Handbook of Liaison Psychiatry

Cover......Page 1
Half-title......Page 3
Title......Page 5
Copyright......Page 6
Contents......Page 7
List of contributors......Page 11
Preface......Page 15
Part I Basic skills......Page 17
1 The development of general hospital psychiatry......Page 19
Early history......Page 20
Nervous disorder......Page 21
General hospital specialist psychiatry......Page 22
Psychiatry during and after the Second World War (1939-1945)......Page 23
Consultation liaison......Page 24
The United States......Page 25
Liaison psychiatry in the UK......Page 26
International comparisons......Page 28
The wide variation in current practice......Page 29
Clinical methods: consultation and liaison......Page 30
Working in varied medical settings......Page 32
Working with other disciplines......Page 34
Teaching......Page 35
Conclusions......Page 36
References......Page 37
Introduction......Page 40
Whom to meet......Page 41
The discussions......Page 42
Estimating the demand......Page 43
Service model......Page 50
Unrestricted versus restricted service model......Page 51
Assessment service or assessment and intervention service......Page 52
Comprehensive service......Page 53
Skill mix......Page 54
Job description and outline of job plan for a consultant in liaison psychiatry......Page 55
Management and funding issues......Page 56
Business case......Page 58
Conclusions......Page 60
References......Page 61
Useful websites......Page 62
Statute law......Page 63
The role of the Mental Health Act (MHA) in the general hospital......Page 64
The use of the medical holding order......Page 65
Section 63......Page 66
The use of the place of safety order and the role of the police......Page 67
The Common Law......Page 68
Assumption of capacity in adults......Page 69
The situation for minors......Page 70
Duty of care......Page 71
The Mental Capacity Act 2005......Page 72
Advanced decisions......Page 73
The law applied to clinical situations......Page 74
Patient refusing medical intervention after deliberate self-harm......Page 75
Comment......Page 76
Best interests in an incapacitated dying man......Page 77
References......Page 78
Coping strategies......Page 80
Personal factors......Page 81
Nature of the illness......Page 83
Drug treatment......Page 84
Other physical factors......Page 85
Communication......Page 86
Stress and previous psychiatric illness......Page 87
Anxiety disorders......Page 88
Depressive disorders......Page 90
Sexual dysfunction......Page 93
Eating disorders......Page 94
Abnormal illness behaviour......Page 95
References......Page 97
Information gathering......Page 99
Interviewing the patient......Page 100
Common disorders......Page 102
Depression......Page 104
Anxiety......Page 107
Treatment......Page 110
Psychosis......Page 111
Questionnaires......Page 112
Symptom Checklist 90 and Brief Symptom Inventory......Page 113
References......Page 114
Introduction......Page 118
The development of mental health liaison nursing......Page 119
The practice of mental health liaison nursing......Page 120
Core skills and competencies......Page 121
Self-harm and suicide prevention......Page 123
Risk assessment......Page 126
Individuals with specific physical illness......Page 129
Conclusion......Page 133
Intervention......Page 134
References......Page 135
Part II Common psychiatric problems across the general hospital......Page 139
Conceptual issues......Page 141
Symptomatic overlap......Page 143
Epidemiology......Page 145
Gender......Page 146
Difficulties in the doctor-patient relationship......Page 147
Genetics......Page 148
Childhood experiences......Page 149
Maintaining factors......Page 150
Neuroendocrine changes......Page 151
Central dysfunction......Page 152
Illness beliefs......Page 153
Social factors......Page 154
Fibromyalgia......Page 155
Other functional somatic syndromes......Page 156
references......Page 157
Alcohol-related diseases......Page 165
The concept of hazardous drinking......Page 167
Diagnosis as the first step in therapy......Page 168
Box 8.2 The CAGE questions for screening for alcohol dependence (Ewing 1984).......Page 169
Blood-test markers......Page 170
Distinguishing primary anxiety and mood disorders......Page 172
Box 8.3 Patients frequently attribute withdrawal symptoms to other causes.......Page 173
Management of alcohol withdrawal......Page 174
Notes on type of medication for withdrawal......Page 175
The signs......Page 176
Effective interventions for alcohol problems......Page 177
'Brief intervention'......Page 179
Box 8.4 The acronym FRAMES captures the essence of the interventions commonly tested under the rubric 'brief intervention' and 'motivational interviewing'.......Page 180
Motivational interviewing......Page 181
Acamprosate......Page 182
Disulfiram......Page 183
Treating the depressed drinker......Page 184
The cardiovascular service......Page 185
Intoxicated patients threatening violence to themselves or others......Page 186
Brief interventions in the A&E setting......Page 187
A first seizure in adulthood......Page 188
Organizational issues......Page 189
References......Page 190
Introduction......Page 196
Diagnosis and classification......Page 197
Morbidity: health aspects......Page 198
Patients in acute general medical settings......Page 201
Psychiatric patients......Page 202
Patients attending obstetric and paediatric units......Page 203
Key issues......Page 204
The key principles underlying assessment......Page 205
Substance use......Page 208
The UK evidence base: outcome research......Page 210
Stimulants and cannabis......Page 212
Antidepressant medication......Page 213
Opiate abstinence syndrome......Page 214
Alcohol withdrawal syndromes......Page 216
The acutely disturbed patient......Page 217
Stimulants (amphetamine and cocaine)......Page 219
Sedatives......Page 220
Psychological interventions......Page 221
Residential rehabilitation and therapeutic communities......Page 223
Pregnant users......Page 224
Children and young people......Page 225
Older people......Page 226
Liaison with the police......Page 227
Conclusion......Page 230
References......Page 232
The anatomy and physiology of sex......Page 237
Common sexual problems......Page 238
Assessment of a sexual problem......Page 239
Sexual development......Page 240
Medical history......Page 241
Mental state examination......Page 242
Prevalence of sexual problems......Page 243
Sexual problems in medical patients......Page 244
Distinguishing medical from psychological aetiology......Page 245
Diabetes......Page 246
Cancer......Page 247
Genital and reproductive organs......Page 248
Prescribed drugs......Page 249
Transsexualism......Page 251
Screening investigations......Page 253
Physical treatments......Page 254
Psychological treatments......Page 255
References......Page 256
Introduction......Page 261
Deliberate self-harm......Page 262
Links between suicide and DSH......Page 263
Aetiology......Page 264
Psychiatric disorders......Page 265
General population risk factors......Page 266
Aetiological models of risk for DSH......Page 267
Social characteristics of suicidal behaviour......Page 268
Psychological models of suicidal behaviour......Page 269
Assessment......Page 270
Mentally ill......Page 272
Deliberate self-harm services......Page 273
Hospital management......Page 274
Treatment interventions......Page 275
Costs......Page 277
References......Page 278
Epidemiology and risk factors......Page 286
Clinical features, differential diagnosis, prognosis......Page 288
Diagnostic DSM and ICD definitions......Page 293
Find the cause......Page 295
Psychopharmacological intervention......Page 296
Non-pharmacological and environmental interventions......Page 298
Liaison issues......Page 299
References......Page 301
13 Childhood experiences......Page 306
Child abuse......Page 307
Eating disorders......Page 308
Physical illness, adjustment and somatization......Page 309
Drug and alcohol abuse......Page 310
Parental physical illness......Page 311
Maternal depression......Page 312
Childhood bereavement......Page 313
Implications for the adult liaison psychiatrist......Page 314
References......Page 315
Part III Working with specific units......Page 319
Introduction......Page 321
Clinical assessment......Page 322
History-taking......Page 323
Attention......Page 325
Memory......Page 326
Language......Page 327
Arithmetic......Page 328
Standard instruments......Page 329
Neurological examination......Page 330
Abnormalities of visual fields and eye movements......Page 331
Frontal release signs......Page 332
Sensory signs......Page 333
Diagnosis......Page 334
Investigations......Page 335
Huntington's disease......Page 339
Wilson's disease (hepatolenticular degeneration)......Page 340
Frontotemporal lobar degeneration (including Pick's disease)......Page 341
Infective dementias......Page 342
Inflammatory dementias......Page 343
Structural dementias......Page 344
'Pseudodementia'......Page 345
Amnestic syndromes......Page 347
Acquired brain injury......Page 348
In relation to prognosis......Page 352
Stroke......Page 353
Depression......Page 354
Emotionalism......Page 356
Executive function......Page 357
Parkinson's disease......Page 358
Multiple sclerosis......Page 360
Epilepsy......Page 362
Psychiatric aspects of epilepsy......Page 367
Tic disorders......Page 369
Dystonias......Page 370
Headache......Page 371
Somatoform and conversion disorders in neurology......Page 373
References......Page 375
Coronary heart disease......Page 381
Evidence for specific psychosocial risk factors......Page 382
Depression and anxiety......Page 383
Social network structure and quality of social support......Page 384
Prognostic implications of depression following MI......Page 385
Psychosocial interventions in coronary heart disease......Page 386
Practical advice on managing psychological factors......Page 387
Box 15.1 Cardiac rehabilitation: general points.......Page 388
Box 15.3 Cardiac rehabilitation: early post-discharge.......Page 389
Drug treatment in cardiovascular disease......Page 390
Respiratory disorders......Page 391
Psychological illness and COPD......Page 392
Box 15.4 Useful criteria for diagnosing patients with a physical illness suspected of having depression.......Page 394
The association of panic and asthma......Page 395
Dysfunctional breathing and hyperventilation......Page 396
Breathing retraining......Page 397
Drug treatment in patients with lung disease......Page 399
Peptic ulcer disease......Page 406
Peptic ulceration and psychological factors......Page 407
Box 16.1 Risk factors for peptic ulcer which have a behavioural component.......Page 408
Psychological factors......Page 409
Psychological treatment and self management......Page 411
Functional gastrointestinal disorders......Page 413
Prevalence......Page 415
Psychological factors......Page 417
Treatment......Page 420
Chronic pancreatitis......Page 421
Stomas......Page 423
Gastrointestinal cancer......Page 424
Palliative care......Page 425
References......Page 426
Psychiatric symptoms of liver disease......Page 432
Hepatic encephalopathy......Page 433
Depression......Page 434
Acute and chronic hepatitis......Page 435
Primary biliary cirrhosis......Page 436
Fatty liver......Page 437
Management of alcoholic liver disease......Page 438
Wilson's disease......Page 439
Liver transplantation......Page 440
Box 17.1 Guidelines for liver transplantation.......Page 441
Psychotropic drugs and liver disease......Page 443
Antipsychotics......Page 444
References......Page 445
Epidemiology......Page 448
General clinical aspects......Page 449
Hypothyroidism......Page 456
Hyperthyroidism......Page 457
Hyperparathyroidism......Page 458
Hypoparathyroidism......Page 460
Cushing's syndrome......Page 461
Addison's disease......Page 463
Phaeochromocytoma......Page 464
References......Page 465
Clincial features of diabetes mellitus......Page 470
Incidence of depression in diabetes......Page 472
Depression and complications......Page 473
Eating disorders......Page 474
Anxiety disorders......Page 475
Psychotic disorders......Page 476
Personality disorders......Page 477
Adjustment problems......Page 478
Family factors......Page 479
Psychotherapy......Page 480
Psychotherapy for type 2 diabetes......Page 481
Summary......Page 482
References......Page 483
Epidemiology of psychiatric morbidity in those infected with HIV......Page 490
Period of post-positive HIV test notification......Page 492
Initiation of anti-HIV or opportunistic infection therapy......Page 493
HIV and child psychiatry......Page 495
Organic and neuropsychiatric disorders in HIV......Page 496
HIV and psychosis......Page 499
Anxiety and related disorders......Page 500
Drug and alcohol misuse......Page 501
Assessment of the HIV liaison patient......Page 502
Pharmacotherapy......Page 503
SSRIs......Page 504
Antipsychotics......Page 506
Interactions between antiretroviral agents and psychotropics......Page 507
Psychological treatments......Page 508
Social interventions......Page 510
References......Page 511
Overview of renal medicine......Page 522
Renal replacement therapy: dialysis and transplantation......Page 523
Psychological issues facing patients with renal disease......Page 525
Awareness of own mortality......Page 526
Involvement of the family in medical issues......Page 527
Frequency of depression......Page 528
Causes and diagnosis of depression......Page 529
Adjustment disorders......Page 530
Organic disorders......Page 531
General issues......Page 532
Pharmacological therapy......Page 533
Psychosocial interventions......Page 535
Non-adherence......Page 536
Problems transferring adolescents to adult services......Page 537
References......Page 538
Rheumatoid arthritis......Page 543
Disability and depression......Page 544
Neuroticism......Page 545
Depression and illness cognitions......Page 546
Assessment and treatments of psychiatric disorders......Page 547
Treatment of psychiatric disorders in RA......Page 548
Prevalence of fibromyalgia and chronic widespread pain......Page 549
Aetiology of fibromyalgia......Page 550
Relationship of psychiatric disorders in fibromyalgia......Page 551
Clinical management......Page 552
Osteoarthritis......Page 554
Depression and psychological distress in chronic low back pain......Page 555
Treatment interventions......Page 556
References......Page 557
23 Oncology......Page 563
Nature of the illness......Page 564
Effects of treatment......Page 565
Other organic factors......Page 567
Previous stress and psychiatric disorder......Page 568
Communication with staff......Page 569
Screening for cancer......Page 570
Do psychological factors influence the prognosis?......Page 571
Psychiatric disorders and their management......Page 572
Emotional support......Page 573
Counselling......Page 574
Psychological therapies......Page 575
Physical treatments for depression......Page 576
References......Page 577
Introduction......Page 580
Public health issues......Page 581
Diet......Page 582
Psychological morbidity associated with diagnosis and treatment......Page 583
Quality-of-life studies......Page 585
Information......Page 588
Fears of recurrence......Page 589
Self-care behaviour......Page 591
High-risk behaviour: smoking......Page 592
Patient reaction to recurrence......Page 593
Appearance......Page 594
Social support......Page 595
Psychological interventions......Page 596
Conclusion......Page 598
References......Page 599
Context......Page 608
Models of coping in advanced disease......Page 609
History......Page 612
Depression......Page 613
Diagnosis......Page 614
Prevalence of depression in advanced disease......Page 615
Treatment of depression......Page 616
Choice of psychotropic medication......Page 617
Anxiety......Page 618
Management of anxiety......Page 619
Delirium......Page 620
Dementia......Page 621
Assessment of mental capacity......Page 622
Suicide and deliberate self-harm......Page 623
Box 25.1 Deliberate self-harm in palliative-care patients.......Page 624
Euthanasia and physician-assisted suicide......Page 625
References......Page 627
Introduction......Page 633
Psychosocial effects of cosmetic surgery......Page 635
Body dysmorphic disorder in psychiatric clinics......Page 638
Body dysmorphic disorder in cosmetic surgery clinics......Page 639
'DIY' cosmetic surgery......Page 642
Implications for cognitive-behaviour therapy......Page 643
Body sculpting......Page 644
References......Page 645
Introduction......Page 648
Menstruation......Page 649
Treatment issues......Page 651
Fertility treatments......Page 652
Pregnancy......Page 653
Mood disorders in pregnancy......Page 654
Treatment issues......Page 655
Treatment issues......Page 658
Schizophrenia and pregnancy......Page 662
Treatment issues......Page 663
Treatment issues......Page 664
Teenage pregnancy......Page 665
Abortion and miscarriage......Page 666
Foetal anomaly......Page 667
Childbirth: postnatal mood disorders......Page 668
Menopause......Page 669
Polycystic ovarian syndrome......Page 671
Pelvic pain......Page 672
Hormone replacement therapy......Page 673
Cervical smear and human papilloma virus......Page 674
Sexual dysfunction......Page 675
References......Page 676
Introduction......Page 689
Depression......Page 690
Post-traumatic stress disorder......Page 691
Delirium......Page 692
Acute stress reactions and adjustment disorders......Page 695
Overdoses and other suicide attempts......Page 697
'ICU psychosis' and 'ICU syndrome'......Page 698
Difficulties with weaning patients off mechanical ventilation......Page 699
Transfer to a general ward......Page 700
Depression......Page 701
Post-traumatic stress disorder......Page 702
Neurocognitive deficits......Page 704
Psychiatric problems in ICU staff......Page 705
Distress in relatives......Page 706
Different approaches to psychiatric liaison with ICU......Page 707
References......Page 708
Nature and prevalence of psychiatric sequelae following burn trauma......Page 713
Predictors of psychological reactions to burn trauma......Page 720
Self-inflicted burn trauma......Page 721
Relatives......Page 722
Early intervention......Page 723
Later intervention......Page 724
Providing a liaison psychiatry service to the burns unit......Page 725
References......Page 727
Psychogenic parasitosis......Page 730
Delusions of parasitosis (Ekbom's disease)......Page 731
Self-inflicted skin disorders......Page 733
Dermatitis artefacta......Page 734
Pruritus......Page 736
Body dysmorphic disorder or dysmorphophobia......Page 738
Pruritus and urticarias......Page 740
Psychogenic purpura syndromes......Page 741
Psoriasis......Page 742
Atopic dermatitis......Page 743
Psychological reactions to chronic dermatological or disfiguring conditions......Page 744
References......Page 745
The historical perspective and syphilophobia......Page 749
The prevalence of psychiatric morbidity in GUM clinics......Page 751
Psychotic illnesses......Page 753
Affective illnesses......Page 755
Anxiety, somatoform and hypochondriacal disorders......Page 756
Sexual dysfunction and assault......Page 758
Sex, society and guilt......Page 759
Epidemiological associations......Page 760
Sexual risk-taking behaviour......Page 761
Herpes genitalis......Page 762
Recognition of psychological distress and referral......Page 763
Clinical recommendations......Page 764
References......Page 765
Introduction......Page 767
Epidemiology and mode of presentation of patients with mental health and substance misuse problems in the ED......Page 768
Clinical skills for practising psychiatry in the ED......Page 769
Resourcing and managing the service......Page 771
Outcomes......Page 774
References......Page 776
Part IV Treatment......Page 777
Principles for drug selection......Page 779
Pharmacodynamics......Page 780
Phase I metabolism and cytochromes......Page 781
Genetic polymorphism......Page 782
Psychotropic drugs used in liaison psychiatry......Page 783
Antidepressants......Page 784
Combined serotonin and noradrenaline reuptake inhibitors (SNARIs)......Page 786
Selective inhibition of noradrenaline and dopamine......Page 787
Antagonism of postsynaptic 5HT2 receptors......Page 788
Unselective monoamine oxidase inhibitors (MAOIs)......Page 789
Risks and side-effects of antidepressants......Page 790
Antidepressants in pregnancy and the puerperium......Page 791
Depression and anxiety......Page 792
Neuroleptics......Page 793
Which neuroleptic should be chosen?......Page 794
Administration and dosage......Page 796
Neurologic side-effects......Page 797
Vegetative and cardiovascular side-effects......Page 798
Neuroleptic malignant syndrome......Page 800
Neuroleptics in pregnancy and the puerperium......Page 801
Special issues related to liaison settings......Page 802
Lithium......Page 803
Antiepileptics......Page 804
Benzodiazepines and related sedative drugs......Page 805
Cognition-improving drugs......Page 806
References......Page 808
Why psychological interventions?......Page 811
Box 34.2 Key aspects of the therapeutic alliance.......Page 812
The context of therapy......Page 813
Prevention......Page 814
Counselling......Page 815
Problem solving......Page 816
Relational therapies......Page 817
Psychodynamic therapy......Page 818
Interpersonal therapy......Page 819
Introduction......Page 820
Adaptation of cognitive therapy to work with people with physical illnesses......Page 822
Box 34.3 Cognitive factors in assessment of the physically ill.......Page 823
Resilience......Page 824
Conclusion......Page 825
References......Page 829
Introduction......Page 834
Initial assessment......Page 835
Management and progress......Page 836
Final thoughts......Page 837
Initial assessment......Page 838
Further information......Page 839
Referral information......Page 840
Initial assessment......Page 841
Pause for thought......Page 842
Referral information......Page 843
Initial assessment......Page 844
Final thoughts......Page 845
Pre-assessment......Page 846
Further information......Page 847
Final thoughts......Page 848
Pre-assessment......Page 849
Initial assessment......Page 850
Management and progress......Page 851
Referral information......Page 852
Initial assessment......Page 853
Management and progress......Page 854
Referral information......Page 855
Further information......Page 856
Initial assessment......Page 857
Summary......Page 858
Part V Different treatment settings......Page 861
Medically unexplained symptoms in primary care......Page 863
Working models of practice held by family doctors......Page 865
Routine care for patients with PMUS......Page 867
Symptom beliefs and outcome in observational studies......Page 868
The effectiveness of simple interventions for PMUS......Page 870
Cognitive-behaviour therapy and other similar therapist interventions for PMUS......Page 871
Reattribution for managing PMUS......Page 872
The effectiveness of reattribution for managing PMUS......Page 874
Modifications to reattribution to improve its efficacy and feasibility......Page 876
Practical approaches to dissemination......Page 877
Box 36.1 Advice for family doctors on the management of patients with chronic MUS.......Page 879
References......Page 880
Concepts and definitions......Page 887
Frequent attendance and psychiatric morbidity......Page 888
The association between frequent attendance and physical disorder......Page 896
The association between frequent attendance and psychosocial factors......Page 897
Frequent attendance and resource use......Page 899
The outcome of frequent attendance......Page 900
Frequent attendance and childhood adversity......Page 901
Frequent attendance and childhood illness experience......Page 902
Quantitative models of frequent attendance......Page 903
Qualitative and theoretical models of frequent attendance......Page 904
The evidence from research studies......Page 905
A pragmatic approach to intervention......Page 907
References......Page 908
Emergency plans......Page 912
Prevalence of psychiatric disorder......Page 913
Course of traumatic stress symptoms......Page 914
Intervention......Page 915
Single-session early interventions......Page 916
Multiple-session early psychosocial interventions......Page 918
Medication......Page 919
Box 38.2 Factors that contribute to a high-quality psychosocial disaster response.......Page 920
Box 38.3 Practical considerations in planning for a psychosocial disaster response.......Page 921
Immediate psychosocial response......Page 922
Box 38.4 Key psychosocial roles immediately following a disaster.......Page 923
References......Page 924
Other sources of information......Page 927
Index......Page 929