Psychiatric Assessment and Consultation
Psychosomatic medicine is clinically rooted in consultation-liaison psychiatry, expanding from its beginnings on a few general medical wards of large hospitals in the 1930s to specialized medical units throughout various parts of the health care delivery system. Practitioners in this discipline assist with the care of a variety of patients, especially those with complex illnesses such as cancer, organ transplantation, and HIV infection (Gitlin et al. 2004; Hackett et al. 2004). In the medical setting, prompt recognition and evaluation of psychiatric problems are essential because psychiatric comorbidity often exacerbates the course of medical illness, causes significant distress in the patient, prolongs hospital length of stay, and increases costs of care. Psychiatrists in medical settings may be asked to evaluate a wide variety of conditions. These can include dementia, delirium, agitation, psychosis, substance abuse or withdrawal, somatoform disorders, personality disorders, and mood and anxiety disorders, as well as suicidal ideation, noncompliance, and aggressive and other behavioral problems. In addition, ethical and legal considerations are often critical elements of the psychiatric consultation.
In this introductory chapter, we present a detailed approach to psychiatric assessment and consultation in a medical setting. Flexibility is essential for psychiatric consultants to be successful in the evaluation of affective, behavioral, and cognitive disturbances in medically ill patients. In the final section of the chapter, we briefly outline the benefits of psychiatric consultation for patients as well as for the greater hospital and medical communities.
Psychiatric consultation in the general hospital
Psychiatrists who work in medical settings are charged with providing expert consultation to medical and surgical patients. In many respects, psychiatric care of such patients is no different from the treatment of patients in a psychiatric clinic or in a private office. However, the constraints of the modern hospital environment demand a high degree of adaptability. Comfort, quiet, and privacy are scarce commodities in medical and surgical units. Interruptions by medical or nursing staff, visitors, and roommates erode the privacy that the psychiatrist usually expects. Patients who are sick, preoccupied with their physical condition, and in pain are ill-disposed to engage in the exploratory interviews that often typify psychiatric evaluations in other settings. Monitoring devices replace the plants, pictures, and other accoutrements of a typical office. Nightstands and tray tables are littered with medical paraphernalia commingled with personal effects.
The consultant must be adept at gathering the requisite diagnostic information efficiently from the data permitted by the patient’s clinical condition and must be able to tolerate the sights, sounds, and smells of the sickroom. Additional visits for more history are often inevitable. In the end, the diagnosis will likely fall into one (or more) of the categories outlined in Lipowski’s (1967) classification, which is still relevant today (Table 1).
Although the consultant is summoned by the patient’s physician, in most cases the visit is unannounced and is not requested by the patient, from whom cooperation is expected. Explicitly acknowledging this reality and apologizing if the patient was not informed are often sufficient to gain the patient’s cooperation. Cooperation is enhanced if the psychiatrist sits down and operates at eye level with the patient. By offering to help the patient get comfortable (e.g., by adjusting the head of the bed, bringing the patient a drink or a blanket, or adjusting the television) before and after the encounter, the consultant can increase the chances of being welcomed then and for follow-up evaluations.
When psychiatrists are consulted for unexplained physical symptoms or for pain management, it is useful to empathize with the distress that the patient is experiencing. This avoids conveying any judgment on the etiology of the pain except that the suffering is real. After introductions, if the patient is in pain, the consultant’s first questions should address this issue. Failing to do so conveys a lack of appreciation for the patient’s suffering and may be taken by the patient as disbelief in his or her symptoms. Starting with empathic questions about the patient’s suffering establishes rapport and also guides the psychiatrist in setting the proper pace of the interview. Finally, because a psychiatric consultation will cause many patients to fear that their physician thinks they are “crazy,” the psychiatrist may first need to address this fear.
The process of the consultation
Although it is rarely as straightforward as the following primer suggests, the process of psychiatric consultation should, in the end, include all the components explained below and summarized in Table 2.
Speak directly with the referring clinician
Requests for psychiatric consultation are notorious for being vague and imprecise (e.g., “rule out depression” or “patient with schizophrenia”). They sometimes signify only that the team recognizes that a problem exists; such problems may range from an untreated psychiatric disorder to the experience of countertransferential feelings. In speaking with a member of the team that has requested the consultation, the consultant employs some of the same techniques that will be used later in examining the patient; that is, he or she listens to the implicit as well as the explicit messages from the other physician (Murray 2004). Is the physician angry with the patient? Is the patient not doing what the team wants him or her to do? Is the fact that the patient is young and dying leading to the team’s overidentification with him or her? Is the team frustrated by an elusive diagnosis? All of these situations generate emotions that are difficult to reduce to a few words conveyed in a consultation request; moreover, the feelings often remain out of the team’s conscious awareness. This brief interaction may give the consultant invaluable information about how the consultation may be useful to the team and to the patient.
Review the current records and pertinent past records
When it is done with the unfailing curiosity of a detective hot on the trail of hidden clues, reading a chart can be an exciting and self-affirming part of the consultation process. Although it does not supplant the consultant’s independent history taking or examination, the chart review provides a general orientation to the case. Moreover, the consultant is in a unique position to focus on details that may have been previously overlooked. For example, nurses often document salient neurobehavioral data (e.g., the level of awareness and the presence of confusion or agitation); physical and occupational therapists estimate functional abilities crucial to the diagnosis of cognitive disorders and to the choice of an appropriate level of care (e.g., nursing home or assisted-living facility); and speech pathologists note alterations in articulation, swallowing, and language, all of which may indicate an organic brain disease. All of them may have written progress notes about adherence to treatment regimens, unusual behavior, interpersonal difficulties, or family issues encountered in their care of the patient. These notes may also provide unique clues to the presence of problems such as domestic violence, factitious illness, or personality disorders. In hospitals or clinics where nurses’ notes are kept separate from the physician’s progress notes, it is essential for the consultant to review those sections.
Review the patient’s medications
Construction of a medication list at various time points (e.g., at home, on admission, on transfer within the hospital, and at present) is always good, if not essential, practice. Special attention should be paid to medications with psychoactive effects and to those associated with withdrawal syndromes (both obvious ones like benzodiazepines and opiates, and less obvious ones like antidepressants, anticonvulsants, and beta-blockers). Review of order sheets or computerized order entries is not always sufficient, because—for a variety of reasons—patients may not always receive prescribed medications; therefore, medication administration records should also be reviewed. Such records are particularly important for determining the frequency of administration of medicines ordered on an as-needed basis. For example, an order for lorazepam 1–2 mg every 4–6 hours as needed may result in a patient receiving anywhere from 0 mg to 12 mg in a day, which can be critical in cases of withdrawal or oversedation.
Gather collateral data
Histories from hospitalized medically ill patients may be especially spotty and unreliable, if not nonexistent (e.g., with a patient who is somnolent, delirious, or comatose). Data from collateral sources (e.g., family members; friends; current and outpatient health care providers; case managers; and, in some cases, police and probation officers) may be of critical importance. However, psychiatric consultants must guard against prizing any single party’s version of historical events over another’s; family members and others may lack objectivity, be in denial, be overinvolved, or have a personal agenda to advance. For example, family members tend to minimize early signs of dementia and to overreport depression in patients with dementia. Confidentiality must be valued when obtaining collateral information. Ideally, one obtains the patient’s consent first; however, this may not be possible if the patient lacks capacity or if a dire emergency is in progress (see Chapter 3, “Legal Issues,” and Chapter 4, “Ethical Issues”). Moreover, in certain situations there may be contraindications to contacting some sources of information (e.g., an employer of a patient with substance abuse or the partner of a woman who is experiencing abuse). Like any astute physician, the psychiatrist collates and synthesizes all available data and weighs each bit of information according to the reliability of its source.
Interview and examine the patient
Armed with information gleaned and elicited from other sources, the psychiatric consultant now makes independent observations of the patient and collects information that may be the most reliable of all because it comes from direct observations. For non-English-speaking patients, a translator is often needed. Although using family members may be expedient, their presence often compromises the questions asked and the translations offered because of embarrassment or other factors. It is therefore important to utilize hospital translators or, for less common languages, services via telephone. This can be difficult, but it may be necessary in obtaining a full and accurate history.
Mental status examination
A thorough mental status examination is central to the psychiatric evaluation of the medically ill patient. Because the examination is hierarchical in nature, care must be taken to complete it in a systematic fashion (Hyman and Tesar 1994). The astute consultant will glean invaluable diagnostic clues from a combination of observation and questioning.
Level of consciousness. Level of consciousness depends on normal cerebral arousal by the reticular activating system. A patient whose level of consciousness is impaired will inevitably perform poorly on cognitive testing. The finding of disorientation implies cognitive failure in one or several domains, and it is helpful to test orientation near the start of the mental status examination.
Attention. The form of attention most relevant to the clinical mental status examination is the sustained attention that allows one to concentrate on cognitive tasks. Disruption of attention—often by factors that diffusely disturb brain function, such as drugs, infection, or organ failure—is a hallmark of delirium. Sustained attention is best tested with moderately demanding, nonautomatic tasks such as reciting the months backward or, as in the Mini-Mental State Examination (MMSE; Folstein et al. 1975), spelling world backward or subtracting 7 serially from 100. Serial subtraction is intended to be a test of attention, not arithmetic ability, so the task should be adjusted to the patient’s native ability and educational level (serial 3s from 50, serial 1s from 20). An inattentive patient’s performance on other parts of the mental status examination may be affected on any task requiring sustained focus.
Memory. Working memory is tested by asking the patient to register some information (e.g., three words) and to recall that information after an interval of at least 3 minutes during which other testing prevents rehearsal. This task can also be considered a test of recent memory. Semantic memory is tapped by asking general-knowledge questions (e.g., “Who is the President?”) and by naming and visual recognition tasks. The patient’s ability to remember aspects of his or her history serves as an elegant test of episodic memory (as well as of remote memory). Because semantic and episodic memories can be articulated, they constitute declarative memory. In contrast, procedural memory is implicit in learned action (e.g., riding a bicycle) and cannot be described in words. Deficits in procedural memory can be observed in a patient’s behavior during the clinical evaluation.
Executive function. Executive function refers to the abilities that allow one to plan, initiate, organize, and monitor thought and behavior. These abilities, which localize broadly to the frontal lobes, are essential for normal social and professional performance but are difficult to test. Frontal lobe disorders often make themselves apparent in social interaction with a patient and are suspected when one observes disinhibition, impulsivity, disorganization, abulia, or amotivation. Tasks that can be used to gain some insight into frontal lobe function include verbal fluency, such as listing as many animals as possible in 1 minute; motor sequencing, such as asking the patient to replicate a sequence of three hand positions; the go/no-go task, which requires the patient to tap the desk once if the examiner taps once, but not to tap if the examiner taps twice; and tests of abstraction, including questions like “What do a tree and a fly have in common?”
Language. Language disorders result from lesions of the dominant hemisphere. In assessing language, one should first note characteristics of the patient’s speech (e.g., nonfluency or paraphasic errors) and then assess comprehension. Naming is impaired in both major varieties of aphasia, and anomia can be a clue to mild dysphasia. Reading and writing should also be assessed. Expressive (Broca’s or motor) aphasia is characterized by effortful, nonfluent speech with use of phonemic paraphasias (incorrect words that approximate the correct ones in sound), reduced use of function words (e.g., prepositions and articles), and well-preserved comprehension. Receptive (Wernicke’s or sensory) aphasia is characterized by fluent speech with both phonemic and semantic paraphasias (incorrect words that approximate the correct ones in meaning) and poor comprehension. The stream of incoherent speech and the lack of insight in patients with Wernicke’s aphasia sometimes lead to misdiagnosis of a primary thought disorder and psychiatric referral; the clue to the diagnosis of a language disorder is the severity of the comprehension deficit. Global dysphasia combines features of Broca’s and Wernicke’s aphasias. Selective impairment of repetition characterizes conduction aphasia. The nondominant hemisphere plays a part in the appreciation and production of the emotional overtones of language.
Praxis. Apraxia refers to an inability to perform skilled actions (e.g., using a screwdriver, brushing one’s teeth) despite intact basic motor and sensory abilities. These abilities can be tested by asking a patient to mime such actions or by asking the patient to copy unfamiliar hand positions. Constructional apraxia is usually tested with the Clock Drawing Test. Gait apraxia involves difficulty in initiating and maintaining gait despite intact basic motor function in the legs. Dressing apraxia is difficulty in dressing caused by an inability to coordinate the spatial arrangement of clothes with the body.
Mood and affect. Mood and affect both refer to the patient’s emotional state, mood being the patient’s perception and affect being the interviewer’s perception. The interviewer must interpret both carefully, taking into account the patient’s medical illness. Normal but intense expressions of emotion (e.g., grief, fear, or irritation) are common in patients with serious medical illness but may be misperceived by nonpsychiatric physicians as evidence of psychiatric disturbance. Disturbances in mood and affect may also be the result of brain dysfunction or injury. Irritability may be the first sign of many illnesses, ranging from alcohol withdrawal to rabies. Blunted affective expression may be a sign of Parkinson’s disease. Intense affective lability (e.g., pathological crying or laughing) with relatively normal mood occurs with some diseases or injuries of the frontal lobes.
Perception. Perception in the mental status examination is primarily concerned with hallucinations and illusions. However, before beginning any part of the clinical interview and the mental status examination, the interviewer should establish whether the patient has any impairment in vision or hearing that could interfere with communication. Unrecognized impairments have led to erroneous impressions that patients were demented, delirious, or psychotic. Although hallucinations in any modality may occur in primary psychotic disorders (e.g., schizophrenia or affective psychosis), prominent visual, olfactory, gustatory, or tactile hallucinations suggest a secondary medical etiology. Olfactory and gustatory hallucinations may be manifestations of seizures, and tactile hallucinations are often seen with substance abuse.
Judgment and insight. The traditional question for the assessment of judgment (i.e., “What would you do if you found a letter on the sidewalk?”) is much less informative than questions tailored to the problems faced by the patient being evaluated; for example, “If you couldn’t stop a nosebleed, what would you do?” “If you run out of medicine and you can’t reach your doctor, what would you do?” Similarly, questions to assess insight should focus on the patient’s understanding of his or her illness, treatment, and life circumstances.
Further guidance on mental status examination. An outline of the essential elements of a comprehensive mental status examination is presented in Table 3. Particular cognitive mental status testing maneuvers are described in more detail in Table 4. More detailed consideration of the mental status examination can be found elsewhere (Strub and Black 2000; Trzepacz and Baker 1993).
Physical examination
Although the interview and mental status examination as outlined above are generally thought to be the primary diagnostic tools of the psychiatrist, the importance of the physical examination should not be forgotten, especially in the medical setting. Most psychiatrists do not perform physical examinations on their patients. The consultation psychiatrist, however, should be familiar with and comfortable performing neurological examinations and other selected features of the physical examination that may uncover the common comorbidities in psychiatric patients (Granacher 1981; Summers et al. 1981a, 1981b). At an absolute minimum, the consultant should review the physical examinations performed by other physicians. However, the psychiatrist’s examination of the patient, especially of central nervous system functions relevant to the differential diagnosis, is often essential. A fuller physical examination is appropriate on medical-psychiatric units or whenever the psychiatrist has assumed responsibility for the care of a patient’s medical problems. Even with a sedated or comatose patient, simple observation and a few maneuvers that involve a laying on of hands may potentially yield a bounty of findings. Although it is beyond the scope of this chapter to discuss a comprehensive physical examination, Table 5 provides a broad outline of selected findings of the physical examination and their relevance to the psychiatric consultation.
Formulate diagnostic and therapeutic strategies
By the time the consultant arrives on the scene, routine chemical and hematological tests and urinalyses are almost always available and should be reviewed along with any other laboratory, imaging, and electrophysiological tests. The consultant then considers what additional tests are needed to arrive at a diagnosis. Attempts have been made in the past to correlate biological tests, such as the dexamethasone suppression test, with psychiatric illness; despite extensive research, however, no definitive biological tests are available to identify psychiatric disorders. Before ordering a test, the consultant must consider the likelihood that the test will contribute to making a diagnosis.
There is an extensive list of studies that could be relevant to psychiatric presentations; the most common screening tests in clinical practice are listed in Table 6. It was once common practice for the psychiatrist to order routine batteries of tests, especially in cognitively impaired patients, in a stereotypical diagnostic approach to the evaluation of dementia or delirium. In modern practice, tests should be ordered selectively, with consideration paid to sensitivity, specificity, and cost-effectiveness. Perhaps most importantly, careful thought should be given to whether the results of each test will affect the patient’s management. Finally, further studies may be beneficial in certain clinical situations as described throughout this book.
Routine tests
As far as screening is concerned, a complete blood cell count may reveal anemia that contributes to depression or infection that causes psychosis. Leukocytosis is seen with infection and other acute inflammatory conditions, lithium therapy, and neuroleptic malignant syndrome, whereas leukopenia and agranulocytosis may be caused by certain psychotropic medications. A serum chemistry panel may point to diagnoses as varied as liver disease, eating disorders, renal disease, malnutrition, and hypoglycemia—all of which may have psychiatric manifestations (Alpay and Park 2004). Serum and urine toxicological screens are helpful in cases of altered sensorium and obviously whenever substance abuse, intoxication, or overdose is suspected. Because blood tests for syphilis, thyroid disease, and deficiencies of vitamin B12 and folic acid (conditions that are curable) are readily available, they warrant a low threshold for their use. In patients with a history of exposures, HIV infection should not be overlooked. Obtaining a pregnancy test is often wise in women of childbearing age to inform diagnostically as well as to guide treatment options. Urinalysis, chest radiography, and electrocardiography are particularly important screening tools in the geriatric population. Although it is not a first-line test, cerebrospinal fluid analysis should be considered in cases of mental status changes associated with fever, leukocytosis, meningismus, or unknown etiology. Increased intracranial pressure should be ruled out before a lumbar puncture is performed, however. More detailed discussion of specific tests is provided in relevant chapters throughout this text.
Neuroimaging
The psychiatric consultant must also be familiar with neuroimaging studies. Neuroimaging may aid in fleshing out the differential diagnosis of neuropsychiatric conditions, although it rarely establishes the diagnosis by itself (Dougherty and Rauch 2004). In most situations, magnetic resonance imaging (MRI) is preferred over computed tomography (CT). MRI provides greater resolution of subcortical structures (e.g., basal ganglia, amygdala, and other limbic structures) of particular interest to psychiatrists. It is also superior for detection of abnormalities of the brain stem and posterior fossa. Furthermore, MRI is better able to distinguish between gray-matter and white-matter lesions. CT is most useful in cases of suspected acute intracranial hemorrhage (having occurred within the past 72 hours) and when MRI is contraindicated (in patients with metallic implants). Dougherty and Rauch (2004) suggest that the following conditions and situations merit consideration of neuroimaging: new-onset psychosis, new-onset dementia, delirium of unknown cause, prior to an initial course of electroconvulsive therapy, and an acute mental status change with an abnormal neurological examination in a patient with either a history of head trauma or an age of 50 years or older. Regardless of the modality, the consultant should read the radiologist’s report, because other physicians tend to dismiss all but acute focal findings or changes and as a result misleadingly record the results of the study as normal in the chart. Psychiatrists recognize, however, that even small abnormalities (e.g., periventricular white-matter changes) or chronic changes (e.g., cortical atrophy) have diagnostic and therapeutic implications (see Chapter 7, “Dementia,” Chapter 9, “Depression,” and Chapter 32, “Neurology and Neurosurgery”).
Electrophysiological tests
The electroencephalogram (EEG) is the most widely available test that can assess brain activity. The EEG is most often indicated in patients with paroxysmal or other symptoms suggestive of a seizure disorder, especially complex partial seizures, or pseudoseizures (see Chapter 32, “Neurology and Neurosurgery”). An EEG may also be helpful in distinguishing between neurological and psychiatric etiologies for a mute, uncommunicative patient. An EEG may be helpful in documenting the presence of generalized slowing in a delirious patient, but it rarely indicates a specific etiology of delirium and it is not indicated in every delirious patient. However, when the diagnosis of delirium is uncertain, electroencephalographic evidence of dysrhythmia may prove useful. For example, when the primary treatment team insists that a patient should be transferred to a psychiatric inpatient service because of a mistaken belief that the symptoms of delirium represent schizophrenia or depression, an EEG may provide concrete data to support the correct diagnosis. EEGs may also facilitate the evaluation of rapidly progressive dementia or profound coma; but because findings are neither sensitive nor specific, they are not often helpful in the evaluation of space-occupying lesions, cerebral infarctions, or head injury (Bostwick and Philbrick 2002). Continuous electroencephalographic recordings with video monitoring or ambulatory electroencephalographic monitoring may be necessary in order to document abnormal electrical activity in cases of complex partial seizures or when factitious seizures are suspected. As with neuroimaging reports, the psychiatric consultant must read the electroencephalographic report, because nonpsychiatrists often misinterpret the absence of dramatic focal abnormalities (e.g., spikes) as indicative of normality, even though psychiatrically significant brain dysfunction may manifest as focal or generalized slowing or as sharp waves. Other electrophysiological tests may be helpful in specific situations; for example, sensory evoked potentials to distinguish multiple sclerosis from conversion disorder, or electromyography with nerve conduction velocities to differentiate neuropathy from malingering.
Other tests
Other diagnostic tools may also prove useful as adjuncts. Neuropsychological testing may be helpful in diagnosis, prognosis, and treatment planning in patients with neuropsychiatric disorders. Psychological testing can help the consultant better understand a patient’s emotional functioning and personality style. For example, elevations on the Hypochondriasis and Hysteria scales of the Minnesota Multiphasic Personality Inventory and a normal or minimally elevated result on the Depression scale constitute the so-called conversion V or psychosomatic V pattern, classically regarded as indicative of a significant psychological contribution to the etiology of somatic symptoms but now recognized as confounded by medical illness. (See Chapter 2, “Neuropsychological and Psychological Evaluation,” for a full description of neuropsychological and psychological testing.)
The amobarbital interview has been used as a tool in the diagnosis and treatment of a variety of psychiatric conditions (e.g., conversion disorder, posttraumatic stress disorder, factitious disorder, psychogenic amnesia, neurosis, and catatonia) for the past 70 years (Kavarirajan 1999). The psychiatric literature has been mixed, however, on the utility of the amobarbital interview, and intravenous lorazepam is now generally regarded as a safer alternative. However, the diagnostic validity of amobarbital and lorazepam interviews has not been systematically assessed.
Write a note
The consultation note should be clear, concise, and free of jargon and should focus on specific diagnostic and therapeutic recommendations. Although an understanding of the patient’s psychodynamics may be helpful, the consultant should usually avoid speculations in the chart regarding unconscious motivations. Consultees fundamentally want to know what is going on with the patient and what they should and can do about it; these themes should dominate the note. Mental health professionals are trained to construct full developmental and psychosocial formulations, but these do not belong in a consultation note (although they may inform key elements of the assessment and recommendations). Finger-pointing and criticism of the primary team or other providers should be avoided. The consultant should also avoid rigid insistence on a preferred mode of management if there is an equally suitable alternative (Kontos et al. 2003).
The consultation note should include a condensed version of all the elements of a general psychiatric note with a few additions (Querques et al. 2004). The consultant should begin the note with a summary of the patient’s medical and psychiatric history, the reason for the current admission, and the reason for the consultation. Next should be a brief summary of the present medical illness with pertinent findings and hospital course; this summary is meant to demonstrate an appreciation for the current medical issues rather than to repeat what has already been documented in the chart. It is often helpful for the consultant to include a description of the patient’s typical patterns of response to stress and illness, if known. Physical and neurological examinations, as well as germane laboratory results or imaging studies, should also be summarized. The consultant should then list the differential diagnosis in order of decreasing likelihood, making clear which is the working diagnosis or diagnoses. If the patient’s symptoms are not likely to be due to a psychiatric disorder, this should be explicitly stated. Finally, the consultant should make recommendations or clearly describe plans in order of decreasing importance. Recommendations include ways to further elucidate the diagnosis as well as therapeutic suggestions. It is especially important to anticipate and address problems that may appear at a later time (e.g., offering a medication recommendation for treatment of agitation in a delirious patient who is currently calm). For medication recommendations, brief notation of side effects and their management is useful. The inclusion of a statement indicating that the consultant will provide follow-up will reassure the consulting team, and the consultant should include contact information in the event that they have further questions.
Speak directly with the referring clinician
The consultation ends in the same way that it began—with a conversation with the referring clinician. Personal contact is especially crucial if diagnostic or therapeutic suggestions are time sensitive. Some information or recommendations may be especially sensitive, whether for reasons of confidentiality or risk management, and are better conveyed verbally than fully documented in the chart. The medical chart is read by a variety of individuals, including the patient at times, and, thus, discretion is warranted.
Provide periodic follow-up
Many consultations cannot be completed in a single visit. Rather, several encounters may be required before the problems identified by both the consultee and the consultant are resolved. Moreover, new issues commonly arise during the course of the consultative process, and a single consultation request often necessitates frequent visits, disciplined follow-up, and easy accessibility. All follow-up visits should be documented in the chart. Finally, it may be appropriate to sign off of a case when the patient stabilizes or when the consultant’s opinion and recommendations are being disregarded (Kontos et al. 2003).
Role of other providers
Although the emphasis of this chapter is on the psychiatrist as consultant, the value of members of other professions, working together as a team, should not be overlooked. Psychologists play an essential role in performing neuropsychological and psychological testing and providing psychotherapeutic and behavioral interventions. Psychiatric clinical nurse specialists provide services to the nursing staff that parallel those that the psychiatrist provides to the medical team. They are especially helpful in organizing interdisciplinary care conferences and nursing behavioral treatment plans that include behavioral contracts with patients. Case managers facilitate transfers and set up aftercare. Chaplains address the spiritual needs of patients in distress. Finally, communication with primary care physicians remains of utmost importance, since the primary care physician is well positioned to oversee and coordinate ongoing care after discharge.
Screening
Screening tools may also be helpful in specific situations. Although a comprehensive survey of cognitive function is not required for every patient, even a slim suspicion of the possibility of a cognitive deficit should prompt performance of cognitive screening. Although individualized mental status examinations performed as part of a psychiatrist’s clinical interview are much preferred to standardized tests, screening tests have been useful in case finding and research.
Tests such as the MMSE or the Mini-Cog (Borson et al. 2000) are helpful adjuncts in the hands of nonpsychiatrists to quickly identify potential cognitive disorders. The MMSE is a 19-question test that provides an overview of a patient’s cognitive function at a moment in time; it includes assessment of orientation, attention, and memory. It is of limited use without modification, however, in patients who are deaf or blind, are intubated, or do not speak English. The MMSE is also particularly insensitive in measuring cognitive decline in very intelligent patients, who may appear less impaired than they really are. The Mini-Cog, on the other hand, combines a portion of the MMSE (3-minute recall) with the Clock Drawing Test, as described by Critchley in 1953 (Scanlan and Borson 2001). In screening for dementia, the MMSE and the Mini-Cog have been shown to have similar sensitivity (76%–79%) and specificity rates (88%–89%) (Borson et al. 2003). However, the Mini-Cog is significantly shorter and enables screening temporoparietal and frontal cortical areas via the Clock Drawing Test—areas that are not fully assessed by the MMSE.
In addition, these tests may be supplemented with others—including Luria maneuvers and cognitive estimations (e.g., How many slices are there in an average loaf of white bread? How long is the human spinal cord?)—that further assess the functioning of frontal-subcortical networks. A formal neuropsychological battery may be useful if these bedside tests produce abnormal results (see Chapter 2, “Neuropsychological and Psychological Evaluation”). In a patient with an altered level of awareness or attention, formal cognitive tests should be deferred until the sensorium clears, because clouding of consciousness will produce uninterpretable results.
Other screening instruments may also prove beneficial, especially in research, for identifying patients in medical settings who could benefit from a comprehensive psychiatric interview. The Primary Care Evaluation of Mental Disorders (PRIME-MD) is a two-stage evaluation tool developed for primary care physicians to screen for five of the most common psychiatric disorders seen in the primary care setting: major depression, substance use disorders, anxiety, somatoform disorders, and eating disorders (Spitzer et al. 1999). The first stage involves a patient questionnaire, and the second stage consists of a clinician-guided evaluation that takes roughly 8 minutes to administer. The PRIME-MD Patient Health Questionnaire (PHQ), an abbreviated form of the PRIME-MD, consists of a shorter three-page questionnaire that can be entirely self-administered by the patient (Spitzer et al. 1999). In addition to the assessment of mood, anxiety, eating, alcohol, and somatoform disorders (as in the original PRIME-MD), the PHQ screens for posttraumatic stress disorder and common psychosocial stressors and also provides a pregnancy history. Although it has also been shown to be a valid screening tool, the PHQ is more efficient, given that the amount of the physician’s time required to administer the tool is diminished. Both the PRIME-MD and the PHQ have improved the diagnosis of psychiatric conditions in primary care settings (Spitzer et al. 1999) and may find a role at the bedside as well.
The General Health Questionnaire is another screening instrument originally developed in the 1970s to help identify the possibility that a medical outpatient has symptoms suggestive of a psychiatric disorder (Goldberg and Blackwell 1970). The original 60-item version has been replaced with well-validated 28- and 12-item versions, and it has been translated into numerous languages worldwide and been cross-culturally validated (Tait et al. 2003). Because of its emphasis on identifying new symptoms, the General Health Questionnaire examines state rather than trait conditions (Tait et al. 2003).
The CAGE is a well-known screening device developed by Ewing (1984) to identify alcohol abuse. A total of two or more positive responses on the four-question screen correlates with an 89% chance of alcohol abuse (Mayfield et al. 1974) (see Chapter 18, “Substance-Related Disorders”).
Benefits of psychiatric services
The benefits of psychiatric services in health care delivery are significant. A growing body of evidence suggests a link between comorbid psychopathology and increased length of hospital stay and, consequently, increased inpatient costs. Levenson et al. (1990) described a longer median length of hospital stay (a 40% increase) and hospital costs that were 35% higher in a group of medical inpatients with depression, anxiety, cognitive dysfunction, or high levels of pain (independent of severity of medical illness). Cognitively impaired geriatric patients were shown to have an increased length of stay compared with those without cognitive impairment (Fulop et al. 1998), whereas depressed elderly patients in another sample had more hospitalizations and longer hospital stays (Koenig and Kuchibhatla 1998). Although some have suggested that psychiatric consultation might decrease length of stay and inpatient costs (Levitan and Kornfeld 1981; Strain et al. 1991), that is not where its primary value lies. Patients benefit from reductions in mental suffering and improvements in psychological well-being, from more accurate diagnosis, and from more appropriate treatment. Providers of health care profit from the added diagnostic and therapeutic expertise of the psychiatric consultant as well as from a better understanding of health behaviors. The hospital milieu benefits from assistance with disruptive and dangerous patients and is enriched by a safer and more pleasant work environment and better risk management.
Conclusion
Psychiatric assessment and consultation can be crucial to seriously ill medical patients. The psychosomatic medicine psychiatrist is an expert in the diagnosis and care of psychopathology in the medically ill. Psychiatric consultation affords a unique ability to offer a panoramic view of the patient, the illness, and the relationship between the two. The psychiatric consultant will be called on to help diagnose, understand, and manage a wide array of conditions; when effective, the consultant addresses the needs of both the patient and the medical-surgical team. In this manner, psychiatric consultation is essential to the provision of comprehensive care in the medical setting.
| Psychiatric presentations of medical conditions |
| Psychiatric complications of medical conditions or treatments |
| Psychological reactions to medical conditions or treatments |
| Medical presentations of psychiatric conditions |
| Medical complications of psychiatric conditions or treatments |
| Comorbid medical and psychiatric conditions |
Source: Adapted from Lipowski 1967
| Speak directly with the referring clinician. |
| Review the current records and pertinent past records. |
| Review the patient’s medications. |
| Gather collateral data. |
| Interview and examine the patient. |
| Formulate diagnostic and therapeutic strategies. |
| Write a note. |
| Speak directly with the referring clinician. |
| Provide periodic follow-up. |
| Level of consciousness |
| Alert, drowsy, somnolent, stuporous, comatose; fluctuations suggest delirium |
| Appearance and behavior |
| Overall appearance, grooming, hygiene |
| Cooperation, eye contact, psychomotor agitation or retardation |
| Abnormal movements: tics, tremors, chorea, posturing |
| Attention |
| Vigilance, concentration, ability to focus, sensory neglect |
| Orientation and memory |
| Orientation to person, place, time, situation |
| Recent, remote, and immediate recall |
| Language |
| Speech: rate, volume, fluency, prosody |
| Comprehension and naming ability |
| Abnormalities include aphasia, dysarthria, agraphia, alexia, clanging, neologisms, echolalia |
| Constructional ability |
| Clock drawing to assess neglect, executive function, and planning |
| Drawing of a cube or intersecting pentagons to assess parietal function |
| Mood and affect |
| Mood: subjective sustained emotion |
| Affect: observed emotion—quality, range, appropriateness |
| Form and content of thought |
| Form: linear, circumstantial, tangential, disorganized, blocked |
| Content: delusions, paranoia, ideas of reference, suicidal or homicidal ideation |
| Perception |
| Auditory, visual, gustatory, tactile, olfactory hallucinations |
| Judgment and insight |
| Understanding of illness and consequences of specific treatments offered |
| Reasoning |
| Illogical versus logical; ability to make consistent decisions |
Source: Adapted from Hyman and Tesar 1994
| Cognitive domain | Assessment |
|---|---|
| Level of consciousness and arousal | Inspect the patient |
| Orientation to place and time | Ask direct questions about both of these |
| Registration (recent memory) | Have the patient repeat three words immediately |
| Recall (working memory) | Have the patient recall the same three words after performing another task for at least 3 minutes |
| Remote memory | Ask about the patient’s age, date of birth, milestones, or significant life or historical events (e.g., names of presidents, dates of wars) |
| Attention and concentration | Subtract serial 7s (adapt to the patient’s level of education; subtract serial 3s if less educated). Spell world backward (this may be difficult for non-English speakers). Test digit span forward and backward. Have the patient recite the months of the year (or the days of the week) in reverse order. |
| Language | (Adapt the degree of difficulty to the patient’s educational level) |
| Comprehension | Inspect the patient while he or she answers questions Ask the patient to point to different objects Ask yes or no questions Ask the patient to write a phrase (paragraph) |
| Naming | Show a watch, pen, or less familiar objects, if needed |
| Fluency | Assess the patient’s speech Have the patient name as many animals as he or she can in 1 minute |
| Articulation | Listen to the patient’s speech Have the patient repeat a phrase |
| Reading | Have the patient read a sentence (or a longer paragraph if needed) |
| Executive function | Determine if the patient requires constant cueing and prompting |
| Commands | Have the patient follow a three-step command |
| Construction | Have the patient draw interlocked pentagons Have the patient draw a clock |
| Motor programming tasks | Have the patient perform serial hand sequences Have the patient perform reciprocal programs of raising fingers |
| Judgment and reasoning | Listen to the patient’s account of his or her history and reason for hospitalization Assess abstraction (similarities: dog/cat; red/green) |
| Ask about the patient’s judgment about simple events or problems: “A construction worker fell to the ground from the seventh floor of the building and broke his two legs; he then ran to the nearby hospital to ask for medical help. Do you have any comment on this?” |
| Elements | Examples of Possible Diagnoses |
|---|---|
| General | |
| General appearance healthier than expected | Somatoform disorder |
| Fever | Infection or NMS |
| Blood pressure or pulse abnormalities | Withdrawal, thyroid or cardiovascular disease |
| Body habitus | Eating disorders, polycystic ovaries, or Cushing syndrome |
| Skin | |
| Diaphoresis | Fever, withdrawal, NMS |
| Dry, flushed | Anticholinergic toxicity, heat stroke |
| Pallor | Anemia |
| Changes in hair, nails, skin | Malnutrition, thyroid or adrenal disease |
| Jaundice | Liver disease |
| Characteristic stigmata | Syphilis, cirrhosis, or self-mutilation |
| Bruises | Physical abuse, ataxia, traumatic brain injury |
| Eyes | |
| Mydriasis | Opiate withdrawal, anticholinergic toxicity |
| Miosis | Opiate intoxication, cholinergic toxicity |
| Kayser-Fleischer pupillary rings | Wilson’s disease |
| Neurological | |
| Tremors | Delirium, withdrawal syndromes, parkinsonism |
| Primitive reflexes present (e.g., snout, glabellar, and grasp) | Dementia, frontal lobe dysfunction |
| Hyperactive deep-tendon reflexes | Withdrawal, hyperthyroidism |
| Ophthalmoplegia | Wernicke’s encephalopathy, brain stem dysfunction, dystonic reaction |
| Papilledema | Increased intracranial pressure |
| Hypertonia, rigidity, catatonia, parkinsonism | EPS, NMS |
| Abnormal movements | Parkinson’s disease, Huntington’s disease, EPS |
| Abnormal gait | Normal pressure hydrocephalus, Parkinson’s disease, Wernicke’s encephalopathy |
| Loss of position and vibratory sense | Vitamin B12 deficiency |
Note: EPS=extrapyramidal side effects; NMS=neuroleptic malignant syndrome
| Complete blood cell count |
| Serum chemistry panel |
| Thyroid-stimulating hormone (thyrotropin) concentration |
| Vitamin B12 (cyanocobalamin) concentration |
| Folic acid (folate) concentration |
| Human chorionic gonadotropin (pregnancy) test |
| Toxicology |
| Serum |
| Urine |
| Serological tests for syphilis |
| HIV tests |
| Urinalysis |
| Chest X ray |
| Electrocardiogram |
Footnote
(Reprinted with permission from The American Psychiatric Publishing Textbook of Psychosomatic Medicine. Edited by Levenson JL. Washington, DC, American Psychiatric Publishing, 2005, pp 3–14)
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