David G. Folks

Conversion symptoms in a general hospital

Abstract Analysis of 1,000 consecutive psychiatric consultations shows that the prevalence of conversion disorder (5%) in a general hospital remains significant. Conversion patients referred for psychiatric consultation were predominantly married young women of lower socioeconomic class and rural background. We observed rapid remissions of presenting symptoms in most cases upon treatment and found a significant proportion of somatization disorder (34%) or history of conversion disorder (38%). Other phenomenologic findings are discussed in regard to previous reports or hypotheses about conversion symptoms.

Denial: predictor of outcome following coronary bypass surgery.

Using a modified version of the Hackett-Cassem denial scale we measured preoperative denial in 121 patients scheduled for CABG surgery. A significant inverse relationship was found between the denial scale and Hamilton Anxiety measures four days postoperatively (p < .02). Longitudinal assessments were carried out using the Spielberger State Anxiety Inventory (SSAI), the Zung Self-Rating Depression Scale (Zung SDS) and the Psychosocial Adjustment to Illness Scale (PAIS). Six months following the surgery, significant negative relationships between denial and these self-report outcome measures were observed as follows: denial and SSAI (p < .001), denial and Zung SDS (p < .01), and denial and PAIS (p < .01). However, the same analysis at twelve months showed no statistically significant correlations between denial and these psychologic outcome measures. Our findings suggest that denial serves as an adaptive mechanism, especially in the immediate postoperative period. Furthermore, higher levels of denial may be predictive of improved psychologic outcome for up to six months following surgery. Subsequently, however, other events, unrelated to the surgery, may be of greater importance than preoperative denial in determining psychological outcome from CABG surgery.

The Role of Psychological Factors in Dermatologic Conditions

Knowledge about the psychiatric factors affecting dermatologic illness is far from conclusive. Studies in the past decade have strengthened concepts regarding associated psychological factors. Many dermatologic conditions are now considered in the context of genetic predisposition, personality, and biopsychosocial factors. Several psychotropic medications have been observed to affect dermatologic conditions. This article reviews the research and clinical reports of the past decade that address nosologic and diagnostic aspects of psychological factors affecting dermatologic conditions. This article is a result of the efforts of a work group to propose revisions to the DSM-III-R diagnostic category of psychological factors affecting physical condition and supports the need for a systematic, nosologic schema that would potentially increase our knowledge and improve our understanding of this important psychosomatic domain.

Factitious disorder and coexisting depression: A report of successful psychiatric consultation and case management

The authors present a case illustrating factitious illness with a coexisting depressive disorder. The factitial presentation involved self-mutilation that served to procure and prolong patient status, while obscuring the recognition of a major depressive episode. The importance of accurate assessment and prompt recognition of factitious illness is discussed, with emphasis upon the identification of contributing psychodynamics, underlying psychopathology and ongoing psychosocial stressors. Psychiatric consultation efforts were successful, but in the context of considerable morbidity. Psychotherapeutic gains occurred only after vigorous antidepressant drug therapy and substantial psychotherapeutic efforts that empathically addressed the patients masochism and dependency.

Alprazolam treatment of postcoronary bypass anxiety and depression.

The effectiveness of alprazolam in treating symptoms of anxiety and depression in 60 patients undergoing coronary bypass surgery was assessed in a double-blind, placebo-controlled study. The results indicate that alprazolam treatment for anxiety following coronary bypass surgery, particularly symptoms occurring in the immediate postoperative period, can significantly affect patient outcome. Specifically, only modest but statistically significant improvement was observed in the alprazolam-treated groups at 1-month follow-up; however, alprazolam-treated patients were significantly more likely to experience a very rapid anxiolytic effect by postoperative day 8. The implications of this study are discussed with respect to patient management and models for future studies of anxiety in postoperative patient populations.

Persistent Depression in Coronary Bypass Patients Reporting Sexual Maladjustment

Four hundred ten patients undergoing coronary artery bypass surgery demonstrated a highly significant correlation between sexual-adjustment disturbance and postoperative depressive symptomatology. Patients were assessed preoperatively with the Psychosocial Adjustment to Illness Scale (PAIS), Zung SDS, and CES-D depression-rating scales; assessments were also made at three, six, and twelve months postoperatively. The PAIS served to examine psychosocial adjustment following bypass surgery. In particular, five of the six subscale items addressing sexual function were significantly correlated with persistent depressive symptoms. Sexual function problems were highly correlated with depression both pre- and postoperatively; of greater importance, preoperative sexual adjustment disturbances were predictive of depressive symptoms postoperatively on all assessment occasions. This study supports the need for an assiduous sexual history and psychiatric evaluation prior to surgery.

Challenges and Opportunities for Consultation-Liaison Psychiatry in the Managed Care Environment

While the evolving managed care revolution is dramatically changing the clinical, educational, and economic systems in which consultation-liaison (C-L) psychiatrists must operate, this revolution also present several important opportunities for those in C-L psychiatry. The authors, who are academic department chairs and formerly directed C-L divisions, discuss C-L psychiatrys potential involvement and suggest approaches to effectively address key aspects of these changes.

Residents’ Structured Versus Nonstructured Assessment of Cognitive Function

We evaluated whether psychiatric residents assigned to the emergency room and consultation services, at comparable stages in their training, would more carefully consider cognitive dysfunction in presenting patients by employing a structured questionnaire rather than the more traditional method of mental status assessment. No significant difference in the frequency of suspected diagnosis of organic mental disorder was noted among 231 patients who were assessed using the Cognitive Capacity Screening Exam versus 281 patients screened by the more traditional clinical mental status examination. Thus, psychiatric residents who utilize a methodical and careful mental status examination remain highly effective in evaluating for the presence of organic psychiatric disorder.