Consultation-Liaison

Psychiatry
(Psychosomatic
medicine)
M.ZAINIE HASSAN A.R.

Three streams of thought flowed

into the area of general hospital
and consultation psychiatry.
The psychophysiologic represented by the
Walter B. Cannon, emphasized the effects of
stress on the body.
The psychoanalytic,best personified by the
psychoanalyst Franz Alexander,focused on the
effects that psychodynamic conflicts had on
the body.
The organic synthesis point of view,
ambitiously pursued by Helen Flanders
Dunbar, tried to unify the physiologic and
psychoanalytic approaches.

Consultation-liaison (C-L)
psychiatry
Consultation-liaison psychiatry is a
subspecialty of psychiatry that incorporates
clinical service, teaching, and research at the
borderland of psychiatry and
medicine.Lipowski, 1983 - Can J Psychiatry, 28
is the study, practice, and teaching of the
relation between medical and psychiatric
disorders.
is the psychiatric sub-specialty that helps
people with mental health problems in general
medical settings such as general hospital.

Consultation Liaison
Psychiatry
The Consultation-Liaison is the psychiatry
subspecialty at the interface of the mind and body
and deals with a range of problems including selfharm, adjustment to illness and physical and
psychological co-morbidities.
Consultant-Liaison (CL) psychiatry team
interfaces with all units of the general medical
hospital to address the psychiatric needs and
treatments of hospitalized patients. Diagnosis,
symptom management, interaction with caregivers
and disposition planning are all components of the
treatment approach.

Consultation-liaison (C-L)
psychiatry
is associated with all the diagnostic,
therapeutic, research, and teaching services
that psychiatrists perform in the general
hospital and serves as a bridge between
psychiatry and other specialties.
Related Terms / Fields:
psychosomatic medicine
psychiatry in the medically ill medical /
surgical psychiatry
behavioural medicine
health psychology

SERVICES PROVIDED
The Consultation-Liaison Service utilizes a
multi-disciplinary team approach
(psychiatry, psychology, and nursing) for
assessment and treatment. Follow-up services
may include: psychiatric or psychological
management, liaison with the (referring)
treatment team, ongoing monitoring of mental
status during hospitalization.
Outpatient follow-up in the form of
psychological management.

Diagnosis
Delirium occurs in 15 to 30 percent of hospitalized
patients.
Many medical illnesses that can have psychiatric
symptoms. Lifetime prevalence of mental illness in
chronically physically ill patients is more than 40 percent.
the diagnosis are to identify :
(1)mental disorders and psychological responses to physical
illness,
(2) (2) patients' personality features.
(3) (3) patients' characteristic coping techniques to
recommend the most appropriate therapeutic
intervention for patients' needs.

Treatment
May recommend a specific therapy, suggest
areas for further medical inquiry, inform
doctors and nurses of their roles in the
patient's psychosocial care.
Recommend a transfer to a psychiatric
facility for long-term psychiatric treatment.
Suggest or undertake brief psychotherapy
with the patient on the medical ward.
The most common symptoms being anxiety,
depression, and disorientation.

The biopsychosocial
model of health is
embraced and promoted.

Spirituality and Religion strong religious

beliefs,spiritual yearnings,prayer,devotional acts have
positive influences on mental& physical health

Bio(anatomical.structrur
al molecular effects on
biological functioning

Psychological,effects of
psychodinamic,motivation,
personality
Social,cultural,famili
al influence
einvironment

George Engel 1977

Neuronal circuits in the organization of stress responses.

Horizontal thick and thin lines indicate short circuit
autonomic (sympathoadrenal and/or parasympathetic) and
defense (withdrawal) spinal reflexes in response to stressful
stimuli. Thin lines represent long circuit, ascending (afferent)
and descending (efferent) neuronal loops between the spinal

Neuroendocrine
hypothalamus
The paraventricular, arcuate, and medial
preoptic nuclei project to both the median
eminence (neurohumoral output) and brainstem
or spinal cord autonomic centers (neuronal
output)
Descending fibers may terminate on autonomic
preganglionic neurons directly or they may exert
their effect through brainstem
catecholaminergic neurons
Various inputs mediating stress converge upon
neurons of the parvocellular subdivisions of the
PVN (Periventricular neuron) which synthesize
and release CRH and vasopressin

Limbic System
Both cortical and subcortical limbic
structures are involved in the organization
of stress responses
subcortical amygdala, septum,
habenula, and related structures
limbic cortex hippocampal formation
(hippocampus, dentate gyrus, subiculum)
and entorhinal, piriform, prelimbic,
intralimbic, and cingulate cortices.

The well-documented
effect of depression
its effect on the outcome of comorbid
medical illness;
For example, depression increases mortality
rates following myocardial infarction (MI)
ischemic stroke.
in all patients, and in women with HIV/AIDS
.
It is also an independent risk factor for the
development of coronary artery disease .

SELECTED EPIDEMIOLOGIC STUDIES OF

DEPRESSION ASSOCIATED WITH
MEDICAL ILLNESS

Illness
Cerebrovascular
accident

Myocardial infarction
Coronary artery disease
Diabetes mellitus
functional
gastrointestinal
disorders

Prevalence of depression (%)

23 (Burvill et al)
27 Major depression
20 Minor depression
(Robinson et al)
18 Major depression
27 Minor depression
(Schleifer et al)
18 (Carney et al. )
8.5 - 27.3(Goodnick et al.)
50-60% anxiety,
depressive, and panic
disorders

Penelitian depresi dan kualitas

hidup di RSHS/FKUP
Depresi pada penderita Diabetes Mellitus 56 % (2003).
Depresi dan kualitas hidup pada penderita Sistemik
Lupus Eritematosus 48 % depresi kualitas hidup
semakin buruk bila depresi semakin berat (2005).
Depresi dan kualitas hidup pada pasien pasca Infark
Miokard 74 % depresi, kualiatas hidup menurun.(2006).
Derajat Depressi dan Stadium penyakit Parkinson pada
penderita Pemyakit Parkinson.84,9% depresi ,depresi
berat pada stadium III dan IV.(2009).
Depresi pada Dispepsia Fungsional 54,3% dan
mengalami stressor psikososial ( kematian keluarga
dekat,kesulitan seks,gangguan kesehatan/tingkah laku anggota keluarga)

2010.

CHEMOTHERAPEUTIC AND OTHER

PHARMACOLOGIC AGENTS LINKED TO
DEPRESSION
ANTINEOPLASTIC AGENTS
Alkylatingagents,Dacarbazine,Hexamethylamine,Cortic
osteroids ,Cyclosporine ,Cyproterone, Interferon ,Lasparaginase ,Methotrexate, Pro carbazine
,Tamoxifen ,Vinblastine, Vincristine
CORTICOSTEROIDS
ANALGESICS,Codeine ,Indomethacin, Oxyco done
CARDIOVASCULAR AGENTS Methyldopa,
Reserpine ,Propranolol ,Calcium channel blockers
NEUROLOGIC AGENTS;Levodopa ,Phenobarbital
GASTROINTESTINAL AGENTS;Cimetidine
ANTIBIOTICS;Amphotericin B

Medical Conditions That

Present with Psychiatric
Symptoms

Hyperthyroidism (thyrotoxicosis)/
Hypothyroidism (myxedema).
Hypoglycemia/Hyperglycemia.
Brain neoplasms/ Frontal /Parietal/Occipital
/Temporal/Cerebellar tumor.
Head trauma.
Acquired immunodeficiency syndrome (AIDS).
Injuries requiring ambulatory surgical
evaluation and treatment (for example, wrist
slashing).
Hyponatremia.

Medical Conditions That

Present with Psychiatric
Symptoms

Pancreatic carcinoma.
Cushing's syndrome.
Adrenocortical insufficiency (Addison's disease).
Seizure disorder.
Hyperparathyroidism/Hypoparathyroidism.
Systemic lupus erythematosus. Multiple
sclerosis.
Acute intermittent porphyria.
Hepatic encephalopathy.

Medical Conditions That

Present with Psychiatric
Symptoms

Injuries requiring inpatient surgical

evaluation and treatment (e.g., suicide
attempts, self-mutilation.
Pheochromocytoma, Wilson's disease,
Huntington's disease.
Vitamin deficiencies Thiamine,
Nicotinamide,
Pyridoxine. Vitamin B12.
Tertiary syphilis.

C-L Psychiatry in Special

Situations
Intensive Care Units (ICUs) (depression or
anxiety, delirium).

Hemodialysis Units.

Complications of dialysis
treatment can include psychiatric problems, such as
depression, and suicide is not rare. Sexual problems
can be neurogenic, psychogenic, or related to gonadal
dysfunction and testicular atrophy.

Surgical Units,

depression or anxiety, delirium.

The factors that contribute to an improved outcome for
surgery are informed consent and education so that
patients know what they can expect to feel, where they
will be.

Psycho-Oncology
To study both the impact of cancer on
psychological functioning and the role that
psychological and behavioral variables
may play in cancer risk and survival.
A landmark study by David Spiegel found
that women with metastatic breast cancer
who received weekly group psychotherapy
survived an average of 18 months longer
than control patients randomly assigned to
routine care.

Terima kasih

References
Blumenfield, Michael; Strain, James J.Psycho somatic
Medicine , 1st Edition,2006 Lippincott Williams & Wilkins.
Sadock, Benjamin James; Sadock, Virginia Alcott, Kaplan &
Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical
Psychiatry, 10th Edition,2007 Lippincott Williams & Wilkins
James J. Amos,Robert G. Robinson,PaulW. Penningroth Chair
Psychosomatic Medicine,An Introduction to ConsultationLiaison Psychiatry , Cambridge University Press 2010
,Department of Psychiatry, University of Iowa, Iowa City,
Iowa, USA
Theodore A. Stern, M.D.Gregory L. Fricchione, M.D.
Massachusetts General Hospital, Handbook of General
Hospital Psychiatry,Sixth Edition,2010.SAUNDERS.