Liaison Psychiatry: Factors Influencing the Consultation Process

In the last two decades psychiatrists in liaison work have asked nonpsychiatrists to accept a greater role in the management of mental illness, sponsoring educational programs and offering consultative services to provide assistance in diagnosis and management of patients. The triadic doctor-doctor-patient relationship and transference-countertransference phenomena often have more influence on the consultation process and the effectiveness of didactic methods than real problems like the degree of availability of consultants. Such factors as 1) the circumstances of the choice of medicine as a profession, 2) the special meaning of the choice of specialty, and 3) personality factors have great influence upon the relationship between the consultant and the consultee, the quality of the consultation, and the effectiveness of educational methods used in liaison psychiatry. The results of an attitudinal survey of fifty physicians, conducted to explore conscious motivations for choosing the medical profession, attitudes toward consultation process, and less conscious elements such as fears of illness or death are discussed as a basis for understanding the consultation process and designing effective continuing education programs on the psychosocial aspects of medical care. An important implication of the study is the need to question the ways in which nonpsychiatrists are encouraged and expected to assume more responsibility for the care of patients with emotional problems.

The Etiologic Significance of Deafness in Ulcerative Colitis

The case histories of several patients whose ulcerative colitis was preceded by partial deafness are presented. It is assumed that the partial deafness had an etiological significance and a series of four steps leading from the communication difficulties created by the deafness to the ulcerative colitis is described. Emphasis is placed upon the role of the partial deafness in the creation of a potentially objectless state which predisposes to the experiencing of the affect depression-withdrawal under conditions of additional stress. Presumably somatic correlates of this affect interact with unknown somatic vulnerabilities to produce ulcerative colitis.

The First Experience in Teaching Psychiatry

For seven years, first year residents in psychiatry have been followed in their initial teaching effort. In the most recent group studied, five residents who taught psychology of adolescence to undergraduate education majors initially experienced considerable anxiety, followed by immediate relief, a progressive sense of mastery and enthusiasm, and a reluctance to end the elective. At the conclusion, all reported that the experience was extremely worthwhile and wished to continue teaching to try out new ideas. All of twenty undergraduate students who responded to an anonymous questionnaire rated their resident-instructor “above average” in comparison with previous instructors in high school and college, and 45 percent rated him “one of the best.” The faculty documented the residents' learning by behavioral changes over the observational period. In our experience, brief but active involvement in teaching has proven to be the best starting point. Educators as supervisors help the resident bypass threatening issues relating to his uncertain identity as a psychiatrist, while guided experience helps him achieve a beginning sense of mastery of teaching skills which can be integrated with his developing knowledge of psychiatry. A concomitantly developing conceptual model of therapy aids the resident in developing an educational model which includes such comparable aspects as a “learning contract,” a “learning alliance” and “transference/countertransference” student-teacher reactions.

Melancholia, a Model in Madness: A Discussion of Recent Psychobiologic Research into Depressive Illness

An attempt is made to provide a cohesive conceptual frame upon which may be placed the recent advances in our understanding of the psychobiology of the affective disorders. Major literature in the areas of neurophysiology, endocrinology and biochemistry is reviewed and placed within a dynamic model which draws heavily upon ideas previously put forward by Meyer and von Bertalanffy. Phenomenologic and semantic difficulties which have retarded research in the depressions are also addressed.

Ego-Supportive Care in Open-Heart Surgery

Open heart surgery has been shown to have a rate of occurrence of postoperative psychopathological phenomena (9 percent-57 percent) many times greater than that of general surgery (1/1500). These phenomena result from an interplay of organic, environmental, psychological, and social factors which act on the integrative and coping capacity of the ego. Treatment is accomplished through support of the ego by: 1) establishment of a relationship, 2) reassurance, 3) environmental support, 4) consultative relationships with staff, 5) ventilation of feelings, 6) medical measures in support of somatic function, and 7) anti-anxiety drugs. Such supportive measures are usually effective in bringing about a rapid remission of these psychopathological phenomena.

“For the Sake of the Children”: Trials and Tribulations of Child Psychiatry-Liaison Service

This paper describes the development of a child psychiatry liaison service to pediatrics in a university hospital setting and discusses the authors' preference for the liaison type of relationship over strictly consultative psychiatry. The success of the liaison service in promoting comprehensive pediatric care can be related to an effective team approach which includes a pediatric social worker and a child psychiatry nurse specialist. In addition to the usual methods of handling consultation requests for psychiatric services, weekly teaching conferences on the pediatric wards were established to draw the house officers' attention to a bio-psycho-social approach to pediatric care, to allow ventilation of intradepartmental conflicts, and to enable nurses and residents to express their feelings freely about difficult patient problems such as the chronically ill and the dying child. The common lack of continuity of house officers and attendings on the pediatric wards hampers efforts to provide well planned and coordinated child care, both during admission and after discharge. This difficulty often gets compounded by the extensive use of consulting “super-specialists,” leaving the young pediatrician uncertain about his functions as the child's primary physician. We propose that the liaison psychiatrist may assume the role of a coordinator of comprehensive child care in many of these “disintegrated” ward situations. Because of inherent difficulties in the acceptance of the coordinator role by the child psychiatrist, we suggest that this role can be adopted more easily by those psychiatrists who have had previous experience in pediatrics or general medicine.

Attitudes of Registered Nurses toward Death in a General Hospital

Nurses' attitudes toward death and dying are of increasing interest as management of dying patients becomes a focus of concern. A death anxiety questionnaire tapping six conceptually distinct aspects of attitudes toward death was developed from work of previous investigators and administered along with other measures to 188 hospital nurses. This sample proved not to express very much anxiety about death; older nurses especially were found to express less anxiety about death of others and more acceptance of conventional medical procedures for managing the dying patient. No aspect of death anxiety was related to death rate on the unit on which the nurse worked, to any of several personality variables, or to peer rating of death anxiety. Finally, the psychometric properties of the death anxiety questionnaire, along with other findings, suggest need for more attention to measurement problems, heretofore largely ignored.

Psychiatric Consultation: Part II. Conceptual and Pragmatic Issues of Formulation

Seven principles governing the selection and organization of data during the process of psychiatric consultation are presented. These are based upon conceptual decisions implicitly made by the psychiatrist during his clinical investigation. Three case examples illustrate the principles, followed by discussion which focuses on the pragmatic considerations influencing how these decisions are made. Three additional case examples serve to illustrate the effects of the pragmatic factors. The entire analysis is based upon the general systems model developed in Part I.1

Consultation between Child Psychiatry and Otolaryngology: A Case of Esophageal Stenosis

In contrast to traditional “interdisciplinary” methods of consultation where independent assessment and treatment are carried out by different treating agencies, the “ecological” approach involves continuing cooperation between all systems affecting the maintenance of the symptom in the patient-biological, psychological, individual, familial, social and community. The present case demonstrates how such an ecological approach resulted in the effective removal of symptoms in a 9-year-old child with intermittent esophageal stenosis. While there had been earlier consultations in the “interdisciplinary” sense by both the Department of Ear, Nose and Throat and the Department of Child Psychiatry, it was only when the family and all disciplines working with them were brought together on the same physical premises face to face that directives became fused and united. This enabled the family to mobilize its resources and effectively deal with its problems, resulting in the alleviation of the manifest symptoms.

The ICU Syndrome: Fact or Fancy

Thirty-two patients admitted to a general medical intensive care unit were compared to twenty patients, matched for age, sex, type and severity of illness, treated in a conventional medical ward. No meaningful difference in incidence of delirium was noted. Neither sensory monotony nor sleep deprivation could be correlated with occurrence of delirium. An organic base was present in all four cases of delirium which occurred in the ICU. By use of a specially devised scale to measure levels of anxiety or depression in medically ill patients, no higher levels of anxiety or depression were found in ICU patients than in comparably ill patients treated in a ward. This comparative study fails to support the proposition that the intensive care unit environment per se causes psychological disturbance.