A 12-year-old girl with no formal past psychiatric history was admitted to the pediatric service with the chief complaint of inability to walk. She had been in her usual state of health until just days before admission when, while running during an activity at her overnight camp, she fell and hurt her ankle. She was brought to the camp infirmary where the nurse diagnosed a minor ankle sprain. However, by the next morning, the patient was unable to stand or bear any weight, and she was transferred by ambulance to the hospital near her home.
Neurological evaluation revealed full motor strength in all extremities and intact sensation. MRI scan, electromyograms, and CSF fluid analysis (biochemical, microbiological, and cytological) from the lumbar puncture were normal and unremarkable. Family history was notable in that the patient's mother had suffered a broken leg earlier in the spring but had since made a full recovery. The pediatric service was prepared to discharge the patient, but the patient remained unable to walk. Psychiatry was therefore consulted to rule out a psychogenic component to the patient's presentation and assist in identifying the appropriate disposition for the patient from the hospital.
In this case, physical therapy, treatment team meetings with family, and daily visits with psychiatry were implemented. The option for transfer to an inpatient psychiatric unit with an ability to address medical issues was discussed and the patient was subsequently transferred.
In managing this consultation request, the psychiatric consultant had to first ascertain the anticipated duration of hospital stay for this child (given the lack of a definitive organic cause to explain the symptoms) and clarify with the team that the child and her family had been informed of the request for psychiatric involvement. The consultant agreed that there likely was a psychogenic component to the child's presentation but needed to help the pediatric team appreciate the child's need for continued medical care (eg, physical therapy) to help her "regain" her strength, as well as her need for ongoing psychiatric treatment to address the reasons that she felt she could not walk.
The consultant might also have considered facilitating a discussion of the unconscious nature of the child's problems to deflect some of the angry feelings that members of the pediatric team may have experienced, such as "she's faking," or "she's taking up the time we could devote to someone who is really sick!"4,5
With all consultations, treatment recommendations should be clear and concise. Lengthy notes with complex psychiatric formulations will be less valuable to the requesting services than suggestions for multidisciplinary approaches to address the issues that triggered the consultation request. In most circumstances, the consultation service provides assistance to the primary treatment team but does not assume primary responsibility or care for the patient unless the patient is transferred to a psychiatric setting. This process ameliorates the potential for unrealistic expectations of the treatment team by patient and family.
Finally, all recommended interventions should be discussed and agreed upon by the entire team before discussion with the family or treatment implementation. These practices can prevent the division of responsibility and emotional responses to the patient among different teams caring for the same patient. A notable exception to these limits includes psychiatric disposition planning. Because insurance regulations, approval processes, and available psychiatric transfer locations are rarely the purview of treaters other than those with psychiatric responsibility, the psychiatric consultant usually assumes substantially more responsibility in this arena.CASE VIGNETTE
A 16-year-old girl with no psychiatric history was brought to the hospital after a motor vehicle accident in which she was a passenger. She was not wearing a seatbelt, and she experienced bilateral tibia/fibula fractures that required open reduction and a right distal radial fracture. The driver, her 18-year-old boyfriend, suffered only minor injuries. At presentation the patient's toxic screen was negative. The nurses noted that the patient frequently lay in bed with the covers pulled over her head, and psychiatric consultation was requested to assess for anxiety and depression.
On evaluation, the patient reported ongoing nightmares of the accident that she remembered in detail. She found herself ruminating about the events leading up to the accident; these thoughts made her extremely anxious. The pediatric service felt somewhat frustrated and angry that she did not recognize how lucky she was. She remained reluctant to speak about the accident because she found it too painful to remember. She also refused to see her boyfriend or any of her other friends, and she steadfastly refused to participate in physical therapy and, eventually, even to eat.
After an assessment by the psychiatrist, a complex acute stress reaction, which required more specialized services, was diagnosed, and she was transferred to a psychiatric facility with physical rehabilitation capacity.
In addition to her physical injuries, this patient sustained psychological trauma that required specialized care and attention. She evoked feelings of anger on the part of her treatment team because she could not see how minor her physical injuries were given the potential severity of her accident.
In a case such as this, psychoeducation, including defining and differentiating acute stress reactions and posttraumatic stress disorder (PTSD) for the patient, the family, and the nonpsychiatric medical team, may be helpful. In particular, the consultant can explicitly stress that the severity of the nonpsychiatric injuries (or lack thereof) does not always correlate with the degree of emotional or affective response or subsequent psychiatric sequelae.6
Increasingly, medical centers with multiple specialty services are incorporating child psychiatric consultants who subspecialize in consultation and liaison to fields as diverse as pediatric gastroenterology, cystic fibrosis, epilepsy, pediatric hematology and oncology, and organ transplantation.3 This subspecialization has led to new findings that are both specific to the disease processes being considered and generalizable to other medical predicaments. For example, some time ago it was observed that children and adolescents who survive malignancies through aggressive and often noxious treatment regimens are at risk for the development of PTSD and other anxiety and cognitive disorders later in life.7 This research has now been generalized to include examination for similar risks in solid organ transplantation. Current studies suggest that posttraumatic symptoms are more likely to develop if patients sense that their predicament is dire, regardless of the actual state of their health.8Conclusions
Child and adolescent psychosomatic medicine involves a rich mixture of psychosocial, cultural, and biological concerns embroiled in the increasingly complex world of modern medical care. The pediatric consultation-liaison psychiatrist must take into consideration the patient's disease, the team responsible for treating the patient, the patient's family, the socio-cultural milieu, and possible comorbid psychiatric illnesses. In addition, for the child and adolescent psychiatrist who serves as a consultant, psychotherapeutic, biological, and multisystemic interventions all require equal consideration and careful implementation firmly grounded in a developmental context.