EMOTIONAL AND BEHAVIORAL SYMPTOMS ACCOMPANY and may exacerbate many chronic diseases, and thus, almost every practitioner will at some point encounter patients with psychiatric comorbidities. This chapter aims to provide a framework for approaching the psychiatric patient. Diagnosing and treatment calls for first viewing the patient as a human with psychiatric symptoms. Some extra precautions for protecting the patient and oneself may be needed, such as obtaining information on safety precautions or reliability as a historian, but many of these should already be part of good clinical practice for any patient.
Some keys to working successfully with psychiatric patients involve:
Having a fundamental knowledge of a patient’s psychiatric condition to help assess treatment compliance, safety issues, and potential barriers to treatment.
Knowing the psychiatrist’s treatment plan, and being able to anticipate a patient’s mental progress over time.
Working in unison with the psychiatric team (and preventing patients from engaging in “team-splitting”).
Protecting oneself mentally to avoid burnout.
Remaining open-minded to increase chances of finding overlooked diagnoses.
Being aware of psychiatric medication side effects such as weight change, orthostatic hypotension, movement disorders, confusion, irritability, fatigue, anxiety, or increased fall risk.
Helping find organic causes for psychiatric symptoms by reviewing labs, screening for infections, and so on.
Helping diagnose movement disorders, which may represent primary medical conditions or medication side effects.
Using exercise and physical movement to help break a downward cycle.
Reducing unnecessary systemic medication usage, especially for pain management, and helping prevent substance abuse.
Recognizing physical maladies as clues to undiagnosed mental disorders.
Mental illness accounts for more disability in the developed world than any other health condition. In the United States, a fourth of adults annually report having mental illness meeting Diagnostic and Statistical Manual of Mental Disorders-IV criteria.
Psychiatric conditions often lead to a host of patient stressors: family, finance, and work are often adversely affected. Often, the patient suffering from psychiatric illness is afflicted with poor health habits, diet, lack of self-care, and inability to perform activities of daily living (ADL). In extreme cases, an individual may have also sustained musculoskeletal injury from dangerous behaviors. A paranoid patient might not even cooperate with therapists, a depressed individual may lack motivation to follow a home exercise program, an Alzheimer’s patient may not comprehend instructions, or a schizophrenic may halt amidst gait training on account of hallucinations. It is no wonder that prior caregivers may have given up on attempts to mobilize a patient, leading to a downward spiral involving inactivity, deconditioning, frailty, and even obesity. In such cases, a progressive physical reconditioning program emphasizing functional training and self-care may help turn things around.
Adding to the toll of mental illness is its often-early onset: in the United States, three-fourths of all lifetime cases start by age 24 years.1 By age 75, about half the population has had some psychiatric condition.1 Table 88–1 lists common mental illnesses, but missing here is schizophrenia, which, despite its low lifetime prevalence of <1%, often has early onset and accounts along with other psychotic disorders for almost a quarter of US ambulatory psychiatric visits.2
| Anxiety disorders | 29% |
| Mood disorders | 21% |
| Impulse-control disorders | 25% |
| Substance use disorders | 15% |
| Any disorder | 46% |
Emotional and behavioral symptoms accompany and exacerbate many chronic diseases including diabetes, obesity, cardiovascular disease, low back pain, and cancer.2 Thus, most physicians, regardless of specialty, will encounter psychiatric issues. Often, psychiatric conditions may be well-hidden initially only to surface over time (and lest practitioners consider themselves immune, concern exists over elevated risks of depression and suicide among physicians themselves).3
Psychiatric encounters in the rehabilitation setting can lead to at least four special challenges. First, psychiatric comorbidities can create powerful barriers to management because of symptoms such as poor motivation, anhedonia, paranoia, distractibility, confusion, or belligerence. Second, patients often “self-medicate” by resorting to maladaptive habits such as smoking and drug use. Third, such encounters can personally “drain” practitioners if the usual patient-physician boundaries dissolve. Finally, physical safety concerns for physicians and therapists can arise from the possibility of violence. Amidst this maze of challenges, hopefully, the guidelines outlined here will help increase one’s sense of reward in managing patients with psychiatric disorders.
To begin, one must remember that behavior in psychiatric patients is affected by underlying conditions likely not under their immediate control. These symptoms, after all, could have arisen from something as simple as a patient missing their usual schizophrenia medications, or perhaps an adverse effect of a new medication (e.g., steroid-induced psychosis).
With about 300 mental conditions identified in DSM-5, it is important at the outset to simplify the approach to the patient. A helpful heuristic in the management of the rehabilitation patients with psychiatric disorders is to understand the patients perception of reality (“reality awareness”). Patients with a fairly strong connection to “reality” (e.g., nonpsychotic depression) should be distinguished from patients with relatively isolated areas of reality distortion (e.g., mild schizophrenia) and those with marked breakdown in “reality testing” severely impairing global function (e.g., severe schizophrenia). A rehabilitation program must take into account the patient’s ability to follow commands and, therefore, is determined by their reality perception. Table 88–2 lists examples of potential barriers to management. This heuristic is not infallible since, for example, an anxiety patient may prove more disabled than a schizophrenic undergoing treatment.
| Condition | Diagnostic Highlights | Examples of Treatment Challenges |
| Depression | Sadness, worthlessness, guilt, anhedonia, suicidality, poor concentration | Poor motivation; missing follow ups |
| Anxiety | Nervousness, perseveration over fears | Diffidence; requiring constant reassurance |
| Obsessive compulsive disorder | Intrusive, unwanted thoughts; compulsions to engage in behaviors to avoid anxiety | Unwillingness to be touched; halting mid-therapy for ritual |
| Somatization disorder | Distressing physical symptoms not explained by medical condition | Perseverating re: disagreements with diagnosis and current therapy |
| Agitation | A concomitant of several conditions | Unpredictable outbursts |
| Neurocognitive disorders | Persistent impaired cognitive function from brain disease; marked by memory deficits, personality change | Inconsistent performance; requiring repeated instructions |
| Schizophrenia | Breakdown in relation between cognition, emotion, behavior, leading to impaired perception, delusions, withdrawal into inner world | “Internal stimuli” may stop patient in tracks; paranoia leading to lack of cooperation or even violence |
A patient management plan must synthesize feedback from the psychiatrist, other rehabilitation specialists, pharmacists, floor staff, insurers, social workers, and family. It is critical to understand and align with the management goals from the psychiatry team and avoid any potential conflict in treatment (e.g., unilateral use of benzodiazepines, narcotics, or neuroleptics without consultation with the psychiatrists). While one may suggest changing psychotropic medications, it is generally best to make final decisions only after consulting the psychiatry team, with the goal of minimizing drug interactions and decreasing adverse outcomes. Order requests from nurses or on-call covering physicians for simple medication changes (e.g., sleep aids or short-acting pain medications) should, therefore, be handled with caution and signed out to the covering team. Ideally, an overnight plan for pain, anxiety, and insomnia will already be in place by the primary team and psychiatry consult service.
It is important—often through the psychiatrists’ notes—to anticipate the trajectory of a psychiatric illness. On inpatient rehabilitation units, new admissions may likely have just hit “rock-bottom,” and because of concomitant combativeness or fatigue, may refuse even basic physical exams or therapies.
The initial step in management of such patients is to determine their compliance with psychotropic medications already prescribed, and, when necessary, re-starting medications with which they have been nonadherent (a situation precipitating many admissions). Concomitant psychiatry consultation for adding or replacing medications, or merely altering doses, is critical. If the psychiatrist has chosen a winning formula, the patient may gradually improve: an initially noncompliant, disheveled, combative, malodorous, and withdrawn patient may give way to a patient more compliant with therapies and likely to make functional gains.
Of course, not every patient suffers from noncompliance with psychotropic medications. Abrupt changes in behavior may also be secondary to systemic disease (e.g., infection, fracture, bleed, etc.) and must be ruled out by the rehabilitation team.
