ABSTRACTS

Patients' reactions topsychiatric consultationKoran LM, Vannatta J, Stephens JR, et al.JAMA 241: 1603-1605,1979.

• This study addresses the wide­spread reluctance of primary carephysicians to obtain psychiatricconsultations for fear that their pa­tients will react negatively to con­tact with a psychiatrist. The authorsnote that the notion has foundsome confirmation in previous ar­ticles in the literature, which reportthat 40% to 65% of patients receiv­ing psychiatric consultation did notfind the experience helpful. Theauthors followed up 60 of 118 con­secutive referrals to a psychiatricconsultation service, excluding pa­tients who were psychotic or dis­charged within two days of beingseen. They found that 72% of thepatients followed up had favorableinitial responses to being seen by apsychiatrist and 63% believed (24hours after the consultation wasperformed) that the consultationhad been "very helpful." Over halfof the patients whose initial atti­tude toward consultation was con­sidered neutral, ambivalent, orhostile had positive feelings anddescribed the intervention of a psy­chiatrist as helpful at 24 hours. Onthe other hand, slightly over a thirdof those with initially accepting at­titudes had a shift in the negativedirection at follow-up. The authorsconsider these findings quite posi­tive, and note that half of the pa­tients with consistently negative at­titudes about psychiatric consulta­tion were substance abusers. Theyattribute their findings partly totheir efforts to educate referringphysicians. They had encouraged

referring physicians to preparetheir patients for consultation byassuring them that the psychiatristwould not be taking over the casefrom the attending physician, andby explaining that a consultation isa sincere attempt to obtain furtherinformation and expert help withthe patient's problems. Only 16%oftheir patients had not been in­formed in advance that a psychiat­ric consultation would take place.Another finding of interest was thatthere was no difference in responseto consultation among various de­mographic groups, or among pa­tients from different services of thehospital. The authors thereforeconclude that there is no particu­lar subgroup of patients who arelikely to respond in a negative wayto psychiatric consultation; theclear majority of patients of alltypes can respond positively topsychiatric intervention if the pur­pose of the consultation is pre­sented to them in a reasonable andsupportive way.

Francis P. LeBuffe, M.D.Falls Church, Va.

Music therapy inpalliative careMunro S, Mount B. Can Med Assoc J119: 1029-1034, 1978.

• The authors describe a very in­teresting program as part of pallia­tive care for terminally ill cancerpatients: music therapy, the con­trolled use of music to aid physio­logic and psychological functionduring the treatment of illness.Music was found to be a potent toolfor improving the quality oflife in anumber of patients with advanced

malignant disease. The authorspresent six touching clinical vi­gnettes that emphasize the powerof music in helping people dealwith extremely painful illness andlife events. Used in a carefully indi­vidualized way, music therapy is avaluable adjunct to other palliativetechniques. Music is able to com­fort when words are inadequate orinappropriate. The use of musictherapy is limited by the number oftherapists available, but could beused more fully by other therapists.Adjunctive therapies are very im­portant for people with terminalillness. Music therapy seems to beone adjunct that is often over­looked but fortunately has not beenforgotten.

David L. Keegan, M.D.Stanford, Calif.

Chronic pain andnarcotic addiction:A multitherapeuticapproach-A pilot studyKhatami M, Woody G, O'Brien C. ComprPsychiatry 20:55-60, 1979.

• Patients with intractable pain areat high risk for narcotic addiction.In the absence of other effectivetreatment, physicians often writeprescriptions for narcotics for thesepain patients, even though theyknow that these powerful analge­sics are no solution for the underly­ing problem. The authors describea pilot study of a multimodal ther­apeutic approach to chronic paininvolving symptom control, stimu­lus control, and social system mod­ification. They used EMG biofeed­back, relaxatiol1 training, and an­tidepressants where indicated to

PSYCHOSOMATICS

break up the "giving-up, given-up"complex. Erroneous cognitive be­liefs concerning the pathogenesis ofthe patient's pain were also con­fronted and modified. Finally, thesecondary gain in the patient'sfamily or other social system fromthe chronic pain was modifiedthrough direct intervention withfamily members or other relevantreinforcers of pain symptoms. Sig­nificant improvements in ratings ofhopelessness, pain, anxiety, anddepression were found in the fivepatients who completed treatmentout of six who commenced. At thecompletion of the program, all fivewere drug-free except for antide­pressants. The authors assert thatthe cognitive therapy and socialsystems interventions apparentlyadded significantly to biofeedbackand relaxation training.

James K. Witschy. M.D.San Antonio. Tex.

Psychogenic aspects ofurinary incontinencein womenStone CB, Judd GE. Clin Obstet Gynecol21:807·815.1978.

• Chronic urinary incontinence inwomen is a common condition withmultiple causative factors. Psycho­logical issues are often prominent.The urologic literature has utilizedthe term dyssynergic detrusor dys­function to explain chronic urinaryincontinence when anatomical ab­normalities are present. This litera­ture often mentions that this condi­tion is "psychosomatic and func­tional." The authors urge adoptionof the term "unstable bladder."Urinary incontinence has not been

JANUARY 1980 • VOL 21 • NO I

examined by psychiatrists, but uri­nary retention has been studied bypsychoanalytic authors. They agreethat the treatment for urinary re­tention is repeated urethral cathe­terization, which allows for vicari­ous sexual gratification. The au­thors studied 18 individuals withunstable bladders in a urologyclinic. All patients were unable tovoluntarily control their urinationwhen stressed by coughing, bystraining, or voluntarily. Threeprominent symptoms emerged. Allpatients exhibited severe interper­sonal problems involving signifi­cant relationships. For example,the urinary incontinence often pro­vided an escape from sexual activ­ity with a spouse. Most of the pa­tients had a chronic depression thatdid not respond to traditional tri­cyclic drug treatment. Finally, mostof the patients complained of func­tional sym ptomatology in otherorgan systems, such as headaches.gastrointestinal complaints. orbackaches. The authors urge ongo­ing supportive psychotherapy as anintervention. They recommendbrief visits to lessen the intensity ofdiscomfort from the symptom. Onegoal the physician may strive for ishaving the patient no longer focuson the symptom. Treatment shouldaim for total cure of the symptom.Concurrent use of psychotropicmedication is also advised, but onlyin conjunction with ongoing visits.The authors advise against the useof minor tranquilizers, but recom­mend small doses of tricyclic an­tidepressants. They emphasize thatdiagnosis may be done in a reason­ably short interview. Patients oftenhave had no goals when youngerand lack self-esteem. As adults,

they tend to welcome invalidism,and thus utilize their symptom asone form of giving up. Inquiringabout the patient's daily activities,difficulties in her closest relation­ships, and other functional symp­toms will demonstrate the chronicdepression. The physician mustrecognize that the patient's com­plaints of chronic urinary inconti­nence are very real and distressing.Offering a sympathetic ear may bea major help in ongoing supportivetreatment. This approach mayavoid recurrent evaluations andsurgical procedures for a conditioninvolving a major psychologicalcomponent.

Thomas N. Wise. M. D.Falls Church. Va.

Cardiovascular safety ofrapid treatment withintramuscular haloperidolDonlon PT. Hopkin J. Schaffer CB. et al.Am J Psychiatry 136: 133-134. 1979.

• The authors describe the effect ofintramuscular haloperidol on heartrate and blood pressure in 25acutely psychotic schizophrenic pa­tients. The patients were given 2.5to to mg haloperidol intramuscu­larly every 30 minutes until a ther­apeutic response was obtained. Themean total dose of haloperidol ad­ministered was 22.5 mg, with arange of to to 40 mg. Vital signswere recorded every 30 minutes forsix hours following the first injec­tion, and cardiac function wasmonitored in six of the 25 patientsvia a Holter monitor. All patientscompleted the study. There was nosignificant reduction in mean val­ues of blood pressure or pulse rate.

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ABSTRACTS

One patient had a clinically signifi­cant blood pressure decrease fol­lowing both of two injections ofhaloperidol; although her pulserate did not increase and she wasasymptomatic, the drug wasstopped. Her blood pressure re­turned to pretreatment levelswithin six hours. Holter monitorrecordings indicated abnormalheart rates with sinus arrhythmia intwo of six patients, and this wasunchanged during the administra­tion of haloperidol. One of thesetwo patients had an episode of par­tial syncope that likely was relatedto mitral valve prolapse rather thanto haloperidol. The authors con­clude that the use of intramuscularhaloperidol for the rapid control ofpsychotic symptoms in young,healthy schizophrenic patients iswithout significant cardiovasculartoxicity.

Robert G. Niven, M.DMayo Clinic

Handling the distressedolder patientPfeiffer E. Geriatrics 34(2):23-29. 1979.

• This is a useful paper, addressedto the general physician, describ­ing interviewing techniques witholder patients. The author pointsout the importance of the initialinterview and the extent to which itcan lay the groundwork for latertherapeutic intervention, both phys­ically and psychologically. Hesuggests that this interview not beone-sided, but that the physician beactive and involved. The physicianneeds to be able not only to com­municate interest, understanding,and desire to help, but also to be

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aware of his or her own behavior,expression, posture, and ability toconvey such warmth as is helpful.The author suggests that the physi­cian begin the discussion with thepatient by describing his own un­derstanding of the situation thatbrought about the referral. Thephysician might suggest that theinformation is incomplete andneeds clarification, that the patientneeds to be an active participant inthe process. He then sits back andlistens attentively to the patient,helping him to organize his storyuntil it makes sense to both of them.Frequently during the interview,the physician should make someobservation about how the patientappears to be feeling, such as, "Youappear worried or depressed." Thephysician should be sensitive totroublesome situations that oftenaffect older people, such as finan­cial problems, and changes in livingarrangements, health status, andrelationships. It is important toidentify what specific symptomshave accompanied the concerns theindividual is presenting, such asrestlessness, insomnia, crying, oranxiety. The interviewer ought alsoto be familiar with some of thepsychological therapies, such aspsychological intervention with in­dividual or group, environmentalchange, medication, or relaxationtherapy and biofeedback. The au­thor suggests that in the initial in­terviews certain measures are ther­apeutic, such as crisis interventionwhen a recent identifiable crisis ap­pears in the history. If there is con­siderable relief of distress duringthe interview, the patient may wellbenefit from psychological inter­vention. (I think this is somewhat

questionable; the patient needs tobe evaluated more often in moredetail.) The interview should endwith a summary of points coveredand possible plans, including thepatient's participation. The patientshould leave with some feeling thathelp is possible.

Miriam Rosenthal, M.D.Cleveland

Death attributed toventricular arrhythmiainduced by thioridazine incombination with a singleContac C capsuleChouinard G. Ghadirian AM, Jones BD.Can Med Assoc J 119:729-731, 1978.

• The authors report on the deathof a 27-year-old woman who suf­fered from schizophrenia and wasbeing treated with thioridazine, 100mg per day. She died one hour afteringesting one Contac C capsulealong with the thioridazine. Thecause of death was thought to beventricular arrhythmia brought onby concurrent use of thioridazine,which does produce ECG repolari­zation abnormalities, and phenyl­propanolamine in the Contac C.Phenylpropanolamine, an ephed­rine-like drug, was thought tohave favored the initiation of theventricular arrhythmia by thiorida­zine. The authors recommend thatwomen particularly vulnerable tothioridazine's ECG effects shouldhave an ECG prior to the start oftherapy. They recommend as wellthat ephedrine-like medicationsnot be given to patients receivingthioridazine or the related drug,mesoridazine.

David L. Keegan, M. D.Stanford, Calif.

PSYCHOSOMATICS