Report- Clinico-pathological Conference on Liaison Psychiatry

The Institute of Psychiatry, Benazir Bhutto Hospital, World Health Organization Collaboration Centre, organised a Clinico-Pathological Conference (CPC), on the theme of Liaison Psychiatry, at the New Teaching Block, Rawalpindi Medical College, on the 27th of July 2016. The CPC sought to appraise the medical students, psychologists, and various physicians and surgeons in attendance, about the intricate relationship between the various disciplines of health care.

The proceedings ensued, with Dr Yousaf Raza reciting from the Holy Qur’an and welcoming the attendees on behalf of the Institute. He introduced the audience to the layout of the presentations and the theme at hand. Dr Sundus Fatima, Academic Registrar at the Institute, then took the stage to present the first case history. She gave a detailed history of a 13-year-old girl who developed psychiatric complications as part of post-encephalitic sequelae; depressive and dissociative symptoms. In addition, she also had pica. She’d had a disturbed childhood marred by inter-parental conflicts and the inability of her mother to respond to her emotional needs.

Dr Ayesha Minhas, Assistant Professor of Psychiatry and Head of the Child Psychiatry Unit at the Institute, was then called up on stage to discuss and elaborate upon the case presented by Dr Sundus. She began her presentation by alluding to the historical background of psychiatry stating that it owes its origins to the philosophy of Rene Descartes and his separation of the mind and body; originally seen by neurologists, we saw psychiatric disorders as separate entities demanding a separate speciality in the aftermath of Cartesian philosophy. She highlighted that an expanding collection of causes, from head trauma, stroke, tumor, demyelination and many others cause symptom complexes that overlap with classic psychiatric disorders. More recently, she said, neuro-inflammatory and immunological abnormalities have been documented in patients with classical psychiatric disorders. She briefly described encephalitis as an acute inflammation of the brain caused by viruses. Occasionally, she said, it may present with psychiatric manifestations. She then elaborated upon depression and dissociation with particular emphasis on their interrelation. She spoke about the dissociation as the process by which we move thought, feelings, and information out of awareness as a human defence mechanism. Depression, she said, triggers dissociative coping, and dissociative coping allows depression to gain momentum. Dissociation and depression exacerbate each other! She also shed light on pica; persistent ingestion of nonnutritive substances for at least 1 month at an age for which this behaviour is developmentally inappropriate. She spoke about how pica might result from a specific nutrient deficiency and also of its relationship to OCD. She concluded by discussing the management of the case, specifically highlighting the importance of maintaining a liaison with the physicians for a follow-up on her encephalitis. They discussed the need for antidepressants in the case with family therapy. In the end, Dr Ayesha alluded to the possibility of a merger between neurology and psychiatry with the advances in neuroscience.

Dr Ayesha Nasir presented the next case, a first-year trainee at the Institute. She spoke about a patient who suffered a head injury and presented to the ER with vomiting and abdominal pain a day later. Surgery, medicine, ophthalmology, psychiatry, gynaecology saw her and finally passed away in the medical ICU. The physicians and surgeons initially thought her overturned hands and feet to be a case of conversion disorder. However, her deranged vitals and labs showed serious physical problems.

Dr. Asad Nizami, Assistant Professor of Psychiatry at the Institute, then took up the discussion of the case. He too began his presentation with a detour to the history of psychiatric illnesses. He alluded to the French neurologist Jean-Martin Charcot and his description of conversion symptoms. Dr Nizami alluded to the fact that usually a patient presenting in the ER with behavioural symptoms is assumed to be suffering from a psychiatric ailment without consideration that there are multiple organic problems that might present with behavioural issues. He went to detail conversion disorder as a presentation of neurological or medical symptoms that can’t be traced to a neurological or medical aetiology. He enlisted various sensory and motor symptoms for conversion. He highlighted the importance of identifying a psychological cause for a definitive diagnosis. Dr Nizami alluded to a study that showed how patients diagnosed with conversion disorder followed for a 9-year period was diagnosed with organic disease. Another study showed that 11.5 % of patients diagnosed with conversion disorder actually had neurological disorders and a systematic review showed a decline in the mean rate of misdiagnosis from the 1950s to the present day.

Prof. Fareed A. Minhas, Head of the Institute & Professor of Psychiatry, then took the stage and presented his paper published in the British Journal of Psychiatry on the development of psychiatric services in Pakistan. The study was a longitudinal descriptive survey presented to the consultation-liaison psychiatry service provided by the Institute of Psychiatry they evaluated to teaching hospitals in Rawalpindi during the first two years of its functioning. He described how the liaison registers are meticulously maintained and all cases seen by on-call trainees are discussed in detail in every morning meeting. He raised the concern that of the three teaching hospitals associated with RMC, only BBH had a psychiatric service and 96 % of the referrals were from the BBH Emergency; how are the psychiatric patients presenting to the other two hospitals being dealt with, he asked. The second highest referral rate, after the emergency, was from the medical unit. This illustrates, he said, the importance of the people working in those departments to have an experience in psychiatry and be cognisant of its nuts and bolts to efficiently identify psychiatric illnesses from organic illnesses. He also highlighted an alarming fact that we may ignore a lot of the medical and surgical problems in those departments if a presumptive suggestion of a psychiatric illness is made by the attendants or the patient. He appreciated the efforts of CPSP in mandating neurology and medicine trainees to rotate for three months in psychiatry and proposed that paediatric trainees do the same in child psychiatry seconding Prof. Rai Asghar’s suggestion, which he gave at an earlier symposium. Similarly, he said, the rotations of psychiatric trainees in the medicine and neurology department are equally important. Prof. Minhas closed the session with a vote of gratitude to all those in attendance.

This CPC provided the audience with an excellent overview of liaison psychiatry in Pakistan. The case histories presented provided the pragmatic challenges in the field. In the end, the most important message delivered was to build bridges between specialities by understanding the other more for the benefit of the patients.

Report prepared by Dr Yousaf Raza, Post-Graduate Resident at the Institute of Psychiatry.