Hero

Videos

Slideshows

Articles

Podcasts

Poll

FROM THE ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY

Consultation-liaison (C-L) psychiatry is a major psychiatric subspecialty that, within general medical/surgical and academic medical and increasingly in primary care settings, serves as the “tip of the spear” for psychiatry. This metaphor reflects consultation-liaison’s place as the most forward clinical psychiatry service in the wider medical world and the opportunity to lead improvements in patient care in all medical services.

Consultation-liaison psychiatrists specialize in the diagnosis and management of psychiatric disorders that are comorbid with general medical/surgical illness. Examples include the psychiatric comorbidity of neurological illnesses (eg, Parkinson disease, multiple sclerosis, cerebrovascular disease), endocrinological illness (eg, diabetes mellitus, hyper- or hypothyroidism), rheumatic illness (eg, systemic lupus erythematosus, giant cell arteritis), and cardiovascular illness (eg, heart disease, vascular disease). In addition to psychiatric comorbidity, there is a broad area of psychiatric adverse effects of systemically administered medications (eg, corticosteroids, other immunomodulators, CNS-active agents) and the often complicated systemic medical and 

 of medications used for primary psychiatric illness (eg, anticonvulsants, lithium, antipsychotics, antidepressants).

The general medical context of consultation-liaison psychiatry practice means that the psychiatric illness profile differs from that of general psychiatry practice. The most common disorders in the general medical setting include dementia, delirium, other neurocognitive disorders (eg, the sequelae of traumatic brain injury), catatonia, substance use disorders, intoxication and withdrawal states, and medical complications of psychiatric interventions (eg, neuroleptic malignant syndrome, serotonin syndrome, medication toxicity states. adverse effects) as well as depressive, anxiety, and substance use disorders. The psychiatric illnesses that constitute much of general psychiatric practice are also seen by consultation-liaison psychiatrists when they are associated with a general medical illness (eg, melancholic/psychotic depressive disorders, acute manic states, acute psychotic states) and when they result from medical illness and the trauma of treatment (eg, acute stress disorder, PTSD following major surgery or intensive care).

Consultation-liaison psychiatrists are expert at the complex task of managing psychiatric illness in the context of the general hospital and the emergency department. The responsibility of the C-L psychiatrist is first to assure that the proper medical evaluation and management are accomplished for the medical stabilization of patients before providing the necessary psychiatric treatment in collaboration with the patient’s clinical team. The C-L psychiatrist then arranges for psychiatric disposition, if and when that is clinically indicated.

Current training models for C-L psychiatry include 2 or more months of core rotation in the standard psychiatry residency program. Following residency there is an additional full academic fellowship year for psychiatrists who wish to qualify for subspecialty board eligibility and certification in consultation-liaison psychiatry.

Modern C-L psychiatry has developed as a distinct model of psychiatric practice. Unlike the care of patients with serious mental illness in long-term inpatient psychiatric facilities or the care for high functioning psychiatric outpatients with psychotherapy, the C-L model 

from placing psychiatric services in general medical hospitals, which began in the mid-20th century. This innovation led to the development of the dual partnered concepts of “consultation” and “liaison” functions in hospital-based psychiatric practice. The consultation role refers to the direct care of the medical inpatient on request from the admitting physician, with recommendations for direct care and brief, in-hospital follow-up. In contradistinction, the liaison function refers to the psychiatrist sharing their understanding and interpretation of behavioral manifestations of psychiatric illness in medical/surgical patients and direct advice to medical and nursing services to improve the care of medical/surgical patients with comorbid psychiatric conditions.

Until recently, with its inpatient medical/surgical hospital heritage, C-L psychiatry was primarily hospital-based subspecialty, with the development of one-year fellowships in C-L psychiatry that were primarily inpatient-based. However, in the past 20 years, there has been an accelerating development of outpatient C-L models. This movement involves placing psychiatrists in outpatient specialty medical settings and in primary care, where specialty physicians and primary care physicians work together with psychiatrists to care for patients.

The development of psychiatry in the general hospital led to a movement to establish C-L psychiatry as a specific and differentiated subspecialty of psychiatry. In the US, this happened in 2003 with the establishment of the subspecialty board in psychosomatic medicine (a synonym of consultation-liaison psychiatry) and with the first 

 examinations offered in 2005. The subspecialty has thrived ever since.

We are now in a period of the rapid and robust development of C-L psychiatry, driven by an increasing awareness of the need to treat the whole patient as well as by increasing amounts of evidence that indicates the clinical and financial importance of better management of psychiatric illnesses in patients under general medical care. Two major medical journals, 

, are devoted specifically to C-L psychiatry scholarship.

There are a rapidly increasing number of C-L psychiatry fellowships. The leading national and international organization, the Academy of Consultation-Liaison Psychiatry (ACLP; 

) has almost 2000 members; the most recent annual meeting in San Diego, CA, attracted more than 1200 attendees-an all-time record. The next annual meeting is in Phoenix, AZ, in November 2020 (

) and promises to be even larger. This spectacular growth largely reflects the expansion of C-L psychiatry beyond academic medical centers into community and other non-academic hospitals.

Within the broader subspecialty of C-L psychiatry, there has been further differentiation to better serve the needs of specific types of patients. Examples include HIV psychiatry, transplant psychiatry, neuro-psychiatry, psycho-oncology, and cardiovascular psychiatry. While these areas are all within the scope of practice of C-L psychiatry, there are C-L psychiatrists whose primary identification is with these sub-subspecialty areas.

Building on the pioneering work of a cadre of C-L psychiatrists such as Wayne Katon, it is increasingly common for mental health services to be embedded within primary care in innovative ways. An example of such is collaborative care, which uses standardized clinical pathways and the extension of psychiatrists’ time by care managers. Care managers deliver care and monitor outcomes under psychiatric supervision. Collaborative care allows primary care services to provide high quality evidence-based care for large number of patients who may have mild to moderate psychiatric illness.

Consultation-liaison psychiatrists have also been early adopters of innovative communication and other technology for advancing patient care. These technologies include the provision of psychiatric care by video communication (telemedicine or telepsychiatry) and the creative use of the electronic health record to enhance psychiatric care for medical patients (eg, standardized clinical pathways, incorporation of outcome and rating measures).

There are many exciting opportunities for C-L psychiatry to improve patient care. It is now clear that all sizeable hospitals must have real-time access to psychiatric consultation (whether in-person or by telemedicine). New proactive and integrated models of inpatient C-L psychiatry are increasing the field’s reach and effectiveness. The incorporation of standard clinical approaches to psychiatric illnesses (eg, dementia, delirium, catatonia, traumatic brain injury) commonly encountered in C-L practice into electronic health records is ensuring better and safer care for patients with these high-acuity psychiatric illnesses. Greater availability of psychiatric consultation for medical outpatients, with standardized pathways for patients with the common psychiatric comorbid illnesses in primary care, is extending consultation-liaison care outside the hospital setting.

Consultation-liaison psychiatrists will also continue to lead in many areas. These include emerging areas of medical genomics in psychiatry, the monitoring of drug-drug interactions, and the management of behavioral and cognitive syndromes with complicated attributable systemic illness causes. Consequently, C-L psychiatry has an important place at the forefront of clinical, academic, and administrative leadership for psychiatry.

As clinical science and technology advances at an extraordinary pace, the value of C-L psychiatry within academic departments of psychiatry, and, indeed, in medical centers and medical schools, is being reflected in increased leadership and academic opportunities acting as the tip of the spear in psychiatry’s reintegration into the house of medicine.

is Chair, Department of Psychiatry, Baylor Scott & White Health, Central Texas Division, and Clinical Professor (Affiliated), College of Medicine, Texas A&M University Health Science Center, Temple, TX; 

is President, Academy of Consultation-Liaison Psychiatry and Professor of Psychological Medicine, University of Oxford, UK. They report no conflicts of interest concerning the subject matter of this article.

The “tip of the spear" metaphor reflects consultation-liaison’s place as the most forward clinical psychiatry service in the wider medical world that can lead improvements in patient care.

Consultation-Liaison Psychiatry: The Interface of Psychiatry and Other Medical Specialties

How much do you know about the innovative Proactive Consultation-Liaison (C-L) Psychiatry model?  Learn more and test your knowledge in this interactive quiz.

Exploring the Proactive Model

Mental illness accounts for a third of all years lived with disability and is associated with twice the relative risk of all-cause mortality. It also contributes to other leading causes of death such as heart disease, cancer, and cerebrovascular disease. An estimated 8 million deaths are attributable to mental disorders every year, with two-thirds due to comorbid medical illness.

Medical and psychiatric conditions are often interdependent with complex relationships between them. Medical conditions can cause mental illness by way of psychological and/or physiological effects; mental illness may make it difficult to engage in medical care due to barriers to access, poor motivation, functional impairment, and the like; and many medical and psychiatric conditions share common psychosocial determinants (eg, adverse childhood experiences).

A 56-year-old man with schizophrenia, hyperlipidemia, and hypertension who smokes a pack of cigarettes a day presents to the emergency department (ED) with chest pain. The diagnosis is acute coronary syndrome; he is admitted and scheduled for cardiac catheterization with possible angioplasty. On admission, blood pressure and cholesterol medications are continued. However, the primary team is unaware of his recent increase in risperidone dose from 2 mg qhs to 2 mg bid and starts him on 2 mg qhs. Nicotine replacement is not discussed.

The patient becomes distressed and increasingly paranoid about blood work and cardiac monitoring; he refuses cardiac catheterization for two days, saying, “I’ll think about it and let you know tomorrow.” On hospital day 3, he accuses his nurse of trying to poison him and refuses all medications. Agitated, he demands an against-medical-advice discharge and pushes the nurse, prompting security involvement, physical restraint, and sedation.

The medical team orders a constant companion (ie, sitter) and consults psychiatry. The patient is psychotic when evaluated by the consultation-liaison (C-L) psychiatrist the following day and found to lack capacity to refuse medical care. The patient’s cardiac enzymes normalize with medical treatment instead of cardiac catheterization while the hospital pursues temporary conservatorship. The patient waits another three days until a psychiatric hospital bed becomes available. He is in the psychiatric wing of the hospital for several days when he once again has chest pain at rest, and he is promptly transferred back to a medical wing.

A 46-year-old woman with chronic PTSD and a general mistrust of authority figures is admitted to the hospital with hematochezia, hypotension, and concern about a lower gastrointestinal bleed. On admission, the patient is identified on chart review by a proactive C-L service because she has a major psychiatric diagnosis and a documented history of psychiatric hospitalization.

During a brief evaluation by a psychiatric social worker the morning of hospital day 2, the patient is hypervigilant and ruminates about an anticipated colonoscopy; the social worker recommends that the primary team order a psychiatric consultation. A C-L psychiatrist sees the patient that day, begins to develop rapport with the patient, and helps to establish basic principles of trauma-informed care. Feeling more comfortable with her treatment team and the outlined plan of care, the patient undergoes colonoscopy without delay or incident; she is referred for mental health aftercare for treatment of PTSD.

These two cases contrast how major mental illness might be managed on a hospital medicine unit supported by traditional reactive C-L psychiatry versus by a proactive C-L model (

). The first case illustrates difficulties in communication and managing psychiatric illness. Ultimately, the patient’s care was compromised, the providers were exasperated, and the system incurred greater costs. The second case illustrates the potential value of meeting psychiatric needs from the time the patient arrives at the hospital. A multidisciplinary team identified patient-specific concerns and facilitated communication, which resulted in safe and efficient care.

Currently, more than a dozen sites around the country, including academic medical centers (eg, University of Rochester, Yale, University of Pennsylvania, Johns Hopkins, Northwestern) and community hospitals (eg, Sarasota Memorial Hospital), have fully established or pilot proactive C-L psychiatry services.

Psychiatric comorbidity among medicine and surgery inpatients is high, yet roughly half of these conditions go unrecognized. Based on claims data, 1 in 3 hospital patients has a psychiatric diagnosis;

 however, more than half of the patients admitted for non-psychiatric admission may have a diagnosis of mental illness.

 SimiCof hospital patients have a mentalN health concern deserving clinical attention.

 Patients with active psychiatric conditions undergo more procedures, receive more consultations of any kind, have longer durations of hospital stay, and are more likely to be discharged to a facility rather than home. They are also more likely to leave against medical advice and to have higher utilization of hospital care and other health care resources after discharge.

Although medical complexity may explain a portion of the poorer outcomes observed in patients with psychiatric comorbidity, other factors contribute as well. For example, patients with mental illness may receive substandard medical care because of a provider’s implicit bias or both patient and provider stigma associated with mental illness.

Psychiatric comorbidity in the hospital is overlooked by primary teams more than half the time, and only one in five medical inpatients with psychiatric comorbidity is in outpatient mental health treatment at the time of acute hospital care.

 Psychiatric consultation offers several benefits including enhanced medication and psychosocial interventions. Moreover, patients may be more likely to engage in care after speaking with a psychiatric consultant, especially where psychological issues contribute to care refusal.

Psychiatric consultation can lead to shorter duration of hospital stay and consequently to financial savings. This effect may be more pronounced when consultations occur earlier during hospitalization. Consultations also facilitate outpatient mental health referrals, which may include psychiatric admission or discharge to another level of mental health care and might also reduce 30-day readmission rates.

Proactive C-L psychiatry provides the benefits of traditional C-L psychiatry while simultaneously enriching the care (

). At Yale New Haven Hospital, the C-L service conducted a pilot study of embedded care, which led to shorter durations of hospital stay; in this program, a psychiatrist rounded daily with a hospital medicine team and provided real-time consultation and advice.

 Subsequently, the Behavioral Intervention Team (BIT) was started as a multidisciplinary form of embedded care. This team engaged the full complement of floor staff, not just the primary medical team.

 Its goals were to identify patients with behavioral issues that could compromise medical care delivery; ensure timely psychiatric treatment; and assist with psychiatric disposition, aftercare, and sitter use.

The 11-month pilot was shown to shorten the duration of stay among patients receiving BIT care compared with patients who had received non-BIT psychiatric consultation a year earlier (6.7 days versus 7.3 days). Moreover, the mean duration of stay for all patients was statistically lower than it was the preceding year. Based on the most conservative models, the BIT service is cost-neutral, but when the cost savings attributable to shorter hospital stays and increased revenue from backfill are considered, a net cost-benefit was shown with a return on investment of nearly 2 to 1.7 BIT was also rated favorably by roughly 9 out of 10 nurses. The financial benefits and staff satisfaction led to an expansion of BIT to serve all medicine units at Yale New Haven Hospital.

As adoption of this model continues to expand, several adaptations of proactive C-L psychiatry have been initiated. A recent systematic review identified two features of proactive C-L psychiatry consistently associated with reduced duration of stay

: a screening process aided by clinical expertise in mental health care and integration of mental health providers with primary services.

Team-based proactive C-L vis-Ã -vis traditional C-L

How does team-based proactive C-L differ from traditional C-L?

 Team-based proactive C-L differs in three ways that derive from modern advances in outpatient mental health care: it proactively identifies patients who might benefit from psychiatric care, employs a collaborative approach, and delivers care using a multidisciplinary team. The first of these seeks to prevent a cascade effect of medical and psychosocial complications that can accumulate in patients with psychiatric disorders.

 The second incorporates insights gleaned from outpatient models of integrated mental health care (eg, as in the IMPACT trial). The third draws on the value of the medical teamwork approach.

How does proactive C-L psychiatry identify mental health needs?

 Rather than providing universal consultation as in some earlier models, which yields a high false-negative rate, proactive C-L psychiatry uses a multi-step process.

The first step aims to achieve selective prevention by identifying patients with or at increased risk of active mental health issues that may interfere with medical care.

 A team member reviews the electronic health record (EHR) of each patient newly admitted to specific units, looking for evidence of psychiatric comorbidity.

Two chart-review approaches have been implemented to date. The original strategy is to have a mental health provider (eg, psychiatric nurse practitioner, clinical social worker) review the History & Physical, Problem List, and home Medications sections, supplemented by a review of notes pertaining to prior mental health care. A recently developed strategy involves an automated EHR reporting tool to screen large numbers of patients across a health care system.

 The result of either strategy is the creation of a daily screening list.

The second step aims to achieve the indicated prevention: a team member, drawing upon their mental health expertise, screens patients on the list by discussing each patient with the patient’s nurse and with the primary care team to identify active mental health concerns. The C-L team social worker also may briefly evaluate patients in person to supplement this process.

One of the following outcomes is chosen for each patient: no change in care is recommended; curbside advice to the primary team is provided without consultation; or full psychiatric consultation is requested. The C-L team member then writes a brief screening note for each patient reviewed and documents that the patient was screened, why the screen occurred (ie, what in the chart prompted the screen), and what the result of the screen was, including any care recommendations.

 The core members of the team are a C-L psychiatrist, a psychiatric nurse practitioner, and a clinical social worker. The psychiatrist is the team leader who oversees clinical care, provides consultations and, as often required in certain jurisdictions and by hospital policies, performs capacity assessments and completes medicolegal forms (eg, involuntary psychiatric commitment). The psychiatric nurse practitioner is the team quarterback who serves as the primary contact for primary teams, triages inquiries and new consultations, performs consultations, and assists with chart reviews and screens. The psychiatric social worker-ideally one with experience in acute psychiatric settings such as inpatient psychiatry or a psychiatric emergency department-is the team coordinator and collaborates with the medical social worker and care management, commonly sees patients with the psychiatrist or psychiatric nurse practitioner, arranges psychiatric aftercare, and performs chart reviews and screens.

How is proactive C-L psychiatry integrated with medicine?

 The overarching element of integration with this model is that it fosters personal relationships between floor staff and C-L team members. The team-based multidisciplinary nature of this model allows for unique collaboration with corresponding providers on the medical unit: physician to physician, nurse practitioner to advanced practice providers and nursing staff, and social worker to social worker and care manager. This kind of multi-level interdisciplinary collaboration overcomes many systemic, referrer, and patient-specific barriers to accessing psychiatric care.

More than a dozen US hospitals have adopted a proactive C-L model. Over the past several years, interest in piloting this model across the country has been growing across the US. We are routinely solicited for information about the model and are increasingly working with institutions who have laid the preliminary groundwork and developed business plans in preparation for launching a proactive C-L program.

Questions remain about several aspects of potential value offered by this model of care, including reduction in cost of sitters, staff turnover, and 30-day readmission rates. Likewise, we need to understand the scope of potential benefits related to patient experience and outcomes, staff satisfaction, unit-based teamwork, work-life quality of care providers, and the culture shift that embraces the interconnectedness of medical and mental health.

The ongoing HOME study in the UK is a randomized hospital-based trial currently looking at the efficacy of proactive C-L psychiatry among older adult inpatients.

 Similar trials in the US are needed and would do well to consider different age groups, hospital settings, and patient mixes.

Proactive C-L is uniquely suited to tackle the Quadruple Aim of patient care: enhancing care experience, improving population health, reducing health care costs, and improving work life of health care providers.

 This model reaches more patients and delivers a broader-base of care to patients. It also offers the promise of comprehensive vertical integration with outpatient services.

Early evidence suggests that proactive C-L psychiatry can shorten the duration of hospital stays, which more than offsets the cost of providing this enhanced care. Perhaps most immediately evident to those who have worked within this model of care, is the near-unanimous satisfaction from medical and nursing staff. Ultimately, in this era of value-based care, team-based proactive C-L psychiatry is poised to enhance the overall value to patient care in the general hospital.

Dr Oldham is Assistant Professor of Psychiatry, Dr Chahal is Fellow, Consultation-Liaison Psychiatry, and Dr Lee is Professor and Chair of Psychiatry, University of Rochester Medical Center. The authors report no conflicts of interest concerning the subject matter of this article.

 Bourgeois JA, Kremen WS, Servis ME, et al. The impact of psychiatric diagnosis on length of stay in a university medical center in the managed care era. 

 Finn CT, Thakur D, Shea KM, et al. Electronic medical record reporting enhances proactive psychiatric consultation. 

 Desan PH, Zimbrean PC, Weinstein AJ, et al. Proactive psychiatric consultation services reduce length of stay for admissions to an inpatient medical team. 

 Hansen MS, Fink P, Frydenberg M, et al. Mental disorders among internal medical inpatients: prevalence, detection, and treatment status. 

 Callaghan P, Eales S, Coates T, Bowers L. A review of research on the structure, process and outcome of liaison mental health services. 

 Sledge WH, Gueorguieva R, Desan P, et al. Multidisciplinary proactive psychiatric consultation service: impact on length of stay for medical inpatients. 

 Sledge WH, Bozzo JE, White-McCullum BA, Lee HB. The cost-benefit from the perspective of the hospital of a proactive psychiatric consultation service on inpatient general medicine services. 

 Oldham MA, Chahal K, Lee HB. A systematic review of proactive psychiatric consultation on hospital length of stay. 

 Sells D, Sledge WH, Wieland M, et al. Cascading crises, resilience and social support within the onset and development of multiple chronic conditions. 

 Rosen MA, DiazGranados D, Dietz AS, et al. Teamwork in healthcare: key discoveries enabling safer, high-quality care. 

 Desan P, Zimbrean P, Lee H, Sledge W. Proactive psychiatric consultation services for the general hospital of the future. Summergrad P, Kathol R, Eds. 

Integrated Care in Psychiatry: Redefining the Role of Mental Health Professionals in the Medical Setting

Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research

. Washington, DC: National Academy Press; 1994.

 ISRCTN Registry. The HOME Study: A Study Comparing Two Different Ways of Looking After Older People in Hospitals to See if We Can Improve How Quickly They Go Home. 2018. 

 Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. 

Mental illness accounts for a third of all years lived with disability and is associated with twice the relative risk of all-cause mortality. An estimated 8 million deaths are attributable to mental disorders every year, with two-thirds due to comorbid medical illness.

Collaborative Care Meets Hospital Medicine: Proactive Consultation-Liaison Psychiatry

The Centers for Disease Control and Prevention estimates that autism affects 1 in every 59 children in the US.

 While the core features of autism impair functioning, a significant source of further impairment is comorbid psychiatric disorders. People with autism spectrum disorder (ASD) are more likely than the general population to have comorbid psychiatric disorders. Although prevalence rates vary widely, converging evidence suggests that anxiety disorders and ADHD are most prevalent.

Numerous factors contribute to the increased risk for comorbid psychiatric disorders. People with autism are at higher risk of being bullied and are more likely to experience adverse life events, which can increase stress and risk for depression and anxiety. Cognitive rigidity, problems with emotion regulation, and intolerance of uncertainty associated with ASD can predispose this population to higher levels of anxiety and depression.

 Emotional regulation deficits may be a transdiagnostic phenomenon that underlies features of ASD as well as anxiety and other psychiatric comorbidities.

The Autism Comorbidity Interview (ACI) is a semi-structured interview that utilizes the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) with adaptation to increase validity in the ASD population. Additional screening questions and coding options were added to the ACI to help distinguish core features of ASD from features of other psychiatric disorders.

The ACI was used to assess psychiatric comorbidity in 109 children with ASD aged 5 to 17 years.

 Findings indicate that 72% of the children had at least one additional DSM-IV psychiatric diagnosis. Anxiety disorders were most common, followed by ADHD (

Assessment of comorbid psychiatric disorders

Screening instruments designed for psychiatric conditions in the general population may not adequately differentiate features of ASD and can result in overdiagnosis. However, there are several validated disorder-specific tools that have been specifically developed to assess for comorbid disorders in children and adults with ASD (

). Features of ASD can appear to overlap with symptoms of other conditions making it difficult to distinguish symptoms that relate to the core features of ASD versus symptoms of other psychiatric disorders (

General considerations for assessing psychiatric comorbidity in ASD

 It is important to establish an individual’s baseline for when he or she has functioned best. For psychiatric conditions that are episodic (eg, mood disorders) or those that appear later in development (eg, OCD, psychosis), it is important to distinguish baseline behaviors and functioning from distinct changes in symptoms that are expected with the onset of a co-occurring psychiatric condition.

 Assess for medical problems that can exacerbate emotional and behavioral symptoms, particularly in less verbal people.

 Some genetic syndromes are known to be associated with psychiatric conditions and behavioral phenotypes. This can help with more targeted screening (eg, fragile X syndrome has a higher prevalence of anxiety and ADHD, Williams syndrome has a higher prevalence of anxiety, and 22q11 deletion syndrome is associated with higher prevalence of psychosis).

4) Consider symptoms in the context of developmental level.

 Comorbid conditions should be considered if there are symptoms that are beyond what would be expected for an individual’s mental age and developmental level.

Using findings from their meta-analysis, vanSteensel and colleagues

 estimated that 40% of youth with ASD have a comorbid anxiety disorder. Risk factors for developing anxiety that are prevalent in ASD include social skill deficits, sensory sensitivity, cognitive rigidity, heightened physiological arousal, and difficulties regulating stress.

 Specific phobia tends to have an onset in childhood. In most cases the phenomenology of specific phobia in ASD tends to be similar to typically developing youth. However, people with developmental disabilities may also develop fears to unusual objects or situations, such as elevators, vacuum cleaners, etc.

Common phobias found in youth with ASD include loud noises, needles, and crowds. Sensory sensitivities can contribute to specific fears in autism, some of which may not rise to the level of meeting criteria for specific phobia but can contribute to impairment. For example, anxiety about eating food due to food textures, avoidance of clothing due to tactile sensitivity, or fear of loud objects such as vacuums and hairdryers due to noise sensitivity.

 Worry related to intense preoccupations, schedules, and environmental changes may be atypical features of anxiety that are important to recognize and ask patients about. Some of these features are captured by Kerns’s

 summation that they represent an “intolerance of uncertainty,” which can mark atypical anxiety in ASD.

Anxiety can present as perseverative questioning and reassurance seeking about an anticipated event or other worry. Repetitive questions used to obtain more information about a restricted interest should be distinguished from questions that are triggered by anxiety. People with ASD can have difficulty verbalizing internal states of anxiety or triggers for anxiety. For those who are non-communicative, an anxiety disorder may have to be considered by inference based on observation, such as persistent resistance to entering crowded rooms.

 Repetitive behaviors and restricted interests in ASD can be difficult to distinguish from the compulsions and obsessions of OCD. In OCD, obsessions are recurrent, intrusive thoughts that are distressing, and compulsive behaviors in OCD are bothersome, unwanted, and serve the function of attempting to alleviate the obsessional content.

Repetitive behaviors in ASD (eg, lining up objects, following the same routine, watching the same video) are generally a preferred or comforting activity, although they can lead to problematic behaviors or irritability when the person is interrupted or needs to stop. In addition, the most common forms of compulsions in OCD: hand washing, cleaning, making things “just right” are distinct from the typical repetitive behaviors of ASD, such as hand flapping, body rocking, and finger flicking.

People with ASD can have difficulty articulating obsessive thoughts and describing whether a behavior is aimed at reducing anxiety. The ACI adapted the criteria for OCD to allow caregivers to infer the mental experiences of people who exhibit compulsive behaviors. For example, caregivers could be asked if a compulsive behavior appeared to be aimed at reducing anxiety or linked to recurrent thoughts. Using this criteria Leyfer and colleagues

 found that 37% of their sample met criteria of OCD. In a different study by Simonoff and colleagues,

 the assessment tool did not allow for caregivers to make this inference and the prevalence of OCD was estimated at 8.2%.

 Diagnosis of social anxiety in ASD requires that a person with ASD is avoiding social interaction due to a fear of potential negative outcome rather than just a lack of interest in social interaction, which is a common core feature of ASD. In older higher-functioning youth social anxiety can develop as awareness of differences from peers increases.

ADHD is a common co-occurring condition with ASD and as such DSM-5 no longer prohibits ADHD to be diagnosed with ASD. Diagnosis of co-occurring ADHD can be challenging because symptoms of inattention, executive functioning problems, and social cognitive deficits are common in both conditions. It is important to distinguish features of inattention and impulsivity that may be inherent in ASD, such as distractibility related to a special interest, sensory seeking behaviors, or processing problems, from those that warrant an additional diagnosis of ADHD in children with ASD. The hyperactive-impulsive subtype of ADHD can also manifest in people with ASD and is best assessed in the context of the youth’s developmental age, expected activity level, and environmental demands.

Diagnosis of depression in neurotypical youth typically relies on self-report of mood symptoms such as feelings of sadness, hopelessness, or decreased self-esteem. Describing these internal states can be difficult for many people with ASD, particularly those with limited verbal skills.

 developed a framework for assessment of depression in ASD. For people with limited verbal skills or difficulties verbalizing feelings, increased self-injurious behavior, decreased self-care, labile moods, decreased interest in special interests, and regression of skills were observable behaviors associated with depression. For verbal youth with ASD, insight into ASD symptoms and their impact on functioning, awareness of being teased or being different from peers, social rejection, and low self-efficacy were risk factors for depression.

While their co-occurrence is uncommon, autism and psychosis have some symptom overlap, which can raise diagnostic questions. Pragmatic language deficits in ASD can include abrupt changes in topic, failure to provide context, and tangential comments, which can contribute to what appears to be a disorganized quality of language and thought process. When people with ASD are under stress they can have more disorganized and tangential speech, which is typically attributable to anxiety, problems with cognitive control, and pragmatic language deficits rather than underlying psychosis.

Moreover, people with ASD may use idiosyncratic language or scripted phrases from favorite movies or songs that appear out of context to the listener and therefore may sound disorganized or delusional. Strong convictions and overvalued ideas about their special interests may seem delusional. Difficulties with theory of mind and understanding the intentions of others may lead to distrust and paranoia but are best understood as the downstream effects of ASD core deficits, rather than a co-occurring psychosis.

There are currently no validated measures for assessing psychosis in ASD. Taking a detailed developmental history is key to distinguishing features of these two conditions. When psychosis occurs in ASD, the onset of psychotic symptoms is typically in adolescence or early adulthood and is associated with a change in functioning from baseline. Symptoms such as restricted affect, repetitive behaviors, tendency to disorganized speech when under stress, self-talk, or magical thinking, which have been chronic and present from a young age are more likely to be consistent with ASD rather than psychosis.

When baseline restricted interests become more morbid, illogical, and held with greater conviction with loss of reality testing, this may be more consistent delusional thought content, which may warrant an additional psychosis diagnosis. Larson and colleagues9 found that when psychosis co-occurs with ASD, the signs and symptoms of psychosis tended to be more transient and of shorter duration. As a result, the researchers noted that there tends to be a higher prevalence of psychotic disorder NOS (from DSM IV) diagnoses compared with schizophrenia diagnoses in part because of not meeting the duration of symptoms requirement.

Catatonic symptoms can develop in people with ASD with age of onset typically in adolescence.

 The occurrence of catatonia in autism is
	rare, but it is important to recognize given the benefit of early treatment and risk for life-threatening complications in severe cases. Diagnosis of catatonia in ASD can be challenging because echolalia, mutism, and stereotypic movements are common in both conditions.

Onset of catatonic symptoms in ASD may be gradual and in its early stages can present with a regression in self-care skills, reduction in speech, and difficulties initiating tasks. New onset of movement problems such as getting stuck part way through an action, difficulty initiating movements, immobility, increase in repetitive behaviors, difficulty crossing thresholds, and holding postures should raise suspicion for catatonia. Repetitive behaviors such as stereotypic movements and echolalia should not be counted toward a separate diagnosis of catatonia if they are consistent with an individual’s baseline symptoms of ASD.

Treatment of comorbid psychiatric conditions in ASD warrants a multimodal approach with contributions from caretaker education (applied behavioral analysis); psychotherapy; pharmacology; sensory, speech, and language interventions; and other disciplines depending on the individual’s history and presentation. Although a review of all of these modalities is beyond the scope of this article, some of the evidence and resources for CBT and pharmacotherapy for psychiatric comorbidity in ASD follow.

 CBT has been shown to reduce anxiety in children with ASD and anxiety disorders. Effective modifications to traditional CBT for youth with ASD have included increased parent involvement to promote generalization, incorporation of visual aids, making sessions highly structured and predictable, increased practice of skills, and explicit teaching of social skills as part of the therapy.

 Use of the child’s restricted interests can make the therapy more salient, help explain therapeutic concepts, create concrete metaphors, and reinforce participation.

ASD-specific CBT programs for anxiety include Multimodal Anxiety and Social Skills Intervention (MASSI), Face Your Fears, and Behavioral Interventions for Anxiety in Children With Autism (BIACA). Programs targeting executive functioning, mindfulness, and emotion regulation have also been found to reduce anxiety.

Pharmacological interventions. There are currently no medications for the core symptoms of ASD. Pharmacologic interventions for comorbid psychiatric conditions may help to alleviate associated symptoms and allow better engagement for the individual in educational and psychosocial treatments.

Targets for medication may include but are not limited to anxiety, impulsivity, hyperactivity, sleep problems, mood instability, depression, aggression, and self-injurious behavior. The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameter on ASD

 provides a summary of ran-
	domized controlled trials of medications to treat comorbid psychiatric conditions in ASD; the AACAP

 provides an overview of medication approaches by symptom area and guidelines for parent-provider discussion. Both are available for free download at

Dr Siegel is Vice President Medical Affairs, Developmental Disorders Service, Maine Behavioral Healthcare, Portland, ME; he is also Associate Professor of Psychiatry and Pediatrics, Tufts University School of Medicine, Boston, MA. Dr Collins is a Child and Adolescent Psychiatrist, Developmental Disorders Program, Sprint Harbor Hospital, Center for Autism and Developmental Disorders, Maine Behavioral Healthcare. The authors report no conflicts of interest concerning the subject matter of this article.

 Baio J, Wiggins L, Christensen DL, et al. Prevalence of autism spectrum disorder among children aged 8 years: Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2014. 

 Cai R, Richdale A, Dissanayake C, Uljarevic, M. Brief report: inter-relationship between emotion regulation, intolerance of uncertainty, anxiety and depression in youth with autism spectrum disorder. 

 Mazefsky C, Herrington J, Siegel M, et al. The role of emotion regulation in autism specgtrum disorder. 

 Leyfer O, Folstein S, Bacalman S, et al. Comorbid psychiatric disorders in children and adolescents with autism: interview development and rates of disorders. 

 vanSteensel F, Bogels S, Perrin S. Anxiety disorders in children and adolescents with autism spectrum disorder: a meta-analysis. 

 Kerns C, Kendall P, Berry L, et al. Traditional and atypical presentations of anxiety in youth with autism spectrum disorders. 

 Simonoff E, Pickles A, Charman T, et al. Psychiatric disorders in children with autism spectrum disorders: prevalance, comorbidity, and associated factors in a population-derived sample. 

 Magnuson K, Constantino J. Characterization of depression in children with autism spectrum disorder. 

 Larson F, Wagner A, Jones P, et al. Psychosis in autism: comparison of the features of both conditions in a dually affected cohort. 

 Wing L, Shaw A. Catatonia in autism spectrum disorder. 

 Johnco C, Storch E. Anxiety in youth with autism spectrum disorder: implications for treatment. 

 White S, Oswald D, Ollendick T, Scahill L. Anxiety in children and adolescents with autism spectrum disorder. 

 Volkmar F, Siegel M, Woodbury-Smith M, et al. Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. 

 American Academy of Child and Adolescent Psychiatry: Autism Parents’ Medication Guide Work Group. 

Autism Spectrum Disorder: Parents’ Medication Guide

While the core features of autism impair functioning, a significant source of further impairment is comorbid psychiatric disorders.

Recognizing and Treating Comorbid Psychiatric Disorders in People With Autism

Based on estimates by the International Diabetes Federation, there are 451 million people with diabetes mellitus worldwide and the prevalence is projected to increase to 693 million by 2045. Worldwide, five million deaths were attributed to diabetes in 2017 and global health care expenditure incurred for diabetes in that year was 850 billion US dollars.

 The prevalence of diabetes mellitus in the US is variously estimated to be around 7% to 9%. Type 2 diabetes mellitus (T2DM) is the more common subtype of the disorder, accounting for 90% to 95% of the cases; the remaining are predominantly type 1 diabetes mellitus (T1DM).

Anxiety disorders are also highly prevalent in the general population, particularly in those with medical illnesses such as diabetes. The umbrella term 

 includes a variety of psychiatric conditions characterized by excessive, impairing, and dysfunctional patterns of anxiety symptoms. Generalized anxiety disorder (GAD), social anxiety disorder, specific phobia, and panic disorder are all common anxiety disorders with varying rates of prevalence. PTSD and OCD used to be classified as anxiety disorders but are currently classified in DSM-5 in the Trauma and Stressor Related Disorders and Obsessive Compulsive and Related Disorders respectively.

Aside from specific anxiety disorders, anxiety symptoms not meeting criteria for a specific disorder, or subthreshold anxiety symptoms, are also common in the population and can nonetheless be distressing and impairing. In a study conducted across 15 primary care clinics in the US, 19.5% of 965 patients had at least one anxiety disorder, 7.6% had GAD, 6.8% had panic disorder, 6.2% had social anxiety disorder, and 8.6% had PTSD. Close to half (41%) of the patients with anxiety disorders were receiving no active treatment.

Comorbid anxiety disorders and diabetes mellitus is known to occur more than would be predicted by chance alone. In a 

 of 12 studies including data from nearly 13,000 individuals with diabetes, diabetes was associated with an increased probability of anxiety disorders (odds ratio [OR] = 1.20) as well as anxiety symptoms (OR = 1.48).

Analysis of data from the 2006 Behavioral Risk Factor Surveillance System (N = 201,575; 20,142 with diabetes) revealed that after adjusting for educational level, marital status, employment status, current smoking, leisure-time physical activity and body mass index, individuals with diabetes had a 20% higher prevalence of lifetime diagnosis of anxiety than those without (prevalence risk 1.20; 95% CI 1.12, 1.30). Young adults (aged 18-29 years) and Hispanics were noted to be at higher risk compared with other age and ethnic groups respectively.

In a systematic review of 18 studies, prevalence of GAD was 14% in individuals with diabetes. The prevalence of anxiety disorder not otherwise specified (subsyndromal presentations) and of elevated anxiety symptoms were reported to be 27% and 40%, respectively. Anxiety symptoms were higher in diabetic women compared with men and similar in patients with T1DM versus T2DM.

Effects of anxiety on outcomes in diabetes

Anxiety symptoms, including those of subclinical severity, are associated with a variety of poor outcomes such as increased risk of diabetic complications, increased pain, unhealthy self-care behaviors, greater disability, greater depression, increased BMI, decreased quality of life, poor functioning, and increased utilization of health care resources.

Several studies have reported an association between anxiety and glycemic control in diabetes. For instance, a 2011 study found significant correlations between anxiety symptom severity (measured by Hospital Anxiety and Depression Scale) and BMI (correlation coefficient r = 0.34), HbA

 levels (r = 0.41), postprandial blood glucose levels (r = 0.51) and daily physical exercise (r = -0.25).

 A 2002 meta-analysis reported that anxiety was significantly associated with hyperglycemia in studies in which the diagnosis of anxiety was determined from diagnostic interviews (although it was only marginally significant when all studies were included).

Comorbid anxiety may also have a relationship with inflammatory markers in diabetic subjects. Higher levels of phobic anxiety in women with diabetes have been associated with higher leptin and soluble TNF-alpha receptor II, and emotion dysregulation has been significantly associated with higher levels of C-reactive protein in African-American women with T2DM.

Meta-cognitive beliefs (such as “worrying about the future keeps me prepared” or ‘‘worry is uncontrollable”) are associated with anxiety as well as depression with both T1DM and T2DM. In a study of nearly 2000 people with T2DM, those with elevated anxiety and/or depression symptoms were less likely to report adhering to self-care recommendations, and were more likely to have poor eating habits, reduced physical activity, and increased risk of smoking.

Anxiety has also been associated with increased mortality risk in diabetes. In an 18-year Norwegian longitudinal study of T2DM, mortality risk in individuals with diabetes increased in the presence of depression or anxiety, or both. This increased mortality risk was lowest for symptoms of anxiety, higher for comorbid depression-anxiety, and highest for depression.

At the same time, anxiety symptoms may predispose some people with diabetes to be more receptive to self-management training approaches. In one randomized controlled trial (RCT) of group-based self-management training directed at patients with serious mental illness and T2DM, those with anxiety comorbidity demonstrated greater improvement in HbA1c with the intervention.

 One possible explanation may be that anxiety symptoms, particularly in the mild to moderate range, may make some people with diabetes more receptive to self-management training by enhancing the awareness and worry surrounding the potential risks of poorly controlled blood glucose.

Mechanisms underlying anxiety-diabetes comorbidity

Three categories of explanations have been proposed to explain this link between diabetes and anxiety. The first two postulate a direct causal link between the two, while the third sees this association as resulting from mutual relationship with other factors.

These three hypotheses are not mutually exclusive, and all three may very well be true (Box).

Anxiety as a risk factor for the development of diabetes.

 This hypothesis pertains to the physiological effects of chronic anxiety on the hypothalamic pituitary axis (HPA) that leads to an increase in diabetogenic hormones such as glucagon, epinephrine, norepinephrine, cortisol, and growth hormone in the body. It has been noted that stressful events can trigger the development and progression of diabetes in at-risk individuals. In a Swedish longitudinal study, individuals who reported elevated symptoms of depression and anxiety at baseline had increased risk of T2DM at 10-year follow-up.

Diabetes as a risk factor for the development of anxiety. 

This hypothesis views anxiety as a response to the stress of diagnosis and management of diabetes. The news of the diagnosis itself as well as the stress of day-to-day management can be a significant source of distress. Many persons with diabetes experience fear of losing control over their health and have difficulty following recommended life style modifications, adhering to regular blood glucose monitoring, and incorporating dietary changes. Furthermore, development of complications associated with diabetes such as neuropathy and cardiovascular disease can be anxiety inducing.

Anxiety and diabetes are indirectly related via mutual factors. 

Factors such as pain, disability, depression, obesity, and inflammatory markers are independently associated with diabetes as well as anxiety, and the presence of one or more of these factors may underlie some of the comorbidity seen between the two conditions.

Physical symptoms of anxiety, particularly during panic attacks, such as increased heart rate, sweating, trembling, nausea or abdominal distress, feeling dizzy, numbness or tingling sensations can mimic symptoms during hypoglycemic states. Patients with diabetes may develop a phobia for needles or they may show an excessive fear for hypoglycemic episodes, and these anxiety reactions can result in poor glucose monitoring, non-adherence with insulin administration as well as deliberately maintaining hyperglycemic states to mitigate the fear of hypoglycemia. These anxiety and phobic symptoms may be particularly prominent in children with T1DM.

Screening for anxiety disorders in patients with diabetes

that all patients be screened and assessed for symptoms of diabetes distress and anxiety (in addition to depression, disordered eating, and cognitive capacities) using standardized and validated tools at the initial visit, at periodic intervals, and when there is a change in disease, treatment, or life circumstance. They also recommend including caregivers and family members in this assessment (with the explicit consent of the patient) and referring to a mental health specialist if indicated.

 Patients with diabetes who have a history of psychiatric disorders are at increased risk for depression and anxiety symptoms, and these high-risk patients should be monitored more vigilantly for symptoms of anxiety.

 is a valid and efficient tool to assess for anxiety and was noted to have a sensitivity of 89% and specificity of 82% for diagnosis of GAD.

 It can be used to assess response to treatment, and it is a good indicator of symptom severity. GAD-2, which consists of the first 2 items of GAD-7, is also utilized as a screening instrument. It uses a cut-off of 3 and has a 

GAD-7 also performs reasonably well as a screening tool for anxiety disorders other than GAD. It is common for outpatient primary care practices to screen all patients with GAD-2 and administer GAD-7 to those who screened positive. GAD-2 and GAD-7 are appropriate screening instruments for patients with diabetes. It is important to note that GAD-7 is a screening instrument, and any diagnosis of an anxiety disorder requires a clinical interview.

Anxiety disorders are highly prevalent in the general population, particularly in those with medical illnesses such as diabetes.

Comorbidity

Consultation-Liaison Psychiatry: The Interface of Psychiatry and Other Medical Specialties

Exploring the Proactive Model

Collaborative Care Meets Hospital Medicine: Proactive Consultation-Liaison Psychiatry

Recognizing and Treating Comorbid Psychiatric Disorders in People With Autism

Treating Patients With Comorbid Anxiety and Diabetes Mellitus

Where There’s Smoke, There’s Fire

Why Are Depressed Patients Inflamed? A New Path to Personalized Treatment in Psychiatry

Psychogenic Purpura

Mini Quiz: Behaviorally Compromised Patients

The Quiz: Diabetic Peripheral Neuropathic Pain