Demystifying Psychiatry

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Why Did They Call for a Psychiatric Consultation?

Medically ill patients may have behavioral disturbances when hospitalized

People are hospitalized for many reasons, including trauma, heart attacks, and stroke. Perhaps, a person needs intensive treatment for cancer or elective surgery to replace a hip or a knee. Regardless of the reason for hospitalization, it is not unusual for the medical or surgical doctor to request a psychiatric consultation. Why? Many medical conditions and/or the treatments used for these conditions are associated with behavioral symptoms, and the internist or surgeon often wants input from a psychiatrist to help determine the cause of the behavioral changes and identify effective treatments.  What are some of these behavioral changes and why do they occur? Here are some examples.

Some medical conditions, for example, heart disease and diabetes, are associated with symptoms of clinical depression. If a hospitalized patient is thought to be seriously depressed or indicates in any way that he or she is thinking about self-harm, the medical team often calls in a psychiatrist to evaluate the nature and severity of the depressive symptoms, assess the risks of self-harm, and make treatment recommendations. Psychiatrists play an important role in the management of these patients because the presence of depression often worsens the outcome of the primary medical disorder, and vice-versa.

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Another common scenario involves a hospitalized patient on a medical or surgical service who develops the sudden onset of agitation, confusion, disorientation, or hallucinations (for example, hearing voices or seeing objects or people that aren’t there). There are many possible reasons for such behaviors in hospitalized patients. For example, some patients have pre-existing psychiatric illnesses that become more symptomatic with the stress of hospitalization. Patients with bipolar disorder or schizophrenia may develop active symptoms of these disorders as a result of stress and disruption in their routine. Hospitalization, with its resulting change from a familiar environment, can also lead to marked behavioral changes in persons with dementias like Alzheimer’s disease.

Another common reason why hospitalized patients exhibit agitation, disorientation, and/or hallucinations is the development of a condition known as delirium. Delirium is a type of acute brain disequilibrium in which multiple brain systems get out of balance.  Sometimes, a person may have a “quiet” delirium and be very confused. Such patients are often overlooked until someone on the treatment team realizes that the person is disoriented or having major problems with memory. Sometimes, the brain disequilibrium leads to more disruptive symptoms such as agitation or hallucinations. These patients can be extremely unruly and dangerous to themselves and others. Although a delirium declares itself via a patient’s disturbed behavior, the causes typically involve the underlying medical condition or its treatment. For example, the cumulative effects of too many medications can lead to delirium.  An undetected infection, such as a urinary tract infection or pneumonia, can trigger delirium. Surgery, especially under general anesthesia, sometimes pushes the brain over the edge, resulting in delirium. A psychiatrist can help the medical or surgical team make the diagnosis of delirium and then encourage an evaluation of underlying medical cause(s). The psychiatrist can also assist with the management of disruptive behavior.  As already mentioned, a person with dementia has a brain that is already compromised and is much more susceptible to developing delirium. Figuring out which symptoms are related to the dementia and which symptoms are caused by a delirium can be challenging.

It is important that deliria are diagnosed and the cause determined.  An ongoing delirium is associated with substantially worse medical outcomes in both the short- and longer-term, i.e., acute brain disequilibrium and its underlying causes can be associated with a downhill clinical course and an increased risk of death. Deliria are also observed in the terminal phases of a number of illnesses.

Sometimes psychiatrists are consulted in a general hospital because a patient is refusing medical or surgical interventions that the treating physicians believe are essential. The medical team may become concerned that the patient is not using reasonable judgment and may ask a psychiatrist to help determine whether the patient has the capacity to decide. Although this decision does not require a psychiatrist, it is not uncommon for psychiatrists to be asked to evaluate a person’s mental function and capacity for making decisions. The role of a psychiatrist in this situation is to give an opinion about the patient’s decision-making ability. If the psychiatrist believes that the person has the capacity to decide about the medical or surgical treatments being offered, then the medical or surgical team may be frustrated, but they should honor the patient’s decision. If it is determined that the patient truly does not understand the nature of the condition and the risks of not accepting treatment, the medical or surgical team may decide to follow established protocols to provide treatment against the patient’s wishes in order to help save his or her life. It is important to note that, in these cases, psychiatrists evaluate mental state and the capacity to make a decision. They do not declare patients “incompetent” as it is sometimes mistakenly believed; competence is a complex legal and not medical/psychiatric decision. 

There are numerous other reasons why medical or surgical doctors may ask a psychiatrist to evaluate a hospitalized patient.  It usually isn’t for counseling or “therapy,” however. Rather, it is to help the treatment team figure out why a patient is demonstrating behaviors suggestive of significant brain dysfunction and how these behaviors should be best addressed.

This column was co-written by Eugene Rubin MD, PhD and Charles Zorumski MD.

Eugene Rubin, M.D., Ph.D., is Professor and Vice-Chair for Education in the Department of Psychiatry at Washington University in St. Louis - School of Medicine.

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