Primary care multidimensional model: A framework for formulating health problems in a primary care setting

There is a need to develop a systematic method for integrating organic, emotional, personal, and environmental data of a patient's lifestyle into the management of health problems. The Primary Care Multidimensional Model (PCMM) was developed to assist in the formulation of an individual's health problem, whether categorized as biological, psychological or social. The PCMM was applied to 276 health problems attended in a consecutive sample of 84 adult patients cared for in an inner city primary care setting. Seventy-five percent of the problems were categorized as primarily biological, 14% as psychological, and 9% as social. Sixty-seven percent of the “biological” problems were found to have emotional, personal, or environmental variables from the patient's lifestyle considered relevant at the time of the study visit. All psychological and social problems were likewise multidimensional. In the population studied, over 75% of the health problems attended in a primary care practice fulfilled the biopsychosocial model of illness as defined by the PCMM. The heuristic value of this study is discussed.     

Interruption of recurrent ventricular fibrillation by psychiatric intervention

A 32-year-old man with a recent myocardial infarction had recurrent episodes of cardiac arrest that resisted medical management until he was interviewed by a psychiatrist. During the interview he shared his terror and associated to an episode during adolescence when he stole a car and was shot in the chest. After the interview he slept for the first time in three days, and subsequently had no further incidence of cardiac arrest. The case illustrates the potentially life-saving role of psychiatric intervention in reducing sympathetic tone in patients with cardiac instability.     

Treating insomnia: A practical guide for managing chronic sleeplessness,circa 1975

Insomnia means a complaint of sleep loss. Between 13% and 32% of surveyed populations suffer frequent insomnia,^1–3 and 7%–10% of the population use sleeping pills.^4,5 Alcohol and minor tranquilizers are also used to ease insomnia. The ubiquity of such drugs and the persistence of insomnia suggest that drugs alone do not remedy insomnia. The possibility of drug habituation, the distortion of sleep patterns, morning hangovers,^6,7 the possible accumulation of long-lived metabolites,⁸ and the risk of aggravated sleep disturbances upon withdrawal from sleeping pills^9,10 further complicate the use of hypnotics.Presently, there are few clinics offering specialized services for the treatment of sleep disorders. The physician is compelled to treat severe cases of insomnia and yet may feel that there is little to offer the insomnia patient besides hypnotic drugs. Some physicians, however, rarely prescribe sleeping pills for insomnia.^11,12 This paper, therefore, will offer practical suggestions on insomnia management, many of which do not depend primarily on the use of hypnotic drugs.     

Emergency ward management of the borderline patient

The authors discuss assessment and management of the borderline patient in a general hospital emergency ward. Effective clinical intervention depends on rapid diagnosis of the personality disorder, understanding its core psychodynamic issues, and recognizing the impact of the emergency ward environment on the patient's behavior. The authors describe three aspects of psychological management: empathic reassurance, borderline crisis intervention, and education. Guidelines for the use of medications, physical restraint, and means of arriving at an appropriate disposition are presented.     

The Munchausen spectrum: borderline character features.

In this paper the author presents a continuum of disease simulation that ranges from hysteria to malingering, with a range of relative unawareness to awareness of producing such deception. Focus is on the particular group of patients who consciously and repeatedly simulate disease. The frequency and form of such disease mimicry vary within such a group. A continuum in terms of frequency ranges from occasional adventures to the simulation of disease as the center of a person's life. Two groups of patients designated as exhibiting Munchausen Syndrome are defined within this continuum: (a) those who work (mostly as nurses or in other medical professions) and (b) those called "hospital hobos" --the more prototypical Munchausen patient. The author takes a somewhat different approach to Munchausen Syndrome in that it is viewed as a subgroup of the borderline character. Further, the often found exhortation for psychiatric treatment of Munchausen patients is reexamined, and caution regarding such zeal and its potential negative effects is registered.     

Into the breach: emergency psychiatry in the general hospital.

In its position at the interface between the community and the general hospital, the emergency ward (EW) serves to reconcile the complex needs of the local population with the traditional organizational structure of the hospital. In recent years, the EW has been faced with the dilemma of managing increasing numbers of psychotic patients with chronic illness and psychosocial problems. In response to this impressive growth in the utilization of psychiatric emergency services, a variety of general hospitals have developed model programs of service delivery and methods for the evaluation of their effectiveness. This paper is an overview of utilization patterns, organization of services, and assessment of the evaluation and referral model. This issues facing general hospitals in the development of emergency care are clarified. The need for further research, program development, and clinical implementation is discussed.     

Behavioral interventions and stress management training for hospitalized adolescents and young adults with cystic fibrosis

Recent studies have demonstrated that the majority of cystic fibrosis (CF) patients are not at high risk for developing psychological problems. Clinical studies emphasizing the development of adaptive coping mechanisms in these patients have been suggested as a more appropriate line of research. The purpose of the present paper is to describe our experience in teaching various behavioral and stress management strategies to help CF patients. Behavioral counseling, relaxation training, and biofeedback have all been used with these patients to help them manage a number of problems more effectively. The predominant presenting problems have included elevated anxiety levels, sleeping difficulties, pain, and hyperventilation episodes. The typical treatment course with these patients is described and a case example is given to help elucidate the nature of behavioral interventions. Patient satisfaction ratings indicate that most patients view these techniques positively. Clinical observations suggest that the acquisition of behavioral coping skills may enhance the CF patient's perceived control of his/her situation, reduce the level of pain and anxiety, and enhance the quality of life.     

Do cancer patients really want counseling?

Newly diagnosed cancer patients who were screened as being “at risk” for future psychosocial distress were offered a counseling program, covering the period from hospital discharge to resumption of regular activity. More than two-thirds of “at risk” patients accepted. Those who refused the program tended to be more antagonistic or apprehensive than those who accepted. Refusers denied difficulties, minimized problems, and in certain instances were truculent and suspicious. Some refusers did not wish to be interviewed, for fear that social and emotional equilibrium would be disturbed; they rejected counseling, which was felt to be either an immediate threat or an omen of disaster. Accepters, while as much “at risk”, did not deny, but felt more hopeless. Differences in cancer site, stage, symptoms, treatment, availability of significant others, age, sex, social status, and so forth were not significant.     

Preventive psychosocial intervention with newly diagnosed cancer patients

To study the effectiveness of preventive intervention in lowering emotional distress and improving coping, 381 newly diagnosed cancer patients were assessed shortly after the time of initial diagnosis. Subjects predicted by a screening instrument to be at risk for high levels of emotional distress and poor coping during the second through sixth months of their illness were randomly allocated to one of two short-term intervention programs (N=59). Specific techniques to lower distress and improve coping were given during the four weeks following diagnosis. A control group (N=58) received no intervention. All were followed at two-month to 6-month intervals by interview and testing. There was a significant lowering of emotional distress in the intervention group as compared to the control group (p < 0.05). There was also a significant increase in the level of problem resolution in the intervention group (p < 0.01), although the numbers of problems experienced by both groups were no different.     

Teaching psychosocial issues to medical house staff: A liaison program on an oncology service

In a one-year controlled study, the authors assessed the impact of an active consultation-liaison teaching program on the attitudes of medical house officers toward psychosocial issues related to the care of oncology patients, consultation-liaison psychiatry, and its importance for them and their patients. Fifty medical interns, residents, and fellows, divided into a test group (N = 25) and a control group (N = 25), were followed during a one year period. A 52-item questionnaire was administered to test group subjects before and after a one- to two-month clinical rotation on the hematology/oncology service, and to the control group members at similar intervals. After their experience with consultation-liaison psychiatry, the test group members showed a significant positive change in the importance they placed upon psychiatric consultations, case presentations and the role of psychiatrists in the development of their attitudes toward the psychological case of cancer patients. The house officers also recorded significant positive changes in their attitudes toward the effectiveness and role of the consultation-liaison service in educating and assisting them in learning more about psychosocial issues. The control group demonstrated no significant change.     

Psychiatry's identity crisis: a critical rational remedy.

Psychiatry has several partial identities reflecting its biologic, psychoanalytic, and social subspecialities. It has, however, no encompassing professional identity. This identity requires three features: (a) a common language and procedure for assessing psychopathology, (b) a common method for evaluation and use of knowledge from outside psychiatry, and (c) a common set of values regarding clinical and research activities. The authors discuss the clinical, biologic, and sociocultural psychiatric traditions to identify the roots and consequences of psychiatry's fragmented state. Psychiatry's identity problems cannot be solved by ignoring them or simply becoming more "medical." Rather, the authors propose a remedy--critical rationality--to help resolve the crisis. Critical rationality requires a discimplined approach to psychiatric knowledge that underscores the necessity of methodologic rigor, practicality, and mid-range theorizing (rationality); and the equal necessity for systematic self-criticism, reform, self-awareness, and attention to the ethical dimensions in teaching, practice, and research (critical).     

Adverse psychological sequelae associated with total joint replacement surgery

Although total joint replacement surgery is generally successful in pain relief and improved joint function, adverse psychological sequelae sometimes do occur. This report highlights potential problems associated with total joint replacement surgery and illustrates with brief cases from a referral hospital for arthritis patients. An appreciation of psychological factors can ensure patients' motivation to participate in the rehabilitative efforts after surgery, and thus enhance optimal results from the surgery.     

Continuity of care: A patient-centered model

A patient-centered model for the delivery of mental health services to acute psychiatric patients is described. This model may also be applicable to more comprehensive delivery systems. Mental health systems usually are centered around separate staff and physical locations of various units. The psychiatric patient's sensitivity to disruptions of the environment may respond favorably to a system of patient-staff continuity, which avoids fragmentation of care.The patient-centered care model allows the treatment staff to follow patients throughout the entire course of their treatment program. Impressions are that this model results in a marked decrease in acting out, suicide gestures, and other regressive manifestations at the time of transfer from one phase of the program to another. Specific issues of patient care account-ability, patient follow-through, and compliance with treatment recomendations, and cost-effectiveness are also discussed. In addition, staff satisfaction and professional growth are enhanced by the ability to follow patients and families through all phases of their treatment. Decreased staff turnover and increased interdisciplinary communication can enhance staff growth as well as patient care.     

Stress,adaptation, and immunity: Studies in humans

The notion that some combination of excessive “stress” and inadequate coping may increase susceptibility to illness has long been part of our conventional wisdom. Yet, until recently, there have been few data to support this contention. During the past decade, the relationship between stress, adaptation, and human immunity has come under closer scrutiny. There is now considerable evidence that certain types of experimental and naturally-occurring stress are associated with alterations of human cellular immune function. Furthermore, these observed changes generally are immunosuppressive. However, the mediating mechanisms underlying this relationship remain poorly understood. Critical factors in the stress-adaptation-immunity relationship are: the duration and proximity of the stressor, the adaptive capacity of the individual, and the differential effects of certain stressors on immunologic components.     

Psychiatric treatment in severe brain injury: A case report

A patient with severe, penetrating brain injury is presented. The patient was in psychiatric treatment for four years, starting two months after the injury; psychological tests were administered four times. By most criteria, the patient recovered completely. The case confirmed earlier observations that intelligence measured by verbal subtests, recovers faster than that measured by performance subtests. The latter continued to improve during the two to four year period after injury. The case clearly indicates the emotional and psychological problems that arise in the presence of severe brain damage. These reactions may hamper rehabilitation, although the gross psychological disabilities caused by the brain injury have improved. It is suggested, therefore, that brain damaged patients should receive psychiatric treatment. Some of the problems of such psychotherapeutic treatment are briefly discussed.     

Should general hospitals accept involuntary psychiatric patients?: A panel discussion

The issue of whether involuntary patients can be treated safely and effectively on inpatient psychiatry units of general hospitals is addressed from several points of view. Parallels are drawn between contemporary reform efforts and 19th century hospital psychiatry, and the danger of repeating errors of the past is pointed out. An account follows, illustrating the recent planning process for mental health care in Massachusetts and recommending the active participation of psychiatrists in that process. Also discussed are the differences in the process of establishing a treatment alliance with voluntary and involuntary patients. The practical considerations in the development of a locked unit in a general hospital are explored, with respect to its effect on reimbursement, the private practice model, and the length and appropriateness of stay. In conclusion, the shared concern is stated that, in respect to making the transition from one system of care to another, safeguards be built in to protect and expand good treatment.     

Defining discipline roles in consultation psychiatry: the multidisciplinary team approach to psychosocial oncology

Multiple mental health professions are often involved in the management of cancer patients. Psychiatry, psychology, social work, and nursing have all developed entrees to the medical setting that lead to clinical involvement of one or more of these professions at any given time. Much confusion remains about the specific contribution of these different mental health professions, and lack of role definition makes it difficult for programs to logically plan for mental health services or for services already in place to organize themselves in a collaborative manner. While these disciplines have interacted formally and informally in a number of settings for many years, there have been few published attempts to delineate the unique contributions of each and to suggest a model for their collaborative interaction. This paper attempts to define the unique contributions of each of these disciplines in relation to an oncology consultation program in a general hospital setting. The definitions are proposed as a model that can be generalized to other consultation programs.     

Psychiatric consultation: A survey and review of utilization

Regardless of what has been written of the need for evaluation of the psychiatric consultation service in the general hospital, there is a dearth of such studies.¹ In a 400-bed university-affiliated general hospital, we have recently increased the staffing and scope of consultation service. In a period of 2 mo, two and one-half staff positions were added. Here was a point at which to take stock of prior performance and future course. One evaluative approach herein involves a survey of recipients of the consultation service, staff physicians of the hospital. We were also interested in the relationship between the findings of such a survey instrument and the actual clinical practice.To that end, we used our service records to explore the following possible associations: Would concurrent use of consultation services by various subgroups within the staff reflect survey support and approval? How would survey respondents' declared profile of reasons to request consultation compare with actual practice?