Psychosis in medically ill


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Psychosis in medically ill is one of the challenging situation face by psychiatrist who work in general hospital.

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Psychosis in medically ill

  1. 1. Curriculum Vitae dr.Andri,SpKJ,FAPM Lahir : Tangerang, 19 Desember 1978 •Pendidikan formal : – Dokter : FKUI Lulus 2003 – Psikiater : FKUI lulus 2008 •Pendidikan tambahan : – Psychosomatic Medicine Course dari American Psychosomatic Society tahun 2010 dan Continuing and Update Course in Psychosomatic Medicine dari Academy of Psychosomatic Medicine 2012 dan 2013 – Pengakuan sebagai Fellow Academy of Psychosomatic Medicine (FAPM) : 18 September 2013 •Keanggotaan organisasi – IDI, PDSKJI, American Psychosomatic Society, Academy of Psychosomatic Medicine •Jabatan saat ini – Dosen Psikiatri di FK UKRIDA, Jakarta – Kepala Klinik Psikosomatik Omni Hospital, Alam Sutera – Ketua Sub Kredensial Komite Medik RS OMNI Alam Sutera – Kepala Unit Riset FK UKRIDA
  2. 2. Psychosis in Medically Ill Patient ANDRI Division of Psychiatry Universitas Kristen Krida Wacana (UKRIDA) Arjuna Utara no.6 Jakarta Barat 11510
  3. 3. Introduction • Are psychiatric symptoms attributable to a primary psychiatric syndrome? Or are they secondary to medical disease, substance use or medication intoxication?
  4. 4. Diagnosis and Assessment Psychotic symptoms in a medically hospitalized patient fall into one of three possibilities : 1.Primary psychiatric illness - New-onset or an acute exacerbation of psychiatric illness associated with psychosis 1.Secondary psychosis – Psychosis due to a general medical condition (systemic or brain- based) – Substance induced psychosis – Medication-induced psychosis 1.Secondary on Primary – A patient with a primary psychotic disorder has psychosis unrelated to his or her primary psychotic disorder
  5. 5. Clinical Case (1) • A 52-years old male patient with diagnosis subarachnoid and subdural hemorrhage after motorcycle traffic accident. • The attending neurosurgeon planned a craniotomy operation to the patient. • Thirteen days after the operation a psychiatrist was consulted because patient was agitated, performed aggressive behavior, irritable and more silent than he used to be • A psychiatric consultation was performed and major depression disorder with aggressive behavior was the diagnosis at that time. • Haloperidol 2.5mg bid and Sertraline 25mg on the morning was given to patient. • Patient was discharged two days after the consultation.
  6. 6. Clinical Case (2) • Three weeks after the last consultation, patient started to experience auditory and visual hallucination. • The treatment program was modified based on the patient condition at that time. • I used Risperidone 2x1mg, Sertraline 1x50mg • A month after the last consultation, psychotic symptoms were improved • Mood was improved but patient remained irritable, became more stubborn, acting out, dis-inhibition and frequently forgot the order of task. • I stopped Risperidone, but still used Sertraline
  7. 7. Diagnosis Diagnostic criteria for 293.xx Psychotic Disorder Due to . . . [Indicate the General Medical Condition] A. Prominent hallucinations or delusions. B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. C. The disturbance is not better accounted for by another mental disorder. D. The disturbance does not occur exclusively during the course of a delirium. Code based on predominant symptom: .81 With Delusions: if delusions are the predominant symptom .82 With Hallucinations: if hallucinations are the predominant symptom Coding note: Include the name of the general medical condition on Axis I, e.g., 293.81 Psychotic Disorder Due to Malignant Lung Neoplasm, With Delusions; also code the general medical condition on Axis III. Coding note: If delusions are part of Vascular Dementia, indicate the delusions by coding the appropriate subtype, e.g., 290.42 Vascular Dementia, With Delusions.
  8. 8. Clinical features Primary Psychosis • Cognitive function and level of consciousness are relatively normal • Focal neurological signs are absent • Hallucinations are most often auditory, delusions tend to be complex • Thought disorder may be prominent, • Incontinence is usually absent, • Vital signs are usually normal Secondary psychosis • Psychotic symptoms first appear at an older age and if there is no personal or family history of primary psychotic disorders. • If the course of the psychotic symptoms parallels the course of the medical disorder suspected as cause, a diagnosis of secondary psychosis is more likely
  9. 9. Medical Evaluation • Laboratory Evaluation – Complete blood count – Electrolytes including calcium and phosphate – Serum urea nitrogen/creatinine – Glucose – Liver function tests – HIV Test – Vitamin B12 and folate – Serum Cortisol level – Urynalisis – Urine cultures – Blood cultures • Brain Imaging – MRI • EEG
  10. 10. Medical Disorders Causing Secondary Psychosis Metabolic Disorder • Vitamin B deficiency • Hyponatremia • Hepatic encephalopathy • Uremia • Hyperadrenalism • Hyper or Hypothyroidism (severe) • Acute intermittent porphyria Brain Disease • Huntington’s disease • Wilson’s disease • Paraneoplastic encephalitis • Encephalitis or other CNS infection (neurosyphillis) • Tumor • HIV encephalophaty • Stroke • Psychosomotor seizure • CNS vasculitis
  11. 11. Drugs Causing Psychotic Symptoms
  12. 12. Recommendation for Attending Physician • Regardless of etiology, acutely psychotic medical inpatients may require constant observation, restraints, and/or involuntary treatment. • Reassurance and education of the patient and the family about the symptoms and their cause(s), if known, are also helpful. • Unnecessary stimulation of the patient should be avoided (eg, repeated interviews by groups of trainees)
  13. 13. • All nonessential medications should be discontinued or reduced in dosage if they are possible contributors. • Close collaboration between psychiatric and medical staff is necessary
  14. 14. Treatment • If the cause cannot be eliminated in medically ill patients with primary or secondary psychosis, antipsychotics is preferred • For short-term use, haloperidol is usually preferred in medically ill patients because of : – extensive experience with its use – Minimal side effects other than extrapyramidal ones – can be administered by mouth, intramuscularly (IM), or intravenously (IV) or as a liquid (eg, haloperidol, risperidone,
  15. 15. Treatment Consideration • Several antipsychotics can be given IM, this route is not practicable if many parenteral doses are required and IV haloperidol should be considered. • Most antipsychotics can be used in cardiac patients even after an acute myocardial infarction. • While antipsychotics rarely cause adverse hepatic reactions, there is no evidence that liver disease increases their risk of hepatotoxicity.
  16. 16. • Since all antipsychotics are metabolized in the liver, they should be used more cautiously in patients with hepatic failure • Antipsychotics can lower seizure threshold, their use is not contraindicated in patients who are receiving anticonvulsants, but clozapine should be avoided. • In patients with diabetes mellitus or those who at high risk for the condition, antipsychotics are less likely to induce glucose intolerance and are therefore preferred
  17. 17. Conclusion • Psychosis in medically ill patient are common and can be found in general medical setting • There are many medical problems and drug that cause psychotic symptoms in medically ill patient • Determine the underlying causes and treat the patient with treatment recommendation • Antipsychotic still has the meaningful role in managing psychotic symptoms in medically ill patient
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