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LETTERS reductionistic dangers in 'relying too heavily on a predominantly biologic approach' to patients, in which subjective experience is minimized. By thus placing biology at conceptual odds with subjectivity, Dr. Marmor himself participates in reductionistic thinking. To differentiate biology from subjectivity is to enact the Cartesian notion of mind-body dualism that insidiously persists in psychiatry. Mind and body are not predicated of different essences that somehow interact with each other. Rather, psyche and soma reflect different organizational levels of biology. The field of consciousness is no less biological than is a cell in the frontal granular cortex. A conscious field is, however, organizationally more complex, and transcendent in that it is not reducible to its enfolded sub-organizations (which include cells in the frontal cortex). Psychiatry is inevitably biological. It need not turn away from itself to embrace consciousness. Thomas D. Geracioti. M.D. University o/California San Francisco The author replies:
It seems to me that Dr. Geracioti is confusing an important theoretical issue with a clinical one. I am, of course, in complete agreement with his statement about the essential unity of mind and body. What I was referring to in my editorial, however, was the question of how one deals clinically with this unity, and I suggested that a bio-psycho-social treatment appreach is the most effective way of coping with most psychosomatic pathology. I was not in any way implying that we ought to turn away from APRIL 1986· VOL 27 • NO 4
the valuable understanding that new research in biology is giving us; rather, I was calling attention to the fact that psychosocial factors inevitably become reflected at biological levels, and must not therefore be ignored in any program of comprehensive treatment. Such a clinical approach is in complete harmony with the theoretical model of mind-body duality and, indeed, is derived from it. Judd Marmor. M.D. Los Angeles
Consultee confusion Sir: We read the recent article by Golinger and associates, "Clarity of request for psychiatric consultation: Its relationship to psychiatric diagnosis" (Psychosomatics 26:649-653, 1985), with great interest, especially since we provide freq.Jent psychiatric consultation to the large medical, surgical, and emergency services in our hospital. Their finding that major mental illness was diagnosed almost twice as often when the request for consultation was unclear versus when the request was clear is consistent with our experience that difficult patients contribute to miscommunication between members of the treatment team and that requests for consultation may signal distress or confusion on the part of the consultee. I Anxiety certainly contributes to the unclarity, as the authors suggest, although we frequently find that simple lack ofknowledge and inexperience with major mental illness also commonly contribute to consultees• inability to articulate clearly their observations and requests. Faced with serious psychopathology, nonpsychiatric clinicians may quickly react by thinking "psych
consult" and then stop pursuing assessment and treatment on their own. We agree with Golinger and associates that an unclear request should prompt the consultant to look for serious psychiatric disorder, and we hasten to add that the consultant should also address and attempt to assuage the consultee's anxiety. This can often be done through an educational approach. Teaching the consultee about the patient's psychiatric illness helps relieve anxiety by restoring a sense of competence and control, and may pay the bonus of making him or her a better consultee in the future. Michael F. Hoyt. Ph.D. Frederick C. Bittiko/er. M.D. Norman W. Weinstein. M.D. Kaiser-Permanente Medical Center Hayward. Calif.
REFERENCE 1. Hoyl MF, Opsvig P, Weinstein NW: Conjoint patient-staff interview in hospital case management 1m J Psychiatry Med 11 :83-87, 1981
Scan orientation corrected Sir: The article' 'CT scanning in psychiatric inpatients: Clinical yield," by Beresford and associates (Psychosomatics 27: 105-112, 1986), is excellently illustrated by CT scan images of the brain. However, the orientation of the photographs as described in the caption appears incorrect. Theodore Pearlman. M.D. Houston
Dr. Pearlman is correct. The caption should have read: "The figures should be viewed as if you were looking up from beneath the chin." We apologize for this error. The Editors
It seems to me that Dr. Geracioti is confusing an important theoretical issue with a clinical one. I am, of course, in complete agreement with his statement about the essential unity of mind and body. What I was referring to in my editorial, however, was the question of how one deals clinically with this unity, and I suggested that a bio-psycho-social treatment appreach is the most effective way of coping with most psychosomatic pathology. I was not in any way implying that we ought to turn away from APRIL 1986· VOL 27 • NO 4
the valuable understanding that new research in biology is giving us; rather, I was calling attention to the fact that psychosocial factors inevitably become reflected at biological levels, and must not therefore be ignored in any program of comprehensive treatment. Such a clinical approach is in complete harmony with the theoretical model of mind-body duality and, indeed, is derived from it. Judd Marmor. M.D. Los Angeles
Consultee confusion Sir: We read the recent article by Golinger and associates, "Clarity of request for psychiatric consultation: Its relationship to psychiatric diagnosis" (Psychosomatics 26:649-653, 1985), with great interest, especially since we provide freq.Jent psychiatric consultation to the large medical, surgical, and emergency services in our hospital. Their finding that major mental illness was diagnosed almost twice as often when the request for consultation was unclear versus when the request was clear is consistent with our experience that difficult patients contribute to miscommunication between members of the treatment team and that requests for consultation may signal distress or confusion on the part of the consultee. I Anxiety certainly contributes to the unclarity, as the authors suggest, although we frequently find that simple lack ofknowledge and inexperience with major mental illness also commonly contribute to consultees• inability to articulate clearly their observations and requests. Faced with serious psychopathology, nonpsychiatric clinicians may quickly react by thinking "psych
consult" and then stop pursuing assessment and treatment on their own. We agree with Golinger and associates that an unclear request should prompt the consultant to look for serious psychiatric disorder, and we hasten to add that the consultant should also address and attempt to assuage the consultee's anxiety. This can often be done through an educational approach. Teaching the consultee about the patient's psychiatric illness helps relieve anxiety by restoring a sense of competence and control, and may pay the bonus of making him or her a better consultee in the future. Michael F. Hoyt. Ph.D. Frederick C. Bittiko/er. M.D. Norman W. Weinstein. M.D. Kaiser-Permanente Medical Center Hayward. Calif.
REFERENCE 1. Hoyl MF, Opsvig P, Weinstein NW: Conjoint patient-staff interview in hospital case management 1m J Psychiatry Med 11 :83-87, 1981
Scan orientation corrected Sir: The article' 'CT scanning in psychiatric inpatients: Clinical yield," by Beresford and associates (Psychosomatics 27: 105-112, 1986), is excellently illustrated by CT scan images of the brain. However, the orientation of the photographs as described in the caption appears incorrect. Theodore Pearlman. M.D. Houston
Dr. Pearlman is correct. The caption should have read: "The figures should be viewed as if you were looking up from beneath the chin." We apologize for this error. The Editors