Julian Stern

Anorexia nervosa in gastrointestinal practice.

Objectives To characterize the demographic, psychosocial and prognostic features of patients with anorexia nervosa (AN) presenting to a gastroenterology service, and to compare them with patients presenting to an eating disorders unit. Methods A retrospective study set in two centres providing a local and tertiary service for gastroenterology and eating disorders. The notes of 20 consecutive patients with AN from each centre were compared. Comparison was made with a control group of 20 consecutive patients with slow transit constipation presenting to a gastroenterology service. Results Patients with AN who presented to a gastroenterology service were significantly older, had often seen a large number of hospital specialists, had a spectrum of gastrointestinal complaints, suffered a substantial delay in being diagnosed, and had undergone a significantly greater number of investigations and hospital admissions than AN patients attending an eating disorders unit. The parents of AN patients presenting to a gastroenterology clinic had a greater burden of physical and psychiatric illness than the parents in either of the other groups, and also tended to have separated when the patients were under the age of 10 years. Adverse prognostic factors among AN patients presenting to a gastroenterology clinic included older age at presentation, long history, unemployment, early parental separation and a body mass index less than 17. Conclusions Patients with AN presenting to a gastroenterology service have profound psychosocial morbidity in excess of those presenting to a specialist eating disorders unit. Their diagnosis is often delayed. Early recognition and prompt referral to a specialist eating disorder unit should form the basis of management.

Psychiatry, psychotherapy and gastroenterology — bringing it all together

In this review, some aspects of functional gastrointestinal disorders are described, with particular reference to psychiatric and psychological features. Seven syndromes or conditions, which may present not uncommonly in a gastroenterology clinic, are identified and clarified. Thereafter, the roles of a psychiatrist and other mental health professionals (psychotherapists, psychologists) within gastroenterology are described, with particular reference to what an integrated service may offer.

Physiological, psychological and behavioural characteristics of men and women with faecal incontinence

Background  The factors leading to faecal incontinence in males are less well understood than those in females. In this prospective study we aimed to compare the physiological, anatomical, psychological and behavioural characteristics of male and female patients presenting with symptoms of faecal incontinence.

Psychoanalytic thinking in primary care: The Tavistock Psychotherapy Consultation model

This paper describes the conceptual underpinnings, structure and operations of a novel service, the City and Hackney Primary Care Psychotherapy Consultation Service – a service set up partly with the aim of addressing the needs of patients who present with ‘medically unexplained symptoms’. As part of the Tavistock and Portman NHS Trust, this service moves its clinical base, staff members and daily work, as well as the foundations of psychoanalytic thinking that define the Trusts work, into the heart of a community, and provides psychoanalytically informed clinical practice and consultation to patients and general practitioners in the City and Hackney, one of Londons (and the UKs) most deprived and ethnically diverse boroughs. The authors describe the psychoanalytical underpinnings of the model, the design and structure of the service, patient demographics and preliminary outcome data, as well as an example of consultation work with general practitioners. The authors propose that psychoanalytic applications have a place in primary care and that psychoanalytic thinking can help general practitioners and patients alike, even when the clinical interventions offered are not solely based on psychoanalytic technique or therapeutic approaches. The paper concludes with thoughts about the model, its origins and its future.

Abdominal pain of psychotic origin

The patient, then in her late 50s was admitted to a general hospital in 1990 for investigation of bleeding per rectum and anaemia. Investigations included barium enema, proctoscopy and colonoscopy. Haemorrhoids were the only positive finding and she eventually underwent diagnostic laparotomy, which was entirely normal. A haemorrhoidectomy was performed. Over the next 5 years she had abdominal pain, poor appetite and constipation which persisted despite use of various laxative preparations. In 1994, gallstones were demonstrated but cholecystectomy had no effect on her symptoms. In 1995 she was readmitted complaining of severe abdominal pain, and investigations at this stage included colonoscopy, barium studies, gastroscopy, abdominal ultrasound, intravenous urography and abdominal computed tomography. All were normal. A psychiatrist diagnosed depression and antidepressants were prescribed; her compliance was poor and she was subsequently lost to psychiatric follow-up. Family concern led to her referral six months later to St Marks Hospital for further management. On admission she was grossly emaciated and anaemic (haemoglobin 10g/dL with microcytic indices), frail, bedbound, anxious and tearful. There were no signs specific to a gastrointestinal cause and psychiatric review was sought. She admitted to feeling depressed, and started by talking about her physical condition. With time, the full extent of her abnormal beliefs slowly emerged. She complained of not having defaecated for 2 months, with no urination for a fortnight. She claimed that her stomach had shrunk to the extent that she could take nothing in, that her swallowing was also impaired, and that only water or food as small as a peanut could pass through her lips. On further questioning, she accused her husband and family of wanting to desert her (though according to all witnesses her family were extremely supportive and visited daily) and believed that the nurses and other patients were stealing from her bedside table. She was diagnosed as having a psychotic depression with somatic features, and after transfer to inpatient psychiatric care her mental state and weight improved dramatically on a combination of an antidepressant (paroxetine 20 mg daily) and a major tranquillizer (thioridazine 150 mg daily).

A dangerous combination of binge and purge

We present a 36-year-old female diagnosed with Crohns disease at the age of 11 years. In 2001, she underwent a total colectomy and further small bowel resection as a result of active Crohns. Her residual anatomy consisted of 150 cm of small bowel to an end jejunostomy. Subsequently, she developed short bowel syndrome with recurrent episodes of hypomagnesaemia, hypocalcaemia, and hypokalaemia. Dietetic assessment revealed her to be severely underweight at 37 kg with a bodymass index (BMI) of 14.4 kg/m(2) . During her admission, our patient underwent psychiatric assessment and was established on home parenteral nutrition (HPN). At the time of discharge, 1 month later, her weight had increased to 44 kg (BMI = 17.7 kg/m(2) ). Over the following 12-month period, she lost weight (BMI, 15.4 mg/m(2) ; weight, 39.5 kg) and she described a high stoma output (up to 17 L) and dehydration. Assessment of her oral intake found she was consuming an estimated 14,000 kcal and 600 g protein per day. At this time, the possibility of a new form of eating disorder was discussed with the patient and she agreed that her behavior i.e., using her stoma as a purging device, fulfilled the criteria for a diagnosis of bulimia nervosa and she was referred to a specialist eating disorder unit.

Keeping the gut in mind

This paper reviews some of the ways in which Alexis Brook pioneered a truly psychosomatic approach at St Marks Hospital (SMH), where he worked from 1986 for 9 years (and where the author succeeded him in 1995). This is a highly specialized hospital for disorders of the lower gastrointestinal tract, attracting referrals from throughout the UK and beyond. Aspects of his work at SMH are described, mainly through the use of his papers, both published and unpublished. The author shows how Brooks legacy lives on, most concretely through a dedicated Psychological Medicine Unit at SMH, which builds on his work, and continues to influence numerous physicians, surgeons, dieticians and nurses who work there, along with many of the patients treated at this hospital.

The functions of a psychotherapy unit in a psychiatric hospital — Refracted through the lenses of trainee psychiatrists

SUMMARY Only a small proportion of patients seen at a psychiatric hospital such as the Maudsley Hospital are referred for an assessment for psychoanalytic psychotherapy. In this study, junior doctors were interviewed regarding forty-two consecutive referrals to the Maudsley Psychotherapy Unit. In many cases there was a strong sense of identification between referring doctor and referred patient, and in almost all cases the patients referred evoked a strong countertransference reaction in the referring psychiatrists. A disproportionate number of referrals were made as psychiatrists were about to rotate from one ward to another. Referrals to the Psychotherapy Unit seem to represent a complex mix of strong countertransference feelings evoked in the referrer, institutional factors including interpersonal rivalries, and patient characteristics. The majority of patients referred to the Psychotherapy Unit were thought to have both a mental illness and a personality disorder by their referring psychiatrists; and,...

The trouble with illness: how illness and disability affect relationships

This is an accessible and thoughtful book by Julia Segal, who has not only published work on Melanie Klein, but has also worked both for the NHS and privately as a counsellor for people affected by neurological and other physical health conditions. The book is aimed primarily at those who work, or whose life brings them into contact, with those who are ill or newly disabled in one way or another. As she writes,

Paradigms, politics and pragmatics: psychotherapy in primary care in City and Hackney – a new model for the NHS: Part 2: operational model, practice and outcomes

Whilst an earlier paper (Part 1) in this journal describes the historical, political and economic drivers behind the creation of the City and Hackney Primary Care Psychotherapy Consultation Service (PCPCS), this paper (Part 2) focuses on exploring the context within which the service functions. The paper provides an overview of its operational model and is organised into 10 sections. The first section outlines the services clinical practice, whilst the second addresses the value of GP consultations as a core part of the PCPCSs provision. The third section addresses how the service, as departure from a more ‘pure’ psychoanalytic tradition of providing longer-term therapy, has managed its provision of brief treatments. There is a description of how the service manages its team of multi-disciplinary clinicians and their work in a variety of micro-cultures, conveying some of the challenges faced by the service and the team since its inception. Thereafter, the quantitative and qualitative evidence for the services clinical and cost effectiveness is assessed, including outcome results and findings from a health economic evaluation. To illustrate some of the services work in practice, some disguised clinical vignettes are presented. The paper also summarises the services recent clinical innovations, as well as its contribution to the field of research, audit and training. Finally, the way forward for the service is considered in the context of current and emerging trends in psychological provision in primary care.