Psychological and psychiatric support at the Limb Reconstruction - PowerPoint PPT Presentation

Psychological and psychiatric support at the Limb Reconstruction clinic TR AU M A AN D OR THOP AE D I CS AT KIN G’ S COLLEGE HOS P ITAL BY N ATALIA FAIN BLU M AN D D R EW A OKON -R OCH A

How it started  Psychological and psychiatric support half a day a week at the Limb Reconstruction Clinic (Orthopaedics) at King’s College Hospital  Started 2012. Funded by Rebuild Charity funds (www.rebuildcharity.org)  Includes a Consultant psychiatrist and a clinical psychologist  Patients fill in IMPARTS measures. Computer indicates need for either CBT, psychiatric input or both  Also referrals from staff and requests from patients

Limb reconstruction liaison service- aim  Bridging gaps between 1 and 2 care – capturing patients who will fall into the gap  Needs specialist psychiatric and psychology input  Assessments, pharmacology advice and psychology intervention  Referral to the tertiary service or in acute cases local psychiatric service  Managing patients- in between orthopaedic treatments, to deal with other medical symptoms- recurrent infections or chronic pain; in relation to loss- personal relationships, work, financial stability; housing;

Psychiatric clinic – basic data  Total cases referred since August’12 - 130  Males- 66%, female 33%  DNAd- 10%  Long-term patients (10+ sessions)- 10%  Co-working with a psychologist- 33%

Psychiatric clinic- diagnoses  Depression (dysthymia, bereavement)- 40%  PTSD- 18%  Anxiety (panic disorder, GAD)- 10%  Mixed anxiety and depressive disorder- 8,5%  Adjustment disorder- 8%  Others- less than 3% (alcohol misuse, cognitive impairment, personality disorder, chronic insomnia, ADHD, Asperger’s syndrome, brief psychotic episode)  Nil psychiatric diagnosis- 9% (inc. capacity assessments)

Psychology clinic- basic data  Around 30 referrals since I started in August 2016 (previous therapist in place since 2012)  About 4 patients never attended  Most patients attended at least one appointment , most two or more appointments. Some long term patients (10 plus sessions)

Psychology- Demographics  Gender:  52% Male  48% Female  Age  Male average age of 41.3 years  Female average age of 51 years

Psychology- Main presenting problems  Low mood/depression: 40% (some specifically linked to adjustment to loss, or adjustment to an acquired disability, or linked to social/financial problems as a result of physical problems, or as a result of pain)  Anxiety: 30% (most with panic disorder. Some generalised anxiety disorder. Adjustment disorder)  PTSD: 15%  Difficulties with relationships (trauma in childhood/diagnosed personality disorder/suspected or diagnosed ASD): 15%

Psychology- Interventions  CBT based  Psychoeducation  Behavioural activation  Problem-solving  Panic intervention  Sleep hygiene  Thought challenging  Finding a compassionate voice  Worry work  Etc.

Psychology- Interventions  Signposting or referral onwards (e.g. local IAPT) due to distance or need for more specialist help (e.g. Autism assessment)  ‘Care coordinator’ role  Contact services, chase referrals up  Get practical help (e.g. grants for adaptations at home)  Liaison with team members  Discussion with other staff about particular presentations  Provision of resources (specific questionnaires, self help leaflets)  Basic training (e.g. teaching session)

Case example - 1  Male, 37-yrs old, single  Med Hx- right tibial plateau fracture in 2014  PC- anxiety and depression  Background hx- carer to his elderly mother, brief relationship in the past, unemployed, previously worked in IT inc programming, socially isolated, in debts  Problems with initial engagement-DNAd first 4 appointments with me; (Feb-Dec 2015), later 90% attendance;  Symptoms- chronic thoughts of being better off dead, poor motivation/concentration, anhedonia, social phobia, panic attacks, paranoia, feelings of emptiness, finds presence of others confusing and tiring; never understood, pretends to be someone else in front of others;

Case example-1  Diagnosis- dysthymia, social phobia  Possible autistic spectrum disorder (referral made in July 2017); differential- schizoid personality disorder;  Rx- sertraline 100mg od; supportive holding;

Psychology- Case example 1  Assessment:  longstanding anxiety in social situations and some difficulties making sense of social situations.  Throughout his life different people tried to take advantage of him and as a result limited number of people he talks to  Labile mood and little sleep.  Longstanding problems with attention and learning difficulties (e.g. problems with reading, possible dyslexia?)  Carer for his mother  He queried ASD?  Possible OCD?

Psychology- Case example 1- Background  Born in London to large immigrant family.  Dad died suddenly of heart problem when patient was 7 year-old and witnessed the event.  Since then, a number of traumatic events occurred (physical abuse by family member, made ‘hostage’ by another family member, homeless).  Use of drugs as teenager (heavy use at times).  Did very well with computer programming.  History of vulnerability (others taking financial advantage, issues in relationships)  Leg fractured 4 years before. Loss of enjoyable activities (running useful for stress management)

Psychology-Case example 1 – Intervention  Extended intervention (10-plus sessions every 4 to 6 weeks)  Psychoeducation on anxiety.  Behavioural Activation and structure of his day  Discussion about future/professions/training  Use of sessions as a ‘space to talk things through’  Very gradual disclosure of traumatic events- building trust, making sense, ‘is this normal’?  Self-esteem  Assertiveness

Psychology-Case example 1- outcomes so far  Very slow progress  Better eye contact  More able to discuss difficult events  Changes to his presentation (clothes, appearance)  Extensive dental treatment (big achievement due to phobia. Very good support from King’s dentistry)  More assertive in dealing with others and services

Psychology- Case example 1- what remains to be done  ASD assessment…?  Better anxiety management  Better practical help in his carer role  More work on self esteem and assertiveness  Work on setting boundaries to siblings and family members  More meaningful activities/professional development?

Case example- 2  Female, 33 yrs old, in relationship  Med Hx- open left tibia fracture January 2017  PC- advice re: starting the family; referred by a psychologist  Background hx- brought up by the grandmother; separation anxiety- father left family home when she was 7 years old; bullied at school; work in finance; married for 11 years and divorced; overdosed; with a current partner for 3 years; wants to start family; pressure at work with self-cutting episodes in 2016;  Psychiatric diagnoses-bipolar affective disorder type II/ EUPD  Rx- Quetiapine XL 150 mg nocte (aripiprazole 5 mg od for metabolic effect)  Symptoms- mostly stable; increased anxiety as a result of moving in together; increased job responsibility

Psychology- Case example 2  Assessment:  Attended with partner (treatment on her own)  Diagnosis of Emotionally Unstable Personality Disorder  History of self-harm and suicidal attempts  Labile mood. History of excessive worry and panic attacks.  Long history of contact with mental health services (discharged from local CMHT)  Fall 18 months ago. High anxiety about falling over again. Avoiding walking on her own and extensive safety behaviours  Unsupportive work. Very supportive partner.

Psychology- Case example 2- Intervention  Referral to Dr Okon-Rocha for medication review.  Psychological intervention on anxiety about falling.  Psychoeducation on anxiety and role of safety behaviour  Graded exposure and habituation

Psychology-Case example 2-outcomes so far  Feeling well in mood and confronting anxiety- provoking situations  Managing to walk on her own (without her partner next to her) and on tricky terrain.  Able to fly on a plane  Dealing well with difficult situation at work  Moved in together with partner  Met his family and managed anxiety well.  Dealt well with small procedure in hospital

Why it works  Team at Limb Clinic is a Multi-disciplinary team of experienced doctors, nurses, physiotherapists, that is very committed and hard working  It’s a team that works very well together under a lot of pressure  Team is very open to providing psychological and psychiatric support in house  Team refers patients frequently and appreciates our presence

Many thanks Discussion and questions