Liaison psychiatry

3 September 2009
 Introduction
 also known as consultative psychiatry or
consultation-liaison psychiatry
 overlap with other distinct disciplines including
psychosomatic medicine, health psychology and
neuropsychiatry
 It is served by psychiatrist, nurses, psychologist and
social worker
 provide consultation regarding medical or surgical
settings and follow up psychiatric treatment
 It is also associated with diagnostic, therapeutic,
research and teaching service (between psychiatrist and
other specialities).

3 September 2009
 Making a referral
 What information to be given??

Medical problem
 Reasons for referral
 Nature of the help required

3 September 2009
 Common Consultation-Liaison Problems

 Suicide attempt or threat

 Risk factor : men over 45, no social support, alcohol
dependent, previous attempt, suicidal ideation
 Depression
 Assess suicidal risk
 Check for history of substance abuse or depressant
drugs (eg : propanolol, reserpine)
 Agitation

Related cognitive disorder, withdrawal from drugs
 Need to rule out toxic reaction to medication

3 September 2009
 Hallucination

Common cause is delirium tremens
 Need to rule out brief psychotic disorder,
schizophrenia, cognitive disorder
 Sleep disorder

Common cause is pain
 Need to rule out ; Depression – early morning
awakening, anxiety – difficulty in falling asleep

3 September 2009
 No organic basis symptom

Need to rule out ; Conversion disorder – glove
and stoking anaesthesia, Somatization
disorder – multiple body complain, Factitious
disorder – wish to be hospitalize
 Disorientation

Assess metabolic status, neurologic finding,
substance history

3 September 2009
 Psychiatric aspects of
physical disorder
Cancer
Surgical treatment
Screening for physical disorder
Genetic counseling

3 September 2009
 Cancer
 Problems:
 Distress to patients, families or carers especially:-
• at diagnosis
• during treatment (surgery, radiotherapy/chemotherapy)
• financial & work
• worries about appearance
 What can be done?
 discussion of information as patient required, practical
and social support, encourage patients to talk about
their worries

3 September 2009
 Psychiatric consequences of cancer

 Emotional reaction on diagnosis or

recurrence
 Anxiety
 Depression
 Anticipatory of chemotherapy side effects
 Neuropsychiatric syndromes (due to
metastasis, paraneoplastic syndromes)

3 September 2009
 Surgical treatment
 Consequences :
 Anxiety : before surgery
 Distress : after surgery
 Delirium (elderly) : after surgery
 changes to body appearance (mastectomy) or
function (colostomy)
 What can be done ?

clear explanation of the operation, its consequences
and plan for postoperative care (including effective
treatment of pain)
 Provide written handouts since anxious patients do
not remember all that they have been told
3 September 2009
 Screening for physical disorder
 Consequences

Anxious – result of the screening procedure
 Distress
 Example :

Hypertension
 Cancer
 DM

3 September 2009
 Genetic counseling
 Who are the persons involved?

contemplating marriage or expecting a child
 Family history of hereditary disease
 previous abnormal pregnancy
 What can be done?
 help in taking well-informed decisions about
family planning and treatment

3 September 2009
 Psychiatric aspects of
O&G
Pregnancy
Postpartum mental disorders
Menstrual disorder

3 September 2009
 Pregnancy
 More common in women with a history of
previous psychiatric disorder
 1st trimester: unwanted pregnancies
associated with anxiety and depression
 3rd trimester: fears about impending
delivery or doubts about the normality of
the fetus
 Sometimes it can become worsen as
more obstetric problem may arise due to
irregular antenatal care visit
3 September 2009
 Psychological problems in
pregnancy
 Unwanted pregnancy
 Planned pregnancy – miscarriage/stillbirth
 Termination due to medical reason
 Hyperemesis gravidarum
 Pseudocyesis
 Believe as if she is pregnant (amenorrhea, abdominal
distension and changes in early pregnancy)
 Couvade syndrome
 Husband experience symptoms of pregnancy

3 September 2009
 Postpartum mental disorder
 Maternity ‘blues’

Brief episode of irritability, disorganized
thinking, tearfullnes, lability of mood
 Peak on 3rd or 4th postpartum day
 No pharmacolgical treatment needed, just
reassurerance
 Puerperal psychosis
 Other puerperal depressive disorder

3 September 2009
 Puerperal psychosis
 Typically 2-3 days after delivery or in the first/second
postpartum weeks
 More frequent among:-
- primiparous women
- single mother
- those who suffered previous psychiatric disorder
- those with family history of psychiatric disorder
 3 types of psychosis are:-
- delirium (secondary to puerperal sepsis)
- mood disorder
- schizophrenia
(mood disorder more common than schizophrenia)

3 September 2009
 Assessment
 Determine whether mother concern about baby
condition

Delusional ideas either the child is malformed or
imperfect and any attempt of killing her child

Suicidal intent
 Treatment
 ECT
 Pharmacological – stop breast-feeding
 Prognosis
 Recover fully
 Recurrence : puerperal depressive disorder

3 September 2009
 Other puerperal depressive
disorder
 Puerperal depression more common than
puerperal psychoses
 Tiredness, irritability, anxiety, phobic symptoms
more common than depressive mood
 Early detection is important, so that
mother/infant relationship is well establish for
cognitive and emotional development of infant
 Treatment : antidepressant

3 September 2009
 Menstrual disorder
Premenstrual syndrome
Menopause

3 September 2009
 Premenstrual syndrome
 Refers to psychological (anxiety, irritability, depression)
and physical ( breast tenderness, abdominal discomfort,
feeling of distension) symptoms few days before and
end shortly after onset of menstrual period
 Physiological changes around menstruation may
exacerbate psychological symptoms
 Treatment :

Biological : progestrone, OCP, bromocriptine,
psychotrophic drugs

Psychosocial : cognitive behavioral therapy and
psychological support

3 September 2009
 Menopause
 Physical symptoms (flushing, sweating, vaginal
dryness, headache, dizziness) and psychological
symptom (depression, anxiety)
 Related with hormonal changes
 Additional factors :

Loneliness
 Alteration in relationship with husband
 Death of parents

3 September 2009