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A Consultant Psychiatrist in Psychotherapy working in a ...

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  • 1. A Consultant Psychiatrist in Psychotherapy working in a Gastroenterology Hospital Julian SternJulian Stern
  • 2. Structure of presentation • Who do we see at a hospital for Gastro-intestinal disorders? • 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 image disturbance • Psychosexual problems • Narcotic use • Depression • Compliance issues
  • 5. First 200 patients seen • 6%: women with eating disorders • Bulimia and/or anorexia • Undiagnosed • 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 gastro-enterology OPD’s • IBS affects 9-12% of the population (F:M=1.1- 2.6:1) • 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 diarrhea/gastroenteritis. • 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 interpersonal therapy • 2. Drossman et al-The role of CBT and/or pharmacotherapy • (Also-Hypnotherapy, Biofeedback, Cognitive Behavioural Group therapy etc)
  • 10. The Work of Francis Creed and Else Guthrie • “The Cost-effectiveness of Psychotherapy and paroxetine for severe irritable bowel syndrome”. Gastroenterology 124:303-317 • Patients with severe IBS were randomly allocated to 8 sessions PT; 20 mg paroxetine; or TAU with GP and/or gastroenterologist
  • 11. Results • 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 psychological component • 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 North Carolina • “Cognitive Behavioural Therapy versus education, and desipramine versus placebo for moderate to severe functional bowel disorders” Gastroenterology 125:19-31 • Results: • CBT>education • 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 referring team • 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 trial interpretations. • But also-is there any need for psychiatric input ? • And, what sort of feedback to the medical team/GP/patient.
  • 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” ?
  • 22. Conclusion • Same principles as any thorough assessment • In addition have the question of psychiatric needs in mind • 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
  • 23. Conclusion • 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 managers . • I do have the freedom to work autonomously, without some of the constraints of the mental health setting • Colleagues are part time psychotherapists…CBT and psychodynamic- but mainly surgeons, physicians, and nurses-pro’s and con’s !
  • 24. References • 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 125: 19-31 • Stern JM (2003) Review Article: psychiatry, psychotherapy and gastroenterology-bringing it all together. Alimentary Pharm Therapeutics. 17;175-184