Psychiatric Care in Lithuania: Organization, Diagnosis, and Treatment

Posted on May 21, 2024 in Medicine & Health

1. Organization of Psychiatry in Lithuania

Organization Levels:

  • Primary (Municipality Level): Primary personal and public mental health care.
  • Secondary (Country Level): Psychiatric hospitals supported by the country.
  • Tertiary (State Level): Institutes that provide education and training.

Team (for Mentally Ill Patients):

  • Psychiatrist for adults, addictions, kids
  • Medical psychologist
  • Mental health nurse
  • Social worker

Rights of the Psychiatrist:

  1. Outpatient support (primary health care)
  2. Inpatient support (in the clinics)
  3. Care of psychoneurological diseases

Psychiatrist vs. Psychologist vs. Psychotherapist:

PsychiatristPsychologistPsychotherapist
MDDegree in psychologyDifferent background
DxWork in health careSeparate training
Tx3 years of doctoral training

2. Nursing of Psychiatric Patients, Acute Psychiatric Treatment

  • Interview the patients
  • Proper interview is a key element to primary diagnosis.
  • Ask not about just illness but general condition.
  • Assess the behavior and decide the condition.

Criteria for Hospitalization:

  • Dangerous patient, that can harm himself or others.
  • Unable to care for himself due to a psychiatric disorder.
  • Under extreme distress and crisis.

Acute Psychiatric Treatment:

  • Must give the patient sedative medication in order to take an interview.
  • Medications:
    • a) Benzodiazepines (lorazepam) 1-2 mg IM
    • b) Typical antipsychotic (haloperidol) 1-40 mg/d
    • c) Atypical antipsychotic olanzapine or ziprasidone

3. Legal Aspects of Psychiatric Aid

Mental Illness:

Disease that was diagnosed by a medical doctor and is confirmed by a psychiatrist.

Mental Patient:

Person which is ill with a mental disease (diagnosed by a psychiatrist).

NB: The purpose of the law is to provide rights for those who are sick with mental diseases.

Rights of the Mentally Ill Patients:

  • No discrimination
  • To be considered incapable
  • To be educated & reintegrated
  • To communicate with others
  • To be visited and receive
  • To have privacy
  • Access communication devices
  • Prohibition to force the mentally ill to work
  • Dangerous to himself or his surrounding
  • 48 hrs (they must notify the representatives of the patient to apply to court)
  • To receive appropriate health care
  • Confidentiality
  • Access to medical information

4. Diagnosis of Acute Psychiatric Conditions

The Physician:

  1. Know the manifestation of various psychiatric (psychosis, depression / suicidal patient)
  2. Complete assessment of psychiatric condition
  3. PE
  4. Lab tests & imaging
  5. Identify if the psychiatric condition is caused by medication condition. Acute condition is treated first.
  6. Identify the psychiatric condition
  7. Treat it
  8. Patients taking X must be monitored for ADR!

Acute Conditions:

  1. Alcohol, illicit X: withdrawal delirium
  2. Delirious patient: Care of DH
  3. Suicidal patient
  4. Violent patient
  5. Acute psychosis patient

I. Delirious Patients:

  • Lab: to rule out any medical cause (urinalysis, metabolic state, CXR or MRI)
  • DX levels: associated conditions (sepsis, alcohol, heart, CNS, COPD, hepatic failure)

II. Suicidal Patients:

  • Interview is the most important risk.
  • Must talk to family members.

III. Violent Patients:

  • Interview: history of person’s violent acts
  • Before interviewing, security check
  • Underlying cause of the violence (drugs, alcohol or medical condition)

IV. Acute Psychiatric Patients:

  • Must know if it is an acute or chronic condition.

5. Examination of Psychiatric Patient

Composed of 3 main things:

  1. History
  2. Clinical exam: mental & physical status
  3. Investigation

N.B: The purpose of the interview is to obtain information, assess emotion & understanding the patient.

Psychiatric Interview and History: Use of open questions and should include:

  • Reason for coming
  • Complaints
  • History of current illness
  • Family and family psychiatric history
  • Personal history from childhood
  • Past medical history

Mental Status Examination:

  • Appearance and behavior (general & facial appearance, posture/movement)
  • Speech (rate and quantity, neologism, accent)
  • Mood (objective-anxiety, subjective-affect)
  • Thought content (preoccupation, obsessions, phobias)
  • Abnormal experiences
  • Cognitive status (orientation)
  • Insight

Physical Examination:

  • Organic causes (psychiatric disease)
  • Neurological examination (consciousness, language ability, memory, verbality, apraxia, agnosia)

Investigation:

  • Information from relatives, GP, and others
  • Blood tests (CBC, urea, electrolytes…)
  • Drugs screening
  • EEG
  • Psychometry
  • CT, MRI
  • Genetics

6. Disturbances in Perception

  • Illusion
  • Hallucination
  • Pseudohallucination

Illusion:

  • Misinterpretation of real external stimuli
  • Type: physical, physiological/ illusion due to lack of attention
  • Pareidolia: psychological stimulus where mind perceives a familiar pattern where none exists.

Hallucination:

  • False perception with no external stimuli, can be any number of sensations.
  • Types:
    1. Elementary
    2. Simple
    3. Complex (couple of senses)
    4. Induced: same hallucination to a group of people
    5. Stereotype (same voice and image)
    6. Hypnagogic (while falling asleep)
    7. Hypnopompic (occur while awake)

Pseudohallucination:

Same as hallucination but person knows it’s unreal!

7. Memory Disorders

  • Amnesia
  • Jamais vu
  • Deja vu
  • Confabulation

8. Thought Disturbance, Mood Disturbance

Thought Disorder:

  1. Stream of thought
  2. Form of thought
  3. Delusions
  4. Overvalued ideas
  5. Obsession & compulsive symptoms

Disorders of Stream of Thoughts:

  • Pressure of thoughts: (rapid, abundant, and varied. In mania and schizophrenia)
  • Poverty of thoughts: (slow, few, and unvaried. Occur in depression and schizophrenia)
  • Thoughts blocking: (sudden emptiness of thoughts. Occur in schizophrenia)

Disorders of Form of Thoughts: Links between thoughts

  1. Flights of ideas: conversation is moved quickly from one topic to the other.
  2. Loosening of association: lack of logical connection between the parts of the sentence.
  3. Perseveration: persistent and inappropriate repetition.

Delusions:

A false belief based on incorrect perception of reality.

I. Primary Delusion:

Occur suddenly with complete conviction and with no abnormal mental events.

Types:

  1. Delusional mood (change of mood after a delusion)
  2. Delusional perception (perception of an event in life not as it is)
  3. Delusional memory (misinterpretation of past events)

II. Secondary Delusion:

Arise from a preceding event (hallucination, mood, or other delusion).

III. Shared Delusion:

Usually a person close to the deluding individual.

IV. Delusional Themes:

  1. Persecution (paranoid): occur in schizophrenia, organic disease and severe depression.

Mood Disorder:

  • In nature of mood
  • In variability of mood
  • In consistency of mood with thinking

Mood changes under stress conditions. Most common changes are in depressive & anxiety disorders. Change in mood will be accompanied by physiological changes (face & posture).

I. Nature of Mood:

  • Depression: low mood with feelings of sadness & anhedonia.
  • Elation: over happiness.
  • Anxiety: feeling of apprehension.

II. Variability of Mood:

  • Blunting/Flattery:
  • Labile: Hyper response.

III. Consistency of Mood with Thinking:

Facial expression does not correlate with the feeling of the person (schizophrenia/depression).

9. Disorders of the Will (Volition)

  1. Abulia
  2. Hyperbulia
  3. Hypobulia
  4. Catatonia

1. Abulia:

  • Complete passivity
  • No ambition
  • No engagement
  • Spends most time in bed
  • No interest
  • In schizophrenia/depression/dementia…

2. Hyperbulia:

  • Hasty decision making
  • Movement agitation
  • Occurs in mania & paranoia

3. Hypobulia:

  • Reduced will
  • Reactive
  • Hesitant
  • Atypical passivity
  • Slow movement
  • Occurs in schizophrenia

4. Catatonia:

  • Psychomotor disorder with movement agitation
  • Complete stagnation

10. Catatonic Symptoms

Catatonia:

  • Psychomotor disorder + movement agitation or akinesia
  • Complete stagnation

Symptoms are:

  1. Stupor: stagnation mode, no response & increased muscle tone.
  2. Embryonic posture: knees bent to chest.
  3. Airbag symptom (neck is strained, chin against chest).
  4. Pavlov symptom:
  5. Catalepsy: rigid body muscle with waxy flexibility.
  6. Negativism:
  7. Stereotypy: repeat same movement.
  8. Mutism: patient is not talking.
  9. Parapraxia: strange posture.
  10. Ambivalent: 2 wills contradict each other.
  11. Echolalia: mimicking of speech.
  12. Echopraxia: mimicking of movement.
  13. Automated obedience:

Catatonic Stupor:

  • Starts suddenly with no reason.
  • Whole body stiffness.
  • Airbag symptom.
  • Occurs after: trauma, hysteria, depression, epilepsy.

Catatonic Agitation:

  • Stereotypy, parapraxia/echolalia, echopraxia.
  • Occurs in mental agitation/mania/epilepsy.

11. Mental Impairment Symptoms, Dementia

Definition:

  • Organic psychiatric disease
  • Psychological (-) higher cortical centers
  • No impairment of consciousness
  • Affects: memory/orientation
  • Acquired and chronic, can be reversible
  • Symptoms: (-) emotional, behavior controlled

Etiology:

  1. Alzheimer’s disease (memory loss, apathy, decreased intellect)
  2. Lewy body dementia
  3. Frontotemporal dementia (altered personality and social conducts)
  4. Pick’s disease (personality deterioration/aphasia)
  5. Vascular dementia (HBP, acute, focal, neurological features)
  6. Huntington’s disease (congenital involuntary movement)
  7. Creutzfeldt-Jakob disease (symptoms depend on the area of the brain affected)

Clinical Features:

  1. Memory (-)
  2. Cognitive disturbances (aphasia, apraxia, agnosia)
  3. (-) in social & occupation function
  4. Deficit is constant

Diagnosis:

  1. Clinical features
  2. Evaluate memory, language, orientation/agnosia
  3. Lab: CBC/electrolytes/liver and renal function
  4. Special investigations (X-ray, CT, MRI)

Treatment:

  • Non-Pharmacological: psychotherapy/psychosocial intervention/education/support
  • Pharmacological:
    1. Antipsychotics: Risperidone, olanzapine, clozapine
    2. Benzodiazepines: lorazepam
    3. Anticonvulsants: carbamazepine!

12. Convulsive Symptoms, Organic Psychosis

Organic Psychosis:

  • Primary: injury directly to the brain (Alzheimer’s)
  • Secondary: systemic disorder, to the brain
  • Psychoactive substance use: alcoholism
  • Sleep disorder
  • Learning disability

Organic psychiatric disorder —-> Psychological reaction —-> Generalized (Acute: Delirium)

Patients with organic disorders often exhibit it as delirium!

Etiology:

  • Medications (anti-muscarinic, anti-HBP)
  • Intracranial pressure (infection, hemorrhage)
  • Metabolic & endocrine disorders (Addison’s, Cushing’s, hypothyroidism)
  • Systemic infection (renal failure/liver failure)
  • Post-operative state

Treatment:

  • Treating the underlying cause
  • Nurse care
  • Haloperidol IM
  • Benzodiazepines

13. Acute Conditions in Psychiatry, Symptoms of Psychosis

Acute Conditions:

  • Term: psychosis
  • Caused by medications, toxicity, medical conditions, or psychiatric disorders.

Proper Treatment Includes:

  • Getting information from family members.
  • ER must be equipped with proper medications for crises.

Symptoms of Psychosis:

  • (-) in reality testing

Types of Primary Psychosis:

  • Paranoid
  • Delirium
  • Depressed
  • Manic
  • Catatonic
  • Hallucinations
  • Severe dissociation

Paranoid:

  • Delusions of persecution
  • Hallucinations (auditory, smell, taste)
  • Anxiety (fear, hostility)

Delirium:

  • Clouding of consciousness & confusion
  • Disorientation, insomnia
  • Lucid periods

Depressive:

  • Depressed mood
  • Loss of interest
  • Fatigue
  • Hopelessness
  • Decrease in concentration
  • Hallucinations: voices
  • Stupor or agitation is rare.

Mania:

  • Elevated mood
  • Increased energy
  • Delusions
  • Hallucinations (visual, auditory, olfactory)
  • Inadequate behavior

Secondary Psychosis:

  • Weakness
  • Transient confusion
  • Night exacerbation
  • Must know the diagnosis
  • Give adequate treatment & monitor.

14. Causes of Schizophrenia

I. Premorbid:

  • Infancy to childhood
  • Neurodevelopmental process
  • Autistic behavior, lack of empathy
  • Passivity

II. Prodromal:

  • Puberty to adolescence
  • Decrease in functional level + both neurodevelopmental + neurodegenerative
  • Decrease in function and strange behavior with no specific symptoms.

III. Progressive:

  • Early adulthood
  • Severe decrease in functional level in exacerbation & remission
  • Lot of neurodegenerative processes

IV. Chronic:

  • Decline but stable function

Diagnosis is done when symptoms of psychosis persist for more than 6 months & acute phase.

15. Clinical Features of Schizophrenia: Main Symptoms, Variants

Endogenous psychotic disorder, involves thought process, emotion, perception, volition.

Main Symptoms:

  • Positive Symptoms: Hallucinations & delusions
  • Catatonic behavior
  • No free will
  • Thought disorder
  • Negative Symptoms: apathy, poor speech, lack of drive, stupor
  • Change in personality

16. Clinical Features of Schizophrenia

Paranoid:

Most common.

  • Positive Symptoms: Delusions & hallucinations.
  • Negative Symptoms: Are not common.

Hebephrenic:

  • Affective changes, emotions.
  • Behavior is unexpected (pranks…).
  • Shallow and inappropriate mood.
  • Disorganized thoughts.

Catatonic:

  • Psychomotor disturbances.
  • Catatonic stupor.
  • Catatonic excitement.

Simple:

  • Negative symptoms progress slowly.
  • Declined social ability.

Chronic:

  • Positive symptoms lasting for one year.
  • Negative symptoms.
  • Past psychotic episode.

17. Schizophrenia: Principles of Treatment & Psychological Rehabilitation

Hospitalization:

  • For patients with acute symptoms and for relapsing schizophrenia.

Pharmacological Therapy:

  • Acute psychosis: 2-6 weeks
  • In typical acute psychosis: (chlorpromazine/haloperidol)
  • Atypical acute psychosis: risperidone

Duration of Treatment, 2 Years:

  • Risperidone
  • Clozapine

Alternative Treatments:

  • Electroconvulsive therapy (ECT)
  • Lithium (sedation)
  • Benzodiazepines
  • Propranolol (aggressive & violent behavior)

Psychosocial Treatment:

  • Social skills training
  • Occupational therapy
  • Group therapy
  • Individual psychotherapy
  • Family intervention & education

18. Symptoms of Affective Disorders: Definition, Diagnostic Criteria

Depression Types:

  • Psychotic
  • Severe
  • Bipolar

Depression Diagnostic Criteria:

  • More than 2 weeks
  • Depressed mood or apathy
  • Combination of 4: weight loss, sleep disorder, agitation, retardation, fatigue, guilt

Dysthymia:

Mild depression.

Dysthymia Diagnostic Criteria:

  • Definition: Chronic depressed mood but does not meet major depressive disorder criteria.
  • Depressed mood for most of the day for 2 years.
  • Combination of 2+: eating disorder/sleep disorder, fatigue/low self-esteem.
  • In 2 years, the patient is never without a symptom.

Cyclothymia:

Mood disorder that causes emotional rollercoaster (highs and lows).

Cyclothymia Diagnostic Criteria:

  • Various hypomanic episodes that are interposed with episodes of depression that do not meet criteria for major depressive disorder.
  • Low-grade cycling of mood.

Bipolar Disorder Diagnostic Criteria:

  • Period of elevation or irritability
  • 3 characteristics: increased talking, racing thoughts, inflated self-esteem, decreased sleep.
  • (-) of occupation & social function.

19. The Problem of Depression, Role of the General Practitioner

Etiology:

  • Cushing’s
  • ACTH-secreting tumor
  • Hypothyroidism
  • Dementia
  • Hormone imbalance (serotonin & adrenaline)
  • Genetic (no particular one gene)

Epidemiology:

  • More prevalent in women.
  • 10% of women are depressed after birth.
  • Moderate & severe —-> psychiatric.

Role of the General Practitioner:

  • To suspect depression.
  • Mild depression: treat.
  • Moderate & severe —-> psychiatrist!

Cues for Recognizing Depression:

  • Complain about depression.
  • Atypical depressive symptoms.
  • Patient is constantly troubled by symptoms.
  • No obvious change in clinical status.

When to Refer?

  • Uncertain diagnosis
  • Psychotic, severe & bipolar depression
  • Comorbid illness
  • Recent suicide attempt or suicidal thoughts
  • Failure to respond to treatment!

20. Masked Depression: Diagnosis & Treatment

Definition:

Depression that does not present as symptoms of depression, but somatic complaints!

Diagnosis:

  • Masking may be due to cultural factors.
  • If the patient has some retardation, it might present as isolation and different behavior.
  • Patients with dementia due to (-) memory and brain function.

Treatment:

  • Hospitalization
  • Psychotherapy
  • Antidepressants:
    1. SSRIs: citalopram/sertraline/fluoxetine
    2. MAOIs: phenelzine/moclobemide/selegiline!
    3. TCAs (tricyclic antidepressants): amitriptyline, clomipramine

TCAs + SNRIs are better for masked depression!