consultee confusion

LETTERS

reductionistic dangers in 'relying tooheavily on a predominantly biologicapproach' to patients, in which sub­jective experience is minimized. Bythus placing biology at conceptualodds with subjectivity, Dr. Marmorhimself participates in reductionisticthinking. To differentiate biologyfrom subjectivity is to enact the Carte­sian notion of mind-body dualism thatinsidiously persists in psychiatry.

Mind and body are not predicated ofdifferent essences that somehow inter­act with each other. Rather, psycheand soma reflect different organiza­tional levels of biology. The field ofconsciousness is no less biologicalthan is a cell in the frontal granularcortex. A conscious field is, however,organizationally more complex, andtranscendent in that it is not reducibleto its enfolded sub-organizations(which include cells in the frontal cor­tex).

Psychiatry is inevitably biological.It need not turn away from itself to em­brace consciousness.

Thomas D. Geracioti. M.D.University o/CaliforniaSan Francisco

The author replies:

It seems to me that Dr. Geracioti isconfusing an important theoretical is­sue with a clinical one. I am, ofcourse, in complete agreement withhis statement about the essential unityof mind and body. What I was refer­ring to in my editorial, however, wasthe question ofhow one deals clinical­ly with this unity, and I suggested thata bio-psycho-social treatment ap­preach is the most effective way ofcoping with most psychosomatic pa­thology. I was not in any way imply­ing that we ought to turn away from

APRIL 1986· VOL 27 • NO 4

the valuable understanding that newresearch in biology is giving us; rath­er, I was calling attention to the factthat psychosocial factors inevitablybecome reflected at biological levels,and must not therefore be ignored inany program of comprehensive treat­ment. Such a clinical approach is incomplete harmony with the theoreti­cal model of mind-body duality and,indeed, is derived from it.

Judd Marmor. M.D.Los Angeles

Consultee confusion

Sir: We read the recent article by Go­linger and associates, "Clarity of re­quest for psychiatric consultation: Itsrelationship to psychiatric diagnosis"(Psychosomatics 26:649-653, 1985),with great interest, especially sincewe provide freq.Jent psychiatric con­sultation to the large medical, surgi­cal, and emergency services in ourhospital. Their finding that majormental illness was diagnosed almosttwice as often when the request forconsultation was unclear versus whenthe request was clear is consistent withour experience that difficult patientscontribute to miscommunication be­tween members of the treatment teamand that requests for consultation maysignal distress or confusion on the partof the consultee. I Anxiety certainlycontributes to the unclarity, as theauthors suggest, although we fre­quently find that simple lack ofknowl­edge and inexperience with majormental illness also commonly contri­bute to consultees• inability to articu­late clearly their observations and re­quests. Faced with serious psycho­pathology, nonpsychiatric cliniciansmay quickly react by thinking "psych

consult" and then stop pursuing as­sessment and treatment on their own.

We agree with Golinger and asso­ciates that an unclear request shouldprompt the consultant to look for ser­ious psychiatric disorder, and we has­ten to add that the consultant shouldalso address and attempt to assuagethe consultee's anxiety. This can oftenbe done through an educational ap­proach. Teaching the consultee aboutthe patient's psychiatric illness helpsrelieve anxiety by restoring a sense ofcompetence and control, and may paythe bonus of making him or her a bet­ter consultee in the future.

Michael F. Hoyt. Ph.D.Frederick C. Bittiko/er. M.D.Norman W. Weinstein. M.D.Kaiser-Permanente Medical CenterHayward. Calif.

REFERENCE1. Hoyl MF, Opsvig P, Weinstein NW: Conjoint

patient-staff interview in hospital case man­agement 1m J Psychiatry Med 11 :83-87,1981

Scan orientation corrected

Sir: The article' 'CT scanning in psy­chiatric inpatients: Clinical yield," byBeresford and associates (Psychoso­matics 27: 105-112, 1986), is excel­lently illustrated by CT scan images ofthe brain. However, the orientation ofthe photographs as described in thecaption appears incorrect.

Theodore Pearlman. M.D.Houston

Dr. Pearlman is correct. The captionshould have read: "The figures shouldbe viewed as if you were looking upfrom beneath the chin." We apolo­gize for this error.

The Editors