CONSULTATION AND LIASION

PSYCHIATRY

Prof. M L AdelekanConsultant Psychiatrist

Royal Blackburn HospitalBlackburn-UK

Introduction Consultation work – Psychiatrist is available to give

opinions on patients referred by physicians and surgeons. Consultation approach implicitly assumes that the team referring

possess the skills of assessment and management of psychiatric patients.

Liaison work – Psychiatrist is part of medical or surgical team, and offers advice about any patient to whose care he feels able to contribute. Liaison approach aims to increase the skills of staff in

assessment and management of psychiatric problems.

In practice, most Consultation Liaison psychiatrists (CL Psychiatrists) combine elements of both the approaches.

The C - L Psychiatrist

Can play many roles in medical wards: A skillful and brief interviewer. A good psychiatrist and psychotherapist. A teacher. A knowledgeable physician who understands the medical

aspects of case.

Tools are interview and serial clinical observations. Purpose of diagnosis:

Identify mental disorders and psychological responses to physical illnesses.

To identify patient’s personality features. Assess patient’s characteristic coping techniques. Recommend therapeutic intervention most appropriate to

patient’s needs.

The Psychiatric consultation The consultation has two parts:

Assessment of the patient. Communication with the referrer.

Assessment: Not essentially different from that of any other patient referred for

psychiatric opinion. Should take into account the patient’s physical health state and

willingness to see a psychiatrist. Information from medical notes and discussion with staff on the

ward are necessary. Psychiatrist should familiarise with the medical treatment plan

and side effect profile of the drugs the patient is receiving.

The assessment interview

Make clear to the patient the purpose of the interview. Discuss the patient’s anxieties about seeing a

psychiatrist. Appropriate detailed history and mental state

examination. Extend the examination of nervous system if necessary. Collect collateral history with regards to patient’s social

background and past psychiatric disorders from: Ward staff or key worker. Relatives. Family doctor.

Discussion with referrer Discuss proposed plan with referrer. Make sure recommendations are feasible and

acceptable. Make sure to answer relevant questions about the

patient.

Management

Care should be taken when prescribing psychotropic medication keeping in view about patient’s metabolism, excretion etc.

Realistic assessment about further supervision of the patient on the ward should be made.

Make arrangements for follow up.

A few C – L Psychiatric situations Post overdose or self harm/suicide attempt Diabetes Mellitus Aggressive, Volatile and Confused patients Accidents

Head trauma, delirium etc. Cardiac Disorders.

Angina, Acute MI, Non cardiac chest pain. Post Operative problems

Delirium, limb amputation, organ transplantation etc. Cancer Pseudo epilepsy Infections Sensory Disorders Consent to treatment.

Diabetes Mellitus Requires prolonged medical supervision and informed

self care. Many physicians emphasize on psychosocial aspect. Stressful situations lead to endocrine changes. Many diabetics show poor compliance during stress

resulting in ‘Brittle Diabetes’. Compliance with blood testing, diet and insulin use is

frequently poor. Psychiatric problems include depression and anxiety. Comorbid Eating Disorders complicate management of

Diabetes. Misuse of insulin can occur in such individuals to lose

weight. Pregnancy is difficult time for diabetic women.

Increased risk of miscarriage and foetal malformations.

Diabetes Mellitus Impotence can occur in men.

Psychogenic impotence found in chronic debilitating disease. Due to Pelvic Autonomic Neuropathy or Endocrine problems.

Organic psychiatric syndromes may present as Disturbed behaviour, headaches, nausea, rapid pulse,

hypotension and dehydration.

Management includes Treatment of co morbid conditions like depression. Blood glucose awareness training to improve the understanding

of symptoms. Behavioural methods to improve self care, psychological and

pharmacological methods of sexual dysfunction etc. Tricyclic antidepressants may be helpful in treating the pain in

Neuropathy.

HIV Infection Emotional distress common due to

The brain is affected at the early stage of infection. Relentless progressive course. Reactions of other people. Neuropsychiatric disorders can occur simultaneously e.g drug

abusers. Psychiatric problems include Adjustment disorder,

Depressive disorder, Anxiety disorder and suicide. Most common at the time of diagnosis. Suicide risk is greater in advanced stages. HIV Encephalopathy and Sub acute Encephalitis occur

late in about 1/3rd of patients. May proceed to Dementia.

Delirium may occur in opportunistic infection or cerebral malignancy.

HIV Infection Social consequences are considerable due to public

fears and stigma. Cultural differences in acceptance, rejection, availability

of family and other support are major determinants of quality of life.

Problems in relation to illicit drug use are very common.

Treatment

Psychiatrists should be involved in planning treatment for AIDS patients.

May provide counselling, treat NeuroPsychiatric conditions and other co morbid Psychiatric conditions.

Extent of care needs in dementia in AIDS is still under research.

Cancer Some patients delay seeking help as they deny

symptoms. Diagnosis of cancer may cause Anxiety or Depression. The diagnosis of cancer may cause shock, anger and

disbelief, as well as anxiety and depression. Most common associated disorder is Adjustment disorder.

Longer – term consequences: Major depression occurs throughout the course of cancer affecting 10-20 % of pxs and appears to be more frequent in those suffering pain.

Progression and recurrence of cancer lead to increased psychiatric disturbance resulting from worsening of physical symptoms, fear of dying or the development of organic brain syndrome.

Cancer (contd)

Delirium and dementia may arise from brain metastases, which originate most often from Ca of the Lung, but also from tumours of the breast and alimentary tract and from melanomas.

Neuropsychiatric problems (paraneoplastic syndromes) are sometimes induced by some types of cancer in the absence of metastases, notably Ca of the Lung, ovary, breast, stomach and Hodgkin’s Lymphoma. Aeitology thought to be autoimmune response to the tumour

Treatment for Ca may cause psychological disorders as follows: Emotional distress may follow mastectomy and other mutilating surgery Radiotherapy causes nausea, fatigue and emotional distress Chemotherapy often causes malaise and nausea and anxiety about the

treatment may cause anticipatory nausea before it is started

Cancer (contd) Family and other close relatives of cancer patients may

experience psychological problems, although may adjust fairly well.

Management Principles Skilled communication in conveying the diagnosis to pxs

and how it would affect their lives Depression and Anxiety should be treated at the earliest. Counselling, social support groups and Cognitive-

behavioural treatments are shown to improve survival rate along with good effects on immunity.

Pxs most likely to need psychological treatment include those with previous psych. disorder, poor adjustment to other problems and lacking a supportive family

Some practical emergency problems Anxious patient

Physical symptoms of panic is the reason for presentation. Hyperventilation responds to rebreathing into a paper bag. Anxiety can become worse by response of uncomprehending

staff. Distress relief can be obtained by understanding manner and

occasional use of a benzodiazepine.

Angry patient Helpful to comment on patient’s anger and ask directly about the

reason. Be honest and give straightforward information. It may be appropriate for the doctor to admit to feeling upset by

any accusations made. It is never sensible to show anger or unduly submissive.

Some practical emergency problems Aggressive patient

Arrange for adequate but unobtrusive help. If needing restraint then it should be with minimal force and

adequate number of people. Physical contact should be avoided unless the purpose is clearly

understood by the team and the patient. Diazepam(5-10mg), Haloperidol(2-5mg) or Lorazepam (1-2mg)

can be given to calm the patient.

Consent to treatment Patients may be unwilling to accept treatment for many reasons. Occasionally it is mental illness that interferes with patient’s

ability to make informed decision. If the patient has mental disorder that is impairing his decision

then use of legal powers of compulsory assessment and treatment are indicated.

Questions/Comments

ThankYou