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Psychological disorders brought on by somatic illness, general medical conditions and adverse events in psychiatry

Janus Oomen, internist (non-practising), medical anthropologist

Introduction

Mental disorders due to a medical condition make up a large grey area between medical specialties. The subjects are too varied for a ‘state-of-the-art' summation. Overviews in the most recent editions of manuals are often the best source for theories about the link between psychological manifestations and somatic causes. Alas these are precisely the chapters which are not reproduced on the Internet. Useful keywords in combination with 'psychiatry' - 'organic' are 'neuropsychiatric'; 'somatic';liaison'; 'consultation'; 'psychosomatic', 'general medical conditions'. In the 21st century, the direction of psychiatry, as a science and discipline, has closed the gap with ('somatic' or general) medicine Psychiatry is (one specialization of ) Medicine. One consequence is that the complications of medicine (AE: adverse events, unintended damage due to treatment) are included in this section. Globally, mental health services are not yet attuned to AE-prevention research and applications. In diagnostic manuals the entities, due to AE, are included in the (DSM-V) 3d axis. For this reason we have extended this section with a review of links to the AE. reserach.

Portal aspects

A tip that is perhaps only useful for internet beginners: the many digital databanks are more appropriate search engines than our site, which is meant mainly as an introductory overview. How do I personally search with the most success? I log onto 'my' digital library (in my case, the UVA(Amsterdam digital univeristy) library, which with a password I can also consult from home; ask your librarian), then "scholar.google.nl" and enter an appropriate search term, for example 'general medical conditions AND psychiatry' /  'adverse event AND psychiatry, and that gives me an overview. The library connection indicates which material (articles, chapters, etc.) are available in full text, as in this example: Burden of general medical conditions among individuals with bipolar disorder - UvA-linker: Full Text

The selection criterion for this portal to internet resources is that which can help the practising psychiatrist with the diagnosis, treatment, and presentation of disorders. Devising a classification system is difficult, since in this forest everyone has his or her own path. We opted to focus on the symptomatology of characteristic "classic pictures": delirium, dementia, and secondary cognitive and affective disorders. The fundamental clinical question is whether this psychiatric symptom / sign is demonstrated to be the effect of this somatic disorder. In clinical practice, symptoms are unspecific. Thus for example hallucinations are observed to have a great variety of somatic and non-somatic causes. Sometimes the causal lesion can be attributed to be in the ‘brain as organ' (synonymous with organic; cerebral, neuro-, direct) or other systems (systemic, indirect). Because psychiatric syndromes provide so little foothold, this topic makes the somatic disorder the point of departure.

Though psychiatric syndromes provide so little foothold, and the link starts at the medical condition, we refer to authors/research well-known in this area, and attempt to keep the content as concise as possible by separating medical conditions from conditions caused by remedies (drugs, etc.), poisons, and other kinds of co- incidence and causality. You will find brief differential diagnostic links under other topics within psychiatrynet.eu. The inclusion of disorders is based on the DSM-IVTR (Axis-III) in conjunction with the ICD-10-V (codes F00-99),and follows therein the diagnostic description which according to the DSM should be coded on Axis-I as a syndrome, and which in ICD code represents somatic factors on Axis-III. An example: dementia, depressive characteristics 294.10 and neurosyphilis F02.83.

Unintended damage: AE (adverse event)

Until recently reports on medical unintended damage have consistently excluded patient conditions in psychiatry and the treatment organisation of mental disorders; Medical errors in psychiatry consequently demand closer attention by experienced professionals and researchers. In medical settings, many of the same risk factors that place patients at risk for poor quality of care also place patients at risk for medical errors (Nath & Marcus 2006). These same risk tirggers, along with factors unique to the mental health system and patients with mental disorders, are likely to create a substantial risk of error in mental health settings. Nath & Marcus (2006) provide an excellent review in one current article from this point of view.

Introduction: an AE portal

In this section of the portal the editors will make information available, associated with prevention and assessment of adverse events (AE) & unintended damage due to (para)medical action in mental health. The initiative derives from research projects undertaken in the Netherlands since 2004, aimed at the development of criteria to define preventable adverse events (Reported in M.C. de Bruijne et al. 2007. Onbedoelde schade in Nederlandse ziekenhuizen. www.nivel.nl). We will provide documentation related to an ongoing research (Trimbos Institute &  NIVEL) in 2009 in Dutch Mental Helathcare (GGz). Editing is by H.A.P.C.Oomen (project adviser to the Trimbos-NIVEL researchers). Contributions are welcome to oomen@xs4all.nl

The 'Medical Conditions' category are replaced by 'triggers' which are 'sentinel events' to unintended damage, known from previous research. The triggers have been chosen in a consent procedure by a panel of experts and rely on the evidence of international literature and the Dutch study results quoted. We aim at a translation and comparison with other European sources in this section. What defines adverse event in this context is the presence of three elements together: (1) the adverse (unwanted) event is an injury (either/both physical/mental), (2) leading to  temporary / permanent damaged health, or prolongation of hospital stay, or death, (3) caused by the care provider and/or system.

In the research we use for reference (retrospective case-studies) the triggers, in mental hospital care, used for screening dossiers on the possibility of AE's, were: 1. A preceding (6 months) hospital admission related to the one presently studied (index-period) 2. A succeeding (6 months) hospital admission related to the one presently studied (index-period) 3. A temporary / permanent damaged health (other than the cause for admission) acquired during the index-period 4. Injury caused by the (para)medical role in medication (prescription, technique) 5. Injury caused by the patient role in medication (compliance, technique) 6. Unintended response to medication 7. Damaging or risky combination of medication 8. Injury related to electroconvulsive treatment (ECT) 9. Restrictive measures during index-period (forced separation, physical restriction) 10. Finding a new somatic health condition or unexpecte deterioration during the index-period etc. (More to follow; 22 triggers in all, the 23d being 'all other unintended unwanted).

We will use the trigger categories as sub-heads for items (links, publications, guidelines) of interest in European Mental Health Care.

Autoimmune disease is a collection of disorders, and their connection to psychological manifestations is complicated. Because there are lifelong lapses in the autoimmune system, there are many relationships. This basic article about gluten sensitivity syndrome is a good introduction to this complexity.