Psychiatric Consultations in a General Hospital

Psychiatric Consultations in a General Hospital (Meaningful Characteri.tic. of Referral Pattems) PETER

A.

PAPASTAMOU,

INTRODUCTION

M.D.

rals; and 1975 were obstetrical-gynecological admissions with 6 referrals. (Table I) The average age of the patients seen in the study was 44 years, the range being from 15 to 87 years. Fifty-two were male and 69 were female patients. Requests for consultations were telephoned to the department's secretary, who notified the consultant, who then saw the patient and discussed his consultation report with the referring house officer. Each case was discussed with a senior psychiatrist, who was responsible for the final diagnosis and recommendations that were made. In reviewing these consultations, specific data was collected regarding the reason given for the consultation request, and the major issues as noted by the consultant.

• A principal function of the psychiatrist in a general hospital is consultative activity. This liaison work carried out in the various departments of general hospitals includes diagnostic, therapeutic, teaching and research activities. In essence, the role of a psychiatric consultant, as stated by Kaufman, should be "practical assistance in the total evaluation and... treatment of any given patient"l. The psychiatric consultation as a process has been described in various forms by several authors2.~; the basic components, however, remain the same; request for consultation and the consultant's diagnosis and recommendations. Information regarding the various reasons for psychiatric consultation is lacking, due to the lack of clarity in the referring physician's conception of his needs concerning RESULTS AND METHODS the patient. In reviewing the referral patterns of the This study was conducted in an attempt 121 inpatients who had a psychiatric conto clarify the meaning of referral patterns, in sultation, it was noticed that although precise regard to their psychiatric significance and and uniform terminology was not required in descriptive accuracy. requesting such consultations, certain terms were used repeatedly as the reason for the METHOD referral. All the psychiatric consultations rendered We could categorize five separate groups to the inpatient ward service population of of patients by using as criteria five specific our 480-bed general hospital over a period of terms which most frequently appeared in the one year (January 1, 1968 - December 31, 1968), were reviewed. TABLE I The total number of ward service patients admitted to the various departments of the Patients Referred for Psychiatric hospital was 3,534; 121 of whom were referConsultation by Service red for psychiatric consultation. Specifically there were 647 medical admissions of whom Admitted Referred Referred Male Female in 1968 in 1968 73 were referred for psychiatric consultation; 911 were surgical admissions with 42 refer- Medicine 38 35 647 73 From Psychiatric Liaison Service, Department of Psychiatry, Sinai Hospital of Baltimore, Inc., Belvedere & Greenspring Avenues. Baltimore. Maryland - 21215. January-Febroary 1970

Surgery Ob-Gyn Total

911 1,975

42 6

17

25 6

3.533

121

52

69 57

PSYCHOSOMATICS

referrals. A sixth group consisted of patients referred for miscellaneous reasons. The six groups consisted of: 1) patients referred for "depressions"; 2) "suicidal" patients; 3) patients displaying "bizarre beTABLE II

Reason for

Consultin~

Request

Number of Patients

25 19 17 14

1. "Depression" 2. "Suicidal" 3. "Bizarre Behavior" 4. "Uncooperative" 5. "Symptoms with minimal or no organic disease" 6. "Disposition problem", "Addiction" etc.

12 121

'Total ~---~-_.

27

----

TABLE III

Diagnostic Results of Consultation Reaso1l for Referral Referred

1. "Depressed"

Psychiatric Diagnosis

25

2. "Suicidal"

19

S. "Bizarre Behavior

17

4. "Uncooperative" 14

5. "Symptoms with or without organic illness

27

6. "Disposition

problems", "Addiction", etc. 58

1 psychotic reaction 10 neurotic reaction 14 personality disorder 3 psychotic reaction 5 neurotic reaction 11 personality disorder 12 pilychotic reaction 4 neurotic reaction lOBS 7 3 2 2

psychotic reaction neurotic reaction personality disorder chronic OBS

2 14 3 8

psychotic reaction neurotic reaction personality disor(cr psychophysiological reaction

2 neurotic reaction 3 personality disorder 7 chronic OBS 12

havior"; 4) "uncooperative" patients; 5) patients having "symptoms with minimal or no organic disease"; and 6) patients referred for miscellaneous reasons, such as "addiction", "disposition problem" etc. (Table II). In reviewing the psychiatric formulation and diagnosis of this group and subsequently comparing this to the referral patterns, the following findings were obtained: There was full agreement as to diagnosis between the referring physician and the consultant in the first group of "depressed" patients. That is to say, all patients referred as depressed were actually found to be depressed by the consultant. The majority of these patients were diagnosed as having in addition to the depression a personality disorder and a neurotic reaction. There was one psychotic reaction. (Table III). Anxiety, fear, and regression usually do accompany physical illness. Depression is quite frequent in patients who are ill and in the hospital and can be easily detected, but the ability to evaluate the depth of a depression depends on the clinical experience and judgment of the physician. We are reminded that Medicine is an art as well as a science, and the severely depressed patient needs treatment beyond his physical symptoms. Case 1: The first case concerns a 38-year-old, single, WM, refugee who shortly after his arrival in this country was admitted to the hospital with mUltiple gastro-intestinal symptoms. The diagnosis at that point was uncertain. Several admissions followed his initial one, and it finally became evident that he was suffer:ng from regicnal enteritis for which he underwent partial re:.:ection of his small intestine. Because of difficulty with the English language he was isolated from h's e:lvironment. He became progressively worse. with each subsequent admission; an accentuation of his symptoms was noted, his sleeping and eating patterns were disturbed, and he became more demanding of attention. Eventually 2. psychiatric consultation was requested because of "depression". The history suggested a previous manic phase. There was weight loss, change in sleep pattern. crying spells and withdrawal from people. Vague. defensive responses were noted and flight behind language barrier when selfesteem was threatened. The diagnosis was severe depressive illness in a borderline patient with

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CONSULTATIONS IN A GENERAL HOSPITAL-PAPASTAMOU strong pa:-anoid features. Recommendations were made regarding his further management. Psychotherapy and drug therapy proved to be extremely helpful; he was able to establish a good relationship with the therapist with gradual disappearance of his symptoms. He was able to return to his work and get married. The therapy was terminated several months later, when he moved to another city.

In the second group, of the 19 patients who were referred as suicidal, only 5 were thought to be suicidal by the consultant. The majority of the patients were diagnosed as having a personality disorder (11), and of the rest, 5 were diagnosed as having a neurotic reaction, and 3 were diagnosed as psychotic. (Table III) Physicians in a hospital setting are in a unique position to pick up the clues which might lead them to anticipate and prevent a suicidal act. The suicidal attempt is a complex behavior pattern based on a variety of motivations: a wish to die, a desire to attack others, an appeal for help and an urge to challenge fate. The discrepancy in the number of the patients diagnosed as suicidal was due to the fact that several patients were suspected as suicidal by giving a history of suicidal attempts or when the. reason for admission was not clear, as for example in the cases of "accidental" overdose of drugs, or injuries following suspicious "accidents". The identification of the suicidal patient is not always easy, even in a hospital setting, and it often requires a certain technique which can be learned, but it can be learned largely by experience. Therefore, it seems understandable that so many more patients were referred as "suicidal" than were thought to be so by the psychiatric consultant. The following two cases concern a y011ng woman who was thought to be suicidal by the consultant and a man who was not thought to be so. In both cases the referring physician had good reason to recommend psychiatric consultation on the grounds of suicidal possibilities. Case !: A 22-year-old, married, NF was admitted following ingestion of an unknown amount

January-February 1970

of imipramine hydrochloride (Tofranil) and methyprylon (Noludar) tablets. She responded well to supportive treatment; while in the cmergency room, she ran away and injured her:elf through the glass of a door. She was referred to psychiatry as suicidal. The patient had been recently admitted to a psychiatric hospital following a similar suicidal attempt. She was married twice, both times for only a few weeks. Very little information could be obtained from the patient, who appeared aggressive, hostile and depressed. In view of the previous as well as the present suicidal attempts, and the disturbed affect, it became clear that she was potentially suicidal and she was transferred to a psychiatric hospital for further management. Case 2b: A 49-year-old, WM was admitted to the surgical ward with the diagnosis of vesicocolic fistula, secondary to diverticulitis of the colon, for which he underwent left hemi-colectomy. The history of 3 suicidal attempts alerted the housestaff to request a psychiatric consultation. He was found by the consultant to be alert and oriented. His affect and mood were normal. as was the rest of the mental status examination. The consultant thought that the patient was not suicidal at that time. He made an excellent recovery and several months later he was readmitted to the hospital for closure of the colestomy.

The third group of patients (17), all of whom displayed bizarre behavior, consisted of patients diagnosed as psychotic (12); neurotic reaction, or personality disorder. One patient was found to have an organic brain syndrome. (Table III). Patients under the stress of fear of the unknown are unable to use their defenses adequately. Such patients may be disoriented, regressed, hostile, destructive or suicidal. They are unable to verbally express themselves and so resort to non-verbal or peculiar forms of communication. The underlying pathology of these odd, unexplained, and impulsive activities, can very easily escape the attention of the inexperienced house-officer. The following case is an example of one such patient who exhibited bizarre behavior. Case 3: A 42-year-old, single, WF was .admitted for mUltiple symptoms particularly involving the musculo-skeletal system. After a prolonged hospitalization, during which time she underwent numerous laboratory procedures, the diagnosis of a nutritional deficiency was made. In the meantime, the patient began to exhibit

59

PSYCHOSOMATICS a bizarre pattern of behavior. No one could pass outside her room without being invited in (sometimes with screams) and queried about her condition. As soon as someone entered her room, she immediately positioned herself between the visitor and the door, thus causing embarrassment to other patients, visitors and those unwary members of the house-staff. The psychiatric consultant was of the opinion that his patient had been chronically psychotic but was able to compensate adequately prior to her admission to the hospital. She responded well to psychopharmacological treatment and supportive psychotherapy, allowing the completion of further tests and necessary treatment.

Of the 14 patients referred as uncooperative, 7 were diagnosed as having a psychotic reaction, 3 as neurotic, 2 as personality disorder, and 2 as chronic organic brain syndrome (Table III). These uncooperative patients found it hard to express their thoughts and feelings clearly. They usually manifested their uncooperativeness either by being unable to make their complaints clear or by refusing treatment. It has been shown that uncooperativeness will vary with the approach the physician takes; that is, according to the doctor's own attitudes and personality. In the following case, the patient's relationship with the house-staff improved after psychiatric referral and treatment. Case 4: A 45-year-old, married, WM was admitted because of chest pains over a long period of time, and at least one previous myocardial infarction. A psychiatric consultation was requested because the patient would not follow instructions, was refusing to take his medications and was threatening to sign himself out of the hospital. As a result of his behavior, there was a disruption of communication between him and the medical and nursing staff. The consultant found the patient to be dependent on the hospital, but unable to admit his dependent needs bec.ause of his long standing pattern of hyperindependence. He felt that the hospital was not giving him the help he needed and so became increasingly tense and depressed, using denial extensively to defend himself against a painful confrontation with the realities of his illness. There was some improvement with psychopharmacological treatment, but the consultant's interpretation to the house staff of the reasons tor the patient's behavior enabled them to develop a more satisfactory relationship

60

with the patient, thereby favorably affecting the remainder of his course in the hospital. It was explained to them that the patient Was making demnnds because of his great need for attention and reassurance. Patients like this may threaten to leave the hospital; repeatedly demand to see the doctor or the nurse, and demand .additional and different treatment. Hospital staff can help this type of patient through the sympathetic recognition that their complaining, demanding, exasperating behavior is an expression of their inncr feelings of desperation.

The fifth group of patients were referred for a psychiatric consultation because, either (a) their complaints were disproportionate to their organic illness, or (b) they were symptomatic in the absence of organic illness. There were 27 such patients, 14 of whom were diagnosed as having a neurotic reaction; two were psychotic; three diagnosed as having personality disorders; and 8 were described as having a psychophysiological reaction. (Table III). This was the only group that includes patients having this type of reaction. All of these patients exhibited some degree of frank emotional disturbance and in addition presented a variety of somatic complaints. The somatic symptoms of psychiatric illness can mimic any clinical entity. These symptoms are frequently the most acceptable distress signals that the patient can give to the doctor. However, we found there is a widespread tendency on the part of the physician to exclude all possibility of organic disease before considering a psychiatric diagnosis. The following case is representative. Case 5: A 40-year-old, single WF was admitted because of right foot pain that had been bothering her for several years before her admission. The diagnosis was "neuroma of the peroneal nerve". The patient had undergone bilateral lumbar sympathectomy a few years before, because of abnormal temperature changes and pain in the right foot. She improved following the operation but shortly thereafter the pain reappeared. Because of the persistent symptoms and their resistance to conservative treatment, as well as inconclusive findings, a psychiatric evaluation was requested. It was found that her anxiety and repressed anger were being focused on her foot. AI-

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CONSULTATIONS IN A GENERAL BOSPITAL-PAPASTAKOU

though a recommendation was made for deferment of any surgical intervention, an operation was undertaken with resection of the right superficial peroneal nerve. On follow-up, after a brief asymptomatic period, the patient again complained of the right foot pain. The sixth and final group consisted of 12 patients referred primarily for miscellaneous reasons, such as "Addiction", "Disposition problem", etc. The majority of these patients were diagnosed as having a chronic organic brain syndrome, secondary to arterisclerotic cardiac vascular disease. Of the rest, 2 had a neurotic reaction and 3 were diagnosed as having a personality disorder. (Table III) A request for psychiatric consultation by a member of the house staff of a general hospital is a request for a particular kind of help. This is outlined in the request and represents the main concern of the consultee, having to do with the patient's diagnosis and management. Frequently, however, and despite the statement of the consultee's difficulties, it is unclear in what areas and for what reasons psychiatric help is being requested. Personal conflicts, the hospital's social structure and, above all, the physician's own anxieties can all be factors influencing the clarity of a referral pattern. Thus the reason expressed in the request for a consultation may have little to do with what the consultant comes to see as the major problem. While the immediate focus of all consultation requests is the individual patient, when the reason for the request seems unclear, it is useful to look at the consultee's implicit concern. In this case the recoonition of the consultee's anxieties as an imp~rtant facet of the consultation is of great importance. The purpose of this study was the identification of specific patterns of referrals and subsequent comparison of those patterns to the findings of the consultant. We found that the consultee uses certain specific terms to describe specific psychiatric nosology. He recognizes and describes the depressed patient accurately. He becomes anxious when confronted with the possibility of suicide. The patients with ''bizarre behavior" and!or the January-February 1970

"uncooperative" patient, who are usually psychotic, are difficult patients to deal with rationally. The patients with somatic complaints but little or no evidence of organic disorder, were found to have a neurotic or psychophysiological reaction. The importance therefore in obtaining a meaningful history, in order to relate a patient's current decompensation to life experience, becomes obvious. This includes the consideration of the patient's physical condition, his personality or psychological status and the interrelationship of these two areas. The "double diagnosis" as described by Lisansky and Shochet4 ,S can be utilized as a useful tool for effective intervention. This technique appears to formulate the basic prerequisites for a comprehensive diagnosis, thus enabling the physician to intervene therapeutically in a meaningful way. SUMMARY

The psychiatric consultations rendered to the ward service inpatient population of our 480-bed general hospital, over a period of one year, were reviewed. Using as criteria five specific terms, which most often appeared in the referrals, we were able to delineate five groups of patients. A sixth group consisted of patients referred for miscellaneous reasons. The six groups consisted of: 1) patients referred for "depression"; 2) "suicidal" patients; 3) patients displaying "bizarre behavior"; 4) "uncooperative" patients; 5) patients having "symptoms with minimal or no organic disease"; and, 6) patients referred for miscellaneous reasons, such as "addiction", "disposition problem", etc. In an attempt to clarify these words in terms of their psychiatric significance and descriptive accuracy, they were compared to the psychiatric formulation and diagnosis. The ~esults were discussed and six illustrative cases were described. REFERENCES 1. Kaufman, R.M.: The Role of a Psychiatrist in a General Hospital. Psychiat. Quart., 27: 367, 1953. 61

PSYCHOSOMATICS 2. Meyer, E. and Mendelson, M.: Psychiatric Consultations with Patients on Medical and Surgical Wards: Patterns and Processes. Psychiatry, 24 :197, 1961. 3. Bibring, G.L.: Psychiatry and Medical Practice in General Hospital, New Eng. J. Med., 254 :366, 1956. 4. Shochet, B.R. and Lisansky, E.T.: Making the "Double Diagnosis" Technique of Comprehensive Medical Diagnosis. Psychosomatics, 9: 12, 1968. 5. Lisansky, E.T. and Shochet, B.R.: Comprehensive Medical Diagnosis for the Internist. A Modification of the Associative Anamnesis of Deutsch. Med. Ol. N. Am., 51:1381,1967. 6. Caplan, G.: Types of Mental Health Consul-

tation. Amer. J. Orthopsychiat., 33 :470, 1963. 7. Schiff, K.S. and Pilot, M.L.: An Approach to Psychiatric Consultation in the General Hospital. AMA Arch. Gen. Psychiat., 1 :349, 1959. 8. Lipowski, Z.J.: Review of Consultation Psychiatry and Psychosomatic Medicine. I. General Principles. Psychosom. Med., 29: 153, 1967. 9. Schwab, J.J., et al.: Problems in Psychosomatic Diagnosis. 1. A Controlled Study of Medical Inpatients. Psychosomatics, 6:369, 1964. 10. Schwab, J. J. et al.: Problems in Psychosomatic Diagnosis. II. Severity of Medical Illness and Psychiatric Consultations. Psychosomatics, 6:69, 1965.

Man holds a unique position...Although man can be classified somatically with the zoological species even his body remains unique...In addition man differs from all the animals in the expressive use he makes of his body...Animals do not laugh or cry as men do...The animal is bound to a natural fate...Man is likewise bound but in addition he has a destiny the fulfillment of which lies in his own hands. Nowhere however do we find man as a completely rational being... (he) is neither animal or a~gel. ' KARL

JASPERS.

General Psychopathology.

University of Chicago Press, Chicago, 1963. (Excerpted from a quote by the Annals of Internal Medicine, June, 1969).

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