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Psychiatric morbidity in a regional plastic surgery centre—one-year review with a proposed categorisation
The British Association of Plastic Surgeons (2004) 57, 440–445
Psychiatric morbidity in a regional plastic surgery centre—one-year review with a proposed categorisation S. Mc Leariea, D.J.A. Orrb,*, A.M. O’Dwyera a
Psychological Medicine Service, St James’s Hospital, Dublin 8, Ireland Department of Plastic Surgery, St James’s Hospital, Dublin 8, Ireland
b
Received 3 July 2003; accepted 17 December 2003
KEYWORDS Psychological medicine; Surgical diagnosis; Psychiatric morbidity; Referral patterns; Clinical contexts
Summary Few studies describe the incidence and nature of psychiatric morbidity in plastic surgery patients. We undertook a review of all referrals from the Plastic Surgery Service to the Psychological Medicine Service over a 1-year period (January – December 2001). Standardised socio-demographic information, nature and cause of injury/defect, surgical intervention, surgical outcome, psychiatric diagnosis and psychiatric follow-up were determined. The majority of patients referred had a significant existing psychiatric illness, had made a suicide/parasuicide attempt, or were burns patients. There was a high rate of referral of plastic surgery inpatients. Liaison with plastic surgery staff to allow rapid identification and early management of psychiatric morbidity is an important role for psychological medicine. We outline a defined categorisation of common contexts in which psychiatric morbidity may present to plastic surgery services. Q 2004 Published by Elsevier Ltd on behalf of The British Association of Plastic Surgeons.
There has been an increasing recognition of psychiatric issues in surgical patients,1 coinciding with a move in recent years towards dedicated psychological medicine services in general hospitals. This provides an opportunity to study different patient groups more closely. Newel2 found that patients who had plastic surgery to the face had higher scores on the hospital anxiety and depression scale, and previous studies have reviewed psychological issues in cosmetic and facial plastic surgery patients.3,4 However, few studies have systematically reviewed psychiatric morbidity in a general plastic surgery patient population. *Corresponding author. Tel.: þ353-1-474-2435; fax: þ 353-1473-0961.
St James’s Hospital is an 800-bedded tertiary referral teaching hospital in the centre of Dublin, Ireland, and incorporates the National Burns Unit. A Psychological Medicine (liaison psychiatry) Service was established in St James’s in July 2000. It was anticipated that provision of this consultant-led service would facilitate awareness, assessment and management of psychiatric issues, allowing documentation of referral patterns and psychiatric morbidity in plastic surgery patients. This paper will present an analysis of patient referrals from the Plastic Surgery Service to the Psychological Medicine Service in St James’s Hospital. It will describe the patterns and types of psychopathology in these patients, and will outline a proposed functional categorisation of the types of psychiatric morbidity
S0007-1226/$ - see front matter Q 2004 Published by Elsevier Ltd on behalf of The British Association of Plastic Surgeons. doi:10.1016/j.bjps.2003.12.037
Psychiatric morbidity in a regional plastic surgery centre
441
Table 1 Sociodemographic details Age (years)
n (%)
Gender
n (%)
Marital status
n (%)
Source of referral
n (%)
11 –19 20 –29 30 –39 40 –49 50 –59 60 þ
15 (18) 29 (34) 22 (26) 14 (16) 3 (4) 2 (2)
Male Female
53 (62) 32 (38)
Single Married Separated Divorced Widowed
54 (64) 14 (16) 10 (12) 6 (7) 1 (1)
Impatient Outpatient
66 (78) 19 (22)
that may exist in patients attending a plastic surgery service.
Methods Between 1st January 2001 and 31st December 2001 details of all patients referred from the Plastic Surgery Service to the Psychological Medicine Service in St James’s Hospital were recorded on a database. We undertook a retrospective case note analysis of the identified patients, and crossreferenced contemporaneous surgical and psychiatric notes with admission details and subsequent detailed reports. Socio-demographic measures, surgical diagnosis, psychiatric diagnosis, outcome, and follow-up were recorded. Surgical diagnosis was categorised as follows: Nature of the injury or tissue defect Cut Burn Crush Congenital Cancer Cause of the injury or defect. Type of intervention carried out. The degree of injury was classified as major, moderate or minor. Major injuries were those involving significant mutilation and/or long-term
functional disability. Included in this category were, for example, major burns and mutilating hand injuries or multiple digit amputations. Minor injuries were those in which a full recovery of function and appearance was expected. Statistical analysis was undertaken using a categorical descriptive comparison between patient groups.
Results In 2001, there were 1994 inpatients admitted under the care of the Plastic Surgery Service, and 3853 new outpatients were reviewed in the plastic surgery clinic. In the same year there were over 1400 new patient referrals to the Psychological Medicine Service—the vast majority (90%) were inpatient referrals which reflects the development of the service as a predominantly inpatient consultation service. Overall 85 plastic surgery patients (1.45%) were referred to the Psychological Medicine Service, comprising 3.3% of plastic surgery inpatients and 0.5% of outpatients. Table 1 illustrates socio-demographic details. Patients referred were mainly young (52% , 30 years), single (64%), males (62%). Table 2 illustrates the nature and cause of injury/defect. The most common type of injury was cut/laceration, 40%. Burns patients accounted for 36% of all referrals. The commonest cause of
Table 2 Nature and Cause of injury/defect Nature of injury/defect
n (%)
Cause of injury/defect
n (%)
Cut/laceration Burn Crush/degloving Cancer Congenital
34 (40) 31 (36) 13 (15) 4 (5) 3 (4)
DSH Domestic Work RTA Congenital Cancer Assault
26 (31) 20 (23) 16 (19) 14 (16) 4 (5) 3 (4) 2 (2)
442
S. Mc Learie et al.
Table 3 Surgical Intervention
Table 5 Length of stay
Surgical intervention
n (%)
Length of stay (days)
N
Skin graft Simple wound repair Tendon repair Major flap reconstruction Amputation/terminalisation Conservative wound management Nerve repair Wound debridement
37 (44) 12 (14) 10 (12) 8 (9) 7 (8) 7 (8) 3 (4) 1 (1)
0–10 11–20 21–30 31–40 41–50 51–60 61–70 71–80 81–90 91–100 100 þ
44 13 10 3 6 0 1 2 2 1 3
injury was deliberate self-harm (DSH), 31%. Only two patients were victims of assaults. Table 3 lists surgical interventions. Skin grafting was the commonest procedure undertaken. Table 4 lists the degree of injury. Almost half, 48%, of patients referred had major injuries. Twenty seven percent were classed as moderate and 25% as minor injuries. Table 5 illustrates length of stay. The majority of patients had short admissions, less than 10 days, reflecting the acute nature and high turnover of a plastic surgery patient population. Table 6 illustrates psychiatric diagnosis and follow-up. Sixty-nine percent of patients referred had a current axis I psychiatric diagnosis when assessed by the Psychological Medicine Service. The most common primary psychiatric diagnosis made was depressive episode, 13%. Psychological Medicine Services in St James’s followed up 23% of patients.
Discussion A Dutch psychological medicine service would anticipate a referral rate of between 1.4 and 3.4% of general hospital inpatients.5 The rate of inpatient referral in this study was 3.3% of all plastic surgery inpatients, at the upper end of that expected. Patients were more likely to be referred if they had a pre-existing psychiatric illness; were burns patients; had self-harmed; or had major disability as outcome. A high proportion of patients referred had a primary psychiatric diagnosis (69%). It is notable that more than one third of referrals Table 4 Degree of Injury Degree of injury
n (%)
Major Moderate Minor
41 (48) 23 (27) 21 (25)
were burns patients (36%). Previous studies have consistently found that burns patients have a high incidence of psychological symptoms.6,7 Possible explanations for the comparatively high incidence of burns patients referred include prolonged length of stay, high incidence of DSH, and close links with Psychological Medicine Services. However, it may reflect a lower recognition of psychological symptoms in other plastic surgery patients. Few victims of assaults or patients following cancer surgery were referred. Although the psychiatric diagnosis is prospective, surgical diagnosis and categorisation of the degree of injury was by a retrospective case note analysis. Children are managed in a separate surgical centre and this explains the lack of congenital anomalies. St James’s Hospital is a public facility, and little or no cosmetic surgery is carried out in the plastic surgery unit. Identifying patients whom we would expect to need referral to psychological medicine may increase recognition of psychiatric morbidity and facilitate the care pathway. Plastic surgery patients are typically cared for by a multidisciplinary team including such disciplines as plastic surgery, nursing, physiotherapy, occupational therapy, speech therapy, clinical nutrition and social work. The initial prompt to refer a patient to the Psychological Medicine Service may come from any of these clinicians and all members of the multidisciplinary team need to be aware of the potential for psychological morbidity in this group of patients. Rather than specifying a list of common psychiatric diagnoses that clinicians should attempt to identify, it may be more useful to define clinical contexts in which psychiatric morbidity should be suspected or sought. We propose five common contexts in which psychological morbidity may coincide or interact with the presentation of a plastic surgical problem. These contexts may be a useful framework that can
Psychiatric morbidity in a regional plastic surgery centre
443
Table 6 Psychiatric diagnosis and follow-up Psychiatric diagnosis
n (%)
Psychiatric follow-up
n (%)
Depressive episode Adjustment disorder Alcohol dependence Post traumatic stress disorder Schizophrenia Opiate dependence Acute stress reaction Bipolar affective disorder Obsessive compulsive disorder Body dysmorphic disorder Anorexia nervosa No current psychiatric diagnosis
11 (13) 10 (12) 9 (11) 7 (8) 6 (7) 6 (7) 5 (6) 2 (2) 1 (1) 1 (1) 1 (1) 26 (31)
Local psychiatry Family doctor Psychological medicine Psychiatric inpatient Substance misuse centre Alcohol services Child psychiatry
28 (33) 21 (25) 20 (23) 6 (7) 5 (6) 4 (5) 1 (1)
be used to raise awareness among clinicians caring for this group of patients.
Patients presenting to plastic surgery as a direct result of psychiatric morbidity The most obvious manifestation of psychiatric morbidity in plastic surgery patients is as a result of DSH. This category includes patients with DSH necessitating tendon or nerve repair, self-inflicted burns, or traumatic accidental injury. Thirty one percent of patients in our study presented with DSH. Psychiatric illness may predispose to trauma in other ways, however, and this category also includes patients experiencing traumatic accidental injury resulting from substance abuse, impaired judgement, or the side effects of medication.
A young male presented with self-inflicted lacerations to both wrists, requiring tendon repair. He was reviewed as an inpatient by the Psychological Medicine Service and a diagnosis was made of severe depressive episode, with symptoms present for 6 weeks prior to the episode of DSH. At the time of assessment there was no suicidal ideation, therefore he was commenced on antidepressant medication and referred for urgent follow-up to the local community mental health team. Other examples in this category include patients who are abusing alcohol or opiates or were intoxicated at the time of the injury, patients with a psychotic illness who may sustain injuries resulting from impaired judgment, or patients on neuroleptic medication.
Psychological/psychiatric conditions presenting as requests for plastic surgery Occasionally patients with a primary psychiatric diagnosis may present to plastic surgeons rather than psychiatrists. This category includes patients with body dysmorphic disorder (imagined ugliness) or somatoform disorders (medically unexplained symptoms). Only one patient in our study was included in this category, reflecting the small amount of cosmetic surgery undertaken in the unit.
A young female presented with a small scar on her forearm following minor surgery several years before to remove a naevus. She had become intensely preoccupied with the scar, believing that it made her ‘ugly’.This belief significantly impacted on her socially, and she was insistent on surgery to improve the appearance of the scar, although objectively the scar had healed well. She attended the psychological medicine outpatient clinic, and over six sessions of cognitive behavioural therapy the beliefs became less prominent and she was able to return to normal functioning.
Patients who experience psychological problems as a result of trauma or plastic surgery interventions Trauma may precipitate psychiatric illness directly, as in, for example, post-traumatic stress disorder. This is generally related to the type of trauma, and typically develops within 6 months of a traumatic event that lies outside normal experience. These patients have clinical features of hyper-arousal, persistent re-experiencing of the event (e.g. nightmares or flashbacks), and avoidance of stimuli
444
related to the trauma. Acute stress reaction (an initial ‘dazed’ state followed by withdrawal or agitation, but rarely lasting more than 3 days), and adjustment disorder (subjective distress and emotional disturbance, usually not exceeding 6 months duration) would be considered on the spectrum of post-traumatic stress reactions. In our study 8% of patients had a diagnosis of PTSD. Twelve percent had a diagnosis of adjustment reaction, and 6% had a diagnosis of acute stress reaction. This category also includes patients who develop post-operative confusional states, and occasionally patients who may have difficulty adjusting to the cosmetic effects of surgery.
A middle-aged male was admitted with extensive burns that required skin grafting. He had received the burns as the result of a firework injury. He was referred to the Psychological Medicine Service 9 months later with clear symptoms of post traumatic stress disorder— intrusive recollections of the accident, persistent arousal, nightmares, and avoidance of the area where the accident occurred. He responded well to treatment with cognitive behavioural therapy.
Patients with a psychiatric condition that interferes with their capacity to engage with plastic surgery treatment Capacity for consent to treatment relies on the ability to comprehend and retain relevant treatment information, believe, and balance that information to come to an informed decision. The capacity to make an informed decision may be impaired by confusion or by primary mental illness. Similarly, physiotherapy and occupational therapy are an essential part of the treatment plan for many patients undergoing reconstructive surgery. Some patients may be unable to engage with such therapy as a result of their mental illness and unless this can be treated in order to allow such engagement, an alternative and perhaps simpler treatment plan may need to be formulated. None of the patients in our study were in this category, reflecting the predominantly inpatient nature of the service.
Examples include patients who refuse to consent to surgery because of underlying psychotic or depressive beliefs and patients with an acute
S. Mc Learie et al.
confusional state who are unable to give informed consent for procedures. Following surgery, patients with depressive illnesses, anxiety disorders, or more rarely psychotic illnesses like schizophrenia, may refuse or be unable to engage with essential post-operative therapies.
Incidental psychological or psychiatric morbidity in a plastic surgery patient population Patients with existing, often long-standing, psychiatric illness may incidentally require plastic surgery. This category includes those with serious mental illness, such as schizophrenia or major mood disorders, who may require monitoring of their mental state and medication to ensure continuity of psychiatric care. This category also includes patients with alcohol dependence who are at risk of acute withdrawal or Wernicke – Korsakoff syndrome.
An elderly female presented with a crush injury following a road traffic accident. She required admission and surgical intervention for skin grafting. She had a long-standing diagnosis of schizophrenia, and had been stable for several years. She was assessed by the Psychological Medicine Service, but there was no evidence of acute psychotic symptoms, and she remained stable throughout admission. Other patients in this category are those with alcohol dependence syndrome, but who present with incidental injuries or conditions. They are likely to require treatment with a reducing dose of chlordiazepoxide, thiamine supplementation and referral for counselling on discharge.
Conclusion This study found significant levels of psychiatric morbidity in patients referred from the plastic surgery service. Referrals were biased towards inpatient referrals, reflecting the current development of the Psychological Medicine Service. Certain groups of plastic surgery patients are at greater risk of psychiatric morbidity and the above categories are an attempt to help clinicians in deciding whom to refer.
Psychiatric morbidity in a regional plastic surgery centre
Acknowledgements We would like to thank Ms Karen Prendergast, departmental secretary, and Ms Allian Crooks and Ms Maria McEvoy, psychology assistants, for their invaluable help and advice at various stages of this project.
3.
4. 5.
References 6. 1. Royal College of Surgeons of England and The Royal College of Psychiatrists (1997). Report of The Working Party on The Psychological Care of Surgical Patients. 2. Newell R. Psychological difficulties amongst plastic surgery
7.
445
ex-patients following surgery to the face: a survey. Br J Plast Surg 2000;53(5):386—92. Meningaud JP, Benadiba L, Servant JM, Herve C, Bertrand JC, Pelicier Y. Depression, anxiety and quality of life: outcome 9 months after facial cosmetic surgery. J Craniomaxillofac Surg 2003;31(1):46—50. Sarwer DB, Crerand CE. Psychological issues in patient outcomes. Facial Plast Surg 2002;18(2):125—33. Hengeveld MW, Rooymans HG, Vecht-van den Bergh R. Psychiatric consultations in a Dutch university hospital: a report on 1814 referrals, compared with a literature review. Gen Hosp Psychiatry 1984;6(4):271—9. Tedstone JE, Tarrier N. An investigation of the prevalence of psychological morbidity in burn-injured patients. Burns 1997; 23(7—8):550—4. Ilechukwu ST. Psychiatry of the medically ill in the burns unit. Psychiatr Clin North Am 2002;25(1):129—47.
Psychiatric morbidity in a regional plastic surgery centre—one-year review with a proposed categorisation S. Mc Leariea, D.J.A. Orrb,*, A.M. O’Dwyera a
Psychological Medicine Service, St James’s Hospital, Dublin 8, Ireland Department of Plastic Surgery, St James’s Hospital, Dublin 8, Ireland
b
Received 3 July 2003; accepted 17 December 2003
KEYWORDS Psychological medicine; Surgical diagnosis; Psychiatric morbidity; Referral patterns; Clinical contexts
Summary Few studies describe the incidence and nature of psychiatric morbidity in plastic surgery patients. We undertook a review of all referrals from the Plastic Surgery Service to the Psychological Medicine Service over a 1-year period (January – December 2001). Standardised socio-demographic information, nature and cause of injury/defect, surgical intervention, surgical outcome, psychiatric diagnosis and psychiatric follow-up were determined. The majority of patients referred had a significant existing psychiatric illness, had made a suicide/parasuicide attempt, or were burns patients. There was a high rate of referral of plastic surgery inpatients. Liaison with plastic surgery staff to allow rapid identification and early management of psychiatric morbidity is an important role for psychological medicine. We outline a defined categorisation of common contexts in which psychiatric morbidity may present to plastic surgery services. Q 2004 Published by Elsevier Ltd on behalf of The British Association of Plastic Surgeons.
There has been an increasing recognition of psychiatric issues in surgical patients,1 coinciding with a move in recent years towards dedicated psychological medicine services in general hospitals. This provides an opportunity to study different patient groups more closely. Newel2 found that patients who had plastic surgery to the face had higher scores on the hospital anxiety and depression scale, and previous studies have reviewed psychological issues in cosmetic and facial plastic surgery patients.3,4 However, few studies have systematically reviewed psychiatric morbidity in a general plastic surgery patient population. *Corresponding author. Tel.: þ353-1-474-2435; fax: þ 353-1473-0961.
St James’s Hospital is an 800-bedded tertiary referral teaching hospital in the centre of Dublin, Ireland, and incorporates the National Burns Unit. A Psychological Medicine (liaison psychiatry) Service was established in St James’s in July 2000. It was anticipated that provision of this consultant-led service would facilitate awareness, assessment and management of psychiatric issues, allowing documentation of referral patterns and psychiatric morbidity in plastic surgery patients. This paper will present an analysis of patient referrals from the Plastic Surgery Service to the Psychological Medicine Service in St James’s Hospital. It will describe the patterns and types of psychopathology in these patients, and will outline a proposed functional categorisation of the types of psychiatric morbidity
S0007-1226/$ - see front matter Q 2004 Published by Elsevier Ltd on behalf of The British Association of Plastic Surgeons. doi:10.1016/j.bjps.2003.12.037
Psychiatric morbidity in a regional plastic surgery centre
441
Table 1 Sociodemographic details Age (years)
n (%)
Gender
n (%)
Marital status
n (%)
Source of referral
n (%)
11 –19 20 –29 30 –39 40 –49 50 –59 60 þ
15 (18) 29 (34) 22 (26) 14 (16) 3 (4) 2 (2)
Male Female
53 (62) 32 (38)
Single Married Separated Divorced Widowed
54 (64) 14 (16) 10 (12) 6 (7) 1 (1)
Impatient Outpatient
66 (78) 19 (22)
that may exist in patients attending a plastic surgery service.
Methods Between 1st January 2001 and 31st December 2001 details of all patients referred from the Plastic Surgery Service to the Psychological Medicine Service in St James’s Hospital were recorded on a database. We undertook a retrospective case note analysis of the identified patients, and crossreferenced contemporaneous surgical and psychiatric notes with admission details and subsequent detailed reports. Socio-demographic measures, surgical diagnosis, psychiatric diagnosis, outcome, and follow-up were recorded. Surgical diagnosis was categorised as follows: Nature of the injury or tissue defect Cut Burn Crush Congenital Cancer Cause of the injury or defect. Type of intervention carried out. The degree of injury was classified as major, moderate or minor. Major injuries were those involving significant mutilation and/or long-term
functional disability. Included in this category were, for example, major burns and mutilating hand injuries or multiple digit amputations. Minor injuries were those in which a full recovery of function and appearance was expected. Statistical analysis was undertaken using a categorical descriptive comparison between patient groups.
Results In 2001, there were 1994 inpatients admitted under the care of the Plastic Surgery Service, and 3853 new outpatients were reviewed in the plastic surgery clinic. In the same year there were over 1400 new patient referrals to the Psychological Medicine Service—the vast majority (90%) were inpatient referrals which reflects the development of the service as a predominantly inpatient consultation service. Overall 85 plastic surgery patients (1.45%) were referred to the Psychological Medicine Service, comprising 3.3% of plastic surgery inpatients and 0.5% of outpatients. Table 1 illustrates socio-demographic details. Patients referred were mainly young (52% , 30 years), single (64%), males (62%). Table 2 illustrates the nature and cause of injury/defect. The most common type of injury was cut/laceration, 40%. Burns patients accounted for 36% of all referrals. The commonest cause of
Table 2 Nature and Cause of injury/defect Nature of injury/defect
n (%)
Cause of injury/defect
n (%)
Cut/laceration Burn Crush/degloving Cancer Congenital
34 (40) 31 (36) 13 (15) 4 (5) 3 (4)
DSH Domestic Work RTA Congenital Cancer Assault
26 (31) 20 (23) 16 (19) 14 (16) 4 (5) 3 (4) 2 (2)
442
S. Mc Learie et al.
Table 3 Surgical Intervention
Table 5 Length of stay
Surgical intervention
n (%)
Length of stay (days)
N
Skin graft Simple wound repair Tendon repair Major flap reconstruction Amputation/terminalisation Conservative wound management Nerve repair Wound debridement
37 (44) 12 (14) 10 (12) 8 (9) 7 (8) 7 (8) 3 (4) 1 (1)
0–10 11–20 21–30 31–40 41–50 51–60 61–70 71–80 81–90 91–100 100 þ
44 13 10 3 6 0 1 2 2 1 3
injury was deliberate self-harm (DSH), 31%. Only two patients were victims of assaults. Table 3 lists surgical interventions. Skin grafting was the commonest procedure undertaken. Table 4 lists the degree of injury. Almost half, 48%, of patients referred had major injuries. Twenty seven percent were classed as moderate and 25% as minor injuries. Table 5 illustrates length of stay. The majority of patients had short admissions, less than 10 days, reflecting the acute nature and high turnover of a plastic surgery patient population. Table 6 illustrates psychiatric diagnosis and follow-up. Sixty-nine percent of patients referred had a current axis I psychiatric diagnosis when assessed by the Psychological Medicine Service. The most common primary psychiatric diagnosis made was depressive episode, 13%. Psychological Medicine Services in St James’s followed up 23% of patients.
Discussion A Dutch psychological medicine service would anticipate a referral rate of between 1.4 and 3.4% of general hospital inpatients.5 The rate of inpatient referral in this study was 3.3% of all plastic surgery inpatients, at the upper end of that expected. Patients were more likely to be referred if they had a pre-existing psychiatric illness; were burns patients; had self-harmed; or had major disability as outcome. A high proportion of patients referred had a primary psychiatric diagnosis (69%). It is notable that more than one third of referrals Table 4 Degree of Injury Degree of injury
n (%)
Major Moderate Minor
41 (48) 23 (27) 21 (25)
were burns patients (36%). Previous studies have consistently found that burns patients have a high incidence of psychological symptoms.6,7 Possible explanations for the comparatively high incidence of burns patients referred include prolonged length of stay, high incidence of DSH, and close links with Psychological Medicine Services. However, it may reflect a lower recognition of psychological symptoms in other plastic surgery patients. Few victims of assaults or patients following cancer surgery were referred. Although the psychiatric diagnosis is prospective, surgical diagnosis and categorisation of the degree of injury was by a retrospective case note analysis. Children are managed in a separate surgical centre and this explains the lack of congenital anomalies. St James’s Hospital is a public facility, and little or no cosmetic surgery is carried out in the plastic surgery unit. Identifying patients whom we would expect to need referral to psychological medicine may increase recognition of psychiatric morbidity and facilitate the care pathway. Plastic surgery patients are typically cared for by a multidisciplinary team including such disciplines as plastic surgery, nursing, physiotherapy, occupational therapy, speech therapy, clinical nutrition and social work. The initial prompt to refer a patient to the Psychological Medicine Service may come from any of these clinicians and all members of the multidisciplinary team need to be aware of the potential for psychological morbidity in this group of patients. Rather than specifying a list of common psychiatric diagnoses that clinicians should attempt to identify, it may be more useful to define clinical contexts in which psychiatric morbidity should be suspected or sought. We propose five common contexts in which psychological morbidity may coincide or interact with the presentation of a plastic surgical problem. These contexts may be a useful framework that can
Psychiatric morbidity in a regional plastic surgery centre
443
Table 6 Psychiatric diagnosis and follow-up Psychiatric diagnosis
n (%)
Psychiatric follow-up
n (%)
Depressive episode Adjustment disorder Alcohol dependence Post traumatic stress disorder Schizophrenia Opiate dependence Acute stress reaction Bipolar affective disorder Obsessive compulsive disorder Body dysmorphic disorder Anorexia nervosa No current psychiatric diagnosis
11 (13) 10 (12) 9 (11) 7 (8) 6 (7) 6 (7) 5 (6) 2 (2) 1 (1) 1 (1) 1 (1) 26 (31)
Local psychiatry Family doctor Psychological medicine Psychiatric inpatient Substance misuse centre Alcohol services Child psychiatry
28 (33) 21 (25) 20 (23) 6 (7) 5 (6) 4 (5) 1 (1)
be used to raise awareness among clinicians caring for this group of patients.
Patients presenting to plastic surgery as a direct result of psychiatric morbidity The most obvious manifestation of psychiatric morbidity in plastic surgery patients is as a result of DSH. This category includes patients with DSH necessitating tendon or nerve repair, self-inflicted burns, or traumatic accidental injury. Thirty one percent of patients in our study presented with DSH. Psychiatric illness may predispose to trauma in other ways, however, and this category also includes patients experiencing traumatic accidental injury resulting from substance abuse, impaired judgement, or the side effects of medication.
A young male presented with self-inflicted lacerations to both wrists, requiring tendon repair. He was reviewed as an inpatient by the Psychological Medicine Service and a diagnosis was made of severe depressive episode, with symptoms present for 6 weeks prior to the episode of DSH. At the time of assessment there was no suicidal ideation, therefore he was commenced on antidepressant medication and referred for urgent follow-up to the local community mental health team. Other examples in this category include patients who are abusing alcohol or opiates or were intoxicated at the time of the injury, patients with a psychotic illness who may sustain injuries resulting from impaired judgment, or patients on neuroleptic medication.
Psychological/psychiatric conditions presenting as requests for plastic surgery Occasionally patients with a primary psychiatric diagnosis may present to plastic surgeons rather than psychiatrists. This category includes patients with body dysmorphic disorder (imagined ugliness) or somatoform disorders (medically unexplained symptoms). Only one patient in our study was included in this category, reflecting the small amount of cosmetic surgery undertaken in the unit.
A young female presented with a small scar on her forearm following minor surgery several years before to remove a naevus. She had become intensely preoccupied with the scar, believing that it made her ‘ugly’.This belief significantly impacted on her socially, and she was insistent on surgery to improve the appearance of the scar, although objectively the scar had healed well. She attended the psychological medicine outpatient clinic, and over six sessions of cognitive behavioural therapy the beliefs became less prominent and she was able to return to normal functioning.
Patients who experience psychological problems as a result of trauma or plastic surgery interventions Trauma may precipitate psychiatric illness directly, as in, for example, post-traumatic stress disorder. This is generally related to the type of trauma, and typically develops within 6 months of a traumatic event that lies outside normal experience. These patients have clinical features of hyper-arousal, persistent re-experiencing of the event (e.g. nightmares or flashbacks), and avoidance of stimuli
444
related to the trauma. Acute stress reaction (an initial ‘dazed’ state followed by withdrawal or agitation, but rarely lasting more than 3 days), and adjustment disorder (subjective distress and emotional disturbance, usually not exceeding 6 months duration) would be considered on the spectrum of post-traumatic stress reactions. In our study 8% of patients had a diagnosis of PTSD. Twelve percent had a diagnosis of adjustment reaction, and 6% had a diagnosis of acute stress reaction. This category also includes patients who develop post-operative confusional states, and occasionally patients who may have difficulty adjusting to the cosmetic effects of surgery.
A middle-aged male was admitted with extensive burns that required skin grafting. He had received the burns as the result of a firework injury. He was referred to the Psychological Medicine Service 9 months later with clear symptoms of post traumatic stress disorder— intrusive recollections of the accident, persistent arousal, nightmares, and avoidance of the area where the accident occurred. He responded well to treatment with cognitive behavioural therapy.
Patients with a psychiatric condition that interferes with their capacity to engage with plastic surgery treatment Capacity for consent to treatment relies on the ability to comprehend and retain relevant treatment information, believe, and balance that information to come to an informed decision. The capacity to make an informed decision may be impaired by confusion or by primary mental illness. Similarly, physiotherapy and occupational therapy are an essential part of the treatment plan for many patients undergoing reconstructive surgery. Some patients may be unable to engage with such therapy as a result of their mental illness and unless this can be treated in order to allow such engagement, an alternative and perhaps simpler treatment plan may need to be formulated. None of the patients in our study were in this category, reflecting the predominantly inpatient nature of the service.
Examples include patients who refuse to consent to surgery because of underlying psychotic or depressive beliefs and patients with an acute
S. Mc Learie et al.
confusional state who are unable to give informed consent for procedures. Following surgery, patients with depressive illnesses, anxiety disorders, or more rarely psychotic illnesses like schizophrenia, may refuse or be unable to engage with essential post-operative therapies.
Incidental psychological or psychiatric morbidity in a plastic surgery patient population Patients with existing, often long-standing, psychiatric illness may incidentally require plastic surgery. This category includes those with serious mental illness, such as schizophrenia or major mood disorders, who may require monitoring of their mental state and medication to ensure continuity of psychiatric care. This category also includes patients with alcohol dependence who are at risk of acute withdrawal or Wernicke – Korsakoff syndrome.
An elderly female presented with a crush injury following a road traffic accident. She required admission and surgical intervention for skin grafting. She had a long-standing diagnosis of schizophrenia, and had been stable for several years. She was assessed by the Psychological Medicine Service, but there was no evidence of acute psychotic symptoms, and she remained stable throughout admission. Other patients in this category are those with alcohol dependence syndrome, but who present with incidental injuries or conditions. They are likely to require treatment with a reducing dose of chlordiazepoxide, thiamine supplementation and referral for counselling on discharge.
Conclusion This study found significant levels of psychiatric morbidity in patients referred from the plastic surgery service. Referrals were biased towards inpatient referrals, reflecting the current development of the Psychological Medicine Service. Certain groups of plastic surgery patients are at greater risk of psychiatric morbidity and the above categories are an attempt to help clinicians in deciding whom to refer.
Psychiatric morbidity in a regional plastic surgery centre
Acknowledgements We would like to thank Ms Karen Prendergast, departmental secretary, and Ms Allian Crooks and Ms Maria McEvoy, psychology assistants, for their invaluable help and advice at various stages of this project.
3.
4. 5.
References 6. 1. Royal College of Surgeons of England and The Royal College of Psychiatrists (1997). Report of The Working Party on The Psychological Care of Surgical Patients. 2. Newell R. Psychological difficulties amongst plastic surgery
7.
445
ex-patients following surgery to the face: a survey. Br J Plast Surg 2000;53(5):386—92. Meningaud JP, Benadiba L, Servant JM, Herve C, Bertrand JC, Pelicier Y. Depression, anxiety and quality of life: outcome 9 months after facial cosmetic surgery. J Craniomaxillofac Surg 2003;31(1):46—50. Sarwer DB, Crerand CE. Psychological issues in patient outcomes. Facial Plast Surg 2002;18(2):125—33. Hengeveld MW, Rooymans HG, Vecht-van den Bergh R. Psychiatric consultations in a Dutch university hospital: a report on 1814 referrals, compared with a literature review. Gen Hosp Psychiatry 1984;6(4):271—9. Tedstone JE, Tarrier N. An investigation of the prevalence of psychological morbidity in burn-injured patients. Burns 1997; 23(7—8):550—4. Ilechukwu ST. Psychiatry of the medically ill in the burns unit. Psychiatr Clin North Am 2002;25(1):129—47.