Alcoholism and the consultation-liaison psychiatrist

This article hopes to remind the practitioner that alcohol abuse and dependence is the most common of psychiatric disorders, impacts on the general hospital at a variety of levels, repels our referrant-colleagues, and is difficult to diagnose but is eminently treatable. Because both clinicians and their patients are subject to alcohol abuse and dependence, the consultation-liaison psychiatrist is in an ideal position to impact therapeutically on alcoholism at all levels of presentation. Alcoholism is a natural object of a consultation-liaison psychiatrist's time, interest, and energy.     

Contemporary issues in obstetrics and gynecology for the consultation-liaison psychiatrist

Medical advances in obstetrics and gynecology, combined with the depersonalization of health care and changes in sexual and reproductive behaviors in the general population, lead to challenging new problems for the psychiatric consultant who deals with reproductive issues. The author describes contemporary issues encountered in consultation-liaison work with the obstetrics and gynecology service in a general hospital. They include the reproductive implications of medical illnesses, the stress of deciding whether to continue a pregnancy known to carry genetic risk, the intrusiveness of certain options for dealing with infertility, parental expectations for a perfect baby, and the difficulties some traditional practitioners have in adapting their practice styles to the changing needs of the patient population.     

Major mental illness and childbearing. A role for the consultation-liaison psychiatrist in obstetrics

Considerable attention has been paid to psychiatric disorders arising in the postpartum period. However, there has been very little systematic study of mental illness during pregnancy. Although quantitatively not a major problem, it can pose several difficulties for mother and fetus. This article reviews the existing literature and along with illustrative cases discusses the management of mental illness related to pregnancy. The relationship between the consultation-liaison psychiatrist and the obstetrician-gynecologist in caring for such problems is emphasized.     

Involuntary hospitalization: an issue for the consultation-liaison psychiatrist

Little has been written about the issue of involuntary hospitalization in consultation-liaison psychiatry. Nevertheless, patients frequently seen in medical and surgical settings may be judged to be a danger to themselves or others because of psychiatric disorders that cloud cognition, impair judgment, or modify insight, and judicial or administrative proceedings leading to involuntary commitment may be needed. The C-L psychiatrist will be the physician most knowledgeable about the concepts of involuntary hospitalization, competency and informed consent. Clinical examples illustrate issues that may arise.     

The psychiatrist and his questions in the face of traditional practices in Northwest Africa

Traditional practices remain frequent in such countries as Maghrab. They interfer with care as well as with clinic, as made evident by some observations. Their weight, shown by many authors, possibly indicates the position of cultural changes of the group and underlines the importance of the pathology of filiation relationship. Nevertheless, meeting them should favour a reflection on the humanism of present society.     

Imaging blood vessels of the head and neck.

ATHEROSCLEROTIC DISEASE: Patients with transient ischaemic attacks or a non-disabling stroke who are surgical candidates should be screened with Doppler ultrasound, or MRA/CT, or both. The choice will depend on local expertise and availability. If DUS is used it is recommended that the equipment is regularly calibrated and a prospective audit of results, particularly of those patients that go on to angiography, is maintained locally. Those patients found to have the DUS equivalent of a 50% stenosis should have angiography only if surgical or balloon angioplasty treatment is contemplated. Angiography should be performed with meticulous technique to minimise risks. ANEURYSM AND ARTERIOVENOUS MALFORMATIONS: Angiography remains the investigation of choice for patients with subarachnoid haemorrhage. Magnetic resonance angiography and CT can demonstrate the larger aneurysm but because even small aneurysms can rupture with devastating effects, these techniques are not the examination of first choice. Angiography is also the only technique that adequately defines the neck of an aneurysm. This information is becoming increasingly important in management decisions-for instance, whether to clip or use a coil. Likewise angiography is the only technique to fully define the vascular anatomy of arteriovenous malformations although the size of the nidus can be monitored by MRA and this is a useful method of follow up after stereotactic radiosurgery, embolisation, or surgery. There are specific uses for MRA such as in patients presenting with a painful 3rd nerve palsy and as a screening test for those patients with a strong family history of aneurysms. VASCULITIS, FIBROMUSCULAR HYPERPLASIA, AND DISSECTION: These rare arterial diseases are best detected by angiography, although there are increasing reports of successful diagnosis by MRA. There are traps for the many unwary and MRA does not give an anatomical depiction of the arteries but a flow map. Slow flow may lead to signal loss and a false positive diagnosis of vasculitis.     

Neurologic manifestations of glomus tumors in the head and neck.

In 75 patients with glomus tumors in the head and neck region, 57 tumors arose from the jugular bulb region, 11 from the middle ear, and seven from the vagus nerve. Thirty-seven percent (28 patients) had cranial nerve paralysis, and 14.6% (11) had intracranial tumor extension. The jugular foramen syndrome was associated with a 50% (two of four patients) incidence, and hypoglossal nerve paralysis with a 75% (three of four) incidence of posterior fossa tumor invasion. Horner syndrome and labyrinthine destruction had a 50% (two of four) incidence of a middle cranial fossa tumor invasion. The incidence of central nervous system (CNS) invasion with cranial nerve paralysis (excluding the seventh nerve) was 52% (11 of 21). Otologic findings and seventh nerve paralysis did not correlate with CNS tumor extension.