Ethical issues for the consultant in the general hospital.

Medical practice has changed dramatically in the past 50 years since psychiatry first made inroads into the general hospital setting. The image of the wise, gentleman-psychiatrist in a tweed jacket, spreading pearls of wisdom to a train of eager students and house-officers has been gradually replaced by that of a harried consultant being summoned for triage and tranquilization. In her quest to be all things to all people, the consultation-liaison psychiatrist has to confront many an ethical dilemma. This article highlights some familiar conflicts and attempts to achieve resolution.

Competency evaluations on the consultation-liaison service. Some overt and covert aspects.

Competency assessments are a growing function of the consultation-liaison (C-L) psychiatrist. Such consultation requests often mask a variety of psychosocial issues that are a source of frustration to the referring physician responding to the pressures of the changing health care delivery system in the acute care setting. This study identifies the issues and the outcome of psychiatric consultation in these patients. The implications of this burgeoning role for the C-L psychiatrist are also explored.

Neurobehaviour rounds and interdisciplinary education in neurology and psychiatry (698).

Increasing emphasis on interdisciplinary medical treatment and education suggests that something valuable has arisen from medical specialization beyond the further development of specialty knowledge: an integration of specialty knowledge that compliments and extends the integrating aspects of the primary care approach to medicine. Several educational models have been described which serve this function. In this paper the authors describe interdisciplinary clinical teaching, and research team linking neurology, neuroradiology, psychiatry and neuropsychology. The team provides neurobehavioural evaluations and sponsors monthly Neurobehaviour Rounds, an interdisciplinary patient conference that is the main formal teaching vehicle for the programme. After the model had been in place for 1 year, eight of nine neurology residents had Residency In-Service Training Examination scores in behavioural neurology that exceeded their overall average scores. This suggests that encouraging neurology residents to see patients through the eyes of different specialists may have contributed to improvement in their performance on a test of interdisciplinary knowledge. A neurobehavioural programme anchored to a formal neurobehaviour conference may encourage interdisciplinary learning within the related disciplines of neurology, neuropsychology and psychiatry.

The chronically mentally ill on a general hospital consultation-liaison service. Their needs and management.

The consultation-liaison (C-L) psychiatrist often sees chronic mentally ill patients when they are admitted to the medical-surgical services of the general hospital. Little research has been directed to the special needs and concerns of these patients in the general hospital. This area has become more relevant now that many of these patients are no longer cared for in the safety of the state hospital setting, often making baseline medical histories inaccessible. They have an overall higher mortality rate than the general population, cannot give adequate histories, and their psychotic illness can mask an underlying medical illness. In this preliminary investigation of the problems of this special population, the authors examined the issues concerning nursing needs, length of hospital stay, medical diagnosis, and possible complicating problems encountered during these patients' hospital stays in the setting of an urban university hospital. The authors discuss the implications of the role of the C-L psychiatrist in addressing their patients' acute problems.

What, why, and how of consultation-liaison psychiatry. An analysis of the consultation process in the 1990s at five urban teaching hospitals.

There is controversy about the role and function of a consultation-liaison (C-L) psychiatrist, as reflected in the ongoing debate about what to call ourselves. To clarify the essential elements of our function, the authors analyzed the process and content of the entire consultation experience from the time of initial consultation to the time of discharge in 50 patients across 5 urban teaching hospitals. The common components of the C-L process, in this pilot study, were identified to be facilitative, consensus-seeking, and interpretative. Implications of these findings for the C-L psychiatrist's role in the general hospital are discussed.

Constant observation in a medical-surgical setting. The role of consultation-liaison psychiatry.

Constant observation (CO) is commonly used in general hospital settings to protect patients who are at risk for harming themselves or others. The role of consultation-liaison psychiatry in the implementation of this procedure is often assumed, but has not been well studied. The authors report the findings of a 6-month study of the use of CO in a general hospital and discuss its implications for quality of care and, possibly, cost-effectiveness.

Pathological grief: two Victorian case studies.

Despite 75 years of investigation, the concept of pathological grief remains tenuous and controversial. The author turns to the stories of two nineteenth century women, one real and the other fictitious to examine the syndrome of grief gone away. He concludes that pathological grief may be best viewed on a continuum of psychopathology, the expression of which depends upon the interaction between the personality of the patient, the nature of the lost relationship, and the circumstances of its loss.

Overdiagnosis of depression in the general hospital.

To test the hypothesis that depression is often inaccurately detected in medical settings, we examined the psychiatric consultations performed at two medical-surgical teaching hospitals. All records for the 4396 consultations seen in a 3-year period were retrospectively reviewed. Consultations were categorized by the reason for referral. These reasons were compared with the consulting psychiatrist's diagnosis. Diagnoses were grouped into "Depressed" and "Not Depressed" categories, depending on whether the psychiatric diagnoses implied any form of depressive illness (alone or in combination with other diagnoses). The majority of the referrals for psychiatric consultation (about 25% and 30% at the respective sites) were for presumed depression. Of these referrals for depression, approximately 40% were judged by the consultant to have no depressive diagnosis. Of the referrals for depression judged not to be depressed, the majority had other undiagnosed illnesses, particularly delirium, dementia, and anxiety disorders. The authors conclude that although numerous studies report that depression is unrecognized in medical patients, it may also be inappropriately suspected. This is of most concern when the presumption of depression delays other medical, neurological, or psychiatric evaluation.

Evolving concepts of psychopathology in inflammatory bowel disease. Implications for treatment.

The role of psychiatric factors in inflammatory bowel disease has been increasingly relegated, according to Aronowitz and Spiro, to "patient's illness, but not to disease, to therapy, but not to etiology, to symptoms, but not to pathology, and finally to the course of the disease, but not to its cause." This is not surprising in view of the fact that to attribute psychological factors to an illness is seen by the patient and physician alike as an attempt to "blame the victim." As a result, there has been a concerted effort in the past two decades in the field to replace the seemingly archaic, developmental, romantic psychoanalytic concepts of causation with more "enlightened," "scientific" paradigms of psychoneuroimmunology and psychiatric comorbidity. Despite major advances in the biomedical understanding of inflammatory bowel disease and its treatment, however, the essential questions about the complex relationship between emotional and physical symptoms remain a source of frustration both to the patient and to the treating physician in the management of the chronic diseases of the bowel. Thus, early assumptions of a psychogenic basis of ulcerative colitis and Crohn's disease may have been imprecise, but the genuine contributions of investigators such as Alexander, Karush, and Engels ought not to be cast aside completely. Experience with the treatment of patients with inflammatory bowel disease shows that attention to psychiatric comorbidity, quality of adaptation to illness, and the patient-physician relationship are essential components of a comprehensive, successful approach to these chronic illnesses.

Hypnosis as an aid for tinnitus patients.

This study was undertaken to evaluate hypnosis versus stress management as therapeutic modalities in the treatment of tinnitus. Participants were recruited from the local tinnitus association and the Otolaryngology Division of the Department of Surgery. The instruments were the following standardized tests (NIMH Diagnostic Int. Schedule; SCL 90R, Beck Depression Inventory) in addition to a tinnitus questionnaire. Improvement was shown on 5 separate scales, some alleviated by both types of treatment and others singularly by hypnosis or stress management. The data reinforce the use of behavioral techniques and suggest that different techniques may be more appropriate for specific symptoms.

Neurobehavior rounds. Their role in promoting psychiatric liaison in a neurology inpatient unit.

A joint neurobehavior conference was established utilizing the models of Lipowski's Montreal conference and Geschwind's aphasia and neurobehavior rounds at the Boston VA Hospital in 1991. The authors report on the usefulness of this conference in promoting the goals of psychiatric consultation and liaison on a neurology inpatient unit, specifically on patient care, education, and collegiality. The value of the multidisciplinary approach in solving complex neuropsychiatric problems is also discussed.

Evaluation of pseudoseizures. A psychiatric perspective.

Two subgroups of patients with psychogenic pseudoseizures were identified among 20 neurology patients referred for consultation to rule out pseudoseizures. Patients with pseudo complex partial seizures were found to have primarily dissociative symptoms with guilt-laden bereavement as an important precursor. Patients with pseudo grand mal type seizures appeared to have developed their illness in the context of longstanding personality traits. Diagnostic and prognostic implications of these findings are discussed.

The lithium toxic patient in the medical hospital: diagnostic and management dilemmas.

OBJECTIVE: Patients with lithium toxicity can pose difficulties in diagnosis and management in the general hospital setting. The authors examined patients who were referred to the Psychiatric Consultation-Liaison Service with suspicion of lithium overdose to delineate and characterize medical and psychiatric risk factors for toxicity and to follow the course and resolution of their toxicity. METHOD: The authors reviewed the charts of patients with lithium levels > 1.5 mEq/L who were admitted consecutively to a general hospital over an 18-month period. RESULTS: Of twelve patients, eight were found to have developed lithium toxicity due to incidental and iatrogenic factors. These patients presented with a variety of confusing signs and symptoms. Hypothyroidism and coexisting organic illness contributed to the lack of clarity in their clinical picture. CONCLUSION: The widening scope of indication for lithium therapy leads to increased risk of toxic reactions which challenge the diagnostic skills of the consulting psychiatrist in a general hospital setting.

The hypomanic personality of Wilkins Micawber: a Dickensian case study.

The concept of hypomanic personality has historically been viewed with ambivalence. However, by replacing cyclothymic personality with cyclothymic disorder, DSM III doomed this entity into oblivion. The author examines the Dickensian portrayal of Mr. Micawber in light of existing descriptions of hypomanic personality in order to justify its inclusion in future psychiatric classifications.

Distinguishing features of pseudocomplex partial seizures.

The authors identify common features in the clinical presentations of three patients whose pseudoseizures mimicked complex partial seizures. All three had suffered the recent traumatic loss of a significant love object, and all manifested unconscious feelings of guilt and the use of defense mechanisms of denial, dissociation, introjection, identification, and symbolization. The authors explore the diagnostic, treatment, and etiological implications of these findings.