Preface

This Handbook of Consultation-Liaison Psychiatry is intended for psychiatrists, psychiatry residents, primary care physicians, medical students, and all members of the health care professions who are interested in psychiatric approaches to patients in medical settings. The practice of consultation-liaison psychiatry must be practical and flexible. It has to provide immediate management of an agitated or suicidal patient, it has to deal with gravely ill patients wishing to sign out against medical advice, and it has to deal with an impasse in communication between the patient and the doctor. The consultation-liaison psychiatrist must be knowledgeable and comfortable in dealing with serious medical diseases. The consultation-liaison setting is now widely recognized as an ideal site for training not only for psychiatry residents but also medical students, primary care residents, and allied health professionals. This handbook is intended to be a practical guide for them. The recent designation of psychosomatic medicine as a subspecialty of psychiatry has stimulated interest in the interface between psychiatry and medicine. What is the relationship between consultation-liaison psychiatry and psychosomatic medicine? The field of psychosomatic medicine was never intended to be specific to psychiatry or any one discipline. Indeed, in many countries, psychosomatic medicine is most closely identified with other specialties of medicine. Consultation-liaison psychiatry, on the other hand, is the clinical application of psychiatry and psychosomatic principles in medical and surgical settings. Consultation-liaison psychiatry is, indeed, a specialty in its own right, with a unique field of knowledge and specific clinical skills beyond that of general psychiatry. This book describes that knowledge base in a practical and useful manner consistent with the clinical orientation of consultation psychiatry. As discussed in Chapter 1, consultation-liaison psychiatrists have a strong interest in ―mind-body‖ medicine, but it is our belief that ―consultation-liaison‖ psychiatry best denotes the type of practice we describe in this book. In Chapter 5, we list the common reasons for consultation request and their immediate management. This chapter serves as a portal from which diagnostic syndromes branch out for further evaluation and treatment. Chapter 26, dealing with psychiatric evaluations in the emergency setting, emphasizes the importance of the patient’s story, which is a must in understanding the patient. We believe that diagnosis is essential in understanding and treating the illness. In Chapter 6, we discuss the concept of psychiatric diagnosis in some detail, and

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show that psychiatric conditions are a continuum of evolutionarily adaptive phenomena, and that major psychiatric syndromes are best conceptualized as final common pathway syndromes reflecting a brain dysfunction. In medically ill hospitalized patients, symptoms of anxiety, depression, and psychosis may develop due to, or be complicated by, the added stress of illness and hospitalization. We preferentially use the term syndrome, as we believe this medical term better describes the psychiatric conditions encountered in consultation-liaison settings than categorical Diagnostic and Statistical Manual, 4th edition (DSM-IV) disorders with specific diagnostic criteria. Most of this book is written by the primary authors who have been involved in teaching consultation-liaison psychiatry for more than three decades. More specialized chapters are written by international experts in the field and provide depth and variety. This book is intended primarily for those who are interested in general psychiatry in general hospitals. Although some subspecialties in consultationliaison psychiatry are covered in this book, others such as psycho-oncology, psychodermatology, and so forth, are not included. To do so would render the book unwieldy and thus less useful as a clinical guide. Advances in genetics, neuroscience, and neuroimaging are rapidly being incorporated in psychiatry. The effects of specific psychotherapy in specific brain areas are being investigated with functional brain imaging, and soon receptor-specific designer drugs will revolutionize psychopharmacology. Specific gene-environment interactions that may result in health or neurosis, and, combined with stress, major psychiatric syndromes are being investigated. Consultation-liaison psychiatry is ready to integrate these developments in caring for our patients in the general hospital. We are indebted to our students and colleagues who have stimulated and encouraged us to write this book. We are grateful to Ms. Janice Stern of Springer for her support in all phases of this endeavor. For bulletin board, information, and discussion, please visit the Handbook‘s website:www.springer.com/978-0387-69253-1. Hoyle Leigh, MD Jon Streltzer, MD Fresno, California, USA Honolulu, Hawaii, USA

Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii List of Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Part I. Nature and Evolution of Consultation-Liaison Psychiatry 1. Evolution of Consultation-Liaison Psychiatry and Psychosomatic Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Hoyle Leigh 2. The Functions of Consultation-Liaison Psychiatry. . . . . . . . . . . . . . . . . 12 Hoyle Leigh 3. The Why and How of Psychiatric Consultation . . . . . . . . . . . . . . . . . . . 16 Hoyle Leigh 4. Evaluating the Evidence Base of Consultation-Liaison Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Tom Sensky 5. Common Reasons for Psychiatric Consultation . . . . . . . . . . . . . . . . . . . 37 Hoyle Leigh Part II. Psychiatric Syndromes in Consultation-Liaison Psychiatry 6. Basic Foundations of Diagnosis, Psychiatric Diagnosis and Final Common Pathway Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Hoyle Leigh 7. Delirium, Dementia, Alcohol Intoxication, and Withdrawal Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Hoyle Leigh 8. Anxiety and Anxiety Syndromes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Hoyle Leigh 9. Depression, Mania, and Mood Syndromes . . . . . . . . . . . . . . . . . . . . . . . 98 Hoyle Leigh 10. Psychosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Hoyle Leigh

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I
Nature and Evolution of Consultation-Liaison Psychiatry

1
Evolution of Consultation-Liaison Psychiatry and Psychosomatic Medicine
Hoyle Leigh
CONTENTS Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Ancient Civilizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 The Mind–Body Philosophy Through the 19th Century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Psychoanalytic Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Studies on Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Biopsychosocial Model and Integrative Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Evolutionary Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Modern Psychosomatic Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Consultation-Liaison Psychiatry Training and Psychosomatic Medicine as a Subspecialty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.10 The Mind–Body Relationship Revisited in the Light of Modern Physics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9

1.1

Definition

Consultation-liaison (CL) psychiatry refers to the skills and knowledge utilized in evaluating and treating the emotional and behavioral conditions in patients who are referred from medical and surgical settings. Many such patients have comorbid psychiatric and medical conditions, and others have emotional and behavioral problems that result from the medical illness either directly or as a reaction to it and its treatment. Psychosomatic medicine refers to the study of ―mind–body‖ relationship in medicine. Investigators in psychosomatic medicine have historically been interested in the psychosomatic aspects of medical patients, and were pioneer practitioners of CL psychiatry.

1.2

Ancient Civilizations

Imhotep, court physician and architect to King Djoser (2630–2611 BCE) of Egypt, built the Step Pyramid in Sakkhara, Egypt, some 4500 years ago, as a medical instrument to keep the king‘s body through eons until his soul returned, a truly ―psychosomatic‖ instrument. This pyramid is the oldest pyramid still

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standing, and Imhotep was deified as god of medicine. Ancient Chinese and Indian medicine was inherently ―psychosomatic‖ in that the psyche and the soma were seen to be intrinsically interconnected. In Chinese medicine, excesses or deficiencies in seven emotions—joy, anger, sadness, grief, worry, fear, and fright—were commonly considered to cause disease (Rainone, 2000). In Vedic medicine, certain personality components were considered to reside in particular organs, for example, passion in the chest and ignorance in the abdomen, and powerful emotions may cause peculiar behavior. Hippocrates (470–370 BCE) was perhaps the first physician to systematize clinically the notion that psychological factors affect health and illness. In a famous, what might now be called ―forensic psychiatric‖ opinion, Hippocrates defended a woman who gave birth to a dark-colored baby on the grounds that her psychological impression on seeing an African was sufficient to change the color of her fetus (Zilboorg, 1941). Hippocrates was an excellent clinical observer of psychiatric manifestations of medical disease as shown by his detailed descriptions of postpartum psychosis and delirium associated with tuberculosis and malaria (Zilboorg, 1941). Hippocrates condemned the prevailing view of epilepsy as a ―sacred‖ disease, holding that it was a disease like any other. Though his theory of the ―wandering uterus‖ underlying hysteria lacked scientific foundation, Hippocrates‘ humoral theory of disease anticipated present-day neurotransmitters. His emphasis on climate, environment, and lifestyle in health and illness, together with his awareness of the role of psychological factors in physical health and his belief in biologic/physiologic explanations of pathogenesis, entitle him to the title of not only the father of medicine, but also the father of psychosomatic medicine and the biopsychosocial approach. With the descent of the Dark Ages, a tyrannical religious monism attributing mental and physical illness to witchcraft, and divine retribution stifled scientific inquiry. A textbook for the diagnosis (torture) and treatment (execution) of witches was the Malleus Maleficarum (The Witch‘s Hammer, 1487) written by two Dominican monks, James Sprenger and Henry Kramer, and prefaced with a bull from Pope Innocent VIII.

1.3

The Mind–Body Philosophy Through the 19th Century

The Hippocratic tradition in medicine was revived with the Renaissance and nourished by the Enlightenment. The French mathematician and philosopher René Descartes (1596–1650) proposed that the human body was like a machine, subject to objective investigation, while the soul or mind was a separate entity that interacted with the body in the pineal gland and that it was in the domain of theology and religion. This mind–body dualism facilitated the scientific study of the body at the expense of such studies of the mind. A number of competing and complementary theories, briefly described below, have been proposed since then to attempt to explain the nature of mind and body/matter. Benedictus de Spinoza (1632–1677), a Dutch lens crafter and philosopher, proposed a monism called double aspect theory, that is, the mental and physical are the two different aspects of the same substance, which in his view was God. Gottfried Wilhelm Leibniz (1646–1716) proposed psychophysical parallelism, that is, mind and body exist in parallel harmony predetermined by God from the beginning. Immaterialism, as advocated by George Berkeley (1685–1753),

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declared that existence is only through perception of the mind, that is, the body is in the mind. On the opposite pole is materialism, which holds that matter is fundamental and that what we call mind is a description of a physical phenomenon. Julien Offroy de la Mettrie (1709–1751) advocated that human souls were completely dependent on the states of the body and that humans were complete automata just like animals as proposed by Descartes. Epiphenomenalism, proposed by Shadworth Holloway Hodgson (1832–1912), an English philosopher, postulates that the mind is an epiphenomenon of the workings of the nervous system. Mind and emotions, being epiphenomena, cannot affect the physical, just as a shadow cannot affect a person. Thomas Henry Huxley (1825–1895) popularized this view and placed it in an evolutionary context. Double aspect monism, proposed by George Henry Lewes (1817–1878), postulates that the same phenomenon, if seen objectively, is physical, and, if seen subjectively, is mental. William Kingdon Clifford (1845–1879) coined the term mind-stuff theory. In this theory, higher mental functions, such as consciousness, volition, and reasoning, are compounded from smaller ―mind-stuff ‖ that does not possess these qualities, and even the most basic material stuff contains some ―mind-stuff ‖ so that compounding of the material stuff would produce higher order ―mind-stuff.‖ This theory holds psychical monism– mind is the only real stuff and the material world is only an aspect in which the mind is perceived. In spite of strong monistic trends, the major trend in medicine and psychiatry through the 19th and 20th century has remained dualistic and interactional, that is, how the mind affects the body and vice versa. Johann Christian Heinroth (1773–1843) coined the term psychosomatic in 1818 in the context of psychogenesis of physical symptoms. Psychosomatic relationship in the form of hypnosis was demonstrated and exploited by Anton Mesmer (1734–1815), though he mistakenly claimed it to be magnetic in nature (―animal magnetism‖). Hypnosis was revived as a subject of medical investigation, diagnostics, and treatment by two competing schools, one at the Salpetriere Hospital in Paris headed by the neurologist, Jean-Martin Charcot (1825–1893), and the other at the university in Nancy, France, led by the internist, Hippolyte Bernheim (1840–1919). Charcot believed that hypnotizability was a result of brain degeneration in hysteria, while Bernheim and the Nancy school (including Ambroise-Auguste Liebeault and Pierre Janet) believed that psychological suggestion underlay the hypnotic phenomena.

1.4

Psychoanalytic Theory

Sigmund Freud (1856–1939) learned hypnosis to treat hysteria under Charcot. Freud gave up hypnosis in favor of free association, and with this tool systematically investigated and proved the psychogenesis of somatic symptoms by reversing them with successful treatment. Franz Alexander (1891–1964) was a student of Sigmund Freud who emigrated to the United States and founded the Chicago Institute of Psychoanalysis in 1932. Alexander psychoanalyzed patients suffering from a variety of somatic illnesses, and formulated that there were seven diseases that were particularly psychosomatic: essential hypertension, peptic ulcer, thyrotoxicosis, ulcerative colitis, neurodermatitis, rheumatoid arthritis, and bronchial asthma. He postulated that specific psychological conflicts were associated with specific autonomic activation, resulting in psychosomatic disease (e.g., in peptic

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ulcer, repressed dependency needs stimulate gastric secretion causing ulceration). This is called the specificity theory of psychosomatic medicine. Flanders Dunbar (1902–1959), a contemporary of Alexander, believed that psychosomatic illnesses were associated with certain personality profiles and constellations rather than specific conflicts. Peter Sifneos and John Nemiah (1971, 1996) proposed that psychosomatic disorders arose as a result of a difficulty in describing or recognizing one‘s own emotions, a limited fantasy life, and general constriction in the affective life, which they called alexithymia. The concrete mode of thinking associated with alexithymia is called operational thinking or pensée opératoire. Alexithymia is postulated to be related to primitive defenses of denial and splitting, and may be associated with a disturbance in cerebral organization. Psychological defense mechanisms have been shown to be essential in modulating psychophysiologic arousal to stress. During the latter half of the 20th century, through the work of various investigators, specificity theory gave way to a field model of psychosomatic medicine in which biological constitution interacts with environment in the development of personality, which, in turn, interacts with current stress in health and disease (Mirsky et al., 1957; Leigh and Reiser, 1992).

1.5

Studies on Stress

The American physiologist Walter Cannon (1871–1945) investigated the physiologic activation associated with the fight–flight reaction and the role of homeostasis in physiology. Hans Selye (1907–1982) systematically studied stress that led to the elucidation of the general adaptation syndrome through the activation of the hypothalamic-pituitary-adrenal (HPA) axis. Later in the 20th century with the development of psychoneuroendocrinology and psychoimmunology, there has been an explosion of knowledge on the relationship between stress and all aspects of the human organism.

1.6

Biopsychosocial Model and Integrative Medicine

George Engel (1913–1999), a well-known psychosomatic investigator, coined the term biopsychosocial model (Engel, 1977), as an alternative to the prevailing disease model in medicine that he called the biomedical model. While recognizing the contributions that the biomedical model made to the development of modern medicine, Engel objected to the ―dogma‖ of the biomedical model on the grounds that it is reductionistic, mechanistic, and dualistic. Utilizing a general systems theory approach, the biopsychosocial model proposes that psychosocial factors influence the pathogenesis of all diseases. The biopsychosocial model has found wide acceptance among psychiatrists and medical educators. In late 20th century, the terms behavioral medicine and integrative medicine appeared. Behavioral medicine is practically indistinguishable from psychosomatic medicine except that, in treatment modalities, it tends to incorporate more behavioral techniques such as biofeedback. Integrative medicine strives to incorporate within the biopsychosocial model approaches derived from nonorthodox medicine such as alternative and complementary medicine.

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1.7

Evolutionary Medicine

Charles Darwin (1809–1882) showed that species evolved through the process of natural selection (The Origin of Species, 1859). With modern advancements of genome analysis, it is now possible to calculate just how closely specific species are related. For example, humans and chimpanzees share almost 99% of the genes. An evolutionary perspective of human illness is shedding light on why illnesses arise. As natural section confers advantage to traits only up to the reproductive age, healthy traits in the post-reproductive period are not selected for. The human body probably evolved so that it was best adapted for the Stone Age, when most adults died in their youth. With the prolongation of human life that came with the progress of civilization and medical advances, the human body is living long past what it was adapted for (Nesse and Williams, 1996). The Stone-Age adapted human body may be ill-adapted for modern life, with its abundance of food, lack of physical exercise, and mental stresses, especially in the post-reproductive age. Evolutionary perspectives also may explain why certain genes that may cause vulnerability to potential mental illness, such as panic, may be adaptive under certain conditions found in evolutionary history (e.g., survival value, as in an overly sensitive smoke-detector).

1.8

Modern Psychosomatic Medicine

Advances in molecular genetics and imaging technology have elucidated the role of genes in our constitution, brain morphology, and behavior. Psychoneuroendocrinology and psychoneuroimmunology have elucidated the mechanism by which stress affects the human organism. Health and illness is now conceptualized as a result of the interactions among genes, early environment, personality development, and later stress (see Chapter 6). This interaction is in no small measure influenced by salutary factors such as good early nurturance and current social support. It is also clear that all illnesses are the results of this interaction, that there is no subset of illnesses that are any more psychosomatic than others. Nevertheless, the term psychosomatic continues to be used to denote studies and knowledge that place particular emphasis on psychosocial factors in medical illness. Some consider psychosomatic medicine to denote an interdisciplinary approach that includes internists, oncologists, psychologists, etc., in contrast to consultation-liaison psychiatry, which is clearly a field within psychiatry. There are a number of national and international ―psychosomatic‖ organizations such as the American Psychosomatic Society, Academy of Psychosomatic Medicine, European Society of Psychosomatic Medicine, and International College of Psychosomatic Medicine, and ―psychosomatic‖ journals such as Psychosomatic Medicine, Psychosomatics, Journal of Psychosomatic Research, and Psychotherapy and Psychosomatics. General Hospital Psychiatry, International Journal of Psychiatry in Medicine, and Psychosomatics are mainly consultationliaison psychiatry journals. Most of the organizations and journals are interdisciplinary, participated in by members of various specialties and professions. In Europe and Japan, there is often a department of psychosomatic medicine in medical schools, apart from the psychiatry department. Such psychosomatic departments mainly deal with patients with psychophysiologic disorders, and may use complementary medicine techniques such as yoga and meditation.

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In the United States, the term psychosomatic medicine is often used interchangeably with consultation-liaison psychiatry, and most CL psychiatrists practice in general hospital settings evaluating and treating psychiatric, emotional, and behavioral problems of medical patients. Research in the emotional aspects of specific medical patients gave rise to such fields as psychonephrology, psycho-oncology, and psychodermatology.

1.9 Consultation-Liaison Psychiatry Training and Psychosomatic Medicine as a Subspecialty
In the early part of the 20th century, formal training in CL psychiatry began in a number of general hospitals, most notably at the University of Rochester under George Engel‘s direction and at the Massachusetts General Hospital (MGH) under Thomas Hackett‘s direction. Other notable training sites included University of Cincinnati, Montefiore Hospital–Albert Einstein Medical College in New York, and Yale–New Haven Hospital. The Rochester model was psychodynamically oriented, and trained both psychiatrists and internists in ―liaison psychiatry.‖ Liaison psychiatry emphasized the educational role, and the trainee was assigned to be a member of the primary medical team including making rounds together. The MGH model, in contrast, emphasized the consultation aspect of training. The training programs were usually one to two years in duration. The CL training programs thrived during the 1960s and 1970s with the support of the National Institute of Mental Health and James Eaton, then head of its education branch. With the advent of managed care, however, ―unbillable‖ liaison activity has faded to a large extent. In 2003, the American Board of Psychiatry and Neurology (ABPN) approved the issuance of certificates in psychosomatic medicine. The Academy of Psychosomatic Medicine, an organization of CL psychiatrists, had been advocating the recognition of a subspecialty for CL psychiatry for some time. The executive summary of the proposal submitted to the ABPN states:
This application is in response to the growing body of scientific evidence demonstrating the high prevalence of psychiatric disorders in patients with medical, surgical, obstetrical, and neurological conditions, particularly for patients with complex and/or chronic conditions (―the complex medically ill‖), and the critical importance of addressing these disorders in managing their care. [Psychosomatic medicine] psychiatrists would, therefore, constitute a group of individuals in psychiatry who have specialized expertise in the diagnosis and treatment of psychiatric disorders/difficulties in complex medically ill patients.

Obviously, this is a description of CL psychiatry. It is ironic that psychosomatic medicine, rather than CL psychiatry, is now recognized as a subspecialty of psychiatry as this designation leaves nonpsychiatric ―psychosomaticists‖ in a Neverland.

1.10 The Mind–Body Relationship Revisited in the Light of Modern Physics
The advances in medicine during the past several decades have been largely due to the elucidation of the mechanisms of pathogenesis based on genetics, the role of stress, and functional morphology. At a philosophical level, the psyche of

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psychosomatic medicine is understood as a label for brain function, particularly of the prefrontal cortex. While this newtonian conceptualization of the mind works at a heuristic level, developments in modern physics may require us to reexamine this epiphenomenologic view of the mind. Sperry (1969, 1980) proposes that mental phenomena have dynamic emergent properties arising from cerebral excitation, which are different from and more than material brain processes. Once generated from neural events, the higher order mental patterns and programs have their own subjective qualities, and progress, operate, and interact by their own causal laws that cannot be reduced to neurophysiology. Popper and Eccles (1981) maintain that mental processes are emergent relative to physical processes but believe in a dualism where the relationship of the brain to the body is that of the computer to the programmer, with the self-conscious mind playing a superior interpretive role. Software written in binary language is both patterns of magnetic or optical properties as well as information, as defined with the interacting entity (without interaction there is no communication and no information). How do these entities become interactional (communicational)? Such interaction may be inherent in nature, as matter and antimatter ―know‖ to annihilate each other upon encounter. Psychological awareness, although a subset of communication (interaction), might arise as an emergent phenomenon in a complex system of lower level interactions. Perhaps, as a critical mass of uranium will start a chain reaction, a ―critical mass‖ of ―proto-awareness‖ might result in a series of events leading to what we call awareness. To the extent that humans can hardly guess at the experience of ―awareness‖ of beings such as photons, electrons, or, for that matter, dogs and chimpanzees, a true description of others‘ awareness may be an impossible task. Nevertheless, whether mental or physical, information is exchanged at all levels of organization in the cosmos. Modern quantum theory presents us some intriguing notions of the mind. Quantum mechanics places the conscious observer at the center of reality. It is a quantum theory maxim that ―no phenomenon is a phenomenon unless it is an observed (or recorded, resulting in some irreversible change) phenomenon.‖ Until observation has occurred, reality exists only as potentials or probabilistic waves. At the instant of observation, however, the wave function collapses into a reality according to the orthodox Copenhagen interpretation (Bohr, 1958), or the universe splits into a number of possible universes according to the many worlds theory (Everett, 1973; Wolf, 1988). Consciousness, though arising as a result of brain processes, may be regarded as a cosmic process of creation (as the choices it makes are not locally determined but cosmically inherent) that produces events or reality (Stapp, 1993). Such events, or the observation-induced collapse of the wave function into particles, seem to supersede the barriers of space-time. Einstein proposed an experiment that tried to show what he considered to be a failing in quantum theory: Suppose two particles arising from an interaction are flying apart at the speed of light. According to quantum theory, if one quality of the particle is observed at a later time (say, a particular spin to the left) at one place by observer A, another observer B, observing the other particle (say, 20 light years away from observer A) must observe the complementary quality that is being observed by A. As it is purely by chance that A would observe the spin to the left, until the moment of observation of A, the spin of B is indeterminate. But once A is observed, B‘s spin can be nothing but ―right,‖ which

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Einstein considered to be ―spooky action at a distance‖ at speeds faster than light—the Einstein-Podolsky-Rosen (EPR) paradox (Einstein et al., 1935). Later reformulation of the EPR experiment (Bell‘s inequality; Bell, 1964) that was carried out by Aspect et al. (1982) proved the quantum theory predictions over Einstein‘s objections. It should be pointed out, however, that the quantum theory predictions do not presuppose ―communication faster than light.‖ It simply shows a cosmic connectedness or unity beyond space-time separation. One way of looking at this is to consider the two particles not to be separate at all, but a part of a whole (a single wave). This is compatible with modern superstring and Membrane or M-theories (Greene, 2004). In playing a role as to when and how observation is done, a series of conscious choices influence the way reality occurs (wave function collapses), or biases the number of split-off universes in a particular direction and therefore the probability that observers will find themselves in a universe in the chosen direction (in a many-worlds interpretation). In this regard, it may be useful to ponder the role of the observing physician in the diagnosis and treatment of disease and in patient care. Will the act of diagnosis result in a collapse of the wave function? What is the role of a patient‘s will (or choice) to live, which may arise out of an interaction between the patient and the physician or the family and friends? The practice of medicine may truly be a creative process. The interaction between the physician and the patient creates new paths of reality for both participants. References
Aspect A, Dalibard J, Roger G. Experimental test of Bell‘s inequalities using timevarying analyzers. Physical Rev Lett 1982;49:1804. Bell JS. On the Einstein-Podolsky-Rosen paradox. Physics 1964;1:195–200. Bohr N. Atomic Physics and Human Knowledge. New York: Wiley, 1958. Einstein A, Podolsky B, Rosen N. Can the quantum mechanical description of physical reality be considered complete? Physiol Rev 1935;47:777. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;196:129–136. Everett H III. The theory of the universal wave function. In: DeWitt B, Graham N, eds. The Many Worlds Interpretation of Quantum Mechanics. Princeton, NJ: Princeton University Press, 1973:3–140. Greene B. The Fabric of the Cosmos: Space, Time, and the Texture of Reality. New York: Knopf, 2004. Leigh H, Reiser MF. The Patient: Biological, Psychological, and Social Dimensions of Medical Practice, 3rd ed. New York: Plenum, 1992. Mirsky IA, Reiser MF, Thaler M, Weiner H. Etiology of duodenal ulcer. I. Relation of specific psychological characteristics to rate of gastric secretion (serum pepsinogen). Psychosom Med 1957;19(1):1–10. Nesse RM, Williams GC, Why We Get Sick: The New Science of Darwinian Medicine. New York: Vintage Books, 1996. Popper KS, Eccles JC. The Self and Its Brain. Springer-Verlag: Berlin, 1981. Rainone F. Acupuncture for mental health. In: Muskin P, ed. Complementary and Alternative Medicine and Psychiatry. Washington, DC: American Psychiatric Press, 2000. Sifneos PE. Alexithymia: past and present. Am J Psychiatry 1996;153(7 suppl):137–142. Sifneos PE. The prevalence of ‗alexithymic‘ characteristics in psychosomatic patients. Psychother Psychosom. 1973;22(2):255–62.

Chapter 1 Evolution of Consultation-Liaison Psychiatry Sperry RW. A modified concept of consciousness. Psychol Rev 1969;76:532–36. Sperry RW. Mind-brain interaction: mentalism, yes; dualism, no. Neuroscience 1980; 5:195–206. Stapp HP. (1993), Mind, Matter, and Quantum Mechanics, (Springer-Verlag, Heidelberg, Berlin). Wolf, Fred Alan. Parallel Universes: The Search for Other Worlds, Touchstone: New York, 1988. Zilboorg G. A History of Medical Psychology. New York: W.W. Norton, 1941.

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Bibliography
Ader R, Felten DL, Cohen N. Psychoneuroimmunology, vol 1 and 2. New York: Academic Press, 2001. Alexander F. Psychosomatic Medicine. New York: W.W. Norton, 1950. Bunge M. Emergence and the mind. Neuroscience 1977;2:501–509. Cannon WB. The Wisdom of the Body, 2nd ed. New York: W.W. Norton, 1939. Dunbar F. Emotions and Bodily Changes: A Survey of Literature on Psychosomatic Interrelationships. New York: Columbia University Press, 1936. Dunbar F. Psychosomatic Diagnosis. New York: P.B. Hoeber, inc., Medical book dept. of Harper & brothers, 1943. Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry 1980;137:535–544. Fink PJ. Response to the presidential address: Is ―biopsychosocial‖ the psychiatric shibboleth? Am J Psychiatry 1988;145:1061–1067. Goodman A. Organic unity theory: the mind-body problem revisited. Am J Psychiatry 1991;148:553–563. Gregory B. Inventing Reality: Physics As Language. New York: Wiley, 1988. Joynt RJ. Introduction to the challenge of the biopsychosocial model. Psychosom Med 1980;42(suppl):77. Leigh H, Feinstein AR, Reiser MF. The patient evaluation grid: a systematic approach to comprehensive care. Gen Hosp Psychiatry 1980;2:3–9. Mind and Body Web site: from Descartes to James: http://serendip.brynmawr.edu/ Mind/Table.html Psychoneuroendocrinology Web site: http://www.elsevier.com/wps/find/journal description.cws_home/473/description#description Psychosomatic Medicine Subspecialty Web site: http://www.apm.org/subspecialty/ index.shtml Selye H. From Dream to Discovery. New York: McGraw-Hill, 1964. Selye H. The general adaptation syndrome and the diseases of adaptation. J Clin Endocrinol 1946;6:117. Selye H. The Story of the Adaptation Syndrome. Montreal, Canada: Acta, 1952. Selye H. Stress and disease. Science 1955;122:625. Selye H. The Stress of Life. New York: McGraw-Hill, 1956. Selye H. The Stress of My Life: A Scientist‘s Memory. New York: Van Nostrand Reinhold, 1979.

2
The Functions of Consultation-Liaison Psychiatry
Hoyle Leigh
CONTENTS 2.1 The Dual Roles of the Consultation-Liaison Psychiatrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 2.1.1 Consultation and Liaison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 2.1.2 Consultant and Psychiatrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Clinical Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Educational Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Administrative Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Research Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

2.2 2.3 2.4 2.5

2.1

The Dual Roles of the Consultation-Liaison Psychiatrist

There are two sets of dual interrelated roles that a consultation-liaison (CL) psychiatrist plays: consultation and liaison, and consultant and psychiatrist. 2.1.1 Consultation and Liaison

The term consultation-liaison psychiatry encompasses two primary functions— that of a psychiatric specialist providing expert advice on the consultee‘s patient, and that of a liaison or link. Historically, the liaison function indicated that the psychiatrist was stationed in and worked as a member of the medical team. Currently, the term has been expanded to indicate the educational and facilitative function of the consulting psychiatrist, that is, the linkage the psychiatrist provides the consultee between medical and psychiatric knowledge and skills on one hand, and the facilitation of communication and understanding that the psychiatrist provides between the patient and the health care personnel. Thus, the liaison function is inherent in the comprehensive approach utilized by the psychiatric consultant to the patient and the health care system. 2.1.2 Consultant and Psychiatrist

The CL psychiatrist is both a consultant and a psychiatrist; that is, he or she has two masters—the requesting physician (consultee) and the patient. The obligation to the requesting physician often extends to serving the interests of the health care facility and of society at large. Sometimes this duality leads to an

12

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internal conflict, such as in situations when the perceived interest of the patient conflicts with the desires of the consultee, the needs of the hospital, or of society (see Administrative Function, below). Consultation-liaison psychiatry developed mainly in teaching hospitals with psychiatric residency training programs. There is usually a psychiatric CL service in major teaching hospitals consisting of one or more full- or part-time faculty position, one or more psychiatry residents rotating to the CL service, and perhaps other staff and trainees, for example, a resident rotating from another specialty (most commonly internal medicine or family practice), a medical student, a psychiatric nurse, a social worker, a psychologist, and so on. Such CL services generally serve several explicit and implicit functions, for example, clinical, educational, administrative, and research. In medical settings without a formal CL service, one or more full- or part-time psychiatrists may be hired or designated to be a consultant for specifically defined times. Such CL psychiatrists‘ function may be limited to the clinical and administrative functions.

2.2

Clinical Function

The consultant‘s primary clinical function in an acute general hospital is to facilitate the medical treatment of the patient, as the patient is in the hospital primarily for medical care. In this sense, consultation should be distinguished from referral, usually seen in outpatient settings and chronic care facilities. In a referral, the psychiatrist is asked to take over the psychiatric care of the patient if indicated, whereas in a consultation, the psychiatrist renders an opinion or advice to the requesting physician. In addition to such advice and opinion, the requesting physician usually, and implicitly, requests collaborative care of the patient if indicated, which forms the basis of the direct rendering of treatment by the CL psychiatrist. Except in emergencies and psychotherapy inherent in diagnostic interview, and facilitation of communication through meetings and phone calls with members of family and staff, direct treatment of patients including ordering medications should be done with the explicit knowledge and cooperation of the consultee so as to prevent a diffusion of responsibility for direct care.

2.3

Educational Function

The liaison part of CL psychiatry largely denotes its educational function. The education is for patients, requesting physicians, nursing staff, patients‘ families and friends, and the health care system. Examples of liaison education include teaching the psychological needs of patients based on their personality styles (see Chapter 15), the immediate management of psychiatric conditions (see Chapter 5), the use of psychotropic drugs, and the determination of capacity to consent to procedures (see Chapter 28). The CL service in teaching hospitals has formal educational functions in addition to the liaison function. They include the teaching of various trainees including psychiatric residents, residents from other departments such as internal medicine and family practice, medical students, nursing and social work students, psychology interns, etc. The CL setting is particularly well suited to teach medical students and primary care residents the aspects of psychiatry that would be most relevant to any physician. Members of the CL team may also give lectures

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and seminars or participate in the grand rounds of other departments as a part of the formal teaching function. A recent survey showed that about 60% of psychiatry departments provide didactic courses, 36% participate in case conferences, and 15% participate in joint rounds with primary care training programs (Leigh et al., 2006).

2.4

Administrative Function

The administrative functions of the CL psychiatrist are often mandated by either the government or the institution and often involve coercive measures such as emergency hold and involuntary hospitalization of patients. Institutional rules usually mandate that an acutely suicidal or homicidal patient has to be evaluated by a psychiatrist, who will decide whether the patient should be placed on an emergency involuntary hold and be transferred to a psychiatric facility when medically stable. The CL psychiatrist may be required to evaluate a patient with suspected dementia and apply for a conservatorship. The risk-management department of the health care institution relies on the CL psychiatrist to evaluate patients‘ capacity to sign out against medical advice or to refuse medical/surgical procedures, and for general behavioral problems that disrupt the facility‘s function. At times, the mandated administrative function may interact or interfere with the clinical function of the consultant, such as an emergency hold disrupting the consultant‘s rapport with the patient. These conflicts can usually be resolved with skillful communication, but the CL psychiatrist must recognize and be comfortable with the multiple roles inherent in the function.

2.5

Research Function

The CL setting provides unique opportunities for research in the interface between psychiatry and medicine. Much of psychosomatic research in the 20th century was done by CL psychiatrists. The CL setting gave rise to such subspecialty fields as psychonephrology, psycho-oncology, and psycho-obstetrics, and gynecology. The role of psychiatric intervention in medical utilization has also been a productive field of research, and has provided evidence that psychiatric intervention actually reduces the cost of health care (Katon et al., 2005; Wells et al., 2005). As the gene–environment interaction becomes better understood, the CL setting may provide unique opportunities to study the role of genotype and environment in the selection or sequence of organ dysfunction (e.g., the subgenual cingulate cortex and the intestines; see Chapter 6). References
Katon WJ, Schoenbaum M, Fan M, et al. Cost-effectiveness of improving primary care treatment of late-life depression. Arch Gen Psychiatry 2005;62:1313–1320. Leigh H, Stewart D, Mallios R. Mental health and psychiatry training in primary care residency programs. Part I. Who teaches, where, when and how satisfied? Gen Hosp Psychiatry 2006 May–Jun; 28(3):189–94. Leigh H, Stewart D, Mallios R. Mental health and psychiatry training in primary care residency programs. Part II. What skills and diagnoses are taught, how adequate, and

Chapter 2 The Functions of Consultation-Liaison Psychiatry what affects training directors‘ satisfaction? Gen Hosp Psychiatry 2006 May–Jun; 28(3):195–204. Wells K, Sherbourne C, Duan N, et al. Quality improvement for depression in primary care: do patients with subthreshold depression benefit in the long run? Am J Psychiatry 2005;162:1149–1157.

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Bibliography
Tilley DH, Silverman JJ. A survey of consultation-liaison psychiatry program characteristics and functions. Gen Hosp Psychiatry 1982;4(4):265–270. Wasylenki D, Harrison MK. Consultation-liaison psychiatry in a chronic care hospital: the consultation function. Can J Psychiatry 1981;26(2):96–100.

3
The Why and How of Psychiatric Consultation
Hoyle Leigh
CONTENTS 3.1 3.2 3.3 Vignette . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 The Nature of Psychiatric Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 The Consultation Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3.3.1 Receive a Consultation Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3.3.2 Talk to the Referring Physician and Clarify the Consultation Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3.3.3 Determine the Scope of Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 3.3.4 Review the Chart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 3.3.5 Interview the Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 3.3.6 Obtain Collateral Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 3.3.7 Diagnose the Consultation: The Syndrome, the Patient, the Environment . . . . . . . . . . . . 26 3.3.8 Provide Diagnosis and Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 3.3.9 Consultation Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 3.3.10 Follow-Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Computerized Psychiatric Consultation Database . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

3.4

3.1

Vignette

A consultation request was received by fax. The request sheet simply had the patient‘s name and ward number and the statement, ―Behavioral problem. Please evaluate.‖ When the consultant called the requesting physician, she said, ―I don‘t really know what the problem is, but the nurses seem to be upset about the patient. The patient just had a myocardial infarction but is doing OK. I think he may be a little depressed, though, because he is so quiet.‖ In the patient‘s chart the night nurse had written that the patient was observed crying in the middle of the night. Upon interview, the consultant was able to diagnose a recurrent major depression.

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Chapter 3 The Why and How of Psychiatric Consultation

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3.2

The Nature of Psychiatric Consultation

Specialty consultations are requested to obtain expert opinion in diagnosing and treating conditions that fall in the specialty area. As psychiatry deals with a vast area of human experience including cognition, emotion, and behavior, it is often difficult to know the exact reason for a referral, as the above vignette illustrates. Psychiatric consultation, like any other consultation, is not the primary reason for the patient‘s hospitalization or contact with the health care system, and not a few patients may be surprised that a psychiatric consultation has been requested. Primary physicians may also be reluctant to request a psychiatric consultation because of the perceived stigma. Therefore, requesting a psychiatric consultation on a patient requires a certain amount of motivation on the part of the referring physician. This motivation is often generated by a strain in the health care unit consisting of the doctors, the nursing staff, and allied professionals. Common causes of such strain are patients‘ anxiety, communication difficulties, or behavioral problems, and administrative/legal requirements. While some psychiatric consultations are generated at the patient‘s request, most arise out of discomfort on the part of one or more health care staff members, and recognizing this discomfort or strain is an essential part of a successful consultation. It is the consultant‘s job to ameliorate the strain so that the health care personnel can proceed to provide medical care without impediment. As discussed in Chapter 2, the consultant serves two masters: the requesting physician (consultee) and the patient. The primary role of the consultant is to provide expert advice to the consultee so that medical/surgical treatment can be successfully rendered. A secondary role is to provide direct psychiatric care for the patient with the consultee‘s agreement. The psychiatric consultant is often the face of psychiatry in the general hospital. It is through the consultant that the nonpsychiatric physicians form an impression about psychiatry, and, it is hoped, learn psychiatric approaches and techniques. The educational function of the consultant psychiatrist, as discussed in the previous chapter, is an integral part of the practice of consultation-liaison psychiatry.

3.3
3.3.1

The Consultation Procedure
Receive a Consultation Request

Most health care institutions have formal mechanisms for requesting a consultation, such as a computerized request form or a written request, delivered by fax, email, or telephone. Informal requests may also be made either by telephone or in person. While informal consultations, especially when urgent, are often attended to, it is a good idea to insist on a formal consultation request as well. 3.3.2 Talk to the Referring Physician and Clarify the Consultation Request

Consultation requests are often vague and sometimes misleading (as in the vignette at the start of this chapter), usually because the consultee lacks the vocabulary of psychiatry. The consultee is aware of the discomfort of the strain caused by the patient, but has difficulty putting it into words. Thus, it is critical that the

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consultant seek out the consultee, usually by phone, and ask for additional information about the consultation, particularly what the consultee would like from the consultant. It is a good idea to ask the referring physician to be sure to let the patient know to expect a psychiatric consultant, and, if possible, to introduce the consultant to the patient. 3.3.3 Determine the Scope of Consultation

The consultant should be able to determine the probable scope of the consultation after speaking with the referring physician, that is, whether it is an emergency management of an agitated or acutely suicidal patient; a comprehensive evaluation of the patient in assisting with diagnosis; or a focused consultation about a specific question, such as the patient‘s ability to sign out against medical advice or to consent to a surgical procedure. Even though the question asked by the consultee may sound focused and straightforward, at times the consultant can facilitate the medical treatment through a comprehensive understanding of the patient and facilitation of communication; for example, a patient may decide to remain in the hospital rather than sign out against medical advice after a discussion between the patient and the physician that was arranged by the consultant. In general, the narrower the scope of the consultation, the quicker should the consultant respond to the referring physician. 3.3.4 Review the Chart

The patient‘s chart should be reviewed prior to seeing the patient. The recent progress notes and nurses‘ notes should provide information about the patient‘s recent and current status. Medication orders, and more specifically the medications actually administered, should be reviewed, especially for any recent additions or changes that might contribute to the patient‘s changed mood or mental status. Laboratory and imaging findings should be reviewed for possible metabolic/structural causes of the psychiatric syndrome, as well as to determine which additional lab tests may be indicated. Talking with the patient‘s nurse can yield important information not only about the patient but also about visitors and patient‘s interactions with the staff. Furthermore, talking with the nursing staff members allows them to discuss their impressions of the patient and to report any difficulties they may be having in patient management. Nurses appreciate a doctor who is interested in their input. Their tolerance for a patient‘s deviant behavior will increase when the consulting psychiatrist shows interest. This alone may influence patient–nurse interactions for the better. 3.3.5 Interview the Patient

The consultant should now have a reasonable idea about the strain that resulted in the consultation and the areas to focus on in evaluating the patient. The consultant is now ready to interview the patient. The patient should be provided as much privacy as possible. If the patient is in a ward or a room with other patients, the consultant should draw the curtains around the patient‘s bed; if the patient is in a private room, the consultant should close the door. If there are visitors with the patient, the consultant should introduce

Chapter 3 The Why and How of Psychiatric Consultation

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him- or herself by name only and ask who they are, and then ask them to wait outside for a few minutes while the consultant talks with the patient. The consultant should not identify him- or herself as a psychiatrist until the visitors have left. An exception to this is when the patient‘s cognitive function is known to be impaired, in which case the visitors may remain, with the patient‘s permission, as they might be able to provide valuable history and additional information. The consultant should ask the patient whether he or she was told that a psychiatric consultation had been requested. If the patient says no, the consultant should explain that the patient‘s primary doctor requested the psychiatric consultation for a comprehensive evaluation, which may be for anxiety, depression, mood changes, memory problems, etc. The consultant should reassure the patient that many medical conditions and medications, as well as the stress of being in the hospital, can cause such problems and that they can be managed effectively. The initial interview should ordinarily take not more than 30 minutes, and should identify the patient‘s current concerns, the presence of major or minor psychiatric syndrome and its history, past history of psychiatric problems, the family history, the occupational status of the patient, and current mental status. In general, if the patient is confused or delirious, a mental status exam may be performed in lieu of a history, which may have to rely on collateral sources. When a patient is not confused, the cognitive exam may be performed for five minutes or less at the end of the interview, which can be prefaced by first asking, ―How is your memory lately?‖ followed by, ―I‘d now like to ask you some questions to assess your current memory and concentration.‖ 3.3.5.1 The Mental Status Examination The mental status consists of the following components: (1) appearance; (2) levels of consciousness and orientation; (3) status of the communicative facilities (speech and movement); (4) content of thought; (5) affect and mood; and (6) cognitive processes (attention, concentration, comprehension, memory, perception, thinking logical thoughts, abstraction, judgment). For patients with cognitive deficits, the Mini–Mental Status Examination (MMSE), in addition to the full mental status examination described here, is useful in quantitatively determining the extent of cognitive deficit, and, when used serially, in documenting changes in cognitive function (see Chapter 8). 3.3.5.1.1 Appearance: Appearance is an excellent indicator of the sum total of a patient‘s mental status at a given point in time. Body build should be first noted, for example, medium, slender, emaciated, moderately obese, morbidly obese, etc. A sloppy, disheveled appearance often signifies self-neglect or preoccupation and distraction. A flushed appearance and the smell of alcohol on the breath, combined with characteristic drunken behavior, point to the diagnosis of alcoholic intoxication. A pale, emaciated appearance, accompanied by malodorous and sloppy clothing, may indicate the presence of depression or cachexia. Some patients with a lesion in the nondominant hemisphere of the brain may dress only one side of the body, completely oblivious to the presence of the other side. Such patients may pay attention only to one half of the visual field. Notations on appearance should include observations on the general impression made by the patient (e.g., neat or sloppy),

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including any unusual features (e.g., completely shaved scalp, unusual bodily habitus or dress). 3.3.5.1.2 Levels of Consciousness and Orientation: Awareness of self and environment constitutes consciousness in the mental status examination. Consciousness may be subdivided into the content of consciousness and arousal. The sum total of mental functions, including the ability to remember and to think, comprises the content of the consciousness, while the appearance of wakefulness and response to stimuli form the basis of inference concerning arousal. The content of consciousness is largely a function of the cerebral hemispheres, while the state of arousal is largely a function of the reticular activating system in the brainstem. 3.3.5.1.2.1 Arousal: Levels of consciousness may be classified as follows:

Hyperalert state: Increased state of arousal in which the patient is acutely aware of all sensory input. Anxiety and certain central nervous system stimulants can cause this state. Normal degree of alertness. Dullness and sleepiness: May be due to fatigue and insomnia, as well as to sedating medications (as either the primary effect or a side effect). Metabolic derangements due to disease can also result in dullness and sleepiness, such as in uremia and hypercalcemia. Clouding of consciousness: A state of reduced wakefulness in which periods of excitability and irritability often alternate with periods of drowsiness. Illusions, especially visual, may occur, and the patient is often startled. Mild to moderate toxic states, withdrawal states, and metabolic derangements can be the cause. Confusional states: In addition to clouding of consciousness, there is consistent misinterpretation of stimuli and shortened attention span. There is disorientation at least to time and often to place. Memory is often poor, and the patient appears perplexed. This is a more severe degree of clouding of consciousness. Delirium: When used to denote a particular and often fluctuating level of consciousness, delirium may include a florid state of agitation, disorientation, fear, misperception of sensory stimuli, and, often, visual hallucinations. The patients are often loud, talkative, and suspicious, and are sometimes completely out of contact with the environment. The degree of contact may vary. Delirium usually occurs in moderately severe toxic states and metabolic derangements of the central nervous system, including withdrawal from central nervous system depressants such as alcohol and barbiturates. The term delirium is sometimes used to denote all reversible organic brain syndromes due to metabolic encephalopathy. When used in this sense, delirium is in contrast to dementia, which implies irreversible changes in the brain. Agitation and florid psychotic picture may be lacking in patients with delirium in this broader sense; that is, the patient with reversible confusion and disorientation may be placid and drowsy rather than agitated. Stupor: In this state, the patient is unresponsive to stimuli unless their application is very strong and repeated. Stupor is usually caused by diffuse cerebral dysfunction.

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Coma: complete unresponsiveness to stimuli. Even strong and repeated stimuli cannot arouse the patient. This occurs in severe dysfunction of the brain, such as serious intoxication or severe head trauma. 3.3.5.1.2.2 Content of Consciousness Orientation refers to the person‘s consciousness of the orienting markers, such as correct awareness of time, place, and person. Impairment of orientation results in confusion. The orientation of a patient is determined by asking questions such as, ―What day of the week is it today?‖ ―Where are you right now?‖ ―What is your name?‖ In case of insufficiency in the cerebral cortical functions for any reason (most often due to metabolic derangement of the brain or neuronal destruction), orientation may be impaired to varying degrees. Impairment of orientation usually proceeds in order from time to place to person. In hospitalized patients, disorientation as to date is not uncommon, perhaps due to the change in daily schedule following hospitalization, distractions by the medical procedures, and other disruptions in the patient‘s usual routine. In the absence of cerebral insufficiency, however, most patients are oriented to the month and year if not to the exact date. In contrast, orientation as to person, especially to the patient‘s self, usually is not impaired until the very last stage, although the patient may often forget the names of others, especially those persons encountered recently. Disorientation to the self despite a relatively normal mental status examination in other areas strongly suggests a dissociative syndrome rather than an organic brain syndrome. 3.3.5.2 Status of Communication Facilities (Speech and Movement) In assessing the communicative facilities of a patient, one should consider the integrity of the apparatuses, the effect of learning and psychological state, and the content of the communication. 3.3.5.2.1 Integrity of Apparatuses: The organs related to speech and movement should be assessed. Weakness of the tongue or facial muscles may produce dysarthria (difficulty in articulating words). Hemiplegia may cause the patient to gesticulate with only one hand. A painful lesion in the mouth may force the patient to be verbally noncommunicative. Deafness may result in nonresponse to a question. Disorders of language (aphasia) caused by brain lesions may be present. Aphasia should be distinguished from dysarthria; the former is due to problems with language itself at the brain level, while the latter refers to difficulty in articulation. In aphasia, written language as well as verbal speech is affected. Aphasias may be roughly classified into expressive and receptive types. Expressive aphasia is related to lesions of the motor speech (Broca‘s) area in the dominant frontal lobe of the brain. The patient with expressive aphasia has major difficulties in translating thoughts to symbols; thus, what the patient wishes to express may come out in a distorted form or not at all. Patients are usually aware of this distortion or difficulty in their speech and thus are usually reluctant to speak (or write). Receptive or sensory aphasia is due to lesions of the sensory speech (Wernicke‘s) area of the dominant temporal lobe. In this condition, patients have difficulties in comprehending language, including their own speech. Thus, patients‘ speech may be garbled, but they may not be aware of it. Unlike patients with expressive aphasia, those with the receptive form are

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usually fluent, although often incomprehensible to others. There are varying combinations and subtypes of aphasias. 3.3.5.2.2 Effect of Learning and Psychological State: Given intact apparatuses for communication, the form of communication often depends on the patient‘s psychological state and the effect of learning. The effect of learning determines the language in which the patients will express their feelings and thoughts as well as the fluency and facility of the language. For example, middle-class patients are more likely to use grammatically correct syntax. Some patients may use dialects or culturally specific expressions. The current psychological state also determines speech and nonverbal communication. A euphoric patient is more likely to be effusive, verbose, and flamboyant; a depressed patient may be uncommunicative and withdrawn. 3.3.5.2.3 Content of Communication: What the patient is communicating forms the content of communication. The content of communication often reveals the patient‘s psychological state, for example, themes of hopelessness and death in depressed states, and bizarre contents in psychotic states. Extreme suspiciousness and ideas of persecution may indicate paranoid psychosis. 3.3.5.3 Affect and Mood In current usage, mood denotes the subjective feeling/emotion of the patient (euthymic, sad, happy, depressed, euphoric, etc.), while affect refers to the way the emotion is expressed (normal range, flat, obtunded, labile, appropriate, inappropriate, etc.). In another, common usage, affect refers to feeling and is synonymous with emotion, while mood refers to prevailing and relatively enduring emotional tone. Mood can be documented by observation and direct questioning. By observation, one can see whether the patient‘s affect is appropriate or inappropriate relative to the topic of conversation (does the patient smile while talking of sad events?) and whether it is stable or labile. Labile affect, as manifested, for example, by laughing one minute and crying the next, may be indicative of organic brain dysfunction, in which case there will be additional signs of cognitive difficulties. Flat affect means the absence of any display of affect and is often associated with extreme use of isolation as a defense mechanism or with schizophrenia. Physiological signs such as sweating, rapid heart rate, and facial expressions also reveal affective states. Family, friends, and relatives of the patient may also provide useful information concerning the patient‘s mood. 3.3.5.4 Cognitive Processes These are the processes that determine the content of consciousness. The processes include attention, perception, memory, concentration, comprehension, abstraction, logical thinking, and judgment. Diminution in the function of any of these areas may indicate the presence of pathology in the cerebral cortex or limbic system. It should be noted, however, that what is important is a decrease in function from the premorbid state and not necessarily the absolute level of functioning, since the absolute levels of abstract thinking, comprehension, and other processes may be determined by background and by long-term variables such as constitutional endowment, educational level, and habitual functional level, as well as by illness. For example, cerebral pathology is more probably present in a college professor who cannot remember the names of the past five U.S. presidents than in a blue-collar worker with a tenth-grade education who evinces the same inability.

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The cognitive processes can be tested both indirectly and directly. Indirectly, inferences can be made concerning patients‘ memory, judgment, concentration, comprehension, and other abilities by asking them to describe their present illness and their personal history. Do they remember the dates (or years) of graduation from school, marriage, and other significant events? Do they comprehend the nature of their illness and the proposed procedures? Do they remember what has been said to them by their physicians? Do they seem to be aware of the possible risks and complications? When there is any question concerning the patient‘s ability to concentrate, comprehend, or think in a logical fashion, a direct and formal testing of the cognitive functions may be necessary. 3.3.5.4.1 Direct Tests of Cognitive Processes: In introducing direct tests of cognitive processes, it may be helpful to explain that the tests evaluate memory, concentration, and so forth, and so are useful in evaluating possible mental effects of medications, procedures, and the illness itself. For example, sedating medications may need to be reduced if the patient is found to be too drowsy or if concentration is diminished. This type of reassurance may put patients at ease about possible errors they may make and gives the testing a medical context. 3.3.5.4.1.1 Orientation The significance of orientation was discussed above. When doing direct cognitive testing, it is useful to ask questions concerning orientation first. The questions may include ―What day is today?‖ ―What is the date (or day of the week)?‖ If the patient does not know, ask, ―What month is it now?‖ ―What year?‖ Mild disorientation as to time (e.g., not knowing the date) is common even among normal persons, but severe disorientation (e.g., not knowing the month and year) is indicative of a cognitive disorder. ―Where are you right now? What is the name of this place?‖ These questions test orientation as to place. If the patient does not know, ask, ―Are you in a hospital, a hotel, or a supermarket?‖ Patients may know that they are in the hospital (or a doctor‘s office) but may not know the name of the hospital or clinic, which indicates a milder degree of dysfunction than not knowing the nature of the place or confusing it with somewhere else, such as a hotel room. The next question (orientation as to self) is ―What is your name?‖ As discussed previously, dysfunction in orientation proceeds in an orderly manner from time to place to person. In fact, except in cases of very severe brain disease, orientation as to self is usually well preserved. Of course, a delusional patient may have a distorted orientation as to self, stating, for example, ―I am Napoleon Bonaparte.‖ 3.3.5.4.1.2 Memory, Attention, Concentration, and Comprehension Ask, ―Who is the President of the United States now?‖ If the patient answers correctly, continue by saying, ―Yes, and the previous President?‖ until four or five names have been given correctly. This tests the patient‘s recent memory and information. Most patients with a high-school education can remember four or five recent presidents. Asking the patient to do simple arithmetic calculations can test the patient‘s ability to attend to and comprehend the physician‘s instructions and to concentrate and utilize immediate memory. ―How much is 15 plus 17?‖ ―25 minus 7?‖ If the patient has difficulty, an easier calculation involving single digits should be tried. Unlike additions and subtractions, simple multiplications, such as 4 times 6,

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are easier tasks, since they involve primarily long-term memory (which is resistant to decay) and comprehension of the instructions. Thus, if the patient can do 4 times 6 but not 15 plus 17, then one might wonder whether the patient has difficulties with concentration and immediate or recent memory but not with remote memory and comprehension (indicating possible brain dysfunction). On the other hand, if the patient has difficulties with both, low educational level or mental retardation might be suspected. If there is reason to suspect difficulties on the basis of simple calculations, serial 7‘s and digit span testing might be done. For serial 7‘s, ask the patient to subtract 7 from 100 and to keep subtracting 7 from the results. This tests sustained attention and concentration as well as short-term memory. If serial 7‘s are too difficult for the patient, serial 5‘s or 2‘s may be tried. Digit span is tested by asking the patient to repeat a number of random digits, not including zero, such as 5-7-2-8-6. Digit span backward is tested by asking the patient to repeat the numbers in reverse order: ―For example, if I say 1-2, you say 2-1.‖ This tests primarily short-term memory and concentration. Most patients without brain dysfunction can do at least six digits forward and four digits backward. Failure to repeat six digits forward strongly suggests cognitive impairment. In contrast, the ability to repeat five numbers backward suggests that a brain dysfunction is very unlikely. Memory, especially recent memory, is very sensitive to dysfunction of the brain. The hippocampus is involved in the coding of recent memory into the long-term memory mechanisms. Any metabolic derangement of the hippocampus and the cerebral hemispheres can result in problems with memory. When memory dysfunction is suspected, the registration, retention, and recall of memory can be tested by the following steps: First, ask the patient if he/she remembers your name. If the patient does not remember it, repeat your name and ask the patient to repeat it (immediate memory: registration and immediate recall). Then, tell the patient that you will name three objects that you are asking him/her to remember, as you will ask again in a few minutes. The objects may be items such as ―apple, penny, and table.‖ Ask the patient to repeat the names of the three objects immediately. In about five minutes or so, ask the patient if he/she remembers your name and the names of the three objects (recent memory: retention and recall). The patient may be able to remember only one or two objects (diminished recent memory). If the patient cannot recall any of the objects, say, ―Please say yes if any of the objects I name now is one of the objects I named before.‖ If the patient can now identify the objects, it may indicate the presence of retention but difficulty with recall. 3.3.5.4.1.3 Abstraction Test the ability of the patient to categorize objects on the basis of similarities. For example, ―What is the similarity between a cat and a dog?‖ The patient may reply, ―They are both animals‖ (a good abstraction) or ―They both have legs‖ (a concrete response). (In case of the latter, you might then ask, ―How about a dog, a cat, and a snake?‖ At this point, the patient may be able to abstract and say, ―They are all animals.‖) An idiosyncratic or bizarre response, such as, ―They are both my enemies,‖ may indicate an unusual way of thinking, as in psychosis. Interpretation of proverbs, such as, ―Don‘t‘ judge a book by its cover‖ and ―Don‘t cry over spilt milk,‖ is most subject to influences of educational level, cultural background, and language. For example, patients from non–English-speaking cultures

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may have great difficulty in abstracting English-language proverbs. A concrete response in tests for abstraction may indicate possible brain dysfunction, low educational level, low intelligence, or formal thought disorder, as in schizophrenia. An idiosyncratic or bizarre response may indicate an unusual way of thinking, as in psychosis. For example, ―What does the proverb ‗People who live in glass houses shouldn‘t throw stones‘ mean?‖ ―It means that even if you have enough money to buy a glass house, you should not throw away money. Stones are gems, you know, which cost a lot of money.‖ 3.3.5.4.1.4 Logical Thinking and Judgment Patients with brain dysfunction may show varying degrees of difficulty with judgment. Judgment means the ability to act appropriately in social and emergency situations. Many questions concerning judgment also involve the ability to think logically. For example, ―If you were in a crowded theater and happened to discover fire and smoke coming from the ceiling, what should you do?‖ A good answer would be ―I would tell the usher or manager.‖ If the patient replies, ―I would yell ‗Fire,‘ ― the physician might ask, ―If you yelled ‗Fire,‘ what would happen?‖ The patient with intact logical thinking may then say, ―I guess that would cause panic . . . perhaps I should not yell ‗Fire.‘ ― (Another judgment question is, ―What should you do if you found an envelope with an address and a stamp on it in the street?‖) Patients with personality disorders without organic brain dysfunction may give idiosyncratic or inappropriate responses to judgment questions. For example, an impulsive patient may say, ―I would try to put out the fire by throwing my can of soda on it.‖ 3.3.5.5 Perception The patient‘s perception can be tested by first observing whether the patient seems to be aware of the tester‘s presence and whether the patient seems to be responding to visual or auditory hallucinations (e.g., carrying on a conversation). Then, the patient can be asked questions such as, ―Have you ever had any experiences of hearing things or seeing things that others couldn‘t see or hear?‖ ―Any experiences of things changing shape or becoming distorted?‖ 3.3.5.6 Delusions and Paranoid Thinking A delusion is an idea firmly held by a patient that is not corroborated by reality. Delusions may be grandiose (―I am God‖), persecutory (―Everybody is out to get me‖), or depressive (―Worms are eating my brain out‖). Some delusions involve diseases, such as, ―I know I have cancer, no matter what the tests show.‖ The term paranoid is often used to describe patients who have persecutory ideas or delusions. The presence of delusions is usually manifested by the content of the patient‘s communications. Delusion formation is a process by which perceptions are put into some kind of perspective. Thus, strange bodily sensations, due to whatever cause, may be attributed to ―poisoning‖ and continuing presence of anxiety to ―people spying on me.‖ Obviously, when cognitive processes are not functioning optimally, and when the anxiety level is high (such as in a hospitalized patient with preexisting cognitive difficulties due to poor blood supply to the brain), the risk of delusion formation is greater; it is easier to misperceive stimuli or attribute confusing stimuli to a cause unrelated to reality (e.g., ―The doctors are trying to kill me so that they can give my kidneys to someone else‖).

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In addition to indicating the possible presence of cognitive difficulties, delusions give clues concerning the emotional state of the patient. For example, persecutory delusions are associated with anxiety, grandiose delusions with euphoria, and depressive delusions with a depressive syndrome. 3.3.6 Obtain Collateral Information

At the end of the interview, the consultant should obtain permission from the patient to speak to his or her spouse or significant other, family members, and friends to obtain collateral information. If the patient is severely cognitively impaired, or the patient refuses to give permission, the consultant may still speak with the others as long as they are aware that the patient is in the health care facility and as long as the consultant only obtains information and does not divulge information about the patient. 3.3.7 Diagnose the Consultation: The Syndrome, the Patient, the Environment

After reviewing the reason for the consultation, patient‘s history, the family history, information received from collaterals, the laboratory findings, and the vital signs and physical examination findings, the consultant is in a position to make a comprehensive diagnosis. Such a diagnosis may include primarily a systems strain, for example, a personality or opinion conflict between the health care professional(s) and the patient (see Chapter 28). When the patient shows evidence of a psychiatric condition, the consultant develops a differential diagnosis leading to a working diagnosis of the psychiatric syndrome, its interaction with the medical condition, and an understanding of the patient as a person dealing with the medical and psychiatric condition. Such an understanding takes into account the patient‘s developmental history and childhood, recent and current stresses, as well as the patient‘s coping ability and psychosocial assets. Differential diagnosis of the psychiatric syndrome should be from general to specific, for example, psychotic syndrome that may be secondary to drug use and/or to delirium caused by electrolyte imbalance and/or increased serum ammonia. Very often, the psychiatric syndrome presents multiple possible contributing etiologies; for example, major depression may be a recurrence of existing unipolar depression, plus the effects of chronic alcohol abuse, plus secondary to hepatic failure, plus cocaine withdrawal. (See Chapter 6 for further discussion of psychiatric diagnosis). 3.3.8 Provide Diagnosis and Recommendations

The consultant should report the diagnosis and treatment recommendations to the referring physician, either directly or on the phone, so that the referring physician may be able to ask questions and discuss the findings with the consultant. The consultant should communicate to the consultee the findings and diagnosis clearly and concisely, without using unnecessary psychiatric jargon, and discuss alternative treatments and recommendations. The recommendations should be presented very concretely and should specify who is to do what. For example, ―I recommend prescribing olanzapine 10 mg po hs on a regular basis, plus lorazepam 1 to 2 mg IV q 4 hrs prn for agitation. Please tell the nurses to orient the patient each time they do any procedure such as taking the vital signs; they should say, ‗I am Nurse so and so and I am going to take your blood pressure.‘‖

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This conversation with the referring physician should be followed by a written consultation report. The report should be concise and legible. It should contain, as a minimum, the reason for referral, a brief history, the mental status examination, the relevant lab findings, the working diagnosis (usually multiaxial diagnosis), and the specific recommendations. 3.3.9 Consultation Interventions

In the course of a psychiatric consultation, the consultant provides intervention through the empathic interview process, and through the supportive psychotherapeutic elements inherent in a psychiatric interview. In addition, the consultant may provide immediate relief of agitation through listening and reassurance, and when indicated, with stat medications. There may be a need for an involuntary hold if the patient is considered to be dangerous to self or others and is in need of psychiatric hospitalization. The consultant may find it advisable, at times, to meet with the nurses, to meet with the patient‘s family, or to meet with the patient, the referring physician, and others to facilitate communication or plan a course of action. The consultant may also perform specialized procedures such as the lorazepam interview or hypnosis (see Chapter 29). 3.3.10 Follow-Up

At least one follow-up visit is recommended for all initial consultations whenever feasible. A follow-up visit is valuable in determining any changes either as a result of the treatment recommendation or in the disease process. In delirious patients, the fluctuation in mental status during follow-up visits may be diagnostic. When a patient no longer requires follow-up but is still in the health care system, the consultant should sign off and communicate it to the referring physician.

3.4

Computerized Psychiatric Consultation Database

I developed a computerized psychiatric consultation database with forms, reports, and queries, which is a Microsoft Access database application. It is available free of charge as a download from Springer. This database is used at the Community Regional Medical Center in Fresno, California. To download, please visit the Handbook website: www.springer.com/978-0-387-69253-1

4
Evaluating the Evidence Base of Consultation-Liaison Psychiatry
Tom Sensky
CONTENTS 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 The Evidence Base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Development of Pharmacologic Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Development of Complex Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Problems in Defining Appropriate and Robust Outcome Measures . . . . . . . . . . . . . . . . . . . . . . . . 31 Comparison Groups in Randomized Controlled Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Problems with Concealment of Randomization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Patient Preference Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Intervention Integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Dealing with Missing Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 The Role of Randomized Controlled Trails in Consultation-Liaison Psychiatry . . . . . . . . . . . . . . 35

This chapter draws on the evidence base of consultation-liaison (CL) psychiatry to ask two questions: Is research in CL psychiatry more challenging or more complex than research in general psychiatry? If so, what factors make it more challenging? The focus here is exclusively on research involving adults, although there is a growing evidence base involving children and adolescents. In addition, the chapter addresses mainly intervention studies.

4.1

The Evidence Base

An approximate overall profile of the evidence base can be gained by examining the design of studies published in the specialist CL psychiatry and psychosomatic medicine journals compared with those in the leading general psychiatry journals (Fig. 4.1). This assessment reveals that papers published in specialist CL psychiatry and psychosomatic medicine journals in the past decade focus predominantly on diagnosis and etiology. The overall focus of published papers is very similar in the specialist journals to that in the general psychiatry ones. If the focus of published work can be assumed to reflect the state of knowledge, this suggests that the knowledge base of CL psychiatry does not lag substantially behind that in general psychiatry. Note, however, that these results must be interpreted cautiously, because they are derived from Medline data aggregated by journal; not all papers in the specialist CL journals are in fact about CL psychiatry, and some papers published in the general psychiatry journals are about CL psychiatry.

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Interventions

Specialist General

Diagnosis

Etiology

Prognosis

0

10

20

30

40

50

% Papers (1995-2005)

Fig. 4.1 Focus of papers in general vs. specialist psychiatry journals. Medline classifications of research design for papers published in five CL psychiatry and psychosomatic medicine journals (Psychotherapy and Psychosomatics, Journal of Psychosomatic Medicine, General Hospital Psychiatry, Psychosomatic Medicine, and Psychosomatics) compared with papers published in Archives of General Psychiatry, American Journal of Psychiatry, and British Journal of Psychiatry. Note that the categories add up to greater than 100% because some papers had more than one focus.

A more focused and rigorous analysis was carried out by Ruddy and House (2005). They examined systematic reviews on the psychological effects of physical illness or treatment, somatoform disorders, and self-harming behavior, searching in particular for meta-analyses, which could be taken as an indication of the availability of good-quality primary research papers. In fact, only 14 of 64 systematic reviews identified included meta-analyses, and the authors concluded that many areas of CL psychiatry lacked robust research evidence. The meta-analyses identified focused particularly on interventions (psychological as well as biological). The study failed to find any meta-analyses concerning assessment or service development. The conclusions of the review above are supported by an examination of published randomized controlled trials in each of the five specialist CL psychiatry journals (Fig. 4.2). For this, a basic appraisal (Guyatt et al., 1993) was conducted of 40 randomized controlled trials, comprising the eight most recently published randomized controlled trials in each of the five specialist CL psychiatry journals up to 2005. The results indicate that these published studies tended to lack information regarding predicted sample size, randomization, and treatment evaluation. In addition, only a minority employed intention-to-treat analysis, creating potential problems in applying their findings to routine clinical practice (see below).

4.2

Development of Pharmacologic Interventions

In the development of therapeutic medications, research usually begins with basic science and then continues with animal work. The next stage is usually to evaluate the efficacy of the new medication, aiming to answer the question whether it provides benefit under strictly controlled conditions. If efficacy can be demonstrated, the next step is to evaluate the effectiveness: Does the new

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Power calculation Information on randomization Randomization concealment Treatment manual Intervention quality Intention-totreat analysis 0% 20% 40% 60% 80% 100% % Applicable Studies Yes No

Fig. 4.2 Quality of papers reporting interventions in CL psychiatry and psychosomatic medicine. Note that of the 40 studies evaluated, 17 were of pharmacologic interventions, for which use of treatment manuals and evaluation of the quality of the interventions was not applicable.

medication provide benefit under conditions as close as possible to routine clinical practice? Once sufficient evidence has been accumulated, a product license is sought. The conditions of use of the new medication are explicitly defined by the product license. Departing from the conditions of the product license (for example, using the new medication for an indication for which it has not been licensed, or in a different patient group) is usually possible only under strictly defined circumstances. These principles apply to medication trials in CL psychiatry just as in the rest of medicine. In this context, it is important to note that standard methods of critical appraisal of interventions have been developed principally to evaluate pharmacologic interventions. Many interventions in CL psychiatry are substantially more complex in their design than randomized controlled trials of medications and, as will be argued, possibly require more complex appraisal.

4.3

Development of Complex Interventions

Complex interventions, such as psychotherapeutic ones, often derive from clinical experience, and tend to emerge first in the published literature as clinical case studies and open case series (Sensky, 2005). Research usually then progresses to effectiveness studies, and only when effectiveness has been demonstrated do researchers focus on examining how and why the intervention works. There is no equivalent for complex interventions of the product license, and no obligation on clinicians or researchers to attempt to use the intervention in a strictly controlled way. Most nonpharmacologic interventions in CL psychiatry probably qualify as complex interventions. The development of psychotherapeutic interventions in CL psychiatry, as in other settings, often follows the sequence just described, culminating in randomized controlled trials. All psychotherapeutic interventions can be conceptualized in terms of two key elements: professional service and personal attachment (Guthrie and Sensky, 2007). In evaluating published

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work, both elements need to be operationalized and measured. This is a considerable challenge, as the rest of this chapter illustrates. Some psychotherapists have criticized the emphasis placed on evidence from randomized controlled trials. For example, it has been argued that in the clinic, psychotherapeutic interventions are seldom of fixed duration, as they are in research studies, and that psychotherapy is self-correcting rather than being tied to manualised techniques (Seligman, 1996). Others have argued that randomized controlled trials tend to exclude those patients most likely to be seen in everyday clinical practice (Persons and Silberschatz, 1998). However, some of these arguments are based on a failure to distinguish between trials assessing efficacy and those assessing effectiveness (Sensky, 2005). Nevertheless, there are difficulties particular to complex interventions that make their evaluation using randomized controlled trials more complex than are most psychopharmacologic interventions. Some of these difficulties are considered below. More generally, randomized controlled trials have been criticized for depriving patients and clinicians of the flexibility to choose the most appropriate intervention for the individual patient‘s circumstances (Taylor et al., 1984). A basic principle underlying use of randomized controlled trials is that of equipoise, the assumption that at the time of randomization, it is genuinely impossible to favor one treatment arm over the other (Weijer et al., 2000). Clearly, this does not apply in many instances. Nevertheless, a recent meta-analysis, comparing the outcomes of participants in randomized controlled trials and those of eligible nonparticipants found that participating in a randomized controlled trial did not lead to worse outcomes than being given the intervention of choice (Gross et al., 2006). Another creative proposal to manage this potential problem is to use equipoise-stratified randomization (Lavori et al., 2001).

4.4 Problems in Defining Appropriate and Robust Outcome Measures
In CL psychiatry as elsewhere, complex interventions are likely to have complex effects. Thus, for example, a cognitive therapy intervention for people recruited only because they had recent-onset rheumatoid arthritis initially led to a greater reduction in depressive symptoms than in the waiting list control group, but after longer follow-up, the intervention led to a significant reduction in pain and disability (Sharpe et al., 2003b). Similarly, there is substantial evidence that cognitive therapy improves symptoms of depression and anxiety in people with physical illness, as it does in those who are physically healthy. However, such interventions can have a wide range of additional benefits, including improvement in functioning, physical symptoms, and even biological markers of disease (Sensky, 2004). One way to attempt to identify the effects of complex interventions is to include multiple outcome measures in randomized controlled trials. These are more likely to capture the complexity of changes attributable to the intervention. However, this makes matching study groups at baseline much more difficult, particularly because, with complex interventions, funding and other resource constraints tend to limit recruitment to relatively modest sample sizes. Also, using multiple outcome measures goes against one of the key requirements of effectiveness studies, namely to have one or a small number of simple and clinically relevant outcome measures (Hotopf et al., 1999).

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4.5

Comparison Groups in Randomized Controlled Trials

In pharmacologic trials, the new medication can be compared with a placebo. With complex interventions, it is extremely difficult to design an effective placebo. This has important consequences particularly for concealment of randomization and for patient expectations. In essence, studies take one of three approaches, each of which has advantages and disadvantages. Comparing the experimental intervention with another model-based intervention might help to control for patient expectations, but it gives no information about how the new intervention compares with routine clinical care. Another option, suitable for psychological interventions, is to design the control intervention to have the same amount of therapy time (or, more particularly, therapist contact) as the experimental intervention. However, such interventions are very difficult to design, particularly given that, in getting proper informed consent to participate in such studies, patients are clearly aware of having been randomized to the control group. There is a considerable risk of increased patient attrition from the control group. This is probably more of a problem with this type of study design than with the third type of control group—routine clinical care. Again, with this design, patients know which group they are in, and thus it is not possible to control for patient expectations. In addition, comparisons with routine clinical care cannot alone yield results supporting the specific, model-based, effects of the intervention; if the experimental intervention is significantly better than the control, this could be attributable (in part or entirely) to nonspecific factors, such as therapist contact or patient expectations.

4.6

Problems with Concealment of Randomization

As already noted, it is very difficult to design studies of complex interventions, such as most of those in CL psychiatry, where the patient is unaware of the group to which he or she has been allocated. Theoretically, at least, this may be a fatal flaw in the design of some studies. In a study of 320 trials derived from meta-analyses from the Cochrane database, Schultz and colleagues (1995) found evidence that reported outcomes were significantly more favorable in those studies that showed inadequacies in randomization, compared with those where randomization was robust. On the other hand, in a more recent meta-analysis of interventions in cardiology, no significant differences were found in outcomes between observational studies and randomized controlled trials (Benson and Hartz, 2000). This indicates that the need for concealment of randomization is perhaps not quite as crucial as some have argued, although this particular study generated a critical editorial that suggested that selection bias might have operated in the papers included in the analysis (Pocock and Elbourne, 2000). Patient expectations are generally considered important and are likely to be very different in the experimental and control arms of randomized studies where concealment is impossible. In a well-known study of patient expectations (Tarrier and Main, 1986), a randomized controlled trial was conducted of applied relaxation for generalized anxiety. Half the patients in each treatment group were told that they should expect continuing benefit if they practiced relaxation regularly; the other half were told that benefits would be slow to become apparent. At outcome, the second group was significantly more anxious than the first. Expectations apply to

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those conducting the interventions as well as to patients. The relationship between patient and therapist has long been recognized as very influential in determining intervention outcomes (Luborsky et al., 1985), and this very likely related to patient and therapist expectations, as well as a multitude of other factors. Even if, in complex interventions in the CL psychiatry, it is impossible to conceal group allocation from either patient or therapist, there is usually the possibility of keeping the treatment group concealed from the clinicians involved in the patient‘s care, and from those assessing the patients. This is usually tested by comparing the actual group to which patients have been allocated with the group allocation ―guessed‖ by the clinician or researcher. Although such details are commonly reported in published studies, they are probably meaningless. In a study of a psychological intervention in rheumatoid arthritis, the assessor (from whom group allocation had been concealed) estimated the groups to which individual patients had been allocated no better than by chance (Sharpe et al., 2003a). However, those patients whom the assessor ―guessed‖ to be in the active intervention group were significantly more likely than those allocated to the control group to show improvements in the particular outcomes investigated in the study. This is hardly surprising; even if assessors are unaware of the group allocation, they are almost always familiar with the study hypotheses, and are therefore likely to infer that those patients who perform better on the study outcomes must have been in the experimental group.

4.7

Patient Preference Trials

One way to overcome some of these problems is to design intervention studies that incorporate patient preferences. In essence, patients expressing a preference for one or another of the treatment arms are allowed to have that intervention, and only patients who expressed no preference are randomized. A major limitation in applying patient preference trials in CL psychiatry is the fact that substantially larger numbers of patients are required than in conventional randomized controlled trials. Although one would expect that patients assigned to an intervention of their choice would have better outcomes than those as signed by randomization, a recent elegant meta-analysis by King and colleagues (2005) reported contrary results. Not only were there no significant differences in effect sizes of the outcome measures in the two types of study design, but patient attrition was also very similar when comparing randomized and patient-preference arms of studies.

4.8

Intervention Integrity

In randomized controlled trials of medications, it is relatively easy to standardize the interventions. Treatment integrity in more complex interventions is frequently modeled on that applicable to medication trials, but this is unlikely to be appropriate. For example, there is no equivalent in medication trials to therapist skill in more complex interventions. In addition, skill is not the same as competence. Complex interventions should be operationalised (that is, broken down into discrete, definable and measurable steps) and the actual interventions audited against these. However, this is hardly ever done. Where possible, interventions should be based on a treatment manual. While this might contribute to demonstrating that all patients treated have received

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similar (and, one hopes, equivalent) interventions, this does not necessarily mean that the interventions have been optimal in every case. It is likely that experienced and skilled therapists depart from the strict limits imposed by a treatment manual. One possible solution, which has hardly ever been applied, is to allocate patients to specific therapists stratified by clinical experience. In model-based psychotherapies, changes in the outcome measures are expected to occur in parallel with, or following, changes in mediating variables predicted by the model. For example, cognitive therapy is expected to lead to changes in cognitions. However, while this effect is helpful when it can be demonstrated, the absence of such a link between outcomes and predicted mechanisms does not imply that treatment integrity is questionable. In an early study comparing cognitive therapy and antidepressants in the treatment of depression, changes in cognitions in the antidepressant group paralleled those in the group treated with cognitive therapy (Simons et al., 1984). In clinical practice, one of the hallmarks of CL psychiatry is the complex context in which it is practiced. It is not only the relationship between patient and psychiatrist that is important, but also the relationships that each has with the other clinicians treating the patient. All these relationships are also important in research, but are difficult if not impossible either to control adequately (except in some tightly controlled efficacy studies) or to evaluate in a way that can be incorporated into study results.

4.9

Dealing with Missing Data

Results of efficacy studies can legitimately be based only on samples of patients who completed the intervention. However, because the results of effectiveness studies are intended to reflect what happens in clinical practice, they must take account of all the patients recruited into the study. Intention-to-treat analysis is sometimes taken to mean simply that patient results are analyzed in the group to which each patient was initially assigned. As this almost always happens in complex interventions, this becomes a trivial requirement. The other requirement of intention-to-treat analysis is that results include data from all patients, even those who left the study prematurely. In other words, missing data must somehow be modeled. It is not uncommon for studies claiming to have used intention-to-treat analysis to have neglected this requirement. In internal medicine, particularly in trials of medication, a common method of modeling missing data is to use the last observation carried forward (LOCF). For example, if a particular patient has outcome data for 12 weeks after the start of a study, but data are missing for the next time point at 16 weeks, the missing data are simply replaced by data from the last available time point (in this case, 12 weeks). While this might sometimes be appropriate in pharmacological interventions, it is very seldom appropriate to use in complex interventions, and not only may be grossly inaccurate, but also can even distort the results. For example, consider an intervention aiming to reduce chronic pain being tested against a control intervention in which the patient meets with someone to talk about the pain (to control for nonspecific therapist contact). As noted above, proper informed consent means that patients will always be aware that they are in the intervention group or control group. It would not be surprising if patients in the control group were more likely than those in the intervention group to withdraw

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from the study prematurely. In reality, pain is unlikely to remain constant but within any particular sample will probably be reduced. Such regression to the mean contributes to changes in both groups. However, if sample attrition is greater in the control group than in the intervention group, using LOCF exaggerates the difference between the two groups, thus making the effects of the intervention appear more substantial than they are. In reality, the rate and pattern of change varies among patients, and this must be taken into account when modeling missing data. Sophisticated data modeling techniques are available to cope with this, but appear to be relatively seldom used. Streiner (2002) has demonstrated the differing results of several methods of dealing with missing data.

4.10 The Role of Randomized Controlled Trails in Consultation-Liaison Psychiatry
The methodology of randomized controlled trials has been particularly well developed to manage pharmacologic studies. This chapter has highlighted a number of ways in which the complex interventions characteristic of CL psychiatry create difficulties in generating high-quality evidence from randomized controlled trials. It is worth noting that many of the difficulties highlighted are by no means specific to CL psychiatry. Most of the difficulties outlined above are equally applicable to developing the evidence base in surgery (McCulloch et al., 2002). Because conducting and interpreting randomized controlled trials in CL psychiatry is challenging, this is not a reason for the abandoning their pursuit. On the contrary, randomized controlled trials will continue to make an important contribution to developing the evidence base in CL psychiatry. Results from randomized controlled trials are still regarded as the main currency in justifying new service developments. However, as Salkovskis (2002) has argued, it is also important not to focus exclusively on evidence from randomized controlled trials, to the exclusion of other types of evidence. As noted above, when a medication is granted a product license, its indications and usage becomes proscribed. However, this is not the case for complex interventions. Although randomized controlled trials probably mark important milestones in the development of particular complex interventions, there is little expectation that such interventions will remain static, and indeed, by the time an intervention is ―mature‖ enough to justify one or more randomized controlled trials, it is very likely that it will have developed further by the time these trials have been published. References
Benson K, Hartz AJ. A comparison of observational studies and randomized, controlled trials. N Engl J Med 2000;342:1878–1886. Gross CP, Krumholz HM, Van Wye G, Emanuel EJ, Wendler D. Does random treatment assignment cause harm to research participants? PLoS Med 2006;3:e188. Guthrie E, Sensky T. Psychological interventions in patients with physical symptoms. In: Guthrie E, Lloyd G, eds. Textbook of Liaison Psychiatry. Cambridge: Cambridge University Press, 2007. Guyatt GH, Sackett DL, Cook DL. Users‘ guides to the medical literature. II. How to use an article about therapy or prevention. A. Are the results of the study valid? JAMA 1993;270:2598–2601. Hotopf M, Churchill R, Lewis G. Pragmatic randomised controlled trials in psychiatry. Br J Psychiatry 1999;175:217–223.

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T. Sensky King M, Nazareth I, Lampe F, et al. Impact of participant and physician intervention preferences on randomized trials: a systematic review. JAMA 2005;293:1089–1099. Lavori PW, Rush AJ, Wisniewski SR, et al. Strengthening clinical effectiveness trials: equipoise-stratified randomization. Biol Psychiatry 2001;50:792–801. Luborsky L, McLellan AT, Woody GE, O‘Brien CP, Auerbach A. Therapist success and its determinants. Arch Gen Psychiatry 1985;42:602–611. McCulloch P, Taylor I, Sasako M, Lovett B, Griffin D. Randomised trials in surgery: problems and possible solutions. Br Med J 2002;324:1448–1451. Persons JB, Silberschatz G. Are results of randomized controlled trials useful to psychotherapists? J Consult Clin Psychol 1998;66:126–135. Pocock SJ, Elbourne DR. Randomized trials or observational tribulations? N Engl J Med 2000;342:1907–1909. Ruddy R, House A. Meta-review of high-quality systematic reviews of interventions in key areas of liaison psychiatry. Br J Psychiatry 2005;187:109–120. Salkovskis PM. Empirically grounded clinical interventions: cognitive-behavioural therapy progresses through a multi-dimensional approach to clinical science. Behav Cogn Psychother 2002;30:3–9. Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 1995;273:408–412. Seligman ME. Science as an ally of practice. Am Psychol 1996;51:1072–1079. Sensky T. Cognitive therapy with medical patients. In: Wright J, ed. American Psychiatric Association Press Review of Psychiatry, vol 23(3). Washington, DC: American Psychiatric Publishing, 2004:83–121. Sensky T. The effectiveness of cognitive therapy for schizophrenia: what can we learn from the meta-analyses? Psychother Psychosom 2005;74:131–135. Sharpe L, Ryan B, Allard S, Sensky T. Testing for the integrity of blinding in clinical trials: how valid are forced choice paradigms? Psychother Psychosom 2003a;72:128–131. Sharpe L, Sensky T, Timberlake N, Ryan B, Allard S. Long-term efficacy of a cognitive behavioural treatment from a randomized controlled trial for patients recently diagnosed with rheumatoid arthritis. Rheumatology 2003b;42:435–441. Simons AD, Garfield SL, Murphy GE. The process of change in cognitive therapy and pharmacotherapy for depression. Arch General Psychiatry 1984;41:45–51. Streiner DL. The case of the missing data: methods of dealing with dropouts and other research vagaries. Can J Psychiatry 2002;47:68–75. Tarrier N, Main CJ. Applied relaxation training for generalised anxiety and panic attacks: the efficacy of a learnt coping strategy on subjective reports. Br J Psychiatry 1986;149:330–336. Taylor KM, Margolese RG, Soskolne CL. Physicians‘ reasons for not entering eligible patients in a randomized clinical trial of surgery for breast cancer. N Engl J Med 1984;310:1363–1367. Weijer C, Shapiro SH, Cranley GK. For and against: clinical equipoise and not the uncertainty principle is the moral underpinning of the randomised controlled trial. Br Med J 2000;321:756–758.

5
Common Reasons for Psychiatric Consultation
Hoyle Leigh
CONTENTS 5.1 Anxiety and Agitated Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 5.1.1 Situational Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 5.1.2 Psychiatric Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 5.1.3 Intoxication and Withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 5.1.4 Immediate Management of Agitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Altered States of Consciousness/Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Psychotic Symptoms: Delusions, Suspiciousness, Hallucinations, and Disturbances with Reality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Depressed Affect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Suicidal Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 5.5.1 Suicide Attempt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 5.5.2 Management of Suicide Attempt/Ideation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Suspected Psychogenic Physical Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 5.6.1 Evaluation of Suspected Psychogenic Symptom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Patient Behavior Generating Strong Feelings in Staff or Splitting Staff . . . . . . . . . . . . . . . . . . . . . . 46 Addiction and Pain Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

5.2 5.3 5.4 5.5

5.6 5.7 5.8

The most frequent emotions, behaviors, and symptoms that patients exhibit that draw the attention of the health care professional and result in a psychiatric consultation request are the following: 1. 2. 3. 4. 5. 6. 7. 8. Anxiety and agitated behavior Altered states of consciousness/delirium Psychotic symptoms Depressed affect Suicidal behavior Suspected psychogenic physical symptoms Patient behavior generating strong feelings in staff or splitting staff Addiction and pain problems

This chapter discusses the immediate evaluation of these common reasons for consultation request, their immediate management, and how to proceed from there.

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5.1

Anxiety and Agitated Behavior

Anxiety refers to an emotional state of dread and apprehension, with or without an easily identifiable stressful situation (see Chapter 8). Fear refers to anxiety specifically tied to an object or situation, for example, fear of hospitalization. A phobia is an irrational fear of a usually harmless object or situation, such as cats (ailurophobia) or open spaces (agoraphobia). Panic refers to the intense anxiety experienced when one finds oneself suddenly thrust into a severely feared or dangerous situation, for example, waking up in a room engulfed in fire. Autonomic (usually sympathetic) arousal is usually associated with anxiety spectrum syndromes. Thus, there is often tachycardia, increased blood pressure, rapid breathing, sweating, dry mouth, gastrointestinal disturbance (diarrhea or constipation), and urinary frequency. As a phenomenon, agitated behavior indicates increased restless motor activity, usually accompanied by hyperarousal and an internal sense of anxiety. When agitated behavior is accompanied with confusion, hallucinations, or delusions, delirium or psychosis should be suspected. 5.1.1 Situational Factors

Mild degrees of anxiety and agitation are commonly seen in stressful situations such as hospitalization and as a result of an internal psychological conflict. Such conflict may be conscious, as in feeling ambivalent about making a decision, or unconscious, as when some trigger awakens a repressed painful memory or an unconscious conflict. An example may be the approaching of the anniversary date of a significant loss. A common trigger for anxiety and agitation in the general hospital setting is inadequate communication between the patient and health care team, especially when patients feel they are not listened to or when they misunderstand the diagnosis and treatment. 5.1.2 Psychiatric Syndromes

Anxiety and agitation are common symptoms of psychosis including schizophrenia, schizoaffective disorder, delusional disorder, and others. They are also common in depression, in which patients may alternate between psychomotor agitation and retardation, as well as in bipolar disorders, both in the manic and the depressive phases. Anxiety disorders, including posttraumatic stress disorder, are usually accompanied by agitation during some phase of the illness. Certain personalities and personality disorders are prone to anxiety/agitation. Patents with a borderline personality may become anxious and agitated when they feel mistreated by staff, patients with an obsessive-compulsive personality are often agitated when the staff is not as exacting and orderly as they expect the staff to be, patients with a narcissistic personality may be particularly sensitive to any evidence of slight or lack of respect, and histrionic and dependent patients may be sensitive to any perceived lack of attention and caring. 5.1.3 Intoxication and Withdrawal

Intoxication and withdrawal from both prescribed and recreational drugs often cause anxiety, agitation, and delirium, as do various medical/surgical conditions. Thus, an important part of the diagnostic workup of severe anxiety

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and agitation is a urine and blood drug screen and blood levels of suspected substances including alcohol. Of particular importance in the consultation-liaison setting is patients who had been dependent on alcohol who find themselves acutely hospitalized. Such patients may develop delirium tremens within days of hospitalization unless a benzodiazepine detoxification schedule is implemented upon ascertaining the alcohol history (Table 5.1). 5.1.4 Immediate Management of Agitation

Acute agitation is often a medical-psychiatric emergency requiring immediate treatment to reduce the potential for harm both to the patient and to the staff. An acutely agitated patient may need to be physically restrained. If an intravenous (IV) line is not already in place, an intramuscular injection of haloperidol 1 to 2 mg may be given stat, and an additional lorazepam 1 to 2 mg IM may be needed. Once an IV line is in place, lorazepam 1 to 5 mg may be given for immediate management of agitation. At this point, the clinician should assess the patient‘s medical condition to determine whether there are risk factors for torsades de pointes due to haloperidol‘s QTc prolongation effect. The risk factors include female gender, cardiac disease, hypokalemia, concomitant medications that may prolong QT, and familial long QT syndrome (Justo et al., 2005). The major risk factor, however, is use of exceedingly high doses. There is rarely a problem when normal doses are used. If such risk factors are present, continuing use of lorazepam IV may be indicated (1 to 5 mg q 2–4 hours). Lorazepam, however, is highly likely to increase confusion in a medically ill patient who has

Table 5.1 Causes of Anxiety/Agitation
Symptom Anxiety/agitation Stress Stress identifiable Cause Acute stress/PTSD/adjustment Specific object/situation: phobia social anxiety, performance anxiety No specific object/situation Stress not identifiable Panic present: panic disorder No panic: generalized anxiety disorder Substances (side effect, intoxication, withdrawal) Prescribed Recreational Medical disease present R/o secondary to medical condition Another major psychiatric syndrome present (e.g. schizophrenia) Part of the psychiatric syndrome
PTSD, posttraumatic stress disorder.

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any degree of cognitive dysfunction (Breitbart et al., 1996) and may also depress respiration. In addition to lorazepam IV, immediately dissolving olanzapine (Zydis) 5 to 10 mg may be given if the patient is willing, or olanzapine 5 to 10 mg may be given IM, to be repeated every 2 to 4 hours up to 20 to 30 mg per day. If risk factors for torsades de pointes are not present, haloperidol 1 to 5 mg IV (depending on the degree of agitation and the size of the patient) every 1 to 4 hours may be needed until the patient is reasonably calm. Then, the patient may be given the effective dose of haloperidol every 4 to 6 hours. In severe agitation associated with delirium, large doses of haloperidol may be used without significant extrapyramidal side effects as long as it is given intravenously. At our center we have prescribed up to 130 mg of haloperidol IV in a 24-hour period, but we have found that a high dose of haloperidol prolongs delirium, which resolves when the drug is stopped. For most delirium, keeping the dose low, in the range of 1 to 6 mg per day, leads to rapid improvement if medical causes of the delirium are not ongoing. Haloperidol IV at high doses, however, may lower the seizure threshold and may also cause QT prolongation in some patients, and if other risk factors are present, it may lead to torsades de pointes. Electrocardiogram monitoring should be done on high-dose IV haloperidol patients. In contrast to IV, oral and IM doses of haloperidol exceeding 1 to 2 mg may be associated with extrapyramidal side effects, requiring the use of benztropine or diphenhydramine. If the patient is willing to take oral medication, immediately dissolving forms of second-generation psychotics may gradually be substituted for IV haloperidol, for example, Zyprexa Zydis 5 or 10 mg po hs, plus IV haloperidol 1 to 2 mg q 4 hours prn for agitation. Lorazepam 1 to 2 mg IV may be added to the haloperidol if the patient is so agitated that inducing sleep might be desirable, but in patients with delirium and dementia, benzodiazepines may cause paradoxical agitation due to suppression of the frontal lobe function and are well known to increase cognitive dysfunction (Kraemer et al. 1999). If the presumptive reason for the agitation is alcohol withdrawal, lorazepam (intermittent lorazepam may increase the chances of developing delirium tremens; see Chapter 7) rather than haloperidol may be used, followed by instituting an alcohol withdrawal schedule using an oral benzodiazepine (e.g., oxazepam, temazepam, or chlordiazepoxide). If the presumptive underlying cause is phencyclidine (PCP) intoxication, haloperidol and phenothiazines should be avoided and the agitation should be controlled with lorazepam. Psychologically, the staff should approach a delirious patient calmly, and avoid any behaviors that might be interpreted as being threatening, including standing or sitting too close to the patient. The patient should be oriented each time the staff approaches, for example, ―I am your nurse, Susan, and you are in University Hospital. I am here to take your temperature and give you an injection for your infection.‖ Agitated patients should be in a quiet room if possible, and there should be someone to observe the patient at all times.

5.2

Altered States of Consciousness / Delirium

Clouding of consciousness is characterized by impaired ability to think clearly and to perceive, respond to, and remember stimuli. Delirium is a state of disturbed and fluctuating consciousness with psychomotor changes, usually

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restlessness or drowsiness, and transient psychotic symptoms. Obtundation is a state in which patients are awake but not alert and exhibit psychomotor retardation. Stupor is the state in which the patient, although conscious, exhibits little or no spontaneous activity. Stuporous patients may be awakened with stimuli but have little motor or verbal activity once aroused. Coma is the state of unarousable unresponsiveness. A comatose patient does not exhibit purposeful movements. In light coma, patients may respond to noxious stimuli reflexively, but in deep coma, there is no response even to strongly noxious stimuli. The Glasgow Coma Scale (GCS) is commonly used in identifying the degree of impairment. A GCS score of 8 or below indicates coma (see Appendix at end of chapter). Psychiatric consultation is often requested to evaluate altered mental states (AMSs). As comatose and stuporous patients do not respond verbally, the immediate approach to such patients is to recognize and treat the underlying medical condition, and to provide physical protection and supportive measures. When the patient presents with delirium or improves to a delirious state, the psychiatric consultant may be of great service in evaluating and managing the condition (see Chapter 7).

5.3 Psychotic Symptoms: Delusions, Suspiciousness, Hallucinations, and Disturbances with Reality
Delusion refers to an irrational and persistent conviction or belief that is not shared by the community. Delusions may be, among others, persecutory, grandiose, pessimistic, simple, complex, or bizarre. Delusions or excessive suspiciousness may be symptoms of psychosis, delirium, dementia, or personality disorders. Hallucination refers to an internally generated perception, that is, a perception without external sensory input. Hallucinations may be visual, auditory, tactile, olfactory, gustatory, or kinesthetic. Visual hallucinations, especially in the absence of auditory hallucinations, should be considered to be organic (delirium, dementia, substance-induced, secondary to a medical disease including neurologic disease, such as Charles Bonnet syndrome) unless organic causes are completely ruled out. Auditory hallucinations of voices coming from outside the head, two voices conversing with each other, giving a running commentary on the patient, or giving orders to patients (command hallucinations) are more likely to be symptoms of schizophrenia. Olfactory and gustatory hallucinations are often associated with the aura of seizure disorder, and tactile and kinesthetic hallucinations may be associated with substance use (e.g., cocaine bug). Illusions, in contrast with delusions, refer to misidentifying sensory input, for example, seeing a gallows instead of an intravenous pole. Illusions are common in delirium. Derealization, where reality does not feel real, and depersonalization, where the person does not feel real, are dissociative symptoms that may be normal under stressful conditions, substance-induced, part of borderline personality syndrome, posttraumatic stress disorder (PTSD), or psychosis. In general, any of the psychotic symptoms above calls for the ruling out of delirium, drug intoxication/withdrawal states (including prescribed medications), and medical conditions causing psychiatric symptoms (see Table 7.1 in Chapter 7). See Chapter 10 for further discussion of psychosis.

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5.4

Depressed Affect

Depressed affect refers to subjective feelings of sadness, feeling blue, feeling like crying, or being ―down in the dumps,‖ which may be accompanied by a sad expression, tearfulness, and either psychomotor retardation or psychomotor agitation. When such feelings persist and are accompanied by physiologic signs such as sleep disturbance (insomnia or hypersomnia), anorexia, fatigue, constipation, loss of libido, cognitive symptoms such as inability to concentrate or memory disturbance, low self-esteem, guilt feelings, hopelessness, helplessness, and suicidal ideations, then the depressive syndrome should be suspected, for which definitive treatment may be imperative (see Chapter 9).

5.5

Suicidal Behavior

A common reason for psychiatric consultation is suicidal behavior—either suicidal ideation or suicidal attempt. Suicidal ideation refers to thoughts about suicide that a patient expresses spontaneously or upon questioning. Such thoughts may be active (―I want to kill myself ‖) or passive (―I wish I were dead,‖ ―I wouldn‘t mind if I died‖), and may be vague thoughts or actual plans. Approximately 3% of the general population has suicidal ideation each year, and about 0.4% attempt suicide. About 20% to 30% of people who have suicidal ideation make plans, and about 30% of those who plan make a suicide attempt (Kessler et al., 2005). Actual plans usually require an immediate involuntary psychiatric hospitalization (see Management of Suicide Attempt/Ideation, below). The underlying, potentially treatable psychiatric conditions should be evaluated as discussed below (see Evaluation of the Attempt, below). 5.5.1 Suicide Attempt

Psychiatric consultation is often automatic in patients admitted because of a suicide attempt. The mode of attempt may range from a mild overdose (e.g., 10 aspirin tablets) to stabbing or gunshot. An immediate consideration in evaluating a suicide attempt is whether the patient is able to provide information or is delirious or comatose. If the patient has an altered state of consciousness, treatment and management of that condition takes first priority. Collateral information from relatives, friends, or a suicide note may be invaluable in determining the patient‘s preattempt state of mind, seriousness of intent, and stressors. Unless the consultant is convinced that the patient is no longer suicidal, postattempt patients should be placed on suicide precautions, which would include close observation by a sitter. An emergency involuntary hold may be necessary if the patient is unwilling to stay in the hospital for necessary treatment. 5.5.1.1 Evaluation of the Attempt

1. Demographics of the patient a. Single, divorced, widowed, or living alone are risk factors. b. Caucasian, older males are more at risk of completed suicide, and females are at higher risk of a suicide attempt. c. Are there supportive persons—significant others, relatives, friends, community, church?

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2.

3.

4.

5.

d. Are there ethnic/cultural factors in the suicide attempt (e.g., social alienation, ostracism, shame)? Seriousness of attempt a. How lethal was the mode? Gunshot, stabbing, hanging, and drowning are in general more serious than a drug overdose, but even in an overdose, taking a whole bottle of pills (empty bottle found nearby) is more serious than taking half or less. A bizarre mode points to a psychotic diagnosis (e.g., setting fire to self, drinking Drano). b. What was the likelihood of help from others? Was the patient alone? Did the patient inform anyone about the attempt? Where was the attempt made? When was it made? c. What did the patient have in mind—to die or to escape? What ideas did the patient have about what would happen after he/she died? Is there a psychotic quality, for example, delusional or bizarre quality to the ideas, or any evidence of hallucinations, for example, commanding voices (which may point to a diagnosis)? Did the patient wish to be relieved of physical pain (more serious)? d. Was it planned? If so, how long, how thoroughly? Was there an obsessivecompulsive quality (more serious)? Medical and psychiatric history of the patient a. Presence of a chronic (especially painful) medical condition (increases risk) b. Past history of suicide attempt (increases risk, also helpful in diagnosis) c. History of psychiatric illness, especially depression, mania, psychosis, schizophrenia, substance use including alcohol, PTSD, anxiety and panic, borderline personality, antisocial personality Family history a. Any psychiatric disorder, especially bipolar disorder, depression, schizophrenia? b. Any suicide? Current Mental State

5.5.1.2 Determination of Underlying Condition On the basis of the evaluation of the above factors, the consultant should be able to determine tentatively the underlying condition(s) for the suicidal behavior/ideation. It should be recognized that suicide per se is not a psychiatric condition; however, it is often associated with underlying psychiatric conditions that may be amenable to treatment (Table 5.2). 5.5.1.2.1 Situational Precipitating Factors: These factors include interpersonal/family conflict, occupational stress, occupational loss or failure, anomie, and altruistic motive. Anomie, first described by the French sociologist, Table 5.2 Lifetime mortality from suicide in discharged hospital patients
Bipolar disorder Unipolar depression Schizophrenia Alcoholism Borderline personality Antisocial personality
From Mann, 2002.

20% 15% 10% 18% 10% 10%

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Emile Durkheim, refers to a sense of loss of definition when something that provided an anchor or purpose in life has disappeared, either through successful attainment (e.g., passing an examination) or loss (e.g., someone the patient cared for, or a cause with which the patient was passionately involved). An example of an altruistic motive might be an elderly person contemplating suicide so as not to be a burden to his family. A situation of special concern is a patient with a serious medical condition, such as Alzheimer‘s disease or Huntington‘s disease, who may choose suicide. If situational factors are present, they should be carefully evaluated. How are the factors affected by the suicide attempt? Are they resolved, the same, or worse? What are the possible avenues of resolution? 5.5.1.2.2 Intoxication and Altered State of Consciousness: Such states increase the impulsiveness and acting out behavior, and up to 50% of successful suicides are intoxicated at the time of death (Moscicki, 2001). 5.5.1.2.3 Depressive Syndrome: Depressive syndrome is suspected when depressive affect (sadness, feeling blue or down in the dumps) or, in more severe cases, apathy is associated with other symptoms, such as sleep disturbance, anhedonia, inability to concentrate, anorexia or overeating, guilt feelings, recurring suicidal ideation, hopelessness, helplessness, lowered self-esteem, and social withdrawal, especially if there is a history of previous such episodes or a family history of depression (see Chapter 9). If a depressive syndrome has been diagnosed, one has to determine whether it is unipolar or bipolar. A history of manic or hypomanic symptoms in the absence of substance use, including feeling full of energy and not needing sleep for nights, feeling ―on top of the world,‖ getting involved in many projects at once, and going on spending sprees, point to bipolar illness, as well as atypical depression (hypersomnia, eating more). Suicidality may come without any prodrome in bipolar illness and may be extremely severe. A family history of bipolar illness and suicide should increase the index of suspicion for bipolar illness. 5.5.1.3 Psychosis When suicidal behavior is particularly bizarre, or accompanied by psychotic symptoms (see above), then psychosis may be suspected as an underlying condition (see Chapter 10). Examples of bizarre suicidal behavior include embracing a hot stove or setting oneself on fire. 5.5.1.4 Borderline Syndrome or Borderline Personality Disorder Borderline personality patients show a pattern of stormy interpersonal relationships and a tendency to see others as all good or all bad, which assessment may change suddenly without apparent reason, often accompanied by substance abuse problems, feelings of emptiness, and previous suicide attempts and self-cutting behavior. Sometimes the cutting behavior of borderline patients is not with the intention of dying, but rather to relieve tension (see Chapter 15). At least 75% of patients with borderline personality engage in suicidal behaviors, particularly, wrist cutting and overdose of medications. About 10% eventually commit suicide, representing up to one third of completed suicides (Black et al., 2004; Pompili et al., 2004). Borderline patients who also have major depression, substance abuse, and previous history of suicide attempts are at particular risk for suicide.

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Table 5.3 Psychiatric disorders in suicide attempters
Disorder All disorders Axis I disorders Anxiety disorders Affective disorders Major depression Bipolar disorder Alcohol abuse Other drugs Stress-related and somatoform disorders Eating disorders Schizophrenia and nonaffective psychosis Impulse control disorder including conduct disorder Axis II disorders Anxious Anancastic (obsessive-compulsive) Paranoid Histrionic Dependent Emotionally unstable Dissocial Schizoid Borderline Axis III disorders (medical disease) Axis IV. major stressors 70–74 60–74 40 20–30 20–45 4–15 26 13 5 5–33 46 21 19 15 13 13 11 5 5 55 45 62 Percent 90

Data from Hawton et al., 2003; Maris et al., 2002; Soderberg, 2001; Persson et al., 1999.

5.5.2

Management of Suicide Attempt/Ideation

Managing a patient with suicide attempt/ideation involves two considerations: (1) determination of the need for immediate measures to protect the patient, and (2) treatment/resolution of the underlying condition. If the patient is considered to be actively suicidal, he or she may need constant observation and psychiatric hospitalization when medically stabilized, under involuntary emergency certificate if necessary. Treatment of the underlying conditions, in such cases, would be implemented in the psychiatric inpatient setting. If the patient is not actively suicidal, then treatment of the underlying conditions should be planned, either on an outpatient or inpatient basis, depending on the severity of the underlying condition and the availability of resources (Table 5.3).

5.6

Suspected Psychogenic Physical Symptoms

Psychiatric consultation may be requested when a patient‘s physical symptoms are suspected of being psychogenic. Such suspicions are aroused when no organic pathology underlying the symptoms is found, or when the symptoms are

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considered to be out of proportion to the pathology. When the symptoms involve the somatosensory nervous system, such as blindness, aphonia, ―glovelike‖ anesthesia, convulsions, or paralysis of a limb, conversion disorder is suspected. When the symptom is primarily pain, chronic pain syndrome is suspected. When the patient is preoccupied with symptoms that might point to a disease, for example, heart disease, hypochondriasis may be suspected. Since Slater‘s (1965) landmark 10-year follow-up study of patients diagnosed with hysteria in which over 50% were found to have clear neurologic or psychiatric conditions, it is generally recognized that a large percentage of patients diagnosed with conversion or psychogenic physical symptoms have serious neurologic or psychiatric illnesses (more recent studies suggest 5% to 25%, perhaps as a result of better medical workup), and that many such patients, even in the absence of serious illness, have persisting functional impairment. 5.6.1 Evaluation of Suspected Psychogenic Symptom

A thorough medical and neurologic workup including laboratory testing and imaging studies is a must. Especially of note is that multiple sclerosis is the most common neurologic condition misdiagnosed as conversion disorder. Many physical symptoms that may have an organic basis may be exaggerated or precipitated by psychological factors (―psychological overlay‖). Stresses, interpersonal relationships, and psychological conflicts may contribute to the amplitude of distress associated with a physical symptom. Thus, whether or not tissue pathology is present, a careful psychiatric examination is also warranted to identify environmental stressors, interpersonal relationships, personality style and psychological conflicts, as well as the patient‘s relationship with the health care system. Specialized techniques such as hypnosis and lorazepam interview may be conducted to further elucidate unconscious factors that may underlie the symptom. The following is an algorithmic approach for further evaluation: 5.6.1.1 Suspected Psychogenic Symptom After Complete Medical / Neurologic Workup 1. 2. 3. 4. 5. One or several somatosensory symptoms: conversion syndrome Many symptoms in many organ systems: somatization syndrome Chronic pain disproportionate to tissue pathology: chronic pain syndrome Preoccupation with a disease: hypochondriasis Preoccupation with a body part: body dysmorphic syndrome

5.7 Patient Behavior Generating Strong Feelings in Staff or Splitting Staff
The consultation request arising for this reason is often not explicit, or may sound like something else entirely, for example, ―Pt refuses meds; please evaluate‖ or ―Pt disruptive; please evaluate.‖ It is only when the consultant actually speaks with the requesting physician that the reason becomes clearer. The physician may indicate that the patient is difficult, refuses to have a particular nurse attend to him/her, or is inconsistent in complying with simple requests such as allowing blood to be drawn. One finds that the staff members taking care of the patient are often divided; some are more sympathetic to the patient while others

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are angry with the patient. Such patients are often seen by staff to be demanding, entitled, and unstable. The consultant may notice nonverbal cues from the consultee that he/she dislikes the patient. The most important consideration in dealing with such patients is that the goal of psychiatric consultation is to allow optimal medical care. Patients with this type of behavior and problems often have borderline personality disorder or traits (see Chapter 15). Though others see such patients as being unstable, for the patients it is others and the external world that is inconsistent and constantly changing. For the patients, people whom they believed loved them suddenly turn against them and behave hatefully. Such patients also have the predisposition to see neutral reality as being hostile. Educating the staff that the patient has a personality trait/disorder that cannot be resolved during an acute medical hospitalization is an important first step. An even-handed, objective, explicit, and firm expectations agreed upon by everyone concerned can be helpful.

5.8

Addiction and Pain Problems

Patients who are suspected of having chronic pain (see Chapter 11) and addiction to pain/prescription drugs (see Chapter 12) often generate frequent consultation requests, especially if the referring physicians believe the psychiatric consultant is skilled in these areas.

Appendix: Glasgow Coma Scale (GCS)
The GCS results in a score between 3 and 15, with 3 being the worst and 15 the best. It is composed of three parameters—best eye response, best verbal response, best motor response—as given below: Best eye response (1 to 4) 1. 2. 3. 4. No eye opening Eye opening to pain Eye opening to verbal command Eyes open spontaneously

Best verbal response (1 to 5) 1. 2. 3. 4. 5. No verbal response Incomprehensible sounds Inappropriate words Confused Orientated

Best motor response (1 to 6) 1. 2. 3. 4. 5. 6. No motor response Extension to pain Flexion to pain Withdrawal from pain Localizing pain Obeys commands

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Note that the phrase ―GCS of 11‖ is essentially meaningless, and it is important to break the figure down into its three components, such as ―E3V3M5 = GCS 11.‖ A GCS of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate injury, and 8 or less a severe brain injury. (From Teasdale G, Jennett B, Murray L, Murray G. Glasgow coma scale: to sum or not to sum. Lancet 1983 Sep 17;2(8351):678, and available at http://www.trauma.org/scores/gcs.html). References
Black DW, Blum N, Pfohl B, Hale N. Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention. J Personal Disord 2004; 18(3):226–239. Breitbart W, Marotta R, Platt MM, et al. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiatry 1996;153:231–237. Justo D, Prokhorov V, Heller K, Zeltser D. Torsade de pointes induced by psychotropic drugs and the prevalence of its risk factors. Acta Psychiatr Scand 2005 Mar; 111(3):171–6. Kraemer KL, Conigliaro J, Saitz R. Managing alcohol withdrawal in the elderly. Drugs Aging 1999;14:409–425. Moscicki E. Epidemiology of Suicide. In: Goldsmith S, ed: Risk Factors for Suicide. Washington, DC: National Academy Press, 2001:1–4. Pompili M, Amadeo R, Paolo G, Tatareli R. Suicidality in DSM IV cluster B personality disorders. Ann Ist Super Sanità 2004;40(4):475–483. Slater E. Diagnosis of hysteria. Br Med J 1965;1:1395–1399.

Bibliography
Bostwick JM, Pankratz VS. Affective disorders and suicide risk: a reexamination. Am J Psychiatry 2000;157:1925–1932. Crimlisk HL, Bhatia K, Cope H, David A, Marsden CD, Ron MA. Slater revisited: 6 year follow up study of patients with medically unexplained motor symptoms. BMJ 1998;316(7131):582–586. Couprie W, Widjdicks EFM, van Gijn Rooijmans J. Outcome in conversion disorder: a follow up study. J Neurol Neurosurg Psychiatry 1995;58:750–752. Frances A, Fyer M, Clarkin J. Personality and suicide. Ann N Y Acad Sci 1986;487:281–293. Gatfield PD, Guze SBG. Prognosis and differential diagnosis of conversion reactions. Dis Nerv System 1962;23:623–631. Hawton K, Houston K, Haw C, Townsend E, Harriss L. Comorbidity of Axis I and Axis II disorders in patients who attempted suicide. Am J Psychiatry 2003;160(8):1494–1500. Jamison KR. Suicide and bipolar disorders. Ann N Y Acad Sci 1986;487:301–315. Johns CA, Stanley M, Stanley B. Suicide in schizophrenia. Ann N Y Acad Sci 1986;487:294–300. Kessler RC, Berglund P, Borges G, Nock M, Wang PS. Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990–1992 to 2001–2003. JAMA 2005;293:2487–2495. Mace CJ, Trimble MR. ―Hysteria,‖ ―functional‖ or ―psychogenic‖? A survey of British neurologists‘ preferences. J R Soc Med 1991;84:471–475. Mace CJ, Trimble MR. Ten year prognosis of conversion disorder. Br J Psychiatry 1996;169:282–288. Mann JJ. A current perspective of suicide and attempted suicide. Ann Intern Med 2002 Feb 19;136(4):302–11. Maris RW. Suicide. Lancet 2002;360:319–326.

Chapter 5 Common Reasons for Psychiatric Consultation Marttunen MJ, Aro HM, Henriksson MM, Lonnqvist JK. Mental disorders in adolescent suicide. DSM-III-R axes I and II diagnoses in suicides among 13- to 19-year-olds in Finland. Arch Gen Psychiatry 1991;48:834–839. Murphy GE, Wetzel RD. The lifetime risk of suicide in alcoholism. Arch Gen Psychiatry 1990;47:383–392. Paris J. Chronic suicidality among patients with borderline personality disorder [review]. Psychiatr Serv 2002;53(6):738–742. Paris J, Zweig-Frank H. A 27–year follow-up of patients with borderline personality disorder. Compr Psychiatry 2001;42:482–487. Persson ML, Runeson BS, Wasserman D. Diagnoses, psychosocial stressors and adaptive functioning in attempted suicide. Ann Clin Psychiatry 1999;11(3):119–128. Raskin M, Talbott JA, Meyerson AT. Diagnosed conversion reactions: predicative value of psychiatric criteria. JAMA 1966;197:530–534. Roy A, Lamparski D, DeJong J, Moore V, Linnoila M. Characteristics of alcoholics who attempt suicide. Am J Psychiatry 1990;147:761–765. Roy A, Linnoila M. Alcoholism and suicide. Suicide Life Threat Behav 1986;16:244–273. Slater E, Glithero E. A follow up of patients diagnosed as suffering from ―hysteria.‖ J Psychosom Res 1965;9:9–13. Soderberg S. Personality disorders in parasuicide. Nord J Psychiatry 2001;55(3):163–167. Stephansson JG, Messina JA, Meyerowitz S. Hysterical neurosis, conversion type: clinical and epidemiological considerations. Acta Psychiatr Scand 1976;53:119–138. Watson CG, Buranen C. The frequency and identification of false positive conversion reactions. J Nerv Ment Dis 1979;167:243–247.

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Psychiatric Syndromes in Consultation-Liaison Psychiatry

6
Basic Foundations of Diagnosis, Psychiatric Diagnosis and Final Common Pathway Syndromes
Hoyle Leigh
CONTENTS 6.1 6.2 Diagnosis, Multiaxial Diagnosis, and Levels of Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 6.1.1 Levels of Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Psychiatric Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 6.2.1 Characteristics of Psychiatric Syndromes: Extremes of Adaptive Normal Traits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 6.2.2 Brain Areas and Circuits in Normal Emotions and Cognition . . . . . . . . . . . . . . . . . . . . . . . 56 6.2.3 Neurotransmitters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 6.2.4 The Brain in Psychiatric Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 6.2.5 Final Common Pathways: Genes, Stress, Brain Function and Psychiatric Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Final Common Pathway Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 6.3.1 Psychiatric Syndromes as Final Common Pathway Phenomena . . . . . . . . . . . . . . . . . . . . . . 67 6.3.2 Evaluation of Final Common Pathway Psychiatric Syndromes . . . . . . . . . . . . . . . . . . . . . . 67 6.3.3 Management of Final Common Pathway Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

6.3

This chapter discusses the basic theoretical and neuroscience foundations of psychiatric syndromes and the diagnostic process. These foundations help in understanding the application of psychiatric diagnosis in the consultationliaison setting.

6.1

Diagnosis, Multiaxial Diagnosis, and Levels of Diagnosis

The word diagnosis derives from the Greek prefix dia, meaning across, apart, or through, and the Greek word gnosis, meaning knowing. Diagnosis, a thorough (through and through) knowing of the patient‘s illness, including knowing it apart from other possibilities (differential diagnosis), is the essential first step in all medical intervention including psychiatric consultation. When a psychiatric consultation is requested from our nonpsychiatric colleagues, one or more medical diagnoses is probably at least suspected or being evaluated. The psychiatric consultant is then expected to consider possible psychiatric diagnoses

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and to integrate an understanding of the patient from the psychiatric, medical, and psychosocial dimensions in making a recommendation. The multiaxial diagnostic scheme of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994) is useful in recognizing the possible coexistence and interaction between medical and psychiatric diagnoses, and the interaction of the personality, stress, and social functioning with the illness. The multiaxial diagnostic scheme, in brief, is as follows: Axis I: major psychiatric disorders, such as schizophrenia, major depression, anxiety disorders, including psychiatric syndromes caused by medical diseases, e.g., delirium Axis II: personality disorders or traits (e.g., borderline personality) or developmental disorders (e.g., mental retardation) Axis III: medical diseases and conditions, e.g., diabetes mellitus, renal failure, status postappendectomy Axis IV: psychosocial and environmental stressors and problems, e.g., divorce, trouble at work, lack of health care, unemployment Axis V: Global Assessment of Function (GAF, a 0 to 100 scale, with 0 meaning not able to assess, 10 meaning very severely impaired, and 100 indicating perfect functioning) Usually the consultant uses a cutoff of 50 on the GAF to determine the need for psychiatric hospitalization; that is, if a patient scores less than 50, there is a need for a protected setting for the patient, for example, psychiatric hospitalization. The DSM-IV diagnostic scheme has many problems. As it is based on research diagnostic criteria (Feighner et al., 1972) and is designed to obtain a ―pure culture‖ for biologic research, the diagnoses are categorical and mutually exclusive, even though many psychiatric syndromes represent extremes of gradations of symptoms, many of which overlap and coexist. This overlap is not surprising, as the same susceptibility genes may have different phenotypic expressions depending on early experience and stress (See Final Common Pathways, below). Furthermore, there is a continuum of experiences and moods from normality to repeated distress, not quite reaching the criteria for the disorders of frank major psychiatric syndromes. Especially in consultation-liaison settings, patients often experience anxiety and depression associated with both medical conditions and the stress of hospitalization. The term disorder, adopted by DSM-III/IV, is also problematic as it is a vague and pejorative term not commonly used in medicine. ―Syndrome‖ is a better designation widely used in medicine, which term may be substituted for ―disorder‖. Axis II does not include personality characteristics, personality assets, and coping styles that might be important especially in consultation-liaison settings. In my opinion, in a future edition of the DSM there should be an axis that records the genes and changes in brain morphology and function that may underlie or contribute to Axis I diagnosis. Axis IV should also include not just recent stressors but, more importantly, the childhood stressors that may have influenced the brain‘s susceptibility to later stress, and that may have influenced the person‘s mood and behavior. There should be an axis that records the patient‘s psychosocial support. Axis V GAF should consider a longer period than 1 year, perhaps 5 years, to assess the longitudinal change in function. Perhaps there should be a radical reconceptualization of the axes for DSM-V.

Chapter 6 Basic Foundations of Psychiatric Diagnosis

55

I find the following modification of the DSM to be useful in consultationliaison psychiatry: Axis I: psychiatric syndromes and symptoms, e.g., depressive syndrome, psychosis, depression associated with serious diagnosis, anxiety concerning prognosis Axis II: personality traits and styles (e.g., impulsive, intellectualizing, brooding) and syndromes and developmental problems, e.g., borderline personality, obsessive traits, mental retardation Axis III: general medical conditions and neuropsychiatric disease, e.g., diabetes mellitus, tertiary syphilis Axis IV: early (childhood), recent, and current stressors Axis V: psychosocial assets such as social support (e.g., supportive spouse), personality assets (e.g., intelligence, coping skills), and GAF—both recent (for the last 5 years) and current. 6.1.1 Levels of Diagnosis

Thorough knowledge of a patient‘s illness involves knowing (1) the patient as a person, who has a personal history that determined his or her way of perceiving the self and the outer world, and habitual ways of coping; (2) the illness, which is a result of the interaction between the patient and the effects of disease, for example, pain, discomfort, anxiety, and its treatment, including drugs, procedures, and laboratory tests; and (3) the patient in interaction with the social and physical environment, including the health care personnel, family, and the hospital setting. Thus, in addition to the five axes cited, one has to also consider who the patient is, what the support systems are, and the nature of the biologic problems that may affect the patient‘s physical and psychological condition. Historically, medical diagnosis evolved from the naming of symptoms (e.g., fever), to a syndromic diagnosis based on a cluster of symptoms and signs that might indicate a common pathology (e.g., grippe: influenza; dropsy: glomerulonephritis and congestive heart failure, a term still in use), to the current etiologic diagnosis, that relies heavily on laboratory findings. Etiologic diagnosis is based on the biologic abnormality that is a necessary condition for the development of the syndrome. Psychiatric diagnosis, on the other hand, has not yet evolved beyond the syndromic stage. Axis I and II diagnoses, with a few exceptions, are based on clusters of symptoms and signs.

6.2

Psychiatric Syndromes

6.2.1 Characteristics of Psychiatric Syndromes: Extremes of Adaptive Normal Traits Most major psychiatric illnesses are chronic conditions and tend to run in families. This seems to indicate that heredity plays an important role. Yet most psychiatric syndromes consist of symptoms that represent extremes of normal human experiences, such as anxiety, depression, and euphoria. These emotions clearly have evolutionarily adaptive value. Imagine a person who congenitally lacks anxiety, sadness, or pleasure. Survival itself from early childhood, let alone socialization and procreation (and therefore empathy), would be seriously in doubt for such a person!

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Many psychiatric conditions are precipitated or exacerbated by stressful events. Once a psychiatric syndrome develops, it often has a course of its own, and is not easily reversible without psychiatric intervention. Taken together, these characteristics indicate that (1) many of the genes that confer susceptibility for psychiatric syndromes probably also subserve normal emotional and cognitive functions, and (2) psychological stress and early environment are important in the eventual precipitation of the illness. A genetic model that might explain this is the cliff-edged fitness model (Nesse, 2004), in which fitness increases as a trait (or its alleles) increases, and then at a certain point it crashes. An example might be one‘s ability to be sensitive to others‘ feelings in social interactions, until it reaches the point of sensing the least amounts of rejection or hostility, leading to anxiety and depression. Some individuals with a very low anxiety threshold might have the equivalent of a highly sensitive smoke-detector alarm that would be a nuisance in normal neighborhoods but might be lifesaving in a fire-prone environment. Some individuals may have inherited such sensitivity genes, which at one time had a great evolutionary advantage. Another example might be the ability to think about and understand others‘ needs and motivations, until it reaches the level where every word or act of another person attains great significance and ulterior motives— that is, paranoia. There is a continuum of emotional and cognitive experiences from normality to abnormality, with repeated abnormal experiences not quite reaching the diagnostic criteria for major syndromes. The subsyndromal personality traits, such as neuroticism (Eysenck, 1990), may predispose an individual to a major syndrome under stress (see Serotonin Transporter Gene, Anxiety, Depression, and Neuroticism, below). 6.2.2 Brain Areas and Circuits in Normal Emotions and Cognition

There are important brain structures and circuits involved in emotions and cognition, the dysfunctions of which may underlie psychiatric symptoms and syndromes. The Web site http://www.thebrain.mcgill.ca/flash/index_i.html has excellent diagrams to use in following the descriptions below. 6.2.2.1 Mood, Emotions, Pleasure, and Sadness How do we experience mood and emotions? Activations of certain areas of the brain seem to be associated with the subjective experience of emotions and are responsible for the patterns of behavioral/muscular activations we call emotional expression, and for the autonomic and endocrine arousal that accompany emotions (Figs. 6.1 and 6.2). The emotion of pleasure and reward seems associated with the dopaminergic activation of a circuitous pathway, first involving a descending medial forebrain bundle component and then involving the ascending mesolimbic ventral tegmental pathway (Bozarth, 1987; Wise and Bozarth, 1984), eventually activating the dopaminergic nucleus accumbens. The septum, the amygdala, the ventromedial prefrontal cortex, and certain parts of the thalamus also participate in the circuit. The ventromedial prefrontal cortex, with its extensive connections with the limbic system, may link the conscious to the unconscious and ascribe meaning to perceptions by associating them with a meaningful whole. The ventral tegmental pathway can also be activated by various substances including alcohol, amphetamines, exogenous and endogenous opiates, barbiturates, caffeine, marijuana, and nicotine.

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