Liaison Psychiatry

Mental Health Problems in the General Hospital

Joan Gomez

• Publisher: Taylor & Francis
• Year: 2018
• Print ISBN: 9781138315693
• eBook ISBN: 9780429851025
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Liaison psychiatry, that is, psychiatry with patients with organic disorders or physical symptoms in general hospitals, is a field that grew rapidly in the 1980s. Yet there had been no introductory book to the subject which might have served the needs of trainee psychiatrists, medical students, and general physicians and surgeons, as well as nurses and others, whose patients might be involved.

This book, originally published in 1987, aimed to fill this gap in the literature. It begins by examining the scope and organisational issues of liaison psychiatry at the time and its role in psychiatric patients with organic disease, psychosomatic disorders, emotional reactions to physical disease, terminal illness, etc. The bulk of the book then reviews liaison in a range of medical specialities. The book should thus have a wide readership.

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Overview: Scope of Liaison Psychiatry

The practice of psychiatry in a general hospital combines the factors in unfamiliar and varied settings, with an overriding intellectual challenge of identifying emotional and pathophysiological need for diplomacy. Consultation/liaison psychiatry promises to be the saviour of its parent discipline (Lipowski, 1974). It is a signpost directing psychiatry back towards the traditional medical arts at a time when it is in danger of disintegrating into a collection of social sciences (Rawnsley, 1984). In the swinging prosperity of the 1950s and 1960s, social psychiatry, community psychiatry, existential psychiatry and behavioural psychiatry all appeared. Non-medical practitioners, including social workers, medical psychologists, community nurses, nurse-therapists, marriage counsellors and bereavement counsellors, started operating autonomously, with exponents of alternative therapies abounding. A medical work-up for patients with mental disorders began to seem outmoded and intrusive, and biologically orientated psychiatrists came to be mistrusted as insensitive and mechanistic at best, and as despoilers of human rights at worst. In many countries legislation reflects this attitude, making the professional activities of psychiatrists subject to constant checking by laymen and to legal constraints. It is fortunate for the future of today’s psychiatrists that liaison work has so much to offer our medical colleagues and modern students that the links between psychiatry and the rest of medicine must be strengthened by it. Collaboration is necessary for complete patient care.

It is estimated that 30 to 65 per cent of medical inpatients have significant psychiatric symptomatology, the most frequent diagnoses being depression, anxiety and organic brain syndrome, and 30 per cent of acute medical inpatients show cognitive deficits (von-Ammon Cavanaugh, 1983; Nabarro, 1984). Equally, there is a high rate of physical illness among psychiatric patients (Davies, 1965), and Granville-Grossman (1983) found 58 per cent of patients attending a psychiatric clinic to have a physical disorder also. Life expectancy is reduced in depression, mania and schizophrenia, and although suicide accounts in part for the high death rate, there is also a higher than expected incidence of accident, infection and circulatory diseases. These patients are likely to come under non-psychiatric care at some time. Despite the high incidence of cognitive and emotional disorders among patients with mental and surgical disorders, only 12–28 per cent of them are evaluated by a psychiatrist (Lipowski, 1977). This is partly because psychiatric distress is not sought, and unless it is troublesome or florid, may not be noticed; or it may be regarded as a normal reaction to illness, requiring no special attention. It is also understandable that the physician or surgeon should wish to look after his own patient completely, within his own team, without advice or interference from outside. He may himself prescribe subtherapeutic doses of an anxiolytic or mild antidepressant. Patients themselves often resist the idea of seeing a psychiatrist, afraid that their symptoms will not be treated seriously, or that they are being classed as ‘nutters’. The primary consultant may genuinely believe that the psychiatrist can have nothing positive to offer and is likely to upset the patient into the bargain. The big divide, however, is traditional and geographical. For many years, psychiatrists worked exclusively in mental hospitals far removed from mainstream medicine, professionally isolated. This is a recipe for mutual mistrust. Added to this, until the 1960s, psychiatric treatment involved long incarceration and a slim chance of recovery.

The development of effective treatments, mainly pharmocological, enabled psychiatrists to take their place next to other physicians. Liaison psychiatry has grown out of the inclusion of a psychiatric department in an increasing number of general hospitals during this century. The first so designated liaison service was at Albany Hospital (New York) in 1902, but now there are more than 850 such services in hospitals in the United States of America. Liaison psychiatry has now become an essential part of medical student training in Europe and America (Lipowski, 1976). Of course, both physician and patient may come to welcome the psychiatrist more warmly if he attaches himself to the medical team and attends at least some ward rounds. As early as 1929 Henry offered guidelines to the psychiatrist who wished to work with physicians (Henry, 1929). These are still valid: that careful observation is more acceptable than inspired guesswork; communication should be free of jargon; and there must be flexibility in the application of theory and the choice of therapy. Psychosomatics — a term coined by Heinroth in 1818 — flourished from the mid-1930s through the 1960s, and gave an added impetus to liaison psychiatry. Flanders Dunbar, who wrote so persuasively about the correlation between personality and somatic symptomatology, was associated with the liaison service of the Columbia Medical Center in the 1930s. However, the lopsided approach of the psychosomatists of that period, trying to fit physical diseases to particular emotional configurations (specificity theory), involved separation of mind from body, and did not hold water in practice. This led to disillusionment among general physicians and to the decline of psychosomatics.

Liaison psychiatry is tied to no one school of thought or theory, but involves the practical application of all psychiatric knowledge, ideas and techniques where they may be helpful to physicians or surgeons in the care and understanding of their patients. The Hippocratic concept is central, that both bodily and emotional disorders follow the established laws of nature, and there is a constant interplay between the two aspects. These fundamental ideas arose from a sea of magic, philosophy and religion, remnants of which still exist today. Traditional Chinese medicine based on the opposing elements, Yin and Yang, is practised side by side with scientific medicine. Lay healers flourish in the fashionable districts of the cities of Western nations, their use alternating with that of orthodox practitioners. The early Christian ethic that disease is a matter of unforgiven sin, even to the fourth generation, is enshrined by Christian Scientists, Jehovah’s Witnesses, treks to Lourdes in search of a miraculous cure, and the patient’s frequent plaint ‘What have I done to deserve this?’ Rene Descartes (1650) tried to separate ‘l’homme machine’, the mechanical body, from the soul-mind directing it from ‘a little kernel in the brain’, the pineal gland. Interestingly, recent evidence suggests that this vestigial third eye, symbolised by the bindi on the forehead of married Indian ladies, is the controller of the biological clocks in the hypothalamus, including those directing sexual activity. In general, however, liaison psychiatrists take the anti-reductionist stance of Francis Bacon (1605). He invited us to consider ‘how, and how farre the humours and affects of the bodie do alter or work upon the mind: or againe, how and how farre the passions or apprehensions of the mind doe alter and work upon the bodie’. Certainly, our aim is to restore and enhance the sympathies and concordances between the parts of the whole that he commends, through a comprehensive biological-social-psychodynamic approach.

COMPOSITION OF A GENERAL HOSPITAL PSYCHIATRY SERVICE

A liaison service should ideally comprise full-time and part-time psychiatric input, with trainees led by a consultant, liaison nurses, social workers, psychologists and occupational therapists. Often it consists only of part of a junior psychiatrist’s time with such access to psychological and social backup as is available to the referring agent. A skeleton service of this kind will be called upon minimally, unless the psychiatrists are exceptionally committed and able doctors.

The areas that may be covered by a liaison service include all departments in a general hospital: wards, outpatient clinics, accident and emergency department, etc. Elsewhere, psychiatric help and advice may be a regular requirement in school, university and other occupational health departments, health centres and general practice surgeries, community nursing, non-medical alcoholic and drug treatment facilities, services for the elderly and the variously handicapped, and in prisons or other institutions. The liaison psychiatrist or nurse must expect to collaborate with all categories of health-care worker. Nevertheless, the major part of liaison activity arises in response to a request from a doctor in a different specialty. His requirements are paramount. Indifference, ambivalence and overt or covert hostility, often manifest in a joking manner, may be encountered by the psychiatrist from other medical men, as from the public. Each referral is an opportunity to modify such negative attitudes (Mayou and Smith, 1986).

THE COMMONEST REASONS FOR REFERRAL

(1) Diagnostic uncertainty: usually when investigations have produced no plausible explanations for the patient’s symptoms, either their presence, their persistence or their severity.

(2) The patient’s complaining continues despite best surgical or medical efforts, which should have settled the problem.

(3) The patient is disturbing the ordered harmony of the ward.

(4) The staff are under strain over this patient: because of his (or her) demanding behaviour, hostility or ability to manipulate, or because they have become emotionally concerned about the patient’s illness.

(5) The patient seems to have a psychiatric disorder, or has a history of such.

(6) He has hinted at suicide.

(7) He has nowhere to go and/or does not seem competent to manage on his own.

(8) He has asked to see a psychiatrist.

The liaison psychiatrist has no all-embracing explanatory theory for disease and emotional upset, and no panacea.

WHAT THE LIAISON PSYCHIATRIST CAN AND SHOULD DO

(1) Consider seriously and objectively the problem he (or she) has been invited to address and make clear, practical recommendations about this, even if these are negative or involve no change of management.

(2) Appraise the social, biological and psychological factors producing, enhancing or maintaining the patient’s symptoms.

(3) Evaluate the extent to which the social and psychodynanic aspects contribute to the current position, including, for instance, such life events as recent redundancy and its meaning to the individual patient.

(4) Assess the patient’s personality and current psychological state, and his likely response to hazardous, uncomfortable or expensive investigations, for instance coronary angiography, or medical or surgical treatments which inevitably carry some risk of side-effects or worse.

(5) Assess and suggest treatment for any functional psychiatric disorder arising in the course of physical illness, or already present.

(5) Give practical advice about the care of substance abusers who are admitted to general hospital beds.

(7) Assess and give guidance about the management of psychiatric disorders presenting with physical symptoms, for instance an anxiety state manifesting in precordial pain.

(8) Collaborate in the management of psychosomatic illness including, among others, Alexander’s ‘Big Seven’: peptic ulcer, bronchial asthma, ulcerative colitis, rheumatoid arthritis, essential hypertension, neurodermatitis, and thyrotoxicosis.

(9) Diagnose and advise on the management of organic brain syndromes, giving short and longer-term prognoses: as in alcoholic and other drug-related psychoses, including iatrogenic (e.g. levodopa psychosis) and psychological manifestations of organic disease (e.g. neurological, ineffective, malignant, endocrine).

(10) Assess the causes and likely outcome of confusional states in the elderly, and make long-term recommendations, with indications as to how these may be achieved.

(11) Advise on the management of unexpectedly severe or intractable pain.

(12) Directly or indirectly provide care and comfort for the dying and their relatives. (Also staff support: see 24.)

(13) Assess suicidal risk in overdose patients and others, with recommendations on management, immediate and to follow.

(14) Educate and help patients and staff in coping with chronic disease and disability, including the psychosocial aspects, for instance in epilepsy.

(15) Support patients and advise ward staff with anxious, depressed or histrionic patients, for instance a woman with a l...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• 1. Overview: Scope of Liaison Psychiatry
• 2. Assessment: Multidimensional Method
• 3. Psychological Presentation in Various Disorders
• 4. Pain
• 5. Liaison in Neurological Disorders
• 6. Liaison in Cardiorespiratory Disorders
• 7. Liaison in Gastrointestinal Problems
• 8. Liaison in Obstetrics and Gynaecology
• 9. Liaison in Endocrine and Metabolic Problems
• 10. Liaison in Renal and Genitourinary Problems
• 11. Liaison in Bone and Joint Problems
• 12. Liaison in Dermatology and Infections
• 13. Liaison in Oncology
• 14. Terminal Illness
• 15. Pharmacology in Liaison Psychiatry: Summary of General Principles
• 16. General Strategies for the Liaison Therapist
• Subject Index
• Author Index