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Handbook of Liaison Psychiatry
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Book description

Liaison psychiatry, the recognition and management of psychiatric problems in the general medical setting, is an essential component of many doctors' work. Depression, anxiety and somatization disorders occur in about 50% of cases presented to primary care physicians. The Handbook of Liaison Psychiatry was first published in 2007 and is a comprehensive reference book for this fast-growing subspecialty. A team of experts in the field cover the full range of issues, from establishing a service and outlining the commonest problems encountered in general hospitals and primary care, to assessment and treatment guidelines, working with specific units within the hospital setting, disaster planning and legal-ethical considerations. It will be essential reading for doctors and other professionals concerned with the psychological health of patients in acute general hospitals and in primary care.

Reviews

Review of the hardback:'The book could have been categorised by symptom, such as pain or depression. However, this would have led to a lot of repetition. … It has an excellent section on establishing a service, which is amusingly pragmatic. I also liked the 'How to do a referral guide', with carefully laid out steps that need to be taken. … There is an excellent index … All budding and established liaison psychiatrists should have this manual and medical libraries should stock it.'British Medical Journal

Review of the hardback:'It will be essential reading for liaison psychiatrists, liaison nurses, other members of the mental health team and services managers. It enthusiastically conveys the excitement and breadth of this developing subspecialty.'Clinical Medicine Journal of the Royal College of Physicians of London

Review of the hardback:'The setup and the extensive index makes it a very useful book for the practising CL psychiatrist. Because of its different character, this book is a good alternative for, or a welcome addition to, the existing American textbooks.'Journal of Psychosomatic Research

Review of the hardback:'This book is a very welcome addition to liaison psychiatry literature. It is the first really comprehensive textbook of liaison psychiatry by authors predominantly working in the UK; however, the inclusion of a number of eminent international contributors greatly enhances it. … Were I asked to recommend a single liaison psychiatry textbook for liaison psychiatrists and trainees it would now be this one.'The British Journal of Psychiatry

Review of the hardback:'… this book can be strongly recommended as a useful introduction to an important subject.'Journal of Mental Health

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Contents


Page 1 of 2


  • 1 - The development of general hospital psychiatry
    pp 3-23
  • View abstract

    Summary

    General hospital psychiatry is the practice of psychiatry in a particular type of medical setting, whilst liaison psychiatry, the principal focus of this chapter, refers to the clinical expertise and practice relating to psychological and psychiatric problems and treatments in patients presenting to general medical care. The practice of liaison psychiatry evolved in the first half of the twentieth century well before it was given the name. Hindsight allows us to see general hospital and liaison psychiatry services being established around the world, developing in response to local demands and in ways that reflected individual enthusiasms. Liaison psychiatry' is incomprehensible to fellow psychiatrists and to medical colleagues. It severely handicaps the task of publicizing a clinically important activity. Although the history of liaison psychiatry as a special interest (or sub-speciality) is rather brief and progress has been relatively slow, it is now well established and widely accepted.
  • 2 - Establishing a service
    pp 24-46
  • View abstract

    Summary

    The provision of liaison services is variable both in terms of the existence of specialized teams based in the general hospital and the model of service. This chapter is a useful starting point for trainees in psychiatry hoping to become consultants in liaison psychiatry and to establish a new unit. The need for a liaison psychiatry service must be established and this, together with feasibility and benefits of providing such a service, has to be clearly demonstrated in a business case to be submitted to the relevant funding bodies. Before any business case for a service can be written, it is important to have some idea of the likely numbers of referrals to the service so that these can be matched with resources. The advice and support of a more senior colleague in liaison psychiatry who may well be based in another town or city is likely to be beneficial.
  • 3 - Legal and ethical issues in liaison psychiatry
    pp 47-63
  • View abstract

    Summary

    Liaison psychiatrists are frequently asked to advise when patients refuse consent to medical intervention. This chapter aims to give practising clinicians a framework for understanding legal issues surrounding refusal of treatment in the general hospital context. Non-psychiatrists in general hospitals are unaware of the limitations of the mental health act (MHA) with respect to issues of non-consent, and may erroneously expect that it normally has a role where there is refusal of treatment for physical health in persons with mental disorder. Every adult who has reached the age of majority (18 years) has, a priori, the right and capacity to decide whether or not he/she will accept medical treatment, even if a refusal may risk permanent damage to his/her physical or mental health, or even lead to premature death. The chapter provides a series of case vignettes and commentaries with regard to law applied to clinical situations.
  • 4 - Understanding psychological reactions to physical illness
    pp 64-82
  • View abstract

    Summary

    People react to illness in a manner that reflects a complex and evolving interaction of several factors. Most illnesses, except the very trivial, require a period of adjustment and a re-appraisal of lifestyle, ability to work and engagement in leisure activities. Potentially fatal and rapidly progressive disease might be expected to result in more severe psychological reactions, but the evidence indicates that there is surprisingly little correlation between psychiatric morbidity and disease severity when this has been measured in a standardized manner. Metabolic changes accentuate the emotional response to illness. Effective communication is an essential element of good clinical practice. Conversely, poor communication is a source of frustration for patients, leading to uncertainty, resentment, anxiety and depression. Depression resulting from the emotional impact of an illness follows an appraisal of the implications that the illness has on relationships, lifestyle, work prospects, long-term disability and mortality.
  • 5 - Detection of psychiatric disorders in the general hospital
    pp 83-101
  • View abstract

    Summary

    Trainees in liaison psychiatry are frequently surprised to find that the detection and management of psychiatric disorders in the general hospital is a complex and time-consuming process. This chapter considers those aspects of psychiatric assessment that are unique to the general hospital, and offers guidance on the assessment of the most prevalent psychiatric symptoms. The assessment process starts as soon as the referral is received. Ideally, the referral should ask a specific question about a patient's psychological health, or ask for guidance on the psychological components of a more complex management problem. Many referrals to liaison psychiatry services are for patients in whom depression or anxiety are suspected. Physical illness is a predictor of completed suicide, so that an assessment of risk should form part of every patient evaluation. Rating scales can supplement information obtained during clinical interviews, whilst assessing medically ill patients.
  • 6 - The role of the nurse in liaison psychiatry
    pp 102-122
  • View abstract

    Summary

    This chapter outlines the development of mental health liaison nursing (MHLN). The role of the nurse within liaison psychiatry developed significantly throughout the 1990s, with many health service trusts employing mental health nurses to practise within the general hospital. Within the general hospital, MHLNs practise in a wide variety of settings focusing on a number of different clinical specialities. The overall aim is to make the skills of the mental health nurse available to patients who may be suffering from a variety of physical illnesses and somatic complaints. Through direct liaison activity and indirect consultation work, MHLNs can have a positive effect on the health and well-being of specific groups of patients, as well as enabling general hospital practitioners to focus on psychological issues, and allowing them to make mental health care a routine part of their practice.
  • 7 - Functional somatic syndromes
    pp 125-148
  • View abstract

    Summary

    The functional somatic syndromes (FSS) refer to a number of related syndromes that have been characterized by the reporting of somatic symptoms and resultant disability rather than on the evidence of underlying conventional disease processes. Chronic fatigue syndrome, irritable bowel syndrome and fibromyalgia have been more extensively researched than most other FSS which has led to specific pathophysiological mechanisms being advanced for each. There is limited data on the predisposing and precipitating factors in FSS. A history of childhood abuse is more common in those who suffer from irritable bowel syndrome, chronic fatigue syndrome, and fibromyalgia. Cognitive behavioural therapy and exercise therapy appear to lead to therapeutic change by tackling biological and psychosocial factors, whilst centrally acting drugs such as antidepressants can sometimes be helpful. For many of the less well recognized FSS, operationalized diagnostic criteria are lacking, as are high quality treatment trials.
  • 8 - Alcohol problems in the general hospital
    pp 149-179
  • View abstract

    Summary

    Liaison psychiatrists may have misgivings when surgeons and physicians refer patients with alcohol problems. Epidemiological overviews including meta-analyses have quantified the relationship of alcohol consumption to morbidity and mortality. Psychiatrists should be aware that alcohol dependence can obscure psychiatric diagnosis. In clinical practice, where a behaviour change is implicated, the diagnostic process is a first step in therapy. Liaison psychiatrists see many patients whose present physical symptoms have been attributed to depression or anxiety. Wernicke's syndrome is believed to be due to critical deprivation of thiamine in neurons in the mid-brain or thalamus. It often has a rapid onset following weeks of heavy drinking which have interfered with the absorption of thiamine from the intestine. It is possible that acamprosate or calcium homotaurinate acts to stabilize glutamate receptors left oversensitive in the newly abstinent alcohol-dependent patient.
  • 9 - Drug misuse in medical patients
    pp 180-220
  • View abstract

    Summary

    This chapter concentrates on illicit drugs and the misuse of prescribed medication. The more serious the substance problem, the more likely there are to be associated psychological, physical and social problems, which require a more intensive level of treatment intervention. Psychiatric disorders such as depression, anxiety, psychosis, eating disorders, and post-traumatic stress disorders are associated with the direct intoxicating effects of acute and chronic substance misuse and withdrawal syndromes, often within an inhospitable social environment. There is an increased risk of traumatic injury resulting in hospitalization among substance users. An awareness of and a high index of suspicion about drug use must pervade all aspects of practice, especially assessment. Pharmacotherapy is available for opiates, alcohol and nicotine. Substance users are heterogeneous, no single approach is universally effective, and evaluation of treatment outcome should be multidimensional.
  • 10 - Sexual problems in medical patients
    pp 221-244
  • View abstract

    Summary

    Sexual dysfunction is a common consequence of medical illness and should be considered in any medical patient undergoing a psychological assessment. The common sexual problem areas are: desire, arousal, orgasm, and pain. Taking a sexual history is a sensitive task. The clinician must make an objective assessment of sexual behaviour, while taking account of the emotional issues and personal values that the patient brings to the interview. Great care is needed here as patients may discuss such experiences for the first time and such disclosures arouse considerable emotion. Useful tests to investigate underlying problems are available. The phosphodiesterase-5 inhibitor sildenafil has revolutionized treatment of men with erectile difficulties of physical or psychological origin. Hormone replacement therapy in menopausal women is the main physical treatment that will enhance sexual function through its action on the vaginal epithelium and the vulval and clitoral erectile tissues.
  • 11 - Suicide and deliberate self-harm
    pp 245-269
  • View abstract

    Summary

    Suicide, as a term, appears easier to define, namely as a self-destructive behaviour with a fatal outcome. Deliberate self-harm (DSH) has been recognized as an increasing public health problem in many contemporary societies for some time. The link between DSH and suicide is a clear but complex one, with many of the factors associated with suicide also common to DSH. Several countries have implemented national suicide prevention strategies, including, for example, Finland, Norway, Australia, the USA and England. A key element of this strategy is the improved management of DSH patients presenting to general hospitals. This is discussed in this chapter, after consideration of the aetiology of suicide and DSH. All DSH patients should receive at least a brief psychosocial assessment, aimed at identifying those with severe mental illness, as well as those at risk of suicide or immediate repetition of DSH.
  • 12 - Delirium
    pp 270-289
  • View abstract

    Summary

    Delirium is frequent among medical and surgical patients and is one of the most common psychiatric complications, affecting 10-30% of patients in the general hospital (GH). One of the main clinical features of delirium include disturbance of consciousness affecting orientation and ability to focus and maintaining attention. Some of the possible causes of delirium are in themselves medical emergencies (e.g. electrolyte alterations, hypo-/hyperglycaemia), or could rapidly develop into emergencies. The consultation-liaison (C-L) is responsible for educating hospital staff, helping to develop guidelines and protocols, and working with the other clinicians in the management of the delirious patient. Therefore liaison, education of medical and nursing staff, and good working relationships and alliances with physicians, is particularly important in the management and prevention of delirium. Formal liaison activities should take place on the initiative of the C-L psychiatry team.
  • 13 - Childhood experiences
    pp 290-302
  • View abstract

    Summary

    Experiences in childhood can have a tremendous influence on wellbeing in adulthood, and on the ways in which illness presents in adulthood. Conversely, illness in a parent, and the way the illness is managed, can have a great impact on the children in the family. This chapter examines these two areas, examining the knowledge base and the implications for practice in adult liaison psychiatry. Child sexual abuse is the environmental factor which has the greatest influence on those areas of adult functioning which are of interest to the liaison psychiatrist. Mental health problems in childhood are common. Some of these conditions are short lived. However, many conditions persist, in varying form, into adulthood, including anxiety, depression, eating disorders and conduct disorder. Children bereaved of a parent have higher rates of morbidity, and substantial numbers meet diagnostic criteria for major depressive disorder in the first year after parental death.
  • 14 - Neurological disorders
    pp 305-364
  • View abstract

    Summary

    In practice the psychiatrist working in a clinical neurosciences centre is likely to have to address three main categories of clinical problems on a daily basis: patients with cognitive impairment, patients who present with neurological disease, and patients who present with physical symptoms. This chapter describes specific drug therapies, and concentrates on medical aspects of psychiatry. Careful clinical assessment reveals the diagnosis in the majority of patients. Psychiatrists should be able to perform a competent basic neurological examination as this often provides the crucial clues to a neuropsychiatric diagnosis. The chapter outlines the principles of assessment and management particularly in relation to commonly encountered conditions. However, the same rules of assessment apply whether it is the everyday work of assessing mood in a patient with multiple sclerosis (MS) or the rarely encountered assessment of a teenager with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS).
  • 15 - Cardiorespiratory disorders
    pp 365-389
  • View abstract

    Summary

    This chapter attempts to describe how psychosocial factors influence both cardiovascular and respiratory diseases. First, psychosocial factors may affect health-related behaviours such as smoking, diet, alcohol consumption, or physical activity, which in turn may influence the risk of coronary heart disease (CHD). Second, psychosocial factors may cause direct acute or chronic pathophysiological changes, possibly by their effect on neuroendocrine or immune systems. Third, access to and content of medical care may be influenced by social factors. The chapter explores psychological consequences of disorders such as CHD and chronic obstructive pulmonary disease (COPD). It discusses the psychological aspects of the transplantation of major organs such as heart and lung transplantations. In a study of 76 patients who were undergoing heart, heart and lung, or lung transplantation, 39% were suffering from psychiatric disorder and 58% reported sexual dysfunction.
  • 16 - Gastrointestinal disorders
    pp 390-415
  • View abstract

    Summary

    This chapter covers psychological issues and psychiatric morbidity in relation to diseases and conditions associated with the gastrointestinal (GI) tract. The two most common functional gastrointestinal disorders are irritable bowel syndrome and functional dyspepsia, and most work in relation to psychological factors has been carried out on individuals with these two conditions. Psychological factors play an important role in the development of certain functional gastrointestinal disorders, together with other physiological factors, and, as yet, other unidentified mechanisms. Psychological and psychiatric conditions are common in patients with gastrointestinal conditions. Psychological treatments and psychopharmacological agents are helpful in patients with moderate to severe functional gastrointestinal disease. Psychiatric conditions such as depression and anxiety should be treated if associated with physical disease as failure to treat results in poor quality of life and greater distress for the patient.
  • 17 - Liver disorders
    pp 416-431
  • View abstract

    Summary

    The association between diseases of the liver and psychiatric disturbance has been a neglected area of clinical research despite the observations of ancient Greek physicians, notably Galen and Hippocrates, who had no doubt of the importance of the liver's influence on the mind. The pattern of psychiatric symptoms of liver disease is greatly influenced by whether the liver disease is acute or chronic in nature. Fatigue has become recognized as being one of the most debilitating symptoms of chronic liver disease. Liver transplantation has transformed the prognosis of patients with end-stage liver disease. Patients with alcoholic liver disease should not be excluded from consideration for transplantation. Their outcome is just as good as that of patients transplanted for non-alcoholic liver disease. Drugs that have a high rate of hepatic clearance are largely cleared during their first passage through the liver, a phenomenon known as the first-pass effect.
  • 18 - Endocrine disorders
    pp 432-453
  • View abstract

    Summary

    This chapter reviews available data in relation to the characteristics and frequency of specific psychiatric syndromes in primary endocrine disturbances. Hypocalcaemia is considered to be the fundamental cause of the psychological symptoms. In asymptomatic patients with calcium levels at the lower limit of normal (partial parathyroid insufficiency), anxiety, depression and related symptoms may be episodic, precipitated by calcium deprivation. A double-blind trial of calcium vs. placebo in these patients was effective in reducing symptomatology. Hyperprolactinaemia is a frequent disturbance in clinical endocrinology, mostly due to prolactinomas in women. Psychiatric presentations in Cushing's syndrome are well substantiated. Depression has been documented in most studies, and clinical experience suggests that its assessment may be critical. Acromegaly, the disease due to overproduction of pituitary growth hormone, has been associated with psychiatric manifestations, but the existing documentation is limited and recent studies suggest lower rates of psychiatric morbidity.
  • 19 - Diabetes
    pp 454-473
  • View abstract

    Summary

    Diabetes mellitus is one of the most common chronic diseases worldwide and is characterized by chronic hyperglycaemia. Despite the high prevalence of diabetes in the general medical setting and good evidence that mental health problems are common and reduce life expectancy, the development of diabetes-specific liaison mental health services is sporadic and piecemeal. This chapter begins by giving an outline of the clinical features of diabetes. Depression is the most common psychiatric disorder observed in diabetes mellitus. The particular clinical problems that occur when patients have both diabetes mellitus and an eating disorder have been highlighted in case reports. Psychiatric disorders are common in diabetes and are associated with poor diabetes control, complications and increased mortality. Diabetes is also an important complication of major psychiatric illnesses such as schizophrenia. There have been recent developments to identify specific psychological problems in diabetes such as depression, diabetes-specific fears and binge eating.
  • 20 - HIV and AIDS
    pp 474-505
  • View abstract

    Summary

    In this chapter, the main aspects of HIV in the adult population and its effects on mental state are considered in terms of epidemiology, clinical manifestations and management. The psychiatric management of individuals with HIV and AIDS may be complicated by biological manifestations of infections which may contribute to altered behaviour. The mainstay of treatment of HIV/AIDS is with antiviral agents of three broad classes, nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors and protease inhibitors. The chapter lists out reported psychiatric side-effects of antiretroviral medications used in the treatment of HIV/AIDS. HIV and AIDS affect individuals, families, friends and the wider community in general. Hence the inclusion of social support is an essential adjunct to successful treatment of any HIV-associated psychiatric mortality. However, the appearance of resistance to antiretroviral medications may eventually result in increases in the prevalence of HIV and AIDS.
  • 21 - Renal disease
    pp 506-526
  • View abstract

    Summary

    Renal services tend to be specialist settings serving patients from a wide geographical area. Some patients in renal services have primary renal diseases such as inherited polycystic kidney disease, others have a multisystem disease. Patients receiving renal replacement therapy often form the bulk of referrals from renal medicine to a liaison psychiatry service. In common with other patients suffering chronic medical conditions, patients with renal disease have to face the loss of their pre-existing health and they may also suffer other losses such as loss of their job, curtailment of leisure activities, relationship breakdown and loss of self-esteem. The multiple losses experienced by patients with end-stage renal disease increase their vulnerability to grief-like adjustment reactions and depression. Thus, as with other medical conditions, diagnosis of depression in patients with renal disease should rely more heavily on the psychological features such as anhedonia, guilt, loss of self-esteem, hopelessness and suicidal ideation.
  • 22 - Musculo-skeletal disorders
    pp 527-546
  • View abstract

    Summary

    The term musculo-skeletal disorders describes a broad range of problems, with varying aetiologies and different natural histories, that are seen and treated in diverse treatment settings. Rheumatoid arthritis (RA) is a chronic inflammatory disorder of unknown aetiology affecting approximately 0.8% of the population, with women being affected three times more often than men. Psychiatric disorders are common in sufferers of rheumatoid arthritis. Complex cases may require more detailed assessment by a consultation-liaison psychiatrist. The diagnosis of fibromyalgia was initially proposed as a descriptive label for a clinical syndrome characterized by widespread pain and increased sensitivity to pressure at various anatomical locations known as tender points. Osteoarthritis (OA) is the most common of all joint diseases. Chronic low back pain (CLBP) and associated disability is a major health and socio-economic problem. Psychological treatments are effective in reducing psychological distress, and improving coping in subjects with a wide range of musculo-skeletal disorders.
  • 23 - Oncology
    pp 547-563
  • View abstract

    Summary

    Cancer is one of the most frightening diagnoses a doctor can convey to a patient. In the minds of most people malignancy is associated with severe pain, disfigurement, impaired quality of life and drastically reduced life expectancy. Although some other illnesses are associated with similar rates of psychiatric disorder, there are several factors, more commonly associated with malignancy, which the clinician needs to consider when trying to understand the development of psychological symptoms. Treatment for malignancy is often extremely unpleasant. Surgical intervention is required for many cancers at some stage. Radiotherapy and chemotherapy both have harmful effects on gonadal function and the consequences for sexual function and fertility can cause profound emotional distress, contributing to the development of a depressive disorder in the patient, partner or both. Patients with cancer may be attracted to non-conventional treatments such as aromatherapy, if they believe that orthodox medicine has little to offer them.

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