TEACHING LIAISON PSYCHIATRY for example; and while of undeniable importance, TO MEDICAL STUDENTS often lie beyond the scope of traditional psychiatric By DR MICHAELA. SIMPSON, therapy. Far from being an extra super-specialty, liaison Academic Department of Psychiatry, Royal Free Hospital psychiatry represents the most appropriate general Consultation-liaison psychiatry has emerged as a psychological medicine to teach the medical under significant area of special interest within clinical graduate. psychiatry in recent years. It seeks to enhance the quality of psycho-social care of medically ill patients and of their psychological reactions to illness; to ACUTE PSYCHOTIC REACTIONS provide effective consultations not only with regard IN IMMIGRANTS to patient management, but also to the complex By DR ROLANDLITTLEWOOD, problems arising where serious medical and psychia Hackney Hospital and tric illness overlap, and to deal with the personal DR MAURICELIPSEDGE, difficulties arising in members of the clinical team St Bartholomew's Hospital caring for the patient. It has an essential contribution to make to the actual practice of holistic, compre Studies of West Indian and West African immi hensive health care; rather than just to the airy grants have consistently shown high rates of diagnosed rhetoric by which whole-person medicine exists in schizophrenia, although they differ in the extent to the medical school's prospectus and objectives but which the illness is seen as atypical. A retrospective not in its wards. We do not teach mere vapid sym examination of hospital notes at an East London pathy, but competent psycho-physiological under Psychiatric Unit showed that although total ad standing of the patient, and sound communication missions were similar in different ethnic groups skills. there was an excess of schizophrenia in Caribbean The liaison psychiatrist is especially well placed and West African migrants similar to that found to teach psychiatry as it applies to the regular, previously. These patients also showed an increase in daily, practice of medicine, and in a context which is two pathoplastic features, religious and paranoid unusually convincing to those students who do not flavour and an increased proportion of women, appreciate the importance of our subject, and who so formal admissions and short admissions. often show a stubborn tendency to believe of psy A prospective study of patients with religious chiatry only what the surgeon says, if not vice delusions (a criterion chosen to yield a high proportion versa. of atypical reactions) using the Present State Exam Examples were provided of the problems en ination, a Religious Interest Questionnaire, video countered in establishing and developing such tapes and interviews with their families, isolated 24 services, including the nature of the stereotypes of West Indian and West African patients. Sixteen of the 'typical' psychiatrist held in other Departments them who did not have first-rank symptoms of (and often reinforced by our own 'different' behaviour schizophrenia differed from the eight who did in and dress) and the importance of being able to talk being more likely to be female, to come from a in pragmatic and understandable terms, and avoiding religious family and have had continuous religious unhelpful jargon. experiences acceptable to the family since childhood, The wide range of clinical problems seen were to have migrated more than five years before first discussed, with illustrations. The liaison psychiatrist psychiatric diagnosis/referral, and to have changed deals with psychiatric illnesses presenting as medical church, often to a more charismatic sect, although and physical problems, and with medical problems not participating in church social life. Judged by presenting psychiatrically; with the various psycho their family to have been quite well in the week somatic and stress disorders; deviant sickness preceding admission, following an event such as a behaviour; and with serious, self-destructive non- threatened eviction they became excited and violent, compliance, excessive dependence, or gross denial of assulting people and damaging property, and were illness. Such difficulties as the unduly angry patient, taken to hospital under Section 136. the seductive patient, the violent or absconding or The full PSE could not initially be rated, the lying patient, are not adequately discussed in patients being suspicious and angry, emotionally traditional textbooks, or classifiable in traditional labile, often refusing to speak or making delusional nosologies. Problems in the management of the misinterpretations. There was no hypomanic affect, dying patient and his relatives are dealt with in thought disorder, clouded consciousness or underlying collaboration with the oncologist and haematologist, organic disorder. They complained of auditory hallucinations, expressed a belief that they were in may be drawn from the relative incidence of psychosis communication with God and that witchcraft had following childbirth and that following induced been practised against them by relatives or neighbours. abortion. Depressive symptoms of a somatic nature became Two recent studies have shown that the incidence of more apparent during the admission of 2—3weeks post-abortion psychosis is no more than o •¿3per i ,000- and in subsequent admissions. abortions, while the incidence of puerperal psychosis Emphasizing that (i) the beliefs expressed were is of the order of i •¿5per i ,000 deliveries. It seems endorsed by the relatives who saw the patients as ill difficult to argue that an abortion is five times less because of their behaviour, (ii) the patients never psychologically stressful than childbirth, but it is a relinquished their beliefs, (iii) affect was appropriate, reasonable supposition that the biochemical changes (iv) the content of the delusions and hallucinations after abortion are much less than those which follow were intelligible (in Jaspers' sense of Verstehende delivery. Even when abortion is done after foetal psychology), the acute psychotic reaction was movements have been felt—which must be about as contrasted with mania, Leonhard's affect-laden stressful as an abortion can be—serious mental paraphenia, the anxiety-elation cycloid psychosis, disturbance remains exceedingly uncommon. the Scandinavian psychogenic psychosis, paranoid This suggests that physiological factors are of and oneroid psychosis. The possibility that this greater importance in the genesis of puerperal reaction was a classical Kraepelinian syndrome with psychosis—and possibly of lesser puerperal disorders a cultural flavour was considered, but it was felt that as well—than psychological factors. It follows that there were considerable affinities with the 'hysterical' 'medical model' treatment may be regarded as of (culture-bound) psychoses such as the Caribbean prime importance in such cases. Comparisons may boufféesdélirantesand the acute paranoid reactions be made with the rare but theoretically interesting of West Africa, although the typical clouding of post-thyroidectomy psychoses. I do not imply that consciousness was absent. The semiological aspects psychological factors and psychological treatments and the association with the dominant culture were should be ignored. related to the subsequent depressive phenomenology. A Clinical Study of Puerperal Psychosis By DR IAN F. BROCKINGTON, PUERPERAL PSYCHOSIS Senior Lecturer in Psychiatry, University of Manchester Post-abortion Psychosis and its Implications The case notes of 85 patients admitted to the for the Aetiology of Puerperal Psychosis Mother and Baby Unit and 50 non-puerperal By DR COLINBREWER, women of the same age group, admitted to Withing- Department of Psychiatry, University of Birmingham ton Hospital, Manchester, were studied. All case notes were abstracted and all information about The aetiology of puerperal psychosis remains their mental state, stripped of contextual clues, was controversial. Because of the obvious psychological noted. The abstracts were reviewed by two social and emotional implications of childbirth, there is a workers and two psychiatrists, all of whom were school of thought which regards it as largely psycho ignorant as to the number of patients with puerperal genic and therefore relies heavily on a psycho- psychosis. therapeutic approach. Fifty of the patients began their illness within two The other school points, in contrast, to the major weeks of delivery. The two psychiatrists were gen hormonal and biochemical changes which follow erally able to identify these patients to within a delivery, and suggests that these could well precipitate significant level of o-oi, while the social workers mental disturbance even without the intervention of were unable to do so beyond a chance level. Of the psychological factors. Adherents of this view may 50 puerperal psychotic women 36 were identified by tend to treat the psychosis rather as they might treat one or other of the psychiatrists (P = o-oooi). a severe endogenous depression, believing that if An analysis using Wing's 'PSE Syndromes' medical treatment is successful there will be little showed that clouding, lability, agitation and loss of need for psychotherapy. reserve were significantly associated with the puer Neither school has yet produced any direct peral state. These results do not support the prevalent evidence for the importance of particular psycho view that puerperal illness is non-specific. They are logical or biochemical disturbances, and research compatible with the hypotheses that this illness is from both standpoints is difficult since the condition either a specific psychosis or a manifestation of manic- is relatively uncommon. However, certain inferences depressive illness..