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The Hospital-Based Consultation and Liaison Service

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Handbook of Clinical Psychology in Medical Settings

Abstract

Psychosocial factors have a broad and substantial impact on patient presentation in the inpatient medical setting. Research clearly demonstrates that psychosocial factors play a crucial role in the etiology, pathophysiology, treatment, and clinical outcomes of numerous chronic and comorbid diseases as well as postsurgical outcomes and recovery. Given that psychiatric and behavioral symptoms can have a significant influence on chronic and acute illness, it is not surprising that inpatient medical settings have reported significant psychiatric issues in approximately 35 % of all inpatients. These psychiatric comorbidities can have negative consequences on medical outcomes as well as fiscal outcomes (e.g., increased length of stay and repeated readmission). Beyond clinical psychiatric diagnosis, the multiple stressors of the hospitalization can negatively impact the quality of life for even high-functioning patients. Unfortunately, these psychosocial factors are often poorly recognized and managed within the hospital setting. For example, less than 5 % of admissions across the hospital appear to receive a mental health consult, far less than the one third of patients estimated to have psychiatric comorbidity.

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Author information

Authors and Affiliations

  1. Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

    Michelle M. Ernst PhD, Carrie Piazza-Waggoner PhD, JoAnne Carey PsyD & Angela Roddenberry PhD

  2. Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA

    Michelle M. Ernst PhD & Carrie Piazza-Waggoner PhD

  3. Addiction Psychiatry Service, Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, Bronx, NY, USA

    Brenda Chabon PhD

  4. Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA

    Mary K. Murphy PhD

Authors
  1. Michelle M. Ernst PhD
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  2. Carrie Piazza-Waggoner PhD
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  3. Brenda Chabon PhD
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  4. Mary K. Murphy PhD
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  5. JoAnne Carey PsyD
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  6. Angela Roddenberry PhD
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Corresponding author

Correspondence to Michelle M. Ernst PhD .

Editor information

Editors and Affiliations

  1. Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes & Digestive & Kidney Diseases, Bethesda, Maryland, USA

    Christine M. Hunter

  2. Patient-Centered Medical Home Branch, Clinical Support Division, Defense Health Agency, Falls Church, Virginia, USA

    Christopher L. Hunter

  3. Fletcher Allen Health Care, Inc., Montpelier, Vermont, USA

    Rodger Kessler

Appendices

Appendix A: Sample CL Initial Intake and Follow-Up Session Forms

Behavioral Medicine Inpatient Consultation-Liaison Service

Initial consultation

Requested by:

Reason for referral:

Date of consult:

Persons interviewed:

Admission information:

Pertinent medical history:

Consent to this consultant:

Mental status exam

  • Appearance:

  • Affect:

  • Mood:

  • Behavior:

  • Orientation:

  • Level of consciousness/attention:

  • Suicidal/homicidal ideation:

  • Patient insight:

  • Family insight:

  • Patient approach to evaluation:

  • Family approach to evaluation:

Current referral concern

  • History:

  • Patient subjective:

  • Family subjective:

Symptomatology

  • Behavioral:

  • Cognitive/emotional:

  • Interpersonal:

  • Physiological:

Relevant medication

Relevant psychosocial factors (include only most relevant to referral question)

  • Family relations/functioning:

  • Interaction between physical/psychosocial factors:

  • Academic/work functioning:

  • Social/interpersonal functioning:

  • Patient’s premorbid functioning:

  • General coping, strengths:

  • Patient’s psychiatric/substance use history:

  • Patient’s traumatic events:

  • Family’s psychiatric history:

  • Family traumatic events:

  • Most salient ongoing psychosocial stressors:

  • Coping strategies:

  • Pleasurable activities:

Intervention

Impressions/recommendations

Plan

Collaborative contacts

Disposition

Consultant signature and contact information

Behavioral Medicine Inpatient Consultation-Liaison Service

Follow-up session

Current referral concern update

Mental status exam

Intervention

Impressions/recommendations

Plan

Collaborative contacts

Disposition

Consultant signature and contact information

Appendix B: Case Example of Adult Consultation

Reason for Consultation

Disruptive, crying, verbally abusive to staff, demanding to sign DNR DNI orders. Rule out suicidality

Mr. S is a 48-year-old admitted to the hospital from a nursing home for work-up of an inflammation in his arm. He has a history of chronic pain (has intrathecal morphine pump) after being run over by a garbage truck (injured legs collar bone feet, walks with a cane), also has a previous medical history of hypertension, hepatitis B, trigeminal neuralgia secondary to neuroma (right jaw).

Medications: Morphine, Oxycodone, Zolpidem, Paroxetine, Cephalexin

Psychiatric History: Major depressive disorder, anxiety, Output treatment 1993–1999 Inpatient 2000.

Social: Grew up in suburbs, did not complete high school. Gay identified—partner died of HIV in 1999. Previous employment in Medieval Times Amusement Park (he was a knight), ski and scuba diving instructor. Homeless, now living in a nursing home for the past 3 years. Unemployed on SSI. Mother died of Alzheimer’s, sister died of HIV. One married sister in New Jersey. History of recreational substance use.

On interview patient denied suicidal, homicidal, or paranoid ideation. Denied auditory or visual hallucinations. Endorsed difficulty eating and sleeping secondary to chronic pain. Misses being active but is future oriented writing song lyrics which he hopes to sell. States he is ambivalent about living or dying because he has lived a full life and as chronic and intractable as his pain is he would not actively chose to end his life. States he understands DNR/ DNI because his lover was a physician. Reports that DNR means that if he had a stroke he would not be poked and prodded. States would never accidentally overdose on pain medications as he is very careful with them. Says he enjoys living but is prepared to die when the time comes. Also said I’m not ready to die because I’m not done with my bucket list—need to sell my songs. Understands the alternative to DNR and does not want any life-saving measures. Also understands that DNR/DNI puts him at risk of dying earlier than he may otherwise.

Discussed with patient his behavior on the unit. Patient admitted to “acting up” because he wanted attention and felt that he was being ignored. Gave patient feedback on how medical staff found him to be rude and disruptive and explored with patient more effective ways to get his needs met. Patient was able to gain some insight to fact that not everyone thought his “jokes” were funny and we role played better communication skills to providers. Gave feedback to providers that patient has been socially isolated and developmentally behaves as an adolescent.

MSE: Alert, oriented X 4, poor eye contact, currently calm cooperative, mood euthymic, affect appropriate, speech fluent, thought process linear goal directed, thought content not bizarre, cognition grossly intact, average intelligence, insight, judgment, impulse control fair to good.

Axis I MDD, anxiety disorder

II deferred (traits evident)

III. chronic pain, neuromas, hepatitis B, trigeminal neuralgia

IV nursing home resident, no family contact, poor social support, unemployed

V = 40

Impression: 48-year-old male requesting DNR/DNI in context of intractable pain. Patient is not suicidal and understands the risks and benefits and alternatives to DNR/DNI.

Appendix C: Case example of pediatric consultation

Behavioral Medicine Initial Consult

Requested by: Generalist Inpatient Service (originally initiated by ICU)

Reason for referral: R’s post-traumatic stress symptoms

Family members interviewed: R’s mother Ms. S; R observed

Consent to this consultant: Yes

Background/History

Admission information: R is a 4-year-old African American boy who was admitted 10 days ago after accidentally being caught beneath a moving lawn mower. He sustained several injuries to his body, most notably to his left leg which required a below-the-knee amputation after several days of admission. Due to medical improvement, he has been transferred out of ICU to a step-down unit with on-going needs for pain management/sedation, rehabilitation and frequent OR trips for debridement and dressing changes. When debridement is complete, he will be transferred to the inpatient physical rehabilitation unit.

Pertinent medical history: None

Mental Status Exam

R was lying in bed watching TV. He appeared his stated age. When I came in he whimpered a bit but did not protest. He refused verbal engagement, and paid no attention to me while I met with his mom in the room. He appeared anxious, visually tracking me closely when I approached. When the consulting rehabilitation physician came in to examine him, R mildly protested but allowed the examination without behavioral opposition.

Current Referral Concern

History: As per the medical team, R is displaying considerable anxiety ever since awakening from constant sedation postamputation. According to his mother, R does not have any history of anxiety.

Family subjective: Ms. S reported that R is not acting “like her child,” and worries that he will always be emotionally traumatized.

Symptomatology

Behavioral symptoms: Will scream or cry when examined or moved. Will say “no” or “don’t” while sleeping. Resists having blankets taken off his body, resists looking at bandaged leg. Startles easily (e.g., when lines are beeping). Not eating very much, having trouble sleeping. Cries out in his sleep and appears to have night terrors.

Cognitive/Emotional symptoms: Very distressed, facial/body tension, appears constantly anxious.

Interpersonal symptoms: Not easily engaged with others, very little spontaneous conversation.

Physiological symptoms: Phantom pain, sleeping difficulties, high levels of physiological stress.

Relevant Psychosocial Factors

Family relations/functioning: Ms. S is in the military. R typically stays with Ms. S unless she has to go “in the field” for training, during which periods he stays with his father (parents divorced). At the time of the accident, he had been living with his father.

Emotional/Behavioral functioning: R is described by Ms. S as a very happy, active child with no notable behavioral/emotional concerns.

Child’s psych/Traumatic events: None noted other than current event. It is possible that R finds frequent separations from his mother to be emotionally challenging but that was not discussed.

Family’s psych/Traumatic events: None noted.

Current stressors: Adjusting to trauma of accident, amputation , pain and hospitalization

Coping strategies: None currently identified.

Family approach to evaluation: Somewhat cautious but willing.

Intervention

In addition to assessment, following interventions were conducted today:

  1. 1.

    Introduced my role and provided emotional support to Ms. S.

  2. 2.

    Provided psychoeducation to Ms. S. on the post-traumatic stress response from a developmental perspective, relating to R’s presentation.

  3. 3.

    Validated Ms. S’s concerns about R’ stress response while also discussing signs of improvement (R more willing this afternoon to let a physician examine him, compliant with attempting to raise his left leg).

  4. 4.

    With Rehab physician, described to Ms. S structure and purpose of inpatient rehabilitation. Provided education regarding R’ ability to return to full level of functioning while also acknowledging how difficult it is to have faith in this process.

  5. 5.

    Discussed importance of establishing a schedule and predictability for R in order to help him regain a sense of order and safety.

  6. 6.

    Modeled praising of R for brave behaviors during physician exam, which Ms. S began to do as well.

Impression

Given the multiple traumatizing events R has experienced during the past few days, it is understandable that R is demonstrating high levels of anxiety with re-experiencing of traumatic event (during sleep), avoidance of accident-related cues, and hyperarousal (all characteristic of post-traumatic stress responses). Ms. S is appropriately concerned about R’s stress responses.

Recommendations

R’s coping will be enhanced by providing a consistent, predictable environment with limited care providers in order to increase his sense of order and mastery, decrease his need for hypervigilance, and maximize his ability to develop supportive inpatient relationships. While it will be important to provide R the opportunity to “re-experience” his trauma in a controlled, supportive setting, this will need to be carefully done in developmentally appropriate ways with providers with whom R has a trusting, supportive relationship; thus, it is likely that this focus of treatment will wait until he has transferred to the Rehab unit. Until R and I have developed more rapport, initial focus of treatment will be on providing recommendations to family and treatment team.

Plan

This provider will:

  1. 1.

    collaborate with health care providers to develop predictable schedule for R

  2. 2.

    discuss with nursing staff importance of having consistent nursing team for R

  3. 3.

    discuss with Ms. S importance of allowing R opportunities for emotional expression

  4. 4.

    teach Ms. S ways to implement relaxation strategies with R.

  5. 5.

    discuss Ms. S’s concerns with inpatient rehabilitation team in anticipation of R’s transfer to that unit.

Collaborative Contacts

Have spoken with Dr. X of referring service today at 1,500 to review impressions, interventions, recommendations and plan.

Disposition

Ongoing

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Ernst, M., Piazza-Waggoner, C., Chabon, B., Murphy, M., Carey, J., Roddenberry, A. (2014). The Hospital-Based Consultation and Liaison Service. In: Hunter, C., Hunter, C., Kessler, R. (eds) Handbook of Clinical Psychology in Medical Settings. Springer, New York, NY. https://doi.org/10.1007/978-0-387-09817-3_16

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  • DOI: https://doi.org/10.1007/978-0-387-09817-3_16

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