Psychiatry and pneumology in focus

Psychiatric emergencies with states of agitation, burnout, ADHD in adulthood, chronic cough, sleep apnea – experts brought the participants of the continuing education event “General Internal Medicine Update Refresher” up to date on these and other practice-relevant topics from psychiatry and pneumology.

Psychiatric emergencies only leave room for a syndrome diagnosis and force rapid symptom-oriented action. Emergency syndromes include psychomotor agitation, deliriant syndromes, disorders of consciousness, acute suicidality, and drug-induced emergencies, reported Dr. Peggy Guler-Stützer, co-chief physician, Psychiatric Services of the Grisons. In states of agitation with increase of drive and motor activity, irritability and aggressiveness, situationally inadequate actions, self-destructive tendencies, anxiety, inner restlessness, and drivenness, various causes come into consideration:

Anxiety, panic, acute stress reaction: patient is rarely aggressive, more likely to seek help, and should return to “normal” after reassurance by supportive conversation (talking down) and lorazepam 1 to 2.5 mg peroral.
Schizophrenia, mania, organic psychosis with the early signs: lack of cooperation, motor restlessness, aimless pacing, intense gesticulating, loud talking with verbal aggressiveness, silent pausing in tense posture, irritability and impulsiveness with sudden excitement.
Drug or alcohol intoxication: if possible, no sedation with medication if the substance consumed is not known; hospitalization required for diagnostic clarification.
Deliriant syndromes with temporal and spatial disorientation but long preserved orientation to self.
BPSD (Behavioural and Psychological Symptoms of Dementia) with physical aggressiveness and disinhibition, agitation and aimless wandering, crying, day-night reversal, depression and anxiety, hallucinations and delusions.

Burnout

Burnout is not recognized as a mental illness, the speaker said. Burnout is not an ICD diagnosis, but it is a risk condition for somatic and psychiatric illness. Burnout is a process usually coupled with work, characterized by emotional and physical exhaustion and associated with reduced performance. In the first stage of the burnout process with increased stress, therapeutic measures must be taken to ensure that those affected gain insight into the problem, that a personal assessment of the situation is carried out and that relief and changes at the workplace take place. In the second stage (mild to moderate burnout with exhaustion, regular difficulty falling asleep and staying asleep, reduced activity, social withdrawal, emotional lability, weariness, demotivation, reduced ability to recover, permanent vegetative symptoms, multiple pains, concentration and memory disorders, dejection) psychotherapy and relaxation methods are indicated. In the third stage (severe burnout with clinical depression), the focus is on antidepressants, referral to a psychiatrist or a specialized clinic, and suicide prevention.

ADHD in adulthood

ADHD (Attention Deficit Hyperactivity Disorder) is not a disease, but a syndrome that can certainly allow a life without impairment, but can also acquire disease value when it comes to functional restrictions in everyday life and losses in the quality of life. In Switzerland, about 5 percent of adults are affected. To date, the diagnosis can only be made if the diagnostic criteria were present before the age of 12 and persistently thereafter (at least 5 of 9 criteria of attention deficit disorder or 5 of 9 criteria of overactivity and impulsivity). In adults, accessory symptoms such as disorganization, stress intolerance, and inability to control one’s own emotions are often prominent. A “Diagnostic Interview for ADHD in Adults” (DIVA 2.0) can be downloaded free of charge from the Internet%20DIVA%.

Multimodal treatment recommended for adults with ADHD includes:

Coaching in areas such as organization, job, family, relationships
Medication for support
Psychotherapy (individualized individual therapy)

Regarding pharmacotherapy, the speaker recommended starting directly with sustained-release methylphenidate (^Concerta®) or dexmethylphenidate (^Focalin® XR). Second-line medications may include lisdexamphetamine dimesylate (^Elvanse®) from the stimulants or atomoxetine (^Strattera®) from the antidepressants.

Chronic cough

If cough persists for more than eight weeks, it is a chronic cough. Affected individuals must have bronchial asthma, COPD, and non-obstructive smoker’s bronchitis ruled out. Coughing asylum seekers should also be thought of as having tuberculosis, said Dr. Thomas Rothe, chief physician, Internal Medicine and Pneumology, Zurich Rehab Center, Davos. Because tuberculosis can cause very different changes (e.g. enlarged hilar lymph nodes, effusion, caverns, tuberculoma, very atypical images in immunosuppressed patients), the lecturer gave the advice to consider for a second on every chest X-ray whether there might be tuberculosis behind it. One quarter of smokers develop COPD, and the diagnosis can only be made by spirometry. However, cough due to smoker’s bronchitis is also common in the remaining three-quarters of smokers. Spirometry should be part of the workup for all smokers between the ages of 30 and 50, the speaker said. Other important causes of cough are: Reflux, post-nasal-drip in chronic rhinosinusitis, and ACE inhibitor cough, which may also become suddenly apparent after several years of treatment.

Sleep apnea

Only longitudinal muscles ensure that the pharynx is kept open during the day. During sleep, a decrease in muscle tone (especially during REM sleep) may cause the lumen to relax and decrease with physiologic snoring. Evening alcohol consumption or use of benzodiazepines further increase the loss of tone. Particularly in men over the age of 50, the pharyngeal muscles lose additional tension due to age and hormones. Pathologic snoring occurs when multiple factors (e.g., anatomic pharyngeal constriction, obesity, and increased neck circumference) cause massive collapse with incomplete closure (hypopnea) or complete closure (apnea). Only wake-up reactions (arousals) terminate the apneas again. Women are less often affected by obstructive sleep apnea than men. Not only central but also obstructive sleep apnea is common in patients with heart failure because edema fluid from the legs is also redistributed to the pharyngeal tissues at night while lying down. The speaker drew attention to the fact that patients with obstructive sleep apnea often suffer from massive reflux, which quickly disappears with CPAP (continuous positive airway pressure) treatment. Repeated nocturnal hypoxia, lack of blood pressure dipping at night, hypertension in the morning, wake-up responses with sympathetic activation and pulse acceleration increase the risk of cardiovascular disease, especially stroke, myocardial infarction, and atrial fibrillation.

Dr. Rothe explains the principle of CPAP treatment to his patients by comparing the pharynx to a fire hose that collapses without contents and only unfolds and hardens with water pressure. Similarly, continuous positive pressure keeps the pharynx open. A recent study confirmed the subjective benefits of CPAP therapy with improvement in sleep apnea symptoms, mood state (less anxiety and depression), and quality of life [1]. This study, which involved patients with moderate to severe obstructive sleep apnea and existing coronary artery disease or cerebrovascular disease, failed to demonstrate a preventive effect for CPAP therapy with respect to further cardiovascular events. However, the speaker critically noted that the duration of wearing the respiratory mask was insufficient, averaging only 3.3 hours per night.

Source: General Internal Medicine Update Refresher, Forum for Continuing Medical Education, November 18, 2016, Technopark Zurich.

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