1. A Consultant Psychiatrist in
Psychotherapy working in a
Julian SternJulian Stern
2. Structure of presentation
• Who do we see at a hospital for Gastro-intestinal
• How do we assess ?
• What is being requested ?
• What is the ailment ?
• 2 cases
3. First 200 patients seen at St Mark’s
Psychological Medicine Unit
• 50%-Functional bowel disorders-Irritable Bowel
Syndrome, chronic constipation.
• Female preponderance
• Often Obsessive-Compulsive Symptoms
• Often anxious, depressed
• Sometimes Abuse in childhood
• Borderline traits
4. First 200 patients seen
• 30% with Crohn’s Disease / Ulcerative Colitis
(Inflammatory Bowel Disease); M=F
• Young adults with relationship difficulties, body
• Psychosexual problems
• Narcotic use
• Compliance issues
5. First 200 patients seen
• 6%: women with eating disorders
• Bulimia and/or anorexia
• Denial ++
• Secrecy ++
• Poor prognosis
6. First 200 patients seen
• Psychotic depression with somatic delusions
• Body Dysmorphic disorder-pertaining to the anus
• Acute sudden depression following surgery
(PTSD-like state, mutism)
• Munchausen syndrome
• Reactions to illness-stoma’s, pouches, fistulae,
solitary rectal ulcers.
7. The scale of the problem
• Functional Dyspepsia and Irritable Bowel
Syndrome account for 40-60% of referrals to
• IBS affects 9-12% of the population (F:M=1.1-
• Well-recognized negative social impact of
significant absenteeism from work, impaired
health-related QoL, and increased medical costs
8. Who develops IBS post infection?
The role of premorbid personality
• Gwee et al (1996, 1999) studied (prospectively)
medical in-patients with infectious
• Who goes on to develop IBS? And who recovers?
• Answer: Those with high levels of
hypochondriasis, neuroticism, anxiety and
somatization and high numbers of adverse life
events develop IBS.
9. Research-what works?
• 1. Guthrie, Creed et al-Psychodynamic
• 2. Drossman et al-The role of CBT and/or
• (Also-Hypnotherapy, Biofeedback, Cognitive
Behavioural Group therapy etc)
10. The Work of Francis Creed and Else
• “The Cost-effectiveness of Psychotherapy and
paroxetine for severe irritable bowel syndrome”.
• Patients with severe IBS were randomly allocated
to 8 sessions PT; 20 mg paroxetine; or TAU with
GP and/or gastroenterologist
• 69% find PT acceptable
• 50% find paroxetine acceptable
• Both PT and paroxetine >TAU in improving the
physical aspects of the SF-36, but not in the
• In the follow-up year, only PT significantly
reduced health care costs.
12. They Conclude…
• “For patients with severe IBS, both
psychotherapy and paroxetine improve health
related quality of life at no additional cost”
13. Drossman et al (2003)-University of
• “Cognitive Behavioural Therapy versus
education, and desipramine versus placebo for
moderate to severe functional bowel disorders”
• TCAD> placebo when those who are non-
compliant are excluded
14. They Conclude…
• “For female patients with moderate to severe
Functional Bowel disorders, CBT is effective and
Desipramine may be effective when taken
adequately. Certain clinical sub-groups are more
or less amenable to these treatments”
15. How do we assess (1) ?
• Context-within a medical setting
• Rooms, privacy
• Patients are not sent a questionnaire
• Recognition that they are being seen by someone
who works with the medical/surgical team
• No background psychiatric information
16. How to assess (2) ?
• Recognition that patient may be unsure as to why
they are here
• (Denial, disavowal)
• Question of confidentiality, and feedback to
• Can the patient allow a sense of colleagues
working as a couple or will there always be a
tendency to splitting
17. How to assess (3) (What is being
requested for the referrer?)
• Does the patient need psychiatric help?
• Does he/she need psychotherapy?
• What is unbearable-the patient, the condition, the
countertransference, the identification ?
• Is the referrer continuing to work with the patient
or is this a “getting rid of the patient” referral ?
18. The assessment (4) (continued)
• Does the patient need psychiatric input?
• Does he/she need psychotherapeutic input ?
• What sort?
• Does he/she agree to psychotherapeutic input ?
• Are there specific issues to do with the medical
condition which need highlighting in the work ?
• What resources are available for therapy ?
19. The assessment (5) (continued)
• So, I am still looking for questions such as the
nature of a “therapeutic alliance”, is there any
curiosity in the patient , can the patient respond to
• But also-is there any need for psychiatric input ?
• And, what sort of feedback to the medical
20. Principles of management
• Collaborative effort with physicians, multi-
disciplinary team, G.P., CMHT
• Establish a rapport
• Patients are extremely wary of stigmatization; but
may well find it more “containing” being seen in
a medical hospital, rather than Psych OPD
21. Principles of management (2)-
questions for psychiatrists!
1. Would these patients reach the “thresh hold” for
being taken on by a CMHT
2. Whom are you “allowed” to see ? And over
what period of time?
3. What skills are you encouraged to develop?
4. Are you able to make use of your psychological
understanding of patients?
5. What risks to your mental health if you are only
seeing “Severely Mentally Ill patients” ?
• Same principles as any thorough assessment
• In addition have the question of psychiatric needs
• Privileged position of meeting patients many of
whom would not otherwise be referred
• Privileged position of meeting patients many of
whom would not otherwise agree to attend a
consultation with a psychotherapist
• Context very important-I don’t have the support
of a bigger team-practical support, thinking
support, CPD, governance-must find it elsewhere
• I don’t have the support of mental health
• I do have the freedom to work autonomously,
without some of the constraints of the mental
• Colleagues are part time psychotherapists…CBT
and psychodynamic- but mainly surgeons,
physicians, and nurses-pro’s and con’s !
• Creed F (2003) Cost-effectiveness of PT and
paroxetine in IBS. Gastroenterology 124: 303-317
• Drossman D et al (2003) CBT vs Education, and
desipramine vs placebo in Moderate to Severe
Functional bowel disorders. Gastroenterology
• Stern JM (2003) Review Article: psychiatry,
psychotherapy and gastroenterology-bringing it
all together. Alimentary Pharm Therapeutics.