Consultation-Liaison Psychiatry

(Psychosomatic medicine)
M.ZAINIE HASSAN A.R.
Three streams of thought flowed into the area
of general hospital and consultation psychiatry.
• The psychophysiologic represented by the Walter B.
Cannon, emphasized the effects of stress on the
body.
• The psychoanalytic,best personified by the
psychoanalyst Franz Alexander,focused on the
effects that psychodynamic conflicts had on
the body.
• The organic synthesis point of view, ambitiously
pursued by Helen Flanders Dunbar, tried to unify
the physiologic and psychoanalytic approaches.
 Consultation-liaison (C-L) psychiatry
• “Consultation-liaison psychiatry is a subspecialty of
psychiatry that incorporates clinical service,
teaching, and research at the borderland of
psychiatry and medicine.”Lipowski, 1983 - Can J
Psychiatry, 28
• is the study, practice, and teaching of the relation
between medical and psychiatric disorders.
• is the psychiatric sub-specialty that helps people with
mental health problems in general medical settings
such as general hospital.
 Consultation Liaison Psychiatry

• The Consultation-Liaison is the psychiatry

subspecialty at the interface of the mind and body
and deals with a range of problems including self-
harm, adjustment to illness and physical and
psychological co-morbidities.
• Consultant-Liaison (CL) psychiatry team interfaces
with all units of the general medical hospital to
address the psychiatric needs and treatments of
hospitalized patients. Diagnosis, symptom
management, interaction with caregivers and
disposition planning are all components of the
treatment approach.
 Consultation-liaison (C-L)
psychiatry
• is associated with all the diagnostic, therapeutic,
research, and teaching services that psychiatrists
perform in the general hospital and serves as a
bridge between psychiatry and other specialties.
• Related Terms / Fields:
 psychosomatic medicine
 psychiatry in the medically ill medical / surgical
psychiatry
 behavioural medicine
 health psychology
 SERVICES PROVIDED
• The Consultation-Liaison Service utilizes a multi-
disciplinary team approach (psychiatry, psychology,
and nursing) for assessment and treatment. Follow-
up services may include: psychiatric or psychological
management, liaison with the (referring) treatment
team, ongoing monitoring of mental status during
hospitalization.
• Outpatient follow-up in the form of psychological
management.
 Diagnosis
• Delirium occurs in 15 to 30 percent of hospitalized patients.
• Many medical illnesses that can have psychiatric symptoms.
Lifetime prevalence of mental illness in chronically physically
ill patients is more than 40 percent.
• the diagnosis are to identify :
(1) mental disorders and psychological responses to physical
illness,
(2) (2) patients' personality features.
(3) (3) patients' characteristic coping techniques to recommend
the most appropriate therapeutic intervention for patients'
needs.
 Treatment
• May recommend a specific therapy, suggest
areas for further medical inquiry, inform
doctors and nurses of their roles in the
patient's psychosocial care.
• Recommend a transfer to a psychiatric facility
for long-term psychiatric treatment.
• Suggest or undertake brief psychotherapy
with the patient on the medical ward.
• The most common symptoms being anxiety,
depression, and disorientation.
The biopsychosocial
model of health is Spirituality and Religion strong religious
embraced and promoted. beliefs,spiritual yearnings,prayer,devotional acts have
positive influences on mental& physical health

Bio(anatomical.structrur
al molecular effects on
biological functioning

Psychological,effects of
psychodinamic,motivation,
personality

Social,cultural,famil
ial influence
einvironment

George Engel 1977

• Neuronal circuits in the organization of stress responses. Horizontal thick and thin
lines indicate short circuit autonomic (sympathoadrenal and/or parasympathetic)
and defense (withdrawal) spinal reflexes in response to stressful stimuli. Thin lines
represent long circuit, ascending (afferent) and descending (efferent) neuronal loops
between the spinal cord/medulla and higher brain centers. Dashed line indicates
neurohumoral hypothalamo-pituitary outflow. CA, Brainstem catecholaminergic
 Neuroendocrine
hypothalamus
 The paraventricular, arcuate, and medial preoptic
nuclei project to both the median eminence
(neurohumoral output) and brainstem or spinal cord
autonomic centers (neuronal output)
 Descending fibers may terminate on autonomic
preganglionic neurons directly or they may exert their
effect through brainstem catecholaminergic neurons
 Various inputs mediating stress converge upon
neurons of the parvocellular subdivisions of the PVN
(Periventricular neuron) which synthesize and release
CRH and vasopressin
 Limbic System
Both cortical and subcortical limbic structures
are involved in the organization of stress
responses
subcortical  amygdala, septum, habenula,
and related structures
limbic cortex hippocampal formation
(hippocampus, dentate gyrus, subiculum) and
entorhinal, piriform, prelimbic, intralimbic, and
cingulate cortices.
 The well-documented effect of
depression
• its effect on the outcome of comorbid medical
illness;
• For example, depression increases mortality rates
following myocardial infarction (MI)
• ischemic stroke.
• in all patients, and in women with HIV/AIDS .
• It is also an independent risk factor for the
development of coronary artery disease .
 SELECTED EPIDEMIOLOGIC STUDIES OF DEPRESSION
ASSOCIATED WITH MEDICAL ILLNESS

Illness Prevalence of depression (%)

• Cerebrovascular accident
• Myocardial infarction
• Coronary artery disease
• Diabetes mellitus
• functional gastrointestinal
disorders
• 23 (Burvill et al)
• 27 Major depression
20 Minor depression
(Robinson et al)
• 18 Major depression
27 Minor depression
(Schleifer et al)
• 18 (Carney et al. )
• 8.5 - 27.3(Goodnick et al.)
• 50-60% anxiety, depressive,
and panic disorders
 Penelitian depresi dan kualitas hidup di
RSHS/FKUP
• Depresi pada penderita Diabetes Mellitus 56 % (2003).
• Depresi dan kualitas hidup pada penderita Sistemik Lupus
Eritematosus 48 % depresi kualitas hidup semakin buruk bila
depresi semakin berat (2005).
• Depresi dan kualitas hidup pada pasien pasca Infark Miokard
74 % depresi, kualiatas hidup menurun.(2006).
• Derajat Depressi dan Stadium penyakit Parkinson pada
penderita Pemyakit Parkinson.84,9% depresi ,depresi berat
pada stadium III dan IV.(2009).
• Depresi pada Dispepsia Fungsional 54,3% dan mengalami
stressor psikososial (kematian keluarga dekat,kesulitan seks,gangguan
kesehatan/tingkah laku anggota keluarga) 2010.
 CHEMOTHERAPEUTIC AND OTHER PHARMACOLOGIC AGENTS
LINKED TO DEPRESSION

• ANTINEOPLASTIC AGENTS
Alkylatingagents,Dacarbazine,Hexamethylamine,Corticosteroi
ds ,Cyclosporine ,Cyproterone, Interferon ,L-asparaginase
,Methotrexate, Pro carbazine ,Tamoxifen ,Vinblastine,
Vincristine
• CORTICOSTEROIDS
• ANALGESICS,Codeine ,Indomethacin, Oxyco done
• CARDIOVASCULAR AGENTS Methyldopa, Reserpine
,Propranolol ,Calcium channel blockers
• NEUROLOGIC AGENTS;Levodopa ,Phenobarbital
• GASTROINTESTINAL AGENTS;Cimetidine
• ANTIBIOTICS;Amphotericin B
 Medical Conditions That Present with
Psychiatric Symptoms
• Hyperthyroidism (thyrotoxicosis)/
Hypothyroidism (myxedema).
• Hypoglycemia/Hyperglycemia.
• Brain neoplasms/ Frontal /Parietal/Occipital
/Temporal/Cerebellar tumor.
• Head trauma.
• Acquired immunodeficiency syndrome (AIDS).
• Injuries requiring ambulatory surgical evaluation
and treatment (for example, wrist slashing).
• Hyponatremia.
 Medical Conditions That Present with
Psychiatric Symptoms
• Pancreatic carcinoma.
• Cushing's syndrome.
• Adrenocortical insufficiency (Addison's disease).
• Seizure disorder.
• Hyperparathyroidism/Hypoparathyroidism.
• Systemic lupus erythematosus. Multiple sclerosis.
• Acute intermittent porphyria.
• Hepatic encephalopathy.
 Medical Conditions That Present with
Psychiatric Symptoms
• Injuries requiring inpatient surgical evaluation
and treatment (e.g., suicide attempts, self-
mutilation.
• Pheochromocytoma, Wilson's disease,
Huntington's disease.
• Vitamin deficiencies Thiamine, Nicotinamide,
Pyridoxine. Vitamin B12.
• Tertiary syphilis.
C-L Psychiatry in Special Situations
• Intensive Care Units (ICUs) (depression or anxiety,
delirium).
• Hemodialysis Units. 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.
• Surgical Units, depression or anxiety, delirium. The
factors that contribute to an improved outcome for surgery
are informed consent and education so that patients know
what they can expect to feel, where they will be.
 Psycho-Oncology
• 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 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.
Terima kasih
 References
• Blumenfield, Michael; Strain, James J.Psycho somatic Medicine , 1st
Edition,2006 Lippincott Williams & Wilkins.
• Sadock, Benjamin James; Sadock, Virginia Alcott, Kaplan & Sadock's
Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th
Edition,2007 Lippincott Williams & Wilkins
• James J. Amos,Robert G. Robinson,PaulW. Penningroth Chair
Psychosomatic Medicine,An Introduction to Consultation-Liaison
Psychiatry , Cambridge University Press 2010 ,Department of Psychiatry,
University of Iowa, Iowa City, Iowa, USA
• Theodore A. Stern, M.D.Gregory L. Fricchione, M.D. Massachusetts
General Hospital, Handbook of General Hospital Psychiatry,Sixth
Edition,2010.SAUNDERS.