This document discusses the relationship between mental and physical health. It describes how psychiatric diagnoses are made based on symptoms and syndromes rather than identifiable bodily pathology like medical diagnoses. Conditions involving bodily symptoms without pathology, like somatic symptom disorder, are reviewed. The management of these disorders focuses on ruling out medical causes and reducing unnecessary medical interventions. Various medical conditions that are associated with increased risk of psychiatric disorders are also summarized, including neurological, cardiovascular, endocrine, and renal disorders as well as infections and cancer.

1. Interface between Psychiatry
and Medicine
Dr. Samuel Maling

2. Association between mental and physical health
•People with serious mental health conditions are
at high risk of experiencing chronic physical
conditions
•People with chronic physical conditions are at risk
of developing poor mental health

3. Medical versus Psychiatric patient diagnoses
• Patient diagnoses are conventionally classified as either ‘medical’ or
‘psychiatric’.
Medical Diagnosis:
• Is a label for a condition that is: (a) conventionally treated by medical
doctors and (b) listed in the classifications of medical conditions
suchas the International Classification of Diseases and Related
Health Problems version 11 (ICD-11).
• Most medical diagnoses are based on identifiable bodily pathology
(abnormal structure and/or function).
• Therefore, to make a medical diagnosis doctors will seek specific
bodily symptoms before confirming the presence of bodily pathology
with physical signs and biological investigations.

4. Psychiatric diagnosis
• A psychiatric diagnosis is a label for a condition that is:
(a) conventionally treated by psychiatrists and (b) defined in ICD-11 Chapter 06-
Mental, behavioral or neurodevelopmental disorders OR Diagnostic and
Statistical Manual of Mental Disorders (DSM–5)
Psychiatric diagnosis are based on the idea of ‘psychopathology’, that is
abnormalities of the mind.
• Patients psychopathology can only be inferred from the patient’s mental
symptoms and their behavior
• Biological investigations contribute little to the diagnosis of psychopathology
• Psychiatric diagnoses are therefore defined on the basis of symptoms and
syndromes.

5. Bodily symptoms with no bodily pathology
• When patients present with bodily symptoms and bodily pathology
is confirmed they are given a medical diagnosis.
• When patients have bodily symptoms but there is no evidence of
bodily pathology the term Somatic Symptom Disorder is used to
describe their illness.
• When a patient presents with evidence of bodily pathology and
psychopathy the term co-morbidity is used/Multimorbidity

6. Somatic Symptom Disorder
• Patients have distressing somatic symptoms along with abnormal
thoughts, feelings, and behaviors in response to these symptoms
• One or more of the somatic symptoms are distressing or
result in significant disruption of daily life.
• Excessive thoughts, feelings, or behaviors related to the
somatic symptoms or associated health concerns as
manifested by at least one of the following:
• Disproportionate and persistent thoughts about the seriousness of
one’s symptoms.
• Persistently high level of anxiety about health or symptoms.
• Excessive time and energy devoted to these symptoms or health
concerns.

7. Essential features of somatic symptom disorder
• The essential feature of Somatic Symptom Disorder and related disorders is
that the patient presents with multiple, medically unexplained symptoms or
functional somatic symptoms.
• These physical complaints are not consistent with the clinical picture of
known, verifiable, conventionally defined diseases, and are unsupported by
clinical findings.
• Illness behavior: patients with Somatic Symptom Disorder persistently exhibit
consulting behavior which results in an excessive use of medical services and
alternative therapies.
• In chronic cases, they have often been subject to a large number of futile
examinations, surgery, and medical/surgical attempts at treatment

8. Illness Anxiety Disorder
•Preoccupation with having or acquiring a serious illness.
•Somatic symptoms are not present or, if present, are only
mild in intensity. There is a high level of anxiety about
health, and the individual is easily alarmed about personal
health status.
•The individual performs excessive health-related behaviors
(e.g., repeatedly checks his or her body for signs of illness)
•Illness preoccupation has been present for at least 6
months, but the specific illness that is feared may change
over that period of time.

9. Conversion Disorder
(Functional Neurological Symptom Disorder)
• One or more symptoms of altered voluntary motor or sensory
function.
• Clinical findings provide evidence of incompatibility between the
symptom and recognized neurological or medical conditions.
• The symptom or deficit is not better explained by another medical or
mental disorder.
• The symptom or deficit causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning or warrants medical evaluation.

10. Conversion Disorder
Symptom types
• Weakness or paralysis
• Abnormal movement (e.g., tremor, dystonia movement, myoclonus, gait
disorder)
• Swallowing symptoms
• Speech symptom (e.g., dysphonia, slurred speech)
• Attacks or seizures
• anesthesia or sensory loss
• Special sensory symptom (e.g., visual, olfactory, or hearing disturbance)
• With mixed symptoms
• The phenomenon of la belle indifference (i.e., lack of concern about
the nature or implications of the symptom) is associated with conversion
disorder

11. Management of Somatic symptom and related
Disorders
• Exclude physical disease or trauma that can be treated medically or surgically
• In an empathic way, make it clear to the patient that he or she does not have
the physical disease he or she fears, and that there is no indication of any other
physical disease or defect that needs medical attention.
• That there is no medical indication for further diagnostic tests or examinations
• Avoid tests and procedures unless indicated by signs of disease or a
Well defined (new) clinical illness picture.
• Reduce unnecessary drugs. Do not use on demand prescriptions
• Avoid dependence-forming medication.
• Consider treatment with psychoactive mediation (primarily antidepressant)

12. • Bodily symptoms with bodily Pathology and Psychopathology

13. Psychiatric aspects of neurological disease
Stroke
Depression and anxiety are common in stroke
• Depression prevalence is around 30 per cent in the first few weeks after a
Stroke
• About a quarter of stroke patients fulfil criteria for generalized anxiety
disorder during the acute post-stroke phase
Two-thirds of the patients fit the criteria for major depression
• Survivors remain at an elevated risk for depression for many years.
• Older age, family history of depression, previous episodes of depression
and negative life events in the preceding 6 months increase the risk of
depression

14. Parkinson's disease and Multiple sclerosis
• Depression in Parkinson's disease
• Overall prevalence of depression in PD is approximately 40 per cent
• Depressive symptoms are more common early in the disease and
in those with onset before the age of 55.
• Multiple sclerosis: Common symptoms are fatigue, vision problems,
numbness and tingling, muscle spasms, stiffness and weakness,
mobility problems and pain. Problems with thinking, learning and planning.
• Depressive symptoms occur in about 50 per cent of patients with multiple
sclerosis

15. Space-Occupying Lesions (SOL)
• SOL manifestations are determined by location and by the effects of raised
intracranial pressure.
• Psychiatric symptoms occur in 50 per cent of patients with SOL.
Symptoms are of three main types:
Confusional states and/or progressive cognitive deterioration:
• occur in a third of patients.
• Disorientation with clouding of consciousness, euphoria, apathy, and loss of insight
are prominent in those with confusional states. Progressive memory impairment, loss
of initiative
• Behavioral and mood disturbances: occur in 20 per cent of patients.
• Irritability, euphoria, depression, and, less frequently, psychosis are part of the
picture.
• Paroxysmal disturbances: such as poorly formed visual hallucinations and
automatisms, indicating temporal lobe involvement.

16. Epilepsy
• The prevalence of psychiatric morbidity among persons with epilepsy is greater
than in the general population
Psychosis
Psychosis in epilepsy takes two forms
• Chronic inter-ictal psychoses: Symptoms resemble those of schizophrenia
• Post Ictal Psychosis: The psychosis usually occurs following a cluster of complex
partial seizures usually followed by secondary generalization.
Sexual function
• A diminution in sexual interest, a decrease in activity, and impaired
performance are the most common aspects of sexual dysfunction in epilepsy.
• Epilepsy and suicide: Suicide is increased fivefold among patients with epilepsy,
but is considerably higher among those with temporal lobe epilepsy

17. Epilepsy
• Depression: Is the commonest psychiatric Disorder in epilepsy
• Generalized Anxiety Disorder, Phobias and Panic Disorders also occur
in epilepsy
• Suicide: Completed suicide is 4-5 times higher in epileptics compared
to the general population

18. Medical conditions associated with psychiatric
disorder
CARDIOVASCULAR DISORDERS:
• Ventricular dysrhythmias: Depression has also been associated with lower
threshold for ventricular dysrhythmias
• Hypertension: Associated with stress, anxiety and depression
• Myocardial infarction: Associated with both physical and psychological stress.
Depression occurs in 30% of patients admitted for MI.

19. Respiratory Disorders
• Chronic obstructive pulmonary disease: The chronic hypoxia caused
by COPD compromises cognition and mood, which, in turn, can
produce delirium, mood lability, mood disorders, and restriction in
daily activities. Depression is the commonest psychiatric disorder in
patients with COPD. Other disorders are anxiety and suicide.
• Asthma: The severity of an asthma attack is highly correlated with
presence of major depressive disorder, panic attacks, general anxiety,
and level of fear among children, adolescents, and adults.
• Asthma patients with psychiatric disorders have worse asthma
control, more frequent exacerbations, and worse quality of life than
asthma patients without psychiatric disorders.

20. Endocrine disorders
Hypothyroidism:
• Hypothyroid patients may present early with prominent
psychiatric signs or symptoms
• At times, the psychiatric presentation may be so striking that
patients are first diagnosed with a primary psychiatric
disturbance rather than hypothyroidism
• Symptoms most commonly related to thyroid deficiency
include forgetfulness, fatigue, mental slowness, inattention,
and emotional lability and psychosis.
• The predominant affective disorder experienced
is depression.

21. Hyperthyroidism:
• Hyperthyroidism is frequently associated with: irritability, insomnia, anxiety,
restlessness, fatigue, impairment in concentrating and memory,
• The symptoms can be episodic or may develop into mania, depression and
delirium.
• Depressive and anxiety syndromes are the most common psychiatric
conditions seen among patients with hyperthyroid states;
• There is a three-fold increased risk for development of mood disorder
following hospitalization with hyperthyroidism.

22. • Diabetes mellitus: The most frequent psychiatric disorders in
patients with diabetes are anxiety and depressive disorders
• Hypoparathyroidism: The most common neuropsychiatric symptoms
and signs are seizures, EEG abnormalities, increased intracranial
pressure, disorientation, confusion, and extrapyramidal symptoms.
• Depressive and anxiety syndromes are the most common psychiatric
conditions.

23. Renal Disorders
• Acute renal failure: Neuropsychiatric manifestations include somnolence,
asterixis (flapping tremor), neuromuscular irritability, and seizures.
• Chronic renal failure and end stage renal disease: Neuropsychiatric
manifestations of chronic renal failure include irritability, insomnia, lethargy,
anorexia, seizures, and restless legs syndrome.

24. Psychiatric aspects of infections
• HIV infection: Patients infected with HIV are at an increased risk for a variety
of psychiatric disorders
• Syphilis: General paresis is form of parenchymal neurosyphilis (also
known as dementia paralytica or general paralysis of the insane).
• It usually first appears some 20 years after the initial infection.
• The symptoms progress to dementia with abnormal motor function and
psychotic symptoms
• Tuberculosis: Associated psychiatric disorders are depression and suicide

25. Psychiatric Aspects of Cancer
• 30-50% of cancer patients met a diagnosis of a
psychiatric disorder
• Cancer is associated with Depression, Suicide and
anxiety, Mania, Delirium
• 38% of children in the Uganda Cancer Institute had a
diagnosis of major depressive Disorder (Akimana et al,
2019)
• Anxiety and depression were found to be associated
with being a family carer of a cancer patient at
Uganda Cancer Institute ( Katende et al, 2017)

26. Psychiatric aspects of vitamin deficiencies
• The following vitamin deficiencies may lead to psychiatric
manifestations:
• Vitamin B12
• Vitamin B1 (Thiamine)
• Folic acid
• Vitamin D
Vitamin deficiencies may lead to psychosis, mood symptoms and
anxiety