Psychosomatic Medicine

Consultation-Liaison Psychiatry

• Consultation-Liaison Psychiatry and Psychosomatic Medicine have been a specific area of concern for over 50 years.

• The term "psychosomatic" comes from the Greek words "psyche" (soul) and "soma" (body), referring to how the mind affects the body.

• The Academy of Psychosomatic Medicine changed its name to the Academy of Consultation-Liaison Psychiatry in 2018.

• The DSM replaced psychophysiological (or psychosomatic) disorders with psychological factors affecting physical conditions.

• The term "psychosomatic" is still used by researchers, journals (e.g., Psychosomatic Medicine, Journal of Psychosomatic Research), and organizations (e.g., American Psychosomatic Society, European Association for Consultation-Liaison Psychiatry and Psychosomatics).

• The American Board of Medical Specialties and the American Board of Psychiatry and Neurology approved the specialty of Psychosomatic Medicine in 2003, changing the name to Consultation-Liaison psychiatry in 2017.

History

• Edward Shorter discusses how presentations of illness vary over history, with patients unconsciously selecting symptoms representing actual somatic illnesses.

• Before 1800, physicians couldn't distinguish somatic from psychogenic illness, leading to diagnoses of hysteria and hypochondriasis even in the presence of genuine medical illnesses.

• Sigmund Freud connected psyche and soma, demonstrating the role of emotions in mental and somatic disorders.

• Freud's psychoanalytic formulations detailed psychic determinism in somatic conversion reactions.

• Karl Abraham (1927) proposed the influence on adult organ tissue of unresolved pregenital impulses.

• Sándor Ferenczi (1926) described applying conversion reaction to organs under autonomic nervous systems control.

• Georg Groddeck (1929) suggested attaching symbolic meaning to fever and hemorrhage.

• George W. Henry described consultation-liaison psychiatry in the United States in the 1920s.

• Divisions of consultation-liaison psychiatry and fellowship programs began in academic departments.

• The American Board of Psychiatry and Neurology offered the first subspecialty examination in 2005.

• In Europe, pioneers like Thure von Uexküll saw psychosomatic medicine as central to all medical diseases, with multifactorial etiologies (organic and psychological).

• In Europe, most departments of psychosomatic medicine are independent of psychiatry departments.

Current Trends

• Consultation-Liaison psychiatry now focuses on psychiatric illnesses in the setting of physical health care due to increased medical complexity, understanding of the relationship between medical and psychiatric illness, and the appreciation of mind and body as one.

• Clinical care is delivered in various healthcare settings using expanding diagnostic tools and somatic and psychotherapeutic interventions.

• Research includes the relationship between chronic medical conditions and psychiatric disorders, pathophysiologic relationships, epidemiology of comorbid disorders, and the role of specific interventions in physiologic, clinical, and economic outcomes (Table 25-1).

• Psychiatric morbidity is prevalent in patients with medical conditions, ranging from 20 to 67 percent, depending on the illness and setting.

• Patients in general hospitals have the highest rate of psychiatric disorders compared to community samples or ambulatory primary care.

• Depressive disorders are more than twice as prevalent in general hospitals compared to community samples, and substance abuse is two to three times as common.

• Delirium occurs in 18 percent of patients.

• Increased rates are also seen in primary and long-term care.

• Psychiatric morbidity has severe effects for medically ill patients and is often a risk factor for their medical conditions.

• Depression is both a risk factor and a poor prognostic indicator in coronary artery disease.

• Psychiatric illness worsens cardiac morbidity and mortality after myocardial infarction, diminishes glycemic control in diabetes, and decreases return to functioning after a stroke.

• Depressive and anxiety disorders compound disability associated with stroke.

• In neurodegenerative diseases (Parkinson’s or Alzheimer’s), depression, psychosis, and behavioral disturbances predict functional decline, institutionalization, and caregiver burden.

• Hospitalized patients with delirium are less likely to improve in function compared to those without delirium.

• Delirium is associated with worse outcomes after surgery, even after controlling for medical illness severity.

• Mental disorders significantly impact the quality of life and adherence to treatment regimens (e.g., in diabetes mellitus or cancer).

• Psychiatric disorders are linked to nonadherence with antiretroviral therapy in HIV-infected patients, affecting survival.

• Psychiatric disorders are also linked to nonadherence with safe sex guidelines and sterile needles in HIV-infected injection drug users, with public health implications.

Evaluation Process

• Psychiatric assessment in medical settings includes a standard psychiatric assessment and a focus on medical history and the context of physical health care.

• A complete psychiatric history, family history, developmental history, and review of systems should be obtained, along with the medical history and current treatment.

• A full mental status examination, including a cognitive examination, should be completed, and neurologic and physical examinations may be indicated.

• Understanding the patient’s experience of their illness is essential and often the central focus.

• It is helpful to understand the patient’s developmental and personal history and dynamic conflicts to make their experience with illness more comprehensible.

• Evaluation can include the use of stress, personality traits, coping strategies, and defense mechanisms.

• Observations and hypotheses can guide psychotherapy aimed at diminishing distress and help the primary medical team in their interactions with the patient.

• A full report synthesizing the information should be completed, including specific recommendations for additional evaluations and intervention.

• Ideally, the report should be accompanied by a discussion with the referring physician.

Treatments

• A host of interventions have been successfully utilized in psychosomatic medicine.

• Specific consideration must be given to medical illness and treatments when recommending psychiatric medications.

• Psychotherapy plays a vital role in psychosomatic medicine and may vary in its structure and outcomes compared to therapy in mental health practice.

• Psychopharmacologic recommendations need to consider several essential factors.

• Consider the history of illness and treatments, and weigh the particular side-effect profile of a particular medication

• Evaluate potential drug–drug interactions and contraindications to the use of potential psychiatric agents.

• Awareness of liver function is essential because most psychiatric medications are metabolized in the liver.

• Consider side effects such as weight gain, risk of developing diabetes, and cardiovascular risk in the choice of medications.

• Incorporate knowledge of recent data that outlines the effectiveness and specific risks involved for patients with co-occurring psychiatric and physical disorders.

• Greater understanding of the side effects of antipsychotic medications has raised concerns about their use in patients with dementia.

• The use of psychosocial interventions also requires adaptation when used in this population.

• The methods and the goals of psychosocial interventions used in the medically ill are often determined by the consideration of disease onset, etiology, course, prognosis, treatment, and understanding of the nature of the presenting psychiatric symptoms in addition to an understanding of the patient’s existing coping skills and social support networks.

• Data shows that psychosocial interventions are effective in addressing identified problems and are associated with positive clinical outcomes.

Common C-L Problems

• Suicide Attempt or Threat:

  • Suicide rates are higher in persons with medical illness than in those without medical or surgical problems.

  • High-risk factors: men over 45, no social support, alcohol dependence, previous suicide attempt, incapacitating or catastrophic medical illness (especially with severe pain).

  • If suicide risk is present, transfer to a psychiatric unit or start on 24-hour nursing care.

• Depression:

  • Suicidal risk must be assessed in every depressed patient.

  • Depression without suicidal ideation is not uncommon in hospitalized patients, and treatment with antidepressant medication can be started if necessary.

  • A careful assessment of drug–drug interactions must be made before prescribing, which should be undertaken in collaboration with the patient’s primary physician.

• Agitation:

  • Often related to cognitive disorder or withdrawal from drugs (e.g., opioids, alcohol, sedative-hypnotics).

  • Antipsychotic medications may be beneficial for excessive agitation.

  • Physical restraints should be used with great caution and only as a last resort as sedation is preferable and safer.

  • Examine for command hallucinations or paranoid ideation to which they are responding in an agitated manner.

  • Toxic reactions to medications that cause agitation should always be ruled out.

• Hallucinations:

  • A common cause in the general hospital setting is delirium tremens, which usually begins 3 to 4 days after hospitalization.

  • Patients in intensive care units (ICUs) who experience sensory isolation may respond with hallucinatory activity.

  • Conditions such as brief psychotic disorder, schizophrenia, and neurocognitive disorders are associated with hallucinations, and they respond rapidly to antipsychotic medication.

  • Fornication, in which the patient believes that bugs are crawling over the skin, is often associated with cocaine use.

• Sleep–Wake Disorders:

  • A common cause of insomnia in hospitalized patients is pain, which, when treated, solves the sleep problem.

  • Early morning awakening is associated with depression, and difficulty falling asleep is associated with anxiety.

  • Depending on the cause, antianxiety or antidepressant agents may be prescribed.

  • Early substance withdrawal as a cause of insomnia should be considered in the differential diagnosis.

• Confusion:

  • Delirium is the most common cause of confusion or disorientation among hospitalized patients in general hospitals.

  • The causes are myriad and relate to metabolic status, neurologic findings, substance abuse, and mental illness, among many others.

  • Small doses of antipsychotics may be used when significant agitation occurs in conjunction with the confused state; however, sedatives, such as benzodiazepines, can worsen the condition and cause sundowner syndrome (ataxia, disorientation).

  • If sensory deprivation is a contributing factor, the environment can be modified so that the patient has sensory cues (e.g., radio, clock, no curtains around the bed).

• Noncompliance or Refusal to Consent to Procedure:

  • The relationship between the patient and their doctor may be a critical underlying factor.

  • A negative transference toward the physician is a common cause of noncompliance.

  • Patients who fear medication or a procedure may respond to education and reassurance.

  • Patients whose refusal to give consent is related to impaired judgment can be declared incompetent, but only by a judge.

  • The leading cause of impaired judgment in hospitalized patients is cognitive disorders.

• No Physiologic Basis for Symptoms:

  • The C-L psychiatrist is often called when the physician cannot find evidence of medical or surgical disease to account for the patient’s symptoms.

  • Several psychiatric conditions must be considered, including conversion disorder, somatization disorder, factitious disorders, and malingering.

  • Glove and stocking anesthesia with autonomic nervous system symptoms is seen in conversion disorder; multiple bodily complaints are present in somatization disorder; the wish to be in the hospital occurs in factitious disorder, and apparent secondary gain is observed in patients who are malingering (e.g., compensation cases).

C-L Psychiatry in Special Situations

Intensive Care Units

• All ICUs deal with patients who experience anxiety, depression, and delirium.

• ICUs impose extraordinarily high stress on staff and patients, related to the intensity of the problems.

• Patients and staff frequently observe cardiac arrests, deaths, and medical disasters, leaving them autonomically aroused and psychologically defensive.

• ICU nurses and their patients experience exceptionally high levels of anxiety and depression.

• As a result, nurse burnout and high turnover rates are frequent.

• Much attention is given to the problem of stress among ICU staff, especially in the nursing literature.

• Less attention is given to the house staff, especially those on the surgical services.

• All persons in ICUs must be able to deal directly with their feelings about their extraordinary experiences and challenging emotional and physical circumstances.

• Regular support groups in which persons can discuss their feelings are recommended for the ICU staff and the house staff.

• Such support groups protect staff members from the otherwise predictable psychiatric morbidity that some may experience and also protect their patients from the loss of concentration, decreased energy, and psychomotor-retarded communications that some staff members otherwise exhibit.

Hemodialysis Units

• Hemodialysis units present a paradigm of complicated modern medical treatment settings.

• Patients are coping with lifelong, debilitating, and limiting disease; they are dependent on a multiplex group of caretakers for access to a machine controlling their well-being.

• Dialysis is scheduled three times a week and takes 4 to 6 hours; thus, it disrupts patients’ previous living routines.

• Patients fight the disease and must come to terms with a level of dependence on others probably not experienced since childhood.

• Patients entering dialysis struggle for their independence; regress to childhood states; show denial by acting out against doctor’s orders (by breaking their diet or by missing sessions); show anger directed against staff members; bargain and plead; or become infantilized and obsequious; however, most often they are accepting and courageous.

• Determinants of patients’ responses include personality styles and previous experiences with this or another chronic illness.

• Patients who have time to react and adapt to their disease are less challenged by the need to adapt to new circumstances.

• Those with recent renal failure and machine dependence may have more difficulty.

• Units are run with a firm hand, which is consistent in dealing with patients; clear contingencies are in place for behavioral failures; and adequate psychological support is available for staff members, which tend to produce the best results.

• Complications of dialysis treatment can include psychiatric problems, such as depression, and suicide is not rare.

• Sexual problems can be neurogenic, psychogenic, or related to gonadal dysfunction and testicular atrophy.

• Dialysis dementia is a rare condition that includes loss of memory, disorientation, dystonias, and seizures.

• The disorder occurs in patients who have been receiving dialysis treatment for many years.

• The leading cause is probably aluminum toxicity, and reducing dialysate aluminum levels and minimizing aluminum intake decreases the incidence of the disease.

• Chelating agents, such as deferoxamine, may also help if given early. However, it should be used sparingly because of its serious adverse effects.

• The psychological treatment of dialysis patients falls into two areas.

• Careful preparation before dialysis, including the work of adaptation to chronic illness, is essential, especially in dealing with denial and unrealistic expectations.

• Before dialysis, all patients should have a psychosocial evaluation.

• Once in a dialysis program, patients need periodic specific inquiries about adaptation that do not encourage dependence or the sick role.

• Staff members should be sensitive to the likelihood of depression and sexual problems.

• Group sessions function well for support, and patient self-help groups restore a useful social network, self-esteem, and self- mastery.

• When needed, antidepressants can be used for dialysis patients.

• Psychiatric care is most effective when brief and problem-oriented.

• The use of home dialysis units has improved attitudes toward treatment.

• Patients treated at home can integrate the treatment into their daily lives more efficiently, and they feel more autonomous and less dependent on others for their care than do those who are treated in the hospital.

Surgical Units

• Some surgeons believe that patients who expect to die during surgery are more likely to die.

• Some patients scheduled for surgery who show depression or anxiety but deny it have a higher risk for morbidity and mortality than those who can express it.

• Even better results occur in those with a positive attitude toward impending surgery.

• Factors contributing to improved surgical outcomes: informed consent, education about expected feelings and the environment (e.g., recovery room), anticipated loss of function and tubes/gadgets, and coping with pain.

• Explain how to compensate for losses (e.g. speech) if patients won't be able to talk or see after surgery

• If postoperative states such as confusion, delirium, and pain can be predicted, they should be discussed with patients in advance, so they do not experience them as unwarranted or as signs of danger.

• Constructive family support can help both before and after surgery.

Transplantation Issues

• Transplantation programs have expanded and C-L psychiatrists play an essential role in helping patients and families deal with the many psychosocial issues involved: (1) which and when patients on a waiting list will receive organs, (2) anxiety about the procedure, (3) fear of death, (4) organ rejection, and (5) adaptation to life after successful transplantation.

• After transplant, patients require complicated aftercare, and achieving compliance with medication may be difficult without supportive psychotherapy.

• This challenge is particularly relevant to patients who have received liver transplants as a result of hepatitis C brought on by promiscuous sexual behavior and patients with a history of substance use disorder who used contaminated needles.

• Group therapy with patients who have had similar transplantation procedures benefits members who can support one another and share information and feelings about particular stressors related to their disease.

• Groups may be conducted or supervised by the psychiatrist.

• Psychiatrists must be especially concerned about psychiatric complications.

• Within 1 year of transplant, almost 20 percent of patients experience major depression or an adjustment disorder with depressed mood. Evaluation for suicidal ideation and risk is essential.

• Another 10 percent of patients experience signs of posttraumatic stress disorder, with nightmares and anxiety attacks related to the procedure.

• Other issues concern whether the transplanted organ came from a cadaver or from a living donor who may or may not be related to the patient.

• Pretransplant consulting sessions with potential organ donors help them to deal with fears about surgery and concerns about who will receive their donated organ.

• Sometimes, both the recipient and donor may be counseled together, as with a family member donating a kidney.

• Peer support groups with both donors and recipients have also been used to facilitate coping with transplantation issues.

PSYCHO-ONCOLOGY

• Psycho-oncology seeks to study both the impact of cancer on psychological functioning and the role that psychological and behavioral variables may play in cancer risk and survival.

• A hallmark of psycho-oncology research has been intervention studies that attempt to influence the course of illness in patients with cancer.

• A landmark study by David Spiegel found that women with metastatic breast cancer who received weekly group psychotherapy survived an average of 18 months longer than control patients randomly assigned to routine care.

• In another study, patients with malignant melanoma who received structured group intervention exhibited a statistically significant lower recurrence of cancer and a lower mortality rate than patients who did not receive such therapy.

• Patients with malignant melanoma who received the group intervention also exhibited significantly more large granular lymphocytes and natural killer (NK) cells as well as indications of increased NK cell activity, suggesting an increased immune response.

• Another study used a group behavioral intervention (relaxation, guided imagery, and biofeedback training) for patients with breast cancer, who demonstrated higher NK cell activity and lymphocyte mitogen responses than the controls.

• New treatment protocols have transformed cancer from an incurable to frequently chronic and often curable disease, the psychiatric aspects of cancer—the reactions to both the diagnosis and the treatment—are increasingly important.

• At least half of the persons who contract cancer in the United States each year are alive 5 years later. Currently, an estimated 3 million cancer survivors have no evidence of the disease.

• About half of all cancer patients have mental disorders.

• The largest groups are those with adjustment disorder (68 percent), and major depressive disorder (13 percent) and delirium (8 percent) are the next most common diagnoses.

• Most of these disorders are thought to be reactive to the knowledge of having cancer.

• When persons learn that they have cancer, their psychological reactions include fear of death, disfigurement, and disability; fear of abandonment and loss of independence; fear of disruption in relationships, role functioning, and financial standings; and denial, anxiety, anger, and guilt.

• Although suicidal thoughts and wishes are frequent in persons with cancer, the actual incidence of suicide is only slightly higher than that in the general population.