VOLUME XVI • NUMBER 1
FIRST QUARTER, 1975
PSYCHOSOMATICS OFFICIAL JOURNAL OF THE ACADEMY OF PSYCHOSOMATIC MEDICINE
The Role of Psychiatric Consultation
•
In
Psychosomatic Medicine MAURICE
J.
Among the most difficult decisions that a practicing physician must make are whether to ask for help in the form of a consultation and when to do so. Because psychiatric and psychosomatic problems are ubiquitous, because many of them seem obvious, and because some physicians may feel omnipotent in regard to psychosomatic issues, the physician may be more reluctant 10 ask for psychiatric consultation than for other types of consultations. Also, a stigma or bias may exist on the part of either the physician or the patient, that produces a resistance to psychiatric evaluation and possible treatment. Perhaps more important, some primary physicians believe that no definitive treatment is available for psychosomatic disorders. One of the major goals of the Academy has been education in an effort to help overcome the mind-body dichotomy that has been and is prevalent. The goals of the Academy are simply stated: To advance scientific knowledge and the practice of medicine which relate to the interaction of mind, body, and environment through study and laboratory and clinical research; to cooperate with other workers in these and related disciplines; to provide a forum for the presentation and discussion of these problems; to publish results of research; and to facilitate total and comprehensive care. Most of my professional career, both in internal medicine and in psychiatry, has been spent at a large referral center-the Mayo Clinic. Psychiatrists at this institution spend about half their time in consultative or liaison practice. This has given me the opportunity to observe the vicissitudes of the psychiatric consultation process. Earlier this year, I personally had my 5,000th outpatient consultation in collaboration with a colleague practicing internal medicine. This work Dr. Martin is Chief, Department of Adult Psychiatry. Mayo Clinic and Mayo Foundation. Rochester. Minnesota 55901. Read as Presidential Address at the meeting of the Academy of Psychosomatic Medicine, Scottsdale. Arizona, November 17 to 21, 1974. January /February/March, 1975
MARTIN, M.D.
has covered a period of 12 years and forms the data base for my remarks. THE PATIENT
The problems seen in a psychiatric consulting practice are highly varied. Some are uncomplicated, straightforward problems that require only a few minutes to make a diagnosis, suggest therapy, or make recommendations to the referring physician. On the other hand, many patients manifest a panoply of complexities that may be as difficult to assess as any problem in the practice of medicine: personality characteristics may be atypical; neurotic problems may be interlaced with characterologic problems; somatization reaction may be related to or superimposed on other illnesses; and, of course, multiple problems may coexist. Medicolegal issues seem to be all too frequent. Patients are often admitted to a medical service for diagnostic evaluation of symptoms that prove to be solely or primarily the result of psychophysiologic or somatization reactions. Patients with depression are often admitted for evaluation of their somatic symptoms. The depression may not be readily apparent and, as with psychophysiologic reactions, a thorough medical evaluation (including a complete medical interview, physical examination, and laboratory and roentgenologic studies) is necessary. The psychiatric consultant must always consider the possibility of hidden organic disease. All medical problems have emotional components-the patient has feelings about and reacts to his illness. Some physicians lose sight of this basic fact. Some medical problems may present as though they were primarily a psychiatric illness (Table 1). Schwab has an extensive list of possible medical sources of emotional symptoms in his Handbook of Psychiatric Consultation!. In my series of consultations, depression has been the most prevalent problem, with almost one-third of all patients manifesting some type of depression (Table 2). Hysterical personality disorders and psychoneurotic
IIIIIIIIIII~ 111111111111111111111111111111111 614R-HDZ-67A7
7
PSYCHOSOMATICS
conversion reactions are also frequently seen in our practice. In my experience, there are certain diagnostic pitfalls other than those organic diseases that masquerade as psychiatric problems. One must be alert for hidden or masked depression, for concealed paranoia, and for subtle organic brain syndromes. Compensation problems present unique challenges2 • The threat of depositions or courtroom appearances at a later date necessitates a history that is elicited carefully and recorded accurately. THE REFERRING PHYSICIAN
It is helpful to be able to understand the dynamics of the referral. The primary physician usualIy is aware of his own need for help in the further evaluation and treatment of the patient. This awareness requires some degree of tolerance of and insight into the emotional problems of his patient. On the other hand, he may be perplexed or intolerant of the patient's emotional status or behavior. In this instance, the nonverbal communication may come across in terms of "do something" or "take this patient off my hands." In the
hospital, the attending physician is often influenced by other members of the health-care team in his decision to request psychiatric consultation. Many psychiatric consultations are requested because of the primary physician's inability to cope with a patient. He may be perplexed or threatened by his patient's behavior. Some physicians equate tearfulness with depression; others are intolerant of emotional problems and request psychiatric help at the first sign of emotional instability on the part of the patient. The information requested by the physician also may relate to the physician's own personal needs. Some physicians are eager to discuss the psychodynamics of their patient in detail, often to confirm their own formulations of the patient. Other physicians merely want "hard facts," such as whether the patient is a danger to himself or others, whether psychiatric treatment may offer help (or result in the transfer of a patient who the primary physician would like to avoid), and which drugs to use and in what dosages. These physicians may be quite impatient with a consultant who, in his eyes. is vague or unable to be helpful. The consultant may modify his interview and subsequent
Table I.-Medical Problems That May Present With Psychiatric Symptoms If apparent problem is:
Anxiety
Organic illness could be: Hyperthyr"idism Porphyria, acute intermittent Hypoglycemia (islet cell adenoma of pancreas) Pheochromocytoma
Depression
Hypothyroidism
Adrenal cortical insufficiency (Addison's disease) Pernicious anemia
Pancreatic carcinoma Hysterical personality Adolescent turmoil
Personality change Fluctuating anxiety and depression
Multiple sclerosis Hepatolenticular degeneration (Wilson's diesase)
Hyperparathyroidism Hypoparathyroidism Hyperadrenalism (Cushing's disease ) Intracranial tumors
Acute psychosis
8
Systemic lupus erythematosus
Differentiating signs and clues to diagnoses Fine tremor, sweating, weight loss. occasional hyperactive or grandiose behavior Sudden onset of severe anxiety, emotional outbursts, abdominal pain. paresthesias; may seem quite neurotic Episodic anxiety, tremor, sweating, hunger, fatigue, dizziness, bizarre behavior, rarely brain damage Severe panic, fear, trembling, flushing, headache; blood pressure increased only during attack Puffy face, dry skin, cold intolerance, fatigue; "myxedema madness" manifests as delusional thinking with disturbed behavior Weight loss, skin pigmentation, fatigue, apathy, negativism; onset usually insidious Weakness, glossitis, peripheral neuritis, feelings of guilt and worthlessness; onset gradual; routine blood counts may be normal Weight loss, abdominal pain, feeling of imminent doom without guilt, often confused with unipolar depression Bland euphoria, labile mood, vague motor and sensory findings Young men, labile mood, explosiveness, liver disease, extrapyramidal signs, Kayser-Fleischer rings, eventual brain damage Symptoms of anxiety may vary with depression, fatigue; anorexia, renal calculi, duodenal ulcer (hyper); hyperreflexia, spasms, tetany (hypo) Anxiety and depression, weight gain with "buffalo hump," purple skin striae, occasional delusional thinking Subtle changes in behavior, headache, poor judgment, clouding of consciousness Young women, multisystem disease, usually more confusion than acute schizophrenia Volume XVI
PSYCHIATRIC CONSULTAnON-MARTIN
note to meet the needs of the referring physician, but he must be wary not to allow the personality of the referring physician to impinge on or influence his objective evaluation of the patient. THE TECHNIQUE OF PSYCHIATRIC CONSULTATION
It is important that the consultation be conducted in a relaxed. quiet, and uninterrupted manner. The consultant must allow adequate time to read the record of the patient, to talk with the referring physician before and after the interview, to conduct an interview, and to write a note. With experience, this usually can be accomplished in I hour. The interview between physician and patient is an intricate interpersonal relationship. The physician should observe every verbal and nonverbal communication. The importance of dress and demeanor should not be underestimated. The ability to read body language is helpful to the consultant, and many diagnostic clues are obtained from such nonverbal communication. The initial aspect of the interview includes the introduction and an attempt at putting the patient at case. It is necessary to be able to understand the patient and his problem. It helps to have lived-to know what it means to lose a loved one, to lose money in the stock market, to scrub pots as a bull cook, to crawl the Army infiltration course under machine-gun fire, to slop hogs, to render lard, to commute on the subway, and to have watched life and death. Does it help to have had personal psychoanalysis? I don't know, but it helps to have a normal MMPI! Empathy is a necessary ingredient for a comprehensive consultation. There is no place for callousness, coldness, or terseness. Because patients seen in psychiatric consultation are extremely variable with regard to problem type and personality pattern, it is imperative for the consultant to be flexible in his approach. The interview must be free flowing and relatively open-ended. IdeaIly, it should cover a longitudinal outline of the patient's history. It is important to focus on the life situation at the time of the onset of the symptoms. Work, social, or marital problems at the onset may have played a causal role but such events may be suppressed by the patient. In order to understand the dynamics as fully as possible, it is important to obtain a background history that includes family data such as the relationship of the patient with the parents and sibling patterns and rivalries as well as a review of the health of significant family members. Those with hysterical personalities often identify with a family member. In my work on muscle-eontraction headaches, it was frequently noted that most patients with such headaches had been closely associated with family members who also had headaches3 In most situations, diagnostic clues are readily available. These may include signs and symptoms of JanuarylFebruary/March, 1975
Table 2.-Types of Problems Diagnosis Depression Hysterical personality Conversion reaction Other neuroses Other personality disorders Psychophysiologic Psychosis Alcoholism Other or no diagnosis
Percent 31 14 6
21 5 8 5 2 8
depression, life-long neurotic patterns, characteristics of hysteroid behavior, or specific medical problems that are apparent. There are those who belittle the importance of a diagnosis in psychiatry but, in the consultative process, it is important for two reasons: ( I) unless a diagnosis is firmly in hand, therapeutic recommendations necessarily will be vague or diffuse; and (2) most practicing family physicians, internists, and surgeons are compulsive, nosologically oriented people who have more confidence in a consultation that carries a diagnosis (or at least an impression) and, consequently, are more likely to carry out the recommendations. A valuable aid to the psychiatric diagnosis is the Minnesota Multiphasic Personality Inventory (MMPI). This test is to the consulting psychiatrist what the hemogram is to the hematologist or the electroencephalogram is to the neurologist. Patterns of neurosis such as conversion "V" responses, agitated depression profiles, and a multitude of other features aid in formulating the diagnosis. A User's Guide to the Mayo Clinic Automated MMPI Program by Pearson and Swenson' is an easy-to-understand manual for this personality test. Other formal psychometrics may be needed. Intelligence tests help in evaluating overachievers and patients with organic brain syndromes; projective tests may clarify the diagnostic dilemma of the borderline and psychotic patients. An interview with relatives can be a productive adjunct to the diagnostic process. A spouse may discuss evidences of alcoholism, personality change, paranoid thinking, or marital or sexual problems that were not revealed by the patient. The use of psychiatric social workers for family interviews may be helpful. The consultant on a psychiatric-liaison hospital service will usuaIly find that his frequent attendance at ward rounds will be essential. This permits better understanding of the medical staff, nurses, and patients on the service in order that he may relate better to all hospital personnel and patients. He is identified as part of the team. This may help toward patient orientation rather than disease orientation. When the consultant shares the staff's routine, as well as their con9
PSYCHOSOMATICS
cerns about particular patients, a growing familiarity develops that helps dispel the staff's fear of criticism and diminishes distorted views of emotional problems. He is able to get a different perspective of the milieu of the hospital and may be able to suggest constructive changes based on his observation of patient-personnel relationships. By his presence, he attests that he is availahle for consultation and may be able to offer effective "curbstone" consultation in some cases. However, it is imperative that the psychiatric consultant not make generalizations based on inadequate data. Poor advice may be worse than no advice. When the consultant is supportive, he is able to gain the confidence of both staff and patients. The opportunity for bedside teaching in the medical tradition is enhanced. This often results in improved interview techniques and an increased awareness of how emotional and social factors influence illness. It is important that the psychiatric consultant blend with the staff-participate and share concern without interfering with essential activities or monopolizing staff attention by making every case a psychiatric problem. CASE VIGNETTE
A 42-year-old married mother of two adolescent daughters came to her physician complaining of fatigue of about 6 months' duration. An extensive medical history, a physical examination, and laboratory studies were noncontributory. She spoke freely of her "conflicts" to her physician, and psychiatric consultation was requested after an automated MMPI completed by the patient revealed significant elevations of the clinical hypochondriasis and hysteria scales with a marked absence of depression. This represented the so-called conversion "V" pattern. Upon entering the examining room, the consultant psychiatrist found the patient sitting in a coquettish manner with a smile and was greeted with a cheery "Hello, Doctor." She was quite verbal, well oriented, and overly friendly. She was restless during the interview and smoked numerous cigarettes. Although seeming to be candid, she actually was quite a difficult historian--evasive and frequently changing the suhject. The examiner attempted to learn about the patient's presenting symptoms, about the current status of her life, and specifically about events at the onset of her fatigue. She described herself as a bored housewife, married to a busy attorney who was 7 years her senior. She had always been active in community and church affairs with an obvious inability to say "no" to demands that were placed upon her by various volunteer groups. She had doted over her children in their younger years but felt "left out" as they proceeded with their own school and social activities. She described her marriage as being ideal despite her husband's busy practice and earlier financial struggles. Further inquiry revealed a history of life-long anorgasmia with the statement that "sex causes trouble"; then, a period of painful silence was followed by a flood of tears. She sobbed a story of her husband's inattentiveness along with her own concerns about aging and boredom that had led her to a torrid extramarital affair which had commenced insidiously about 1 year previously and had been terminated by the patient because of the onset of fatigue 6 months prior to the examination. The pa10
tient had then withdrawn from all social acllvttles and came to her physician at her husband's insistence. She denied feelings of guilt or overt depression and insisted that her doctor must have missed the organic cause of her fatigue. The psychiatrist felt that the patient manifested an hysterical personality diso~der with fatigue being a type of conversion reaction. The secondary gain seemed obvious. Intensive psychotherapy was recommended but the patient declined the psychiatrist's advice. The primary physician refused to be manipulated by the patient's demands for more laboratory studies. Two weeks later, the patient returned for psychotherapy which eventually also involved the husband and produced not only an alleviation of symptoms but also a marked improvement in the marital relationship. In this instance, the psychiatrist helped both the patient and the referring physician. Of course, the primary physician recognized the emotional aspects of the patient's symptom. but the psychiatrist was able to take the time to unravel the difficult history and to explain the dynamics to the patient's physician in such a way that he felt comfortable with his evaluation and was able to avoid fostering her symptoms or, even worse, contributing iatrogenic symptoms by misdiagnosis or inappropriate drug regimens. THERAPEUTIC CONSIDERATIONS
Let us not forget that patients expect treatment. The prime role of a consultant is to help the referring physician manage the case. Of course, diagnosis comes first, but specific therapeutic suggestions are expected. It is important to be specific. If a minor tranquilizer is deemed desirable as an adjunctive agent, it is important to name the drug of choice and to suggest a dosage and a schedule of administration. In the treatment of depression with tricyclic antidepressant drugs, it is essential to discuss with both the patient and the physician the need for adequate doses and patience in treatment because of the lag period in onset of effect of this type of drug. Furthermore, the consultant must be specific regarding the duration of treatment and recommendations for follow-up. The patient is paying for a firm opinion, not a vague generalization. The referring physician will, of course, he free to decide whether or not to implement the consultant's recommendations, but he will be much more secure if the specifics of the recommendation are spelled out. Recommendations relative to therapy and disposition of the patient should take into consideration the relationship of the patient to the primary physician and also the expectations of the referring physician. SUMMARY
Psychosomatic medicine, with all its parameters and pitfalls, can and should be approached with a holistic view of the patient and with the goal of a diagnosis and appropriate treatment as the step toward restoration to health. Psychiatric consultation is a valuable aid to the primary physician in the evaluation and treatment of psychosomatic problems. Special techVolume XV.
PSYCHIATRIC CONSULTATION-MARTIN
niques that may aid the consultant include the use of personality tests such as the MMPI, the understanding of the referring physician's needs, and an organized approach to the evaluation. It is important to make a diagnosis if possible and to make specific recommendations that may be applied by the primary physician. These educational aspects of such consultation for both the patient and the referring physician should not be underestimated. In regard to the role of the psychiatric consultation in psychosomatic problems, the
goals parallel in an amazing fashion the goals of the Academy of Psychosomatic Medicine. REFERENCES Handbook of Psychiatric Consultation. New York: Appleton-Century-Crofts, 1968. 2. Martin, M. J.: Psychosomatics, 11 :81, March-April 1970. 3. Martin, M. J.: Psychosomatics, 13:16, January-February 1972. 4. Pearson, J. S. and Swenson, W. M.: A User's Guide to the Mayo Clinic Automated MMPI Pro~ram. New York: Psychological Corporation, 1967. I. Schwab, J. J.:
ACADEMY ANNOUNCES MANUSCRIPT CONTEST FOR 1975 The Academy of Psychosomatic Medicine announces an annual contest for the best paper on a clinical or research subject in the field of psychosomatic medicine. The winner will be awarded the Academy's plaque for scientific writing and the manuscript will be presented by the author at the annual meeting of the Academy of Psychosomatic Medicine, and will be published in the official journal of the Academy.
Rules Eligibility. All persons in training will be eligible to enter this contest. The training must be postgraduate training in medical practice or the basic sciences, or paramedical areas. Contestants must have a degree from an accredited college in their field of science. Submission of Manuscript. The manuscripts should not exceed 4000 words. They should be typed (double spaced), on one side of the paper, with ample margins on both sides. Legends should accompany all illustrations. Tables and charts should be numbered and submitted on separate sheets. Footnotes and references should be listed at the end of the article, numbered as they appear in the text. References to an article should include the author, title of article, name of periodical, volume number, date and page. If the reference is to a book it should also contain the name of the publisher, city and the year of publication. An original and three copies of each manuscript must be submitted on or before July I, 1975, to James A. Page, M.D., Suite 200, 44 Nassau Street, Princeton, New Jersey 08540. Awarding of the Prize. The Awards Committee under
January /February /March, 1975
its rules and regulations will judge the merits of each manuscript and will select the winner before October I, 1975. If none of the submitted manuscripts are deemed worthy by the committee, no award shall be made. The winning author will be notified by the Chairman of the Awards Committee and invited to participate in the annual meeting of the Academy of Psychosomatic Medicine in New Orleans, Louisiana. The committee reserves the right to submit all entries including the winning entry, to Psychosomatics, official Academy journal. Manuscripts not accepted for publication by Psychosomatics will be returned to their authors. Award. The winning author will receive a plaque suitably inscribed to respect the dignity of the award, along with expenses to the annual meeting of the Academy to present the paper at that meeting.
Awards Committee Karl Rickels, M.D., Chairman 203 Piersol Building 3400 Spruce Street Philadelphia, Pa. 19104 Alberto DiMascio, Ph.D. 21 Marion Street Randolph, Massachusetts 02360 James A. Page, M.D. Suite 200 444 Nassau Street Princeton, New Jersey 08540
11
FIRST QUARTER, 1975
PSYCHOSOMATICS OFFICIAL JOURNAL OF THE ACADEMY OF PSYCHOSOMATIC MEDICINE
The Role of Psychiatric Consultation
•
In
Psychosomatic Medicine MAURICE
J.
Among the most difficult decisions that a practicing physician must make are whether to ask for help in the form of a consultation and when to do so. Because psychiatric and psychosomatic problems are ubiquitous, because many of them seem obvious, and because some physicians may feel omnipotent in regard to psychosomatic issues, the physician may be more reluctant 10 ask for psychiatric consultation than for other types of consultations. Also, a stigma or bias may exist on the part of either the physician or the patient, that produces a resistance to psychiatric evaluation and possible treatment. Perhaps more important, some primary physicians believe that no definitive treatment is available for psychosomatic disorders. One of the major goals of the Academy has been education in an effort to help overcome the mind-body dichotomy that has been and is prevalent. The goals of the Academy are simply stated: To advance scientific knowledge and the practice of medicine which relate to the interaction of mind, body, and environment through study and laboratory and clinical research; to cooperate with other workers in these and related disciplines; to provide a forum for the presentation and discussion of these problems; to publish results of research; and to facilitate total and comprehensive care. Most of my professional career, both in internal medicine and in psychiatry, has been spent at a large referral center-the Mayo Clinic. Psychiatrists at this institution spend about half their time in consultative or liaison practice. This has given me the opportunity to observe the vicissitudes of the psychiatric consultation process. Earlier this year, I personally had my 5,000th outpatient consultation in collaboration with a colleague practicing internal medicine. This work Dr. Martin is Chief, Department of Adult Psychiatry. Mayo Clinic and Mayo Foundation. Rochester. Minnesota 55901. Read as Presidential Address at the meeting of the Academy of Psychosomatic Medicine, Scottsdale. Arizona, November 17 to 21, 1974. January /February/March, 1975
MARTIN, M.D.
has covered a period of 12 years and forms the data base for my remarks. THE PATIENT
The problems seen in a psychiatric consulting practice are highly varied. Some are uncomplicated, straightforward problems that require only a few minutes to make a diagnosis, suggest therapy, or make recommendations to the referring physician. On the other hand, many patients manifest a panoply of complexities that may be as difficult to assess as any problem in the practice of medicine: personality characteristics may be atypical; neurotic problems may be interlaced with characterologic problems; somatization reaction may be related to or superimposed on other illnesses; and, of course, multiple problems may coexist. Medicolegal issues seem to be all too frequent. Patients are often admitted to a medical service for diagnostic evaluation of symptoms that prove to be solely or primarily the result of psychophysiologic or somatization reactions. Patients with depression are often admitted for evaluation of their somatic symptoms. The depression may not be readily apparent and, as with psychophysiologic reactions, a thorough medical evaluation (including a complete medical interview, physical examination, and laboratory and roentgenologic studies) is necessary. The psychiatric consultant must always consider the possibility of hidden organic disease. All medical problems have emotional components-the patient has feelings about and reacts to his illness. Some physicians lose sight of this basic fact. Some medical problems may present as though they were primarily a psychiatric illness (Table 1). Schwab has an extensive list of possible medical sources of emotional symptoms in his Handbook of Psychiatric Consultation!. In my series of consultations, depression has been the most prevalent problem, with almost one-third of all patients manifesting some type of depression (Table 2). Hysterical personality disorders and psychoneurotic
IIIIIIIIIII~ 111111111111111111111111111111111 614R-HDZ-67A7
7
PSYCHOSOMATICS
conversion reactions are also frequently seen in our practice. In my experience, there are certain diagnostic pitfalls other than those organic diseases that masquerade as psychiatric problems. One must be alert for hidden or masked depression, for concealed paranoia, and for subtle organic brain syndromes. Compensation problems present unique challenges2 • The threat of depositions or courtroom appearances at a later date necessitates a history that is elicited carefully and recorded accurately. THE REFERRING PHYSICIAN
It is helpful to be able to understand the dynamics of the referral. The primary physician usualIy is aware of his own need for help in the further evaluation and treatment of the patient. This awareness requires some degree of tolerance of and insight into the emotional problems of his patient. On the other hand, he may be perplexed or intolerant of the patient's emotional status or behavior. In this instance, the nonverbal communication may come across in terms of "do something" or "take this patient off my hands." In the
hospital, the attending physician is often influenced by other members of the health-care team in his decision to request psychiatric consultation. Many psychiatric consultations are requested because of the primary physician's inability to cope with a patient. He may be perplexed or threatened by his patient's behavior. Some physicians equate tearfulness with depression; others are intolerant of emotional problems and request psychiatric help at the first sign of emotional instability on the part of the patient. The information requested by the physician also may relate to the physician's own personal needs. Some physicians are eager to discuss the psychodynamics of their patient in detail, often to confirm their own formulations of the patient. Other physicians merely want "hard facts," such as whether the patient is a danger to himself or others, whether psychiatric treatment may offer help (or result in the transfer of a patient who the primary physician would like to avoid), and which drugs to use and in what dosages. These physicians may be quite impatient with a consultant who, in his eyes. is vague or unable to be helpful. The consultant may modify his interview and subsequent
Table I.-Medical Problems That May Present With Psychiatric Symptoms If apparent problem is:
Anxiety
Organic illness could be: Hyperthyr"idism Porphyria, acute intermittent Hypoglycemia (islet cell adenoma of pancreas) Pheochromocytoma
Depression
Hypothyroidism
Adrenal cortical insufficiency (Addison's disease) Pernicious anemia
Pancreatic carcinoma Hysterical personality Adolescent turmoil
Personality change Fluctuating anxiety and depression
Multiple sclerosis Hepatolenticular degeneration (Wilson's diesase)
Hyperparathyroidism Hypoparathyroidism Hyperadrenalism (Cushing's disease ) Intracranial tumors
Acute psychosis
8
Systemic lupus erythematosus
Differentiating signs and clues to diagnoses Fine tremor, sweating, weight loss. occasional hyperactive or grandiose behavior Sudden onset of severe anxiety, emotional outbursts, abdominal pain. paresthesias; may seem quite neurotic Episodic anxiety, tremor, sweating, hunger, fatigue, dizziness, bizarre behavior, rarely brain damage Severe panic, fear, trembling, flushing, headache; blood pressure increased only during attack Puffy face, dry skin, cold intolerance, fatigue; "myxedema madness" manifests as delusional thinking with disturbed behavior Weight loss, skin pigmentation, fatigue, apathy, negativism; onset usually insidious Weakness, glossitis, peripheral neuritis, feelings of guilt and worthlessness; onset gradual; routine blood counts may be normal Weight loss, abdominal pain, feeling of imminent doom without guilt, often confused with unipolar depression Bland euphoria, labile mood, vague motor and sensory findings Young men, labile mood, explosiveness, liver disease, extrapyramidal signs, Kayser-Fleischer rings, eventual brain damage Symptoms of anxiety may vary with depression, fatigue; anorexia, renal calculi, duodenal ulcer (hyper); hyperreflexia, spasms, tetany (hypo) Anxiety and depression, weight gain with "buffalo hump," purple skin striae, occasional delusional thinking Subtle changes in behavior, headache, poor judgment, clouding of consciousness Young women, multisystem disease, usually more confusion than acute schizophrenia Volume XVI
PSYCHIATRIC CONSULTAnON-MARTIN
note to meet the needs of the referring physician, but he must be wary not to allow the personality of the referring physician to impinge on or influence his objective evaluation of the patient. THE TECHNIQUE OF PSYCHIATRIC CONSULTATION
It is important that the consultation be conducted in a relaxed. quiet, and uninterrupted manner. The consultant must allow adequate time to read the record of the patient, to talk with the referring physician before and after the interview, to conduct an interview, and to write a note. With experience, this usually can be accomplished in I hour. The interview between physician and patient is an intricate interpersonal relationship. The physician should observe every verbal and nonverbal communication. The importance of dress and demeanor should not be underestimated. The ability to read body language is helpful to the consultant, and many diagnostic clues are obtained from such nonverbal communication. The initial aspect of the interview includes the introduction and an attempt at putting the patient at case. It is necessary to be able to understand the patient and his problem. It helps to have lived-to know what it means to lose a loved one, to lose money in the stock market, to scrub pots as a bull cook, to crawl the Army infiltration course under machine-gun fire, to slop hogs, to render lard, to commute on the subway, and to have watched life and death. Does it help to have had personal psychoanalysis? I don't know, but it helps to have a normal MMPI! Empathy is a necessary ingredient for a comprehensive consultation. There is no place for callousness, coldness, or terseness. Because patients seen in psychiatric consultation are extremely variable with regard to problem type and personality pattern, it is imperative for the consultant to be flexible in his approach. The interview must be free flowing and relatively open-ended. IdeaIly, it should cover a longitudinal outline of the patient's history. It is important to focus on the life situation at the time of the onset of the symptoms. Work, social, or marital problems at the onset may have played a causal role but such events may be suppressed by the patient. In order to understand the dynamics as fully as possible, it is important to obtain a background history that includes family data such as the relationship of the patient with the parents and sibling patterns and rivalries as well as a review of the health of significant family members. Those with hysterical personalities often identify with a family member. In my work on muscle-eontraction headaches, it was frequently noted that most patients with such headaches had been closely associated with family members who also had headaches3 In most situations, diagnostic clues are readily available. These may include signs and symptoms of JanuarylFebruary/March, 1975
Table 2.-Types of Problems Diagnosis Depression Hysterical personality Conversion reaction Other neuroses Other personality disorders Psychophysiologic Psychosis Alcoholism Other or no diagnosis
Percent 31 14 6
21 5 8 5 2 8
depression, life-long neurotic patterns, characteristics of hysteroid behavior, or specific medical problems that are apparent. There are those who belittle the importance of a diagnosis in psychiatry but, in the consultative process, it is important for two reasons: ( I) unless a diagnosis is firmly in hand, therapeutic recommendations necessarily will be vague or diffuse; and (2) most practicing family physicians, internists, and surgeons are compulsive, nosologically oriented people who have more confidence in a consultation that carries a diagnosis (or at least an impression) and, consequently, are more likely to carry out the recommendations. A valuable aid to the psychiatric diagnosis is the Minnesota Multiphasic Personality Inventory (MMPI). This test is to the consulting psychiatrist what the hemogram is to the hematologist or the electroencephalogram is to the neurologist. Patterns of neurosis such as conversion "V" responses, agitated depression profiles, and a multitude of other features aid in formulating the diagnosis. A User's Guide to the Mayo Clinic Automated MMPI Program by Pearson and Swenson' is an easy-to-understand manual for this personality test. Other formal psychometrics may be needed. Intelligence tests help in evaluating overachievers and patients with organic brain syndromes; projective tests may clarify the diagnostic dilemma of the borderline and psychotic patients. An interview with relatives can be a productive adjunct to the diagnostic process. A spouse may discuss evidences of alcoholism, personality change, paranoid thinking, or marital or sexual problems that were not revealed by the patient. The use of psychiatric social workers for family interviews may be helpful. The consultant on a psychiatric-liaison hospital service will usuaIly find that his frequent attendance at ward rounds will be essential. This permits better understanding of the medical staff, nurses, and patients on the service in order that he may relate better to all hospital personnel and patients. He is identified as part of the team. This may help toward patient orientation rather than disease orientation. When the consultant shares the staff's routine, as well as their con9
PSYCHOSOMATICS
cerns about particular patients, a growing familiarity develops that helps dispel the staff's fear of criticism and diminishes distorted views of emotional problems. He is able to get a different perspective of the milieu of the hospital and may be able to suggest constructive changes based on his observation of patient-personnel relationships. By his presence, he attests that he is availahle for consultation and may be able to offer effective "curbstone" consultation in some cases. However, it is imperative that the psychiatric consultant not make generalizations based on inadequate data. Poor advice may be worse than no advice. When the consultant is supportive, he is able to gain the confidence of both staff and patients. The opportunity for bedside teaching in the medical tradition is enhanced. This often results in improved interview techniques and an increased awareness of how emotional and social factors influence illness. It is important that the psychiatric consultant blend with the staff-participate and share concern without interfering with essential activities or monopolizing staff attention by making every case a psychiatric problem. CASE VIGNETTE
A 42-year-old married mother of two adolescent daughters came to her physician complaining of fatigue of about 6 months' duration. An extensive medical history, a physical examination, and laboratory studies were noncontributory. She spoke freely of her "conflicts" to her physician, and psychiatric consultation was requested after an automated MMPI completed by the patient revealed significant elevations of the clinical hypochondriasis and hysteria scales with a marked absence of depression. This represented the so-called conversion "V" pattern. Upon entering the examining room, the consultant psychiatrist found the patient sitting in a coquettish manner with a smile and was greeted with a cheery "Hello, Doctor." She was quite verbal, well oriented, and overly friendly. She was restless during the interview and smoked numerous cigarettes. Although seeming to be candid, she actually was quite a difficult historian--evasive and frequently changing the suhject. The examiner attempted to learn about the patient's presenting symptoms, about the current status of her life, and specifically about events at the onset of her fatigue. She described herself as a bored housewife, married to a busy attorney who was 7 years her senior. She had always been active in community and church affairs with an obvious inability to say "no" to demands that were placed upon her by various volunteer groups. She had doted over her children in their younger years but felt "left out" as they proceeded with their own school and social activities. She described her marriage as being ideal despite her husband's busy practice and earlier financial struggles. Further inquiry revealed a history of life-long anorgasmia with the statement that "sex causes trouble"; then, a period of painful silence was followed by a flood of tears. She sobbed a story of her husband's inattentiveness along with her own concerns about aging and boredom that had led her to a torrid extramarital affair which had commenced insidiously about 1 year previously and had been terminated by the patient because of the onset of fatigue 6 months prior to the examination. The pa10
tient had then withdrawn from all social acllvttles and came to her physician at her husband's insistence. She denied feelings of guilt or overt depression and insisted that her doctor must have missed the organic cause of her fatigue. The psychiatrist felt that the patient manifested an hysterical personality diso~der with fatigue being a type of conversion reaction. The secondary gain seemed obvious. Intensive psychotherapy was recommended but the patient declined the psychiatrist's advice. The primary physician refused to be manipulated by the patient's demands for more laboratory studies. Two weeks later, the patient returned for psychotherapy which eventually also involved the husband and produced not only an alleviation of symptoms but also a marked improvement in the marital relationship. In this instance, the psychiatrist helped both the patient and the referring physician. Of course, the primary physician recognized the emotional aspects of the patient's symptom. but the psychiatrist was able to take the time to unravel the difficult history and to explain the dynamics to the patient's physician in such a way that he felt comfortable with his evaluation and was able to avoid fostering her symptoms or, even worse, contributing iatrogenic symptoms by misdiagnosis or inappropriate drug regimens. THERAPEUTIC CONSIDERATIONS
Let us not forget that patients expect treatment. The prime role of a consultant is to help the referring physician manage the case. Of course, diagnosis comes first, but specific therapeutic suggestions are expected. It is important to be specific. If a minor tranquilizer is deemed desirable as an adjunctive agent, it is important to name the drug of choice and to suggest a dosage and a schedule of administration. In the treatment of depression with tricyclic antidepressant drugs, it is essential to discuss with both the patient and the physician the need for adequate doses and patience in treatment because of the lag period in onset of effect of this type of drug. Furthermore, the consultant must be specific regarding the duration of treatment and recommendations for follow-up. The patient is paying for a firm opinion, not a vague generalization. The referring physician will, of course, he free to decide whether or not to implement the consultant's recommendations, but he will be much more secure if the specifics of the recommendation are spelled out. Recommendations relative to therapy and disposition of the patient should take into consideration the relationship of the patient to the primary physician and also the expectations of the referring physician. SUMMARY
Psychosomatic medicine, with all its parameters and pitfalls, can and should be approached with a holistic view of the patient and with the goal of a diagnosis and appropriate treatment as the step toward restoration to health. Psychiatric consultation is a valuable aid to the primary physician in the evaluation and treatment of psychosomatic problems. Special techVolume XV.
PSYCHIATRIC CONSULTATION-MARTIN
niques that may aid the consultant include the use of personality tests such as the MMPI, the understanding of the referring physician's needs, and an organized approach to the evaluation. It is important to make a diagnosis if possible and to make specific recommendations that may be applied by the primary physician. These educational aspects of such consultation for both the patient and the referring physician should not be underestimated. In regard to the role of the psychiatric consultation in psychosomatic problems, the
goals parallel in an amazing fashion the goals of the Academy of Psychosomatic Medicine. REFERENCES Handbook of Psychiatric Consultation. New York: Appleton-Century-Crofts, 1968. 2. Martin, M. J.: Psychosomatics, 11 :81, March-April 1970. 3. Martin, M. J.: Psychosomatics, 13:16, January-February 1972. 4. Pearson, J. S. and Swenson, W. M.: A User's Guide to the Mayo Clinic Automated MMPI Pro~ram. New York: Psychological Corporation, 1967. I. Schwab, J. J.:
ACADEMY ANNOUNCES MANUSCRIPT CONTEST FOR 1975 The Academy of Psychosomatic Medicine announces an annual contest for the best paper on a clinical or research subject in the field of psychosomatic medicine. The winner will be awarded the Academy's plaque for scientific writing and the manuscript will be presented by the author at the annual meeting of the Academy of Psychosomatic Medicine, and will be published in the official journal of the Academy.
Rules Eligibility. All persons in training will be eligible to enter this contest. The training must be postgraduate training in medical practice or the basic sciences, or paramedical areas. Contestants must have a degree from an accredited college in their field of science. Submission of Manuscript. The manuscripts should not exceed 4000 words. They should be typed (double spaced), on one side of the paper, with ample margins on both sides. Legends should accompany all illustrations. Tables and charts should be numbered and submitted on separate sheets. Footnotes and references should be listed at the end of the article, numbered as they appear in the text. References to an article should include the author, title of article, name of periodical, volume number, date and page. If the reference is to a book it should also contain the name of the publisher, city and the year of publication. An original and three copies of each manuscript must be submitted on or before July I, 1975, to James A. Page, M.D., Suite 200, 44 Nassau Street, Princeton, New Jersey 08540. Awarding of the Prize. The Awards Committee under
January /February /March, 1975
its rules and regulations will judge the merits of each manuscript and will select the winner before October I, 1975. If none of the submitted manuscripts are deemed worthy by the committee, no award shall be made. The winning author will be notified by the Chairman of the Awards Committee and invited to participate in the annual meeting of the Academy of Psychosomatic Medicine in New Orleans, Louisiana. The committee reserves the right to submit all entries including the winning entry, to Psychosomatics, official Academy journal. Manuscripts not accepted for publication by Psychosomatics will be returned to their authors. Award. The winning author will receive a plaque suitably inscribed to respect the dignity of the award, along with expenses to the annual meeting of the Academy to present the paper at that meeting.
Awards Committee Karl Rickels, M.D., Chairman 203 Piersol Building 3400 Spruce Street Philadelphia, Pa. 19104 Alberto DiMascio, Ph.D. 21 Marion Street Randolph, Massachusetts 02360 James A. Page, M.D. Suite 200 444 Nassau Street Princeton, New Jersey 08540
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