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Approach to Psychiatric Consultations in the General Hospital
This chapter provides a practical approach to the assessment of affective, behavioral, and cognitive problems of patients in the general hospital. We first survey the landscape of consultation psychiatry and then identify six broad domains of psychiatric problems commonly encountered in the medical setting. Next, we describe the differences in clinical approach, environment, interactive style, and use of language that distinguish psychiatry in the general hospital from practice in other venues. Then we offer a step-by-step guide to the conduct of a psychiatric consultation. The chapter concludes with a review of treatment principles critical to caring for the medically ill. Throughout this chapter, we emphasize the hallmarks of competence identified by Cassem more than three decades ago: accountability, commitment, industry, and discipline.
Categories of Psychiatric Differential Diagnosis in the General Hospital
The borderland between psychiatry and medicine, in which consultation psychiatrists ply their trade can be visualized as the area shared by two intersecting circles in a Venn diagram ( Figure 2-1 ). As depicted in the figure and consistent with the fundamental tenet of psychosomatic medicine (i.e., that mind and body are indivisible), the likelihood that either a psychiatric or a medical condition will have no impact on the other is incredibly slim. Within the broad region of bi-directional influence (the area of overlap in the Venn diagram), the problems most commonly encountered on a consultation–liaison (C-L) service can be grouped into six categories (modified from Lipowski; see Figure 2-1 ). Examples of each classification follow.
Psychiatric Presentations of Medical Conditions
Case 1
An elderly man underwent neurosurgery for clipping of an aneurysm of the anterior communicating artery. A few days after surgery, he became diaphoretic, confused, and agitated and was tachycardic and hypertensive. Because of a history of alcoholism, a diagnosis of alcohol withdrawal delirium was made. He remained confused, despite aggressive benzodiazepine treatment. When he later became febrile, a lumbar puncture was done and the cerebrospinal fluid (CSF) analysis was consistent with herpes simplex virus (HSV) infection. His sensorium cleared after a course of acyclovir.
In this case, infection of the central nervous system (CNS) by HSV was heralded by delirium.
Psychiatric Complications of Medical Conditions or Treatments
Case 2
Newly diagnosed with human immunodeficiency virus (HIV) infection with a high viral load, a young man without a history of psychiatric illness began treatment with efavirenz, a non-nucleoside reverse transcriptase inhibitor. Within a few days, he experienced vivid nightmares; a known side effect of efavirenz. Over the next several weeks, the nightmares resolved. He continued antiretroviral treatment, but became increasingly despondent with a full complement of neurovegetative symptoms of major depression.
A chronic, incurable viral illness—the treatment of which caused a neuropsychiatric complication—precipitated a depressive episode.
Psychological Reactions to Medical Conditions or Treatments
Case 3
A woman with a history of pre-eclampsia during her first pregnancy was admitted with hypertension in the 38th week of her second pregnancy. Pre-eclampsia was diagnosed, and she delivered a healthy baby. As she prepared for discharge, and despite her obstetrician's reassurance, she fretted that a hypertensive catastrophe was going to befall her at home.
Pathologic anxiety resulting from an acute obstetric condition.
Medical Presentations of Psychiatric Conditions
Case 4
A young female graduate student from another country, who for several years had habitually induced vomiting to relieve persistent abdominal pain, presented with generalized weakness and was found to have low serum potassium. She had long since been diagnosed with bulimia nervosa, but the psychiatric consultant found no evidence for this disorder and instead diagnosed conversion disorder, construing her chronic abdominal pain as a converted symptom of psychological distress over leaving her family to study abroad.
Conversion disorder presenting as persistent abdominal pain.
Medical Complications of Psychiatric Conditions or Treatments
Case 5
An obese man with schizophrenia treated with olanzapine gained 30 pounds in 6 months. Repeated measurements of fasting serum glucose were consistent with a diagnosis of diabetes mellitus.
Treatment with an atypical antipsychotic complicated by an endocrine condition.
Co-morbid Medical and Psychiatric Conditions
Case 6
A middle-aged man with long-standing obsessive–compulsive disorder (OCD), effectively treated with high-dose fluoxetine, presented with cough, dyspnea, and fever. Chest radiography showed a left lower-lobe infiltrate, consistent with pneumonia. He defervesced after a few doses of intravenous (IV) antibiotics and was discharged to complete the antibiotic course at home. His OCD remained in remission.
Infectious and psychiatric conditions existed independently.
The Art of Psychiatric Consultation in the General Hospital
Determining where on the vast border between psychiatry and medicine a patient's pathologic condition is located is the psychiatric consultant's fundamental task. As for any physician, his or her chief responsibility is diagnosis. The C-L psychiatrist (i.e., practitioner of psychosomatic medicine) is aided in this enterprise, by appreciation of four key differences between general hospital psychiatry and practice in other venues: clinical approach, environment, style of interaction, and use of language.
Clinical Approach
The late senior psychiatrist at the Massachusetts General Hospital (MGH) and founding director of its Psychosomatic Medicine–Consultation Psychiatry Fellowship Program, Dr. George Murray, advised his trainees to think in three ways when consulting on patients: physiologically, existentially, and “dirty.” Each element of this tripartite conceptualization is no more or less important than the other, and the most accurate formulation of a patient's problem will prove elusive without attention to all three.
First, psychiatrists are physicians and, as such, subscribe to the medical model: altered bodily structures and functions lead to disease; their correction through physical means leads to restoration of health. Although allegiance to this model may be impolitic in this era of biopsychosocial holism, the degree of morbidity in general hospitals is ever more acute and the technology brought to bear against it increasingly more sophisticated. Consultation psychiatrists who fail to keep pace with their medical and surgical colleagues jeopardize their usefulness to physicians and patients alike.
Alongside the physiologic frame of mind, consultation psychiatrists must think existentially; that is, they must nurture a healthy curiosity about the meaning of illness to their patients at this particular moment in their patients' lives and the circumstances in which their patients find themselves at particular moments in the course of illness. For example, what does it mean to the patient in Case 3 that both of her two pregnancies have been complicated by pre-eclampsia? How might this meaning relate to her unshakeable fear that she will become dangerously hypertensive at home? How does this fear impact her ability to care for her children and how does it impact her husband? To be curious about such matters, the consulting psychiatrist must first know the details of the patient's situation, largely achieved by a careful reading of the chart, and then ask the patient about it.
Consultation psychiatrists are wise to maintain a measured skepticism toward patients' and others' statements, motivations, and desires. In other words, they should consider the possibility that the patient (or another informant) is somehow distorting information to serve his or her own agenda. Providers of history can distort the truth in myriad ways, ranging from innocuous exaggeration of the truth to outright lies; their aims are equally legion: money, revenge, convenience, and cover-up of peccadilloes, infidelities, or crimes. For example, the beleaguered mother of a young woman with borderline personality disorder embellished her daughter's suicidal comments in an effort to secure involuntary commitment for her daughter and respite for herself. By paying attention to his or her own countertransference—his or her personal reading of the limbic music emanating from the mother–daughter dyad—the psychiatric consultant called in to assess the patient's suicidal thoughts ably detected the mother's self-serving distortion and thus avoided unwitting collusion with it. This special case of distortion to remove a relative to a mental or other hospital has been termed the gaslight phenomenon . Although thinking “dirty” is merely a realization that people refract reality through the lens of their own personal experience, other health professionals—even some psychiatrists—bristle at even a consideration, let alone a suggestion, that patients and their families harbor unseemly ulterior motives. Consequently, this perspective does not make the consultation psychiatrist many friends; his or her thinking “dirty” may even earn him or her an unsavory reputation. However, neither an ever-widening social circle nor victory in popularity contests is the C-L psychiatrist's raison d'être —competent doctoring is.
Environment
The successful psychiatric consultant must be prepared to work in an atmosphere less formal, rigid, and predictable than one typically found in an office or a clinic; flexibility and adaptability are crucial. Patients are often seen in two-bedded rooms with nothing but a thin curtain providing only the appearance of privacy; roommates—as well as nurses, aides, dietary personnel, and other physicians—are frequent interlocutors. Cramped quarters are the rule, with IV poles, tray tables, and one or two chairs, leaving little room for much else. When family members and other visitors are present, the physician may ask them to leave the room; alternatively, he or she may invite them to stay to “biopsy” the interpersonal dynamics among the family and friends, as was done in the case of the borderline patient described previously. The various alarms and warning signals of medical equipment (e.g., IV pumps, cardiac monitors, ventilators) and assorted catheters and tubes traveling into and out of the patient's body add to the unique ambiance of the bedside experience that distinguishes it from the quiet comfort afforded by a private office. Perhaps off-putting at first, for the psychiatrist who, as Lewis Glickman in his book on consultation put it (as cited in Cassem ), loves medicine and is fascinated with medical illness, the exigencies of life and work in a modern hospital quickly become compelling.
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