Process of Psychiatric Consultation in the Medical Setting

The connection between the mind and physical symptoms appears with Thomas Sydenham’s 1682 description of hysteria where he brought forth the notion that this condition of the mind could mimic any organic disease. Johann Christian Reil, a German physician who coined the term “psychiatry,” urged clinicians to use medical psychotherapy to cure both physical and mental illness. A monumental step in the reconceptualization of psychiatry as a medical discipline occurred when Benjamin Rush published the first textbook of mental diseases. In the late 19th century, Breuer and Freud cemented the understanding of psychological phenomena manifesting as physical symptoms in Studies of Hysteria (1).

Adolf Meyer, the director of the first university-based psychiatric clinic and the father of psychobiology, lay the groundwork for consultation-liaison psychiatry by integrating psychiatry into the main hospital. He promoted the idea that psychiatrists should be involved in medical care on the wards (2).

By the middle of the 20th century, many researchers and clinicians started to wonder about the influence of stress on medical illness. Respect for psychiatry grew as soldiers returned home from war with psychiatric illnesses, and psychiatrists began to work with internists and surgeons. Consultation Psychiatry was considered to be the clinical aspect of the field, while the term “psychosomatic medicine” was used to describe ongoing research.

As psychiatric units started to open in general hospitals, psychiatrists began to work side-by-side with other physicians and to round on the medical floors. Albert Barrett was likely the first to refer to psychiatry as liaison to medicine in 1922 (1). A formal consultation-liaison service was created at Massachusetts General Hospital in 1956, and by the 1970s there was a psychiatrist on every MGH ward. C-L psychiatry became a residency requirement in 1987. Levitan and Kornfeld showed that C-L could be cost effective to the hospital (3). In 2001, “Consultation-Liaison Psychiatry” changed to “Psychosomatic Medicine,” becoming the seventh accredited psychiatric subspecialty in psychiatry in 2003. It was defined by a population and not by an illness. The population served was described as complex medically ill, which includes patients with somatoform disorders, patients who have mental disorders secondary to primary medical conditions, and patients whose psychiatric disorders affect their medical care.

Psychiatric consultation in the general hospital differs from an outpatient consultation. Due to the pressure to reduce the length of stay, consultants must perform the assessment and provide recommendations in a swift manner. There are many barriers to a speedy assessment. Patients are often debilitated and/or in pain and are unable to participate in lengthy interviews. There are numerous interruptions to the consultation: patients must be seen by the primary team or other consultants, their vital signs must be taken, and they might be taken away for procedures. The ability to reproduce the comfortable and private atmosphere of the office is all but an illusion in the hospital setting (4).

While patients come to the psychiatrist’s office often, if not always, of their own accord, patients in the hospital might not know about the psychiatric consult. Thus they might perceive it as an intrusion or as a sign that their doctor thinks they are “crazy.” The physical structure of the hospital does not help matters; its size, odor, and the confusing labyrinth of rooms and hallways may be anxiety provoking for both the patient and the consultant. Upon entering the hospital, patients relinquish their armamentarium of comforting measures, including constant access to family, clothing, and other personal items. Patients give up their privacy, control over their surroundings, and even control over bodily functions (4).

In their offices psychiatrists are the primary decision makers. Psychiatric consultants must learn to relinquish control to the medical or surgical team. In the hospital we can recommend and give advice, but that does not always determine what actually happens. At times we serve at least three masters: the patient, the medical team, and the hospital system. Consultants must become experts in managing responsibilities to all three.

Meyer and Mendelson note that uncertainty and responsibility in the clinician drive the request for a psychiatric consultation (5). Problems that commonly lead to requests for psychiatric consultations include acute stress reactions, aggression, agitation, substance abuse/intoxication/withdrawal, anxiety, depression, presence of psychiatric history, delirium, dementia, need for capacity determination, somatoform disorders, pain, malingering, personality disorders, psychosis, and suicidality (6). Lipowski proposes a classification of five diagnostic problems: psychological presentation of organic disease, psychological complications of organic disease, psychological reactions to organic disease, somatic presentation of psychiatric disorders, and “psychosomatic” disorders (7).

The tasks of consulting psychiatrists are diverse. We may need to diagnose and treat a medically ill patient with a psychiatric disorder and then transfer the patient to a psychiatric unit. We may be called to help manage behavioral disturbances that are part and parcel of certain medical illnesses, such as dementia, delirium, and traumatic brain injury. These tasks require a good understanding of the behavioral manifestations of a variety of medical disorders (6). Many patients require our assistance to cope with the hospital environment or with the experience of a debilitating illness. Some patients require brief psychotherapy, and consultants must possess the skills to provide such treatment. At the same time a consultant must be well versed in psychopharmacology. We assist the team in dealing with difficult or uncooperative patients, helping to manage countertransference and resolve conflicts. We must always be sensitive to the effects of the patient on the staff (6). We are often asked to assess a patient’s capacity to make decisions, and as many as 10% of consultations are for this request (8, 9). We are involved in ethically and legally complicated cases dealing with end of life issues, surrogacy, and guardianship. Psychiatric consultation provides an educational opportunity to teach in real time regarding real patients, and the consultant should be skilled in bedside teaching.

According to the Academy of Psychosomatic Medicine Practice Guidelines, the aims of the psychiatric consultation include ensuring patient’s safety within the medical setting, collecting history and medical data, performing a mental status exam and neurological/physical exam when necessary, establishing a differential diagnosis, and initiating treatment (6). The consultant should remember that the ultimate goal of each consultation is “the promotion of improved patient care” (10). Consultants are not responsible for providing psychotherapy to the consultee; however, we may help the consultee in gaining self-insight in so far as it aids in providing better patient care.

The consulting psychiatrist may work with many specialized populations, such as obstetrics, transplantation, HIV, and oncology patients. Details of every subspecialty are beyond the scope of this paper, but we will mention some areas of interest.

In obstetrics, we may be asked to aid in infertility assessment and to ascertain potential psychiatric causes and sequelae of infertility. We may assess a woman’s feelings and understanding of hysterectomy and its aftermath, counsel patients after spontaneous and elective abortions, assess psychosexual factors in vulvodynia, and work with pregnant women on the psychological and physical stresses of pregnancy. We assess antepartum and postpartum psychiatric illnesses, such as depression, mania, psychosis, and substance abuse; providing recommendations regarding psychopharmacology in pregnancy and lactation (16). A psychiatrist may be asked to evaluate maternal competency or the capacity to care adequately for a newborn (17).

Psychiatrists who work with HIV patients help treat and diagnose neuropsychiatric complications and symptoms, such as cytomegalovirus, toxoplasmosis, neoplasms, and fatigue. Depression, delirium, dementia, and substance abuse occur at high rates in patients with HIV, and consultants should have expertise in psychopharmacology to understand interactions between psychotropic medications and HAART (18, 19).

The psychiatric consultant to oncology evaluates patients’ adjustment to the diagnosis and treatment. We evaluate and diagnose depression and anxiety, which may interfere with treatment adherence. Management of illness and treatment complications, such as mania and delirium, is often necessary. End-of-life issues are an area of importance and goals of care should be part of every consultation (20).

A psychiatric consultant is an integral part of the transplant team. Psychiatrists aid in evaluation of the patient’s eligibility for transplant, identify needs that must be addressed prior to transplant, and assess risk factors that foreshadow poor outcomes (21).

An important scenario that warrants consideration is the assessment and treatment of suicidal patients. Consultants are asked to evaluate patients after a suicidal attempt or gesture or patients who have expressed suicidal thoughts. The first task is to assess the risk and to ensure the patient’s safety. Medical/surgical units are full of items that can be used for self-harm, such as cords, needles, medications, windows that open, and patients’ own belongings. Medical/surgical units are unlocked, and the medical personnel may not be trained in suicide safety measures (22). The consultant must educate staff, ensure a secure environment, and when appropriate, place the patient on constant observation. The second task is to identify causes of suicidality and impulsivity, and to determine which of the causes are reversible and can be treated. A patient may be intoxicated, withdrawing, delirious, psychotic, and/or depressed. While some medical illnesses, such as cancer, HIV, and Huntington’s disease, have been associated with increased risk of suicide (22), it is psychiatric illness that portends the highest risk. Treating the psychiatric illness, as well as symptoms of medical conditions, such as pain, insomnia, and disinhibition, may significantly lower the suicide risk.

The consultant must also aid in the transfer of the patient to a psychiatric unit if necessary and evaluate whether the patient is truly “medically cleared” before transfer. Countertransference toward the suicidal patient on the part of the medical team can lead to clearing the patient prematurely without a proper medical workup (22). For any transfer to a psychiatric ward, the consultant should make sure that the ward is able to handle any required medical care (6).

If agitation is due to delirium, the consultant may help manage the agitation as well as guide the team to determine the cause. The prevalence of delirium is 10%−30% in the general medical populations and up to 80% in the ICU population (23). Untreated delirium is associated with higher morbidity and mortality (24). Delirium can be hyperactive, hypoactive, or mixed. Hyperactive delirium can present as agitation, prompting a psychiatric consult. Hypoactive delirium, on the other hand, can be mistaken for depression. The main treatment of delirium is correction of the underlying cause(s) (infection, medication side effect, metabolic derangement, etc.). A careful chart review and work up may elucidate a potential cause, though the pathogenesis of delirium is often multifactorial. In addition to correcting the underlying cause, behavioral manifestations of delirium, such as agitation, paranoia, hallucinosis, and confusion can be treated behaviorally and pharmacologically. If behavioral interventions fail, antipsychotics are the mainstay of treatment. As always, risks and benefits of the medications should be assessed carefully. The FDA has issued warnings regarding first- and second-generation antipsychotics as treatment of behavioral disorders in elderly patients with dementia, stating that these medications are associated with increased mortality. Long-term antipsychotic use may put patients at an increased risk of extrapyramidal symptoms (EPS), cardiac events, hyperglycemia, hyperlipidemia, and metabolic syndrome. Short-term use may increase the risk of EPS, sedation, as well as prolonged QTc interval, which is associated with torsades de pointes and sudden death. In addition to antipsychotics, an alpha-2 agonist, dexmedetomidine, has been investigated recently as a treatment for delirium (25). Risks of medications should be weighed against risks of untreated symptoms, such as agitation and psychosis. Lowest effective doses should be used, medications should be discontinued when it is safe to do so, and drug-drug interactions should be considered carefully.

Agitation may be due to drug withdrawal. Alcohol, benzodiazepine, and barbiturate withdrawal may present with anxiety, agitation, tremor, hyperreflexia, vital sign instability, hallucinosis, confusion, and seizures. It is important to understand the cause of delirium or agitation, since treatment with benzodiazepines can improve alcohol or benzodiazepine withdrawal, while exacerbating delirium due to other conditions. If withdrawal is suspected, patients should be treated promptly, usually with benzodiazepines (26). Exact medication preferences for withdrawal treatment are institution-specific and are beyond the scope of this paper. In general, benzodiazepines with fast-onset of action should be used frequently initially, with the goal of minimizing withdrawal symptoms, erring on the side of mild sedation rather than agitation. Once the symptoms are controlled, the physician should calculate the average daily medication requirement and switch the patient to a standing medication regimen. If the patient has only mild signs of withdrawal and does not have a significant withdrawal history, benzodiazepines can be used on an as-needed basis. If the patient requires significant amounts of benzodiazepines and continues to have withdrawal symptoms and/or autonomic instability, transfer to an ICU should be considered. Overall, it is best to have a clear protocol for medications, including doses and frequencies, that are administered based on objective measures, such as CIWA (Clinical Institute Withdrawal Assessment) scores (27–29). Patients with alcohol abuse, as well as patients with other risk factors for nutritional deficiency, should be started on intravenous or intramuscular thiamine (30).

Psychiatric consultants are frequently asked to assess capacity in spite of the fact that any physician can assess capacity. Psychosomatic medicine practitioners do not rate their capacity assessment training highly, they find capacity consultations to be more challenging and time-consuming than other consultations, and feel they have less of an evidence-base to rely upon (31). Psychiatrists are asked to assess capacity if the primary physicians are not aware that they are permitted to make the assessment, are unsure of whether the patient has capacity, or have an answer in mind but want legal protection in the form of a psychiatric evaluation. Nearly 40% of capacity requests are actually not about capacity and many such requests entail underlying ethical dilemmas (9, 32). If there is a need to determine capacity, the consultant must clarify that capacity is specific to a particular decision, since the same patient may have capacity to make one decision, such as appointing a health care proxy, but not another, such as consenting to a complicated surgical procedure (6). The consultant must also clarify the urgency of the consultation, the extent of the information provided to the patient, and the significance of the decision. The determination of capacity is relative; the threshold for capacity varies based on the urgency of the situation and the risks of the treatment and the alternatives (33). Appelbaum suggested four criteria for determining capacity: communicating a choice, understanding the relevant information, appreciating the situation and its consequences, and reasoning about treatment options (8). Research shows that most common diagnoses in patients lacking capacity are dementia and delirium, followed by psychoses (31). The consultant can recommend treatment for potentially reversible causes when the patient is found to lack capacity. Although psychiatric symptoms may at times contribute to lack of capacity, a psychiatric diagnosis in itself does not automatically preclude a patient’s ability to make decisions.

A common reason for consultation involves assessment of depressed mood. A patient who appears depressed may have hypoactive delirium, adjustment disorder or major depressive disorder. Mood disorders are prevalent in patients with chronic medical illnesses. The presence of depression can worsen medical prognosis, worsen adherence to medical treatment, increase morbidity, and decrease survival (34, 35). Depression increases the risk of coronary and cerebrovascular disease and worsens prognosis in patients with existing cardiac disease or history of strokes. Depression can affect the course of neurological disorders, diabetes, cancer, and HIV, complicating treatment, worsening prognosis, and increasing health care costs (34).

Hospitalization is potentially stressful for even the most well-adjusted patient. Numerous authors have addressed the issues that patients must handle when hospitalized (36, 37). Consultations are often generated in response to patients’ maladaptive coping with medical illness and hospitalization, particularly regression. Emotional responses to medical illness include anxiety, anger, shame, sadness, guilt, and relief. Such emotional and/or behavioral responses may interfere with diagnostic workup and treatment. Patients’ subjective experience and behavior may be influenced by personality type, coping style, and defense mechanisms (38). Countertransference can be a powerful guide in helping the physician understand the patient’s internal state and personality type (39).

The seven personality types (oral, compulsive, hysterical, masochistic, narcissistic, schizoid, and paranoid) first described by Kahana and Bibring (40) that determine subjective experience and behavior are still useful. These habitual ways of dealing with the world may work well when the person is not medically ill but may interfere with treatment and provoke countertransference reactions in treaters.

Understanding the coping styles of each personality type can help the consultant to understand the patient’s experience and tailor management appropriately. A more modern approach to the personality types, based upon DSM terminology, is useful in understanding such patients (41).

Groves in 1978 described four types of challenging patients: dependent clingers, entitled demanders, manipulative help-rejecters, and self-destructive deniers (42). Dependent clingers can be compared with Kahana and Bibring’s oral personality type. They are needy and evoke aversion and anger in their treaters. Management of such a patient includes firm limit setting in addition to empathy. Entitled demanders, like patients with narcissistic personality type, use intimidation and devaluation to control the physician and provoke a fear and a wish to counterattack. Their entitlement should be acknowledged and used as a tool to involve them in partnering with a physician to get the best care possible. Manipulative help-rejecters, like the masochistic patients, appear hopeless and do not improve despite extensive workup and treatment. They do not seek symptom relief but rather an ongoing relationship with a caregiver. They evoke feelings of inadequacy in the physician. The treater needs to convey that losing the symptom does not mean losing the doctor. This can be done by scheduling frequent follow-up visits that are independent of symptom severity. Self-destructive deniers appear to work hard to not stay well, likely because they have given up hope of ever getting better. They evoke rescue fantasies as well as wishes for the patient’s death. The physician should recognize limitations of caring for such patients and not expect to be able to provide perfect care. The physician should rule out depression in this kind of patient.

In addition to personality types, a patient’s coping style determines the way he or she deals with medical illness (38). To elucidate one’s coping style, a consultant can ask patients how they have dealt with stressful situations in the past. Folkman et al. (43) divide coping strategies into problem-focused and emotion-focused. They note that when people see the situation as within their control, they use problem-focused coping strategies. When people see the situation as out of their control, they use emotion-focused coping. The consultant can change the patient’s appraisal of the situation and help the patient feel in control and, thus, use the problem-focused coping strategy (38).

Patients’ experience of illness and response to illness can also be influenced by defense mechanisms (38). A psychiatric consultation may be initiated if the patient uses denial that the primary team cannot comprehend. Denial can be adaptive and can help the patient to not become overwhelmed. It can also be maladaptive if it delays diagnosis and treatment or causes nonadherence. Denial becomes maladaptive when it causes a distortion of reality (42). The best way to deal with denial is to work on the emotions underlying denial, instead of confronting the patient. Improving anxiety, fear, and sadness may decrease the patient’s need for denial (42).

One behavioral response that may precipitate a psychiatric consultation is signing out against medical advice. Albert and Kornfeld (44) identified overwhelming fear, anger, and psychosis or confusion as the most common reasons for signing out against medical advice. By empathic listening a psychiatrist can help decrease the patient’s frustration, make the patient feel understood, and allow the primary team to re-engage with the patient (38).

In general, ways to improve treatment adherence include informing the patient of the illness and treatments, ruling out cognitive deficits, addressing psychological motivating factors, minimizing side effects and complexity of the treatment, involving the family, using positive reinforcement, and building alliance with the patient (38).

The psychodynamic life narrative is a brief intervention that helps some patients deal with illness and hospitalization and is based on the premise that all patients have a life narrative underlying their response to illness (45). The psychiatrist “comes to understand the underlying dynamics that have formed the trajectory of the patient’s life, his personality type, his ego strengths and weaknesses, and his core conflicts.” (46). The psychiatrist then forms a psychodynamic narrative of the patient’s life, which is presented to the patient. This narrative focuses on how the medical illness has compromised the patient’s sense of identity and connects the illness and the patient’s response to the illness to the narrative of the patient’s life. When successfully employed, the patient feels understood and develops better coping mechanisms (45).

We have described the ways in which patients cope with illness. Equally important is how physicians deal with performing psychiatric consultations. There are three maladaptive approaches to working with medically ill patients: pseudoanalytic, rigidly biological, and overly sympathetic (10). A pseudoanalytic physician is “excessively stilted and constrained” and fearful of being spontaneous. A rigidly biological physician treats a patient as a constellation of symptoms and does not pay attention to dynamics of the interactions, using emotional detachment and intellectualization. An overly sympathetic physician fails to establish sufficient distance from a patient and loses perspective. A “therapeutic stance” approach works best, deviating as necessary from the standard anonymity, abstinence, and neutrality (12). There are three maladaptive responses in working with medical teams, which include being overly competitive, solicitous, or detached. In such situations the physician might assume a “liaison stance,” which involves establishment of an alliance and use of therapeutic maneuvers to alter staff behavior (47). This approach encourages consultants to use psychodynamic knowledge not only to understand the patient’s feelings and behavior, but those of the staff as well.