consultee confusion
TRANSCRIPT
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