Consult Liaison & Therapeutic Alliance Tony A. Hanna PGY-IIIPsychiatry

Consult Liaison Consult Liaison & Therapeutic Alliance& Therapeutic Alliance

Tony A. Hanna Tony A. Hanna PGY-IIIPGY-III

PsychiatryPsychiatry

ObjectivesObjectivesDefine Consultation liaison psychiatry.Define Consultation liaison psychiatry.Understand the scope of psychosomatic Understand the scope of psychosomatic medicine.medicine.Outline the indications for consultation in Outline the indications for consultation in C/L psychiatry.C/L psychiatry.Outline the model for C/L psychiatry.Outline the model for C/L psychiatry.Understand the approach to C/L Understand the approach to C/L psychiatry.psychiatry.Define therapeutic alliance and the 12 Define therapeutic alliance and the 12 “do’s” of C/L psychiatric etiquette.“do’s” of C/L psychiatric etiquette.

Consult Liaison ServicesConsult Liaison Services

Dr. Fitzgerald (Attending)Dr. Fitzgerald (Attending)

Dr. Tzoneva (Fellow)Dr. Tzoneva (Fellow)

Dr. PGY (resident)Dr. PGY (resident)

Medical studentMedical student

DefinitionDefinition

Consultation-Liaison Psychiatry is a sub-Consultation-Liaison Psychiatry is a sub-specialty of psychiatry that incorporates specialty of psychiatry that incorporates clinical service, teaching, and research at clinical service, teaching, and research at the borderland of psychiatry and medicine.the borderland of psychiatry and medicine.

(Lipowski, 1983)(Lipowski, 1983)

Psychosomatic medicine:Psychosomatic medicine:

1) Studies the correlations of 1) Studies the correlations of psychological and social phenomena psychological and social phenomena with physiological functionswith physiological functions

2) Focuses on the interplay of biological 2) Focuses on the interplay of biological and psychosocial factors in the and psychosocial factors in the development, course and outcome of development, course and outcome of all diseases. all diseases.

3) Advocates the biopsychosocial 3) Advocates the biopsychosocial approach to patient care. approach to patient care.

History of Consultation – Liaison History of Consultation – Liaison PsychiatryPsychiatry

Its early origins reflect the emergence of General Its early origins reflect the emergence of General Hospital Psychiatry. Hospital Psychiatry. In the 1920s psychiatry became closer to In the 1920s psychiatry became closer to medicine as hospitals started to establish medicine as hospitals started to establish psychiatric units . psychiatric units . The concept of psychosomatic relationships and The concept of psychosomatic relationships and the role of emotions and psychological states in the role of emotions and psychological states in the genesis and maintenance of organic the genesis and maintenance of organic diseases emerged.diseases emerged.Thus, Consultation – Liaison Psychiatry became Thus, Consultation – Liaison Psychiatry became an applied form of psychosomatic medicine. an applied form of psychosomatic medicine.


Considered the earliest advocate Considered the earliest advocate for integration of psychiatry and for integration of psychiatry and medicine.medicine.

Wrote the first comprehensive book Wrote the first comprehensive book on mental illness by an American – on mental illness by an American – “Medical Inquiries and “Medical Inquiries and Observations upon the Diseases Observations upon the Diseases of the Mind”of the Mind”

Stressed that diseases of the mind Stressed that diseases of the mind are as certainly object of medicine are as certainly object of medicine as diseases of the body.as diseases of the body.

Benjamin Rush Benjamin Rush 1745 - 18131745 - 1813


Developed the concept Developed the concept of of psychobiologypsychobiology. .

Advocated the study of Advocated the study of the the person in the person in the context of physical, context of physical, social, social, psychological psychological life life events.events.

Spoke of the medically Spoke of the medically useless contrast useless contrast between mental and between mental and physical disordersphysical disorders

Adolf Meyer Adolf Meyer (1866 – 1959)(1866 – 1959)


Considered one of the Considered one of the pioneers of pioneers of psychosomatic medicine.psychosomatic medicine.

Worked at the Columbia-Presbyterian Worked at the Columbia-Presbyterian Hospital as a psychiatrist assigned to Hospital as a psychiatrist assigned to the department of medicine.the department of medicine.

In 1936 published the conclusions of In 1936 published the conclusions of her study of 600 patients with her study of 600 patients with cardiovascular diseases, diabetes, or cardiovascular diseases, diabetes, or fractures.fractures.

Psychological factors appeared to Psychological factors appeared to influence both the etiology and course influence both the etiology and course of the illness in a substantial of the illness in a substantial proportion of these patients. proportion of these patients.

Helen Flanders DunbarHelen Flanders Dunbar

In 1934/35 with Rockefeller foundation grants In 1934/35 with Rockefeller foundation grants five general hospitals were able to develop five general hospitals were able to develop psychiatric departments and stimulate closer psychiatric departments and stimulate closer collaboration between psychiatrists and other collaboration between psychiatrists and other physicians.physicians.

By the 1960’s-1970’s a subspecialty scientific By the 1960’s-1970’s a subspecialty scientific literature had developed.literature had developed.

In 1974 the psychiatric education branch of the In 1974 the psychiatric education branch of the NIMH decided to support the development and NIMH decided to support the development and the expansion of consultation liaison services the expansion of consultation liaison services throughout the US. throughout the US.

By 1980, NIMH supported 130 programs By 1980, NIMH supported 130 programs and materially contributed to the training of and materially contributed to the training of more than 300 consult-liaison psychiatry more than 300 consult-liaison psychiatry fellows. fellows.

Consult-liaison psychiatry continued to Consult-liaison psychiatry continued to grow during the 1980’s despite the federal grow during the 1980’s despite the federal budget cuts.budget cuts.

The years since 2000 have seen a focus The years since 2000 have seen a focus on achieving added qualification status by on achieving added qualification status by the American Board of Medical Specialty.the American Board of Medical Specialty.

Fellowship training guidelines and Fellowship training guidelines and certification examination development are certification examination development are necessary steps toward that goal.necessary steps toward that goal.

Most common reasons for Most common reasons for consultation:consultation:

Delirium, dementia, amnesia and other cognitive Delirium, dementia, amnesia and other cognitive disorders-25%disorders-25%Affective disorders, primary or secondary to Affective disorders, primary or secondary to medical condition-25%medical condition-25%Adjustment disorder, maladaptive response to Adjustment disorder, maladaptive response to identified stressors, including medical illness-identified stressors, including medical illness-15%15%Somatoform disorders, anxiety disorders, Somatoform disorders, anxiety disorders, personality disorders -each <10%personality disorders -each <10%Data on the distribution of axis II disorders are Data on the distribution of axis II disorders are limited.limited.

Models for ConsultationModels for Consultation

The five models for consultation:The five models for consultation:

Patient-oriented (Lipowski 1967)Patient-oriented (Lipowski 1967) Crisis-oriented (Weisman and Hackett 1960)Crisis-oriented (Weisman and Hackett 1960) Consultee-oriented (Shiff and Pilot 1959)Consultee-oriented (Shiff and Pilot 1959) Situation-oriented (Greenberg 1960)Situation-oriented (Greenberg 1960) Expanded psychiatric consultation (E. Meyer Expanded psychiatric consultation (E. Meyer

and Mendelson 1961)and Mendelson 1961)

Approach to the ConsultationApproach to the Consultation

Consultation style Consultation style

Patient confidentiality Patient confidentiality

Patient follow-upPatient follow-up

Consultation styleConsultation style

Characteristics of effective psychiatric Characteristics of effective psychiatric consultant (Goldman, Lee, Rudd, 1983):consultant (Goldman, Lee, Rudd, 1983):

1. Talks with the referring physician, nursing 1. Talks with the referring physician, nursing and other staff before and after and other staff before and after consultation. Clarifying the reason for the consultation. Clarifying the reason for the consultation is the initial goal.consultation is the initial goal.

2. Establishes the level of urgency.2. Establishes the level of urgency.3. Reviews the chart and the data 3. Reviews the chart and the data

thoroughly.thoroughly.4. Performs a complete mental status exam 4. Performs a complete mental status exam

and relevant portions of a history and and relevant portions of a history and physical exam.physical exam.

5. Gets collateral from family, friends as 5. Gets collateral from family, friends as indicated.indicated.

6. Makes notes as brief as appropriate.6. Makes notes as brief as appropriate.7. Arrives at a tentative diagnosis.7. Arrives at a tentative diagnosis.8. Formulates a differential diagnosis.8. Formulates a differential diagnosis.9. Recommends diagnostic tests.9. Recommends diagnostic tests.

10. Has the knowledge to prescribe 10. Has the knowledge to prescribe psychotropic drugs and be aware of their psychotropic drugs and be aware of their interactions.interactions.

11. Makes specific recommendations that 11. Makes specific recommendations that are brief, goal oriented and free of are brief, goal oriented and free of psychiatric jargon and psychiatric jargon and discusses discusses findingsfindings and recommendation with and recommendation with consultee – consultee – In personIn person whenever possible. whenever possible.

12. Respects patient’s rights to know that 12. Respects patient’s rights to know that the identified “customer” is the consulting the identified “customer” is the consulting physician.physician.

13. Follows-up the patient in hospital, and 13. Follows-up the patient in hospital, and arranges out-patient care, including help arranges out-patient care, including help arranging postdischarge referrals.arranging postdischarge referrals.

14. Does not take over the aspects of the 14. Does not take over the aspects of the patient’s medical care unless asked to do patient’s medical care unless asked to do so.so.

15. Follows advances in the other medical 15. Follows advances in the other medical fields and is not isolated from the rest of fields and is not isolated from the rest of the medical community.the medical community.

Patient ConfidentialityPatient Confidentiality

Maintaining absolute Doctor-Patient Maintaining absolute Doctor-Patient confidentiality is not possible for a confidentiality is not possible for a psychiatric consultant. psychiatric consultant.

Explain the dual relationship to the patient. Explain the dual relationship to the patient.

Patient Follow-upPatient Follow-up

Frequency and duration of psychiatric Frequency and duration of psychiatric follow-up will vary widely depending on the follow-up will vary widely depending on the patient’s needs and the financial patient’s needs and the financial circumstances. circumstances.

Psychiatric consultant should follow-up Psychiatric consultant should follow-up patient until they are discharged from the patient until they are discharged from the hospital or clinic or until the goals of the hospital or clinic or until the goals of the consultation are achieved.consultation are achieved.

Case PresentaionCase Presentaion

Reason for Consult: LG- 38/y/y AAF was Reason for Consult: LG- 38/y/y AAF was assaulted and sustained multiple facial assaulted and sustained multiple facial fractures, pt. developed meningitis and fractures, pt. developed meningitis and endocarditis and is treated with oral Zyvox. endocarditis and is treated with oral Zyvox. Pt refused to leave the room, she thinks Pt refused to leave the room, she thinks that people will look at her and treat her that people will look at her and treat her funny. funny.

HPI- 38y/y AAF who lives with her mother, HPI- 38y/y AAF who lives with her mother, grandmother, daughter and 2 grandchildren. Sits grandmother, daughter and 2 grandchildren. Sits for the grandchildren and grandmother who had for the grandchildren and grandmother who had stroke.stroke.4/21/06 spent the weekend at a motel and upon 4/21/06 spent the weekend at a motel and upon leaving at midnight, her boyfriend dropped her leaving at midnight, her boyfriend dropped her (at her request) at a disabled neighbor who lives (at her request) at a disabled neighbor who lives two blocks from the Pt’s house. According to the two blocks from the Pt’s house. According to the patient, she wanted to check on her neighbor, patient, she wanted to check on her neighbor, but her neighbor did not answer the door. The Pt but her neighbor did not answer the door. The Pt walked to her house but first decided to stop at a walked to her house but first decided to stop at a grocery across the street from her house. Before grocery across the street from her house. Before entering the store, she was assaulted and the entering the store, she was assaulted and the Pt. does not remember any details until she was Pt. does not remember any details until she was in the ER at LSU-S. Pt was transferred from in the ER at LSU-S. Pt was transferred from Monroe.Monroe.

Pt denies being depressed but stated she Pt denies being depressed but stated she is self-conscious because of her left eye, is self-conscious because of her left eye, periorbital scar, loss of vision and ptosis.periorbital scar, loss of vision and ptosis.

” ”What will people say about this?” “My What will people say about this?” “My grandchildren will be scared of me.” grandchildren will be scared of me.”

Psychiatric review of systemsPsychiatric review of systemsMAPSSMAPSS

Mood-depression (sigecaps): sleeps 8-10 hours,+ Mood-depression (sigecaps): sleeps 8-10 hours,+ helpless, occasional crying spells, no guilt or frustration, helpless, occasional crying spells, no guilt or frustration, not hopeless, appetite normal, good energy with normal not hopeless, appetite normal, good energy with normal concentration.concentration.Mood-mania (digfast): negativeMood-mania (digfast): negativeAnxiety- no flash back, no nightmareAnxiety- no flash back, no nightmarePsychosis- no hallucination, no delusionPsychosis- no hallucination, no delusionSubstance- no tobacco, started beer drinking at age 17 Substance- no tobacco, started beer drinking at age 17 which increased to 6 beer/daily for the last year, history which increased to 6 beer/daily for the last year, history of THC and cocaine abuse X 9 years, last use 3 years of THC and cocaine abuse X 9 years, last use 3 years ago.ago.Safety- no SI/HISafety- no SI/HI

Social HistorySocial History

1212thth grade education, single with 6 grade education, single with 6 children, liked to socialize, watch TV, go to children, liked to socialize, watch TV, go to casino, no church activity, no military casino, no church activity, no military service, no history of abuse, jailed a few service, no history of abuse, jailed a few months, 13 years ago due to an altercation months, 13 years ago due to an altercation and violating her parole.and violating her parole.

Past Medical & Psychiatric HistoryPast Medical & Psychiatric History

nonenone

Family HistoryFamily History

Father & Mother living but separated, Father & Mother living but separated,

no problems.no problems.

3 sisters – one sister with HTN3 sisters – one sister with HTN

6 children- two daughters, 4 sons, no 6 children- two daughters, 4 sons, no problems.problems.

MSEMSE

A&O x4 in casual clothes, cooperative and A&O x4 in casual clothes, cooperative and pleasant, speech normal, mood and affect pleasant, speech normal, mood and affect euthymic, TP organized, TC no euthymic, TP organized, TC no hallucinations or delusions, no SI/HIhallucinations or delusions, no SI/HI

Registration 3/3, Recall 2/3, spells Registration 3/3, Recall 2/3, spells WORLD forward and backward, abstract WORLD forward and backward, abstract intact ( do not cry over spilled milk) insight intact ( do not cry over spilled milk) insight and judgment good. and judgment good.

AssessmentAssessment

Axis I - Adjustment disorder with anxietyAxis I - Adjustment disorder with anxiety - ETOH / cocaine abuse- ETOH / cocaine abuse - THC abuse in remission- THC abuse in remission Axis II- deferredAxis II- deferred Axis III- s/p assault with facial and skull fxAxis III- s/p assault with facial and skull fx meningitis, endocarditis, loss ofmeningitis, endocarditis, loss of vision-left, ptosis, anemia NC/NCvision-left, ptosis, anemia NC/NC Axis IV- unemployedAxis IV- unemployed Axis V- GAF45/55 Axis V- GAF45/55

Treatment/RecommendationTreatment/Recommendation

Self disclosureSelf disclosureExamine pt thoughtsExamine pt thoughtsDesensitizationDesensitizationAlcohol and drug counselingAlcohol and drug counselingFollow-up with MMH upon dischargeFollow-up with MMH upon dischargeContinue to encourage pt to walk out of Continue to encourage pt to walk out of the roomthe roomNo need for medication.No need for medication.

Follow-upFollow-up

Pt was called at home 5/20/06Pt was called at home 5/20/06

Mother stated that the Pt is back to her Mother stated that the Pt is back to her self, not depressed and is following up self, not depressed and is following up with MMH, also the Pt has weekend plans with MMH, also the Pt has weekend plans to go away and will not return until to go away and will not return until Monday.Monday.

What is the most important What is the most important issue in psychiatric care?issue in psychiatric care?

SAFETYSAFETY

What is the second most What is the second most important issue?important issue?

Therapeutic AllianceTherapeutic Alliance

What is Therapeutic Alliance?What is Therapeutic Alliance?

The readiness of a patient to work with energy with a The readiness of a patient to work with energy with a willing psychotherapist.willing psychotherapist.It has not commonly applied to the type of brief It has not commonly applied to the type of brief encounter experience by the consultation-liaison encounter experience by the consultation-liaison psychiatrist in hospital setting. Nonetheless, insofar as psychiatrist in hospital setting. Nonetheless, insofar as the consulting psychiatrist fosters hope and expectation the consulting psychiatrist fosters hope and expectation in patients seen in that context, however brief the contact in patients seen in that context, however brief the contact , the relationship (alliance) has the capacity to promote , the relationship (alliance) has the capacity to promote maturation and well-being in any patient.maturation and well-being in any patient.The psychiatric consultant makes use of all the principals The psychiatric consultant makes use of all the principals of good psychotherapy although they are often modified of good psychotherapy although they are often modified to accommodate the realities of the hospital setting and to accommodate the realities of the hospital setting and the unusual way in which psychiatrist and patient are the unusual way in which psychiatrist and patient are brought together.brought together.

Dr. Joel Yager’s twelve Dr. Joel Yager’s twelve behaviors behaviors

as a list of “do’s”, somewhat as a list of “do’s”, somewhat analogous to the ten analogous to the ten

commandments of etiquette in commandments of etiquette in the psychiatric consultation the psychiatric consultation

described by Pasnau.described by Pasnau.

I. I. Sit DownSit Down..

Sitting reduces the status difference Sitting reduces the status difference between MD and Pt and the likelihood that between MD and Pt and the likelihood that the Pt will perceive the MD to be assuming the Pt will perceive the MD to be assuming a lordly demeanor and also conveys to the a lordly demeanor and also conveys to the patient that the MD has some time to patient that the MD has some time to spend with them.spend with them.Introduce yourself.Introduce yourself.State the reason for the visit.State the reason for the visit.Ask for permission to sit.Ask for permission to sit.

II. II. Do something tangible for the Do something tangible for the patientpatient..

Farther the rapport.Farther the rapport.

Be helpful in small ways, do what a good Be helpful in small ways, do what a good nurse will do, ask the Pt if he is nurse will do, ask the Pt if he is comfortable.comfortable.

Increase the comfort of the Pt.Increase the comfort of the Pt.

III. III. Touch the PatientTouch the Patient

The physical intimacy of touch is helpful The physical intimacy of touch is helpful with a frightened, dependant, and/or very with a frightened, dependant, and/or very physically ill patient and conveys a human physically ill patient and conveys a human caring that can reduce the feeling of caring that can reduce the feeling of aloneness and alienation in dehumanizing aloneness and alienation in dehumanizing medical environments.medical environments.Handshake, hold Pt hand, touch Pt Handshake, hold Pt hand, touch Pt shouldershoulderThe least touched Pt – AIDS, CancerThe least touched Pt – AIDS, Cancer

IV. IV. SmileSmile

Reduces interpersonal distanceReduces interpersonal distance

Decreases sense of threatDecreases sense of threat

Has a disarming effectHas a disarming effect

Must be culturally acceptableMust be culturally acceptable

VV. Begin by telling the patient . Begin by telling the patient what you know about his/her what you know about his/her

situation.situation.Ask the patient to correct you.Ask the patient to correct you.The positive effectsThe positive effects

* Pt does not have to go through the * Pt does not have to go through the information again.information again. * helps to get feed-back from Pt.* helps to get feed-back from Pt. * Pt will assess the level of the* Pt will assess the level of the consultants understanding and concern.consultants understanding and concern.

VI. VI. Ask the patient what his/her Ask the patient what his/her most pressing concerns of the most pressing concerns of the

moment are.moment are.

The Pt’s preoccupation with major fear or The Pt’s preoccupation with major fear or concern needs to be cleared to have the concern needs to be cleared to have the Pt’s full attention and cooperation.Pt’s full attention and cooperation.

Clears the air so the necessary Clears the air so the necessary information can be used more effectively.information can be used more effectively.

VII. VII. Ask in detail about the Ask in detail about the patient’s belief system regarding patient’s belief system regarding the nature, cause and prognosis the nature, cause and prognosis of the illness or injury, and about of the illness or injury, and about

the patient’s specific concerns the patient’s specific concerns about pain, disability, about pain, disability,

disfigurement or death.disfigurement or death.

Tune into the Pt perspective and expectations of Tune into the Pt perspective and expectations of what the Pt is confronting.what the Pt is confronting.

Correct misimpressions and provide education. Correct misimpressions and provide education. (facilitate cooperation with RX)(facilitate cooperation with RX)

VIII. VIII. Ask in detail about the Ask in detail about the patient’s family major social patient’s family major social

roles such as occupation, and roles such as occupation, and the impact of the current illness the impact of the current illness or injury on those relationships or injury on those relationships

and roles.and roles.

Pt is concerned about the negative Pt is concerned about the negative consequences of the illness on loved ones and consequences of the illness on loved ones and on the ability to maintain major social role on the ability to maintain major social role functions in family, work and community.functions in family, work and community.

IX. IX. Ask about the specific Ask about the specific personal characteristics, personal characteristics,

activities and attainments the activities and attainments the patient has achieved in life in patient has achieved in life in which he/she takes pride and which he/she takes pride and

find an opportunity to find an opportunity to complement these qualities.complement these qualities.

Improve self esteem and the Pt feels that Improve self esteem and the Pt feels that the consultant appreciates the Pt, not as a the consultant appreciates the Pt, not as a simply dependent creature.simply dependent creature.

X. X. Acknowledge the human blight Acknowledge the human blight in which the patient finds in which the patient finds

him/herself.him/herself.

The physician should tell the Pt that faced The physician should tell the Pt that faced with similar circumstances, the physician with similar circumstances, the physician might well display similar psychological might well display similar psychological difficulties.difficulties.

Strengthen the physician/Pt relationshipStrengthen the physician/Pt relationship

Legitimize and validate the Pt and support Legitimize and validate the Pt and support self esteem.self esteem.

XI. XI. Fully explain the need for Fully explain the need for and purpose of mental status and purpose of mental status exam in an informative way exam in an informative way

and involve the Pt as an ally and involve the Pt as an ally an co-investigator.an co-investigator.

XII. XII. Leave the patient with Leave the patient with something concrete.something concrete.

Give the Pt a revised formulation.Give the Pt a revised formulation.

Tell the Pt what you intent to do with the Tell the Pt what you intent to do with the information.information.

Ask the Pt for feedback.Ask the Pt for feedback.

Tell the Pt when you are coming back for Tell the Pt when you are coming back for follow-up.follow-up.

2000 My vet gave me an Axis II 2000 My vet gave me an Axis II diagnosis.diagnosis.

Personality disorder -incompatible with Personality disorder -incompatible with large dogs in house.large dogs in house.

TreatmentTreatment

Guido Hanna a pure-bred dachshund, who Guido Hanna a pure-bred dachshund, who believes he is a doberman, was added to believes he is a doberman, was added to the family.the family.

Guido HannaGuido Hanna

DiscussionDiscussion

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Consult Liaison & Therapeutic Alliance Tony A. Hanna PGY-IIIPsychiatry