MIND & MEDICINE
Vo l u m e 2 Issue 1
Q u a r te r l y b u l l e t i n o f t h e D e p a r t m e n t o f P s yc h i a t r y
January-March
MAHATMA GANDHI MEDICAL COLLEGE & RESEARCH INSTITUTE ● PONDICHERRY ● INDIA
2014
In this issue:
CONSULTATION-LIAISON PSYCHIATRY ATTITUDES OF HEALTH CARE PROVIDERS TOWARDS MENTAL ILLNESS CASE REPORT (ORGANIC MOOD DISORDER)
The roots of psychosomatic medicine… A historical persepective Walter Bradford Cannon (1871 - 1945) Pioneer Physiologist of Human Emotions “Taught to deal with concrete and demonstrable bodily changes, we are likely to minimize or neglect the influence of an emotional upset, or to call the patient who complains of it "neurotic", perphaps tell him to "go home and forget it," and then be indifferent to the consequences. But emotional upsets have concrete and demonstrable effects in the organism.” - Walter Cannon, The Role of Emotion in Disease, 1936. Walter Cannon was one of America’s leading physiologists and most respected scientific statesmen of the 20th century. He collected evidence to show that when an animal is strongly aroused, the sympathetic division of its autonomic nervous system combines with the hormone adrenaline to mobilize the animal for an emergency response of “flight or fight.” The “sympathico-adrenal system” orchestrates changes in blood supply, sugar availability, and the blood’s clotting capacity in a marshalling of resources keyed to the “violent display of energy.” He summarized his initial findings in his path-breaking 1915 book, Bodily Changes in Pain, Hunger, Fear and Rage. Beginning in 1928, Cannon turned increasing attention to the clinical implications of his physiological discoveries, thus becoming a major authority in the emerging research field of psychosomatic medicine.
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EDITORS Dr. Abu Backer S Dr. Sivaprakash B A S S O C I AT E E D I T O R S Dr. Eswaran S Dr. Sukanto Sarkar
MIND & MEDICINE ● 2014 ● Volume 2 ● Issue 1
WHAT IS CONSULTATION-LIAISON PSYCHIATRY? Consultation-liaison (C-L) psychiatry as a subspecialty has been defined as the area of clinical psychiatry that encompasses clinical, teaching and research activities of psychiatrists and allied mental health professionals in the non-psychiatric divisions of a general hospital.1 C-L Psychiatry is derived conceptually from the old tradition, which advocates a ceaseless dynamic interaction between mind and body. It has brought psychiatry out of the mental asylums to the general hospitals and has also contributed significantly to the reduction of stigma that follows mental illness not only among members of the public but within the medical professionals and establishments also. Over the years C-L Psychiatry has contributed significantly to the growth of the psychiatry and has brought psychiatry very close to the advances in the medicine. It has also led to changes in the medical education and in the providing comprehensive management to the physically ill. According to Lipowski, the designation “Consultation-Liaison” reflects two interrelated roles of the consultants. “Consultation” refers to the provision of expert opinion about the diagnosis and advice on management regarding a patient's mental state and behavior at the request of another health professional. The term “Liaison” refers to linking up of groups for the purpose of effective collaboration. In the context of current C-L Psychiatry, liaison involves interpretation and mediation i.e., the consultant psychiatrist mediates between patients and members of the clinical team and between mental health and other health professionals, respectively.1–4 Further the consultation and liaison are mutually complementary. A consultation encompass three interlocked foci i.e., the patient, the consultee, and the therapeutic team. Hence for consultation to be most effective the consultant psychiatrist need to have personal contact with both the patient (including his family) and those taking care of him.1 However it, is important to understand the differences between the terms C-L Psychiatry and “Psychosomatic Medicine”. Psychosomatic medicine is a discipline that is concerned with “the interplay of biological and psychosocial factors in the development, course and outcome of all diseases.” Hence, some authors consider C-L Psychiatry as the practical/clinical arm or an applied form of psychosomatic medicine.5 The basic assumption of C-L Psychiatry is to integrate the information so as to provide optimal health care, which is sensitive to people's needs, mindful of prevention, and economically sound.1 References 1. 2. 3. 4. 5.
Lipowski ZJ. Current trends in consultation-liaison psychiatry. Can J Psychiatry. 1983;28:329–38. [PubMed: 6627188] Lipowski ZJ. Review of consultation psychiatry and psychosomatic medicine. I. General principles. Psychosom Med. 1967;29:153– 71. [PubMed: 5341979] Lipowski ZJ. Review of consultation psychiatry and psychosomatic medicine. II. Clinical aspects. Psychosom Med. 1967;29:201–24. [PubMed: 5340349] Lipowski ZJ. Consultation-liaison psychiatry in a general hospital. Compr Psychiatry. 1971;12:461–5. [PubMed: 5124938] Lipowski ZJ, Wise TN. History of consultation-liaison psychiatry. In: Wise MG, Rundell JR, editors. Textbook of Consultation Liaison Psychiatry. Washington, DC: American Psychiatric Publishing; 2002. pp. 3–11.
Source: Grover S. State of Consultation-Liaison Psychiatry in India: Current status and vision for future. Indian J Psychiatry. 2011 Jul-Sep; 53(3): 202–213.
Zbigniew J Lipowski, 1924–1997, Poland Dr. Lipowski was the 1991 recipient of the Academy of Psychosomatic Medicine’s Hackett Award. He was a mentor to many current leaders in consultation-liaison (C-L) psychiatry. His classic triad Review of Consultation Psychiatry and Psychosomatic Medicine is as relevant today as it was three decades ago. He devoted his career to the study and development of the field of psychosomatic medicine and liaison psychiatry, and he conducted extensive research on delirium. In 1970 he was elected Founding Fellow of the International College of Psychosomatic Medicine. A prolific writer, whose body of work includes over 100 publications and 4 textbooks in psychiatry, Dr. Lipowski is remembered for his humane approach to the mentally ill and for his numerous academic contributions to the medical community.
Department of Psychiatry
2
MGMCRI ● Pondicherry 607402
MIND & MEDICINE ● 2014 ● Volume 2 ● Issue 1
ATTITUDES OF HEALTH CARE PROVIDERS TOWARDS MENTAL ILLNESS People with mental illness have poorer physical health in part because medical professionals wrongly associate the physical symptoms experienced by the person with mental illness to the mental illness itself.1 This could be due to a phenomenon called ‘diagnostic overshadowing’2. Diagnostic overshadowing can be defined as the process by which the physical problems of a patient are over-shadowed by their psychiatric diagnosis.2 Diagnostic overshadowing is not unique to primary care and may occur in other areas of health services.3 People with schizophrenia are no more likely than the general population to be targeted for physical health checks despite increased physical health risks.4 Furthermore, people with schizophrenia are significantly less likely to receive important basic health checks such as blood pressure and cholesterol measurement.4 Medical practitioners also diagnose and treat people with mental illness differently. For example, people with mental illness are “substantially less likely to undergo coronary re-vascularisation procedures” compared to people without mental illness.5 Similarly, people with co-morbid mental illness and diabetes are less likely to be admitted to hospital for diabetic complications than those with no mental illness.6 Furthermore, people with mental illness may have less access to medical care7 such as obtaining a primary care physician7 as there is a need for community mental health centres to address barriers to primary medical care.8 People with mental illness may also feel unwelcome in certain medical settings because of staff attitudes.9 -10 The problem of knowledge: IGNORANCE
The problem of attitudes: PREJUDICE
STIGMA
The problem of behavior: DISCRIMINATION Although health care providers are thought to hold attitudes that are positive, compassionate and encouraging towards people with mental illness, this is often not the case. A large body of research on the attitudes of health care providers has repeatedly shown negative attitudes towards people with mental illness. This has been a problem and continues to be a problem in primary care mental health services and within the education of health care providers.11 References 1. 2.
Disability Rights Commission: Equal treatment-Closing the gap (Report No. 1). Great Britain 2006, . Jones S, Howard L, Thornicroft G: `Diagnostic overshadowing': worsen physical health care for people with mental illness. Acta Psychiatr Scand 2008, 118:169–173. 3. Kassam A, Glozier N, Leese M, et al: Development and responsiveness of a scale to measure clinicians' attitudes to people with mental illness (medical student version). Acta Psychiatr Scand 2010, 122:153-61 4. Roberts L, Roalfe A, Wilson S, Lester H: Physical health care of patients with schizophrenia in primary care: A comparative study. Fam Pract 2007, 24(1):34–40. 5. Druss BG, Bradford DW, Rosenheck RA, Radford MJ, Krumholz HM: Mental disorders and use of cardiovascular procedures after myocardial infarction. JAMA 2000, 283:506–511. 6. Sullivan G, Han X, Moore S, Kotrla K: Disparities in hospitalization for diabetes among persons with and without co-occurring mental disorders. Psychiatr Serv 2006, 57:1126–1131. 7. Druss BG, Rosenheck RA: Mental disorders and access to medical care in the United States. Am J Psychiatry 1998, 155:1775 8. Hodges B, Inch C, Silver I: Improving the psychiatric knowledge, skills, and attitudes of primary care physicians, 1950–2000: a review. Am J Psychiatry 2001, 158:1579–1586. 9. Mirabi M, Weinman ML, Magnetti SM, Keppler KN: Professional attitudes toward the chronic mentally ill. Psychiatr Serv 1985, 36:404–405. 10. Ucok A: Other people stigmatize but, what about us? Attitudes of mental health professionals towards patients with schizophrenia. Archives of Neuropsychiatry 2007, 44:108–116. 11. Mirabi M, Weinman ML, Magnetti SM, Keppler KN: Professional attitudes toward the chronic mentally ill. Psychiatr Serv 1985, 36:404–405. Source: Kassam A, Papish A, Modgill G, Patten S. The development and psychometric properties of a new scale to measure mental illness related stigma by health care providers: the Opening Minds Scale for Health Care Providers (OMS-HC). BMC Psychiatry. 2012;12:62.
Department of Psychiatry
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MGMCRI ● Pondicherry 607402
MIND & MEDICINE ● 2014 ● Volume 2 ● Issue 1
CASE REPORT Mrs. S, a 38 year-old woman presented with history of brief episodes of self-injurious behaviour for the past two years. According to her spouse, these episodes usually began with a shrill cry, followed by aggression, attempts to bite or strangulate herself, or jump from a height. During these episodes, she was conscious and able to obey simple verbal commands but seemed unable to reply to questions. She was drowsy after such episodes. The patient was unable to recall these behavioural disturbances. Most of these episodes were characterized by the same sequence of events. The patient had been prescribed several antiepileptic drugs before consulting us. However, these medications had no significant benefit. In addition, her spouse reported that she seemed to be dull, detached and uninterested in her daily chores over the last two years. She was often seen weeping and was withdrawn from her family members. She reported of sadness and expressed a wish to cease her life because of her poor health and various family stressors. She also complained of persistent low back ache, pain in multiple joints and irregular menstrual cycles. On examination, patient was pale and had widespread discolouration of the skin over the face and trunk. She had a hoarse voice. She appeared sad and anxious. She was admitted in the psychiatric ward for further evaluation. Referrals were made to General Medicine, Neurology, Orthopaedics, Dermatology, and Obstetrics and Gynaecology. Investigations revealed that she was anaemic, [haemoglobin = 8 mg/dl (N = 12-15.2 mg/dl)] and hypothyroid, with significant increase in TSH level [90.40 U/ml (N = 0.4-4.5 U/ml)] and anti-thyroid antibodies [135.09 IU/ml (N < 9 IU/ml). Bender Visual Motor Gestalt test suggested organic pathology. EEG showed no abnormalities. MRI of brain and spine showed lacunar infarcts in the frontal, temporal and occipital lobes and L4-L5 instability respectively. Diagnoses of organic depressive disorder (ICD-10 F06.32), complex partial seizures, hypothyroidism, anaemia, polyarthritis and tinea versicolor were made. In addition to antidepressant medication and supportive psychotherapy, treatments recommended by other specialties were also implemented. In view of the fact that seizures were not adequately controlled in the past, careful optimization of anticonvulsant medication was ensured. The patient had no further episodes of seizures in the ward. At discharge, she reported of improvement in mood and general health. This case is a typical example of mental-physical comorbidity. Apart from complex pathophysiological interactions between various diseased bodily systems, an interplay between biological, psychological and social factors is apparent in this patient. It is well-known that depression has an adverse impact on general health outcomes. There is strong evidence that pro-inflammatory cytokines, endocrine factors, metabolic markers and peripheral growth factors play a role in the pathophysiology of depressive disorders.1 Depression and epilepsy are characterized by overlap of neurobiological mechanisms. The sex hormones also play an important role in both epilepsy and depression through the hippocampus.2 The relationship between epilepsy and depression appears to be bidirectional.3 In addition, current research shows evidence of elevated risk of depression in autoimmune diseases.4 The association between hypothyroidism and depression is well-known. Early detection and comprehensive management of mental-physical comorbidity can have a positive impact on overall health outcomes. Bibliography 1. 2. 3. 4.
Schmidt HD, Shelton RC, Duman RS. Functional biomarkers of depression: diagnosis, treatment, and pathophysiology. Neuropsychopharmacol Off Publ Am Coll Neuropsychopharmacol. 2011 Nov;36(12):2375–94. Cavanna AE, Cavanna S, Bertero L, Robertson MM. Depression in women with epilepsy: clinical and neurobiological aspects. Funct Neurol. 2009 Jun;24(2):83–7. Fiest KM, Dykeman J, Patten SB, Wiebe S, Kaplan GG, Maxwell CJ, et al. Depression in epilepsy: a systematic review and metaanalysis. Neurology. 2013 Feb 5;80(6):590–9. Renoir T, Hasebe K, Gray L. Mind and body: how the health of the body impacts on neuropsychiatry. Front Pharmacol. 2013;4:158.
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Department of Psychiatry
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MGMCRI ● Pondicherry 607402