Challenging Consultations

Psychosomatic medicine, or medical psychiatry-also known as consultation-liaison (CL) psychiatry-specializes in the diagnosis and treatment of psychiatric disorders and psychiatric manifestations of complex medical illness.¹ CL psychiatrists treat a challenging and diverse patient population both in the general hospital setting and in the outpatient setting. They specialize in the care of patients with comorbid psychiatric and medical illnesses, as well as patients whose psychiatric illness is a direct consequence of a primary medical condition.

Psychosomatic medicine psychiatrists also have expertise in managing psychiatric effects of medical treatments and medications. Their roles include consulting to the patient’s primary medical team, serving as a liaison between the psychiatry service and the primary medical service, and treating patients’ psychiatric disorders while active medical care is being provided.² Consultation psychiatrists have the unique ability to do this work while navigating the logistics of managing psychiatric treatment of sometimes very complex patients in the general hospital setting.

The Psychiatric TimesSpecial Report on psychosomatic medicine that was published in the March and April issues-the last article in that series appears on page 32 of this issue-includes articles on the management of some of the more challenging consultations seen in the general medical hospital. Topics in neuropsychiatry, oncology, and pediatrics were selected not only to illustrate interesting and challenging issues but also to represent the diversity of the field of psychosomatic medicine.

Drs. Abbasi and TsungWai³ discuss psychogenic non-epileptic seizures (PNES). They review the history, epidemiology, diagnosis, and treatment of PNES. The authors provide an interesting look into the diagnosis with a discussion of the significance non-epileptic seizures hold in the context of a patient’s medical illness, and they suggest ways of communicating with patients who have this disorder.

Drs. Wilson, Denysenko, and Francis⁴ discuss catatonia, its diagnosis, incidence, and possible etiologies as well as its relationship to delirium. They present the broad and often confusing differential diagnosis for catatonia as well as treatment strategies.

Also included is an article on the role of psychiatric care for patients living with cancer. Drs. Pozo-Kaderman and Pirl⁵ address some of the varied psychiatric issues that the consultant must take into account when caring for these patients. They discuss the importance of coordination of care, management of medications (including attention to pain control), and the involvement of a supportive care team.

In the April issue, Drs. Thienemann and Frankovich⁶ present a case, supplemented with a comprehensive discussion, of pediatric auto-immune neuropsychiatric disorder associated with streptococcal infection (PANDAS). The authors characterize the roles of infection, immune dysregulation, and inflammation in the development of this disorder. They also address psychiatric effects of the illness and of psychiatric treatments.

Finally, in this issue, Dr. Certa discusses the topic of determining where patients with both significant psychiatric symptoms and medical illness should be treated. There is little literature on this issue, but it remains a common challenge for both the hospitalist and the consulting psychiatrist. He discusses the evolution of the psychiatric hospital housed within the general hospital and some of the more common factors that might pose as barriers to the transfer of patients from the general to the psychiatric ward.

The authors and I hope that you find these articles useful and informative!

MORE ABOUT Madeleine Becker, MD, FAPM

I am Director of the Psychiatric Hospital and Consultation Liaison Services at Thomas Jefferson University Hospital, a 965-bed academic general hospital in Center City, Philadelphia, Pa. In addition, I am the Program Director for the Psychosomatic Medicine Fellowship. As the medical student clerkship site director for the Consultation Liaison rotation, I’ve mentored and taught over 700 medical students in hospital psychiatry over the past 10 years.

My areas of clinical expertise are general hospital psychiatry and psychiatric treatment of women during the peripartum period. I’ve published on and lecture locally and nationally on women’s mental health. I am proud to serve as a council member for the Academy of Psychosomatic Medicine. I also chair their Fellowship Education Subcommittee, where I have the pleasure of working with some of the brightest and most talented psychosomatic medicine Program Directors from around the country.

Working in the field of consult psychiatry constantly reminds us that we must treat the whole patient, both in mind and body, and that these are not disparate. Entering the room as a psychiatric consultant, at a time when a patient is ill and most vulnerable, is the most rewarding work I do as a psychiatrist. The hospital is an ideal setting to teach future physicians. In this setting, it becomes most apparent that psychiatry is truly an essential specialty of medicine. Teaching psychiatry allows us to show trainees that psychiatric illness can be understandable and is treatable.

As an undergraduate at Drew University, I double majored in art and psychology. I worked as an art therapist for several years while in graduate school. I have two Masters Degrees-one in psychology from New York University and one in clinical health psychology from Albert Einstein College of Medicine; my medical degree is from Jefferson Medical College. I completed my residency in psychiatry at the University of Pennsylvania.

Even before medical school, I had been interested in integrative medicine and the integrative approach to patient care. I pursued multiple opportunities to increase my knowledge of the treatment of patients, including a fellowship at the Psychoanalytic Center of Philadelphia and also graduate training in Mindfulness Based Stress Reduction. Having skills in different modalities for treating patients is helpful for delivering care to a diverse patient population. It also helps me to keep an open mind when approaching each patient.

The study of traditional yoga has been one of my great interests as well. I have practiced regularly for the past 9 years and recently obtained yoga instructor certification after intensive training and study on weekends over the past 7 months. The foundations of yoga and meditation can help people control their breath, body, thoughts, and behavior. It provides people with insight into themselves and can help them be more attentive to their actions. I continue to paint and sketch when time allows. Last fall, I travelled to Sicily and found it to be the most peaceful and beautiful place that I have ever visited.

Editor’s note: This introduction to our Special Report on psychosomatic medicine should have run in the March issue with the bulk of the articles on that broad topic. We are grateful for the time and expertise Dr. Becker put into the articles of that Special Report, which you can find on our website in the Special Report section.

Disclosures:

Dr. Becker is Director, Consultation-Liaison/Hospital Psychiatry and Program Director, Psychosomatic Medicine Fellowship, Thomas Jefferson University Hospital, Department of Psychiatry and Human Behavior, Philadelphia, PA.

References:

1. Levenson JL, ed. American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill. 2nd ed. Arlington, VA: American Psychiatric Association Publishing; 2011.

2. Fogel BS, Greenberg DB, eds. Psychiatric Care of the Medical Patient. 3rd ed. New York: Oxford University Press; 2015.

3. Abbasi OH, TsungWai A. Psychogenic non-epileptic seizures: clinical issues for psychiatrists. Psychiatric Times. 2017;34(3):17-20.

4. Wilson JE, Denysenko L, Francis A. Update on medical catatonia: highlights on delirium. Psychiatric Times. 2017;34(3):20-22.

5. Pozo-Kaderman C, Pirl WF. Depression and anxiety disorders in patients with cancer.Psychiatric Times. 2017;34(3):22-23.

6. Thienemann M, Frankovich J. Sudden onset of tics, tantrums, hyperactivity, and emotional lability: update on PANS and PANDAS. Psychiatric Times. 2017;33(4):24-27.