Bibliotheca psychiatrica最新文献

Pain is both the commonest and one of the most enigmatic symptoms in medicine. Its subjective nature renders management difficult and its conceptualization is complex. Reaction to pain cannot be easily generalized; group differences are postulated, based on sex, age, culture, psychiatric diagnosis and personality variables. Early developmental aspects of pain and discussed in animal studies and case reports but little systematic data exist. Experimental findings show the influence on pain response of cognitive and emotional factors. Clinically, the variables determining perception, reporting and reaction to pain are numerous and harder to study scientifically. Acute and chronic pain should be distinguished: the latter is more complicated, leading of ten to diagnostic problems and management stalemates. Discovering the relationship of pain to emotional phenomena, as cause or effect, is difficult, though essential to effective treatment. Various frames of reference apply: e.g., individual medical, familial, and "workmen's compensation" models. Reaction by family, lawyer, or work commission involves potential secondary gain and may reinforce or discourage pathological responses by the patient. The potential of pain for symbolic meaning and its acceptance as a "legitimate" medical symptom renders it ideal for both expression and masquerading of intrapsychic and interpersonal conflicts involving anger, punishment, control and dependency. Teaching about pain and its significance is best done in clinical settings such as obstetrical units and multidisciplinary pain clinics. Videotaped modular presentations with discussion provide a satisfactory though less desirable alternative.

One of the recent trends in the general hospital is the increase of psychiatric units and the number of psychiatrists working therein. Thus the psychiatrist has had greater opportunities to participate as a member of a clinical team in the care of patients of other units. Accordingly, daily cooperation with other specialties casts him into new roles which transcend those of the traditional psychiatric consultant. The role of liasion psychiatrist involves the complex relations of doctor--nurse--patient--family, interdepartmental relations, communications and so on. By improving these relationships he tries to bring about a more holistic approach in the general hospital.

The prerequisites for effective rehabilitation programmes in elderly patients are described, taking into account the specific social, physiological and psychological changes associated with senescence. The special problems facing elderly patients admitted to hospital are discussed and how their needs can be met. The importance of dementia as a factor influencing rehabilitation is considered and the various forms of residential and non-residential care described. Similarly, the paramount importance of accurate diagnosis of the causes of confusional states is emphasized and principles of management described. The fruitfulness of effective liaison between the psychiatrist and geriatrician is underlined and various ways by which this can be achieved, including the place of psychogeriatric assessment unit, and the role of the acute geriatric ward and geriatric rehabilitation unit. The principles of management of the elderly mentally ill in hospital are outlined. As specific examples of the principles and problems of rehabilitation programmes for disorders in the elderly, a detailed description is presented of the rehabilitation of the patient with myocardial infarction and the patient who has developed a hemiplegia following a cerebrovascular accident.

The first part of this paper is based on a study by the author in 1975--1976. The conclusions were that liaison psychiatry with geriatric patients differs from that with other age groups in the following ways: (1) referrals occur primarily when behavior becomes disturbing; (2) organic causes are often overrated but psychological and social causes and functional disorders are underestimated; (3) psychopharmaceutical agents and vasodilators are overused, while psychotherapy and other forms of treatment are underutilized. Attitudes towards consultations among these patients, their families and consultees do not differ from those of younger groups. Liaison psychiatry with a situation-oriented approach is well suited to the needs of all concerned. Review of the psychosomatic parameters of aging is summarized as a basis of the proposed psychosomatic differential model for management.

In the developed world, comprehensive services for disabled patients are usually well established for children and elderly people. Services for rehabilitation of middle-aged patients generally consist of specific treatment facilities, such as for physiotherapy. On the other hand, a range of services of psychiatric patients is now established, with a model suitable for most disorders. Arrangements are flexible, ranging from crisis intervention to long-term care, in some places being remarkably comprehensive and well coordinated. There is a need to plan development of medical and social services for patients prone to chronic morbidity from whatever cause; this plan for the physicially disabled should take account of their many needs, and of the many facilities now available, some statutory, some voluntary. There is reason to believe that redeployment of resources existing in many countries could improve the standard of medical rehabilitation for patients of all ages.

The hemodialysis unit is usually a uniquely desirable place for liaison teaching because of the importance and variety of behavioral problems seen there. The trainee may be educated at these units about the syndrome of delirium because of the potential for his seeing in a given patient the presentation and resolution of the syndrome before and after each run. Because of the abject dependency of these patients, issues surrounding patient dependency "needs" and frustration of their independence are common with patient "uncooperativeness", an important area in which the professional staff need education and patients need intervention. Depression, common among these patients because of their many losses, is among the host of psychological problems to be potentially diagnosed and treated by the liaison trainee and/or teacher. The theme of life setting conductive to medical illness and the setting of realistic rehabiliation goals are also important areas of liaison training, particularly suitable for demonstration there. Therefore, hemodialysis centers offer usual wide variety and often untapped resources for liaison education.

In the United States, teaching and training of the psychosomatic approach relies upon (1) the application of psychosomatic concepts, such as reaction to stress, life change and illness, and neuroendocrine influences on disease process to the delivery of mental health services to the sick and dying through liaison programs, and (2) the focussing upon relevant methodology of psychological care in the context of American medicine with its growing knowledge of social implications of health care. Such methodology includes the teaching of data collection, substantive psychiatric disorders in the medically ill, supportive therapy and crisis intervention, psychopharmacology, emotional reaction to illness, and management of obstacles to a psychosocial approach. The resistance of nonpsychiatrist personnel to psychological factors and of psychiatric personnel to medical factors are obstacles which require particular emphasis in graduate and postgraduate training in this clinical area.

The author describes a curriculum in which the emphasis is on teaching of medical students a general systems approach to health and illness from the first year of medical school through the fourth year. In the first year, a three-part course in behavioral science includes: Introduction to the Patient; Social and Ethical Issues in Medicine; Exercises in Decision-Making; and a didactic lecture series, Determinants of Behavior. This is followed in the second year by a course in psychopathology taught from environmental, psychological and social perspectives. The third-year clerkship emphasizes a liaison approach where students return to the medical and surgical services to work-up patients from a broad multidimensional perspective. The formal program in psychiatry and behavioral science is supported by more than 40 electives in human development, biological, social and psychological psychiatry, including behavior. During these phases the student has experience in working as a member of a team. She/he approaches the health of an individual in terms of the life phase of the individual, the present life of the individual, his/her past experiences, previous personality, reaction to the current illness phenomenon while following the illness through the hospital phase of the present illness, studying coping and adaptational processes.