- Email: [email protected]
Discussion: Liaison psychiatry and the quest for new knowledge
Discussion: Liaison Psychiatryand the Quest for New Knowledge Z. J. Lipowski, M.D. Professor of Psychiatry,
Dartmouth
Medical School, Hanover,
Abstract: Liaison psychiatry has become a subspecialty ofpsychiatry. This Symposium illustrates a new trend for liaison psychiatrists to become involved in collaborative research at the interface of medicine and psychiatry. The contributors have shown how such research can be organized with help ofconsultation-liaison clinical work. Liaison psychiatry’s future will depend on the provision of competent clinical service and high quality research of the type reported here. Liaison psychiatry has grown rapidly in recent years. In the past decade it has become transformed from a rather marginal area of special interest into a full-fledged subspecialty of psychiatry, one concerned with psychiatric problems among the physically ill and somatizing patients. The latter communicate their distress in the form of somatic symptoms and seek medical help even though they may be physically healthy. Clinical research has been an integral part of liaison psychiatry since its beginnings half a century ago, but had lagged behind clinical and teaching activities until recently. Faced with demands for service and teaching, and the need to justify their existence, liaison psychiatrists had little time and energy to spare for serious research. In the past 10 years or so, however, thanks largely to the support of liaison psychiatry by the National Institute of Mental Health, many young and enthusiastic psychiatrists, well trained in research methodology, have entered the field and revitalized the quest for new knowledge at the interface between medicine and psychiatry. This Symposium represents a welcome example of this quest. Doctors Loewenstein and Sharfstein touch on the history of liaison psychiatry in their paper and General Hospital Psychiatry 5, 111-114,
New Hampshire
give George W. Henry a well-deserved credit for pioneering liaison work on medical and surgical wards. In his seminal paper, published in 1929, Henry wrote “In no psychiatric work is it so necessary to determine the facts and the less the psychiatrist is influenced by theories the more accurate are his observations likely to be” (1). This admonition reflects no doubt the influence of Henry’s teacher and the founder of psychobiology, Adolf Meyer. It was not accidental that Meyer’s two pupils, Henry and Dunbar, pioneered liaison psychiatry in America and gave it the fact- and research-oriented psychobiological stamp and the holistic approach (2). It was Dunbar and her coworkers who in 1934 initiated studies on the influence of personality variables on the causation, course, and therapeutic response of several common physical illnesses (3). Furthermore, she was concerned with the personality changes induced by those illnesses. Research papers in this Symposium address some of the same issues and, thus, continue the investigative tradition established by the pioneers of liaison psychiatry. That tradition, one marked by respect for observation and facts, has waxed and waned over the past 50 years. In the 1950s and 1960s it was eclipsed to some extent by a tendency to substitute inspired psychodynamic speculations for careful observation and rigorous search for facts. The distinction between what is a plausible hypothesis and what is an established fact was often blurred, and various disproof-proof hypotheses gained a certain currency. In recent years, however, the scientific attitude has prevailed in American psychiatry generally and liaison psychiatrists have not remained behind.
1983
0 Elsevier Science Publishing Co., Inc. 1983 52 Vanderbilt Avenue, New York, NY 10017
111 ISSN 0163-8343/83&3.00
Z. J. Lipowski
They have turned increasingly from speculative interpretation of behavior, clinical anecdote, and medical evangelism, to a systematic quest for factual knowledge. The present Symposium attests to this growing trend that pioneers like Henry and Dunbar would have applauded. Our colleagues at the NIH Clinical Center have given us an example of how liaison psychiatrists can go about organizing collaborative research projects. They set out first to identify the most promising areas for investigation feasible in their work setting and then used liaison with the various components of the Clinical Center as a strategy aimed at facilitating collaborative studies. One may surmise that by providing prompt, competent, and helpful consultations to their nonpsychiatric colleagues, they managed to create a favorable climate for the initiation of such studies. The latter are in turn likely to strengthen the bonds between the liaison psychiatrists and their medical colleagues and, consequently, to enhance collaboration in matters of patient care and raise the prestige of liaison psychiatry in the Clinical Center. In this way a liaison service may come to be regarded as an integral part of the hospital’s organizational structure and it will have a better chance of withstanding unpredictable vagaries of the funding of liaison work by government agencies. It is an example that other liaison services could profitably follow. To combine clinical service in the form of consultations and liaison with collaborative clinical research is surely the most effective way to demonstrate the value of liaison psychiatry in a given hospital. Loewenstein and Sharfstein touch on the thorny issue of the relative importance of consultations and liaison. Personally, I see no reason why this issue should raise controversy. Consultation is, in my opinion, the cornerstone of the liaison psychiatrist’s clinical service without which he could not justify his existence. Liaison, on the other hand, is a strategy aimed at facilitating collaboration with nonpsychiatric staff in clinical, research, and educational matters (4). Controversy has surrounded the issue of what the optimal amount of liaison should be. Some liaison psychiatrists believe that liaison, being time consuming and not reimbursed by thirdparty payers, is a luxury that we cannot afford. Others extol it as the very essence of liaison psychiatry and disparage consultation as an obsolete, or at least a subordinate, activity. This divisive controversy strikes me as being pointless and harmful to the cause of our subspecialty. The issue of how much liaison a given service should provide has to 112
be decided in each individual case on the basis of how much manpower and time one can afford to devote to it. I have argued elsewhere that a welltrained liaison nurse can provide a goodly proportion of liaison aimed at raising the quality of psychosocial aspects of patient care through her collaboration with medical and surgical nurses (4). Loewenstein and Sharfstein report briefly on the referral patterns for consultation at the Clinical Center. The distribution of psychiatric diagnoses in their patient sample is very similar to ours at Dartmouth (5). Depressive and anxiety disorders and delirium head the list of the assigned diagnoses. It stands to reason that these disorders should become the focus of clinical research by liaison psychiatrists. There is a pressing need, for example, to work out clear criteria for differentiating between a depressive disorder associated with a physical illness on the one hand, and the patient’s despondent mood in response to such illness on the other. Furthermore, we need to have more explicit guidelines on how to distinguish a major depressive disorder from an adjustment disorder with depressive mood. These questions have important epidemiological and therapeutic implications and will have to be addressed by liaison researchers. Dr. Rubinow’s reaffirmation of the holistic foundations of liaison psychiatry is most opportune. We are currently witnessing a major shift in American psychiatry towards a predominantly biological perspective. While this shift has created a favorable climate for research at the interface between medicine and psychiatry, and reflects the zeitgeisf and the advances in medical technology, it should not be allowed to overshadow the view of the whole person. As Woodger, an eminent biologist and philosopher of science, observed, “If we approach psychological problems exclusively from the biological point of view we shall miss some important facts about persons altogether” (6, p. 118). A holistic approach may help us to avoid such misguided reductionism. Rubinow correctly stresses the need for research on the complex interplay of psychosocial and biological variables in a wide range of established physical illnesses. Psychosomatic researchers have tended in the past to disregard such “somatopsychic” studies in favor of the search for the putative etiological role of psychological factors in disease. Yet, such studies are long overdue and may indeed prove to be more fruitful in terms of theoretical and therapeutic advances than the previous quest for psychogenesis of physical illnesses. As
Liaison Psychiatry and New Knowledge
Rubinow points out, phenomenological studies on psychiatric syndromes concurrent with a variety of such illnesses may eventually throw new light on the pathogenetic mechanisms of both medical and psychiatric disorders and, hence, result in more effective preventive and therapeutic methods. In their paper, Becker and Gold illustrate the potential value of comparative phenomenological studies of psychiatric disorders, such as the depressive ones, associated with specific physical illnesses versus those not so associated. Their study of depression associated with Cushing’s disease may, among other things, help us establish the validity or invalidity of the concept of the organic affective syndrome introduced by DSM-III. Furthermore, their work may throw new light on the influence of cortisol on cognitive processes and mood and, hence, advance our understanding of the pathophysiology of primary depressive disorders. It is conceivable that cortisol may play a role in the pathogenesis of depressive pseudodementia and pseudodelirium, conditions so common among the elderly. Systemic lupus erythematosus (SLE) has intrigued psychiatrists for a long time because of its unusually frequent association with a wide spectrum of psychiatric disorders. Liaison psychiatrists are strategically placed to investigate the phenomenology and psychophysiology of this interesting disease, as Dr. Goldman’s study exemplifies. He has focused on the central nervous system SLE, which is a logical approach, since psychiatric complications in this form of the disease are particularly common. Yet, CNS involvement does not seem to account for all of the psychopathology associated with SLE. For example, Kremer et al. have recently reported a high incidence of nonorganic and nonpsychotic psychiatric disorders among SLE patients showing no correlation with either CNS pathology or SLE disease activity (7). Here is another promising area for research involving, concurrently, a phenomenological study of psychopathology and of associated selected biological variables such as the immune complexes. Collaborative research between liaison psychiatrists and surgeons appears to be infrequent, with the possible exception of studies of psychiatric complications of open-heart surgery. Thus, the work of Pickar, Cohen, and Dubois is a welcome example of research at the interface between surgery and psychiatry. The measurement of beta-endorphin immunoreactivity provides a new indicator of stress, yet, if any link to psychological variables such as
anxiety exists, it is still unknown and invites a future study. So far, no correlation has been found between preoperative anxiety and coping behavior on the one hand and postoperative pain on the other (8-10). It is not clear at this time how these negative findings can be related to those of Pickar and his colleagues. Nor do the results of their study provide any support for the claimed benefits of preoperative psychological intervention on the level of perceived postoperative pain. The latter has been reportedly reduced by such diverse methods as adding hydroxyzine, an anxiolytic, or amphetamine, a stimulant, to morphine administered following surgery (11). Furthermore, low endorphin levels have been reported in the CSF of patients with acute postoperative pain (12). All these apparently contradictory findings suggest caution in interpreting the results of the Pickar et al. study. In any case, their work should encourage other liaison psychiatrists to embark on collaborative research with surgeons. The borderland between neurology and psychiatry is a particularly important, if relatively neglected, area that clamors for joint studies by liaison psychiatrists and the neuroscientists. As a former consultant psychiatrist to the Montreal Neurological Institute, I am well aware of the wealth of clinical problems that await such collaborative research (13). Dr. Ebert offers an interesting sample of his work in this area. Liaison psychiatrists have been increasingly involved in recent years in diagnostic investigations of patients with suspected dementia and are, thus, well placed to engage in research in this area. Differentiation between dementia, pseudodementia, delirium, and pseudodelirium is often difficult and hampered by our inadequate knowledge of their respective clinical features. These disorders are particularly common in the elderly, who account for about a third of hospital admissions and of referrals for psychiatric consultation (14). Except for Alzheimer’s disease, research on the epidemiology, pathogenesis, phenomenology, and natural history of organic mental disorders has been very limited. In view of the expected rise in the incidence of these disorders related to the aging of the population, research on them is urgently needed. They represent an area where collaborative studies by liaison psychiatrists and neuroscientists could lead to important advances in knowledge and therapy. To conclude, this Symposium may yet come to be viewed as a landmark, not so much because of the importance of the findings reported, but on 113
Z. J. Lipowski
account of the model it sets up for liaison psychiat&t_s_~verywhere. The contributors .have shown how to take advantage of the potential research opportunities offered by a given clinical setting and how to apply the most advanced investigative techniques to studies at the interface between medicine and psychiatry. If their example is followed by others, the stature of liaison psychiatry will inevitably rise and its acceptance by the nonpsychiatrists increase. This should prove beneficial to our clinical and teaching activities, and help liaison psychiatry ride out the coming financial crisis that is likely to follow cessation of NIMI-I grants.
References 1. Henry GW: Some modem aspects of psychiatry in general hospital practice. Am J Psychiatry 86:481499, 1929 2. Lipowski ZJ: Holistic-medical foundations of American psychiatry: A bicentennial. Am J Psychiatry 138:888-895, 1981 3. Dunbar FH, Wolfe TP, Rioch JM: Psychiatric aspects of medical problems. Am J Psychiatry 93649-679, 1936 4. Lipowski ZJ: Liaison psychiatry, liaison nursing, and behavioral medicine. Compr Psychiatry 22:554-561, 1981 5. Lipowski, ZJ, Wolston EJ: Liaison psychiatry: Referral patterns and their stability over time. Am J Psychiatry 138:1608-1611, 1981
114
6. Woodger JH: Physics, Psychology and Medicine. Cambridge, University Press, 1956 ,,, 7. Kremer JM, Rynes RI, Bartholemew LE, et al. i Nonorganic nonpsychotic psychopathology (NONPP) in patients with systemic lupus erythematosus. Semin Arthritis Rheum 11:182-189, 1981 8. Bruegel MA: Relationship of preoperative anxiety to perception of postoperative pain. Nurs Res 20:26-31, 1971 9. Cohen F, Lazarus RS: Active coping processes, coping dispositions, and recovery from surgery. Psychosom Med 35375-389, 1973 10. Johnston M, Carpenter L: Relationship between preoperative anxiety and postoperative state. Psycho1 Med 10361-367, 1980 11. Hupert C, Yacoub M, Turgeon LR: Effect of hydroxyzine on morphine analgesia for the treatment of postoperative pain. Anesth Analg 59:690-696, 1980 12. Puig MM, Laorden ML, Miralles FS, Olaso MJ: Endorphin levels in cerebrospinal fluid of patients with postoperative and chronic pain. Anesthesiology 57:1-4, 1982 13. Lipowski ZJ, Kiriakos RZ: Borderlands between neurology and psychiatry: Observations in a neurological hospital. Psychiatry Med 3:131-147, 1972 14. Lipowski ZJ: The need to integrate liaison psychiatry and geropsychiatry. Am J Psychiatry, in press Direct reprintrequests to:
Z. J. Lipowski, M.D. Department of Psychiatry Dartmouth Medical School Hanover, NH 03756
Dartmouth
Medical School, Hanover,
Abstract: Liaison psychiatry has become a subspecialty ofpsychiatry. This Symposium illustrates a new trend for liaison psychiatrists to become involved in collaborative research at the interface of medicine and psychiatry. The contributors have shown how such research can be organized with help ofconsultation-liaison clinical work. Liaison psychiatry’s future will depend on the provision of competent clinical service and high quality research of the type reported here. Liaison psychiatry has grown rapidly in recent years. In the past decade it has become transformed from a rather marginal area of special interest into a full-fledged subspecialty of psychiatry, one concerned with psychiatric problems among the physically ill and somatizing patients. The latter communicate their distress in the form of somatic symptoms and seek medical help even though they may be physically healthy. Clinical research has been an integral part of liaison psychiatry since its beginnings half a century ago, but had lagged behind clinical and teaching activities until recently. Faced with demands for service and teaching, and the need to justify their existence, liaison psychiatrists had little time and energy to spare for serious research. In the past 10 years or so, however, thanks largely to the support of liaison psychiatry by the National Institute of Mental Health, many young and enthusiastic psychiatrists, well trained in research methodology, have entered the field and revitalized the quest for new knowledge at the interface between medicine and psychiatry. This Symposium represents a welcome example of this quest. Doctors Loewenstein and Sharfstein touch on the history of liaison psychiatry in their paper and General Hospital Psychiatry 5, 111-114,
New Hampshire
give George W. Henry a well-deserved credit for pioneering liaison work on medical and surgical wards. In his seminal paper, published in 1929, Henry wrote “In no psychiatric work is it so necessary to determine the facts and the less the psychiatrist is influenced by theories the more accurate are his observations likely to be” (1). This admonition reflects no doubt the influence of Henry’s teacher and the founder of psychobiology, Adolf Meyer. It was not accidental that Meyer’s two pupils, Henry and Dunbar, pioneered liaison psychiatry in America and gave it the fact- and research-oriented psychobiological stamp and the holistic approach (2). It was Dunbar and her coworkers who in 1934 initiated studies on the influence of personality variables on the causation, course, and therapeutic response of several common physical illnesses (3). Furthermore, she was concerned with the personality changes induced by those illnesses. Research papers in this Symposium address some of the same issues and, thus, continue the investigative tradition established by the pioneers of liaison psychiatry. That tradition, one marked by respect for observation and facts, has waxed and waned over the past 50 years. In the 1950s and 1960s it was eclipsed to some extent by a tendency to substitute inspired psychodynamic speculations for careful observation and rigorous search for facts. The distinction between what is a plausible hypothesis and what is an established fact was often blurred, and various disproof-proof hypotheses gained a certain currency. In recent years, however, the scientific attitude has prevailed in American psychiatry generally and liaison psychiatrists have not remained behind.
1983
0 Elsevier Science Publishing Co., Inc. 1983 52 Vanderbilt Avenue, New York, NY 10017
111 ISSN 0163-8343/83&3.00
Z. J. Lipowski
They have turned increasingly from speculative interpretation of behavior, clinical anecdote, and medical evangelism, to a systematic quest for factual knowledge. The present Symposium attests to this growing trend that pioneers like Henry and Dunbar would have applauded. Our colleagues at the NIH Clinical Center have given us an example of how liaison psychiatrists can go about organizing collaborative research projects. They set out first to identify the most promising areas for investigation feasible in their work setting and then used liaison with the various components of the Clinical Center as a strategy aimed at facilitating collaborative studies. One may surmise that by providing prompt, competent, and helpful consultations to their nonpsychiatric colleagues, they managed to create a favorable climate for the initiation of such studies. The latter are in turn likely to strengthen the bonds between the liaison psychiatrists and their medical colleagues and, consequently, to enhance collaboration in matters of patient care and raise the prestige of liaison psychiatry in the Clinical Center. In this way a liaison service may come to be regarded as an integral part of the hospital’s organizational structure and it will have a better chance of withstanding unpredictable vagaries of the funding of liaison work by government agencies. It is an example that other liaison services could profitably follow. To combine clinical service in the form of consultations and liaison with collaborative clinical research is surely the most effective way to demonstrate the value of liaison psychiatry in a given hospital. Loewenstein and Sharfstein touch on the thorny issue of the relative importance of consultations and liaison. Personally, I see no reason why this issue should raise controversy. Consultation is, in my opinion, the cornerstone of the liaison psychiatrist’s clinical service without which he could not justify his existence. Liaison, on the other hand, is a strategy aimed at facilitating collaboration with nonpsychiatric staff in clinical, research, and educational matters (4). Controversy has surrounded the issue of what the optimal amount of liaison should be. Some liaison psychiatrists believe that liaison, being time consuming and not reimbursed by thirdparty payers, is a luxury that we cannot afford. Others extol it as the very essence of liaison psychiatry and disparage consultation as an obsolete, or at least a subordinate, activity. This divisive controversy strikes me as being pointless and harmful to the cause of our subspecialty. The issue of how much liaison a given service should provide has to 112
be decided in each individual case on the basis of how much manpower and time one can afford to devote to it. I have argued elsewhere that a welltrained liaison nurse can provide a goodly proportion of liaison aimed at raising the quality of psychosocial aspects of patient care through her collaboration with medical and surgical nurses (4). Loewenstein and Sharfstein report briefly on the referral patterns for consultation at the Clinical Center. The distribution of psychiatric diagnoses in their patient sample is very similar to ours at Dartmouth (5). Depressive and anxiety disorders and delirium head the list of the assigned diagnoses. It stands to reason that these disorders should become the focus of clinical research by liaison psychiatrists. There is a pressing need, for example, to work out clear criteria for differentiating between a depressive disorder associated with a physical illness on the one hand, and the patient’s despondent mood in response to such illness on the other. Furthermore, we need to have more explicit guidelines on how to distinguish a major depressive disorder from an adjustment disorder with depressive mood. These questions have important epidemiological and therapeutic implications and will have to be addressed by liaison researchers. Dr. Rubinow’s reaffirmation of the holistic foundations of liaison psychiatry is most opportune. We are currently witnessing a major shift in American psychiatry towards a predominantly biological perspective. While this shift has created a favorable climate for research at the interface between medicine and psychiatry, and reflects the zeitgeisf and the advances in medical technology, it should not be allowed to overshadow the view of the whole person. As Woodger, an eminent biologist and philosopher of science, observed, “If we approach psychological problems exclusively from the biological point of view we shall miss some important facts about persons altogether” (6, p. 118). A holistic approach may help us to avoid such misguided reductionism. Rubinow correctly stresses the need for research on the complex interplay of psychosocial and biological variables in a wide range of established physical illnesses. Psychosomatic researchers have tended in the past to disregard such “somatopsychic” studies in favor of the search for the putative etiological role of psychological factors in disease. Yet, such studies are long overdue and may indeed prove to be more fruitful in terms of theoretical and therapeutic advances than the previous quest for psychogenesis of physical illnesses. As
Liaison Psychiatry and New Knowledge
Rubinow points out, phenomenological studies on psychiatric syndromes concurrent with a variety of such illnesses may eventually throw new light on the pathogenetic mechanisms of both medical and psychiatric disorders and, hence, result in more effective preventive and therapeutic methods. In their paper, Becker and Gold illustrate the potential value of comparative phenomenological studies of psychiatric disorders, such as the depressive ones, associated with specific physical illnesses versus those not so associated. Their study of depression associated with Cushing’s disease may, among other things, help us establish the validity or invalidity of the concept of the organic affective syndrome introduced by DSM-III. Furthermore, their work may throw new light on the influence of cortisol on cognitive processes and mood and, hence, advance our understanding of the pathophysiology of primary depressive disorders. It is conceivable that cortisol may play a role in the pathogenesis of depressive pseudodementia and pseudodelirium, conditions so common among the elderly. Systemic lupus erythematosus (SLE) has intrigued psychiatrists for a long time because of its unusually frequent association with a wide spectrum of psychiatric disorders. Liaison psychiatrists are strategically placed to investigate the phenomenology and psychophysiology of this interesting disease, as Dr. Goldman’s study exemplifies. He has focused on the central nervous system SLE, which is a logical approach, since psychiatric complications in this form of the disease are particularly common. Yet, CNS involvement does not seem to account for all of the psychopathology associated with SLE. For example, Kremer et al. have recently reported a high incidence of nonorganic and nonpsychotic psychiatric disorders among SLE patients showing no correlation with either CNS pathology or SLE disease activity (7). Here is another promising area for research involving, concurrently, a phenomenological study of psychopathology and of associated selected biological variables such as the immune complexes. Collaborative research between liaison psychiatrists and surgeons appears to be infrequent, with the possible exception of studies of psychiatric complications of open-heart surgery. Thus, the work of Pickar, Cohen, and Dubois is a welcome example of research at the interface between surgery and psychiatry. The measurement of beta-endorphin immunoreactivity provides a new indicator of stress, yet, if any link to psychological variables such as
anxiety exists, it is still unknown and invites a future study. So far, no correlation has been found between preoperative anxiety and coping behavior on the one hand and postoperative pain on the other (8-10). It is not clear at this time how these negative findings can be related to those of Pickar and his colleagues. Nor do the results of their study provide any support for the claimed benefits of preoperative psychological intervention on the level of perceived postoperative pain. The latter has been reportedly reduced by such diverse methods as adding hydroxyzine, an anxiolytic, or amphetamine, a stimulant, to morphine administered following surgery (11). Furthermore, low endorphin levels have been reported in the CSF of patients with acute postoperative pain (12). All these apparently contradictory findings suggest caution in interpreting the results of the Pickar et al. study. In any case, their work should encourage other liaison psychiatrists to embark on collaborative research with surgeons. The borderland between neurology and psychiatry is a particularly important, if relatively neglected, area that clamors for joint studies by liaison psychiatrists and the neuroscientists. As a former consultant psychiatrist to the Montreal Neurological Institute, I am well aware of the wealth of clinical problems that await such collaborative research (13). Dr. Ebert offers an interesting sample of his work in this area. Liaison psychiatrists have been increasingly involved in recent years in diagnostic investigations of patients with suspected dementia and are, thus, well placed to engage in research in this area. Differentiation between dementia, pseudodementia, delirium, and pseudodelirium is often difficult and hampered by our inadequate knowledge of their respective clinical features. These disorders are particularly common in the elderly, who account for about a third of hospital admissions and of referrals for psychiatric consultation (14). Except for Alzheimer’s disease, research on the epidemiology, pathogenesis, phenomenology, and natural history of organic mental disorders has been very limited. In view of the expected rise in the incidence of these disorders related to the aging of the population, research on them is urgently needed. They represent an area where collaborative studies by liaison psychiatrists and neuroscientists could lead to important advances in knowledge and therapy. To conclude, this Symposium may yet come to be viewed as a landmark, not so much because of the importance of the findings reported, but on 113
Z. J. Lipowski
account of the model it sets up for liaison psychiat&t_s_~verywhere. The contributors .have shown how to take advantage of the potential research opportunities offered by a given clinical setting and how to apply the most advanced investigative techniques to studies at the interface between medicine and psychiatry. If their example is followed by others, the stature of liaison psychiatry will inevitably rise and its acceptance by the nonpsychiatrists increase. This should prove beneficial to our clinical and teaching activities, and help liaison psychiatry ride out the coming financial crisis that is likely to follow cessation of NIMI-I grants.
References 1. Henry GW: Some modem aspects of psychiatry in general hospital practice. Am J Psychiatry 86:481499, 1929 2. Lipowski ZJ: Holistic-medical foundations of American psychiatry: A bicentennial. Am J Psychiatry 138:888-895, 1981 3. Dunbar FH, Wolfe TP, Rioch JM: Psychiatric aspects of medical problems. Am J Psychiatry 93649-679, 1936 4. Lipowski ZJ: Liaison psychiatry, liaison nursing, and behavioral medicine. Compr Psychiatry 22:554-561, 1981 5. Lipowski, ZJ, Wolston EJ: Liaison psychiatry: Referral patterns and their stability over time. Am J Psychiatry 138:1608-1611, 1981
114
6. Woodger JH: Physics, Psychology and Medicine. Cambridge, University Press, 1956 ,,, 7. Kremer JM, Rynes RI, Bartholemew LE, et al. i Nonorganic nonpsychotic psychopathology (NONPP) in patients with systemic lupus erythematosus. Semin Arthritis Rheum 11:182-189, 1981 8. Bruegel MA: Relationship of preoperative anxiety to perception of postoperative pain. Nurs Res 20:26-31, 1971 9. Cohen F, Lazarus RS: Active coping processes, coping dispositions, and recovery from surgery. Psychosom Med 35375-389, 1973 10. Johnston M, Carpenter L: Relationship between preoperative anxiety and postoperative state. Psycho1 Med 10361-367, 1980 11. Hupert C, Yacoub M, Turgeon LR: Effect of hydroxyzine on morphine analgesia for the treatment of postoperative pain. Anesth Analg 59:690-696, 1980 12. Puig MM, Laorden ML, Miralles FS, Olaso MJ: Endorphin levels in cerebrospinal fluid of patients with postoperative and chronic pain. Anesthesiology 57:1-4, 1982 13. Lipowski ZJ, Kiriakos RZ: Borderlands between neurology and psychiatry: Observations in a neurological hospital. Psychiatry Med 3:131-147, 1972 14. Lipowski ZJ: The need to integrate liaison psychiatry and geropsychiatry. Am J Psychiatry, in press Direct reprintrequests to:
Z. J. Lipowski, M.D. Department of Psychiatry Dartmouth Medical School Hanover, NH 03756