Somatoform disorders: The role of consultation liaison psychiatry

The somatoform disorders are encountered commonly in both primary and secondary care. Despite their high incidence, few hospitals have teams with the expertise to manage this group of conditions. The lack of appropriate carers leads to inappropriate care, including increased numbers of admissions and investigations, to the detriment of the patients. The absence of appropriate care also increases the cost to the health services. Multidisciplinary Consultation Liaison (C-L) Psychiatry teams operate within non-psychiatric settings and are dedicated to the mental health care of patients presenting in these areas. Their unique skills and approaches offer support and education to these non-psychiatric teams and care to this group of patients. They are thus ideally placed to assess, diagnose and manage individuals presenting with somatoform disorders. Unfortunately, these teams are not widely available, largely because the current climate within psychiatry leads services to concentrate on what is defined as serious mental illness, a term usually used synonymously with psychotic disorders, despite the large number of people suffering from somatoform disorders and the cost of their care. The dislike that some colleagues have for this group of conditions may further hamper the creation of these services. In order to provide efficient assessment of and treatment for individuals with somatoform disorders, C-L Psychiatry teams must be created to lead clinical development, research and training in this discipline. These teams will also lead on the further research required.     

The role of an old age psychiatry consultation liaison nurse

Objective. To assess and describe service changes when a psychiatric consultation liaison nursing service is introduced. Design. Prospective collection of basic service data before and after implementation of the service change. Setting. A newly established comprehensive old age psychiatry service. Patients. People on medical and surgical wards aged over 65 years referred for psychiatric assessment. Outcome measures. Numbers of referrals made and patients seen, details of psychiatric diagnoses made and follow-up offered before and after the change in the service. Results. Within 6 months there was an increase in liaison referrals to the service. The proportion of people offered follow-up showed little change and delay before assessment decreased substantially with the PCLN service. Conclusions. A psychiatric consultation liaison nursing (PCLN) service was successfully initiated. Numerous difficulties were encountered but this is a useful model for old age psychiatry services to consider researching and developing further. © 1998 John Wiley & Sons, Ltd.     

Supervision in liaison and consultation psychiatry

This paper reports special problems and techniques of teaching liaison and consultation psychiatry to psychiatric residents. It has become apparent that traditional methods of resident training are inadequate, and that specialized techniques of supervision are required to help the resident deal with the unique aspects of the liaison and consultation environment. Specific recommendations are made and discussed.     

"Big MAC": the role of consultation liaison psychiatry in hospital medical advisory committees

OBJECTIVES: The aim of this paper is to describe the participation of a consultation-liaison (CL) psychiatrist within a hospital medical advisory committee (MAC) and examine how this may generally contribute to improved patient care as well as assist in the development of governance within the hospital. CONCLUSIONS: Psychiatrists have a role in a MAC in enhancing the recognition of psychiatric care issues within the hospital, educating other members of the committee with respect to improved recognition of mental illness affecting hospital inpatients and enhanced care of patients requiring substitute decision-making. The psychiatrist also has a role in advising the committee on psychosocial issues generally affecting the hospital service as well as informing on psychological issues that impact on hospital staff performance. To an extent, CL psychiatry also encompasses issues involving all the other medical craft groups in hospitals, offering the opportunity for a "global" perspective that may be expressed through participation in a MAC.     

会诊联络精神病学在综合医院的现状分析

目的对综合医院精神病学会诊现状进行分析研究。方法2007年度申请精神科会诊的病例279例,分析其申请科室、原发病、申请理由及精神科诊断处理。结果综合医院精神病学会诊中最常见的精神科诊断是脑器质性精神障碍、躯体疾病伴发精神障碍、焦虑障碍和抑郁障碍。结论应在综合医院积极开展会诊联络精神病学服务及对综合科医生加强精神病学知识教育。     

Somatoform disorders in consultation-liaison psychiatry: a comparison with other mental disorders

Consultation-liaison (C-L) psychiatry has an important role in the management of somatoform disorders (SD). Characteristics of SD patients in C-L psychiatry are largely unknown and are presented in this paper. We analyzed 13,314 Dutch psychiatric consultations from 1984 to 1991 and compared patients diagnosed with SD to patients with other mental disorders and to those without a mental disorder. The comparison included socio-demographic variables, consult characteristics, medical history, current somatic morbidity, information about additional diagnostic tests, hospital admission time and aftercare management. Of the 544 SD patients 39.5% (n = 215) were diagnosed with a conversion disorder that illustrates the highly selected nature of SD patients in C-L psychiatry. Employment among SD patients decreased significantly from 58% in the group aged 20-29 years to 6% in the group aged 50-59 years. This decrease was significantly larger as compared to other mental disorders and no mental disorders and was virtually unaffected by correction for potential confounding by gender. Contrary to our expectation no difference between the three groups was observed in claims for disability benefits. Of the SD patients 74.5% were referred for aftercare management, significantly more than the other two groups which is considered a promising development in C-L psychiatry.     

Interventions in consultation/liaison psychiatry. Part I: Patterns of recommendations

In a previous study, a checklist and a schema for operationalized interventions have been described. In this study, these operationalized interventions have been used in clinical practice in 820 cases. In 287 cases (35%), recommendations focusing on the medical treatment, other than diagnostic action (41%) and medication (68%), were provided. This emphasis on the intensity of medical treatment is an unreported finding. The further distribution of recommendations over the different intervention domains was: obtaining additional psychosocial information, 30%; psychosocial management on the ward, 61%, specifically its organization; discharge planning, 41%; and aftercare management, 24%. Recommendations infrequently used included: monitoring of cognition and behavior, referrals to occupational therapy and alcohol- and drug-related facilities, and a detailed specification of postdischarge care. Since consultee concordance with the consultant's recommendations is important to treatment outcome, this method of a systematic recording of operationalized recommendations is a first step toward enhancing the evaluation of treatment recommended and provided by consultation/liaison (C/L) psychiatrists. Moreover, these operationalized recommendations help advance the specification of protocols for psychiatric intervention studies.     

Effect of liaison psychiatry on attitudes toward psychiatry, rate of consultation, and psychosocial documentation

Prior literature suggested that psychiatric liaison on medical wards would produce a more positive attitude towards psychiatry, more psychosocial chart documentation, and a higher consultation request rate. Over 3 years, liaison was conducted on two medical wards, and its effect was contrasted with two control (consultation only) medical wards. Liaison activities were more favorably received by consultees than consultation alone and increased the consultation request rate, but produced no change in psychosocial documentation. Additional effectiveness of liaison activities might be achieved through direct, focused interventions, and through active involvement of senior medical faculty.     

Beyond liaison: a future role for psychiatry in medicine

Integrated biopsychosocial treatment is necessary for medical patients in whom psychosocial and behavioral issues strongly influence medical outcome. In this article the authors identify several large groups of such patients, and point out the limitations of three established approaches to improving their care: psychosocial education for non-psychiatrists, traditional consultation-liaison psychiatry, and 'behavioral medicine.' They present reasons why many of these patients would best be served by having psychiatrists as their primary physicians. Primary care of selected medical patients by psychiatrists is feasible and would improve patient care, interspecialty communication, reimbursement, and recruitment of psychiatric residents.     

AIDS: challenge to liaison psychiatry. Various expectations by clinicians concerning liaison psychiatry]

Interdisciplinary group work could be conceived as shared common abilities in order to provide a global management of diseases. In this regard, psychologists should assumed several tasks: to advise on patient's psychological resources to keep them less anxious or more cooperative, to humanize hospital and death, to prevent burn-out. This does not mean a management of the illness, but a careful listening to help patients to find a meaning to what they are living. The aim should not to harmonize different skills but to define each other place (physician, social worker, nurse, psychologist...) concerning queries that involve us and that wonder us about life, health, sexuality, love, the way we take risks.     

The teaching of liaison psychiatry

ObjectiveTo document performance and satisfaction of medical students in a short course on liaison psychiatry.MethodsThe emphasis in this optional course is placed on the discussion of clinical cases, bed-side clinical teaching, and a research-oriented part. The "Innovative Teaching Plan" (ITP) is intended to train student-leaders to guide small groups (SG) of students. Trainee performance was assessed by the marks in the final examination, and a reliable and valid tool, the Medical Teaching Quality Questionnaire (MTQQ) was used to document trainee satisfaction. The results of four academic courses are presented in this report.ResultsExternal experts consulted assured that the content of the course was adequate. It has been completed by more than 200 medical students, and high marks have been obtained by most. Above average scores (AA, “high” or “very high”) were given by substantial proportions of students in most items, related to the “relevance” of the subject, the “usefulness of the clinical cases” or the "enhancement of student-teacher interaction". Compared to the first academic course, students’ satisfaction has improved. "Enhancement of a researcher's mind" was rated AA by 61.1% of students in the last academic course, and "global satisfaction" by 88.8%.ConclusionsGood performance and high satisfaction of medical students was documented in a course on liaison psychiatry. Lessons may be drawn to inform about efficient and effective ways of teaching and learning this subject.     

Detection of the anxio-depressive disorders in liaison psychiatry. Contribution of the General Health Questionnaire

Among self-report inventories of psychopathology for adults, the General Health Questionnaire (GHQ) is one of the prominent instruments developed for the screening of minor psychiatric morbidity. Four versions of the GHQ were provided from the original 60 items (GHQ-30, 28, 20, 12) and three different scorings have been suggested. A large number of validity studies, mostly favourable, have been performed and are reviewed in this paper. Recent work has suggested that the sensitivity of the GHQ to clinical change was fair, compared to the Present State Examination. The most recent version, the GHQ-28, was built from factor analyses of the 60-item version and covered four dimensions, with seven items each: anxiety and insomnia, severe depression, social impairment, somatic complaints, but their subscores were not independent. Several international extensive studies have confirmed that the GHQ was an interesting tool in Community as well as in General Practice. But, as it falls short from detecting all the chronic cases, research aimed at improving its quality in this direction is still in progress. The use of the French version of the GHQ-28 is expected to be encouraged.     

Somatoform disorders: perspectives from Pakistan

Somatoform disorders represent widespread and largely unsolved problems at the border between psychiatry and medicine. Patients with somatoform disorders often present difficult diagnostic and management problems. A series of three community-based epidemiological surveys of rural and urban populations in Pakistan found high prevalence of common mental disorders where the core presentations were somatic complaints. All the three epidemiological surveys used the Bradford Somatic Inventory (BSI), which was developed from symptom reports by psychiatric patients in Pakistan; these enquired about somatic symptoms in the local language, taking into account local cultural idioms of distress. At a conservative estimate, 66% of women and 25% men suffered from anxiety and depressive disorders whereby the complaints predominantly were somatic in nature. People in rural non-Western cultures are not psychologically minded and do not have abstract language or concepts of emotional distress and therefore communicate their emotions somatically. In Pakistan somatoform disorders possess a prominent diagnostic dilemma. The cornerstone of the management is a comprehensive medical, psychiatric and psychosocial evaluation of the patient. Patients with multiple somatic complaints not only present formidable management problems but also often have severe functional impairments that may outweigh those of patients with other so-called severe mental illnesses. Since somatoform disorders are the most common psychiatric disorders to present in non-psychiatric settings, it is important that training about them begin at undergraduate level. It should also be incorporated in the training of a wide variety of non-psychiatric specialists, both medical and non-medical.     

Somatoform disorders: Perspectives from Pakistan

Somatoform disorders represent widespread and largely unsolved problems at the border between psychiatry and medicine. Patients with somatoform disorders often present difficult diagnostic and management problems. A series of three community-based epidemiological surveys of rural and urban populations in Pakistan found high prevalence of common mental disorders where the core presentations were somatic complaints. All the three epidemiological surveys used the Bradford Somatic Inventory (BSI), which was developed from symptom reports by psychiatric patients in Pakistan; these enquired about somatic symptoms in the local language, taking into account local cultural idioms of distress. At a conservative estimate, 66% of women and 25% men suffered from anxiety and depressive disorders whereby the complaints predominantly were somatic in nature. People in rural non-Western cultures are not psychologically minded and do not have abstract language or concepts of emotional distress and therefore communicate their emotions somatically. In Pakistan somatoform disorders possess a prominent diagnostic dilemma. The cornerstone of the management is a comprehensive medical, psychiatric and psychosocial evaluation of the patient. Patients with multiple somatic complaints not only present formidable management problems but also often have severe functional impairments that may outweigh those of patients with other so-called severe mental illnesses. Since somatoform disorders are the most common psychiatric disorders to present in non-psychiatric settings, it is important that training about them begin at undergraduate level. It should also be incorporated in the training of a wide variety of non-psychiatric specialists, both medical and non-medical.