Consult Liaison

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Consult Liaison Therapeutic Alliance

• Tony A. Hanna
• PGY-III
• Psychiatry

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Objectives

• Define Consultation liaison psychiatry.
• Understand the scope of psychosomatic medicine.
• Outline the indications for consultation in C/L
  psychiatry.
  
• Outline the model for C/L psychiatry.
• Understand the approach to C/L psychiatry.
• Define therapeutic alliance and the 12 dos of
  C/L psychiatric etiquette.

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Consult Liaison Services

• Dr. Fitzgerald (Attending)
• Dr. Tzoneva (Fellow)
• Dr. PGY (resident)
• Medical student

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Definition

• Consultation-Liaison Psychiatry is a
  sub-specialty of psychiatry that incorporates
  clinical service, teaching, and research at the
  borderland of psychiatry and medicine.
• (Lipowski, 1983)

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• Psychosomatic medicine
• 1) Studies the correlations of psychological and
  social phenomena with physiological functions
  
• 2) Focuses on the interplay of biological and
  psychosocial factors in the development, course
  and outcome of all diseases.
  
• 3) Advocates the biopsychosocial approach to
  patient care.
  

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History of Consultation Liaison Psychiatry

• Its early origins reflect the emergence of
  General Hospital Psychiatry.
  
• In the 1920s psychiatry became closer to medicine
  as hospitals started to establish psychiatric
  units .
  
• The concept of psychosomatic relationships and
  the role of emotions and psychological states in
  the genesis and maintenance of organic diseases
  emerged.
• Thus, Consultation Liaison Psychiatry became an
  applied form of psychosomatic medicine.

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History of Consultation Liaison Psychiatry

• Considered the earliest advocate for integration
  of psychiatry and medicine.
  
• Wrote the first comprehensive book on mental
  illness by an American Medical Inquiries and
  Observations upon the Diseases of the Mind
  
• Stressed that diseases of the mind are as
  certainly object of medicine as diseases of the
  body.
  

Benjamin Rush 1745 - 18
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History of Consultation Liaison Psychiatry

• Developed the concept of psychobiology.
• Advocated the study of the person in the
  context of physical, social, psychological
  life events.
  
• Spoke of the medically useless contrast
  between mental and physical disorders

Adolf Meyer (1866 1959)
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History of Consultation Liaison Psychiatry

• Considered one of the pioneers of psychosomatic
  medicine.
  
• Worked at the Columbia-Presbyterian Hospital as
  a psychiatrist assigned to the department of
  medicine.
  
• In 1936 published the conclusions of her study of
  600 patients with cardiovascular diseases,
  diabetes, or fractures.
  
• Psychological factors appeared to influence both
  the etiology and course of the illness in a
  substantial proportion of these patients.
  

Helen Flanders Dunbar
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• In 1934/35 with Rockefeller foundation grants
  five general hospitals were able to develop
  psychiatric departments and stimulate closer
  collaboration between psychiatrists and other
  physicians.
• By the 1960s-1970s a subspecialty scientific
  literature had developed.
  
• In 1974 the psychiatric education branch of the
  NIMH decided to support the development and the
  expansion of consultation liaison services
  throughout the US.

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• By 1980, NIMH supported 130 programs and
  materially contributed to the training of more
  than 300 consult-liaison psychiatry fellows.
  
• Consult-liaison psychiatry continued to grow
  during the 1980s despite the federal budget
  cuts.
  

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• The years since 2000 have seen a focus on
  achieving added qualification status by the
  American Board of Medical Specialty.
  
• Fellowship training guidelines and certification
  examination development are necessary steps
  toward that goal.

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Most common reasons for consultation

• Delirium, dementia, amnesia and other cognitive
  disorders-25
  
• Affective disorders, primary or secondary to
  medical condition-25
  
• Adjustment disorder, maladaptive response to
  identified stressors, including medical
  illness-15
  
• Somatoform disorders, anxiety disorders,
  personality disorders -each
• Data on the distribution of axis II disorders are
  limited.

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Models for Consultation

• The five models for consultation
• Patient-oriented (Lipowski 1967)
• Crisis-oriented (Weisman and Hackett 1960)
• Consultee-oriented (Shiff and Pilot 1959)
• Situation-oriented (Greenberg 1960)
• Expanded psychiatric consultation (E. Meyer and
  Mendelson 1961)

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Approach to the Consultation

• Consultation style
• Patient confidentiality
• Patient follow-up

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Consultation style

• Characteristics of effective psychiatric
  consultant (Goldman, Lee, Rudd, 1983)
  
• 1. Talks with the referring physician, nursing
  and other staff before and after consultation.
  Clarifying the reason for the consultation is the
  initial goal.

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• 2. Establishes the level of urgency.
• 3. Reviews the chart and the data thoroughly.
• 4. Performs a complete mental status exam and
  relevant portions of a history and physical
  exam.
  
• 5. Gets collateral from family, friends as
  indicated.
  
• 6. Makes notes as brief as appropriate.
• 7. Arrives at a tentative diagnosis.
• 8. Formulates a differential diagnosis.
• 9. Recommends diagnostic tests.

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• 10. Has the knowledge to prescribe psychotropic
  drugs and be aware of their interactions.
  
• 11. Makes specific recommendations that are
  brief, goal oriented and free of psychiatric
  jargon and discusses findings and recommendation
  with consultee In person whenever possible.
• 12. Respects patients rights to know that the
  identified customer is the consulting physician.

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• 13. Follows-up the patient in hospital, and
  arranges out-patient care, including help
  arranging postdischarge referrals.
  
• 14. Does not take over the aspects of the
  patients medical care unless asked to do so.
  
• 15. Follows advances in the other medical fields
  and is not isolated from the rest of the medical
  community.

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Patient Confidentiality

• Maintaining absolute Doctor-Patient
  confidentiality is not possible for a psychiatric
  consultant.
  
• Explain the dual relationship to the patient.

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Patient Follow-up

• Frequency and duration of psychiatric follow-up
  will vary widely depending on the patients needs
  and the financial circumstances.
  
• Psychiatric consultant should follow-up patient
  until they are discharged from the hospital or
  clinic or until the goals of the consultation are
  achieved.

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Case Presentaion

• Reason for Consult LG- 38/y/y AAF was assaulted
  and sustained multiple facial fractures, pt.
  developed meningitis and endocarditis and is
  treated with oral Zyvox. Pt refused to leave the
  room, she thinks that people will look at her and
  treat her funny.

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• HPI- 38y/y AAF who lives with her mother,
  grandmother, daughter and 2 grandchildren. Sits
  for the grandchildren and grandmother who had
  stroke.
• 4/21/06 spent the weekend at a motel and upon
  leaving at midnight, her boyfriend dropped her
  (at her request) at a disabled neighbor who lives
  two blocks from the Pts house. According to the
  patient, she wanted to check on her neighbor, but
  her neighbor did not answer the door. The Pt
  walked to her house but first decided to stop at
  a grocery across the street from her house.
  Before entering the store, she was assaulted and
  the Pt. does not remember any details until she
  was in the ER at LSU-S. Pt was transferred from
  Monroe.

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• Pt denies being depressed but stated she is
  self-conscious because of her left eye,
  periorbital scar, loss of vision and ptosis.
  
• What will people say about this? My
  grandchildren will be scared of me.

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Psychiatric review of systemsMAPSS

• Mood-depression (sigecaps) sleeps 8-10 hours,
  helpless, occasional crying spells, no guilt or
  frustration, not hopeless, appetite normal, good
  energy with normal concentration.
• Mood-mania (digfast) negative
• Anxiety- no flash back, no nightmare
• Psychosis- no hallucination, no delusion
• Substance- no tobacco, started beer drinking at
  age 17 which increased to 6 beer/daily for the
  last year, history of THC and cocaine abuse X 9
  years, last use 3 years ago.
• Safety- no SI/HI

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Social History

• 12th grade education, single with 6 children,
  liked to socialize, watch TV, go to casino, no
  church activity, no military service, no history
  of abuse, jailed a few months, 13 years ago due
  to an altercation and violating her parole.

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Past Medical Psychiatric History

• none

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Family History

• Father Mother living but separated,
• no problems.
• 3 sisters one sister with HTN
• 6 children- two daughters, 4 sons, no problems.

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MSE

• AO x4 in casual clothes, cooperative and
  pleasant, speech normal, mood and affect
  euthymic, TP organized, TC no hallucinations or
  delusions, no SI/HI
• Registration 3/3, Recall 2/3, spells WORLD
  forward and backward, abstract intact ( do not
  cry over spilled milk) insight and judgment good.

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Assessment

• Axis I - Adjustment disorder with anxiety
• - ETOH / cocaine abuse
• - THC abuse in remission
• Axis II- deferred
• Axis III- s/p assault with facial and skull
  fx
  
• meningitis, endocarditis, loss
  of
  
• vision-left, ptosis, anemia
  NC/NC
  
• Axis IV- unemployed
• Axis V- GAF45/55
  

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Treatment/Recommendation

• Self disclosure
• Examine pt thoughts
• Desensitization
• Alcohol and drug counseling
• Follow-up with MMH upon discharge
• Continue to encourage pt to walk out of the room
• No need for medication.

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Follow-up

• Pt was called at home 5/20/06
• Mother stated that the Pt is back to her self,
  not depressed and is following up with MMH, also
  the Pt has weekend plans to go away and will not
  return until Monday.

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What is the most important issue in psychiatric
care?
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SAFETY
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What is the second most important issue?
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Therapeutic Alliance
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What is Therapeutic Alliance?

• The readiness of a patient to work with energy
  with a willing psychotherapist.
  
• It has not commonly applied to the type of brief
  encounter experience by the consultation-liaison
  psychiatrist in hospital setting. Nonetheless,
  insofar as the consulting psychiatrist fosters
  hope and expectation in patients seen in that
  context, however brief the contact , the
  relationship (alliance) has the capacity to
  promote maturation and well-being in any
  patient.
• The psychiatric consultant makes use of all the
  principals of good psychotherapy although they
  are often modified to accommodate the realities
  of the hospital setting and the unusual way in
  which psychiatrist and patient are brought
  together.

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Dr. Joel Yagers twelve behaviors as a list of
dos, somewhat analogous to the ten
commandments of etiquette in the psychiatric
consultation described by Pasnau.
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I. Sit Down.

• Sitting reduces the status difference between MD
  and Pt and the likelihood that the Pt will
  perceive the MD to be assuming a lordly demeanor
  and also conveys to the patient that the MD has
  some time to spend with them.
• Introduce yourself.
• State the reason for the visit.
• Ask for permission to sit.

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II. Do something tangible for the patient.

• Farther the rapport.
• Be helpful in small ways, do what a good nurse
  will do, ask the Pt if he is comfortable.
  
• Increase the comfort of the Pt.

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III. Touch the Patient

• The physical intimacy of touch is helpful with a
  frightened, dependant, and/or very physically ill
  patient and conveys a human caring that can
  reduce the feeling of aloneness and alienation in
  dehumanizing medical environments.
• Handshake, hold Pt hand, touch Pt shoulder
• The least touched Pt AIDS, Cancer

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IV. Smile

• Reduces interpersonal distance
• Decreases sense of threat
• Has a disarming effect
• Must be culturally acceptable

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V. Begin by telling the patient what you know
about his/her situation.

• Ask the patient to correct you.
• The positive effects
• Pt does not have to go through the
• information again.
• helps to get feed-back from Pt.
• Pt will assess the level of the
• consultants understanding and concern.

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VI. Ask the patient what his/her most pressing
concerns of the moment are.

• The Pts preoccupation with major fear or concern
  needs to be cleared to have the Pts full
  attention and cooperation.
  
• Clears the air so the necessary information can
  be used more effectively.

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VII. Ask in detail about the patients belief
system regarding the nature, cause and prognosis
of the illness or injury, and about the patients
specific concerns about pain, disability,
disfigurement or death.

• Tune into the Pt perspective and expectations of
  what the Pt is confronting.
  
• Correct misimpressions and provide education.
  (facilitate cooperation with RX)

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VIII. Ask in detail about the patients family
major social roles such as occupation, and the
impact of the current illness or injury on those
relationships and roles.

• Pt is concerned about the negative consequences
  of the illness on loved ones and on the ability
  to maintain major social role functions in
  family, work and community.

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IX. Ask about the specific personal
characteristics, activities and attainments the
patient has achieved in life in which he/she
takes pride and find an opportunity to complement
these qualities.

• Improve self esteem and the Pt feels that the
  consultant appreciates the Pt, not as a simply
  dependent creature.

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X. Acknowledge the human blight in which the
patient finds him/herself.

• The physician should tell the Pt that faced with
  similar circumstances, the physician might well
  display similar psychological difficulties.
  
• Strengthen the physician/Pt relationship
• Legitimize and validate the Pt and support self
  esteem.

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XI. Fully explain the need for and purpose of
mental status exam in an informative way and
involve the Pt as an ally an co-investigator.
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XII. Leave the patient with something concrete.

• Give the Pt a revised formulation.
• Tell the Pt what you intent to do with the
  information.
  
• Ask the Pt for feedback.
• Tell the Pt when you are coming back for
  follow-up.

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2000 My vet gave me an Axis II diagnosis.

• Personality disorder -incompatible with large
  dogs in house.

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Treatment

• Guido Hanna a pure-bred dachshund, who believes
  he is a doberman, was added to the family.

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Guido Hanna
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Discussion