Psychological and physical symptoms commonly occur together; surveys have shown that they tend to cluster in some people, while others remain relatively free from illnesses. The commonest presentation of psychiatric illhealth in physically ill patients is as affective disorders or acute organic brain syndromes. The relationship between psychological and physical symptoms may be understood
in one of three ways:
1 Psychological distress and disorder can provoke and precipitate physical disease.
2 Physical distress and disease can cause psychological illhealth (Table 19.2), as can the medication given for the disease.
3 Physical and psychological symptoms and disorders coexist because both are common, particularly in the elderly.
Physically ill patients often respond to their illness by feeling depressed, anxious, angry and/or unable to cope. Such reactions are very often transient and require little in the way of management other than recognition, reassurance and support. Sometimes, however, they persist after the acute stage of the physical illness has passed. Certain factors also increase the risk of a psychiatric disorder occurring in the setting of physical disease (Table 19.3). Treatment is the same as for physically healthy, psychiatrically ill patients, but care must be taken when prescribing psychotropic drugs to avoid drug interactions.
Previous history of psychiatric illness
History of difficulty in coping with stress
Disturbed personal, family or social circumstances
Intensive care units
Coronary care units
Renal dialysis units
Drugs (e.g. steroids)
Factors increasing the risk of psychiatric illness in physically ill patients.
PAIN is one symptom that can be thought of as both physical and psychological. It is the commonest medical symptom, can cause considerable psychological distress and can arise from psychological disturbance. The main sites of psychologically determined pain are the head, the neck, the lower back, the abdomen and the genitalia. Psychologically determined pain is often continuous for lengthy periods and responds poorly to analgesics.
It is often described by the patient as waxing and waning in response to emotional stress and, despite its severity, does not necessarily wake the patient from sleep. A particularly dramatic form of chronic, atypical pain is facial pain; antidepressant therapy has been found to be effective in up to 50% of such patients. Another common painful condition in which depression is often present but is masked by the physical symptoms is the irritable bowel syndrome.
Chronic fatigue syndrome
The cardinal symptoms are fatigue, poor concentration and memory, irritability, alteration in sleep and muscular aches. This syndrome, previously known as myalgic encephalomyelitis (ME), has been attributed to an infection, usually viral. There is, however, no good evidence of any infective cause of this condition at present and laboratory investigations are normal; many patients are depressed.
CLASSIFICATION OF PSYCHIATRIC DISORDERS
The concept of mental illness is complicated. The diagnosis is only made when:
• There is a recognizable disturbance in one or more psychological functions, e.g. perception, emotion,
• The disturbance is not under the comprehensive control of the individual concerned.
• The disturbance usually (though not invariably) causes distress to the affected individual.
• The disturbance usually (though not invariably) requires expert, professional assessment and treatment for recovery.
Particular problems in psychiatry are posed by such conditions as sexual disorders, drug and alcohol dependence and personality disorders. In 1980, the third edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM III) was published (revised 1987). This scheme has five axes. The two main axes are:
• Psychiatric syndromes
• Personality disorders
The others are:
• Physical disorders
• Severity of psychological stressors
• Highest level of adaptive functioning
The most recent revision of the International Classification of Disease and Related Health Problems (ICD-10) published by the World Health Organization includes a detailed classification of 300 psychiatric and behavioural disorders.
A simple classification of psychiatric disorders is shown in Table 19.4.
PSYCHOSIS is the term usually applied to a psychiatric disorder that significantly impairs insight, involves a substantial break with reality, exercises a major impact on the individual’s personality and functioning, and which may require specialized, inpatient treatment.
Certain Organic disorders (FOO-F09)
Manic-depressive disorder (F30-39)
Phobic anxiety neurosis (F40)
Obsessive-compulsive disorder (F42)
Dissociative (conversion) disorders (F44)
Stress and adjustment reactions (F43)
Hypochondriacal disorders (F45)
Personality disorders (F60-69)
Alcohol and drug abuse and dependence (F10-19)
Eating disorders (F50)
The three-character codes refer to the diagnostic
categories of the latest edition (the 10th) of the
International Classification of Diseases, produced by the
World Health Organization.
A classification of psychiatric disorders.
symptoms that by definition involve an impairment of reality, such as delusions, hallucinations and formal thought disorder, are often termed psychotic symptoms. NEUROSIS is the term applied to psychiatric disorders in which psychotic symptoms and features are absent, the patient’s personality is relatively undamaged, and contact with reality is unimpaired. Neuroses can be thought of as exaggerated forms of the normal reactions to stressful events. Anxiety, depression, irritability and physical symptoms lacking an organic cause are experienced by many people in response to stressful circumstances and events.