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Preventive Psychiatry in the General Hospital By DAVIII BARTON AND HARRY S. ABRAM I N RECENT YEARS new dimensions and methods have been added to the process of psychiatric consultation in the general hospital. Once concerned primarily with diagnosis of specific psychopathological states and treatment and dispositional care of the individual patient, the process now involves the consideration of a wide variety of factors in the patient’s psychological adaptation to the hospital setting. The scope of the psychiatric consultation process has been widened to include consideration of the stresses of the hospital environment, psychological responses of individuals to illness and surgical procedures, the effects of psychological responses on the onset and course of illness, and the interpersonal responses within the patient’s transactional field that may contribute to psychological dysfunction. The consultation process may now involve, in addition to the psychiatrist, consultation-liaison teams utilizing the skills of a social worker, nurse, psychologist and chaplain, in a group effort. The consultation process may be viewed as being patient-oriented when the patient is the primary focus of the effort, consultee-oriented when the focus involves clarification of the referring physician’s role in the process, and situation-oriented when the patient’s behavior is viewed in terms of his interpersonal transactions in the hospital setting. Any given consultation may involve any one or a combination of these approaches and one does not exclude the other. Consultation psychiatry can be conceptualized as a branch of preventive psychiatry and as the practice and teaching of psychosomatic medicine.l The psychiatric consultation is viewed as prevention-oriented when it is aimed at preventing failures in psychosocial adaptation in patients and their care-giving milieu. In the latter case, psychological treatment is facilitated through attention to interpersonal responses in the hospital milieu. An important goal of psychiatr; ic consultation is the fostering of a psychologically therapeutic milieu on the general hospital ward-a milieu which will insure that all care-giving personnel are aware of the importance of their patients’ emotional responses and the relationship of these responses to medical treatment and the course of illness. Bibring’s medicopsychotherapeutic approach identifies such an attitude. In this approach, illness is understood as a stressful situation potentially threatening to the psychologic equilibrium. The physician’s skills are blended with his medical knowledge and the understanding of the From Vanderbilt Uniuersity School of Medicine, Nashoille, Tenn. DAVID BARTON, M.D.: Assistant Professor of Pspchiatry, Department of Psychiatry, Vanderbilt Uniuersity School of Medicine, Nashville, Tenn. HARRY S. ABRAM, M.D.: Professor of Psychiatry and Director of the Consultation-Liaison Seruice, Department of Psychiatry, Vanderbilt University School of Medicine, Nashuille, Tenn. 330 COMPREHENSIVEPSYCHIATRY,VOL. 12, No. 4 (JULY), 1971 PREVENTIVE PSYCHIATRY IN HOSPITAL 331 patient’s personality and psychological needs. In addition self-awareness is brought into the process of patient care.2 According to Caplan, “. , . the term ‘preventive psychiatry’ refers to the body of professional knowledge, both theoretic and practical, that may be utilized to plan and carry out programs for reducing the incidence of mental disorders of all types in a community (primary prevention) ; the duration of a significant number of those disorders that do occur (secondary prevention) ; and the impairment that may result from those disorders (tertiary prevention) .“3 While this definition has been applied primarily to preventive psychiatry in the community at large, the conceptual model is applicable in the general hospital “community.” We suggest the term ‘psychosocial adaptive failure” in the discussion of aspects of preventive psychiatry in the general hospital for important psychological responses that do not reach the proportion of frank mental disorder, and for maladaptation on the part of the hospital staff in their interaction with the patient. Preventive psychiatry in the general hospital must encompass the prevention of psychosocial adaptive failure as well as dealing with mental disorder per se. In this context, psychosocial adaptive failure on the part of the patient means that he develops emotional or behavioral responses to the stresses of illness, surgical procedures, or the hospital milieu which are in themselves incapacitating or interfere with receipt of optimal care. In some situations failure in adaptation reaches the proportions of “mental disorder” or a specific psychopathological state, such as an acute schizophrenic episode or a psychotic depression. Hostility, anxiety, regressive phenomena with increased dependency, or withdrawal may develop in the patient in response to illness or the routine of hospitalization, while another patient may develop a severe psychotic depressive illness in response to treatment in a unit such as a coronary care ward. In both cases the responses may seriously compromise the patient’s potential participation in the hospital process, impede receipt of optimal care and influence the course of his illness and treatment. The hospital milieu undergoes adaptive failure when emotional responses in care-taking personnel interfere with their providing adequate levels of medical treatment. When in a state of psychosocial adaptive failure, the milieu is no longer able to respond to the patients’ needs in a fashion that facilitates the patient’s psychological adaptation. For example, an overly demanding patient may evoke anger, leading to avoidance by the nurses and thus increasing demands for attention by the patient. PRIMARY PREVENTION Primary prevention in the general hospital or the reduction of the incidence of psychosocial adaptive failure and mental disorder involves: (1) the recognition and reduction of psychological stresses resulting from the hospital setting and illness; (2 ) the recognition of personality traits and other predisposing factors in the individual’s environment that render him vulnerable to psychosocial adaptive failure during the course of hospitalization and illness; (3) the appreciation of interactional patterns between the patient and those taking care of him; (4) the recognition and strengthening of those factors in the 332 BARTON AND ABRAM doctor-patient relationship, nurse-patient relationship and general hospital environment that support the individuals’ adaptive abilities; and (5) appreciation of those disorders resulting in organic dysfunction that predispose the individual to adaptive failure, Modern hospitalization requires considerable adaptive skill on the part of the patient. A large number of stresses exist in the hospital setting to which both the psychologically vulnerable and adjusted individual may react with adaptive failure. Diagnostic tests and procedures often perceived by hospital staff as routine and nonthreatening may represent a terrifying anxiety-laden experience for the patient. In the large medical center the patient who is designated an “interesting patient” invites the stresses involved in innumerable consultants’ visits and visits of interested students and house staff. Each of these relationships represents a new and sometimes trying interpersonal setting. There are a number of situations in the hospital setting that represent high risk situations for psychosocial adaptive failure. These range from the stresses evoked by ward rounds to those involved in specialized areas such as coronary care and renal dialysis units. 4-6 In addition to being stressful for patients some of these areas provide additional stresses for staff. For example the stresses on nurses working in intensive-care units are increased by the requirements of the type of care.’ ,Patients with certain personality structures may react to illness in terms of their characterological traits, e.g., overly dependent patients who are excessively demanding, or patients with orderly, controlled compulsive personalities who require control of their environment often manifest these traits in an exaggerated form in response to their illness.8 An integrated understanding of these traits into the care of these patients may effectively prevent psychosocial crises. An important method of dealing with psychosocial adaptive failure is outlined in Weisman and Hackett’s paper on “black patch” delirium, Noting a high percentage of delirium in patients who have temporary loss of vision after eye surgery requiring the covering of both eyes, these authors propose a specific doctor-patient relationship that fortifies ego functions and supplements reality testing to prevent the occurrence of postoperative delirium. Their concept is based on the observation that when ego function (perception) and reality testing are impaired in the patient having undergone eye surgery, delirium follows. Instead of utilizing the systematic investigation of conflict, they approach the problem through correction of faulty reality testing with a doctorpatient relationship in which the therapist can be accepted as an ally in mastering the stress of the operation and the patching. They provide supplementation of impaired visual perception by providing other sensory cues and concentrating on strong areas of ego function in the patient’s life.g The frequently employed “light on at night” with increased interpersonal contact and input of orienting sensory cues used in the management of delirium are other ways of improving ego function impaired through sensory deprivation induced by darkness and unfamiliar environment. We have seen two patients who developed delirium in a coronary care unit after their corrective lenses were taken from them at the time of admission. Rapid improvement in their mental states occurred when their eyeglasses were worn. PREVENTIVE PSYCHIATRY IN HOSPITAL 333 The area of interaction between the patient and his milieu represents an important area in which the techniques of primary prevention may be applied. When a hospitalized patient reacts in a manner that is incomprehensible or evokes strong feelings in the care-giving milieu, psychosocial failure occurs. When the patient does not conform with the expectation of his milieu he creates anxiety in those about him. Unless these feelings are resolved, the patient is avoided. In other cases, the feelings are reflected back to the patient as dismay or hostility. Meyer and Mendelson trace the development of such “dysphoric” affects and the interpersonal alienation which ensue in response to incomprehensible emotional and behavioral responses in the social matrix of the hospital ward.lO These responses often prompt a psychiatric consultation after the development of a crisis, but they are often amenable to a preventive approach when the milieu is educated to their occurrence. The nurse on the general medical or surgical ward and in specialized care units is in a key position to both perceive and manage early signs of psychosocial adaptive failure. Her role is facilitated through the efforts of other nurses with special skills in the area of attending the psychological needs of the patient and milieu.ll Including the nurse as a member of the consultation team is a helpful means of bringing to the consultation process her skills and viewpoint.12 In addition, this enhances the development of a psychologically therapeutic milieu throughout the hospital setting. SECONDARY PREVENTION Secondary prevention, the early identification, effective management and reduction of the duration of psychosocial adaptive failures and mental disorders in the general hospital setting, involves: ( 1) recognition and management of psychosocial adaptive failure and mental disorders occurring during hospitalization; (2) case finding and treatment of psychological illnesses present in disguised or masked forms that have led to hospitalization on medical and surgical wards; and (3) rapid management and resolution of psychosocial adaptive failures, thereby decreasing interference with the therapeutic functions of the milieu. Patients with flagrant psychopathology are usually recognized in the hospital setting. They are more readily recognized when they become uncooperative or disrupt routine. More subtle forms of psychological responses may, however, go unrecognized until they reach crisis proportions. Psychological responses to illness, surgical procedures and hospitalization include depression, denial, regression and anxiety.13 These responses are often involved in transactions between the care-giving milieu and the patient and often lead to interpersonal difficulties and impairment of medical care. These responses may frequently be appropriate and to some extent adaptive for the individual. When this is recognized they are less likely to evoke negative responses in the milieu. It should be recognized, however, that these same responses may reach such proportions as to incapacitate the individual or interfere with his medical care. For example, a depressed individual suifering from damaged self-esteem after a disfiguring surgical procedure may evoke an avoidance response or actual anger in the milieu to seek punishment and validate his feelings of worthless- 334 BARTON AND ABRAM ness. These reactions to illness should neither be ignored nor viewed as totally adaptive responses. Rather they underline the necessity for the consultant or primary physician to understand the basis for the patient’s response and render appropriate support, reassurance or exploration of conflict. When this is accomplished these responses are less likely to develop to the proportion of actual mental disorder. An important area for secondary prevention is the identification and effective management of those patients who express their psychosocial difficulties in terms of somatic symptoms. Early recognition of these patients is essential, as their unconscious resistances, often fortified by numerous workups and token “organic” diagnosis, become increasingly difficult to work with over a period of time. Duff and Hollingshead, in their study Sicknms and Societg,14 report that in a sample of 161 patients from medical and surgical services, 26% were “underdiagnosed mentally.” A patient was placed in this category when a diagnosis of physical disease was given, even though the patient’s illness as presented to his physician was indicative of a major psychological disturbance. A number of patients in their study received what they refer to as an “ad hoc” diagnosis, which obscured the underlying psychosocial basis for medical intervention. In viewing the patient’s illness holistically, these authors offer a different perspective for viewing disease. In this framework, four categories of patients emerged: ( 1) the illness was “a response to a way of life” inasmuch as the symptoms arose from psychosocial unrest and there was lack of evidence of physical illness; (2) “the patient was organically ill because of his way of life” in that his way of life caused specific organic disease of body malfunction, as in alcoholism; (3) “the symptoms were related partially to a way of life,” since important psychosocial elements combined with organ vulnerability or organ systems; or (4) there were “no apparent links between the symptoms of patients and their way of life.” Such a framework is helpful in focusing the physician’s attention on the psychosocial aspects of illness and serves to delineate more effectively those patients whose illness is largely related to psychosocial factors.14 Viewing patients in this framework also serves to promote earlier detection of psychosocial determinants in illness. Patients with depressive illnesses contribute a large percentage of those patients seen in psychiatric consultation in the general hospital. Often the depression is masked by hypochondriacal somatic complaints.15 A number of these patients have been found to have suicidal ideation.16 The recognition of these patients has obvious implication for secondary prevention. TERTIARY PREVENTION Tertiary prevention involves reducing impairment resulting from psychosocial adaptive failure. The category of patient most commonly involved in tertiary prevention is the individual with an illness in which psychosocial adaptive failure results in his accepting the illness as a way of life. In this case psychological and social aspects of the patient’s life align with the illness to produce prolonged incapacitation. Disability is primarily psychologically determined rather than physical. Those patients who have reached a stage of incapacitation PREVENTIVE through PSYCHIATRY IN of the role of being ill can best be helped when psycho- over-acceptance social determinants leading to these difficulties of their illness. As time passes, treatment becomes 335 HOSPITAL are identified early in the course become obscured these determinants increasingly further and difficult. COMMENT hospital The of preventive vention, tant community improved These The methods in the general who has urged logical of patients viewed It should factors on the general actions within have the milieu, and treatment of care-giving plans. milieu these communications attitudes within response to illness. where adaptive By preventive failures of the social on a theoret- and trans- of the practicality has frequently the physical of those between overpsycho- vitally and gains aspects in diagnostic and members in begins a better be and tasks of the unit, with the consultee important can adaptive the trans- involved so, he recognizes techniques be accomplished psychosocial must understand procedures the consultant doing goals cannot office. To appreciate Communication are Through areas that preventive appreciate the milieu speculative interactions ward the consultant knowledge workup subtle approach as being in illness. hospital a working highly with psychopathology of the consultant’s failure psychological and holistic and little consideration of the often also be emphasized from the comfort the A concern at setting. consider out of the context impor- to the community has often been designated setting, the consideration and somatic his colleague crisis inter- methods, hospital from poor communication, of the recommendations. and in general, milieu of the hospital shadowed that not be limited asking for a more comprehensive “soap box.” This resulted actional and rehabilitation are valuable of medicine ical appraisals of consultation, area for the application early case finding, need in illness, thereby to the practice target Education, psychiatrist, techniques psychiatrist factors an important techniques. to the community large. forms psychiatric a preventive to appreciate understanding developing employed approach. interpersonal of the patient’s crises before and other psychosocial occur. REFEFuzNCES 1. Lipowski, Z. J.: Review of consultation psychiatry and psychosomatic medicine: I. General principles. Psychosom. Med. 29: 153, 1967. 2. Bibring, G. L.: Psychiatry and medical practice in a general hospital. New Eng. J. Med. 254:366, 1956. 3. Caplan, G.: Principles of Preventive Psychiatry. New York, Basic Books, 1964. 4. Abram, H. S.: Survival by machine: The psycho!ogical stress of chronic hemodialysis. Psychiat. in Med. 1:37, 1970. 5. Preuss, H., and Solomon, P.: The patient’s reaction to bedside teaching. New Eng. J. Med. 259:520, 1958. 6. Hackett, T. P., Cassem, N. H., and Wishnie, H. A.: The coronary care tit: An appraisal of its psychological hazards. New Eng. J. Med. 279:1365, 1968. 7. Vreeland, R., and Ellis, G. L.: Stress on the nurse in an interview care unit. JAMA 208:332, 1969. 8. Kahana, R. J., and Bibring, G. L.: Personality types in medical management. In Zinberg, N. E. (Ed.) : Psychiatry and Medical Practice in a General Hospital. New York, International Universities Press, 1964. 9. Weisman, A. D., and Hackett, T. P.: Psychosis after eye surgery: Establishment of a specific doctor-patient relation in the 336 prevention and treatment of “blackpatch delirium.” New Eng. J. Med. 258:1284, 1958. 10. Meyer, E., and Mendelson, M.: Psychiatric consultations with patients on medical and surgical wards: Patterns and processes. Psychiatry, 24: 197, 1961. 11. Holstein, S., and Schwab, J.: A coordinated consultation program for nurses and psychiatrists. JAMA 194:103, 1965. 12. Barton, D., and Kelso, M. T.: The nurse as a psychiatric consultation team member. Psychiat. Med. (in press). BARTON AND ABRAM 13. Abram, H. S.: Psychological responses to illness and hospitalization. Psychosomatics 10:218, 1969. 14. Duff, R. S., and Holhngshead, A. B.: Sickness and Society. New York, Harper & Row, 1968. 15. Lesse, S.: The multivariant masks of depression. Amer. J. Psychiat. 124:35, 1968 ( Supplement). 16. -: Hypochondriasis and psychosomatic disorders masking depression. Amer. J. Psychother. 21:6M, 1967.