Psychiatry in

Medicine &
Surgery
Presenter: Kah Jun
 Psychological
Physical disorder Links between disorder

❖ Occurring together by chance, as both of them are common

❖ Psychiatric disorder causing physical symptoms
➢ Alcohol dependence → cirrhosis
➢ Depression → anergia, amenorrhea, constipation

❖ Psychiatric disorder adversely affect the outcome of physical disorder

❖ Psychological factors increasing disability associated with physical disorder
❖ Untreated psychological problems leading to the inappropriate use of medical resources and
poor compliance with medical service
❖ Physical symptoms and disorders having psychological consequences
➢ Hypothyroidism, CVA → anxiety or depression

❖ Physical disorder exacerbating unrelated psychiatric symptoms

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disorder
● Lead to unhealthy habit (eg: overeating,
smoking, excessive use of alcohol)

● Results in hormonal, immunological

or neurophysiological changes

● Affect symptom perception (eg:

experience more physical pain when depressed)

● Affect medical help seeking

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● Affect treatment adherence
Physical disorder → psychiatric
complication
● Disturbances of mental state, of which
about a quarter are severe enough to be
classified as a psychiatric disorder

● Heightened perception of physical

symptoms and disability

● Impaired quality of everyday life

● Unnecessarily poor physical outcome

● Adverse effects on family and others;

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Adjustment disorder
A. The development of emotional or behavioral symptoms in response to an identifiable
stressor(s) occurring within 3 months of the onset of the stressor(s).

B. These symptoms or behaviors are clinically significant, as evidenced by one or both of the
following:

1. Marked distress that is out of proportion to the severity or intensity of the stressor,
taking into account the external context and the cultural factors that might influence
symptom severity and presentation.
2. Significant impairment in social, occupational, or other important areas of
functioning.

C. The stress-related disturbance does not meet the criteria for another mental disorder and is
not merely an exacerbation of a preexisting mental disorder.

D. The symptoms do not represent normal bereavement.

E. Once the stressor or its consequences have terminated, the symptoms do not persist for
more than an additional 6 months. 7
Posttraumatic stress disorder
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more)
of the following ways

1. Directly experiencing the traumatic event(s).

2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or close friend. In
cases of actual or threatened death of a family member or friend, the event(s) must have
been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s)
(e.g., first responders collecting human remains; police officers repeatedly exposed to
details of child abuse).

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Posttraumatic stress disorder
B. Presence of one (or more) of the following intrusion symptoms associated with the
traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

2. Recurrent distressing dreams in which the content and/or affect of the dream are related
to the traumatic event(s).
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the
traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the
most extreme expression being a complete loss of awareness of present surroundings.)
4. Intense or prolonged psychological distress at exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolize or resemble
an aspect of the traumatic event(s).

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Posttraumatic stress disorder
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the
traumatic event(s) occurred, as evidenced by one or both of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or

closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places, conversations,
activities, objects, situations) that arouse distressing memories, thoughts, or feelings
about or closely associated with the traumatic event(s).

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Posttraumatic stress disorder
D. Negative alterations in cognitions and mood associated with the traumatic event(s),
beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the
following:

1. Inability to remember an important aspect of the traumatic event(s) (typically due to

dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the
world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My
whole nervous system is permanently ruined”).
3. Persistent, distorted cognitions about the cause or consequences of the traumatic
event(s) that lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to experience
happiness, satisfaction, or loving feelings). 11
Posttraumatic stress disorder
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning
or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed
as verbal or physical aggression toward people or objects.
2. Reckless or self-destructive behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

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Posttraumatic stress disorder
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

G. The disturbance causes clinically significant distress or impairment in social, occupational, or

other important areas of functioning.

H. The disturbance is not attributable to the physiological effects of a substance (e.g.,

medication, alcohol) or another medical condition.

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Acute stress disorder
A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more)
of the following ways:

1. Directly experiencing the traumatic event(s).

2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the event(s) occurred to a close family member or close friend. Note: In
cases of actual or threatened death of a family member or friend, the event(s) must have
been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s)
(e.g., first responders collecting human remains, police officers repeatedly exposed to
details of child abuse).

Note: This does not apply to exposure through electronic media, television, movies, or pictures,
unless this exposure is work related.

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Acute stress disorder
B. Presence of nine (or more) of the following symptoms from any of the five categories of
intrusion, negative mood, dissociation,avoidance, and arousal, beginning or worsening after the
traumatic event(s) occurred:

Intrusion Symptoms
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note:
In children, repetitive play may occur in which themes or aspects of the traumatic event(s) are
expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to
the event(s). Note: In children, there may be frightening dreams without recognizable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the
traumatic event(s) were recurring.(Such reactions may occur on a continuum, with the most
extreme expression being a complete loss of awareness of present surroundings.) Note: In
children, trauma-specific reenactment may occur in play.
4. Intense or prolonged psychological distress or marked physiological reactions in response
to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

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Acute stress disorder
Negative Mood
5. Persistent inability to experience positive emotions (e.g., inability to experience happiness,
satisfaction, or loving feelings).

Dissociative Symptoms
6. An altered sense of the reality of one’s surroundings or oneself (e.g., seeing oneself from
another’s perspective, being in a daze, time slowing).
7. Inability to remember an important aspect of the traumatic event(s) (typically due to
dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

Avoidance Symptoms
8. Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with
the traumatic event(s).
9. Efforts to avoid external reminders (people, places, conversations, activities, objects,
situations) that arouse distressing memories, thoughts, or feelings about or closely associated
with the traumatic event(s).

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Acute stress disorder
Arousal Symptoms
10. Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep).
11. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as
verbal or physical aggression toward people or objects.
12. Hypervigilance.
13. Problems with concentration.
14. Exaggerated startle response.

C. Duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma

exposure.
Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up
to a month is needed to meet disorder criteria.

D. The disturbance causes clinically significant distress or impairment in social, occupational, or

other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g.,

medication or alcohol) or another medical condition (e.g., mild traumatic brain injury) and is not
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better explained by brief psychotic disorder.
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Epidemiology
● Psychiatric disorder is 2-3 times more likely when physical ill health is present
● Psychiatric disorder is present in 1/3 of patients with serious acute, recurrent, or
progressive medical conditions.
● In medical wards
○ Mood disorder are commonly seen in young women
○ Organic mental disorder in elderly
○ Drinking problems in young men and women
● In outpatient clinics
○ 15% patient with definite medical diagnosis have an associated psychiatric
disorder
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○ Around 40% with no medical diagnosis have a psychiatric disorder
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Psychiatric Assessment of Physically
Ill Patient

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Additional
➢ Speak to relatives who can provide extra information

➢ Review medical notes and referral letters

➢ Be aware that some symptoms, such as mental and

physical fatigue and poor sleep, may occur in both

physical and psychiatric disorder

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Management of acute reaction to
illness
1. Effective patient education
(psychoeducation)
a. Nature of illness
b. Likely causes of illness
c. The proposed treatment plan
d. Advice about the ways the patient can help
himself
2. Inform patient of available support
organizations
3. Systematic assessment and alertness
of verbal and nonverbal cues of
distress

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Management of psychological problems of
chronic illness
Step one care Psychologically informed medical care is provided for everyone
● Information about and encouragement of self-care, including symptom
management
● Discussion of how the patient and their family will be involved in care
● Explanation of who will be providing treatment, and routine and
emergency contact arrangement, including a named key worker where
possible
● Practical support with occupational, financial and accomodation
problems, perhaps with the assistance of a social worker or benefits
expert
● Systematic monitoring of progress
● The identification of those needing step two care

Step two care Provided by patient’s GP or by team providing patient’s physical care
● Initial treatment of common psychiatric disorder
● Following telephone advice from mental health service

Step three care Provided by mental health professional

● Within physical setting (liaison psychiatry service) or within community
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mental health teams
Treatment of psychiatric disorder
➢ The treatment of any specific psychiatric disorder among the physically ill is similar
to that of the same condition in a physically healthy person

➢ Additional attention should be paid to adverse consequences of the side effects

of antidepressant and other drugs, and to drug interactions.

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Treatment of psychiatric disorder
Adjustment disorder ● Give patient opportunities for discussion, explanation
and problem solving
● Simple advantage about disadvantage of substance
use

Anxiety disorder ● Advice and self-help via cognitive behaviourally

informed book
● Formal psychological treatment or pharmacological
treatment (SSRI), if severe or persistent

Depressive disorder ● MILD: Illness support, advice or problem solving, and

encouragement of re-engagement with aspect of the
patient’s occupational, home and social life
● MODERATE OR SEVERE: Antidepressant medication or 30
Prevention of psychiatric disorder in the
medically ill
3 main strategies:
➢ Identify those at risk
➢ Minimize the negative effect of illness by providing good medical and nursing
care
➢ Detect, and treat effectively, the early stages of an psychiatric disorder

Prevention should focus on those suffering illnesses or undergoing treatments that are
known to be associated with the development of psychiatric disorder, and on patients who
are psychologically vulnerable as evidenced, for example, by a previous history of
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psychiatric disorder.
Some practical problems
Acutely distressed patients
● Distress, anxiety, or anger (reflects patients’ uncertainties and fears)
● Try understand the cause, show sympathy, correct misunderstanding
● Remain calm and take time to understand his/her concern
● Avoid unintentional exacerbation of problems
● If severe anxiety → anxiolytic

Patients who refuse consent to medical treatment

● Due to frightened or anger, misunderstanding, or had aversive previous experience
● Discuss and explain to patient, involving relative
● Build trust
● Treat if have underlying mental illness

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Some practical problems
Psychiatric emergencies in general hospital practice
● Clinical assessment to:
○ Establish a satisfactory relationship with patient
○ Take a brief history, from patient and a key healthcare professional
○ Assess the mental state, including observation of behaviour
● Deliberate self-harm, substance intoxication, acute stress reaction to trauma, delirium

Acute disturbed behaviour and violence

● Most often conditions requiring immediate action
○ Delirium, schizophrenia, mania, agitated depression, alcohol- and drug-related problems
● De-escalation technique, tranquilization, control & restraint

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Psychiatric services in medical setting
General practitioners
● Responsible for physical, psychological and social aspect of patient’s care
● Step one psychological care (assessment, advice about self-care, simple cognitive-
behavioural strategies, first-line medication)

Referral to a mental health team

Specialist psychiatric
multidisciplinary team, decide:
● Which of its members is best placed
to respond (availability, skill set)
● How they will respond (phone call,
visit, or phone call followed by visit;
emergency, urgent, or routine).
care should provide basic information about:
❖ The medical problem(s);
❖ The reason(s) for the referral;
❖ The specific question to be
asked, or specific nature of the
help required;
❖ The urgency of the referral.
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Psychiatric services in medical setting
Consultation (special) liaison service:
● Assessment and collaborative management of patients with either medically
unexplained symptoms or psychiatric disorders comorbid with chronic medical
illness
● An emergency service for patients admitted after deliberate self-harm
● Emergency consultation for other Accident and Emergency department attenders
● A consultation service, to provide advice on the management of inpatient
● Outpatient care for patients referred with psychiatric complications of physical
illness or functional somatic symptoms
● Regular visits to selected medical and surgical units in which psychiatric problems re
especially common

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Psychiatric services in medical setting
Consultation-liaison psychiatry
1. Received patient, read relevant medical notes, do MSE
2. Assessment interview
3. Clinical notes (concise, clear summary with full record of assessment)
4. Writing response to the referral
5. Management
6. Continuing care

https://www.youtube.com/watch?time_continue=18&v=zG4Hr7F1EzM

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Psychiatric aspects of medical
procedures and conditions

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Infection
➢ Psychological factors may affect course of recovery from acute infection
➢ Some infection → followed by period of depression and fatigue

HIV infection
➢ Common in drug abuser
➢ Affect brain at early stage and chronic progressive course associated with
psychiatric consequences
➢ Adjustment disorder, depressive disorder, anxiety disorder
➢ Suicide and deliberate self-harm
➢ Neuropsychiatric disorder secondary to immunosuppression (HIV-associated
dementia, HIV encephalopathy, subacute encephalitis)

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Diabetes mellitus
Problems
➢ Psychological factor and diabetic control (stress → endocrine change/not compliant)
➢ Problems of being diabetic (Complication of DM → psychosocial problems)
➢ Other problems (associated eating disorder, medical complication, sexual problem, gestational DM)
➢ Organic psychiatric syndromes in diabetes patients (delirium, dementia)

Psychiatric aspect of diabetes management

➢ Treatment for depressive disorder
➢ Blood glucose awareness training
➢ Weight management programmes
➢ Cognitive behavioural approaches (improve self-care)
➢ Help with psychosocial problems
➢ Treatment of sexual dysfunction
➢ Tricyclic antidepressant → relieve neuropathy pain
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Cardiac disorder
➢ Type A personality → increase risk of heart disease

Angina
➢ Precipitated by emotions (anxiety, anger, excitement)
➢ Sometimes accompanied by anxiety or hyperventilation, causing atypical chest
pain and breathlessness

Myocardial infarction
➢ May associated with: denial, depression, anxiety and social isolation
➢ Cardiac arrest → might cause cognitive impairment, personality change or
behavioural symptoms
➢ CBT, medication and exercise, antidepressant (avoid TCAs)

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Cardiac disorder
Non-cardiac chest pain
➢ Conviction that heart was diseased, together with palpitation, breathlessness,
fatigue and inframammary pain
➢ Due to minor non-cardiac physical causes or hyperventilation, associated with
anxiety
➢ Psychiatric concomitant: panic disorder, depressive disorder, hypochondriasis
➢ Management: reassured by a thorough assessment, treat hyperventilation, CBT,
antidepressant

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Sensory disorder
Deafness
➢ Profound early deafness → high risk behavioural problems & social maladjustment
➢ Acute onset deafness → extreme distress, depression, social disability
➢ High risk persecutory delusion/paranoid disorder in elderly

Tinnitus
➢ Persistent low mood
➢ Antidepressant, CBT

Blindness
➢ Later onset blindness → initial denial & subsequent depression, prolonged
difficulties in adjustment

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Cancer
Psychological consequences
❖ Delay in seeking medical help due to fear or denial
❖ Response to the diagnosis, which may be anxiety, shock, nager, disbelief or
depression. Adjustment disorder and depressive disorder are common, with
increase suicidal risk.
❖ Later consequences: Major depression
❖ Progression and recurrence of cancer are often associated with psychiatric
disturbance
❖ Delirium and dementia (from brain metastasis)
❖ Neuropsychiatric problem (paraneoplasia)
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Cancer
❖ Cause distress to patients and families (during diagnosis, treatment or recurrence)
❖ Psychological and social problems (family worries, financial & working difficulties,
worries about appearance)
❖ Impact on self-esteem, self-confidence and personal relationships
❖ Sexual difficulties (due to illness or treatment)
❖ Some develop psychiatric disorder (adjustment disorder, anxiety, depression,
psychiatric syndrome)

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Cancer
Management
❖ Care should be planned to involve patients and families to prevent or minimize
psychological and social problems.
❖ Information and explanation, provided in a staged manner
❖ Practical and social support and willingness to encourage patients to talk about
their worries
❖ Specific psychiatric treatments (pharmacological and psychological) are effective
for anxiety and depression and in helping patients to cope with physical
symptoms.

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Childhood cancer
❖ Affect stage of development, behaviour; Adulthood: social difficulty
❖ Difficult to be diagnose
❖ Parents: shock and denial, anxiety or depressive
❖ Management: advice of practical matters, discussion of feeling

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Screening for physical disorder or risk
❖ Screening usually causes little distress if it is properly explained
❖ However, a few recipients are made anxious by the screening

❖ Screening programmes should incorporate the routine provision of background

information, the opportunity for the discussion of anxieties, and additional help for the
small proportion of people who become anxious.

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Genetic counselling
❖ Counselling about the risk of hereditary disease
❖ Providing information about risks, help with worry about increased risk, help
in taking well-informed decisions about family planning (including sterilization),
and treatment.
❖ Usually provided in obstetric and genetic clinics, but there is also a need for advice
and support by family doctors.

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Genetic counselling
Guidelines
1. The written protocol for the testing programme should detail how the laboratory tests will
be conducted and how communications with patients will be managed.
2. Before they decide whether to undergo a test, clear and simple information should be
presented to those eligible for testing. This should include the advantages and disadvantages
of testing, as well as the meaning of each possible test result.
3. The initial offer of a test should be separated by at least a day from the collection of the
biological sample, to allow time for reflection and ‘cooling off’.
4. Test results should be explained and support offered to all those tested and, where
appropriate, their relatives.

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Accidents
Psychiatric association
❖ Psychiatric disorder predisposing to accident, often through cognitive impairment
(alcohol or drug intoxication, delirium, dementia, depression, personality disorder)
❖ Psychiatric disorder caused by accident, adjustment disorder, anxiety, depressive
disorder, post-traumatic stress disorder, phobic anxiety disorder.
❖ Head injury → specific cognitive disorders and personality change

Common accidents
❖ Criminal assault, road traffic accidents, occupational injury, spinal cord injury,
burns
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Compensation neurosis
❖ Psychologically determined physical or mental symptoms occurring when
there is an unsettled claim for compensation
❖ Settlement was followed by recovery

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Psychiatry in surgery

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Surgery
❖ Most patients are anxious before major and they may be distressed afterwards
❖ Increase risk of perioperative complication (etc: impaired biological response to
stress)
❖ Anxiety can be reduced by a clear explanation of the operation, its likely
consequences, and the plan for post-operative care
❖ Provide written handout
❖ Delirium is common after major surgery, especially in the elderly

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Preoperative anxiety and phobias
❖ Process of obtaining consent can cause anxiety
➢ Management
■ Benzodiazepine
■ Adequate information
■ Patient education
■ Social support

❖ Health-related phobia
➢ Fear of needles (Trypanophobia)
➢ Fear of blood (Hemophobia)
➢ Fear of contamination
➢ Fear of anaesthesia

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Preoperative
Assessment of patients before surgery
❖ Clarification of the role of emotional factors in the patient’s physical complaints
❖ Uncertainty about the patient’s cognitive state and capacity to provide informed
consent
❖ Help in the management of current psychiatric problems
❖ Help in predicting the patient’s response to surgery and their capacity to cooperate
with postoperative treatment and rehabilitation.

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Psychiatric problems in the
postoperative period
Delirium
➢ Common in elderly
➢ Depends on type of surgery, anaesthetic, medication and the presence of
postoperative physical complication
➢ Usually on day 3 and resolve within 1 week
➢ Increase mortality, longer duration of hospitalization
➢ Risk factors: old age, alcohol abuse, pre-existing cognitive dysfunction, sleep
deprivation, malnutrition

Pain
➢ Unusually severe postoperative pain patient
➢ Anxiety management, resolving anger arising

When surgery leads to changes in the body’s appearance (e.g. mastectomy) or

function (e.g. colostomy) there may be additional psychological problems.
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These patients benefit from psychological support
Psychiatric problems in the
postoperative period
Posttraumatic stress disorder (PTSD)
➢ Common in trauma surgery patients, prolonged and complicated post-op course
➢ Not dependent on severity, best predictor is presence of acute stress symptoms
(severe anxiety, dissociation, and other symptoms that occurs within one month
after exposure to an extreme traumatic stressor)
➢ Diagnosis is difficult in patient with delirium

Adjustment problems
➢ Common after mastectomy and laryngectomy
➢ Look for psychosocial factors that impede adjustment
➢ Antidepressant

Long-term psychological problems after surgery

➢ Adjustment problem, anxiety, depression, bipolar, schizophrenia, personality
disorder
➢ Help patient resolve or come to terms with the problems
➢ Antidepressant 59
Other surgery
Plastic surgery
➢ People with physical deformities often suffer embarrassment and distress, and this
may markedly restrict their lives as children and as adults
➢ Patient who have delusion about appearance, dysmorphophobia, greatly
unrealistic expectation → likely to have poor outcome after surgery
➢ Psychological assessment before surgery

Limb amputation
➢ Depression, phantom limbs

Organ transplant
➢ Selection for transplantation → stressful
➢ Postoperative → anxiety, delirium, depression
➢ Liver transplantation: highest rate of neuropsychiatric complication 60
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