Psychiatric consultation as conflict resolution

Interpersonal conflict between patient and physician is a frequent concomitant of the complex issues arising from medical or surgical illness and hospitalization. It is an often unacknowledged stimulus for seeking psychiatric consultation. Consultation may be sought to assist in resolving conflicts over problem definition, the treatment contract, or the patient-physician relationship per se. An understanding of potential sources and manifestations of conflict guides effective intervention by the consultant. The integration of concepts of conflict and conflict resolution with existing models of consultation-liaison and practice is illustrated in several case discussion.     

Psychogeriatric consultation in "reception centres": a descriptive account.

"Centres d'accueil" (reception centres) for the aged will be required to become increasingly involved with seniors presenting psychological or psychiatric problems, because of both the increase in life expectancy and the philosophy of avoiding the institutionalization of such seniors in psychiatric settings. One of the activities of the consulting psychiatrist is to meet the patient to establish a diagnosis and suggest treatment; however, the support of the care-giving team is the consultant's primary concern. The psychogeriatric consultant makes a rapid, on-site decision on suitable treatment for the patient, thus avoiding a potentially upsetting transfer. In addition, the consultant encourages active involvement by staff in the management of the psychiatric problem.     

Neuroradiology in psychiatry

This article explored methods of brain imaging as they relate to the practice of psychiatry. In particular, technical aspects and clinical applications of CAT scanning are reviewed, and some neurologic conditions that may masquerade as psychiatric illness are considered. Suggested guidelines for CAT scanning in psychiatric patients are put forth, and implications of recent research findings in psychiatric disorders are discussed. In closing, we offer the following caveat: As "psychiatric" symptoms may be the earliest sign of structural CNS disease, the psychiatrist may be the first physician to evaluate patients with neurologic abnormalities. Because even the neurologic consultant may not be alert to the possibility of psychiatric symptoms alone heralding CNS pathology, the decision to augment the clinical impression with neuroradiologic or other brain imaging adjuncts (and to choose among them) may rest solely with the psychiatrist. Of these adjuncts, CAT scanning is almost always the most conclusive and reliable.     

Psychiatry and the primary care physician

The author discusses problems that have hindered active collaboration between psychiatrists and primary care physicians, presents models for clinical interaction between them, and describes the role of psychiatrists in the education of primary care physicians. He identifies the differing models of psychiatric and physical medicine as the source of the poor communication that has existed between the two specialties and advocates adherence to a biopsychosocial model as a means of fostering collaboration. He concludes that the psychiatrist can best serve as a teacher and consultant to the primary care physician and as a specialist dealing with serious mental and emotional problems that are beyond the skill of the primary care physician.     

Evaluation and Management in Consultation-Liaison Psychiatry

Abstract: The subjects were 95 medical and surgical inpatients referred to Kyushu University Hospital Psychiatric Consultation Service. The authors studied the mental status of each referred patient and elicited some Unclassified mental status cases. It was recommended, therefore, to bring in new concepts of normal condition and polymorphous condition in dealing with those Unclassified mental status cases which are often recognized as problematic both by the patient's primary physician and the psychiatric consultant. The ordinary style Single contact consultation was also compared with the Active follow-up consultation regarding the function of psychiatric consultations. The authors confirmed that most referring physicians who were supported by the Active follow-up consultation appreciated highly the evaluating function of a psychiatric consultant     

Ownership, responsibility and hospital care: lessons for the consultation psychiatrist

OBJECTIVE: To identify scenarios in which consultation psychiatrists encounter difficulty reconciling their clinical role with consultees' expectations and to suggest concepts that help navigate these situations. METHODS: The authors' clinical experiences are used to generate and discuss three major categories of situations that require psychiatric consultants to thoughtfully adjust the breadth and depth of their obligation to patients and consultees. RESULTS: "Occam's razor 'dulled," "Conflation of the psychosocial with the psychiatric" and "Disposition preoccupation" are proposed as the major categories leading to conflicting patient management views between consultant and consultee. Each has, at its core, a compromise of patient ownership that blurs the boundaries of the consulting psychiatrist's responsibility. CONCLUSIONS: Understanding and channeling ownership back to the consultee, while appropriately gauging and embracing one's responsibility, form a two-pronged approach to clarifying one's role in consultations.     

Psychiatric Consultations at Medical and Surgical Wards: The Role of Psychiatric Consultant

Abstract: A one-year survey was conducted on the psychiatric consultation work at Kyushu University Hospital. It was found that an organic brain syndrome was the most frequent psychiatric diagnosis of the referred patients. The most frequent purpose of request for psychiatric consultations was for the management of the patient. The main consultant functions were diagnoses and to advise on the management of the patient. The consultant functions agreed with the purposes of request in many cases, but discrepancies between the two were found about the patient disposition. The nature of the consultant role was compared with some American studies. It was deemed necessary that consultation-liaison psychiatry based on Japan's present conditions, medical and social, should be developed.     

Making space for the inner guide

The therapeutic relationship is described as a curative factor in its own right as well as facilitative for other tasks. Experiential tasks that facilitate working on the intrapsychic, interpersonal, and existential domains are distinguished. Focusing is an intrapsychic task of paying attention to one's bodily felt experience. Clearing space helps clients finding a right distance for exploring their experience when they are too close or too distanced from their emotions. Interpersonal work takes the lead when maladaptive interactional patterns are hindering the relational life of the client. Metacommunicative feedback and interpersonal experiences in the therapeutic encounter act as an invitation to develop new ways of communicating. Existential processes are challenged when the client struggles with the givens of life. Finally, the "inner guide" found in accessing experiencing may involve an awareness of a transcendent dimension that leads one to spiritual growth. Vignettes from short term psychotherapy illustrate how this approach is established in practice.     

Psychiatric residency training in the management of emergencies

As a psychiatry resident on the Emergency Service or on call at night, the resident learns to function on several levels, as consultant, liaison, colleague, and occasionally as primary physician. At the outset, the resident needs to know that he or she is not expected to know all that yet. It is especially necessary to emphasize to a beginning resident that it is acceptable and important to ask for help. The resident is never the only physician caring for an emergency department patient. There should always be other psychiatry residents, psychiatry attending physicians, other house staff, and emergency medicine attending physicians who can help and often have an interest in each patients. The resident has an obligation to involve other physicians if there is uncertainty about the proper moves to make, and an obligation to discuss the management of a patient with the physician who initially consulted, as well as any other doctors responsible for the patient. Emergency cases can be discussed at morning rounds as well as at various seminars. The resident should also know that an interested or helpful ear can always be found among more experienced residents and attending physicians. The supervisor may present the option to the resident that he or she is available to see the patient with the resident, afterwards, or not at all, and can teach by watching and commenting, by modeling, and by supervision of the observations and reactions that the resident presents. There are a number of benefits to these models of emergency psychiatry training. In the first place, all of the drawbacks seen in present systems are addressed or avoided. The psychiatry resident retains his or her identity as a physician, working in consultation and cooperation with other physicians in a medical facility, rather than in a community clinic or psychiatric hospital. When a resident sees an emergency patient in revisit one or two days later, the resident has the opportunity to observe the effect of the psychotherapeutic intervention. One outcome of this observation is a decreased reliance on medication, and an increased use of outpatient modalities. The resident also gains an appreciation of the mental health system as he or she must work with many agencies and many levels of care.     

The Psychiatric Consultation Checklist: a structured form to improve the clarity of psychiatric consultation requests

Medical specialty consultation is requested to obtain expert review of a patient's condition. The specialist usually receives a case synopsis with pertinent positives and negatives and a specific request for assistance. In contrast, the psychiatrist often gets a statement of diagnostic speculation (e.g., "depressed") with a request to "please evaluate." Classically, the psychiatric consultant begins with open-ended empathic questioning in an attempt to redefine the written consultation question. However, given the difficulty consultees have in forming questions, and increasing time limitations, a more structured approach to obtaining data might assist both the consultee (M.D. requesting assistance) and the consultant (psychiatrist). The Psychiatric Consultation Checklist (PCC) was devised to function as a paper "expert" questioning system to provide such assistance. In a pilot study, 10 administrations of the PCC took an average of 3.6 minutes. In comparison to consultations using standard forms, more data were supplied in several categories when the PCC was used, particularly regarding patient stressors, patient behaviors of concern, and consultee speculation on psychiatric diagnostic formulation. The PCC may be used in consultation research, for assessment and education of physicians in training (regarding psychiatric issues in the medical/surgical setting), and for general clinical consultation purposes.     

Music therapy used on a patient in the terminal stage of cancer who narrated a tale based on her fantasy]

Music therapy was used on a patient in the terminal stage of cancer who described a fantastic tale built around her imagined pregnancy. We believe that psychiatric intervention was successful through the introduction of music therapy as part of her palliative treatment. Particularly notable in this case was that the patient dealt with the development of ascites by telling a fantastic tale related to a pregnancy--i.e., becoming pregnant with the therapist's child. Her tale started by statements such as "I am pregnant and suffering from morning sickness" and "I am in the third month of pregnancy with the child of my therapist." This progressed in parallel with the actual changes in her physiological symptoms. Among the attending physician, the patient, and her family, this imaginary tale was an important means of communication. The theme of pregnancy, love, and family developed from an unconscious dynamic process between the physician and patient, which could be interpreted as a family-related story originating in the mind of a terminally ill patient. Through this family romance with a major theme of pregnancy, the patient was able to sense her physical crises. This process may be thought of as a product of the so-called "mythgenerating capacity" under limited conditions, which was proposed by Ellenberger. Being aware of this situation, the attending physician and others in charge of her care did not insist on negating her story: instead they accepted her fantasy, and through it they succeeded in establishing psychiatric communications. The process may be considered a form of the narrative approach that is currently attracting attention. In this example, the "process of mourning" and "stages of accepting death" in the terminal state found an outlet in the creation of a fantasy. We believe that this case illustrates the important role of communication between the physician and a patient through the acceptance by the former of a fantastic tale given by the latter; and of a psychotherapeutic intervention, i.e., a sincere interaction between them through music therapy.     

Prevalence and recognition of depressive disorders in general medical inpatients

The Beck Depression Inventory (BDI) was administered to 220 of 340 patients consecutively admitted to three general medical wards of a University Hospital, whose length of hospital stay was more than five days. At least mild symptoms of depression (BDI greater than or equal to 13) were reported by 70/220 (32%) of the patients. Alternate BDI depressive patients underwent psychiatric consultation. The psychiatric consultant established a DSM-III depressive disorder in 10/33 (30%) of these patients. Only 3/10 (30%) of the DSM-III depressive patients had been referred to the consultant psychiatrist by their physician.     

Pilot study of televideo psychiatric assessments in an underserviced community.

OBJECTIVE: The goal of this study was to evaluate patient and physician acceptance of televideo interviews for general psychiatric assessments. METHOD: DSM-III-R diagnoses for axes I and II were made for 40 patients by using the Structured Clinical Interview for DSM-III-R. The patients were then randomly assigned to face-to-face or televideo interviews for general psychiatric assessments conducted by psychiatrists. After each interview the patient and psychiatrist completed measures evaluating perceived rapport and level of satisfaction with the interview. RESULTS: The patients gave high ratings to both satisfaction and ability to develop rapport for both the televideo and face-to-face interviews. The psychiatrists expressed significantly less satisfaction with the televideo interviews, but their actual ratings were positive. CONCLUSIONS: Despite geographic distance, televideo interviews allow a sense of connection between patient and psychiatrist. Lower-cost technology may increase the use of televideo to extend psychiatric service to geographically isolated communities.     

Diagnosis of late life depression: the view from primary care.

In the typical primary care practice, in which patients with a wide range of diseases and symptoms present with numerous needs, concerns, and requests, a chronic disease that lacks quantitative, biologically based diagnostic testing, such as depression, can present a daunting diagnostic challenge to even the best and most dedicated primary care physician. Depression does not compete well for patient and physician time and energy with other medical problems and medical co-morbidity in patients who seek care from their primary care physician. Primary care patients may be more comfortable with and accepting of depression being framed as a "normal" chronic disease rather than a psychiatric "brain" disease subject to cultural and generational stigmas, nihilism, and prejudice. Insurance parity in mental health care would make depression and other mental illness more legitimate in the eyes of patients, family members, employers, and physicians. Of particular value would be new and creative approaches to collaborative care, including telephone monitoring, nurse clinician outreach, and improved availability of psychiatric consultation in primary care, because elderly depressed patients often see the care of their depression as part of the integrated care of multiple chronic medical diseases, rather than a separate psychiatric problem to be referred for specialty care.     

Victimization and Vulnerability: A Study of Incarceration,Interpersonal Trauma,and Patient–Physician Trust

Despite the critical importance of patient–physician trust, it may be compromised among vulnerable patients, such as (1) incarcerated patients and (2) those patients who have been victims of trauma. The purpose of this study was to examine patient–physician trust among forensic and civilian psychiatric inpatient populations and to explore whether it varied based on a patient’s history of incarceration and/or victimization. A trust survey (WFPTS) and a trauma instrument (LEC-5) were administered to 93 patients hospitalized on forensic and civilian psychiatric hospital units in a large, urban public hospital. Results showed no difference in patient–physician trust between incarcerated and civilian patients. Similarly, there was no effect of a history of physical assault or sexual assault on ratings of patient–physician trust. However, the hospitalized civilian and forensic patients who reported being the victim of weapons assault had significantly lower patient–physician trust scores than their counterparts.     

The rehabilitation of the chronic psychiatric patient: Beyond the hospital-based token economy system

Summary Token economy programmes have offered a promise in the rehabilitation and community resettlement of the chronic psychiatric patient. However, most studies have concentrated on the behavioural gains while the patient is still in hospital with little or no follow-up on the subsequent community adjustment. This paper describes a comparative evaluative study between a token economy programme and a generic programme for chronic psychiatric patients. Social interpersonal parameters and follow-up discharge and readmission rates are given for the patients of the two programmes. The findings of this study indicate that neither programme by itself is effective in the rehabilitation of the chronic psychiatric patient as reflected in the discharge rates, maintenance of patients in the community and readmission rates. It is suggested that behavioural technology must be integrated with community psychiatry concepts and practice if adjustments to and stability in community life is to be achieved. Token economy programmes must extend into a structured and supportive posthospital community environment, and utilize community resources to maintain and further behavioural gains.     

The role of the psychiatric consultant in the treatment of burned patients.

Two cases of seriously burned patients are presented which differ in initial psychiatric presentation and subsequent course. In each case, the role of the psychiatric consultant is described. The role includes direct evaluative and psychotherapeutic contact with the patient and liaison with the surgical and nursing staff. This dual approach is necessary for a consistent rehabilitative effort, particularly in hospitals that do not have a psychiatric liaison team.     

Informed consent--mandating the consultation

This article illustrates how a mandatory consult procedure identified treatable psychiatric problems. Using a computerized data-based format, 372 (37.4%) patients (the "judgment" group) of 996 psychiatric consultations were identified as referred to assess the patient's capacity to execute a consent form for a medical or surgical procedure. One hundred twenty-nine (35%) of the 372 patients thus referred by hospital mandate were given psychiatric diagnoses (DSM-II) by the consultant and received recommendations for primary psychiatric treatment. The "judgment" group had significantly more organic brain syndrome and psychoses associated with CNS conditions (p less than 0.001), whereas the "nonjudgment" group was diagnosed as exhibiting significantly more neurosis, alcoholism, psychophysiologic disorders, transient situational reactions, and personality disorders (p less than 0.001). Without a required psychiatric consultation sanctioned by administrative hospital mandate, the majority of the "judgment" cases with major psychopathology would not have been identified. The use of the mandated psychiatric consultation in the general hospital is discussed.     

The difficult patient: identification and response.

A group of "difficult" psychiatric outpatients in a university hospital system was identified and its distinguishing characteristics compared to a sample of other psychiatric outpatients not so labeled. "Difficult" patients were perceived to be significantly more demanding (p less than or equal to 0.005), dangerous, difficult to empathize with, manipulative and likely to polarize the staff. These patient were perceived differently by physician and nonphysican staff. An analysis revealed that a major source of "difficulty" appeared to be the structure of the treatment system rather than the patient. A corrective strategy was devised to test this hypothesis.     

Psychiatric issues of childhood seizure disorders

Children who suffer from childhood seizure disorders, especially epilepsy, have various potential psychiatric issues and concerns that the treating physician and psychiatric consultant should consider. These children are at increased risk of adjustment reactions, anxiety and mood disorders, ADHD, learning difficulties, and familial and social stress. Because of potential risks and vulnerabilities for the development of comorbid psychiatric conditions and the increased risk for individual, familial, and social impairment, a psychiatric consultation to children and families dealing with epilepsy may play an important role in the successful management of this complex disorder.