happens • Medications
• Occupational therapy o SSRI, SNRI
• Social Intervention o Benzodiazepines
• Hypnosis, Mindfulness Meditation, Biofeedback
DEPRESSION DUE TO AMC
Illness Anxiety Disorder (DSM-5)
Causes • Under Somatic Symptom and Related Disorders in DSM-5
• Stroke • Preoccupation with having or acquiring a serious illness
o Part ng brain na tinamaan dahil sa stroke - merong • Somatic symptoms are absent or are only mild in intensity
infarct kahit mag PTOT • If another medical condition is present, preoccupation is clearly
o Common for stroke patients – nadedepress sila excessive or disproportionate
• MS • Excessive health-related behavior (repeated checking body for
• Huntington's Disease signs of illness) or maladaptive avoidance (avoiding doctor
• Parkinsons appointments)
o after 6 or 7 years, may behavioral manifestations o Care seeking type
• Hypothyroidism o Care avoidant type
• TBI • Illness Anxiety Disorder vs Somatic Symptom Disorder
o SSD – old term nya is hypochondriasis
Management
• TREAT UNDERLYING MEDICAL CONDITION - maximize medical OCD & RELATED D/O
management
• When hypomania/mania persists, px may need maintenance Compulsive Skin Picking
treatment with antidepressants, possibly combination therapy • Anemia
with atypical antipsychotics • Liver Disease
• Psychoeducation - px and family • Uremia
• Occupational therapy • Allergic Reactions
• Social Intervention • Acne Vulgaris
• Other Dermatologic Conditions with Pruritus
ANXIETY RELATED MEDICAL CONDITIONS • Skin picking is part of OCD
• Cardiac Issues
o Angina, Arrhythmia, CHF, Ml, Valve Disease Trichotillomania
• Endocrine • Tinea capitis
o Cushing, DM, Parathyroid Disorders, Pancreatic Tumors, • Scalp acne
Pheochromocytoma, Pituitary Disease, Thyroid • Psoriasis
Disorders • Seborrheic dermatitis
• GI • Other scalp conditions
o GERD, IBS, PUD
• Inflammatory Conditions
o Polyarteritis nodosa, rheumatoid arthritis, SLE,
Temporal arteritis
• Metabolic Conditions

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 PSYCHIATRY II
(1st SEMESTER)| Management Of Psychiatric Disorders Due to Another Medical Condition|Dr. Alipio
OCD Type Specifiers
• PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder • Labile Type
Associated with Streptococcal Infection) • Disinhibited Type
o Sudden of "OCD" symptoms • Aggressive Type
o Challengs with eating • Apathetic Type
o Intense sensory issues with textures, sound, light • Paranoid Type
o Deterioration of small motor skills • OtherType
o Tics • Combine'CI Type
o ADHD • Unspecified Type
o Sudden onset of severe anxiety associated with OCD and Management
panic attakcs • Be pragmatic about setting goals (especially with irreversible
o Severe separation anxiety conditions like TBI)
o Intense fear of germs and contamination associated • Treat underlying condition if possible
with pure OCD • Psychotherapy
• Wilson's Disease • Mood Stabilizers, Atypical Antipsychotics, Antidepressants
o Neurodegenerative which includes OCD symptoms • No hard and fast rules

Treatment
• Symptoms usually disappear once underlying problems are
treated
• If causative organic illness is treated but OCD symptoms persist,
they can be treated with SSRI and CBT (Learned Behavior-Classical
Conditioning)

SEXUAL DYSFUNCTION SECONDARY TO A GENERAL MEDICAL CONDITION

(DSM-IV-TR)
• Removed from roster of DSM-5
• A sexual dysfunction that is better accounted for by a medical
condition is no longer given a psychiatric diagnosis
• Required exclusion criterion on all Sexual Dysfunction Disorders in
DSM-5 - "not better explained by a nonsexual mental disorder or
as a consequence of severe relationship distress or other
significant stressors and is not attributable to the effects of a
substance/medication OR ANOTHER MEDICAL CONDITION."
o Delayed Ejaculation
o Erectile Disorder
o Female Orgasmic Disorder
o Female Sexual Interest/Arousal Disorder
o Genito-Pelvic Pain/Penetration Disorder
o Male Hypoactive Sexual Desire Disorder
o Premature (Early) Ejaculation
PERSONALITY CHANGE DUE TO…
Causes
• Major Neurocognitive Disorder due to Traumatic Brain Injury (TBI)
o Ex: accident sa motor, tumama sa gutter, after accident
normal then explode aggressive tapos normal this is
called frontal lobe syndrome
o Treated with mood stabilizers and antipsychotics
• Epilepsy
• Delirium
• Substance Use Disorder (Intoxication, Withdrawal)
o ookay pag nawala na substance
• Primary Tumors and Mets
o frontal lobe
• Another Mental Condition - e.g. PTSD

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