Gomez - Liaison Psychiatry: Volume 9 (Routledge Library Editions: Psychiatry)

ROUTLEDGE LIBRARY EDITIONS: PSYCHIATRY

Volume 9

LIAISON PSYCHIATRY

LIAISON PSYCHIATRY

Mental Health Problems in the General Hospital

JOAN GOMEZ

First published in 1987 by Croom Helm

This edition first published in 2019
by Routledge
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1987 Joan Gomez

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British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library

ISBN: 978-1-138-60492-6 (Set)
ISBN: 978-0-429-43807-3 (Set) (ebk)
ISBN: 978-1-138-31564-8 (Volume 9) (hbk)
ISBN: 978-0-429-45620-6 (Volume 9) (ebk)

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The publisher has gone to great lengths to ensure the quality of this reprint but points out that some imperfections in the original copies may be apparent.

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LIAISON PSYCHIATRY

Mental Health Problems in the General Hospital

JOAN GOMEZ, MB, FRCPsych, DPM,

Consultant Psychiatrist.
Westminster Hospital, London

1987 Joan Gomez

Croom Helm Ltd, Provident House, Burrell Row,
Beckenham, Kent BR3 1AT
Croom Helm Australia, 4450 Waterloo Road,
North Ryde, 2113, New South Wales

British Library Cataloguing in Publication Data

Gomez, Joan

Liaison psychiatry: mental health problems in the general hospital.
1. Psychiatric consultation
I. Title
616.891 RC455.2.C65
ISBN 0-7099-1190-4
ISBN 0-7099-1191-2 Pbk

Printed and bound in Great Britain
by Billing & Sons Limited, Worcester.

Contents

The practice of psychiatry in a general hospital combines the factors in unfamiliar and varied settings, with an overriding intellectual challenge of identifying emotional and pathophysiological need for diplomacy. Consultation/liaison psychiatry promises to be the saviour of its parent discipline (Lipowski, 1974). It is a signpost directing psychiatry back towards the traditional medical arts at a time when it is in danger of disintegrating into a collection of social sciences (Rawnsley, 1984). In the swinging prosperity of the 1950s and 1960s, social psychiatry, community psychiatry, existential psychiatry and behavioural psychiatry all appeared. Non-medical practitioners, including social workers, medical psychologists, community nurses, nurse-therapists, marriage counsellors and bereavement counsellors, started operating autonomously, with exponents of alternative therapies abounding. A medical work-up for patients with mental disorders began to seem outmoded and intrusive, and biologically orientated psychiatrists came to be mistrusted as insensitive and mechanistic at best, and as despoilers of human rights at worst. In many countries legislation reflects this attitude, making the professional activities of psychiatrists subject to constant checking by laymen and to legal constraints. It is fortunate for the future of todays psychiatrists that liaison work has so much to offer our medical colleagues and modern students that the links between psychiatry and the rest of medicine must be strengthened by it. Collaboration is necessary for complete patient care.

It is estimated that 30 to 65 per cent of medical inpatients have significant psychiatric symptomatology, the most frequent diagnoses being depression, anxiety and organic brain syndrome, and 30 per cent of acute medical inpatients show cognitive deficits (von-Ammon Cavanaugh, 1983; Nabarro, 1984). Equally, there is a high rate of physical illness among psychiatric patients (Davies, 1965), and Granville-Grossman (1983) found 58 per cent of patients attending a psychiatric clinic to have a physical disorder also. Life expectancy is reduced in depression, mania and schizophrenia, and although suicide accounts in part for the high death rate, there is also a higher than expected incidence of accident, infection and circulatory diseases. These patients are likely to come under non-psychiatric care at some time. Despite the high incidence of cognitive and emotional disorders among patients with mental and surgical disorders, only 1228 per cent of them are evaluated by a psychiatrist (Lipowski, 1977). This is partly because psychiatric distress is not sought, and unless it is troublesome or florid, may not be noticed; or it may be regarded as a normal reaction to illness, requiring no special attention. It is also understandable that the physician or surgeon should wish to look after his own patient completely, within his own team, without advice or interference from outside. He may himself prescribe subtherapeutic doses of an anxiolytic or mild antidepressant. Patients themselves often resist the idea of seeing a psychiatrist, afraid that their symptoms will not be treated seriously, or that they are being classed as nutters. The primary consultant may genuinely believe that the psychiatrist can have nothing positive to offer and is likely to upset the patient into the bargain. The big divide, however, is traditional and geographical. For many years, psychiatrists worked exclusively in mental hospitals far removed from mainstream medicine, professionally isolated. This is a recipe for mutual mistrust. Added to this, until the 1960s, psychiatric treatment involved long incarceration and a slim chance of recovery.

The development of effective treatments, mainly pharmocological, enabled psychiatrists to take their place next to other physicians. Liaison psychiatry has grown out of the inclusion of a psychiatric department in an increasing number of general hospitals during this century. The first so designated liaison service was at Albany Hospital (New York) in 1902, but now there are more than 850 such services in hospitals in the United States of America. Liaison psychiatry has now become an essential part of medical student training in Europe and America (Lipowski, 1976). Of course, both physician and patient may come to welcome the psychiatrist more warmly if he attaches himself to the medical team and attends at least some ward rounds. As early as 1929 Henry offered guidelines to the psychiatrist who wished to work with physicians (Henry, 1929). These are still valid: that careful observation is more acceptable than inspired guesswork; communication should be free of jargon; and there must be flexibility in the application of theory and the choice of therapy. Psychosomatics a term coined by Heinroth in 1818 flourished from the mid-1930s through the 1960s, and gave an added impetus to liaison psychiatry. Flanders Dunbar, who wrote so persuasively about the correlation between personality and somatic symptomatology, was associated with the liaison service of the Columbia Medical Center in the 1930s. However, the lopsided approach of the psychosomatists of that period, trying to fit physical diseases to particular emotional configurations (specificity theory), involved separation of mind from body, and did not hold water in practice. This led to disillusionment among general physicians and to the decline of psychosomatics.