Physical examination in psychiatric practice

Physical disease is more prevalent in people with mental disorder than in the general population. It is important for psychiatrists to maintain skills in physical examination to ensure that physical illness is diagnosed and treated appropriately. A sound knowledge of medical illness ensures that examination is targeted at the relevant diseases. Mental health units should provide adequate facilities and equipment. All detailed examinations should be undertaken in the presence of a chaperone. Opportunities for psychiatrists to refresh their knowledge and skill are suggested. Gill Garden is a consultant psychiatrist at Pilgrim Hospital (Sibsey Road, Boston PE21 9QS, UK. E-mail: [email protected]). She trained in medicine, passing the membership examinations for the Royal College of Physicians before changing to psychiatry. She is a member of the Objective Structured Clinical Examination (OSCE) panel and an examiner for Part I of the Royal College of Psychiatrists’ membership examinations. The literature on physical examination in psychiatric practice is sparse, much is dated and from overseas, and so of limited use in extrapolation to current practice in the UK. British studies have reported the recording of physical examination carried out on admission by psychiatric trainees to be ‘uniformly poor’ (Rigby & Oswald, 1986) or ‘variable’ (Hodgson & Adeyemo, 2004). The earlier study found that significant positive findings were unrecorded, especially in the neurological and locomotor systems. The recent study showed little progress, with under 60% of patients having a comprehensive central nervous system (CNS) examination. Why should psychiatrists be able to do a physical examination? Age-adjusted annual death rates from all causes among psychiatric patients are 2–4 times higher than in the general population (Harris & Barraclough, 1998), with higher rates of physical disorder across the entire range of mental disorders. The risks of reliance on the belief that the patient’s general practitioner or other referring doctor will have done a thorough examination have been emphasised (Sternberg, 1986). It has been reported that between 6 and 20% of patients with physical illness are misdiagnosed as having mental disorder (Koranyi, 1979; Koran et al, 1989). This discrepancy may be due to the fact that patients who are mentally disturbed may be unable to give a clear account of their symptoms, even in the presence of a lifethreatening disorder (Kampmeier, 1977). Studies have shown that, in many cases, physical diseases will not be diagnosed and treated when a patient is admitted to a psychiatric unit (Felker et al, 1996; Moos & Mertens, 1996), which has potentially serious implications for patients’ overall health, delaying recovery and increasing length of stay. Consequently, an important aspect of psychiatric evaluation is differentiating organic disease from ‘functional’ psychiatric disorders. A competent assessment of patients’ physical health also helps to tailor drug use and reduce the risk of side-effects. Additionally, it gives a clear baseline for comparison, should a patient’s physical state change, thus informing the clinician of the severity of the effect of a drug and of the need for action. Therefore, there appears to be compelling evidence that care of people with mental illnesses should encompass physical as well as mental healthcare. How can this be achieved and what barriers are there to overcome? Barriers to overcome