1. Physical examination is important in mental health assessment to identify any underlying organic causes for psychiatric presentations such as infections, metabolic disorders, endocrine abnormalities, and neurological conditions. 2. The physical examination should be tailored to the particular mental health presentation and may include systems like cardiovascular, respiratory, abdominal, neurological, and endocrine examinations. 3. Good documentation of physical findings, assessment, and management plan is important for continuity of care, medical-legal purposes, and showing thorough clinical reasoning.

1. Importance of Physical Examination in Mental Health Assessment Dr D A Harniess MBChB MRCGP DCH DRCOG

2. Learning Objectives Rationale for physical examination in mental health Considering organic causes for different psychiatric presentations Tailoring physical examination to different mental health presentations Recording and documentation of findings Relationship of physical problems to mental health

3. Pair Work Why do you think it is important to consider a physical examination in someone presenting with a psychiatric illness?

4. Rational for Medical Examination in Mental Health Presentations Lessons of history – many inpatients of mental health institutions had underlying organic cause for psychosis/depression Report of undetected infectious disease and metabolic conditions in psychiatric inpatients 1 Identifying a physical cause for depression allows appropriate treatment to be given that may well ease the depression e.g. pain control 1 Rothbard, AB., Blank, MB., Staab, JP et al Previously Undetected Metabolic Syndromes and Infectious Diseases Among Psychiatric Inpatients Psychiatric Serv Amercian Psychiatric Association April 2009 60:534-537

5. Rational for Medical Examination in Mental Health Presentations Temporal lobe epilepsy or brain tumour manifesting as unusual behaviour often misdiagnosed as psychiatric condition Need to consider postpartum thyroid disease or anaemia in postnatal depression/ psychosis Association between anxiety disorder and hyperthyroidism & asthma Coronary Heart Disease and link to depression 1 Rothbard, AB., Blank, MB., Staab, JP et al Previously Undetected Metabolic Syndromes and Infectious Diseases Among Psychiatric Inpatients Psychiatric Serv Amercian Psychiatric Association April 2009 60:534-537

6. What different organic causes can you think of for the following mental health presentations? Depression Fatigue, insomnia, concentration difficulties, weight loss/gain… Anxiety Chest tightness, breathlessness, palpitations, tremor… Psychosis Hallucinations, delusions, personality changes… Group Work

7. Depression: possible organic causes 1 Anaemia Endocrine – hypo/ hyperthyroidism and diabetes/ (more rarely) adrenal disease - Addison’s or Cushing’s disease Alcohol / drug use – cannabis/heroin HIV/AIDs (consider testing if in high risk group) Malignancy (more commonly oropharyngeal, pancreatic, breast and lung cancers) 2 Medications – steriods, beta-blockers, calcium channel blockers, hypnotics, anticonvulsants…. Neurological condition (especially in older patients) e.g. Parkinson’s or Dementia or even CVA Connective tissue disease e.g. SLE (rare) 1 mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings WHO 2010 p23 2 Massie, J Prevalence of Depression in Patients With Cancer Oxford Journals JNCI, VOl 2004, Issue 32 , p. 57-71

8. Anxiety: possible organic causes 1 Chest tightness Angina/MI Asthma Breathlessness PE, COPD, asthma, heart failure, mitral valve disease, pneumothorax Tremor Hyperthyroidism, underlying neurological disorder – Parkinson’s disease, MS… Other organic causes Drugs – antidepressants (SSRI – esp citalopram), stimulants Pheochromocytoma – palpitations, tachycardia, hypertension or orthostatic hypotension, N&V and epigastric pain Rabies – painful laryngeal spasms/dysphagia http://www.wrongdiagnosis.com/symptoms/anxiety/book-causes-5d.htm [website accessed on 2.1.10]

9. Psychosis: possible organic causes 1 Infection – cerebral malaria/ sepsis/encephalitis/ meningitis/ HIV/AIDS Alcohol/ drugs withdrawal (heroin, marijuana) Neurological – stroke/ dementia/ Huntington’s chorea Diabetes (especially hypoglycaemia) Electrolyte imbalance (hypo/hypercalcaemia, hyponatraemia, hypomagnesia) Hepatic encephalopathy Brain tumour Medications (e.g. steroids, digoxin, phenytoin, cimetidine, anticholinergic medications) 1 mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings WHO 2010 p32 2 http://www.fpnotebook.com/Psych/Psychosis/PsychsDfrntlDgns.htm [website accessed on 3.1.11]

10. What different physical examinations would you consider in someone presenting with anxiety symptoms? depressive symptoms? psychotic symptoms? manic symptoms?

11. General Examination Temperature Pulse BP Height and Weight Check for pallor Thyroid swelling? Chronic liver stigmata? Cushingoid appearance?

12. Endocrine Examination Thyroid examination Pulse/BP Sweaty palms? Tremor? Thyroid gland inspection ?swelling Palpitation ?lump – symmetrical (Grave’s) /nodular (toxic goitre) irregular (cancer) ?tender – thyroiditis Check for eye signs – proptosis/ exopthalmos/ lid lag Pretibial swelling Munro, JF., Campbell, IW. MaCleod’s Clinical Examination Churchill Livingstone May 2000

13. Case Scenario of a tired young woman 23 year old woman complained to her GP that she had been feeling tired and low had gained weight recently (she admitted to comfort eating) and had also noticed developing more facial hair. Her GP organised some blood tests which were as follows: UE: Sodium 130 (135-145 mmol/L) Potassium 5.0 (3.5- 5.0 mmol/L) Urea 12.0 (2.5-7) Creatinine 90 (60-110) Random glucose 11.0 What is your differential diagnoses? What is the likely diagnosis? What is your next test to confirm or disprove your diagnosis?

14. Signs of Cushing’s Disease

15. Signs of Addison’s Disease

16. Neurological Examination Pulse/ BP Tremor Cranial nerve examination + fundoscopy Gait Tone Power Reflexes Coordination

17. A 73 year old lady comes to you concerned she has a tremor that goes away when she starts eating and is worse when she is under stress and worry. Her husband has also noticed she seems to have difficulty getting out of a chair and feels she has been more withdrawn recently. What is your differential diagnoses? What is the likely diagnosis in this lady’s case? How would you tailor your neurological examination to check for this condition? Case Scenario – an anxious old lady?

18. What minimum investigations would be appropriate for someone with depression (e.g. tiredness)? What is your reasoning? On what are you basing your reasoning? Considering Investigations

19. Case discussion on documentation Case 1 Middle aged man suffering with anxiety. Not eating well and feeling on edge all the time. Travels away a lot on international conferences and feeling stressed with too many lectures to prepare. Felt panicky and heart racing. General examination looked OK. Propranolol prescribed. Case 2 27 year old doctor feeling low last 3 months with no obvious triggers or past history of depression. Anhedonia and not going out with female friends. Difficulty falling off to sleep and early morning wakening on 5 out of 7 nights – she feels tired most days. Poor appetite and believes has lost 1 stone in weight. Having difficult concentrating on ward rounds which is affecting her performance at work. She denies any suicidal ideation. She doesn’t drink alcohol or use recreational drugs. On examination poor eye contact, lack of facial expression and slow in speech and movements. Well dressed and kempt. Her pulse 74 reg, BP 150/90mmHg Height 1.65 Weight 52kg (BMI 19.1). No thyroid swelling and no pallor. PHQ score 25/27. Impression New onset severe depression. Plan Discussed options – check bloods in view of fatigue and likely weight loss – FBC/UE/TFT/glucose and she is keen to consider medication after bloods – review 1 week Discuss the 2 different examples of documentation above Why is good documentation important?

20. Recording and documentation of findings SOAP acronym S ubjective findings (onset, associated symptoms..) O bjective findings (+ve and –ve physical examination findings) A ssessment (working diagnosis with possible differentials) P lan Good documentation: Shows good discriminatory thinking Good evidence for any potential medico-legal cases Continuation of care (colleague sees next time)

21. Relationship of mental illness to physical health problems Depression a prognostic factor for MI (1.8 relative risk) 1 and having a MI a risk factor for depression (prevalence 20%) 2 Having moderate to severe depression impacts on post MI survival (relative risk 1.7) 3 Chronic disease and association with depression – cancer (0-58%)/IHD /diabetes (18-28%) 4-6 1 Nicholson A. Depression as an aetiologic and prognostic factor in coronary heart disease: a meta-analysis of 6362 events among 146 538 participants in 54 observational studies Eur Heart J (2006) 27 (23): 2763-2774 2 Frasure-Smith N et al. Depression following myocardial infarction. Impact on 6-month survival. JAMA 1993;270(15):1819-25 3 Brett D. et al Prevalence of Depression in Survivors of Acute Myocardial Infarction 4 Review of the Evidence Journal of General Internal MedicineVol 21, Issue 1, Jan 2006 30-31 4 Massie MJ. Prevalence of depression in patients with cancer. Journal Natl Cancer Inst Monogr 2004;(32):57-71 5 Anderson RJ. et al The Prevalence of Comorbid Depression in Adults With Diabetes - A meta-analysis Diabetes Care June 2001 vol. 24 no. 6 1069-1078 6 Van Ede L. et al Prevalence of depression in patients with COPD : a systematic review Thorax 1999 54 p688-692

22. Depression screening in chronic Illness 1 2 screening questions During the last month, have you often been bothered by feeling down, depressed or hopeless? During the last month, have you often been bothered by having little interest or pleasure in doing things? 2 1 Ischaemic Heart Disease/ Diabetes/ Cancer/ chronic pain 2 Nice Guidelines Depression October 2009 p17 [www.nice.org.uk]

23. Relationship of mental illness to physical health problems Physical health of schizophrenic patients: Unhealthy lifestyles Affect of long term anti-psychotics on their health – increase rate of obesity, impaired glucose intolerance Thus schizophrenic patients have higher cardiovascular risk (premature death from IHD)

24. Cardiovascular Risk Factors and Schizophrenia 1 Davidson et al. Aust NZ J Psychiatry. 2001;35:196–202 ; 2 Herran et al. Schizophr Res. 2000;4:373–381 ; 3 Dixon et al. Schizophr Bull. 2000;26:903–912; 4 Kato et al. Prim Care Companion J Clin Psychiatry. 2005;7:115–118 Non-modifiable risk factors Modifiable risk factors Prevalence in schizophrenia Gender Obesity 1 30–40% (1.5–2 ×) Family history Smoking 2 50–80% (2–3 ×) Personal history Diabetes 3 11–15% (2 ×) Age Hypertension 4 58% Ethnicity Dyslipidaemia 4 45%

25. Prevalence of Obesity is Increased in Schizophrenia BMI = Body Mass Index Allison et al. J Clin Psychiatry . 1999;60:215–220 Normal weight Overweight Obese 0 5 10 15 20 25 30 BMI category Schizophrenia No schizophrenia <20 20 – 22 >22 – 25 >24 – 26 >26 – 28 >28 – 30 >30 – 33 >33 – 35 >35 Percentage

26. Prevalence of Diabetes in Schizophrenia vs. General Population Prevalence (%) 25–35 15–35 35–45 45–55 55–65 Age range (years) De Hert et al. Clin Pract Epidemiol Mental Health. 2006;2:14 n=415 patients with schizophrenia

27. What do you think should go into a annual health check with someone with severe mental illness?

28. Health check on patients with enduring severe mental illness 1 General Examination BMI (height and weight)- checking for obesity Smoking Alcohol/ drug use BP and pulse check Blood screening – annual lipids/glucose ?prolactin (esp. if on atypical antipsychotic) Specific drug monitoring: Lithium – Lithium level 3 monthly, annual TFT/UE Anticonvulsant as mood stabiliser – annual LFT 1 Bipolar affective disorder, severe complex depression, schizophrenia and other long term psychoses

29. Learning Objectives Rationale for physical examination in mental health Considering organic causes for different psychiatric presentations Tailoring physical examination to different mental health presentations Recording and documentation of findings Relationship of physical problems to mental health

30. Identifying Learning Needs Follow reflective work sheet on learning 2-3 things learnt and how will it change your practice? What do you want to go and find out more about? How and where are you going to go to find out this information?