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Basic readings in consultation psychiatry
CONSULTATION-LIAISON PSYCHIATRY
PAUL C. MOHL, M.D. STEVEN A. COHEN-COLE, M.D.
Basic readings in consultation psychiatry As tertiary care medicine has grown more specialized, the clinical need for and cost-effectiveness of psychiatric and psychosocial care for medical patients have increasingly been recognized. Similarly, the growth of primary care programs in medicine and family practice has led to parallel needs for psychiatric and psychosocial services for general medical patients, and for psychiatric training of medical housestaff. In recognition of these relatively new demands and opportunities for psychiatric services and training, the Consultation-Liaison (C-L) Section of the Association for Academic Psychiatry (AAP) has been working to develop a more thorough and intellectually coherent basis for C-L psychiatry. Under the chairmanship of Don Lipsitt, M.D., the C-L section has encouraged required C-L rotations in general psychiatry residencies and it has proposed a set of basic objectives for provision of competent consulta-
tion to medical colleagues. I These objectives, developed by a task force chaired by one of the authors (SC-C), were derived from recommendations of leading academic C-L psychiatrists concerning the basic knowledge and skills needed by general psychiatrists in consultation psychiatry. To increase the usefulness of these objectives, the Section then sought to develop a set of readings tied to each of them. It was thought that such a reading list would help the field of C-L psychiatry, as a relatively new area of practice and training, and would further define its distinct educational content and clinical approaches. In order to create this reading list, a task force, chaired by the two authors, solicited readings from AAP members as well as from several additional nationally prominent C-L programs (eg. at UCLA). In all, 617 different readings from 18 different programs were proposed for the final list. Evaluation forms were developed to rate each ar-
Dr. Mohl is an associate professor ofpsychiatry at the University ofTexas Health Science Center. and Dr. Cohen-Cole is an associate professor ofpsychiatry at Emory University. Reprint requests to Dr. Mohl in the Department ofPsychiatry. University ofTexas Health Science Center at San Antonio. 7703 Floyd Curl Drive. San Antonio. TX. 78284.
ticle's comprehensiveness, relevance, clarity. brevity, current content, and overall suitability for a basic reading list. All recommended readings were evaluated by at least one of 27 reviewers as well as by one of II task force members (see Appendix). Task force members then made final recommendations for the list based on these evaluations. When there was disagreement or lack of certainty, the two co-authors collaboratively made final decisions concerning which readings should be recommended for each objective. A draft reading list was presented to the C-L section of the AAP at its annual meeting in March 1984. This presentation led to additional modifications. The final choice of 86 recommended readings tied to 46 specific objectives is listed below. These are suggested as basic readings on material that the Section believed should be mastered by psychiatrists. Terminal objective To provide competent consultation to nonpsychiatric medical personnel regarding psychiatric and behavioral problems in medical patients. This re(continued)
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Basic readings
quires the mastery and integration of specific knowledge objectives with a broad range of clinical skills. Enabling knowledge objectives Cohen-Cole. SA. Haggerty J. Raft D: Objectives for Residents in Consultation Psychiatry: Recommendations of a task force. Psychosomatics 23:699-703.1982.
A. Tbe consultation process I. Describe the objectives, responsibilities, authority, and limitations of the psychiatric consultant in medical settings. Discuss the way these vary in different situations. Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine: I. General principles. Psychos om Med 29:153-171. 1967.
2. Describe the way the consultation relationship is different from supervision, referral, or psychotherapy. Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine: II. Clinical aspects. PsychosomMed29:201-224.1967.
3. Discuss the way common factors influence the initiation, process, and outcome of a consultation. Meyer E, Mendelson M: Psychiatric consultations with patients on medical and surgical wards: Patterns and processes. Psychiatry 24:179220,1961. Popkin MK, Mackenzie lB. Hall RCW. et al: Consultees' concordance with consultants' psychotropic drug recommendations: Related variables. Arch Gen Psychiatry37:1017-1021.1980. Popkin MK. Mackenzie TB. Hall RCW. et al: Physicians' concordance with consultants' psychotropic drug recommendations for psychotropic medication. Arch Gen Psychiatry 36:386-389. 1979. Koran LM, Van Natta J. Stephens
JR, et al: PCJtients' reactions to psychiatric consultation. JAMA 241:1603-1605.1979.
Bibring G: Psychiatry in medical practice in the general hospital. N Engl J Med 254:366-372. 1956.
4. Describe different types of psychiatric consultation in medical settings (eg, patient-centered, physician-centered, and nurse-centered). Discuss indications, objectives, and relevant strategies for each.
Groves JE: Taking care of the hateful patient. N Engl J Med 298:883887,1978.
Glazer WM, Astrachan BM: Social systems approach to consultationliaison psychiatry. Int J Psychiatry Med9:33-47,1978-1979.
4. Describe the basic components of general systems theory as they relate to understanding and influencing health outcomes. Engel GL: The need for a new medical model. Science 196: 129-136, 1977.
Caldwell T. Weiner MF: Stresses and coping in ICU nursing: II. Support groups on intensive care units. Gen Hosp Psychiatry 3:129-134, 1981.
Miller WB: Psychiatric consultation. Part I: A general systems approach. Psychiatry Med 4: 135145,1973.
Mohl PC: The liaison psychiatrist: Social role and status. Psychosomatics 20:19-23.1979.
C. Clinical syndromes Describe the signs and symptoms, differential diagnosis, psychodynamics, psychophysiology, epidemiology, and course ofthose psychiatric and behavioral conditions that are most commonly encountered in medical settings. I. Psychiatric conditions a. DeliriUm/dementia
Hengeveld MW. Rooymans HGM: The relevance of a staff-oriented approach in consultation psychiatry: A preliminary study. Gen Hosp Psychiatry 5:259-264. 1983.
B. Biopsycbosocial dimensions of medical practice I. Describe the influence of psychological and social variables on the predisposition, onset, course, and outcome of somatic illness.
Glickman, L: Psychiatric Consultation in the General Hospital. New York. Marcel Dekker. 1980, pp 55114.
Cohen F: Stress and bodily illness. Psychiatr Clin North Am 4:269-286, 1981.
McAllister TW: Overview: Pseudodementia. Am J Psychiatry 140:528-533, 1983.
2. Describe common patterns of psychological and social adaptation to illness in general, and to specific illnesses.
Lipowski ZJ: Transient cognitive disorders (delirium, acute confusional states) in the elderly. Am J Psychiatry 140: 1426-1436, 1983.
Strain JJ: Psychological reactions to medical illness and hospitalization, in Strain JJ, Grossman S (eds): Psychological Care of the Medically III. New York. Appleton-CenturyCrofts, 1975, pp 23-36.
3. Describe factors that influence a caregiver's responses to patients. Discuss the way these responses affect health outcomes.
b. Somatoform disorders Ford CV: The Somatizing Disorders. New York, Elsevier, 1983, pp 49-97.
c. Factitious disorders Hyler SE, Sussman N: Chronic factitious disorder with physical symptoms (the Munchausen syndrome). Psychiatr Clin North Am 4:365-377, 1981. (continued)
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Ann Intern Med99:240-247. 1983.
Theory to Practice. New York, Oxford University Press. 1977, pp 469-480.
d. Depression in medical conditions
b. Behavioral manifestations of physical illness
Cavanaugh S: The diagnosis and treatment of depression in the medically ill. in Guggenheim FG, Weiner MF (eds): Manual of Psychiatric
Dietch JR: Diagnosis of organic anxiety disorders. Psychosomatics 22:661-669,1981.
Reich p. Gottfried LA: Factitious disorders in a teaching hospital.
Consultation and Emergency Care.
Hall RCW. Popkin MK, DeVaul RA, et al: Physical illness presenting as psychiatric disease. Arch Gen Psy-
New York. Jason Aronson, 1984. pp211-222.
chiatry35:1315-1320.1978.
e. Drug and alcohol dependence, intoxication, and withdrawal
c. Noncompliance (including medication or treatment refusal)
Hackett TP: Alcoholism: Acute and chronic states, in Hackett TP, Cassem N (eds): Massachusetts Gen-
Albert HD, Kornfeld OS: The threat to sign out against medical advice. Ann Intern Med 79:888- 891, 1973.
eral Hospital Handbook of General Hospital Psychiatry. St. Louis, CV
Mosby 1978, pp 15-28. Khantzian EJ, McKenna GJ: Acute toxic and withdrawal reactions associated with drug use and abuse. Ann Intern Med90:361-372, 1979.
f. Psychological factors affecting physical conditions Looney JG, Spitzer RL, Lipp MR: Classifying psychosomatic disorders in DSM-1I1. Psychosomatics 22:6-8, 1981.
g. Sexual disorders in medical patients Kaplan HS: The New Sex Therapy. New York, Brunner/Mazel, 1976. p 75-104. Wise TN: Sexual dysfunction in the medically ill. Psychosomatics 24:787-805,1983.
2. Behavioral conditions a. Behavioral side effects of nonpsychiatric drugs Cluff LE. Caranasos GJ. Stewart RB: Clinical Problems with Drugs. Philadelphia, WB Saunders. 1975, pp 194-196. Davis KL: Psychological effects of nonpsychiatric drugs, in Barchas JD, Berger PA, Ciaranello RD, et al (eds): Psychopharmacology from
Strain JJ: Psychologicallnterventions in Medical Practice. New York, Appleton-Century-Crofts, 1978. pp91-104.
d. Grief, death, and dying Cassem NH, Steward RS: Management and care of the dying patient. Int J Psychiatry Med 6:293-304, 1975.
Zinberg NE (ed): Psychiatry and Medical Practice in a General Hospital. New York, International Uni-
versitiesPress. 1964. pp 108-123. Groves JE: Management of the borderline patient on a medical-surgical ward: The psychiatric consultant's role. Int J Psychiatry Med 6:337-348, 1975. Mohl PC. Burstein AG: The application of Kohutian self-psychology to consultation-liaison psychiatry. Gen Hosp Psychiatry 4: 113-119, 1982.
g. Suicidal and homicidal threats Guggenheim FG: Suicide, in Hackett T, Cassem NH (eds): Massachusetts General Hospital Handbook of General Hospital Psychiatry. St. Louis. CV Mosby, 1978,
pp250-263. Tupin JP: Management of violent patients. in Shader RI (ed): Manual of Psychiatric Therapeutics. Boston. Little, Brown, 1975. pp 125136.
h. Obesity
Greenblatt M: The grieving spouse. AmJ Psychiatry 135:43-47,1978.
Stunkard AJ: Obesity. Philadel· phia, WB Saunders, 1980. pp 1-23.
Jackson 0, Younger S: Patient autonomy and death with dignity. N Engl J Med 301 :404-408, 1979.
i. Sleep disorders Kales A. Kales J: Evaluation and Treatment of Insomnia. New York. Oxford University Press. 1984. pp 134-213. Consensus conference. Drugs and insomnia. The use of medications to promote sleep. JAMA 251 :24102414.1984.
Konior GS. Levine AS: The fear of dying: How patients and their doctors behave. Semin Onco/2:311316,1975.
e. Anxiety in medical conditions or situations (eg, presurgery, postmyocardial infarction, etc) Schuckit MA: Anxiety related to medical disease. J Clin Psychiatry 44:31-37. 1983.
j. Chronic pain Webb WL: Chronic pain. Psychosomatics 24:1053-1063,1983.
f. Personality problems affecting the doctor-patient relationship (eg, the angry, demanding, demeaning, sexually provocative, dependent, or hyper-independent patient).
D.1reatments 1. Effectiveness of psychiatric treatment of medical patients. Outline the data pointing to the clinical effectiveness and cost-effectiveness of the psychiatric care of medical patients.
Kahana RF, Bibring GL: Personality types in medical management. in
Mumford E, Schlesinger HJ, Glass GV: The effects of psychological in(continued)
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MBI.ARI[ (thcr~azine)
Basic readings
because there's no substitute for textbook efficacy TAlms: 10 mg. 15 mg. 25 mg. 50 mg. 100 mn. 150 mg. ano 200 mg th'Ofillilline HCI. USP COIICEllTRATl: 38 "1/11I1 (each ml conlalns 30 mg Ihlolidaline Hel. USP ano 30% alcotool. USP) ano 100 11I1/11I1 (each ml contalns 100 mg thlOfIda/lne HCt USP ano 42% alcohol) MEUAllIL·S· (lIIl"__"ISUSPEIlSIOIl: 2511I11511I1 (each 5 ml cor.lains thiOflllilllne USP equIValent to 25 mg thlorillaline HCI. USP) ano . . .15 11I1 (each 5 ml conlalns thior'llaline USP equivalent 10 100 mg Ih,orollilline HCI. USP)
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Belore prescflllmg or aammlsJermg. see Sanaol Ilteralure tor fUll pro<1uCI mformatlon The lo/lowing IS abrIef summary CoIlnlldlcltlonl: Severe cen!ral nervous system depreSSion. comatose states trom any cause. hypertensive or hypotensive heart disease 01 extreme degree WlIIl'nll: Adminoster cautiouSly to patienls wtIo have prev,ously exhibited a hypersensitivity reaction (eg. bloOd dyscraSlas Jaund,ce) to phenothlazlnes Phenothlazones are capable ot potentiating cenlral nervous system depressants (e.g. anesthetics. opiales. alcohOl. etc) as well as atropine and phOsphOrus onsecticldes. caretully conSider benelit versus risk in less severe disorders During pregnancy administer only when the potential benetits exceed the possible risks 10 mother and felus PrIUMUllIll: There have been ,nlreQuent reports Of leukopenoa andior agranulocytosis and convulsive seizures In epileptic patients anticonvulsant medication ShOuld also be maintained Pigmentary retinopathy. observed plimalily In patients receiving larger than recommended doses. is characteriZed by diminution 01 visual acuity. brownish colollng of VISion. and impallment of nighf vision: lhe posslbilify Of its occurrence may be reduced by remainong within recommended dosage limits Administer cautiously fo patients partiCipating in activities reQuiling complete mental alertness (eg.. driVing). ana oncrease dosage gradually Orthostatic hypotenSion is more common in lemales than on males Do not use ep,nephllne on treating drug-Induced hypotenSion sonce phenothiazines may induce areversed eplnephllne effect on occasion Neurolepfic drugs elevate prolaclin levels. the elevation persists dUling chronic administration. Tissue culture experunents ,nd,cafe that approxlmafely one-thlld 01 human breast cancers are prolactin dependen! on VllrO. a factor of potent,al Importance If the preSCliption 01 these drugs IS cQnlemplaled on apatient With apreviously detected breast cancer. Although disturbances such as galactorrhea. amenorrhea. gynecomaslia and Impotence have been reported. the ctinlcal significance 01 elevated serum prolactin levels IS unknown for most patients. Daily dOses in excess 01300 mg should be used only In severe neuropsychiatllc conditions Aft"" R.lellonl: CentralNervous Syslem - Drowsiness. espeClallyw'th large doses. early In Ireatmenl: onfrequently. pseudoparklnsonlsm and other extrapyramidal symptoms: rarely. nocturnal contusion. hyperactiVity. lethargy. psyChOtiC reactions. restlessness. and headache Autonomic Nervous System - Dryness 01 mouth. blurred vision. constipation. nausea. vomiting. diarrhea. nasal stuffiness. and pallor Enaocrme System - Galactorrhea. breast engorgement, amenorrhea. inhiblllon 01 eJaculation and pellpheral edema Skin - Dermatitis and skin eruptions of the urticarial type. photosenSitivity. Cara,ovascu/ilr System - ECG Changes (see Caraiovascular E!leefs below). Other - Rare cases descllbed as parotid swelling It shOUld be noled that ellicacy. Indications and untoward effects have valled wHh the dillerent Phenothiazines It has been reported that old age lowers the tolerance for phenothiazines: the most common neurological side ellects are parklnsonosm ano akalhlsla. and the risk of agranulocytosis and leukopenia increases The follOWIng reactions have occurred with phenothiazlnes and should be considered whenever one otthese drugs IS used: Aufonomlc Reactions - Mios,s. obslopalion. anorexia. paralyllc Ileus Cutaneous ReacliOnsErythema, exfoloalove dermatilos. contact dermalolos 8100aDyscraslas - Agranulocytosls.leukope· noa. eoSInophilia. thromllOCytopenla. anemia, aplastic anemia. pancytopenia AllergIC ReactIons - Fever. laryngeal edema. angloneuroloC edema. asthma Hef}atoloxlClty - Jaundice. biliary stasis Caraiovascu/ilr Effects - Changes In the terminal portion of electrocardiogram including prOlongallon ot Q. TInlerval. lowering and Inversion 01 T-wave. and appearanceot awave tentatively ldenlllied as a biM Tor a Uwave have been obServed wilh phenothiazlnes. InCluding Mellaril (Ihlorlda/,ne). these appear to be reverSible and due to allered repolarizaloon not myocardial damage. While there is no evidence of acausal relaloonship belween these changes and significant disturbance 01 cardiac rhythm several sudden and unexpected deaths apparently due 10 cardiac arrest have occurred in patients showing Characleristic electrocardiographiC Changes while taking lhe drug. While proposed, periodic electrocardiograms are nol regarded as predictive Hypotension, rarely resuhlng In cardiac arrest ExtriJ{Jyramiaat Symptoms - Akalhlsia. agltallon. motor restlessness, dystonic reacllons, trismus. torticollis. opislhotonus. OCUlogyric crises, tremor, muscular rigIdity, and akinesIa. PersiSlent Tiiraive OySkmesia - Persistenl ana sometimes irreversibte tardive dyskinesia. characterized by rhythmical involuntary movements 01 the tongue, face. mouth, or taw (eg. protrUSion 01 tongue, pulling of cheeks, puckerong of mouth chewing movements) ana sometimes of extremities may occur on long·term therapy or after discontinuation 01 fherapy. the riSk being greater in elderly patients on h'gh-dOse therapy. especially temales: if symptoms appear, discontinue all anllpsychotic agents. Syndrome may be maSked of treatment is reinstituted. dosage is Increased. or antipsychotic agent is switched Fine vermicular movements of tongue may be an early sign. and syndrome may not develop il medication IS stopped atlhattime Endocrine DiSlurliances - MenSlrual irregUlarilles. aUered libidO. gynecomastia. lactation. weight gain. edema, false positive pregnancy tests Uflnary D,sJurliances - Retenllon. Inconllnence Others - Hyperpyrexia: behavioral effects suggestive 01 a paradOXical reaction. Including excite· ment. bizarre dreams. aggravallon of PSychOseS. and toxiC conlusional states: lollowong long-term treatment. apeculiar Skin·eye syndrome marked by progressive pigmentation 01 SkiO or conluncllva arid/or accompanied by discoloration 01 exposed sclera and cornea: stellate or irregular opacities of anterior lens and cornea. systemic lupus erythematosus-like syndrome D.....: Dosage must be individualized according to the degree of mental and emotional disturbance, ana the smallest effective dosage should be determined lor each patient. IMEL·Z3_S/9/831
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Adrrllnostratoon. t980. PlI 10-55 2. Murplly JM Ma"" IranQUIILIer usaoe In psychlalroc paloenlS at Yelerans Admonlstl1l00n tr_llaclllll~ ClIO Tiler 1984 6699-707 3. Granacner RP Jr. Rulh 00 ACO/TlIliIflson ot Ihiorillaline (MEllAAll) and rnlolhlleoe (NAVANE) ,n the trealmenl 01 hospitalized PSycholoc pallenls CUff Tiler Res 1982:31:692·705 4. Baillessaflni RJ Drugs and I!le trealmenl 01 psychlalroc oisolllers. In Gilman AG. Goodman lS. Gilman A(eelS) GoodmanandG,lmans TIleP/larrnacologlCJtBasls 01 TllerapeulICS. eo6 New 'lbrk. MacMiliafl PuIlI'$hlng Co Inc. 1960. PlI39t-418
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tervention on recovery from surgery and heart attacks: An analysis of the literature, Am J Public Health, 72:141-151,1982. Maguire P, Tait A, Brooke M, et al: Effect of counselling on the psychiatric morbidity associated with mastectomy. Br Med J 281: 14541456,1980. Levitan SJ, Kornfeld OS: Clinical and cost benefits of liaison psychiatry_ Am J Psychiatry 138:790793,1981.
2. Organic psychiatric treatments for medical patients. a. Describe indications, contraindications, dosage, and side effects of psychotropic medications for the conditions described above. These include antianxiety, antidepressant, and antipsychotic agents, as well as lithium carbonate. Bernstein JG: Chemotherapy in psychiatry, in Hackett TP, Cassem NH (eds): Massachusetts General Hospital Handbook of General Hospital Psychiatry. St. Louis, CV Mosby, 1978, pp451-482.
b. Describe the way various illnesses or conditions require modification in the customary prescribing practices for psychotropic medications. These include but are not limited to kidney, liver, or heart disease; organic brain syndrome; old age, etc. Greenblatt OJ, Shader RI: Drug interactions in psychopharmacology, in Shader RI (ed): Manual of Psychiatric Therapeutics. Boston, Little, Brown, 1975, pp 269-279. Muskin PR, Glassman AH: The use of tricyclic antidepressants in a medical setting, in Finkel J (ed): Consultation-Liaison Psychiatry: Current Trends and Future Directions_ New York, Grune & Stratton, 1983, pp 137-158. Thompson TL, Moran MG, Nies AS: Psychotropic drug use in the elder(continued)
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MTAlUSf..... " lllIUl.flIWI. AI.COllOUSII IIllICAJIOIl: AHTAIlUSf is III lid in 1Ile mwgemenl 01 seIecI1ld chronic alcoholic pati.nts who nnI to remain in a stalt o' tnlorted sobriety so that SlIPPOrtMo and psyc!lolIltIape lIeII· IIItlll may be applied to best advaI1laOe. (Used aIont. witIloul _ _ and witIloul suPllOfllvt Ihtrapy. AHTABUSE is not a QII' 'or aIc:oholism. and it is unlillely that ~ will have mort INn a brill tfftcl on 1Ile drinking patlefn o' 1Ile chronic: aIcohoIic:.) COIITIW1IIlCA1lOIIS: Patients who are receiving or _ recently I1Ceiwd llItlronidlzolt. p.arJldehydt. alc:ohol. or IIc:ohoH,ontain· ing PlIPIrations. •. g.. cough syrupS. toniCS and the like. should not be given AHTABUSf. ANTASUSE (disul'iram) is contraindic.rted in the presence o' - . . myocardial disease or coronary oc:dUSion. psychoses. and hyptrsensi1ivily to disulfiram or to oilier lliiuram dlrivllives used in pestic:idts and ruIlbtt vulc.rnization.
Basic readings
Iy. N Eng/ J Med 308:194-199; 308: 134-138, 1983.
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AHTAIlUSf should llbIl be administered to a p.atitnt when he Is in a stIt. 0I1k:oho1 intoxiwion or wMout his full kno~. The physician should instruct reIItivts aa:ordingly.
The p.atient must be Mly informed of the AHTASUSE·atc:o/lol reac:. lion. He must be stronoIY CIUlioned ogainst surreptitious drinking whilt taking th. drug. He should be warned to ayoid alcohol in disguised form. i.•.. in sautts. Yineoars. cough mixtures. and - . IIImhIYe Jobons and bid< rulIs. He should also be warned that rtlClions may occur with ak:ohoI up to 14 dIys aher ingesting AHTASUSE. The AHTAIlUSE-.\l.COHOL REACTION: ANTAIlUSE plus alcohol. - . smalll/llOtlnts. produces hushing. llirobbing in head and _ . throbbing _ . resporatory difflQll1y. nausea. aJllioUS yomiting. sw.lling. thirst. chest pain. palpitation. dyspnea. hyperventilation. tachyc.rrdia. hypOtension. syncope. marked uneasiness. wtIkness. vertigo. blurred yision. and confusion. In - . . reactionS llIere may be respiratory depression. cardiovas· cular collapse. arrllythmias. myocardial inlarction. acute conges· tive heart failure. unconSciOusness. convulsIonS. and _ The intensity of the rtlction varies with each individual. but is gentlIIIy PnlllOr1iOnaI to the I/llOtlnts O' ANTABUSE and aJc:ohu; ingtsltd. ORUG INTERACTIONS: Oisu"iram appears to decrease 1Ile rate at whiCh certain drugs are metabotlltd and so may increase the IIlood Itvtls and the possilli1i1y of clinical toxocrty of drugs given c:onc:omitlInl1y. OISULFIRAM SHOULD SE USED WITH CAUTION IN THOSE PATIENTS RECEMNG PHENYTOIN AND ITS CONGENERS. SINCE THE CONCOMITAHT ADMINISTRATION OF THESE TWO DRUGS CAN LEAD TO PHENYTOIN INTOXICATION. h may be necessary to adjust the dosage of oral anticoagulants UlJOIl beginning or slopping disulfiram. Since disulfiram may proJong protllrombin time. Patients taking isoniazid wh.n disulfiram is giyen should be observed tor 11le appearance of unsteadY ~ or mart
Prec:autions.) OPTIC NEURITIS. PERIPHERAL NEURITIS AND POLYNEURITIS MAY OCCUR FOLLOWING ADMINISTRATION OF AHTASUSE. OccaSional Skin eruptions are. as a rult. readIly controlled by _ t administration 01 an antihistaminic drug. In a small numbtt of p.alients. a tranSient mild drOWSineSS. 'ahga' IIilriy. impolenc:e. heada<:he. acneform .ruptions. allergic dlrma· titis, Of a metallic: or gallic:·like aftertaste may be experienced during 1Ile first two _ of Il1erapy. These compiaints usually disappear spontaneously wrift lI1e continuation of lherapy or with
reduced dosage. Psychotic: reactions have been noted. annbutablt in most cases to high dosage. combined toxicriy (wiIh metronldazol. or isoniazid). or to 1Ile unmasking of underlying pSychoses in p.atients stressed by 11le withdrawal of alc:ollol. One case 01 choIestatic: hepatitis has been reponed. but rts rell· tionship to ANTASUSE has not bien unequiYOc:ally tStalJlishtd. One case of fulminlllt hep.ahhs temporally associated wrth admin· istration o. ANTASUSE has bien reponed. IlOUIIE AlII AIlIlIllllTRATlOIl: ANTASUSE (disu"iram) should .....r be administered unW the patient has abstained from alcol1ol for at Itast 12 hours. INITIAL DOSAGE SCHEDULE: In 1Ile first phase of treatment. a !IlIllimlIm 01 SOO mg dirty IS gi·.en in a single dose for one to two
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MAINTENANCE REGIMEN: The ayerage maintenance dose is 250 mg daily (rang•. 125 to 500 mgl: it should not exceed 5OOmgtlaily. DURATION OF THERAPY: Tha daily. uninterrupted administration of ANTASUSE must be continued until1lle p.atient is fully recovered sociIJly and a basis for permanent self-control is establishad. HOW IUl'l'lJED: ANTASUSE-No. 809-Each talJltt (scored) con· tains 250 mg dlsu"iram. in tioltftS 01 lOG-No. 81o-Each talJIel (soortd) c:ontains 500 mg disuniram. in tioltftS of 50 and 1.000.
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c. Describe the indications, contraindications, and side effects of electroconvulsive therapy in patients with physical illnesses. Weiner AD: ECT in the physically ill. J Psychiatr Treat Eva/5:457-462, 1983.
3. Nonorganic treatments Describe indications and contraindications for the nonorganic treatment of the conditions described above. These include: a. Crisis intervention Blacher AS: The briefest encounter: Psychotherapy for medical and surgical patients. Gen Hosp Psychiatry 6:226-232, 1984.
b. Individual brief psychotherapy (including specific techniques of support, clarification, abreaction, confrontation, and interpretation) Viederman M, Perry S: Use of a psychodynamic life narrative in the treatment of depression in the physically ill. Gen Hosp Psychiatry 3:177-185,1980. Stein EH, Murdaugh J, MacCleod JA: Brief psychotherapy of psychiatric reactions to physical illness. Am J Psychiatry 125: 1040-1 047, 1969. Wahl C: The technique of brief psychotherapy with hospitalized psychosomatic patients. tnt J Psychoana/ Psychother 1:69-82, 1972.
c. Individual long-term psychotherapy Karasu TB: Psychotherapy in medical illness. Curr Psychiatry Ther 20:155-166,1981. Krystal H: Alexithymia and psychotherapy. Am J Psychother 33:17-31,1979.
tion rehabilitation: Three- to fouryear follow-up of a controlled trial. Psychosom Med 41 :229-242, 1979. Liebman A, Minuchin S, Baker L: The use of structural family therapy in the treatment of intractable asthma. Am J Psychiatry 131 :535-540, 1974.
e. Behavior therapy AhoadsJM: Psychosomatic illness: A behavioral approach. Psychosomatics 19:601-607,1978. Weddington WW, Blindt K: Behavioral medicine: A new development. Hosp Community Psychiatry 34:702-708,1983.
f. Intervention by nonpsychiatric medical personnel (eg, behavior modification or supportive counseling by referring physician, nurse, or social worker) Gans JS: The consultee-attended interview. Gen Hosp Psychiatry 1:24-30, 1979.
g. Other treatments such as biofeedback, relaxation training, and hypnosis Shapiro D: Biofeedback, in Pasnau AO (ed): Consu/tation-Uaison Psychiatry. New York, Grune & Stratton, 1975, pp87-102. Wain JH: Hypnosis on a consultation-liaison service. Psychosomatics 20:678-689,1979. Frankel FH: Hypnosis as a treatment method in psychosomatic medicine. tnt J Psychiatry Med 6:75-85,1975.
h. Patient education (eg, for nonadherence) Bartlett EE: The contribution of consumer health education to primary care practice: A review. Med Care 18:862-871, 1980.
d. Family and group therapy
Enabling skills objectives
Aahe AH, Ward HW, Hayes V: Brief group therapy in myocardial infarc-
The resident will demonstrate the ability to:
438
PSYCHOSOMATICS
A. Gather data Collect infonnation about the patient (ie, interviewing skill), from the medical chart, from the referring physician, and from relevant other sources (eg, family, ward staff, social agencies, etc). Strain JJ, Grossman S: Psychological Care of the Medically 11/: A Primer in Uaison Psychiatry. New York, Appleton-Century-Crofts, 1975, pp 11- 22.
B. Formulate cases 1. Integrate biologic, psychological, and social contributions to any consultation problem. Miller WB: Psychiatric consultation: Part II. Conceptual and pragmatic issues of formulation. Psychiatry Med4:251-271 , 1973. Leigh H, Feinstein AR, Reiser MF: The patient evaluation grid: A systematic approach to comprehensive care. Gen Hosp Psychiatry 2:3-9, 1980.
2. Clarify the relation of a specific consultation request to the underlying intentions of a referring physician (ie, be able to elucidate the ••actual" versus the "expressed" reason for consultation). SChiff SK, Pilot ML: An approach to psychiatric care in the general hospital. AMA Arch Gen Psychiatry 1:349-357,1959.
3. Design appropriate biologic, psychological, and social interventions for any consultation problem. Edelstein P, Ross WO, Schultz JR: The biopsychosocial approach: Clinical examples from a consultation-liaison service. Part 1. Psychosomatics23:15-19,1982 Ross WO, SChultz JR, Edelstein P: The biopsychosocial approach: Clinical examples from a consultation-liaison service. Part 2. Psychosomatics 23:141-151,1982. Schultz JR, Edelstein P, Ross WO:
MAY 1985· VOL 26·· NO 5
The biopsychosocial approach: Clinical examples from a consultation-liaison service. Part 3: Psychosomatics 23:233-242,1982.
4. Write a tactful, clear, succinct consultation report using nontechnical language (no jargon), which directly answers the questions posed and provides the infonnation necessary to support the recommendations. Garrick TR, Stotland NL: How to write a psychiatric consultation. Am J Psychiatry 139:849-855, 1982. Popkin MK, Mackenzie TB, Callies AL: Improving the effectiveness of psychiatric consultation. Psychosomatics 22:559-563,1981.
C. Intervene 1. Mobilize and teach, when necessary, various nonpsychiatric personnel to deliver appropriate interventions (these include the referring physician, the ward staff, the patient's family, or social agencies). Perry S, Viederman M: Adaptation of residents to consultation-liaison psychiatry: II. Working with nonpsychiatric staff. Gen Hosp Psychiatry 3:149-156, 1981.
2. Choose and utilize appropriate psychotherapeutic strategies in talking with medical patients. These include support, clarification, ventilation, confrontation, and interpretation. Peteet JR: A closer look at the concept of support. Gen Hosp Psychiatry4:19-23,1982.
3. Use appropriate behavioral management techniques such as relaxation therapy, behavior modification. and patient education to improve psychological coping and physical status. Taylor CB: Adult medical disorders, in Bellack AS, Kazdin AE, Hersen M (eds): International HandbookofBehav~rModmcation
and Therapy. New York, Plenum Press, 1982, pp467-500.
4. Recognize and therapeutically uti-
lize emotional reactions (including countertransference feelings) that arise in ward staff, referring physicians, or the psychiatric consultant himselflherself. Perry S, Viederman M: Adaptation of residents to consultation-liaison psychiatry: I. Working with physically ill. Gen Hosp Psychiatry 3:141-147,1981. Mendelson M, Meyer M: Countertransference problems of the liaison psychiatrist. Psychosom Med 23:115-122,1961.
5. Use effective techniques to prevent and reduce noncompliance (clear explanations and instructions, checking patient understanding, checking extent and causes of noncompliance, simplifying regimen, tailoring to existing habits). Stoudemire A, Thompson TL: Medication noncompliance: Systematic approaches to evaluation and intervention. Gen Hosp Psychiatry 5:233-239, 1983.
Discussion This list was developed to help ground the knowledge base of CoL psychiatry in a set of key objectives and accompanying readings. It has not been proposed as a document that should be unilaterally endorsed, recommended, or necessarily applied in totality to all residency programs. Rather, it is seen as a vehicle to help define the field of CoL psychiatry, to aid in training future psychiatrists, and to help currently practicing psychiatrists, trained before the advent of fonnal CoL experiences, to learn of appropriate sources for their own continuing education. The task of choosing one or two basic readings for each of 46 objectives was not an easy one. For many objectives there were so many excellent articles available that the choice for the final recommendations had to be somewhat arbitrary. For a few objec-
439
Basic readings
tives, however. the task force could not locate any fully adequate readings. and our final choices represent the best available. A few C-L classics were omitted because of concerns of length. fit with the current set of objectives, or lack of current relevance. Although many psychiatrists provided input into the formation of this reading list. the two authors must bear full re-
I
clinicians and trainees will be able to test their comprehension and retention of important information from the specific readings that they choose or are assigned to read. 0
REFERENCE 1. Cohen-Cole SA. Haggerty J. Raft 0: Objectives for residents in consultation psychiatry: Recommendations of a task force. Psychoso·
matics 23:699-703. 1982
Appendix T.sk force members Craig Beesley, M.D. Aaron Billowitz, M.D. Bernard Frankel, M.D. Arnold Goldman, M.D JohnJ. Haggerty, M.D. Judith Milne, M.D. Geoffrey Neustadt, M.D. DavId Preven, M.D. Daniel S.P. SChubert, M.D. Alan Stoudemire, M.D. Troy L. Thompson II, M.D.
440
sponsibility for a substantial number of the different choices that were ultimately made. In order to help increase the usefulness of these readings for training and continuing medical education, the CL section of the AAP is now developing a competency-based knowledge examination keyed to each of the basic suggested readings. With this tool.
Reviewers William Anixter, M.D. John Creighton, M.D. Ginette Dreyfuss, M.D. W. Terry Gipson, M.D. Byron Goldberg, D.O. Kevin Hails, M.D. Linda Haines, M.D. John Harding, M.D. Mark Helm, M.D. Jean Werner Helz, M.D. Eric Jensen, M.D. Irving Kitchner, M.D. William M. Patterson, M.D.
Chester Pearlman, M.D. Seymour Perlin, M.D. Pauline S. Powers, M.D. David Raft, M.D. Joseph Rawlings, M.D. William Richardson, M.D. Michael Robinson, M.D. Ellen Rothchild, M.D. Barbara A. SChindler, M.D. Bradley H. Sevin, M.D. Theodore Weiss. M.D. James Winston, M.D. Dean Wollcott, M.D. Ruth P. Zager. M.D.
PSYCHOSOMATICS
PAUL C. MOHL, M.D. STEVEN A. COHEN-COLE, M.D.
Basic readings in consultation psychiatry As tertiary care medicine has grown more specialized, the clinical need for and cost-effectiveness of psychiatric and psychosocial care for medical patients have increasingly been recognized. Similarly, the growth of primary care programs in medicine and family practice has led to parallel needs for psychiatric and psychosocial services for general medical patients, and for psychiatric training of medical housestaff. In recognition of these relatively new demands and opportunities for psychiatric services and training, the Consultation-Liaison (C-L) Section of the Association for Academic Psychiatry (AAP) has been working to develop a more thorough and intellectually coherent basis for C-L psychiatry. Under the chairmanship of Don Lipsitt, M.D., the C-L section has encouraged required C-L rotations in general psychiatry residencies and it has proposed a set of basic objectives for provision of competent consulta-
tion to medical colleagues. I These objectives, developed by a task force chaired by one of the authors (SC-C), were derived from recommendations of leading academic C-L psychiatrists concerning the basic knowledge and skills needed by general psychiatrists in consultation psychiatry. To increase the usefulness of these objectives, the Section then sought to develop a set of readings tied to each of them. It was thought that such a reading list would help the field of C-L psychiatry, as a relatively new area of practice and training, and would further define its distinct educational content and clinical approaches. In order to create this reading list, a task force, chaired by the two authors, solicited readings from AAP members as well as from several additional nationally prominent C-L programs (eg. at UCLA). In all, 617 different readings from 18 different programs were proposed for the final list. Evaluation forms were developed to rate each ar-
Dr. Mohl is an associate professor ofpsychiatry at the University ofTexas Health Science Center. and Dr. Cohen-Cole is an associate professor ofpsychiatry at Emory University. Reprint requests to Dr. Mohl in the Department ofPsychiatry. University ofTexas Health Science Center at San Antonio. 7703 Floyd Curl Drive. San Antonio. TX. 78284.
ticle's comprehensiveness, relevance, clarity. brevity, current content, and overall suitability for a basic reading list. All recommended readings were evaluated by at least one of 27 reviewers as well as by one of II task force members (see Appendix). Task force members then made final recommendations for the list based on these evaluations. When there was disagreement or lack of certainty, the two co-authors collaboratively made final decisions concerning which readings should be recommended for each objective. A draft reading list was presented to the C-L section of the AAP at its annual meeting in March 1984. This presentation led to additional modifications. The final choice of 86 recommended readings tied to 46 specific objectives is listed below. These are suggested as basic readings on material that the Section believed should be mastered by psychiatrists. Terminal objective To provide competent consultation to nonpsychiatric medical personnel regarding psychiatric and behavioral problems in medical patients. This re(continued)
MAY 1985 • VOL 26 • NO 5
431
Basic readings
quires the mastery and integration of specific knowledge objectives with a broad range of clinical skills. Enabling knowledge objectives Cohen-Cole. SA. Haggerty J. Raft D: Objectives for Residents in Consultation Psychiatry: Recommendations of a task force. Psychosomatics 23:699-703.1982.
A. Tbe consultation process I. Describe the objectives, responsibilities, authority, and limitations of the psychiatric consultant in medical settings. Discuss the way these vary in different situations. Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine: I. General principles. Psychos om Med 29:153-171. 1967.
2. Describe the way the consultation relationship is different from supervision, referral, or psychotherapy. Lipowski ZJ: Review of consultation psychiatry and psychosomatic medicine: II. Clinical aspects. PsychosomMed29:201-224.1967.
3. Discuss the way common factors influence the initiation, process, and outcome of a consultation. Meyer E, Mendelson M: Psychiatric consultations with patients on medical and surgical wards: Patterns and processes. Psychiatry 24:179220,1961. Popkin MK, Mackenzie lB. Hall RCW. et al: Consultees' concordance with consultants' psychotropic drug recommendations: Related variables. Arch Gen Psychiatry37:1017-1021.1980. Popkin MK. Mackenzie TB. Hall RCW. et al: Physicians' concordance with consultants' psychotropic drug recommendations for psychotropic medication. Arch Gen Psychiatry 36:386-389. 1979. Koran LM, Van Natta J. Stephens
JR, et al: PCJtients' reactions to psychiatric consultation. JAMA 241:1603-1605.1979.
Bibring G: Psychiatry in medical practice in the general hospital. N Engl J Med 254:366-372. 1956.
4. Describe different types of psychiatric consultation in medical settings (eg, patient-centered, physician-centered, and nurse-centered). Discuss indications, objectives, and relevant strategies for each.
Groves JE: Taking care of the hateful patient. N Engl J Med 298:883887,1978.
Glazer WM, Astrachan BM: Social systems approach to consultationliaison psychiatry. Int J Psychiatry Med9:33-47,1978-1979.
4. Describe the basic components of general systems theory as they relate to understanding and influencing health outcomes. Engel GL: The need for a new medical model. Science 196: 129-136, 1977.
Caldwell T. Weiner MF: Stresses and coping in ICU nursing: II. Support groups on intensive care units. Gen Hosp Psychiatry 3:129-134, 1981.
Miller WB: Psychiatric consultation. Part I: A general systems approach. Psychiatry Med 4: 135145,1973.
Mohl PC: The liaison psychiatrist: Social role and status. Psychosomatics 20:19-23.1979.
C. Clinical syndromes Describe the signs and symptoms, differential diagnosis, psychodynamics, psychophysiology, epidemiology, and course ofthose psychiatric and behavioral conditions that are most commonly encountered in medical settings. I. Psychiatric conditions a. DeliriUm/dementia
Hengeveld MW. Rooymans HGM: The relevance of a staff-oriented approach in consultation psychiatry: A preliminary study. Gen Hosp Psychiatry 5:259-264. 1983.
B. Biopsycbosocial dimensions of medical practice I. Describe the influence of psychological and social variables on the predisposition, onset, course, and outcome of somatic illness.
Glickman, L: Psychiatric Consultation in the General Hospital. New York. Marcel Dekker. 1980, pp 55114.
Cohen F: Stress and bodily illness. Psychiatr Clin North Am 4:269-286, 1981.
McAllister TW: Overview: Pseudodementia. Am J Psychiatry 140:528-533, 1983.
2. Describe common patterns of psychological and social adaptation to illness in general, and to specific illnesses.
Lipowski ZJ: Transient cognitive disorders (delirium, acute confusional states) in the elderly. Am J Psychiatry 140: 1426-1436, 1983.
Strain JJ: Psychological reactions to medical illness and hospitalization, in Strain JJ, Grossman S (eds): Psychological Care of the Medically III. New York. Appleton-CenturyCrofts, 1975, pp 23-36.
3. Describe factors that influence a caregiver's responses to patients. Discuss the way these responses affect health outcomes.
b. Somatoform disorders Ford CV: The Somatizing Disorders. New York, Elsevier, 1983, pp 49-97.
c. Factitious disorders Hyler SE, Sussman N: Chronic factitious disorder with physical symptoms (the Munchausen syndrome). Psychiatr Clin North Am 4:365-377, 1981. (continued)
432
PSYCHOSOMATICS
Ann Intern Med99:240-247. 1983.
Theory to Practice. New York, Oxford University Press. 1977, pp 469-480.
d. Depression in medical conditions
b. Behavioral manifestations of physical illness
Cavanaugh S: The diagnosis and treatment of depression in the medically ill. in Guggenheim FG, Weiner MF (eds): Manual of Psychiatric
Dietch JR: Diagnosis of organic anxiety disorders. Psychosomatics 22:661-669,1981.
Reich p. Gottfried LA: Factitious disorders in a teaching hospital.
Consultation and Emergency Care.
Hall RCW. Popkin MK, DeVaul RA, et al: Physical illness presenting as psychiatric disease. Arch Gen Psy-
New York. Jason Aronson, 1984. pp211-222.
chiatry35:1315-1320.1978.
e. Drug and alcohol dependence, intoxication, and withdrawal
c. Noncompliance (including medication or treatment refusal)
Hackett TP: Alcoholism: Acute and chronic states, in Hackett TP, Cassem N (eds): Massachusetts Gen-
Albert HD, Kornfeld OS: The threat to sign out against medical advice. Ann Intern Med 79:888- 891, 1973.
eral Hospital Handbook of General Hospital Psychiatry. St. Louis, CV
Mosby 1978, pp 15-28. Khantzian EJ, McKenna GJ: Acute toxic and withdrawal reactions associated with drug use and abuse. Ann Intern Med90:361-372, 1979.
f. Psychological factors affecting physical conditions Looney JG, Spitzer RL, Lipp MR: Classifying psychosomatic disorders in DSM-1I1. Psychosomatics 22:6-8, 1981.
g. Sexual disorders in medical patients Kaplan HS: The New Sex Therapy. New York, Brunner/Mazel, 1976. p 75-104. Wise TN: Sexual dysfunction in the medically ill. Psychosomatics 24:787-805,1983.
2. Behavioral conditions a. Behavioral side effects of nonpsychiatric drugs Cluff LE. Caranasos GJ. Stewart RB: Clinical Problems with Drugs. Philadelphia, WB Saunders. 1975, pp 194-196. Davis KL: Psychological effects of nonpsychiatric drugs, in Barchas JD, Berger PA, Ciaranello RD, et al (eds): Psychopharmacology from
Strain JJ: Psychologicallnterventions in Medical Practice. New York, Appleton-Century-Crofts, 1978. pp91-104.
d. Grief, death, and dying Cassem NH, Steward RS: Management and care of the dying patient. Int J Psychiatry Med 6:293-304, 1975.
Zinberg NE (ed): Psychiatry and Medical Practice in a General Hospital. New York, International Uni-
versitiesPress. 1964. pp 108-123. Groves JE: Management of the borderline patient on a medical-surgical ward: The psychiatric consultant's role. Int J Psychiatry Med 6:337-348, 1975. Mohl PC. Burstein AG: The application of Kohutian self-psychology to consultation-liaison psychiatry. Gen Hosp Psychiatry 4: 113-119, 1982.
g. Suicidal and homicidal threats Guggenheim FG: Suicide, in Hackett T, Cassem NH (eds): Massachusetts General Hospital Handbook of General Hospital Psychiatry. St. Louis. CV Mosby, 1978,
pp250-263. Tupin JP: Management of violent patients. in Shader RI (ed): Manual of Psychiatric Therapeutics. Boston. Little, Brown, 1975. pp 125136.
h. Obesity
Greenblatt M: The grieving spouse. AmJ Psychiatry 135:43-47,1978.
Stunkard AJ: Obesity. Philadel· phia, WB Saunders, 1980. pp 1-23.
Jackson 0, Younger S: Patient autonomy and death with dignity. N Engl J Med 301 :404-408, 1979.
i. Sleep disorders Kales A. Kales J: Evaluation and Treatment of Insomnia. New York. Oxford University Press. 1984. pp 134-213. Consensus conference. Drugs and insomnia. The use of medications to promote sleep. JAMA 251 :24102414.1984.
Konior GS. Levine AS: The fear of dying: How patients and their doctors behave. Semin Onco/2:311316,1975.
e. Anxiety in medical conditions or situations (eg, presurgery, postmyocardial infarction, etc) Schuckit MA: Anxiety related to medical disease. J Clin Psychiatry 44:31-37. 1983.
j. Chronic pain Webb WL: Chronic pain. Psychosomatics 24:1053-1063,1983.
f. Personality problems affecting the doctor-patient relationship (eg, the angry, demanding, demeaning, sexually provocative, dependent, or hyper-independent patient).
D.1reatments 1. Effectiveness of psychiatric treatment of medical patients. Outline the data pointing to the clinical effectiveness and cost-effectiveness of the psychiatric care of medical patients.
Kahana RF, Bibring GL: Personality types in medical management. in
Mumford E, Schlesinger HJ, Glass GV: The effects of psychological in(continued)
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MBI.ARI[ (thcr~azine)
Basic readings
because there's no substitute for textbook efficacy TAlms: 10 mg. 15 mg. 25 mg. 50 mg. 100 mn. 150 mg. ano 200 mg th'Ofillilline HCI. USP COIICEllTRATl: 38 "1/11I1 (each ml conlalns 30 mg Ihlolidaline Hel. USP ano 30% alcotool. USP) ano 100 11I1/11I1 (each ml contalns 100 mg thlOfIda/lne HCt USP ano 42% alcohol) MEUAllIL·S· (lIIl"__"ISUSPEIlSIOIl: 2511I11511I1 (each 5 ml cor.lains thiOflllilllne USP equIValent to 25 mg thlorillaline HCI. USP) ano . . .15 11I1 (each 5 ml conlalns thior'llaline USP equivalent 10 100 mg Ih,orollilline HCI. USP)
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Belore prescflllmg or aammlsJermg. see Sanaol Ilteralure tor fUll pro<1uCI mformatlon The lo/lowing IS abrIef summary CoIlnlldlcltlonl: Severe cen!ral nervous system depreSSion. comatose states trom any cause. hypertensive or hypotensive heart disease 01 extreme degree WlIIl'nll: Adminoster cautiouSly to patienls wtIo have prev,ously exhibited a hypersensitivity reaction (eg. bloOd dyscraSlas Jaund,ce) to phenothlazlnes Phenothlazones are capable ot potentiating cenlral nervous system depressants (e.g. anesthetics. opiales. alcohOl. etc) as well as atropine and phOsphOrus onsecticldes. caretully conSider benelit versus risk in less severe disorders During pregnancy administer only when the potential benetits exceed the possible risks 10 mother and felus PrIUMUllIll: There have been ,nlreQuent reports Of leukopenoa andior agranulocytosis and convulsive seizures In epileptic patients anticonvulsant medication ShOuld also be maintained Pigmentary retinopathy. observed plimalily In patients receiving larger than recommended doses. is characteriZed by diminution 01 visual acuity. brownish colollng of VISion. and impallment of nighf vision: lhe posslbilify Of its occurrence may be reduced by remainong within recommended dosage limits Administer cautiously fo patients partiCipating in activities reQuiling complete mental alertness (eg.. driVing). ana oncrease dosage gradually Orthostatic hypotenSion is more common in lemales than on males Do not use ep,nephllne on treating drug-Induced hypotenSion sonce phenothiazines may induce areversed eplnephllne effect on occasion Neurolepfic drugs elevate prolaclin levels. the elevation persists dUling chronic administration. Tissue culture experunents ,nd,cafe that approxlmafely one-thlld 01 human breast cancers are prolactin dependen! on VllrO. a factor of potent,al Importance If the preSCliption 01 these drugs IS cQnlemplaled on apatient With apreviously detected breast cancer. Although disturbances such as galactorrhea. amenorrhea. gynecomaslia and Impotence have been reported. the ctinlcal significance 01 elevated serum prolactin levels IS unknown for most patients. Daily dOses in excess 01300 mg should be used only In severe neuropsychiatllc conditions Aft"" R.lellonl: CentralNervous Syslem - Drowsiness. espeClallyw'th large doses. early In Ireatmenl: onfrequently. pseudoparklnsonlsm and other extrapyramidal symptoms: rarely. nocturnal contusion. hyperactiVity. lethargy. psyChOtiC reactions. restlessness. and headache Autonomic Nervous System - Dryness 01 mouth. blurred vision. constipation. nausea. vomiting. diarrhea. nasal stuffiness. and pallor Enaocrme System - Galactorrhea. breast engorgement, amenorrhea. inhiblllon 01 eJaculation and pellpheral edema Skin - Dermatitis and skin eruptions of the urticarial type. photosenSitivity. Cara,ovascu/ilr System - ECG Changes (see Caraiovascular E!leefs below). Other - Rare cases descllbed as parotid swelling It shOUld be noled that ellicacy. Indications and untoward effects have valled wHh the dillerent Phenothiazines It has been reported that old age lowers the tolerance for phenothiazines: the most common neurological side ellects are parklnsonosm ano akalhlsla. and the risk of agranulocytosis and leukopenia increases The follOWIng reactions have occurred with phenothiazlnes and should be considered whenever one otthese drugs IS used: Aufonomlc Reactions - Mios,s. obslopalion. anorexia. paralyllc Ileus Cutaneous ReacliOnsErythema, exfoloalove dermatilos. contact dermalolos 8100aDyscraslas - Agranulocytosls.leukope· noa. eoSInophilia. thromllOCytopenla. anemia, aplastic anemia. pancytopenia AllergIC ReactIons - Fever. laryngeal edema. angloneuroloC edema. asthma Hef}atoloxlClty - Jaundice. biliary stasis Caraiovascu/ilr Effects - Changes In the terminal portion of electrocardiogram including prOlongallon ot Q. TInlerval. lowering and Inversion 01 T-wave. and appearanceot awave tentatively ldenlllied as a biM Tor a Uwave have been obServed wilh phenothiazlnes. InCluding Mellaril (Ihlorlda/,ne). these appear to be reverSible and due to allered repolarizaloon not myocardial damage. While there is no evidence of acausal relaloonship belween these changes and significant disturbance 01 cardiac rhythm several sudden and unexpected deaths apparently due 10 cardiac arrest have occurred in patients showing Characleristic electrocardiographiC Changes while taking lhe drug. While proposed, periodic electrocardiograms are nol regarded as predictive Hypotension, rarely resuhlng In cardiac arrest ExtriJ{Jyramiaat Symptoms - Akalhlsia. agltallon. motor restlessness, dystonic reacllons, trismus. torticollis. opislhotonus. OCUlogyric crises, tremor, muscular rigIdity, and akinesIa. PersiSlent Tiiraive OySkmesia - Persistenl ana sometimes irreversibte tardive dyskinesia. characterized by rhythmical involuntary movements 01 the tongue, face. mouth, or taw (eg. protrUSion 01 tongue, pulling of cheeks, puckerong of mouth chewing movements) ana sometimes of extremities may occur on long·term therapy or after discontinuation 01 fherapy. the riSk being greater in elderly patients on h'gh-dOse therapy. especially temales: if symptoms appear, discontinue all anllpsychotic agents. Syndrome may be maSked of treatment is reinstituted. dosage is Increased. or antipsychotic agent is switched Fine vermicular movements of tongue may be an early sign. and syndrome may not develop il medication IS stopped atlhattime Endocrine DiSlurliances - MenSlrual irregUlarilles. aUered libidO. gynecomastia. lactation. weight gain. edema, false positive pregnancy tests Uflnary D,sJurliances - Retenllon. Inconllnence Others - Hyperpyrexia: behavioral effects suggestive 01 a paradOXical reaction. Including excite· ment. bizarre dreams. aggravallon of PSychOseS. and toxiC conlusional states: lollowong long-term treatment. apeculiar Skin·eye syndrome marked by progressive pigmentation 01 SkiO or conluncllva arid/or accompanied by discoloration 01 exposed sclera and cornea: stellate or irregular opacities of anterior lens and cornea. systemic lupus erythematosus-like syndrome D.....: Dosage must be individualized according to the degree of mental and emotional disturbance, ana the smallest effective dosage should be determined lor each patient. IMEL·Z3_S/9/831
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Adrrllnostratoon. t980. PlI 10-55 2. Murplly JM Ma"" IranQUIILIer usaoe In psychlalroc paloenlS at Yelerans Admonlstl1l00n tr_llaclllll~ ClIO Tiler 1984 6699-707 3. Granacner RP Jr. Rulh 00 ACO/TlIliIflson ot Ihiorillaline (MEllAAll) and rnlolhlleoe (NAVANE) ,n the trealmenl 01 hospitalized PSycholoc pallenls CUff Tiler Res 1982:31:692·705 4. Baillessaflni RJ Drugs and I!le trealmenl 01 psychlalroc oisolllers. In Gilman AG. Goodman lS. Gilman A(eelS) GoodmanandG,lmans TIleP/larrnacologlCJtBasls 01 TllerapeulICS. eo6 New 'lbrk. MacMiliafl PuIlI'$hlng Co Inc. 1960. PlI39t-418
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tervention on recovery from surgery and heart attacks: An analysis of the literature, Am J Public Health, 72:141-151,1982. Maguire P, Tait A, Brooke M, et al: Effect of counselling on the psychiatric morbidity associated with mastectomy. Br Med J 281: 14541456,1980. Levitan SJ, Kornfeld OS: Clinical and cost benefits of liaison psychiatry_ Am J Psychiatry 138:790793,1981.
2. Organic psychiatric treatments for medical patients. a. Describe indications, contraindications, dosage, and side effects of psychotropic medications for the conditions described above. These include antianxiety, antidepressant, and antipsychotic agents, as well as lithium carbonate. Bernstein JG: Chemotherapy in psychiatry, in Hackett TP, Cassem NH (eds): Massachusetts General Hospital Handbook of General Hospital Psychiatry. St. Louis, CV Mosby, 1978, pp451-482.
b. Describe the way various illnesses or conditions require modification in the customary prescribing practices for psychotropic medications. These include but are not limited to kidney, liver, or heart disease; organic brain syndrome; old age, etc. Greenblatt OJ, Shader RI: Drug interactions in psychopharmacology, in Shader RI (ed): Manual of Psychiatric Therapeutics. Boston, Little, Brown, 1975, pp 269-279. Muskin PR, Glassman AH: The use of tricyclic antidepressants in a medical setting, in Finkel J (ed): Consultation-Liaison Psychiatry: Current Trends and Future Directions_ New York, Grune & Stratton, 1983, pp 137-158. Thompson TL, Moran MG, Nies AS: Psychotropic drug use in the elder(continued)
436
PSYCHOSOMATICS
_ _I
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MTAlUSf..... " lllIUl.flIWI. AI.COllOUSII IIllICAJIOIl: AHTAIlUSf is III lid in 1Ile mwgemenl 01 seIecI1ld chronic alcoholic pati.nts who nnI to remain in a stalt o' tnlorted sobriety so that SlIPPOrtMo and psyc!lolIltIape lIeII· IIItlll may be applied to best advaI1laOe. (Used aIont. witIloul _ _ and witIloul suPllOfllvt Ihtrapy. AHTABUSE is not a QII' 'or aIc:oholism. and it is unlillely that ~ will have mort INn a brill tfftcl on 1Ile drinking patlefn o' 1Ile chronic: aIcohoIic:.) COIITIW1IIlCA1lOIIS: Patients who are receiving or _ recently I1Ceiwd llItlronidlzolt. p.arJldehydt. alc:ohol. or IIc:ohoH,ontain· ing PlIPIrations. •. g.. cough syrupS. toniCS and the like. should not be given AHTABUSf. ANTASUSE (disul'iram) is contraindic.rted in the presence o' - . . myocardial disease or coronary oc:dUSion. psychoses. and hyptrsensi1ivily to disulfiram or to oilier lliiuram dlrivllives used in pestic:idts and ruIlbtt vulc.rnization.
Basic readings
Iy. N Eng/ J Med 308:194-199; 308: 134-138, 1983.
_S:
AHTAIlUSf should llbIl be administered to a p.atitnt when he Is in a stIt. 0I1k:oho1 intoxiwion or wMout his full kno~. The physician should instruct reIItivts aa:ordingly.
The p.atient must be Mly informed of the AHTASUSE·atc:o/lol reac:. lion. He must be stronoIY CIUlioned ogainst surreptitious drinking whilt taking th. drug. He should be warned to ayoid alcohol in disguised form. i.•.. in sautts. Yineoars. cough mixtures. and - . IIImhIYe Jobons and bid< rulIs. He should also be warned that rtlClions may occur with ak:ohoI up to 14 dIys aher ingesting AHTASUSE. The AHTAIlUSE-.\l.COHOL REACTION: ANTAIlUSE plus alcohol. - . smalll/llOtlnts. produces hushing. llirobbing in head and _ . throbbing _ . resporatory difflQll1y. nausea. aJllioUS yomiting. sw.lling. thirst. chest pain. palpitation. dyspnea. hyperventilation. tachyc.rrdia. hypOtension. syncope. marked uneasiness. wtIkness. vertigo. blurred yision. and confusion. In - . . reactionS llIere may be respiratory depression. cardiovas· cular collapse. arrllythmias. myocardial inlarction. acute conges· tive heart failure. unconSciOusness. convulsIonS. and _ The intensity of the rtlction varies with each individual. but is gentlIIIy PnlllOr1iOnaI to the I/llOtlnts O' ANTABUSE and aJc:ohu; ingtsltd. ORUG INTERACTIONS: Oisu"iram appears to decrease 1Ile rate at whiCh certain drugs are metabotlltd and so may increase the IIlood Itvtls and the possilli1i1y of clinical toxocrty of drugs given c:onc:omitlInl1y. OISULFIRAM SHOULD SE USED WITH CAUTION IN THOSE PATIENTS RECEMNG PHENYTOIN AND ITS CONGENERS. SINCE THE CONCOMITAHT ADMINISTRATION OF THESE TWO DRUGS CAN LEAD TO PHENYTOIN INTOXICATION. h may be necessary to adjust the dosage of oral anticoagulants UlJOIl beginning or slopping disulfiram. Since disulfiram may proJong protllrombin time. Patients taking isoniazid wh.n disulfiram is giyen should be observed tor 11le appearance of unsteadY ~ or mart
Prec:autions.) OPTIC NEURITIS. PERIPHERAL NEURITIS AND POLYNEURITIS MAY OCCUR FOLLOWING ADMINISTRATION OF AHTASUSE. OccaSional Skin eruptions are. as a rult. readIly controlled by _ t administration 01 an antihistaminic drug. In a small numbtt of p.alients. a tranSient mild drOWSineSS. 'ahga' IIilriy. impolenc:e. heada<:he. acneform .ruptions. allergic dlrma· titis, Of a metallic: or gallic:·like aftertaste may be experienced during 1Ile first two _ of Il1erapy. These compiaints usually disappear spontaneously wrift lI1e continuation of lherapy or with
reduced dosage. Psychotic: reactions have been noted. annbutablt in most cases to high dosage. combined toxicriy (wiIh metronldazol. or isoniazid). or to 1Ile unmasking of underlying pSychoses in p.atients stressed by 11le withdrawal of alc:ollol. One case 01 choIestatic: hepatitis has been reponed. but rts rell· tionship to ANTASUSE has not bien unequiYOc:ally tStalJlishtd. One case of fulminlllt hep.ahhs temporally associated wrth admin· istration o. ANTASUSE has bien reponed. IlOUIIE AlII AIlIlIllllTRATlOIl: ANTASUSE (disu"iram) should .....r be administered unW the patient has abstained from alcol1ol for at Itast 12 hours. INITIAL DOSAGE SCHEDULE: In 1Ile first phase of treatment. a !IlIllimlIm 01 SOO mg dirty IS gi·.en in a single dose for one to two
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MAINTENANCE REGIMEN: The ayerage maintenance dose is 250 mg daily (rang•. 125 to 500 mgl: it should not exceed 5OOmgtlaily. DURATION OF THERAPY: Tha daily. uninterrupted administration of ANTASUSE must be continued until1lle p.atient is fully recovered sociIJly and a basis for permanent self-control is establishad. HOW IUl'l'lJED: ANTASUSE-No. 809-Each talJltt (scored) con· tains 250 mg dlsu"iram. in tioltftS 01 lOG-No. 81o-Each talJIel (soortd) c:ontains 500 mg disuniram. in tioltftS of 50 and 1.000.
~I AYERST lASORATORIES .r""IIJ'Il"- New York. NY 10017
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c. Describe the indications, contraindications, and side effects of electroconvulsive therapy in patients with physical illnesses. Weiner AD: ECT in the physically ill. J Psychiatr Treat Eva/5:457-462, 1983.
3. Nonorganic treatments Describe indications and contraindications for the nonorganic treatment of the conditions described above. These include: a. Crisis intervention Blacher AS: The briefest encounter: Psychotherapy for medical and surgical patients. Gen Hosp Psychiatry 6:226-232, 1984.
b. Individual brief psychotherapy (including specific techniques of support, clarification, abreaction, confrontation, and interpretation) Viederman M, Perry S: Use of a psychodynamic life narrative in the treatment of depression in the physically ill. Gen Hosp Psychiatry 3:177-185,1980. Stein EH, Murdaugh J, MacCleod JA: Brief psychotherapy of psychiatric reactions to physical illness. Am J Psychiatry 125: 1040-1 047, 1969. Wahl C: The technique of brief psychotherapy with hospitalized psychosomatic patients. tnt J Psychoana/ Psychother 1:69-82, 1972.
c. Individual long-term psychotherapy Karasu TB: Psychotherapy in medical illness. Curr Psychiatry Ther 20:155-166,1981. Krystal H: Alexithymia and psychotherapy. Am J Psychother 33:17-31,1979.
tion rehabilitation: Three- to fouryear follow-up of a controlled trial. Psychosom Med 41 :229-242, 1979. Liebman A, Minuchin S, Baker L: The use of structural family therapy in the treatment of intractable asthma. Am J Psychiatry 131 :535-540, 1974.
e. Behavior therapy AhoadsJM: Psychosomatic illness: A behavioral approach. Psychosomatics 19:601-607,1978. Weddington WW, Blindt K: Behavioral medicine: A new development. Hosp Community Psychiatry 34:702-708,1983.
f. Intervention by nonpsychiatric medical personnel (eg, behavior modification or supportive counseling by referring physician, nurse, or social worker) Gans JS: The consultee-attended interview. Gen Hosp Psychiatry 1:24-30, 1979.
g. Other treatments such as biofeedback, relaxation training, and hypnosis Shapiro D: Biofeedback, in Pasnau AO (ed): Consu/tation-Uaison Psychiatry. New York, Grune & Stratton, 1975, pp87-102. Wain JH: Hypnosis on a consultation-liaison service. Psychosomatics 20:678-689,1979. Frankel FH: Hypnosis as a treatment method in psychosomatic medicine. tnt J Psychiatry Med 6:75-85,1975.
h. Patient education (eg, for nonadherence) Bartlett EE: The contribution of consumer health education to primary care practice: A review. Med Care 18:862-871, 1980.
d. Family and group therapy
Enabling skills objectives
Aahe AH, Ward HW, Hayes V: Brief group therapy in myocardial infarc-
The resident will demonstrate the ability to:
438
PSYCHOSOMATICS
A. Gather data Collect infonnation about the patient (ie, interviewing skill), from the medical chart, from the referring physician, and from relevant other sources (eg, family, ward staff, social agencies, etc). Strain JJ, Grossman S: Psychological Care of the Medically 11/: A Primer in Uaison Psychiatry. New York, Appleton-Century-Crofts, 1975, pp 11- 22.
B. Formulate cases 1. Integrate biologic, psychological, and social contributions to any consultation problem. Miller WB: Psychiatric consultation: Part II. Conceptual and pragmatic issues of formulation. Psychiatry Med4:251-271 , 1973. Leigh H, Feinstein AR, Reiser MF: The patient evaluation grid: A systematic approach to comprehensive care. Gen Hosp Psychiatry 2:3-9, 1980.
2. Clarify the relation of a specific consultation request to the underlying intentions of a referring physician (ie, be able to elucidate the ••actual" versus the "expressed" reason for consultation). SChiff SK, Pilot ML: An approach to psychiatric care in the general hospital. AMA Arch Gen Psychiatry 1:349-357,1959.
3. Design appropriate biologic, psychological, and social interventions for any consultation problem. Edelstein P, Ross WO, Schultz JR: The biopsychosocial approach: Clinical examples from a consultation-liaison service. Part 1. Psychosomatics23:15-19,1982 Ross WO, SChultz JR, Edelstein P: The biopsychosocial approach: Clinical examples from a consultation-liaison service. Part 2. Psychosomatics 23:141-151,1982. Schultz JR, Edelstein P, Ross WO:
MAY 1985· VOL 26·· NO 5
The biopsychosocial approach: Clinical examples from a consultation-liaison service. Part 3: Psychosomatics 23:233-242,1982.
4. Write a tactful, clear, succinct consultation report using nontechnical language (no jargon), which directly answers the questions posed and provides the infonnation necessary to support the recommendations. Garrick TR, Stotland NL: How to write a psychiatric consultation. Am J Psychiatry 139:849-855, 1982. Popkin MK, Mackenzie TB, Callies AL: Improving the effectiveness of psychiatric consultation. Psychosomatics 22:559-563,1981.
C. Intervene 1. Mobilize and teach, when necessary, various nonpsychiatric personnel to deliver appropriate interventions (these include the referring physician, the ward staff, the patient's family, or social agencies). Perry S, Viederman M: Adaptation of residents to consultation-liaison psychiatry: II. Working with nonpsychiatric staff. Gen Hosp Psychiatry 3:149-156, 1981.
2. Choose and utilize appropriate psychotherapeutic strategies in talking with medical patients. These include support, clarification, ventilation, confrontation, and interpretation. Peteet JR: A closer look at the concept of support. Gen Hosp Psychiatry4:19-23,1982.
3. Use appropriate behavioral management techniques such as relaxation therapy, behavior modification. and patient education to improve psychological coping and physical status. Taylor CB: Adult medical disorders, in Bellack AS, Kazdin AE, Hersen M (eds): International HandbookofBehav~rModmcation
and Therapy. New York, Plenum Press, 1982, pp467-500.
4. Recognize and therapeutically uti-
lize emotional reactions (including countertransference feelings) that arise in ward staff, referring physicians, or the psychiatric consultant himselflherself. Perry S, Viederman M: Adaptation of residents to consultation-liaison psychiatry: I. Working with physically ill. Gen Hosp Psychiatry 3:141-147,1981. Mendelson M, Meyer M: Countertransference problems of the liaison psychiatrist. Psychosom Med 23:115-122,1961.
5. Use effective techniques to prevent and reduce noncompliance (clear explanations and instructions, checking patient understanding, checking extent and causes of noncompliance, simplifying regimen, tailoring to existing habits). Stoudemire A, Thompson TL: Medication noncompliance: Systematic approaches to evaluation and intervention. Gen Hosp Psychiatry 5:233-239, 1983.
Discussion This list was developed to help ground the knowledge base of CoL psychiatry in a set of key objectives and accompanying readings. It has not been proposed as a document that should be unilaterally endorsed, recommended, or necessarily applied in totality to all residency programs. Rather, it is seen as a vehicle to help define the field of CoL psychiatry, to aid in training future psychiatrists, and to help currently practicing psychiatrists, trained before the advent of fonnal CoL experiences, to learn of appropriate sources for their own continuing education. The task of choosing one or two basic readings for each of 46 objectives was not an easy one. For many objectives there were so many excellent articles available that the choice for the final recommendations had to be somewhat arbitrary. For a few objec-
439
Basic readings
tives, however. the task force could not locate any fully adequate readings. and our final choices represent the best available. A few C-L classics were omitted because of concerns of length. fit with the current set of objectives, or lack of current relevance. Although many psychiatrists provided input into the formation of this reading list. the two authors must bear full re-
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clinicians and trainees will be able to test their comprehension and retention of important information from the specific readings that they choose or are assigned to read. 0
REFERENCE 1. Cohen-Cole SA. Haggerty J. Raft 0: Objectives for residents in consultation psychiatry: Recommendations of a task force. Psychoso·
matics 23:699-703. 1982
Appendix T.sk force members Craig Beesley, M.D. Aaron Billowitz, M.D. Bernard Frankel, M.D. Arnold Goldman, M.D JohnJ. Haggerty, M.D. Judith Milne, M.D. Geoffrey Neustadt, M.D. DavId Preven, M.D. Daniel S.P. SChubert, M.D. Alan Stoudemire, M.D. Troy L. Thompson II, M.D.
440
sponsibility for a substantial number of the different choices that were ultimately made. In order to help increase the usefulness of these readings for training and continuing medical education, the CL section of the AAP is now developing a competency-based knowledge examination keyed to each of the basic suggested readings. With this tool.
Reviewers William Anixter, M.D. John Creighton, M.D. Ginette Dreyfuss, M.D. W. Terry Gipson, M.D. Byron Goldberg, D.O. Kevin Hails, M.D. Linda Haines, M.D. John Harding, M.D. Mark Helm, M.D. Jean Werner Helz, M.D. Eric Jensen, M.D. Irving Kitchner, M.D. William M. Patterson, M.D.
Chester Pearlman, M.D. Seymour Perlin, M.D. Pauline S. Powers, M.D. David Raft, M.D. Joseph Rawlings, M.D. William Richardson, M.D. Michael Robinson, M.D. Ellen Rothchild, M.D. Barbara A. SChindler, M.D. Bradley H. Sevin, M.D. Theodore Weiss. M.D. James Winston, M.D. Dean Wollcott, M.D. Ruth P. Zager. M.D.
PSYCHOSOMATICS