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

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

Psychological and psychiatric support at the Limb Reconstruction clinic

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

• r 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

• thers;

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

• f 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