Psychosomatics 46:95-103, February 2005
© 2005 The Academy of Psychosomatic Medicine
The American Psychiatric Publishing Textbook of Psychosomatic Medicine
Edited by James L. Levenson, M.D., Arlington, Va., American Psychiatric Publishing, Inc., 2005, 1,120 pages, $169.00, ISBN 1-58562-127-7
Donald S. Kornfeld, M.D., and
Ralph N. Wharton, M.D.
Dr. James Levenson, the Editor, and his chapter authors set out on a daunting task, to write a comprehensive textbook of our field that coincides with its designation as a certified specialty and its first qualification examination. We believe they have successfully accomplished their mission. However, this judgment is not ours alone. We have enlisted the expertise of the faculty of the Columbia Psychosomatic Service to review chapters in their areas of expertise, as follows: Oncology and HIV-AIDS, Jon Levenson; Obstetrics and Gynecology, Jennifer Downey; Pediatrics, Jonathan Slater; and Psychodermatology, Iona Ginsburg.
We would hope that Dr. Levenson and his colleagues will find whatever criticism is offered to be helpful in writing, what will likely be, a second edition.
The book is divided into four sections: General Principles in Evaluation and Management; Symptoms and Disorders; Specialties and Subspecialties; and Treatment. We will review the book’s chapters in that order.
GENERAL PRINCIPLES IN EVALUATION AND MANAGEMENT
The chapter "Psychiatric Assessment and Consultation" makes it clear that while a psychiatric interview at the bedside in a general hospital setting may be based on certain basic psychiatric principles, it requires that the consultant be prepared to work in some unusual settings. The authors provide useful advice on how to deal with another very basic difference: these patients rarely, if ever, have asked for our help. They also point out the pitfalls that can impede the successful implementation of our recommendations and how to deal with them. Considerable space is devoted to formal mental status testing methods, which might better be used to discuss how clinical data alone can be adequate to make a diagnosis. Not many situations allow for the implementation of such testing. There is a recommendation that the consultation note begin with a review of the summary of the patient’s medical and psychiatric history. Our advice to trainees is to begin with the reason they have been asked to consult. Medical history is likely reviewed elsewhere in the chart and can be referred to. The shorter the note, the greater the likelihood that it will be read in its entirety. We require that no note exceed one page in length.
The chapter "Neuropsychological and Psychological Evaluation" contains useful information on a number of tests that are available and frequently used. It is helpful for a psychiatrist to understand the advantages and disadvantages of each assessment and therefore how they can best be applied.
The chapter "Legal Issues" is quite comprehensive and useful in reminding us of how often we are involved in issues that involve the law. However, a psychiatric consultation must go beyond merely establishing a patient’s legal competency. Our concern regarding the law should not divert us from a thorough evaluation of the wide range of issues, as noted below, which created the clinical impasse and produced the consultation.
The authors of the chapter on clinical ethics rightfully point out that problems formally designated as "ethical" are in reality issues often best handled by a psychiatric consultant. We agree. A formal knowledge of ethical principles rarely, if ever, has led to a resolution of such issues at the bedside. Psychiatrists are too often used merely to determine mental capacity when the issue is more likely a personal, family, or staff conflict or a failure to provide patients with an adequate opportunity to discuss their anxiety or anger. These are not "ethical" issues and are better solved by a consultation-liaison psychiatrist1 than an "ethicist."
A chapter "Psychological Responses to Illness" requires considerable experience in our field in order to have witnessed the wide range of such responses and the ability to clearly categorize these observations. Green and Muskin have combined their personal experience with such classic observations as those of Bibring and Kahane to provide a useful review of this issue.
SYMPTOMS AND DISORDERS
Delirium is given the attention it deserves. This is the book’s longest chapter and necessarily so. Delirium is probably the most common and most serious of all clinical problems with which consultation-liaison psychiatrists must deal. Drs. Trzepacz and Meagher have provided a very comprehensive up-to-date review of the complexity of its diagnosis, etiologies, and treatment. The chapter discusses strategies to minimize the occurrence of delirium as well as current data on the apparently successful use of dexmedetomidine to diminish delirium following cardiac surgery.
Pharmacological treatment with antipsychotic agents—both the most common one, haloperidol, and the newer atypicals—is discussed. The inadequacies of each in the treatment of agitation are pointed out. Haloperidol is not particularly sedating at lower doses, and the most commonly used atypicals are not available in parenteral form. The authors describe a common solution: combining haloperidol with lorazepam for sedation, often given intravenously. They do note a potential hazard: that halperidol given via this route can produce torsade de pointes, a fatal arrhythmia. However, these two reviewers of an earlier generation must point out that for many years chlorpromazine, in appropriate doses, was used very effectively to manage agitated delirium without serious complications. It has the advantage of being available in intramuscular, oral liquid, and rectal preparations. Its use should be considered more often.2
Dementia is becoming an increasingly greater problem for an aging population. This chapter is a very thorough review of its diagnosis, underlying neuropathology, manifestations over its clinical course, and the available psychopharmacologic and psychosocial treatments. The bibliography is particularly useful for those who wish to delve further into the subject. There is an excellent review of worldwide epidemiological data and useful tables that summarize the power of the known predictor variables. Since the Mini-Mental Status Exam is so universally used, its value as well as its limitations as a diagnostic instrument are appropriately discussed. The subcortical syndrome is a less well-known entity and is well described.
We are all aware of the inadequacy of definitive treatment. The chapter was probably written before memantine (Namenda®) became available, but this new medication has not proven to be particularly effective. It has been suggested that its use in combination with donezepil (Aricept®) may be more effective, but there are not enough data to support that claim. The use of psychosocial treatments is also reviewed.
The authors of the chapter "Aggression and Violence" do an excellent job of reviewing the literature on such behaviors in general. They provide information which a consultation-liaison psychiatrist will find useful. They review their occurrence in psychoses, personality disorders, epilepsy and related neurological disorders, and substance abuse, and provide advice on management. However, in their effort to be comprehensive, they dilute this basic information by using 20 pages to transmit it.
The chapter on depression is excellent. There is a fine review of screening instruments. It contains a well-documented section on depression in medical conditions and in heart disease and stroke in particular. The authors also provide a useful review of drugs that may cause depression. They point out the important role of primary care givers in the diagnosis and management of depression and their need to know when and how to refer patients for psychiatric consultation.
The chapter on suicidality places appropriate emphasis on the need to train primary care physicians on the identification of the problem and the need for psychiatric consultation. More should be written on what advice to give our colleagues on how this can best be done. There is also a review of court rulings on the legal issues related to physician-assisted suicide and the experience of the Netherlands.
Similarly, while the chapter "Mania, Catatonia, and Psychosis" is very thorough, we question how much of this information needs to be included in this particular textbook. We will add one nugget: mefloquine (Lariam®), an anti-malarial drug, can cause a range of psychiatric disturbances including psychosis.
The authors begin the chapter on anxiety disorder with a formalized method of diagnosing anxiety that is unlikely to be used by the consultation-liaison psychiatrists at the bedside. They emphasize that our task is to identify pathological anxiety, or its absence, in situations where anxiety is to be expected.
We agree with Breitbart et al.3 that anxiety in delirious patients is better treated with sedating antipsychotics than benzodiazepines. Useful tables list drugs that can cause anxiety and dose equivalents of various benzodiazepines. The rather detailed review of SSRIs in this chapter could be eliminated by referring to the chapter on Psychopharmacology.
The authors of the chapter "Somatization and Somatoform Disorders," through no fault of their own, are saddled with the confusing DSM-IV categorization of these disorders. We are told that a committee is already at work to devise a better diagnostic system for DSM-V. However, once past the problem of nosology, the chapter is clinically sound. The writers point out that most patients with somatoform disorder are managed by their primary care physicians. Smith published a useful paper on how that can effectively be done to reduce hospital admissions and medical costs.4 Another useful reference is the work of Raskin et.al. on conversion disorder.5 They found that the classic symptoms of la belle indifference and the symbolism of the symptom are not common. The chapter's authors provide a comprehensive list of therapies that can be used. It would be helpful to have clinical vignettes demonstrating how and when and in what combinations they can be used.
The chapter "Deception Syndromes: Factitious Disorders and Malingering" is written by someone with years of experience exploring this subject. Charles V. Ford, M.D. It begins with a fascinating historical note, a description of medical deception in 200 A.D. He notes that it is essential in management to distinguish among the three categories of such patients: the patient with the classical Munchausen syndrome who may assume multiple identities and plague many institutions; the patient of established identity who essentially remains the responsibility of one physician and/or one institution; and the patient who consciously feigns illness motivated by anticipation of financial or other benefits. While patients with true Munchausen syndrome have proven, for the most part, to be untreatable, not enough is written about the potentially successful treatment approaches to patients in the second category. Not making this distinction is a very serious error. These are individuals struggling with personal problems, who have, for whatever unconscious reason, chosen this unusual self-destructive mechanism to deal with them. The most difficult, but not insurmountable, task is to motivate these people to enter psychiatric treatment without feeling humiliated and risking severe depression and even suicide. What is needed is a sympathetic physician who is able to communicate his appreciation for the emotional suffering which has driven the patient to such a desperate solution of the problem, and also formulate a treatment plan which minimizes humiliation.
While eating disorder patients are occasionally admitted to the hospital to treat the severe medical/metabolic effects of starvation, they do not very often require the skills of a consultation-liaison psychiatrist. Severe nutritional or metabolic disorders are managed by an internist. Internists can manage that while the consultation-liaison psychiatrist seeks a consultation with a colleague who specializes in this disorder. Knowledge regarding the diagnosis and treatment of anorexia and other related disorders should be a part of any good psychiatric residency program. However, it is not needed in this textbook. On the other hand, the absence of a discussion of obesity is striking, since it is certainly an eating disorder more likely to be addressed by a psychiatrist specializing in psychosomatic medicine.
The chapter on sleep disorders presents a short course in what is known about the most common sleep disorders. Is it needed in a textbook of psychosomatic medicine? The case can be made that consultation-liaison psychiatrists should be able to provide advice to our colleagues in medicine whose patients are most likely to present with the "problem." This chapter meets that need quite well. It also provides a useful reference on a variety of herbal agents commonly used for insomnia. In addition, it provides useful information on sleep apnea and narcolepsy. Surprisingly, however, it does not discuss the use of modafinil (Provigil®) in the latter.
The authors of the chapter on sexual disorders present a particularly detailed review of the literature pertaining to sexual disorders that occur either as the result of illness or its treatment. They begin with the cautionary note that one must not too quickly eliminate the role of psychological/psychiatric factors in patients with medical disorders that can produce sexual dysfunction. They provide clinical examples to support that observation. There is a systematic review of the most common medical and surgical disorders associated with sexual dysfunction: heart disease, malignancy, HIV/AIDS, neurologic disorders (including spinal cord injury), multiple sclerosis, dementia, and stroke. They report the relatively successful use of sildenafil. They also discuss the use of this drug for individuals without concurrent medical/surgical illness which need not have been included here. There is a useful table of medications, including nonprescription substances, which may produce sexual dysfunction.
The chapter on substance-related disorders is a must read for core competence in psychosomatic medicine. Noted wisely is the frequent reluctance of primary care givers to make referrals to a psychiatrist for this problem, or to do so effectively. It would be useful if the authors provided advice to be conveyed to primary care physicians on how to best accomplish this.
SPECIALTIES AND SUBSPECIALTIES
The chapter "Heart Disease" begins with a review of the role that emotional factors can play at various phases in the course of heart disease. Whenever possible, it includes a review of possible associated psychophysiological mechanisms. It goes on to address the opposite problem, the psychiatric effects which can arise as a result of heart disease and cardiac surgery.
Consulation-liaison psychiatrists have played an important role at each new phase in the history of cardiac surgery. Their very important role in the various phases of heart transplantation, from the selection of recipients to rehabilitation of heart transplantation, is well described.
The final section addresses treatment issues: the use of psychotherapy to reduce psychological risk factors for coronary heart disease and the after-effects of an infarction; the use and possible protective effect of antidepressants in patients with coronary heart disease and a review of how best to use antipsychotic agents, anxiolytics, and stimulants in cardiac patients.
There are two particularly useful tables. One contains a list of cardiac-psychiatric drug interactions and the other a list of medications used in the treatment of cardiac disease and their psychiatric side effects.
The authors of the chapter "Lung Disease" have organized this review of the role of psychosomatic medicine in lung diseases as they occur over a lifespan. There is no better place to begin than with asthma, where the role of psychosocial factors has been extensively studied. We are alerted to the need to use the methacholine test to distinguish anxiety attacks from asthma. The extensive literature on the role of psychosocial factors in provoking attacks, the possible mechanisms by which these effects can be produced, and the effectiveness of psychosocial interventions which have been used are summarized. On the other hand, cystic fibrosis is discussed from the standpoint of the emotional impact of the disease on its victims and the coping mechanisms they can utilize.
The increasing incidence of chronic obstructive pulmonary disease requires the serious attention the authors provide. There are psychosocial factors in play at different stages of the illness, e.g., in its etiology (the inability to stop smoking) and the influence of depression and anxiety in the manifestation and severity of symptoms and level of disability. The neurocognitive consequences of chronic oxygen deprivation must not be overlooked. The authors provide references to recent reviews of psychotherapeutic, psychopharmacologic and rehabilitation interventions and summarize these findings.
They provide a thorough review of the large literature on the role of psychosocial factors in the diagnosis and treatment of hyperventilation. The problem of nonadherence to tuberculosis treatment deserves more attention. The section on ventilator weaning discusses the problems this creates at the end of life but does not address those difficulties associated with assisting patients to become independent of the machine. There is a helpful review of drugs used in the treatment of pulmonary illness which may produce psychiatric symptoms and also how best to use psychopharmacological agents in these patients. Space need not have been devoted to lung cancer or lung transplantation, since they are included in the chapters on oncology and transplantation.
The authors of the chapter "Gastrointestinal Disorders" begin by noting the close relationship between the gut and the psyche, well known to all clinicians. The Second Brain by Gershon6 would be a useful additional reference to help better understand possible neurophysiological relationships.
The authors note that their use of the term "functional disorder of the bowel" refers to a multifactorial view of gastrointestinal illness which helps to avoid the artificial separation of mind and body that so often plagues this field. They point out, for example, that while H. pylori is considered a causative agent in peptic ulcer, not all patients who carry the bacteria develop the lesion. Much has been written on the relationship between psychological factors and inflammatory bowel disease. The authors thoroughly review this work in all its complexity. They provide a summary of pharmacological and psychotherapeutic treatments and how they can be used most effectively. Their section on liver disease notes that hepatitis C virus has become the leading cause of chronic liver disease in the U.S. and that the most effective treatment, interferon, has significant psychiatric side effects, especially depression which can be severe. This was probably written before the publication of Musselman’s paper, which suggests that SSRIs may be effectively used prophylactically.7
Psychonephrology was created to help nephrologists decide which patients were most suitable candidates for renal dialysis, since initially the machines were not universally available. Fortunately, that is no longer the case, and with the subsequent availability of renal transplantation, psychonephrology has become a subspecialty dealing with the needs of a unique group of patients. The authors of the chapter "Renal Disease" do an excellent job of reviewing the psychiatric problems of patients with end-stage renal disease at different stages of that illness. They describe the responses of patients to the symbolic and organic effects of chronic dialysis. The major psychiatric problem is depression and the availability of suicide by noncompliance is discussed. They provide a review of the psychotherapeutic and psychopharmacologic treatments that are most effective in dealing with the symptoms in this patient population. There is an excellent discussion of the role of the psychiatrist in the vexing question of withholding or withdrawing treatment.
The authors of the chapter "Endocrine and Metabolic Disorders" begin by pointing out that the study of endocrine disorders may present the best opportunity to study the interaction of psyche and soma. Diabetes, understandably, gets the greatest attention. The brief review of the pathophysiology of Type 1 and Type 2 diabetes is useful. This is followed by a review of the literature exploring the possible role of psychiatric factors in the onset and course of diabetes. The literature on the role of "stress" is reviewed with the conclusion that the psychophysiology of glucose metabolism is still not clear. Of course, there is a review of the literature on the relationship of behavior (compliance) to diabetic control. The complex relationship between depression and diabetes is thoroughly reviewed. There is a particularly interesting discussion of the relationship between diabetes and eating disorders. The sections on the thyroid, parathyroid, and adrenal gland review the associated psychiatric disorders. In summary, a very thoughtful review of a fascinating topic.
The chapter "Oncology," written by two leading psycho-oncologists, is a state-of-the-art review of clinical psycho-oncology. The chapter is organized into several segments, starting with a section devoted to psychological factors affecting cancer risk and progression, followed by a review of psychiatric disorders in cancer patients (depression, anxiety, mania, and delirium) and a brief section on pain management (the book also contains a chapter devoted to pain management). There is a section devoted to the psychiatric issues in specific cancers (prostate, breast, colorectal, lung). The remaining sections include psychiatric aspects of cancer treatments (chemotherapy, radiotherapy, and bone marrow transplantation). The chapter concludes with a summary of the uses of psychotherapy and psychopharmacology. Particularly relevant today is the section devoted to the use of complementary and alternative medicines, often used without the supervision or knowledge of the patient’s oncologist. There is an interesting short section on what is referred to as cancer survivorship. The chapter would benefit from the use of case vignettes. The section on bone marrow transplantation might also have included a discussion of stem cell transplants, now used for a variety of cancers. The many summary tables are quite well done.
The authors of the chapter "Rheumatology" address the two primary autoimmune disorders, rheumatoid arthritis and systemic lupus erythematosus. They begin with a thorough review of the diagnosis and treatment of central nervous system pathology. We believe it would have been preferable to begin with the discussions of the two diseases and place the CNS segment with the section devoted to systemic lupus erythematosus, where these problems primarily occur. They do an excellent job of reviewing the emotional reactions to rheumatoid arthritis with emphasis on the detection and treatment of depression. They note the research linking stress and depression to immune dysfunction but express a reasonable degree of skepticism on any direct link to the disease process. Patients with systemic lupus erythematosus are much more likely to manifest psychiatric symptoms as a direct result of the disease process and its treatment, usually with steroids. They provide a useful table to help distinguish these corticosteroid-induced symptoms from those caused by the illness itself.
The chapter "Chronic Fatigue and Fibromyalgia Syndromes" addresses what may be the most frustrating diagnostic and therapeutic problems in medical practice today. These are patients with often disabling symptoms, without enough convincing evidence of pathophysiology, but with enough findings so that they cannot be assumed to be free of physical disease. The authors do an excellent job of laying out the conflicting facts as they appear in the literature. They argue convincingly that it is a major clinical error to take an extreme position by attributing the symptoms to either an organic or psychogenic etiology (which reflects our own experience). They point out that the authors of DSM-V will struggle to find a category for these patients.
The chapter contains an excellent clinical description of each of these disorders, which have much in common. Fibromyalgia is referred to by some as fatigue with pain while chronic fatigue syndrome is fatigue without pain. In our experience the differences are more distinct. The authors also treat them as separate entities with overlapping features. Chronic Fatigue Syndrome is considered by some to be the same illness previously described as post-viral fatigue syndrome or chronic Epstein-Barr virus infection.
The authors provide a useful table of diagnostic criteria for chronic fatigue syndrome and also present the diagnostic criteria of the American College of Rheumatology for the diagnosis of fibromyalgia. It includes the need to demonstrate pain on digital palpitation at 11–18 specific body sites. They do an extensive review of the literature on possible etiological factors which they categorize as predisposing, precipitating, or perpetuating. Recently, brain imaging has been used as a diagnostic tool and produced findings which are tantalizing but not definitive.
They do an excellent job of describing how these patients might best be treated with a combination of supportive psychotherapy, psychopharmacology and physical therapies, with the goal of maximum function, but not elimination of symptoms.
The fascinating chapter "Infectious Diseases" reviews infections by a multiplicity of agents: bacterial, viral, prion, parasitic, fungal, and pfiesteria (look it up) and the neuropsychiatric problems that can accompany them. The authors note that such neurological and psychiatric symptoms can be the result of the direct effect of the organism, the body’s efforts to thwart it or a combination of the two. The list of organisms is comprehensive and there are some details of which most consulation-liaison psychiatrists may be unaware. For example, how many of us know about PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection)? Of course, there are reviews of the literature on controversial topics such as chronic Epstein-Barr virus and Lyme disease and a reminder that syphilis, in its various manifestations, may be having a resurgence. This chapter will be a useful resource.
The chapter "HIV/AIDS" is organized into the following sections: a brief overview of the epidemiology of HIV, a strong section entitled Neuropsychiatric and Medical Complications of HIV (including cryptococcal meningitis, toxoplasmosis, cytomegalovirus infections and PML [progressive multifocal leukoencephalopathy], fatigue, and CNS neoplasms). Another outstanding section reviews the diagnosis and treatment of the psychiatric conditions associated with HIV: delirium, dementia, major depression, bipolar disorder, schizophrenia, PTSD, and substance abuse. This latter section is extremely well written, detailed, and well referenced. The discussion of HIV dementia is exemplary. The area of personality and personality disorders is based primarily on the authors’ own experience and would benefit from a review of the pertinent literature. The section dealing with psychosocial interventions to prevent HIV transmission and adherence and nonadherence to treatment regimens is well done. The chapter would benefit from a review of the basic diagnostic tests and current medical treatments, especially of drugs such as efavirenz (Sustiva®), which has known neuropsychiatric side effects.
The author of the chapter "Dermatology" describes skin diseases that are affected by psychosocial factors as well as psychiatric illness in which the skin is the target of disordered thinking, behavior, or perception. In the first category are such illnesses as atopic dermatitis (eczema), psoriasis, urticaria, and acne. This chapter also provides another example of the problems that DSM-IV has had in dealing with such disorders. In the second category are impulse control disorders (psychological excoriation) such as trichotillomania and formication. A table has a useful list of the cutaneous effects of psychiatric medications. It would have been useful if there were a similar list of the psychiatric side effects of medications such as corticosteroids, commonly used in dermatology.
We would have wanted the author to devote more space to the psychological impact of skin disease on individuals, since that is usually what brings the patient to a psychiatrist. The author also discusses in some detail the use of pimozide for delusions of parasitosis without a discussion of the use of the atypical antipsychotics, which are coming into greater use. However, we are unaware of any studies comparing their effectiveness.
The authors of the chapter "Surgery" review psychiatric issues as they pertain to the basic experience of surgery: preoperative anxiety, the response to early post-operative complications, and the adjustments required for a successful recovery after hospital discharge. The authors also deal with a common, but little discussed, issue: the transference and countertransference responses of surgeons to their patients. They provide a comprehensive review of the management of the post-operative problems, some of which are generic, such as post-operative delirium. One reviewer (D.S.K.) was pleased to note that they pointed out the danger of invoking the misuse of the diagnosis of ICU psychosis while not pursuing more likely underlying pathophysiological etiologies. They also discuss the psychiatric problems that are procedure- and specialty-specific, for example, phantom limb after amputation, the treatment of severe burns, and surgery for severe obesity as well as those associated with gynecology, cosmetic surgery, and ophthalmology.
In the 50 years since its first success, organ transplantation has become accepted as almost a routine procedure by the medical community, but it continues to be perceived as miraculous by organ recipients and their families. The chapter "Organ Transplantation" is very well done. It reviews the roles of the consulation-liaison psychiatrist as a critical participant in the initial evaluation of the potential recipient and, perhaps, a living donor; in pre-operative preparation of patients and donors; in hospital post-operative management, and finally, dealing with patients’ reactions to their efforts to re-enter the world of the well while they must still deal with the demands of their lifelong life-saving medical regimens. The authors do an excellent job of providing the knowledge required to assist a psychiatrist at each of these stages. The information provided comes with an excellent review of the pertinent literature.
The various psychological instruments most often used as initial screening devices for transplant candidates are described. The use of self-report methods is efficient, but is it adequate for this task? Can it replace the value of an interview by a psychiatrist who knows what lies ahead for the potential patient? The authors believe that psychiatrists play a complex role in which their primary goal is to serve the needs of the transplant team and not those of the patient. To strike a balance between these two responsibilities may be the greatest challenge, and an even more daunting one as living donors are being used more frequently.
The authors provide a very comprehensive review of the specific psychopharmacologic and psychotherapeutic knowledge required to manage the wide range of psychiatric problems which may emerge along the way. This includes the specific information needed in the management of the transplantation of each of the organs most commonly transplanted: kidney, heart, liver, and lung.
The authors of the chapter "Neurology and Neurosurgery" observe that for some, the divide between neurology and psychiatry has been a "historical artifact." Certainly, recent developments in both fields suggest that may be true. Their chapter reviews the various clinical states in which a knowledge of both is required for optimal patient care.
The issues encompassed by the chapter "Obstetric and Gynecology" should not be confined to the knowledge base of consulation-liaison psychiatrists alone. They are matters which should be of concern to all practicing psychiatrists. Reproductive issues in women are likely to arise in a psychiatrist’s practice every day.
The chapter begins with issues in benign gynecology: gender identity, infertility, contraception, sterilization, hysterectomy, abortion, chronic pelvic pain. The second section deals with issues of pregnancy, psychiatric disorders during pregnancy, denial of pregnancy, pseudocyesis, hyperemesis, postpartum psychiatric issues, and finally, psychiatric treatments (drugs, psychotherapy, and ECT) during pregnancy and lactation. Following these, there are sections on premenstrual problems, perimenopause and menopause, urinary incontinence, and a brief section on how these issues affect the men in women’s lives. The authors may have assumed that gynecologic oncology would be covered in the Oncology chapter, which it is not. A future edition can address that.
It might have been preferable to organize the latter section by phases in a woman’s life, i.e., beginning with pre-menstrual disorders rather than placing it together with problems such as menopause and urinary incontinence, which affect older women. It might also have been preferable to discuss treatments during pregnancy in the same section devoted to psychiatric disorders of pregnancy.
The references are up to date and relevant. However, future editions should include the most recent edition of Drugs in Pregnancy and Lactation by Briggs et al.8 Still, there is much that is valuable here for all psychiatrists.
Overall, the chapter "Pediatrics" is a comprehensive and useful overview of the identification, evaluation, and management of psychiatric syndromes seen in children with medical illness or children who present with physical symptoms. Its strengths include literature reviews of data on psychiatric illness and symptoms in specific populations of medically ill children; recommendations for factors to consider when evaluating specific populations of medically ill children; and the treatment sections, which include reviews of psychotropic agents that can be used in specific syndromes.
Also strong are discussions of children’s cognitive understanding of illness; the importance of a focus on family systems issues; the relationship of depression to functional disability; the importance of social support; the differential diagnosis of mood and anxiety symptoms, and the importance of screening and prevention measures. There is an important discussion of problems of adherence to treatment and the issues surrounding death and dying. Delirium and the management of chronic somatic symptoms are addressed, including the lack of utility of the "organic vs. nonorganic" dichotomy. A number of specific illnesses were addressed in order to emphasize the potential psychological factors that can affect medical morbidity. Unfortunately, the section entitled "Psychotropic Medication," focuses exclusively on potential cardiac side effects of psychotropic medication (perhaps that could have been reflected in the title), rather than giving any overview of other potential side effects or the use of such medication. The authors might have referenced Scahill et al.’s Textbook of Pediatric Psychopharmacology.9
Our role in "Physical Medicine and Rehabilitation" deserves more attention than it currently receives in consultation-liaison training programs. This chapter will help. It begins with the current WHO classification system of disabilities, The International Classification of Functioning, Disability and Health (ICF) which now treats the burden of all illnesses, including mental illness, equally. It focuses on two of the most common disorders: traumatic brain injury and spinal cord injury, and their psychiatric consequences.
The chapter reviews the fascinating sequence of pathophysiological events following traumatic brain injury, which produce varied psychiatric pathology: depression, anxiety (including PTSD), anger, agitation and aggressiveness, and the postconcussive syndrome. A similar thorough approach is used in the discussion of spinal cord injury. Each diagnosis is discussed in depth with a thorough review of the pertinent literature providing useful tools in diagnosis and treatment. The discussions of the merits of various psychotherapeutic and psychopharmacological interventions are thorough and helpful. In summary, this is an outstanding effort on a subject which merits it.
The authors of the chapter "Pain" provide a comprehensive review of the topic. They describe the management of acute pain and the common chronic pain syndromes. Each of the latter is well described and, where known, the underlying pathophysiology is reported.
Consulation-liaison psychiatrists often play an important role in the management of both acute and chronic pain. With acute pain, they must be prepared to deal with the persistent reluctance of physicians to provide adequate treatment with narcotics for fear of patients developing addiction.
The discussion of each chronic pain syndrome contains a review of the current treatments and their relative merits. The chapter includes an important section on the psychiatric comorbidity that is common in these patients. Particular attention is paid to the complex role of depression. The chapter concludes with a summary of the various pharmacological and psychological treatments used for the treatment of pain. Acupuncture and hypnosis are not included and should be discussed since they are in common use, and consulation-liaison psychiatrists should be aware of how they might be used most effectively.
TREATMENT
The chapter "Psychopharmacology" is very well done. It initially reviews principles of pharmacokinetics in the medically ill and drug-drug interactions. In addition to the standard psychiatric pharmacopiae there is an interesting section on Complementary Medicine, including herbal compounds. Particularly pertinent for the users of this textbook is the excellent section reviewing drugs that require particular monitoring in patients with renal and hepatic insufficiency. The table would be even more useful if it included patients with cardiac failure and pulmonary insufficiency. The final review of P450 interactions is also particularly useful.
The chapter "Psychosocial Treatments" includes a thorough review of the non-pharmacological therapies. A variety of group therapies are evaluated, as well as hypnosis, psycho-education, and family treatment. The summary tables unfortunately demonstrate the need for more well-designed statistically significant outcome studies of these modalities. The lack of such data should not be interpreted to reflect negatively on their potential value,
Since a convulsion is no longer produced in this treatment we believe the chapter "Electroconvulsive Therapy," should be retitled "Electrical Stimulation Therapy." That would be technically more correct and less likely to produce the fear and stigmatization associated with use of the older terminology. We also doubt the need to include this subject in a book for trainees and practitioners of psychosomatic medicine.
The final chapter, perhaps appropriately, deals with "Palliative Care." This is a valuable contribution at a time when hospitals have become increasingly aware of the needs of terminally ill patients. These needs are being met by the creation of multidisciplinary palliative care services. The crucial role of the psychiatrist in these services is well described in this excellent chapter. It reflects the authors’ vast experience in dealing with these issues at the Memorial Sloan Kettering Cancer Center, and their knowledge of the pertinent literature. They begin with a useful list of books on the subject for those who wish to explore it in more depth. A useful addition would be Becker’s Denial of Death.10 The subtext of the entire chapter is a description of the complex psychological process of dying. Layered upon that is a description of the variety of ways in which the psychiatrist can play a therapeutic role.
They point out the need to distinguish clinical depression from what others may consider the "normal reaction" to the situation and how to make that distinction. There is a sophisticated discussion of suicide, assisted suicide, and the desire for hastened death. They deal with the detection, assessment, and management of these different reactions to the impending end of life. The chapter also includes a discussion of the pharmacological issues to be considered for patients at this late stage of illness, and the psychotherapeutic interventions that have been utilized and where they seem to be most effective. While the symptoms of pain, asthenia, anorexia, and nausea are usually considered the responsibility of other caregivers, this chapter provides useful information and references for the psychiatrist who may ultimately serve as a patient’s primary physician when an interdisciplinary palliative care team is not available.
SUMMARY
This is a very well written comprehensive textbook. Like previous books on this subject (quaintly entitled Textbooks of Consultation-Liaison Psychiatry), it is over 1000 pages long and weighs almost seven pounds. This size reflects its successful effort to be comprehensive; however, like its predecessors, it unnecessarily includes information that its audience of trained psychiatrists should already know, in addition to what fellows in training should learn and practitioners should have available. The weightiness of our specialty need not be demonstrated by the heft of our textbooks (or the length of its book reviews).
FOOTNOTES
Dr. Kornfeld is the Associate Dean of Faculty and Dr. Wharton is Clinical Professor of Psychiatry at Columbia University College of Physicians and Surgeons.
REFERENCES
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