CONSULTATION LIAISON PSYCHIATRY

O.K. NARAYANANKUTTY

M. D. (Psych-A. F. M. C.)

Consultant Psychiatrist

Cannanore - 670002
INTRODUCTION
 The concept of Consultation Liaison Psychiatry is not at all a new one. In the olden pre-specialization days, the family physician would verbally liaison with the superintendent of the mental hospital and seek help for the management and care of their "hysterical" or "emotionally disturbed" or even "nervous breakdown" cases. The idea was to care for his patient without stigmatizing him.
 Gradually as specialization became fashionable, the general practitioner began to seek the proper consultations with qualified psychiatrists, seeking not just his guidance, but treating him conjointly with the psychiatrist, who now had direct access to the patient. By the 1960's, the role of a psychiatrist in the heal care team became well established and the term "Liaison Psychiatry" was coined.
 Today, in most progressive primary health care centers, there has been a growing trend for psychiatrists to establish formal attachments, whether such centers are isolated primary health care centers; whether they are large teaching institution complexes with attached general hospitals; or they are private nursing homes providing overall health care services in their communities.
 Even among private practitioners the concept of liaising with psychiatrists has become popular, because the family physicians have become aware of the secondary gains, both the physician, and the psychiatrist derive by working together, to accord better health care facility to their patient.
 Similarly the other disciplines of medicine (surgeons, paediatricians, obstetricians, geriatricians), also realized the benefit of liaison psychiatry, and began to refer their cases.
 The most recent addition in this list has been the role of a liaison psychiatrist in the team managing organ transplant centers, intensive and cardiac care centers; crisis intervention (suicide and substance abuse) centers; and hospitals caring for the terminally ill patient.
 In all these centers, the referring doctor plays a pivotal role of referring, conjointly assessing, diagnosing and deciding upon the management. which then continues, in periodic consultations with and under the guidance of the psychiatrist. Management of any crisis during this period can also become easy.
 Confidence gained by sharing doubts about the ongoing management of difficult patients results in better patient care.
 If one goes through the literature of the last 10 years, one gets a total picture of how the importance of liaison psychiatry has grown with the years in the management of posttraumatic stress disorders, violence and aggression; battered wives and child sexual abuse.
 Charlesworth et al (1984) found that group-based stress management and relaxation programmes conducted at work-site can be effective in a modest lowering of blood pressure.
 Thus can appreciate that liaison psychiatry should definitely be established as separate service.
 JUSTIFICATION
 No one can deny the interaction between somatic disease and psychological states they affect each other, and can be divided into three categories;
1) The influence of somatic diseases on the mind.
2) Somatic symptoms of anxiety (palpitations), hysteria (paralyses & Fits), and depression (anorexia and cephalalgia).
3) Psychological factors affecting somatic disorders, also called psychophysiological or psychosomatic disorders, like asthma, hypertension, rheumatiod arthritis, peptic ulcer and many more. Most of these psychophysiological conditions are precipitated by "life events" which are stressful psychologically and therefore call for a holistic approach to patient care.
 Since SELYE first gave us an insight about how stress can affect the mind and the body, many retrospective studies have corroborated that stressful situations affect the mind and body.
 Nearly 60-70% of first consultations by the general practitioners are patients suffering from some form of psychological disorder, serious enough to warrant attention and treatment.
 In therefore stands to reason, that if the patient is to derive maximum benefit, all disciplines of medicine should be made easily available and accessible for optimum benefit.
 Some useful models for Liaison psychiatry are No.1. the O. P. D. model No.2. selected Consultation model and No. 3 joint team Consultation model.
UTILITY OF LIAISON PSYCHIATRY IN VARIOUS SETTINGS
1. Utility in Primary Health Care Settings:
 The traditional method of the general practitioner referring the patient to the psychiatrist, and sharing the responsibility of management conjointly, is being replaced by the more modern method of liaising, which consists of the psychiatrist being invited to work directly in the consulting chamber or health center with the general practitioner, or the whole primary health care team. Such liaison attachments are boon for patients, though very time consuming for the consultant. The main bulk of the referral comprises of somatoform disorders, depression, anxiety neuroses, hypochondriasis, and patients with suicidal attempt. Certain types of psychiatrically diagnosable patients like phobics, paranoids, socially deteriorating schizophrenics and chronic alcoholics have a very poor motivation to consult even the general practitioner, and therefore rarely seen by the liaison psychiatrist in such a set up. It therefore requires a significant acumen and diagnosing skill on the part of general practitioner to vigilantly refer such a patient to the psychiatrist. In private practice, referral to the liaison psychiatrist, is even rarer, because of the stigma attached.
 Summarizing his study on 15,000 patients, Shepherd (1974) concluded:
1) 14% consulted their G. P. for some form of disorder diagnosable as a psychiatric disorder. Of these, hardly 1:20 patients were referred to the mental health facility..
2) Large proportion of psychiatric morbidity encountered in family practice is made up of chronically sick patients with a very poor prognosis.
3) Rather than manifesting as frank emotional disorders, they usually were associated with general morbidity (somatizations).
 Stolly & Krupinski (1969) in Australia & Strozka et al (1969) in Austria had reported similar findings.
 Psychiatric morbidity is much higher among the office patients of family practitioners.
 Shepherd (1966) recorded 63% neurotics, 4% character distorders & 4% psychotics in a study of office patients.
 Psychiatric patients not only consult more frequently and maintain a high level of demand for medical attention, but also presented with more physical symptoms and are therefore left undiagnosed in medical and surgical wards. Eastwood and Trevelyan (1972), Goldberg and Blackwell (1970) found that 33% of such cases unless screened with the help of specific questionairres remain undiagnosed. 80% of chronic neurotics usually suffer from depression snd anxiety states, a majority of them, females (Cooper 1072).
 Social status and social class too, have a bearing on the prevalence of psychiatric morbidity (Haris(1955); Brown et al (1975).
 Brown et al (1975). Cooper &Sylph (1973); Weissman & Paykal (1974) have established a relationship between psychiatric morbidity and social functioning. In such cases, a liaison psychiatrist with his team can be of great help to the primary health care team.
 Zoccolilo & Cloninger (1986) mooted the idea that somatoform disorder is heritable, with both general and social factors playing a role. Many of the patients manifesting chronic somatic problems are of psychological origin which can be treated by a liaison psychiatrist and family physicians together.
2) Utility in Teaching Hospitals & General Nursing Homes
 In this setting, the function of a liaison psychiatrist is not only to diagnose and advice on patient management, but also to actively treat the patients referred to him from the various other disciplines to his department; teach doctors, nurses and wherever available, the psychiatric social workers; and in close collaboration with the departments of other disciplines, chalk out some research programmes which would help to enhance the image and utility of liaison psychiatry.
 The diagnostic skill of a liaison psychiatrist though essential should be based on thorough knowledge, does not cover the all ground. Through a detailed first interview and several subsequent clinical observation, the psychiatrist and his team should study the basic  personality of the patient, his defence mechanisms, and copings kills, his socio-economic background, his familial and developmental (from early childhood) background and the present psychological and familiar background. Once the patient's and psychiatric and desorder as related to the pshysical illness is established, and a detailed picture of the familial and psychosocio- economic factors is obtained, therapeutic intervention can be recommended and undertaken.
 In their studies Kimball (1975) Spaudling (1977), Enelow & Swisher (1979) emphasized the importance of collecting and intergrating a comprehensive data of the above mentioned factors affecting the patient's health. This would be practicable only if a team approach is taken, otherwise, it would be very time consuming.
 The management skill of liaison psychiatrist is put to test when he not only has to handle the treatment of the patient, but also has to train the referring doctors, medical students, nurses, and family members on how to manage the patient.
 Any one or several in combination, of the treatment modalities can be used. Whether it is short-term, or long term treatment depends upon the settings in which the patient is treated (acute myocardial infarction, intensive care, burns, carcinoma or other  chronically sick and terminal cases), the patient's co-operation and the ability to accept the help, and the type of illness for which the patient seeks help.
 Most commonly used techniques in our Indian teaching hospitals are short term, and long term psychotherapies, behaviour therapies, reality based problem solving, and wherever possible, patient counseling by professional counselors. 
 Formal teaching about liaison psychiatry skills, and research in the field of liaison psychiatry are highly neglected, and it is hoped it will soon be undertaken in all most all teaching hospitals.
 I firmly believe that the liaison psychiatrist requires a certain type of skill and co-ordinating capacity to successfully handle his job for maximum patient benefit.
 3. Utility in Social Service Organization
  There is very great need for close liaison work between the social service organizations and a mental health team, working under the leadership psychiatrist.
 Bruce at al (1991) found a very close relationship between low socio - economic status, frank poverty, homelessness and diagnosable psychiatric disorders.
 It is the social service organizations, and governmental social service departments who have very easy access to such improverished populations, that harbor not only substance abusers, and antisocial elements, but also other undetected but diagnosable mental health problems. Under the leadership of a liaison psychiatrist, the mental health team and social work agencies can embark on early detection, early intervention, and preventive, mental health programmes.
 Other areas suitable for liaison psychiatry work are the various institutions for the visually, aurally, physically, socially and mentally handicapped children adults, run by voluntary or state social service organizations. There is tremendous scope in these areas to demonstrate how a humane and knowledgeable liaison psychiatrist can,by understanding the dynamic of the individual person's behaviour, help him to change his attitudes and beliefs, and interact better with others and enjoy better mental health. Many sources of his conflicts, frustrations, socio-psychological interactions can be improved through good counseling and other therapeutic techniques. 
 Liaison psychiatrist also can give useful services for antisocial persons in juvenile certified institution and prisons, by helping select patients with impulse control disorders, unmanageable aggression and fears.
 The not to say that every act of aggression of violence can and should be vindicated in this field. The liaison psychiatrist should not allow himself to be used either by the antisocial person, or his lawyer to shield and protect such a person from the law of the land.
 4. Utility in Variuos Subspecialities
 a) Paediatrics :
 Apart from the traditional psychological disturbances like phobias, psychophysiological problems encountered in paediatric wards, one very sensitive, Yet neglected area of paediatric emotional distress is fear of being seperated from the family, fear of dying, and fear of any surgical inervention.
 These young patients need to taught coping mechanism for dealing with this dilemma. They need to verbalize there fears to a good listener, and need to be told the practicable and realistic methods of dealing with this fears; they need truthful explanations which they can understand, and they need reassurance; and they dying need to be taught how to accept death without fear. The last is the most difficult task, even for an experienced liaison mental health worker. 
 b) Burns Wards :
 Here again, whether it is severally burnt dying person or a minor burns case, the fear and the pain in the initial stages, and the complicating dysfunctions and disfigurement, not to mention the discomfort of several invasive investigations, surgical interventions procedures, are constant source of anger, frustration, anxiety and even aggression in most cases
c) Substance abusers and deaddiction wards/centers :
 In these settings a part from crisis intervention phase of relieving delirium, violence, and perceptual disorders, the liaison psychiatrist has to undertake a complete biographical study of the addict, and treat him with various techniques at his disposal. In this effort, again, without the close collaboration of the primary health care team, and the liaison mental health care team management would be haphazard and useless.
d) The Geriatric wards and old peoples homes :
 Like every other subspeciality, Gerontology and Geriatric psychiatry are coming into their own. Here the emphasis is not on the curative aspect of therapy, as most of the cases are patients with degenerative lesions, but on improving the mental attitude of the geriatric patient.
 These patients are long past the age changing their attitudes, or learning new coping skills, but with adequate counseling and psychopharmacologycal help their life can be made happier and more comfortable Unconventional methods like pet therapy , music therapy and occupational therapy are being utilized by several mental health teams as adjuvants to make life happier for their geriatric patients.
e) Utility in the intensive care units and hospitals
Acute myocardial infarction patients, chronic Kochs' cases, patients dying of AIDS, Cancers or other terminal illness, react to the idea of death in differing manners.
Johnston (1985) postulates that a cardiologist liaising with a psychiatrist can accord better management care for his patients. The high risk " type-A" personality, the severe hypertensive and other healthy, but " high risk for cardiovascular disorders" clients can benefit from stress - reducing and attitude changing behaviour therapy and psychotherapy. During acute cardiovascular disorders, psychiatric intervention with psychotherapy and hynotherapy can reduce the pain and calm the apprehensive and anxious patient.
The dying young have to be taught coping skills to accept death; but most older patients pass though a definite sequence of steps with shifting defense mechanisms and emergence of undisguised strong feelings. They start off with the mechanism of denial (it just cannot be true), then indifference  ( I have no emotianal feelings towards dying), then anger (but why me), then bargaining (if I survive, I will give an offering or do charity for the poor, or help some other dying persons), then acute depression (I am helpless to cope with this hopeless situation), and finally equanimity and acceptence of the inevitable. Depending on how the patient dealt with other stressful life events earlier, that coping mechanism will be utilized for accepting death. The liaison psychiatrist can help the patient to utilize mature defense mechanism of sublimation  and intellectualization, to promote the concept of dying with dignity by accepting the inevitable, help the patient to maintain his dignity, by giving him every possible consideration and allowing him to make choices regarding the management of pain, body care, and giving him exclusive emotional and  moral support in his effort to face death.
The liaison mental health team can undertake the guidance of the liaison psychiatrist to ease the painful process of dying.
F) Utility in Organ Transplant Units
Here the reason for providing liaison psychiatric care is the same, it is the approach which differs. The psychiatrist has to deal with the psychological problems of a chronically sick patient, who already may have severe emotional problems, in addition to which there may be acute anxiety (When will be organ be available; will my body reject the organ; if it is rejected, what will be my chances of survival ; even if my body accepts the organ, will I ever be able to lead a normal life?). 
The liaison mental health team has to deal with all these anxieties , phobias and even aggression and prepare the recipient patient to go through the procedure with a reasonable sense of security and mental equanimity. 
Post-operatively the recipient passes through a different set of phobias, fears and anxieties , may be confusion, helplessness and a distorted body image. The liaison psychiatrist and his team, working under very adverse conditions of having to deal with a completely isolated person in a sterile environment has to restore the emotional stability and a self- assured good body image, by psychotherapy and counceling. 
G) Utility in some unconventional areas: Sports Medicine
Psychodynamic factors can and do influence the performance of individuals and teams, who are to be "motivated to win" the events for which they are selected. Athletic success depends upon the capacity to give free and full expression to aggression, at the same time, to respect the progress of other athletes. A skillful psychiatrist, liaising with the coach and other managing personal train them for first class  competitive sport and athletics by skillful professional listening, guidance and counseling . It has been established that a lot of aggression and hostility builds up among the high altitude  mountain climbers towards their team mates which disappears when they return to base, leading to a residuam of severe guilt feelings. These can be diffused by adequate briefings. 
Danial Begel (1992) over viewing scientific and nonscientific studies in sports psychiatry concluded that a liaison psychiatrist would have definite roll to play in sports medicine. Psychiatric research can help to understand the behaviour attitudes of  some athletes ,at the same time. Screen out the athletes with psychiatric disorders and substance abuse problems. Coleman (1989) found that many retired sportsman and athletes suffered from diagnosable (according to DSM - III-R criteria) mental disorders. Little (1969) established a relationship between injuries and  somatoform disorders and psychiatric illness among athletes .  
Space Shuttle Medicine :
Perhaps the most futuristic use of liaison psychiatry would be to pick up the challenge of dealing with stresses encountered by space voyagers and liaison with medical health care team of aerospace medicine. The psychological stresses encountered by the voyagers as a result of prolonged confinement in a very small area and the severeance from the earth's gravitational force and a sense of "weightlessness" may lead to acute psychosis, delusional states, aggression towards shuttle-mates, and a sense of helplessness which could adversely affect the efficient functioning of the voyager.
The liaison psychiatrist's job would be to mentally prepare such voyagers capable of functioning safely and effectively, screen out those whose coping skills for such delicate precision and stressful work were not reliable, and "debrief" and care for the mental health of returning voyagers. Such an arrangement could prove financially sound and human power wise, more beneficial in the long run.
CONCLUDING REMARKS
The concept and utility of Consultation Liaison Psychiatry has changed continuously over the past 50 years, from a passing informal discussion about cases between a family or general practitioner and a psychiatrist to conjoint management of psychophysiological disordered or neurotic or psychotic cases by the specialist concerned and the liaison psychiatrist, to more recently, preventive as well as therapeutic mental health care in diversified formal and informal areas. Working in close in collaboration with the health care teams of specialized and superspecialized disciplines of medicine, the liaison mental health team, under the guidance of an innovative liaison psychiatrist can offer positive mental health care, as well as therapeutic relief to psychologically distressed persons. 
Working in close collaboration with the physician and other health care personnel in sprots medicine and space shuttle medicine, the liaison psychiatrist can ensure positive mental health for the persons concerned bys adequate training, briefing and debriefing.
Liaison Psychiatry has indeed ramified far a field within the past 50 years.

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